Survey of the use and effect of assistive devices in patients with early rheumatoid arthritis: A two-year followup of women and men

Authors


Abstract

Objective

To identify activity limitation in early rheumatoid arthritis (RA) to detect patients needing assistive devices. To evaluate the effects of assistive devices.

Methods

A multicenter cohort of 284 early RA patients was examined using the Evaluation of Daily Activity Questionnaire 12 and 24 months after diagnosis.

Results

The extent of activity limitation was stable over time for both women and men. Most limitations concerned eating and drinking. Women reported more difficulties than did men. The use of assistive devices was related to subgroups with severe disease and more disability. Use of assistive devices reduced difficulties significantly. For both women and men, assistive devices were mostly used in activities related to eating and drinking.

Conclusion

Already 1 year after diagnosis, RA patients reported activity limitation that remained stable over time. Use of assistive devices was related to more severe disease and more pronounced disability. Use of devices reduced difficulties significantly.

INTRODUCTION

The consequences of rheumatoid arthritis (RA) include many forms of disability, including different difficulties performing daily activities (1–4). Occupational therapists or physiotherapists may evaluate these aspects and the possibilities to alleviate the disability, e.g., by the use of assistive devices (ADs) (5–8). In some countries, the community subsidizes the costs for ADs and organizes their distribution (9, 10). In a medical as well as a political perspective, however, the value of providing ADs to patients with certain diagnoses or disabilities may be questioned. Regarding RA, our knowledge is restricted to patients with longstanding disease (5, 7, 10–12). Furthermore, many studies have been restricted to women (11, 13). Thus, there is a great need to evaluate the efficacy of assistive devices in early RA in women and men (14, 15).

The aim of this study was to identify and measure the extent of activity limitation in women and men with early RA, to measure the effect of ADs, and to identify other aspects of disease activity and disability signaling a possible need for early AD intervention.

PATIENTS AND METHODS

Patients.

The present study is associated with the ongoing, multicenter, early-arthritis project TIRA, a collaboration between 10 rheumatology units in southeast Sweden (16). In total, 320 patients with recent-onset (≤1 year) RA were included during 27 months between 1996 and 1998. All 284 patients, 196 women (median age 55 years, interquartile range [IQR] 23 years) and 88 men (median age 60 years, IQR 20 years), remaining in the TIRA project at the 12- and 24-month visits after diagnosis were included in the present study.

Disease course was measured at the 12- and 24-month visits by variables representing disease activity and disability. Disease activity was measured by erythrocyte sedimentation rate (ESR), the physicians' global assessment of disease activity (PGA; score 0–4 where 0 corresponds to no activity and 4 represents high activity), and by the Disease Activity Score in 28 joints (DAS-28) (17). Impairment was assessed by measuring grip force with a digital electronic device (Grippit, Detektor AB, Göteborg, Sweden). Maximum, momentary, and average grip force over a period of 10 seconds were measured in newtons (18). In this study, we analyzed the average grip force over 10 seconds of the right hand. Pain and fatigue were reported by visual analog scales of 0–100 mm, where 0 represents no pain and no fatigue, respectively (19). Disability was measured by the Swedish version of the Health Assessment Questionnaire (HAQ) with a score of 0–3, where 0 corresponds to no difficulty and 3 to unable to do (20). Data were collected at the clinic visits.

All patients gave written informed consent to participate. Local ethics committees of the participating units approved the study protocol.

Activity limitation.

The self-administered disease-specific Swedish questionnaire Evaluation of Daily Activity Questionnaire (EDAQ) was used for measuring activity limitation (13). EDAQ consists of 102 items grouped into 11 dimensions: eating and drinking, transfer, toileting, dressing, bathing, cooking, mobility indoors, cleaning, washing and clothes care, mobility outdoors and shopping, and communication. Each dimension contains 4–13 items. The questionnaire consists of 2 parts, the first part with the question, “How do you perform the following activities without assistive devices?” and the second part with the question, “How do you perform the following activities in another way, with assistive devices/altered working methods?” The patients also wrote down their own solutions for the different items in the questionnaire. The scale concerning the 2 questions ranges from 0 to 3 (0 = without difficulty, 1 = with some difficulty, 2 = with much difficulty, and 3 = unable to do). The patient is asked to answer questions regarding activities as performed during the last 2 weeks. EDAQ can be used on an individual level for clinical intervention as well as for analyzing groups of patients. EDAQ has been tested for validity and responsiveness and is sensitive to detect changes in items both across a sample and within individual patients with RA (13, 21).

