Measurement of stiffness in patients with rheumatoid arthritis in low disease activity or remission: a systematic review

Is it possible to objectively determine morning stiffness in rheumatoid arthritis?

Objectives

This study aimed to objectively and quantitatively exhibit morning stiffness by using electrophysiological methods.

Patients and methods

The prospective, controlled study was conducted with 52 participants between February 2013 and February 2014. Of the participants, 26 were recruited among RA patients (3 males, 23 females; mean age: 55.9±11.2 years; range, 24 to 74 years) followed at the rheumatology clinic, and 26 were healthy subjects (4 males, 22 females; mean age: 54.9±8.3 years; range, 41 to 70 years) for the control group. Duration and severity of morning stiffness were recorded for all participants. Activity of disease and functional status were evaluated by the Disease Activity Score 28 and Health Assessment Questionnaire (HAQ), respectively. Electrophysiological reaction times, severity of pain (Visual Analog Scale), HAQ, and grip strength were measured for each participant twice in 24 h in the morning (08:00-09:00 am) and afternoon (03:00-05:00 pm).

Results

In the RA group, motor reaction and response times and severity of pain values were significantly lower in the afternoon compared to the morning (p=0.030, p=0.031, and p=0.002, respectively), and hand grip strengths were significantly higher in the afternoon (p=0.007). In the control group, no change was observed between morning and afternoon measurements in the strength and reaction time variables.

Conclusion

Our hypothesis that stiffness would slow down the movements in the morning in RA was supported by the prolonged motor and response times in the morning compared to the afternoon. However, in the control group (no morning stiffness), there was no difference in reaction time variables between the morning and afternoon, objectively demonstrating the concept of morning stiffness in this study.

Patient satisfaction, preferences, expectations, characteristics, and impact of suboptimal control of rheumatoid arthritis: A subgroup analysis of Japanese patients from a large international cohort study (SENSE)

OBJECTIVE

To evaluate treatment satisfaction, disease outcomes, and perspectives of patients with poorly controlled rheumatoid arthritis (RA) treated with conventional synthetic, targeted synthetic, or biologic disease-modifying antirheumatic drugs (DMARDs), we conducted a subgroup (post hoc) analysis of Japanese patients participating in the SENSE study.

METHODS

Data for Japanese patients (n/N = 118/1629) from the global, multicenter, cross-sectional, observational SENSE study were analyzed. The primary endpoint was the global satisfaction subscore assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM) version 1.4. Other patient-reported outcomes included self-reported RA medication adherence and Work Productivity and Activity Impairment-RA. Patient perspectives included patients' expectations and preference of pharmacologic treatment.

RESULTS

Median (range) age and RA disease duration were 67.0 (18.0-87.0) years and 8 (0.0-54) years, respectively; 81.4% of patients were female. Mean (SD) TSQM global satisfaction subscore was 56.8 (17.5), and only 5.9% of patients reported good satisfaction with treatment (TSQM global ≥80). Mean (SD) self-reported treatment adherence using VAS was high (93.5% [13.8%]). Mean (SD) total work productivity impairment was 45.6% (32.0%); presenteeism contributed toward more total work productivity impairment (43.9% [30.4%]) than absenteeism (8.3% [24.4%]). Patients expected improvement in all parameters from their treatment, especially improvement in joint symptoms. Most patients (80.7%) preferred oral medication and 18.7% preferred monotherapy. Patient acceptability of potentially manageable side effects was high (7.5%-34.0%). Although most patients (81.3%) found combination therapy acceptable, 43.2% were receiving DMARD monotherapy.

CONCLUSION

Although most Japanese patients with RA with moderate-to-high disease activity were dissatisfied with their current DMARD treatment, high treatment adherence, high acceptability of combination therapy, high acceptability of manageable potential side effects, and preference for oral medication were reported. Data support the development of a more individualized and patient-centric approach for RA treatment.

