Keeping physically active with rheumatoid arthritis: semi-structured interviews to explore patient perspectives, experiences and strategies.

BACKGROUND: Regular physical activity is safe and beneficial for people with rheumatoid arthritis (RA) but the majority of people with RA are less active than the general population and have a higher risk of co-morbidities. Exploring strategies used by physically active people with RA could inform effective methods to support those who are less active. OBJECTIVE: To explore the perspectives, experiences and strategies employed by people with RA who successfully engage with regular physical activity. DESIGN: Individual semi-structured interviews and thematic analysis. PARTICIPANTS: A purposive sample of physically active people with RA. RESULTS: Twelve females and three males participated (mean age 56, range 29 to 80; mean disease duration 13 years, range 10 months to 46 years). Analysis revealed eight constructs clustered into three themes. Theme 1: 'the individual' incorporated constructs of symptoms, feelings and role; theme 2: 'management' incorporated medical and self-management; theme 3: 'physical activity' incorporated constructs of type of physical activity, including barriers or facilitators. Participants reported a long history of physical activity prior to diagnosis and good support networks. All participants recognised that physical activity was key to their RA management, acknowledged the benefits from engaging in physical activity and were able to overcome barriers. Participants had strong beliefs that physical function would decline without regular physical activity. CONCLUSIONS: People with RA who successfully maintain physical activity are motivated by a desire to manage symptoms, resist functional decline and maintain health and independence. These findings should be explored with a wider range of people with RA.

Sodium hypochlorite and its use as root canal irrigant: a survey among ghanaian dental practitioners

Background: The majority of endodontic treatment in Ghana is provided by general dental practitioners due to the absence of specialists in endodontics. Sodium hypochlorite has been described as one of the commonly used irrigation solutions during endodontic treatment. However, there are no published reports on its use in Ghana. Aim: The study was to determine the proportion of Ghanaian dental practitioners who have used sodium hypochlorite for irrigation and the concentrations they usually use. Materials and methods: Self -administered questionnaires were mailed to dental practitioners in private clinics, government hospitals and clinics, teaching hospitals and training institutions across the country between December 2015 and March 2016. The collated data was analyzed using Microsoft Excel 2010 and SPSS 20.0.Results: The most commonly used root canal irrigant was 2.5% Sodium Hypochlorite (Milton®). This was routinely used by 31 (73.7%) of the respondents as root canal irrigant while normal saline solution was used regularly by only 6(15.8%) respondents. The various concentrations of sodium hypochlorite used were 0.5%, 2.5%,1%and 5.0%; with the following percentage-use respectively, 42.9%, 32.1%,21.4%and 6.1%. Three (10.7%) respondents had reported experiencing some complications with the use of sodium hypochlorite. Conclusion: Sodium hypochlorite is the most commonly used root canal irrigant by dental practitioners in Ghana. The concentrations usually used ranges between 0.5% and 5.0%

Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches.

INTRODUCTION: Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability. METHODS AND ANALYSIS: This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥ 6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6 × 2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and cost-effective. Effects of teaching CB skills to clinicians will be evaluated qualitatively. ETHICS AND DISSEMINATION: Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments. ISRCTN: 52709998; Protocol v3 09.02.2015.

Predictors of Subjective Well-Being among Older Ghanaians

Background: Later years of life are accompanied by many physical; emotional and environmental changes which may impact on the well-being of the individual. Many factors are known to influence the subjective well-being of older adults; but most; if not all of this information was the result of studies in the Western world. This study aimed at obtaining and documenting the predictors of subjective well-being (SWB) among older Ghanaians. Methods: Data for the study was obtained from the WHO SAGE study. The single item measure of life satisfaction was used to determine subjective wellbeing. Descriptive statistics as well as logistic regression analysis were carried out to determine the predictors of SWB. Results: A total of 4724 individuals aged 50 years and above responded to the questionnaires. Of these 50.4 were males. Following multivariate logistic regression analysis; age; sex; educational level; income and ethnic background were found to significantly affect the SWB of older Ghanaians. Being male was associated with higher level of SWB (OR=1.68; CI: 1.39 - 2.03). For those 50 years and above; being younger (50-59 years) was also associated with a high level of SWB (OR=17.72; CI: 10.13-30.98). Earning a low income and having low educational level were both associated with low levels of SWB (OR=0.304; CI: 0.22-0.42; and OR=0.47; CI: 0.37-0.60 respectively). Ewes (p=0.027); Grumas (p=0.002) and Mole-Dagbons (p=0.04) had significantly higher SWB compared to the other ethnic groups. Conclusion: Among older Ghanaians; factors that positively influence SWB are younger age; male sex; high educational level and high income

Type II diabetes and oral health: perceptions among adults with diabetes and oral/health care providers in Ghana.

