Life events and disability in rheumatoid arthritis: a European cohort

The role of stress in the mosaic of autoimmunity: An overlooked association

Stress is defined as the pscyophysiological reaction in which the steady state is disturbed or threatened. Stress is not always perceived as a negative response. Stress results when environmental demands exceed an individuals' adaptive capacities. Autoimmune diseases are heterogeneous group of chronic diseases which occur secondary to loss of self antigen tolerance. The etiopathogenesis of autoimmune disease is uncertain. Genetic factors as well as environmental factors appear to interplay, leading to a cascade of events resulting in disease onset. Stress has been postulated to play a role in disease onset in the genetically susceptible patients. During the stress response, catecholamines and glucocorticoids are released from locus coeruleus and adrenal gland. These biomolecules exert control over various immune cells in the innate and adaptive arms of the immune system, thereby altering the cytokine profile released. The increase of IL-4 promotes T-helper 2 (T_h2) cell differentiation, while the decrease in IL-12 and the increased IL-10 production reduce the number of T-helper 1 (T_h1) cells. The relationship between stress and autoimmune diseases is intricate. Stress has been shown to be associated with disease onset, and disease exacerbations in rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, multiple sclerosis, Graves' disease as well as other autoimmune conditions. In certain conditions such as psoriasis, stress has been implicated in delaying lesion clearance upon the application of standard treatment regimes. Finally, psychological therapy and cognitive behavioral therapy aimed to reduce stress levels was shown to be effective in influencing better outcomes in many autoimmune diseases. The purpose of this paper is to closer inspect the clinical evidence regarding the role of stress on influencing the various aspects of disease entities.

The course of established rheumatoid arthritis

Rheumatoid arthritis (RA) varies over time in individual patients and there are marked differences between patients in its impact and progression. The course of RA is therefore unique to each individual patient and is affected by the overall pattern of disease; many patients have classical polyarticular disease but there is also a range of subtypes, such as fibromyalgic and polymyalgic disease. Some patients with RA enter a period of sustained remission; this varies between 10% and 36% of cases; its frequency is mainly influenced by the different approaches to studying RA patients over time, and does not represent a true difference in disease outcome. Most patients have persisting synovial inflammation and disease activity scores average between 3 and 4; there is some evidence that inflammation is less marked in late RA. Persisting synovitis results in increasing disability - this worsens by an average of 0.6% each year - and in joint damage, which increases by an average of 2% each year. Comorbidities and extra-articular features are commonplace: about one-third of patients, respectively, have associated cardiovascular disease, lung disease or extra-articular features, although severe extra-articular problems like vasculitis affect only about 10% of patients. Some aspects of the course of RA are influenced by genetic risks; currently these are only weak predictors but it is anticipated their value will increase with time.

Pain and psychological health status over a 10-year period in patients with recent onset rheumatoid arthritis

OBJECTIVE

To examine rheumatoid arthritis (RA) with short disease duration over 10 years, and to identify factors that are associated with the course of pain, depression and anxiety.

METHODS

A cohort of 238 patients with RA (age 20-70 years, mean disease duration 2.3 years, 68% rheumatoid factor positive) was followed with assessments at baseline and after 1, 2, 5 and 10 years. Self-reported health status was assessed by pain on a 100 mm visual analogue scale, the Arthritis Impact Measurement Scales (AIMS), the 28-item version of General Health Questionnaires, and the Health Assessment Questionnaire. We also examined the erythrocyte sedimentation ratio, grip strength (kg) and radiographic progression of the hands (van der Heijde modified Sharp score). Repeated measures analyses of variance were used to explore the effect of time on measures of outcome among completers, whereas repeated measures analyses using a mixed model were applied to identify factors that were longitudinally associated with pain, depression and anxiety.

RESULTS

At the various assessment points 30% had a visual analogue scale pain score of > or =40 mm, 5-13% had an AIMS depression score of > or =4.0 and 20-30% had an AIMS anxiety score of > or =4.0. The perceived level of pain was explained longitudinally by anxiety, disease activity, physical function and female gender, depression by high disease activity and anxiety, whereas anxiety was explained by low disease activity and depression.

CONCLUSION

More patients had increased levels of anxiety (20-30%) than increased levels of depression (5-13%). Several factors, including anxiety, but not depression, were associated with the course of pain.

