| |
 |
Volunteer Opportunities |
 |
|
|
|
|
Resources
for Clinicians
| Topics
A-Z |
|
|
Acupuncture
Systematic
Reviews & Meta-Analyses
- Acupuncture
for the management of chronic headache: a systematic review
Sun Y, Gan TJ.
Anesth Analg. 2008 Dec;107(6):2038-47
The majority of included trials comparing true acupuncture and sham
acupuncture showed a trend in favor of acupuncture. The combined response
rate in the acupuncture group was significantly higher compared with
sham acupuncture either at the early follow-up period. Combined data
also showed acupuncture was superior to medication therapy for headache
intensity, headache frequency, physical function, and response rate.
Needling acupuncture is superior to sham acupuncture and medication
therapy in improving headache intensity, frequency, and response rate.
- Acupuncture
treatment for pain: systematic review of randomised clinical trials
with acupuncture, placebo acupuncture, and no acupuncture groups
Madsen MV, Gøtzsche PC, Hróbjartsson A.
BMJ. 2009 Jan 27;338:a3115
A small difference was found between acupuncture and placebo acupuncture.
A moderate difference was found between placebo acupuncture and no acupuncture.
However, considerable heterogeneity was also found, as large trials
reported both small and large effects of placebo. No association was
detected between the type of placebo acupuncture and the effect of acupuncture.
A small analgesic effect of acupuncture was found, which seems to lack
clinical relevance and cannot be clearly distinguished from bias. Whether
needling at acupuncture points, or at any site, reduces pain independently
of the psychological impact of the treatment ritual is unclear.
- Effectiveness
of acupuncture for low back pain: a systematic review
Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S.
Spine. 2008 Nov 1;33(23):E887-900.
Twenty-three trials (n = 6359) were included and classified into 5 types
of comparisons, 6 of which were of high quality. There is moderate evidence
that acupuncture is more effective than no treatment, and strong evidence
of no significant difference between acupuncture and sham acupuncture,
for short-term pain relief. There is strong evidence that acupuncture
can be a useful supplement to other forms of conventional therapy for
nonspecific LBP, but the effectiveness of acupuncture compared with
other forms of conventional therapies still requires further investigation.
Acupuncture versus no treatment, and as an adjunct to conventional care,
should be advocated in the European Guidelines for the treatment of
chronic LBP.
- Treatment
regimens of acupuncture for low back pain--a systematic review
Yuan J, Kerr D, Park J, Liu XH, McDonough S.
Complement Ther Med. 2008 Oct;16(5):295-304.
For non-specific LBP, treatment regimens of acupuncture differ by the
types of reference sources, in terms of treatment frequency, the points
chosen, number of points needled per session, duration and sessions,
and co-interventions.
Chronic Fatigue
Systematic Reviews &
Meta-Analyses
- Efficacy
of cognitive behavioral therapy for chronic fatigue syndrome: a meta-analysis
Malouff JM, Thorsteinsson EB, Rooke SE, Bhullar N, Schutte NS.
Clin Psychol Rev. 2008 Jun;28(5):736-45.
A meta-analysis of the efficacy of cognitive behavioral therapy (CBT)
in treating chronic fatigue included 15 effect sizes for between-group
outcome comparisons. Across analyses, which included a total of 1371
participants, there was a significant difference, d=0.48, in post-treatment
fatigue between participants receiving CBT and those in control conditions.
Results indicate that CBT for chronic fatigue syndrome tends to be moderately
efficacious. Dropout rates in CBT varied from 0-42%, with a mean of
16%. In the five studies that reported the number of CBT clients who
were no longer in the clinical range with regard to fatigue at the latest
follow-up, the percentage varied from 33% to 73% of those assigned to
CBT, with a mean of 50%. Moderator results suggest directions for future
investigations.
- Exercise
therapy for chronic fatigue syndrome
Edmonds M, McGuire H, Price J.
Cochrane Database of Systematic Reviews. 2004 Issue 3
There is encouraging evidence that some patients may benefit from exercise
therapy and no evidence that exercise therapy may worsen outcomes on
average. However the treatment may be less acceptable to patients than
other management approaches, such as rest or pacing. Patients with CFS
who are similar to those in these trials should be offered exercise
therapy, and their progress monitored Further high quality randomised
studies are needed.