Ultrasound to identify systemic lupus erythematosus patients with musculoskeletal symptoms who respond best to therapy: the US Evaluation For mUsculoskeletal Lupus longitudinal multicentre study

OBJECTIVES

To determine whether SLE patients with inflammatory joint symptoms and US synovitis/tenosyovitis achieve better clinical responses to glucocorticoids compared with patients with normal scans. Secondary objectives included identification of clinical features predicting US synovitis/tenosynovitis.

METHODS

In a longitudinal multicentre study, SLE patients with physician-diagnosed inflammatory joint pain received intramuscular methylprednisolone 120 mg once. Clinical assessments, patient-reported outcomes and bilateral hand/wrist USs were collected at 0, 2 and 6 weeks. The primary outcome (determined via internal pilot) was the early morning stiffness visual analogue scale (EMS-VAS) at 2 weeks, adjusted for baseline, comparing patients with positive (greyscale ≥2 and/or power Doppler ≥1) and negative US. Post hoc analyses excluded FM.

RESULTS

Of 133 patients, 78 had a positive US. Only 53 (68%) of these had one or more swollen joint. Of 66 patients with one or more swollen joint, 20% had a negative US. A positive US was associated with joint swelling, symmetrical small joint distribution and serology. The primary endpoint was not met: in the full analysis set (N = 133) there was no difference in baseline-adjusted EMS-VAS at week 2 [-7.7 mm (95% CI -19.0, 3.5); P = 0.178]. After excluding 32 patients with FM, response was significantly better in patients with a positive US at baseline [baseline-adjusted EMS-VAS at 2 weeks -12.1 mm (95% CI -22.2, -0.1); P = 0.049]. This difference was greater when adjusted for treatment [-12.8 mm (95% CI -22, -3); P = 0.007]. BILAG and SLEDAI responses were higher in US-positive patients.

CONCLUSION

In SLE patients without FM, those with a positive US had a better clinical response to therapy. Imaging-detected synovitis/tenosynovitis may be considered to decide on therapy and enrich clinical trials.

Development and Validity Testing of a Morning Stiffness Assessment Scale for Patients with Rheumatoid Arthritis

Morning stiffness is known to exert a significant impact on functional ability, quality of life, and employment status. There is an increasing need for a valid, reliable tool to comprehensively assess morning stiffness. The purpose of this study was to develop and verify a Morning Stiffness Assessment Scale. Items were developed on the basis of a framework of the conceptual attributes of morning stiffness. Validity and reliability tests were conducted on the devised scale. Eighty-five patients with rheumatoid arthritis were included to verify the devised scale. A 10-item Morning Stiffness Assessment Scale was developed. Its content and construct validities were well supported. The scale was found to have good reliability. The devised scale is simple and brief, but it provides a more comprehensive means of evaluation for morning stiffness. We believe this scale offers a clinically useful means of properly assessing morning stiffness and has potential utility for evaluating the effects of morning stiffness treatments.

Musculoskeletal stiffness is common in healthy adults and increases with age

INTRODUCTION/OBJECTIVE

Musculoskeletal stiffness is a common feature in rheumatologic inflammatory diseases but little is known about background joint stiffness in the healthy population. The aim of this survey was to determine the variation in musculoskeletal stiffness with age in a cohort of healthy adults using a patient reported outcome instrument designed to assess stiffness in rheumatoid arthritis.

METHODS

Healthy subjects ≥18 years old were enrolled at two sites. Those with a diagnosis of rheumatological disease were excluded. Each subject completed a 21-item questionnaire designed to evaluate the severity of musculoskeletal stiffness, its physical impact and psychosocial impact, and to provide an overall stiffness score, expressed as a percentage. Scores were analyzed by age group.

RESULTS

Two hundred eighty-two subjects were included with a mean age of 42 years (±17, range 18-85). More than 50% of subjects reported stiffness in each age group but with a low median overall stiffness score of 5.4% (IQR 0, 12.6). Scores were markedly higher in those aged ≥60 years, median 10.0% (IQR 2.6, 21.9), and only in this age group did the majority of subjects report a physical or psychosocial impact of stiffness. Scores in males and females were similar.

