Journal of Rehabilitation Research and Development

Rehabilitation R & D Progress Reports 1986

X. Arthritis

X. Arthritis

The Use of Biofeedback and Cognitive Behavioral Psychotherapy in the Treat ent ofSevere Rheumatoid Arthritis Patients : A Controlled Evaluation

Kenneth E . Applebaum; Edward B. Blanchard, Ph .D .; Maria Paz-Alfonso, M .D.; Edward J . Tickling, Psy.D.East Orange Veterans Administration Medical Center, State University of New York, Albany, NY and VeteransAdministration Medical Center, Albany, NY 12208Sponsor: VA Medical Center and State University of New York at Albany

Purpose—According to the Arthritis Founda-tion, arthritis is the number one crippling dis-ease in the United States . The majority of allarthritis patients under the age of 45 are thosewith rheumatoid arthritis (RA) . Five million in-dividuals in the United States have RA. Littleis known about the etiology of this disease;however, it is known that RA may manifest asa chronic and degenerative disease . This dete-rioration may affect many aspects of life, in-cluding psychological and functional activities.

Medical treatment provided by a multidis-ciplinary team has become the standard totreat the RA patient. Within this team ap-proach, psychophysiological intervention, as anadjunct to the standard medical regimen, hasbeen used. Psychophysiological treatments haveincluded relaxation training, biofeedback, andcognitive behavioral approaches to chronicpain. These interventions have a logical basiswith regard to the maintenance of the RA con-dition. Lysosomal activity in the inflamed jointsmay prove differentially responsive to thermalbiofeedback . Also, the behavioral manifesta-tions accompanying chronic pain may be ame-nable to cognitive behavioral interventions inan effort to help patients cope and deal withthe chronic nature of the RA condition.

Progress—This study utilized both a within-groups and a between-groups design in an effortto assess the effectiveness of a psychophysiolo-gical approach to the treatment of RA . Anactive treatment group was compared with await list control group. Both groups receivedpre- and post-assessments . The treatment con-sisted of progressive relaxation training, ther-

mal biofeedback, and cognitive-behavioral ap-proaches to the treatment of chronic pain . Bothgroups were monitored for pain, sleep, andmedication indices for a 10-week period, usingboth psychological and functional test measuresduring the treatment.

The participants in this study were 18Stage II and Stage III RA sufferers, 8 malesand 1 female per group. All subjects were fromthe Albany Veterans Administration MedicalCenter, referred from the Rehabilitative Medi-cine or Rheumatology Services.

During the initial assessment, a detailedarthritis history was administered to each sub-ject. Additionally, psychological measures in-cluding the Beck Depression Inventory, StateTrait Anxiety Inventory, McGill Pain Question-naire, MMPI, and Functional Activities Ques-tionnaire were administered. Following thecompletion of these inventories, all patientswere shown how to monitor pain, sleep, andmedication indices on preprinted arthritis dia-ries. At the conclusion of this initial assess-ment, all patients were assessed in PhysicalTherapy for range of motion, grip strength, andtimed walk.

At the conclusion of the initial assessment,all patients in the wait list control group wereinstructed to monitor pain, sleep, and medica-tion indices for a 10-week period of time . Thepatients in the active treatment group wereasked to return to the hospital in 2 weeks inorder to begin treatment. Treatment consistedof twice-weekly meetings for the first 4 weeks.Then, once-a-week meetings were held for 2weeks. Two weeks after the last treatment ses-sion, patients in the active treatment group re-

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turned to the hospital for post-treatment assess-ment. Thus, all patients in each group had apre-assessment followed in 10 weeks by a post-assessment.

Preliminary Results—All data have been col-lected and are currently undergoing analysis . Itis hoped that this intervention will have afford-

ed an improvement in chronic pain and adjust-ments that these patients have in their dailyliving. It is conjectured that this may be due tothe perceived sense of control gained in psycho-physiological intervention as well as modest im-provements in physical functioning . Dependingon results of this study, a more comprehensiveambitious project may be begun.

