Rheumatoid arthritis, oteoarthritis, osteoporosis, fibromyalgia, and low back pain are some conditions that can lead to work disability, increased stress, and reduced quality of life (Carmona, et al., 2001;
Gilworth, et al., 2003; Backman, 2004). Researchers have studied persons with these diseases in terms of risk factors, health care dis- parities, disability levels, occupational factors, stress, quality of life, and coping strategies.
Arthritis Risk Factors and Health Care Disparities
For reasons that are still not well understood, arthritis is more prevalent among women than men. Osteoarthritis and rheumatoid arthritis, and less prevalent diseases that cause arthralgia, are between two and 10 times higher in women than men (Buckwal- ter and Lappin, 2000). Other investigations have documented that gender, age, socioeconomic, and lifestyle factors predict increased prevalence of arthritis.
Using cross-sectional survey data from the Behavioral Risk Factor Surveillance System, Mili, et al. (2002) showed that the fol- lowing groups had high prevalence rates of arthritis: older persons, women, individuals with low educational attainment, persons with low income, sedentary individuals, and overweight and obese persons. According to the researchers, high rates of arthritis were also prevalent among groups that had not been previously recog- nized: separated and divorced individuals, those unemployed or unable to return to work, and current or former smokers.
Similar gender, age, and socioeconomic disparities associated with arthritis have been identified in other countries. Using a rep- resentative population survey in South Australia, Hill, et al. (1999) reported that individuals with arthritis had a higher probability of being female, aged, and of lower socioeconomic status compared to persons without arthritis.
Based on a sample of 7,575 Shanghai residents, aged 15 years and older, Shi, et al. (2003) discovered older age, female gender, and obesity may be risk factors for arthritis. The authors recommend weight control and more exercise to reduce the risks of arthritis.
Arthritis, Increased Stress, Disability, and Quality of Life Individuals who suffer from arthritis and musculoskeletal dis- orders can experience increased stress, work disability, impaired social and family functioning, and diminished quality of life. An analysis of population-based health and activity limitation surveys showed that arthritis/rheumatism was responsible for over 30% of all disabilities related to mobility and agility (Raina, et al., 1998).
According to the Mini-Finland Health Survey of 7,217 men and women aged 30 years or more, inflammatory arthritis was the best predictor of all types of disability (Makela, et al., 1993). Persons with inflammatory arthritis were at increased risk for having reduced work capacity and a regular need for help in daily activi- ties. Those individuals with inflammatory disease in the 30 to 64 year age group had a higher probability of occasionally needing assistance.
Disability rates are influenced by the number of co-existing chronic diseases. Using data from the National Health Interview Survey, Supplement on Aging, Verbrugge, et al. (1991) reported
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that the rate of impairment among individuals with arthritis increases with the number of chronic diseases and associated impairments. In their study, long duration of arthritis and recent medical care for the condition predicted disability.
Obesity may be an important determinant of disability among arthritis sufferers. Verbrugge, et al. (1991) discovered that obesity (a body mass index greater than or equal to 30 kg/m2) predicts dis- ability in persons with arthritis. Low body mass index (less than 20 kg/m2) also was related to an increased rate of disability among individuals with arthritis.
Persons with musculoskeletal disorders report some of the poorest quality of life, particularly in regard to bodily pain and physical functioning (Reginster, 2002). These persons have com- plained of lower quality of life than persons with gastrointestinal problems, chronic respiratory conditions, and cardiovascular diseases.
Persons who suffer from arthritis and chronic co-morbidity may be physically inactive and experience higher rates of disabil- ity and impaired quality of life (Breedveld, 2004; Kriegsman, et al., 2004). Drawing on data from 2,497 older persons in the Longitudi- nal Aging Study Amsterdam, Kriegsman, et al. (2004) found that arthritis led to a major decline in physical functioning in persons with diabetes or malignancies. The authors showed that combina- tions of chronic diseases that both affect physical functioning but through different pathways (e.g., reduced locomotor functioning compared to decreased endurance) may result in more disability than other combination of diseases.
Physical inactivity among those afflicted with arthritis is asso- ciated with functional limitations, disability, and increased risk for cardiovascular disease. Kaplan, et al. (2003) investigated older adults with arthritis and identified risk factors for physical inac- tivity using data from the Canadian National Population Health Survey. Their findings indicated that physically inactive persons with arthritis were more likely to be women, older than 75 years, have functional impairments, be underweight (body mass index less than 25 kg/m2) or overweight (body mass index over 25 kg/
m2), have high levels of pain, and not have prescription drug insurance.
