Effects of concurrent strength and endurance training in women with early or longstanding rheumatoid arthritis: Comparison with healthy subjects

OBJECTIVE

To investigate the effects of a 21-week concurrent strength and endurance training protocol on physical fitness profile in women with early or longstanding rheumatoid arthritis (RA) compared with healthy subjects.

METHODS

Twenty-three female patients with RA volunteered for the study. Twelve had early RA and eleven had longstanding RA. Twelve healthy women served as controls. Maximal strength of different muscle groups was measured by dynamometers, walking speed with light cells, and vertical squat jump on the force platform to mirror explosive force. Maximal oxygen uptake was measured by gas analyzer. Six training sessions (3 strength training and 3 endurance training) were carried out in a 2-week period for 21 weeks.

RESULTS

The training led to large gains in maximal strength both in women with RA and in healthy women (P < 0.043-0.001). The strength gains were accompanied by increases in walking speed (P < 0.034-0.001) and vertical squat jump (P < 0.034-0.001). Significant improvements also occurred in maximal aerobic capacity in all groups (P < 0.023-0.014).

CONCLUSIONS

Both early and longstanding RA patients with stable disease can safely improve all characteristics of their physical fitness profile using a progressive concurrent strength and endurance training protocol.

Erosions develop rarely in joints without clinically detectable inflammation in patients with early rheumatoid arthritis

OBJECTIVE

To study whether clinically observed tenderness and/or swelling of a wrist joint over the first 3 years after diagnosis predict the development of erosions in radiographs of the same joint at 5 years in patients with early rheumatoid arthritis (RA).

METHODS

A total of 58 patients with recent onset RA were enrolled in a prospective RA study at Jyväskylä Central Hospital in 1983-85. Physical examination including joint counts was performed 6 times over 3 years (at 0, 6, 12, 18, 24, and 36 mo). Radiographs of hands and feet taken at the 5-year visit were scored according to the Larsen method (0-1 = non-erosive; 2-5 = erosive). At each visit, the wrist joints were assessed for tenderness (0/1) and swelling (0/1). A frequency (ranging from 0 to 6) was calculated for 4 inflammation categories tenderness, swelling, tenderness or swelling, and tenderness and swelling over the 3 years. Percentages of wrist joints with erosions on the 5-year radiographs were calculated for the frequency groups 0, 1, 2-3, and 4-6 of each category. Two patients died, and 5 wrists were erosive at baseline. Thus the data for 107 wrist joints of 54 patients were available for analyses.

RESULTS

A statistically significant correlation was seen in the frequency of clinical inflammation and the development of erosions. Only one (3.3%) wrist with no tenderness in 6 examinations over the first 3 years developed erosions over 5 years, while 13 (59.1%) wrists that were tender 4-6 times in 6 examinations developed erosions. The corresponding percentages were 4.4% and 50.0% for wrists with swelling, 3.4% and 51.6% for wrists with tenderness or swelling, and 6.1% and 75.0% for wrists with tenderness and swelling.

CONCLUSION

Radiographic erosions develop rarely without preceding clinically detectable inflammation in the joints of patients with early RA.

Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis

OBJECTIVE

To study the prevalence of cervical spine subluxations and predictive factors for atlantoaxial subluxations (including anterior atlantoaxial subluxation and atlantoaxial impaction, i.e., vertical subluxation) in patients with rheumatoid arthritis (RA) who were treated early and continuously with disease-modifying antirheumatic drugs for 8-13 years.

METHODS

Radiographs of the cervical spine were obtained in 103 of 110 patients (the 110 surviving patients of the original 135-patient cohort) at their 8-13-year followup visits. The prevalence of cervical spine subluxations was determined. Demographic variables and the first 5-year serial data concerning disease course were analyzed in a logistic regression model to find predictive factors for atlantoaxial subluxations.

RESULTS

Atlantoaxial subluxations were found in 14 patients (14%), and 5 patients (5%) had subaxial subluxations. Older age at baseline, greater disease activity during the first 5 years, and early erosiveness in peripheral joints predicted the development of atlantoaxial subluxations. Patients who had >or=10% of the maximum possible radiographic damage (by Larsen score) in peripheral joints at 5 years were 15.9 times more likely to develop atlantoaxial subluxations at 8-13 years than patients whose peripheral joint damage remained <10% of the maximum.

CONCLUSION

Compared with historical control RA cohorts, a lower prevalence of cervical spine destruction was found in the present group of patients. Rapid erosiveness in peripheral joints was the best predictor for atlantoaxial subluxations. Extensive erosiveness in peripheral joints should alert rheumatologists to the possible development of atlantoaxial subluxations in patients with RA.

Does yttrium radiosynovectomy increase the risk of cancer in patients with rheumatoid arthritis?

OBJECTIVE

To study the long term risk of cancer in patients with rheumatoid arthritis (RA) who have been treated with yttrium.

METHODS

The medical record numbers of 1228 patients with RA who were admitted to hospital in 1979-85 were identified in the database of Jyväskylä Central Hospital. Radiosynovectomy of the knee joint was performed in a total of 143 patients using yttrium-90 silicate during the years 1970-85, while 1075 did not receive yttrium radiosynovectomy; 10 received yttrium treatment later than 1985 and were excluded from the analysis. The Finnish Cancer Registry database was used to examine whether the subjects had cancer during the follow up from 1979 until the end of 1999.

RESULTS

Nine cases of cancer were found among the patients who had received yttrium, whereas the expected number based on the incidence among the population in the region was 14.9. The standardised incidence ratio of cancer was 0.6 (95% confidence interval (CI) 0.3 to 1.1) for the patients who received yttrium, and 1.1 (95% CI 0.9 to 1.3) for the patients who did not receive yttrium.

CONCLUSIONS

Yttrium treatment did not increase the risk of cancer.

Effects of dynamic strength training on physical function, Valpar 9 work sample test, and working capacity in patients with recent-onset rheumatoid arthritis

OBJECTIVE

To study the impact of 24 months of strength training on the physical function of patients with early rheumatoid arthritis (RA).

METHODS

Seventy patients were assigned to either the strength training (experimental) group (n = 35) or the control group (n = 35). Patients in the experimental group performed strength training for 24 months, and control patients were instructed to perform range of motion exercises. Maximal strength of the knee extensors, trunk flexors, and extensors, as well as grip strength were recorded with dynamometers. Disease activity was assessed by the erythrocyte sedimentation rate and Ritchie's articular index, joint damage was determined by the Larsen x-ray index, and functional capacity was assessed using the Valpar 9 test and the Stanford Health Assessment Questionnaire (HAQ). The employment status of each patient was recorded.

RESULTS

In the experimental group, strength training led to significant increases (19-59%) in maximal strength of the trained muscles. Such increases in the control group varied from 1% to 31%. There was a clear training effect on muscular strength in favor of the experimental group, but significant improvements in the HAQ indices as well as in the Valpar 9 test were seen also in control patients. Results of the Valpar 9 and the HAQ were statistically significantly better in patients who remained gainfully employed compared with patients who retired preterm during followup. However, compared with patients who remained in the work force, patients who retired were older, and their work was physically more demanding.

CONCLUSION

As expected, strength training led to increased muscle strength, but this increase did not correlate with improved physical function as assessed by the Valpar 9 work sample test. The increased muscle performance did not prevent a substantial proportion of patients from retiring preterm. The 2 items from the Valpar 9 test that were applied were not sensitive enough to differentiate the patients according to their working status.