Arthritis Rehabilitation Unit

Carolyn Brunner, M.D . ; Cynthia Stabenow, OTR ; Stephen Wegener, Ph.D . ; Amy O'Leary, MARehabilitation Research and Training Center, University of Virginia Medical Center, Charlottesville, VA 22908Sponsor : National Institute of Handicapped Research

Purpose—The purpose of the Arthritis Reha-bilitation Unit (ARU), which consists of fivebeds in a 22-bed general rehabilitation unit, isto identify methods of managing arthritis pa-tients that will result in either keeping thememployed or in eliminating the need . The staffconsists of a rheumatologist, orthopedic sur-geon, psychiatrist, rehabilitation nurses, occu-pational and physical therapists, social work-ers, psychologists, and a vocational rehabilita-tion counselor.

Progress—To date, more than 160 patientshave been admitted to the inpatient rehabilita-tion program. The primary diagnosis is rheu-matoid arthritis, although patients with otherdiagnoses such as osteoarthritis and ankylosingspondylitis are admitted.

During the grant period the staff of theARU have been collecting demographic data onpatients participating in the program . In addi-tion, the staff is using the Arthritis ImpactMeasurement Scale, an outcome measure devel-oped at the Boston University Multipurpose Ar-thritis Center, to assess patients on nine scales:mobility, physical activity, dexterity, householdactivity, social activity, ADL, pain, depression,and anxiety . Three-month, 6-month, and 1-yearfollowup data are collected on all of the pa-tients at the rehabilitation unit to help deter-mine the long-term benefits of the rehabilita-

tion program.Training efforts have included a program

in arthritis for the rehabilitation nurses on theunit, a physical therapy consultant to discussmanagement of musculoskeletal problems in ar-thritis for the entire staff, a statewide programfor public health nurses in rehabilitation of pa-tients with arthritis, and a nationwide videoconference on management of arthritis usingthe multidisciplinary team approach.

The staff has completed a survey of morethan 500 rehabilitation units to help determinethe scope of arthritis rehabilitation in theUnited States and the need for staff training inmanagement of arthritis patients . The ARUstaff has also been engaged in a cooperativeeffort with the Virginia Division of Rehabilita-tion Services to place a part-time vocationalcounselor in the Arthritic Clinic and makeavailable a program evaluator to interview pa-tients. Information is gathered on their employ-ment status or disability status to determinethe extent to which people with arthritis areplaced on disability and the extent to which re-habilitation services are utilized.

The staff currently has two researchprojects under way . These include an investiga-tion of sleep problems in patients with rheuma-toid arthritis and an outcome study of equip-ment use following discharge from the inpa-tient rehabilitation program .

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Impact of Arthritis Self-Care for Rural Persons

Jean Goeppinger, Ph.D.University of Virginia, School of Nursing, Charlottesville, VA 22903Sponsor : National Institute of Handicapped Research

Purpose—The purpose of the Arthritis Self- thritis pain and function.Care (ASC) project is to develop and evaluatethe impact of arthritis self-care programs for Preliminary Results—In 1985 we : 1) began therural persons. The independent variable is type

process of entry into the rural communities se-of arthritis self-care program, correspondence

lected as research settings ; 2) identified andcourse, or small-group format; the dependent trained approximately 55 lay persons as corn-variables are knowledge, self-care behavior,

munity coordinators of the correspondencepain, depression, and function/disability ; inter-

course or as lay leaders of the small groups ; 3)vening variables are self-care efficacy and

recruited participants; and 4) completed thesocial support .

processes of random assignment, pretesting,and intervention with the first cohort of partici-

Progress—Between 1982 and 1984 we : 1) con- pants (N = 250) . In 1986 we completed randomducted an assessment of the education needs of assignment, pretesting, and intervention with arural persons with arthritis; 2) developed the

second cohort of participants (N = 250) . Weself-care curriculum; 3) "packaged" the curricu-

also began the collection of post-test data, at 4-lum in six classes that are offered to the par- month, 8-month, and 12-month intervals.ticipants in either the correspondence course or Throughout the project we have presented oursmall-group format; and 4) completed a study of preliminary findings at professional meetings,the psychometric properties and ease of admin- regional and national, and have recently begunistration of selected instruments to assess ar-

to publish our results.

Multipurpose Arthritis Center: Stanford University

Halsted R. Homan; James F. Fries; Deborah P. Lubeck; Diana B . DuttonStanford University, Palo Alto, CA 94304Sponsor : National Institutes of Health

Purpose—The Stanford Arthritis Center (SAC)conducts research, educational, and patientcare programs to improve health outcomes ofarthritic patients. In particular, SAC designsand implements new educational and communi-ty programs and gauges their success by out-comes experienced by patients . To do so, SACdraws upon multifaceted research activities,large numbers of patients and community phy-sicians, cooperating hospitals and health serv-ices, a major system for managing data(ARAMIS), and skills of economists, epidemiolo-gists, educators, and health professionals in as-sessing new programs.

