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Leerling AT, Niesters M, Flendrie M, Tel M, Appelman-Dijkstra NM, Dekkers OM, Winter EM. Response to: "Is Mixed Pain Really Common in Adult CNO?". Calcif Tissue Int 2024:10.1007/s00223-024-01264-7. [PMID: 39031206 DOI: 10.1007/s00223-024-01264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/22/2024]
Affiliation(s)
- Anne T Leerling
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology and Pain Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel Flendrie
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Marije Tel
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
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Leerling AT, Ueckert DA, Van der Giesen FJ, Vliet-Vlieland T, Winter EM. Role of physical therapy in adult chronic non-bacterial osteitis: patients' and therapists' perspectives. Scand J Rheumatol 2024:1-10. [PMID: 38832471 DOI: 10.1080/03009742.2024.2352965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Chronic nonbacterial osteitis (CNO) is a rare bone disease causing pain and functional impairment. We aimed to explore the application of physical therapy (PT) for adult CNO from the patients' and primary care therapists' perspective. METHOD Cross-sectional study among the Dutch adult CNO cohort (1992-present). A survey on PT-use for axial spondylarthritis was adapted for CNO. Patients using PT in the past 2 years (recent PT-users) were asked about modalities, perceived effects, satisfaction, and preferences for provision. Their current physical therapists were invited to complete a self-developed survey covering therapy details and educational preferences. RESULTS 80/199 invited patients and 14/16 invited therapists completed the survey respectively. 41 (51%) patients used PT for CNO in the preceding 2 years, 14 (18%) used PT >2 years back, and 25 (31%) never used PT. Recent PT-users (n=41) reported diverse treatment modalities, involving massage (61%), joint mobilizations (44%), breathing exercises (49%), muscle strengthening (32%) and counselling through of home-exercises (46%) and pain education (32%). 64% of all patients desired greater emphasis from physicians regarding the role of PT. Most therapists would appreciate referral letters with CNO-specific information (93%), and consultations with specialized therapists (86%). CONCLUSIONS In this study, two-third of adult CNO patients had -ever or recently- used PT, which involved variable therapeutic modalities. Most patients were receptive to a larger role of PT in CNO-management and most therapists preferred CNO-specific information to optimize their care. These findings provide a foundation for the development and systematic evaluation of CNO-specific PT.
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Affiliation(s)
- A T Leerling
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - D A Ueckert
- Department of Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Van der Giesen
- Department of Rheumatology, Zuyderland Ziekenhuis, Heerlen, The Netherlands
| | - Tpm Vliet-Vlieland
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E M Winter
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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Leerling AT, Niesters M, Flendrie M, Tel M, Appelman-Dijkstra NM, Dekkers OM, Winter EM. Neuropathic and Nociplastic Pain Profiles are Common in Adult Chronic Nonbacterial Osteitis (CNO). Calcif Tissue Int 2024; 114:603-613. [PMID: 38627292 PMCID: PMC11090977 DOI: 10.1007/s00223-024-01214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/28/2024] [Indexed: 05/14/2024]
Abstract
Chronic nonbacterial osteitis (CNO) is a rare musculoskeletal disease causing chronic bone pain. It is known that chronic musculoskeletal pain may involve other mechanisms than nociceptive pain only. We investigate the prevalence of neuropathic and nociplastic pain in adult CNO and their association with clinical characteristics and treatment outcomes. Survey study among the Dutch adult CNO cohort (n = 84/195 participated), including PAIN-detect for neuropathic pain, and the Central Sensitization Inventory (CSI), Fibromyalgia Rapid Screening Tool (FiRST), and ACTTION-APS Pain Taxonomy (AAPT) for nociplastic pain. Clinical characteristics and CNO-related bone pain scores were compared between patients with exclusive nociceptive pain and those with nociceptive pain plus neuropathic and/or nociplastic pain (mixed pain). 31% (95% CI 21-41) of patients classified as likely having neuropathic pain according to PAIN-detect. 53% (41-64) of patients displayed central sensitization on CSI, 61% (50-72) screened positive for fibromyalgia on FiRST and 14% (7-23) of patients fulfilled the AAPT criteria, all indicative of nociplastic pain. Mixed pain was associated with longer diagnostic delay (mean difference 2.8 years, 95% CI 0.4-5.2, p = 0.023), lower educational level (72% versus 20%, p < 0.001), and opioid use (37% versus 13%, p = 0.036). Despite comparable disease severity and extent, patients with mixed pain reported significantly higher CNO-related bone pain scores. This study demonstrates the high prevalence of mixed pain in adult CNO, in which neuropathic and nociplastic pain exist alongside nociceptive inflammatory bone pain. Disease burden in CNO may extend beyond inflammatory activity, highlighting the need for a multifaceted management approach.
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Affiliation(s)
- Anne T Leerling
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology and Pain Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel Flendrie
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Marije Tel
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Olaf M Dekkers
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- Center for Bone Quality, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.
