ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A
ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A
ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A
REVIEW ARTICLE
Objective. To determine the impact of occupational therapy (OT) on the self-management of function, pain, fatigue,
and lived experience for people living with rheumatoid arthritis (RA).
Methods. Five databases and gray literature were searched up to June 30, 2022. Three reviewers screened titles
and abstracts, with two independently extracting and assessing full texts using the Cochrane risk of bias (quantitative)
and Critical Appraisal Skills Programme (qualitative) tools to assess study quality. Studies were categorized into four
intervention types. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (quantitative)
and GRADE- Confidence in Evidence from Reviews of Qualitative research (qualitative) were used to assess the quality
of evidence for each intervention type.
Results. Of 39 eligible papers, 29 were quantitative (n = 2,029), 4 qualitative (n = 50), and 6 mixed methods (n = 896).
Good evidence supports patient education and behavior change programs for improving pain and function, particularly
group sessions of joint protection education, but these do not translate to long-term improvements for RA
(>24 months). Comprehensive OT had mixed evidence (limited to home OT and an arthritis gloves program), whereas
limited evidence was available for qualitative insights, splints and assistive devices, and self-management for fatigue.
Conclusion. Although patient education is promising for self-managing RA, no strong evidence was found to sup-
port OT programs for self-managing fatigue or patient experience and long-term effectiveness. More research is
required on lived experience, and the long-term efficacy of self-management approaches incorporating OT, particularly
timing programs to meet the individual’s conditional needs (i.e., early or established RA) to build on the few studies
to date.
214
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OT IMPACT ON RA SELF-MANAGEMENT 215
nodul*” OR
“rheumat*
*AMED, Allied and Complementary Medicine Database; APA, American Psychological Association; CINAHL, Cumulative Index to Nursing and Allied Health Literature.
[including culturally adapted programs]), study Design (primary,
“occupation* “rheumat*
arthrit*”
then full screening (including title and abstract, and then full text).
Term set 1
(arthrit* OR
nodul*)
NEAR/1
Occupational Therapy/
Occupational Therapy
Occupational Therapy
Occupational Therapy
Service/ OR Research,
Practice, Research-
Home Occupational
Therapy Practice,
OR Occupational
Therapists/ OR
Occupational
Practice/ OR
Based/ OR
(arthrit* OR
abstracts, and lastly, two reviewers (JG and LR) screened the
nodul*)
Arthritis,
“occupation*
Occupational
Therapy/ OR
Therapists/
Occupational
“inflammatory
(arthrit* OR
arthrit*”
nodul*)
“occupation*
Occupational
Occupational
Term set 3
Department,
Therapy/ OR
Hospital/
Therapy
rheumat* N1
Term set 1
(arthrit* OR
and assessed the data quality from included papers using a stan-
Arthritis/
arthrit*”
Nodule/
nodul*)
and analysis, and other information (including conclusions and papers from a workplace RCT,11,28 two papers from an arthritis
recommendations). When further information was required, the gloves trial,36,37 and one study and report from a group cognitive
lead reviewer (JG) contacted the paper’s author(s). behavioral therapy (CBT) RCT.38,39 Only four studies reported on
The Cochrane risk of bias tool29 was used to assess the participant ethnicity.35,38,40,41
quality of quantitative papers (seven assessment domains), and
the Critical Appraisal Skills Program (CASP) tool30 for qualitative Patient education. Studies with interventions emphasiz-
papers (10 assessment domains). For mixed methods papers, ing patient education were reported in 16 papers (n = 1,021):
quantitative data were assessed with risk of bias and qualitative 1 high,42 1 moderate quality43 (qualitative), and 6 moderate and
data with CASP. The overall quality of quantitative papers was 8 high risk of bias (quantitative, including an MA thesis43). In
determined using the criteria “low risk,” when three or fewer Hammond’s44 cohort study, behavior change was assessed
domains were deemed an unclear risk and no domains were high using the Joint Protection Behavior Assessment44 following two
risk; “moderate risk,” when three or more domains were unclear educational sessions on joint protection and awareness of activi-
risk and one domain was deemed high risk; and “high risk,” when ties of daily living (ADLs) (85 minutes) and energy conservation/
two or more domains were rated as high risk.31 The overall quality management and exercise (120 minutes). Greater attention to
of qualitative papers was scored out of 10, with scores greater joint protection was reported after intervention, yet this did not
than 9 deemed high quality; between 7 and 9 deemed moderate translate into behavior change. The follow-up RCT focusing on
quality; and scores less than 7 deemed low quality.16 behavior change found that four group education sessions
Selected papers were categorized into the following four (2 hours weekly on joint protection behaviors), led to improved
intervention types: 1) patient education; 2) behavior change; pain, fewer GP visits, and flare-ups post-12 months.33 Although
3) comprehensive, community (home) OT (quantitative and adherence to joint protection and reduced joint stiffness were
qualitative); and 4) other interventions (including exercise and reported after 48 months,34 functional ability and pain returned
workplace) (10). Confidence in the findings for each intervention to baseline levels. Both studies33,44 focused on early RA (mean
type was rated using the Grading of Recommendations, Assess- duration = 1.6 years) and did not blind outcome assessors.
ment, Development and Evaluations’ (GRADE) approach for Masiero and colleagues’45 RCT involved occupational
quantitative, and the GRADE Confidence in Evidence from therapists in developing and delivering a multidisciplinary
Reviews of Qualitative research approach for mixed methods intervention focusing on joint protection for moderate-to-severe
and qualitative.32 Papers were rated as high, moderate, low, or RA (mean duration = 15.4 years). Like Hammond and
very low-quality evidence. Freeman,33 four 2-hour group education sessions involving
spouses and partners were run every 3 weeks, covering joint pro-
Data synthesis and analysis. Characterization and qual- tection in ADLs, environmental adaptations, and exercises. Pain,
ity assessment of selected papers were based on those deemed function, and disability significantly improved after intervention for
most effective in promoting physical and psychosocial health in the education group, but not usual care.
people with RA. Information from papers are presented in sepa- One RCT used a Pictorial Representation of Illness and Self
rate quantitative and qualitative tables32 containing descriptive Measure (PRISM) tool (based on social learning and self-manage-
statistics and quotations, respectively, to summarize papers. ment) to complement traditional education and to enhance short-
Given the limited qualitative papers eligible for review, thematic term improvements in joint protection behavior (6 months) and
analysis was unnecessary; instead, the reviewers used the adherence (12 months).46 Four 45-minute sessions involving
themes identified by the paper authors. partners and spouses, plus a 2-month follow-up, led to partici-
pants viewing joint protection as a coping method for daily tasks
via pain and function management.42 Other benefits included per-
RESULTS
sonal control, self-acceptance, and improved psychological well-
Study selection and characteristics. Initially, 2,389 being: “…more positive towards life”; “less stress because of
articles were identified, including 23 gray literature articles. Follow- easier task performance.”42
ing title and abstract screening, 160 articles were accepted for Barriers to joint protection education related to a negative
full-text screening. Finally, 34 articles and 5 gray literature articles self-image, perceived disability, and complicating task perfor-
met the eligibility criteria (29 quantitative, including 15 randomized mance (Table 3). Adherence to self-management was also
controlled trials [RCTs], 6 controlled clinical trials (CCTs), 4 qualitative, reported up to 24 months for early RA following four 1-hour indi-
and 6 mixed methods) (Figure 1). vidual treatments and a 2-hour group workshop.35 Function,
Characteristics of the 39 included articles (n = 2,018 adults pain, or self-efficacy remained unchanged. Elsewhere, adding
with RA) are summarized in Tables 2 (intervention type and hand exercises to an 8-week RCT of joint protection education
OT role) and 3 (participants, methods, and results). Three led to increased strength, but not disability, pain, or ADLs.47
papers reported from an education behavioral RCT,33–35 two Two pilot RCTs promoting energy conservation48,49 found that
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218 GAVIN ET AL
Figure 1. PRISMA flow chart of literature identification, screening, eligibility, and inclusion of studies. OT, occupational therapy; PRISMA, Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses.
