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To compare magnetic resonance imaging (MRI)-detected structural abnormalities in patients with symptomatic midfoot osteoarthritis (OA), patients with persistent midfoot pain, and asymptomatic controls, and to explore the association between MRI features, pain, and foot-related disability.One hundred seven adults consisting of 50 patients with symptomatic and radiographically confirmed midfoot OA, 22 adults with persistent midfoot pain but absence of radiographic OA, and 35 asymptomatic adults underwent 3T MRI of the midfoot and clinical assessment. MRIs were read for the presence and severity of abnormalities (bone marrow lesions [BMLs], subchondral cysts, osteophytes, joint space narrowing [JSN], effusion-synovitis, tenosynovitis, and enthesopathy) using the Foot Osteoarthritis MRI Score. Pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index.The severity sum score of BMLs in the midfoot was greater in patients with midfoot pain and no signs of OA on radiography compared to controls (P = 0.007), with a pattern of involvement in the cuneiform-metatarsal joints similar to that in patients with midfoot OA. In univariable models, BMLs (ρ = 0.307), JSN (ρ = 0.423), and subchondral cysts (ρ = 0.302) were positively associated with pain (P 0.01). In multivariable models, MRI abnormalities were not associated with pain and disability when adjusted for covariates.In individuals with persistent midfoot pain but no signs of OA on radiography, MRI findings suggested an underrecognized prevalence of OA, particularly in the second and third cuneiform-metatarsal joints, where BML patterns were consistent with previously recognized sites of elevated mechanical loading. Joint abnormalities were not strongly associated with pain or foot-related disability.

Background End-stage ankle osteoarthritis typically causes severe pain and impaired function. Surgical treatment involves total ankle replacement (TAR) or ankle fusion. Definitive evidence about which procedure is optimal is lacking. No previous studies have thoroughly explored patients’ experiences across the entire TAR/ankle fusion pathway. This study aimed to address this gap by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who had undergone TAR or ankle fusion. Methods Seven participants were purposively selected from an orthopaedic centre in northern England (3 females, 4 males). Participants had undergone primary TAR without revision (n = 2), TAR requiring revision (n = 3) or ankle fusion (n = 2). Each participant completed a single semi-structured interview. Interviews were digitally recorded, transcribed verbatim and analysed thematically. Results Three themes, each with two subthemes, were identified: decision-making (seeking help; surgical options), perceptions of support (information/education; clinical support) and impact on the individual (personal circumstances and beliefs; post-operative outcomes). Pain affecting participants’ valued activities was key to their decision to seek help. Participants’ decision between TAR and ankle fusion was influenced by multiple factors. Concerns regarding the lack of joint flexibility following fusion were highlighted, with some participants perceiving TAR as a “proper ankle” that would enable them to avoid limping. Participants obtained information from various sources, with most feeling that the education from their care team was inadequate. Participants’ individual circumstances and beliefs influenced their decision-making and perceptions of their post-operative outcomes. Finally, whilst most participants were pleased with their outcomes, some experienced substantial ongoing problems such as difficulty walking and chronic pain. Conclusions This study demonstrates the importance of providing adequate education about TAR and ankle fusion to enable patients to make informed decisions. Most participants felt that the education and clinical support they received did not fully meet their needs. Participants’ personal circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor education and clinical support. Future work with a larger sample of patients and other key stakeholders is required to develop consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion.

End-stage ankle osteoarthritis typically causes severe pain and impaired function. Surgical treatment involves total ankle replacement (TAR) or ankle fusion. Definitive evidence about which procedure is optimal is lacking. No previous studies have thoroughly explored patients' experiences across the entire TAR/ankle fusion pathway. This study aimed to address this gap by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who had undergone TAR or ankle fusion.Seven participants were purposively selected from an orthopaedic centre in northern England (3 females, 4 males). Participants had undergone primary TAR without revision (n = 2), TAR requiring revision (n = 3) or ankle fusion (n = 2). Each participant completed a single semi-structured interview. Interviews were digitally recorded, transcribed verbatim and analysed thematically.Three themes, each with two subthemes, were identified: decision-making (seeking help; surgical options), perceptions of support (information/education; clinical support) and impact on the individual (personal circumstances and beliefs; post-operative outcomes). Pain affecting participants' valued activities was key to their decision to seek help. Participants' decision between TAR and ankle fusion was influenced by multiple factors. Concerns regarding the lack of joint flexibility following fusion were highlighted, with some participants perceiving TAR as a "proper ankle" that would enable them to avoid limping. Participants obtained information from various sources, with most feeling that the education from their care team was inadequate. Participants' individual circumstances and beliefs influenced their decision-making and perceptions of their post-operative outcomes. Finally, whilst most participants were pleased with their outcomes, some experienced substantial ongoing problems such as difficulty walking and chronic pain.This study demonstrates the importance of providing adequate education about TAR and ankle fusion to enable patients to make informed decisions. Most participants felt that the education and clinical support they received did not fully meet their needs. Participants' personal circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor education and clinical support. Future work with a larger sample of patients and other key stakeholders is required to develop consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion.

