Incidence and risk factors of falling in ambulatory patients with rheumatoid arthritis: a prospective 1-year study

Decreased foot-related quality of life is a risk factor for falls in patients with rheumatoid arthritis

OBJECTIVES

The aim of this study is to assess the need to treat forefoot lesions in rheumatoid arthritis (RA) patients who are unaware of their foot problems.

METHODS

From April to September 2022, 116 RA patients at Yamaguchi Red Cross hospitalwere administered the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), a self-assessment questionnaire on foot-related issues, and underwent forefoot radiography. We also assessed the occurrence of falls 1 year later. Among the 88 patients who were unaware of foot problems, we analysed the frequency and type of forefoot deformities and conducted a multivariate analysis to identify factors predicting falls during the 12-month follow-up.

RESULTS

Of the unaware patients, 64 (72.7%) had forefoot deformities and 17 (19.3%) experienced falls within the first year. The fall group had a history of falls and lower SAFE-Q scores but did not significantly differ from others in terms of forefoot deformities. Multivariate analysis identified a history of falls and lower SAFE-Q scores as predictive factors for future falls.

CONCLUSIONS

Decreased foot-related quality of life is a risk factor for falls, even in patients who are unaware of their foot problems. Physicians should regularly assess foot-related quality of life using tools such as SAFE-Q to help prevent falls in RA patients.

Gait Rehabilitation for Early rheumatoid Arthritis Trial (GREAT): lessons learnt from a mixed-methods feasibility study and internal pilot trial

Background

People with rheumatoid arthritis experience foot and lower limb pain due to active synovitis, resulting in impaired lower limb function. Earlier intervention may help with prevention of functional decline. The aims of this research were to develop and evaluate a new gait rehabilitation intervention for people with early rheumatoid arthritis, evaluate its feasibility, and to test whether or not gait rehabilitation plus usual care is more clinically and cost-effective than usual care alone.

Design and methods

We undertook a single-arm, repeated-measures, pre- and post-intervention, mixed-methods feasibility study with embedded qualitative components. We planned to undertake a pragmatic, two-arm, multicentre, superiority randomised controlled trial, with health economic evaluation, process evaluation and internal pilot.

Setting and participants

Participants with early rheumatoid arthritis (< 2 years post diagnosis) were identified from early arthritis and rheumatology outpatient clinics and referred for intervention in either podiatry or physiotherapy clinics.

Intervention(s)

Participants were randomised to a gait rehabilitation programme (Gait Rehabilitation Early Arthritis Trial Strides) involving a six-task gait circuit. Sessions were underpinned by motivational interviewing to facilitate behaviour change, supported by trained physiotherapists or podiatrists for a minimum of two sessions. Both groups received their normal usual care from the rheumatology multidisciplinary team.

Main outcome measures

Outcome measures for the feasibility study were intervention acceptability, adherence using the Exercise Adherence Rating Scale and fidelity using the Motivational Interviewing Treatment Integrity Scale. The main outcome measure for the internal pilot/randomised controlled trial was the Foot Function Index disability subscale. Outcomes were measured at baseline, 3 months, 6 months and 12 months. Other outcomes: intervention acceptability questionnaire, Exercise Adherence Rating Scale, exercise treatment beliefs via the Theory of Planned Behaviour Questionnaire, intervention fidelity (Motivational Interviewing Treatment Integrity Scale), health-related quality of life (EuroQol-5 Dimensions, five-level score).

Results

Thirty-five participants were recruited for feasibility and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent: 21/23 were confident that it could help and would recommend it and 22/23 indicated it made sense to them. Adherence was good, with a median (interquartile range) Exercise Adherence Rating Scale score of 17/24 (12.5-22.5). Twelve participants' and nine therapists' interviews confirmed intervention acceptability, identified perceptions of benefit, but highlighted some barriers to completion. Motivational Interviewing Treatment Integrity Scale scores demonstrated good fidelity. The trial did not progress from internal pilot to full main trial as a result of low recruitment and high attrition, after 53 participants were recruited from 9 sites over 12 months. Process evaluation confirmed good intervention acceptability and adherence, and fair fidelity. Evaluation of clinical and cost-effectiveness was not possible.

Limitations

Significant delays were experienced with the impact of coronavirus disease 2019, regulatory approvals, contracts and site readiness, resulting in few sites opening in time and low recruitment capacity. Foot and/or ankle pain prevalence was lower than anticipated, resulting in a low potential participant pool and a low conversion rate from screening to enrolment.

Conclusions

The Gait Rehabilitation Early Arthritis Trial Strides intervention was acceptable to people with early rheumatoid arthritis and intervention clinicians, safe, with good levels of adherence by participants, and fair intervention fidelity. The randomised controlled trial stopped early following failure to meet recruitment targets. Gait Rehabilitation Early Arthritis Trial Strides is a promising intervention that could be adapted for future evaluations. A definitive trial of the Gait Rehabilitation Early Arthritis Trial Strides gait rehabilitation intervention still needs to be done.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/165/04.

Postural stability and fall risk in systemic sclerosis patients

Objectives

This study aims to objectively assess the fall risk and postural balance status of systemic sclerosis (SS) patients and investigate its association with various clinical findings.

Patients and methods

The cross-sectional study was conducted between July 2020 and September 2020. The study included 14 patients (12 females, 2 males; mean age: 48.4±12.3 years; range, 21 to 63 years) diagnosed with SS and a control group of 20 healthy volunteers (17 females, 3 males; mean age: 46.8±9.0 years; range, 25 to 60 years). Demographic and clinical data of the participants were noted. Results of anti-nuclear antibodies and anti-Scl-70 antibodies were recorded. The fall index, indicating fall risk, was determined using a posturography device, and postural stability measurements were performed. The Falls Efficacy Scale-International was used to evaluate fall activity. The modified Rodnan skin score was used to assess the degree of cutaneous involvement in SS.

Results

Fall index results were higher in the SS group (p<0.05). The rate of falls in the past year among SS patients was 7.1%. The SS group showed deviations from the normal population in the postural measurement when eyes closed on a solid surface in normal position with the stability index, eyes closed on a pillow with the stability index, and eyes closed on a solid surface with the head tilted 30° forward with the weight distribution index (p<0.05). Fear of falling scores were higher in diffuse-type SS compared to limited-type SS (p<0.01). No differences were observed in other parameters.

Conclusion

This study revealed impaired postural balance and increased fall risk in SS patients compared to the normal population. Evaluation of postural balance and fall risk in SS patients should be done in the early period, and necessary treatments should be applied.

Relationship between falls and the use of hypnotics, antidepressants, antipsychotics, and anxiolytics in patients with rheumatoid arthritis: A cross-sectional study

OBJECTIVES

This cross-sectional study aimed to determine the relationship between falls and the use of psychotropic medications in patients with rheumatoid arthritis (RA).

METHODS

The psychotropic medication group included patients with RA prescribed psychotropic medications [hypnotics/sedatives, antidepressants, antipsychotics, and anxiolytic (benzodiazepines) drugs]. Poisson regression with robust variance was performed to investigate the relationship between falls and the use of psychotropic medications, with adjustment for age, sex, RA disease activity, stroke, dementia, diabetes mellitus, and osteoarthritis.

RESULTS

Of the 307 patients enrolled, 49 (16.0%) used psychotropic medications and 70 (22.8%) experienced at least one fall per year. Nineteen of the 49 patients (38.8%) taking psychotropic medications and 51 of 258 (19.8%) not taking psychotropic medications experienced at least one fall per year. Falls were significantly more frequent in the group with psychotropic medications than in the group without psychotropic medications (adjusted incidence rate ratio, 1.63; 95% confidence interval, 1.08-2.48; P = .02). No relationship was found between the number of falls and the use of psychotropic medications (adjusted incidence rate ratio, 1.16; 95% confidence interval, 0.39-3.44; P = .78).

CONCLUSIONS

There may be a relationship between psychotropic medication use and falls in patients with RA.