Smoking-gender interaction and risk for rheumatoid arthritis

The present case-control study was conducted to investigate the relationship between smoking and rheumatoid arthritis, and to investigate formally the interaction between sex, smoking, and risk for developing rheumatoid arthritis. The study was performed in the Central District of Finland. Cases were patients with rheumatoid arthritis and the control group was a random sample of the general population. Logistic regression models were used to evaluate the effect of smoking on risk for rheumatoid arthritis, after adjusting for the effects of age, education, body mass index, and indices of general health and pain. Overall, 1095 patients with rheumatoid arthritis and 1530 control individuals were included. Patients were older, less well educated, more disabled, and had poorer levels of general health as compared with control individuals (all P < 0.01). Preliminary analyses revealed the presence of substantial statistical interaction between smoking and sex (P < 0.001). In separate multivariable analyses, past history of smoking was associated with increased risk for rheumatoid arthritis overall in men (odds ratio 2.0, 95% confidence interval 1.2-3.2) but not in women. Among men, this effect was seen only for rheumatoid factor-positive rheumatoid arthritis. There were significant interactions between smoking and age among women but not among men. We conclude that sex is a biologic effect modifier in the association between smoking and rheumatoid arthritis. The role of menopause in the etiology of rheumatoid arthritis merits further research.

Functional disability in rheumatoid arthritis patients compared with a community population in Finland

OBJECTIVE

To compare Health Assessment Questionnaire (HAQ) scores of patients with rheumatoid arthritis (RA) with HAQ scores from a sex- and age-adjusted population.

METHODS

Patients with RA (n = 1,095) and control subjects (n = 1,530) completed a mailed questionnaire that comprised the HAQ, pain and global health scores, education level, and comorbidities, as well as height, weight, and lifestyle attitudes, including smoking and exercise habits.

RESULTS

The HAQ scores increased (indicating declining function) with older age in patients and controls. The HAQ scores were above the reference values (>95th percentile of the HAQ scores of the age- and sex-matched population) in 17-45% of women with RA and in 7-32% of men with RA ages 30-79 years, while the HAQ scores of the patients > or =80 years were similar to those of the age- and sex-matched population. In a logistic regression model, the odds ratio for disability (HAQ score > or =1; at least some difficulties in most activities of daily living) was 7.7 (95% confidence interval 5.3-11.1; P < 0.001) among patients with RA compared with community controls, when adjusted for age, sex, education, smoking, exercise, body mass index, number of comorbidities, and pain.

CONCLUSION

RA is associated with a >7-fold risk of disability compared with that in a general population of adults in the same community. The impact of disability due to RA appears to be greater in younger and middle-age people than in elderly patients.

Effects of strength training on muscle strength, cross-sectional area, maximal electromyographic activity, and serum hormones in premenopausal women with fibromyalgia

OBJECTIVE

To examine the effects of strength training on basal concentrations and acute responses of serum hormones, and their possible interrelationships with training induced muscle hypertrophy and strength gains of the knee extensor muscles in women with fibromyalgia (FM) and healthy controls.

METHODS

Twenty-one premenopausal women with FM were randomized to 21 week strength training (FMT; n = 11) or control (FMC; n = 10) groups. Twelve premenopausal sedentary healthy women served as controls (HC). Surface electromyographic (EMG) activity, maximal unilateral isometric force of the right knee extensors, and muscle cross-sectional area (CSA) of the quadriceps femoris throughout the lengths of 3/12 to 12/15 of the femur (Lf) were measured. Serum concentrations of total and free testosterone and growth hormone (GH) were analyzed at rest and in pre- and post-exercise conditions, while levels of insulin-like growth factor and dehydroepiandrosterone sulfate were measured at rest only.

RESULTS

Mean (SD) maximal force increased by 18% (10%) (p < 0.001) in the FMT group, and by 22% (12%) (p < 0.001) in the HC, while in the FMC it remained unchanged. Maximum integrated EMG of the agonists (VL + VM/2) increased in HC by 22% (p < 0.05) and in the FMT by 19% (p < 0.05). Significant increases in the CSA of the QF were observed at 5 to 12/15 Lf in FMT (p < 0.05-0.01) and at 3 to 12/15 Lf in HC (p < 0.05-0.001), while in FMC the CSA remained unchanged. No training induced changes occurred in the basal concentrations of serum hormones examined. A significant acute increase took place in the mean concentration of GH at pre-training in HC (p < 0.01) and in the FMT (p < 0.05), while at post-training the elevations after the loading (p < 0.001 and 0.05) remained elevated up to 15 min (p < 0.05) in HC and up to 30 min (p < 0.01) post-loading in the FMT.

CONCLUSION

Both the magnitude and time course of adaptations of the neuromuscular system to resistance training in women with FM were completely comparable to those taking place in healthy women. Basal levels of the anabolic hormones seem to be similar in women with FM compared to age matched healthy women. Observations recorded during the acute loading conditions might be considered an indication of the training induced adaptation of the endocrine system, showing that the acute GH response may become systematic after strength training in both women with FM and controls.

Long term efficacy and safety of cyclosporin versus parenteral gold in early rheumatoid arthritis: a three year study of radiographic progression, renal function, and arterial hypertension

OBJECTIVE

To compare the three year safety and efficacy of cyclosporin and parenteral gold in the treatment of early, active, severe rheumatoid arthritis (RA), and to study the reversibility of cyclosporin associated renal dysfunction in patients who discontinued cyclosporin treatment.

METHODS

The patients continued to receive cyclosporin or parenteral gold in an 18 month open extension to an 18 month randomised, parallel group study. The main efficacy variable was blinded evaluation of radiographic progression of joint damage. Safety variables included serum creatinine, calculated creatinine clearance, and blood pressure.

RESULTS

Radiographic progression during follow up was similar in both groups. About 60% of the patients in the intention to treat groups (n=272) and about half of the patients in the completer groups (n=114) had definite radiographic progression in joint damage (increases >6 in the Larsen-Dale score), and about one in three also had substantial progression (>18 increase in Larsen-Dale score). Both systolic and diastolic blood pressure were significantly increased in the cyclosporin group compared with the gold group, and 12/139 (9%) versus 3/139 (2%) (p=0.03) had notably raised blood pressure. The mean serum creatinine increased by 28% at the treatment end point in the cyclosporin group as compared with 7% in the gold group. The mean calculated creatinine clearance was reduced by 16% and increased by 1% in the cyclosporin and gold groups, respectively, at the end of the study. At the final follow up visit after discontinuation of cyclosporin (at least three months after treatment was stopped) the mean serum creatinine was increased by 15% and creatinine clearance reduced by 16%. Sustained increases in serum creatinine at this post-treatment end point were mostly seen in patients with a raised serum creatinine during treatment of at least 50%.

CONCLUSION

Three year changes in radiographic damage during cyclosporin and parenteral gold were similar in patients with early, active RA. Abnormal renal function and raised blood pressure were often seen in the cyclosporin treated patients.

Delay to institution of therapy and induction of remission using single-drug or combination-disease-modifying antirheumatic drug therapy in early rheumatoid arthritis

OBJECTIVE

To study the impacts of 1) the delay from the onset of symptoms to the institution of disease-modifying antirheumatic drug (DMARD) therapy, 2) two treatment strategies (treatment with a combination of DMARDs or with a single drug), and 3) the presence of HLA-DRB1 alleles (shared epitope) on the prediction of disease remission after 2 years in patients with early rheumatoid arthritis (RA).

