Arthritis Clinical Link Newsletter

Arthritis Clinical Link Newsletter!!!! Created and Distributed by the Mary Pack Arthritis Program A newsletter for health professionals working with people with arthritis November 2015 Editor s Message You may think otherwise, but I believe that some of the more exciting work happening these days in the field of arthritis care is in the area of osteoarthritis (OA). I attribute this to the recognition that occurred 7-10 years ago that the Baby Boomers were aging, myself included, and that we d soon be faced with ever larger numbers of people with OA seeking services. To address this burgeoning need, we needed to find new treatments and more innovative ways of providing care for this patient population. This issue of the Clinical Link Newsletter highlights some of what s new in relation to key education messages for your patients with OA, an overview of strategies for the prevention of knee OA, and an internetbased exercise resource for people with knee OA. There is also an interesting article on screening for depression in people with chronic disease. Finally, I ve included an overview of new resources that are available to health professionals on the MPAP website, as well as other Internet-based resources you may find of interest. As always, I welcome your comments and feedback. Paul Adam, Rheumatology Liaison & Outreach Services Coordinator Paul.Adam@vch.ca Rheumatoid Arthritis for Physiotherapists-eLearning (RAP-eL) The RAP-eL is a free web-based resource developed in Australia to educate community-based physiotherapists (PTs) about the assessment and management of patients with rheumatoid arthritis (RA). This web-based resource consists of 4 learning modules and 2 clinical case studies. The modules include: 1) RA: the disease and recognition in practice; 2) RA: the early stage of the disease; 3) RA: the chronic stage of the disease; and 4) Extraarticular features of RA and comorbid conditions. Modules purposefully follow the natural history of RA. Each module is focused on delivering essential knowledge and then translating that knowledge into practical clinical skills, what the creators describe as, the know and do for best-practice physiotherapy management of RA. The educational content that comprises RAP-eL is based on a previous international Delphi Study and critical appraisal of RA guidelines. Experienced clinician-educators used a knowledge-to-action approach to translate the RA guidelines identified in the previous study into web-appropriate knowledge and skills-based content, as well as being integrated into 2 practice-related case scenarios. An independent group of external reviewers that included 2 rheumatologists, 2 rheumatology PTs, 2 RA patients, and 1 clinical educator assessed both the accuracy and clinical appropriateness of content and website usability on 2 occasions. Concerns identified in the first review were corrected in the next iteration of RAP-eL and concerns noted in the second review were corrected for the final version of RAP-eL that was tested by physiotherapists in the study summarized in the last section (Recent Articles of Interest) in the July 2015 article by Fary et al. The modules are not intended 1

to be a comprehensive curriculum for rheumatoid arthritis and completion of these modules does not necessarily imply clinical competence in this area. The creators suggest it is best to undertake the modules in sequential order; however this is not a necessity. Embedded videos in the modules highlight particular experiences from those with rheumatoid arthritis. Additional resources can be accessed via a bibliography at the end of each module or via a resources box on the right of the screen. Finally, case studies contain two clinical vignettes with accompanying quizzes to test your knowledge. Marie Westby reviewed the site and stated that while it does not include the most current reviews and guidelines on RA, has little information on exercise prescription, and uses a different joint count than we use, it s still a useful resource that can help to reinforce learning. The website is located at http://www.rap-el.com.au/index.html Important Information a Patient with Osteoarthritis Needs to Know A recent study identified the information a patient with osteoarthritis needs to know about the disease, its causes, its diagnosis and its management in plain language and ranked in order of importance. The study is summarized in the last section (Recent Articles of Interest) in the June 2015 article by French et al. The ranking (and topic area) of each message is as follows: 1. Regular physical activity and individualized exercise programs (including muscle strengthening, cardiovascular activity, and flexibility exercises) can reduce your pain, prevent worsening of your osteoarthritis, and improve your daily function. (Exercise, physical activity and weight loss) 2. If you are overweight and have osteoarthritis, it will be beneficial to lose weight and maintain a healthy weight through an individualized plan involving dietary changes and increased physical activity. (Exercise, physical activity and weight loss) 3. Your osteoarthritis symptoms can often be eased significantly without requiring an operation. (Surgery) 4. Living a sedentary life could worsen your osteoarthritis and also increase your risk of other lifestylerelated diseases, such as diabetes and cardiovascular disease (Exercise, physical activity and weight loss) 5. Individualized exercise is an integral component of treatment for everyone with osteoarthritis (Exercise, physical activity and weight loss) 6. Maintaining sufficient muscle strength around the joints is important in reducing pain and maintaining function, and if you require an operation will benefit both pre- and post-operative periods of your treatment. (Exercise, physical activity and weight loss) 7. Nondrug treatments have similar benefits for your osteoarthritis symptoms to pain relieving drugs, but with very few adverse side effects. (Principles of management) 8. Linking your individualized exercises to your other daily activities is a useful way to become more active. (Exercise, physical activity and weight loss) 9. Individualized exercises only work for your osteoarthritis if you do them regularly. (Exercise, physical activity and weight loss) 10.Actively taking part in self-management programs could benefit your osteoarthritis. (Principles of management) 11. Treatment interventions and lifestyle changes for your osteoarthritis should be individualized and include long- and short-term goals. These should be reviewed regularly with your health professionals. (Principles of management) 2

