Andreas J. Peeters

Motivation as a determinant of physical activity in patients with rheumatoid arthritis

A sufficient level of physical activity is important in reducing the impact of disease in rheumatoid arthritis (RA) patients. According to self‐determination theory, the achievement and maintenance of physical activity is related to goal setting and ownership, which can be supported by health professionals. Our objective was to examine the association between physical activity and the extent to which RA patients 1) believe that physical activity is a goal set by themselves (autonomous regulation) or by others (coerced regulation) and 2) feel supported by rheumatologists (autonomy supportiveness).

Maintenance of physical activity after Internet-based physical activity interventions in patients with rheumatoid arthritis

OBJECTIVES To investigate the maintenance of physical activity 12 months after two 1-year Internet-based physical activity interventions in patients with RA. METHODS This follow-up study was a randomized comparison of an Internet-based individualized training (IT) and a general training (GT) programme in sedentary RA patients. Outcome measures included physical activity (meeting public health recommendations for moderate physical activity, i.e. 30 min for at least 5 days/week; or vigorous physical activity, i.e. 20 min for at least 3 days/week), functional ability and quality of life (QoL). RESULTS Of the 152 RA patients who completed the initial study, 110 (72%) were available at follow-up. At 24 months, the proportions of patients meeting public health recommendations for moderate intensity physical activity were significantly higher compared with baseline in both the IT and GT groups (19 and 24%, respectively, P < 0.05), whereas the proportions of patients meeting the recommendation for vigorous activity was only significantly higher compared with baseline in the IT group (P < 0.05) but not in the GT group. There were no differences between the IT and GT groups concerning proportions of patients meeting moderate or vigorous physical activity recommendations at 24 months. Apart from a significantly higher RAQoL score in the IT group at 24 months compared with baseline, there were no significant differences within or between the programmes regarding functional ability or QoL. CONCLUSION In RA patients, the effectiveness of both an individualized and a general 1-year Internet-based physical activity programme is sustained with respect to moderate intensity physical activity up to 12 months after the interventions.

Assistive devices: usage in patients with rheumatoid arthritis

We describe the usage of various assistive devices and identify factors associated with usage in patients with rheumatoid arthritis (RA). A cross-sectional, multicentre study was performed in three outpatient rheumatology clinics in the Netherlands. Two hundred forty patients with RA participated in the study. The main measures were questionnaires and a semi-structured interview regarding the possession and usage of 21 common assistive devices in the ISO9999 categories orthopaedic footwear, personal care, mobility, household and adaptations for housing. Potential factors associated with usage included sociodemographic variables, health status, quality of life, coping strategies, self-efficacy, outcome expectations and satisfaction. Out of 240 patients, 213 (89%) had one or more assistive devices in possession (median number of devices 3.0, interquartile range 3.0). The proportions of patients never using a device in possession varied between 8% for orthopaedic insoles and 23% for grab bars. The main factors related to usage varied among categories, but common determinants were a specific impairment or disability, satisfaction with the device or related services, self-efficacy and the number of devices in possession. In conclusion, in patients with RA, possession rates are high, with 23% or less of the devices in possession being abandoned. Overall, satisfaction rates were high. Factors associated with usage varied among categories and comprised, apart from the number of devices in possession and variables related to health status, also aspects of satisfaction with the device or related services or self-efficacy. The latter findings underline the need for a systematic evaluation of the outcomes of assistive devices by prescribing health professionals or suppliers in every individual case.

Promoting physical activity in patients with rheumatoid arthritis: rheumatologists’ and health professionals’ practice and educational needs

Despite the proven health benefits, patients with rheumatoid arthritis (RA) are found to be less physically active than their healthy peers. The aim of this study was to examine to what extent and how physical activity, defined as any bodily movement resulting in energy expenditure, is currently promoted by health care providers in patients with RA and how they perceive their competencies and educational needs. For this cross-sectional study, Dutch rheumatologists, rheumatology clinical nurse specialists, and expert physical therapists were sent a postal survey including four domains: attitudes towards physical activity in RA, advices given to patients with RA, and perceived competencies and educational needs. A total of 126 rheumatologists (50%), 132 clinical nurse specialists (56%), and 112 physical therapists (53%) returned the questionnaire. More than 90% agreed that physical activity is an important health goal for RA patients and regularly advised their patients to engage in physical activity. Public health recommendations for moderate-intensity physical activity were found attainable in RA patients by 66%, 74%, and 65% and were by used by 19%, 41%, and 49% of them, respectively. On average, respondents rated their competency to promote physical activity as low to medium, and 54%, 85%, and 72% of the respondents expressed a need for additional education regarding this topic. Rheumatologists, nurses, and physical therapists considered regular physical activity to be an important health goal for RA patients. The majority of them commonly gave advice on physical activity but felt not sufficiently competent and indicated a need for additional education.

