Romain Forestier

Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines

OBJECTIVES Because drugs do not halt joint destruction in rheumatoid arthritis (RA), non-drug treatments are an important adjunct to drug treatment. Establishing rules governing their use is difficult because treatment is multidisciplinary, complex, and difficult to assess. The aims of these guidelines were to (a) establish the indications for physical therapies and for educational, psychological, and other non-drug interventions, (b) address social welfare, occupational, and organizational issues. METHODS A systematic literature search (MEDLINE, EMBASE, CINAHL, Pascal, Cochrane Library, HTA database) (1985-2006) was completed with information obtained from specialty societies and the grey literature. A review of the studies meeting inclusion criteria, with evidence levels, was used by a multidisciplinary working group (18 experts) to draft guidelines. Consensus was reached when evidence was lacking on key topics. The draft guidelines were scored by 60 peer reviewers, amended when necessary, and then validated by the HAS Board. RESULTS Of the 1819 articles retrieved, 817 were analysed and 382 cited in the report. Low-power randomized clinical trials constituted the highest level of evidence. Grade B guidelines (intermediate evidence level) concerned aerobic activities, dynamic muscular strengthening, and therapeutic patient education. Grade C (low evidence level) concerned use of rest orthoses or assistive devices, balneotherapy and spa therapy, self-exercise programmes, and conventional physiotherapy. Professional agreement (no scientific evidence) was reached for orthotic insoles and footwear, chiropody care, thermotherapy, acupuncture, psychological support, occupational adjustments, and referral to social workers. CONCLUSION Aerobic activities, dynamic muscular reinforcement, and therapeutic patient education are valuable in non-drug management of RA.

Management of osteoporosis in women with peripheral osteoporotic fractures after 50 years of age: a study of practices.

OBJECTIVE To evaluate practices regarding the management of osteoporosis revealed by low-impact peripheral fractures in women older than 50 years of age. METHODS Six orthopedic surgeons prospectively recruited patients presenting with their first low-impact peripheral fracture. Three months after the fracture, each patients usual primary-care physician provided information on management. RESULTS The 132 patients (140 fractures) included in the study had a mean age of 73.8 years. Fracture sites in decreasing order of frequency were the wrist (29%), the hip (28%), the ankle (19%), the pelvis, the humerus, and the leg. Data on management by the primary-care physician were available for 106 patients. Fifty patients (50/106, 47%) were given a diagnosis of osteoporosis by their primary-care physician and 38 (38/106, 35%) received medications for osteoporosis. CONCLUSION In two-thirds of patients, a valuable opportunity for using the effective treatments available for osteoporosis was lost. Given the high risk of further fractures in this population, our finding is of great concern.

Prevalence of generalized osteoarthritis in a population with knee osteoarthritis.

OBJECTIVE To determine the prevalence of generalized osteoarthritis in patients with knee osteoarthritis. METHODS Patients with knee osteoarthritis were recruited for a therapeutic trial via press announcement and selected based on American College of Rheumatology radioclinical criteria for femorotibial arthritis. Patients were asked to bring all their radiographs to the study visits, which included a physical examination. Each patient had an inclusion visit and a second visit 1 month later. The study physicians used a standardized chart to indicate clinical and radiographic evidence of osteoarthritis in each patient. At the hands and feet, the presence of clinical criteria was sufficient for the diagnosis of osteoarthritis. The shoulders and elbows were not assessed. Three criteria sets for generalized osteoarthritis were evaluated: Kellgren and Moore criteria (Heberdens nodes or interphalangeal osteoarthritis), ACR criteria (osteoarthritis of the spine and at least two other joints), and Dougados criteria (bilateral finger osteoarthritis or osteoarthritis of the spine and both knees). RESULTS We included 302 patients for whom the side affected with knee osteoarthritis was known. Mean symptom duration was 5.9±5.7 years, mean number of painful flares was 10.1±9.4, mean number of joints with osteoarthritis was 2.6±1.8, and mean body mass index was 29.5±5.3 kg/m(2). A family history of osteoarthritis was noted in 154 (51%) patients and spinal osteoarthritis in 148 (49%) patients. Kellgren-Moore criteria for interphalangeal osteoarthritis were met in 42 (13.9%) patients, ACR criteria by 124 (41%) patients, and Dougados criteria by 127 (42%) patients. In all, 156 (52%) patients met at least one of the three definitions of generalized osteoarthritis. CONCLUSION More than half the patients included in a therapeutic trial in knee osteoarthritis had generalized osteoarthritis with maximum symptoms at the knee at baseline. Some patients with osteoarthritis in multiple joints met none of the three criteria sets for generalized osteoarthritis. Further studies are needed to assess the sensitivity and specificity of current criteria sets and, if needed, to identify new criteria.

Spa therapy and knee osteoarthritis: A systematic review.

