Search

Clinical trials are essential for evaluating the efficacy and safety of new treatments and health interventions. However, while pharmacological trials are well-established, non-pharmacological trials face unique challenges related to their complexity and difficulties such as recruitment, retention, intervention standardisation, selection of outcome measures and blinding of clinicians, participants and data collectors. This communication paper describes the objectives, implementation steps and bylaws of the 'Trials foR heAlth Care inTerventIONs' Network (TRACTION), established by an international multiprofessional task force of experts to foster high-quality non-pharmacological research, ultimately improving patient care and healthcare outcomes.The TRACTION research network will provide information and resources through a collaborative hub for researchers, health professionals, patient research partners and stakeholders in diverse biomedical and healthcare areas, connecting people with different levels of expertise but with the same interests (eg, to evaluate the effect of non-pharmacological interventions, recruiting participants). This open network will support researchers in optimising trial design, participant recruitment, data management and analysis, and disseminating and implementing trial results.The network will also facilitate specialisation training and provide educational materials and mentoring., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The objective of this study is to develop classification criteria for overall hand osteoarthritis (OA), interphalangeal OA and thumb base OA based on self-reported data and radiographic features., Methods: The classification criteria sets were developed in three phases. In phase 1, we identified criteria that discriminated hand OA from controls. In phase 2, we used a consensus-based decision analysis approach to derive a clinician-based evaluation of the relative importance of the criteria. In phase 3, we refined the scoring system, determined the cut-offs for disease classification and compared the sensitivity and specificity of the European Alliance of Associations for Rheumatology (EULAR) criteria with the 1990 American College of Rheumatology (ACR) criteria., Results: In persons with hand symptoms and no other disease (including psoriasis) or acute injury that can explain the hand symptoms (mandatory criteria), hand OA can be classified based on age, duration of morning stiffness, number of joints with osteophytes and joint space narrowing, and concordance between symptoms and radiographic findings. Using a sum of scores based on each diagnostic element, overall hand OA can be classified if a person achieves 9 or more points on a 0-15 scale. The cut-off for interphalangeal OA and thumb base OA is 8 points. While the EULAR criteria demonstrated better sensitivity than the ACR criteria in the phase 1 data set, the performance of the two criteria sets was similar in two external cohorts., Conclusions: International experts developed the EULAR criteria to classify overall hand OA, interphalangeal OA and thumb base OA in clinical studies using a rigorous methodology., Competing Interests: Competing interests: IKH reports personal fees from Novartis and GSK; research grants from Pfizer and IMI-APPROACH (both paid to the institution); and unpaid role as secretary general of OARSI, all outside of the submitted work. AA reports institutional research grants from AstraZeneca and Oxford Immunotech; and personal fees from UpToDate (royalty), Springer (royalty), Cadilla Pharmaceuticals (lecture fees), NGM Bio (consulting), Limbic (consulting) and Inflazome (consulting), all outside of the submitted work. FB reports shares of 4P Pharma and 4Moving Biotech; personal fees from Boehringer Ingelgeim, Galapagos, Gilead, GSK, Merck Sereno, MSD, Novartis, Pfizer, Roche, Sanofi, Servier and Viatris; and research grant from TRB Chemedica, all outside the submitted work.Sita Bierma-Zeinstra reports research grants from Dutch Arthritis Association, EU Horizon, EU ERC and ZonMW (paid to institution), personal fees from Pfizer, Infirst healthcare, and paid role as deputy editor of Osteoarthritis and Cartilage, all outside of the submitted work.Krysia Dziedzic reports research grants from National Institute for Health and Care Research (NIHR); royalty/licence for Textbook for Rheumatology Therapists; payment for lecture at Australian Rheumatology Association Conference in May 2022; Implementation Advisor Fellows and Scholars Programme National Institute for Health and Care Excellence (UK 2019-22), Steering group member of NICE Implementation subgroup and Steering group member of OARSI Joint Effort initiative, all paid to institution and outside of the submitted work.Martin Englund reports personal fees from Cellcolabs AB (Sweden) and Key2 Compliance (Sweden), outside of the submitted work. Ying Ying Leung reports grants from National Medical Research Council (NMRC/CSA-INV/0022/2017), and personal fees from AbbVie, DKSH, Janssen, Novartis and Pfizer, outside of the submitted work. EM reports personal fees from Expanscience, Keyrus Life Science, Pierre Fabre, Rottapharm, MEDA-Mylan, Sublimed, TRB Chemedica, outside the submitted work. RR reports personal fees from from Novartis, AbbVie, Pfizer, MSD, Janssen, Lilly; support for attending EULAR, ACR and SIR; advisory board for Janssen, Novartis and Abbvie, outside of the submitted work. TAS reports grants and personal fees from AbbVie and Roche, and personal fees from Sanofi, Takeda and Novartis, outside the submitted work. ZS reports personal fees from AbbVie, Pfizer, Roche, Novartis, Lilly, Gedeon Richter, Sobi/Galapagos, outside of the submitted work. RW reports institutional research grants from Pfizer and Amgen, unrelated to this work, and is a Senior Clinical Investigator of the Research Foundation Flanders (Belgium) (FWO) (1803023N). MK reports consulting fees from Abbvie, Pfizer, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Novartis and UCB (all paid to institution), outside of the submitted work. DF, JJE, MH-E, GH-B, CH, MLI, HJ, TK, CDM, MM, RHM, VR, MJPFR, FVG, LAS, CM, EG and HL report no conflicts of interest., (© European Alliance of Associations for Rheumatology, EULAR 2024. Re-use permitted under CC BY-NC-ND. No commercial re-use. No derivatives. See rights and permissions. Published by BMJ on behalf of EULAR.”.)

This narrative review discusses the importance of rehabilitation in rheumatic and musculoskeletal diseases (RMDs), ultimately aiming to reduce their impact on individuals and society. It specifically emphasizes the need for rehabilitation in inflammatory arthritis (IA), particularly in cases where medical management is insufficient. It acknowledges that the complexity of rehabilitation demands a flexible approach. Thereby, it touches on the various models of rehabilitation, which may include multidisciplinary team care, extended practice models, shared care, remote care, and work rehabilitation. It discusses the challenges in research, practice, and policy implementation. In research, the need for innovative research designs is highlighted, whereas regarding clinical practice the importance of early detection of disability and patient engagement is underlined, as well as the role of telehealth and AI in reshaping the rehabilitation landscape. Financial barriers and work force shortages are identified as challenges that hinder the effective delivery of rehabilitative care. On the policy level, this paper suggests that the allocation of healthcare resources often prioritizes acute conditions over chronic diseases, leading to disparities in care. This paper concludes by emphasizing the critical role of evidence-based rehabilitation in improving the quality of life for people with RMDs, in particular for those with IA, and promoting their healthy aging. It also calls for tailored rehabilitation models and the early identification of persons with rehabilitation needs as future challenges in this field.

