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Papers by Karina Malm

Additional file 1. Cross-sectional description and comparison between patients fulfilling MVPA re... more Additional file 1. Cross-sectional description and comparison between patients fulfilling MVPA recommendations or not (non-MVPA) in 2010 and 2017.

FRIDAY, 15 JUNE 2018, 2018

Annals of the Rheumatic Diseases, 2015

Background Fatigue, pain, stiffness, impaired muscle function and impaired physical function are ... more Background Fatigue, pain, stiffness, impaired muscle function and impaired physical function are some of the most pronounced symptoms in rheumatoid arthritis (RA) and these may be related to lifestyle habits such as physical activity, diet, smoking and alcohol. There is limited knowledge about how patient with longstanding RA understand their lifestyles habits in relation to their disease and quality of life. Objectives To describe experiences of how lifestyle habits relate to quality of life in patients with longstanding RA. Methods A qualitative study with a deductive content analysis design, including 17 patients from the Swedish BARFOT (Better Anti-Rheumatic FarmacoTherapy) cohort. BARFOT is a long time follow up study of early RA. Informants were strategically selected by gender (ten women and seven men), age (range 30-84 years), disease duration (8-23 years), function as measured by HAQ, and quality of life as measured by EQ5D. Semi-structured interviews focused on four lifestyle habits (main categories); Physical activity, Diet, Smoking, and Alcohol. The interviews were recorded, transcribed verbatim and coded into subcategories within each of the four main categories. Results In patients with longstanding RA quality of life was related to the four given main categories (lifestyle habits). Each main category included two to three subcategories; (1) Physical activity means barrier, opportunities and well-being, (2) Diet means shame, well-being and social relationship, (3) Smoking means reward and fear, and (4) Alcohol means ambivalence and social relationship. Conclusions In longstanding RA, lifestyle habits relates to quality of life through both positive and negative experiences. This has to be taken into account in clinical care for a better understanding of how patients conceive and adherer to advice on lifestyle. References Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746):1094-108. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-88. Acknowledgements Disclosure of Interest None declared

FRIDAY, 15 JUNE 2018, 2018

The warmer pool temperature was stated as a reason for the benefits obtained. Reported benefits o... more The warmer pool temperature was stated as a reason for the benefits obtained. Reported benefits of hydrotherapy are illustrated in graph 1: Conclusions: This survey suggests variability in utilisation of hospital hydrotherapy services by a national AS patient group in the UK, with barriers to access, lack of promotion and pool closures. Similar benefits of hydrotherapy to those stated in the NICE guidance were experienced. 1 Future service recommendations which focus on flexible access for flare management, 'Pay as you Go' schemes, group exercise and self-management may increase utilisation, optimise experience and reverse decline. Research to assess the benefits of these service recommendations in a clinical population is needed.

Rheumatoid Arthritis (RA) is a chronic, inflammatory, and systemic disease of unknown aetiology t... more Rheumatoid Arthritis (RA) is a chronic, inflammatory, and systemic disease of unknown aetiology that affects 0.5‒1.0% of the population in Europe, more women than men. Pain, physical disability, fatigue, and sleep disturbances are some of the most pronounced symptoms in patients with a more severe disease or with a longer disease duration, resulting in activity limitations that affect quality of life. RA is associated with an increased risk of developing comorbidities, some of which are known to be associated with a sedentary lifestyle. A healthy lifestyle can reduce the risk to develop diseases and help to improve quality of life in patients with RA. In guidelines and recommendations for management of patients with RA, health professionals are encouraged to prioritise discussions about lifestyle, especially physical activity, diet, smoking, and alcohol use. The overall aim of the present work was to explore factors that affect disability and quality of life in patients with establi...

