Hand osteoarthritis phenotypes based on a biopsychosocial approach, and their associations with cross-sectional and longitudinal pain

OBJECTIVE

Hand osteoarthritis (OA) pain is characterized as heterogeneous and multifactorial. Differences in pain may be explained by underlying phenotypes, which have not been previously explored.

DESIGN

Latent class analysis determined classes of participants with hand OA from the Nor-Hand study baseline examination (2016-17) based on a biopsychosocial framework. Outcomes were hand and overall bodily pain intensity (Numeric Rating Scale, 0-10) at baseline and follow-up (2019-21), The relations of the classes to pain outcomes at baseline, follow-up, and change over time were analysed in separate models by linear regression, using the overall healthiest class as reference.

RESULTS

Five classes differing in radiographic hand OA burden and OA burden in the lower extremities by ultrasound, demographic factors, psychosocial burden and pain sensitization was identified. Persons with the least severe OA but higher burden of biopsychosocial factors reported the most hand pain (beta 3.65, 95% CI 2.53, 4.75). Pain was less pronounced in persons with the most severe hand OA but low burden of biopsychosocial factors (beta 1.03, 95% CI 0.41, 1.65). Results were similar for overall bodily pain and at follow-up. Changes in pain were small, but the association between a separate class defined by higher levels of biopsychosocial burden and pain changes was significant.

CONCLUSION

The five hand OA phenotypes were associated with pain at baseline and 3.5 years later. The phenotype with the least OA severity, but higher burden of biopsychosocial factors reported more pain than the phenotype with the most severe OA, reflecting the symptom-structure discordance of the hand OA pain experience.

Delivery of a quality improvement program in team-based rehabilitation for patients with rheumatic and musculoskeletal diseases: a mixed methods study

PURPOSE

To investigate how a quality improvement program (BRIDGE), designed to promote coordination and continuity in rehabilitation services, was delivered and perceived by providers in routine practice for patients with rheumatic and musculoskeletal diseases.

METHODS

A convergent mixed methods approach was nested within a stepped-wedge, randomized controlled trial. The intervention program was developed to bridge gaps between secondary and primary healthcare, comprising the following elements: motivational interviewing; patient-specific goal setting; written rehabilitation-plans; personalized feedback on progress; and tailored follow-up. Data from health professionals who delivered the program were collected and analyzed separately, using two questionnaires and three focus groups. Results were integrated during the overall interpretation and discussion.

RESULTS

The program delivery depended on the providers' skills and competence, as well as on contextual factors in their teams and institutions. Suggested possibilities for improvements included follow-up with sufficient support from next of kin and external services, and the practicing of action and coping plans, standardized outcome measures, and feedback on progress.

CONCLUSIONS

Leaders and clinicians should discuss efforts to ensure confident and qualified rehabilitation delivery at the levels of individual providers, teams, and institutions, and pay equal attention to each component in the process from admission to follow-up.

Reduced sleep quality is highly prevalent and associated with physical function and cardiorespiratory fitness in patients with axial spondyloarthritis: a cross-sectional study

OBJECTIVES

To assess sleep quality, and its associations with physical function, cardiorespiratory fitness, and spinal mobility, in axial spondyloarthritis (axSpA) patients.

METHOD

Baseline data from the Exercise for Spondyloarthritis trial were used. Assessments included [Pittsburgh Sleep Quality Index (PSQI), 0-21, 21 = worst], performance-based physical function [Ankylosing Spondylitis Performance Index (ASPI), seconds, higher = worse], patient-reported physical function [Bath Ankylosing Spondylitis Functional Index (BASFI), 0-10, 10 = worst], cardiorespiratory fitness [peak oxygen uptake (V O2peak), mL/kg/min, lower = worse], and spinal mobility [Bath Ankylosing Spondylitis Metrology Index (BASMI), 0-10, 10 = worst]. Associations were examined in separate models using multiple linear regression.

RESULTS

Ninety-nine patients with axSpA were included, 53% female, mean age 46 years, and 72% with high disease activity (ASDAS-C-reactive protein ≥ 2.1), of whom 84 (85%) had reduced sleep quality. Sleep disturbance was most frequently reported (65%), followed by poor subjective sleep quality (53%), daytime dysfunction (41%), and increased sleep latency (41%). Positive associations were observed between PSQI and ASPI [β = 0.10, 95% confidence interval (CI) 0.01, 0.19] and PSQI and BASFI (β = 0.85, 95% CI 0.51, 1.20), and there was an inverse association between PSQI and V O2peak (β = -0.14, 95% CI -0.27, -0.01), adjusted for age and sex. There was no association between PSQI and BASMI.

CONCLUSION

Reduced sleep quality was common in axSpA patients with moderate to high disease activity. Better sleep quality was associated with better physical function and higher cardiorespiratory fitness. There was no association between sleep quality and spinal mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02356874.

Effects of Analgesics on Self-Reported Physical Function and Walking Ability in People With Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Hip and knee osteoarthritis are among the leading causes of global disability, and one of the main aims of the management is to improve physical function. The objective of this review was to investigate the effect of analgesics on physical function (self-reported physical function and walking ability).

METHODS

A systematic review and meta-analysis of the findings were performed. Randomized controlled trials investigating the effect of analgesics on self-reported physical function and walking ability were included. Analgesics were orally administered acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), or opioids. Data were pooled in a random-effects model, and the standardized mean difference (SMD) with 95% CI was calculated (SMDs: 0.2-0.4 = small, 0.5-0.7 = medium, and ≥0.8 = large effect sizes). The quality of the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A total of 1454 studies were identified, of which 33 were included. On self-reported physical function, the results showed low- to moderate-quality evidence for a small beneficial effect of acetaminophen (SMD = -0.13 [95% CI = -0.26 to 0.00]), NSAIDs (SMD = -0.32 [95% CI = -0.37 to -0.27]), or opioids (SMD = -0.20 [95% CI = -0.32 to -0.09]). There was moderate-quality evidence for a small effect of NSAIDs on pain during walking (SMD = -0.34 [95% CI = -0.45 to -0.23]).

CONCLUSION

In people with hip or knee osteoarthritis, there was low- to moderate-quality evidence for small beneficial effects of analgesics on physical function and walking ability.

IMPACT

Analgesics may improve physical function by reducing pain during exercise and walking.

Effect of high-intensity interval training in physiotherapy primary care for patients with inflammatory arthritis: the ExeHeart randomised controlled trial

OBJECTIVES

To assess the effect of high-intensity interval training (HIIT) delivered in physiotherapy primary care on the primary outcome of cardiorespiratory fitness (CRF) in patients with inflammatory arthritis (IA). Additionally, to explore the effects of HIIT on secondary outcomes, including cardiovascular disease (CVD) risk factors and disease activity.

METHODS

Single-blinded randomised controlled trial with 60 patients randomly assigned to either a control group receiving usual care or an exercise group receiving usual care and 12 weeks of individualised HIIT at 90%-95% peak heart rate. Outcomes were assessed at baseline, 3 months and 6 months post baseline and included CRF measured as peak oxygen uptake (VO2peak), classic CVD risk factors, disease activity, anthropometry and patient-reported physical activity, pain, fatigue, disease impact and exercise beliefs and self-efficacy.

RESULTS

Intention-to-treat analysis demonstrated a significant between-group difference in VO2peak at 3 months (2.5 mL/kg/min, 95% CI 0.9 to 4.0) and 6 months (2.6 mL/kg/min, 95% CI 0.8 to 4.3) in favour of the exercise group. A beneficial change in self-reported physical activity in favour of the exercise group was observed at 3 and 6 months. The HIIT intervention was well-tolerated with minimal adverse events and no apparent impact on disease activity. Differences in secondary outcomes related to CVD risk factors, disease impact, pain, fatigue and exercise beliefs and self-efficacy were generally small and non-significant.

CONCLUSION

After 12 weeks of supervised HIIT delivered in physiotherapy primary care, patients with IA demonstrated a favourable improvement in CRF, with sustained effects at 6-month follow-up.

TRIAL REGISTRATION NUMBER

NCT04922840.

Patient Involvement in the Rehabilitation Process Is Associated with Improvement in Function and Goal Attainment: Results from an Explorative Longitudinal Study

The objective was to explore the associations between patient involvement in the rehabilitation process and improvements in function and goal attainment in the first year after rehabilitation. The longitudinal multicenter study RehabNytte provided data from participants who had been referred to rehabilitation (n = 2113). Quality indicator (QI) pass rates (% yes) were used to assess patient involvement in the rehabilitation process. The Patient-Specific Functional Scale (PSFS) (10 = best possible) was used to assess function. The outcome QI on goal achievement (response options of yes/no) was used to assess goal attainment. Logistic regression and paired sample t-tests were used to examine associations and mean changes in function from rehabilitation admission up to 3, 6, and 12 months. Most participants (95%) were involved in goal-setting, which was positively associated with younger age (OR 0.97, 95% CI 0.95-0.99) and female sex (OR 1.87, 95% CI 1.15-3.02). Function improved over the follow-up period, with greater improvements in the active goal-setting group. Being involved in goal planning almost tripled the odds of goal attainment (OR 2.78, 95% CI 1.60-4.83) and involvement in the rehabilitation plan almost doubled it (OR 1.99, 95% CI 1.41-2.81). Most participants were involved in rehabilitation goal-setting/planning and being involved was associated with beneficial functional outcomes and greater goal attainment.

Cardiovascular organ damage in relation to hypertension status in patients with ankylosing spondylitis

PURPOSE

Hypertension is a major cardiovascular (CV) risk factor in ankylosing spondylitis (AS) patients. Less is known about the prevalence of CV organ damage in relation to hypertension status in AS patients.

