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What is the role of the occupational therapist?
Alison Hammond*
Occupational therapy (OT) is widely provided for people with chronic musculoskeletal
conditions. The aims are to improve their ability to perform daily occupations (i.e. activities
and valued life roles at work, in the home, at leisure and socially), facilitate successful adaptations
to disruptions in lifestyle, prevent losses of function and improve or maintain psychological status.
This chapter reviews the evidence for the effectiveness of OT interventions, suggests who is
relevant for referral and indicates the appropriate timing for referral. The main emphasis is on OT
for people with rheumatoid arthritisprimarily because most evidence to date is for this
condition.
Comprehensive OT is effective in improving function in people with moderate severe
arthritis. Some interventions (e.g. joint protection and hand exercises) are effective. People are
increasingly being referred sooner after diagnosis for interventions to help prevent progression of
functional, physical and psychological problems. Little is known of the effectiveness of therapy at
this early stage.
Key words: arthritis; occupational therapy; rehabilitation.
492 A. Hammond
with RA, this will be the main focus. Studies evaluating OT as part of a multidisciplinary intervention are not included. The need for systematic programmes of
OT research will be highlighted.
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
Source: Yasuda (2000)21, Cordery & Rocchi (1998)22, Mann (1998)23, Sanford et al. (2000)24,
Hammond & Jeffreson (2002).25
Source: Eberhardt et al. (1990)8, Reisine et al. (1987)9, Reisine & Fifield (1992)10, Eberhardt & Fex (1995).11
494 A. Hammond
therapeutic and educational interventions.16,17 For example, a woman with early RA, or
OA of the carpometacarpal joint, is referred with hand problems affecting daily tasks at
home. The focused interventions provided include joint protection, assistive devices,
hand exercises and splinting to reduce hand pain and to increase movement, dexterity
and hand function. For a person with a work related upper limb disorder (WRULD), the
same treatment is combined with an ergonomic assessment in the workplace, including
psychological and work activity factors affecting stress levels. A cognitive-behavioural
approach is adopted, including stress management, retraining of hand habits, postures
and work routines, ergonomic modification of the work area and liaison with
employers to modify work activities and roles.
As chronic musculoskeletal conditions impact more widely, OT becomes more
complex. For example, a person with RA or FM progressively experiences more
difficulties in their work, personal and family care, household activities, driving, hobbies,
leisure and social roles. Coping with daily life and symptoms can affect psychological
state. A complex programme is provided, including most, or all, of the interventions
listed in Table 1, which address a wide range of physical, functional, psychological, social
and environmental factors.16 20 The therapist liases closely with other agencies and the
multi-disciplinary team and may be involved with clients over many years in helping
them adapt to living successfully with a chronic condition.
496 A. Hammond
pain, stiffness and improved hand movement in people with 6 10 years disease
duration. When combined with wax therapy this also improved grip.42 However, these
studies all had methodological problems such as small treatment groups, self-selected
participants, low recruitment from applicable patients or the exclusion of non- or poor
adherers, making it difficult to extrapolate the findings to clinical practice.
Adherence with hand exercise is variable. After 6 months, 53% of people with early
RA continued, almost daily, a programme of 10 ROM exercises following a 30 minutes
training session, with reinforcement 1 week later, which is reflective of typical
practice.46 A small study demonstrated that using a hand exerciser with an electronic
counter and visual display providing feedback can significantly increase exercise
frequency.47 The efficacy of hand exercisers or their ease of home use has not been
evaluated. Occupational therapists also use therapeutic activities (e.g. crafts and
remedial games) to improve hand function. The benefits of these have not been
evaluated.
In summary, a combination of ROM and resistive exercises seem to be more effective
than ROM exercises alone in improving or maintaining hand function in RA. This may be
enhanced by the application of heat before exercising.42 Adherence is highly variable
and clinically therapists need to focus on strategies to increase this, such as use of
exercise diaries, booster sessions and designing exercise regimens that are achievable
and easy to follow.
