REVISTA
BRASILEIRA
DE
REUMATOLOGIA
www . r e u m a t o l o g i a . c o m . b r
Brief
communication
The
influence
of
physical
function
on
the
risk
of
falls
among
adults
with
rheumatoid
arthritis
夽
Wanessa
Vieira
Marques
a,∗,
Vitor
Alves
Cruz
b,
Jozelia
Rego
b,
Nilzio
Antonio
da
Silva
baMedicineSchool,UniversidadeFederaldeGoiás,Goiânia,GO,Brazil
bRheumatologyService,HospitaldasClínicas,MedicineSchool,UniversidadeFederaldeGoiás,Goiânia,GO,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received30August2013 Accepted20March2014
Keywords:
Rheumatoidarthritis Falls
Functionalcapacity Diseaseactivity
a
b
s
t
r
a
c
t
Objectives:Identifyfallprevalenceinthelast12monthsamongpatientswithrheumatoid arthritis(RA)andverifytheinfluenceofdiseaseactivityandphysicalfunctionintheriskof falls.
Methods:43patientswithRAparticipatedinthisstudy.Thefollowingparameterswere eval-uated:clinicalaspects;falloccurrenceinthelast12months;ESR(mm/h);painonavisual analoguescale(VAS)rangingfrom0to10cm;diseaseactivity,measuredbytheDisease ActivityScore28/ESR(DAS-28/ESR);physicalfunction,assessedbytheHealthAssessment Questionnaire(HAQ);andriskoffalling,assessedbytwotests,the5-timesitdown-to-stand uptest(SST5)andthegetupandgotimedtest(GUGT).
Results:Thefallprevalenceinthelast12monthswas30.2%(13/43).TheHAQtotalscore wastheindependentriskfactorthathadsignificantinfluenceonSST5performance,and theothervariablesdidnotsucceededtoexplaintheSST5variability.HAQexplained42.9% ofSST5variability(P<0.001,adjustedR2=0.429).HAQtotalscoreandESRhadasignificant influenceonGUGTscoreperformance.Together,thesetwovariablesexplained68.8%ofthe totalvariationinGUGTscore(adjustedR2=0.688).
Conclusion:PatientswithRAhavehighfallprevalenceandthefunctionaldisability repre-sentsthemainfactorrelatedtofallsrisk.
©2014ElsevierEditoraLtda.Allrightsreserved.
Influência
da
capacidade
funcional
no
risco
de
quedas
em
adultos
com
artrite
reumatoide
Palavras-chave: Artritereumatoide Quedas
r
e
s
u
m
o
Objetivos:Identificaraprevalênciadequedasnosúltimos12mesesempacientescomartrite reumatoide(AR)everificarainfluênciadaatividadedadoenc¸aedacapacidadefuncional noriscodequedas.
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rbr.2014.03.019. 夽
RheumatologyService,DepartmentofInternalMedicine,HospitaldasClínicas,MedicineSchool,UniversidadeFederaldeGoiás.
∗ Correspondingauthor.
E-mail:[email protected](W.V.Marques).
http://dx.doi.org/10.1016/j.rbre.2014.03.019
Capacidadefuncional Atividadedadoenc¸a
Pacientes emétodos: Participaram do estudo 43 pacientescom AR.Foramavaliados os seguintesparâmetros:aspectosclínicos;ocorrênciadequedasnosúltimos12meses;VHS (mm/h);dor,atravésdaescalavisualanalógica(EVA)comescorede0a10cm;atividadeda doenc¸a,medidapeloÍndicedeAtividadedaDoenc¸a–28/VHS(DiseaseActivityScore28– DAS-28/VHS);capacidadefuncional,avaliadapeloQuestionáriodeAvaliac¸ãodaSaúde(Health AssessmentQuestionnaire–HAQ);eoriscodequedas,avaliadopormeiodedoistestes,o testesenta-levantadacadeiracincovezes(TSL)eotestegetupandgotimedtest(GUGT). Resultados: Aprevalência dequedasnosúltimos12mesesfoide30,2%(13/43).Ofator independentequeinfluenciousignificativamenteodesempenhonoTSLfoioescoretotal doHAQ,sendoqueasdemaisvariáveisnãoconseguiramcontribuirdeformasignificativa naexplicac¸ãodavariabilidadenoTSL.AvariávelHAQfoiresponsávelporexplicar42,9% (P<0,001,R2ajustado=0,429)davariabilidadedoTSL.AsvariáveisHAQeVHSinfluenciaram deformasignificativaodesempenhonoescoredoGUGT.Essesdoisfatoresemconjunto foramcapazesdeexplicar68,8%davariabilidadedoGUGT(R2ajustado=0,688).
