EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVES

To develop evidence based recommendations for the management of hand osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference.

RESULTS

Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise.

CONCLUSION

Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

The Genetics of Generalized Osteoarthritis (GOGO) study: study design and evaluation of osteoarthritis phenotypes

PURPOSE

The primary goal of the Genetics of Generalized Osteoarthritis (GOGO) study is to identify chromosomal regions associated with increased susceptibility to generalized osteoarthritis (OA). Here we describe the study design and phenotype of the 2728 participants from the 1145 families recruited for this study.

METHODS

GOGO is an investigator-initiated collaboration involving seven clinical academic sites and sponsored by GlaxoSmithKline. Family ascertainment was carried out between 1999 and 2002. A qualifying family required self-reported Caucasian ethnicity and at least two affected siblings with clinical hand OA. We hypothesized that this clinical phenotype would facilitate identification of participants with multijoint radiographic OA (rOA) in and beyond the hand. The "gold standard" case definition, however, was based on rOA (Kellgren-Lawrence grade > or =2) involving > or =3 hand joints distributed bilaterally and including at least one distal interphalangeal joint, with two of the three involved joints within a joint group (distal interphalangeal, proximal interphalangeal, or carpometacarpal). Radiographs of hips, knees and spine were also obtained. Additional siblings and living parents from qualifying families, both affected and unaffected, were invited to participate.

RESULTS

A total of 2706 participants had complete clinical and radiological examination data. Of these, 2569 participants met clinical examination criteria for affected status; while 1963 (73%) participants met the prespecified radiographic criteria for affected status. This corresponded to a total of 707 families with at least two affected siblings that met the hand rOA criteria. Of those individuals with rOA of the hand, the frequency of rOA at other sites was highest for the knee (51%) and spine (54%), and less common for the hip (25%). Concordance rates among hand affected siblings were greatest for spine (36%) followed by knee (31%) and hip (9%); a total of 53% of the affected sib pairs were concordant for specific patterns of generalized rOA involving the hand and large joints (knees, hips or spine).

CONCLUSIONS

GOGO represents a large multicenter collection of families with multiple joint OA that have been characterized both clinically and radiographically. The GOGO study will employ a comprehensive strategy for genetic screening based upon both qualitative and quantitative radiographic trait analyses, circulating biomarkers in a quantitative trait-based analysis, fine mapping, and candidate gene analysis. This sample should provide sufficient power to detect linkage to OA associated genes.

The ecological validity of laboratory cycling: Does body size explain the difference between laboratory- and field-based cycling performance?

Previous researchers have identified significant differences between laboratory and road cycling performances. To establish the ecological validity of laboratory time-trial cycling performances, the causes of such differences should be understood. Hence, the purpose of the present study was to quantify differences between laboratory- and road-based time-trial cycling and to establish to what extent body size [mass (m) and height (h)] may help to explain such differences. Twenty-three male competitive, but non-elite, cyclists completed two 25 mile time-trials, one in the laboratory using an air-braked ergometer (Kingcycle) and the other outdoors on a local road course over relatively flat terrain. Although laboratory speed was a reasonably strong predictor of road speed (R2 = 69.3%), a significant 4% difference (P < 0.001) in cycling speed was identified (laboratory vs. road speed: 40.4 +/- 3.02 vs. 38.7 +/- 3.55 km x h(-1); mean +/- s). When linear regression was used to predict these differences (Diff) in cycling speeds, the following equation was obtained: Diff (km x h(-1)) = 24.9 - 0.0969 x m - 10.7 x h, R2 = 52.1% and the standard deviation of residuals about the fitted regression line = 1.428 (km . h-1). The difference between road and laboratory cycling speeds (km x h(-1)) was found to be minimal for small individuals (mass = 65 kg and height = 1.738 m) but larger riders would appear to benefit from the fixed resistance in the laboratory compared with the progressively increasing drag due to increased body size that would be experienced in the field. This difference was found to be proportional to the cyclists' body surface area that we speculate might be associated with the cyclists' frontal surface area.

