Should we use non-steroidal anti-inflammatory drugs?

Both the relative efficacy and inefficacy of non-steroidal antiinflammatory drugs (NSAIDs) contribute to their use in chronic rheumatic diseases. There are also sociological trends in patients, and in the population as a whole, increasing demand for treatment. In view of the risks of such treatment, the most rational approach to prescribing would be the use of a scientific risk-benefit analysis. Unfortunately, the data, especially those related to symptom relief, are inadequate for such an analysis. Until more meaningful figures are produced, good clinical practise concentrates on the responsibilities of physicians who both start and stop drugs, and makes it essential that strategies to minimize risk are produced.

Heel pad stiffness in runners with plantar heel pain

OBJECTIVE

To evaluate significant differences in heel pad stiffness within a cohort of runners with diagnosed plantar heel pain and to explore the clinical importance of maximum heel pad stiffness values.

DESIGN

A cross-sectional design was used to quantify the heel pad stiffness of 166 runners with 33 diagnosed with plantar heel pain.

BACKGROUND

Palpation is still widely used to evaluate heel pad stiffness subjectively in everyday clinical practice. However, there is limited quantifiable data pertaining to heel pad stiffness measurements in runners and those with heel pain.

METHODS

A portable hand-held device measured force applied by a metal probe, and its displacement into the plantar surface of the heel pad. Non-linear modelling allowed curve coefficients b0 and b1 to be evaluated and was described by an exponential function using a non-linear regression equation. Exploratory analysis was used to describe a single-point approximation for clinical use.

RESULTS

An independent t-test demonstrated a statistically significant difference between the curve coefficient b1 (p<0.05). No significant difference was found for coefficient b0 between the plantar heel pain group and the non-plantar heel pain group (p>0.05). Exploratory analysis demonstrated maximum mean stiffness of 3.22 N/mm for the non-plantar heel pain group and 2.87 N/mm for the plantar heel pain-group, an 11% mean difference.

CONCLUSION

The results suggested that heel pad stiffness may be associated with plantar heel pain subjects.

RELEVANCE

Heel pad stiffness measurements may give a better insight into the mechanical properties of the heel pad in subjects with plantar heel pain.

Development and validation of a self-efficacy scale for use in British patients with rheumatoid arthritis (RASE)

OBJECTIVE

Current arthritis self-efficacy scales have attracted some criticism. Therefore, the aim of this study was to develop and validate a measure of self-efficacy for use in British rheumatoid arthritis patients [Rheumatoid Arthritis Self-efficacy (RASE) scale].

METHODS

Phase I: item generation of self-management strategies by rheumatology professionals and patients to create a pilot RASE. Phase II: examination of the internal structure (n=88) using correlation coefficients and principal component analysis (PCA) to create the final RASE. Phase III: reliability in 23 patients. Phase IV: comprehension, construct validity and sensitivity to change in 48 rheumatoid arthritis patients undergoing a self-management programme, using correlation coefficients, PCA and inter-item correlation.

RESULTS

Phase I: of 166 self-management items generated, 100 commonly cited items were selected for the pilot RASE. Phase II: using a correlation matrix and PCA, a 28-item RASE was created. Phase III: good 4-week reliability was seen (r=0.889, P<0.001). Phase IV: the final RASE was shown to be independent of mood, disease status and disability and weakly associated with other self-efficacy scales (r=0.313, P<0.05). The RASE was sensitive to change following an education programme (+5.167, P<0.025), and was associated with behaviour initiation (r=0.35, P<0.01).

CONCLUSIONS

Careful construction means that the RASE examines beliefs in potential ability to perform tasks, rather than actual ability, performance or outcome expectancy. It shows good face validity and reliability, plus reasonable construct validity and sensitivity. Further studies are needed to support the validation of this new scale.

Introducing clinical governance in an acute trust

The introduction of clinical governance is a major imperative for the NHS. This paper describes the initial actions taken in a large acute trust to prepare for the clinical governance process. While this description is particular to one trust, it is hoped that it offers some generalizable lessons.