The effect of Benson Relaxation Technique on rheumatoid arthritis patients: Extended report

Rheumatoid arthritis (RA) is a chronic disease and has the highest rate of prevalence among rheumatic inflammatory diseases. The purpose of this study was to determine the effect of Benson Relaxation Technique (BRT) combined with medication on disease activity in patients with RA. Following ethical approval, 50 consecutive matched patients were selected and allocated into two groups, either an experimental or a control group. Patients in the experimental group received BRT combined with medication and patients in the control group were given only medication. Clinical symptoms, laboratory findings, anxiety, depression and feeling of well-being were measured before and after intervention to evaluate the effect of BRT. There was a significant difference between the two groups in anxiety, depression and feeling of well-being. Changes in clinical symptoms and laboratory findings were not large enough to be statistically significant between the two groups, but they indicated decline in disease progress. The results demonstrate that BRT can be an effective technique in reducing disease process in patients suffering from RA. However, in order to support the findings of this trial, studies with large sample size and > 8-week intervention are recommended.

The Impact of Stressors on Health Status and Hypothalamic-Pituitary-Adrenal Axis and Autonomic Nervous System Responsiveness in Rheumatoid Arthritis

The hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS) are critically involved in inflammation and are activated by stress. This suggests that stressful circumstances may affect the chronic inflammation of rheumatoid arthritis (RA). Fifty-six scientific publications of the past 15 years were reviewed to get insight into the possible impact of stressors (grouped in five categories) on the health status and HPA axis and ANS functioning of adult patients with RA. Our findings in this review were: (1) In response to mental and physical effort and applied physiological stressors, patients demonstrate ANS hyporesponsiveness and "too normal" HPA axis responsiveness considering the elevated immune activity. A premorbid defect, past and current inflammatory activity, past and current stress, and physical deconditioning may explain disturbed physiological responses. (2) After brief naturalistic stressors, self-perceived and clinician's ratings of disease activity are increased; inflammation parameters have been insufficiently examined. (3) Major life events do not univocally affect disease status, but appear able to modify disease activity in a positive or negative way, depending on the nature, duration, and dose of the accompanying physiological stress response. (4) Enduring (e.g., work-related or interpersonal) stressors are associated with perceived health. Because this stressor category mingles with personality variables, the mere observation of a correlation does not prove that chronic stressors provoke health changes, although this might be the case. (5) Not one study rigorously examined the prospective hypothesis that past stressors (e.g., childhood victimization or pre-onset stressful incidents) may trigger RA or aggravate existing RA, which is a realistic belief for some patients.

Are there more than cross-sectional relationships of social support and support networks with functional limitations and psychological distress in early rheumatoid arthritis? The European Research on Incapacitating Diseases and Social Support Longitudinal

OBJECTIVE

To investigate whether greater social support and support network are cross-sectionally associated with less functional limitations and psychological distress in patients with early rheumatoid arthritis (RA); whether this association is constant over time; and whether increases in social support or support network are associated with less functional limitations and psychological distress.

METHODS

Subjects were from the European Research on Incapacitating Diseases and Social Support cohort and had early RA. Social support, support network, functional limitations (Health Assessment Questionnaire), and psychological distress (General Health Questionnaire) were assessed annually. Variance and covariance analyses with repeated measures were performed.

RESULTS

A total of 542 subjects were assessed for 3 years. On average, patients with a greater amount of specific social support or a stronger specific support network experienced less functional limitation and less psychological distress. Changes in a given subject's functional limitations and psychological distress did not depend on his or her baseline social support or support network. Neither social support nor support network change over time.

CONCLUSION

There may be a cross-sectional link between specific social support or support network and functional limitations and psychological distress, but no longitudinal association could be evidenced.

Stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis

OBJECTIVE

Stress-vulnerability factors were studied for their ability to predict long-term disease activity in early rheumatoid arthritis.

METHODS

In a prospective study involving 78 recently diagnosed rheumatoid arthritis (RA) patients, the role of personality characteristics (neuroticism, extraversion), physical and psychological stressors (chronic, disease-related stressors of functional disability, pain, disease impact on daily life, as well as major life events), coping and social support at the time of diagnosis was examined to predict changes in clinical indicators of disease activity 1, 3 and 5 years later.

RESULTS

While stress-vulnerability factors failed to predict disease activity at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis, after adjusting for disease activity at first assessment, other biomedical and psychosocial factors and use of medication. Low levels of social support predicted increased disease activity at the 3-year follow-up, and high avoidance coping predicted increased disease activity at the 3- and 5-year follow-ups.

