what is the role of the ot

Best Practice & Research Clinical Rheumatology Vol. 18, No. 4, pp. 491–505, 2004 doi:10.1016/j.berh.2004.04.001 available online at http://www.sci http://www.sciencedirect.com encedirect.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

Occupa Occupatio tional nal therap therapyy (OT) (OT) is widel widelyy provid provided ed for people people with with chroni chronicc muscul musculosk oskele eletal tal 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 rheumatoid arthritis—pr arthritis—primari imarily ly because because most evidence evidence to date is for this condition. Comprehens Comprehensive ive OT is effecti effective ve in improving improving function function in people people with moderate– seve severe re arthritis. Some interventions (e.g. joint protection and hand exercises) are effective. People are increasin increasingly gly being referred referred sooner sooner after diagnosi diagnosiss for interventions interventions to help prevent prevent progress progression ion 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 Most of the rheuma rheumatol tology ogy occ occupa upatio tional nal therap therapist ist’’s wor work k is with with people people with with rheumatoi rheumatoid d and inflammato inflammatory ry arthritis, arthritis, although although people people with osteoarthr osteoarthritis itis (OA), (OA), fibrom fibromyal yalgia gia (FM), (FM), soft soft tissue tissue rheuma rheumatis tism m and other other condit condition ionss are reg regula ularly rly treate treated. d. Recen Recentt clinica clinicall guidel guideline iness emphas emphasise ise the fact fact that that skille skilled d occ occupa upatio tional nal therapy therapy (OT) advice should should be availabl available e to people people with rheumatoid rheumatoid arthritis arthritis (RA) who are experienci experiencing ng limitation limitationss in function function and that optimal optimal manageme management nt should should includ include e early early referr referral al to OT for patient patient educati ducation on and therap therapyy to help help mainta maintain in joint function and adapt to living with RA.1 – 3 This review will explain the role of the occupational therapist in rheumatology, consid consider er the freque frequency ncy with with which which people people have have proble problems ms nee needin dingg referr referral, al, the evidence evidence for the effective effectiveness ness of OT, who should be referred referred and when. when. Where Where possibl possible, e, system systemati aticc revie reviews ws and rando randomise mised d contro controlle lled d trials trials are discus discussed sed to supp support ort evid eviden ence ce and, and, since since most most OT resear research ch to date date has has been been with with peop people le * Tel.: þ 44-1332-347141x2418 44-1332-347141x2418;; Fax: þ 44-1332-254989. E-mail address: alison.hammond@sdah-tr [email protected] .trent.nhs.uk k (A. Hammond). 1521-6942/$ - see front matter

Q

2004 Elsevier Ltd. All rights reserved.

492 A. Hammon Hammond d

with with RA, RA, this this will will be the the main main focu focus. s. Stud Studie iess eval evalua uati ting ng OT as part part of a mult multiidisciplinary intervention are not included. The need for systematic programmes of OT research research will be highlight highlighted. ed.

OCCUPA OCCUPATIONAL THERAPY IN RHEUMATOLOGY RHEUMATOLOGY

Livi Living ng a mean meanin ingf gful ul,, enjo enjoya yabl ble e life life is cent centra rall to we wellll-b -bei eing ng.. The The occu occupa pati tion onal al therap therapist ist aims aims to impro improve ve a perso person’ n’ss abilit abilityy to perfor perform m daily daily occ occupa upatio tions ns (i.e. (i.e. acti activi viti ties es and and valu valued ed life life role roless at work work,, in the the home home,, at leis leisur ure e and and soci social ally) ly),, facili facilitat tate e succes successfu sfull adapta adaptatio tions ns to disrupt disruption ionss in lifest lifestyle yle,, preve prevent nt losse lossess of funct functio ion n and and impro improve ve or maint maintain ain psycho psycholog logica icall status status..4,5 Therapi Therapists sts work coll collab abor orat ativ ivel elyy with with clie client ntss to achi achiev eve e ‘occu ‘occupa pati tion onal al bala balanc nce’ e’ (i.e (i.e.. a bala balanc nce ed lifestyle) within the context of the person’s illness, disability or other limitations. 6 A wide range of interventions are used (see Table 1). 1). There is a particular focus on maintaining hand function, since we use our hands in almost every activity and role role in life. life.

Table 1. Occupational therapy interventions in chronic musculoskeletal diseases.

Self-management 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 behavioural approaches, 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 Hobby/leisure activity modification and advice Avocational counselling (e.g. voluntary, adult education and leisure opportunities) Driving/transport advice; wheelchair prescription Communication, Communication, assertiveness and cognitive training where applicable Advice on social security benefits and community resources

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

What is the role role of the occupatio occupational nal therapist 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 househol household activities and 33% with hobbies hobbies and leisure activities because of arthritis 7 (mainly OA). OA). People with RA have higher levels of role and activity disruption (see Table 2). 2).8–11 Longitudinal studies have identified the fact that fact that although although functional ability 8,11– 1– 13 doess not significa doe significantl ntlyy dec decrea rease se in the first 5 yea years rs8,1 , there there is consid considera erable ble variability: 40% do relatively well, well, 44% develop a remitting/relapsing course and 16% have severe functional disability. disability.14 Thus, some 60% of people with RA experience functional functional difficulties difficulties from an early stage. By 20 years, 80% are moderately or severely 1 disabled. 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 finan fin ancial cial 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, ev en 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. problems. These facts facts suggest suggest that most people 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 asso as sociated ciated 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 WHAT DOES AN OCCUPATIONAL OCCUPATIONAL THERAPIST DO?

