Purpose: The overall aim of this study was to identify risk factors for knee osteoarthritis (OA) structural disease progression. More specifically, we aimed to identify what personal factors (age, sex, obesity, co-morbidity, Herberden’s nodes, history of injury, manual occupation and medication use), radiographic findings (Kellgren and Lawrence (K&L) grade, joint space width, alignment) and activity limitations (self-reported physical activity and physical function) independently predict medial knee joint space narrowing (JSN) over 2 years in people with painful medial knee OA. Methods: We conducted a prospective longitudinal observational study within a large multicenter randomized placebo-controlled trial, the Long-term Evaluation of Glucosamine Sulfate (LEGS study), that evaluated effects of dietary supplements among an Australian cohort of community-dwelling participants. Eligibility criteria included people aged 45 to 75 years, chronic knee pain and medial compartment joint space narrowing but still retaining 2.0mm medial joint space width at baseline. All measures (personal, radiographic and activity limitations) were collected at baseline, 1 year and 2 years. A single assessor (MF) measured joint space width at all time-points but was not blinded to assessment time-point. A strict protocol required 30kg/m2 or high waist circumference: males>102 cm, females>88 cm), comorbidity score ≥6, presence of Herberden’s nodes, knee surgery or trauma, allocation to active study treatments (glucosamine and chondroitin), use of non-steroidal anti-inflammatory drugs (NSAIDs) or statins (HMG-CoA reductase inhibitors). Radiographic risk factors evaluated were moderate-to-severe OA (K&L grade ≥2), low medial joint space width (lowest 20% of cohort: <3.2 mm) and varus alignment (mechanical alignment ≤178°, derived from anatomical alignment). Predictive activity limitations evaluated were inadequate physical activity (33/68). Age, sex, obesity and allocation to active study treatment were included as covariates in the models. Results: From 605 eligible participants, complete radiographic assessments of JSN were available for 498 participants (mean age: 60 years (SD=8), BMI: 28.7 kg/m2 (SD=5.3)). Unadjusted and adjusted associations between risk factors and structural disease progression are shown in Tables 1 and 2. Factors predictive of JSN ≥7% were: <3.2 mm medial joint space width at baseline, K&L grade ≥2, varus alignment, statin use, not allocated to the combination of glucosamine and chondroitin. Factors predictive of JSN ≥0.5mm were: <3.2 mm medial joint space width, varus alignment, K&L grade ≥2, NSAID use and not meeting physical activity guidelines. Conclusions: Our findings suggest that among people with medial knee OA, presence of already established structural disease increases the risk of further structural disease progression. Varus alignment, not meeting physical activity guidelines, use of NSAIDs and statins are potentially modifiable risk factors. However, despite the evaluation of co-morbidity in our model, it is difficult to distinguish between increased risk due to medication use or the underlying reason for their use. Further research is needed to investigate if targeting these risk factors can modify medial knee OA disease progression.Tabled 1Table 1. Unadjusted and adjusted (all variables) risk associations between for JSN 7% (R2=18%)PredictorExposed with progressionNon-exposed with progressionUnadjusted odds ratio(95% CI)Adjusted odds ratio(95% CI)P valueJoint space width less than 3.2mm52.6%19.6%4.54 (2.91, 7.07)3.31 (2.03, 5.41)<0.001Medial K&L grade 2 or higher37.8%18.7%2.64 (1.76, 3.97)1.74 (1.11, 2.75)0.02Varus alignment49.3%23.5%3.17 (1.90, 5.28)1.75 (0.97, 3.15)0.06Statin use35.9%24.3%1.75 (1.14, 2.69)1.66 (1.03, 2.69)0.04Not allocated to glucosamine & chondroitin combination29.3%21.7%1.49 (0.93, 2.40)1.61 (0.96, 2.70)0.07Age (over 60 years)30.5%23.5%1.43 (0.96, 2.14)1.08 (0.69, 1.68)0.73Sex (Female)25.9%29.1%0.85 (0.57, 1.26)1.00 (0.64, 1.56)0.99Obesity (BMI or waist