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ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A

This mixed methods systematic review examines the impact of occupational therapy on self-management of rheumatoid arthritis. It finds that educational programs incorporating behavioral strategies offered by occupational therapists appear most effective for improving pain and function up to 24 months. Limited evidence supports self-management programs for reducing fatigue. More research is needed on patient experiences and long-term effectiveness of different approaches.

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ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A

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ACR Open Rheumatology

Vol. 6, No. 4, April 2024, pp 214–249

DOI 10.1002/acr2.11650
© 2024 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

REVIEW ARTICLE

The Impact of Occupational Therapy on the

Self-Management of Rheumatoid Arthritis:
A Mixed Methods Systematic Review
James P. Gavin,1 Laura Rossiter,1 Vicky Fenerty,1 Jenny Leese,2 Jo Adams,1 Alison Hammond,3
Eileen Davidson, and Catherine L. Backman5
4

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.

INTRODUCTION improve disease, mental health, and physical outcomes. Occupa-

tional therapists are well placed to support RA self-management
Rheumatoid arthritis (RA) is a systemic, autoimmune beyond outpatient care and into daily life. They can equip
inflammatory disease impacting around 18 million people individuals to adopt strategies to manage the symptoms, the
worldwide,1,2 which can cause joint pain, fatigue, and muscle physical and psychological consequences, and the lifestyle transi-
weakness.3 In the long term, uncontrolled disease activity tions associated with RA.6,7 Although access is limited,8 the
(ie, inflammation) leads to deterioration of joint cartilage and bone holistic approach of occupational therapy (OT) supports
tissue,4 and consequently, disability. Treatment involves medica- multidisciplinary teams to facilitate client involvement for long-
tion to control inflammation5 and multidisciplinary team care to term self-management beyond hospital care. Examples include,

Review registration number: PROSPERO CRD42022302205.

Supported by the Royal College of Occupational Therapists Research
Foundation (grant RCP014518). Additional supplementary information cited in this article can be found
1
James P. Gavin, PhD, FHEA, Laura Rossiter, MSc, Vicky Fenerty, MSc, Jo online in the Supporting Information section (http://onlinelibrary.wiley.com/
Adams, PhD, MSc, DipCOT, PFHEA: University of Southampton, Southampton, doi/10.1002/acr2.11650).
United Kingdom; 2Jenny Leese, PhD: Arthritis Research Canada, Vancouver, Author disclosures are available at https://onlinelibrary.wiley.com/doi/10.
British Columbia, University of Ottawa, Ottawa, Ontario, Canada; 3Alison 1002/acr2.11650.
Hammond, PhD, MSc, DipCOT: University of Salford, Salford, United Kingdom; Address correspondence via email to James P. Gavin at J.P.Gavin@soton.
4
Eileen Davidson: Arthritis Research Canada, Vancouver, British Columbia, ac.uk.
Canada; 5Catherine L. Backman, OT, PhD: Arthritis Research Canada and Submitted for publication June 30, 2023; accepted in revised form
University of British Columbia, Vancouver, British Columbia, Canada. December 11, 2023.

214
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OT IMPACT ON RA SELF-MANAGEMENT 215

This is the ﬁrst mixed methods review of the role of OT in the

SIGNIFICANCE AND INNOVATIONS self-management of RA. It assesses both the effectiveness of
• This is the first mixed methods systematic review of self-management interventions involving OT, and provides
the role of occupational therapy (OT) in the self- insights into individuals’ experiences of participating in OT for the
management of rheumatoid arthritis (RA). self-management of RA. It aims to assess the impact of OT on
• Educational programs incorporating behavioral
the self-management of RA by reviewing quantitative, and qualita-
strategies, offered by OT, appear to be the most
effective strategy to improve pain and function for tive evidence, addressing both patient perspectives and quantifi-
people living with RA for up to 24 months. able outcomes.
• As yet, limited evidence exists supporting self-
management programs incorporating OT to reduce
fatigue in people living with RA.
MATERIALS AND METHODS
• Future research should aim to capture qualitative
evidence from people with RA to better understand The review protocol was registered on PROSPERO
why self-management programs are effective
(CRD42022302205) and published in June 2022.20 Findings are
or not.
reported following the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA).21 This article reports a
mixed methods systematic review, whereby no human partici-
pants participated in the research. Ethical approval was not
supporting patients with RA in managing medications, regular
required.
physical activity, pacing and energy conservation/management,
and accessing medical care during flare-ups.9,10
RA symptoms fluctuate, and over time, the disease can limit Information sources and searches. Searches were
an individual’s participation in work, caring, household duties, conducted via five electronic databases (MEDLINE, CINAHL,
and social activities.11,12 OT is an effective, non-pharmacological AMED, PsycINFO, and Web of Science [Core Collection]) from
treatment for RA10,13 that supports individuals in self-managing their earliest date to April 1, 2022, with a refresher search on June
their everyday lives.14 Occupational therapists provide strategies 30, 2022. Gray literature searches were across patient-specific
to enhance performance in daily activities, support choices in bibliographic databases (OTseeker, OTSearch, OTDBase); the
meaningful occupations, and engage in practical tasks while Lippincott, Williams and Wilkins (LWW) Health Library: Occupa-
managing pain and fatigue.10 The effectiveness of OT for RA tional Therapy Collection; the Rehabilitation Field and Musculo-
was last reviewed systematically in 2017,13 with studies included skeletal Group databases (Cochrane Collaboration); and
up to 2014. Based on trials, the evidence suggests that academic theses, trials databases, and conference abstracts (pub-
OT-related interventions can improve function through joint lished and unpublished), and the Cochrane Library, NICE Evidence
protection training,10,15 physical activity, and educational- search, UpToDate (Wolters Kluwer), and the Royal College of Occu-
behavioral programs, including self-management and assistive pational Therapist’s Library.
devices.13,15 No synthesis of both quantitative and qualitative The search strategy was co-produced with patients with RA
findings related to the self-management of RA incorporating OT and professionals (Table 1).22 The initial search terms were
exists. What remains unclear is the effectiveness of OT in support- drafted by the principal investigator (JG) and then peer-reviewed
ing long-term, patient-led self-management of RA on measurable by the co-authors (JL, CB, JA, and VF) for the project grant bid
outcomes (e.g., function) and the lived experience of individuals (January-February 2021). These terms were then used as the
with RA. basis of the review’s search strategy. Thereafter, our newly quali-
Recent narrative reviews of the experiences of living with RA fied OT researcher (LR) was guided by our librarian co-author (VF)
highlight the importance of self-management in equipping people to test the search terms, and subsequently refine the search strat-
to “renegotiate the self” to manage the emotional and cognitive egy based on scoping searches (May-July 2021). Co-author, JL, pro-
impacts after disease onset.16,17 Based on these reviews, OT is vided expertise on search terms common to qualitative and mixed
most likely to be effective in supporting the self-management of methods research. Finally, a 90-minute online workshop was held with
RA by targeting self-esteem, self-efficacy, and self-perception patients with RA (n = 5) and facilitated by two reviewers (JG and LR) to
of the illness. Self-efficacy is a major contributor to self- refine the search strategy, taking into account patient perspectives
management, given that it reflects an individual’s belief in their (September 2021). The draft search terms, structured using the SPI-
ability to manage the disease and it’s symptoms.14 These findings DER framework (Sample Phenomenon of Interest/Intervention, study
are particularly relevant given recent evidence that the COVID-19 Design, Evaluation/outcome, Research type), were shared with our
pandemic has significantly impacted people’s ability to self-man- patient partners who provided feedback to ensure that terms reso-
age effectively, because of heightened anxieties and increased nated with their lived experiences. Partners contributed 12 additional
uncertainty.18,19 terms; these were finally checked by two rheumatology
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
216 GAVIN ET AL

occupational therapists within the lead reviewer’s (JG) professional

“occupation*
Term set 3
network.
therap*”
OR OT
Study selection. The inclusion criteria were based on the
AMED