OT is a complex intervention that includes a wide range of elemen eleme nts, although the effective ‘active ingredients’ can be difficult to specify (see Table 1). 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…

50–60% 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: Eberha Eberhardtet rdtet al.(1990)8, Reisin Reisine e et al.(1987) al.(1987) 9, Reisin Reisinee & Fifield Fifield (1992) (1992)10, Eberha Eberhardt& rdt& Fex(1995). Fex(1995).11


therapeutic and educational interventions. 16,17 For example, a woman with early RA, 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 hand function. function. For a person person with a work related related upper limb limb disorder disorder (WRULD), (WRULD), the 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 wor work k routin routines, es, erg ergono onomic mic modific modificati ation on of the work are areaa and liaiso liaison n with with employers to modify work activities and roles. As chronic chronic musculoske musculoskeleta letall conditions conditions impact impact more widely, widely, OT becomes becomes more complex. complex. For example, example, a person person with RA or FM progressively progressively experience experiencess 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 in Table 1, 1, which address 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 WHAT IS THE EVIDENCE THAT OCCUPA 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 intervent interventions ions on psychological status and social participation 21 being only minimally explored. Authors have highlighted the fact that in emerging fields of research, such as OT, 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 benefit most? When is the best time to provide these—and these—and can any act as secondary secondary preventi preventions, ons, limiting limiting deteriora deterioration tion of function? function? These questions will be addressed 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 effort required to carry out daily activities activities should reduce strain on joint structures weakened by the disease processes, pressure on pain recep tors, tors, irritation of the synovium, localised inflammation and overall levels of fatigue. 17,22 In OA, it aims aims to reduc reduce e the the load loadin ingg on the the articu articula larr carti cartila lage ge and and subcho subchondr ndral al bone, bone,


495

to strengthe strengthen n muscle support and shock absorbing capabilities. capabilities.22 In peo people with WRULDs, it aims to reduce pain, inflammation and the stress on soft tissues. 28 A randomi randomised sed control controlled led trial trial using using people people with early early RA (aver (average age 18 months months durati duration; on; n ¼ 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 educational–behavioural joint protection progra programme mme.. This progra programme mme was signific significant antly ly more more effect effective ive in increas increasing ing adheren adherence ce than than ‘standard’ joint protection training (which involves giving information about the cond condition ition and joint joint protec protectio tion n principl principles, es, provid providing ing demons demonstra tratio tions ns and supervise supervised d practic practice). e).29 Two other short-term studies of this programme tested people with later stage RA (avera (a verage ge 29,30 6–9 years duration) have also identified significant behavioural change occurs. A further study evaluating standard joint join t 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 hou rs of of joint protection, reported increased use of joint 27 protection and assistive devices , as did an individual self-i self-instructional nstructional 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, However, given that most individual education uses a standard approach, much of current practice may not be optimally effective. Education Education needs needs to be timed timed appropria appropriately tely.. The educationa educationall – behavioura behaviourall 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 m onth onth 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 combined programme programme of joint protection protection and range of motion motion (ROM) (ROM) hand exercise training has been evaluated in people with hand OA. Significant improvements in grip strength and self-perceived han ha nd 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 Energy conservation conservation includes pacing, balancing activities activities and taking rest breaks (includ (including ing micro microbre breaks aks). ). It aims aims to red reduce uce fatigu fatigue, e, pain pain and impro improve ve functi functiona onall abilit abilityy. Fatig Fatigue ue manage managemen mentt is a wider wider concep conceptt that, that, in additi addition, on, includ includes es sleep sleep hygiene, cognitive-behavioural strategies, physica physi call fitness and lifestyle behaviours to help the person improve functional endurance. 17 These have been little evaluated in arth arthri riti tis. s. A 3 mont month h foll follow ow-u -up p stud studyy ðn ¼ 28 Þ of an ener energy gy cons conser erva vati tion on prog progra ramm mme e (bas (based ed on cogn cognit itiv ive, e, beha behavi viou oura rall and and lear learni ning ng theo theorie ries) s) with with RA suffe sufferer rerss compar compared ed to standa standard rd trainin trainingg method methodss (educa (educatio tion, n, discus discussio sion n 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


to change change their practice practice methods methods to include include cognitive cognitive-beha -behavioura viourall training training approaches.5,24,32 Activities of daily living training and assistive technology

