Health Assessment Questionnaire Disability Research Articles

Functional limitations and well-being in injured municipal workers: a longitudinal study.

Two instruments, the Health Assessment Questionnaire (HAQ) and the Short Form-36 (SF-36), were used to document both the immediate and short-term effects of workplace injuries in municipal workers. Telephone interviews were conducted up to 3 months following the injury. One hundred fourteen subjects agreed to participate in the study; 90 workers completed at least one useable interview. The relationship between functional limitation and lost days was evaluated using Cox proportional hazards models. At 3 months following the onset of injury, SF-36 scores for physical function, role-physical, and bodily pain differed significantly from population norms. Using one standard deviation of change, statistically significant hazard ratios were seen in subjects with lower SF-36 physical component summary, physical function, and bodily pain scores, and higher HAQ disability and fatigue scores. Functional limitations persisted in workers after relatively minor workplace injuries despite a 91% return to work rate.

Vaccination does not exacerbate juvenile idiopathic arthritis disease activity in a cohort of Dutch patients

In 2002, all children in the Netherlands from four to 18 years of age, including the Juvenile Idiopathic Arthritis (JIA) population, were vaccinated with the group-C meningococci conjugate vaccine. The aim of this study is to determine whether the vaccine increases JIA disease activity by monitoring the core set criteria of JIA patients as well as investigates the efficacy of this vaccine in those receiving DMARDs. The core set criteria included Childhood Health Assessment Questionnaire (CHAQ) disability, CHAQ pain, CHAQ well being, number of inflamed joints, range of motion, ESR, CRP, and semi-quantitative physicians global assessment. These were monitored for six months prior to as well as after vaccination for any changes in 86 JIA patients. Blood samples were taken from patients to measure antibody production using ELISA as well as T cell proliferation through intracellular fluorescent dye CFSE. In summary, no significant differences (P>0.05) were found when comparing the core set criteria six months before as well as six months after vaccination. However, there were significant increases of CD4+ T cell proliferation both against the carrier protein of the vaccine (P=0.034) as well as the whole vaccine (P=0.035). Furthermore, anti-Men C IgG antibody production increased significantly (>18µg/ml) irrespective of DMARD therapy. In conclusion, our data suggests that the group-C meningococci conjugated vaccine does not increase JIA disease activity. Moreover, B as well as T lymphocyte activity against group-C meningococci are not significantly diminished in patients undergoing immune suppressive treatments.

Infliximab in Refractory Behcet's Disease

Objective: To describe the use of infliximab in a patient with refractory Behcet's disease (BD).Clinical features: The patient, a 39‐year‐old woman, had been suffering from BD for over 15 years. Previous therapy, including cyclophosphamide, methotrexate, interferon alpha‐ 2a and steroids, was not controlling her symptoms of severe cutaneous/oral/genital ulcers, uveitis, iritis, chronic sinusitis, diarrhoea, abdominal cramps and severe joint pain. A trial of infliximab, an anti‐tumour necrosis factor alpha (TNFα) monoclonal antibody, was commenced to control the symptoms.Outcome: A course of IV infliximab at 3 mg/kg was administered at weeks zero, two and six. During this period progress was measured using various indices, including the Health Assessment Questionnaire (HAQ) Disability Index and the Arthritis Impact Measurement Scale (AIMS) Anxiety Score, as well as a personal diary. The patient described almost immediate relief from diarrhoea and abdominal cramps. At the end of the six week treatment period, both the HAQ Disability Index and AIMS Anxiety score had decreased from 2.1 and 4.6 respectively, to zero, and the patient reported relief from joint pain, and healing of oral and genital ulcers. Six weeks after treatment finished the patient suffered a relapse of ulcers, joint pain and abdominal symptoms. Maintenance infliximab was commenced at 3 mg/kg IV every eight weeks.Discussion: This case, and other published reports describing short‐term use of infliximab in BD, suggest that infliximab may be suitable for the treatment of refractory BD. However maintenance therapy may be required to achieve long‐term symptom control in some patients, such as the one described in this report.

Measuring disease activity and functional status in patients with scleroderma and Raynaud's phenomenon.