“inﬂammation SPIDER framework: Sample (adults diagnosed with RA),

Phenomenon of Interest/Intervention (OT for self-management
arthrit*” OR
Term set 1

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*”

qualitative and quantitative research), Evaluation/outcome,

Research type (qualitative, quantitative or mixed methods) (see
Supplementary Table 1). Only English language papers were
Term set 3

included. Based on pilot searches, and to limit the likelihood of

therap*)
OR OT

excluding relevant studies, outcomes informed the screening

Web of Science

process but were not included in the ﬁnal search strategy.20

Selection involved ﬁrstly conducting a pilot screening and
“inﬂammatory

then full screening (including title and abstract, and then full text).
Term set 1

(arthrit* OR

To begin, one reviewer ran the search strategy and removed

arthrit*”
Rheumat*

nodul*)
NEAR/1

duplicates (LR) using EndnoteWeb, then papers were exported

to a shared Microsoft OneDrive account, and ﬁnally uploaded to
Rayyan for screening and data extraction. Next, in piloting three
“occupation* therap*”
Occupational Therapy/

Occupational Therapy/
Occupational Therapy

Occupational Therapy

Occupational Therapy
Service/ OR Research,

reviewers (LR, VF, and JG) used Rayyan software23 to indepen-

Evidence-Based/ OR

Practice, Research-
Home Occupational

Therapy Practice,
OR Occupational

dently screen 20 randomly selected papers. Titles and abstracts

Term set 3

Therapists/ OR
Occupational

of the pilot papers were screened using a predeﬁned tool based

Therapy/ OR

Practice/ OR

Based/ OR

on the eligibility criteria and published elsewhere.20 Finally, all

OR OT
CINAHL

three reviewers met to agree on individual papers and reﬁne the

eligibility criteria.
In full screening, three reviewers (JG, LR and VF) used the eli-
“inﬂammatory
rheumat* N1
Rheumatoid/
Rheumatoid
Term set 1

(arthrit* OR

gibility criteria (Supplementary Table 1) to screen titles and

arthrit*”
Nodule/

abstracts, and lastly, two reviewers (JG and LR) screened the
nodul*)
Arthritis,

full-text papers to identify papers for data extraction. Disagree-

ments were resolved in discussion with a clinically experienced
reviewer (AH or CB). The reference lists of full-text papers and
therap*” OR OT

previous reviews were checked for additional papers.11,24–28

Term set 3

“occupation*
Occupational
Therapy/ OR

Therapists/
Occupational

Gray literature screening followed the same process and was

conducted via the OneDrive account.
APA PsycInfo

Outcomes. Based on previous reviews,10,13 the primary

Table 1. Search strategy for the mixed methods review

“inﬂammatory

quantitative outcomes were function (including strength and

rheumat* N1
Term set 1

(arthrit* OR

mobility), pain, and fatigue. The primary qualitative evaluation

Rheumatoid
Arthritis/

arthrit*”
nodul*)

was lived experience and related concepts, including self-care,

self-efﬁcacy, occupational balance, and self-management (includ-
ing problem-solving and goal setting). Patients with RA reviewed
therap*” OR OT

and reﬁned the initial outcomes identiﬁed by the reviewers22;

Therapists/ OR

“occupation*
Occupational

Occupational
Term set 3

Department,
Therapy/ OR

these were later ﬁnalized by the research team. Some outcomes

Occupational

Hospital/
Therapy

were assessed both quantitatively and qualitatively (e.g., self-efﬁ-

cacy and pain).
Medline

Data extraction and quality assessment. Two

“inﬂammatory
Exp Rheumatoid

rheumat* N1
Term set 1

reviewers (JG and LR) independently extracted, synthesized,

Rheumatoid

(arthrit* OR

and assessed the data quality from included papers using a stan-
Arthritis/

arthrit*”
Nodule/

nodul*)

dardized Microsoft Excel form.20 Data were extracted on general

information (including date and methodology), study eligibility,
characteristics of included studies, risk of bias assessment, data
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 217

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
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
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

(Continued)

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

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
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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Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Feinberg, 1992 (60) 46, N/D; mean 48.8 y; RA Intervention = 20: Assessed Pain, duration of morning Pre, post splinting Patients wore their splints a mean
diagnosis (functional patient, fabricated hand stiffness, compliance. 5-point (28 days) 23.3 days (intervention) and
class I or II), outpatients splint, and fostered patient- VAS, 4-point VAS, diary. 18.1 days (control), respectively
with no prior hand splint practitioner relationship (P = 0.056). Nine (45%) in the
referral. (including education intervention group, but only
principles, expectations, and four (20%) in the control group
encouragement). Follow-up used their splints daily (P = 0.04).
phone call at 2 weeks. Greater knowledge of splint use
Control = 20: Assessed related to actual use for both
patient and fabricated hand groups (P = 0.035). Wrist and
splint. hand pain did not change in
either group. Experimental
group had less morning
stiffness (P = 0.013).
Furst et al, 1987 (48) 28, 89%, mean 54.1 y; aged Intervention = 18: Six, 90 Knowledge, ADL status, pain, Pre, post 3 and 9 No difference after 3 and 9
older than 18 y, RA minute weekly educational fatigue, psychological months months in either group. Post 3
diagnosis (American sessions on energy adjustment to illness, disease months, the intervention
Rheumatism Association conservation, body position, activity, energy conservation group showed a tendency for
criteria) rest, activity analysis (1 & 2), behavior. Questionnaire, HAQ, improved energy conservation
and joint protection. Instructor VAS, PAIS, RAI, IPA/activity behaviors for rest during physical
guide and patient workbook to record (for behavior). activity (P = 0.07), balance
standardize across centers. between rest and physical activity
Control = 10: Standard OT (P = 0.0), and time being
(one to three sessions). physically active (P = 0.1).
Gerber et al, 1987 (49) 28, 89%, mean 54.1 y; aged Intervention = 18: Six, 90 Psychological adjustment to Pre, post 3 months 50% of intervention group
older than 18 y, RA minute weekly educational illness, grip strength, walk increased physical activity time
diagnosis. sections on energy speed, tender/swollen joints, (P = 0.1). A total of 11% of
conservation, body position, ADLs, daily activity. RAI and PAIS, control group increased
rest, activity analysis (1 & 2), hand dyno, walk time (50 ft), physical activity time (P = 0.1). A
and joint protection. HAQ (including VAS), activities total of 22% of control group
Instructor guide and patient log. and 50% of intervention group
workbook to standardize achieved better balance of rest
across centers. Control = 10: and physical activity (P = 0.07).
Standard OT (one to three These were not signiﬁcant and
sessions). tendencies only.
Hammond, 1994 (43) 10, 90%, mean 56.2 y; ages Intervention = 10: Two Hand movement patterns Pre, post 2 and 6 weeks Joint protection behavior did not
older than 18 y, RA educational sessions on (primary), swelling, pain, change 2- or 6-weeks
diagnosis (ACR class I or 1) the disease, JP principles, disability, ROM, functional postintervention (P > 0.1).
II), no other medical and identifying ADL issues disability. JPBA, ACR disease Participants indicated that
conditions affecting (85 minutes) and 2) energy classiﬁcation of progression they paid increased attention
hand function. conservation, practicing JP and functional class, hand joint to joint care since education.
methods, and hand count (0–120 scale), HAQ, VAS, However, there was no
exercises (120 minutes). disease duration. relationship between self-
Sessions formed part of a perceived and observed joint
6-week arthritis program. protection behavior for these
participants who indicated
they had changed behavior.
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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

