SUMMARY OF THESIS

Dynamic Therapeutic Exercise in Rheumatoid Arthritis The aim of the thesis was to develop a comprehensive rationale for dynamic therapeutic exercise, and to investigate the influence of such exercise on functionally independent patients with rheumatoid arthritis (RA). Dynamic therapeutic exercise was defined as an aerobic exercise approach with muscle work during joint motion, which takes into account not only quantitative aspects such as joint mobility, muscle function and aerobic capacity, but also qualitative aspects regarding the psychosocial distress imposed by the disease, and its impact on daily functioning.

Few patients in a population of functionally independent RA patients (n = 69) had a high inflammatory activity index, and Larsen’s radiological index indicated low-to-moderate joint destruction. Pain and stiffness were experienced as significant problems, and as important obstacles to exercise. Lowered performance and significant activity-induced pain were found in functional tests. Activity-induced pain was strongly related with functional impairment and work status, weakly with inflammatory activity, and not at all with Lar- sen’s radiological index. In a controlled study, once-weekly water exercise during four years did not have any negative side-effects, but conferred better grip strength, fewer admis- sions for acute hospital care and increased frequencies of self-selected exercise. Radiological progression during four years was related with mean ESR, but not with self-selected exercise frequencies, gender, age, symptom duration or rheu- matoid factor positivity. Uncertainty was identified, in a phenomenographic study, as a central theme of thoughts in nine interviewed females with RA, and the needs it raised, and strategies for meeting them and reducing it were cate- gorized. A dynamic therapeutic 12-week home exercise pro- gramme carried out by 42 RA patients 5 times a week conferred better physical capacity, decreased pain, and in- creased self-efficacy for mood and sleep. Joint tenderness and the perception of activity-induced pain were further improved by adding cognitive treatment (goal-setting and reinterpretation of pain) to the exercise programme for one of two randomized exercise sub-groups.

In conclusion, a comprehensive rationale for dynamic therapeutic exercise in functionally independent RA patients would include their desires to be active, their need for in- creased control over the disease, a decreased physical capac- ity, and activity-induced pain. Such exercise does not aggra- vate the rheumatic disease, but contributes, even with limited clinical supervision, to improved physical capacity, better self-efficacy , decreased pain and changed exercise beha- viour.

Christina H. Stenstrorn, Department of Rehabilitation and Physical Medicine, Kurolinska Institute, P. 0. Box 60500, S-104 01 Stockholm, Sweden.

On the Significance of Sulphated Polysaccharides in the Pathogenesis of Arnyloidosis The hallmark of amyloidosis is the deposition of amyloid in the extracellular matrix of virtually all kinds of tissue. Irre- spective of what biochemical or clinical variant is involved, the amyloid deposits are always constituted by unique fibrils of protein nature. In addition, a series of extracellular matrix and basement membrane elements seem to occur in all forms of amyloid so far studied, glycosaminoglycans (GAGS) and proteoglycans (PGs) being among the principal components. The present investigation was aimed at characterizing such complex polysaccharides associated with different amyloids. Moreover, the association between amyloid fibrils and GAGsPGs was adressed. Evidence is provided that there is a specific and relatively strong association between various GAGs/PGs and different amyloid fibrils of human origin. Heparan sulphate PGs, some of which exhibit immunolog- ical identity with certain basement membrane PGs, comprise a quantitatively important component of the amyloid-associ- ated polysaccharides. Immuno-localization of such PGs in amyloid was demonstrated. In addition, galactosaminogly- can chains, apparently detached from their protein back- bone, are major constituents as well. It seems that both types of macromolecules are in part calcium-dependently associ- ated with the fibrils and have a specific affinity to the amyloid P-component (protein AP). Employing an expefl- mental model of reactive (AA) amyloidosis was given the opportunity of characterizing the amyloid-associated PGs in more detail. Important similarities with the data obtained from human materials were disclosed. First, the accumu- lation of sulphated polysaccharides in amyloid does not seem to depend on a decreased catabolism alone, but rather on an enhanced PG-synthesis. Intriguingly, the upregulation of PG synthesis precedes deposition of amyloid fibrils. Heparan sulphate PGs, resembling those found in human prepara- tions, were demonstrated in addition to free dermatan/chon- droitin sulphate chains which seem to accumulate in the deposits during advanced disease.

The fact that biochemically and clinically distinct human amyloids, and those from other species, exhibit similar G A G P G distribution profiles probably bears on the signif- icance of such polysaccharides in the pathogenesis of amy- loidosis. Enhanced PG synthesis even at the stage prior to amyloid deposition might also suggest that the polysaccha- rides contribute to fibril aggregation and stabilization in vivo.

Tore Stenstad, Department of Rheurnatology, Institute of Clinicul Medicine, University of Trams@, N-9037 Tromsm, Norway.

Received 7 December 1993

Received 2 December 1993

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0 1994 Scandinavian University Press on license from Scandinavian Rheumatology Research Foundation

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