Conclusões: PacientescomARtêmprevalênciadequedasaumentada,sendoaincapacidade funcionaloprincipalfatorrelacionadoaoriscodequedas.
©2014ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Patientswithrheumatoidarthritis(RA)areinincreasedrisk offalls,astheyoftenexperiencemuscleweakness,jointpain or stiffness and disorders of balance and gait. The risk of fallingisevengreaterwhenthereisinvolvementofthelower extremities.1–3
Studiesinthispopulationdemonstrateanincreasedrate offalls,from27-50%overayearofresearch.3–7However,due toshortageofpapersonthissubject,theprevalenceoffalls maybeunderestimated.1
Fallsaretheleadingcause ofaccidentaldeathinpeople over65yearsold.8Approximately40-60%offallsamongthe elderlyleadtosomekindofinjury.Ofthetotalinjuries,30to 50%areconsideredofminorseverity,5-6%areconsideredas moreseriousinjuriesand5%resultinfractures.8–10
Fewstudiesinvolving patientswithRAhave focusedon theevaluationoffalls,despitebeingconsideredapopulation atrisk.1
Thus,thepurposeofthisstudywastoidentifythe preva-lenceoffallsinaperiodof12months,inadditiontoverifying theinfluenceofdiseaseactivityandoffunctionalityintherisk offallsinpatientswithrheumatoidarthritis.
Patients
and
methods
PatientsandProcedures
Thisstudyhasacross-sectionaldesign.
PatientsinourreferralcenterwithadiagnosisofRA accord-ingtoAmericanCollegeofRheumatologycriteria(ACR,1987)11 wereincludedaftersigningthefreeinformedconsentterm. ThestudywasapprovedbythelocalResearchEthics Commit-tee(ProtocolNo.013/2012).
Exclusioncriteriawere:ageunder30years;hospitalization duetoacuteillnessintheprevioussixmonthsfromthe inter-view;andpresenceofanytemporarydisabilitypreventingthe
participantfromperformingthemobilitytests.Thesubjects werefirstaskedtoansweraquestionnaireabout:(1) identifica-tiondata;(2)durationofillness;(3)presenceofcomorbidities; (4)use ofagaitsupportivegear;(5) historyofarthroplasty; (6) historyoffallsinthe past12 months;(7)occurrenceof fracturessecondarytofalls;(8)lifestyle;and(9)current med-ications.
ToevaluatetheactivityofRA,thefollowingvariableswere used:ESR(mm/h);painusingavisualanalogscale(VAS)with ascore of0to10cm; and IndexofDiseaseActivity-28/ESR (DiseaseActivityScore28-DAS-28/ESR).12
Theassessmentoffunctionalcapacityofpatientswas esti-matedbytheHealthAssessmentQuestionnaire-HAQ.
Toassesstheriskoffallsandthemobilityofpatients,two tests were performed: (1) 5-timesit down-to-stand up test (SST5)and(2)getupandgotimedtest(GUGT).
The 5-time sit down-to-stand up test (SST5) is used to assessthemusclestrengthoflowerlimbs,mobilityandriskof falls.13,14 Inthistest,thesubjectbeginssittingonthecenter ofachairwithhis/herspineerect,feetseparatedbyadistance equivalenttothedistancebetweentheshoulders,andarms foldedacrossthethorax.Thenthepatientisaskedtostand upandsitdownonthechairfivetimesasquicklyashe/she can,withoutusinghis/herarms.13
Thegetupand gotimedtest(GUGT)isusedtoidentify patientsatriskoffallsandformobilityrestrictions.8,15Inthis test, the subject begins in aseated position withhis back against the backrest ofthe chair, being asked to stand up (his/herarmscanbeused),walkforadistanceofthreemeters inhis/herusualgaitspeed,turnaround,returntothechair andsitinthestartposition.15
ThetimespenttocompleteSST5andGUGTtestsistimed, andthelongerthetime,theworsethemobilityofthesubject.
