TNF blockers inhibit spinal radiographic progression in ankylosing spondylitis by reducing disease activity: results from the Swiss Clinical Quality Management cohort.

OBJECTIVES: To analyse the impact of tumour necrosis factor inhibitors (TNFis) on spinal radiographic progression in ankylosing spondylitis (AS). METHODS: Patients with AS in the Swiss Clinical Quality Management cohort with up to 10 years of follow-up and radiographic assessments every 2 years were included. Radiographs were scored by two readers according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) with known chronology. The relationship between TNFi use before a 2-year radiographic interval and progression within the interval was investigated using binomial generalised estimating equation models with adjustment for potential confounding and multiple imputation of missing values. Ankylosing Spondylitis Disease Activity Score (ASDAS) was regarded as mediating the effect of TNFi on progression and added to the model in a sensitivity analysis. RESULTS: A total of 432 patients with AS contributed to data for 616 radiographic intervals. Radiographic progression was defined as an increase in ≥2 mSASSS units in 2 years. Mean (SD) mSASSS increase was 0.9 (2.6) units in 2 years. Prior use of TNFi reduced the odds of progression by 50% (OR 0.50, 95% CI 0.28 to 0.88) in the multivariable analysis. While no direct effect of TNFi on progression was present in an analysis including time-varying ASDAS (OR 0.61, 95% CI 0.34 to 1.08), the indirect effect, via a reduction in ASDAS, was statistically significant (OR 0.75, 95% CI 0.59 to 0.97). CONCLUSION: TNFis are associated with a reduction of spinal radiographic progression in patients with AS. This effect seems mediated through the inhibiting effect of TNFi on disease activity.

Does the reason for discontinuation of a first TNF inhibitor influence the effectiveness of a second TNF inhibitor in axial spondyloarthritis? Results from the Swiss Clinical Quality Management Cohort.

BACKGROUND: With regard to switching tumor necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA), conflicting results have been reported as to whether the effectiveness of a second TNFi depends on the reason for discontinuation of the first TNFi. METHODS: Patients with a clinical diagnosis of axSpA starting a second TNFi in the Swiss Clinical Quality Management cohort were included. Effectiveness of treatment at 1 year, as well as drug survival, was compared between subgroups having discontinued the first TNFi because of lack of response, adverse events (AEs), or other reasons. Lack of response was further divided into primary or secondary lack of response (PLR or SLR, respectively), depending on whether the first TNFi was stopped before or after 6 months of treatment. RESULTS: Among 632 patients with axSpA, median survival of a second TNFi was 1.1 years after PLR and 3.8 years after SLR (p = 0.003). At least moderate disease activity as defined by an Ankylosing Spondylitis Disease Activity Score using the erythrocyte sedimentation rate (ASDAS-ESR) <2.1 was achieved after 12 months by 11 %, 39 %, 26 %, and 39 % of patients who discontinued their first TNFi because of PLR, SLR, AEs, and other reasons, respectively (p = 0.01). Only 4 % of patients achieved an ASDAS-ESR inactive disease state after PLR, in comparison to 22 % of those after SLR. Similar results were demonstrated in patients fulfilling the Assessment of SpondyloArthritis international Society classification criteria for axSpA (n = 488): ASDAS-ESR <2.1 was achieved after 12 months by 9 %, 41 %, 29 %, and 39 % of patients who discontinued their first TNFi because of PLR, SLR, AEs, and other reasons, respectively (p = 0.01). CONCLUSIONS: The effectiveness of a second TNFi is significantly impaired in patients with axSpA after PLR to a first TNFi compared with SLR.

Impaired response to treatment with tumour necrosis factor α inhibitors in smokers with axial spondyloarthritis.

