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OBJECTIVE: To assess disability and functioning of elderly patients with rheumatoid arthritis (RA) and population controls by linking the items included in the self-report Multidimensional Health Assessment Questionnaire (MDHAQ) with components of the WHO International Classification of Functioning, Disability and Health (ICF) instrument. METHODS: In total, 1439 patients with RA (mean age 66 yrs, men 29%) and 957 population controls (65 yrs, men 27%) completed a mailed questionnaire. Functioning was recorded by the Finnish version of MDHAQ. Data included comorbidity, subjective health, education level, employment, exercise habits, self-report joint pain/tenderness, and, for patients, the disease duration. RESULTS: Patients had lower levels of functioning compared to controls in all ICF domains, with the exception that male patients functioned comparably to male controls in the "general tasks and demands" domain. In patients, disease activity, education, exercise frequency, and comorbidities were expectedly associated with lower functioning in the body structure and function component, while male sex and subjectively perceived health were associated with more favorable functioning. In the activity and participation components, disease activity, exercise frequency, and comorbidities were associated with impaired functioning, while better health on self-report was associated with better functioning. CONCLUSION: There is an extra burden of disability in elderly patients with RA compared to the reference population. With a large patient and control population sample, our study shows that use of the self-report MDHAQ identifies all 3 main components of the ICF framework, thus covering a wide spectrum of functioning. Elderly patients with RA, in comparison to population controls, encounter more difficulties in daily activities and their social life.

OBJECTIVE: To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies. METHODS: In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi). RESULTS: At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup. CONCLUSION: RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recent-onset RA.

OBJECTIVE: To develop a continuous composite index of disease activity for rheumatoid arthritis (RA) based on the 7 American College of Rheumatology (ACR) core data set of disease activity measures: Mean Overall Index for Rheumatoid Arthritis (MOI-RA). METHODS: The MOI-RA is the mean of standardized values of tender and swollen joint counts (28, 42, or 66/68 joint counts), physical function (Health Assessment Questionnaire 0-3), patient's and physician's assessments of global health and patient's assessment of pain (visual analog scale 0-100 mm) and erythrocyte sedimentation rate (1-100). All the 7 components were standardized (0-100), and the mean of standardized values was calculated. The range of MOI-RA is 0-100; higher values indicate poorer outcomes. The validity and measurement properties of MOI-RA were analyzed in 169 patients in the Finnish RA Combination therapy trial. RESULTS: The mean MOI-RA28 decreased from 38.5 to 13.3 [standardized response mean (SRM) = 1.8, effect size (ES) = 1.9] from baseline to 6 months, compared to Disease Activity Score (DAS) 28, which decreased from 5.55 to 2.77 (SRM = 2.0, ES = 2.8). Correlation between MOI-RA28 and DAS28 was 0.90. When compared to the ACR response categories (20/50/ACR remission), changes in MOI-RA versions (using 28/42/66 joints) were similar. The reproducibility of MOI-RA with different joint counts was 0.97. A simulation in which 15% of the component values of MOI-RA were randomly omitted indicated an intraclass correlation coefficient of 0.98 between incomplete and complete data. CONCLUSION: MOI-RA is a simple and feasible index based on the ACR core data set of disease activity measures for assessment of disease activity and treatment response in RA trials and clinical settings.

OBJECTIVE: To examine the influence of components of the Disease Activity Score 28 (DAS28) [tender joint count (TJC), swollen joint count (SJC), patient’s general health (GH), and erythrocyte sedimentation rate (ESR)] on the total DAS28 score, and overlapping of the 4 individual components in rheumatoid arthritis (RA) patients with low, moderate, or high disease activity. METHODS: The effect of each component was studied in the FIN-RACo trial patients at 6 months and in a "theoretical model," where each component of the DAS28 ranged as follows: TJC and SJC from 0 to 28, GH from 0 to 100, and ESR from 1 to 100, while the other 3 components were 0 (ESR1). Overlapping of the components was studied in the FIN-RACo trial patients at 6 months with low (DAS28 ≤ 3.2), moderate (DAS28 > 3.2 and ≤ 5.1), and high (DAS28 > 5.1) disease activity. The higher limit for overlapping was defined as the highest SJC in the low disease activity group, and the lower limit as the lowest SJC in the high disease activity group; the percentage of patients who fall between these limits represent overlapping in SJC. Overlapping was calculated similarly concerning TJC, ESR, and GH. RESULTS: ESR had the greatest effect on DAS28, followed by TJC, GH, and SJC, while in the "theoretical model" TJC had the greatest effect on the DAS28, followed by ESR, SJC, and GH. At 6 months, overlapping was present in 54%, 45%, 49%, and 31% of patients in SJC, TJC, GH, and ESR, respectively. CONCLUSION: in real-life patients, ESR had the greatest effect of the 4 components of DAS28 on the total DAS28 score. The values of the individual components of DAS28 overlap considerably among the 3 disease activity groups.

