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Objectives: Although physical therapy is recommended as part of the non-pharmacological management of patients with psoriatic arthritis (PsA), the evidence is still unclear. Therefore, this study aimed to systematically review and appraise the quality of research on physical therapy in the management of patients with PsA., Methods: In June 2024, a systematic literature search using four different databases (Medline, Embase, Web of Science and the Cochrane Library) was performed to include interventional and observational studies examining physical therapy in patients with PsA (PROSPERO ID 255501). A risk of bias assessment was conducted. Due to the wide variety of interventions and outcomes, a narrative synthesis was used., Results: Of 9442 abstracts, 15 papers examining physical therapy uptake in clinical practice ( N  = 2) and different physical therapy interventions ( N  = 13) were included: cardiorespiratory exercises ( N  = 5), resistance exercises ( N  = 2), therapeutic modalities ( N  = 4) and mixed rehabilitation programs ( N  = 2). A low risk of bias was scored in only one RCT assessing cardiorespiratory exercises. The well-tolerated 11-week high-intensity interval training resulted in a long-term increase in peak oxygen uptake and a short-term decrease in truncal fat percentage in patients with low disease activity. Resistance training in patients with active disease did not increase muscle strength, but improved functional capacity, disease activity, pain and general health after the intervention. Evidence for other modalities was inconclusive., Conclusion: High-quality evidence on physical therapy in PsA was scarce. Cardiorespiratory and resistance exercises demonstrated promising results to positively influence cardiometabolic risk as well as disease-related outcomes. Future research on physical therapy in PsA with adequate methodological quality is needed., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Objective: To understand (1) what guidance exists to assess the methodological quality of qualitative research; (2) what methods exist to grade levels of evidence from qualitative research to inform recommendations within European Alliance of Associations for Rheumatology (EULAR)., Methods: A systematic literature review was performed in multiple databases including PubMed/Medline, EMBASE, Web of Science, COCHRANE and PsycINFO, from inception to 23 October 2020. Eligible studies included primary articles and guideline documents available in English, describing the: (1) development; (2) application of validated tools (eg, checklists); (3) guidance on assessing methodological quality of qualitative research and (4) guidance on grading levels of qualitative evidence. A narrative synthesis was conducted to identify key similarities between included studies., Results: Of 9073 records retrieved, 51 went through to full-manuscript review, with 15 selected for inclusion. Six articles described methodological tools to assess the quality of qualitative research. The tools evaluated research design, recruitment, ethical rigour, data collection and analysis. Seven articles described one approach, focusing on four key components to determine how much confidence to place in findings from systematic reviews of qualitative research. Two articles focused on grading levels of clinical recommendations based on qualitative evidence; one described a qualitative evidence hierarchy, and another a research pyramid., Conclusion: There is a lack of consensus on the use of tools, checklists and approaches suitable for appraising the methodological quality of qualitative research and the grading of qualitative evidence to inform clinical practice. This work is expected to facilitate the inclusion of qualitative evidence in the process of developing recommendations at EULAR level., Competing Interests: Competing interests: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Fresenius-Kabi, Lilly and holds research grants from Pfizer and Lilly., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway., Design: A cross-sectional, qualitative study with an interpretive descriptive design., Setting: Academic and non-academic hospital setting in Belgium., Participants: 31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed., Results: Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS., Conclusions: This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness., Trial Registration Number: This study was registered at clinicaltrials.gov (NCT03427294)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway., Aim: To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS., Design: A modified Delphi Study., Setting: Belgium and the Netherlands., Population: A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway., Methods: A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group., Results: A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process., Conclusions: This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients., Clinical Rehabilitation Impact: The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Objectives: Self-monitoring of physical activity (PA) has the potential to contribute to successful behaviour change in PA interventions in different populations, including people with inflammatory joint diseases (IJDs). The objectives of this study were to describe the use and knowledge of self-report-based and device-based PA measures in people with IJDs in four European countries, and to explore if the use of such devices, sociodemographic or disease-related variables were associated with adherence to the recommendations of at least 150 min of moderate to vigorous PA per week., Setting: Cross-sectional survey, performed in 2015-2016., Participants: People with IJDs in Belgium, Denmark, Ireland and Sweden., Primary and Secondary Outcome Measures: Use of self-report and device-based PA measures, receipt of instructions how to use PA measures, confidence in using them, adherence to PA recommendations and associated factors for adherence to PA recommendations., Results: Of the 1305 respondents answering questions on PA measures, 600 (46%) reported use of any kind of self-report or device-based measures to self-monitor PA. Between country differences of 34%-58% was observed. Six per cent and four per cent received instructions from health professionals on how to use simple and complex devices, respectively. Independent associated factors of fulfilment of recommendations of PA were living in Ireland (OR=84.89, p<0.001) and Sweden (OR=1.68, p=0.017) compared with living in Denmark, not perceiving activity limitations in moderate activities (OR=1.92, p<0.001) and using a device to measure PA (OR=1.56, p<0.001). Those living in Belgium (OR=0.21, p<0.001) were less likely to fulfil recommendations of PA., Conclusions: Almost half of the participants with IJDs used self-report-based or deviced-based PA measures, although few used wearable devices regularly. The results indicate that participants meeting public PA health guidelines were engaged in self-monitoring of PA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is convincing evidence to suggest that exercise interventions can significantly improve disease-related outcomes as well as comorbidities in rheumatic and musculoskeletal diseases (RMDs). All exercise interventions should be appropriately defined by their dose, which comprises of two components: a) the FITT (frequency, intensity, time and type) and b) the training (ie, specificity, overload, progression, initial values, reversibility, and diminishing returns) principles. In the published RMD literature, exercise dosage is often misreported, which in "pharmaceutical treatment terms", this would be the equivalent of receiving the wrong medication dosage. Lack of appropriately reporting exercise dosage in RMDs, therefore, results in limited clarity on the effects of exercise interventions on different outcomes while it also hinders reproducibility, generalisability and accuracy of research findings. Based on the collective but limited current knowledge, the main purpose of the present Position Statement is to provide specific guidance for RMD researchers to help improve the reporting of exercise dosage and help advance research into this important field of investigation. We also propose the use of the IMPACT-RMD toolkit, a tool that can be used in the design and reporting phase of every trial., (© 2021 The Mediterranean Journal of Rheumatology (MJR).)

