title: The Nottingham Health Profile as a measure of disease activity and outcome in rheumatoid arthritis. Validation of the Functional Assessment of Chronic Illness Therapy Fatigue Scale relative to other instrumentation in patients with rheumatoid arthritis. Patients' perceptions of fatigue in rheumatoid arthritis: overwhelming, uncontrollable, ignored. Patient education program to teach energy conservation behaviors to patients with rheumatoid arthritis: a pilot study. Effects of exercise on fatigue, aerobic fitness, and disease activity measures in persons with rheumatoid arthritis. Quality of life assessment: a comparison of four questionnaires: for measuring improvements after total hip replacement Diclofenac sodium (Voltaren) and ibuprofen in rheumatoid arthritis. A randomized double-blind study. Statistical approach to indices of disease activity in rheumatoid arthritis. A program for improving energy conservation behaviors in adults with rheumatoid arthritis. Effect of recombinant human erythropoietin and intravenous iron on anemia and disease activity in rheumatoid arthritis. EFFECTS OF A MODIFIED DANCE-BASED EXERCISE ON CARDIORESPIRATORY FITNESS, PSYCHOLOGICAL STATE AND HEALTH STATUS OF PERSONS WITH RHEUMATOID ARTHRITIS
abstract: Clinical measurement in rheumatoid arthritis ( RA ) has focused on articular problems . Although measures like the Health Assessment Question naire ( HAQ ) are widely used to determine functional impairment , there is a need to determine the overall effect of RA on general health status . We evaluated the relationship of a generic health status measure-the Nottingham Health Profile (NHP)-to the clinical , laboratory and radiological changes in the EULAR core data set for RA . Two hundred consecutive out- patients with RA were recruited . Their mean age was 58.9 yr and mean disease duration 11.3 yr . Patients completed the NHP and the following assessment s were made : the EULAR Core Data Set , the duration of morning stiffness , the Disease Activity Score ( DAS ) , rheumatoid factor ( RF ) levels , and Larsen 's score for X-rays of h and s and wrists .  RA patients had higher scores on the NHP than both a r and om population sample and a second sample of patients with a variety of common diseases . NHP scores were not related to age or disease duration in RA . There was little relationship between perceived distress and the Larsen score , RF , ESR and C-reactive protein levels . Moderate associations were seen between NHP scores and disease activity measures , including the number of tender and swollen joints , pain and the duration of early morning stiffness , and also with a disability measure-the HAQ . NHP scores were highly related to disease activity measured by DAS . High DAS scores were associated with high scores in the energy level , pain and sleep sections of the NHP . The NHP gives relevant information about RA patients . They have high scores for pain , physical mobility and energy level sections , and also have high distress for sleep and emotional reactions OBJECTIVE This study vali date d a brief measure of fatigue in rheumatoid arthritis ( RA ) , the Functional Assessment of Chronic Illness Therapy ( FACIT ) Fatigue Scale . METHODS The FACIT Fatigue was tested along with measures previously vali date d in RA : the Multidimensional Assessment of Fatigue ( MAF ) and Medical Outcomes Study Short-Form 36 ( SF-36 ) Vitality . The sample included 636 patients with RA enrolled in a 24 week double blind , r and omized clinical trial ( RCT ) of adalimumab versus placebo . RESULTS The FACIT Fatigue showed good internal consistency ( alpha = 0.86 to 0.87 ) , strong association with SF-36 Vitality ( r = 0.73 to 0.84 ) and MAF ( r = -0.84 to -0.88 ) , and the ability to differentiate patients according to clinical change using the American College of Rheumatology ( ACR ) response criteria ( ACR 20/50/70 ) . Psychometric performance of the FACIT Fatigue scale was comparable to that of the other 2 fatigue measures . A minimally important difference in FACIT Fatigue change score of 3 - 4 points was confirmed in a separate sample of 271 patients with RA enrolled in a second double blind RCT of adalimumab versus placebo . CONCLUSION The FACIT Fatigue is a brief , valid measure for monitoring this important symptom and its effects on patients with RA OBJECTIVE Fatigue is commonly reported by patients with rheumatoid arthritis ( RA ) but is rarely a treatment target . The aim of this study was to explore the concept of fatigue as experienced by patients with RA . METHODS Fifteen patients with RA and fatigue ( > or = 7 on a 10-cm visual analog scale ) were individually interviewed and asked about the description , cause , consequence , and management of fatigue . Transcripts were systematic ally analyzed by 2 research ers independently , relevant phrases were coded , and earlier transcripts were checked for the emerging codes . A r and om sample of analyses were independently review ed . A total of 191 codes arising from the data were grouped into 46 categories and overarching themes . RESULTS Vivid descriptions reflect 2 types of fatigue : severe weariness and dramatic overwhelming fatigue . RA fatigue is different from normal tiredness because it is extreme , often not earned , and unresolving . Participants described physical , cognitive , and emotional components and attributed fatigue to inflammation , working the joints harder , and unrefreshing sleep . Participants described far-reaching effects on physical activities , emotions , relationships , and social and family roles . Participants used self-management strategies but with limited success . Most did not discuss fatigue with clinicians but when they did , they felt it was dismissed . Participants held negative views on the management of fatigue . CONCLUSION The data show that RA fatigue is important , intrusive , and overwhelming , and patients struggle to manage it alone . These data on the complexity of fatigue experiences will help clinicians design measures , interventions , and self-managment guidance We report a prospect i ve , r and omized pilot study comparing a new workbook-based program , design ed to teach patients with rheumatoid arthritis ( RA ) energy conservation behaviors , with st and ard occupational therapy ( OT ) .  