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Occupational therapy during the first 10 years of rheumatoid arthritis
Abstract
To describe disease development and occupational therapy during the first 10 years of rheumatoid arthritis (RA), and to assess patients' experiences of occupational therapy and comprehensive care.
A total of 168 early RA patients with variable disease severity were followed up with regular team visits. The occupational therapist evaluated hand function and activity and performed the necessary interventions. These were recorded and the number of visits generating interventions was calculated. Semi-structured interview of 11 patients regarding their views of occupational therapy and team contact was performed.
Impairments of hand function were in general mild to moderate and remained fairly unchanged over time. Activity limitations increased slowly. Half of the follow-up visits generated interventions. Most common were prescriptions of assistive devices and orthoses, hand-training instructions and patient education. The patients interviewed were positive regarding occupational therapy and felt safe with comprehensive care.
RA patients in all stages of the disease benefit from regular contact with an occupational therapist and team care.
... Ett medelvärde mellan 0-3 räknas fram (5). Ett lågt medelvärde innebär inga eller små problem medan medelvärde >2 innebär betydande funktionsnedsättningar (6). Instrumentet är reliabilitets och validitetstestat (5). ...
... Arbetsterapeutens lär ut sådant som kan underlätta i vardagssituationen till exempel avlastande arbetssätt, rörelseövningar och hjälpmedel (10). Studier visar dock att patienten är mer benägen att ta till sig tips och råd vid individuell information när han/hon kanske är redo för det (6). ...
... En studie gjord av Malcus-Johnson et al (6) visar att hjälpmedel kan uppfattas som nödvändiga av vissa patienter, men av andra patienter som något som kan väljas bort. Samma studie visar att ortoser används i olika omfattning, en del använder dem hela dagen eller natten och andra använder dem bara vid speciella tillfällen, då de behöver extra stöd. ...
... De vanligaste svenska arbetsterapeutiska interventionerna vid RA är förskrivning av hjälpmedel, handträning, tillverkning av ortoser, patientundervisning individuellt eller i grupp samt anpassningar i hemmet eller på arbetsplatsen (Malcus-Johnson et al. 2005). Adaptiva tekniker där arbetsterapeuten hjälper individen att anamma nya strategier, avlastande arbetsmetoder samt tillhandahåller hjälpmedel och ortoser (stödskenor) kan användas i syftet att reducera sjukdomens inverkan på de funktionella förmågorna så att individen kan bibehålla sin självständighet. ...
... Undervisning i gruppform kan vara ett bra tillfälle för deltagarna att dela med sig av kunskaper och erfarenheter samt diskutera problem (Nordenskiöld 2001). Enligt en studie av Malcus-Johnson et al. (2005) upplevdes det som värdefullt att få råd gällande förändring av beteenden och aktivitetsutföranden samt tips och förslag till vad individen kan köpa själv för att underlätta vardagen. ...
... Enligt Barlow et al. (1999) kan tillgången till resurser som hjälpmedel och anpassningar kan ha betydelse för vardagen som förälder. I en studie Malcus-Johnson et al. (2005) uttryckte deltagarna att det var viktigt att veta var de skulle vända sig då problem uppstod. ...
... RA is a chronic systemic disease (12) afflicting 0.5% to 1% of the population (11). Symptoms which may be present are pain, fatigue, swollen joints, restricted mobility, and joint deformities (10,12,13). In contrast to RA, JIA occurs in childhood. ...
... The women expressed the need to compensate for their physical limitations in order to be able to perform daily occupations. By having access to assistive devices, the women could cope with their daily occupations, which in turn influenced their occupational performance and their perceptions of health, which also has been highlighted before (13,42,43). Furthermore, although the women continued to try to perform several of their daily occupations independently, some individuals could not be as active as they wanted without assistance. ...
... The possibility to have access to a rheumatology team and to have a good relationship with team members was also highlighted. The significance of a team has proved salient to individuals with rheumatic diseases previously (13,36). Furthermore, it was important to have access to training and water exercise in a pool to maintain the women's mobility and they also highlighted the importance of having access to other types of training for their performance of daily occupations and to perceive good health, which confirmed the results of previous studies (43,44). ...
Objective:
The purpose was to describe and characterize what women with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) perceive as important in considering the performance of daily occupations to perceive good health.
Methods:
By using a phenomenographic research approach with semi-structured interviews with nine women between the ages of 42 and 65 the core category "Being able to be as active as possible in daily occupations" emerged.
Results:
The women's repertoire of daily occupations had changed as the years had passed. To perceive good health the women expressed the importance of continuing to be active and to perform occupations as independently as possible despite their chronic rheumatic diseases.
Conclusions:
By adapting to their level of physical function and strength and by compensation with assistive devices, selecting adjusted environment, and by getting support from others, the women perceived good health. The results also suggested that training in different ways, medical treatment, and rheumatologic team care were related to increased performance of daily occupations and the perceptions of good health.
... A AR e a OA são doenças que geram impacto funcional na vida das pessoas, tornando as atividades cotidianas difíceis e muitas vezes dolorosas (Conaghan, 2008). Elas podem ocasionar dificuldades no desempenho de atividades, como: autocuidado, manutenção do lar, entre outras (Malcus-Johnson et al., 2005). Nesses casos, a Tecnologia Assistiva é apontada como umas das soluções para melhorar a qualidade de vida (Clark, 2000;Almeida et al., 2015). ...
Introduction
Assistive Technology (AT) is pointed as one of the possible solutions to offer better functionality and quality of life for people with rheumatological diseases. Interdisciplinary projects focused on assessing, indicating, and developing AT are important for advances in research and clinical care. Motion capture, through technological instrumentation, is an innovative theme for providing objective data about the user. Further studies in this area are needed to know the possibilities of applying technological instrumentation in AT research.
Objective
To describe the applicability of motion capture, using high-tech equipment, in an interdisciplinary AT research for rheumatological patients.
Method
It is an Experience Report, with a qualitative approach, in which the actions were described using specific technological equipment to motion capture. Results: Motion capture was used for three purposes: educational support; usability evaluation of AT resources developed; and support for study groups of occupational therapists to activity analysis.
Conclusion
In the different actions, the motion capture was used as a complementary resource for activities’ analysis performed by occupational therapists, which contributed to the indication, development, and evaluation of AT devices and to facilitate the instructions provided in manual and in the guidance groups about Joint Protection. Interdisciplinary work was differentiated for the proper use of equipment.
... Rheumatoid arthritis (RA) is a chronic, disabling disease characterized by chronic inflammation of joints that, in most patients, results in progressive joint destruction with deformities and various degrees of limitation in daily activities. 9 Disease severity can vary considerably even from day one to the next. The unpredictable and painful course of the disease cause a lot of stress on patients and greatly impact their quality of life. ...
Objectives: This study aims to examine the effectiveness of client-centered occupational therapy in patients with rheumatoid arthritis (RA).
Patients and methods: The study included 40 patients (2 males, 38 females; range 39 to 60 years) with RA. Patients were divided into two groups as intervention group (n=20) and control group (n=20) by random sampling method. Each group was given 10 sessions of physical therapy program. In addition, the intervention group received client-centered occupational therapy. Patients were evaluated with Turkish versions of Short-Form McGill Pain Questionnaire, Health Assessment Questionnaire, The Arthritis Impact Measurement Scales 2, RA Quality of Life Questionnaire, and Canadian Occupational Performance Measurement.
Results: Pain, activity limitation, and participation restriction scores decreased significantly more in the intervention group compared to the control group. Also, quality of life increased significantly in the intervention group (p<0.05).
