Reactions to disability in patients with early versus established rheumatoid arthritis

Experiences of individuals with rheumatoid arthritis interacting with health care and the use of a digital self-care application: a qualitative interview study

OBJECTIVES

Over the last few decades, there have been significant improvements in the treatment of rheumatoid arthritis (RA), with the development of new treatments and guidelines for teamwork and patient self-care and access to digital tools. This study aimed to explore the experiences of individuals with RA interacting with healthcare. It also looked at how a self-care application, an educational programme called the 'healthcare encounter', improved patient-doctor communication.

DESIGN

Semistructured interviews were conducted, and qualitative content analysis was performed.

SETTING

The potential participants, individuals with established, or under investigation for, RA diagnosis at rheumatology clinics in Sweden, were asked to participate in the study via a digital self-care application called the Elsa Science Self-care app.

PARTICIPANTS

Ten interviews were performed with participants from nine clinics following a meeting with the rheumatologist or other healthcare personnel between September 2022 and October 2022. Phrases, sentences or paragraphs referring to experiences from healthcare meetings and opinions about the digital programme were identified and coded. Codes that reflected similar concepts were grouped; subcategories were formulated, and categories were connected to their experiences and opinions.

RESULTS

Among our participants, three main categories emerged: the availability of healthcare, individual efforts to have a healthier life and personal interaction with healthcare. Participants described that the 'healthcare encounter' educational programme can be a source of information, which confirms, supports and creates a sense of control.

CONCLUSION

The participants valued being seen and taking part in a dialogue when they had prepared themselves (observed symptoms over time and prepared questions). The implementation of digital self-care applications might need to be incorporated into the healthcare setting, so that both the patients and the healthcare personnel have a shared understanding. Collaboration is essential in this context.

Illness Denial in Medical Disorders: A Systematic Review

INTRODUCTION

Illness denial pertains to medical patients who do not acknowledge the presence or severity of their disease or the need of treatment.

OBJECTIVE

This systematic review was performed to clarify the clinical role and manifestations of illness denial, its impact on health attitudes and behavior, as well as on short- and long-term outcomes in patients with medical disorders.

METHODS

The systematic search according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was conducted on PubMed, Scopus, and Web of Science.

RESULTS

The initial search yielded a total of 14,098 articles; 176 studies met the criteria for inclusion. Illness denial appeared to be a relatively common condition affecting a wide spectrum of health attitudes and behavior. In some cases, it may help a person cope with various stages of illness and treatment. In other situations, it may determine delay in seeking treatment, impaired adherence, and reduced self-management, leading to adverse outcomes. The Diagnostic Criteria for Psychosomatic Research (DCPR) were found to set a useful severity threshold for the condition. An important clinical distinction can also be made based on the DCPR for illness denial, which require the assessment of whether the patient has been provided with an adequate appraisal of the medical situation.

CONCLUSIONS

This systematic review indicates that patients with medical disorders experience and express illness denial in many forms and with varying degrees of severity. The findings suggest the need for a multidimensional assessment and provide challenging insights into the management of medical disorders.

Defining Pain That Does Not Interfere With Activities Among Rheumatoid Arthritis Patients

OBJECTIVE

The objectives of this study were to: 1) characterize the distribution of noninterfering pain (defined as the pain intensity level at which individuals can function without interference) across different aspects of life among patients with rheumatoid arthritis (RA), and 2) identify clinical characteristics associated with differing levels of noninterfering pain.

METHODS

Patients with RA in FORWARD, The National Databank for Rheumatic Diseases completed 8 items from the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference item bank that asked about interference with activities. If subjects reported pain interference, they were asked, "At what level would pain no longer interfere with this activity?" on a scale of 0 to 10. Subjects were also asked, "At what level of pain would you be able to do everything you want to do?" Multiple linear regression analyses examined associations between clinical characteristics and noninterfering pain.

RESULTS

A total of 3,949 patients with RA completed the questionnaires. Pain interference was most common for daily activities and least common for ability to concentrate. The mean ± SD level at which pain no longer interfered with activities ranged from 2.7 ± 2.1 for ability to fall/stay asleep to 3.1 ± 2.0 for social activities. Overall, the mean ± SD threshold for noninterfering pain was 2.8 ± 1.9. The mean ± SD level of pain at which patients could do everything they wanted to do was 2.3 ± 1.9. More severe pain intensity was associated with higher noninterfering pain.

CONCLUSION

The mean pain level that did not interfere with activities was 3. High pain intensity was associated with high self-reported noninterfering pain.

