Occupational therapy in rheumatoid arthritis: what rheumatologists need to know?

Pedro Henrique Tavares Queiroz de Almeida Tatiana Barcelos Pontes João Paulo Chieregato Matheus Luciana Feitosa Muniz Licia Maria Henrique da Mota About the authors

Abstracts

Intervenções voltadas para a educação e o autogerenciamento da artrite reumatoide (AR) pelo paciente aumentam a adesão e a eficácia da abordagem precoce. A combinação de tratamento medicamentoso e tratamento de reabilitação visa a potencializar as possibilidades de intervenção, retardar o aparecimento de novos sintomas, reduzir incapacidades, minimizar sequelas e reduzir o impacto dos sintomas sobre a funcionalidade do paciente. A terapia ocupacional é uma profissão da área da saúde que objetiva a melhoria do desempenho de atividades pelo paciente e fornece meios para a prevenção de limitações funcionais, adaptação a modificações no cotidiano e manutenção ou melhoria de seu estado emocional e participação social. Devido ao caráter sistêmico da AR o acompanhamento multidisciplinar é necessário para o adequado manejo do impacto da doença sobre os mais diversos aspetos da vida do paciente. Como membro da equipe de saúde, o terapeuta ocupacional objetiva a melhoria e manutenção da capacidade funcional do paciente, prevenir o agravamento de deformidades, auxiliar o processo de compreensão e enfrentamento da doença, fornecer meios para as atividades necessárias para o engajamento do indivíduo em ocupações significativas, favorecer sua autonomia e independência em atividades de autocuidado, laborais, educacionais, sociais e de lazer. O objetivo desta revisão é familiarizar o reumatologista com as ferramentas de avaliação e intervenção usadas na terapia ocupacional, com enfoque na aplicação desses princípios para o tratamento de pacientes com diagnóstico de AR.

Artrite reumatoide; Reabilitação; Atividades cotidianas; Terapia ocupacional


Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of intervention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient's functionality. Occupational therapy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupational therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and coping with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and independence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA.

Rheumatoid arthritis; Rehabilitation; Activities of daily living; Occupational therapy


Introduction

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by impairment of the peripheral joints, especially hands and feet.1Mota LMH, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al. Consenso 2012 da Sociedade Brasileira de Reumatologia para o tratamento da artrite reumatoide. Revista Brasileira de Reumatologia. 2012;52:152-74. A prevalence of up to three times higher among women is observed, with increasing incidence after the age of 25 years, with greater involvement of populations between 35 and 55 years.2Lipsky PE. Rheumatoid arthritis. In: Fauci AS, Langford CA, editors. Harrison's Rheumatology. 2 nd ed. McGraw-Hill Professional; 2010. p. 82-99.

Although there is no consensus on the etiology of RA, it is observed that the combination of inflammation and synovial hypertrophy favor cartilage and bone destruction, promoting joint damage and instability,3Pitzalis C, Kelly S, Humby F. New learnings on the pathophysiology of RA from synovial biopsies. Curr Opin Rheumatol. 2013;25(3):334-4. PubMed PMID: 23492740. Epub 2013/03/16. eng. predominantly affecting the joints of the wrist and metacarpophalangeal and proximal interphalangeal joints of upper limbs.4Beasley J. Osteoarthritis and rheumatoid arthritis: conservative therapeutic management. J Hand Ther. 2012;25(2):163-71, quiz 72. PubMed PMID: 22326361. Epub 2012/02/14. eng. For these reasons, the treatment of patients diagnosed with RA should be started as soon as possible, aiming to reduce the inflammatory activity of the disease and even to obtain remission of symptoms.5Mota LMHd, Laurindo IMM, Santos Neto LLd. Artrite reumatoide inicial: conceitos. Revista da Associacäo Médica Brasileira. 2010;56:227-9.