To document disease activity and functional status in patients with scleroderma (systemic sclerosis [SSc]) and Raynaud's phenomenon (RP) and to determine the sensitivity to change, reliability, ease of use, and validity of various outcome measures in these patients. Patients with SSc and moderate-to-severe RP participating in a multicenter RP treatment trial completed daily diaries documenting the frequency and duration of RP attacks and recorded a daily Raynaud's Condition Score (RCS). Mean scores for the 2-week periods prior to baseline (week 0), end of trial (week 6), and posttrial followup (week 12) were calculated. At weeks 0, 6, and 12, physicians completed 3 global assessment scales and performed clinical assessments of digital ulcers and infarcts; patients completed the Health Assessment Questionnaire (HAQ), the Arthritis Impact Measurement Scales 2 (AIMS2) mood and tension subscales, 5 specific SSc/RP-related visual analog scales (VAS), and 3 other VAS global assessments. We used these measures to document baseline disease activity and to assess their construct validity, sensitivity to change, and reliability in trial data. Two hundred eighty-one patients (248 women, 33 men; mean age 50.4 years [range 18-82 years]) from 14 centers participated. Forty-eight percent had limited cutaneous SSc; 52% had diffuse cutaneous SSc. Fifty-nine patients (21%) had digital ulcers at baseline. Patients had 3.89 +/- 2.33 (mean +/- SD) daily RP attacks (range 0.8-14.6), with a duration of 82.1 +/- 91.6 minutes/attack. RCS for RP activity (possible range 0-10) was 4.30 +/- 1.92. HAQ scores (0-3 scale) indicated substantial disability at baseline (total disability 0.86, pain 1.19), especially among the subscales pertaining to hand function (grip, eating, dressing). AIMS2 mood and tension scores were fairly high, as were many of the VAS scores. Patients with digital ulcers had worse RCS, pain, HAQ disability (overall, grip, eating, and dressing), physician's global assessment, and tension, but no significant difference in the frequency of RP, duration of RP, patient's global assessment, or mood, compared with patients without digital ulcers. VAS scores for digital ulcers as rated by the patients were not consistent with the physician's ratings. Factor analysis of the 18 measures showed strong associations among variables in 4 distinct domains: disease activity, RP measures, digital ulcer measures, and mood/tension. Reliability of the RCS, HAQ pain and disability scales, and AIMS2 mood and tension subscales was high. The RP measures demonstrated good sensitivity to change (effect sizes 0.33-0.76). Our findings demonstrate that the significant activity, disability, pain, and psychological impact of RP and digital ulcers in SSc can be measured by a small set of valid and reliable outcome measures. These outcome measures provide information beyond the quantitative metrics of RP attacks. We propose a core set of measures for use in clinical trials of RP in SSc patients that includes the RCS, patient and physician VAS ratings of RP activity, a digital ulcer/infarct measure, measures of disability and pain (HAQ), and measures of psychological function (AIMS2).

Rehabilitation in Myositis: Preliminary study

Summary A total of 22 patients with myositis attended an exercise-based multidisciplinary inpatient course of three weeks. Twenty of them were on oral glucocorticoid medication, alone or combined (N = 11) with cytotoxic agents. Functional index for myositis (FI), Health Assessment Questionnaire (HAQ), pain visual analogue scale (Pain-VAS) and laboratory parameters for disease activity (ie erythrocyte sedimentation rate and creatine kinase) were assessed before and after the course. Short-term intensive training yielded small but important improvements in the FI (mean change 4.1 points, p < 0.001) in patients with myositis, though the HAQ disability index (mean change 0.1 points) and pain (mean reduction pain score −2.8 mm) were not significantly modified. Neither clinical symptoms nor creatine kinase values were altered, implying no increase in the inflammatory activity of the disease. The results indicate that the inpatient training programme can be safely employed for myositis patients, possibly with beneficial effect on functional ability. A total of 22 patients with myositis attended an exercise-based multidisciplinary inpatient course of three weeks. Twenty of them were on oral glucocorticoid medication, alone or combined (N = 11) with cytotoxic agents. Functional index for myositis (FI), Health Assessment Questionnaire (HAQ), pain visual analogue scale (Pain-VAS) and laboratory parameters for disease activity (ie erythrocyte sedimentation rate and creatine kinase) were assessed before and after the course. Short-term intensive training yielded small but important improvements in the FI (mean change 4.1 points, p < 0.001) in patients with myositis, though the HAQ disability index (mean change 0.1 points) and pain (mean reduction pain score −2.8 mm) were not significantly modified. Neither clinical symptoms nor creatine kinase values were altered, implying no increase in the inflammatory activity of the disease. The results indicate that the inpatient training programme can be safely employed for myositis patients, possibly with beneficial effect on functional ability.

