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Background: Clinically suspect arthralgia (CSA) is characterised by arthralgia of small joints and considered a risk stage for development of rheumatoid arthritis (RA). However, it remains unknown if the function of the hands is already affected and what mechanisms underlie impaired hand-function in CSA., Methods: We studied various measures of hand function in two CSA populations. CSA patients in the TREAT EARLIER-trial (n=236) were evaluated at baseline for: grip strength on a dynamometer (GS), patient-reported difficulties in the grip domain of the Health Assessment Questionnaire (HAQ) questionnaire and incomplete fist closure at physical examination. Findings were validated in an independent CSA cohort (n=600) where hand function was measured as: GS evaluated by squeezing the examiner's fingers, grip domain of the HAQ questionnaire and fist closure. Contrast-enhanced MRI of the hands measured synovitis, tenosynovitis and bone marrow oedema (summed as subclinical inflammation) in both cohorts., Results: GS (on a dynamometer) was reduced in 75% compared with reference values in healthy controls, 60% reported grip difficulties and 13% had incomplete fist closure. Reduced GS was associated with subclinical inflammation (-0.38 kg/point inflammation, 95% CI -0.68 to -0.08). Studying separate MRI features, GS reduction was independently associated with tenosynovitis, decreasing with -2.63 kg (95% CI -2.26 to -0.33)/point tenosynovitis (range observed tenosynovitis scores: 0-20). Similar relations with tenosynovitis were seen for patient-reported grip difficulties (OR 1.12/point, 95% CI 1.07 to 1.42) and incomplete fist closure (OR 1.36/point, 95% CI 1.03 to 1.79). In the validation cohort, 36% had decreased examiner-assessed GS, 51% reported grip difficulties and 14% incomplete fist closure: all were associated with tenosynovitis. Decreased dynamometer-measured GS was most sensitive for detecting tenosynovitis (75%), while incomplete fist closure was most specific (88%-90%)., Conclusion: Hand function is already often affected before RA development. These limitations are related to subclinical inflammation and tenosynovitis in particular., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA., Methods: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested., Results: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good., Conclusion: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets., Competing Interests: Competing interests: IKH reports personal fees from Abbvie and Novartis, and research grants from Pfizer and IMI-APPROACH (both paid to the institution), all outside of the submitted work. FB reports being CEO of 4MOVING BIOTECH, received personal fees from 4P PHARMA, Boehringer, Bone Therapeutics, CellProthera, Galapagos, GSK, Lilly, Merck Sereno, MSD, Novartis, Pfizer, Servier and Peptinov, and research grant from TRB Chemedica and IMI-APPROACH (paid to the institution), all outside the submitted work. GHB reports personal fees from Pfizer, Sobi, Fresenius, Mylan, Tedec Meiji, Novartis, Sandoz and Faes, outside of the submitted work. EM reports personal fees from Expanscience, Mylan-Meda, TRB Chemedica, Pierre Fabre, Celgene and Fidia, and non-financial support from Pfizer, outside the submitted work. CDM and JJE report a research grant from BMS, outside the submitted work. RR reports personal fees from Abbvie, Celgene, Novartis, Pfizer and Lilly, outside of the submitted work. TAS reports personal fees from Sanofi, AbbVie, Roche and Takeda, outside of the submitted work. ZS reports personal fees from AbbVie, Roche, Pfizer, Berlin Chemie, UCB and Bristol-Myers, outside of the submitted work. RW reports personal fees from Abbvie, Galapagos, UCB, Bristol Myers Squib and Tilman, and grants from Amgen, outside the submitted work. ME reports serving on an advisory board for Pfizer (tanezumab) and research grant from IMI-APPROACH (paid to the institution), outside of the submitted work. SB-Z reports personal fees from Infirst healthcare, Pfizer and Osteoarthritis and Cartilage, outside the submitted work. PH is a co-inventor of the 1000minds software used in this study. MK reports personal fees from Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Novartis and UCB, and research grants from Pfizer, IMI-APPROACH (all paid to the institution), and royalties from Wolters Kluwer and Springer Verlag, all outside the submitted work. YYL reports grants from National Medical Research Council of Singapore, and personal fees from Abbvie, DKSH, Janssen, Novartis and Pfizer, all outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim was to assess the validity and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with SSc., Methods: Data were gathered in connection with a randomized, controlled trial comparing the effectiveness of a 12-week multidisciplinary team care programme, including a hand function treatment module, with regular care. Hand function was evaluated by the MHQ (37 items, six domains: Function, Daily activities, Pain, Work, Aesthetics and Satisfaction) and other measurements, including the HAQ, Hand Mobility in Scleroderma, Sequential Occupational Dexterity Assessment (SODA), grip strength, pinch grip and modified Rodnan Skin Score. Fifty-three patients (28 intervention group and 25 control group) completed evaluation at baseline and after 12 weeks. Validity was determined by computing Spearman correlation coefficients between the baseline MHQ total score and subscales and other measures of (hand) disability. Responsiveness in the intervention group was evaluated by the standardized response mean and effect size (ES). In addition, the pooled ES for the difference between the two groups was computed., Results: Significant correlations were seen between the MHQ total score and the HAQ (r = -0.62), Hand Mobility in Scleroderma (r = -0.54), SODA (r = 0.47), SODA Pain (r = 0.32) and modified Rodnan Skin Score (r = 0.46). The ES of the MHQ total score within the intervention group was 0.49, which was larger than that of all other outcome measures. Similar results were obtained for the standardized response mean. The pooled ES of the difference between intervention and control groups for the MHQ total score was 0.86., Conclusion: The MHQ demonstrated adequate validity and responsiveness in patients with SSc., (© The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc; scleroderma)., Methods: We performed a randomized controlled trial comparing a 12-week multidisciplinary team care program (1 day per week; individual treatments, group exercises, and group education) with outpatient clinic care. Outcome measures included the Hand Mobility in Scleroderma (HAMIS) test, grip strength, maximal mouth opening (MMO), 6-minute walk distance (6MWD), maximum aerobic capacity (VO(2max) ), Checklist Individual Strength 20 (CIS-20), SSc Health Assessment Questionnaire (HAQ), and Short Form 36 (SF-36), assessed at 0, 12, and 24 weeks. Statistical comparisons of change scores were done by analysis of covariance., Results: Twenty-eight patients were assigned to the intervention group (mean age 53.9 years, 15 of 28 with diffuse SSc) and 25 were assigned to the control group (mean age 51.7 years, 15 of 25 with diffuse SSc). Twenty-five patients (89%) in the intervention group completed the treatment program. At 12 weeks, there was a significantly greater improvement in grip strength (2.2 versus -1.8 kg; P = 0.001), MMO (1.4 versus -0.9 mm; P = 0.011), 6MWD (42.8 versus 3.9 meters; P = 0.021), and HAQ score (-0.18 versus 0.13; P = 0.025) in the intervention group, whereas differences for the other outcome measures did not reach significance. At 24 weeks, the effect on grip strength persisted., Conclusion: In patients with SSc, a 12-week multidisciplinary day patient treatment program was more effective than regular outpatient care with respect to 6MWD, grip strength, MMO, and HAQ score, but not for VO(2max) , HAMIS test, CIS-20, SF-36, and visual analog scale for pain. This study provides a first step in quantifying the effect of a multidisciplinary team care program and warrants the conduct of further intervention studies., (Copyright © 2011 by the American College of Rheumatology.)

