Occupational Therapy Can Benefit Rheumatology Patients

Imagine you have a rheumatoid arthritis (RA) patient who’s struggling with her regular activities. It takes her seemingly forever to get ready in the morning because of her painful, swollen joints. She finds it hard to cook because she can’t grip pots, pans or milk gallons like she did before. She doesn’t want to socialize much, because she feels flustered managing her difficult daily routine.

For patients like this and others who face challenges due to their rheumatologic condition, occupational therapy (OT) may be just the help they need.

“Occupational therapists are key players in arthritis management,” says Theodore Fields, MD, director, Rheumatology Faculty Practice Plan, Hospital for Special Surgery, New York. Dr. Fields commonly refers patients with hand, wrist and elbow problems to OT. He finds that patients better manage their condition and activities of daily living with help from occupational therapists.

Occupational therapists can be part of a team of allied health professionals working with rheumatology patients, depending on the patient’s particular challenges, motivation and insurance. In addition to occupational therapists, other parts of the allied health mix can include physical therapists, chiropractors, massage therapists and acupuncturists, says rheumatologist Elyse Rubenstein, MD, Providence Saint John’s Health Center, Santa Monica, Calif.

Although occupational therapists may step in most often to treat patients with arthritic conditions, they treat other rheumatologic conditions as well, including scleroderma, psoriatic arthritis and ankylosing spondylitis, says occupational therapist Jane W. McCabe, MS, OTR/L, CAPS, Laguna Hills, Calif. Occupational therapy also may be part of postoperative care for certain kinds of joint-related surgery.

What Happens in OT

Just what is it that occupational therapists do with patients who have rheumatologic conditions?

First, there’s a little bit of education that takes place. “Someone recently said to me, ‘I don’t work anymore, why do I need you?’ I had to chuckle,” says occupational therapist Elsa Perniciaro, OT, Los Robles Hospital, Thousand Oaks, Calif.

Another misconception some patients have is that occupational therapists will help get their joints working like they did previously. “We’re not going to do that,” says Perniciaro.

What therapists actually do is educate patients on how to reduce joint strain—frequently referred to as joint protection, says Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, New York. “Additionally, occupational therapists can help the patient analyze their daily activities, rethink the way they do things, position their bodies and achieve the right balance between rest and activity,” he says. “Therapists can also provide splints, either custom or ready made, to support affected joints.”

“They are especially helpful with patients who have issues that include reduced range of motion in the hands and in patients who are unable to do activities of daily living,” Dr. Rubenstein says.

Because visits might be limited by what insurance will cover or how often patients can come for appointments, Perniciaro likes to ask patients about the two or three activities that are most important to them, and she will focus on those. “If it’s not meaningful to the patient, then they won’t do it,” she says.

Occupational therapists will consider patient goals along with treatment orders from rheumatologists, which are sometimes as vague as “evaluate and treat,” says occupational therapist Lenore Frost, PhD, OTR/L, CHT, clinical associate professor, Department of Occupational Therapy and Health Sciences, Sacred Heart University, Fairfield, Conn. Other times, the orders are more focused, with requests for specific splints or patient education.

Here’s some of what goes on during OT sessions for patients with rheumatologic conditions. The therapist will:

• Review activities of daily living that are difficult for the patient and suggest ways to make those tasks easier (see below). “If the hands and upper extremities are largely affected, fine motor ability, such as picking up small objects, giving change to a cashier, putting on earrings, buttoning, pulling the tab on a baby diaper or turning a car key can be more difficult,” says Frost. Gross activities that may be difficult could include drinking from a coffee mug with one hand, washing one’s hair, bathing a child or participating in such activities as golf or tennis.
  The therapist provides concrete solutions to approach activities in a different but easier way, says ARHP member Carole Dodge, OT, CHT, allied health supervisor/clinical specialist, physical medicine and rehabilitation, Occupational Therapy Division, University of Michigan Hospital and Health Systems, Ann Arbor, Mich. Although patients may need some time to get accustomed to those new approaches, “by the third or fourth time, it’s habitual,” she says.
• Use heat to help loosen joints. Rheumatologist Arlene Tieng, MD, Bronx-Lebanon Hospital, and instructor, Department of Medicine, Albert Einstein College of Medicine, New York, had an occupational therapist tell her that she likens the heated paraffin wax treatments some patients receive to that used at nail salons—a description that many patients immediately understand. That description helped Tieng better describe at least one type of therapy patients might get in OT.
  Fluidotherapy, which involves dry heat provided by cellulose particles in a special machine, can provide relief to the hands and forearms in certain patients, says occupational therapist John Indalecio, OT, Hand Therapy Center, Hospital for Special Surgery, New York.
  Design splints to help patients reduce their joint swelling, pain and use.
• Discuss ways to conserve energy throughout the day or even long time periods. By carefully planning daily, weekly or even monthly activities, patients can help reduce joint stress and not overextend their energy on a particular task, says Indalecio. “When patients are overfatigued, a rush of symptoms can occur,” he says.
• Educate the patient on how to use walkers and canes, something the patient may be resistant to do.

An analysis of six reviews published on the efficacy of RA-related interventions used by occupational therapists found sufficient evidence to support the profession’s therapeutic exercise, patient education on joint protection and splinting for pain, inflammation and joint strength, according to a study published this year in Occupational Therapy in Health Care.¹

To some extent, occupational therapists are seeing fewer patients from rheumatology because of the effectiveness of biologics, Indalecio says.

However, OT is still relied on for patients who are just starting biologics or those who are looking for an alternative to medication, Tieng says.

It can be difficult to treat patients who are not motivated to participate in their own care, McCabe says. “Some people with chronic pain have concomitant depression that makes it harder for them to see a light at the end of the tunnel,” she says.

Therapists often have to temper patient expectations of what they will be able to do once OT ends, keeping in mind the limitations that come with their condition, says Indalecio.

A therapist giving muscle training for the elbow joint.

Tips for Better Collaboration, Communication

In today’s hectic medical environment, rheumatologists and occupational therapists may not have much time, if any, to compare notes—but that doesn’t mean they shouldn’t make the effort. Here are some ways that therapists say rheumatologists could work more collaboratively with them and maximize patient care.

1. Pick up the phone. Or at least, send a quick note to check in on a patient’s progress or comment on how OT has helped. “It’s nice to have a doctor who is approachable in terms of taking phone calls to discuss a patient or at least is responsive to questions left by messages,” McCabe says. “Everyone is busy, but we all benefit from some human interaction and collaboration.”
   “Occupational therapists can share vital information with the rheumatologist about patients’ understanding of their condition, adherence and response to treatment,” says Efthimiou.
2. Be as specific as possible in your order for therapy. If you have a specific goal in mind, write it down so the therapist knows. By providing as much information as you can, the occupational therapist can better perform his or her job.
3. Encourage patients. “Sometimes, doctors tell patients there’s nothing that can be done to help them, and that’s untrue and sends the wrong message,” Dodge says. Occupational therapists want patients to use their medications as needed but also explore joint protection for better outcomes overall.
4. Consider referring patients to hand surgeons when appropriate. Although it may be natural to feel territorial, Indalecio finds that a consult with a hand surgeon in addition to rheumatologic care can benefit a number of patients with hand issues.
5. Take advantage of professional development related to OT. The ACR/ARHP Annual Meeting includes sessions geared toward OT, but that are also relevant and educational for rheumatologists, says Dodge. These sessions are held in the same place as ACR sessions, so they are easy to attend, says Dodge, who has been involved with session planning.

Rheumatologists have some words of wisdom for occupational therapists as well. They also want to see better communication across the professional fence. “You can’t have too much communication,” Dr. Fields says. “Therapists should be encouraged to call with a new idea or thoughts on how often the patient should be seen.”

Communication about specific splints used can be helpful so the rheumatologist can better understand how that splint helps the patient, Tieng says. the rheumatologist

Vanessa Caceres is a medical writer in Bradenton, Fla.

Reference

1. Ekelman BA, Hooker L, Davis A, et al. Occupational therapy interventions for adults with rheumatoid arthritis: An appraisal of the evidence. Occup Ther Health Care. 2014 May 27 [epub ahead of print].