six weekly educational sessions (each 90 minutes, using the Reasons for unchanged behavior related to difficulties changing
PRECEDE model50) did not significantly affect pain, fatigue, func- habits, lack of skill, and joint protection, viewed as inappropriate
tion, or behavior at 9 months, nor did standard OT. for established RA (disease duration = 6.4 years). The follow-up
One 2-hour self-help group involving relaxation, exercise, RCT33 did reduce pain and showed trends for improved
and joint protection led to 84% changing their ADL performance self-efficacy at 6 months (duration = 1.1 years). One RCT38 used
and 85% of participants improving their understanding of RA.43 group CBT (6 weekly 2-hour sessions with an hour consolidation)
In a 6-month CCT,51 elective group workshops and individual to increase self-efficacy at 26 weeks and reduce fatigue 2 years
education were associated with improved problem-solving, but postintervention. In a head-to-head comparison, CBT and OT
not knowledge or fatigue. Another high-risk CCT involving a half- group for 10 weekly sessions (2 hours each) had similar effects
day OT education session over 3 months led to increased on increasing knowledge and promoting active involvement in
strength and function at 3 months.26 One self-instructional OT self-management.25 Only CBT led to improved pain-coping
program (four 20–25-minute sessions) increased knowledge, behavior. A similar program was used for self-management
but not task performance/function; mobility exercises, joint pro- for short-term improvements in illness perception and pain
tection, and nursing had no added benefit.27 Finally, a high-risk self-efficacy, but not pain.54 Interestingly, only six studies
cohort study reported 1-hour of OT increased patient knowledge measured self-efficacy (three behavior change,33,38,54 three
at 6 months, but pain, function, and fatigue were not assessed patient education,35,41,46 with one report,39 and one guideline55
(Table 3).52 reporting on these studies) (Table 3).
Behavior change. Six RCTs and one cohort study Comprehensive, community-based (home) OT.
reported programs focusing on behavior change. The cohort Quantitative studies. Interventions targeting occupational perfor-
study53 observed improved knowledge, but not pain or behavior mance were reported in two RCTs and one CCT. Two additional
up to 12 weeks, after four 2-hour weekly group sessions (includ- studies used comprehensive OT, but were not community-based
ing personalized strategies and goal setting for joint protection). and instead addressed patient education.35,52 One RCT24
Table 2. Study characteristics—type of intervention (or phenomenon of interest), study type, and the role of occupational therapya
Author, year (ref.) Country Type of intervention Research type Study type Role of occupational therapist
Barry et al, 1994 (52) UK Patient education Quantitative Single group, pretest, posttest Survey development (on patient knowledge and join
(cohort) study protection maneuvers) and deliver treatment.
Bowell and Ashmore, UK Patient education Mixed methods Single group, posttest (cohort) Offer education and advice on joint protection
1992 (41) study techniques, hand care, and assistive devices.
Callinan and Mathiowetz, USA Other interventions Quantitative Nonrandomized, single group Fabricate, fit, and instruct on using splints.
1996 (59) crossover trial
Carter, 1979 (49)b USA Patient education Quantitative (MA thesis) Single group, pretest, posttest Delivered program.
(cohort) study
Dubouloz et al, 2004 (55) Canada Comprehensive community- Qualitative Qualitative interviews/ Delivered home-based rehabilitation. Coordination of
based (home) OT grounded theory research (treatment and interviews).
OT IMPACT ON RA SELF-MANAGEMENT
Dubouloz et al, 2008 (57) Canada Comprehensive, community- Qualitative Qualitative interviews/ Delivered home-based rehabilitation. Coordination of
based (home) OT grounded theory research (treatment and interviews).
Dubouloz, 2008 (58) Canada Comprehensive, community- Qualitative Qualitative interviews/ Assess and implement modifications for meaningful
based (home) OT grounded theory occupations, involving how to adapt performance
for daily living activities.
Ellegard et al, 2019 (47) Denmark Patient education Quantitative RCT Delivered all four, 1-hour intervention sessions.
Feinberg, 1992 (60) USA Other inventions Quantitative CCT Assessed patient and fabricated hand splints.
Intervention only: initial consultation to develop
patient-practitioner relationship and a follow-up
phone call (approximately 2 weeks after splinting).
Furst et al, 1987 (48) USA Patient education (with a focus on Quantitative Pilot CCT Delivered standard care for control group and energy
energy conservation) conservation and joint protection education to the
intervention group.
Gerber et al, 1987 (49) USA Patient education (with a focus on Quantitative Pilot RCT Delivered standard care for control group and energy
energy conservation) conservation and joint protection education to the
intervention group.
Hammond, 1994 (43) UK Patient education (with a focus on Quantitative Single group, pretest, posttest Developed observational assessment to evaluate
joint protection) (cohort) study behavior change. Delivered intervention and
performed outcome testing.
Hammond and Lincoln, UK Behavior change (with a focus on Quantitative Single group, pretest, posttest Developed observational assessment to evaluate
1999 (44) joint protection) (cohort) study. Repeated behavior change. Delivered intervention and
measures design with a performed outcome testing.
6-week control phase
preintervention
Hammond and Freeman, UK Behavior change (with a focus on Quantitative RCT (1-year follow-up) Assisted in recruitment. Assisted in the delivery of a
2001 (33) joint protection) standard educational program as part of a
multidisciplinary team. Delivered the joint
protection intervention program.
Hammond and Freeman, UK Behavior change (with a focus on Quantitative RCT (4-year follow-up) See above.
2004 (34) joint protection)
Hammond, Young, and UK Patient education (involving Quantitative RCT Developed and delivered intervention.
Kidao, 2004 (35) comprehensive OT)
Hammond et al, UK Other interventions Quantitative RCT Developed and delivered intervention.
2021 (36)
Helewa et al, 1991 (24) Canada Comprehensive, community- Quantitative RCT Developed the primary outcome measure (as an
based (home) OT MDT) and delivered intervention.
Hewlett et al, 2019 (38) UK Behavior change Quantitative RCT Codelivered intervention with rheumatology nurses.
219
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Table 2. (Cont’d) 220
Author, year (ref.) Country Type of intervention Research type Study type Role of occupational therapist
Hewlett et al, 2019 (39)b UK Behavior change Mixed methods RCT with nested qualitative Codelivered intervention with rheumatology nurses.
(technical report) evaluation (interviews/focus
group)
Kashani, 2016 (63)b Canada Other interventions (virtual joint Mixed methods (PhD Pilot RCT informed by Interviewed participants and developed the
protection) thesis) interviews intervention.
Kraimaat et al, Netherlands Behavior change (involving Quantitative RCT Delivered one of two interventions (ie, standard OT,
1995 (25) cognitive behavioral therapy) not CBT).
Lahiri et al, 2021 (62) Singapore Other interventions Quantitative CCT Provide patient education on self-management,
(multidisciplinary including cognitive-behavioral approaches, and joint
patient education/behavior protection strategies to managing daily activities as
change) part of MDT intervention.
Macedo et al, 2009 (54) UK Comprehensive, community- Quantitative RCT Delivered pre- and postintervention assessments
based (home) OT and delivered intervention.
Masiero et al, 2007 (45) Italy Patient education Quantitative RCT Developed intervention as an MDT.
