Abstract
Background:
Rheumatoid arthritis (RA) is a polyarthritis classically affecting bilateral and symmetrical joints. Although a progressive disease, RA patients experience high and low disease activity phases, which are reflected in symptoms and functional ability. Any worsening of the illness results in permanent changes to the joints. This study was conducted to assess the functional disability among patients with RA, to elicit its association with selected sociodemographic and clinical variables and with disease activity.
Methods:
A cross-sectional study was conducted by a convenience sampling method, amongst 400 consenting RA patients, visiting the rheumatology outpatient department (OPD) of the hospital. Sociodemographic and clinical data were taken and their functional disability.
Background:
RA is a polyarthritis classically affecting bilateral and symmetrical joints. Although a progressive disease, RA patients experience high and low disease activity phases, which are reflected in symptoms and functional ability. Any worsening of the illness results in permanent changes to the joints. This study was conducted to assess the functional disability among patients with RA, to elicit its association with selected sociodemographic and clinical variables and with disease activity.
Methods:
A cross-sectional study was conducted by convenience sampling method, amongst 400 consenting RA patients, visiting the rheumatology OPD of the hospital. Sociodemographic and clinical data were taken and their functional disability assessed using Health Assessment Questionnaire Disability Index (HAQ-DI) score and its association with the variables of disease activity studied using the Disease Activity Score 28 (DAS28) scale, from June 2022 to July 2024.
Results:
The mean age of the study participants was 50.2 ± 10.48 years; 86.4% of them were females. The mean HAQ-DI score was 0.70 ± 0.83. The eating and hygiene component of the eight domains studied in HAQ-DI was most affected in RA patients in this study. Functional disability was found to be significantly associated with a higher total cholesterol/high density lipoprotein (TC/HDL) ratio and measures of disease activity.
Conclusion:
This study found functional limitations in all domains with eating and personal hygiene being the most prevalent; similarly, higher TC/HDL ratio and disease severity were also associated with higher functional disability. These domains and risk factors being modifiable, can help physicians in early identification and prevention of disability.
Keywords
Introduction
Rheumatoid arthritis (RA) is a disease of chronic nature and unknown aetiology affecting multiple systems and characterised by persistent inflammatory synovitis, generally involving symmetrical peripheral joints. 1 RA affects approximately 17.6 million individuals worldwide (of all ages) as of 2020 and has increased by 121% since 1990. 2
Although a progressive disease, RA patients experience high and low disease activity phases, affecting their symptoms and functional ability. RA is associated with pain, tiredness, functional impairment and a decline in emotional stability. It is a debilitating condition that can cause systemic, articular and extra-articular complications. 3 RA patients frequently receive incorrect diagnoses and treatment. Despite the potential benefits of early diagnosis and appropriate treatment, delays in presentation remain common especially in tertiary care settings, resulting in established disability by the time of evaluation. 4
In recent decades, pharmacological treatment options have significantly advanced, improving overall functioning and quality of life. However, a subset continues to experience significant limitations due to persistent disease activity, comorbidities or joint deformities. These patients are often considered to have difficult-to-treat RA. 5
The burden of RA-related disability has broader implications on national productivity and healthcare costs. A more effective management of the disease and its complications will have a positive impact on the economy of the nation. There is a paucity of studies on functional disability among RA patients in India and Odisha. This study was done with a primary objective to determine the functional disability of patients with RA. The secondary objectives were to elicit its determinants and also to determine its association with disease activity.
