Ingrid Thyberg

Comparison between women and men with recent onset rheumatoid arthritis of disease activity and functional ability over two years (the TIRA project)

Objective: To describe the course of recent onset rheumatoid arthritis (RA) and to compare consequences of the disease in men and women. Methods: 284 patients with recent onset RA were followed up prospectively for two years from the time of diagnosis. Measures of disease activity (for example, 28 joint disease activity score (DAS28), C reactive protein, morning stiffness, physician’s global assessment) and function outcome (for example, range of movement, hand function, walking time) were determined. The patients’ self reported assessment of functional capacity (Health Assessment Questionnaire (HAQ)) and grading of wellbeing and pain (visual analogue scale) were registered. Changes over time and differences between men and women were evaluated. Results: Improvements were seen for all variables within the first three months. Disease activity then remained unchanged. Function variables followed the same pattern during the first year, but then tended to worsen. HAQ scores were similar at baseline, but significantly worse in women than in men at the one and two year follow ups. Conclusions: Disease activity was well managed and had improved substantially after two years, whereas function seemed slowly to deteriorate. Although disease variables were similar for men and women, functional ability (HAQ) had a less favourable course in women.

Pain and daily activities in rheumatoid arthritis.

Aim: The aim of this study was to describe experiences of pain and its relationship to daily activities in people with rheumatoid arthritis (RA). Method: Seven semi-structured focus group discussions were conducted with 33 men and women of different ages with RA. Data were analysed with content analysis. Results: Pain affected everyday life and may be a barrier to perform valued activities. Regarding the impact of pain on participation and independence, personal factors and the social environment were found to be important. It could be a struggle to find the right activity balance, since it was easy to be overactive, triggering subsequent elevation of pain levels. However, the participants also described activities as a mediator of pain and a distraction from it. Conclusion: The relationship between pain and daily activities in RA was complex. Pain as an impairment was expressed to be related to activity limitations and participation restrictions, as well as to contextual factors. These findings highlight the clinical importance of paying attention to the complexity of pain and its relation to daily activities and participation. Implications for Rehabilitation Pain in RA needs to be comprehensively analyzed and treated in the context of the patients’ perspective and needs. The relation between pain and performance of activities in RA highlights the importance of rehabilitative interventions to reduce pain in order to facilitate daily activity. The complexity of pain implies the need for multimodal approach in rehabilitation.

Factors related to fatigue in women and men with early rheumatoid arthritis: the Swedish TIRA study.

OBJECTIVE To study whether there are differences between women and men with regard to the reported level of fatigue, to explore the strength of the relations between fatigue and disease activity, pain, sleep disturbance, mental health, and activity limitation in early rheumatoid arthritis, and to explore the consistency of such findings. DESIGN Analyses and comparisons of cross-sectional data. SUBJECTS Two hundred and seventy-six patients, 191 women and 85 men, with early rheumatoid arthritis were included. METHODS Patients were examined with respect to 28-joint count disease activity score, and disability variables reflecting pain, sleep disturbance, fatigue, mental health, and activity limitation, at follow-ups at 1, 2 and 3 years after diagnosis. RESULTS Women reported somewhat more fatigue than men. Fatigue was closely and rather consistently related to disease activity, pain and activity limitation, and also to mental health and sleep disturbance. CONCLUSION Although this study does not permit conclusions to be drawn about causal directions, statistical relationships may be related to clinical conceptions about causation: when disease activity can be significantly reduced by pharmacological treatment this may have a positive effect on fatigue. Specific treatment with respect to the mentioned disability aspects that are related to fatigue is also a clinically reasonable strategy.

Sick Leave Before and After Diagnosis of Rheumatoid Arthritis ― A Report from the Swedish TIRA Project