Arthritis has been found to adversely influence different aspects of a person’s quality of life. In one investigation of older
adults with arthritis, Dominick, et al. (2004b) showed that patients with osteoarthritis and rheumatoid arthritis reported worse gen- eral health, physical health, mental health, reduced participation in activities, pain, and less sleep than controls. Osteoarthritis and rheumatoid arthritis patients also were less likely to report feeling healthy and being full of energy compared to controls.
A variety of demographic, socioeconomic, and psychosocial factors influence disability levels among persons with arthritis (Makela, et al., 1993). Gender may influence the odds of becoming disabled among persons with arthritis and other musculoskeletal problems (van Schaardenburg, et al., 1994). One study of persons, aged 85 years and over, with musculoskeletal disorders revealed that female gender was associated with disability (van Schaardenburg, et al., 1994).
Age factors may affect disability levels among individuals with arthritis and musculoskeletal problems. Verbrugge, et al.
(1991) found that older age increases the risks of disability among arthritis sufferers. In an investigation based on data from the Cana- dian Health and Activity Limitation Survey, Badley and Ibanez (1994) showed that increasing age is a predictor of disability among individuals with musculoskeletal disorders.
Using data from four national surveys, Miles, et al. (1993) eval- uated disability among older adults with arthritis. They discovered that among individuals, aged 65–74 years, 20% of individuals with arthritis stated that they had difficulty walking. The percentages of persons with arthritis reporting this disability increased in older age groups.
The elderly are especially vulnerable to high rates of disabil- ity since other conditions besides muscuoloskeletal disorders con- tribute to increased risks of disability (van Schaardenburg, et al., 1994). One report showed that vision problems, cognitive difficul- ties, and neurological disorders in women and men, aged 85 years and over, were related to other disabilities in addition to muscu- loskeletal problems.
Racial and ethnic factors are increasingly recognized as pre- dictors of disability in individuals with arthritis and other muscu- loskeletal problems. Disadvantaged minority groups with various musculoskeletal disorders may be especially at risk of becoming disabled. In their study of arthritis, Verbrugge, et al. (1991) discov-
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ered that non-whites with arthritis had higher odds of becoming disabled than whites with arthritis.
Marital status may predict disability among sufferers of arthri- tis and other musculoskeletal problems. In their investigation, Badley and Ibanez (1994) found that being single predicted dis- ability among persons with musculoskeletal disorders. Likewise, not being married was associated with increased odds of disabil- ity in another report (Verbrugge, et al., 1991).
Socioeconomic conditions may affect the degree to which indi- viduals with arthritis become disabled. Low educational attain- ment among persons with different musculoskeletal disorders may increase their chances of being impaired. Makela, et al. (1993) dis- covered that a low educational level was an independent predictor of disability among individuals suffering from various muscu- loskeletal problems. In another study, Badley and Ibanez (1994) indicated that fewer years of education was independently related to disability among individuals suffering from musculoskeletal dis- orders. Verbrugge, et al. (1991) also reported that lower education predicted impairment among arthritis sufferers.
Arthritis sufferers with low income may be especially at risk of becoming disabled because of their reduced access to health care services and inadequate knowledge about techniques to prevent the disabling effects of arthritis. One report using the population- based 1998 National Health Interview Survey analyzed possible income disparities in arthritis impairment among non-insulin- taking diabetics (Morewitz, 2003a). The findings showed that non- insulin taking diabetics with incomes less than $20,000 were more likely to report that arthritis impaired their daily activities than non-insulin-taking diabetics with incomes of $20,000 or more. The income differences persisted after controlling for possible predic- tor variables.
Unemployment may increase the risk of disability among sufferers of musculoskeletal disorders. In one investigation, not being employed was an independent predictor of disability among persons with musculoskeletal disorders (Badley and Ibanez, 1994).
Low socioeconomic status is an impediment to accessing and using health care services for musculoskeletal problems. Since early medical treatment can minimize the development of perma- nent joint and visceral damage in patients with rheumatoid arthri-
tis and other inflammatory diseases, a delay in treatment may result in irreversible impairment (Buckwalter and Lappin, 2000).
Some of the same occupational and lifestyle characteristics that are risk factors for arthritis also may increase disability levels in individuals who suffer from arthritis and related disorders.
Repetitive heavy lifting at work, obesity and overweight, smoking, alcohol use, and inadequate nutrition may influence disability rates among persons suffering from arthritis and related disorders.
