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Mengi G, Aydoğmuş H, Özyemişçi Taşkıran Ö, Göğüş F, Beyazova M. Is it possible to objectively determine morning stiffness in rheumatoid arthritis? Turk J Phys Med Rehabil 2024; 70:180-187. [PMID: 38948637 PMCID: PMC11209333 DOI: 10.5606/tftrd.2024.12219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/07/2023] [Indexed: 07/02/2024] Open
Abstract
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.
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Affiliation(s)
- Gönen Mengi
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla, Türkiye
| | - Hüseyin Aydoğmuş
- Department of Physical Medicine and Rehabilitation, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla, Türkiye
| | - Özden Özyemişçi Taşkıran
- Department of Physical Medicine and Rehabilitation, Koç University, School of Medicine, Istanbul, Türkiye
| | - Feride Göğüş
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Mehmet Beyazova
- Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Türkiye
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da Silva Duarte G, Jones AD, de Goes Cavalcanti LP, de Melo Rêgo MJB, Ribeiro GS, Boyton RJ, Pereira DB, Croda JHR, Costa FTM, Duarte AP, Consolaro MEL, Stabeli RG, Negrão FJ, Proenca-Modena JL, Villalobos-Salcedo JM, da Rocha Castelar Pinheiro G, de Barros Albuquerque AP, de Almeida Barreto FK, Moreira J, Ferrari IC, Évora PM, da Silva VRS, Lacerda MVG, Altmann DM, Siqueira AM. Multicenter study of the natural history and therapeutic responses of patients with chikungunya, focusing on acute and chronic musculoskeletal manifestations - a study protocol from the clinical and applied research in Chikungunya (REPLICK network). BMC Infect Dis 2023; 23:499. [PMID: 37507666 PMCID: PMC10386654 DOI: 10.1186/s12879-023-08292-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/28/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Chikungunya is associated with high morbidity and the natural history of symptomatic infection has been divided into three phases (acute, post-acute, and chronic) according to the duration of musculoskeletal symptoms. Although this classification has been designed to help guide therapeutic decisions, it does not encompass the complexity of the clinical expression of the disease and does not assist in the evaluation of the prognosis of severity nor chronic disease. Thus, the current challenge is to identify and diagnose musculoskeletal disorders and to provide the optimal treatment in order to prevent perpetuation or progression to a potentially destructive disease course. METHODS The study is the first product of the Clinical and Applied Research Network in Chikungunya (REPLICK). This is a prospective, outpatient department-based, multicenter cohort study in Brazil. Four work packages were defined: i. Clinical research; ii) Translational Science - comprising immunology and virology streams; iii) Epidemiology and Economics; iv) Therapeutic Response and clinical trials design. Scheduled appointments on days 21 (D21) ± 7 after enrollment, D90 ± 15, D120 ± 30, D180 ± 30; D360 ± 30; D720 ± 60, and D1080 ± 60 days. On these visits a panel of blood tests are collected in addition to the clinical report forms to obtain data on socio-demographic, medical history, physical examination and questionnaires devoted to the evaluation of musculoskeletal manifestations and overall health are performed. Participants are asked to consent for their specimens to be maintained in a biobank. Aliquots of blood, serum, saliva, PAXgene, and when clinically indicated to be examined, synovial fluid, are stored at -80° C. The study protocol was submitted and approved to the National IRB and local IRB at each study site. DISCUSSION Standardized and harmonized patient cohorts are needed to provide better estimates of chronic arthralgia development, the clinical spectra of acute and chronic disease and investigation of associated risk factors. This study is the largest evaluation of the long-term sequelae of individuals infected with CHIKV in the Brazilian population focusing on musculoskeletal manifestations, mental health, quality of life, and chronic pain. This information will both define disease burden and costs associated with CHIKV infection, and better inform therapeutic guidelines.