CONCLUSION

The prevalence of musculoskeletal stiffness in healthy subjects of all ages is not negligible, and the high frequency of stiffness and greater severity in the upper age cohort suggest that the background joint stiffness amongst older subjects should be considered when interpreting stiffness in rheumatologic patients.

Contribution of tenosynovitis of small joints to the symptom morning stiffness in patients presenting with undifferentiated and rheumatoid arthritis

Objective: Morning stiffness (MS) is characteristic of rheumatoid arthritis (RA). Despite its association with functional disability, the extent to which local inflammatory processes contribute to this symptom is unknown. Magnetic resonance imaging (MRI)-detected tenosynovitis of small joints is recognized as an early feature of RA, which is also associated with functional impairments. It has been proposed that tenosynovitis contributes to MS. Therefore, we assessed the relationship between MS and MRI-detected inflammation, in particular tenosynovitis.Method: In total, 286 consecutive patients newly presenting with undifferentiated arthritis and RA underwent contrast-enhanced 1.5 T MRI of (2-5) metacarpophalangeal, wrist, and (1-5) metatarsophalangeal joints. Scans were scored for tenosynovitis according to Haavardsholm, and for synovitis by Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS). MS was dichotomized as ≥ 60 min or not. Associations between MS and tenosynovitis/synovitis were tested with logistic regression, data were categorized (solitary or simultaneous presence of synovitis/tenosynovitis), and the presence of an additive interaction was assessed.Results: MS was present in 40% of patients. Tenosynovitis was more often present in patients with MS than without MS [80% vs 65%, odds ratio (OR) 2.11, 95% confidence interval (1.21;3.69)]. Synovitis was more often present in patients with MS [58% vs 44%, OR 1.79 (1.11;2.91)]. In categorized analyses, concurrent synovitis and tenosynovitis had the largest association [OR 2.43 (1.30;4.54)], in contrast to solitary synovitis [OR 0.85 (0.21;3.47)]. The additive interaction was non-significant. The variance explained in all analyses was small (range 4-5%).Conclusion: Tenosynovitis, combined with synovitis, at small joints is associated with MS and contributes to the pathophysiology of MS.

Factors Associated With Hand and Upper Arm Functional Disability in People With Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

This original systematic review aimed to summarize evidence within observational studies on the factors associated with hand functional disability in adults with rheumatoid arthritis (RA).

METHODS

A rigorous extensive systematic literature search was conducted in 6 medical databases for peer-reviewed English language observational studies that explore the factors associated with hand function for people with RA. Factors were critically classified under the domains of the International Classification of Functioning, Disability and Health (ICF) framework and health-related factors. The methodologic quality was determined using the appraisal tool for cross-sectional studies. Factors related to hand function that were investigated in ≥2 studies were explored using a best-evidence synthesis.

RESULTS

Twenty articles from 1,271 citations met the inclusion criteria. All presented cross-sectional data (5 high-quality and 15 low-quality articles), resulting in limited evidence in the best-evidence synthesis. For the factors classified under the ICF domains, the best-evidence synthesis indicated that a diverse range of positive and negative factors were associated with hand function. However, key factors were hand strength, disease activity, and pain intensity. It is evident that few sociodemographic factors have been explored for the association with hand function.

CONCLUSION

Although the level of evidence was limited, modifiable factors such as grip strength, disease activity, and pain were identified as the most influential factors on hand function in people with RA. The findings of the present review indicate that important sociodemographic factors that impact hand function in individuals with RA have not yet been considered or reported in clinical research.

Advancing Stiffness Measurement in Rheumatic Disease: Report from the Stiffness Special Interest Group at OMERACT 2018

OBJECTIVE

To improve measurement of stiffness in rheumatic disease.

