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Multimodal rheumatologic complex treatment (MRCT) is based on an acute inpatient treatment concept for patients with clinically relevant functional impairments and exacerbation of pain, which are caused by rheumatic and musculoskeletal diseases. Patients with axial spondylarthritis (axSpA) including ankylosing spondylarthritis (AS) often suffer from such health problems. Regular movement exercises and physical therapy measures are an important pillar of treatment management. The ASAS Health Index (ASAS-HI) can be used to document the global functional ability and health of axSpA patients. The selectivity of the ASAS HI for nonpharmacological treatment changes has so far not yet been proven.Evaluation of the MRCT and ASAS HI for nonpharmacological treatment measures of patients with axSpA carried out in the Ruhr Area Rheumatism Center. The primary endpoint was an improvement of the ASDAS≥ 1.1. It was assumed that 25% of the patients would achieve this threshold.Consecutively included patients with active axSpA and relevant functional impairments received inpatient treatment for 14 days during MRCT. On days 1 (V1) and 14 (V2) all patients completed questionnaires on pain (NRS), disease activity (BASDAI, ASDAS) and function (BASFI, ASAS HI). The clinical examination was carried out using BASMI and measurement of C‑reactive protein (CRP) at both times.The 66 prospectively included patients had an average age of 47.2 years (SD 14.2 years), a duration of symptoms of ca. 20 years, 65.3% were male, 75% were positive for HLA B27 and CRP was elevated in 41.3%. The disease activity at V1 was elevated: BASDAI 5.6 (1.8), ASDAS 3.1 (0.9), whereas functional ability and mobility were reduced: BASFI 3.5 (1.8), BASMI 5.6 (2.1), ASAS-HI 8.4 (3.4). During the course the global patient verdict improved (NRS 0-10) from 6.9 (1.7) at V1 to 4.8 (1.8) at V2 and the pain from 6.9 (1.9) to 4.7 (2.0) (all p 0.001). The disease activity also decreased at V2: BASDAI 4.1 (1.9), ASDAS 2.4 (1.0), function and mobility were also improved: BASFI 4.3 (2.4), BASMI 2.7 (1.6), ASAS HI 6.5 (3.8) (all p 0.001).In this study the effectiveness of a 2‑week MRCT according to OPS 8-983.1 with respect to important patient-centered outcomes (PCO) could be proven and the results of previous studies could be confirmed. In this context ASAS-HI was also sensitive to change.HINTERGRUND: Die multimodale rheumatologische Komplexbehandlung (MRKB) beruht auf einem akutstationären Versorgungskonzept zur Behandlung von Patienten mit klinisch relevanten Funktionseinschränkungen und Schmerzexazerbationen, die durch rheumatische und muskuloskeletale Erkrankungen bedingt sind. Patienten mit axialer Spondyloarthritis (axSpA) einschließlich der ankylosierenden Spondylitis (AS) leiden häufig unter solchen Gesundheitsproblemen. Regelmäßige Bewegungsübungen und physikalische Therapiemaßnahmen sind ein wichtiger Pfeiler im Behandlungsmanagement. Mit dem ASAS Health Index (ASAS HI) können die globale Funktionsfähigkeit und Gesundheit von axSpA-Patienten erfasst werden. Die Trennschärfe des ASAS HI für nichtpharmakologische Therapieänderungen ist bisher noch nicht nachgewiesen worden.Evaluation der im Rheumazentrum Ruhrgebiet durchgeführten MRKB und des ASAS HI für nichtpharmakologische Therapiemaßnahmen bei Patienten mit axSpA. Als primärer Endpunkt wurde eine Verbesserung des ASDAS ≥ 1,1 festgelegt. Hierbei wurde angenommen, dass 25 % der Patienten diesen Schwellenwert erreichen.Konsekutiv eingeschlossene Patienten mit aktiver axSpA und relevanten Funktionseinschränkungen wurden im Rahmen einer MRKB 14 Tage stationär behandelt. Alle Patienten beantworteten am ersten (V1) und am 14. Tag (V2) des Aufenthalts Fragebögen zu Schmerzen (NRS), Krankheitsaktivität (BASDAI, ASDAS) und Funktion (BASFI, ASAS HI). Die klinische Untersuchung erfolgte mittels BASMI und eine Messung des C‑reaktiven Proteins (CRP) zu beiden Zeitpunkten.Die prospektiv eingeschlossenen 66 Patienten hatten ein mittleres Alter von 47,2 Jahren (SD 14,2), eine Symptomdauer von ca. 20 Jahren, 65,3 % waren Männer und 75 % HLA B27+, das CRP war bei 41,3 % erhöht. Die Krankheitsaktivität zu V1 war erhöht: BASDAI 5,6 (1,8), ASDAS 3,1 (0,9), während Funktionsfähigkeit und Mobilität vermindert waren: BASFI 3,5 (1,8), BASMI 5,6 (2,1), ASAS HI 8,4 (3,4). Im Verlauf verbesserte sich das globale Patientenurteil (NRS 0–10) von 6,9 (1,7) zu V1 auf 4,8 (1,8) zu V2 und der Schmerz von 6,9 (1,9) auf 4,7 (2,0) (alle p 0,001). Auch die Krankheitsaktivität nahm zu V2 ab: BASDAI 4,1 (1,9), ASDAS 2,4 (1,0), Funktion und Mobilität waren auch verbessert: BASFI 4,3 (2,4), BASMI 2,7 (1,6), ASAS HI 6,5 (3,8) (alle p 0,001).In dieser Studie konnte die Wirksamkeit einer 2‑wöchigen MRKB gemäß OPS 8–983,1 hinsichtlich wichtiger patientenzentrierter Outcomes (PRO) nachgewiesen und frühere Studienergebnisse konnten bestätigt werden. In diesem Rahmen war auch der ASAS-HI veränderungssensitiv.

