Vol.2, No.9, 1101-1109 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Temperament and character as predictor of health
related quality of life after metacarpophalangeal
joint arthroplasty
——Personality and MCP joint arthroplasty outcome
Sven Brändström1, Kurt Pettersson2, Jörg Richter3*
1Department of Neuroscience and Locomotion, Division of Psychiatry Linköping University, Linköping, Sweden;
2Department of Hand Surgery, Örebro University Hospital, Örebro, Sweden; kurt.pettersson@orebroll.se
3Department of Psychology, Center for Child and Adolescent Mental Health, Oslo, Norway; *Corresponding Author:
jrichterj@ web.de
Received 30 March 2010; revised 26 April 2010; accepted 28 April 2010.
Purpose: To evaluate personality characteris-
tics’ impact upon outcome after silicone-based
MP arthroplasty in RA patients. Methods: 40 RA
patients who had undergone operations on their
MP joints were investigated in a one-year fol-
low-up. Objective measurement to assess grip
strength and active range of motionPaper-
pencil-tests to assess pain during activity and at
rest performance, QoL, and personality. Results:
Significant improvement was observed in func-
tion and pain related scores except for the pain
related VAS and in several QoL facets and do-
mains. Patients who experienced improvement
reported higher scores on the activities of daily
living facet of the WHO QoL questionnaire.
Those with lower pain showed more independ-
ence. The variance of the QoL domain scores,
other than social and physical domains, could
substantially and meaningfully be explained by
variance of objective measures combined with
personality scores. Conclusions: Most RA pa-
tients’ QoL can be improved by MP arthroplasty
despite remaining substantial level of pain. NS
and HA seem to play an important role in the
adaptation process during the long term, chronic
illness; whereas SD represents a tool of coping
with the burden of pain and disability. Personal-
ity characteristics are highly predictive for QoL
suggesting their important mediating role be-
tween experienced pain and disability and HR
Keywords: Rheumatoid Arthritis; Health Related
Quality of Life; MP Joint Arthroplasty; Temperament;
Rheumatoid arthritis (RA) patients usually suffer from
pain, joint or muscle stiffness, and fatigue, causing dis-
ability complicated by unpredictable exacerbations [1,2]
which impacts upon social and psychological function-
ing such as employability, independence, self-concept,
mood and subsequently upon general wellbeing in terms
of health related quality of life (HRQoL). However,
there are patients with objective indications of RA who
do not report pain and others who report severe pain
without positive immunological parameters [3]. This
observed variability in pain experience suggests that
other factors might be of importance as mediators be-
tween objective measures, such as joint dysfunction or
clinical findings in the serum, and pain experience or
HRQoL as indicators of well-being. There has been
much discussion as to whether patients suffering from
RA have a particular personality type. The evidence is
not convincing and the role of stress in the aetiology of
rheumatoid arthritis is not fully understood [4]. However,
coping responses to stress (in the case of RA patients in
terms of pain, physical and social disabilities) are deter-
mined by several psychological processes including
personality characteristics. Therefore, personality is con-
sidered to be a major phenomenon impacting upon pain-
perception and quality of life. Indeed, Chou and Brauer
[1] found negative affect in the sense of Watson’s and
Clark’s theory [5] determining subjective health inde-
pendent of age, marriage, or length of disease. This might
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
be explained by the fact that negative affect is often com-
bined with self-focused attention and with a negative
memory bias. Self-esteem and adjustment to RA has to
be regarded as mediators between RA on the one hand,
and subjective experience of pain and psychological
well-being on the other hand [2]. Furthermore relating to
emotional processing in older women with RA, the
variability of pain reactivity was found dependent on
both emotional intensity and the ability to regulate emo-
tion in a longitudinal investigation by Hamilton, Zautra
and Reich [6].
There is general agreement that psychological factors
such as personality may influence patients’ adjustment
and outcome of surgical interventions [7,8]. For example,
dissatisfied patients were characterized by significantly
higher aggressiveness, lower extraversion, and more health
worries compared to satisfied patients without differences
in hallux valgus angle or intermetatarsal angle (I-II) three
month after operative hallux valgus correction [9]. In
another study, Hyphantis et al. [10] reported that arthri-
tis-related pain and hostility were negatively related to
both physical as well as psychological health in patients
suffering from systemic sclerosis.