At the 12- and 24-month visits, the occupational therapist gave instructions regarding EDAQ, which was completed in the patients' homes within the following 2 weeks and sent back to the rheumatology unit by mail. When need for AD interventions were identified, the patients were contacted for problem solving and intervention. In this study, items in EDAQ were termed “activities” and the expression “difficulty in activities” included the scale steps “with some difficulties,” “with much difficulties,” and “unable to do.” The total and average number of used ADs were calculated for each patient. Activities where >5% of the patients reported use of ADs were identified and tested regarding the effect of ADs. Nonresponded activities represent a mixture of missing data and “usually not performed.”

Interventions.

After physical examination, the patient was offered medication and multiprofessional intervention when considered appropriate. Ongoing medication was registered at all visits. All patients were offered a patient education program carried out by the multiprofessional teams in the period between the 12- and 24-month visits.

Statistics.

Percentage distribution was calculated for ongoing medication and reported difficulties in EDAQ. Differences between groups were performed by Mann-Whitney U test and differences between related samples were performed by Wilcoxon's signed rank test. P values < 0.05 were considered significant. All statistics were performed using the Statistical Package for the Social Sciences (SPSS for Windows version 10.0, Chicago, IL).

RESULTS

Patient data.

At the 12-month visit, 253 (89%) patients completed the EDAQ and at the 24-month visit, 239 (84%) patients completed it; 215 (76%) completed the questionnaire at both visits (159 women, median age 55 years, IQR 21 years; 56 men, median age 63 years, IQR 23 years; Table 1). The group of women was significantly younger than the group of men. Of the 69 patients who dropped out, 37 were women (median age 51 years, IQR 29 years) and 32 were men (median age 57 years, IQR 18 years). Age, ESR, PGA, DAS-28, grip force, pain, and HAQ for the women and men at the 12-month visit did not differ between the study group and the dropouts.

Table 1. Median and interquartile range for age and patient characteristics at the 12- and 24-month visits for women and men*
 WomenMen
Total (n = 159)AD user (n = 124) Month 24Not AD user (n = 35) Month 24PTotal (n = 56)AD user (n = 30) Month 24Not AD user (n = 26) Month 24P
Month 12Month 24PMonth 12Month 24P
  • *

    Data presented as median (interquartile range). AD = assistive device; NS = not significant; ESR = erythrocyte sedimentation rate; PGA = physicians global assessment of disease activity; DAS-28 = Disease Activity Score in 28 joints; Grippit = grip force average over 10 seconds; VAS = visual analog scale; HAQ = Health Assessment Questionnaire.

Age, years55 (21)  55 (42)60 (39)NS63 (23)  60 (24)66 (17)NS
ESR, mm/hour16 (23)16 (22)NS18 (23)12 (12)0.00915 (23)14 (16)NS14 (18)14 (20)NS
PGA, score 0–41 (1)1 (1)NS1 (1)1 (1)<0.0011 (1)1 (0)NS1 (0.3)1 (0.5)NS
DAS-283.9 (2.0)3.6 (1.8)NS3.8 (1.6)2.9 (1.9)0.0053.6 (2)3.1 (2)NS3.6 (2.3)2.9 (1.2)0.024
Grippit, newtons95 (94)104 (96)NS90 (89)167 (121)0.002197 (132)214 (151)NS164 (135)238 (179)0.003
Pain, VAS 0–100 mm35 (52)30 (44)0.0433 (42)13 (40)0.00529 (62)25 (42)NS33 (41)18 (23)0.014
Fatigue, VAS 0–100 mm34 (50)35 (51)NS39 (46)10 (33)<0.00121 (44)25 (40)NS26 (39)23 (41)NS
HAQ, score 0–30.6 (0.9)0.6 (0.8)NS0.6 (0.8)0.3 (0.8)<0.0010.3 (0.8)0.4 (0.75)NS0.6 (0.8)0 (0.5)0.001

