The course of rheumatoid arthritis and predictors of psychological, physical and radiographic outcome after 5 years of follow-up

Longitudinal effects of affective distress on disease outcomes in rheumatoid arthritis: a meta-analysis and systematic review

Patients with rheumatoid arthritis have higher rates of mental health conditions compared to the general population. It is believed that affective distress and rheumatoid arthritis have a bi-directional relationship. This review will examine the associations between affective distress and rheumatoid arthritis outcomes over time. Several disease outcomes are included covering disease activity, function, and disability to provide a broad picture of the various ways patients are impacted. A quality assessment was also conducted. There were 71 studies included in the review. Three measures (disease activity, disability, and mortality) had enough data to complete meta-analyses of odds ratios or hazard ratios. The outcomes included were disease activity, tender joint count, swollen joints, pain, physician global assessment, patient global assessment, physical disability, acute phase reactants, stiffness, fatigue, work disability, and mortality. Numerous measures were included for most of the outcomes due to the variability across studies of measures used. Patients with affective distress had lower rates of remission according to the DAS-28, greater disability, and higher mortality. All of the outcomes covered had studies with mixed results, but swollen joint count, tender joint count, patient global assessment, and physician global assessment had the strongest evidence that they were associated with mental health longitudinally. The relationships between affective distress and disease outcomes are complex and vary depending on the measures. Overall, the effects fade over time. It is important for clinicians to be aware of the differing manifestations of the relationship between affective distress and rheumatoid arthritis outcomes.

Repeated social defeat stress differently affects arthritis-associated hypersensitivity in male and female mice

Chronic stress enhances the risk of neuropsychiatric disorders and contributes to the aggravation and chronicity of pain. The development of stress-associated diseases, including pain, is affected by individual vulnerability or resilience to stress, although the mechanisms remain elusive. We used the repeated social defeat stress model promoting susceptible and resilient phenotypes in male and female mice and induced knee mono-arthritis to investigate the impact of stress vulnerability on pain and immune system regulation. We analyzed different pain-related behaviors, measured blood cytokine and immune cell levels, and performed histological analyses at the knee joints and pain/stress-related brain areas. Stress susceptible male and female mice showed prolonged arthritis-associated hypersensitivity. Interestingly, hypersensitivity was exacerbated in male but not female mice. In males, stress promoted transiently increased neutrophils and Ly6Chigh monocytes, lasting longer in susceptible than resilient mice. While resilient male mice displayed persistently increased levels of the anti-inflammatory interleukin (IL)-10, susceptible mice showed increased levels of the pro-inflammatory IL-6 at the early- and IL-12 at the late arthritis stage. Although joint inflammation levels were comparable among groups, macrophage and neutrophil infiltration was higher in the synovium of susceptible mice. Notably, only susceptible male mice, but not females, presented microgliosis and monocyte infiltration in the prefrontal cortex at the late arthritis stage. Blood Ly6Chigh monocyte depletion during the early inflammatory phase abrogated late-stage hypersensitivity and the associated histological alterations in susceptible male mice. Thus, recruitment of blood Ly6Chigh monocytes during the early arthritis phase might be a key factor mediating the persistence of arthritis pain in susceptible male mice. Alternative neuro-immune pathways that remain to be explored might be involved in females.

Transgenic disruption of endogenous glucocorticoid signaling in osteoblasts does not alter long-term K/BxN serum transfer-induced arthritis

BACKGROUND

Disruption of glucocorticoid (GC) signaling in osteoblasts results in a marked attenuation of acute antibody-induced arthritis. The role of endogenous GCs in chronic inflammatory arthritis is however not fully understood. Here, we investigated the impact of endogenous GC signaling in osteoblasts on inflammation and bone integrity under chronic inflammatory arthritis by inactivating osteoblastic GC signaling in a long-term K/BxN serum transfer-induced induced arthritis (STIA) model.

METHODS

Intracellular GC signaling in osteoblasts was disrupted by transgenic (tg) overexpression of 11beta-hydroxysteroid dehydrogenase type 2 (11ß-HSD2). Inflammatory arthritis was induced in 5-week-old male tg mice and their wild type (WT) littermates by intraperitoneal (i.p.) injection of K/BxN serum while controls (CTRLs) received phosphate-buffered saline (PBS). In a first cohort, K/BxN STIA was allowed to abate until  the endpoint of 42 days (STIA). To mimic rheumatic flares, a second cohort was additionally injected on days 14 and 28 with K/BxN serum (STIA boost). Arthritis severity was assessed daily by clinical scoring and ankle size measurements. Ankle joints were assessed histopathologically. Systemic effects of inflammation on long bone metabolism were analyzed in proximal tibiae by micro-computed tomography (μCT) and histomorphometry.

RESULTS

Acute arthritis developed in both tg and WT mice (STIA and STIA boost) and peaked around day 8. While WT STIA and tg STIA mice showed a steady decline of inflammation until day 42, WT STIA boost and tg STIA boost mice exhibited an arthritic phenotype over a period of 42 days. Clinical arthritis severity did not differ significantly between WT and tg mice, neither in the STIA nor in the STIA boost cohorts. Correspondingly, histological indices of inflammation, cartilage damage, and bone erosion showed no significant difference between WT and tg mice on day 42. Histomorphometry revealed an increased bone turnover in tg CTRL and tg STIA boost compared to WT CTRL and WT STIA boost animals, respectively.

CONCLUSIONS

In contrast to the previously reported modulating effects of endogenous GC signaling in osteoblasts during acute K/BxN STIA, this effect seems to perish during the chronic inflammatory and resolution phase. These findings indicate that endogenous GC signaling in osteoblasts may mainly be relevant during acute and subacute inflammatory processes.

Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments.

OBJECTIVE

To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2).

DATA SOURCES

Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts.

STUDY SELECTION

Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients.

RESULTS

Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant.

LIMITATIONS

The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment.

SUGGESTED RESEARCH PRIORITIES

Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice.

CONCLUSIONS

Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016042402.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Effects of Early Rheumatoid Arthritis on Dominant and Non-dominant Hand Impairment and Function

Rheumatoid arthritis (RA) is defined as a symmetrical disease yet there is evidence that hand joint damage sustained in RA is related to use, and hand dominance could affect the degree of structural impairment evident in the wrist and hand. This exploratory research aimed to examine the relationship of dominant and non-dominant wrist and hand joint impairment and function in an early rheumatoid population. A multi-centre cohort study was conducted, recruiting consenting patients with early rheumatoid arthritis from eight outpatient occupational therapy departments. Wrist and hand joint impairment and function were assessed by measuring joint pain and swelling, range of motion and joint deviation, handgrip and hand dexterity. The results demonstrated that the non-dominant hand showed less pathological structural and functional involvement than the dominant hand in all but one outcome measure. These differences reached statistical significance between dominant and non-dominant hands on active range of motion in the wrist and some digits. Dominant hand structural impairment and dysfunction in this early RA sample was consistently greater than the non-dominant hand and bilateral handgrip ratio did not reflect healthy values for norms. Individuals with early RA showed a greater level of impairment in their dominant hands.

