Comprehensive care and psycho-social factors in rehabilitation in chronic rheumatoid arthritis: A controlled study

Comprehensive care and psycho-social factors in rehabilitation in chronic rheumatoid arthritis: A controlled study

J Chron Dis 1972, Vol. 457-467. Pergamon Press. Printed in Great Britain COMPREHENSIVE CARE AND PSYCHO-SOCIAL FACTORS IN REHABILITATION IN CHRONIC RH...

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J Chron Dis 1972, Vol. 457-467. Pergamon Press. Printed in Great Britain

COMPREHENSIVE CARE AND PSYCHO-SOCIAL FACTORS IN REHABILITATION IN CHRONIC RHEUMATOID ARTHRITIS : A CONTROLLED STUDY P. J. VIGNOS,Jr, H. M. THOMPSON,S. KATZ, R. W. MOSKOWITZ, S. FINK* and K. H. SVEC Department of Medicine, University Hospitals of Cleveland, University Circle, Cleveland, Ohio 44106, U.S.A. (Received 7 April 1971; in revised form 21 October 1971)

INTRODUCTION

A CONTROLLED study of comprehensive care in ambulatory patients with severe rheumatoid arthritis was conducted to determine the interrelationships between the type of medical care, psycho-social factors and functional performance. Few of the previously published rehabilitation studies in rheumatoid arthritis which interrelated medical and psycho-social aspects had adequate controls. Furthermore, past studies have generally dealt with hospitalized patients [l-5] although the majority of arthritis patients are cared for on an ambulatory basis. This paper deals with the psycho-social aspects of a controlled one-year rehabilitation study on forty ambulatory patients with chronic severe rheumatoid arthritis. METHODS

Both the intensive treatment and the control groups received medical care through University Hospitals’ multidisciplinary arthritis clinic. The management program for the intensive treatment group included: (1) multidisciplinary management conferences for the purpose of defining goals and recommending a comprehensive treatment program; (2) prompt implementation of the recommendations; and (3) close supervision in the home by means of regular follow-up calls on each treatment patient by a visiting nurse thoroughly familiar with the patient’s prescribed program. Nurses helped with planning and coordinating of home care and assisted with exercises, treatments, activities of daily living and psychological therapy. Selection of study patients and randomization

The study sample consisted of 40 patients with classical or definite rheumatoid arthritis by American Rheumatism Association (ARA) criteria [6] who were between

*Present Address: University of New Hampshire,

Durham, New Hampshire 457

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P. J. VIGNOS,Jr, H. M. THOMPSON,S. KATZ, R. W. M~~KOWITZ, S. FINK and K. H. SVEC

16 and 75 yr of age, who had attended the clinic regularly and who lived within the area served by the Visiting Nurse Association. Further criteria included the presence of rheumatoid arthritis continuously for at least 1 yr with limitation in normal activities, namely, class 2 or 3 by ARA functional criteria and stage 2, 3 or 4 by ARA anatomic classification [7]. Because of a known tendency toward spontaneous remissions in early stages and in order to narrow the variable spectrum of disease, patients with early disease were excluded. At the time of a physician’s prestudy review, at least four joints had to be involved with swelling, tenderness or pain on motion and at least two of the involved joints had to be joints other than hands and wrists. Most patients had more than four joints involved. Patients eligible for the study were hospitalized for two or three days of prestudy evaluations on the clinical research division after which they were assigned at random to either the treatment or the control group. At the time of entry into the study the randomly selected treatment and control groups did not differ significantly in age, sex, race, marital status, socio-economic dependence, social position, ARA diagnostic category, anatomical stage of disease, Lansbury index score, intellectual function, status in activities of daily living, walking status and degree of house confinement. A more detailed description of the patient sample has been published previously [S]. Variables measured

