Background: Clinically suspect arthralgia (CSA) is characterised by arthralgia of small joints and considered a risk stage for development of rheumatoid arthritis (RA). However, it remains unknown... Show moreBackground: Clinically suspect arthralgia (CSA) is characterised by arthralgia of small joints and considered a risk stage for development of rheumatoid arthritis (RA). However, it remains unknown if the function of the hands is already affected and what mechanisms underlie impaired hand-function in CSA.Methods: We studied various measures of hand function in two CSA populations. CSA patients in the TREAT EARLIER-trial (n=236) were evaluated at baseline for: grip strength on a dynamometer (GS), patient-reported difficulties in the grip domain of the Health Assessment Questionnaire (HAQ) questionnaire and incomplete fist closure at physical examination. Findings were validated in an independent CSA cohort (n=600) where hand function was measured as: GS evaluated by squeezing the examiner's fingers, grip domain of the HAQ questionnaire and fist closure. Contrast-enhanced MRI of the hands measured synovitis, tenosynovitis and bone marrow oedema (summed as subclinical inflammation) in both cohorts. Results: GS (on a dynamometer) was reduced in 75% compared with reference values in healthy controls, 60% reported grip difficulties and 13% had incomplete fist closure. Reduced GS was associated with subclinical inflammation (-0.38 kg/point inflammation, 95% CI -0.68 to -0.08). Studying separate MRI features, GS reduction was independently associated with tenosynovitis, decreasing with -2.63 kg (95% CI -2.26 to -0.33)/point tenosynovitis (range observed tenosynovitis scores: 0-20). Similar relations with tenosynovitis were seen for patient-reported grip difficulties (OR 1.12/point, 95% CI 1.07 to 1.42) and incomplete fist closure (OR 1.36/point, 95% CI 1.03 to 1.79). In the validation cohort, 36% had decreased examiner-assessed GS, 51% reported grip difficulties and 14% incomplete fist closure: all were associated with tenosynovitis. Decreased dynamometer-measured GS was most sensitive for detecting tenosynovitis (75%), while incomplete fist closure was most specific (88%-90%). Conclusion: Hand function is already often affected before RA development. These limitations are related to subclinical inflammation and tenosynovitis in particular. Show less
Objectives: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic... Show moreObjectives: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA. Methods: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested. Results: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good. Conclusion: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets. Show less
Wouters, F.; Giesen, F.J. van der; Matthijssen, X.M.E.; Niemantsverdriet, E.; Helm-van Mil, A.H.M. van der 2019
Objective. To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc; scleroderma). Methods. We performed a... Show moreObjective. To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc; scleroderma). Methods. We performed a randomized controlled trial comparing a 12-week multidisciplinary team care program (1 day per week; individual treatments, group exercises, and group education) with outpatient clinic care. Outcome measures included the Hand Mobility in Scleroderma (HAMIS) test, grip strength, maximal mouth opening (MMO), 6-minute walk distance (6MWD), maximum aerobic capacity (Vo(2max)), Checklist Individual Strength 20 (CIS-20), SSc Health Assessment Questionnaire (HAQ), and Short Form 36 (SF-36), assessed at 0, 12, and 24 weeks. Statistical comparisons of change scores were done by analysis of covariance. Results. Twenty-eight patients were assigned to the intervention group (mean age 53.9 years, 15 of 28 with diffuse SSc) and 25 were assigned to the control group (mean age 51.7 years, 15 of 25 with diffuse SSc). Twenty-five patients (89%) in the intervention group completed the treatment program. At 12 weeks, there was a significantly greater improvement in grip strength (2.2 versus -1.8 kg; P = 0.001), MMO (1.4 versus -0.9 mm; P = 0.011), 6MWD (42.8 versus 3.9 meters; P = 0.021), and HAQ score (-0.18 versus 0.13; P = 0.025) in the intervention group, whereas differences for the other outcome measures did not reach significance. At 24 weeks, the effect on grip strength persisted. Conclusion. In patients with SSc, a 12-week multidisciplinary day patient treatment program was more effective than regular outpatient care with respect to 6MWD, grip strength, MMO, and HAQ score, but not for Vo(2max), HAMIS test, CIS-20, SF-36, and visual analog scale for pain. This study provides a first step in quantifying the effect of a multidisciplinary team care program and warrants the conduct of further intervention studies. Show less
Hurkmans, E.J.; Giesen, F.J. van der; Bloo, H.; Boonman, D.C.G.; Esch, M. van der; Fluit, M.; ... ; Vlieland, T.P.M.V. 2011
Background: To improve the quality of the physiotherapy management in patients with rheumatoid arthritis (RA) a Dutch practice guideline, based on current scientific evidence and best practice, was... Show moreBackground: To improve the quality of the physiotherapy management in patients with rheumatoid arthritis (RA) a Dutch practice guideline, based on current scientific evidence and best practice, was developed. This guideline comprised all elements of a structured approach (assessment, treatment and evaluation) and was based on the International Classification of Functioning, disability and Health (ICF) and the ICF core sets for RA. Methods: A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 10 experts from different professional backgrounds resulting in the final guideline. Results: In total 7 topics were selected. For the initial assessment, three recommendations were made. Based on the ICF core sets for RA a list of health problems relevant for the physiotherapist was made and completed with red flags and points of attention. Concerning