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Rheumatoid Arthritis (RA) is one of the most prevalent inflammatory joint diseases in the developed world and 1% of the UK population is affected. Arthritis pathology is complex and is driven by pro-inflammatory cytokines such as Interleukin 1 (IL-1) and Tumour Necrosis Factor-a. Biologics which target these cytokines have proved successful in the clinic although not all patients respond to these treatments suggesting that other pro-inflammatory cytokines are involved. Research has suggested a role for Oncostatin M (OSM) in the pathology of arthritis and studies have suggested OSM can synergise with IL-1 to promote cartilage catabolism.

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An investigation into the effects of plantar foot pressure on the microcirculation of healthy subjects and patients with Rheumatoid Arthritis was carried out. In the light of no equipment available to carry out this study a new system was developed. A shoe device was built with a combined pressure/skin blood flow transducer embedded in a three-tier piston mechanism in the heel so that plantar foot pressure could be applied/removed and quantified. The skin blood flow transducer made contact with the skin and was able to collect data about the microcirculatory state of the skin. The first system developed consisted of the laser Doppler Fluxmeter (Moor Instruments Ltd., UK) used to collect skin blood flow information and incorporating a strain gauge (Kyowa Electronic Instruments Co. Ltd., Japan) to quantify plantar foot pressure applied to the centre of the heel. This system was visually/sound synchronised and due to the time delay error it was modified. For the final system developed, the strain gauge was replaced with a custom-made Novel capacitative transducer (Novel, Germany) to quantify pressure. This allowed for the pressure system to be electronically synchronised in real time with the laser Doppler fluxmeter using an electronic synchronisation box. A number of studies were carried out to validate the systems. The developed systems were used to: (a) investigate the effects of the venoarteriolar response in healthy subjects with regards to the effects of plantar foot pressure on skin blood flow. The study concluded that subject positioning (that is, supine or semi-weight bearing) has an effect on how the microcirculation of the skin reacts to applied pressure. Thus, studies investigating the effects of external pressure on skin blood flow must have their subjects in a position that is related to what is being studies; (b) investigate the effects of plantar foot pressure on skin blood flow in patients with Rheumatoid Arthritis. A healthy control group was compared with a cohort of patients with Rheumatoid Arthritis with no evidence of vasculitis. The study concluded that there were no significant differences between both groups. A number of articles have been published from this thesis (see Appendix 14).

The chronic pain associated with rheumatoid arthritis (RA) is identified by patients as a priority for treatment and is said to shape their illness experience. However, review of the literature reveals that little is known about patients' perspectives on pain in RA, with even less being known about how rheumatologists, the clinical experts in patient care, perceive this phenomenon. Increasing knowledge and understanding of patients' and rheumatologists' perspectives on pain can be used to try to influence their action/inactions as well as helping to identify patients' specific concerns and unmet needs. The aims of this study were: To describe patients' and rheumatologists' perspectives on the meaning of pain in RA; To explore how these pain meanings are constructed; and To consider the implications of these constructions for pain management. This interpretive, qualitative study used semi-structured interviews to generate accounts related to respondents' perspectives on pain in RA. Purposive sampling was used to select a heterogeneous group of patients with RA (n=29) and rheumatologists (n=16). Thematic analysis was used inductively to generate findings using a cumulative, constant comparative technique (Strauss and Corbin, 1998). Both patients and rheumatologists presented multiple pain meanings but generally viewed pain as an expected symptom of the disease, both being resigned to the belief that most patients would have some degree of daily pain. Additionally, both groups considered the pain experience to have a pervasive, negative impact on life, potentially threatening the patient's concept of 'self'. In contrast, patients' and rheumatologists' pain meanings regarding clinical topics were not similar. Patients' views of medical responsibility were narrowly difined, rooted in western biomedical conceptions of pain and were influenced by experiences of clinical interactions. Accordingly, patients viewed the rheumatologist to be responsible only for 'legitimate' pain i.e. pain associated with the body and disease processes. Rheumatologists, on the other hand, presented a more comprehensive understanding of pain by incorporating psychological and social theories along with an associated 'ideal' model of care (reflecting a biopsychosocial approach). Consequently, they identified eclectic roles/responsibilities for themselves in patient management. However, rheumatologists viewed this 'ideal' as difficult to attain in the context of their experiences of clinical work where multiple constraints were perceived to exist, such as difficulties in deciphering pain, the perception of limited resources (e.g. time) and organisational barriers. In light of this, their role was often reduced to focusing simply on disease management, thus displacing the 'ideals' of patient-centred care and perpetuating the dominant biomedical discourse of pain in the clinical context. This thesis adds to the body of knowledge about patients' perspectives on pain when they live with a chronically painful condition and patient barriers to reporting pain. New findings are presented regarding the medical experts' conceptions of pain; in particular, those related to complex clinical work. The findings also identify areas of unmet need regarding patients' knowledge of pain, pain management and of the roles and responsibilities of healthcare professionals. Suggestions are made for further work in the areas of investigating patient barriers to reporting pain; exploring patient perspectives on self-management and using alternative research methods to complement and develop the findings from this study.