This study aimed to identify the challenges faced by nurses engaged in rheumatology care in Japan. We conducted a questionnaire survey of nurses in Japan in 2020 on challenges experienced in rheumatology care. The participants were nurses certified by the Japan Rheumatism Foundation. Participants' answers were coded and categorized based on relevant phrases and words. Content analysis was performed on the findings. Responses were collected from 162 participants, and a total of 228 issues were identified. Eighteen categories with 56 subcategories emerged from the data analysis, which were grouped into five types of challenges: (1) communication, (2) understanding, (3) expertise, (4) system, and (5) collaboration. In particular, the results highlighted deficiencies in needs-based multidisciplinary team care. This study elucidated issues experienced by rheumatology nurses in clinical settings in Japan. Furthermore, this investigation revealed the necessity of patient-centered multidisciplinary team care, including health professionals, patients, and other relevant individuals. This study provided practical directions to facilitate the implementation of effective care focused on improving patients' quality of life.

We are exposed to various external and internal threats which might hurt us. The role of taking flexible and appropriate actions against threats is played by “the limbic system” and at the heart of it there is the ventral tegmental area and nucleus accumbens (brain reward system). Pain-related fear causes excessive excitation of amygdala, which in turn causes the suppression of medial prefrontal cortex, leading to chronification of pain.Since the limbic system of chronic pain patients is functionally impaired, they are maladaptive to their situations, unable to take goal-directed behavior and are easily caught by fear-avoidance thinking.We describe the neural mechanisms how exercise activates the brain reward system and enables chronic pain patients to take goal-directed behavior and overcome fear-avoidance thinking. A key to getting out from chronic pain state is to take advantage of the behavioral switching function of the basal nucleus of amygdala. We show that exercise activates positive neurons in this nucleus which project to the nucleus accumbens and promote reward behavior.We also describe fear conditioning and extinction are affected by exercise. In chronic pain patients, the fear response to pain is enhanced and the extinction of fear memories is impaired, so it is difficult to get out of “fear-avoidance thinking”. Prolonged avoidance of movement and physical inactivity exacerbate pain and have detrimental effects on the musculoskeletal and cardiovascular systems.Based on the recent findings on multiple bran networks, we propose a well-balanced exercise prescription considering the adherence and pacing of exercise practice. We conclude that therapies targeting the mesocortico-limbic system, such as exercise therapy and cognitive behavioral therapy, may become promising tools in the fight against chronic pain.

To investigate nurses' opinions and practices regarding psychological support and patient-centered care (PCC) for patients with rheumatoid arthritis. Registered nurses engaged in rheumatic care in Japan were asked to complete the questionnaire regarding nurses' perceived necessity, understanding, and implementation of psychological support, and six patient supports related to PCC, using a seven-point Likert scale. Correlation on practice between psychological support and PCC was evaluated. A total of 53 nurses participated. Nurses indicated high necessity of providing psychological support, whereas implementation was statistically significantly lower than necessity and motivation. Nurses' answers showed significantly lower implementation compared with understanding regarding basic concepts of psychological support: listening, empathy, acceptance, open questions, and closed questions. Most nurses (54.7%) sometimes provided psychological support, followed by often (34.0%), always (5.7%), and not at all (5.6%). Perceived necessity of PCC was rated high. However, its implementation was significantly lower than necessity for all evaluated cares, such as patients' need-based support and support to patients' families, related to PCC. Positive correlations were observed between the implementation of psychological support and PCC. Nurses stressed the importance of psychological support for patient education and shared decision-making. This preliminary study indicated that most nurses considered psychological support and PCC necessary, but their implementation was relatively low. As psychological support is also crucial to shared decision-making, in addition to PCC, barriers to its implementation should be addressed to improve patients' outcomes and quality of life.

