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Effects of dynamic strength training on physical function Valpar 9 work sample test and working capacity in patients with recent-onset rheumatoid arthritis.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 49, No. 1, February 15, 2003, pp 71–77
DOI 10.1002/art.10902
© 2003, American College of Rheumatology
Effects of Dynamic Strength Training on
Physical Function, Valpar 9 Work Sample Test,
and Working Capacity in Patients With
Recent-Onset Rheumatoid Arthritis
Objective. To study the impact of 24 months of strength training on the physical function of patients with early
rheumatoid arthritis (RA).
Methods. Seventy patients were assigned to either the strength training (experimental) group (n ⴝ 35) or the control
group (n ⴝ 35). Patients in the experimental group performed strength training for 24 months, and control patients were
instructed to perform range of motion exercises. Maximal strength of the knee extensors, trunk flexors, and extensors, as
well as grip strength were recorded with dynamometers. Disease activity was assessed by the erythrocyte sedimentation
rate and Ritchie’s articular index, joint damage was determined by the Larsen x-ray index, and functional capacity was
assessed using the Valpar 9 test and the Stanford Health Assessment Questionnaire (HAQ). The employment status of each
patient was recorded.
Results. In the experimental group, strength training led to significant increases (19 –59%) in maximal strength of the
trained muscles. Such increases in the control group varied from 1% to 31%. There was a clear training effect on muscular
strength in favor of the experimental group, but significant improvements in the HAQ indices as well as in the Valpar 9
test were seen also in control patients. Results of the Valpar 9 and the HAQ were statistically significantly better in
patients who remained gainfully employed compared with patients who retired preterm during followup. However,
compared with patients who remained in the work force, patients who retired were older, and their work was physically
more demanding.
Conclusion. As expected, strength training led to increased muscle strength, but this increase did not correlate with
improved physical function as assessed by the Valpar 9 work sample test. The increased muscle performance did not
prevent a substantial proportion of patients from retiring preterm. The 2 items from the Valpar 9 test that were applied
were not sensitive enough to differentiate the patients according to their working status.
KEY WORDS. Rheumatoid arthritis; Muscle strength; Physical function; Valpar 9.
Rheumatoid arthritis (RA) is a severe, progressive disease
with an unpredictable course and outcome (1,2). Although
Supported by grants from Central Finland Health Care
District and the Yrjö Jahnsson Foundation, Finland.
Arja Häkkinen, PhD, Tuulikki Sokka, MD, PhD, AnnaMaria Lietsalmi, OT, Pekka Hannonen, MD, PhD: Central Finland Health Care District, Jyväskylä, Finland; 2Hannu Kautiainen: Rheumatism Foundation Hospital Heinola, Finland.
Address correspondence to Arja Häkkinen, PhD, Department of Physical Medicine and Rehabilitation, Central Hospital, Keskussairaalantie 19, FIN 40620 Jyväskylä, Finland.
Submitted for publication October 3, 2001; accepted in
revised form March 29, 2002.
the majority of the RA population is functionally independent, a substantial decline in functional capacity is often
observed over time, and health professionals are increasingly asked to make judgments regarding the degree of
disability of the patients (3,4). The functional capacity of
the musculoskeletal system can be assessed by various
physical measures, including grip strength, walking speed,
stair climbing, and the button test (5–7). More often, selfreport questionnaires such as the Stanford Health Assessment Questionnaire (HAQ) (8) and the Arthritis Impact
Measurement Scales (AIMS) (9) have been applied.
Functional limitations in RA are associated with inflammation and subsequent pain and fatigue (10,11), muscle
weakness and atrophy (12,13), and damage in joint structures resulting in limitations of joint mobility (14). Be71
cause the impairment often is associated with pain, it is
sufficient to limit an individual’s capacity to perform the
tasks required for his or her employment. Conversely,
Yelin et al in 1986 and 1987 (15,16) showed that workrelated disability in arthritis is often a function of the job
itself. A job with fewer physical requirements and a higher
degree of worker autonomy allows a person with arthritis
to remain gainfully employed. In addition to limitations in
paid work, RA may lead to limitations to satisfy one’s
personal needs as well as pursuits at home (17).