Silicone-based metacarpophalangeal (MP) arthroplasty
still remains the primary treatment for patients with se-
vere degenerative destruction of joints. Joint pain and
deformity affecting hand function are the two primary
indications for performing metacarpophalangeal joint
arthroplasties. Most rheumatoid patients with significant
pain and destroyed MP joints are also noted to have
palmar subluxation of the proximal phalanx with ulnar
subluxation of the extensor tendon, resulting in a fixed
flexed posture of the MP joints, which impairs overall
function and reduces power. However, the main disad-
vantage is the inability to obtain a postoperative range of
motion close to that of the normal hand [11].
Substantial improvement in range of motion, pain, ul-
nar deviation and patient satisfaction have been reported
as the outcomes of MP arthroplasty with “reported post-
operative arcs of motion vary from 38 to 60 degrees”
and “extension lags also vary from 9 to 22 degrees” [12].
Rittmeister et al. [13] evaluated the outcome of silicon
MP arthroplasty as “good” in 40 joints, as “fair” in 10
joints, and as “poor” in none. In a “formal systematic
review of all available world literature” Squitieri and
Chung [14] found silicone MP joint arthroplasty to be
superior to vascularised toe joints or PyroCarbon joints
with a mean active range of motion of 47 +/- 16 degrees
and a complication rate of 18%. However, maintenance
or recurrence even years later after surgery were re-
ported in some patients [12].
The aim of the study was to evaluate if personality cha-
racteristics impact upon the outcome of silicone-based
MP arthroplasty in RA patients.
The following questions were to be answered; 1) Are
there differences between recovered and non-recovered
patients pre- and post silicone-based MP arthroplasty
according to pain severity, movement capacity, HRQoL,
and personality? 2) Is the objectively measureable change
associated with perceived improvement? 3) Are there
differences in personality characteristics between severe
RA patients who received silicone-based MP arthro-
plasty and healthy individuals? 4) Do psychological or
sociodemographic variables predict QoL after silicone-
based MP arthroplasty or can related differences between
recovered and non-recovered patients be explained by
personality characteristics?
2.1. Sample
40 RA consecutive patients (7 male; 33 female) with an
average age of 61.54 ± 9.93 years (range: 32-78) were
recruited for this prospective follow-up study. One pa-
tient died before follow-up investigation and was there-
fore excluded from the analysis. All patients had opera-
tions on four MP joints, totalling 156 joints. Indications
for surgery were pain and severe deformity of MP joints,
which had resulted in severe impairment of hand func-
tions in daily life. The MP joints were either volarly
subluxated or ulnarly dislocated. No reoperation was per-
formed during the study period.
In order to control for personality characteristics, data
was used from a previous standardisation investigation
in northern Sweden [15] investigating the Temperament
and Character Inventory [16]. From this data a group of
individuals from the general population were matched to
the patients, with two individuals matched by age (60.5/
60.6 ± 10.3 years; range: 30-80) and gender to each pa-
Informed consent was obtained from all participants
prior to the investigation; and the study was approved by
the Ethics Committee at Umeå University (§127/99 dnr
2.2. Measurements
2.2.1. Objective Measurements
Preoperatively and postoperatively, all patients were
examined by an independent physiotherapist and an oc-
cupational therapist. Maximum and mean grip strength
was measured with Grippit (AB Detektor, Göteborg, Sw-
eden) [17].
The active range of motion was measured with goni-
ometry for each phalanx in all joints (MP-metacarpop-
halangeal joint, PIP-proximal interphalangeal joint, and
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
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DIP-distal interphalangeal joint).
The active arc of motion was determined by subtract-
ing active extension from active flexion.
2.2.2. Rating of Others
The Canadian Occupational Performance Measure (COPM)
[18] was used to evaluate patient participation in the goal
formulation process. It is a semi-structured interview in
which the patients identify their problems in occupa-
tional performance and rank them. The patients rate their
occupational performance related to identified problems
and satisfaction with their performance in areas of self-
care, productivity, and leisure. Ten-point scales are used
ranging from 1—“not able to do it” or “not satisfied at all”
to 10—“able to do it extremely well” or “extremely sat-
2.2.3. Self-Report Measurements
A visual analogue scale (VAS) relating to pain during
activities and another concerning pain at rest was applied.
