50th Year of Publication: Revisiting the 1980s

As I mentioned in my editorial appearing in this year’s January issue, 2023 is the 50th anniversary of the publication of The Journal of Rheumatology.¹ Over the course of the year, I will be highlighting articles published in The Journal that have been important publications in terms of their influence on the practice of rheumatology. In this month’s edition, I have selected 3 articles published in The Journal during the 1980s that I feel were, and continue to be, important to rheumatologists and therefore worthy of a second look by you, the readers. These are (1) a validation study of WOMAC by Bellamy et al²; (2) a description of 9 patients with primary antiphospholipid syndrome by Alarcon-Segovia and Sanchez-Guerrero³; and (3) a study introducing the Arthritis Helplessness Index by Nicassio et al.⁴

The article “Validation Study of WOMAC: A Health Status Instrument for Measuring Clinically Important Patient Relevant Outcomes to Antirheumatic Drug Therapy in Patients With Osteoarthritis of the Hip or Knee” describes the validation of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in a randomized controlled trial that compared the efficacy of 2 nonsteroidal antiinflammatory therapies in patients with symptomatic knee or hip osteoarthritis (OA).² The WOMAC 41-item list describing 5 dimensions that characterize OA was developed by interviewing 100 patients with OA. This was at a time when patient-reported outcome measures were not as prominent a feature of outcome measures as they are today. The construct validity was tested for each of the 5 individual dimensions by comparing the results from these WOMAC domains to previously validated scales and traditional measures that measured each domain separately. The WOMAC was shown to be responsive to change, have good test-retest reliability, and have superior relative efficacy over the traditional measures. In 2023—35 years after its development—the WOMAC remains the validated primary outcome measure for clinical and research studies for both knee and hip OA.^5-7

The second article to bring to your attention, “Primary Antiphospholipid Syndrome,” was one of the first studies to describe and define the occurrence of primary antiphospholipid syndrome (APS) not associated with systemic lupus erythematosus (SLE) or another autoimmune disease.³ Prior to this publication, it had been only postulated, but not shown, that antiphospholipid antibodies (aPL) and APS could occur as a primary disorder. The authors described 9 young people, the majority of whom were women (8/9), whose clinical and laboratory features included at least 2 of the following: venous thrombosis, arterial occlusions, thrombocytopenia, hemolytic anemia, recurrent fetal loss livedo reticularis, transverse myelitis, and/or leg ulcers. None fulfilled the criteria for SLE. Laboratory testing showed that 8 of 9 had high titer aPL, 8 of 8 had prolonged partial thromboplastin time, 5 of 5 had lupus anticoagulant, and only 1 of 9 had a positive antinuclear antibody (low titer). This may seem strange in 2023, but up until this article,³ almost all descriptions of APS were secondary to an autoimmune disease, which usually was SLE.^8,9

The final article I wish to highlight, “The Measurement of Helplessness in Rheumatoid Arthritis,” validated a simple 15-item questionnaire measuring helplessness in patients with rheumatoid arthritis (RA).⁴ They found that patients who reported a high degree of helplessness felt that their health status was beyond their control, and that this was significantly correlated with patient-reported functional incapacity. The importance lies not so much in the questionnaire itself but rather in emphasizing the importance of this issue to patients with RA. The study of helplessness has led to further associations of this phenomenon with catastrophic pain, depression, and coping strategies, all of which are important components of health-related quality of life. Although these concepts are currently well-recognized, this was not the case at the time this article was published.

I encourage you to read all 3 papers for their current and historic value. Notable articles that were previously published in The Journal of Rheumatology from the 1990s will appear in the May 2023 edition, accompanied by an editorial to highlight their importance and influence on the field of rheumatology.

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