Despite advances in the pharmacological treatment achieved in the last 30 years, especially with the advent of disease-modifying anti-rheumatic drugs (DMARDs),6Firestein GS. Etiology and pathogenesis of rheumatoid arthritis. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'Dell JR, editors. Kelley's Textbook of Rheumatology II. 9 th ed. Philadelphia: Elsevier Saunders; 2013. p. 1059-108. the chronicity of RA implies interventions aimed to the education and self-management of the disease to favor the treatment, increasing the adherence and effectiveness of an early approach.7Ottenvall Hammar I, Hakansson C. The importance for daily occupations of perceiving good health: perceptions among women with rheumatic diseases. Scandinavian Journal of Occupational Therapy. 2013;20(2):82-92. PubMed PMID: 22784433. Epub 2012/07/13. eng.,8Primdahl J, Wagner L, Holst R, Horslev-Petersen K. The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis - A randomized trial. Patient Education and Counseling. 2012;88(1):121-8. PubMed PMID: 22386009. Epub 2012/03/06. eng.

The combination of drug treatment and rehabilitation therapy aims to maximize the possibilities of intervention,9Marion CE, Balfe LM. Potential advantages of interprofessional care in rheumatoid arthritis. J Manag Care Pharm. 2011;17 9 Suppl B:S25-9. PubMed PMID: 22073937. Epub 2011/12/07. eng. delay the onset of new symptoms, reduce disability, minimize sequelae and diminish the impact of symptoms on functionality of the patient.1010 Hammond A, Niedermann K. Patient education and self management. In: Dziedzic K, Hammond A, editors. Rheumatology - Evidence-based practice for physiotherapists and occupational therapists. United Kingdom: Elsevier; 2010. p. 78-93.,1111 Hand C, Law M, McColl MA. Occupational therapy interventions for chronic diseases: a scoping review. Am J O ccup Ther. 2011;65(4):428-36. PubMed PMID: 21834458. Epub 2011/08/13. eng.

Occupational therapy (OT) is a health care profession which aims at improving the performance of activities by the patient, providing a means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of his/her emotional state and social participation.1212 Hammond A. What is the role of the occupational therapist? Best Practice & Research Clinical Rheumatology. 2004;18(4):491-505.

The aim of this review is to familiarize the rheumatologist with the assessment and intervention tools used in occupational therapy, focusing on the application of these principles to the treatment of patients diagnosed with RA.

Multidisciplinary treatment – practice of occupational therapy

Due to the characteristic joint impairment of RA, the functionality of the patient is reduced not only by the painful condition, but also by those motor constraints associated.1313 Lutze U, Archenholtz B. The impact of arthritis on daily life with the patient perspective in focus. Scand J Caring Sci. 2007;21(1):64-70. PubMed PMID: 17428216. Epub 2007/04/13. eng. The difficulty in performing daily tasks is one of the main complaints of patients with the disease1414 Nyman A, Lund ML. Influences of the social environment on engagement in occupations: the experience of persons with rheumatoid arthritis. Scandinavian Journal of Occupational Therapy. 2007;14(1):63-72. PubMed PMID: 17366079. Epub 2007/03/17. eng.,1515 Reinseth L, Espnes GA. Women with rheumatoid arthritis: non-vocational activities and quality of life. Scandinavian Journal of Occupational Therapy. 2007;14(2): 108-15. causing restrictions in most of their areas of performance1616 Mathieux R, Marotte H, Battistini L, Sarrazin A, Berthier M, Miossec P. Early occupational therapy programme increases hand grip strength at 3 months: results from a randomised, blind, controlled study in early rheumatoid arthritis. Ann Rheum Dis. 2009;68(3):400-3. PubMed PMID: 19015209. Epub 2008/11/19. eng.: from simple activities related to self-care and home maintenance to complex work tasks, the patient presents limitations in doing many of his/her activities of daily living (ADLs).1717 Malcus-Johnson PCarlqvist C, Sturesson AL, Eberhardt K. Occupational therapy during the first 10 years of rheumatoid arthritis. Scandinavian Journal of Occupational Therapy. 2005;12(3):128-35. PubMed PMID: 16389738. Epub 2006/01/05. eng.