METHODS

In the FIN-RACo (FINnish Rheumatoid Arthritis Combination therapy) trial, 195 patients with recent-onset RA (median duration 6 months) were randomly assigned to receive either 1) a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or 2) a single DMARD with or without prednisolone. The presence of a shared epitope was tested for in 165 of the 178 patients completing the study. The additional variables of age, sex, presence of rheumatoid factor, number of fulfilled American College of Rheumatology criteria for the classification of RA, and length of delay from onset of symptoms to institution of therapy were entered into a logistic regression model to determine the significant predictors for remission at 2 years.

RESULTS

The delay to therapy (cut point of 4 months) was the only significant predictor for remission in patients treated using the single-DMARD strategy, while no variable was a significant predictor for remission in those treated using the combination-DMARD strategy. The frequency of achieving remission in the combination-DMARD group after 2 years was similar in patients with short (0-4 months) and long (>4 months) delay periods (11 of 26 patients and 22 of 53 patients, respectively [approximately 42% in each group]), while the corresponding frequencies in the single-DMARD group were 8 of 23 patients (35%) and 7 of 63 patients (11%) (P = 0.021). The presence of a shared epitope was not related to the induction of remission.

CONCLUSION

The delay of a few months from the onset of symptoms to institution of therapy decreases the ability of the traditional single-drug strategy to induce remission in early RA.

Differences between female and male patients with familial rheumatoid arthritis

OBJECTIVE

To determine whether there are genetic differences between female and male patients with familial rheumatoid arthritis (RA).

METHODS

45 men and 119 women from 78 families with RA who all had at least one first degree relative with RA were compared. HLA-DRB1 alleles were analysed, including DRB1*04 subtypes and associations of DRB1*04 haplotypes with DQB1*0301 or DQB1*0302 alleles, the age of the patients at disease onset, the presence of rheumatoid factor (RF), joint erosions, and rheumatoid nodules.

RESULTS

HLA-DRB1*13 allele (the subtype allele of DR6, reported to be protective against the development of RA) was found in 14/119 (12%) of female but in none of the male patients (p=0.036). The HLA-DR4 allele was found slightly more often in men than women patients with familial RA (31/45 (69%) v 75/119 (63%), NS). Men were also more often RF positive than women (44/45 (98%) v 98/117 (84%); p=0.031). On the other hand, the mean age at onset of RA was significantly lower in the female group (40.4 years) than in men (46.6 years, p=0.0044).

CONCLUSION

The results indicate that there is stronger genetic background in familial male than female patients with RA in the genetic susceptibility defined by the studied HLA antigens. However, the earlier age of onset of the disease in female group and the increased proportion of women with RA indicate that there are additional sex related predisposing factors enhanced in familial cases.

A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis

OBJECTIVE

To evaluate the impact of a 2-year program of strength training on muscle strength, bone mineral density (BMD), physical function, joint damage, and disease activity in patients with recent-onset (<2 years) rheumatoid arthritis (RA).

METHODS

In this prospective trial, 70 RA patients were randomly assigned to perform either strength training (all major muscle groups of the lower and upper extremities and trunk, with loads of 50-70% of repetition maximum) or range of motion exercises (without resistance) twice a week; all were encouraged to engage in recreational activities 2-3 times a week. All patients completed training diaries (evaluated bi-monthly) and were examined at 6-month intervals. All were treated with medications to achieve disease remission. Maximum strength of the knee extensors, trunk flexors and extensors, and grip strength was measured with dynamometers. BMD was measured at the femoral neck and lumbar spine by dual x-ray densitometry. Disease activity was determined by the Disease Activity Score, the extent of joint damage by the Larsen score, and functional capacity by the Health Assessment Questionnaire (HAQ); walking speed was also measured.

RESULTS

Sixty-two patients (31 per group) completed the study. Strength training compliance averaged 1.4-1.5 times/week. The maximum strength of all muscle groups examined increased significantly (19-59%) in the strength-training group, with statistically significant improvements in clinical disease activity parameters, HAQ scores, and walking speed. While muscle strength, disease activity parameters, and physical function also improved significantly in the control group, the changes were not as great as those in the strength-training group. BMD in the femoral neck and spine increased by a mean +/- SD of 0.51 +/- 1.64% and by 1.17 +/- 5.34%, respectively, in the strength-training group, but decreased by 0.70 +/- 2.25% and 0.91 +/- 4.07% in the controls. Femoral neck BMD in the 17 patients with high initial disease activity (and subsequent use of oral glucocorticoids) remained constantly at a statistically significantly lower level than that in the other 45 patients.

CONCLUSION

Regular dynamic strength training combined with endurance-type physical activities improves muscle strength and physical function, but not BMD, in patients with early RA, without detrimental effects on disease activity.

Strength training induced adaptations in neuromuscular function of premenopausal women with fibromyalgia: comparison with healthy women

OBJECTIVE

To investigate the effects of 21 weeks' progressive strength training on neuromuscular function and subjectively perceived symptoms in premenopausal women with fibromyalgia (FM).

METHODS

Twenty one women with FM were randomly assigned to experimental (FM(T)) or control (FM(C)) groups. Twelve healthy women served as training controls (H(T)). The FM(T) and H(T) groups carried out progressive strength training twice a week for 21 weeks. The major outcome measures were muscle strength and electromyographic (EMG) recordings. Secondary outcome measures were pain, sleep, fatigue, physical function capacity (Stanford Health Assessment Questionnaire), and mood (short version of Beck's depression index).

RESULTS

Female FM(T) subjects increased their maximal and explosive strength and EMG activity to the same extent as the H(T) group. Moreover, the progressive strength training showed immediate benefits on subjectively perceived fatigue, depression, and neck pain of training patients with FM.

CONCLUSIONS

The strength training data indicate comparable trainability of the neuromuscular system of women with FM and healthy women. Progressive strength training can safely be used in the treatment of FM to decrease the impact of the syndrome on the neuromuscular system, perceived symptoms, and functional capacity. These results confirm the opinion that FM syndrome has a central rather than a peripheral or muscular basis.

Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations

OBJECTIVE

To compare the efficacy of combination therapy with disease-modifying antirheumatic drugs (DMARDs) versus single therapy with DMARDs in the prevention of early cervical spine changes in patients with rheumatoid arthritis (RA).

METHODS

One hundred ninety-five patients with recent-onset RA (mean disease duration 8 months) were randomly assigned to receive a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single DMARD with or without prednisolone. After 2 years of followup, cervical spine radiographs were taken of 176 of these patients (85 in the combination-therapy group and 91 in the single-therapy group). These radiographs were evaluated, and the findings were correlated with the therapy strategies as well as with peripheral joint destruction and clinical and laboratory variables describing the disease activity.

RESULTS

Anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI; i.e., vertical subluxation), and subaxial subluxation (SAS) were found in only 6 (3.4%), 2 (1.1%), and 5 (2.8%) of the patients, respectively. Interestingly, none of the patients in the combination-therapy group had aAAS or AAI. The incidences of aAAS and AAI in the single-therapy group were 6.6% and 2.2%, respectively. SAS was present in 2 patients (2.2%) in the single-therapy group and in 3 patients (3.5%) in the combination-therapy group. The difference in the incidence of aAAS between the treatment groups was statistically significant (P = 0.029). None of the patients with cervical spine changes achieved remission of RA during the study.

CONCLUSION

In the present study, the incidence of cervical spine subluxations in patients treated with single-drug therapy was in accord with findings of previous studies. However, none of the patients in the combination-therapy group had aAAS or AAI. These findings suggest that early, aggressive combination-DMARD therapy with sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone can prevent or retard the development of rheumatoid atlantoaxial disorders.

Healing of erosions in rheumatoid arthritis

Reports on healing of erosions in rheumatoid arthritis are rare. However, it is expected that repair of erosions should be seen more often during the period of extensive use of disease modifying antirheumatic drugs, especially in patients who experience sustained remission. Two such cases are described.