Conclusion: Our findings suggest that occupational therapy intervention reduces activity limitation and participation restrictions in patients with RA. Therefore, such interventions may be generalized for this patient group.
... 13 A dificuldade na feitura de tarefas cotidianas constitui uma das principais queixas de pacientes com a doença 14,15 e ocasiona restriç ões na maioria de suas áreas de desempenho: 16 de atividades simples, relacionadas ao autocuidado e manutenção do lar, a tarefas laborais complexas o paciente apresenta limitaç ões na feitura de muitas de suas atividades de vida diária (AVDs). 17 Observa-se que tais restriç ões influenciam não apenas a feitura de atividades de modo independente e autônomo, mas apresentam impacto negativo sobre o estado emocional, as relaç ões sociais e a qualidade de vida do paciente. 7,18 Tendo em vista as restriç ões de participação e a importância do engajamento em atividades produtivas para a manutenção da saúde física e psicossocial dessa população, o terapeuta ocupacional compõe a equipe multiprofissional de assistência ao paciente com AR e tem como objeto de intervenção o desempenho das AVDs e a inserção do paciente em ocupaç ões significativas para seu cotidiano. ...
Intervenções voltadas para a educação e o autogerenciamento da artrite reumatoide (AR) pelo paciente aumentam a adesão e a eficácia da abordagem precoce. A combinação de tratamento medicamentoso e tratamento de reabilitação visa a potencializar as possibilidades de intervenção, retardar o aparecimento de novos sintomas, reduzir incapacidades, minimizar sequelas e reduzir o impacto dos sintomas sobre a funcionalidade do paciente. A terapia ocupacional é uma profissão da área da saúde que objetiva a melhoria do desempenho de atividades pelo paciente e fornece meios para a prevenção de limitações funcionais, adaptação a modificações no cotidiano e manutenção ou melhoria de seu estado emocional e participação social. Devido ao caráter sistêmico da AR o acompanhamento multidisciplinar é necessário para o adequado manejo do impacto da doença sobre os mais diversos aspetos da vida do paciente. Como membro da equipe de saúde, o terapeuta ocupacional objetiva a melhoria e manutenção da capacidade funcional do paciente, prevenir o agravamento de deformidades, auxiliar o processo de compreensão e enfrentamento da doença, fornecer meios para as atividades necessárias para o engajamento do indivíduo em ocupações significativas, favorecer sua autonomia e independência em atividades de autocuidado, laborais, educacionais, sociais e de lazer. O objetivo desta revisão é familiarizar o reumatologista com as ferramentas de avaliação e intervenção usadas na terapia ocupacional, com enfoque na aplicação desses princípios para o tratamento de pacientes com diagnóstico de AR.
... 13 The difficulty in performing daily tasks is one of the main complaints of patients with the disease 14,15 causing restrictions in most of their areas of performance 16 : from simple activities related to self-care and home maintenance to complex work tasks, the patient presents limitations in doing many of his/her activities of daily living (ADLs). 17 It is observed that such restrictions affect not only the performance of the activities independently and autonomously, but has a negative impact on the emotional state, social relationships and quality of life of the patient. 7,18 Given the participation constraints and the importance of engaging in productive activities for the maintenance of physical and psychosocial health of this population, the occupational therapist is an integral part of the multidisciplinary team of care for patients with RA, being concerned with the performance of ADLs and the inclusion of the patient in meaningful occupations for his/her everyday life. ...
Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of intervention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient's functionality. Occupational therapy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupational therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and coping with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and independence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA.
Copyright © 2014 Elsevier Editora Ltda. All rights reserved.
... 87 The most commonly provided treatments appear to be prescriptions of assistive devices, orthoses, hand-training instructions and patient education. 88 Evidence of effectiveness varies with relatively strong support for exercise and self-management interventions and modest support for JP programmes, orthoses and comprehensive care interventions. 89 Research clinic appointment Elibility confirmed, consent taken and baseline assessment performed The control arm treatment for the SARAH trial consisted of an initial assessment and advice session with the option of a further two follow-up sessions as necessary. ...
The effectiveness of exercise for improving hand and wrist function in people with rheumatoid arthritis (RA) is uncertain.
The study aims were (1) to estimate the clinical effectiveness and cost-effectiveness of adding an optimised exercise programme for hands and upper limbs to standard care for patients with RA; and (2) to qualitatively describe the experience of participants in the trial with a particular emphasis on acceptability of the intervention, exercise behaviours and reasons for adherence/non-adherence.
A pragmatic, multicentred, individually randomised controlled trial with an embedded qualitative study. Outcome assessors were blind to group assignment and independent of treatment delivery.
Seventeen NHS trusts in England comprising 21 rheumatology and therapy departments.
Adults with RA who had pain and dysfunction of the hands and/or wrists and had been on stable medication for at least 3 months. Patients were excluded if they were under 18 years old, had undergone upper limb surgery/fracture in the last 6 months, were on a waiting list for upper limb surgery or were pregnant.
Usual care or usual care plus an individualised exercise programme. Usual care consisted of joint protection education, general exercise advice and functional splinting if required. The exercise programme consisted of six sessions of strengthening and stretching exercises with a hand therapist, daily home exercises and strategies to maximise adherence.
The primary outcome was the Michigan Hand Outcome Questionnaire (MHQ) overall hand function subscale score at 12 months. Secondary outcome measures included the full MHQ, pain, health-related quality of life (Short Form questionnaire-12 items), impairment (grip strength, dexterity and range of motion) and self-efficacy. European Quality of Life-5 Dimensions, medication and health-care use were collected for the health economics evaluation. Follow-up was at 4 and 12 months post randomisation. Analysis was performed on an intention-to-treat basis.
We randomised 490 patients (244 to usual care, 246 to exercise programme). Compliance with the treatments was very good (93% of usual care participants and 75% of exercise programme participants completed treatment). Outcomes were obtained for 89% of participants at 12 months (222 for usual care, 216 for exercise programme). There was a statistically significant difference in favour of the exercise programme for the primary outcome at 4 and 12 months [mean difference 4.6 points, 95% confidence interval (CI) 2.2 to 7.0 points; and mean difference 4.4 points, 95% CI 1.6 to 7.1 points, respectively]. There were no significant differences in pain scores or adverse events. The estimated difference in mean quality-adjusted life-years (QALYs) accrued over 12 months was 0.01 greater (95% CI -0.03 to 0.05) in the exercise programme group. Imputed analysis produced incremental cost-effectiveness ratio estimates of £17,941 (0.59 probability of cost-effectiveness at willingness-to-pay threshold of £30,000 per QALY). The qualitative study found the exercise programme to be acceptable and highlighted the importance of the therapist in enabling patients to establish a routine and incorporate the exercises into their lives.
The results of the Strengthening And stretching for Rheumatoid Arthritis of the Hand trial suggest that the addition of an exercise programme for RA hands/wrists to usual care is clinically effective and cost-effective when compared with usual care alone. No adverse effects were associated with the exercise programme. The economic analysis suggests that the intervention is likely to be cost-effective.
Current Controlled Trials ISRCTN 89936343.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 19. See the NIHR Journals Library website for further project information. This report has been developed in association with the NIHR Collaboration for Leadership in Applied Health Research and Care Oxford and the NIHR Biomedical Research Unit Funding Scheme. This project benefited from facilities funded through Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands.
... Of all the non-pharmacological treatments for RA, orthoses, or splints, are one of the most widely used (Bielefeld & Neumann 2005;Malcus-Johnson, Carlqvist, Sturesson, Eberhardt, 2005;McKee & Rivard 2004). Bielefeld and Neumann (2005) regard splinting as the most accepted intervention to prevent the "progression of instability of the MCP joint" (p. ...
