THU0570 EXPERTS’ VIEWS ON THE IMPACT OF REHABILITATION FOR PATIENTS WITH RHEUMATOID ARTHRITIS IN AUSTRIA

Background:

Rehabilitation methods and standards for patients with rheumatoid arthritis (RA) have significantly changed due to more efficient medication improving the course of the disease. Therefore, physical activity, participation, disease management and patient education are most important goals in rehabilitation of patients with RA.

Objectives:

Aim of this study was to evaluate the significance and impact of rehabilitation methods according to the subjective attitudes and views of experts and professionals in the field of RA. Opinions of members of the task force (TF) “Rehabilitation” of the Austrian Society of Rheumatology (ÖGR) were compared to the estimation of the other members of the ÖGR.

Methods:

All members of the ÖGR were invited to participate in an online survey to rate the impact of rehabilitation for patients with RA between 0 (no impact) and 10 (high impact). Besides sociodemographic and experience related data about the experts and professionals, two main issues were investigated: (1) Impact of rehabilitation related to specific interventions (2) Impact of rehabilitation methods for patients with RA according to different disease and treatment points.

Results:

129 members (50% male, 50% female) of the ÖGR participated in the online survey. 12 persons were members of the TF “Rehabilitation” of the ÖGR. 11 (8.6%) respondents were general physicians, 66 (51.6%) specialists in internal medicine with further expertise in rheumatology, 15 (11.5%) specialists in internal medicine, 14 (10.9%) specialists for physical medicine with further expertise in rheumatology, 2 (1.6%) specialists in orthopaedics, 13 (10.2%) health professionals and 7 (5.5%) persons were from other profession categories such as researchers for example. The majority of respondents (80%) worked already more than five years with patients with RA in a stationary setting. Results of the online survey demonstrate that the ranking of the impact of specific rehabilitation interventions did only marginally differ between the two person groups: Both groups ranked the importance of occupational and physical therapy the highest. Only the subjective importance of splints and assistive technologies was higher assessed by the general members of the ÖGR. Further, the ranking about the estimated impact of rehabilitation methods for patients with RA was very similar between the two person groups: The importance of rehabilitation for patients with functionality restrictions and for patients with RA in the first years of their disease was ranked the highest by both groups.

Conclusion:

Results of the online survey demonstrate that ratings related to the impact of rehabilitation interventions for RA patients do only slightly differ between the investigated member groups of the ÖGR. Finally, the results indicate that rehabilitation methods for RA patients and rehabilitation related knowledge are well accepted and successfully transferred into disease management of patients with RA by professionals and experts in rheumatology in Austria.

Disclosure of Interests:

Claudia Oppenauer: None declared, Elke Böttcher Grant/research support from: UCB,Roche, MSD, Speakers bureau: UCB, Pfizer, BMS,MSD,Roche,Amgen, Lilly, Gabriele Eberl: None declared, Albrecht Falkenbach: None declared, Winfried Habelsberger: None declared, Johannes Kirchheimer: None declared, Werner Kullich Shareholder of: Roche Stocks, Grant/research support from: MedTec Company, Germany - MedizinTechnik, Erich Mur: None declared, Christa Oliveira-Sittenthaler: None declared, Georg Stummvoll Speakers bureau: Lilly, Roche, gsk, Christian Wiederer Consultant of: Firma Grünenthal, Thema Capsaicin, Dezember 2019, Harald Zeindler: None declared, Valerie Nell-Duxneuner Speakers bureau: MSD, Pfizer, Jansen, Abbvie, Lilly, Novartis

Body image in patients with ankylosing spondylitis

OBJECTIVES

Physical disabilities generally cause disturbances in a patient's body image. The aim of the present study is to assess the prevalence of different aspects of body image disturbances (attractiveness /self-confidence, negative body judgement, accentuation of external appearance, worry about possible physical deficits, sexual problems and physical vitality) in patients with ankylosing spondylitis (AS) in the context of the severity of impairment, mood and pain intensity.

METHODS

Fifty-six patients with AS and 48 healthy controls were investigated using a questionnaire for assessing one's body (1) and the body image questionnaire (2). Furthermore, in the AS patients' medical parameters including BASMI and BASFI, pain intensity and state of well-being were assessed.

RESULTS

In comparison to the controls, the AS patients reported significantly more worries about possible physical deficits. The mildly impaired patients (including significantly more women) were even more insecure than the severely impaired patients. Furthermore the patients considered themselves as being less attractive. The AS patients reported better physical vitality than the controls. This result might be due to patients carrying out regular physical activity and performing exercises with therapeutic value. There were no differences between the groups concerning sexual problems. The total group of AS patients showed normal scores in the state of well-being and did not report pain intensity as being higher than what is expected in chronic pain patients in general.

CONCLUSIONS

Rheumatologists should address problems in body image in patients with AS and in severe cases psychological therapy should be initiated.

[Retrospective analysis of falls in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases]

AIM

To analyse the frequency and circumstances of falls in an inpatient rehabilitation centre.

METHODS

In a survey all falls reported to the Austrian accident insurance carrier were analysed and external circumstances of falls were evaluated. The survey covers a period of 64 months (Jan 2000 to April 2005): 10 820 inpatients (234 502 patient days); mean age 52.8 years; 1,252 patients aged >/= 70 years; 47 % male, 53 % female.

RESULTS

Of 223 accidents registered, 140 (62.8 %) were falls. Of these, 17 patients had to be referred to a surgical unit for further treatment. In total, 1.29 % of all patients fell during their stay (with report to the accident insurance carrier), 0.16 % suffered major injuries from falls (with referral to surgical unit). Females fell more frequently than males. 39 % of the falls were associated with physical therapy. Most falls occurred in daytime. The location in the centre or the day of week showed no major influence on the frequency of falls. Falls occurred slightly more often in the first part of the three-week inpatient stay.

