Rheumatoid Arthritis: Helliwell PS

Healy PJ, Helliwell PS. · Academic Unit of Musculoskeletal Medicine, University of Leeds, UK. · Curr Opin Rheumatol. · Pubmed #15956834 No free full text.

Abstract: 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.

Helliwell PS, Taylor WJ. · Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds LS2 9NZ, UK. · Ann Rheum Dis. · Pubmed #15708931 links to  free full text

Abstract: BACKGROUND: The study of psoriatic arthritis is difficult and has lagged behind the study of other arthropathies in that there are no universally agreed or properly validated case definitions. METHOD: This paper examined the validity and practicality of the original Moll and Wright criteria and subsequent criteria sets. Key features discriminating between psoriatic and other arthropathies were reviewed. A comparative study involving patients with psoriatic arthritis and rheumatoid arthritis was used to contrast the different classification methods. RESULTS: Although the Moll and Wright criteria continue to be widely used, they have been shown to discriminate poorly between psoriatic and rheumatoid arthritis. In comparison, the most sensitive criteria were those of Vasey and Espinoza, McGonagle et al, and Gladman et al (99%), whereas the others were significantly less sensitive (between 56% and 94%). The specificity of all methods was high and statistically similar (between 93% and 99%). Models that had reasonably good accuracy even without such key variables as psoriasis or rheumatoid factor were developed. Spinal involvement continues to be a key feature of psoriatic arthritis, but dissimilarities with classic ankylosing spondylitis have been highlighted. CONCLUSIONS: Further work is required to produce classification criteria for psoriatic arthritis. A prospective study collecting clinical, radiological, human leucocyte antigen (HLA) and immunological data from both psoriatic and non-psoriatic cases should provide agreed criteria for use in psoriatic arthritis studies in the future.

Helliwell PS. · Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, United Kingdom. · Curr Opin Rheumatol. · Pubmed #15201595 No free full text.

Abstract: 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.

Davys HJ, Turner DE, Helliwell PS, Conaghan PG, Emery P, Woodburn J. · Health Department, The Leeds General Infirmary, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK. · Rheumatology (Oxford). · Pubmed #15479752 links to  free full text

Abstract: OBJECTIVE: To compare forefoot pain, pressure and function before and after normal and sham callus treatment in rheumatoid arthritis (RA). Patients and METHODS: Thirty-eight RA patients were randomly assigned to normal (NCT group) or sham (SCT) scalpel debridement. The sham procedure comprised blunt-edged scalpel paring of the callus which delivered a physical stimulus but left the hyperkeratotic tissue intact, the procedure being partially obscured from the patient. Forefoot pain was assessed using a 100 mm visual analogue scale (VAS), pressure using a high-resolution foot pressure scanner and function using the spatial-temporal gait parameters measured on an instrumented walkway. Radiographic scores of joint erosion were obtained for metatarsophalangeal (MTP) joints with and without overlying callosities. The trial consisted of a randomized sham-controlled phase evaluating the immediate same-day treatment effect and an unblinded 4-week follow-up phase. RESULTS: During the sham-controlled phase, forefoot pain improved in both groups by only 3 points on a VAS and no statistically significant between-group difference was found (P = 0.48). When data were pooled during the unblinded phase, the improvement in forefoot pain reached a peak after 2 days and gradually lessened over the next 28 days. Following debridement, peak pressures at the callus sites decreased in the NCT group and increased in the SCT group, but there was no statistically significant between-group difference (P = 0.16). The area of and duration of contact of the callus site on the ground remained unchanged following treatment in both groups. Following debridement, walking speed was increased, the stride-length was longer and the double-support time shorter in both groups; however, between-group differences did not reach levels of statistical significance. MTP joints with overlying callus were significantly more eroded than those without (P = 0.02). CONCLUSIONS: Treatment of painful plantar callosities in RA using scalpel debridement lessened forefoot pain but the effect was no greater than sham treatment. Localized pressure or gait function was not significantly improved following treatment.

Woodburn J, Helliwell PS, Barker S. · Rheumatology & Rehabilitation Research Unit, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, United Kingdom. · J Rheumatol. · Pubmed #14677177 No free full text.

Abstract: 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.

Woodburn J, Barker S, Helliwell PS. · Rheumatology and Rehabilitation Research Unit, University of Leeds, UK. · J Rheumatol. · Pubmed #12136891 No free full text.

