A case of rheumatoid arthritis in a Nubian woman from the site of Sheikh Mohamed, near Aswan, Egypt

OBJECTIVE

To differentially diagnose and contextualize pathological lesions suggestive of rheumatoid arthritis.

MATERIALS

The skeletal remains of a 25-30-year-old female dated to c. 1750-1550 BCE from a Nubian Pan-Grave cemetery at the site of Sheik Mohamed, near Aswan, Egypt.

METHODS

The skeletal remains were examined macroscopically and a differential diagnosis was conducted following established protocols in the palaeopathological literature.

RESULTS

Symmetrical, bilateral, erosive periarticular lesions with smooth edges were observed in multiple joints (especially in the hands and feet).

CONCLUSIONS

Differential diagnosis suggests this individual had rheumatoid arthritis.

SIGNIFICANCE

This case suggests the presence of rheumatoid arthritis in ancient Egypt, contributing to a more finely grained understanding of the antiquity and geographical distribution of the condition.

LIMITATIONS

It was not possible to radiograph the skeletal remains.

SUGGESTIONS FOR FURTHER RESEARCH

Researchers are encouraged to re-examine any archaeological examples of erosive polyarthropathy using current palaeopathological protocols and to explore the manifestation of rheumatoid arthritis on the African continent.

Using Patient Blogs on Social Media to Assess the Content Validity of Patient-Reported Outcome Measures: Qualitative Analysis of Patient-Written Blogs

BACKGROUND

Patient-reported outcome measures (PROMs) are questionnaires that measure patient outcomes related to quality of life, health, and functioning, and are increasingly used to assess important outcomes from the patient's perspective. For PROMs to contribute to better health and better care, it is vital that their content validity be adequate. This requires patient involvement in various steps of PROM development. PROM developers not only recognize the benefits of patient involvement but also report difficulties in recruiting patients and experience patient involvement as time-consuming, logistically challenging, and expensive.

OBJECTIVE

This study seeks to explore different strategies for disclosing the experiential knowledge of patients, namely through analyzing patient stories on the web and social media. The research questions are as follows: (1) how do bloggers living with a disease experience their health-related quality of life? (2) How are these experiences reflected in the domains and items of PROMs related to their disease?

METHODS

First, a qualitative analysis of blogs written by patients was performed. Second, subthemes and underlying codes resulting from this qualitative analysis were systematically compared with the domains and items in PROMs for the respective diseases that the bloggers write about. Blogs were identified via the Google search engine between December 2019 and May 2021.

RESULTS

Bloggers describe a wide range of experiences regarding their physical functioning and health; mental well-being; social network and support; daily life, education, work, and leisure; coping; and self-management. Bloggers also write about their positive and negative experiences with health care delivery, the organization of health care, and health care professionals. In general, patients' experiences as described in blogs were reflected in the domains and items of the PROMs related to their disease. However, except for diabetes mellitus, in all the sets of PROMs, potentially missing topics could be identified. Similarly, with the exception of Parkinson disease, all PROMs address issues that patients did not write about in their blogs and that might therefore be redundant.

CONCLUSIONS

Web-based patient stories in the form of blogs reveal how people living with a certain disease experience their health-related quality of life. These stories enable analyses of patients' experiences that can be used to assess the content validity of PROMs. This can be a useful step for researchers who are looking for sets of measuring instruments that match their purposes.

Effects of WeChat platform-based continuing care on self-management and quality of life in patients with arthritis: A quasi-experimental study

Objective

To assess the effects of WeChat platform-based continuing care for arthritis on patients' self-management, self-efficiency, quality of life (QoL), and medication compliance.

Methods

A study was conducted on arthritis patients recruited between December 2017 and February 2018 and divided into two groups. The intervention group received continuing care from the WeChat platform and regular follow-ups, while the control group only received regular follow-ups. The outcomes in both groups were assessed using questionnaires twice: before the study (T0) and eight weeks after T0 (T1), which consists of the evaluation of self-management, QoL, self-efficacy, and medication compliance.

Results

There were 23 people in each of the intervention and control groups completed two outcome measures. At eight weeks, participants in the intervention group showed an improvement in psychological QoL, cognitive symptom management, and self-efficacy, compared to the control group (QoL scores: mean difference in change between groups was 12.29, 95% CI: 4.51, 20.07, p < 0.001; cognitive symptom management: mean difference in change between groups was 0.65, 95% CI: 0.24, 1.05, p < 0.001; self-efficacy: mean difference in change between groups was 0.69, 95% CI: 0.14, 1.24, p < 0.05). Self-management, self-efficacy, and psychological quality of life were significantly improved in the intervention group before and after the intervention (p < 0.05).

Conclusion

Using the WeChat platform for continuing care is useful in improving the psychological state, self-efficacy, and self-management ability of patients with arthritis. The study is relevant to Clinical Practice.

The effect of rheumatoid arthritis on upper extremity functions: A kinematic perspective

AIM

To examine the global upper extremity kinematics in 3D while performing "jar opening motion" in Rheumatoid Arthritis (RA) and to compare these with healthy individuals.

METHOD

Twenty-four women (12 healthy, 12 RA) were included. Evaluations were made with a JAMAR dynamometer, Health Assessment Questionnaire, and 3D kinematic analysis of global upper extremity during "jar opening motion." The time taken during "jar opening motion" was analyzed in 2 parts (Part 1, Part 2), with total time: part 1 + part 2. In addition, shoulder-to-table distance; elbow flexion angle; wrist extension angle; the area scanned and angular rotation by arm, forearm and hand were used in the analysis.

