Arthritis patients show long-term benefits from 3 weeks intensive exercise training directly following hospital discharge.

OBJECTIVE: To examine the efficacy of short-term intensive exercise training (IET) directly following hospital discharge. METHODS: In the Disabled Arthritis Patients Post-hospitalization Intensive Exercise Rehabilitation (DAPPER) study, patients with rheumatoid arthritis or osteoarthritis were eligible when they needed hospitalization for either a flare-up in disease, elective hip or knee arthroplasty. The intervention group received IET for 3 weeks immediately after discharge; the control group was treated with the usual care (UC). The intensive exercise was provided in a resort. Outcomes were assessed at baseline, after 3, 13, 26 and 52 weeks. Range of motion was measured using the Escola Paulista de Medicina-Range of Motion scale (EPM-ROM), disability was measured using the HAQ and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and for health-related quality of life (HRQoL), the Research and Development 36-Item Health Survey (RAND-36) was used. RESULTS: The IET showed a better and faster improvement than UC on all outcome measures except for HRQoL. Up to 52 weeks after baseline, the EPM-ROM and the MACTAR remained favourable in IET compared with UC. At 3 weeks, the MACTAR improved significantly more in the IET compared with the UC: mean difference -5.5 (95% CI -8.4 to -2.2). At 26 weeks, the mean difference remained significant (-5.2; 95% CI -10.0 to -0.34). At 52 weeks, the effect was not significant; however, the mean difference in improvement between the groups can be considered clinically relevant. At 3 weeks, the IET had improved significantly more on the HAQ walking and rising subscales. CONCLUSION: Intensive short-term exercise training of arthritis patients, immediately after hospital discharge results in improved regain of function. The DAPPER programme has a direct effect, which lasts up to 52 weeks.

Postural control in rheumatoid arthritis patients scheduled for total knee arthroplasty.

OBJECTIVE: To investigate the use of compensatory visual and attentional control strategies for standing balance in patients with rheumatoid arthritis (RA) with severe knee joint impairment. DESIGN: Experimental 2-group design. SETTING: Specialized clinic for orthopedics, rheumatology, and rehabilitation in The Netherlands. PARTICIPANTS: Eighteen patients without comorbidity (age range, 65 +/- 7.7 yr; 16 women, 2 men) from a consecutive sample of patients with RA scheduled for total knee arthroplasty; 23 controls of the same age group also were tested (13 women, 10 men). MAIN OUTCOME MEASURES: By means of a dual-plate force platform, the velocity of center of pressure (COP) fluctuations were analyzed in the anteroposterior and lateral sway directions during quiet standing with eyes open, eyes closed, and while performing a secondary attention-demanding arithmetic task. RESULTS: Patients showed an average 80% greater COP velocity in both directions of sway compared with controls. In addition, stability deteriorated substantially more in patients than controls when deprived of visual information, which was associated with the degree of knee destruction. The effect of the arithmetic task was small and similar in patients and controls. CONCLUSION: RA patients with severe knee joint impairment can have a substantial basic postural instability; their relatively high reliance on visual information suggests impaired sensory feedback from the lower limbs. Current research is aimed at determining whether these postural deficits can be improved by total knee replacement.

Evaluating hand surgery in patients with rheumatoid arthritis: short-term effect on dexterity and pain and its relationship with patient satisfaction.

Short-term effect of hand surgery on hand function in activities of daily life (dexterity) and pain were studied in 70 patients with rheumatoid arthritis. Only surgical interventions aimed at improvement of function and/or pain relief were included in the study. Patients were assessed before surgery and 6 and 12 months after surgery. Clinical change in the surgical group was observed in the number of painful and swollen joints, observed dexterity, and pain in the hand. Six months after surgery 74% of the patients showed positive clinical change in hand functioning and/or hand pain. Clinical effects remained stable between 6 and 12 months after surgical assessments. Both change in observed dexterity and pain had an independent impact on the patient's satisfaction with the results of the surgery.

The negative effect of decreasing the level of activity in coping with pain in rheumatoid arthritis: an increase in psychological distress and disease impact.

The objective of this study was to analyze the effect of coping with pain in rheumatoid arthritis (RA) on subsequent changes in psychological distress and disease impact. A sample of 109 randomly selected RA patients was asked to participate in a longitudinal study. Patients were measured at baseline and after 3 years. Both measurements were completed in 80 patients. At each assessment the following variables were assessed: disease activity, pain, physical and psychological distress, disease impact, and coping. The relation between coping with pain at baseline and subsequent changes in psychological distress and disease impact was analyzed using stepwise regression. Disease status variables assessed at baseline and after 3 years were entered in the regression analysis as control variables. Results show that cognitive coping with pain at baseline was not related to subsequent changes in psychological distress or disease impact. On the other hand, behavioral pain coping assessed at baseline was related to subsequent changes in psychological distress and disease impact. "Decreasing activity" was related to an increase in self-reported psychological distress and disease impact after controlling for disease status at both assessments. It was concluded that cognitive pain coping did not predict any subsequent changes in psychological distress or disease impact. "Decreasing activity" as a behavioral pain coping style has a negative effect on subsequent changes in psychological distress and disease impact.