The Grade Chronic Pain Status (GCPS—[19]) was
developed as “a simple method of grading the severity of
chronic pain” (p. 133). Based on the patient’s responses
to 7 questions, pain severity is classified into 4 hierar-
chical groups: “Grade I, low disability-low intensity;
Grade II, low disability-high intensity; Grade III, high
disability-moderately limiting; and Grade IV, high dis-
ability-severely limiting” (p. 133). Internationally this
scale is often used to classify chronic pain combined
with pain related disability [10,20,21].
The Quality of Life questionnaire (WHOQoL-100 –
[22]) consists of 100 items covering six domains (physi-
cal health, psychological health, level of independence,
social relationships, environment, spirituality, and one
general domain - overall quality of life). Each item is
measured from 1 to 5 according to four underlying Likert
scales referring to intensity, capacity, frequency and eva-
luation. All scores are standardized as 0 = worst quality
of life to 100 = best quality of life scale. The internal
consistency was reported to be 0.97; the test-retest reli-
ability was 0.70; and an intensive validation study of the
Danish version supports the satisfactory external and dis-
criminant validity [23].
A special feature of this WHOQoL questionnaire is its
focus on satisfaction with various aspects of life. It cov-
ers relevant factors of health related QoL such as pain,
physical function, and capacity for work.
The Temperament and Character Inventory (TCI-9
version) is a 238 item true-false self-administered paper-
and-pencil test based on Cloninger’s biosocial personal-
ity theory [16]) and measures the four largely genetically
determined and independently inherited temperament
dimensions Novelty Seeking (NS—4 subscales); Harm
Avoidance (HA—4 subscales); Reward Dependence
(RD—3 subscales); and Persistence (PS—single scale)
and the three character dimensions Self-Directedness
(SD—5 subscales); Cooperativeness (CO—5 subscales);
and Self-Transcendence (ST—3 subscales). Tempera-
ment refers to individual differences in conditioned emo-
tional responses, such as anger, fear, and disgust; and
character refers to individual differences in goals, values
and self-conscious emotions like shame, guilt and em-
pathy [16].
2.3. Design
The RA patients were investigated twice—1) preopera-
tive assessment and 2) postoperative assessment after 12
months with all the above described preoperative invest-
tigations conducted repeated.
Physiotherapeutic treatment and training sessions took
place between the two assessments. In postoperative
week 6 gradually increased motion was initiated without
pressure in radial and ulnar directions. In week 8 daily
activities were allowed without weight loading in the
ulnar direction. From the postoperative third month no
restrictions were set limiting daily activities or work
except pain; and finally at 6 months, a clinical evaluation
was made and an additional training program, some
technical advice or equipment was added or optimised.
2.4. Statistical Analysis
Various dichotomous groupings were established relat-
ing to the RA patients based on the difference between
pre- and postsurgical assessment on several outcome
criteria including GCPS, the COPM scores and the vis-
ual analogue scales. One group consisted of patients with
lower or equal scores (not recovered/not improved) and
the other group had higher postoperative scores (recov-
ered, improved). The T-test for independent and paired
samples was applied in order to test for various group
differences for continuous variables on univariate level
and MANOVA was calculated on multivariate level.
Hierarchical multiple regression analyses were calcu-
lated in order to test for predictive value of personality
scores for QoL post-surgery controlling for age and
gender in the first level followed by the measured mo-
tion and grip-strength as an control-indicator for object-
tive surgery results.
We found a significant difference between pre- and post-
surgical assessment concerning all the parameters meas-
ured except for pain. The functional arc of motion in the
metacarpal joint changed from 30. preoperative to
48.6º one year postoperative (p < 0.001). The active
flexion arc changed from 69.4º preoperative to 82.5º (p
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
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< 0.001). Extension lag improved significantly in all fin-
gers between 51.7º to 20.8º (p < 0.001). The range of
movement of each of the operated fingers was post-
operatively significantly wider than preoperatively (t
between 3.15; p = 0.002 for the little finger and 4.16; p <
0.001 for the ring finger). Patients improved signify-
cantly in joint mobility and strength (t = 2.57; p = 0.010).
The COPM score of performance and satisfaction with
occupational performance was significantly higher after
surgery. The disability score, number of disability days
and the disability points as well as the characteristic pain
intensity measured by the GCPS were significantly lower
after surgery, whereas the difference in self-evaluation of
pain intensity in rest and while active assessed by means
of the visual analogue scales did not reach any mean-
ingful level of statistical significance (Table 1).