usc Objective: To compare foot and leg muscle strength in people with symptomatic midfoot osteoarthritis (OA) with asymptomatic controls, and to determine the association between muscle strength, foot pain, and disability. Methods: Participants with symptomatic midfoot OA and asymptomatic controls were recruited for this cross-sectional study from general practices and community health clinics. The maximum isometric muscle strength of the ankle plantarflexors, dorsiflexors, invertors and evertors, and the hallux and lesser toe plantarflexors was measured using hand-held dynamometry. Self-reported foot pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. Differences in muscle strength were compared between groups. Multivariable regression was used to determine the association between muscle strength, foot pain, and disability after adjusting for covariates. Results: People with midfoot OA (n = 52) exhibited strength deficits in all muscle groups, ranging from 19% (dorsiflexors) to 30% (invertors) relative to the control group (n = 36), with effect sizes of 0.6–1.1 (P < 0.001). In those with midfoot OA, ankle invertor muscle strength was negatively and independently associated with foot pain (β = –0.026 [95% confidence interval (95% CI) –0.051, –0.001]; P = 0.045). Invertor muscle strength was negatively associated with foot-related disability, although not after adjustment for depressive symptoms (β = –0.023 [95% CI –0.063, 0.017]; P = 0.250). Conclusion: People with symptomatic midfoot OA demonstrate weakness in the foot and leg muscles compared to asymptomatic controls. Preliminary indications from this study suggest that strengthening of the foot and leg muscles may offer potential to reduce pain and improve function in people with midfoot OA. Refereed/Peer-reviewed

Refereed/Peer-reviewed Background: To compare intrinsic foot muscle size between people with and without symptomatic midfoot osteoarthritis, and examine the association between muscle size and strength, pain and foot-related disability. Methods: Twenty-three participants with symptomatic midfoot osteoarthritis and 23 age, sex and BMI matched controls were included. Intrinsic foot muscle cross-sectional area was measured using MRI. Hand-held dynamometry was used to assess foot and ankle muscle strength, and foot-related pain and disability was measured using Manchester Foot Pain & Disability Index. Findings: Small and non-statistically significant differences were found in intrinsic foot muscle cross-sectional area between the two groups (effect sizes 0.15–0.26, p > 0.05). Muscle strength was reduced in the midfoot osteoarthritis group, with differences of 12–33% (effect sizes 0.47–1.2). In the control group, moderate positive associations) existed between foot muscle cross-sectional area and lesser digits flexor strength (r = 0.5 to 0.7, p < 0.05). Conversely, in the midfoot osteoarthritis group, negligible positive associations were found (r < 0.3, p > 0.05). Associations between foot muscle cross-sectional with and pain and disability scores in the midfoot osteoarthritis group were negligible (r < −0.3, p > 0.05). Interpretation: Despite reductions in maximal isometric muscle strength, midfoot osteoarthritis does not appear to be associated with reduced intrinsic foot muscle cross-sectional area measured by MRI. Muscle compositional or neural factors may explain the reductions in muscle strength and variation in symptoms in people with midfoot osteoarthritis and should be investigated.

Background Medical imaging can be used to assist with the diagnosis of plantar heel pain. The aim of this study was to synthesise medical imaging features associated with plantar heel pain. Methods This systematic review and meta-analysis conducted searches in MEDLINE, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to 12th February 2021. Peer-reviewed articles of cross-sectional observational studies written in English that compared medical imaging findings in adult participants with plantar heel pain to control participants without plantar heel pain were included. Study quality and risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Sensitivity analyses were conducted where appropriate to account for studies that used unblinded assessors. Results Forty-two studies (2928 participants) were identified and included in analyses. Only 21% of studies were rated ‘good’ on quality assessment. Imaging features associated with plantar heel pain included a thickened plantar fascia (on ultrasound and MRI), abnormalities of the plantar fascia (on ultrasound and MRI), abnormalities of adjacent tissue such as a thickened loaded plantar heel fat pad (on ultrasound), and a plantar calcaneal spur (on x-ray). In addition, there is some evidence from more than one study that there is increased hyperaemia within the fascia (on power Doppler ultrasound) and abnormalities of bone in the calcaneus (increased uptake on technetium-99 m bone scan and bone marrow oedema on MRI). Conclusions People with plantar heel pain are more likely to have a thickened plantar fascia, abnormal plantar fascia tissue, a thicker loaded plantar heel fat pad, and a plantar calcaneal spur. In addition, there is some evidence of hyperaemia within the plantar fascia and abnormalities of the calcaneus. Whilst these medical imaging features may aid with diagnosis, additional high-quality studies investigating medical imaging findings for some of these imaging features would be worthwhile to improve the precision of these findings and determine their clinical relevance.

Over the past decade, the role of nurses, midwives and allied health professionals (NMAHPs) have been transformed within the UK research community. Assisted by new funding opportunities and a recognition of their role in interdisciplinary working, NMAHPs are driving innovative patient care. Challenges still remain to maximise the potential of NHAMPs in clinical research; signposting opportunities to become involved in research, promoting clear career pathways and developing innovative roles with the NHS to attract and retain this community are critical.

