Measurement of the quality of life in rheumatic disorders using the EuroQol

The EuroQol is a validated quality of life (QOL) scale that has been used in population and clinical studies, and has been reported in patients with rheumatoid arthritis (RA). It is short, simple to complete, and might be suitable for surveys of rheumatic disease patients. The properties of this instrument were investigated in a postal survey of 1372 rheumatic disease patients, including 537 with RA, 319 with osteoarthritis (OA) and 516 with fibromyalgia. In addition, simultaneous measurements of functional disability, pain, psychological status, global severity and demographic characteristics were made. EuroQol scores (0.57) were significantly lower than VAS health state scores (0.67) and arthritis-related global severity scores (0.62). QOL was similar in RA and OA, but lower in fibromyalgia, across all instruments. The distribution of EuroQol scores had many gaps and was not continuous. EuroQol did not reflect VAS QOL scores at EuroQol levels below 0.5, and the mean score difference between the instruments below that level was 0.43. Many patients with low EuroQol scores (including some with health states that were 'worse than death') had high VAS scores. These differences appear to have arisen because disability, pain and depression questions ask about mild or moderate problems, but not both, thereby forcing scale compression in the mid ranges. In addition, the 'severe' value is so extremely abnormal that few patients endorse it. Finally, penalty scores are applied to those with at least one maximally abnormal score. The scoring properties and distributional aspects of the EuroQol indicate substantial problems in its use in rheumatic disease patients.      

Dissatisfaction,disability, and rheumatoid arthritis

Objectives. To investigate dissatisfaction with function in patients with rheumatoid arthritis [RA], and to see if dissatisfaction can be adequately explained by level of function. Methods. Fifty patients with RA were assessed for disease activity, psychological status, disability, expectation of future disability, and satisfaction with both global function and individual activities of daily living [ADL]. Results. Fifty percent of patients expressed dissatisfaction with global function, which correlated more strongly with pain (r = 0.474) and psychological status than with function (r = 0.398). Only 10% predicted improvement in global function. Seventy-two percent expressed dissatisfaction with performing at least one ADL. Conclusions. Patient dissatisfaction with both global function and individual ADL function is high and cannot adequately be explained by disability alone. Correlation with pain and psychological status implies that modifying these variables (perhaps through education programs about pain relief or relaxation) could reduce dissatisfaction.     

Primary juvenile fibromyalgia. Psychological adjustment,family functioning,coping, and functional disability

Objectives. 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. Methods. Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. Results. All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. Conclusion. The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.     

Determinants of WOMAC function, pain and stiffness scores: evidence for the role of low back pain, symptom counts, fatigue and depression in osteoarthritis, rheumatoid arthritis and fibromyalgia.

OBJECTIVES: The Western Ontario MacMaster (WOMAC) is a validated instrument designed specifically for the assessment of lower extremity pain and function in osteoarthritis (OA) of the knee or hip. In the clinic, however, we have noted that OA patients frequently have other musculoskeletal and non-musculoskeletal problems that might contribute to the total level of pain and functional abnormality that is measured by the WOMAC. In this report, we investigated back pain and non-articular factors that might explain WOMAC scores in patients with OA, rheumatoid arthritis (RA) and fibromyalgia (FM) in order to understand the specificity of this instrument. METHODS: RA, OA and FM patients participating in long-term outcomes studies completed the WOMAC and were assessed for low back pain, fatigue, depression and rheumatic disease symptoms by mailed questionnaires. RESULTS: Regardless of diagnosis, WOMAC functional and pain scores were very much higher (abnormal) among those complaining of back pain. On average, WOMAC scores for back pain (+) patients exceeded those of back pain (-) patients by approximately 65%,, and 52% of OA patients reported back pain. In regression analyses, study symptom variables explained 42, 44 and 38% of the variance in WOMAC function, pain and stiffness scores, respectively. In the subset of OA patients, radiographic scores added little to the explained variance. The strongest predictor of WOMAC abnormality in bivariate and multivariate analyses was the fatigue score, with correlations of 0.58, 0.60 and 0.53 with WOMAC function, pain and stiffness, respectively. The WOMAC performed well in RA and FM, and correlated strongly with the Health Assessment Questionnaire (HAQ) disability scale and a visual analogue scale (VAS) pain scale. CONCLUSION: The WOMAC captures more than just knee or hip pain and dysfunction, and is clearly influenced by the presence of fatigue, symptom counts, depression and low back pain. WOMAC scores also appear to reflect psychological and constitutional status. These observations suggest the need for care in interpreting WOMAC scores as just a measure of function, pain or stiffness, and indicate the considerable importance of psychological factors in rheumatic disease and rheumatic disease assessments.     

