Alessandro Lo Nigro

Rehabilitation Treatment in Patients with Ankylosing Spondylitis Stabilized with Tumor Necrosis Factor Inhibitor Therapy. A Randomized Controlled Trial

Objective. To assess the 2- (T1) and 6-month (T2) followup effects on pain, spine mobility, physical function, and disability outcome of a rehabilitation intervention in patients with ankylosing spondylitis (AS) stabilized with tumor necrosis factor (TNF) inhibitor therapy. Methods. Sixty-two outpatients (49 men, 13 women, mean age 47.5 ± 10.6 yrs) were randomized to rehabilitation plus an educational-behavioral (n = 20) program, to an educational-behavioral program only (n = 20), or to a control group (n = 22). The educational-behavioral program included 2 educational meetings and 12 rehabilitation exercise sessions (stretching, strengthening, chest and spine/hip joint flexibility exercises), which patients then performed at home. Outcome assessment at the end of rehabilitation training (T1) and at T2 was based on spinal pain intensity in the previous 4 weeks by self-report visual analog scale (VAS; 100 mm: 0 = no pain, 100 = maximum pain), BASMI, BASFI, BASDAI, and on chest expansion and the active range of motion of the cervical and lumbar spine measured by a pocket goniometer. Results. The 3 groups were comparable at baseline. On intragroup comparison at T1, the rehabilitation group showed significant improvement in the BASMI and BASDAI, in chest expansion, and in most spinal active range of motion measurements. BASFI and cervical and lumbar VAS scores improved in both the rehabilitation and educational-behavioral groups. The positive results achieved in the rehabilitation group were maintained at the 6-month followup. Conclusion. Combining intensive group exercise with an educational-behavioral program can provide promising results in the management of patients with clinically stabilized AS on TNF inhibitor treatment.

Anterior Chest Wall Involvement in Early Stages of Spondyloarthritis: Advanced Diagnostic Tools

Objective. Anterior chest wall (ACW) involvement is difficult to evaluate in patients with spondyloarthritis (SpA). Bone scan is sensitive to ACW involvement, while magnetic resonance imaging (MRI) detects early alterations in SpA. We compared the sensitivity and specificity of bone scans and MRI in assessing ACW in early SpA. Methods. Out of 110 patients with early SpA attending the Outpatient Rheumatology Unit Clinic of Padua University from January 2008 to December 2010, the 40 complaining of pain and/or tenderness [60% with psoriatic arthritis (PsA), 12.5% with ankylosing spondylitis, and 27.5% with undifferentiated SpA] underwent bone scans and MRI. Results. At clinical examination, sternocostoclavicular joints were involved in 87.5% on the right, 77.5% on the left, and 35% on the sternum. Bone scan was positive in 100% and MRI in 62.5% of these patients. Early MRI signs (bone edema, synovial hyperemia) were observed in 27.5%, swelling in 5%, capsular structure thickness in 37.5%, erosions in 15%, bone irregularities in 15%, osteoproductive processes in 12.5%, and osteophytes in 5%. A higher prevalence of Cw6, Cw7, B35, and B38 was found in 15%, 48%, 28%, and 12%, respectively, of the patients with PsA who had bone scans. Conclusion. Noted mainly in women, ACW involvement was frequent in early SpA. Both bone scans and MRI are useful in investigating ACW inflammation. Bone scans were found to have high sensitivity in revealing subclinical involvement, but a low specificity. MRI provides useful information for therapeutic decision making because it reveals the type and extent of the process. The significant associations of HLA-Cw6 and Cw7 with PsA could suggest that genetic factors influence ACW involvement.

Synovial biomarkers in psoriatic arthritis.

Objective. To find candidate biomarkers of psoriatic arthritis (PsA). A panel of synovial fluid (SF) and synovial tissue (ST) biomarkers was analyzed in patients with resistant peripheral PsA, in relation to clinical and imaging outcomes of synovitis response following serial intraarticular (IA) etanercept injections (12.5 mg). Methods. Fourteen PsA patients with resistant knee joint synovitis were treated with 4 IA etanercept injections in a single knee joint, once every 2 weeks. Primary outcome (Thompson’s knee index: THOMP) and secondary outcomes were assessed at baseline and end of study: C-reactive protein, Knee Joint Articular Index (KJAI), Health Assessment Questionnaire disability index, maximal synovial thickness (MST) by gray-scale ultrasonography, contrast-enhanced magnetic resonance imaging (C+MRI), ST-cluster differentiation (CD)45+ mononuclear cell, ST-CD31+ vessels, and ST-CD105+ angiogenic endothelial cells, along with levels of SF interleukin 1ß (IL-1ß), IL-1 receptor antagonist (Ra), and IL-6. Results. At the end of the study, clinical and imaging outcomes, ST and SF biological markers were significantly reduced compared to baseline. There was a significant association between IL-6 and either THOMP or KJAI; between either ST-CD31+ or ST-CD105+ or ST-CD45+; between ST and SF biomarkers expression (CD45+ and IL-1ß) and between ST-CD45+ and both KJAI and MRI-MST. Comparing pre- versus post-IA etanercept injection changes (Δ), Δ IL-1ß was significantly correlated with both Δ IL-6 and with Δ IL-1Ra and Δ IL-6 with Δ IL-1Ra. Conclusion. The association to disease activity and the changes following IA treatment indicate that ST-CD45+ and ST-CD31+, along with SF-IL-6 and SF-IL-1ß, may represent candidate biomarkers of the knee synovitis response to IA tumor necrosis factor-α blockade.

