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Rheumatoid arthritis is a progressive systemic disease that affects 1.3 million Americans. Disease onset is usually between ages 20 and 40, and affects three times as many women as men. Upper extremity joint pain, instability, and tendon rupture are common problems for patients with RA. If untreated, joint deformity can result.

Treatments include drug therapy with DMARDs (disease modifying antirheumatic drugs) to reduce inflammation and occupational therapy to provide joint protection strategies such as splinting, ADL exercises, and assistive devices.

A recent review suggests that the earlier OT intervention is initiated, the more effective it will be in preventing deformities. Joanna M. Akladiss, MS, OTR/L, CHT, an occupational therapist at Massachusetts General Hospital, Hand and Upper Extremity Service in Boston, agrees.

“It’s a progressive disease; the earlier we see [patients with RA] the earlier we can educate them about their symptoms and disease process,” she says.

Splinting

Splinting can be an effective way to provide joint stability and manage pain at rest or while performing a task. Although splinting has not been shown to improve overall function, grip strength, or dexterity at early stages of RA, splints can correct deformities or prevent worsening of deformity.

The choice of custom or prefabricated splints depends on the patient. A recent study found that soft cloth splints are well-tolerated, but newer thermodynamic plastic splints are lightweight and enable the therapist to customize the splint, molding it to custom fit a patient’s joints.

Jo Koludrovich, OTR/L, CHT, hand therapy clinical specialist at the Cleveland Clinic, agrees that the choice of splints really depends on the patient’s unique presentation, as well as their preferences: “All patients are different in their presentation as well as their tolerance for splinting and potential compliance.”

For multiple deformities, the most common splint made is a custom resting hand splint that aligns joints in an optimal position while it is worn at night. Akladiss adds that splint choice depends on “joint mobility, laxity, pain, [and] skin integrity.”

For finger deformities, Koludrovich has had success with ring splints: “I think [they] are excellent long-term splinting options for passively correctable finger deformities; this means before a fixed deformity occurs. This style of splint is preferred mostly by ladies as well, as it is worn daily like a piece of jewelry.”

Assistive Devices

The use of assistive devices and adaptive equipment can improve the quality of life for patients with RA. A recent study showed the use of such items can reduce disability scores, compared to the more common practice of accommodations.

Assistive devices for the home include “built-up handles, reachers for loss of shoulder or hand mobility … electric can openers, toothbrushes, and eating utensils,” Akladiss says.

Besides home assistive devices, many patients with RA need worksite accommodation for upper extremity functional limitations such as finger dexterity or wrist problems. A new study found that 35% of patients with RA report work disabilities in the first 10 years of disease onset.

“Different keyboards and voice-activated software for people who have stiff fingers and [are] slow on their keyboarding … make the job more doable,” says Timothy Gilmore, MD, PE, occupational medicine specialist at Group Health Cooperative in Seattle. Gilmore communicates weekly with OTs through team meetings and chart notes, and relies on OTs to be patient liaisons.

“Patients talk to the OT about their day-to-day activities that they don’t share with physicians. Patients are not always the best communicators about their condition … and the OT has intimate knowledge of the patient’s joints.”

Koludrovich agrees that it is important for OTs to let physicians know about their patients’ conditions: “OT plays a huge role with RA whether [with] kids or adults, as [OTs] can take the time to check for all the deformity patterns and instruct the patient in joint protection principles. An OT can identify areas of joint laxity and deformity patterns that a patient would be unable to identify. No two patients are alike, just as the intensity of their RA remains unpredictable.”

ADL Exercises

“Range of motion exercises are given to patients with careful attention given to avoidance of patterns of deformity as well as avoiding hypermobility; patients with RA are already prone to hypermobility, and this makes them more vulnerable to deforming forces on their joints,” Koludrovich notes. “Water exercise is frequently recommended from most professionals for patients with RA since it avoids excessive weight bearing on joints.”

A new study suggests that cardiovascular exercises are particularly important for patients with RA, who often develop heart problems due to side effects of drug therapy or lack of mobility.

“We encourage cardio exercise to all of our patients who are deconditioned to promote good [oxygen]/blood flow to tissue. We try to modify [home exercise programs] to accommodate flare-ups as our primary focus is usually joint preservation and protection,” Akladiss says.

“Because RA is a systemic disease, in addition to cardiovascular exercise, we encourage patients to eat well, get appropriate amounts of sleep, and take care of their overall health. Symptoms may be exacerbated when patients are fatigued or sick,” says, Suzanne Curley, MS, OTR/L, CHT, a clinical specialist at Massachusetts General Hospital.

Putting it All Together

How often a patient with RA is seen by an OT is “dependent on the severity of their deformity and loss of function. It may be few appointments early on for education and progressive splinting; otherwise we see them as needed as the disease progresses,” Akladiss says.

Koludrovich recommends that “patients with RA check in with OT at least once a year.” Both Akladiss and Koludrovich agree that OTs need to not only educate patients about their condition, but also educate physicians about the importance of referring patients with RA to OT early on.

“We can’t improve their joint integrity, but we can improve their quality of life,” Akladiss says.

Curley adds, “It’s important to educate physicians on the multifaceted aspects of our roles in management of these patients. Speaking directly with physicians, sending out letters outlining our treatment techniques and focus on management of functional activities, [and] getting patient testimonials are all good ways to let physicians know about our larger role.”

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Sandra Ripley Distelhorst is a medical writer for the Gannett Healthcare Group. To commeny, e-mail oteditor@gannetthg.com.

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