Introduction Activity pacing is considered a key component of rehabilitation programmes for chronic pain/fatigue. However, there are no widely used guidelines to standardize how pacing is delivered. This study aimed to undertake the first stage in developing a comprehensive evidence‐based activity pacing framework. Methods An online survey across pain/fatigue services in English National Health Service trusts explored healthcare professionals' opinions on the types/uses of pacing, aims, facets and perceived effects. Data were analysed using descriptive statistics for closed‐ended questions and thematic analysis for open‐ended questions. Purposeful recruitment with a snowball effect engaged 92 healthcare professionals (physiotherapists, occupational therapists, nurses, doctors and psychologists) to the study. Results Pacing was highly utilized, with perceived long‐term benefits for patients (n = 83, 90.2% healthcare professionals instructed pacing). The most endorsed aim of pacing was “achievement of meaningful activities” (24.5% of ranked votes). The least endorsed aim was “to conserve energy” (0.1% of ranked votes). The most frequently supported facet of pacing was “breaking down tasks” (n = 91, 98.9%). The least supported facet was “stopping activities when symptoms increase” (n = 6, 6.5%). Thematic analysis showed recurring themes that pacing involved flexibility and sense of choice. Conclusions Pacing is a multidimensional coping strategy and complex behaviour. The message is clear that pacing should enable increases in meaningful activities, as opposed to attempting to avoid symptoms. The survey findings have informed the development of an activity pacing framework to guide healthcare professionals on the multiple components of pacing. This will help to standardize and optimize treatments for chronic pain/fatigue and enable future investigations.

OBJECTIVES: We have developed and feasibility tested an activity pacing framework for clinicians to standardise their recommendations of activity pacing to patients with chronic pain/fatigue. This study aimed to explore the acceptability and fidelity to this framework in preparation for a future trial of activity pacing. \ud \ud DESIGN: Acceptability and fidelity were explored using semi-structured interviews. Data were analysed using framework analysis. \ud \ud PARTICIPANTS: Patients who attended a rehabilitation programme for chronic pain/fatigue underpinned by the framework, and clinicians (physiotherapists and psychological wellbeing practitioners) who led the programmes. \ud \ud RESULTS: Seventeen interviews were conducted, involving 12 patients with chronic pain/fatigue and five clinicians. The framework analysis revealed four deductive themes: (1) Acceptability of the activity pacing framework, (2) Acceptability of the feasibility study methods, (3) Processes of change and (4) Barriers and facilitators to activity pacing; and one inductive theme: (5) Perspectives of patients and clinicians. \ud \ud CONCLUSIONS: The activity pacing framework appeared acceptable to patients and clinicians, and adherence to the framework was demonstrated. Processes of behaviour change included patients' regulation of activities through activity pacing. Barriers to pacing included work/social commitments and facilitators included identifying the benefits of pacing on symptoms. Different perspectives emerged between clinicians and patients regarding interpretations of symptom-contingent and quota-contingent strategies. The framework recognises fluctuations in symptoms of chronic pain/fatigue and encourages a quota-contingent approach with flexibility. Future work will develop a patient friendly guide ahead of a clinical trial to explore the effects of pacing.

Objectives\ud \ud This is a protocol for a Cochrane Review (intervention). The objectives are as follows:\ud \ud \ud \ud Main objective: to assess the effects of computerised clinical decision support systems (CDSS) use on nurses' and allied health professionals’ performance and patient outcomes, by comparing those who use CDSS and those who do not use CDSS.\ud \ud \ud \ud Secondary objective: to assess the resource use associated with CDSS used by nurses and allied health professionals.

Introduction To measure the range of T1 values of synovitis using three Tesla (3 T) magnetic resonance imaging (MRI) in patients with osteoarthritis to assess the potential of T1 mapping for identifying synovitis from other features in the knee on unenhanced magnetic resonance scans. Methods After receiving institutional ethical approval, 83 patients who met the American College of Rheumatology criteria for diagnosis of osteoarthritis of the knee were scanned using a 3 T Magnetic Resonance Imaging scanner. T1 maps were calculated from spoiled gradient echo images acquired with five different flip angles of 5°–25°. Mean values for the T1 measurements were calculated and compared to existing data from the published literature for anatomical and pathological structures of the knee. Results T1 values recorded in patients suffering from osteoarthritis demonstrated that T1 values for synovitis (confirmed on gadolinium enhanced images) fall in a narrow range (849–1277 ms, mean 1005 ms SD 91) delineating this from other structures of the knee such as muscle (T1 value range 1305–2638 ms, mean 1785 ms SD 304) and synovial fluid (T1 value range 3867–4129 ms, mean 3915 SD 899) at 3 T. Conclusion T1 values measured in synovitis in patients with osteoarthritis of the knee demonstrated a range of values distinct to those measured in muscle and synovial fluid at 3 T. This offers potential for the use of T1 maps to delineate or quantify synovitis in patients who are unwilling or unable to receive injectable contrast agents.

ObjectiveComputerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals’ performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this.Materials and methodsThe following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion.ResultsA total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved ‘smart’ mobile/handheld-technology.DiscussionCDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses’ adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness.ConclusionCDSS may have a positive impact on selected aspects of nurses’ and AHPs’ performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.