Statisticalanalysis
Table1–Patients’characteristics.
Characteristic Value
Patients,n 43
Women,n(%) 37(86.0%)
Positivityforrheumatoidfactor,n(%) 26(60.5%)
Age(years),mean±SD(min-max) 58.7±9.1(43-80)
Self-reportedcolor,n(%)
White 18(41.9%)
Black 8(18.6%)
Mixed(brown) 17(39.5%)
Diseaseduration(years),mean±SD(min-max) 12.2±9.1(1-30)
Useofagaitsupportivegear,n(%) 8(18.6%)
Presenceofarthroplasty(kneeand/orhip),n(%) 3(7.0%)
HAQ,mean±SD(min-max) 1.15±0.78(0-3)
DAS-28,mean±SD(min-max) 4.01±1.31(0.8-6.8)
ESR(mm/h),mean±SD(min-max) 29.86±22.11(3-118)
PainbyVAS(cm),mean±SD(min-max) 4.74±2.52(0-10)
SST5(seconds),mean±SD(min-max) 15.07±5.81(8.3-25)
GUGT(seconds),mean±SD(min-max) 17.40±11.61(9.2-60)
Smokersorex-smokers,n(%) 24(55.8%)
Practicingphysicalactivityn(%) 6(14.0%)
SD,standarddeviation;HAQ,HealthAssessmentQuestionnaire; DAS-28,DiseaseActivityIndex-28;ESR,erythrocyte sedimenta-tionrate;VAS,visualanalogscaleusedtoassesspain;SST5,5-time sit-to-standtest;GUGT,getupandgotimedtest.
alogarithmiclinkfunctioninordertoverifytheinfluenceof diseaseactivity,functionalcapacityandothervariablesonthe riskoffalls.
Inthemultivariateregressionfinalanalysis,theStepwise selectionalgorithm was used, referred to as Stepwise log-linearregression.
Thelevelofsignificancewassetat5%.Thestatistical anal-ysiswasperformedusingRsoftwareversion2.15.3.
Results
Patients
Accordingtoexclusion criteria, onepatientwithlimitation duetoafallwasexcludedbecauseofarecentfootfracture thatmadeitimpossibletowalk.
Forty-threepatientsparticipatedinthestudy.Table1lists thecharacteristicsofthispopulation.
As for medications, the major pharmacological classes
used in these patients were: disease-modifying
anti-rheumatic drugs (DMARDs) (95.3%); calcium carbonate
supplementation with vitamin D3 (88.4%); corticosteroids
(74.4%);gastric protectors(74.4%); bisphosphonates(53.5%); antihypertensive drugs (46.5%); nonsteroidal anti- inflam-matorydrugs(44.2%); andlipid-loweringdrugs (37.2%).Ten patients(23.2%)wereusingcentralactiondrugs,asfollows: 8weretakingantidepressants;1wasonantidepressantand benzodiazepinetherapy;and1wasmedicatedwithan anti-convulsantdrug.And eightpatients(18.6%)usedbiological agentsforcontrolofthedisease.
Eachpatient presenteda mean of4±2.1 comorbidities, rangingfrom0to9.Thefourmostprevalentcomorbiditiesin thisstudywere:osteoporosis(55.8%),secondaryosteoarthritis (53.5%),hypertension(51.2%)anddyslipidemia(41.9%).
Fallsandfracturessecondarytofalls
Atthetimeoftheinterview,13patients(30.2%)reportedat leastoneepisodeoffallinginthepast12months.
Amongthe13 patientswhohad sufferedfalls, onlyone reportedafracturesecondarytofall(7.7%).
Five patients (11.6%) reported post-fall fractures that occurredearliertothe12-monthperiodofouranalysis.