The objective was to explore the associations between patient involvement in the rehabilitation process and improvements in function and goal attainment in the first year after rehabilitation. The longitudinal multicenter study RehabNytte provided data from participants who had been referred to rehabilitation ( n = 2113). Quality indicator (QI) pass rates (% yes) were used to assess patient involvement in the rehabilitation process. The Patient-Specific Functional Scale (PSFS) (10 = best possible) was used to assess function. The outcome QI on goal achievement (response options of yes/no) was used to assess goal attainment. Logistic regression and paired sample t-tests were used to examine associations and mean changes in function from rehabilitation admission up to 3, 6, and 12 months. Most participants (95%) were involved in goal-setting, which was positively associated with younger age (OR 0.97, 95% CI 0.95-0.99) and female sex (OR 1.87, 95% CI 1.15-3.02). Function improved over the follow-up period, with greater improvements in the active goal-setting group. Being involved in goal planning almost tripled the odds of goal attainment (OR 2.78, 95% CI 1.60-4.83) and involvement in the rehabilitation plan almost doubled it (OR 1.99, 95% CI 1.41-2.81). Most participants were involved in rehabilitation goal-setting/planning and being involved was associated with beneficial functional outcomes and greater goal attainment.

Background: There is limited knowledge regarding the impact of rehabilitation on work ability. The aim of this study was to explore factors associated with work ability 12 months following a multidisciplinary rehabilitation program in a cohort with different diagnoses., Methods: Of 9108 potentially eligible participants for the RehabNytte research project, 3731 were eligible for the present study, and 2649 participants (mean age 48.6 years, 71% female) consented to contribute with work-related data, and were included. Self-perceived work ability was assessed by the Work Ability Score (WAS) (0-10, 10 = best), during the follow-up period using paired t -tests and logistic regression to examine associations between demographic and disease-related factors and work ability at 12-month follow-up., Results: The mean baseline WAS for the total cohort was 3.53 (SD 2.97), and increased significantly to 4.59 (SD 3.31) at 12-month follow-up. High work ability (WAS ≥ 8) at 12 months was associated with high self-perceived health at the baseline (OR 3.83, 95% CI 2.45, 5.96), while low work ability was associated with a higher number of comorbidities (OR 0.26, 95% CI 0.11, 0.61), medium pain intensity (OR 0.56, 95% CI 0.38, 0.83) and being married or cohabiting (OR 0.61, 95% CI 0.43, 0.88). There were no significant differences in work ability between participants receiving occupational and standard rehabilitation., Conclusions: Work ability increased significantly over the follow-up period. High work ability at 12-month follow-up was associated with high self-perceived health at baseline, while being married or cohabiting, having higher number of comorbidities, and experiencing medium baseline pain intensity was associated with lower work ability. Rehabilitation interventions targeting these factors may potentially enhance work ability, leading to a positive impact on work participation among people in need of rehabilitation.

Physical activity (PA) is a key strategy for improving symptoms in people with rheumatic and musculoskeletal diseases (RMDs). The aim of this study was to investigate and rank the importance of known barriers and facilitators for engaging in PA, from the perspective of people living with RMD. Five hundred thirty-three people with RMD responded to a survey (nine questions) disseminated by the People with Arthritis and Rheumatism (PARE) network of the European Alliance of Associations for Rheumatology (EULAR). The survey required participants to rank - based on their perceived importance - known PA barriers and facilitators from the literature, and specifically RMD symptoms as well as healthcare and community factors that may affect PA participation. Of the participants, 58% reported rheumatoid arthritis as their primary diagnosis, 89% were female, and 59% were between 51 and 70 years of age. Overall, participants reported fatigue (61.4%), pain (53.6%) and painful/swollen joints (50.6%) as the highest ranked barriers for engaging in PA. Conversely, less fatigue (66.8%) and pain (63.6%), and being able to do daily activities more easy (56.3%) were identified as the most important facilitators to PA. Three literature identified PA barriers, i.e., general health (78.8%), fitness (75.3%) and mental health (68.1%), were also ranked as being the most important for PA engagement. Symptoms of RMDs, such as pain and fatigue, seem to be considered the predominant barriers to PA by people with RMD; the same barriers are also the ones that they want to improve through increasing PA, suggesting a bi-directional relationship between these factors. Key Points • Symptoms of rheumatic and musculoskeletal disease (RMD) are the predominant barriers for lack of physical activity engagement. • RMD symptoms are the factors that people with RMDs want to improve when engaging in PA. • The barriers that stop people living with RMDs to do more PA are the ones that can be significantly improved through PA engagement., (© 2023. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Background: Patient engagement (PE) is required to improve future healthcare services. PE in the development and delivery of healthcare services is likely to be complex but is scarcely described., Objectives: The objective of this scoping review was to summarise primary studies on mesolevel PE regarding structure, process and outcomes. More specifically, the aim was to explore barriers and facilitators to successful PE, how persons are engaged in the process and summarise reported consequences., Method: A systematic scoping review was conducted, searching the MEDLINE, EMBASE, Cochrane and PsycINFO databases. Primary studies, published between 7 July 2005 and 4 October 2022, were considered for inclusion. Two reviewers extracted data about PE (eg, attributes of PE settings, facilitators and barriers, and outcomes to PE) and the first author coded the extracted data into structural, processual and outcome themes., Results: Of 8588 identified records, 37 studies were eligible. Most of the included studies were conducted in Europe (n=19; 51%) and North America (n=13; 35%). Structures that ensure sufficient stakeholder representativeness and PE knowledge through education may facilitate the PE process further, regardless of the environmental setting. Interpersonal relationships with uneven power dynamics were reported as noteworthy processual barriers to meaningful PE, while clearly described roles and tasks were reported as important facilitators. In contrast to hard outcomes with operationalised PE effects, the most noteworthy outcomes of PE were reported as soft processual consequences such as patient representatives improving their self-esteem and feeling valued., Conclusions: Unfortunately, there is a dearth of studies exploring hard and operationalised PE outcomes on healthcare services and patients receiving healthcare. The PE process may be facilitated by dedicated finances to PE education and by ensuring sufficient stakeholder representativeness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Research evidence suggests that, individually, diet and physical activity are effective interventions for reducing levels of inflammation in inflammatory joint diseases (IJD), however little is known about their combined use. This systematic review and meta-analysis aimed to examine the effects and/or associations of combined diet and physical activity interventions in IJD, specifically rheumatoid arthritis (RA) and the spondyloarthropathies (SpA) (PROSPERO registration number: CRD42022370993). Ten out of 11 eligible studies examined RA patients. We found that a combination of diet/nutrition and physical activity/exercise improved Health Assessment Questionnaire score (standardized mean difference = -1.36, confidence interval (CI) = (-2.43)-(-0.30), I 2 = 90%, Z = 2.5, p = 0.01), while surprisingly they increased erythrocyte sedimentation rate (mean difference = 0.20, CI = 0.09-0.31, I 2 = 0%, Z = 3.45, p < 0.01). No effects were found on C-reactive protein or weight ( p > 0.05) of RA patients. We did not find studies in other IJDs that provided sufficient data for a meta-analysis. The narrative data synthesis provided limited evidence to address our research question. No firm conclusions can be made as to whether the combination of diet/nutrition and physical activity/exercise affects inflammatory load in IJDs. The results of this study can only be used as a means of highlighting the low-quality evidence in this field of investigation and the need for further and better-quality research.