12.Osteoarthritis is not just a disease of the cartilage but affects your whole joint including muscles and ligaments. (Disease knowledge) 13.If you cannot achieve pain relief from your osteoarthritis, have undertaken a sustained period of conservative management, and it is very difficult to perform activities of daily living, joint replacement surgery is an option. (Surgery) 14.Small amounts of individualized exercises undertaken frequently can be beneficial for your osteoarthritis. (Exercise, physical activity and weight loss) 15.Joint damage on an x-ray does not indicate how much osteoarthritis will affect you. (Disease knowledge) 16.The symptoms of osteoarthritis can vary greatly from person to person. (Disease knowledge) 17.You should avoid the use of nonsteroidal anti-inflammatory drugs for your osteoarthritis over the long term (Drugs) 18.Methods for you to self-manage your osteoarthritis should be discussed and agreed upon by you and your health professionals (Principles of management) 19.Keyhole surgery (arthroscopy) that involves washout of the joint and joint scraping should not be used to treat your pain unless there is a mechanical blocking of your joint. (Surgery) 20.Osteoarthritis is not an inevitable part of getting older. (Disease knowledge) 21.You may get some pain relief from your osteoarthritis by using acetaminophen (paracetamol) medications. (Drugs) The authors note that these messages can form the basis of evidence-based patient educational materials, and help to facilitate the translation of evidence into patient knowledge and decision-making. Strategies for the Prevention of Knee Osteoarthritis A recent review article in Nature Reviews, Rheumatology argued for the importance of prevention and early treatment of OA in the hopes of potentially preventing many years of pain and functional impairment, as well as the attendant costs to the health care system. To foster early treatment the article has provided a nice synopsis of primary and secondary strategies for common OA risk factors such as obesity and joint injury. It is thought that the structural signs of OA are common outcomes that can arise by way of a number of different pathways, involving a variety of risk factors. The discord between structural signs (e.g., joint damage) and symptoms (e.g., pain) can be substantial and is influenced by comorbidities (e.g., depression, anxiety), pain-processing factors (e.g., pain sensitization) and other personal traits. It is known that OA affects all tissues of the synovial joint including cartilage, bone, ligament, tendon, synovium, and meniscus. The degree to which each is involved varies from person to person and from one point in the course of the disease to another. While models exist to predict the onset of OA, and in particular knee OA, the authors state that these need improvement and validation before they can be used in clinical practice. However, once available they could be used to identify the risk phenotype of each individual so as to determine the most appropriate interventions. 3

Primary prevention strategies are meant to prevent the onset of specific diseases through risk reduction. Preventing knee injury and obesity during adolescence are examples of strategies relevant to knee OA. Secondary prevention involves the detection and treatment of risk factors for progression in those who are already at risk. Strategies relevant to knee OA might include exercises to improve dynamic joint stability and muscle function. Obesity, trauma, and impaired muscle function thus offer three potential targets for primary or secondary intervention. The evidence suggests that obesity leads to knee OA and pain, and that weight loss will reduce both clinical OA and knee pain. A variety of interventions have been shown to reduce weight in the short and medium term, such as dietary restriction. Exercise on its own is less effective than dieting in producing weight loss, but exercise is considered pivotal in maintaining weight loss. Cognitive behavioral therapy (CBT) can also be an effective weight loss strategy. Currently, the gold standard in achieving effective weight reduction and long-term maintenance is bariatric surgery. Previous research has identified a number of factors shown to be related to long-term weight loss maintenance (e.g., low stress, low sugar consumption, increased moderate physical activity) and regaining weight after weight loss (e.g., depression, increased high-salt food intake, poor sleep). These factors point to the importance of recognizing the connection between weight loss and general wellness, and of targeting interventions to the individual. Early intervention focused on the prevention of knee injuries in young adults, especially those who are considered at high risk for sports-related injuries, could reduce the future burden from knee OA. A large meta-analysis showed that neuromuscular and proprioceptive training programs are successful in preventing approximately 50% of ACL injuries. Secondary prevention would best target individuals who have had major knee trauma or orthopaedic surgery. Strategies could include neuromuscular exercise therapy, strength training, knee bracing, and use of lateral-wedge foot orthotics. As with weight management, exercise strategies and biomechanical modifications should be tailored to the individual. Roos EM, Arden NK. Strategies for the prevention of knee osteoarthritis. Nature Reviews, Rheumatology, advance online publication 6 October 2015;doi:10.1038/nrrheum.2015.135 An Internet-based Exercise Resource for Patients with Knee Osteoarthritis (OA) The May 2015 issue of The Rheumatologist described an ongoing study to evaluate the effectiveness of a standalone Internet-based exercise resource for people with knee OA. The rationale for the development of this resource is that while physiotherapy can be of great benefit to people with knee OA, some studies have shown that PT is under-utilized by this population, whether for financial reasons or because access to PT service may be limited or non-existent. This is a comparative effectiveness trial in which patients with knee OA have been randomized to usual physical therapy care, an Internet-based exercise training program, or a waitlist control group that receives care at the end of the study. The study will compare effectiveness of each intervention for improving pain and functional outcomes at 4-month and 12-month assessment visits. It will also identify if such a standalone exercise program is more effective for certain types of patients (e.g., patients with less advanced knee OA). It is expected that the 4-month outcome assessments will be completed by the summer of 2016. The Internet-based exercise resource used in this study is called the Therapeutic Exercise Resource Center (TERC) and was designed by Visual Health Information Inc. to be a comprehensive, Web-based system to 4

