Rheumatoid arthritis : hand function , activities of daily living , grip strength and essential assistive devices

Persons with rheumatoid arthritis use assistive devices to enable them, in spite of impaired hand dexterity and grip strength, to manage Activities of Daily Living (ADL). The aim of the research was to lay the foundation for a list of essential assistive devices through • determining which assistive devices for ADL were most often used and requested, • investigating whether there was a correlation be­ tween grip strength and the o number of assistive devices, o duration of disease, o degree of difficulty in performing ADL and by • investigating whether there was a correlation be­ tween difficulty in ADL and o number of assistive devices, o duration of the disease. Study sample Fifty five persons, 42 females and 13 males, seen at the Pretoria Academic Hospital’s Arthritis Clinic were re­ cruited. M ate rials and m ethods • A questionnaire was used to determine the level o f difficulty with ADL. • Details about assistive devices were recorded. • The modified sphygmomanometer was used to measure grip strength. Results • Assistive devices most in use were the tap turner and the dagger knife with built up handle. • The highest correlation was found between grip strength and difficulty in ADL and between dif­ ficulty in ADL and the number of assistive de­ vices used. It seems therefore that loss of grip strength is the main indicator for assistive devices. Abstrak Persone met rumatoïde artritis gebruik hulpmiddels om hulle in staat te stel, om ten spyte van beperkte handvaardigheid en greepsterkte, A ktiw ite ite van die Daaglikse Lewe (ADL) uit te voer. Die doel van die navorsing was om ‘n basis te lê vir ‘n lys van noodsaaklike hulpmiddels deur • vas te stel watter huplmiddels die meeste gebruik en aangevra word. • ondersoek in te stel na die korrelasie tussen greepsterkte en o aantal huplmiddels, o duur van die siekte en o en moeilikheidsgraad in ADL en deur • ondersoek in te stel na die korrelasie tussen moeilikheidsgraad in ADL en die o aantal hulpmiddels, o duur van die siekte. Studiesteekproef ‘n Groep van 55 persone, 42 dames en 13 mans, het aan die studie deelgeneem by die Artritiskliniek van die Pretoriase Akademiese Hospitaal. M ate riale en metode • ‘n Vraelys is gebruik om die moeilikheidsgraad in ADL te bepaal. • Besonderhede oor hulpmiddels is ingewin. • ‘n Aangepaste sfigmomanometer is gebruik om greepsterkte mee te meet. Resultate • Hulpmiddels meeste in gebruik was kraanoopmakers en die mes met opgeboude dolkhandvatsel. • Die hoogste korrelasie is gevind tussen greep­ sterkte en moeilikheidgraad in ADL en tussen moeilikheidsgraad in ADL en aantal hulpmiddels in gebruik. D it b lyk dus da t v erm in d erd e g reep ste rk te die belangrikste indikasie vir die gebruik van hulpmiddels is. 98 Curationis Novem ber 2003 Introduction Implications of rheumatoid arthritis for everyday living Rheumatoid arthritis (RA) is a chronic and progressive sys­ temic disease that affects connective tissue. It involves many joints, especially those of the hands and feet, leading to deformities and disability. According to Harris, cited in Dellhag and Burckhardt (1995:16), over ninety percent of people with rheumatoid arthritis are believed to have some involvement of their hand joints. This involvement often leads to diminished grip strength and difficulty with per­ forming everyday tasks. Changes in health care delivery in South Africa With the implementation of the Primary Health Care ap­ proach fewer patients attend clinics at tertiary institutions where specialist arthritis services, including those of an occupational therapist, are available. At present only patients with uncontrolled symptoms are seen at specialist clinics. Patients now receive their routine care at primary health care clinics and district hospitals. Very few of the latter institutions have the services of an occupational therapist. At the specialist clinic for patients with arthritis at Pretoria Academic Hospital one of the functions of the occupa­ tional therapist is to give attention to impaired hand func­ tion. This includes the evaluation for and provision of assistive devices, also called technical aids or assistive technology. Apart from the fact that very few primary health care clinics and district hospitals have the services of an occupational therapist, no assistive devices are available at these facili­ ties. Aim of the research This study was done to lay a basis for a list of the most useful assistive devices for people with rheumatoid arthri­ tis. Similar to the essential drugs list, these assistive de­ vices could be kept in stock at primary health care sites and hospitals other than tertiary institutions. This would sup­ port the National Rehabilitation Policy (2000:18) in estab­ lishing and updating a list of basic assistive devices, and in making devices available for all those who need them. Objectives of the study The objectives of the study were to * determine which assistive devices for manual ac­ tivities were most often issued, used and requested • investigate whether there was a correlation between grip strength and the o number of assistive devices used, o duration of disease, o degree of difficulty in performing ADL and • investigate whether there was a correlation between difficulty in ADL and o the number of assistive devices o disease duration. M ain areas of concern The main areas of concern in Occupational Therapy in the management of rheumatoid arthritis are grip strength, ac­ tivities of daily living and assistive devices. Grip strength There are several reasons why strength of the handgrip in rheumatoid arthritis is impaired (Melvin 1989:440): • The ability to apply strength becomes diminished when there is pain, active inflammation and swell­ ing. • Wrist tenosinovitis may impair flexor tendon glid­ ing and thereby reduce applied strength of the long flexor muscles of the fingers. • Loss of finger flexion due to contractures makes it difficult to apply strength in grasping thin or nar­ row handles. Grip strength correlates well with functional indices and other assessments of disease activity (Myers, Grennan & Palmer 1980: 369; Felson, Anderson, Boers, Bombarde, Chernoff, Fried, Furst, Goldsmith, Kieszak, Lightfoot, Paulus, Tugwell, Weinblatt, Widmark, Williams, Wolfe 1993: 738). According to Dellhag & Burckhardt (1995: 19), grip strength is one of the predictors for actual and self-estimated hand function. It is one component of hand evaluation that can be meas­ ured objectively, quickly and frequently and should be monitored. Activities of Daily Living In occupational therapy the concept of Activities of Daily Living (ADL) describes those activities or tasks that a per­ son does every day to maintain independence (Reed & Sanderson 1980:227). It is not difficult to imagine that decrease in grip strength and hand dexterity will lead to greater difficulty and pain during ADL. Assistive Devices Assistive devices contribute to an increase in independ­ ence in tasks that could otherwise not be performed, or performed only with difficulty. They comprise “any item, piece of equipment or product system, whether acquired commercially, modified or cus­ tomized, that is used to increase, maintain or improve the functional capabilities of individuals with disabilities” (Hopkins and Smith 1993:326). For persons with rheumatoid arthritis, pain reduction and increase in comfort during activity performance can be 99 Curationis November 2003 Figure 1 Age of respondents (yrs) Average: 48.5 Male: 44.5 Female 53.4

