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

'Gout was like the boss'. A qualitative study exploring the impact of gout on employment

OBJECTIVE

Previous research has identified that gout impacts various domains of daily life. However, there have been no qualitative studies focusing on employment. This study aimed to understand the impact of gout on employment.

METHODS

Semistructured interviews were conducted in Spain and Aotearoa/New Zealand, in people with gout (according to the 2015 American College of Rheumatology/European Alliance of Associations for Rheumatology criteria) who had experienced a gout flare during their employment. The interviews were guided by questions exploring the impact on employment, job changes, disclosure and co-workers' reactions. Data were analysed thematically.

RESULTS

Eighteen participants were interviewed (89% male, mean age 52.9 years). Six themes were identified. The characteristics of the disease (pain intensity, tophi and joints affected) and the job itself (including physical job requirement and workplace flexibility) determined the experience of working with gout. The experiences were divided into physical (from total incapacity to working despite pain), emotional (feeling responsible, embarrassment, guilt and depression) and social (including disclosure responses and financial impact). Gout management strategies including rapid gout flare management and urate-lowering therapy reduced the number of flares and the intensity of pain, and allowed work attendance and participation.

CONCLUSION

Both gout and work characteristics influence the employment experience for people with gout. Effective management of gout led to improved work experiences in all its domains.

A multidisciplinary-led early arthritis service to manage client-identified participation restrictions in early inflammatory arthritis: A qualitative study of service user and staff perspectives

BACKGROUND

The impact of inflammatory arthritis (IA) on occupational performance and on participation in meaningful life roles is recognised. However, limited research has explored how clinical services support broader life impact and participation restrictions associated with early disease as part of routine healthcare. This exploratory study was undertaken to describe how a novel multidisciplinary-led early arthritis service approach addresses client-identified participation restrictions in early IA.

METHODS

Qualitative Description (QD) approaches were used to explore perspectives of staff and clients of these multidisciplinary-led early arthritis services in Ireland. Data were gathered using focus groups with staff, and individual semi-structured interviews with clients. Transcripts were analysed using thematic analysis.

RESULTS

Fifteen staff working in these services participated in the focus groups and 43 clients with IA participated in interviews (female n = 31); diagnosis duration ranged from 5 to 24 months. Participants described how the multidisciplinary-led service had a clear remit to address participation alongside traditional symptom management and provided automatic, immediate access to interventions focussed on identification and management of participation restrictions experienced in early disease. The service model utilised a delivery approach that allowed for ease of early access to a full multidisciplinary team and prolonged support. The most significant feature of the service approach was 'the centrality of the client' which influenced a person-centred approach to identification of needs and priorities for interventions.

CONCLUSION

Findings indicate the role and value of this innovative multidisciplinary approach in addressing client-identified participation restrictions in routine clinical practice that is positively regarded by clients and staff.

"My role as a parent, to me, it has narrowed" the impact of early inflammatory arthritis on parenting roles: a qualitative study

PURPOSE

To explore the impact of early inflammatory arthritis on participation in parenting roles.

MATERIALS AND METHODS

Twenty-four individuals (20 female) aged between 32 and 62 years with early inflammatory arthritis (<2 years duration) and who were parents of dependent children (≤21 years) were interviewed. A qualitative description study design was used, and thematic analysis methodologies were employed in the data analysis.

RESULTS

Parenting roles were significantly impacted in early disease and extensive parenting restrictions were identified regardless of age and gender. Physical symptoms hampered "everyday mammy activities." Parent-child interactions were altered by the emotional impact of early arthritis including low mood and irritability. Participants emphasised remorse at the negative impact of their arthritis on their children's childhood. Parent-role identity and parents' perception of how they were viewed by their children were negatively impacted by early disease with considerable self-imposed pressure to shield children from the consequences of arthritis. A forced "role switch" requiring relinquishing of some parenting tasks was identified as an unwanted burden associated with inflammatory arthritis.