Background: Ongoing education of health professionals in rheumatology (HPR) is critical for high-quality care. An essential factor is education readiness and a high quality of educational offerings. We explored which factors contributed to education readiness and investigated currently offered postgraduate education, including the European Alliance of Associations for Rheumatology (EULAR) offerings., Methods and Participants: We developed an online questionnaire, translated it into 24 languages and distributed it in 30 European countries. We used natural language processing and the Latent Dirichlet Allocation to analyse the qualitative experiences of the participants as well as descriptive statistics and multiple logistic regression to determine factors influencing postgraduate educational readiness. Reporting followed the Checklist for Reporting Results of Internet E-Surveys guideline., Results: The questionnaire was accessed 3589 times, and 667 complete responses from 34 European countries were recorded. The highest educational needs were 'professional development', 'prevention and lifestyle intervention'. Older age, more working experience in rheumatology and higher education levels were positively associated with higher postgraduate educational readiness. While more than half of the HPR were familiar with EULAR as an association and the respondents reported an increased interest in the content of the educational offerings, the courses and the annual congress were poorly attended due to a lack of awareness, comparatively high costs and language barriers., Conclusions: To promote the uptake of EULAR educational offerings, attention is needed to increase awareness among national organisations, offer accessible participation costs, and address language barriers., Competing Interests: Competing interests: VR, LS, MRRA, MB, CB, JC, TD, JdlT, AdT, AD, FE-L, RJOF, GEF, JG, KK, MLK, CM-B, AM, JM, RHM, ElM, ErM, CN-S: no competing interest to declare. RD: Speaker fees from Abbvie, Elly Lilly, EwoPharma, Sandoz, and Novartis, all outside the submitted work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: A EULAR taskforce was convened to develop recommendations for lifestyle behaviours amongst people with rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on work-related factors and disease-specific outcomes for people with osteoarthritis, rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis (SSc) and gout., Methods: Two separate systematic literature reviews (SLRs) were conducted. The first identified SLRs, published between 01/2013 and 09/2018. The second identified original observational and intervention studies published before 05/2019. Manuscripts were included if they assessed the effects of vocational interventions on disease-specific outcomes (i.e. clinical outcomes, patient-reported outcomes, and work outcomes) or if they assessed the association between work-related factors and these outcomes. Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases were searched., Results: Two SLRs were identified including individuals with SSc and inflammatory arthritis. Subsequently, 23 original manuscripts were identified, with most of them (43.5%) including people with RA and no manuscripts on gout. Most observational studies evaluated the association between work-related factors and work outcomes while limited information was available on the impact of work on clinical outcomes. A few studies suggested that physically demanding jobs have a small detrimental effect on radiographic progression in axSpA and PsA. Intervention studies showed beneficial effects of vocational interventions for disease-specific outcomes, but with small effect sizes., Conclusion: Many studies indicated that work participation is not likely to be detrimental and, in some cases, may be beneficial for RMD-specific outcomes and should therefore receive attention within healthcare consultations., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs)., Methods: Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed., Results: Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations., Conclusions: These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patient participation is highlighted as an important facilitator for patient-centered care. Patient participation organised as patient advisory boards (PABs) is an integral part of health care institutions in Norway. More knowledge is needed on how PAB representatives experience patient engagement (PE) with regard to organisation, influence, and impact. The objective was to describe how PAB representatives experience their tasks, roles, and impact on decision-making processes and service delivery in the setting of rehabilitation institutions., Methods: PAB representatives recruited from rehabilitation institutions completed the Norwegian version of the generic Public and Patient Engagement evaluation tool (Norwegian abbreviation EBNOR). EBNOR is tested for reliability and validity with good results and comprises 35 items within four main domains, policies and practices, participatory culture, collaboration, and influence and impact that provide responses about PE-levels. The domain items are scored from "strongly disagree" to "strongly agree" on a five-point scale, in addition to a don't know category. Items in the domain "influence and impact" are scored from "never" to "all of the time" on a four-point scale. Categorical data were summarized using frequencies and percentages, and response categories were collapsed into three PE-levels: barrier, intermediate, and facilitating level. Free-text responses were analysed according to principles of manifest content analysis, summed up, and used to elaborate the results of the scores., Results: Of the 150 contacted PAB representatives, 47 (32%) consented to participate. The results showed that approximately 75% agreed that the organisation as a whole was strengthened as a result of patient participation. Four out of five domains were scored indicating a facilitating level; policies and practices (53%), participatory culture (53%), collaboration and common purpose (37%), and final thoughts (63%). The modal score in the domain influence and impact was in the intermediate PE-level (44%). Of a total of 34 codes from free text analyses, barriers to PE were coded 26 times, and PE facilitators were coded 8 times., Conclusions: The findings indicate that most PAB representatives are satisfied with how rehabilitation institutions organise their PAB, but they still experience their impact as limited., (© 2022. The Author(s).)

Background: Patient engagement is recommended for improving health care services, and to evaluate its organisation and impact appropriate, and rigorously evaluated outcome measures are needed., Methods: Interviews (N = 12) were conducted to assess relevance of the Canadian Public and Patient Engagement Evaluation Tool (PPEET) in a Norwegian setting were performed. The tool was translated, back translated, and assessed following cognitive interviews (N = 13), according to the COSMIN checklist. Data quality was assessed in a cross-sectional survey of patient advisory board members from different rehabilitation institutions (N = 47)., Results: Interviews with patient board representatives confirmed the relevance of the PPEET Organisational questionnaire in a Norwegian setting and contributed five additional items. Translation and back translation of the original PPEET showed no major content differences. Differences in vocabulary and sentence structure were solved by discussion among the translators. Comments from cognitive interviews mainly related to the use of different synonyms, layout, and minor differences in semantic structure. Results of the cross-sectional survey support the data quality and construct validity of PPEET items, including 95 score comparisons where 76 (80%) were as hypothesized., Conclusions: The PPEET Organisational questionnaire has been thoroughly translated and tested, and the resulting Evalueringsverktøy for Brukermedvirkning (EBNOR) has adequate levels of comprehensibility and content validity. Further testing for measurement properties is recommended, but given these results, the EBNOR should be considered for assessing patient engagement in a Norwegian health care organisational context., (© 2022. The Author(s).)

