Number of active joints, not diagnosis, is the primary determinant of function and performance in early synovitis.

OBJECTIVE: A substudy within a larger study of patients with inflammatory arthritis of less than one year, to analyze baseline measures or joint counts, laboratory values, patient questionnaires and ARA diagnostic criteria for rheumatoid arthritis, as predictors of one year performance and functional status. METHODS: 229 patients with synovitis of less than one year were enrolled and evaluated at baseline and one year. Measures included the number of swollen or tender joints [active joint counts]; biological indices of inflammation [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]; and patient questionnaire measures of pain [Wisconsin Brief Pain Inventory], fatigue [multi-dimensional assessment of fatigue], depression [Center for Epidemiologic Studies--Depression Scale], sleep [Sleep Quality Index], performance [Human Activity Profile], and function [Sickness Impact Profile ambulation subscale and Health Assessment Questionnaire]. Correlations between these measures were evaluated using the Spearman rank order correlation. Patients were classified according to whether they met ARA criteria for RA, had high (> 7) or low (< or = 7) numbers of affected joints; and high, intermediate, or low levels of performance; and were compared using the Kruskal-Wallis test. RESULTS: At baseline, an active joint count of > 7 versus < or = 7 was associated significantly with higher age, rheumatoid factor positivity, a diagnosis of rheumatoid arthritis versus spondyloarthropathy or undifferentiated arthritis, and receiving a disease modifying antirheumatic drug (DMARD), but not with sex, race, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), or receiving prednisone. Furthermore, high baseline active joint counts were associated significantly with patient questionnaire scores for maximum activity, fatigue and depression, but differences were not significant for sleep, ambulation and pain scores. A comparison of patients who met or did not meet criteria for RA indicated significant differences only according to the fatigue scores, but none of the other questionnaire measures. Correlations of baseline measures with one-year performance were highest for the baseline active joint count compared to laboratory and questionnaire variables. The maximum activity score at one year was predicted significantly by the baseline maximum activity score, active joint count, and age, but not by laboratory tests or whether the patient met criteria for RA. CONCLUSION: The active joint count predicts subsequent performance and function for patients with recent onset, inflammatory synovitis more effectively than whether patients met ARA criteria for RA.

Cancer rehabilitation into the future.

The 5-year survival for many cancer sites exceeds 50%, suggesting that these patients are living longer and may be considered to have a chronic illness. The incidence of cancer increases from 500 in 100,000 to 2000-4000 in 100,000 as women or men age from 50 to 80 years. Our population is aging and the prevalence of cancer is increasing. Treatments for cancer are quite complex, and they are often delivered to elders who have a variety of medical problems and are receiving additional medications that may complicate overall patient management. Hence, these patients may have extremely complex functional problems. Cancer patients need comprehensive care designed to relieve symptoms of pain, fatigue, and weakness. They need education to help support their ability to reach functional independence and maintain quality of life. Rehabilitation professionals are essential for the comprehensive care of cancer patients throughout the phases of their disease: treatment planning, treatment, remission, recurrence, and end of life. The needs of this population can better be served if several processes are put into effect. Rehabilitation professionals must be trained to manage problems associated with cancer and its treatments. Research about what are effective and efficient rehabilitation treatments must be done to determine how best to treat cancer patients throughout the various phases of their illness. Physicians and patients must be alerted to the importance of rehabilitation interventions to the overall function of these patients.

Forefoot deformity, pain, and mobility in rheumatoid and nonarthritic subjects.

OBJECTIVE: To evaluate how painful metatarsal arthritis affects foot and ankle mechanics and mobility. METHODS: We studied 16 symptomatic forefeet in 10 patients with rheumatoid arthritis (RA) and compared them with 14 asymptomatic forefeet in 7 nonarthritic subjects. RA limbs with significant disease at other locations were excluded. We measured pain and deformity of the foot using a visual analog scale and a modified articular index. A video based 3 dimensional gait analysis system and force platform were used to collect data on subjects walking barefoot at a self-selected pace according to an established protocol. Mobility level was quantified using the Sickness Impact Profile (SIP) ambulation subscale. RESULTS: We observed considerable pain and deformity of the forefeet of RA subjects. During gait, motion and force measures revealed that RA subjects significantly (p < 0.005) delayed and reduced forefoot loading, which minimized use of the foot as a rigid level for push off. As a result, stride lengths were shorter and gait was slower compared to nonarthritic subjects. SIP scores revealed that these changes in gait resulted in moderate disability in RA subjects (p=0.05). CONCLUSION: Impairments of the forefoot due to RA include pain and deformity, which produce characteristic stance phase abnormalities in foot function, a slow walking speed, and moderate disability.

