GRAPPA--Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, Stockholm, May/June 2006.
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Antirheumatic Agents↗
Biomedical subjects
Philip S Helliwell
Publications and source records attributed to Philip S Helliwell.
The impact of rheumatoid arthritis on foot function in the early stages of disease: a clinical case series.
BACKGROUND: Foot involvement occurs early in rheumatoid arthritis but the extent to which this impacts on the structure and function leading to impairment and foot related disability is unknown. The purpose of this study was to compare clinical disease activity, impairment, disability, and foot function in normal and early rheumatoid arthritis (RA) feet using standardised clinical measures and 3D gait analysis. METHODS: Twelve RA patients with disease duration < or =2 years and 12 able-bodied adults matched for age and sex underwent 3D gait analysis to measure foot function. Disease impact was measured using the Leeds Foot impact Scale (LFIS) along with standard clinical measures of disease activity, pain and foot deformity. For this small sample, the mean differences between the groups and associated confidence intervals were calculated using the t distribution RESULTS: Moderate-to-high foot impairment and related disability were detected amongst the RA patients. In comparison with age- and sex-matched controls, the patients with early RA walked slower (1.05 m/s Vs 1.30 m/s) and had a longer double-support phase (19.3% Vs 15.8%). In terminal stance, the heel rise angle was reduced in the patients in comparison with normal (-78.9 degrees Vs -85.7 degrees). Medial arch height was lower and peak eversion in stance greater in the RA patients. The peak ankle plantarflexion power profile was lower in the patients in comparison with the controls (3.4 W/kg Vs 4.6 W/kg). Pressure analysis indicated that the RA patients had a reduced lesser toe contact area (7.6 cm2 Vs 8.1 cm2), elevated peak forefoot pressure (672 kPa Vs 553 kPa) and a larger mid-foot contact area (24.6 cm2 Vs 19.4 cm2). CONCLUSION: Analysis detected small but clinically important changes in foot function in a small cohort of RA patients with disease duration <2 years. These were accompanied by active joint disease and impairment and disability.
Adult↗
Regionalised centre of pressure analysis in patients with rheumatoid arthritis.
BACKGROUND: Rheumatoid arthritis patients alter their gait pattern to compensate for painful foot symptoms. The centre of pressure may be a useful indicator of these altered loading patterns. Our purpose was to undertake a comparison of the regionalised duration and velocity of the centre of pressure between rheumatoid arthritis patients with foot impairments and healthy able-bodied adults. METHODS: The progression of the centre of pressure through the foot, heel, midfoot, forefoot and toe regions was measured using an EMED-ST pressure platform. Patients walked at self selected cadence. Variables analysed were the average and maximum velocity and the duration of the centre of pressure (as % stance). RESULTS: In comparison with able-bodied adults, rheumatoid arthritis patients had a statistically significant decrease in the average velocity of the centre of pressure in the total foot (P<0.001), heel (P=0.001) and midfoot (P<0.001) regions. The maximum velocity of the centre of pressure was slower in rheumatoid arthritis patients in only the midfoot region (P=0.002). During stance, the duration of the centre of pressure was longer in the midfoot (P<0.001) and shorter in the forefoot (P=0.001) in the rheumatoid arthritis patients. INTERPRETATION: Alteration of the foot loading patterns in patients with rheumatoid arthritis can be characterised by changes to the centre of pressure patterns. Off-loading the painful and deformed forefoot was a characteristic feature in this patient cohort.
Adult↗
Therapies for dactylitis in psoriatic arthritis. A systematic review.
Dactylitis is a hallmark clinical feature of psoriatic arthritis (PsA). Acute dactylitis appears to be a severity marker for PsA and psoriasis. Traditionally, clinicians have used nonsteroidal antiinflammatory rheumatic drugs and local corticosteroid injections to treat dactylitis, although conventional disease modifying antirheumatic drugs also are recommended. In this systematic review, the limited data on treatments for dactylitis in PsA highlight the need for a valid, reliable, and responsive clinical outcome measure. Infliximab is the only drug to demonstrate significant improvement of dactylitis during a clinical study.
Anti-Inflammatory Agents, Non-Steroidal↗
Dactylitis: pathogenesis and clinical considerations.