"Just get on with it": qualitative insights of coming to terms with a deteriorating body for older women with osteoarthritis

Objective

To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease.

Methods

Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women’s Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework.

Results

The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic ‘day to day’ process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management.

Conclusion

The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.

Relationship between disease activity indices and their individual components and radiographic progression in RA: a systematic literature review

OBJECTIVE

The aim of this study was to investigate the relationship between different disease activity indices (DAIs) and their individual components and radiographic progression in patients with RA.

METHODS

A systematic literature review until July 2013 was performed by two independent reviewers using the Medline and Embase databases. Longitudinal studies assessing the relationship between DAIs and single instruments and radiographic progression were included. The results were grouped based on the means of measurement (baseline vs time integrated) and analysis (univariable or multivariable).

RESULTS

Fifty-seven studies from 1232 hits were included. All published studies that assessed the relationship between any time-integrated DAI including joint count and radiographic progression reached a statistically significant association. Among the single instruments, only swollen joint count and ESR were associated with radiographic progression, while no significant association was found for tender joint count. Data with respect to CRP are conflicting. Data on patient's global health, pain assessment and evaluator's global assessment are limited and do not support a positive association with progression of joint damage.

CONCLUSION

Published data indicate that all DAIs that include swollen joints are related to radiographic progression while, of the individual components, only swollen joints and acute phase reactants are associated. Therefore composite DAIs are the optimal tool to monitor disease activity in patients with RA.

Which Factors Influence Radiographic Progression During Treatment with Tumor Necrosis Factor Inhibitors in Clinical Practice? Results from 930 Patients with Rheumatoid Arthritis in the Nationwide Danish DANBIO Registry

Objective.

To investigate baseline characteristics associated with radiographic progression and the effect of disease activity, drug, switching, and withdrawal on radiographic progression in tumor necrosis factor (TNF) inhibitor-naive patients with rheumatoid arthritis (RA) followed for about 2 years after anti-TNF initiation in clinical practice.

Methods.

DANBIO-registered patients with RA who had available radiographs (anti-TNF initiation and ∼2 yrs followup) were included. Radiographs were scored, blinded to chronology with the Sharp/van der Heijde method and linked with DANBIO data. Baseline characteristics were investigated with univariate regression and significant variables included in a multivariable logistic regression analysis with ± radiographic progression [Δ total Sharp score (TSS) > 0] as dependent variable. Effect of time-averaged C-reactive protein (CRP), 28-joint Disease Activity Score with CRP (DAS28-CRP), and treatment status at followup were investigated with univariate regression analysis.

Results.

The study included 930 patients. They were 75% women, 79% positive for IgM-rheumatoid factor (IgM-RF), median age was 57 yrs (range 19–88), disease duration 9 yrs (1–59), DAS28-CRP 5.0 (1.4–7.8), TSS median 15 [3–45 interquartile range (IQR)] and mean 31 (SD 40). Patients started treatment with infliximab (59%), etanercept (18%), or adalimumab (23%). At followup (median 526 days, IQR 392–735), 61% were treated with the initial anti-TNF, 29% had switched TNF inhibitor, and 10% had withdrawn. Twenty-seven percent of patients had progressed radiographically. ΔTSS was median 0.0 [0.0–0.5 IQR/mean 0.6 (SD 2.4)] units/year. Higher TSS, older age, positive IgM-RF, and concomitant prednisolone at baseline were associated with radiographic progression. Time-averaged DAS28-CRP and time-averaged CRP, but not type of TNF inhibitor, were associated with radiographic progression. Patients who stopped/switched during followup progressed more than patients who continued treatment.

Conclusion.

High TSS, older age, IgM-RF positivity, and concomitant prednisolone were associated with radiographic progression during 2 years of followup of 930 anti-TNF–treated patients with RA in clinical practice. High disease activity and switching/stopping anti-TNF treatment were associated with radiographic progression.

Sense of coherence and self-sacrificing defense style as predictors of psychological distress and quality of life in rheumatoid arthritis: a 5-year prospective study

Individual differences in adjustment during a disease's course determine psychological response and outcome. This study aimed to investigate prospectively whether coping with health stressors and self-sacrificing defense style could predict psychological adjustment and health-related quality of life (HRQoL) in patients with rheumatoid arthritis (RA). Seventy-four consecutive RA patients attending a rheumatology clinic were assessed for psychological distress (SCL-90-R), sense of coherence (SOC scale), self-sacrificing defense style (Defense Style Questionnaire-88), disease activity (DAS-28), pain, disability (Health Assessment Questionnaire) and HRQoL (World Health Organization Quality of Life Instrument, Short Form) at baseline and 5 years later. Multiple regression and moderator analyses were carried out. The results showed that disease activity (p < .001), pain (p = .005), psychological distress (p = .031), social relations HRQoL (p = .042) and environment HRQoL (p = .020) significantly improved over time. SOC was found an independent predictor of improvement in psychological distress (p = .003), overall general health (p = .002) and social relations HRQoL (p = .004); self-sacrificing independently predicted environment HRQoL (p = .042). The self-sacrificing defense style moderated the relationships between improvement in pain and improvement in overall general health (p = .024) and between improvement in pain and improvement in social relations HRQoL (p = .006). These findings indicate that, in RA, SOC predicts improvement in psychological distress and HRQoL over time, while a self-sacrificing defense style moderates the relationship of pain with HRQoL in the long term. These variables may partly explain inter-individual differences in adaptation to RA. Therefore, the design of psychotherapeutic trials targeting the patients' defensive profiles and coping with health stressors capacities is an important research perspective.

