Assessing function in patients with rheumatoid arthritis (RA) is a challenging but important part of the rheumatology office visit.
ABSTRACT: Knowing how rheumatoid arthritis (RA) symptoms are affecting patients' everyday activities enhances your ability to provide best “treat to target” practice interventions. Impairments can result in activity limitations and participation restrictions. An important impairment in RA is structural joint deformities; others are pain, fatigue, and adverse emotional reactions. Persons with RA often make some type of adaptation to their activities. Activity performance may be assessed by patient self-report with directed questions and by direct observation. Knowledge about RA and perspectives on what constitutes a particular activity differ greatly among patients. A challenge during an office visit is to make an accurate assessment of patients' functional activities. Identifying problems is easier if attention is focused on specific body areas that are likely to be problematic. (J Musculoskel Med. 2012;29:78-81)
Assessing function in patients with rheumatoid arthritis (RA) is a challenging but important part of the rheumatology office visit. Knowing how the symptoms of RA are affecting patients' everyday activities enhances your ability to provide best “treat to target” practice interventions for improved patient outcomes and quality of life.
This is the third article in a 5-part series designed to provide a practical approach to better understanding of function in RA as an essential component of treat to target management strategies. The first article (“Understanding Function in RA: An Update on ‘Treat to Target,’” The Journal of Musculoskeletal Medicine, February 2012, page 10) provided an overview. In the second article (“Understanding Function in RA: Importance and Measurement,” The Journal of Musculoskeletal Medicine, March 2012, page 41), we first presented a standardized vocabulary for describing function, based on the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health (ICF), and then applied it to an assessment tool frequently used in rheumatology, the Health Assessment Questionnaire (HAQ). This third article describes how impairments in body systems caused by RA can affect function, and how patients can adapt their activities to cope with these impairments. We review methods to obtain information about patient function, including observations of activity performance during an office visit. Upcoming articles will discuss how functional assessment may be incorporated into clinical practice and the role of the nurse in multidisciplinary RA care.
Impairments Can Affect Function
The ICF model developed by the WHO provides a framework for classifying the health components of functioning and disability. The model suggests that impairments can result in activity limitations and restrictions in participation in a variety of life situations.1
An important impairment caused by rheumatoid synovial inflammation is structural joint deformities.2 They may cause restrictions in joint range of motion and decreased muscle strength,3 both of which contribute to reduced function.
Additional impairments seen frequently in RA are pain, fatigue, and adverse emotional reactions.2,4,5 Pain, which has been associated with decreased function,6 may have a cascading effect, ranging from interference with the performance of even simple tasks to major participation restrictions. For example, finger pain may affect patients' ability to use electronic devices and manipulate small objects, such as coins. As a result, they may experience difficulties with computer or cell phone use and avoid shopping so they do not need to make change.
Fatigue, defined by the ICF as the subjective experience of extreme and persistent mental or physical tiredness that is not relieved by rest, is experienced by up to 90% of patients with RA.7,8 Fatigue may profoundly affect activity performance,9 such as housecleaning or working an 8-hour day, as well as participation in social events, hobbies, and parenting. As a result, patients may need to reduce their number of tasks, take rest breaks, or eliminate activities.
In addition to physical challenges, patients with RA may experience emotional reactions, including depression and anxiety. The prevalence of depression in RA is 20% to 40%, and anxiety occurs in 13% to 20% of patients.5,10 Depression has been linked to decreased function, although the causal direction of the association is not clear. Decreased function may increase depression, and having depression may reduce function.5 A similar relationship between anxiety and function has been suggested.11
Adapting Activities to Promote Function
Persons who have RA often are remarkably resourceful. One study reported that 96% of 464 patients with RA made some type of adaptation to their activities.12
A variety of methods may be used. One is modifying the activity's performance elements, or mechanics.13 Components may be simplified, such as cooking with prechopped vegetables or wearing clothing that does not have buttons or zippers. Patients also may alter an activity by using one extremity to help another, such as lifting a cup or other object with two hands. Tasks that typically are performed when standing, including dressing and bathing, may instead be done sitting. More time may be taken for activity completion, such as cleaning a room in 30 minutes instead of 10.
Another type of adaptation involves assistive devices.12 In one study, 89% of patients with RA used a variety of devices.14 For lower extremity problems, canes and walkers can maintain patients' mobility and provide stability. For personal care, function restrictions resulting from joint involvement may be helped with long-handled shoehorns, reachers, bottle openers, hook and loop fasteners, thicker handles, and touch-free dispensers. Environmental issues may be addressed with stair glides, grab bars, and shower chairs.
A third type of adaptation is obtaining assistance from another person, such as a family member, friend, or professional caregiver.12 Assistance may be as simple as asking family members to help tie shoes or as complex as asking them to do all shopping and household tasks.