Ultrasonic heel pad thickness measurements: a preliminary study

The heel pad has an important role in pain-free locomotion due to its shock-attenuation function. Various diagnostic techniques are available to measure heel pad thickness. Ultrasonic measurement of the heel pad is inexpensive, involves no ionizing radiation and is portable, making it an ideal screening technique. Measurement errors may occur between different ultrasonic techniques used to measure heel pad thickness. A new standardized ultrasonic technique was performed on 15 healthy volunteers. The ultrasonic measurements were compared with the measurement obtained from a normal non-weightbearing heel pad thickness ultrasonic assessment. The results demonstrated a significant mean difference (p < 0.001) between the two techniques. The 95% confidence interval of the heel pad thickness difference indicated values between 7.68 and 9.13 mm. These results suggest that a standardized technique reduces the variability of measurement error when using weightbearing ultrasound, allowing a more reproducible diagnostic technique for assessing heel pad function, and improving patient management.

Choice of NSAID and management strategy in rheumatoid arthritis and osteoarthritis. The impact on costs and outcomes in the UK

OBJECTIVE

Although nonsteroidal anti-inflammatory drugs (NSAIDs) are an effective therapy for rheumatoid arthritis, they are associated with significant adverse effects, the management of which imposes additional costs on the healthcare system. Prescribing NSAIDs which have a lower risk of major adverse effects as the first-line NSAID for patients with rheumatoid arthritis and osteoarthritis may be expected to lead to an improvement in clinical outcomes and reduce overall treatment costs. This analysis examines data from a published randomised controlled trial of 5 NSAIDs to explore these hypotheses.

DESIGN AND SETTING

Data from a clinical trial comparing 5 NSAIDs were combined with published cost data to construct 2 clinical decision models, reflecting alternative approaches to the management of major and minor adverse effects in the UK.

INTERVENTIONS

The 5 NSAIDs evaluated in the analysis were nabumetone, diclofenac, ibuprofen, piroxicam and naproxen, although only the results for ibuprofen and nabumetone are reported.

MAIN OUTCOME MEASURES AND RESULTS

The total cost of care per patient receiving nabumetone was estimated to be between 25 pounds sterling (Pound) and 41 Pounds more expensive than ibuprofen. In a hypothetical cohort of 100,000 patients, there were between 690 and 821 more major adverse effects using ibuprofen than nabumetone. The cost per life-year gained (LYG) from using nabumetone rather than ibuprofen ranged between 1880 Pounds and 2517 Pounds (1995 values), depending upon the management of adverse effects.

CONCLUSIONS

These results indicate that: (i) prescribing the newer, currently more expensive, NSAIDs will not necessarily lead to cost savings; (ii) the management of adverse effects can have a significant impact on costs; and (iii) the additional cost may be justifiable in terms of the mortality and morbidity gains associated with the new lower-risk NSAIDs.

Clinical economics review: gastrointestinal complications of non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used symptomatic remedies for rheumatic disorders. Their major side-effects involve the gastrointestinal tract and, while the stomach is often the prime focus of adverse reactions, the whole gut may be involved. A number of strategies have been used to reduce both the incidence of side-effects and their economic consequences. Decreased NSAID use can be achieved both by rational prescribing and by active promotion of other, usually non-pharmacological, methods of controlling symptoms. Prescribing NSAIDs based on their cost assumes all have equal efficacy and side-effects, which is demonstrably untrue. Picking the least toxic NSAID is more logical. Most of the larger studies and meta-analyses available concentrate on older NSAIDs and risk overlooking the advantages of newer preparations which have been shown to be cost beneficial by more comprehensive economic analyses. Misoprostol prophylaxis has been the subject of a number of economic evaluations which, until recently, were based on extrapolations rather than clinical data. There are now good clinical data available which show a small but significant reduction in major side-effects at the expense of an increase in minor but unpleasant ones. Proton pump inhibitors appear to offer the same degree of gastroprotection as misoprostol, with the additional benefit of symptom relief. Economic data regarding the costs and benefits of prophylaxis with proton pump inhibitors are not yet available. There is still a need for a more comprehensive evaluation of the benefits of NSAIDs in different clinical situations to balance against the costs of adverse reactions.