The Casual Association Inference for the Chain of Falls Risk Factors-Falls-Falls Outcomes: A Mendelian Randomization Study

Previous associations have been observed not only between risk factors and falls but also between falls and their clinical outcomes based on some cross-sectional designs, but their causal associations were still largely unclear. We performed Mendelian randomization (MR), multivariate Mendelian randomization (MVMR), and mediation analyses to explore the effects of falls. Our study data are mainly based on White European individuals (40-69 years) downloaded from the UK Biobank. MR analyses showed that osteoporosis (p = 0.006), BMI (p = 0.003), sleeplessness (p < 0.001), rheumatoid arthritis (p = 0.001), waist circumference (p < 0.001), and hip circumference (p < 0.001) have causal effects on falls. In addition, for every one standard deviation increase in fall risk, the risk of fracture increased by 1.148 (p < 0.001), the risk of stroke increased by 2.908 (p = 0.003), and a 1.016-fold risk increase in epilepsy (p = 0.009). The MVMR found that sleeplessness is an important risk factor for falls. Finally, our mediation analyses estimated the mediation effects of falls on the hip circumference and fracture (p < 0.001), waist circumference and epilepsy (p < 0.001), and sleeplessness and fracture (p = 0.005). Our study inferred the causal effects between risk factors and falls, falls, and outcomes, and also constructed three causal chains from risk factors → falls → falls outcomes.

Combined Effects of Diet and Physical Activity on Inflammatory Joint Disease: A Systematic Review and Meta-Analysis

Research evidence suggests that, individually, diet and physical activity are effective interventions for reducing levels of inflammation in inflammatory joint diseases (IJD), however little is known about their combined use. This systematic review and meta-analysis aimed to examine the effects and/or associations of combined diet and physical activity interventions in IJD, specifically rheumatoid arthritis (RA) and the spondyloarthropathies (SpA) (PROSPERO registration number: CRD42022370993). Ten out of 11 eligible studies examined RA patients. We found that a combination of diet/nutrition and physical activity/exercise improved Health Assessment Questionnaire score (standardized mean difference = -1.36, confidence interval (CI) = (-2.43)-(-0.30), I2 = 90%, Z = 2.5, p = 0.01), while surprisingly they increased erythrocyte sedimentation rate (mean difference = 0.20, CI = 0.09-0.31, I2 = 0%, Z = 3.45, p < 0.01). No effects were found on C-reactive protein or weight (p > 0.05) of RA patients. We did not find studies in other IJDs that provided sufficient data for a meta-analysis. The narrative data synthesis provided limited evidence to address our research question. No firm conclusions can be made as to whether the combination of diet/nutrition and physical activity/exercise affects inflammatory load in IJDs. The results of this study can only be used as a means of highlighting the low-quality evidence in this field of investigation and the need for further and better-quality research.

Prevalence and risk factors of falls in adults with rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Despite the fact that the estimated prevalence and risk factors of falls in adults with rheumatoid arthritis (RA) are widely reported, these results have not been synthesized. The systematic review and meta-analysis aimed to investigate the prevalence and risk factors of falls in adults with RA.

METHODS

PubMed, EMBASE, Web of Science, the Cochrane Library, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Wanfang Database, China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Chinese Biomedical Database (CBM) were searched for relevant studies published from the inception of the database until July 4, 2022. Stata 15.0 Software was used to perform the meta-analysis. For the prevalence of falls in adults with RA and risk factors that were investigated in at least 2 studies in a comparable way, we calculated pooled incidence and odds ratios (ORs) using random-effects models, with a test for heterogeneity. A study protocol was registered in PROSPERO (CRD42022358120).

RESULTS

A total of 6,470 articles were screened and data from 34 studies involving 24,123 subjects were used in meta-analysis. The pooled prevalence of any falls was 34% (95% confidence interval, CI: 29% to 38%, I²=97.7%, P<0.001), and 16% for recurrent falls (95% CI: 12% to 20%, I²=97.5%, P<0.001). 25 risk factors were considered, including sociodemographic, medical and psychological, medication, and physical function. The strongest associations were found for history of falls (OR=3.08, 95%CI: 2.32 to 4.08, I²=0.0%, P = 0.660), history of fracture (OR=4.03, 95%CI: 3.12 to 5.21, I²=97.3%, P<0.001), walking aid use (OR=1.60, 95%CI: 1.23 to 2.08, I²=67.7%, P = 0.026), dizziness (OR=1.95, 95%CI: 1.43 to 2.64, I²=82.9%, P = 0.003), psychotropic medication use (OR=1.79, 95%CI: 1.39 to 2.30, I²=22.0%, P = 0.254), antihypertensive medicine/diuretic (OR=1.83, 95%CI: 1.37 to 2.46, I²=51.4%, P = 0.055), taking four or more medicine(OR=1.51, 95%CI: 1.26 to 1.81, I²=26.0%, P = 0.256), and HAQ score(OR=1.54, 95%CI: 1.40 to 1.69, I²=36.9%, P = 0.135).

CONCLUSIONS

This meta-analysis provides a comprehensive evidence-based assessment of the prevalence and risk factors for falls in adults with RA, confirming their multifactorial etiology. Understanding the risk factors of falls can provide healthcare personnel with a theoretical basis for the management and prevention of RA patients.

Sensory Integration for Postural Control in Rheumatoid Arthritis Revealed by Computerized Dynamic Posturography

Rheumatoid arthritis (RA) is a systemic autoimmune disease that impairs mobility. How does sensory information influence postural responses in people with RA? The aim of this study was to evaluate the postural control of people with RA during a sensory organization test, comparing how sensory information influences postural responses in people with rheumatoid arthritis compared with healthy people. Participants were 28 women with rheumatoid arthritis (RA group) and 16 women without any rheumatoid disease (Control group CG). The Sensory Organization Test (SOT) was performed on a Smart Balance Master^® (NeuroCom International, Inc., Clackamas, OR, USA) and center of pressure (COP) was measured. SOT conditions: SOT1 (eyes open, fixed support surface and surround; SOT2) eyes closed, fixed support surface and surround; and SOT5) eyes closed, sway-referenced support surface, and fixed surround. To compare the demographic and clinical aspects between groups, independent t-test or Mann-Whitney's U-test were used. Differences were found between groups. Between SOT conditions, for CG and RA, COP was faster for SOT-5 than SOT-1, while SOT-1 and SOT-2 presented similar COP velocity. For SOT-2 and SOT-5, COP was larger for the RA group. For both groups, SOT-1 presented the smallest COP, and SOT-5 showed the largest COP.

Evaluation of the balance function before and after total knee arthroplasty using Berg balance scale

INTRODUCTION

The purpose of this study was to evaluate balance function before and after total knee arthroplasty (TKA) using Berg balance scale (BBS). The study also aimed to identify factors associated with balance impairment.

MATERIALS AND METHODS

Ninety-three knees in 90 patients were prospectively evaluated using their BBS scores, passive knee extension/flexion angles, Visual analogue scale for pain scores, hip-knee-ankle angles, and knee extensor/flexor muscle strengths before and after TKA. A total BBS score of less than 45 indicates an enhanced risk of multiple falls. Multivariate logistic regression models were performed to elucidate factors associated with post-operative BBS score.

RESULTS

A significant difference in mean pre- and post-operative BBS scores were noted (49.3 ± 6.4 vs. 52.2 ± 4.7) (p < 0.05). The percentage of pre- and post-operative BBS scores less than 45 were 20% and 10% (p < 0.05). Rheumatoid Arthritis (RA), lower pre-operative BBS score, and larger post-operative knee flexion contracture were significantly associated with lower post-operative BBS score (p < 0.01). The post-operative knee flexion contracture greater than 10° was significantly associated with substantially high odds of post-operative BBS scores less than 45 (Odds ratio 7.6; 95% confidential interval 1.69-34.17).

CONCLUSIONS

While TKA significantly improved BBS scores, 10% of the patients remained at a risk for multiple falls. RA, lower pre-operative BBS score, and post-operative knee flexion contracture greater than 10° retained balance impairment even after TKA.

Risk factors for osteoporosis and fractures in rheumatoid arthritis

People with rheumatoid arthritis (RA) have both disease-specific risk factors for osteoporosis and fractures in addition to those that affect the general population. Disease specific risks include directly pathogenic auto-antibodies, chronic exposure to systemic inflammation, and joint damage causing early disability. Risk factors that affect the general population which may have a higher prevalence in RA include smoking, calcium and vitamin D deficiency as well as hypogonadism. Additionally, chronic exposure to glucocorticoids results in reduced bone mineral density and body composition changes which can further increase fracture risk. In this review we discuss these risk-factors for osteoporosis as well as factors that may impact fall and fracture risk in people with RA.