On average the scores of the QoL facets pain and dis-
comfort, energy and fatigue, sleep and rest, activities of
daily living, and work capacity were significantly higher
one year after surgery (t between –4.60; p < 0.001 for
work capacity and –2.02; 0.050 for energy and fatigue),
but the score for home environment and transport de-
creased (t = 2.2.5; p = 0.031, t = 5.09; p < 0.001 respec-
tively). At the domain level, QoL relating to physical (t =
–3.68; p < 0.001) and independence (t = –3.25; p = 0.002)
were found to be improved (Table 2).
When referring to the dichotomised outcome indica-
tors GCPS, COPM performance and satisfaction, as well
as the visual analogue scale for pain in rest and in active-
ity with constant or lower scores at postsurgical assess-
ment were considered to be not recovered and higher
scores considered recovered 54%, 78%, 81%, 47%, and
47% respectively were characterised as recovered (ques-
tion A).
Multivariate analyses of variance were separately cal-
culated with groups (recovered versus not recovered)
based on every outcome indicator as fixed factor and with
the active range of motion of the operated fingers and the
strength of the hand grip at the follow-up assessment as
well as with the change of these parameters as dependent
variables. None of these models proved to be statistically
significant (question B). Nevertheless, the model with
COPM performance group as a fixed factor demonstrated
a significant tendency (Wilk’s Lambda = 0.68; F(5/27) =
2.53; p = 0.053; η2 = 0.319; power = 0.695); and the
change in grip strength yielded a significant result in the
test of between-subject-effects relating to the COPM per-
formance grouping (F = 6.92; p = 0.013) and in the GCPS
grouping MANOVA (F = 4.56; p = 0.040), even though
the latter overall model was not significant.
When referring to the same groups in MANOVA with
QoL facets or domains at 12 months after the operation
as dependent variables, none of the models showed a
significant main effect of the group variable except for 1)
the groups based on the COPM performance scale (Wilk’s
Lambda = 0.16; F(24/11) = 2.47; p = 0.060; η2 = 0.840;
power = 0.762) with the activities of daily living facet
showing a significant between-subject-effect test result
Table 1. Mean scores (SD) of outcome indicators at baseline and one year follow-up (paired sample t-test) and follow-up scores de-
pendent on recovery classification (based on CPGS classification change—no significant differences).
n Baseline prior to surgeryOne year after surgeryT p Recovered
N = 21
N = 18
COPM performance 36 4.1 (1.8) 6.9 (2.3) –6.050.001 7.0 (2.3) 6.7 (2.2)
COPM satisfaction 36 3.5 (2.0) 6.6 (2.5) –6.050.001 6.7 (2.7) 6.5 (2.3)
VAS Pain at rest 33 3.7 (3.0) 3.3 (2.6) 0.720.478 3.2 (2.5) 3.2 (2.9)
VAS Pain in activity 33 4.1 (2.9) 3.4 (2.7) 1.300.203 3.3 (2.6) 3.2 (2.9)
GCPS Classification 39 2.6 (1.2) 1.8 (2.0) 3.520.001 1.7 (1.0) 2.0 (1.3)
GCPS Disability points 39 3.1 (2.1) 1.8 (2.0) 3.110.001 1.5 (1.6) 2.2 (2.3)
GCPS Disability Days 39 1.4 (1.2) 0.7 (1.1) 2.890.006 0.6 (1.0) 0.9 (1.2)
GCPS Characteristic Pain Intensity39 47.9 (19.0) 39.0 (22.0) 2.140.039 34.6 (18.3) 44.1 (25.2)
Range of motion forefinger 37 134.9 (47.4) 154.1 (55.4) –3.90< 0.001 154.7 (55.0) 153.3 (57.4)
Range of motion middle finger 37 144.6 (45.8) 167.8 (46.0) –5.30< .001 173.2 (47.2) 162.2 (45.5)
Range of motion ring finger 35 135.0 (50.0 161.9 (46.7) –5.43< 0.001 163.9 (50.6) 159.7 (43.6)
Range of motion little finger 35 126.7 (50.1) 152.6 (54.5) –3.570.001 149.2 (57.8) 156.2 (52.4)
Hand-grip strength 35 70.9 (46.4) 87.0 (48.9) –2.170.036 93.8 (61.8) 79.5 (28.6)
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 2. WHOQoL questionnaire facets and domains pre- and post-surgical (× (SD)—paired sample t-test).