Patients with RA have low physical performance capacity, as shown in tests measuring aerobic capacity, muscle
strength, and endurance or range of motion (ROM) of individual joints (13,18,19). In contrast, aerobic and dynamic exercises have shown positive influence on the
physical function of patients (20 –22). The factors contributing to work disability in RA have been studied extensively (3). However, little is known about the contribution
of resistance strength training to the working capacity of
RA patients.
The Valpar 9 Whole Body Range of Motion Work Sample test (Valpar 9) is used by occupational therapists to
assess the working and home-making capacity of patients.
Valpar 9 simulates light work and assesses whole-body
ROM, agility, and stamina in the whole body, as well as
movements of the trunk, arms, hands, and overhead reaching (23). This type of testing is functional and may give
more multifaceted information than the testing of a single
muscle group or ROM of a joint. Although the test is quite
widely used by occupational therapists in the evaluation
of working capacity of patients with musculoskeletal diseases, the search in the MEDLINE database did not present
any earlier research on this topic. Thus, the purpose of this
study was to examine the effects of 24-month strength
training especially on the results obtained by the Valpar 9
test, and more generally on working capacity in patients
with early RA.
Subjects. Jyväskylä Central Hospital is the only rheumatology center in the Central Finland District, with a population of 263,000. All patients with new RA who live in
the area are referred to the center for diagnostic and therapeutic purposes. Seventy patients with recent-onset RA
according to the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 criteria for RA (24) volunteered for the study. Originally, 35
patients were randomly allocated to the experimental
group or the control group. Randomization was performed
using clusters of 4 patients who had been stratified according to age (⬍50 years and ⱖ50 years) and sex, to ensure
that the demographic data of the study groups remained
comparable. Two patients from the experimental group
and 3 from the control group withdrew after the baseline
measurements were performed (2 discontinued the exercise, 1 became ill with cancer, 1 drowned, and 1 was
involved in an accident that resulted in neurologic symptoms). Moreover, the diagnosis of 3 patients changed
(spondylarthrosis, psoriatic arthritis, and long-standing
Häkkinen et al
Table 1. Characteristics of 31 experimental and 31
control patients with rheumatoid arthritis
Sex, no. male/no. female
Age, mean ⫾ SD years
Weight, mean ⫾ SD kg
Height, mean ⫾ SD cm
Duration of symptoms,
mean ⫾ months
Employment status at
Employed, no.
Retired, no.
Unemployed, no.
Employment status at
Employed, no.
Retired, no.
Unemployed, no.
Physical loading of the work,
mean ⫾ SD score (scale
At baseline
At posttest
49 ⫾ 10
74 ⫾ 14
169 ⫾ 8
10 ⫾ 10
49 ⫾ 11
72 ⫾ 11
167 ⫾ 9
8 ⫾ 12
4.0 ⫾ 1.7
4.3 ⫾ 1.4
4.3 ⫾ 2.2
3.8 ⫾ 1.7
RA), and they were also excluded from the analysis. At
baseline, there were no significant differences in the demographic, strength, or clinical variables between the patients who completed the trial and those who withdrew
(data not shown). Data of the other 62 patients include that
of 1 patient in the experimental group who withdrew after
the first year due to lack of motivation for the training
(Tables 1–3).
At baseline, there were no salient differences in physical
characteristics between groups (Table 1). Therapy with
disease-modifying antirheumatic drugs (DMARDs) was instituted in all patients after the initial measurements were
performed. During the 24-month trial, 15 patients in the
experimental group and 19 in the control group had to
change their initial DMARD due to inefficacy and/or adverse events. Three patients in the experimental group and
12 control patients were treated with low-dose perioral
glucocorticoids periodically during the last 24 months
(2.5–7.5 mg of prednisolone daily).
