Education in the management of juvenile chronic arthritis. Changes in self-reported competencies among adolescents and parents of young children

OBJECTIVE

The purpose was to evaluate changes in self-reported competencies following an education program among parents of children with juvenile chronic arthritis (JCA) and among adolescents with JCA.

METHODS

The self-reported, 24-item MEPS questionnaire was used for evaluating the program. Fifty-five parents and 11 adolescents completed the questionnaire before, directly after, and four months after the eight-hour program.

RESULTS

Parents in the education program improved significantly concerning their self-reported competencies on medical, exercise, pain and social support issues, while the adolescents showed only minor improvement. The parents' positive development in some comparisons was also significant in relation to that of a non-educated group, whose responses remained mainly unchanged over the four months.

CONCLUSION

Given the advantages of the education program indicated in the study, parent education should be a self-evident part of the treatment in JCA.

Variability of forces applied by experienced physiotherapists during provocation of the sacroiliac joint

OBJECTIVE

To evaluate the distribution of total force vector and force components intended for the right and left sacroiliac joint, respectively, during pain-provocation sacroiliac joint tests.

DESIGN

Two force plates, each capable of sensing three orthogonal forces, were used in a descriptive study to assess force.

BACKGROUND

Studies evaluating the reliability of sacroiliac joint tests have revealed conflicting results and to our knowledge, no studies have evaluated the distribution of forces and their variations.

METHODS

Fifteen physiotherapists, experienced in musculoskeletal therapy, performed the distraction test and pressure on apex sacralis on the same healthy person on two occasions.

RESULTS

In both tests, the total force vector was less on the force plate closer to the physiotherapist. The vertical force component dominated and was considerably greater than the lateral (examined person supine/prone). The caudal/cranial force component was small. Systematic differences were found for the total force vector and for the lateral and vertical force components between occasions and/or between the force plates.

CONCLUSIONS

The consistency of total force vector and force components was incomplete within and between physiotherapists and between occasions. Relevance. The results indicate that forces have to be investigated as the questions still arise of whether the variation in force distribution has any importance in pain response, whether force registration could be a useful pain evaluation instrument, and whether force registration could be a step towards standardising pain-provocation sacroiliac joint tests.

The safety of a resistive home exercise program in patients with recent onset active polymyositis or dermatomyositis

The objective was to investigate whether a 12-week resistive home exercise program in addition to conventional medical treatment could be safely performed regarding muscle inflammation, muscle function, and quality of life in patients with active polymyositis (PM) or dermatomyositis (DM). Eleven patients diagnosed with active PM or DM were included. Muscle biopsies and Magnetic Resonance Imaging (MRI) of the thighs were performed. Quality of life, function, and subjective global disease impact (SGDI) were assessed and creatine phosphokinase levels (CPK) were analysed. The patients exercised with the exercise program for 15 minutes and took a 15-minute walk five days a week for 12 weeks. After the exercise period there was no sign of increased muscle inflammation. The group showed significantly improved function and quality of life compared to the start of study. It seems that this exercise program safely can be employed in patients with active PM or DM, and we suggest that physical exercise should be included in the rehabilitation of these patients.

Reliability and validity of a Swedish version of the Revised Leeds Disability Questionnaire for patients with ankylosing spondylitis

The aim of the study was to investigate the reliability and the validity of a Swedish version of the Revised Leeds Disability Questionnaire (RLDQ). Forty-two patients, 36 men and 6 women, median age 52.5 years, median symptom duration 24 years, with spondylarthropathy were assessed with the RLDQ, three questions on the content of the questionnaire, and range-of-motion measures. The results indicated satisfactory test-retest stability and internal consistency, and only minor internal redundancy. RLDQ items were generally considered relevant and suggested additions were similar to items already included in the questionnaire. Patients with low disability scores tended to be older and have better joint mobility than those with higher scores. Physiotherapists observed and scored disability significantly higher than patients. Correlations between subscores of the RLDQ and range-of-motion measures were in the main weak. In conclusion the Swedish version of the RLDQ may be considered as reliable and valid.

