British Journal of Rheumatology 1992 ;31:145-148
EDITORIALS
RHEUMATOLOGY AND RHEUMATOLOGY RESEARCH, A MISMATCH THE study by Williams and his colleagues [1] raises the questions: What is the rheumatologist's job description? How should he dispense his time between seeing patients and training his staff and in what directions should he lead his researchers? There could be as many answers as there are rheumatologists. One feature of life as a consultant in Britain is freedom to play the consultant game constructively in many ways. The absence of a rigid job description allows him to do what he is best at. How he spends his time depends largely on what his colleagues consult him about. This in turn depends on how they perceive his fields of interest as judged by his publications and background. His hobby horses, in fact. But the National Health Service is not just a hippodrome for hobby horses. There has to be some frame of reference in the overall provision of rheumatological expertise and facilities which will still allow scope for variation within the whole. The dimensions of the frame are the prevalence of the different forms of rheumatic suffering (as judged by complaint rates and days of sickness absence) and the rheumatologist's confidence in doing something about that suffering, a confidence (and competence) which is born of his previous training and research. In the past the Arthritis and Rheumatism Council for Research found itself in a somewhat hypocritical postition in that, when soliciting support from the public and citing the numbers of rheumatism sufferers, it counted back pain and soft tissue rheumatism as part of the enormous national burden of rheumatic disease. At the same time it had supported few projects in those fields, according to its annual reports. No blame could attach to the Council since it could only reflect the subjects which applicants put forward for funding. To redress the balance as far as back pain was concerned, the Back Pain Research Society (BPRS) was set up in 1970, to promote research in this field and to counter the feeling that 'respectable' rheumatologists didn't like to get identified with a subject which had been invaded by the host of heterodox healers. Despite the existence of the BPRS, bias against back pain still persists in rheumatology research as Williams and his colleagues have shown. Articles on back pain accounted for less than 1% of those published in five major rheumatology journals between 1985 and 1989. At rheumatology conferences the percentage was about 2% of abstracts submitted. That things are much
the same in 1991 is shown by a count of papers and posters accepted for the Vlllth Annual General Meeting of the British Society for Rheumatology [2]. Of 299 submissions, 12 could be classified as mainly concerned with backs or bone diseases against 127 concerned with rheumatoid arthritis (RA) and its treatment and 42 concerned with systemic lupus erythematosus (SLE) or SLE plus RA. Most of the SLE papers and half of the RA papers together with another 38 submissions on myositis, systemic sclerosis, Sjogren's syndrome, etc. were concerned with immunology. In contrast, in the recent Calderdale survey of rheumatic disorders Badley and Tennant [3] found that arthritis (mainly osteoarthritis) caused most rheumatic dependence (2.2%) followed by back and neck disorders (1 %), soft tissue disorders (0.7%) and RA (0.3%). Some bias in favour of research into rheumatoid arthritis can be justified, since this disease is common, has a low spontaneous recovery rate and causes much trouble to those who suffer from it. So much concentration on the immunology of systemic lupus erythematosus (SLE), a rare disease, is less easy to explain. This is not to decry the achievements of those who have pursued the phenomenon of the anticardiolipin antibody, opening up new fields in cardiovascular disease, obstetrics, blood clotting and neonatal cardiology. But most of the vast output of me-too research on SLE-immunology seems so often to end up with only permissive conclusions: 'These results may indicate that. . . may possibly be involved in the aetiology of SLE . . . etc' Could thesefiguressuggest that the rheumatological community has taken a wrong turn somewhere and that some of it is out of its depth and would do well to wait until better equipped basic scientists can sort out all the processes involved in normal immunological self-tolerance and where it might go wrong? As Weatherall [4] has pointed out, in connection with tomorrow's biotechnology, 'the basic scientists already seem to be moving too fast for the doctors'. Every month seems to discover new steps in the sequence: recognition of an antigen by one cell; its presentation to other cells for processing; followed by the inhibition or conversely the triggering and amplification of the immune response. Much of it, it is said, will be elucidated by computer modelling when the individual molecules involved are identified, their three-dimensional shapes, their charge patterns and the way they fit 145
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BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 3