- Systematic
Review of the Current Literature Related to Disability and Chronic Fatigue
Syndrome
Agency for Healthcare Research and Quality. December 2002
While relationships between various impairment measures and work/disability
status might be explored in some cases, the best available evidence
from the literature did not allow for determination of causality. The
limitations inherent in the current literature review are noted and
the research community is urged to conduct methodologically rigorous,
longitudinal, interventional studies to determine what baseline characteristics
are associated with inability to work, and what interventions are effective
in restoring the ability to work in the CFS population.
Additional Resources
- Defining
and Managing Chronic Fatigue Syndrome
Evidence Report/Technology Assessment Number 42
Agency for Healthcare Research and Quality. October 2001
Existing case definitions for CFS appear to characterize a group of
people with prolonged fatigue and impaired ability to function. The
validity and superiority of any particular case definition are not well
established. Surveys suggest that the prevalence of CFS in community
populations is less than 1%. Precise estimates of rates of recovery,
improvement and/or relapse from CFS are not available. Although several
therapies have been studied, potential benefits as well as harms of
most therapies are not well established. Behavioral interventions that
emphasize increasing activity levels may improve quality of life and
function in some people with CFS.
Chronic Illness & Disability
- Chronic
illness experience: insights from a metastudy
Thorne S, Paterson B, Acorn S, Canam C, Joachim G, Jillings C.
Qual Health Res. 2002 Apr;12(4):437-52.
Concurrent with the recent enthusiasm for qualitative research in the
health fields, an energetic call for methods by which to synthesize
the knowledge has been generated on various substantive topics. Although
there is an emerging literature on meta-analysis and metasynthesis,
many authors overestimate the simplicity of such approaches and erroneously
assume that useful knowledge can be synthesized from limited collections
of study reports without a thorough analysis of their theoretical, methodological,
and contextual foundations and features. In this article, the authors
report some of the insights obtained from an extensive and exhaustive
metastudy of qualitative studies of chronic illness experience. Their
findings reveal the complexities inherent not only in any phenomenon
of interest to health researchers but also in the study of how we have
come to know what we think we know about it.
- Is
it beneficial to involve a family member? A meta-analysis of psychosocial
interventions for chronic illness
Martire LM, Lustig AP, Schulz R, Miller GE, Helgeson VS.
Health Psychol. 2004 Nov;23(6):599-611
Links between chronic illness and family relationships have led to psychosocial
interventions targeted at the patient's closest family member or both
patient and family member. The authors conducted a meta-analytic review
of randomized studies comparing these interventions with usual medical
care (k=70), focusing on patient outcomes (depression, anxiety, relationship
satisfaction, disability, and mortality) and family member outcomes
(depression, anxiety, relationship satisfaction, and caregiving burden).
Among patients, interventions had positive effects on depression when
the spouse was included and, in some cases, on mortality. Among family
members, positive effects were found for caregiving burden, depression,
and anxiety; these effects were strongest for nondementing illnesses
and for interventions that targeted only the family member and that
addressed relationship issues. Although statistically significant aggregate
effects were found, they were generally small in magnitude. These findings
provide guidance in developing future interventions in this area.
- The
shifting perspectives model of chronic illness
Paterson BL.
J Nurs Scholarsh. 2001;33(1):21-6.
Shifting Perspectives Model of Chronic Illness, which was derived from
a metasynthesis of 292 qualitative research studies, was derived from
a metasynthesis of qualitative research about the reported experiences
of adults with a chronic illness. The 292 primary research studies included
a variety of interpretive research methods and were conducted by researchers
from numerous countries and disciplines. Many of the assumptions that
underlie previous models, such as a single, linear trajectory of living
with a chronic disease, were challenged. The Shifting Perspectives Model
indicated that living with chronic illness was an ongoing and continually
shifting process in which an illness-in-the-foreground or wellness-in-the-foreground
perspective has specific functions in the person's world. The Shifting
Perspectives Model helps users provide an explanation of chronically
ill persons' variations in their attention to symptoms over time, sometimes
in ways that seem ill-advised or even harmful to their health. The model
also indicates direction to health professionals about supporting people
with chronic illness.
