Shoulder and upper extremity impairments, activity limitation and physiotherapeutic exercise in women with rheumatoid arthritis : a biopsychosocial approach

University dissertation from Stockholm : Karolinska Institutet, Department of Public Health Sciences

Abstract: The aim of this thesis was to evaluate both specially-designed and commonly used instruments for measuring impairments, activity limitation and health-related quality of life (overall Sickness Impact Profile (SIP)). The focus was on shoulder and upper extremity. The relationships between concepts according to the International Classification of Impairments, Activity limitation and Participation (ICIDH) were studied. The instruments studied were also used in an evaluation of physiotherapeutic shoulder exercises. Ninety patients with mild or moderate RA were included in the studies. The results showed low clinical reliability and large day-to-day variations when measuring active motion range in the shoulder. A dynamic muscle function test for the shoulder also showed large day-to-day variations. A functional shoulder-arm movement impairment instrument showed satisfactory reliability though day-to-day variations. It correlated significantly (r=0.42-0.68) to pain during shoulder-arm movement, passive shoulder (except passive adduction) and elbow extension motion ranges, and active wrist motion range, isometric shoulder rotational muscle strength, a part of a specially-constructed shoulder-arm activity limitation questionnaire (SDQ), the Health Assessment Questionnaire, parts of the Functional Status Questionnaire, and the physical dimension and overall SIP. The shoulder-arm movement impairment instrument indicated construct and content validity and the SDQ indicated construct validity. The single variables as number of swollen joints in the upper extremity, passive shoulder (except adduction) and elbow motion range, isometric and isokinetic (concentric internal rotation) shoulder rotational strength did not indicate activity limitation or the overall SIP. However, the variables pain (including Ritchie index for upper-body half and shoulder tendalgia), shoulder-arm movement, passive shoulder adduction, and active elbow supination and wrist motion, and shoulder isokinetic eccentric internal rotational strength range did. In combining the variables, shoulder-arm movement, pain during movement and isokinetic eccentric shoulder internal rotation strength explained a rather large proportion (61.4 %) of the SDQ 1, covering predominantly personal hygiene activities. Still, the shoulder and upper-extremity variables indicated activity limitation and overall SIP to a rather small extent (11.330.2 %). Static and dynamic shoulder rotator endurance training in a group of women (n=37) were compared in a randomised study and measurements were taken at start, after 10 weeks training, and after a further 10 weeks. After the training both groups had fewer swollen joints (p=0.02) and less pain during movements (p=0.04) and during dynamic (p<0.002) and static (p=0.02) muscle function test of shoulder. The dynamic exercising group also improved according to the physical dimension (p=0.004) and overall SIP (p<0.002). The results of the studies showed that movement, pain and muscle strength are related to activity limitation and overall SIP but to a rather small extent although shoulder-arm activity limitation, disease-specific and more general activity limitation and health-related quality of life questionnaires were used in the analysis. Threshold levels, the severity of the disease, motivational, emotional and coping factors and impairments in other joints not studied in this thesis might explain the part of variation that our variables did not explain. Thus, it seems that all levels in the ICIDH-model have to be measured if all consequences of the disease are to be understood.

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