Effects of static and dynamic shoulder rotator exercises in women with rheumatoid arthritis: a randomised comparison of impairment, disability, handicap, and health.

The aim was to compare static and dynamic shoulder rotator endurance training in a group of women with mild rheumatoid arthritis and to see whether such training could influence impairment, disability, and handicap. The effects on general health were also studied. Patients were randomly assigned to a static (n = 17) (average age 59, median disease duration 7) or a dynamic training group (n = 20) (average age 56, median disease duration 10.5). Measurements were taken at the start, 10 weeks later when the training period was finished, and after a further 10 weeks. After the training both groups had fewer swollen joints in the upper extremity and less shoulder-arm pain. The dynamic group patients also improved according to the physical and overall dimensions of the Sickness Impact Profile. As impairment and aspects of disability and handicap were influenced by training but not by the patients' opinions regarding perceived disease activity and health, these relationships must be studied further.

Associations between self-rated psychosocial work conditions and musculoskeletal symptoms and signs. Stockholm MUSIC I Study Group.

OBJECTIVES: The aim was to study the associations between self-rated psychosocial work conditions and the characteristics and location of musculoskeletal symptoms, signs, and syndromes. METHODS: Perceived psychosocial work conditions were recorded in a cross-sectional study with 358 men and women in various occupations. Symptoms were recorded from the musculoskeletal system with a questionnaire, and signs were detected in a medical examination of all body regions. The analyses of statistical associations between the psychosocial factors and musculoskeletal disorders were performed with control for age, gender, and physical load. RESULTS: The most consistent and pronounced associations were mainly seen between poor psychosocial work conditions and coexisting symptoms and signs of the neck and back regions. Poor psychosocial work conditions were more consistently and strongly associated with signs of muscular (soft tissue) tenderness than with signs of tenderness in the joints, tendons, or muscular insertions or signs in nerve compression tests. Mainly low social support at work, but also high psychological demands and high job strain, were associated with such symptoms and signs, whereas decision latitude at work showed few associations with musculoskeletal disorders. CONCLUSIONS: Perceived poor psychosocial work conditions are statistically associated mainly with symptoms and signs of muscular tenderness in the central body regions. Studies on associations between psychosocial work conditions and musculoskeletal disorders should separate effect measures of different clinical signs and different body regions in order to avoid attenuation of the risk estimates.

Shoulder, elbow and wrist movement impairment--predictors of disability in female patients with rheumatoid arthritis.

To explore and describe how shoulder, elbow and wrist movement impairment and age, disease duration, disease activity and shoulder-upper arm pain are associated with disability in rheumatoid arthritis, these variables were investigated in 63 females. Multiple linear regression analysis indicated that limitations in functional shoulder-arm movement and in active wrist motion ranges explained 30-35% of the variation among the patients' results within each of the physical disability instruments used. The Ritchie index for the upper-extremity might be a predictor of disability, explaining 6-28% of the variation within different disability questionnaires, while shoulder tendalgia explained 24% of the variation in shoulder-arm disability. Altogether, however, our predicting variables only explained 11-30% of the variation in shoulder-arm disability and 25-50% of the variation in the other disability areas studied. Thus, other factors not studied here, e.g. muscle strength and hand grip function, and e.g. psychological and social factors are probably also of importance and remain to be elucidated.

Relationships between measurements of impairment, disability, pain, and disease activity in rheumatoid arthritis patients with shoulder problems.

