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In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European aEurostandards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

Die Verminderung der entzundlichen Krankheitsaktivitat allein ist aus Sicht von Menschen mit rheumatischen Krankheiten kein ausreichendes Behandlungsziel. Vielmehr mussen die funktionale Gesundheit und Teilhabe verbessert werden. Dabei sind auch die betroffenen Patienten von Beginn an zum eigenverantwortlichen Krankheitsmanagement zu befahigen. Deshalb ist die etablierte Treat-to-Target-Strategie um die funktionelle Dimension im Sinne von „Treat to Participation“ zu erweitern. Das Positionspapier der Deutschen Gesellschaft fur Rheumatologie (DGRh) fasst relevante Handlungsfelder der vielfach dazu erforderlichen multimodalen Versorgung zusammen. Dazu gehoren der Erwerb funktionsorientierter Kompetenzen in der Aus-, Weiter- und Fortbildung und deren regelhafte Anwendung in der rheumatologischen Versorgungspraxis. Weiterhin sieht die DGRh Bedarf in der Forschung zu funktionellen und sozialmedizinischen Folgen rheumatischer Krankheiten sowie zu funktionsorientierten Einzelinterventionen und deren Kombination in komplexen Programmen der ambulanten und stationaren rheumatologischen Versorgung.

In aktuellen Leitlinien der Deutschen Gesellschaft fur Rheumatologie (DGRh) wird eine koordinierte multiprofessionelle Behandlung und Rehabilitation von Patienten mit entzundlich-rheumatischen Krankheiten gefordert. In der Realitat sind Rehabilitationsleistungen der Deutschen Rentenversicherung (DRV) bei diesen Patienten von 2000 bis 2012 bundesweit zuruckgegangen, am deutlichsten bei Mannern mit ankylosierender Spondylitis (AS) um fast ein Drittel. Daruber hinaus zeigen sich fur stationare Rehabilitationsleistungen der DRV wegen rheumatoider Arthritis (RA) zwischen den Bundeslandern Unterschiede um den Faktor 2,6. Rehabilitationsleistungen wegen RA oder AS werden von der DRV bis zu 14-mal haufiger durchgefuhrt als von einer der grosten Krankenkassen, die gesetzlich fur die Rehabilitation jenseits des Erwerbslebens zustandig sind. Die Struktur- und Prozessqualitat sind in Rehabilitationseinrichtungen mit hohen Zahlen von Patienten mit entzundlich-rheumatischen Krankheiten deutlich erhoht. Unter den RA-Patienten in deutschen Rheumazentren sind im Jahr 2011 noch 40 % von mittelgradigen bis erheblichen Alltagseinschrankungen (Funktionsfragebogen Hannover [FFBH] ≤ 70) betroffen. Dennoch halbierten sich nach den Daten der Kerndokumentation von 1995 bis 2011 die stationaren Rehabilitationsleistungen fur RA-Patienten mit FFBH ≤ 70 um etwa die Halfte. In ambulanter rheumatologischer Versorgung erhielten nach eigenen Angaben innerhalb der letzten 12 Monate 38 % der RA-Kranken mit FFBH

In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European "standards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