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Affiliation(s)
- Giselle da Silva Duarte
- Laboratório de Pesquisa Clínica Em Doenças Febris Agudas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jose Moreira
- Laboratório de Pesquisa Clínica Em Doenças Febris Agudas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | | | | | - André M Siqueira
- Laboratório de Pesquisa Clínica Em Doenças Febris Agudas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
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3
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Boeth H, Biesen R, Hollnagel J, Herrmann S, Ehrig RM, Pelli L, Taylor WR, Duda GN, Buttgereit F. Quantification of morning stiffness to assess disease activity and treatment effects in rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:5282-5291. [PMID: 33822899 DOI: 10.1093/rheumatology/keab323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The clinical parameter of morning stiffness is widely used to assess the status of RA, but its accurate quantitative assessment in a clinical setting has not yet been successful. This lack of individual quantification limits both personalized medication and efficacy evaluation in the treatment of RA. METHODS We developed a novel technology to assess passive resistance of the MCP III joint (stiffness) and its passive range of motion (PRoM). Within this pilot study, 19 female postmenopausal RA patients and 9 healthy controls were examined in the evening as well as the morning of the following day. To verify the specificity of the biomechanical quantification, 11 patients with RA were assessed both prior to and ∼3 h after glucocorticoid therapy. RESULTS While the healthy controls showed only minor changes between afternoon and morning, in RA patients the mean PRoM decreased significantly by 18% (s.d. 22) and stiffness increased significantly by 20% (s.d. 18) in the morning compared with the previous afternoon. We found a significant positive correlation between RA activity and biomechanical measures. Glucocorticoids significantly increased the mean PRoM by 16% (s.d. 11) and reduced the mean stiffness by 23% (s.d. 22). CONCLUSION This technology allowed mechanical stiffness to be quantified in MCP joints and demonstrated high sensitivity with respect to disease status as well as medication effect in RA patients. Such non-invasive, low-risk and rapid assessment of biomechanical joint stiffness opens a novel avenue for judging therapy efficacy in patients with RA and potentially also in other non-RA inflammatory joint diseases.
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Affiliation(s)
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin
| | | | - Sandra Herrmann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin
| | - Rainald M Ehrig
- Julius Wolff Institute.,Zuse Institute Berlin, Berlin, Germany
| | | | - William R Taylor
- Eidgenössische Technische Hochschule Zürich, Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin
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Mok CC. Morning Stiffness in Elderly Patients with Rheumatoid Arthritis: What is Known About the Effect of Biological and Targeted Agents? Drugs Aging 2018; 35:477-483. [PMID: 29704191 DOI: 10.1007/s40266-018-0548-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects all age groups, but the prevalence appears to increase with age. Elderly-onset RA (after the age of 60 years) has distinct clinical patterns. Treatment of RA in older individuals is confounded by the presence of medical comorbidities, concurrent medications, drug interactions, and the altered pharmacokinetics and pharmacodynamics related to aging and organ dysfunction. Patients with RA commonly experience morning stiffness, which is associated with reduced quality of life and work disability. However, despite its importance, morning stiffness is seldom assessed in clinical practice and usually only its duration is measured in the research setting. Whether the intensity, timing, location and impact of this symptom should be assessed in future clinical trials requires further evaluation. The biologic and newer targeted synthetic disease-modifying anti-rheumatic drugs have been shown to be effective in reducing the duration of morning stiffness in patients with RA. Glucocorticoids are a double-edged sword in RA. Although they can effectively reduce inflammation and retard radiological damage (disease modifying), the long-term use of glucocorticoids is associated with numerous adverse effects. Thus, glucocorticoids should be used for short-term treatment of RA only. Night-time administration of glucocorticoids has been shown to alleviate morning stiffness and should be considered in patients with serious morning joint stiffness symptoms.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, New Territories, Hong Kong SAR, China.
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Halls S, Dures E, Kirwan JR, Pollock J, Baker G, Edmunds A, Hewlett S. Development and testing of candidate items for inclusion in a new rheumatoid arthritis stiffness patient-reported outcome measure. Rheumatology (Oxford) 2018; 57:263-272. [PMID: 28407140 DOI: 10.1093/rheumatology/kex085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Serena Halls
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - John R Kirwan
- School of Clinical Sciences, University of Bristol, UK
| | - Jon Pollock
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Gill Baker
- Rheumatology Department, Bristol Royal Infirmary, Bristol, UK
| | - Avis Edmunds
- Rheumatology Department, Bristol Royal Infirmary, Bristol, UK
| | - Sarah Hewlett
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Mok CC, Cha HS, Perez EC, Tsay GJ, Yoon KH. Dissonance between physicians’ and patients’ perspectives on managing impaired morning function in Asian patients with rheumatoid arthritis. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2017. [DOI: 10.1515/hkbrd-2017-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
To estimate the prevalence of impaired morning function (IMF) in rheumatoid arthritis (RA), and to understand physicians’ and patients’ perceptions on the impact of IMF and treatment in selected Asian countries.
