Temperament and character as predictor of health related quality of life after metacarpophalangeal joint arthroplasty ——Personality and MCP joint arthroplasty outcome

doi:10.4236/health.2010.29163

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Vol.2, No.9, 1101-1109 (2010) Health

doi:10.4236/health.2010.29163

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;

sosb@telia.com

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.

ABSTRACT

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 motion—Paper-

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

QoL.

Keywords: Rheumatoid Arthritis; Health Related

Quality of Life; MP Joint Arthroplasty; Temperament;

Character

1. INTRODUCTION

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

1102

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. METHODS

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-

tient.

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

99-017).

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

1103

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-

isfied”.

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.

3. 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 30.8º 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

1104

< 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

Non-recovered

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

1105

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

S. Brändström et al. / HEALTH 2 (2010) 1101-1109

1106

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 =

0.036);

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

COPM

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

COPM

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

1107

Table 4. Hierarchical multiple regression on QoL domains at one year follow-up.

WHOQoL

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

Psychological

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

Independence

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

Environment

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

Spiritual

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)

4. DISCUSSION

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

1108

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

meaningful.

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.

REFERENCES

[1] Chou, C.Y. and Brauer, D.J. (2005) Temperament and

satisfaction with health status among persons with rheu-

matoid arthritis. Clinical Nurse Spectrum, 19(3), 94-100.

[2] Nagyova, I., Stewart, R.E., Macejova, Z., van Dijk, J.P.

and van den Heuvel, W.J. (2005) The impact of pain on

psychological well-being in rheumatoid arthritis: The

mediating effects of self-esteem and adjustment to dis-

ease. Patient Education and Counselling, 58(1), 55-62.

[3] Munafò, M.R. and Stevenson, J. (2001) Anxiety and

surgical recovery. Reinterpreting the literature. Journal of

Psychosomatic Research, 51(4), 589-596.

[4] Anselm, B.M. (1976) Psyche and rheuma. Journal of

International Medical Research, 4(Suppl. 2), 50-53.

[5] Watson, D. and Clark, L.A. (1984) Negative affectivity:

The disposition to experience aversive emotional states.

Psychological Bulletin, 96(3), 465-490.

[6] Hamilton, N.A., Zautra, A.J. and Reich, J. (2007) Indi-

vidual differences in emotional processing and reactivity

to pain among older women with rheumatoid arthritis.

Clinical Journal of Pain, 23(2), 165-172.

[7] Dohnke, B., Knäuper, B. and Müller-Fahrnow, W. (2005)

S. Brändström et al. / HEALTH 2 (2010) 1101-1109

1109

Perceived self-efficacy gained from, and health effects of

a rehabilitation program after hip joint replacement. Ar-

thritis and Rheumatism, 53(6), 585-592.

[8] Weinryb, R.M., Gustavsson, J.P. and Barber, J.P. (2003)

Personality traits predicting long-term adjustment after

surgery for ulcerative colitis. Journal of Clinical Psy-

chology, 59, 1015-1029.

[9] Radl, R., Leithner, A., Zacherl, M., Lackner, U., Egger, J.

and Windhager, R. (2004) The influence of personality

traits on the subjective outcome of operative hallux val-

gus correction. International Orthopedics, 28(5), 303-

306.

[10] Hyphantis, T.N., Tsifetaki, N., Siafaka, V., Voulgari, P.V.,

Pappa, C., Bai, M., Palieraki, K., Venetsanopoulou, A.,

Mavreas, V. and Drosos, A. (2007) The impact of psy-

chological functioning upon systemic sclerosis patients’

quality of life. Seminars in Arthritis and Rheumatism,

37(2), 81-92.

[11] Williams, N.W., Penrose, J.M.T. and Hose, D.R. (2000)

Computer model analysis of the Swanson and Sutter

metacarpophalangeal joint implants. Journal of Hand

Surgery, 25(2), 212-220.

[12] Blazer, P. E. (1998) Metacarpophalangeal arthroplasty.

University of Pennsylvania Orthopaedic Journal, 11, 47-51.

[13] Rittmeister, M., Porsch, M., Starker, M. and Kerschbau-

mer, F. (1999) Metacarpophalangeal joint arthroplasty in

rheumatoid arthritis: Results of Swanson implants and

digital joint operative arthroplasty. Archives of Orthope-

dics and Trauma Surgery, 119, 190-194.