Progress—Central to SAC activities is develop-

ment of reliable methods to evaluate healthoutcomes. SAC has developed instrumentsmeasuring functional status, symptoms, adverseeffects of drugs, and costs of health care for ar-thritic persons; other instruments, particularlyconcerning psychological variables and qualityof life, are in developmental phases . This workdepends upon a core unit that assists in experi-mental design, instrument development, datamanagement and computational issues, biosta-tistics, and data analysis.

Continuing are seven successful programsconcerning long-term outcomes for rheumatoidarthritis, juvenile arthritis and joint replace-ment; self-management education for patients;comparison of osteoarthritis outcomes in three

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different health services ; comparison of teamversus individual physician care of chronic ar-thritis of the elderly; and treatment of refracto-ry lupus nephritis with total lymphoid irradia-tion. Six new projects are added, all related tochronic arthritis : identification of influentialpsychological factors; analysis of incidence bypopulation characteristics ; a new method for es-timating indirect costs ; the impact of exerciseon incidence of osteoarthritis ; distinction be-

tween seronegative and seropositive arthro-pathies; and search for a pathogenic antigen incartilage of rheumatoid joints.

Improved outcomes for arthritic patientsnationally must occur within the limits of fi-nancial resources available . This center devel-ops and evaluates care programs for largegroups of arthritic patients with the objectiveof improving the effectiveness, efficiency, andsatisfaction achieved by health services.

Multipurpose Arthritis Center: Boston University

Robert F . MeenanBoston University, School of Medicine, Boston, MA 02118Sponsor : National Institutes of Health

Purpose—This proposal describes in detail aplan to expand and strengthen the Boston Uni-versity Multipurpose Arthritis Center (MAC) . Aprogram of activities and specific projects willbe pursued in three major components : re-search, education, and community/health serv-ices research. The proposal also describes aplan to support areas of special research inter-est by means of two core units and to continuean effective administration component.

The research component will build on astrong base of work funded from other sources.In addition, four developmental and feasibilitystudies are proposed : 1) a study of Vitamin Ametabolism in prealbumin forms of amyloid dis-ease; 2) the isolation of cDNA clones for serumamyloid A; 3) an investigation of stair climbingand arthritis ; and 4) a study of the difficulty di-mension in functional assessments.

Progress—MAC education efforts will continueto be aimed at a broad spectrum of arthritishealth professionals in conjunction with theSchools of Medicine, Nursing and Allied HealthProfessions of Boston University . Specificprojects in the education component will in-clude an evaluation of the current status ofhouse officer education in rheumatology at in-ternal medicine and family practice residencyprograms, a study of the effects of a targetedtraining program on interpersonal skills of

physical therapy students, and an investigationof coping in chronic arthritis.

Future Plans—Activities in the Community/HSR component of the MAC will continue tofocus on the inner-city community in conjunc-tion with the Department of Health and Hospi-tals of the city of Boston . Seven specific commu-nity/health services research projects are pro-posed: 1) a project to modify the ArthritisImpact Measurement Scales for use in clinicalpractice; 2) a project to develop a computer-based community network for clinical rheuma-tology trials; 3) an inner-city nursing homeproject combining outreach and data collectionfor this important population ; 4) a study of therheumatology referral behavior of general in-ternists and family practitioners ; 5) an epide-miologic study of osteoarthritis in conjunctionwith the Framingham Heart Study ; 6) an epide-miologic study of oral contraceptives and rheu-matoid arthritis in conjunction with an estab-lished drug epidemiology group ; and 7) an in-vestigation of the relationship between stressfullife events and disease activity in rheumatoidarthritis.

Two core units are proposed : an amyloidstudies core unit and a research and evaluationsupport core unit . These core units will supportnumerous investigations in areas of special in-terest to the Center .

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Northeast Ohio Arthritis Center Support : Legal Aspects of Chronic Illness—A Study ofArthritis Patients

Judith P. LiptonCase Western Reserve University, Cleveland, OH 44106

Sponsor : National Institutes of Health

Purpose—The long-term objectives of this pro-posal are: 1) to expand efforts directed towardsthe education of health professionals, patients,families, and the general public ; 2) to develop,implement, and evaluate prototype community/health services programs at a high level of sci-entific endeavor ; and 3) to expand clinical andbasic research efforts.