Abstract: OBJECTIVE: To investigate the clinical effectiveness of early foot orthosis intervention for painful correctable valgus deformity of the rearfoot in rheumatoid arthritis (RA). METHODS: Patients with RA were randomized to receive custom manufactured rigid foot orthoses under podiatry supervision (n = 50) or enter a control group (n = 48). The control group received foot orthoses only when prescribed under normal medical care. Foot pain and disability, using the Foot Function Index (FFI), along with disease activity, tolerance, and adverse reactions, were serially measured over 30 mo continuous treatment. RESULTS: The group assigned foot orthoses demonstrated an immediate clinical improvement, the effect peaking at 12 mo. At 30 mo the FFI total score was reduced by 23.1% from baseline in the intervention group. Area under the curve analysis showed a statistically significant reduction in FFI scores for total score (p = 0.026), foot pain (p = 0.014), and foot disability (p = 0.016) when intervention was compared to control scores. There were no confounding effects from differences between groups for disease activity or pharmacological or other management strategies. Most patients (96%) used their orthoses and most found them comfortable (97%), although minor adverse reactions, such as tender spots, blisters, and callus, were reported in 30% of patients in the early stages of treatment and persisted in 12% for 30 mo. CONCLUSION: Custom designed foot orthoses used continuously over a 30 mo treatment period resulted in a reduction in foot pain by 19.1%, foot disability by 30.8%, and functional limitation by 13.5%. Clinical effectiveness might be enhanced by their use in the early stages of rearfoot pain and deformity.

Woodburn J, Stableford Z, Helliwell PS. · Rheumatology and Rehabilitation Research Unit, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK. · Rheumatology (Oxford). · Pubmed #10888711 links to  free full text

Abstract: OBJECTIVE: To determine the effect of expert debridement of foot callosities on forefoot pain and plantar pressure distribution in rheumatoid arthritis (RA). METHODS: Plantar callosities on 14 feet of eight RA patients were debrided by a single podiatrist. Measurements of subjective pain severity in the forefoot and global arthritis pain were undertaken using a visual analogue scale, repeated at 7-day intervals to the next treatment (28 days). Plantar pressures were recorded at the lesion sites using an in-shoe flexible transducer insole before and after lesion debridement. RESULTS: Following debridement, all patients reported symptomatic relief with an average change in pain score of 48% (P = 0.01) but the treatment effect was lost by 7 days. Immediately following scalpel debridement, peak pressures were elevated in 10 of 14 feet, whilst contact time was reduced and peak force increased. None, however, reached statistical significance. CONCLUSION: Scalpel debridement of forefoot plantar callosities reduces forefoot pain for about 7 days, but pressure distribution is not significantly altered.

Woodburn J, Turner DE, Helliwell PS, Barker S. · Rheumatology & Rehabilitation Research Unit, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK. · Rheumatology (Oxford). · Pubmed #10587556 links to  free full text

Abstract: OBJECTIVE: To determine the feasibility of using electromagnetic tracking (EMT) for quantifying three-dimensional kinematics at the ankle joint complex (AJC). METHODS: AJC kinematics were recorded in 10 normal healthy adults, and 10 rheumatoid arthritis patients presenting with AJC instability and deformity who were undergoing footwear and orthotic intervention. RESULTS: Kinematics in normal subjects had strong face validity, curve shape showing moderate (n=9), good (n=8) or excellent (n=4) agreement with data from seven published studies. The range of motion about the x-axis (15.2 degrees ) was similar to reference values (17.0 degrees ), but our technique underestimated rotations about the y- (8.1 degrees vs 14.0 degrees ) and z-axes (7.7 degrees vs 12.2 degrees ). In the rheumatoid arthritis pronated foot group, eversion and internal rotation during the stance phase of gait were between 2 and 5 times greater than for normal subjects. The use of a corrective foot orthosis in this group restored normal kinematics, reducing maximum eversion and internal rotation by 57 and 68%, respectively. CONCLUSION: A new technique for measuring kinematics at the AJC is described. Based upon the findings of this pilot study, EMT may be useful for diagnosing AJC dysfunction and quantifying the mechanical efficacy of footwear and orthosis interventions.