Coincident seronegative spondarthritis: a case report

A patient is described in whom ankylosing spondylitis (AS) and reactive arthritis (ReA) coincided. Follow-up five years later showed no progression of his AS. He demonstrates that some individuals do have the capacity to express seronegative spondarthritides in different ways, possibly dependent on the infective trigger. The lack of long term effect of the second disease is both clinically reassuring and theoretically intriguing.

Polymyalgia rheumatica, temporal arteritis and malignancy

The use of steroid therapy in polymyalgia rheumatica and temporal arteritis is necessary and usually effective, but may mask coexisting disease. The importance of early consideration of other disorders in such patients is illustrated by three case histories.

Intra-articular and soft tissue injections: a survey of current practice

Intra-articular and soft tissue injections are the two most frequently used procedures in rheumatological practice. A questionnaire completed by 172 consultant rheumatologists aimed to ascertain the techniques used in these procedures. The results showed a wide divergence of practice in almost every aspect of technique. Respondents were willing to undertake injections in almost any location, but differed widely regarding personal and patient preparation before injection. About one-quarter used no local anaesthetic, the majority using local anaesthetic before or with the corticosteroid. Admission overnight or as a day case for injection of weight-bearing joints was practised by 18%. Post-injection advice was extremely variable. The results suggest that there is at present no single consensus technique for intra-articular and soft tissue injections amongst British consultant rheumatologists.

Non-steroidal anti-inflammatory induced diaphragm disease of the small intestine: complexities of diagnosis and management

A 52-yr-old lady with RA on long term NSAIDs developed an iron-deficiency anaemia and subsequently presented with subacute intestinal obstruction. After intensive investigation, a diagnosis of diaphragm disease of the small intestine was made at laparotomy. The features of diaphragm disease and the difficulties with diagnosis and management of the condition are discussed.

Changes in stiffness following short- and long-term application of standard physiotherapeutic techniques

A computer-controlled MCP joint arthrograph was developed to measure the stiffness of finger joints objectively. This was used to study the short-term (one application) and long-term (multiple applications over 6 weeks) effects of several physiotherapeutic methods on the reduction in joint stiffness. The techniques used were hot wax baths, pulsed ultrasound alone, wax baths plus pulsed ultrasound and exercise. In the short-term (i.e. after each application) wax plus ultrasound produced a statistically significant reduction in elastic torque range (P < 0.01) and dissipated energy (P < 0.05). However, the reductions in these stiffness parameters were temporary. Long-term no significant reductions in stiffness were measured. In other words, stiffness was reduced by each therapy session, but it then increased again before the next session. Wax, ultrasound alone or exercise produced no short- or long-term effects.

Evaluating new physical treatments

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The effect of exercise on ankylosing spondylitis--a preliminary study

The Polhemus Navigation Sciences 3Space Isotrak system was used to measure the range of lumbar spinal motion of 57 patients with ankylosing spondylitis. Forty-three of these attended voluntary exercise sessions for an average of one and a half hours per week while 14 did not participate in any formal exercise groups. Exercising patients fell into two groups: those attending moderate and those attending vigorous exercise sessions. Results for exercising patients obtained immediately pre- and post- a single exercise session showed a small but significant increase in extension for the vigorous exercise group but no significant changes in any other movement for either of the groups. In a group of 44 patients (33 exercising, 11 non-exercising) who were followed-up over a 2 to 6 month period, slight loss of flexion (5.5 degrees) and lateral bend (3 degrees) was observed but there was no change in range of extension.