Are depression and anxiety associated with disease activity in rheumatoid arthritis? A prospective study

Background

This study aimed to investigate the impact of depression and anxiety scores on disease activity at 1-year follow-up in people with Rheumatoid Arthritis (RA).

Methods

The Hospital Anxiety Depression Scale (HADS) was used to measure depression and anxiety in a cross-section of RA patients. The primary outcome of interest was disease activity (DAS28), measured one-year after baseline assessment. Secondary outcomes were: tender joint count, swollen joint count, erythrocyte sedimentation rate and patient global assessment, also measured one-year after baseline assessment. We also examined the impact of baseline depression and anxiety on odds of reaching clinical remission at 1-year follow-up.

Results

In total, 56 RA patients were eligible for inclusion in this analysis. Before adjusting for key demographic and disease variables, increased baseline depression and anxiety were associated with increased disease activity at one-year follow-up, although this was not sustained after adjusting for baseline disease activity. There was a strong association between depression and anxiety and the subjective components of the DAS28 at 12-month follow-up: tender joint count and patient global assessment. After adjusting for age, gender, disease duration and baseline tender joint count and patient global assessment respectively, higher levels of depression and anxiety at baseline were associated with increased tender joint count and patient global assessment scores at 1-year follow-up.

Conclusions

Symptoms of depression and anxiety have implications for disease activity, as measured via the DAS28, primarily due to their influence on tender joints and patient global assessment. These findings have implications for treatment decision-making as inflated DAS28 despite well controlled inflammatory disease markers may indicate significant psychological morbidity and related non-inflammatory pain, rather than true disease activity.

Self-acceptance of stuttering: A preliminary study

PURPOSE

This study explored the relationship between self-acceptance of stuttering and (1) psychosocial factors (self-esteem, hostility towards others, emotional support, and perceived discrimination); (2) treatment history (support group participation, therapy duration, and perceived therapy success); and (3) previously reported variables in self-acceptance of stuttering, which include age and stuttering severity.

METHOD

Participants were 80 adults who stutter who were recruited with assistance from the National Stuttering Association and Board Certified Specialists in Fluency Disorders. Participants completed an electronic survey composed of an acceptance of stuttering scale, psychosocial scales, and a participant information questionnaire.

RESULTS

Statistical analysis identified significant correlations between participants' reports of self-acceptance of stuttering and self-esteem, perceived discrimination, hostility towards others, and perceived therapy outcome. Self-esteem was positively correlated with self-acceptance, while hostility towards others and perceived discrimination was negatively correlated with self-acceptance. Participants who perceived their therapy outcome to be successful were significantly more likely to report higher levels of self-acceptance. No significant relationships were found between self-acceptance of stuttering and support group participation, emotional support, stuttering severity, and participant age.

CONCLUSION

This exploratory investigation has provided a foundation for future studies on the self-acceptance of stuttering. The findings indicate common psychosocial variables in self-acceptance of stuttering and of other disabilities. The significant relationships between self-acceptance of stuttering and psychosocial and therapeutic variables found need to be further explored to identify its causalities and clinical implications.

LEARNING OUTCOMES

The reader will be able to (1) discuss the importance of assessing self-acceptance of stuttering, (2) summarize the literature on self-acceptance of disability, and (3) describe the significant findings related to self-acceptance of stuttering and psychosocial, therapeutic variables.

Coping strategies for health and daily-life stressors in patients with rheumatoid arthritis, ankylosing spondylitis, and gout: STROBE-compliant article

This article aims to identify the strategies for coping with health and daily-life stressors of Mexican patients with chronic rheumatic disease. We analyzed the baseline data of a cohort of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout. Their strategies for coping were identified with a validated questionnaire. Comparisons between health and daily-life stressors and between the 3 clinical conditions were made. With regression analyses, we determined the contribution of individual, socioeconomic, educational, and health-related quality-of-life variables to health status and coping strategy. We identified several predominant coping strategies in response to daily-life and health stressors in 261 patients with RA, 226 with AS, and 206 with gout. Evasive and reappraisal strategies were predominant when patients cope with health stressors; emotional/negative and evasive strategies predominated when coping with daily-life stressors. There was a significant association between the evasive pattern and the low short-form health survey (SF-36) scores and health stressors across the 3 diseases. Besides some differences between diagnoses, the most important finding was the predominance of the evasive strategy and its association with low SF-36 score and high level of pain in patients with gout. Patients with rheumatic diseases cope in different ways when confronted with health and daily-life stressors. The strategy of coping differs across diagnoses; emotional/negative and evasive strategies are associated with poor health-related quality of life. The identification of the coping strategies could result in the design of psychosocial interventions to improve self-management.