evaluate, prescribe, monitor and adjust therapeutic exercise programs for patients with knee OA. 1 The system works by having participants with knee OA input answers to questions related to pain, function and exercise history. The system then prescribes an individualized exercise routine, including stretching, strengthening, and aerobic exercises. As time progresses, participants are able to request more or less challenging exercises to which the system can respond by changing exercise difficulty, the number of exercises, or the number of sets or repetitions of exercises prescribed. Prior to assigning a more difficult exercise, participants are prompted to complete the modified Short Form Western Ontario and McMaster Universities Arthritis Index (msf-womac). Exercises of greater difficulty are only assigned if the msf-womac score is equal to or better than the prior score. The system can also prompt the user to consider a more difficult or easier exercise routine if the participant records two weeks of exercising without an increase in pain, or records 3 or more consecutive days of increased knee pain, respectively. For all prescribed stretching and strengthening exercises, the website provides motion captured animations to demonstrate proper technique. The site also includes evidence-based educational materials to help participants better understand knee OA risk factors and strategies for managing symptoms. As with many exercise tracking programs, participants keep a record of exercises completed and the system provides a visual display of progress over time. Automated exercise reminders are sent when a participant does not log unto the website within specified a time period. An initial pilot test of TERC with 52 participants showed that msf-womac scores decreased (p<.001), World Health Organization Quality of Life scale (WHO-QOL) physical scores increased (p=.015), and Knee Self-Efficacy Scale (K-SES) scores increased (p<.001). While likely not viable solely as a standalone resource, TERC may be a valuable component of a stepped care approach to arthritis management. Von Korff, et al. note that stepped care is based on 3 assumptions: different people require different levels of care; finding the right level of care often depends on monitoring outcomes; and moving from lower to higher levels of care based on patient outcomes often increases effectiveness and lowers costs overall. 2 Level 1 care entails monitoring of patient status so as to guide long-term management and some aspect of preventative care (e.g., education classes offered by The Arthritis Society). Level 2 entails self-management with low-intensity support (e.g., TERC, community-based exercise class). Level 3 entails some degree of low intensity care management (e.g., therapeutic group exercise class) and Level 4 entails some degree of high intensity care management (e.g., individualized treatment by a therapist). This approach can also include tailoring care based on disease severity, functional or clinical status, and patient preference in accord with evidence-based guidelines. What this means is that the most optimal first line of care may not be the least expensive or least intense. New Best Practice Recommendations for the Management of Flexor Tenosynovitis in the RA Hand. In 2014, the physiotherapists and occupational therapists at the Mary Pack Arthritis Program met to discuss the treatment of flexor tenosynovitis in the hand with Rheumatoid Arthritis. We reviewed the modalities, exercise, splints and activity modification that we were using to treat this condition. We also discussed when to treat and how long to treat flexor tenosynovitis. 1 Brooks MA, Beaulieu JE, Severson HH, et al. Web-based therapeutic exercise resource center as a treatment for knee osteoarthritis: A prospective cohort pilot study. BMC Musculoskeltal Disorders. 2014 May 17;15:157. doi: 10.1186/1471-2474-15-158. 2 Von Korff M, Tiemens B. Individualized stepped care of chronic illness. Western Journal of Medicine. 2000;172:133-137. 5

After coming to a consensus about current practice, a working group of physical and occupational therapists searched the literature back to 2000, looking for evidence to support and enhance our practice. Over 50 articles were reviewed and many have been referenced in this document. Our best practice recommendations include information about: Description (diffuse and nodular forms) Classification (Amsterdam Severity Scale) Assessment Pain Inflammation Movement Special tests Differential diagnosis Treatment Heat Laser Ultrasound Cryotherapy Contrast baths Massage Exercise (for diffuse and nodular forms) Taping Splinting (MCP, PIP, thumb IP, hand) Compression Joint protection guidelines Other treatments Reference list It contains detailed descriptions and pictures of many assessment and treatment techniques, and where available, lists the evidence to support their use with clients who have flexor tenosynovitis. It is available on our website http://mpap.vch.ca/, listed under professional resources. Submitted by Cathy Busby OT 2016 Introduction to the Assessment & Management of Rheumatic Diseases: A Skills Workshop for PTs, OTs, and Nurses The next ACE course will take place in Vancouver from April 11 14, 2016. Registration deadline is March 11, 2016. This workshop is useful if you re new to the field of rheumatology or if it s been many years since you last took the workshop and are interested in getting a refresher. Workshop brochures are available at http://mpap.vch.ca/resources-for-professionals/becoming-an-ace-member 6