Initially and at the end of 1 yr of study, measurements were made of disease activity, functional performance, socio-economic dependence level, intelligence, motivation, social adjustment and personal adjustment. The results obtained by each measure were scored in numerical or letter units such that each patient could be compared with every other patient or with himself at a later time. Disease activity was measured by means of a five-point corrected Lansbury index [9] combining stiffness, fatigue, grip strength, erythrocyte sedimentation rate and articular index. Change in Lansbury index was defined as any change of five units or more. Functional performance in activities of daily living (ADL) was measured according to the index of ADL devised by Katz et al [lo], which employs an ordered seven-grade scale ranging from a high of A to a low of G. Ratings, determined by a research observer, who was not a part of the treatment team, were based both on detailed history and on actual observation of patient performance in bathing, dressing, going to toilet, transferring and feeding. ADL scores were recorded in terms of the most dependent level present during the two-week period preceding the evaluation. In this study, change in ADL was defined as any change of one grade or more in the Katz index of ADL. Walking status was based on the patient’s ability to ambulate with or without assistance and by objective measurement in seconds of time required to walk 50 ft and climb eight steps in a standard setting. House confinement was determined on the basis of whether or not the patient had been outside his residence three or more times during the two weeks preceding the date of evaluation. Economic independence was rated according to the index of independence in socio-economic function [II], an ordered five-class scale with grading based on

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detailed evaluation of four profiled indicators including employment status, home ownership, degree of assistance provided within the residence and economic support from charitable agencies. Social class was determined on the basis of Hollingshead’s two-factor index [12] which defines social position as a function of occupation and education. Intellectual function was measured initially and again at the end of 1 yr with Raven’s coloured progressive matrices [13]. Psycho-social status was estimated for both treatment and control patients initially and after 1 yr of treatment by a psychologist experienced in studying psycho-social factors in chronic locomotor diseases. The psychologist, who evaluated but did not treat, used a structured interview technique designed to reveal information relative to the patient’s motivation to rehabilitation, his social adjustment and personal adjustment. To assess motivation for rehabilitation the clinical psychologist explored the patient’s willingness to cooperate in carrying out prescribed treatment, his understanding of his illness and its management, his attitude toward physical activity and his degree of self-confidence. The social adjustment of the arthritic patient is an important factor influencing the patient’s over-all adaptation to the impact of continuing disease. The social adjustment measure used in this study reflects primarily the patient’s role in the family setting and reflects to a lesser extent outside social relationships. The psychologist appraised the following factors in arriving at his impression of social adjustment: 1. 2. 3. 4.

the extent to which the family was relating to the patient as an equal ; the degree of mutual acceptance in the family; the degree to which the patient was maintaining mature social relationships; the expression of appropriate (honest) feelings in the family as opposed to constant resentment or extreme solicitousness.

Personal adjustment was appraised in the structured psychologic interview in terms of: 1. patient’s acceptance or denial of existing disability; 2. emotionality defined as appropriateness of reaction as opposed to agitation or apathy; 3. the ability to profit from education about his disease; 4. tendency to blame others or himself for his difficulties. Using the information obtained in the interview, the psychologist then made certain judgements concerning the patient’s behavior. His judgements were transferred into a rating scale designed by Shontz and Fink [ 141which employs a Q sort technique to separate types of behavior regarded as indicative of good to poor motivation toward rehabilitation, good to poor social adjustment to environment and good to poor personal adjustment to disability. Statistics were calculated using Fisher’s exact test [I 51. RESULTS

Social adjustment Poor social adjustment was found initially in both treatment and control groups. Such poor adjustment is to be expected in a chronic debilitating disease which affects 1.

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P. J. VIGNOS,Jr, H. M. THOMPSON, S. KATZ, R. W. MOSKOWI~Z, S. FINK and K. H. SVEC

normal life adjustment patterns. When the social adjustment status of the intensive treatment and the control groups was compared at the end of 1 yr, the increase in the number of socially well adjusted patients was significantly greater in the treatment than in the control group (Table 1). The improved adjustment in the intensive treatment group may have been related to identification at the regular interdisciplinary management conferences of family problems related to the patient’s disease. Interpretation and counseling given by physicians in clinic and by the visiting nurse in the home setting may have resulted in beneficial modification of family interactions. TABLE1.