METHODS

Data presented included (1) 2 qualitative projects, (2) the rheumatoid arthritis (RA) stiffness patient-reported outcome measure (RAST), and (3) 3 items assessing stiffness severity, duration, and interference.

RESULTS

Stiffness is multidimensional and includes aspects of stiffness experience such as duration, severity, and effect. Stiffness items showed construct validity in RA. Further efforts are required to develop an instrument that will be taken through the Outcome Measures in Rheumatology (OMERACT) Filter 2.1 for instrument selection.

CONCLUSION

The research agenda for the group includes domain content voting for individual diseases, and development of stiffness item banks and disease-specific short forms.

Investigating Dimensions of Stiffness in Rheumatoid and Psoriatic Arthritis: The Australian Rheumatology Association Database Registry and OMERACT Collaboration

OBJECTIVE

It is not known how the experience of stiffness varies between diagnoses or how best to measure stiffness. The aims of our study were to (1) compare stiffness in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) using patient-reported outcomes, (2) investigate how dimensions of stiffness are associated with each other and reflect the patient experience, and (3) analyze how different dimensions of stiffness are associated with physical function.

METHODS

An online survey was sent to Australian Rheumatology Association Database participants (158 PsA, and 158 age- and sex-matched RA), assessing stiffness severity, duration, impact, importance, coping, and physical function [modified Health Assessment Questionnaire (mHAQ)]. Scores were compared between diagnoses and correlations among stiffness dimensions calculated. Multivariate regression was performed for stiffness severity, impact, and duration on mHAQ, adjusting for age, sex, disease duration, obesity, and pain. Cognitive debriefing was conducted through semistructured telephone interviews.

RESULTS

Overall, 240/316 (75.9%) responded [124/158 RA (78.5%) and 116/158 PsA (73.4%)], with no significant difference in stiffness ratings between diagnoses. Scores for all stiffness dimensions were strongly correlated (r = 0.52-0.89), and severity and impact were associated with mHAQ in both diagnoses. Stiffness duration was not associated with mHAQ in RA. In cognitive debriefing, participants described stiffness severity and impact by their effect on daily activities (10/16 and 14/16 participants, respectively).

CONCLUSION

Stiffness ratings were similar between PsA and RA. Different dimensions of stiffness were strongly correlated. Stiffness severity and impact both independently predicted mHAQ. Stiffness was important to participants; however, measuring multiple dimensions of stiffness may have minimal additive value.

Development and testing of candidate items for inclusion in a new rheumatoid arthritis stiffness patient-reported outcome measure

Objective

To qualitatively develop and test a set of candidate items for a new RA stiffness patient-reported outcome measure (PROM) that capture the patient perspective. This is an essential first step in PROM development, prior to quantitative development, assessment and validation.

Methods

Focus groups further examined the previously developed stiffness conceptual model and explored the patient perspective regarding stiffness assessment. Data were analysed using thematic analysis. An iterative process of item development was then performed by the expert study team of researchers, patients and clinicians, based on the two qualitative datasets and informed by measurement theory and guidelines. Finally, these candidate items were tested using formal cognitive interview methodology and subsequently refined.

Results

Sixteen RA patients from the UK participated in focus groups. Data confirmed the conceptual model of the RA patient experience of stiffness and provided insight into stiffness assessment, including suggestions regarding patient-relevant stiffness assessment categories such as impact, location and timing. These data informed the development of 77 candidate stiffness PROM items, including multiple formats for some. Eleven RA patients participated in cognitive interviews. Minor changes were made to items to enhance understanding and 32 items were removed, resulting in 45 candidate PROM items.

Conclusion

Rigorous qualitative methodology and considerable patient involvement has underpinned items for a new RA stiffness PROM with strong content validity. Crucially, patient involvement broadened assessment beyond early morning stiffness duration, which may address existing PROM limitations. Items are now suitable for quantitative item reduction, structural development of the final PROM and validation.