The Swedish version of the Bath ankylosing spondylitis disease activity index. Reliability and validity

The aim of the study was to investigate the reliability and the validity of the Swedish version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). A total of 113 patients with ankylosing spondylitis were assessed with the BASDAI, the Swedish version of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), the Bath Ankylosing Spondylitis Patient Global Score (BAS-G), and a questionnaire on their opinions of the relevance of the BASDAI. The test-retest stability investigation of the BASDAI over 24 hours did not show any difference between the two occasions (md 4.4, range 0.80-8.43 vs md 4.0, range 0-7.80, p > 0.05). The correlation coefficient between the BASDAI and the BASMI was r(s) = 0.07, between the BASDAI and the BASFI r(s) = 0.64, and between the BASDAI and the BAS-G r(s) = 0.80. Eighty percent of the patients considered the contents of the BASDAI to be relevant. The BASDAI, the BAS-G and the BASMI showed significant improvements after an intensive rehabilitation period. In conclusion the results of the present study indicate that the Swedish BASDAI is reliable and valid.

The Swedish version of the Bath ankylosing spondylitis functional index. Reliability and validity

The aim of the study was to investigate the reliability and the validity of the Swedish version of the Bath Ankylosing Spondylitis Functional Index (BASFI). A total of 113 patients were assessed with the BASFI, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), and the Bath Ankylosing Spondylitis Patient Global Score (BAS-G). The median BASFI scores on two occasions within 24 hours were 3.6 versus 3.7 (p>0.05). The patients found the BASFI items relevant. The median self-reported and physiotherapist-observed BASFI scores were 3.4 and 2.8 respectively (p>0.05). The correlation coefficient between the BASFI and the BASMI was r(s)=0.55, between the BASFI and the BASDAI r(s)=0.68, and between the BASFI and the BAS-G r(s)=0.67. Significant improvements between the pre- and post-training results for both the BASFI (3.1 vs 2.0, p<0.001) and the BASMI (3.0 vs 1.0, p<0.001) were found after three weeks' inpatient rehabilitation. The results indicated that the Swedish BASFI is reliable and valid.

Perceived ability to manage juvenile chronic arthritis among adolescents and parents: development of a questionnaire to assess medical issues, exercise, pain, and social support

OBJECTIVE

To develop a questionnaire to assess perceived ability to manage juvenile chronic arthritis (JCA) among adolescents and parents.

METHODS

The questionnaire contained 24 (parents' version) and 23 (adolescents' version) questions accompanied by visual analog scales in the areas of knowledge, skill, behavior, attitudes, and self-efficacy. One hundred seven persons participated in the examination of validity and 25 in the examination of test-retest reliability.

RESULTS

Factor analyses indicated that the questionnaire, now termed the MEPS (abbreviation for "medical issues, exercise, pain, and social support") questionnaire, contained 4 underlying dimensions: medical issues, exercise, pain, and social support, including 9, 4, 7, and 4 questions, respectively. The content of the questionnaire was judged mainly to be easily understood, relevant, and exhaustive. Intraclass correlation coefficients for the test-retest reliability of the questionnaire answers over a week ranged from 0.68 to 0.96 for single questions.

CONCLUSION

The MEPS questionnaire appears to be a valid and reliable tool for assessing the perceived ability to manage JCA. Whether it is sufficiently responsive to interventions remains to be investigated.

Exercise and variations in neuropeptide concentrations in rheumatoid arthritis

The aim of the present study was to investigate the influence of an exercise program on neuropeptide concentrations, disease activity, impairments and disabilities in rheumatoid arthritis (RA). Eleven females (median age 60 years, median disease duration 6.5 years, ARA functional classes I or II) exercised 30 min daily for 4 weeks. The urine concentrations of calcitonin gene-related peptide-like immunoreactivity (CGRP-LI) and neuropeptide Y-like immunoreactivity (NPY-LI) were analyzed 1 week prior to exercise start, at exercise start, after 2 and 4 weeks of exercise, and after a 4-week follow-up period. Measurements of disease activity, aerobic capacity, grip force, limb muscle function, and activities of daily living (ADL) were also undertaken. The results indicate a decrease (md 5.64 pM to md 3.48 pM, P</=0.05) of CGRP-LI concentrations after 4 weeks' exercise. NPY-LI concentrations remained unchanged, as did disease activity and aerobic capacity. Muscle function and ADL capacity improved significantly (P</=0.05) after the exercise period. Only the improved grip force remained after the follow-up period. In conclusion the results indicate that decreased CGRP-LI concentration, probably reflecting a decreased sympathetic tone, follows physical exercise and suggest that regular physical activity might be important among individuals with RA to maintain a decreased sympathetic tone and less symptoms from their disease.