Marital quality and self-efficacy: influence on disease management among individuals with rheumatoid arthritis

Individuals with rheumatoid arthritis (RA) struggle to maintain improved functional ability and reduced pain levels. Health education emphasizing self-efficacy helps individuals to adjust with the disease outcome and progression. As a basis to develop comprehensive evidence-based patient education programs, the aim of the study was to examine the role of marriage as a predictor of pain and functional self-efficacy among individuals with RA. Review of the regression analysis did not provide support for the relationships between marital quality and self-efficacy. Relationships were not observed between marital quality, length of marriage, and self-efficacy as predicted by the first hypothesis. Additional regression analysis examination found that marital quality, length of marriage, pain, and health assessment together reported significant variance in self-efficacy. However, only health assessment significantly predicted self-efficacy. Other nonexamined variables could have influenced the independent marital quality effects. Future longitudinal studies with larger sample sizes can further validate the current findings.

Review of treatment response in rheumatoid arthritis: assessment of heterogeneity

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic, systemic, progressive, inflammatory disorder. The primary goals of treatment in RA are to reduce the signs and symptoms of disease, prevent progression of joint damage and improve patients' physical function. Patients with different sociodemographic characteristics, varying degrees of severity of illness, and comorbidities tend to exhibit differential response to treatment. The purpose of this review was to identify a broad set of factors that are associated with and/or predictive of RA treatment response and determine those that warrant further research.

RESEARCH DESIGN AND METHODS

A comprehensive review of the literature from the last 10 years was performed using three key databases (PubMed, EMBASE, and Cochrane). All relevant articles that met the inclusion/exclusion criteria were selected and scored for their levels of evidence using the National Institute of Clinical Excellence (NICE) scoring method. Data on study design, interventions and treatment outcomes were abstracted using a structured abstraction table.

RESULTS

A total of 30 articles were included in the review and data abstraction. Besides gender, baseline clinical variables such as C-reactive protein level, erythrocyte sedimentation rate, measures of disease activity, and Health Assessment Questionnaire scores (based on five patient-centered dimensions) were consistently associated with treatment response over time.

CONCLUSIONS

This comprehensive literature review identified several factors associated with treatment response which might be valuable to include as relevant measures in future studies of RA treatment. Inclusion of these factors, particularly those in the clinical and sociodemographic domains, in the design of future trials will further the understanding that ultimately may help clinicians deliver targeted treatment to community practice RA patients, thus resulting in improved patient outcomes.

Effects of long-term corticosteroid usage on functional disability in patients with early rheumatoid arthritis, regardless of controlled disease activity

We investigated the effect of long-term corticosteroid usage in suppressing the progression of functional disability in patients with early rheumatoid arthritis (RA). We studied 3,982 RA patients, who had continuous enrollment for at least 3 years, among 9,132 RA patients enrolled in an observational cohort study, IORRA, in Tokyo, Japan, from 2000 to 2007. The DAS28 and Japanese version of Health Assessment Questionnaire (J-HAQ) scores were collected at 6-month intervals (each phase). Among these patients, those with DAS28 values under 3.2 in all phases and RA disease duration under 2 years at study entry were selected as "early RA patients with well-controlled disease". These patients were further classified into 3 groups based on average months of steroid usage per year: Non-users, Medium-users, and Frequent-users. Multiple linear regression analysis was used to study the relationship between steroid usage and the final J-HAQ scores. Among the 3,982 patients, 109 had DAS28 values under 3.2 in all the phases and were selected as study cohort. The average Final J-HAQ in Non-user (N = 64), in Medium-user (N = 25), in Frequent-user group (N = 20) was 0.04, 0.06, and 0.33, respectively. Multiple linear regression analysis after adjusting for all potential covariates confirmed that frequent steroid usage was the most significant factor associated with higher final J-HAQ scores (P < 0.05). Frequent steroid usage was associated with significantly higher final J-HAQ scores in early RA patients, even though their disease was managed efficiently by maintaining the DAS28 values under 3.2 over a long-term period.

NT-proBNP predicts mortality in patients with rheumatoid arthritis: results from 10-year follow-up of the EURIDISS study

OBJECTIVES

Patients with rheumatoid arthritis (RA) have a higher mortality than the general population, and this increased mortality is related to demographic and disease variables. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a predictor of mortality both in general and patient populations, but has not been shown to predict mortality in patients with RA. This study examines whether NT-proBNP can further improve the prediction of mortality in RA.

METHODS

182 patients with RA of 5-9 years disease duration were comprehensively examined in 1997. Serum samples were frozen and later batch analysed for NT-proBNP levels and other biomarkers. Adjusted univariate and logistic regression analyses were performed with death within the 10-year follow-up period as the dependent variable. Significant predictors were also examined as dichotomised variables.

RESULTS

Mortality was predicted in univariate analyses by the following variables: age, sex, homozygosity for HLA-DRB1 shared epitope alleles, Health Assessment Questionnaire, 28-joint Disease Activity Score (DAS28) and NT-proBNP. A multivariate model with age, sex, DAS28 and NT-proBNP as independent variables showed the greatest discrimination.

CONCLUSION

NT-proBNP provided incremental information in the prediction of mortality in this cohort of patients with RA.

Prognostic Factors of Radiological Damage in Rheumatoid Arthritis: A 10-year Retrospective Study

Objective.

To describe the longterm clinical and radiological outcomes in rheumatoid arthritis (RA) in a cohort in northwestern Greece; and to investigate predictive factors of radiological damage at the 10-year followup in patients with RA.

Methods.

We studied the disease course and outcome of 144 patients with RA and radiographs of the hands and wrists available at baseline and at 10 years. Baseline measurements and time-averaged measures of swollen joint count (SJC) and inflammatory markers [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)] were tested in univariate analysis, and then those presenting a statistically significant association with either Larsen score at 10 years or annual progression rate were included in 2 logistic regression models in order to determine relevant independent prognostic factors.

Results.

A significant clinical improvement was noted, associated with a decrease of inflammatory markers along the timepoints. Larsen score and the number of erosive joints were increased. In the univariate analysis, both final Larsen score at 10 years and accelerated annual radiological progression rate were significantly associated with baseline radiographic measurements (Larsen score and number of erosive joints), the presence of autoantibodies [anticyclic citrullinated peptide antibodies (anti-CCP) and rheumatoid factor of IgA and IgM isotype], disease duration, and time-averaged measures of ESR, CRP, and SJC. In the logistic regression analysis, the baseline Larsen score, anti-CCP antibodies, and time-averaged CRP presented significant and independent associations with Larsen score at 10 years. An accelerated annual radiological progression rate was also predicted by baseline Larsen score and time-averaged measures of SJC and CRP.

Conclusion.

Despite clinical improvement, the radiologic progression of RA continues over time, because of the underlying inflammatory process. Baseline radiographic damage, anti-CCP antibodies, and time-averaged CRP constitute the main predictive factors of poor radiologic outcome in the long term.