Helliwell PS, O'Hara M, Holdsworth J, Hesselden A, King T, Evans P. · Rheumatology Rehabilitation Research Unit, University of Leeds, UK. · Rheumatology (Oxford). · Pubmed #10378705 links to  free full text

Abstract: OBJECTIVE: In rheumatoid arthritis, education programmes successfully impart knowledge but, notwithstanding issues of empowerment, this knowledge has to be translated into behavioural change to have a chance of improving disease outcome. Arguably, behavioural change must also occur early if outcomes are to be improved. For these reasons, we planned a study of patient education in early disease, with radiological damage and quality of life as the main outcome variables. METHODS: We performed a randomized controlled trial in people with rheumatoid arthritis of < 5 yr duration. The main intervention was a 4 week education programme, each weekly session lasting 2 h. Assessments were made at entry, at 4 weeks and at 12 months. The main outcome variables were the modified Larsen radiological score for the hands and the SF-36 quality of life questionnaire. Secondary outcome variables were the Health Assessment Questionnaire (HAQ), Ritchie Articular Index (RAI), Patient Knowledge Questionnaire (PKQ), Compliance Questionnaire (CQ), plasma viscosity (PV), pharmaceutical changes and consulting behaviour. RESULTS: The patient numbers were 34 (10 male, 24 female) for the control group and 43 (16 male, 27 female) for the education group. The groups were matched for age (56.5 yr for control, 55 yr for education), disease duration (3.5 yr vs 3.0 yr) and duration of second-line drug therapy (14 months vs 12 months). We found no significant difference between the groups for Larsen scores at 12 months, although scores for the education group were lower (39.5 vs 43.0, P = 0.13). The 'social functioning' and 'general health perception' subscales of the SF-36 showed a significant improvement in the education group, but no significant differences between groups were seen. No significant differences were found for the HAQ, RAI, PV and CQ, but the education group had more disease-specific knowledge than the control group at 12 months (PKQ scores: 17 vs 21, P = 0.0002). No differences were found for out-patient visits and in-patient admissions, but the education group had slightly more changes in second-line drugs during the study (0.43 changes/person in the control group, 0.51 changes/person in the education group). CONCLUSIONS: We found no significant difference between the groups in our primary outcome measures, but a trend in favour of the education group was found in radiological progression. Further studies of this kind, using larger patient numbers, are required since the difference may result from improved self-care, better compliance with joint protection strategies and, possibly, improved drug compliance.

Wakefield RJ, Freeston JE, O'Connor P, Reay N, Budgen A, Hensor EM, Helliwell PS, Emery P, Woodburn J. · Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK. · Ann Rheum Dis. · Pubmed #18258710 No free full text.

Abstract: OBJECTIVES: The aim of this pilot study was to compare clinical examination (CE) and ultrasound (US) with high field MRI (as the reference standard) for the detection of rearfoot and midtarsal joint synovitis and secondly tenosynovitis of the ankle tendons in patients with established rheumatoid arthritis (RA). METHODS: Patients with RA (as determined by the modified American College of Rheumatology (ACR) criteria) with symptoms of midfoot and rearfoot disease were recruited. Demographic data were collected. All underwent CE, US and high field MRI (with intravenous gadolinium contrast) of their right foot. Percentage exact agreement (PEA), sensitivity and specificity were calculated for CE and US when compared to MRI. Inter-reader reliability for CE and US was also assessed. RESULTS: Compared to the gold standard of MRI, for CE (joint synovitis) the ranges for sensitivity, specificity and PEA were 55-83%, 23-46% and 46-60%, and for US were 64-89%, 60-80% and 64-78%, respectively. Compared to the gold standard of MRI, for CE (tenosynovitis) the ranges for sensitivity, specificity and PEA were 0-100%, 20-91% and 55-91%, and for US were 0-67%, 86-100% and 59-86%, respectively. CONCLUSION: CE was sensitive but US more specific in identifying hindfoot pathology in RA when compared to the reference standard of MRI. There was poor interobserver variability between ultrasonographers suggesting a need for standardisation of acquisition and interpretation of US images of the hindfoot.

Helliwell PS, Taylor WJ, Anonymous00278. · Academic Unit of Musculoskeletal and Rehabilitation Medicine, University of Leeds, Leeds, UK. · J Rheumatol. · Pubmed #18203324 No free full text.