Splinting
Hand splints are provided to relieve pain, decrease swelling, improve strength, ROM and
function and to prevent deformity.48 A recent systematic review of hand splinting in RA
identified three studies that had evaluated the effects of wrist working splints versus
control groups and two studies that had compared different models of splints.49 Most
studies had short follow-upsthe longest being for 6 months.50 The reviewers
concluded there was no clear evidence for pain relief or improved function in the longerterm, but that splints do not detrimentally affect grip strength or ROM. Most patients use
splints only during heavy activities to reduce the force on the wrists, suggesting that the
main benefit is short-term. Increased grip strength and significant pain relief have been
observed in two studies of immediate effects.50,51 People should also be advised that
initially grip strength and dexterity can be reduced during working wrist splint wear until
the patient has become adjusted to their use.5 Different splint models have differing
effects, indicating that a selection should be available for patients to try.5
Two studies have evaluated resting splint use at homeone looked at the effect of wear
versus non-wear and the other compared splint models.52,53 There were no differences in
pain or joint swelling after 6 months, although people with painful, swollen hands preferred
wearing a padded splint to no splint at night.53 A further small study n 7 highlighted the
fact that most patients reported pain relief at night, but ulnar deviation progressed similarly
in splinted and non-splinted hands.54 Adherence is highly variable with splints and their use
is correlated with a belief in the efficacy of splinting and splint fit. Common beliefs are that
they can cause muscle weakness and stiffness and there is a fear of becoming reliant on
splints.55 Adherence with resting splint wear is increased through careful attention to splint
education, emphasis on benefits and follow-up.56
In summary, there is no evidence as yet as to whether splinting can help to reduce or
prevent deformity, or improve or maintain function in the longer term. Working splints
main benefits are for pain relief and improved grip and function during splint wear.
Resting splints can provide pain relief at night during wear for those with painful,
498 A. Hammond
swollen hands. Ready-made elastic wrist gauntlets are relatively inexpensive and, since
they may provide pain relief for many people, it is reasonable to provide these.49
How effective are work interventions?
Occupational therapists undertake work-based assessments and modify work
equipment and environments. They provide training in altering movement patterns,
in task modifications and in work postures (both in real and simulated work
environments in OT departments). They identify psychological factors affecting work
ability, provide training in cognitive-behavioural coping strategies, liase with employers
and the worker with arthritis about job activities, rotations, shifts, flexible work and
lighter duties if necessary. Work hardening programmes can also be provided in
appropriately equipped OT departments to facilitate a return to work.
A recent UK report summarised various lines of research and found that vocational
rehabilitation programmes are, in general, highly cost-effective, but generally they are
not sufficiently available and are almost a lost skill in the UK National Health Service.57
A systematic review of vocational rehabilitation programmes identified six uncontrolled
studies of multi-disciplinary interventions. Five had marked positive effects on work
status, but the evidence was relatively weak because of methodological shortcomings.58
This suggests that OT work interventions can help maintain people with arthritis in
work but no trials have been conducted.
How effective are leisure and therapeutic activities?
Meaningful and enjoyable leisure activities contribute to quality of life. A survey of people
with a median RA duration of 7 years n 50 found that most had reduced their leisure
activities by 60%. The greatest losses were in physical activities (e.g. going to the gym, golf,
dance, with only swimming and walking being maintained), hobbies needing dexterity
(e.g. crafts, sewing) and social activities (e.g. going to the theatre or cinema). On a Quality
of Life Scale, least satisfaction was expressed for participating in active recreation and
expressing oneself creatively.59 Occupational therapists use leisure counselling and a
range of therapeutic (e.g. crafts, gardening) and leisure exercises (e.g. yoga, Tai Chi,
swimming) to improve functional ability, psychological well-being, occupational balance
and satisfaction with life. No trials of leisure therapy in arthritis have been conducted,
although in stroke patients increased mobility and psychological well-being result.60 A 4
month follow-up of a randomised trial of Tai Chi and relaxation (the ROM Dance
programme: n 33) compared to a traditional exercise and rest programme resulted in
significantly better upper limb function and greater satisfaction.61
How effective are psychological interventions?