Methods
A survey on the impact of IMF was conducted in Asia on rheumatologists and patients with moderate-to-severe RA who experienced IMF for ≥3 mornings a week. Participants underwent comprehensive face-to-face interviews using structured questionnaires.
Results
Sixty physicians and 300 patients from Hong Kong, Philippines, Singapore, South Korea, and Taiwan were surveyed. Rheumatologists estimated that two-thirds of patients with RA experienced IMF and believed that the prevalence of IMF increased with RA severity (present in 42%, 73%, and 87% of patients with mild, moderate, and severe disease, respectively). Patients’ survey revealed that, on an average, patients with RA experienced IMF 5 days a week for 2 h each day. Thirty-eight percent of patients with RA considered a reduction in morning stiffness as an important treatment goal, but this was agreed by only 3% of rheumatologists. Only 22% of rheumatologists modified the treatment regimen specifically for IMF. Physicians considered prednisolone and other glucocorticoids (GCs) to be the most effective medication for the treatment of IMF. Fifty-one percent of patients with RA did not find their current medication effective in relieving IMF, and as a result, they reported negative emotions such as frustration, defeat, and anger, and 56% had missed work because of this symptom.
Conclusions
IMF is prevalent in RA and significantly affects patients’ quality of life (QoL). A higher proportion of patients compared to physicians view the reduction of morning stiffness as an important goal. More should be done to address the dissonance between physicians’ and patients’ views on IMF.
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Affiliation(s)
| | | | - Emmanuel C Perez
- De La Salle University Medical Center, Health Science Institute , Dasmarinas City, Cavite , Philippines
| | - Gregory J Tsay
- China Medical University and China Medical University Hospital , Taichung , Taiwan
| | - Kam Hon Yoon
- El Shaddai Arthritis and Rheumatism Specialist Medical Centre , Gain city , Singapore
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Kobayashi Y, Ikeda K, Nakamura T, Yamagata M, Nakazawa T, Tanaka S, Furuta S, Umibe T, Nakajima H. Severity and Diurnal Improvement of Morning Stiffness Independently Associate with Tenosynovitis in Patients with Rheumatoid Arthritis. PLoS One 2016; 11:e0166616. [PMID: 27851825 PMCID: PMC5113064 DOI: 10.1371/journal.pone.0166616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/01/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although morning stiffness has long been recognized as a characteristic feature of rheumatoid arthritis (RA), it is no more included in the 2010 ACR/EULAR Classification Criteria or in the current major instruments for evaluating disease activity of RA. In this cross-sectional study, we aimed to determine the independent value and the optimal measurement of morning stiffness by clarifying the associations between morning stiffness and synovial inflammation. PATIENTS AND METHODS We enrolled 76 consecutive RA patients who underwent musculoskeletal ultrasound examination and agreed to participate in the study. In addition to asking the duration of morning stiffness, we asked patients to complete a diagram which represents the time course of their morning stiffness in the dominant hand. Based on this diagram, we calculated the severity and the diurnal improvement of morning stiffness. We also determined the activity of intra-articular synovitis in 11 joints and tenosynovitis in 8 tendons/tendon compartments in the same hand by using power Doppler (PD) ultrasound with a semiquantitative score (0-3). RESULTS For intra-articular synovitis, swollen/tender joint counts more strongly correlated with total PD scores (ρ = 0.379-0.561, p ≤ 0.001) than did any parameters of morning stiffness (ρ = 0.217-0.314, p = 0.006-0.021). For tenosynovitis, however, the severity on awakening and the improvement of morning stiffness more strongly correlated with total PD scores (ρ = 0.503-0.561, p < 0.001) than did swollen/tender joint counts (ρ = 0.276-0.388, p = 0.001-0.016). Multivariate analyses identified the severity on awakening and the improvement but not the duration of morning stiffness as factors that independently associate with the total tenosynovial PD score. CONCLUSIONS Our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and also give an insight into the optimal measurement of morning stiffness. Our data support an independent value of evaluating morning stiffness in the management of RA.