Prior to surgery One year follow-up T p
Pain and discomfort 45,8 (15,2) 59,6 (17,1) –3.97 < 0.001
Energy and fatigue 49,0 (15,4) 54,8 (14,2) –2.02 0.050
Sleep and rest 59,8 (21,9) 68,4 (19,1) –2.94 0.006
Positive feelings 60,6 (11,8) 59,6 (10,1) 0.50 0.623
Thinking, concentration 64,9 (12,2) 64,6 (12,0) 0.18 0.857
Self-esteem 58,2 (11,1) 57,7 (13,4) 0.28 0.784
Body image 64,7 (15,1) 65,4 (14,5) –0.24 0.810
Negative feelings 64,7 (18,1) 64,9 (16,5) –0.06 0.950
Mobility 56,3 (16,7) 60,4 (19,1) –1.77 0.085
Activities of daily living 59,8 (16,4) 65,9 (18,0) –2.15 0.028
Medication 48,6 (17.0) 49,8 (18,8) –0.38 0.707
Work capacity 43,6 (21,7) 62,0 (22,6) –4.60 < 0.001
Personal relationships 73,4 (12,7) 72,6 (15,2) 0.43 0.673
Social support 72,1 (16,2) 69,9 (18,5) 1.06 0.297
Sexual activity 54,2 (20,9) 55,5 (17,7) –0.64 0.529
Physical safety 64,1 (12,9) 63,3 (12,8) 0.39 0.697
Home environment 70,2 (16,6) 66,7 (14.0) 2.25 0.031
Financial resources 65,5 (21.0) 63,9 (21,6) 0.96 0.342
Health and social care 61,2 (10,6) 61,1 (12,6) 0.10 0.924
New information 65,2 (13,7) 65,1 (14,1) 0.07 0.945
Recreation/leisure 57,2 (14,7) 59,0 (14,8) –0.88 0.384
Environment 65,2 (13,3) 62,5 (11,8) –0.96 0.344
Transport 71,6 (19,1) 68,4 (19,9) 5.09 < 001
Spirituality 47,9 (21,7) 50,2 (21,2) –0.95 0.350
Physical 51,6 (13,2) 61,0 (13,5) –3.68 < 0.001
Psychological 62,6 (8,9) 62,5 (10,3) 0.14 0.888
Independence 52,0 (13,6) 59,5 (14,9) –3.25 0.002
Social 66,6 (13,2) 65,9 (14,2) 0.42 0.676
Environment 65,0 (10,6) 63,7 (10,6) 1.20 0.239
Spiritual 47,9 (21,7) 50,2 (21,2) –0.95 0.350
(F = 6.65; p = 0.014) and 2) groups based on COPM
satisfaction scale (Wilk’s Lambda = 0.09; F(24/11) =
4.43; p = 0.007; η2 = 0.906; power = 0.967).
When using the change score of the WHOQoL ques-
tionnaire as dependent variables the MANOVA models
for all the various groups failed to reach significant main
effects. However, several significant between-subjects-
effects appeared. Therefore, we decided to add analyses
on the univariate level. We could not find any difference
relating to finger-motion or hand-grip strength between
recovered and non-recovered patients on any of the out-
come indicator groupings. However, recovered patients,
as defined by the
1) GCPS change score, reported higher scores on the
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WHOQoL facets thinking and concentration (z = –2.32;
p = 0.020), activities of daily living (z = –2.18; p =
0.029), work capacity (z = –2.53; p = 0.011), and finan-
cial resources (z = –2.97; p = 0.003), as well as on the
domains independence (z = –2.14; p = 0.032) and envi-
ronment (z = –2.30; p = 0.022);
2) COPM performance scored higher than non-reco-
vered patients on the thinking and concentration facets
of the QoL measurement (z = –2.10; p = 0.040);
3) “pain at rest visual analogue scale”, reported a lower
chronic pain intensity in the CPGS (z = –2.31; p =
0.021), as well as higher scores in QoL facets energy and
fatigue (z = –2.10; p = 0.036), negative feelings (z =
–2.13; p = 0.034), and financial resources (z = –2.09; p =
4) “pain in activity visual analogue scale” reported a
lower chronic pain intensity in the CPGS (z = –2.92; p =
0.003), as well as higher scores in QoL facets negative
feelings (z = –2.38; p = 0.019), work capacity (z = –2.03;
p = 0.045), and financial resources (z = –2.09; p = 0.041).