Fear-avoidance beliefs about physical activity in adults with rheumatoid arthritis

Objectives

The aim of this study was to describe fear-avoidance beliefs about physical activity and explore how these beliefs correlate with sociodemographic, disease-specific, and psychosocial factors in adults with rheumatoid arthritis (RA).

Method

This cross-sectional study is part of the Physical Activity in Rheumatoid Arthritis (PARA) 2010 study. The study participants (n = 2351) were identified through the Swedish Rheumatology Quality (SRQ) registries from six rheumatology clinics in Sweden. Univariate and backwards stepwise logistic regressions were performed.

Results

Stepwise logistic regressions showed that male gender [odds ratio (OR) 1.55, 95% confidence interval (CI) 1.26–1.91] and having a below average income (OR 1.35, 95% CI 1.12–1.63) were associated with an increased risk of high scores on the modified Fear Avoidance-Belief Questionnaire (mFABQ). The two disease-specific factors most indicative of high mFABQ scores were high level of pain (OR 1.99, 95% CI 1.40–2.84) and poor health (OR 1.59, 95% CI 1.10–2.29). With regard to psychosocial factors, low health-related quality of life (HRQoL; OR 0.44, 95% CI 0.35–0.55) and a low score on the Exercise Self-Efficacy Scale (ESES; OR 0.66, 95% CI 0.52–0.82) were significantly associated with a high mFABQ score. The model fit was 0.27 (Nagelkerke's R²).

Conclusions

High fear-avoidance beliefs about physical activity in patients with RA were found to be associated with being male and having a below average income, a high level of pain, poor health, a low HRQoL, and low ESES score. Additional research is warranted for adults with RA to capture the multiple potential correlates to fear-avoidance beliefs about physical activity.

The relative importance of psychosocial factors in arthritis: findings from 10,509 Australian women

OBJECTIVE

To determine the relative importance of psychosocial factors in arthritis diagnosis in an ageing cohort of Australian women.

METHODS

This study focused on 10,509 women from the 1946-1951 cohort who responded to questions on arthritis in the fifth mailed population-based survey of the Australian Longitudinal Study on Women's Health conducted in 2007.

RESULTS

Arthritis was characterised by widespread psychosocial concerns, particularly relating to chronic stress and poor mental health. Univariate analyses revealed that in comparison to women without stress, women with moderate/high stress levels had a 2.5-fold increase in reporting arthritis. Experiencing ongoing negative interpersonal life events concerning illness of a family member/close friend and relationship difficulties was also associated with a 1.4-fold increase in the reporting of arthritis. Likewise, significantly reduced levels of optimism and perceived social support were noted (all associations p<.001). Psychiatric diagnosis was also associated with a two-fold increase in having arthritis (p<.001). Following adjustment for behavioural, demographic and health-related characteristics, anxiety was the only psychosocial factor associated with arthritis (OR=1.4, 95% CI=1.2, 1.7; p<.001).

CONCLUSION

This study examined, epidemiologically, the relative importance of psychosocial factors in arthritis in an ageing cohort of Australian women. The findings from this population-based study indicate that women with arthritis are more likely to report a range of psychosocial-related problems, particularly with regard to chronic stress perception and anxiety. Longitudinal analyses are required to examine the processes by which stress and psychosocial factors may contribute to arthritis risk and poor adaptation in terms of health-related quality of life.

Work ability of Dutch employees with rheumatoid arthritis

OBJECTIVES

To (i) examine the association between fatigue, psychosocial work characteristics (job control, support, participation in decision making, psychological job demands), and physical work requirements on the one hand and work ability of employees with rheumatoid arthritis (RA) on the other, and (ii) determine the advice that health care professionals give to employees with RA on how to maintain their work ability.

METHODS

Data were gathered from 78 employees with early RA (response = 99%) by telephone interviews and self-report questionnaires.

RESULTS

Fatigue, lack of autonomy, low coworker/supervisor support, low participation in decision making, and high physical work requirements (i.e. using manual force) predicted low work ability. High psychological job demands, however, did not predict low work ability. The rheumatologist, occupational physician, occupational therapist, physiotherapist, and psychologist gave advice on how to cope with RA at work to 36, 30, 27, 26, and 17% of the employees, respectively. Advice was directed mainly at factors intrinsic to the employee. Employees expressed a positive attitude towards this advice.