Abstract: OBJECTIVE: Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic inflammatory diseases of the musculoskeletal system. Although it seems likely that these conditions have a different pathogenesis, the drugs used to treat them are the same. Our study used a cross-sectional clinical database to compare drug use and side-effect profile in these 2 diseases. METHODS: The CASPAR study collected data on 588 patients with PsA and 536 controls, 70% of whom had RA. Data on disease modifying drug treatments used over the whole illness were recorded, together with their outcomes, including adverse events, for RA and PsA. RESULTS: For both diseases methotrexate (MTX) was the most frequently used disease modifying drug (39% of patients with PsA, 30% with RA), with over 70% of patients in both diseases still taking the drug. Other drugs were used with the following frequencies in PsA and RA, respectively: sulfasalazine 22%/13%, gold salts 7%/11%, antimalarial drugs 5%/14%, corticosteroids 10%/17%, and anti-tumor necrosis factor (TNF) drugs 6%/5%. Compared to RA, cyclosporine and anti-TNF agents were less likely to be ineffective in PsA. Compared to RA, subjects with PsA were less likely to be taking MTX and more likely to be taking anti-TNF agents. Hepatotoxicity with MTX was more common in PsA and pulmonary toxicity with MTX was found more often in RA. CONCLUSION: These data provide insight into prescribing patterns of disease modifying drugs in RA and PsA in a large international cohort, together with the differential adverse events of these drugs between these diseases.

Turner DE, Helliwell PS, Woodburn J. · HealthQWest, School of Health & Social Care, Glasgow Caledonian University, Glasgow, UK. · BMC Musculoskelet Disord. · Pubmed #17986338 links to  free full text

Abstract: BACKGROUND: Whilst evidence exists to support the use of single treatments such as orthoses and footwear, the effectiveness of podiatry-led care as a complex intervention for patients with rheumatoid arthritis (RA) related foot problems is unknown. The aim of this study was to undertake an exploratory randomised controlled parallel arm clinical trial (RheumAFooT) to inform the design and implementation of a definitive trial and to understand the potential benefits of this care. METHODS: Patients with a definite diagnosis of RA, stable drug management 3 months prior to entry, and a current history of foot problems (pain, deformity, stiffness, skin or nail lesions, or footwear problems) were recruited from a hospital outpatient rheumatology clinic and randomised to receive 12 months of podiatry treatment or no care. The primary outcome was change in foot health status using the impairment/footwear (LFISIF) and activity limitation/participation restriction (LFISAP) subscales of the Leeds Foot Impact Scale. Disease Activity Score (DAS), Health Assessment Questionnaire (HAQ) score and walking speed (m/s) were also recorded. RESULTS: Of the 80 patients identified, 64 patients were eligible to participate in the pilot and 34 were recruited. 16 patients were randomised to receive podiatry led foot care and 18 received no care. Against a backdrop of stable disease (DAS and HAQ scores), there was a statistically significant between group difference in the change in foot health status for foot impairment (LFISIF) but not activity/participation (LFISAP) or function (walking speed) over 12 months. In the podiatry arm, 1 patient declined treatment following randomisation (did not want additional hospital visits) and 3 self-withdrew (lost to follow-up). Patients received an average of 3 consultations for assessment and treatment comprising routine care for skin and nail lesions (n = 3), foot orthoses (n = 9), footwear referral to the orthotist (n = 5), and ultrasound guided intra-articular steroid injection (n = 1). CONCLUSION: In this exploratory trial patients were difficult to recruit (stable drug management and co-morbid disease) and retain (lack of benefit/additional treatment burden) but overall the intervention was safe (no adverse reactions). Twelve months of podiatry care maintained but did not improve foot health status. These observations are important for the design and implementation of a definitive randomised controlled trial. TRIAL REGISTRATION: ISRCTN: 01982076.

Turner DE, Helliwell PS, Siegel KL, Woodburn J. · School of Health & Social Care and HealthQWest, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK. · Clin Biomech (Bristol, Avon). · Pubmed #17904711 No free full text.