Safety of a home exercise programme in patients with polymyositis and dermatomyositis: a pilot study

OBJECTIVES

To investigate whether a home exercise programme could safely be performed by patients with stable, inactive polymyositis (PM) and dermatomyositis (DM), regarding disease activity, muscle function, health status and pain.

METHODS

Ten patients with reduced muscle function completed the study. A home exercise programme including exercises for strength in the upper and lower limbs, neck and trunk, for mobility in the upper limbs and moderate stretching was developed. The patients exercised for 15 min and took a 15 min walk 5 days a week during a 12 week period. Assessments included clinical evaluation of disease activity, serum creatinine phosphokinase (CPK) levels, magnetic resonance imaging (MRI) of the quadriceps, repeated muscle biopsy of the vastus lateralis, a muscle function index (FI), a walking test and a health status instrument (the SF 36) performed at the start of the study and after 12 weeks.

RESULTS

After 12 weeks of exercise, there were no signs of increased disease activity as assessed clinically, by CPK values, MRI or muscle biopsy findings. On an individual basis, all patients improved regarding muscle function according to the FI, in six cases the improvement reached statistical significance (P < 0.05). A significant improvement regarding muscle function in the upper and lower limbs, walking distance and general health status was achieved.

CONCLUSIONS

Our results indicate that this home exercise programme can be safely employed in patients with stable, inactive PM and DM, with beneficial effects on muscle function.

Muscle relaxation training and quality of life in rheumatoid arthritis. A randomized controlled clinical trial

The purpose of the study was to investigate the effects of supervised muscle relaxation training in individuals with rheumatoid arthritis (RA). Sixty-eight participants were allocated at random either to a muscle relaxation training group or to a control group. Every participant was evaluated for health-related quality of life, muscle function, pain, and disease activity. The training group exercised 30 minutes, twice a week for 10 weeks, while no intervention was made in the control group. The results indicated improvements in the training group regarding self-care according to the Arthritis Impact Measurement Scales 2, and in recreation and pastimes according to the Sickness Impact Profile-RA (p < 0.05) directly after the intervention. Mobility and arm function (p < 0.01) according to the Arthritis Impact Measurement Scales 2, and muscle function of the lower limbs (p < 0.05) were improved after six months. No improvements remained after twelve months. It thus seems that 10 weeks' relaxation training might have some short-term influence in individuals with RA.

Reproducibility of manual pressure force on provocation of the sacroiliac joint

BACKGROUND AND PURPOSE

Previous studies of pain-provocation sacroiliac (SI) joint tests have revealed conflicting results. The aim of the present study was to evaluate the intra- and inter-test reliability of pressure force applied during distraction test, compression test and pressure on the apex sacralis.

METHODS

Seventeen physiotherapists (PTs), median age 43 years and median clinical experience 11 years, all experienced in musculoskeletal evaluation and therapy, participated in the study. Each PT performed each test on the same healthy volunteer for 20 s, on three separate occasions, at intervals of one week using a specially constructed examination table which registered pressure force.

RESULTS

The PTs were capable of maintaining a relatively constant pressure force for 20 s. The intra-test reliability was acceptable even though there were individual differences on different occasions between those PTs who used the SI joint tests often and those who seldom or never used them. The inter-test reliability was insufficient.

CONCLUSIONS

The findings indicate the advantage of registering pressure force as a complement for standardized methods for pain-provoking tests and when learning provocation tests, since individual variability was considerable.

Home exercise and compliance in inflammatory rheumatic diseases--a prospective clinical trial

OBJECTIVE

To survey and to compare the one year effects of dynamic muscle training and progressive muscle relaxation as home exercise for patients with inflammatory rheumatic diseases; and to identify predictors for compliance with a longterm home exercise regimen.

METHODS

Fifty-four patients (mean age 54 yrs, mean symptom duration 14 yrs) were assessed for health related quality of life, exercise motivation, joint tenderness, and physical capacities. After randomization into 2 groups, every patient was instructed on one occasion in a 30 min program of either dynamic training or muscle relaxation to carry out at home, 5 times a week during 3 months, and then 2-3 times a week for another 9 months.

RESULTS

Seventeen patients in each group completed the one year exercise protocol, while 10 from each group did not. Compliance with the one year exercise regimen seemed to be predicted by high self-efficacy for exercise, regular range-of-motion exercises before the intervention, and being unmarried. After one year, minor improvements in physical effect (p < or = 0.05) and work effect (p < or = 0.05) were found in the dynamic training group, while minor improvements in pain effect (p < or = 0.05), emotional reactions (p < or = 0.05), and arm endurance (p < or = 0.01) were found in the muscle relaxation group. No differences between the groups regarding changes in health status, joint tenderness, or physical capacities during the intervention period were found.