Individuals with arthritis can experience work instability, the condition under which there is a mismatch between their func- tional limitations associated with their disease and the demands of their job (Gilworth, et al., 2003). This mismatch may lead to work disability if it is not corrected.
Lower extremity problems also increase the risk of disability among persons with arthritis, diabetes, and associated disorders.
In one population-based report, Morewitz, Dintcho, and Lim, et al.
(2002) discovered that diabetics and non-diabetics suffering ankle pain, stiffness, and aching in the last 12 months were more likely to have significant decreased physical mobility.
Anxiety and depression may increase the risk of disability in individuals with arthritis and related problems. Zautra and Smith (2001) investigated a study of 188 older women with rheumatoid arthritis and osteoarthritis (n = 101), and discovered that depres- sive symptoms were related to pain increases in persons with rheumatoid arthritis and osteoarthritis and to increased reactivity to stress and pain in individuals with rheumatoid arthritis.
Ethnic and cultural factors may influence the extent to which individuals with anthritis and lower extremity pain develop anxiety and lower extremity impairment. Using the population- based 1998 National Health Interview Survey, Morewitz, Sham- toub, and Ky, et al. (2002) explored possible ethnic and racial differences in feelings of anxiety and ankle pain and stiffness.
According to their results, African-Americans who suffer ankle pain, stiffness, and aching in the previous 12 months were less likely to report anxiety than whites with similar ankle problems.
Researchers are studying the degree to which personality factors and coping strategies influence increased disease severity and disability in arthritis sufferers. Evers, et al. (2003) studied patients with early rheumatoid arthritis and examined the role of
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personality characteristics, e.g., neuroticism and extroversion, and coping and social support at initial diagnosis as predictors of changes in disease activity. The study results showed that person- ality characteristics did not predict subsequent disease activity at a 1-year follow-up. However, low levels of social support and extensive use of avoidance coping strategies were linked to increased disease activity at the 3- and 5-year follow-ups.
Below is a discussion of risk factors, quality of life and disabil- ity, coping strategies, social support factors, treatment outcomes, and patient education programs for patients with rheumatoid arthritis and other disorders.
Rheumatoid Arthritis
Rheumatoid Arthritis Risk Factors
Genetic, environmental, and social risk factors have been im- plicated in the etiology of rheumatoid arthritis. Social and envi- ronmental factors may influence the development of rheumatoid arthritis even in genetically-related communities. Solomon, et al.
(1975) studied two South African black communities, one rural in north-western Transvaal, and the other urban in Johannesburg.
They found that blacks in the rural community had a much lower prevalence of rheumatoid arthritis than those in the urban com- munity. The study subjects in therural community had a mild form of rheumatoid arthritis and lacked the classical features of rheuma- toid arthritis, whereas the urban community subjects resembled classical rheumatoid arthritis in the white populations. These results highlight the salience of sociological and environmental factors in the development of rheumatoid arthritis in genetically related communities.
Cigarette smoking is a well-known rheumatoid arthritis risk factor (Stolt, et al., 2003; Harrison, 2002). A study, using 679 persons diagnosed with rheumatoid arthritis and 847 controls, showed that smoking was related to an increased risk of developing seropostive rheumatoid arthritis, but not seronegative rheumatoid arthritis.
(Stolt, et al., 2003). In their study, current smokers, and ex-smokers, of both sexes had greater odds of developing seropositive rheuma-
toid arthritis. Individuals who had smoked for 20 or more years had increased odds of acquiring seropostive rheumatoid arthritis.
Smoking 6 to 9 cigarettes a day also was related to an increased risk of developing the disease, and the risks for developing seropostive rheumatoid arthritis continued for 10 to 19 years after quitting smoking.
One study by Krishnan, et al. (2003) evaluated the possible association between gender, smoking, and the risk for acquiring rheumatoid arthritis. Based on a sample of Finnish patients with rheumatoid arthritis, the investigators discovered that in men, a past history of smoking was linked to an increased risk of devel- oping seropostive rheumatoid arthritis. However, among women, smoking history was not associated with an increased risk of the disease.
Researchers have assessed the effects of smoking on the risk of acquiring rheumatoid arthritis among postmenopausal women.
Using data from the Iowa Women’s Health Study, Criswell, et al.
(2002) found that postmenopausal women who were current smokers or who had stopped smoking 10 years or less before the start of the study had an increased risk of acquiring rheumatoid arthritis compared to those postmenopausal women who had never smoked. Their results indicated that the duration and inten- sity of smoking were related to an increased risk of developing rheumatoid arthritis.