Sixteen patients took part in the new program and nine received the st and ard therapy .  Data on the number of tender or swollen joints , grip strength , walk time , activities of daily living , psychologic adjustment to illness , and daily activity log , were measured before and three months after intervention . Eleven percent of those who received st and ard therapy and 50 % of those who received the workbook increased their amount of physically active time ( p = .10 ) . Twenty-two percent of the control group and 50 % of those in the workbook group achieved a better balance of rest and physical activity ( p = .07 ) . We conclude that the adoption of energy conservation behaviors is different in the two groups . This initial study suggests that interrupting physical activity with rest periods may result in increased physical activity in patients with RA The effects of 12 weeks of low-impact aerobic exercise on fatigue , aerobic fitness , and disease activity were examined in a quasi-experimental time series study of 25 adults with rheumatoid arthritis ( RA ) . Measures were obtained preintervention , midtreatment ( after 6 weeks of exercise ) , end of treatment ( after 12 weeks of exercise ) , and at a 15-week follow-up . ANOVAS for repeated measures showed that those subjects who participated more frequently reported decreased fatigue , while those who participated less frequently reported an increase in fatigue . All subjects , on average , showed increased aerobic fitness and increased right and left h and grip strength , decreased pain , and decreased walk time . There were no significant increases in joint count or sedimentation rate . Significant improvements in measures at the 15-week follow-up also were found . Findings indicate that persons with RA who participate in appropriate exercises may lessen fatigue levels and experience other positive effects without worsening their arthritis Summary Three experimental question naires were compared with the Influence of Rheumatic Diseases on Health and Lifestyle ( IRGL ) question naire , a Dutch version of the Arthritis Impact Measurement Scales . Sixty-two patients with osteoarthritis ( OA ) and 35 patients with rheumatoid arthritis ( RA ) , all of whom underwent hip arthroplasty , completed the study . Results showed that visual analogue scales for pain , stiffness , fatigue , and anxiety were strongly correlated with a number of the IRGL scales . Patient preference scales were sensitive to change and provided additional information on aspects of the patients ' quality of life ( QOL ) that were felt to be important by the patients themselves . The question naire on performance in various roles in life was insensitive to change . In existing question naires , there is an attempt to represent the concept of QOL in terms of its most important aspects . Such realizations of the concept of QOL are not entirely suitable for application in clinical trials . The IRGL is overly complex , and its sometimes comprehensive scales do not deal with the possible effects of treatment . Neither of these properties is conducive to sensitivity to change . Visual analogue scales reduce the complexity . A simpler representation of QOL that can evaluate aspects relevant to treatment is recommended A double-blind , cross-over trial compared the antiinflammatory and analgesic effects as well as tolerability of diclofenac sodium ( Voltaren ) and ibuprofen .  Twenty-four out patients with rheumatoid arthritis were included . A single-blind placebo period was inserted between the two active treatments . The daily dose of diclofenac sodium was 50 mg bid and that of ibuprofen 400 mg tid . The duration of each treatment period was 14 days . The efficacy was measured by the following criteria : Articular index ( Lansbury ) , morning stiffness , fatigue , pain ( measured on a visual analogue scale ) , consumption of rescue-analgesics , status of the arthritic condition , and patient preference . No significant differences were found between diclofenac sodium and ibuprofen , but regarding consumption of analgesic , global evaluation , rheumatic activity , and activity index , a slight trend towards a better effect of diclofenac sodium was found . The study had an adequate sensitivity as it could distinguish placebo from the active treatments for all parameters evaluated . No patient was withdrawn for unwanted effects . None of the laboratory data showed abnormalities of clinical relevance When any drug trial is being carried out it is essential that some criterion of improvement be available to assess the efficacy . In the ideal case there is one single measure , reliably and validly assessed , which is acceptable as this criterion . More frequently , however , there are several possible criteria . The usual practice is to deal with each separately and then in the discussion to point out which symptoms responded to treatment . Clinical ly this has obvious advantages in suggesting the appropriate applications of the treatment , but reliability will be increased if the various scores can be combined in some meaningful way . The unsophisticated way to do this is to add together the various scores , but there may be some clinical justification for weighting major symptoms more than minor