CONCLUSION

These results may improve the selection of patients for home exercise, and form a basis for improved administration of home exercise programs.

Why exercise?: a preliminary investigation of an exercise motivation index among individuals with rheumatic conditions and healthy individuals

The study was undertaken to investigate the test-retest stability and the criterion-related validity of a modified Swedish version of an exercise motivation index (EMI), and its use with individuals with rheumatic conditions, and with healthy individuals who exercised regularly. The EMI consists of 23 statements divided into three sub-scores for physical, psychological and social motivation. Ninety-five individuals with rheumatic conditions (mean age 60 years, mean symptom duration 15 years, 79% female) and 131 healthy individuals (mean age 52 years, 76% female), all attending exercise classes at least once a week, filled out the EMI. Sub-samples also filled out three visual analogue scales designed to measure physical, psychological and social exercise motivation, and filled out the EMI a second time one week later. The results indicated that psychological and physical exercise motivation was equally important in both samples. Social motivation was less important in both samples, but more pronounced in the rheumatic sample and among older individuals. In the rheumatic sample, physical motivation was more important among women and psychological motivation was more important among younger individuals. Test-retest stability for the EMI was satisfactory in both samples, while criterion-related validity was poor. The results of our preliminary investigation of the EMI suggest that the survey of physical, psychological and social motivation for exercise seems meaningful. Further work on the validity of the EMI is needed.

Dynamic training versus relaxation training as home exercise for patients with inflammatory rheumatic diseases. A randomized controlled study

The aim of the study was to evaluate the effects of a dynamic training program versus a muscle relaxation training program as home exercise in patients with inflammatory rheumatic diseases. Fifty-four patients (mean age 54 years, mean symptom duration 14 years) were randomized to one of the two programs. After personal instructions every patient exercised at home for half an hour, 5 days a week during 3 months. Before and after the interventions, all patients were assessed for health-related quality of life, joint tenderness and physical capacities. The dynamic training group had improved in perceived exertion at the walking test (p < or = 0.05), while the relaxation training group had improved their total Nottingham Health Profile (p < or = 0.01), its subscale for lack of energy (p < or = 0.05), Ritchie's articular index (p < or = 0.05), muscle function of the lower extremities (p < or = 0.01), and arm endurance (p < or = 0.01). Regarding changes in muscle function of the lower extremities during the intervention period, there was a significant difference (p < or = 0.05) between the groups in favour of the relaxation training group. The results of the study thus indicated that progressive muscle relaxation training might improve health related quality of life, reduce joint tenderness and be superior to dynamic muscle training in improving the muscle function of the lower extremities in patients with inflammatory rheumatic diseases. The clinical effects were small and the results have to be interpreted with caution.

Therapeutic exercise in rheumatoid arthritis

Although about 80% of individuals with rheumatoid arthritis [RA] are functionally independent on any given occasion [1], substantial functional disability is often observed over time in the average patient [2]. One important goal in rehabilitation of individuals with RA is the prevention of functional decline, and therapeutic exercise is frequently used for this purpose. The target population for therapeutic exercise consists mainly of functionally independent persons with RA [3]. For these individuals, aerobic exercise seems superior to nonaerobic methods of exercise [4]. Likewise, dynamic exercise, requiring muscle work during joint motion, appears to be superior to static or isometric exercises [5].

Home exercise in rheumatoid arthritis functional class II: goal setting versus pain attention

OBJECTIVE

To evaluate the effects of a 12-week home exercise and cognitive treatment program in functionally independent patients with rheumatoid arthritis.

METHODS

Forty-two patients were assessed with the Arthritis Self-efficacy Scale, the Stanford Health Assessment Questionnaire, the Ritchie articular index, measurement of joint mobility, and registration of capacity and pain in functional tasks. The patients were then randomized to either a "goal-setting" subgroup, in which individual goals for the exercise were set and exercise encouraged despite pain, or to a "pain attention" subgroup, where advice to decrease exercise load in case of pain was given. All patients used the same home exercise program aiming at improved range of motion, muscle function and aerobic capacity.

RESULTS

After the intervention period, exercise had conferred better self-efficacy for "other symptoms," increased capacity in most functional tasks, decreased activity induced pain, lowered Ritchie index, and increased joint mobility. Some improvements regarding pain were larger in the goal-setting subgroup.