Chronic Pain & Depression
Systematic Reviews &
Meta-Analyses
- A
systematic review on the effectiveness of treatment with antidepressants
in fibromyalgia syndrome
Uçeyler N, Häuser W, Sommer C.
Arthritis Rheum. 2008 Sep 15;59(9):1279-98
Amitriptyline 25-50 mg/day reduces pain, fatigue, and depressiveness
in patients with FMS and improves sleep and quality of life. Most SSRIs
and the SNRIs duloxetine and milnacipran are probably also effective.
Short-term treatment of patients with FMS using amitriptyline or another
of the antidepressants that were effective in RCTs can be recommended.
Data on long-term efficacy are lacking.
- Treatment
of fibromyalgia syndrome with antidepressants: a meta-analysis
Häuser W, Bernardy K, Uçeyler N, Sommer C.
JAMA. 2009 Jan 14;301(2):198-209
Eighteen randomized controlled trials (median duration, 8 weeks; range,
4-28 weeks) involving 1427 participants were included. Overall, there
was strong evidence for an association of antidepressants with reduction
in pain, depressed mood , and sleep disturbances. There was strong evidence
for an association of antidepressants with improved health-related quality
of life. Antidepressant medications are associated with improvements
in pain, depression, fatigue, sleep disturbances, and health-related
quality of life in patients with FMS.
Additional Resources
- Clinician
beliefs about opioid use and barriers in chronic nonmalignant pain
Grahmann PH, Jackson KC, Lipman AG.
J Pain Palliat Care Pharmacother, 18(2): 7-28 2004
A survey of the medical directors of multidisciplinary pain clinics
and multidisciplinary pain centers listed in the American Pain Society
Pain Facilities Directory was conducted to define those pain specialists'
beliefs about the role of opioid analgesia in 14 types of chronic nonmalignant
pain. Respondents also reported their perceptions of barriers to their
prescribing opioids for chronic nonmalignant pain and what they perceived
as barriers to opioid prescribing for chronic nonmalignant pain by other,
non-pain specialist clinicians in their communities. The respondents
are characterized by demographics, disciplines, specialties, and time
in practice. The percentage of time that a pharmacist was available
in the pain programs also is reported. There is increasing acceptance
of opioids for most of the listed types of chronic nonmalignant pain,
but the acceptance varies by types of pain syndromes. Opioids were most
consistently accepted for sickle cell disease pain and least commonly
endorsed for headaches, myofascial pain, and fibromyalgia. Factors that
may influence clinicians' perceptions about opioids are discussed.
- Common
pathways of depression and pain
Delgado PL
J Clin Psychiatry, 65 Suppl 12(): 16-9 2004
Depressive disorders are chronic conditions that produce both emotional
and physical symptoms. Increasing evidence suggests that in some patients
with depressive disorders a neurodegenerative process may occur, highlighting
the importance of early and aggressive intervention. Serotonin (5-HT)
and norepinephrine (NE) neurotransmitter systems influence neuroplasticity
in the brain, and both are involved in mediating the therapeutic effects
of most currently available antidepressants. Some dual-action antidepressants
have been shown to be effective in managing the pain symptoms associated
with depression. These agents may have advantages over others by treating
a wider array of physical symptoms. Additionally, these agents may also
have a role in modulating neurogenesis and other neuroplastic changes,
thereby leading to more complete recovery in patients suffering from
the emotional and physical symptoms of chronic depression.
- Managing
Chronic Pain, Depression & Antidepressants: Issues & Relationships
Clarke, M.
Johns Hopkins Arthritis Center. 2001
Chronic pain is an intrapersonal experience not a specific diagnosis.
Patients with chronic pain should receive treatment for underlying medical
conditions, and should be evaluated for anxiety and distress. Major
depression is a common psychiatric comorbidity of chronic pain, is associated
with severe consequences, and is very responsive to treatment. In addition
to being a primary treatment for depression, antidepressants are effective
in the treatment of many chronic pain syndromes such as neuropathic
disorders. The complexity of chronic pain requires an extensive knowledge
of the potential actions of many pharmacological agents. The physician
should always think about the innovative application of medications
regardless of how they are traditionally classified.
