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Best Practice & Research Clinical Rheumatology

Vol. 18, No. 4, pp. 491505, 2004


doi:10.1016/j.berh.2004.04.001
available online at http://www.sciencedirect.com

3
What is the role of the occupational therapist?
Alison Hammond*

MSc, Bsc (Hons), Dip COT

Senior Research Therapist


Department of Rheumatology, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK

Occupational therapy (OT) is widely provided for people with chronic musculoskeletal
conditions. The aims are to improve their ability to perform daily occupations (i.e. activities
and valued life roles at work, in the home, at leisure and socially), facilitate successful adaptations
to disruptions in lifestyle, prevent losses of function and improve or maintain psychological status.
This chapter reviews the evidence for the effectiveness of OT interventions, suggests who is
relevant for referral and indicates the appropriate timing for referral. The main emphasis is on OT
for people with rheumatoid arthritisprimarily because most evidence to date is for this
condition.
Comprehensive OT is effective in improving function in people with moderate severe
arthritis. Some interventions (e.g. joint protection and hand exercises) are effective. People are
increasingly being referred sooner after diagnosis for interventions to help prevent progression of
functional, physical and psychological problems. Little is known of the effectiveness of therapy at
this early stage.
Key words: arthritis; occupational therapy; rehabilitation.

Most of the rheumatology occupational therapists work is with people with


rheumatoid and inflammatory arthritis, although people with osteoarthritis (OA),
fibromyalgia (FM), soft tissue rheumatism and other conditions are regularly
treated. Recent clinical guidelines emphasise the fact that skilled occupational
therapy (OT) advice should be available to people with rheumatoid arthritis (RA)
who are experiencing limitations in function and that optimal management should
include early referral to OT for patient education and therapy to help maintain
joint function and adapt to living with RA.1 3
This review will explain the role of the occupational therapist in rheumatology,
consider the frequency with which people have problems needing referral, the
evidence for the effectiveness of OT, who should be referred and when. Where
possible, systematic reviews and randomised controlled trials are discussed to
support evidence and, since most OT research to date has been with people
* Tel.: 44-1332-347141x2418; Fax: 44-1332-254989.
E-mail address: alison.hammond@sdah-tr.trent.nhs.uk (A. Hammond).
1521-6942/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved.

492 A. Hammond

with RA, this will be the main focus. Studies evaluating OT as part of a multidisciplinary intervention are not included. The need for systematic programmes of
OT research will be highlighted.

OCCUPATIONAL THERAPY IN RHEUMATOLOGY


Living a meaningful, enjoyable life is central to well-being. The occupational
therapist aims to improve a persons ability to perform daily occupations (i.e.
activities and valued life roles at work, in the home, at leisure and socially),
facilitate successful adaptations to disruptions in lifestyle, prevent losses of
function and improve or maintain psychological status.4,5 Therapists work
collaboratively with clients to achieve occupational balance (i.e. a balanced
lifestyle) within the context of the persons illness, disability or other limitations.6
A wide range of interventions are used (see Table 1). There is a particular focus
on maintaining hand function, since we use our hands in almost every activity and
role in life.

Table 1. Occupational therapy interventions in chronic musculoskeletal diseases.


Self-management education
(individual and group work)
Joint protection education/
ergonomic training
Fatigue management and sleep
hygiene education
Mood and pain management
(including use of cognitivebehavioural approaches,
relaxation; individual and group)

Counselling
Upper and lower limb therapeutic
activities (e.g. crafts, gardening)
Hand therapy (including hand exercises)
Orthoses (e.g. resting and working hand
splints; elbow and neck orthoses)
Foot care advice and simple orthoses
(e.g. metatarsal pads, arch supports, insoles)
Exercise for health and well-being (e.g. Tai
Chi, yoga, swimming, walking, low impact
dance programmes)
Sexual advice