Effect of sarcopenia and poor balance on vertebral spinal osteoporotic fracture in female rheumatoid arthritis

This study investigated the effect of poor balance and sarcopenia on vertebral spinal osteoporotic fracture (VOPF) in female rheumatoid arthritic (RA) patients. A total of 195 female RA and 126 normal subjects were enrolled, and the correlations between sarcopenia, poor balance and VOPF were analyzed. Furthermore, we explored the relationships between sarcopenia or poor balance with disease related indexes of female RA. Binary logistic regression analyses were performed to identify potential risk factors for VOPF in female RA. We found that female RA had an increased risk of sarcopenia, poor balance (Berg balance scale, BBS ≤ 40) and VOPF than controls (P < 0.0001). Female RA with VOPF were more likely to have poor balance and sarcopenia than those without VOPF (P < 0.0001-0.05). Meanwhile, female RA with sarcopenia and poor balance often had higher disease activity, more serious joint damage and worse joint function (P < 0.05) compared with those without sarcopenia and poor balance. Binary logistic regression analysis (LR backwald) revealed that age (OR = 1.112, 95% CI 1.065-1.160, P < 0.0001), OP (OR = 10.137, 95% CI 4.224-24.330, P < 0.0001) and GCs usage (OR = 3.532, 95% CI 1.427-8.741, P = 0.006) were risk factors, while SMI (OR = 0.386, 95% CI 0.243-0.614, P < 0.0001) and BBS (OR = 0.952, 95% CI 0.929-0.976, P < 0.0001) were protective factors for VOPF in female RA. Hence, sarcopenia and poor balance are associated with a higher risk for VOPF and are closely related to disease activity and joint structure damage of female RA.

Balance and prospective falls in patients with rheumatoid arthritis

Background

Postural control is associated with fall risk. Patients with rheumatoid arthritis (RA) have a higher risk to fall than healthy subjects. The objective of this study was to identify associations between variables of postural control with prospective falls in patients with RA.

Methods

For the baseline, the balance performance of 289 men and women with RA, ages 24–85 years, was evaluated by SPPB, FICSIT-4 and Romberg tests. Postural sway for Romberg, semitandem, tandem and one-leg stands were measured with the Leonardo Mechanograph®. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ) and the Activity-specific Balance Confidence Scale (ABC-scale). Falls were reported in quarterly reports over a year. Univariate and multiple logistic regression analysis were used to explore any associations with falling. Receiver-operating characteristics were determined, and the area under the curve is reported.

Results

A total of 238 subjects completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), FICSIT-4 scoring 0–4 (OR = 2.38, 1.13–5.0), and one-leg standing (OR = 2.14, 1.06–4.31) showed significant associations with falls. With regard to the SPPB and ABC-scale, no statistically significant associations with falls were found. The quartiles containing the worst results of medio-lateral sway of Romberg (OR = 2.63, CI 1.03–6.69), total sway of semitandem (OR = 3.07, CI 1.10–8.57) and tandem (OR = 2.86, CI 1.06–7.69), and area of sway of semitandem (OR = 2.80, CI 1.11–7.08) stands were associated with falls.

Conclusions

The assessment of a one-leg stand seems to be a good screening tool to discriminate between high and low risk of falls in RA patients in clinical practice. A low FICSIT-4 score and several sway parameters are important predictors of falls.

Trial registration

The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).

A quantitative assessment of the risk of falls in rheumatoid arthritis patients and determination of the risk factors

Objectives

The aim of this study was to compare the risk of falling in patients with rheumatoid arthritis (RA) to the healthy individuals and to identify the factors affecting the risk of falls.

Patients and methods

Between December 2015 and August 2016, a total of 100 consecutive patients with RA (16 males, 84 females; mean age: 49.5±11.1 years; range, 21 to 65 years) and 50 healthy controls (11 males, 39 females; mean age: 34.3±12.7 years; range, 19 to 63 years) were included in this prospective study. The fall risk was evaluated using the Tetrax Portable Balance System. The Health Assessment Questionnaire Disability Index (HAQ-DI), RA disease activity (Disease Activity Score 28 [DAS28], Clinical Disease Activity Index [CDAI], and Simple Disease Activity Index [SDAI]), and Falls Efficacy Scale International (FES-I) were applied to all participants.

Results

The fall risk scores and the FES-I scores were significantly higher in the patients with RA than the control group (p<0.001, p<0.001). A positive significant correlation was found between the Tetrax values of the patients and age, and the scores of the HAQ-DI, FES, DAS28, DAS28-C-reactive protein, CDAI and SDAI.

Conclusion

Our study results showed higher fall risk scores in patients with RA than healthy individuals an objective computerized technique, and this higher fall risk appeared to be affected by older age, disease activity, and disability.

Evaluation of peripheral neuropathy in lower limbs of patients with rheumatoid arthritis and its relation to fall risk

Background

Rheumatoid Arthritis (RA) is a chronic disabling systemic disease characterized by joint inflammation, and extra-articular manifestations, including peripheral neuropathy, a condition that can be associated with changes in muscle strength, proprioception and postural balance contributing for the risk of falls. The objective of this study is to analyze the incidence of peripheral neuropathy in patients with RA and its association with the occurrence of falls.

Methods

Patients were assessed by an electroneuromyography (ENMG) exam and by a questionnaire on accidental falls occurrence in the previous 12 months. They were also assessed on balance by the Short Physical Performance Battery (SPPB), functionality by the Health Assessment Questionnaire (HAQ), disease activity by the Disease Activity Score (DAS-28), neuropathic pain by the Questionnaire for the Diagnosis of Neuropathic Pain (DN4), and cutaneous sensitivity of the feet by the monofilament testing of Semmes–Weinstein. Monthly calls on falls were made in the subsequent six months. Data analysis was performed using the Shapiro–Wilk test for normality and Spearman, Chi-square, and T-student correlation tests, with a significant P level ≤ 0.05.

Results

A sample of 33 patients were evaluated. The incidence of peripheral neuropathy was 48.5%, of which 68.7% were axonal and 31.3% myelinic. The sensorimotor type was present in 64.7%, motor in 17.6%, and sensorial in 11.7% of the cases. Neuropathy was associated to balance (P = 0.026), neuropathic pain (P = 0.016), deep tendon reflexes absence (P = 0,049), altered skin sensitivity of the feet (P = 0.029) and fear of falling (P = 0.001). No association was found between peripheral neuropathy and age, gender, disease activity, or functionality. No significant association was found between peripheral neuropathy and occurrence of falls, in a 12-month retrospective and 6-month prospective evaluation.

Conclusion

Peripheral neuropathy has a high incidence in patients with RA, and is related to neuropathic pain, altered postural balance, but not to the occurrence of falls.

Clinical Observations of Osteoporosis in Japanese Patients with Rheumatoid Arthritis

Osteoporosis is the one of the major adverse outcomes in patients with rheumatoid arthritis (RA). Recently, we and others have been reported many clinical observations related to osteoporosis in Japanese RA patients. In this article, I reviewed these findings. Japanese patients with RA have a two-fold risk of fractures compared with those without RA. Among the fractures in Japanese RA patients, three quarters of the fractures were non-vertebral fractures. The incidence of non-vertebral fractures did not change, despite an improvement in RA disease activity. Older age, female gender, history of fractures, history of total knee replacements, disease activity scores in 28 joints (DAS28), health assessment questionnaire disability index (HAQ-DI), low bone mineral density, glucocorticoid dose, and vitamin D deficiency were significantly associated with fractures. Older age, high body mass index (BMI), HAQ-DI, and polypharmacy were significantly associated with falls. BMI (both overweight and underweight), DAS28, and HAQ-DI were significantly associated with frailty. Half and three quarters of Japanese men and women with RA had vitamin D deficiency, respectively. The incidence of osteonecrosis of the jaw may be higher in Japanese RA patients than those without RA. Undertreatment of osteoporosis appears to exist in Japanese patients with RA.