RESULTS

Between groups, there was a statistical difference in: bilateral hand grip strength; part 1, part 2, total time; shoulder-to-table distance; elbow flexion angle; the area scanned by hand; angular rotation of arm and hand in favor of the healthy group (P < .05). In stepwise multiple regression analysis, the most predictive variable for disability was elbow flexion, explaining 53.9% of disability.

CONCLUSION

Compared to healthy individuals, individuals with RA have slower motion, more elbow flexion, less hand grip strength, circular pattern in hand, rotation in arm and hand. Increased disability may result in greater load on elbow flexion.

Assessment of Rheumatoid Hand Function as a Characteristic Feature of Rheumatoid Arthritis in Patients Treated with Methotrexate or Methotrexate with Biological Agents with and without Deformation of Hands

BACKGROUND

The hand is an excellent work tool that provides the functional ability to mechanical work. The hand is affected in rheumatoid arthritis (RA) patients, it is a significant problem in the functional sphere as a result of deformities, the grasping function limitation and muscle strength.

OBJECTIVES

The aim of the study was the assessment of grip strength, endurance and manipulation abilities of rheumatoid hands with or without deformities treated with methotrexate (MTX) or MTX plus biologics (MTX+BIO).

MATERIAL AND METHODS

The study involved 80 RA women, (40 received MTX+BIO, 40 MTX), treated at the Rheumatology Department of the Central Clinical Hospital of Interior Affairs in Warsaw. VAS-pain, DAS28, SDAI, HAQ, HAQ hands, estimation of hand grip strength, endurance, manipulation ability were analyzed.

RESULTS

In group MTX+BIO values of DAS28 (3.7±1.3 vs 4.3±1.2, p=0.019), HAQ (0.72 ± 0.57 vs 1.08± 0.87, p=0.011) and HAQ-hand (0.85±0.65 vs. 1.19±0.68, p=0.024) were statistically lower than in MTX group. Hand deformations recorded in 35 (43.7%) cases, 16 (40%) in MTX group, 19 (47.5%) in MTX+BIO. Comparison of grip strength, endurance, manipulation ability showed better results in MTX+BIO group with deformities (significance level from 0.013 to 0.046) than in MTX group. Relative differences in hand function in MTX + BIO group ranged from 10.8% (maximal power grip strength) to 127.6% (minimal hand endurance), after disease duration adjustment - from 28.2% (maximal power grip strength) to 148.4% (minimal hand endurance).

CONCLUSION

Measuring grip strength, hand endurance, manipulation abilities are useful in RA patients with hand deformities.

Triggers of Cardiovascular Diseases in Rheumatoid Arthritis

The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) is higher than that in patients without RA, and it is even higher than that in patients with diabetes. Autoimmune-mediated inflammation is observed in patients with RA, resulting in endothelial dysfunction, oxidative stress and activation, and vascular migration of white blood cells. Traditionally, RA-associated CVD was assumed to be mediated by disease-related inflammation, resulting in atherosclerosis (AS). However, this concept has been challenged because treatment with anti-rheumatic drugs, such as methotrexate or proinflammatory cytokine antagonists, such as tumor necrosis factor-alpha (TNF-α) inhibitors, did not reduce the risk of CVD in patients with RA. Current cardiovascular guidelines recommend screening and treatment of CVD risk factors in patients with RA but without clear biomarkers and treatment goals. There is no scientific basis for establishing therapeutic targets for cardiovascular risk factors in RA. Numerous studies have shown that the mechanism of early cardiac dysfunction in patients with RA may occur prior to AS. Therefore, it is crucial to explore the related mechanisms to prevent early cardiac dysfunction in patients with RA.

Comprehensive assessment of alterations in hand deformities over 11 years in patients with rheumatoid arthritis using cluster analysis and analysis of covariance

Background

Although drug therapy for rheumatoid arthritis (RA) has recently improved, treating patients with established disease, whose hands have three major deformities (thumb deformity, finger deformities, and ulnar drift), remains a challenge. The underlying complex pathophysiology makes understanding these deformities difficult, and comprehensive assessment methods require accumulated skill with long learning curves. We aimed to establish a simpler composite method to understand the pathophysiology of and alterations in the hand deformities of patients with RA.

Methods

We established a rheumatoid hand cohort in 2004 and clinically evaluated 134 hands (67 patients). We repeated the evaluations in 2009 (100 hands of 52 patients) and 2015 (63 hands of 37 patients) after case exclusion. Thumb deformities, finger deformities (swan-neck and boutonnière deformity), and ulnar drift were semi-quantitated and entered as parameters into a two-step cross-sectional cluster analysis for the data in 2004. The parameters in each cluster were plotted at each evaluation point. Two-way analysis of covariance was used to examine whether differences existed between evaluation points and clusters of deformity parameters.

Results

Five clusters most appropriately described hand deformity: (i) cluster 1, minimal deformity; (ii) cluster 2, type 1 thumb deformity; (iii) cluster 3, thumb deformity and severe boutonnière deformity; (iv) cluster 4, type 2 or 3 thumb deformity and severe ulnar drift; and (v) cluster 5, thumb deformity and severe swan-neck deformity. Clusters 1 and 2 had higher function than cluster 5, and cluster 3 had moderate function. Clusters 1–4 had similar disease duration but showed different paths of deformity progression from disease onset. Clusters 1 and 2 represented conservative deformity parameters and clusters 3, 4, and 5 represented progressive deformity parameters. Over time, thumb deformity evolved into other types of deformities and swan-neck deformity worsened significantly.