Activity/role planning; goal


clarification and setting
Activities of daily living training (personal
and domestic/extended), activity modification,
assistive devices
Home assessment, housing adaptation
Family/carer liaison and support
Ergonomic work assessment and rehabilitation;
work advice, liaison with disability employment
advisors and employers
Environmental modifications (home, work,
other relevant locations)
Hobby/leisure activity modification
and advice
Avocational counselling (e.g. voluntary,
adult education and leisure opportunities)
Driving/transport advice; wheelchair
prescription
Communication, assertiveness and
cognitive training where applicable
Advice on social security benefits and
community resources

Source: Yasuda (2000)21, Cordery & Rocchi (1998)22, Mann (1998)23, Sanford et al. (2000)24,
Hammond & Jeffreson (2002).25

What is the role of the occupational therapist? 493

HOW DO CHRONIC MUSCULOSKELETAL CONDITIONS IMPACT ON


OCCUPATIONAL BALANCE AND FUNCTION?
A population-based survey of people aged over 65 years, found that 43% had difficulty
with household activities and 33% with hobbies and leisure activities because of arthritis
(mainly OA).7 People with RA have higher levels of role and activity disruption (see
Table 2).8 11 Longitudinal studies have identified the fact that although functional ability
does not significantly decrease in the first 5 years8,11 13, there is considerable
variability: 40% do relatively well, 44% develop a remitting/relapsing course and 16%
have severe functional disability.14 Thus, some 60% of people with RA experience
functional difficulties from an early stage. By 20 years, 80% are moderately or severely
disabled.1 Amongst people still working, 15% are work disabled at 1 year, 27% by 5
years, rising to over 50% by 10 years, leading to serious financial consequences for that
person and their family and increased social security costs.14 Women with RA have, on
average, 40% of the normal power and pinch grip within 6 months of diagnosis, even
with early commencement of disease modifying anti-rheumatic drugs (DMARDs).15
Grip in established RA is only 29% of normal, leading to increasing hand function
problems. These facts suggest that most people with RA could benefit from OT,
particularly for work and for hand rehabilitation.
People with RA who perform fewer valued activities (e.g. at work and in leisure) and
spend more time on personal care, passive leisure and rest activities, are significantly
more likely to be dissatisfied with their abilities and lifestyle and to be depressed. Loss
of valued activities is correlated with poorer psychological status, which is associated
with poorer functional and disease outcome and increased health service use.13 These
associations are likely to be true in other chronic conditions. OT, designed to improve
participation in activities and roles, should theoretically impact on health status in the
longer term, improve quality of life and reduce health care and social costs.

WHAT DOES AN OCCUPATIONAL THERAPIST DO?


OT is a complex intervention that includes a wide range of elements, although the
effective active ingredients can be difficult to specify (see Table 1).6 It includes both

Table 2. The impact of chronic musculoskeletal conditions on life activities.


Early RA ,2 years: difficulties in

Later RA .10 years: difficulties in

5060% with household activities, shopping, leisure and


social activities
37% with work (giving up, reduced hours
or increased sick leave)
35% with parent and family roles
29% (of mothers) with child care

89% with leisure


88% with household activities
66% with shopping
53% with work (giving up, reduced hours
or increased sick leave),
42% with meal preparation
42% with family and social roles

Source: Eberhardt et al. (1990)8, Reisine et al. (1987)9, Reisine & Fifield (1992)10, Eberhardt & Fex (1995).11