A reappraisal of HAQ disability in rheumatoid arthritis

To investigate the course of self-reported disability in rheumatoid arthritis (RA) using the major self-report measure of functional impairment, the Health Assessment Questionnaire (HAQ). The course of HAQ disability was assessed in 32,525 observations (1,843 patients) in which the HAQ was administered. In addition, a subset of 2,189 visits from 50 patients, followed on average for 17 years, was studied to model the effect of disease duration on the course of HAQ disability in individual patients. Linear and fractional polynomial regression as well as smoothing algorithms were applied to the group of RA patients and then to the individual course of patients. Group linear and nonlinear models of the effect of disease duration on HAQ disability were found to have 3 characteristics: 1) HAQ disability scores are high at disease onset rather than gradually increasing; 2) HAQ disability increases very slowly over time (0.03 units per year); and 3) all such models fit very poorly, explaining only 5% of the variance in HAQ disability scores. However, application of nonlinear models to individual patient courses (as opposed to groups of patients) explains 37% of the HAQ disability score variation. In some patients, the course of HAQ disability was either 1) chaotic (scores change without any pattern) or 2) determinable, but unrelated to time. When covariates were added to the group model, however, the course of HAQ disability became clearer, and 51% of the variance in the disability score could be explained, statistically, by pain, depression, erythrocyte sedimentation rate, and disease duration. Individual RA patients have differing, characterizable courses: 1) nonlinear, 2) chaotic, or 3) non-time determined. The model that self-reported physical disability, as measured by the HAQ, occurs as a function of disease acting over time does not fit the data well and is an inadequate model. This discrepancy may also be the result of the patient's upward reappraisal of functional ability with increasing time. The predominant determinants of HAQ disability in RA are disease activity, pain, and psychosocial factors rather than structural abnormality. Although the HAQ is a useful clinical tool and a central measure of disease outcome, it measures both process and outcome, and usually more process than outcome. Individual patient models that include all that is known about the patient--the paradigm of clinical care-may be a more effective way to examine the course of RA than are conventional group-based models.

Exercise and changes in health status in patients with ankylosing spondylitis.

Although exercise is a commonly recommended treatment for ankylosing spondylitis (AS), little is known about the effectiveness of unsupervised recreational and back exercises. We examined the effects of recreational exercise and back exercises on patient-reported pain severity, stiffness severity, and functional disability in a prospective longitudinal study of 220 patients with AS. Participants provided information on exercise habits and health status every 6 months using mailed questionnaires (median follow-up, 4.5 years). Pain severity and stiffness severity were measured using visual analog scales, and functional disability was measured using the Health Assessment Questionnaire (HAQ) Disability Index. Among all patients, there were no associations between either the number of exercise minutes per week or the number of days of back exercise per week and short-term (6-month) changes in pain, stiffness, or HAQ Disability Index. However, among those who had AS for 15 years or less, pain scores were 0.18 points lower (on a scale of 0-3; P =.04), and stiffness scores were 6.4 points lower (on a scale of 0-100; P =.005) during periods with more than 200 minutes per week of exercise compared with periods with 0 to 30 minutes of exercise per week. Among those who had AS for more than 15 years, pain scores were 0.11 points lower (on a scale of 0-3; P =. 03), and HAQ Disability Indexes were 0.08 points lower (on a scale of 0-3; P<.001) during periods with 5 to 7 days per week of back exercise compared with periods when back exercises were not performed. Less intense levels of exercise were not associated with improvements in health status. Unsupervised recreational exercise improves pain and stiffness, and back exercise improves pain and function in patients with AS, but these effects differ with the duration of AS. Health status is improved when patients perform recreational exercise at least 30 minutes per day and back exercises at least 5 days per week. Arch Intern Med. 2000;160:2969-2975