Purpose in life in patients with rheumatoid arthritis.

To evaluate the role of purpose in life among people with rheumatoid arthritis (RA), a questionnaire comprising the Purpose in Life test (PIL) and the purpose in life dimension of the Psychological Well-Being test (PWB-pil) was sent to a random sample of 300 patients with RA. Additional questions comprised sociodemographic and disease characteristics, physical, mental and social functioning, coping (Coping with rheumatic stressors questionnaire), and quality of life (RAND-36). Associations between sociodemographic and disease characteristics, physical, mental and social functioning, and coping on the one side and the two measures of purpose in life on the other side and associations between the two purpose of life measures and physical and mental dimensions of quality of life were assessed by means of univariate and multivariate regression analyses. The response rate was 156 of 300 (52%). The median PIL and PWB-pil scores were 103 (range 63–131) and 82 (41–110), respectively. A lower age, a better mental health status, and an optimistic coping style were significantly associated with both higher PIL and PWB-pil scores, whereas more participation in leisure and/or social activities was associated with a higher PIL score. It was found that the PIL and PWB-pil contributed independently and significantly to the mental component summary scale of the RAND-36. In RA patients, lower age, a better mental health status, an optimistic coping style, and participation in leisure and/or social activities were significantly associated with more sense of purpose in life. Purpose in life pays a significant and independent contribution to the mental component of quality of life. These findings highlight the significance of the concept of purpose in life in patients with RA.

Effectiveness of two finger splints for swan neck deformity in patients with rheumatoid arthritis: a randomized, crossover trial.

OBJECTIVE To compare the effectiveness and acceptability of silver ring splints (SRS) and commercial prefabricated thermoplastic splints (PTS) in treating swan neck deformities in patients with rheumatoid arthritis (RA). METHODS Consecutive patients with RA and a mobile swan neck deformity were included in a randomized, crossover trial. In 2 different sequences, patients used both splints for 4 weeks, with a washout period of 2 weeks. Afterward, patients used the preferred splint for another 12 weeks. The primary outcome measure was dexterity measured with the Sequential Occupational Dexterity Assessment (SODA). Secondary outcome measures included other measures of hand function, satisfaction with the splints, and splint preference. RESULTS Fifty patients were included, and 47 (94%) of those completed the study. Eighteen patients (36%) had 1 swan neck deformity, whereas the other patients had 2 or more. The improvement of the total SODA score with the SRS (11.2; 95% confidence interval [95% CI] 8.1, 14.3) and PTS (10.8; 95% CI 7.5, 14.1) was similar (difference -0.5; 95% CI -2.2, 1.2). In addition, there were no significant differences in change scores regarding the other clinical outcome measures, or satisfaction. Twenty-four patients preferred the SRS, 21 preferred the PTS, and 2 patients chose neither. A comparison in the 12-week followup period yielded similar clinical outcomes, with the exception of a significantly higher score in 3 items of satisfaction in the SRS group. CONCLUSION For patients with RA and a mobile swan neck deformity, SRS and PTS are equally effective and acceptable.

Exploring the public health impact of an intensive exercise program for patients with rheumatoid arthritis: A dissemination and implementation study

To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA).