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Affiliation(s)
- Yoshihisa Kobayashi
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Rheumatology Center, Matsudo City Hospital, Matsudo, Chiba, Japan
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- * E-mail:
| | - Takayuki Nakamura
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, Asahi, Chiba, Japan
| | - Mieko Yamagata
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba, Japan
| | - Takuya Nakazawa
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, Allergy, and Clinical Immunology, National Hospital Organization Chiba-East Hospital, Chiba, Japan
| | - Shigeru Tanaka
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Takeshi Umibe
- Rheumatology Center, Matsudo City Hospital, Matsudo, Chiba, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
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Boers M, Buttgereit F, Saag K, Alten R, Grahn A, Storey D, Rice P, Kirwan J. What Is the Relationship Between Morning Symptoms and Measures of Disease Activity in Patients With Rheumatoid Arthritis? Arthritis Care Res (Hoboken) 2016; 67:1202-1209. [PMID: 25807939 DOI: 10.1002/acr.22592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 03/08/2015] [Accepted: 03/17/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | | | - K Saag
- Schlosspark-Klinik, University Medicine, Berlin, Germany
| | - R Alten
- University of Alabama, Birmingham
| | - A Grahn
- Horizon Pharma, Deerfield, Illinois
| | | | - P Rice
- Premier Research, Naperville, Illinois
| | - J Kirwan
- University of Bristol, Bristol, UK
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Mok CC, Cha HS, Hidayat R, Nguyen LTN, Perez EC, Ramachandran R, Tsay GJ, Yoo DH. The importance of assessment and management of morning stiffness in Asian patients with rheumatoid arthritis: Recommendations from an expert panel. Int J Rheum Dis 2015; 19:30-7. [DOI: 10.1111/1756-185x.12755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Chi Chiu Mok
- Department of Medicine; Tuen Mun Hospital; Hong Kong China
| | | | - Rudy Hidayat
- Dr Ciptomangunkusumo Hospital; Jakarta Indonesia
| | | | - Emmanuel C. Perez
- De la Salle University Medical Center; Health Science Institute; Cavite Philippines
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van Nies JAB, Alves C, Radix-Bloemen ALS, Gaujoux-Viala C, Huizinga TWJ, Hazes JMW, Brouwer E, Fautrel B, van der Helm-van Mil AHM. Reappraisal of the diagnostic and prognostic value of morning stiffness in arthralgia and early arthritis: results from the Groningen EARC, Leiden EARC, ESPOIR, Leiden EAC and REACH. Arthritis Res Ther 2015; 17:108. [PMID: 25904188 PMCID: PMC4445798 DOI: 10.1186/s13075-015-0616-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 04/02/2015] [Indexed: 01/21/2023] Open
Abstract
Introduction Morning stiffness is assessed daily in the diagnostic process of arthralgia and arthritis, but large-scale studies on the discriminative ability are absent. This study explored the diagnostic value of morning stiffness in 5,202 arthralgia and arthritis patients and the prognostic value in early rheumatoid arthritis (RA). Methods In arthralgia patients referred to the Early Arthritis Recognition Clinics (EARC) of Leiden (n = 807) and Groningen (n = 481) or included in the Rotterdam Early Arthritis Cohort (REACH) study (n = 353), the associations (cross-sectional analyses) between morning stiffness and presence of arthritis at physical examination were studied. In early arthritis patients, included in the Leiden Early Arthritis Clinic (EAC) (n = 2,748) and Evaluation et Suivi de POlyarthrites Indifférenciées Récentes (ESPOIR) (n = 813), associations with fulfilling the 2010-RA criteria after one year were assessed. In 2010-RA patients included in the EAC (n = 1,140) and ESPOIR (n = 