Design and implementation of flexible advanced training in rheumatology: report of a pilot programme.

BACKGROUND: Training in medicine is highly demanding and coincides with critical life tasks including relationship development, childbearing and rearing. The rigid requirements of training programmes risk precluding successful achievement of these extracurricular roles, forcing choices between work and other life commitments. Flexible employment structures that facilitate the development of high-quality physicians are needed. AIM: To assess the outcomes of 2 novel flexible training positions in Rheumatology. METHODS: The clinical department, trainees and senior administration designed flexible, part-time advanced training positions in rheumatology. We sought to deliver excellent training, supervision and support while ensuring safe, efficient clinical service delivery within existing systems and cultures. Barriers to implementation were actively identified. We rejected job share arrangements in favour of independent part-time positions anchored to departmental education, clinical and trainee needs. The outcomes of these positions have been determined through regular trainee meetings, clinic activity and costs. RESULTS: Trainees achieved all training requirements, reported high levels of job satisfaction, strong professional development, improved work-life balance and reduction of stress. Outpatient events increased and waiting times have decreased. We estimate that increased rebatable outpatient services have rendered the positions cost neutral. CONCLUSION: Flexible training positions can enhance clinical departments while enabling high-quality training for junior doctors. Further work should consider longer term outcomes and application to different clinical and training settings.

Train High Eat Low for Osteoarthritis study (THE LO study): protocol for a randomized controlled trial.

INTRODUCTION: Osteoarthritis (OA) is one of the most prevalent chronic conditions among older adults, with the medial tibio-femoral joint being most frequently affected. The knee adduction moment is recognized as a surrogate measure of the medial tibio-femoral compartment joint load and therefore represents a valid intervention target. This article provides the rationale and methodology for THE LO study (Train High, Eat Low for Osteoarthritis), which is a randomized controlled trial that is investigating the effects of a unique, targeted lifestyle intervention in overweight/obese adults with symptomatic medial knee OA. RESEARCH QUESTION: Compared to a control group given only lifestyle advice, do the effects of the following interventions result in significant reductions in the knee adduction moment: (1) gait retraining; and (2) combined intervention (which involves a combination of three interventions: (a) gait retraining, (b) high-intensity progressive resistance training, and (c) high-protein/low-glycaemic-index energy-restricted diet)? It is hypothesized that the combined intervention group will be superior to the isolated interventions of the high-protein/low-glycaemic-index diet group and the progressive resistance training group. Finally, it is hypothesized that the combined intervention will result in a greater range of improvements in secondary outcomes, including: muscle strength, functional status, body composition, metabolic profile, and psychological wellbeing, compared to any of the isolated interventions or control group. DESIGN: Single-blinded, randomized controlled trial adhering to the CONSORT guidelines on conduct and reporting of non-pharmacological clinical trials. PARTICIPANTS: One hundred and twenty-five community-dwelling people are being recruited. Inclusion criteria include: medial knee OA, low physical activity levels, no current resistance training, body mass index ≥ 25kg/m(2) and age ≥ 40 years. INTERVENTION AND CONTROL: The participants are stratified by sex and body mass index, and randomized into one of five groups: (1) gait retraining; (2) progressive resistance training; (3) high-protein/low-glycaemic-index energy-restricted diet (25 to 30% of energy from protein, 45% of energy from carbohydrates, < 30% of energy from fat, and glycaemic index diet value < 50); (4) a combination of these three active interventions; or (5) a lifestyle-advice control group. All participants receive weekly telephone checks for health status, adverse events and optimisation of compliance. MEASUREMENTS: Outcomes are measured at baseline, 6 and 12 months. The primary outcome is the peak knee adduction moment during the early stance phase of gait. The secondary outcome measures are both structural (radiological), with longitudinal reduction in medial minimal joint space width at 12 months, and clinical, including: change in body mass index; joint pain, stiffness and function; body composition; muscle strength; physical performance/mobility; nutritional intake; habitual physical activity and sedentary behaviour; sleep quality; psychological wellbeing and quality of life. DISCUSSION: THE LO study will provide the first direct comparison of the long-term benefits of gait retraining, progressive resistance training and a high-protein/low-glycaemic-index energy-restricted diet, separately and in combination, on joint load, radiographic progression, symptoms, and associated co-morbidities in overweight/obese adults with OA of the knee.

Obesity & osteoarthritis.

The most significant impact of obesity on the musculoskeletal system is associated with osteoarthritis (OA), a disabling degenerative joint disorder characterized by pain, decreased mobility and negative impact on quality of life. OA pathogenesis relates to both excessive joint loading and altered biomechanical patterns together with hormonal and cytokine dysregulation. Obesity is associated with the incidence and progression of OA of both weight-bearing and non weight-bearing joints, to rate of joint replacements as well as operative complications. Weight loss in OA can impart clinically significant improvements in pain and delay progression of joint structural damage. Further work is required to determine the relative contributions of mechanical and metabolic factors in the pathogenesis of OA.