494 A. Hammond

therapeutic and educational interventions.16,17 For example, a woman with early RA, or
OA of the carpometacarpal joint, is referred with hand problems affecting daily tasks at
home. The focused interventions provided include joint protection, assistive devices,
hand exercises and splinting to reduce hand pain and to increase movement, dexterity
and hand function. For a person with a work related upper limb disorder (WRULD), the
same treatment is combined with an ergonomic assessment in the workplace, including
psychological and work activity factors affecting stress levels. A cognitive-behavioural
approach is adopted, including stress management, retraining of hand habits, postures
and work routines, ergonomic modification of the work area and liaison with
employers to modify work activities and roles.
As chronic musculoskeletal conditions impact more widely, OT becomes more
complex. For example, a person with RA or FM progressively experiences more
difficulties in their work, personal and family care, household activities, driving, hobbies,
leisure and social roles. Coping with daily life and symptoms can affect psychological
state. A complex programme is provided, including most, or all, of the interventions
listed in Table 1, which address a wide range of physical, functional, psychological, social
and environmental factors.16 20 The therapist liases closely with other agencies and the
multi-disciplinary team and may be involved with clients over many years in helping
them adapt to living successfully with a chronic condition.

WHAT IS THE EVIDENCE THAT OCCUPATIONAL THERAPY


IS EFFECTIVE?
The only systematic review of OT in chronic musculoskeletal conditions evaluates its
effectiveness in RA. This concluded that there is only limited evidence, as yet, of its
effectiveness in maintaining functional ability and reducing pain. Most studies have been
underpowered and of poor methodological quality. Some common interventions have
been little evaluated (e.g. activities of daily living (ADL) training, leisure counselling)
with the impact of OT interventions on psychological status and social participation
being only minimally explored.21 Authors have highlighted the fact that in emerging
fields of research, such as OT, studies other than controlled trials may have an indicative
value.
The effects of specific occupational therapy interventions
Which interventions are effective? What is the best way of delivering these? Who can
benefit most? When is the best time to provide theseand can any act as secondary
preventions, limiting deterioration of function? These questions will be addressed
below.
Joint protection and energy conservation
Joint protection is a frequently taught self-management strategy that aims to maintain
functional ability through altering working methods, education in proper joint and body
mechanics and encouraging the use of assistive devices. Theoretically in RA, reducing
the load and effort required to carry out daily activities should reduce strain on joint
structures weakened by the disease processes, pressure on pain receptors, irritation
of the synovium, localised inflammation and overall levels of fatigue.17,22 In OA, it
aims to reduce the loading on the articular cartilage and subchondral bone,

What is the role of the occupational therapist? 495

to strengthen muscle support and shock absorbing capabilities.22 In people with


WRULDs, it aims to reduce pain, inflammation and the stress on soft tissues.28
A randomised controlled trial using people with early RA (average 18 months duration;
n 126) demonstrated that, over a 1 year period, using joint protection could reduce
pain, early morning stiffness, number of self-reported disease flares and arthritis-related
doctor visits, while improving grip strength, self-efficacy and maintaining function. This
occurred in people attending an 8 hours group educationalbehavioural joint protection
programme. This programme was significantly more effective in increasing adherence than
standard joint protection training (which involves giving information about the condition
and joint protection principles, providing demonstrations and supervised practice).29 Two
other short-term studies of this programme tested people with later stage RA (average
69 years duration) have also identified significant behavioural change occurs.29,30 A
further study evaluating standard joint protection training identified this is not effective in
changing behaviour in later stage RA.31
A post-test only study of a 13 hours multi-disciplinary group arthritis education
programme that included 6 hours of joint protection, reported increased use of joint
protection and assistive devices27, as did an individual self-instructional programme,
combined with goal-setting and supervised practice time.28 Neither study evaluated
impact on health status. Most joint protection education is provided by therapists on a
one-to-one basis and, apart from the latter study, no evaluation of the effectiveness of
individual teaching has been undertaken. However, given that most individual education
uses a standard approach, much of current practice may not be optimally effective.
Education needs to be timed appropriately. The educational behavioural joint
protection programme has been tested in people with early RA (, 6 months duration)
and found not to affect pain and health status outcomes, although the 6 month followup period may have been too short to detect differences at this early stage.29 A study of
a 20 hours joint protection programme in people with established RA (15 20 years
duration) also showed no improvements in health status.30 If provided too early, people
may not yet perceive the need for change. If provided too late, people may have already
developed their own alternative methods and routines that they prefer to use.
A combined programme of joint protection and range of motion (ROM) hand
exercise training has been evaluated in people with hand OA. Significant improvements
in grip strength and self-perceived hand function were identified at 3 month follow-up
when compared to a control group.31 Since both exercise and joint protection were
given it is difficult to identify the effectiveness of joint protection alone in hand OA.
Energy conservation includes pacing, balancing activities and taking rest breaks
(including microbreaks). It aims to reduce fatigue, pain and improve functional
ability. Fatigue management is a wider concept that, in addition, includes sleep
hygiene, cognitive-behavioural strategies, physical fitness and lifestyle behaviours to
help the person improve functional endurance.17 These have been little evaluated in
arthritis. A 3 month follow-up study n 28 of an energy conservation
programme (based on cognitive, behavioural and learning theories) with RA
sufferers compared to standard training methods (education, discussion and
information leaflets) showed both groups had improved levels of pain and fatigue,
but the behavioural programme led to significantly higher levels of physical activity
overall.32 The authors concluded that standard training was not optimally effective
in facilitating behaviour change.
In summary, joint protection can improve and maintain function and health status in
RA. Energy conservation training can increase physical activity levels. Standard training
techniques are not optimally effective in achieving this and occupational therapists need