Association between sarcopenia, physical performance and falls in patients with rheumatoid arthritis: a 1-year prospective study

Background

Patients with rheumatoid arthritis (RA) are at increased risk of falls and fractures. Sarcopenia occurs more frequently in RA patients due to the inflammatory processes. Early diagnosis and prevention programmes are essential to avoid serious complications. The present study aims to identify risk factors for falls related to sarcopenia and physical performance.

Methods

In a 1-year prospective study, a total of 289 patients with RA, ages 24–85 years, were followed using quarterly fall diaries to report falls. At the baseline, medical data such as RA disease duration and Disease Activity Score (DAS28_CRP) were collected. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ). Appendicular skeletal mass was determined by Dual X-ray-Absorptiometry (DXA). Physical performance was evaluated by handgrip strength, gait speed, chair rise test, Short Physical Performance Battery, and FICSIT-4. Muscle mechanography was measured with the Leonardo Mechanograph®. Sarcopenia was assessed according to established definitions by the European Working Group on Sarcopenia in Older People (EWGSOP2) and The Foundation for the National Institutes of Health (FNIH). Univariate and multiple logistic regression analysis were used to explore associations with falling. Receiver-operating characteristics (ROC) were performed, and the area under the curve is reported.

Results

A total of 238 subjects with RA completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. No association was found between sarcopenia and prospective falls. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), and low FICSIT-4 score (OR = 2.38, 1.13–5.0) showed significant associations with falls.

Conclusions

In clinical practice, a fall assessment including age, self-reported activities of daily life and a physical performance measure can identify RA patients at risk of falling.

Trial registration

The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).

Clinical and biomechanical factors associated with falls and rheumatoid arthritis: baseline cohort with longitudinal nested case-control study

OBJECTIVE

To identify the clinical and biomechanical characteristics associated with falls in people with RA.

METHODS

A total of 436 people ≥60 years of age with RA completed a 1 year prospective survey of falls in the UK. At baseline, questionnaires recorded data including personal and medical history, pain and fatigue scores, health-related quality of life (HRQoL), physical activity and medication history. The occurrence of falls wasmonitored prospectively over 12 months by monthly self-reporting. A nested sample of 30 fallers (defined as the report of one or more falls in 12 months) and 30 non-fallers was evaluated to assess joint range of motion (ROM), muscle strength and gait parameters. Multivariate regression analyses were undertaken to determine variables associated with falling.

RESULTS

Compared with non-fallers (n = 236), fallers (n = 200) were older (P = 0.05), less likely to be married (P = 0.03), had higher pain scores (P < 0.01), experienced more frequent dizziness (P < 0.01), were frequently taking psychotropic medications (P = 0.02) and reported lower HRQoL (P = 0.02). Among those who underwent gait laboratory assessments, compared with non-fallers, fallers showed a greater anteroposterior (AP; P = 0.03) and medial-lateral (ML) sway range (P = 0.02) and reduced isokinetic peak torque and isometric strength at 60° knee flexion (P = 0.03). Fallers also showed shorter stride length (P = 0.04), shorter double support time (P = 0.04) and reduced percentage time in swing phase (P = 0.02) and in knee range of motion through the gait cycle (P < 0.01).

CONCLUSION

People with RA have distinct clinical and biomechanical characteristics that place them at increased risk of falling. Assessment for these factors may be important to offer more targeted rehabilitation interventions.

Analysis of the Associations between Arthritis and Fall Histories in Korean Adults

(1) Background: the purpose of the present study was to analyze the associations between arthritis and fall histories in Korean adults. (2) Methods: data from the 2015 and 2017 Korean Community Health Survey were analyzed. In total, 322,962 participants aged ≥40 years were included. The participants were divided into two different groups. First, the participants were divided into the ‘arthritis (osteoarthritis or rheumatoid arthritis) for entire life’ and ‘nonarthritis for entire life (comparison I)’ groups. Subsequently, the participants were divided into the ‘current arthritis’ and ‘noncurrent arthritis (comparison II)’ groups. Afterwards, we analyzed the prevalence odds ratios (pORs) of the fall histories of the participants using a logistic regression analysis with the 95% confidence interval (CI). The variables of income, education level, region of residence, smoking status, alcohol consumption, obesity, subjective health status, stress level, physical activity, and sleep hours were adjusted for as covariates. (3) Results: both the arthritis for entire life and current arthritis groups had higher prevalence rates of falls than the comparison I and comparison II groups, respectively (each p < 0.001). The pORs of falling ≥1 time and ≥2 times per year in the arthritis for the entire life group were 1.42 (95% CI = 1.38–1.46) and 1.69 (95% CI = 1.62–1.76), respectively. The adjusted pORs for falling ≥1 time and ≥2 times per year in the current arthritis group were 1.35 (95% CI = 1.31–1.39) and 1.56 (95% CI = 1.50–1.63), respectively. (4) Conclusions: previous arthritis has a significant impact on the risk of falling.

Synergistic effect of sarcopenia and poor balance on osteoporotic vertebral fracture in Chinese patients with rheumatoid arthritis

OBJECTIVES

This study aimed to investigate the synergistic effect of sarcopenia and poor balance on osteoporotic vertebral fracture (VOPF) in Chinese patients with rheumatoid arthritis (RA).

METHODS

A total of 238 RA patients and 158 normal subjects were enrolled in the case-control study. Poor balance capability (Berg balance scale (BBS) score < 40) and sarcopenia (skeletal muscle mass index (SMI) <7.0 (male)/5.7 (female)) between RA patients and normal subjects were compared. Associations of poor balance capability or sarcopenia with disease activity, structural damage, and joint function in different groups were also investigated.

RESULTS

The incidence of sarcopenia in RA was 58.4%, significantly higher than that in controls (P<0.0001). Moreover, the percentages of low balance capacity (BBS<40) in RA were 43.7%, which was higher than that in controls (P<0.0001). The prevalence of VOPF in the case group was 19.3%, which was higher than that in the controls (P<0.0001). In the RA group, compared to RA patients without VOPF, RA patients with VOPF had higher percentages of poor balance and sarcopenia (P<0.05). Compared with RA patients without sarcopenia or good balance, RA patients with sarcopenia or poor balance had a higher incidence of VOPF, higher disease activity, severer structural damage, and worse joint function (P<0.05). The incidence of VOPF in patients combined with good balance and non-sarcopenia (4.8%) was significantly lower than that in patients combined with poor balance and sarcopenia (38.2%) (P<0.0001). Logistic regression indicated that higher SMI and higher BBS scores were protective factors for VOPF in RA patients, while age was a risk factor for VOPF in RA patients (P<0.0001).

CONCLUSION

Sarcopenia and poor balance are popular in Chinese patients with RA, and they are associated with disease activity and structural damage. There is a synergistic effect of sarcopenia and poor balance on VOPF in RA. Key Points • Sarcopenia and balance capability were popular (about a half) in patients with RA. • Sarcopenia and poor balance had a synergistic effect on VOPF in RA.

Fear-of-falling and associated risk factors in persons with rheumatoid arthritis: a 1 year prospective study

Background

Falls, associated injuries and fear-of-falling are common in adults with RA. Fear-of-falling can be a major consequence of, and as debilitating as falling, resulting in a cycle of activity restriction, reduced quality of life, institutionalisation and potentially increase risk of falls. The objective of this study was to examine the relationship between fear-of-falling and risk factors associated with fear-of-falling in adults with rheumatoid arthritis (RA) over a 1 year period.

Methods

Five hundred fifty-nine patients with RA were recruited from four outpatient clinics in this prospective cohort study. Baseline assessments included socio-demographic, medical and lifestyle related risk factors. Fall incidence was prospectively obtained monthly using postal cards over a 1 year period. Fear-of-falling was assessed at baseline and 1 year using the Short Falls Efficacy Scale-International (Short FES-I). Logistic regression was used to determine the association between high fear-of-falling (Short FES-I > 11) at baseline (outcome) and a range of putative predictor variables including previous falls, and also baseline factors associated with a high fear-of-falling at follow-up.

