Stanford Health Assessment Questionnaire Disability Research Articles

Galectin-9 as an indicator of functional limitations and radiographic joint damage in patients with rheumatoid arthritis.

Previous studies have revealed that Galectin-9 (Gal-9) acts as an apoptosis modulator in autoimmunity and rheumatic inflammation. In the present study, we investigated the potential role of Gal-9 as a biomarker in patients with rheumatoid arthritis (RA), especially as an indicator of functional limitations and radiographic joint damage. A total of 146 patients with RA and 52 age- and sex-matched healthy controls were included in this study. Clinical data including disease activity, physical function, and radiographic joint damage were assessed. Functional limitation was defined as the Stanford Health Assessment Questionnaire (HAQ) disability index >1. Subjects with joint erosion >0 or joint space narrowing >0 were considered to have radiographic joint damage. Serum Gal-9 levels were detected by an enzyme-linked immunosorbent assay. Univariate and multivariate logistic regression analysis were used to evaluate the association between Gal-9 and high disease activity and functional limitations, and a prediction model was established to construct predictive nomograms. Serum levels of Gal-9 were significantly increased in patients with RA compared to those in healthy controls (median 13.1 ng/mL vs. 7.6 ng/mL). Patients with RA who were older (>65 years), had a longer disease duration (>5 years), longer morning stiffness (>60mins), elevated serum erythrocyte sedimentation rate and C-reactive protein, and difficult-to-treat RA had significantly higher Gal-9 levels than those in the corresponding control subgroups (all p <0.05). Patients with RA were divided into two subgroups according to the cut-off value of Gal-9 of 11.6 ng/mL. Patients with RA with Gal-9 >11.6 ng/mL had a significantly higher core clinical disease activity index, HAQ scores, Sharp/van der Heijde modified Sharp scores, as well as a higher percentage of advanced joint damage (all p<0.05) than patients with Gal-9 ≤11.6 ng/mL. Accordingly, patients with RA presenting either functional limitations or radiographic joint damage had significantly higher serum Gal-9 levels than those without (both p <0.05). Furthermore, multivariate logistic regression analysis showed that a serum level of Gal-9 >11.6 ng/mL was an independent risk factor for high disease activity (OR=3.138, 95% CI 1.150-8.567, p=0.026) and presence of functional limitations (OR=2.455, 95% CI 1.017-5.926, p=0.046), respectively. Gal-9 could be considered as a potential indicator in patients with RA, especially with respect to functional limitations and joint damage.

Correlation between disease activity and patient-reported health-related quality of life in rheumatoid arthritis: a cross-sectional study

ObjectiveWe aimed to provide a comprehensive assessment of health-related quality of life (HRQoL) in patients with rheumatoid arthritis (RA) of different activities and to evaluate the correlation between clinical activity...

Conversion of the MDHAQ to the HAQ score: a simple algorithm developed and validated in a cohort of 13 391 real-world patients.

To develop and validate in real-world patients a conversion algorithm from the Multidimensionel Health Assessment Questionnaire physical function scale (MDHAQ) to the Stanford Health Assessment Questionnaire disability index physical function scale (HAQ) score. From the DANBIO registry, 13 391 patients with RA (n = 8983), PsA (n = 2649) and axial spondyloarthritis (axSpA, n = 1759) with longitudinal data on HAQ and MDHAQ were included, stratified by diagnosis, and randomized 1:1 into development and validation cohorts. Conversion algorithms were developed by linear regression and applied in validation cohorts. From MDHAQ, the HAQ was calculated (cHAQ) and validated against the observed HAQ for criterion, correlational and construct validity. For RA, we developed the conversion algorithm cHAQ = 0.15+MDHAQ*1.08, and validated it in the RA validation cohort. Criterion validity: HAQ and cHAQ had comparable discriminative power to distinguish between high and low patient global scores (standardized mean difference: HAQ:-1.29, cHAQ:-1.35). Kappa value between HAQ and cHAQ functional states indicated good agreement (0.83). Correlational validity: baseline HAQ and cHAQ, respectively, correlated well with patient global scores (r = 0.65/0.67). Bland-Altman plots showed good agreement across all functional states. Construct validity: HAQ and cHAQ discriminated equally well between patients reporting symptom state as acceptable vs not, and across responses to an external anchor. Aiming for a common algorithm, the RA conversion algorithm was validated for PsA and axSpA with similar results. This study suggests that in observational datasets with only the MDHAQ available, a simple algorithm allows valid conversion to HAQ on the group level in RA, PsA and axSpA.