Screening for depression in people living with chronic disease The August 2014 issue of The Rheumatologist provided a wonderful overview of depression screening tools and the factors to consider when choosing one over another. The article notes that the rate of depression for people with chronic diseases is 2 3 times higher than the general population, and that people with 3 or more chronic diseases are 7 times more likely to be depressed. Thus, our clients with arthritis, and especially those with multi-morbidities, are prime candidates for depression. Depression can present with a range of symptoms including those that are cognitive (e.g., suicidal thoughts), physiological (e.g., fatigue or loss of energy), emotional (e.g., lack of affect, inability to feel joy or pleasure), and behavioural (e.g., social withdrawal or isolation). This can pose a problem when diagnosing depression in people with arthritis, as there can be overlap in the symptoms for each condition. For example, difficulty sleeping or irritability can be symptomatic of depression or related to living with chronic pain. A second factor to consider is the sensitivity and specificity of the test. Sensitivity is a measure of how likely it is for a test to pick up the presence of a disease in a person who has it. Specificity is the probability that the test says a person does not have the disease when in fact they are disease free. Sensitivity and specificity that are.8 are considered good. A test with a sensitivity of.8 will find 80% of patients who have the disorder being screened for. A specificity of.8 will rule out 80% of the patients who do not have the target condition. The table below compares key data for the most common depression screening instruments. Test Name Sensitivity Specificity Number of Questions Beck Depression Inventory BDI for Primary Care How Given Comments 0.86 0.82 21 Self-report Includes somatic symptoms that overlap with arthritis 0.92 0.61 7 Self-report HADS 0.84 0.50 7 - depression 7 - anxiety Self-report CES-D 0.93 0.62 20 Self-report Includes somatic symptoms that overlap with arthritis PHQ-9 0.88 0.88 9 Self-report Includes somatic symptoms that overlap with arthritis PHQ-2 0.83 0.92 2 Self-report PRIME-MD 0.96 0.57 2 Interview The U.S. Preventive Services Screening Task published the following recommendations related to screening for depression: 1. A variety of screening tools exists. 2. Using a 2-question tool that asks for depressed mood and loss of interest may be as effective as longer tools. 3. All positive screens should be referred for full diagnostic interviews. Severity of depression and other comorbid psychological problems should be addressed. 7

4. Clinical practices that screen for depression should have systems in place for appropriate treatment and follow-up. 5. Benefits are unlikely to occur as a result of screening without follow-up. 6. Treatment should include appropriate medication and/or psychotherapy. 7. The benefits of screening children and adolescents are unknown. Consider referring to the Mary Pack Arthritis Program (MPAP) social workers any arthritis patients who have screened positive for depression. Vancouver Island patients can contact Carol Ray at 250.519.4004. Arthritis patients elsewhere in BC can contact Greg Taylor at 604.875.4111 ext. 68812. MPAP Vancouver also has a psychiatrist that is available on the basis of a rheumatologist referral. The Western Canada Chapter of the Rheumatology Nurses Society is Born The number of nurses working in urban and rural rheumatology in BC and Yukon has grown to over 50 nurses in the last few years. This growth is in part due to an MSP billing code allowing B.C. Rheumatologists to hire nurses to work in their private practice clinics in 2011. In order to increase educational and networking opportunities for these nurses, especially those working in more rural clinics, and to establish Canadian guidelines for the scope and standards of practice for rheumatology nurses, a need was identified to develop a formalized rheumatology nursing group. After a review of local and national organizations, it was established that the Rheumatology Nurses Society (RNS), an American based professional rheumatology nursing community could support the nurses in BC. The RNS have developed the following: Scope and Standards of Practice for Rheumatology Nurses Rheumatology Nursing textbook written by nurses (Core Curriculum for Rheumatology Nursing) Website with a variety of nursing and other resources for improved of patient care through evidence based practice Shared framework for learning United voice from professional rheumatology nurses for health authorities, governments, our profession and the public Annual RNS conference, in existence for 8 years, highlights communication amongst professional nurses to share new trends in rheumatology affecting patient care and the role of the rheumatology nurse. The Western Canada Rheumatology Nurses Society is being established as a Not-for-Profit Corporation that has a dedicated mailing address, executive, budget, regular chapter meetings, and in the future, a webpage portal on the RNS website specifically for their members. This chapter looks forward to collaborating with AHPA, CRA, and all other allied health professionals dedicated to providing excellence and evidence based care to our patients. For more information about the Western Canada Rheumatology Nurses Society please contact westerncanadarns@gmail.com or a member of the executive team (Gwen Ellert, MEd, BScN, RN, President, Vancouver; Patricia Patrick, BA, BSN, RN, Vice President, Vancouver; Bonnie Leung, MN, NP, Secretary, Vancouver; Helen Eng, BA, BSN, RN, Treasurer, Nanaimo; Joel Shaw, BSN, RN, Program Chairperson, Penticton). To join go to www.rnsnurse.org. 8