OBJECTIVES: To investigate the impact of smoking on the response to treatment with a first tumour necrosis factor inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) in a real-life cohort. METHODS: Patients fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA in the Swiss Clinical Quality Management Cohort were included in this study. The potential association between smoking status and differential response to TNFi in terms of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) was analysed using multiple adjusted longitudinal mixed effect models. Binary response rates at 1 year were assessed with multiple adjusted logistic analyses. RESULTS: A first TNFi was initiated in 698 patients with axSpA with available smoking status and a baseline or follow-up BASDAI assessment, of which 490 (70%) had complete covariate data. In comparison to non-smokers, current smokers demonstrated significantly smaller reductions in BASDAI and ASDAS scores upon treatment with TNFi (0.75 BASDAI units and 0.69 ASDAS units less, p=0.005 and 0.001, respectively) for patients with elevated baseline C-reactive protein (CRP) level. This effect was numerically smaller in patients with normal CRP. The odds for reaching a 50% improvement in BASDAI response or the ASAS criteria for 40% improvement after 1 year were significantly lower in current smokers than in non-smokers (0.54, 95% CI 0.31 to 0.95, p=0.03 and 0.43, 95% CI 0.24 to 0.76, p=0.004, respectively). CONCLUSIONS: Current smoking is associated with an impaired response to TNFi in axSpA.

Whole Body Magnetic Resonance Imaging Features in Diffuse Idiopathic Skeletal Hyperostosis in Conjunction with Clinical Variables to Whole Body MRI and Clinical Variables in Ankylosing Spondylitis.

OBJECTIVE: Discrimination of diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) can be challenging. Usefulness of whole-body magnetic resonance imaging (WB-MRI) in diagnosing spondyloarthritis has been recently proved. We assessed the value of clinical variables alone and in combination with WB-MRI to distinguish between DISH and AS. METHODS: Diagnostic case-control study: 33 patients with AS and 15 patients with DISH were included. All patients underwent 1.5 Tesla WB-MRI scanning. MR scans were read by a blinded radiologist using the Canadian-Danish Working Group's recommendation. Imaging and clinical variables were identified using the bootstrap. The most important variables from MR and clinical history were assessed in a multivariate fashion resulting in 3 diagnostic models (MRI, clinical, and combined). The discriminative capacity was quantified using the area under the receiver-operating characteristic (ROC) curve. The strength of diagnostic variables was quantified with OR. RESULTS: Forty-eight patients provided 1545 positive findings (193 DISH/1352 AS). The final MR model contained upper anterior corner fat infiltration (32 DISH/181 AS), ankylosis on the vertebral endplate (4 DISH/60 AS), facet joint ankylosis (4 DISH/49 AS), sacroiliac joint edema (11 DISH/91 AS), sacroiliac joint fat infiltration (2 DISH/114 AS), sacroiliac joint ankylosis (2 DISH/119 AS); area under the ROC curve was 0.71, 95% CI 0.64-0.78. The final clinical model contained patient's age and body mass index (area under the ROC curve 0.90, 95% CI 0.89-0.91). The full diagnostic model containing clinical and MR information had an area under the ROC curve of 0.93 (95% CI 0.92-0.95). CONCLUSION: WB-MRI features can contribute to the correct diagnosis after a thorough conventional workup of patients with DISH and AS.

Treatment with tumor necrosis factor inhibitors in axial spondyloarthritis: comparison between private rheumatology practices and academic centers in a large observational cohort.

OBJECTIVE: To evaluate the initiation of and response to tumor necrosis factor (TNF) inhibitors for axial spondyloarthritis (axSpA) in private rheumatology practices versus academic centers. METHODS: We compared newly initiated TNF inhibition for axSpA in 363 patients enrolled in private practices with 100 patients recruited in 6 university hospitals within the Swiss Clinical Quality Management (SCQM) cohort. RESULTS: All patients had been treated with ≥ 1 nonsteroidal antiinflammatory drug and > 70% of patients had a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4 before anti-TNF agent initiation. The proportion of patients with nonradiographic axSpA (nr-axSpA) treated with TNF inhibitors was higher in hospitals versus private practices (30.4% vs 18.7%, p = 0.02). The burden of disease as assessed by patient-reported outcomes at baseline was slightly higher in the hospital setting. Mean levels (± SD) of the Ankylosing Spondylitis Disease Activity Score were, however, virtually identical in private practices and academic centers (3.4 ± 1.0 vs 3.4 ± 0.9, p = 0.68). An Assessment of SpondyloArthritis international Society (ASAS40) response at 1 year was reached for ankylosing spondylitis in 51.7% in private practices and 52.9% in university hospitals (p = 1.0) and for nr-axSpA in 27.5% versus 25.0%, respectively (p = 1.0). CONCLUSION: With the exception of a lower proportion of patients with nr-axSpA newly treated with anti-TNF agents in private practices in comparison to academic centers, adherence to ASAS treatment recommendations for TNF inhibition was equally high, and similar response rates to TNF blockers were achieved in both clinical settings.