Health-related quality of life and functional status of patients with rheumatoid arthritis randomly assigned to receive etanercept or placebo

To compare the functional status and well-being of patients with rheumatoid arthritis (RA) who were randomly assigned to receive placebo, etanercept 10 mg, or etanercept 25 mg during a 26-week, phase III, double-blind clinical trial. No single indicator of disease activity, severity, or therapeutic efficacy has been established for RA. During the past decade, health-related quality of life, a multidimensional way to assess physical, emotional, and social aspects of a disease or its treatment, has become an important outcome in RA studies and in assessments of RA drug therapies. A total of 234 patients completed the Health Assessment Questionnaire (HAQ), the Short-Form 36 (SF-36) (n = 48 patients), items assessing energy and mental health from the Medical Outcomes Study (MOS), and a single-item rating scale assessing current health (feeling thermometer) at baseline and several times during 6 months. Significant improvements from baseline to last assessment were reported with etanercept versus placebo and in the HAQ Disability Index score (ie, the total HAQ score) and all 8 HAQ categories (P < 0.05), with the exception of grip. Significant improvements with etanercept in the MOS energy and mental health subscales, current health (from the feeling thermometer), and mental and physical function components of the SF-36 were reported (P < 0.05). Patients receiving 10- or 25-mg doses of etanercept reported significantly better functional status and well-being than did patients receiving placebo.

Back pain in osteoarthritis of the knee.

To compare patients with knee osteoarthritis (OA) who have and do not have back pain, and evaluate the prevalence, characteristics, and consequences of back pain among knee OA patients. During a 3-year period, consecutive patients attending an outpatient rheumatology clinic were evaluated for the presence of back pain, and 368 were found to have OA of the knee. Clinical status was evaluated by the Clinical Health Assessment Questionnaire, radiographs, and joint examinations. Back pain was present in 54.6% of patients with OA of the knee. Almost every clinical status measure was worse among those reporting back pain, including Health Assessment Questionnaire (HAQ) disability, pain, global severity, fatigue, and psychological status. Back pain was more common in women and the obese, but was not associated with age, marital status, formal education, smoking history, or knee radiographic scores. In multivariate analyses the strongest correlates of back pain in knee OA patients were anxiety, night pain, HAQ disability, and global severity. Back pain is prevalent among OA clinic patients, more common than in rheumatoid arthritis or population studies, is linked to body mass index, and is associated with clinically significant increases in pain and other measures of clinical distress.

Reduction in long‐term disability in patients with rheumatoid arthritis by disease‐modifying antirheumatic drug–based treatment strategies

Therapeutic strategies for rheumatoid arthritis (RA) have been evolving from the traditional "pyramid" approach toward one based upon early and sustained use of disease-modifying antirheumatic drugs (DMARDs), in the hope of improving long-term health outcomes. However, few data to have been presented to document the effects of this approach. We sought to directly assess associations between consistent DMARD use and long-term functional outcomes. We studied 2,888 RA patients who were followed up prospectively for up to 20 years (average 9 years) at 8 databank centers. The independent variable was the proportion of patient encounters that resulted in treatment with > or = 1 DMARD (hydroxychloroquine, sulfasalazine, auranofin, intramuscular gold, D-penicillamine, methotrexate, and/or azathioprine). The dependent variable was each patient's last recorded Disability Index value from the Health Assessment Questionnaire (HAQ). Increased DMARD use was strongly associated with better long-term Disability Index values (P < 0.0001). The association was strengthened when restricted to more seriously affected (rheumatoid factor (RF)-positive) patients. The magnitude of the effect, unadjusted, was a difference of 0.53 HAQ Disability units (scale 0-3) between 100% DMARD use and 0%. Correlation coefficients ranged up to 0.26. Effects were similar for all disease duration periods (0-4, 5-9, 10-14, 15-19, and 20+ years). "Control" correlations, with variables computed to represent the proportion of time in which patients were taking either nonsteroidal anti-inflammatory drugs or prednisone, failed to show positive associations. A multiple linear regression model, which controlled for age, disease duration, sex, RF positivity, proportion of visits under a prednisone regimen, and initial disability level, included the proportion of time in which patients were taking DMARDs (P < 0.0001), with a model R2 of 0.54. These results were obtained despite an adverse selection bias in which more severely affected individuals were given DMARDS more frequently, and despite absence of data on drug use early in the disease course of many patients. Thus, these results, which suggest up to a 30 percent reduction in long term disability with consistent DMARD use, are most likely conservative. An association between consistent DMARD use and improvement in long-term functional outcomes in RA is supported by these data.