Conclusions

Our comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand. Knowledge of the characteristics of progressive deformity parameters may allow rheumatologists to more easily implement practical interventions and determine functional prognosis.

Cultural adaptation, translation and validation of Cochin Hand Function Scale and evaluation of hand dysfunction in systemic sclerosis

OBJECTIVES

Hand dysfunction causes significant reduction in quality of life in systemic sclerosis. We assessed the validity and reliability of the culturally adapted Indian version of Cochin Hand Function Scale (I-CHFS). We determined the factors contributing to hand dysfunction and its burden on quality of life.

METHOD

I-CHFS was formulated by replacing five questions (questions 7, 9, 10, 14 and 15) in CHFS which were determined as unsuitable in an Indian setting. The instrument was assessed for acceptability, reliability, reproducibility and validity measures. A total of 87 patients were assessed for various demographic and disease parameters, hand disability and quality of life.

RESULTS

The median I-CHFS score was 22(5-54) and 04 (0.5-17.5) among diffuse (dcSSc) and limited cutaneous systemic sclerosis (lcSSc). I-CHFS showed good reproducibility (interclass correlation coefficient = 0.92) and a strong correlation with I-HAQ (r_s = 0.832), usual activities EQ-5D-5L (r_s = 0.744), self-care EQ-5D-5L (r_s = 0.734) and anxiety/depression EQ-5D-5L (r_s = 0.729). It had moderate correlation with pain/discomfort EQ-5D-5L (r_s = 0.661) and hand HAQ (r_s = 0.576) and poor correlation with HAQ-DI (r_s = 0.396) and modified Rodnan skin score (r_s = 0.390). Finger to table distance, finger to palm distance in extension and limited hand modified Rodnan skin score were significantly associated with higher values of I-CHFS.

CONCLUSIONS

Hand dysfunction in systemic sclerosis is substantial and contributes significantly to poor quality of life. The culturally adapted I-CHFS is a valid and reliable tool to assess it and correlated well with the overall disease burden. Key Points • Hand dysfunction is common among systemic sclerosis patients. • Hand dysfunction contributes to the poor quality of life and more disease burden. • Culturally adapted Cochin Hand function Scale helps assess hand dysfunction among Indian scleroderma patients.

Differentiating Rheumatoid and Psoriatic Arthritis of the Hand: Multimodality Imaging Characteristics

Accurate diagnosis and therapeutic intervention at an early stage is paramount for the management of rheumatoid arthritis (RA) and psoriatic arthritis (PsA), which are the two major types of inflammatory arthritis that involve the hand joints. As more disease-specific medications are developed, medication selection according to the correct diagnosis becomes more important. A delay in diagnosis and inappropriate medication selection may result in poor functional prognosis. However, clinical differentiation between RA and PsA can be challenging and may become largely dependent on imaging interpretation results. Although there is substantial overlap in the imaging findings of RA and PsA, there are differences in the affected primary target sites, reflected by the various patterns of joint involvement, and different microanatomic localization of abnormalities within a single joint in each disease. Therefore, appropriate use of various imaging modalities and accurate image interpretation add significant value to the diagnosis and treatment process. The synovio-entheseal complex is an important concept for understanding the imaging features of PsA. The authors review the different features of RA and PsA of the hands seen with various imaging modalities, including radiography, US, MRI, and dual-energy CT, with updates on the contemporary role of imaging in diagnosis and treatment. The radiologist should have sufficient knowledge to interpret imaging findings and understand the strengths and weaknesses of each modality to recommend the appropriate imaging method and differentiate both diseases accurately. ^©RSNA, 2020.

Efficacy and safety of dual filtration plasmapheresis combined with biological agents in active refractory rheumatod arthritis: A retrospective cohort study

To investigate the effectiveness of dual filtration plasmapheresis (DFPP), a novel blood purification treatment, as a rapid and sustained disease-modifying therapy for active refractory rheumatoid arthritis (RA).A retrospective cohort study had been conducted. One hundred fifty three patients aged 18 years or older with active refractory RA were treated with DFPP combined with infliximab (IFX), IFX, or glucocorticoid (GC), all the above treatments were combined with methotrexate (MTX).Baseline characteristic of the 153 patients (DFPP: n = 53; IFX: n = 51; GC: n = 49) were similar across groups. The remission rate of CDAI (SDAI) in the DFPP treatment group was significantly higher than that of the IFX and GC group after 3 months of treatment. The remission rate of DFPP treatment group was above 50%, while in IFX and GC group, the rate of CDAI (SDAI) remission was 41.2% (37.3%) and 22.4% (14.2%) after 3 months of treatment.A combination of DFPP and biological agents can quickly induce remission or low disease activity of active refractory RA.

Disease activity affects the recurrent deformities of the lesser toes after resection arthroplasty for rheumatoid forefoot deformity

OBJECTIVES

The purpose of this study was to clarify the effect of disease activity on recurrent deformities after resection arthroplasty for forefoot deformities in patients with rheumatoid arthritis (RA).

METHODS

This study included 83 feet in 58 patients with RA who underwent resection arthroplasty of all metatarsal heads, with a minimum follow-up of 2 years. The patients' demographic characteristics, preoperative radiographic findings, and RA disease activity evaluated using the 28-joint disease activity score based on the erythrocyte sedimentation rate (determined preoperatively and at the final follow-up) were compared between feet with and without postoperative recurrent deformities of the toes. Recurrent deformities were assessed separately for the hallux and lesser toes.