Background While the prevalence and impact of musculoskeletal problems are high, most attention has been directed towards the back, knee and hip disorders. Foot pain is known to be common in older adults and accounts for a significant burden on health services. The aim of this study was to assess the impact of foot and ankle joint pain, considering age, presence of co-morbidities and other site joint pain, in a large community sample. Methods In the North Yorkshire Health study, 16,222 people over 55 years participated in a detailed survey of the prevalence and impact of lower limb joint problems. Self-assessment of overall body pain and functional activities of daily living were assessed. Participants indicated the presence of joint pain, stiffness or swelling during the last 3 months which had lasted for more than 6 weeks on a manikin: data were captured on the foot and the ankle. Results The prevalence of self-reported foot and ankle joint pain was substantial: 184.33 per 1000, second only to knee problems. While foot pain was common, it was mostly associated with joint pain at other sites; only 1 in 11 of those with foot and ankle pain reported it only in the foot. Logistic regression modeling revealed while established factors such as co-morbidities, knee and hip problems contributed to functional impairment, foot and ankle problems contributed to an additional increased risk of having difficulty standing and walking by two fold (OR = 2.314, 95%CI 2.061–2.598), going up and down stairs by 71% (OR = 1.711, 95%CI 1.478–1.980) and getting up from a seated position by 44% (OR = 1.438, 95%CI 1.197–1.729). Conclusion These results suggest that not only are foot problems in the over 55 age group extremely prevalent, they have a considerable impact on functional abilities.

Due to the current absence of a standardized guide for activity pacing, the concept of pacing is interpreted in various ways by healthcare professionals, patients and researchers. Consequently, the effects of pacing across different conditions are unclear. The present study aimed to undertake the second stage in the development of an activity pacing framework for chronic pain/fatigue. The newly developed activity pacing framework was refined using a consensus method. A nominal group technique (NGT) was selected to engage stakeholders to reach agreement on the top 10 priorities for inclusion in the framework and accompanying appendices. Participants included patients with diagnoses of chronic pain/fatigue and healthcare professionals working in fields of chronic pain/fatigue. Ten participants were recruited via purposive sampling: four patients, two physiotherapists, two occupational therapists and two psychological wellbeing practitioners. The top priorities for the pacing framework included a clear definition of pacing, and stating the aims and context of pacing. The appendices were refined as a teaching guide, including priorities of detailing the stages of pacing, the overactivity-underactivity cycle/pain cycle and goal setting. Incorporating a diverse panel of stakeholders was an effective and inclusive method to refine the activity pacing framework. The framework has been purposefully designed for wider use across patients with chronic pain/fatigue and by various healthcare professionals. The framework provides a comprehensive definition, background and manual for healthcare professionals to instruct activity pacing. Further study will test the clinical usability of the framework, to enable the standardization of activity pacing in future investigations. [Abstract copyright: © 2019 John Wiley & Sons, Ltd.]

This chapter covers soft-tissue disorders, a common occurrence in rheumatology. There is a brief overview of 10 of the most common soft-tissue disorders of the foot in rheumatology, including Achilles tendinopathy, ankle sprains, retrocalcaneal bursitis, tarsal tunnel syndrome, peroneal tendinopathy, tibialis posterior tendinopathy, plantar heel pain, and more. For each disorder, presentation, signs, and management are discussed.

In this chapter, we will cover osteoarthritis. First we will provide an overview, with definitions, pathogenesis and risk factors, and clinical features, followed by recommendations for holistic management of the disease. A detailed discussion on the prevalence and impact of foot disease is then given, by area of the foot. Specific non-pharmacological and pharmacological management are described, and surgical options are outlined. Finally, clinical trials and the future direction of research are covered.

Background Guidelines recommend foot orthoses for people with both early (

Free text comments. (DOCX 13 kb)

Supplementary data from other countries. (DOCX 16 kb)

Foot orthoses survey full. (PDF 119 kb)

Background:A growing number of professional societies in clinical and medically related disciplines investigate evidence, make recommendations, and take action to advance gender equity. Evidence on women’s advancement and leadership in the context of the European Alliance of Associations for Rheumatology, EULAR, is limited [1].Objectives:The objective of the EULAR Task Force on Gender Equity in Academic Rheumatology was to establish the extent of the unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology and develop a framework to address this through EULAR and Emerging EULAR Network (EMEUNET).Methods:Potential interventions to accelerate gender-equitable career advancement in academic rheumatology were gathered from a narrative review of the relevant literature, expert opinion of a multi-disciplinary Task Force (comprised of 23 members from 11 countries), data from the surveys of EULAR scientific member society leaders, EULAR and EMEUNET members, and EULAR Executive Committee members. These interventions were rated by Task Force members, who ranked each according to perceived priority on a five-point numeric scale from 1 = very low to 5 = very high.Results:A framework of 29 potential interventions was formulated, which covers six thematic areas, namely, EULAR policies, advocacy and communication, EULAR Congress and associated symposia, training courses, mentoring/peer support, and EULAR funding (Figure 1).Figure 1.A framework of potential interventions with the levels of priority, mean and standard deviation (SD)Conclusion:The framework provides structured interventions for accelerating gender-equitable career advancement in academic rheumatology.References:[1]Andreoli L, Ovseiko PV, Hassan N, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine 2019;86(6):669-72.Acknowledgements:The task force is grateful to EULAR for funding this activity under project number EPI 024.Disclosure of Interests:None declared