... Further, Nordenskiöld et al. have demonstrated significant correlations between grip strength and difficulties in hand activities such as eating, tying shoelaces, buttoning, shampooing hair, opening car doors and opening jars in women with RA (8). Thus, hand exercises to improve function have been a recommended and frequently used strategy in this group of patients (10). ...
The aim of this study was to test the effect of an intensive hand exercise programme in patients with rheumatoid arthritis (RA). Designed as a clinical controlled trial, the first 30 participants received a conservative exercise programme (CEP), while the next 30 received an intensive exercise programme (IEP). Outcomes were assessed at baseline, and after 2 and 14 weeks. Hand strength, measured as grip strength and pinch strength, was the primary outcome variable. Secondary outcomes were joint mobility, hand pain, and functional ability. After two weeks, there were significant differences between the groups in favour of the IEP in pinch strength in the dominant hand (p = 0.01), as well as grip and pinch strength in the non-dominant hand (p = 0.04 and 0.05, respectively). After 14 weeks, there was a significant difference between the two groups in grip strength in the non-dominant hand (p = 0.04), again in favour of the IEP. There was a trend towards increased pain in the CEP group and towards decreased pain in the IEP group, with significant differences between the groups in several measures of pain after 2 and 14 weeks. However, there were few significant differences between the two groups regarding joint mobility and functional ability. The results indicate that, compared with a traditional programme, an intensive hand exercise programme is well tolerated and more effective in improving hand function in patients with RA.
In this study, the effectiveness of classic and intensive exercise programs in patients with rheumatoid arthritis and the relationship of these programs with disease activity and patient functional well-being were investigated. Sixty patients between the ages of 18 and 65, who were followed up with a diagnosis of RA in our clinic, were randomly divided into two groups of 30 each and included in the study. An intensive exercise program was given to the first group and a classic exercise program was given to the second group. Disease activity was evaluated by erythrocyte sedimentation rate, C-reactive protein, DAS28Sedim, and DAS28Crp. Daily life activities were evaluated by HAQ score and Duruöz hand index. Joint mobility measurements were performed with a goniometer, and muscle strength measurements were performed with a manual dynamometer and pinch meter. Before exercise therapy, hand and wrist radiographs were taken and evaluated according to Steinbroker stages. The mean age of patients in the classic exercise group was 49.5±8.4, and the mean age of patients in the intensive exercise treatment group was 47.6±8.6. The distribution of women/men in the groups is similar. Improvement was observed in both VAS and HAQ scores in both groups. The improvement in VAS scores was significant in favor of the Intensive exercise group, while no significant difference was observed in HAQ scores between the two groups. We observed that exercise treatment given to regularly followed and treated patients had positive effects on patients' hand functions. We concluded that the intensive exercise program was more effective.
This review highlights the issue of psychosomatic conditions in rheumatoid arthritis, paying a special attention to new researches and trends in this field. Emerging concepts in all the major parts of the problem are covered consecutively, from the impact of chronic musculoskeletal pain on emotional state to disease influence over quality of life, socio-psychological, and interpersonal relationships. Chronic pain is closely related to emotional responses and coping ability, with pronounced positive effect of psychotherapeutic interventions, family and social support on it. Psychosexual disorders, anxiety, depression also commonly coexist with rheumatoid arthritis, leading to further decrease of quality of life, low compliance, and high suicide risk. Influence of psychosomatic conditions on overall treatment effect is usually underestimated by rheumatologists and general practitioners. Psychosomatic considerations are of great importance for up-to-date management of rheumatoid arthritis, as they strongly influence quality of life, compliance, and thereby disease outcomes. Two major approaches of psychological rehabilitation exist, both coping with pain through regulation of emotion and psychotherapeutic intervention, which not only helps patients in coping with the disease, but also aimed at improving the overall adaptation of the patient. It includes techniques of relaxation, cognitive-behavioral therapy, and biofeedback therapy. Current data about efficacy of the additional correcting therapies for patients with rheumatoid arthritis, both emerging and common ones, are discussed in the review.
Therapeutic gloves are an intervention widely recommended and prescribed by rheumatologists and occupational therapists for the management and treatment of hand arthritis. Different models of therapeutic gloves are commercially available, with varying design, construction and materials. However, a systematic classification for therapeutic gloves and their effectiveness has not been well established. In addition, little research has addressed the issue of material choice on glove performance. These knowledge gaps prompted the development of a framework for the design and engineering of functional and comfortable therapeutic gloves. Knowledge from multiple domains was integrated into a single framework and relationships between components were identified and characterised. The framework demonstrates that the design and engineering of therapeutic gloves requires fusion of functional design with comfort design to meet users’ demand for wearing comfort, relief of arthritic symptoms and improvement of hand function.
Study design:
Cross-sectional descriptive study.
Introduction:
Osteoarthritis (OA) is the most prevalent musculoskeletal disease in the adult and older adult populations. The use of orthoses to stabilize the thumb's articular complex is one of the most common conservative management strategies. Despite substantial research about this topic, there is insufficient evidence about the optimal use of orthoses to inform clinical practice, contributing to practice variations within and across health professionals.
Purpose of the study:
To identify the prescription patterns, design preferences, and barriers for the use of orthotic devices among Brazilian health care professionals involved in the treatment of patients with OA of the basal thumb joint.
Methods:
An electronic questionnaire was sent to occupational therapists, physiotherapists, and rheumatologists across Brazil through professional association mailing lists. Survey included questions about orthosis design, materials, and barriers to the use of orthotic interventions. Respondents indicated their use based on photographs of 25 orthoses models that were selected through bibliographic review and expert consultation. Descriptive statistics, the chi-square test for independence, and the Fisher exact test were used to compare differences among orthotic prescription preferences, barriers, and challenges observed amidst the 3 participants' professional classes.
Results:
There was no consensus about orthotic prescription among 275 professionals who answered the survey. About 69% of participants reported the use of multiple orthosis during treatment of patients with thumb OA. Results suggest significant variations in the number of joints included and stabilization strategies adopted, with a preference for orthotics made in rigid materials and involving the wrist, carpometacarpal, and metacarpophalangeal joints (P < .001). The lack of knowledge about orthotic options, institutional regulations, and policies were the major barriers reported by respondents (P < .01).
Conclusion:
A plentiful variety of different orthoses designs were observed in this study, and the prescriptions made by 3 professional classes showed differences regarding types of stabilization, joint involvement, and positioning. Despite the existence of clinical trials suggesting benefits for specific custom-made design models, our results indicated widespread clinical variation in practices and preferences.
Level of evidence:
Not applicable.
The review considers the results of studies of the psychosomatic aspects of rheumatoid arthritis (RA), which have been published in the past 5 years. In particular, there is evidence for the impact of chronic pain on the psychological status of patients with RA, for that of the disease on quality of life in the patients, their sociopsychological and interpersonal relationships; trials of the efficiency of additional treatment options for RA are given.
Based on the high prevalence of people with problems in the wrist and hand simultaneously, it is of its importance to clarify whether hand joints exert extra motion to compensate for wrist motion while immobilized.
This study aimed to measure the compensatory movement of the thumb and index finger when people perform daily activities with an immobilized wrist.
Thirty healthy volunteers were recruited in this study. A wrist splint, the Jebsen-Taylor Hand Function Test, and the OptoTrak Certus motion tracking system were used. Seven inter-digit mean joint angles of the index finger and thumb were calculated. Paired sample t-test was used.