Behavioral coping and physical functioning: the effect of adjusting the level of activity on observed dexterity.

OBJECTIVE: To assess the relationship between behavioral coping and dexterity in rheumatoid arthritis (RA) after controlling for disease activity, impairment of the hands, and pain. METHODS: A random sample of 109 patients with RA was assessed twice within one year. Dexterity, disease activity, and impairment of the hands were measured using observational methods. Pain and coping with RA were assessed using self-report instruments. RESULTS: Correlational findings showed that "decreasing activity" to cope with pain was negatively related to dexterity. "Pacing" as a way of coping with limitations was positively related to dexterity. Both relations were significant after controlling for duration of disease, impairment of hands, disease activity, and pain. "Decreasing activity" as a way of coping with pain was related to a decrease in dexterity in the subsequent year, after controlling for baseline measurements of dexterity, impairment, and disease activity as well as measurements of current disease activity and pain. "Pacing" as a way of coping with limitations was unrelated to subsequent changes in dexterity, after controlling for the above mentioned variables. CONCLUSION: Behaviorial coping is related to current and subsequent levels of dexterity. Therefore, it is concluded that more attention should be given to behaviorial coping in both research and clinical practice.

The Short Version of the Sequential Occupational Dexterity Assessment based on individual tasks' sensitivity to change.

OBJECTIVE: The Sequential Occupational Dexterity Assessment (SODA) is a reliable and valid instrument to measure bimanual hand function in rheumatoid arthritis. Since administering SODA is time-consuming, the aim of this study is to construct a short SODA (SODA-S). METHODS: Dexterity was measured with the SODA twice (with an interval of one year) in 94 patients. Item analyses based on the different SODA tasks were carried out to determine which of the 12 individual tasks were most responsible for the observed changes in dexterity. RESULTS: Six of the 12 SODA tasks were identified as sensitive to change. Based on these 6 tasks, the SODA-S was computed. Internal consistency of the SODA-S is good (Cronbach's alphas at baseline and followup were 0.82 and 0.85, respectively). The correlation between the SODA and SODA-S is 0.92. This means that the information gathered from the SODA-S is almost equal to the information gathered from the full SODA. Norm scores are provided for both instruments. CONCLUSION: The SODA-S is a good alternative to the full SODA in following patient's dexterity in daily practice. However, when evaluating the effect of specific hand treatment, the full SODA may be preferred.

The social environment and health in rheumatoid arthritis: marital quality predicts individual variability in pain severity.

OBJECTIVE: To examine prospective relations between a wide array of measures of social functioning and pain, while controlling for disease duration and activity and functional grade. METHODS: As part of a larger study on health care utilization, longitudinal data were collected from 136 Dutch and 98 German outpatients on clinical status and pain. Social data included information on sexual handicap, spouse behavior, loneliness, daily emotional support, and the maintenance of pleasurable life domains. Pain severity was assessed at baseline and 12 months later with standard measures of pain and analyzed with hierarchical regressions. RESULTS: Social measures obtained at baseline were consistently associated with pain at followup. Depression was a moderate correlate of pain in the Dutch and German samples. The regressions revealed that patient reports of negative spouse behavior (such as avoidance and critical remarks) and baseline depression predicted worse pain outcome, and this association remained significant in analyses controlling for baseline pain. The level of formal education was a weak correlate of disability, emotional support, and pain. Daily emotional support and social life domains associated with positive affect had an indirect influence on outcome. The absence of strong rather than weak social ties was the component of the loneliness construct linked to pain. These associations between social prognostic factors and pain severity, however, were mediated by psychological functioning at baseline. CONCLUSION: The social environment was found to operate on the core health outcome, pain severity, via several pathways. Social functioning may be affected by rheumatoid arthritis (RA) progression, but it also appears to form a determinant of future health outcome. Not only the status of being married but also the quality of the relationship in terms of long-term stress and emotional support may be useful prognostic factors in RA.

Predictors of changes in observed dexterity during one year in patients with rheumatoid arthritis.

OBJECTIVE: To determine which disease-related variables predict loss of dexterity in patients with rheumatoid arthritis (RA). METHODS: A random sample of 94 RA patients was measured twice 1 yr apart. Dexterity, or hand-related disability, was measured with the Sequential Occupational Dexterity Assessment (SODA). The SODA measures dexterity in activities of daily life based on the observation of standardized tasks. Impairment of the hands, disease activity, pain and self-reported functioning were additionally assessed. RESULTS: After 1 yr, observed dexterity was significantly decreased. Change in dexterity was predicted by impairment of the hands at baseline. Changes in dexterity were related to changes in grip strength, disease activity indicators, self-care, depressive mood and cheerful mood. An increase in the number of swollen joints was most strongly correlated with a decrease in dexterity, even after controlling for impairment at baseline. CONCLUSION: It was concluded that even in patients with longer disease duration, observed dexterity declines gradually.

