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Cognitive behavioural therapy (CBT) was combined with graded exercise therapy (GET) for patients with chronic fatigue syndrome (CFS) in an uncontrolled implementation study of an inpatient multidisciplinary group therapy. During the intake procedure, 160 CFS patients completed a questionnaire on fatigue related measurements, physical impairment, depression, somatic and psychological attributions, somatic focus, and sense of control over symptoms. Pre-treatment physical activity level was measured with an actometer. At baseline, post-treatment and 6-month follow-up individual strength, subjective fatigue and physical impairment, were reassessed. Large effect sizes were found on subjective fatigue (1.2 post-treatment; 1.2 follow-up) and physical impairment (-.9 post-treatment; -.9 follow-up), Clinically significant improvement was found in 33.8% of the participants at post-treatment and 30.6% at follow-up. Individual strength at post-treatment was predicted by level of physical activity before treatment, and by sense of control over symptoms and physical activity at follow-up. Clinically significant improvement in subjective fatigue was predicted by not receiving a disablement insurance benefit, shorter duration of fatigue, higher sense of control over symptoms and, at follow-up by more pre-treatment physical activity. In conclusion, the intervention was effective for CFS patients. Cognitive behavioural factors that perpetuate fatigue symptoms are also predictors of treatment outcome.

To investigate the efficacy of wrist working splints after a period of splinting in patients with rheumatoid arthritis (RA).We performed a 4-week randomized controlled trial among 33 RA patients with wrist arthritis. Patients were randomly allocated to the splinting group (n = 17) or the control group (n = 16). Patients in the splinting group received a prefabricated wrist working splint and were instructed to use this splint as much as possible during the day. The primary outcome measure was average wrist pain during the past week, measured using a visual analog scale (VAS). Secondary outcome measures were grip strength and functional ability. The latter was measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the short version of the Sequential Occupational Dexterity Assessment. Measurements were performed at baseline and after 4 weeks. Performance tests were performed without splint. Differences in change scores between the splinting and the control group were analyzed using analysis of covariance. To indicate the magnitude of the treatment effects, effect sizes were calculated.A large and highly significant treatment effect on wrist pain was found. VAS pain scores decreased by 32% in the splinting group and increased by 17% in the control group. Small and nonsignificant treatment effects were found with regard to nonsplinted grip strength and functional ability.Prefabricated wrist working splints are highly effective in reducing wrist pain after 4 weeks of splint wearing in RA patients with wrist arthritis.

Contains fulltext : 71296_p85.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To examine the factorial validity of the short form Arthritis Impact Measurement Scales 2 (AIMS2-SF) in patients with rheumatoid arthritis (RA). METHODS: Data were from a sample of 279 patients with active RA who completed the long form AIMS2 before starting treatment with tumor necrosis factor alpha-blocking agents. Confirmatory factor analyses were conducted to test and compare the fit of the currently used theoretical measurement model of the AIMS2-SF, originally suggested for the long form AIMS2, and 2 alternative models based on previous exploratory research. RESULTS: A model with the physical dimension divided into upper and lower body limitations was superior to the current model, and both models provided a clearly better fit than a model without a separate symptom dimension. Under the restrictive assumption of uncorrelated error terms, none of the models achieved a consistent and acceptable fit as judged by several goodness-of-fit indices. Allowing error covariances between 6 pairs of items within the same dimension resulted in an improved and acceptable fit of both the current model and the model with a separate upper and lower body component. CONCLUSION: This study generally supports the factorial validity of the AIMS2-SF and suggests the use of separate scores for upper and lower body limitations. Further research is needed to resolve the issue of high error correlations associated with particular items.

The number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.

The treatment and care of patients with rheumatoid arthritis (RA) is complex and various health professionals with different areas of expertise may be involved. The objective of this article is to review the treatments and their efficacy as provided by health care professionals in RA care. The requirements for further research in this area are formulated. To achieve better effects of treatment it is necessary to improve the coordination of services as provided by the different specialists. The important roles of the patients themselves in the care and management of the disease are emphasized, as well as the roles of the informal caregivers such as a spouse or other family members and friends and the role of patient societies. The possible role of the International Classification of Functioning, Disability and Health (ICF) to improve the communication and facilitate the coordination among health professionals and between patients and health professionals is mentioned. The topics presented in this article may encourage further discussion and research, particularly concerning the effects of the treatments as provided by allied health professionals. Health professionals play an important role in the life of patients with rheumatic disorders, in all the domains of the ICF: body functions and structure, activities (action by an individual) and participation (involvement in a life situation). Health professionals in rheumatology can make the difference in the lives of RA patients and their families.