It is observed that such restrictions affect not only the performance of the activities independently and autonomously, but has a negative impact on the emotional state, social relationships and quality of life of the patient.7Ottenvall Hammar I, Hakansson C. The importance for daily occupations of perceiving good health: perceptions among women with rheumatic diseases. Scandinavian Journal of Occupational Therapy. 2013;20(2):82-92. PubMed PMID: 22784433. Epub 2012/07/13. eng.,1818 Mella LFB, Bértolo MB, Dalgalarrondo P.Depressive symptoms in rheumatoid arthritis. Revista Brasileira de Psiquiatria. 2010;32:257-63.

Given the participation constraints and the importance of engaging in productive activities for the maintenance of physical and psychosocial health of this population, the occupational therapist is an integral part of the multidisciplinary team of care for patients with RA, being concerned with the performance of ADLs and the inclusion of the patient in meaningful occupations for his/her everyday life.1919 Engel JM. Physiotherapy and ergotherapy are indispensable. Concrete prescription of remedies - without recourse. Z Rheumatol. 2012;71:369-80.,2020 Adams J, Burridge J, Mullee M, Hammond A, Cooper C. Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population. Clin Rehabil. 2004;18:405-13.

Due to the multiplicity of involvements motivated by the disease and the singularity represented by the daily activities for each patient, the first step toward the realization of an effective therapeutic intervention is to obtain relevant data on the state of the disease and its impact on the patient's ADLs. The evaluation is an ongoing process, which enables the monitoring of treatment and the interventions needed, as well as the modification of these during periods of exacerbation and remission.2121 Sands A, Goodacre L. Occupational therapy assessment and outcome measurement. In: Goodacre L, McArthur M, editors. Rheumatology practice in occupational therapy. 1 st ed. Oxford: Wiley-Blackwell; 2013.

Assessment in occupational therapy

The evaluation aims at obtaining data relating to the physical, emotional and social state of the patient, as well as the impact of the disease on his/her ADLs, providing objective data on the patient's occupational performance that allow monitoring of his/her evolution during treatment.2222 McDonald HN, Dietrich T, Townsend A, Li LC, Cox S, Backman CL. Exploring occupational disruption among women after onset of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(2):197-205. PubMed PMID: 22006430. Epub 2011/10/19. eng.

Historically, occupational therapists combine the use of semi-structured interviews and standardized tools for gathering information to enable the establishment of a baseline for the therapy: disease status and functional limitations, expansion of the understanding of the contexts of a patient's life, identification of his/her priorities, monitoring of the disease and the effectiveness of proposed interventions.2121 Sands A, Goodacre L. Occupational therapy assessment and outcome measurement. In: Goodacre L, McArthur M, editors. Rheumatology practice in occupational therapy. 1 st ed. Oxford: Wiley-Blackwell; 2013. The selection of assessment methods should take into consideration the main complaints of the patient and their relevance to the clinical presentation.2323 Feldman DE, Bernatsky S, Levesque JF, Van MT, Houde M, April KT. Access and perceived need for physical and occupational therapy in chronic arthritis. Disabil Rehabil. 2010;32(22):1827-32. PubMed PMID: 20345251. Epub 2010/03/30. eng. Table 1 illustrates some of the standardized assessment tools that comprise the evaluation of patients with RA by the occupational therapist.

Table 1
Standardized instruments for the functional assessment of patients with RA.

Independent of the choice of instruments for assessment, is important that the information obtained is related to the occupational performance of the patient, i.e., the data must aim not only to measure the intensity of a particular symptom (fatigue, pain, functional capacity), but also the influence of this on the patient's ability to engage and perform tasks relevant to his/her day-to-day.1212 Hammond A. What is the role of the occupational therapist? Best Practice & Research Clinical Rheumatology. 2004;18(4):491-505.,2121 Sands A, Goodacre L. Occupational therapy assessment and outcome measurement. In: Goodacre L, McArthur M, editors. Rheumatology practice in occupational therapy. 1 st ed. Oxford: Wiley-Blackwell; 2013.

Interventions of occupational therapy

Patient guidance and education – changing habits to cope with illness

The transmission of knowledge and the understanding of the patient about his/her condition do not guarantee, by itself, any change of attitudes necessary for the management of complications arising from a chronic disease; so that OT has as main objective the voluntary change of habits, extended to all areas of the patient's performance and not only to those activities afflicted by pain or biomechanical imbalances driven by the disease.2424 Aktekin LA, Eser F, Baskan BM, Sivas F, Malhan S, Oksuz E, et al. Disability of arm shoulder and hand questionnaire in rheumatoid arthritis patients: relationship with disease activity, HAQ, SF-36. Rheumatol Int. 2011;31(6):823-6. PubMed PMID: 20680284. Epub 2010/08/04. eng.