Much of the occupational therapist’s 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 modificatio modifications ns (e.g. home re-organ re-organisatio isation, n, stair rails, access access ramps, ramps, steps, steps, housing housing adaptations) to improve function. There have been very few studies of the effectiveness effectiveness of ADL training and assistive technology specifically in arthritis. A retrospective survey indica indicated ted that that altere altered d wor workin kingg method methods, s, assist assistive ive device devicess and envir environm onment ental al modifica modifications tions 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 indepen independen dence, ce, red reduci ucing ng pain, pain, compen compensat sating ing for muscle muscle wea weakne kness ss and increa increasin singg 34 safety. Two small studies found that people with RA experienced significantly less hand pain when when using using specific assistive devices leg adapted knives, tap turners) during daily activities.27,35 A study of frail older people with arthritis f ound that ound 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 su rveys indicate indicate a substantial number are 38,39 abandoned, although the reason why is unclear. Non-users (29%) of one type of device had significantly greater greater self-efficacy 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 pa and pain. in. Many people prefer to carry out activities in a ‘normal’ manner, despite difficulty.34 Device provision should, therefore, always be combined with joint prote protecti ction on and exer exercis cise e traini training ng to maximi maximise se physi physical cal abilit abilityy and emphas emphasise ise the protective benefits of devices. An observational study of people referred to OT for driving difficulties ðn ¼ 94Þ found that most problems could be satisfactorily resolved by simple driving techn ique ique or vehicle modifications, enabling the majority to continue driving independently. 40 Hand exercises

Five randomised controlled trials of hand exercises have been published 41–45, although two combined hand exercise with other interventions (e.g. ultrasound, faradic far adic baths, baths, wax therapy), hence the effectiveness of the exercise component is unclear. 41,45 There There are concerns that resistive hand exercises might promote deformity in some people 43 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 an d dexterity over a 12 week period in people with a disease duration of less than 5 years 44 and improved grip and pi and pinch nch strength over a 4 year period in people with at least 1 year of active disease. 43 Deformity was not evalua eva luated ted specific specificall allyy in either either study study,, but in the long-t long-term erm,, a contr control ol group group had significantly greater loss of proximal interphalangeal (IP) joint extension, indicating Boutonnie Boutonniere re defo deformities, rmities, and increased hyperextension hyperextension of the thumb IP joints, reducing 43 thumb stability. Long-term adherence was promoted thr t hrough ough regular reinforcement during clinic sessions, which is unusual in clinical practice.43 An intensive out-patient OT OT programme of ROM and resistive hand exercises (12 sessions over 4 weeks) reduced


497

pain, pain, stif stiffness fness and improve improved d hand hand moveme movement nt in people people with with 6– 1 6– 10 year years’ s’ 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 sessio session, n, with with reinfo reinforc rceme ement nt 1 wee week k later later,, which which is reflect reflective ive of typica typicall practice.46 A small study demonstrated that using a hand exerciser with an electronic counte counterr and visual visual displa displayy provi providin dingg feedb feedback ack can signifi significan cantly tly increa increase se exer exercis cise e frequency.47 The efficacy of hand exercisers or their ease of home use has not been evaluate evaluated. d. Occupation Occupational al therapists therapists also use therapeu therapeutic tic activities activities (e.g. crafts and remed remedial ial games games)) to improv improve e hand hand functi function. on. The benefit benefitss of these these have have not bee been n evaluated. In summary, summary, a combination of ROM and resistive exercises exercises seem to be more effective effective than ROM exercises exercises alone in improving or maintaining han h and d function in RA. This may be enhanced by the application of heat before exercising. 42 Adherence Adherence is highly highly variable variable and clinically therapists need to focus on strategies to increase this, such as use of exercise diaries, diaries, ‘booster’ sessions and designing exercise regimens regimens that are achievable and easy to follow. Splinting

Hand Hand splint splintss are provid provided ed to relie relievve pain, ain, dec decrea rease se swe swelli lling, ng, improv improvee streng strength, th, ROM and 48 function and to prevent deformity. A recent systematic review of hand splinting in RA identified three studies that had evaluated the effects of wrist working splints versus v ersus control groups and two studies that had compared different models of o f splints.49 Most studie studiess had short short follow follow-up -ups—t s—the he longe longest st being being for 6 months months..50 The reviewe reviewers rs conclud concluded ed there there was no clear clear eviden evidence ce for pain pain relief relief or improv improved ed functi function on in the longer longer-term, term, butthat splint splintss do not detri detrimen mental tally ly affe affect ct grip grip streng strength th or ROM. Most Most patien patients ts use splints only during heavy activities to reduce the force on the wrists, suggesting that the main benefit is short-term. Increased grip strength stre ngth and and significant pain relief have been observed in two studies of immediate effects. 50,51 People should also be advised that initia initially lly grip grip streng strength th and dexte dexterit rityy can be red reduc uceed during during worki working ng wrist wrist splint splint wear wear until until the patient has become adjusted to their use. 5 Different splint models mode ls have have differing effects, indicating that a selection should be available for patients to try. 5 Two studies studies have have eva evalua luated ted restingsplint restingsplint use at home —one —one look looked ed at the the effe effect ct of wear wear versus ver sus non-we non-wear ar and the other other compare compared d splint splint models models..52,53 There There wer were e no differ differenc ences es in painor joint joint swe swellin llingg after after 6 months, months, althou although gh people people withpainful, withpainful, swolle swollen n hands hands prefer preferred red wear wearinga inga padd padded ed splin splintt to no splintat splintat nigh night. t.53 A further further small small study study ðn ¼ 7 Þ highlighted highlighted the fact fact that that mostpatients mostpatients reporte reported d pain pain reliefat reliefat night, night, but ulnar ulnar devia deviatio tion n progre progressed ssed similar similarly ly 54 in splinte splinted d and non-spli non-splinte nted d hands. hands. Adhere Adherence nce is highly highly variabl variablee with splints splints and their their use is corr correla elated ted with a belie belieff in the effica efficacy cy of splintin splintingg and splint splint fit. Common Common belief beliefss are that that they can can cause muscle weakness and stiffness and there is a fear of becoming reliant on splints.55 Adheren Adherence ce withresting withresting splint splint wea wearr is increas ncreased ed throug through h carefu carefull attent attentionto ionto splint 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, 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,


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?