CONCLUSION

The high total number of falls shows that falls are important in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases. The analysis did not reveal any special location inside the rehabilitation centre with an increased risk of falls calling for urgent interventions. The active and activating physical therapies do not seem to increase the number of falls significantly.

Effect of combined spa-exercise therapy on circulating TGF-β1 levels in patients with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial joints with no satisfactory therapy. Reduction of joint pain has been reported after a course of therapy at a spa, Gasteiner Heilstollen, in Badgastein in Austria. The mechanism underlying this beneficial effect is not clearly understood and objective evidence for the biological response to therapy is lacking. The aim of this study was to find evidence for a biological response to speleotherapy in patients with AS and to study the involvement of the antiinflammatory cytokine TGF-beta1 in this response.

PATIENTS AND METHODS

83 patients with AS were treated in Badgastein for 3-4 weeks. Therapy included active exercises, hyperthermia and exposure to low doses of radon in a former mine. Response to therapy was assessed from measurement of morning pain and immunoassay of serum levels of TGF-beta1 before and after therapy. Ten AS patients who received conventional therapy and 10 patients with low back pain (LBP) served as controls.

RESULTS

A significant increase in TGF-beta1 (total and active) was found in AS patients after spa therapy. Mean concentration of total TGF-beta1 increased from 28,715 pg/ml to 43,136 pg/ml, (P<0.01) and active TGF-beta1 increased from 77 pg/ml to 1096 pg/ml (P<0.001). When the AS patients were divided into two groups according to pain reduction, group 1 (decrease in morning pain, responders: n=46) exhibited a 17-fold increase of active TGF-beta1 levels (96 pg/ml to 1654 pg/ml, P<0.0001) whereas group 2 (no change or an increase in morning pain: nonresponders: n=37), showed only 7-fold increase (53 pg/ml to 402 pg/ml, P<0.01). There was a moderate increase in active TGF-beta1 from 31 pg/ml to 42 pg/ml (P<0.05) in patients with LBP and no significant change was observed in the patients treated with conventional therapy.

CONCLUSION

These results demonstrate a significant increase in circulating TGF-beta1 in patients with AS after the combined spa-exercise therapy in Badgastein. The results also provide evidence for a biological response to speleotherapy and suggest that TGF-beta, through its antiinflammatory function, may play a role in this response.

Preferential type 1 chemokine receptors and cytokine production of CD28- T cells in ankylosing spondylitis

OBJECTIVE

To examine serum levels of type 1 and type 2 chemokines and lymphocytic expression of chemokine receptors, and to compare the results with lymphocytic cytokine production in patients with ankylosing spondylitis (AS).

METHODS

Twelve patients with AS (mean (SD) age 44.9 (14.7) years) and 27 healthy controls (46.4 (12.8) years) were enrolled into the study. The expression of chemokine receptors (CCR-5, CXCR-3, CCR-4) and cytokines (interferon gamma (IFNgamma), interleukin (IL)2, IL4, IL10, tumour necrosis factor alpha (TNFalpha)) on CD28(+) and CD28(-) T cell subtypes was analysed by a three colour FACS technique of peripheral blood samples. Serum ELISAs were performed to detect the CCR-5 ligands CCL-5, CCL-3; the CXCR-3 ligands CXCL-10, CXCL-9; and the CCR-4 ligand, CCL-17 before and after administration of the TNFalpha blocking agent infliximab.

RESULTS

CD4(+)CD28(-) T cells had higher ratios of CXCR-3 to CCR-4 than CD4(+)CD28(+) T cells. Both, CD4(+) and CD8(+)CD28(-) T cells of patients with AS produced more IFNgamma, TNFalpha, and IL10 than their CD28(+) counterparts (p<0.05), and lacked the production of IL2 and IL4. Serum levels of CXCL-9 were increased in patients with AS to 59.2 pg/ml (34.1-730.5) compared with 32.5 pg/ml (20.0-79.5) in healthy controls (p = 0.016). The levels of both type 1 (CCL-5, CXCL-9) and type 2 chemokines (CCL-17) decreased under blockade of TNFalpha (p<0.05).

CONCLUSIONS

The profile of chemokine receptor expression and cytokine production by CD28(-) T cells suggests a type 1 immune reaction in AS, although IL10 is frequently produced by CD28(-) T cells. Treatment with TNFalpha blocking antibodies decreased both types of chemokines in patients' sera.

High positive predictive value of specific antibodies cross-reacting with a 28-kDa Drosophila antigen for diagnosis of ankylosing spondylitis

OBJECTIVES

Diagnosis of ankylosing spondylitis (AS) can be difficult, and a specific laboratory test has not yet been introduced as a routine diagnostic tool. Our aim was to evaluate the diagnostic value of antibodies specifically binding to a recombinant 28-kDa antigen for the diagnosis of AS.

METHODS

Blinded sera were tested for antibodies binding to the procaryotically expressed 28-kDa protein using an enzyme-linked immunosorbent assay (ELISA). This purified 28-kDa protein is produced by a specific clone from an embryonic Drosophila hydei Xgtl I c-DNA library and is bound by human antibodies cross-reacting with both a 36-kDa protein of chromosomes from Drosophila melanogaster and a 69-Da HeLa S3 protein potentially involved in signal transduction pathways.

RESULTS

Serum concentrations of antibodies cross-reacting with this specific antigen were increased in 371 patients with AS compared with 37 healthy controls (39.5 vs 22.6 U/ml; P = 0.004). The positive predictive values of this ELISA test for AS were between 95.1% (95% confidence interval 90.6-97.9%) for a cut-off level of 50 U/ml and 97.4% (92.7-99.5%) for a cut-off level of 75 U/ml, and the sensitivities were between 42.1% (37.0-47.3%) for a cut-off level of 50 U/ml and 30.7% (26.1-35.7%) for a cut-off level of 75 U/ml.