circumference)29.8%24.7%1.30 (0.87, 1.93)1.19 (0.77, 1.83)0.44 Open table in a new tab Tabled 1Table 2. Unadjusted and adjusted (all variables) risk associations between for JSN 0.5mm (R2=14%)PredictorExposed with progressionNon-exposed with progressionUnadjusted odds ratio (95% CI)Adjusted odds ratio (95% CI)P valueJoint space width less than 3.2 mm23.3%8.1%3.44 (1.95, 6.05)2.47 (1.29, 4.73)0.006Varus alignment26.0%9.3%3.45 (1.86, 6.39)2.21 (1.09, 4.49)0.03NSAID use15.2%10.3%1.57 (0.88, 2.79)1.89 (1.03, 3.50)0.04Medial K&L grade 2 or higher17.3%7.0%2.80 (1.57, 5.01)1.86 (0.98, 3.53)0.06Inadequate physical activity13.3%6.8%2.08 (0.96, 4.53)2.08 (0.93, 4.65)0.08Not allocated to glucosamine & chondroitin combination12.5%9.3%1.39 (0.71, 2.71)1.29 (0.64, 2.61)0.48Age (over 60 years)12.5%10.6%1.20 (0.69,2.10)0.94 (0.52, 1.69)0.82Sex (Female)10.3%13.4%0.74 (0.43, 1.28)0.88 (0.49, 1.60)0.69Obesity (BMI or waist circumference)11.8%11.5%1.02 (0.59, 1.77)1.00 (0.56, 1.79)1.00 Open table in a new tab

Background Treat to target strategy trials have been shown to improve patient outcomes in the research setting. However, a general goal in exploring targeted therapy in rheumatoid arthritis (RA) will continue to be maximizing flexibility of the rheumatologist in treatment decisions. The Objectives Study in Rheumatoid Arthritis (OSRA) was a targeted biomarker randomized controlled trial (RCT) that compared two different biomarkers head to head against a usual care control arm. Objectives To evaluate which clinical, laboratory and patient self-report measures drive rheumatologists’ treatment decisions in the “usual-care” non-target control arm. Methods Active RA patients were randomized to 1 of 2 treat-to-target arms: swollen joint count (SJC) <3 or normal CRP; or to a usual care arm. Patients were seen monthly for 24 months by a study nurse. The study nurse collected data on drug treatment, patient self report clinical status, joint count, laboratory tests and patient safety. The treatment and the interval between visits of patients randomized to the usual care were determined by the treating rheumatologist. Results Of the 249 patients recruited by 31 rheumatologists, 82 were randomized to usual care, given a total of 1817 research patient-months. Mean age and disease duration were 56 and 7 years. Baseline DAS28 (ESR) was 5.08 (1.6-7.95). Patients were seen by their rheumatologist usually every 2 to 4 months. Treatment as a percentage of study nurse patient-months was: methotrexate 79%, prednisone 61%, leflunomide 31%, hydroxychloroquine, 30%, sulphasalazine 29%. Only 10% were treated with a TNFalpha blocker. Use a 5-point treatment change scale, on average, DMARD treatment was reduced in 222 visits, unchanged in 1314 visits and increased in 255 visits. The average DAS28 was 4.11 for treatment reduction, 3.95 when treatment was unchanged, 5.16 when treatment was increased and 6.03 with introduction of a TNF blocker. These differences were significant (p<0.02). Other measures of RA activity, no change versus increase in DMARDs, were as follows: 7 vs.11; 6 vs.10; 20 vs.32; 10 vs.23; 23 vs.38; 24 vs.39; 0.82 vs.1.2 for SJC, TJC, ESR, CRP, patient global, patient pain, and HAQ, respectively. In a fixed-effects regression the only components of the DAS (i.e. SJC, SJC, ESR, patient global) that significantly predicted treatment decisions were SJC and ESR; with a explanatory power of only 11%. Conclusions In an analysis of the usual care arm from a biomarker-target randomized controlled trial of patients with active RA, implicit rheumatologists’ treatment decisions are not clearly explained by standard measures of RA disease activity. Furthermore, DAS scores of moderate disease activity, on average, did not lead to increases in DMARD treatment. Patient preferences, including patient adaptation, or toxicity/adverse effects may explain some of these findings, which in turn, may impact treat to target strategies. However, with increased use, experience and breadth of effective biologic agents, rheumatologists may be more likely to engage in treat to target strategies. Disclosure of Interest M. Lassere Grant/Research support from: Unrestricted Educational Grant Sanofi Aventis, J. Edmonds Grant/Research support from: Unrestricted Educational Grant Sanofi Aventis, K. Johnson: None Declared

