Impairment of quality of life: rheumatoid arthritis versus sarcoidosis

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1 The Netherlnds Journl of Medicine 54 (1999) Originl rticle Impirment of qulity of life: rheumtoid rthritis versus srcoidosis b c b R.M. Wirnsberger, J. De Vries, T.L.Th.A. Jnsen, G.L. Vn Heck,, * E.F.M. Wouters, M. Drent Deprtment of Pulmonology, University Hospitl, Mstricht, The Netherlnds b Deprtment of Psychology, Tilburg University, Tilburg, The Netherlnds c Deprtment of Rheumtology, Medicl Centre Leeuwrden, Leeuwrden, The Netherlnds Received 17 August 1998; received in revised form 29 October 1998; ccepted 26 November 1998 Abstrct Bckground: Qulity of life (QOL) hs become n importnt item in helth cre. QOL should be mjor trget of tretment in chronic diseses such s rheumtoid rthritis (RA) nd srcoidosis. The im of this study ws to compre the impct of RA nd srcoidosis on ptients QOL. We expected more serious impirment of QOL in the RA group thn in the srcoidosis group. Methods: QOL ws studied in RA ptients (n 5 32), srcoidosis ptients (n 5 37), nd helthy control group (n 5 37) employing the World Helth Orgniztion Qulity of Life ssessment instrument (WHOQOL-100). Results: In both ptient groups QOL ws impired with respect to Physicl Helth, Level of Independence (P, 0.001), nd Overll QOL nd Generl Helth (P, 0.01). Moreover, RA ptients ppered to hve lower QOL with respect to Pin nd Discomfort (P, 0.001) nd Mobility (P, 0.001). Conclusions: In RA nd srcoidosis, ftigue nd sleep were mjor problems. In contrst to our expecttions, with respect to ctivities of dily living nd working cpcity, the two ptient groups did not show ny difference. Impirment of QOL ws more serious nd included more spects of QOL in RA thn in srcoidosis. (See Editoril p. 83.) 1999 Elsevier Science B.V. All rights reserved. Keywords: Srcoidosis; Rheumtoid rthritis (RA); Qulity of life; WHOQOL-100 Introduction tients with chronic diseses, including rheumtoid rthritis (RA) [1 5]. Improvement of ptients QOL In the pst two decdes, ssessment of helth hs become mjor trget of tretment. In generl, sttus nd qulity of life (QOL) s n outcome helth sttus nd QOL of RA ptients re substntilmesure hs become incresingly importnt in p- ly impired, wheres disese sttus s ssessed by disese relted vribles does not reflect ccurtely *Corresponding uthor. Tel.: ; fx: the impct of the disese on psychologicl nd socil ; e-mil: mdr@slon.zm.nl well-being [4,6]. In srcoidosis, helth sttus nd / 99/ $ see front mtter 1999 Elsevier Science B.V. All rights reserved. PII: S (98)00148-X

2 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) QOL hve hd little ttention. Recently, we found Therefore, the im of this study ws to compre the impirment of helth sttus nd QOL in srcoidosis impct on QOL of RA nd srcoidosis. Recently, we ptients [7,8]. No reltionship of routinely performed showed tht QOL in symptomtic srcoidosis ppulmonry function tests nd serum ngiotensin tients ws more seriously impired thn QOL in converting enzyme (sace) with helth sttus nd ptients without current symptoms [8]. We hypoth- QOL ws found [7,8]. esized tht QOL would be impired in RA s well s Srcoidosis nd rheumtoid rthritis (RA) hve srcoidosis compred to helthy controls. Srcoidosis severl sequele in common. Both re inflmmtory ptients were expected to hve better QOL thn RA disorders of unknown etiology. In both disorders the ptients. Especilly with respect to pin nd levels of mode of onset is vrible nd they both regulrly independence we expected more serious impiroccur in reltively young people. The clinicl course ment of QOL in the RA ptients. With respect to in both disorders is rther unpredictble, rnging ftigue no difference between the ptient groups ws from spontneous remission to rpid progression or expected. Therefore, in the present study QOL in more chronic course. Some immunologic disturbnce ctive RA ws compred with QOL of symptomtic is thought to ply centrl role in the pthogenesis srcoidosis ptients. For this purpose brod-rnging of srcoidosis [9] s well s in RA [10]. Mni- generic QOL instrument, the World Helth Orgnizfesttions of RA re primrily in the joints, but tion Qulity of Life ssessment instrument systemic symptoms nd extr-rticulr inflmmtion (WHOQOL-100) [19], ws used. my be present s well. In RA, s in srcoidosis, pulmonry involvement with interstitil pneumonitis or