(1) The compensatory motions were noted in the Metacarpophalangeal and Carpometacarpal joints of the thumb, and the proximal interphalangeal joints of the index finger; (2) The manifestation of compensatory motion was related to type of activity performed except when picking up light and heavy cans.
The compensatory motions appeared while the wrist was immobilized and were found to be disadvantageous to the progression of disease. In the future, studies need to be done to understand how to select products with correct ergonomic design to enable people to reap greater benefits from wearing wrist splints.
The aim of this systematic review is to summarise the available evidence on the effectiveness of assistive technology for adults with rheumatoid arthritis in terms of improving functional ability and reducing pain, and to assess potential adverse effects related to device use.
In this review, randomised controlled trials, clinical controlled trials, controlled before and after studies and interrupted time series available through systematic searches (electronic databases, grey literature, contact with authors, reference lists) up to October 2008 were included. Two reviewers independently selected trials for inclusion, assessed the validity of included trials, and extracted data. Investigators were contacted to obtain missing information.
Out of 7177 hits, 13 articles were reviewed in full text and only one trial was finally included (N.=29). The study was a randomised crossover trial, in which the use of an eye drop device was compared to a standard bottle in people with rheumatoid arthritis suffering from persistent dry eyes. The results show that the eye drop device improved application of eye drops and prevented adverse effects in terms of touching the eye with the bottle tip. The study was considered to have low quality of evidence.
Since only one trial met the inclusion criteria for this review, there is very limited evidence for the effect of assistive technology for adults with rheumatoid arthritis. There is an urgent need for high-quality research in this field, in order to reach sufficient evidence on the effectiveness of this commonly used intervention.
Objective: The “Comprehensive ICF Core Set for Rheumatoid Arthritis (RA)” is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in functioning of patients with RA. The objective of this study was to validate this ICF Core Set from the perspective of physicians.
Methods: Physicians experienced in RA treatment were asked about the patients’ problems, patients’ resources and aspects of environment from their scope of practice. This survey was conducted via e-mail in three rounds using the Delphi technique. The responses were linked to the ICF by two trained individuals according to empirically tested linking rules. Consensus of the results was calculated statistically by the statistical Kappa coefficient.
Results: 79 physicians in 41 countries named 512 patients’ problems spanning all ICF components. 227 ICF categories were linked to the physicians’ responses. 16 ICF categories were not represented in the Comprehensive ICF Core Set for RA although at least 75% of the participants have rated them as important. 19 issues were not covered by the ICF classification and 26 answers were linked to the not yet developed ICF component Personal factors.
Conclusion: The validity of the ICF components Body Structures, Activities and Participation and Environmental Factors was well supported by the physicians whereas there was less support for the validity of the component Body Functions. Several issues arose that are not covered and need to be investigated further.
Dissertação (mestrado)—Universidade de Brasília, Faculdade de Medicina, 2006. Introdução: O Health Assessment Questionnaire (HAQ) é um questionário desenvolvido para avaliar o impacto funcional da Artrite Reumatóide (AR) nos pacientes. Tem como um dos fatores que podem impedir sua boa utilização o baixo nível sócio-cultural de quem o responde, que é o que encontramos na população de pacientes atendidos nos serviços públicos de saúde no Brasil, o que poderia comprometer sua utilização em nossa realidade. Objetivo: Correlacionar os escores encontrados no HAQ quando este for respondido pelos pacientes com os escores encontrados quando o mesmo é respondido pela equipe assistente. Material e Métodos: Foram estudados 90 pacientes portadores de AR, que preenchiam os critérios para classificação da doença do American College fo Rheumatology (ACR). Primeiramente os pacientes respondiam o HAQ e, após um intervalo mínimo de tempo, o HAQ era respondido pela equipe. Os escores foram, então, analisados utilizando-se o método de correlação de Pearson. Resultados: A população estudada tinha idade média de 48,2 ± 12,8 anos, com média de tempo de educação formal de 7 ± 3,2 anos, e média de renda per capta de 0,9 ± 1,5 salários-mínimos. Os escores de HAQ encontrados nos questionários respondidos pelos pacientes tiveram média de 1,156 ± 0,835. Nos escores encontrados nos questionários aplicados pelos entrevistadores a média foi de 1,293, com desvio-padrão de ± 0,856. Houve correlação significativa entre os escores dos dois grupos – correlação de 0,84 (p<0.001 e intervalo com 95% de confiança de [0,77;0,90]). Conclusão: Mesmo em uma população com baixo nível sócio-educacional no Brasil o HAQ, quando auto-aplicado, é ferramenta confiável, com baixa variância inter-observador. ___________________________________________________________________________________ ABSTRACT Introduction: The Health Assessment Questionnaire (HAQ) is a tool developed to address the functional impact of Rheumatoid Arthritis (RA) in the individual patient. One of the factors that can implicated in a wrong use of it is low socioeducational level, which is the prevalent situation among our patients in Brazil. This finding can impact in the correct use of HAQ in our reality. Objective: To correlate HAQ scores found when it is self-administered by our patient, with the scores found when it is administered by the staff. Material and Methods: 90 RA patients, whom fulfilled the American College of Rheumatology set criteria for RA, were included. In a first moment the patients self-administered the HAQ and, after a time, the HAQ was answered by a staff with the patient. The scores were analyzed using the Pearson´s correlation method. Results: The population of the study showed median age of 48,2 years ±12,8, with a median monthly income of $144 ± 240. The median spare time of formal education was 7 years ± 3,2. HAQ scores found in the self-administered questionnaires had a median of 1.156 ± 0,835, and the median of the HAQ scores found in the questionnaires fulfilled by the medical staff was 1,293 ± 0,856. The correlation found was 0,84 (p<0.001 and CI [0,77;0,90]). Conclusion: Even in a population of low socio-economic level in Brazil, the HAQ, when self-administered, is a reliable tool, with a low inter-observer variance.
Provision of assistive technology is a widely used intervention for people with rheumatoid arthritis. Assistive technology is any item used to increase or maintain functional ability in individuals with disabilities. It includes a wide range of products, from low-technology devices to technologically complex equipment. Yet, there are few systematic reviews on the effectiveness of assistive technology in this population.
To assess the benefits of assistive technology for adults with rheumatoid arthritis in terms of improving functional ability and reducing pain, and to assess potential adverse effects in terms of psychological discomfort, personal injury or material damage related to device use.
We searched the following databases: CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, ISI Web of Science, PEDro, and OTseeker (to October 2008). In addition, we scanned reference lists, sought grey literature, and had personally communicated with authors. We updated the literature searches in January 2009.
Included study designs were randomised controlled trials, clinical controlled trials, controlled before and after studies, and interrupted time series where the effectiveness of assistive technology was evaluated. In addition, comparative observational studies were included if addressing adverse effects.
Two authors independently selected trials, extracted data, and assessed study quality. Investigators were contacted to obtain missing information.
Only one randomised controlled trial with 29 participants was included. The study compared the use of an eye drop device to a standard bottle in people with rheumatoid arthritis suffering from persistent dry eyes. The study was considered to have low quality of evidence. The proportions with observed difficulties when using the device to squeeze out drops and getting the drops in the eyes were 10% and 14%, respectively. This compared to 52% and 52% when using the standard bottle (P = 0.001; P = 0.003, respectively). The proportions of participants reporting difficulties with squeezing the bottle, controlling the number of drops, and aiming the drops when using the device were 40%, 44%, and 46% respectively, while using the standard bottle the proportions with difficulties were 72%, 84%, and 76% (P = 0.001; P = 0.003; P = 0.031, respectively).