Physikalische Therapie und Ergotherapie sind als Heilmittel in der Behandlung entzundlich rheumatischer Krankheiten den Arzneimitteln gleichrangig und unverzichtbar. Hierzu gibt es gesicherte Evidenz und Verankerung in den aktuellen Leitlinien. Bei der Verordnung von Heilmitteln fur Versicherte gesetzlicher Krankenkassen muss sich der Arzt an die vom Gemeinsamen Bundesausschuss (G-BA) verabschiedete und seit 01.07.2011 geltende Heilmittelrichtlinie halten. Danach reicht eine Krankheit an sich oder eine globale Diagnose wie „rheumatoide Arthritis“ oder „HWS-Syndrom“ nicht aus, eine Heilmittelverordnung zu begrunden. Anzugeben ist in „Gesamtbetrachtung des Patienten“ die funktionelle oder strukturelle Schadigung und/oder die Beeintrachtigung der Aktivitat einschlieslich „individueller Kontextfaktoren“. Das ist fur eine regressfreie Heilmittelverordnung bei Rheumapatienten eher hilfreich, auch wenn sich anfanglich der Zeitaufwand fur das Ausstellen einer Heilmittelverordnung erhoht. Fur den Arzt ebenfalls hilfreich sind die Festschreibung der Prufung der Verordnung auf formale Richtigkeit durch den Heilmittelerbringer, die fachubergreifende Festlegung von Behandlungsbeginn, Unterbrechungszeiten auf 14 Kalendertage und insbesondere die Neuregelung der Genehmigung von Verordnungen auserhalb des Regelfalls durch die Krankenkassen einschlieslich der Moglichkeit einer Langzeitverordnung fur 1 Jahr.

Da eine Ubersicht zu verschiedenen sozialmedizinischen Folgen entzundlich-rheumatischer Krankheiten fur Deutschland bisher nicht vorliegt, wurden Daten der letzten 10 Jahre fur die rheumatoide Arthritis (RA), Spondylitis ankylosans, Psoriasisarthritis, systemische Sklerose, den systemischen Lupus erythematodes und M. Wegener zusammengestellt. Neben Ergebnissen vor allem klinischer Studien sind die Kerndokumentation der Regionalen Kooperativen Rheumazentren sowie Statistiken der Gesetzlichen Kranken- und Rentenversicherung wichtige Datenquellen.

From the perspective of patients with rheumatic diseases, the reduction of inflammatory disease activity alone is not a sufficient treatment goal. In addition the functional health and participation also have to be improved. Starting with the first symptoms the empowerment for the self-management of the disease is important for the patients; therefore, the established treat to target-strategy has to be expanded by the functional dimension to treat to participation. The position paper of the German Society for Rheumatology (GSR) summarizes the relevant fields of the multiprofessional action that is frequently necessary. This includes the acquirement of function-related competencies during training, further education and advanced training as well as implementation in the everyday practice of patient care. Furthermore, the GSR acknowledges the need for research related to functional and sociomedical consequences of rheumatic diseases and to individual and combined function-related programs in outpatient and inpatient care in rheumatology.

The commission "Rehabilitation" of the German Society of Rheumatology compiled a data set for a routine report of the rehabilitation system for muskuloskeletal diseases. More than 250 rehabilitation hospitals offer inpatient rehabilitation for patients with musculoskeletal diseases. The prevalence of inpatient rehabilitation decreased due to new legislative rules in 1997, increased again thereafter but has not reached the former level. The prevalence of inpatient rehabilitation during the preceding year in patients with inflammatory rheumatic diseases treated by rheumatologists amounts to 12% with higher figures in men than in women and lower figures in the area of the former German Democratic Republic. The prevalence of outpatient rehabilitation increased during the last few years but, currently, does not exceed 5% of the entire rehabilitation procedures.

Physical therapy and occupational therapy are essential for the treatment of inflammatory rheumatic diseases equal in rank to any drug therapy. They have enough evidence and are part of all current guidelines even if mostly not specified. In the German social security system the doctor prescribing physical therapy or occupational therapy has to act according to the different rules and forms as described in the current "Heilmittel Richtlinie" (Remedy directive) effective since July 2011. The multiple formal conditions and requirements of prescriptions are described in detail. Of special interest is that the global diagnosis of rheumatoid arthritis can no longer be used as the reason or justification for the individual prescription but detailed sub-diagnoses, regarding the essential ICF domains of structural damage, functional impairment, activity limitation and participation restriction as well as individual context factors are necessary. Of special interest is the fact that the prescribing doctor is no longer responsible for the formal correctness of prescriptions but the performing therapist, who will not be reimbursed if the prescription shows even minor formal errors. Another important improvement is the newly introduced long-term prescription of physical and occupational therapy. This facilitates the application of these therapies in the multimodal treatment regimen of rheumatic diseases.

