Quality of Life Assessment and Its Relationship with Fatigue Symptom, Demographic and Clinical Factors in Rheumatoid Arthritis Polish Patients

Research Article

Ann Nurs Res Pract. 2023; 8(2): 1058.

Quality of Life Assessment and Its Relationship with Fatigue Symptom, Demographic and Clinical Factors in Rheumatoid Arthritis Polish Patients

Katarzyna Anna Kozlowska1; Grazyna Baczyk2*; Dorota Formanowicz3

¹Department of Nursing Practices, Poznan University of Medical Sciences, 61-701 Poznan, Poland. Email: [email protected]

²Department of Nursing Practices, Poznan University of Medical Sciences, 61-701 Poznan, Poland. Email: [email protected]

³Department of Medical Chemistry and Laboratory Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland. Email: [email protected]

*Corresponding author: Baczyk G Department of Nursing Practices, Poznan University of Medical Sciences, Rokietnicka street 2a, 61-701 Poznan, Poland. Tel: (61) 845-26-79; Fax: 61 854-62-62 Email: [email protected]

Received: November 13, 2023 Accepted: December 14, 2023 Published: December 21, 2023


The variety of clinical symptoms occurring during rheumatoid arthritis may reduce patients’ quality of life. Hence, the study aimed to assess RA patients’ quality of life and determine its relationship with fatigue, demographic and clinical factors. The study group consisted of 128 RA patients diagnosed according to ACR/EULAR criteria and treated in rheumatology departments. The Arthritis Impact Measurement Scales-2 (AIMS-2) scale was used to assess the quality of life. The Functional Assessment of Chronic Illness Therapy - Fatigue Scale was used to assess the symptom of fatigue. The analyzed variables were sex, age, pharmacological treatment, arthritis pain, morning stiffness, hemoglobin, CRP, rheumatoid factor, Ritchie Articular Index, and DAS28 disease activity. In the AIMS-2 scale, the patients had the lowest quality of life in the following subscales: arthritis pain (average 6.25±2.52 points), walking and bending (average 5.63±2.71 points), and emotional tension (average 4.99±1.92 points); while patients presented the highest quality of life for the following subscales: support from family and friends (average 1.39±2.21 points) and self-care (average 2.11±2.45 points). There was a correlation between the level of quality of life and age (r=0.24), morning stiffness (r=0.45), CRP concentration (r=0.29), joint tenderness (r=0.34), and disease activity (r=0.39). Increasing the values of parameters such as arthritis pain, disease activity, morning stiffness, and CRP level may cause a decrease in the level of quality of life. Assessment of the quality of life should be a permanent element of assessing patients with RA.

Keywords: Quality of life; Rheumatoid arthritis; Fatigue; Clinical factors; AIMS-2 scale

Abbreviations: RA: Rheumatoid Arthritis; HRQOL: Health-Related Quality of Life; CRP: C-Reactive Protein; RF: Rheumatoid Factor; DAS28: Disease Activity; VAS: Arthritis Pain; Hgb: Hemoglobin; ACR: The American College of Rheumatology; EULAR: The European League Against Rheumatism; AIMS-2: The Arthritis Impact Measurement Scales-2; FACIT-F: The Functional Assessment of Chronic Illness Therapy – Fatigue; Avg: The Arithmetic Mean; SD: Standard Deviation; Me: Median; min: Minimum; max: Maximum


Rheumatoid Arthritis (RA) is a connective tissue disease that affects symmetrical joints (in the course of a non-specific inflammatory process) and extra-articular tissues (e.g., kidneys, heart, lungs) and causes systemic complications [1,2]. The disease is a non-specific inflammatory-related process of unknown etiology. Inflammatory changes occur in the synovium of the joints, cartilage, and bones. The main symptoms are pain, swelling, and stiffness of the joints [1-4]. Especially problems with the joints of the hands, feet and ankles make it difficult to perform everyday activities [5,6]. RA leads to disability, deformities in the limbs, invalidity, and premature death of patients [1-6].

Patients affected by this disease not only suffer from physical ailments, such as joint pain and morning stiffness, resulting from complications of pharmacological treatment or fatigue, but they also experience consequences in the mental, economic, social, and interpersonal spheres. RA can lead to a reduction in employment and even loss of work, sometimes even poverty [2,3,5,6]. Patients are unable to perform all activities of daily living on their own. Washing, dressing, cleaning, preparing meals, going shopping in the exacerbation phase of the disease, or as a result of the progress of destructive changes, causes dependence on third parties, use of social assistance, or even resignation from them when there is no one to take care of a given person [5,6]. Their physical and mental condition makes it impossible to lead a typical family, social and cultural life. Social isolation, anxiety, and depression appear. Changing body image adversely affects self-perception, especially among women [5,6].

