Is the severity of knee osteoarthritis on magnetic resonance imaging associated with outcome of exercise therapy?

OBJECTIVE

To evaluate associations between severity of knee osteoarthritis (OA) on magnetic resonance imaging (MRI) and treatment outcomes in knee OA patients treated with exercise therapy in an exploratory study.

METHODS

Ninety-five participants with knee OA in a 12-week exercise program had obtained 3.0T MRI scans of the knee joint prior to treatment. MRI data were systematically assessed for OA severity of multiple features (cartilage integrity, bone marrow lesions, osteophyte formation, effusion/synovitis, and meniscal abnormalities) according to the Boston Leeds Osteoarthritis Knee Score method. Regression analyses were performed to analyze associations between OA severity on MRI (for the tibiofemoral and patellofemoral [PF] compartments) and outcome of exercise therapy, i.e., changes in activity limitations (Western Ontario and McMaster Universities Osteoarthritis Index physical function; primary outcome), pain and upper leg muscle strength, and treatment response (Outcome Measures in Rheumatology/Osteoarthritis Research Society International criteria).

RESULTS

Improvements of 24%, 34%, and 21% on average in activity limitations, pain, and muscle strength, respectively, after 12-week exercise therapy were found (P < 0.001). Severity of abnormalities in PF cartilage integrity was significantly associated with fewer improvements in both activity limitations (P = 0.01) and muscle strength (P = 0.04). Severity of PF osteophyte formation was significantly associated with fewer improvements in muscle strength (P < 0.01). All other features on MRI were not associated with treatment outcome.

CONCLUSION

Effectiveness of exercise therapy seems to be independent of OA severity on MRI, except for abnormalities in cartilage integrity and osteophyte formation, both in the PF compartment. Our study suggests that all grades of OA severity on MRI can benefit from professionally supervised exercise therapy, although the effects might be reduced in patients with advanced PF OA.

Transient inflammatory-like state and microbial dysbiosis are pivotal in establishment of mucosal homeostasis during colonisation of germ-free mice

The gut microbiota is increasingly recognised as a key-player in defining the health status of the gastrointestinal tract. Recently, we demonstrated that colonisation of healthy germfree mice with a conventional microbiota (conventionalisation) elicits temporal and region specific host-microbe communication responses that lead to the establishment of a microbiota-accommodating homeostatic state within 30 days. Here, the microbiota composition profiles, mucosal transcriptomes and plasma-analytes in germ-free and conventionalised C57/BL 6 J mice were assessed to decipher the features of the distinctive and pivotal events occurring four days after initiation of the conventionalisation process. The dominance of the microbial genera Helicobacter, Sphingomonas and Mucispirillum in the gut microbiota coincided with the transient mounting of proinflammatory responses in the mucosa and the transiently elevated levels of specific (inflammatory) cytokines and amines in plasma. The overrepresented microbes have previously been associated with the potential to cause disease under certain conditions, illustrating that conventionalisation proceeds through a transient state that resembles situations associated with dysbiosis. However, no overt mucosal inflammation was observed, suggesting a pivotal role of the overrepresented bacterial groups in priming and maturation of the immune system during the process of conventionalisation. These findings imply that the transiently elevated relative overgrowth of particular microbial genera functions as pivotal adjuvants to elicit the corresponding proinflammatory cascades, which precede the full maturation of the different arms of the immune system following these events and is required to achieve a microbiota-accommodating homeostasis in healthy animals.

Avoidance of activity and limitations in activities in patients with osteoarthritis of the hip or knee: a 5 year follow-up study on the mediating role of reduced muscle strength

OBJECTIVE

To evaluate the mediating role of reduced muscle strength in the relationship between avoidance of activity and limitations in activities in patients with knee or hip osteoarthritis (OA).

METHODS

A longitudinal cohort study with 5 years follow-up was conducted. Patients with knee or hip OA (n = 288) were recruited at rehabilitation centers and hospitals. Self-reported and performance based limitations in activities, avoidance of activity and muscle strength were assessed at baseline, 1, 2, 3 and 5 years follow-up. Generalized Estimating Equations (GEE) analyses were used to evaluate mediation.

RESULTS

In patients with knee OA, reduced knee extensor muscle strength mediated the relationship between avoidance of activity and limitations in activities. In patients with hip OA reduced hip abductor muscle strength mediates the relationship between avoidance of activity and limitations in activities.

CONCLUSION

The results of this longitudinal study support the theory that avoidance of activity leads to deterioration of muscle strength and consequently to more limitations in activities in patients with knee and hip OA.

Success or failure of chronic pain rehabilitation: the importance of good interaction - a qualitative study under patients and professionals

AIM

The aim of this study was to explore which factors are associated with a successful treatment outcome in chronic pain patients and professionals participating in a multidisciplinary rehabilitation program, with a specific focus on the patient-professional interaction.