CONCLUSION

Inflammatory arthritis has a negative impact on parenting which is present from disease onset. Understanding factors which influence parenting with arthritis is important to identify appropriate healthcare interventions.Implications for rehabilitationAn early diagnosis of inflammatory arthritis is synonymous with considerable challenges in performing parenting tasks and activities which are present despite early medical management and drug therapy.Physical and psychosocial sequelae of early inflammatory arthritis result in restrictions in the execution of parenting activities and are accompanied by a forced "role switch".The disease impact on parenting differs in early and established inflammatory arthritis and requires distinct healthcare approaches and interventions to adequately address the needs.Parent role identity and perceived lack of control are intrinsically linked to the degree of perceived negative impact on parenting and these factors should be considered in the design and evaluation of appropriate healthcare interventions for this population.

'You don't want to be seen as a burden' experiences of working with early inflammatory arthritis: a qualitative study

PURPOSE

To describe the impact of early inflammatory arthritis on work participation.

MATERIALS AND METHODS

Thirty individuals (24 women) of working age (age 18-69 years) with inflammatory arthritis (<2 years duration) who were in paid employment or fulltime education were interviewed using qualitative description methodology. Data was analysed using thematic analysis.

RESULTS

Half of participants (n = 15) reported work disability within the first two-years of diagnosis. Five descriptive themes were identified that explained the early impact of IA on participation in paid employment. These themes were: (i) altered capacity for work; (ii) work comes first; (iii) the invisible burden; (iv) the disclosure effect; and (v) a reconstructed work future.

CONCLUSION

The scale of early work disability appears to be higher than previously understood. Although early medical intervention has improved disease management, significant work-based restrictions requiring intervention remain. Internalised and invisible work-related anxieties present early in the disease and need to be acknowledged and addressed by healthcare providers.IMPLICATIONS FOR REHABILITATIONEarly inflammatory arthritis causes significant challenges in work ability, and early work-based participation restrictions are present despite early use of drug therapy.Assessment of the client's subjective experience, including understanding the invisible burden, is an important aspect in determining the types of work interventions required.Disclosure of diagnosis in the work environment is associated with anxiety and fear, however, disclosure is influential in supporting capacity to retain work participation and should be included in work interventions.Routine healthcare should include early interventions to address work-based restrictions and supporting work retention to avoid work disability.

Development of Resilience Among Rheumatoid Arthritis Patients: A Qualitative Study

OBJECTIVE

Resilience, the ability to recover from and adapt successfully to stressful situations, is a valuable resource for patients who live with chronic conditions. This qualitative study examines the development of resilience among rheumatoid arthritis (RA) patients. We aimed to describe the resilience development process and to describe strategies used by patients to cultivate resilience.

METHODS

Our approach combined ethnographic data collection and narrative analysis methods. Semistructured interviews were conducted with adult RA patients in the US. Interviewees were asked to discuss their experiences with diagnosis, living with RA, coping with challenges, treatment, and health care providers. The interviews were audiorecorded, transcribed, and analyzed to describe the stages of resilience development and to identify patients' strategies for building/maintaining resilience.

RESULTS

Eighteen patients were interviewed, ages 27-80 years and with RA duration of 5-41 years. Patient responses to challenging situations were grouped into 3 stages: 1) lacking capacity to handle the situation, 2) struggling but growing in capacity to handle the situation, and 3) attaining mastery. Patients used 10 strategies to cultivate resilience: perseverance, exchanging social support, pursuing valued activities, flexibility, positive reframing, acceptance, humor, avoiding threatening thoughts, equanimity, and maintaining a sense of control.

CONCLUSION

RA patients acquire resilience in a dynamic process of learning in response to new challenges. Patients use a combination of behavioral and emotion management strategies to cultivate resilience. Awareness of these strategies may benefit patients, health care providers, and researchers developing behavioral interventions and social support programs in the context of RA and other chronic diseases.

The experience of living with rheumatoid arthritis: A qualitative metasynthesis

AIMS AND OBJECTIVES

To develop a model of understanding of how rheumatoid arthritis (RA) affects daily life based on a third-order interpretation of qualitative findings.