RESULTS

Recurrence in the hallux and lesser toes occurred in 23 feet (27.7%) and 13 feet (15.7%), respectively. With respect to recurrent hallux deformity, only the preoperative severity of hallux deformity was associated with recurrence. On the other hand, postoperative deformity of the lesser toes was positively associated with disease activity alone and not with other preoperative factors.

CONCLUSION

Postoperative control of RA disease activity was associated with recurrent deformity of the lesser toes but not that of the hallux after resection arthroplasty of all metatarsals for rheumatoid forefoot deformities.

Evaluation of Risk Factors for Falls in Patients with Rheumatoid Arthritis

Background

The aim of our study was to investigate the risk factors for falls in the rheumatoid arthritis (RA) patient population in Poland. This would be a major step towards the development of new fall prevention programs.

Material/Methods

There were 450 RA patients who met the criteria of the American College of Rheumatology who participated in this study. The average age of patient participants was 54.2 years; the average RA duration was 15.1 years. All patients filled out the study questionnaire regarding falls, medications, and diseases, and they filled out the Polish version of the Health Assessment Questionnaire (HAQ).

Results

Of the 400 patients, 203 patients (51%) experienced falls. Out of the 268 falls experienced by study patients, 113 falls (42%) were due to an environmental cause, the remainder 155 falls were caused by health conditions. The number of falls positively correlated with HAQ scores (r=0.42, P<0.01) and the duration of RA (r=0.39, P<0.05). For individuals who had fallen 3 or more times, there was a stronger positive correlation between the number of falls and the total HAQ score (r=0.61, P<0.01). The main risk factors for falls in the study group were dizziness (odds ratio [OR]=3.42), the use of hypotensive medication (OR=2.82), foot deformities (OR=4.09), and a high HAQ score (OR=2.59). Other factors such as drug use (e.g., glucocorticoids), pain, and duration of RA were measured using a visual analogue scale, and were found not to have increased the risk for falls and fractures (P>0.05).

Conclusions

Knowledge about risk factors can help identify high-risk patients to help decrease their risk of falling, thus preventing fall-related injuries.

A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis: a cross-sectional analysis

The most common thumb deformity in rheumatoid arthritis is Nalebuff Type 1 deformity (boutonniere deformity). Type 1 deformity severely impairs hand function, and this impairment is evaluated by the Terrono classification. In some cases, the Terrono classification incorrectly categorizes advanced thumb deformity into earlier stages. We modified the Terrono classification by assessing the active range of motion of the interphalangeal joint prior to assessing the passive range of movement of the metacarpophalangeal joint. An active range of movement of the interphalangeal joint was strongly correlated with hand function. In 55 hands that we treated between 2004 and 2015, we compared the modified classification with the original Terrono classification. Our modified classification could detect advanced deformity earlier, and was more strongly correlated with hand function. Additionally, correlation analysis showed that advanced Type 1 deformity should be treated first, even in cases with severe ulnar drift. Our results suggest that the modified classification may benefit the treatment of Type 1 deformity, including joint-preserving surgery. Level of evidence: III.

The relation between upper extremity joint involvement and grip force in early rheumatoid arthritis: a retrospective study

To investigate the relation between joint involvement in the upper extremities and grip force in patients with early rheumatoid arthritis (RA). An inception cohort of 225 patients with early RA was followed according to a structured protocol. The same rheumatologist assessed all patients for swollen joints and joint tenderness. Grip force was measured (Grippit; AB Detektor, Gothenburg, Sweden) at the same visit. Average grip force values for the dominant hand were expressed as % of expected, based on age- and sex-specific reference values from the literature. Associations between grip force and current synovitis or tenderness of individual joints, and other disease parameters measured at the same visit, were examined. Patients with current synovitis of the wrist joint or ≥ 1 metacarpophalangeal (MCP) joint of the dominant hand had a significantly lower grip force at inclusion, at 1 year and at 5 years. Proximal interphalangeal joint tenderness and MCP joint tenderness were consistently associated with reduced grip force. In multivariate analysis, extensive MCP joint synovitis was associated with lower grip force at inclusion (β - 2.8% per joint; 95% CI - 5.3 to - 0.4), and also at the 1-year follow-up. Patient reported pain scores and erythrocyte sedimentation rates had independent negative associations with grip force at all time points. In patients with early RA, extensive synovitis of the MCP joints was associated with reduced grip force, independently of other upper extremity joint involvement. Pain and inflammation have effects on hand function beyond those mediated by local synovitis.

Usability of Prefilled Syringe and Autoinjector for SB4 (An Etanercept Biosimilar) in Patients with Rheumatoid Arthritis

INTRODUCTION

This study aimed to compare the usability of subcutaneous administration of SB4 (an etanercept biosimilar) via prefilled syringe (PFS) and autoinjector (AI) based on injection site pain, patient preference, and safety in patients with rheumatoid arthritis (RA).

METHODS

This was an open-label, single-arm, multicenter study to evaluate the usability and safety of the AI and PFS of SB4. Adult patients with RA received two injections of SB4 via the PFS, followed by six injections by the AI every week, up to 8 weeks. The primary endpoint was the change in injection site pain score immediately post-injection from week 1 (PFS) to week 3 (AI). Injection site pain after 15-30 min post-injection, overall impression, and preference for PFS and AI were also assessed. Safety was assessed up to 11 weeks after the first injection.

