Paul Creamer

Sustained improvement produced by nonpharmacologic intervention in fibromyalgia: results of a pilot study.

OBJECTIVEnThe aim of this pilot study was to examine the practicality of delivering a package of nonpharmacologic, behavioral-based treatment, previously found to be effective in chronic back pain, to patients with fibromyalgia (FM) and to assess the efficacy of the intervention using a range of outcome measures up to 4 months posttreatment.nnnMETHODSnParticipants with FM (n = 28) formed a single group for 8 sessions at weekly intervals. Each session comprised an education/cognitive-behavioral component, formal relaxation/meditation training, and instruction in a Chinese movement therapy (Qi Gong).nnnRESULTSnTwenty of 28 subjects completed at least 5 of the 8 sessions. Significant improvement was seen in the Fibromyalgia Impact Questionnaire and a range of other outcome measures including tender points and pain threshold. Improvement was sustained 4 months after the end of the intervention.nnnCONCLUSIONnA simple behavioral intervention using large groups can be administered to subjects with FM and appears to produce sustained benefit in a range of outcomes. Controlled trials are currently being planned.

Association of cytokine and matrix metalloproteinase profiles with disease activity and function in ankylosing spondylitis

IntroductionThe pathology of ankylosing spondylitis (AS) suggests that certain cytokines and matrix metalloproteinases (MMPs) might provide useful markers of disease activity. Serum levels of some cytokines and MMPs have been found to be elevated in active disease, but there is a general lack of information about biomarker profiles in AS and how these are related to disease activity and function. The purpose of this study was to investigate whether clinical measures of disease activity and function in AS are associated with particular profiles of circulating cytokines and MMPs.MethodsMeasurement of 30 cytokines, five MMPs and four tissue inhibitors of metalloproteinases was carried out using Luminex® technology on a well-characterised population of AS patients (n = 157). The relationship between biomarker levels and measures of disease activity (Bath ankylosing spondylitis disease activity index (BASDAI)), function (Bath ankylosing spondylitis functional index) and global health (Bath ankylosing spondylitis global health) was investigated. Principal component analysis was used to reduce the large number of biomarkers to a smaller set of independent components, which were investigated for their association with clinical measures. Further analyses were carried out using hierarchical clustering, multiple regression or multivariate logistic regression.ResultsPrincipal component analysis identified eight clusters consisting of various combinations of cytokines and MMPs. The strongest association with the BASDAI was found with a component consisting of MMP-8, MMP-9, hepatocyte growth factor and CXCL8, and was independent of C-reactive protein levels. This component was also associated with current smoking. Hierarchical clustering revealed two distinct patient clusters that could be separated on the basis of MMP levels. The high MMP cluster was associated with increased C-reactive protein, the BASDAI and the Bath ankylosing spondylitis functional index.ConclusionsA profile consisting of high levels of MMP-8, MMP-9, hepatocyte growth factor and CXCL8 is associated with increased disease activity in AS. High MMP levels are also associated with smoking and worse function in AS.

Factors influencing work disability in psoriatic arthritis: first results from a large UK multicentre study

OBJECTIVEnThe aim of this study was to determine the extent to which structural damage, clinical disease activity, demographic and social factors are associated with work disability (WD) in PsA.nnnMETHODSnFour hundred patients fulfilling CASPAR (Classification Criteria for Psoriatic Arthritis) criteria for PsA were recruited from 23 hospitals across the UK. Demographic, socio-economic, work, clinical and radiographic data were collected. WD was assessed with the Work Productivity and Activity Impairment Specific Health Problem (WPAI-SHP) questionnaire reporting WD as a percentage of absenteeism (work time missed), presenteeism (impairment at work/reduced effectiveness) and work productivity loss (overall work impairment/absenteeism plus presenteeism). Logistic and linear regressions were conducted to investigate associations with WD.nnnRESULTSnTwo hundred and thirty-six participants of any age were in work. Absenteeism, presenteeism and productivity loss rates were 14% (s.d. 29.0), 39% (s.d. 27.2) and 46% (s.d. 30.4), respectively. Ninety-two (26%) participants of working age were unemployed. Greater age, disease duration of 2-5 years and worse physical function were associated with unemployment. Patients reported that employer awareness and helpfulness exerted a strongly positive influence on remaining in employment. Higher levels of global and joint-specific disease activity and worse physical function were associated with greater levels of presenteeism and productivity loss among those who remained in work.nnnCONCLUSIONnReduced effectiveness at work was associated with measures of disease activity, whereas unemployment, considered the endpoint of WD, was associated with employer factors, age and disease duration. A longitudinal study is under way to determine whether treatment to reduce disease activity ameliorates WD in the real-world setting.