Tumor necrosis factor α inhibition in radiographic and nonradiographic axial spondyloarthritis: results from a large observational cohort.

OBJECTIVE: To evaluate the baseline characteristics of patients with radiographic axial spondyloarthritis (SpA; ankylosing spondylitis [AS]) and patients with nonradiographic axial SpA, to investigate determinants of anti-tumor necrosis factor (anti-TNF) agent prescription on the background of a nonrestrictive reimbursement policy, and to assess the response to TNF inhibition. METHODS: We compared the characteristics of radiographic axial SpA and nonradiographic axial SpA in 1,070 patients from the Swiss Clinical Quality Management (SCQM) Cohort who fulfilled the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial SpA. By taking advantage of the situation that patients who are eligible for anti-TNF treatment are preferentially enrolled in the SCQM Cohort for patients with AS/axial SpA, we explored parameters leading to the initiation of anti-TNF treatment in single and multiple regression models and assessed treatment responses. RESULTS: We confirmed a similar burden of disease (as determined by self-reported disease activity, impaired function, and quality of life) in patients with nonradiographic axial SpA (n = 232) and those with radiographic axial SpA (n = 838). Patients with radiographic axial SpA had higher median levels of acute-phase reactants and higher median AS Disease Activity Scores (ASDAS; 3.2 versus 3.0). Anti-TNF treatment was initiated in 363 patients with radiographic axial SpA and 102 patients with nonradiographic axial SpA, preferentially in those with sacroiliitis on magnetic resonance imaging, peripheral arthritis, a higher C-reactive protein (CRP) level, a higher ASDAS, and a higher Bath Ankylosing Spondylitis Disease Activity Index level. The ASAS criteria for 40% improvement responses at 1 year were higher in patients with radiographic axial SpA compared with those with nonradiographic axial SpA (48.1% versus 29.6%; odds ratio [OR] 2.2, 95% confidence interval [95% CI] 1.12-4.46, P = 0.02). The difference was smaller in the subgroups of patients with elevated baseline CRP levels (51.6% in patients with radiographic axial SpA versus 38.5% in those with nonradiographic axial SpA; OR 1.7, 95% CI 0.68-4.48, P = 0.29). CONCLUSION: The indications for treatment with anti-TNF agents were comparable for patients with radiographic axial SpA and those with nonradiographic axial SpA. With the exception of patients with elevated CRP levels at baseline, higher rates of response to TNF inhibition were achieved in the group of patients with radiographic axial SpA than in the group with nonradiographic axial SpA.

Anterior chest wall inflammation by whole-body magnetic resonance imaging in patients with spondyloarthritis: lack of association between clinical and imaging findings in a cross-sectional study.

INTRODUCTION: Inflammatory involvement of the anterior chest wall (ACW) affects the quality of life of patients with spondyloarthritis (SpA), although involvement of the ACW is often neglected on clinical and imaging evaluation. Whole-body (WB) MRI is an imaging method used to assess the ACW in addition to the sacroiliac joints and spine without inconvenience for patients. Our goals in this study were to describe the distribution of ACW inflammation by WB MRI in both early and established SpA and associations between clinical and imaging findings indicative of inflammation. METHODS: The ACWs of 122 consecutive SpA patients (95 with ankylosing spondylitis (AS) and 27 with nonradiographic SpA (nrSpA)) and 75 healthy controls were scanned by sagittal and coronal WB MRI. The MRI scans were scored independently in random order by seven readers blinded to patient identifiers. Active and structural inflammatory lesions of the ACW were recorded on a web-based data entry form. ACW pain by patient self-report, ACW tenderness on physical examination according to the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and lesions detected by MRI were analyzed descriptively. κ statistics served to assess the agreement between clinical and imaging findings. RESULTS: ACW pain or tenderness was present in 26% of patients, with little difference between AS and nrSpA patients. Bone marrow edema (BME), erosion and fat infiltration were recorded in 44.3%, 34.4% and 27.0% of SpA patients and in 9.3%, 12.0% and 5.3% of controls, respectively. Lesions found by MRI occurred more frequently in AS patients (BME, erosion and fat infiltration in 49.5%, 36.8% and 33.7%, respectively) than in nrSpA patients (25.9%, 25.9% and 3.7%, respectively). The joint most frequently affected by lesions found on MRI scans was the manubriosternal joint. The κ values between clinical assessments and MRI inflammation ranged from -0.10 to only 0.33 for both AS and nrSpA patients. CONCLUSIONS: Among SpA patients, 26% had clinical involvement of the ACW. WB MRI signs of ACW inflammation were found in a substantial proportion of patients with AS (49.5%) and nrSpA (25.9%). There was no association between clinical assessments of ACW, including the MASES, and MRI features.