Highlights from the ACR/ARHP 2015 Annual Meeting I was fortunate to attend the ACR/ARHP Annual Meeting earlier this month in San Francisco where I came away with these highlights: Coursera is a web-based platform that has provided 1,475 online courses to over 16 million learners. Coursera has partnered with 136 major universities around the world to offer free or low-cost courses on topics that range from Introduction to Project Management to Questionnaire Design for Social Surveys and Preventing Chronic Pain: A Human Systems Approach. Online content is engaging and interactive. Cultural humility is the idea that as health care professionals we need to engage in critical selfreflection, recognize & challenge power imbalances, and foster institutional accountability so as to prevent placing our own biases, ways of seeing the world and preconceptions on others. Cultural humility video here Gender differences in coping with RA. Women are more likely to use healthy coping strategies, whereas men are more likely to reject self-management interventions. Men tend to cope by getting on with it, staying as active as possible, hiding RA in public, or by seeking discreet help. Women have higher rates of depression, but men are more likely to commit suicide. And while men generally won t go to support/discussion groups, they will often go to information groups where they will share, if given the opportunity to do so. Are physical activity booster sessions effective, and if so, what types are most effective? Data were from a systematic review of 8 randomized controlled trials. Booster strategies varied from study to study and included telephone calls (automated or with health care provider), email messages, behavioural-based mailing, links to exercise resources, counselling, online tailored education, and a personalized website. In summary, while there was little evidence of the benefit of boosters it was felt that giving individuals a choice in the type of booster offered could be a key factor in determining effectiveness. Between 15% 40% of people with rheumatic disease have anxiety and/or depression and the cumulative risk of depression rises to 38% after 9 years. An anxiety disorder is more common in women, younger individuals, earlier in the diagnosis, and of lower income. Cognitive behavioural therapy often works well in treating anxiety disorders. Depression is more common in those of minority status, with less education, more comorbidities, higher disease activity, and more limitations in physical function. The PHQ-2 is a nice screening tool for depression. The Quantified Self movement incorporates computing applications, wearable sensors and wireless communication to quantify and track daily life inputs, health states, and mental and physical function. Current targets for biosensors include brain activity, sleep activity, chewing & swallowing, heart rate/blood pressure, respiratory rate, digestive activity, sweating, oxygenation, movement, and glucose monitoring. People are more likely to use wearable technology if they understand the rationale as to how this device may be of benefit. Other considerations are the device s practicality, such as its accuracy and acceptability. There are a large number of new therapeutics on the horizon for both rheumatoid arthritis and spondyloarthropathies. For RA, these include monoclonal antibodies to GMCSF (Mavrilimumab), subsequent-entry biologics (Infliximab in 2016, and Adalimumab and Rituximab in 2017), IL-6 blockers (Sarilumab and Sirukumab), JAK inhibition (Tofacitinib, Baracitinib, Decer- 9

notinib, Ast015k, and Filgotinib) and bi-specifics that target multiple areas. It is hoped that bispecifics will have a larger magnitude of response while being more cost-effective. An example is Covagen that targets TNF-alpha and IL-17. For spondyloarthropathies like psoriatic arthritis there are IL-17A blockers like Ixekizumbab and Secukinumbab. The future of these medications will depend on their effectiveness, safety profile, and economic considerations. How to make learning more effective Research has shown the benefits of several strategies for enhancing learning. Repeated retrieval or continually pulling learning from one s memory is more effective than re-studying. Spacing retrieval at longer intervals (e.g., 15 minutes) also increases the durability of learning. Finally, hand written note-taking is more effective than typed notes for enhancing memory. One strategy for improving understanding is to take a 15-minute break and to then summarize what you have learned. This aids meta-cognition, which is the awareness of whether one does or does not understand something. Constructivism maintains that individuals incorporate new information into their prior understanding of how something works and that a person will only change their ideas when they realize that the new information conflicts with what they previously thought they knew. Peer discussion has been shown to enhance understanding. Online Standardized Assessment of Joint Inflammation A reminder that the Standardized Assessment of Joint Inflammation training videos are online and freely available. This assessment approach is taught at the MPAP Introduction to the Assessment & Management of Rheumatic Diseases Skills Workshop. The online resource covers the following topics: Physical Assessment Purpose, Morning Stiffness, Grip Strength Active Joint Count: a) effusion, b) joint tenderness, and c) stress pain Recording the findings Joint Evaluation Techniques Complete evaluation, Temperal-mandibular, Sternal-clavicular, Acromial-clavicular, Shoulder, Elbow, Wrist, Thumb, Finger, Hip, Knee, Ankle, and Toe Other Bulge sign, References, and Webography The website can be found at http://arthritis.scholarlab.com/jointinflammation/english/ Articles of Interest Markusse IM, Dirven L, Han KH, et al. Continued participation in a ten-year tight control treat-to-target study in rheumatoid arthritis: Why keep patients doing their best? Arthritis Care & Research June 2015; 67(6): 739-745. The purpose of this study was to determine the predictors of early study participation termination and motives for adherence of participants in the BeSt (Dutch acronym for Treatment Strategies for Rheumatoid Arthritis) trial, a 10-year study investigating 4 treatment strategies in people with RA. The BeSt study protocol entailed quarterly visits during which a physical examination and lab tests were performed by a nurse, and annual radiographs and joint imaging with other techniques were obtained. Participants in the BeSt trial were randomized to one of four arms: sequential monotherapy; step-up combination therapy (both starting with 10