Effects of withdrawal of bracing in matched pairs of children with osteogenesis imperfecta.

OBJECTIVES: To evaluate the effects of withdrawal of long-leg braces (hip-knee-ankle-foot orthoses [HKAFO]) on activity and ambulation in children with osteogenesis imperfecta. DESIGN: A prospective, randomized cross-over trial, that describes the effects of withdrawing HKAFO. PATIENTS: Ten children who were ambulatory with the assistance of braces. All had type III or IV osteogenesis imperfecta. Children were paired for age and clinical severity. Strength testing, fractures, and independence in daily activity were monitored at 4-month intervals for 32 months (16 months each of braced and unbraced periods). Gait was analyzed during braced and unbraced conditions. RESULTS: Muscle strength declined .35 grade during unbraced and .1 grade during braced intervals. Children spent more time in upright activity during braced intervals than during unbraced intervals (p = .17). Children were more independent in daily activities during braced than during unbraced periods (p = .14). Seventeen fractures of lower extremities occurred during all the unbraced periods, and 8 occurred during the braced intervals (p = .08); the fracture rate was higher during unbraced intervals. (p = .06) Bracing was associated with increased hip flexion and stride length and decreased transverse plane pelvic rotation. CONCLUSION: Withdrawal of HKAFO in children with osteogenesis imperfecta who had achieved upright activity was not associated with significant decrease in muscle strength or independence, but there was an associated increase in fracture rate that nearly reached significance.

A review of measures of lymphedema.

BACKGROUND: Lymphedema usually is identified by patients, and rarely is it screened for routinely. Many assessments have been reported and have been used in evaluating a variety of treatments for lymphedema. METHODS: A review of the literature was undertaken. RESULTS: Five frequently used measures of lymphedema include circumferential measures of limbs at various points (usually at bony landmarks); volumetric measures using limb submersion in water; skin tonometry, in which soft tissue compression is quantified; imaging techniques to describe tissue characteristics as well as to quantify soft tissue swelling (magnetic resonance imaging and computerized tomography; and ultrasound with and without Doppler flow studies for volumetric measures. Circumferential measures with calculations designed to compute limb volumes and volumetric measures are used most frequently, but these have some difficulty with reliability. No significant effort has been made to develop a patient based questionnaire that describes the size as well as the impact of lymphedema on an individual's functional level. CONCLUSIONS: Existing physical measures of lymphedema are available that are easy to use, inexpensive, have limited reliability, and do not address the issue of functional impact. Imaging techniques may provide valuable qualitative and quantitative information in selected populations.

A technique to evaluate foot function during the stance phase of gait.

A technique to measure foot function during the stance phase of gait is described. Advantages of the method include its three-dimensional approach with anatomically based segment coordinate systems. This allows variables such as ground reaction forces and center of pressure location to be expressed in a local foot coordinate system, which gives more anatomical meaning to the interpretation of results. Application of the measurement technique to case examples of patients with rheumatoid arthritis demonstrated its ability to discriminate normal from various levels of pathological function. Future studies will utilize this technique to study the impact of pathology and treatment on foot function.

Surgical and rehabilitation options in the treatment of the rheumatoid arthritis patient resistant to pharmacologic agents.

People with rheumatoid arthritis whose disease is poorly controlled with pharmacologic agents require treatment designed to reduce pain and inflammation and promote function and mechanical alignment. The proper evaluation of the musculoskeletal system and the patient's functional level must be performed. Heat, cold, splints, adaptive equipment, exercise, alternative therapies, and surgery are important adjunctive treatments for disease modulation and to maintain function and well being.

Frontiers in rehabilitation medicine: osteogenesis imperfecta.

This Frontiers in Osteogenesis Imperfecta conference has been organized to foster communication between clinical and laboratory scientists as well as future collaborations. In fact, one of the goals we have had as organizers of this meeting is that new areas of investigation would be fostered. I will attempt to present some of the as yet unanswered clinical questions that I believe are important for this population.