This review article presents the innovations in the update of the S3 guidelines on axial spondylarthritis. The total of eight new recommendations address the areas of the consideration of differential diagnoses, coordination of comorbidity management, including a vaccination strategy, treatment targets, safety of nonsteroidal anti-inflammatory drugs (NSAID), treatment response to biological disease-modifying antirheumatic drugs (bDMARD) and discontinuation strategies when remission has been achieved. In this article the authors deal particularly with the areas of early diagnosis and referral as well as exercise therapy and drug treatment.Die vorliegende Übersicht stellt die Neuerungen des Updates der S3-Leitlinie zur axialen Spondyloarthritis vor. Die insgesamt 8 neuen Empfehlungen adressieren die Bereiche der Beachtung von Differenzialdiagnosen, Koordination des Komorbiditätenmanagements einschließlich einer Impfstrategie, Therapieziele, der NSAR(nichtsteroidale Antirheumatika)-Sicherheit, Therapieansprechen von b(„biological“)DMARD („disease-modifying antirheumatic drugs“) und Absetzstrategien bei Erreichen einer Remission. Die Autoren gehen in dem Beitrag insbesondere auf die Bereiche Frühdiagnose und Überweisung sowie Bewegungstherapie und medikamentöse Therapie ein.

Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany.Trotz einer qualitativ und strukturell guten Versorgung von Patient*innen mit rheumatoider Arthritis (RA) in Deutschland bestehen weiterhin potenziell behebbare Defizite in der Qualität der Versorgung. Aus diesem Grund hat die Deutsche Gesellschaft für Rheumatologie (DGRh) eine Expert*innengruppe, in der verschiedene Interessengruppen vertreten waren, beauftragt, nationale Qualitätsstandards (QS) mit dem Ziel zu entwickeln, die rheumatologische Versorgung von Patient*innen mit RA in Deutschland qualitativ zu verbessern. QS dienen der Festlegung und quantitativen Messung guter Versorgungsqualität unter dem Vorbehalt von Relevanz und Realisierbarkeit. Als Grundlage für die Entwicklung dienten die kürzlich publizierten Standards von NICE und ASAS und eine systematische Literatursuche. Insgesamt wurden 8 hiermit erstmals veröffentlichte QS konsentiert, die als Grundlage dienen können, die Versorgungsqualität von Patient*innen mit RA in Deutschland zu messen und weiter zu optimieren.

The Apple and Google app stores offer a wide range of health apps. It is still a challenge to find valuable and qualified apps.Can German language apps be identified using the "semiautomated retrospective app store analysis" (SARASA) method for the field of rheumatology?The SARASA is a semiautomated method to select and characterize apps listed in the app store. After the first application in February 2018 SARASA was applied again to the Apple app store in February 2020.In February 2018 it was possible to acquire metadata for 103,046 apps and in February 2020 data for 94,735 apps that were listed in the category "health and fitness" or "medicine" in Apple's app store frontend for Germany. After applying the search terms 59 apps with a German language app description were identified for the field of rheumatology in 2018 and 53 apps in 2020. For these, more detailed manual reviews seem worthwhile. In 2018, the apps found were more likely to address patients than physicians and this was more balanced in 2020. In addition, it became apparent that for certain diseases there was no app developer activity. The percentage breakdown of matches by search term revealed substantial fluctuations in the app market when comparing 2018 to 2020.The SARASA method provides a useful tool to identify apps from app stores that meet predefined, formal criteria. Subsequent manual checks of the quality of the contents are still necessary. Further development of the SARASA method and consensus and standardization of quality criteria are worthwhile. Quality criteria should be considered for offers of mobile health apps in app stores.HINTERGRUND: Die App Stores von Apple und Google bieten eine Vielzahl von Gesundheits-Apps an. Das Auffinden qualitativ hochwertiger Apps ist immer noch eine Herausforderung.Lassen sich unter Anwendung der SARASA(„semiautomated retrospective App Store analysis“)-Methode für das Fachgebiet Rheumatologie deutschsprachige Apps identifizieren?SARASA ist eine Methode zur teilautomatisierten Auswahl und Charakterisierung von App Store-gelisteten Apps nach formalen Kriterien. Nach der ersten Anwendung in 02/2018 wurde SARASA 02/2020 erneut auf den Apple App Store angewendet.In 02/2018 konnten für Apps in den Store-Kategorien „Medizin“ oder „Gesundheit und Fitness“ Metadaten zu 103.046 Apps und bei einer erneuten Erhebung in 02/2020 Daten zu 94.735 Apps über das deutsche Frontend des Apple App Stores ausgelesen werden. Im Jahr 2018 wurden nach Anwendung der Suchbegriffe 59 Apps mit einer deutschsprachigen Beschreibung für das Fachgebiet Rheumatologie identifiziert, 2020 waren dies 53 Apps, die jeweils manuell weiter überprüft wurden; 2018 waren noch mehr der gefundenen Apps für Patienten als für Ärzte vorgesehen, dies war 2020 ausgeglichener. Zudem zeigte sich, dass bei bestimmten Krankheitsbildern von den App-Entwicklern keine Bearbeitungen erfolgten. Die prozentuale Verteilung von Treffern nach Suchbegriffen zeigte im Vergleich von 2018 zu 2020 große Schwankungen.Die SARASA-Methode stellt ein hilfreiches Werkzeug dar, um Gesundheits-Apps teilautomatisiert zu identifizieren, die vordefinierten, formalen Kriterien entsprechen. Die inhaltliche Qualität muss anschließend manuell überprüft werden. Weiterentwicklungen der SARASA-Methode und die weitere Konsentierung und Standardisierung von Qualitätskriterien sind sinnvoll. Qualitätskriterien sollten beim Angebot von Gesundheits-Apps in den App-Stores berücksichtigt werden.