Background: A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). In this paper, the literature on the effect of diet on the progression of RMDs is reviewed., Methods: Systematic reviews and meta-analyses were performed of studies related to diet and disease outcomes in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis, psoriatic arthritis, systemic sclerosis and gout. In the first phase, existing relevant systematic reviews and meta-analyses, published from 2013 to 2018, were identified. In the second phase, the review was expanded to include published original studies on diet in RMDs, with no restriction on publication date. Systematic reviews or original studies were included if they assessed a dietary exposure in one of the above RMDs, and reported results regarding progression of disease (eg, pain, function, joint damage)., Results: In total, 24 systematic reviews and 150 original articles were included. Many dietary exposures have been studied (n=83), although the majority of studies addressed people with OA and RA. Most dietary exposures were assessed by relatively few studies. Exposures that have been assessed by multiple, well conducted studies (eg, OA: vitamin D, chondroitin, glucosamine; RA: omega-3) were classified as moderate evidence of small effects on disease progression., Conclusion: The current literature suggests that there is moderate evidence for a small benefit for certain dietary components. High-level evidence of clinically meaningful effect sizes from individual dietary exposures on outcomes in RMDs is missing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)., Methods: European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously., Results: A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel., Conclusion: These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs., Competing Interests: Competing interests: CDejaco has received consulting/speaker’s fees from Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, all unrelated to this manuscript. PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, and is supported by the National Institute for Health Research (NIHR), University College London Hospitals (UCLH), Biomedical Research Centre (BRC). FC has received consulting/speaker’s fees from Abbvie and Celgene, all unrelated to this manuscript. LT has received speakers fee from Novartis, UCB, Roche and Pfizer. GT has received research grants from Iqone and received consulting/speaker’s fees from Menarini, all unrelated to this manuscript. LMS has received consulting/speaker’s fees from Janssen-Cilag, Novartis, Pfizer, Abiogen, Samsung Medison, Esaote, all unrelated to this manuscript. FP has received research grants from Novartis and UCB and received consulting/speaker’s fees from Abbvie, AMGEN, BMS, Hexal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this manuscript. CP has received honoraria and/or research and development grants from: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, CelGene, Grunenthal, GSK, Janssen/J&J, MSD, Pfizer, Sanofi, Roche/Genentech/Chugai, UCB. HBH has received fees for speaking and/or consulting from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis. WH has received fees for speaking and/or consulting from AbbVie, Alpinion, Canon, Celgene, Chugai, Janssen-Cilag, Pfizer, Roche. CDuftner has received consulting/speaker’s fees from Abbvie, BMS, Eli Lilly, Janssen, Novartis, Pfizer, Roche and UCB, all unrelated to this manuscript. PVB has received consulting/speaker’s fees from Abbvie, BMS, Celgene,Celltrion, Eli Lilly, IBSA, Janssen-Cilag, MSD, Novartis, Pfizer, Professional Publishing Hungary, Richter, Roche, Sandoz, Springer Nature, UCB, all unrelated to this manuscript. XB has received consulting/speaker’s fees or grant support from Abbvie, Amgen, BMS, Chugai, Galapagos, Gilead, Hexal, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, all unrelated to this manuscript., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). The aim of this paper was to review the literature on the relationship between smoking and alcohol consumption with regard to RMD-specific outcomes., Methods: Two systematic reviews were conducted to identify systematic reviews and meta-analyses, published between 2013 and 2018, related to smoking and alcohol consumption in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), systemic sclerosis (SSc) and gout. Two additional systematic reviews were performed to identify original longitudinal studies on smoking and alcohol consumption and disease-specific outcomes., Results: Nine reviews and 65 original studies on smoking as well as two reviews and 14 original studies on alcohol consumption met the inclusion criteria. While most studies were moderate/poor quality, smoking was significantly associated with poorer outcomes: cardiovascular comorbidity; poorer response to RA treatment; higher disease activity and severity in early RA; axSpA radiographic progression. Results were heterogeneous for OA while there was limited evidence for PsA, SSc and gout. Available studies on alcohol mainly focused on RA, reporting a positive association between alcohol intake and radiographic progression. Five studies assessed alcohol consumption in gout, reporting a significant association between the number and type of alcoholic beverages and the occurrence of flares., Conclusion: Current literature supports that smoking has a negative impact on several RMD-specific outcomes and that moderate or high alcohol consumption is associated with increased risk of flares in RA and gout., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs., Methods: Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases., Results: 236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies., Conclusion: The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA., Methods: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested., Results: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good., Conclusion: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets., Competing Interests: Competing interests: IKH reports personal fees from Abbvie and Novartis, and research grants from Pfizer and IMI-APPROACH (both paid to the institution), all outside of the submitted work. FB reports being CEO of 4MOVING BIOTECH, received personal fees from 4P PHARMA, Boehringer, Bone Therapeutics, CellProthera, Galapagos, GSK, Lilly, Merck Sereno, MSD, Novartis, Pfizer, Servier and Peptinov, and research grant from TRB Chemedica and IMI-APPROACH (paid to the institution), all outside the submitted work. GHB reports personal fees from Pfizer, Sobi, Fresenius, Mylan, Tedec Meiji, Novartis, Sandoz and Faes, outside of the submitted work. EM reports personal fees from Expanscience, Mylan-Meda, TRB Chemedica, Pierre Fabre, Celgene and Fidia, and non-financial support from Pfizer, outside the submitted work. CDM and JJE report a research grant from BMS, outside the submitted work. RR reports personal fees from Abbvie, Celgene, Novartis, Pfizer and Lilly, outside of the submitted work. TAS reports personal fees from Sanofi, AbbVie, Roche and Takeda, outside of the submitted work. ZS reports personal fees from AbbVie, Roche, Pfizer, Berlin Chemie, UCB and Bristol-Myers, outside of the submitted work. RW reports personal fees from Abbvie, Galapagos, UCB, Bristol Myers Squib and Tilman, and grants from Amgen, outside the submitted work. ME reports serving on an advisory board for Pfizer (tanezumab) and research grant from IMI-APPROACH (paid to the institution), outside of the submitted work. SB-Z reports personal fees from Infirst healthcare, Pfizer and Osteoarthritis and Cartilage, outside the submitted work. PH is a co-inventor of the 1000minds software used in this study. MK reports personal fees from Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Novartis and UCB, and research grants from Pfizer, IMI-APPROACH (all paid to the institution), and royalties from Wolters Kluwer and Springer Verlag, all outside the submitted work. YYL reports grants from National Medical Research Council of Singapore, and personal fees from Abbvie, DKSH, Janssen, Novartis and Pfizer, all outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is convincing evidence to suggest that exercise interventions can significantly improve disease-related outcomes as well as comorbidities in rheumatic and musculoskeletal diseases (RMDs). All exercise interventions should be appropriately defined by their dose, which comprises of two components: a) the FITT (frequency, intensity, time and type) and b) the training (ie, specificity, overload, progression, initial values, reversibility, and diminishing returns) principles. In the published RMD literature, exercise dosage is often misreported, which in "pharmaceutical treatment terms", this would be the equivalent of receiving the wrong medication dosage. Lack of appropriately reporting exercise dosage in RMDs, therefore, results in limited clarity on the effects of exercise interventions on different outcomes while it also hinders reproducibility, generalisability and accuracy of research findings. Based on the collective but limited current knowledge, the main purpose of the present Position Statement is to provide specific guidance for RMD researchers to help improve the reporting of exercise dosage and help advance research into this important field of investigation. We also propose the use of the IMPACT-RMD toolkit, a tool that can be used in the design and reporting phase of every trial., (© 2021 The Mediterranean Journal of Rheumatology (MJR).)