Dactylitis is considered a hallmark feature of psoriatic arthritis (PsA), but it is found in other spondyloarthropathies, especially reactive arthritis, and other conditions (eg, sarcoidosis, gout, sickle cell disease, and a variety of infections). Dactylitis is difficult to define and assess with any level of consensus and consistency in PsA. A new objective measure has been developed to make assessment more uniform for clinical trials. The underlying pathophysiology has also been difficult to determine in spondyloarthropathy: synovitis, tenosynovitis, and enthesitis have all been recognized. The pathophysiology in other conditions varies but usually involves soft tissue and sometimes involves bone or joint. In non-spondyloarthropathies,treatment is determined by the underlying cause. Research on dactylitis treatment in PsA suffers from a paucity of trials and inconsistent outcome measurement. The only drug with good evidence of benefit from randomized controlled trials thus far is infliximab.
Anti-Inflammatory Agents, Non-Steroidal↗
Classification of the spondyloarthropathies.
PURPOSE OF REVIEW: The spondyloarthropathies are a group of conditions which share similar clinical features. Classification criteria permit separation of the conditions, allow better targeting of therapies, better measurement of outcomes, and better prognostic information. Early diagnosis remains problematic, but validated criteria for established disease are now emerging. RECENT FINDINGS: Histopathology and histochemistry are providing a better understanding of the underlying process of inflammatory arthritis in spondyloarthropathy and other inflammatory arthritides. Early disease, however, continues to challenge current criteria. Sophisticated imaging with magnetic resonance imaging is being increasingly used and is proving useful for early diagnosis as well as helping to understand the pathophysiology of disease. Juvenile idiopathic arthritis continues to provide problems and criteria have recently been modified to allow a greater clinical utility and inclusion of more patients. Poststreptococcal reactive arthritis appears to be a heterogeneous clinical entity, with a group looking more like rheumatic fever and a group with spondyloarthropathy traits. It may be that the association is not streptococcal, but is a throat infection. Currently available criteria for psoriatic arthritis have been evaluated in a large cohort. Four of the criteria performed well with high specificity and sensitivity whereas the other two had moderate specificity and low sensitivity. It was shown that rheumatoid factor positivity does not exclude a diagnosis of psoriatic arthritis--the single most important clinical feature of this condition being the presence of psoriasis. SUMMARY: The spondyloarthropathy classification criteria continue to be an area of development. This is most apparent in juvenile arthritis and psoriatic arthritis. The latter is currently undergoing intense scrutiny to develop classification criteria and outcome measures.
Biomarkers↗
Selectively attenuating soft tissues close to sites of inflammation in the peritalar region of patients with rheumatoid arthritis leads to development of pes planovalgus.
OBJECTIVE: To compare the 3-dimensional (3D) orientation of the tibiotalar, tibiocalcaneal, and intertarsal joints in cadaveric specimens following structural weakening to predetermined ligaments in the peritalar region and medial ankle tendons under axial loads and simulated calcaneal valgus deformity. METHODS: Eight fresh-frozen, unembalmed human lower leg and foot specimens were placed in a materials testing machine. The mid-stance period of gait was simulated and the 3D orientation of the tibiotalar, tibiocalcaneal, and intertarsal joints was measured using an electromagnetic motion analysis system. Specimens were then axially loaded at 840 N for 5400 cycles with the calcaneus in its initial orientation and under simulated valgus conditions using a heel wedge following attenuation (multiple stab incisions) of selected ligaments (tibionavicular, anterior tibiotalar and tibiocalcaneal portions of the medial deltoid ligament, the inferior calcaneonavicular ligament, and the superomedial calcaneonavicular ligament) or tendons (tibialis posterior, flexor digitorum longus, and flexor hallucis longus). The joint orientation measurements were then repeated and compared with baseline intact measurements. RESULTS: Pes planovalgus was observed in 6/8 specimens following testing. The tibiotalar, tibiocalcaneal, talonavicular, and calcaneocuboid joints were more dorsiflexed, everted, and externally rotated following either ligament or tendon compromise. The changes in orientation were small but showed consistent patterns with the smallest changes (typically < 1 degrees ) for the transverse plane and largest (up to 3.5 degrees ) for the frontal plane. The magnitude of change was similar for the tibiotalar and tibiocalcaneal joints, largest for the talonavicular joint, and smallest for the calcaneocuboid joint for both ligament and tendon compromise. The orientation of the talocalcaneal joint was more plantarflexed and everted relative to baseline, for both the ligament and tendon compromise with < 1 degrees of change in orientation about the transverse plane. Under simulated valgus heel conditions, joint orientation was further increased especially about the frontal plane in the direction of eversion. The smallest changes were noted for the calcaneocuboid joint (approximately 1 degrees ), similar change (approximately 2-3 degrees ) for the tibiotalar, tibiocalcaneal and talocalcaneal joints, and the largest changes (> 3 degrees ) for the talonavicular joint. There were no observed differences in the magnitude of change between ligament or tendon condition. CONCLUSION: Selective attenuation to either the ligaments supporting the tibiotalar, talocalcaneal, and talonavicular joints or the medial ankle tendons followed by cyclic loading results in small but important changes in the orientation of the tarsal bones consistent with the development of pes planovalgus.