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.HINTERGRUND: Körperliche Aktivität und spezifisches Training haben großen gesundheitlichen Nutzen. Empfehlungen zum Management von rheumatoider Arthritis (RA), Spondyloarthritis (SpA) sowie Hüft- und Kniegelenkarthose (HKA) sind bisher in Bezug auf Art und Dosierung aber unspezifisch. Darum wurden die 2018 EULAR Empfehlungen zu körperlicher Aktivität für Menschen mit entzündlich-rheumatischen und degenerativen Erkrankungen formuliert. Sie bestehen aus 4 übergeordneten Prinzipien und 10 Empfehlungen. Die EULAR Bewegungsempfehlungen wurden auch als laienverständliche Version in englischer Sprache publiziert. ZIEL: Übersetzung der laienverständlichen Version ins Deutsche und sprachliche Validierung in Deutschland, Österreich und der Schweiz.Eine professionelle Übersetzung ins Deutsche wurde von den Autor*innen einschließlich Personen mit RA, SpA und HKA zu einer präfinalen Version bearbeitet. Anschließend wurden in den 3 Ländern je 8 Interviews mit Personen mit RA, SpA und HKA durchgeführt, um die Verständlichkeit, Wortwahl, Vollständigkeit und Umsetzbarkeit zu prüfen. Die Patientenvertreter*innen der Autor*innengruppe bewerteten anonym ihre Zustimmung zur finalen Version auf einer Skala von 0 bis 10.Die professionelle Übersetzung wurde von den Autor*innen und auf Grundlage der Interviews substanziell überarbeitet. Dabei wurden Formulierungen angepasst, um Lesbarkeit und Verständlichkeit zu verbessern und Aussagen zu präzisieren. Inhalt und Struktur des Originaltextes wurden dabei nicht verändert. Die Zustimmung zu den einzelnen Empfehlungen lag zwischen 10 (SD 0) und 7,6 (SD 1,67).Für Menschen mit RA/SpA/HKA sollten die EULAR Bewegungsempfehlungen in deren Muttersprache vorliegen. Die laienverständliche deutsche Version ist valide und wurde in allen 3 Ländern gut akzeptiert. Damit können die EULAR Bewegungsempfehlungen verständlich und praktikabel vermittelt werden.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.Qualitätsstandards (QS) sind messbare Konstrukte, die helfen sollen, Versorgungslücken quantitativ zu erfassen, um langfristig die Versorgungsqualität zu verbessern. Die Assessment of SpondyloArthritis International Society (ASAS) hat kürzlich erstmals internationale QS für das Management von Patient*innen mit axialer Spondyloarthritis (axSpA) konsentiert und veröffentlicht. Die Deutsche Gesellschaft für Rheumatologie (DGRh) hat daraufhin beschlossen, diese Standards durch eine Gruppe von Expert*innen aus unterschiedlichen Versorgungsbereichen zu übersetzen, zu prüfen und ggf. zu übernehmen. Vor diesem Hintergrund wurden erstmals nationale QS für das Management von Patient*innen mit axSpA für Deutschland entwickelt. Hierbei wurde v. a. auf Machbarkeit und Praxisrelevanz geachtet. Letztlich wurden 9 QS definiert, mit denen die Qualität der Versorgung in Deutschland gemessen und verbessert werden kann bzw. soll.

The standardized assessment of health-related quality of life is becoming increasingly more important. The English questionnaire on psoriatic arthritis quality of life (PsAQoL) is a disease-specific instrument for measuring the quality of life of patients with psoriatic arthritis (PsA). The aim of the present study was to translate the PsAQoL into German and to validate the German version in a cohort of PsA patients recruited from routine care.The translation and validation of the PsAQoL questionnaire was carried out in a stepwise procedure involving affected patients with PsA. After translation of the original English questionnaire the German version was evaluated in a field test. The psychometric features of the questionnaire were then examined in a PsA cohort from routine care. In addition to the construct and group validity, the reliability of the questionnaire was tested using test-retest reliability and internal consistency. The physical functioning was measured with the health assessment questionnaire (HAQ) and domains of the quality of life with the Nottingham health profile (NHP).In a field test with 10 patients the German version of the PsAQoL questionnaire proved to be relevant, easily understandable and feasible (processing time 4.7 ± 2.1 min). A total of 126 patients (37.3% male, age 55.6 ± 11.3 years) were included in the validation cohort. The PsAQoL showed moderate correlation with the HAQ (r = 0.65) and moderate to good correlation with the NHP (subdomains r = 0.58-0.75). The internal consistency was high (Cronbach's α 0.92) and reliability in patients with stable disease course was very good (Spearman correlation coefficient 0.94). The PsAQoL can differentiate between different patient groups.The German translation of the PsAQoL provides a valid disease-specific instrument for the standardized assessment of health-related quality of life in patients with PsA. The psychometric characteristics of this questionnaire are comparable with the original English version. The German PsAQoL can therefore be recommended for clinical and scientific application.EINLEITUNG: Die standardisierte Beurteilung der gesundheitsbezogenen Lebensqualität gewinnt in der Rheumatologie zunehmend an Bedeutung. Der englische Fragebogen „Psoriasis Arthritis Quality of Life Questionnaire (PsAQoL)“ ist ein krankheitsspezifisches Instrument zur Messung der Lebensqualität von Patienten mit Psoriasisarthritis (PsA). Ziel der vorliegenden Arbeit ist die Übersetzung des PsAQoL ins Deutsche und die Validierung der deutschen Version in einer aus der Routineversorgung rekrutierten Kohorte von PsA-Patienten.Die Übersetzung und Validierung des Fragebogens PsAQoL wurde in einem mehrstufigen Verfahren unter Beteiligung von betroffenen Patienten mit PsA durchgeführt. Nach Übersetzung des englischsprachigen Fragebogens wurde die deutsche Version in einem Feldtest überprüft. Die psychometrischen Merkmale des Fragebogens wurden anschließend in einer PsA-Kohorte aus der Routineversorgung untersucht. Neben der Konstrukt- und Gruppenvalidität wurden die Zuverlässigkeit des Fragebogens mittels Test/Retest-Reliabilität sowie die interne Konsistenz getestet. Die körperliche Funktionsfähigkeit wurde mit dem Health Assessment Questionnaire (HAQ) und Domänen der Lebensqualität mit dem Nottingham Health Profile (NHP) gemessen.In einem Feldtest mit 10 Patienten erwies sich die deutsche Version des PsAQoL-Fragebogens als relevant, gut verständlich und durchführbar (Bearbeitungszeit: 4,7 ± 2,1 min). Insgesamt 126 Patienten (37,3 % männlich, Alter 55,6 ± 11,3 Jahre) wurden in die Validierungskohorte eingeschlossen. Der PsAQoL korrelierte moderat mit dem HAQ (r = 0,65) sowie moderat bis gut mit dem NHP (Subdomänen r = 0,58–0,75). Die interne Konsistenz war hoch (Cronbach’s α 0,92), und die Zuverlässigkeit bei Patienten mit stabilem Krankheitsverlauf war sehr gut (Spearman-Korrelationskoeffizient 0,94). Der PsAQoL kann zwischen unterschiedlichen Patientengruppen differenzieren.Mit der deutschen Übersetzung des PsAQoLs steht ein valides und krankheitsspezifisches Messinstrument zur standardisierten Erfassung der gesundheitsbezogenen Lebensqualität bei Patienten mit PsA zur Verfügung. Die psychometrischen Eigenschaften der englischsprachigen Originalversion sind vergleichbar. Der deutsche PsAQoL kann damit für die klinische und wissenschaftliche Verwendung empfohlen werden.