Background: An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard., Objectives: To develop recommendations for the implementation of self-management strategies in IA., Methods: A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations., Results: Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients., Conclusion: These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes., Competing Interests: Competing interests: EN reports personal fees and other from AbbVie, Eli-Lilly, Gilead, Celltrion and Pfizer and other from Sanofi, outside the submitted work. JWJB reports personal fees from Roche, Lilly and Galapagos, outside the submitted work. CID reports personal fees and other from AbbVie, Abivax, BMS, Fresenius, Galapagos, Lilly, Pfizer, Roche-Chugaï and Sanofi, outside the submitted work. BAE has received speaking fees from Pfizer and Eli Lilly. RJOF reports personal fees from Sanofi and UCB, outside the submitted work. GEF reports honoraria from UCB and Aenorasis, outside the submitted work. TAS has received grant/research support from AbbVie and Roche, has been consultant for AbbVie and Sanofi Genzyme and has been a paid speaker for AbbVie, Roche, Sanofi and Takeda. EJFS, AM, PB, PH, HM, GSM, RHM, AdT, CZ, LC and AB report no conflicts of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The number of published clinical practice guidelines related to COVID-19 has rapidly increased. This study explored if basic methodological standards of guideline development have been met in the published clinical practice guidelines related to COVID-19., Study Design and Setting: Rapid systematic review from February 1 until April 27, 2020 using MEDLINE [PubMed], CINAHL [Ebsco], Trip and manual search, including all types of healthcare workers providing any kind of healthcare to any patient population in any setting., Results: There were 1342 titles screened and 188 guidelines included. The highest average AGREE II domain score was 89% for scope and purpose, the lowest for rigor of development (25%). Only eight guidelines (4%) were based on a systematic literature search and a structured consensus process by representative experts (classified as the highest methodological quality). The majority (156; 83%) was solely built on an informal expert consensus. A process for regular updates was described in 27 guidelines (14%). Patients were included in the development of only one guideline., Conclusion: Despite clear scope, most publications fell short of basic methodological standards of guideline development. Clinicians should use guidelines that include up-to-date information, were informed by stakeholder involvement, and employed rigorous methodologies., (Copyright © 2021. Published by Elsevier Inc.)

To develop and validate a self-administered questionnaire to identify in people with Inflammatory arthritis (IA) Facilitators And Barriers to Physical activity (PA): the IFAB questionnaire. The development of the questionnaire included a systematic review of barriers and facilitators to PA to identify key themes, face validity assessment by 11 experts, and cognitive debriefing with 14 patients. The psychometric properties of the questionnaire were assessed by convergent validity (Spearman correlation) against the modified Health Assessment Questionnaire (mHAQ), the Fear-Avoidance Beliefs Questionnaire subscale for PA and the Tampa Scale for Kinesiophobia, internal consistency (Cronbach α) in 63 IA patients with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA). Reliability and feasibility were assessed in 32 IA patients. The questionnaire comprises 10 items: 4 assessing either barriers or facilitators, 3 assessing barriers, and 3 assessing facilitators. The items are related to psychological status (N = 6), social support (N = 2), disease (N = 1), environmental factors (N = 1). The validation study included 63 patients: 26 RA, 24 axSpA, 13 PsA; with mean age 52.8 (standard deviation 16.5) years, mean disease duration 12.5 (12.3) years, and 53% of women. The questionnaire was correlated (rho = 0.24) with mHAQ. Internal consistency (Cronbach α 0.69) and reliability (interclass coefficient 0.79 [95% confidence interval 0.59; 0.88]) were satisfactory, as was feasibility (missing data 12%, mean completion time < 5 min). The questionnaire allows the assessment of barriers and facilitators to PA in patients with IA. This questionnaire may guide targeted interventions to increase levels of PA in these patients.

Objective: As part of European League against Rheumatism (EULAR)/European Musculoskeletal Conditions Surveillance and Information Network, 20 user-focused standards of care (SoCs) for rheumatoid arthritis (RA) addressing 16 domains of care were developed. This study aimed to explore gaps in implementation of these SoCs across Europe., Methods: Two cross-sectional surveys on the importance, level of and barriers (patients only) to implementation of each SoC (0-10, 10 highest) were designed to be conducted among patients and rheumatologists in 50 European countries. Care gaps were calculated as the difference between the actual and maximum possible score for implementation (ie, 10) multiplied by the care importance score, resulting in care gaps (0-100, maximal gap). Factors associated with the problematic care gaps (ie, gap≥30 and importance≥6 and implementation<6) and strong barriers (≥6) were further analysed in multilevel logistic regression models., Results: Overall, 26 and 31 countries provided data from 1873 patients and 1131 rheumatologists, respectively. 19 out of 20 SoCs were problematic from the perspectives of more than 20% of patients, while this was true for only 10 SoCs for rheumatologists. Rheumatologists in countries with lower gross domestic product and non-European Union countries were more likely to report problematic gaps in 15 of 20 SoCs, while virtually no differences were observed among patients. Lack of relevance of some SoCs (71%) and limited time of professionals (66%) were the most frequent implementation barriers identified by patients., Conclusions: Many problematic gaps were reported across several essential aspects of RA care. More efforts need to be devoted to implementation of EULAR SoCs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Based on current knowledge deriving from studies in animals and humans (the general population and patients with non-communicable diseases), there is biological plausibility that exercise may have anti-inflammatory effects. This may be particularly important for patients with chronic inflammatory rheumatic and musculoskeletal diseases (RMDs). The present review discusses the current state-of-the-art on exercise and inflammation, explores how exercise can moderate inflammation-dependent RMD outcomes and the most prevalent systemic manifestations and addresses the relationship between the dosage (particularly the intensity) of exercise and inflammation. We conclude that present data support potential beneficial effects of exercise on inflammation, however, the evidence specifically in RMDs is limited and inconclusive. More targeted research is required to elucidate the effects of exercise on inflammation in the context of RMDs., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Cardiovascular disease (CVD) morbidity and mortality is highly prevalent in patients with rheumatoid arthritis (RA) with debilitating effects for the individual as well as significant healthcare impact. Current evidence demonstrates that engaging in aerobic and resistance exercise (i.e. structured physical activity) can significantly improve patient-reported and clinical index-assessed outcomes in RA. In addition to this, engagement in exercise programmes improves, in a dose-dependent manner, the risk of developing CVD as well as CVD symptoms and outcomes. The present narrative review uses evidence from systematic reviews and meta-analyses as well as controlled trials, to synthesize the current state-of-the-art on the potential effects of aerobic and resistance exercise on CVD risk factors as well as on cardiac and vascular function and structure in people with RA. Where there is a lack of evidence in RA to explain potential mechanisms, relevant studies from the general population are also discussed and linked to RA.

Objective:: To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis., Methods:: A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05)., Results:: Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength., Conclusion:: Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

Objectives: The eumusc.net standards of care (SOCs) for rheumatoid arthritis (RA) aimed to improve quality of care across Europe. This study investigated importance and implementation of each standard according to patients and health care professionals (HCPs) in the Netherlands and identified barriers towards implementation., Methods: Dutch patients, rheumatologists and rheumatology nurses rated importance and implementation (0-10 numeric rating scale (NRS); 10=most important/best implemented) for each of the 20 SOCs. A care gap, adjusted for importance, was calculated: (100=highest gap). Statistical differences between a) patients and HCPs and b) subgroups of patients (demographics, health) were tested. Additionally, patients indicated agreement (0-10) with 6 implementation barriers., Results: 386 patients and 91 HCPs were included. Both ranked adequate disease modifying anti-rheumatic drug treatment (9.3(SD1.2), 9.2(SD0.8)), access to care in emergencies (9.2(SD1.2), 9.2(SD1.0)) and regular re-appraisal when treatment fails (9.2(SD1.3), 9.0(SD1.0)) the most important SOCs, and these were among the best implemented (NRS≥8.5) SOCs. After accounting for applicability, patients and HCP identified care gaps for early diagnosis (25.5(SD32.0), 22.3(SD16.3)), availability of a treatment plan (25.1(SD22.7), 25.7(SD18.5)) and patients also for a regular schedule of assessment of disease (28.6(SD25.5)).Patients with poorer health or higher education scored systematically lower on care received while sharing similar priorities. Patients and HCPs considered limited reimbursement of specific health services a main barrier for implementation and patients additionally identified limited time of physicians., Conclusions: Dutch patients and HCPs overall agreed on priorities in care and found relevant SOCs well implemented. However, suggestions for improvement were raised especially by patients with poorer health and/or higher education.