Muscle strength characteristics and central bone mineral density in women with recent onset rheumatoid arthritis compared with healthy controls

Muscle strength and bone mineral density (BMD) at the lumbar spine (BMDspine) and femoral neck (BMDfem) were determined in 20 healthy women and in 20 women with recent onset rheumatoid arthritis (RA). The mean duration of articular symptoms of the patients was eleven months and none of them had used glucocorticoids or disease modifying antirheumatic drugs. BMDs were measured by dual x-ray absorptiometry (DXA). Knee extension, trunk extension, and flexion as well as grip strength were measured with David 200 and Digitest dynamometers. BMDspine (1.17 g/cm2 and 1.20 g/cm2) and BMDfem (0.98 g/cm2 and 0.96 g/cm2) between the women with early RA and healthy women did not differ. However, knee extension strength was 46%, grip strength 31%, trunk extension strength 14% and overall muscle strength index 29% lower in RA women (p < 0.020-0.001) than in healthy subjects. Femoral neck BMD correlated statistically significantly with knee extension strength and muscle strength index in both groups and with trunk extension and flexion strength as well as rapid force development in RA women. The data indicates that the loss of muscle strength is clearly visible during the first months of disease but the significant bone loss at central bone regions develops later.

Force production capacity and acute neuromuscular responses to fatiguing loading in women with fibromyalgia are not different from those of healthy women

OBJECTIVE

To compare the maximal and explosive strength characteristics of the leg muscles in premenopausal women with fibromyalgia (FM) with those of healthy female controls (HC) and to examine acute neuromuscular fatigue during heavy resistance loading and short term recovery from fatigue in these 2 groups.

METHODS

Subjects were 11 women with FM, 38.6 (5.8) years old, and 12 healthy female controls, 37.3 (6.1) years old. The following were recorded before, during, and after a fatiguing loading session: maximal bilateral concentric and isometric force, isometric force-time curves and relaxation-time curves with agonist-antagonist neural activation (by EMG) of the leg muscles, muscle pain, and blood lactate concentrations.

RESULTS

At baseline all the measured muscle strength characteristics were comparable between the study groups. The heavy fatiguing loading led to considerable and comparable acute fatigue found in both muscle strength characteristics and agonist-antagonist electromyography in both groups. The respective changes in blood lactate concentration and subjectively perceived muscular pain in the loaded muscles during strenuous resistance loading and recovery from fatigue were similar in both groups.

CONCLUSION

Premenopausal women with FM do not demonstrate lower dynamic or isometric muscle strength characteristics compared to matched healthy controls. Second, the similar neuromuscular responses recorded during and after the fatiguing loading strongly support the hypothesis of normal muscle structure and neuromuscular function in patients with FM.

Immunogenetic differences between patients with familial and non-familial rheumatoid arthritis

OBJECTIVE

To search for possible immunogenetic differencies between the patients with familial and non-familial rheumatoid arthritis (RA).

METHODS

The study compared 129 familial RA patients with 217 non-familial patients for the frequencies of HLA-DR antigens including DR4 subtypes, DR4-DQB1*0301 and DR4-DQB1*0302 haplotypes and HLA-B27 antigen as well as the age of disease onset and existence of rheumatoid factor or joint erosions.

RESULTS

Two major differences between familial and non-familial groups were found: firstly, familial RA patients had increased frequency of HLA-DR4 as compared with the non-familial RA group (68.2 v. 54.8%; p = 0.019). Secondly, the mean age at onset of RA was significantly lower in the familial than in the sporadic RA patients (42.0 v. 46.5 years; p = 0.0020) and the difference still remained when the DR4 positive and negative subgroups were compared separately.

CONCLUSION

These results confirm the more prominent association with HLA-DR4 in familial than in the non-familial cases and suggest that accumulation of HLA risk genes may, at least partly, explain the familial occurrence of the disease. Other susceptibility genes may also be concentrated in multiplex case families as suggested by an earlier age at the onset of RA in both HLA-DR4 positive and negative familial patients.

Scores for functional disability in patients with rheumatoid arthritis are correlated at higher levels with pain scores than with radiographic scores

OBJECTIVE

To analyze correlations of functional disability scores with other measures of clinical status, in particular, Larsen radiographic scores and pain scores, in patients with rheumatoid arthritis (RA).

METHODS

The functional capacity of 141 patients with RA (102 women, 39 men; median age 57 years; median disease duration 11.8 years; 83% rheumatoid factor positive) was assessed according to the Stanford Health Assessment Questionnaire (HAQ). Other variables studied included Larsen scores for radiographic damage of the small joints of the hands, wrists, and feet, pain scores by visual analog scale (VAS), Disease Activity Scores, general health scores by VAS, and Beck Depression Inventory (BDI) scores.

RESULTS

The Spearman correlation coefficient comparing HAQ and Larsen scores was 0.277 (P = 0.001) and between HAQ and pain scores 0.652 (P < 0.001). In regression analysis, pain scores explained 41.4% of the variation in HAQ scores, normalized Larsen scores explained 7.3%, and BDI scores explained 5.5%; other variables were not significant in the model.

CONCLUSION

Functional capacity scores of patients with RA are correlated at higher levels with pain scores than with radiographic scores of small joints.

Disease-modifying anti-rheumatic drug use according to the 'sawtooth' treatment strategy improves the functional outcome in rheumatoid arthritis: results of a long-term follow-up study with review of the literature

OBJECTIVES

To investigate long-term functional outcomes of early rheumatoid arthritis (RA) patients treated actively with disease-modifying anti-rheumatic drugs (DMARDs) from diagnosis, according to the 'sawtooth' principle, and to compare the results to historical data.

METHODS

The surviving 46 and 65 patients from two early RA cohorts were examined on average 13.0 (cohort 1) and 8.5 (cohort 2) yr, respectively, after onset of disease. Functional outcome was measured by the Health Assessment Questionnaire (HAQ) and compared with the HAQ scores of 57 RA patient cohorts found through a Medline computer search.

RESULTS

The respective cross-sectional mean HAQ scores of cohorts 1 and 2 were 0.75 and 0. 55, and were more favourable than the mean HAQ scores of 1.27 (27 cohorts, disease duration >10 yr) and 1.13 (13 cohorts, disease duration 5-10 yr) of the comparator cohorts. The median time that our patients were treated with DMARDs out of the total follow-up period was 88%, while in the majority of comparator cohorts the use of DMARDs was less extensive or poorly described.

CONCLUSIONS

The observation of better preserved function in patients with RA over 13 and 8.5 yr, compared to earlier reports which indicated more severe declines, is a hopeful sign for the rheumatology community.

Mortality in early "sawtooth" treated rheumatoid arthritis patients during the first 8-14 years

OBJECTIVE

To describe mortality in a cohort of early RA patients treated from the onset with disease-modifying antirheumatic drugs (DMARDs) according to the 'sawtooth' strategy.

PATIENTS AND METHODS

A total of 135 early RA patients were followed up for 8-14 years or until death. Causes of death were checked on the death certificates and in patient files. Standardized mortality ratio (SMR) was calculated. Results. A total of 25 (14F, 11M) patients died during the 1422 person-years of follow-up. The SMR (95%CI) was 1.28 (0.83-1.89); 1.69 (0.92-2.82) for women and 0.98 (0.49-1.74) for men. In five cases death was closely related to RA. No one died from amyloidosis. Not a single death was caused by DMARDs in spite of extensive use of these drugs. Patient's age at the start was the only statistically significant predictor for death.