Only one trial met the inclusion criteria for this review. Thus, there is very limited evidence for the effect of assistive technology for adults with rheumatoid arthritis and, therefore, an urgent need for high-quality research addressing the effectiveness of commonly used interventions.
The rehabilitative approach for the patient with rheumatoid arthritis should be early, global and complementary to an early pharmacological therapy, in the context of a multidisciplinary approach, that should include physicians with different specialties and other health professionals. Evaluation scales assessing disability and quality of life are necessary for the rehabilitative approach. These can be classified in 2 groups: specific tools and generic tools, each evaluating different components of the health status. After the evaluation and the definition of the aims of the rehabilitation, a rehabilitative project, potentially including physical therapies, therapeutic exercises, occupational therapy and orthosis should be defined.
The goal of occupational therapy (OT) is to facilitate adjustments to lifestyle and to prevent function loss. This study evaluated the effects of an early OT programme in early rheumatoid arthritis (RA).
We conducted a randomised, blind, controlled trial enrolling 60 patients with early RA, divided into 2 groups. At baseline, group 1 received the full information programme and group 2 received no information. In an extension phase, patients in group 2 received the full information programme at 3 months and were assessed at 6 months. The main outcomes were grip strength of hands (as objective assessment) and Health Assessment Questionnaire (HAQ) score (as subjective assessment).
At 3 months, grip strength of the dominant and non-dominant hands increased more in group 1 than in group 2 (p = 0.021 and 0.047 respectively). HAQ score decreased more in group 1 than in group 2 (p<0.001). In the extension phase, changes in grip strength and HAQ score in group 2 were similar to those seen in group 1 between baseline and 3 months.
This study comparing two schedules of OT programme showed that an early extended information programme improved hand function in patients with early RA.
Joint protection (JP) education is a common feature in rheumatoid arthritis (RA) treatment programs. However, no objective studies have been published demonstrating patients' behavior changes following such education. This study evaluated whether RA patients' hand movement patterns altered following a JP education program.
An assessment procedure was constructed to assess application of four JP principles related to altering patterns of hand use during common everyday activities (making a hot drink and snack meal).
Eleven RA patients were assessed. There was no significant behavioral change at 6 weeks post-JP education (t = 10; P > 0.1). In contrast, follow-up interviews of self-perceived JP behavior showed all subjects considered JP relevant for them and seven believed they had changed to using these techniques.
This suggests education led to attitudinal change but that behavioral change requires longer and more targeted input than is currently normally provided.
A substantial proportion of the patients treated by occupational therapists have a chronic disease. The aim of this study was to describe the outlines of occupational therapy treatment for three specific groups of chronic diseases: progressive neurological diseases, cerebrovascular accident and rheumatoid arthritis. A total of 143 therapists, working in 49 occupational therapy departments in The Netherlands, were asked to complete a standard registration from based on the ICIDH. This form consisted of three sections: (a) patient characteristics, (b) occupational therapy diagnosis and treatment goals in terms of ICIDH and (c) treatment characteristics. The present study concerns 507 patients: 102 had progressive neurological diseases (PND), 338 had a CVA and 67 had rheumatoid arthritis (RA). Our results showed that each patient group was characterized by a specific treatment approach. Especially at the level of treatment programmes substantial differences between groups were observed. Besides the clear differences, similarities in approaches were found between the PND and RA group, e.g. total time spent on therapy differed largely between the PND and RA patients (both averages 6 h) and the CVA patients (average 14 h).
To investigate outcome as measured by health status, disease process, and damage in an unselected group of patients with early rheumatoid arthritis (RA) monitored prospectively for 10 years and to search for prognostic factors.
183 patients with RA with disease duration <2 years were assessed annually at a team care unit. Health status was measured by the Health Assessment Questionnaire (HAQ) and functional class. Disease process was assessed by clinical and laboratory measures of disease activity and evaluation of disease course. Damage was quantified as occurrence of major extra-articular manifestations and need for large joint replacements. Possible predictive factors were evaluated by logistic regression analyses.
168/183 patients completed the entire follow up period. Of all 183 patients, 137 (75%) had been treated with disease modifying antirheumatic drugs and 84 (46%) with low dose oral glucocorticoids. After 10 years 158 patients (94%) managed daily life activities independently (functional class I-II). As measured by the HAQ 20% had almost no disability, 28% were mildly disabled, and 10% were seriously disabled. Median HAQ score had increased from 0.8 to 1.1 (p<0.001). Disease activity was significantly reduced. 133 patients (79%) had a relapsing remitting disease course and 30 patients (18%) were in remission as defined by the American College of Rheumatology criteria. Thirty patients (17%) had undergone large joint replacements. Fifteen patients (8%) had developed major extra-articular complications. The HAQ score during the first three months predicted disability at 10 years with an odds ratio of 13.4.
Prospective studies such as this give important knowledge of the variable long term prognosis of RA and provide necessary background information for clinical trials of new treatment modalities.
To investigate development of radiographic damage in hands and feet of patients with early rheumatoid arthritis (RA) monitored prospectively for 10 years, and to search for prognostic factors.
181 patients with early RA (mean disease duration one year) were assessed annually with radiographs of hands and feet during years 0-5 and at year 10. Radiographs were evaluated according to Larsen (range 0-200). Predictive factors for progressive disease for years 0-5 and 5-10 were evaluated by logistic regression analyses.
82/168 (49%) patients had erosions at inclusion and almost all became erosive with time (90% after two years and 96% after 10 years). Radiographic progression was most rapid during the first two years and 75% of all damage occurred during the first five years. The median Larsen score increased from 6 at inclusion to 41 after five years and 54 after 10 years. Only 5.3% of all evaluated joints became maximally eroded, the second metacarpophalangeal joint being the most commonly affected. Mean ESR during the first three months and rheumatoid factor status were significant predictors for radiographic progressive disease, it was not possible to predict non-progressive disease.
Joint damage in hands and feet developed early and progression was most rapid during the first years of disease. The different rates of progression at different stages should be considered in the design of trials of drugs aimed at retarding joint damage. Disease activity at study start influenced the degree of joint damage during the entire 10 years.
Objective. To examine the efficacy of wrist orthoses on pain, motion, and function of the wrist. Methods. Consecutive patients were randomized to a treatment group using wrist orthoses or to a control group using no wrist orthoses, in a prospective, controlled, 6-month study. Results. Changes in wrist joint variables and general disease activity variables were not statistically different between the orthosis group (n=36) and the control group (n=33). Patients in the orthosis group had 25% and 12% improvements in grip strength and pinch grip and 50% reduction in pain while using the wrist orthosis. Conclusion. Use of wrist orthoses improves function and reduces pain, but has no effects after 6 months, compared to a control group, on measures of local or general disease activity.
Purpose. Joint protection (JP) education is a common feature in rheumatoid arthritis (RA) treatment programs. However, no objective studies have been published demonstrating patients' behavior changes following such education. This study evaluated whether RA patients' hand movement patterns altered following a JP education program. Methods. An assessment procedure was constructed to assess application of four JP principles related to altering patterns of hand use during common everyday activities (making a hot drink and snack meal). Results. Eleven RA patients were assessed. There was no significant behavioral change at 6 weeks post-JP education (t = 10; P > 0.1). In contrast, follow-up interviews of self-perceived JP behavior showed all subjects considered JP relevant for them and seven believed they had changed to using these techniques. Conclusions. This suggests education led to attitudinal change but that behavioral change requires longer and more targeted input than is currently normally provided.