Analysisoftheinfluenceofdiseaseactivityandfunctional capacityontheriskoffalls
Table2showstheresultsofanalysesofaunivariatelog-linear regressionofthefactorsassociatedtotheriskoffalls, evalu-atedbySST5andGUGTtests.
In the univariate model, a significant association was observedbetweenriskoffalls,ratedbySST5,andthefollowing variables:age(P=0.052;R2=0.070),diseaseduration(P=0.045,
R2=0.075), ESR (P=0.032; R2=0.083), number of
comorbidi-ties(P=0.041,R2=0.078)andHAQscore(P<0.001,R2=0.429)
(Table2).
Also in the univariate model, a significant association wasobservedbetweentheriskoffalls,ratedbyGUGT, and the following variables: ESR (P=0.001; R2=0.250), presence
ofarthroplasty(P=0.038,R2=0.083)andHAQscore(P<0.001,
R2=0.665)(Table2).
InthefinalmodelofStepwiselog-linearregressionwith respecttotheperformanceinSST5,onlytheHAQvariablewas significant,andsucceedtoexplain42.9%ofSST5variability (R2=0.429)(Table3).
AstotheperformanceofsubjectsinGUGT,inthe multi-variatemodelthevariablesHAQandESRweresignificantin explaining,together,68.8%ofthevariabilityofGUGT(adjusted R2=0.688)(Table3).
Discussion
This study identified the prevalence of falls in the past 12monthsandevaluatedtheinfluenceofdiseaseactivityand functionalcapacityintheriskoffallsinadultswithRA.
Inthisstudy,aprevalenceoffallsof30.2%,similarto retro-spectivestudies,hasbeenfound.3–5Functionaldisabilitywas themainfactorassociatedwithriskoffallsinthispopulation. Previous studies show different frequencies of falls in patientswithRA.Inretrospectivestudies,theoccurrenceof falls in patients with RA over a period of 12 months was 27%,433%3and35%.5Inprospectivestudies,theincidenceof fallsin12monthsrangedfrom36.4%6to50%.7
Inthisstudy,patientswereinquiredabouttheoccurrence offallsinthepast12months;thus,followingaretrospective design.Theliteraturedemonstratesthatretrospective stud-iesmayunderestimatetheprevalenceoffalls,sincepatients tendtoforgetprogressivelytheseepisodes.16Thisfactor con-stitutesalimitation,andmayunderestimatetheprevalence offallsobservedinoursample.
Table2–Resultoftheassociationamongriskoffall(SST5andGUGT)andevaluationparametersofdiseaseactivity(ESR, VASandDAS-28)andfunctionalcapacity(HAQ).
Variable SST5 GUGT
exp() P-value 95%CI R2 exp() P-value 95%CI R2
Age(years) 1.012 0.052 [1.000-1.025] 0.070 1.017 0.116 [0.996-1.038] 0.046
Diseaseduration(years) 1.013 0.045 [1.001-1.025] 0.075 1.012 0.305 [0.990-1.034] 0.002
ESR(mm/h) 1.005 0.032 [1.001-1.01] 0.083 1.012 0.001 [1.005-1.018] 0.250
PainbyVAS(cm) 1.021 0.398 [0.974-1.069] 0.000 1.015 0.729 [0.935-1.101] 0.000
Numberofcomorbidities 1.058 0.041 [1.004-1.115] 0.078 1.095 0.06 [0.999-1.199] 0.079
Presenceofarthroplasty 1.158 0.506 [0.755-1.777] 0.000 1.859 0.038 [1.056-3.273] 0.083
Positiverheumatoidfactor 0.932 0.561 [0.736-1.18] 0.000 0.889 0.574 [0.592-1.335] 0.000
DAS-28 1.06 0.215 [0.968-1.159] 0.015 1.11 0.185 [0.954-1.292] 0.025
HAQ 1.365 <0.001 [1.227-1.518] 0.429 1.796 <0.001 [1.585-2.035] 0.665
Univariatelog-linearregressions.
ESR,erythrocytesedimentationrate;VAS,visualanalogscaleusedtoassesspain;DAS-28,DiseaseActivityIndex-28;HAQ,HealthAssessment Questionnaire;SST5,5-timesit-to-standtest;GUGT,getupandgotimedtest.