fibrosis, however only occsionlly, my occur Mterils nd methods [11,12]. In srcoidosis, symptoms vry considerbly depending on the orgn involvement. Ptients with Ptients srcoidosis my present with specific symptoms lso present in RA such s ftigue, rthrlgi, nd A group of RA ptients (n 5 35) ws recruited muscle pin. In previous study, we found tht in selectively from consecutive ptients with RA not bout 5% of ptients with srcoidosis, the symptoms in remission visiting the Outptient Deprtment of were initilly ttributed to RA [13]. Finlly, in both Rheumtology, Rijnstte Hospitl, Arnhem. When disorders no specific cusl tretment is known t sked to prticipte in the study, three ptients present. refused for vrious resons, wheres 32 ptients In rheumtology number of helth sttus me- greed to prticipte in the study. None of those sures hve been used to ssess QOL [4]. Recently, ltter ptients hd ny co-morbidity. The dignosis Rut et l. vlidted the SF-36, generic helth of RA ws bsed on the Americn College of sttus mesure, in RA ptients [14]. However, usul- Rheumtology (formerly the Americn Rheumtism ly, disese impct of RA on ptients lives hs been Assocition) criteri for RA [20]. The ptients were ssessed rther by disese-specific helth sttus cliniclly ssessed by rheumtologist, who commesures [5,15 17] thn by subjective QOL me- pleted questionnire with the clinicl chrcterissures. Helth sttus mesures ssess minly func- tics: disese durtion, functionl clss ccording to tionl sttus, wheres QOL instruments ssess the Steinbrocker [21], current serum mrkers (erythroindividuls subjective perception of their life. When cyte sedimenttion rte (ERS) nd C-rective protein using helth sttus mesures, it would be mistke (CRP)), 28 swollen joint index, nd current medicto equte lower levels of functioning with lower tion. At the sme visit the ptient completed the QOL. For this conclusion would contrst with find- WHOQOL-100 [19]. ings in QOL reserch reflecting high perceived QOL The srcoidosis ptient group ws recruited from in spite of low levels of functioning [18]. eight Dutch hospitls (Rijnstte Hospitl, Arnhem; To the best of our knowledge, there exist no Acdemic Hospitl St Rdboud, Nijmegen; Rehbilicomprtive studies on QOL in RA nd other ttion Center Dekkerswld, Nijmegen; District chronic inflmmtory disorders such s srcoidosis. Hospitl Middle Twente, Hengelo; St. Jns-Hospitl,

3 88 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) Weert; Mslnd Hospitl, Sittrd; The Wever Tble 2 Hospitl, Heerlen; nd University Hospitl, Ms- Chrcteristics of the RA ptient group tricht). Seventy-one unselected consecutive out-p Vrible tients with srcoidosis, without ny co-morbidity Disese durtion, yers 8.4 (9.3) were contcted. Seven srcoidosis ptients declined Type RA seropositive/ seronegtive 26/ 4 for vrious resons, but 64 greed to prticipte. The Steinbrocker I/II/III/IV 9/22/1/0 dignosis of srcoidosis ws bsed on clinicl find- 28 swollen joint index 8.3 (8.0) CRP 25.9 (34.2) ings, long with histologicl evidence. None of the ESR 33.7 (25.8) ptients hd ny previous medicl condition which Corticosteroid use yes/ no 5/ 27 might hve influenced their QOL. All ptients com- Present tretment with DMARDs yes/ no 31/ 1 pleted the WHOQOL-100. In ddition, the physicin Number of DMARDs in the pst 2.2 (2.3) sked them whether they hd ny of the following Dt re mens (SD); CRP 5 C-rective protein, norml levels complints: ftigue, dyspne, coughing, rthrlgi, or, 9 U/ l; ESR 5 erythrocyte sedimenttion rte; DMARDs 5 erythem nodosum. Twenty-seven out of the 64 disese modifying nti-rheumtic drugs. studied srcoidosis ptients reported no ctul symptoms, wheres 37 ptients ppered to suffer from mg/dy, one with 15 mg/dy, nd of one ptient one or more symptom(s). In order to be ble to informtion on the dose ws missing. Only one compre the impct of symptoms between sr- ptient did not receive disese modifying nticoidosis ptients nd the studied RA ptients, who rheumtic drugs (DMARDs) t the time of the study. were not in remission, only srcoidosis ptients with Ten ptients were currently treted with Methothrecurrent symptoms relted to their disorder (n 5 37) xte, nine with Sulphslzine, four with Azthiowere included in the present study. Using the ptient prine, three with Penicillmine, two with Hydroxyrecord, the vlues of serum ngiotensin converting chloroquine, one with Auromyosis, nd one ptient