An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: a pre-post test evaluation in highly distressed patients with rheumatic diseases.

OBJECTIVE: To examine the potential effectiveness of a multimodal rehabilitation program including an acceptance-oriented cognitive-behavioral therapy for highly distressed patients with rheumatic diseases. METHODS: An observational study employing a one-group pre-post test design (N=25). The primary outcome was psychological distress. Secondary outcomes were quality of life, illness acceptance, and coping flexibility. Group pre-to-post and pre-to-12 months follow-up treatment changes were evaluated by paired-samples t-tests and Cohen's effect sizes (d). Individual changes were evaluated by the reliable change index (RCI) and clinically significant change (CSC) parameters. RESULTS: Significant effects were found post-treatment and maintained at 12 months in psychological distress (d>0.80), illness acceptance (d=1.48) and the SF-36 subscales role physical, vitality, and mental health (d ≥ 0.65). No significant effects were found for coping flexibility and the SF-36 subscales physical functioning, bodily pain, social functioning, and role emotional. Both a reliable (RCI) and clinically significant (CSC) improvement was observed for almost half of the highly distressed patients. CONCLUSION: The patients enrolled in the multimodal rehabilitation program showed improved psychological health status from pre to post-treatment. PRACTICE IMPLICATIONS: A randomized clinical trial is needed to confirm or refute the added value of an acceptance-oriented cognitive-behavioral therapy for highly distressed patients in rehabilitation.

The coping flexibility questionnaire: development and initial validation in patients with chronic rheumatic diseases.

Coping flexibility may be beneficial for the adjustment in the context of a progressive and unpredictable course of chronic rheumatic diseases. The aim of this study was to develop and initially validate a self-report measure that assesses coping flexibility. Study participants were 147 outpatients with chronic rheumatic diseases (73% women, mean age 59 (range 20-79) years). Principal axis factoring analysis with oblique rotation was applied and internal consistency was determined. To investigate the initial validity of the coping flexibility questionnaire (COFLEX), hypothesised correlations with psychological and physical adjustment outcomes, pain, and coping strategies were examined. Factor analysis yielded a two-factor model of coping flexibility with acceptable internal consistency: versatility, the capability of switching between assimilative and accommodative coping strategies according to personal goals and situational demands (α = .88) and reflective coping, the capability of generating and considering coping options, and appraising the suitability of a coping strategy in a given situation (α = .70). Versatility was correlated with adaptive ways of coping and psychological adjustment, but not with physical adjustment and pain. Reflective coping was correlated with both adaptive and maladaptive ways of coping, but it was not correlated with adjustment outcomes. In conclusion, the current study suggests acceptable internal consistency of the COFLEX. Preliminary evidence of the validity of the versatility dimension is indicated, while the validity of reflective coping could not be firmly established. The associations of versatility with favourable adjustment to the disease warrant future confirmatory and validity research in larger samples of patients with chronic rheumatic diseases.

Effects of naproxen and sulphasalazine or methotrexate on hypothalamic-pituitary-adrenal axis activity in patients with rheumatoid arthritis.

OBJECTIVES: To study the effects of antirheumatic drugs on hypothalamic-pituitary-adrenal (HPA) axis activity in patients with rheumatoid arthritis (RA). METHODS: Twenty patients with recent-onset active RA were studied before antirheumatic treatment, after 2 weeks of naproxen, and after 5½ months of additional treatment with sulphasalazine or methotrexate. The results before treatment were compared with those obtained in 20 age and sex-matched healthy controls (HC). Activity of the HPA-axis was assessed under basal conditions and during insulin tolerance tests (ITT). The ex-vivo production of interleukin (IL)-1ß, tumour necrosis factor-α (TNF-α) and IL-6 in whole blood samples was measured with and without stimulation by LPS. RESULTS: At baseline, plasma ACTH and cortisol levels were not different between patients with RA and HC. The unstimulated production of IL-6 was significantly higher in RA patients than in HC. After 2 weeks of treatment with naproxen, urinary cortisol excretion decreased significantly (p=0.03), and the area under the curve for plasma cortisol during the ITT was significantly lower (p=0.015). The LPS stimulated production of IL-1ß was significantly lower compared with baseline. After 6 months, basal plasma, salivary and urinary cortisol levels, and plasma cortisol and ACTH levels during the ITT, were all unchanged in comparison to the pre-treatment period. The unstimulated ex-vivo production of IL-1ß was significantly lower than before treatment. CONCLUSIONS: Our results suggest that the non-steroidal anti-inflammatory drug naproxen suppresses the HPA-axis in the first weeks of treatment. After 6 months, this suppressive effect is no longer present, suggesting the existence of adaptive mechanisms.