BACKGROUND

Rheumatoid arthritis is a chronic condition subject to a progressive deterioration of joints, limiting the ability to move and causing severe impairment in patients' lives.

DESIGN

A qualitative metasynthesis.

METHODS

CINHAL, ProQuest, PsycINFO, PubMed, SCOPUS and Web of Science databases were searched for relevant studies applying appropriate criteria. Screening and selection of studies were performed following the PRISMA guidelines and the PRISMA checklist was completed. Thirty-eight qualitative articles were retrieved: in total, 17 were excluded for failing to meet inclusion criteria, and 21 were considered for synthesis. Data analysis followed a third-order interpretation of data for synthesising qualitative research.

RESULTS

Findings led to the creation of a model consisting of two overarching categories: "rheumatoid arthritis impact on life domains" and "Confronting the illness," and two cross-sectional codes: "Health" and "Independence and normality."

CONCLUSION

This meta-study provides a model that is both inclusive of participants' own viewpoint and solidly grounded in a health psychology model.

RELEVANCE TO CLINICAL PRACTICE

The model can be highly informative for both practitioners and researchers in developing tailored interventions of support and prevention.

"I Would be More of a Liability than an Asset": Navigating the Workplace as a Younger Person with Arthritis

Purpose Over half the population in Australia with arthritis and other musculoskeletal conditions is aged 25-64 years. This reflects the peak income-earning years for most, yet little research has examined the influence of arthritis on work issues specific to younger people. The aim of this research was to examine the work-related experiences of younger people (defined as those aged 18-50 years). Methods A qualitative exploratory design was used. Participants with inflammatory arthritis or osteoarthritis were recruited from the community, including urban and rural settings. An interview guide was based on the World Health Organization's International Classification of Functioning, Disability and Health. Deductive and inductive coding techniques were used to identify emerging work-related themes from the data. Results Semi-structured interviews were conducted with 21 younger people (90% female) with a mix of arthritis conditions, vocational backgrounds and career stages. Three themes were identified: (1) the perceived impacts of arthritis on career trajectories, (2) the impacts of arthritis on participants' workplace environment, employers, and colleagues, and (3) the personal toll of working with arthritis. The personal toll of working with arthritis relates to the arthritis-attributable impacts of physical and psychological symptoms on productivity and presenteeism in the workplace. Conclusion Younger people with arthritis experience numerous challenges at key stages of their careers, from career planning through to productive working. This can be used to inform workplace accommodations for people with arthritis and increase awareness of likely barriers to work productivity among colleagues, employers and clinicians.

Occupational balance and its association with life satisfaction in men and women with rheumatoid arthritis

INTRODUCTION

Despite improved treatments and reduced disability, people with rheumatoid arthritis (RA) experience difficulties in daily life, which may negatively affect their balance of everyday life activities (occupational balance). The aim of this study was to describe occupational balance and its association with self-rated life satisfaction in men and women with RA.

METHODS

A survey, including demographic and health-related questions, was sent to 1,277 people who met the following criteria: with RA >4 years, aged 18-80 years, included in the Swedish Rheumatology Quality Register (SRQ), and had at least one registered visit to the participating rheumatology units in the year before inclusion. The 682 who answered all items in the Occupational Balance Questionnaire (OBQ) were included in the study. Their answers were analysed with descriptive statistics, and logistic regression analyses were conducted on men and women separately.

RESULTS

Significantly higher occupational balance was identified in those participants who were >65 years, had no children at home, had a lower disease activity score, were not continuously stressed and reported low pain intensity. The results of the logistic regression analyses of both genders showed that higher occupational balance was significantly associated with a higher probability for rating themselves as being satisfied with life as a whole.

CONCLUSION

Occupational balance was identified as related to satisfaction with life as a whole, which is valuable information for health professionals. Enhanced occupational balance may be achieved in people with RA by working towards reducing their stress and pain.