OBJECTIVE: This study sought to examine oral health beliefs and attitudes, and utilisation of oral health care services among individuals with diabetes and health professionals who serve them in Ghana. BASIC RESEARCH DESIGN: A qualitative study using grounded theory was conducted. CLINICAL SETTING: University of Ghana Dental School at Korle Bu, University of Ghana School of Public Health, National Diabetes Research and Management Centre at Korle Bu, and New York University College of Dentistry. PARTICIPANTS: A convenience sample of 59 patients comprised 7 focus groups conducted in either Twi or English. Seven key informant interviews with healthcare professionals and one spiritual leader were completed. RESULTS: Data from the focus groups and interviews reveal: 1, half of the participants with diabetes have oral manifestations (e.g., bleeding gums) and participants are generally unaware of interrelationship between diabetes and oral health; 2, dental treatment utilisation is minimal and associated almost exclusively with reparative and emergency care; and 3, medical health providers do not acknowledge the interrelationship between oral health and diabetes nor do they incorporate oral health issues into diabetes screening/treatment. CONCLUSION: Oral health knowledge and practices are limited among patients with diabetes in Accra, Ghana. Collaborative efforts for in-service education and training for oral health and medical professionals may be beneficial in serving the oral and general health care needs as well as improving the oral health-related quality of life of Ghanaians with diabetes.

Predictors of subjective well-being among older Ghanaians.

BACKGROUND: Later years of life are accompanied by many physical, emotional and environmental changes which may impact on the well-being of the individual. Many factors are known to influence the subjective well-being of older adults, but most, if not all of this information was the result of studies in the Western world. This study aimed at obtaining and documenting the predictors of subjective well-being (SWB) among older Ghanaians. METHODS: Data for the study was obtained from the WHO SAGE study. The single item measure of life satisfaction was used to determine subjective well-being. Descriptive statistics as well as logistic regression analysis were carried out to determine the predictors of SWB. RESULTS: A total of 4724 individuals aged 50 years and above responded to the questionnaires. Of these 50.4% were males. Following multivariate logistic regression analysis, age, sex, educational level, income and ethnic background were found to significantly affect the SWB of older Ghanaians. Being male was associated with higher level of SWB (OR=1.68; CI: 1.39 - 2.03). For those 50 years and above, being younger (50-59 years) was also associated with a high level of SWB (OR=17.72; CI: 10.13-30.98). Earning a low income and having low educational level were both associated with low levels of SWB (OR=0.304; CI: 0.22-0.42; and OR=0.47; CI: 0.37-0.60 respectively). Ewes (p=0.027), Grumas (p=0.002) and Mole-Dagbons (p=0.04) had significantly higher SWB compared to the other ethnic groups. CONCLUSION: Among older Ghanaians, factors that positively influence SWB are younger age, male sex, high educational level and high income.

"They didn't tell us, they made us work it out ourselves": patient perspectives of a cognitive-behavioral program for rheumatoid arthritis fatigue.

OBJECTIVE: Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive-behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes. METHODS: Ten exit focus groups were held (38 patients). Transcripts were analyzed by an independent researcher using a hybrid thematic approach, with a subset analyzed by a team member and patient partner. RESULTS: Three overarching themes were identified. In "they made us work it out ourselves" (program factors facilitating changes), patients spontaneously identified elements of group CBT as pivotal, including guided discovery, the impact of metaphors, and working as a group. In "feeling much better about yourself and coping much better" (the nature of changes), patients described cognitive changes, including enhanced self-efficacy and problem solving, and emotional changes, including being less volatile and fearful of fatigue. In "my life has changed so much it's unbelievable" (benefits beyond fatigue), patients reengaged in previously abandoned activities, were more active, and enjoyed greater social participation. CONCLUSION: Patients highlighted that CBT elements were key to making behavior changes and that these had far-reaching impacts on their lives. This suggests it could be beneficial in clinical practice to incorporate cognitive-behavioral approaches into patient education programs that aim to enhance self-management.