The proportion of neck injuries due to traffic accidents is increasing. Little is known about high-cost patients with acute whiplash-associated disorder (WAD). The present study aimed to investigate whether time to first visit for conventional medicine, multiple doctor visits, or alternative medicine could predict high-cost patients with acute WAD in Japan. Data from a compulsory, no-fault, government automobile liability insurance agency in Japan between 2014 and 2019 were used. The primary economic outcome was the total cost of healthcare per person. Treatment-related variables were assessed based on the time to first visit for conventional and alternative medicine, multiple doctor visits, and visits for alternative medicine. Patients were categorized according to total healthcare cost (low, medium, and high cost). The variables were subjected to univariate and multivariate analysis to compare high-cost and low-cost patients. A total of 104,911 participants with a median age of 42 years were analyzed. The median total healthcare cost per person was 67,366 yen. The cost for consecutive medicine, for consecutive and alternative medicine, and total healthcare costs were significantly associated with all clinical outcomes. Female sex, being a homemaker, a history of WAD claim, residential area, patient responsibility in a traffic accident, multiple doctor visits, and visits for alternative medicine were identified as independent predictive factors for a high cost in multivariate analysis. Multiple doctor visits and visits for alternative medicine showed large differences between groups (odds ratios 2673 and 694, respectively). Patients with multiple doctor visits and visits for alternative medicine showed a significantly high total healthcare cost per person (292,346 yen) compared to those without (53,587 yen). A high total healthcare cost is strongly associated with multiple doctor visits and visits for alternative medicine in patients with acute WAD in Japan.

Perspectives regarding the disease state often differ between patients with rheumatoid arthritis (RA) and physicians. The aim of the present longitudinal cohort study was to investigate the impact of the discordance in global assessments between patients and physicians on 9-year pain-related outcomes in patients with rheumatoid arthritis. Sixty-eight consecutive outpatients with rheumatoid arthritis on their first visit to a tertiary center were included. Baseline measurements included demographic data, drugs used, disease activity, and a modified Health Assessment Questionnaire (mHAQ). Discordance in global assessment between patients and physicians at baseline was defined as 10 mm higher in the patient global assessment (PGA) than in the physician global assessment. A 9-year follow-up assessment included pain intensity, the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L) scale, Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), Pain Disability Assessment Scale (PDAS), and Pain Self-Efficacy Questionnaire (PSEQ). The number of patients with discordance was 26 (38%) in 68 patients. Patients with a 10 mm higher PGA than the physician global assessment at baseline measurements had significantly worse pain intensity, PCS score, PSEQ score, and EQ-5D-3L score measurements at the 9-year follow-up than those with concordance. A higher mHAQ score and 10 mm higher PGA at baseline were significantly independently associated with the EQ-5D-3L scale score and pain intensity at the 9-year follow-up. This longitudinal cohort study suggested that discordance in global assessment between patients and physicians modestly predicted worse 9-year pain-related outcomes in patients with rheumatoid arthritis.

Being younger than 20 years old at the time of arthroscopic Bankart repair (ABR) is known to be one of the most important risk factors for postoperative recurrence of instability. When deciding on the appropriate surgical approach, surgeons generally consider only the size of a critical glenoid defect, and most of them do not take into account factors such as the size of bone fragments and possible bone union after arthroscopic bony Bankart repair (ABBR). Therefore, this retrospective study aimed to clarify the risk factors for postoperative recurrence after ABR in teenage competitive athletes by focusing on glenoid rim morphologies and bone union. Participants were 115 teenage competitive athletes without a capsular injury who underwent primary ABR for chronic traumatic anterior instability and were followed for a minimum of 2 years. Possible risk factors for postoperative recurrence were investigated by univariate and multivariate analysis. In shoulders with a glenoid defect and bone fragment, the influence of glenoid defect size and bone fragment size on bone union after ABBR was also investigated. Postoperative recurrence was seen in 16 patients (13.9%). Regarding glenoid defect size, recurrence was seen in 1 (3.2%) of 31 shoulders with a glenoid defect smaller than 5% (including those with a normal glenoid), 15 (22.1%) of 68 shoulders with a glenoid defect of 5% to 20%, and 0 (0%) of 16 shoulders with a glenoid defect of 20% or larger (p=0.009). Regarding bone union, recurrence was seen in 4 (6.9%) of 58 shoulders with complete or partial bone union after ABBR and 8 (40%) of 20 shoulders with non-union or disappearance of the bone fragment (p=0.001). Regarding bone fragment size, recurrence was seen in 12 (20.7%) of 58 shoulders with a small or no bone fragment (<7.5%) and in 3 (8.6%) of 35 shoulders with a large bone fragment (>7.5%; p=0.154). Multivariate analysis identified non-union or disappearance of the bone fragment after ABBR as a significant risk factor for recurrence. Complete or partial bone union was seen in 25 (58.1%) of 43 shoulders with a small bone fragment (<7.5%) and 33 (94.3%) of 35 shoulders with a large bone fragment (>7.5%; p<0.001). In teenage competitive athletes, bone union after ABBR affects postoperative recurrence after ABR, regardless of the preoperative glenoid defect size, and bone union rate after ABBR is significantly influenced by bone fragment size.