"Mastering a New Life Situation" - Patients' Preferences of Treatment Outcomes in Early Rheumatoid Arthritis - A Longitudinal Qualitative Study

PURPOSE

To explore patients' preferred treatment outcomes during their first two years with rheumatoid arthritis (RA).

PATIENTS AND METHODS

A qualitative, longitudinal, multicenter study with interviews at two time points was performed in Sweden. Individual interviews were conducted at time point 1 with 31 patients with RA, defined as disease duration of ≤1 year and treatment for 3-7 months. Seven focus group interviews and five individual interviews were conducted at time point 2 with 22 patients 12-20 months after treatment initiation. The interviews were analyzed using the Qualitative Analysis Guide of Leuven. A core category with four related concepts emerged.

RESULTS

The core finding of patient-preferred treatment outcomes was "mastering a new life situation". Patients preferred to experience control of the disease by controlling the symptoms and by experiencing absence of disease. To experience autonomy by regaining former activity level, experiencing independence, and being empowered was another preferred outcome. Patients preferred to regain identity through being able to participate, experience well-being, and regain former self-image. To experience joy in everyday life through vitality and believing in the future was another preferred outcome. Patients' preferences developed over time from the acute phase of controlling the symptoms and wanting to return to the life they lived prior to diagnosis, to a more preventive way of self-management and empowerment to master the new life situation.

CONCLUSION

The patients' preferred treatment outcomes during the first two years with RA were to master their new life situation and changed from a preference to return to a life lived prior disease onset, to a preference of living with quality of life, despite RA. This study increases the understanding of patients' preferred treatment outcomes in the early disease course and can be a foundation for tailoring interventions to be more person-centered and to improve long-term treatment outcomes.

Re-conceptualizing functional status through experiences of young adults with inflammatory arthritis

The objective of this study is to assess the impact of inflammatory arthritis on young adults' activity participation using quantitative and qualitative methods to advance the field's conceptualization of functional status. Young adults diagnosed with juvenile idiopathic arthritis or rheumatoid arthritis completed (1) the Health Assessment Questionnaire-Disability Index to determine functional status and (2) the day reconstruction method to explore experiential dimensions of function, including functional performance, functional satisfaction, and severity of arthritis symptoms during activities on the previous day. Bivariate analyses were conducted to examine relationships between functional status, experiential variables, and demographic variables. Open-ended questions were provided for participants to report ways that arthritis affected their participation that were not otherwise reflected within survey questions; responses were numerically coded using summative content analysis. Among 37 participants (24.8 ± 3.3 years old), 70% reported moderate-to-severe disability. On average, participants experienced pain, stiffness, or fatigue for more than 50% of their waking hours. Functional status significantly correlated with functional performance (r = - 0.39, p = 0.02) and satisfaction (r = - 0.39, p = 0.02), yet did not correlate with stiffness or fatigue severity or duration of symptoms throughout the day. Participants described strategies that improved their ability to participate in certain activities but reduced their overall quality of activity engagement and caused emotional distress. Young adults with arthritis may experience more significant functional limitations than previously reported. Traditional measures of functional assessment may not capture experiential components of activity that affect participation, such as severity of stiffness or fatigue or the duration of symptoms throughout the day.

A qualitative study investigating the meaning of participation to improve the measurement of this construct

PURPOSE

The purpose of this study was to improve the measurement of participation. Research questions were as follows: (1) What constitutes participation according to adults? (2) Do they mention participation subdomains that are not covered in the Patient-Reported Outcomes Measurement Information System (PROMIS) item bank "Ability to Participate in Social Roles and Activities"?

METHODS

Semi-structured interviews were conducted with 46 adults from the general population. Interviews were thematically analysed using the International Classification of Functioning, Disability and Health (ICF) as conceptual framework. Thereafter, assigned codes were compared to PROMIS item bank.