The often slow onset of ankylosing spondylitis (AS), the initially partially unspecific symptoms (back pain) and the scarcity of resources in rheumatological care are important factors leading to delayed diagnosis and treatment of these mostly young patients in Germany. Qualified nurses specialized in rheumatology might improve quality of care by providing medical services delegated by the rheumatologists.The aim was to investigate whether qualified nurses specialized in rheumatology can interpret anamnestic and clinical findings such as rheumatologists in patients with chronic low back pain and still unclear diagnosis using a structured questionnaire.In the multicenter PredAS study a structured anamnestic questionnaire was applied independently by qualified nurses specialized in rheumatology and rheumatologists to patients referred to rheumatology practices with the leading symptom of low back pain. The questionnaire covered basic demographic data, medical history and patient reported outcomes. Additionally, measurements of physical function using the Bath ankylosing spondylitis functional index (BASFI) and spinal mobility using the Bath ankylosing spondylitis metrology index (BASMI) were standardized. In order to test the possible facilitation by using digital media, the results of two patient groups were separately documented on paper-based report forms and on an i‑pad. Concordance between documentation by qualified nurses specialized in rheumatology and rheumatologists was studied by calculating Cohen's kappa, intraclass correlation coefficients (ICC) and percentage agreement on an individual patient level.Nearly 75% of the 141 patients with chronic low back pain were identified as having the characteristics of inflammatory back pain. The concordance of the documentation for the anamnesis of back pain by qualified nurses specialized in rheumatology and physicians was higher than for the localization of the back pain. The results for the BASMI showed no differences between qualified nurses specialized in rheumatology and physicians (ICC 0.925, 95 % confidence interval, CI 0.879-0.953). The time taken for the structured documentation was 20 ± 6.7 min for physicians and 28.5 ± 13 min for qualified nurses specialized in rheumatology.The results indicate that well-trained qualified nurses specialized in rheumatology have a high potential to take over some of the workload from rheumatologists during documentation of the anamnesis and the initial physical examination in the diagnosis of ankylosing spondylitis.HINTERGRUND: Der oft langsame Beginn einer axialen Spondyloarthritis (axSpA), die initial zum Teil wenig spezifischen Symptome (Rückenschmerzen), aber auch begrenzte Ressourcen und die damit verbundenen Verzögerungen in der rheumatologischen Versorgung sind Faktoren, die zu verspäteter Diagnose und Therapie dieser meist jungen Patienten mit beitragen. Rheumatologische Fachassistenten (RFA) können zur Verbesserung der Versorgung beitragen, indem sie vom Rheumatologen delegierte ärztliche Leistungen übernehmen.Ziel ist, zu untersuchen, ob geschulte RFA bei Patienten mit chronischem Rückenschmerz und noch unklarer Diagnose mithilfe eines strukturierten Fragebogens anamnestische und klinische Befunde wie Rheumatologen erheben können.In der multizentrisch durchgeführten PredAS-Studie wurden bei Patienten mit dem Leitsymptom chronischer Rückenschmerz demografische Basisdaten, Anamnese und patientenberichtete Endpunkte mittels strukturierter Fragebögen von RFA und Rheumatologen unabhängig voneinander erfasst. Zudem wurden Funktion (BASFI) und Wirbelsäulenbeweglichkeit (BASMI) standardisiert gemessen. Um die mögliche Erleichterung durch Nutzung digitaler Medien zu testen, wurden 2 Patientengruppen getrennt untersucht: Die Ergebnisse der einen Kohorte wurden mittels papierbasierter Case Report Forms (CRF) und die Ergebnisse der anderen elektronisch mittels iPad dokumentiert. Die Konkordanz der Dokumentationen zwischen RFA und Rheumatologen wurde als Kappa-Koeffizient, als prozentuale Übereinstimmung und auf individueller Patientenebene berechnet.Bei fast drei Viertel der 141 Patienten mit chronischen Rückenschmerzen wurden Charakteristika des entzündlichen Rückenschmerzes identifiziert. Die Konkordanz bei Dokumentation durch RFA und Arzt war bei den anamnestischen Angaben zum Rückenschmerz höher als bei der Angabe zur Lokalisation des Rückenschmerzes. Bei der Erhebung des BASMI zeigte sich kein Unterschied zwischen RFA und Arzt (ICC 0,925) (95 %-CI 0,879–0,953). Der Zeitaufwand für die strukturierte Dokumentation betrug beim Arzt 20 ± 6,7 min und bei der RFA 28,5 ± 13 min.Die Ergebnisse sprechen dafür, dass geschulte RFA die Rheumatologen bei der anamnestischen Aufarbeitung und ersten körperlichen Untersuchung im Rahmen der Diagnosestellung erheblich und qualifiziert unterstützen können.