Annals of the Rheumatic Diseases

Background Fatigue, pain, stiffness and impaired physical function are some of the most pronounce... more Background Fatigue, pain, stiffness and impaired physical function are some of the most pronounced symptoms in rheumatoid arthritis (RA) that may affect quality of life. Quality of life is an individual experience composed of a wide range of factors, including physical health, psychological state, level of independence, social relationships, and the patients' relationship to salient features of their environment. There is a need to describe and assess quality of life in chronic diseases like established RA. Previous research has mainly focused on disease-specific instruments for assessing quality of life. A deeper understanding of patients' experience of quality of life in established RA is important in both clinical research and daily clinical practice. Objectives To describe variations in patients' experiences of quality of life in established RA Methods The study had a qualitative design with a phenomenographic approach, including 22 interviews with patients from the Swedish BARFOT (Better Anti-Rheumatic FarmacoTherapy) cohort, BARFOT, a long time follow up study of early RA. Patients were strategically selected by gender (14 women and 8 men), age (30 to 84 years old), disease duration (8–23 years), function as measured by HAQ (0–1.38), and quality of life as measured by EQ5D (0.52–1.00). The interviews were recorded, transcribed verbatim and coded into categories. Results Four categories emerged from the patients' experiences of quality of life in established RA: well-being, freedom, empowerment, and participation. Quality of life as well-being meant pleasure and being physical active. Quality of life as freedom meant dependence or independence in the ability to manage daily life activities. Quality of life as empowerment meant different coping strategies, such as positive thinking and resources to manage fatigue, pain and physical function. Quality of life as participation meant togetherness in different contexts with other people. Conclusions Quality of life in established RA could be understood by the patients in different ways. The patients experienced quality of life as well-being, freedom, empowerment, and participation. This is important knowledge when evaluating the concept of quality of life in RA research, and for health professionals when promoting quality of life in patients with RA. Disclosure of Interest None declared

BMC Rheumatology

Background A large number of patients with RA do not adhere to the recommended levels of physical... more Background A large number of patients with RA do not adhere to the recommended levels of physical activity to enhance health. According to EULAR recommendations, physical activity should be part of standard care in people with rheumatic diseases. There have been few larger studies on maintenance of physical activity over longer periods of time. The aim was to study self-reported physical activity levels over 7 years in patients with established rheumatoid arthritis (RA). In addition, to determine variables associated with maintenance or change of physical activity behavior. Methods Questionnaires were sent to the BARFOT cohort in 2010 (n = 1525) and in 2017 (n = 1046), and 950 patients responded to both questionnaires. Patients were dichotomized according to meeting MVPA recommendations (physically active at a moderate level ≥ 150 min/week or at an intense level ≥ 75 min/week) or not. Body mass index, smoking habits, tender joint count (TJC), swollen joint count (SJC), Patient Globa...

Rheumatology Advances in Practice

Objectives The aim was to study if patients with RA recalled having discussions concerning lifest... more Objectives The aim was to study if patients with RA recalled having discussions concerning lifestyle habits during their healthcare visits. A secondary aim was to study the association between patients' reported lifestyle and their wish to discuss it. Methods A postal questionnaire sent to 1,542 eligible patients from the Better Anti-Rheumatic Pharmacotherapy (BARFOT) study included questions on lifestyle habits (physical activity, diet, smoking, and alcohol), on whether these were discussed during healthcare visits, and on whether there was an interest in such discussions. Results A total of 1,061 patients (68%) responded (mean age 67 years (SD 13), 73% women). Half of the patients (49%) recalled discussions on physical activity and 23% recalled discussions about diet. Those who reported health-enhancing levels of physical activity were more likely to discuss physical activity with their health professionals. Similarly, patients who reported having a non-traditional mixed diet ...

Open Access Rheumatology: Research and Reviews

Purpose: At the end of the twentieth century, the outcome of rheumatoid arthritis (RA) was shown ... more Purpose: At the end of the twentieth century, the outcome of rheumatoid arthritis (RA) was shown to be unsatisfactory and new therapeutic strategies were introduced. This initiated a register-based long-term study of early RA, the Better Anti-Rheumatic PharmacOTherapy (BARFOT) study. The aims were to evaluate the disease course and to acquire knowledge for improved care. Patients and methods: BARFOT is a multicentre observational study of patients with early RA, consecutively included 1992-2006. The patients are followed in daily practice according to a structured protocol for 15 years and data recorded in a web-based register. Also, through linkage of the BARFOT register to national registers we have acquired information on comorbidity and mortality. Results: In all, 2857 patients have been included and over 80 scientific articles have been published. Phenotypic characteristics at disease onset, i.e. gender, smoking habits and autoantibody profiles have been addressed. The disease course over 15 years was described. Early predictors for persistent disease activity, impaired function, joint damage and comorbidities have been identified. Treatment strategies have been studied. A randomized sub-study gave strong support for the treatment of recent RA with low-dose prednisolone in combination with disease-modifying anti-rheumatic drug. Furthermore, the impact of lifestyle factors, such as smoking, alcohol consumption, body weight and physical activity has been addressed. Conclusion: A register-based study like BARFOT has provided a basis for optimal longterm management of patients with RA. In addition, the register has made it possible to perform a diversity of studies of RA addressing various issues of major relevance to the patients.