changing behavior: problems

recalling information; joint
protection being considered
inappropriate for early RA; lack
of skill; difficulties changing
habits.
Hammond and Freeman, 139, 76.5%, mean (SD) 50.5 Intervention = 65: Four, 2-hour Hand paint, adherence (primary), Pre, post 6 and 12 Intervention group improved in
2001 (33) (10.6) y; aged 18–65 y, RA weekly group sessions (4–8 disease activity, hand status, months adherence (P = 0.001), hand
diagnosis, experiencing participants, including function, psychological status. pain (P = 0.02), general pain
hand pain, no other partners) involving 100 mm VAS, JPBA (primary), (P = 0.05), morning stiffness
medical condition demonstration and practice, EULAR28 joint count, during of (P = 0.01), self-reported
affecting hand function. personalized strategies, and morning stiffness, AIMS2, hand number of flare-ups
goal setting for joint dyno, self-efficacy scale, RAI. (P = 0.004), visit to the doctor
protection. Control = 62: for arthritis (P < 0.01), and
standard education activities of daily living
program involving group (P = 0.04). Trend toward
sessions (6–12 participants, improved swollen joint counts
including partners; 8-hour was shown (P = 0.07) and
total). improvements in self-efficacy
and perceived control.
Hammond and Freeman, See above. See above. See above. See above. Pre, post 48 mo The intervention group had
2004 (34) significantly increased
adherence (P = 0.001).
Functional ability worsened in
both groups but significantly
more for the control group. The
intervention group had
significantly less early morning
joint stiffness (P = 0.01);
however, improvements in pain
during activity had returned to
preintervention level.
Participants in the control group
who increased joint protection
behavior were more likely to
have lower baseline physical
function (P = 0.002).
223

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Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Hammond, Young, and 326, 72%, mean (SD) 55.5 Intervention = 162: Four Function, disease activity, hand Pre, post 6, 12, and 24 The intervention group received
Kidao, 2004 (35) (13.7) y; aged older than 1-hour individual status, psychosocial status, months a mean (SD) 7.6 (3.0) hours of
18 y, RA diagnosis treatments, plus one 2-hour adherence. HAQ, AIMS2, OT. The intervention group
group arthritis education 100 mm VAS, handgrip dyno, significantly increased in self-
program. Individual ASES. management post 12 months
treatment plan included (hand exercises, P < 0.001;
information about RA joint protection, P < 0.01; rest
management, ADL training, P = 0.05). There were no
joint protection and energy significant differences in any
conservation, posture and outcome measures or
positioning, coping between groups for function
strategies, and home (AIMS2, P = 0.96), pain
exercises. Control = 164: (P = 0.74), or self-efficacy
usual care. (P = 0.39).
Hammond et al, 2021 (36) 206, 80%, median 59 y; Intervention = 103: Fitted Hand pain (primary), Pre, post 12 weeks 84 (intervention) and 79 (control)
aged over 18 y, RA, or three-quarter length finger nondominant hand pain, hand participants completed the
undifferentiated Isotoner glover. stiffness, duration of morning 12-week follow-up. Both
inflammatory arthritis Control = 103: Fitted loose- hand stiffness, function groups had less hand pain at
diagnosis. fitting three-quarter length disability, health status, 12-weeks post intervention
finger Jobskin classic edema perceptions on treatment. (intervention 1.0 and control
gloves. Both groups: 10-point NRS, Michigan Hand 1.2; both lower NPRS score)
instructed to wear most of Outcomes questionnaire HAQ, (adjusted mean
the day and not, but not for EQ-5D-3L, treatment log. difference = 10.10 [95% CI:
24 hours −0.47 to 0.67; P = 0.72]). No
clinically important
improvement in either group
for hand pain, stiffness,
function. 51% of intervention
and 36% of control group had
adverse events, with 6% and
7% discontinuing glove wear,
respectively. Arthritis gloves
provision = £129, with not
additional benefit.
Helewa et al, 1991 (24) 105, 87%, mean (SD) 54 Intervention = 53: 6 weeks Functional ability, morning Pre, post 6 and The intervention group had
(12.2) y; aged 18–70 y, RA individual, home OT within stiffness, pain, depression, 12 weeks greater function than the
diagnosis (American 10 days of referral. inflammation. Questionnaire, control group post 6 weeks
Rheumatism Association Treatment included hand HAQ, AIMS, VAS, Beck (mean difference = 8.1 [95% CI
criteria), limitation in and foot management, depression scale, erythrocyte 1.7–15.8]; P = 0.012). The
physical function, no vocational assessment, work sedimentation rate. intervention group were
other disability affecting adaptation, stress stable between post 6 and
function, stable clinical management and 12 weeks (all outcomes). No
status. psychological counseling. significant difference in pain,
Control = 52: no treatment. function, and depression
between groups post
12 weeks.
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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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Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
information on RA
management. Subsequent
sessions included: energy
conservation, joint
protection, and use of
assistive devices.
Control = 19: Waiting list/
usual care.
Lahiri et al, 2021 (62) 140, 86%, mean 56.6 y Intervention = 70: Single, MDT Outcomes: HR-QOL (primary), Pre, post 6 months 40.6% of the intervention group
(range 46.7–62.4 y); aged 2-hour clinic visit. Led by a pain, disease activity, physical and 34.3% of the control
≥21 y, RA diagnosis, rheumatologist, with 20 function, coping, self-efficacy, group improved in HR-QOL
attending outpatient minutes each spent with a symptom state, medication (P = 0.46; minimal clinically
rheumatology clinics. nurse (education and adherence, disease-specific important difference of 0.1). In
counseling), medical social knowledge, and patient the intervention group,
worker (psychological and experience. Outcome patients with high disease
emotional support and measures: EQ-5D-3L (primary), activity were more likely to
financial needs), VAS, DAS28, MHAQ, RASE, PASS, achieve an improvement in
physiotherapist (exercise), MARS, 12-item questionnaire HR-QOL. Intervention group
hand OT (self-management, (disease-specific knowledge), had a within-group
cognitive-behavioral survey (patient experience). improvement in pain
approaches, and joint (P = 0.02), RASE (P < 0.001),
protection), and podiatrist and coping (P < 0.001) but not
(foot care). Control = 70: in the control group. No group
Usual care, involving three × time interaction stated.
visits to their Intervention group had a
rheumatologist. small, significant improvement
for HR-QOL (P = 0.04), disease
activity (P = 0.03), and coping
(P = 0.02) when compared
with the control group.
Macedo et al, 2009 (54) 32, 93%, mean 50.6 (9.85) Intervention = 16: Six to eight Outcomes: Function, work Pre, post 6 months The intervention (OT) group had
y; RA diagnosis, sessions (30 to 120 minutes) productivity, coping, disease greater improvements than
employed, English of comprehensive OT and activity, pain, morning stiffness, the control group in:
speaking, medium-high usual rheumatology care for fatigue. Outcome measures: • All functional assessments
work disability risk (by RA 6 months. OT-involved COPM (primary), HAQ disability (COPM performance, P < 0.001,
work instability scale) assessments of medical index, RA-WIS, number of illness COPM satisfaction,
history and work, functional, days, Modified Health P < 0.001, HAQ)
and psychosocial Economics Questionnaire, • Disability index, P = 0.02)
capabilities. Sessions AIMS2, AHI, EQ-5D, VAS, DAS28. • Majority of work outcomes (RA
involved: education, self- work instability index, P = 0.04,
advocacy, workplace rights VAS work satisfaction,
and responsibilities, P < 0.001, VAS work
reasonable adjustments, performance, P = 0.01).
pacing, stress management, • Coping outcomes (AHI, P = 0.02,
sleep, exercise, and AIMS2 pain, P = 0.03, VAS pain,
MDT support (as required). P = 0.007, EQ-5D, P = 0.02,
Control = 16: DAS28, P = 0.03)
GAVIN ET AL