Purpose: To determine whether Tai Chi or hydrotherapy classes for people with chronic symptomatic hip or knee osteoarthritis (OA) can result in measurable clinical benefits. Methods: A randomised controlled trial was conducted among 152 people, aged 59 years and over, with chronic symptomatic hip or knee OA. Participants were randomly allocated for 12 weeks to hydrotherapy classes (n=55), Tai Chi classes (n=56) or waiting list control (n=41). Outcomes were assessed at 12 weeks (post treatment) and 24 weeks (sustainability) after randomisation and included pain and physical function (WOMAC), general health status (SF-12v2), psychological well being and physical performance (‘up and go’, 50 ft walk time, timed stair climb). Results: At the 12 week post treatment assessment, 49% (n=27), 34% (n=19) and 15% (n=6) of participants allocated to hydrotherapy, Tai Chi and control group, respectively, were treatment responders according to OMERACT-OARSI responder criteria D. The difference in treatment responder rate between the three allocation groups was significant (chi-squared=12.4, df = 2, p=0.002). Compared with control, participants allocated to hydrotherapy classes demonstrated mean improvements (95% confidence interval) of 6.5 (0.4 to 12.7) and 10.5 (3.6 to 14.5) for pain and physical function scores (range 0-100), respectively, while participants allocated to Tai Chi classes demonstrated improvements of 5.2 (-0.8 to 11.1) and 9.7 (2.8 to 16.7). The 95% CI for treatment effect sizes for physical function for hydrotherapy or Tai Chi classes ranged from moderate to large (.50 to .76). Both class allocations achieved significant improvements in the SF-12 physical component summary score, but only allocation to hydrotherapy classes achieved significant improvements in the measures of physical performance. All significant improvements were sustained at 24 weeks after randomisation. In this almost exclusively Caucasian sample, class attendance was higher for hydrotherapy with 81% attending at least half of the available 24 classes, compared with 61% for Tai Chi. Conclusions: Access to either hydrotherapy or Tai Chi classes can provide sustained improvements in pain and physical function for many older, sedentary people with chronic symptomatic hip or knee OA. The improvements achieved in physical function were greater than those demonstrated for traditional land-based exercise programs.

The aim of this study was to determine if transducer pressure modifies power Doppler assessments of rheumatoid arthritis synovium at the metacarpophalangeal joints and metatarsophalangeal joints. Five rheumatoid arthritis patients of varying degrees of 'disease activity' and damage were assessed with power Doppler ultrasound scanning of the dominant hand second to fifth metacarpophalangeal joints. Two rheumatoid arthritis patients had their dominant foot first to fifth metatarsophalangeal joints assessed with power Doppler ultrasound. Ultrasonography was performed with a high frequency transducer (14 MHz) with a colour mode frequency of 10 Mhz, and a standard colour box and gain. In the joint that showed the highest power Doppler signal, an image was made. A further image was taken after transducer pressure was applied. In all patients, there was increased flow to at least one joint. After pressure was applied, power Doppler signal intensity markedly reduced in all images and in some there was no recordable power Doppler signal. Increased transducer pressure can result in a marked reduction or obliteration in power Doppler signal. This power Doppler 'blanching' shows the need for further studies to evaluate sources of error and standardization before power Doppler ultrasound becomes a routine measure of 'disease activity' in rheumatoid arthritis.