Therapy group Treatment Control Total

SOCIALADJUSTMENT IN RHEUMATOID ARTHRITIS

Number of patients

Good social adjustment Number of patients Initially At 1 yr

20 16*

3 4

12 5

36

7

17

Increase in number of patients with good social adjustment 9 1 10

p co.05 *4 control patients omitted: 1 died; 3 did not have two psycho-social evaluations

The social adjustment of an arthritis patient within the family setting may depend on the patient’s degree of independence in carrying out the usual activities of daily living. The patient’s role in the family can be adversely affected by his continued dependence on other members for physical assistance. Therefore, the relationship between improvement in social adjustment and maintenance or improvement of performance of activities of daily living was examined. There was a statistically significant positive correlation between improved social adjustment and maintenance or improvement of ADL performance during the period of study (Table 2). Of 22 patients who maintained or improved their ADL functional status during the period of study, more than half or 14 of 22 improved in social adjustment, whereas none of the remaining 14 patients who deteriorated in ADL improved in social adjustment regardless of whether they were in the treatment or control group. Patients who maintained or improved their activities of daily living status during the year and also TABLE2.

IMPROVEMENT IN socr~~ ADJUSTMENT IN RHEUMATOID ARTHRITIS RELATED TOADL STATUS AFI-ER

Therapy group

ADL status at 1 yr

1 YR

Number of patients

Number of patients improved in social adjustment at 1 yr

Treatment

Maintained or improved Deteriorated

13 7

10 0

Control*

Maintained or improved Deteriorated Maintained or improved Deteriorated

9 7 22 14

4 0 14 0

36

14

Both groups Total

p < 0.0001 *4 control patients omitted: 1 died; 3 did not have two psycho-social evaluations

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improved their social adjustment were found in both the treatment and control groups. However, relatively more treatment than control patients improved in social adjustment at the end of 1 yr. This apparent tendency is not statistically significant but may represent a trend that might become clearer with larger numbers of patients. These findings suggest that patients who function better in daily living activities may be more capable of establishing normal social adjustments. Social adjustment was not related to disease activity as measured by the Lansbury index. Patients with less disease activity at onset of the study were not better adjusted socially than were patients with greater disease activity and improvement in disease activity during the study was not correlated with improved social adjustment. It would appear, therefore, that the social adjustment of the patient with arthritis correlates better with his functional capacity for activities of daily living rather than with the degree of inflammatory activity of the disease process. 2. Personal adjustment A personal adjustment score was determined for each patient initially and at the end of 1 yr. Slightly more than half of the total patient population, treatment and control, were rated as personally well adjusted initially. At the end of 1 yr there was little change in patients’ personal adjustment scores in either treatment or control groups. Apparently the intensive treatment program did not change the patient’s personal adjustment in contrast to the favorable effect of intensive care on social adjustment. However, there does appear to be a relationship between a patient’s personal adjustment and his social adjustment, since at the initial evaluation none of the patients with poor personal adjustment showed good social adjustment (Table 3). TABLET.

RELA~ONSHIPOFPERSONALADJUSTMENTTOSOCIALADJUSTMENTINRHEUMATOWARTHRITIS

Social adjustment

Personal adjustment

Number good initially

Therapy group

Status

Number initially

Treatment

Good Poor

12 8

3 0

Control*

Good Poor

7 9

4 0

Both groups

Good Poor

19 17 36

7 0 7

Total

p < 0.01 *4 control patients omitted:

1 died; 3 did not have two psycho-social

evaluations

3. Intelligence

The relationship of intellectual function to results of rehabilitation has been examined only once in previous studies of rehabilitation in rheumatoid arthritis [5]. This seems remarkable in view of the potential importance of intelligence as a predictive factor in selecting patients with ability to carry out currently prescribed complex arthritis management programs. It seemed possible, therefore, that intellectual capacity might be correlated with response to some phase of the rehabilitation program. The Raven progressive matrices, a test of intellectual capacity, were administered to patients at the onset of the study. Patients were classified into two groups on