Background: Physical activity is an important intervention for improving disease-related symptoms and systemic manifestations in rheumatic and musculoskeletal disease (RMDs). However, studies suggest that RMD patients report that the lack of individualized and consistent information about physical activity from managing doctors and healthcare professionals, acts as a barrier for engagement. On the other hand, managing doctors and healthcare professionals report lack of knowledge in this area and thus lack of confidence to educate and advise RMD patients about the beneficial effects of physical activity. The aim of the present study therefore, is to develop two e-Learning courses for RMD doctors and health professionals: a) the first one to provide consistent information about the collective benefits of physical activity in RMDs and b) the second on how to implement physical activity advice in routine clinical practice., Methods: An international collaboration of seven countries, consisting of one academic institution and one patient organization from each country, will co-develop the two e-Learning courses. The final e-Learning courses will primarily target to improve - through physical activity advice - RMD symptoms which are important for patients., Discussion: The main result of this study will be to co-develop two e-Learning courses that can be used by managing RMD doctors and healthcare professionals to be made aware of the overall benefits of physical activity in RMDs as well as how to implement physical activity advise within their practice., (© 2019 The Mediterranean Journal of Rheumatology (MJR).)

Background: Patients with chronic arthritis (CA) ideally apply self-management behaviors between consultations. This enduring, tedious task of keeping track of disease-related parameters, adhering to medication schemes, and engaging in physical therapy may be supported by using a mobile health (mHealth) app. However, further research is needed to determine which self-management features are valued most by adult patients with CA patients., Objective: The aim of this study was to determine the preference of features for an mHealth app to support self-management behavior in patients with CA. In addition, we aimed to explore the motives behind these ratings., Methods: A mixed-methods approach was used to gather information from 31 adult patients (14 females), aged 23 to 71 years (mean 51 [SD 12.16]), with CA. Structured interviews were conducted to gather data pertaining to preferences of app features. Interviews were analyzed qualitatively, whereas ratings for each of the 28 features studied were analyzed quantitatively., Results: In general, patients with CA favored the use of features pertaining to supporting active and direct disease management, (eg, medication intake and detecting and alarming of bad posture), helping them to keep a close watch on their disease status and inform their health care professional (eg, providing a means to log and report disease-related data) and receiving personalized information (eg, offering tailored information based on the patient's health data). Patients strongly disliked features that provide a means of social interaction or provide incentivization for disease-related actions (eg, being able to compare yourself with other patients, cooperating toward a common goal, and receiving encouragement from friends and/or family). Driving these evaluations is the finding that every patient with CA hurts in his/her own way, the way the disease unfolds over time and manifests itself in the patient and social environment is different for every patient, and patients with CA are well aware of this., Conclusions: We have offered an insight into how patients with CA favor mHealth features for self-management apps. The results of this research can inform the design and development of prospective self-management apps for patients with CA., (©Jonas Geuens, Luc Geurts, Thijs W Swinnen, Rene Westhovens, Vero Vanden Abeele. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 25.03.2019.)