Usual care.

(Continued)
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
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

daily living, advice on Service Interview questionnaire, signiﬁcantly improved

environmental adaptations, VAS, HAQ, AIMS2 (Italian disability and health status
and home exercise version), personal diary, (HAQ) (P = 0.01), but the
prescription. Control = 39: questionnaire. control group significantly
Usual care. worsened (P = 0.09). The
intervention group
significantly improved
symptoms (P = 0.02), function
(P = 0.05), and social
interaction (P = 0.04) (HAQ),
but not in work (P = 0.31) and
psychological dimensions
(P = 0.19). During the trial, 24
intervention participants
exercised on average twice a
week, whereas only 12 control
group exercised regularly.
Hand exercises were
performed most frequently.
75% of the intervention group
found the program very useful
(n = 27), 16.6% found it
moderately useful (n = 6), and
8.4% found it not useful (n = 3)
for daily activities.
Mathieux et al, 2009 (26) 60, 72%, mean 47.5 (13.1) Intervention = 30: One half-day Outcomes: Grip strength, Pre, post 3 months Both groups showed similar
y; RA diagnosis (ACR session, including joint function, satisfaction, improvements in strength and
criteria), early disease protection practices compliance. Outcome function after they received
duration (<2 y). (including fabrication) and measures: Hand dyno, HAQ, the intervention. In the
twice daily hand and wrist questionnaire (verbal scale). intervention second group,
exercises. Booklet provided; 85% used their hand splints
intervention over 3 months. compared with 57% in the
Control = 30: Usual care, intervention first group (0–3
and then the intervention months) (P < 001). In the
from months 3 to 6, in an intervention first group, 90%
open label extension phase. were practicing self-
rehabilitation exercises
227

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Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
compared with 40% in the
intervention second group
(P < 0.001).
Mohanty, Padhan, and 40, 82.5%, mean 46 (6) y; Intervention = 20: Outcomes: Health (ie, hand) Pre, post immediately Both intervention and control
Singh, 2018 (64) aged 20–74 y, RA Proprioceptive exercise status, hand function. Outcome (after 8-week groups showed a significant
diagnosis (2010 retraining three times a measures: Brief MHAQ, Jebsen intervention) improvement in health status
ACR/EULAR functional week for 8 weeks. Seated hand function test. and hand function at 8 weeks
class II and III), stable exercises included hand (no P values). Improvement
medications. gripping, weighted finger was significantly greater for
pulleys, lifting dumbbells the intervention group than
with hand, wrist roller the control group (no P
activity, and stretch and hold values).
of bilateral counterpart
fingers. Each exercise was
held for 3–5 seconds for 10
repetitions (10 second rest).
Control = 20: Home
exercises, three times a
week for 8 weeks. Seated
exercises included wrist and
finger movements, thumb
movement (resistance),
volar and dorsal flexion of
wrist, forearm pronation
and supination, and tendon
gliding exercises. Each
exercise was held for 3–5
seconds for 10 repetitions
(10 seconds rest).
Neuberger et al, 1993 45 (n = 31 complete), All Intervention = 15: Self- Outcomes: Function, task Pre, post 3 to 16 weeks The intervention group
(pilot study) (27) female, mean 48.3 y; instructional OT program. performance, knowledge. performed significantly higher
aged 18–76 y, English Four 20–25-minute sessions Outcome measures: than the control group
speaking, mentally involved pathophysiology of Observation, questionnaire (40 (P = 0.005) in knowledge after
competent, and female. RA; medication therapy; rest, multiple choice questions). the self-instructional OT.
pacing and joint protection; There was no significant
and exercise and posture. difference in task
Control = 16: No self- performance (ie, function)
instructional OT. between groups after the self-
instructional OT (P = 0.08).
Neuberger et al, 1993 98 (n = 53 complete), 66%, Intervention 1 = 13: Self- Outcomes: Function/task Pre, post 3 to 16 weeks All intervention groups scored
(follow-up) (27) mean 52.6 (14.3) y (range instructional OT program performance, knowledge, pain, higher than the control group
25–81 y); aged 18–76 y, (see above). Intervention depression. Outcome on the knowledge test
English speaking, 2 = 14: Self-instructional OT measures: Observation, (P < 0.01), performance of JP
mentally competent, and program, plus ROM and questionnaire (40 multiple practices (P = 0.01), ROM
either male or female. joint protection practices. choice questions), VAS, CES-D. exercises (P = 0.01), and
Intervention 3 = 15: Self- adherence to home joint
GAVIN ET AL

(Continued)

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.