So far, numerous definitions of quality of life have been developed, reflecting its meaning. Their difference results from the complex nature of the issue, which has many dimensions, depending on the perspective of the subject from which it is considered [7]. The World Health Organization gave the following definition of quality of life: a person's perception of their life situation in the context of cultural conditions, value systems, and in relation to their goals, norms, and interests. And Health-Related Quality of Life (HRQOL) is defined as “a term referring to the health-related aspects of quality of life, widely regarded as reflecting the impact of disease and treatment on disability and daily functioning; it was also considered to reflect the impact of perceived health on an individual's ability to lead a fulfilling life; it is a measure of the value assigned to lifespan modified by impairments, functional states, perceptions, and abilities, influenced by disease, injury, treatment, and policy” [7-9]. Thanks to this definition, the concept of quality of life indicates its multifaceted and multifaceted nature, and thus that in medical science, its assessment cannot be based on only one paradigm but on a holistic approach. Nowadays, the clinical evaluation of the patient should take into account not only the physical condition but also its connections with other areas of life, as a consequence of, for example, the costs of health care, prolongation of life, or the possibility of choosing the method of treatment and related complications. Its dimension is subjective and objective [7-11].

Most studies on the quality of life of patients with RA focus on assessing the impact of demographic and clinical factors on the quality of life of these patients. However, our research, in addition to the variables listed above, takes into account the results of laboratory tests. The innovation of these studies is the use of multivariate analysis, which explains the share of the analyzed variables in the assessment of the quality of life of patients with RA.

The study aimed to assess the quality of life of patients with RA and to determine the relationship between the quality of life and the symptom of fatigue, as well as demographic and clinical factors, including the results of laboratory tests.

The following research questions were posed:

What is the quality of life of patients with RA?

1. Is there a relationship between the quality of life of patients with RA and demographic factors?

2. Is there a relationship between the quality of life of patients with RA, the symptom of fatigue, clinical factors and the disease's duration?

3. What clinical factors affect the quality of life of patients with RA:

a. do the clinical variables analyzed jointly: hemoglobin concentration, C-Reactive Protein (CRP), and Rheumatoid Factor (RF), influence the quality of life of the subjects?

b. do the clinical variables analyzed jointly: the type of pharmacological treatment (biological/classic) and Disease Activity (DAS28), affect the quality of life of the respondents?

c. do the clinical variables analyzed jointly: Arthritis Pain (VAS), morning stiffness (in minutes), hemoglobin (Hgb), tender joint (Ritchie Articular Index), and Disease Activity (DAS28), affect the quality of life of the subjects?

Materials and Methods

Study Design and Studied Subjects

The study group consisted of 128 patients hospitalized in Poznan’s rheumatology departments (the Rheumatology Ward of the M. Dega Orthopedic and Rehabilitation Clinical Hospital of Poznan University of Medical Sciences and the Józef Strus Poznan Multidisciplinary City Hospital) from December 2016 to January 2018, see [12]. The main criterion for inclusion in the study was a diagnosis of RA according to the American College of Rheumatology (ACR) criteria and the European League Against Rheumatism (EULAR) from 2010 [13].

On the day of admission to treatment, patients received questionnaires to answer the questions included in the questionnaires. A researcher (the first author) participated in the answering process and explained any doubts about understanding the questions in the survey. In addition, the researcher checked whether all questions in the questionnaire had been answered, and if they were missing, the respondent was asked to complete the answer. Then, the physician, and rheumatologist, in the presence of the researcher (the first author), assessed the clinical status, disease activity, and pressure pain in the joints - they used the clinical tests listed later in the article.

The patients participating in the study underwent the laboratory tests listed in the other part of the article.

The exclusion criteria were people who were diagnosed with mental health-related diseases - which did not allow them to complete the questionnaires, cancer, and lack of consent or resignation during the study.



The specific scale Arthritis Impact Measurement Scales-2 (AIMS-2), developed by experts from the Boston Center for Rheumatic Diseases, was used to assess the quality of life [14]. The AIMS-2 scale has been translated into many languages, and in many studies, the study group consisted of patients with RA.

The cultural and linguistic adaptation and the assessment of the psychometric properties of the Polish version of the AIMS-2 scale were prepared by a team led by Baczyk [15]. For the Polish version of the scale, Cronbach's a coefficient is 0.89 for the entire scale, while for individual subscales, the values range from 0.70 for a social activity to 0.89 for support from family and friends [15].

