Marike van der Leeden

Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis

OBJECTIVE To evaluate the prevalence and 8-year course of forefoot impairments and walking disability in patients with rheumatoid arthritis (RA). METHODS A total of 848 patients with recent-onset RA from 1995 through the present were included. The patients were assessed annually. Pain and swelling of the metatarsophalangeal (MTP) joints, erosions and joint space narrowing of the MTP joints and first interphalangeal joints, and the Health Assessment Questionnaire walking subscale were analyzed using descriptive and correlational techniques. RESULTS Pain and swelling of > or = 1 MTP joint was present in 70% of patients at baseline, decreasing to approximately 40-50% after 2 years. The forefoot erosion score was > or = 1 in 19% of the patients at baseline, and the prevalence of forefoot erosion increased to approximately 60% after 8 years, during which the mean forefoot erosion score increased from 1.3 to 7.9. At least mild walking disability was present in 57% of patients at baseline, stabilizing at approximately 40% after 1 year. CONCLUSION The prevalence rates for pain and swelling of the MTP joints and walking disability are initially high and then stabilize, but the prevalence and severity of forefoot joint damage increase during an 8-year course of RA. The findings of this study quantitatively emphasize the importance of forefoot involvement in patients with RA.

Identification of phenotypes with different clinical outcomes in knee osteoarthritis: data from the Osteoarthritis Initiative

To identify subgroups or phenotypes of knee osteoarthritis (OA) patients based on similarities of clinically relevant patient characteristics, and to compare clinical outcomes of these phenotypes.

Association of lower muscle strength with self-reported knee instability in osteoarthritis of the knee: Results from the Amsterdam Osteoarthritis Cohort

To determine whether muscle strength, proprioceptive accuracy, and laxity are associated with self‐reported knee instability in a large cohort of knee osteoarthritis (OA) patients, and to investigate whether muscle strength may compensate for impairment in proprioceptive accuracy or laxity, in order to maintain knee stability.

Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required.

Background: Plantar pressure measurement may be a helpful evaluation tool in patients with foot complaints. Determination of dynamic pressure distribution under the foot may give information regarding gait, progress of disorders, and the effect of treatment. However, for these measurements to have clinical application, reproducibility, consistency, and accuracy must be ascertained. We compared the reproducibility of measurements among one-step, two-step, and three-step protocols for data collection in patients with arthritis. In addition, the number of measurements needed for a consistent average was determined for the protocol that was found to be the most reproducible. Methods: Twenty patients with foot complaints secondary to arthritis participated in the study. Each patient was tested with a pressure platform system using two of the three testing protocols. Reproducibility of contact time and maximal peak pressure were assessed. Intraclass Correlation Coefficients (ICC) were calculated for measurement results among protocols. In stage two of the study, the number of measurements needed for a consistent average was determined by calculating the first three measurements, the first five measurements, and then all seven measurements for both feet. ICC of three, five, and seven measurements were compared. The two-step protocol (13 patients), which was found in stage one of the study to be the most reproducible, was used for this determination. Results: Reproducibility was found to be reasonable or good for all three measurement protocols. The mean values of contact time for the one-step protocol were found to be higher than the mean values of contact time for the two-step or three-step protocols in both feet. The differences between the one-step and three-step protocols were statistically significant for the left foot only. The mean peak pressure did not show statistically-significant differences among the three protocols. The one-step and three-step protocols were not used for stage two of the study. Using the two-step protocol, three measurements were found to be sufficient for obtaining a consistent average. Conclusions: The results of our study indicated that the one-step, two-step, and three-step protocols of collecting plantar pressure measurements in patients with foot complaints secondary to chronic arthritis were all similar. However, the use of the two-step protocol is recommended over the one-step and three-step protocols; the one-step protocol produced a longer stance phase that did not resemble normal walking and when comparing the two-step and three-step protocols, the two-step protocol was less time consuming and less strenuous for patients with painful feet.