enzyme (sace) levels nd the pulmonry function received the combintion Sulphslzine nd Metotests were obtined from the visit closest to the threxte t the time of the study. session in which the questionnires were completed. The chrcteristics of the srcoidosis ptients re Furthermore, 240 control persons were recruited summrized in Tble 3. The srcoidosis ptients who were willing to prticipte in study on QOL. From the group of persons who returned completed Tble 3 test-booklet (n 5 178; 74.2%), helthy control sub- Chrcteristics of the srcoidosis ptient group jects (n 5 37) were selected on the bsis of gender Vrible nd ge, mtched for the srcoidosis ptients. For demogrphicl chrcteristics of the two ptient Disese durtion 4.4 (5.1) FEV 1 (norml/ decresed) 29/ 8 groups nd the control group see Tble 1. T L,CO (norml/ decresed) 22/ 15 The chrcteristics of the RA ptients re summ- sace U/l (9 25 U/l) 30 (25) rized in Tble 2. During the previous week five of Use of corticosteroids (yes/ no) 14/ 23 the RA ptients hd received systemic corticoste- Dt re mens (SD); FEV1 5 forced expirtory volume in one roids; ll these ptients received prednisolone. One second; T L,CO 5 trnsfer fctor of the lung for crbon monoxide; ptient ws treted with 7.5 mg/ dy, two with 10 sace 5 serum ngiotensin converting enzyme. Tble 1 Chrcteristics of the studied srcoidosis ptients, rheumtoid rthritis (RA) ptients, nd the helthy control group Vrible RA ptients Srcoidosis ptients Control group Number Age, yer 54.3 (29 70) 45.3 (26 73) 45.4 (26 73) Gender mle/ femle 13/ 19 21/ 16 21/ 16 Dt re mens with the rnge in prentheses.

4 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) reported the following symptoms: ftigue in 28, (60 80%); (3) moderte decrese (40 60%); (4) dyspne in 15, rthrlgi in 11, cough in six ptients, severe decrese (, 40%), of the vlues predicted. nd erythem nodosum in one ptient. With respect to the pulmonry function tests, eight of the srcoidosis ptients (21.6%) showed mildly decresed Sttisticl methods forced expirtion volume in one second (FEV 1), nd Dt re expressed s men (SD) nd, if ppro- 15 ptients showed decresed trnsfer fctor of the prite, s men with rnge. Sttisticl differences in lung for crbon monoxide (T L,CO). In 12 of the ge nd gender between ptient groups were studied ptients the T L,CO ws mildly decresed nd in three 2 using Student s t-tests nd x -tests. Person correlptients it ws modertely decresed, ccording to tion coefficients were used. Significnce ws cthe Americn Medicl Assocition clsses. cepted with P-vlues, Furthermore, dt were Questionnire nlyzed using nlysis of vrince (ANOVA) with ge nd gender s covrites between groups. Within the RA group one-wy nlyses of vrince were Both ptient groups nd the helthy controls used. In ANOVA, significnce ws ccepted with completed the World Helth Orgniztion Qulity of P-vlues, 0.01 due to the number of nlyses. All Life ssessment instrument, WHOQOL-100, (Dutch nlyses were performed using the Sttisticl Pckversion) [19]. This is cross-culturlly developed ge for Socil Science (SPSS) for Windows [25]. generic multidimensionl QOL mesure tht hs been simultneously developed in 15 centres round the world, e.g. in Frnce, Russi, USA, Pnm, Zimbbwe, Jpn, Thilnd, nd The Netherlnds Results [22]. It consists of 100 items ssessing 24 fcets of QOL within six domins (Physicl Helth, Psycho- The RA ptients were significntly older thn the logicl Helth, Level of Independence, Socil Rel- srcoidosis ptients (P, 0.001). Tble 4 summrizes tionships, Environment, nd Spiritulity/ Religion/ the QOL scores for domins nd fcets with signifi- Personl Beliefs) nd generl evlutive fcet cnt differences between the groups. Impirment ws (Overll Qulity of Life nd Generl Helth). Ech found with respect to the evlutive fcet Overll fcet is represented by four items. The response scle QOL nd Generl Helth, the domins Physicl is 5-point Likert scle, scores cn rnge from 4 to Helth nd its fcets, s well s the domin Level of 20. Except for the fcets Pin nd Discomfort, Independence nd its fcets, for both ptient groups. Negtive Feelings, nd Dependence on Mediction The fcets Overll QOL nd Generl Helth (F 5 nd Tretment, higher scores men better QOL. 7.4; df 5 2, P, 0.01), Energy nd Ftigue (F 5 The relibility nd vlidity of the Dutch version of 16.5; df 5 2, P, 0.001), Sleep nd Rest (F 5 9.8; the instrument re high [19,23]. df 5 2, P, 