Occupatio Occupational nal therapists therapists undertak undertake e work work-base -based d assessment assessmentss and modify modify work equipment and environments. They provide training in altering movement patterns, in task task modi modific ficat atio ions ns and and in work work post postur ures es (bot (both h in real real and and simu simula late ted d work 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 lighter duties duties if necessary necessary.. Work hardening hardening programme programmess can also be provided 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 a re not sufficiently available and are almost a lost skill in the UK National Health Service. 57 A systematic review of vocational rehabilitation programmes programmes identified six uncontrolled studies of multi-disciplinary interventions. Five had marked positive effects on wo rk 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?

Meani Meaningf ngful ul and enjoya enjoyableleisu bleleisure re activi activitie tiess contri contribut butee to qualit qualityy of life. life. A survey survey of people people with with a medi median an RA dura durati tion on of 7 year yearss ðn ¼ 50 Þ found found that that most most had reduc reduced ed their their leisur leisure e activi activitie tiess by 60%. 60%. Thegreates Thegreatestt losses losses wer weree in physic physical al activi activitie tiess (e.g. (e.g. going going to thegym, golf, golf, dance, with only swimming and walking being maintained), hobbies needing dexterity (e.g. (e.g. crafts crafts,, sew sewing ing)) andsocial andsocial activi activitie tiess (e.g. (e.g. going going to thetheatre thetheatre or cinema cinema). ). On a Qualit Qualityy of Life Scale, least satisfaction was w as 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 conduc cond ucted, ted, 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 ¼ 33)comparedto 33)comparedto a ‘trad ‘traditio itional nal’’ exer exercis cisee andrest andres t programme rogramme resulted 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. evaluated. One small stu small study dy found that the Mitchell relaxation method improved pain and psychological status.62 Some therapists with additional training use cognitiv cognitive-b e-beha ehaviou vioural ral therap therapyy (CBT). (CBT). Studies Studies by psycholo psychologist gistss have have found found that that multimodal CBT (i.e. relaxation, imagery, stress management, cognitive coping skills, biofee biofeedba dback ck and psychot psychothera herapeu peutic tic interve interventio ntions, ns, both both group group and individ individual ual)) signifi significan cantly tly impro improved ved pain pain and functi functiona onall disabi disabilit lityy in the short short term. term. Anxiet Anxietyy, depress depression, ion, self-efficacy and coping skills were also improved in both the short and long term.63 Whethe Whetherr the typica typicall traini training ng method methodss used used in OT for relaxa relaxatio tion, n, stress stress management and other psychological interventions are equally effective is unknown.


499

How effective are complex occupational therapy programmes?

There There have have onlybeen only beentwo tworand randomise omised d controll controlled ed trials trials evaluat evaluating ing complex complex OT program programmes mes in RA, RA, and and non none f oroth or other ercon condit dition ions. s. Thestudytha Thestudy thatt showe showed d themost benefitwas benefitwas carrie carried d outby out by Helewa et al64 who evaluated a primary care OT programme in a crossover trial ðn ¼ 105Þ: Thestudy Thestudy recru recruite ited d peopl peoplee with with RA for, for, on avera average,13 ge,13 years years.. OT includ included edev evalu aluati ation onof ofdis diseas ease e activi activity ty,, functi functiona onall abilit abilityy in ADL, ADL, wor workk and leisur leisure, e, housin housingg adapta adaptatio tion n nee needs, ds, and assess assessmen ments ts of the hands and feet. Interventions (see Table 1) 1) were included as relevant to the person’s needs needs.. The The progr programm ammee was provid provided ed inten intensiv sively ely ove overr 6 we week ekss in client clients’ s’ homes. homes. Immed Immediat iately ely following and 6 weeks later, significant improvements occurred in function (specifically selfcare, care, home home manag manageme ement nt andmob and mobili ility) ty)and andaa pooled pooledind index ex (i.e. (i.e. active activejoi joint nt count, count,gri grip p streng strength, th, erythrocy erythrocyte te sedimenta sedimentation tion rate, rate, morning morning stiffnes stiffnesss and function functional al change) change),, compare compared d 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. ability. A randomised controlled trial ðn ¼ 326Þ recruiting people with early RA (average disease duration 10 months) evaluat evaluated ed an out-patient OT programme of, on average, 7.5 hours (spread over over 4 – 8 weeks).46 Over 70% of participants were prescribed diseasemodify modifying ing drugs drugs and 36% wer were e prescri prescribed bed low dose oral steroi steroids. ds. The progra programme mme included a wide of range interventions according to the individual’s needs (see Table 1), 1), althou although gh the commone commonest st wer were e self-ma self-manag nageme ement nt educat education ion,, joint joint protec protectio tion, n, hand hand exercises, assistive devices, ADL training and splinting. Adherence with self-management was signific significant antly ly higher higher in the OT group. group. Howev However er,, after after 2 yea years rs there there wer were e no differ differenc ences es in physical, functional or psychological status compared to the control group. Why Why was OT (appar (apparent ently) ly) inef ineffecti fective ve in this this study? study? Physic Physical al functi function on strong strongly ly correlates with disea disease activity in early RA, meaning drug management plays a major role in affecting this 65 and over one-third of participants had ‘mild’ disease throughout this study. study. Interviews Interviews with the OT group group participan participants ts identified identified process changes: changes: knowing knowing more about RA and self-managem self-management, ent, greater greater acceptance acceptance of living with arthritis, greater satisfaction with daily activities and roles, believing self-mana self- management gement 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 hasn’t made a difference…’ difference…’ ‘I am not that bad yet’. Potentially, 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 before a concordant worsening of functional functiona l ability ability in a control group enables the effects of secondary prevention to be identified. 65