496 A. Hammond

to change their practice methods to include cognitive-behavioural training


approaches.5,24,32
Activities of daily living training and assistive technology
Much of the occupational therapists work focuses on difficulties in ADL, i.e. personal
care, extended ADL (e.g. home care and maintenance, shopping, family care, outdoor
mobility, driving, communication). The therapist problem-solves with the client and
provides training in alternate methods, assistive devices and facilitates environmental
modifications (e.g. home re-organisation, stair rails, access ramps, steps, housing
adaptations) to improve function. There have been very few studies of the effectiveness
of ADL training and assistive technology specifically in arthritis. A retrospective survey
indicated that altered working methods, assistive devices and environmental
modifications reduced self-reported difficulty in ADL when compared to not using
these.33
A wide range of assistive devices can be prescribed with the aim of increasing
independence, reducing pain, compensating for muscle weakness and increasing
safety.34 Two small studies found that people with RA experienced significantly less
hand pain when using specific assistive devices leg adapted knives, tap turners) during
daily activities.27,35 A study of frail older people with arthritis found that they had, on
average, 10 assistive devices and satisfaction with these was high.36,37 Although assistive
devices are now more widely available commercially, many people have inadequate
information about appropriate designs. Usage surveys indicate a substantial number are
abandoned, although the reason why is unclear.38,39 Non-users (29%) of one type of
device had significantly greater self-efficacy for function and pain and held more negative
impressions of assistive devices than users, even though both groups had similar levels
of disability and pain. Many people prefer to carry out activities in a normal manner,
despite difficulty.34 Device provision should, therefore, always be combined with joint
protection and exercise training to maximise physical ability and emphasise the
protective benefits of devices.
An observational study of people referred to OT for driving difficulties n 94
found that most problems could be satisfactorily resolved by simple driving technique
or vehicle modifications, enabling the majority to continue driving independently.40
Hand exercises
Five randomised controlled trials of hand exercises have been published41 45, although
two combined hand exercise with other interventions (e.g. ultrasound, faradic baths,
wax therapy), hence the effectiveness of the exercise component is unclear.41,45 There
are concerns that resistive hand exercises might promote deformity in some people43
and, clinically, it is common for home programmes to only include ROM exercises. A
daily ROM and resistive (e.g. therapeutic putty, towel rolling, resisted pinch) home
programme improved grip strength and dexterity over a 12 week period in people with
a disease duration of less than 5 years44 and improved grip and pinch strength over a 4
year period in people with at least 1 year of active disease.43 Deformity was not
evaluated specifically in either study, but in the long-term, a control group had
significantly greater loss of proximal interphalangeal (IP) joint extension, indicating
Boutonniere deformities, and increased hyperextension of the thumb IP joints, reducing
thumb stability.43 Long-term adherence was promoted through regular reinforcement
during clinic sessions, which is unusual in clinical practice.43 An intensive out-patient OT
programme of ROM and resistive hand exercises (12 sessions over 4 weeks) reduced