- Specific
characteristics of the pain/depression association in the general population
Ohayon MM
J Clin Psychiatry, 65 Suppl 12(): 5-9 2004
A chronic painful physical condition (CPPC) was present in nearly half
of subjects with major depressive disorder(MDD). CPPCs increased the
severity of physical symptoms of depression (fatigue, insomnia, psychomotor
retardation, weight gain). Moreover, CPPCs affected the duration of
depressive episodes and their recurrence. Physicians should consider
CPPCs as a major factor in the expression and evolution of MDD. They
must remember that MDD patients tend to amplify physical symptoms, to
the detriment of their depressive symptomatology.
Fibromyalgia
Systematic Reviews &
Meta-Analyses
- A
systematic review on the effectiveness of treatment with antidepressants
in fibromyalgia syndrome
Uçeyler N, Häuser W, Sommer C.
Arthritis Rheum. 2008 Sep 15;59(9):1279-98
Amitriptyline 25-50 mg/day reduces pain, fatigue, and depressiveness
in patients with FMS and improves sleep and quality of life. Most SSRIs
and the SNRIs duloxetine and milnacipran are probably also effective.
Short-term treatment of patients with FMS using amitriptyline or another
of the antidepressants that were effective in RCTs can be recommended.
Data on long-term efficacy are lacking.
- Efficacy
of multicomponent treatment in fibromyalgia syndrome: A meta-analysis
of randomized controlled clinical trials
Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M.
Arthritis Rheum. 2009 Feb 15;61(2):216-24.Click here to read
There was strong evidence that multicomponent treatment reduces pain,
fatigue, depressive symptoms, and limitations to health-related quality
of life and improves self-efficacy pain and physical fitness at posttreatment.
There was no evidence of its efficacy on pain, fatigue, sleep disturbances,
depressive symptoms, HRQOL, or self-efficacy pain in the long term.
There was strong evidence that positive effects on physical fitness
can be maintained in the long term (median followup 7 months).There
is strong evidence that multicomponent treatment has beneficial short-term
effects on the key symptoms of FMS. Strategies to maintain the benefits
of multicomponent treatment in the long term need to be developed.
- Treatment
of fibromyalgia syndrome with antidepressants: a meta-analysis
Häuser W, Bernardy K, Uçeyler N, Sommer C.
JAMA. 2009 Jan 14;301(2):198-209
Eighteen randomized controlled trials (median duration, 8 weeks; range,
4-28 weeks) involving 1427 participants were included. Overall, there
was strong evidence for an association of antidepressants with reduction
in pain, depressed mood , and sleep disturbances. There was strong evidence
for an association of antidepressants with improved health-related quality
of life. Antidepressant medications are associated with improvements
in pain, depression, fatigue, sleep disturbances, and health-related
quality of life in patients with FMS.
Additional Resources
- Psychological
stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine
link
Gupta A, Silman AJ.
Arthritis Res Ther. 2004;6(3):98-106.
The present review attempts to reconcile the dichotomy that exists in the literature in relation to fibromyalgia, in that it is considered either a somatic response to psychological stress or a distinct organically based syndrome. Specifically, the hypothesis explored is that the link between chronic stress and the subsequent development of fibromyalgia can be explained by one or more abnormalities in neuroendocrine function. There are several such abnormalities recognised that both occur as a result of chronic stress and are observed in fibromyalgia. Whether such abnormalities have an aetiologic role remains uncertain but should be testable by well-designed prospective studies.
Health Professional & Patient
Communication
- Beliefs
about control in the physician-patient relationship: effect on communication
in medical encounters
Street RL Jr, Krupat E, Bell RA, Kravitz RL, Haidet P.
J Gen Intern Med. 2003 Aug;18(8):609-16.
This investigation examined the extent to which physicians' and patients'
preferences for control in their relationship (e.g., shared control
vs doctor control) were related to their communications styles and adaptations
(i.e., how they responded to the communication of the other participant).