together are characterized. But computer modelling is not something which rheumatologists know a lot about. Meanwhile research is neglecting some of the more common problems which are seen every day in the clinic and which rheumatologists alone are best placed to study. How has this bias come about and can it be corrected? Its chief source is the interests of the professional departments of rheumatology. There are 11 such departments in the United Kingdom and all but four, as judged by their research output, appear to have identified immunology as the important and sometimes exclusive science base of rheumatology. But these departments are where the next generations of rheumatologists are trained. Their professors sit on the Advisory Appointment Committees where senior registrars and consultants are selected. Being human they are likely to select their disciples. They are represented on the editorial boards of rheumatology journals where they referee papers submitted for publication. Clearly the present system will tend to be self-replicating. This is not a criticism of the professional ranks, only a humble suggestion that there needs to be reflection on whether the pendulum has swung too far and whether a fashion set up in the USA is being too closely followed when a glance around might show problems to be tackled more relevant to the needs of the public which ultimately pays the bills. Twenty years ago the response of rheumatology to the charge that research into back pain was being neglected might quite reasonably have been that there were no leads to follow. All this is changing. The change can be said to have started with the discovery of the near 100% prevalence of the human leucocyte antigen HLA-B27 in ankylosing spondylitis. It continued with the invention of computerized axial tomography and magnetic resonance imaging (MRI) giving new insights into the morbid anatomy of the painful spine. It has seen physiological studies which measure directly the pressure inside intervertebral discs during ordinary activities. Cybex machines can now quantify spinal movements and function. The anatomists have called our attention to the remarkable amount of venous blood which returns from the lower half of the body through the spinal canal, estimated at a quarter of that which returns through the vena cava. This may have something to do with protective cushioning of the spinal cord and its nerve roots, but it can go wrong, with painful oedema and congestion of the nerve roots when loss of discal or vertebral body height leads to wrinkling of the ligamentum flavum, obstructing nerve root veins and leading to fibrin deposition and periradicular fibrosis [5]. There is plenty new going on and plenty still to be done. The age-related changes in spinal musculature, for example, which make so obvious the difference between spinal posture and mobility in young and old people need more study. It is the first thing that an actor playing an 'old' role will imitate but far from the first thing a rheumatologist will investigate.
We have better defined diagnoses for classifying causes of back pain, essential in amassing groups for study. Discitis; facet joint syndromes; congenital, inflammatory and metabolic spondylopathies; spinal stenosis; spinal instability; spinal osteoporosis—to name but a few. Important also is the debunking of mythical pathology beloved of heterodox practitioners, the 'displacements' which are never measured and the 'adjustments' which anyone who has ever dissected the spine would know are nonsense. Then there is the challenge of guiding family doctors and other colleagues so as to diminish the immense load of inappropriate referral of back pain problems for spinal X-rays, too often ordered thoughtlessly, without prior examination or influence on treatment decisions even though there is a definite increase in radiation hazards for patients [6]. On the treatment side, MRI has given orthopaedic surgeons new control over their interventions. Advances in 'key-hole' techniques have brought minimal surgery to the relief of prolapsed intervertebral discs. We understand the contribution of the size and shape of the spinal canal into which the prolapse occurs. Medical statisticians and physicians are better at designing clinical trials and validating outcome measures for non-surgical treatments such as back pain rehabilitation classes. It we accept Williams' and others' evidence that the current strategy for rheumatological research does not match the needs then potential candidates for the next vacant consultant posts and professional chairs will have to start thinking now about whether SLE-immunology is really the box out of which they will retrieve the cure of rheumatoid arthritis or whether it might be more fruitful to invest in another field. And those professors who are not too deeply committed to SLEimmunology should think carefully about how they select and guide their aspirants. A. ST J. DIXON
Tregisky, Coverack, Cornwall TR12 6TQ REFERENCES
1. Williams GH, Rigby AS, Papageorgiou AC. Viewpoint, Back to front? Examining research priorities in rheumatology. Br J Rheumatol 1992;31:193-6. 2. Eighth Annual General Meeting of the British Society for Rheumatology, 18-20 September, 1991. Br J Rheumatol 1991;30(Abstr suppl 2). 3. Badley EM, Tennant A. Which rheumatic disorders have the greatest impact on the population? Estimates of the severity and prevalence from the Calderdale rheumatic disability survey. Br J Rheumatol 1991;30:(Abstr Suppl 2):102. 4. Weatheral D. Tomorrow's biotechnology—beyond the ploughman's lunch. Br Med J 1991;303:1282-3. 5. Hoyland JA, Freemont AJ, Jayson MIV. Intervertebral venous obstruction. A cause for periradicular fibrosis? Spine 1989;14:558-68. 6. Halpin SFS, Yeoman L, Dundas DD. Radiographic examination of the lumbar spine in a community hospital: an audit of current practice. Br Med J 1991;303:813-15.