Methodology
This study was a hospital-based cross-sectional study conducted in the Department of Clinical Immunology and Rheumatology outpatient department (OPD) of a tertiary care hospital in Bhubaneswar, Odisha, between June 2022 and July 2024. Patients between 25 and 84 years diagnosed as established RA (disease duration ≥6 months from the date of diagnosis by a qualified medical practitioner, irrespective of the centre where diagnosed), fulfilling 2010 american college of rheumatology/european league against rheumatism (ACR/EULAR) criteria 6 and under treatment at the rheumatology clinic were included in the study using a convenience sampling method. Patients who were uncooperative, diagnosed with coronary heart disease or had severe comorbidities were excluded from the study. The sample size was calculated by using the formula n = [(z2) p (1–p)]/d2. Taking 50.8% prevalence from a previous study, 4 a 95% confidence level and 5% allowable error, the final sample size came to be 384 (approximately 400). A predesigned, pre-validated questionnaire was used to collect data from the participants. Education, being one of the three parameters of the modified Kuppuswamy scale (used to assess socioeconomic status in the current study), was graded as illiterate, primary school certificate, middle school certificate, high school certificate, intermediate/post high school diploma, graduate and professional degree. Socioeconomic status was assessed using the modified Kuppuswamy scale (2022), which has three parameters: education and occupation of the head of the family and total income of the family; it has five classes (Class I: Upper, Class II: Upper-middle, Class III: Middle, Class IV: Upper-lower, Class V: Lower). The body mass index (BMI) was calculated using the formula BMI = weight (in kg)/height 2 (in metres). Routine blood tests done among RA patients during follow-up at this centre are RA factor and anti-citrullinated peptide antibody (ACPA) factor (for diagnosis as per ACR/EULAR criteria 2010), CBC, erythrocyte sedimentation rate (ESR) and total cholesterol/high density lipoprotein (TC/HDL) (for assessing cardiovascular risk). As TC/HDL ratio was available in the reports and is also a risk factor hence the authors have tried to find out the association for the same.
The patient’s disease activity was assessed using the 28-joint Disease Activity Score based on DAS28 ESR at the time of the interview. It evaluates 28 joints for tenderness and swelling and incorporates the levels, along with a global health assessment by the patient. Scoring Interpretation was: <2.6: Remission, 2.6–3.2: Low disease activity, 3.2–5.1: Moderate disease activity, >5.1: High disease activity. 7
Health Assessment Questionnaire Disability Index (HAQ-DI): Questions concerning the eight domains of activities, reach, grip, hygiene, eating, walking, dressing and grooming and waking were asked to the patients. Items or subcategories were created from these eight categories. According to the degree of disability experienced in carrying out those activities, the patient answered these questions on a four-level scale (0, 1, 2 and 3). Zero denotes no difficulty, 1 denotes some difficulty, 2 denotes much difficulty and 3 denotes unable to do. With the exception of aids or devices, the HAQ-DI was thus computed using the highest sub-category score to determine the value for each category. A total HAQ-DI between 0 and 3 is then calculated by averaging the category scores. Additionally, it included a companion aids or devices variable to document any help the patient might need to perform daily tasks. To better reflect underlying disabilities, the use of aids, devices or physical assistance raises a score of 0 or 1 to 2; scores of 3 remain unchanged. The overall score is the mean of the eight domain scores and varies from 0 to 3. A score of 0–1 was considered a low disability and a score of 2 or more was considered a severe disability. Anything between 1 and 2 was considered moderate disability. 8
Scores were calculated for DAS28 and HAQ-DI, which were then compared among selected sociodemographic and clinical factors. Categorical variables were presented by frequency and percentage and continuous variables were presented as mean ± SD or median inter quartile range (IQR). Comparison between the two categorical variables was done using the chi-square test. Means were compared using a one-way analysis of variance (ANOVA) test and medians were compared using the Kruskal-Wallis test. A P value of less than .05 was considered statistically significant. All analyses were carried out using the standard statistical software Statistical Package for the Social Sciences version 21.0.