None of the variables representing the disease course, apart from pain in women, changed significantly between the 12- and 24-month visits (Table 1). Compared with men, women had significantly higher HAQ scores at both visits (month 12 P < 0.001; month 24 P = 0.004) and a higher DAS-28 at the 24-month visit (P = 0.038). Women also had significantly lower grip force than men at both visits (month 12 P < 0.001; month 24 P < 0.001). No differences were found between women and men regarding the proportion of patients taking nonsteroidal antiinflammatory drugs, analgesics, or oral corticosteroids at the 12- and 24-month visits. The use of disease-modifying antirheumatic drugs (DMARDs) did not differ significantly at the 12-month visit, whereas significantly more women (72%) were treated with DMARDs compared with men (59%) at the 24-month visit.

Activity limitations at the 12- and 24-month visits.

When adding all the 102 recorded activities in EDAQ, women reported 69% of the activities as performed without any difficulty 12 months after diagnosis and 72% at the 24-month visit. The corresponding percentages for men were 82% and 83% (Figure 1).

Figure 1.

Percentage distribution (rating of difficulties) without use of assistive devices in all 102 Evaluation of Daily Activity Questionnaire activities at the 12- and 24-month visits.

Difficulty in performing activities without using ADs was significantly reduced in 6 activities for women at the 24-month visit compared with the 12-month visit. For men, difficulty in performing activities had increased significantly in 1 and significantly decreased in 2 activities at the 24-month visit compared with the followup at 12 months (Table 2).

Table 2. Summary of the 9 EDAQ activities where difficulties changed significantly between 24- and 12-month visits without the use of ADs*
ActivityMonth 12Month 24P
0123Missing0123Missing
  • *

    Data presented as percentages of respondents answering in each level of difficulty. EDAQ = Evaluation of Daily Activity Questionnaire; ADs = assistive devices; 0 = without any difficulty; 1 = with some difficulty; 2 = with much difficulty; 3 = unable to do.

Women (n = 159)           
 Filling up milk66266 272233 20.042
 Drying oneself after toilet visit77183 284151  0.037
 Using toothpaste732031383141 10.002
 Opening balcony door74165 581141 40.016
 Cleaning kitchen floor5230115357309310.045
 Ironing blouse692431477143140.029
Men (n = 56)           
 Turning on stove915  48411 290.035
 Picking up dishes8611  47718 290.035
 Opening outer door937   100    0.046

The most frequently reported difficulty by women concerned activities in the dimensions eating and drinking (opening glass jar and opening juice bottle), cooking (lifting frying pan by its handle and reaching for sugar), and mobility outdoors and shopping (taking long walks, bringing home groceries, and shopping on a large scale; Table 3). For men, the most frequently reported difficulties were opening glass jar and opening juice bottle in the dimension eating and drinking. For both women and men, a high frequency of missing values was noted concerning the use of suppositories. Men had a high frequency of missing values in the activities putting hair in rollers, making sponge cake, turning a hem of a shirt, and cutting out material. The corresponding was found for women concerning driving a car.

Table 3. EDAQ activities grouped in dimensions*
Dimension/activity0123Not respondedPNo use of AD
WMWMWMWMWM
  • *

    Percentage with difficulties without use of an assistive device (AD) at the 24-month visits for women (W) and men (M). Statistical comparison of difficulties between women (n = 159) and men (n = 56). EDAQ = Evaluation of Daily Activity Questionnaire; 0 = without any difficulty; 1 = with some difficulty; 2 = with much difficulty; 3 = unable to do; NS = not significant.