Mathieux et al, France Patient education Quantitative CCT Delivered intervention as an MDT.
2009 (26)
Mohanty, Padhan, and India Other interventions (hand Quantitative Two group, pretest, posttest Delivered pre- and postintervention assessments.
Singh, 2018 (64) exercises) (cohort) study
Neuberger et al, 1993 (27) USA Patient education Quantitative RCT (pilot study) Developed intervention as an MDT.
Neuberger et al, 1993 (27) USA Patient education Quantitative CCT (follow-up) Developed intervention as an MDT.
Niedermann et al, Switzerland Patient education (with a focus on Mixed methods Survey with follow-up Developed outcome measure and delivered
2010 (40) joint protection) qualitative interviews/ intervention (joint protection) as usual care. Also,
interpretive provided their perceptions on barriers and
phenomenological analysis benefits of delivering joint protection.
Niedermann et al, Switzerland Patient education (with a focus on Quantitative RCT Delivered both treatment programs.
2012 (46) joint protection)
Pimm, 2003 (53)b UK Behavior change Quantitative (PhD RCT Input into specific group sessions only; sessions led
thesis) by clinical psychologist and rheumatology nurse
specialist.
Pot-Vaucel et al, France Patient education Quantitative CCT Involved in intervention delivery (either individual
2016 (51) consultation or joint MDT workshop).
Prior et al, 2022 (37) UK Other interventions Qualitative Nested qualitative interviews/ Developed and delivered intervention.
grounded theory within an
RCT
RCOT, 2022 (61)b UK Other interventions Mixed methods N/A OT developed national guidelines.
(practice guideline)
Tonga, Düger, and Turkey Comprehensive, community- Quantitative CCT Planned and delivered treatment (intervention and
Karatas, 2016 (55) based (home) OT control).
Van Vilsteren et al, Netherlands Other interventions (workplace Quantitative RCT Delivered the integrated care treatment (within an
2017a (11) program) MDT) and the follow-up workplace intervention (OT
only).
Van Vilsteren et al, Netherlands Other interventions (workplace Quantitative RCT (1-year follow-up) See above.
2017b (28) program)
a
CBT, cognitive behavioral therapy; CCT, controlled clinical trial (does not mention randomization process); MDT, multidisciplinary team; N/A, not applicable; OT, occupational therapy;
RCOT, Royal College of Occupational Therapists; RCT, randomized controlled trial.
b
Gray literature.
GAVIN ET AL
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Table 3. Study characteristics for quantitative, qualitative, and mixed methods papers—participants, methods, and results from included articles
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Quantitative studies
Barry et al, 1994 (52) 55, 60%, mean 57.4 y; RA Single, 1-hour session with Patient knowledge, performance Pre, post 1 and 6 Patient knowledge increased
diagnosis, attending a individual attention. of joint protection for months from 2.83 (pre-OT) to 5.72
rheumatology clinic, not maneuvers. Photographic (1 month) and 5.48 (6 month)
previously received OT. questionnaire. post-OT (out of 12; P < 0.001).
Patient performance was not
influenced by age, sex, or disease
duration 1-month post-OT.
Callinan and Mathiowetz, 39, 92%, mean 51 y (range OT administered 28 days each Function, pain, grip strength, Post immediately (for No improvement in finger and
OT IMPACT ON RA SELF-MANAGEMENT
1996 (59) 19–76 y); RA diagnosis of soft splint, hard splint, splint use (ie, time worn, each condition) hand function. Pain decreased
(American Rheumatism and no splint (in random duration of morning stiffness, after soft and hard splints.
Association 1987 order). comfort, and preference). Fewer joints were painful when
criteria), hand pain, AIMS-2, self-reported (diagram- using the soft splints when
and/or morning stiffness. based), handgrip dyno, daily compared with no splint. The
diary. hard splint scored highest for
appearance and cleanliness,
but the splint for pain reduction
and compliance (82%). 57%
preferred the soft splint, 33%
the hard splint, and 10% no
splint.
Carter, 1979 (42)b 5; 100%, range 59–63 y; RA Two, 45-minute sessions over Knowledge, attitude, and Pre, post 1 weeks and 2 Knowledge increased by 27%
diagnosis ≤3 y, English 2 to 4 days apart. performance. MCQs, months postintervention (with 7% set
speaking, limited prior Presentations on joint statements on feelings of joint as requisite threshold for
joint protection protection principles and protection, rated correct or change). Attitude increased by
education. means of avoiding incorrect patient use of joint 8% (with 7% set as requisite
deforming forces. Group protection principle. for change). Performance
discussion and problem increased by 19% (with 25%
solving. set as requisite for change).
Ellegard et al, 2019 (47) 55, 100%, mean (SD) 63.7 Intervention = 28: Four, 1-hour ADL motor ability, ADL process Pre, post immediately No significant differences in
(13) y; aged older than 18 sessions over 8 weeks, with ability, (self-reported) ADL (after 8-week outcomes after 8 weeks
y, RA diagnosis hand exercises (four times ability, (self-reported) disability, intervention) between the groups. Both
(ACR/EULAR 2010 per week [one supervised, disease activity, grip strength, groups involved in ADL motor
criteria), stable three home-based; pain. AMPS (ADL motor ability; ability (intervention: mean
medication, reduced approximately 35 minutes]). ADL process ability), ADL- change = 0.24 logits; 95%
ability to perform ADLs. Control = 27: Four 1-hour questionnaire (ADL ability), CI = 0.09–0.39; control: mean
sessions over 8 weeks. HAQ-DI (self-reported change = 0.20 logits; 95%
Sessions involved 1) disability), DAS28 (disease CI = 0.05–0.35). Clinically
assessment and goal activity), handgrip dyno, VAS relevant improvements in ADL
setting, 2) joint protection (pain). motor ability for 46.4% (n =13)
principles, 3) joint protection of intervention group and in
and assistive device practice, 44.4% (n = 12) the control
and 4) social prescribing in group. Grip strength increased
the community. in the intervention group;
marker of inflammation (ESR)
increased in the control group.
221
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Table 3. (Cont’d) 222
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Hammond and Lincoln, 21, 81%, mean (SD) 48.9 Intervention = 21: Four, 2-hour Hand movement patterns Pre 6 and 1 weeks, post No improvement in JPBA scores
1999 (44) (6.4) y; RA diagnosis and arthritis education sessions (primary), joint protection 6 and 12 weeks (P = 0.65), hand pain (P = 0.7),
currently attending an (including 2-hour joint knowledge, hand pain, hand hand joint pain (P = 0.6), and
arthritis education projection education). joint paint, function, attitude, HAQ (P = 0.5). Joint protection
program at the site. Control: Control phase attitude toward joint protection. knowledge improved after the
included prior to the JPBA, questionnaire, 10-point intervention (P = 0.01), and
intervention. VAS, HAQ, quantitative most participants believed
interview. joint protection to be
beneficial. Reasons for not
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
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Table 3. (Cont’d) 224
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Hewlett et al, 2019 (38) 33, 79%, mean 62.8 y Intervention = 175: six, weekly Fatigue (primary; impact, severity, Pre, post immediately, BRAF-NRS impact at 26 weeks
(range 54.3–69 y); aged 2-hour sessions (weeks 1–6) coping), fatigue impact, pain, 6, 26, 52, 78 and decreased for both
≥18 y, RA diagnosis and and one 1-hour disability, sleep, disease activity, 104 weeks (with intervention (P < 0.001) and
recurrent fatigue (BRAF- consolidation session (week mood, quality of life, value fatigue at 10 and control groups (P < 0.004),
NRS score of ≥6 [out of 14). Treatment involved leisure activities, self-efficacy. 18 weeks) with greater reduction in the
10]) group CBT using reflective BRAF-NRS, BRAF-MDQ, VAS, intervention group up to
questioning and support for MHAQ, Pittsburgh Sleep Quality 2 years (P = 0.01). The
fatigue validation, pacing, Index, DAS28, self-reported intervention group had
goal setting, and problem HADS, AIMS, VLA (discretionary greater improvements in
OT IMPACT ON RA SELF-MANAGEMENT
solving. Participants self- activity subscale), RASE, AHI. fatigue impact (P = 0.03), living
monitor activity, rest, and with fatigue (P = 0.02), and
fatigue to support goal emotional fatigue (P = 0.01) at
setting. Control = 158: usual 26 weeks. Fatigue differences
care involving short were sustained over 2 years.
discussion with nurse. The intervention group had
greater self-efficacy at
26 weeks (P = 0.02) and coping
over 2 years (P = 0.02). Fatigue
severity and clinical outcomes
were similar between groups.