OBJECTIVE: Although there has been growing evidence for the efficacy of mindfulness-based cognitive therapy (MBCT) for different clinical populations, its effectiveness as a public mental health intervention has not been studied. The present study evaluates a community-based MBCT intervention for adults with mild to moderate depressive symptomatology in a large multi-site, pragmatic randomized controlled trial. METHOD: The participants with mild to moderate depressive symptomatology were recruited from the general population and randomized to the MBCT intervention (n = 76) or to a waiting list control group (n = 75). Participants completed measures before and after the intervention. Participants in the experimental condition also completed these measures at a 3-month follow-up. RESULTS: In the experimental condition significant reductions in depression, anxiety, and experiential avoidance, and improvements in mindfulness and emotional- and psychological mental health were found, compared to the waiting list (effect sizes Cohen's d = 0.31-0.56). These effects were sustained at the 3-month follow-up. The likelihood of a clinically significant change in depressive symptoms was significantly higher for the MBCT group [odds ratio (OR) 3.026, p

Acceptance-based psychological interventions can potentially minimize the burden of chronic pain. This randomized controlled trial evaluated an internet-delivered, guided self-help intervention based on Acceptance and Commitment Therapy (ACT). A total of 238 chronic pain sufferers from the general population were randomly allocated to either ACT (n = 82), an internet-based control condition Expressive Writing (n = 79) or a waiting list condition (n = 77). Participants completed measures at baseline, posttreatment (3 months) and at a 3-month follow-up. At follow-up, ACT participants had improved in pain interference in daily life (primary outcome) compared to participants in Expressive Writing (Cohen’s d = .47), but not compared to waiting list participants (p value = .11). Those who adhered to the ACT-intervention (48 %) did improve significantly compared to waiting list participants (d = .49). ACT-participants also showed superior improvement on depression, pain intensity, psychological inflexibility and pain catastrophizing (d: .28–.60). Significant clinical improvement was present. Especially, 28 % of ACT-participants showed general clinically relevant improvement in pain interference, as well as in pain intensity and depression (vs. Expressive Writing and waiting list 5 %). Given these findings, internet-based ACT programs may be a promising treatment modality for chronic pain.

Acceptance and Commitment Therapy (ACT) is een behandelvorm waarin inzichten uit de gedragstherapie, cognitieve gedragstherapie en therapieen gebaseerd op mindfulness worden geintegreerd. Centraal uitgangspunt van ACT is dat pijn, ongewenste sensaties, emoties en gedachten bij het leven horen en dat het vermijden ervan juist meer lijden meebrengt. In ACT ligt het accent daarom op het nastreven van dat wat het leven de moeite waard maakt en het aanvaarden van pijnklachten wanneer die niet te verhelpen zijn. In dit hoofdstuk wordt ingegaan op de theoretische achtergronden van ACT. Vervolgens worden de klinische processen uitgelegd van een behandeling gebaseerd op ACT. Aan de betekenis van pijnbestrijding en herstel wordt een afzonderlijke paragraaf gewijd. Het hoofdstuk wordt afgesloten met een overzicht van de effecten van ACT bij chronische pijn.

The wrist is almost invariably affected in rheumatoid arthritis (RA) and inflammation of the wrist can lead to impaired function and eventually to severe destruction. Classical signs of inflammation, pain, swelling and heat may often be observed in clinical examination of wrist arthritis and in ultrasound (US) investigation. We described the relation between clinical and ultrasound parameters of wrist arthritis and secondly their relation to function.In 33 RA patients with wrist arthritis, clinical and US parameters were measured. Function was evaluated with the SODA-S (Sequential Occupational Dexterity Assessment-Short) and the DASH-DLV (Disabilities of the Arm, Shoulder and Hand-Dutch Language Version). Correlation coefficients were calculated and factor analysis was performed to describe the relation between the aforementioned measures.Correlation coefficients between clinical and ultrasound parameters of RA wrist inflammation in this study were fair to moderate. We found a good correlation between ultrasound and observed function.The classical signs of inflammation (pain, swelling, redness, heat and impaired function) seem to reflect different aspects of arthritis. Ultrasound correlates well with function, thus can give paramount information on wrist function, and might therefore be a valuable complementary tool in measuring wrist arthritis in RA.

Objective: To gain insight into the determinants of the use of wrist working splints among patients with rheumatoid arthritis (RA). - Methods: A qualitative descriptive study was performed among 18 patients with RA who recently received a fabric wrist working splint because of pain due to arthritis of the wrist. Patients were interviewed at home using semistructured in-depth interviews. Interviews were audiotaped and transcribed verbatim and analyzed using the framework approach. - Results: The majority of patients indicated that their splint use was dependent on the seriousness of the symptoms (pain, swelling, or tingling feelings) they perceived. Important reasons to wear the splint were reduction of symptoms, wrist support, and immobilization of the wrist. Important reasons to stop wearing the splint were reduced functional abilities using the splint and the performance of dirty or wet activities. - Conclusion: The reasons for patients to wear and not wear wrist working splints are related to intentional decisions of the patients, which are primarily based on perceived benefits and barriers of splint wearing. The results of this study have been used to develop educational and behavioral strategies to increase adherence to wearing wrist working splints.