The characteristics and associated factors of functional limitation in patients with rheumatoid arthritis

Objective: To investigate the characteristics of functional limitation and associated factors in patients with rheumatoid arthritis (RA). Methods: Consecutive patients with RA were recruited from August 2015 to June 2019 at Department of Rheumatology, Sun Yat-Sen Memorial Hospital. Demographic and clinical characteristics including age, gender, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) of pain, clinical disease activity index (CDAI), modified total Sharp score were collected. Physical function was assessed by the Stanford health assessment questionnaire disability index (HAQ-DI).Ordered logistic regression was used to analyze the related factors of HAQ-DI. Results: A total of 643 RA patients were finally recruited including 114 males and 529 females with mean age (49.7±12.9) years. There were 399 (62.1%) patients having different degrees of functional limitation, who were classified as mild (293, 45.6%), moderate (73, 11.4%) and severe (33, 5.1%). The prevalence of functional limitation was positively correlated with age and disease activity. The most restricted activity was walking [43.5% (280/643)], followed by gripping [36.1% (232/643)], reaching [35.5% (228/643)], daily activities [33.4% (215/643)], hygiene [33.0% (212/643)], dressing and grooming [29.7% (191/643)] and arising [29.1% (187/643)], and the last eating [18.4% (118/643)]. Multivariate ordered logistic regression analysis showed that age (OR=1.019, 95%CI 1.004-1.035),pain VAS (OR=1.820, 95%CI 1.616-2.050), ESR (OR=1.009, 95%CI 1.001-1.017), CDAI (OR=1.080, 95%CI 1.059-1.102) and modified total Sharp score (OR=1.010, 95%CI 1.004-1.015) were associated factors of functional limitation. Conclusion: The majority RA patients have functional limitation. Age, pain and active disease are independent associated factors. Therefore, target treatment and control of pain should be emphasized in RA patients.

Physical, Psychological, and Sexual Implications of Living with Rheumatoid Arthritis among Women in Reproductive Age

Background: Rheumatic arthritis (RA) affect all aspects of patients' life, lead to various degrees of disability, and ultimately has a profound impact on the social, economic, psychological, and sexual aspects of the patient's life. Aim of the study: Identify physical, psychological, and sexual implications of rheumatoid arthritis among women in reproductive age. In addition to investigating the correlations between physical functional disability, psychological problems, and sexual dysfunction. Settings: The study was conducted at Rheumatology Clinic at the Main University Hospital of Alexandria. Subjects: Purposive sample was chosen from women patients with rheumatoid arthritis to be subjects of this study (n=250). Tools: Four tools were used to collect data. Tool I: Socio-demographic questionnaire. Tool II: Stanford Health Assessment Questionnaire Disability Index (HAQ-DI). Tool III: Depression Anxiety Stress Scale (DASS). Tool IV: The Sexual Dysfunction Questionnaire (SDQ) Results: The majority of the studied women suffer from severe physical disability, extreme level of depression, anxiety and about half of them had an extreme level of stress. Also, the majority of the studied women had a severe level of sexual dysfunction. Also, statistically significant correlations between women's physical disability index, psychological problems, and sexual dysfunction were detected. Conclusion: The findings from this study confirm that women patients with RA suffer from multiple negative implications on the physical, psychological and sexual functions. Recommendations: Provide ongoing support to the patients from the time of diagnosis throughout their care and management. To help them to manage their pain and disabilities, improve their sexual function, promote their mental health, and optimize psychosocial functioning.