Digitalization in the healthcare system is a great challenge for rheumatology as for other medical disciplines. The German Society for Rheumatology (DGRh) wants to actively participate in this process and benefit from it. By founding the commission on digital rheumatology, the DGRh has created a committee that deals with the associated tasks, advises the DGRh on questions and positions associated with digital health. For the DGRh, this affects the most diverse areas of digitalization in medicine and rheumatology. This position paper presents the topics and developments currently handled by the commission and the tasks identified.

Biosimilars have been approved for use in Germany for many years and in the meantime also in rheumatology but only a few years ago. Biosimilars, which are biotechnologically manufactured products the same as reference biologicals, have actually now achieved a substantial proportion of the market in some regions but there are still doubters among patients and physicians who fear a loss of quality even if there is no evidence for this. A part of this problem can be explained by the nocebo effect but which furthermore also has a substantial medical importance. This effect is described and explained in this article. Psychosocial and context-related factors, such as the relationship between patient and physician, previous experience with treatment and treatment expectations can either improve or impair the efficacy of treatment interventions. These phenomena are commonly known as placebo and nocebo effects. As placebo and nocebo effects can influence the development of symptoms, the frequency of undesired events and the efficacy of treatment, it is decisive to know these effects and to develop strategies for prevention in order to optimize the treatment results. Although in recent years experimental studies have achieved substantial progress in the clarification of the psychosocial and neurobiological mechanisms of placebo effects, detailed mechanisms of nocebo effects are still widely unexplored. An improved understanding of these mechanisms promises the development of user-friendly strategies for the clinical care to improve treatment results and patient satisfaction.

Drug treatment in patients with axial spondylarthritis (axSpA) aims to modify symptoms and complaints and currently includes the substance groups of nonsteroidal anti-inflammatory drugs (NSAID) and biologicals (disease-modifying antirheumatic drugs, bDMARDS). Treatment with NSAIDs is the first line treatment according to international and national recommendations. Patients with persisting high disease activity despite continuous standard treatment with NSAIDs, should be treated with biologicals. In Germany treatment with tumor necosis factor (TNF) inhibitors or interleukin 17 inhibitor (secukinumab) are currently approved for treating patients with ankylosing spondylitis (AS). Treatment of patients with non-radiographic axSpA (nr-axSpA) is restricted to TNF inhibitors (except infliximab) in Germany. The efficacy and safety are documented for both substance groups; however, due to the longer time since approval longitudinal data for TNF inhibitors are more robust and the data contain information about switching within a substance group. Although overall retention rates of TNF inhibitors are similar despite the difference in formation of antidrug antibodies, data from cohorts provide information about long-term loss of efficacy, switching and also discontinuation strategies. In the meantime, various biosimilars have been approved for infliximab, etanercept and adalimumab. Conventional basic treatment (csDMARDs) and in particular intra-articular administration of glucocorticoids can only be prescribed for axSpA patients with peripheral arthritis.

Axial spondylarthritis (axSpA) is a chronic inflammatory disease of the spine that can be associated with loss of physical function, mobility and upright postural impairment. Established tools for the assessment of function that are largely based on subjective perception are semiquantitatively recorded by standardized questionnaires (Bath ankylosing spondylitis functional index, BASFI), while measurement of spinal mobility of patients with axSpA is based on physical examination of various movement regions particularly the axial skeleton (Bath ankylosing spondylitis metrology index, BASMI). Recently, a performance test has been added to assess the range of motion and speed of certain tasks (AS performance-based improved test, ASPI); however, since these tests have limited reliability and reproducibility, more objective tests would be desirable. In this study the spinal mobility of patients with axSpA was quantified using the Epionics SPINE device (ES) and data were evaluated using the outcome measures in rheumatology (OMERACT) criteria. The ES automatically measures various patterns of spinal movements using electronic sensors, which also assess the range and speed of carrying out movements. Patients with back pain from other causes and persons without back pain served as controls. The measurement results obtained with ES differed between the groups and correlated with BASMI values (r = 0.53-0.82, all p = 0.03). Patients with radiographically detectable axSpA had more limited and slower mobility than those with non-radiographically detectable axSpA. Overall, the results presented here suggest that ES measurements represent a valid and objective measurement procedure of spinal mobility for axSpA patients.Die axiale Spondyloarthritis (axSpA) ist eine chronisch entzündliche Erkrankung der Wirbelsäule, die langfristig mit einem Verlust körperlicher Funktionen, der Beweglichkeit und der aufrechten Haltung einhergehen kann. Bisher gängige Methoden zur Messung der Beweglichkeit basieren zum einen auf subjektiver Patientenwahrnehmung, wobei verschiedene Funktionen durch standardisierte Fragebögen (BASFI) semiquantitativ erfasst werden, und zum anderen werden im Rahmen einer körperlichen Untersuchung verschiedene Bewegungsbereiche v. a. des Achsenskeletts vermessen (BASMI). Vor Kurzem kam der erste Test hinzu, mit dem die Durchführung und Geschwindigkeit bestimmter Aufgaben erfasst werden kann (ASPI). Da diese Tests nur begrenzt verlässlich und reproduzierbar sind, wäre ein objektiverer Test wünschenswert. In der hier berichteten Studie wurde die Mobilität der Wirbelsäule (WS) von Patienten mit axSpA mit dem Epionics SPINE-Gerät (ES) quantitativ untersucht und anhand der OMERACT(outcome measures in rheumatology)-Kriterien evaluiert. Das Gerät misst verschiedene Bewegungsmuster der Wirbelsäule anhand elektronischer Sensoren automatisiert, das schließt die Geschwindigkeit der Bewegungsdurchführung ein. Als Kontrollen dienten Patienten mit Rückenschmerzen anderer Genese und Menschen ohne Rückenschmerzen. Die mit ES erhobenen Messungen unterschieden sich zwischen den Gruppen und korrelierten mit den BASMI-Werten (r =0,53–0,82, alle p = 0,03). Röntgenologische axSpA-Patienten hatten zudem eine eingeschränktere und langsamere Beweglichkeit als die mit nr-axSpA. Insgesamt sprechen die Ergebnisse dieser Arbeit dafür, dass Messungen mit dem ES ein valides und objektives Messverfahren der Wirbelsäulenbeweglichkeit für axSpA-Patienten darstellen.