The multidisciplinary interventions for patients with RA aim to control pain and fatigue, aiming their functional improvement by combining different modalities of treatment.

Among some of the interventions focused on patient adjustment and empowerment concerning the disease, the techniques of joint protection and energy conservation are examples of changes in habits, by the way of conducting ADLs, which promote changes not only on functional capacity, but also on the psychological well-being, personal control and self-acceptance – fundamental concepts for improving the quality of life of the patient.3434 Vliet Vlieland TP, Pattison D. Non-drug therapies in early rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2009;23(1):103-16. PubMed PMID: 19233050. Epub 2009/02/24. eng.

Joint protection and energy conservation

Joint protection techniques are a set of guidelines and preventive strategies used in the management of pain and fatigue,3535 Niedermann K, Hammond A, Forster A, de Bie R. Perceived benefits and barriers to joint protection among people with rheumatoid arthritis and occupational therapists. A mixed methods study. Musculoskeletal Care. 2010;8(3):143-56. PubMed PMID: 20803632. Epub 2010/08/31. eng. associated with other symptoms in patients with RA, which aim to apply ergonomic and biomechanical principles while performing ADLs to protect joint structures of normal and abnormal forces that may contribute to the installation of deformities or aggravate deformities already present.3636 Hammond A. Joint Protection. In: Goodacre L, McArthur M, editors. Rheumatology practice in occupational therapy. 1 st ed. Oxford: Willey-Blackwell; 2013. p. 111-32.,3737 Noordhoek J, Loschiavo FQ. Intervencäo da terapia ocupacional no tratamento de individuos com doencas reumáticas utilizando a abordagem da protecäo articular. Revista Brasileira de Reumatologia 2005;45: 242-4.

This approach was first described in 1965,3838 Cordery JC. Joint protection; a responsibility of the occupational therapist. Am J Occup Ther. 1965;19(5):285-94. PubMed PMID: 5832168. Epub 1965/09/01. eng. through the analysis of motor impairments motivated by the inflammatory process common to RA and its combination with biomechanical principles, aiming to minimize the action of forces that favored the development of joint deviations and deformities during performing daily tasks,3939 Cordery JC. Joint deformity in rheumatoid arthritis. Am J Occup Ther. 1965;19(5):243-8. PubMed PMID: 5832161. Epub 1965/09/01. eng. for example, hyperextension of the metacarpophalangeal joint of the finger I, ulnar deviation of metacarpophalangeal joints of the fingers II–V and installation of deformity standards, such as swan neck, hammer toe or buttonhole toe, through involvement of distal interphalangeal joints.4040 Kozlow JH, Chung KC. Current concepts in the surgical managemen of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011;27(1):31-41. PubMed PMID: 21176798. Pubmed Central PMCID: PMC3053090. Epub 2010/12/24. eng.

Due to the importance and constancy necessary for the accomplishment of ADLs, modifications in their performance allow a significant reduction in joint stress and energy expenditure, facilitating or enabling the participation of the patient in meaningful occupations.3636 Hammond A. Joint Protection. In: Goodacre L, McArthur M, editors. Rheumatology practice in occupational therapy. 1 st ed. Oxford: Willey-Blackwell; 2013. p. 111-32.,3737 Noordhoek J, Loschiavo FQ. Intervencäo da terapia ocupacional no tratamento de individuos com doencas reumáticas utilizando a abordagem da protecäo articular. Revista Brasileira de Reumatologia 2005;45: 242-4. Table 2 illustrates the main guidelines of the concepts of joint protection and energy conservation.

Table 2
Principles of joint protection and energy conservation.