Effect of naproxen on the hypothalamic-pituitary-adrenal axis in healthy volunteers.

AIM: To study the effect of the nonsteroidal anti-inflammatory drug naproxen on the activity of the hypothalamic-pituitary-adrenal (HPA) axis in healthy volunteers. METHODS: A double-blind, randomized study in two groups of 20 healthy volunteers was performed. The activity of the HPA axis was measured before and after the use of naproxen or placebo during a period of 2 weeks. Basal plasma adrenocorticotropic hormone (ACTH) and cortisol, 24-h urinary cortisol, and circadian cortisol rhythm in saliva were determined. Plasma ACTH and cortisol were also measured during submaximal physical exercise. RESULTS: There were no significant differences between the placebo and naproxen groups in basal plasma ACTH [09.00 h 3.1 pmol l(-1), 95% confidence interval (CI) 2.0, 4.2, and 2.8 pmol l(-1), 95% CI 1.9, 3.7, respectively], cortisol levels (09.00 h 0.45 micromol l(-1), 95% CI 0.39, 0.51, and 0.40 micromol l(-1), 95% CI 0.35, 0.44, respectively), 24 h urinary cortisol excretion (67.5 nmol 24 h(-1), 95% CI 54.3, 80.7, and 86.8 nmol 24 h(-1), 95% CI 54.4, 119.2, respectively), circadian cortisol rhythm measured in salivary samples, or ACTH and cortisol concentrations after physical exercise. After the use of placebo or naproxen for 2 weeks, no significant change in any of the parameters occurred (ACTH 09.00 h 3.0 pmol l(-1), 95% CI 2.0, 3.9, and 3.0 pmol l(-1), 95% CI 2.2, 3.8, respectively; cortisol 09.00 h 0.45 micromol l(-1), 95% CI 0.37, 0.52, and 0.39 micromol l(-1), 95% CI 0.34, 0.44, respectively; cortisol urine 79.5 nmol 24 h(-1), 95% CI 59.5, 99.4, and 81.7 nmol 24 h(-1), 95% CI 64.0, 99.4, respectively), and no significant differences were found in these parameters between the placebo and naproxen groups. CONCLUSIONS: The use of naproxen does not influence the activity of the HPA axis in healthy volunteers under basal circumstances or in response to physical stress.

Circulating levels of the chemokine CCL18 but not CXCL16 are elevated and correlate with disease activity in rheumatoid arthritis.

BACKGROUND: Antigen-presenting cells (APC) and T cells are considered to play a significant role in the pathogenesis of rheumatoid arthritis (RA). CCL18 and CXCL16 are two chemokines that facilitate T cell attraction by APC, of which a role in the pathogenesis of RA has been suggested. OBJECTIVE: To compare the circulating levels of CXCL16 and CCL18 in RA with controls and to investigate the relation of CXCL16 and CCL18 with RA disease activity and joint damage. METHODS: Circulating CCL18 and CXCL16 levels were determined in 61 RA patients with a follow-up of 6 years and a group of 41 healthy controls with ELISA. Chemokine levels were correlated with demographic data, disease activity (DAS28) and joint damage (modified Sharp score). In addition, serum CCL18 and CXCL16 levels from a cohort of 44 RA patients treated with anti-TNF-alpha were correlated with disease activity. RESULTS: CCL18 levels in serum were significantly elevated in RA patients compared with controls, while serum CXCL16 levels were not. In contrast to CXCL16, serum CCL18 was positively correlated with disease activity. Both CCL18 and CXCL16 levels decreased upon treatment with anti-TNF-alpha. Neither CCL18 nor CXCL16 correlated with joint damage and progression. CONCLUSION: Here, we show, for the first time, that circulating CCL18 and not CXCL16 levels are elevated in RA patients as compared with controls and correlate with disease activity in RA. More knowledge regarding the regulation and function of both CCL18 and CXCL16 is essential to value their role in RA.