Background:Women represent an increasing proportion of the overall rheumatology workforce, but are underrepresented in academic rheumatology, especially in leadership roles [1].Objectives:The EULAR Task Force on Gender Equity in Academic Rheumatology has been convened to establish the extent of the unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology and develop a framework to address this through EULAR and EMEUNET.Methods:To investigate gender equity in academic rheumatology, an anonymous web-based survey was targeted at the membership of EULAR and Emerging EULAR Network (EMEUNET) and their wider networks. The survey was developed based on a narrative literature review [1], best practice from The Association of Women in Rheumatology, a survey of task force members and face-to-face task force discussions. Personal experiences were explored and 24 potential interventions to aid career advancement were ranked. Statistics were descriptive with significance testing for male/female responses compared using chi-squared/t-tests. The level of significance was set at pResults:A total of 301 respondents from 24 countries fully completed the survey. By profession, 290 (86.4%) were rheumatologists, 19 (6.3%) health professionals, and 22 (7.3%) non-clinical scientists. By gender, 217 (72.1%) were women, 83 (27.6%) men, and 1 (0.3%) third gender. By age, 203 (67.5%) were 40 or under. By ethnicity, 30 (10.0%) identified themselves as ethnic minority. A high proportion of respondents reported having experienced gender discrimination (47.2% total: 58.1% for women and 18.1% for men) and sexual harassment (26.2%: 31.8% and 10.8% respectively) (Figure 1). Chi-squared tests on the numbers on which these proportions were based showed statistically significant differences between women and men in having experienced gender discrimination (Χ2=36.959 (df=1), p Figure 1.Perceived gender discrimination and sexual harassment, 301 responsesFigure 2.Mean perceived utility of potential interventions for career advancement by gender and statistically significant gender differences (pConclusion:The results of the survey will inform the development of task force policy proposals for interventions to support career advancement among EULAR and EMEUNET members. The identified interventions have potential to support career advancement of all rheumatologists, health professionals and non-clinical scientists regardless of gender.References:[1]Andreoli L, Ovseiko PV, Hassan N, Kiltz U, van Mens L, Gossec L, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint, Bone, Spine: Revue du Rhumatisme. 2019;86(6):669-672.Acknowledgments:We gratefully acknowledge the rheumatologists, health professionals and non-clinical scientists who responded to the survey.Disclosure of Interests:Pavel V Ovseiko: None declared, Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, Laura Andreoli: None declared, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Leonieke van Mens: None declared, Neelam Hassan: None declared, Marike van der Leeden: None declared, Heidi J Siddle: None declared, Alessia Alunno: None declared, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Florence Apparailly: None declared, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences., Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Elena Nikiphorou: None declared, Katie Druce Speakers bureau: Pfizer and Lilly, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Alexandre Sepriano: None declared, Tadej Avcin: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Anne Maree Keenan: None declared, Laura C Coates: None declared

Objective.Foot osteoarthritis (OA) is very common but underinvestigated musculoskeletal condition and there is little consensus as to common magnetic resonance imaging (MRI) features. The aim of this study was to develop a preliminary foot OA MRI score (FOAMRIS) and evaluate its reliability.Methods.This preliminary semiquantitative score included the hindfoot, midfoot, and metatarsophalangeal joints. Joints were scored for joint space narrowing (JSN; 0–3), osteophytes (0–3), joint effusion/synovitis, and bone cysts (present/absent). Erosions and bone marrow lesions (BML) were scored (0–3) and BML were evaluated adjacent to entheses and at sub-tendon sites (present/absent). Additionally, tenosynovitis (0–3) and midfoot ligament pathology (present/absent) were scored. Reliability was evaluated in 15 people with foot pain and MRI-detected OA using 3.0T MRI multi-sequence protocols, and assessed using ICC as an overall score and per anatomical site.Results.Intrareader agreement (ICC) was generally good to excellent across the foot in joint features (JSN 0.90, osteophytes 0.90, effusion/synovitis 0.46, cysts 0.87), bone features (BML 0.83, erosion 0.66, BML entheses 0.66, BML sub-tendon 0.60) and soft tissue features (tenosynovitis 0.83, ligaments 0.77). Interreader agreement was lower for joint features (JSN 0.43, osteophytes 0.27, effusion/synovitis 0.02, cysts 0.48), bone features (BML 0.68, erosion 0.00, BML entheses 0.34, BML sub-tendon 0.13), and soft tissue features (tenosynovitis 0.35, ligaments 0.33).Conclusion.This preliminary FOAMRIS demonstrated good intrareader reliability and fair interreader reliability when assessing the total feature scores. Further development is required in cohorts with a range of pathologies and to assess the psychometric measurement properties.

Bespoke user-tested patient information sheet. (PDF 328Â kb)

Original, control patient information sheet. (DOC 103Â kb)

Template-developed patient information sheet. (PDF 162Â kb)

Evolution of codes used in thematic analysis. (DOC 80Â kb)

Current UK management of RA initially employs conventional DMARDs, with biological therapy reserved for DMARD-resistant RA patients with persistently high 28-joint disease activity score (DAS-28). The aim of this study was to examine the effect on patient-reported function of persistently moderate DAS-28 despite modern step-up DMARD therapy in an early arthritis cohort.Data were obtained from the Yorkshire Early Arthritis Register, a cohort of early (12 months) RA patients treated with dose-escalated DMARDs. Change in HAQ exceeding the minimum clinically important difference (MCID) was determined for three values of MCID (0.22, 0.31 and 0.49). Changes in HAQ over Months 6-12 were compared between patients whose DAS-28(ESR) was persistently high (5.1 at 6- and/or 9-month visits and at the 12-month visit), persistently moderate (3.2 and ≤ 5.1) or persistently low (≤ 3.2).We selected 194 patients for this analysis. Deteriorating HAQ scores were observed in 10.9% of patients with persistently low DAS-28 compared with 21.4% (persistently moderate DAS-28) and 46.7% (persistently high DAS-28), respectively, for MCID = 0.22; 7.3, 14.3 and 20.0% for MCID = 0.31; 5.5, 10.7 and 11.1% for MCID = 0.49.A high DAS-28 was generally associated with a greater degree of functional decline, but persistent moderate elevation of DAS-28 was associated with important functional deterioration in 10-21% of early RA patients (depending on choice of MCID) following a modern DMARD protocol. A proportion of patients with persistently moderate DAS-28 may therefore benefit from more aggressive therapy than that allowed by current UK recommendations.