EDITORIALS
RHEUMATOLOGY AND RHEUMATOLOGY RESEARCH, A MISMATCH THE study by Williams and his colleagues [1] raises the questions: What is the rheumatologist's job description? How should he dispense his time between seeing patients and training his staff and in what directions should he lead his researchers? There could be as many answers as there are rheumatologists. One feature of life as a consultant in Britain is freedom to play the consultant game constructively in many ways. The absence of a rigid job description allows him to do what he is best at. How he spends his time depends largely on what his colleagues consult him about. This in turn depends on how they perceive his fields of interest as judged by his publications and background. His hobby horses, in fact. But the National Health Service is not just a hippodrome for hobby horses. There has to be some frame of reference in the overall provision of rheumatological expertise and facilities which will still allow scope for variation within the whole. The dimensions of the frame are the prevalence of the different forms of rheumatic suffering (as judged by complaint rates and days of sickness absence) and the rheumatologist's confidence in doing something about that suffering, a confidence (and competence) which is born of his previous training and research. In the past the Arthritis and Rheumatism Council for Research found itself in a somewhat hypocritical postition in that, when soliciting support from the public and citing the numbers of rheumatism sufferers, it counted back pain and soft tissue rheumatism as part of the enormous national burden of rheumatic disease. At the same time it had supported few projects in those fields, according to its annual reports. No blame could attach to the Council since it could only reflect the subjects which applicants put forward for funding. To redress the balance as far as back pain was concerned, the Back Pain Research Society (BPRS) was set up in 1970, to promote research in this field and to counter the feeling that 'respectable' rheumatologists didn't like to get identified with a subject which had been invaded by the host of heterodox healers. Despite the existence of the BPRS, bias against back pain still persists in rheumatology research as Williams and his colleagues have shown. Articles on back pain accounted for less than 1% of those published in five major rheumatology journals between 1985 and 1989. At rheumatology conferences the percentage was about 2% of abstracts submitted. That things are much
the same in 1991 is shown by a count of papers and posters accepted for the Vlllth Annual General Meeting of the British Society for Rheumatology [2]. Of 299 submissions, 12 could be classified as mainly concerned with backs or bone diseases against 127 concerned with rheumatoid arthritis (RA) and its treatment and 42 concerned with systemic lupus erythematosus (SLE) or SLE plus RA. Most of the SLE papers and half of the RA papers together with another 38 submissions on myositis, systemic sclerosis, Sjogren's syndrome, etc. were concerned with immunology. In contrast, in the recent Calderdale survey of rheumatic disorders Badley and Tennant [3] found that arthritis (mainly osteoarthritis) caused most rheumatic dependence (2.2%) followed by back and neck disorders (1 %), soft tissue disorders (0.7%) and RA (0.3%). Some bias in favour of research into rheumatoid arthritis can be justified, since this disease is common, has a low spontaneous recovery rate and causes much trouble to those who suffer from it. So much concentration on the immunology of systemic lupus erythematosus (SLE), a rare disease, is less easy to explain. This is not to decry the achievements of those who have pursued the phenomenon of the anticardiolipin antibody, opening up new fields in cardiovascular disease, obstetrics, blood clotting and neonatal cardiology. But most of the vast output of me-too research on SLE-immunology seems so often to end up with only permissive conclusions: 'These results may indicate that. . . may possibly be involved in the aetiology of SLE . . . etc' Could thesefiguressuggest that the rheumatological community has taken a wrong turn somewhere and that some of it is out of its depth and would do well to wait until better equipped basic scientists can sort out all the processes involved in normal immunological self-tolerance and where it might go wrong? As Weatherall [4] has pointed out, in connection with tomorrow's biotechnology, 'the basic scientists already seem to be moving too fast for the doctors'. Every month seems to discover new steps in the sequence: recognition of an antigen by one cell; its presentation to other cells for processing; followed by the inhibition or conversely the triggering and amplification of the immune response. Much of it, it is said, will be elucidated by computer modelling when the individual molecules involved are identified, their three-dimensional shapes, their charge patterns and the way they fit 145
146
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 3
