Rheumatic diseases (RD) generally affect the upper limb, especially the hands, and can cause deformity or swelling followed by pain and functional limitation, affecting the patient’s performance of daily activities, lifestyle and, therefore, motivation and general satisfaction.1–3 Therefore, the assessment of functional disability in the hand with rheumatic diseases should be carried out through the performance of activities covering all occupational areas,4 and taking into account factors such as self-efficacy or pain intensity. Self-efficacy expectations refer to the belief in one’s own capabilities, and arise when performing certain behaviours to successfully achieve a goal,5 such as pain management6 or occupational performance.7 Self-efficacy is a component that can determine a person's effort or involvement in the achievement of goals, and a person with a high level of self-efficacy is one who makes more effort and is more involved.8 Previous studies have shown that there is a low level of self-efficacy in people suffering from rheumatic diseases,9 and that if self-efficacy is increased, functionality will improve by up to 28%.10 Pain is considered one of the most relevant symptoms in rheumatic diseases, and can become a barrier to carrying out occupations independently.11 The perception of self-efficacy has also been associated with a better state of health in diseases with chronic pain, even being a predictive value in the general state of health in patients with fibromyalgia.12

In rheumatic diseases, the duration of symptoms is proportional to the accumulated damage due to the progression of symptoms and the passage of time.13,14 It is important to consider self-efficacy, symptom duration and pain as a set of interrelated factors that can directly influence the patient with rheumatic disease, the performance of daily activities and possible functional disability of the upper limb. Previous research shows that self-efficacy is related to functional disability of the upper limb15 and emotional state, highlighting that the greater the self-efficacy, the less the pain and the better the occupational performance in adults,11 but we do not know to what extent this correlation holds in people diagnosed with rheumatoid arthritis (RA). Thus, the main objective of this study is to investigate the relationship between self-efficacy, pain and function, as well as the predictive capacity of self-efficacy, measured with the Spanish scale of self-efficacy in rheumatic diseases, with respect to pain intensity, symptom duration and functional disability of the upper limb measured with the Spanish version of the QuickDASH questionnaire in patients with RA.

A total of 117 women participated in the study with a mean age of 52.8 (SD = 2.6) years. In reference to employment status, a total of 76 women (64.9%) were in employment, while 14 (11.9%) were inactive and 27 of them reported having “other status” (23.07%). One hundred and three (n = 103) participants reported using their right hand as dominant (88.2%). In reference to disease involvement, 62 participants (53%) showed dominant hand involvement and 55 of them (47%) bilateral involvement at the time of the study (Table 1).

In order to analyse which functional variables (QuickDASH and pain) are the best predictors of self-efficacy measured with the Spanish scale of rheumatic diseases and self-efficacy, a series of linear regression analyses were performed using self-efficacy as the dependent variable. For this purpose, we introduced the functional variables of pain and function (VAS and QuickDASH). As our aim is to find among the variables studied those that best explain the dependent variable without any of them being a linear combination of the others, we used the “stepwise” procedure. For the inclusion of the variables in the model, the probability had to be <.5.

A directly proportional relationship was found between self-efficacy, pain intensity and upper limb functionality (p < .05). The level of association between self-efficacy, pain intensity and QuickDASH is 35%, with an R2 = .356 (Table 2).

Specifically, the variables measuring self-efficacy show a low correlation with the VAS scale (r = −.437; p = .079) and a high correlation with the QuickDASH questionnaire (r = −.595; p = .012). Regarding the variables that measure pain intensity, the Spanish scale of rheumatic diseases and general mastery self-efficacy shows a low relationship (r = −,437; p = .079), while the domain-specific pain self-efficacy scale shows a high relationship (r = −.545; p = .024) as with the QuickDASH questionnaire (r = −.693; p = .002). Finally, the variable measuring upper limb functional disability, the Spanish scale of rheumatic diseases and general mastery self-efficacy, presents a moderate relationship (r = −.595; p = .012), while the domain-specific one in relation to function, shows a moderate relationship as well (r = −.513; p = .013), and with VAS it shows a high relationship (r = −.693; p = .02) (Table 3). Upper limb functional ability and pain intensity have a significant negative correlation with self-efficacy (<.01).

In the step-by-step analysis, using self-efficacy as the dependent variable and pain and function as predictors. The most significant model is obtained using as independent variables the pain variable and the function variable with an R = .596 and an R2 = .35 with a significance level of p = .000.