Results

Five hundred thirty-five (ninety-six percent) participants (mean age 62.1 yrs.; 18–88 yrs) completed 1 year follow-up and of these, 254 (47%) completed the Short FES-I questionnaire at 1 year. In a multivariate model, a history of multiple falls (OR = 6.08) higher HAQ score (OR = 4.87) and increased time to complete the Chair Stand Test (OR = 1.11) were found to be independent predictors of high fear-of-falling and had an overall classification rate of 87.7%. There were no significant differences found in fear-of-falling at 1 year follow-up in those who reported falls during the study, participant’s baseline fear appeared to predict future fear, regardless of further falls.

Conclusions

Fear-of-falling is significantly associated with previous falls and predictive of future falls and fear. RA patients would benefit from fall prevention measures whether or not they have previously fallen.

Falls in Rheumatoid Patients: Does Ankle and Foot Ultrasonography have a Predictive Role? A Single-blind Study

Background Rheumatoid arthritis (RA) patients have a higher prevalence of falls compared with the healthy population. Several risk factors of falls in RA have been postulated, including high disease activity, low balance, muscle weakness and non-treatment with biologics.

Aim of the work We investigated our hypothesis that the sonographically detected ankle and foot changes in RA patients can predict falls in this population. To our knowledge, no previous study had investigated this before.

Methods In a total of 101 RA patients, we performed assessments of disease activity, disability level, gait speed, balance status, clinical examination of ankle and foot and an MSUS assessment of the ankle and foot joints and tendons as possible risk factors of falls.

Results The Berg balance test had the highest fall-predicting power (71.3%), followed by a gait speed test and restricted range of motion (ROM) of the Rt. subtalar joint, each with a predictive power of 70.3%. Of the sonographic findings, erosion of the first metatarsophalangeal (MTP) joint was the most accurate fall predictor, followed by erosion of the talonavicular joint and tenosynovitis of the ankle dorsal flexors with an area under the curve of 0.656, 0.642 and 0.614, respectively.

Conclusion The use of the MSUS as an adjunct objective method for predicting falls in RA patients has not been studied before. It was found that clinical foot and balance testing was a superior and easier way of predicting falls in RA patients than using ultrasonography.

Relationships of the stand-up time to falls and fractures in patients with rheumatoid arthritis: Results from the CHIKARA study

AIM

Patients with rheumatoid arthritis (RA) have a higher risk of falls and fractures due to muscle weakness and painful joints of the lower extremities. Evaluation of muscle functions is important to predict falls and fractures. The aim was to investigate the relationships of muscle functions with falls and fractures in RA patients.

METHODS

Stand-up muscle power, speed, and stabilizing time were evaluated by a muscle function analyzer in 90 RA patients in the CHIKARA study (UMIN000023744). The relationships of the muscle functions with falls, fractures, body composition, Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS28-ESR), modified Health Assessment Questionnaire (mHAQ) scores, Steinbrocker class, stage, sarcopenia, and frailty were investigated in a cross-sectional study.

RESULTS

Each parameter of muscle function was related to age, falls, frailty, and the leg muscle score. However, only stabilizing time was related with fractures (r = .217, P = .04). When stabilizing time was ≥ 1.13 and ≥1.36 seconds, the odds ratios for falls and fractures were increased 6.2-fold compared to < 1.13 seconds (95% CI: 1.2-20.1, P = .002) and 11.4-fold compared to <1.36 seconds (95% CI: 1.7-92.5, P = .071), respectively. Sarcopenia and skeletal muscle mass were not significantly related to each muscle function. There was a negative correlation between DAS28-ESR and power. Steinbrocker class and mHAQ had negative correlations with power and speed.

CONCLUSIONS

Sarcopenia and skeletal muscle mass were not adequate indicators of muscle functions in RA patients. Analyzing muscle functions is helpful to predict falls and fractures. Patients with extended stabilizing times should recognize the increased risk of falls and fractures.

Missing Diagnosis, Pain, and Loss of Function in Older Adults with Rheumatoid Arthritis and Insufficiency Fractures: A Qualitative Study of the Patient's Perspective

Rheumatoid arthritis (RA) is characterised by a chronic, progressive inflammation in the joints and leads to substantial pain, disability, and other morbidities. Few studies document the occurrence of insufficiency fractures, but no studies document the patient's perspective on incurring an insufficiency fracture. The aim of this qualitative study was to explore the patients' perspective on how insufficiency fractures influence their level of activity and to detect their need for rehabilitation. Two focus-group interviews were performed with 10 patients diagnosed with RA and insufficiency fractures. The data from the focus-group interviews were subjected to thematic analysis to provide a sense of the important themes. The 10 patients were all females, aged 57-88 years. Magnetic resonance imaging were performed at a mean of six months and seven days. All patients identified the delayed diagnosis of fracture as a significant burden. They experienced pain but did not receive a diagnosis. When the patients were immobilised, some of them were offered aids such as crutches, which they were unable to use due to their RA. The patients needed a focus on diagnosis and individually customised rehabilitation, taking into account RA and including guidance concerning daily activities, aids, and the regain of physical function.

Risk factors associated with history of falls in adults with intellectual disability

BACKGROUND

Adults with intellectual disability (ID) have a higher risk for falls than the general population.

AIM

The purpose of this study was to identify risk factors for falls in adults with ID using objective measurements.

METHODS

Eighty adults with ID (men 36 women 44 age 43 ± 13 years) provided data on falls history, health problems or limitations in daily life, physical activity (PA), and physical performance. We conducted independent-samples t-tests, and Chi-square (χ²) tests to examine the difference between fallers and non-fallers. Multivariate logistic regressions were performed to identify the independent effects of risk factors for falls in adults with ID.

RESULTS

Fallers had significantly lower SPPB, mobility, and moderate PA than non-fallers (p <  .05). Fallers were more likely to be older, need support with activities of daily living (ADLs), and have arthritis or rheumatism, walking problem, and limitations to participating in PA than non-fallers (p <  .05). Among these variables, only needing support with ADLs remained a significant independent predictor of falls in a multivariate model.

CONCLUSION

Support need for ADLs can predict falls in individuals with ID. Caregivers may need to closely monitor adults with ID who need support for ADLs.

Gait disturbances in patients with rheumatoid arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic inflammation resulting in the involvement of all the structures constituting a joint. We determined the type and severity of foot deformities, determined the impact of the degree of disturbances of foot statics and the disease activity on the duration of the particular phases of gait, determined the impact of the maximum foot load and the percentage distribution of loads between the forefoot and hindfoot on the duration of the particular phases of gait, and established the link between observed disorders and the stage of rheumatoid arthritis.

Material and methods

The control group consisted of 41 healthy women. Rheumatoid arthritis patients, whose disease had been diagnosed based on the American College of Rheumatology (ACR) criteria, were divided into three groups. Group I consisted of 56 women, Group II of 28 patients in the first and second stage of RA, Group III of 28 patients in the third and fourth stage of the disease. We calculated the disease activity score (DAS28 index) and body mass index, and we conducted a pedobarographic examination.

Results

The results obtained in our study revealed the disturbances of the parameters of foot statics in RA patients. We also detected a prolongation of gait phases, resulting from the disturbances of statics and the displacement of the maximum foot load both in static and dynamic conditions. Increased activity of the disease constituted an additional factor affecting the prolongation of gait phases.

Conclusions

Our results confirm the usefulness of baropodometric examination as an important diagnostic tool in the evaluation of the locomotor system of RA patients.

Evaluation of Risk Factors for Falls in Patients with Rheumatoid Arthritis

Background

The aim of our study was to investigate the risk factors for falls in the rheumatoid arthritis (RA) patient population in Poland. This would be a major step towards the development of new fall prevention programs.

Material/Methods

There were 450 RA patients who met the criteria of the American College of Rheumatology who participated in this study. The average age of patient participants was 54.2 years; the average RA duration was 15.1 years. All patients filled out the study questionnaire regarding falls, medications, and diseases, and they filled out the Polish version of the Health Assessment Questionnaire (HAQ).