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Pimm, 2003b (53) 136, 77%, mean 52.9 y; RA Intervention = 58: Six, weekly Outcomes: Pain, physical Pre, post immediately, 2 No difference in pain between
diagnosis (≥1 year), aged 2-hour meetings, involving disability, emotional state and 12 to 13 weeks, groups after intervention
16–70 y, English sharing information and (primary), social and and 9 months (P = 0.051). Immediately after,
speaking. coping strategies. Topics occupational function, QOL, the intervention group had a
included medication advice, disease activity, health care greater improvement in illness
joint protection, use of aids, utilization, illness perception (identity and
nutrition, and stress and representations, self-efficacy, consequence scales), and pain
pain management. coping procedures (secondary). self-efficacy, use of coping
Outcome measures: VAS, strategies, and exercise
graphic rating scale, NPRS, adherence than the control.
Stanford Health Assessment, Improvements in illness
AIMS 2, customized perception (identity), pain self-
questionnaire (function), HADS, efficacy, and use of coping
POMS, PANAS. strategies were maintained at
3 months post, and illness
perception (identity) at 9
months post. Pain and
depression improvements
were not maintained at 9
months for the intervention
group.
Pot-Vaucel et al, 2016 (51) 62, N/D, mean 60.2 (10.4) y; Intervention = 28: 6-month Outcomes: Knowledge (success in Pre, post immediately The most positively evaluated
RA diagnosis (ACR 2009 patient education, involving solving three predefined ADL (after 6-month choices in the intervention
classification), aged 1) 1-hour interview with a problems), skills acquisition, intervention) were OT and physiotherapy
greater than 18 y, stable nurse (identification of key medication use, engagement in (84%), with least interest in
RA 6 months prior. priorities for disease health care, disease social rights (1 person in 5)
management), 2) three development, disease activity and self-image (1 person in 4).
90-minute group workshops and health status (secondary). Knowledge, assessed by
and/or individual Outcome measures: problem solving, was achieved
consultations, and 3) a final Questionnaire, including VAS, by 76.9% of the intervention
1-hour interview with a HAQ, and Beck depression group and 42.4% of control
nurse. Patients had choice scale. group (P < 0.0001). Knowledge
between individual of treatments and managing
consultation (eg, social side-effects did not change
worker, OT, psychologist) during the intervention, nor
and/or joint workshops did fatigue, stiffness, or
(three out of six topics). number of consultations.
Control = 26: Waiting list/ Following intervention,
usual care. participants reported they
required less corticotherapy,
more OT, more demand for
social aid, more physical
activity, greater understanding
of RA of RA, and how to cope
with RA.

(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

management, exercises P = 0.02), and only the

(stretching and intervention group in QOL
strengthening), educational (P = 0.001). The intervention
therapy (ie, joint protection group significantly improved
techniques, energy activity limitation and
conservation, assistive participation restriction when
device use). compared to the control
group after the trial
(P = 0.001). The intervention
group had significant
increases in occupational
performance and
occupational satisfaction,
whereas the control group
only increased occupational
performance (P = 0.001).
Van Vilsteren et al, 2017a 150, 84%, mean 49.7 (8.6) Intervention = 75: 12 week Outcomes: Supervisor support, Pre, post 6 months Supervisor support had a
(11) y; RA diagnosis, “Care for Work” program work instability, work statistically significant effect in
employed (>8 hour per involving integrated care productivity. Outcome favor of the intervention group
week), minor difficulties and a participatory measures: Job Centre (95% CI 0.007–0.38). There
in functioning at work. workplace intervention, questionnaire, RA-WIS, Work was no difference in work
based on participatory Limitations questionnaire. instability (difference: −0.50
ergonomics. Intervention [95% CI 1.71–0.71]) or work
weeks involved 1 - initial productivity (difference: 0.1
consultation and treatment [95% CI 0.7–0.9]) between
plan, 2 - workplace intervention and control
intervention (OT, involving groups.
care manager, patient, and
employer), 6 - second
consultation/evaluation, and
12 - third consultation/
evaluation. Control = 75:
Usual care.
Van Vilsteren et al, 2017b See above. See above. Outcomes: Work productivity Pre, post 6 and 12 143 participants completed
(28) (primary), QOL, pain and months follow-up questionnaire at
fatigue, work instability. post 12 months. There were
Outcome measures: Work no intervention effects on
231

(Continued)

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Limitations questionnaire, work productivity loss, work
Rand-36, 10-point VAS, RA-WIS. instability, pain, fatigue, and
QOL
Qualitative and mixed
methods studies
Bowell and Ashmore, n = 450 patients and 350 Intervention: Single, 2-hour Outcomes/evaluations: Feedback Pre, post immediately All participants and partners
1992 (41): Mixed partners/carers group session led by a on the program (including and 6 months found the program helpful
methods (enrolled), n = 100 physiotherapist and OT. usefulness, requirement for and informative, with 2-hour
patients and 100 additional information or suitable duration. 50% wanted
partners/carers (for data training, and timings). Outcome more sessions. Further
collection); Inclusion measures: RASH evaluation information was requested on
criteria: RA diagnosis and form. living with RA (65%) and
clinic referral. relaxation (63%) and coping
techniques (52%). 84%
changed the way they
performed daily activities, and
“many” purchased
equipment. 85% of partners
reported that their attitude
changed toward RA, in that
they had greater insight and
understanding.
Dubouloz et al, 2004 (56): 5, All female, aged 38–67 y; Intervention: Individual home- Evaluations: Two to seven, 1-hour During Themes (postintervention):
Qualitative RA diagnosis within last based OT (up to 8 months) interviews during home-based • Illness: Some maintained the
year, beginning focusing on information OT. Transformation of personal same personal values as
community-based OT. provision, reflection, and beliefs, values, feelings, and before their illness, while
adaptation of the daily knowledge (meaning recognizing that they had to
environment and activities. perspectives) underlying find different ways of
occupational change. functioning for independence
and activity. Others found
functional reorganization
difficult to accept and
perceived illness as a lesser
part of oneself.
“Look, it’s just another part of life
like getting a pimple, bad
haircut, that’s it. It, it’s certainly
not…beating me up. It’s just, it’s
[a] part of me.”
Some assessed the illness less
negatively, as an inconvenient
and manageable condition.
• Independence: Individuals
continued to strongly value
the meaning and function of
independence:
GAVIN ET AL

(Continued)

independently disabled person…

chronically ill person who
occasionally needs help, you
know.”
Participants seemed able to
redeﬁne what independence
was for them.
• Activity: The function,
meaning, and assessment of
activity remained similar for
individuals but become
“within my means.” Alternate
ways to be and remain active
developed.
“It’s all the same. Being active,
being able to work. Being able to
volunteer. Being able to use my
brain and whatever. I mean,
that’s all still there…I just have to
learn different roads to get to the
same way…”
• Altruism: Became less of a
priority in becoming
secondary to the individual’s
own needs.
“…I don’t need to feel obligated to
do anything that somebody else
wants to do. It’s OK to say no[…]
and I think that is
positive in a way because you’re
responding to, like I’m
responding to my own needs,
not to the needs of everyone
around me.”
• Self-care: A new meaning
emerged acknowledging a

(Continued)
233

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
balance between the giving
and receiving help.
“So it’s a balance there, what they
[other people] give to me. [A
friend told me] ‘Think of all you
do for other people’…in another
way maybe they [other people]
are helping somebody and they
don’t realize it…I guess everyone
has their own perception, my
own is that it [getting help]
shouldn’t be a
loss of independence.”
Instead of being socially
dependent, intervention
helped transform participants
from “dependent” to
“interdependent” (ie,
independent with help).
• Self-respect: Some individuals
altered their views on their
problems and judgment of
others, which empowered
them to respond to personal
needs. Participants began to
better pace themselves in
daily tasks. For example, only
tackling what they could
achieve, doing tasks slower,
and sleeping when tired.
“Pacing myself…I think it’s
more pleasurable now.…I tend to
take more pleasure in what I
do…. instead of thinking about
it, I’m actually feeling it. …I’ll
sleep if I want. I get up when I
want. And in the end, I
accomplish as much in a day on
a Saturday as if I woke up 3
hours earlier.”
Dubouloz et al, 2008 (57): 10, 80%, aged 39 to 66 y; Intervention: Individual, weekly Evaluations: Two, 1-hour During Themes (postintervention):
Qualitative aged 21–70 y, RA home-based OT (between 6 interviews during home-based 80% reported a conﬂict between
diagnosis, receiving and 12 weeks) focusing on OT. Transformation of personal their perspectives and OT
community-based OT. information provision, beliefs, values, feelings, and interventional strategies.
reﬂection, and adaptation of knowledge (meaning These included energy
conservation (ie, pacing and
GAVIN ET AL