Persons with rheum atoid arthritis use assistive devices to enable them, in spite o f im paired hand dexterity and grip strength, to manage Activities of Daily Living (ADL).The aim o f the research was to lay the foundation for a list o f essential assistive devices through • determining which assistive devices for ADL were most often used and requested, • investigating whether there was a correlation be tween grip strength and the o num ber o f assistive devices, o duration o f disease, o degree o f difficulty in performing ADL and by • investigating whether there was a correlation be tween difficulty in ADL and o num ber o f assistive devices, o duration of the disease.

Study sample
Fifty five persons, 42 females and 13 males, seen at the Pretoria Academic H ospital's Arthritis Clinic were re cruited.

M aterials and methods
• A questionnaire was used to determ ine the level o f difficulty with ADL.• Details about assistive devices were recorded.

•
The modified sphygm om anom eter was used to measure grip strength.

Results
• Assistive devices most in use were the tap turner and the dagger knife with built up handle.

•
The highest correlation was found between grip strength and difficulty in A D L and between dif ficulty in A D L and the num ber o f assistive de vices used.It seems therefore that loss o f grip strength is the main indicator for assistive devices.

Introduction Implications of rheumatoid arthritis for everyday living
Rheumatoid arthritis (RA) is a chronic and progressive sys temic disease that affects connective tissue.It involves many joints, especially those of the hands and feet, leading to deformities and disability.According to Harris, cited in Dellhag and Burckhardt (1995:16), over ninety percent of people with rheumatoid arthritis are believed to have some involvem ent of their hand joints.This involvement often leads to diminished grip strength and difficulty with per form ing everyday tasks.

Changes in health care delivery in South Africa
With the im plementation of the Primary Health Care ap proach fewer patients attend clinics at tertiary institutions where specialist arthritis services, including those of an occupational therapist, are available.
A t present only patients with uncontrolled symptoms are seen at specialist clinics.Patients now receive their routine care at primary health care clinics and district hospitals.Very few o f the latter institutions have the services of an occupational therapist.
At the specialist clinic for patients with arthritis at Pretoria Academ ic Hospital one of the functions o f the occupa tional therapist is to give attention to impaired hand func tion.This includes the evaluation for and provision of assistive devices, also called technical aids or assistive technology.
Apart from the fact that very few primary health care clinics and district hospitals have the services o f an occupational therapist, no assistive devices are available at these facili ties.