European League Against Rheumatism recommendations for the inclusion of patient representatives in scientific projects.

OBJECTIVE: To develop recommendations to enable successful inclusion of the patient perspective in European League Against Rheumatism (EULAR)-funded scientific research projects. METHODS: The EULAR standardised operational procedures for guideline development were followed. A systematic literature review was presented during a first task force meeting, including 3 rheumatologists, 1 rheumatologist/epidemiologist, 2 allied health professionals, 2 representatives of arthritis research organisations and 7 patient representatives, resulting in 38 statements. A Delphi method was carried out to reduce and refine the statements and agree on a set of eight. Next, a survey among a wider group of experts, professionals and patient representatives (n=42), was completed. Feedback from this wider group was discussed at the second meeting and integrated in the final wording of the recommendations. Subsequently, the level of agreement of the group of experts (n=81) was re-evaluated. RESULTS: The project resulted in a definition of patient research partner and agreement on a set of eight recommendations for their involvement in research projects. These recommendations provide practical guidance for organising patient participation, capturing (1) the role of patient research partners, (2) phase of involvement, (3) the recommended number, (4) recruitment, (5) selection, (6) support, (7) training and (8) acknowledgement. CONCLUSION: Collaboration between patients and professionals in research is relatively new. Trials or effectiveness studies are not yet available. Nevertheless, it is possible to define recommendations for the inclusion of patients in research following a solid expert opinion based consensus process.

'It's this whole picture, this well-being': patients' understanding of 'feeling well' with rheumatoid arthritis.

OBJECTIVES: The aim of this study was to explore the meaning of 'feeling well' for people with rheumatoid arthritis (RA). METHODS: In-depth interviews were conducted with 23 RA patients, purposively sampled for medication type, disease duration, disease activity, age and gender. Data were analysed using Framework, emphasizing participants' personal contexts. RESULTS: Well-being was viewed as a broad concept, with 'feeling well' being the result of an on-going process to actively engage with a changing body, self and life. Four dimensions emerged: 'Living in the body', 'Being in the mind', 'Adapting to illness' and 'Being in the world'. The physical impact of RA underpinned the global perception of well-being and was clearly described as linking to the experience of psychological well-being. Physical and psychological wellness was often affected by the individual's adaptation to RA and personal context (e.g. home environment, broader social attitudes). DISCUSSION: Well-being is a multidimensional concept that is meaningful to RA patients regardless of medication type and disease severity. Patients commonly illustrated a process of actively engaging in cognitive and behavioural adjustments to move towards wellness. Clinical practice and research must take account of the complexity of well-being in long-term conditions, in order to fulfil patients' expectations.

What outcomes from pharmacologic treatments are important to people with rheumatoid arthritis? Creating the basis of a patient core set.

OBJECTIVE: Function, patient global assessment, and pain are routinely measured in rheumatoid arthritis (RA) clinical trials. However, other patient-reported outcomes identified as important to patients in qualitative studies, such as fatigue and quality of life, are commonly not included, and modern treatment regimens may have changed patients' expectations of treatment outcomes. Our objective was to elicit patient priority treatment outcomes for pharmacologic interventions since the common use of anti-tumor necrosis factor (anti-TNF) therapy, which will form the basis of a core set of patient priorities to complement existing professional core sets. METHODS: In-depth interviews were conducted with 23 RA patients, purposively sampled for age, sex, medication (anti-TNF or other disease-modifying antirheumatic drugs), disease severity, and work status. Grounded theory guided iterative data collection and analysis. Coding of the data was peer reviewed. A patient research partner collaborated in the research design and analysis. RESULTS: Sixty-three different outcomes important to patients were generated from the interviews. Four major categories of patient outcomes from pharmacologic treatments were developed: "RA under control," "Doing things," "Emotional health," and "Coping with illness." The core category (or overall theme) was "Minimizing the personal impact of RA." CONCLUSION: Although the routine outcomes of pain, function, and overall well-being were raised by the patients, they also generated a further 60 important outcomes that they look for from treatment. This difference in perspective may potentially influence treatment decisions. The next step is therefore to use these data to develop a patient core set.