CONCLUSIONS

Serum ELISA tests for antibodies cross-reacting with the 28-kDa antigen show a high positive predictive value for AS of more than 95%.

Radon therapy for the treatment of rheumatic diseases--review and meta-analysis of controlled clinical trials

OBJECTIVE

The aim of this study was to analyze the effect of radon therapy on pain in rheumatic diseases.

METHODS

MEDLINE and MedKur databases were searched for the terms radon plus therapy, rheum, arthritis, and osteo. Radon therapy centers and experts in the field were contacted, proceedings hand-searched, and bibliographies checked for references of potential importance. Included were all prospective randomized controlled clinical trials that compared clinical effects of radon therapy with other interventions in patients with rheumatic diseases and studied pain intensity. Information concerning patients, interventions, results, and methodology were extracted in a standardized manner by all authors independently and summarized descriptively. Reports on pain reduction were pooled for meta-analysis.

RESULTS

Five clinical trials with a total of 338 patients and comparing the effect on pain of radon baths (three trials) or radon speleotherapy (two trials) with control intervention in degenerative spinal disease (two trials), rheumatoid arthritis (one trial) and ankylosing spondylitis (two trials) met the inclusion criteria. In meta-analysis, the pooled data showed no difference immediately after treatment (P=0.13) but significantly better pain reduction in the radon group than the control group at 3 months (P=0.02) and 6 months (P=0.002) after treatment.

CONCLUSIONS

The existing trials suggest a positive effect of radon therapy on pain in rheumatic diseases. With respect to the potential clinical effect and given the increasing public interest in radon therapy, there is an urgent need for further randomized controlled clinical investigations with long-term follow-up.

Factors associated with body function and disability in patients with ankylosing spondylitis: a cross-sectional study

OBJECTIVE

To determine for patients with ankylosing spondylitis (AS) which factors are associated with disability and restricted body function.

METHODS

In 1538 patients with AS, occiput-to-wall distance, chest expansion, cervical rotation, finger-floor distance, and modified Schober test were measured cross-sectionally, and for each measure the patient's respective percentile was calculated. The mean of the 5 percentiles was summarized in the mobility restriction score (MRS). In addition, patients answered questions on disease progression and completed the Bath AS Functional Index (BASFI) questionnaire. All data were coded into 40 variables, used as independent variables in multiple regression analyses to identify factors associated with BASFI and MRS.

RESULTS

Finger-to-floor distance (beta positive, +), cervical rotation (-), time since first AS symptoms (-), age (+), height loss (+), maximum height (-), delay in diagnosis (+), hip replacement (+), regular practice of sports (-), chest expansion (-), sex (worse BASFI in females), exposure to cold and dampness (+), and regular participation in AS group physical exercises (+) were significantly associated with worse BASFI. Significantly associated factors for worse MRS were height loss (+), sex (higher MRS in males), active inflammation of the cervical region (+), age (+), maximum height (-), active inflammation of the hip region (+), involvement of shoulders (+), time since first AS symptoms (+), urethritis (-), regular practice of sports (-), involvement of feet (-), and hip replacement (+). The models explain 47% of the variance observed for both the BASFI and MRS.

CONCLUSION

The amount of variance explained for both BASFI and MRS is rather high. The results apply primarily to groups of patients, but are insufficient to guide clinical decisions in individual patients. These findings contribute to our understanding of factors influencing disability and restriction in body function in AS.

Disability motivates patients with ankylosing spondylitis for more frequent physical exercise

OBJECTIVE

To evaluate whether patients with ankylosing spondylitis who perform disease-specific exercises more frequently have fewer functional limitations and disability than those who exercise more often.

DESIGN

Cross-sectional; retrospective chart review.

SETTING

Rehabilitation center in Austria.

PARTICIPANTS

A sample of 1,500 patients with ankylosing spondylitis (1,163 men, 337 women; mean age +/- standard deviation, 50+/-12 y; disease duration, 21+/-11 y) grouped by how many times per week they performed disease-specific exercises for at least 5 minutes: group A (n=542), less than 1 time; group B (n=691), 1 to 3 times; and group C (n=267), more than 3 times.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-report of exercise frequency and a German version of the Health Assessment Questionnaire for the spondyloarthropathies (HAQ-S).

RESULTS

The HAQ-S showed significant differences among the groups (analysis of variance on ranks, P<.001). In pairwise multiple comparison, group A showed significantly less disability (median, 0.5; interquartile range [IQR], 0.2-0.8) than group B (median, 0.6; IQR, 0.3-0.9) or group C (median, 0.7; IQR, 0.3-1.0).

CONCLUSION

Patients with less disability exercised less than their more disabled counterparts. The reasons for this difference, particularly the issue of motivation, deserve more attention.

Qualitätssicherung in der Lehre von Medizinstudenten illustriert am Beispiel der Kurorttherapie beirheumatischen Erkrankungen

BACKGROUND

The currently employed methods for quality assurance in student education are frequently considered as being inadequate. In the present study the request to plan a budget for the treatment of patients with ankylosing spondylitis is presented as an additional method to assess the influence of a teaching course on the student's attitude towards certain interventions. How would medical students distribute financial resources for the treatment of patients with ankylosing spondylitis? Does a course 'Excursion to a Spa' lead to changes in budgeting by the student?

MATERIAL AND METHODS

Before and after a 4-day excursion to Bad Gastein (health resort primarily for patients with rheumatic diseases) to become better acquainted with the local treatment modalities medical students in semester 8.4 +/- 3.8 (5th year in medical school) were asked how they would distribute a fixed sum of EUR 5,000.- (= 100%) for a prospective period of 5 years over 9 given forms of treatment in a patient with ankylosing spondylitis in order to provide optimal improvement of the disease and quality of life.