Abstract: BACKGROUND: Rheumatoid arthritis is a chronic inflammatory joint disease which affects the joints and soft-tissues of the foot and ankle. The aim of this study was to evaluate biomechanical foot function and determine factors associated with localised disease burden in patients with this disease. METHODS: Seventy-four rheumatoid arthritis patients (mean (standard deviation) age, 56 years (12); median (interquartile range) disease duration, 13 (5,19)) and 54 able-bodied adults (mean (standard deviation) age, 55 years (12)) completed the Leeds foot impact scale. Biomechanical foot function was measured using three-dimensional instrumented gait analysis. Disease activity score, the number of swollen and tender foot joints, and rearfoot and forefoot deformity were recorded. Sequential multiple linear regression was undertaken to identify independent predictors of foot disease burden. FINDINGS: The median (interquartile range) Leeds foot impact scale scores in the impairment and activity/participation subscales were 13 (10,14) and 17 (12,22) for the rheumatoid arthritis and 1 (0,3) and 0 (0,1) for the able-bodied adults, P<0.0001 both subscales. The patients had significantly higher numbers of swollen (P<0.0001) and tender foot joints (P<0.0001) and greater rearfoot (P<0.0001) and forefoot (P<0.0001) deformity. Rheumatoid arthritis patients walked slower (P<0.0001) and had altered biomechanical foot function. Sequential regression analysis revealed that when the effects of global disease activity and disease duration were statistically controlled for, foot pain, the number of swollen foot joints and walking speed, and foot pain and walking speed were able to predict disease burden on the Leeds foot impact scale impairment (P<0.0005) and Leeds foot impact scale activity/participation (P<0.0005) subscales, respectively. INTERPRETATION: In this cohort of rheumatoid arthritis patients, foot pain, swollen foot joint count and walking speed were identified as independent predictors of impairment and activity limitation and participation restriction. The foot disease burden model comprises important elements of pain, inflammatory and functional (biomechanical) factors.

Helliwell PS, Porter G, Anonymous00356. · Academic Unit of Musculoskeletal and Rehabilitation Medicine, University of Leeds, 36, Clarendon Road, Leeds LS2 9NZ, UK. · Skeletal Radiol. · Pubmed #17849113 No free full text.

Abstract: BACKGROUND: It has been proposed that the defining difference between rheumatoid arthritis and spondyloarthropathy (including psoriatic arthritis) is the initial pathological lesion where the emphasis in psoriatic arthritis is on the enthesis and in rheumatoid arthritis on the synovium. Classical radiological descriptions of seronegative spondyloarthropathy include enthesopathy at major entheseal insertions characterised by erosions and exuberant new bone formation. In this study, the plain radiographic features of spondyloarthropathy are compared between psoriatic arthritis, other spondyloarthropathies and rheumatoid arthritis. METHODS: The CASPAR study collected clinical, radiological and laboratory data on 588 patients with physician diagnosed psoriatic arthritis and 525 controls with other inflammatory arthritis, 70% of which had rheumatoid arthritis. Plain radiographs of the pelvis and heels were part of the study protocol, although radiographs of other potential entheseal sites such as the knee, elbow and shoulder, were interpreted if available. All radiographs were read blind by two observers working in tandem. RESULTS: Significant differences in entheseal erosion and entheseal new bone formation were found between psoriatic arthritis, ankylosing spondylitis, undifferentiated spondyloarthropathy, rheumatoid arthritis and other diagnoses (entheseal erosion, chi-squared 20.8, p=0.008; entheseal new bone formation, chi-squared 24.5, p=0.001). These differences were mainly due to a higher proportion of these features in ankylosing spondylitis. No differences in the plain radiographic features of enthesopathy were found between psoriatic arthritis and rheumatoid arthritis except in the case of entheseal new bone formation at sites of attachment of inguinal ligament, sartorius and rectus femoris muscles to the ilium (OR 3.01, 95% CI 1.13-8.02). Very few subjects with symptomatic heel involvement had radiographic changes and minimal differences were found between those with and without symptoms in terms of new bone formation and erosion at either calcaneal site. CONCLUSIONS: New bone formation and erosion at major entheseal sites is most commonly seen in ankylosing spondylitis. Plain radiographic features of major enthesopathy are poor discriminators between psoriatic arthritis and rheumatoid arthritis.

Walker D, Adebajo A, Heslop P, Hill J, Firth J, Bishop P, Helliwell PS. · Freeman Hospital, Newcastle Upon Tyne, University of Leeds, UK. · Rheumatology (Oxford). · Pubmed #17767002 No free full text.