Patients who preferred shared control were more active participants
(i.e., expressed more opinions, concerns, and questions) than were patients
oriented toward doctor control. Physicians' beliefs about control were
not related to their use of partnership building. However, physicians
did use more partnership building with male patients. Not only were
active patient participation and physician partnership building mutually
predictive of each other, but also approximately 14% of patient participation
was prompted by physician partnership building and 33% of physician
partnership building was in response to active patient participation.
Conclusions: Communication in medical encounters is influenced by the
physician's and patient's beliefs about control in their relationship
as well as by one another's behavior. The relationship between physicians'
partnership building and active patient participation is one of mutual
influence such that increases in one often lead to increases in the
other.
Low Back Pain
- Acupuncture
and dry-needling for low back pain
Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman
BM.
Cochrane Database of Systematic Reviews. 2004 Issue 4
Thirty-five RCTs covering 2861 patients were included in this systematic
review. There is insufficient evidence to make any recommendations about
acupuncture or dry-needling for acute low-back pain. For chronic low-back
pain, results show that acupuncture is more effective for pain relief
than no treatment or sham treatment, in measurements taken up to three
months. The results also show that for chronic low-back pain, acupuncture
is more effective for improving function than no treatment, in the short-term.
Acupuncture is not more effective than other conventional and "alternative"
treatments. When acupuncture is added to other conventional therapies,
it relieves pain and improves function better than the conventional
therapies alone. However, effects are only small. Dry-needling appears
to be a useful adjunct to other therapies for chronic low-back pain.
- Antidepressants
for non-specific low back pain
Urquhart D, Hoving JL, Assendelft WJJ, Roland M, van Tulder MW.
Cochrane Database of Systematic Reviews. 2008 Issue 1
Ten trials that compared antidepressants with placebo were included
in this review. The pooled analyses showed no difference in pain relief
(six trials; standardized mean difference (SMD) -0.06 (95% confidence
interval (CI) -0.28 to 0.16)) or depression (two trials; SMD 0.06 (95%
CI -0.29 to 0.40)) between antidepressant and placebo treatments. The
qualitative analyses found conflicting evidence on the effect of antidepressants
on pain intensity in chronic low-back pain, and no clear evidence that
antidepressants reduce depression in chronic low-back pain patients.
Two pooled analyses showed no difference in pain relief between different
types of antidepressants and placebo. Our findings were not altered
by the sensitivity analyses which varied the level of methodological
quality required for inclusion in the meta-analyses to allow data from
additional trials to be examined. Two additional trials were identified
in September 2007 and await assessment. AUTHORS' CONCLUSIONS: There
is no clear evidence that antidepressants are more effective than placebo
in the management of patients with chronic low-back pain. These findings
do not imply that severely depressed patients with back pain should
not be treated with antidepressants; furthermore, there is evidence
for their use in other forms of chronic pain.
- Effectiveness
of acupuncture for low back pain: a systematic review
Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S.
Spine. 2008 Nov 1;33(23):E887-900.
Twenty-three trials (n = 6359) were included and classified into 5 types
of comparisons, 6 of which were of high quality. There is moderate evidence
that acupuncture is more effective than no treatment, and strong evidence
of no significant difference between acupuncture and sham acupuncture,
for short-term pain relief. There is strong evidence that acupuncture
can be a useful supplement to other forms of conventional therapy for
nonspecific LBP, but the effectiveness of acupuncture compared with
other forms of conventional therapies still requires further investigation.
Acupuncture versus no treatment, and as an adjunct to conventional care,
should be advocated in the European Guidelines for the treatment of
chronic LBP.
- Exercise
therapy for treatment of non-specific low back pain
Hayden JA, van Tulder MW, Malmivaara A, Koes BW.
Cochrane Database of Systematic Reviews. 2005 Issue 2
Exercise therapy appears to be slightly effective at decreasing pain
and improving function in adults with chronic low-back pain, particularly
in populations visiting a healthcare provider. In adults with subacute
low-back pain there is some evidence that a graded activity program
improves absenteeism outcomes, though evidence for other types of exercise
is unclear. For patients with acute low-back pain, exercise therapy
is as effective as either no treatment or other conservative treatments.
- Neuroreflexotherapy
for non-specific low-back pain
Urrútia G, Burton AK, Morral A, Bonfill X, Zanoli G.
