Osteoarthritis-Related Walking Disability and Arterial Stiffness: Results From a Cross-Sectional Study.

OBJECTIVE: To compare the 6-minute walking distance (6MWD) in a population-based cohort of patients with osteoarthritis (OA) with that in matched peers from the general population, and to explore the associations between walking ability and risk of cardiovascular disease (CVD) in the OA cohort. METHODS: This cross-sectional study included individuals (ages 40-80 years) who had self-reported OA (n = 500) in a previous population-based study and age- and sex-matched peers from the general population (n = 235). Clinical examinations of the patients with OA included classification according to the American College of Rheumatology criteria, blood sampling, and measuring arterial stiffness (PWV; pulse wave velocity). Group differences in the 6MWD were calculated with t-tests. The association between walking ability and CVD risk in the OA cohort was examined using multivariate regression models. RESULTS: In the age-stratified analyses, the largest mean difference in the 6MWD was observed in the youngest age groups (40-49 years); female patients in the OA group walked 84.6 fewer meters compared with the reference group (579.4 meters and 663.9 meters, respectively; P < 0.001), and male patients walked 88.3 fewer meters compared with the reference group (619.9 meters and 708.3 meters, respectively; P = 0.001). In the OA group, the 6MWD was significantly associated with PWV in the adjusted analysis (P = 0.001); an increase in the walking distance of 100 meters corresponded to a reduction in PWV of 0.3 meters/second. CONCLUSION: Even at age 40 years, patients with OA had a significantly shorter mean walking distance compared with their matched peers, underlining the importance of an early clinical approach to OA. Furthermore, in the OA group, the 6MWD was significantly associated with arterial stiffness, suggesting that walking ability is important for the CVD risk profile in patients with OA.

Structured Goal Planning and Supportive Telephone Follow-up in Rheumatology Care: Results From a Pragmatic, Stepped-Wedge, Cluster-Randomized Trial.

OBJECTIVE: To evaluate patient-reported health effects of an add-on structured goal-planning and supportive telephone follow-up rehabilitation program compared with traditional rehabilitation programs in patients with rheumatic diseases. METHODS: In this pragmatic stepped-wedge, cluster-randomized, controlled trial, 389 patients with rheumatic diseases recruited from 6 rehabilitation centers received either traditional rehabilitation or traditional rehabilitation extended with an add-on program tailored to individual needs. The add-on program comprised a self-management booklet, motivational interviewing in structured individualized goal planning, and 4 supportive follow-up phone calls after discharge. Data were collected by questionnaires on admission and discharge from rehabilitation stay, and at 6 months and 12 months after discharge. The primary outcome was health-related quality of life (HRQoL) measured by the Patient Generated Index (range 0-100, where 0 = low). Secondary outcomes included patient-reported health status, self-efficacy, pain, fatigue, global disease activity, and motivation for change. The main statistical analysis was a linear repeated measures mixed model performed on the intent-to-treat population using all available data. RESULTS: A significant treatment effect of the add-on intervention on HRQoL was found on discharge (mean difference 3.32 [95% confidence interval 0.27, 6.37]; P = 0.03). No significant between-group differences were found after 6 or 12 months. Both groups showed positive changes in HRQoL following rehabilitation, which gradually declined, although the values remained at higher levels after 6 and 12 months compared with baseline values. CONCLUSION: The add-on program enhanced the short-term effect of rehabilitation with respect to patient-specific HRQoL, but it did not prolong the effect as intended.

Quality of Community-Based Osteoarthritis Care: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the state of quality of care for osteoarthritis (OA) by summarizing studies that have assessed the care provided to patients. METHODS: A systematic review of community-based observational studies of actual clinical practice treating people with OA compared with quality indicators (QIs) was performed. Four databases were searched from January 2000 to November 2015. Two reviewers independently determined study eligibility, assessed risk of bias, and extracted study data. The outcome was adherence to the QIs (pass rate). The overall pass rate (the total number of indicators passed divided by the total number of indicators for which the patients were eligible) was extracted from each study. When at least 50% of the studies had comparable individual QIs, the data were pooled with proportion meta-analyses. RESULTS: Fifteen studies comprising 16,103 patients were included, and the median overall pass rate across studies was 41% (range 22-65%). The pooled pass rates for individual QIs were "referral to orthopedic surgeon if no response to other therapy": 59.4% (95% confidence interval [95% CI] 47.5-70.3); "paracetamol or acetaminophen first drug used": 46.0% (95% CI 26.6-66.7); "assessed for pain and/or function": 45.5% (95% CI 33.9-57.6); "referral or recommendation to exercise": 38.7% (28.9-49.5); "offered education and self-management": 35.4% (95% CI 27.8-44.0); and "informed about potential risks if NSAIDs prescribed": 34.1% (95% CI 24.7-44.9). CONCLUSION: There is room for improvement in community-based OA care.