The influence of ramp rate on VO2peak and "excess" VO2 during arm crank ergometry

The principal aim of this study was to examine how different ramp rates influenced the attainment of peak physiological responses during incremental arm crank ergometry (ACE). Additionally, the study examined whether there was any evidence for the development of an "excess" VO (2) during ACE due to upward curvi-linearity in the VO (2)-work rate relationship, and whether this was influenced by the ramp rate. Sixteen physically active, though non-specifically trained, men (mean +/- S age 30 +/- 8 years; height 1.79 +/- 0.07 m; body mass 84.7 +/- 13.2 kg) volunteered to participate. Having completed a familiarisation test, all subjects returned to the laboratory to complete two ramp tests on an electrically-braked ergometer in a counter-balanced order. Both ramp tests started at 60 W with work rate subsequently incremented by either 6 or 12 W . min (-1). Pulmonary gas exchange was measured breath-by-breath throughout the tests. Subjects achieved a greater final work rate during the 12 W . min (-1) test compared to the 6 W . min (-1) test (168 +/- 28 vs. 149 +/- 26 W; p < 0.001). The VO (2peak) (3.06 +/- 0.65 vs. 2.96 +/- 0.48 L . min (-1); p = 0.27), HR (peak) (179 +/- 15 vs. 177 +/- 16 b . min (-1); p = 0.17) and V.E (peak) (112 +/- 22 vs. 105 +/- 16 L . min (-1); p = 0.09) were not different between the tests, but VCO (2peak) (3.54 +/- 0.64 vs. 3.27 +/- 0.46 L . min (-1); p = 0.01) RER (peak) (1.17 +/- 0.07 vs. 1.11 +/- 0.06; p < 0.001), and end-exercise blood (lactate) (11.9 +/- 2.1 vs. 10.8 +/- 2.6 mmol . L (-1); p = 0.005) were all higher in the 12 W . min (-1) test. An "excess" VO (2) was observed in 13 out of 16 tests at 12 W . min (-1) and in 15 out of 16 tests at 6 W . min (-1). Neither the magnitude of the "excess" VO (2) (0.42 +/- 0.41 vs. 0.37 +/- 0.18 L . min (-1); p = 0.66) nor the VO (2) at which the V.O (2)-work rate relationship departed from linearity (2.17 +/- 0.34 vs. 2.18 +/- 0.32 L . min (-1); p = 0.94) were significantly different between the two ramp tests. These data indicate that differences in ramp rate within the range of 6 - 12 W . min (-1) influence the peak values of work rate, VCO (2) and RER, but do not influence peak values of VO (2) or HR during ACE. The development of an "excess" VO (2) appears to be a common feature of ramp exercise in ACE, although the mechanistic basis for this effect is presently unclear.

EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To develop evidence based recommendations for the management of gout.

METHODS

The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales.

RESULTS

12 key propositions were generated after three Delphi rounds. Propositions included both non-pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) are recommended.

CONCLUSIONS

12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.

EULAR recommendations for knee and hip osteoarthritis: a critique of the methodology

The quality of the EULAR recommendations for the management of hip and knee osteoarthritis (OA) was evaluated using a validated instrument. The quality and methods were compared with other guidelines and recommendations. EULAR recommendations were found to be among the best for overall quality. They show strengths with respect to scope, rigour of development, and clarity, but weaknesses with respect to stakeholder involvement, applicability, and editorial independence. However, a principal strength is their attempt to fill the gap between guidelines based solely on either research evidence or expert opinion. The methods used to synthesise research evidence (systematic review) and expert opinion (Delphi exercise) are robust. Strength of recommendation, based on combined consideration of research evidence, clinical expertise, and perceived patient preference, is valid and approaches the true essence of "evidence based practice" that considers each of these different forms of evidence.

The effect of crank rate on physiological responses and exercise efficiency using a range of submaximal workloads during arm crank ergometry

This study examined the effects of variations in crank rate on physiological responses during submaximal arm ergometry. Fifteen non-specifically trained male subjects volunteered to participate in this study. Each subject undertook a discontinuous arm crank ergometry test (30, 50, 70, 90 W) on three separate occasions using crank rates of 50, 70, and 90 rev.min(-1). Respiratory parameters and heart rate were continuously monitored. An 80-microL capillary blood sample was obtained immediately following each exercise bout for the determination of whole blood lactate. Measures of efficiency were calculated using specific caloric equivalents of oxygen consumption (V(O2)). Heart rate was lowest (p < 0.05) at 30, 50, and 70 W using 50 rev.min(-1). Values of gross and net efficiency tended to be higher (p < 0.05) using 50 rev.min (-1) at the lower absolute workloads, but no differences (p > 0.05) were observed between the three crank rates at 90 W. No differences (p > 0.05) were observed between crank rates for delta efficiency. This study confirms that variations in crank rate can influence gross and net values of V(O2) and exercise efficiency at low absolute workloads, but crank rate ceases to be an influential factor at moderate workloads. Further research is required to identify the specific mechanisms underpinning the observations reported in the present study relating to the interaction between crank rate, workload, and exercise efficiency during arm crank ergometry.