FRI0586 HOW TO GET FROM THE MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE TO STANFORD HEALTH ASSESSMENT QUESTIONNAIRE DISABILITY INDEX SCORES IN PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND AXIAL SPONDYLOARTHRITIS: DEVELOPMENT AND VALIDATION OF A CONVERSION ALGORITHM

Background:In the DANBIO quality registry in Denmark, patients with rheumatoid arthritis (RA) psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) have reported Patient Reported Outcomes (PROs) including the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) for nearly twenty years as part of routine care. Patients’ feedback have stressed a need for a shorter registration of disability (1). While the shorter Multidimensional Health Assessment Questionnaire (MDHAQ) is preferred by patients, the original HAQ-DI is the preferred tool in observational studies. Thus, a conversion algorithm between the MDHAQ and HAQ-DI scores is warranted.Objectives:To develop and validate a simple conversion algorithm between MDHAQ and HAQ-DI scores in RA, PsA and axSpA patients.Methods:Patients registered in DANBIO with a diagnosis of RA, PsA or axSpA who had completed both HAQ-DI and MDHAQ simultaneously at a visit +/- 30 days from start of conventional synthetic (cs)DMARD or biological (b)DMARD were eligible for the analysis, and randomly divided into development and validation cohorts stratified by diagnosis. The conversion algorithm was developed in the RA development cohort using linear regression with HAQ-DI as the dependent variable and MDHAQ as the independent variable. The predicted HAQ (pHAQ) scores were then calculated by applying the conversion algorithm to the MDHAQ scores in the RA, PsA and axSpA validation cohorts. The pHAQ was validated against the HAQ-DI in the validation cohorts regarding criterion, correlational and construct validity.Results:We included 8983/4410/1760 patients with RA/PsA/axSpA, respectively. The conversion algorithm pHAQ=0.15+MDHAQ*1.08 had the best fit (R2=0.83) in the RA development cohort.Criterion validity: The correlation coefficients between HAQ-DI/pHAQ and patient global score at baseline were 0.66/0.65. In groups of patients with high and low disability (defined as patient global score ≥50), standardized mean difference was -1.4 for HAQ-DI, and -1.4 for pHAQ.Correlational validity: Correlation coefficients between HAQ-DI/pHAQ and ΔHAQ-DI/ΔpHAQ between baseline and first follow-up visit were r=0.91 and r=0.87, respectively. Correlation coefficients between HAQ-DI/pHAQ and pain score, DAS28CRP and physician global score were 0.63/0.64, 0.55/0.55 and 0.34/0.34, respectively. A Bland-Altman plot showed good agreement of HAQ-DI and pHAQ across all functional states.Construct validity: HAQ-DI/pHAQ at the first follow-up visit after baseline was comparable between Patient Acceptable Symptom State groups (PASS=No: mean 1.17 vs 1.18/PASS=Yes: 0.55 vs 0.60). Similar results were seen for the external anchor (Figure 1).In PsA and axSpA validation cohorts, similar results were found.Conclusion:A conversion algorithm from MDHAQ to HAQ-DI was developed in ≈ 4500 RA patients. In separate large validation cohorts of RA, PsA and axSpA patients, the predicted HAQ calculated from the MDHAQ scores showed good criterion, correlational and construct validity comparable to the original HAQ-DI. The results suggest that for research purposes the MDHAQ can be converted to HAQ-DI if a full HAQ-DI has not been performed.

Evaluation of the Interaction Model of Client Health Behavior-based multifaceted intervention on patient activation and osteoarthritis symptoms.

This study evaluated a multifaceted intervention for osteoarthritis symptoms. A cluster randomized controlled trial was conducted with a convenience sample of 90 patients aged between 45 and 82 years, who were recruited from three Community Health Posts (CHPs). The CHPs were randomized into two experimental groups (E1 and E2) and one control group (C). The intervention included health education and counseling combined with exercise classes based on the Interaction Model of Client Health Behavior. Trained community health nurse practitioners led the intervention. Stretching exercise (E1) and walking (E2) combined with muscle strengthening exercise were provided. The instruments included the Patient Activation Measure (PAM), Korean version of the Western Ontario and McMaster Universities Osteoarthritis Index (K-WOMAC), Stanford Health Assessment Questionnaire Disability Scale (HAQDS), and Center for Epidemiologic Studies Depression Scale (CES-D). The HAQDS was measured using an ordinal scale, and Likert scales were used for the other instruments. Chi-square test and analysis of covariance were used; P values <.05 were considered significant. The study was conducted in 2014. The groups were similar at the baseline (P > .05) except for joint pain and patient activation (P < .05). At post-test, the changes in the mean scores were significant for joint pain and stiffness, and physical functioning. E2 with walking exercise showed better improvements in joint pain and physical functioning than the other groups (P < .01). Eight sessions of multifaceted intervention improved the osteoarthritis symptoms. Follow-up studies will be needed to determine the intermediate and long-term effects of the multifaceted intervention.