Measurement properties of instruments assessing self-efficacy in patients with rheumatic diseases.

The measurement properties of instruments assessing self-efficacy (SE) in patients with rheumatic diseases were reviewed. The consensus-based standards for the selection of health measurement instruments (COSMIN) checklist was applied following systematic searches of seven electronic databases from 1989 to December 2011. Fifteen articles met the inclusion criteria that included the arthritis SE scales (ASES), generalized SE scale (GSES), joint protection SE scale (JP-SES), Marcus & Resnick SE exercise behaviour (SEEB) instruments, and RA SE scale (RASE). The ASES and RASE have undergone more than one evaluation. There was little formal evaluation of content validity for the instruments. Evidence for the RASE suggests that it is not unidimensional. The JP-SES and SEEB were evaluated using modern psychometric methods. The instruments require further evaluation before application. The quality of the evidence for the ASES and RASE is generally poor. The generic focus of the GSES limits its relevance. The JP-SES and SEEB have only undergone one evaluation and that relating to the latter was narrow in scope. Future studies should address these methodological weaknesses.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

What's in the black box of arthritis rehabilitation? A comparison of rehabilitation practice for patients with inflammatory arthritis in northern Europe.

BACKGROUND: In evaluating complex interventions, it is a challenge for researchers to provide transparent reporting of the intervention content with sufficient detail and clarity such that effects can be compared across studies or countries. OBJECTIVE: To describe and compare the content of current rehabilitation for patients with inflammatory arthritis across 4 northern European countries. PATIENTS AND METHODS: A total of 731 patients with inflammatory rheumatic diseases participated in a multicentre, longitudinal observational study carried out in Sweden, The Netherlands, Denmark and Norway. Data on context, structure and process were reported by patients and teams at the different participating study sites according to the Scandinavian Team Arthritis Register-European Team Intiative for Care Research (STAR-ETIC) framework. RESULTS: Although large similarities were found in the context, there were important differences between the Netherlands and the Scandinavian countries. Regarding structure, there were considerable differences in the length of the rehabilitation period across settings and countries. The most evident differences concerned process variables, especially the type and dosage of individual treatment modalities. CONCLUSION: The variation in important aspects of arthritis rehabilitation found in the present study underline the need for transparent and standardized description of these variables when comparing effects across settings and countries. A standardized description of current practice can be achieved by the STAR-ETIC framework.

Patient-reported quality of care for osteoarthritis: development and testing of the osteoarthritis quality indicator questionnaire.

OBJECTIVE: To develop and test a new instrument for patient self-reported quality of osteoarthritis (OA) care, and to provide quality indicator (QI) pass rates in a Norwegian OA cohort. METHODS: The OsteoArthritis Quality Indicator (OA-QI) questionnaire was developed using published QIs, expert panels, and patient interviews. Self-reported data were collected from 359 persons in a Norwegian OA cohort, and test-retest reliability and validity were assessed. Separate QI pass rates and summary QI pass rates were calculated. RESULTS: The 17-item questionnaire includes QIs related to patient education and information, regular provider assessments, referrals, and pharmacologic treatment. The patient self-reported questionnaire was completed with minimal respondent burden. Support for content validity was confirmed by 2 patient research partners and 2 expert panels. All 10 predefined hypotheses relating to construct validity were confirmed. Test-retest kappa coefficients ranged from 0.20-0.80 and the percentage of exact agreement ranged from 62-90%. The mean pass rate for individual QIs was 31% (range 5-49%). The median summary QI pass rate was 27% (interquartile range 12-50%), with lower summary pass rates for nonpharmacologic compared to pharmacologic treatments. CONCLUSION: To our knowledge, this is the first instrument developed to measure patient-reported QI pass rates for OA care. This study indicates that the OA-QI questionnaire is acceptable to persons with OA, and its short format makes it suitable for population surveys. The low patient self-reported QI pass rates in this study suggest a potential for quality improvement in OA care.