Relative impact of radiographic osteoarthritis and pain on quadriceps strength, proprioception, static postural sway and lower limb function

OBJECTIVE

To investigate the relative impact of radiographic osteoarthritis (ROA) and current knee pain on lower limb physical function, quadriceps strength, knee joint proprioception, and postural sway.

METHODS

Using a 2x2 factorial design, 142 community derived subjects aged over 45 were divided into four subgroups based on the presence or absence of ROA (Kellgren & Lawrence>grade 2) and knee pain (as assessed by NHANES questions and a 100 mm visual analogue scale). Maximum isometric contraction of the quadriceps, knee joint proprioceptive acuity, static postural sway, and WOMAC index (both whole and function subscale) were assessed in all subjects.

RESULTS

Compared with normal subjects, reported disability was greater for all other subgroups (p<0.01). Subjects with both ROA and knee pain reported the greatest disability, and those with knee pain only had greater disability than those with ROA only. Quadriceps weakness was observed in all groups compared with normal subjects (p<0.01), though they were no significant intergroup differences. Subjects with knee pain had a greater sway area than those without (p<0.05) but the presence of ROA was not associated with increased postural sway. No differences in proprioceptive acuity were observed between groups.

CONCLUSIONS

The presence of knee pain has a negative association with quadriceps strength, postural sway, and disability compared with ROA. However, the presence of pain-free ROA has a significant negative influence on relative quadriceps strength and reported disability.

Reliability of Repeated Sprint Exercise in Non-Motorised Treadmill Ergometry

Although repeated sprint tests are relatively common, there have been few investigations of repeated sprint exercise using non-motorised treadmill ergometry. The purpose of this study was to determine the reliability of a repeated sprint procedure using this apparatus. Ten healthy, active males, performed three repeated sprint tests (six repetitions of 6 s sprints with 30 s recovery) on three separate occasions. Performance as determined by maximal speed, average force production, and fatigue were compared across the three trials. Maximal speed and average force were not significantly different between visits (p < 0.05) and a variety of reliability measures suggested good agreement (e.g., coefficient of variations no more than 5 %). The fatigue indices for maximal speed and for average force were generally less reliable (coefficients of variation around 30 % in both cases). In conclusion, measures of performance (maximal speed and average force) can provide reliable results in a repeated sprint protocol but the reliability of fatigue measures appears to be low.

EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To develop evidence based recommendations for the diagnosis of gout.

METHODS

The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert, representing 13 European countries. Ten key propositions regarding diagnosis were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Wherever possible the sensitivity, specificity, likelihood ratio (LR), and incremental cost-effectiveness ratio were calculated for diagnostic tests. Relative risk and odds ratios were estimated for risk factors and co-morbidities associated with gout. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales.

RESULTS

10 key propositions were generated though three Delphi rounds including diagnostic topics in clinical manifestations, urate crystal identification, biochemical tests, radiographs, and risk factors/co-morbidities. Urate crystal identification varies according to symptoms and observer skill but is very likely to be positive in symptomatic gout (LR = 567 (95% confidence interval (CI), 35.5 to 9053)). Classic podagra and presence of tophi have the highest clinical diagnostic value for gout (LR = 30.64 (95% CI, 20.51 to 45.77), and LR = 39.95 (21.06 to 75.79), respectively). Hyperuricaemia is a major risk factor for gout and may be a useful diagnostic marker when defined by the normal range of the local population (LR = 9.74 (7.45 to 12.72)), although some gouty patients may have normal serum uric acid concentrations at the time of investigation. Radiographs have little role in diagnosis, though in late or severe gout radiographic changes of asymmetrical swelling (LR = 4.13 (2.97 to 5.74)) and subcortical cysts without erosion (LR = 6.39 (3.00 to 13.57)) may be useful to differentiate chronic gout from other joint conditions. In addition, risk factors (sex, diuretics, purine-rich foods, alcohol, lead) and co-morbidities (cardiovascular diseases, hypertension, diabetes, obesity, and chronic renal failure) are associated with gout. SOR for each proposition varied according to both the research evidence and expert opinion.

