Axial Spondyloarthritis: Does Magnetic Resonance Imaging Classification Improve Report Interpretation.

OBJECTIVE: The interpretation of magnetic resonance imaging (MRI) reports is crucial for the diagnosis of axial spondyloarthritis, but the subjective nature of narrative reports can lead to varying interpretations. This study presents a validation of a novel MRI reporting system for the sacroiliac joint in clinical practice. METHODS: A historical review was conducted on 130 consecutive patients referred by 2 rheumatologists for initial MRI assessment of possible axial spondyloarthritis. The original MRI reports were interpreted by the rheumatologists and the radiologist who originally read the images and then categorized according to the novel system. Two musculoskeletal radiologists then reinterpreted the original MRI scans using the new system, and the resulting reports were interpreted and categorized by the same rheumatologists. The quality of the new framework was assessed by comparing the interpretations of both reports. RESULTS: Ninety-two patients met the study criteria. The rheumatologists disagreed on the categorization of the original MRI reports in 12% of cases. The rheumatologists and original radiologists disagreed on the categorization of the initial report in 23.4% of cases. In contrast, there was 100% agreement between the rheumatologists and radiologists on the categorization of the new MRI report. CONCLUSION: The new MRI categorization system significantly improved the agreement between the clinician and radiologist in report interpretation. The system provided a standard vocabulary for reporting, reduced variability in report interpretation, and may therefore improve clinical decision-making.

Mind the Gap: A Longitudinal Analysis of the Experiences of Adolescents and Parents in a Rheumatology Transition Clinic.

BACKGROUND: The transition from pediatric to adult care is a critical time when adolescent patients and their families face many challenges. This period can be associated with an increase in disease-related morbidity and mortality. The aim of our study is to identify gaps in transition-related care to help guide areas for improvement. METHODS: Patients (14-19 years) with juvenile idiopathic arthritis or systemic lupus erythematosus and one of their parents were recruited from the McMaster Rheumatology Transition Clinic. Both were asked to complete the Mind the Gap questionnaire, a validated tool to assess experience and satisfaction with transition care in a clinic setting. The questionnaire, addressing 3 important domains of care: management of the environment, provider characteristics, and process issues, was completed twice-once based on their current clinical experience and again based on their ideal clinical encounter. Positive scores suggest current care is less than ideal; negative scores suggest current care exceeds the ideal experience. RESULTS: Most patients (n = 65, 68% female) had a diagnosis of juvenile idiopathic arthritis (87%). Patients identified mean gap scores between 0.2 and 0.3 for each domain of Mind the Gap, with female patients having higher gap scores compared with male patients. Parents (n = 51) identified gap scores between 0.0 and 0.3. Patients identified process issues as having the largest gap, whereas parents identified management of the environment as having the largest gap. CONCLUSIONS: We identified several gaps in transition clinic care relative to what patients and parents identify as ideal. These can be used to improve the rheumatology transition care that is currently being provided.

Effect of pregnancy on scleroderma progression.

Objective: To explore the trajectory of scleroderma disease activity in women who experienced a pregnancy after systemic sclerosis diagnosis compared to nulliparous women. Methods: We analyzed data from the Canadian Scleroderma Research Group registry by identifying nulliparous women and women with ⩾1 pregnancy after systemic sclerosis diagnosis. Patient characteristics were compared between groups at registry entry. Controlling for age, smoking, and time since systemic sclerosis diagnosis, generalized estimating equations tested the effect of pregnancy on force vital capacity, diffusing capacity of the lungs for carbon monoxide, right ventricular systolic pressure, glomerular filtration rate, antibody status, active digital ulcers, physician global assessment of activity, and severity over 9 years. Results: At registry entry, numbers of women in the nulliparous and pregnancy after systemic sclerosis diagnosis groups were 153 and 45, respectively. Corresponding numbers at 6 and 9 years were 48 and 21, and 18 and 9, respectively. The prevalence of anti-topoisomerase positivity was 18.3% in nulliparous and 12.5% in pregnancy after systemic sclerosis diagnosis. Baseline differences included mean (Standard deviation) age of diagnosis (nulliparous: 38.8 (14.0), pregnancy after systemic sclerosis diagnosis: 22.6 (6.8) years, p < 0.001), disease duration (nulliparous: 9.6 (8.9), pregnancy after systemic sclerosis diagnosis: 21.9 (9.6) years; p < 0.001), and inflammatory arthritis (nulliparous: 41 (28%), pregnancy after systemic sclerosis diagnosis: 22 (49%), p = 0.009). There were no significant differences between groups in the change of any outcomes over time. Conclusion: Results demonstrated that having ⩾1 pregnancy after systemic sclerosis diagnosis did not appear to significantly impact long-term renal, respiratory, or global function outcomes. While this offers a hopeful message to systemic sclerosis patients planning a pregnancy, physicians and patients should remain vigilant for potential post-partum complications.