RESULTS

Participants mentioned a variety of participation subdomains that were meaningful to them, such as socializing and employment. All subdomains could be classified into the ICF. The following subdomains were not covered by the PROMIS item bank: acquisition of necessities, education life, economic life, community life, and religion and spirituality. Also a distinction between remunerative (i.e. paid) and non-remunerative (i.e. unpaid) employment, and domestic life was missing. Several ICF sub-codes were not mentioned, such as ceremonies.

CONCLUSIONS

Many participation subdomains were mentioned to be meaningful. As several of these subdomains are not covered in the PROMIS item bank, it may benefit from extension with new (patient-)reported subdomains of participation.

Time to update the ICF by including socioemotional qualities of participation? The development of a "patient ladder of participation" based on interview data of people with early rheumatoid arthritis (the Swedish TIRA study)

Purpose: The aim of was to identify and illustrate in what situations and with what qualities people with early RA experience participation in every day's life.Methods: Fifty-nine patients (age 18-63 years) were interviewed; 25 men and 34 women. Content analysis was used to identify meaning units that were sorted based on the type of situations described and later on, categories based on quality aspects of participation were developed.Results: Participation was described as: 1. being part of a group, where a sense of belonging arose. 2. In doing activities with others for example at work or in leisure. 3. When sharing everyday chores and responsibilities for example in domestic duties. 4. When experiencing influence on actions such as when being asked for opinions on how to conduct a specific task. 5. When having the possibility to give direction of goals in rehabilitation, or elsewhere. 6. When sharing decision making and experiencing a high degree of influence in the situation.Conclusions: Participation from an individual's perspective is about belonging and having influence that mediates a positive feeling of being included and that you matter as a person. The results are important when using participation as a goal in clinical care. It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Implications for rehabilitationFacilitation of participation in daily activities is an important part of rehabilitation.Participation is expressed as determined by a person's unique life circumstances often in engagement with others.It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Collected information about socioemotional participation can serve as a starting point for interventions aimed at the patient's social environment and also provide support for health professions how to involve significant others in the rehabilitation.

Foot Barriers in Patients With Early Rheumatoid Arthritis: An Interview Study Among Swedish Women and Men

OBJECTIVE

Foot impairments are related to reduced mobility and participation restrictions in daily activities in patients with established rheumatoid arthritis (RA). The new biologic medications are effective and reduce disease activity, but not disability to the same extent. Foot impairments are assumed to be related to participation restrictions also in patients with early RA, diagnosed after the introduction of biologic medications. Knowledge of foot impairments needs to be explored further after the introduction of biologic disease-modifying antirheumatic drugs (bDMARDs). The aim of this study was to explore the patients' perspective of foot impairments related to early RA.

METHODS

The sample included 59 patients (ages 20-63 years) who were interviewed about participation dilemmas in daily life using the critical incident technique. The interviews were audio-recorded and transcribed. Data related to foot impairments were extracted and analyzed thematically. A research partner validated the analysis.

RESULTS

Patients with early RA described a variety of participation restrictions related to foot impairments: foot hindrances in domestic life, foot impairments influencing work, leisure activities restricted by one's feet, struggling to be mobile, and foot impairments as an early sign of rheumatic disease.

CONCLUSION

There is a need to focus on foot impairments related to early RA, and for health care professionals to understand these signs. A suggestion for future research is to conduct a longitudinal followup of foot impairment related to medication, disease activity, and disability in patients diagnosed after the introduction of bDMARDs.

Swimming Against the Current: A Qualitative Review of the Work Experiences and Adaptations Made by Employees With Arthritis

OBJECTIVE

To describe the experiences and strategies of employees with arthritis to maintain employment, and to use this information to build a conceptual model.

METHODS

We conducted a systematic review of qualitative studies that examined the work experiences of employees with arthritis. Published studies on arthritis and employment were searched from electronic databases (1980-2017) and bibliographic reviews of relevant studies. We used meta-ethnography to synthesize the findings.