methotrexate monotherapy); initial combination with methotrexate, sulphasalazine, and prednisone; or initial combination with methotrexate and infliximab. All four arms adhered to a treat-to-target strategy, such that Disease Activity Score (DAS) assessments conducted during the quarterly visits were used to guide treatment adjustments. When disease activity was high (DAS >2.4), the next treatment step was taken. Low disease activity maintained for 6 months resulted in the medication being tapered to a maintenance dose, and with longstanding remission (DAS <1.6) the medication was discontinued. To identify predictors for early study termination, univariate and multivariate Cox regression analyses were performed using a wide range of variables for all 508 BeSt study participants. At the final visit, patients also filled in a questionnaire about their motivations for study participation. After 10 years, 307 of 508 participants were still under follow-up, and of these, 282 completed the motivations for study participation questionnaire. Six of the participants who dropped out of the BeSt study also agreed to complete this questionnaire for a final tally of 288 completed questionnaires. The multivariate Cox regression analysis showed that higher age, functional disability and having achieved drug-free remission were independent predictors for study discontinuation in the following year. The more adverse events a patient reported, the lower the risk of dropping out. Greater absolute radiographic joint damage and damage progression also lowered the risk of dropping out. The top 5 reasons for continued study participation were tight disease monitoring, contribution to scientific research, good treatment strategy, good medication, and favourable halfterm study results. Siu S, Haraoui B, Bissonnette R, Bessette L, et al. Meta-analysis of tumor necrosis factor inhibitors and glucocorticoids on bone density in rheumatoid arthritis and ankylosing spondylitis trials. Arthritis Care & Research June 2015; 67(6):754-764. This meta-analysis sought to examine the effects of antirheumatic drugs on bone loss at various sites (hand, lumbar spine, and hip) in rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), and psoriasis, based on evidence from randomized controlled trials (RCTs). The team searched Medline, Embase and the Cochrane Library for the years 1960 to May 2013, as well as abstracts presented between 2010 and 2012 at many of the major rheumatology and dermatology scientific meetings. Studies meeting the criteria were analyzed in groups based on disease type, treatment, and site where bone mineral density (BMD) was measured. The outcome of interest was change in BMD from baseline to end of study ( BMD) and change of 3% in BMD was considered relevant based on previous literature from osteoporosis trials. Thirteen studies met the search criteria, of which 11 involved patients with RA (5 studies involved tumor necrosis factor inhibitors [TNFi], 7 studies involved use of glucocorticoids, and 1 study used both TNFi and glucocorticoids and hence was included in both meta-analyses) and 2 studies were with AS patients using TNFi. No studies involving patients with PsA or psoriasis were found. Use of TNFi was associated with less hand bone loss compared with control treatment. No significant differences were seen between TNFi and control groups at the lumbar spine or hip. In the AS studies, use of TNFi was associated with increased BMD at both the lumbar spine and hip. Use of glucocorticoids was associated with less hand bone loss than control treatment. Conversely, use of glucocorticoids was associated with greater decreases in BMD at the lumbar spine than control treatment. No significant differences were seen in hip BMD between the groups treated with glucocorticoids and controls. French SD, Bennell KL, Nicolson PJA, et al. What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis. Arthritis Care & Research June 2015; 67(6):809-816. The aim of this study was to identify the important information a patient needs to know about the disease, its causes, its diagnosis and its management in plain language and ranked in order of importance. The study comprised 4 stages: 11

1) Identification of relevant messages from published clinical practice guideline evidence-based clinical practice guidelines published since 2008 for the management of hip and/or knee osteoarthritis were identified via a PubMed search. Key messages were extracted from 12 clinical practice guidelines and similar statements with overlapping content were reviewed by the investigators and merged into a single statement. 2) Delphi study to identify essential messages a Delphi panel was formed and 85 osteoarthritis experts from a range of backgrounds and countries were invited to participate, as well as English-speaking consumers with hip and/or knee osteoarthritis from Melbourne, Australia. Questionnaires were completed online and the Delphi process comprised 3 rounds. Consensus was defined as being achieved when 70% of panel members agreed on the importance of including a particular statement. 3) Consumer consultation process to ensure essential messages were conveyed in plain language a focus group with a sub-group of 5 consumer panel members reviewed each statement to ensure that the content of the messages were clear and understandable to consumers, and that the final message was consistent with its original intent. 4) Pairwise ranking activity to prioritize essential messages in order of importance an online decision survey was completed by the expert and consumer panel members using 1000Minds software. Panel members were asked to rank pairwise statements by determining which of two randomly selected messages was considered most important for consumers with hip and/or knee osteoarthritis. Of the 85 invited international OA experts, 51 agreed to join the panel and 43 completed all 3 rounds of the Stage 2 Delphi panel process. Of the 15 invited OA consumers, 9 agreed to join the panel and 8 completed all 3 rounds of the Stage 2 Delphi panel process. All panel members who completed the full Stage 2 Delphi process also completed the Stage 4 ranking process. An initial list of 83 statements was created at Stage 1. In round 1 of Stage 2, there was consensus that 59 of 83 statements were important, and a further 31 additional statements were suggested by panel members. In round 2, there was consensus that 57 of 90 statements were important. And in round 3, 21 of the 57 statements were considered essential by at least 70% of panel members. The 21 essential statements have been detailed in a piece earlier in the newsletter entitled, Important Information a Patient with Osteoarthritis Needs to Know. Westby MD, Klemm A, Li LC, Jones CA. Emerging role of quality indicators in physical therapist practice and health service delivery. Physical Therapy, 2015 June 18. ISSN: 1538-6724. The aims of this perspective article were to introduce the value of quality indicators (QIs) to guide clinical practice and health service delivery; to outline a framework to develop, select, implement, measure, and report QIs; and to describe the application of this framework in the development of QIs for total joint arthroplasty (TJA) rehabilitation. QIs are specific and measurable, and define the minimum standard of care patients can expect to receive for a given health condition. QIs typically address 1 or more of the 6 quality domains identified by the Institute of Medicine: safety, timeliness, effectiveness, efficiency, equity and patient centeredness. QIs have been developed and validated for the pharmacological and nonpharmacological management of osteoarthritis (OA), rheumatoid arthritis, gout, osteoporosis, and surgical and medical processes of care for hip and knee TJA. Clinicians, patients and their family members, managers, decision makers, and policy makers can all benefit from the use QIs. For clinicians, QIs can be used to guide clinical decision making, implement guideline recommendations, evaluate treatment effectiveness, and report achievement of benchmarks to key stakeholders. 12