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P. J. VIGNOS, Jr, M. M. THOMPSON, S. KATZ, R. W. MOSKOWITZ, S. FINK and K. H. SVEC

the basis of the Raven test scores at intake - a more intelligent group of 21 patients with higher intellectual scores (24-35) and a less intelligent group of 17 patients with Raven scores (10-23). The predictive value of Raven intelligence test scores in estimating functional prognosis was evaluated by relating Raven scores at the time of intake to change in ADL status at the end of 1 yr as measured by the Katz index of dependence in activities of daily living (Table 4). Patients with higher intellectual scores showed a significantly better maintenance of ADL function after 1 yr than did patients with low Raven scores when changes in ADL performance were related to high and low intellectual function. It would appear, therefore, that the testing of intellectual function may have an important predictive value in selecting patients who may benefit from functional activity training during rehabilitation. TABLE4. RELATIONOF INTELLIGENCE TO ADL FUNCTION AT ONE YEARIN RHEUMATOID ARTHRITIS ADL function Number of patients with Number of patients no deterioration at 1 yr

Therapy group

Intelligence

Treatment

Raven score 24-35

12

Raven score below 24

8

11 2

Control*

Raven score 24-35 Raven score below 24

9 9

7 3

Both groups

Raven score 24-35 Raven score below 24

21 17

18 5

38

23

Total

p < 0.001 *2 control patients omitted:

1 died; 1 did not have Raven score determined initially

The effect of intellectual function on social adjustment was also examined. A larger number of pstients with higher intellectual function, as defined by initial Raven test scores, showed improved social adjustment at the end of 1 yr than did the less intellectually endowed group (Table 5). The better social adjustment occurred principally in the intensive care group. Patients who are more intelligent apparently benefit by the added counseling available in an intensive treatment program. TABLE5. RELATIONSHIP OFINTELLECTUAL FUNCTION TOSOCIAL ADJUSTMENT IN RHEUMATOID ARTHRITIS Intelligence Therapy group

Status

Number of patients

Social adjustment Number improved

Number good initially

Treatment

Raven score 24-35 Raven score below 24

12 8

3 0

8 2

Control*

Raven score 24-35 Raven score below 24

8 8

2 2

3 1

Both groups

Raven score 24-35 Raven score below 24

20 16 36

5 2 7

11 3 14

Total

p < 0.05 *4 control patients omitted:

1 died; 3 did not have two psycho-social

evaluations

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No positive correlation was found between intelligence level and improvement in inflammatory activity of the disease as measured by final Lansbury index or by change in Lansbury index during the year of treatment. The relation of intellectual function to patient motivation for rehabilitation was examined by comparing the initial motivation indices of the patients with high Raven test scores with the motivation indices of the group of patients with low Raven test scores (Table 6). A larger number of patients with good intellectual function was judged to be well motivated to rehabilitation than were the patients with lower intellectual function. Thus, it would appear that intelligence is a factor in patient motivation to rehabilitation. TABLE

6.

CORRELATIONOFINTELLIGENCE

LEVELANDMO~VATION ARTHRITIS

TOREHABILITATION

Initial motivation score good

Intelligence Therapy group

Status

IN RHEUMATOID

Number of patients

Number of patients 10

Treatment

Raven score 24-35 Raven score below 24

12 8

Control*

Raven score 24-35 Raven score below 24

8 8

3 6 3

Both groups

Raven score 24-35 Raven score below 24

20 16

16 6

36

22

Total

p i 0.05 *4 control patients omitted:

4.