0.001), Activities of Dily Living (F ; df 5 2, P, 0.001), nd Working Cpcity (F 5 Pulmonry function tests 18.5; df 5 2, P, 0.001) were low in the two ptient groups compred to the helthy controls. Pulmonry function mesurements of the sr- In the domins Physicl Helth (F ; df 5 2, coidosis ptients included the FEV 1 (Compctbody, P, 0.001) s well s Level of Independence (F 5 Jeger, Wurzburg, Germny). The best mesure of 26.6; df 5 2, P, 0.001) nd its fcet Dependence on three efforts ws selected. All volumes re expressed Mediction or Tretment (F ; df 5 2, P, s percentges of the reference vlues [24]. The 0.001) ll three groups scored significntly different T L,CO ws mesured using the single breth method from ech other, the helthy controls hving the (Msterlb, Jeger, Wurzburg, Germny). Four highest QOL in these res nd the RA group the rnges of FEV1 nd T L,CO levels were clssified lowest. Furthermore, the group of RA ptients scored ccording to the Americn Medicl Assocition worse on the fcets Pin nd Discomfort (F ; clsses: (1) norml (. 80%); (2) mild decrese df 5 2, P, 0.001) nd Mobility (F 5 6.9; df 5 2,

5 90 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) Tble 4 WHOQOL-100 domin nd fcet scores with significnt differences between the rheumtoid rthritis (RA) ptients, the srcoidosis ptients, nd the mtched control group WHOQOL-100 RA Srcoidosis Control group group group b,f Overll Qulity of Life nd Generl Helth 13.6 (2.5) 14.2 (3.7) 16.2 (2.3) c,e Physicl Helth 12.3 (2.6) 14.3 (2.8) 16.1 (1.7) d,e Pin nd Discomfort 12.9 (2.7) 9.2 (3.1) 9.1 (2.8) b,e Energy nd Ftigue 11.7 (3.6) 12.2 (3.7) 15.8 (2.0) b,e Sleep nd Rest 14.0 (3.7) 14.8 (3.8) 17.4 (2.5) c,e Level of Independence 12.1 (2.9) 13.9 (3.3) 17.4 (2.3) d,f Mobility 13.6 (2.5) 15.5 (3.4) 17.2 (3.3) b,e Activities of Dily Living 12.8 (3.5) 13.4 (3.7) 17.2 (2.1) c,e Dependence on Mediction or Tretments 13.8 (3.0) 10.0 (4.2) 5.7 (2.7) b,e Working Cpcity 12.1 (3.5) 12.8 (4.2) 17.0 (2.9) Anlysis of vrince (covrites ge); scores re mens (SD). b Control group scored differently from the two ptient groups. c All three groups scored differently from ech other. d RA group scored differently from the two other groups. e P, f P, Note: domins re printed in bold; for the fcets Pin nd Discomfort nd Dependence on Mediction or Tretment higher scores men worse QOL. P, 0.01) thn the srcoidosis ptients nd the P, 0.05) s well s Spiritulity/ Religion/ Personl helthy group. Beliefs (r , P, 0.05) nd the doses of For the RA ptients we found significnt correl- systemic corticosteroids. tion between the evlutive fcet Overll QOL nd On the fcet level, Energy nd Ftigue correlted Generl Helth nd the fcet Pin nd Discomfort with the number of courses with DMARDs in the (r , P, 0.001). Moreover, reltionship pst (r , P, 0.01), nd the doses of sysws found between the fcet Energy nd Ftigue nd temic corticosteroids (r , P, 0.05). Morethe fcet Pin nd Discomfort (r , P, over, RA ptients with elevted CRP levels showed 0.001). (Note, tht for the fcet Pin nd Discomfort, even lower scores for Energy nd Ftigue (t , in contrst to most other fcets, higher scores men df 5 12, P ) thn those with norml CRP. worse QOL). No reltionship ws found for the fcet The fcet Sleep nd Rest correlted with the ESR Pin nd Discomfort with Sleep nd Rest nd (r P, 0.001). The fcets Thinking, Lernbetween the fcets Energy nd Ftigue nd Sleep nd ing, Memory, nd Concentrtion nd Bodily Imge Rest. Although the RA ptients did not show n nd Appernce were relted to the swollen joint impirment of their psychologicl helth, the fcet index (r , P, 0.05 nd r , P, Energy nd Ftigue ws relted to the domin 0.05, respectively). Mobility correlted with the ESR Psychologicl Helth of the WHOQOL-100 (r 5 (r , P, 0.01). Moreover, reltionship ws 0.75, P, 0.001). For the srcoidosis ptients no found between Activities of Dily Living nd the such reltionship ws found. number of courses of DMARDs (r , P, For the RA ptients, severl reltionships were 0.05). The QOL fcets Ability to Acquire New found between the physiologicl mesures of disese Informtion nd Skills ws relted to the number of severity nd QOL. On the domin level, reltion- courses with DMARDs (r , P, 0.05) nd ship ws found between Physicl Helth nd the the doses of systemic corticosteroids (r , ESR (r , P, 0.01), Level of Independence P, 0.01). No reltionships were found between the nd number of courses with DMARDs (r , QOL fcet Pin nd Discomfort nd ny of the P ), nd between Environment (r , physiologicl mesures of disese severity. In ddi-