Disease impact of hand OA compared with hip, knee and generalized disease in specialist rheumatology health care.

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.

Effects of a one week multidisciplinary inpatient self-management programme for patients with fibromyalgia: a randomised controlled trial.

BACKGROUND: Self-management programmes (SMP) are recommended for patients with fibromyalgia. The purpose of this study was to evaluate effects of a one week multidisciplinary inpatient self-management programme on psychological distress, skills as a consumer of health services, self-efficacy, and functional and symptomatic consequences of fibromyalgia (FM). METHODS: A randomised controlled two-armed, assessor-blinded trial with three-week follow-up to evaluate SMP. Primary outcomes were the General Health Questionnaire (GHQ-20) and the Effective Musculoskeletal Consumer Scale (EC-17), while secondary outcomes included the Fibromyalgia Impact Questionnaire (FIQ) and Self-efficacy scales for pain, function and symptoms (ASES). RESULTS: 150 patients with FM were randomised to one week one SMP (n = 75) or to a waiting list control group (n = 75). Of these, 58 participants in the treatment group and 60 in the control group completed the study. At three weeks' follow up there was a significant difference in EC-17 (0-100) in favour of the treatment group (mean difference 4.26, 95 CI 0.8 to 7.7, p = 0.02). There were no differences between the groups for any of the other outcomes. CONCLUSION: This study shows that in patients with FM the SMP had no effect on psychological distress, functional and symptomatic consequences and self-efficacy, except for a small short-term effect on skills and behaviour that are important for managing and participating in health care (EC-17). Clinical Trials.gov Id: NCT01035125. TRIAL REGISTRATION: Clinical Trials.gov Id: NCT01035125.

Physical fitness in patients with ankylosing spondylitis: comparison with population controls.

BACKGROUND: Although flexibility traditionally has been the main focus for physical therapy in patients with ankylosing spondylitis (AS), there is now evidence for an increased risk of cardiovascular diseases (CVDs) in this group. OBJECTIVE: The purposes of this study were: (1) to compare physical fitness (cardiorespiratory fitness, muscular capacity, flexibility, and balance) in patients with AS and controls and (2) to explore associations between physical fitness and disease activity in the patient group. DESIGN: This was a cross-sectional study. METHODS: The physical fitness variables were cardiorespiratory fitness (treadmill test for estimation of peak oxygen uptake [V(O(2))peak]), muscular capacity (push-ups test), balance (30-second single-leg stand and walking in a figure-of-eight pattern), and flexibility (Bath Ankylosing Spondylitis Metrology Index [BASMI]). The Ankylosing Spondylitis Disease Activity Score (ASDAS) was used to assess disease activity. Group differences and associations were tested with the chi-square test for categorical variables, the Mann-Whitney U test for ordinal variables, and analysis of covariance for continuous variables. RESULTS: One hundred forty-nine of 250 of the invited patients with AS and 133 of 329 of the invited controls were included in the study. The mean ASDAS score of the patient group was 2.3 (range=0.5-4.7), and the median disease duration was 23 years (range=7-55). The patient group had significantly lower V(O(2)) peak values, with a mean difference of -2.7 mL·kg(-1)·min(-1) (95% confidence interval=-4.3, -1.1), and higher BASMI scores, with a mean difference of 1.6 (95% confidence interval=1.5, 1.8), compared with the control group. No group differences were found in balance or muscular capacity. In the patient group, significant inverse associations were found between ASDAS scores and V(O(2))peak and muscular capacity. LIMITATIONS: The response rate was lower in the control group (40.4%) than in the patient group (59.6%). CONCLUSION: The lower cardiorespiratory fitness and reduced flexibility in the AS group indicate that physical therapy programs should include cardiorespiratory fitness exercises as a basic component to reduce the risk of cardiovascular disease.

A mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: a randomised controlled trial.