RESULTS

We reviewed 17 studies that reported on the experiences of 873 employees. We identified 11 main themes that highlight common issues experienced by employees with arthritis and grouped these into 4 higher-order categories: changing nature of the disease (emotional issues, cognitive struggles, unpredictable physical symptoms), intrapersonal issues (personal meaning of work, preserving a work identity), interpersonal issues (managing disclosure, gaining coworker support, organizational culture issues), and work-sustainability strategies (making personal adjustments, using social support, using workplace accommodations). Using these themes, we developed the Job Sustainability Model to illustrate how disease, personal, and work-related factors interact to influence what type of coping behaviors are used and when. Initially, employees with arthritis rely on making personal adjustments, using social support, and medical intervention. However, when these coping behaviors fail to be effective, they draw upon workplace accommodations and resources.

CONCLUSION

Arthritis disrupts an employee's work life by impairing his or her capacity to be a productive worker. Our results highlight how employees with arthritis make strategic adaptations to maintain a productive work life for as long as possible. The findings of this study have implications for work-related interventions aimed at preserving employment.

The Use of Avoidance, Adjustment, Interaction and Acceptance Strategies to Handle Participation Restrictions Among Swedish Men with Early Rheumatoid Arthritis

OBJECTIVES

Living with a chronic disease means learning to live under new circumstances and involves a continuous adaptation to new ways of living. There is increasing knowledge about how people cope with stressful life events and adapt to new life situations. Approximately a third of patients diagnosed with rheumatoid arthritis (RA) are men; however, few studies have described the needs and experiences of men living with RA. The aim of the present study was to explore men's strategies for handling challenges related to participation in everyday life.

METHODS

The present study was associated with the prospective Swedish multicentre early arthritis project (given the Swedish acronym TIRA), which, in 2006-2009, included patients with early RA, contemporarily treated, with a mean disease duration of three years. From this cohort, 25 men, aged 20-63 years, were recruited consecutively. Data were collected in individual interviews, using the critical incident technique. The strategies for dealing with the challenges of RA in everyday life were analysed and categorized using content analysis.

RESULTS

Men with RA described four types of strategy for dealing with participation restrictions in everyday life: (i) Adjustment strategies - adjust behaviour, movements, medication, equipment and clothing to find new ways to conduct tasks or activities; (ii) Avoidance strategies - avoid activities, movements, social contacts and sometimes medication; (iii) Interaction strategies - say no, ask for help and work together to handle participation restrictions; and (iv) Acceptance strategies - learn to accept RA, with the pain, the slower work pace and the extended time needed.

CONCLUSIONS

According to men's lived experiences, a combination of strategies was used to deal with RA, depending on the situation and the experienced restriction. The results provided an understanding of how men with RA manage their disease, to reduce physical, social and emotional challenges. This knowledge may be used further to develop multi-professional interventions and patient education tailored to men with RA.

The Workplace Experiences of Women with Fibromyalgia

PURPOSE

Fibromyalgia (FM) is a common pain syndrome that mostly affects women. Chronic pain and other symptoms often chalenge work for women with FM. This study aimed to explore how women with FM experience their work situations.

METHOD

A purposive sample of 15 women with FM was interviewed with in-depth qualitative interviews. Data were analysed using a hermeneutic approach.

RESULTS

The results revealed that women with FM experienced incapacity to work as they had previously and eventually accepted that their work life had changed or reached its end. Since their work had great significance in their lives, feelings of loss and sorrow were common. Women who were working, unemployed, or on sick leave described feelings of fear for their future work situations.

CONCLUSIONS

Women with FM greatly value their work. Their wish to perform work as before is however, not consistent with their abilities. As such, women with FM need support in continuing to work for as long as possible, after which they need support in finding new values in life.

Simplified bipartite concepts of functioning and disability recommended for interdisciplinary use of the ICF

PURPOSE

To argue for and propose bipartite concepts of functioning and disability, to tally with the structure of the ICF classification list, concepts of social models and clinical needs.

METHOD

The ICF concepts are discussed in relation to the history of ideas regarding disability concepts and the needs for such concepts in interdisciplinary rehabilitation.