WHO SHOULD THE RHEUMATOLOGIST RHEUMATOLOGIST REFER TO 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.


Consultant/ Rheumatology Nurse Practitioner/ Extended Role Practitioner

Regular screening for problems with: • Work • Upper limb • Functional (ADL, leisure) • Psychological status

Work problems identified: 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: 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

•

Cognitive–behavioural based group arthritis self-management programmes. programmes. Provide programmes flexibly (day and evening/ hospital and community). (May be part of MDT provision)

•

Individual cognitive–behavioural based self management education: if person unwilling/ unable to attend group programme

Increasing mobility, functional, psychosocial problems: • Regular OT monitoring (e.g. 6–12m/ 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 interventions e.g. relaxation, stress and pain management, counselling). 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: problems: OT as part of intensive multidisciplinary rehabilitation (day 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, MTD, multidisciplinary team.

What is the role role of the occupatio occupational nal therapist therapist?? †

†

†

501

Difficult Difficultyy performin performingg ADL, household, household, caring caring and leisure leisure activities activities because of arthritis—when these problems become apparent. Poorer Poorerpsych psycholog ological icalstat status, us, especial especially ly withred with reduced ucedleisu leisure reand andsoci social al activities. vities. Early Early identific identificatio ation n and and refe referr rral al is reco recomm mmen ende ded d as this this grou group p is more more like likely ly to have have a wors worsee outc outcom ome. e. People People who are are willin willingg to use self-mana f-manage geme ment nt meth methods ods (e.g. g. joint nt prot protect ection ion,, fatigu fatigue e management, hand exercises, pain management) to manage symptoms should be referred for patient education. education.

SUMMARY

A summary pathwa pathwayy for OT OT in RA is shown in Figure 1. Many OT OT interventions interventions have have been been little evaluated. Further research is needed on the effects of OT interventions in early arthrit arthritis is to eva evalua luate te whethe whetherr they they can have have seconda secondary ry preven preventat tativeeffe iveeffects, cts, as well 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 on specific interventions that are relevant to the client’s functional needs nee ds is most most releva relevant. nt.2,5 In ear early ly RA, the therapi therapist st should should assess assess the person’ person’s rea readine diness ss to use self-management approaches first (see Figure 1). 1). If not ready, brief interventions of information and motivational interviewing are appropriate. Behavioural self-management trainin trainingg (e.g. (e.g. joint joint protec protectio tion, n, fatigu fatigue e manage managemen ment, t, hand hand exerc exercise ises, s, pain and stress stress manage management ment)) is more more effect effectivewhen ivewhen the person person is rea ready dy forchange. forchange. Work rehabi rehabilita litatio tion n 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. outcome. Cognitive Cognitive-beh -behavio avioural ural approache approachess and goal-set goal-setting ting are the more effective effective methods joint protection training (using cognitive-behavioural 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


†

†

†

†

†

†

†

†

†

†

†

†

people are helped to live more satisfying, balanced lifestyles. This is particularly important in early arthritis—as patients are increasingly being referred early longer longer-term follow-ups follow-ups are needed to evaluate evaluate the impact impact of OT on role participation, activities and impairments, quality of life and psychological status the Internati International onal Classificatio Classification n of Function, Function, Disabili Disability ty and and Heal Health th shou should ld be used used as a common framework for outcome evaluation. 67 Outcomes should include process process measure measuress (e.g. (e.g. coping coping strateg strategies, ies, satisfa satisfactio ction n with life activiti activities, es, psycholog psychological ical adjustme adjustment nt to living living with chronic chronic conditio conditions) ns) and include include individualised outcomes, relevant to the client’s specific needs 65,68 itmay be more more relev relevantto antto constru construct ct trialsfocus trialsfocused ed on ‘atrisk’groups, ‘atrisk’groups, rathe ratherr than than heterogeneous samples, so it becomes clearer what works with whom 68 biomechanical studies with people with chronic musculoskeletal musculoskeletal conditions are neede nee ded d to identi identify fy which which joint joint protec protectio tion n method methodss aremost effec effectiv tive e in red reduci ucing ng 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 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 deformity has not been systematic systematically ally evaluate evaluated. d. Detailed Detailed evaluatio evaluation n 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 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 needed to evaluate evaluate hand exe exercise rcise programme programmes, s, including including long-term long-term follow-up follow-up of their effects on deformity the benefits of therapeutic therapeutic and hand activity programmes, ADL training, leisure therapy, therapy, work rehabilitation and psychological interventions need evaluation to identify effective methods of providing these no studies have yet evaluated the cost-effectiveness cost-effectiveness of OT in arthritis

REFERENCES 1. Scott Scott DL, Shipley Shipley M, Dawso Dawson n A, et al. The clinical clinical manage manageme ment nt of rheum rheumato atoid id arthri arthritis tis and osteoarthritis: strategies for improving clinical effectiveness. British Journal of Rheumatology 1998; 37: 546–554. 2. Scottish Intercollegiate Intercollegiate Guidelines Network, Network, Management of Early Rheumatoid Arthritis . Edinburgh: Royal College of Physicians of Edinburgh, 2000. Accessed 7.3.03.www.sign.ac.uk 7.3.03. www.sign.ac.uk ..