RESULTS

Before the excursion the students distributed the budget as follows: drug therapy 15%, spa therapy 17%, physical therapy 14%, exercise therapy 19%, massage therapy 11%, unconventional therapies 5%, psychological therapy 7%, changes in the household environment 8%, private pleasure 4%. After the excursion to the spa the medical students assigned more financial means on spa therapy (p = 0.024, Wilcoxon test) and unconventional therapies (p = 0.015).

CONCLUSION

Creating a budget for a defined disease appears to be a useful instrument for assessing the influence of a teaching course on medical students' attitude towards certain interventions and for detecting imbalances in the presentation of therapy procedures or discrepancies between the presentation and the aims of teaching.

Prevalence, clinical relevance and characterization of circulating cytotoxic CD4+CD28- T cells in ankylosing spondylitis

Circulating CD3+CD4+CD28- cells exhibit reduced apoptosis and were found to be more enriched in patients with ankylosing spondylitis than in age-matched healthy control individuals (7.40 +/- 6.6% versus 1.03 +/- 1.0%; P < 0.001). Levels of CD4+CD28- T cells correlate with disease status as measured using a modified metrology score, but they are independent of age and duration of ankylosing spondylitis. CD4+CD28- T cells produce IFN-gamma and perforin, and thus they must be considered proinflammatory and cytotoxic. These T cells share phenotypic and functional properties of natural killer cells, strongly expressing CD57 but lacking the lymphocyte marker CD7. MHC class I recognizing and activating natural killer cell receptors on the surface of CD4+CD28- T cells may be involved in a HLA-B27 mediated co-stimulation of these proinflammatory and cytotoxic cells.

Vascular endothelial growth factor (VEGF) in ankylosing spondylitis--a pilot study

INTRODUCTION

Angiogenesis is important for the pathogenesis of chronic inflammatory diseases in joints. Inflammation itself may upregulate the expression of VEGF in rheumatic diseases. Angiogenesis may become a new target for therapeutic intervention in inflammatory joint disease.

AIM OF THE STUDY

To examine plasma levels of VEGF in AS patients and to test a possible correlation with serological and/or clinical parameters.

PATIENTS AND METHODS

Sixteen consecutive patients with definite AS were recruited from the Gasteiner Heilstollen Hospital and compared to eight healthy probands as controls. VEGF was determined in EDTA plasma samples by using an ELISA kit. Data are given as mean values (+/- SEM). The Spearman two-sided test was used to test possible correlations.

RESULTS

EDTA-plasma levels of VEGF were 75.3 +/- 19.0 pg/ml, compared to 13.8 +/- 4.7 pg/ml measured in the control group (P = 0.001). A significant correlation was found between plasma VEGF of AS patients and the BASMI score (r = 0.665, P = 0.013). Whereas VEGF was elevated in patients without treatment or NSAIDs (88.9 +/- 24.2 pg/ml), lower levels up to 43.8 pg/ml were found in patients treated with corticosteroids (34.7 +/- 4.0 pg/ml, P = 0.039).

CONCLUSIONS

Disease status of AS appears to be associated with elevated VEGF plasma levels. Whether this reflects inflammation or a truly angiogenic pathomechanism requires further investigation.

Assessment of functional ability in younger and older patients with ankylosing spondylitis: performance of the bath ankylosing spondylitis functional index

OBJECTIVE

To determine whether the Bath Ankylosing Spondylitis Functional Index (BASFI) is applicable in older patients with ankylosing spondylitis and whether it shows major differences between younger and older patients with ankylosing spondylitis.

DESIGN

BASFI total scores and every BASFI item of 202 patients with ankylosing spondylitis aged >or=60 yr (group A) and 267 patients with ankylosing spondylitis aged <or=40 yr (group B) were calculated. The results were compared with the results of the Health Assessment Questionnaire for the Spondyloarthropathies.

RESULTS

The BASFI scores had a median of 4.2 in group A and 2.6 in group B. Marked differences between the age groups were found for every item of the BASFI. Internal consistency was high in both groups. The Spearman correlation coefficient between BASFI and the Health Assessment Questionnaire for the Spondyloarthropathies was rs(A) = 0.83 in group A and rs(B) = 0.78 in group B.

CONCLUSION

The data suggest that the BASFI is also applicable to older patients experiencing AS. There is a significant difference in the BASFI score between younger and older patients with ankylosing spondylitis.

[Retained and discontinued conventional and unconventional measures by patients with Bechterew disease for modifying the course of illness]

BACKGROUND

Patients with chronic rheumatic disease often seek relief in unconventional treatments, but many of them do not share this information with their physician.

OBJECTIVE

To explore which conventional and unconventional interventions are used by patients with ankylosing spondylitis. Which of these do they continue to use and which do they give up?

PATIENTS

One-hundred fifty patients (36 female, 114 male) with ankylosing spondylitis, who presented for radon thermal treatment at the Gasteiner Heilstollen Hospital (mean age 50 +/- 11 years; disease duration 24 +/- 11 years).

METHOD

A previous investigation identified 75 interventions used by patients with AS to influence their disease. In a face-to-face, structured interview all these interventions (terms used by the patients) were now presented to 150 other patients with AS. They were asked to state whether they had already used (and given up) the respective intervention or whether they intend to continue using it and intend to use it in future.

RESULTS

A summary of all interventions previously and still used by patients showed conventional interventions (67%) to out-number unconventional (33%) interventions. Of the 150 patients, 20 stated that they use or have used more than 15 different unconventional interventions. In addition to health resort medicine (interview at a health resort!), massage therapy, physiotherapy and physical exercise were the most commonly used of the conventional interventions. Of the unconventional interventions warm climate, sea bathing, self-applied psychotherapy, vitamin pills, repression, showering with alternating cold and warm water, and self-help groups were named most frequently.

CONCLUSION

Some patients with ankylosing spondylitis use many different (33% unconventional) interventions. In the patient's view, even rather general interventions such as warm climate or sea bathing are regarded as relevant to the disease. An open doctor-patient discussion of unconventional interventions used by the patient appears reasonable. The results confirm that most patients suffering from chronic and incurable disease seek relief in unconventional therapies.