Handicap in inflammatory arthritis.

Two instruments measuring handicap were evaluated and compared with clinical, laboratory and disability measures. Participants were 133 patients attending a rheumatology follow-up clinic in a district general hospital, of whom 102 were followed up after 3 months. Measurements included acute-phase response, early morning stiffness, pain, wellbeing, joint involvement (impairments), the Stanford Health Assessment Questionnaire (disability), the Disease Repercussion Profile and the London Handicap Scale (handicap). A substantial burden of disability and handicap was recorded. There were moderate correlations between impairments (0.4 < rho < 0.6), and moderate to strong correlations between disability and handicap measures (0.4 < rho < 0.8). Correlations between impairment and disability/handicap were weak (rho < 0.4). Mean changes in all variables over 3 months were small, and none was statistically significant. A comprehensive description of the impact of disease and treatment requires measurements to be made of impairments, disabilities and handicaps. The use of clinical and laboratory variables alone may be misleading.

Concurrent validity of the Health Assessment Questionnaire Disability Index in Scleroderma.

To establish the concurrent validity of the Health Assessment Questionnaire (HAQ) Disability Index in systemic sclerosis (SSc; scleroderma). Eighty subjects with SSc completed the HAQ Disability Index questionnaire. An occupational therapist, who was blind to the subjects' responses, observed each subject's performance on 10 of the items. Paired t-tests showed significant differences between the observer and subjects' responses for tying shoes, buttoning, gripping, and walking. Intra-class correlations between observer and subjects ranged from 0.38 to 0.76. The results support the validity of the HAQ Disability Index in patients with systemic sclerosis.

Predictors of disability in a longitudinal sample of patients with rheumatoid arthritis.

Information from the Health Assessment Questionnaire (HAQ) is used to identify which variables measured in 1981 successfully predict the severity of disease in 1989 and the eight year change in severity of disease in a sample of 330 residents of Santa Clara County, California, USA. This study is exploratory and no previous hypotheses are made. Using univariate correlations and stepwise linear regressions, initial values of a number of variables are found to be useful predictors including, in order: the HAQ disability index, pain scale, global health status, tender joints, few work hours, age, female sex, never married, widowhood, and occupation as operative (e.g. dry wall installers, assemblers). Data suggest that deterioration over eight years is least rapid for those with severe disease in 1981. A mathematical identity suggests that analyses of the changes in severity versus analyses of 1989 severity are identical, provided that the 1981 disability index is entered as a covariate. The initial level of the disability index of the HAQ is by far the strongest predictive variable and provides a clinically important gauge for the likelihood of future impairment.

The use of the Health Assessment Questionnaire (HAQ) to determine physical disability in systemic sclerosis.

The health assessment questionnaire (HAQ), a self-administered instrument to determine physical disability, was completed by 211 patients with systemic sclerosis who subsequently received scleroderma examinations. The mean HAQ disability index for the entire group was 0.92. Patients with high skin scores had significantly higher disability indices as compared to patients with low skin scores (p < 0.001). Higher disability indices were found for patients with joint pain, tendon rubs, and contractures. However, the presence of ulcers on the digital tip did not interfere with patients' abilities to function as measured by this scale. Intensive hand evaluations were performed on a subset of these 211 patients with systemic sclerosis (n = 80). Grip strength, thumb abduction, wrist extension, and motion of the index and middle fingers significantly correlated with the HAQ scores (p < 0.01). The findings from this study suggest that patients with systemic sclerosis have significant physical disability. Furthermore, the HAQ appears to be useful in assisting health professionals in quantitating this disability.