Impact of the COVID-19 pandemic on juvenile idiopathic arthritis presentation and research recruitment: results from the CAPRI registry.

OBJECTIVE: The COVID-19 pandemic has disrupted healthcare delivery and clinical research worldwide, with data from areas most affected demonstrating an impact on rheumatology care. This study aimed to characterize the impact of the pandemic on the initial presentation of JIA and JIA-related research in Canada. METHODS: Data collected from the Canadian Alliance of Pediatric Rheumatology Investigators JIA Registry from the year pre-pandemic (11 March 2019 to 10 March 2020) was compared with data collected during the first year of the pandemic (11 March 2020 to 10 March 2021). Outcomes included time from symptom onset to first assessment, disease severity at presentation and registry recruitment. Proportions and medians were used to describe categorical and continuous variables, respectively. RESULTS: The median time from symptom onset to first assessment was 138 (IQR 64-365) days pre-pandemic vs 146 (IQR 83-359) days during the pandemic. The JIA category frequencies remained overall stable (44% oligoarticular JIA pre-pandemic, 46.8% pandemic), except for systemic JIA (12 cases pre-pandemic, 1 pandemic). Clinical features, disease activity (cJADAS10), disability (CHAQ) and quality of life (JAQQ) scores were similar between the two cohorts. Pre-pandemic, 225 patients were enrolled, compared with 111 in the pandemic year, with the greatest decrease from March to June 2020. CONCLUSIONS: We did not observe the anticipated delay in time to presentation or increased severity at presentation, suggesting that, within Canada, care adapted well to provide support to new patient consults without negative impacts. The COVID-19 pandemic was associated with an initial 50% decrease in registry enrolment but has since improved.

Pediatric Patients with a Dual Diagnosis of Inflammatory Bowel Disease and Chronic Recurrent Multifocal Osteomyelitis.

ABSTRACT: There is a paucity of information about the epidemiology, pathophysiology, and treatment of patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). A retrospective chart review was performed of patients at McMaster Children's Hospital with a diagnosis of either IBD or CRMO, to identify those with the dual diagnosis over a 10-year period. A dual diagnosis was identified in seven patients. Most patients (6/7) had a diagnosis of IBD first and were subsequently diagnosed with CRMO. At the time of CRMO diagnosis, IBD treatment regimens included one or more of, sulfasalazine (1/6), infliximab (3/6), adalimumab (1/6), or no treatment (1/6). Although the etiology of the link remains unknown, there does not seem to be an association to a specific IBD subtype, age, or treatment. Our patient population demonstrated a response to biologic agents, specifically tumor necrosis factor-α inhibitors, as treatment for both conditions.

Transition Readiness in Adolescents With Juvenile Idiopathic Arthritis and Childhood-Onset Systemic Lupus Erythematosus.