Objective: To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand osteoarthritis (OA)., Methods: Systematic review using Cochrane Collaboration methodology. Six electronic databases were searched up until September 2015., Inclusion Criteria: randomized or controlled clinical trials comparing therapeutic exercise versus no exercise, or comparing different exercise programs., Main Outcomes: hand pain, hand function, finger joint stiffness, quality of life, adverse events, and withdrawals because of adverse effects. Risk of bias and quality of the evidence were assessed., Results: Seven trials were included in the review, and up to 5 trials (n = 381) were included in the pooled analyses with data from postintervention. Compared to no exercise, low-quality evidence indicated that exercise may improve hand pain [5 trials, standardized mean difference (SMD) -0.27, 95% CI -0.47 to -0.07], hand function (4 trials, SMD -0.28, 95% CI -0.58 to 0.02), and finger joint stiffness (4 trials, SMD -0.36, 95% CI -0.58 to -0.15) in people with hand OA. Quality of life was evaluated by 1 study (113 participants) showing very low-quality evidence for no difference. Three studies reported on adverse events, which were very few and not severe., Conclusion: Pooled results from 5 studies with low risk of bias showed low-quality evidence for small to moderate beneficial effects of exercise on hand pain, function, and finger joint stiffness postintervention. Estimated effect sizes were small, and whether they represent a clinically important change may be debated.

Background: Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand-related activities of daily living. Currently, no cure for OA is known, and non-pharmacological modalities are recommended as first-line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain., Objectives: To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function., Search Methods: We searched six electronic databases up until September 2015., Selection Criteria: All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes., Data Collection and Analysis: Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals)., Main Results: We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress abstract. It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self-reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self-reported outcomes. Two studies with high drop-out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self-reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.Low-quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).Four studies (369 participants) indicated that exercise improved hand function (SMD -0.28, 95% CI -0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI -0.2 to 4.6; NNTB 9).One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI -3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD -0.36, 95% CI -0.58 to -0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).Three studies reported intervention-related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low-quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.Included studies did not measure radiographic joint structure changes. Two studies provided six-month follow-up data (220 participants), and one (102 participants) provided 12-month follow-up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium- and long-term follow-up.The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self-reported. Self-reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions., Authors' Conclusions: When we pooled results from five studies, we found low-quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.

Objective: Osteoarthritis (OA) is one of the leading causes of pain and disability. Given the constraint in the provision of care, there is a need to develop and assess effectiveness of new treatment models. The objective was to compare satisfaction with and effectiveness of a new integrated multidisciplinary outpatient program with usual care in an outpatient clinic for patients with OA., Methods: Patients with clinical OA referred to a rheumatology outpatient clinic were randomized to a 3.5-h multidisciplinary group-based educational program followed by individual consultations, or to usual care. The primary outcome was satisfaction with the health service evaluated on a numerical rating scale (0 = extremely unsatisfied, 10 = extremely satisfied) after 4 months. Secondary outcomes included health-related quality of life measures., Results: Of 391 patients, 86.4% (n = 338) were women, and mean age was 61.2 (SD 8.0) years. At 4 months, patients who received integrated multidisciplinary care were significantly more satisfied with the health service compared with controls, with a mean difference of -1.05 (95% CI -1.68 to -0.43, p < 0.001). Among secondary outcomes, only self-efficacy with other symptoms scale (10-100) improved significantly in the multidisciplinary group compared with controls at 4 months (3.59, 95% CI 0.69-6.5, p = 0.02). At 12 months, the Australian/Canadian Hand Osteoarthritis Index pain (0-10) and fatigue scores (0-10) were slightly worse in the multidisciplinary group with differences of 0.38 (95% CI 0.06-0.71, p = 0.02) and 0.55 (95% CI 0.02-1.07, p = 0.04), respectively., Conclusion: Patients receiving an integrated multidisciplinary care model were more satisfied with healthcare than those receiving usual care, whereas there were no clinically relevant improvements in health outcomes.

Objective: The eumusc.net project is an initiative founded by the European Community and the European League Against Rheumatism. One aim of the project was to facilitate equal standards for musculoskeletal health across Europe. The aim of this work-package was to develop patient-centred and consensus based standards of care (SOC) for osteoarthritis (OA), which should be available in a professional and a patient version., Methods: A systematic review concerning guidelines dealing with OA was conducted. Furthermore, experts in musculoskeletal diseases were contacted to ensure that 'grey' literature was not excluded. Documents that fulfilled predefined inclusion/exclusion criteria were included and all interventions for OA were extracted and categorised. Based on this list of interventions, a three round Delphi exercise with an international and multidisciplinary expert panel, including patient research partners, was performed to achieve expert consensus., Results: Six documents were included and used for further analysis. Out of them, 46 interventions have been extracted and 10 consensus based SOC were formulated. In addition, a patient version, written in a lay-understandable wording and in the format of checklist questions was developed. An example is SOC 5: "People with OA should achieve optimal pain control using pharmacological and non-pharmacological means." The matching patient-centred checklist question reads: "Do I know how to control pain associated with OA?", Conclusions: The SOC for OA will be available in the 23 languages of the European Union to enhance unified information to patients and professionals and to further harmonise the treatment/care of OA within Europe., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Rheumatoid arthritis (RA) is a chronic inflammatory disease which, if left untreated, leads to functional disability, pain, reduced health-related quality of life and premature mortality. Between 0.5% and 1% of the population are affected worldwide, and between 25 and 50 new cases evolve in a population of 100,000. Practically all patients with RA require initiation with disease-modifying antirheumatic treatment to retard or stop progression, control disease manifestations and reduce the disease burden. If disease course is monitored with adjustment of medication, lifestyle factors, and exercise, as well as physical activity levels, co-morbidities may be prevented in the course of RA. During the last decade, major progress has been made in treating RA through early identification and treatment of the disease. Many patients still experience premature work disability and co-morbidities. For societies, the economic burden of RA is high in terms of direct and indirect costs, including modern drug treatment.