OBJECTIVE: To determine whether nonresponse to a mailed health survey predicts mortality in patients with rheumatoid arthritis (RA) and in a community sample in Finland. METHODS: A 5-page health questionnaire was administered in 2000. Two years later the vital status of the subjects was ascertained from the Population Registry. RESULTS: A total of 1095 (73%) patients with RA and 1530 (77%) community control subjects returned a completed questionnaire. Over the 2-year period, the number of deaths was 57 (5.2%) in RA responders and 37 (9.3%) in RA nonresponders (p = 0.004). The corresponding figures in community controls were 34 (2.2%) and 23 (4.9%) (p = 0.002). In a Cox regression model adjusted for age and sex, RA patient and community control nonresponders were respectively 1.65 (95% CI 1.07 to 2.55) and 2.89 (95% CI 1.69 to 4.94) times more likely to die over the 2 years compared to the responders. CONCLUSION: Nonresponders to a mailed health survey were more likely to die over 2 years compared to responders. The possible nonresponse bias should be kept in mind in the interpretation of the results of studies that are based on mail questionnaires only.

OBJECTIVE: To study the frequency of remission using 3 sets of criteria in patients with rheumatoid arthritis (RA) at 5 years after the diagnosis. METHODS: All adult patients with recent onset inflammatory arthritis who did not meet criteria or show clinical signs of other specific arthritides were included in the RA1997 inception cohort at Jyväskylä Central Hospital, Finland, and were assessed for remission at 5-year control examination. Remission was defined as (1) American College of Rheumatology (ACR) remission (fatigue excluded), (2) clinical remission with no tender and no swollen joints and normal erythrocyte sedimentation rate, and (3) radiographic remission with no worsening of erosions and no new erosions from baseline to 5 years. RESULTS: The study included 127 patients with early RA (mean age 56 yrs, 61% female, 54% with positive rheumatoid factor, and 25% with erosions). At 5 years, 111 patients were examined, 17% (95% CI 11%–25%) of whom met ACR remission criteria, 37% (95% CI 28%–47%) met clinical remission criteria, and 55% (95% CI 49%–68%) met radiographic remission criteria. Only 13 (12%) patients met all 3 sets of remission criteria. The rate of remission was statistically significantly different (p < 0.001) using the 3 sets. CONCLUSION: The rate of remission in RA depends on the criteria used. No gold standard exists for defining remission in RA. A set of criteria including no sign of inflammatory activity and no radiographic progression might be a basis for development of clinically relevant remission criteria for RA.

OBJECTIVE: There is a common impression, rarely documented, that the outlook of patients with rheumatoid arthritis (RA) is different today compared to previous decades. We investigated the 5-year radiographic progression of 3 cohorts of patients with early RA enrolled in the 1980s and 1990s. METHODS: Patients with early RA were enrolled into 3 separate studies in 1983-85 (n = 58; Cohort A), 1988-89 (n = 77; Cohort B), and 1995-96 (n = 62; Cohort C) at one rheumatology center; all were subsequently treated actively with disease-modifying antirheumatic drugs according to the "sawtooth strategy" to control inflammation, and monitored regularly to collect data for evaluation of longterm outcome. Evaluation over 5 years included disease activity measures and medications. Radiographs of hands and feet taken at baseline and at 2 and 5 years were analyzed by Larsen score (0–100). RESULTS: Larsen score increased by a median of 12, 6, and 4 points by Year 5 in cohorts A, B, and C, respectively (p = 0.001), adjusted for age, sex, rheumatoid factor (+/–), and the baseline values for Larsen score and erythrocyte sedimentation rate. RF positivity and persistent high disease activity over 5 years were associated with greater progression of radiographic damage. CONCLUSION: Radiographic progression was greatest in the earliest cohort and mildest in the most recent cohort, a phenomenon that was also seen in the literature review. The reasons for the observation may include (1) improved therapy, (2) milder disease, and (3) patient selection.