CONCLUSION

Despite active treatment with available DMARDs, RA seems still to be a fatal disease in a proportion of cases.

Utility of disease modifying antirheumatic drugs in "sawtooth" strategy. A prospective study of early rheumatoid arthritis patients up to 15 years

OBJECTIVES

To study long term utility of early, continual, and serial use of disease modifying antirheumatic drugs (DMARDs) in early rheumatoid arthritis (RA) in clinical setting.

METHODS

A total of 135 patients with early RA were treated according to the "sawtooth" strategy and prospectively followed up to 15 years. DMARD survivals as well as reasons for drug terminations were documented and are reported here.

RESULTS

During 1401 person years of follow up, a DMARD or a combination of two or several DMARDs (COMBOs) was started 606 times. A total of 528 drug periods were terminated because of inefficacy, adverse effects, remission, and other reasons in respective 270 (51.1%), 149 (28.2%), 32 (6.1%), and 77 (14.6%) cases. Severe drug related adverse events were rare. The median duration of DMARD periods of individual DMARDs or COMBOs was 10 months ranging from six to 18 months. Not a single DMARD/COMBO stood out favourably from the others with respect to ineffecacy, toxicity or drug survival.

CONCLUSION

The use of serial DMARDs/COMBOs was safe even in the long run. Inefficacy rather than toxicity was the leading reason for drug terminations. More powerful drug therapies are needed.

Work disability in rheumatoid arthritis 10 years after the diagnosis

OBJECTIVE

To describe employment status of patients with early rheumatoid arthritis (RA) 10 years after diagnosis; and to identify predictive and associative factors related to permanent work disability.

METHODS

The study population consisted of 82 patients with early RA who were gainfully employed at onset of RA. Patients were prospectively followed for an average of 10 years and were treated according to the "sawtooth" strategy.

RESULTS

After a time since diagnosis of 2 and an average of 9.9 years, respectively, 19/82 (19%) and 36/82 (44%) cases have been retired merely or partly due to RA. Further, at the latest checkup 42/82 (51%) patients were still gainfully employed, while the prevalence of patients working full time under the common retirement age of 65 yrs was 58% (42/72). Cox regression analysis revealed that physically heavy work at baseline was the strongest independent predictive factor for permanent work disability. Ten years after disease onset, however, work disabled patients had more severe disease than those who continued in work.

CONCLUSION

Our study confirms that the working capacity of patients with RA is in danger from the very start. Despite early and active therapy with disease modifying antirheumatic drugs, at 10 years the cumulative work disability prevalence was 44%.

Dynamic strength training in patients with early rheumatoid arthritis increases muscle strength but not bone mineral density

OBJECTIVE

To assess the effects of 12 months' dynamic strength training on muscle strength and bone mineral density (BMD) at the lumbar spine and femoral neck in patients with early rheumatoid arthritis (RA).

METHODS

Thirty-two subjects in the training group (EG) and 33 in the control group (CG) completed the study. EG carried out strength training 2 times a week with moderate loads of 50-70% of repetition maximum. They were also encouraged to do recreational physical activities. CG performed recreational physical activities and range of motion exercises. Maximal strength of the knee extensors, trunk extensors and flexors, and grip strength were recorded with dynamometers. BMD was measured using dual x-ray absorptiometry. Modified Disease Activity Score, erythrocyte sedimentation rate, and pain were used for the estimation of disease activity, and Stanford Health Assessment Questionnaire to measure functional disability.

RESULTS

The 12 month resistance training in EG led to statistically significant mean increases of 22-35% in all muscle groups examined. CG patients were also able to increase their strength to some degree (3-24%), but at the end of the study strengths in CG were significantly lower than in EG. By the end of the study lumbar spine BMD had changed by +0.19% (4.24) in EG and by -1.14% (4.36) in CG. The corresponding changes of femoral BMD were +1.10% (3.71) and -0.03% (3.58). The changes in BMD were minor and statistically not significant in both groups. However, femoral BMD was found to be decreased among those patients treated periodically with oral glucocorticoids (n = 15, 3 subjects from EG and 12 from CG) compared with changes in BMD among those not treated with systemic glucocorticoids (n = 50).

CONCLUSION

Minimally supervised strength training resulted in significant improvements in muscle strength without detrimental effects on disease activity. The detected annual changes in central BMD were minor and statistically insignificant in both groups. Special attention should be focused on those patients with RA with high disease activity and concomitant glucocorticoid treatment.

Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group

BACKGROUND

The treatment of rheumatoid arthritis should aim at clinical remission. This multicentre, randomised trial with 2-year follow-up sought evidence on the efficacy and tolerability of combination therapy (sulphasalazine, methotrexate, hydroxychloroquine, and prednisolone) compared with treatment with a single disease-modifying antirheumatic drug, with or without prednisolone, in the treatment of early rheumatoid arthritis.

METHODS

199 patients were randomly assigned to two treatment groups. 195 started the treatment (97 received combination and 98 single drug therapy). Single-drug therapy in all patients started with sulphasalazine; in 51 patients methotrexate was later substituted. Oral prednisolone was required by 63 patients. The primary outcome measure was induction of remission. Analyses were intention to treat.

FINDINGS

87 patients in the combination group and 91 in the single-therapy group completed the trial. After a year, remission was achieved in 24 of 97 patients with combination therapy, and 11 of 98 with single-drug therapy (p=0.011). The remission frequencies at 2 years were 36 of 97 and 18 of 98 (p=0.003). Clinical improvement (American College of Rheumatology criteria of 50% clinical response) was achieved after 1 year in 68 (75%) patients with combination therapy, and in 56 (60%) using single-drug therapy (p=0.028), while at the 2-year visit 69 and 57 respectively (71% vs 58%, p=0.058) had clinically improved. The frequencies of adverse events were similar in both treatment groups.

INTERPRETATION

Combination therapy was better and not more hazardous than single treatment in induction of remission in early rheumatoid arthritis. The combination strategy as an initial therapy seems to increase the efficacy of the treatment in at least a proportion of patients with early rheumatoid arthritis.

Conversion of patients with rheumatoid arthritis from the conventional to a microemulsion formulation of cyclosporine: a double blind comparison to screen for differences in safety, efficacy, and pharmacokinetics

OBJECTIVE

To assess whether patients with rheumatoid arthritis (RA) may be converted, on a milligram-to-milligram basis, from conventional cyclosporin A (CyA, Sandimmun) to the microemulsion formulation (Neoral) with maintenance of longterm safety, and to compare cyclosporin A (CyA) pharmacokinetics between formulations.

METHODS

In this double blind, multicenter, parallel group study, 51 patients receiving stable conventional CyA maintenance treatment were randomized to continue conventional CyA (n = 27) or to convert to CyA microemulsion (n = 24) and were monitored for 52 weeks. Trough blood CyA levels were measured before and at intervals after conversion. CyA steady-state area under the curve was assessed one week before and 2 and 6 weeks after randomization in 15 patients in each treatment arm. CyA trough levels and pharmacokinetic results remained unknown to investigators throughout the study. CyA doses were titrated as necessary on the basis of clinical evaluation and disease activity assessments.

RESULTS

Initial mean daily doses were 3.5 mg/kg/day (conventional CyA) and 3.3 mg/kg/day (CyA microemulsion) and did not change significantly during the study. The mean bioavailability of CyA from the microemulsion formulation was 23% higher than from conventional CyA. Replicate assessments indicated a more reproducible pharmacokinetic profile with CyA microemulsion. The overall incidence and nature of adverse events and changes in vital signs and laboratory variables were similar in both groups. No clinically relevant differences in efficacy were found between treatments. No loss of efficacy and no tolerability problems occurred after conversion from conventional to microemulsion CyA.

