Rheumatoid arthritis is a chronic syndrome that is characterized by inflammation of the peripheral joints, but it may also involve the lungs, heart, blood vessels, and eyes. The prevalence of this autoimmune disease is between 0.3% to 1.5% of the population in the United States (Feinberg, pp 815). It affects women two to three times more often than men, and the onset of RA is usually between 25 and 50 years of age, but it can occur at any age (Reed, pp 584). RA can be diagnosed by establishing the presence of persistent joint pain, swelling in a symmetric distribution, and prolonged morning stiffness. RA usually affects multiple joints, such as the hands, wrists, knees, elbows, feet, shoulders, hips, and small hand joints. RA is usually characterized by the inflammation of the synovium, which lines the joints and tendon sheaths of the body.
The etiology of this disease is unknown. There are multiple factors involved in this disease, including autoimmune reactions and environmental factors.There is also a genetic predisposition that has been identified that can be related to the cause of RA. Rheumatoid arthritis develops as a result of an interaction of many factors. Much research is going on now to understand these factors and how they work together. Rheumatoid arthritis is one of several “autoimmune” diseases because a person’s immune system attacks his or her own body tissues (Gordon, pp 16). A feature of rheumatoid arthritis is that it varies a lot from person to person. For some people, it lasts only a few months or a year or two and goes away without causing any noticeable damage. Other people have mild or moderate disease, with periods of worsening symptoms, called flares, and periods in which they feel better, called remissions. Still others have severe disease that is active most of the time, lasts for many years, and leads to serious joint damage and disability. Rheumatoid arthritis occurs in all races and ethnic groups. Although the disease often begins in middle age and occurs with increased frequency in older people, children and young adults also develop it.
In 1987, the American Rheumatism Association developed seven criteria to define RA. First, morning stiffness in and around joints lasting at least one hour before improvement. Second, there is arthritis of three or more joint areas. Third, there is swelling of at least one wrist, MCP, or PIP joint. Fourth, there is simultaneous symmetrical swelling in joints. Fifth and sixth, there are subcutaneous rheumatoid nodules and presence of rheumatoid factor. Lastly, there are radiographic erosions and/or Perarticular osteopenia in hand and/or wrist joints (Ryan, pp 57).
Diagnosing and treating rheumatoid arthritis is a team effort between the patient and several types of health care professionals. When assessing a patient with RA, the professional should be looking at their activities of daily living, productivity skills and interests, leisure skills and interests, active and passive range of motion, muscle strength, hand functions, endurance, and cognitive features. Some psychosocial areas to be aware of are self-concept, coping skills, interpersonal and social skills, communication skills, and support systems.
Occupational therapy for an individual with RA will help the patient understand his or her disease and its effects on his or her life. The Occupational therapist will help the patient to improve his or her ability to perform daily activities, prevent loss of function, and direct successful adaptation with the disease. The Occupational therapist will also help the patient to develop problem-solving skills needed to make adaptations throughout one’s life. The Occupational therapist will also treat the physical and psychosocial difficulties that may limit the patient’s occupational performance (Fienberg, pp 816). The Occupational Therapist will review, observe and interview the patient, as well as administrating screening tests, to determine the capabilities and limitations of the patient’s occupational performance.
Some assessment tests that can be done to determine areas of occupational dysfunction important to the person are the Canadian Occupational Performance (COPM) interview, the Robinson Bashall Functional Assessment, the Stanford Health Assessment Questionnaire, the Assessment of Motor and Process Skills (AMPS), manual muscle tests, the goniometer, and the dynamometer and pinch meter (Hammond, pp 257). The Robinson Bashall Functional Assessment, as well as the Stanford Health Assessment Questionnaire, is a functional assessment that allows the therapist to get a better understanding of the practical capabilities of patients that are suffering from RA. The Assessment of Motor and Process Skills allows an accurate estimate of ability to do IADLs based on performance of three tasks.
Treatment addresses the problems identified by evaluation of the patient, and often are guided by the progression of the disease. Some specific goals to work on with an individual with RA may be to maintain joint mobility, prevent joint deformity, maintain or increase strength and functional ability, balancing activity with rest, develop problem-solving skills to modify daily activities at home and at work to protect joints and preserve energy, and especially promote psychosocial adaptations to deal with their chronic disability. (Pisetsky, 2789).