RESULTS

Bipartite concepts are presented; they refer to actual functioning, simply body functions/structures and participation, including functioning in standardized environments. Participation refers to actually performed "activities", with "activities" simply denoting things that people may do. Bipartite concepts are congruent with the ICF classification and the structure of social models of disability, suitable for clinical and interdisciplinary use and easy to understand. The issue of standardized environments represents a methodological issue rather than the conceptual issue of defining functioning and disability. An individual perspective on activity and activity limitations, i.e. the middle part of the tripartite ICF concept, is somewhat similar to concepts of traditional language that were regarded as too generalizing already in 1912, when the interactional concept of "disability in a social sense" was introduced in rehabilitation practices.

CONCLUSION

Bipartite concepts of functioning and disability are recommended for interdisciplinary use of the ICF.

IMPLICATIONS FOR REHABILITATION

The ICF classification is useful, but the ICF concept of activities in an individual perspective is confusing. We suggest a use of the term "activities" simply to denote things that people may do and "participation" to denote actually performed activities. Estimations of ability should be explicit about how they are related to environmental factors.

Dilemmas of participation in everyday life in early rheumatoid arthritis: a qualitative interview study (The Swedish TIRA Project)

PURPOSE

To explore the experiences of today's patients with early rheumatoid arthritis (RA) with respect to dilemmas of everyday life, especially regarding patterns of participation restrictions in valued life activities.

METHODS

A total of 48 patients, aged 20-63, three years post-RA diagnosis were interviewed using the Critical Incident Technique. Transcribed interviews were condensed into meaningful units describing actions/situations. These descriptions were linked to ICF participation codes according to the International Classification of Functioning, Disability and Health (ICF) linking rules.

RESULTS

Dilemmas in everyday life were experienced in domestic life, interpersonal interactions and relationships, community, social and civic life. Most dilemmas were experienced in domestic life, including participation restrictions in, e.g. gardening, repairing houses, shovelling snow, watering pot plants, sewing or walking the dog. Also many dilemmas were experienced related to recreation and leisure within the domain community, social and civic life. The different dilemmas were often related to each other. For instance, dilemmas related to community life were combined with dilemmas within mobility, such as lifting and carrying objects.

CONCLUSIONS

Participation restrictions in today's RA patients are complex. Our results underline that the health care needs to be aware of the patients' own preferences and goals to support the early multi-professional interventions in clinical practice. Implications of Rehabilitation Today's rheumatoid arthritis (RA) patients experience participation restrictions in activities not included in International Classification of Functioning, Disability and Health (ICF) core set for RA or in traditionally questionnaires with predefined activities. The health care need to be aware of the patients' own preferences and goals to meet the individual needs and optimize the rehabilitation in early RA in clinical practice.

Emotions related to participation restrictions as experienced by patients with early rheumatoid arthritis: a qualitative interview study (the Swedish TIRA project)

Psychological distress is a well-known complication in rheumatoid arthritis (RA), but knowledge regarding emotions and their relationship to participation restrictions is scarce. The objective of the study was to explore emotions related to participation restrictions by patients with early RA. In this study, 48 patients with early RA, aged 20-63 years, were interviewed about participation restrictions using the critical incident technique. Information from transcribed interviews was converted into dilemmas and linked to International Classification of Functioning, Disability, and Health (ICF) participation codes. The emotions described were condensed and categorized. Hopelessness and sadness were described when trying to perform daily activities such as getting up in the mornings and getting dressed, or not being able to perform duties at work. Sadness was experienced in relation to not being able to continue leisure activities or care for children. Examples of fear descriptions were found in relation to deteriorating health and fumble fear, which made the individual withdraw from activities as a result of mistrusting the body. Anger and irritation were described in relation to domestic and employed work but also in social relations where the individual felt unable to continue valued activities. Shame or embarrassment was described when participation restrictions became visible in public. Feelings of grief, aggressiveness, fear, and shame are emotions closely related to participation restrictions in everyday life in early RA. Emotions related to disability need to be addressed both in clinical settings in order to optimize rehabilitative multi-professional interventions and in research to achieve further knowledge.