1 died; 3 did not have both motivation

score and Raven score

Motivation

Criteria for identification of patients with good potential for successful rehabilitation, presumably, should include a motivation rating score since comprehensive medical management requires a high degree of patient cooperation. A motivation index, determined for each patient at the start of the study and again after 1 yr, was compared with other patient variables. At the beginning of the study, over half of the patients in the combined treatment and control groups were judged to be well motivated. The relatively high percentage of patients with good motivation toward rehabilitation may have been influenced by patient selection since only patients with good clinic attendance records were accepted for the study. The number of well motivated patients did not change significantly at the end of 1 yr of study regardless of whether the patients were in the intensive treatment or control groups. Thus, intensive treatment including additional attention in clinic and in home visits by public health nurses did not appear to alter patient motivation. Furthermore, no positive correlation was found between the degree of motivation for rehabilitation and the social adjustment or economic status as determined by independence in socio-economic function. More patients in the intensive treatment group showed improvement in disease activity as measured by the Lansbury five-item index than did patients in the control group, as we have reported in a previous communication [8]. However, contrary to our expectations, there was no positive correlation between improvement in disease

464 P. J. VIGNOS,Jr, H. M. THOMPSON,S.

KATZ,

R. W.

MOSKOWITZ,

S. FUNK

and K. H. SVEC

activity and a good motivation index (Table 7). Improvement in disease activity did not appear to alter motivation to rehabilitation. Better health status and potentially better psychologic reaction to disease did not appear to be important in altering the basic motivation of the patient toward arthritis rehabilitation. Improvement in Lansbury disease activity index seems to be related more to participation in an intensive treatment program than to good motivation. Apparently, the patient who is doing well medically does not become better motivated in the process. TABLE7.

CORRELATION OF MOTIVATION AND

IMPROVEMENT IN LANSBURYINDEXIN REHABILITATION OFRHEUMATOIDARTHRITISPATIENTS

Initial motivation Therapy group

Status

Number of patients

Patients with improved Lansbury index at 1 yr

Treatment

Good Poor

13 7

IO 5

20

15

9 9

3 3

18

6

22 16

13 8

38

21

Total Control*

Good Poor

Total Both groups

Good Poor

Total *2 control patients omitted:

1 died; 1 did not have motivation

index

In terms of activities of daily living, the well motivated patients as a whole did little better than the poorly motivated patients. Only in the intensive treatment group was a suggestive trend found between good motivation and preservation of functional performance as measured by activities of daily living. The group of well motivated intensive treatment patients appeared to do better functionally, as shown by fewer deteriorations in ADL rating at the end of 1 yr, than did either the well motivated control group or the poorly motivated patients in either the treatment or control groups. Thus the combination of good motivation and intensive treatment appeared to produce the best functional results. It must be noted here that these results are not statistically significant and must be treated with caution. We report them mainly because they suggest an important direction for further research on a larger sample of patients and also because they support what we would logically expect as an outcome in the treatment of patients with physical disability.

DISCUSSION

Most investigators agree that psycho-social factors are important in the management of rheumatoid arthritis. Few previously published studies of long term rehabilitation in rheumatoid arthritis, however, have been designed to explore the interrelationships of non-medical factors to the outcome of rehabilitation in rheumatoid arthritis. Lowman et al [5] studied psycho-social factors having predictive value for the selection of rheumatoid patients with good rehabilitation potential. The potential for