METHODS

Patients (n = 16) and professionals (n = 10) were interviewed and/or observed. The transcribed interviews and observations were analyzed and themes were described.

RESULTS

Patients with a positive treatment outcome came to a shared understanding of their pain with their professional, demonstrated new learned behavior and were able to continue their learning process at home. Patients with a negative treatment outcome did not reach a shared understanding of their pain with their professional, were not able to change their behavior and wanted more help to achieve this. Both patient groups experienced organizational barriers within the treatment process. Factors associated with a high quality of patient-professional interaction included the patient experience of being taken seriously, the involvement of the professional with the patient, a clear explanation of the pain, and an open interaction between patient and professional.

CONCLUSION

This study provides insight into factors which were related to a positively or negatively experienced outcome of pain rehabilitation. A good match within the patient-professional interaction seems essential. IMPLICATIONS OF REHABILITATION: Within chronic pain rehabilitation good didactic skills and a client-centered attitude of the professional may be helpful in order to make the patient feel being taken seriously. An assessment of the patient's learning style might lead to a better fit of the patient education and training according to an individual's learning style. Relapse might be prevented by paying special attention to the integration of new behavior within important life areas as work and sports.

Depression in systemic lupus erythematosus, dependent on or independent of severity of disease

OBJECTIVES

To estimate the prevalence of depression in subjects with systemic lupus erythematosus (SLE) in relation to the general population and to unravel the relation between depression and SLE disease characteristics.

METHODS

One hundred and two subjects with SLE (mean age 44.4 years) were studied using the Beck Depression Inventory (BDI) score to estimate the prevalence of depression. The BDI scores in subjects with SLE were compared with BDI scores from a pan-European population based study (Outcome in Depression International Network (ODIN) study, n = 7934), i.e. the general population.

RESULTS

The mean BDI score was higher in SLE subjects (10.1 points) compared with the BDI scores derived from the general population (10.1 versus 5.6 points, respectively, p < 0.001). This corresponds to a prevalence of depression of 16.6% and 6.7%, respectively. There was no association between disease activity or organ damage and BDI scores in subjects with SLE (p > 0.1). Only 7% of SLE subjects with high BDI scores used antidepressants.

CONCLUSION

The mean BDI score and prevalence of depression are significantly higher in SLE subjects compared with the general population. No association was found between SLE disease characteristics and BDI scores. The number of depressed SLE subjects treated with antidepressants is low, suggesting inadequate recognition and treatment of depression in SLE.

Distress, problems and supportive care needs of patients treated with auto- or allo-SCT

Hematological malignancies and treatment with hematopoietic SCT are known to affect patients' quality of life. The problem profile and care needs of this patient group need clarification, however. This study aimed to assess distress, problems and care needs after allo- or auto-SCT, and to identify risk factors for distress, problems or care needs. In this cross-sectional study, patients treated with allo-SCT or auto-SCT for hematological malignancies completed the Distress Thermometer and Problem List. Three patient groups were created: 0-1, 1-2.5 and 2.5-5.5 years after transplantation. After allo-SCT, distress and the number of problems tended to be lower with longer follow-up. After auto-SCT, distress was highest at 1-2.5 year(s). Patients mainly reported physical problems, followed by cognitive-emotional and practical problems. A minority reported care needs. Risk factors for distress as well as problems after allo-SCT included younger age, shorter time after transplantation and GVHD. A risk factor for distress as well as problems after auto-SCT was the presence of comorbid diseases. Up to 5 years after auto-SCT or allo-SCT, patients continue to experience distress and problems. Judged by prevalence, physical problems are first priority in supportive care, followed by cognitive-emotional and practical problems.

Long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis: a longitudinal study

OBJECTIVE

To describe long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA).

METHODS

Longitudinal data over a period of 11 years were collected from 882 patients with RA at study inclusion. Patient-reported outcomes were collected in 1997, 1998, 1999, 2002, and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the physical component summary score of the Short Form 36 health survey. Somatic comorbidity was measured by a questionnaire including 12 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Studies Depression Scale. We distinguished 4 groups of patients based on comorbidity at baseline.

RESULTS

Seventy-two percent of the patients at baseline were women. The mean ± SD age was 59.3 ± 14.8 years and the median disease duration was 5.0 years (interquartile range 2.0-14.0 years). For the total group of patients with RA, physical functioning improved over time. Patients with somatic comorbidity, comorbid depression, or both demonstrated worse physical functioning than patients without comorbidity at all data collection points. Both groups with comorbid depression had the lowest scores. Only patients with both somatic comorbidity and comorbid depression showed significantly less improvement in physical functioning over time.