Early detection of patients with axial spondylarthritis (axSpA) in primary care is difficult. The combination of various parameters indicative of inflammatory back pain (AWARE criteria) was found to be beneficial in an initial study.Review of the criteria for the identification of young patients with axSpA and chronic back pain (≥3 months of back pain).In adult patients with chronic back pain and age at onset of symptoms45 years, orthopedic surgeons documented various possible axSpA characteristics before referral to the rheumatologist.Overall, the data from 1306 patients were recorded. Of these, ultimately 500 patients were also seen by rheumatologists, 199 patients (39.8%) were diagnosed with axSpA while 301 (60.2%) had non-specific back pain. A total of 87 patients had ankylosing spondylitis (44%) and 112 non-radiographic axSpA (56%). The ASAS classification criteria were fulfilled by 226 patients (45.2%). The mean age of axSpA patients was 38 years, 56% were male with a mean duration of back pain of 98 months. The AWARE criteria had a sensitivity and specificity of 69.3% and 40.3% (n = 343), respectively, when ≥4/5 criteria were chosen. Positive imaging for sacroiliitis using magnetic resonance imaging (MRI) or X‑ray was present in 77% of patients and positive HLA-B27 was identified in 59% of axSpA patients. The combination of positive imaging and HLA-B27 had the highest likelihood ratio for diagnosis of axSpA.Although the study design used here led to a preselection and thus to a bias in the statistical evaluation, the study confirmed the benefit of the AWARE criteria for the early detection of patients with axSpA. In further studies, the 2‑stage approach with initially 3 clinical questions and then an optional HLA-B27 test is currently being investigated further.

The Ruhrgebiet Rheumatism Center, which is highly specialized for rheumatic diseases, is the largest of its kind in Germany. For many years it has fulfilled all the requirements for structural quality required by the Association of Rheumatological Acute Clinics (VRA) including regular participation in the KOBRA benchmarking project. Therefore, the center regularly receives the VRA seal for quality of care. In 2018 more than 7500 patients were treated as inpatients. Within the framework of care according to §116b (ASV since May 2019) there were nearly 25,000 outpatient patient contacts. Furthermore, an early screening program (triage) was established 5 years ago in order to be able to identify patients with musculoskeletal complaints on a potentially inflammatory rheumatic basis. This functions in the sense of an early diagnosis and treatment in accordance with the treat-to-target concept within less than 4 weeks (initially) on an outpatient basis with respect to the required urgency, in order to subsequently provide sound diagnostic support. In the last 2 years 2017 and 2018, this deadline was met in more than 90% of cases. Within the scope of inpatient care approximately one third of patients were treated in recent years with a defined rheumatological complex therapy and 10% with pain complex therapy. Approximately 3% were treated with geriatric complex therapy and 65% were short-stay patients (4 days), i.e. patients who received the necessary diagnostics and treatment on an inpatient basis at short notice. The overall structure of the rheumatism center, the cooperation with rheumatologists in private practice, many cooperation partners, referring physicians and patients represents a model for rheumatological care in large conurbations. The care of large numbers of patients also enables the further training of many assistants and this is essential for the future of good rheumatological medicine.

Familial Mediterranean fever (FMF) in Germany is a rare, genetically linked disease of childhood and adolescence, which is characterized by recurrent febrile episodes and clinical signs of peritonitis, pleuritis and arthritis. Treatment with colchicine is effective and well-tolerated in the majority of patients; however, some patients do not sufficiently respond to this treatment or are intolerant to colchicine. For these patients first-line treatment with biologics which block interleukin-1 can be used.The aim was to formulate evidence-based treatment recommendations for patients with an insufficient response and intolerance to colchicine treatment.Based on a literature search and the European League Against Rheumatism (EULAR) recommendations on FMF from 2016 the appointed members of the Society for Pediatric and Adolescent Rheumatology (GKJR) and the German Society for Rheumatology (DGRh) convened to work out and form a consensus in a joint statement on evidence-based treatment recommendations on FMF.After intensive discussions all decisions were in concordance. A total of 5 superordinate principles and 10 recommendations were agreed upon.The joint activities of the GKJR and the DGRh were successfully concluded in a timely manner. The recommendations form a good basis for optimal treatment of all age groups of patients with FMF.