CONCLUSIONS

Fatigue, lack of support, lack of autonomy, lack of participation in decision making, and using manual force at work (e.g. pushing and pulling) threaten the work ability of employees with RA. According to the employees with RA, involvement of health care professionals from different disciplines and the implementation of organizational and technical interventions would help them to tackle these threats.

A two‐year follow‐up of work capacity in early rheumatoid arthritis: a study of multidisciplinary team care with emphasis on vocational support

OBJECTIVE

To explore changes in sick leave patterns and work ability in patients with early rheumatoid arthritis (RA). The patients received active team support focusing on vocational rehabilitation, in addition to treatment with disease-modifying anti-rheumatic drugs (DMARDs).

METHODS

This is an observational study of 110 patients with early RA aged 18-60 years and not permanently disabled. All patients were monitored regularly during a 2-year period by a team comprising a nurse, an occupational therapist, a physiotherapist, a rheumatologist, and a social worker. Intervention included work-site visits and rehabilitation meetings with the employer and the official from the local social insurance office in addition to DMARD treatment and different individual treatments, and support from the team members.

RESULTS

The number of patients working full-time increased from 65 to 74 (14%), those with full-time work disability decreased from 37 to 13 (65%), and patients working part-time increased from 8 to 23 (65%). This change was already evident during the first year.

CONCLUSION

Active vocational support in addition to DMARD treatment may prevent or delay work disability in patients with early RA.

“Nothing is Wrong, Doctor”: Understanding and Managing Denial in Patients with Cancer

From a psychological perspective, denial is the process by which the mind defends itself against painful or threatening thoughts, feelings, perceptions, or information and may manifest in healthy or sick persons as well as in patients or those who care for them. For someone with a possible cancer diagnosis, there are several individual steps involved in the denial process, as the threatened meaning of one or more symptoms is sculpted into a more acceptable reality. Although most often felt to be a dysfunctional response, denial of illness is widespread and may serve an important adaptive or coping function, especially in a person facing the challenge of cancer. It may help a person cope with the various stages of their illness and treatment by allowing them time to process distressing information at a manageable rate. However, denial may also be dysfunctional, especially if it causes delay in seeking treatment for symptoms that present in the context of a true malignancy. Many clinicians misdiagnose denial when avoidance, disavowal, or another coping mechanism is invoked or when cognitive impairment or sensory deficits adversely affect perception. This article discusses denial in the context of cancer diagnosis, treatment, and prognosis and strategies for managing this common condition.

'It's quite hard to grasp the enormity of it': perceived needs of people upon diagnosis of rheumatoid arthritis

OBJECTIVES

The diagnosis of rheumatoid arthritis (RA) brings rapid pharmacological and multidisciplinary team interventions to address inflammatory processes and symptom management. However, people may also need support on the journey to self-management. The aim of this study was to explore what professional support patients feel they receive upon diagnosis, and what support they feel would be most helpful.

METHODS

Two focus groups comprised patients with at least five years'; disease duration (n = 7), and patients more recently diagnosed (5-18 months, n = 5). The latter had attended at least two appointments in a rheumatology nurse specialist clinic during the previous year, aimed at providing support upon diagnosis. Transcripts were subjected to thematic analysis to identify common issues regarding support needs, which were then grouped into themes. Interviewing and analysis was performed by researchers not involved in clinical care.

RESULTS

Four overarching themes emerged. 'Information' was needed about the symptoms of RA, its management and personal outcome, while 'Support' related to emotional needs ('It's quite hard to grasp the enormity of it'). Information and Support overlapped, in that patients wanted someone to talk to, and to be listened to. These two themes were underpinned by issues of service delivery: 'Choice' (patient or professional to talk to, groups, one-to-one) and 'Involvement' (holistic care, partnership), which overlapped in terms of the opportunity to decide when and which interventions to access.

CONCLUSIONS

People with RA report not only informational, but also emotional support needs at diagnosis. The potential for delivering emotional support to patients around the time of diagnosis warrants further exploration.

Psychological well-being across 1 year with rheumatoid arthritis: coping resources as buffers of perceived stress

OBJECTIVES

Using the transactional model of stress and coping, the present study investigated whether specific coping resources act as buffers of the relationship between perceived stress and psychological well-being among rheumatoid arthritis (RA) patients.

DESIGN

A longitudinal observational study was carried out with assessments at baseline, 6 months and 1 year.

METHODS

Measures of perceived stress, coping resources (optimism/pessimism, social support and explicit active coping strategies) and psychological well-being (anxiety, depression and life satisfaction) were completed by 134 RA patients. Demographics, RA duration, pain, fatigue, functional disability, antidepressant use and physical comorbidities were recorded and statistically controlled for.