Functional ability and work status in patients with fibromyalgia

To assess functional ability in fibromyalgia patients, we examined 28 patients during the performance of five standardized work tasks (SWT), and compared their performance to 26 RA patients and 11 healthy community controls. Fibromyalgia patients performed 58.6% and RA patients 62.1% of the work done by normals. Work performance was strongly associated with pretest Stanford Health Assessment Disability Index (HAQ) scores (r = 0.705), but also with pain, global severity, and psychologic status in both RA and fibromyalgia groups. We also examined work status in 176 fibromyalgia patients. Sixty percent were employed, 9.6% considered themselves disabled, but only 6.2% received disability payments (none for the specific diagnosis of fibromyalgia). Thirty percent of patients had changed jobs because of this illness. Functional ability is impaired in Fibromyalgia. SWT and the HAQ disability instrument may be effective in the clinical assessment of fibromyalgia.     

Hand disability and related variables in patients with rheumatoid arthritis

Objective: To carry out a cross-sectional study of patients with rheumatoid arthritis (RA) for hand disability, articular damage and to define their relation with demographic, laboratory and clinical parameters. Methods: The study included 105 RA patients with a mean age of 49.4 years. Demographic parameters of the patients were recorded. Clinical parameters including disease duration, duration of morning stiffness, pain assessed by visual analog scale, Ritchie Articular Index, grip strength, lateral, tip and three-fingered pinch, and laboratory parameters comprising C-reactive protein, erythrocyte sedimentation rate and rheumatoid factor were evaluated in all patients. The Rheumatoid Arthritis Articular Damage (RAAD) score was used to assess the irreversible articular damage and deformities of the hand. Hand disability was assessed by the special hand disability index of Standford Health Assessment Questionnaire (HAQ). Results: Hand disabilities of various levels were detected in 81% of the patients. Disease duration, grip strength, pinch measurements, clinical and laboratory activity parameters were strongly correlated with hand disability (p<0.01). Hand disability was more related to disease activity parameters than articular damage (p<0.01 and p<0.05, respectively). Grip strength and pinch measurements were the most related parameters with hand disability. The disability scores were significantly higher in female patients (p<0.01). The RAAD score was correlated with disease duration and grip strength (p<0.01). The clinical and laboratory parameters and seropositivity were not correlated with articular damage assessed by RAAD score (p>0.05). Conclusion: Our data suggest that grip strength and pinch measurements seem to be the most related variables with hand disability and articular damage. Therefore, grip strength and pinch measurement should be included in the evaluation and follow-up of the patients with RA in hand rehabilitation units.     

Factors associated with functional disability in patients with rheumatoid arthritis

To determine factors associated with functional disability in patients with rheumatoid arthritis (RA). A total of 100 RA patients were reviewed retrospectively. Multiple regression analysis was used to investigate associations between the dependent variable (health assessment questionnaire) and independent variables (age, disease duration, hand grip strength values, VAS and DAS-28 scores). Main factors associated with functional disability were disease activity score as reflected in a high score on the DAS-28 (r = 0.68, p < 0.001) and disease duration (r = 0.23, p < 0.05). Increased age, decreased grip strength and high pain level were associated with lower functional ability, but none of these was a predictor of disability in the regression model. The results indicate that age, disease duration, disease activity, pain intensity and hand grip strength are related to physical disability in patients with RA. However, only disease activity has an impact on physical function. Thus, treatment of RA patients should focus on early inhibition of disease activity in order to achieve a good functional outcome.     