OBJECTIVE: The transition from pediatric to adult rheumatology care represents a particularly vulnerable time for patients with juvenile idiopathic arthritis (JIA) and childhood-onset systemic lupus erythematosus (cSLE). Improving self-management skills is important in optimizing health care transition. The study's objectives were to 1) examine variability in transition readiness of adolescents and young adults within and between different ages, sexes, and disease types; 2) determine the association between age and transition readiness; and 3) identify specific challenges to transition readiness for adolescents. METHODS: Over 1 year, patients 14 to 20 years of age with JIA or cSLE were recruited from pediatric transition and young adult clinics at a single academic institution. Participants completed the 14-item Transition-Q at a single time point. Total scores range from 0 to 100; higher scores indicate greater health care self-management skills as a proxy for transition readiness. Descriptive statistics summarized patient characteristics and Transition-Q scores for the population. Regression analyses determined the association between age, sex, and disease type and Transition-Q score. RESULTS: Among 70 participants, 61 had JIA and 9 cSLE (mean disease duration 4.6 years). The mean (SD) total Transition-Q score was 59.8 (14.9). Age was significantly associated with Transition-Q score (standardized ß = 0.372l P = 0.002). The most commonly reported challenges were seeing the physician alone (without parents), making one's own appointments, picking up prescriptions, and independent transportation for appointments. CONCLUSION: Transition readiness appears to increase with patient age. There is significant variability in Transition-Q scores between patients of the same age, suggesting that an individualized approach to improving self-management skills is necessary.

Fecal microbiome differs between patients with systemic sclerosis with and without small intestinal bacterial overgrowth.

Introduction: Gastrointestinal manifestations of systemic sclerosis affect up to 90% of patients, with symptoms including diarrhea and constipation. Small intestinal bacterial overgrowth is a condition associated with increased numbers of pathogenic bacteria in the small bowel. While currently unknown, it has been suggested that dysregulation of the fecal microbiota may play a role in the development of systemic sclerosis and small intestinal bacterial overgrowth. Objectives: Our study aimed to describe the fecal microbiota of patients with systemic sclerosis and compare it between those with and without a diagnosis of small intestinal bacterial overgrowth. We also compared the fecal microbiota of systemic sclerosis patients with that of healthy controls to understand the association between particular bacterial taxa and clinical gastrointestinal manifestations of systemic sclerosis. Methods: A total of 29 patients with systemic sclerosis underwent breath testing to assess for small intestinal bacterial overgrowth, provided stool samples to determine taxonomic assignments, and completed the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0, which details symptoms and quality-of-life factors. Stool samples were compared between systemic sclerosis patients with and without small intestinal bacterial overgrowth, and between patients with systemic sclerosis and a healthy control cohort (n = 20), aged 18-80 years. Results: Fecal microbiome analyses demonstrated differences between systemic sclerosis patients with and without small intestinal bacterial overgrowth and differences in the diversity of species between healthy controls and patients with systemic sclerosis. Trends were also observed in anticentromere antibody systemic sclerosis patients, including higher Alistipies indistincus spp. levels associated with increased methane levels of breath gas testing and higher Slakia spp. levels associated with increased rates of fecal soiling. Conclusions: Our results suggest that changes to the fecal microbiome occur in patients with small intestinal bacterial overgrowth and systemic sclerosis when compared to healthy controls. As a cross-sectional study, the potential pathophysiologic role of an altered microbiome in the development of systemic sclerosis was not considered and hence needs to be further investigated.

Ultrasonography supplements clinical exam to improve early rheumatoid arthritis disease activity monitoring in metatarsophalangeal joints.

