Chronic physical illnesses, such as rheumatoid arthritis (RA), that are painful and disabling not only impact on a person’s ability to complete normal daily activities (e.g. dressing, bathing, walking etc.) but may also have a negative impact on psychological well-being. Although a large number of prospective observational studies have examined psychological well-being in RA, none has used appropriate statistical techniques to examine variability in change over time at the individual level. The overarching aim of this dissertation is to use advanced quantitative methods to examine how psychological well-being in RA changes over the course of the disease; and to identify demographic, clinical and psychosocial factors that influence how the disease affects psychological well-being. This aim is addressed via a programme of research with three objectives: (i) to describe patterns of change in psychological well-being during the RA disease course; (ii) to quantify the association between psychological well-being and somatic symptoms; and (iii) to investigate the impact of illness cognitions and coping on psychological well-being. The programme of research consists mainly of analysis of a subsample of data collected as part of the Early RA Study (ERAS, N = 784), an ongoing observational study of RA patients followed prospectively from first presentation to a rheumatologist. A major problem relating to the assessment of psychological distress in individuals with chronic physical illness is the overlapping symptomatology with depression. An examination of the factorial validity of the Hospital Anxiety and Depression Scale (HADS), in the ERAS cohort, indicated the presence of a bifactor structure. Specifically, a general distress factor along with orthogonal (autonomic) anxiety and (anhedonic) depression factors was found to provide the optimal empirical explanation of the covariance in item responses. Further analysis, revealed that responses to one of the depression items were biased by disease severity. However, the magnitude of this bias was negligible, confirming the suitability of this tool in RA populations. For the ERAS cohort, general psychological distress was observed to reduce rapidly early in the course of the disease, stabilising after around two to three-years. However, further analysis suggested that subgroups with distinct longitudinal patterns of distress were present within the sample. Confirming observations in other disease groups, four distinct longitudinal patterns of distress were identified: resilient, chronic distress, delayed distress and recovered. Interestingly, changes in distress were related to self-reported somatic symptoms but not serological markers of disease activity. Building on these findings, analyses that jointly modelled changes in psychological distress with changes in the common somatic symptoms of pain and functional limitation revealed strong cross-sectional and longitudinal associations. This extends the findings of previous research by showing the importance of considering the impact of the disease course on the underlying trajectory of distress. Due to the lack of psychosocial data available in the ERAS cohort a further prospective study, involving 230 RA patients, was conducted to examine the influence of illness cognitions and coping on the affect of the disease on psychological well-being over a period of 6-months. Coping was not found to be related to changes in psychological well-being. Analysis revealed two groupings of patients with similar patterns of illness cognitions that were labelled adapters and non-adapters. Furthermore, cognitions concerning the attribution of symptoms to RA and the perceived personal consequences of their condition were related to changes in psychological distress, even after controlling for demographic and clinical characteristics; and there was some indication that a higher reported level of understanding of their condition was related to increased future positive outlook. In conclusion, the findings of this programme of research highlight the need for the early identification and treatment of RA, not only to slow the progression of the disease but also to maintain or improve psychological well-being. Early treatment is currently focused on pharmaceutical interventions. A tailored psychosomatic approach to treatment involving the skills of a wide range of health professionals, such as nurses, physiotherapists, occupational therapists and psychologists is likely to improve outcomes in RA.

No description available.

A number of studies have indicated that individuals with arthritis have a decreased risk for Alzheimer's disease (AD). Inflammatory processes are implicated in the neurodegeneration associated with AD and the reduced risk associated with arthritis may be due to the anti-inflammatory (AI) drugs used by these individuals. The present project used magnetic resonance imaging (MRI) to assess the integrity of gray and white brain matter in AI users compared to controls not taking AIs. Thirty six female AI users were compared to thirty three controls. All participants underwent extensive neuropsychological testing. MRI scans included diffusion-weighted imaging, sensitive to the microstructural integrity of brain matter, high resolution anatomical imaging for the determination of brain volume, and T2 fluid attenuated inversion recovery (FLAIR) imaging, sensitive to white matter damage that is seen as hyperintense regions on this type of image. AI users showed increased brain integrity in the frontal lobes and in the corpus callosum, compared to controls indicated by diffusion imaging. Volumetric analysis indicated that AI users and controls have different relationships between brain volume and age. AI users showed greater brain volume than controls at higher ages, particularly in frontal and parietal brain regions, and in the cingulate. White matter hyperintensity volume did not differ between AI users and controls. Finally, the data indicated that non-steroidal anti-inflammatory drug (NSAID) use, but not methotrexate use, had a beneficial effect on cognitive function, particularly in the domain of memory function.