Validation and assessment of minimally clinically important difference of the unadjusted Health Assessment Questionnaire in a Danish cohort: uncovering ordinal bias

Objectives: The Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) is a widely used patient-reported outcome for functional disability in rheumatoid arthritis (RA). Minimal clinically important differences (MCIDs) in the HAQ-DI were previously calculated based on device-corrected ordinal HAQ-DI scores, leading to limited generalizability and validity for today’s patients. Our objectives were to examine the internal construct validity of the unadjusted HAQ-DI and to determine an MCID in a cohort of Danish RA patients based on the transformed linear logit scale of the HAQ-DI.Method: The study included 362 RA patients registered in the DANBIO registry. The Rasch model was fitted to HAQ-DI data at baseline and after 3 months’ follow-up. MCID was calculated as the median changes in the original HAQ-DI score and logit HAQ-DI score in those patients who had experienced minimal improvement (15–30 mm on a 0–100 mm Patient Global scale).Results: HAQ-DI data showed acceptable fit to the Rasch model at both time-points, and consistent item ranking across time indicated instrument invariance. Sixty-one patients (16.8%, ~1/6) had an improvement above the MCID on the logit scale but improvement below the MCID on the original scale, while the opposite was not the case for any patients.Conclusions: The Danish unadjusted version of the HAQ-DI showed acceptable internal construct validity. Application of the logit MCID classified an additional one in six patients as having achieved an MCID compared to the MCID calculated on the ordinal scale, which may have potential implications for the powering of future studies.

The Impact of Belimumab and Rituximab on Health‐Related Quality of Life in Patients With Systemic Lupus Erythematosus

Accumulating evidence supports an impaired health-related quality of life (HRQoL) in patients with systemic lupus erythematosus (SLE). We investigated the effects of 2 biologic treatments on HRQoL of patients with SLE. Patients with SLE from the Karolinska University Hospital treated with belimumab (n = 34) or rituximab (n = 35) were included; normative values derived from Swedish population-based controls matched for age and sex were used for the purpose of comparisons. Data were collected prospectively at treatment initiation and at months 3, 6, 12, and 24, using the Short Form 36 (SF-36) health questionnaire, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) scale, the EuroQol 5-dimension (EQ-5D) instrument, and the Stanford Health Assessment Questionnaire disability index (HAQ DI). Substantial decrements from Swedish norms were observed across all SF-36 domains at baseline. Patients treated with belimumab reported gradual improvements in the SF-36 physical component summary (significant from month 12; P = 0.023) and FACIT-Fatigue (significant by month 24; P = 0.001), no changes in EQ-5D scores, and improvements in HAQ DI by month 6 (P = 0.014). Patients treated with rituximab showed rapid improvements in the SF-36 mental component summary and FACIT-Fatigue by month 3 (P = 0.031 and P = 0.007, respectively), as well as improvements in EQ-5D at month 6 (P = 0.016) and HAQ DI at month 3 (P = 0.033). Based on baseline evaluations, patients receiving antimalarial agents (n = 33) performed better in the SF-36 social functioning (P = 0.022) and mental health (P = 0.023) domains compared to patients who did not receive antimalarial agents (n = 36). Our results corroborated previous findings of considerable HRQoL impairments in patients with SLE. Patients' perceptions of HRQoL showed discrepant patterns over time in the 2 treatment groups and could provide additional information along with the clinical evaluation of biologic therapy in SLE. Further survey on the effects of antimalarial agents on the HRQoL of patients with SLE in larger cohorts is merited.

Myopenia is associated with joint damage in rheumatoid arthritis: a cross-sectional study.