Patient perspective of measuring treatment efficacy: the rheumatoid arthritis patient priorities for pharmacologic interventions outcomes.

OBJECTIVE: Collaboration with patients with rheumatoid arthritis (RA) highlights that outcomes important to them include fatigue, coping, and life enjoyment. However, these are not commonly measured in clinical trials. There is little evidence about which outcomes patients would prioritize, or what factors influence patients' prioritization. Our objective was to develop a complementary core set with patients to promote inclusion of their priority outcomes in pharmacologic interventions. METHODS: Nominal groups were conducted with RA patients to rank 63 outcomes generated from previous in-depth interviews. A multicenter postal survey provided the final selection of core outcomes for the Rheumatoid Arthritis Patient Priorities for Pharmacologic Interventions (RAPP-PI), in which RA patients rated the importance of the priority outcomes from the nominal groups and ranked the top 6. RESULTS: Twenty-six patients participated in 5 nominal group discussions and reduced the 63 initial outcomes to the 32 most important. A total of 254 participants in the survey ranked priority treatment outcomes to form the RAPP-PI: pain, activities of daily living, joint damage, mobility, life enjoyment, independence, fatigue, and valued activities. The 8 priorities represent 3 domains of treatment outcomes: direct impact of RA, psychosocial well-being, and function/participation. Chi-square tests showed that disease severity, disease duration, sex, and patients' perceptions of managing, self-efficacy, and normality influenced the selection of priority treatment outcomes. CONCLUSION: Collaboration with patients has captured their perspectives of priority outcomes from pharmacologic interventions. Although there is some overlap with professional core outcomes, the additional use of this complementary set will give a broader evaluation of effectiveness of interventions from the key stakeholders: patients.

'Your whole life, your whole world, it changes': partners' experiences of living with rheumatoid arthritis.

OBJECTIVES: Research suggests that rheumatoid arthritis (RA) can have a negative psychosocial impact on partners, as well as patients. However, until now there has been very little in-depth qualitative research in this area. The aim of this study was to explore the experiences of partners of people with RA. METHODS: Semi-structured interviews were conducted with a heterogeneous sample of eight partners of people with RA (six men, two women, age range 48-73 years). Transcripts were analysed thematically. RESULTS: Five overarching themes emerged: psychological burden in partners was substantial, as they experienced frustration and distress at watching their partner suffer and tried to protect their spouse from emotional and physical distress. 'It's a restricted life': partners reported having to cut back on previously enjoyable shared activities and had difficulty making future plans. Adjusting lives: partners had to make considerable adjustments to many aspects of their lives, and had adopted practical and psychological ways to cope. 'It's a joint approach': many partners discussed adopting a joint approach to managing the RA. Met and unmet support needs varied considerably, and many partners felt that a joint approach to treatment taken by health professionals is needed, which involves and recognizes their role. CONCLUSIONS: Partners of people with RA are vital to the patients' disease management, but the data show that many carry a substantial psychosocial burden. Healthcare professionals should be aware of this, so that couples coping with RA can be better supported.

Confinement effects on glass transition temperature, transition breadth, and expansivity: comparison of ellipsometry and fluorescence measurements on polystyrene films.

Using ellipsometry, we characterized the nanoconfinement effect on the glass transition temperature (T (g)of supported polystyrene (PS) films employing two methods: the intersection of fits to the temperature (Tdependences of rubbery- and glassy-state thicknesses, and the transition mid-point between rubbery- and glassy-state expansivities. The results demonstrate a strong effect of thickness: T(g) (bulk) - T(g)(23 nm) = 10 degrees C. The T -range needed for accurate measurement increases significantly with decreasing thickness, an effect that arises from the broadening of the transition with confinement and a region below T (g) where expansivity slowly decreases with decreasing T . As determined from expansivities, the T (g) breadth triples in going from bulk films to a 21-nm-thick film; this broadening of the transition may be a more dramatic effect of confinement than the T (g) reduction itself. In contrast, there is little effect of confinement on the rubbery- and glassy-state expansivities. Compared with ellipsometry, T (g) 's from fluorescence agree well in bulk films but yield lower values in nanoconfined films: T (g)(bulk) - T (g)(23 nm) = 15( degrees ) C via fluorescence. This small difference in the T (g) confinement effect reflects differences in how fluorescence and ellipsometry report "average T (g) " with confinement. With decreasing nanoscale thickness, fluorescence may slightly overweight the contribution of the free-surface layer while ellipsometry may evenly weight or underweight its contribution.