Background: Rheumatoid arthritis (RA) and osteoarthritis (OA) are important musculoskeletal diseases that the EUMUSC.NET project developed Standards of Care (SOC) for., Objective: The purpose was to explore factors to enable successful implementation of the SOC for RA and OA., Methods: A combined set of methods was used; a literature search, a European survey among patients, clinicians and policymakers; and focus groups., Results: Potential facilitators were identified during a literature search. The online survey captured 282 responses from clinicians, patients and policymakers from 35 European countries, and focus groups from 5 countries contributed with knowledge about possible additional facilitators and strategies. Both the survey and the focus groups endorsed all 11 facilitators. The most important facilitators for implementing the SOC were motivation, agreement, knowledge and personal attitude. The focus groups underlined the lack of access to recommended care in some countries, that multidisciplinary teams should be strengthened and that some healthcare reimbursement systems need change to implement recommended clinical practice., Conclusion: Eleven facilitators key for the implementation of the SOC for RA and OA were endorsed by patients and clinicians from 35 European countries. This knowledge may contribute to improved care for patients with RA and OA in Europe., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To describe and compare disease impact in patients with hand OA with those with hip, knee and generalized disease., Methods: Patients with OA referred to a specialized rheumatology clinic (408 patients, 86% women) were included in a cross-sectional study. They were examined by a rheumatologist and classified into primary hand, hip, knee and/or generalized (more than two joint localizations) OA. Patient-reported disease impact was collected on numeric rating scales (pain, fatigue), Hopkins Symptom Checklist-25 (emotional distress), Western Ontario and McMaster and Australian/Canadian Hand OA indexes (disease-specific functioning), Short Form 36 (generic health-related quality of life) and a comorbidity checklist., Results: Considerable disease impact was detected across all localizations: patients scored >5 on pain (range 0-10), had on average two comorbidities and scored >1.5 on emotional distress (Hopkins Symptom Checklist-25, range 1-4). Patients with hand OA scored poor on disease-specific functioning of the lower extremities, and patients with lower extremity OA also scored poor on disease-specific hand functioning. Patients with hand OA scored better on pain (P = 0.001, one-way analyses of variance) and the Short Form 36 Health Survey physical component (P < 0.001), whereas no major differences were observed for the mental component (P = 0.07)., Conclusion: OA patients referred to specialist care reported considerable levels of disease impact across localizations. Regardless of functional impairments related to the primary OA localization, patients generally reported high levels of impaired disease-specific functioning at other sites. In the management of OA clinicians should also consider functioning in joint sites other than the primary OA localization. Trial registration. Current controlled trials, www.controlled-trials.com, ISRCTN25778426.

Background: Musculoskeletal conditions (MSCs) are widely prevalent in present-day society, with resultant high healthcare costs and substantial negative effects on patient health and quality of life. The main aim of this overview was to synthesize evidence from systematic reviews on the effects of exercise therapy (ET) on pain and physical function for patients with MSCs. In addition, the evidence for the effect of ET on disease pathogenesis, and whether particular components of exercise programs are associated with the size of the treatment effects, was also explored., Methods: We included four common conditions: fibromyalgia (FM), low back pain (LBP), neck pain (NP), and shoulder pain (SP), and four specific musculoskeletal diseases: osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), and osteoporosis (OP). We first included Cochrane reviews with the most recent update being January 2007 or later, and then searched for non-Cochrane reviews published after this date. Pain and physical functioning were selected as primary outcomes., Results: We identified 9 reviews, comprising a total of 224 trials and 24,059 patients. In addition, one review addressing the effect of exercise on pathogenesis was included. Overall, we found solid evidence supporting ET in the management of MSCs, but there were substantial differences in the level of research evidence between the included diagnostic groups. The standardized mean differences for knee OA, LBP, FM, and SP varied between 0.30 and 0.65 and were significantly in favor of exercise for both pain and function. For NP, hip OA, RA, and AS, the effect estimates were generally smaller and not always significant. There was little or no evidence that ET can influence disease pathogenesis. The only exception was for osteoporosis, where there was evidence that ET increases bone mineral density in postmenopausal women, but no significant effects were found for clinically relevant outcomes (fractures). For LBP and knee OA, there was evidence suggesting that the treatment effect increases with the number of exercise sessions., Conclusions: There is empirical evidence that ET has beneficial clinical effects for most MSCs. Except for osteoporosis, there seems to be a gap in the understanding of the ways in which ET influences disease mechanisms.

Question: Does daily use of a cane for two months produce clinical benefits in patients with knee osteoarthritis (OA)?, Design: A randomised, controlled trial where group allocation was carried out by computer-generated randomisation in a 1:1 ratio., Setting: An outpatient rheumatology clinic in Sao Paulo, Brazil., Participants: Men and women with the diagnosis of knee OA according to the American College of Rheumatology criteria, knee pain score between 3 and 7 (on a 0-10 Visual Analogue Scale), stable doses of non-steroidal anti-inflammatory drugs (NSAIDs), and no regular physical exercise or use of canes in the months prior to the study. Additional exclusion criteria were: symptomatic heart disease, symptomatic disease of the lower limbs (other than knee osteoarthritis) or of the upper limb that would hold the cane, symptomatic lung disease, severe systemic disease, and severe psychiatric illness., Interventions: Each participant in the intervention group received an individually height adjusted wooden cane with a T-shaped handle and instruction in how to use it on the contralateral side at the start of the intervention and after one month. They were instructed to use the cane daily. The participants in the control group were instructed not use any gait device for two months, but otherwise to maintain their normal lives including treatment as usual., Outcome Measures: The primary outcome was pain measured on a 0-10 Visual Analogue Scale at one and two months. Secondary outcomes were function measured with the Lequesne knee questionnaire and the Western Ontario and McMaster Universities (WOMAC) questionnaire), health related quality of life (SF-36), energy expenditure during a 6-minute walk test, and consumption of NSAIDs., Results: In total 64 patients were assigned to the intervention (n=32) and control groups (n=32), and 59 completed the two month follow-up. Mean differences in pain were 0.8 (95% CI 0.3 to 1.3) at one month follow up and 2.1 (95% CI 1.4 to 2.8) at two months, both in the favour of the intervention group. There were significant differences in favour of the intervention group in Lequesne knee questionnaire, SF-36 Bodily Pain and Role Physical scores, and consumption of NSAIDs., Conclusion: Use of a cane can diminish pain and improve physical functioning in patients with knee osteoarthritis. [95% CIs calculated by the CAP Editors.]., (Copyright © 2012 Australian Physiotherapy Association. Published by .. All rights reserved.)

Background: Osteoarthritis (OA) is a prevalent progressive musculoskeletal disorder, leading to pain and disability. Patient information and education are considered core elements in treatment guidelines for OA; however, there is to our knowledge no evidence-based recommendation on the best approach, content or length on educational programmes in OA., Objective: to develop a brief, patient oriented disease specific multidisciplinary education programme (MEP) to enhance self-management in patients with OA., Method: Twelve persons (80% female mean age 59 years) diagnosed with hand, hip or knee OA participated in focus group interviews. In the first focus group, six participants were interviewed about their educational needs, attitudes and expectations for the MEP. The interviews were transcribed verbatim and thereafter condensed.Based on results from focus group interviews, current research evidence, clinical knowledge and patients' experience, a multidisciplinary OA team (dietist, nurse, occupational therapist, pharmacist, physical therapist and rheumatologist) and a patient representative developed a pilot-MEP after having attended a work-shop in health pedagogics. Finally, the pilot-MEP was evaluated by a second focus group consisting of four members from the first focus group and six other experienced patients, before final adjustments were made., Results: The focus group interviews revealed four important themes: what is OA, treatment options, barriers and coping strategies in performing daily activities, and how to live with osteoarthritis. Identified gaps between patient expectations and experience with the pilot-programme were discussed and adapted into a final MEP. The final MEP was developed as a 3.5 hour educational programme provided in groups of 6-9 patients. All members from the multidisciplinary team are involved in the education programme, including a facilitator who during the provision of the programme ensures that the individual questions are addressed. As part of an ongoing process, a patient representative regularly attends the MEP and gives feedback concerning content and perceived value., Conclusion: A MEP has been developed to enhance self-management in patients with OA attending a multidisciplinary OA outpatient clinic. The effectiveness of the MEP followed by individual consultations with members of the multidisciplinary team is currently evaluated in a randomised controlled trial with respect to patient satisfaction and functioning.