Progress—New programs in education include:1) an evaluation of use of the education-influen-tial in teaching rheumatology to family prac-tice training units ; 2) studies of continuinggraduate medical education in arthritis withemphasis upon involvement of the learner inthe identification of objectives ; and 3) augmen-tation of an audiovisual library as an umbrellaeducational resource.

Specific new community programs include:1) a systems analysis of arthritis health care de-livery in Northeast Ohio; 2) identification of thelegal needs of arthritis (chronically ill) patients ;

3) studies of the perceived needs of arthritis pa-tients, and available resources to meet thoseneeds as viewed by the patient and communityhealth nurses ; 4) the establishment of an indus-trial database pertaining to arthritis problemsand management in Northeast Ohio ; and 5) anevaluation of Northeast Ohio MAC/communityorganizations' behavioral interrelationships . Re-search programs are targeted to study cartilagemetabolism and osteoarthritis, mediators of in-flammation, acute phase reactants, the immuneresponse in arthritis, genetic /clinical interplaysin ankylosing spondylitis, and myopathic disor-ders .

Core programs include a cell/tissue cultureunit, and an evaluation/education core as anoverall resource to center project components.Administration includes administrative policy,executive, steering (operations), and communityadvisory committees to fully integrate center/university/community activities.

Multipurpose Arthritis Center: Community Component—Coping Responses toRheumatoid Arthritis ; Social Security Disability Study; Role Performance Limitations inWomen With RA

Glenn G. Affleck; Arthur Weinstein ; Susan T. ReisineUniversity of Connecticut Health Center, Farmington, CT 06032Sponsor: National Institutes of Health

Progress—The NIH Multipurpose ArthritisCenter is currently funding four major educa-tional efforts: the computer-assisted patienteducation project, the physician-assisted pro-gram, family resident training education, andphysical therapist education.

The computer-assisted patient educationproject has successfully completed a programfor patients and families of patients with rheu-matoid arthritis. This has been well received bypatients and is currently undergoing testing byboth patients and their families . Editing of the

program will proceed along with the evaluationprocess.

The physician-assisted program has com-pleted a longitudinal study in which physiciansare in contact with a patient with rheumatoidarthritis (the computer) over a period of 7years. This is being evaluated by various typesof physicians and by medical students . Editingof the program will continue as the evaluationproceeds.

The third program involves developingmethods for teaching family medicine residents

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and is continuing during the next year inwhich more data will be available and the test-ing methods improved.

The fourth program involves teachingmethods and content development in the areaof physical therapy . Undergraduate teaching ofrheumatology by our NIH Multipurpose Arthri-tis Center funded physical therapist-educator isnow in progress, and efficacy will be evaluated

during the coming year.The research project on C3 phenotypes has

led to interesting findings in that juvenile onsetsystemic lupus erythematosus patients have ahigher incidence of one phenotype than adultonset patients. Patients with other rheumaticdiseases are currently being evaluated . The Ad-ministrative Unit is functioning adequately forthe Center.

Multipurpose Arthritis Center: Pain Management in Arthritis ; Physical ConditioningExercise Programs for the Arthritis Patient ; Motor Skill Learning; Mini-Sabbatical forPhysical and Occupational Therapists

Jerry C. Parker; Marian A. Minor; Terry D . Tenbrink; Marilyn K. SanfordUniversity of Missouri, Department of Medicine, Columbia, MO 65212Sponsor : National Institutes of Health

Purpose—We propose the following objectives for arthritis patients.under education and training : 1) train arthritis

The community program objective is to: 1)specialist professionals to become educators ; 2)

determine the needs of various communities asprovide high quality continuing education pro-

related to arthritis ; 2) plan programs bestgrams for all professionals ; 3) develop improved suited to meet these needs; and 3) conduct com-curricula in musculoskeletal disease for under- munity demonstration programs in public andgraduate and graduate education of primary professional groups.care professionals ; and 4) study the effect of pa-

Methods will include questionnaires on in-tient education and team care in knowledge, at- formation, attitudes, and behavior ; computertitudes, and behavior in rheumatoid arthritis .