Training programs. Patients in the dynamic strength
training group were personally instructed to perform a
strength training program for 24 months at home. Loading
of the strength training program was individually designed
according to the present capacity of each patient. A physiotherapist with lengthy experience guided the patients
during their 5-day inpatient period. Strength training included exercises for all main muscle groups of the body,
using elastic bands and dumbbells as resistance. Subjects
were programmed to exercise twice weekly with moderate
loads of 50 –70% of the repetition maximum, 2 sets per
exercise, 8 –12 repetitions per set. The intensity of the
strength training was reevaluated (according to the
strength measurements) every six months, during visits to
the clinic. In addition, patients were encouraged to engage
Strength Training in Patients With Recent-Onset RA
Table 2. Clinical parameters in 31 experimental and 31 control patients with
rheumatoid arthritis at baseline, 12 months, and 24 months*
ESR, mm/hr
12 months
24 months
Ritchie’s index
12 months
24 months
Larsen score (0–100 scale)
12 months
24 mo
Pain (0–100 mm scale)
0 months
12 months
24 months
groups (95% CI)
24.4 ⫾ 17.8
9.5 ⫾ 7.5
10.9 ⫾ 9.8
24.8 ⫾ 15.7
17.3 ⫾ 16.1
15.4 ⫾ 11.5
⫺0.4 (⫺8.8, 8.2)
⫺7.8 (⫺14.1, ⫺1.4)
⫺4.5 (⫺10.0, 0.9)
11.8 ⫾ 8.5
2.6 ⫾ 4.6
2.2 ⫾ 3.1
16.7 ⫾ 9.5
3.9 ⫾ 4.2
3.0 ⫾ 4.7
⫺4.9 (⫺9.5, ⫺0.3)
⫺1.3 (⫺3.7, 0.8)
⫺0.8 (⫺2.8, 1.2)
0.9 ⫾ 1.8
1.4 ⫾ 2.9
1.5 ⫾ 3.4
1.2 ⫾ 2.9
2.3 ⫾ 2.7
3.1 ⫾ 3.5
41.7 ⫾ 19.5
21.1 ⫾ 20.6
13.7 ⫾ 16.2
41.3 ⫾ 27.1
24.2 ⫾ 22.7
24.9 ⫾ 22.8
⫺0.3 (⫺1.4, 0.6)
⫺0.9 (⫺1.6, 0.7)
⫺1.6 (⫺3.1, 0.4)
0.4 (⫺11.6, 12.4)
⫺3.1 (⫺14.3, 8.1)
⫺11.2 (⫺21.4, ⫺1.0)
* Values are the mean ⫾ SD. CI ⫽ confidence interval; ESR ⫽ erythrocyte sedimentation rate.
in recreational physical activities, such as walking, cycling, skiing, and swimming, an average of 2–3 times per
week. Patients in the control group were instructed to
perform ROM and stretching exercises twice weekly, without any additional resistance, in order to maintain their
joint mobility. They were free to continue their recreational physical activities, with the exception of strength
training of any kind. All patients completed training diaries during the 2-year followup period. Diaries were
mailed to the investigators every second month for evaluation.
Muscle strength. Maximal unilateral concentric
strength of the knee extensors was measured using the
David 200 dynamometer (25), and isometric grip strength
was measured by a Digitest dynamometer (26). For the
results, the sum of the right and left side of knee extension
and grip strength were used. The maximal isometric force
Table 3. Functional capacity parameters in experimental and control groups at baseline and after 24 months*
Work sample test
Transfer I (s)
Pain during Transfer
1, mm
Fatigue during Transfer
1, mm
Transfer II (s)
Pain during Transfer 1, mm
Fatigue during Transfer
1, mm
HAQ (range 0–3)
Muscle strength, kg
Trunk extension
Trunk flexion
Knee extension
Change from baseline to month 24
Experimental group Control group
Mean ⴞ SD
Mean ⴞ SD
Experimental group
Mean (95% CI)
383 ⫾ 77
23 ⫾ 28
411 ⫾ 78
33 ⫾ 32
⫺10 (⫺28, 8)
⫺9 (1, 23)
26 ⫾ 25
31 ⫾ 25
2 (⫺11, 1)
537 ⫾ 109
34 ⫾ 30
28 ⫾ 24
552 ⫾ 118
46 ⫾ 37
41 ⫾ 35
⫺42 (⫺70, ⫺14)
⫺4 (⫺9, 13)
⫺1 (⫺11, 9)
0.56 ⫾ 0.48
0.76 ⫾ 0.55
55 ⫾ 21
42 ⫾ 14
67 ⫾ 30
56 ⫾ 31
54 ⫾ 18
37 ⫾ 11
53 ⫾ 26
50 ⫾ 22
* CI ⫽ confidence interval; HAQ ⫽ Health Assessment Questionnaire.
† Analysis of covariance. Baseline was covariate.