Three trajectories of activity limitations in early symptomatic knee osteoarthritis: a 5-year follow-up study

Objectives Knee osteoarthritis (OA) is a leading cause of activity limitations. The knee OA population is likely to consist of subgroups. The aim of the present study was to identify homogeneous subgroups with distinct trajectories of activity limitations in patients with early symptomatic knee OA and to describe characteristics of these subgroups. Methods Follow-up data over a period of 5 years of 697 participants with early symptomatic knee OA from the Cohort Hip and Cohort Knee (CHECK) were used. Activity limitations were measured yearly with the Western Ontario and McMaster Universities Osteoarthritis Index. Latent class growth analyses identified homogeneous subgroups with distinct trajectories of activity limitations. Multivariable regression analyses examined differences in characteristics between the subgroups. Results Three subgroups were identified. Participants in Subgroup 1 (‘good outcome’; n=330) developed or displayed slight activity limitations over time. Participants in Subgroup 2 (‘moderate outcome’; n=257) developed or displayed moderate activity limitations over time. Participants in subgroup 3 (‘poor outcome’; n=110) developed or displayed severe activity limitations over time. Compared with the ‘good outcome’ subgroup, the ‘moderate outcome’ and ‘poor outcome’ subgroups were characterised by: younger age, higher body mass index, greater pain, bony tenderness, reduced knee flexion, hip pain, osteophytosis, ≥3 comorbidities, lower vitality or avoidance of activities. Conclusions Based on the 5-year course of activity limitations, we identified homogeneous subgroups of knee OA patients with good, moderate or poor outcome. Characteristics of these subgroups were consistent with existing knowledge on prognostic factors regarding activity limitations, which supports the validity of this classification.

A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis

OBJECTIVE To compose an inventory of instruments that have been described to measure foot function (i.e., pressure and/or gait parameters), foot pain, and foot-related disability in rheumatoid arthritis (RA), and to investigate the clinimetric quality of these measures. METHODS A systematic search was conducted in Medline, CINAHL, EMBase, and Sportdiscus. Standardized criteria, extended with levels of evidence, were applied to assess the quality of the clinimetric studies and the properties (i.e., reliability, validity, and responsiveness) of the described instruments. RESULTS A variety of measurement instruments were identified. Only 16 instruments have been studied for their measurement properties in RA patients: 7 for assessing foot function, 3 for measuring foot-related disability, and 6 for measuring both foot pain and foot-related disability. Thirteen instruments were rated for reliability, of which 10 were rated positively on different levels of evidence. No positive rating for absolute measurement error was applicable for any of the tests. Internal consistency was reported for 7 instruments; 3 assigned a positive rating. For 2 instruments, Rasch analysis was used to assess the methodologic quality. A positive rating was reported for goodness-of-fit only, not for item calibration. Seven instruments were rated for construct validity, and 3 assigned a positive rating. Only 2 instruments were rated positively for responsiveness. CONCLUSION This review offers a basis for choosing the most appropriate instruments for measuring foot function, foot pain, and foot-related disability in RA patients, both for clinical practice and for research. Further research on the quality of these measures is urgently needed.

Forefoot disease activity in rheumatoid arthritis patients in remission: results of a cohort study

IntroductionThe aim of our study was to investigate the presence of disease activity in the metatarsophalangeal (MTP) joints of the forefoot in rheumatoid arthritis (RA) patients in remission according to the Disease Activity Score based on 28 joints (DAS28) remission criterion.MethodsA total of 848 patients with recent-onset RA were included from 1995 through 2007. The DAS28 and pain and swelling of the MTP joints were assessed annually. The data were analyzed using descriptive techniques.ResultsOn average, 35% of the patients fulfilled the remission criterion of DAS28 <2.6 during the first eight years of RA. On average, 29% of these patients had at least one painful MTP joint and, on average, 31% had at least one swollen MTP joint during follow-up. Forty percent, on average, had at least one involved MTP joint (pain and/or swelling).ConclusionsPainful and/or swollen MTP joints were detected in a substantial proportion of patients classified as being in remission. Therefore, examination of the foot joints - irrespective of the patients state of remission - seems indicated in order to provide optimal foot care.

