To identify activity limitation in early rheumatoid arthritis (RA) to detect patients needing assistive devices. To evaluate the effects of assistive devices.
To identify activity limitation in early rheumatoid arthritis (RA) to detect patients needing assistive devices. To evaluate the effects of assistive devices.
A multicenter cohort of 284 early RA patients was examined using the Evaluation of Daily Activity Questionnaire 12 and 24 months after diagnosis.
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.
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.
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.
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.
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.”
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.
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).
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.
|Total (n = 159)||AD user (n = 124) Month 24||Not AD user (n = 35) Month 24||P||Total (n = 56)||AD user (n = 30) Month 24||Not AD user (n = 26) Month 24||P|
|Month 12||Month 24||P||Month 12||Month 24||P|
|Age, years||55 (21)||55 (42)||60 (39)||NS||63 (23)||60 (24)||66 (17)||NS|
|ESR, mm/hour||16 (23)||16 (22)||NS||18 (23)||12 (12)||0.009||15 (23)||14 (16)||NS||14 (18)||14 (20)||NS|
|PGA, score 0–4||1 (1)||1 (1)||NS||1 (1)||1 (1)||<0.001||1 (1)||1 (0)||NS||1 (0.3)||1 (0.5)||NS|
|DAS-28||3.9 (2.0)||3.6 (1.8)||NS||3.8 (1.6)||2.9 (1.9)||0.005||3.6 (2)||3.1 (2)||NS||3.6 (2.3)||2.9 (1.2)||0.024|
|Grippit, newtons||95 (94)||104 (96)||NS||90 (89)||167 (121)||0.002||197 (132)||214 (151)||NS||164 (135)||238 (179)||0.003|
|Pain, VAS 0–100 mm||35 (52)||30 (44)||0.04||33 (42)||13 (40)||0.005||29 (62)||25 (42)||NS||33 (41)||18 (23)||0.014|
|Fatigue, VAS 0–100 mm||34 (50)||35 (51)||NS||39 (46)||10 (33)||<0.001||21 (44)||25 (40)||NS||26 (39)||23 (41)||NS|
|HAQ, score 0–3||0.6 (0.9)||0.6 (0.8)||NS||0.6 (0.8)||0.3 (0.8)||<0.001||0.3 (0.8)||0.4 (0.75)||NS||0.6 (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.
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).
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).
|Activity||Month 12||Month 24||P|
|Women (n = 159)|
|Filling up milk||66||26||6||2||72||23||3||2||0.042|
|Drying oneself after toilet visit||77||18||3||2||84||15||1||0.037|
|Opening balcony door||74||16||5||5||81||14||1||4||0.016|
|Cleaning kitchen floor||52||30||11||5||3||57||30||9||3||1||0.045|
|Men (n = 56)|
|Turning on stove||91||5||4||84||11||2||9||0.035|
|Picking up dishes||86||11||4||77||18||2||9||0.035|
|Opening outer door||93||7||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.
|Dimension/activity||0||1||2||3||Not responded||P||No use of AD|
|Using knife, fork||76||88||21||11||2||2||1||NS|
|Bringing down milk carton||66||87||27||11||4||1||3||2||0.002|
|Opening milk carton||43||59||44||36||8||5||2||3||NS|
|Opening glass jar||20||39||47||46||19||7||13||5||2||2||0.001|
|Opening juice bottle||26||54||45||34||19||9||8||4||2||<0.001|
|Getting to toilet||94||96||5||2||1||1||2||NS|
|Sitting on and rising from toilet||76||88||23||13||NS|
|Drying oneself after toilet visit||84||93||15||7||NS||X|
|Brushing and combing hair||82||93||17||7||1||0.046|
|Opening medicine bottle||66||86||30||14||3||1||NS|
|Putting on makeup||79||88||8||9||13||4||NS||X|
|Putting on jewelry||69||77||23||5||6||1||18||0.001||X|
|Clothes over head||70||82||30||18||1||1||NS|
|Clothes with front button||76||80||20||20||3||1||NS|
|Buttoning and unbuttoning||63||66||33||32||3||1||2||NS|