Objective To compare work disability and job loss in early rheumatoid arthritis (RA) patients receiving adalimumab plus methotrexate (adalimumab + MTX) versus MTX alone. Methods In this multicenter, randomized, controlled trial, patients with RA for

Objective To develop and validate a disease-specific quality of life (QOL) measure for osteoarthritis (OA), the OAQoL, using the needs-based conceptual model. Methods In the first phase of this study, in-depth, semistructured interviews were conducted with 44 OA patients to explore the issues associated with impact of OA and to derive items for a draft OAQoL questionnaire. In phase 2, 17 OA patients were interviewed on the relevance, clarity, and ease of completion of the measure in structured interviews. In phase 3, the draft questionnaire was mailed to 635 patients to test the psychometric properties of the questionnaire using Rasch analysis. Test–retest assessment of the revised questionnaire was performed in phase 4 by mailing the questionnaire to an additional 201 participants, with a second questionnaire repeated 2 weeks later. Results A 38-item draft measure was devised during phase 1 and mailed in phase 2. Rasch analysis of the draft questionnaire (n = 259) indicated initial misfit, which was rectified with the removal of 13 problematic items (χ2[75] = 83.602, P = 0.232). For the test–retest assessment (n = 60), 3 additional items were removed, leaving a 22-item OAQoL that demonstrated good fit to the Rasch model (χ2[44] = 44.559, P = 0.533) with excellent test–retest correlation (ρ = 0.925, P < 0.001; z = −0.06, P = 0.995). Conclusion The OAQoL is a simple and easy to use 22-item unidimensional questionnaire developed specifically to assess the impact of OA on QOL. The measure has been developed as a true patient-based questionnaire and demonstrates good psychometric properties, including test–retest reliability.

Background While capillary refill time test (CRTT) has been commonly used as a quick and convenient clinical vascular assessment of the lower limb, the validity of this test has not been established. Objectives There were three aims to this study: the first was to evaluate the reliability of CRTT, the second to investigate the premise that CRTT represents skin perfusion, and thirdly to determine whether CRTT can detect lower limb vascular disease. Method Intra- and inter-tester reliability was evaluated for five experienced physicians who used CRTT on 10 participants. Criterion validity for measurement of skin perfusion was investigated by comparison with laser Doppler flowmetry on 49 participants, and for this same group the usefulness of detecting those persons with peripheral arterial disease and a state of impaired healing was evaluated. Results CRTT had reasonable intra-tester reliability (ICC=0.72) but poorer inter-tester reliability (ICC range=0.12–0.81). For measurement of skin perfusion, CRTT was predictive of only 38% of the variance in laser Doppler flowmetry measures ( r 2 =0.38, P z =−1.86, P =0.062), nor could it discern between patients with and without impaired lower extremity healing ( z =−0.21, P =0.830). Laser Doppler flowmetry was also unable to predict the presence of peripheral arterial disease ( t 96 =0.27, P =0.787) and impaired healing ( t 96 =1.95, P =0.054). Conclusion These results question the usefulness of capillary refill time test for assessment of vascular status in the lower limb.

Keenan A-M, Redmond AC, Horton M, Conaghan PG, Tennant A. The Foot Posture Index: Rasch analysis of a novel, foot-specific outcome measure. Objective To investigate the internal construct validity of a clinician-assessed measure of foot position, the Foot Posture Index (FPI), versions FPI-8 and FPI-6. Design Rasch analysis of baseline FPI scores from studies conducted during the development of the instrument. Setting A community-based and a hospital-based study, conducted at 2 institutions. Participants Measures were obtained from 143 participants (98 men, 45 women; age range, 8–65y). Interventions Not applicable. Main Outcome Measures Rasch analysis was undertaken using RUMM2020 software in order to evaluate the following properties of the FPI: unidimensionality of each item included in the FPI, the differential item functioning (DIF) of each item, and item and person separation indices. Results In the developmental draft of the instrument, the 8-item FPI-8 showed some misfit to the Rasch model (χ 16 2 test=27.63, P =.03), indicating lack of unidimensionality. Two items were identified as problematic in the Rasch modeling: Achilles' tendon insertion (Helbing's sign), which showed illogical response ordering and "congruence of the lateral border of the foot," which showed misfit, indicating that this item may be measuring a different construct (χ 2 2 test=15.35, P 12 2 test=11.49, P =.49), indicating a good overall fit to the model, and improvement over the preliminary version. With the removal of the 2 problematic items, there were no disordered thresholds; all items remained DIF free and all individual items displayed a good fit to the model. The person-separation index for the FPI was similar for both the 8-item (FPI-8=.880) and 6-item (FPI-6=.884) versions. Conclusions The original FPI-8 showed significant mismatching to the model. The 2 items in the FPI-8 that were identified as problematic in clinical validation studies were also found to be contributing to the lack of fit to the Rasch model. The finalized 6-item instrument showed good metric properties, including good individual item fit and good overall fit to the model, along with a lack of differential item functioning. This analysis provides further evidence for the validity of the FPI-6 as a clinical instrument for use in screening studies and shows that it has the potential to be analyzed using parametric strategies.