What is the role of the occupational therapist? 497

pain, stiffness and improved hand movement in people with 6 10 years disease
duration. When combined with wax therapy this also improved grip.42 However, these
studies all had methodological problems such as small treatment groups, self-selected
participants, low recruitment from applicable patients or the exclusion of non- or poor
adherers, making it difficult to extrapolate the findings to clinical practice.
Adherence with hand exercise is variable. After 6 months, 53% of people with early
RA continued, almost daily, a programme of 10 ROM exercises following a 30 minutes
training session, with reinforcement 1 week later, which is reflective of typical
practice.46 A small study demonstrated that using a hand exerciser with an electronic
counter and visual display providing feedback can significantly increase exercise
frequency.47 The efficacy of hand exercisers or their ease of home use has not been
evaluated. Occupational therapists also use therapeutic activities (e.g. crafts and
remedial games) to improve hand function. The benefits of these have not been
evaluated.
In summary, a combination of ROM and resistive exercises seem to be more effective
than ROM exercises alone in improving or maintaining hand function in RA. This may be
enhanced by the application of heat before exercising.42 Adherence is highly variable
and clinically therapists need to focus on strategies to increase this, such as use of
exercise diaries, booster sessions and designing exercise regimens that are achievable
and easy to follow.
Splinting
Hand splints are provided to relieve pain, decrease swelling, improve strength, ROM and
function and to prevent deformity.48 A recent systematic review of hand splinting in RA
identified three studies that had evaluated the effects of wrist working splints versus
control groups and two studies that had compared different models of splints.49 Most
studies had short follow-upsthe longest being for 6 months.50 The reviewers
concluded there was no clear evidence for pain relief or improved function in the longerterm, but that splints do not detrimentally affect grip strength or ROM. Most patients use
splints only during heavy activities to reduce the force on the wrists, suggesting that the
main benefit is short-term. Increased grip strength and significant pain relief have been
observed in two studies of immediate effects.50,51 People should also be advised that
initially grip strength and dexterity can be reduced during working wrist splint wear until
the patient has become adjusted to their use.5 Different splint models have differing
effects, indicating that a selection should be available for patients to try.5
Two studies have evaluated resting splint use at homeone looked at the effect of wear
versus non-wear and the other compared splint models.52,53 There were no differences in
pain or joint swelling after 6 months, although people with painful, swollen hands preferred
wearing a padded splint to no splint at night.53 A further small study n 7 highlighted the
fact that most patients reported pain relief at night, but ulnar deviation progressed similarly
in splinted and non-splinted hands.54 Adherence is highly variable with splints and their use
is correlated with a belief in the efficacy of splinting and splint fit. Common beliefs are that
they can cause muscle weakness and stiffness and there is a fear of becoming reliant on
splints.55 Adherence with resting splint wear is increased through careful attention to splint
education, emphasis on benefits and follow-up.56
In summary, there is no evidence as yet as to whether splinting can help to reduce or
prevent deformity, or improve or maintain function in the longer term. Working splints
main benefits are for pain relief and improved grip and function during splint wear.
Resting splints can provide pain relief at night during wear for those with painful,