Abstract: OBJECTIVE: To determine the effectiveness of a pictorial 'mind map' together with the Arthritis Research Campaign (ARC) booklet for imparting knowledge to participants with rheumatoid arthritis (RA). Also, we wished to relate this to their reading ability. METHODS: We studied 363 participants with RA. Reading ability was assessed using the REALM, and knowledge was assessed using the Knowledge Scale Questionnaire (KSQ). Information on educational attainment, disease state and levels of anxiety and depression was also collected. Participants were randomly assigned to receive either the ARC booklet alone or the booklet and the mind map together. RESULTS: A significant minority (15%) of participants were functionally illiterate. There was a statistically significant increase in knowledge across both groups from baseline to reassessment after they were given the literature, but there was no difference in attainment between the groups. The more literate participants gained more knowledge regardless of the information they were given. They were also significantly less anxious and less depressed. CONCLUSIONS: The ARC booklet with or without the mind map was associated with a significant increase in knowledge. Poor readers had poor educational attainment and poor knowledge acquisition. The information on the mind map was not more accessible to them. Different educational strategies will be necessary to educate these patients.

Turner DE, Helliwell PS, Emery P, Woodburn J. · Department of Podiatry, University of Huddersfield, Huddersfield, UK. <> · BMC Musculoskelet Disord. · Pubmed #17184535 links to  free full text

Abstract: 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.

Semple R, Turner DE, Helliwell PS, Woodburn J. · Division of Podiatric Medicine and Surgery, School of Health and Social Care, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, United Kingdom. · Clin Biomech (Bristol, Avon). · Pubmed #17052826 No free full text.

Abstract: 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.

Helliwell PS, Porter G, Taylor WJ, Anonymous00813. · Academic Unit of Musculoskeletal and Rehabilitation Medicine, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK. · Ann Rheum Dis. · Pubmed #16840501 No free full text.

Abstract: BACKGROUND: and objective: Since the original description of psoriatic arthritis (PsA) subgroups by Moll and Wright, there has been some discrepancy in the precise prevalence of the different subgroups and in particular the proportion of patients with polyarthritis. The higher prevalence of the polyarthritis subgroup may be due to the inclusion of patients with seronegative rheumatoid arthritis with coincidental psoriasis. The classification of psoriatic arthritis (CASPAR) study database provided an opportunity to examine this question. METHODS: The CASPAR study collected clinical, radiological and laboratory data on 588 patients with physician-diagnosed PsA and 525 controls with other inflammatory arthritis, 70% of whom had rheumatoid arthritis. Patients with PsA were divided into two groups: polyarthritis and non-polyarthritis (which included the Moll and Wright subgroups of spinal disease, distal interphalangeal predominant and arthritis mutilans) and were compared with patients with rheumatoid arthritis. Comparisons were made between all three groups and, if a significant difference occurred, between the two groups with PsA. RESULTS: The three groups differed significantly with regard to all clinical and laboratory variables except duration of disease. Significant differences were also found between the two groups of PsA in terms of age, sex, total number of involved joints, disability score and symmetry. However, no differences were found between the groups of patients with PsA in terms of seropositivity for rheumatoid factor and antibodies to cyclic citrullinated peptide, enthesitis, and spinal pain and stiffness. Further, dactylitis was commonly seen in patients with PsA (57% in the polyarticular group and 45% in non-polyarticular group), and uncommonly found in patients with rheumatoid arthritis (5%). With the exception of entheseal changes, syndesmophytes and osteolysis, typical radiological features of PsA could not be used to distinguish between the PsA subgroups. CONCLUSIONS: The evidence suggests that the changing prevalence of the polyarticular subgroup of PsA is not because doctors include patients with seronegative rheumatoid arthritis with coincidental psoriasis.

Woodburn J, Cornwall MW, Soames RW, Helliwell PS. · Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, UK. · J Rheumatol. · Pubmed #15693086 No free full text.

Abstract: 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.

Taylor WJ, Marchesoni A, Arreghini M, Sokoll K, Helliwell PS. · Rheumatology and Rehabilitation Research Unit, University of Leeds, UK. · Semin Arthritis Rheum. · Pubmed #15609261 No free full text.

Abstract: 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.