MATERIALS AND METHODS

CV organ damage was assessed by echocardiography, carotid ultrasound and pulse wave velocity (PWV) by applanation tonometry in 126 AS patients (mean age 49 ± 12 years, 39% women) and 71 normotensive controls (mean age 47 ± 11 years, 52% women). CV organ damage was defined as presence of abnormal left ventricular (LV) geometry, LV diastolic dysfunction, left atrial (LA) dilatation, carotid plaque or high pulse wave velocity (PWV).

RESULTS

Thirty-four percent of AS patients had hypertension. AS patients with hypertension were older and had higher C-reactive protein (CRP) levels compared to AS patients without hypertension and controls (p < 0.05). The prevalence of CV organ damage was 84% in AS patients with hypertension, 29% in AS patients without hypertension and 30% in controls (p < 0.001). In multivariable logistic regression analyses, having hypertension was associated with a fourfold increased risk of CV organ damage independent of age, presence of AS, gender, body mass index, CRP, and cholesterol (odds ratio (OR) 4.57, 95% confidence interval (CI) 1.53 to 13.61, p = 0.006). In AS patients, presence of hypertension was the only covariable significantly associated with presence of CV organ damage (OR 4.40, 95% CI 1.40 to 13.84, p = 0.011).

CONCLUSIONS

CV organ damage in AS was strongly associated with hypertension, pointing to the importance of guideline-based hypertension management in AS patients.

Criterion Validity and Responsiveness of Estimated Cardiorespiratory Fitness Models in Patients with Inflammatory Joint Disease

Cardiorespiratory fitness (CRF) is an excellent marker of overall health. This study aimed to assess criterion validity and responsiveness of estimated CRF models (eCRF) in patients with inflammatory joint disease (IJD). CRF was measured directly as peak oxygen uptake (VO2peak) by a Cardiopulmonary Exercise Test (CPET), while one generic eCRF model (eCRFGEN) and two disease-specific eCRF models (eCRFALT and eCRFPGA) were used to estimate CRF at baseline and after 3 months in 55 Norwegian patients with IJD. Moderate correlations were observed between eCRFGEN, eCRFALT, eCRFPGA, and VO2peak at baseline (ICC 0.60, 0.64 and 0.62, respectively) and 3 months (ICC 0.62, 0.65 and 0.57, respectively). All eCRF models overestimated measured VO2peak, and there was large variability in agreement of individual measurements at baseline and at 3 months. Weak correlations were observed for responsiveness of eCRFGEN (ICC 0.39), eCRFALT (ICC 0.40) and eCRFPGA (ICC 0.39). Mean differences between change in eCRF models and change in VO2peak were small, but the wide limits of agreement exceeded the pre-defined clinically acceptable margins. The eCRF models possessed adequate ability to detect ≥3.5 mL/kg/min improvement in VO2peak. eCRF may suffice for group-level assessment, but caution is advised when applying eCRF to individual patients with IJD.

Comorbidities in people with hand OA and their associations with pain severity and sensitization: Data from the longitudinal Nor-Hand study

Objective

To determine whether the comorbidity burden and co-existing comorbidities are cross-sectionally and/or longitudinally associated with pain and pain sensitization in a cohort study of people with hand OA.

Design

We examined whether comorbidity burden and individual comorbidities based on the self-administered Comorbidity Index (range: 0-42) at baseline were associated with pain outcomes at baseline and 3 years follow-up. Pain outcomes included hand and overall bodily pain (range: 0-10) as well as pressure pain thresholds at the tibialis anterior muscle (kg/cm²) and temporal summation (distal radioulnar joint) as measures of central pain sensitization. We performed linear regression analyses adjusted for age, sex, body mass index, physical exercise and education.

Results

We included 300 and 196 participants in cross-sectional and longitudinal analyses, respectively. Using baseline data, the burden of comorbidities was associated with greater pain in hands (beta ​= ​0.61, 95% CI 0.37, 0.85) and overall body (beta ​= ​0.60, 95% CI 0.37, 0.87). Similar strength of associations was found between comorbidity burden (baseline) and follow-up pain. Among the individual comorbidities, back pain and depression were associated with nearly one unit higher pain score in hands and overall body at both baseline and follow-up. Only back pain was related to lower pressure pain thresholds at follow up (beta ​= ​-0.24, 95% CI -0.50, -0.001).

Conclusion

People with hand OA and greater comorbidity burden, co-existing back pain or depression reported greater pain severity than their counterparts, also 3 years later. These results acknowledge the relevance of accounting for comorbidities in the pain experience in people with hand OA.

Adherence to a Web-based Exercise Programme: A Feasibility Study Among Patients with Hip or Knee Osteoarthritis

OBJECTIVES

To describe adherence to a 12-week web-based aerobic exercise programme, to compare characteristics between those who adhere or not, and to identify barriers for exercising in patients with hip or knee osteoarthritis.

DESIGN

Single-arm feasibility study.

SUBJECTS

Patients with hip or knee osteoarthritis in specialist healthcare, age 40-80 years, and not candidates for joint surgery.

METHODS

Adherence to a 12-week exercise programme was defined as having completed ≥ 2 exercise sessions a week for at least 8 weeks. Baseline differences between adherent and non-adherent groups in demographics, symptoms, disability, physical activity and fitness were assessed using Mann-Whitney U or χ2 tests. Reasons for not completing exercise sessions were reported in weekly diaries.  Results: A total of 29 patients (median age 64 years, 72% female) were included. Median baseline pain (numerical rating scale 0-10) was 5. Fifteen patients adhered to the exercise programme, 14 did not. Non-adherent patients were less active (p = 0.032) and had lower cardiorespiratory fitness (p = 0.031). The most frequently reported barrier to exercising was sickness. Less than 10% reported pain as a barrier.

CONCLUSION

Half of the patients with hip or knee osteoarthritis adhered to the digitally delivered exercise programme and the most frequently reported barrier for adherence was sickness, while less than 10% reported pain as a reason for not exercising.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04084834. The Regional Committee for Medical and Health Research Ethics South-East, 2018/2198.

Patient engagement in the development and delivery of healthcare services: a systematic scoping review

BACKGROUND

Patient engagement (PE) is required to improve future healthcare services. PE in the development and delivery of healthcare services is likely to be complex but is scarcely described.

OBJECTIVES

The objective of this scoping review was to summarise primary studies on mesolevel PE regarding structure, process and outcomes. More specifically, the aim was to explore barriers and facilitators to successful PE, how persons are engaged in the process and summarise reported consequences.

METHOD

A systematic scoping review was conducted, searching the MEDLINE, EMBASE, Cochrane and PsycINFO databases. Primary studies, published between 7 July 2005 and 4 October 2022, were considered for inclusion. Two reviewers extracted data about PE (eg, attributes of PE settings, facilitators and barriers, and outcomes to PE) and the first author coded the extracted data into structural, processual and outcome themes.

RESULTS

Of 8588 identified records, 37 studies were eligible. Most of the included studies were conducted in Europe (n=19; 51%) and North America (n=13; 35%). Structures that ensure sufficient stakeholder representativeness and PE knowledge through education may facilitate the PE process further, regardless of the environmental setting. Interpersonal relationships with uneven power dynamics were reported as noteworthy processual barriers to meaningful PE, while clearly described roles and tasks were reported as important facilitators. In contrast to hard outcomes with operationalised PE effects, the most noteworthy outcomes of PE were reported as soft processual consequences such as patient representatives improving their self-esteem and feeling valued.

CONCLUSIONS

Unfortunately, there is a dearth of studies exploring hard and operationalised PE outcomes on healthcare services and patients receiving healthcare. The PE process may be facilitated by dedicated finances to PE education and by ensuring sufficient stakeholder representativeness.

Associations between cardiovascular risk factors, disease activity and cardiorespiratory fitness in patients with inflammatory joint disease: a cross-sectional analysis

BACKGROUND

Inflammatory joint diseases (IJD) are accompanied by an increased risk of cardiovascular disease (CVD). Cardiorespiratory fitness (CRF) is a modifiable CVD risk factor and low levels of CRF associate with an elevated CVD risk. This study aimed to investigate the associations between CVD risk factors, disease activity and CRF in patients with IJD and to explore differences between patients with normal versus low levels of CRF.

METHODS

CRF was measured as peak oxygen uptake (VO_2peak) with a cardiopulmonary exercise test. Participants were also evaluated for: Body composition, blood pressure, blood lipids, inflammatory markers and disease activity. Patient-reported use of cigarettes/snuff, medication, disease duration, pain, fatigue, CVD history, habitual physical activity and exercise beliefs and self-efficacy were collected by questionnaire. Cross-sectional associations between CVD risk factors, disease-related factors and CRF were analyzed by multiple linear regression. CRF was categorized to normal CRF (VO_2peak ≥ 80%) or low CRF (VO_2peak < 80%) according to age- and gender-stratified reference data. Differences in demographic, CVD and disease-related factors between patients with normal versus low CRF were explored.

RESULTS

In 60 Norwegian patients with IJD [34 females, age 59 years (IQR: 52-63)], mean VO_2peak was 30.2 (± 6.9) mL/kg/min, corresponding to 83% (± 18) of normative reference values. Age (coefficient: - 0.18 years, p = 0.01) and fat mass (coefficient: - 0.67 %, p < 0.001) were inversely associated with CRF, while physical activity index (coefficient: 0.13 points, p = 0.05) was positively associated with CRF (R² = 0.66). There were no significant associations between CRF, classical CVD risk factors and disease-related variables. Compared to patients with low CRF (n = 30), patients with normal CRF (n = 30) had higher peak oxygen uptake (+ 9.4 mL/kg/min, p < 0.001), high-density lipoprotein cholesterol (+ 0.5 mmol L^-1, p < 0.001), and exercise self-efficacy (+ 6.9, p < 0.01) as well as lower fat mass (- 8.7%, p < 0.001), resting heart rate (- 8.0 beats/min, p < 0.01) and triglycerides (- 0.5 mmol L^-1, p < 0.01).