Objective. Our study describes sick leave during 3 years before and 3 years after diagnosis of rheumatoid arthritis (RA) in relation to referents and identifies predictors for sick leave during the third year after diagnosis of RA. Methods. One hundred twenty patients (76% women) from the Swedish early RA study TIRA were included. Disease activity and disability were registered regularly during 3 years in TIRA. Referents were matched for sex, age, and home town. Sick leave data were obtained for patients 3 years before and 3 years after diagnosis and for the referents for the corresponding 6 years. Results. No differences were seen between patients and referents regarding sick leave during the first 2 years, whereas sick leave increased in patients 6 months before diagnosis, from 30% to 53%. During the 3 years after diagnosis, sick leave among patients was rather stable, varying between 50% and 60%, even though disability pension increased and sickness benefit decreased. Sick leave before diagnosis, disability 1 year after diagnosis, and type of work were identified as predictors for sick leave during the third year after diagnosis. Conclusion. Not surprisingly, sick leave in patients increased the year before diagnosis. Although disease activity and disability diminished after diagnosis, the patients’ sick leave remained essentially unchanged. Sick leave 3 years after diagnosis was foremost predicted by earlier sick leave, disability, and type of work.

Disease activity and disability in women and men with early rheumatoid arthritis (RA) : An 8-year followup of a Swedish early RA project

To compare women and men regarding the course of disease activity and disability over 8 years from diagnosis of recent‐onset rheumatoid arthritis (RA).

Recent-onset rheumatoid arthritis: a 1-year observational study of correlations between health-related quality of life and clinical/laboratory data.

OBJECTIVE To analyse correlations within and between clinical/laboratory assessments and health-related quality of life variables for recent-onset rheumatoid arthritis at the time of diagnosis and 12 months later. METHODS A total of 297 patients with recent-onset (< or =12 months) rheumatoid arthritis were included at diagnosis and followed up for 12 months. Clinical/laboratory assessment was performed by erythrocyte sedimentation rate, C-reactive protein, 28-joint count of tender/swollen joints, physicians global assessment, grip force, grip ability, functional impairment and walking speed. The self-reported health-related quality of life included symptoms (pain, morning stiffness), patients estimated general health, Health Assessment Questionnaire and SF-36. RESULTS All tested variables improved within 6 months of diagnosis and then remained stable but still affected at the 12-month follow-up. Multivariate correlations between clinical/laboratory variables and health-related quality of life were weak. At inclusion, clinical/laboratory assessments explained 18% of health-related quality of life at the same time-point and predicted 7% of the variation in health-related quality of life after 12 months. CONCLUSION The time-course followed similar patterns for most variables, but only a small part of the variation in health-related quality of life was explained or predicted by the clinical/laboratory variables. This implies that health-related quality of life adds important information to clinical/laboratory assessments in clinical practice and should be considered in goal setting together with clinical/laboratory assessment in order to optimize healthcare and outcome.

Multivariate relationships between pain intensity and other aspects of health in rheumatoid arthritis : cross sectional and five year longitudinal analyses (the Swedish TIRA project)

Objectives. This study analyses the relationships between pain intensity and other aspects of health commonly used to assess disease activity and disability in early rheumatoid arthritis and examines whether such relationships were different between women and men. Subjects and methods. This study included the 189 patients (69% women) with early RA (symptoms <12 months at diagnosis) still remaining in the Swedish TIRA cohort 5 years after inclusion. Disease activity and disability was assessed 3, 6, 12, 18, 24, 36, 48, and 60 months (M0-M60) after inclusion by erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), number of swollen and tender joints, physicians global assessment of disease activity (PGA), grip force average over 10 seconds (Grippit), Grip Ability Test (GAT), Signals of Functional Impairment (SOFI) in hand, lower limb and upper limb, Health Assessment Questionnaire (HAQ), and pain intensity measured with a visual analogue scale (VAS). The variables were divided into meaningful blocks according to the correlation structure in a principal component analysis (PCA) at M60. Using hierarchical partial least squares (PLS) analyses, this study investigated the blocks cross-sectionally to test for correlations with pain intensity at M0 and M60. The blocks at M0 were also used as predictors of pain intensity at M60 in a hierarchical PLS. Results. The strongest relationship was found between pain intensity and the second block, consisting of HAQ and SOFI-lower limb at the cross-sectional analyses in both women and men. The block representing disease activity (i.e., ESR, CRP, PGA, and swollen and tender joints) had the weakest relation to pain intensity. According to the longitudinal analyses, the disease activity variables (block 1) at M0 had the strongest relationship to pain intensity at M60 in men. In contrast, HAQ and SOFI-lower limb (block 2) at M0 had a strong relation to pain intensity in women.