Disease-related knowledge of patients with chronic regional pain syndrome.

OBJECTIVE: The aim of this study was to investigate patients' knowledge of the most salient features of complex regional pain syndrome and to identify patient characteristics associated with the patients' level of knowledge. METHODS: Questionnaire interview of 101 patients with complex regional pain syndrome in Switzerland (mean age 54 years, 77% female). A questionnaire about patients' disease-related knowledge was developed and piloted. The level of knowledge was defined by a consensus process among clinical experts and a patient. The questions were based on expert consensus about the minimum knowledge a person affected with complex regional pain syndrome should have. RESULTS: Only 6 patients (6%) reached the minimum medical knowledge. The mean score for all participants was 7.6 points out of a total score of 11 points (range 3-11, SD 2.1). The scores were slightly higher among patients with higher education (apprenticeship, vocational school +0.38 (95% confidence interval (CI); -0.59 to 1.34: p=0.44), university entrance diploma +1.12 (95% CI-0.16 to 2.49: p=0.08), university diploma, advanced technical college +2.36 (95% CI 1.11-3.61: p<0.001)) compared with mandatory school, and among those with professional medical backgrounds +1.13 (95% CI 0.06-2.20: p=0.04). Most patients received information from their caregivers and wanted to know more about therapy or general aspects of the condition. CONCLUSION: Many patients with complex regional pain syndrome do not have the minimum knowledge of their disease as defined by clinical experts. Physicians should be aware that patients expect to receive disease-related information primarily from their caregivers. In particular, patients wanted more information about therapy and general aspects of the illness.

German translation and external validation of the Radboud Skills Questionnaire in patients suffering from Complex Regional Pain Syndrome 1.

BACKGROUND: Patients suffering from Complex Regional Pain Syndrome commonly complain of substantial limitations in their activities of daily living. The Radboud Skills Questionnaire measures alterations in the level of disability of patients with Complex Regional Pain Syndrome, but this instrument is currently not available in German. The goals of our study were to translate the Dutch Radboud Skills Questionnaire into German and to assess its external criterion validity with the German version of the Disabilities of the Arm, Shoulder and Hand Questionnaire. METHODS: We translated the Radboud Skills Questionnaire according to published guidelines. Demographic data and validity were assessed in 57 consecutive patients with Complex Regional Pain Syndrome 1 of the upper extremity. Information on age, duration of symptoms, type of Complex Regional Pain Syndrome 1 and type of initiating event was obtained. We assessed the external criterion validity by comparing the German Radboud Skills Questionnaire and the German Disabilities of the Arm, Shoulder and Hand Questionnaire and calculated the prediction intervals. RESULTS: Score values ranged from 55.4 +/- 22.0 for the Disabilities of the Arm, Shoulder and Hand Questionnaire score and 140.1 +/- 39.2 for the Radboud Skills Questionnaire. We found a high correlation between the Radboud Skills Questionnaire and the Disabilities of the Arm, Shoulder and Hand Questionnaire (R2 = 0.83). CONCLUSION: This validation of the Radboud Skills Questionnaire demonstrates that this German version is a simple and accurate instrument to assess and quantify disabilities of patients suffering from Complex Regional Pain Syndrome 1 of the upper extremity for clinical and research purposes.