CONCLUSIONS

In this sample of IJD-patients, age, fatmass and physical activity level were associated with CRF. CRF was lower than reference values and patients with normal CRF presented with a more favorable health profile. There is a continued need for exercise interventions to improve CRF in patients with IJD.

TRIAL REGISTRATION

NCT04922840.

Suitability of the animated activity questionnaire for use as computer adaptive test: establishing the AAQ-CAT

PURPOSE

The animated activity questionnaire (AAQ) is a computer-based measure of activity limitations. To answer a question, patients choose the animation of a person performing an activity that matches their own level of limitation. The AAQ has not yet been tested for suitability to be applied as computer-adaptive test (CAT). Thus, the objective of this study was to develop and evaluate an AAQ-based CAT to facilitate the application of the AAQ in daily clinical care.

METHODS

Patients (n = 1408) with hip/knee osteoarthritis from Brazil, Denmark, France, The Netherlands, Norway, Spain, and the UK responded to all 17 AAQ items. Assumptions of item-response theory (IRT) modelling were investigated. To establish item parameters for the CAT, a graded response model was estimated. To evaluate the performance of post-hoc simulated AAQ-based CATs, precision, test length, and construct validity (correlations with well-established measures of activity limitations) were evaluated.

RESULTS

Unidimensionality (CFI = 0.95), measurement invariance (R²-change < 2%), and IRT item fit (S-X² p > .003) of the AAQ were supported. Performing simulated CATs, the mean test length was more than halved (≤ 8 items), while the range of precise measurement (standard error ≤ 0.3) was comparable to the full AAQ. The correlations between original AAQ scores and three AAQ-CAT versions were ≥ 0.95. Correlations of AAQ-CAT scores with patient-reported and performance measures of activity limitations were ≥ 0.60.

CONCLUSION

The almost non-verbal AAQ-CAT is an innovative and efficient tool in patients with hip/knee osteoarthritis from various countries, measuring activity limitations with lower respondent burden, but similar precision and construct validity compared to the full AAQ.

Organisation, influence, and impact of patient advisory boards in rehabilitation institutions-an explorative cross-sectional study

Background

Patient participation is highlighted as an important facilitator for patient-centered care. Patient participation organised as patient advisory boards (PABs) is an integral part of health care institutions in Norway. More knowledge is needed on how PAB representatives experience patient engagement (PE) with regard to organisation, influence, and impact. The objective was to describe how PAB representatives experience their tasks, roles, and impact on decision-making processes and service delivery in the setting of rehabilitation institutions.

Methods

PAB representatives recruited from rehabilitation institutions completed the Norwegian version of the generic Public and Patient Engagement evaluation tool (Norwegian abbreviation EBNOR). EBNOR is tested for reliability and validity with good results and comprises 35 items within four main domains, policies and practices, participatory culture, collaboration, and influence and impact that provide responses about PE-levels. The domain items are scored from “strongly disagree” to “strongly agree” on a five-point scale, in addition to a don’t know category. Items in the domain “influence and impact” are scored from “never” to “all of the time” on a four-point scale. Categorical data were summarized using frequencies and percentages, and response categories were collapsed into three PE-levels: barrier, intermediate, and facilitating level. Free-text responses were analysed according to principles of manifest content analysis, summed up, and used to elaborate the results of the scores.

Results

Of the 150 contacted PAB representatives, 47 (32%) consented to participate. The results showed that approximately 75% agreed that the organisation as a whole was strengthened as a result of patient participation. Four out of five domains were scored indicating a facilitating level; policies and practices (53%), participatory culture (53%), collaboration and common purpose (37%), and final thoughts (63%). The modal score in the domain influence and impact was in the intermediate PE-level (44%). Of a total of 34 codes from free text analyses, barriers to PE were coded 26 times, and PE facilitators were coded 8 times.

Conclusions

The findings indicate that most PAB representatives are satisfied with how rehabilitation institutions organise their PAB, but they still experience their impact as limited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05678-y.

The AktiWeb study: feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis

Background

Patient organisations may be an under-utilised resource in follow-up of patients requiring long-term exercise as part of their disease management. The purpose of this study was to explore the feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis (OA).

Methods

In this pre–post feasibility study, patients aged 40–80 years with hip and/or knee OA were recruited from Diakonhjemmet Hospital. The 12-week intervention was delivered through a patient organisation’s digital platform. Feasibility was evaluated by proportion of eligible patients enrolled, proportion of enrolled patients who provided valid accelerometer data at baseline, and proportion completing the cardiorespiratory exercise test according to protocol at baseline and completed follow-up assessments. Patient acceptability was evaluated for website usability, satisfaction with the initial exercise level and comprehensibility of the exercise program. Change in clinical outcomes were assessed for physical activity, cardiorespiratory fitness and patient-reported variables.

Results

In total, 49 eligible patients were identified and 35 were enrolled. Thirty (86%) of these attended baseline assessments and provided valid accelerometer data and 18 (51%) completed the maximal cardiorespiratory exercise test according to protocol. Twenty-two (63%) patients completed the follow-up questionnaire, and they rated the website usability as ‘acceptable’ [median 77.5 out of 100 (IQR 56.9, 85.6)], 19 (86%) reported that the initial exercise level was ‘just right’ and 18 (82%) that the exercise program was ‘very easy’ or ’quite easy’ to comprehend. Improvement in both moderate to vigorous physical activity (mean change 16.4 min/day; 95% CI 6.9 to 25.9) and cardiorespiratory fitness, VO_2peak (mean change 1.83 ml/kg/min; 95% CI 0.29 to 3.36) were found in a subgroup of 8 patients completing these tests. Across all patient-reported outcomes 24–52% of the patients had a meaningful improvement (n = 22).

Conclusion

A web-based exercise program delivered by a patient organisation was found to be feasible and acceptable in patients with hip and/or knee OA.

Trial registration

ClinicalTrials.gov, NCT04084834 (registered 10 September 2019). The Regional Committee for Medical and Health Research Ethics south-east, 2018/2198. URL: Prosjekt #632074 - Aktiv med web-basert støtte. - Cristin (registered 7 June 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01110-3.

Instrument selection for the ASAS core outcome set for axial spondyloarthritis

OBJECTIVES

To define the instruments for the Assessment of SpondyloArthritis international Society-Outcomes Measures in Rheumatology (ASAS-OMERACT) core domain set for axial spondyloarthritis (axSpA).

METHODS

An international working group representing key stakeholders selected the core outcome instruments following a predefined process: (1) identifying candidate instruments using a systematic literature review; (2) reducing the list of candidate instruments by the working group, (3) assessing the instruments' psychometric properties following OMERACT filter 2.2, (4) selection of the core instruments by the working group and (5) voting and endorsement by ASAS.

RESULTS

The updated core set for axSpA includes seven instruments for the domains that are mandatory for all trials: Ankylosing Spondylitis Disease Activity Score and Numerical Rate Scale (NRS) patient global assessment of disease activity, NRS total back pain, average NRS of duration and severity of morning stiffness, NRS fatigue, Bath Ankylosing Spondylitis Function Index and ASAS Health Index. There are 9 additional instruments considered mandatory for disease-modifying antirheumatic drugs (DMARDs) trials: MRI activity Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joints and SPARCC spine, uveitis, inflammatory bowel disease and psoriasis assessed as recommended by ASAS, 44 swollen joint count, Maastricht Ankylosing Spondylitis Enthesitis Score, dactylitis count and modified Stoke Ankylosing Spondylitis Spinal Score. The imaging outcomes are considered mandatory to be included in at least one trial for a drug tested for properties of DMARD. Furthermore, 11 additional instruments were also endorsed by ASAS, which can be used in axSpA trials on top of the core instruments.

CONCLUSIONS

The selection of the instruments for the ASAS-OMERACT core domain set completes the update of the core outcome set for axSpA, which should be used in all trials.

The Public and Patient Engagement Evaluation Tool: forward-backwards translation and cultural adaption to Norwegian

Background

Patient engagement is recommended for improving health care services, and to evaluate its organisation and impact appropriate, and rigorously evaluated outcome measures are needed.

Methods

Interviews (N = 12) were conducted to assess relevance of the Canadian Public and Patient Engagement Evaluation Tool (PPEET) in a Norwegian setting were performed. The tool was translated, back translated, and assessed following cognitive interviews (N = 13), according to the COSMIN checklist. Data quality was assessed in a cross-sectional survey of patient advisory board members from different rehabilitation institutions (N = 47).

Results

Interviews with patient board representatives confirmed the relevance of the PPEET Organisational questionnaire in a Norwegian setting and contributed five additional items. Translation and back translation of the original PPEET showed no major content differences. Differences in vocabulary and sentence structure were solved by discussion among the translators. Comments from cognitive interviews mainly related to the use of different synonyms, layout, and minor differences in semantic structure. Results of the cross-sectional survey support the data quality and construct validity of PPEET items, including 95 score comparisons where 76 (80%) were as hypothesized.

Conclusions

The PPEET Organisational questionnaire has been thoroughly translated and tested, and the resulting Evalueringsverktøy for Brukermedvirkning (EBNOR) has adequate levels of comprehensibility and content validity. Further testing for measurement properties is recommended, but given these results, the EBNOR should be considered for assessing patient engagement in a Norwegian health care organisational context.

POS0090-PARE ORGANIZATION, INFLUENCE, AND IMPACT OF PATIENT ADVISORY BOARD REPRESENTATION IN PRIVATE REHABILITATION INSTITUTIONS – AN EXPLORATIVE CROSS-SECTIONAL STUDY

Background

Patient participation (PP) organised as patient advisory boards (PABs) is a statutory part of health care institutions in Norway (1). There is limited agreement on how to engage PABs in a meaningful manner (2). More knowledge on how PAB representatives experience patient engagement (PE) is needed.