Results

Of the 400 patients, 203 patients (51%) experienced falls. Out of the 268 falls experienced by study patients, 113 falls (42%) were due to an environmental cause, the remainder 155 falls were caused by health conditions. The number of falls positively correlated with HAQ scores (r=0.42, P<0.01) and the duration of RA (r=0.39, P<0.05). For individuals who had fallen 3 or more times, there was a stronger positive correlation between the number of falls and the total HAQ score (r=0.61, P<0.01). The main risk factors for falls in the study group were dizziness (odds ratio [OR]=3.42), the use of hypotensive medication (OR=2.82), foot deformities (OR=4.09), and a high HAQ score (OR=2.59). Other factors such as drug use (e.g., glucocorticoids), pain, and duration of RA were measured using a visual analogue scale, and were found not to have increased the risk for falls and fractures (P>0.05).

Conclusions

Knowledge about risk factors can help identify high-risk patients to help decrease their risk of falling, thus preventing fall-related injuries.

Association between fall history and performance-based physical function and postural sway in patients with rheumatoid arthritis

OBJECTIVES

Patients with rheumatoid arthritis (RA) are at increased risk of falling; therefore, fall prevision and prevention are critical. The present study aimed to evaluate the ability of physical performance assessments to discriminate between RA patients with and without a history of falling.

METHODS

Fifty patients with RA were divided into two groups according to the presence or absence of a history of falls within the previous 1 year. Physical performance was assessed using the short physical performance battery (SPPB), which consists of the timed standing balance, gait speed, and chair stand tests. Standing balance was also assessed as postural sway using a force platform in several positions including standing with both feet together, semitandem, and tandem. Backgrounds, SPPB, and postural sway were compared between the two groups.

RESULTS

Fourteen patients (28%) reported one or more falls within the previous year. There were no significant intergroup differences in baseline characteristics or SPPB score. The group with a history of falls had significantly longer measured time for the 5-repetition chair stand test and significantly longer postural sway in the semitandem position. The discriminate analysis revealed that 5-repetition chair stand test or its combination with postural sway in the semitandem position significantly discriminated between fallers and non-fallers.

CONCLUSION

Numerical evaluation of the chair stand test and postural sway in the semitandem position seems more appropriate than SPPB for assessing the fall risk of patients with RA.

Physical and Psychological Factors Affecting Falls in Older Patients with Arthritis

As the population ages, falls are becoming one of the leading causes of morbidity and mortality. Joint disease (either osteoarthritis or rheumatoid arthritis) is a well-known predictor of falls, and these medical conditions increase in accordance with the aging population. This study aimed to describe individual, physical, and psychological characteristics between older adults with and without a fall history. Further, we aimed to identify statistically significant physical or psychological factors associated with falls by controlling individual variables. We analyzed data from the 2014 Survey of Living Conditions and Welfare Needs of Korean Older Adults. Adults aged 65 years or over with doctor-diagnosed joint disease were eligible. A total of 2707 women and 784 men (n = 3491) were enrolled. Of these, 1174 patients suffered a fall within a year (average number of falls = 2.4). We adopted individual variable-adjusted models and found that limited activities of daily living (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.04-1.87), fear of falling (OR 7.18, 95% CI 4.26-12.09), and depression (OR 1.28, 95% CI 1.09-1.50) significantly increased fall risks on logistic regression analysis. Our findings suggest that physical and psychological factors, especially the fear of falling, need to be addressed to prevent falls in elderly patients with arthritis.

Multisite pain and self-reported falls in older people: systematic review and meta-analysis

Background

Multisite pain and falls are common in older people, and isolated studies have identified multisite pain as a potential falls risk factor. This study aims to synthesise published literature to further explore the relationship between multisite pain and falls and to quantify associated risks.

Methods

Bibliographic databases were searched from inception to December 2017. Studies of community-dwelling adults aged 50 years and older with a multisite pain measurement and a falls outcome were included. Two reviewers screened articles, undertook quality assessment and extracted data. Random-effects meta-analysis was used to pool the effect estimate (odds ratio (OR) and 95% confidence interval (95%CI)). Heterogeneity was assessed by I²; sensitivity analyses used adjusted risk estimates and exclusively longitudinal studies.

Results

The search identified 49,577 articles, 3145 underwent abstract review, 22 articles were included in the systematic review and 18 were included in the meta-analysis. The unadjusted pooled OR of 1.82 (95%CI 1.55–2.13), demonstrating that those reporting multisite pain are at increased risk of falls, is supported by the adjusted pooled OR of 1.56 (95%CI 1.39–1.74). Multisite pain predicts future falls risk (OR = 1.74 (95%CI 1.57–1.93)). For high-quality studies, those reporting multisite pain have double the odds of a future fall compared to their pain-free counterparts.

Conclusion

Multisite pain is associated with an increased future falls risk in community-dwelling older people. Increasing public awareness of multisite pain as a falls risk factor and advising health and social care professionals to identify older people with multisite pain to signpost accordingly will enable timely falls prevention strategies to be implemented.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1847-5) contains supplementary material, which is available to authorized users.

Role of musculoskeletal disorders in falls of postmenopausal women

We aimed to investigate the role of musculoskeletal disorders (MSDs) as risk factors for falls among postmenopausal women. Our results indicate that MSDs are common and are associated with increased falling risk, especially nonslip falls. Excess number of falls due to MSDs is greater than that due to any other disease class.

PURPOSE

Falls are a major public health problem worldwide. The aim of the study was to investigate the role of MSDs as risk factors for falls among postmenopausal women.

METHODS

This cohort study utilized data from a population-based, prospective cohort study (OSTPRE). The study population consisted of 8656 women aged 57-66 years (in 1999) living in Kuopio Province, Eastern Finland, who responded to postal enquiries in 1999 and 2004. Information on MSDs and other morbidities was obtained from the 1999 enquiry and information on falls from the 2004 enquiry. Women were classified as fallers or non-fallers according to their falling events in the preceding 12 months. The fallers were further divided into women with slip and nonslip falls.

RESULTS

Of the study sample, 53.3% reported a MSD and 39.2% reported a fall during the preceding 12 months. MSDs predicted falls (OR = 1.38; 95% CI 1.26-1.50) and the association was stronger for nonslip (OR = 1.56; 95% CI 1.39-1.75) than slip falls (OR 1.22; 95% CI 1.08-1.38) compared to the women without MSDs. The risk of falls increased with increasing number (1, 2, ≥ 3) of MSDs: 1.25 (95%CI 1.13-1.38), 1.48 (95%CI 1.30-1.68), and 1.92 (95%CI 1.60-2.31), respectively. After adjustments, the risk of falling related to MSDs reduced by about 5% (adjusted p < 0.001). The population attributable fraction of falls due to MSDs was 10.3% of all falls, greater than that due to any other disease class.

CONCLUSION

MSDs are common and an important risk factor for falls and especially nonslip falls among postmenopausal women. The number of excess falls due to MSDs in this population group is greater than that due to any other disease class.

Disease-related outcomes influence prevalence of falls in people with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) are at increased risk of falls, with potential adverse outcomes. There is a considerable variation across studies regarding the prevalence of falls and its correlation with clinical data, disease-related outcomes and physical performance tests.

OBJECTIVE

The aim of this study was to evaluate the prevalence of falls and its association with clinical data, disease-related outcomes and physical performance tests.

METHODS

In this cross-sectional study, 113 RA patients were divided into 3 groups - "non-fallers", "sporadic fallers" and "recurrent fallers" - and compared in terms of clinical data, Clinical Disease Activity Index (CDAI), lower-limb tender and swollen joint count, disability (Health Assessment Questionnaire-Disability Index [HAQ-DI]), Foot Function Index (FFI), Berg Balance Scale (BBS), Timed-up-and-go Test (TUG) and 5-Time Sit Down-To-Stand Up Test (SST5). Logistic regression analysis was performed to analyze the associations between the studied variables and the occurrence of falls, estimating odds ratios (ORs). We also analyzed the correlation between disease outcome measures (HAQ-DI and CDAI) and physical tests (BBS, TUG, SST5).

RESULTS

Falls and fear of falling were reported by 59 (52.21%) and 71 (64.5%) patients, respectively. Significant associations were found between "recurrent fallers" and vertigo (OR=3.42; P=0.03), fear of falling (OR=3.44; P=0.01), low income (OR=2.02; P=0.04), CDAI (OR=1.08; P<0.01), HAQ-DI (OR=3.66; P<0.01), Lower-limb HAQ (OR=3.48; P<0.01), FFI-pain (OR=1.24; P=0.03), FFI-total (OR=1.23; P=0.04), lower-limb tender joint count (OR=1.22; P<0.01), BBS score (OR=1.14; P<0.01), TUG score (OR=1.13; P=0.03) and SST5 score (OR=1.06; P=0.02). On multivariate analysis, CDAI was the only significant predictor of recurrent falls (OR=1.08; P<0.01). Physical performance test scores (BBS, TUG, SST5) were correlated with the CDAI and HAQ-DI.