498 A. Hammond

swollen hands. Ready-made elastic wrist gauntlets are relatively inexpensive and, since
they may provide pain relief for many people, it is reasonable to provide these.49
How effective are work interventions?
Occupational therapists undertake work-based assessments and modify work
equipment and environments. They provide training in altering movement patterns,
in task modifications and in work postures (both in real and simulated work
environments in OT departments). They identify psychological factors affecting work
ability, provide training in cognitive-behavioural coping strategies, liase with employers
and the worker with arthritis about job activities, rotations, shifts, flexible work and
lighter duties if necessary. Work hardening programmes can also be provided in
appropriately equipped OT departments to facilitate a return to work.
A recent UK report summarised various lines of research and found that vocational
rehabilitation programmes are, in general, highly cost-effective, but generally they are
not sufficiently available and are almost a lost skill in the UK National Health Service.57
A systematic review of vocational rehabilitation programmes identified six uncontrolled
studies of multi-disciplinary interventions. Five had marked positive effects on work
status, but the evidence was relatively weak because of methodological shortcomings.58
This suggests that OT work interventions can help maintain people with arthritis in
work but no trials have been conducted.
How effective are leisure and therapeutic activities?
Meaningful and enjoyable leisure activities contribute to quality of life. A survey of people
with a median RA duration of 7 years n 50 found that most had reduced their leisure
activities by 60%. The greatest losses were in physical activities (e.g. going to the gym, golf,
dance, with only swimming and walking being maintained), hobbies needing dexterity
(e.g. crafts, sewing) and social activities (e.g. going to the theatre or cinema). On a Quality
of Life Scale, least satisfaction was expressed for participating in active recreation and
expressing oneself creatively.59 Occupational therapists use leisure counselling and a
range of therapeutic (e.g. crafts, gardening) and leisure exercises (e.g. yoga, Tai Chi,
swimming) to improve functional ability, psychological well-being, occupational balance
and satisfaction with life. No trials of leisure therapy in arthritis have been conducted,
although in stroke patients increased mobility and psychological well-being result.60 A 4
month follow-up of a randomised trial of Tai Chi and relaxation (the ROM Dance
programme: n 33) compared to a traditional exercise and rest programme resulted in
significantly better upper limb function and greater satisfaction.61
How effective are psychological interventions?
Therapists provide counselling, relaxation and stress management in programmes, but
this has been little evaluated. One small study found that the Mitchell relaxation method
improved pain and psychological status.62 Some therapists with additional training use
cognitive-behavioural therapy (CBT). Studies by psychologists have found that
multimodal CBT (i.e. relaxation, imagery, stress management, cognitive coping skills,
biofeedback and psychotherapeutic interventions, both group and individual)
significantly improved pain and functional disability in the short term. Anxiety,
depression, self-efficacy and coping skills were also improved in both the short and long
term.63 Whether the typical training methods used in OT for relaxation, stress
management and other psychological interventions are equally effective is unknown.

What is the role of the occupational therapist? 499

How effective are complex occupational therapy programmes?


There have only been two randomised controlled trials evaluating complex OT programmes in
RA, and none for other conditions. The study that showed the most benefit was carried out by
Helewa et al64 who evaluated a primary care OT programme in a crossover trial n 105:
The study recruited people with RA for, on average, 13 years. OT included evaluation of disease
activity, functional ability in ADL, work and leisure, housing adaptation needs, and assessments
of the hands and feet. Interventions (see Table 1) were included as relevant to the persons
needs. The programme was provided intensively over 6 weeks in clients homes. Immediately
following and 6 weeks later, significant improvements occurred in function (specifically selfcare, home management and mobility) and a pooled index (i.e. active joint count, grip strength,
erythrocyte sedimentation rate, morning stiffness and functional change), compared to a
waiting list control group. The 6-week follow-up was too short to identify any potential
improvements in pain, psychological status, work and/or leisure ability. However, the study
demonstrates that for those with established disease, and on stable medication regimes, OT
improves functional ability.
A randomised controlled trial n 326 recruiting people with early RA (average
disease duration 10 months) evaluated an out-patient OT programme of, on average,
7.5 hours (spread over 48 weeks).46 Over 70% of participants were prescribed diseasemodifying drugs and 36% were prescribed low dose oral steroids. The programme
included a wide of range interventions according to the individuals needs (see Table 1),
although the commonest were self-management education, joint protection, hand
exercises, assistive devices, ADL training and splinting. Adherence with self-management
was significantly higher in the OT group. However, after 2 years there were no differences
in physical, functional or psychological status compared to the control group.
Why was OT (apparently) ineffective in this study? Physical function strongly
correlates with disease activity in early RA, meaning drug management plays a major
role in affecting this65 and over one-third of participants had mild disease throughout
this study. Interviews with the OT group participants identified process changes:
knowing more about RA and self-management, greater acceptance of living with
arthritis, greater satisfaction with daily activities and roles, believing self-management to
be beneficial and a greater belief in their ability to self-manage arthritis.46,66 However,
one-third of those interviewed thought the programme inappropriate: It hasnt made a
difference I am not that bad yet. Potentially, OT was inappropriate for a large subgroup and this masked the detection of any benefits in those receiving more complex
interventions. More effective behavioural approaches to sustain long-term adherence
were not included. Since functional ability is relatively well preserved in the first 5 years
after diagnosis, it may take years before a concordant worsening of functional ability in a
control group enables the effects of secondary prevention to be identified.65