Kashani, 2016b (63) 50, 76%, Range 24–72 y; RA Intervention = 25: Negotiate Outcomes: Joint protection 30 days post-study 15 out of 25 reported using
diagnosis not previously interactive displays and knowledge. Outcome entry program (60%), 15 felt capable
received self- receive joint protection measures: AIMS2SF and PSEQ. of learning with the program, 5
management involving information for at least 1 had difficulty accessing
joint protection, internet, hour over 30-day period. program. Intervention group
and computer access. score doubled that of control
group (52.8%) for joint
protection knowledge.
Intervention group scored
favorably on some.
Kraimaat et al, 1995 (25) 77, 68%, mean 57 (12.7) y; Intervention 1 = 24: Ten, Outcomes: Pain, functional ability, Pre, post immediately CBT led to minor changes in pain
Minimum age of 20 y, a weekly 2-hour sessions of depression and anxiety, and 6 months coping behavior (P < 0.01;
duration of illness >1 y, cognitive behavioral therapy knowledge, disease activity. effect size, 0.5). CBT and OT
and RA class I, II, III. to groups of 6–10. Sessions Outcome measures: IRLG groups increased knowledge
1–4 involved information on (measure for pain, functional of RA after intervention (CBT,
RA management. ability, depression, and anxiety), P < 0.01) (OT, P < 0.01).
Subsequent sessions questionnaire, joint score, 30 m Duration of RA explained 12%
included: teaching walk time, blood samples, PCI. of variance in self-care
progressive relaxation, (P < 0.001), 6% variance in pain
rational thinking, goal (P < 0.05), 9% variance in
setting, and using coping anxiety (P < 0.01) and 12%
strategies (for pain, mobility, variance in depression
and self-care). (P < 0.001).
Intervention = 28: Ten,
weekly 2-hour sessions of
standard OT to groups of
6–10. Sessions 1–4 involved
225
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Table 3. (Cont’d) 226
Usual care.
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Masiero et al, 2007 (45) 91, 81%, mean 53.7 (11.6) y, Intervention = 46: Four, 3-hour Outcomes: Sociodemographics, Pre, post 8 months The intervention group had
aged 18–65 y, stable group meetings every knowledge of disease, quality of greater improvements in
medication 6 months 3 weeks. Sessions included the health care service, pain, disability and health status
prior, not severely four to six patients, plus one function, disability and health (P = 0.0001) (HAQ), physical
disabled. or more family member. status, frequency of home symptoms (P = 0.049), social
Group meetings included: exercises, usefulness of interaction (P = 0.045) (both
pathophysiology and education program for daily AIMS2), and pain (P = 0.001)
development of RA, joint living. Outcome measures: than the control group. The
protection in activities of Clinical consultation, RAI, Health intervention group
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
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Table 3. (Cont’d) 228
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
instructional OT program, protection practices (P < 0.01)
plus ROM and joint after self-instructional OT.
protection practices, and There was no difference
nurse-patient contracts for between intervention groups
behavior change. Four, for any outcome, including an
30–45-minute sessions for increase in adherence to
each intervention. Control home ROM exercises
1 = 11; No self-instruction, (P = 0.83).
no intervention.
OT IMPACT ON RA SELF-MANAGEMENT
Niedermann et al, 54, 85%, mean 57.8 (14.1) Intervention = 26: “PRISM” Outcomes: Joint protection Pre, post 6 and 12 Post 6 month: Greater
2012 (46) y; RA diagnosis (ACR class joint protection, involving a behavior (primary), hand months improvement in joint
II, III, or IV), hand pain pictorial tool, visualizing the function, pain, self-efficacy, protection behavior in the
justifying OT, German relationship between an QOL, drug treatment and PRISM-JP group than the
speaking. illness and other aspects of disease activity, and PRISM data conventional group (effect size
a patient’s life (eg, work, (ie, perceived burden of illness; 0.32, P = 0.02). 14 patients
hobbies, and friends/family), resource use) (secondary). (53%) increased joint
plus conventional joint Outcome measures: D-JPBA-S protection behavior scores by
protection (see below). (German version), handgrip more than 30% (ie, smallest
Control = 27: Conventional dyno, 10-point VAS, EUROHIS- detectable change) in the
joint protection, involving QUOL8, HADS (German PRISM group, whereas 5
information on RA, and joint version), DAS28, PRISM task patients (19%) in the
protection and assistive observation. conventional group increased
device practices. Four, by more than 30% (P = 0.008).
45-minute session; four over Joint protection self-efficacy
a 3-week period, and one significantly increased in both
refresher session 2 months groups. Post 12 month:
later. Greater joint protection
adherence in the PRISM group
compared with the
conventional group (effect size
0.28, P = 0.04). More PRISM
group participants increased
joint protection behavior by
more than 30% from baseline
(53%), compared with
conventional (19%) (P = 0.008).
The conventional group had
significantly better QOL at 12
months compared with the
PRISM group (P = 0.04).
Within-group, the PRISM
group improved joint
protection self-efficacy
(P = 0.02) and grip strength
(P = 0.04); the conventional
group improved in
depression, QOL and disease
229
activity.
(Continued)
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Table 3. (Cont’d) 230
(Continued)
GAVIN ET AL
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Tonga, Düger, and 40, 95%, aged 39–60 y; RA Intervention = 20: Ten, daily Outcomes: Pain, function, Pre, post immediately The intervention group had a
Karatas, 2016 (55) diagnosis (ACR criteria 45-minute physiotherapy disability and health status, (after 1 month significant decrease in pain
stage 2 or 3), aged 18–65 sessions, plus four or more occupational performance, and intervention) scores (>0.002), whereas the
y, stable medications 6 60–90-minute client- occupational satisfaction control group only improved
months prior. centered OT sessions. (relating to self-care), QOL. in sensory pain (P = 0.001). The
Control = 20: Ten, daily Outcome measures: Short-form intervention group and
45-minute physiotherapy MPI, Turkish version HAQ, control group both improved
sessions. For both groups, AIMS2, COPM (semistructured in global disability and health
physiotherapy involved pain interview), questionnaire. status scores (P = 0.0001 to
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
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Table 3. (Cont’d) 232
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
“I thought seriously about meals
on wheels for a while but then
the ugly horns come up, ‘Uh…
dependency.’”
However, others redefined the
definition of independence via
self-reflection.
“…instead of being an
independently fit person, I’m an
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
233
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Table 3. (Cont’d) 234
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
the daily environment and perspectives) underlying resting), using help from
activities. occupational change. others, and/or assistive
devices.
Pacing and resting conflicted
with some of the participants’
beliefs.
“…to finish what I start was
important.”
“…resting made me feel guilty.”