together are characterized. But computer modelling is not something which rheumatologists know a lot about. Meanwhile research is neglecting some of the more common problems which are seen every day in the clinic and which rheumatologists alone are best placed to study. How has this bias come about and can it be corrected? Its chief source is the interests of the professional departments of rheumatology. There are 11 such departments in the United Kingdom and all but four, as judged by their research output, appear to have identified immunology as the important and sometimes exclusive science base of rheumatology. But these departments are where the next generations of rheumatologists are trained. Their professors sit on the Advisory Appointment Committees where senior registrars and consultants are selected. Being human they are likely to select their disciples. They are represented on the editorial boards of rheumatology journals where they referee papers submitted for publication. Clearly the present system will tend to be self-replicating. This is not a criticism of the professional ranks, only a humble suggestion that there needs to be reflection on whether the pendulum has swung too far and whether a fashion set up in the USA is being too closely followed when a glance around might show problems to be tackled more relevant to the needs of the public which ultimately pays the bills. Twenty years ago the response of rheumatology to the charge that research into back pain was being neglected might quite reasonably have been that there were no leads to follow. All this is changing. The change can be said to have started with the discovery of the near 100% prevalence of the human leucocyte antigen HLA-B27 in ankylosing spondylitis. It continued with the invention of computerized axial tomography and magnetic resonance imaging (MRI) giving new insights into the morbid anatomy of the painful spine. It has seen physiological studies which measure directly the pressure inside intervertebral discs during ordinary activities. Cybex machines can now quantify spinal movements and function. The anatomists have called our attention to the remarkable amount of venous blood which returns from the lower half of the body through the spinal canal, estimated at a quarter of that which returns through the vena cava. This may have something to do with protective cushioning of the spinal cord and its nerve roots, but it can go wrong, with painful oedema and congestion of the nerve roots when loss of discal or vertebral body height leads to wrinkling of the ligamentum flavum, obstructing nerve root veins and leading to fibrin deposition and periradicular fibrosis [5]. There is plenty new going on and plenty still to be done. The age-related changes in spinal musculature, for example, which make so obvious the difference between spinal posture and mobility in young and old people need more study. It is the first thing that an actor playing an 'old' role will imitate but far from the first thing a rheumatologist will investigate.
We have better defined diagnoses for classifying causes of back pain, essential in amassing groups for study. Discitis; facet joint syndromes; congenital, inflammatory and metabolic spondylopathies; spinal stenosis; spinal instability; spinal osteoporosis—to name but a few. Important also is the debunking of mythical pathology beloved of heterodox practitioners, the 'displacements' which are never measured and the 'adjustments' which anyone who has ever dissected the spine would know are nonsense. Then there is the challenge of guiding family doctors and other colleagues so as to diminish the immense load of inappropriate referral of back pain problems for spinal X-rays, too often ordered thoughtlessly, without prior examination or influence on treatment decisions even though there is a definite increase in radiation hazards for patients [6]. On the treatment side, MRI has given orthopaedic surgeons new control over their interventions. Advances in 'key-hole' techniques have brought minimal surgery to the relief of prolapsed intervertebral discs. We understand the contribution of the size and shape of the spinal canal into which the prolapse occurs. Medical statisticians and physicians are better at designing clinical trials and validating outcome measures for non-surgical treatments such as back pain rehabilitation classes. It we accept Williams' and others' evidence that the current strategy for rheumatological research does not match the needs then potential candidates for the next vacant consultant posts and professional chairs will have to start thinking now about whether SLE-immunology is really the box out of which they will retrieve the cure of rheumatoid arthritis or whether it might be more fruitful to invest in another field. And those professors who are not too deeply committed to SLEimmunology should think carefully about how they select and guide their aspirants. A. ST J. DIXON
Tregisky, Coverack, Cornwall TR12 6TQ REFERENCES
1. Williams GH, Rigby AS, Papageorgiou AC. Viewpoint, Back to front? Examining research priorities in rheumatology. Br J Rheumatol 1992;31:193-6. 2. Eighth Annual General Meeting of the British Society for Rheumatology, 18-20 September, 1991. Br J Rheumatol 1991;30(Abstr suppl 2). 3. Badley EM, Tennant A. Which rheumatic disorders have the greatest impact on the population? Estimates of the severity and prevalence from the Calderdale rheumatic disability survey. Br J Rheumatol 1991;30:(Abstr Suppl 2):102. 4. Weatheral D. Tomorrow's biotechnology—beyond the ploughman's lunch. Br Med J 1991;303:1282-3. 5. Hoyland JA, Freemont AJ, Jayson MIV. Intervertebral venous obstruction. A cause for periradicular fibrosis? Spine 1989;14:558-68. 6. Halpin SFS, Yeoman L, Dundas DD. Radiographic examination of the lumbar spine in a community hospital: an audit of current practice. Br Med J 1991;303:813-15.