RESULTS

A total of 54 patients were enrolled and 52 patients (96.3%) completed the 8-week treatment period. The mean difference in pain scores between PFS and AI was - 0.057 and the 95% CI of the difference was [- 0.63, 0.51], which was within the equivalence margin of ± 5. Overall impression of the device slightly favored the AI. Overall preference for the AI was more favorable when compared to the PFS in all categories. Adverse events were mild to moderate and found to be generally consistent with those expected for reference etanercept. There were no deaths or serious adverse events reported.

CONCLUSIONS

This study demonstrated comparable usability and safety between the PFS and AI when self-administrated by patients with RA.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03193957.

FUNDING

Samsung Bioepis.

Measure of activity performance of the hand (MAP-Hand) questionnaire: linguistic validation, cultural adaptation and psychometric testing in people with rheumatoid arthritis in the UK

BACKGROUND

Developed in the Norway, the Measure of Activity Performance of the Hand (MAP-Hand) assesses 18 activities performed using the hands. It was developed for people with rheumatoid arthritis (RA) using patient generated items, which are scored on a 0-3 scale and summarised into a total score range (0 to 54). This study reports the development and psychometric testing of the British English MAP-Hand in a UK population of people with RA.

METHODS

Recruitment took place in the National Health Service (NHS) through 17 Rheumatology outpatient clinics. Phase 1 (cross-cultural adaptation) involved: forward translation to British English; synthesis; expert panel review and cognitive debriefing interviews with people with RA. Phase 2 (psychometric testing) involved postal completion of the MAP-Hand, Health Assessment Questionnaire (HAQ), Upper Limb HAQ (ULHAQ), Short-Form 36 (SF-36_v2) and Disabilities of the Arm Shoulder Hand (DASH) to measure internal consistency (Cronbach's alpha); concurrent validity (Spearman's correlations) and Minimal Detectable Difference (MDC⁹⁵). The MAP-Hand was repeated three-weeks later to assess test-retest reliability (linear weighted kappa and Intra-Class Correlations (ICC (2,1)). Unidimensionality (internal construct validity) was assessed using (i) Confirmatory Factor Analysis (CFA) (ii) Mokken scaling and (iii) Rasch model. The RUMM2030 software was used, applying the Rasch partial credit model.

RESULTS

In Phase 1, 31 participants considered all items relevant. In Phase 2, 340 people completed Test-1 and 273 (80%) completed Test-2 questionnaires. Internal consistency was excellent (α = 0.96). Test-retest reliability was good (ICC (2,1) = 0.96 (95% CI 0.94, 0.97)). The MAP-Hand correlated strongly with HAQ20 (r_s = .88), ULHAQ (r_s = .91), SF-36_v2 Physical Functioning (PF) Score (r_s = -.80) and DASH (r_s = .93), indicating strong concurrent validity. CFA failed to support unidimensionality (Chi-Square 236.0 (df 120; p < 0.001)). However, Mokken scaling suggested a probabilistic ordering. There was differential item functioning (DIF) for gender. Four testlets were formed, resulting in much improved fit and unidimensionality. Following this, testlets were further merged in pairs where opposite bias existed. This resulted in perfect fit to the model.

CONCLUSIONS

The British English version of the MAP-Hand has good validity and reliability in people with RA and can be used in both research and clinical practice.

Linguistic validation, validity and reliability of the British English versions of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and QuickDASH in people with rheumatoid arthritis

Background

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is widely used in the UK, no British English version is available. The aim of this study was to linguistically validate the DASH into British English and then test the reliability and validity of the British English DASH, (including the Work and Sport/Music DASH) and QuickDASH, in people with rheumatoid arthritis (RA).

Methods

The DASH was forward translated, reviewed by an expert panel and cognitive debriefing interviews undertaken with 31 people with RA. Content validity was evaluated using the ICF Core Set for RA. Participants with RA (n = 340) then completed the DASH, Health Assessment Questionnaire (HAQ), Short Form Health Survey v2 (SF36v2) and Measure of Activity Performance of the Hand (MAPHAND). We examined internal consistency and concurrent validity for the DASH, Work and Sport/Music DASH modules and QuickDASH. Participants repeated the DASH to assess test-retest reliability.

Results

Minor wording changes were made as required. The DASH addresses a quarter of Body Function and half of Activities and Participation codes in the ICF RA Core Set. Internal consistency for DASH scales were consistent with individual use (Cronbach’s alpha = 0.94–0.98). Concurrent validity was strong with the HAQ (r_s = 0.69–0.91), SF36v2 Physical Function (r_s = − 0.71 - − 0.85), Bodily Pain (r_s = − 0.71 - − 0.74) scales and MAPHAND (r_s = 0.71–0.93). Test-retest reliability was good (r_s = 0.74–0.95).

Conclusions

British English versions of the DASH, QuickDASH and Work and Sport/Music modules are now available to evaluate upper limb disabilities in the UK. The DASH, QuickDASH, Work and Sport/Music modules are reliable and valid to use in clinical practice and research with British people with RA.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2032-8) contains supplementary material, which is available to authorized users.

Course of Grip Force Impairment in Patients With Early Rheumatoid Arthritis Over the First Five Years After Diagnosis

OBJECTIVE

Objective measures of function are important in rheumatoid arthritis (RA). The objective of this study was to investigate grip strength in patients with early RA.

METHODS

An inception cohort of 225 patients with early RA was followed in accordance with a structured protocol. Average and peak grip force values of the dominant hand (measured using a Grippit device [AB Detektor]) were evaluated and compared to expected age- and sex-specific reference values from the literature. Separate analyses were performed for those with limited self-reported disability (Health Assessment Questionnaire disability index [HAQ DI] score ≤0.5) and clinical remission (Disease Activity Score in 28 joints <2.6).