Control group
Mean (95% CI)
P value
in change†
⫺20 (⫺35, ⫺6)
⫺9 (⫺1, 21)
⫺12 (10, 14)
⫺26 (⫺51, ⫺2)
⫺15 (⫺1, 27)
⫺11 (⫺3, 25)
⫺0.43 (⫺0.61, ⫺0.26)
⫺0.41 (⫺0.59, ⫺0.24)
8 (4, 12)
9 (6, 11)
33 (26, 40)
18 (11, 24)
⫺1 (⫺5, 3)
6 (1, 10)
15 (9, 20)
9 (3, 15)
Häkkinen et al
Physical loading of work. Physical loading of work was
evaluated with a self-administered questionnaire. The
questionnaire included a 7-point scale accompanied by
more detailed illustrations and descriptions of various
types of work corresponding to each scale point. The scale
ranged from 1 (not at work) to 7 (very heavy manual work)
(29). Each patient’s employment status over the 24-month
study period was recorded.
Disease activity. Disease activity was measured using
the erythrocyte sedimentation rate (ESR) and Ritchie’s articular index (30). Radiographs of the hands and feet were
obtained at the time of diagnosis and at 12 and 24 months
thereafter. The Larsen score (0 –100) was applied to grade
the structural damage of the first through fifth metacarpophalangeal joints, the wrist, and the second through fifth
metatarsophalangeal joints (31). Pain was assessed using a
100-mm VAS (32).
Statistical analysis. Results are expressed as the mean
and standard deviation (SD) or the mean with 95% confidence intervals. Statistical evaluation between the groups
was performed by analysis of covariance (Pillai’s trace
criterion), using baseline values and age as covariates. The
crude Spearman’s correlation coefficient was used to determine the relationships between the variables. The alpha
level was set at 0.05 for all tests.
The local ethics committee approved this study, and
participants gave written informed consent.
Figure 1. In Valpar 9 test, Transfer 1 was performed moving 3
different objects from eye-level panel to overhead panel.
of the trunk flexors and extensors was measured using an
isometric strain-gauge dynamometer (27).
Functional capacity. The Valpar Whole Body Range of
Motion Work Sample (Valpar 9) was used to measure a
patient’s capacity to handle various-sized objects while
standing, stooping, crouching, and reaching overhead (28).
In the present study, 2 of the 4 transfers of the Valpar 9 test
were used. Transfer 1 was performed moving 3 different
objects from the eye-level panel to the overhead panel
(Figure 1), activating mostly the upper extremities. Transfer 2 was performed from the overhead panel to the kneelevel panel, with vision occluded while stooping (Figure
2), which demands more stamina and flexibility of the
lower extremities. These 2 transfers require working in
extreme positions. The height of the test panel was adjusted individually for each patient. Pain and fatigue experienced during the transfers were measured using a
100-mm visual analog scale (VAS). The time in seconds
used to move objects from one panel to another was registered. In addition, the percentage reference values of the
manual were applied: the relative result ⬎112.5% was
graded to exceed the normal working capacity
(87–112.5%) to meet the normal working capacity and
⬍87% below the normal working capacity (23). The Stanford Health Assessment Questionnaire (HAQ) was used to
assess subjectively perceived functional capacity (8).
At baseline, 28 patients in the experimental group were
engaged in paid employment, 2 were retired, and 1 was
unemployed. Corresponding numbers in the control group
were 24, 6, and 1 (Table 1). At the end of followup, 18
patients in the experimental group and 16 in the control
group were gainfully employed. The mean physical loading of the work of those patients able to continue paid
work remained constant. During the 24-month study pe-
Figure 2. In Valpar 9 test, Transfer 2 was performed from overhead panel to down to knee-level panel with vision occluded
while stooping.
Strength Training in Patients With Recent-Onset RA
riod, clinical parameters improved in favor of the experimental group, but pain was the only variable that reached
a statistically significant difference between groups (Table
In the experimental group, the reported compliance
with the exercise program averaged 1.5 times per week
during the first 12 months and 1.4 times per week during
months 13–24, instead of the planned 2 times per week.
The respective mean ⫾ SD times used for various types of
physical exercises (including strength training in the experimental group) during the first year were 240 ⫾ 124
minutes per week for the experimental group and 205 ⫾
103 minutes per week for the control group. During the
second year, the corresponding figures were 249 ⫾ 121 and
187 ⫾ 107 minutes per week. Three male patients in the
experimental group started to exercise in the gym instead
of performing in-home exercises with the rubber bands.