Objectives: Evaluate the internal construct validity of the Australian/Canadian (AUSCAN) index for hand osteoarthritis (HOA) and identify the physical function instrument with best performance., Study Design and Setting: AUSCAN, AIMS-2 (Arthritis Impact Measurement Scale 2), and Functional Index of HOA (FIHOA) were self-completed by 209 HOA patients (mean [standard deviation] age 61.6 [5.7] years) at baseline and 128 at follow-up. Rasch analysis was performed., Results: AUSCAN pain, physical function, and stiffness subscales comprised three constructs. AUSCAN scale performance was improved after removal of "Pain at rest" from the pain scale and division of physical function into two scales of high precision and grip strength tasks. AIMS-2 hand/finger subscale and FIHOA were improved after removal of one and two items, respectively and collapse of two AIMS-2 response categories. AUSCAN physical function scale showed better targeting to the sample and higher person reliability compared with FIHOA and especially AIMS-2 because of less "severe" items concerning grip strength tasks as opposed to precision tasks., Conclusion: The AUSCAN subscales, AIMS-2 hand/finger scale, and FIHOA were not unidimensional. However, deletion of misfitting items improved scale performance. The revised AUSCAN physical function and FIHOA scales are preferable for measurement of grip strength and precision tasks, respectively., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To describe and evaluate the design and effects of splints and exercise programs in hand osteoarthritis., Methods: Controlled trials identified through systematic literature reviews were included. Design of splints and exercise programs were evaluated according to existing recommendations and classification systems. The risk of bias was assessed by 2 independent reviewers and effects were summarized descriptively or by meta-analyses., Results: Twelve trials were included in the review: 7 assessed the effect of splints, 3 the effect of exercises, and 2 a combination of splints and exercises. The results revealed a great variety in the design of splint and exercise programs. A meta-analysis of the 2 randomized trials with low risk of bias demonstrated that splints significantly reduced hand pain at short-term (<3 months) and long-term (≥3 months) followup, with a standardized mean difference of 0.37 (95% confidence interval [95% CI] 0.03, 0.71) and 0.80 (95% CI 0.45, 1.15), respectively. Further, results from single trials indicated that hand exercises may reduce pain and increase range of motion and strength, while a combination of splints and daily exercises may reduce pain and stiffness and improve function., Conclusion: There is consistent evidence that splints reduce hand pain, but limited evidence for the effects of hand exercises and a combination of hand exercises and splints in hand osteoarthritis., (Copyright © 2011 by the American College of Rheumatology.)

Objectives: Concurrent evaluation of data quality, internal consistency, test-retest reliability and validity of two patient-reported outcome measures (PROMs) for measuring functional impairment in hand OA (HOA); the Australian/Canadian Osteoarthritis Hand Index (AUSCAN; 15 items) and the Functional Index of HOA (FIHOA; 10 items)., Methods: Patients from an HOA cohort [n=128, mean age 68.6 (s.d. 5.8) years, 91% women] completed PROMs and performance measures during routine follow-up. One week later, a subsample (n=40) reporting no change on an HOA-specific transition question contributed with test-retest data., Results: Both instruments had satisfactory levels of data quality, internal consistency, test-retest reliability and construct validity. The AUSCAN performed slightly better than the FIHOA relating to levels of missing data (0 vs 5%), floor effects, principal component analysis loadings (0.62-0.83 vs 0.52-0.83), item-total correlation (0.77-0.91 vs 0.45-0.76) and Cronbach's α (0.94-0.96 vs 0.90), respectively. AUSCAN items had slightly lower test-retest κ-values (0.29-0.77 vs FIHOA 0.41-0.77) and AUSCAN scales lower intra-class correlations (0.80-0.92 vs FIHOA 0.94). Correlations between the two instruments ranged from 0.58 to 0.88 for the AUSCAN scales of stiffness and physical function, respectively. AUSCAN physical function scale was generally slightly strongly correlated with the other PROMS and performance measures., Conclusion: The AUSCAN and the FIHOA are reliable and valid instruments suitable for measuring physical functioning in HOA. The FIHOA had higher test-retest reliability and is shorter, but the AUSCAN performed slightly better concerning data quality and construct validity.

Background: Osteoarthritis (OA) is a prevalent joint disorder with a need for efficient and evidence-based management strategies., Objectives: The primary purpose of this study is to compare the effects of a multidisciplinary outpatient clinic, including a brief group-based educational programme, with a traditional individual outpatient clinic for patients with hip, knee, hand or generalized OA. A secondary purpose is to investigate the effects of a telephone follow-up call., Methods: This is a pragmatic randomised single-blind controlled study with a total of 400 patients with hip, knee, hand or generalized OA between 40 and 80 years referred to an outpatient rheumatology hospital clinic. The randomisation is stratified according to the diagnostic subgroups. The experimental group is exposed to a multidisciplinary and multifaceted intervention, including a 3.5 hour group-based patient education programme about OA in addition to individual consultations with members of a multidisciplinary team. The control intervention is based on regular care with an individual outpatient consultation with a rheumatologist (treatment as usual). Primary outcomes are patient satisfaction measured at 4 months and cost-effectiveness measured at 12 months. Secondary outcomes are pain and global disease activity measured on a numeric rating scales (NRS), generic and disease specific functioning and disability using Short Form-36 (SF-36) health survey, the Western Ontario and McMaster Universities Osteoarthritis Index 3 (WOMAC), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), and a patient-generated measure of disability (Patient-Specific Functional scale, PSFS). Global perceived effect of change in health status during the study period is also reported. At 4-month follow-up, patients in both groups will be randomly allocated to a 10-minute telephone call or no follow-up ("treatment as usual"). After additional 8 months (12-month follow-up) the four groups will be compared in a secondary analysis with regard to health outcomes and health care costs., Discussion: This trial will provide results on how multidisciplinary and multifaceted management of patients with OA affects health outcomes and health care costs., Trial Registration: Current Controlled Trials ISRCTN25778426.

Background: Patients with hand osteoarthritis are commonly treated by health care professionals (allied to medicine). Practice should be informed by updated evidence from systematic reviews of randomized controlled trials., Purpose: The purpose of this overview is to summarize the evidence from systematic reviews of the effectiveness of nonpharmacological and nonsurgical interventions for patients with hand osteoarthritis., Data Sources and Study Selection: Systematic reviews published between January 2000 and October 2008 were identified by a comprehensive literature search., Data Extraction and Synthesis: Two reviewers independently selected reviews for inclusion, assessed their methodological quality, and extracted and synthesized data according to predefined criteria. Four systematic reviews finally were included. Based on single randomized controlled trials, there is some evidence of the effect of pain relief from topical capsaicin compared with placebo and for favorable functional outcomes for exercise and education compared with osteoarthritis information alone., Limitations: In overviews, results are dependent on available systematic reviews. They are important tools to guide choice of interventions and locate areas where more research is needed, but they might not be useful for deciding specifically how interventions should be carried out., Conclusions: There currently is insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hand osteoarthritis. Considering the limited research evidence and the prevalence and impact of the disease, there is an urgent need for more trials of nonpharmacological and nonsurgical interventions for hand osteoarthritis.