CONCLUSIONS

10 key recommendations for diagnosis of gout were developed using a combination of research based evidence and expert consensus. The evidence for diagnostic tests, risk factors, and co-morbidities was evaluated and the strength of recommendation was provided.

The relationship between body mass index and health-related quality of life: comparing the EQ-5D, EuroQol VAS and SF-6D

BACKGROUND

No other studies have compared the relationship between body mass index (BMI) and health-related quality of life (HRQL) on more than one utility measure. Estimating the HRQL effects of obesity on a (common) utility scale enables the relative cost-effectiveness of interventions designed to alleviate obesity to be estimated.

OBJECTIVE

To examine the relationship between BMI and HRQL according to the EQ-5D, EuroQol visual analogue scale (EQ-VAS) and SF-6D.

METHODS

Patients aged >/=45 years at one UK general practice were asked to complete the EQ-5D, EQ-VAS, SF-36 questionnaire (used to derive the SF-6D), and information on their characteristics and co-morbidity. Body mass index was categorized according to the World Health Organization (WHO) recommendations. Regression analysis was used to compare the HRQL of normal BMI patients to the HRQL of patients in other BMI categories, while controlling for patient characteristics and co-morbidity.

RESULTS

A total of 1865 patients responded (67%), mean BMI 26.0 kg/m(2), 16% obese (BMI>/=30). Patients with back pain, hip pain, knee pain, asthma, diabetes or osteoarthritis were also significantly more likely to be obese. After controlling for other factors, compared to normal BMI patients, obese patients had a lower HRQL according to the EQ-5D (P<0.01), EQ-VAS (P<0.001) and SF-6D (P<0.001). Pre-obese patients were not estimated to have a significantly lower HRQL, and underweight patients were only estimated to have a significantly lower HRQL according to the SF-6D. These results arose because, on the EQ-5D, obese patients were found to have significantly more problems with mobility and pain, compared to physical functioning, social functioning and role limitations on the SF-6D. Whereas, according to the SF-6D, underweight patients had significantly more problems on the dimension of role limitation.

CONCLUSION

The EQ-5D, EQ-VAS and SF-6D were in agreement that, relative to a normal BMI, obesity is associated with a lower HRQL, even after controlling for patient characteristics and co-morbidity. These three measures are thereby sensitive to the HRQL effects of obesity and can be used to estimate the cost-effectiveness of interventions designed to alleviate obesity.

Linkage to nodal osteoarthritis: quantitative and qualitative analyses of data from a whole-genome screen identify trait-dependent susceptibility loci

OBJECTIVE

To identify susceptibility loci for nodal osteoarthritis.

METHODS

A genome screen at an average marker spacing of 9.29 cM was carried out on 558 people from 202 families, of whom 491 had nodal osteoarthritis. All genotyped people were graded for the incidence and severity of distal interphalangeal (DIP) nodes, and radiographs from 354 people were graded for joint-space narrowing (JSN) and osteophytes (OSTs). Age-regressed indices for DIP nodes, JSN and OSTs were calculated using these phenotypic data. Affected sibling pair (ASP) and quantitative trait analyses were carried out using MERLIN.

RESULTS

The data analysis identified suggestive linkage to loci on chromosomes 3 (for JSN and OST), 4 (for JSN), 8 (for DIP), 11 (for radiographic osteoarthritis) and 16 (for JSN). Both the ASP and quantitative analyses identified the loci on chromosomes 4 and 11. The loci on chromosomes 3 and 16 overlap with those previously identified for large-joint osteoarthritis. Of the loci identified by the quantitative analyses with the logarithm of the odds of linkage >1.5, two were linked to more than one trait, whereas nine were linked to single traits: one for DIP, six for JSN and two for OST.

CONCLUSION

The ASP and quantitative analyses of the cohort with nodal osteoarthritis suggest that multiple susceptibility loci for osteoarthritis influence the traits, which combine to form the osteoarthritis phenotype, and that these loci may not act exclusively on the joints of the hand.

Cost effectiveness of a two-year home exercise program for the treatment of knee pain

OBJECTIVE

To assess the cost effectiveness of a 2-year home exercise program for the treatment of knee pain.