By modifying work methods and environments, use of assistive devices (assistive technologies) and inclusion of breaks in the routine, the objective here is the reduction of pain at rest and during movement, by minimizing nociceptive stimuli on the inflamed joint capsules, decreasing the force incident on the joints and controlling energy expenditure during daily activities, enabling joint preservation and improvement or maintenance of the patient's functionality.4141 Niedermann K, Buchi S, Ciurea A, Kubli R, Steurer-Stey C, Villiger PM, et al. Six and 12 months' effects of individual joint protection education in people with rheumatoid arthritis: a randomized controlled trial. Scandinavian Journal of Occupational Therapy. 2012;19(4):360-9. PubMed PMID: 21936735. Epub 2011/09/23. eng.

Moreover, conducting activities to strengthen the periarticular muscles and maintain joint range of motion, especially in the upper limbs, are also resources that contribute to the maintenance or improvement of the patient's functional capacity,4242 Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-74. PubMed PMID: 22563589. Epub 2012/05/09. eng.,4343 Larkin L, Kennedy N. Correlates of physical activity in adults with Rreumatoid arthritis: a systematic review. Journal of Physical Activity & Health. 2013;19. PubMed PMID: 23963816. Epub 2013/08/22. Eng. allowing a better performance and preservation of joint structures impaired by RA.

Practical examples of some of the techniques of joint protection and energy conservation4444 Almeida PHTQ, Sime MM, Mendes JB, Bittencourt G, Ferrigno ISV. Como proteger suas articulações - Manual de proteção articular e conservação de energia para pacientes com doenças reumatológicas. São Carlos: Universidade Federal de São Carlos; 2012. are illustrated inFig. 1.

Fig. 1
Examples of modifications in performing activities of daily living. The items on the left indicate movement patterns in which the position of the joints of the wrist and fingers enhance mechanical forces toward deformities commonly observed among patients with RA. The illustrations on the right suggest modifications that favor the use of other, more stable, joints, or the distribution of the load among multiple joints, avoiding painful and potentially harmful positions.

Randomized trials with high levels of evidence on the effectiveness of methods of joint protection and energy conservation showed significant improvement with respect to pain reduction among patients receiving the guidelines for changes in their ADLs.4545 Christie A, Jamtvedt G, Dahm KT, Moe RH, Haavardsholm EA, Hagen KB. Effectiveness of nonpharmacological and nonsurgical interventions for patients with rheumatoid arthritis: an overview of systematic reviews. Phys Ther. 2007;87(12):1697-715. PubMed PMID: 17906290. Epub 2007/10/02. eng.4747 Hammond A, Freeman K. The long-term outcomes from a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Clin Rehabil. 2004;18(5):520-8. PubMed PMID: 15293486. Epub 2004/08/06. eng. Improvement in fatigue and increased social participation,4747 Hammond A, Freeman K. The long-term outcomes from a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Clin Rehabil. 2004;18(5):520-8. PubMed PMID: 15293486. Epub 2004/08/06. eng. reduction of morning stiffness, lower incidence of deformities in the hands4848 Steultjens EM, Dekker J, Bouter LM, Van Schaardenburg D, Vvan Kuyk MA, Van den Ende CH. Occupational therapy for rheumatoid arthritis. Cochrane Database Syst Rev. 2004;(1):CD003114. PubMed PMID: 14974005. Epub 2004/02/20. eng. and improved functionality4949 Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Punzi L. Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clin Rheumatol. 2007;26(12):2043-50. PubMed PMID: 17404783. Epub 2007/04/04. eng. were observed, even among patients with severe RA state.5050 Nilsson I, Fitinghoff H, Lilja M. Continuing to work after the onset of rheumatoid arthritis. Work. 2007;28(4):335-42. PubMed PMID: 17522454. Epub 2007/05/25. eng.

Modifying activities and work environments

Although most functional assessments have focused on the difficulty presented by the patient while performing self-care and mobility activities, dysfunctions related to work activities represent a serious consequence of RA.5151 Tiippana-Kinnunen T, Paimela L, Peltomaa R, Kautiainen H, Laasonen L, Leirisalo-Repo M. Work disability in finnish patients with rheumatoid arthritis: a 15-year follow-up. Clin Exp Rheumatol. 2013. PubMed PMID: 24143915. Epub 2013/10/23. Eng.