What is the role role of the occupatio occupational nal therapis therapist? t?

503

3. American College of Rheumatology Rheumatology Subcommittee on RA Guidelines, Guidelines, Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis and Rheumatism 2002; 46: 328–346. * 4. Association of Rheumatology Rheumatology Health Professionals. Professionals. Briefing Paper: The Role of the Occupational Therapist in the Manageme Management nt of Patient Patientss with Rheumati Rheumaticc Diseases Diseases. Availabl Available e at: http://www.theumatology.org/arhp/ briefing/ot.html.. Accessed 1/10/03.. briefing/ot.html * 5. Clinical Guidelines Working Working Party of the National Association of Rheumatology Occupational Therapists, Therapists, Occupational Therapy Clinical Guidelines for Rheumatology . London: College of Occupational Therapists, 2003. 6. Cree Creek k J. Occupational Therapy as a Complex Intervention . London: College of Occupational Therapists, 2003. 7. Jordan JM, Bernard SL, Callahan LF, LF, et al. Self-reported arthritis-related disruptions disruptions in sleep and daily life and the use of medical, complementary and self-care strategies for arthritis: The National Survey of SelfCare and Ageing. Archives of Family Medicine 2000; 9: 143–149. 8. Eberhardt KB, Rydgren LC, Pettersson H & Wollheim Wollheim FA. Early rheumatoid arthritis—onset, arthritis—onset, course and International 1990; 10: 135–142. outcome over two years. Rheumatology International 9. Reisine ST, ST, Goodenow C & Grady KE. The impact of rheumatoid arthritis on the homemaker homemaker.. Social Sciences and Medicine 1987; 25: 89– 95. 95. 10. Reisine S & Fifield J. Expanding the definition of disability: implications for planning, policy and research. research. Milbank Quarterly 1992; 1992; 70: 491–508. 11. Eberhardt K & Fex E. Functional impairment and disability in early rheumatoid arthritis—development arthritis—development over 5 years. Journal of Rheumatology 1995; 22: 1037–1042. 12. Harrison B & Symmons D. D. Early inflammatory polyarthritis: results from the Norfolk Arthritis register with a review of the literature. II. Outcome at three years. Rheumatology 2000; 2000; 39: 939–949. 13. Uhlig T, T, Smedstad LM, Vaglum P, P, et al. The course of rheumatoid arthritis and predictors of psychological, physical and radiographic outcome after 5 years follow-up. Rheumatology 2000; 2000; 39: 732–741. 14. Young A, Dixey J, Cox N, et al. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology 2000; 39: 603–611. 15. Hammond A, Kidao R & Young A. Hand impairment and function in early rheumatoid arthritis. Arthritis and Rheumatism 2000; 43 (supplement 9) : S285. * 16. Yasuda YL. Occupational Therapy Practice Guidelines for Adults with Rheumatoid Arthritis . Bethesda, MD: The American Occupational Therapy Association, 2000. * 17. 17. Corder Corderyy J & Rocch Rocchii M. Joint Joint protect protection ion and fatigu fatigue e manage manageme ment nt.. In Melvin Melvin JL & Jense Jensen n G (eds) (eds) Rheumatologic Rehabilitation Series, Volume 1: Assessment and Management . Bethesda, MD: The American Occupational Therapy Association, 1998, pp 279–322. 18. Mann W. W. Chapter Chapter 16: assistive assistive technology technology for persons persons with arthritis. In Melvin Melvin JL & Jensen Jensen G (eds) Rheumatologic Rehabilitation Series, Volume 1: Assessment and Management . Bethesda, MD: The American Occupational Therapy Association, 1998, pp 369–392. * 19. 19. Sanfor Sanford d M, Silve Silverma rman n SL & Wolfe olfe T. Ch7 Rheumat Rheumatoid oid arthritis arthritis.. In Melvin Melvin JL & Ferre Ferrellll KM (eds) (eds) Rheumatologic Rheumatologic Rehabilitation Series, Volume Volume 2: Adult Rheumatic Diseases . Bethesda, MD: The American Occupational Therapy Association, 2000, pp 161–204. 20. Hammond A & Jeffreson P. P. Rheumatoid arthritis. In Turner Turner A, Foster M & Johnson SE (eds), fifth edn. Occupational Therapy and Physical Dysfunction: Principles, Skills and Practice, Edinburgh: Churchill Livingstone, 2002, pp 543–563. * 21. Steultjens EMJ, Dekker Dekker J, Bouter LM, et al. Occupational therapy therapy for rheumatoid arthritis: a systematic review. Arthritis and Rheumatism (Arthritis Care and Research) 2002; 47: 672–685. * 22. Hammond Hammond A & Free Freeman man K. One year outcomes outcomes of a randomise randomised d controll controlled ed trial of an educational– educational– behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology 2001; 40: 1044–1051. 23. Sheon RP. RP. A joint protection guide for non-articular rheumatic disorders. Postgraduate Medicine 1985; 77: 329–337. 24. Hammond A, Lincoln N & Sutcliffe L. A crossover trial evaluating an educational–behavioural joint protection programme for people with rheumatoid arthritis. Patient Education and Counselling 1999; 37: 19–32. 25. Hammond A, Jeffres Jeffreson on P, Jones Jones N, et al. Clinical Clinical applicabi applicability lity of an educatio educational– nal– behaviou behavioural ral joint joint protection programme for people with rheumatoid arthritis. British Journal of Occupational Therapy 2002; 65: 405–412. 26. Hammond Hammond A & Lincoln Lincoln N. The effect effect of a joint protecti protection on programme programme for people people with rheumatoid rheumatoid arthritis. Clinical Rehabilitation 1999; 13: 392–400. 27. Nordenskiold U. Evaluation Evaluation of assistive devices after a course of joint protection. International Journal of Technology Assessment in Health Care 1994; 10: 293–304.