Radon progeny activity on skin and hair after speleotherapeutic radon exposure

The objective of present investigation was to measure radon progeny activity on hair and skin (forehead, paraumbilical, paravertebral) and its decrease after speleotherapeutic radon exposure in the gallery of the Gasteiner Heilstollen. Radon progeny activity was measured by means of a halogen-quenched Geiger-Mueller tube with a mica window (density 1.5-2.0 mg/cm2) and an effective diameter of 45 mm; beta efficiency 32% (210Bi), alpha efficiency 18% (241Am). Results are in counts per minute (cpm). All 17 patients were being treated for rheumatic disease in the galleries of the Gasteiner Heilstollen Hospital. The following activity (mean +/- standard error of the mean) was measured 25 (+/- 5) min after leaving the treatment area: on hair of the head, 1235+/-141 cpm; forehead, 503+/-78 cpm; paraumbilical 460+/-85 cpm; paravertebral, 270+/-39 cpm. Taking a shower did not significantly reduce radon progeny activity. Speleotherapeutic radon exposure causes a considerable increase in radon progeny activity on skin. The large surface of hair causes much greater activity on hair than on skin. Owing to their high adhesive properties, radon progenies are not reduced by taking a shower.

Circulating cytotoxic CD8(+) CD28(-) T cells in ankylosing spondylitis

Circulating CD8(+) CD28(-) T cells were found to be expanded more in patients with ankylosing spondylitis than in an age-matched healthy population (41.2 +/- 17.7% versus 18.6 +/- 7.6%). The level of CD8(+)CD28(-) T cells was dependent on the disease status, but was independent of age. Most of the CD8(+) CD28(-) T cells produced perforin after stimulation in vitro, in contrast to their CD8(+)CD28(+) counterparts. From the clinical perspective, the percentage of the cytotoxic CD8(+) CD28(-) T cells reflected a more severe course of disease, as it correlated with distinct movement restrictions, as well as the metrology score summarizing cervical rotation (in sitting position), chin-to-jugulum distance, thoracic Schober, chest expansion, and fingers-to-floor distance (P = 0.032).

Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial

OBJECTIVE

To determine the efficacy of combined spa-exercise therapy in addition to standard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis (AS).

METHODS

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 +/- 10 years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria; group 2 (mean age 49 +/- 9 years; male:female ratio 28:12) in a spa resort in Arcen, The Netherlands. The control group (mean age 48 +/- 10 years; male:female ratio 34:6) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises, walking, correction therapy (lying supine on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or sauna (Netherlands). After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks. Primary outcomes were functional ability, patient's global well-being, pain, and duration of morning stiffness, aggregated in a pooled index of change (PIC).

RESULTS

Analysis of variance showed a statistically significant time-effect (P < 0.001) and time-by-treatment interaction (P = 0.004), indicating that the 3 groups differed over time with respect to the course of the PIC. Four weeks after start of spa-exercise therapy, the mean difference in PIC between group 1 and controls was 0.49 (95% confidence interval [CI] 0.16-0.82, P = 0.004) and between group 2 and controls was 0.46 (95% CI 0.15-0.78, P = 0.005). At 16 weeks, the difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P = 0.002) and between group 2 and controls was 0.34 (95% CI--0.05-0.73; P = 0.086). At 28 and 40 weeks, more improvement was found for group 1 compared with controls (P = 0.012 and P = 0.062, respectively) but not for group 2 compared with controls.

CONCLUSION

In patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug treatment and weekly group physical therapy alone, provides beneficial effects. These beneficial effects may last for at least 40 weeks.

Prospective controlled evaluation of the influence of an excursion to a health resort on medical students' opinion about chances for outpatient rehabilitation at a health resort

OBJECTIVE

To assess the influence of an excursion to a health resort on students' opinion on the chances for outpatient rehabilitation at a health resort for cardiac and rheumatic diseases.

METHODS

A group of 17 medical students went on a 1-day excursion to Bad Orb (near Frankfurt/M.) where mainly patients with heart diseases are treated. Another group of 44 students went on a 5-day excursion to Bad Gastein (Austria) where mainly patients with rheumatic diseases are treated. Before and after the excursion students completed a questionnaire asking their opinion on the chances for outpatient rehabilitation at a health resort for acute and chronic cardiac and rheumatic diseases.

RESULTS

Students judged the chances for beneficial effects of outpatient rehabilitation at a health resort for chronic rheumatic diseases to be significantly better after the excursion to Bad Gastein than before, whereas there was no difference after the excursion to Bad Orb.

CONCLUSION

Students' opinion of chances for outpatient rehabilitation at a health resort can be influenced by an excursion to a spa, but a single 1-day excursion may not be sufficient.

[Symptoms, effects on quality of life, judgement and expectations of treatment in active ankylosing spondylitis: the patient's view]

Symptoms, Effects on Quality of Life, Judgement and Expectations of Treatment in Active Ankylosing Spondylitis: The Patient's View.In ankylosing spondylitis uncertainty prevails among rheumatologists on how to define and measure activity. In the present study the patient's view of activity was evaluated. What does active ankylosing spondylitis mean for the patient? In a standardized interview the patient was asked to describe, from his own experience, what active ankylosing spondylitis means, what bothers him most, what helps most, and what he expects from therapy. For the patient, active ankylosing spondylitis means pain (99 responses), mobility restriction (19), muscle tension (10), inability to stay supine (6), restriction in chest mobility (5) and dyspnea (5). Fatigue was mentioned by two patients. In active states patients are mainly bothered by pain (77), mobility restriction (55), consequences for social life (20) and work (18), disturbed sleep (17) and difficult breathing (16). Drugs (84) and physical activity (42) were judged the best treatments during active ankylosing spondylitis. It was no surprise that pain and mobility restriction were cited most often by the patients. Breathing difficulties were cited rather often, whereas fatigue seems not to play an important role for most patients. The results suggest that modern rheumatology may have underestimated the relevance of difficult breathing and paid too much attention to fatigue.