analysis, regional and national conferences;The research objective of our work is to de- team visits to communities ; and personal par-

termine if a computer-assisted program can in- ticipation in a multidisciplinary team approachcrease the efficacy of the expert rheumatologist

to patient care in arthritis.to influence favorably the medical management

Multipurpose Arthritis Center : Community Component—Studies Using a Panel ofRheumatoid Arthritis Patients ; Secondary Data Studies; Education Component-Arthritis In-Service Program for Home Health Agencies

Edward H. Yelin and Ida M . MartinsonSan Francisco General Hospital, San Francisco, CA 94110Sponsor: National Institutes of Health

Purpose—The Multipurpose Arthritis Centerconducts a broad range of activities in each ofthree areas—education, community programs,and research . A strong basic research programincludes studies in the underlying mechanismsof the rheumatic diseases, particularly immuno-logical mechanisms. Almost all this research issupported by sources other than the center

grant. Among the activities directly supportedby the current grant, the highest priority isgiven to education, particularly education ofprimary care physicians, nurses, and alliedhealth professionals.

One objective is to improve the knowledgeand skills of students and practitioners of thesedisciplines in caring for people with arthritis .

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High priority is also given to research on a va-riety of issues in the delivery of health care topeople with arthritis . Other objectives of thisresearch are to construct a database in suchareas as the distribution of rheumatology man-power, the costs and utilization of health serv-ices, and the causes and consequences of work

disability, and to analyze the data for their im-plications for public policy.

The center also conducts programs in pa-tient and public education and is both an advo-cate in the community for people with arthritisand a source of authoritative information aboutthe special needs of this group.

A National Arthritis Data Source (ARAMIS)

James F . FriesStanford University, Palo Alto, CA 94304Sponsor: National Institutes of Health

Purpose—ARAMIS (the American RheumatismAssociation Medical Information System) is arheumatic disease computer data bank systemcontaining longitudinal clinical data for ap-proximately 19,000 patients and 120,000 patientencounters, and representing more than100,000 patient-years of observation . Thesystem operates from an IBM 370/3081 comput-er at Stanford University and is accessed na-tionally through TYMNET or TELENET com-munications networks using the Time-OrientedData Bank (TOD) data management system.

Progress—The program is based upon thepremises that chronic diseases have become themost prevalent health problems, that study ofsuch diseases requires observation of occur-rences over prolonged time periods, that the ex-pense of longitudinal study requires use ofeconomies of scale, that patient outcome inchronic disease results from a complex inter-play between multiple factors, and that manyimportant questions need to be studied with ob-servation and experiments . This program hasthe goal of improving knowledge, management,and patient outcome in arthritis by providinglong-term information relating disease severity,patient characteristics, social factors, and treat-ment to patient outcome.

The program has two major aims : first, tocontinue to develop a national data resource ofhigh quality, longitudinal, accessible clinicaldata; and second, to employ these data in a sys-tematic, multicenter investigative program ofmajor clinical questions in the rheumatic dis-eases . Program priorities include the classifica-tion and definition of diseases, the systematicstudy of long-term (6- to 20-year) outcomes, theeconomic impact of illness and treatment, andstudy of regional and national differences.Thirty clinical investigators and epidemiolo-gists at 12 institutions undertake more than 50projects annually.

The present proposal includes classificationstudies of osteoarthritis, rheumatoid arthritis,vasculitis, and systemic lupus erythematosus;economic impact studies in each major disease;comparative studies of arthritis at differentsites; population-based studies of incidence andprevalence; and long-term studies of outcome inrheumatoid arthritis, juvenile arthritis, sclero-derma, systemic lupus, osteoarthritis, and fol-lowing joint surgery . With this project, 15 yearsof data development at numerous institutionsare brought to bear upon major clinical ques-tions, and very large and detailed longitudinalpatient data sets are made nationally available .

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Epidemiology Program Project : Rheumatoid Arthritis—Course and Outcome

Leonard T . KurlandMayo Foundation, Rochester, MN 55901Sponsor: National Institutes of Health

Purpose—Under the Rochester EpidemiologicProgram Project (REPP), a unique population-based data source, covering the medical histo-ries of the Olmsted County population through-out their local residence, has been developed.

Progress—This central diagnostic index hasserved as the basis for over 180 epidemiologicstudies on a myriad of topics—many relating tocritical health issues of national importance,and all with excellent case ascertainment . Theresearch facility has been used not only by theREPP staff, but also by many clinical andpublic health colleagues both within and out-side of the Mayo Clinic . The REPP provides thepopulation-based data for several other majorprogram projects, including the Comprehensive(Minnesota) Epilepsy Center and the MayoStroke Center . The continued updating of thecentral diagnostic index is essential to preservethis research potential .