Exploring Tai Chi in rheumatoid arthritis: a quantitative and qualitative study

Background

Rheumatoid arthritis (RA) is a chronic, inflammatory and systemic disease which affects the musculoskeletal system. Exercise programmes are reported to improve physical functioning in patients with RA. Tai Chi is a traditional Chinese martial art which combines slow and gentle movements with mental focus. The purpose of this study was to study in which way Tai Chi group exercise impacted on disease activity, physical function, health status and experience in RA patients, applying quantitative and qualitative methods.

Methods

Fifteen patients with RA (13 females, age 33-70 years) were recruited from a rheumatology department into a single group study. The patients were instructed in Tai Chi exercise twice weekly for 12 weeks. Assessments at baseline, 12 weeks, and 12 weeks follow-up were performed with a wide range of measures, including disease activity, self-reported health status, physical performance tests (Walking in Figure of Eight, Timed-Stands Test, and Shoulder Movement Impairment Scale). Qualitative data were obtained from a focus group interview conducted after completed intervention with taping and verbatim transcription. Review of the transcripts identified themes important to patients practicing Tai Chi.

Results

Within the group, Tai Chi practice lead to improved lower-limb muscle function at the end of intervention and at 12 weeks follow-up. Qualitative analyses showed that patients experienced improved physical condition, confidence in moving, balance and less pain during exercise and in daily life. Other experience included stress reduction, increased body awareness, confidence in moving and indicated that Tai Chi was a feasible exercise modality in RA.

Conclusions

Improved muscle function in lower limbs was also reflected when patient experiences with Tai Chi were studied in depth in this explorative study. The combination of qualitative and quantitative research methods shows that Tai Chi has beneficial effects on health not related to disease activity and standardised health status assessment, and may contribute to an understanding of how Tai Chi exerts its effects.

Trial registration

NCT00522054

Women with rheumatoid arthritis: Non-vocational activities and quality of life

The aim of this study was to examine a possible relationship between partaking in non-vocational activities and health-related quality of life in women with rheumatoid arthritis (RA). Two questionnaires were completed by 45 women with RA aged from 25 to 80. The MOS Short-Form 36 (SF-36) measured the health-related quality of life and the Interest Checklist measured the amount of non-vocational activities performed. The present study revealed a significant decrease in non-vocational activities by the participants during the last 10 years. Mental health status seemed to be of greater importance than physical function to perform non-vocational activities in daily life. There were indications that a high number of activities performed correlated positively with scores on psychological well-being, and that a low amount of activities performed correlated with the psychological distress scores.

Symptoms of Depression Predict the Trajectory of Pain Among Patients with Early Inflammatory Arthritis: A Path Analysis Approach to Assessing Change

Objective.

To assess the longitudinal relationships, including directionality, among chronic pain, symptoms of depression, and disease activity in patients with early inflammatory arthritis (EIA).

Methods.

One hundred eighty patients with EIA completed an examination, including swollen joint count, and were administered the Center for Epidemiological Studies Depression Scale (CES-D) and the McGill Pain Questionnaire (MPQ) at 2 timepoints 6 months apart. Cross-lagged panel path analysis was used to simultaneously assess concurrent and longitudinal relationships among pain, symptoms of depression, and number of swollen joints.

Results.

Pain, symptoms of depression, and number of swollen joints decreased over time (p < 0.001) and were prospectively linked to pain, symptoms of depression, and number of swollen joints, respectively, at 6 months. Symptoms of depression and pain were correlated with each other at baseline (0.47) and at 6-month followup assessments (0.28). Baseline symptoms of depression significantly predicted pain symptoms at 6 months (standardized regression coefficient = 0.28, p = 0.001), whereas pain and disease activity did not predict the course of any other variable after controlling for baseline values.

Conclusion.

Symptoms of depression predicted the trajectory of pain from baseline to 6 months. In addition, there were reciprocal/bidirectional associations between pain and symptoms of depression over time. More research is needed to better understand the relationship between pain and depressive symptoms and how to best manage patients with EIA who have high levels of both.

Methods of deriving EULAR/ACR recommendations on reporting disease activity in clinical trials of patients with rheumatoid arthritis

OBJECTIVE

To use an evidence-based and consensus-based approach to elaborate recommendations on how to report disease activity in clinical trials of patients with rheumatoid arthritis (RA) endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR).

METHODS

After an initial expert meeting, during which relevant research questions were identified, a systematic literature search was performed using Medline, Embase and the Cochrane Library as sources. To ensure literature retrieved was comprehensive, we emphasised search algorithms that were sensitive rather than specific. The results of the literature search were discussed by the expert panel, modified and expanded, and were used as the basis for the elaboration of the recommendation in the consensus process. Finally, an independent ACR panel approved these items with some minor modifications.

RESULTS

The following pieces of evidence were obtained from the literature search: (1) timing and the sustaining of a response is relevant to achieve better outcomes; (2) composite disease activity indices have been used to define low disease activity and remission and these definitions have been validated as has the American Rheumatism Association (ARA) remission criteria. The "patient-reported symptom state" (PASS) is not yet well validated; (3) evidence was obtained to identify those measures, scales and patient-reported instruments, for which there is a documented association with relevant outcomes; (4) baseline disease activity is associated with disease activity levels at the end of follow-up; and (5) there was not sufficient evidence relating the added benefit of MRI or ultrasound over clinical assessments. Most data stemmed from observational studies rather than clinical trials and literature review was supplemented by input from experts. The results served as the basis for the elaboration of the seven recommendations by the experts.

CONCLUSIONS

The approach based on scientific evidence from the literature as well as on expert input provided sufficient information to derive recommendations on reporting disease activity in RA clinical trials. The methodology, results and conclusions of this project were endorsed by EULAR and the ACR.

Efficient management of rheumatoid arthritis significantly reduces long-term functional disability

OBJECTIVES

The aim of this study was to examine the effect of efficient management of rheumatoid arthritis (RA) in relation to disability levels in a large cohort of patients with RA over a period of 3 years.

METHODS

We studied 2775 patients with RA who had continuous enrolment for at least 3 years from 7511 patients with RA enrolled in an observational cohort study (Institute of Rheumatology, Rheumatoid Arthritis (IORRA)) from October 2000 to April 2005. The 28-joint Disease Activity Scores (DAS28) were calculated at 6 month intervals for all the patients and a value <2.6 was considered as a tight control. We have set up a new variable for each patient, "Avg-Dscore", based on the transition of each patient's DAS28 value, taking the threshold level of 2.6 into consideration. The "Avg-DAS28" is the average of DAS28 values over all the phases. Functional disability status was assessed by J-HAQ, the validated Japanese version of the Health Assessment Questionnaire (HAQ). The relationship of "Avg-Dscore" and "Avg-DAS28" with the functional disability level was determined using Spearman correlation coefficients and multiple linear regression models.

