Rheumatoid Arthritis- Assessment Of Functional Performances Of The Patients

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 SB CLASSIFICATION CLASS1 CLASS2 CLASS3 S. Type No joint

1.

Knees affected

of N %

N %

4 16.7%

2 0

Pearson chi square test

N %

83.3% -

-

χ2=12.4 P=0.001 significant

6 6 Hand joints 4 2.9% 47.1% 50.0% 4 8 affected 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.(χ2=12.4, P=0.001) 2.

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 joint

DISABILITY INDEX of 1 2

1.

Knees affected

2.

Hand joints affected

3

N

%

N

%

N

%

-

-

-

-

24

100.0%

48

32%

80 50%

32

28%

Pearson chi-square Test χ2=26.1 P=0.001 significant

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.( χ2=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.