Aim of the research
This study was done to lay a basis for a list of the most useful assistive devices for people with rheumatoid arthri tis.Sim ilar to the essential drugs list, these assistive de vices could be kept in stock at primary health care sites and hospitals other than tertiary institutions.This would sup port the National Rehabilitation Policy (2000:18) in estab lishing and updating a list o f basic assistive devices, and in making devices available for all those who need them.

Objectives of the study
The objectives of the study were to * determine which assistive devices for manual ac tivities were most often issued, used and requested

Main areas of concern
The main areas of concern in Occupational Therapy in the management of rheumatoid arthritis are grip strength, ac tivities of daily living and assistive devices.

Grip strength
There are several reasons why strength o f the handgrip in rheumatoid arthritis is impaired (Melvin 1989:440): • The ability to apply strength becomes dim inished when there is pain, active inflammation and swell ing.
• Wrist tenosinovitis may impair flexor tendon glid ing and thereby reduce applied strength o f the long flexor muscles of the fingers.
It is one component o f hand evaluation that can be m eas ured objectively, quickly and frequently and should be monitored.

Activities of Daily Living
In occupational therapy the concept o f Activities o f Daily Living (ADL) describes those activities or tasks that a per son does every day to maintain independence (Reed & Sanderson 1980:227).
It is not difficult to imagine that decrease in grip strength and hand dexterity will lead to greater difficulty and pain during ADL.

Assistive Devices
Assistive devices contribute to an increase in independ ence in tasks that could otherwise not be performed, or performed only with difficulty.
They comprise "any item, piece o f equipm ent or product system, whether acquired commercially, modified or cus tomized, that is used to increase, maintain or improve the functional capabilities of individuals with disabilities" (Hopkins and Smith 1993:326).For persons with rheumatoid arthritis, pain reduction and increase in comfort during activity perform ance can be First world countries have developed and com m ercialised a large variety of assistive devices from which the occupa tional therapist can choose.Im portation o f these assistive devices is expensive, and this technology therefore remains relatively inaccessible to the South African population.In order to overcome this, a num ber o f the commercially avail able devices have been modified, using appropriate design and locally available equipment, material and expertise.
Another approach to maximize arthritis sufferers' ability to perform daily activities would be to produce and market e.g.kitchen equipment, suitable for people with arthritis, to the general public.An additional advantage o f this ap proach would be that people with arthritis would feel less "different".
Currently a variety o f assistive devices at the Arthritis Clinic at Pretoria Academic Hospital are available, (see Table III).Although limited, this list of assistive devices is typical of assistive devices reported by M elvin (1989: 441) and Dellhag & Bjelle (1999:36) as being of value in the manage ment of rheumatoid arthritis.

The research design
A cross sectional survey over a 4-m onth period at the A r thritis Clinic at Pretoria Academic Hospital was carried out.

Population and sample
The researchers recruited all the patients over the age of 18 diagnosed with rheum atoid arthritis that visited the clinic at Pretoria Academic Hospital between July and October 2000.This convenience sample was assumed to be reason ably representative o f the patients with rheum atoid arthri tis treated at the hospital.A total of 55 patients (42 female and 13 male) were included in the study.The racial and gender distribution of the sam- pie is shown in Table I and the ages o f the subjects in Figure 1 .
Although the sample was small, it reflected the classic gen der distribution o f three out of four cases with rheumatoid arthritis being female (M elvin 1989: 45).The ages ranged between 20 and 74 years, with an average age for the whole sample of 48.5 years.The average for the males as 44.5 years and the females 53.4 years.
Most male subjects had had the disease for less than six years, while most o f the females fell in the 6 -1 0 years dura tion category.Not one of the male subjects had had the disease longer than 21 years.The longest duration for females was 30 years.The duration o f the disease for males and females is shown in Figure 2.