CONCLUSION

Existing CyA dosing guidelines, formulated for conventional CyA, are suitable for longterm CyA microemulsion therapy of patients with RA. These results indicate the pharmacokinetic advantages of the microemulsion formulation.

A randomized, double-blind, placebo-controlled study of moclobemide and amitriptyline in the treatment of fibromyalgia in females without psychiatric disorder

OBJECTIVE

To study the usefulness of moclobemide and amitriptyline in the treatment of fibromyalgia (FM) in females without psychiatric disorder.

METHODS

In the present four centre, 12 week study, 130 female FM patients not suffering from psychiatric disorders were randomized to receive amitriptyline (AMI; 25 37.5 mg), moclobemide (MOCLO; 450-600 mg) or identical placebo.

RESULTS

Seventy-four, 54 and 49 per cent of patients on AMI, MOCLO and placebo, respectively, were judged as responders. The patients on AMI also managed best regarding the respective improvements during the trial in general health, pain, sleep quality and quantity, and fatigue on visual analogue scales (VAS), the areas of the Nottingham Health Profile (NHP), as well as in the three Sheehan's functional disability scales. In the within-group comparisons, MOCLO also improved pain assessed both on VAS and on the NHP pain dimension, but the improvement was invalidated by the poor success of the drug with regard to sleep. The tolerabilities of all three drugs were comparable.

CONCLUSION

The study indicates that MOCLO may not be helpful in FM patients free from clinically meaningful psychiatric problems.

Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with "sawtooth" strategy

OBJECTIVES

To investigate the prognostic significance of clinical and genetic markers on the outcome of patients with recent-onset rheumatoid arthritis (RA) treated actively with slow acting antirheumatic drugs (SAARDs).

METHODS

A total of 142 consecutive patients with early RA (median disease duration of 7 months) were treated according to the "sawtooth" strategy and prospectively followed up for an average of 6.2 years. Several clinical parameters at start as well as genetic markers were related to the functional outcome (ARA Functional class and HAQ disability score) and radiographic joint damage (Larsen's score) at the latest visit.

RESULTS

In logistic regression analysis only Mallya score (including morning stiffness, pain scale, grip strength, Ritchie's articular index, haemoglobin, and erythrocyte sedimentation rate) at baseline, and Mallya score and rheumatoid factor (RF) positivity at one year were found to be of significance with respect to the radiographic outcome of the patients. Furthermore, at the latest visit HAQ score was related to radiographic score. At baseline the mean ages of the DR4 positive patients and the patients with RA associated DR alleles were statistically significantly lower than those without the above mentioned risk factors (44 v 49, p = 0.03 and 41 v 53, p = 0.04, respectively). However, these genetic markers had no prognostic significance on the functional or radiographic outcome of the patients.

CONCLUSION

High clinical disease activity at baseline and RF positivity especially at one year after the institution of SAARD treatment are the best predictors of poor prognosis in early RA. However, from the clinical point of view, the disease outcome of an individual patient with early RA, cannot be predicted accurately enough by present means.

Progression of joint damage in early active severe rheumatoid arthritis during 18 months of treatment: comparison of low-dose cyclosporin and parenteral gold

OBJECTIVE

This study compared the progression of joint damage in patients with early active severe rheumatoid arthritis (RA) treated with cyclosporin or parenteral gold.

METHODS

In this open, randomized, multicentre study with a blinded radiological endpoint, 375 patients who had suffered from active severe RA for <3 yr were randomized to be treated for 18 months with low-dose cyclosporin or parenteral gold. The groups were stratified with regard to corticosteroid use. Primary efficacy variables were numbers of erosions, erosion score and the Larsen-Dale joint damage score.

RESULTS

Joint damage progressed at similar rates in both treatment arms. In both groups, patients receiving corticosteroids had less X-ray progression. Rheumatoid factor positivity, high swollen joint count, high erythrocyte sedimentation rate and pre-existing X-ray abnormalities predicted progression of joint damage. Although numbers of serious adverse events were similar, more gold patients (n = 65) than cyclosporin patients (n = 45) withdrew from study medication because of adverse events.

CONCLUSION

Cyclosporin was comparable to parenteral gold in retarding progression of joint damage and was better tolerated in terms of adherence to therapy. The open label design should be kept in mind when assessing this difference.

Nonsteroidal anti-inflammatory drug-associated upper gastrointestinal lesions in rheumatoid arthritis patients. Relationships to gastric histology, Helicobacter pylori infection, and other risk factors for peptic ulcer

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for peptic ulcer in rheumatoid arthritis (RA) patients, but the contribution of reactive gastritis, concomitant Helicobacter pylori infection, or RA activity to NSAID ulcer pathogenesis is unknown.

METHODS

Ninety-six RA patients taking NSAIDs and dyspeptic sex- and age-matched control patients without NSAID use or an RA diagnosis were enrolled in the study.

RESULTS

Gastric ulcer (GU) was detected in 29 (30%) RA patients and 3 control patients (P < 0.001). Sixteen RA patients and no control patient had an H. pylori-negative GU. The GUs of the RA patients were mainly located in the prepyloric region (28%) and antrum (62%). Nine of the 29 RA patients (31%) with GU had more than 1 ulcer. Erosive gastropathy was detected in 34 (71% H. pylori-negative) RA patients and in 13 (62% H. pylori-negative) control subjects (P < 0.001). Chronic gastritis was observed in 65 RA patients (48% H. pylori-negative) and in 58 control subjects (43% H. pylori-negative) (NS). whereas reactive gastritis was found in only 2 RA patients and in none of the controls. Corticosteroid use was the only independent risk factor for GU: odds ratio was 6.8 (95% confidence interval, 1.3-36.0). The prevalences of duodenal ulcer or esophagitis were not increased in RA patients.

CONCLUSIONS

RA patients using NSAIDs continuously are at a greatly increased risk of developing both H. pylori-negative and -positive GUs, and corticosteroid use is an independent risk factor for ulcer development. Most RA patients have chronic gastritis, whereas reactive gastritis is rarely associated with continuous NSAID use in RA patients.

Depressed fibromyalgia patients are equipped with an emphatic competence dependent self-esteem

Employing a recently developed questionnaire we studied the self-esteem structure of 61 female fibromyalgia (FM) patients by comparing them with i) 40 healthy psychology students and ii) 37 patients suffering from rheumatoid arthritis. Depressed FM patients (n=36) had a high need to gain self-esteem through competence and others' approval combined with a low basic sense of self-esteem. In this regard they differed significantly from the healthy controls who had a more equal amount of the two types of self-esteem. These patients had also a more demanding and "hard-driving" self-esteem structure than either control group and exhibited a lower self-assertiveness and less emotional candour than the healthy controls. The non-depressed FM patients did not display this self-esteem pattern. In conclusion, FM patients are probably not a homogeneous group. Furthermore, we suggest that an emphatic competence-dependent self-esteem is one vulnerability factor which, in proper genetic and environmental conditions, increases susceptibility to fibromyalgia and depression.