There are various drugs to treat RA and can be divided into four different classes. These classes are nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and analgesics. The drugs from the first three classes can reduce the number of painful and tender joints, duration of morning stiffness, and indicators of inflammation. NSAIDs are useful for their treatment of RA due to their anti-inflammatory and analgesic actions. These medications will improve mobility and strength, but they will not stop disease progression. DMARDs alter the course of RA, although they do not prevent bone erosion. Methotrexate (Rheumatrex) is the most frequently prescribed drug for the initial treatment of moderate to severe RA. Some other DMARD drugs that are used are Sulfasalazine (Azulfidine), Hydroxychloroquine (Plaquenil), Cyclosporine (Neoral), Azathioprine (Imuran) (Pisetsky, 2792). Among the newest therapies that are being used to treat RA, ‘biologics’ act on altering the normal immune response by blocking the inflammatory process. These drugs, Etanercept (Enbrel) and Infliximab (Remicade), are administered intravenously and subcutaneously, so that it binds to tumor necrosis factor (TNF), blocking its interaction with cell surface receptors (TNFR). These drugs reduce the signs and symptoms of moderately to severely active RA (Pisetsky, pp 2793).
A person with arthritis may state independence in a given activity but it may be difficult or painful to complete. An individual with RA may experience problems in various areas of living. Self-care is one area in that the patient may be experiencing difficulty, such that the person may be unable to perform ADLs because of motor limitations. These limitations may be related to those of bending, reaching, lifting, and carrying. The Occupational therapist may provide the patient with self-help devices, if needed, and instructions on how to use them. This may allow the individual to perform his or her ADLs so that he or she is able to keep his or her body clean and managed.
Another area that the RA patient may have difficulty is in productivity. The person may be unable to perform some job tasks when pain and swelling intensify. These job tasks may involve bending, reaching, lifting, or carrying. With such demands, his or her productivity skills may be impaired and need to be adapted to fit his or her needs. An Occupational therapist may suggest modifications or adaptations in the workplace that will help the person to perform his or her job tasks. The OT may also suggest modifications or adaptations in the home that will improve safety and help the person to perform household tasks. The person may also be limited to the leisure activities that he or she can participate in due to their physical limitations, so the OT may explore interests and develop leisure activities that are based on the patient’s interests and physical abilities.
An Occupational therapist may also help the patient to deal with sensorimotor issues that the RA patient deals with. The person may have limited ROM of the major joints, muscle weakness in the large muscle groups, swelling in the major joints, and joint deformities, especially in the hand and wrist. The person may also experience stiffness in the morning, feelings of constant fatigue, and also may experience pain and tenderness in the joints. The Occupational therapist must work on all these areas to improve and increase mobility in the joints. The OT may consider splints to maintain wrist extension of the hand or even knee splints to maintain knee extension. The OT would work on increasing or maintaining muscle strength, positioning, and even improving functional ability and endurance. All these interventions would help the person to maintain or increase their function in their joints, so that he or she can be more productive in his or her meaningful daily activities.
The person may also experience some psychosocial areas of difficulty that may need to be addressed to the Occupational therapist. The person suffering from RA may experience feelings of hopelessness and helplessness and may have a poor self-concept. He or she may have anxiety or become depressed. Lastly, the person may exhibit manipulative behavior. The OT may address these problems by promoting acceptance of this chronic disability, so that he or she can live with this disease. The OT may also provide stress management techniques so that the person’s tension can be released in more positive ways rather in a harmful manner towards himself/herself or towards others. The OT may also promote the person to participate in more social activities to get him or her to feel more competent and increase one’s self-esteem.
Persons with arthritis often do not comply with treatment and management routines, so the Occupational therapist may need to provide him or her with good learning or teaching techniques. The OT must also share with the patient the expectations about treatment and management, encourage personal responsibility for his or her care, and maintain a relaxed environment to encourage communication with other professionals and loved ones. The OT must also be cautious of any other health concerns that may arise due to the progression of the illness or even side effects from the medications. There are so many affected by Rheumatoid Arthritis and it is a growing illness that has been seen across the United States. In the future of medicine, more and more research will be done to find the cure to this illness, but for now, such treatment like Occupational therapy will further advance the lives of those living with RA.