Translating the Dutch Walking Stairs, Walking Ability and Rising and Sitting Questionnaires into German and assessing their concurrent validity with VAS measures of pain and activities in daily living.

BACKGROUND: The Dutch Walking Stairs, Walking Ability and Rising and Sitting Questionnaires are three validated instruments to measure physical activity and limitations in daily living in patients with lower extremity disorders living at home of which no German equivalents are available. Our scope was to translate the Walking Stairs, Walking Ability and Rising and Sitting Questionnaires into German and to verify its concurrent validity in the two domains pain and activities in daily living by comparing them with the corresponding measures on the Visual Analogue Scale. METHODS: We translated the Walking Stairs, Walking Ability and Rising and Sitting Questionnaires according to published guidelines. Demographic data and validity were assessed in 52 consecutive patients with Complex Regional Pain Syndrome 1 of the lower extremity. Information on age, duration of symptoms, type of Complex Regional Pain Syndrome 1 and type of initiating event were obtained. We assessed the concurrent validity in the two domains pain and activities in daily living by comparing them with the corresponding measures on the Visual Analogue Scale. RESULTS: We found that variability in the German Walking Stairs, Walking Ability and Rising and Sitting Questionnaires was largely explained by measures of pain and activities in daily living on the Visual Analogue Scale. CONCLUSION: Our study shows that the domains pain and activities in daily living are properly represented in the German versions of the Walking Stairs, Walking Ability and Raising and Sitting Questionnaires. We would like to propagate their use in clinical practice and research alike.

Assessment of active spinal inflammatory changes in patients with axial spondyloarthritis: validation of whole body MRI against conventional MRI.

OBJECTIVE: To evaluate the performance of whole body (WB) MRI versus conventional (CON) MRI in assessing active inflammatory lesions of the entire spine in patients with established and clinically active axial spondyloarthritis (SpA) using the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI index. METHODS: 32 consecutive patients with SpA fulfilling the modified New York criteria and with clinically active disease (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score > or =4) were scanned by sagittal WB and CON MRI of the spine. The MR images were scored independently in random order by three readers blinded to patient identifiers. Active inflammatory lesions of the spine were recorded on a web-based scoring form. Pearson correlation coefficients were used to compare scores for WB MRI and CON MRI for each rater and intraclass correlation coefficients (ICC) were used to assess interobserver reliability. RESULTS: The median percentage of inflammatory lesions recorded concordantly for both WB MRI and CON MRI ranged from 83% to 91% for the three readers; 4-9% were only recorded by WB MRI and 4-9% were recorded by CON MRI only. The Pearson correlation coefficients between WB and CON MRI per rater were 0.79, 0.89 and 0.81, respectively. The ICC(2, 1) were 0.75, 0.80 and 0.68 for CON MRI and 0.82, 0.83 and 0.93 for WB MRI for the three possible reader pairs. CONCLUSION: WB MRI and CON MRI scores showed a high correlation and comparable high reliability for the detection of active inflammatory lesions in the spine of patients with clinically active SpA.

Validation of whole-body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis.

OBJECTIVE: To compare the performance of whole-body magnetic resonance imaging (MRI) versus conventional MRI in assessing acute inflammatory lesions of the sacroiliac (SI) joints in patients with established and active spondylarthritis (SpA) using the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI index. This study is validating whole-body MRI against the current MRI standard for assessing active inflammatory lesions of the SI joints in patients with SpA. METHODS: Thirty-two SpA patients with clinically active disease (Bath Ankylosing Spondylitis Disease Activity Index score >/=4) fulfilling the modified New York criteria were scanned by whole-body and conventional MRI of the SI joints. The MRIs were scored independently in random order by 3 readers blinded to patient identity. Active inflammatory lesions of the SI joints were recorded on a Web-based SPARCC index. Pearson's correlation coefficients were used to compare scores for whole-body and conventional MRI for each reader, whereas intraclass correlation coefficients (ICCs) were used to compare interobserver reliability. RESULTS: The Pearson's correlation coefficients between whole-body and conventional MRI per rater were 0.94, 0.87, and 0.93. The mean sum scores for conventional versus whole-body MRI were statistically significantly higher for all 3 readers, although all patients showing inflammatory lesions on conventional MRI also demonstrated them on whole-body MRI. The ICCs(2,1) were 0.69, 0.78, and 0.95 for conventional MRI, and 0.79, 0.85, and 0.96 for whole-body MRI for the 3 possible reader pairs. CONCLUSION: Whole-body and conventional MRI scores show a strong correlation and comparable reliability for the detection of inflammatory lesions of the SI joints.