BackgroundThe link between body mass index (BMI) and disease characteristics in rheumatoid arthritis (RA) remains controversial. Body composition (BC) has been more frequently recommended to be used instead of BMI for more accurate assessment. Our study aimed to investigate the characteristics of BC in RA patients and their associations with disease characteristics.MethodsBody composition was assessed in consecutive Chinese RA patients and control subjects by bioelectric impedance analysis. Overfat was defined by body fat percentage (BF%) as ≥25% for men and ≥35% for women. Myopenia was defined by appendicular skeletal muscle mass index (ASMI) ≤7.0 kg/m2 in men and ≤5.7 kg/m2 in women. BMI and clinical data including disease activity, function, and radiographic assessment were collected. Active disease was defined by disease activity score in 28 joints with four variables including C‐reactive protein (DAS28‐CRP) ≥2.6. Functional limitation was defined as Stanford health assessment questionnaire disability index (HAQ‐DI) >1. Radiographic joint damage (RJD) was defined as the Sharp/van der Heijde modified sharp score (mTSS) >10.ResultsThere were 457 RA patients (mean age 49.5 ± 13.1 years old with 82.7% women) and 1860 control subjects (mean age 34.3 ± 9.9 years old with 51.2% women) recruited. Comparisons of BMI and BC between RA patients and control subjects in age and gender stratification showed that lower BMI with 17.7% underweight and lower ASMI with 45.1% myopenia are the main characteristics in RA patients. Compared with those without myopenia, RA patients with myopenia had significantly higher DAS28‐CRP (median 3.5 vs. 3.0), higher HAQ‐DI (median 0.38 vs. 0.13) with higher rate of functional limitation (24.8% vs. 7.6%), and higher mTSS (median 22.3 vs. 9.0) with more RJD (71.8% vs. 45.8%) (all P < 0.001). Multivariate logistic regression analysis showed myopenia were positively associated with functional limitation (OR = 2.546, 95% CI: 1.043–6.217) and RJD (OR = 2.660, 95% CI: 1.443–4.904). All RA patients were divided into four BC subgroups according to overfat and myopenia. Those with both overfat and myopenia had the worst disease characteristics. After adjustment for confounding factors, significant additive interactions were observed between overfat and myopenia in active disease (AP = 0.528, 95% CI: 0.086–0.971), functional limitation (AP = 0.647, 95% CI: 0.356–0.937), and RJD (AP = 0.514, 95% CI: 0.139–0.890).ConclusionsMyopenia is very common in RA patients that is associated with functional limitation and joint damage in RA. Further research on the underlying mechanism and the effect of skeletal muscle mass improvement in RA management are worth exploring in the future.

Disability and health-related quality of life in Chinese patients with rheumatoid arthritis: A cross-sectional study.

The objective of this study was to evaluate the impact of rheumatoid arthritis (RA) on physical function and health-related quality of life (HRQoL) in China. A cross-section survey was conducted in 21 general hospitals in China. Eight hundred and seven patients were recruited. Data on demographics, clinical data, physical function (Stanford Health Assessment Questionnaire Disability Index, HAQ-DI) and HRQoL (Study Short Form 36 Health Survey, SF-36) were collected on site. In our cohort, physical function was impaired in 77.6% of patients (HAQ-DI >0). The median (interquartile range, IQR) of HAQ-DI was 0.750 (0.125, 1.500). Rated by HAQ-DI 0-1, >1-2, and >2-3, percentage of patients with mild, moderate and severe disability was 61.0%, 25.4%, and 13.6%, respectively. Older age, long disease duration, presence of extra-articular manifestations, tender joint count (TJC), overall status (assessed by patient Global Visual Analogue Scale [G-VAS] and physician G-VAS) and lacking disease-modifying anti-rheumatic drugs were identified as predictive factors for worse physical function (P<.05). The composite scores of SF-36 in the observed patients were: physical component summary 40.4 (IQR 27.4, 60.3), and mental component summary 49.0 (IQR 33.6, 70.9). Impaired physical health may be predicted by low income, presence of extra-articular manifestations, TJC, patient G-VAS and high HAQ-DI. Predictors for suboptimal mental health were low income, physical labor, married status, increased swollen joint count (SJC), physician G-VAS and high HAQ-DI. Rheumatoid arthritis has profound effects on physical function and HRQoL in Chinese patients. Patients with identified predictive factors for poor outcome should be closely monitored.