INTRODUCTION: Compared with clinical examination (CE), ultrasonography (US) provides additional and more accurate assessment of inflammation and visualization of structural damage. To better understand the effectiveness of US in metatarsophalangeal joints (MTPJs), we compared disease activity in MTPJs 2-5 assessed by CE and US, with magnetic resonance imaging (MRI) as reference standard. METHOD: Treatment-naïve adult patients with early RA (ACR criteria, disease duration < 2 years) were consecutively recruited. MTPJs 2-5 were assessed for swelling and tenderness, and imaged by US (Esaote MyLab70). The most symptomatic foot was imaged by peripheral MRI (1.0 Tesla). US was semiquantitatively graded for synovial thickening (ST) and power Doppler (PD) (0-3), and erosions (yes/no). MRI was semiquantitatively graded for bone marrow edema (BME), synovitis, and erosions (OMERACT). Kappa agreement, sensitivity, specificity, and predictive values were analyzed using cut-offs at ST ≥ 2, PD ≥ 1, and MRI synovitis and BME at both ≥ 1 and ≥ 2. RESULTS: This study included 39 patients (85% female, mean (SD) age = 51.6 (10.3)). Using MRI synovitis and BME grade ≥ 2 as the reference, PD had superior sensitivity (82%) and kappa agreement (k = 0.43) than swollen joint count (55%, k = 0.20), but similar high specificity (88%, 83%). ST and PD were often observed in clinically asymptomatic MTPJs. US detected very few MRI erosions, but several observed erosions corresponded to grade ≥ 2 MRI erosions. CONCLUSION: Clinical swelling and PD are highly specific for active inflammation in the MTPJs. US supplemented CE by allowing observation of subclinical inflammation and structural damage. Key Points • Ultrasonography detected many subclinical synovial inflammations in metatarsophalangeal joints (MTPJs), many confirmed by MRI • Ultrasonography may best be used clinically to supplement clinical examination by assessing non-swollen joints • Ultrasonography provided quick method of visualizing bone erosions that were grade ≥ 2 on MRI.

Pulmonary arterial hypertension screening practices in scleroderma patients among Canadian rheumatologists.

Background: Current international guidelines recommend annual screening for pulmonary arterial hypertension with transthoracic echocardiogram and pulmonary function testing in all patients with scleroderma (systemic sclerosis). Our objectives were to determine Canadian rheumatologists' screening practices for pulmonary arterial hypertension in patients with systemic sclerosis and identify reasons why current guideline recommendations may not be followed. Methods: A survey was emailed to all Canadian Rheumatology Association members. They self-identified as systemic sclerosis experts or non-experts and provided basic demographic data. Participants were asked how frequently they screened with transthoracic echocardiogram and pulmonary function testing and, if applicable, why they did not adhere to recommendations. Results: A total of 71 rheumatologists participated, of whom 43 identified as non-experts. Overall, 81.4% ordered annual transthoracic echocardiogram and 77.6% annual pulmonary function testing. Rates of annual transthoracic echocardiogram testing were similar between experts and non-experts, whereas experts ordered annual pulmonary function testing more often. Clinicians with a higher proportion of systemic sclerosis patients in their practice were more likely to follow guidelines. There was an inverse relationship between years in practice and adherence to screening guidelines. The most common reason for not following screening guidelines was disagreement with recommendations, followed by unfamiliarity with guidelines. Conclusions: Pulmonary arterial hypertension screening rates remain sub-optimal in Canada but have improved since 2012. Failure to adopt guidelines is due to rheumatologists disagreeing with or not knowing current recommendations. Future studies should examine why rheumatologists disagree with guidelines and how to improve awareness.

Determining known-group validity and test-retest reliability in the PEQ (personalized exercise questionnaire).

BACKGROUND: To determine the known-group validity, a type of construct validity, and the test-retest reliability of a newly developed tool, the Personalized Exercise Questionnaire (PEQ), that assesses the barriers, facilitators, and preferences to exercise in individuals with low bone mass and osteoporosis. METHODS: A comparative design was used to assess known-group validity and a test-retest design to examine the reproducibility. Ninety-five participants with low bone mass and osteoporosis were recruited from an outpatient clinic in Hamilton, Ontario. The questionnaire was administered to 95 participants at baseline and a subset of 42 participants completed the survey again one week later. The known-group validity of the PEQ was determined using four hypotheses that compared two known groups based on employment level, age, socioeconomic status, and physical activity level. The reproducibility of individual responses was analyzed using the Kappa Coefficient (κ). RESULTS: There was known-group validity for three of the four hypotheses. Test-retest reliability scores ranged from no agreement to almost perfect agreement; seven items had almost perfect agreement (κ: 0.81-1.00), 12 substantial agreement (κ: 0.68-0.74), six moderate agreement (κ: 0.56-0.60), two fair agreement (κ: 0.36-0.40), one slight agreement (κ = 0.23) and one no agreement (κ = - 0.03). CONCLUSION: Preliminary support for the usefulness of the PEQ is indicated since the majority of the items had at least substantial agreement and known-group validity was moderately supported for some items. TRIAL REGISTRATION: This study was retrospectively registered with ClinicalTrials.gov , NCT03125590, on April 24, 2017.