International journal of qualitative studies on health and well-being, 2016

Rheumatoid arthritis (RA) is a chronic, inflammatory, and systemic disease with symptoms that lim... more Rheumatoid arthritis (RA) is a chronic, inflammatory, and systemic disease with symptoms that limit activities and affect quality of life. RA is associated with an increased risk of developing comorbidities, some of which are also known to be associated with lifestyle habits such as physical activity, diet, smoking, and alcohol. There has been an augmented focus on the implementation and maintenance of healthy lifestyle habits even for patients with RA in the past decade, but little is known about the link between patients' experiences of lifestyle habits and quality of life. The aim of the study was thus to describe and explore how patients with established RA experience the influence of lifestyle habits on quality of life. The study had a descriptive and explorative design, based on qualitative content analysis. Strategic sampling was used in order to achieve variations in experiences. Twenty-two patients with RA (14 women and 8 men) from 30 to 84 years old, with a disease dur...

Annals of the Rheumatic Diseases, 2012

Abstract Purpose: Identify factors predictive for severe self-reported disability in patients wit... more Abstract Purpose: Identify factors predictive for severe self-reported disability in patients with rheumatoid arthritis. Methods: Patients (n = 1910) were sent a questionnaire 5-18 years after disease onset. Outcomes were the Health Assessment Questionnaire (HAQ), Rheumatoid Arthritis Outcome Score (RAOS) and physical activity. The tertile of patients most affected by the disease were compared to those less affected. Proposed predictive factors were function, pain, general health, radiographic joint damage, swollen/tender joints and disease activity measures at baseline. Age, gender and disease duration were controlled for in logistic regression analyses. Results: Seventy-three percent (n = 1387) responded to the questionnaire, mean age 65 years (SD 15) and 70% were women. Worse scores in function, pain, general health and tender joints at baseline increased the risk of being in the most affected group, as measured by HAQ and RAOS 5-18 years after disease onset (p < 0.000). Conclusion: High levels of pain and worse reports of function at disease onset were risk factors for being in the most disabled tertile of patients after 5-18 years. Pain and function proved to be predictors of the outcome while some measures of inflammation were not. It is important to recognize these patients who may be in need of multidisciplinary treatments already at disease onset. Implications for Rehabilitation Health care providers should be aware of the subgroup of patients with more severe symptoms of pain and impaired function at disease onset since they have an increased risk of being in the most disabled tertile of rheumatoid arthritis patients several years later. Health care providers should assess pain and function and act on high pain and impaired function already at disease onset as they proved to be predictors of patient-reported outcomes controlled for inflammatory parameters. These findings support European guidelines and research findings that patients with high pain and impaired function despite of well-managed inflammatory parameters should early in the disease course be referred to multidisciplinary treatment for supplementary regime.

SAGE open medicine, 2017

Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as p... more Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as physical health, level of independence, environment and personal beliefs, compared with the healthy population. There is an increasing interest in quality of life in clinical and medical interventions. Few studies have explored patients' individual conceptions of quality of life, and interviews can thus complement quantitative studies. There is a need for a deeper understanding of the patients' experiences of quality of life, with regard to living with a long-term condition such as rheumatoid arthritis. The aim of this study was to explore the variation of ways in which patients with established rheumatoid arthritis understand the concept of quality of life. The study had a qualitative design with a phenomenographic approach, which was used to describe variations in how individuals experience their quality of life. The study is based on interviews with 22 patients with established...

