ASSESSMENT OF FUNCTIONAL CAPACITY AMONG PATIENTS

WITH RHEUMATOID ARTHRITIS – IMPLEMENTING

STRATEGIES ON SELF CARE MANAGEMENT.

INTRODUCTION

Rheumatoid arthritis is an inflammatory disease that causes pain, swelling,

stiffness, and affects people differently. For some people, it lasts only a few

months or a year or two and goes away without causing any noticeable damage.

Other people have mild or moderate forms of the disease, with periods of

worsening symptoms, called flares, and periods in which they feel better, called

remissions. Still others have a severe form of the disease that is active most of the

time, lasts for many years or a lifetime, and leads to serious joint damage and

disability.

Rheumatoid arthritis is a chronic diseases cause pain, functional impairment,

social and emotional dysfunction, and premature loss of wage earnings constitutes a

challenging problem society. In the absence of any effective cure for these

frequently progressive conditions, the secondary prevention of complications is

essential. This requires a high degree of communication and cooperation between

patient and health care provider in improving quality of life and functional capacity

through better disease self-management.

Although rheumatoid arthritis can have serious effects on a person's life and

well-being, current treatment strategies—including

Pain-relieving drugs and medications that slow joint damage,

Hot and cold application

Measures for protection of joints

Balance between rest and exercise,

Patient education and support programs--allow most people with the disease

to lead active and productive lives.

SIGNIFICANCE OF THE STUDY

Measurement of physical functional limitations in patients with rheumatoid

arthritis (RA) is a time-honored strategy to assess the disease's outcome .

Performance-based tests of physical function such as grip strength and

walking velocity were included in some of the earliest trials of antirheumatic

therapy . In recent years Stein Broker classification of functional

capacity,Health and quality of life assessment questionnaire are used for this

purpose. These tests provide reproducible, quantitative information about a

patient's current status and the prognosis .

The investigators from their clinical practice felt that the need of assessment

of functional performance by nurses for rheumatoid arthritis patients. Nurses as

health care providers have important role in educating patients about rheumatoid

arthritis and self care management at home. Hence the study was conducted and

the functional capacity, performance of the patients suffering from rheumatoid

arthritis were assessed.

OBJECTIVE:

The objective of the study were

To assess the functional capacity and performance of patients with RA.

To provide strategies on self care management.

METHODS AND MATERIALS

The research design selected for the present study was Exploratory Design. The

samples were selected and functional capacity, performance were assessed. The

study was conducted in the Government General Hospital, a tertiary referral centre

Chennai-3, Tamilnadu, India. The population of this project comprises of all

patients attending the rheumatology outpatient department. 160 Patients with

rheumatoid arthritis attending the rheumatology outpatient department were

selected as samples using Systematic random sampling . Every 5th patient was

selected for the study. Around 25-30 patients with RA attend the OPD daily.

DATA COLLECTION METHOD

Physical Examination

Interview Schedule method- for demographic data.

DESCRIPTION OF TOOL

Format of the tool

Section A: Demographic data

Section B: Functional performance assessment

Part-1 Musculo skeletal Examination.

In this patients joints were assessed for the following,

Swelling Warmth Tenderness Limitation of movement

All the joints including proximal inter phalangeal joints, meta carpo phalyngeal joints, wrist, elbow, shouldr, knee joints (28 joints) were assessed on both left and right side of the body. Finally total number of joints affected was assessed out of 28 joints

Part-2 Physical Disability Index

It included the measurement of performance following activities by the patients with RA.

1. Dressing

2. Getting out of bed.

3. Lifting a cup.

4. Walking

5. Bathing

6. Bending, kneeling

7. Turning taps

8. Getting in & out of vehicle.

Score:

1. With difficulty – 4. 0-8-unable to do

2. With some difficulty – 3. 9-16-with much difficulty

3. With much difficulty – 2. 17-24-withsome difficulty

4. Unable to do – 1. 25-32-with difficulty

PART 3- Functional Capacity Assessment

STEIN BROKERS CLASSIFICATION

CLASS-I complete functional capacity with ability to carry on all usual

duties duties without handicap

CLASS-II functional capacity adequate to conduct normal activities

despite handicap of discomfort or limited mobility in one or more joints.

CLASS-III functional capacity adequate to perform only few or none of

the duties of usual or self care.

CLASS-IV largely nor wholly incapacitated with bedridden or confined to

wheelchair or no self care

SCORING:

CLASS-I -3

CLASS-II -2

CLASS-III -1

CLASS-IV -0

DATA COLLECTION PROCEDURE

A formal approval was obtained from the authorities of the hospital.

Samples for the study were selected based on the sample selection criteria.Initial

rapport was established and the purpose of the study was explained to the sample

subjects. A total of 160 patients with RA, who attend the rheumatology outpatient

department were selected for the study using systemic random sampling. Every

fifth patient was selected followed by evaluation. The evaluation lasted

approximately 90 minutes and consisted of, a physical examination including

detailed musculoskeletal examination, grouping patients under Steinbrocker

functional capacity classification followed by assessment of physical disability

index based on modified health assessment questionnaire, a review of medical

records, and laboratory and x-ray tests. Brochures related to self care management

of patients with RA were distributed to the patients after data collection.