Sensitivity and specificity of spinal inflammatory lesions assessed by whole-body magnetic resonance imaging in patients with ankylosing spondylitis or recent-onset inflammatory back pain.

OBJECTIVE: To determine the diagnostic utility of different spinal inflammatory lesions assessed by whole-body magnetic resonance imaging (MRI) in patients with ankylosing spondylitis (AS) or with recent-onset inflammatory back pain (IBP) compared with healthy controls. METHODS: We scanned 35 consecutive patients with AS fulfilling the modified New York criteria, 25 patients with IBP of <24 months' duration (both groups were age < or =45 years and had a Bath Ankylosing Spondylitis Disease Activity Index score > or =4), and 35 healthy age- and sex-matched volunteers using whole-body MRI STIR sequences of the spine. MRIs were independently assessed in random order by 3 readers blinded to patient identity. Inflammatory spinal lesions were recorded consistent with definitions proposed by the Canada/Denmark International MRI Working Group: vertebral corner inflammatory lesions (CIL) and noncorner inflammatory lesions in central sagittal slices and lateral inflammatory lesions (LIL) in lateral slices. Concordantly scored lesions for the 3 possible reader pairs were used in the analysis of sensitivity, specificity, likelihood ratios (LRs), and areas under the curve for the entire spine and by spinal segment. RESULTS: Diagnostic utility was optimal when > or =2 CIL were recorded (for patients with AS, values for sensitivity, specificity, and positive LR were 69%, 94%, and 12, respectively, and for patients with IBP were 32%, 96%, and 8, respectively). LIL had high specificity (97%) but low sensitivity (31%). Nine controls had > or =1 CIL, but only 2 controls had >2 CIL. CONCLUSION: Diagnostic utility of STIR MRI for AS is optimal when > or =2 CIL are present. A single CIL can be found in up to 26% of healthy individuals.

Biphosphonates for the therapy of complex regional pain syndrome I--systematic review.

OBJECTIVES: Several studies found that biphosphonates counteract locally increased bone resorption and associated pain in patients with complex regional pain syndrome I (CRPS I). We performed a systematic review of all randomised controlled trials to assess the benefit of biphosphonates in the treatment of CRPS I patients with bone loss. DATA SOURCES: We searched Medline, Embase (April 2007) and the Cochrane Library and screened bibliographies of included studies. REVIEW METHODS: We selected randomised trials comparing biphosphonates with placebo, with the goal of improving pain, function and quality of life in patients with CRPS I. Two reviewers independently assessed trial eligibility and quality, and extracted data. Where data were incomplete or unclear, conflicts were resolved with discussion and/or trial authors were contacted for further details. We calculated the study size weighted pooled mean reduction of pain intensity (measured with a visual analogue scale (VAS)). RESULTS: Four trials of moderate quality fulfilled our inclusion criteria. In respect to function and quality of life there was a trend in favour of biphosphonates but differences in outcome assessment impeded pooling of results. Two trials provided sufficient data to pool pain outcomes. Biphosphonates reduced pain intensity by 22.4 and 21.6mm on a VAS after 4 and 12 weeks of follow-up. Data on adverse effects were scarce. CONCLUSIONS: The very limited data reviewed showed that bisphosphonates have the potential to reduce pain associated with bone loss in patients with CRPS I. However, at present there is not sufficient evidence to recommend their use in practice.

Bone metastases mimicking Complex Regional Pain Syndrome I: a case report.

INTRODUCTION: Since there are no valid tools available for the diagnosis of Complex Regional Pain Syndrome I, exclusion of other underlying conditions plays an important role in the diagnostic process. CASE PRESENTATION: A 77-year-old Caucasian man was referred with painful swelling and dysfunction of the right knee. Based on the history and clinical presentation, the referring physician assumed a case of Complex Regional Pain Syndrome I. However, after careful evaluation of the differential diagnosis, a metastatic urothelial carcinoma was diagnosed. CONCLUSION: Even if the clinical picture resembles Complex Regional Pain Syndrome I, the differential diagnosis must be evaluated carefully.

