Open Access Open Badges Research article

Measurement of stiffness in patients with rheumatoid arthritis in low disease activity or remission: a systematic review

Lilian HD van Tuyl1*, Willem F Lems1 and Maarten Boers12

Author Affiliations

1 Department of Rheumatology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands

2 Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands

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BMC Musculoskeletal Disorders 2014, 15:28  doi:10.1186/1471-2474-15-28

Published: 29 January 2014



Recent qualitative research has shown that stiffness is an important symptom for patients to identify remission. However, it is unclear how to measure stiffness in low disease activity. This systematic review aims to summarise the existing literature on validity of patient reported outcomes to measure stiffness in RA low disease activity states, to aid the choice for a measurement instrument.


An extensive pubmed-search was undertaken, identifying measurement instruments for patient perceived stiffness used in low disease activity. Eligible studies reported on 1) stiffness as an outcome in relation to other core set measures, 2) development of a patient reported tool to measure stiffness, or 3) comparison of two different tools to measure aspects of stiffness, all in low disease activity.


Of 788 titles, only two studies report on validity of stiffness measures within low disease activity. Morning stiffness (MS) is reported in 44 to 80% of patients in low disease activity. A difference of 40 to 60 minutes in duration until maximum improvement is observed between active and inactive patients. Severity of MS might discriminate better between high and low disease activity compared to measurement of duration of MS.


There is insufficient data on measurement of stiffness in the spectrum of low disease activity or remission.

Rheumatoid arthritis; Remission; Morning stiffness; Outcome assessment; Systematic review