Biopsychosocial contributions to the management of arthritis disability. Blueprints from an NIDRR-sponsored conference.

The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.

Rehabilitation approaches to children with osteogenesis imperfecta: a ten-year experience.

Twenty-five children with severe osteogenesis imperfecta were followed and treated with physical and occupational therapy for a mean of five years, two months, 80% since the first two years of life. According to their highest achieved motor skill, they fell into three groups: (A) able to stand in braces, (B) able to ambulate short distances without braces, and (C) able to ambulate in the community without assistance. Preventable functional impairment is caused in group A by shoulder joint and hand contractures and upper extremity weakness, group by hip flexion and plantar flexion contractures of the feet, shoulder joint contractures, and upper extremity weakness, and group C by poor lower extremity joint alignment, impaired balance, and low endurance. Appropriate rehabilitation strategies have led to slow, continued functional improvement in the majority of patients. Results of the ten-year retrospective study suggest that clinical groupings based in part on functional needs will enable the clinician to provide optimal rehabilitation services.

Comprehensive rehabilitation of the child with osteogenesis imperfecta.

Children with osteogenesis imperfecta (OI) that results in considerable deformity are often viewed as poor candidates for aggressive physical therapy and rehabilitation. To determine if this view is realistic, we have entered almost 50 children with OI type III and OI type IV into a comprehensive graduated rehabilitation program, based at the National Institutes of Health, but designed to be implemented by continuing involvement of community resources. Children are begun in the program early with emphasis on gain of head and trunk control and progression to sitting and walking, if possible, with the aid of a variety of physical supports, including internal and external bracing. Although not conducted in a randomized fashion, the program's success in bringing children into graded exercise regimes and fostering their increased involvement in school and social situations suggest that aggressive physical therapy and rehabilitation have a major place in the overall care of the infants and children with OI.

Scoring methods and application of the activity record (ACTRE) for patients with musculoskeletal disorders.

The National Institutes of Health (NIH) Activity Record (ACTRE) has been used to document daily activities in patients with musculoskeletal disorders. Quantification of the amount of time spent resting and physically active, the intensity of pain and fatigue associated with patterns of activities, and motivational considerations are possible with the ACTRE. Scoring has been streamlined to permit identification of the amount of pain, fatigue, and motivational factors as they relate to activity patterns (e.g., rest and physical activity). The ACTRE provides a performance-based, quantifiable measure of daily activity.

Validation of the NIH activity record: a quantitative measure of life activities.

This article reports the results of the validation of a life activity record. We devised a self-administered daily log (the NIH Activity Record, ACTRE), for persons with rheumatoid arthritis (RA), which recorded specific daily activities over a 24-hour period and identified the level of physical effort for each task. In addition, each activity was assigned a level of pain, fatigue, difficulty, competence, meaningfulness and enjoyment. Twenty-one persons with RA completed the log. They underwent an articular examination (AI) (Ritchie Articular Index) as well as completed the following self-reports: Psychosocial Adjustment to Illness Scale (PAIS); The Feeling Tone Checklist (FTC), a measure of fatigue; The Modified Health Assessment Questionnaire (ALI); and the Pain and Disability Index (PDI). Significant correlations were found between fatigue measured by ACTRE and FTC (p = 0.028); pain measured by ACTRE, PDI (p = 0.002), and (p = 0.01) and the visual analog scale in the ALI (p = 0.0002). Pain experienced while performing self-care measured by ACTRE correlated with AI (p = 0.001) and ALI (p = 0.0013). Difficulty with self-care activities on the ACTRE correlated with difficulty (p = 0.007) and pain (p = 0.012) on the ALI. The ACTRE is a valid measure of symptoms and perceptions that can be quantified, and is unique in that it identifies specific daily activities likely to produce them.

Arthritis in patients with psoriasis treated with gamma-interferon.

We observed 3 patients with psoriasis who developed arthritis during treatment of psoriatic skin disease with intramuscular recombinant human gamma-interferon (IFN-gamma). Symptoms primarily involved the hands, feet, shoulders, and neck. One patient had acute plantar fasciitis. Routine laboratory studies were unrevealing. Patients presented with symptoms initially between the 10th and 12th weeks of treatment and the arthritis resolved after cessation of IFN-gamma. One patient was subsequently retreated with IFN-gamma for 4 weeks and had a temporary recurrence of arthritis with an associated rise and fall of his articular index.