Cochrane Database of Systematic Reviews. 2005 Issue 2
Neuroreflexotherapy, provided in specialized clinics in Spain, appears
to reduce pain and disability for patients with chronic non-specific
low-back pain. In this review, neuroreflexotherapy performed better
than placebo or standard care. However, until research duplicates these
results in different settings, there is no strong evidence that it will
work as well outside the specialty clinics in Spain.
- Patient
expectations of treatment for back pain: a systematic review of qualitative
and quantitative studies
Verbeek J, Sengers MJ, Riemens L, Haafkens J.
2004 Oct 15;29(20):2309-18.
A systematic review concluded patients have explicit expectations on
diagnosis, instructions, and interpersonal management. New strategies
need to be developed in order to meet patients' expectations better.
Practice guidelines should pay more attention to the best way of discussing
the causes and diagnosis with the patient and should involve them in
the decision-making process.
- Spinal
manipulative therapy for low-back pain
Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG.
Cochrane Database of Systematic Reviews. 2004 Issue 1
There was little or no difference in pain reduction or the ability to
perform everyday activities between people with low-back pain who received
spinal manipulation and those who received other advocated therapies.
This review of 39 trials found that spinal manipulation was more effective
in reducing pain and improving the ability to perform everyday activities
than sham (fake) therapy and therapies already known to be unhelpful.
However, it was no more or less effective than medication for pain,
physical therapy, exercises, back school or the care given by a general
practitioner.
- Treatment
regimens of acupuncture for low back pain--a systematic review
Yuan J, Kerr D, Park J, Liu XH, McDonough S.
Complement Ther Med. 2008 Oct;16(5):295-304.
For non-specific LBP, treatment regimens of acupuncture differ by the
types of reference sources, in terms of treatment frequency, the points
chosen, number of points needled per session, duration and sessions,
and co-interventions.
Musculoskeletal Pain & Osteoarthritis
Systematic Reviews &
Meta-Analyses
- Osteotomy
for treating knee osteoarthritis
Brouwer RW, Raaij van TM, Bierma-Zeinstra SMA, Verhagen AP, Jakma TSC,
Verhaar JAN.
Cochrane Database of Systematic Reviews. 2007 Issue 3
Based on 13 studies, the authors conclude that there is 'silver' level
evidence (www.cochranemsk.org) that valgus HTO improves knee function
and reduces pain. There is no evidence whether an osteotomy is more
effective than conservative treatment and the results so far do not
justify a conclusion about effectiveness of specific surgical techniques.
Additional Resources
- Musculoskeletal
conditions and complementary/alternative medicine
Ernst E.
Best Pract Res Clin Rheumatol, 18(4):539-56 2004
Complementary/alternative medicine (CAM) is immensely popular for musculoskeletal conditions. It is, therefore,
essential to define CAM's value for such indications. This chapter summarises the trial data for or against CAM as a
symptomatic treatment for back pain, fibromyalgia, neck pain, osteoarthritis and rheumatoid arthritis.
Collectively the evidence demonstrates that some CAM modalities show significant promise, e.g. acupuncture, diets, herbal
medicine, homoeopathy, massage, supplements. None of the treatments in question is totally devoid of risks. By and large
the data are not compelling, not least due to their paucity and methodological limitations. It is, therefore, concluded
that our research efforts must be directed towards defining which form of CAM generates more good than harm for which
condition.
- What
patients want - Treatment of OA of the Knee
Bandolier. 2004
There is much to say about how informative this study is. That patients
prefer rapid action, good effect, and few adverse events (common or
rare) from a once a day medicine is predictable. That adverse events
(common or rare) dominate over efficacy is predictable. Bandolier would
not have predicted that topical capsaicin would be preferred over other
choices, nor that traditional NSAIDs would be chosen by none. Where
patient choice is meant to be increasingly important in healthcare,
the difference between these results and most guidelines for treatment
is stark. For most of those topical capsaicin would not get a look in,
and NSAIDs would be preferred over Cox-2 inhibitors on grounds of acquisition
costs.
Neck Pain
Systematic Reviews &
Meta-Analyses
- Manipulation
and mobilization for mechanical neck disorders
Gross A, Hoving JL, Haines T, Goldsmith CH, Kay TM, Aker P, Brønfort
G.