Return to sport after joint replacement.

Our aim was to determine the pre-operative sporting profiles of patients undergoing primary joint replacement and to establish if they were able to return to sport after surgery. A postal survey was completed by 2085 patients between one and three years after operation. They had undergone one of five operations, namely total hip replacement, hip resurfacing, total knee replacement, unicompartmental knee replacement or patellar resurfacing. In the three years before operation 726 (34.8%) patients were participating in sport, the most common being swimming, walking and golf. A total of 446 (61.4%) had returned to their sporting activities by one to three years after operation and 192 (26.4%) were unable to do so because of their joint replacement, with the most common reason being pain. The largest decline was in high-impact sports including badminton, tennis and dancing. After controlling for the influence of age and gender, there was no significant difference in the rate of return to sport according to the type of operation.

'It's quite hard to grasp the enormity of it': perceived needs of people upon diagnosis of rheumatoid arthritis.

OBJECTIVES: The diagnosis of rheumatoid arthritis (RA) brings rapid pharmacological and multidisciplinary team interventions to address inflammatory processes and symptom management. However, people may also need support on the journey to self-management. The aim of this study was to explore what professional support patients feel they receive upon diagnosis, and what support they feel would be most helpful. METHODS: Two focus groups comprised patients with at least five years'; disease duration (n = 7), and patients more recently diagnosed (5-18 months, n = 5). The latter had attended at least two appointments in a rheumatology nurse specialist clinic during the previous year, aimed at providing support upon diagnosis. Transcripts were subjected to thematic analysis to identify common issues regarding support needs, which were then grouped into themes. Interviewing and analysis was performed by researchers not involved in clinical care. RESULTS: Four overarching themes emerged. 'Information' was needed about the symptoms of RA, its management and personal outcome, while 'Support' related to emotional needs ('It's quite hard to grasp the enormity of it'). Information and Support overlapped, in that patients wanted someone to talk to, and to be listened to. These two themes were underpinned by issues of service delivery: 'Choice' (patient or professional to talk to, groups, one-to-one) and 'Involvement' (holistic care, partnership), which overlapped in terms of the opportunity to decide when and which interventions to access. CONCLUSIONS: People with RA report not only informational, but also emotional support needs at diagnosis. The potential for delivering emotional support to patients around the time of diagnosis warrants further exploration.

Rheumatology education for undergraduate nursing, physiotherapy and occupational therapy students in the UK: standards, challenges and solutions.

OBJECTIVES: Rheumatological conditions are common, thus nurses (Ns) occupational therapists (OTs) and physiotherapists (PTs) require at least basic rheumatology knowledge upon qualifying. The aim of this study was to develop a core set of teaching topics and potential ways of delivering them. METHODS: A modified Delphi technique was used for clinicians to develop preliminary core sets of teaching topics for each profession. Telephone interviews with educationalists explored their views on these, and challenges and solutions for delivering them. Inter-professional workshops enabled clinicians and educationalists to finalize the core set together, and generate methods for delivery. RESULTS: Thirty-nine rheumatology clinicians (12N, 14OT, 13PT) completed the Delphi consensus, proposing three preliminary core sets (N71 items, OT29, PT26). Nineteen educationalists (6N, 7OT, 6PT) participated in telephone interviews, raising concerns about disease-specific vs generic teaching and proposing many methods for delivery. Three inter-professional workshops involved 34 participants (clinicians: N12, OT9, PT5; educationalists: N2, OT3, PT2; Patient 1) who reached consensus on a single core set comprising six teaching units: Anatomy and Physiology; Assessment; Management and Intervention; Psychosocial Issues; Patient Education; and the Multi-disciplinary Team, recommending some topics within the units receive greater depth for some professions. An innovative range of delivery options was generated plus two brief interventions: a Rheumatology Chat Show and a Rheumatology Road Show. CONCLUSIONS: Working together, clinicians and educationalists proposed a realistic core set of rheumatology topics for undergraduate health professionals. They proposed innovative delivery methods, with collaboration between educationalists, clinicians and patients strongly recommended. These potential interventions need testing.

Nursing support at the onset of rheumatoid arthritis: Time and space for emotions, practicalities and self-management.