RESULTS

Baseline average grip force among RA patients was significantly lower than the corresponding expected value (mean 105N versus 266N; P < 0.001). Observed average and peak grip force values were significantly reduced compared to those expected in women as well as in men over time and at all time points. The average grip force improved significantly from inclusion to the 12-month visit (age-corrected mean change 34N [95% confidence interval 26-43]). At 5 years, the average grip force was still lower than that expected overall (mean 139N versus 244N; P < 0.001), and also among those with HAQ DI scores ≤0.5 and those in clinical remission.

CONCLUSION

Grip strength improved in early RA patients, particularly during the first year. However, it was still significantly impaired 5 years after diagnosis, even among those with limited self-reported disability and those in clinical remission. This suggests that further efforts to improve hand function are important in early RA.

A new assessment tool for ulnar drift in patients with rheumatoid arthritis using pathophysiological parameters of the metacarpophalangeal joint

OBJECTIVES

To establish a new assessment tool for ulnar drift (UD) in rheumatoid arthritis (RA).

METHODS

We established an observational cohort of 67 patients (134 rheumatoid hands) beginning in 2004. Fifty-two patients (100 hands) had follow-up in 2009 and 37 patients (63 hands) completed follow-up in 2015. UD was evaluated with the Fearnley classification and our scoring method, which assesses four parameters of the metacarpophalangeal joint. Cluster analysis using UD parameters divided hands into groups. Changes in UD over time, correlation of the Fearnley stage and cluster with a functional assessment, and reliability of the parameters were analyzed.

RESULTS

UD increased and worsened over time according to the trend test. A dendrogram indicated five clusters would be appropriate. Both the Fearnley classification and cluster were associated with function; however, our method related to function more linearly (R-squared: 0.42). We found one type of hand in which bone destruction precedes the joint dislocation and one type in which joint dislocation progresses with little deviation during UD progression.

CONCLUSION

Our UD evaluation appeared to be simple and related to function. Additionally, it enables dividing UD hands into five stages. Thus, our assessment should be beneficial compared to the Fearnley classification in considering treatments of UD.

Anti-Inflammatory Effects of p-Coumaric Acid, a Natural Compound of Oldenlandia diffusa, on Arthritis Model Rats

Objectives

In China, Oldenlandia diffusa (OD) is a natural herb that is widely used and has been proven to be effective in the treatment of rheumatoid arthritis (RA). This study aimed to preliminarily reveal the mechanism by which OD exerts its beneficial effect.

Methods

Ultra-performance liquid chromatography photodiode array was applied to identify the absorbable compounds in the plasma of collagen-induced arthritis (CIA) model rats. After 2 weeks, an OD decoction or the identified absorbable compound was administered to CIA rats. Morphology, X-ray images of the joints, pathological images, arthritis index, and cytokine (TNF-α and IL-6) levels were evaluated.

Results

p-Coumaric acid (p-CA) was identified as the absorbed compound in plasma. After administration of p-CA solution or the OD decoction, symptoms in the treated rats were alleviated as compared to the untreated model rats, and inflammatory cell infiltration was suppressed. The arthritis index and serum levels of TNF-α and IL-6 were decreased as compared to the control group.

Conclusions

OD may exert its anti-inflammatory effect on RA via its active ingredient, p-CA. This information sheds light on the mechanism by which OD exerts its anti-inflammatory effort in RA and forms the basis for further development of therapeutic agents for RA.

Functional disability associated with disease and quality-of-life parameters in Chinese patients with rheumatoid arthritis

Background

As an important outcome measure among rheumatoid arthritis (RA) patients, functional disability may contribute to unemployment, loss of work productivity, and impaired quality of life. However, little is known about the risk factors of functional disability in Chinese RA patients. This study aimed (1) to examine the prevalence of functional disability in Chinese RA patients; (2) to explore factors associated with the health assessment questionnaire-disability index (HAQ-DI).

Methods

A total of 101 RA patients in this cross-sectional study underwent standardized laboratory examinations and responded to the questionnaire for demographic data, the HAQ-DI for functional disability, the Compliance Questionnaire on Rheumatology (CQR) for medication adherence, the Hospital Anxiety and Depression Scale (HADS) for psychological status, and the Short Form 36 health survey (SF-36) for quality of life. Pain, grip/pinch strength, disease activity, and large joint mobility were recorded. Independent samples t-tests, chi-square analyses, and logistic regression modeling were used to analyze the data.

Results

The mean ± SD age of RA patients was 54.9 ± 11.9 years. Approximately 15.8% RA patients in mainland China experience functional disability (defined as a HAQ-DI score ≥ 1). Long disease duration, pain, high disease activity, a larger number of tender and swollen joints, high C-reactive protein (CRP) level, decreased grip strength, and limitation of shoulder, elbow, wrist, knee, and ankle motion were associated with the HAQ-DI. Participants with functional disability tended to have more severe depressive symptoms and a lower quality of life compared with individuals without functional disability. Stepwise logistic regression analyses found that limitation of wrist extension (P = 0.001) and lower body pain (BP) score (P = 0.001) explained higher HAQ-DI score.

Conclusions

The present study reported that functional disability was common in Chinese RA patients. A low quality of life and limitation of joint mobility had great impacts on functional disability in Chinese RA patients. Targeted and culturally sensitive interventions should be strengthened to delay the onset of disabilities of this population.