BACKGROUND Osteoarthritis (OA) is a public health problem that will probably increase in the future with the aging of the population. Crenobalneotherapy is commonly used to treat OA, but evidence from previous reviews was not sufficient. This systematic review aimed to identify the best evidence for the clinical effect of crenobalneotherapy for knee OA. METHODS We systematically searched MEDLINE via PubMed, PEDRO and the Cochrane Central Register of Controlled Trials for articles published up to September 2015. Articles were included if trials were comparative, if one or more of the subgroups had knee OA with separate data, and if spa therapy or any hydrotherapy techniques involving mineral water or mineral mud was compared to any other intervention or no treatment. Statistical validity, external validity and quality of side effects assessment were evaluated by personal checklists. Risk of bias was assessed by the CLEAR NTP. RESULTS Treatments (hot mineral water baths, mud therapy, hot showers, and sometimes massage and supervised water exercises) delivered in spa centers across Europe and the Middle East seem to improve symptoms in knee OA. They may be effective for pain and function. There are conflicting results about the effect on quality of life and drug consumption. CONCLUSIONS Improvements with spa therapy for knee OA appear to be clinically relevant until 3 to 6 months and sometimes 9 months.

Current role for spa therapy in rheumatology

Joint Bone Spine - In Press.Proof corrected by the author Available online since mardi 7 juin 2016

Balneohydrotherapy in the treatment of chronic venous insufficiency

BACKGROUND Physical therapy has not been evaluated much for the treatment of chronic venous insufficiency before. The question is whether balneohydrotherapy and usual care combined is superior to usual care alone. PATIENTS AND METHODS In a randomized trial comparing spa therapy versus waiting list patients were treated on an out-patient basis in a private spa center. Patients had to be between 18 and 80 years old, with chronic venous insufficiency (stage 3 or 4 according to the CEAP classification). The balneohydrotherapy group received 18 days of treatment in Aix-Les-Bains spa center continuing their usual care. The control group continued their usual care as well during the study. The balneohydrotherapy program consisted of Kneipp therapy (10 minutes), walking 10 minutes in a special mineral water pool with underwater jets at 23 °C, massage and bathing in a mineral water tub at 34 °C. The main outcome criterion was the number of patients with 20 % self assessed improvement on the Chronic Venous Insufficiency Questionnaire at three months after therapy. RESULTS 192 patients were assessed for eligibility, 99 were randomized 5 retired drew back their consent and were not included in the intention to treat analysis. None were lost to follow up. After three months 32 (66 %) patients improved in the balneohydrotherapy group and 13 (28 %) in the control group. The difference between groups was significant (odd ratio 5.08 [1.94 - 13.55], relative risk reduction 2.33 [1.42 - 3.84]).There were no serious side effects. CONCLUSIONS Balneohydrotherapy seems to improve quality of life of patients with chronic venous insufficiency.

Diagnostic criteria for generalized osteoarthritis: a preliminary study in a population with knee osteoarthritis.

Joint Bone Spine - In Press.Proof corrected by the author Available online since vendredi 27 mai 2011

La prise en charge médicale de l'ostéoporose après fractures périphériques chez la femme de plus de 50 ans

Resume Objectif. – Savoir comment se faisait la prise en charge medicale de l’osteoporose revelee par une fracture peripherique chez la femme de plus de 50 ans. Patients et methode. – Enquete prospective avec 6 chirurgiens orthopedistes charges de recueillir, chez les patientes qui se presentaient avec leur premiere fracture peripherique non traumatique, leurs coordonnees ainsi que celles de leur medecin traitant. Puis enquete aupres des medecins traitants pour connaitre la prise en charge realisee. Resultats. – Sur 132 patientes recrutees (140 fractures), âge moyen 73,8 ans, 106 ont pu etre suivies. Vingt-neuf pour cent avaient une fracture du poignet, 28 % de hanche, 19 % de cheville et le reste des fractures du bassin, d’humerus ou de jambe. Cinquante sur cent six (47 %) ont ete considerees comme osteoporotiques par leur medecin traitant et 38/106 (35 %) ont beneficie d’un traitement adapte. Conclusion. – Seulement 35 % des patients ayant une fracture osteoporotique peripherique ont eu une prise en charge medicale alors qu’elles sont a risque majeur de recidive et que nous disposons de traitements efficaces.

Intensive spa and exercise therapy program for returning to work for low back pain patients: a randomized controlled trial

We aimed to determine whether a 5-day intensive inpatient spa and exercise therapy and educational program is more effective than usual care in improving the rate of returning to work at 1 year for patients with subacute and chronic low back pain (LBP) on sick leave for 4 to 24 weeks. We conducted a 12-month randomized controlled trial. LBP patients were assigned to 5-day spa (2 hr/day), exercise (30 min/day) and education (45 min/day) or to usual care. The primary outcome was the percentage of patients returning to work at 1 year after randomization. Secondary outcomes were pain, disability and health-related quality of life at 1 year and number of sick leave days from 6 to 12 months. The projected recruitment was not achieved. Only 88/700 (12.6%) patients planned were enrolled: 45 in the spa therapy group and 43 in the usual care group. At 1 year, returning to work was 56.3% versus 41.9% (OR 1.69 [95% CI 0.60–4.73], p = 0.32) respectively. There was no significant difference for any of the secondary outcomes. However, our study lacked power.

A CRENOBALNEOTERAPIA NA FRANÇA: VISÃO GERAL

Apos uma breve historia, descreve-sea balneoterapia francesa a partir das diferentes fontes e estacoes termais e as respectivas indicacoes de tratamentos financiadas pelo sistema publico de saude.