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
235
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Table 3. (Cont’d) 236
(Continued)
GAVIN ET AL
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
“I do things in moderation; I stop
for pain even if the activity is not
finished."
Participants divided large tasks
into smaller and more
manageable tasks, performed
over longer duration. When
strategies of pacing,
instrumental help, and social
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
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Table 3. (Cont’d) 238
(Continued)
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
participants attributed
improved psychological
wellbeing to the use of joint
protection, associating it with
“…feeling better and more positive
towards life” (two patients),
“having less pain” (two
patients), “less stress because of
easier task performance” (two
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
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Table 3. (Cont’d) 240
(Continued)
GAVIN ET AL
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Table 3. (Cont’d)
Participants: n, % female, Outcomes and outcome
Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
“I mostly wear it at night because…
my mornings are worse. So, if I
wear it at night this helps me in
the morning. You know, my
wrist, it won’t get stuck.”
Ambivalence about glove use:
Participants were mostly
ambivalent about the benefit
of wearing gloves for hand
OT IMPACT ON RA SELF-MANAGEMENT
(Continued)
241
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Table 3. (Cont’d) 242
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Table 4. Quality assessment—risk of bias for quantitative studiesa
Blinding of Blinding of Incomplete Incomplete outcome Selective
Random sequence Allocation participants outcome outcome data data (attrition outcome
generation concealment and personnel assessment (attrition bias bias long-term reporting? Overall risk
Author, year (ref.) (selection bias) (selection bias) (performance and bias) (detection bias) short-term 0–6 weeks) >6 weeks) (report bias) of bias
Barry et al, 1994 (52) N/A N/A N/A N/A + + + Mb
Callinan and Mathiowetz, ? − − − + N/A − H
1996 (59)
Carter, 1979c (42) − − − − + + + H
Ellegard et al, 2019 (47) + + − + + N/A + M
OT IMPACT ON RA SELF-MANAGEMENT
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244 GAVIN ET AL
Each qualitative study is scored out of 10, with scores >9 deemed high quality; scores between 7 and 9 deemed moderate quality; and scores <7 deemed low quality according to
reported that home-based OT (6 weeks, individual treatment)
7.5
4.5
9.5
6.5
8
9
improved function 12 weeks postintervention for established
RA. Assessor blinding was used, but not participant blinding
1
1
1
1
1
1
1
Donnelly et al (16). Individual item scores were assigned as 1, clear and/or detailed discussion; 0.5, unclear or little discussion; or 0, not discussed or inadequate quality.
home, clinics, and/or workplace), which improved function, cop-
ing, and work performance more than usual care. The CCT56
clear
10-day physiotherapy program, reporting improvements in pain,
1
1
0
1
1
1
1
disability, and occupational performance 1-month postinterven-
tion. However, there was no control, nor participant and assessor
0.5
0.5
0.5
1
1
1
1
1
Qualitative studies. Two interview studies involving
personalized home OT (weekly for 6–12 weeks) were reported
consideration?
across three papers exploring the changing beliefs, values, and
7. Have
knowledge in participants with early RA (n = 21; aged 38–67 years;
0.5
0.5
1
0
1
0
1
diagnosis ≤2 years).40,56,57 Two papers were of moderate
quality57,58 and one of low quality59 (Table 5).
Six core themes were identified relating to 1) illness, as a
considered?
relationship
adequately
driver for personal change, 2) independence, 3) activity and 4)
6. Has the
between
N/A
0.5
0.5
altruism, as values/traits the participants possessed before diag-
0
0
0
0
nosis (that were subsequently influenced by RA and home OT),
CASP, Critical Appraisal Skills Program; N/A not applicable; RCOT, Royal College of Occupational Therapists.
5) self-care, and 6) self-respect, as emerging from engaging in
home OT (Table 3).57,59 Patients with RA redefined their views of
recruitment 5. Were the data
the research
independence; however, functioning in activities remained similar,
issue?
0.5
0.5
albeit “within their means”: “Being active, being able to work…
1
1
1
1
1
Being able to use my brain…that’s all still there…I just have to
learn different roads to get to the same way…”57
of the aims of methodology address the aims to the aims of
the research? appropriate? of the research? the research?
appropriate
strategy
N/A
independence to being more accepting of help while continuing
0.5
1
1
1
1
1
1
to help others (Table 3).57 Device and splint provision were initially
observed as “a step down,” whereas postintervention, these aids
research design
1
1
1
1
feeling it.”57
Around 80% reported OT recommendations conflicted with
clear statement qualitative
0.5
0.5
1
1
1
1
1
1
0
0
0
1
1
1
(40)
group receiving Jobskin edema gloves (exerting 15–25 mmHg low RA work instability scores reported, which may have limited
pressure); both groups were provided with a hand self- the intervention’s effectiveness. Other workplace and employ-
management booklet including joint protection and hand ment studies were identified in screening; these were not exclu-
exercises. Isotoner compression gloves were no more effective sively involving RA participants (or group data identifiable for RA
than the loose-fitting placebo gloves, nor cost-effective.36 Nested among other rheumatologic conditions), including a component
interviews revealed participants liked both the compression and of self-management, and/or including OT as an intervention.
placebo gloves’ thermal qualities and comfort in light activities
but were ambivalent about use.37
DISCUSSION
One practice guideline (updated for36,37) advocated wrist
orthoses to reduce pain, based on review evidence alone.55 This review synthesized 39 papers to assess the effective-
Quantitative studies focusing on methods of splint provision60,61 ness of self-management interventions involving OT and under-
were limited to pre- and postimmediate time points, lacked stand the lived experiences of participants in self-management
allocation concealment, and lacked participant, personnel, and for RA. This involved searching databases from their inception to
assessor blinding. Callinan and Mathiowetz60 used a single-group 2022 to capture quantitative and qualitative evidence, as thera-
crossover study with random allocation to a soft, hard, or no splint peutic services have developed over time. Of the 39 included
for 28 days without a “washout” period. Occupational therapists papers, interventions were characterized as patient education,
fitted and instructed participants on splint use for the dominant behavior change, comprehensive community-based OT (i.e., tar-
hand, which did not affect function, but soft splints did result in geted at improving occupational performance), and other
fewer painful joints. Soft splints were preferred (by 57%) based interventions (including workplace and exercise programs). Good
on pain reduction and compliance when compared with hard evidence was found for patient education and behavior change
(33%) and no splint (10%). Although there was no structured programs on pain and function, particularly group sessions involv-
self-management program, each participant was briefed to be ing joint protection education. However, few qualitative insights
aware of the comfort and preference for the material quality of exist into patients’ lived experiences.
each splint type. Feinberg61 involved OT further by delivering an At first glance, the included papers in Table 2 omit key
initial consultation and a follow-up phone call to foster the articles within the search period, including the “Strengthening
patient-practitioner relationship and increase adherence. Splints and stretching for rheumatoid arthritis of the hand” (SARAH)64
were worn between rheumatology appointments (28–55 days). and “Job retention vocational rehabilitation for employed people
After which, adherence for daily use was 45% (OT consultation) with inflammatory arthritis” (WORK-IA)65 trials. Studies evaluating
and 20% (usual care); pain was unaffected, but the intervention OT interventions, without explicitly stating how they involved OT in
group had marginally less morning stiffness. self-management support for people with RA were excluded,
A multidisciplinary intervention41 used a 2-hour clinic com- which is consistent with the review’s purpose.