The commission "Rehabilitation" of the German Society of Rheumatology compiled a data set for a routine report of the rehabilitation system for muskuloskeletal diseases. More than 250 rehabilitation hospitals offer inpatient rehabilitation for patients with musculoskeletal diseases. The prevalence of inpatient rehabilitation decreased due to new legislative rules in 1997, increased again thereafter but has not reached the former level. The prevalence of inpatient rehabilitation during the preceding year in patients with inflammatory rheumatic diseases treated by rheumatologists amounts to 12% with higher figures in men than in women and lower figures in the area of the former German Democratic Republic. The prevalence of outpatient rehabilitation increased during the last few years but, currently, does not exceed 5% of the entire rehabilitation procedures.

By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

Autoreactivity plays a major role in the pathogenesis of RA. The rheumatoid factor has been and still is for now more than 50 years the only autoreactivity that is clinically applied in the diagnosis of RA. This well reflects the current way of thinking that a single antigen or a single cause drives an individual into disease. Although by now many other autoantigens and autoreactivities have been described, their discovery was always on the search for the one and only autoreactivity that causes RA. This includes also immune reactivities directed against xenogenic antigens. But, none of the known RA-associated autoreactivities is present in all RA patients and none of them occurs exclusively in RA. Thus, the observed sensitivities and specificities are well below 100%. Therefore, RA has often been postulated to consist of various immunological subentities with similar clinical symptoms. Nevertheless, none of the autoreactivities correlates with a distinct clinical feature or course of disease. It is about time to say good-bye to the idea that a single antigen or immunoreactvity causes and maintains rheumatoid arthritis. In this paper we present RA as the clinical outcome of an immune system that has shifted from a healthy to an autoimmune steady state. This is accomplished by many different reactivities and autoreactivities that occur either in parallel or one after the other. The entirety of the known RA-associated reactivities and (auto)antigens is presented in detail. The major RA-relevant autoantigens comprise BiP, citrulline, the Sa-antigen, hnRNP A2, p205, IgG, calpastatin, calreticulin, collagen and the shared HLA-DR epitope. The accumulation of factor--involving autoreactivities, cytokines, environmental and genetic factors--that challenge the normal regulatory mechanisms of the immune system lead to a regulatory catastrophe. In individuals developing the clinical features of RA the immune system has been regulated to a new--autoimmune--steady state. This attractor "rheumatoid arthritis" has many features of what has originally been described by Irun Cohen as the immunological homunculus: The healthy immune system is configured such as to direct its attention to major self-antigens. Thus it creates an autoreactivity to many autoantigens as a prerequisite for regulatory mechanisms that are sufficient to control them. The shift from the normal to rheumatoid attractor involves the inflammatory cytokines TNF-alpha, IL-1 and IL-6, autoreactive T- and B cells directed at a variety of synovial and systemic antigens, activated dendritic cells and macrophages, tissue destruction and genetic factors such as the association with shared epitope. Environmental factors involved may also, but do not necessarily, include infection. With the appearance of clinical features of RA, naive, potentially autoreactive T cells infiltrate the synovial compartment and become activated by dendritic cells and other APCs. The autoantigenic peptides that are presented to these T cells are derived from inflammatory cell and tissue destruction as well as from tissue repair and remodeling processes. These T cells proliferate and either provide help to B cells with the specificity to the same antigens or cause direct cytopathic tissue damage. Thereby, more and novel antigens are generated, released and presented again to naive or primed autoreactive T cells. These processes involving cytokines, tissue destruction and autoreactive T cells are sufficient to maintain RA even without the permanent presence of a triggering agent. The recursive autoimmune processes are well consistent with the finding of the many different autoreactivities in RA and their respective sensitivities and specificities. The massive influx of T cells into the arthritic joint is accompanied by the anergization of over 90% of T cells in this compartment--which further substantiates the concept of the RA attractor within the self-regulating immune system. Thereby, the RA-attracted immune system is not able to completely downregulate the inflammation and the local tissue damage/repair. Thus, the immune system is permanently stimulated and suddenly by chance shifts to a stable state different from the healthy system--reaching the wide fields of rheumatoid arthritis which in itself is self-sustaining as the healthy state before disease onset.