None of the MANOVA models with the outcome
groups as fixed factors and the personality domains of
the TCI as dependent variables yielded a significant re-
sult; and only ST appeared as significantly differentiat-
ing between satisfied and dissatisfied patients after sur-
gery (F = 4.95; p = 0.009) in the between-subjects-effect
tests. However, when using the TCI subscales as de-
pendent variables MANOVA gave significant results for
the outcome group-differentiation except for the groups
relating to GCPS scores (Table 3). The subscales ‘dis-
orderliness versus regimentation’ (NS 4), ‘anticipatory
worry versus uninhibited optimism’ (HA 1) and ‘fatiga-
bility versus asthenia and vigour’ (HA 4), and ‘self-for-
getfulness versus self-conscious experience’ (ST 1) as
well as ‘transpersonal identification versus self-isolation’
(ST 2) were most often of differentiating effect between
improved and not improved patients.
The comparisons of personality domain scores be-
tween RA patients and the two groups of general popula-
tion controls matched for age and gender did not render
any significant result by means of t-test for dependent
samples (question C). Based on the subscales of the TCI,
the controls of both matched samples had significantly
higher scores for ‘disorderliness’ (NS 4–t = –2.66/–2.29;
p = 0.011/0.028) and HA 1 (t = –2.30/–2.75; p = 0.027/
0.009); as well as lower scores for ‘fatigability’ (HA 4–t
= 3.08/3.02; p = 0.004/0.005). Partly contradictory results
between the two comparisons occurred for ‘sentimentality’
(RD 1–t = 2.14/.257; p = 0.039/0.798), ‘compassion’
(CO 4–t = 2.54/1.74; p = 0.015/0.090), ‘pure-hearted
conscience’ (CO 5–t = –0.49/–2.14; p = 0.628/0.039),
‘self-forgetfulness versus self-conscious experience’ (ST
1–t = 1.73/3.74, p = 0.090/0.001) and ‘transpersonal
identification versus self-isolation’ (ST 2–t = 1.87/2.02;
p = 0.069/0.050).
In order to test for prediction of QoL hierarchical mul-
tiple regression analyses were calculated entering gender
and age at the first step, either the functional range of
motion and hand-grip strength from follow-up assess-
ment or the change in these scores at the second step and
TCI dimensional scores at the third step as independent
variables together with either the six WHOQoL domains
or the change in these domains as dependent variables
(question D). We could not find any significant regres-
sion model relating to the change scores between pre-
and postoperative assessments except for domain ‘envi-
ronment’ with the difference in hand-grip-strength as a
single substantial indicator in the equation (standardised
Beta = –0.54; F = –3.25; p = 0.004); whereas, based on
the scores from follow-up assessment, the variance in
this set of variables could substantially explain variance in
the QoL domains other than social and physical (Table 4).
Table 3. Results of MANAOVA with outcome scores as fixed factors and TCI subscales as dependent factors.
Wilk’s λ F Df/df P η2 Power Significant-between-subjects-effects
CPGS 0.55 1.26 50/180 0.138 0.2600.987 NS4: F = 3.92; p = 0.023; HA1: 3.49; p = 0.034; HA4: F = 6.42;
p = 0.002; ST1: F = 4.56; p = 0.012
performance 0.44 1.80 50/174 0.003 0.3401.000 NS4: F = 4.14; p = 0.019; HA1: 4.36; p = 0.015; HA4: F = 5.23;
p = 0.007; ST1: F = 6.17; p = 0.003; ST2: F = 3.53; p = 0.033
satisfaction 0.46 1.6750/174 0.008 0.3240.999 HA1: 3.63; p = 0.030; HA4: F = 5.37; p = 0.006; ST1: F = 7.06;
p = 0.001; ST2: F = 3.63; p = 0.030
VAS pain rest 0.42 1.8350/168 0.002 0.3521.000 NS4: F = 3.28; p = 0.041; HA1: 3.85; p = 0.024; HA4: F = 3.72;
p = 0.027; ST1: F = 5.83; p = 0.004; ST2: F = 3.46; p = 0.035
VAS pain
activity 0.47 1.5450/168 0.023 0.3140.997 HA1: 3.10; p = 0.049; HA3: F = 4.34; p = 0.015; HA4: F = 3.72;
p = 0.027; CO4: f 3.28; P = 0.041; ST1: F = 5.67; p = 0.005
HA1 ‘anticipatory worry versus uninhibited optimism’; HA3 ‘shyness with strangers versus confidence’; HA4 ‘fatigability versus asthenia and vig- our’; NS4
‘disorderliness versus regimentation’; CO ‘compassion versus revengefulness’; ST1 ‘self-forgetfulness versus self-conscious experience’; ST2 ‘transpersonal
identification versus self-isolation’; GCPS Grade Chronic Pain Status; COPM Canadian Occupational Performance Measure; VAS visual analogue scale.