prising five 20-minute appointments (nurse, social worker, phys- We initially intended to adopt Thomas and Harden’s66
iotherapist, podiatrist, and hand OT [provided self-management, thematic synthesis in generating codes and themes from primary
cognitive-behavioral approaches, and joint protection]) to margin- qualitative studies to help explain quantitative findings across the
ally improve health-related quality of life, disease activity, and cop- different intervention types. However, given that our qualitative
ing, over usual care. Newly diagnosed or severe patients with RA evidence was limited to comprehensive, community-based OT
had a greater likelihood of improving health-related quality of care and other interventions (i.e., an arthritis gloves trial), we opted to
following multidisciplinary care. A 30-day virtual program focusing focus our synthesis solely on these intervention types to avoid
on joint protection techniques and coproduced with patients with decontextualizing findings beyond their settings.66 The improve-
RA62 did not benefit function but improved joint protection knowl- ments in function24,40 and coping40 shown following comprehen-
edge (by 52%) compared with the control. Adherence was poor sive, community OT, could be partly explained in the short-term at
(60%) with the program deemed “acceptable” by participants. least (up to 6 months) by the greater independence and self-
Mohanty et al63 found that an 8-week proprioceptive hand exer- care57,59 arising from personalized and occupational support.
cise program had a greater effect on health status and function The qualitative findings suggest a shift in perspectives for inde-
when compared with home hand exercises (both three times pendence in that the individual may be more capable of adapting
weekly). No details were reported on randomization or blinding, and coping, particularly in maintaining work performance/
and data were selectively reported. One 12-week “Care for Work” remaining in work.40 As a meaningful occupation, this could, in
program11,28 involved integrated care and a participatory work- turn, bring a sense of empowerment and help preserve indepen-
place intervention (including consultations, individualized plans, dence as the disease progresses.
and evaluations) and had little impact on work instability or pro- Previous reviews on the effectiveness of OT for RA identified
ductivity for up to 12 months. However, the authors concluded interventions across therapeutic exercise,13,67 comprehensive
that participants were potentially recruited too early, given the OT, motor skills training,10 splint provision,10,13,67 and
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246 GAVIN ET AL
educational-behavioral approaches (typically patient education, change did not translate to changed behavior 3 years postinter-
self-management, CBT, assistive devices, and joint protec- vention; although, those with lower functional ability were more
tion10,13,67). These interventions differ from this review’s focus, susceptible to change. Perhaps, as shown by our qualitative evi-
which examined self-management interventions, incorporating dence, this could partly be explained by a greater relative func-
OT as either a stand-alone intervention or component of multidis- tional improvement, not “within their [functional] means,” but
ciplinary care. Our main finding concurs with previous reviews, in beyond. Increasing patient knowledge in early diagnosis,
that good evidence supports patient education and behavior although promoting active involvement in self-management, may
change for improving pain and function (particularly via joint pro- be important for mental health and coping, particularly for flare-
tection education for enhancing self-management). We advance ups and physical deterioration over the long term. It should be
previous work by 1) reviewing evidence beyond Level 1 studies noted, however, that the lack of evidence for changed behavior
in peer-reviewed publications, 2) including quantitative and quali- may reflect the challenges associated with the implementation of
tative evidence, and 3) focusing solely on RA (excluding mixed complex behavioral trials, and not necessarily because of a lack
diagnoses [e.g., osteoarthritis/lupus] but including undifferenti- of OT impact.
ated inflammatory arthritis), and OT interventions for supporting Evidence of self-management interventions on patient expe-
patient self-management. Studies varied across intervention rience and health inequalities is lacking. However, group sessions
types in sample size, sessions (number and duration), outcome were impactful in providing patients and partners with greater
measures, and follow-up periods (0–48 months) (Table 3), making insights into their situations and sharing self-help strategies. Qual-
comparisons difficult. Papers were consistent, however, in rarely itative insights from individual, home-based OT show that beliefs,
reporting participants’ economic, educational, and ethnicity values, and knowledge change in early diagnosis,57–59 making
demographics. group-based sessions appealing for promoting acceptance with
Our review suggests that OT interventions (including patient peer support and in developing strategies for long-term self-
education and behavior change) may not impact pain, function, management. Only one study, using group cognitive-behavioral
and fatigue outcomes for those with early RA (<2 years) based approaches to complement usual care, was associated with
on limited longitudinal, long-term evidence, and condition-specific reduced fatigue for up to 2 years.38 Tutors highlighted that the
management strategies.34,35 This may partly be attributable to course’s success was contingent upon buy-in from managers
pathologic and psychological changes, as the individual must and colleagues, models of training and support, and observing
adapt as functional symptoms manifest. Medications are used in patient progression.39 Rheumatology care has been significantly
early RA to suppress inflammation and, in turn, avoid or delay disrupted by COVID-1918,69 but has seen telehealth adopted
the progression of joint damage and control pain.5 Although OT widely, potentially offering greater access to group interventions.
can support the management of acute functional limitations in Telehealth also offers promise, in terms of overcoming the lack
early RA through behavior change,33 it cannot limit physical joint of access to OT in rheumatology practice, which is currently a
deterioration. As RA progresses, the need for patients to develop worldwide problem.69,70
strategies for managing daily occupations grows,57,59 increasing This is the first mixed methods review of the evidence on the
the potential for OT to support patient self-management lifestyle impact of OT in the self-management of RA providing a holistic
adaptations. In turn, this can increase function24,40 and reduce overview of outcomes and patient experience. There were limita-
pain.45 This is where qualitative studies could be focused—to tions in our review. Firstly, it was beyond the scope of this review
provide better understanding as to how behavioral changes fol- to identify the most effective components of OT intervention for
lowing OT intervention can lead to functional and “physical” RA self-management. Intervention components (e.g., practitioner
improvements. It is, therefore, surprising that only six studies roles or educational-behavioral strategies) and characteristics (eg,
measured self-efficacy (all relating to patient education and/or home/clinic or individual/group) most related to effectiveness are
behavior change interventions), and none studied readiness to crucial in translating research evidence into clinical programs.
change. Although readiness for change is more likely in those with Secondly, qualitative evidence was derived from only four eligible
established RA, early OT involvement may lead to greater long- studies of low-to-moderate quality, and therefore inconclusive.
term engagement for self-management.68 Our review has generated three key recommendations.
Although the results indicated that patient education and Firstly, to improve the OT evidence base and inform
behavior change interventions support RA self-management out- decision-making on implementing self-management involving
comes, only five trials assessed outcomes greater than or equal OT, consensus in the research community is needed on core out-
to 12 months.28,33–35,38,46 Scant evidence exists to support that come measures and participant demographic characteristics.
behavior change following OT intervention can lead to improved Secondly, opportunities should be sought to implement digital
long-term physical outcomes. Increased knowledge and adher- technologies to support “early OT” in RA diagnosis and manage-
ence after OT intervention does not correspond to behavior ment. This can help patients understand their condition holisti-
change. Hammond and Freeman34 observed that self-perceived cally. Peer support can be used to facilitate this by promoting
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OT IMPACT ON RA SELF-MANAGEMENT 247
active involvement in self-management. Finally, to develop the OT 5. Emery P. Evidence supporting the benefit of early intervention in
evidence base for RA self-management, research should reflect rheumatoid arthritis. J Rheumatol Suppl 2002;66:3–8.
6. Lorig KR, Holman H. Self-management education: history, definition,
real-life, multidisciplinary care. Research should assess the long-
outcomes, and mechanisms. Ann Behav Med 2003;26:1–7.
term effectiveness of OT intervention for improving RA self-man-
7. Barlow J, Wright C, Sheasby J, et al. Self-management approaches
agement and it’s impact on health outcomes and patient experi- for people with chronic conditions: a review. Patient Educ Couns
ence. As advocated in the 2022 ACR Guideline for Exercise, 2002;48:177–187.