Objectives

To explore how PAB representatives engage in PABs with regard to organisation, influence, and impact on decision-making processes and service delivery.

Methods

PAB representatives recruited from rehabilitation institutions, representing all four health regions in Norway completed a PE evaluation tool. The tool is tested for reliability and content validity with good results and comprises 35 items including four main domains policies and practices, participatory culture, collaboration, and influence and impact that provided responses about PE-levels (3). Categorical data were summarized to modal scores using frequencies and percentages, and response categories were collapsed from five to three. The collapsed categories were divided into PE-levels; barrier, intermediate, and facilitator (Table 1). Free-text responses were analysed according to principles of manifest content analysis, summed up, and used to complete the results of the scores. Free text responses were analysed using Quirkos version 2.4.1.

Results

Of the 150 contacted PAB representatives, 47 (32%) responded. PAB representatives’ mean age was 60.5 (min-max 30 - 80), 62% were female and a majority (81%) had prior experience with PP. The results showed that 75% of the participants agreed that patient-centered care was strengthened as a result of PE. Three out of four main domains scored indicating a facilitating PE-level (Table 1). The domain, influence and impact scored with an intermediate PE-level. Regarding influence and impact, half of the participants did not know if PE input had influenced management decisions, and 60% had rarely identified any PE contributions. The results from free text analyses showed that PE was coded as a facilitator seven times, and as a barrier to PE 26 times. The most frequent barrier was exclusion of PAB (13 codes), and the most coded facilitator was inclusion of PAB (3 codes).

Conclusion

Findings indicate that PAB representatives are satisfied with how rehabilitation institutions organise PABs. Unclear adherence to the values and principles of PP may hinder influence and visibility from PE contributions.

References

[1](The Norwegian Directorate of Health) Helsedirektoratet. Veileder om oppfølging av personer med store og sammensatte behov [online document]. Oslo: Helsedirektoratet; 2017 [updated 11.02.2019; cited 2021 20.09]. Available from: https://www.helsedirektoratet.no/veiledere/oppfolging-av-personer-med-store-og-sammensatte-behov

[2]Scholl, I., et al., Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them - a scoping review. Implement Sci, 2018. 13(1): p. 40.

[3]Garratt A, Sagen J, Børøsund E, Varsi C, Kjeken I, Dagfinrud H, et al. The Public and Patient Engagement Evaluation Tool: Forward-backwards translation and cultural adaption to Norwegian BMC Musculoskelet Disord. Submitted.

Table 1

Acknowledgements

The authors acknowledge all participants who took part in this study, VIRKE and UNICARE rehabilitation organisations for cooperation, and DAM Foundation for founding.

Disclosure of Interests

None declared

Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study

Background

The quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs).

Methods

In this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. We measured perceived quality of rehabilitation by 11 process indicators that cover the domains of initial assessments, patient participation and individual goal-setting, and individual follow-up and coordination across levels of health care. The patients responded “yes” or “no” to each indicator. Scores were calculated as pass rates (PRs) from 0 to 100% (best score). Clinical outcomes were goal attainment (Patient-Specific Functional Scale), physical function (30 s sit-to-stand test), and health-related quality of life (EuroQoL 5D-5L). Associations between patient-reported quality of care and each outcome measure at 7 months was analysed by linear mixed models.

Results

A total of 293 patients were enrolled in this study (mean age 52 years, 76% female). Primary diagnoses were inflammatory rheumatic disease (64%), fibromyalgia syndrome (18%), unspecific neck, shoulder, or low back pain (8%), connective tissue disease (6%), and osteoarthritis (4%). The overall median PR for the process indicators was 73% (range 11–100%). The PR was lowest (median 40%) for individual follow-up and coordination across levels of care. The mixed model analyses showed that higher PRs for the process indicators were not associated with improved goal attainment or improved physical function or improved health-related quality of life.

Conclusions

The quality of rehabilitation processes was not associated with important clinical outcomes. An implication of this is that measuring only the outcome dimension of quality may result in incomplete evaluation and monitoring of the quality of care, and we suggest using information from both the structure, process, and outcome dimensions to draw inferences about the quality, and plan future quality initiatives in the field of complex rehabilitation.

Trial registration

The study is part of the larger BRIDGE trial (ClinicalTrials.gov NCT03102814).

Effect of high-intensity exercise on cardiorespiratory fitness, cardiovascular disease risk and disease activity in patients with inflammatory joint disease: protocol for the ExeHeart randomised controlled trial

INTRODUCTION

Inflammatory joint disease (IJD) is associated with increased risk of cardiovascular disease (CVD) fostered by systemic inflammation and a high prevalence of CVD risk factors. Cardiorespiratory fitness (CRF) is an important health parameter and CRF-measures are advocated in routine health evaluations. CRF associates with CVD risk, and exercise modalities such as high intensity interval training (HIIT) can increase CRF and mitigate CVD risk factors. In IJD, exercise is rarely used in CVD risk management and the cardioprotective effect of HIIT is unclear. Furthermore, the clinical applicability of HIIT to primary care settings is largely unknown and warrants investigation. The primary aim is to assess the effect of a HIIT programme on CRF in patients with IJD. Second, we will evaluate the effect of HIIT on CVD risk and disease activity in patients with IJD, feasibility of HIIT in primary care and validity of non-exercise algorithms to detect change in CRF.

METHODS AND ANALYSIS

ExeHeart is a single-blinded, randomised controlled trial. Sixty patients with IJD will be recruited from the Preventive Cardio-Rheuma clinic at Diakonhjemmet Hospital, Norway. Patients will be assigned to receive standard care (relevant lifestyle advice and cardio-preventive medication) or standard care plus a 12-week HIIT intervention by physiotherapists in primary care. HIIT sessions will be prescribed at 90%-95% of peak heart rate. Outcomes include CRF (primary outcome), CVD risk factors, anthropometric measures, disease activity and patient-reported outcomes related to pain, fatigue, disease, physical activity and exercise and will be assessed at baseline, 3 months (primary endpoint) and 6 months postbaseline.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics (201227). Participants are required to sign a written informed consent form. Results will be discussed with patient representatives, submitted to peer-reviewed journals and presented at relevant platforms.

TRIAL REGISTRATION NUMBER

NCT04922840.

Lifestyle Factors and Disease Activity over Time in Early Axial Spondyloarthritis - The SPondyloArthritis Caught Early (SPACE) Cohort

OBJECTIVE

Our aim was to study the importance of baseline Body Mass Index (BMI), smoking and alcohol consumption (AC) for disease activity (DA) over one year in early axial spondyloarthritis (axSpA), stratified by sex.

METHODS

In the SPondyloArthritis Caught Early cohort (patients with chronic back pain for ≥3 months, ≤2 years and onset <45 years), ASDAS was recorded at inclusion, 3 and 12 months. All patients included in the analysis had axSpA based on a high physician's level of confidence at baseline. Differences in ASDAS over 1 year by BMI (normal <25, overweight 25-29.9, obese ≥30 kg/m²), smoking history (never/previous/current) and AC (none, 0.1-2, 3-5, ≥6 units/week) at baseline were estimated using mixed linear regression models.

RESULTS

There were 344 subjects (mean age 30 years; 49% men). In women, obesity was associated with 0.60 (95% CL 0.28, 0.91) higher ASDAS compared to normal BMI. In both sexes, AC tended to be associated with lower DA over one year, with a significant association only in women with the highest AC (mean difference -0.55 (96% CL-1.05, -0.04). Smoking was associated with higher ASDAS over one year compared to never smoking in both sexes, albeit the difference reached statistical significance only in female former smokers. Results were similar in multivariable analysis, adjusted for all lifestyle factors and other confounders.

CONCLUSION

In early axSpA, BMI and smoking are associated with higher DA over one year, and AC with lower DA. The magnitude of the modest associations may differ between men and women.

The ASAS-OMERACT core domain set for axial spondyloarthritis

BACKGROUND

The current core outcome set for ankylosing spondylitis (AS) has had only minor adaptations since its development 20 years ago. Considering the significant advances in this field during the preceding decades, an update of this core set is necessary.

OBJECTIVE

To update the ASAS-OMERACT core outcome set for AS into the ASAS-OMERACT core outcome set for axial spondyloarthritis (axSpA).

METHODS

Following OMERACT and COMET guidelines, an international working group representing key stakeholders (patients, rheumatologists, health professionals, pharmaceutical industry and drug regulatory agency representatives) defined the core domain set for axSpA. The development process consisted of: i) Identifying candidate domains using a systematic literature review and qualitative studies; ii) Selection of the most relevant domains for different stakeholders through a 3-round Delphi survey involving axSpA patients and axSpA experts; iii) Consensus and voting by ASAS; iv) Endorsement by OMERACT. Two scenarios are considered based on the type of therapy investigated in the trial: symptom modifying therapies and disease modifying therapies.

RESULTS

The updated core outcome set for axSpA includes 7 mandatory domains for all trials (disease activity, pain, morning stiffness, fatigue, physical function, overall functioning and health, and adverse events including death). There are 3 additional domains (extra-musculoskeletal manifestations, peripheral manifestations and structural damage) that are mandatory for disease modifying therapies and important but optional for symptom modifying therapies. Finally, 3 other domains (spinal mobility, sleep, and work and employment) are defined as important but optional domains for all trials.

CONCLUSION

The ASAS-OMERACT core domain set for AS has been updated into the ASAS-OMERACT core domain set for axSpA. The next step is the selection of instruments for each domain.