Current evidence for osteoarthritis treatments.

Osteoarthritis (OA) is the most common form of arthritis and the leading cause of chronic disability among older people. The burden of the disease is expected to rise with an aging population and the increasing prevalence of obesity. Despite this, there is as yet no cure for OA. However, in recent years, a number of potential therapeutic advances have been made, in part due to improved understanding of the underlying pathophysiology. This review provides the current evidence for symptomatic management of OA including nonpharmacological, pharmacological and surgical approaches. The current state of evidence for disease-modifying therapy in OA is also reviewed.

Cartilage defects are associated with physical disability in obese adults.

OBJECTIVE: To describe the associations between physical disability measures and knee cartilage defects in obese adults. METHODS: One hundred and eleven obese subjects were recruited from laparoscopic adjustable gastric banding or exercise/diet weight loss programmes. All subjects completed disease-specific (WOMAC) and general health status (SF-36) questionnaires, and were assessed for range of knee motion, tibiofemoral alignment and quadriceps strength. Knee cartilage defects were graded on MRI according to established protocol. Regression analysis was adjusted for age, gender, BMI and presence of clinical knee OA. RESULTS: The association between higher whole compartment cartilage defect scores and increasing BMI, age and clinical knee OA was confirmed in this obese cohort (r = 0.27, P = 0.01; r = 0.26, P = 0.007; P < 0.0001, respectively), whereas new associations were found with reduced knee range of motion (r = 0.5, P < 0.0001). No associations were found between defect scores and quadriceps strength. Varus malalignment was associated with higher medial cartilage defect scores (r = 0.33, P = 0.013). Higher levels of pain, stiffness and physical disability (WOMAC, SF-36) were associated with higher medial compartment and patella cartilage defect scores. CONCLUSIONS: Knee cartilage defects increase with increasing obesity and are associated with both objective and self-reported measures of physical disability. Longitudinal studies are required to assess the potential for change or improvement in cartilage defects with weight loss.

Influence of BMI on health-related quality of life: comparison between an obese adult cohort and age-matched population norms.

The aim of this study was to determine health-related quality of life and fatigue measures in obese subjects and to compare scores with age- and gender-matched population norms. A total of 163 obese subjects were recruited from laparoscopic-adjustable gastric banding or exercise and diet weight loss programs between March 2006 and December 2007. All subjects completed the Medical Outcomes Study Short Form 36 (SF-36), Assessment of Quality of Life (AQoL), and Multidimensional Assessment of Fatigue (MAF) questionnaires. One-sample t-tests were used to compare transformed scores with age- and gender-matched population norms and controls. Obese subjects have significantly lower SF-36 physical and emotional component scores, significantly lower AQoL utility scores and significantly higher fatigue scores compared to age-matched population norms. Within the study cohort, the SF-36 physical functioning, role physical and bodily pain scores, and AQoL utility index were even lower in subjects with clinical knee osteoarthritis (OA). However, obese individuals without OA still had significantly lower scores compared to population norms. Obesity is associated with impaired health-related quality of life and disability as measured by the SF-36, AQoL, and fatigue score (MAF) compared to matched population norms.

Delayed gadolinium-enhanced magnetic resonance imaging of cartilage: clinical associations in obese adults.

OBJECTIVE: Delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) is used to assess cartilage glycosaminoglycan distribution. Our aim was to determine the relationships between self-reported pain and disability, clinical variables, and serum leptin, and dGEMRIC indices in obese subjects with and without clinical knee osteoarthritis (OA). METHODS: Seventy-seven subjects were recruited from laparoscopic adjustable gastric banding or exercise and diet-weight loss programs. The dGEMRIC index was assessed on MRI according to established protocol. Regression analysis adjusted for age, sex, body mass index (BMI), and presence of clinical knee OA. RESULTS: Mean age and BMI were 51 +/- 12.7 years and 39.6 +/- 6.2 kg/m(2). Twenty-three subjects (30%) had clinical knee OA (American College of Rheumatology criteria). The medial and lateral dGEMRIC indices were 538 +/- 80 ms and 539 +/- 86 ms. Age correlated negatively with medial (r = -0.40, p < 0.001) and lateral (r = -0.29, p = 0.012) dGEMRIC index. Subjects with clinical knee OA had significantly lower medial dGEMRIC index; however, no association was found for BMI. Varus alignment correlated with lower medial dGEMRIC index (r = -0.43, p < 0.006), while quadriceps strength correlated positively with lateral dGEMRIC index (r = 0.32, p = 0.008). There was also a negative correlation between serum leptin and lateral dGEMRIC index in women (r = -0.39, p = 0.035), with a trend in men (r = -0.52, p = 0.08). There were weak associations with physical disability, as self-reported on the WOMAC questionnaire. CONCLUSION: In obese subjects, knee dGEMRIC index was associated with age, clinical knee OA, abnormal tibiofemoral alignment, and quadriceps strength. Longitudinal studies are required to assess the potential for improvement in dGEMRIC index with interventions such as strength training.