AB1056 Psychometric Testing of The Dutch Evaluation of Daily Activities Questionnaire in Rheumatoid Arthritis

Background The Evaluation of Daily Activity Questionnaire (EDAQ) is a patient reported measure of activity limitations in Rheumatoid Arthritis (RA) and other musculoskeletal conditions, for which there is a Swedish (1) and an updated English version (2–4). The English version was translated into Dutch, and linguistically validated, with phrasing changes made following cognitive debriefing interviews with six Dutch people with RA. The Dutch EDAQ includes 138 items in 14 “domains” (Eating/ Drinking; Personal Care; Dressing; Bathing; Cooking; Moving Indoors; House Cleaning; Laundry; Moving and Transfers; Moving Outdoors; Gardening/Household Maintenance; Caring; and Leisure/ Social Activities). Each domain is split into two sections: one (A) scores whether activities can be performed without aids, alternate methods or help; and another (B) which scores whether the activities can be performed with aids or alternate methods. All items are scored on a 0–3 scale (no difficulty to unable to do). Objectives To test the reliability and validity of the Dutch version of the EDAQ in people with RA in the Netherlands. Methods Participants from an out-patient Rheumatology clinic (Reinier de Graaf Hospital, Delft) completed postal questionnaires of demographic questions, the EDAQ, HAQ, SF36v2, RAQOL, a hand pain numeric rating scale (NRS) and a current condition severity scale. Three weeks later, the EDAQ was mailed again. Test-retest reliability of domain scores was evaluated using nonparametric correlations. Internal consistency was tested using Cronbachs alpha. Validity of the 14 domains of the EDAQ against the other measures was assessed with non-parametric correlations. Results 252 people participated: 155 women and 93 men; age =65.16 (SD 13.45) years; RA duration =11.75 years (SD 9.93). 68 (27%) were employed; 20 had children <18y at home. Average pain score =3 (IQR 1–6) and fatigue =4 (IQR 2–7). 155 (62%) completed Test 2 and test-retest reliability of total domain scores was excellent for nine domains (rs=0.81 -0.88) and moderate-substantial for five (rs=0.56–0.78). Internal consistency was high in all domains: Cronbachs alpha=0.79–0.92 for Section A. All domains of the EDAQ correlated significantly (p<0.001) with: HAQ rs=0.51- 0.88; SF36v2 (Physical Function) rs= -0.55 to -0.87; SF36v2 Bodily Pain rs=0.44–0.67; SF36v2 (Vitality) rs= -0.35 to -0.62; RAQOL rs=0.50–0.83; and hand pain rs=0.46–0.64. An exception was the “Caring” domain as many did not have childcare responsibilities, and thus validity was lower compared to the above variables, although still significant (p<0.01; rs=0.16 to 0.31). Conclusions The Dutch version of the EDAQ is a valid and reliable measure of daily activity in people with RA. It can be used in both clinical practice and research. References Nordenskiold et al (1998) Clin Rheumatol 17:6–16. Hammond et al (2015) HQLO 12:143; Hammond et al (2015) Rheumatology 54:1605–1615. Hammond et al (2015) Br J Occ Ther 78:144–157. Acknowledgement This research was funded by a EULAR Health Professionals Research Grant. Disclosure of Interest None declared

FRI0061 Remission after one year follow up of the improved-study, a randomized clinical trial aiming at remission in patients with early rheumatoid and undifferentiated arthritis