Table3–Influenceoffunctionalcapacity(HAQ)andESRontheriskoffalls,evaluatedbySST5andGUGTtests.
Variable SST5 GUGT
exp() P-value 95%CI AdjustedR2 exp() P-value 95%CI AdjustedR2
HAQ 1.365 <0.001 [1.227–1.518] 0.429 1.684 <0.001 [1.471–1.928] 0.688
ESR(mm/h) - - - - 1.004 0.0477 [1.001–1.008]
Stepwiselog-linearmultivariateregression.
HAQ,HealthAssessmentQuestionnaire;ESR,erythrocytesedimentationrate;SST5,5-timesit-to-standtest;GUGT,getupandgotimedtest.
Böhleretal.4foundacorrelationamongthetestsfor assess-mentoftheriskoffalls,amongthemSST5andGUGT,with thefollowingvariables:HAQ,DAS-28,painbyVAS,andESR. InthespecificcaseofESR,theseauthorsfoundacorrelation onlywithGUGTandnotwithSST5.Similartoourstudy find-ings,HAQinfluencedtheperformanceofbothtestsusedto assesstheriskoffalls;ontheotherhand,ESRonlyactedon GUGT.
Duyurc¸akitetal.17 foundapositive association between historyoffallsandperformanceontheTinettitestusedto assesstheriskoffalls.Theseauthorsalsoobservedan associ-ationbetweenfearoffallingandTinettiandHAQfinalscores. Theauthors foundnoassociation betweendisease activity andtheriskoffalls.
Theinfluenceoffunctionaldisabilityintheriskoffalls,as foundinourstudy,wasanexpectedfinding.Inpatientswith RA,otherauthorsfoundanassociationofhigh HAQscores withjoint destructionandwithdecreasedmusclestrength, thelatterbeingconsideredasriskfactorforfalls.18–20
Inthepresent study,noassociationwas foundbetween diseaseactivity,asassessedbyDAS-28,andanincreasedrisk offalls.However,anassociationbetweenthevalueofESRand performanceonGUGTtestwasfound.
Duetotheexistinglimitationsincountingthejointsused inDAS-28,someauthorsrecommendaddingotherformsof disease activity assessment, suchas laboratory tests, self-reportedmeasures in questionnaires,and global estimates madebydoctorsandpatients.21
Withregardtoassociatedfactorsofriskoffalls,thisstudy hassomelimitations.Mostpatientsshowedamoderatelevel ofdiseaseactivity,calculatedbyDAS-28,which,togetherwith
thesamplesize,mayhavesomeinfluenceinthelackof asso-ciationbetweenDAS-28andtheriskoffalls.Furthermore,the influenceofotherfactorsontheriskoffalls,suchastheuse ofcertainclassesofdrugs(antihypertensivedrugs,diuretics, antidepressantsandsedatives)wasnotanalyzed.
Inourstudy,theagelimitof30yearswasestablished,since thepeakincidenceofRAoccursbetweenthefourthandsixth decadesoflife.Itisworthtomentionthattheprevalenceof RAincreaseswithage;andtheliteraturepointstoan increas-inglyagingprofileofpatientswithRA.22Themeanageofour samplewas58.7±9.1years.
Wealsoobservedthatosteoporosiswasthemostprevalent comorbidity (55.8%). Osteoporosis is associated with frac-turerisk.23Studies evaluatinginjuriesfrom fallsshowthat hip,wrist,vertebrae,humerusandhandfracturesaremainly causedbyfalls.24
Therelevanceofthis studyistopoint outanincreased prevalenceoffallsinpatientswithRA.Moreover,ourpaper drawsattention totheimpactoffunctional disability, mea-suredbytheHAQscore,ontheriskoffallsinthispopulation. Inconclusion,patientswithRAhaveanincreased preva-lenceoffalls,andfunctionaldisabilityisassociatedwiththe riskoffallsintheseindividuals.
RApatientsshouldbemonitoredforfunctionalcapacity and bone mass, aiming to prevent falls and consequently to prevent fractures, contributing to a better prognosis of rheumaticdisease.
Conflict
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