6 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) Fig. 1. Reltionships between functionl clsses nd the domins Physicl Helth, Level of Independence, nd Overll QOL nd Generl Helth. tion, no reltionship ws found between gender, Discussion durtion of the disese, nd the current mediction with DMARDs nd ptients QOL. Fig. 1 shows the Generlly, prmeters of disese ctivity or proreltionship between the functionl clss nd the gression in RA re mesured by the disese ctivity domins Physicl Helth, Level of Independence, score (DAS). The DAS hs shortcomings with nd the evlutive fcet Overll Qulity of Life nd respect to the subjective feeling the RA ptient hs. Generl Helth. In Fig. 2., the reltionship between In this study, we compred qulity of life (QOL) in the fcets of these two domins nd the functionl RA with QOL in srcoidosis using the WHOQOLclss is illustrted The results showed tht compred with helthy The domin Psychologicl Helth (F 5 5.4, df 5 control subjects, QOL ws impired in both RA 2; P, 0.05), nd its fcets Self-Esteem (F 5 9.0, ptients nd srcoidosis ptients in mny spects of df 5 2; P, 0.001) nd Negtive Feelings (F 5 7.5, dily life. Compred to srcoidosis ptients, the df 5 2; P, 0.01) were relted to positivity of the impirment of QOL in RA ptients ws more severe rheumtoid fctor (RF). Scores for both fcets were nd included more spects of dily life. higher in ptients with positivity for RF thn in those Both ptient groups felt nergic nd suffered from with positivity for APF or seronegtivity for RF, ftigue. Recurrent or persistent ftigue is feture of indicting tht ptients with positive RF hd mny cute or chronic inflmmtory conditions. better psychologicl helth, more self-esteem, nd Ftigue is generlly recognized s subjective less negtive feelings. feture in RA not being in clinicl remission [26]. For the srcoidosis ptients, no reltionships were Crosby found in ptient group with RA tht more found between physiologicl mesures, tht is sace thn 50% of ptients suffered from ftigue nd levels s well s pulmonry function tests, nd QOL. constnt lck of energy [27]. Furthermore, in nother

7 92 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) Fig. 2. Reltionships between functionl clsses nd the fcets of the domins Physicl Helth nd Level of Independence. study she demonstrted correltion of pin, frg- found, tht ptients with RA hve to cope simulmented sleep, nd functionl bility with ftigue in tneously with pin, limittions nd dependence nd RA ptients [28]. In the present study, pin nd tht ll three fctors were negtively relted to QOL ftigue were interrelted in the RA ptients. How- [32]. Moreover, depressive symptoms re more ever, no interreltionships of pin nd ftigue with frequent in ptients with RA thn in helthy controls, sleep were found, lthough ll three spects were even fter controlling for criterion contmintion significntly impired. In srcoidosis, the symptom [31,33]. In the present study, the RA ptients s ftigue hs received little ttention in literture [29]. group were not impired with respect to their Recently, we found lower levels of energy nd more psychologicl helth. However, ptients with lower ftigue in group of srcoidosis ptients compred levels of energy showed more impirment of their to helthy controls. This finding ws not ssocited psychologicl helth. In rheumtology reserch, the with current symptoms; it ppered to be present lso negtive ffect component of QOL hs been emphin ptients who initilly hd reported no symptoms sized [31]. In the present study, RA ptients did not [8]. In nother study, we found besides reduced hve more negtive feelings thn srcoidosis ptients respirtory muscle strength nd respirtory muscle nd helthy controls. However, ptients with endurnce, n interreltionship between the symptom seropositivity for rheumtoid fctor (RF) showed ftigue nd decresed expirtory muscle strength better psychologicl helth, less negtive feelings, [30]. nd better self-esteem compred with positivity for RA cn hve negtive effect on ffective, APF. Fewer psychopthologicl tendencies in pbehviorl, nd socil functioning of ptients [31]. tients with positivity for RF thn in those with Studying psychologicl stressors in RA, others hve seronegtivity for RF hve been reported before [34].