Predictors of multidisciplinary treatment outcome in fibromyalgia:a systematic review

Purpose: To identify outcome predictors for multidisciplinary treatment in patients with chronic widespread pain (CWP) or fibromyalgia (FM). Methods: A systematic literature search in PubMed, PsycINFO, CINAHL, Cochrane Library, EMBASE and Pedro. Selection criteria included: age over 18; diagnosis CWP or FM; multidisciplinary treatment; longitudinal study design; original research report. Outcome domains: pain, physical functioning, emotional functioning, global treatment effect and ‘others’. Methodological quality of the selected articles was assessed and a qualitative data synthesis was performed to identify the level of evidence. Results: Fourteen studies (all with FM patients) fulfilled the selection criteria. Six were of high quality. Poorer outcome (pain, moderate evidence; physical functioning and quality of life, weak evidence) was predicted by depression. Similarly, poorer outcome was predicted by the disturbance and pain profile of the Minnesota Multiphasic Personality Inventory (MMPI), strong beliefs in fate and high disability (weak evidence). A better outcome was predicted by a worse baseline status, the dysfunctional and the adaptive copers profile of the Multidimensional Pain Inventory (MPI), and high levels of pain (weak evidence). Some predictors were related to specific multidisciplinary treatment (weak evidence). Inconclusive evidence was found for other demographic and clinical factors, cognitive and emotional factors, symptoms and physical functioning as predictors of outcome. Discussion: It was found that a higher level of depression was a predictor of poor outcome in FM (moderate evidence). In addition, it was found that the baseline status, specific patient profiles, belief in fate, disability, and pain were predictors of the outcome of multidisciplinary treatment. Our results highlight the lack of high quality studies for evaluating predictors of the outcome of multidisciplinary treatment in FM. Further research on predictors of multidisciplinary treatment outcome is needed. Implications for Rehabilitation Predictors can be used either to adjust treatment to the needs of specific patients, or to allocate patients to suitable programs Depression seems to predict poor multidisciplinary treatment outcome in FM More well designed studies are needed to investigate predictors of treatment outcome

Avoidance of Activities in Early Symptomatic Knee Osteoarthritis: Results from the CHECK Cohort

BackgroundPain-related avoidance of activities is hypothesized to lead to lower muscle strength and thereby activity limitations. Negative affect (e.g., low vitality, depression) is thought to strengthen the tendency to avoid activities.PurposeThe aim of this study was to assess the validity of this “avoidance model” in patients with early symptomatic knee osteoarthritis (OA).MethodsCross-sectional data (n = 151) were used. The associations between pain, negative affect, avoidance, muscle strength, and activity limitations were modeled using structural equation modeling.ResultsPain and negative affect were associated with lower muscle strength via avoidance (mediation by avoidance). Avoidance was associated with activity limitations via lower muscle strength (mediation by muscle strength). There were also direct associations between pain, negative affect, avoidance, muscle strength, and activity limitations.ConclusionsThe results support the validity of the avoidance model, which explains the associations between pain, negative affect, avoidance, muscle strength, and activity limitations in patients with early symptomatic knee OA.

Association of postural control with muscle strength, proprioception, self-reported knee instability and activity limitations in patients with knee osteoarthritis

OBJECTIVE To determine the association of postural control with muscle strength, proprioception, self-reported knee instability and activity limitations in patients with knee osteoarthritis. METHODS A total of 284 patients with knee osteoarthritis from the Amsterdam Osteoarthritis cohort were included. Postural control was assessed using the One-Leg Stand Test (OLST), in which the patients were asked to stand on one leg for 30 s. Muscle strength (isokinetic dynamometer), proprioception (joint motion detection threshold) and self-reported knee instability (episodes of buckling, shifting or giving way) were also assessed. Activity limitations were assessed using the Get Up and Go (GUG) test, the walking up-down stairs test, and Western Ontario and McMaster University Osteoarthritis Index - Physical Function subscale. Regression analyses were used to assess the associations. RESULTS Muscle weakness (p = 0.02) and proprioceptive inaccuracy (p < 0.001) were associated with decreased postural control. Decreased postural control was associated with less time performing the GUG test (p < 0.001) and the walking up-down stairs test (p < 0.001). These associations were found after adjustment for relevant confounders. CONCLUSION In patients with knee osteoarthritis, decreased postural control is associated with muscle weakness, proprioceptive inaccuracy and performance-based activity limitations. These results highlight the importance of including assessment and training of postural control in this group of patients.