Rehabilitation, Diet, and Additional Integrative Interventions for 8. Ndosi M, Ferguson R, Backhouse MR, et al. National variation in the
Rheumatoid Arthritis,69 we must work to raise awareness of OT composition of rheumatology multidisciplinary teams: a cross-
sectional study. Rheumatol Int 2017;37:1453–1459.
to support the long-term care of RA. OT has clear beneficial
9. Hammond A. The use of self-management strategies by people with
impacts on RA self-management, yet we must continue to rheumatoid arthritis. Clin Rehabil 1998;12:81–87.
generate robust evidence to educate the medical community 10. Steultjens EMJ, Dekker J, Bouter LM, et al. Occupational therapy for
and inform people living with RA. rheumatoid arthritis. Cochrane Database Syst Rev 2004;2004:
This review has highlighted what is known from the published CD003114.
literature on the impact of OT to support self-management of RA 11. Van Vilsteren M, Boot CR, Twisk JW, et al. Effectiveness of an inte-
grated care intervention on supervisor support and work functioning
in terms of function, fatigue, pain, and lived experience. Patient of workers with rheumatoid arthritis. Disabil Rehabil 2017;39:
education offers improvements in pain and function (≤24 months) 354–362.
in adults with RA. However, there is insufficient evidence to 12. Benka J, Nagyova I, Rosenberger J, et al. Social participation in early
demonstrate that improvements persist for the long term. No and established rheumatoid arthritis patients. Disabil Rehabil 2016;
38:1172–1179.
strong evidence was found to support OT programs for improving
13. Siegel P, Tencza M, Apodaca B, et al. Effectiveness of occupational
fatigue management or patient experience. Qualitative insights therapy interventions for adults with rheumatoid arthritis: a systematic
were limited to home OT (focusing on illness and independence) review. Am J Occup Ther 2017;71:7101180050p1-p11.
and arthritis gloves for hand pain and function. 14. Hammond A, Bryan J, Hardy A. Effects of a modular behavioural
arthritis education programme: a pragmatic parallel-group random-
ized controlled trial. Rheumatology (Oxford) 2008;47:1712–1718.
ACKNOWLEDGMENTS 15. Carandang K, Pyatak EA, Vigen CL. Systematic review of educational
interventions for rheumatoid arthritis. Am J Occup Ther 2016;70:
We would like to thank the project advisory group, comprising 7006290020p1-p12.
people with lived experience of RA, academics, and a rheumatologist.
16. Donnelly S, Manning M, Mannan H, et al. Renegotiating dimensions of
Our search strategy also benefited from peer review from those living
the self: a systematic review and qualitative evidence synthesis of the
with RA, those who volunteered for a public and patient involvement
lived experience of self-managing rheumatoid arthritis. Health Expect
workshop to inform the strategy.
2020;23:1388–1411.
17. Toye F, Seers K, Barker KL. Living life precariously with rheumatoid
arthritis - a mega-ethnography of nine qualitative evidence syntheses.
AUTHOR CONTRIBUTIONS BMC Rheumatol 2019;3:5.
All authors were involved in drafting the article or revising it critically 18. Leese J, Backman CL, Ma JK, et al. Experiences of self-care during
for important intellectual content, and all authors approved the final ver- the COVID-19 pandemic among individuals with rheumatoid arthritis:
sion to be published. Dr Gavin has full access to all of the data in the a qualitative study. Health Expect 2022;25:482–498.
study and takes responsibility for the integrity of the data and the accu- 19. Berkovic D, Ackerman IN, Briggs AM, et al. Tweets by people with
racy of the data analysis. arthritis during the COVID-19 pandemic: content and sentiment anal-
Study conception and design. Gavin, Fenerty, Leese, Adams, ysis. J Med Internet Res 2020;22:e24550.
Hammond, Davidson, Backman.
Acquisition of data. Gavin, Rossiter, Fenerty, Leese. 20. Gavin JP, Rossiter L, Fenerty V, et al. The role of occupational therapy
for the self-management of rheumatoid arthritis: a protocol for a mixed
Analysis and interpretation of data. Gavin, Rossiter, Fenerty, Leese,
methods systematic review. Musculoskeletal Care 2023;21:56–62.
Adams, Hammond, Backman.
21. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 state-
ment: an updated guideline for reporting systematic reviews. BMJ
2021;372:n71.
REFERENCES
22. Gavin JP, Rossiter L, Fenerty V, et al. Public and professional involve-
1. Cieza A, Causey K, Kamenov K, et al. Global estimates of the need for ment in a systematic review investigating the impact of occupational
rehabilitation based on the Global Burden of Disease Study 2019: a therapy on the self-management of rheumatoid arthritis. Brit J Occup
systematic analysis for the Global Burden of Disease Study 2019. Therapy 2023. doi: https://doi.org/10.1177/03080226231219106
Lancet 2021;396:2006–2017. 23. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan-a web and
2. World Health Organisation. Musculoskeletal health 2022. Accessed mobile app for systematic reviews. Syst Rev 2016;5:210.
March 10, 2022. https://www.who.int/news-room/fact-sheets/detail/ 24. Helewa A, Goldsmith CH, Lee P, et al. Effects of occupational therapy
musculoskeletal-conditions home service on patients with rheumatoid arthritis. Lancet 1991;337:
3. McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N 1453–1456.
Engl J Med 2011;365:2205–2219. 25. Kraaimaat FW, Brons MR, Geenen R, et al. The effect of cognitive
4. Cooles FA, Isaacs JD. Pathophysiology of rheumatoid arthritis. Curr behavior therapy in patients with rheumatoid arthritis. Behav Res Ther
Opin Rheumatol 2011;23:233–240. 1995;33:487–495.
25785745, 2024, 4, Downloaded from https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr2.11650 by Nat Prov Indonesia, Wiley Online Library on [04/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
248 GAVIN ET AL
26. Mathieux R, Marotte H, Battistini L, et al. Early occupational therapy 44. Hammond A. Joint protection behavior in patients with rheumatoid
programme increases hand grip strength at 3 months: results from a arthritis following an education program: a pilot study. Arthritis Care
randomised, blind, controlled study in early rheumatoid arthritis. Ann Res 1994;7:5–9.
Rheum Dis 2009;68:400–403. 45. Masiero S, Boniolo A, Wassermann L, et al. Effects of an educational-
27. Neuberger GB, Smith KV, Black SO, et al. Promoting self-care in behavioral joint protection program on people with moderate to
clients with arthritis. Arthritis Care Res 1993;6:141–148. severe rheumatoid arthritis: a randomized controlled trial. Clin Rheu-
28. Van Vilsteren M, Boot CR, Twisk JW, et al. One year effects of a work- matol 2007;26:2043–2050.
place integrated care intervention for workers with rheumatoid arthri- 46. Niedermann K, Buchi S, Ciurea A, et al. Six and 12 months’ effects of
tis: results of a randomized controlled trial. J Occup Rehabil 2017; individual joint protection education in people with rheumatoid arthri-
27:128–136. tis: a randomized controlled trial. Scand J Occup Ther 2012;19:
29. Ryan R, Synnot A, Prictor M, et al. Data extraction template for 360–369.
included studies. La Trobe University: La Trobe University; 2018 47. Ellegaard K, von Bülow C, Røpke A, et al. Hand exercise for women
Accessed February 20, 2022. https://opal.latrobe.edu.au/articles/ with rheumatoid arthritis and decreased hand function: an exploratory
journal_contribution/Data_extraction_template/6818852/1 randomized controlled trial. Arthritis Res Ther 2019;21:158.