Still another method is reducing the frequency of an activity or eliminating it.12 Patients may eliminate activities because they become too difficult or because they do not have enough time or energy to perform them.
An important consideration about a patient's specific adaptation is the potential risk of injury. For example, using a shower curtain or soap dish to maintain balance when entering or exiting the shower increases the chances of falling.
How Function May Be Best Evaluated
Activity performance may be assessed by patient self-report with directed questions and by direct observation of the patient. Each method provides important information about functional status,15 but each also has limitations.
Patient self-report about specific activities may be obtained verbally in an interview or by a written questionnaire. Both approaches provide information about patients' perception of their abilities and are particularly useful for tasks that cannot be observed.15 However, many complex factors determine how patients and health care professionals interpret and respond to self-report questions.
Knowledge about RA and perspectives on what constitutes a particular activity differ greatly among patients. For example, a patient may overestimate his or her abilities and answer “no difficulty” in dressing without accounting for the spouse laying out clothing. Or, a patient may be embarrassed to admit that completing an activity, such as cooking a meal or cutting the grass, now takes much longer than it used to.
On the other end of the scale, patients may underestimate their abilities and report “much difficulty” because their performance does not match their personal expectations. Observation involves watching patients perform activities and assessing their abilities. This method may provide direct insight into patients' actual capabilities. However, because the environment can influence performance,15 patients may not be able to perform an activity in the physician's office that they could accomplish easily in their home that has had adaptations.
Follow-up questioning often is helpful for completing the picture of a patient's functioning. For example, when a patient has filled out a questionnaire, a physician might ask, “You report 'some difficulty' getting out of a car. Can you tell me what exactly makes this difficult?” When observing a patient putting on a sweater, the physician may comment, “I notice that you had trouble raising your arms to pull your sweater over your head. Is putting on other clothing as difficult for you?” These types of questions can elicit further descriptions of patients' experiences, leading to a more individualized and in-depth understanding of the specifics of their function.
Certain visual cues may help determine whether a patient with rheumatoid arthritis is having difficulty with a task
Accurate Assessment a Challenge
A challenge during an office visit is to make an accurate assessment of the functional activities of patients with RA, including who will benefit from interventions. Patients often report having no function difficulties when they actually have difficulties. Or, they may express no perceived problems because they made adaptations but may not recognize or understand how their activities of daily living may be affecting their arthritis adversely.
One self-report questionnaire, the Multidimensional Health Assessment Questionnaire (MDHAQ)-a modification of the HAQ16-allows health care professionals to evaluate the patient's perception of the difficulty of a variety activities. The MDHAQ queries 8 domains of function-dressing and grooming, arising, eating, walking, hygiene, reach, grip, and activities.
Although items on the MDHAQ can identify certain activity limitations, they do not always provide a complete picture of function. Actual observation of patients performing functional tasks in the office can help health care professionals assess whether patients are underestimating or overestimating their function and adaptations. The MDHAQ may serve as an anchor for the combination of self-report and observation during an office visit.
Focus on Specific Body Areas
When activities are observed during an office visit, identifying problems is easier if attention is focused on specific body areas that are likely to be problematic during a particular activity. Three general body areas to observe are the upper body, including the head, shoulders, arms, and hands; the trunk, including the back and hips; and the lower body, including the legs and feet.
Some items on the MDHAQ generally emphasize one body area. For example, the task of “lifting a full cup or glass to the mouth” focuses on the upper body.
Other examination items combine several body areas. Arising from a chair involves a 2-step sequence-the patient first uses his lower body to position his feet and then his trunk to move to the edge of the chair, and he then shifts his weight and center of gravity forward. Also, observing a patient getting on and off the examination table can provide clues about his upper and lower body coordination. The movements are similar, in part, to those involved in transferring to and from a car or bed and in walking stairs.
Visual Cues to Task Difficulty
Certain visual cues-speed and smoothness of movement, the number of attempts needed for completion, substitution of movement, and the presence of pain behaviors-may help determine whether a patient is having difficulty with a task. Those who are experiencing task difficulty typically move slowly.17 Their movements may be jerky and appear constrained. When writing, patients may move their hand slowly and hesitate between strokes of the pen (Figure). The finished writing may be uneven, less legible, and unsatisfactory to them.
For a well-learned activity, such as the ones on the MDHAQ, most patients complete the task without difficulty on the first attempt. Those who are experiencing difficulty may require repeated attempts.17 They may fumble or backtrack to obtain the desired outcome.
Patients who have limitations in strength and range of motion or who are experiencing pain often compensate by substituting movements by less impaired body parts for those by more impaired body parts.17 When reaching for the faucet, for example, patients may use trunk flexion at the waist for shoulder flexion.