Criterion validity of The International Physical Activity Questionnaire-Short Form (IPAQ-SF) for use in clinical practice in patients with osteoarthritis

BACKGROUND

To tailor physical activity treatment programs for patients with osteoarthritis, clinicians need valid and feasible measurement tools to evaluate habitual physical activity. The widely used International Physical Activity Questionnaire-Short Form (IPAQ-SF) is not previously validated in patients with osteoarthritis.

PURPOSE

To assess the concurrent criterion validity of the IPAQ-SF in patients with osteoarthritis, using an accelerometer as a criterion-method.

METHOD

Patients with osteoarthritis (n = 115) were recruited at The Division of Rheumatology and Research at Diakonhjemmet Hospital (Oslo, Norway). Physical activity was measured by patients wearing an accelerometer (ActiGraph wGT3X-BT) for seven consecutive days, followed by reporting their physical activity for the past 7 days using the IPAQ-SF. Comparison of proportions that fulfilled physical activity recommendations as measured by the two methods were tested by Pearson Chi-Square analysis. Differences in physical activity levels between the IPAQ-SF and the accelerometer were analyzed with Wilcoxon Signed-Rank Test and Spearman rank correlation test. Bland-Altman plots were used to visualize the concurrent criterion validity for total- and intensity-specific physical activity levels.

RESULTS

In total, 93 patients provided complete physical activity data, mean (SD) age was 65 (8.7) years, 87% were women. According to the IPAQ-SF, 57% of the patients fulfilled the minimum physical activity recommendations compared to 31% according to the accelerometer (p = 0.043). When comparing the IPAQ-SF to the accelerometer we found significant under-reporting of total physical activity MET-minutes (p = < 0.001), sitting (p = < 0.001) and walking (p < 0.001), and significant over-reporting of moderate-to-vigorous physical activity (p < 0.001). For the different physical activity levels, correlations between the IPAQ-SF and the accelerometer ranged from rho 0.106 to 0.462. The Bland-Altman plots indicated an increased divergence between the two methods with increasing time spent on moderate-to-vigorous intensity physical activity.

CONCLUSION

Physical activity is a core treatment of osteoarthritis. Our finding that patients tend to over-report activity of higher intensity and under-report low-intensity activity and sitting-time is of clinical importance. We conclude that the concurrent criterion validity of the IPAQ-SF was weak in patients with osteoarthritis.

A quality indicator set for rehabilitation services for people with rheumatic and musculoskeletal diseases demonstrates adequate responsiveness in a pre-post evaluation

BACKGROUND

Quality of care is gaining increasing attention in research, clinical practice, and health care planning. Methods for quality assessment and monitoring, such as quality indicators (QIs), are needed to ensure health services in line with norms and recommendations. The aim of this study was to assess the responsiveness of a newly developed QI set for rehabiliation for people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

We used two yes/no questionnaires to measure quality from both the provider and patient perspectives, scored in a range of 0-100% (best score, 100%). We collected QI data from a multicenter stepped-wedge cluster-randomized controlled trial (the BRIDGE trial) that compared traditional rehabilitation with a new BRIDGE program designed to improve quality and continuity in rehabilitation. Assessment of the responsiveness was performed as a pre-post evaluation: Providers at rehabilitation centers in Norway completed the center-reported QIs (n = 19 structure indicators) before (T1) and 6-8 weeks after (T2) adding the BRIDGE intervention. The patient-reported QIs comprised 14 process and outcomes indicators, measuring quality in health services from the patient perspective. Pre-intervention patient-reported data were collected from patients participating in the traditional program (T1), and post-intervention data were collected from patients participating in the BRIDGE program (T2). The patient groups were comparable. We used a construct approach, with a priori hypotheses regarding the expected direction and magnitude of PR changes between T1 and T2. For acceptable responsivess, at least 75% of the hypotheses needed to be confirmed.

RESULTS

All eight participating centers and 82% of the patients (293/357) completed the QI questionnaires. Responsiveness was acceptable, with 44 of 53 hypotheses (83%) confirmed for single indicators and 3 of 4 hypotheses (75%) confirmed for the sum scores.

CONCLUSION

We found this QI set for rehabilitation to be responsive when applied in rehabilitation services for adults with various RMD conditions. We recommend this QI set as a timely method for establishing quality-of-rehabilitation benchmarks, promoting important progress toward high-quality rehabilitation, and tracking trends over time.

TRIAL REGISTRATION

The study is part of the larger BRIDGE trial, registered at ClinicalTrials.gov (Identifier: NCT03102814).

Supervised intensive Exercise strengthen Exercise Health Beliefs in Patients with Axial Spondyloarthritis: A Multicentre Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of a three-month supervised high-intensity exercise program, on exercise health beliefs in patients with Axial Spondyloarthritis.

METHODS

This was secondary analysis of a randomized controlled trial. Participants (ages 23-69 years), were randomized to an exercise group (n=50) or a control group (n=50). The intervention was an individually guided cardiorespiratory and strength exercise program performed two times per week, plus an additional individual exercise session of personal choice. The control group received standard care and instructions to maintain their physical activity level. Exercise health beliefs using the Exercise health beliefs questionnaire (ranges 20-100, 100= best) i.e. barriers, benefits, self-efficacy and exercise impact on arthritis and physical activity were assessed with self-reported questionnaires at baseline, three months and 12 months after inclusion.

RESULTS

The majority, (76%) of the participants in the exercise group followed ≥ 80% of the prescribed exercise protocol. There was a significant effect of the intervention on exercise health beliefs at 3 months (estimated mean group differences 4.0 [95%CI 1.4, 6.6], p=0.003) and the effect persisted at 12 months follow-up (estimated mean group differences 3.8 [95%CI 1.0, 6.6], p=0.008). Participants with higher exercise health beliefs had a higher odds ratio (1.1 [95%CI 1.0, 1.20], p=0.003) for being physically active at 12 months follow-up.

CONCLUSIONS

A supervised high intensity exercise program had beneficial short- and long-term effects on participants' exercise health beliefs. Stronger exercise health beliefs were positively associated with a higher chance to be physically active on a health enhancing level at 12-months follow-up.

Obesity Increases Disease Activity of Norwegian Patients with Axial Spondyloarthritis: Results from the European Map of Axial Spondyloarthritis Survey

OBJECTIVE

To investigate the prevalence of overweight and obesity, as well as the association between body mass index (BMI) and disease activity in patients with axial spondyloarthritis (axSpA).

METHODS

Norwegian axSpA patients from the European Map of Axial Spondyloarthritis (EMAS) survey were included in this analysis. Sociodemographic, anthropomorphic, and disease-related variables (HLA-B27, comorbidities, BASDAI, and self-reported spinal stiffness) were reported. Patients were categorized into under/normal weight (BMI < 25 kg/m²), overweight (BMI ≥ 25 to < 30 kg/m²), and obese (≥ 30 kg/m²).

RESULTS

Of the 509 participants in the EMAS survey, 35% were categorized as under/normal weight, 39% overweight, and 26% obese. Compared to under/normal-weight patients, overweight patients had significantly higher degree of spinal stiffness (mean (SD) 7.91 ± 2.02 vs 7.48 (2.15) and number of comorbidities (2.45 ± 2.11, vs 1.94), both p < 0.001. Obese patients had significantly higher disease activity (BASDAI mean (SD) 5.87 ± 1.78 vs 4.99 ± 2.08, p < 0.001), degree of spinal stiffness (8.18 ± 2.03 vs 7.48 ± 2.15, p = 0.006), and number of comorbidities (3.43 ± 2.43 vs 1.94. ± .38, p < 0.001) than under/normal weight patients. After adjusting for gender and age, obesity proved to be independently associated with disease activity.

CONCLUSION

Obesity was associated with higher reported BASDAI score, and being overweight or obese was associated with a higher degree of spinal stiffness and number of comorbidities compared to under/normal weight respondents. The results highlight the serious impact of obesity on health status, and obesity should therefore be considered as a modifiable risk factor for disease activity within the disease management of axSpA.

High-Intensity Exercise Improves Fatigue, Sleep, and Mood in Patients With Axial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Although exercise is recommended in the treatment of axial spondyloarthritis (axSpa), the focus has been on flexibility, and the effect of high-intensity exercises is unknown. The purpose of this study was to investigate the effect of high-intensity exercises on fatigue, sleep, and mood in patients with axSpA.

METHODS

In this secondary analysis of a randomized controlled trial, participants were recruited from outpatient clinics at 4 hospitals in Scandinavia. A total of 100 patients with axSpA were randomized to either an exercise group (n = 50) or a control group (n = 50). High-intensity exercise was provided 3 times per week for 3 months and supervised by a physical therapist. The controls received no intervention. Measurements were self-reported at baseline, 3 months, and 12 months: fatigue, using the Fatigue Severity Scale (range = 0-7, 7 = worst, ≥5 = severe); vitality, using the RAND 36-item short-form health survey (SF-36, range = 0-100, 100 = best); sleep, using the Pittsburgh Sleep Quality Index (range = 0-21, 21 = worst, >5 = poor quality); mood, using the General Health Questionnaire 12 (range = 0-36, 36 = worst); and general health, using the EUROQoL (range = 0-100, 100 = best).

RESULTS

A total of 38 participants (76%) in the exercise group followed ≥80% of the exercise protocol. At 3 months, there was a significant beneficial effect on fatigue (mean group differences = -0.4, 95% CI = -0.7 to -0.1), vitality (5.0, 95% CI = 1.1 to 10.5), mood (-2, 95% CI = -3.7 to -0.04), and general health (9.0, 95% CI = 3.3 to 14.7) but no effect on sleep (-1.1, 95% CI = -2.1 to 0.2). Compared with the control group, the exercise group had a reduced rate of severe fatigue and poor sleep. No differences were seen between the groups at 12 months.