Local weather is associated with rates of online searches for musculoskeletal pain symptoms

Weather conditions are commonly believed to influence musculoskeletal pain, however the evidence for this is mixed. This study aimed to examine the relationship between local meteorological conditions and online search trends for terms related to knee pain, hip pain, and arthritis. Five years of relative online search volumes for these terms were obtained for the 50 most populous cities in the contiguous United States, along with corresponding local weather data for temperature, relative humidity, barometric pressure, and precipitation. Methods from the climate econometrics literature were used to assess the casual impact of these meteorological variables on the relative volumes of searches for pain. For temperatures between -5°C and 30°C, search volumes for hip pain increased by 12 index points, and knee pain increased by 18 index points. Precipitation had a negative effect on search volumes for these terms. At temperatures >30°C, search volumes for arthritis related pain decreased by 7 index points. These patterns were not seen for pain searches unrelated to the musculoskeletal system. In summary, selected local weather conditions are significantly associated with online search volumes for specific musculoskeletal pain symptoms. We believe the predominate driver for this to be the relative changes in physical activity levels associated with meteorological conditions.

The Use of patient Reported Outcome Measures for Rheumatoid Arthritis in Japan: A Systematic Literature Review

Background:

Patient-reported outcomes (PRO) obtained through routine medical care may identify patients’ day-to-day burden and help tackle the disease from the patients’ perspective. However, there is a paucity of information regarding the availability of PRO data and PRO tools for rheumatoid arthritis (RA) in Japan.

Objective:

We reviewed the literature on PRO data availability and to identify PRO measures implemented in Japan for RA patients.

Method:

We conducted a systematic literature review using ICHUSHI and the PubMed databases on PRO measures for RA published from January 2011 to August 2015 in Japan.

Results:

After removing duplicates, 2423 manuscripts were found. From these, 100 manuscripts were included for review and analysis. We found 29 PRO tools that were used to assess various domains of health such as general well-being, pain, functionality, and fatigue. More than 90% of the studies utilized PRO tools for research purpose. Only one study reported PRO tool implementation in the routine medical care.

Conclusion:

The importance of PROs is recognized in Japan. PRO tools varied significantly and were mostly used for research purposes, while reports on the use of PRO measures in routine medical care were limited. Despite the awareness of PROs in the research community, unmet needs remain among RA patients in Japan. Further work is needed to investigate ways in which PROs can better reflect these unmet needs and be utilized in routine medical care.

Stiffness Is the Cardinal Symptom of Inflammatory Musculoskeletal Diseases, Yet Still Variably Measured: Report from the OMERACT 2016 Stiffness Special Interest Group

Objective.

The objectives of the Outcome Measures in Rheumatology (OMERACT) Stiffness special interest group (SIG) are to characterize stiffness as an outcome in rheumatic disease and to identify and validate a stiffness patient-reported outcome (PRO) in rheumatology.

Methods.

At OMERACT 2016, international groups presented and discussed results of several concurrent research projects on stiffness: a literature review of rheumatoid arthritis (RA) stiffness PRO measures, a qualitative investigation into the RA and polymyalgia rheumatica patient perspective of stiffness, data-driven stiffness conceptual model development, development and testing of an RA stiffness PRO measure, and a quantitative work testing stiffness items in patients with RA and psoriatic arthritis.

Results.

The literature review identified 52 individual stiffness PRO measures assessing morning or early morning stiffness severity/intensity or duration. Items were heterogeneous, had little or inconsistent psychometric property evidence, and did not appear to have been developed according to the PRO development guidelines. A poor match between current stiffness PRO and the conceptual model identifying the RA patient experience of stiffness was identified, highlighting a major flaw in PRO selection according to the OMERACT filter 2.0.

Conclusion.

Discussions within the Stiffness SIG highlighted the importance of further research on stiffness and defined a research agenda.

What Is the Relationship Between Morning Symptoms and Measures of Disease Activity in Patients With Rheumatoid Arthritis?