A biopsychosocial model of disability in rheumatoid arthritis

Objective. To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time. Methods. Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables. Results. Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations. Conclusion. The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.     

Functional disability in rheumatoid arthritis patients compared with a community population in Finland

OBJECTIVE: To compare Health Assessment Questionnaire (HAQ) scores of patients with rheumatoid arthritis (RA) with HAQ scores from a sex- and age-adjusted population. METHODS: Patients with RA (n = 1,095) and control subjects (n = 1,530) completed a mailed questionnaire that comprised the HAQ, pain and global health scores, education level, and comorbidities, as well as height, weight, and lifestyle attitudes, including smoking and exercise habits. RESULTS: The HAQ scores increased (indicating declining function) with older age in patients and controls. The HAQ scores were above the reference values (>95th percentile of the HAQ scores of the age- and sex-matched population) in 17-45% of women with RA and in 7-32% of men with RA ages 30-79 years, while the HAQ scores of the patients > or =80 years were similar to those of the age- and sex-matched population. In a logistic regression model, the odds ratio for disability (HAQ score > or =1; at least some difficulties in most activities of daily living) was 7.7 (95% confidence interval 5.3-11.1; P < 0.001) among patients with RA compared with community controls, when adjusted for age, sex, education, smoking, exercise, body mass index, number of comorbidities, and pain. CONCLUSION: RA is associated with a >7-fold risk of disability compared with that in a general population of adults in the same community. The impact of disability due to RA appears to be greater in younger and middle-age people than in elderly patients.     

A comparative evaluation of health related quality of life and depression in patients with fibromyalgia syndrome and rheumatoid arthritis

The aim of this study was to compare health related quality of life (HRQoL) and assess functional and psychological status in rheumatoid arthritis (RA), fibromyalgia syndrome (FS) patients and controls (each 30 subjects). Demographic characteristics, pain and sleep disturbance by Visual Analog Scale, depression by Beck Depression Inventory (BDI), disease impact by fibromyalgia impact questionnaire, DAS-28, and HRQoL by SF-36 were gathered. The FS group scored significantly worser than the RA group with respect to physical role, social functioning and bodily pain subscales of SF-36. The scores of all SF-36 subscales were significantly lower in FS and RA patients than controls except mental health score. All of the subscales of SF-36 were negatively correlated with BDI scores in FS patients. In RA group, the DAS-28 scores were inversely correlated with all of SF-36 subscales. In conclusion, presence of comorbid depression must be taken into account when determining HRQoL in FS and RA. Essentials improving the HRQoL are management of depression in FS and control of disease activity in RA.     

A pilot study to determine whether disability and disease activity are different in African-American and Caucasian patients with rheumatoid arthritis in St. Louis, Missouri, USA

OBJECTIVE: To compare the levels of disability and disease activity in African-Americans and Caucasians with rheumatoid arthritis (RA) in an academic medical center practice, and to determine whether the differences are independently associated with ethnicity. METHODS: Data on socioeconomic, disease related, psychological, and behavioral variables were obtained from 100 outpatients (67 Caucasians, 33 African-Americans) with RA. Functional status was assessed with the Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS-28). Chi-square and Student t tests were used to test for differences between groups. Multiple regression analysis was used to determine whether ethnicity was associated with these differences independent of other factors known to influence disease outcome. RESULTS: African-Americans and Caucasians did not differ with respect to age, sex, disease duration, rheumatoid factor positivity, and medication compliance. African-Americans had higher scores than Caucasians for HAQ (1.5 +/- 0.8 vs 0.9 +/- 0.7; p < 0.001) and DAS-28 (5.5 +/- 1.3 vs 4.3 +/- 1.4; p < 0.001). Regression models showed that ethnicity was not independently associated with the higher HAQ and DAS-28 scores when controlled for demographic, socioeconomic, psychological, and behavioral factors. Arthritis self-efficacy approaches significance in the regression model. CONCLUSION: HAQ disability and RA disease activity were higher in African-Americans than Caucasians in this sample from an academic medical center practice. However, ethnicity was not independently associated with these outcomes when socioeconomic and psychological factors were taken into account. Improvement in self-efficacy has the potential to improve outcome in African-Americans with RA.     