Cochrane Database of Systematic Reviews. 2004 Issue 1
People with neck pain as well as people with neck pain plus related
headache that lasted at least one month, who received multimodal care
that included exercises plus mobilisation [movement imposed onto joints
and muscles] or manipulation [adjustments] reported greater pain reduction,
improved ability to perform everyday activities and an increase in their
perceived effects of treatment than those who received no treatment.
Outcome Measures
Psoriatic Arthritis
Systematic Reviews &
Meta-Analyses
- A
systematic review and meta-analysis of efficacy and toxicity of disease
modifying anti-rheumatic drugs and biological agents for psoriatic arthritis
Ravindran V, Scott DL, Choy EH.
Ann Rheum Dis. 2008 Jun;67(6):855-9.
Treatment was more effective than placebo (RR = 0.35; 95% CI 0.25, 0.49)
but caused more toxicity (RR = 2.33; 95% CI 1.61, 3.37). There was evidence
that gold, sulfasalazine, leflunomide and TNF inhibitors were effective;
gold and TNF inhibitors showed the largest effect sizes; TNF inhibitors
had the best efficacy/toxicity ratio (number needed to harm/number needed
to treat = 0.25); tolerability was least with gold and leflunomide.
Efficacy/toxicity ratios were highest with TNF inhibitors followed by
leflunomide, gold and sulfasalazine. Gold, though effective, has excessive
toxicity and sulfasalazine, though of low toxicity, was also relatively
ineffective.
- Etanercept
and infliximab for the treatment of psoriatic arthritis: a systematic
review and economic evaluation
Woolacott N, Bravo Vergel Y, Hawkins N, Kainth A, Khadjesari Z, Misso
K, Light K, Asseburg C, Palmer S, Claxton K, Bruce I, Sculpher M, Riemsma
R.
Health Technol Assess. 2006 Sep;10(31):iii-iv, xiii-xvi, 1-239.
The limited data available indicated that etanercept and infliximab
are efficacious in the treatment of PsA with beneficial effects on both
joint and psoriasis symptoms and on functional status. Short-term data
indicated that etanercept can delay joint disease progression, but long-term
data are needed. There are no controlled data as yet to indicate that
infliximab can delay joint disease progression. Treatment with both
etanercept and infliximab for 12 weeks demonstrated a significant degree
of efficacy, with no statistically significant difference between them.
For both drugs, adverse events were common with mild injection/infusion
reactions being the main treatment-related effect. The York model indicated
that etanercept is more cost-effective than infliximab as it has a lower
cost with little difference in outcomes. The cost-effectiveness of etanercept
is also sensitive to assumptions made about the extent of disease progression
when patients are responding to therapy. The number of years for which
a patient can be safely on biologicals is uncertain so these results
should be considered with caution. Further research should include long-term
controlled trials to confirm benefits, review adverse events and to
explore further the implications of biologic therapy.
Rheumatoid Arthrirtis
Systematic Reviews &
Meta-Analyses
- Balneotherapy
for rheumatoid arthritis
Verhagen AP, Bierma-Zeinstra SMA, Boers M, Cardoso JR, Lambeck J, de
Bie R, de Vet HCW.
Cochrane Database of Systematic Reviews. 2004 Issue 1
Overall there is insufficient evidence that balneotherapy is more effective
than no treatment, that one type of bath is more effective than another,
or that one type of bath is more effective than mudpacks, exercises
or relaxation therapy. Authors' conclusions Silver level evidence was
found for one study in favour of mineral baths compared to drug treatment
at eight weeks. Insufficient evidence was found for all other comparisons.
However the scientific evidence is insufficient because of poor methodological
quality. Therefore, the noted "positive findings" should be viewed with
caution. Because of the methodological flaws, an answer about the apparent
effectiveness of balneotherapy cannot be provided at this moment.
- Tai
chi for treating rheumatoid arthritis
Han A, Judd MG, Robinson VA, Taixiang W, Tugwell P, Wells G.
Cochrane Database of Systematic Reviews. 2004 Issue 3
Four trials including 206 participants, were included in this review.