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 4. Hierarchical multiple regression on QoL domains at one year follow-up.
domain Standardised r2 Model F P r2 F P Variables in final equation with significant standardised Beta
–0.06 0.22 0.941
–0.14 0.40 0.891
0.33 2.21 0.050 0.513.720.010
HA (B = –0.48; t = –2.22; p = 0.038)
–0.03 0.21 0.434
0.26 2.68 0.030
0.17 1.51 0.196 0.431.090.422
Motion range middle finger (B = –1.17; t = –2.74; p = 0.013)
–0.05 0.24 0.786
–0.07 0.69 0.681
0.74 7.92 < 0.001 0.7013.02< 0.001
Age (B = 0.27; t = 2.66; p = 0.015); motion range middle
finger (B = 0.87; t = 3.06; p = 0.006); little finger (B = –0.60;
t = –3.08; p = 0.006); NS (B = –0.37; t = –3.61; p = 0.002);
RD (B = 0.33; t = 2.70; p = 0.014); PS (B = –0.57; t = –4.51;
p < 0.001); CO (B = 0.44; t = 3.95; p = 0.001); ST (B = –0.29;
t = –2.92; p = 0.008)
0.04 1.72 0.195
0.22 2.39 0.049
0.42 2.77 0.019 0.282.330.065
Gender (B = 0.48; t = 2.68; p = 0.014); motion range ring
finger (B = –0.81; t = –2.28; p = 0.034); hand-grip strength (B
= 0.68; t = 2.96; p = 0.008); PS (B = –0.45; t = –2.39; p =
0.027); ST (B = 0.35; t = 2.38; p = 0.027)
For this follow-up investigation, 40 RA patients could be
recruited representing a reasonable sample compared
with other studies in this field (e.g., 33 patients [24]; 45
patients [25]; 68 patients from three sites [26]).
Our results showed an average improved range of mo-
tion in all MP-joints resulting in improved grip strength
after surgery. We assume that our good results in the
whole group are a consequence of early controlled active
motion; intense physiotherapy with special focus on
functional grip; and the use of the metacarpal joint in-
stead of the distal interphalangeal joints combined with
the functional plasters individually manufactured by the
occupational therapist. This assumption is supported by
a review of effective post-operative therapy for MP ar-
throplasty that reported passive motion as ineffective in
increasing motion or strength under this condition [27].
Moreover, we found average substantial improvement
in all applied functional related and pain related scores
except in the pain related VAS and, consequently, in
several QoL facets and domains at the one year fol-
low-up after surgery. This might be caused by the fact
that surgery in RA patients only addresses one of several
problems in the hand and the effects of surgery may be
overshadowed by the more general nature of the disease.
Colville et al. [28] reported improvements in active daily
living and reduced hand pain but could not report any
improvement in arthritis activity, mood or QoL after
surgery in correspondence with our findings. Further-
more the difference found between objectively meas-
ureable changes and the subjective experience, particular
in pain, represents further evidence of their relative as-
sociation mediated by several other conditions. The ob-
jective change in motion and strength is obviously not
directly and linearly correlated with changes in pain in-
tensity or QoL.
Nevertheless, there are about 50% of the RA patients
who reported less pain compared to pre-surgery (based
on the dichotomized sample on pain related visual ana-
logue scales and the GCPS score) and about 80% re-
ported improved function and satisfaction one year after
the surgery. Seemingly, the strength of the hand-grip is
an important indicator of a perceived improved func-
tional status of the hand causing an increased independ-
ence in activities of daily living and overall QoL. This
might in turn imply an increase of QoL based on an im-
proved functional status despite still suffering from se-
vere pain.
Our RA patients were characterised by some devia-
tions in personality compared to the general population
subjects, implying that RA patients are more organised,
preferring activities with strict roles and that they lose
their temper more slowly (NS 4). Furthermore, they are
pessimistic, anticipating harm or failure and ruminating
about embarrassing experiences for long time (HA 1);
and they are asthenic, lacking energy and recovering
slowly from minor illness or stress (HA 4). These dif-
ferences compared to people from the general population
can probably be explained to a substantial amount by
adaptation to the pain, impairment and disability caused
by RA.