Relationships between the results from shoulder movement impairment assessments, a shoulder-arm disability questionnaire, the disability indices Health Assessment Questionnaire (HAQ), Sickness Impact Profile (SIP) and Functional Status Questionnaire (FSQ), shoulder pain, and disease activity (ESR and the number of swollen joints) were analysed in a study evaluation outcome measurements to rheumatoid arthritis patients with shoulder problems. Sixty-seven women aged 24-82 years (mean 59.3) average disease duration 13 years were involved. The associations between shoulder movement impairment and HAQ, SIP physical and overall, FSQ and shoulder-arm disability questionnaire factor 1 were statistically significant, but of moderate magnitude (0.45 < or = r < or = 0.55, p or = 0.001). Shoulder pain correlated significantly but moderately to shoulder impairment and to FSQ (0.44 < or = r < or = 0.49, p < or = 0.001). Disease activity did not correlate to shoulder impairment, disability or shoulder pain. Despite some overlapping, impairment, disability, pain, and disease activity represent different areas and must be measured separately.

The Disability Rating Index: an instrument for the assessment of disability in clinical settings.

The purpose of this study was to evaluate an instrument for assessment of physical disability, mainly intended for clinical settings, the Disability Rating Index (DRI). Healthy persons (n = 1092), both white and blue collar workers, and patients (n = 366) with different levels of physical capacity, were assessed. Most of the patients (n = 303) underwent rehabilitation programmes for neck/shoulder/low-back pain but some (n = 47) were arthritis patients waiting for hip or knee replacement surgery, or wheelchair patients with multiple sclerosis (n = 16). The reliability was investigated by test-retest studies, intra- and inter-rater and internal consistency studies. Five construct validity tests were carried out: a discrimination study; a converging validity test; a test for sensitivity to small alterations in health status; and two correlational validity tests. Correlation of the self-reported DRI to the actual performance in similar activities was carried out. Responsiveness was tested by correlation of the DRI before/after replacement surgery for arthritis. The test-retest correlations were 0.83-0.95 in the studies, including correlation of different versions. The intra- and inter-rater reproducibility was 0.98 and 0.99 respectively. The Kruskal-Wallis test in the discrimination study yielded p < 0.0001. More than 90% of the respondents completed the questionnaire correctly. Correlation of the DRI to the Functional Status Questionnaire was 0.46. The responsiveness was excellent, p = 0.0001. The DRI proved to be a robust, practical clinical and research instrument with good responsiveness and acceptability for assessment of disability caused by impairment of common motor functions.

An activity analysis of hand grips used in housework by female rheumatoid arthritics.

In this nonexperimental study, videofilmed, self-selected housework activities of rheumatic women were analyzed. The women gripped and manipulated objects in their homes. The activities were analyzed under the headings Activity, Actions, Objects, and Grip. The films were viewed frame by frame, and the data was computerized for statistical analysis. The women performed five self-selected housework activities and eight groups of actions (n = 340). During the actions the women handled 12 groups of objects using the eight grip classes of Sollerman's grip classification. The diagonal volar grip was the most common grip (20%), and the tripoid pinch was the least common (0.29%); 34% of the actions were right-handed, 19% left-handed, and 47% bimanual. No clear grip pattern was revealed by the activity analysis.

A comparison of pressure pain thresholds in different tissues and body regions. Long-term reliability of pressure algometry in healthy volunteers.

Pressure pain thresholds (PPTs) were measured in 12 healthy female volunteers with a hand-held electronic pressure algometer (Somedic). The PPTs over 30 points, mainly located on the trunk, were measured in a randomized order. The measurements were repeated after one week and again 10-13 weeks later. Three spots over nerve tissue had lower PPTs than nearby muscle. There were no consistent differences between muscle and periosteum within the same region. Overall there was a tendency for points in the nape region to have the lowest PPT, and those in the lumbosacral region to have the highest. The shoulder points had intermediate values. The interindividual differences were great. There was no difference between the mean PPTs from the first session and those from the second session. However, at the third session, 10 weeks later, the average PPT value was substantially higher than in the previous sessions.

Assessment of patients with chronic back pain using the "Functional Status Questionnaire".