Eating/drinking            
 Lifting glass869613212  1 0.040 
 Lifting cup849515412  1 NS 
 Using knife, fork7688211122  1 NS 
 Cutting bread517940218   2 <0.001 
 Slicing cheese5373382582  1 0.007 
 Bringing down milk carton668727114  1320.002 
 Pouring milk7288231132   20.030 
 Opening milk carton4359443685 2 3NS 
 Opening bottle48733318102 367<0.001 
 Opening glass jar20394746197135220.001 
 Opening juice bottle2654453419984 2<0.001 
 Open can45683429154 4 20.001 
Toileting            
 Getting to toilet9496521  1 2NS 
 Sitting on and rising from toilet76882313      NS 
 Drying oneself after toilet visit8493157      NSX
 Washing back8796134      NS 
 Arranging clothes8695135     1NSX
 Washing hands959852      NSX
 Brushing and combing hair82931771     0.046 
 Brushing teeth88951151    1NS 
 Using toothpaste83951451    2NS 
 Using suppository52486 1   4252NSX
 Opening medicine bottle668630143    1NS 
 Putting on makeup798889    134NSX
 Putting on jewelry69772356   1180.001X
Dressing            
 Outdoor clothing798420161    1NSX
 Clothes over head708230181    1NS 
 Clothes with front button768020203    1NS 
 Buttoning and unbuttoning636633323   12NS 
 Clothes over feet738219184  1 3NS 
 Zipping and unzipping81931672    10.043 
 Putting on tights706422204  1316NS 
 Putting on shoes747723203    1NS 
 Putting on boots687520215  3 4NSX
 Tying shoelaces7479162042 4 3NS 
 Putting on finger gloves84931272  1 2NSX
Bathing/shower            
 Getting to bathroom9298621  1 1NS 
 Getting in and out of bathtub4852201652622129NS 
 Standing up to take a shower8693953 12 1NS 
 Washing neck and back637530213232 1NS 
 Drying neck and back708223143 2222NS 
 Washing and drying feet748021182 32 1NS 
 Managing lever80931673    10.028 
 Washing hair818816934 1 1NSX
 Putting hair in rollers562510 6  326750.033X
 Blow-drying hair653915 4  313610.008X
 Manicure72712094 12318NS 
 Pedicure595424237552516NS 
Cooking            
 Walking into kitchen8995641 1 32NS 
 Working in kitchen768218133 1234NS 
 Laying the table84931121 1234NS 
 Peeling potatoes527540203 12440.003 
 Turning on stove748421112 1234NS 
 Lifting frying pan by its handle27544129169125440.001 
 Emptying potato water487337189232450.001 
 Reaching for sugar3055383413215544<0.001 
 Making sponge cake73551554212836NS 
 Bread in and out of oven607027115 226180.007 
 Washing the dishes82881341 1237NS 
 Picking up dishes677726181 1244NS 
Mobility indoors            
 Walking indoors8993971  1  NS 
 Opening outer door8610013 1    10.004 
 Opening Yale lock758821132    2NS 
 Answering the door84961341  1 10.027 
 Opening balcony door818414111   45NS 
 Walking out on balcony9091541   45NS 
 Getting to the telephone87861141  1  0.044 
Cleaning            
 Making the bed708426141 22 1NS 
 Dusting82931542 12 10.030 
 Sweeping the floor668421134 22720.032 
 Cleaning kitchen floor577930169234 10.007 
 Wringing out cloth3561503213422120.001 
 Using vacuum cleaner528633139 52 2<0.001 
 Opening window748920942 1 10.022 
Washing/clothes care            
 Washing up in bowl66901872  11340.009 
 Putting wash in machine9088721  428NS 
 Hanging up wash678023135222340.045 
 Ironing blouse77661553212425NS 
 Turning up hem of a shirt633020234351359NS 
 Cutting out material554626444 311460.020 
 Picking up needles585531217214318NS 
 Putting in and taking out plug648228146  1240.003 
 Opening/folding ironing board6066221482 37180.032 
Transferring            
 Getting into bed9096941     NS 
 Turning in bed7786201322 1  NSX
 Getting out of bed7979161854    NS 
 Rising from chair7373202354 1 1NSX
Communication            
 Using telephone931008       0.035 
 Holding a book73812314 3 114NS 
 Writing a postcard788921712   20.040 
 Taking out money80891811 2    NS 
Mobility outdoors/shopping            
 Walking on flat ground817912161  165NS 
 Taking long walks385234321159595NS 
 Walking up stairs50573132943275NS 
 Going by tram/bus747512222 39210.024X
 Getting in and out of car6071312132  65NSX
 Driving a car58861322 3225110.004 
 Opening entrance doors65862395  1650.002 
 Opening elevator door70861674  1970.014X
 Walking to the shops70801311621295NS 
 Bringing home groceries246146291548285<0.001 
 Shopping on a large scale26613220155155129<0.001 