OBJECTIVE

Little is known about the relationship between morning symptoms of rheumatoid arthritis (RA) and measures of disease activity currently used to assess RA. Information available from the Circadian Administration of Prednisone in Rheumatoid Arthritis (CAPRA-2) study was used to investigate these relationships.

METHODS

CAPRA-2 included 350 patients with RA who were symptomatic despite treatment with disease-modifying antirheumatic drugs, randomized 2:1 to additional treatment with a 5-mg daily dose of delayed-release prednisone or placebo. Pearson's correlations were used to evaluate the relationships between change from baseline in symptoms (duration of morning stiffness, severity of morning stiffness, and intensity of pain on waking) and measures of disease activity (the American College of Rheumatology 20% improvement criteria [ACR20], the Disease Activity Score in 28 joints [DAS28], and the Health Assessment Questionnaire disability index). Correlations were defined as weak (<0.3), moderate (0.3-0.7), or strong (>0.7).

RESULTS

There was a strong correlation between the severity of morning stiffness and the intensity of morning pain (Pearson's correlation 0.91, P < 0.001). There was a weak correlation between the duration of morning stiffness and measures of disease activity (0.24-0.28), with moderate correlations between the severity of morning stiffness or intensity of pain on waking and DAS28 or ACR20 scores (0.44-0.48). Severity of morning stiffness showed less variability and a greater effect size than did duration of morning stiffness.

CONCLUSION

Morning symptoms and measures of disease activity show weak to moderate correlations. Severity of morning stiffness showed less variability and greater effect size than did duration of morning stiffness. These findings suggest that severity is the preferred construct to measure the impact of morning stiffness in patients with RA, information that is not fully captured in the RA core set.

Factors that influence fatigue status in patients with severe rheumatoid arthritis (RA) and good disease outcome following 6 months of TNF inhibitor therapy: a comparative analysis

The objective of the present study is to determine the factors associated with persistent fatigue in patients with severe rheumatoid arthritis (RA) and good disease response to 6 months of tumour necrosis factor inhibitor therapy. Eligible patients with either persistent (PF) or no fatigue (NF) were compared. Using validated questionnaires and bivariate analysis, this cross-sectional survey explored if clinical characteristics, pain, self-efficacy, sleep and mood/depression differed between groups. Patients with PF (PF; NF) (n = 28; 28) reported significantly more overall pain (11.3 ± 9.4 (0–33); 6.9 ± 8.9 (0–33)), more recent and current pain intensity (41.4 ± 26.6 (0–80) 24.4 ± 26.6 (0–100) and depression (11.8 ± 7.5 (1–35); 8.2 ± 6.6 (0–26)), than the NF group. There was no significant difference between groups in self-efficacy and both groups experienced poor sleep quality (Pittsburgh Sleep Quality Index >5). Despite having good disease response, the PF group had significantly higher rheumatoid factor incidence, disease activity score-28, early morning stiffness duration and lower incidence of ever-failing disease-modifying anti-rheumatic drugs than the NF group. These findings enhance the fatigue literature in patients with RA prescribed tumour necrosis factor (TNF) inhibition therapy, identifying the potentially modifiable factors of pain and depression, previously demonstrated to be strongly associated with fatigue in non-biologic populations. In addition, this study highlights the association between persistent fatigue and an on-going state of low disease activity. This infers that more judicious disease management could minimise the symptom burden of pain and depression and consequentially fatigue.

The quality of systematic reviews of health-related outcome measurement instruments

BACKGROUND

Systematic reviews of outcome measurement instruments are important tools for the selection of instruments for research and clinical practice. Our aim was to assess the quality of systematic reviews of health-related outcome measurement instruments and to determine whether the quality has improved since our previous study in 2007.

METHODS

A systematic literature search was performed in MEDLINE and EMBASE between July 1, 2013, and June 19, 2014. The quality of the reviews was rated using a study-specific checklist.