OBJECTIVE: To evaluate the effects of a mindfulness-based group intervention, the Vitality Training Programme (VTP), in adults with inflammatory rheumatic joint diseases. METHODS: In a randomised controlled trial, the VTP-a 10-session mindfulness-based group intervention including a booster session after 6 months-was compared with a control group that received routine care plus a CD for voluntary use with mindfulness-based home exercises. The primary outcome was psychological distress measured by the General Health Questionnaire-20. Self-efficacy (pain and symptoms) and emotion-focused coping (emotional processing and expression) were used as co-primary outcomes. Secondary outcomes included pain, fatigue, patient global disease activity, self-care ability and well-being. Effects were estimated by mixed models repeated measures post-intervention and at 12-month follow-up. RESULTS: Of 73 participants randomised, 68 completed assessments post-intervention and 67 at 12 months. Significant treatment effects in favour of the VTP group were found post-treatment and maintained at 12 months in psychological distress (adjusted mean between-group difference -3.7, 95% CI -6.3 to -1.1), self-efficacy pain (9.1, 95% CI 3.4 to 14.8) and symptoms (13.1, 95% CI 6.7 to 19.3), emotional processing (0.3, 95% CI 0.02 to 0.5), fatigue (-1.1, 95% CI -1.8 to -0.4), self-care ability (1.0, 95% CI 0.5 to 1.6) and overall well-being (0.6, 95% CI 0.1 to 1.2). No significant group differences were found in emotional expression, pain or disease activity. CONCLUSION: The VTP improved most primary and secondary outcomes compared with individual use of CD exercises. Improvements were maintained at 12 months, suggesting that the VTP is a beneficial complement to existing treatments for patients with inflammatory rheumatic joint diseases.

'I have come here to learn how to cope with my illness, not to be cured': a qualitative study of patient expectations prior to a one-week self-management programme.

BACKGROUND: Self-management programmes (SMPs) have been developed to help patients with chronic rheumatic diseases to manage their health problems. Patients' expectations prior to treatment are important determinants of outcomes, and should therefore be identified, to ensure that interventions meet the participants' needs. The aim of the present study was to determine participant expectations with respect to a one-week inpatient SMP for those with fibromyalgia (FM) and rheumatoid arthritis (RA). METHODS: A qualitative study consisting of semi-structured interviews was used to explore the expectations of eight participants with FM and eight with RA. The data were analysed using thematic analysis. RESULTS: The findings show that the participants expected the SMP to be a turning point towards a better future and to empower them to assume more responsibility for their own health and self-care. They also expected the SMP to facilitate acceptance, help them to gain new knowledge and be a forum in which to share their experience. Participants who were employed assumed that participation in the SMP would help to ensure that they would continue in their jobs. CONCLUSIONS: This qualitative study indicated that identifying expectations prior to an SMP provides important information which has implications for the programme's implementation. Additional themes, such as acceptance of the illness and management of work, should also be included in the programmes and they should focus more on sharing experience.

Exercise programs in trials for patients with ankylosing spondylitis: do they really have the potential for effectiveness?

OBJECTIVE: To evaluate if exercise programs in trials for patients with ankylosing spondylitis (AS) have the potential for effectiveness. METHODS: A systematic literature search was performed and randomized trials examining the effectiveness of exercise programs for AS patients were analyzed according to 3 elements: whether the exercise programs were designed according to the American College of Sports Medicine (ACSM) recommendations for developing cardiorespiratory fitness, muscular strength, and flexibility; whether physiologic responses were properly measured; and whether adherence to programs was monitored. RESULTS: Twelve trials with a total of 826 AS patients were evaluated. Five trials included cardiorespiratory exercise as a part of the exercise programs. One of these met the ACSM recommendations for intensity, duration, frequency, and length of the exercise period. This trial showed the greatest within-group improvement in aerobic capacity (effect size [ES] 2.19). Five trials included muscular strength training, but none measured the physiologic responses nor met the recommendations for improving muscular strength. Eleven trials included flexibility training, but the programs were poorly described overall. Small improvements in spinal mobility (ES range 0.02-0.67) were reported in all trials. Finally, 4 trials reported on participants' adherence to the exercise programs, but only 1 provided sufficient information to evaluate the possible influence of the adherence. CONCLUSION: The quality of interventions in exercise trials for patients with AS can be improved. Future trials should also focus on measuring and reporting physiologic responses and adherence to exercise interventions.