BACKGROUND: Following a diagnosis of rheumatoid arthritis (RA), patients have to adapt to lifelong, unpredictable but repeated episodes of pain and disability, potentially leading to permanent loss of function and its consequences on their lives. We established nurse clinics with the aim of supporting newly diagnosed RA patients in adapting to and managing their long-term condition. The aim of this study was to explore the content of clinic discussions in this new clinical service, in order to ascertain patients' needs upon diagnosis. METHODS: All clinic letters from the nurse to the family doctor were analysed. Every topic mentioned was systematically coded independently by a researcher and a patient research partner, who compared and agreed codes. Codes were organized into categories, and, finally, into overarching themes. RESULTS: Twenty-four patients had 74 appointment letters. A total of 79 codes were identified, from which ten categories emerged, and, finally, three overarching themes. The first theme related to 'Emotional support', which underpinned the other two themes and was discussed in almost all appointments. Issues included discussions about the emotional consequences of RA, needing time to adjust, frustration and fears for the future. The second theme 'Practicalities of the treatment of RA', included subordinate themes relating to the nature of RA, such as identity, cause, timeline, consequences and treatment. Medication issues were discussed and referrals to the multidisciplinary team were made. The final theme related to the 'Self-management of RA', and included discussions on physical symptoms and their management. CONCLUSIONS: The offer to attend a nurse clinic soon after diagnosis allowed RA patients to discuss a wide range of practical and self-management issues. However, most patients also took the opportunity and time to discuss emotional reactions and adaptations to diagnosis. The data suggest an unmet need for emotional support that a nurse clinic might be able to provide.

Total knee replacement: is it really an effective procedure for all?

Total knee replacement (TKR) is considered an effective intervention for the treatment of chronic knee pain and disability. Yet there is increasing evidence, based on research using patient-based outcome measures, that a significant proportion of patients experience chronic knee pain, functional disability, a poor quality of life and dissatisfaction after TKR. Although some poor outcomes after TKR are due to surgical technique and implant factors, much of the pain and disability after surgery is medically unexplained. A range of possible patient factors could contribute to a poor outcome after TKR. Socio-demographic factors that have been found to correlate with a poor outcome after TKR include female gender, older age and low socio-economical status. Medical factors that are highly predictive of pain and disability after TKR are a greater number of co-morbidities and a worse pre-operative status. A range of psychological factors could be predictive of a poor outcome after surgery including depression, low self-efficacy, poor pain coping strategies, somatization, low social support and patient expectations. It is also proposed that a biological explanation for continuing pain after TKR could involve central sensitisation, a dysfunction of pain modulation by the central nervous system. To improve patient selection for TKR, future research needs to focus on developing a pre-operative screening protocol to identify those patients at risk of medically unexplained pain and disability after TKR.

Measuring fatigue in rheumatoid arthritis: a systematic review of scales in use.

OBJECTIVE: Fatigue is an important outcome for patients with rheumatoid arthritis (RA). The purpose of this study was to identify the scales being used to measure RA fatigue, and to systematically examine the evidence for their validation. METHODS: Articles measuring fatigue in RA were sought using the terms RA and fatigue, and RA and tiredness, plus scale, questionnaire, inventory, and checklist. Index articles reporting identifiable RA fatigue data were examined for the fatigue scale used. Index and validation articles for each scale were reviewed for evidence supporting scale validation to measure RA fatigue using a standardized checklist of content, face, criterion, and construct validity, reliability, and sensitivity to change. RESULTS: A total of 61 index articles used 23 different fatigue scales to measure RA fatigue on 71 occasions. Seventeen scales had either no data on validation in RA or limited evidence. Reasonable evidence of validation was identified for 6 scales, each also having some evidence of sensitivity to change: ordinal scales, the Short Form 36 vitality subscale, the Functional Assessment of Chronic Illness Therapy Fatigue Scale, visual analog scales (VAS), the Profile of Mood States, and the RA-specific Multidimensional Assessment of Fatigue scale (MAF). However, the 4 generic scales would benefit from further validation in patients with RA, the VAS requires standardization, and the MAF would benefit from further sensitivity data. CONCLUSION: It was possible to identify evidence of reasonable validation for 6 of 23 scales being used to measure RA fatigue. Researchers and clinicians should select scales to measure RA fatigue carefully.