Objective: To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA)., Methods: In 4 regions in The Netherlands, the Rheumatoid Arthritis Patients In Training exercise program was implemented on a limited scale. Evaluation using the RE-AIM model included: Reach, the proportion of the target population participating; Efficacy, effects on muscle strength, aerobic capacity, functional ability, and psychological functioning; Adoption, program adoption by stakeholders; Implementation, intervention quality (quality audits); and Maintenance, stakeholders' willingness to continue the program in the future., Results: Twenty-five physical therapists from 14 practices were trained to provide the program. In total, 150 RA patients were recruited (by estimation, 2% of the target population). Of the 81 patients who had finished the 12-month intervention and were available for followup directly after the intervention, 62 patients provided clinical data. Muscle strength improved significantly, whereas aerobic capacity, functional ability, psychological functioning, and disease activity did not change. All 9 informed local patient organizations facilitated patient recruitment, and 35 of 51 rheumatologists involved referred one or more patients. All 10 approached health insurance companies funded the program for 12 months. The quality audits showed sufficient quality in 9 of 12 practices. All of the providers of the program were willing to provide the program in the future, whereas future reimbursement by health insurance companies remained unclear., Conclusion: The implementation of an intensive exercise program for RA patients on a limited scale can be considered successful regarding its reach, adoption, and implementation. The limited effectiveness and the limited data regarding maintenance warrant additional research.

Background: An up-to-date overview of the effectiveness and safety of dynamic exercise therapy (exercise therapy with a sufficient intensity, duration, and frequency to establish improvement in aerobic capacity and/or muscle strength) is lacking., Objectives: To assess the effectiveness and safety of short-term (< three months) and long-term (> three months) dynamic exercise therapy programs (aerobic capacity and/or muscle strength training), either land or water-based, for people with RA. To do this we updated a previous Cochrane review (van den Ende 1998) and made categories for the different forms of dynamic exercise programs., Search Strategy: A literature search (to December 2008) within various databases was performed in order to identify randomised controlled trials (RCTs)., Selection Criteria: RCTs that included an exercise program fulfilling the following criteria were selected: a) frequency at least twice weekly for > 20 minutes; b) duration > 6 weeks; c) aerobic exercise intensity > 55% of the maximum heart rate and/or muscle strengthening exercises starting at 30% to 50% of one repetition maximum; and d) performed under supervision. Moreover, the RCT included one or more of the following outcome measures: functional ability, aerobic capacity, muscle strength, pain, disease activity or radiological damage., Data Collection and Analysis: Two review authors independently selected eligible studies, rated the methodological quality, and extracted data. A qualitative analysis (best-evidence synthesis) was performed and, where appropriate, a quantitative data analysis (pooled effect sizes)., Main Results: In total, eight studies were included in this updated review (two additional studies). Four of the eight studies fulfilled at least 8/10 methodological criteria. In this updated review four different dynamic exercise programs were found: (1) short-term, land-based aerobic capacity training, which results show moderate evidence for a positive effect on aerobic capacity (pooled effect size 0.99 (95% CI 0.29 to 1.68). (2) short-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength (pooled effect size 0.47 (95% CI 0.01 to 0.93). (3) short-term, water-based aerobic capacity training, which results show limited evidence for a positive effect on functional ability and aerobic capacity. (4) long-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength. With respect to safety, no deleterious effects were found in any of the included studies., Authors' Conclusions: Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA.