The aim of this study was the validation of the German translation of the ASAS Health Index (ASAS HI), which measures functioning and health in patients with axial and peripheral spondyloarthritis (SpA).Patients with SpA who fulfilled the ASAS classification criteria for axial (axSpA) or peripheral SpA (pSpA) were included in this study. Constuct validity of the ASAS HI was tested by using Spearman's correlation coefficients. Reliability was analyzed by intraclass correlation coefficients (ICC) in patients with stable disease. In patients requiring an important therapeutic change because of unacceptable high disease activity, the sensitivity to change was analyzed using standardized response mean (SRM).A total of 171 patients (57.9% male, age 44.4 ± 13.0 years) were included. The internal consistency was high with a Cronbach's alpha of 0.83. The reliability (n = 63) was good (ICC = 0.94; 95% confidence interval [CI] 0.90-0.96). The sensitivity to change of the ASAS HI was low for a relatively small number of cases (n = 33) with a SRM of -0.27 but showed a good ability to discriminate between various stages of disease activity and physical functioning.We showed that the German translation of the ASAS HI provide good psychometric properties to assess functioning and health in patients with SpA. This reliable and sensitive to change questionnaire therefore enables the assessment of disease-specific global functioning and severity in patients with all forms of SpA.

Polymyalgia rheumatica (PMR) occurs almost exclusively in persons aged 50 years or older and it is the second most common inflammatory rheumatic disease in older people after rheumatoid arthritis. Since there are no specific tests for PMR, the exclusion of clinically similar differential diagnoses is essential to ascertain the diagnosis. These recommendations for the management of PMR assume an already established diagnosis of PMR. It is recommended to initiate treatment with glucocorticoids immediately after diagnosis and to provide appropriate patient information and education about the impact of the disease and its treatment. Methotrexate should be considered in patients at high risk for relapse and/or glucocorticoid-related adverse events. These guidelines have been elaborated because there is significant heterogeneity in the management of PMR in clinical practice in Germany (but also Europe and worldwide), despite the large number of patients with this disease. These guidelines are primarily based on the 2015 EULAR-ACR recommendations for the management of PMR, which were updated by the guideline committee and adapted to the German speaking countries.

The combination of physiological age-related changes (e. g. reduction in muscle mass and function, reduction in organ function and degenerative changes in joints) and disease-specific changes of ankylosing spondylitis (AS), make older AS patients vulnerable for additional diseases. In this patient population various processes lead to a reduction in physical function, changes in posture, osteoporosis and sarcopenia, which then can result in falls and fractures, especially vertebral fractures. Mortality is increased in patients with AS, particularly in men due to an increase in cardiovascular mortality. Although the standardized assessment of cardiovascular risk factors in patients with inflammatory rheumatic diseases (independent of age) has been recommended for years, it is rarely done in clinical practice. Overall, data on comorbidities and risk factors are only available for AS patients and are lacking for other forms of spondyloarthritides.

The diagnosis of axial spondyloarthritis (axSpA) includes classical ankylosing spondylitis (AS) as well as earlier stages and abortive courses of the disease, in which structural alterations have not yet occurred. These are classified as non-radiographic axSpA (nr-axSpa). Inflammatory changes in the entire axial skeleton are characteristic for axSpA and can be visualized by magnetic resonance imaging (MRI), while in most patients structural alterations, such as new bone formation with syndesmophytes and ankylosis develop in the later course of the disease. These bony alterations can best be visualized by conventional radiography and by computed tomography. Certain MRI sequences are nowadays considered as the standard method for depiction of inflammatory changes in axSpA. The introduction of MRI has led to a paradigm shift for this disease because the inflammatory lesions characteristic for the disease can be visualized at an early stage using appropriate MRI sequences.

Due to the increasing prevalence of gout, particularly in old age, the disease is becoming of increasing importance in Germany. Gout is one of the most common forms of recurrent inflammatory arthritis and is induced by the deposition of monosodium urate crystals in synovial fluid and other tissues. The principal goals of therapy in chronic gout are the symptomatic treatment of the acute joint inflammation and the causal treatment of the underlying metabolic cause, the hyperuricemia. Only a consistent and permanent reduction of the serum uric acid level ultimately results in an efficient avoidance of further gout attacks and therefore the prevention of structural damage. Due to an often inadequate treatment of gout, the target of healing the disease is often not achieved. A correct and timely diagnosis and adequate assessment of comorbidities associated with gout are, however, of substantial importance for patient and physician to achieve remission of the disease. In order to create a solid basis for a timely and effective treatment of affected patients, in 2016 the German Society of Rheumatology (DGRh) initiated the development of S2e guidelines on gouty arthritis for specialists. This article summarizes these S2e guidelines on the management of gouty arthritis in the specialist sector.

The clinical course of axial spondyloarthritis (SpA) is variable and characterized by chronic back pain and extraspinal manifestations, such as asymmetrical arthritis, dactylitis and enthesitis. Extra-articular manifestations in the eyes (anterior uveitis), skin (psoriasis) and intestines (chronic inflammatory bowel disease) are also frequent manifestations in patients with SpA. Due to the heterogeneity of disease manifestations and the partial concentration on structural alterations in the sacroiliac joints visible in X‑ray images, the diagnosis is often delayed for many years. An important step in the direction of improved early recognition of axial SpA was establishment of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria published in 2009, which focused on the initally deep-seated back pain and chronicity in relatively young patients as well as the importance of magnetic resonance imaging and HLA B 27 determination in the early stages of the disease. In order to achieve the foundations for an effective and timely therapy of affected patients, in 2014 on the initiative of the German Society of Rheumatology, S3 guidelines on axial SpA including Bechterew's disease and early forms were formulated in cooperation with other specialist societies. This article gives an overview of the contents of the S3 guidelines on axial SpA.