During the 24-month followup period, statistically significant improvements in the results of the Valpar 9 (except transfer 1 in the experimental group) and the HAQ
were observed in both groups (Table 3). At baseline, the
mean ⫾ SD performance scores in the experimental group
were 94% ⫾ 22% for transfer 1 and 83% ⫾ 15% for
transfer 2 compared with the reference values of healthy
persons. The corresponding percentages for the control
group were 80% ⫾ 19% and 88% ⫾ 19%. During the
24-month followup period, improvements in transfers 1
and 2 were 8% ⫾ 24% and 7% ⫾ 13%, and 5% ⫾ 10% and
9% ⫾ 11% in the experimental and control groups, respectively. The intergroup differences were not statistically
significant. Changes in pain and fatigue experienced during the tests were not statistically significant in either
However, when comparing the Valpar 9 test results of
patients who were still gainfully employed (workers) at 24
months (n ⫽ 34) and those who retired during followup
(n ⫽ 16), the respective mean ⫾ SD scores were 87% ⫾
19% and 71% ⫾ 8% in transfer 1 at baseline and 99% ⫾
23% and 87% ⫾ 19% in transfer 2 (P ⬍ 0.001 for both
transfers). At month 24, transfer 1 and transfer 2 scores of
93% ⫾ 22% and 104% ⫾ 22%, respectively, for the workers remained significantly better than the scores of 73% ⫾
12% and 84% ⫾ 9% for patients who retired (P ⬍ 0.001 for
both transfers).
At baseline, the 16 patients who retired were statistically significantly older compared with workers (56.3 ⫾
4.6 years versus 43.8 ⫾ 9.1 years; P ⬍ 0.001). The mean
physical loading scores for the job were 3.9 ⫾ 2.0 and
4.4 ⫾ 1.7 (P not significant) for workers and patients who
retired, respectively. When changes in the Valpar 9 test
results between workers and retired patients were adjusted
for age, the differences between groups still existed (P ⬍
0.049 for transfer 1 and P ⬍ 0.033 for transfer 2). In comparison, the baseline HAQ indices were 0.65 ⫾ 0.51 and
0.73 ⫾ 0.56 for workers and patients who retired, respectively. During the 24-month followup period, the HAQ
score improved in favor of workers, with respective indices of 0.15 ⫾ 0.34 and 0.39 ⫾ 0.40) (P ⬍ 0.020). In contrast,
the values in muscle strength, ESR, and Ritchie’s index did
not differ between groups with regard to employment status.
Improvements in the values for muscle strength favored
the experimental group, although for trunk flexion the
difference between groups did not reach statistical significance (Table 3). When all patients were evaluated as a
group, the changes in transfer 1 correlated with the
changes in trunk extension (r ⫽ ⫺0.47, 95% confidence
interval [CI] ⫺0.66, ⫺0.21) and flexion strengths (r ⫽
⫺0.59, 95 % CI ⫺0.74, ⫺0.36). Also, the combined HAQ
index correlated with transfer 1 as well as with transfer 2,
both at baseline (r ⫽ 0.41, 95% CI 0.17, 0.60 and r ⫽ 0.38,
95% CI 0.14, 0.58) and after followup (r ⫽ 0 .37, 95% CI
0.12, 0.58 and r ⫽ 0.47, 95% CI 0.23, 0.66).
Strength training, performed in the home for 24 months,
led to significant increases (19 –59%) in maximal strength
of the trained muscles. Corresponding changes in the control group varied from 1% to 31%. Both groups also demonstrated significant improvements in physical function,
as assessed by either the Valpar 9 test or the HAQ index. In
contrast, although muscle strength is an important part of
the endurance type of activity, the Valpar 9 test was unable
to detect improvements in muscle strength. Further, although Valpar 9 test results were, both at baseline and after
followup, statistically significantly lower in patients who
retired during the 24-month trial compared with those
who remained in the work force, the test cannot be used to
predict preterm retirement—information that is indispensable for preventive purposes.