Factors that influence Canadian internal medicine residents' choice to pursue a rheumatology career.

In Canada, little is known about residents' self-confidence to diagnose/treat musculoskeletal (MSK) disease and factors affecting pursuit of a rheumatology career. Our study explored these factors. An online survey (descriptive cross-sectional design) was distributed to Canadian postgraduate year (PGY) 1 and 2 internal medicine (IM) residents. Questions probed self-confidence in rheumatology and factors influencing subspecialty career choice. Frequencies were determined and responses compared between PGY-1 and PGY-2 using univariate statistical analyses. Fifty-four IM residents completed the survey. PGY-2 residents were statistically more certain in subspecialty decidedness and had higher levels of self-confidence to diagnose/treat MSK disease and perform a physical exam. "Quality of life" was the most encouraging factor for a rheumatology career choice followed by "job opportunities" and "previous clinical exposure." Although 50% of PGY-1 residents had completed a rheumatology clinical rotation, 76% indicated that increased knowledge would affect rheumatology career choice. Only 38% were interested in novel rheumatology education. No difference in rheumatology exposure, rheumatology clinical rotation completion year, or rheumatology career choice was observed. Our research confirms findings from similar United States (US) and United Kingdom (UK) studies that suggest that increased MSK knowledge positively influences residents' confidence to diagnose/treat MSK disease. Our study differs with Canadian PGY-1 and PGY-2 IM residents by evaluating self-confidence to diagnose/treat MSK disease separately from self-confidence to perform a physical exam. Significant differences between first and second year trainees suggest types/quality of rheumatology experiences (e.g., case complexity, diagnostic problem-solving competency) may affect self-confidence to diagnose/treat MSK disease factors and rheumatology career choice.

Treatment of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review.

Objectives: Almost all patients with SSc have gastrointestinal manifestations. Small intestinal bacterial overgrowth (SIBO) occurs in 30-60% of patients and leads to malnutrition and impaired quality of life. Recent systematic reviews have reported efficacy of treatments for SIBO, but these are not specific to patients with SSc. We conducted a systematic review of the evidence for all possible SIBO treatments in the SSc population. Methods: The following databases were searched: MEDLINE, EMBASE and the Cochrane Library, from database inception to 1 January 2017. All evidence for all possible SIBO treatments including antibiotics, prokinetics, probiotics and alternative treatments was included. Treatment outcomes included symptomatic relief or demonstrated SIBO eradication. Results: Of 5295 articles, five non-randomized studies were reviewed with a total of 78 SSc patients with SIBO. One trial assessed octreotide while the remaining four trials investigated the effectiveness of ciprofloxacin, rifaximin, norfloxacin and metronidazole, and the combination of amoxicillin, ciprofloxacin and metronidazole. Studies were generally of low quality and most were un-controlled. Conclusion: Data indicate that, for some SSc patients, antibiotics can eradicate SIBO. There is a paucity of data reporting the effectiveness of either prokinetics or probiotics in SSc.

Development and validation of a new tool to measure the facilitators, barriers and preferences to exercise in people with osteoporosis.