677), association with the long-term outcomes of disease-modifying antirheumatic drug (DMARD)-free sustained remission and radiological progression were determined. Morning stiffness was defined as a duration ≥60 minutes; sensitivity analyses were performed for other definitions. Results In arthralgia, morning stiffness (≥60 minutes) associated with the presence of arthritis; Leiden EARC odds ratio (OR) 1.49 (95% CI 1.001 to 2.20), Groningen EARC OR 2.21 (1.33 to 3.69) and REACH OR 1.55 (0.97 to 2.47) but the areas under the receiver operating characteristic curve (AUCs) were low (0.52, 0.57, 0.54). In early arthritis, morning stiffness was associated with 2010-RA independent of other predictors (Leiden EAC OR 1.72 (95% CI 1.31 to 2.25, AUC 0.68), ESPOIR OR 1.68 (1.03 to 2.74, AUC 0.64)). Duration of ≥30 minutes provided optimal discrimination for RA in early arthritis. Morning stiffness was not associated with radiological progression or DMARD-free sustained remission. Conclusions Morning stiffness in arthralgia and early arthritis is associated with arthritis and RA respectively. This supports the incorporation of morning stiffness in the diagnostic process. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0616-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica A B van Nies
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZC, Leiden, the Netherlands.
| | - Celina Alves
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Audrey L S Radix-Bloemen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands.
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital; EA 2415, Montpellier I University, 4 Rue du Professeur Robert Debré, 30029, Nîmes, France.
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZC, Leiden, the Netherlands.
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands.
| | - Bruno Fautrel
- Department of Rheumatology, Université Pierre et Marie Curie Curie - Paris 6, GRC08, Institut Pierre Louis de d'Epidémiologie et Santé Publique, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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van Tuyl LHD, Lems WF, Boers M. Measurement of stiffness in patients with rheumatoid arthritis in low disease activity or remission: a systematic review. BMC Musculoskelet Disord 2014; 15:28. [PMID: 24476506 PMCID: PMC3914735 DOI: 10.1186/1471-2474-15-28] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 01/21/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Recent qualitative research has shown that stiffness is an important symptom for patients to identify remission. However, it is unclear how to measure stiffness in low disease activity. This systematic review aims to summarise the existing literature on validity of patient reported outcomes to measure stiffness in RA low disease activity states, to aid the choice for a measurement instrument. METHODS An extensive pubmed-search was undertaken, identifying measurement instruments for patient perceived stiffness used in low disease activity. Eligible studies reported on 1) stiffness as an outcome in relation to other core set measures, 2) development of a patient reported tool to measure stiffness, or 3) comparison of two different tools to measure aspects of stiffness, all in low disease activity. RESULTS Of 788 titles, only two studies report on validity of stiffness measures within low disease activity. Morning stiffness (MS) is reported in 44 to 80% of patients in low disease activity. A difference of 40 to 60 minutes in duration until maximum improvement is observed between active and inactive patients. Severity of MS might discriminate better between high and low disease activity compared to measurement of duration of MS. CONCLUSIONS There is insufficient data on measurement of stiffness in the spectrum of low disease activity or remission.