CONCLUSIONS

A 3-month exercise program had a beneficial effect on fatigue, sleep, mood, and general health in patients with axSpA at the end of the intervention; however, no long-term effects were seen.

IMPACT

High-intensity cardiorespiratory and strength exercises should be considered as important in exercise programs for patients with axSpA.

Responsiveness and Interpretability of 2 Measures of Physical Function in Patients With Spondyloarthritis

BACKGROUND

Maintenance or improvement of physical function is an important treatment target in the management of patients with axial spondyloarthritis (axSpA); measurement tools that can detect changes in physical function are therefore important.

OBJECTIVES

The objective of this study was to compare responsiveness and interpretability of the patient-reported Bath Ankylosing Spondylitis Functional Index (BASFI) and the Ankylosing Spondylitis Performed-Based Improvement (ASPI) in measuring change in physical function after exercise in patients with axSpA.

DESIGN

This was a sub-study of 58 patients nested within a randomized controlled trial comparing the effect of 12 weeks of exercise with usual care.

METHODS

Responsiveness and interpretability were assessed according to the Consensus-based Standards for the selection of health status Measurement Instrument. Responsiveness was assessed by testing 8 predefined hypotheses for ASPI and BASFI. Interpretability was assessed by: (1) using patients' reported change as an anchor ("a little better" = minimal important change) and (2) by categorizing patients with a 20% improvement as responders.

RESULTS

For ASPI and BASFI, 5 of 8 (63%) versus 2 of 8 (25%) of the predefined hypotheses for responsiveness were confirmed. The minimal important change values for improvement in physical function were 3.7 seconds in ASPI and 0.8 points (on a scale from 0 to 10) for BASFI. In the intervention group, 21 of 30 (70%) and 13 of 30 (43%) of the patients were categorized as responders measured with ASPI and BASFI, respectively. There was a tendency towards a floor effect in BASFI, as 8 of 58 (14%) patients scored the lowest value at baseline.

LIMITATIONS

This study was limited by its moderate sample size.

CONCLUSIONS

Our findings suggest that ASPI is preferable over BASFI when evaluating physical function after exercise interventions in patients with axSpA.

Physical Fitness in Patients With Oligoarticular and Polyarticular Juvenile Idiopathic Arthritis Diagnosed in the Era of Biologics: A Controlled Cross-Sectional Study

OBJECTIVE

To perform a comprehensive evaluation of and identify correlates for physical fitness in consecutive patients with juvenile idiopathic arthritis (JIA) who have been diagnosed in the era of biologics and to compare the results with those obtained in healthy controls.

METHODS

The study cohort included 60 patients with JIA (50 girls) ages 10-16 years and 60 age- and sex-matched controls. The JIA group included 30 patients with persistent oligoarticular JIA and 30 patients with extended oligoarticular or polyarticular disease. Measures of physical fitness included cardiorespiratory fitness (CRF) by peak oxygen uptake (Vo_2peak ) during a continuous graded treadmill exercise test, muscle strength by isokinetic and isometric knee and hand grip evaluations, and bone mineral density (BMD) and body composition by dual-energy x-ray absorptiometry. Physical activity was assessed by accelerometry.

RESULTS

Forty-two percent of the patients were being treated with biologic drugs. Patients with JIA demonstrated lower muscle strength and total body BMD compared to controls, but there were no differences in CRF and body composition. Physical fitness was comparable between the persistent oligoarticular and extended oligoarticular/polyarticular-JIA groups. In patients with JIA, we identified associations between higher vigorous physical activity and higher CRF and muscle strength, but did not find any association between physical fitness and disease variables.

CONCLUSION

In this cohort of patients with JIA, we found suboptimal muscle strength and BMD compared to controls, but no differences in CRF and body composition. Vigorous physical activities appeared important for optimizing muscle strength and CRF in patients with JIA; the importance of such activities should be highlighted in patient education.

Low adherence to exercise may have influenced the proportion of OMERACT-OARSI responders in an integrated osteoarthritis care model: secondary analyses from a cluster-randomised stepped-wedge trial

BACKGROUND

To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model.

METHODS

The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8-12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0-10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group.

RESULTS

Two hundred eighty-four intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (OR_adjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders.

CONCLUSIONS

The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02333656. Registered 7. January 2015.

How Do Patients With Axial Spondyloarthritis Experience High-Intensity Exercise?

Objective

In a few studies, high‐intensity exercise has displayed beneficial effects on cardiovascular health among patients with rheumatic diseases, yet the high‐intensity exercise mode is still not fully accepted among health care professionals. The aim of this study was to investigate experiences of high‐intensity exercise among patients with axial spondyloarthritis.

Methods

Fourteen respondents who had participated in a high‐intensity exercise program for 12 weeks were included in this qualitative study with individual semistructured, in‐depth interviews. The respondents’ median age was 53, ranging from 23 to 63 years old, and both men and women of different ethnicities were represented. Interviews were analyzed by qualitative content analysis, including both manifest content and interpretations of underlying latent meaning.

Results

The analysis resulted in five categories describing the respondents’ experiences with high‐intensity exercise: 1) high‐intensity exercise as a challenge for both body and mind, 2) increased faith in one's own body, 3) changed attitude toward exercise, 4) taking charge of one's own health by challenging the disease, and 5) exercise in a social context.

Conclusion

Supervised high‐intensity interval exercise was perceived as challenging for both body and mind but was also described as a positive experience, with rapid bodily effects that strengthened respondents’ faith in their own bodies. The new experience seemed to have changed the respondents’ attitude and motivation for exercise and made them start taking charge of their health by challenging the disease. Exercise in a social context, under professional leadership, enhanced exercise self‐efficacy and helped the respondents to adhere to the exercise program.

Longterm Effect on Leisure Time Physical Activity Level in Individuals with Axial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To explore the longterm effect of a 3-month exercise program on leisure time physical activity level in individuals with axial spondyloarthritis (axSpA).

METHODS

A secondary analysis was performed on data from 100 individuals with axSpA who were included in a randomized controlled trial. The exercise group (EG) participated in a 3-month exercise program while the control group (CG) received no intervention. Physical activity during leisure time was measured with a questionnaire (physically active: ≥ 1 h/week with moderate/vigorous intensity physical activity). Disease activity was measured with the Ankylosing Spondylitis Disease Activity Scale (ASDAS; higher score = worst). Statistical analyses were performed on an intention-to-treat basis using chi-square tests, logistic regression, and mixed models.

RESULTS

At the 12-month followup, significantly more individuals in the EG than in the CG were physically active [29 (67%) vs 13 (30%), p < 0.001] and exercised 2-3 times/week [25 (58%) vs 15 (34%), p = 0.02], and fewer exercised at light intensity [3 (8%) vs 14 (44%), p = 0.002]. "Participation in the EG" (OR 6.7, 95% CI 2.4-18.6, p < 0.001) and "being physically active at baseline" (OR 4.7, 95% CI 1.4-15.8, p = 0.01) were the factors most associated with being physically active. There were no differences between the groups in ASDAS (p = 0.79).

CONCLUSION

A 3-month exercise program had a beneficial longterm effect on leisure time physical activity in individuals with axSpA, thus indicating a more beneficial health profile. Still, few individuals continued the intensive program, and there was no difference between the groups in disease activity after 12 months. (ClinicalTrials.gov: NCT02356874).

Implementing international osteoarthritis guidelines in primary care: uptake and fidelity among health professionals and patients

OBJECTIVE

This paper evaluates the implementation fidelity of a strategy and intervention used to implement osteoarthritis (OA) treatment recommendations in primary care. We also evaluate uptake of core treatment (patient information, exercise and referral to weight management) among OA patients.

DESIGN

A stepped-wedge cluster-randomised controlled study (RCT) in primary care. The study involved general practitioners (GPs), physiotherapists (PTs) and patients with hip and/or knee OA in six Norwegian municipalities (clusters). Workshops for general practitioners (GPs) and PTs represented the main implementation activity. Uptake of core treatment (patient education, exercise and weight management) was evaluated using self-reported data from the patient intervention and control group, analysed with logistic regression models. Fidelity was evaluated using six components representing adherence to the content and dose instructions in the implementation strategy and assessed against a-priori criteria for high adherence.

RESULTS

Data were collected from 40 GPs, 37 PTs and 393 OA patients. The patient-reported data showed statistically significant higher uptake for exercise, patient education and referral to support for weight reduction, among the intervention group compared to the control group (P < 0.05). Evaluation of fidelity showed high adherence to GP and PT workshop attendance and physiotherapy use, partly adherence to PT knowledge after workshops, and low adherence to exercise attendance, dose and progression instructions.

CONCLUSIONS

The implementation strategy and intervention successfully improved OA patients' access to physiotherapy and uptake of recommended core treatment. However, the strategy was less effective in providing exercise programs with sufficient dose and progression and in supporting patients' adherence to the exercise program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02333656.

Measurement properties and performance of an eight-minute submaximal treadmill test in patients with juvenile idiopathic arthritis: a controlled study

BACKGROUND

Poor cardiorespiratory fitness is previously reported in patients with juvenile idiopathic arthritis (JIA) measured both by maximal and submaximal exercise tests, but a submaximal exercise test with acceptable measurement properties is currently lacking for both clinical and research purposes in this patient population. The objectives of this study were to evaluate the measurement properties and performance of a submaximal treadmill test in patients with JIA, and to compare the results with those obtained in controls.