Additional file 1. Cross-sectional description and comparison between patients fulfilling MVPA re... more Additional file 1. Cross-sectional description and comparison between patients fulfilling MVPA recommendations or not (non-MVPA) in 2010 and 2017.

FRIDAY, 15 JUNE 2018, 2018

Annals of the Rheumatic Diseases, 2015

Background Fatigue, pain, stiffness, impaired muscle function and impaired physical function are ... more Background Fatigue, pain, stiffness, impaired muscle function and impaired physical function are some of the most pronounced symptoms in rheumatoid arthritis (RA) and these may be related to lifestyle habits such as physical activity, diet, smoking and alcohol. There is limited knowledge about how patient with longstanding RA understand their lifestyles habits in relation to their disease and quality of life. Objectives To describe experiences of how lifestyle habits relate to quality of life in patients with longstanding RA. Methods A qualitative study with a deductive content analysis design, including 17 patients from the Swedish BARFOT (Better Anti-Rheumatic FarmacoTherapy) cohort. BARFOT is a long time follow up study of early RA. Informants were strategically selected by gender (ten women and seven men), age (range 30-84 years), disease duration (8-23 years), function as measured by HAQ, and quality of life as measured by EQ5D. Semi-structured interviews focused on four lifestyle habits (main categories); Physical activity, Diet, Smoking, and Alcohol. The interviews were recorded, transcribed verbatim and coded into subcategories within each of the four main categories. Results In patients with longstanding RA quality of life was related to the four given main categories (lifestyle habits). Each main category included two to three subcategories; (1) Physical activity means barrier, opportunities and well-being, (2) Diet means shame, well-being and social relationship, (3) Smoking means reward and fear, and (4) Alcohol means ambivalence and social relationship. Conclusions In longstanding RA, lifestyle habits relates to quality of life through both positive and negative experiences. This has to be taken into account in clinical care for a better understanding of how patients conceive and adherer to advice on lifestyle. References Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746):1094-108. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-88. Acknowledgements Disclosure of Interest None declared

FRIDAY, 15 JUNE 2018, 2018

The warmer pool temperature was stated as a reason for the benefits obtained. Reported benefits o... more The warmer pool temperature was stated as a reason for the benefits obtained. Reported benefits of hydrotherapy are illustrated in graph 1: Conclusions: This survey suggests variability in utilisation of hospital hydrotherapy services by a national AS patient group in the UK, with barriers to access, lack of promotion and pool closures. Similar benefits of hydrotherapy to those stated in the NICE guidance were experienced. 1 Future service recommendations which focus on flexible access for flare management, 'Pay as you Go' schemes, group exercise and self-management may increase utilisation, optimise experience and reverse decline. Research to assess the benefits of these service recommendations in a clinical population is needed.

Rheumatoid Arthritis (RA) is a chronic, inflammatory, and systemic disease of unknown aetiology t... more Rheumatoid Arthritis (RA) is a chronic, inflammatory, and systemic disease of unknown aetiology that affects 0.5‒1.0% of the population in Europe, more women than men. Pain, physical disability, fatigue, and sleep disturbances are some of the most pronounced symptoms in patients with a more severe disease or with a longer disease duration, resulting in activity limitations that affect quality of life. RA is associated with an increased risk of developing comorbidities, some of which are known to be associated with a sedentary lifestyle. A healthy lifestyle can reduce the risk to develop diseases and help to improve quality of life in patients with RA. In guidelines and recommendations for management of patients with RA, health professionals are encouraged to prioritise discussions about lifestyle, especially physical activity, diet, smoking, and alcohol use. The overall aim of the present work was to explore factors that affect disability and quality of life in patients with establi...