The rate of retirement for reasons related to RA can vary from 7% of cases in the first year after diagnosis up to 39% of patients with over 15 years of diagnosis in the absence of treatment targeted to labor difficulties5151 Tiippana-Kinnunen T, Paimela L, Peltomaa R, Kautiainen H, Laasonen L, Leirisalo-Repo M. Work disability in finnish patients with rheumatoid arthritis: a 15-year follow-up. Clin Exp Rheumatol. 2013. PubMed PMID: 24143915. Epub 2013/10/23. Eng.; with respect to North American and European populations, is expected that up to one third of patients will abandon the work during the first three years of the disease.5252 Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy. Arthritis Rheum. 2009;61(11):1522-30. PubMed PMID: 19877106. Epub 2009/10/31. eng.

Abandonment of employment is a last resort, face to the limitations encountered by patients with RA: before retirement, increases of stress levels, job changes, restrictions on workload, loss of promotion opportunities and greater frequency of absenteeism and of job changes are observed more often among this population.5353 Bansback N, Zhang W,Walsh D, Kiely RWilliams R, Guh D, et al. Factors associated with absenteeism, presenteeism and activity impairment in patients in the first years of RA. Rheumatology (Oxford). 2012;51(2):375-84. PubMed PMID: 22179728. Epub 2011/12/20. eng. It is estimated that the reduction in productivity motivated by RA caused losses of approximately 7000 Euros/year per patient,5454 Puolakka K, Kautiainen H, Pekurinen M, Mottonen T, Hannonen P, Korpela M, et al. Monetary value of lost productivity over a five year follow up in early rheumatoid arthritis estimated on the basis of official register data on patients' sickness absence and gross income: experience from the FIN-RAC trial. Ann Rheum Dis. 2006;65(7):899-904. PubMed PMID: 16291811. Pubmed Central PMCID: PMC1798230. Epub 2005/11/18. eng. and up to 25% of the working period may be affected by conditions related to the disease.5555 Puolakka K, Kautiainen H, Mottonen T, Hannonen P, Korpela M, Hakala M, et al. Early suppression of disease activity is essential for maintenance of work capacit in patients with recent-onset rheumatoid arthritis: five-year experience from the FIN-RACo trial. Arthritis Rheum. 2005;52(1):36-41. PubMed PMID: 15641055. Epub 2005/01/11. eng.

The early treatment conducted by a multidisciplinary team is an effective method to minimize complications related to work, maintaining the work capacity of these patients for a period of time similar to that found among the healthy population.5151 Tiippana-Kinnunen T, Paimela L, Peltomaa R, Kautiainen H, Laasonen L, Leirisalo-Repo M. Work disability in finnish patients with rheumatoid arthritis: a 15-year follow-up. Clin Exp Rheumatol. 2013. PubMed PMID: 24143915. Epub 2013/10/23. Eng.,5555 Puolakka K, Kautiainen H, Mottonen T, Hannonen P, Korpela M, Hakala M, et al. Early suppression of disease activity is essential for maintenance of work capacit in patients with recent-onset rheumatoid arthritis: five-year experience from the FIN-RACo trial. Arthritis Rheum. 2005;52(1):36-41. PubMed PMID: 15641055. Epub 2005/01/11. eng.

Given the multiplicity of situations and perceptions about work activity reported by patients, individualized strategies are indicated as the best approach to labor difficulties, including a specific evaluation of the situation and of the workplace.5252 Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy. Arthritis Rheum. 2009;61(11):1522-30. PubMed PMID: 19877106. Epub 2009/10/31. eng.