METHODS

Fifty-nine patients (50 girls), aged 10-16 years, with oligo- (n = 30) and polyarticular (n = 29) JIA, and 59 age- and sex-matched controls performed an eight-minute submaximal treadmill test for estimating peak oxygen uptake (VO2peak) followed by a maximal treadmill test measuring VO2peak directly. During the submaximal treadmill test, the study participants walked with no inclination at a speed between 3.2-7.2 km/h for four minutes, and then continued to walk at the same speed for four minutes with five % inclination. VO2peak was directly measured during a continuous graded exercise test on treadmill until exhaustion. Thirty-seven patients participated in the evaluation of the reliability. Criterion validity and reliability were evaluated with interclass correlation coefficient (ICC); measurement errors by Bland-Altman plot, standard error of measurement and smallest detectable change.

RESULTS

In patients with JIA, the ICC (95% CI) for criterion validity was acceptable at group level 0.71 (0.51, 0.82), but not at individual level. The test-retest reliability and inter-rater reliability were acceptable at individual (0.84 (0.71, 0.91) and 0.92 (0.83, 0.96), respectively) and group levels (0.91 (0.83, 0.96) and 0.96 (0.91, 0.98), respectively). The measurement errors (for test-retest reliability/inter-rater reliability) were large. Bland-Altman plots showed no systematic differences, but a large variability for both the validity and reliability. The performance of and estimated VO2peak from the submaximal test were not associated with disease variables and were comparable between patients and controls.

CONCLUSION

The submaximal treadmill test is valid for use in patients with JIA on group level, but not on individual level. The reliability is acceptable. Due to large measurement errors, the submaximal treadmill test is not optimal for use in daily clinical practice to estimate VO2peak in individual patients.

High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients

Background

Exercise is considered important in the management of patients with rheumatic diseases, but the effect of high intensity exercises on disease activity is unknown.

Objective

To investigate the effectiveness of high intensity exercises on disease activity in patients with axial spondyloarthritis (axSpA).

Method

Assessor blinded multicentre randomised controlled trial. 100 patients (aged from their 20s to their 60s) with axSpA were randomly assigned to an exercise group or to a no-intervention control group. The exercise group performed cardiorespiratory and muscular strength exercises at high intensity over 3 months. The control group received standard care and was instructed to maintain their usual physical activity level. Primary outcome was disease activity measured with the Ankylosing Spondylitis (AS) Disease Activity Scale (ASDAS, higher score=worst) and the Bath AS Disease Activity Index (BASDAI, 0–10, 10=worst). Secondary outcomes were inflammatory markers, physical function and cardiovascular (CV)-health. There was patient involvement in the design and reporting of this study.

Results

97 of the 100 (97%) randomised patients completed the measurements after the intervention. There was a significant treatment effect of the intervention on the primary outcome (ASDAS: −0.6 [–0.8 to –0.3], p<0.001 and BASDAI: −1.2 [–1.8 to –0.7], p<0.001). Significant treatment effects were also seen for inflammation, physical function and CV-health.

Conclusion

High intensity exercises reduced disease symptoms (pain, fatigue, stiffness) and also inflammation in patients with axSpA. It improves patients’ function and CV health. This debunks concerns that high intensity exercise might exacerbate disease activity in patients with axSpA.

Trial registration number

NCT02356874.

Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis

Objective

To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle strength, flexibility, neuromotor performance (eg, balance) and daily PA in people with rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip/knee osteoarthritis (HOA/KOA).

Methods

systematic review (SR) and meta-analysis (MA) were performed searching the databases PubMed/Medline, CENTRAL, Embase, Web of Science, Emcare and PsycInfo until April 2017. We included randomised controlled trials (RCTs) in adults (≥18 years) with RA, SpA and HOA/KOA, investigating the effects of exercise or PA promotion according to the public health PA recommendations by the American College of Sports Medicine. The time point of interest was the first assessment after the intervention period. If suitable, data were pooled in a MA using a random-effects model presented as standardised mean difference (SMD).

Results

The SR included 63 RCTs, of which 49 (3909 people with RA/SpA/HOA/KOA) were included in the MA. Moderate effects were found of aerobic exercises and resistance training on cardiovascular fitness (SMD 0.56 (95% CI 0.38 to 0.75)) and muscle strength (SMD 0.54 (95% CI 0.35 to 0.72)), respectively, but no effect of combined strength/aerobic/flexibility exercises on flexibility (SMD 0.12 (95% CI -0.16 to 0.41)). PA promotion interventions produced a small increase in PA behaviour (SMD 0.21 (95% CI 0.03 to 0.38)).

Conclusion

Exercises and PA promotion according to public health recommendations for PA improved cardiovascular fitness, muscle strength and PA behaviour, with moderate effect sizes in people with SpA, RA and HOA/KOA.

Trial registration number

CRD42017082131.

Physical activity in patients with oligo- and polyarticular juvenile idiopathic arthritis diagnosed in the era of biologics: a controlled cross-sectional study

BACKGROUND

Knowledge about objectively measured levels of physical activity (PA) and PA participation (included facilitators and barriers for PA) in patients with juvenile idiopathic arthritis (JIA) diagnosed in the era of biologics is limited. We aimed to compare objectively measured PA in patients with oligo- and polyarticular JIA diagnosed in the biologic era with controls and to examine associations between PA and disease variables; furthermore, to explore participation in PA, physical education (PE) and facilitators and barriers for PA participation in patients and controls.

METHODS

The study cohort included 60 patients (30 persistent oligo JIA/30 poly-articular disease) and 60 age- and sex-matched controls. Age range was 10-16 years and 83% were female. PA was measured with accelerometry for seven consecutive days. Disease activity, current treatment, disease duration, functional ability, pain and fatigue were assessed. Structured interviews were applied to explore participation in PA and PE, and PA facilitators and barriers.

RESULTS

Patients spent less time in daily vigorous PA than controls, (mean(SE) 21(2) min vs. 26(2) min, p = 0.02), while counts per minute (cpm), steps daily, sedentary time and light and moderate PA did not differ. No differences were found between JIA subgroups. The use of biologic medication was associated with higher cpm and lower sedentary time. Most patients and controls participated in organized or unorganized PA and PE, and enjoyment was the most reported facilitator for PA participation. More patients than controls reported pain as a PA barrier.

CONCLUSION

The PA levels and participation in patients with oligo- and polyarticular JIA are mostly comparable to controls, but patients still need to be encouraged to increase vigorous PA. Enjoyment is the most important facilitator for PA participation in patients with JIA.

2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis

Regular physical activity (PA) is increasingly promoted for people with rheumatic and musculoskeletal diseases as well as the general population. We evaluated if the public health recommendations for PA are applicable for people with inflammatory arthritis (iA; Rheumatoid Arthritis and Spondyloarthritis) and osteoarthritis (hip/knee OA) in order to develop evidence-based recommendations for advice and guidance on PA in clinical practice. The EULAR standardised operating procedures for the development of recommendations were followed. A task force (TF) (including rheumatologists, other medical specialists and physicians, health professionals, patient-representatives, methodologists) from 16 countries met twice. In the first TF meeting, 13 research questions to support a systematic literature review (SLR) were identified and defined. In the second meeting, the SLR evidence was presented and discussed before the recommendations, research agenda and education agenda were formulated. The TF developed and agreed on four overarching principles and 10 recommendations for PA in people with iA and OA. The mean level of agreement between the TF members ranged between 9.8 and 8.8. Given the evidence for its effectiveness, feasibility and safety, PA is advocated as integral part of standard care throughout the course of these diseases. Finally, the TF agreed on related research and education agendas. Evidence and expert opinion inform these recommendations to provide guidance in the development, conduct and evaluation of PA-interventions and promotion in people with iA and OA. It is advised that these recommendations should be implemented considering individual needs and national health systems.

Frequency of Impaired Spinal Mobility in Patients with Chronic Back Pain Compared to Patients with Early Axial Spondyloarthritis

OBJECTIVE

To examine the frequency of impaired spinal mobility in patients with chronic back pain of short duration and to compare it with the frequency of impaired spinal mobility in patients with axial spondyloarthritis (axSpA), possible SpA, and no SpA.

METHODS

The SpondyloArthritis Caught Early (SPACE) cohort includes patients with chronic back pain (≥ 3 mos, ≤ 2 yrs, onset < 45 yrs). Spinal mobility was assessed with lateral spinal flexion, chest expansion, cervical rotation, occiput-to-wall distance, and lumbar flexion. Hip mobility was assessed with intermalleolar distance. Mobility measures were defined as impaired if below the 5th percentile reference curve from general population, adjusted for age and height when appropriate. Proportions of patients categorized with impaired mobility were examined with chi square.

RESULTS

In total, 393 patients with chronic back pain were included: 142 axSpA, 140 possible SpA, and 111 no SpA. Impairment in ≥ 1 mobility measure was present in 66% of all patients. The most frequently impaired mobility measure was lateral spinal flexion (40%), followed by chest expansion (22%), cervical rotation (18%), intermalleolar distance (17%), lumbar flexion (15%), and occiput-to-wall distance (11%). No statistically significant differences in proportion of patients with impaired spinal mobility were found between patients with axSpA and the other subgroups in any of the tests.

CONCLUSION

Two out of 3 patients with chronic back pain of short duration had impaired spinal mobility compared to the general population. Impaired spinal mobility occurs as often in patients with early axSpA as in other forms of chronic back pain.

Associations Between Cardiorespiratory Fitness and Arterial Stiffness in Ankylosing Spondylitis: A Cross-sectional Study

Objective.

To assess associations between cardiorespiratory fitness (CRF), measured as peak oxygen uptake (VO2peak), and cardiovascular disease (CVD) risk, measured by arterial stiffness, in patients with ankylosing spondylitis (AS).

Methods.

VO2peak was assessed by a maximal walking test on a treadmill. Arterial stiffness was measured noninvasively (Sphygmocor apparatus). Cross-sectional associations between VO2peak and arterial stiffness were analyzed using backward multivariable linear regression.

Results.

Among 118 participating patients, there were significant inverse associations between VO2peak and arterial stiffness, independent of traditional CVD risk factors and measures of disease activity.