The role of menopause as a risk factor for rheumatoid arthritis needs further investigation (Krishnan, et al., 2003).
Epidemiologic data has shown a strong association between hormonal and reproductive factors and the risk of rheumatoid arthritis. Oral contraceptives or estrogen replacement therapy may protect against the onset of the disease. In addition, at least one pregnancy may have a protective effect. Oral contraceptives or estrogen replacement therapy may lead to higher levels of endogenous heat shock proteins, which triggers immunotolerance to subsequent exposure to triggering agents of rheumatoid arthritis.
Some men with rheumatoid arthritis are more likely to have low levels testosterone levels. However, less is known about the levels of other sex hormones (estradiol, estrone, and the adrenal androgen dehydroepiandrosterone) among male rheumatoid
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arthritis sufferers (Tengstrand, et al., 2003). Based on a study of 101 men with rheumatoid arthritis, one report revealed that subjects had high levels of estradiol and other abnormalities in sex hor- mones. In these subjects, high concentrations of estradiol were related consistently to joint inflammation. The authors suggest that the high levels of estradiol may be due to an increased conversion of estrone to estradiol (Tengstrand, et al., 2003).
Occupational factors have been linked to the etiology of rheumatoid arthritis. In a study of 422 individuals with rheuma- toid arthritis and 858 controls, Olsson, et al. (2004) discovered that the risk for rheumatoid arthritis increased with increasing duration of occupational exposure to vibrations and mineral dust. The find- ings supported a causal relationship among men and multiple exposures were related to an increased risk of rheumatoid arthritis for most occupations. For example, among farmers, exposure to organic dust was related to an increased risk of rheumatoid arthri- tis, and multiple exposures predicted an elevated risk of the disease.
Older age and low socioeconomic status, including low edu- cational attainment, are correlated with the incidence of rheuma- toid arthritis in the United States (Markenson, 1991). These factors are also associated with a poorer prognosis.
Risk Factors for Rheumatoid Arthritis-Related Disability Backman (2004) noted that about one third of individuals with rheumatoid arthritis will leave employment prematurely. Prospec- tive cohort studies have shown that 20% to 30% of individuals with early rheumatoid arthritis become permanently work dis- abled during the first 2 to 3 years of the disease (Sokka, 2003). In addition to causing early retirement, rheumatoid arthritis can cause a significant number of absences fromwork(Kapidzic-Basic, et al., 2004).
Although rheumatoid arthritis can not be assessedby a single diagnostic measure, a variety of measures can be used to determine disability in patients with rheumatoid arthritis. Various measures, including pain assessment, Ritchie articular index, the number of painful and swollen joints, morning stiffness duration, and index of joint motion, can be used to assess disability in rheumatoid
arthritis patients (Kapidzic-Basic, et al., 2004; Pincus and Sokka, 2003).
Kapidzic-Basic, et al. (2004) recommended that assessment of working ability should not be made based on current status of certain measures, such as pain assessment, Ritchie articular index, motion assessment, functional ability, and number of painful and swollen joints. However, clinicians should make their decisions based on the progression of the disease.
Genetic and non-genetic factors may be risk factors for work disability among patients with rheumatoid arthritis (Symmons, 2003; Backman, 2004). Pain, joint destruction, demographic, socioe- conomic status, occupational factors, policies related to work accommodation, and psychosocial distress and social support are some of the factors that influence work disability and failure to return to work among persons with rheumatoid arthritis (Backman, 2004; Reisine, et al., 2001).
Rheumatoid factor status, disease activity, joint destruction, deformity, and intense chronic pain are associated with rheuma- toid arthritis-related work disability and decreased quality of life (Mullan and Bresnihan, 2003; Scott, et al., 2003). The development of measurable structural joint damage indicates severity of rheumatoid arthritis and future disability (Mullan and Bresnihan, 2003).
However, more research is needed to evaluate the role of pain, joint destruction, and other factors in predicting work disability compared to other risk factors. For example, both joint damage and disability in rheumatoid arthritis increase with disease duration, but the nature of their association is not certain. Scott, et al. (2003) noted that 39 to 73% of patients with early rheumatoid arthritis acquire one or more erosions in their hands and wrists in 5 years.
In addition, there is a constant worsening of joint damage during the first 20 years of the disease. With regard to work disability, there is an initial drop in disability in the first years of the disease fol- lowed by an increase in disability. Theirstudies show that in early rheumatoid arthritis, there is either no association or a weak association between joint damage and disability. However, as the duration of rheumatoid arthritis increases, the link between joint damage and disability becomes more prominent. The authors
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