Results
The present study was a hospital-based cross-sectional study conducted in the Department of Clinical Immunology and Rheumatology OPD at a tertiary care hospital in Bhubaneswar, Odisha. A total of 400 consenting RA participants were included in the study to assess their disease activity levels using the DAS28 score and functional disability using the HAQ-DI score and to find the correlation between them. The mean age of the participants was 50.2 ± 10.48 years with an age range of 18–76 years. Participants with severe disability were most commonly seen in the age group 31–45 years (19 of 133, 14.3%) and female gender (86.4%) (Table 1). Maximum participants across all the disability levels belonged to the Hindu religion. Severe functional disability was more common among women, participants with lower education, higher BMI and comorbid diabetes or hypertension. However, these associations were not statistically significant.
Functional Disability of the Participants with Selected Sociodemographic and Clinical Variables [N = 400].
#using ANOVA.
A significant association was observed between a higher TC/HDL ratio and increasing disability severity (P = .029). Participants with severe disability also had a longer mean disease duration, though the association was not statistically significant (P = .098) (Table 1).
The composite mean score of HAQ-DI was 0.70 ± 0.83 with a score range of 0–3. Most participants had low disability (72.3%), while 16.8% had moderate and 11% had severe disability. Among the eight functional domains assessed, eating and hygiene were the most affected (Figure 1).
The Percentages of Patients with Categories Ranging from Ability to Work as no Difficulty to Unable to do for Each Domain and Mean HAQ-DI Category Scores (n = 400).
Table 2 shows the association of the DAS28 score with selected variables. Higher DAS28 scores were significantly associated with older age (P = .013) and lower education levels (P = .043). No significant associations were found with gender, BMI or comorbid conditions (Table 2).
Association of DAS28 Score of the Participants with Selected Variables [N = 400].
#Using ANOVA test.
The majority of individuals with all three categories of disabilities had moderate disease activity. There was a statistically significant association between functional disability and disease activity (P < .001) (Table 3). A moderate positive correlation (r = 0.487) was observed between DAS28 and HAQ-DI scores (Figure 2).
Association of Functional Disability with the Disease Severity of the Participant [N = 400].
Scatter Plot Between DAS28 Scores and HAQ-DI Scores.
TJC: Tender joint count, SJC: Swollen joint count, VAS-P: Visual analogue scale for pain, VAS-GH: Visual analogue scale for general health.
Higher HAQ-DI scores were significantly associated with greater tender joint count (TJC), swollen joint count (SJC), visual analogue scale for pain (VAS-P) and poorer general health (VAS-GH) (all P < .001). Median TJC increased from two in the low disability group to 14 in the severe disability group (Table 4).
Association of HAQ-DI with Indicators of Disease Severity.
Discussion
Our study revealed that about 11% of the participants had a severe functional disability and 16.75% had a moderate functional disability. The mean HAQ-DI score was 0.70 ± 0.83. Among the eight domains of the HAQ-DI, eating and hygiene were the most affected in RA patients. A study done by Ghosh and Sengupta 7 indicated that 43% of the patients had severe disability, 34.72% had moderate disability and 22.22% had low disability with a mean HAQ-DI score of 1.73, which is much higher than that of the current study. However, in a study done by Al-Jabi et al. 9 in Palestine, the mean HAQ-DI score was 0.94, more comparable to our findings. This difference could be due to the demographics and access of patients to healthcare, as the studies were done in different geographical areas.
Severe functional disability was seen more in the age group 31–45 years, followed by the age group 45–60 years. It was more in females than in males, in the lower socioeconomic group, the higher BMI group, diabetics and hypertensives. However, these associations were not found to be statistically significant. A study done by Ji et al. 10 also demonstrated no significant associations between these variables and HAQ-DI. However, Al-Jabi et al. 9 found that the older age group, unemployed and lower income group participants had significantly higher HAQ-DI scores (indicating severe disability). Munchey and Pongmesa 11 stated that gender, age and longer disease duration were the factors significantly associated with functional disability in Thai patients. These differences may be attributed to the variation in the methodology of the study and also their quality of life.