(Continued)

Seeking or receiving help from

others conflicted with some
participants’ values of
independence.
“…not counting on somebody else
to go to places.”
Receiving help led to feelings of:
“…being useless; incapacitated.”
Recommendations by OTs and
the use of assistive devices led
to conflicted with belief
systems for some:
“A wheelchair was not plausible at
35 years old, with a young
child.”
Pacing and rest strategies were
initially challenged, and for
some a cause of guilt.
“I couldn’t imagine resting before, I
felt guilty. Now… rest allows me
to feel myself, to be a joyful wife
and a nice person.”
For some with long-term RA,
they developed rule for
managing occupations.
“I do things in moderation; I stop
for pain even if the activity is not
finished.”
This also involved redefining the
concept of rest. Initially, rest
meant strictly “going to bed at
night,” later becoming part of
“sedentary activity.” This
allowed rest to become
meaningful and part of daily
routine.

(Continued)
235

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
Seeking help was initially a major
barrier, later becoming “a joy
that people give to me.”
Priorities seemed to change
from completing activities
alone over prolonged time, to
saving time and seeking help,
“freedom to do, to freedom to
be.”
An evolution to a positive
perspective occurred before
devices were incorporated
into daily life. Initially, splint
wearing was seen as a “step
down,” later becoming
associated with “a way to
increase what I am able to do.”
This view of gaining control
over symptoms contrasted
with the previous perceived
view of capitulation.
Dubouloz, 2008 (58): 16, 81%, mean 50 y; Having Intervention: Individual home- Evaluations: Two to seven, 1-hour During Themes (postintervention):
Qualitative received or receiving OT based OT focusing on interviews during home-based • Independence: Individuals
and other rehabilitation. adaptation of the daily OT. Experiences of adapting to had to create self-care
environment and activities. living with RA strategies to establish a new
occupational balance.
Self-reflecting on their new
situation enabled individuals
to recognize self-continuity
and self-acceptability in illness.
"Rarely will I ask for assistance. It’s
just my nature. So that’s going to
be one of the hardest lessons I’ll
ever have to learn if I have to
become dependent…"
The definition of independence
broadened to
accepting external help.
• Activity: The definition of the
value of activity adapted from
how busy the individual was to
engaging in moderated activity
that recognized the
individual’s health needs.

(Continued)
GAVIN ET AL

support were integrated into

daily occupations, participants
found that they could remain
productive, as well as active
and independent.
• Altruism: A commitment to
helping others become less of
a priority; instead, OT
intervention helped to shift
focus to valuing and satisfying
individual needs.
“…my character make-up is
providing help as opposed to
asking for help."
Hewlett et al, 2019b (39): 333, 79%, mean 62.8 y Intervention = 175: Six weekly Outcomes: Fatigue (primary; Pre, post immediately, See (36) for quantitative results.
Mixed methods (range 54.3–69 y); aged 2-hour sessions (week 1–6) impact, severity, coping), fatigue 6, 26, 52, 78, and Satisfaction with the
≥18 y, RA diagnosis and and one 1-hour impact, pain, disability, sleep, 104 weeks (with intervention was high, with
recurrent fatigue (BRAF- consolidation session (week disease activity, mood, quality of fatigue at 10 and 89% of participants rating the
NRS score of ≥6 [out of 14). Treatment involved life, valued leisure activities, self- 18 weeks) booklet (P < 0.0001),
10]). group CBT using reflective efficacy. Outcome measures: compared with 54% in the
questioning and support for BRAF-NRS, BRAF-MDQ, VAS, control group. 96%
fatigue validation, pacing, MHAQ, Pittsburgh Sleep Quality recommended the
goal setting, and problem Index, DAS28, self-reported intervention and 68% the
solving. Participants self- HADS, AIMS, VLA (discretionary intervention booklet to others
monitor activity, rest, and activity subscale), RASE, AHI. (P < 0.001). Qualitative results:
fatigue to support goal Economic outcomes: Cost- Becoming confident required
setting. Control = 158: Usual effectiveness was calculated by time and effort.
care involving short the QALYs with the EQ-5D-5L. “…the RAFT programme was a
discussion with nurse. Evaluations: Individual face- daunting but exciting
to-face interviews with tutors undertaking.”
(n = 14), plus one focus group Training together and expert
(n = 8) to discuss clinical demonstrations were helpful.
implementation. “…skills practice and
demonstrations were essential.”
Clinical supervision helped and
tutors develop dynamics of
pair work.
237

(Continued)

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
“…developing an individual
approach to a standardised
intervention…”
Tutors described working with
patients as a whole person in
clinic; their new “ask don’t tell”
skills helped them listen, draw
things out, and confidently
discuss fatigue using the
intervention resources.
“…enhanced clinical practice
beyond the RAFT programme.”
a
Niedermann et al, 10, 80%, mean 58.4 (12.8) Study aim: To evaluate the Outcomes (questionnaire): Post intervention Only three of the barriers were
2010 (40): Mixed y; RA diagnosis (ACR class retrospective views (patients Psychological wellbeing, (retrospective) relevant for the majority of
methods II, III or IV), German and OTs) of the benefits and physical wellbeing, potential people with RA; and these
speaking, had previously barriers to the intervention.b benefit, self-acceptance, related to using assistive
used and continued to Intervention: Joint altruism (benefits); negative devices. Perceived benefits of
use hand joint protection protection education, impact on self-image, negative joint protection: Physical
methods. provided individually up to 3 attitude on others, taking time wellbeing. Joint protection use
to 4 hours over several from other things, difficulties/ was consistently related to
sessions. Standard effort (barriers). Outcomes improving pain and function.
education included oral and (demographics): Disease These benefits were also
written information on RA activity, drug therapy, functional considered lead to improved
and joint protection disability. Evaluations psychological wellbeing. Joint
principles, demonstration (interviews): Outcomes above protection was seen as a
and practice of hand joint were used to direct interviews. helpful ergonomic technique
protection methods, and Outcome measures: to help cope with specific
demonstration of assistive Questionnaire, interviews, tasks. Potential benefits: The
devices. DAS28, HAQ (German version). belief of preventing damage
and saving later health costs
varied in strength from hope
to conviction among patients
with RA. The belief in potential
long-term benefits may be an
important motivation.
Personal control: Joint
protection use was
consistently related to making
an active contribution to
physical and psychological
wellbeing. Two participants
emphasized the importance
of staying physically
independent as a benefit of
joint protection use.
Psychological wellbeing: Seven
GAVIN ET AL