CONCLUSION

The prevalence of falls in RA is high, most influenced by disease-related outcomes and linked to worse performance on physical tests (BBS, TUG and SST5).

The effect of glucocorticoids on bone mineral density in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomized, controlled trials

PURPOSE

The role of glucocorticoids in the treatment of rheumatoid arthritis (RA) is widely debated. Impairment of bone formation may be counter-balanced by reduced systemic inflammation. This review aims to assess the effect of prednisolone/prednisone on bone mineral density (BMD) in patients with RA analyzed in randomized, controlled trials.

METHODS

We performed a systematic literature search and identified randomized, double-blinded placebo-controlled studies including patients with RA and using prednisolone or prednisone as the intervention. We selected studies that measured BMD by DXA at baseline and at least once thereafter. Two authors independently performed reference review, data extraction and risk of bias assessment. Primary outcome was mean change in BMD from baseline to follow-up. Secondary endpoints included radiographic scores, RA disease activity indices and fractures. We rated the quality of evidence using the GRADE approach. Outcomes were standardized for meta-analyses and 95% confidence intervals (95% CI) were calculated.

RESULTS

We identified 7 studies and included previously unpublished data. Studies were similar regarding study population and intervention. Standard mean difference (SMD) in change in BMD from 0 to 24 months was -0.02 (95%CI -0.16, 0.12) at the lumbar spine and -0.11 (95% CI -0.25, 0.02) at the hip (both high quality evidence) between patients treated with prednisolone/prednisone or not. Data completeness was low in some studies, concomitant treatment of RA differed between studies and differences in use of anti-osteoporotic medication may have influenced the results. However, sensitivity analyses excluding studies in which participants used either the most or the least potent concomitant RA treatment or used anti-osteoporotic therapies did not alter the estimates.

CONCLUSIONS

In patients with early and active RA, we found no difference in change in BMD between patients treated with prednisone/prednisolone versus placebo, suggesting that at least through 24 months, the suppression of inflammation by glucocorticoids may counterbalance their adverse effects on bone remodeling.

A prospective cohort study measuring cost-benefit analysis of the Otago Exercise Programme in community dwelling adults with rheumatoid arthritis

Background

Falls are one of the major health problems in adults with Rheumatoid Arthritis (RA). Interventions, such as the Otago Exercise Programme (OEP), can reduce falls in community dwelling adults by up to 35%. The cost-benefits of such a programme in adults with RA have not been studied.

The aims of this study were to determine the healthcare cost of falls in adults with RA, and estimate whether it may be cost efficient to roll out the OEP to improve function and prevent falls in adults living with RA.

Methods

Patients with Rheumatoid Arthritis aged ≥18 years were recruited from four rheumatology clinics across the Northwest of England. Participants were followed up for 1 year with monthly fall calendars, telephone calls and self-report questionnaires. Estimated medical cost of a fall-related injury incurred per-person were calculated and compared with OEP implementation costs to establish potential economic benefits.

Results

Five hundred thirty-five patients were recruited and 598 falls were reported by 195 patients. Cumulative medical costs resulting from all injury leading to hospital services is £374,354 (US$540,485). Average estimated cost per fall is £1120 (US$1617). Estimated cost of implementing the OEP for 535 people is £116,479 (US$168,504) or £217.72 (US$314.34) per-person. Based on effectiveness of the OEP it can be estimated that out of the 598 falls, 209 falls would be prevented. This suggests that £234,583 (US$338,116) savings could be made, a net benefit of £118,104 (US$170,623).

Conclusions

Implementation of the OEP programme for patients with RA has potentially significant economic benefits and should be considered for patients with the condition.

Falls, fear of falling, and associated factors in ambulatory patients with rheumatoid arthritis: A comparative study with healthy controls

Objectives

This study aims to compare fall history and fear of falling (FOF) in patients with rheumatoid arthritis (RA) and healthy controls and to evaluate associated factors for fall risk and FOF in patients with RA.

Materials and methods

Between March 2016 and July 2016, a total of 120 patients with RA and 60 age- and sex-matched healthy volunteers were included in the study. The presence of FOF (Yes/No), fall history, and the number of falls within the past 12 month were questioned. All participants were assessed with the Falls Efficacy Scale-International (FES-I), 10 Meter Walk Test (10MWT), One-Leg Stand Test (OLST), Berg Balance Scale (BBS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Pain Severity and Patient Global Assessment (PGA) by Visual Analog Scale (VAS), disability by the Health Assessment Questionnaire (HAQ), and disease activity by Disease Activity Score in 28 joints (DAS28) were evaluated in patients with RA.

Results

There was no statistically difference between the RA patients and healthy controls in terms of presence of fall history, while the presence of FOF and FES-I scores were significantly higher in the RA patients (p<0.05). In the patient group, the FES-I score was positively correlated with pain VAS, PGA, DAS-28, HAQ, BAI, BDI, and 10MWT and negatively BBS and OLST (p<0.05). The number of falls, HAQ, BBS, and BDI scores were found to be significant independent risk factors affecting variations in the FES-I scores (p<0.001).

Conclusion

Fear of falling seems to be an important problem in patients with RA, and patients without fall history may also have FOF. The most important factors associated with FOF were impaired balance, increased disability and depression, and number of falls in RA patients. Strategies for preventing falls, maintaining balance, improving emotional status and against FOF are of utmost importance in patients with RA.

Dynamic joint stiffness of the ankle in healthy and rheumatoid arthritis post-menopausal women

The purpose of this study was to compare rheumatoid arthritis post-menopausal women (RAPW) with pathological involvement of the lower limb joints and age-matched healthy post-menopausal women (AHPW) in regard to the dynamic joint stiffness of the ankle (DJS_ankle) during the stance phase of gait. Data were collected from 18 RAPW and 18 AHPW. Gait was assessed by a three-dimensional motion analysis system synchronised with a force plate. Subjects walked barefoot at natural and self-selected speed, performing 14 valid trials (comprising 7 left and 7 right foot-steps on a force plate). The stance phase was split into three sub-phases that corresponded to the three angular displacements of the ankle that occurred during this phase, namely, controlled plantar flexion (CPF), controlled dorsiflexion (CDF), and powered plantar flexion (PPF). A linear model represented each sub-phase and computed DJS_ankle. Model fitting was assessed by the coefficient of determination (R²). The coefficient of variation (CV) was used to assess intra-individual variability. In all sub-phases, R² values for both groups were higher than 0.85. There were no differences in the R² values among groups. RAPW showed a higher DJS_ankle during the CPF (p < 0.05). CDF and PPF yielded no differences among groups. During CPF, RAPW yielded a higher CV for DJS_ankle (p < 0.01). RAPW also yielded lower ankle angular displacements during CPF and PPF (p < 0.05). Findings suggested that the stance phase of RAPW and AHPW can be studied by a linear ankle 'moment of force -- angle' relationship. During CPF, RAPW exhibited excessive ankle stiffness and presented a higher intra-individual DJS_ankle variability.

Static and Dynamic Balance Disorders in Patients With Rheumatoid Arthritis and Relationships With Lower Extremity Function and Deformities: A Prospective Controlled Study

Objectives

This study aims to evaluate the static and dynamic balance disorders of patients with rheumatoid arthritis (RA) and to disclose the relationships with clinical, functional, and radiological findings of lower extremities.

Patients and methods

A total of 81 patients with RA (15 males, 66 females; mean age 48.9±10.4 years; range 22 to 67 years) were compared with 84 age and sex-matched healthy controls (14 males, 70 females; mean age 45.9±12.1 years; range 24 to 70 years). Radiographic assessments of feet were performed to evaluate the presence of pes planus, hallux valgus, metatarsus primus varus, and splaying foot deformities. Foot functions of patients were determined with Foot and Ankle Outcome Score. The balance disorders of the subjects were evaluated with three static (modified clinical test of sensory interaction and balance, unilateral stance, weight bearing squat) and three dynamic (step-up-and-over, sit-to-stand, tandem walk) balance tests via the 'Neurocom Balance Master' device.