WHO SHOULD THE RHEUMATOLOGIST REFER TO OT AND WHEN?


People experiencing:
Hand and upper limb function difficulties affecting their ability to perform their
occupations (due to e.g. weak grip, reduced dexterity, range of movement and
deformity). Early referral may help limit deterioration of function.
Difficulty with work activities (paid, unpaid or study). Early referral for ergonomic
assessment and rehabilitation to prevent work disability is recommended.

500 A. Hammond

Consultant/ Rheumatology Nurse


Practitioner/ Extended Role Practitioner

Regular screening for problems with:


Work
Upper limb
Functional (ADL, leisure)
Psychological status

Work problems identified:


EARLY referral to OT for
workrehabilitation

Mobility/ function/ psychosocial status


beginning to be affected:
Comprehensive OT assessment:
identification of treatment goals
with client
Education in benefits of joint
protection, fatigue and stress
management, upper limb exercise.
Evaluate readiness to use selfmanagement
ADL/ work / leisure advice as
appropriate

Education: emphasise benefits of selfmanagement; motivational interviewing;


comprehensive information packs. Evaluate
readiness to use self- management. Refer to
OT for:

Poor psychological status:


EARLY referral for counselling and
comprehensive OT

Cognitivebehavioural based

group arthritis self-management


programmes. Provide programmes
flexibly (day and evening/ hospital
and community). (May be part of
MDT provision)
Individual cognitivebehavioural
based self management education:
if person unwilling/ unable to
attend group programme

Increasing mobility, functional, psychosocial problems:


Regular OT monitoring (e.g. 612m/ open access policy) to identify new problems
rapidly
Splinting (hand, neck, insoles), upper limb rehabilitation, assistive devices
ADL/work/leisure rehabilitation, family liaison/ support
Driving/ transport assessment/advice
Psychological interventions e.g. relaxation, stress and pain management, counselling).
Liaison with Social Services (e.g. benefits advice, family support, home support)
Refer to Community Arthritis Self-Management programmes for continuing education

Multiple functional problems:


OT as part of intensive multidisciplinary rehabilitation (day or in-patient as above)
Regular monitoring (with case management if needed)
Hand problems: joint clinics with hand surgeon; hand therapy
Joint replacement surgery: referral to OT pre-operatively to maximise functional ability,
pre-operative education, home assessment
Social Services liaison:housing adaptation, environmental controls, home care support
Wheelchair provision and indoor/ outdoor mobility adaptations/ equipment
Leisure/ avocational activity rehabilitation
Figure 1. Summary pathway for occupational therapy in rheumatoid arthritis. ADL, activities of daily living;
OT, occupational therapist; MTD, multidisciplinary team.