Effects of detraining subsequent to strength training on neuromuscular function in patients with inflammatory arthritis

The effects of detraining subsequent to strength training on neuromuscular function were examined in 39 recent-onset rheumatoid arthritis (RA) patients. Eighteen age- and sex-matched healthy people (H) served as controls. Patients were randomly allocated either to the experimental group (PE), who carried out progressive strength training for 6 months, or to the control group (PC), who maintained only their habitual physical activities. After 6 months, PE returned to their earlier physical activities and strength training was terminated. At baseline, the maximal strength of the trunk extensors (not significant), grip strength and maximal dynamic strength and the shape of the force-time curve of the knee extensors were lower in PE and PC (P < 0.05-0.001) than in H. Strength training in PE led to remarkable increases (P < 0.05-0.001) in the maximal strength of all muscle groups without changes in the shape of the force-time curve. The increases in muscle strength in PE obtained by strength training were lost to a great degree during the detraining period for the isometric trunk extension (P < 0.01) and flexion (P < 0.01) strength and for the dynamic knee extension strength (P < 0.05), but not for the grip strength. In PC, trunk extension and flexion strength decreased significantly throughout the study period. At the post-test, all the strength values in both patient groups were much lower than in H. RA is a chronic disease which seems to need continuous physical exercise with sufficient intensity to minimize/prevent the loss of muscle strength and functional capacity.

Outcome in patients with early rheumatoid arthritis treated according to the "sawtooth" strategy

OBJECTIVE

To investigate the outcome of early rheumatoid arthritis (RA) when treated according to the "sawtooth" strategy, and to compare the results with the findings of other studies.

METHODS

In this prospective study, 142 patients with early RA were treated actively with slow-acting antirheumatic drugs (SAARDs) for an average of 6.2 years, and were closely monitored clinically. Several outcome measures were applied, and the results were compared with findings in previously described cohorts.

RESULTS

The mean cumulative number of SAARDs used during the study was 3.3. Treatment changes were made because of inefficacy more often than because of adverse events. The percentage of patients whose disease entered remission increased with time to 32% (45 of 142). Only 24% of the patients (34 of 142) had deterioration to Steinbrocker functional class III or IV. The "sawtooth" treatment strategy seemed to improve the outcome of the patients with early RA.

CONCLUSION

In the majority of patients with early RA, "sawtooth" therapy remains beneficial for at least 6 years. However, in one-fourth of the patients, the disease fails to respond to this drug treatment strategy.

Persistence of parvovirus B19 in synovial fluid and bone marrow

OBJECTIVES

To determine whether parvovirus B19 (B19) persists in rheumatoid arthritis (RA).

METHODS

Polymerase chain reaction (PCR) was used to detect parvovirus B19 genome in the synovial fluid cells or peripheral blood mononuclear cells from 61 patients with early RA; bone marrow from one patient was also studied. The synovium or synovial fluid cells from 28 patients with advanced RA, and synovial fluid cell samples from 18 patients with reactive arthritis (as controls) were studied. Two separate sets of primers and probe were used.

RESULTS

Parvovirus B19 specific gene sequences were detected in two patients with early arthritis fulfilling the criteria for RA.

CONCLUSION

Parvovirus B19 does not play a significant role in the aetiopathogenesis of RA. However, a few cases of a disease indistinguishable from RA may be triggered by parvovirus B19 infection.

Hypertension in cyclosporin A-treated patients is independent of circulating endothelin levels

OBJECTIVES

To measure blood pressure (BP), plasma endothelin-1 (ET-1), atrial natriuretic peptide (ANP), antidiuretic hormone (ADH) and aldosterone (ALDO) concentration, and plasma renin activity (PRA) in patients treated with a low-dose cyclosporin A (CyA).

DESIGN

An open study of patients with rheumatoid arthritis (RA) or palmoplantar pustulosis (PPP).

SETTING

Out-patient clinics at the Central Hospital of Jyväskylä and Helsinki University Central Hospital.

SUBJECTS

CyA was given to 25 patients with RA and to 10 patients with PPP.

INTERVENTION

RA patients were given CyA at a dose of 2.5 +/- 0.13 mg kg-1 body weight (BW) to 3.47 +/- 0.79 mg kg-1 BW (mean values +/- SD) at the start of the study and after 6 months, respectively, and the CyA dose was 2.67 +/- 0.13 mg kg-1 BW decreasing to 2.07 +/- 0.96 mg kg-1 (P < 0.001) after 4 months in PPP subjects.

RESULTS

Systolic (sBP) and diastolic blood pressure (dBP) increased from 127.8 +/- 13.6/79.7 +/- 8.4 mmHg to 140.0 +/- 19.8/83.8 +/- 9.7 mmHg during the study (P < 0.03). Plasma ET-1, ANP, ALDO and ADH concentration and PRA did not change during 4 to 6 months of CyA treatment. The plasma ANP concentration was constantly higher in CyA-treated RA patients (112 +/- 87 ng 1-1 to 118 +/- 78 ng 1-1) than in PPP patients (37.3 +/- 26 ng 1-1 to 47.7 +/- 39.9 ng 1-1; P < 0.02). The serum creatinine concentration remained within the normal range, but increased from baseline (76.7 +/- 11.9 mumol 1-1), to 90 +/- 15.4 mumol 1-1 (p < 0.001). The serum magnesium concentration decreased significantly (P < 0.005) after 6 months of CyA treatment in RA patients. No correlation was found between serum creatinine and plasma ET-1 concentration.

CONCLUSIONS

Increased blood pressure during CyA treatment was independent of circulating ET-1 levels. A low dose of CyA did not induce increased ET-1 synthesis as judged from plasma samples. The high plasma ANP level observed in RA patients could be due to fluid retention caused by concomitant treatment with non-steroid anti-inflammatory drugs. Fluid retention and decreased magnesium levels could also be involved in the development of hypertension in CyA-treated subjects.

Muscle strength in healthy people and in patients suffering from recent-onset inflammatory arthritis

Neuromuscular function was compared among 20 patients with relatively recent onset (symptomatic period 17 +/- 24 months) rheumatoid arthritis (RA) (experimental group; EG), and 20 age- and sex-matched healthy people (control group; CG). The comparison was repeated after a period of 6 months, when 16 patients had carried out progressive strength training. At baseline maximal grip strength and maximal dynamic unilateral strength of the knee extensors in the EG were significantly (P < 0.05) lower in comparison to the CG. The groups did not differ from each other in maximal isometric strength of the trunk flexors and extensors or the knee extensors. The 6-month dynamic strength training in the EG resulted in significant increases in maximal dynamic strength of the knee extensors (P < 0.001), in isometric grip strength (P < 0.001) and in isometric strength of the trunk flexors (P < 0.05) and extensors (P < 0.05) to the level of the healthy controls. Only minor changes took place in explosive strength and maximal isometric strength of the knee extensors. Erythrocyte sedimentation rate (P < 0.001), Ritchie's articular index (P < 0.01) and modified health assessment questionnaire (P < 0.01) improved significantly during the training period. The results suggest that inflammatory arthritis decreases dynamic and/or isometric muscle strength in selected muscle groups of the body already in the early stages of disease. However, progressive dynamic strength training rapidly increases the neuromuscular performance capacity of the patients even to the level of healthy people without detrimental effects on disease activity.

Intestinal flora in early rheumatoid arthritis

To study the role of intestinal flora in the pathogenesis of RA, we have applied computerized gas-liquid chromatography (GLC) for bacterial cellular fatty acids (CFAs) present in the stool. The CFA spectra represents the total composition of bacterial CFAs in a faecal sample. Correlation and cluster analysis of CFA spectra gathers samples with quantitatively and qualitatively similar bacterial flora into clusters, which then reveal the relationship of samples to each other. Stool samples were collected at the time of hospital admission from patients with early RA before any specific treatment. The CFA spectra in stool samples of RA patients were significantly different from those of non-RA controls. Patients with erosive RA formed a group most clearly different from the controls. Analyses based on the CFA composition of reference bacteria revealed that anaerobic bacteria are primarily responsible for the differences observed. These results suggest that intestinal bacteria play a role in the development of RA.