CONCLUSION

Both somatic comorbidity and comorbid depression were negatively associated with physical functioning during an 11-year followup period. Furthermore, their combination seems to be especially detrimental to physical functioning over time. These results emphasize the need to take somatic comorbidity and comorbid depression into account in the screening and treatment of patients with RA.

Are long-term psychiatric patients causing more crisis consultations outside office hours in mental health care?

BACKGROUND

As well as an improvement in community services, the de-institutionalization of patients receiving long-term psychiatric care can lead to marginally staffed mental health services, more homelessness, rising admission rates and more people in prison cells. It is assumed that an imbalance between community and hospital care for chronic patients puts pressure on crisis services.

AIMS

In this study, the central question is whether patients receiving long-term psychiatric care in Amsterdam do indeed put pressure on the city's emergency mental health services. We compare the pressure exerted by this group with the pressure resulting from the use of these services by all registered patients.

METHODS

Data were taken from the client registration systems of three mental health organizations in Amsterdam in the period from 2000 to 2004. Inclusion criteria for long-term psychiatric patients were age above 19 years and uninterrupted receipt of mental health care for a minimum of two successive years.

RESULTS

Annually, 6%-8% of all non-long-term patients experienced a crisis outside office hours in the period under investigation; this was 4%-6% for long-term patients. The non-long-term patients accounted for 83% of crisis contacts outside office hours over the entire study period, with long-term patients accounting for 17%.

CONCLUSIONS

The assumption that crises are more prevalent in long-term patients in the community seems to be an example of stigmatization rather than an observation based on fact.

Knee joint stabilization therapy in patients with osteoarthritis of the knee: a randomized, controlled trial

OBJECTIVE

To investigate whether an exercise program, initially focusing on knee stabilization and subsequently on muscle strength and performance of daily activities is more effective than an exercise program focusing on muscle strength and performance of daily activities only, in reducing activity limitations in patients with knee osteoarthritis (OA) and instability of the knee joint.

DESIGN

A single-blind, randomized, controlled trial involving 159 knee OA patients with self-reported and/or biomechanically assessed knee instability, randomly assigned to two treatment groups. Both groups received a supervised exercise program for 12 weeks, consisting of muscle strengthening exercises and training of daily activities, but only in the experimental group specific knee joint stabilization training was provided. Outcome measures included activity limitations (Western Ontario and McMaster Universities Osteoarthritis Index - WOMAC physical function, primary outcome), pain, global perceived effect and knee stability.

RESULTS

Both treatment groups demonstrated large (∼20-40%) and clinically relevant reductions in activity limitations, pain and knee instability, which were sustained 6 months post-treatment. No differences in effectiveness between experimental and control treatment were found on WOMAC physical function (B (95% confidence interval - CI) = -0.01 (-2.58 to 2.57)) or secondary outcome measures, except for a higher global perceived effect in the experimental group (P = 0.04).

CONCLUSIONS

Both exercise programs were highly effective in reducing activity limitations and pain and restoring knee stability in knee OA patients with instability of the knee. In knee OA patients suffering from knee instability, specific knee joint stabilization training, in addition to muscle strengthening and functional exercises, does not seem to have any additional value. Dutch Trial Register (NTR) registration number: NTR1475.

No evidence for the effectiveness of a multidisciplinary group based treatment program in patients with osteoarthritis of hands on the short term; results of a randomized controlled trial

OBJECTIVE

To examine the efficacy of a multidisciplinary non-pharmacological intervention in patients with hand osteoarthritis (OA).

METHOD

Parallel group randomized controlled trial was performed in three participating rheumatology outpatient clinics in the Netherlands. Block randomization was performed using a computer generated permuted block scheme (blocks of four). An independent person randomly assigned 151 participants with clinical hand OA to four sessions of multidisciplinary non-pharmacological treatment, or 30 min education followed by 3 months waiting time. Participants and therapists were not blinded to the assigned intervention. The research assistant who assessed all outcomes was blinded to the assigned intervention. Subscale limitations in activities of the Australian Canadian Osteoarthritis Hand Index (AUSCAN) and OARSI responder criteria (primary outcomes) and secondary outcome measures, were assessed at baseline and 12 weeks. Linear or logistic regression analyses were used, where appropriate, with the outcome as dependent and the intervention group as independent variable. The analyses were adjusted for baseline values.

RESULTS

At 3 months no significant and no relevant differences were observed between the experimental (n = 76) and control group (n = 75) in any of the primary or secondary outcome measures. In both groups about one-third of patients were classified as responder.

CONCLUSION

There is insufficient evidence to confirm a clinically relevant treatment effect on the short term, between patients who followed a multidisciplinary treatment program and those who received only written information. Since hand OA causes a range of impairments and limitations in activities, programs with more guidance to formulate and implement individually tailored treatment plans could be probably more effective. Furthermore, more research is needed on the efficacy of single treatment elements. (Dutch Trial Register trial number NTR1191).