CONCLUSION

Home exercise influences self-efficacy for mood and fatigue, physical capacity, and pain. Additional cognitive treatment seems to positively influence the perception of pain.

Radiologically observed progression of joint destruction and its relationship with demographic factors, disease severity, and exercise frequency in patients with rheumatoid arthritis

BACKGROUND AND PURPOSE

The aim of the study was to investigate the 4-year progression of radiologically observed joint destruction and its relationship with demographic factors, disease severity, and exercise frequency in patients with rheumatoid arthritis.

SUBJECTS

The subjects were 69 patients (56 women, 13 men; mean age = 54 years; mean duration of symptoms = 14 years) with American Rheumatism Association functional class II rheumatoid arthritis.

METHODS

The patients were assessed with a modified Larsen's radiological index (maximum score = 220), laboratory tests, Ritchie's articular index, and questionnaires regarding their self-selected low-intensive-intensive dynamic exercise frequency.

RESULTS

The Larsen's radiological index was initially 67 (SD = 42.4) and progressed to 82 (SD = 42.3) during the 4-year study period. Four-year radiological progression correlated with mean erythrocyte sedimentation rate (30 mm/h, SD = 12.6), but not with self-selected exercise frequency (< or = once a week or > or = twice a week) or with any other variables investigated.

CONCLUSION AND DISCUSSION

The radiologically observed progression of joint destruction seemed rather slow in this group of nonhospitalized, functionally independent patients with rheumatoid arthritis, and it was only related with mean erythrocyte sedimentation rate. Self-selected exercise frequency did not seem to be related with radiologically observed progression of joint destruction.

Activity-induced pain in rheumatoid arthritis functional class II and its relations with demographic, medical, functional, psychosocial, and work variables. Result of a survey in Bollnäs Medical District, Sweden, II

One aim of this study was to describe inflammatory activity, joint destruction, work status, and demographic factors in a group of 69 American Rheumatism Association functional class-II rheumatoid arthritis patients: 56 women and 13 men, mean age 54 years (SD 11), mean symptom duration 14 years (SD 11). Another aim was to determine correlations between activity-induced pain and other variables. Patients were assessed with Ritchie's articular index, Larsen's radiologic index, and laboratory tests. Deformity in hands and knee joints, and grip strength, were determined. Results from earlier investigations of functional impairment and psychosocial capacity were also used. Of the patients, 4% had high inflammatory activity. Joint erosions were found in between 4% (knee joints) and 55% (wrists) of the joints examined. Of the patients aged less than 65, 43% were working. Activity-induced pain was related with work status (p = 0.0002). It also correlated significantly (p less than or equal to 0.01) with inflammatory activity (r(s) = 0.34), but not with joint destruction (r(s) = 0.21).

Intensive dynamic training in water for rheumatoid arthritis functional class II--a long-term study of effects

The aim of the study was to assess the effects of once-weekly, intensive dynamic training in water of patients with Rheumatoid Arthritis (RA). Thirty patients with RA, functional class II, in a training group (TG) and 30 in a comparison group (CG) were assessed with respect to clinical, radiological and functional disease manifestations and psychosocial consequences before and after a four-year training period. After the training period the TG patients had significantly better grip strength and higher activity level, the latter maintained at two-year follow-up. There were significantly more CG patient admittances for acute hospital care during the training period. No other differences between the groups were found. Dynamic training at an intensive tempo does not seem, even in a long perspective, to lead to any undesirable consequences.

Functional and psychosocial consequences of disease and experience of pain and exertion in a group of rheumatic patients considered for active training. Result of a survey in Bollnäs Medical District. I

The purpose of this study was to select and describe a group of RA patients within a defined area who had, on clinical grounds, been considered for active training. The material consisted of 69 patients with classical or definite RA. It comprised half of the RA patients known to the clinic. The patients were assessed by means of a questionnaire, functional tests with rating of activity-induced pain, a cycling-test with rating of perceived exertion, and an interview by a psychologist. Subjective disease consequences were pain and stiffness. 38% of the patients never or seldom exercised. 72% wished to increase their activity but were prevented by pain. The functional tests indicated slow performance and considerable pain in activities of daily life. The interview disclosed above all, a low degree of self-confidence. Generalized pain and functional impairment correlated slightly with psychosocial factors. The results of the study indicate the need for active training as one strategy to alleviate pain and to maintain functional capacity in RA patients.