Contains fulltext : 71315_p41.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To examine the psychometric properties of the self-administered Dutch Rheumatoid Arthritis Disease Activity Index (RADAI) and its short form (RADAI-SF) in patients with rheumatoid arthritis starting anti-tumour necrosis factor treatment. METHOD: Internal consistency was assessed with Cronbach's alpha. A confirmatory factor analysis (CFA) was carried out to test the single-factor structure. Construct validity was examined by correlating RADAI and RADAI-SF scores with Disease Activity Score in 28 joints (DAS28). Internal responsiveness was evaluated with the paired t test and the standardised response mean (SRM). External responsiveness was assessed with receiver operating characteristic analysis and the SRM, using the EULAR response criterion as external criterion. Change scores were correlated with changes in DAS28. RESULTS: At baseline and after 3 months' treatment, respectively, 191 and 171 patients completed the RADAI. The internal consistency of the RADAI and the RADAI-SF was satisfactory. CFAs confirmed the single-factor structure of both RADAI versions, but the short form provided the best model fit. Moderate correlations were found with the DAS28. SRMs of the RADAI and the RADAI-SF were, respectively, 0.76 and 0.80. Both versions had moderate accuracy to distinguish responders from non-responders. Changes scores were moderately correlated with DAS28 change scores. CONCLUSIONS: This study showed satisfactory psychometric properties of the Dutch version of the RADAI. Omission of the tender joint count (RADAI-SF) produced comparable results and is justified for research purposes. The tender joint count might be useful as additional clinical information in patient management.

Contains fulltext : 53171.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To examine priorities for health status improvement in patients with active rheumatoid arthritis (RA) during anti-tumour necrosis factor (TNF) treatment. METHODS: Data were used from 173 patients with RA starting treatment with TNF-blocking agents. Outcome measures included assessment of health status with the Arthritis Impact Measurement Scales 2 (AIMS2) at baseline and after 3 and 12 months. The AIMS2 contains a priority list from which patients are asked to select from 12 areas of health the 3 in which they would most like to see improvement. RESULTS: After 1 year of treatment, 10 out of 12 areas of health on the AIMS2 were significantly improved. The most commonly selected priorities for improvement at baseline were pain (88%), hand and finger function (57%), walking and bending (42%), mobility (33%), and work (29%). At group level, this priority ranking remained largely unchanged during treatment. After adjustment for multiple comparisons, only pain was selected significantly less often at 3 and 12 months (71% at both assessments). Within individual patients, however, priorities often changed. Changes in the priority of pain were related to the achieved level of patient-perceived pain and disease activity. CONCLUSIONS: This study shows that, at the group level, patients' priorities for improvement are fairly stable during 12 months of anti-TNF therapy, despite major improvements in health status. Although pain reduction becomes somewhat less important, it remains the most commonly selected priority. In contrast, individual patient priorities are not stable over the course of treatment and appear to be associated with differences in disease state.

To identify the determinants of the possession of assistive devices among patients with various rheumatic conditions. In order to determine the influence of the country-related health care system, patients from two different countries were studied.Patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) were selected from rheumatology outpatient clinics in two adjacent regions in The Netherlands and Germany. A total of 142 patients completed a self-administered questionnaire. Information on the possession of assistive devices and data on socio-demographics, clinical status and health status were obtained. Logistic regression analyses were used to identify determinants of the possession of assistive devices.The majority (78%) of the patients possessed at least one or more assistive devices. Obviously, functional status was the most important determinant, followed by the country where the patient resided. More assistive devices were found in increasingly disabled patients as well as in patients living in The Netherlands.Functional status and the patient's country are the most important determinants of the possession of assistive devices among patients with rheumatic conditions. We hypothesize that the most likely explanation for the differences in possession rates between countries are differences in societal systems for the prescription and reimbursement of assistive devices.

Acceptance-based interventions such as mindfulness-based stress reduction program and acceptance and commitment therapy are alternative therapies for cognitive behavioral therapy for treating chronic pain patients. To assess the effects of acceptance-based interventions on patients with chronic pain, we conducted a systematic review and meta-analysis of controlled and noncontrolled studies reporting effects on mental and physical health of pain patients. All studies were rated for quality. Primary outcome measures were pain intensity and depression. Secondary outcomes were anxiety, physical wellbeing, and quality of life. Twenty-two studies (9 randomized controlled studies, 5 clinical controlled studies [without randomization] and 8 noncontrolled studies) were included, totaling 1235 patients with chronic pain. An effect size on pain of 0.37 was found for the controlled studies. The effect on depression was 0.32. The quality of the studies was not found to moderate the effects of acceptance-based interventions. The results suggest that at present mindfulness-based stress reduction program and acceptance and commitment therapy are not superior to cognitive behavioral therapy but can be good alternatives. More high-quality studies are needed. It is recommended to focus on therapies that integrate mindfulness and behavioral therapy.Acceptance-based therapies have small to medium effects on physical and mental health in chronic pain patients. These effects are comparable to those of cognitive behavioral therapy.