ones and this can be done . In rheumatoid arthritis , Lansbury ( 1958 ) has been a keen advocate of indices . His Articular Index weighted the score on each joint by the area of joint ( Lansbury and Haut , 1956 ) and his Systemic Index based on morning stiffness , fatigue , aspirin need , grip strength , and erythrocyte sedimentation rate was believed to measure the inflammatory aspects of the disease ( Lansbury , 1956 ) . A double-blind cross-over trial of indomethacin , previously undertaken ( Wright , Walker , and McGuire , 1969 ) in 24 patients with rheumatoid arthritis to investigate the value of the drug compared with phenylbutazone and placebo , was set up in such a way that the Lansbury Systemic Index could be evaluated and the place of other indices determined . The results of this aspect of the study are reported in this paper This paper presents the design and evaluation of an occupational therapy program developed at the National Institutes of Health for teaching energy conservation and joint protection to adults with rheumatoid arthritis . An existing model for educational diagnosis in health education was used to identify program , behavioral , and educational objectives for the new program . The use of this model result ed in measurable objectives , which were used as outcome measures in the r and omized research evaluation of the new program . The dependent variables measured were activity-of-daily-living status , psychosocial adjustment to illness , knowledge , disease activity , pain , and fatigue . None were significantly different after the intervention . The independent variables measured included components of balancing rest and physical activity . After 3 months , a greater percentage of the subjects receiving the workbook-based occupational therapy program than those receiving traditional occupational therapy demonstrated an application of the behaviors the intervention was design ed to change OBJECTIVE To investigate whether treatment of anemia of chronic disease ( ACD ) in patients with rheumatoid arthritis ( RA ) with recombinant human erythropoietin ( rHu-Epo ) in combination with intravenous ( i.v . ) iron influences health related quality of life ( HRQoL ) and clinical outcome including disease activity . METHODS Thirty patients with ACD and RA were treated with 150 IU/kg rHu-Epo twice weekly for 12 weeks . As well , in case of functional iron deficiency 200 mg of iron-sucrose per week was given intravenously . Vitality and fatigue as dimensions of HRQoL were evaluated by the vitality subscale of the Short Form-36 ( SF-36-VT ) and the Multidimensional Assessment of Fatigue ( MAF ) . Muscle strength was measured by the Muscle Strength Index . RESULTS All 28 patients completing the study responded to treatment ; 23/28 patients developed functional iron deficiency and received i.v . iron ( mean absolute dose 710 + /- 560 mg ) . Average hemoglobin concentration increased from 10.7 + /- 1.1 to 13.2 + /- 1.0 g/dl after a mean treatment period of 8.7 + /- 2.3 weeks . Muscle strength increased from 43.5 + /- 11.2 to 49.1 + /- 12.9 and SF-36-VT from 28.2 % + /- 14.3 % to 47.1 % + /- 20.8 % . while fatigue decreased ( MAF from 34.7 + /- 9.3 to 25.0 + /- 11.3 ) . Among the disease activity variables the number of swollen/tender joints , erythrocyte sedimentation rate , Disease Activity Score , and RA Disease Activity Index improved significantly during treatment . CONCLUSION Treatment of ACD in RA patients with rHu-Epo and i.v . iron is safe and effective in correction of anemia , increases muscle strength . improves vitality , and lowers fatigue . In addition we observed a reduction of disease activity ABSTRACT Cardiorespiratory function and exercise tolerance appear very limited in persons with rheumatoid arthritis ( RA ) . Many studies have demonstrated that aerobic exercise training is beneficial to prevent physical deconditioning without inducing adverse effects on an individual 's joints and general health . The present study was conducted to demonstrate that a dance-based exercise program is a safe and efficient activity to improve physical fitness and psychological state in persons with RA . A group of 19 persons ( mean age , 49.3 ± 13 yr ) participated in a  12-wk exercise program  ( twice weekly ) , whereas 10 persons ( mean age , 49.4 ± 12 yr ) served as controls . Health status , use of medication , joint pain and swelling , physical fitness , activity of daily living and psychological state were assessed at baseline , after the 12-wk training program and 6 mo after the end of the program . Exercise training induced a mean improvement of 13 % in aerobic power , with the highest values reaching 40 % . No significant changes were observed in joint status , even though the count of painful joints tended to decrease in the exercise group . Positive changes in depression , anxiety , fatigue and tension were observed after the 12-wk exercise program . These findings provide some evidence s in favor of aerobic exercise in individuals with RA . Furthermore , it is of primary interest to note that a weight-bearing activity with limited ground impacts do not provoke short-term adverse effects on joint status . Further studies , however , are required to determine the long-term effect of weight-bearing exercise on the health status of individuals with RA
target: However , the 4 generic scales would benefit from further validation in patients with RA , the VAS requires st and ardization , and the MAF would benefit from further sensitivity data .
background: OBJECTIVE Fatigue is an important outcome for patients with rheumatoid arthritis ( RA ) .
  The purpose of this study was to identify the scales being used to measure RA fatigue , and to systematic ally examine the evidence for their validation .