RESULTS

Perceived stress had the strongest relationship with psychological well-being at baseline, and affected anxiety after 6 months. Optimism and pessimism predicted psychological well-being across 1 year. Active behavioural coping buffered an association of stress with depression at baseline, while baseline active cognitive coping buffered the effect of baseline stress on life satisfaction after 6 months.

CONCLUSIONS

Patients with RA under greater perceived stress who do not use active coping strategies appear to be at risk of psychological comorbidity and may therefore benefit from interventions teaching specific active coping strategies. Larger observational studies and interventions are required to confirm and extend these findings.

Sleep disruption frequency in rheumatoid arthritis: perceived stress predicts poor outcome over one year

BACKGROUND

Sleep is an important daily process that can be disrupted by chronic illnesses including rheumatoid arthritis (RA).

AIMS

We tested whether demographic, medical and psychological factors act as predictors of change in frequency of sleep disruption associated with RA.

METHODS

A cohort of 129 White British people with RA (mean duration of RA 7.19 years; mean age 55.40 years; 75% women) was followed for one year. Self-report questionnaires were employed to record demographic information and assess participants' sleep disruption (on a 4-point frequency scale), morning stiffness (duration), pain and fatigue (visual analogue scales), impact of disability, anxiety, depression, stress, coping, illness perceptions and self-efficacy. Hospital notes were reviewed for duration of RA, antidepressant use and comorbidity.

RESULTS

Participants were split into those with sleep disruption that was consistently infrequent or decreasing in frequency (n = 56; 43%) and those with sleep disruption that was consistently frequent or increasing in frequency (n = 73; 57%). Results of a logistic regression demonstrated that greater perceived stress at baseline predicted sleep disruption that was consistently frequent or increasing in frequency over the year. Change in sleep disruption frequency was not predicted by any other assessed variable. Perceived stress at the end of the year was not predicted by change in frequency of sleep disruption.

CONCLUSIONS

Self-reported frequency of sleep disruption among people with RA relates to perceived stress. Psychoeducational programmes that help people with RA manage their stress may be a non-pharmacological method of improving sleep quality and therefore merits testing in specific interventional studies.

Work disability in rheumatoid arthritis is predicted by physical and psychological health status: a 7-year study from the Oslo RA register

OBJECTIVE

To explore the prevalence of work disability (WD) and to identify bio-psychological factors that predicts future WD in rheumatoid arthritis (RA) over a 7-year period.

METHODS

Patients were selected from the Oslo RA register. The prevalence of WD was studied cross-sectionally among respondents <67 years (n = 526) in a postal survey. Mean age (SD) was 51.1 (11.9) years, mean disease duration 11.3 (9.4) years, and 49% of patients were RF-positive. The patients studied for predictive factors for WD were respondents in postal surveys both at baseline and at the 7-year follow-up, in work at baseline and still in working age (<67 years) at follow-up (n = 159). Mean age at baseline (SD) was 44.5 (9.7) years, mean disease duration 8.4 (6.6) years, mean years of formal education 12.7 (3.1) years, 48% were RF-positive. Assessments included socio-demographic variables and health status measures (MHAQ, AIMS2, SF-36, fatigue and pain on VAS 0-100 mm, self efficacy, and RAI as a measure for helplessness).

RESULTS

Among the 526 respondents at baseline <67 years, the prevalence of WD was 40%. A high level of education was a predictor of reduced risk of work disability [odds ratio (OR) = 0.4, 95% confidence interval (CI) 0.1; 0.9], while female gender (OR 3.0, 95% CI 1.1; 8.0), physical disability (MHAQ-score) (OR = 3.9, 95% CI 1.2; 12.5) and helplessness over median RAI-score (OR = 3.0, 95% CI 1.4; 6.7) were independent predictors of increased risk for new work disability over 7 years.

CONCLUSION

Physical disability, increased helplessness, low formal education, and female gender were found to be independent risk factors for new work disability over the 7-year study period.

Well-being in rheumatoid arthritis: the effects of disease duration and psychosocial factors

This study examined the multivariate relationships of psychosocial factors with well-being in rheumatoid arthritis (RA). Fifty-five patients with early RA (<six months), 52 with intermediate RA (one-seven years) and 47 with established RA (>seven years) completed questionnaires on psychosocial factors and psychological and physical well-being. Illness perceptions related to worse depression and life satisfaction (especially in early RA) and to longer morning stiffness (especially in intermediate RA). Optimism related to lower pain in early and intermediate RA. Social support related to lower fatigue in established RA. Indications for interventions targeted by disease duration are discussed.