Results

Rheumatoid arthritis patients had significantly higher sway velocity in unilateral stance and modified clinical test of sensory interaction and balance tests, higher step width and lower speed when walking on a line, lower rising index and higher movement time in step-up-and-over test compared to healthy controls (p<0.05). Performances on the sit-to-stand and weight bearing squat tests were comparable between both groups. Of the patients, although 61% had hallux valgus, 52% had metatarsus primus varus, 33% had pes planus, and 26% had splaying foot, these deformities were not correlated with Foot and Ankle Outcome Score or balance disorders. Presence of swollen joint was determined as the most relevant factor for balance disorders of RA patients.

Conclusion

Patients with RA may have increased risk for balance disorders due to cumulative effect of the lower extremity impairments seen in the course of disease.

Are Foot and Ankle Characteristics Associated With Falls in People With Rheumatoid Arthritis? A Prospective Study

OBJECTIVE

To determine whether foot and ankle characteristics are associated with falls in people with rheumatoid arthritis (RA).

METHODS

A total of 201 adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Participants were prospectively studied for 12 months to record the occurrence of falls using falls diaries. Logistic regression analysis identified baseline variables that were independent predictors of falls over the 12 months.

RESULTS

Eighty-four participants (42%) fell at least once and 39 (19%) experienced multiple (>1) falls over the 12-month followup period. In logistic regression analysis, including age and significant baseline variables in bivariate analysis but not baseline fall history, presence of foot or ankle tender joints (odds ratio [OR] 1.95, P = 0.034) and psychotropic medication (OR 2.35, P = 0.025) were independent predictors of prospective falls. However, when baseline fall history was included in the analysis, psychotropic medication (OR 2.34, P = 0.025) and baseline fall history (over the preceding 12 months) (OR 2.27, P = 0.008) were independent predictors of prospective falls.

CONCLUSION

Foot and ankle characteristics are not associated with falls in people with RA, independent of prior falls. Inquiry about prior falls and psychotropic medications may assist in identifying patients with RA who are at high risk of future falls.

Fall Risk and Related Factors in Systemic Lupus Erythematosus

Objectives

This study aims to determine the fall risk in systemic lupus erythematosus (SLE) patients with an objective computerized technique and to evaluate the potential related risk factors for falls in these patients.

Patients and methods

A total of 48 female patients (mean age 37.8±12.6 years; range 18 to 65 years) with SLE and 30 female controls (mean age 39.1±15.7 years; range 19 to 66 years) were included. Age, disease duration, anamnesis of falls, fear of falling, and drugs used were recorded. Disease activity (measured with SLE disease activity index Safety of Estrogens in Lupus Erythematosus National Assessment modification) and damage (measured with Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were evaluated. For the evaluation of fall efficacy, we used the Falls Efficacy Scale International. Fall risk analysis was performed by using a computerized posturography device.

Results

Seven patients (15%) had anamnesis of falls during the last 12 months, whereas only one control (3%) had this anamnesis (p=0.042). Fear of falling was reported by 40% of the patients and 30% of the controls (p=0.042). Falls Efficacy Scale International scores were found to be higher in patients than in controls (p=0.042). With the computerized system used, higher fall risk results were recorded in patients than in controls (59.3±29.5 and 35.8±26.9, respectively; p<0.001). Low, moderate, and high fall risks were recorded as 31%, 15%, and 54% in the patients, respectively, and as 53%, 23%, and 23% in the controls, respectively. Low, moderate and high fall risk distribution was also worse in patients than in the controls (p=0.030). No significant correlation was found between fall risk and the other factors evaluated, except Falls Efficacy Scale International, which was significantly correlated with both fall risk assessment and fall risk category in the patients (r=0.311, p=0.031).

Conclusion

Fall risk was found to be higher in SLE patients than in controls. The higher fall risk in these patients seems to be affected by the disease itself rather than its other characteristics. Future studies investigating the possible coexisting balance problems in SLE may contribute to the management of the disease.

Combination of BTrackS and Geri-Fit as a targeted approach for assessing and reducing the postural sway of older adults with high fall risk

Atypically high postural sway measured by a force plate is a known risk factor for falls in older adults. Further, it has been shown that small, but significant, reductions in postural sway are possible with various balance exercise interventions. In the present study, a new low-cost force-plate technology called the Balance Tracking System (BTrackS) was utilized to assess postural sway of older adults before and after 90 days of a well-established exercise program called Geri-Fit. Results showed an overall reduction in postural sway across all participants from pre- to post-intervention. However, the magnitude of effects was significantly influenced by the amount of postural sway demonstrated by individuals prior to Geri-Fit training. Specifically, more participants with atypically high postural sway pre-intervention experienced an overall postural sway reduction. These reductions experienced were typically greater than the minimum detectable change statistic for the BTrackS Balance Test. Taken together, these findings suggest that BTrackS is an effective means of identifying older adults with elevated postural sway, who are likely to benefit from Geri-Fit training to mitigate fall risk.

Falls and their association with physical tests, functional capacity, clinical and demographic factors in patients with rheumatoid arthritis

OBJECTIVE

To evaluate the occurrence of falls reported by rheumatoid arthritis patients and its relation to disease activity, functional capacity and physical fitness.

MATERIALS AND METHODS

A cross-sectional study constituted by a sample of 97 rheumatoid arthritis patients from the city of Marília (SP) from 2012 to 2013, were assessed for disease activity. Instruments validated for Brazilian population in order to evaluate physical and functional capacity were used. Data analysis was carried out with descriptive statistics, Spearman correlation and Chi-squared test, considering p<0.05.

RESULTS

88.7% were female subjects with a mean age of 56 (±11.7) years. The median duration of rheumatoid arthritis was 10 years (P25=6 and P75=17) and the mean of disease activity was 3.6 (±1.3), what was considered a moderate activity. In the last 12 months 37.1% of patients experienced at least one fall, with a total of 52 episodes, and fear of falling was reported by 74.2% of them, but this was not associated to the occurrence of a fall (χ²=1.19, p=0.27). Gender, number of medications, age, disease activity, duration of rheumatoid arthritis, functional capacity, and physical tests showed no associations with history of falls in the past year.

CONCLUSION

It was observed that the occurrence of falls and the fear of falling are quite common in this population. The occurrence of falls in this sample of rheumatoid arthritis patients bears no relation to disease activity, functional capacity, or physical fitness tests.

Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study

BACKGROUND

People with rheumatoid arthritis (RA) have an increased risk of falls. The foot is a common site of pathology in RA and foot problems are reported in up to 90% of patients with established disease. The aim of this study was to determine whether foot and ankle characteristics are associated with falls in people with RA.

METHODS

Adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Participants reported whether they had fallen in the preceding year, and the number of falls. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Univariate parametric and non-parametric analysis compared fallers and non-fallers on all variables to determine significant differences. Logistic regression analysis identified variables independently associated with falls.

RESULTS

Two hundred and one participants were prospectively recruited. At least one fall in the preceding 12-months was reported by 119 (59%) participants. Univariate analysis showed that fallers had significantly longer mean disease duration, more co-morbid conditions, an increase in lower limb tender joints, higher midfoot peak plantar pressures and were more likely to have a history of vascular disease than non-fallers. Fallers also reported greater difficulty with activities of daily living, increased fear of falling and greater self-reported foot impairment. Logistic regression analysis revealed that increased midfoot peak plantar pressures (odds ratio (OR) 1.12 [for each 20 kPa increase], 95% confidence interval (CI) 1.00-1.25), self-reported foot impairment (OR 1.17 [for each three point increase], 95% CI 1.05-1.31) and history of vascular disease (OR 3.22, 95% CI 1.17-8.88) were independently associated with a fall in the preceding 12 months.

CONCLUSIONS

Elevated midfoot peak plantar pressures, self-reported foot impairment and vascular disease are associated with falls in people with RA. Assessment of foot deformity, foot function and self-reported foot impairment may be of benefit when considering falls prevention strategies in people with RA.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (trial ACTRN12612000597897).