An unusual association between erosive hand osteoarthritis and morphea.

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 21 mai 2011

Multiple paradoxical adverse events in a patient affected with ankylosing spondylitis treated with TNF blockers.

ejd.2010.1235 Auteur(s) : Alessandro LO NIGRO1 alessandro.lonigro@sanita.padova.it, Roberta RAMONDA1, Mauro ALAIBAC2, Valentina MODESTI1, Leonardo PUNZI1 1 Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy 2 Dermatology Unit, Department of Medical and Surgical Sciences, University of Padova, Italy TNF blockers represent a milestone in the treatment of inflammatory joint diseases, including ankylosing spondylitis (AS). Some [...]

TNF blockade and cutaneous lupus erythematosus: where do we stand and where are we going?

Anti-TNF - a agents are used as a reserve treatment for cases of severe psoriasis and psoriatic arthritis that do not respond to conventional therapies. The current use of anti-TNF -a for systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE) is limited by the clinical observations of the induction of a SLE syndrome. Despite the great number of SLE-like syndromes reported as a side effect of anti-TNF - a blockers, only very few cases of CLE are believed to be a consequence of these drugs. Moreover, on the basis of clinical and laboratory data, anti-TNF -a blockers could be considered as an option for CLE refractory to conventional

Poster 7: Effects of a Rehabilitation and Educational-Behavioral Program on Pain, Disability and Quality of Life in Patients with Ankylosing Spondylitis in Anti-TNFα Therapy: A Randomized Controlled Trial

Disclosures: S. Masiero, None. Objective: To evaluate the effects on pain, disability and quality of life of a rehabilitation and educational-behavioral program in patients with ankylosing spondylitis (AS) in anti-TNF therapy. Design: Randomized controlled trial, 6-month follow-up. Setting: Outpatients of Rheumatologic Department. Participants: Fifty-eight patients with SA in anti-TNF therapy for more than 9 months were randomly allocated to 3 groups. Interventions: Group A (n 18) received an educationalbehavioral meeting with a home guide (2 hours) associated with an intensive group exercise program under the supervision of a physiotherapist (1 hours twice a week for 5 weeks) that was then performed at home; group B (n 18) received only educational-behavioral information by a meeting with a home guide (2 hours); group C (n 17) not effected any treatment. Main Outcome Measures: Visual analogue scale (VAS) of axial pain and stiffness (last month), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Activity Index (BASDAI), Health Assessment Questionnaire (HAQ), MOS 36-item short form health survey (SF-36). Results: Group A showed significant gains at the evaluations defined as the difference between the 2 assessments (beginning and after 6 months) compared with groups B and C as resulted, respectively, for BASFI (-1.9 1.7 vs -0.89 0.9 and 0.08 0.8; P .001), BASDAI ( -1.5 1.3 vs 0.8 1.2 and 0.4 0.5; P .040) and HAQ (-039 0.11 vs -0.14 0.19 and -0.09 0.15; P .021), but not for back pain at the VAS (P .121), and SF-36 (P .161 and .06). Conclusions: Our study showed that after 6 months, attending an educational-behavioral program associated with intensive group exercise can reduce the intensity of pain and disability and improve the quality of life for patients with SA who were pharmacologically stabilized with anti-TNF therapy. This approach may effectively complement drug therapy in these patients.

Poster 8: Effects of a Rehabilitation and Educational-Behavioral Program on Spinal Mobility in Patients with Ankylosing Spondylitis in Anti-TNFα Therapy: A Randomized Controlled Trial

Disclosures: S. Masiero, None. Objective: To evaluate the effects on pain, disability and quality of life of a rehabilitation and educational-behavioral program in patients with ankylosing spondylitis (AS) in anti-TNF therapy. Design: Randomized controlled trial, 6-month follow-up. Setting: Outpatients of Rheumatologic Department. Participants: Fifty-eight patients with SA in anti-TNF therapy for more than 9 months were randomly allocated to 3 groups. Interventions: Group A (n 18) received an educationalbehavioral meeting with a home guide (2 hours) associated with an intensive group exercise program under the supervision of a physiotherapist (1 hours twice a week for 5 weeks) that was then performed at home; group B (n 18) received only educational-behavioral information by a meeting with a home guide (2 hours); group C (n 17) not effected any treatment. Main Outcome Measures: Visual analogue scale (VAS) of axial pain and stiffness (last month), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Activity Index (BASDAI), Health Assessment Questionnaire (HAQ), MOS 36-item short form health survey (SF-36). Results: Group A showed significant gains at the evaluations defined as the difference between the 2 assessments (beginning and after 6 months) compared with groups B and C as resulted, respectively, for BASFI (-1.9 1.7 vs -0.89 0.9 and 0.08 0.8; P .001), BASDAI ( -1.5 1.3 vs 0.8 1.2 and 0.4 0.5; P .040) and HAQ (-039 0.11 vs -0.14 0.19 and -0.09 0.15; P .021), but not for back pain at the VAS (P .121), and SF-36 (P .161 and .06). Conclusions: Our study showed that after 6 months, attending an educational-behavioral program associated with intensive group exercise can reduce the intensity of pain and disability and improve the quality of life for patients with SA who were pharmacologically stabilized with anti-TNF therapy. This approach may effectively complement drug therapy in these patients.