Autonomic nervous system changes associated with rheumatoid arthritis: Clinical and electrophysiological study

Aim of the workThe aim of this study was to evaluate clinically and electrophysiologically the autonomic nervous system changes associated with rheumatoid arthritis (RA). Patients and methodsThe present study included 25 patients with RA[22 women (88%)] and 30 apparently healthy control subjects[27 women (90%)]. A thorough clinical examination was carried out. Disease activity and functional disability were assessed. Tests for assessment of autonomic functions include active and passive orthostatic stress tests, and sympathetic skin response (SSR). The presence of abnormality in 2 tests or more was a clue for the presence of autonomic neuropathy (AN). Sural sensory nerve conduction study and posterior tibial motor nerve conduction study were done. ResultsThere was a statistically significant decrease in standing systolic and diastolic blood pressure (BP) components of the active orthostatic stress test and SSR amplitude as well as statistically significant prolongation of SSR latency of RA patients when compared to control. Three patients (12%) had clinical symptoms suggestive of AN; increased to 14 patients (56%) when orthostatic stress tests and SSR were utilized. There were no statistically significant differences between patients with different disease activity score 28 with 4 variables grades of RA activity and SSR latency and amplitude. There were no statistically significant differences between patients with different Stanford Health Assessment Questionnaire Disability Index grades of RA functional disability and SSR latency and amplitude. ConclusionsAutonomic neuropathy is a common extra-articular manifestation of RA affecting sympathetic and parasympathetic fibers.

Swedish version of the multi dimensional health assessment questionnaire – translation and psychometric evaluation

BackgroundHealth assessment measurements for patients with Rheumatoid arthritis (RA) have to be meaningful, valid and relevant. A commonly used questionnaire for patients with RA is the Stanford Health Assessment Questionnaire Disability Index (HAQ), which has been available in Swedish since 1988. The HAQ has been revised and improved several times and the latest version is the Multi Dimensional Health Assessment Questionnaire (MDHAQ). The aim of this study was to translate the MDHAQ to Swedish conditions and to test the validity and reliability of this version for persons with RA.MethodsTranslation and adaption of the MDHAQ were performed according to guidelines by Guillemin et al. The translated version was tested for face validity and test-retest in a group of 30 patients with RA. Content validity, criterion validity and internal consistency were tested in a larger study group of 83 patients with RA. Reliability was tested with test-retest and Cronbach´s alpha for internal consistency. Two aspects of validity were explored: content and criterion validity. Content validity was tested with a content validity index.Criterion validity was tested with concurrent validity by exploring the correlation between the MDHAQ-S and the AIMS2-SF. Floor and ceiling effects were explored.ResultsTest-retest with intra-class correlation coefficient (ICC) gave a coefficient of 0.85 for physical function and 0.79 for psychological properties. Reliability test with Cronbach´s alpha gave an alpha of 0.65 for the psychological dimension and an alpha of 0.88 for the physical dimension of the MDHAQ-S.The average sum of the content validity index for each item was of the MDHAQ-S was 0.94. The MDHAQ-S had mainly a moderate correlation with the AIMS2-SF, except for the social dimension of the AIMS2-SF, which had a very low correlation with the MDHAQ-S.ConclusionsThe MDHAQ-S was considered to be reliable and valid, but further research is needed concerning sensitivity to change.

Evaluating the Association of Preoperative Functional Status and Postoperative Functional Decline in Older Patients Undergoing Major Surgery

This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Preoperative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.

Impact of an Exercise Program for Morbidly Obese Patients on Quality of Life and on Clinical and Metabolic Profile

Purpose: This study aims to assess the short-term effects of a preoperative program of exercises developed for the morbidly obese, on their quality of life within clinical and metabolic parameters. Methods: Thirty seven consecutive patients were enrolled. Twenty-three completed the study and had the following parameters assessed before the start and at the end of the program: Stanford Health Assessment Questionnaire Disability Index (HAQ – DI) and Moorehead Ardelt Quality of Life Questionnaire II (MA QoLQII); the six-minute walk test (6MWT); and clinical-metabolic assessment. Results: Nineteen patients (82.6%) lost weight with the program. Cholesterol and LDL cholesterol levels were lower at the end of the program (166.78 ± 22.47 mg/dl versus 179.52 ± 31.30 mg/dl, p < 0.05 and 87.02 ± 20.21 mg/ dl versus 108.73 ± 31.27 mg/dl, p < 0.01, respectively). The distance covered during the 6MWT was higher at the end of the program (556.26 ± 42.27 m versus 528.34 ± 44.56 m, p < 0.01). Quality of life questionnaires had better scores at the end of the program. Conclusion: The practice of regular physical activities is feasible for morbidly obese patients, and leads to beneficial effects on lipid profile and on the quality of life.