|Clothes over feet||73||82||19||18||4||1||3||NS|
|Zipping and unzipping||81||93||16||7||2||1||0.043|
|Putting on tights||70||64||22||20||4||1||3||16||NS|
|Putting on shoes||74||77||23||20||3||1||NS|
|Putting on boots||68||75||20||21||5||3||4||NS||X|
|Putting on finger gloves||84||93||12||7||2||1||2||NS||X|
|Getting to bathroom||92||98||6||2||1||1||1||NS|
|Getting in and out of bathtub||48||52||20||16||5||2||6||2||21||29||NS|
|Standing up to take a shower||86||93||9||5||3||1||2||1||NS|
|Washing neck and back||63||75||30||21||3||2||3||2||1||NS|
|Drying neck and back||70||82||23||14||3||2||2||2||2||NS|
|Washing and drying feet||74||80||21||18||2||3||2||1||NS|
|Putting hair in rollers||56||25||10||6||3||26||75||0.033||X|
|Walking into kitchen||89||95||6||4||1||1||3||2||NS|
|Working in kitchen||76||82||18||13||3||1||2||3||4||NS|
|Laying the table||84||93||11||2||1||1||2||3||4||NS|
|Turning on stove||74||84||21||11||2||1||2||3||4||NS|
|Lifting frying pan by its handle||27||54||41||29||16||9||12||5||4||4||0.001|
|Emptying potato water||48||73||37||18||9||2||3||2||4||5||0.001|
|Reaching for sugar||30||55||38||34||13||2||15||5||4||4||<0.001|
|Making sponge cake||73||55||15||5||4||2||1||2||8||36||NS|
|Bread in and out of oven||60||70||27||11||5||2||2||6||18||0.007|
|Washing the dishes||82||88||13||4||1||1||2||3||7||NS|
|Picking up dishes||67||77||26||18||1||1||2||4||4||NS|
|Opening outer door||86||100||13||1||1||0.004|
|Opening Yale lock||75||88||21||13||2||2||NS|
|Answering the door||84||96||13||4||1||1||1||0.027|
|Opening balcony door||81||84||14||11||1||4||5||NS|
|Walking out on balcony||90||91||5||4||1||4||5||NS|
|Getting to the telephone||87||86||11||4||1||1||0.044|
|Making the bed||70||84||26||14||1||2||2||1||NS|
|Sweeping the floor||66||84||21||13||4||2||2||7||2||0.032|
|Cleaning kitchen floor||57||79||30||16||9||2||3||4||1||0.007|
|Wringing out cloth||35||61||50||32||13||4||2||2||1||2||0.001|
|Using vacuum cleaner||52||86||33||13||9||5||2||2||<0.001|
|Washing up in bowl||66||90||18||7||2||1||13||4||0.009|
|Putting wash in machine||90||88||7||2||1||4||2||8||NS|
|Hanging up wash||67||80||23||13||5||2||2||2||3||4||0.045|
|Turning up hem of a shirt||63||30||20||2||3||4||3||5||13||59||NS|
|Cutting out material||55||46||26||4||4||4||3||11||46||0.020|
|Picking up needles||58||55||31||21||7||2||1||4||3||18||NS|
|Putting in and taking out plug||64||82||28||14||6||1||2||4||0.003|
|Opening/folding ironing board||60||66||22||14||8||2||3||7||18||0.032|
|Getting into bed||90||96||9||4||1||NS|
|Turning in bed||77||86||20||13||2||2||1||NS||X|
|Getting out of bed||79||79||16||18||5||4||NS|
|Rising from chair||73||73||20||23||5||4||1||1||NS||X|
|Holding a book||73||81||23||14||3||1||1||4||NS|
|Writing a postcard||78||89||21||7||1||2||2||0.040|
|Taking out money||80||89||18||11||2||NS|
|Walking on flat ground||81||79||12||16||1||1||6||5||NS|
|Taking long walks||38||52||34||32||11||5||9||5||9||5||NS|
|Walking up stairs||50||57||31||32||9||4||3||2||7||5||NS|
|Going by tram/bus||74||75||12||2||2||2||3||9||21||0.024||X|
|Getting in and out of car||60||71||31||21||3||2||6||5||NS||X|
|Driving a car||58||86||13||2||2||3||2||25||11||0.004|
|Opening entrance doors||65||86||23||9||5||1||6||5||0.002|
|Opening elevator door||70||86||16||7||4||1||9||7||0.014||X|
|Walking to the shops||70||80||13||11||6||2||1||2||9||5||NS|
|Bringing home groceries||24||61||46||29||15||4||8||2||8||5||<0.001|
|Shopping on a large scale||26||61||32||20||15||5||15||5||12||9||<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.