(Continued)

patients) and “making an active

contribution” (one patient).
Self-acceptance, self-image and
altruism: The commitment to
performing joint protection
was associated with disease
acceptance. One person
associated a positive self-
image with a positive
perception of their body and
personal control and linked it
to disease acceptance. Being a
role-model when performing
joint protection (on approval
by others) was rated as
relevant by all participants.
Perceived barriers to joint
protection: The themes
“attracting attention/feeling
embarrassed” and “assistive
devices/feeling disabled”
emerged from the key themes
“negative impact on self-image”
and “negative attitudes of
others.” The themes
“complicate task performance”
and “difﬁcult learning”
emerged as key themes from
“difﬁculties/effort.”
Negative impact on self-image/
negative attitudes of others:
No participant reported
negative experiences with
others because of using joint
protection, but some did fear
that using joint protection may
attract attention and lead to
239

(Continued)

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
embarrassment. The main
issue related to the use of
assistive devices giving the
image of being disabled.
Difficulties/effort: Joint
protection was suggested to
make task performance
slower, or more complicated,
earlier in the condition, but it
became a habitual behavior
over time. Once joint
protection was learned, it
became easy. The interview
item “there is too much to learn
to perform joint protection
correctly” seemed particularly
relevant when starting to use
joint protection.
Prior et al, 2022 (37): 19, 63%, Range 30–79 y; Intervention = 10: Fitted three- Evaluations: One-to-one, Post 12-week Themes (postintervention):
Qualitative aged more than 18 y, RA quarter length finger semistructured interviews (in- intervention Mechanisms determining
or undifferentiated Isotoner gloves. Control 9: person or telephone). glove use. Many participants
inflammatory arthritis Fitted loose-fitting three- Experiences of wearing arthritis used gloves indoors to keep
diagnosis. quarter length finger Jobskin gloves for up to 12 weeks hands warm at rest and for
classic edema gloves. Both light activities. Participants
groups: instructed to wear valued the gloves thermal
most of the day and night, qualities:
but not for 24 hr. “As soon as your joints get a bit
warmer, the pain actually
eases.”
Glove use in daily, sedentary
activities was also common,
such as watching television,
reading, or doing light
housework. These did not
require getting the hands wet
or tight gripping.
“It helped a great deal with
support, when I was doing
housework…carrying shopping
bags. It helped then.”
Participants who used gloves at
night during sleep, to help with
night pain and/or morning
stiffness found their warming
and comforting effect helpful.

(Continued)
GAVIN ET AL

pain and function:

“I suppose a normal pair of gloves
would do the same sort of
thing?”
Some could not tell if hand pain
or function had improved, or
not. Others found gloves a
hindrance rather than a help,
because of having to take
them on and off for daily
activities requiring wet hands
or a firm grip.
“I can’t say that I found them
particularly helpful, as I say,
apart from the comfort factor of
having the warmth on my
hands…but I think that’s
probably the only benefit, I
think.”
Some participants found the
appearance of the gloves
acceptable and unobtrusive
and liked that they could cover
their hands.
“I think they are really nice, and
they are like, I can hide my
hands with them, that’s what I
like.”
RCOT, 2022b (61): Mixed N/A Practice guideline Aim: to optimize occupational N/A It is recommended that to
methods performance by improving pain, optimize adherence to
swelling, deformity, self-efficacy, wearing a prescribed orthosis,
dexterity, sensory symptoms, the OT should discuss with the
grip strength, ROM, QOL, self- person:
management strategies • The potential benefits and
limitations

(Continued)
241

Participants: n, % female, Outcomes and outcome

Author, year (ref.) age; inclusion criteria Intervention and control measures Time points Results
• Practicalities of use and
comfort
• Provide the opportunity to try
on orthoses prior to issue, and
routinely follow-up review of
the intervention.
a
95% CI, 95% confidence interval; ACR, American College of Rheumatology; ADL, activities of daily living; AHI, Arthritis Helplessness Index; AIMS, Arthritis Impact Measurement Scale;
AIMS2, Arthritis Impact Measurement Scale 2; AIMS2SF, AIMS Short Form (version 2); AMPS, Assessment of Motor and Process Skills; ASES, Arthritis Self-Efficacy Scale; BRAF-MDQ, Bristol
RA Fatigue Multidimensional Questionnaire; BRAF-NRS, Bristol RA Fatigue Numerical Rating Scale; CBT, cognitive behavioral therapy; CES-D, Center for Epidemiologic Studies Depression
Scale; COPM, Canadian Occupational Performance Measure; DAS28, Disease Activity Score; D-JPBA-S, Joint Protection Behavioural Assessment (German version); EQ-5D-5L, EuroQol-5
Dimensions, 5-level version; EQ-5D-3L, EuroQol-5 Dimensions, 3-level version; ESR, erythrocyte sedimentation rate; EULAR-28, European League Against Rheumatism version - DAS28;
EUROHIS-QUOL8, World Health Organisation Quality of Life Instrument-Abbreviated Version (8-item) Questionnaire; HADS, Hospital Anxiety and Depression Scale; HAQ, Stanford Health
Assessment questionnaire; HAQ-DI, HAQ disability index; HR-QOL, health-related quality of life; IPA, Index of Physical Activity; IRLG, Impact of Rheumatic Diseases on Health and Lifestyle;
JPBA, Joint Protection Behaviour Assessment; MARS, Medication Adherence Report Scale; MCQ, multiple choice question; MDT, multidisciplinary team; MHAQ, Modified Health Assess-
ment Questionnaire; MPI, McGill Pain Index; N/A, not applicable; N/D, not disclosed; NPRS, Numeric Pain Rating Scale; NRS, numerical rating scale; OT, occupational therapy; PAIS, Psycho-
social Adjustment to Illness Scale; PANAS, Positive and Negative Affect Scale; PASS, Patient Acceptable Symptom State; PCI, Pain Coping Inventory; POMS, Profile of Mood States; PRISM,
Pictorial Representation of Illness and Self Measure; PSEQ, Pain Self-Efficacy Questionnaire; QALY, quality-adjusted life-year; QOL, quality of life; RA, rheumatoid arthritis; RAI, Ritchie Artic-
ular Index; Rand-36, Rand Corporation survey; RASE, RA Self-efficacy scale; RASH, Rheumatoid Arthritis Self-Help; RA-WIS, RA Work Instability Scale; RCOT, Royal College of Occupational
Therapists; ROM, range of movement; VAS, visual analog scale; VLA, Valued Life Activities; WIS, Work Instability Scale.
b
Gray literature.
GAVIN ET AL

