Outcomes of early rheumatoid arthritis--the WHO ICF framework

With the establishment of the new American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 criteria for rheumatoid arthritis (RA) to diagnose patients earlier and with the introduction of early and aggressive treatment, the current aim is remission resulting in less functional disability, halting of radiographic damage, less pain, less fatigue and no loss of employment. These outcomes can be related to the World Health Organization International Classification of Functioning, Disability and Health (the WHO ICF framework). This framework includes the component body functions, body structures, activities and participation related to the disease. These components are related to each other in a bidirectional way and can be influenced by contextual factors including environmental and personal factors. This framework can be used to describe trends in RA outcomes and the impact of contextual factors on these outcomes. Despite aggressive treatment strategies, patients with RA still experience loss of function, pain and fatigue, and a relatively high proportion of patients have to take sick leave or become work disabled within the first few years of the disease. There is evidence that more stringent definitions of remission lead to greater improvement of outcomes and that the aim should be sustained remission and not just remission. There is, however, a need for a better understanding of the relation between contextual factors and activity and participation outcomes to better guide therapy decisions by rheumatologists and provide information to patients, families and policymakers about the impact of RA on their lives and to the society. The overall aim of this overview is to highlight the important contextual factors and consequences that relate to outcomes typically measured in RA studies and to demonstrate the additional benefits that can be achieved with remission and sustained remission.