Annals of the Rheumatic Diseases

Background Fatigue, pain, stiffness and impaired physical function are some of the most pronounce... more Background Fatigue, pain, stiffness and impaired physical function are some of the most pronounced symptoms in rheumatoid arthritis (RA) that may affect quality of life. Quality of life is an individual experience composed of a wide range of factors, including physical health, psychological state, level of independence, social relationships, and the patients' relationship to salient features of their environment. There is a need to describe and assess quality of life in chronic diseases like established RA. Previous research has mainly focused on disease-specific instruments for assessing quality of life. A deeper understanding of patients' experience of quality of life in established RA is important in both clinical research and daily clinical practice. Objectives To describe variations in patients' experiences of quality of life in established RA Methods The study had a qualitative design with a phenomenographic approach, including 22 interviews with patients from the Swedish BARFOT (Better Anti-Rheumatic FarmacoTherapy) cohort, BARFOT, a long time follow up study of early RA. Patients were strategically selected by gender (14 women and 8 men), age (30 to 84 years old), disease duration (8–23 years), function as measured by HAQ (0–1.38), and quality of life as measured by EQ5D (0.52–1.00). The interviews were recorded, transcribed verbatim and coded into categories. Results Four categories emerged from the patients' experiences of quality of life in established RA: well-being, freedom, empowerment, and participation. Quality of life as well-being meant pleasure and being physical active. Quality of life as freedom meant dependence or independence in the ability to manage daily life activities. Quality of life as empowerment meant different coping strategies, such as positive thinking and resources to manage fatigue, pain and physical function. Quality of life as participation meant togetherness in different contexts with other people. Conclusions Quality of life in established RA could be understood by the patients in different ways. The patients experienced quality of life as well-being, freedom, empowerment, and participation. This is important knowledge when evaluating the concept of quality of life in RA research, and for health professionals when promoting quality of life in patients with RA. Disclosure of Interest None declared

BMC Rheumatology

Background A large number of patients with RA do not adhere to the recommended levels of physical... more Background A large number of patients with RA do not adhere to the recommended levels of physical activity to enhance health. According to EULAR recommendations, physical activity should be part of standard care in people with rheumatic diseases. There have been few larger studies on maintenance of physical activity over longer periods of time. The aim was to study self-reported physical activity levels over 7 years in patients with established rheumatoid arthritis (RA). In addition, to determine variables associated with maintenance or change of physical activity behavior. Methods Questionnaires were sent to the BARFOT cohort in 2010 (n = 1525) and in 2017 (n = 1046), and 950 patients responded to both questionnaires. Patients were dichotomized according to meeting MVPA recommendations (physically active at a moderate level ≥ 150 min/week or at an intense level ≥ 75 min/week) or not. Body mass index, smoking habits, tender joint count (TJC), swollen joint count (SJC), Patient Globa...

Rheumatology Advances in Practice

Objectives The aim was to study if patients with RA recalled having discussions concerning lifest... more Objectives The aim was to study if patients with RA recalled having discussions concerning lifestyle habits during their healthcare visits. A secondary aim was to study the association between patients' reported lifestyle and their wish to discuss it. Methods A postal questionnaire sent to 1,542 eligible patients from the Better Anti-Rheumatic Pharmacotherapy (BARFOT) study included questions on lifestyle habits (physical activity, diet, smoking, and alcohol), on whether these were discussed during healthcare visits, and on whether there was an interest in such discussions. Results A total of 1,061 patients (68%) responded (mean age 67 years (SD 13), 73% women). Half of the patients (49%) recalled discussions on physical activity and 23% recalled discussions about diet. Those who reported health-enhancing levels of physical activity were more likely to discuss physical activity with their health professionals. Similarly, patients who reported having a non-traditional mixed diet ...

Open Access Rheumatology: Research and Reviews

Purpose: At the end of the twentieth century, the outcome of rheumatoid arthritis (RA) was shown ... more Purpose: At the end of the twentieth century, the outcome of rheumatoid arthritis (RA) was shown to be unsatisfactory and new therapeutic strategies were introduced. This initiated a register-based long-term study of early RA, the Better Anti-Rheumatic PharmacOTherapy (BARFOT) study. The aims were to evaluate the disease course and to acquire knowledge for improved care. Patients and methods: BARFOT is a multicentre observational study of patients with early RA, consecutively included 1992-2006. The patients are followed in daily practice according to a structured protocol for 15 years and data recorded in a web-based register. Also, through linkage of the BARFOT register to national registers we have acquired information on comorbidity and mortality. Results: In all, 2857 patients have been included and over 80 scientific articles have been published. Phenotypic characteristics at disease onset, i.e. gender, smoking habits and autoantibody profiles have been addressed. The disease course over 15 years was described. Early predictors for persistent disease activity, impaired function, joint damage and comorbidities have been identified. Treatment strategies have been studied. A randomized sub-study gave strong support for the treatment of recent RA with low-dose prednisolone in combination with disease-modifying anti-rheumatic drug. Furthermore, the impact of lifestyle factors, such as smoking, alcohol consumption, body weight and physical activity has been addressed. Conclusion: A register-based study like BARFOT has provided a basis for optimal longterm management of patients with RA. In addition, the register has made it possible to perform a diversity of studies of RA addressing various issues of major relevance to the patients.