The AIMS -2 [14,15] scale consists of 78 questions. The first 57 questions are made up of 12 subscales, which include: mobility level, walking and bending, hand and finger function, arm function, self-care, household tasks, social activities, support from family and friends, arthritis pain, work, level of tension, mood, satisfaction.

Each of these subscales contains 4 or 5 items, with a possible answer consisting of 5 alternatives: from "always" to "never" and from "all days" to "not at all - no day” [15].

The possible range of scores for individual subscales is 0 - 10, where: 0 means good functioning and good quality of life, while 10 means poor functioning and poor quality of life [14,15].

The remaining questions of the AIMS -2 scale concern the respondents' life satisfaction assessment [14].

Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) [16] Polish versions with the consent of the authors.

The FACIT-F scale allows assessing fatigue in the following domains: physical, mental, and social as part of the daily functioning of patients and their daily activities (within the last week). The scale consists of 13 questions (each question is scored from 0 to 4), with a maximum of 52 points and a minimum of 0. The questions allow you to assess whether fatigue occurs at all and the degree of its intensity in the examined area. The lower the score, the more severe the fatigue [16].

Clinical Tests

The Visual Analogue Scale (0 – 10 cm VAS Pain Scale) was used to determine the severity of joint pain; 0 cm VAS - no pain, 10 cm VAS - very severe pain [17].

The Ritchie Articular Index was used to assess joint soreness. This index determines the pain of pressing joints in points from 0 to 3:

• 0 points - the joint is not sensitive to pressure,

• 1 point - pain when pressed,

• 2 points - pain and defensive reactions to pressure,

• 3 points - violent defensive reaction to pressure.

The index value is the sum of the points for all involved joints. Its maximum value is 53 points [18].

DAS28 disease activity was assessed using a medical calculator (DAS28 CRP 3) version 1.1. [19]. the number of painful joints according to the Ritchie Articular Index and the number of swollen joints and CRP value were entered into the calculator.

A questionnaire collecting information on demographic and clinical factors as well as the results of laboratory tests

The self-designed questionnaire included the following questions: sex, age, duration of the disease, current treatment (classic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), drugs modifying disease activity, glucocorticoids), and biological treatment (yes/no), duration of morning stiffness symptom (in minutes) and Hemoglobin Concentration (Hgb), C-Reactive Protein (CRP), and Rheumatoid Factor (RF) titers.


The study was approved by the Ethics Committee of the Poznan University of Medical Sciences, under reference numbers 46/16 and 564/16, and was carried out in accordance with the Declaration of Helsinki. Participants of the study received an informed consent form, where they were informed about the purpose and course of the study and that they could terminate their participation in the project at any time without incurring any consequences. All patients gave their written informed consent to participate in the study.

Statistical Analysis

Qualitative variables are described by the number (n) and frequency (%), and the measurable variables are characterized by the Arithmetic Mean (Avg), Standard Deviation (SD), Median (Me) and Minimum (min), and Maximum (max) values.

Due to the nature of the variables (measurable variables described on an ordinal scale and the lack of normal distribution of quantitative variables), non-parametric tests were used for statistical analyses.

The Mann-Whitney and Kruskal-Wallis U test was used to assess the relationship between quality of life and clinical, demographic, and fatigue factors. The significance level a=0.05 was assumed (if the test probability p>0.05, the variables in both groups were consider to be the same).

Correlations between measurable variables were checked using Spearman's rank correlation coefficient significance test. If the test probability p exceeded the assumed significance level of a=0.05, it meant that there was no correlation between the tested variables.

To assess the impact of several independent variables (clinical factors) on the level of quality of life, multiple linear regression and in-depth stepwise multiple regression were used for the most significant coefficient.

The value of p<0.05 was considered statistically significant.

Statistical calculations were performed using the STATISTICA 10 PL statistical package.


Characteristics of the Study Group

The study group consisted of 128 patients with RA, and the fewest were men (n=18). The respondents were between 19 and 83 years of age; the average age for women was 53.7±14.4, and for men, 54±15.6. Only 24 patients were treated with biological drugs (19 women and 5 men). The mean duration of the disease was 11 years and the mean duration of morning stiffness was 53.3 minutes, see Table 1 and 2. More than 58% of patients had at least one comorbidity; about 37% suffered from hypertension, about 9% from type 2 diabetes, and about 7% from ischemic heart disease.