RESULTS

The baseline features of these 2775 patients were: female 83.7%, mean age 56.8 years, mean RA duration 9.5 years, mean initial DAS28 4.0, mean initial J-HAQ score 0.79, and mean final J-HAQ score 0.86. There was a statistically significant correlation between "Avg-DAS28" and final J-HAQ score (r = 0.57, p<0.001), indicating that tighter disease control has significant association with lower disability levels. A similar relationship was observed between "Avg-Dscore" and final J-HAQ score (r = 0.47, p<0.001). Multiple linear regression analysis, after adjusting for all the covariates, revealed that "Avg-Dscore" and "Avg-DAS28" were the most significant factors contributing to final J-HAQ score, and confirmed the strong relationship between disease activity and functional disability.

CONCLUSIONS

In patients with RA efficient disease management, by maintaining the DAS28 values at a level under 2.6, has significant association with improving functional capability. The threshold DAS28 level of 2.6 may be useful in developing targeted treatment guidelines for patients with RA.

Chronic stress and regulation of cellular markers of inflammation in rheumatoid arthritis: implications for fatigue

OBJECTIVES

This study examined whether chronic interpersonal stress is associated with cellular markers of inflammation and regulation of these responses by in vitro doses of glucocorticoids in rheumatoid arthritis (RA) patients. The association between these markers of inflammation and fatigue was also tested.

METHODS

Fifty-eight RA patients completed up to 30 daily ratings of the stressfulness of their interpersonal relations. Interleukin-6 (IL-6) production was analyzed in lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cell cultures with and without varying concentrations of the glucocorticoid hydrocortisone. In addition, plasma levels of IL-6 and C-reactive protein (CRP) were analyzed, and subjective ratings of fatigue and pain were obtained on the day of blood sampling.

RESULTS

Multilevel modeling showed that higher chronic interpersonal stress was associated with greater stimulated IL-6 production (p<0.05) as well as greater resistance to hydrocortisone inhibition of IL-6 production (p<0.05). These relations were not accounted for by demographic factors, body mass index, or steroid medication use. Stimulated production of IL-6, in turn, was associated with greater levels of self-reported fatigue, controlling for pain (p<0.05). Neither chronic stress ratings nor fatigue symptoms were related to plasma levels of IL-6 or CRP (ps>.05).

CONCLUSIONS

Among RA patients, chronic interpersonal stress is associated with greater stimulated cellular production of IL-6 along with impairments in the capacity of glucocorticoids to inhibit this cellular inflammatory response. Moreover, these findings add to a growing body of data that implicate heightened proinflammatory cytokine activity in those at risk for fatigue symptoms.

Established rheumatoid arthritis: clinical assessments

Clinical assessment of established rheumatoid arthritis (RA) can have several purposes. It can be used to evaluate prognosis, disease course or interventions at both the individual and the group level (i.e. in a clinical trial), over the short or long term. The instruments used for the different purposes are not always the same. For example, information on prognosis is very useful when assessing the risk:benefit ratio of early aggressive pharmacotherapy; however, established prognostic factors are currently of limited use in individual patients with established RA. As, at the individual patient level, disease activity, disability and joint damage have variable courses, the course of the disease should be evaluated regularly both with process (i.e. erythrocyte sedimentation rate, joint counts) and with outcome (i.e. radiological progression, sum of past process) measures. For the evaluation of interventions, 'core sets' of valid measures to assess disease activity, outcome and specific criteria for improvement are used; these can, to some extent, be useful in clinical practice.

Can pinch grip strength be used as a valid indicator of manual dexterity?

Outcome measurement is important in clinical practice. Manual dexterity is a relevant component of hand function and improvement in dexterity can often be a treatment aim following hand injury. However, standardized dexterity tests can be costly and time consuming to complete in busy clinical practice. Valid, quick and practical clinical indicators of broader functional performance can be a useful adjunct to outcome measurement. This study examined whether tripod pinch grip strength was a valid indicator of manual dexterity.

Thirty healthy volunteers were recruited and their tripod pinch strength was measured using the B+L pinch gauge (B and L Engineering). Manual dexterity was assessed using the Purdue Pegboard.

There were strong, statistically signifi cant correlations between pinch strength and manual dexterity for males but not for females in this healthy sample. Tripod pinch grip could be used as a valid indicator for manual dexterity for males but the relationship between dexterity and pinch grip differs between sexes.

Reliability of the ICF Core Set for rheumatoid arthritis

BACKGROUND

The comprehensive ICF Core Set for rheumatoid arthritis (RA) is a selection of 96 categories from the International Classification of Functioning, Disability and Health (ICF), representing relevant aspects in the functioning of RA patients.

OBJECTIVES

To study the reliability of the ICF Core Set for RA in rheumatological practice, and to explore the metric of the qualifiers' scale.

METHODS

25 RA patients from an outpatient department of rheumatology were interviewed using the ICF Core Set for RA (76% females, mean (SD) age 57.5 (12.5) years, disease duration 15.9 (14.6) years). Interviews were performed independently by both a physiotherapist and an occupational therapist on the same day and again after one week by one of them. The severity of the patients' problems was quantified on a qualifier scale ranging from 0 (no problem) to 4 (complete problem). Analyses of intra-rater and inter-rater agreement, kappa statistics, and Rasch analyses were applied.

RESULTS

Mean intra-rater (inter-rater) complete agreement for all categories was seen in 59% (47%) of observations, ranging from 29% (0%) to 96% (80%) for individual categories. Weighted kappa statistics with value > or =0.4 showed reliability in 86% of categories within raters, and in 43% of categories between raters. Improved inter-rater and intra-rater reliability was observed with a reduced number of qualifiers for the categories.

CONCLUSIONS

Inter-rater and intra-rater reliability of the ICF Core Set of RA was low to moderate. The metric of the qualifiers' scale may be improved by reducing the number of qualifiers to three for all components.