Sequential occupational dexterity assessment (SODA): a new test to measure hand disability.

Measuring hand-related disability poses a problem due to a lack of validated tests. This report introduces the sequential occupational dexterity assessment (SODA), a test that measures bimanual dexterity in daily life. The design of the SODA is described. Validity and reliability of the SODA are demonstrated in a sample of patients with rheumatoid arthritis (RA), in whom impairment of the hands may cause serious disability in daily life. Good reliability was found, as measured by internal consistency, test-retest correlation, and interrater stability. Validity was established by relating the SODA to a number of other variables. Current disease activity was only weakly related to the SODA score. Impairment of the hands is more strongly related to dexterity than to current disease activity. However, dexterity could vary considerably in patients with similar degrees of impairment. Pain during the SODA proved to be more important for dexterity than general level of pain. Considerable variation was found in self-reported and observed dexterity. It was concluded that the SODA may guide the therapist in making decisions about hand therapy. The use of the SODA allows standardized evaluation of the effects of hand surgery on bimanual dexterity.

Disease-specific stressors in rheumatoid arthritis: coping and well-being.

Results with Coping with Rheumatic Stressors (CORS) are reported. The CORS measures eight coping styles directed at the most important chronic stressors of RA i.e. pain, limitations, and dependence. The relation between coping and well-being was analysed while controlling for relevant disease status variables. Comforting cognitions, decreasing activity and diverting attention were styles of coping with pain that were related to well-being, when level of pain was controlled. Optimism, pacing, and seeking creative solutions were styles of coping with limitations. Both optimism and pacing were related to well-being, when functional capacity was being controlled. Acceptance and showing consideration were styles of coping with dependence. Consideration was the only coping style related to well-being, when functional capacity and social network were being controlled.

Stress caused by rheumatoid arthritis: relation among subjective stressors of the disease, disease status, and well-being.

Two integrated studies, examining the chronic stressors specific to the disease rheumatoid arthritis, are described. Pain, limitation, and dependence were rated as the most annoying chronic stressors of the disease. Pain was measured with the Visual Analog Scale and the McGill Pain Questionnaire. Both pain scores were only weakly related to the medical assessment variables. New scales were developed to measure perceived limitation and dependence. Perceived limitation was inversely related to both mobility and self-care, but this association was not strong. Perceived dependence was unrelated to any of the health status measures. All three stressors were associated with indicators of quality of life even after controlling for interaction with clinical assessment and functional status variables. It was concluded from these studies that patients with rheumatoid arthritis must cope simultaneously with pain, limitation, and dependence.

[Pain in rheumatoid arthritis measured with the visual analogue scale and the Dutch version of the McGill Pain Questionnaire]. / Pijn bij reumatoïde artritis gemeten met de visuele analoge schaal en de Nederlandse versie van de 'McGill pain questionnaire'.

Chronic pain is an important symptom of rheumatoid arthritis (RA). Pain is a complex experience and is not easily measured with a single instrument. Recently a Dutch version of the McGill Pain Questionnaire (MPQ) became available. The MPQ is a measure of the quality of pain as opposed to the traditional measures of pain intensity such as the Visual Analog Scale (VAS). In a study of 415 RA patients both measures of pain were administered. Both pain measures were only weakly related to medical variables. The VAS is easily administered and is reliable. The MPQ offers insight in the sensory experience of pain and gives more information about the quality of life of the patient. The conclusion is that the MPQ is a useful instrument to obtain a better picture of the complexity of the pain experience in RA.

Remarkably similar response to gold therapy in HLA identical sibs with rheumatoid arthritis.

Two pairs of sibs with definite rheumatoid arthritis responded in a remarkably similar way to parenteral gold therapy, in terms of both toxicity and efficacy. Both pairs proved to be HLA identical. One of the pairs possessed the HLA antigens B8 and DR3, which have been associated with both drug toxicity and excellent clinical response. The other pair did not possess either of these antigens, suggesting that the reaction to gold therapy in patients with rheumatoid arthritis may be determined by other HLA or genetic factors coded for by chromosome 6, or both.

Radiosynoviorthesis in haemophilic joint disease.

The effects of radiosynoviorthesis on chronic haemophilic arthropathic joints were studied in six patients with severe haemophilia by a follow up study which spanned two and a half years. On clinical grounds the treatment was successful because pain and bleeding frequency diminished, although radiographic examination showed further deterioration of the treated joint. Chromosome damage was not detected. We conclude that radiosynoviorthesis is apparently changing the bleeding pattern of articular tissues without arresting the destruction and deformation of joints.