The main steps in QI development and implementation include defining the target audience, determining the clinical area to evaluate, identifying existing or developing new QIs, assessing new or existing QIs, and collecting and reporting QI data. When defining the target it s important to consider not only who will most benefit from the data, but also how that data is to be used (e.g., clinical decision making, quality improvement, benchmarking, etc.). Two important considerations when determining the clinical area to evaluate are importance (e.g., high volume, practice and outcome variations, costs, etc.) and having the opportunity for intervention. As QI development is time-consuming and expensive, the easiest approach is to identify and select pre-existing QIs that are relevant to one s practice in terms of the type of healthcare provided (e.g., primary care, prevention), practice setting (acute care, outpatient care), and patient demographics (e.g., age, diagnosis). There are several QI repositories including but not limited to the Agency for Healthcare Research and Quality, Centers for Medicare & Medicaid, National Quality Measures Clearinghouse, National Quality Forum, Canadian Institute for Health Information, Canadian Foundation for Healthcare Improvement, and the European Musculoskeletal Conditions Surveillance and Information Network. A QI is often accompanied by information specifying appropriate data collection tools, a scoring process and acceptable performance level. In Canada, an option for physiotherapists wanting to collect, report and receive feedback patient outcome measure data is to participate in the Focus On Therapeutic Outcomes system (www.- fotoinc.com) launched in April 2015 by the Canadian Physiotherapy Association. When electronic data are not readily available, QI data can be collected by chart audit, or clinician or patient surveys. Ideally, QI data collection becomes part of routine care through the standardization of clinical documentation or by embedding of QIs in electronic health records or other digital applications. The authors developed QIs for TJA rehabilitation by using a combination of QI sets and practice guidelines for OA care, systematic reviews, and rapid reviews of the literature to create QI statements. These statements were reviewed by an 18-member expert panel of clinicians, researchers, methodologists and patients for importance and validity. Statements deemed to be important and scientifically sound were then converted into a clinician-friendly checklist that can be used during encounters with patients. Look for a summary of these TJA indicators in a future edition of the ACE Clinical Link. Fary RE, Slater H, Chua J, Ranelli S, et al. Policy-into-practice for rheumatoid arthritis: Randomized controlled trial and cohort study of e-learning targeting improved physiotherapy management. Arthritis Care & Research July 2015; 67(7):913-922. The purpose of this study was to evaluate the effectiveness of the RAP-eL resource in increasing self-reported confidence and knowledge of Australian PTs in managing people with RA and to evaluate the retention of that confidence and knowledge over the short-term. This single-blind randomized controlled trial used a waitlist control design such that the participants in the intervention group received immediate access to RAP-eL while the waitlist group waited a period of 5 weeks. All participants were followed for a period of 8 weeks after their respective 4-week access to RAP-eL. The study evaluated physiotherapists selfreported knowledge and clinical skills in managing people with RA, satisfaction with ability to manage people with RA, knowledge of red flags and critical management issues, and practice behaviours assessed through clinical vignettes. The satisfaction and clinical vignette questions were sourced from the Arthritis Community Research and Evaluation Unit (ACREU) Primary Care Survey that was developed to evaluate how primary care physicians manage their patients with RA. One hundred and fifty-nine PTs participated in the study with 79 allocated to the waitlist control group and 80 to the intervention group. In the waitlist control group 48 provided baseline data and 43 provided follow-up data while in the intervention group 56 provided baseline data and 43 provided follow-up data. Significant between-group differences were observed at the end of the 4-week RCT with the intervention group having significantly greater levels of confidence in knowledge, confidence in skills, and satisfaction in ability to manage people with RA than the control group. Satisfaction with the RAP-eL web- 13

