Current Rheumatology Reviews - Volume 9, Issue 3, 2013

Osteoarthritis (OA) is a prevalent condition and the leading cause of disability in the world. Bone marrow lesions (BMLs) are a relatively new phenomenon and their association with OA is not well understood. A systematic review was undertaken of published and unpublished or grey literature databases from their inception until 1st August 2012. Specific data in relation to BMLs was extracted from each study and each study underwent independent critical appraisal using the CASP appraisal tool. Thirty two studies were deemed eligible for review, identified from a total of 148 citations. These included a total of 8623 participants. The studies presented moderate to strong methodological quality although many did not identify confounding factors or failed to account for them in study design. Overall BML prevalence was found to be 55% of people with OA, with a variable natural course. BML prevalence was more common in the medial knee compartment and was highly predictive of cartilage loss and positively associated with progression to total knee replacement. There was however no consensus on whether BMLs effected pain and function. Presence of large BMLs was associated with meniscal injury and severity of arthritic changes. To conclude, BML research is an emerging field. Standardised methods of radiological quantitative and qualitative BML assessment are necessary to allow study comparison and homogenisation.

Objectives: To identify whether cognitive behavioural therapy (CBT) is effective in the management of osteoarthritis (OA). Methods: A mixed meta-analysis and narrative review of the literature was conducted. Three hundred and eighty five studies were identified by literature search, five of which were included for review. The included studies were randomised controlled trials (RCT) that compared CBT to conventional therapy. Results: On analysis, meta-analysis of the primary outcome, pain, revealed a statistically significant improvement in symptoms (p<0.05) between those who received CBT versus conventional management. Narrative review revealed varying results from no change in pain to significant improvements. A meta-analysis was also performed to assess ‘other symptoms’. This demonstrated no significant difference between the groups (p>0.05). Narrative review of patient function revealed a trend of no clinical benefit (p>0.05). Anxiety and depression scores were more positive for those who received CBT compared to conventional therapy, with significant improvement seen in the short-term (p<0.05). Conclusions: The role of CBT in the management of OA remains equivocal. Some encouraging results were seen with regard to pain, anxiety and depression. We believe further high quality RCTs are necessary to adequately answer the study question.

Osteoarthritis is one of the most common chronic, disabling diseases, which typically causes pain, stiffness and functional impairment. Self-management programmes have been advocated in clinical guidelines aimed at reducing the effect of symptoms and illness from impacting on lifestyle and activities. This study assesses the evidence-base examining the clinical and cost-effectiveness of self-management programmes for adults with osteoarthritis. An electronic search was conducted on 6th June 2013 of the published literature including the databases: AMED, CINAHL, MEDLINE, EMBASE, PubMed and the Cochrane Library. This was supplemented with a search of unpublished databases and trial registries. All randomised and quasi-randomised controlled trials comparing the clinical and/or cost-effectiveness of people with osteoarthritis randomised to self-management programmes or control group were included. Methodological quality was assessed using the PEDro appraisal tool. Meta-analyses were conducted when minimal methodological study heterogeneity was exhibited. A total of nine studies were identified, including 2237 participants. The results indicated self-management interventions provided no statistically significant benefit in respect to pain, function, perceived quality of life, depression or satisfaction during the first twelve months compared to not receiving this intervention (p>0.05). Whilst there was some evidence to suggest that self-management intervention may improve participant’s knowledge of their condition, this appeared to have no significant impact on their use of analgesics or the frequency to which they consulted community physicians or physiotherapists (p>0.05). The evidence assessing the effectiveness of self-management programmes for people with osteoarthritis is equivocal. Evaluation of the different components of a self-management intervention, and investigation on how best this should be delivered for long-term adherence is required to systematically assess the clinical effectiveness of self-management programmes for different patient-groups with osteoarthritis.

Activity pacing is commonly provided by occupational therapists, physiotherapists and other healthcare professionals. Pacing education encourages people to intersperse activity with rest periods in order to alter inefficient activity patterns. The purpose of this study was to examine the literature assessing the clinical outcomes of activity pacing with people diagnosed with osteoarthritis (OA). The electronic databases AMED, CINAHL, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Biomed Central, unpublished literature databases and trial registries, were searched to 1st June 2013. All studies assessing the clinical outcomes of activity pacing or modifying/change programmes for people with OA were included. The methodological quality of the studies was assessed using the PEDro critical appraisal tool. A total of 164 citations were reviewed, identifying three papers, reporting clinical outcomes from one trial in total. Thirty-two participants were reviewed with hip and knee OA. The evidence-base, whilst based on small, underpowered cohorts, provided moderate rigour based on the PEDro appraisal findings. The results indicated that activity pacing can reduce joint stiffness, fatigue and potentially pain in those with hip and knee OA. This appears more effective tailored to an individual. Whilst the current evidence suggests that activity pacing may have value for people with hip and knee OA, there is a major paucity of literature assessing the efficacy or effectiveness of activity pacing for people with OA. Further study is required to assess the clinical outcomes of activity pacing for those with OA affecting different joints, within a variety of different populations.