Conclusion.

Reduced CRF may be related to increased risk of CVD in AS.

In Early Axial Spondyloarthritis, Increasing Disease Activity Is Associated with Worsening of Health-related Quality of Life over Time

OBJECTIVE

In early axial spondyloarthritis (axSpA), data are lacking about the relationship between disease activity and health-related quality of life (HRQOL). We assessed and quantified the association between change in Ankylosing Spondylitis Disease Activity Score (ASDAS) and HRQOL over time in early axSpA.

METHODS

Baseline and 1-year data of patients with axSpA fulfilling the Assessment of Spondyloarthritis international Society (ASAS) classification criteria from the SPondyloArthritis Caught Early (SPACE) cohort were analyzed. Associations between change in ASDAS and in physical (PCS) or mental component summary (MCS) of the Medical Outcomes Study Short Form-36 were tested by linear regression models. Age, sex, ASAS criteria arm, and blue- versus white-collar work were tested for effect modification. Subsequently, these factors and medication were tested for confounding.

RESULTS

There were 161 patients with axSpA [53% male, mean (± SD) age 29.7 (± 7.5) yrs, symptom duration 13.6 (± 7.2) months, HLA-B27-positive 91%, radiographic sacroiliitis 22%] who had ASDAS of 2.5 (± 1.0) and 2.0 (± 0.8), PCS of 28.4 (± 14.3) and 36.9 (± 13.1), and MCS of 48.2 (± 13.8) and 49.3 (± 12.0) at baseline and 1 year, respectively. Per unit increase in ASDAS between baseline and 1 year, PCS worsened by 9.5 points. The same level of disease activity had fewer adverse effects on physical HRQOL in women and white-collar workers.

CONCLUSION

To our knowledge, our data are the first to show that in a broad group of patients with early axSpA, increasing ASDAS is associated with worsening of physical HRQOL, but not mental HRQOL, over time.

Evidence of reduced parasympathetic autonomic regulation in inflammatory joint disease: A meta-analyses study

BACKGROUND

Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are inflammatory joint disorders (IJD) with increased risk of cardiovascular disease (CVD). Autonomic dysfunction (AD) is a risk factor for CVD, and parasympathetic AD is linked to key features of IJD such as inflammation, physical inactivity and pain. Heart-rate variability (HRV) is a marker of cardiac AD. The study objective was to compare parasympathetic cardiac AD, measured by HRV, between patients with IJD and healthy controls, using meta-analysis methodology, and to examine the impact of inflammation, physical inactivity and pain on HRV in IJD.

METHODS

Medline, Embase and Amed were searched. Inclusion criteria were adult case-control studies published in English or a Scandinavian language, presenting HRV data in IJD. Two measures of HRV and 3 from the Ewing protocol were selected: square root of mean squared difference of successive R-R intervals (RMSSD), high frequency (HF), Ewing protocol; standing (E-S), breathing (E-B) and Valsalva (E-V). Patients with RA, SpA and healthy controls were compared separately using random-effects meta-analyses of standardized mean differences (SMD).

RESULTS

In all, 35 papers were eligible for inclusion. For RMSSD the pooled SMD (95% CI) RA vs. controls was -0.90 (-1.35 to -0.44), for SpA vs. controls; -0.34 (-0.73 to 0.06). For HF pooled SMD RA vs. controls was -0.78 (-0.99 to -0.57), for SpA vs. controls; -0.04 (-0.22 to 0.13). All Ewing parameters were significantly lower in cases, except for E-V which was comparable between cases and controls in patients with RA.

CONCLUSION

Patients with IJD have cardiac parasympathetic AD which is related to inflammation.

Developing and testing a consensus-based core set of outcome measures for rehabilitation in musculoskeletal diseases

OBJECTIVES

Rehabilitation is important for people with musculoskeletal diseases (MSDs), and evaluating the effect of rehabilitation on both an individual and group level is advocated. A consensus concerning use of outcome measures will improve collaboration between healthcare providers, and increase the possibility of conducting meta-analyses in future research. The aim of this study was to develop a consensus-based core set of outcome measures for rehabilitation in MSDs, and to test the feasibility and responsiveness of the set.

METHOD

The core set was developed through a stepwise process comprising a Delphi consensus procedure, systematic literature searches, and a pilot study, including 386 patients, to test the feasibility and responsiveness of the set.

RESULTS

The following aspects and outcome measures were selected: pain [numeric rating scale (NRS)], fatigue (NRS), physical fitness (the 30-second Sit to Stand test), mental health (Hopkins Symptom Checklist 5), daily activities (Hannover Functional Questionnaire), goal attainment (Patient-Specific Functional Scale including motivation score for baseline assessment), quality of life (5-level EuroQol 5 Dimensions), social participation (the social participation item from COOP/WONCA) and coping (Effective Musculoskeletal Consumer Scale-17). All tested outcome measures were found to be feasible, with high completion rates and acceptable score distribution. Standard response means varied from 0.3 to 0.9.

CONCLUSIONS

A consensus-based core set of patient reported outcome measures is presented for evaluating rehabilitation in MSDs. The core set is feasible and responsive for use in Norway, but needs further testing in other countries.

High-intensity cardiorespiratory and strength exercises reduced emotional distress and fatigue in patients with axial spondyloarthritis: a randomized controlled pilot study

OBJECTIVE

To investigate the effect of high-intensity exercise on emotional distress, fatigue, and ability to do a full day's activities in patients with axial spondyloarthritis (axSpA).

METHOD

A total of 28 physically inactive axSpA patients were randomized to either an exercise group (EG), which performed 12 weeks of cardiorespiratory and strength exercises, or a control group (CG), which received treatment as usual. The outcomes reported in this paper are secondary outcomes in the trial and included emotional distress (General Health Questionnaire-12, 0-36, 36 = worst), fatigue [numeric rating scale (NRS), 0-10, 10 = worst], and ability to do a full day's activities (NRS, 0-10, 10 = worst). Post-intervention differences were assessed by analysis of covariance with baseline values as covariates.

RESULTS

Twenty-four patients were included in the analyses. All patients in the EG followed the exercise protocol. The EG had a statistically significant beneficial effect [mean group differences (95% confidence interval)] on emotional distress [-5.8, (-9.7, -1.9), p < 0.01], fatigue [-2.4, (-4.3, -0.4), p = 0.02], and ability to do a full day's work [-2.2, (-3.9, -0.4), p = 0.02] compared to the CG.

CONCLUSION

This pilot study showed promising effects of cardiorespiratory and strength exercises on emotional distress, fatigue, and ability to do a full day's activities in patients with axSpA. The findings need to be confirmed in a larger trial.

Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of cardiorespiratory and strength exercises on disease activity for patients with inflammatory rheumatic diseases (IRDs).

DESIGN

A systematic review with meta-analysis registered at PROSPERO (CRD42015020004).

PARTICIPANTS

Patients with IRDs.

DATA SOURCES

The databases MEDLINE, AMED, Embase and CINAHL were searched from inception up to April 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Trials were included if they were randomised controlled trials of adults with IRDs, comparing the effect of cardiorespiratory and strength exercises with usual care on disease activity and followed the American College of Sports Medicine's exercise recommendations. The primary outcome was disease activity in terms of inflammation, joint damage and symptoms.

DATA SYNTHESIS

Data were pooled in a random-effect model for all outcomes, and standardised mean differences (SMDs) were calculated. The quality of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Twenty-six trials with a total of 1286 participants were included. There was high to moderate quality evidence, for a small beneficial effect on disease activity scores (0.19 (95% CI 0.05 to 0.33), p<0.01) and joint damage (SMD 0.27 (95% CI 0.07 to 0.46), p<0.01). Furthermore, moderate quality evidence for a small beneficial effect on erythrocyte sedimentation rate (SMD 0.20 (95% CI 0.0 to 0.39), p=0.04) and for no effect on C reactive protein (SMD -0.14 (95% CI -0.37 to 0.08), p=0.21). Beneficial effects were also seen for symptoms.

CONCLUSIONS

The results of this review suggest beneficial effects of exercises on inflammation, joint damage and symptoms in patients with IRDs.

2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis

To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

Reliability and screening ability of the StarT Back screening tool in patients with low back pain in physiotherapy practice, a cohort study

Background

Low back pain (LBP) is the most common reported musculoskeletal disorder, with large prevalence numbers and high costs. Focus on early identification of patients at risk of developing chronic LBP has increased. The Keele Start Back Tool (SBT) is a questionnaire aiming at screening prognostic indicators in LBP patients, categorizing patients into risk-groups and guide treatment. The aim of this study was to explore the Norwegian version of the SBT with regard to reliability of the SBT-scoring and the screening ability in LBP patients in primary care physiotherapy.

Methods

LBP patients answered a package of questionnaires twice, with 1-3 days in between, containing SBT, Hannover functional ability questionnaire, pain intensity questions and demographics. The relative and absolute reliability of SBT was calculated using intraclass correlation coefficient (ICC) and the smallest detectable change respectively. Independent sample t-tests were used for group comparisons.

Results

Fifty-two patients with LBP. Mean age (SD) was 45 (12) years and 62% were female. The ICC (95% CI) for SBT total score and psychosocial subscore was 0.89 (0.82, 0.94) and 0.82 (0.70, 0.90) respectively. None of the participants were allocated to the high risk group. The medium risk group reported significantly more pain last week and more activity limitations than the low risk group at both test and retest (0.001 ≤ p ≤ 0.003), whereas no significant difference between the groups was found on pain now (0.05 ≤ p ≤ 0.16).

Conclusions

The Norwegian version of the SBT was reliable and the screening ability was good as the subgrouping of patients into risk-groups reflected the severity of their back problems. The SBT may be an applicable and useful tool in physiotherapy practice.