Aims: The overall aim of this thesis was to further our understanding of extensor muscles and their role for hand function. The aims of the studies were: To develop and evaluate a new device for finger extensor force measurements. To evaluate ultrasound as a tool for assessment of muscle architecture. To determine the correlation between extensor muscle force and hand function. To evaluate the degree of impaired finger extensor force in rheumatoid arthritis (RA) and the correlation to impaired... mer hand function. To analyse the effect of hand exercise in RA patients and healthy subjects with ultrasound and finger extension force measurements. Method: A new finger extension force measuring device was developed and an ultrasound based method was used to be able to objectively measure the finger extension force and analyze the static and dynamic extensor muscle architectures. Measurements were made of healthy volunteers (n=127) and RA patients (n=77) during uninfluenced and experimental conditions. A hand exercise program was performed and evaluated with hand force measurements, hand function test, patient relevant questionnaires (DASH and SF-36) and ultrasound measurements. Results: The new finger extension force measurement device was developed and then validated with measurements of accuracy as well as test-retest reliability. The coefficient of variation was 1.8 % of the applied load, and the test-retest reliability showed a coefficient of variation no more than 7.1% for healthy subjects. Ultrasound examination on m. extensor digitorum communis (EDC) showed significant differences between healthy men and healthy women as well as between healthy women and RA patients. The extension and flexion force improved in both groups after six weeks of hand exercise (p<0.01). Hand function improved in both groups (p<0.01). The RA group showed improvement in the results of the DASH questionnaire (p<0.05). The cross-sectional area of the EDC increased significantly in both groups. Conclusions: A new finger extension force measuring device has been developed which provides objective and reliable data on the extension force capacity of normal and dysfunctional hands and is sufficiently sensitive to evaluate the effects of hand exercise. US provide useful information about muscle architecture. A significant improvement of hand strength and hand function in RA patients was seen after six weeks of hand training, the improvement was even more pronounced after 12 weeks. Hand exercise is thus an effective intervention for RA patients, providing better strength and function.

Rheumatoid arthritis (RA) is a chronic, destructive, inflammatory arthritis that places significant burden on the individual and society. This thesis represents the most comprehensive effort to date to determine the accuracy of administrative data for detecting RA patients; and describes the development and validation of an administrative data algorithm to establish a province-wide RA database. Beginning with a systematic review to guide the conduct of this research, two independent, multicentre, retrospective chart abstraction studies were performed amongst two random samples of patients from rheumatology and primary care family physician practices, respectively. While a diagnosis by a rheumatologist remains the gold standard for establishing a RA diagnosis, the high prevalence of RA in rheumatology clinics can falsely elevate positive predictive values. It was therefore important we also perform a validation study in a primary care setting where prevalence of RA would more closely approximate that observed in the general population. The algorithm of [1 hospitalization RA code] OR [3 physician RA diagnosis codes (claims) with ≥1 by a specialist in a 2 year period)] demonstrated a high degree of accuracy in terms of minimizing both the number of false positives (moderately good PPV; 78%) and true negatives (high specificity: 100%). Moreover, this algorithm has excellent sensitivity at capturing contemporary RA patients under active rheumatology care (>96%). Application of this algorithm to Ontario health administrative data to establish the Ontario RA administrative Database (ORAD) identified 97,499 Ontarians with RA as of 2010, yielding a cumulative prevalence of (0.9%). Age/sex-standardized RA prevalence has doubled from 473 per 100,000 in 1996 to 784 per 100,000 in 2010, with approximately 50 new cases of RA emerging per 100,000 Ontarians each year. Our findings will inform future population-based research and will serve to improve arthritis surveillance activities across Canada and abroad.