Rehabilitation in rheumatoid arthritis: a critical review

This article considers the evidence for effectiveness and timing of rehabilitation for people with rheumatoid arthritis (RA). The Cochrane Library, DARE, Medline, Embase, CINAHL and AMED were searched to identify systematic reviews and randomized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis. Many trials identified had methodological limitations (e.g. short follow-up periods, small sample sizes). Evidence to date is that symptomatic relief results from thermotherapy, laser therapy, acupuncture and assistive devices. In the short-term, comprehensive occupational therapy (in established rheumatoid arthritis), orthoses, and mind-body approaches can help maintain function. Over at least a one-year period, the following are effective in reducing pain and maintaining function: patient education and joint protection training using behavioural approaches; dynamic exercise therapy, hand exercises and hydrotherapy; and cognitive-behavioural therapy (in people with poorer psychological status). Many trials have recruited people with moderate to severe, established RA and relatively little is known about the long-term effectiveness of early rehabilitation, although this is becoming much more common in practice. Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Further well-designed clinical trials are needed recruiting people with early disease using patient-centred outcomes.

Management of established rheumatoid arthritis with an emphasis on pharmacotherapy

The goals for the management of established rheumatoid arthritis (RA) differ slightly from the goals for the management of early RA. In established RA, in most cases, joint damage will be present, therefore the main goals are aimed at keeping the disease activity as low as possible to prevent joint damage progression. Furthermore, patients with RA have a reduced life expectancy, mainly due to co-morbid conditions such as cardiovascular disease. As in early disease, pharmacotherapy is the cornerstone of the management of patients with established RA. In this article we will discuss the characteristic manifestations of established RA, the pharmacological treatment strategies available for reaching the management goals of established RA, the role of prognostic factors and the measurements available for evaluating the outcomes of the management of individual patients with established RA in daily clinical practice.

Patients’ Perceptions of Health Related Quality of Life in Rheumatoid Arthritis and Chronic Low Back Pain

OBJECTIVES

To determine how health related quality of life (HRQL) is perceived by patients with rheumatoid arthritis (RA) and chronic low back pain (CLBP) using a textual analysis approach.

PATIENTS

Two-hundred and forty-eight outpatients (85% female), mean age 58+/-13 years (40% RA and 60% CLBP).

METHODS

Observational descriptive study. Sociodemographic and clinical variables were determined. A questionnaire was designed which included an open question "What does health related quality of life mean to you." which patients answered in writing. Textual data analysis was performed using a previous described method based on multivariate descriptive statistical methods.

RESULTS

The two groups were homogenous with respect to gender, educational level, disease duration, comorbid conditions and global functional status. Patients with RA and CLBP used clearly differentiated terms to describe HRQL (RA: to be able (capable), house; CLBP: life, health, quality). RA patients were specific and primarily concerned with functional status and CLBP patients with health and life. The most characteristic phrase used by RA patients was: "to be able to do housework" and for CLBP: "health is the most important thing for quality of life." In the factorial representation, the two pathologies were markedly separated.

CONCLUSIONS

A series of characteristic answers on HRQL may be identified in patients with RA and CLBP, showing that they have different perceptions about what HRQL is according to their pathology. The use of open questions in a group of homogenous patients with specific pathologies could result in more disease-specific responses. Textual statistical analysis of open questions may provide more information than standard methods, and may be considered as valid for the analysis of subjective issues such as quality of life.

Comparison of the Health Assessment Questionnaire (HAQ) and the modified HAQ (MHAQ) in patients with rheumatoid arthritis

OBJECTIVES

Physical disability in patients with rheumatoid arthritis (RA) is often assessed by questionnaires. We compared the Health Assessment Questionnaire (HAQ) with the modified HAQ (MHAQ) in a cohort of RA patients across various levels of disability, and examined correlations with other measures of physical function.

METHODS

Patients with RA (n = 182) completed self-report questionnaires assessing functional capacity. Instruments included the MHAQ and HAQ completed separately, as well as SF-36 and the Arthritis Impact Measurement Scales (AIMS). Scores from unadjusted and adjusted HAQ were compared with MHAQ at various disability levels.

RESULTS

A clear ceiling effect with aggregation of normal scores for physical function was observed for MHAQ (23%) and HAQ (12%), but not for SF-36 (4%) or AIMS (5%). The correlations between adjusted/unadjusted HAQ and MHAQ scores were 0.85/0.88. A discrepancy in HAQ and MHAQ scores was observed in patients with high levels of disability, especially when MHAQ was compared with the adjusted final HAQ score. Adjustment of HAQ by aids or help increased the final score by an average of 0.15, and both adjusted and unadjusted HAQ scores were numerically clearly higher (mean 0.45 and 0.30, respectively) than the MHAQ score.

CONCLUSION

The present findings indicate that MHAQ and HAQ may be applicable as measures of physical capacity in RA patients, but clinicians and researchers should select the appropriate instrument for the setting, and be aware of differences in scores, especially at different disability levels.

The development of emotional distress in 158 patients with recently diagnosed rheumatoid arthritis: a prospective 5-year follow-up study

OBJECTIVES

To describe the development of emotional distress among patients with newly diagnosed rheumatoid arthritis (RA), and to explore for early predictors of elevated distress over time.

METHODS

The study group consisted of 158 early RA patients (64% females) with mean age of 51.4 (SD = 12.7) years at disease onset. The patients were evaluated once a year for up to at least 4 years after baseline. Emotional distress was measured with the Symptom Checklist (SCL-90), disability with the Health Assessment Questionnaire (HAQ), pain with a visual analogue scale (VAS), and disease activity by an active joint count and erythrocyte sedimentation rate (ESR). Questions concerning social support were also included.

RESULTS

Emotional distress decreased slowly for a majority of the patients. The change reached statistical significance in the third year from study start. A minority (12%) showed continuously high and increasing levels of distress. Measures of disease activity were poor predictors of distress. The best predictor of distress over time was distress at baseline. Other predictors were gender, age, civil status, and social support.

CONCLUSIONS

Emotional distress tended to decrease for most patients in this cohort, but a minority showed continuously high levels. Patients at higher risk of developing emotional distress over time had higher levels of distress at baseline, were younger, more often female, and cohabiting, and experienced less social support.

What factors influence functional ability in patients with rheumatoid arthritis. Do they alter over time?

OBJECTIVES

To describe the changes in functional ability (FA) taking place over 5 yr in patients with rheumatoid arthritis (RA) starting disease-modifying anti-rheumatic drug (DMARD) therapy, to investigate the factors having most influence upon FA and to compare these factors at baseline and after 5 yr of treatment.

METHODS

Three hundred and sixty-six patients with active RA were studied as part of a 5-yr randomized controlled study of DMARD therapy. FA was assessed by Health Assessment Questionnaire (HAQ) score every 6 months. Multiple linear regression was used to identify factors affecting FA at baseline and at 5 yr. The independent variables used were age, sex, visual analogue scale (VAS) pain, Ritchie articular index, C-reactive protein (CRP), Larsen score and log-transformed morning stiffness (EMS).