Nine (6%) of the women reported they could do all 102 activities without any difficulty (median 79, IQR 37) compared with 3 (5%) of the men (median 84, IQR 23) at the 24-month visit. The median (IQR) number of activities reported as difficult was 17 (25) for women and 10 (19) for men.

Use and effect of ADs at the 24-month visit.

One hundred twenty-four (78%) of the women used ADs. In total, 802 ADs was used by these 124 women with an average of 6 ADs used per woman. Thirty (54%) of the men used ADs. These 30 men used 181 ADs, giving an average of 6 ADs per man. In the total 159 women and 56 men, the average number of ADs used were 5 and 3, respectively.

For women, the effects of ADs were tested in 25 activities and were found to reduce difficulties significantly in 24 of these 25 activities. The most frequently reported beneficial effect was reported for ADs used in the dimension eating and drinking (Table 4). The effect of ADs was tested in 7 activities in men and ADs reduced difficulties significantly in all of these activities. Men most frequently reported reduced difficulties in the dimension eating and drinking when using ADs (Table 5). Activities in which no AD was used are presented in Table 3.

Table 4. EDAQ activities where >5% of the 124 women reported use of assistive devices (ADs) at the 24-month visit*
Dimension/activityWithout use of AD, no.With use of AD, no.Women, no. (%)Missing, no.PTypes of AD
01230123
  • *

    EDAQ = Evaluation of Daily Activity Questionnaire; 0 = without any difficulty; 1 = with some difficulty; 2 = with much difficulty; 3 = unable to do; NS = not significant.

Eating/drinking            
 Using knife, fork282 75  12 (8) 0.008Large handled grips, angled handle
 Cutting bread12499 5218  70 (44) <0.001Bread knife with angled handle
 Slicing cheese5488 4615  62 (39)1<0.001Angled cheese slicer, wrist orthoses
 Opening milk carton3307 319  41 (26)1<0.001Springy scissors and tongs
 Opening bottle31664217 131 (20)2<0.001Prolonged opener
 Opening glass jar34215942233171 (45)2<0.001Prolonged opener, antislip pad
 Opening juice bottle32711327122344 (28) <0.001Springy tongs, antislip pad, vacuum opener
 Open can1121823181143 (27)1<0.001Jar opener, electric opener, antislip pad
Toileting            
 Sitting on and rising from toilet3161 182  21 (13)1<0.001Raised toilet seat, arm stay
 Brushing teeth19  73  10 (6) 0.014Electric tooth brush
 Opening medicine bottle243 81  10 (6)10.024Prolonged jar opener, antislip pad, springy tongs
Dressing            
 Putting on shoes 141 69  15 (9) 0.008Elongated grip
Bathing/shower            
 Getting in and out of bathtub 9 146  10 (6) 0.034Bathtub board
 Washing neck and back1122 68  15 (9) 0.008Elongated flexible grip, terry band
Cooking            
 Peeling potatoes3372 2121  43 (27)1<0.001Enlarged potato peeler, machine
 Emptying potato water2115 117  18 (11) <0.001Special strainer
 Making sponge cake451 91  10 (6) NSElectric mixer
 Washing the dishes36  63  10 (6)10.014Washing machine
Mobility indoors            
 Opening Yale lock 11  74  11 (7) 0.008Enlarged key grip
Cleaning            
 Cleaning kitchen floor3123 711  18 (11) 0.005Long brush, wrist orthoses
 Wringing out cloth 103 94  12 (8) 0.003Swab press, wrist orthoses
Washing/cloths care            
 Cutting out material2121 141  17 (11)20.001Springy scissors
 Picking up needles1651 1093 24 (15)2<0.001Prolonged grip with magnet
Communication            
 Holding a book 123 114  15 (9) 0.001Book holder
 Writing a postcard 151 106  16 (10) 0.001Enlarged grip on pen
Table 5. EDAQ activities where >5% of the 30 men reported use of assistive devices (ADs) at 24-month visit*
Dimension/activityWithout use of AD, no.With use of AD, no.Men, no. (%)Missing, no.PTypes of AD
01230123
  • *