Ankle Joint↗
Problems with the definition of axial and peripheral disease patterns in psoriatic arthritis.
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Arthritis, Psoriatic↗
Development of an assessment tool for dactylitis in patients with psoriatic arthritis.
OBJECTIVE: Psoriatic arthritis (PsA) is characterized by inflammatory arthritis in the presence of psoriasis. Certain clinical features help characterize this disorder, one of which is dactylitis. Hitherto an instrument for quantifying dactylitis has not been developed. METHODS: A dactylitis score sheet was developed. The score is a function of finger circumference and tenderness, assessed and summed across all dactylitic digits. Initial results were obtained on a small sample of patients attending clinics. Inter and intraobserver agreement on the presence of dactylitis using kappa agreement statistics, and the validity and reliability of the instrument, using intraclass correlation coefficients (ICC), were assessed in a further group of 7 patients with PsA. RESULTS: Tender dactylitis was deemed present in 74 digits out of a total of 280 (140 digits on each occasion). Kappa agreement scores for the presence of tender dactylitis were poor to good, both within and between observers (0.25 to 0.89 between observers and 0.29 to 0.91 within observers). Agreement scores for non-tender dactylitis were poor (0.01 to 0.66 between observers and 0.01 to 0.59 within-observer agreement). The new dactylitis instrument was simple and easy to administer and was found to measure appropriate scores in patients with different severity of dactylitis. Inter and intraobserver agreement was good (interobserver ICC 0.90, 95% CI 0.74-0.98; intraobserver ICC 0.84, 95% CI 0.71-0.92). Intraobserver ICC improved but interobserver ICC deteriorated by rating simply presence or absence, rather than a 4 point grade, of tenderness. CONCLUSION: A new method for quantifying dactylitis based on digital circumference and tenderness has been described. This instrument has shown good inter and intraobserver reliability. Further studies of responsiveness are now required.
Adult↗
Outcome measures in psoriatic arthritis.
Recent advances in biologic therapies have provided hope for patients with psoriatic arthritis (PsA). However, studies have been hampered by the lack of acceptable and validated outcome measures. This article reviews outcome measures used in the assessment of both skin and joints in PsA, and provides a summary of the Psoriatic Arthritis Workshop during OMERACT 7. A set of domains to be included in the assessment of patients with PsA was derived, and a research agenda was developed.
Arthritis, Psoriatic↗
Development of diagnostic criteria for psoriatic arthritis: methods and process.
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis but this simple definition obscures the difficulty in defining the condition for epidemiologic purposes. Since the original description by Moll and Wright, a number of other classification criteria have been published. None of these have been fully evaluated and only one has been developed using patient derived data. Methodologic problems in developing classification criteria--their purpose, utility, and accuracy--are discussed in relation to a new International collaboration, the International Multicentre Validation of Diagnostic Criteria for Psoriatic Arthritis (CASPAR).
Arthritis, Psoriatic↗
A comparison of the performance characteristics of classification criteria for the diagnosis of psoriatic arthritis.