Ankylosing spondylitis

Ankylosing spondylitis is an inflammatory disease involving entheses and joints, especially those in and around the spine. The most widespread involvement of the respiratory system by this disease occurs when this pathological process gives rise to chest wall pain, diminished chest wall movement and a dorsal stoop. As healing of the inflammatory process takes place, calcification occurs which leads to rigidity of these structures, with consequent loss of chest expansion which is exacerbated by the increasingly kyphotic spinal posture and intercostal muscle inefficiency. Fortunately diaphragmatic function is unimpaired and compensates well, so that there are only minor restrictive changes found in tests of respiratory function. Treatment is by mobilizing physiotherapy coupled with a home exercise programme encouraging mobility and improved cardiovascular fitness. As with many physical treatment methods, good quality controlled studies of efficacy are rare. The role of medication is to ease symptoms and hence enable exercise. Apical fibrobullous lung disease is found in a small proportion of AS patients. The initial changes are mainly fibrotic, with bullae becoming more important as the condition progresses. The disease may progress to major cavitation, which is prone to infection, especially with aspergillae. No methods exist which can either prevent the development of fibrobullous disease or halt its progression, although this may happen spontaneously. The main effects of therapy are aimed at the diagnosis and treatment of superinfection. Treatment of established aspergillosis, especially when aspergilloma formation has taken place, is unsatisfactory and carries substantial risks of morbidity and death. Non-apical pleural involvement, including pleural effusion, is very rare. The most common cause of breathlessness in AS patients is cardiac involvement by the disease.

A finger function simulator and the laboratory testing of joint replacements

The design of a metacarpophalangeal (MCP) joint function simulator was undertaken and resulted in a versatile machine which offers the facility to apply both dynamic and static loading to a joint, following closely the physiological levels and patterns imposed in vivo. An additional feature was the opportunity to investigate the effect of varying the degree of joint instability. Long-term tests performed on Swanson silastic implants have produced failures of the kind seen clinically, which is very encouraging since it would seem to validate the claim that the simulator successfully imitates the finger function.

A laboratory and clinical study of pneumatic 'grip strength' devices

The use of inflated bags or cuffs to measure grip strength is now a well established technique. The method does have a number of problems. Bags of different diameter and volume were seen to give statistically significantly different pressure readings when squeezed by the same subjects. Different initial pressures (from 20 mmHg to 60 mmHg) also gave significantly different results both in laboratory tests on a materials testing machine and when patients with rheumatoid arthritis squeezed the bag. The technique of squeezing also affected the results. Despite the intrinsic drawbacks of the system, it is likely to remain in general use because of familiarity and convenience. We recommend the minimum details required when pneumodynamometer-derived data are published.

Prevalence of NSAID-induced gastrointestinal morbidity and mortality

Nonsteroidal antiinflammatory drugs (NSAID) are prescribed to tens of millions of patients worldwide, usually for the treatment of rheumatic symptoms. Rheumatologists consider them to be safe and effective drugs, whereas gastroenterologists have increasing concern regarding their gut toxicity. Although dyspepsia may be overcome by a variety of methods, major gut hemorrhage and perforation often occur in the absence of symptoms. It has been estimated that as many as one third of such events in people over age 60 years may be attributable to NSAID. We need, therefore, to devise strategies to cope with this problem. The goals of such strategies must include minimizing inappropriate NSAID prescribing and identifying particularly vulnerable patients among those who need such drugs so that prophylactic coprescription can be effectively and economically targeted.

A comparison of nefopam and flurbiprofen in the treatment of osteoarthrosis

A double-blind cross-over study was undertaken comparing the analgesic nefopam with the NSAID flurbiprofen in the treatment of osteoarthritis of the knees. Thirty patients entered the study and 18 completed the full trial protocol of one month on each drug. There was no significant difference in efficacy between the two treatments, although there were more side effects during the nefopam period. These must be balanced against the known gastrotoxicity of NSAIDs when choosing symptomatic treatment for osteoarthrosis.

Disappearing hypertrophic osteoarthropathy

A case is presented in which florid hypertrophic osteoarthropathy regressed clinically and radiologically when a Celestin tube was removed.