Participation in work in early rheumatoid arthritis: a qualitative interview study interpreted in terms of the ICF

Abstract Purpose: To explore what work-related dilemmas are experienced by patients with early rheumatoid arthritis (RA), according to their own descriptions, and to interpret this in terms of participation categories of the International Classification of Functioning, Disability and Health (ICF). Method: In 48 patients with early RA, qualitative interviews were analyzed, followed by linking of concepts to the activity/participation component of the ICF and interpretation of general themes. Results: Work-related dilemmas represented different societal perspectives on work related to acquiring, keeping and terminating a job, self-employment, part-time, full-time and non-remunerative employment. Dilemmas also represented participation priorities in economic self-sufficiency, self-care such as health care, and avoiding social relationships and recreation in favor of work. Leisure time was influenced because efforts of working took energy and time of day-to-day procedures. Embedded actions in work-related dilemmas were carrying out daily routine, mobility including using transportation, self-care, domestic life and social interaction. Conclusion: The general themes societal perspectives, participation priorities and embedded actions, with the included ICF categories that are described in detail according to the experiences of the patients, can support clinical reasoning and research on quantitative relations to disease activity, body functions, ability and contextual factors. Implications for Rehabilitation In early rheumatoid arthritis, keeping a job is complex; patients and practitioners need to know and handle the perspectives of, e.g. employers and social insurance agents. Participation in work is an issue of prioritizing against, e.g. maintaining ones health and social relationships. Rehabilitation practitioners need to analyze what actions are embedded in a work situation.

International Classification of Functioning, Disability and Health categories explored for self-rated participation in Swedish adolescents and adults with a mild intellectual disability.

OBJECTIVE To explore internal consistency and correlations between perceived ability, performance and perceived importance in a preliminary selection of self-reported items representing the activity/participation component of the International Classification of Functioning, Disability and Health (ICF). DESIGN Structured interview study. SUBJECTS Fifty-five Swedish adolescents and adults with a mild intellectual disability. METHODS Questions about perceived ability, performance and perceived importance were asked on the basis of a 3-grade Likert-scale regarding each of 68 items representing the 9 ICF domains of activity/participation. RESULTS Internal consistency for perceived ability (Cronbachs alpha for all 68 items): 0.95 (values for each domain varied between 0.57 and 0.85), for performance: 0.86 (between 0.27 and 0.66), for perceived importance: 0.84 (between 0.27 and 0.68). Seventy-two percent of the items showed correlations >0.5 (mean=0.59) for performance vs perceived importance, 41% >0.5 (mean=0.47) for perceived ability vs performance and 12% >0.5 (mean=0.28) for perceived ability vs perceived importance. CONCLUSION Measures of performance and perceived importance may have to be based primarily on their estimated clinical relevance for describing aspects of the ICF participation concept. With a clinimetric approach, parts of the studied items and domains may be used to investigate factors related to different patterns and levels of participation, and outcomes of rehabilitation.

Differences in activity limitation, pain intensity, and global health in patients with rheumatoid arthritis in Sweden and the USA: a 5-year follow-up.

Objective: In this study we compared activity limitations, pain intensity, and global health in patients with rheumatoid arthritis (RA) in Sweden and the USA and aimed to determine whether nationality is associated with these outcomes. Methods: We used longitudinal data from the ‘Swedish TIRA project’ (n = 149) and the University of California, San Francisco (UCSF) RA panel study (n = 85). Data were collected annually concerning use of medications [disease-modifying anti-rheumatic drugs (DMARDs), biologics, and corticosteroids], morning stiffness, number of swollen joints, and number of painful joints. Three self-reported outcome measures were examined: pain intensity measured on a 0–100 visual analogue scale (VAS), activity limitation according to the Health Assessment Questionnaire (HAQ), and global health. To analyse the data, the Student’s t-test, the χ2-test, and the generalized estimating equation (GEE) method were used. Results: Nationality was significantly related to HAQ score and pain intensity, even after adjustment for covariates. The patients in the TIRA cohort reported a lower HAQ score and a higher pain intensity than the patients in the UCSF cohort. Nationality was not related to global health. Conclusion: Patients with RA should be assessed with awareness of the psychosocial and cultural context because disability seems to be affected by nationality. Further knowledge to clarify how a multinational setting affects disability could improve the translation of interventions for patients with RA across nationalities.