Randomised controlled trial examining the effect of exercise in people with rheumatoid arthritis taking anti-TNFα therapy medication

BackgroundSubstantial progress has been made in the medical management of rheumatoid arthritis (RA) over the past decade with the introduction of biologic therapies, including anti-tumour necrosis factor alpha (anti-TNFα) therapy medications. However, individuals with RA taking anti-TNFα medication continue to experience physical, psychological and functional consequences, which could potentially benefit from rehabilitation. There is evidence that therapeutic exercise should be included as an intervention for people with RA, but to date there is little evidence of the benefits of therapeutic exercise for people with RA on anti-TNFα therapy medication. A protocol for a multicentre randomised controlled three-armed study which aims to examine the effect of dynamic group exercise therapy on land or in water for people with RA taking anti-TNFα therapy medication is described.Methods/DesignSix hundred and eighteen individuals with RA, on anti-TNFα therapy medication, will be randomised into one of 3 groups: a land-based exercise group; a water-based exercise group or a control group. The land and water-based groups will exercise for one hour, twice a week for eight weeks. The control group will receive no intervention and will be asked not to alter their exercise habits for the duration of the study. The primary outcome measure, the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) which measures functional ability, and secondary measures of pain, fatigue and quality of life, will be assessed at baseline, eight and 24 weeks by an independent assessor unaware of group allocation. Changes in outcome from 0 to 8 weeks and 0 to 24 weeks in the 'land-based exercise group versus control group' and the 'water-based exercise group versus control group' will be examined. Analysis will be conducted on an intention to treat basis.DiscussionThis trial will evaluate the effectiveness of group exercise therapy on land or in water, for people with RA taking anti-TNFα therapy medication. If these exercise groups are found to be beneficial, they could be conducted in local community facilities thus making these forms of exercise more easily accessible for individuals and potentially reduce the burden on health services.Trial RegistrationThis trial is registered with ClinicalTrials.gov (a service of the United States National Institutes of Health) identifier: NCT00855322.

Validating English- and Spanish-language patient-reported outcome measures in underserved patients with rheumatic disease

IntroductionRheumatic diseases are among the most common and debilitating health problems in the United States. These diseases are chronic, can result in severe decrements of physical and psychosocial functioning and affect patients' overall quality of life. A consensus regarding the best patient outcomes to be measured in randomized, controlled trials and prospective natural history studies is essential to provide best estimates of efficacy and safety of interventions across diverse patient populations.MethodsFace-to-face English- and Spanish-language cognitive interviews were conducted among urban Hispanic and African American patients with rheumatic disease to develop a questionnaire booklet. Six measures validating patient-reported outcomes were included: the Arthritis Self-Efficacy Scale, the Stanford Health Assessment Questionnaire Disability Index, the Wong-Baker Faces Pain Scale, the Short Acculturation Scale, the Center for Epidemiologic Studies Depression Scale and the Inventory of Complementary and Alternative Medicine Practices. A sample of patients (n = 15) attending the National Institute of Arthritis and Musculoskeletal and Skin Diseases Community Health Center participated in the initial interviews. Revised measures were further tested for reliability in a separate sample of patients (n = 109) upon enrollment at the health center.ResultsCognitive interviews provided feedback for questionnaire modifications and methods to enhance content validity and data quality, including discarding redundant questions, providing visual aids and concrete examples when appropriate and increasing the use of racially and ethnically concordant interviewers. The cognitive interviews further elucidated that some contextual assumptions and language usage in the original questionnaires may not have taken each respondent's environmental and sociocultural context into consideration. Internal reliability for previously tested measures remained high (Cronbach's α = 0.87-0.94).ConclusionsCognitive interviewing techniques are useful in a diverse sample of racial and ethnic minority patients with rheumatic disease as a method to assess the content validity of the specific outcome measures selected. The data collection approaches and methods described here ultimately enhance data quality. Vigilance is required in the selection of outcome measures in studies or in practice, particularly with each new language translation and/or culturally unique or diverse sample.