RESULTS

A total of 102 reviews were included. In many reviews the search strategy was considered not comprehensive; in only 59 % of the reviews a search was performed in EMBASE and in about half of the reviews there was doubt about the comprehensiveness of the search terms used for type of measurement instruments and measurement properties. In 41 % of the reviews, compared to 30 % in our previous study, the methodological quality of the included studies was assessed. In 58 %, compared to 55 %, the quality of the included instruments was assessed. In 42 %, compared to 7 %, a data synthesis was performed in which the results from multiple studies on the same instrument were somehow combined.

CONCLUSION

Despite a clear improvement in the quality of systematic reviews of outcome measurement instruments in comparison with our previous study in 2007, there is still room for improvement with regard to the search strategy, and especially the quality assessment of the included studies and the included instruments, and the data synthesis.

Two new inflammatory markers associated with Disease Activity Score-28 in patients with rheumatoid arthritis: neutrophil-lymphocyte ratio and platelet-lymphocyte ratio

AIM

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease with unknown etiology and systemic involvement. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are two new inflammatory markers used in the assessment of systemic inflammation. The aim here is to study NLR and PLR in patients with RA to investigate their relation with Disease Activity Score of 28 joints (DAS-28).

METHODS

The study included 104 patients with RA and a control group of 51 age- and gender-matched healthy subjects. We divided the patients into two groups according to the DAS-28 score. Group 1 included patients with a score of lower than 2.6 by the DAS-28 (patients in remission) and Group 2 included patients with a score of 2.6 and higher (patients with active disease).

RESULTS

NLR was 2.12 ± 0.83 in the patient group and 1.58 ± 0.57 in the control group. PLR was 136.50 ± 53.52 in the patient group and 114.84 ± 29.41 in the control group. There was a statistically significant difference in NLR and PLR between the patient and control groups (P ≤ 0.0001 and P = 0.001, respectively). Patients in Group 1 had an NLR of 1.84 ± 0.61 and a PLR of 119.25 ± 41.77. Patients in Group 2 had an NLR of 2.29 ± 0.90 and a PLR of 147.28 ± 56.96. There was a statistically significant difference in NLR and PLR between the two groups (P = 0.003 and P = 0.005 respectively). A correlation was observed between NLR and PLR by DAS-28 (r = 0.345, P ≤ 0.0001 and r = 0.352, P ≤ 0.0001, respectively).

CONCLUSIONS

The present study showed us that NLR and PLR were two new inflammatory markers which could be used to assess disease activity in patients with RA.

Stiffness is more than just duration and severity: a qualitative exploration in people with rheumatoid arthritis

OBJECTIVE

Stiffness is internationally recognized as an important indicator of inflammatory activity in RA but is poorly understood and difficult to measure. The aim of this study was to explore the experience of stiffness from the patient perspective.

METHODS

Semi-structured interviews conducted with 16 RA patients were analysed independently by researchers and pat.ient partners using inductive thematic analysis.

RESULTS

Six themes were identified. Part of having RA identified stiffness as a normal consequence of RA, perceived as associated with disease-related aspects such as fluctuating disease activity, other RA symptoms and disease duration. Local and widespread highlighted stiffness occurring not only in joints, but also over the whole body, being more widespread during the morning or flare. Linked to behaviour and environment illustrated factors that influence stiffness, including movement, medications and weather. Highly variable captured the fluctuating nature of stiffness within and between patients and in relation to temporality, duration and intensity. Impacts on daily life emphasized the effect of stiffness on a range of domains, including physical function, quality of life, psychological well-being, activities of daily living and participation in work and leisure activities. Requires self-management detailed self-management strategies targeting both the symptom and its consequences.

CONCLUSION

Patients' experiences of stiffness were varied, complex and not exclusive to the morning period. Importantly, stiffness was reported in terms of impact rather than the traditional measurement concepts of severity or duration. Based on these findings, further research is needed to develop a patient-centred measure that adequately reflects inflammatory activity.