504 A. Hammon Hammond d 28. Neuberger GB, Smith KV, KV, Black SO & Hassanein R. Promoting self-care in clients with arthritis. Arthritis Care and Research 1993; 6: 141–148. 29. Freeman K, Hammond A & Lincoln NB. Use of cognitive behavioural arthritis education programmes programmes in newly diagnosed rheumatoid arthritis. Clinical Rehabilitation 2002; 16: 828–836. 30. Kraaimaat FW, FW, Brons MR, Geenen R & Biljsma JWJ. The effect of a cognitive behaviour therapy in patients with rheumatoid arthritis. Behaviour Research and Therapy 1995; 33: 487–495. 31. Stamm TA, TA, Machold KP, Smolen JS, et al. Joint protection and home hand exercises improve improve hand function in patients with hand osteoarthritis: a randomised controlled trial. Arthritis Care and Research 2002; 47: 44–49. 32. Furst GP, GP, Gerber LH, Smith CC, et al. A program for improving energy conservation behaviours behaviours in adults with rheumatoid arthritis. American Journal of Occupational Therapy 1987; 41: 102–111. 33. Nordenskiold U, Grimby G & Dahlin-Ivanoff S. Questionnaire to evaluate the effects of assistive devices and altered working methods in women with arthritis. Clinical Rheumatology 1998; 1998; 19: 6–16. 34. Rogers Rogers JC, Holm Holm MB & Perki Perkins ns L. Traject rajectory ory of assist assistive ive device device usage usage and user user and non-us non-user er characteristics: long handled bath sponge. Arthritis Care and Research 2002; 47: 645–650. 35. Hass U, Brodin H, Andersson A & Person J. Assistive technology technology selection: a study of participation of users with rheumatoid arthritis. IEEE Transactions on Rehabilitation Engineering 1997; 5: 263–275. 36. Mann WC, Hurren D & Tomita M. Assistive devices used by home-based elderly persons with arthritis. American Journal of Occupational Therapy 1995; 1995; 49: 810–820. 37. Mann WC, Tomita Tomita M, Hurren D & Char vat B. Changes in health, functional and psychosocial status and coping strategies of home-based older persons with arthritis over three years. Occupational Therapy Journal of Research 1999; 19: 126–146. 38. Sutton Sutton D, Gignac MM & Cott C. Medical Medical and everyday everyday assistive assistive device device use among among older older adults adults with arthritis. Canadian Journal on Ageing 2002; 2002; 21: 535–548. 39. Eckloff Eckloff SG & Thornton BC. Prescribing assistive devices for patients with rheumatoid rheumatoid arthritis: careful Musculoskeletal Medicine 2002; 19: selection of equipment helps patients perform daily functions. Journal of Musculoskeletal 27–34. Rheumatology 1994; 30: 361–364. 40. Jones Jones JG, McCan McCann n J & Lassere Lassere MN. MN. Driving Driving and arthritis. arthritis. British Journal of Rheumatology 41. Hawkes Hawkes J, Care G, Dixon Dixon JS, et al. A compariso comparison n of three three differe different nt physioth physiotherap erapyy treatmen treatments ts for rheumatoid arthritis of the hands. Physiotherapy Practice 1986; 2: 155–160. 42. Dellhag B, Wollersjo Wollersjo I & Bkjelle A. Effect of active hand exercise exercise and wax bath treatment in rheumatoid arthritis patients. Arthris Care and Research 1992; 5: 87–92. 43. Brighton Brighton SW, SW, Lubbe Lubbe JE & van der Merwe CA. The effect effect of a long-term long-term exercis exercise e programme programme on the rheumatoid hand. British Journal of Rheumatology 1993; 32: 392–395. 44. Hoenig H, Groth G, Pratt K, et al. A randomised controlled trial of home exercise on the rheumatoid hand. British Journal of Rheumatology 1993; 20: 785–789. 45. Buljina AL, Taljanovic Taljanovic MS, Advic DM & Hunter TB. Physical and exercise exercise therapy for treatment of the rheumatoid hand. Arthritis and Rheumatism (Arthritis Care and Research) 2001; 45: 392–397. * 46. Hammond A, Kidao R & Young A. A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis. Annals of the Rheumatic Diseases 2003; 63: 23–30. 47. Waggoner Waggoner CD & LeLieuvre RB. A method to increase compliance to exercise exercise regimens in rheumatoid arthritis patients. Journal of Behavioral Medicine 1981; 4: 191–201. 48. Harrell PB. Splinting of the hand. In Robbins Robbins L, Burckhardt CS, Hannan MT & DeHoratius DeHoratius RJ (eds) Clinical Care Care in the Rheuma Rheumatic tic Diseas Diseases es, Second Second edn. edn. Atlant Atlanta, a, GA: GA: Associ Associati ation on of Rheuma Rheumatol tology ogy Health Health Professionals, American College of Rheumatology, 2001, pp 191–196. * 49. Egan M, Brosseau L, Farmer M, et al. Splints and orthoses for treating rheumatoid arthritis (Cochrane Review) . The Cochrane Library, Issue 4, Chichester, UK: Wiley, 2003. 50. Kjeken I, Moller G & Kvien TK. Use of commercially commercially produced produced elastic wrist orthoses orthoses in chronic chronic arthritis: a controlled study. Arthritis Care and Research 1995; 8: 108–113. 51. Nordensk Nordenskiold iold U. Elastic Elastic wrist orthoses: orthoses: reduction reduction of pain and increase increase in grip force for women women with rheumatoid arthritis. Arthritis Care and Research 1990; 3: 158–162. 52. Janssen Janssen M, Phiferons Phiferons JPWM & van den Velde Velde EA. The preven prevention tion of hand deformiti deformities es with resting resting splints splints in Arthritis and rheumato rheumatoid id arthritis arthritis patients. patients. A randomized randomized single blind blind one year follow-up follow-up study. study. Arthritis Rheumatism 1990; 33: 123. 53. Callinan Callinan NJ & Mathiowe Mathiowetz tz V. Soft versus hard resting resting hand splints splints in RA: pain relief, relief, preference preference,, and compliance. The American Journal of Occupational Therapy 1996; 50: 347–353. 54. Malcus Malcus Johnson Johnson P, P, Sandkvist Sandkvist G, Eberhardt Eberhardt K, et al. The usefulness usefulness of nocturnal nocturnal resting resting splints splints in the treatment of ulnar deviation of the rheumatoid hand. Clinical Rheumatology 1992; 11: 72–75. 55. Hammond A. The use of self-mana self-managem gement ent strategies strategies by people people with rheumatoid rheumatoid arthritis. arthritis. Clinical Rehabilitation 1998; 12: 81–87.