Forty-eight patients with chronic back pain undergoing a rehabilitation program were assessed with the Functional Status Questionnaire (FSQ) during the first week of rehabilitation and after 6 weeks, 6 months and one year. In their first test, all the patients showed diminished functional capacity in at least one of five summary scales, indicating serious health problems and a need for rehabilitation. The test-retest correlation was k = 0.96, indicating high reliability of the questionnaire. After 6 weeks of rehabilitation the patients estimated significant improvements regarding "Satisfaction with health", "Mental health" and "Number of close friends". Some of these improvements were maintained after 6 months and one year. The "Basic ADL" and "Intermediate ADL" scales, however, showed no changes, indicating either low sensitivity or that no real changes had occurred during the rehabilitation period. The FSQ is recommended for use among patients with chronic back pain, but the tests need to be supplemented with other measurements concerning ADL capacity.

Pain thresholds during standardized psychological stress in relation to perceived psychosocial work situation. Stockholm Music I Study Group.

The hypothesis that perceived psychosocial work situation is associated with pain threshold was tested on a sample of 103 men and women aged 19-65 yr in Stockholm. Half of the studied sample was a random sample of men (N = 26) and women (N = 31), while the remaining subjects were medical secretaries (women, N = 28) and furniture movers (N = 31). Pain thresholds were measured by means of an algometer before, during and after a standardized colour word test. The measurements were made on six different points in the neck and shoulder region. Before psychological stress in the laboratory, perceived psychological demands were significantly associated with pain threshold--the higher the demands the higher the pain threshold. During stress those who reported low decision latitude and high degree of sleep disturbance were shown to have a low pain threshold. The findings are consistent with the hypothesis that subjects with high demand levels have an elevated pain threshold when they are not under excessive psychological stress. During psychological stress, on the other hand, those with low decision latitude are more pain sensitive than others, and this is aggravated in those who also report a high degree of sleep disturbance.

Activity-induced pain in rheumatoid arthritis functional class II and its relations with demographic, medical, functional, psychosocial, and work variables. Result of a survey in Bollnäs Medical District, Sweden, II.

One aim of this study was to describe inflammatory activity, joint destruction, work status, and demographic factors in a group of 69 American Rheumatism Association functional class-II rheumatoid arthritis patients: 56 women and 13 men, mean age 54 years (SD 11), mean symptom duration 14 years (SD 11). Another aim was to determine correlations between activity-induced pain and other variables. Patients were assessed with Ritchie's articular index, Larsen's radiologic index, and laboratory tests. Deformity in hands and knee joints, and grip strength, were determined. Results from earlier investigations of functional impairment and psychosocial capacity were also used. Of the patients, 4% had high inflammatory activity. Joint erosions were found in between 4% (knee joints) and 55% (wrists) of the joints examined. Of the patients aged less than 65, 43% were working. Activity-induced pain was related with work status (p = 0.0002). It also correlated significantly (p less than or equal to 0.01) with inflammatory activity (r(s) = 0.34), but not with joint destruction (r(s) = 0.21).

Intensive dynamic training in water for rheumatoid arthritis functional class II--a long-term study of effects.

The aim of the study was to assess the effects of once-weekly, intensive dynamic training in water of patients with Rheumatoid Arthritis (RA). Thirty patients with RA, functional class II, in a training group (TG) and 30 in a comparison group (CG) were assessed with respect to clinical, radiological and functional disease manifestations and psychosocial consequences before and after a four-year training period. After the training period the TG patients had significantly better grip strength and higher activity level, the latter maintained at two-year follow-up. There were significantly more CG patient admittances for acute hospital care during the training period. No other differences between the groups were found. Dynamic training at an intensive tempo does not seem, even in a long perspective, to lead to any undesirable consequences.

Clinical reliability of shoulder function assessment in patients with rheumatoid arthritis.