Against our expectations, the increases in muscle
strength values did not reflect improvements in Valpar 9
test performance or disease activity parameters. Only increases in abdominal and back muscle strength correlated
with transfer 1, performed from eye-level panel to overhead panel. Stronger trunk muscles apparently are an advantage for postural control during this phase of the test
(which takes 6 –7 minutes), which also places demands on
muscle endurance. Both parts of the applied Valpar 9 test
also require fine-motor skill of the fingers, while other
parts of the body have primarily a stabilizing role. In
contrast, a patient’s ability to perform the tests did not
correlate with improvements in maximal grip strength.
Obviously, in addition to hand movement, the test tasks
require accuracy in other key components of upper extremity function as well as in eye– head and eye– hand
coordination. The learning effect as well as motivational
factors of the patients must be considered when interpreting the results of the repeated test. Thus, it seems apparent
that the results obtained by the Valpar 9 test poorly reflect
changes in muscle strength, one of the most important
components of physical performance.
Another unexpected finding was that although patients
could improve their performance both in muscle strength
and Valpar work sample tests, 8 of 28 patients in the
experimental group and 8 of 24 patients in the control
group retired preterm during the trial. Nevertheless, the
mean physical loading of the work of those who continued
at paid employment remained constant. When these workers (n ⫽ 32) were examined as a group, regardless of their
training background, they obtained significantly better results in the Valpar 9 tests compared with patients who
retired preterm. Among workers, the performance percentages of 93% and 104% in transfers 1 and 2, respectively,
met the limits of normal working capacity in the reference
population (87–112%) given in the manual. Among retired
patients, the corresponding values (73% and 84%) mirrored satisfactory working capacity. Thus, it seems that the
applied Valpar 9 test could be used to determine which
functional skills of patients are required to be able to
continue at paid employment. However, although we do
not have reference values according to age, the older age of
the patients who retired preterm may have contributed to
their poorer Valpar 9 test results.
The Valpar 9 test has some limitations that should be
taken into consideration when using and interpreting the
test results. First, the Valpar 9 test does not assess the
quality of the task performed, as subjects are free to choose
the way to perform the test. Second, the test does not
reveal the reason for decreased functional capacity. Finally, use of Valpar work samples assumes that patients
engaged in different types of physical work should be
individually tested using 1 of the 19 standardized tests
available. This, however, is a complicated and unrealistic
requirement in a clinical setting. Our occupational therapist spent almost an hour testing one patient, even though
only 2 of the 4 transfers of the Valpar 9 test chosen for this
study were applied. Furthermore, at baseline, as well as at
the outcome, both transfer 1 and transfer 2 results correlated with those obtained by the much more easily instrumented patient self-report, the HAQ. Thus, the 2 items
from the Valpar 9 that were used were not useful predictors of work status in the patient sample studied, and the
additional information provided by the test was limited. In
contrast, the degree of functional disability of the patients
was rather low, and further studies are needed to obtain
information regarding the suitability of the test for assessing patients with more severe disability.
The results confirmed that the working capacity of patients with RA is at risk from the very start of the disease,
as evidenced by the fact that 31% of our patients retired
preterm during the 2-year followup period. This result is
consistent with that of other prospective studies concerning work disability in patients with early RA (33–36).
Although our results, due to the small sample size, should
be interpreted with caution, older age and a physically
more demanding job obviously predict preterm retirement.
Nevertheless, work disability is a complex process in
which the circumstances and qualities of the work as well
as the characteristics of the patient or the disease process
may variably play a major role. Finally, all of our patients
were actively treated with DMARDs, and a proportion of
the patients received low-dose glucocorticoids as well.
Most probably, the applied drug treatment policy contributed little to improvements in muscle strength, and its
accurate role in the observed functional improvement of
the patients remain uncertain.
In conclusion, the results of the present study indicate
that strength training for 24 months resulted in salient
improvement in muscle strength. However, muscle
strength is only 1 component of physical function, and
Häkkinen et al
improvement in muscle strength poorly reflected the results obtained by the Valpar 9 test and a patient’s ability to
remain gainfully employed. Furthermore, regardless of
working status, the 2 items applied from the Valpar 9 work
sample test did not distinguish between the physical functional skills of patients with a rather low degree of disability better than the more simple HAQ. Thus, we do not
recommend use of the Valpar 9 test as a routine tool in
clinical practice.
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physical, recen, test, working, patients, capacity, work, training, strength, dynamics, onset, effect, arthritis, samples, function, valpar, rheumatoid
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