    EDAQ = Evaluation of Daily Activity Questionnaire; 0 = without any difficulty; 1 = with some difficulty; 2 = with much difficulty; 3 = unable to do.

Eating/drinking            
 Cutting bread310  103  13 (23) 0.008Bread knife with angled handle
 Slicing cheese 10  73  10 (18) 0.008Angled cheese slicer, wrist orthoses
 Opening milk carton 73 91  10 (18) 0.003Springy scissors and tongs
 Opening glass jar1103196  16 (29)10.006Prolonged opener, antislip pad
 Opening juice bottle 622631 10 (18) 0.026Springy tongs, antislip pad, vacuum opener
 Open can451 91  10 (18) 0.034Jar opener, electric opener, antislip pad
Cooking            
 Peeling potatoes142 52  7 (13) 0.046Enlarged potato peeler, machine

Patient characteristics in subgroups at the 24-month visit.

The subgroup of 124 women who used ADs had significantly more severe disease and more pronounced disability than the subgroup of 35 women who did not use ADs, as reflected by DAS-28, pain, fatigue, grip force, HAQ, and in 18 of the 25 EDAQ activities where ADs were used. Also, the subgroup of 30 men who used ADs had significantly more severe disease and more pronounced disability compared with the subgroup of 26 men who did not use ADs, as reflected by DAS-28, pain, grip force, HAQ, and in the 7 EDAQ activities where ADs were used. The subgroups of women and men who used ADs had comparable impact on ESR, DAS-28, PGA, pain, and HAQ (Table 1). Nordenskiöld and Grimby reported that the mean values for grip force in healthy subjects were 229N for women (n = 105) and 432N for men (n = 64) (18). The corresponding mean values at the 24-month visit in the subgroups that used ADs were 108N for women and 170N for men. This means that in the subgroups that used ADs, the reduction in grip force was 53% and 61% in women and men, respectively.

DISCUSSION

In all but 1 of the statistically analyzed activities, the use of ADs was reported to reduce difficulty significantly. Also, 78% of women and 54% of men reported using ADs. These results indicate a need for specific assessment and intervention with regard to ADs early after the diagnosis of RA in both women and men. Also, some of these needs may be met by early and general patient education programs that include a presentation of the possibilities offered by different types of ADs (22). This study does not explore to what extent the evaluated ADs were prescribed by the specialized teams, acquired from other health care contacts, or bought directly from other providers.

The types of ADs reported in this study cost little compared with many other interventions in RA. For 2 groups of Swedish patients with RA, Hass et al reported in 1995 that the average cost per person for 1 prescribed AD was $8 (US) and $32 for 9 prescribed ADs (10). In the present study, the mean number of ADs used per person in the study groups were 5 for women and 3 for men. Within the subgroups of AD users, both women and men used 6 ADs. Nordenskiöld reported that patients with 8 years' mean duration of RA on average used 11 ADs to an average cost of 1,683 SEK per person (∼$170 US in 1994) (11). These patients performed daily activities with ADs, changed working methods, and remained unchanged in their roles both at home and at work. Depending on disease severity, Mann and coworkers reported that RA patients used from 3 to 5 ADs for physical disabilities (5). In this type of study, the number of ADs recalled by the patient may differ from the number prescribed and acquired, or may differ in the degree of regular use. However, our detailed questionnaire EDAQ regarding daily activities is assumed to support the recalling of ADs that are used.