30. Critical Skills Apprasial Programme (CASP). CASP Qualitative Studies 48. Furst GP, Gerber LH, Smith CC, et al. A program for improving energy
Checklist 2022. Accessed February 2, 2022. https://casp-uk.net/ conservation behaviors in adults with rheumatoid arthritis.
casp-tools-checklists/ Am J Occup Ther 1987;41:102–111.
31. Rizzo RRN, Ferraro MC, Wewege MA, et al. Targeting neurotrophic 49. Gerber L, Furst G, Shulman B, et al. Patient education program to
factors for low back pain and sciatica: a systematic review and teach energy conservation behaviors to patients with rheumatoid
meta-analysis. Rheumatology (Oxford) 2022;61:2243–2254. arthritis: a pilot study. Arch Phys Med Rehabil 1987;68:442–445.
32. Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to 50. Green LW. Health education planning: a diagnostic approach. 1st ed.
qualitative evidence synthesis findings: introduction to the series. Palo Alto, Calif: Mayfield Pub. Co; 1980: xvi, 1-306.
Implement Sci 2018;13:2. 51. Pot-Vaucel M, Aubert MP, Guillot P, et al. Randomised study versus
33. Hammond A, Freeman K. One-year outcomes of a randomized con- control group of customised therapeutic education for patients in
trolled trial of an educational-behavioural joint protection programme follow-up for rheumatoid arthritis. Joint Bone Spine 2016;83:
for people with rheumatoid arthritis. Rheumatology (Oxford) 2001; 199–206.
40:1044–1051. 52. Barry MA, Purser J, Hazleman R, et al. Effect of energy conservation
34. Hammond A, Freeman K. The long-term outcomes from a random- and joint protection education in rheumatoid arthritis. Br J Rheumatol
ized controlled trial of an educational-behavioural joint protection pro- 1994;33:1171–1174.
gramme for people with rheumatoid arthritis. Clin Rehabil 2004;18: 53. Hammond A, Lincoln N. Development of the joint protection behavior
520–528. assessment. Arthritis Care Res 1999;12:200–207.
35. Hammond A, Young A, Kidao R. A randomised controlled trial of 54. Pimm TJ. Investigating the efficacy of a self-management intervention
occupational therapy for people with early rheumatoid arthritis. Ann for people with chronic rheumatoid arthritis: using an illness represen-
Rheum Dis 2004;63:23–30. tations approach to understand change processes and outcome.
36. Hammond A, Prior Y, Cotterill S, et al. Clinical and cost effectiveness PhD thesis. University of London: King’s College London; 2003.
of arthritis gloves in rheumatoid arthritis (A-GLOVES): randomised 55. Royal College of Occupational Therapists (RCOT). Hand and wrist
controlled trial with economic analysis. BMC Musculoskelet Disord orthoses for people with rheumatological conditions: practice guideline
2021;22:47. for occupational therapists. 2nd ed. London: RCOT. 2022. Accessed
37. Prior Y, Bartley C, Adams J, et al. Does wearing arthritis gloves help March 23, 2022. Available at: https://www.rcot.co.uk/orthoses-
with hand pain and function? A qualitative study into patients’ views guideline
and experiences. Rheumatol Adv Pract 2022;6:rkac007. 56. Tonga E, Duger T, Karatas M. Effectiveness of client-centered occu-
38. Hewlett S, Almeida C, Ambler N, et al. Reducing arthritis fatigue pational therapy in patients with rheumatoid arthritis: exploratory ran-
impact: two-year randomised controlled trial of cognitive behavioural domized controlled trial. Arch Rheumatol 2016;31:6–13.
approaches by rheumatology teams (RAFT). Ann Rheum Dis 2019; 57. Dubouloz CJ, Laporte D, Hall M, et al. Transformation of meaning per-
78:465–472. spectives in clients with rheumatoid arthritis. Am J Occup Ther 2004;
39. Hewlett S, Almeida C, Ambler N, et al. Group cognitive–behavioural 58:398–407.
programme to reduce the impact of rheumatoid arthritis fatigue: the 58. Dubouloz C-J, Vallerand J, Laporte D, et al. Occupational perfor-
RAFT RCT with economic and qualitative evaluations. Health Tech mance modification and personal change among clients receiving
Assess 2019;23:1–130. rehabilitation services for rheumatoid arthritis. Aust Occup Ther J
40. Macedo AM, Oakley SP, Panayi GS, et al. Functional and work 2008;55:30–38.
outcomes improve in patients with rheumatoid arthritis who receive 59. Dubouloz C-J. Transformative learning process: enabling personal
targeted, comprehensive occupational therapy. Arthritis Rheum change during occupational therapy. Israeli J Occup Ther 2008;
2009;61:1522–1530. E23–E41.
41. Lahiri M, Cheung PPM, Dhanasekaran P, et al. Evaluation of a multi- 60. Callinan NJ, Mathiowetz V. Soft versus hard resting hand splints in
disciplinary care model to improve quality of life in rheumatoid arthritis: rheumatoid arthritis: pain relief, preference, and compliance.
a randomised controlled trial. Qual Life Res 2022;31:1749–1759. Am J Occup Ther 1996;50:347–353.
42. Niedermann K, Hammond A, Forster A, et al. Perceived benefits and 61. Feinberg J. Effect of the arthritis health professional on compliance
barriers to joint protection among people with rheumatoid arthritis with use of resting hand splints by patients with rheumatoid arthritis.
and occupational therapists. A mixed methods study. Musculoskele- Arthritis Care Res 1992;5:17–23.
tal Care 2010;8:143–156. 62. Kashani RM. Using a virtual world to teach joint protection to people
43. Bowell C, Ashmore A. The initiation and evaluation of a Rheumatoid living with rheumatoid arthritis: a pilot randomised controlled trial.
Arthritis Self-Help Group (RASH). Br J Occup Ther 1992;55:21–24. PhD thesis. University of Plymouth; 2016.
25785745, 2024, 4, Downloaded from https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr2.11650 by Nat Prov Indonesia, Wiley Online Library on [04/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
OT IMPACT ON RA SELF-MANAGEMENT 249
63. Mohanty B, Padhan P, Singh P. Comparing the effect of propriocep- 67. Ekelman BA, Hooker L, Davis A, et al. Occupational therapy interven-
tive retraining technique against home exercise programme on hand tions for adults with rheumatoid arthritis: an appraisal of the evidence.
functions in patients with rheumatoid arthritis. Indian J Physiother Occup Ther Health Care 2014;28:347–361.
Occup Ther 2018;12:48–53. 68. Keefe FJ, Lefebvre JC, Kerns RD, et al. Understanding the adoption of
64. Lamb SE, Williamson EM, Heine PJ, et al. Exercises to improve func- arthritis self-management: stages of change profiles among arthritis
tion of the rheumatoid hand (SARAH): a randomised controlled trial. patients. Pain 2000;87:303–313.
Lancet 2015;385:421–429. 69. George MD, Danila MI, Watrous D, et al. Disruptions in rheumatology
65. Hammond A, O’Brien R, Woodbridge S, et al. Job retention voca- care and the rise of telehealth in response to the COVID-19 pandemic
tional rehabilitation for employed people with inflammatory arthritis in a community practice-based network. Arthritis Care Res (Hoboken)
(WORK-IA): a feasibility randomized controlled trial. BMC Musculos- 2021;73:1153–1161.
kelet Disord 2017;18:315. 70. England BR, Smith BJ, Baker NA, et al. 2022 American College of
66. Thomas J, Harden A. Methods for the thematic synthesis of qualita- Rheumatology Guideline for exercise, rehabilitation, diet, and addi-
tive research in systematic reviews. BMC Med Res Methodol 2008; tional integrative interventions for rheumatoid arthritis. Arthritis Care
8:45. Res (Hoboken) 2023;75:1603–1615.