Woodburn J, Udupa JK, Hirsch BE, Wakefield RJ, Helliwell PS, Reay N, O'Connor P, Budgen A, Emery P. · Rheumatology & Rehabilitation Research Unit, University of Leeds, Leeds, UK. · Arthritis Rheum. · Pubmed #12483720 links to  free full text

Abstract: OBJECTIVE: To compare in vivo the 3-dimensional (3-D) geometric architecture of the subtalar and midtarsal joints in normal and rheumatoid arthritic (RA) feet, using magnetic resonance imaging (MRI) analysis. METHODS: MRI was performed on 23 patients with RA, all of whom had disease activity in the subtalar and/or midtarsal joints. Image processing techniques were used to create 3-D reconstructions of the calcaneus (C), cuboid (c), navicular (N), and talus (T) bones. Twenty-four standard architectural parameters were measured from the reconstructions and were compared with data from 10 normal subjects. These parameters defined both 3-D distance and angular relationships among the 4 bones studied. Pattern classification techniques were used to establish a geometric architecture foot profile for the RA patients. The degree of individual patient fit to the new RA foot profile and to profiles for normal, pes planus, and pes cavus foot types was derived. Logistic regression was used to examine the relationship of foot architecture to inflammatory disease characteristics and physical examination variables. RESULTS: Subtalar or midtarsal pain was reported by all 23 patients, and 22 of the 23 patients presented with >/=1 clinical feature of pes planovalgus deformity. In 21 patients, ultrasonography revealed synovitis at >/=1 tarsal joint or surrounding tendon. In the RA group, the normalized distances between the geometric centroids were significantly closer for bone pairs Cc and cT and significantly distracted for bone pair CN compared with the distances in normal subjects. In RA patients (versus normal subjects), the angles subtended at the bone centroids were significantly decreased in 3 bone groups (CNc, TCN, and TNc) and significantly increased in 3 bone groups (CcN, CcT, NTc). The angles formed between the major principal axes of bone pairs CT and cT were significantly increased in RA patients compared with those in normal subjects. Pattern classification defined 11 RA feet as having normal structure and 12 as having abnormal structure. However, the abnormal feet did not fit consistently with structures defined for RA, pes planus, or pes cavus foot types. Logistic regression demonstrated that subtalar joint synovitis was the only predictive factor for abnormal subtalar and midtarsal architecture (odds ratio 19.2, 95% confidence interval 1.77-200.0). CONCLUSION: This unique 3-D MRI-based technique successfully quantified the effects of RA on the geometric architecture of the foot and the patient-specific nature of these changes. This technique can be used to provide logical therapy for correction.

Woodburn J, Helliwell PS, Barker S. · Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, UK. · Rheumatology (Oxford). · Pubmed #12468821 links to  free full text

Abstract: OBJECTIVE: To evaluate the three-dimensional (3D) kinematics of the ankle joint complex (AJC) in rheumatoid arthritis (RA) patients with painful valgus deformity of the rearfoot. METHODS: Fifty patients with RA underwent gait analysis using electromagnetic tracking techniques to measure 3D kinematics at the AJC under barefoot and shod walking conditions. Three axial rotations (dorsiflexion/plantarflexion, inversion/eversion and internal/external rotation) were measured during the gait cycle, and the angular positions at key gait events, range of motion and the motion: time integral were measured. Descriptive and analytical comparisons were made with normative data derived from a sex- and age-matched population (n=45). RESULTS: AJC dysfunction in RA was characterized by excessive eversion motion (within an eversion range) and no inversion motion through the neutral joint position for the subtalar component of the joint complex, in both barefoot and shod walking conditions. Motion was coupled such that internal rotation of the leg relative to the rearfoot was greater than normal. AJC motion was different for all rotations between barefoot and shod conditions, but in both situations there were statistically significant between-group differences in the motion:time integral for inversion/eversion (barefoot, P<0.0001; shod, P<0.0001) and external/internal rotation (barefoot, P<0.0001; shod, P<0.0001). There were no statistically significant differences between RA and normative data for dorsiflexion/plantarflexion motion under barefoot (P=0.16) and shod (P=0.50) walking conditions. CONCLUSION: Painful valgus deformity of the rearfoot is associated with changes in the 3D kinematics affecting eversion at the AJC and internal rotation of the leg, both when walking barefoot and in shoes.

Sokoll KB, Helliwell PS. · Department of Rheumatology, St Luke's Hospital, Bradford, UK. · J Rheumatol. · Pubmed #11508587 No free full text.