Translation, data quality, reliability, validity and responsiveness of the Norwegian version of the Effective Musculoskeletal Consumer Scale (EC-17).

BACKGROUND: The Effective Musculoskeletal Consumer Scale (EC-17) is a self-administered questionnaire for evaluating self-management interventions that empower and educate people with rheumatic conditions. The aim of the study was to translate and evaluate the Norwegian version of EC-17 against the necessary criteria for a patient-reported outcome measure, including responsiveness to change. METHODS: Data quality, reliability, validity and responsiveness were assessed in two groups. One group comprising 103 patients received a questionnaire before and at the end of a self-management programme. The second group comprising 96 patients' received the questionnaire two weeks before and on arrival of the program. Internal consistency and test-retest reliability were assessed. Construct validity was assessed through comparisons with the Brief Approach/Avoidance Coping Questionnaire, (BACQ), the Emotional Approach Coping Scale (EAC) and the General Health Questionnaire (GHQ-20). Responsiveness was assessed with the Standardised Response Mean (SRM). RESULTS: Respondents included 66 (64%) and 52 (54%) patients from the first and second groups respectively. Levels of missing data were low for all items. There was good evidence for unidimensionality, item-total correlations ranged from 0.59 to 0.82 and Cronbach's Alpha and test-retest correlations were over 0.90. As hypothesised EC-17 scores had statistically significant low to moderate correlations with the BACQ, EAC and GHQ-20 in the range 0.26 to 0.42. Following the self-management program, EC-17 scores showed a significant improvement with an SRM of 0.48. CONCLUSION: The Norwegian version of the EC-17 has evidence for data quality, internal consistency and test-retest reliability, construct validity and responsiveness to change. The EC-17 seems promising as an outcome measure for evaluating self-management interventions for people with rheumatic conditions, but further studies are needed.

What's in team rehabilitation care after arthroplasty for osteoarthritis? Results from a multicenter, longitudinal study assessing structure, process, and outcome.

BACKGROUND: Clinical course and outcome connected to rehabilitation after hip or knee arthroplasty have been studied extensively, but few studies have assessed the content of team rehabilitation care for these patients. OBJECTIVE: The purpose of this study was to provide a thorough description of the structure, process, and outcome of team rehabilitation care for patients with hip or knee arthroplasty for osteoarthritis. DESIGN: This was a multicenter, longitudinal observational study. METHODS: Patients (N=183) from 6 rehabilitation centers in Norway who were undergoing inpatient rehabilitation following hip or knee arthroplasty were included in the study. Structure and process components were recorded by participants and health care professionals in a patient diary. Participants also completed questionnaires regarding their experiences during their rehabilitation stay and recorded data for outcome measures at admission, at discharge, and 6 months after discharge. The main outcome measures were pain intensity and physical function, as assessed with the physical function scale of the Medical OUTCOMES: Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Data were complete for 172 participants (94%) at discharge and for 148 patients (81%) at the 6-month follow-up. Health care professionals, physical therapists, nurses, and physicians were most often involved in team care. Occupational therapists, social workers, and psychologists were seldom part of the rehabilitation team. Exercises provided by physical therapists were the most common treatment modality. Patient education, massage, and manual therapy also frequently were provided. The participants were very satisfied with their care and its organization, information, and communication and with the availability of health care professionals. They were moderately satisfied with the social environment of the rehabilitation setting. The participants had large improvements in the outcome measures during the rehabilitation stay and at the 6-month follow-up. LIMITATIONS: For typical physical therapy modalities such as exercises, electrotherapy, and acupuncture, there are limited descriptions and assessments of treatment doses. CONCLUSIONS: Current team rehabilitation care involves a traditional team with physical therapists, nurses, and physicians. Several types of treatment modalities are used, with greatest emphasis on physical training. This detailed description of current team rehabilitation practice might help clinicians and researchers in planning clinical trials within a rehabilitation setting, as well as in improving rehabilitation practice.

The evidence for non-pharmacological therapy of hand and hip OA.