S. Brändström et al. / HEALTH 2 (2010) 1101-1109
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
However, it partly confirms findings of Chou and
Brauer [1] of high negative affect in RA patients as well
of difficulties in regulating emotions in pain patients by
Hamilton et al. [6]. The many anticipatory worries iden-
tified, combined with the limited openness and flexibil-
ity in their behaviour might in turn cause more self-
focussed attention, including attention to pain signals,
leading to increased passivity and avoidance of activity
in order to prevent increasing pain which in turn would
negatively affect QoL. This explanation would argue
against an interpretation in favour of a RA personality
and only supports the assumption that the identified de-
viations in personality characteristics of RA patients
compared to healthy people are primarily personality
changes due to RA.
Interestingly, improved and not improved patients af-
ter surgery differ on the same personality characteristics
in the same way as the RA patients differ from healthy
subjects – namely, a high self-transcendence in the sense
of abilities to transcend their boundaries when deeply
involved in something or concentrating on the present
activity (ST 1) and highly intensive perception and ex-
perience of connectedness to the world (ST 2). These
self-transcendent skills might enable the patients to be
more accepting, better able to cope and to be more satis-
fied with their lives than those lacking these abilities.
HA as a personality trait reflecting the type or colour
of focus and orientation on the world, the ability to deal
with uncertainties, strange and unfamiliar situations as
well as the overall level of energy was found to be the
only substantially predicting variable for ’Psychological
health’ as one important domain of QoL after controlling
for age, gender and range of motion. This finding was
expected because there are many reports in the literature
of close relationships between HA and various psycho-
pathological manifestations, suggesting a non-specific
vulnerable role of HA in relation to psychopathology in
general [16]. Interestingly, the QoL domain ’Independ-
ence` is substantially predicted by one of the objective
indicators implying that the improved movement abili-
ties after surgery cause an improved independency in
self-care and other general daily living activities. Par-
ticular personality characteristics do not increase the
prediction of ’Independence.
It appears somewhat curious that the QoL ’Environ-
ment’ domain is predicted by personality characteristics
to the greatest degree; 74% of the variance could be ex-
plained and 70% only by personality characteristics in
terms of TCI temperament and character domains. This
QoL domain integrates several areas of life including the
availability of health-care services, possibilities of in-
formation and knowledge acquisition, as well as the pos-
sibilities of active participation at recreational and lei-
sure activities. Even though age and movement abilities
are of significant predictive value, a wide range of per-
sonality characteristics consisting of NS, RD, PS, CO,
and ST is of predictive power; with only HA as less
The interpretation of the study results is limited by the
consecutive nature and the small size of the sample. This
might have caused an under-evaluation of findings be-
cause of the level of statistical significance. However,
well established measurements were applied and the use
of two matched general population sample concerning
personality measurement can be considered as strength
as it allowed a cross-validation of the differences be-
tween RA patients and controls to be performed. The
combined consideration of objective and subjective in-
dicators of surgery outcome and HRQoL can be seen as
an additional strength.
In summary, RA patients’ QoL can be significantly
improved by MP arthroplasty in most cases by improve-
ing their movement abilities, despite substantial levels of
pain remaining. NS and HA temperament systems of
personality seem to play an important role in the adapta-
tion process during the long term, chronic illness causing
measureable differences compared to general population
subjects. However, the character dimension ST repre-
sents a tool for coping with the burden of the pain and
disability leading to a better experienced QoL after hand-
surgery. Finally, personality characteristics are highly
predictive of QoL, particularly relating to ‘Environment’
and ‘Psychological Health’ suggesting their important
mediating role between experienced pain and disability
and HRQoL.
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List of Abbreviations
CO Cooperativeness
COPM Canadian Occupational Performance Measure
GCPS Grade Chronic Pain Status
HA Harm Avoidance
HRQoL health Related Quality of Life
MP Metacarpophalangeal
NS Novelty Seeking
PS Persistence
QoL Quality of Life
RA Rheumatoid Arthritis
RD Reward Dependence
SD Self-Directedness
ST Self-Transcendence
TCI Temperament and Character Inventory
VAS Visual Analogue Scale