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successful rehabilitation appeared related to six socio-economic and five psychological factors which were present in the patients in the successful group only. One of these factors, the acceptance of reasonable rehabilitation goals, compares with one of our personal adjustment criteria, the ability to function as well as possible within the limits of physical disability. However, we found that personal adjustment scores were not related to improvement in functional ADL performance or to improvement in disease activity. Intelligence appears to be a significant factor in rehabilitation since our study indicated that high scores on the Raven intelligence test are more often associated with preservation of ADL function than are low Raven scores. Patients in our study, with better intellectual function, also showed better social adjustment after 1 yr than did the less intellectually endowed group. These results tend to agree with the more general conclusion of Lowman [5] who found that intellectual level as defined by a low-average or better verbal intelligence was a factor predictive of good rehabilitation potential. Thus, similar conclusions were reached by widely different types of intelligence testing. No correlation was found in our studies, however, between intellectual function and improvement in disease activity. The positive correlation of intelligence with ADL function suggests that future long term rehabilitation studies should include assessment of the intelligence level and that studies relating changes in ADL to treatment of rheumatoid arthritis should utilize control and treatment groups with comparable intellectual levels. It appears that functional results of rehabilitation treatment programs in arthritis may depend on a variety of variables including the patient’s intellectual capacity, the severity of the disease process and the type of treatment program prescribed. With less intelligent patients, more intensive instruction in treatment routines and rationale of therapy may lead to better functional results. We used methods of psycho-social evaluation in our study which could be administered effectively in a limited period of time in an attempt to restrict our methodology to measures which might be practical for use in a clinical setting. Intelligence testing using the Raven index [13] does not depend on verbal or written instructions which usually accompany other tests of general intelligence. Patients can be compared, by means of their Raven scores, with respect to their immediate capacities for observation and clear thinking without regard to nationality or education. Because of the brevity of the Raven test and its lack of dependence on formal education, it appeared to us to be more suitable for patients with limited schooling than more extensive intelligence testing. Previously published reports [l-3] on long-term rehabilitation in rheumatoid arthritis have dealt principally with hospitalized patients and make little or no mention of the effects of intelligence or other psycho-social factors on therapeutic results. Furthermore, evaluation of the results in these studies is difficult because of absence of satisfactory comparison groups [l, 2, 43. Problems encountered in attempting to compare results obtained by different investigators studying the effects of treatment on rheumatoid arthritis are attributed by Steinbrocker [7] to the failure to use common denominators. These include failure to segregate patients according to the severity of their disease, failure to separate changes in disease activity from changes in functional capacity, failure to define the nature and extent of changes by classing patients as ‘improved’ or ‘not improved’ and

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failure to include a control series of rheumatoid patients not receiving the treatment being evaluated. In our study, an effort was made to reduce variability by requiring that participants in both the treatment and control groups be rheumatoid arthritics similar in stage and function as defined by ARA criteria. Randomization appeared to be successful since the two groups were comparable in age, sex, race, social and economic status, intellectual capacity and disease activity 183. Rating scales used in recording results made it possible to compare scores from one patient to the next and on the same patient at different points in time. To keep evaluations as objective as possible, measurements of disease activity in terms of the Lansbury index were made by a rheumatologist not involved with the treatment of the patient and ADL ratings were determined by a research observer not a part of the treatment team. It was not possible to eliminate from our study many of the limitations inherent in the interview technique especially in assessing the psycho-social factors such as motivation, social adjustment and personal adjustment. Nevertheless, periodic home visits to the treatment and control patients alike by a nurse research observer, who was not a part of the treatment team, supplied objective evaluations of the subject’s ADL performance and particular social and economic problems. The psychologist who determined the social adjustment scores at the beginning of the study and at the end of 1 yr was not involved in treating or counseling the patients. It is possible that the greater improvement in social adjustment scores in the intensive care patients in our study may be attributed, at least in part, to the assistance of the visiting nurse who helped these patients cope with home and family problems. The visiting nurse not only assisted the intensive care patients in carrying out the home aspects of the treatment program, but also interpreted to the patient and to the family members the nature of the patient’s disease, the rationale of the treatment prescribed and what to expect in the way of treatment goals. The visiting nurse also supplied important feedback communication to the management team so that treatment measures could be realistically adjusted to goals. Our results support Steinbrocker’s suggestion [7] that changes in disease activity and changes in function may be related to different factors and should be separated in reporting rehabilitation study results. Disease activity in our patients was influenced primarily by the quality of the medical treatment program, while maintenance and improvement in ADL and improved social adjustment correlated with non-medical factors such as intelligence. Our conclusions appear to differ from that of Duthie et al [3] who reported a positive correlation between medical and social improvement. Functional performance and social adjustment results in the two studies are not comparable, however, due to differences in the patient sample and in methods of measuring disease activity. Rheumatoid arthritis patients with disease of less than 1 yr’s duration appear to respond well regardless of type of treatment prescribed [3,16-181. Our study attempted to eliminate this enhanced responsiveness of patients with early disease by limiting the study to patients with disease of more than 1 yr’s duration. Under these study conditions, only intensive treatment appeared to influence disease activity. For more accurate assessment of the influence of non-medical factors on long-term rehabilitation in rheumatoid arthritis, it would appear that both treatment and control patients should have disease of more than 1 yr’s duration.