Objectives To evaluate the 1 year clinical outcomes of remission steered therapy in early arthritis, initially with methotrexate (MTX) and a tapered high dose of prednisone, in case of remission followed by tapering medication to zero, in case of no remission followed by randomization to two combination therapy strategies. Methods IMPROVED is a multicenter clinical trial in 479 patients with early (symptoms <2 years) rheumatoid arthritis (RA 2010 criteria) and 131 patients with undifferentiated arthritis (UA) with a baseline Disease Activity Score (DAS) ≥1.6. All patients started with MTX 25mg/wk and prednisone 60mg/day tapered in 7 weeks to 7.5 mg/day. Patients in early remission (DAS <1.6 at t=4 months) tapered prednisone to zero and when still in remission at t=8 months, also tapered MTX to zero. Patients not in early remission were randomized either to a combination of MTX 25 mg/wk, hydroxychloroquine (HCQ) 400mg/day, sulphasalazine 2000mg/day (SSZ) and prednisone 7.5 mg/day (arm 1) or to adalimumab (ADA) 40mg/2weeks with MTX 25mg/wk (arm 2). If not in remission at t=8 months, patients in arm 1 switched to ADA+MTX and patients in arm 2 increased ADA to 40mg/week. Proportions of remission after one year follow up were compared between the different treatment strategies and between RA and UA patients. Results After 4 months 375/610 (61%) patients achieved early remission (mean DAS (SD) 0.94 (0.36)) and 221/610 (36%) did not (mean DAS (SD) 2.45 (0.65), p<0.001). 161/610 patients (26%) were randomized, 83 to arm 1 and 78 to arm 2. In 66/610 (11%) patients the appropriate treatment step was not taken for various reasons. 12 patients were lost to follow up at t=4 months and 34 at t=1 year. At t=4 months, 361/375 (96%) patients in early remission started tapering prednisone. At t=8 months 257/375 (68%) were still in remission on MTX monotherapy and 200/375 (53%) tapered MTX to zero. At t=1 year, 255/375 (68%) were in remission, 135/375 (36%) were in drug free remission. At t=8 months 50/83 (60%) patients in arm 1 did not achieve remission and 31/83 (37%) switched to ADA+MTX. 47/78 (60%) patients in arm 2 did not achieve remission and 27/78 (35%) increased ADA. At t=1 year 21/83 (25%) patients in arm 1 and 32/78 (41%) in arm 2 were in remission (p<0.001). At t=1 year, 326/610 (53%) of the total study population were in remission: 252/479 (53%) RA patients and 70/131 (53%) UA patients. Conclusions In patients with early RA or UA, early remission was achieved in 61% after initial treatment with MTX and a tapered high dose of prednisone. After one year of tapering treatment, 68% of those were still in remission and 36% in drug free remission. For those not in early remission, treatment with adalimumab resulted in more remission than a combination of DMARDs with low dose prednisone. Of the total study population 53% were in remission after one year, without a significant difference between early RA and UA patients. Disclosure of Interest L. Heimans: None Declared, K. Wevers-de Boer Grant/Research support from: Abbott, K. Visser: None Declared, H. Ronday: None Declared, M. Oosterhout: None Declared, J. Harbers: None Declared, A. Peeters: None Declared, M. Westedt: None Declared, P. de Buck: None Declared, P. de Sonnaville: None Declared, B. Grillet: None Declared, T. Huizinga: None Declared, C. Allaart: None Declared

FRI0155 Patient reported outcomes in early arthritis patients

Background Besides suppression of inflammation and prevention of radiographic damage, improvement of functional ability and Health Related Quality Of Life (HRQOL) is one of the main goals of treatment in patients with RA. Objectives To investigate patient reported outcomes (PROs) of functioning and HRQOL after 1 year remission-steered treatment. Methods 610 patients with early RA or undifferentiated arthritis (UA) were included in the IMPROVED-study. All started with methotrexate (MTX) and tapered high dose prednisone. Patients in early remission (Disease Activity Score (DAS)<1.6 after 4 months) tapered prednisone to 0 and when in remission after 8 months, also tapered MTX. Patients not in early remission were randomized to MTX plus hydroxychloroquine, sulphasalazine and prednisone (arm 1) or to MTX+adalimumab (arm 2). Every 4 months, patients filled out the McMaster-Toronto Arthritis Patients Preference Questionnaire (MACTAR) and the Health Assessment Questionnaire (HAQ) to measure functional ability, the Short Form 36 (SF-36) for mental en physical HRQOL and visual analogue scales (VAS). Scores were analyzed separately for all treatment arms and compared between arm 1 and 2. Predictors of HRQOL were identified using linear mixed models. Results 387 patients achieved early remission and 221 patients did not; 83 patients were randomized to arm 1 and 78 to arm 2, 50 did not follow the protocol. After 1 year, remission was most often achieved by patients who were in early remission. Patients in arm 2 more often achieved remission (40%) than patients in arm 1 (25%). Except mental HRQOL, which was stable over 1 year and close to the population mean of 50 in all patients, all PROs and VAS results improved over 1 year, the most during the first 4 months (table). Only VAS disease activity improved significantly more in arm 2 (mean difference 13, 95%CI 2;23), other VAS scores were similar in both arms. The strongest independent predictor for HRQOL was baseline HAQ (beta for mental HRQOL:-1.8, 95%CI -2.8;-0.8, for physical HRQOL:-9.1, 95%CI -9.8;-8.4). Conclusions In early arthritis patients functional ability and HRQOL improve after 1 year of remission targeted treatment, with the largest change in the first 4 months. Patients who achieve early remission improve the most, achieving functional ability and HRQOL in the normal range. In patients who did not achieve early remission, there was no difference in improvement after treatment with DMARD+prednisone or adalimumab+MTX although more patients achieved remission after 1 year in the latter group. Disclosure of Interest None Declared