Occupational Therapy interventions for adults with rheumatoid arthritis

The Paper
Siegel, P., Tencza, M., Apodaca, B., & Poole, J. L. (2017). Effectiveness of occupational therapy interventions for adults with rheumatoid arthritis: A systematic review. American Journal of Occupational Therapy, 71(1), 7101180050p1-7101180050p11..

The Problem
Nearly 76 million people worldwide are affected by Rheumatoid Arthritis (RA), leading to pain, loss of function and disability. 

Breakthroughs in the treatment and management of RA have happened over the past few decades (including medications, early diagnosis and management), but it’s still unclear if improvements in occupational performance have correlated with these advancements.

What interventions can you use to better outcomes for your patients with RA?
 

How The Author's Did It
The last systematic review on RA and OT was done back in 2004, so the authors wanted an update on the current evidence.

To do this, they included only Level I studies (i.e Just Randomized Control Trials), and they looked at studies with interventions that could be delivered in an OT practice framework.


Key Findings
Results were reported based on the interventions used; broken down into two broad categories of physical activity and psycho-education.  

See below for our summary of the key findings based broadly on if the interventions appear effective in reducing pain, disability, depression or improving function.

Physical activity interventions

  • Dynamic exercise or aquatic exercise: full body exercise appears to be effective no matter if it’s on land or in the water.

  • Yoga: appears to be effective for pain, function and general health and effects are maintained over time.

  • Resistive exercise: high intensity training tends to do be effective and has been shown to be safe.

  • Home exercise and coaching: appears effective while coaching is delivered, but results might not be sustained in the long run.

  • Aerobic exercise: might help with overall pain but doesn’t necessarily generalize to function.

  • Tai Chi: not a lot of research here, but doesn’t seem to improve outcomes measured (although people do enjoy engaging in it).


Psycho-educational interventions included: patient education and self-management, cognitive–behavioral therapy, multidisciplinary approaches, joint protection, assistive devices, emotional disclosure, and “comprehensive occupational therapy”

  • Joint protection: does appear to help, and may slow functional decline over time.

  • Patient education and self-management, or cognitive behavioural therapy:probably not effective when delivered on its own.

  • Multidisciplinary approaches: probably effective, but maybe not substantially more effective than solo interventions delivered by an OT, PT or other health professional on their own.

  • Assistive devices: not enough research to make meaningful conclusions here.

  • Emotional disclosure (eg. journaling): doesn’t appear to be that useful for improving outcomes.

  • Comprehensive occupational therapy: just one RCT looked at a specifically OT-delivered set of interventions individualized to the client (which may of included a combination of all the above options) - but results appear promising and positive.


Summary
There are many methods for you to support patients with RA (see above).  This systematic review suggests:

  1. OTs should be mindful of each person’s disease process and plan around both flare-ups and stable periods to make the most of interventions.

  2. Exercise interventions and strengthening should be primary. Incorporate exercise approaches such as aquatic exercise, coaching, home exercise, general strength training, or aerobic exercise. 

  3. Consider Yoga, Tai Chi, or dynamic exercise programs as adjunct options. 

  4. Consider patient education, self-management, CBT, and joint protection as adjunct options.

P.S 
We'd argue that just because the interventions above could be delivered by you as an OT, doesn’t necessarily make it occupational therapy.  In fact, none of the studies above specifically looked at occupational performance or engagement.

This can make it hard to feel confident that you're really practicing OT!

To find your confidence and still practice in an evidence based way, try seeing if you can deliver the above interventions in a way that still makes specific, clear, and powerful connections to:

  1. Meaningful occupation (as identified by the patient)

  2. Clear occupational based outcomes