[Physical exercise, nutrition and sunshine exposure for the prevention of osteoporosis]

BACKGROUND

Social and economic impact of osteoporosis is growing. Prevention deserves more attention than at present. Since previous reviews on prevention of osteoporosis by the author, many original papers and reviews on the subject have been published. Which interventions are effective?

METHODS

A MEDLINE search was performed using the search terms 'osteoporosis' and 'calcium' or 'vitamin D' or 'ultraviolet' or 'sunshine' or 'nutrition' or 'exercise' or 'hormone'. Additionally, references of recent publications were searched for significant contributions. Relevant publications as assessed by the author were included into the present review.

RESULTS AND CONCLUSIONS

Regular high-impact physical exercise, a daily allowance of at least 1000 mg calcium, a sufficient supplementation with vitamin D through UVB-exposure of the skin or oral supplementation, and hormonal replacement therapy in deficiency states are the fundamentals of prevention of osteoporosis.

Serum 25-hydroxyvitamin D and parathyroid hormone in patients with ankylosing spondylitis before and after a three-week rehabilitation treatment at high altitude during winter and spring

Does a sojourn at high altitude during the winter and spring improve vitamin D status (and possibly suppress parathyroid hormone [PTH]) in patients with ankylosing spondylitis (AS)? In 73 patients with AS, serum concentrations of 25-hydroxy-vitamin D [25(OH)D] and PTH were determined before and after a three-week rehabilitation treatment at Bad Gastein (1000 m above sea level). At the first examination, serum 25(OH)D was median (25th, 75th percentile) 15.5 ng mL-1 (10.0 ng mL-1, 20.6 ng mL-1). Thirteen patients (18%) had a 25(OH)D concentration below 8 ng mL-1. In 53 patients (73%) the level was below 20 ng mL-1. After the sojourn, 25(OH)D significantly (p = 0.02) increased to 19.7 (11.3, 24.6) ng mL-1. PTH did not change significantly, being 32 (22.4, 43.9) pg mL-1 before and 30.3 (24.1, 39.9) pg mL-1 after the sojourn. Analysing different periods of sojourn, a significant (p < 0.001) increase in 25(OH)D was found in April but not in the other months. Patients with ankylosing spondylitis may have extremely low levels of 25(OH)D. The results of the present study suggest that a sojourn at high altitude in early spring is liable to reduce vitamin D deficiency.

Is chronic lymphocytic leukemia a contraindication for radon and thermotherapy?--a case report

A growing number of patients presenting for radon-thermotherapy have a history of malignant disease. The question as to whether malignancies in general are a contraindication for radon treatment or mild hyperthermia during spa therapy is still a subject of controversy. We report a patient with osteoarthritis and a frozen shoulder who repeatedly underwent speleotherapeutic radon and hyperthermia treatment in the gallery of the Gasteiner Heilstollen, Austria, despite concomitant chronic lymphocytic leukemia (B-CLL, Rai stage 0). After nine courses of radon-thermotherapy over eight years, no apparent negative impact on CLL was noted. The purpose of this case report is to encourage discussion as to whether CLL or other past or present malignancies must be considered a contraindication for spa treatment such as radon-thermotherapy.

Speleotherapeutic radon exposure of a child suffering from juvenile chronic arthritis

OBJECTIVE

Should a child be exposed to radon for therapeutic purposes?

CASE REPORT

We report on a 7-year-old boy with juvenile chronic arthritis who experienced good pain relief after therapeutic radon exposure.

DISCUSSION

Controversy exists whether children should be exposed to radon for therapeutic purposes. Benefit and risk of therapeutic radon exposure should be discussed more objectively and not emotionally.

Low radon doses sensitize MCF-7 human breast cancer cells to taxol

We studied whether human breast cancer cells show increased sensitivity to the chemotherapeutic agent taxol when they have been treated with low radiation doses (1.7-3.2 x 10(-3) Gy) from the gas radon. To this end, MCF-7 cells were cultivated in a medium either with or without dissolved radon for 3 days and then exposed to taxol (50 nM). Cells exposed to low doses of radon and then to a concentration of 50 nM of taxol exhibit a lower proliferation rate and a lower viability than cells treated with the same concentration of taxol but not irradiated. These findings indicate an important interaction of radon and taxol in the inhibition of MCF-7 cell growth.

Interleukin-6 serum concentration in ankylosing spondylitis: a reliable predictor of disease progression in the subsequent year?

The aim of the present study was to evaluate whether in ankylosing spondylitis (AS), interleukin-6 (IL-6) is a reliable predictor of changes in mobility in the subsequent year. Of 261 AS patients who had been enrolled in a previous study, 128 returned for treatment at our health centre after 1 year (+/-3 months). The variables for mobility after 1 year (II) were compared with the findings of the previous year (I). Differences in parameters for mobility were related to the serum concentration of IL-6 in the previous year. Relation between serum concentration of IL-6 and difference (II-I) in occiput-to-wall distance (Spearman's rank correlation coefficient r(s), P value) was 0.02, 0.82; chin-chest distance -0.09, 0.31; cervical rotation -0.08, 0.39; chest expansion 0.05, 0.54; finger-floor distance -0.02, 0.84; Ott sign (flexibility of the thoracic spine) -0.11, 0.22; Schober sign 0.01, 0.94. After 1 year there was a significant improvement in cervical rotation in patients with low IL-6 serum concentration (lower quartile), but not in those with high levels of IL-6 (upper quartile). No further difference was seen between patients with high or low levels of IL-6. The present data suggest that the serum concentration of IL-6 does not allow a prediction of disease progression in the subsequent year.