Documentation of the severity of the disease in patients with spondyloarthritis (SpA) can represent a clinical challenge, especially as the course of SpA can be very different. Patients with SpA often complain of symptoms, such as pain, fatigue and stiffness as well as limitations in mental functions and social participation. This wide range of functional impairments could so far only be insufficiently documented and not with one single measurement instrument. Despite various attempts in recent years, experts could not reach agreement on a definition of the severity and documentation of the extent of the severity. This was the starting point for the development of the ASAS health index presented here, which initially focused on patients with ankylosing spondylitis (AS). This questionnaire serves to document the health and functional ability of patients with AS and has been available since 2015 as the original english version of the ASAS health index together with the accompanying environmental factors set. This article describes the German translation and transcultural adaptation of the ASAS health index and the accompanying environmental factors set.

The term spondyloarthritis (SpA) is now increasingly used to classify and diagnose patients who are characterized by inflammation in the axial skeleton and peripheral manifestations (arthritis and enthesitis). The management of SpA should be tailored according to the current manifestations of the disease, the disease activity and functional impairment. The current article focuses on diagnosis and therapy in patients with axial SpA. Diagnostic procedures are discussed in light of diagnostic utility and feasibility in daily routine care. Cornerstones of treatment in patients with axial SpA are a combination of regular exercise and pharmacological treatment options aiming at anti-inflammatory strategies.

The management of patients with spondyloarthritis (SpA) has experienced a paradigm shift in recent years. This is true for the treatment of axial as well as peripheral manifestations. International treat to target (T2T) recommendations for SpA based on the T2T strategy have now also been published, which contain 5 higher level principles (A-E) in addition to the 15 recommendations. In order to make the recommendations known and to promote national distribution, German experts have now issued a translation of the T2T recommendations for SpA into German.

Despite a large number of approved therapies demonstrating efficacy in the treatment of rheumatic diseases, only 60-85 % of patients with the indications for rheumatoid arthritis are adequately treated in Germany. Additionally, approved therapies for other immune-mediated diseases are often entirely lacking, indicating the great medical need for the development of new innovative therapies in this specialized field. The development of new drugs is expensive due to the high costs of conducting clinical trials in all phases of development up to obtaining approval; therefore, pharmaceutical companies are looking for ways to save costs in the particular developmental stages. Although the classical regions for drug development (i.e. western Europe, the USA and Japan) offer both a high level of data quality and a good infrastructure to conduct clinical trials due to high standards of education and quality, clinical trials are expensive in these regions. Beside high costs, the comparatively low recruitment rates in these regions are one of the main reasons for the shifting of drug developmental stages from classical regions to eastern European, Latin American and Asian countries, which provide services for drug development and high recruitment rates for comparatively less money. However, there are many strong arguments for the participation of regions in western Europe, especially German sites in clinical trials. In this article these arguments are discussed and possible solutions and strategies for conducting and compensation of study centers in Germany for clinical trials in the field of rheumatology are provided.

The new term axial spondyloarthritis (axSpA) includes classic ankylosing spondylitis and non-radiographic (nr-) axSpA. The definition was introduced in 2009 as part of the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA, where-apart from chronic back pain starting before the age of 45 years and the presence of HLA-B27-magnetic resonance imaging demonstrated bone marrow edema of the sacroiliac joints (osteomyelitis) or structural changes on x-rays may play an important role. These criteria can also be used for diagnosis. A major advantage of the new criteria is the identification of patients in early disease stages. In addition to physical therapy, drug treatment with steroidal anti-inflammatory agents (NSAIDs), corticosteroid injections, and biologics [blocker of tumor necrosis factor (TNF)] have all been shown to be effective, while conventional disease modifying drugs (DMARDs) such as sulfasalazine and methotrexate seem to work mainly for peripheral arthritis but not for enthesitis. Biologics are indicated when NSAIDs in optimal dosage have failed. Both these drugs have the potential to improve pain, stiffness, and function but they may also have an influence on new bone formation (syndesmophytes). NSAIDs need to be given continuously and biologics for longer periods of time. Patients with elevated C-reactive protein levels benefit most when treated consequently.

The ASAS recommendations on the use of tumor necrosis factor (TNF) inhibitors for patients with axial spondyloarthritis were amended in 2010. Essential new aspects have been included in the update. The diagnosis is extended from patients with ankylosing spondlitis (AS) to all patient groups of axial spondyloarthritis. Pretreatment with at least two non-steroidal anti-rheumatic drugs (NSARD) for 4 weeks is recommended. The success of therapy with TNF inhibitors is to be compiled after at least 12 weeks.This article presents the results of the evaluation of the German translation of these recommendations. A total of 25 experts from Germany, Austria and Switzerland have scored the translation on a scale between 0 (no agreement) and 10 (full agreement) with respect to the recommendation grade. The agreement on the recommendations between the experts was very high (8.98 ± 1.25).

The ASAS/EULAR recommendations for the management of ankylosing spondylitis have been updated in 2010. The recommendations have been extended from 10 to 11 recommendations and 4 superior principles have been introduced based on the level of evidence and expert knowledge. The recommendations have been translated into German and have been evaluated by 25 experts from Germany, Austria and Switzerland. The experts scored the strength of the recommendations (SOR) on an 11 point numerical rating scale (from 0 = no agreement to 10 = total agreement). With a mean score of 9.6 ± 1.05 the SOR was generally very good.

The characteristic features of spondyloarthritis are inflammation in the axial skeleton (sacroiliitis, spondylitis) and inflammation in peripheral joints (arthritis) and entheses (enthesitis). According to the leading clinical symptom SpA is today differentiated in the either predominant axial or the peripheral form. The axial SpA are further subdivided in ankylosing spondylitis and non-radiographic axial SpA. This subset is characterized by the absence of structural changes on conventional x-rays. In this review we describe the clinical symptoms, the diagnosis and therapy of patients with axial SpA.