Being progressive and also involving variations in the severity of symptoms, chronic rheumatic diseases present difficulties with respect to documentation. Since dramatic changes in the course of disease are rare, early detection of very slight changes is essential to successful antirheumatic therapy. Practical means of documentation are necessary if an overview of the various clinical findings and subjectively reported symptoms is to be maintained over a period of many years. This is especially true in the case of therapeutic studies. The documentation form should enable the recording of suitably grouped data on the various rheumatic diseases and modes of therapy. With governmental support (BMFT project MT 0289), a uniform documentation form, "Dokumentation Rheuma", was set up and tested at 14 hospitals for rheumatic diseases. The modular form chosen and the definition of items were well received by the clinicians. After several modifications, a modularly structured documentation system is now available, elements of which can be expanded according to the needs of the individual therapeutic study. The form can both constitute a part of the patient history and act as a link between different but parallel-running studies, thus making it unnecessary to record the same information twice for different purposes. At the same time, the data base can be used to answer scientific and epidemiological questions independent of the study in progress.

Physiotherapy is well regarded by all patients with diseases of the locomotor system. In a questionnaire aimed at the self-evaluation of "non-proven remedies", we offered hospitalized patients of the Rheumaklinik Bad Bramstedt questions regarding classical forms of physiotherapy. Of 1600 questionnaires distributed, 447 (27.9%) could be counted and analysed. Categorized into four major groups of rheumatic diseases (rheumatoid arthritis/inflammatory diseases of joints, ankylosing spondylitis, osteoarthritis and degenerative spine disease, including minor rheumatic complaints) we collected patients' opinions of different therapies. In addition, we set up a list of preferred therapies and a list of negative therapies, estimated as less helpful or even harmful, as well as a list of therapies which patients would like to try. The results confirm the value of classical methods of physiotherapy (exercises, pelotherapy, massage), which had a high degree of acceptance and effectiveness.

The measurement of absolute temperatures on the surface of the human body using quantitative thermography allows this technique to be used in rheumatology, for the diagnosis and monitoring the course of inflammatory diseases of the locomotor system. The patient is exposed to a room temperature of 18 degrees C and the skin temperature measured over the joint for a defined area (region of interest). Inflamed joints show distinctly higher absolute temperatures than normal ones within the observation time of 40 minutes. Moreover, the skin over healthy joints cools faster and to a greater extent than skin over inflamed joints, whose temperatures remain the same or even rise minimally in more acute cases. Using two measurements, the determination of the absolute temperatures (static thermography), and the changes in these temperatures within a definite time interval (dynamic thermography) it is thus possible to establish a diagnosis of arthritis in the regions of the peripheral joints with the help of standardised nomograms with an accuracy of more than 90%, and to follow the course of the disease more exactly.

Computer-assisted evaluation of thermography of the knee joints allows diagnosis and quantitation of inflammatory processes. This needs an adequate thermography camera, registration standards and a thermographic index. With the aid of this index normal knee joints and those with inflammatory changes can clearly be differentiated: an index of less than 3.5 is normal, values above 5.0 indicate an inflammation. The author proposes to correct the thermographic index with reference to actual rectal temperature in order to improve inter- and intra-individual comparability of thermograms. Apart from the thermographic index, the formal analysis of the line-scan over the joint space and the maximal temperature of the joint can be used as further diagnostic criteria.