Questionnaire administered to respondents
The questionnaire recorded the following: a) Level of independence

b) Assistive devices
The second part o f the questionnaire recorded details of assistive devices that had previously been issued to the patient and which assistive devices were still being used.It also provided for recording a request and need for an addi tional assistive device.
For the purpose o f this study the researchers classified the assistive devices available according to whether they com pensate for the loss of: • strength • dexterity • both strength and dexterity (See Table III)

Instruments for measuring grip strength
Various instruments are available to measure grip strength, with the Jam ar dynam om eter being reported as the most accurate and reliable (Lusardi, Bohannon 1991 :117 & Innesl999 :134).It is, however, expensive, heavy and un comfortable for people with weak and painful hands.The rigidity and shape o f the instrument causes pain and inhib its the application o f force.
An alternative to the dynam om eter for patients with rheu matoid arthritis is the modified sphygmomanometer (Fig ure 3).A criticism o f pneumatic instruments, such as a sphygmomanometer to measure grip strength, is that the pressure m easurem ent is dependent on the surface area over which the force is applied.If the area is small, the force will register as a greater pressure, than if the same force is spread over a larger area.It is therefore important to ensure maximum contact between the hand and the cuff during measurement (Innes 1999:121).Giles (1984 : 36), in reviewing grip strength testing, con cluded that the modified sphygm om anom eter is an objec tive and easily applied measurement.It is inexpensive and does not have the drawbacks o f the Jam ar dynamometer.(Balogun,Akomolafe, Amusa 1990:290;Melvin 1989:354).A sphygmomanometer is readily available at Primary Health Care sites.to use the m odified aneroid sphygmomanometer with a nylon cuff for the research.A standard sphygmomanometer was modified by folding the cuff into three parts and insert ing it into a cloth bag (See Figure 3).

For reasons of comfort and pain avoidance it was decided
The standard procedure described by Melvin (1989: 354) was used, with the sphygm omanometer pre-inflated to 30 mmHg.Patients were encouraged to press the rolled-up cuff once as hard as they could.The American Society of Hand Therapists also em pha size the elbow flexion position, with the forearm midway be tween pro-and supination dur ing testing and caution against supporting the elbow or fore arm in any way (Lusardi andB o h a n n o n 1991: 118 andMathiowitz 1985:695).

Data collection
The researchers measured patients' grip strength.After this the following was recorded: • Assistive devices in use.

•
The assistive device requested by the patient.(This was then issued.)

•
The need for another assistive device that would be issued at a subsequent visit to the clinic.

Data analysis and results
Descriptive statistics and correlations were used to analyse the data.

Grip strength
The mean grip strength of the dom inant and non dominant hand in the males and females is shown in Figure 4.
The age and disease duration distribution in the two groups is not equal, and direct comparisons o f strength between men and woman can therefore not be made.

Difficulty in A D L
See Figure 5 for difficulty in ADL experienced by the re spondents.

Ethical considerations
T he re se a rc h p ro p o sa l w as subm itted to the University of P reto ria's Faculty o f H ealth S c ie n c e s ' R e se a rc h E th ic s Committee.Ethical clearance w as g ra n te d fo r th e stu d y (clearance certificate num ber 152/2001).The researchers obtained writ ten, informed consent from par ticipants.A data sheet was made available and the content explained to participants.They were advised that participation was voluntary and could with draw from the study at any time.M ost difficulty was found with the activities that require strength, namely turning a tap, cutting, and opening and unlocking doors.Tasks that required dexterity, (writing, doing b.uttons and handling money) were generally not a problem.For instance, handling money was the activity for which nobody scored an "unable to do".One patient was illiterate and could not comment on difficulty with writing.Two patients reported that unlocking a door was not appli cable to them.

Assistive devices in use, requested and still needed
Table III shows which assistive devices were in use, re quested and needed.
The men in the study hardly used or requested assistive devices.A total of ninety assistive devices were in use, of which only four were used by males.Twenty three devices were requested, of which only two by males.M ale patients made no request for more devices.This confirm s findings from Dellhag and Bjelle (1 9 9 9 :3 6 ) who found that women had on average three times as many devices available than men.In their study women also used more o f the devices available than men.
Eighty three percent (83%) of all assistive devices in use are designed to com pensate for loss o f strength.O f this group o f assistive devices, dagger knives with built-up handles and tap turners were m ost in use, and also most often requested.
Eleven percent (11%) o f assistive devices that were in use and requested were to com pensate for loss o f dexterity.
The rem aining devices, (5.8% o f the total), com bined fea tures to com pensate for loss o f both dexterity and strength.

Correlations
Because o f the ordinal nature o f the data, non-parametric statistics (Spearman Rank Correlations) were done (Payton  IV. The strongest correlations were between grip strength and difficulty in ADL (0.47 and 0.54 for the two hands), and between difficulty in ADL and the num ber of assistive de vices (0.34).