treatment, three recommendations were formulated; both exercise therapy and education on physiotherapy were recommended, whereas passive interventions (delivery of heat or cold, mechanical, electric and electromagnetic energy, massage, passive mobilization/manipulation and balneotherapy) were neither recommended nor discouraged. For treatment evaluation at the level of activities and participation, the Health Assessment Questionnaire was recommended. For evaluating specific body structures and functions the handheld dynamometer, 6-minute walk test or Astrand bicycle test (including Borg-scale for rating the perceived exertion), Escola Paulista de Medicina Range of Motion Scale and a Visual Analog Scale for pain and morning stiffness were recommended. Conclusion: This physiotherapy practice guideline for RA included seven recommendations on the initial assessment, treatment and evaluation, which were all based on the ICF and the ICF Core Set for RA. The implementation of the guideline in clinical practice needs further evaluation. Show less
Schouffoer, A.A.; Ninaber, M.K.; Beaart-van de Voorde, L.J.J.; Giesen, F.J. van der; Jong, Z. de; Stolk, J.; ... ; Vlieland, T.P.M.V. 2011
OBJECTIVE: To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc). METHODS: A randomized controlled trial... Show moreOBJECTIVE: To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc). METHODS: A randomized controlled trial comparing a 12-week multidisciplinary team care program (1 day per week; individual treatments, group-exercises and group-education) with outpatient clinic care. Outcome measures included the HAMIS (Hand Mobility in SSc), grip-strength, maximal mouth-opening (MMO), 6-minute-walk-distance (6MWD), maximum aerobic-capacity (VO2(max) ), CIS-20 (Checklist Individual Strength), SSc-HAQ (Health Assessment Questionnaire) and SF-36 (0, 12 and 24 weeks). Statistical comparisons of change scores were done by analysis of covariance. RESULTS: Twenty-eight patients were assigned to the intervention group (mean age 54.6 years, 15/28 diffuse SSc) and 25 to the control group (mean age 52.2 years, 15/25 diffuse SSc). Twenty-five (89%) patients in the intervention group completed the treatment program. At 12 weeks there was a significantly greater improvement in grip-strength (2.2 versus -1.8 kg; p=0.001), MMO (1.4 versus -0.9 mm; p=0.000), 6MWD (42.8 versus 3.9 meter; p=0.015) and HAQ (-0.18 versus 0.13; p=0.003) in the intervention group, whereas differences for the other outcome measures didn't reach significance. At 24 weeks the effect on MMO persisted. CONCLUSION: In patients with SSc a 12-week multidisciplinary day patient treatment program was more effective than regular outpatient care with respect to 6MWD, grip-strength, MMO and HAQ, but not for VO2(max) , HAMIS, CIS-20, SF-36 and VAS pain. This study provides a first step in quantifying the effect of a multidisciplinary team care program and warrants the conduct of further intervention studies. Show less
Giesen, F.J. van der; Lankveld, W. van; Hopman-Rock, M.; Jong, Z. de; Munneke, M.; Hazes, J.M.W.; ... ; Vlieland, T.P.M.V. 2010
Objective. To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA). Methods. In 4 regions in The Netherlands, the Rheumatoid Arthritis... Show moreObjective. To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA). Methods. In 4 regions in The Netherlands, the Rheumatoid Arthritis Patients In Training exercise program was implemented on a limited scale. Evaluation using the RE-AIM model included: Reach, the proportion of the target population participating; Efficacy, effects on muscle strength, aerobic capacity, functional ability, and psychological functioning; Adoption, program adoption by stakeholders; Implementation, intervention quality (quality audits); and Maintenance, stakeholders' willingness to continue the program in the future. Results. Twenty-five physical therapists from 14 practices were trained to provide the program. In total, 150 RA patients were recruited (by estimation, 2% of the target population). Of the 81 patients who had finished the 12-month intervention and were available for followup directly after the intervention, 62 patients provided clinical data. Muscle strength improved significantly, whereas aerobic capacity, functional ability, psychological functioning, and disease activity did not change. All 9 informed local patient organizations facilitated patient recruitment, and 35 of 51 rheumatologists involved referred one or more patients. All 10 approached health insurance companies funded the program for 12 months. The quality audits showed sufficient quality in 9 of 12 practices. All of the providers of the program were willing to provide the program in the future, whereas future reimbursement by health insurance companies remained unclear. Conclusion. The implementation of an intensive exercise program for RA patients on a limited scale can be considered successful regarding its reach, adoption, and implementation. The limited effectiveness and the limited data regarding maintenance warrant additional research. Show less
Musculoskeletal diseases affect many people in European communities, with rheumatoid arthritis (RA) and osteoarthritis (OA) being the most common conditions. In general, the impact of... Show moreMusculoskeletal diseases affect many people in European communities, with rheumatoid arthritis (RA) and osteoarthritis (OA) being the most common conditions. In general, the impact of musculoskeletal diseases on individuals__ lives including physical functioning is substantial, despite the growing number of effective drugs for specific rheumatic conditions. This thesis describes interventions aiming to reduce disability, with the example of interventions targeted on hand function disability as well as their evaluation, and the implementation of evidence-based interventions in daily practice, with the example of physical activity and exercise interventions for patients with RA. Show less
