Hand and wrist problems in general practice--patient characteristics and factors related to symptom severity.

OBJECTIVES: Hand and wrist problems are common, but little is known about characteristics of patients consulting the general practitioner (GP) for these problems. The objectives are: (i) to describe wrist and hand problems presented to the GP in terms of severity of symptoms, and their impact on physical, emotional and social functioning; (ii) to describe patient and disease characteristics across different diagnostic categories; and (iii) to study factors related to the severity of hand or wrist problems. METHODS: Patients consulting their GP with hand or wrist problems were sent a questionnaire containing questions on socio-demographic variables, characteristics of the complaint, physical activity and psychosocial factors. The GP recorded information on symptoms, signs and medical diagnosis. We studied the cross-sectional association between a variety of factors and severity of hand or wrist problems, using the Symptom Severity Scale as the outcome measure. RESULTS: Mean age of the 267 participants was 49.3 yrs and 74% were female. The three most frequently recorded diagnoses were osteoarthritits (17%), tenosynovitis (16%) and nerve entrapment (12%). The characteristics of patients varied slightly across diagnostic categories. Patients who did not have paid work, had longer duration of symptoms, diagnosis of entrapment, higher pain intensity, higher body mass index and higher scores on worrying reported significantly higher scores on severity of hand or wrist problems (P-value <0.10). CONCLUSION: Primary care patients with hand or wrist problems report pain and reduced function. Impact on other aspects of perceived health is limited. Severity seems to be associated with socio-demographic, physical and psychosocial factors, more than with medical diagnosis.

The relationship of disease duration to foot function, pain and disability in rheumatoid arthritis patients with foot complaints.

OBJECTIVE: To assess the relationship between disease duration and foot function (expressed as pressure and gait parameters), foot pain and disability, in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Disease duration was defined as the time since RA was diagnosed. A pressure platform was used to measure both pressure parameters (i.e. pressure-time integrals and peak pressures in the forefoot) and gait parameters (i.e. total loading time and loading time in different foot regions). In addition, measurements of foot pain, disability (i.e. walking time and self reported disability), forefoot joint damage and disease activity were obtained. Data were analysed using partial correlations (Spearman), correcting for age. RESULTS: Disease duration was significantly correlated with the maximum pressure-time integral (PTI) measured under the forefoot (r = 0.330, p = 0.01). Disease duration was also significantly correlated with gait parameters, i.e. total loading time (r = 0.265, p = 0.04), duration of heel loading and duration of toe loading (r = 0.326, p = 0.01 and r = -0.288, p = 0.03 respectively), and walking time (r = 0.297, p = 0.02). Disease duration did not correlate with self-reported foot pain or disability. CONCLUSION: In patients with RA-related foot complaints, longer disease duration is associated with impaired foot function and reduced walking speed. These findings are interpreted as an alteration in pressure distribution and gait pattern during the course of disease, with a shift from a heel-to-toe roll-over process to a more shuffling gait.

Forefoot joint damage, pain and disability in rheumatoid arthritis patients with foot complaints: the role of plantar pressure and gait characteristics.

OBJECTIVE: To assess (i) the relationship between forefoot joint damage and foot function (expressed as gait and pressure parameters), (ii) the relationship between foot function and pain, and (iii) the relationship between foot function and disability in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Measurements of joint damage, gait characteristics, plantar pressure, pain and disability were obtained. Data were analysed using descriptive and correlational techniques. RESULT: s. Joint damage on radiographs of the forefoot correlated significantly with forefoot pressure (r = 0.296, P = 0.020). Further investigation of the metatarsophalangeal joints (MTPs) showed joint damage to correlate significantly with peak pressure and pressure-time integral (PTI) of MTP1 and MTP4. A significant correlation between PTI under the forefoot and barefoot pain was found (r = 0.290, P = 0.022). Gait parameters (total contact time and the duration of heel loading) and disability, measured with the Foot Function Index, were significantly correlated (r = 0.315, P = 0.013 and r = 0.266, P = 0.037, respectively). CONCLUSION: Forefoot joint damage in the rheumatoid foot is related to increased pressure under the forefoot, especially pressure under the first and fourth MTP joints. High forefoot pressure is associated with pain during barefoot walking. A prolonged stance phase and delayed heel lift are related to disability in daily activities.

Cyclosporin A monotherapy versus cyclosporin A and methotrexate combination therapy in patients with early rheumatoid arthritis: a double blind randomised placebo controlled trial.

OBJECTIVE: To compare the efficacy and toxicity of cyclosporin A (CsA) monotherapy with CsA plus methotrexate (MTX) combination therapy in patients with early rheumatoid arthritis (RA). PATIENTS AND METHODS: 120 patients with active RA, rheumatoid factor positive and/or erosive, were randomly allocated to receive CsA with MTX (n=60) or CsA with placebo (n=60). Treatment with CsA was started in all patients at 2.5 mg/kg/day and increased to a maximum of 5 mg/kg/day in 16 weeks. MTX was started at 7.5 mg/week and increased to a maximal dose of 15 mg/week at week 16. Primary outcomes were clinical remission (Pinals criteria) and radiological damage (Larsen score), at week 48. RESULTS: Treatment was discontinued prematurely in 27 patients in the monotherapy group (21 because of inefficacy, and six because of toxicity) and in 26 patients in the combination therapy group (14 and 12, respectively). At week 48, clinical remission was achieved in four patients in the monotherapy group and in six patients in the combination therapy group (p=0.5). The median Larsen score increased to 10 (25th, 75th centiles: 3.5; 13.3) points in the monotherapy group and to 4 (1.0; 10.5) points in the combination therapy group (p=0.004). 28/60 (47%) of patients in the monotherapy group v 34/60 (57%) of patients in the combination therapy group had reached an American college of Rheumatology 20% (ACR20) response (p=0.36) at week 48; 15/60 (25%) v 29/60 (48%) of patients had reached an ACR50 response (p=0.013); and 7 (12%) v 12 (20%) of patients had reached an ACR70 response (p=0.11). Their was a tendency towards more toxicity in the combination therapy group. CONCLUSIONS: In patients with early RA, neither CsA plus MTX combination therapy nor CsA monotherapy is very effective in inducing clinical remission. Combination therapy is probably better at improving clinical disease activity, and definitely better at slowing radiological progression. Combination therapy should still be compared with methotrexate monotherapy.