Severity and Diurnal Improvement of Morning Stiffness Independently Associate with Tenosynovitis in Patients with Rheumatoid Arthritis

<div><p>Background and objectives</p><p>Although morning stiffness has long been recognized as a characteristic feature of rheumatoid arthritis (RA), it is no more included in the 2010 ACR/EULAR Classification Criteria or in the current major instruments for evaluating disease activity of RA. In this cross-sectional study, we aimed to determine the independent value and the optimal measurement of morning stiffness by clarifying the associations between morning stiffness and synovial inflammation.</p><p>Patients and methods</p><p>We enrolled 76 consecutive RA patients who underwent musculoskeletal ultrasound examination and agreed to participate in the study. In addition to asking the duration of morning stiffness, we asked patients to complete a diagram which represents the time course of their morning stiffness in the dominant hand. Based on this diagram, we calculated the severity and the diurnal improvement of morning stiffness. We also determined the activity of intra-articular synovitis in 11 joints and tenosynovitis in 8 tendons/tendon compartments in the same hand by using power Doppler (PD) ultrasound with a semiquantitative score (0–3).</p><p>Results</p><p>For intra-articular synovitis, swollen/tender joint counts more strongly correlated with total PD scores (ρ = 0.379–0.561, p ≤ 0.001) than did any parameters of morning stiffness (ρ = 0.217–0.314, p = 0.006–0.021). For tenosynovitis, however, the severity on awakening and the improvement of morning stiffness more strongly correlated with total PD scores (ρ = 0.503–0.561, p < 0.001) than did swollen/tender joint counts (ρ = 0.276–0.388, p = 0.001–0.016). Multivariate analyses identified the severity on awakening and the improvement but not the duration of morning stiffness as factors that independently associate with the total tenosynovial PD score.</p><p>Conclusions</p><p>Our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and also give an insight into the optimal measurement of morning stiffness. Our data support an independent value of evaluating morning stiffness in the management of RA.</p></div

Multivariate linear regression models to identify factors which independently associate with power Doppler scores.

<p>Multivariate linear regression models to identify factors which independently associate with power Doppler scores.</p

An example diagram for time course of morning stiffness in dominant hand.

<p>(1) Severity of stiffness on awakening, (2) Severity of stiffness at the first 1/4 of total awake time, (3) Improvement of stiffness at the first 1/4 of total awake time, (4) Severity of stiffness at the first 1/2 of total awake time, (5) Improvement of stiffness at the first 1/2 of total awake time, (6) Severity of stiffness at bed time, (7) Improvement of stiffness at bed time.</p

Prevalence of power Doppler signals in each joint/tendon region.

<p>Prevalence of each power Doppler (PD) grade > 0 in each joint (A) and each tendon region (B). IP, interphalangeal joint; PIP, proximal interphalangeal joint; MCP, metacarpo-phalangeal joint; FD, flexor digitorum; Wrist Ext, wrist extensor tendons.</p

Local clinical manifestations and ultrasound scores in dominant hand.

<p>Local clinical manifestations and ultrasound scores in dominant hand.</p

Patients’ characteristics, current treatment, and disease activity.

<p>Patients’ characteristics, current treatment, and disease activity.</p

The relationship between radiation therapy fraction number and normalized prostate volume in 19 patients.

<p>There was no significant time trend.</p

Values of the average prostate deformation in the manually defined segments.

<p>Values of the average prostate deformation in the manually defined segments.</p

Definition of the proposed prostate deformation quantification metric.

<p>The solid and dashed lines represent the prostate contours in the planning CT and CBCT scans, respectively. (a) A 2D representation of the sagittal contours of the prostate. To align the positions of the base and apex of prostate contours in the CBCT scans to those in the planning CT scan, craniocaudal views of the prostate contour in the CBCT scans were either expanded or contracted. They were returned to their original states after the alignment. (b) A 2D representation of the axial contours of a prostate. The cross mark is the CoG of the prostate in a representative slice. The arrows indicate the prostate deformation directions.</p

Standard deviations of the prostate deformation in the manually defined segments.

<p><i>Abbreviations</i>: superior-anterior segment: S-A; superior-posterior segment: S-P; superior-right segment: S-R; superior-left segment: S-L; middle-anterior segment: M-A; middle–posterior segment: M-P; middle–right segment: M-R; middle–left segment: M-L; inferior-anterior segment: I-A; inferior–posterior segment: I-P; inferior–right segment: I-R; inferior–left segment: I-L.</p><p>Standard deviations of the prostate deformation in the manually defined segments.</p