Patient and physician perspectives of hand function in a cohort of rheumatoid arthritis patients: the impact of disease activity

Background

In 2004, we initiated an inception cohort of patients with recent-onset rheumatoid arthritis (RA). Hand function was incorporated into evaluations from 2014 onward. The objectives were to examine hand function in our cohort, compare hand function with function in healthy controls and determine the factors associated with impaired function.

Methods

From February 2014 to June 2015, 139 patients (97.2 % of the cohort) had disease activity scored (28 joints, [DAS28]); the Michigan Hand Outcome Questionnaire (MHQ) and Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) were completed, and the tip-, key- and palmar-pinch and grip strengths were measured. Sixty-nine healthy controls underwent the same evaluations. Ninety-nine patients underwent a second evaluation one year after their baseline. Descriptive statistics and linear regression models were used. Patients and controls signed informed consent.

Results

Patients were primarily middle-aged females with a median disease duration of 7 years; 91 patients had DAS28-remission, and 16, 23, and 9 patients had low, moderate and high disease activity, respectively. Controls scored better than did patients with (any) disease activity level; remission patients had similar DASH and key pinch function as did controls with poorer MHQ and both tip and palmar pinch and grip strength. DAS28 was consistently associated with impaired hand function. Among the patients with a one-year re-assessment, changes in DAS28 correlated (rho = 0.34 to 0.63) with changes in hand function (p ≤ 0.01 for all comparisons), but there was no correlation with palmar pinch strength.

Conclusions

Disease activity was associated with hand function impairment in RA patients with variable follow-up. MHQ discriminated poorer hand function in remission patients who otherwise had similar DASH scores as the controls did.

The effectiveness of home hand exercise programmes in rheumatoid arthritis: a systematic review

INTRODUCTION

Rheumatoid arthritis (RA) commonly reduces hand function. We systematically reviewed trials to investigate effects of home hand exercise programmes on hand symptoms and function in RA.

SOURCES OF DATA

We searched: Medline (1946-), AMED, CINAHL, Physiotherapy Evidence Database, OT Seeker, the Cochrane Library, ISI Web of Science from inception to January 2016.

AREAS OF AGREEMENT

Nineteen trials were evaluated. Only three were randomized controlled trials with a low risk of bias (n = 665). Significant short-term improvements occurred in hand function, pain and grip strength, with long-term improvements in hand and upper limb function and pinch strength.

AREAS OF CONTROVERSY

Heterogeneity of outcome measures meant meta-analysis was not possible.

GROWING POINTS

Evaluation of low and moderate risk of bias trials indicated high-intensity home hand exercise programmes led to better short-term outcomes than low-intensity programmes. Such programmes are cost-effective.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research is required to evaluate methods of helping people with RA maintain long-term home hand exercise.

Education, self-management, and upper extremity exercise training in people with rheumatoid arthritis: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a brief supervised education, self-management, and global upper extremity exercise training program, supplementing a home exercise regimen, for people with rheumatoid arthritis (RA; the Education, Self-Management, and Upper Extremity Exercise Training in People with Rheumatoid Arthritis [EXTRA] program).

METHODS

Adults with RA of ≤5 years' duration were randomized to receive either usual care or the EXTRA program comprising 4 (1-hour) group education, self-management, and global upper extremity exercise training sessions supplementing the first 2 weeks of a 12-week individualized, functional home exercise regimen in addition to usual care. Outcome measures were assessed at baseline, 12 weeks (primary end point), and 36 weeks and included the Disabilities of the Arm, Shoulder, and Hand questionnaire (primary outcome measure), the Grip Ability Test, handgrip strength (N), the Arthritis Self-Efficacy Scale (pain, function, and symptoms subscales), and the 28-joint Disease Activity Score.

RESULTS

One hundred eight participants (26 men, mean ± SD age 55 ± 15 years, mean ± SD disease duration 20 ± 19 months) were randomized to receive either usual care (n = 56) or the EXTRA program (n = 52). At 12 weeks, there was a significant between-group difference in the mean change in disability (-6.8 [95% confidence interval (95% CI) -12.6, -1.0]; P = 0.022), function (-3.0 [95% CI -5.0, -0.5]; P = 0.011), nondominant handgrip strength (31.3N [95% CI 9.8, 52.8]; P = 0.009), self-efficacy (10.5 [95% CI 1.6, 19.5]; P = 0.021 for pain and 9.3 [95% CI 0.5, 18.2]; P = 0.039 for symptoms), and disease activity (-0.7 [95% CI -1.4, 0.0]; P = 0.047), all favoring the EXTRA program.

CONCLUSION

The EXTRA program improves upper extremity disability, function, handgrip strength, and self-efficacy in people with RA, with no adverse effects on disease activity.

A customized protocol to assess bone quality in the metacarpal head, metacarpal shaft and distal radius: a high resolution peripheral quantitative computed tomography precision study

Background

High Resolution-Peripheral Quantitative Computed Tomography (HR-pQCT) is an emerging technology for evaluation of bone quality in Rheumatoid Arthritis (RA). However, there are limitations with standard HR-pQCT imaging protocols for examination of regions of bone commonly affected in RA. We developed a customized protocol for evaluation of volumetric bone mineral density (vBMD) and microstructure at the metacarpal head (MH), metacarpal shaft (MS) and ultra-ultra-distal (UUD) radius; three sites commonly affected in RA. The purpose was to evaluate short-term measurement precision for bone density and microstructure at these sites.