Changes for a better performance of the activity may include the organization of the tasks that compose the work activity, changing shifts, and a fair division of the workload throughout the day5656 Herrera-Saray P,Pelaez-Ballestas I, Ramos-Lira L, Sanchez-Monroy D, Burgos-Vargas R. Usage problems and social barriers faced by persons with a wheelchair and other aids qualitative study from the ergonomics perspective in persons disabled by rheumatoid arthritis and other conditions. Reumatologia Clínica. 2013;9(1):24-30. PubMed PMID: 22854174. Epub 2012/08/03. eng.; ergonomic modifications such as new furniture and changes in the workplace, ensuring a proper joint positioning during activity, replacement of fixtures by other of smaller weight or with better handgrip5757 Baldwin D, Johnstone B, Ge B, Hewett J, Smith M, Sharp G. Randomized prospective study of a work place ergonomic intervention for individuals with rheumatoid arthritis and osteoarthritis. Arthritis Care Res (Hoboken). 2012;64(10):1527-35. PubMed PMID: 22511570. Epub 2012/04/19. eng. and guidance on stress management and acquisition of strategies (coping) to handle with the workload.5858 Daker-White G, Donovan J, Campbell R. Redefined by illness: meta-ethnography of qualitative studies on the experience of rheumatoid arthritis. Disabil Rehabil. 2013. PubMed PMID: 24001261. Epub 2013/09/05. Eng.

Although some review studies show no high level evidence on the effectiveness of specific ergonomic interventions to reduce problems related to upper limbs,5959 Hoe VC, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Cochrane Database Syst Rev. 2012;8:CD008570. PubMed PMID: 22895977. Epub 2012/08/17. eng. there is satisfactory evidence to support such interventions with respect to patients with RA,5757 Baldwin D, Johnstone B, Ge B, Hewett J, Smith M, Sharp G. Randomized prospective study of a work place ergonomic intervention for individuals with rheumatoid arthritis and osteoarthritis. Arthritis Care Res (Hoboken). 2012;64(10):1527-35. PubMed PMID: 22511570. Epub 2012/04/19. eng. suggesting improvement in functionality, pain and satisfaction with the work in the long term, when compared to individuals who did not get these interventions.

Assistive technologies – orthotics and adaptations

The concept of assistive technology includes devices, guidelines and practices that aim to maintain, enhance or facilitate the performance of self-care, instrumental, educational, employment or social activities.6060 Tuntland H, Kjeken I, Nordheim L, Falzon L, Jamtvedt G, Hagen K. The Cochrane review of assistive technology for rheumatoid arthritis. European Journal of Physical and Rehabilitation Medicine. 2010;46(2):261-8. PubMed PMID: 20485228. Epub 2010/05/21. eng.

Among the range of instruments available to patients with RA, the adaptations of utensils and the use of orthotics are some of the major resources to promote improved grip, biomechanical alignment and joint stress reduction, as well as to allow the development of activities and occupations, contributing to the patient's functionality and autonomy.6161 Wilson DJ, Mitchell JM, Kemp BJ, Adkins RH, Mann W. Effects of assistive technology on functional decline in people aging with a disability. Assistive Technology: The Official Journal of Resna. 2009;21(4):208-17 PubMed PMID: 20066887. Epub 2010/01/14. eng.

The adaptation of utensils requires a thorough analysis of the activity performed by the patient, in order to determine what are the main challenges encountered and possible solutions to be proposed. Such modifications may include from changes in the way of conducting the activity (such as guidance on joint protection and energy conservation) to changes in the shape, weight and size of utensils.

Thicker handles and adaptations to facilitate or replace the handgrip strength, for example, elastic or neoprene strips, favor the handling of cutlery, writing instruments and personal hygiene materials, such as toothbrushes and hair combs.

The replacement of drinking glasses for mugs, the use of modified cutting boards, soap and detergent dispensers and clotting adaptations are examples of simple devices which promote important functional changes to the patient.6262 Noordhoek J, Loschiavo FQ. Instrumento adaptador para facilitar abertura de latas. Revista Brasileira de Reumatologia. 2006;46:347-8.

63 Noordhoek J, Torquetti A. Adaptacão para facilitar descascar alimentos. Revista Brasileira de Reumatologia. 2007;47:52.
-6464 Noordhoek J, Torquetti A. Adaptações para osteoartrite de mãos. Revista Brasileira de Reumatologia. 2008;48:100-1. Examples of adaptations to promote improvement in performing ADLs are illustrated inFig. 2.

Fig. 2
Adapted utensils. The proposed adjustments are based on the principles of joint protection and energy conservation, with distribution of mechanical loads and promoting the use of larger joints during activities.