METHODS

A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self-reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included.

RESULTS

Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no-exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001).

CONCLUSION

Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.

Effects of caffeine ingestion on rating of perceived exertion during and after exercise: a meta-analysis

The purpose of this study was to use the meta-analytic approach to examine the effects of caffeine ingestion on ratings of perceived exertion (RPE). Twenty-one studies with 109 effect sizes (ESs) met the inclusion criteria. Coding incorporated RPE scores obtained both during constant load exercise (n=89) and upon termination of exhausting exercise (n=20). In addition, when reported, the exercise performance ES was also computed (n=16). In comparison to placebo, caffeine reduced RPE during exercise by 5.6% (95% CI (confidence interval), -4.5% to -6.7%), with an equivalent RPE ES of -0.47 (95% CI, -0.35 to -0.59). These values were significantly greater (P<0.05) than RPE obtained at the end of exercise (RPE % change, 0.01%; 95% CI, -1.9 to 2.0%; RPE ES, 0.00, 95% CI, -0.17 to 0.17). In addition, caffeine improved exercise performance by 11.2% (95% CI; 4.6-17.8%). Regression analysis revealed that RPE obtained during exercise could account for approximately 29% of the variance in the improvement in exercise performance. The results demonstrate that caffeine reduces RPE during exercise and this may partly explain the subsequent ergogenic effects of caffeine on performance.

Haplotypes of the low-density lipoprotein receptor-related protein 5 (LRP5) gene: are they a risk factor in osteoarthritis?

OBJECTIVE

Several genome-wide scans have revealed an osteoarthritis (OA)-susceptibility locus on chromosome 11q in close proximity to the low-density lipoprotein receptor-related protein 5 (LRP5) gene. The regulation of bone mass is under the control of LRP5 and since increased bone mass is thought to play a role in the pathology of OA we examined LRP5 polymorphisms and haplotypes to determine if variants of this locus may predispose to OA.

METHODS

A UK control population of 187 individuals was examined for five commonly occurring polymorphisms against a cohort of 158 DNAs from patients with knee OA. An additional UK cohort was also examined to confirm the findings of the first study; this second group consisted of 110 knee OA patients. Haplotype analysis was also performed on patient and control DNAs.

RESULTS

A study of individual polymorphisms revealed no association with disease. However, haplotype analysis of the initial two populations revealed a common haplotype (C-G-C-C-A) that provided a 1.6-fold increased risk of OA (P(c)=0.021). The data obtained from the second cohort confirmed the initial findings, with a 1.6-fold increased risk observed within this cohort for the risk haplotype (P=0.012).

CONCLUSIONS

A closer investigation of LRP5 and associated Wnt signalling molecules in OA will help determine disease aetiology and the development of novel treatment strategies that specifically target the bone compartment.

Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review

OBJECTIVE

To compare the efficacy of aerobic walking and home based quadriceps strengthening exercises in patients with knee osteoarthritis.

METHODS

The Medline, Pubmed, EMBASE, CINAHL, and PEDro databases and the Cochrane controlled trials register were searched for randomised controlled trials (RCTs) of subjects with knee osteoarthritis comparing aerobic walking or home based quadriceps strengthening exercise with a non-exercise control group. Methodological quality of retrieved RCTs was assessed. Outcome data were abstracted for pain and self reported disability and the effect size calculated for each outcome. RCTs were grouped according to exercise mode and the data pooled using both fixed and random effects models.

RESULTS

35 RCTs were identified, 13 of which met inclusion criteria and provided data suitable for further analysis. Pooled effect sizes for pain were 0.52 for aerobic walking and 0.39 for quadriceps strengthening. For self reported disability, pooled effect sizes were 0.46 for aerobic walking and 0.32 for quadriceps strengthening.

CONCLUSIONS

Both aerobic walking and home based quadriceps strengthening exercise reduce pain and disability from knee osteoarthritis but no difference between them was found on indirect comparison.

Does increasing the grades of the knee osteoarthritis line drawing atlas alter its clinimetric properties?

OBJECTIVES

To (a) develop further logically derived line drawing atlases (LDAs) for grading radiographic knee osteoarthritis (OA); and (b) determine which is superior using metrological criteria.