Therapists provide counselling, relaxation and stress management in programmes, but
this has been little evaluated. One small study found that the Mitchell relaxation method
improved pain and psychological status.62 Some therapists with additional training use
cognitive-behavioural therapy (CBT). Studies by psychologists have found that
multimodal CBT (i.e. relaxation, imagery, stress management, cognitive coping skills,
biofeedback and psychotherapeutic interventions, both group and individual)
significantly improved pain and functional disability in the short term. Anxiety,
depression, self-efficacy and coping skills were also improved in both the short and long
term.63 Whether the typical training methods used in OT for relaxation, stress
management and other psychological interventions are equally effective is unknown.
500 A. Hammond
Cognitivebehavioural based
SUMMARY
A summary pathway for OT in RA is shown in Figure 1. Many OT interventions have been
little evaluated. Further research is needed on the effects of OT interventions in early
arthritis to evaluate whether they can have secondary preventative effects, as well as to see
whether, in later stages, they can help to improve functional ability. Currently, clinical
guidelines recommend that for people with early stage RA a self-management education
approach, focussing on specific interventions that are relevant to the clients functional
needs is most relevant.2,5 In early RA, the therapist should assess the persons readiness to
use self-management approaches first (see Figure 1). If not ready, brief interventions of
information and motivational interviewing are appropriate. Behavioural self-management
training (e.g. joint protection, fatigue management, hand exercises, pain and stress
management) is more effective when the person is ready for change. Work rehabilitation is
important at an early stage to prevent work disability. Complex OT programmes are
applicable when lifestyles are beginning to be affected more extensively.5
Practice points
the way in which OT interventions are provided influences adherence and
outcome. Cognitive-behavioural approaches and goal-setting are the more
effective methods
joint protection training (using cognitive-behavioural methods) can reduce pain
and maintain function in people with RA and hand OA. Energy conservation can
increase physical activity levels
wrist splints can reduce pain when worn during activities
assistive devices can reduce pain and improve the ability to perform daily tasks
comprehensive OT programmes can help improve functional ability in people
with moderate severe RA. The benefits of complex OT interventions in early
arthritis are unclear, although they can increase the use of self-management
Research agenda
clinical trials are needed to evaluate the effects of complex OT interventions
using evidence-based approaches (e.g. cognitive-behavioural methods) on the
maintenance of physical, functional and psychological status and on whether
502 A. Hammond
people are helped to live more satisfying, balanced lifestyles. This is particularly
important in early arthritisas patients are increasingly being referred early
longer-term follow-ups are needed to evaluate the impact of OT on role
participation, activities and impairments, quality of life and psychological status
the International Classification of Function, Disability and Health should be used
as a common framework for outcome evaluation.67 Outcomes should include
process measures (e.g. coping strategies, satisfaction with life activities,
psychological adjustment to living with chronic conditions) and include
individualised outcomes, relevant to the clients specific needs65,68
it may be more relevant to construct trials focused on at risk groups, rather than
heterogeneous samples, so it becomes clearer what works with whom68
biomechanical studies with people with chronic musculoskeletal conditions are
needed to identify which joint protection methods are most effective in reducing
pain and avoiding stressful positions
trials of individual joint protection and energy conservation education, using
cognitive-behavioural approaches is required, since most education clinically is
provided on an individual basis
a larger randomised controlled trial of energy conservation training/fatigue
management is needed to evaluate its effects on pain, fatigue, physical activity
levels and function in the longer-term
the effects of joint protection training on other joints (apart from hands) in RA,
OA and in WRULDs require evaluation. The effect on limiting progress of
deformity has not been systematically evaluated. Detailed evaluation
and radiographic analysis over a 2 5 year period would address this question
evaluations of some types of assistive devices are available, but further survey
work and short-term trials could identify which designs of assistive devices are
found to be most effective and acceptable and why. These would help guide
device choice more specifically
since there is some evidence that joint protection can help maintain function if
applied relatively early in RA, psycho-educational and motivational strategies to
help people be psychologically prepared to change need to be developed and
evaluated
a larger trial recruiting a more representative sample of people with RA is
needed to evaluate hand exercise programmes, including long-term follow-up of
their effects on deformity
the benefits of therapeutic and hand activity programmes, ADL training, leisure
therapy, work rehabilitation and psychological interventions need evaluation to
identify effective methods of providing these
no studies have yet evaluated the cost-effectiveness of OT in arthritis
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