Discussion
It is to be expected that the weaker the grip, the more diffi cult ADL would be, and that more assistive devices would be used.The moderate correlation between duration o f dis ease and grip strength is also not unexpected.The lack of correlation between the duration of disease and difficulty in ADL may be an indication of people's ability to adapt to their impaired hand function in spite of loss o f grip strength.The loss o f strength may also, at least partially, be due to normal loss o f strength with ageing.The greater use by female subjects o f assistive devices in the study supports work by Dellhag & Bjelle (1999 :36).They explain this greater use by the fact that women in the study were more severely affected than men.Another ex planation they offer is that many o f the devices handed out were intended for household use.
It must also be borne in mind that life style, socio economic conditions and attitude towards disease and disability could also influence the need for and the use o f assistive de vices.

Lim itations of the study
Patients were not asked to indicate why they used, or did I None Some M uch Unable not use the assistive devices that had been issued to them, nor were they asked whether they used them continuously or intermittently.It is therefore not possible to get the "big picture" o f the use of assistive devices in the reported pa tient group.The relatively small sample size also makes it difficult to extrapolate the results to the patient population.

References Conclusion
From the survey it is clear that the category of assistive devices that com pensate for loss of grip strength have pri ority for the Essential Assistive Devices List at Primary Health Care facilities, with tap turners and dagger knives with built-up handles the items most needed.This is sup ported by the m oderate to strong negative correlation be tween the grip strength and difficulty in ADL.
It is therefore justified both from an empirical and theoreti cal perspective, to start the Essential Assistive Devices List with tap turners and dagger knives with built-up han dles.
A num ber o f issues still need to be researched around the assistive devices issued at the arthritis clinic, like record ing the effect o f using assistive devices on pain and dis com fort during ADL; investigating positive and negative experiences o f using assistive devices; difference in need for o f assistive devices for patients with predominantly wrist involvement and those with predominantly m etacar pal phalangeal joint involvement.

Figure 4
Figure 4 Grip strenght of male and fem ale 160

Figure
Figure 5 Difficulty with A D L BALOGUN, JA, AKOM OLAFE, CT & AMUSA, LO 1990: Reproducibility and criterion-related validity of the modified sphygmomanometer for isometric testing of grip strength.Physiotherapy Canada.42:6290 -295.D E IG H T O N , C, SU R T E E S, D & W A L K E R D J 1992: Influence of the severity o f rheumatoid arthritis on sex difference in H ealth A ssessm ent Q uestionnaire Score.Annals of Rheumatic Disease.51:473 -475.D ELLH A G , B & B JE L L E , A 1999: A five-year follow-up of hand function and ADL in rheumatoid arthritis patients.Arthritis Care and Research.12(1): 33 -41.D ELLH A G , B & BURCKHA RDT, C S 1995: Predictors of hand function in patients with rheumatoid arthritis.Arthritis Care and Research.8(1): 16-20.F E L S O N , D T ; A N D E R S O N , J J ; B O E R S , M ; BOMBARDIE, C; CHERNOFF, M ; FRIED, B F I RST, D; GOLDSMITH, C KBESZAK,S:UGHTFOOT,R,PAULUS, H ; T U G W E L L , P; W EIN B LA TT, M,-W ID M A R K , R; W ILLIA M S, H J; W O L FE , F 1993: The American College o f Rheumatology preliminary core set o f disease activity measures for rheumatoid arthritis clinical trials.Arthritis and Rheumatism.36(6): 729 -740.G IL E S , C 1984.The modified sphygmomanometer: An

Table I
Gender and racial distribution of the study sample

Table 2
The researchers used a list o f questions and the scoring method from the Stanford Health Assessment Question naire (SHAQ) to document patients' level o f difficulty in ADL.The SHAQ is reported as a reliable and valid instru ment for the rheumatoid arthritis population (Deighton, Surtees &Walker 1992:473;Ramey, Raynauld & Fries 1992:  121 and Ward 1994: 24).It is a self-report instrum ent on which patients rate the degree of difficulty they experience in everyday tasks.The scoring is as follows: 1= no diffi culty, 2= some difficulty, 3= much difficulty and 4= unable to do( Kirwan & Reeback 1986:207).The tasks listed in the SHAQ require unilateral and bilateral Figure 2 Duration of disease (yrs) List of tasks in the questionnaire

Compensate for loss of: Assistive device available at the clinic In use Requested Still needed "Total interest"
Table III Classification of Assistive Devices Assistive devices used, requested and needed