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Ramautar AIE, Navas A, Winter EM, Kroon HM, Smit F, Vriens D, Hamdy NAT, Appelman-Dijkstra NM. Defining the imaging diagnostic criteria for adult chronic non-bacterial osteitis. JBMR Plus 2024; 8:ziae024. [PMID: 38606147 PMCID: PMC11008733 DOI: 10.1093/jbmrpl/ziae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 04/13/2024] Open
Abstract
Osteitis of the sternocostoclavicular (SCC) region, referred to as sternocostoclavicular hyperostosis (SCCH), is the clinical expression of chronic non-bacterial osteitis (CNO) in adults with this rare chronic auto-inflammatory disorder of the axial skeleton. The diagnosis is based on distinctive computerized tomography (CT) features of sclerosis and hyperostosis of the SCC region, and local increases in osteoid formation visualized by high radiopharmacon uptake on skeletal scintigraphy but clear radiologic diagnostic criteria are lacking. In a cross-sectional study, CT scans and whole-body skeletal scintigraphy images obtained in 169 patients seen at the Center for Bone Quality of the Leiden University Medical Center between 2008 and 2018 with a suspected diagnosis of CNO of the SCC region were re-evaluated by 2 skeletal radiologists and 2 nuclear physicians. The diagnosis was confirmed in 118 (70%) predominantly female patients (n = 103, 89.2%); median age at first symptoms 45 years (range 20-73). The diagnosis was excluded in the remaining 51 "non-CNO" patients. Increased radiopharmacon uptake at the SCC region was observed in 82% CNO patients, with the manubrium sterni having the highest predictive ability to discriminate on both imaging modalities. The prevalence of sclerosis of the clavicles, manubrium and first ribs was significantly higher in CNO patients (P < 0.001). Hyperostosis was not observed in non-CNO patients. 46 CNO versus only 2 non-CNO patients had costoclavicular ligament calcification. Our findings identify CT scan features of sclerosis and hyperostosis of manubrium sterni, medial end of clavicles and first ribs, and calcification of costoclavicular ligaments, associated with increased tracer uptake on skeletal scintigraphy at the SCC region, specifically manubrium sterni, as well-defined imaging diagnostic criteria for adult CNO. Pitfalls encountered in the diagnosis of CNO are highlighted. These defined imaging diagnostic criteria for adult CNO should facilitate the diagnosis of this rare auto-inflammatory bone disease across the spectrum of its early to late stages.
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Affiliation(s)
- Ashna I E Ramautar
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Ana Navas
- Section of Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Herman M Kroon
- Section of Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits Smit
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Dennis Vriens
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Neveen A T Hamdy
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Li SWS, Roberts E, Hedrich C. Treatment and monitoring of SAPHO syndrome: a systematic review. RMD Open 2023; 9:e003688. [PMID: 38151265 PMCID: PMC10753757 DOI: 10.1136/rmdopen-2023-003688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Synovitis acne pustulosis hyperostosis osteitis (SAPHO) is a rare heterogeneous disease of unknown aetiopathology. Externally validated and internationally agreed diagnostic criteria or outcomes and, as a result, prospective randomised controlled trials in SAPHO are absent. Consequently, there is no agreed treatment standard. This study aimed to systematically collate and discuss treatment options in SAPHO. METHODS Following 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' guidance, a systematic literature search was conducted using PubMed, Scopus and Web of Science databases. Prospective clinical studies and retrospective case collections discussing management and outcomes in SAPHO involving five or more participants were included. Articles not published in English, studies not reporting defined outcomes, and studies solely relying on patient-reported outcomes were excluded. RESULTS A total of 28 studies (20 observational, 8 open-label clinical studies) reporting 796 patients of predominantly European ethnicity were included. Reported therapies varied greatly, with many centres using multiple treatments in parallel. Most patients (37.1%) received non-steroidal anti-inflammatory drugs alone or in combination. Bisphosphonates (22.1%), conventional (21.7%) and biological (11.3%) disease-modifying antirheumatic drugs were the next most frequently reported treatments. Reported outcomes varied and delivered mixed results, which complicates comparisons. Bisphosphonates demonstrated the most consistent improvement of osteoarticular symptoms and were associated with transient influenza-like symptoms. Paradoxical skin reactions were reported in patients treated with TNF inhibitors, but no serious adverse events were recorded. Most treatments had limited or mixed effects on cutaneous involvement. A recent study investigating the Janus kinase inhibitor tofacitinib delivered promising results in relation to skin and nail involvement. CONCLUSIONS No single currently available treatment option sufficiently addresses all SAPHO-associated symptoms. Variable, sometimes descriptive outcomes and the use of treatment combinations complicate conclusions and treatment recommendations. Randomised clinical trials are necessary to generate reliable evidence.
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Affiliation(s)
- Sophie W S Li
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Eve Roberts
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Christian Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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