Teaching medical students about chronic disease: patient-led teaching in rheumatoid arthritis

OBJECTIVESnTo evaluate the effectiveness of patient-led teaching compared with doctor-led teaching, regarding the impact of chronic disease (rheumatoid arthritis [RA]).nnnMETHODSnA set of learning objectives regarding the impact of RA on patient and family was designed. Students (n = 42) attached to the academy for their musculoskeletal diseases module were randomized to teaching either by a doctor or a patient. Outcome was assessed using a knowledge test, feedback forms and qualitative written interview.nnnRESULTSnIn the knowledge test, the groups performed equally. The patient-taught group scored 24.5 +/- 3.5 (max 35); the doctor-taught group scored 24.6 +/- 4.1 (p > 0.05; NS). Feedback was completed by 40/42 students. Mean scores for the overall grading of teaching (1-5, where 1 = worst, 5 = best) were: patient teaching 4.36 (95% confidence interval [CI] 4.11, 4.61); doctor teaching 3.69 (95% CI 3.52, 3.92).The difference between the average scores was 0.42 (p = 0.005). Qualitative feedback showed recurring themes that students appreciated the personal nature of the patients teaching, enabling them to understand the impact of the disease on patients and their families. The doctors teaching was also appreciated, particularly the interactive style and opportunity to participate in role play.nnnCONCLUSIONSnWe have demonstrated that our patient was at least as good as a doctor at teaching about the impact of chronic disease on patients. Furthermore, this experience is valued by students who appreciate the personal insight that a patient can offer.

Effect of anti-TNF and conventional synthetic disease-modifying anti-rheumatic drug treatment on work disability and clinical outcome in a multicentre observational cohort study of psoriatic arthritis

Objective. To determine the effect of medical treatment on work disability in patients with active PsA in a real‐world setting. Methods. Four hundred patients with active PsA commencing or switching to anti‐TNF or conventional synthetic DMARD (csDMARD) were recruited to a multicentre UK prospective observational cohort study. Work disability was measured using the work productivity and activity‐specific health problem instrument and peripheral joint activity was measured with the disease activity in PsA composite measure. Results. Four hundred patients were recruited, of whom 229 (57.25%) were working (of any age). Sixty‐two patients of working age (24%) were unemployed. At 6 months there was a 10% improvement in presenteeism (P = 0.007) and a 15% improvement in work productivity (P = 0.001) among working patients commenced on csDMARDs (n = 164) vs a larger and more rapid 30% improvement in presenteeism (P < 0.001) and 40% improvement in work productivity (P < 0.001) among those commenced on anti‐TNF therapy (n = 65). Clinical response was poor among patients commenced on a csDMARD (n = 272), with an 8.4 point improvement in disease activity in PsA (P < 0.001) vs those commenced on anti‐TNF therapy (n = 121), who had a 36.8 point improvement (P < 0.001). Conclusion. We report significant and clinically meaningful improvements in both work disability and clinical outcomes after commencement of anti‐TNF therapy in a real‐world setting. Improvements in all outcomes among those commencing csDMARDs were slower and of a smaller magnitude.