BACKGROUND: Despite the widely known benefits of exercise and physical activity, adherence rates to these activities are poor. Understanding exercise facilitators, barriers, and preferences may provide an opportunity to personalize exercise prescription and improve adherence. The purpose of this study was to develop the Personalized Exercise Questionnaire (PEQ) to identify these facilitators, barriers, and preferences to exercise in people with osteoporosis. METHODS: This study comprises two phases, instrument design and judgmental evidence. A panel of 42 experts was used to validate the instrument through quantitative (content validity) and qualitative (cognitive interviewing) methods. Content Validity Index (CVI) is the most commonly used method to calculate content validity quantitatively. There are two kinds of CVI: Item-CVI (I-CVI) and Scale-level CVI (S-CVI). RESULTS: Preliminary versions of this tool showed high content validity of individual items (I-CVI range: 0.50 to 1.00) and moderate to high overall content validity of the PEQ (S-CVI/UA = 0.63; S-CVI/Ave = 0.91). Through qualitative methods, items were improved until saturation was achieved. The tool consists of 6 domains and 38 questions. The 6 domains are: 1) support network; 2) access; 3) goals; 4) preferences; 5) feedback and tracking; and 6) barriers. There are 35 categorical questions and 3 open-ended items. CONCLUSIONS: Using an iterative approach, the development and evaluation of the PEQ demonstrated high item-content validity for assessing the facilitators, barriers, and preferences to exercise in people with osteoporosis. Upon further validation it is expected that this measure might be used to develop more client-centered exercise programs, and potentially improve adherence.

Baseline knee adduction moment interacts with body mass index to predict loss of medial tibial cartilage volume over 2.5 years in knee Osteoarthritis.

This study aimed to determine the extent to which changes over 2.5 years in medial knee cartilage thickness and volume were predicted by: (1) Peak values of the knee adduction (KAM) and flexion moments; and (2) KAM impulse and loading frequency, representing cumulative load, after controlling for age, sex and body mass index (BMI). Adults with clinical knee osteoarthritis participated. At baseline and approximately 2.5 years follow-up, cartilage thickness and volume of the medial tibia and femur were segmented from magnetic resonance imaging scans. Gait kinematics and kinetics, and daily knee loading frequency were also collected at baseline. Multiple linear regressions predicted changes in cartilage morphology from baseline gait mechanics. Data were collected from 52 participants (41 women) [age 61.0 (6.9) y; BMI 28.5 (5.7) kg/m2 ] over 2.56 (0.51) years. There were significant KAM peak-by-BMI (p = 0.023) and KAM impulse-by-BMI (p = 0.034) interactions, which revealed that larger joint loads in those with higher BMIs were associated with greater loss of medial tibial cartilage volume. In conclusion, with adjustments for age, sex, and cartilage measurement at baseline, large magnitude KAM peak and KAM impulse each interacted with BMI to predict loss of cartilage volume of the medial tibia over 2.5 years among individuals with knee osteoarthritis. These data suggest that, in clinical knee osteoarthritis, exposure to large KAMs may be detrimental to cartilage in those with larger BMIs. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2476-2483, 2017.

Relationships between fatty infiltration in the thigh and calf in women with knee osteoarthritis.

BACKGROUND: In individuals with knee osteoarthritis (OA), fatty infiltration into thigh muscle is associated with poor physical performance and strength. However, it is not known whether this also occurs in the calf and if this impacts physical function. AIMS: We investigated the relationships between volumes of intramuscular fat (intraMF), intermuscular fat (IMF), subcutaneous fat (SCF), lean muscle and muscle adiposity, in the thighs compared to the calves of women with knee OA. METHODS: MRI scans of the thigh and calf were acquired from 20 women over 55 years with knee OA (3.0T Discovery MR750, GE Healthcare). Axial IDEAL (iterative decomposition of water and fat with echo asymmetry and least-squares estimation) fat-separated images were segmented to quantify intraMF, IMF, SCF and lean muscle volumes (SliceOmatic 5.0, Tomovision). Correlation and linear regression analyses were run. RESULTS: We found a positive relationship between thigh and calf intraMF (R 2 = 0.592; B = 5.49; p = 0.001), muscle adiposity (R 2 = 0.539; B = 0.567; p = 0.001), and SCF volume (R 2 = 0.699; B = 12.847; p = 0.001), controlling for waist-to-hip ratio. Relationships between thigh and calf IMF (R 2 = 0.239; B = 7.743; p = 0.061), lean muscle (R 2 = 0.245; B = 4.149; p = 0.047) and combined intraMF and IMF volume (R 2 = 0.242; B = 6.162; p = 0.044) were not significant. DISCUSSION: Although a correlation exists between thigh and calf muscle adiposity, intraMF and SCF, this does not hold true for IMF or lean muscle. A greater amount of intraMF infiltration occurs in the thigh compared to the calf of women with knee OA. CONCLUSION: The calf and thigh may both be involved in pathologic changes in muscle composition in knee OA.