Methods

12 non-RA participants, individuals likely to have no pre-existing bone damage, consented to participate [8 females, aged 23 to 71 y [median (IQR): 44 (28) y]. The custom protocol includes more comfortable/stable positioning and adapted cortical segmentation and direct transformation analysis methods. Dominant arm MH, MS and UUD radius scans were completed on day one; repeated twice (with repositioning) three to seven days later. Short-term precision for repeated measures was explored using intraclass correlational coefficient (ICC), mean coefficient of variation (CV%), root mean square coefficient of variation (RMSCV%) and least significant change (LSC%₉₅).

Results

Bone density and microstructure precision was excellent: ICCs varied from 0.88 (MH₂ trabecular number) to .99 (MS₃ polar moment of inertia); CV% varied from < 1 (MS₂ vBMD) to 6 (MS₃ marrow space diameter); RMSCV% varied from < 1 (MH₂ full bone vBMD) to 7 (MS₃ marrow space diameter); and LSC% ₉₅varied from 2 (MS₂ full bone vBMD to 21 (MS₃ marrow space diameter). Cortical porosity measures were the exception; RMSCV% varying from 19 (MS₃) to 42 (UUD). No scans were stopped for discomfort. 5% (5/104) were repeated due to motion during imaging. 8% (8/104) of final images had motion artifact graded > 3 on 5 point scale.

Conclusion

In our facility, this custom protocol extends the potential for in vivo HR-pQCT imaging to assess, with high precision, regional differences in bone quality at three sites commonly affected in RA. Our methods are easy to adopt and we recommend other users of HR-pQCT consider this protocol for further evaluations of its precision and feasibility in their imaging facilities.

Physiotherapy co-management of rheumatoid arthritis: identification of red flags, significance to clinical practice and management pathways

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease. Physiotherapy interventions for people with RA are predominantly targeted at ameliorating disability resulting from articular and peri-articular manifestations of the disease and providing advice and education to improve functional capacity and quality of life. To ensure safe and effective care, it is critical that physiotherapists are able to identify potentially serious articular and peri-articular manifestations of RA, such as instability of the cervical spine. Additionally, as primary contact professionals, it is essential that physiotherapists are aware of the potentially serious extra-articular manifestations of RA. This paper provides an overview of the practice-relevant manifestations associated with RA that might warrant further investigation by a medical practitioner (red flags), their relevance to physiotherapy practice, and recommended management pathways.

Splinting and hand exercise for three common hand deformities in rheumatoid arthritis: a clinical perspective

PURPOSE OF REVIEW

Hand deformities (ulnar drift, swan neck and boutonniere) are prevalent in rheumatoid arthritis and develop early in the disease process. These deformities cause significant functional impairment and impact quality of life. This review will provide a clinical perspective using the most recent evidence regarding the role of splinting and hand exercise in their management. The pathomechanics and functional consequences of these deformities are also described.

RECENT FINDINGS

Patients tend to under-report their hand problems and are often reluctant to seek treatment for their deformities. There is limited evidence to support or refute the role of splinting and hand exercises in their management. Clinical experience suggests splinting and hand exercise are most beneficial when prescribed for early, flexible deformities.

SUMMARY

More research is required to guide clinicians on the most effective approach to the management of these three hand deformities. It is imperative that clinicians assess for and recognize these deformities in order to ensure timely and appropriate treatment. Until more evidence becomes available, an evidenced-informed approach is recommended.

Early changes in bone mineral density measured by digital X-ray radiogrammetry predict up to 20 years radiological outcome in rheumatoid arthritis

INTRODUCTION

Changes in bone mineral density (BMD) in the hand as evaluated by digital X-ray radiogrammetry (DXR) of the second to fourth metacarpal bones has been suggested to predict future joint damage in patients with rheumatoid arthritis (RA). This study's objective was to investigate whether DXR-BMD loss early in the course of the disease predicts the development of joint damage in RA patients followed for up to 20 years.

METHODS

A total of 183 patients (115 women and 68 men) with early RA (mean disease duration, 11 months) included from 1985 to 1989 were followed prospectively (the Lund early RA cohort). Clinical and functional measures were assessed yearly. Joint damage was evaluated according to the Larsen score on radiographs of the hands and feet obtained in years 0 to 5 and years 10, 15 and 20. These radiographs were digitized, and BMD of the second to fourth metacarpal bones was evaluated by DXR. Early DXR-BMD change rate (that is, bone loss) per year calculated from the first two radiographs obtained on average 9 months apart (SD ± 4.8) were available for 135 patients. Mean values of the right and left hand were used.

RESULTS

Mean early DXR-BMD loss during the first year calculated was -0.023 g/cm2 (SD ± 0.025). Patients with marked bone loss, that is, early DXR-BMD loss above the median for the group, had significantly worse progression of joint damage at all examinations during the 20-year period.

CONCLUSIONS

Early DXR-BMD progression rate predicted the development of joint damage evaluated according to Larsen score at year 1 and for up to 20 years in this cohort of early RA patients.

Reconstruction of digital deformities in rheumatoid arthritis

Digital deformities result from rheumatoid synovitis. These deformities are easier to treat in the early stage, when the deformity is passively correctable. Treatment options become limited as the disease progresses and the deformity becomes fixed. Surgical treatment of digital deformities is last in the priority of surgical procedures for the rheumatoid hand and wrist. It is therefore important to understand the patient's needs and expectations for improvement and attempt to match them with the surgical options that can predictably improve the patient's function. A close collaboration with the patient's rheumatologist is helpful in the overall management of patients.