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Evidence-based guidelines and recommendations for the treatment of OA consider non-pharmacological modalities as the cornerstone of modern OA management. Nonetheless, research evidence from clinical trials on non-pharmacological interventions for the treatment of hand and hip OA is scarce and considerably less than that for knee OA. In addition, research on non-pharmacological interventions for OA appears highly on the list of patients' research priorities. Thus, there is a clear mismatch between the available research evidence for non-pharmacological interventions for hip and hand OA and both the treatment guidelines and the interests of patients.

Early multidisciplinary evaluation and advice was ineffective for whiplash-associated disorders.

BACKGROUND: Whiplash is the most common type of injury reported in traffic accidents, but the effectiveness of conservative treatment for whiplash lacks evidence. AIMS: To assess the effect of early multidisciplinary evaluation and advice on the frequency of chronic neck pain three years post-injury in persons with minor or moderate traffic injuries. METHODS: In an insurance setting, we tested the effect by (1) a risk score matched prospective cohort design, (2) a propensity score matched nested case-control design and, (3) a risk and propensity score adjusted multivariate analysis in an unmatched prospective cohort design. We simulated unobserved risk and propensity factors to evaluate the robustness of the results for hidden bias. RESULTS: All three designs showed a significantly increased risk for chronic neck pain among those who received the intervention compared to those who did not. The relative risks ranged from 1.7 (95% CI: 1.0-2.6) to 2.6 (95% CI: 1.5-4.0). The results were robust to hidden bias. CONCLUSION: The consistency of the findings across the different designs strongly suggest that early multidisciplinary evaluation and advice increased the risk of having chronic neck pain three years following a minor or moderate traffic injury. Literally, the intervention may therefore have done more harm than good.

Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up.

BACKGROUND: Obesity is one of the most important risk factors for osteoarthritis (OA) in knee(s). However, the relationship between obesity and OA in hand(s) and hip(s) remains controversial and needs further investigation. The purpose of this study was to investigate the impact of obesity on incident osteoarthritis (OA) in hip, knee, and hand in a general population followed in 10 years. METHODS: A total of 1854 people aged 24-76 years in 1994 participated in a Norwegian study on musculoskeletal pain in both 1994 and 2004. Participants with OA or rheumatoid arthritis in 1994 and those above 74 years in 1994 were excluded, leaving n = 1675 for the analyses. The main outcome measure was OA diagnosis at follow-up based on self-report. Obesity was defined by a body mass index (BMI) of 30 and above. RESULTS: At 10-years follow-up the incidence rates were 5.8% (CI 4.3-7.3) for hip OA, 7.3% (CI 5.7-9.0) for knee OA, and 5.6% (CI 4.2-7.1) for hand OA. When adjusting for age, gender, work status and leisure time activities, a high BMI (> 30) was significantly associated with knee OA (OR 2.81; 95%CI 1.32-5.96), and a dose-response relationship was found for this association. Obesity was also significantly associated with hand OA (OR 2.59; 1.08-6.19), but not with hip OA (OR 1.11; 0.41-2.97). There was no statistically significant interaction effect between BMI and gender, age or any of the other confounding variables. CONCLUSION: A high BMI was significantly associated with knee OA and hand OA, but not with hip OA.

Repeated measures in rheumatoid arthritis reduced the required sample size in a two-armed clinical trial.

OBJECTIVES: To investigate whether repeated measures in patients with rheumatoid arthritis will reduce the between subject variation and if so, to determine the optimal number of measures to effectively reduce the number of participants required in controlled clinical trials. STUDY DESIGN AND SETTING: A prospective observational study. Thirty-eight rheumatoid arthritis patients with a stable disease reported level of joint pain, fatigue and patient global assessment of disease activity on VAS scales as well as the Rheumatoid Arthritis Disease Activity Index (RADAI) daily during a total of 42 days. RESULTS: In all measures, the variation within each individual was substantial over a 42-day period. By increasing the number of measurements from one to five, the standard deviation (SD) decreased from 5.5% (RADAI score) to 11% (Pain VAS) resulting in a reduction in the number of patients needed in a clinical trial from 11% to 22%, respectively. When we used from 6 to 42 individual measurements, the decrease continued but the reduction was of a smaller magnitude. CONCLUSION: The use of up to five repeated measurements per patient will decrease the number of patients required in a two armed clinical trial by as much as 22%.