Application of the health assessment questionnaire disability index to various rheumatic diseases

PurposeTo investigate whether the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) can serve as a generic instrument for measuring disability across different rheumatic diseases and to propose a scoring method based on item response theory (IRT) modeling to support this goal.MethodsThe HAQ-DI was administered to a cross-sectional sample of patients with confirmed rheumatoid arthritis (n = 619), osteoarthritis (n = 125), or gout (n = 102). The results were analyzed using the generalized partial credit model as an IRT model.ResultsIt was found that 4 out of 8 item categories of the HAQ-DI displayed substantial differential item functioning (DIF) over the three diseases. Further, it was shown that this DIF could be modeled using an IRT model with disease-specific item parameters, which produces measures that are comparable for the three diseases.ConclusionAlthough the HAQ-DI partially functioned differently in the three disease groups, the measurement regarding the disability level of the patients can be made comparable using IRT methods.

Converting modified health assessment questionnaire (HAQ), multidimensional HAQ, and HAQII scores into original HAQ scores using models developed with a large cohort of rheumatoid arthritis patients

The Stanford Health Assessment Questionnaire Disability Index (HAQ) is the gold standard functional status questionnaire in rheumatology, but it is lengthy. Three shorter versions, the modified HAQ (MHAQ), the Multidimensional HAQ (MDHAQ), and the HAQII are often used in outcomes research as HAQ substitutes. We developed conversion formulas between these modified versions and the original HAQ. Analysis was limited to the comparison of rheumatoid arthritis (RA) patients at a random observation when the HAQ was recorded in conjunction with the MHAQ (n = 29,596), the MDHAQ (n = 13,665), or the HAQII (n = 15,823). Development models were randomly limited to 80% of the data (development sample) and the remaining 20% was used for model validation. Two conversion formulas were developed for each of the MHAQ, the MDHAQ, and the HAQII: a short model and a long model inclusive of questions common to both the modified measures and the original HAQ. Short models explained 81-83%, and long models 82-86%, of the variance. Predicted HAQ values of zero were assigned to all cases with an MDHAQ or HAQII score of zero, with remaining cases used for model estimation. Bland-Altman plots demonstrated good concordance between actual and predicted values for each measure. The validation sample closely approximated the results from the development sample (0.005 ≤ ΔR² ≤ 0.009) for each measure. We have developed and validated highly accurate conversion formulas from the MHAQ, MDHAQ, and HAQII to the original HAQ in a large sample of RA patients. The developed models are useful for conversion of measures in the research setting. Because of substantial variability at the individual patient level, application of the formulas to individual patients is inadvisable.

Patient-reported Outcomes in a Randomized Trial of Etanercept in Psoriatic Arthritis

To evaluate the effects of etanercept treatment on patient-reported outcomes (PRO) in patients with psoriatic arthritis (PsA). A 24-week double-blind comparison to placebo was followed by a 48-week open-label phase in which all eligible patients received etanercept. PRO were measured using the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI), the Medical Outcomes Study Short-Form (SF-36), the EQ-5D visual analog scale (VAS), and the American College of Rheumatology (ACR) patient pain assessment. Beginning at Week 4 and continuing through Week 24 of double-blind treatment, patients treated with etanercept had significantly higher mean percentage improvement in HAQ-DI relative to baseline than patients given placebo (53.6% vs 6.4% at Week 24; p < 0.001). After 48 weeks of open-label treatment with etanercept, the mean percentage change from study baseline was 52.8% for the original etanercept group and 46.9% for the original placebo group, with 41.2% of patients overall achieving a HAQ-DI of 0. Mean changes relative to baseline for SF-36 physical component summary scores, EQ-5D VAS, and ACR pain assessment were also significant in the double-blind period for etanercept compared with placebo (p < 0.001 for all 3 measures). Patients taking placebo achieved similar improvements once they began treatment with etanercept in the open-label period. Patients with PsA treated with etanercept reported significant improvements in physical function that were almost 10 times the improvement seen with placebo and were maintained for up to 2 years. Almost half of patients treated with etanercept reported no disability by the end of the study.