The aim of this study was to investigate effects of elastic wrist orthoses on pain, grip strength, and function. Twenty-two women with seropositive rheumatoid arthritis (mean age, 53 years) registered their pain on a visual analogue scale both with and without orthosis on the wrist of the dominant hand in three standardized activities of daily living (ADL) situations. Grip force at onset of pain was measured on an electronic instrument (Grippit) with three different grips. Pain was decreased by 39%, 42%, and 52% when using an orthosis in the three ADL situations. Anecdotally, the women noted that the splints provided support and decreased pain both in home, at work, and during leisure activities. Orthoses improved grip force at onset of pain by 26%, 22%, and 29%. All subjects showed reduced strength (20%-25%) when compared to grip strength in a group of women without rheumatoid arthritis.
The effect of active hand exercise and warm wax treatment was evaluated in 52 rheumatoid arthritis patients randomized into four groups: (1) both exercise and wax bath, (2) exercise only, (3) wax bath only, and (4) controls. Treatment was given three times a week for 4 weeks. Deficits in flexion and extension in digits II-V bilaterally, grip function, grip strength, pain, and stiffness were measured before and after the treatment period. The control group was measured at corresponding times. Wax bath treatment followed by active hand exercise resulted in significant improvements of range of motion (ROM) and grip function. Active hand exercise alone reduced stiffness and pain with nonresisted motion and increased ROM. Wax bath alone had no significant effect.
The major aims of the papers were to identify the difficulties in activities of daily living (ADL) of women with rheumatoid arthritis (RA) and to demonstrate the effect of interventions. Methods were developed for measuring grip force, the Grippit® instrument and assessing ADL without and with assistive devices. Effects of interventions were explored, and the need for new solutions concerning daily activities was identified. Seventy-three women with RA participated in the study, 14 women with fibromyalgia were included for comparison and 187 healthy women and 65 healthy men acted as a reference group. In describing the consequences of the disease with regard to ADL, the patient's perspective was taken into account.
In a rheumatology department, 2 randomized groups of female outpatients with rheumatoid arthritis were studied prospectively for 1 year. The outcome of multidisciplinary team care (T group, 31 patients) was compared with that of regular outpatient clinic care (NT group, 28 patients). Pharmacologic treatment and orthopedic specialist consultations were similar in both groups, but use of paramedical care was higher in the T group. Outcome measures of disease activity, specific joint function, and self-rated physical discomfort disclosed no significant differences between the 2 groups. Mental well-being increased in the T group. Overall health, measured by the Sickness Impact Profile, improved significantly only in the T group. This improvement was also significant compared with the NT group.
Objective. To describe the experiences of women who have learned to live with rheumatoid arthritis (RA), and to explore how women manage this chronic illness and the demands of their everyday lives.
Methods. Thirty women with a diagnosis of RA were interviewed in their homes. The women were encouraged to “tell their story of living with RA,” from the first symptom to the present, using a semistructured questionnaire. Qualitative data were analyzed using a constant comparative analytic process.
Results. Learning to live with RA was characterized by periods of uncertainty, of learning about the illness, discovering strategies that allowed the women to meet the expectations of their roles as women, and the establishment of new patterns of daily life. The women became experts at managing their RA and developed a sense of mastery in coping with their symptoms.
Conclusions. Persons with RA need support and guidance, beginning with the onset of the disease, to facilitate achieving mastery in living with this chronic illness.
The aim of this study was to investigate effects of elastic wrist orthoses on pain, grip strength, and function. Twenty-two women with seropositive rheumatoid arthritis (mean age, 53 years) registered their pain on a visual analogue scale both with and without orthosis on the wrist of the dominant hand in three standardized activities of daily living (ADL) situations. Grip force at onset of pain was measured on an electronic instrument (Grippit) with three different grips. Pain was decreased by 39%, 42%, and 52% when using an orthosis in the three ADL situations. Anecdotally, the women noted that the splints provided support and decreased pain both in home, at work, and during leisure activities. Orthoses improved grip force at onset of pain by 26%, 22%, and 29%. All subjects showed reduced strength (20%–25%) when compared to grip strength in a group of women without rheumatoid arthritis.
We report the interaction of RA and psychological factors over 2 years in a group of 89 patients with newly established disease. Short-time outcome regarding physical features was fairly good. Disease activity decreased, and disability evaluated by HAQ remained at a low level. Psychological distress as measured by the depression and anxiety subscales of SCL 90 (Symptom Check List) was not very pronounced and not related to disease state factors. A slight decrease of anxiety was recorded after 2 years. A new adjustment test was applied. It contained 13 items focused mainly on negative illness effects such as loss of independence, feelings of guilt, and change of social and leisure time activities. Three factors (regret of lost life values, dysphoric mood, and acceptance) explained 48% of the variance of the 13 items. The validity of the test was acceptable. The patients' degree of adjustment changed slowly or not at all during the 2 years.
Being physically comfortable and doing a simple chore can raise one's spirits to levels of supreme joy. Persistent pain and wretched tiredness brings one to near despair. In the next forty years, I wonder how many variations thereof I shall experience. The above is excerpted from the journal of a 29-yr-old woman, who has been afflicted with rheumatoid arthritis since age 15. It has become her practice to make such notations during sleepless, pain-filled nights. Her phrase, “I wonder”, only mildly captures the social-psychological burden of rheumatoid arthritis— that of tolerating the uncertainty that pervades all facets of the disease condition, and life with it.All living requires tolerating a considerable amount of uncertainty—to state this is to state the obvious. But a study of the victims of rheumatoid arthritis provides an insight into the demands placed upon living when uncertainty is exaggerated beyond the usual level of toleration. This paer examines the disease conditions which produce variable uncertainty. It then analyzes the strategies arthritics develop in order to tolerate the dread of progression, the social strategies of normalizing (covering-up, keeping-up and pacing) and of re-normalizing (adjusting to reduced activities). Considered throughout are the problems generated by both the uncertainly and by the use of these strategies (problems such as justifying inaction, the fear of dependency, eliciting help). Although each strategy is taken up separately for purposes of clarity, the ultimate social-psychological tyranny of tolerating the uncertainty lies in balancing thier use, one against the other. Compounding this is the additional problem of balancing drug side effects against relief. This burden of balancing limited options is examined at the conclusion of the paper.
The effect of active hand exercise and warm wax treatment was evaluated in 52 rheumatoid arthritis patients randomized into four groups: (1) both exercise and wax bath, (2) exercise only, (3) wax bath only, and (4) controls. Treatment was given three times a week for 4 weeks. Deficits in flexion and extension in digits II-V bilaterally, grip function, grip strength, pain, and stiffness were measured before and after the treatment period. The control group was measured at corresponding times. Wax bath treatment followed by active hand exercise resulted in significant improvements of range of motion (ROM) and grip function. Active hand exercise alone reduced stiffness and pain with nonresisted motion and increased ROM. Wax bath alone had no significant effect.
One hundred rheumatoid arthritis patients (38 men, 62 women), with mean age of 53 years and mean disease duration of 11.5
months, were followed. Standardized clinical, biochemical, and radiographic evaluation was performed regularly. After 2 years
the prevalence of ulnar deviation, buttonhole deformity, and swan neck deformity was 13%, 16%, and 8%, respectively. Altogether,
31 patients had developed one or more deformities. There was no difference in age or gender distribution and no predominance
of the dominant hand. Each patient with a deformity was matched according to age, sex, and disease duration with another early
RA patient without deformity. The deformity group had more active disease, less grip strength, more disability, and markedly
more severe radiographic changes. When studied retrospectively at a time point 3 months prior to the detection of deformity,
synovitis of relevant joints was as common in the group who developed deformities as in the control group. This suggests that
joint inflammation may contribute to the genesis of deformity but additional factors are needed. Hand deformities were found
to be common in early RA.