8 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) Also the srcoidosis ptients included in this study sking ptients, whether they hve complints [8]. were not impired in their psychologicl helth. We The WHOQOL-100 fcet Energy nd Ftigue pfound no reltionship between psychologicl helth pers to be sensitive for the ssessment of ftigue in nd ftigue. With respect to depressive symptoms in RA ptients s well. srcoidosis ptients, we found in previous study Physiologicl mesures such s ESR nd the tht ptients with current symptoms experienced current mediction s well s mediction in the pst more depressive symptoms thn symptomtic p- were relted to only few spects of QOL. As tients [7]. discussed bove, elevted CRP levels correlted with In the present study, the QOL in both ptient ptients pin nd discomfort. No reltionship ws groups ws impired minly with respect to spects found between durtion of the disese nd QOL. In of physicl helth nd level of independence, s well generl, non-significnt correltions were found bes generl helth nd overll QOL. As discussed tween QOL nd the routinely performed physiologibove, with respect to ftigue nd sleeping problems, cl mesures. These results re in line with other the two ptient groups did not differ significntly studies tht hve shown tht disese sttus in RA, from ech other. Also difficulties performing c- ssessed by the routinely performed mesures of tivities of dily living nd work were eqully im- physicl helth, did not reflect the impct of RA on pired in both ptient groups. In ddition, the RA psychosocil well-being [38]. Self-reported low ptients were impired in their mobility. Also pin physicl well-being, however, ws ssocited with nd discomfort ppered to be mjor problem only more depressive feelings [6]. Other subjective stresin RA ptients. This could be expected, s chronic sors such s perceived limittion nd dependence nd cute pin is known to be the mjor consequence were found only wekly relted to trditionlly used of this disorder [31,32]. Surprisingly, no reltionship disese sttus mesures [32]. ws found between the levels of pin of RA ptients For the srcoidosis ptients no reltionship bessessed by the WHOQOL-100 nd ny of the tween pulmonry function tests such s FEV1 nd physiologicl mesures of disese severity. In con- T L,CO nd the WHOQOL-100 scores were found. trst, Meenn et l. found for the AIMS pin scle Also helth sttus ws not relted to durtion of the reltionships with criteri of disese severity such s disese nd routinely performed tests such s puljoint count [35]. However, the AIMS is helth monry function tests nd serum ngiotensin consttus mesure nd the questions re closer relted to verting enzyme (sace) levels, respectively, s we objective mesures thn the WHOQOL-100 items. showed in previous study [7]. However, s men- The questions of the ltter ssess, e.g. to wht extent tioned bove, ftigue ws found relted to higher the ptient hs difficulties to cope with pin or levels of CRP in srcoidosis ptients [37]. Although discomfort, worries bout pin or discomfort, nd the impirment of QOL ws more severe in the RA mesure the extent tht pin keeps you from doing ptients, QOL ws considerbly impired in the wht you must do. These questions ssess rther the srcoidosis ptients s well. When only considering ptient s subjective perception. The impirment the the pulmonry function tests, one would expect only ptient perceives by the pin is not necessrily mild impirment of QOL in these srcoidosis prelted to mesures such s functionl sttus or tients, s these tests were norml in most ptients, or swollen joint count. showed only mild impirment. RA ptients with elevted CRP levels hd low The present study hs couple of limittions. levels of energy nd more ftigue. This is in line Disese severity s ssessed by the different, routinewith other studies, in which improvement of ftigue ly performed physiologicl mesures for both discoincided with descend of CRP levels fter tret- orders re not directly comprble. Moreover, the ment [36]. Previously, we found reltionship disese durtion of the RA ptients ws longer thn between ftigue nd CRP levels for srcoidosis tht of the srcoidosis ptients. Although one my ptients s well [37]. Moreover, we found tht in hypothesize tht durtion of the disese influences srcoidosis ptients, the symptom ftigue is ssessed QOL, this ws clerly not the cse in both ptient more ccurtely by the WHOQOL-100 thn by only groups. In ddition, the RA ptients were signifi-