site was also high with 70/77 participants who answered this question rating the website as 8 out of 10. Eightweek scores showed a decline in most outcomes, but generally remained higher than at baseline. The authors suggested that this decline in outcomes over a 4-week period pointed to the need for the reinforcement of learning. They also noted that web-based learning likely cannot replace clinical skills education that requires doing rather than just thinking about doing. More detailed information about the modules and the development process are outlined in a piece earlier in the newsletter entitled, Rheumatoid Arthritis for PhysiotherapistseLearning (RAP-eL). Sota I, Drossaert CHC, Taal E et al. Patients considerations in the decision-making process of initiating disease-modifying antirheumatic drugs. Arthritis Care & Research July 2015; 67(7):956-964. The aim of this qualitative study was to deepen the understanding of patients considerations when deciding about disease-modifying anti-rheumatic drugs (DMARDs) and the kinds of information that patients need to participate in the decision-making process. The study recruited Dutch-speaking patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis who had discussed starting a DMARD with their rheumatologist in the previous month. Face-to-face interviews 45 120 minutes in duration were conducted with each participant. A semistructured interview technique was used to ask participants about their considerations, questions, concerns, and information needs when deciding about DMARDs. Interviews were taped and transcribed verbatim. Constant comparison was used in the data analysis, in conjunction with a sequential process of open coding, axial coding and selective coding. Two analysts compared and analyzed individual findings until consensus was reached. Twenty-six women and 6 men participated in the study. Of these, 5 discussed starting a DMARD for the first time while the remainder had already used a synthetic or biologic DMARD and therefore addressed considerations in changing DMARDs. Three primary considerations were identified in favour of, and 2 against initiating DMARD therapy. Necessity was one of the considerations in starting DMARDs and was related to relief of symptoms and/or prevention of joint damage. Trust in the physician or health care system was the second consideration, and in some cases was irrespective of necessity. Relative benefits were the third consideration and included factors such as lower risk of side effects compared to other drugs and/or less frequent and friendlier drug administration compared to other drugs. Concerns with medications were the most common consideration against initiating DMARD therapy. Specifically, this included concerns about the aggressive and harmful nature of medicine, risks for side effects, influence on fertility and pregnancy, combination with other medicines, time to benefit, manner of drug administration, and future treatment. The second consideration against taking DMARDs was the emotional impact it had on some people. Some equated DMARD use with having to accept the seriousness of their condition, whether in terms of the amount and number of drugs taken or the perceived potency of the drugs. Some participants stated they had received sufficient information. Those who didn t identified various types of information that would have helped to inform their decision including detailing proposed options, a clear explanation of differences between options, information about how DMARDs may impact daily life, and help with resolving confusion caused by getting contradictory information from different sources. Sharma L, Chmiel JS, Almagor O et al. Knee instability and basic and advanced function decline in knee osteoarthritis. Arthritis Care & Research August 2015;67(8):1095-1102. Knee instability in relation to osteoarthritis (OA) includes a range of symptoms and phenomena, such as a feeling of lower overall confidence in the knees, low confidence that the knees will not buckle, actual buckling, and excessive frontal plane motion. The purpose of this study was to determine if buckling contributes to or is a result of poor function. Community participants were recruited by targeting older people and neighbourhood organizations. Participants were also recruited from a health centre database and local medical centres. Inclusion criteria included definite osteophyte presence (Kellgren/Lawrence [K/L] radiographic grade 2) in one or both knees and functioning at the level of 14

at least a little difficulty for 2 or more items on the WOMAC physical function scale. Knee confidence was assessed using the Knee Injury and OA Outcome Score (KOOS) quality of life subscale question, How much are you troubled with lack of confidence in your knees? Buckling confidence was assessed separately for each knee using the question How confident are you that your knee will not buckle or give way? Buckling was determined by asking has your knee buckled or given way at least once in the past 3 months (yes or no)? Frontal plane knee instability was assessed using an 8-camera Eagle Digital Real-Time motion measurement system and OrthoTrak gait analysis software. Physical function was measured at baseline and 2 years later using both the LLFDI Basic and Advanced Lower Extremity Domain scaled score. Of 250 participants, 212 completed the 2-year followup evaluation. Buckling was significantly associated with poor advanced function outcome but not basic function outcome. Overall knee confidence was significantly associated with advanced function outcome. Neither varus-valgus excursion nor angular velocity during gait was associated with basic or advanced function outcome. The authors concluded that addressing knee buckling and confidence through neuromuscular training during task performance, taping, or bracing, as well as using reinforcement and other social cognitive psychology approaches could improve outcomes in people with OA. Scheibe MM, Imboden JB, Schmajuk G et al. Efficiency gains for rheumatology consultation using a novel electronic referral system in a safety-net health setting. Arthritis Care & Research August 2015;67(8): 1158-1163. Preconsultation exchange is a process of communication between primary care and specialty care physicians so as to maximize the efficiency of specialty visits both by answering clinical questions that may not require a formal patient visit and by streamlining the prespecialty visit workup. Health information technology has the potential to facilitate the primary-specialty care information exchange. The aim of this study was to evaluate the use and impact of a novel electronic referral (ereferral) system in rheumatology. San Francisco General Hospital has an ereferral system to facilitate 2-way communication between referring and speciality providers for new patient referrals. Each referral has the relevant patient demographic information and reason for referral, as well as relevant history, physical examination findings, laboratory results, and other data. The specialist reviewer evaluates the data received and determines the outcome of the referral using iterative communication with the referring physician. All communication via ereferral is captured in real time and recorded within the electronic medical record. The average time for a rheumatologist reviewer to complete an ereferral is 8 minutes/referral. There were several outcomes that could result from the review. At the discretion of the reviewing specialist the patient may be scheduled directly into the rheumatology clinic on a routine, expedited or urgent basis. In other instances the consult referral may be determined to be inappropriate for rheumatology, additional information may be requested from the referral source, or the clinical question posed through the ereferral may be answered without the need for a scheduled patient visit. The latter 3 outcomes are considered a preconsultation exchange. The study population was comprised of all rheumatology ereferrals between January 1, 2008 and May 31, 2012. Excluded from the study were referrals made by a rheumatologist, duplicate referrals, and referrals for DEXA scans. The study population included 2,383 ereferrals, of which 2,105 met the inclusion criteria. A majority of ereferrals underwent preconsultation exchange, increasing from 55% in the second half of 2008 to 74% in the second half of 2011. Of the ereferrals that went through consultation, 63% were subsequently scheduled for a face-to-face appointment. Overall, approximately 25% of all ereferrals were not scheduled as they were not deemed to need an appointment. Wait times were stable at 70 80 days despite the fact that patient volume increased during the latter half of the study. Hendry GJ, Brenton-Rule A, Barr G, Rome K. Footwear experiences of people with chronic musculoskeletal diseases. Arthritis Care & Research August 2015;67(8):1164-1172. The purpose of this study was to explore, identify, and describe the main issues surrounding the footwear experiences of people with chronic muscu- 15