RESULTS

Mean HAQ score was 1.64 at baseline, improved by 21% at 1 yr and gradually returned towards baseline levels by 5 yr. At baseline only 34% of variance in HAQ score could be explained; the most significant explanatory variables were the Ritchie articular index and CRP. At 5 yr the variance explained was 60%. The Ritchie articular index remained the strongest factor followed by VAS pain, log(10) EMS and Larsen score.

CONCLUSIONS

Improvement in function did occur after commencement of the first DMARD therapy but was not maintained to 5 yr. The most consistent factor affecting function was joint tenderness. Global pain and duration of EMS were of lesser importance. Disease activity measures such as the CRP exerted an influence in the earlier, more active stages of disease: radiographic damage assumed greater importance as the arthritis progressed.

Association of early radiographic damage with impaired physical function in rheumatoid arthritis: A ten-year, longitudinal observational study in 238 patients

OBJECTIVE

To investigate the longitudinal relationship between physical disability, disease activity, and radiographic damage over 10 years in patients with rheumatoid arthritis (RA).

METHODS

A cohort of 238 consecutively enrolled RA patients from the European Research on Incapacitating Disease and Social Support study (age range 20-70 years, mean disease duration 2.3 years, 68% rheumatoid factor [RF] positive) was followed up longitudinally for 10 years. Assessments at baseline and at years 1, 2, 5, and 10 comprised review of demographic variables, measurement of disease activity with the erythrocyte sedimentation rate (ESR), functional evaluations using the Health Assessment Questionnaire (HAQ) and grip strength (average value of the right and left hand), and radiographs of the hands scored by the van der Heijde modification of the Sharp method. Marginal modeling by generalized estimating equations was used to study the longitudinal relationship between the ESR and modified Sharp radiographic damage score with respect to explaining the HAQ score and grip strength. Age, sex, RF status, and disease duration were entered as covariates.

RESULTS

The HAQ score and grip strength were longitudinally associated with the momentary modified Sharp/van der Heijde score as well as with progression in this score, independent of the ESR. Therefore, an increase of 10 units in the modified Sharp/van der Heijde score will result in a 0.03-unit increase in HAQ score and a 0.95-kg decrease in grip strength, after adjustment for the ESR.

CONCLUSION

This 10-year observational study provides evidence that both radiographic damage and disease activity are independent contributors to impaired physical function in RA, both early and late in the disease process.

Long-term followup of health status in patients with severe rheumatoid arthritis after high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation

OBJECTIVE

High-dose chemotherapy (HDC) followed by autologous hematopoietic stem cell transplantation (HSCT) is a new treatment for patients with severe, refractory rheumatoid arthritis (RA). The present study was undertaken to assess the health status of patients with severe RA over a long-term followup period after treatment with HDC + HSCT.

METHODS

Health status and utility scores were assessed in 8 patients before and after treatment with HDC + HSCT. Patients were followed up for 5 years posttransplantation. Health status was assessed by the Health Assessment Questionnaire (HAQ), the RAND-36 version of the Short Form 36 (SF-36) health survey, and the Arthritis Impact Measurement Scales (AIMS). Utility scores were calculated using the EuroQol (EQ-5D) questionnaire and the SF-36-derived utility index (called the SF-6D), from which quality-adjusted life years (QALYs) were derived.

RESULTS

Most measures of health status improved compared with baseline in the first 2 years posttransplantation, notably HAQ and AIMS scores and scores on the functional status, general health, and health change summary scales of the RAND-36 version of the SF-36. Utility scores derived from the EQ-5D questionnaire and the SF-6D also increased significantly after transplantation. This was reflected in the 0.28 QALYs gained compared with baseline. For a putative 50-year-old RA patient with a life expectancy of 20 years, a threshold analysis revealed that HDC + HSCT yielded more QALYs than conventional therapy when treatment-related mortality (TRM) was <2.8%.

CONCLUSION

HDC + HSCT temporarily increased the functionality and health status of patients with severe, refractory RA. With a reported TRM of 1.3%, HDC + HSCT can be considered a realistic treatment option for patients with severe RA.

Radiography as primary outcome in rheumatoid arthritis: acceptable sample sizes for trials with 3 months' follow up

OBJECTIVES

To investigate whether plain radiographs can show changes in joint damage due to rheumatoid arthritis (RA) within 3 months.

METHODS

188 film pairs taken with a 3 month interval were evaluated. They were scored with (chronological) and without (paired) knowledge of the sequence of the films according to the Sharp/van der Heijde method. Changes in joint damage were analysed on a group and an individual level for different subsets of patients. Sample sizes required to detect statistically and clinically significant differences were estimated based on the percentages of patients with progression larger than the smallest detectable change (SDC).

RESULTS

Changes in joint damage were seen by both the chronological and the paired scoring method. The percentage of patients with progression of joint damage larger than the corresponding SDCs (1.7 and 2.4) varied in the subsets from 18% to 64% if based on the chronological change-scores and from 9% to 36% using paired change-scores. Acceptable sample size estimates were seen in several subsets, depending on (a) how the investigated drug would reduce the individual risk of progression of joint damage (by an absolute or a relative risk reduction model); (b) how damage was scored (chronological or paired); (c) the baseline risk; and (d) whether a two sided or one sided test would be used.

CONCLUSIONS

Changes in joint damage due to RA can be detected reliably already within 3 months. This finding can be used to plan short term, randomised controlled trials with radiographic progression as primary outcome.

How the type of risk reduction influences required sample sizes in randomised clinical trials

To increase change between groups, randomised clinical trials (RCT) often include patients with high risk for a particular outcome, by inclusion criteria that select predictors for that outcome. This increases the statistical power, and fewer patients are required for that RCT. The way in which patient selection influences the power, and thus sample size required, depends on how an intervention reduces the individual risk: by an absolute or relative risk reduction model.

Are there more than cross-sectional relationships of social support and support networks with functional limitations and psychological distress in early rheumatoid arthritis? The European Research on Incapacitating Diseases and Social Support Longitudinal

OBJECTIVE

To investigate whether greater social support and support network are cross-sectionally associated with less functional limitations and psychological distress in patients with early rheumatoid arthritis (RA); whether this association is constant over time; and whether increases in social support or support network are associated with less functional limitations and psychological distress.

METHODS

Subjects were from the European Research on Incapacitating Diseases and Social Support cohort and had early RA. Social support, support network, functional limitations (Health Assessment Questionnaire), and psychological distress (General Health Questionnaire) were assessed annually. Variance and covariance analyses with repeated measures were performed.