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.
|Dimension/activity||Without use of AD, no.||With use of AD, no.||Women, no. (%)||Missing, no.||P||Types of AD|
|Using knife, fork||2||8||2||7||5||12 (8)||0.008||Large handled grips, angled handle|
|Cutting bread||12||49||9||52||18||70 (44)||<0.001||Bread knife with angled handle|
|Slicing cheese||5||48||8||46||15||62 (39)||1||<0.001||Angled cheese slicer, wrist orthoses|
|Opening milk carton||3||30||7||31||9||41 (26)||1||<0.001||Springy scissors and tongs|
|Opening bottle||3||16||6||4||21||7||1||31 (20)||2||<0.001||Prolonged opener|
|Opening glass jar||3||42||15||9||42||23||3||1||71 (45)||2||<0.001||Prolonged opener, antislip pad|
|Opening juice bottle||3||27||11||3||27||12||2||3||44 (28)||<0.001||Springy tongs, antislip pad, vacuum opener|
|Open can||11||21||8||2||31||8||1||1||43 (27)||1||<0.001||Jar opener, electric opener, antislip pad|
|Sitting on and rising from toilet||3||16||1||18||2||21 (13)||1||<0.001||Raised toilet seat, arm stay|
|Brushing teeth||1||9||7||3||10 (6)||0.014||Electric tooth brush|
|Opening medicine bottle||2||4||3||8||1||10 (6)||1||0.024||Prolonged jar opener, antislip pad, springy tongs|
|Putting on shoes||14||1||6||9||15 (9)||0.008||Elongated grip|
|Getting in and out of bathtub||9||1||4||6||10 (6)||0.034||Bathtub board|
|Washing neck and back||1||12||2||6||8||15 (9)||0.008||Elongated flexible grip, terry band|
|Peeling potatoes||3||37||2||21||21||43 (27)||1||<0.001||Enlarged potato peeler, machine|
|Emptying potato water||2||11||5||11||7||18 (11)||<0.001||Special strainer|
|Making sponge cake||4||5||1||9||1||10 (6)||NS||Electric mixer|
|Washing the dishes||3||6||6||3||10 (6)||1||0.014||Washing machine|
|Opening Yale lock||11||7||4||11 (7)||0.008||Enlarged key grip|
|Cleaning kitchen floor||3||12||3||7||11||18 (11)||0.005||Long brush, wrist orthoses|
|Wringing out cloth||10||3||9||4||12 (8)||0.003||Swab press, wrist orthoses|
|Cutting out material||2||12||1||14||1||17 (11)||2||0.001||Springy scissors|
|Picking up needles||16||5||1||10||9||3||24 (15)||2||<0.001||Prolonged grip with magnet|
|Holding a book||12||3||11||4||15 (9)||0.001||Book holder|
|Writing a postcard||15||1||10||6||16 (10)||0.001||Enlarged grip on pen|
|Dimension/activity||Without use of AD, no.||With use of AD, no.||Men, no. (%)||Missing, no.||P||Types of AD|
|Cutting bread||3||10||10||3||13 (23)||0.008||Bread knife with angled handle|
|Slicing cheese||10||7||3||10 (18)||0.008||Angled cheese slicer, wrist orthoses|
|Opening milk carton||7||3||9||1||10 (18)||0.003||Springy scissors and tongs|
|Opening glass jar||1||10||3||1||9||6||16 (29)||1||0.006||Prolonged opener, antislip pad|
|Opening juice bottle||6||2||2||6||3||1||10 (18)||0.026||Springy tongs, antislip pad, vacuum opener|
|Open can||4||5||1||9||1||10 (18)||0.034||Jar opener, electric opener, antislip pad|
|Peeling potatoes||1||4||2||5||2||7 (13)||0.046||Enlarged potato peeler, machine|
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.
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.
We would like to thank Ms Ylva Billing and all coworkers in the TIRA Project for their fruitful cooperation.