A reappraisal of HAQ disability in rheumatoid arthritis

OBJECTIVE: To investigate the course of self-reported disability in rheumatoid arthritis (RA) using the major self-report measure of functional impairment, the Health Assessment Questionnaire (HAQ). METHODS: The course of HAQ disability was assessed in 32,525 observations (1,843 patients) in which the HAQ was administered. In addition, a subset of 2,189 visits from 50 patients, followed on average for 17 years, was studied to model the effect of disease duration on the course of HAQ disability in individual patients. Linear and fractional polynomial regression as well as smoothing algorithms were applied to the group of RA patients and then to the individual course of patients. RESULTS: Group linear and nonlinear models of the effect of disease duration on HAQ disability were found to have 3 characteristics: 1) HAQ disability scores are high at disease onset rather than gradually increasing; 2) HAQ disability increases very slowly over time (0.03 units per year); and 3) all such models fit very poorly, explaining only 5% of the variance in HAQ disability scores. However, application of nonlinear models to individual patient courses (as opposed to groups of patients) explains 37% of the HAQ disability score variation. In some patients, the course of HAQ disability was either 1) chaotic (scores change without any pattern) or 2) determinable, but unrelated to time. When covariates were added to the group model, however, the course of HAQ disability became clearer, and 51% of the variance in the disability score could be explained, statistically, by pain, depression, erythrocyte sedimentation rate, and disease duration. CONCLUSION: Individual RA patients have differing, characterizable courses: 1) nonlinear, 2) chaotic, or 3) non-time determined. The model that self-reported physical disability, as measured by the HAQ, occurs as a function of disease acting over time does not fit the data well and is an inadequate model. This discrepancy may also be the result of the patient's upward reappraisal of functional ability with increasing time. The predominant determinants of HAQ disability in RA are disease activity, pain, and psychosocial factors rather than structural abnormality. Although the HAQ is a useful clinical tool and a central measure of disease outcome, it measures both process and outcome, and usually more process than outcome. Individual patient models that include all that is known about the patient--the paradigm of clinical care-may be a more effective way to examine the course of RA than are conventional group-based models.     

Effort testing in patients with fibromyalgia and disability incentives

OBJECTIVE: To examine whether symptom exaggeration is a factor in complaints of cognitive dysfunction using 2 new validated instruments in patients with fibromyalgia (FM). METHODS: Ninety-six patients with FM and 16 patients with rheumatoid arthritis (RA) were administered 2 effort or symptom validity tests designed to detect exaggerated memory complaints as part of a battery of psychological tests and self-report questionnaires. RESULTS: A large percentage of patients with FM who were on or seeking disability benefits failed the effort tests. Only 2 patients with FM who were working and/or not claiming disability benefits and no patient with RA scored below the cutoffs for exaggeration of memory difficulties. CONCLUSION: This study illustrates the importance of assessing for exaggeration of cognitive symptoms and biased responding in patients with FM presenting for disability related evaluations.     

Health-related quality of life measured by the Short Form 36 (SF-36) in systemic sclerosis: correlations with indexes of disease activity and severity, disability, and depressive symptoms

The aim of this study was to evaluate health-related quality of life (HR-QOL) in patients with systemic sclerosis (SSc), to compare it with that of patients with rheumatoid arthritis (RA), and to correlate it with other parameters. HR-QOL was evaluated by the Short Form 36 (SF-36), SSc disease activity and severity by preliminary indexes recently proposed, disability by the Health Assessment Questionnaire (HAQ), and depressive symptoms by the Beck Depression Inventory. HR-QOL perception was not statistically different in patients with SSc and RA, except that patients with diffuse cutaneous involvement had worse scores in the general health and mental health dimensions than patients with RA (p=0.03). Compared with RA, patients with SSc tended to perceive less bodily pain (p=0.06) and have less disability (p=0.04) but to report higher depressive symptom scores (p=0.05). SSc patients HR-QOL was associated with some disease severity scales (general, kidney and, less significantly, heart), but it was poorly correlated with the other evaluated disease activity and severity indexes. A strong correlation with disability and with depressive symptoms was observed. In conclusion, patients with SSc perceived a reduced HR-QOL similar to that of patients with RA. SF-36 may provide useful information in their evaluation.     