BackgroundFibromyalgia (FM) is a chronic pain syndrome characterized by widespread pain, tenderness, and fatigue. Patients with FM have no effective medication so far, and their activity of daily living and quality of life are remarkably impaired. Therefore, new therapeutic approaches are awaited. Recently, exercise therapy has been gathering much attention as a promising treatment for FM. However, the underlying mechanisms are not fully understood, particularly, in the central nervous system, including the brain. Therefore, we investigated functional connectivity changes and their relationship with clinical improvement in patients with FM after exercise therapy to investigate the underlying mechanisms in the brain using resting-state fMRI (rs-fMRI) and functional connectivity (FC) analysis. MethodsSeventeen patients with FM participated in this study. They underwent a 3-week exercise therapy on in-patient basis and a 5-min rs-fMRI scan before and after the exercise therapy. We compared the FC strength of sensorimotor regions and the mesocortico-limbic system between two scans. We also performed a multiple regression analysis to examine the relationship between pre-post differences in FC strength and improvement of patients’ clinical symptoms or motor abilities. ResultsPatients with FM showed significant improvement in clinical symptoms and motor abilities. They also showed a significant pre-post difference in FC of the anterior cingulate cortex and a significant correlation between pre-post FC changes and improvement of clinical symptoms and motor abilities. Although sensorimotor regions tended to be related to the improvement of general disease severity and depression, brain regions belonging to the mesocortico-limbic system tended to be related to the improvement of motor abilities. ConclusionOur 3-week exercise therapy could ameliorate clinical symptoms and motor abilities of patients with FM, and lead to FC changes in sensorimotor regions and brain regions belonging to the mesocortico-limbic system. Furthermore, these changes were related to improvement of clinical symptoms and motor abilities. Our findings suggest that, as predicted by previous animal studies, spontaneous brain activities modified by exercise therapy, including the mesocortico-limbic system, improve clinical symptoms in patients with FM.

The exact mechanism of exercise-induced hypoalgesia (EIH) in exercise therapy to improve chronic pain has not been fully clarified. Recent studies have suggested the importance of the ventral hippocampus (vHPC) in inducing chronic pain. We investigated the effects of voluntary running (VR) on FosB+ cells and GABAergic interneurons (parvalbumin-positive [PV+] and somatostatin-positive [SOM+]) in the vHPC-CA1 in neuropathic pain (NPP) model mice. VR significantly improved thermal hyperalgesia in the NPP model. The number of the FosB+ cells was significantly higher in partial sciatic nerve ligation-sedentary mice than in Sham and Naive mice, whereas VR significantly suppressed the FosB+ cells in the vHPC-CA1. Furthermore, VR significantly increased the proportion of activated PV+ and SOM+ interneurons in the vHPC-CA1, and tracer experiments indicated that approximately 24% of neurons projecting from the vHPC-CA1 to the basolateral nucleus of amygdala were activated in NPP mice. These results indicate that feedforward suppression of the activated neurons via VR-induced activation of GABAergic interneurons in the vHPC-CA1 may be a mechanism to produce EIH effects, and suggested that disappearance of negative emotions such as fear and anxiety by VR may play a critical role in improving chronic pain.

The Japanese Orthopaedic Association National Registry (JOANR) is Japan's first national registry of orthopaedic surgery, which has been developed after having been selected for the Project for Developing a Database of Clinical Outcome approved by the Health Policy Bureau of the Ministry of Health, Labour and Welfare. Its architecture has two levels of registration, one being the basic items of surgical procedure, disease, information on surgeons, surgery-related information, and outcome, and the other being detailed items in the affiliated registries of partner medical associations. It has a number of features, including the facts that, because it handles medical data, which constitute special care-required personal information, data processing is conducted entirely in a cloud environment with the imposition of high-level data security measures; registration of the implant data required to assess implant performance has been automated via a bar code reader app; and the system structure enables flexible collaboration with the registries of partner associations. JOANR registration is a requirement for accreditation as a core institution or partner institution under the board certification system, and the total number of cases registered during the first year of operation (2020) was 899,421 registered by 2,247 institutions, providing real-world evidence concerning orthopaedic surgery.