Background: There is a remarkable lack of detailed knowledge on pain areas in axial spondyloarthritis (axSpA), and their clinical relevance is largely unknown. Pain area may reflect local disease processes, but amplification of nervous system signalling may alter this relationship. Also, gender differences in pain area may exist in axSpA, possibly confounding disease activity outcomes. Therefore, we firstly detailed pain locations in axSpA and evaluated gender differences. Secondly, we explored the relationship of regional pain definitions with clinical outcomes. Finally, we explored the role of pain area in the assessment of disease activity., Methods: Body charts informed on the presence of axial, peripheral articular and non-articular pain in 170 patients (108 men, 62 women) with axSpA. Multivariate Odds Ratios (ORs) were used to compare genders. General linear models were used to explore clinical differences in disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), activity limitations (Bath Ankylosing Spondylitis Functional Index [BASFI]), fear of movement (Tampa Scale for Kinesiophobia 11-item version [TSK-11]), anxiety (Hospital Anxiety and Depression Scale subscale anxiety [HADS-A]) and depression (HADS subscale depression [HADS-D]) between four subgroups classified by widespread non-articular pain (WNAP+/-) and physician global assessment of disease activity (PGDA+/-) (p < .05). Principal Component Analysis (PCA) was performed to explore gender differences in the structure of disease activity., Results: Axial thoracic pain was least prevalent (lumbar, 74.4%; cervical, 47.6%; cervicothoracic, 47.6%; thoracic, 32.4%), but it was about three times more likely in women (OR, 2.92; p = .009). Axial cervicothoracic junction pain spread more diffusely in women (OR, 2.48; p = .018). Women exhibited a two- to threefold increased likelihood of widespread axial (OR, 3.33; p = .007) and peripheral articular (OR, 2.34; p = .023) pain. A subgroup of WNAP+/PGDA- combined with low PGDA (27% of all patients) was associated with worse BASFI, BASDAI, HADS-A and HADS-D in men and worse TSK-11 and HADS-A in women (p < .05). Disease activity outcomes showed a two-factor structure in women but not in men., Conclusions: In patients with axSpA, the location and spread of pain was different between genders and was related to worse clinical status. On the basis of pain area and PGDA, clinical subgroups exhibiting a remarkably distinct health status were identified. Outcome instruments such as BASDAI should acknowledge gender differences to ensure structural validity.

Objectives: The objectives of this study were to determine rheumatology health professionals' (HPs)' awareness of and confidence in using physical activity (PA) measures in people with inflammatory joint diseases (IJDs), their own self-reported PA levels and to identify HP-related educational needs., Methods: Rheumatology HPs in Denmark, Sweden, Ireland and Belgium participated in an on-line survey. Descriptive statistics and latent class analysis (LCA) were undertaken SPSS (v21and SASv9.4) to describe data aggregates and range and to identify subclasses of groups with respect to use of PA measures., Results: 322 (n=322, 75.5% women) HPs responded from Denmark (n=50, 15.5%), Sweden (n=66, 20.5%), Ireland (n=28, 8.7%) and Belgium (n=178, 55.3%) and the majority of respondents (n=286, 91.7%) reported it was important to measure PA in people with IJDs. Only 28.2% of HPs used simple body worn sensors to measure PA levels in their patients. The majority were interested in on-line education on measuring PA (82.9%). LCA, used to generate classes of PA measures employed by HPs, revealed three distinct classes reflecting differences in self-reported PA levels, awareness of PA measures, further education requirements and professional background., Conclusions: The majority of respondents reported that they considered measuring PA as important in people with IJDs; however, the majority lacked confidence in how to measure it. There was strong interest in further education around measuring PA. Three distinct respondent classes were identified to inform targeted education on how to measure PA., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

One of the important aspects to be considered in rheumatic and musculoskeletal diseases is the patient's activity capacity (or performance), defined as the ability to perform a task. Currently, it is assessed by physicians or health professionals mainly by means of a patient-reported questionnaire, sometimes combined with the therapist's judgment on performance-based tasks. This work introduces an approach to assess the activity capacity at home in a more objective, yet interpretable way. It offers a pilot study on 28 patients suffering from axial spondyloarthritis (axSpA) to demonstrate its efficacy. Firstly, a protocol is introduced to recognize a limited set of six transition activities in the home environment using a single accelerometer. To this end, a hierarchical classifier with the rejection of non-informative activity segments has been developed drawing on both direct pattern recognition and statistical signal features. Secondly, the recognized activities should be assessed, similarly to the scoring performed by patients themselves. This is achieved through the interval coded scoring (ICS) system, a novel method to extract an interpretable scoring system from data. The activity recognition reaches an average accuracy of 93.5%; assessment is currently 64.3% accurate. These results indicate the potential of the approach; a next step should be its validation in a larger patient study., Competing Interests: The authors declare no conflict of interest.