In addition to factors related to availability, the actual use of ADs can be assumed to depend on the perceived effect with respect to, e.g., hand function, pain, or the performance of daily activities. EDAQ measures difficulties in the listed daily activities as experienced by the patients performing their normal choice of activities in their own environment, in accordance with most activities of daily living instruments, but in contrast to the Canadian Occupational Performance Measure (COPM). In COPM, the patient identifies meaningful activities perceived as problematic to perform, assesses the importance in order to make priorities, and scores performance and satisfaction with performance (23). Hewlett et al (24) points out the need to assess the personal impact of disability as well as disability itself. They conclude that patients, professionals, and healthy controls do not agree on the impact on disability; they present a model for calculating the personal impact of disability (24). However, the reported difficulties, and especially the reported use of ADs, may indicate that the corresponding activities are important to these individuals.

In clinical practice, detailed questionnaires like EDAQ may be used by the patients to list perceived difficulties in activities that will require further consultation; they may also be used by occupational therapists to assess the need for specific interventions. For physicians, knowledge about common patterns of activity limitations is important to detect a need for intervention from allied health professionals. At 24 months after the diagnosis of RA, difficulties related to the dimension eating and drinking were the most frequent, followed by mobility outdoors and cleaning. Patients with longstanding RA have also been reporting this pattern (13, 21). Between the 12- and 24-month visits, the extent of activity limitations in most daily activities was persistent for both women and men. Also, this stability was a common pattern for most other aspects of the disease course in this study group (16). EDAQ was not used at inclusion to avoid too many examinations at this encounter. The activity limitation in our study group was probably not caused by RA alone, but may also have been influenced by comorbidity or age-related disability. In a disability perspective, however, the total pattern of difficulties in the RA population is also clinically relevant.

Compared with the groups that did not use ADs, both women and men using ADs were more severely affected concerning the majority of the disease variables. The relative difference between women and men concerning grip force is not surprising because similar findings are seen in a healthy Swedish reference population (18). In the Swedish version of HAQ used here, the score increases automatically when an AD is used. The rationale for using ADs may sometimes be pain relief or other preventive purposes, and may in many instances be prerequisites to perform an activity. Thus, the reason for scoring a higher HAQ by AD users, regardless of sex, always requires a careful analysis. Zandbelt et al (25) showed significant differences in the Dutch version of HAQ when correcting for the use of aid or devises or not. Therefore, instruments like the EDAQ, which distinguish difficulties with and without AD use (i.e., evaluating AD efficacy), are valuable. In clinical practice, the disease course as measured by DAS-28, HAQ, pain, and grip force may suggest further assessments of the need for AD intervention.

Women reported significantly more activity limitations than men did in the dimensions cleaning and washing and clothes care. These differences are probably sex biased. At the same time, the significant differences in activities concerning the dimensions eating and drinking and mobility outdoors and shopping probably lack this bias. Both women and men gave a low response rate concerning the use of suppositories, indicating low actuality. Not surprisingly, men had low response rates regarding the activities putting in hair rollers, making sponge cake, turning a hem of a shirt, and cutting out material. The same was true for women concerning driving a car. This indicates a need for further development of EDAQ based on a sex perspective. There is also a need for further analyses regarding the relation between grip force and difficulties performing daily activities.

To conclude, just 1 year after RA diagnosis, patients report activity limitations in many daily activities. The extent of activity limitations seems to be stable between 12 and 24 months after diagnosis. Women reported significantly more activity limitations than men in EDAQ at 24 months after diagnosis and used substantially more ADs. The use of ADs was related to more severe disease and more pronounced impairment, indicating a need for early AD intervention. ADs significantly improved performance of daily activities in both women and men.

Acknowledgements

We would like to thank Ms Ylva Billing and all coworkers in the TIRA Project for their fruitful cooperation.

Ancillary