This paper presents the wrist joint MR images of the EULAR–OMERACT rheumatoid arthritis MRI reference image atlas. Reference images for scoring synovitis, bone oedema, and bone erosions according to the OMERACT RA MRI scoring (RAMRIS) system are provided. All grades (0–3) of synovitis are illustrated in each of the three wrist joint areas defined in the scoring system—that is, the distal radioulnar joint, the radiocarpal joint, and the intercarpal-carpometacarpal joints. For reasons of feasibility, examples of bone abnormalities are limited to five selected bones: the radius, scaphoid, lunate, capitate, and a metacarpal base. In these bones, grades 0–3 of bone oedema are illustrated, and for bone erosion, grades 0–3 and examples of higher grades are presented. The presented reference images can be used to guide scoring of wrist joints according to the OMERACT RA MRI scoring system.

OBJECTIVE:To assess the inter-reader reliability of 3 rheumatologist readers before and after training using 2 methods of assessment: magnetic resonance imaging (MRI) computerized erosion volume assessment and MRI scoring using the OMERACT-5 Rheumatoid Arthritis MRI Score (OM-5 RAMRIS) criteria.METHODS:Erosion volumes were measured in 10 patients [5 wrist and 5 metacarpophalangeal (MCP) joint studies] with rheumatoid arthritis. Erosion scores were derived from this group and 8 additional subjects to provide a total of 18 subjects (10 wrist and 8 MCP joint studies) with MRI scores for comparison. Subjects were selected from existing MRI databases to provide a spectrum of joint damage for assessment. Initial reading was undertaken after the 2 inexperienced readers were provided with instructions regarding OSIRIS computer software and definitions of the OMERACT score; no other formal training was undertaken. One month after the initial reading, the 2 inexperienced readers undertook a 3 hour training session and all 3 readers then took part in 2 subsequent 2 hour calibration sessions. Each reader then reread the original MRI studies using the computerized erosion volume method and the OMERACT MRI RA score. The interval between the baseline and post-training reading was 2 months. All reading was undertaken on a computer workstation and readers were blinded to other readers' results.RESULTS:For the wrist MRI studies, inter-reader agreement improved considerably after training for both the computerized MRI volume method and the OMERACT MRI score [intraclass correlation coefficients (ICC) 0.21 and 0.46, respectively, pre-training; 0.92 and 0.85 post-training]. The correlation between all readers' scores and volumes was excellent at baseline and post-training. For the MCP joint studies, inter-reader agreement was moderate at baseline for the erosion volume and score (ICC 0.51 and 0.61). While there was some improvement in agreement post-training for the scoring method (ICC 0.75), there was no significant improvement for the erosion volumes (ICC 0.58).CONCLUSION:Overall, inter-reader agreement for erosion scoring and volume measurement was higher for the wrist joint. The lack of improvement in the MCP joint region for the erosion volume measurements appears to relate primarily to difficulties in estimating the erosion border in the proximal MCP joints using the manual outlining tool. This limits the usefulness of erosion volume measurements in this joint region.

This paper outlines the most important pitfalls which are likely to be encountered in the assessment of magnetic resonance images of the wrist and metacarpophalangeal joints in patients with rheumatoid arthritis. Imaging artefacts and how these can be recognised using various sequences and views are discussed. Normal structures such as interosseous ligaments and nutrient foramina may appear prominent on certain images and need to be identified correctly. Pathological change in the rheumatoid hand involves many tissues and when substantial damage has occurred, it may be difficult to identify individual structures correctly. Bone erosion, bone oedema, synovitis, and tenosynovitis frequently occur together and in close proximity to each other, potentially leading to false positive scoring of any of these. Examples are given to illustrate the various dilemmas the user of this atlas may face when scoring the rheumatoid hand and suggestions are made to assist correct interpretation of what can be very complex images.