Future Plans—In the near future it will be nec-essary to obtain support for our epidemiologicprogram from the several categorical institutesof NIH. The purpose of this continuation pro-posal is to apply for funds that will allow for anorderly transition without a breakdown of thebasic system. In this proposal, we request fund-ing for: 1) continued supplementation of theMayo Clinic diagnostic index with data fromthe Olmsted Medical group, Olmsted Communi-ty Hospital, and several other non-Mayosources of medical care in Olmsted County ; 2)the development, from the medical records, ofan Olmsted County population frame to permitunbiased selection of controls for case-controlstudies; 3) development of methods within thedatabase for studies of familial aggregation ; 4)continued support for epidemiologic projectsnow nearing completion, such as rheumaticfever, prostate cancer, and cholelithiasis; and 5)new studies in limb fractures and trauma tothe nervous system.

Multipurpose Arthritis Center : Problem-Oriented Educational Program for ArthritisUsing Aerobic-Type Exercise

Susan G . PerlmanNorthwestern University, Chicago, IL 60611Sponsor: National Institutes of Health

Purpose—This MAC proposal engages scholarsand scientists from various schools and depart-ments of Northwestern University and fromthe community in a comprehensive arthritisprogram. Five feasibility projects are proposed:cell cytotoxicity in rheumatoid arthritis; phe-nytoin modulation of collagen and collagenesesynthesis in synovial cells and effect on macro-phages; connective tissue constituent immuno-genicity in juvenile chronic arthritis ; synovialpathology in early osteoarthritis ; and analysisof osteoarthritic and rheumatoid bone for usein prosthesis design. These projects will supportnew young scientists as well as allow three

senior scientists to extend or redirect theirwork.

The second area of focus is an interdiscipli-nary educational program, utilizing a problem-solving approach, aimed at both professionalsand patients. The three projects proposed areto: train and evaluate rheumatology fellows asteachers of medical residents using a new cur-riculum to be developed in outpatient musculos-kelatal disease; evaluate a problem-oriented,aerobic-like exercise program for arthritics ; anduse a discussion group format to enhance prob-lem-solving skills in the older osteoarthritic.The interdisciplinary team includes profession-

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al educators, a medical education evaluator,and health professionals at the medical school.

The third area of focus, community andhealth services research, draws upon a strongbase of community involvement combined withthe research excellence of Northwestern'sCenter for Health Service and Policy Research(CHSPR). Three interrelated projects explorevarious aspects of knee pathology. The first willdevelop and validate a measure of outcome fora subsequent comparative study. The secondwill examine the costs of treatments for osteo-arthritis of the knee . The third builds upon the

work of the earlier two to compare costs and ef-ficacy of arthroscopic surgery and alternatives.Three additional projects add breadth to the re-search agenda focusing upon musculoskeletalimpairment in the elderly, status of familieswith juvenile arthritic children and a multi-center study of Social Security payment alloca-tion systems.' The Biostatistics and Data Management

Core will provide individual project technicalassistance as well as database management fora computerized case finding patient index.

Multipurpose Arthritis Center: Education—Arthritis Patient Education Model;Medical Allied Health Professions Integrated Curriculum in Arthritis; ArthritisRehabilitation Training Program for Industrial Managers ; DisabilityDetermination of Arthritis

Brenda Devellis ; Marlys M . Mitchell; Charles P. Friedman; Paul LeungUniversity of North Carolina at Chapel Hill, Chapel Hill, NC 27514Sponsor: National Institutes of Health

Purpose—The UNC-CH Multipurpose ArthritisCenter (MAC) represents a broadly based, co-ordinated effort by faculty and staff in theSchools of Medicine, Nursing, and PublicHealth to develop new basic knowledge, en-hanced education, and improved mechanismsfor health care delivery in arthritis . Providingspecial impetus and support in this regard arethe following: Area Health Education CentersProgram; NC Rehabilitation Network ; UNC Re-habilitation Program; the ongoing Arthritis Re-habilitation in Industry Program; and the NCState Arthritis Act and its legislated planningcommittee. Certain new directions in an al-ready well-established immunology researchprogram will be pursued, e .g., study of the idio-type/anti-idiotype network in human auto-immune disease, analysis of tissue depositedimmune complex function in SLE, and the es-tablishment of an immunoreagent/immunoas-say core facility.