What is the role of the occupational therapist? 501

Difficulty performing ADL, household, caring and leisure activities because of


arthritiswhen these problems become apparent.
Poorer psychological status, especially with reduced leisure and social activities. Early identification
and referral is recommended as this group is more likely to have a worse outcome.
People who are willing to use self-management methods (e.g. joint protection, fatigue
management, hand exercises, pain management) to manage symptoms should be referred for
patient education.

SUMMARY
A summary pathway for OT in RA is shown in Figure 1. Many OT interventions have been
little evaluated. Further research is needed on the effects of OT interventions in early
arthritis to evaluate whether they can have secondary preventative effects, as well as to see
whether, in later stages, they can help to improve functional ability. Currently, clinical
guidelines recommend that for people with early stage RA a self-management education
approach, focussing on specific interventions that are relevant to the clients functional
needs is most relevant.2,5 In early RA, the therapist should assess the persons readiness to
use self-management approaches first (see Figure 1). If not ready, brief interventions of
information and motivational interviewing are appropriate. Behavioural self-management
training (e.g. joint protection, fatigue management, hand exercises, pain and stress
management) is more effective when the person is ready for change. Work rehabilitation is
important at an early stage to prevent work disability. Complex OT programmes are
applicable when lifestyles are beginning to be affected more extensively.5

Practice points
the way in which OT interventions are provided influences adherence and
outcome. Cognitive-behavioural approaches and goal-setting are the more
effective methods
joint protection training (using cognitive-behavioural methods) can reduce pain
and maintain function in people with RA and hand OA. Energy conservation can
increase physical activity levels
wrist splints can reduce pain when worn during activities
assistive devices can reduce pain and improve the ability to perform daily tasks
comprehensive OT programmes can help improve functional ability in people
with moderate severe RA. The benefits of complex OT interventions in early
arthritis are unclear, although they can increase the use of self-management

Research agenda
clinical trials are needed to evaluate the effects of complex OT interventions
using evidence-based approaches (e.g. cognitive-behavioural methods) on the
maintenance of physical, functional and psychological status and on whether

502 A. Hammond

people are helped to live more satisfying, balanced lifestyles. This is particularly
important in early arthritisas patients are increasingly being referred early
longer-term follow-ups are needed to evaluate the impact of OT on role
participation, activities and impairments, quality of life and psychological status
the International Classification of Function, Disability and Health should be used
as a common framework for outcome evaluation.67 Outcomes should include
process measures (e.g. coping strategies, satisfaction with life activities,
psychological adjustment to living with chronic conditions) and include
individualised outcomes, relevant to the clients specific needs65,68
it may be more relevant to construct trials focused on at risk groups, rather than
heterogeneous samples, so it becomes clearer what works with whom68
biomechanical studies with people with chronic musculoskeletal conditions are
needed to identify which joint protection methods are most effective in reducing
pain and avoiding stressful positions
trials of individual joint protection and energy conservation education, using
cognitive-behavioural approaches is required, since most education clinically is
provided on an individual basis
a larger randomised controlled trial of energy conservation training/fatigue
management is needed to evaluate its effects on pain, fatigue, physical activity
levels and function in the longer-term
the effects of joint protection training on other joints (apart from hands) in RA,
OA and in WRULDs require evaluation. The effect on limiting progress of
deformity has not been systematically evaluated. Detailed evaluation
and radiographic analysis over a 2 5 year period would address this question
evaluations of some types of assistive devices are available, but further survey
work and short-term trials could identify which designs of assistive devices are
found to be most effective and acceptable and why. These would help guide
device choice more specifically
since there is some evidence that joint protection can help maintain function if
applied relatively early in RA, psycho-educational and motivational strategies to
help people be psychologically prepared to change need to be developed and
evaluated
a larger trial recruiting a more representative sample of people with RA is
needed to evaluate hand exercise programmes, including long-term follow-up of
their effects on deformity
the benefits of therapeutic and hand activity programmes, ADL training, leisure
therapy, work rehabilitation and psychological interventions need evaluation to
identify effective methods of providing these
no studies have yet evaluated the cost-effectiveness of OT in arthritis

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