Obesity and the musculoskeletal system.

PURPOSE OF REVIEW: To describe recent developments highlighting the effects and mechanisms of obesity and weight loss on the musculoskeletal system. RECENT FINDINGS: The global epidemic of obesity has far-reaching effects on the musculoskeletal system and associated conditions such as osteoarthritis, rheumatoid arthritis, spondyloarthropathy, and fibromyalgia. Obesity increases the need for, and reduces the health outcomes from, joint replacement surgery, which has enormous implications for societal economic burden. New insights have been gained into the possible mechanisms by which obesity is associated with musculoskeletal disease incidence, symptom severity and treatment outcomes particularly for osteoarthritis. Research exploring the role of adipocytokines provides a novel possible metabolic link for these diseases. SUMMARY: Obesity has a significant impact on the musculoskeletal system being associated with both degenerative and inflammatory conditions. Future research assessing the effects of obesity and weight loss as well as further elucidating the action of adipocytokines will aid in the assessment and management of this increasingly prevalent condition.

Predictors of clinical response to intraarticular Hylan injections -- a prospective study using synovial fluid measures, clinical outcomes, and magnetic resonance imaging.

OBJECTIVE: To evaluate synovial fluid (SF) and clinical and imaging predictors of clinical response in patients receiving intraarticular Hylan GF-20 injections. METHODS: Thirty-two patients with mild to moderate osteoarthritis (OA) of the knee [OsteoArthritis Research Society International (OARSI) grades I-II] were followed over 6 months. SF and clinical and radiographic measures were assessed. Patella and tibial cartilage volume and cartilage defect scores were measured at baseline and 6 months using magnetic resonance imaging (MRI). The primary outcome measure was the relationship between SF measures and clinical response as defined by the OARSI-Outcome Measures in Rheumatology Clinical Trials responder criteria for OA ("High improvement" >or= 50% improvement in pain or function; absolute change >or= 20 NU on Western Ontario and McMaster University Osteoarthritis Index questionnaire). Secondary outcomes included MRI outcomes (change in cartilage volume and cartilage defect scores). RESULTS: Fifteen patients achieved "High improvement." High baseline SF hyaluronic acid (HA) concentration was a statistically significant predictor of clinical response with odds ratio (OR) 6.04 (p < 0.02). HA concentration was divided into tertiles and fitted to a univariate regression model against clinical response. A baseline HA concentration value of > 2 mg/ml provided the greatest tradeoff between sensitivity and specificity with values of 60% and 77%, respectively, a likelihood ratio of 2.55, and OR of 4.88. Baseline clinical and radiological measures did not predict clinical response in this cohort with mild to moderate OA. Nineteen subjects had MRI at both timepoints. No change was noted in cartilage volumes or cartilage defect scores over 6 months. There was no association between baseline HA concentration and baseline cartilage volume. CONCLUSION: Baseline SF HA concentration predicts clinical response in patients receiving intraarticular Hylan. This has implications for the selection of patients who are likely to respond to this therapy.

Reconstructive hand surgery for scleroderma joint contractures.

Systemic scleroderma can cause significant hand deformity and functional impairment. Surgery is often avoided due to the perceived risks of wound healing. The most common surgical procedures have been digital sympathectomy, arthrodesis or arthroplasty of the proximal interphalangeal (PIP) or both, and metacarpophalangeal (MCP) joints. We describe herein successful soft tissue hand surgery in 2 patients for treatment of scleroderma claw deformities without the use of arthrodesis or arthroplasty. At the MCP joint, the tight capsules were excised, and the collateral ligaments and volar plates were released. At the PIP joints, the volar plates were released and the tight palmar skin was released, resulting in marked improvement of joint position. Intensive hand therapy was used to maximize function. In these 2 patients with claw deformity, we found that tight volar skin was the main contributor to flexion contracture at the PIP level. In contrast, joint capsule contracture was the main contributor to hyperextension deformity at the MCP level.

Magnetic resonance imaging in Löfgren's syndrome: demonstration of periarthritis.

In Löfgren's syndrome, pain and swelling commonly involves the ankle joints. In this prospective case series, the magnetic resonance imaging findings of ankle joint involvement are described. Extensive subcutaneous and soft tissue oedema was commonly seen around the ankles. Bone, cartilage, ligaments and tendons were typically uninvolved. Small amounts of joint and tenosynovial fluid were present without evidence of synovial thickening or synovitis. The fluid is probably reactive to adjacent inflammation in the para-articular soft tissues and probably not representing a primary site of involvement. These findings demonstrate that the arthritis in Löfgren's syndrome stems primarily from periarthritis. This is consistent with prior descriptions using ultrasonography.

Magnetic resonance imaging in pachydermodactyly.

The magnetic resonance imaging (MRI) findings of a teenage boy with pachydermodactyly are described. The findings include fusiform soft tissue swelling around the proximal interphalangeal joints of the hands, with sparing of the tendons and ligaments. There was no capsular involvement and no evidence of periosteal reaction.