Tai Chi-based exercise programs had no clinically important or statistically
significant effect on most outcomes of disease activity, which included
activities of daily living, tender and swollen joints and patient global
overall rating. For range of motion, Tai Chi participants had statistically
significant and clinically important improvements in ankle plantar flexion.
No detrimental effects were found. One study found that compared to
people who participated in traditional ROM exercise/rest programs those
in a Tai Chi dance program reported a significantly higher level of
participation in and enjoyment of exercise both immediately and four
months after completion of the Tai Chi program. The results suggest
Tai Chi does not exacerbate symptoms of rheumatoid arthritis. In addition,
Tai Chi has statistically significant benefits on lower extremity range
of motion, in particular ankle range of motion, for people with RA.
The included studies did not assess the effects on patient-reported
pain.
- The
effectiveness of infliximab and etanercept for the treatment of rheumatoid
arthritis: a systematic review and economic evaluation
Jobanputra P, Barton P, Bryan S, Burls A.
Health Technol Assess. 2002;6(21):1-110.
Further research and development of economic models is necessary to
reflect clinical practice more accurately. Future models need to include
other aspects of RA, such as disease complications, to improve current
models. Comparative studies of anti-TNF agents and other DMARDs (new
and old) should be carried out, as only one study included in this review
compared anti-TNF directly with another DMARD. This showed equivalent
efficacy. Such direct comparisons have a potential for informing practice,
especially where therapeutic choices that take cost into account are
to be made. Studies of the quality of life of RA patients in the long
term and the impact of DMARDs and other interventions on quality of
life are needed. Also needed are studies of the impact of DMARDs on
joint replacemphasizent, and other disease and drug-related morbidity,
and on mortality.
- The
effect of treatment on radiological progression in rheumatoid arthritis:
a systematic review of randomized placebo-controlled trials
G. Jones, J. Halbert1, M. Crotty1, E. M. Shanahan2, M. Batterham1 and
M. Ahern.
Rheumatology 2003; 42: 6-13
A total of 38 trials were identified. Of these, 13 were excluded, leaving
data on 3907 subjects. Infliximab, cyclosporin, sulphasalazine, leflunomide,
methotrexate, parenteral gold, corticosteroids, auranofin and interleukin
1 receptor antagonist were statistically better than placebo in terms
of change in erosion scores. All agents were equivalent statistically,
with the exception of infliximab (which was superior to the last five
agents). There were similar findings for the odds of progression, with
the exception of auranofin (P=0.06) and the infliximab–methotrexate
comparison (P=0.07). Other agents did not reach statistical significance
in either outcome measure. With the exception of the antimalarials,
the magnitude of the effect was consistent with the effect seen in short-term
disease activity trials. Conclusion. There is published evidence which
supports the efficacy of nine agents in decreasing radiological progression
in rheumatoid arthritis.
Additional Resources
-
Evidence for early disease-modifying drugs in rheumatoid arthritis
Scott, DL.
Arthritis Res Ther. 2004; 6(1): 15–18.
Some research evidence supports early aggressive treatment of rheumatoid
arthritis (RA) using combination therapy with two or more disease modifying
anti-rheumatic drugs (DMARDs) plus steroids, or even DMARDs plus an
anti-TNF. By contrast, conservatively delayed DMARD monotherapy, given
after non-steroidal anti-inflammatory drugs have failed, has been criticised.
However, recent long-term studies highlight the complexities in evaluating
whether to abandon pyramidal treatment in favour of early DMARDs. Although
patients given early DMARD therapy show short-term benefits, longer-term
results show no prolonged clinical advantages from early DMARDs. By
5 years patients receiving early DMARDs had similar disease activity
and comparable health assessment questionnaire scores to patients who
received DMARDs later in their disease course. X-ray progression was
persistent and virtually identical in both groups. These negative findings
do not invalidate the case for early DMARD therapy, as it is gives sustained
reductions in disease activity in the early years of treatment without
excessive risks from adverse effects. However, early DMARDs alone do
not adequately control RA in the longer term. This may require starting
with very aggressive therapy or treating patients more aggressively
after early DMARD therapy has been initiated.
|
| |
|
| |
|
|
|
|
|
|
|
|
|
PRINT FRIENDLY PAGE