RESULTS

The data were analysed using descriptive and inferential statistics. Pearson chi

square test was used to find the significance.

Considering the musculo skeletal examination , 80% of patients had swelling in

their joints,majority (92.5%) of patients had painful tender joints, only 55%of

patients had warm joints and 85% of patients had limitation in movement of the

joints.

The relationship between type of joints involved and class of steinbrocker functional classification. 50%of Patients whose hand joints are affected have more

functional performance impairment (class-3) than patients whose knee joints are affected. There is a significant difference in the functional performance and the type of joints involved.(2=12.4, P=0.001)

Table1 RELATIONSHIP BETWEEN TYPE OF JOINTS INVOLVED AND

STEINBROCKER CLASSIFICATION OF FUNCTIONAL CAPACITY

Table2 RELATIONSHIP BETWEEN TYPE OF JOINTS INVOLVED AND DISABILITY INDEX

S. No

Type of joint

SB CLASSIFICATION Pearsonchi square test

CLASS1 CLASS2 CLASS3

N % N % N %

1. Knees affected

4 16.7% 20 83.3% - -2=12.4P=0.001significant

2. Hand joints affected

4 2.9% 64 47.1% 68 50.0%

S.NOType of joint

DISABILITY INDEX Pearson chi-square Test

1 2 3

N % N % N %

1.Knees affected

- - - - 24 100.0%2=26.1P=0.001significant

2.Hand jointsaffected

48 32% 80 50% 32 28%

Majority (50%) of patients whose hand joints are affected are able to do their daily activities with much difficulty and 32% of patients are unable to do their daily activities by own due to disability.( 2=26.1, P=0.001)

From the above tables1 & 2 , it is revealed that Functional capacity and the

functional performance is affected more in patients whose hand joints are affected

than patients whose knee joints are affected. Patient teaching and brochures

regarding, strategies for self care management of patients with rheumatoid arthritis

were provided to the patients and significant others in the OPD

Discussion

The objective was to measure the degree of functional limitation in a sample of

RA patients. 4 established, performance-based test were elected. It helped to

demonstrate RA impairments such as the amount of pain and the number of

tender, swollen, and deformed joints; and measures of physical disability,

including the Modified Health Assessment Questionnaire, Steinbrocker

Functional Capacity classification, as well as knowledge on self care

management of RA.

The polyarticular nature of RA usually causes a global limitation in joint

function. This characteristic of RA makes a global functional scale valuable for

investigators who wish to capture the full impact of RA on a patient's performance.

However, each of the RFTs we chose is influenced by different upper and lower

extremity properties. The following findings are drawn from the study,

1. Majority of Patients had painful tender joints (92.5%) and they had

difference in experiencing swelling, warmth, tenderness, limitation in joint

movement independent to each other.

2. The functional performance level was assessed for the patients with

rheumatoid arthritis , patients whose knee joints were affected had minimal

physical disability index .

3. Majority of Patients whose hand joints were involved are classified under

class II, III of Steinbrocker classification and also had high physical

disability index score .

4. Most of them, 75% patients belonged to age group of 20-40 years and 88%

were females.

CONCLUSION

Rheumatoid arthritis is a chronic disease that would cause varying degrees

of disability among patients. Nurses play vital role in providing quality care

and education regarding self care management at home for the patients.

Nurses must give teaching to patients periodically regarding new

rehabilitative measures. Regular follow ups and treatment facilities must be

arranged for the patients. Counseling facilities must be provided to the

patients by the staff nurses to ventilate the stress related to the presence of

chronic illness. Constant evaluation and performance appraisal of functional

capacity and home care ability must be conducted.

STRATEGIES FOR HOME CARE MANAGEMENT OF PATIENTS

WITH RHEUMATOID ARTHRITIS

Balance between rest and exercise

Measures for protection of joints

Hot and cold application

Stress reduction

Healthy diet

Climate

Pain-relieving drugs and medications that slow joint damage,

Routine monitoring and ongoing care

REST AND EXERCISE: People with rheumatoid arthritis need a good balance between

rest and exercise, with more rest when the disease is active and more exercise when it

is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The

length of time for rest will vary from person to person, but in general, shorter rest breaks

every now and then are more helpful than long times spent in bed. Alternate periods of

rest and activity through the day. This is called pacing.

General rest is an important part of rheumatoid arthritis treatment, but avoid

keeping your joints in the same position for too long a time. Get up and move;

use your hands.

Holding the joint still for long periods just promotes stiffness. Keep the joints

moving to keep them flexible.

If you must sit for long periods, say at work or while traveling, take a short break

every hour: stand up, walk around, stretch, and flex your joints.

Rest before you become tired or sore.

Exercise is important for maintaining healthy and strong muscles, preserving joint

mobility, and maintaining flexibility.

Three types of exercise are helpful: range of motion exercise, strengthening

exercise, and endurance (cardio or aerobic) exercise. Water aerobics are an

excellent choice because they increase range of motion and endurance while

keeping weight off the joints of your lower body.

Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and

lose weight. Exercise programs should take into account the person’s physical abilities,

limitations, and changing needs.

PROTECTION OF JOINTS:

At least once a day, move each joint through its full range of motion. Do not

overdo or move the joint in any way that causes pain. This helps keep freedom of

motion in your joints

Avoid situations that are likely to strain your joints. Remember that your joints are

more susceptible to damage when they are swollen and painful. Avoid stressing

the joint at such times.

Learn proper body mechanics. This means learning to use and move your body

in ways that reduce the stress on your joints. This is especially true for your

hands, since you want to protect their flexibility. Ask your health care provider or

physical therapist for suggestions on how to avoid joint strain.

Use the strongest joint available for the job. Avoid using your fingers, for

example, use your wrist or shoulder for the job.

using a splint for a short time around a painful joint reduces pain and swelling by

supporting the joint and letting it rest. Splints are used mostly on wrists and

hands, but also on ankles and feet.

Other ways to reduce stress on joints include self-help devices like zipper pullers,

long-handled shoe horns help with getting on and off chairs, toilet seats, and beds;

and changes in the ways that a person carries out daily activities.

HOT AND COLD APPLICATION

Apply heat. Heat can help ease your pain and relax tense, painful muscles. One

of the easiest and most effective ways to apply heat is to take a hot shower or bath

for 15 minutes. Other options include using a hot pack or an electric heat pad set

on its lowest setting. If your skin has poor sensation or if you have poor circulation,

don't use heat treatments.

Apply cold. Cold may dull the sensation of pain. Cold also has a numbing effect

and decreases muscle spasms. Don't use cold treatments if you have poor

circulation or numbness. Techniques may include using cold packs, soaking the

affected joints in cold water and ice massage.

Alternating the application of hot and cold helps in reducing joint stiffness

and pain.

STRESS REDUCTION: People with rheumatoid arthritis face emotional challenges as

well as physical ones. The emotions they feel because of the disease – fear, anger, and

frustration – combined with any pain and physical limitations can increase their stress

level. Although there is no evidence that stress plays a role in causing rheumatoid

arthritis, it can make living with the disease difficult at times. Stress also may affect the

amount of pain a person feels. There are a number of successful techniques for coping

with stress. Regular rest periods can help, as can relaxation, distraction, or visualization

exercises. Exercise programs, participation in support groups, and good communication

with the health care team are other ways to reduce stress.

HEALTHY DIET: With the exception of several specific types of oils there is no scientific

evidence that any specific food or nutrient helps or harms people with rheumatoid

arthritis. However, an overall nutritious diet with enough – but not an excess of –

calories, protein, and calcium is important. Some people may need to be careful about

drinking alcoholic beverages because of the medications they take for rheumatoid

arthritis.

CLIMATE: Some people notice that their arthritis gets worse when there is a sudden

change in the weather. However, there is no evidence that a specific climate can

prevent or reduce the effects of rheumatoid arthritis. Exposure to extreme cold climate

can be avoided.

MEDICATIONS:

Some medications are used only for pain relief; others are used to reduce inflammation.

Still others, often called disease-modifying antirheumatic drugs (DMARDs), are used to

try to slow the course of the disease.

Strict adherence to medications as directed by your health care provider is required.

If you think a medication is not working or is causing side effects, talk to your health

care provider before stopping the medication. Some medications take weeks or even

months to reach their full benefit. In a few cases, stopping a medication suddenly

can even be dangerous.

ABSTRACT

OBJECTIVE

The objective of the study were to assess the functional capacity and performance

of patients with RA and to provide strategies on self care management of patients

with RA.

METHODS AND MATERIALS

The research design selected for the present study was Exploratory Design. The

samples were selected assessed, and interviewed by interview schedule. The

project was conducted in the Government General Hospital, a tertiary referral

centre Chennai-3, TamilNadu, India. 160 Patients with rheumatoid arthritis

attending the rheumatology outpatient department were selected as samples using

Systematic random sampling was used. Every 5th patient was selected for the

study. RA impairments such as the amount of pain and the number of tender,

swollen, and deformed joints; and measures of physical disability, including the

Modified Health Assessment Questionnaire, Steinbrocker Functional Capacity

classification were assessed and strategies on on self care management of patients

with RA were provided.

RESULTS

Majority of Patients had painful tender joints (92.5%) and they had difference in

experiencing swelling, warmth, tenderness, limitation in joint movement

independent to each other.the functional performance level was assessed for the

patients with rheumatoid arthritis , patients whose knee joints were affected had

minimal physical disability index .Majority of Patients whose hand joints were

involved are classified under class II, III of Steinbrocker classification and also

had high physical disability index score .

CONCLUSION

Rheumatoid arthritis is a chronic disease that would cause varying degrees of

disability among patients. Nurses play vital role in providing quality care and

education regarding self care management at home for the patients with RA.

Nurses must be able to assess their performance, capacity and provide teaching to

patients periodically regarding new rehabilitative measures.