Orthoses (splints) are resources used by therapists to promote better joint support, reduce pain and optimize functional performance of the patient.6565 Egan M, Brosseau L, Farmer M, Ouimet MA, Rees S, Wells G, et al. Splints/orthoses in the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2003;(1):CD004018. PubMed PMID: 12535502. Epub 2003/01/22. eng. Although several models are available, clinical reasoning used for prescribing an orthosis involves the needs for each case; the same orthosis can be prescribed for multiple objectives.

Among the most common indications, pain control, decreased morning stiffness, mechanical support for joints, encouragement of joint motion and functionality, and certain postoperative situations (where the combination of joint alignment, immobilization and application of traction forces is required) can be cited.6666 Egan MY, Brousseau L. Splinting for osteoarthritis of the carpometacarpal joint: a review of the evidence. Am J Oççup Ther. 2007;61(1):70-8. PubMed PMID: 17302107. Epub 2007/02/17. eng.

67 Formsma SA, Van der Sluis CK, Dijkstra PU. Effectiveness of a MP-bloçking splint and therapy in rheumatoid arthritis: a descriptive pilot study. J Hand Ther. 2008;21(4):347-53. PubMed PMID: 19006761. Epub 2008/11/14. eng.
-6868 Veehof MM, Taal E, Heijnsdijk-Rouwenhorst LM, Van de Laar MA. Effiçaçy of wrist working splints in patients with rheumatoid arthritis: a randomized controlled study. Arthritis Rheum. 2008;59(12):1698-704. PubMed PMID: 19035420. Epub 2008/11/28. eng. Some models of orthoses commonly indicated are illustrated inFig. 3.

Fig. 3
Examples of orthoses for upper limbs, suggested for patients with RA.

Although to date there is no conclusive evidence on the effectiveness of orthoses for improved functionality and handgrip strength,6565 Egan M, Brosseau L, Farmer M, Ouimet MA, Rees S, Wells G, et al. Splints/orthoses in the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2003;(1):CD004018. PubMed PMID: 12535502. Epub 2003/01/22. eng. some studies suggest that the use of orthotics for hands and wrists positioning during inflammatory phases promote improvement in pain and morning stiffness for the patient.6868 Veehof MM, Taal E, Heijnsdijk-Rouwenhorst LM, Van de Laar MA. Effiçaçy of wrist working splints in patients with rheumatoid arthritis: a randomized controlled study. Arthritis Rheum. 2008;59(12):1698-704. PubMed PMID: 19035420. Epub 2008/11/28. eng.,6969 Silva AC, Jones A, Silva PG, Natour J. Effeçtiveness of a night-time hand positioning splint in rheumatoid arthritis: a randomized çontrolled trial. J Rehabil Med. 2008;40(9):749-54. PubMed PMID: 18843428. Epub 2008/10/10. eng.

Braces used for stabilization of the interphalangeal joints also exhibit significant levels of evidence in reducing pain, although no significant changes on hand function or strength during its use have been observed.7070 Silva PG, Lombardi I Jr, Breitsçhwerdt C, Poli Araujo PM, Natour J. Funçtional thumb orthosis for type I and II boutonniere deformity on the dominant hand in patients with rheumatoid arthritis: a randomized çontrolled study. Clin Rehabil. 2008;22(8):684-9. PubMed PMID: 18678568. Epub 2008/08/06. eng.

Conclusions

Due to the systemic nature of RA, a multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life of the patient. As a member of the health team, the occupational therapist aims to improve and maintain his/her patient's functional capacity, preventing the worsening of deformities, aiding in the process of understanding and coping with the disease, and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, contributing to his/her autonomy and independence in self-care, labor, educational, social and leisure activities.

It is important that the rheumatologist become aware of the general principles of therapy, so that he/she can suggest their use more consciously, as an additional tool in the treatment of patients diagnosed with RA.

  • Institution: Faculdade de Ceilândia – Course of Occupational Therapy; Hospital Universitário de Brasília – Rheumatology – Outpatient Clinic of Early Rheumatoid Arthritis.

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Publication Dates

  • Publication in this collection
    May-Jun 2015

History

  • Received
    11 Apr 2014
  • Accepted
    10 July 2014
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