Eighty-nine patients, 33 men and 56 women, with early definite rheumatoid arthritis were followed for 2 years. Two-thirds were seropositive. About 1/3 were eventually treated with second line drugs. The disease mostly had an insidious onset initially involving the finger joints. Early remission occurred in 16%. Patient relevant measures such as pain, patient's overall assessment of disease activity and anxiety decreased significantly. Disability evaluated by the HAQ disability index remained at a low level. The joint damage score (JDS) in hands and feet increased steadily and only 18% were nonerosive after 2 years. One-third developed hand deformities which was associated with higher JDS. A joint function index (SOFI) correlated significantly with JDS. Twenty-eight percent had a slower rate of joint damage progression the second year. There was no significant correlation between JDS and disease duration. Six patients developed rapidly progressive damage in larger joints, five in the hip joints and one in the shoulder joint, all requiring joint replacement. The ability to predict outcomes with clinical and laboratory variable obtained at entry was of limited clinical usefulness. By applying discriminant analyses 67%-80% of the cases who fared worst regarding clinical, functional, and radiological features could be correctly classified.
Who is in control of treatment is an issue clinicians address on a daily basis. This represents an ethical dilemma, which sets the principle of autonomy in direct conflict with the principle of beneficence. This article advocates giving autonomy precedence over beneficence to achieve patient control of treatment. Patient control of treatment is essential in chronic disease because the patient is the expert in his or her own goals and values, the sick role is inappropriate in chronic disease and may have devastating emotional consequences, and in actuality the patient is the health care provider.
The benefits of patient education for those with chronic arthritis are well documented. Informed patients should practice
self care more often, and may show reduced disability from their disease. An important question relates to maintenance of
the knowledge and skills acquired in educational programmes. This prospective study evaluated an education programme for people
with rheumatoid arthritis (RA) and osteoarthntis (OA). The intervention group participated in a comprehensively planned six
session behaviourally based programme. A questionnaire was given to 100 patients and 95 matched but non-random controls before
the programme, 1 month later, and at 3 and 12 months. The intervention group demonstrated improvements in knowledge, self-reported
health behaviour and disability scores at 12 months, compared to the controls. No differences were reported in symptoms, compliance
with therapy, pain perception, and locus of control.
A new performance index, SOFI (Signals of Functional Impairment), is described. This aims to detect functional impairment
of different joints as early as possible It comprises assessments of hand, arm and leg function. The assessment time is short
and reliability is satisfactory. The index correlates significantly with range of motion, Ritchie index, grip strength. and
the Stanford Health Assessment Questionnaire (HAQ) disability index. The last mentioned was used in parallel with the new
index to study 50 early RA patients. These were followed every 3—6 months for 1 year. Both indices seemed to fluctuate with
changes in the patient's state.
The validity and reliability under Swedish conditions of a translated and slightly modified version of the Stanford Health Assessment Questionnaire (HAQ), referred to here as the ADL questionnaire, was studied. Sixty-four patients with definite/classical rheumatoid arthritis (RA) participated in the major part of the investigation. In addition, inter-observer reliability was studied in the testing of 15 other patients with RA. The questionnaire was filled in by the patients twice (ADL Tests 1 and 2) with a one-week interval between. A physiotherapist or occupational therapist also assessed each of the patients on a sample of ADL functions (ADL Test 3). Joint mobility, grip-strength, pain, Ritchie index and ESR were likewise checked. Results indicated inter-observer reliability to be high for the ADL (r(S) = 0.98), for joint mobility (r(S) = 0.86), and for the Ritchie index (r(S) = 0.83). The test-retest reliability for the ADL questionnaire which the patients filled in (Tests 1 and 2) was high r(S) = 0.91. Results of the ADL questionnaires the patients completed were found to correlate fairly closely with the observations of the therapists, r(S) = 0.71. The validity of the scoring system was found to be sufficient, using Ward's cluster analysis for comparing the original HAQ scores with scores on all the questions included in the questionnaire. Thus, the translated and somewhat modified version of the ADL questionnaire studied here appears to possess a high degree of reliability and validity in assessing patients with RA.
In a rheumatology department, 2 randomized groups of female outpatients with rheumatoid arthritis were studied prospectively for 1 year. The outcome of multidisciplinary team care (T group, 31 patients) was compared with that of regular outpatient clinic care (NT group, 28 patients). Pharmacologic treatment and orthopedic specialist consultations were similar in both groups, but use of paramedical care was higher in the T group. Outcome measures of disease activity, specific joint function, and self-rated physical discomfort disclosed no significant differences between the 2 groups. Mental well-being increased in the T group. Overall health, measured by the Sickness Impact Profile, improved significantly only in the T group. This improvement was also significant compared with the NT group.
The present investigation reports on the effects of a program of comprehensive care for patients with rheumatoid arthritis. Five dependent variables representing indices of disease activity were employed in assessing the merit of comprehensive, continuing management when compared with conventional management, often episodic, provided in arthritis clinics. Over the short duration of the project, this controlled study suggests greater benefits for patients in the comprehensive program. Greater insight into the relative benefits of different management modalities may be provided for future projects of this type in which a longer period of observation is possible.
To evaluate the development of functional impairment and disability in early rheumatoid arthritis (RA).
Sixty-three patients with definite RA with mean disease duration of about 1 year were followed for 5 years. Joint inflammation was evaluated with an active joint count, and radiographic changes in hands and feet with the Larsen method. Functional impairment of particular joint systems was assessed with a performance index, Signals of Functional Impairment Index, and disability with the Health Assessment Questionnaire (HAQ).
During the observation time the disease activity decreased, and the radiographic changes of hands and feet increased significantly. Joint replacement in 10 hips, 1 knee, and 1 shoulder were performed in 9 patients after median 43 months. At study start almost half the patients had impaired hand function, mostly affecting finger flexion and pincer grip. The most marked deterioration of joint function had occurred already after 2 years in metatarsophalangeal joints (55%), elbow joints (35%), ankle joints (30%), shoulder joints (28%), and hip joints (25%). The median HAQ level at study start was 0.8, and the median change of HAQ over 5 years was 0.1. (not significant). The progression of dysfunction was not linear but followed a highly variable course over the years. Patients with higher HAQ scores at study end could be correctly classified in 75% of the cases by the 3 factors, baseline HAQ score, female sex, and a low educational level. Presence of a replaced joint did not contribute significantly, but patients with joint replacement tended to be more disabled.
Functional outcome of RA after about 6 years of disease was fairly good. Functional impairment of different joints had progressed, but most patients were still mildly disabled. A subgroup of 9 patients had a worse disease course with rapidly progressing large joint destruction.
To examine the efficacy of wrist orthoses on pain, motion, and function of the wrist.
Consecutive patients were randomized to a treatment group using wrist orthoses or to a control group using no wrist orthoses, in a prospective, controlled, 6-month study.
Changes in wrist joint variables and general disease activity variables were not statistically different between the orthosis group (n = 36) and the control group (n = 33). Patients in the orthosis group had 25% and 12% improvements in grip strength and pinch grip and 50% reduction in pain while using the wrist orthosis.
Use of wrist orthoses improves function and reduces pain, but has no effects after 6 months, compared to a control group, on measures of local or general disease activity.