Background: Chronic arthritis (CA), an umbrella term for inflammatory rheumatic and other musculoskeletal diseases, is highly prevalent. Effective disease-modifying antirheumatic drugs for CA are available, with the exception of osteoarthritis, but require a long-term commitment of patients to comply with the medication regimen and management program as well as a tight follow-up by the treating physician and health professionals. Additionally, patients are advised to participate in physical exercise programs. Adherence to exercises and physical activity programs is often very low. Patients would benefit from support to increase medication compliance as well as compliance to the physical exercise programs. To address these shortcomings, health apps for CA patients have been created. These mobile apps assist patients in self-management of overall health measures, health prevention, and disease management. By including persuasive principles designed to reinforce, change, or shape attitudes or behaviors, health apps can transform into support tools that motivate and stimulate users to achieve or keep up with target behavior, also called persuasive systems. However, the extent to which health apps for CA patients consciously and successfully employ such persuasive principles remains unknown., Objective: The objective of this study was to evaluate the number and type of persuasive principles present in current health apps for CA patients., Methods: A review of apps for arthritis patients was conducted across the three major app stores (Google Play, Apple App Store, and Windows Phone Store). Collected apps were coded according to 37 persuasive principles, based on an altered version of the Persuasive System Design taxonomy of Oinas-Kukkonen and Harjuma and the taxonomy of Behavior Change Techniques of Michie and Abraham. In addition, user ratings, number of installs, and price of the apps were also coded., Results: We coded 28 apps. On average, 5.8 out of 37 persuasive principles were used in each app. The most used category of persuasive principles was System Credibility with an average of 2.6 principles. Task Support was the second most used, with an average of 2.3 persuasive principles. Next was Dialogue Support with an average of 0.5 principles. Social Support was last with an average of 0.01 persuasive principles only., Conclusions: Current health apps for CA patients would benefit from adding Social Support techniques (eg, social media, user fora) and extending Dialogue Support techniques (eg, rewards, praise). The addition of automated tracking of health-related parameters (eg, physical activity, step count) could further reduce the effort for CA patients to manage their disease and thus increase Task Support. Finally, apps for health could benefit from a more evidence-based approach, both in developing the app as well as ensuring that content can be verified as scientifically proven, which will result in enhanced System Credibility., Competing Interests: Conflicts of Interest: None declared.

Introduction: Traditionally, assessment in axial Spondyloarthritis (aSpA) includes the evaluation of the capacity to execute tasks, conceptualized as physical function. The role of physical activity, defined as movement-related energy expenditure, is largely unknown and almost exclusively studied using patient-reported outcome measures. The aims of this observational cross-sectional study are to compare physical activity between patients with aSpA and healthy controls (HC) and to evaluate the contribution of disease activity to physical activity differences between groups., Methods: Forty patients with aSpA were matched by age, gender, period of data acquisition in terms of days and season to 40 HC. Physical activity was measured during five consecutive days (three weekdays and two weekend days) using ambulatory monitoring (SenseWear Armband). Self-reported disease activity was measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Differences in physical activity between patients with aSpA and HC were examined with Wilcoxon signed-rank tests and a mixed linear model. Difference scores between patients and HC were correlated with disease activity., Results: Average weekly physical activity level (Med(IQR); HC:1.54(1.41-1.73); aSpA:1.45(1.31-1.67),MET) and energy expenditure (HC:36.40(33.43-41.01); aSpA:34.55(31.08-39.41),MET.hrs/day) were significantly lower in patients with aSpA. Analyses across intensity levels revealed no significant differences between groups for inactivity and time spent at light or moderate physical activities. In contrast, weekly averages of vigorous (HC:4.02(1.20-12.60); aSpA:0.00(0.00-1.20),min/d), very vigorous physical activities (HC0.00(0.00-1.08); aSpA:0.00(0.00-0.00),mind/d) and moderate/(very)vigorous combined (HC2.41(1.62-3.48); aSpA:1.63(1.20-2.82),hrs/d) were significantly lower in patients with aSpA. Disease activity did not interact with differences in physical activity between patients with aSpA and HC, evidenced by non-significant and very low correlations (range: -0.06-0.17) between BASDAI and HC-aSpA patients' difference scores., Conclusions: Patients with aSpA exhibit lower physical activity compared to HC and these differences are independent of self-reported disease activity. Further research on PA in patients with aSpA should be prioritized.