CONCLUSION

Findings indicate the potential prognostic value of avoidance coping and social support for the long-term course of disease activity in early RA and suggest that the effects of these vulnerability factors predominantly operate in the long term.

Biopsychosocial mediators and moderators of stress-health relationships in patients with recently diagnosed rheumatoid arthritis

OBJECTIVE

To investigate the mediating and moderating roles of social support, coping, and physiological variables in the relationship between life events and health status.

METHODS

Psychological and biological measurements were taken in 54 patients (38 women, 16 men, mean age +/- SD 56 +/-14.4 years) with recently diagnosed rheumatoid arthritis (RA).

RESULTS

Life events were correlated with psychological distress, but not with disease activity. No mediators for the relationship of life events with psychological well-being and disease activity were observed. In 40 tests, 4 moderators were found: Problem-focused coping, perceived support, diastolic blood pressure, and total number of lymphocytes were moderators of the relationship between daily hassles and health status (P < or = 0.05).

CONCLUSION

Our study provides limited support for the notion that the interactions of life stress with biopsychosocial variables have an impact on health. None of these variables were found to be crucial mediators of stress-health associations in recently diagnosed patients with RA, but some provocative evidence was given that biopsychosocial variables may have a minor impact on stress-health relationships.

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis

OBJECTIVES

To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.

METHODS

Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.

RESULTS

In cluster analysis, a 2-cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.

CONCLUSIONS

The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

Quality of life measures: use and abuse

Health status and quality of life measures are widely used in the clinical assessment of rheumatoid and other forms of arthritis. A range of measures is available, mainly as self-administered instruments. Most of these are reliable, valid and sensitive to change. They can be used to assess clinical status, evaluate effectiveness in randomized trials, define outcome and help to plan for health-care needs for people with arthritis. The instruments form a continuum with assessments of disease activity and functional disability. Some instruments are specifically designed for use in rheumatoid arthritis, other instruments are generic and can be used across a range of conditions including arthritis, and some generic instruments can be specifically scored to reflect the problems most prominent in arthritis. There are trade-offs between simplicity and sensitivity and between using familiar and unusual instruments. Against this background, the most widely used disease-specific measure remains the health assessment questionnaire (HAQ), and the most commonly employed generic measure is the SF-36. Evidence currently suggests focusing on these well-known and widely used measures. In both cases, the pain score is the predominant clinical assessment associated with poor health status measured using either instrument. HAQ scores also reflect unchanging aspects of patients' overall status, such as their degree of deprivation. It is sensible for all future clinical trials to include one disease-specific and one generic measure of health status.

The links between joint damage and disability in rheumatoid arthritis

OBJECTIVE

The characteristic joint damage and disability of rheumatoid arthritis (RA) increase slowly over 10-20 yr. Although it is generally believed that persisting inflammatory synovitis causes joint damage and subsequent disability, the strength of their relationship has not been systematically evaluated. This review describes their progression and interrelationship in treated RA.

METHODS

MEDLINE and Current Contents databases were searched for the combined terms of rheumatoid arthritis AND X-rays, Health Assessment Questionnaire, slow-acting anti-rheumatic drugs and all identifiable synonyms. This search identified 1303 articles and from these we evaluated in detail 23 reports on the progression of joint damage, 12 reports on the progression of disability and 25 reports dealing with their interrelationship. Additional information was obtained from four data sets comprising 725 RA patients studied cross-sectionally and 33-126 cases followed prospectively for 1-5 yr. X-ray damage was primarily assessed by Larsen and Sharp indices, and disability by the Health Assessment Questionnaire (HAQ).

RESULTS

Joint damage and disability both increase throughout the duration of RA. Although disability (HAQ score) is correlated with disease duration (correlation coefficients between 0.27 and 0.30), the link between X-ray damage and disability is stronger (correlation coefficients between 0.30 and 0.70). In the earliest phases of RA, X-ray damage and HAQ scores are not related. By 5-8 yr, there are significant correlations with correlation coefficients between 0.30 and 0.50. In late RA (>8 yr), most studies show highly significant correlations between 0.30 and 0.70.

CONCLUSIONS

Joint damage progresses constantly over the first 20 yr of RA. It accounts for approximately 25% of disability in established RA. The link between damage and disability is strongest in late (>8 yr) RA. However, avoiding or reducing joint damage in both early and established/late RA is likely to maintain function.