Rheumatoid arthritis (RA) is a chronic, destructive, inflammatory arthritis that places significant burden on the individual and society. This thesis represents the most comprehensive effort to date to determine the accuracy of administrative data for detecting RA patients; and describes the development and validation of an administrative data algorithm to establish a province-wide RA database. Beginning with a systematic review to guide the conduct of this research, two independent, multicentre, retrospective chart abstraction studies were performed amongst two random samples of patients from rheumatology and primary care family physician practices, respectively. While a diagnosis by a rheumatologist remains the gold standard for establishing a RA diagnosis, the high prevalence of RA in rheumatology clinics can falsely elevate positive predictive values. It was therefore important we also perform a validation study in a primary care setting where prevalence of RA would more closely approximate that observed in the general population. The algorithm of [1 hospitalization RA code] OR [3 physician RA diagnosis codes (claims) with ≥1 by a specialist in a 2 year period)] demonstrated a high degree of accuracy in terms of minimizing both the number of false positives (moderately good PPV; 78%) and true negatives (high specificity: 100%). Moreover, this algorithm has excellent sensitivity at capturing contemporary RA patients under active rheumatology care (>96%). Application of this algorithm to Ontario health administrative data to establish the Ontario RA administrative Database (ORAD) identified 97,499 Ontarians with RA as of 2010, yielding a cumulative prevalence of (0.9%). Age/sex-standardized RA prevalence has doubled from 473 per 100,000 in 1996 to 784 per 100,000 in 2010, with approximately 50 new cases of RA emerging per 100,000 Ontarians each year. Our findings will inform future population-based research and will serve to improve arthritis surveillance activities across Canada and abroad.

No description available.

Over the past decade results from a series of research studies have contributed to the development and evaluation of the Arthritis Self-Management Program (ASMP), a volunteer-led patient education program for persons with arthritis. To date, these studies have primarily focussed on program effectiveness, process, implementation, and dissemination. In these studies self-efficacy was identified as an important construct contributing to the program's effectiveness, however, the exact relationship between self-efficacy and health outcomes has not been determined. In this dissertation research I investigate the evidence of a causal relationship between self-efficacy and three program outcomes (a decrease in depression, less pain, and a higher self-rating of overall health status), and attempt to determine the nature of that relationship. The research methodology involved the use of structural equation modeling (SEM) with two longitudinal samples, one (n=122) of 1991 ASMP participants in British Columbia, the other (n=189) of 1992 ASMP participants in Ontario. In the analysis self-efficacy was paired separately with depression, pain and perceived health status. The results of the SEM failed to confirm a dominant causal relationship from self-efficacy to depression, or to pain. This may indicate that these variables have a reciprocal or "spiral" relationship or that both sets of variables may be caused by factors not considered in the analysis. The results of the SEM between self-efficacy and perceived health status did, however, show that higher self-rated health status leads to higher self-efficacy at a later time. The data did not show statistical significance for other causal patterns among these variables. The findings suggest that self-efficacy may play a moderator role in the complex relationship involving individuals with arthritis, their behaviors, and health outcomes. As well, the findings have implications for health promotion planning and research in that they reinforce the complex interplay of psychological and behavioral variables (probably influenced by social variables) in programs which attempt to give individuals greater control over their health. The efficacy and effectiveness of the ASMP has been established in previous studies. This study in no way calls these into question. It does, however, suggest that the mechanism by which these effective outcomes are achieved warrants further investigation.

No description available.

The hypothalamic-pituitary-adrenal (HPA) axis, a system activated by stress, is traditionally considered to affect the susceptibility to chronic pain via effects on peripheral processes. This study investigates whether the HPA axis contributes to the development of chronic pain in an animal model via direct effects on central pain mechanisms. / First, correlations between pain processes and the susceptibility to chronic pain in an animal model that is correlated with HPA-axis function were examined. The results show that, in the Fischer rat, the amount of pain suppression observed during the formalin interphase depression is negatively correlated with susceptibility to polyarthritis. Since the formalin interphase depression mechanisms are within the central nervous system, the results suggest a role for central pain mechanisms in the development of polyarthritis. / Hypophysectomy inhibits the development of adjuvant-induced arthritis. To test whether hypophysectomy inhibits adjuvant-induced polyarthritis via central pain mechanisms, the analgesic effect of hypophysectomy was examined in the formalin test. The results show that hypophysectomy specifically prolongs the formalin interphase depression, further supporting that the underlying central pain suppression mechanisms are associated with resistance to adjuvant-induced polyarthritis. / Corticotropin-releasing factor (CRF) was then investigated as a possible underlying mechanism of the effects of hypophysectomy. Peripheral injection of CRF into inflamed tissue affects pain mechanisms unrelated to the susceptibility to adjuvant-induced polyarthritis. However, central and intravenous administration of CRF preferentially affect the formalin interphase depression mechanisms. The observed dose-response relationships indicate that these effects are due to direct actions of CRF within the central nervous system. / In conclusion, the results strongly suggest that the HPA axis modulates the susceptibility to adjuvant-induced polyarthritis via direct effects on supraspinal pain suppression mechanisms. Thus, the HPA axis may contribute to the development of chronic pain syndromes associated with HPA-axis abnormalities, such as rheumatoid arthritis and fibromyalgia, via effects on pain mechanisms within the central nervous system.