Pain, functional disability, and psychological status: a 12-month study of severity in fibromyalgia

We mailed monthly questionnaires regarding fibromyalgia symptoms to 75 patients during a one-year period. Fibromyalgia symptoms in individual patients were generally stable over time as assessed by repeated measures and slope analyses, but patients clearly differed from one another in symptom severity. Pain, psychological status, and functional disability, but not sleep disturbance or morning stiffness, were the independent explanatory factors for disease severity in regression models. Functional disability has not been recognized previously as an important factor in fibromyalgia severity, but our data suggest that it should be assessed as a process and outcome measure in future fibromyalgia studies.     

Correlates and predictors of disability in vulnerable US Hispanics with rheumatoid arthritis

Objective

US Hispanics with rheumatoid arthritis experience worse functional outcomes compared to whites. The determinants of disability, however, are not well established in large Hispanic cohorts. In the present report, we identified factors associated with disability in a cross‐sectional design, and evaluated their individual contributions to disability over time.

Methods

Two hundred fifty‐one Hispanic subjects from a single center were evaluated. Disease activity, serologies, radiographs, treatments, irreversible articular damage (defined as subluxation, arthrodesis, fusion, or prosthesis), and joint replacement surgeries were recorded. Self‐reported disability (Health Assessment Questionnaire disability index), patient pain by a visual analog scale, and depression assessments were collected. Cross‐sectional factors associated with disability were identified, and their effects on future disability were evaluated in a subgroup of 114 patients assessed 6 months later.

Results

Six parameters were independently related to disability cross‐sectionally: pain was the strongest (P < 0.0001), followed by irreversible articular damage, disease activity, depression, age, and fibromyalgia (P < 0.03 for all). Baseline parameters predicting disability 6 months later included, in decreasing significance, irreversible articular damage (P = 0.004), depression, disease activity, age, and pain (all P < 0.04).

Conclusion

In cross‐sectional analysis, self‐reported pain had the strongest relationship with disability; however, factors such as irreversible articular damage, depression, and disease activity were more important in predicting future disability. Most of these factors are amenable to targeted interventions and should be addressed in an effort to improve functional outcomes.     

Determinants of sexual disability and dissatisfaction in female patients with rheumatoid arthritis

Previous research has identified two main problems of sexuality in female rheumatoid arthritis (RA) patients: difficulties in sexual performance and diminution of sexual desire and satisfaction. This study attempts to determine the clinical and psychological factors significantly contributing to sexual disability and dissatisfaction in female RA patients. Ninety consecutive female RA outpatients were assessed by a gynecologist. After excluding patients who were not sexually active and those with genital tract abnormalities, 52 patients were examined and investigated rheumatologically and given questionnaires assessing sexual performance, desire, and satisfaction, as well as demographic variables, pain, disability, anxiety, and depression. Following a correlation analysis, the contributions of demographic, disease, and psychological variables to sexual disability and dissatisfaction were explored by hierarchical and stepwise regression. Thirty-two patients (62%) had difficulties in sexual performance including nine patients (17%) who were totally unable to engage in sexual intercourse because of arthritis. Sexual desire or satisfaction were diminished in 24 patients (46%) and completely lost in 24 patients (46%). Sexual disability was not significantly correlated with any psychodemographic variables, but with parameters of disease activity (p<0.001), Health Assessment Questionnaire (HAQ)-disability (p<0.001), hip (p<0.001) but not knee joint disease, seropositivity (p<0.05), and diminished desire (p<0.05). However, HAQ-disability and hip joint disease were the only independent and significant determinants of sexual disability in the regression model after controlling for the effects of age and disease duration. These variables together explained 64% of the variance of sexual disability. On the other hand, pain (p<0.001), age (p<0.05), and depression (p<0.05) were the significant determinants in the regression model for sexual dissatisfaction, all together contributing 36% of its variance. More than 60% of female RA patients experience variable degrees of sexual disability and diminished sexual desire and satisfaction. Difficulties in sexual performance are related more to overall disability and hip involvement, while diminished desire and satisfaction are influenced more by perceived pain, age, and depression.     