Patients who are experiencing pain may exhibit pain behaviors, such as grimacing, sighing, guarding, assuming protective postures, and rubbing the affected area. These signs are variable; research suggests that some patients with high levels of pain may exhibit few pain behaviors.18
Raising a Red Flag
Any of these cues may raise a red flag indicating possible difficulty with an activity. A limitation of observing activities in the office lies in the ability of patients with RA to adapt an activity in their own home. Although in your office they may struggle with unfamiliar objects in an unfamiliar environment, they may have modified their own home to facilitate and support their function.15
Asking patients directed questions when an activity appears difficult is important. The question, “Is this typical of the way you do this at home? If not, can you tell me what's different here in the office?” can elicit useful information about home adaptations.
Using the MDHAQ as an anchor for an observational assessment of RA function is limited in that it does not assess a patient's community participation, such as work or travel. Additional directed questions may help provide details about participation. For example, a physician can ask, “Since your last doctor's visit, have you changed activities that you perform outside of the house, such as visiting, hobbies, work, or shopping?”
This series of articles on function in RA will help you and your patients attain practical understanding of their function quickly and efficiently. The next article will discuss how functional assessment may be incorporated into clinical practice.
Video Demonstrates In-Office Assessment of Function
“A Practical Understanding of Function in Rheumatoid Arthritis,” a new video program, demonstrates in-office assessment of function. The video provides relevant information for determining more targeted and individualized treatment and emphasizes the various roles of medications and occupational therapy in those treatment strategies.
1. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization; 2001. http://www.who.int/classifications/icf/en. Accessed March 8, 2012.
2. Anderson RJ. Rheumatoid arthritis: B. Clinical and laboratory features. In: Klippel JH, ed. Primer on the Rheumatic Diseases. 12th ed. Atlanta: Arthritis Foundation; 2001:218-225.
3. Biese J. Arthritis. In: Cooper C, ed. Fundamentals of Hand Therapy. St Louis: Mosby, Inc; 2007:248-375.
4. Walker JR, Graff LA, Dutz JP, Bernstein CN. Psychiatric disorders in patients with immune-mediated inflammatory diseases: prevalence, association with disease activity, and overall patient well-being. J Rheumatol Suppl. 2011;88:31-35.
5. SÃ¶derlin MK, Nieminen P, Hakala M. Arthritis impact measurement scales in a community-based rheumatoid arthritis population. Clin Rheumatol. 2000;19:30-34.
6. Katz PP, Morris A, Yelin EH. Prevalence and predictors of disability in valued life activities among individuals with rheumatoid arthritis. Ann Rheum Dis. 2006;65:763-769.
7. Wolfe F, Hawley DJ, Wilson K. The prevalence and meaning of fatigue in rheumatic disease. J Rheumatol. 1996;23:1407-1417.
8. Pollard LC, Choy EH, Gonzalez J, et al. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford). 2006;45:885-889.
9. Pouchot J, Kherani RB, Brant R, et al. Determination of the minimal clinically important difference for seven fatigue measures in rheumatoid arthritis. J Clin Epidemiol. 2008;61:705-713.
10. Isik A, Koca SS, Ozturk A, Mermi O. Anxiety and depression in patients with rheumatoid arthritis. Clin Rheumatol. 2007;26:872-878.
11. VanDyke MM, Parker JC, Smarr KL, et al. Anxiety in rheumatoid arthritis. Arthritis Rheum. 2004;51:408-412.
12. Katz PP, Morris A. Use of accommodations for valued life activities: prevalence and effects on disability scores. Arthritis Rheum. 2007;57:730-737.
13. Holm MB, Rogers JC. The occupational therapy process. In: Crepeau EB, Cohn ES, Schell BA, eds. Willard & Spackman's Occupational Therapy. 11th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009:478-518.
14. de Boer IG, Peeters AJ, Ronday HK, et al. Assistive devices: usage in patients with rheumatoid arthritis. Clin Rheumatol. 2009;28:119-128.
15. Rogers JC, Holm MB, Beach S, et al. Concordance of four methods of disability assessment using performance in the home as the criterion method. Arthritis Rheum. 2003;49:640-647.
16. Pincus T, Swearingen C, Wolfe F. Toward a multidimensional Health Assessment Questionnaire (MDHAQ): assessment of advanced activities of daily living and psychological status in the patient-friendly health assessment questionnaire format. Arthritis Rheum. 1999;42:2220-2230.
17. Alt Murphy M, WillÃ©n C, Sunnerhagen KS. Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass. Neurorehabil Neural Repair. 2011;25:71-80.
18. Waters SJ, Riordan PA, Keefe FJ, Lefebvre JC. Pain behavior in rheumatoid arthritis patients: identification of pain behavior subgroups. J Pain Symptom Manage. 2008;36:69-78.