This study assessed a joint protection education program and investigated the costs and effects of assistive devices. Fifty-three women with seropositive rheumatoid arthritis, whose ages ranged from 29 to 65 years, attended a standardized joint protection course (13 hours). A self-report questionnaire was constructed listing the most common devices, and the subjects were asked to check which devices they had received, which ones they used and did not use, and why. Pain during activities of daily living and when using assistive devices was measured using the visual analogue scale. Results show that the subjects reported great benefits from the joint protection course, assistive devices, and wrist orthosis. The women had tried 663 devices, 91% of which were still being used. Pain decreased significantly (p < .001) when using assistive devices. The utility of 11 devices at a cost of SEK 1,683 per person can be described as increased capacity and ability to work at home, work outside the home, and perform leisure activities with less pain.
This article examines assistive device use by home-based elderly persons with arthritis.
Sixty-six persons were interviewed for the State University of New York at Buffalo (University at Buffalo) Rehabilitation Engineering Research Center Consumer Assessment Study, which sought information on need for and current use of assistive devices. Subjects were assigned to a moderate or a severe arthritis group according to the impact of arthritis on their activities.
Subjects in the severe arthritis group had more chronic diseases, a higher level of pain, and a lower level of independence in self-care activities than subjects in the moderate arthritis group. Similarities between the groups included relatively poor health, high rate of medication use, depression, use of a high number of assistive devices (about 10 per person), and an expressed need for additional devices, such as reachers, magnifiers, grab bars, jar openers, and hearing aids. Generally, there was a high rate of satisfaction with the assistive devices used. Most subjects missed being able to participate in at least one activity; most of these activities were active and many related to leisure time.
Findings also revealed that subjects had inadequate information on assistive devices, which suggests the importance of more occupational therapy involvement with elderly persons in selecting devices.
THE increase in consumerism in the Health Service has focused attention on patients' perceptions of, and satisfaction with, the service they receive. The implication that acknowledging patients' views is an innovation is deeply resented by those who have worked hard to respond to their patients' needs and desires for many years. However, there is an increased understanding that patient satisfaction is an integral part of quality care, and that some form of measurement can aid performance in this area. The problems are what to measure, how to measure and how valid are measurements. WHAT MEASURES SHOULD BE USED Donabedian's triad of structure, process and outcome [1] provides a useful starting point.
The intent of this paper has been to introduce qualitative methods to arthritis researchers and provide them with basic skills to critically evaluate results of qualitative research. Qualitative research provides the arthritis researcher with the opportunity to look at the meaning that the subject places on his or her behavior, their knowledge of their condition and of its treatment, and the meaning they infer from the actions of those around them, including their care providers and social supports. If carefully conducted, qualitative research methods can produce rich and insightful findings. We have limited our discussion to an overview of qualitative research and data collection methods. We will discuss issues related to how participants are selected and methods of data analysis in a subsequent paper.
To evaluate the development of handicap in patients with rheumatoid arthritis (RA) followed 8 years from onset.
The study group consisted of 106 patients participating in a prospective early RA study. The mean duration of joint symptoms at inclusion was one year. The patients were assessed at least once annually. Disability was measured with the Health Assessment Questionnaire (HAQ) and emotional distress with a self-administered test (Symptom Checklist). Work status and different social measures were registered. A structured interview regarding work capacity, leisure time, and social activities was performed about 8 years after disease onset.
Compared to study start, disease activity had decreased, emotional distress was unchanged, disability had increased somewhat, and radiographic changes had increased markedly. The prevalence of work disability at the end of the study was 37%. The majority of patients that eventually got disability pension had stopped working the first year after onset. Seventy-eight percent of the patients who continued to work had to adjust their work conditions to stay employed. The 3 most important predictors for work disability were higher HAQ at study start, lower educational level, and older age. Three-quarters of the patients had to alter leisure time activities and half of them were not satisfied with their recreation. Many patients experienced difficulties in their roles as spouse and parent. Higher levels of emotional distress were associated with these handicaps.
In this cohort of patients with RA we found a high frequency of different types of handicaps at an early stage. Slightly more than 1/3 were work disabled. The majority had stopped working during the first year. Patients perceived handicaps in terms of changed leisure time activities, and difficulties performing different social roles were frequent. Patients with these handicaps felt more emotional distress.
Occupational therapy has been defined as the science of eliciting adaptive responses characterised by prescription of purposeful activities that are goal-orientated to maximise independence and functional life skills in disability management. The scope of its intervention in the rehabilitation of rheumatoid arthritis is outlined with an overview of literature update on patient education.
To identify concerns and learning interests of patients with arthritis.
A questionnaire was developed, pilot tested, and then used to evaluate 197 patients with arthritis, including osteoarthritis (OA) (n = 41), rheumatoid arthritis (RA) (n = 57), back disease (n = 55), systemic lupus erythematosus (n = 27), and systemic sclerosis (SSc) (n = 17). Twenty concerns and 12 learning interests were rated. Questionnaires were also administered to assess physical disability (Health Assessment Questionnaire), psychological disability (Arthritis Impact Measurement Scales 2), and pain (visual analog scale). Participants addressed accessibility of health services, satisfaction with their physician, psychosocial needs, use of self-help groups, and behavioral strategies used to assist coping. Patients with RA, OA, and back disease, at both a community and a hospital center, were tested to assess whether concerns and learning interests differed based on site of treatment. Analytic methods included analysis of variance, factor analysis, and multiple linear regression.
There were no differences in concerns or learning interests based on treatment site. Between diagnostic groups, patients with SSc were more interested in learning about self-help groups. The most frequently reported concern was worsening of the illness. The majority of respondents were interested in learning more about topics that were illness specific. The physician was chosen as the preferred source of information, and the preferred format was in writing. On factor analysis, the 20 concerns were reduced to 5 factors: psychological, coping, medication, social, and financial. Three factors were identified for learning interests: the illness, traditional health management topics, and nontraditional health management topics. Stepwise multiple linear regression revealed predictors for the 5 concern and 3 learning interest factors. The concerns were best predicted by self-reported disease severity, physical disability, and psychological distress, while learning interests were best predicted by self-reported disease severity, pain, and self-help group membership.
Concerns and learning interests of persons with arthritis did not differ based on the center of treatment or the diagnosis, but can be predicted by the level of pain and simple measures of disability. Better understanding of the relationship between health status and patient-perceived needs will result in improved patient-centered care.
The Canadian Occupational Performance Measure (COPM) is receiving international attention as an important assessment for directing occupational therapy interventions and measuring client-centred outcomes. The COPM measures individuals' perceptions of disability by identifying those tasks that are important to them and difficult to perform. The Health Assessment Questionnaire (HAQ) has been used extensively with persons with arthritis and measures individuals' perceived difficulty in performing predetermined tasks of daily living. The HAQ has been shown to correlate with actual performance and has reported concurrent validity with a number of similar scales. In this study, 13 participants diagnosed with rheumatoid arthritis were assessed with the COPM and the disability dimension of the HAQ. Participants scored performance limitations on both the COPM and the HAQ; the correlation coefficient between the scores was not statistically significant. However, when the COPM and the HAQ scores for similar activities were compared, a statistically significant correlation was found. These findings support the use of the COPM as a valid measure of self-reported performance.
Grundläggande forskningsmetodik
- Carlsson B
- Carlsson B
Arbetsterapi vid nydebuterad reumatoid artrit. Kartläggning av typ, frekvens och kostnad
- Grånefors S
- Holm M
- Thulin M
- Grånefors S
- Holm M
- Thulin M
Stockholm: Almqvist &
- B Carlsson
- Grundläggande Forskningsmetodik
Kartläggning av typ, frekvens och kostnad. C-uppsats Linköpings Universitet
- S Grånefors
- M Holm
- M Thulin
- Arbetsterapi Vid Nydebuterad