The major thrust of MAC-proposed activi-

ties, however, concerns a series of innovativeprojects in the education and community com-ponents. These include : 1) study of a new psy-chosocial model for patient education; 2) devel-opment of educational models in arthritis foroccupational and physical therapists, both aspart of a core undergraduate curriculum, andalso in the community for those already inpractice; 3) development of a health care modelfor ambulatory elderly patients with arthritisto be conducted jointly by nurse practitionersand occupational therapists ; 4) analysis of theSocial Security Administration disability deter-mination process for arthritis ; 5) developmentof a model training program in arthritis and re-habilitation for industrial managers with appli-cability to the general problem of the workerwith arthritis; and 6) an epidemiologic study ofpatterns of arthritis care in Eastern NorthCarolina. In all of these projects, particular em-phasis has been placed upon effective evalua-tion, which will be aided by an evaluation core .

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Robert B. Brigham Multipurpose Arthritis Center : Feasibility Study—Evaluation of TotalKnee Replacement by Gait Analysis ; Community Component—Social Security ,Disability Study

Sheldon R . Simon and Matthew H. KiangBrigham and Women's Hospital, Boston, MA 02115Sponsor: National Institutes of Health

Purpose—This grant is requested to developthree areas of special interest. The first is ap-plied research in which we aim to : 1) develop anecessary and sufficient database for the ra-tional planning of health services to arthritics;and 2) develop and evaluate model componentsof cost-effective health care delivery for arthri-tis patients. Thus, under community compo-nent, we propose to develop and criticallyevaluate: a seven-day rehabilitation workschedule; a model health care system for arthri-tis disability ; stepped-up rehabilitation servicesto homebound patients ; a system of follow-up ofrheumatic disease patients discharged from atertiary care facility ; a patient-oriented strate-gy to improve clinical outcomes; and an educa-tional strategy for the primary prevention oflow back injuries in the work place.

As one of the four major joint replacementcenters in the world, we propose to evaluate thecost-effectiveness of joint replacement by a mul-tidimensional outcome assessment . We seek todocument the economic burden to arthriticsand shortfalls in the present health care reim-

bursement scheme. We also propose to evaluatethe means by which interventions can be evalu-ated by comparing the relative merits of exist-ing health status functional instruments.

The second priority is the development of acore unit for quantitative research methods,clinical epidemiology and evaluation research,which would overlap with many activities ofthe center and would aid investigators in train-ing and establishing investigators . The unitwould support at least 10 projects, from theday-to-day management of special disease regis-tries to clinical studies directed at improvingclinical strategies and registries to clinical stud-ies directed at improving clinical strategies anddecision-making in rheumatology, and applica-tions of basic research.

Finally, we propose pilot studies in a ne-glected area of research, the management ofsevere rheumatoid arthritis patients who havefailed all conventional therapy ; thus, the proto-cols addressing the critical evaluation of totalnodal irradiation therapy and leukapheresistherapy of refractory rheumatoid arthritis.

Study of Behavioral Aspects of Rheumatoid Arthritis

Kenneth A. WallstonVanderbilt University, School of Nursing, Nashville, TN 37240Sponsor : National Institutes of Health

Purpose—The long-term objective of thisproject is to gain a fuller understanding of thebehavioral aspects of rheumatoid arthritis (RA),a chronic condition that affects more than 5million persons in the United States and is aleading cause of disability . The major questionto be explored is : Why and how do some per-sons with RA manage to cope very effectivelywith this disease while others appear to becomehelpless in the face of it? Specifically, this in-vestigation aims to 1) investigate longitudinally

the health and illness behaviors of a samples(panel) of persons with RA ; and 2) to determinethe extent and developmental course of learnedhelplessness and active coping in persons withthis condition.

This investigation will lay the groundworkfor future interventions aimed at helping per-sons with RA cope with their illness . A panel of360 patients with RA ranging from those newlydiagnosed to those who have had the conditionfrom 5 to 6 years will be studied at six-month

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intervals over a 3-to-3.5-year-period via mailedquestionnaires and/or telephone interviews.

Progress—Among the instruments already de-veloped for this project are measures of arthri-tis-specific attitudes, locus of control beliefs, de-pressive affect, values, health and illness behav-iors, and functional capacity . These measureswill be administered repeatedly over the courseof the study to ascertain changes in behaviorand its psychological concomitants . This designwas chosen to provide data over the first 10years of a person's history with rheumatoid ar-

thritis and its resulting disabilities.