OBJECTIVE: To study whether clinically observed tenderness and/or swelling of a wrist joint over the first 3 years after diagnosis predict the development of erosions in radiographs of the same joint at 5 years in patients with early rheumatoid arthritis (RA). METHODS: A total of 58 patients with recent onset RA were enrolled in a prospective RA study at Jyväskylä Central Hospital in 1983-85. Physical examination including joint counts was performed 6 times over 3 years (at 0, 6, 12, 18, 24, and 36 mo). Radiographs of hands and feet taken at the 5-year visit were scored according to the Larsen method (0–1 = non-erosive; 2–5 = erosive). At each visit, the wrist joints were assessed for tenderness (0/1) and swelling (0/1). A frequency (ranging from 0 to 6) was calculated for 4 inflammation categories — tenderness, swelling, tenderness or swelling, and tenderness and swelling — over the 3 years. Percentages of wrist joints with erosions on the 5-year radiographs were calculated for the frequency groups 0, 1, 2–3, and 4–6 of each category. Two patients died, and 5 wrists were erosive at baseline. Thus the data for 107 wrist joints of 54 patients were available for analyses. RESULTS: A statistically significant correlation was seen in the frequency of clinical inflammation and the development of erosions. Only one (3.3%) wrist with no tenderness in 6 examinations over the first 3 years developed erosions over 5 years, while 13 (59.1%) wrists that were tender 4–6 times in 6 examinations developed erosions. The corresponding percentages were 4.4% and 50.0% for wrists with swelling, 3.4% and 51.6% for wrists with tenderness or swelling, and 6.1% and 75.0% for wrists with tenderness and swelling. CONCLUSION: Radiographic erosions develop rarely without preceding clinically detectable inflammation in the joints of patients with early RA.

OBJECTIVE: To examine the effects of strength training on basal concentrations and acute responses of serum hormones, and their possible interrelationships with training induced muscle hypertrophy and strength gains of the knee extensor muscles in women with fibromyalgia (FM) and healthy controls. METHODS: Twenty-one premenopausal women with FM were randomized to 21 week strength training (FMT; n = 11) or control (FMC; n = 10) groups. Twelve premenopausal sedentary healthy women served as controls (HC). Surface electromyographic (EMG) activity, maximal unilateral isometric force of the right knee extensors, and muscle cross-sectional area (CSA) of the quadriceps femoris throughout the lengths of 3/12 to 12/15 of the femur (Lf) were measured. Serum concentrations of total and free testosterone and growth hormone (GH) were analyzed at rest and in pre- and post-exercise conditions, while levels of insulin-like growth factor and dehydroepiandrosterone sulfate were measured at rest only. RESULTS: Mean (SD) maximal force increased by 18% (10%) (p < 0.001) in the FMT group, and by 22% (12%) (p < 0.001) in the HC, while in the FMC it remained unchanged. Maximum integrated EMG of the agonists (VL + VM/2) increased in HC by 22% (p < 0.05) and in the FMT by 19% (p < 0.05). Significant increases in the CSA of the QF were observed at 5 to 12/15 Lf in FMT (p < 0.05-0.01) and at 3 to 12/15 Lf in HC (p < 0.05-0.001), while in FMC the CSA remained unchanged. No training induced changes occurred in the basal concentrations of serum hormones examined. A significant acute increase took place in the mean concentration of GH at pre-training in HC (p < 0.01) and in the FMT (p < 0.05), while at post-training the elevations after the loading (p < 0.001 and 0.05) remained elevated up to 15 min (p < 0.05) in HC and up to 30 min (p < 0.01) post-loading in the FMT. CONCLUSION: Both the magnitude and time course of adaptations of the neuromuscular system to resistance training in women with FM were completely comparable to those taking place in healthy women. Basal levels of the anabolic hormones seem to be similar in women with FM compared to age matched healthy women. Observations recorded during the acute loading conditions might be considered an indication of the training induced adaptation of the endocrine system, showing that the acute GH response may become systematic after strength training in both women with FM and controls.

OBJECTIVE: To study longterm outcomes of 60 patients with palindromic rheumatism (PR) diagnosed in 1967–1984. METHODS: A cohort of patients with PR was identified in Jyväskylä Central Hospital in 1967–84, and reexamined in 1984–86. In 2006, medical records of the patients were reviewed to analyze the proportion of patients who had developed chronic rheumatoid arthritis (RA), had joint replacement surgery, or had died. Patients’ health status was reviewed by mail questionnaires including functional status on the Health Assessment Questionnaire (HAQ), pain, and the number of painful joints. RESULTS: Forty patients developed chronic RA over the observation period of over 20 years, among whom 38 patients within 10 years and 2 patients after 10 years. Twenty-four patients had died by 2006, 17 (42%) in the RA group and 7 (35%) in the non-RA group. Nine patients, all in the RA group (23%), had received 1 or more joint replacements. The mean HAQ score was 0.57 in the non-RA survivors (mean age 70 yrs), compared to 0.89 in the RA group (mean age 66 yrs) (p = 0.020, adjusted for age). Pain scores and the number of painful joints were similar between the groups. CONCLUSION: Two-thirds of the patients with PR developed chronic arthritis. The risk to develop chronic arthritis remained over 10 years. The RA group was characterized with functional declines and having joint replacements as longterm outcomes of the disease.