METHODS

A series of LDAs (-3 to +3, -4 to +4, and -5 to +5) were produced by (a) incorporating additional grades for osteophyte and joint space width (JSW) above the 0-3 pilot LDA, over an equivalent range of disease; and (b) adding negative grades for JSW. 121 sets of bilateral knee radiographs (standing, anteroposterior plus flexed skyline), plus serial views of 68 tibiofemoral joints (TFJs) and 36 patellofemoral joints were scored twice by one observer for each LDA. Minimum JSW of 50 radiograph sets was directly measured and awarded a categorical grade dependent upon the boundaries of each LDA grade. Time taken to grade 30 randomly selected knee radiograph sets was measured.

RESULTS

Intraobserver reproducibility was similar for all LDAs, (weighted kappa: JSW = 0.85-0.87; osteophyte = 0.77-0.79), with no deterioration with increasing grades. Criterion validity favoured the -5 to +5 LDA, which was also quickest to use. All atlases showed similar responsiveness (standardised response mean: medial TFJ JSW = 0.78-0.83; medial femoral osteophyte = 0.61-0.73), with most sites compromised by small sample size, little change in score, and high variation between subjects.

CONCLUSIONS

A set of LDAs was created illustrating the full range of normality/abnormality likely to be encountered in a community study of knee pain or OA. Despite superior validity and equivalent reproducibility, improved responsiveness of the -5 to +5 LDA was not confirmed.

The influence of step and ramp type protocols on the attainment of peak physiological responses during arm crank ergometry

The present study examined the impact of two exercise protocols on the attainment of peak physiological responses during arm crank ergometry (ACE). Fourteen physically active, although non-specifically trained male subjects completed two V.O (2) peak tests using an electrically braked arm ergometer (Lode Angio, Groningen, Netherlands). The tests consisted of a stepwise or rampwise increase in external workload. The order of tests was randomised and each test was separated by at least two days. Respiratory data were collected continuously using an on-line gas analysis system with sample time set at 30 s. Fingertip capillary blood samples ( approximately 20 microL) were collected at volitional exhaustion and at minute intervals for 7 min of passive recovery for the determination of peak whole blood lactate concentration. Time on the test (T (lim); s), peak minute power (PMP; W), and total work done (TWD; kJ) were also recorded. In addition to determining systematic bias using separate independent t-tests, the level of agreement was also examined by way of calculating the 95 % limits of agreement. Sub-maximal values of V.O (2), V.E, and HR were similar (p > 0.05) between test when the amount of external work completed was taken into consideration. There was no systematic bias (p > 0.05) for mean (+/- s) peak values of V.O (2) (3.12 [0.37] vs. 3.04 [0.38] L . min (-1)) or any other parameter between the step and ramp tests, respectively. Mean values of T (lim), PMP, and TWD were also similar (p > 0.05) between tests. However, the level of agreement for peak values of all test parameters was low. It is therefore concluded that while either test can be considered as being suitable for the purpose of eliciting V.O (2) peak and other physiological responses using ACE, they should not be used interchangeably for the purpose of assessing parameters linked to the aerobic capacity of the upper-body.

Relationship between Heberden's nodes and underlying radiographic changes of osteoarthritis

OBJECTIVE

To determine whether clinically determined Heberden's nodes (HN) and Bouchard's nodes (BN) are associated with underlying individual radiographic changes of osteoarthritis (OA).

METHODS

232 index patients with symptomatic large joint and/or hand OA, and 257 of their first degree relatives were included. HN were graded 0-2; BN were scored as present/absent. Joint space narrowing (JSN) and osteophyte (OST) were each scored 0-3 using the OARSI atlas. A weighted kappa test was used to examine intraobserver reproducibility. Odds ratio (OR) was estimated for the relationship between nodes and associated JSN and OST.

RESULTS

The adjusted OR of HN for underlying JSN in the same digit was 1.72 (95% CI 1.47 to 2.02), whereas for OST it was higher at 5.15 (95% CI 4.37 to 6.08). A similar trend was seen with BN and underlying OA, with OST having a higher OR (OR = 2.98, 95% CI 2.55 to 3.47) than JSN (OR = 1.62, 95% CI 1.37 to 1.91).

CONCLUSION

There is a positive relationship between HN/BN and underlying radiographic changes of OA, especially OST. Nodes do appear to link pathologically to OA in interphalangeal joints.

EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To develop evidence based recommendations for the management of hip osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale.

RESULTS

Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.