Participants with severe functional disability had longer RA disease duration, although this association was not statistically significant. Prior studies, including those by Al-Jabi et al. 9 and Ghosh and Sengupta 8 found significant correlations between longer disease duration and increased functional impairment, attributing this to delayed diagnosis and progressive joint damage.
Notably, our study identified a significant association between higher TC/HDL ratios and severe functional disability. The observed association may be explained by the metabolic consequences of chronic systemic inflammation. Inflam-matory states are known to induce significant alterations in lipid metabolism, including elevated total cholesterol, increased triglycerides and reduced high-density lipoprotein (HDL) levels. These changes result in a more atherogenic lipid profile, which has been implicated in both increased cardiovascular risk and poorer physical function outcomes in chronic disease populations. 12
In their study, Turk et al. 13 showed that the DAS28 score is significantly associated with the age of the RA subjects (P < .001) which is similar to the findings of the present study. Along with age, they also reported that other factors such as gender, BMI and the total cholesterol: HDL ratio were significantly associated with disease activity levels, as indicated by the DAS28 score. These findings were not present in the current study. Interestingly, our study revealed that lower levels of education were significantly associated with higher disease activity levels, suggesting that health literacy may influence disease control.
The current study indicated that higher TJC, SJC, pain score and overall health score were significantly associated with higher HAQ-DI scores. This is consistent with findings from Ji et al. 9 and Rosa-Gonçalves et al. 14 who also reported strong correlations between HAQ-DI and these clinical parameters.
This study also showed a highly significant association between disease activity and disability score. Other studies (Goma et al., Markaki et al.)15,16 also had similar findings in their study indicating that increased RA activity and joint destruction were associated with deteriorated functional capacity. The association between high disease activity and poor functional status in RA has been consistently reported, including in Indian studies. Mandal et al. (2020) found poor quality of life among RA patients in Kolkata, while Kumar et al. (2017) reported a direct correlation between DAS28 and HAQ-DI scores.4,17 Although in our study the associations of functional disability with educational status and socio-economic background were not statistically significant, the observed trends suggest a potential influence. Importantly, our study highlights the association between TC/HDL ratio and functional disability, an emerging but underexplored area, indicating the possible role of metabolic factors. These findings are consistent with emerging literature and highlight the importance of considering both inflammatory and non-inflammatory determinants of disability in RA, particularly in Indian settings.
There were various limitations of this study. The cross-sectional design, while providing a snapshot, does not allow for the assessment of changes over time or the determination of causality between factors and outcomes. The study was conducted in a single tertiary centre, which may affect the generalisability of the findings. Some of the data, such as those obtained from questionnaires, are self-reported, which can introduce bias or inaccuracies.
Conclusion
Functional disabilities exist in all domains in this RA subgroup, with the most prevalent functional limitations occurring in the areas of eating and personal hygiene. As a result, daily clinical practice requires a thorough evaluation of every aspect of daily activities in this RA subgroup. Understanding the domains of functional disability may help doctors and other health care providers focus on pertinent and changeable factors to preserve and restore function and avoid disability. Furthermore, the severity and type of the reported disability might point to the need for non-pharmacological treatment tailored to this subgroup’s needs. There appeared to be an association between higher HAQ-DI scores and longer disease duration, higher TC/HDL ratio and measures of disease activity. The onset of disabilities can be delayed by controlling disease activity, enhancing functional exercises. Implementation of comprehensive rehabilitation programmes for patients, especially those with moderate to severe disability. These programmes should focus on improving activities of daily living, such as dressing, grooming, walking and hygiene, which are commonly affected in RA patients. Educating patients on the importance of regular exercise, joint protection techniques and ergonomic adjustments to manage daily activities and prevent further disability.
Footnotes
Acknowledgements
To the Principal, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha for permission and the Medical Superintendent for facilitating the study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval and Informed Consent
The ethical approval was obtained from the institutional ethics committee with reference no XXXX/XXXX/IEC/1074/2022. Written informed consent was obtained from the participants.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.