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Affiliation(s)
- Lilian HD van Tuyl
- Department of Rheumatology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Willem F Lems
- Department of Rheumatology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Maarten Boers
- Department of Rheumatology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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Dunlop W, Iqbal I, Khan I, Ouwens M, Heron L. Cost-effectiveness of modified-release prednisone in the treatment of moderate to severe rheumatoid arthritis with morning stiffness based on directly elicited public preference values. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:555-64. [PMID: 24204166 PMCID: PMC3816994 DOI: 10.2147/ceor.s47867] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Assessing the cost-effectiveness of treatments in rheumatoid arthritis (RA) is of growing importance due to the chronic nature of the disease, rising treatment costs, and budget-constrained health care systems. This analysis assesses the cost-effectiveness of modified-release (MR) prednisone compared with immediate-release (IR) prednisone for the treatment of morning stiffness due to RA. Methods A health state transition model was used to categorize RA patients into four health states, defined by duration of morning stiffness. The model applied a 1-year time horizon and adopted a UK National Health Service (NHS) perspective. Health benefits were measured in quality-adjusted life years (QALYs) and the final output was the incremental cost-effectiveness ratio (ICER). Efficacy data were derived from the CAPRA-1 (Circadian Administration of Prednisone in Rheumatoid Arthritis) study, drug costs from the British National Formulary (BNF), and utility data from a direct elicitation time-trade-off (TTO) study in the general population. Sensitivity analyses were conducted. Results Mean treatment costs per patient were higher for MR-prednisone (£649.70) than for IR-prednisone (£46.54) for the duration of the model. However, the model generated an incremental QALY of 0.044 in favor of MR-prednisone which resulted in an ICER of £13,577. Deterministic sensitivity analyses did not lead to significant changes in the ICER. Probabilistic sensitivity analysis reported that MR-prednisone had an 84% probability of being cost-effective at a willingness-to-pay threshold of £30,000 per QALY. The model only considers drug costs and there was a lack of comparative long-term data for IR-prednisone. Furthermore, utility benefits were not captured in the clinical setting. Conclusion This analysis demonstrates that, based on the CAPRA-1 trial and directly elicited public preference values, MR-prednisone is a cost-effective treatment option when compared with IR-prednisone for RA patients with morning stiffness over one year, according to commonly applied UK thresholds (£20,000–£30,000 per QALY). Further research into the costs of morning stiffness in RA is required.
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Affiliation(s)
- William Dunlop
- Mundipharma International Limited, Cambridge, United Kingdom
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13
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Phillips S, Dow L. Impact of impaired morning function on quality of life in rheumatoid arthritis: results of an exploratory patient survey. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.62] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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14
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Current World Literature. Curr Opin Rheumatol 2012; 24:342-9. [DOI: 10.1097/bor.0b013e328352d26c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Iqbal I, Dasgupta B, Taylor P, Heron L, Pilling C. Elicitation of health state utilities associated with differing durations of morning stiffness in rheumatoid arthritis. J Med Econ 2012; 15:1192-200. [PMID: 22804691 DOI: 10.3111/13696998.2012.712927] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Specific symptoms of rheumatoid arthritis (RA), including joint stiffness and functional disability, are most severe in the morning. 'Morning stiffness' has a negative impact on health-related quality-of-life (HRQoL); however, how HRQoL is correlated to morning stiffness duration is unknown. The objective of this study was to obtain population-based utility values associated with different durations of morning stiffness in RA. DESIGN AND METHODS The time-trade-off (TTO) approach was used to elicit utility values for four different health states (HS), which differed in morning stiffness duration. One hundred and nine members of the UK general public rated each HS in individual face-to-face interviews with trained investigators. TTO scores were converted into utility values. Visual Analog Scale (VAS) scores were obtained to validate TTO scores. RESULTS On a scale of 0 (death) to 1 (full health), a mean utility value of 0.45±0.29 was elicited for ∼3 h of morning stiffness (anchor HS), 0.50±0.28 for 2-3 h of morning stiffness (HS1), 0.61±0.25 for 1-2 h of morning stiffness (HS2) and 0.78±0.20 for <1 h of morning stiffness (HS3). The difference between each HS was statistically significant (p<0.01). Mean VAS utility scores followed the same trend. Utility incrementally increased with each HS associated with a shorter duration of morning stiffness. Limitations of this research include potential bias from the TTO method due to the discounting effect of time, scale compatibility, and loss aversion. CONCLUSIONS The UK population-based utility values show a reduction in morning stiffness duration in RA is associated with improved HRQoL. Despite the impact of morning stiffness on HRQoL, it is rarely evaluated and little is known as to how it is affected by current treatments. The results of this study can be applied in future cost-utility analyses of healthcare interventions which target an improvement in morning stiffness duration for RA patients.
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Affiliation(s)
- I Iqbal
- Mundipharma International Limited, Cambridge Science Park, Cambridge, UK.
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16
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Buttgereit F. How should impaired morning function in rheumatoid arthritis be treated? Scand J Rheumatol 2011; 125:28-39. [DOI: 10.3109/03009742.2011.566438] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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