Objective To determine the outcome after 52 weeks of early intervention with intraarticular corticosteroid injections followed by sulfasalazine versus conservative therapy in patients with recent-onset oligoarthritis in a randomized controlled trial. Methods Patients with ≤4 joints with clinical synovitis (disease duration ≤12 months) were randomized to early intervention (EI) with intraarticular methylprednisolone into all synovitic joints or to conservative treatment (CT) with nonsteroidal antiinflammatory drugs alone. Sulfasalazine was administered in both groups for persistent disease or disease that evolved into a polyarthritis. Primary outcome was complete response (CR) defined as the absence of synovitis at 52 weeks. Secondary outcomes included CR at weeks 4 and 12, function (Health Assessment Questionnaire), pain (0–100-mm visual analog scale), and work status. Results Fifty-nine patients (34 men, 25 women; mean age 32.9 years; median early morning stiffness 30 minutes) were randomized. At baseline, two-thirds reported that they were work impaired. At 52 weeks, 81% of patients in the EI group achieved CR compared with 57% in the CT group (χ2 = 3.833, 1 df, P = 0.05). In addition, 45% of patients in the EI group received sulfasalazine as opposed to 14% in the CT group (χ2 = 5.156, 1 df, P = 0.019). There were no differences in physical disability or work impairment between the treatment groups. Conclusion Oligoarthritis has a significant impact on function and work ability. Patients treated with EI using intraarticular corticosteroids followed by sulfasalazine therapy if resistant demonstrated reduced synovitis 12 months after treatment compared with those initially treated with more conservative therapy.

During recruitment, potential trial participants are usually given a written study patient information sheet (PIS). These are often long, complex and visually unappealing documents, which may have a negative impact on recruitment. Improving their readability by employing user testing, and their presentation by using graphic designers may improve patient understanding and aid recruitment. We undertook an embedded randomised controlled trial within the NIHR-funded REFORM study, as part of the MRC START initiative, to evaluate whether enhancing PIS improves trial recruitment and retention. 6,900 patients due to be mailed a REFORM recruitment pack were randomised in a 1:1:1 ratio to receive one of three types of PIS: the original based on the NHS ethics template (n=2,298); an enhanced, user tested PIS (n=2,301); or a ‘template’ PIS which was developed using an enhanced PIS from another trial in a similar population (n=2,301). 193 participants (2.8%) were randomised to the trial: 62 (2.7%) in the control group; 63 (2.7%) in the user tested group; and 68 (3.0%) in the template group (OR: template vs control 1.10 (95% CI 0.77-1.56, p=60); user tested vs control 1.01 (95% CI 0.71-1.45, p=0.94); and user tested vs template 0.92 (95% CI 0.65-1.31, p=0.65)). Logistic regression analysis demonstrated that PIS allocation did not significantly predict recruitment (p= 0.33) or retention in the trial (p=0.83). There was no evidence to suggest that enhanced PIS increased recruitment and retention rates to the REFORM trial. However, the number of patients randomised was low and we may be underpowered to detect a difference.

Evaluation of interventions to enhance recruitment or reduce attrition within randomised controlled trials is uncommon. A number of initiatives have tried to increase this evidence base by encouraging the embedding of such trials within trials evaluating healthcare interventions. The NIHR-funded REFORM study recruited and followed up participants by mailing out invitation packs and questionnaires to participants. We undertook four embedded studies during the recruitment and follow-up phases: (1) Exploration of the feasibility and validity of the EQ5D-5L: 332 participants were sent a baseline questionnaire containing both the EQ5D-5L and the EQ5D-3L; (2) Two embedded trials evaluating i) the effectiveness of an enhanced patient information sheet (PIS) and ii) pre-notification with a study newsletter, to increase recruitment to the trial; and (3) An embedded factorial trial evaluating the effectiveness of a Post-it® note and/or newsletter to increase questionnaire response rates and minimise attrition to the trial. The EQ5D-5L and Post-It® note studies were easily incorporated using in-house funding. The PIS study required £6,500 funding from the MRC START team. Undertaking these studies did cause some delay to the main study, but not to the detriment of the study. To date, results for only the PIS and pre-notification studies are available, and no statistically significant differences have been observed. We have demonstrated that it can be relatively easy to embed several trials within a trial. Whilst funding in some cases may be an issue, can provide useful learning experiences for inexperienced researchers and inform future studies and they do produce academic publications.

not provided. Disclosure statement: The author has declared no conflicts of interest. i20 Thursday 30 April 2015 INVITED SPEAKER ABSTRACTS