Abstract: OBJECTIVE: There is controversy about the severity of peripheral psoriatic arthritis (PsA) compared to rheumatoid arthritis (RA). Early reports found PsA to be a milder disorder, excepting the mutilans form. Recent reports suggest that PsA can be as severe as RA. We compared severity, disability, and quality of life in patients with PsA and RA matched primarily for disease duration. METHODS: Data relating to the extent and severity of disease were recorded in a hospital clinic setting. Recent radiographs of hands and feet were read blinded to diagnosis, and information on function and quality of life was collected with the Health Assessment Questionnaire (HAQ) and EuroQol-5D, respectively. RESULTS: Forty-seven patients were matched for disease duration (median PsA 5 yrs, RA 7 yrs). The male/female ratio was 24/23 for PsA, 16/31 for RA, and median ages were 45 and 51 years, respectively. Patients with RA had significantly more joint involvement of metacarpophalangeal joints and wrists, whereas distal interphalangeal joints, spine, sternoclavicular joints, and sacroiliac joints were significantly more involved in PsA. No difference was found regarding Ritchie Articular Index, inflammatory markers, HAQ score, or EuroQol-5D. Patients with RA had significantly more damage on radiographs of hands and feet: median (range) Larsen score hands PsA 8 (0-91), RA 38 (0-125); feet PsA 4 (0-34), RA 11(0-56). Patients with RA were taking significantly more disease modifying drugs. CONCLUSION: Peripheral joint damage is significantly greater in RA than in PsA after equivalent disease duration, but function and quality of life scores are the same for both groups. The additional burden of skin disease in PsA may account for this.

Helliwell PS, Hetthen J, Sokoll K, Green M, Marchesoni A, Lubrano E, Veale D, Emery P. · Rheumatology and Rehabilitation Research Unit, University of Leeds, UK. · Arthritis Rheum. · Pubmed #10765932 links to  free full text

Abstract: OBJECTIVE: To establish a mathematical model to predict the probability of symmetry of joint involvement as a function of the number of joints involved and to compare expected with actual probabilities in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) and in early and late disease. METHODS: Random involvement of joints was assumed, and the binomial theorem was used to give the frequency distribution of involved joints as a function of each joint count. Ten joint pairs were included: shoulder, elbow, wrist, metacarpophalangeal joints, proximal interphalangeal (PIP) joints of the hands, hip, knee, ankle, metatarsophalangeal joints, and PIP joints of the feet. Observed probabilities were obtained from subjects with early (duration < or =12 months) and late PsA and RA. RESULTS: The number of subjects in each of the disease subgroups was as follows: early PsA n = 33, late PsA n = 77, early RA n = 61, late RA n = 93. Observed probabilities of symmetry exceeded predicted probabilities for all disease subgroups. The median number of involved joints in each group was as follows: early PsA 4, late PsA 8, early RA 8, late RA 15 (chi2 = 95.3, 3 degrees of freedom, P = 0.0001, by Kruskal-Wallis test). After correcting for the discrepancy in the number of involved joints, no difference in joint symmetry was found between the groups (chi2 = 1.77, P = 0.62 by Friedman two-way analysis of variance). Similar results were obtained when individual hand and foot joints were analyzed separately. CONCLUSION: The pattern of joint involvement is often used to distinguish between rheumatoid and psoriatic arthritis. This study confirms that symmetry is largely a function of the total number of joints involved and that, in terms of joint pattern, differences between these disorders are more quantitative than qualitative. Both disorders have high absolute values of symmetry, particularly in the joints of the wrist and hand.

Gladman DD, Mease PJ, Healy P, Helliwell PS, Fitzgerald O, Cauli A, Lubrano E, Krueger GG, van der Heijde D, Veale DJ, Kavanaugh A, Nash P, Ritchlin C, Taylor W, Strand V. · The University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada. · J Rheumatol. · Pubmed #17477479 No free full text.

Abstract: Psoriatic arthritis (PsA), an inflammatory arthritis associated with psoriasis usually seronegative for rheumatoid factor, has emerged as a more common and severe disease than previously appreciated. The disease is multifaceted. Thus the assessment of PsA requires attention to peripheral joint involvement, axial disease, dactylitis, and enthesitis, as well as the skin manifestations. In addition, the assessment of patient reported features such as patient assessment of disease activity, pain, fatigue, quality of life, and the new concept of participation are important. The assessment of damage and the assessment of tissue histology are also important outcome measures. This article summarizes these features of PsA as well as current knowledge on the instruments available for the assessment of these domains.