A model for functional assessment and a dynamic test of the shoulder joint were designed and tested for normal variation and clinical inter- and intra-rater reliability. The functional assessments, which covered four common shoulder functions, were compared with assessments of pain, recordings of active motion range and the results of a Health Assessment Questionnaire, in eight patients with rheumatoid arthritis according to the ARA criteria. Intra-rater reliability was satisfactory for all four functions and inter-rater reliability was satisfactory for the hand-raising and hand-to-opposite-shoulder functions but less so for hand-behind-back and hand-to-neck. A second test-retest study in 15 patients, with a slight modification of one of the functional tests, confirmed the results and improved the reliability of the modified test. The reliability of the dynamic test and of the active motion range measurement was less satisfactory or not satisfactory. No significant correlation was found between shoulder functional assessment and the Fries index, but there were positive significant correlations between active motion range and shoulder functions. It is concluded that the method presented for evaluating shoulder functions has satisfactory reliability and in the first test-retest study was more reliable than conventional motion range measurement of the shoulder joint.

Functional and psychosocial consequences of disease and experience of pain and exertion in a group of rheumatic patients considered for active training. Result of a survey in Bollnäs Medical District. I.

The purpose of this study was to select and describe a group of RA patients within a defined area who had, on clinical grounds, been considered for active training. The material consisted of 69 patients with classical or definite RA. It comprised half of the RA patients known to the clinic. The patients were assessed by means of a questionnaire, functional tests with rating of activity-induced pain, a cycling-test with rating of perceived exertion, and an interview by a psychologist. Subjective disease consequences were pain and stiffness. 38% of the patients never or seldom exercised. 72% wished to increase their activity but were prevented by pain. The functional tests indicated slow performance and considerable pain in activities of daily life. The interview disclosed above all, a low degree of self-confidence. Generalized pain and functional impairment correlated slightly with psychosocial factors. The results of the study indicate the need for active training as one strategy to alleviate pain and to maintain functional capacity in RA patients.

Pain alleviation by vibratory stimulation.

In the present study 366 patients suffering acute or chronic musculoskeletal pain of different origin were given vibratory stimulation for the pain. Many of the patients had previously had treatments of various kinds without satisfactory relief. The effect of vibratory stimulation was assessed during and after stimulation using a graphic rating scale. Sixty-nine per cent of the patients reported a reduction of pain during vibratory stimulation. The best pain reducing site was found to be either the area of pain, the affected muscle or tendon, the antagonistic muscle or a trigger point outside the painful area. In most patients the best pain reducing effect was obtained when the vibratory stimulation was applied with moderate pressure. To obtain a maximal duration of pain relief the stimulation had to be applied for about 25-45 min.

Physical training in rheumatoid arthritis: a controlled long-term study. I.

Twenty-three patients with rheumatoid arthritis (RA) have been given physical training for 4 to 8 years. To compare, we have had a control group of equal size and with the same disease severity. The training program consisted of home-training and for most of the patients also group-training led by a physiotherapist. During the observation period we have found a significantly less pronounced progress of X-ray changes in the joints of the active patients compared with control patients. Physiological tests and clinical parameters, including sick-pension and sick-leave, show unanimously a better disease outcome in the active group of patients. There is probably a risk of overuse or disuse of the joints in RA but we believe that it is better to be overactive rather than the reverse. As in many other diseases, the general prescription of rest in RA is not adequate.

Physical training in rheumatoid arthritis: A controlled long-term study. II. Functional capacity and general attitudes.

Twenty-three patients with rheumatoid arthritis have been given physical training for 4-8 years. They are compared with a control group of patients with the same disease. In order to evaluate disease outcome, patients were given a self-administered questionnaire to report ADL capacity and some attitudes and feelings concerning their situation. Results are in agreement with earlier reports and show a significantly higher ADL capacity in the trained group compared with the control group. There is a positive correlation between ADL capacity and reported amount of physical training and a negative correlation between ADL capacity and X-ray findings and findings at clinical examination. The feeling of weakness is more pronounced in the control group and patients in this group get more discomfort from joints after physical strain than patients in the trained group. A majority of patients in the two groups wish to participate in organized group-training.