Identification of factors limiting the accurate measurement of plasma D-penicillamine in rheumatoid arthritis patients

Free and total reduced concentrations of D-penicillamine have been measured in the plasma of rheumatoid arthritis patients by HPLC and electro-chemical detection. A reverse-phase ion-pair separation in conjunction with a dual porous graphite electrode satisfied the requirements of robustness, sensitivity, selectivity and suitable retention time. Plasma levels measured between 1.5 and 3 h after an oral dose, were less than 0.3 to 57.6 mumol/L and 0.6 to 85.0 mumol/L (n = 26) for free and total reduced drug concentrations, respectively. Sources of error in the accurate measurement of peak plasma D-penicillamine levels were identified as oxidative loss and alteration in the free to protein-bound ratio in the period following sample collection.

Assessment of stiffness in rheumatology: the use of rating scales

A study of 100 patients with rheumatoid arthritis has shown good correlation amongst three rating scales when used for measuring severity of morning stiffness and severity of stiffness present at the time of interview. Duration of morning stiffness was found to correlate only moderately well with severity of morning stiffness and poorly with severity of stiffness present at the time of interview. Investigation of the patients' definitions of stiffness, with and without the aid of a list of descriptive words, indicated an inter-relationship of pain and limited movement in the majority. This linking of the two symptoms under the term 'stiffness' may explain why some objective methods of measurement do not appear to reflect the subjective stiffness of which patients complain.

Saline washout for knee osteoarthritis: results of a controlled study

Twenty patients with persistent symptoms due to osteoarthritis of the knee were randomly allocated to a saline washout or control group. Both groups showed improvement. Knee washout conferred no more benefit than intra-articular saline injection.

The effects of differing pharmaceutical preparations of indomethacin on night pain and morning stiffness in patients with rheumatoid arthritis

A study was carried out in 18 patients with rheumatoid arthritis to compare the effects of two different preparations of indomethacin with placebo on night pain, sleep and duration of morning stiffness. Patients were treated for 1 night each, in random order, with identical capsules containing 75 mg indomethacin, either as 'Indomod' (all sustained-release form) or 'Indocid' R (25 mg normal, 50 mg sustained-release form), or placebo as a substitute for their usual night-time medication. The results of visual analogue scale scores and a standard sleep assessment questionnaire score indicated the same order of effectiveness for each of the three parameters, with 'Indomod' best, 'Indocid' R intermediate and placebo worst, but only the difference in sleep was statistically significant. 'Indomod', therefore, might offer a slight advantage over the same dose of indomethacin as 'Indocid' R given at night. Less side-effects were produced by active treatment than by placebo and none was severe.

Measurement of stiffness in the metacarpophalangeal joint: the effects of physiotherapy

Five common modes of physiotherapy were applied to a group of normal subjects and to a group of patients with rheumatoid arthritis. The metacarpophalangeal joint stiffness was measured before therapy and immediately afterwards and the results compared. The only statistically significant result was that short-wave diathermy and ultrasound both reduced the amount of energy dissipated in the joints of the patients. No significant changes occurred in the normal group.

A microcomputer controlled hand assessment system used for clinical measurement

To improve the objectivity of clinical assessment of hand function, a microcomputer controlled system of force transducers has been developed and used to study twenty normal subjects and thirty-eight patients suffering from rheumatoid arthritis. The parameters measured were grip and individual finger forces, pan and kettle handle grip and lift force, key twist torque, lateral pinch force, and individual finger pulp pinch forces.

‘Power’ grip forces were found to be remarkably similar in the left and right hands as indeed was the contribution made by each finger to the total force. Pan grip and lift forces were also similar in left and right hands, but the grip force was far greater than the lift force in both normals and patients. Kettle grip forces were much less than the lift force in normal subjects, while patients gripped the kettle with almost as much force as they used to lift it.

Patients were weaker than normals exerting roughly one third of the forces of normals in all modes of measurement. There were different styles of lifting demonstrated by the patient group.

Measurement of stiffness in the metacarpophalangeal joint: circadian variation

A finger arthrograph has been used to investigate circadian variation of stiffness in the metacarpophalangeal joints of normal subjects. A marked increase in the resistive torques of male and female joints was noted during the early hours of the morning (typically 2 to 3 times the torque found during the afternoon). The amount of energy dissipated by the joint and associated soft tissues also showed a circadian variation, with the highest levels of energy dissipation again occurring during the early hours of the morning (0200-0400).