OBJECTIVE: To compare the accuracy of published classification criteria for the diagnosis of psoriatic arthritis (PsA) and to see whether data-derived classification criteria would be more accurate. METHODS: Data were abstracted from case-note review and radiographic review of patients identified with PsA or rheumatoid arthritis (RA) from 2 clinical disease registers. Each patient was classified according to 7 criteria sets. The test performance characteristics were compared using conditional logistic regression analysis. In an attempt to overcome the problems of the diagnostic gold standard, latent class analysis also was used to calculate test-performance characteristics. Classification and regression-tree methodology was used to derive new criteria and to indicate the diagnostic importance of particular data items, especially rheumatoid factor (RF). RESULTS: Four hundred ninety-nine patients were identified with RA (n=156) or PsA (n=343). Excluding the criteria of Fournie, which could not be applied in 24% of subjects, 446 cases could be classified by all of the other 6 methods. The most sensitive criteria for the diagnosis of PsA were those of Vasey and Espinoza, McGonagle, and Gladman (99%), whereas the others were significantly less sensitive (between 56% and 94%). The specificity of the criteria was high and statistically similar (between 93% and 99%). The Fournie criteria were the most difficult to use, whereas the Vasey and Espinoza and Moll and Wright criteria were the easiest (98% of subjects were able to be classified). A 2-latent class model found very similar test-performance characteristics. Logistic regression and classification and regression-tree models suggested that negative RF was not necessary for diagnosis in the presence of other characteristic features of PsA. CONCLUSIONS: Apart from the Bennett and European Spondyloarthropathy Study Group criteria, which have inadequate sensitivity, the published classification criteria for PsA have similar test-performance characteristics. These data suggest that the criteria proposed by Vasey and Espinoza, Gladman, or McGonagle are the most accurate and feasible in distinguishing between PsA and RA. Relevance International agreement about classification criteria for PsA will assist the interpretation of clinical and epidemiologic research. However, further prospective studies on unselected patients with and without PsA, including controls with non-rheumatoid inflammatory arthritis, are required to confirm these findings.
Arthritis, Psoriatic↗
Relationship of psoriatic arthritis with the other spondyloarthropathies.
PURPOSE OF REVIEW: The seronegative spondyloarthropathies are a group of disorders sharing common clinical features, the hallmark of which is sacroiliitis. Despite the 40 years since psoriatic arthritis was recognized, controversy still exists about which patients to include within this disease group and the relation of psoriatic arthritis with the other spondyloarthropathies. RECENT FINDINGS: Early disease can present difficulties because it is inappropriate to use criteria developed on established cases in early arthritis, in which many cases may be initially undifferentiated. The taxonomy of juvenile spondyloarthropathy remains a contentious issue, and further modifications of the Durban criteria have been suggested. The predictive value of the European Spondyloarthropathy Study Group criteria for spondyloarthropathy varies with the prevalence of the disease in the population under consideration, as has been demonstrated in ambulatory practice in France and Spain. It appears that physicians differ in their interpretation of the individual features, particularly of such clinical items as asymmetry and predominantly lower limb involvement. The combination of dactylitis of a toe, heel pain, and oligoarthritis appears to be strongly suggestive of psoriatic arthritis. However, solitary heel pain can be problematic, and ultrasonographic entheseal erosion at the calcaneum has been shown equally in rheumatoid arthritis and psoriatic arthritis. MRI may be more sensitive and quantitatively discriminative in psoriatic arthritis. Spinal involvement in psoriatic arthritis can be asymptomatic, as in classical ankylosing spondylitis. Importantly, psoriatic spondylitis has been observed in the absence of sacroiliitis. SUMMARY: Clinicians generally agree that psoriatic arthritis constitutes a discreet subset within the spondyloarthropathy group, but the demarcation continues to be the subject of clinical research. The matter is confounded by the lack of agreed classification criteria for psoriatic arthritis; although in both adult and juvenile disease criteria for spondyloarthropathy exist, the place of psoriatic arthritis within this larger group requires further definition.
Adult↗
Towards epidemiological criteria for soft-tissue disorders of the arm.
BACKGROUND: The lack of universally agreed criteria has hampered population studies of the prevalence and causation of soft-tissue disorders of the upper limb. OBJECTIVES: To establish core variables for classification of the commonest disorders seen in population samples. METHODS: Consecutive new cases seen in clinical practice in five different centres were evaluated with respect to 30 variables shown to have discriminatory value in univariate analysis. Multivariate analysis using logistic regression modelling was carried out with these as the independent variables and with the clinical diagnosis as the dependent variable. RESULTS: A total of 1382 cases of soft-tissue disorder were recorded and only those diagnostic groups with 50 or more cases were included. In multivariate logistic regression, significant variables positively discriminating for each disorder were identified for carpal tunnel syndrome (n = 56), lateral epicondylitis (n = 87), tenosynovitis (n = 63), shoulder tendonitis (n = 157), non-specific upper limb disorder (n = 458), fibromyalgia (n = 124) and inflammatory arthritis (n = 100), which was used for comparison purposes. Significant discrimination for each model was demonstrated by the construction of receiver operating characteristic (ROC) curves and appropriate area under the curve statistics. CONCLUSIONS: This approach to classification criteria is based on multivariate modelling rather than on a consensus statement. This includes the effects of negative as well as positive associations. Further work is required on both the reproducibility of the clinical signs and the application of the criteria to other datasets.