International journal of qualitative studies on health and well-being, 2016

Rheumatoid arthritis (RA) is a chronic, inflammatory, and systemic disease with symptoms that lim... more Rheumatoid arthritis (RA) is a chronic, inflammatory, and systemic disease with symptoms that limit activities and affect quality of life. RA is associated with an increased risk of developing comorbidities, some of which are also known to be associated with lifestyle habits such as physical activity, diet, smoking, and alcohol. There has been an augmented focus on the implementation and maintenance of healthy lifestyle habits even for patients with RA in the past decade, but little is known about the link between patients' experiences of lifestyle habits and quality of life. The aim of the study was thus to describe and explore how patients with established RA experience the influence of lifestyle habits on quality of life. The study had a descriptive and explorative design, based on qualitative content analysis. Strategic sampling was used in order to achieve variations in experiences. Twenty-two patients with RA (14 women and 8 men) from 30 to 84 years old, with a disease dur...

Annals of the Rheumatic Diseases, 2012

Abstract Purpose: Identify factors predictive for severe self-reported disability in patients wit... more Abstract Purpose: Identify factors predictive for severe self-reported disability in patients with rheumatoid arthritis. Methods: Patients (n = 1910) were sent a questionnaire 5-18 years after disease onset. Outcomes were the Health Assessment Questionnaire (HAQ), Rheumatoid Arthritis Outcome Score (RAOS) and physical activity. The tertile of patients most affected by the disease were compared to those less affected. Proposed predictive factors were function, pain, general health, radiographic joint damage, swollen/tender joints and disease activity measures at baseline. Age, gender and disease duration were controlled for in logistic regression analyses. Results: Seventy-three percent (n = 1387) responded to the questionnaire, mean age 65 years (SD 15) and 70% were women. Worse scores in function, pain, general health and tender joints at baseline increased the risk of being in the most affected group, as measured by HAQ and RAOS 5-18 years after disease onset (p < 0.000). Conclusion: High levels of pain and worse reports of function at disease onset were risk factors for being in the most disabled tertile of patients after 5-18 years. Pain and function proved to be predictors of the outcome while some measures of inflammation were not. It is important to recognize these patients who may be in need of multidisciplinary treatments already at disease onset. Implications for Rehabilitation Health care providers should be aware of the subgroup of patients with more severe symptoms of pain and impaired function at disease onset since they have an increased risk of being in the most disabled tertile of rheumatoid arthritis patients several years later. Health care providers should assess pain and function and act on high pain and impaired function already at disease onset as they proved to be predictors of patient-reported outcomes controlled for inflammatory parameters. These findings support European guidelines and research findings that patients with high pain and impaired function despite of well-managed inflammatory parameters should early in the disease course be referred to multidisciplinary treatment for supplementary regime.

SAGE open medicine, 2017

Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as p... more Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as physical health, level of independence, environment and personal beliefs, compared with the healthy population. There is an increasing interest in quality of life in clinical and medical interventions. Few studies have explored patients' individual conceptions of quality of life, and interviews can thus complement quantitative studies. There is a need for a deeper understanding of the patients' experiences of quality of life, with regard to living with a long-term condition such as rheumatoid arthritis. The aim of this study was to explore the variation of ways in which patients with established rheumatoid arthritis understand the concept of quality of life. The study had a qualitative design with a phenomenographic approach, which was used to describe variations in how individuals experience their quality of life. The study is based on interviews with 22 patients with established...