[14] Squitieri, L. and Chung, K.C.A. (2008) A systematic

review of outcomes and complications of vascularized

toe joint transfer, silicone arthroplasty, and PyroCarbon

arthroplasty for posttraumatic joint reconstruction of the

finger. Plastic and Reconstructive Surgery, 121(5), 1697-

1707.

[15] Brändström, S., Sigvardsson, S., Nylander, P.-O. and

Richter, J. (2008) The Swedish version of the Tempera-

ment and Character Inventory (TCI): A cross-validation

of age and gender influences. European Journal of Psy-

chological Assessment, 24(3), 14-21.

[16] Cloninger, C.R., Przybeck, T.R., Svrakic, D.M. and Wet-

zel, R.D. (1994) The temperament and character invent-

tory (TCI): A guide to its development and use. Center

for Psychobiology of Personality Washington University,

St.Louis, Missouri.

[17] Nordenskiöld, U.M. and Grimby, G. (1992) Grip force in

patients with rheumatoid arthritis and fibromyalgia and

in healthy subjects. A study with the Grippit instrument.

Scandinavian Journal of Rheumatology, 22(1), 14-19.

[18] Wressle, E., Lindstrand, J., Neher, M., Marcusson, J. and

Henriksson, C. (2003) The Canadian Occupational Per-

formance Measure as an outcome measure and team tool

in a day treatment program. Disability and Rehabilitation,

25(10), 497-506.

[19] Von Korff, M., Ormel, J., Keefe, F.J. and Dworkin, S.F.

(1992) Grading the severity of chronic pain. Pain, 50(2),

133-149.

[20] Dasch, B., Endres, H.G., Maier, C., Lungenhausen, M.,

Smektala, R., Trampisch, H.J. and Pientka, L. (2008)

Fracture-related hip pain in elderly patients with proxi-

mal femoral fracture after discharge from stationary

treatment. European Journal of Pain, 12(2), 149-156.

[21] Sieben, J.M., Vlaeyen, J.W., Portegijs, P.J., Verbunt, J.A.,

van Riet-Rutgers, S., Kester, A.D., Von Korff , M., Arntz,

A. and Knottnerus, J.A. (2005) A longitudinal study on

the predictive validity of the fear-avoidance model in low

back pain. Pain, 117(1-2), 162-170.

[22] WHOQOL Group. (1998) The World Health Organiza-

tion Quality of Life Assessment (WHOQOL) Develop-

ment and general psychometric properties. Social Science

and Medicine, 46(12), 1569-1585.

[23] Noerholm, V. and Bech, P. (2001) The WHO Quality of

Life (WHOQOL) questionnaire: Danish validation study.

Nordic Journal of Psychiatry, 55(4), 229-235.

[24] Escott, B.G., Ronald, K., Judd, M.G. and Bogoch, E.R.

(2010) NeuFlex and Swanson metacarpophalangeal im-

plants for rheumatoid arthritis: a prospective randomized,

controlled clinical trial. Journal of Hand Surgery, 35(1),

44-51.

[25] Chung, K.C., Burns, P.B., Wilgis, E.F., Burke, F.D., Regan,

M, Kim, H.M. and Fox, D.A. (2009) A multicenter trial

in rheumatoid arthritis comparing silicone metacarpo-

phalangeal joint arthroplasty with medical treatment.

Journal of Hand Surgery, 34(5), 815-823.

[26] Chung, K.C., Kotsis, S.V., Wilgis, E.F., Fox, D.A., Regan,

M, Kim, H.M. and Burke, F.D. (2009) A multicenter trial

in rheumatoid arthritis comparing silicone metacarpopha-

langeal joint arthroplasty with medical treatment. Journal

of Hand Surgery, 34, 734-747.

[27] Massy-Westropp, N., Johnston, R.V. and Hill, C. (2008)

Post-operative therapy for metacarpophalangeal arthro-

plasty. Cochrane Database of Systematic Reviews, 1.

[28] Colville, R.J., Nicholson, K.S. and Belcher, H.J. (1999)

Hand surgery and quality of life. Journal of Hand Sur-

gery, 24(3), 263-266.

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