9 94 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) cntly older thn the srcoidosis ptients. This Self-evlution processes nd djustment to rheumtoid difference between the ptient groups did not in- rthritis. Arthritis Rheum 1988;31: [3] Long AF, Scott DL. Meeting Report. Mesuring helth sttus fluence the results, s ge ws used s covrite in nd outcomes in rheumtoid rthritis within routine clinicl the nlyses. prctice. Br J Rheumtol 1994;33: In conclusion, QOL is impired in both RA s [4] Vn Riel P, Vn Lnkveld W. Qulity of life in rheumtoid well s in srcoidosis. As hypothesized, QOL ws rthritis: review. Phrm World Sci 1993;15:93 7. more seriously impired nd included more spects [5] Meenn RF. The AIMS pproch to helth sttus mesure- ment: conceptul bckground nd mesurement properties. J of QOL in RA ptients thn in srcoidosis ptients. Rheumtol 1982;9: Min problems for both ptient groups were sleeping [6] Bijlsm JWJ, Huiskes CJAE, Krimt FW, Vnderveen MJ, problems nd ftigue. As expected, pin nd im- Huber-Bruning O. Reltion between ptients own helth pired mobility were found only in the RA ptients. ssessment nd clinicl nd lbortory findings in However, in contrst to our expecttions, with rheumtoid rthritis. J Rheumtol 1991;18: respect to their working cpcity nd problems [7] Drent M, Wirnsberger RM, Breteler MHM, Kock LMM, De Vries J, Wouters EFM. Qulity of life nd depressive performing ctivities of dily living the two ptient symptoms in ptients suffering from srcoidosis. Srcoidosis groups did not show ny differences. Although the Vsc Diffuse Lung Dis 1998;15: disese impct on the qulity of life ws more severe [8] Wirnsberger RM, De Vries J, Breteler MHM, Vn Heck GL, in the RA ptients, the impct of the disese on Drent M. Evlution of qulity of life in srcoidosis ptients. symptomtic srcoidosis ptients ws considerble. Respir Med 1998;92: [9] Semenzto G, Zmbello R, Trentin L, Agostini C. Cellulr This study indicted tht QOL indeed is prtly immunity in srcoidosis nd hypersensitivity pneumonitis. relted to physiologicl mesures of disese severity Recent dvnces. Chest 1993;103(suppl):139S 43S. in RA, but not t ll in srcoidosis. Thus, in RA, s [10] Bennett JC. The etiology of Rheumtoid rthritis. in: Kelley in other chronic diseses such s srcoidosis, ssess- WN, Hrris ED, Ruddy S, Sledge CB (Eds.), Textbook of ment of QOL is of dditionl vlue nd, therefore, Rheumtology, Sunders, Phildelphi, 1981, pp [11] King TE. Connective tissue disese. in: Schwrz MI, King should be included in the follow-up for brod TE (Eds.), Interstitil Lung Disese, Mosby-Yer Book, St. evlution of the ptients clinicl sitution. The Louis, Missouri, 1993, pp WHOQOL-100 ppered to be n pproprite instru- [12] Rees JH, Woodhed MA, Shepprd MN, dubois RM. ment to ssess QOL in both diseses studied. Rheumtoid rthritis nd crypogenic orgnizing pneumoni. Respir Med 1991;85: [13] Wirnsberger RM, De Vries J, Wouters EFM, Drent M. Clinicl presenttion of srcoidosis in The Netherlnds. An epidemiologicl study. Neth J Med 1998;53: Acknowledgements [14] Rut DA, Hurst NP, Kind P, Hunter M, Stubbings A. The uthors thnk the Deprtments of Pulmonolo- Mesuring helth sttus in British ptients with rheumtoid rthritis: relibility, vlidity nd responsiveness of the Short gy of the prticipting Dutch Hospitls nd the Form 36 item Helth Survey (SF-36). Br J Rheumtol Deprtment of Rheumtology of the Rijnstte Hospi- 1998;37: [15] Fries JF, Spitz P, Krines RG, Holmn HR. Mesurement of