Adolescent↗
Psychosocial factors in diffuse upper limb disorder.
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Arm↗
Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis.
OBJECTIVE: To evaluate the efficacy of custom foot orthoses for the management of painful rearfoot valgus in patients with rheumatoid arthritis (RA). METHODS: Patients were randomized to receive custom-manufactured rigid carbon graphite foot orthoses (RA-orthosis) or enter a control group (RA-control) receiving no orthotic intervention. Three-dimensional (3D) kinematics were measured at the ankle joint complex (AJC) using an electromagnetic tracking (EMT) system under barefoot, shod, and orthosis walking conditions. Previously established normal 3D kinematic data were used to descriptively compare motion patterns in both RA groups and statistical analyses were performed on integrals of motion-time for each axis of rotation from data collected at baseline, 3, 6, 12, 18, 24, and 30 months. RESULTS: Compared with healthy control subjects, all patients with RA demonstrated excessive subtalar joint eversion motion through the stance phase of gait (p < 0.0001) coupled with excessive internal leg rotation (p < 0.0001). Custom-manufactured orthoses significantly reduced eversion through stance (p = 0.009) and re-established equilibrium of motion relative to neutral joint position. Correcting the frontal plane component of the deformity did not lead to a significant reduction in internal leg rotation (p = 0.294). The devices had no effect on tibiotalar dorsiflexion/plantarflexion (p = 0.960). Prospectively, the rigid orthoses maintained and then improved the reduction in cumulative subtalar eversion motion (p < 0.0001). Minimal changes in cumulative subtalar component eversion and internal leg rotation were recorded for both RA groups when walking barefoot but the effect was significantly less for the RA-control group. From 12 months onwards, internal leg rotation started to decrease, suggesting re-coupling of motion, but the overall motion pattern remained abnormal in comparison with normal reference values. CONCLUSION: These results support the continuous use of custom-manufactured foot orthoses to correct deformity and optimize AJC function in RA patients with early painful deformity of the rearfoot.
Arthritis, Rheumatoid↗
Operational definitions and observer reliability of the plain radiographic features of psoriatic arthritis.
OBJECTIVE: To determine the standardization and the observer reliability of potentially diagnostic plain radiographic features of psoriatic arthritis (PsA). METHODS: Radiographic features were chosen on the basis of a systematic review of the literature. One hundred sixty-four radiographs from 62 patients were selected from various sources by a musculoskeletal radiologist. Radiographs were read independently by 2 observers (WJT, PSH) and scored for the presence or absence of each evaluated feature. Cohen's kappa was used to determine observer agreement beyond chance, and the accuracy of each observer (with reference to the radiologist's judgment) was determined by likelihood ratios. RESULTS: The 2 observers demonstrated similar accuracy, although WJT tended to be more accurate for items classed as absent and PSH more accurate for items classed as present. The following features showed sufficient reliability to be reasonably included in further testing of their discriminatory value (intra- and interobserver kappa values): marginal syndesmophyte (0.68, 0.69), non-marginal syndesmophyte (0.75, 0.59), paravertebral ossification (0.89, 0.79), destructive discovertebral lesion (0.85, 0.65), Romanus lesion (0.64, 0.43), sacroiliitis (0.99, 0.86), entheseal erosion (0.80, 0.71), entheseal ossification (0.69, 0.76), distal interphalangeal erosive disease (0.58, 0.52), joint osteolysis (0.62, 0.47), juxtaarticular bony proliferation (0.43, 0.42), bony ankylosis (0.53, 0.54), tuft osteolysis (0.51, 0.36). The features that showed inadequate reliability were: loss of cortical definition of terminal tuft (0.33, 0.31) and periosteal new bone formation (0.42, 0.03). CONCLUSION: A number of plain radiographic features of PsA have sufficient reliability to justify inclusion in diagnostic classification criteria sets for further testing.
Arthritis, Psoriatic↗
Comparison of a disease-specific and a generic instrument for measuring health-related quality of life in ankylosing spondylitis.
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Humans↗