Feinberg, 1992 (60) + - - - + N/A + H

Furst et al, 1987 (48) + + − ? N/A + − H
Gerber et al, 1987 (49) + + − ? N/A + − H
Hammond, 1994 (43) N/A − − − + N/A + H
Hammond and Lincoln, 1999 N/A N/A − ? ? ? + M
(44)
Hammond and Freeman, + + + − N/A + + M
2001 (33)
Hammond and Freeman, + + + − N/A + + M
2004 (34)
Hammond, Young, and + + − + N/A + + M
Kidao, 2004 (35)
Hammond et al, 2021 (36) + + − ? N/A + + M
Helewa et al, 1991 (24) + + − + + + + M
Hewlett et al, 2019 (38) + + − ? + + + M
Hewlett et al, 2019c (39) + + − ? + + + M
Kashani, 2016c (63) + + − ? − + + H
Kraimaat et al, 1995 (25) ? ? − ? N/A + + M
Lahiri et al, 2021 (62) + + − + N/A + + M
Macedo et al, 2009 (54) + + − - N/A + + H
Masiero et al, 2007 (45) + + − + N/A + + M
Mathiuex et al, 2009 (26) ? ? − ? N/A + − H
Mohanty, Padhan, and Singh, − − − − − N/A − H
2018 (64) Neuberger et al,
1993 (pilot study) (27)
Neuberger et al, 1993 (follow- ? ? − ? − N/A + H
up) (27)
Niedermann et al, 2012 (46) + ? − ? − N/A + H
Pimm, 2003c (53) + ? − + + + + M
Pot-Vaucel et al, 2016 (51) + + ? − + N/A + M
Tonga, Düger, and Karatas, ? ? − − + N/A + H
2016 (55)
Van Vilsteren et al, 2017a (11) + + − − N/A + + H
Van Vilsteren et al, 2017b (28) + - − − N/A + + H
a
Individual item scores were ranked as +, low risk; − high risk; ?, unclear; or n/a, not applicable (eg, studies without randomization). Overall risk of bias for individual studies was ranked as
low, moderate, or high bias according to Rizzo et al (31).
b
Study had no control group.
c
Gray literature.
243

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)

rigorous? of ﬁndings? is the research? Score

7.5

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

been taken into sufﬁciently statement 10. How valuable

(Table 4). The other 6-month RCT40 did not blind participants or
assessors. This involved 6 to 8 sessions (30–120 minutes; at

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

8. Were the 9. Is there a

incorporated four OT sessions (each 60–90 minutes) into a

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

that addressed participants been ethical issues data analysis

blinding.

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

collected in a way researcher and

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

Following home OT, self-care changed from a fear of losing

4. Was the

strategy

N/A
independence to being more accepting of help while continuing
0.5
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

became “a way to increase what I am able to do.”58 Pacing in

appropriate to
3. Was the

daily tasks also became beneﬁcial: “Pacing myself? … take more

0.5
0.5
0.5
0

1
1

pleasure in what I do…instead of thinking about it, I’m actually

Table 5. Quality assessment—CASP for qualitative studiesa

feeling it.”57
Around 80% reported OT recommendations conﬂicted with
clear statement qualitative

personal values, particularly energy conservation advice, self-

2. Is a

0.5

0.5
1
1
1
1
1

pacing, and help-seeking strategies58: “…to ﬁnish what I start

was important … resting made me feel guilty.”57 Patients with
established RA developed rules for moderating daily activities
1. Was there a

based on pain and tiredness.

1
0
0
0
1

1
1

Other interventions. Four studies involving 267 partici-

pants found that splint provision and assistive devices36,37,60,61
Bowell and Ashmore, 1992

Dubouloz et al, 2004 (56)

Dubouloz et al, 2008 (57)

Hewlett et al, 2019b (39)

had little impact on function, pain, and occupational performance.

Niedermann et al, 2010
Author, year (ref.)

Dubouloz, 2008 (58)

Prior et al, 2022 (37)

Other salient splint and device studies targeting RA were identi-

RCOT, 2022b (61)

ﬁed in screening. However, only the four above involved both OT

Gray literature.

and self-management, and were delivered to patients with RA or

undifferentiated inﬂammatory arthritis. The arthritis gloves trial36,37
(41)

(40)

ﬁtted intervention group participants with three-quarter length

Isotoner gloves (exerting 23–32 mmHg pressure), and the control
b
a
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 245

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
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
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
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 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.
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OT IMPACT ON RA SELF-MANAGEMENT 249

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ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A

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ACR Open Rheumatology - 2024 - Gavin - The Impact of Occupational Therapy On The Self Management of Rheumatoid Arthritis A

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ACR Open Rheumatology

Vol. 6, No. 4, April 2024, pp 214–249

The Impact of Occupational Therapy on the

INTRODUCTION improve disease, mental health, and physical outcomes. Occupa-

Review registration number: PROSPERO CRD42022302205.

This is the ﬁrst mixed methods review of the role of OT in the

occupational therapists within the lead reviewer’s (JG) professional

“inﬂammation SPIDER framework: Sample (adults diagnosed with RA),

qualitative and quantitative research), Evaluation/outcome,

included. Based on pilot searches, and to limit the likelihood of

excluding relevant studies, outcomes informed the screening

process but were not included in the ﬁnal search strategy.20

To begin, one reviewer ran the search strategy and removed

duplicates (LR) using EndnoteWeb, then papers were exported

reviewers (LR, VF, and JG) used Rayyan software23 to indepen-

dently screen 20 randomly selected papers. Titles and abstracts

of the pilot papers were screened using a predeﬁned tool based

on the eligibility criteria and published elsewhere.20 Finally, all

three reviewers met to agree on individual papers and reﬁne the

gibility criteria (Supplementary Table 1) to screen titles and

full-text papers to identify papers for data extraction. Disagree-

previous reviews were checked for additional papers.11,24–28

Gray literature screening followed the same process and was

Outcomes. Based on previous reviews,10,13 the primary

quantitative outcomes were function (including strength and

mobility), pain, and fatigue. The primary qualitative evaluation

was lived experience and related concepts, including self-care,

and reﬁned the initial outcomes identiﬁed by the reviewers22;

these were later ﬁnalized by the research team. Some outcomes

were assessed both quantitatively and qualitatively (e.g., self-efﬁ-

Data extraction and quality assessment. Two

reviewers (JG and LR) independently extracted, synthesized,

dardized Microsoft Excel form.20 Data were extracted on general

Participants: n, % female, Outcomes and outcome

changing behavior: problems

Participants: n, % female, Outcomes and outcome

Participants: n, % female, Outcomes and outcome

daily living, advice on Service Interview questionnaire, signiﬁcantly improved

Participants: n, % female, Outcomes and outcome

Participants: n, % female, Outcomes and outcome

management, exercises P = 0.02), and only the

Participants: n, % female, Outcomes and outcome

independently disabled person…

Participants: n, % female, Outcomes and outcome

Seeking or receiving help from

Participants: n, % female, Outcomes and outcome

support were integrated into

Participants: n, % female, Outcomes and outcome

patients) and “making an active

Participants: n, % female, Outcomes and outcome

pain and function:

Participants: n, % female, Outcomes and outcome

Feinberg, 1992 (60) + - - - + N/A + H

rigorous? of ﬁndings? is the research? Score

been taken into sufﬁciently statement 10. How valuable

8. Were the 9. Is there a

that addressed participants been ethical issues data analysis

collected in a way researcher and

Following home OT, self-care changed from a fear of losing

became “a way to increase what I am able to do.”58 Pacing in

daily tasks also became beneﬁcial: “Pacing myself? … take more

pleasure in what I do…instead of thinking about it, I’m actually

personal values, particularly energy conservation advice, self-

pacing, and help-seeking strategies58: “…to ﬁnish what I start

based on pain and tiredness.

Other interventions. Four studies involving 267 partici-

Dubouloz et al, 2004 (56)

Hewlett et al, 2019b (39)

had little impact on function, pain, and occupational performance.

Dubouloz, 2008 (58)

Prior et al, 2022 (37)

Other salient splint and device studies targeting RA were identi-

ﬁed in screening. However, only the four above involved both OT

and self-management, and were delivered to patients with RA or

ﬁtted intervention group participants with three-quarter length

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