Future Plans—Multiple regression analyses areplanned to test theoretical models linking ar-thritis history and experience variables to indi-cators of learned helplessness or coping which,in turn, will be regressed upon health and ill-ness behaviors and health outcomes . In addi-tion to testing models, these data will provide awealth of systematically gathered descriptiveinformation to greatly expand our knowledge ofrheumatoid arthritis.

Energy Conservation and Joint Protection in Rheumatoid Arthritis

L. H. GerberNational Institutes of Health, Bethesda, MD 20892Sponsor: National Institutes of Health

Progress—To facilitate the adoption of energyconservation (EC) and joint protection (JP) be-haviors in adults with rheumatoid arthritis(RA), a workbook-based education programusing behavioral modification techniques withemphasis on developing behavioral awarenessand problem-solving skills was designed . Toevaluate the effectiveness of this intervention,a randomized study was designed to comparetraditional occupational therapy (OT) trainingin the NIH and EC centers (Ann Arbor, Michi-gan; Brigham and Women's, Boston ; and GoodSamaritan, Baltimore). Patients were evaluatedusing an activity record adapted to measure be-havioral objectives, as well as ADL, joint, psy-chosocial adjustment to illness, and patient andfamily knowledge evaluations . Experimentaland control patients were tested immediatelybefore treatment, and three months and oneyear following treatment . Behavioral objectivesincluded modified patterns of rest and physicalactivity, including increasing frequency of restduring physical activity periods, increasingtime spent physically active and in preparationand planning .

Preliminary Results—A total of 28 patientsfrom all centers were entered from March 1983until March 1984 . Three months of data on 23patients are currently available . Findings fromthe activity record showed that 46 percent ofthe experimental and 12 percent of the controlpatients improved in the amount of time spentphysically active (p = 0 .1); 53 percent of the ex-perimental and 16 percent of the control pa-tients increased the frequency of rest during pe-riods of physical activity (p = 0 .07); and 50 per-cent of the experimental and 20 percent of thecontrol patients increased the time spent inpreparation and planning . Three months aftertreatment, 25 percent of the control patients in-creased their index of physical activity (IPA)(i.e., index of the balance between rest andphysical activity) while 47 percent of the exper-imental patients increased their IPA.

Although the number of patients in thispreliminary research study is small, the resultsindicate that the new program may be more ef-fective in changing energy conservation behav-iors in RA than current approaches .

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Arthritis

Ferrographic and Biochemical Analysis of Wear Particles in Human Joints Dana C . Mears, B .M., B .CH., D .D. S., and Christopher H. EvansVeterans Administration Medical Center, Pittsburgh, PA 15240Sponsor : VA Rehabilitation Research and Development Service

Purpose—This project had two goals . The firstwas to use the technique of ferrography to ana-lyze the wear particles of human synovial fluidswith the aim of providing improved diagnosticand prognostic information. The second was todetermine to what extent the wear particleswere involved in pathophysiological processesin arthritic joints.

The ferrographic analysis has confirmedthe presence of discrete populations of cartilagi-nous particles within the synovial fluids ofhuman joints. Furthermore, these populationsvaried according to the nature of the disorderswithin the joint . This was best illustrated bythe results obtained with knees with torn ante-rior cruciate ligaments . Here, a large popula-tion of very small microspheres of cartilage wasrecovered . Our biochemical studies suggest thatthese particles may be involved in the arthriticdegeneration that often follows transection ofthis ligament.

Preliminary Results—Preliminary ferrographicstudies have also shown that the pattern of par-ticles obtained from rheumatoid fluids is quitedifferent from those seen in non-rheumatoidfluids. Furthermore, the ferrographic analysisof fluids from prosthetic joint replacements hasyielded promising results.

Wear particles activate synoviocyte cul-tures, promoting the synthesis of collagenaseand other neutral proteinases . At least part ofthis response is due to the collagenous compo-nent of the particles, as this alone is active.These reactions are probably important in vivo,as our results have shown that intraarcticular-ly injected wear particles or highly purified car-tilage proteoglycans promote arthritic changesin rabbits' knees.

Synoviocytes activated by wear particles, ortheir products, secrete substances related to in-terleukin-1 which cause chondrocytes to de-grade their own cartilaginous matrix .