[Dynamics of radon decay product activity in saliva following therapeutic radon exposure]

Radon decay product activity was measured in saliva of 10 male patients 20-30 min after a 1-hour radon exposure in the gallery of the Gasteiner Heilstollen (radon activity 36.2 kBq/m(3), radon progeny activity 20.3 kBq/m(3)). In 1 patient showing relatively high activity (75th percentile) measurements were continued until 65 min after exposure. Patients were asked to collect about 2 ml of saliva in the mouth and produce it on a filter. After drying the filter at 300 degrees C, radon progeny activity was measured. Activity (median) at 20-30 min after leaving the treatment area was 4.5 Bq (25th percentile 1 Bq; 75th percentile 21 Bq). In the patient who underwent additional measurements the activity showed a further increase up to 29 Bq (35 min after radon exposure) before it continuously decreased to a very low activity (1-3 Bq) at 65 min after exposure. The results show that a significantly increased radon decay product activity is found in saliva after speleotherapeutic radon exposure. Maximum values were observed 35 min after radon exposure. Radon decay product activity almost disappeared after about 1 h.

Radon progeny activity in sweat following radon exposure in a warm and humid environment

The objective was to evaluate whether activity of radon progenies can be detected in sweat following speleotherapeutic radon exposure (40 kBq/m3) in a warm (38 degrees C) and humid (relative humidity > 70%) environment. A group of 11 male patients with spondyloarthropathy (n = 6) or non-inflammatory rheumatic diseases (n = 5) underwent a 1-h treatment in the gallery of the Gasteiner Heilstollen, and 20 min after leaving the treatment area radon progeny activity was measured in sweat by utilizing a special filter set. The results suggest that radon is discharged with sweat, causing a significant activity of radon and radon progenies on the skin. This finding may be important from a clinical point of view, since specialists experienced in radon therapy have repeatedly emphasized the importance of the degree of radioactivity on the skin for the effectiveness of treatment. It has even been claimed that the skin is the major target for radon therapy, possibly because of the influence on Langerhans' cell function.

[Use of conventional and unconventional therapies among patients with ankylosing spondylitis]

OBJECTIVE

A large share of rheumatism patients who are treated by rheumatologists use unconventional therapies additionally. What is the frequency in patients with ankylosing spondylitis who present for treatment at a radon spa?

PATIENTS

75 patients with ankylosing spondylitis presenting for treatment at the Gasteiner Heilstollen Hospital agreed to participate in the study (6 refused).

DESIGN

In an open interview a research assistant asked the patients to name all interventions which they have used for the treatment of ankylosing spondylitis.

RESULTS

Unconventional therapies (beside treatment at the Gasteiner Heilstollen) were used by 39 patients. Most frequently cited were acupuncture (15x), diet (8x), herbal therapy (7x), and homeopathy (6x). In total 40 different forms of unconventional therapies were mentioned. All patients claimed to have used at least two conventional therapies.

CONCLUSION

Patients presenting for treatment at a radon spa claim to have used conventional therapies more frequently than unconventional forms of treatment.

Speleotherapy for asthma

BACKGROUND

Speleotherapy, the use of subterranean environments, is a therapeutic measure in the treatment of chronic obstructive airways diseases. It is virtually unknown in the UK or the US, but has considerable widespread use in some Central and Eastern European countries.

OBJECTIVES

To review evidence for the efficacy of speleotherapy in the treatment of asthma.

SEARCH STRATEGY

We searched electronic databases (Medline, Embase, Cochrane Airways group database), contacted speleotherapy centres and experts in the field, hand searched proceedings, and checked bibliographies of articles obtained to identify possible relevant publications.

SELECTION CRITERIA

We included controlled clinical trials (i.e., both randomized and those not reporting the method of allocation) that compared clinical effects of speleotherapy with another intervention or no intervention in patients with chronic asthma.

DATA COLLECTION AND ANALYSIS

Information concerning patients, interventions, results, and methodology were extracted in standardized manner by two independent reviewers and summarized descriptively.

MAIN RESULTS

Three trials including a total of 124 asthmatic children met the inclusion criteria, but only one trial had reasonable methodological quality. Two trials reported that speleotherapy had a beneficial short-term effect on lung function. Other outcomes could not be assessed in a reliable manner.

REVIEWER'S CONCLUSIONS

The available evidence does not permit a reliable conclusion as to whether speleo-therapeutic interventions are effective for the treatment of chronic asthma. Randomized controlled trials with long-term follow-up are necessary.

Unconventional medicine in Central Europe: a misuse of public health insurance?

OBJECTIVE

To scrutinize the presumption maintained by critics that patients seeking medical treatment at a health resort may be more motivated by the prospect of a pleasant sojourn paid for by health insurance than by the impairment caused by a disease.

DESIGN

Variables for mobility (occiput-to-wall distance, cervical rotation, chest expansion, thoracic flexion, lumbar flexion, and finger-to-floor distance) and C-reactive protein were determined in 181 patients (male 134, female 47; age 52.4 +/- SEM 0.8 years) with ankylosing spondylitis (AS) whose costs were covered by their health insurance (group A) and in 77 AS patients (male 66, female 11; age 51.6 +/- 1.2 years) who paid their own costs (group B).

SUBJECTS

A group of 258 patients with AS presenting for 3- or 4-week speleotherapeutic radon treatment at the Gasteiner Heilstollen Hospital, a medical institution located at Badgastein in the Austrian Alps.

RESULTS

After Bonferroni correction for multiple calculations no significant difference was seen between the two groups.

CONCLUSIONS

The results suggest that patients presenting for medical treatment at a health resort suffer a like degree of disease impairment, whether they pay their own costs or not. There was no evidence that seeking treatment at a health resort may be an attempt by patients to misuse the health insurance for "sponsored" holidays.