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SUMMARY

A controlled study of comprehensive care in ambulatory patients with severe rheumatoid arthritis was carried out to determine the interrelationships between intensity of care, psycho-social factors and functional benefits. Psycho-social factors did not appear to influence disease activity. Results suggest that patients with higher intelligence scores more often maintain functional performance and improve in social adjustment than do patients with low intelligence scores. The more intelligent patients also had better motivation for rehabilitation. Improved social adjustment was more often seen in the intensive treatment group. A combination of good motivation and intensive treatment appeared to favor the achievement of superior functional results as judged by ADL performance. Furthermore, the patients showing better ADL function after 1 yr improved more in social adjustment. The results suggest that psycho-social factors, although they do not alter rheumatoid disease activity, can affect functional results of rehabilitation measures. Acknowledgements-This study was supported, Chapter of the Arthritis Foundation.

in part, by a grant from the Northeastern

Ohio

Our thanks to Dorothy I. Rusby, Director of the Visiting Nurse Association of Cleveland, Georgina G. Hurd, MSN and Hazel Deuble for their assistance in this investigation. REFERENCES 1.

Zeller JW, Waine H, Jellinek K: Sanatorium management of rheumatoid arthritis. JAM.4 186: 1143,1963. 2. Mason RM, Wenley WG: Treatment of rheumatoid arthritis by a sanatorium regime. Ann Rheum Dis 18: 91,1959 3. Duthie JJR, Thompson M, Weir MM et al: Medical and social aspects of the treatment of rheumatoid arthritis with special reference to factors affecting prognosis. Ann Rheum Dis 14: 133,1955 4. Lowman EW, Lee PR, Rusk HA: Total rehabilitation of the rheumatoid arthritic cripple. JAMA 158/15: 1335, 1955 5. Lowman EW, Miller S, Lee PR ef al: Psycho-social factors in rehabilitation of the chronic rheumatoid arthritic. Ann Rheum Dis 13: 312, 1954 6. Ropes MW, BeMett GA, Cobb S et al: 1958 revision of diagnostic criteria for rheumatoid arthritis. Ball Rheam Dis 9: 175, 1958 7. Steinbrocker 0, Traeger CH, Batterman RC: Therapeutic criteria in rheumatoid arthritis. JAMA 140: 659,1949 8. Katz S, Vignos PH, Moskowitz RW et al: Comprehensive outpatient care in rheumatoid arthritis: A controlled study. JAMA 206/6: 1249, 1968 9. Lansbury J: Report of a three-year study of the systemic and articular indexes in rheumatoid arthritis. Arth & Rheum 1: 505, 1958 10. Katz S, Ford AB, Moskowitz RW: Studies of illness in the aged: The index of ADL, a standardized measure of biological and psychosocial function. JAMA 185: 914, 1963 11. The StatI of the Benjamin Rose Hospital: Multidisciplinary studies of illness in aged persons: A new classification of socioeconomic functioning of the aged. J Chroo Dis 13: 453, 1961 12. Hollingshead AB : Two-factor Index of Social Position. New Haven, Conn,August B. Hollingshead Publication, pp. l-11,1957. 13. Raven JC: Coioured Progressive Matrices (Sets A, AB, B of Revised Order 1956) London: H K Lewis Kt Co., Ltd., 1962 14. Shontz FC, Fink S: A method for evaluating psychosocial adjustment of the chronically ill. Amer J Phys Med 40/2: 63, 1961 15. Maxwell AE: Fisher’s Exact Test for 2 x 2 Tables in Anaiysing Qualitative Data. John Wiley, New York, 1961. 16. Short CL, Bauer W: The course of rheumatoid arthritis in patients receiving simple medical and orthopedic measures. New Eng J Med 238: 142, 1948. 17. Cecil RL, Archer BH: Classification and treatment of chronic arthritis. JAM4 87: 741, 1926. 18. Steinbrocker 0: Therapeutic results in rheumatoid arthritis. JAMA 131: 189, 1946 D