Lean muscle volume of the thigh has a stronger relationship with muscle power than muscle strength in women with knee osteoarthritis.

BACKGROUND: Thigh lean muscle and intramuscular fat have been implicated in the impairment of physical function observed in people with knee osteoarthritis. We investigated the relationships of quadriceps and hamstrings intramuscular fat fraction and lean muscle volume with muscle power and strength, controlling for neuromuscular activation, and physical performance in women with knee OA. METHODS: Women (n=20) 55years or older with symptomatic, radiographic knee osteoarthritis underwent a 3.0T magnetic resonance imaging scan of the thigh of their most symptomatic knee. Axial fat-separated images were analyzed using software to quantify intramuscular fat and lean muscle volumes of the quadriceps and hamstrings. To quantify strength and power of the knee extensors and flexors, participants performed maximum voluntary isometric contraction and isotonic knee extensions and flexions, respectively. Electromyography of the quadriceps and hamstrings was measured. Participants also completed five physical performance tests. FINDINGS: Quadriceps and hamstrings lean muscle volumes were related to isotonic knee extensor (B=0.624; p=0.017) and flexor (B=1.518; p=0.032) power, but not knee extensor (B=0.001; p=0.615) or flexor (B=0.001; p=0.564) isometric strength. Intramuscular fat fractions were not related to isotonic knee extensor or flexor power, nor isometric strength. No relationships were found between intramuscular fat or lean muscle volume and physical performance. INTERPRETATION: Muscle power may be more sensitive than strength to lean muscle mass in women with knee osteoarthritis. Thigh lean muscle mass, but neither intramuscular nor intermuscular fat, is related to knee extensor and flexor power in women with knee osteoarthritis.

Identifying real and perceived barriers to therapeutic education programs for individuals with inflammatory arthritis.

Therapeutic Education Programs (TEPs) grounded in self-management principles have been shown to improve quality of life of patients with chronic conditions and reduce patient-related healthcare costs. Though these programs are becoming more readily available, patients often experience barriers in participating. This study sought to identify barriers faced by inflammatory arthritis (IA) patients in attending a TEP and understand how patients overcame perceived barriers. A mixed-method study design was used. Questionnaires were distributed to individuals with IA who were invited to attend a TEP between 2010 and 2013. Respondents were those that chose not to attend (group A), individuals who attended ≤4 of 10 sessions (group B), individuals who attended ≥5 of 10 sessions prior to May 2013 (group C), and individuals who attended ≥5 of 10 sessions from June 2013 to November 2013 (group D). Individuals in group D were also invited to participate in focus groups to discuss how they had overcome perceived barriers. Real barriers identified by individuals in groups A and B included time, distance, and cost associated with attendance. Individuals who overcame perceived barriers (groups C and D) discussed strategies they used to do so. Aspects of the overall program experience and access to clinic and program also contributed to patients being able to overcome barriers. Time, distance, and cost are external barriers that prevented individuals from utilizing self-management education opportunities. These barriers were overcome if and when individuals had resources available to them. Readiness for behavior change also influenced commitment to participate in the program.