RESULTS

A total of 542 subjects were assessed for 3 years. On average, patients with a greater amount of specific social support or a stronger specific support network experienced less functional limitation and less psychological distress. Changes in a given subject's functional limitations and psychological distress did not depend on his or her baseline social support or support network. Neither social support nor support network change over time.

CONCLUSION

There may be a cross-sectional link between specific social support or support network and functional limitations and psychological distress, but no longitudinal association could be evidenced.

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population

OBJECTIVE

To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation).

DESIGN

Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments.

OUTCOME MEASURES

Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist.

RESULTS

Strong correlations (> 0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side.

CONCLUSION

In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.

Progression of radiographic changes in the temporomandibular joints of patients with rheumatoid arthritis in relation to inflammatory markers and mediators in the blood

The aim of this study was to investigate longitudinal radiographic changes in the temporomandibular joint (TMJ) with clinical involvement of rheumatoid arthritis (RA) and its relation to the blood level of inflammatory mediators and markers. Sixteen patients were investigated by computed tomography on two occasions 25-46 months apart. The radiographs were assessed independently for changes in presence of erosions, sclerosis, flattening, osteophytes, and subchondral pseudocysts. The serum (S) or plasma (P) concentrations of C-reactive protein (CRP), thrombocyte particle concentration, scrotonin (S-5-HT and P-5-HT), tumor necrosis factor alpha, interleukin-1 receptor antagonist, tumor necrosis factor soluble receptor type II, interleukin-1 soluble receptor type II (P-IL-1sRII) and interleukin 6 as well as the erythrocyte sedimentation rate (ESR) were measured. The radiographic status showed no consistent or significant change during the observation period, but the individual variation was considerable. The radiographic signs of erosion and sclerosis varied most. Regression of erosions was associated with high S-5-HT and P-IL-1sRII, while progression of erosions was associated with high P-5-HT. Regression of sclerosis was associated with an increase in P-5-HT and high ESR. Progression of flattening was associated with high CRP. In conclusion, this study indicates that the progression of radiographic changes that occurs in the TMJ of patients with well-controlled RA during a period of 25-46 months seems to be related to the blood levels of CRP, 5-HT, and IL-1sRII. However, only minor progression can be expected to occur, and with considerable individual variation.

A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis

BACKGROUND

Occupational therapy (OT) aims at improving performance of daily living tasks, facilitating successful adjustments in lifestyle, and preventing losses of function.

OBJECTIVE

To evaluate the effects of a pragmatic, comprehensive OT programme on self management and health status of people with early rheumatoid arthritis (RA) (<2.5 years).

METHODS

A randomised, controlled "assessor blinded" trial was conducted with assessments made at entry, 6, 12, and 24 months. Main outcomes were AIMS2: physical function (PF), pain visual analogue scale (VAS), and Arthritis Self-Efficacy Scale (ASES).

RESULTS

Groups had similar disease duration (9 months OT (n = 162) v 10 months control (n = 164)). The OT group received 7.57 (SD 3.04) hours of therapy. Self management significantly increased in the OT group. Otherwise, there were no significant differences in any outcome measures, or between groups, by ACR functional class: AIMS2: PF (F = 0.04; p = 0.96); pain VAS (F = 0.29; p = 0.74); total ASES score (F = 0.93; p = 0.39).

CONCLUSIONS

OT improved self management but not health status in early RA. Functional ability remains reasonably good for many in the first five years, so preventive benefits of self management may not yet be apparent and longer follow up is needed. Although many considered the education and therapy useful, insufficient numbers in the OT group used self management sufficiently to make a difference. Behavioural approaches can improve adherence and, potentially, the long term benefits. Future research should evaluate OT as a complex intervention and develop programmes from a theoretical and evidence base.

Course of radiographic damage over 10 years in a cohort with early rheumatoid arthritis

OBJECTIVE

To investigate development of radiographic damage in hands and feet of patients with early rheumatoid arthritis (RA) monitored prospectively for 10 years, and to search for prognostic factors.

PATIENTS AND METHODS

181 patients with early RA (mean disease duration one year) were assessed annually with radiographs of hands and feet during years 0-5 and at year 10. Radiographs were evaluated according to Larsen (range 0-200). Predictive factors for progressive disease for years 0-5 and 5-10 were evaluated by logistic regression analyses.

RESULTS

82/168 (49%) patients had erosions at inclusion and almost all became erosive with time (90% after two years and 96% after 10 years). Radiographic progression was most rapid during the first two years and 75% of all damage occurred during the first five years. The median Larsen score increased from 6 at inclusion to 41 after five years and 54 after 10 years. Only 5.3% of all evaluated joints became maximally eroded, the second metacarpophalangeal joint being the most commonly affected. Mean ESR during the first three months and rheumatoid factor status were significant predictors for radiographic progressive disease, it was not possible to predict non-progressive disease.

CONCLUSIONS

Joint damage in hands and feet developed early and progression was most rapid during the first years of disease. The different rates of progression at different stages should be considered in the design of trials of drugs aimed at retarding joint damage. Disease activity at study start influenced the degree of joint damage during the entire 10 years.

Changes in self-efficacy and health status over 5 years: a longitudinal observational study of 306 patients with rheumatoid arthritis

OBJECTIVE

To investigate changes in self-efficacy and health status over 5 years in patients with rheumatoid arthritis (RA), the relationships between these changes, and the influence of baseline values on subsequent changes.

METHODS

306 adult patients with RA, born in 1926 or later, were examined by questionnaire in 1994 and again in 1999. We analyzed data regarding pain (visual analogue scale [VAS], Arthritis Impact Measurement Scale [AIMS2] symptom scale, Short Form-36 [SF-36] pain scale), fatigue (VAS, SF-36 vitality scale), mental distress (AIMS2 affect scale, SF-36 mental health scale) and self-efficacy (Arthritis Self-Efficacy Scales for pain and for other symptoms).

RESULTS

On group level, all health status measures were numerically somewhat improved, and self-efficacy slightly reduced. Changes in self-efficacy and in corresponding health status measures were significantly correlated. For patients with above average educational level self-efficacy for pain at baseline was positively correlated to improvement in pain measures. Good mental health at baseline was correlated to improvement in self-efficacy for other symptoms, but only for patients with below average educational level.

CONCLUSION

Baseline self-efficacy seems to influence future level of perceived pain and baseline mental health status seems to influence future self-efficacy. These associations seem to be affected by level of education.