Does parvovirus B19 have a role in rheumatoid arthritis?

OBJECTIVES

To determine whether parvovirus B19 (B19) infection is associated with rheumatoid arthritis (RA).

METHODS

The polymerase chain reaction was applied to serum, cells isolated from synovial fluid, and synovial fluid. Enzyme immunoassay technique was used to detect antibodies against B19.

RESULTS

Of 142 patients with early RA (onset of disease under one year) and 67 control patients, serological evidence of recent parvoviral infection was found in 4/135 and 2/62, respectively. However, no evidence for the presence of parvoviral DNA was observed in 18 synovial fluids, 21 samples of synovial fluid granulocytes or 40 sera, all obtained from 65 patients diagnosed with early RA.

CONCLUSION

Although there is published evidence of chronic rheumatoid-like arthropathy following acute parvovirus infection, our findings do not support the involvement of B19 in the aetiopathogenesis of RA.

Effects of strength training on neuromuscular function and disease activity in patients with recent-onset inflammatory arthritis

Thirty-nine consecutive patients with recent-onset rheumatoid or psoriatic arthritis were randomly allotted for six months period either to the experimental progressive dynamic strength training group (EG, 10 women and 11 men; 41 +/- 10 yrs), or to the control group (CG, 10 women and 8 men; 45 +/- 11 yrs) who just maintained their habitual physical activities. All patients received antirheumatic medication throughout the experimental period. During the study period significant improvements took place in the EG in maximal muscle strength of all examined muscle groups (31.5% for the knee extensors, p < 0.001; 14.8% and 10.7% for the trunk flexors and extensors, p < 0.01; 27.8% and 20.4% for grip strength, p < 0.001) as well as in erytrocyte sedimentation rate (p < 0.05). Ritchie's articular index (RI) (p < 0.001) and HAQ (p < 0.01). In the CG only the decrease in RI was statistically significant (p < 0.05). Erosive changes in joints increased only slightly and less in the EG than in the CG. The present results suggest that dynamic strength training in early arthritis increases the neuromuscular performance without detrimental effects on disease activity or joint damage.

Sulfasalazine in early rheumatoid arthritis. A 48-week double-blind, prospective, placebo-controlled study

OBJECTIVE

To investigate the efficacy and tolerability of sulfasalazine (SSZ) in the treatment of early rheumatoid arthritis (RA).

METHODS

Eighty patients (symptomatic disease < 12 months) were randomly assigned to treatment with SSZ or placebo for 48 weeks. Clinical, laboratory, and scintigraphic data were used to determine the effects of treatment.

RESULTS

SSZ was superior to placebo in reducing the laboratory features of inflammation, the clinical parameters of disease activity, as well as the scintigraphic activity in the joints. Furthermore, fewer erosive changes developed in the joints of patients receiving active treatment, but the difference between treatment groups did not reach statistical significance.

CONCLUSION

SSZ is effective in the treatment of RA, and its onset of action is rapid. The results support the view that SSZ retards the development of joint erosions. However, like other conventional disease-modifying antirheumatic drugs, its remission-inducing ability is insufficient.

Analysis of impaired in vitro immunoglobulin synthesis in rheumatoid arthritis

Decreased immunoglobulin production in pokeweed mitogen driven lymphocyte cultures has been reported in rheumatoid arthritis (RA). Here various activators and experimental designs have been used to determine the contribution of B cells, T cells, or monocytes to this low response. Sixty patients with RA and paired controls were studied at the onset of disease and again six months later. Concentrations of IgA, IgG, and IgM in cultures of RA peripheral blood mononuclear cells stimulated with thymus dependent activators were already decreased at the onset of the disease. Six months later RA mononuclear cells produced even lower concentrations of immunoglobulin. In contrast, stimulation with a T cell independent activator showed that RA B lymphocytes had retained normal potential to synthesise immunoglobulin. Poor helper function was indicated by costimulation experiments and cultures of mixed mononuclear cells from patients and controls. This notion was supported also by the fact that phytohaemagglutinin induced interleukin-2 production by RA mononuclear cells was less than half of the control values. Nonspecific suppressor activity was similar in RA and controls. Monocyte functions were normal when tested by addition of indomethacin or 2-mercaptoethanol to the mitogen activated cultures. The defect in mitogen stimulated immunoglobulin production in vitro of RA mononuclear cells thus was more pronounced with time and probably reflects impaired mediator associated help in the differentiation of B lymphocytes into immunoglobulin secreting cells.

HLA-DR antigens and HLA-DQ beta chain polymorphism in susceptibility to rheumatoid arthritis

Forty four patients with rheumatoid arthritis (RA) were studied for HLA-DR antigens and for HLA-DQ beta chain gene restriction fragment length polymorphism using DNA hybridisation. A significant increase in the prevalence of the DR4 antigen and a tendency towards an increase of DR1 was found in patients with RA. No allelic form of HLA-DQ restriction fragment length polymorphism patterns was increased, but the prevalence of an allele characterised by a combination of 7.5 and 3 kb fragments was decreased among patients with RA. The DQw8 subtype represented by a 12 kb fragment was the most common DR4 associated allele, and a 3.7 kb fragment related to DQw7 was found in only 5/25 (20%) DR4 positive patients and 2/12 (17%) controls. The results support the hypothesis that RA susceptibility factors are primarily located within HLA-DR genes but HLA-DQ genes may have a role in protection from the disease.

Clinical sequelae and sacroiliac joint changes by computed tomography after recovery from septic sacroiliitis

Nine cases of septic sacroiliitis were re-examined clinically and by CT after a follow-up period of 1.5-7 years. At the final check-up, six of the patients were asymptomatic, while pain could be provoked by palpation or compression in three cases. The sacroiliac joint CT findings were considered normal in two cases. Joint space narrowing, subchondral sclerosis, cysts, erosions, ankylosis and/or osteophytes were detected in seven cases. We conclude that recovery from septic sacroiliitis is good although destructive and degenerative changes often develop as sequelae of an osteolytic involvement.

Antibodies against native type II collagen do not precede the clinical onset of rheumatoid arthritis

Serum levels of IgG and IgM antibodies to native human type II collagen were determined in 22 pre-illness sera from subjects who developed seropositive rheumatoid arthritis (RA) 4 months to 5 years after sera were obtained, in 51 specimens from 35 healthy controls, and in 4-5 specimens from 58 patients with recent-onset RA. The antibody levels in all pre-illness serum specimens fell within the range seen for the healthy controls. Four RA patients had an IgG class antibody level and 4 had an IgM class antibody level that was above the highest level observed for controls, in at least 1 serum sample. No significant difference in the mean level of anticollagen antibodies was observed in the followup specimens from RA patients.

Class specific rheumatoid factors and their complement binding property in the sera of patients suffering from recent-onset rheumatoid arthritis

In this prospective study of 44 patients suffering from recent-onset rheumatoid arthritis we followed the changes in serum levels of rheumatoid factors (RF) of the main immunoglobulin classes and their complement binding property (C3BP) and studied the correlations of these variables with clinical and laboratory parameters of disease activity. The study showed that RFs of all immunoglobulin classes and C3BP fluctuated longitudinally correlating significantly with each other and with laboratory variables of disease activity. IgG-RFs, however, appeared to predict the erosiveness and to correlate best with the articular activity of the disease. Chrysotherapy was shown to decrease serum levels of all RF isotypes irrespectively of whether the patients responded to the therapy or not.