505

56. Feinberg J. Effect of the arthritis health professional on compliance with use of resting hand splints by patients with rheumatoid arthritis. Arthritis Care and Research 1992; 5: 17–23. Vocational Rehabilitation: The Way Way Forward . London: British 57. British British Society Society of Rehabilit Rehabilitation ation Medicine, Medicine, Vocational Society of Rehabilitation Medicine, 2000. 58. DeBuck PDM, Schoones JW, JW, Allaire SH & Vliet Vlieland TPM. Vocational rehabilitation in patients with chronic rheumatic diseases: a systematic review. review. Seminars in Arthritis and Rheumatism 2002; 32: 196–203. 59. Wikstrom I. Leisure activities activities in rheumatoid arthritis: change after disease onset and associated factors. British Journal of Occupational Therapy 2001; 64: 87–92. 60. Drummond A & Walker Walker M. Generalisation of the effect of leisure rehabilitation rehabilitation for stroke patients. British Journal of Occupational Occupational Therapy 1996; 1996; 59: 330–334. 61. Van Deusen Deusen J & Harlowe D. D. The efficacy of the ROM Dance Program for adults with rheumatoid arthritis. American Journal of Occupational Therapy 1987; 1987; 40: 90–95. 62. Jackson Jackson T. An evaluati evaluation on of the Mitchell method method of simple simple physiol physiologica ogicall relaxation relaxation for women women with rheumatoid arthritis. British Journal of Occupational Therapy 1991; 54: 105–107. 63. Astin JA, Beckner W, W, Soeken K, et al. Psychological interventions for rheumatoid arthritis: a meta-analysis of randomised controlled trials. Arthritis and Rheumatism (Arthritis Care and Research) 2002; 47: 291–302. * 64. Helewa Helewa A, Goldsmith Goldsmith C, Lee P, P, et al. Effect Effectss of occupati occupational onal therapy therapy home service service on patients patients with rheumatoid arthritis. Lancet 1991; 337: 1453– 1456. 1456. 65. Stucki G. Understanding Understanding disability. Annals of the Rheumatic Diseases 2003; 62: 289–290. 66. Kidao R. The psychosocial impact of occupational therapy on the experience of people with early rheumatoid arthritis. Unpublished MPhil Thesis, University of Derby, 2001.. 67. International International Classification of Function, Disability and Health. Geneva: World World Health Organization. http:// Organization. http:// www3.who.int/icf/icftemplate.cfm . Accessed 21.10.03.. 68. Vliet Vlieland TM. CARE: international conference on multi-disciplinary multi-disciplinary care in rheumatoid arthritis. International Journal of Advances in Rheumatology 2003; 1: 34–36.

what is the role of the ot

Recommend Documents