Objective: To compare the effectiveness and acceptability of silver ring splints (SRS) and commercial prefabricated thermoplastic splints (PTS) in treating swan neck deformities in patients with rheumatoid arthritis (RA)., Methods: Consecutive patients with RA and a mobile swan neck deformity were included in a randomized, crossover trial. In 2 different sequences, patients used both splints for 4 weeks, with a washout period of 2 weeks. Afterward, patients used the preferred splint for another 12 weeks. The primary outcome measure was dexterity measured with the Sequential Occupational Dexterity Assessment (SODA). Secondary outcome measures included other measures of hand function, satisfaction with the splints, and splint preference., Results: Fifty patients were included, and 47 (94%) of those completed the study. Eighteen patients (36%) had 1 swan neck deformity, whereas the other patients had 2 or more. The improvement of the total SODA score with the SRS (11.2; 95% confidence interval [95% CI] 8.1, 14.3) and PTS (10.8; 95% CI 7.5, 14.1) was similar (difference -0.5; 95% CI -2.2, 1.2). In addition, there were no significant differences in change scores regarding the other clinical outcome measures, or satisfaction. Twenty-four patients preferred the SRS, 21 preferred the PTS, and 2 patients chose neither. A comparison in the 12-week followup period yielded similar clinical outcomes, with the exception of a significantly higher score in 3 items of satisfaction in the SRS group., Conclusion: For patients with RA and a mobile swan neck deformity, SRS and PTS are equally effective and acceptable.

Objective: To compare the effectiveness of 2 Internet-based physical activity interventions for patients with rheumatoid arthritis (RA)., Methods: A total of 160 physically inactive patients with RA who had a computer with Internet access were randomly assigned to an Internet-based physical activity program with individual guidance, a bicycle ergometer, and group contacts (individualized training [IT] group; n = 82) or to an Internet-based program providing only general information on exercises and physical activity (general training [GT] group; n = 78). Outcome measures included quantity of physical activity (questionnaire and activity monitor), functional ability, quality of life, and disease activity (baseline, 3, 6, 9, and 12 months)., Results: The proportion of physically active patients was significantly greater in the IT than in the GT group at 6 (38% versus 22%) and 9 months (35% versus 11%; both P < 0.05) regarding a moderate intensity level for 30 minutes in succession on at least 5 days a week, and at 6 (35% versus 13%), 9 (40% versus 14%), and 12 months (34% versus 10%; all P < 0.005) regarding a vigorous intensity level for 20 minutes in succession on at least 3 days a week. In general, there were no statistically significant differences regarding changes in physical activity as measured with an activity monitor, functional ability, quality of life, or disease activity., Conclusion: An Internet-based physical activity intervention with individually tailored supervision, exercise equipment, and group contacts is more effective with respect to the proportion of patients who report meeting physical activity recommendations than an Internet-based program without these additional elements in patients with RA. No differences were found regarding the total amount of physical activity measured with an activity monitor.

Objective: To investigate patients' and occupational physicians' satisfaction with the quality of a vocational rehabilitation programme for maintaining work ability in chronic rheumatic diseases., Methods: The vocational rehabilitation programme was developed for patients with rheumatic diseases and consisted of systematic assessment of the problems at work and the development of individual solutions. The programme was run by a multidisciplinary team comprising a rheumatologist, a social worker, a physical and occupational therapist, and a psychologist. Satisfaction ratings were measured using a multidimensional questionnaire involving a rating scale (0-10) and a structured telephone interview., Results: 59 of the 65 patients who participated in the programme (91%) completed the questionnaire. Patients were most satisfied with the interpersonal approach and professional knowledge, and least satisfied with the waiting time for the final report and the practical application of the given advice. Mean satisfaction score was 7.3 (SD 1.0). Twenty eight of the occupational physicians involved were interviewed. They were satisfied with the programme overall; 21 (75%) stated that their role in the vocational rehabilitation process could be defined more clearly, and they would appreciate more contact with the team members, preferably in the early phases., Conclusions: Patients' and occupational physicians' satisfaction with a multidisciplinary vocational rehabilitation programme was good. Areas for improvement mainly concerned the speed of the process and the communication between team members and occupational physicians.