Complex regional pain syndrome 1--the Swiss cohort study.

BACKGROUND: Little is known about the course of Complex Regional Pain Syndrome 1 and potential factors influencing the course of this disorder over time. The goal of this study is a) to set up a database with patients suffering from suspected CRPS 1 in an initial stadium, b) to perform investigations on epidemiology, diagnosis, prognosis, and socioeconomics within the database and c) to develop a prognostic risk assessment tool for patients with CRPS 1 taking into account symptomatology and specific therapies. METHODS/DESIGN: Prospective cohort study. Patients suffering from a painful swelling of the hand or foot which appeared within 8 weeks after a trauma or a surgery and which cannot be explained by conditions that would otherwise account for the degree of pain and dysfunction will be included. In accordance with the recommendations of International Classification of Functioning, Disability and Health (ICF model), standardised and validated questionnaires will be used. Patients will be monitored over a period of 2 years at 6 scheduled visits (0 and 6 weeks, 3, 6, 12, and 24 months). Each visit involves a physical examination, registration of therapeutic interventions, and completion of the various study questionnaires. Outcomes involve changes in health status, quality of life and costs/utility. DISCUSSION: This paper describes the rationale and design of patients with CRPS 1. Ideally, potential risk factors may be identified at an early stage in order to initiate an early and adequate treatment in patients with increased risk for delayed recovery.

Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I--a Delphi survey.

BACKGROUND: Although the current clinical guideline of diagnostic criteria for the complex regional pain syndrome I (CRPS I) is a landmark endeavour to define this complex condition it does not prioritise its most important clinical manifestations. AIM: We set out to obtain an expert agreed priority list of diagnostic and follow-up parameters in the diagnosis and management of CRPS I. METHODS: A two round Delphi survey: We asked international experts to list (first round) and weight (second round) parameters (scale 1-10) they believed to be relevant in diagnosis and follow-up. Median ratings and interquartile ranges (IQR) were calculated. Rates 7 and IQR 3 depicted important and expert agreed parameters. RESULTS: Thirty-two diagnostic and 23 follow-up listings and ratings of 13 experts were available for analysis. In three domains (clinical presentation, further examinations and follow-up) experts agreed on the following parameters, pain (10; 9-10) with its subcategories hyperesthesia (7; 5-8) hyperalgesia (8; 8-8) and allodynia (8; 7-10), signs with oedema (9; 8-10) and colour change (8; 5-8) and mobility with its categories motor change (7; 5-8) and decreased range of motion (8; 8-8). The experts agreed that no further examinations were necessary for diagnosis (10; 8-10). The agreed important follow-up parameter was clinical course (10; 8-10) with its categories decrease in pain (8; 8-9) and hyperalgesia (8; 6-8), decreased oedema (8; 7-10) and improvements in motor function (10; 8-10) and strength (8; 6-9). CONCLUSION: This expert survey conveys an agreed set of relevant diagnostic parameters of CRPS I and proposes that in follow-up examinations treatment success should be based on restoration of those manifestations.

Advances in musculoskeletal imaging and their clinical utility in the early diagnosis of spondyloarthritis.

Interest in imaging ankylosing spondylitis (AS) and related spondyloarthropathies has increased in recent years. MRI is regarded as the most sensitive imaging modality to detect early inflammatory lesions in the sacroiliac joints and in the spine. Standard radiography plays a major role in evaluating potential disease-modifying properties of the recently introduced, symptomatically effective anti-tumor necrosis factor-alpha agents. Various radiographic scoring methods have been developed to assess and monitor spinal structural damage in AS. The modified stoke ankylosing spondylitis spine score is the method of choice based on its sensitivity to change. MRI is emerging as a useful tool to detect AS early, but this remains a challenge. Recent progress in MR technology with the advent of whole body MRI has expanded the potential role of imaging in AS. Further data are needed before MRI can replace radiographs for earlier diagnosis of AS.