Therefore, function (QuickDASH) and pain (VAS) are predictor variables in the rheumatic hand with a standardised B coefficient = 78.561 (p = .000), with neither separately being more predictive than the other.

In this study we found a correlation between self-efficacy, pain intensity and functional disability of the upper limb in patients with RA. The results obtained indicated the contrast of the main hypothesis, which established a relationship between variables, since a high score on the VAS also implied a high score on the QuickDASH questionnaire and the Spanish scale of rheumatic diseases and general self-efficacy and, therefore, greater pain intensity, greater functional disability and lower self-efficacy of the subject, but without any variable being more predictive than another. This may be due to the fact that upper limb function measured with the QuickDASH scale and pain measured with the VAS scale have a positive correlation, similar to the results presented in the studies of Kadzielski et al.26 and MacDermid et al.,27 and those of Goldfarb and Stern28 and Barthel et al.,29 where a relationship is established with a high level of significance (p < .001) between the variables function and pain in patients with rheumatic diseases. Our results are consistent with previous studies establishing a possible relationship between self-efficacy and functional disability,30,31 as well as self-efficacy and its relationship with physical functions such as strength, range of motion and hand coordination,9 demonstrating that a low level of self-efficacy implies a decrease in functionality. The results of our research also concur with the results obtained recently by Rodríguez-García et al.,4 a study with a similar design to ours, a multicentre, observational, cross-sectional study, which demonstrates the relationship between self-efficacy, pain intensity and functional disability, also taking into account the duration of the disease and the performance of activities of daily living (ADLs).4 However, in the study by Rodriguez-Garcia et al., despite the larger sample size, there is heterogeneity in the sample, as it includes patients with rheumatic involvement and patients with degenerative osteoarthritis of the base of the thumb where the rest of the fingers are not affected in daily activities and where the result of the DASH scale may not be conclusive as this scale, which assesses the global disability of both upper limbs, may not be specific for osteoarthritis of the base of the thumb and may not be sensitive to changes.

Other studies relate in their results a high level of self-efficacy to correct occupational performance, focusing specifically on basic activities of daily living (BADL).26 RA is a disease whose main symptom is pain, being one of the constant symptoms in RD, which is defined as “disabling and intense”32 and therefore, self-efficacy and upper limb functionality will be affected by the intensity of the subject’s pain, so that the pain variable and occupational performance could also have a positive correlation, as demonstrated in the study by Cantero-Téllez et al. where patient satisfaction, perception and pain intensity show correlative data.33 We therefore believe that pain should be a priority target for intervention in RA, since its improvement will lead to an increase in the self-efficacy and functionality of the subject, as demonstrated in numerous studies that point out that the main consequence of pain is the deterioration of functionality, resulting in a limitation of independence and autonomy, which in turn affects self-efficacy, the patient’s quality of life and the occupations performed.34–38

With regard to symptomatology, it should be noted that RA presents with symptoms involving an alteration of the joint structures that lead to a loss of functionality of the patient’s upper limb. In their study, Blazar et al.39 demonstrate not only the inability of subjects to perform activities such as manipulating an object, but also the loss of functionality of the upper limb and occupational performance, which is often triggered by the subject’s abstention from performing specific manual activities. Given that these symptoms appear in more advanced stages of the disease, and that our sample has a mean age of 52.8 years, which can be considered young and not very advanced in the disease, we have not been able to assess whether and to what extent these factors may influence the functional capacity of the subjects. Larger, more heterogeneous samples would be necessary to determine this fact.

The preliminary conclusions drawn from this study could help in the design and planning of individualised assessments and interventions to address different factors related to functional disability of the upper limb, as well as to promote the development of early interventions that prioritise self-efficacy, since its improvement would also imply an improvement in the independence and autonomy of patients, reducing the number of resources in terms of assessment scales during the patient's intervention process. The implementation of the self-efficacy scale from an interdisciplinary approach together with rheumatologists, nurses, physiotherapists and occupational therapists among other health professionals, will allow self-efficacy to acquire greater significance and, therefore, interventions to be more oriented to the patient’s needs and their satisfaction. Future research with longitudinal multicentre studies with a larger number of subjects where more clinical and psychological variables are included could help us to obtain representative results in the Spanish RA population.

There is a positive correlation between self-efficacy, function and pain in patients diagnosed with RA. Therefore, the results suggest that the systematic use of the Spanish scale of rheumatic diseases and self-efficacy in isolation could be used as a single assessment method whose outcome would encompass functionality and pain intensity in patients with RA.

The authors have no conflict of interests to declare.