This randomised feasibility study aimed to examine the clinical and biomechanical effects of functional foot orthoses (FFOs) in the treatment of midfoot osteoarthritis (OA) and the feasibility of conducting a full randomised controlled trial. Participants with painful, radiographically confirmed midfoot OA were recruited and randomised to receive either FFOs or a sham control orthosis. Feasibility measures included recruitment and attrition rates, practicality of blinding and adherence rates. Clinical outcome measures were: change from baseline to 12 weeks for severity of pain (numerical rating scale), foot function (Manchester Foot Pain and Disability Index) and patient global impression of change scale. To investigate the biomechanical effect of foot orthoses, in-shoe foot kinematics and plantar pressures were evaluated at 12 weeks. Of the 119 participants screened, 37 were randomised and 33 completed the study (FFO = 18, sham = 15). Compliance with foot orthoses and blinding of the intervention was achieved in three quarters of the group. Both groups reported improvements in pain, function and global impression of change; the FFO group reporting greater improvements compared to the sham group. The biomechanical outcomes indicated the FFO group inverted the hindfoot and increased midfoot maximum plantar force compared to the sham group. The present findings suggest FFOs worn over 12 weeks may provide detectable clinical and biomechanical benefits compared to sham orthoses. This feasibility study provides useful clinical, biomechanical and statistical information for the design and implementation of a definitive randomised controlled trial to evaluate the effectiveness of FFOs in treating painful midfoot OA. Electronic supplementary material The online version of this article (doi:10.1007/s10067-015-2946-6) contains supplementary material, which is available to authorized users.

Objectives. To assess symptomatic change after intra-articular corticosteroid (IAST) injection at 2 doses in hip osteoarthritis (OA), and to examine dose response and predictors of response.Methods. Patients with hip OA (90 women and 30 men and median age 64 yrs) referred for IAST fluoroscopic injection were included in this longitudinal, clinical trial. WOMAC scores, body mass index (BMI), conventional radiographic grade (Kellgren and Lawrence scoring) and ultrasound measures (including capsular thickness and osteophyte assessments) were recorded at baseline. In the first phase of the study, 75 patients were injected with 40 mg methylprednisolone; another 45 patients were injected with 80 mg in the second phase. Change in WOMAC scores from baseline to weeks 6 and 12 were calculated for each dose and then dose comparisons were made. Clinical responders (>15% reduction in baseline pain score) were identified in order to establish predictors of response.Results. For the 40 mg dose, there was a statistically significant improvement in pain (P < 0.001) and stiffness (P < 0.001) but not disability at week 6, and only the improvement in stiffness at week 12 was maintained (P = 0.041). For the 80 mg dose, there was significant improvement in pain (P < 0.001), stiffness (P < 0.001) and disability (P < 0.001) at week 6, which was maintained for all domains at week 12 (P = 0.002; P = 0.001; P < 0.001). When the doses were compared, the 80 mg dose demonstrated a significant improvement compared with the 40 mg group for stiffness at week 12 (P = 0.026) and disability at both weeks 6 and 12 (P = 0.026; P = 0.004). Imaging findings did not relate to severity of symptoms or response to IAST.Conclusions. In these two hip OA cohorts, both the 40 mg and 80 mg IAST doses had a beneficial effect at week 6, while the 80 mg dose maintained this improvement at week 12. Comparison of the two dose groups provided some evidence of a dose response. Randomized controlled trials of IAST for hip OA are now required.

The objectives of this study were to validate a semiquantitative scoring system for estimating perimeniscal synovitis in osteoarthritic (OA) knees and to examine the relationship between the extent of synovitis and the degree of meniscal pathology using gadolinium-enhanced magnetic resonance imaging (MRI). Forty-three subjects with clinically diagnosed OA knee were assessed for peri-meniscal synovitis using gadolinium-enhanced MRI. Quantitative measurements of synovitis were made by summing areas in consecutive slices within generated regions of interest, and the synovitis was also scored semi-quantitatively using a 0-3 scale. Meniscal pathology (extrusion, degeneration and tearing) was also scored semiquantitatively. Establishment of a correlative relationship was undertaken using Spearman's rho (rho). A total of 86 sites were assessed. The semi-quantitative synovitis score correlated well with the quantitative synovitis score (rho0.9). A moderate association between medial meniscal extrusion and synovitis was demonstrated (rho=0.762, P0.000), although this association was not as strong in the lateral compartment (rho=0.524, P0..000). The results suggest the semiquantitative scoring system is valid for assessing perimeniscal synovitis. The relationship between meniscal pathology and adjacent synovitis requires further study.

To assess whether simple, limited section analysis can replace detailed volumetric assessment of synovitis in patients with osteoarthritis (OA) of the knee using contrast-enhanced magnetic resonance imaging (MRI).Thirty-five patients with clinical and radiographic OA of the knee were assessed for synovitis using gadolinium-enhanced MRI. The volume of enhancing synovium was quantitatively assessed in four anatomical sites (the medial and lateral parapatellar recesses, the intercondylar notch and the suprapatellar pouch) by summing the volumes of synovitis in consecutive sections. Four different combinations of section analysis were evaluated for their ability to predict total synovial volume.A total of 114 intra-articular sites were assessed. Simple linear regression demonstrated that the best predictor of total synovial volume was the analysis containing the inferior, mid and superior sections of each of the intra-articular sites, which predicted between 40-80% (r(2) = 0.396, p0.001 for notch; r(2) = 0.818, p0.001 for medial parapatellar recess) of the total volume assessment.The results suggest that a three-section analysis on axial post-gadolinium sequences provides a simple surrogate measure of synovial volume in OA knees.