Decrease of respiratory burst in neutrophils of patients with ankylosing spondylitis by combined radon-hyperthermia treatment

OBJECTIVE

To define the respiratory burst activity of neutrophils, the total anti-oxidative status of plasma, and the parameters of systemic inflammation in patients with ankylosing spondylitis (AS) before and after a combined radon-hyperthermia treatment in the thermal tunnels of Böckstein-Bad Gastein in Austria.

METHODS

In 20 patients with AS the effects of a total of 15 hours of radon-hyperthermia-treatment spread over a period of three weeks were studied. The respiratory burst activity of neutrophils was measured fluorometrically using dichlorofluorescein diacetate, the total anti-oxidant status was measured using azinodiethyl-benzthiazoline-sulphonate, and inflammation parameters were determined by routine laboratory assays.

RESULTS

Before treatment, the basal neutrophil respiratory burst in patients (n = 20) was 409 +/- 62 fluorescence arbitrary units (AU; mean +/- SEM) and 359 +/- 37 AU in controls (n = 9; p > 0.5); the stimulated respiratory burst (fMet-Leu-Phe, 10(-6) M) was 1,027 +/- 133 AU in patients and 1,152 +/- 218 AU in controls (p > 0.5). After treatment, the basal neutrophil respiratory burst in patients (n = 19) was 137 +/- 16 and in controls it was 174 +/- 35 AU (n = 8; p > 0.1); the stimulated respiratory burst was 670 +/- 66 and 1,305 +/- 82 AU, in patients and controls respectively (p < 0.001). No effects of treatment on the total anti-oxidant status of the plasma or on the parameters of inflammation were detected.

CONCLUSION

Combined radon-hyperthermia treatment reduces the respiratory burst activity of the blood circulating neutrophils in patients with AS. If respiratory burst activity from the neutrophils plays a role in the pathophysiology of ankylosing spondylitis, the observed reduction may be related to the beneficial effects of radon-hyperthermia treatment.

In ankylosing spondylitis serum interleukin-6 correlates with the degree of mobility restriction, but not with short-term changes in the variables for mobility

The aim of this study was to evaluate whether the serum concentration of interleukin-6 (IL-6) reflects disease activity in ankylosing spondylitis (AS). A group of 271 AS patients were enrolled in the study, 261 of whom completed the entire protocol (201 males, 60 females, median age of 53 years). Serum IL-6 was measured three times (I, baseline; II, after 10-12 days; III, after 17-24 days) during a 3- or 4-week treatment at the health resort. At the same times, the variables for mobility were measured, and the patients were asked to assess their complaints (score) in a self-styled questionnaire. The serum concentration of IL-6 correlated with the measurements of occiput-to-wall distance, cervical rotation, finger-floor distance and Schober sign, and with morning pain at all three evaluations. Comparisons between changes in IL-6 and changes in the variables (measures of mobility, scores of the questionnaires) did not reveal significant correlations. Present data would suggest that in AS the serum concentration of IL-6 indicates the degree of mobility restriction resulting from previous disease progression, but is not a reliable marker of current disease activity.

Course in massage therapy for medical students

Massage courses for medical students have been held at Frankfurt University Medical School since 1987. To evaluate the motives for participation and to record possible changes in the attitude towards massage therapy, the students were asked to fill out a standardized questionnaire in 1990, 1993 and 1995/96. The results show that the motive for participation and the attitude towards massage therapy remained widely unchanged during these years. Summarizing all data (n = 199) the motives for participation were: (1) to practise massage therapy (86%), (2) to be better able to (later) prescribe massage therapy (66%), (3) to improve palpation skills (75%), (4) to do 'something practical' (56%), and (5) to (later) practise massage therapy as a medical doctor (23%). On average, the proportion of theory and practical instruction of 1:3.2 was considered suitable.

UVB radiation and its role in the treatment of postmenopausal women with osteoporosis

In humans, the serum concentration of parathyroid hormone (PTH) is higher in winter than in summer. The increase of PTH can be suppressed by oral vitamin D supplements, which is considered beneficial to those with osteoporosis. The present study investigates whether this effect can also be achieved by serial ultraviolet (UV) irradiation of the skin. In total, 34 women suffering from postmenopausal osteoporosis were included in the open trial. In late winter, 20 patients were irradiated with a spectrum containing UVB, eight times over a period of 4 weeks. The serum concentrations of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)2D], PTH, osteocalcin, alkaline phosphatase (AP), calcium and phosphorus were measured before the first, and 2 days after the last, dose of radiation. The data were compared to the controls (n = 14, no UV exposure), who were evaluated once at the start of the study and then again 4 weeks later. After UV irradiation the level of 25(OH)D was increased, whilst that of PTH remained unchanged. The serum level of osteocalcin decreased in the control group, but did not change in the group of women who had been exposed to UV radiation. The present study of osteoporotic women does not confirm previous findings in studies of healthy volunteers i.e. that PTH can be suppressed by exposure to UVB radiation in winter. Further studies are required to specify whether there are subgroups of osteoporotic people who may benefit from exposure to UVB radiation during winter.

[Effect of a positive family history on the prognosis in patient with Bechterew disease]

The objective of the present study was to evaluate whether the patients with a family history of ankylosing spondylitis might have a milder course of the disease than patients with a negative family history. We investigated a group of 197 patients with ankylosing spondylitis who had been suffering from symptoms of the disease for > or = 20 years. After exclusion of the patients with a history, or current evidence of colitis or urethritis, the remaining 148 patients with ankylosing spondylitis (none with psoriasis) were divided into 2 groups on the basis of a positive (25 patients) or a negative (123 patients) family history of ankylosing spondylitis. The variables of mobility were compared. Furthermore, the present height was compared with the former (maximum) height. All variables measured in the present study showed slightly better results in the patients with a positive family history, but the differences were not significant. The decrease of height was slightly larger in patients with a positive family history. Evidently, a positive family history does not appear to give a reliable prediction of the long-term prognosis in Austrian and German patients with ankylosing spondylitis.