tl, Arnhem. Moreover, we would like to thnk S. ptient outcome in rthritis. Arthritis Rheum 1980;23:137 Drent, L.M.M. Kock, M. Jnssen, A.J.L. de Jong, 45. nd N. de Vries for their help in collecting the dt, [16] Fries JF, Spitz PW, Young DY. The dimensions of helth nd M.D.P. Elfferich for her vluble dvice nd outcomes: The Helth Assessment Questionnire, disbility comments. nd pin scles. J Rheumt 1982;9: [17] Pincus T, Summey JA, Sorci SA, Wllston KA, Hummon NP. Assessment of ptient stisfction in ctivities of dily living using modified Stnford Helth Assessment Questionnire. References Arthritis Rheum 1983;26: [18] O Boyle CA. The schedule for the evlution of individul qulity of life (SEIQoL). Int J Ment Helth 1994;23:3 23. [1] Ptrick DL, Deyo RA. Generic nd disese specific mesures [19] De Vries J, Vn Heck GL. Nederlndse WHOQOL-100, in ssessing helth sttus nd qulity of life. Med Cre Tilburg: Tilburg University 1989;27(suppl): [20] Arnett FC, Edworthy SM, Bloch DA et l. The Americn [2] Bllock SJ, McEvoy devellis B, devellis RF, vn Suter SH. Rheumtism Assocition 1987 revised criteri for the clssi-

10 R.M. Wirnsberger et l. / The Netherlnds Journl of Medicine 54 (1999) fiction of rheumtoid rthritis. Arthritis Rheum [31] Anderson KO, Brdley LA, Young LD, McDniel LK, Wise 1988;31: CM. Rheumtoid rthritis: Review of psychologicl fctors [21] Steinbrocker O, Treger CH, Bttermn RC. Therpeutic relted to etiology, effects, nd tretment. Psychol Bull criteri in rheumtoid rthritis. J Am Med Assoc 1985;98: ;140: [32] Vn Lnkveld W, Nring G, Vn der Stk C, Vn t Pd [22] WHOQOL group. Development of the WHOQOL: Rtionle Bosch P, Vn de Putte L. Stress cused by rheumtoid nd current sttus. Int J Ment Helth 1994;23:24 56 rthritis: The reltion between subjective stressors of the [23] De Vries J. Beyond helth sttus. Construction nd vlidtion disese, disese sttus nd well-being. J Behviorl Med of the Dutch WHO Qulity of life ssessment instrument 1993;16: (disserttion). Tilburg, The Netherlnds: Tilburg University, [33] Pincus T, Cllhn LF. Depression scles in rheumtoid 1996 rthritis: criterion contmintion in interprettion of ptient [24] Qunjer PH, Tmmeling GJ, Cotes JE, Pedersen OF, Peslin responses. Ptient Educ Couns 1993;20: R, Yernult J-C. Lung volumes nd forced ventiltory flows. [34] Vollhrdt BR, Ackermn SH, Gryzel AI, Brlnd P. Psycho- Report working prty. Stndrdiztion of lung function tests. logiclly distinguishble groups of rheumtoid rthritis p- Europen Commission for Steel nd Col. Officil sttement tients: controlled, single blind study. Psychosom Med of the Europen Respirtory Society. Eur Respir J 1993;6 1982;44: (suppl 16):5 40. [35] Meenn RF, Gertmn PM, Mson JH, Dunif R. The 1 [25] SPSS-PC for the IBM PC/ XT/AT. SPSS Inc., Chicgo, Arthritis Impct Mesurement Scles: further investigtions 1986 of helth sttus mesure. Arthritis Rheum 1982;25:1048 [26] Pinls RS, Msi AT, Lrsen RA. Preliminry criteri for 53. clinicl remission in rheumtoid rthritis. Arthritis Rheum [36] Elliott MJ, Mini RN, Feldmnn M et l. Rndomised 1981;24: double-blind comprison of chimeric monoclonl ntibody to [27] Crosby LJ. Stress fctors, emotionl stress nd rheumtoid tumour necrosis fctor (ca2) versus plcebo in rheumtoid rthritis disese ctivity. J Adv Nurs 1988;13: rthritis. Lncet 1994;344: [28] Crosby LJ. Fctors which contribute to ftigue ssocited [37] Drent M, Wirnsberger RM, De Vries J, Vn Dieijen-Visser with rheumtoid rthritis. J Adv Nurs 1991;16: MP, Wouters EFM, Schols AMWJ. Assocition of ftigue [29] Jmes DG. Complictions of srcoidosis. Chronic ftigue with n cute phse response in srcoidosis. Eur Respir J syndrome. Srcoidosis 1993;10: ; 13 (in press). [30] Wirnsberger RM, Drent M, Hekelr N et l. Reltionship [38] Vn Lnkveld WGJM. Coping with chronic stressors of between respirtory muscle function nd qulity of life in rheumtoid rthritis (disserttion). Nijmegen, The Nethersrcoidosis. Eur Respir J 1997;10: lnds: Ctholic University Nijmegen, 1993.