Osteoarthritis is the most prevalent musculoskeletal disorder, affecting millions of people worldwide. There has been limited consensus on the use of magnets for this condition. This study specifically assessed the evidence pertaining to the use of static magnets to manage symptoms in people with osteoarthritis. A systematic review of the published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and the Cochrane Library) and unpublished literature (WHO International Clinical Trials Registry Platform, Current Controlled Trials and the United States National Institute of Health Trials Registry, Open Grey) was undertaken to July 2013. All studies assessing the clinical effects of static magnets as a therapeutic intervention for adults with osteoarthritis were included. Methodological quality was assessed using the PEDro appraisal tool. When appropriate, meta-analysis was conducted to pool data. From a total of 301 citations, six studies met the eligibility criteria. These included 374 participants, 220 allocated to a magnet group, 154 to a placebo control. The findings indicated that magnets did not significantly reduce pain or medicine requirement nor enhanced function, joint proprioception or muscle strength compared to placebo (p>0.05). There was limited evidence that higher strength magnets may have a greater effect on pain than lower field strength magnets. However, the quality of the current evidence-base was limited and underpowered. The longer-term outcomes of magnet use and limited control of field strength within the current literature suggests that further, adequately sample-sized, randomised controlled trials to assess dose-response are initially required to begin to rigorously assess the efficacy of this intervention with people with osteoarthritis.

Leprosy is special not only because of its historical and biblical context and the fear it generates but because it is confined to man. As a chronic infect contagious disease, leprosy is recognized by a slow progress, high infectivity, and low pathogenicity. The development depends on multifactorial aspects, as genetical and immunological features. The epidemiology in developing countries has shown that the detection rate was still not decreased, although its prevalence has been diminished. Acute arthritis can appear and usually occurs as part of lepra reactions (types I and II), whereas chronic arthritis may result from direct infiltration of the synovia by lepra bacilli. Hansen’s disease must be included in the differential diagnosis of acute onset polyarthritis, mainly in countries where leprosy are not eradicated. In undifferentiated arthritis, anti-CCP and rheumatoid factor tests can be useful in distinguishing patients with leprosy-induced arthritis from patients with rheumatoid arthritis. The pro-inflammatory cytokine TNF-α is relevant to anti-mycobacterial immunity and plays an important role in granuloma formation. There are few published cases of leprosy in patients in use of anti-TNFα, but it is probable that this number increase and rheumatologists must be able to make the differential diagnosis.

The use of biologic drugs for treating inflammatory joint diseases was approved at the end of last century. Several cases of active lung and extra-pulmonary tuberculosis (TB) were reported at the beginning, and led to creating mandatory screening for latent tuberculosis infection (LTBI) before initiating the treatment with them. The purified protein derivative (PPD) test is the test of choice for diagnosing LTBI, but it has limited sensitivity and specificity, especially in the tropical area. Furthermore, patients with autoimmune diseases have a low frequency of positive skin test compared to patients who do not. Therefore, tests using Interferon Gamma Release Assays (IGRAs) have been carried out with a view to their use in assisting to diagnose LTBI. This chapter places tuberculosis and latent tuberculosis infection (LTBI) in a world context; recounts the origins of the two main tests for detecting LTBI and ant-TNF; evaluates their effectiveness as seen today bearing in mind the incidence of active TB in any given country; and makes proposals for their optimum use including when IGRAs might be used most appropriately.

Almost 200 species fungus are associated with human infections have been described. The musculoskeletal involvement can develop by direct extension of a lesion or by inoculation and hematogenous spread. The joint infection has an indolent course and diagnosis tends to be delayed because of the paucity of clinical signs and the rarity of the pathology. Despite the small number of fungal species involved, the incidence of diseases they can provoke has increased over the last 40 years particularly in hospital environments which has resulted in individuals having their immunologic system compromised. There is no special prevalence for gender or age. A review of the joint involvement in such conditions is described on this chapter.

Intestinal parasites infections caused by a variety of worms are very common in low-income people without access to sewage and treated water. Contamination occurs in various forms and the main one is the intake of contaminated food or water and through the skin by small wounds. The host response will be different according to the place of parasite replication: intra or extracellular. Usually the musculoskeletal symptom develops within a period of a few days after the intestinal infection. And the clinical manifestations are more likely similar to those seems in Spondiloarthropathies. It is more frequent in children and adolescent, and a slight prevalence for female. Many parasites are able to bypass the host’s immune system, and parasitic disease is the prototype of chronic infection in humans. Persistent parasites have the capacity to release large quantities of antigens, inducing a variety of immunologic reactions.

Medications, through their mechanisms of action, can help elucidate the pathogenesis of SLE. Unfortunately, most medications used to treat SLE have multiple mechanisms of action or are not highly specific. Nevertheless, some understanding of SLE's pathogenesis can be derived from the medications used to treat it. Agents inhibiting B and T cells globally such as leflunomide, mycophenolate mofetil, cyclophosphamide and azathioprine show that a global effect is generally effective. While limited by issues of unclear outcome measures and difficulty in study design, the usefulness of agents principally inhibiting B-cells thru CD19/20/22, such as rituximab and belimumab, indicate that B-cell abnormalities are important in SLE. Agents blocking B and T-cell co-stimulation such as abatacept and atacicept indicate modest but real effects, supporting this mechanism as of some importance in SLE Agents principally inhibiting T cells such as cyclosporine and tacrolimus also seem to have some efficacy, indicating that the calcineurin pathway is active in SLE. Transplant based therapies and re-establishing tolerance are of interest but and are effective but their effect seems to be transient, attesting to the highly reactive nature of the immune system in SLE. Finally, other investigational approaches such as inhibiting the IL-6 pathway (tocilizumab) or IFN pathway are being tested but results are too preliminary to make statements regarding the importance of these pathways, or treatments, in SLE.