Alexithymia and anger in patients with fibromyalgia

Our objective was to delineate the relevance of the personality construct alexithymia and anger-in in patients with fibromyalgia syndrome. Fifty subjects with fibromyalgia syndrome were compared to 20 subjects with rheumatoid arthritis and 42 healthy controls on the measures of anxiety, depression, anger, alexithymia, pain intensity and disability. There was a significant difference on the measures of anxiety and anger between FMS and RA groups, and also between FMS patients and healthy controls. There was a significant difference between FMS patients and healthy controls on the measures of depression, difficulty in identifying feelings subscale of TAS (TAS-dif), and total alexithymia scores. When the severity of pain was controlled for, there was a significant difference on the measures of anger and alexithymia between the FMS and the RA groups. Fibromyalgia patients were more alexithymic than rheumatoid arthritis patients even when the level of depression was controlled for. Anger towards oneself, which is anger-in, was higher in patients with fibromyalgia patients than in the rheumatoid arthritis sample. A stepwise regression model showed that the anger-out scores and the anxiety scores predicted the level of pain severity, and this explained 32% of the variance in the fibromyalgia syndrome group. Although anger-in is consistently higher in fibromyalgia patients, it is the behavioral expression of anger, together with anxiety, that predicts the severity of the pain. The difficulty of identifying feelings, rather than other dimensions of alexithymia, seems to be associated with fibromyalgia.Abbreviations CLBP Chronic low back pain - FMS Fibromyalgia syndrome - RA Rheumatoid arthritis - VAS Visual analog scale     

Determining rheumatologists' accuracy at assessing functional disability in rheumatoid arthritis patients using the Health Assessment Questionnaire-Disability Index

OBJECTIVE: To test rheumatologists' accuracy in determining functional disability of their patients with rheumatoid arthritis (RA). METHODS: We used the Health Assessment Questionnaire-Disability Index (HAQ-DI) as our guide at assessing functional disability in patients with RA. Included were male and female patients, 18 to 65 years of age, diagnosed with RA. Demographic data collected included the patients' age, disease duration, rheumatoid factor (RF) status, presence of rheumatoid nodules, absence or presence of erosive disease, and class and stage of their disease. The primary endpoint was the mean difference in the patients' HAQ-DI scores versus that of the physicians' (mHAQ-Diff). Secondary endpoints were the mean difference in pain assessment scale (mPAS-Diff) score; and assessing to see if the physicians' HAQ-DI was altered by the patients' age, disease duration, RF status, rheumatoid nodules, absence or presence of erosive disease, and class or stage of the patient's RA. RESULTS: A total of 223 patients (139 female, 84 male) were evaluated. The mHAQ-Diff score was statistically significant at -0.3 (p = 0.03) with the rheumatologists more often overestimating the degree of functional disability in their RA patients. The mPAS-Diff score was 0.16, but this was not significant (p = 0.53). There was no significant difference between the scores based on sex, presence or absence of RF, erosions, or rheumatoid nodules. However, the rheumatologists' estimated HAQ and PAS did seem to be more accurate in patients with lower class and stage of their RA. CONCLUSION: Our results indicate that there is a clear difference between patients' and rheumatologists' assessment of patients' functional disability in RA, with the rheumatologists significantly overestimating the degree of this disability. Although the rheumatologists' accuracy at determining the amount of their patients' functional disability was poor overall, they were somewhat more accurate in patients with RA having less severe disease.