Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a long-term, chronic autoimmune disease and is categorized as an inflammatory arthritic condition.¹ Inflammatory arthritis affects the joints of the body, causing deterioration of joint cartilage and bone. This can lead to loss of range of motion and functional abilities.¹ Although RA primarily attacks the synovial joints of the body, the disease may cause inflammation in other organ systems such as the skin and circulatory organs, particularly if the condition is left untreated.² RA can impair an individual’s ability to perform a variety of everyday activities.³ An occupational therapist can provide a variety of services to assist clients in managing their symptoms as well as maintaining, restoring, or improving their function.

Etiology of Rheumatoid Arthritis

RA is the result of improper immune functioning which results in immune cells attacking healthy joints. Although the etiology of RA is unknown, both immuno-genetic risk factors and environmental factors are involved in RA’s progression.⁴

RA is not directly inherited, but susceptibility to develop RA can be inherited. MacGregor et al⁵ used quantitative genetic methods to assess the heritability of RA in two nationwide studies of twins with RA in Finland and the United Kingdom. The result indicated that genetic factors account for about 60% of the population liability to RA.

Epidemiological studies indicate cigarette smoking is a significant environmental risk factor for RA.⁶ Moreover, the influence of smoking is greater in people with genetic susceptibility.⁷ Another environmental risk factor is silica exposure. Stolt et al⁸ found that men who had worked in rock drilling or stone crushing (classed as a high exposure to silica) had a threefold increased risk of RA. Infection is implicated as an initiator of the inflammatory process and the most consistent evidence comes from Epstein–Barr virus (EBV). Balandraud et al⁹ found the EBV DNA load in peripheral blood mononuclear cells of RA patients was 10 times that of controls. EBV has also been detected in the synovial fluid of RA patients suggesting that it may play a role in the pathogenesis of RA.¹⁰

Prevalence of Rheumatoid Arthritis

RA affects individuals worldwide. Although it affects all ethnic groups, North American Indians and Caucasians tend to be affected more often than African Americans, Japanese and Chinese.⁴ About 1%, or 300, 000, of Canadians have RA. RA can occur at any age, but the prevalence rises with age. RA symptoms usually appear between the ages of 35 and 50 years old. Women are roughly 3 times more likely to be affected than men.⁴

Common signs and symptoms (and differential diagnosis, if appropriate) of the condition

The onset of RA varies, and while the disease often begins slowly, onset may also occur suddenly.² While the course of RA is commonly marked by fluctuating periods of remission and exacerbation, the course of the disease varies considerably across individuals.¹¹ However, the course of the disease varies considerably across individuals. For example, some individuals with RA experience brief, mild monoarticular involvement with minimal joint damage while others experience ongoing progression of the disease, polyarticular involvement and significant joint deformity.⁴

During onset of RA, symptoms are often general and common to many other conditions, therefore diagnosis can be difficult. Symptoms at this stage may include pain, loss of appetite, low fever, swollen glands, fatigue and weakness.²

Stages of Inflammation and Symptoms

There are four stages of the inflammatory process: acute, subacute, chronic-active and chronic-inactive.⁴ During the acute and sub acute phases, fatigue generally increases significantly and may lead to joint disuse, loss of joint ROM and muscle atrophy.⁵ Research has shown that over 60% of those who experience exacerbations feel symptoms of weakness, fatigue, malaise, and possible signs of weight loss.^4,12 Further, as noted during a lecture by L. Li, PT,(February, 2011), fatigue is one of the primary symptoms impairing function and engagement in occupation.

Other acute and subacute inflamatory symptoms include general aching, pain and soreness followed by possible tingling/numbness, localized joint pain, localized joint warmth and joint swelling. Swelling can range from moderate to severe during acute and sub-acute phases and is a consequence of synovial thickening, enlargement of the joint capsule and accumulation of synovial fluid.⁴ Synovial thickening causes generalized stiffness including the inability to move joints after sleep or rest, known as the gel phenomenon.⁴

Inflammation may cause joint redness (rubor) in some individuals during the acute phase, changing to a pink colour during subacute inflammation.⁴ Symptoms are most commonly polyarticular⁵ and cause significant joint stiffness, most often occurring symmetrically.¹¹ Decreased range of motion due to pain and swelling is very common during the acute phase while poor endurance and decreased muscle strength often occur during the sub acute phase.

During the chronic-active phase, contractures may form due to avoidance of moving due to significant pain experienced during the acute phase.⁴

Morning Stiffness

Morning stiffness is an almost universal, unique symptom of RA which can help differentiate RA from other conditions.⁴ In most individuals, morning stiffness can take at the individual an hour or more to loosen up.¹¹ However, stiffness may also last the entire day, with many individuals experiencing some level of pain throughout the day and night.¹¹

Specific Joint Changes and Joint Manifestations

RA most commonly affects the small joints of the hands, feet and ankles, and spine, with the hands being the most severely affected by RA.⁴ More specifically, the wrists, proximal interphalangeal (PIP) joints and metacarpal phalangeal (MCP) joints of the fingers, elbows, metatarsophalagneal joints of the toes, and temporomandibular joints are often affected.¹¹ Other joints that may be affected include shoulders, hips, knees, jaw and neck.²

Deformities of the PIP, DIP and CMC joints occur in some individuals with RA and can impair functioning of the hands and interfere with performance of activities of daily living.¹¹ For example, a boutonniere is a deformity of the fingers or toes in which PIP hyperflexion is combined with DIP hyperextension. Swan neck deformities result in hyperextension of the PIP joint and flexion of the DIP joint.⁴

Nodules

Rheumatoid nodules are a common extra-articular manifestation of rheumatoid arthritis.¹³ Nodules are often located subcutaneously over bony prominences such as the elbow or the heel bone.¹³ Less commonly, nodules may be found in the lungs, heart and liver which can cause medical complications in rare cases.¹³ Rheumatoid nodules affect approximately 20-30% of individuals with RA¹⁴ and are usually painless and asymptomatic¹³ posing little or no interference with range of motion or function (L.Li, PT, verbal communication, February 2011).

Other Symptoms

Due to the fact that RA is a systemic condition, other body systems may be involved. Symptoms may range from mild, non-specific problems such as sore throat, dysphagia, and eye burning/itching, to more serious complications such as airway obstruction, stridor and cricothyroid joint abnormalities.¹⁴

Diagnosis

Diagnosis can be difficult as early symptoms are often subtle and may be confused with other diseases. Furthermore, there is no single test that verifies diagnosis. Due to the difficulty in diagnosis, a rheumatologist should evaluate those suspected to be developing RA and take special note of the individual’s medical history.¹⁵ Consultation with the revised diagnostic criteria from the 1987 American Rheumatism Association (ARA) can also be helpful for diagnostic purposes. The ARA states that the individual must meet four or more of the following criteria, with criteria 1 through 4 being present for a minimum of 6 weeks¹⁶:

morning stiffness in and around joints lasting at least 1 hour before maximal improvement
soft tissue swelling of 3 or more joint areas observed by a physician
swelling of the PIP, MCP or wrist joints
symmetric swelling
rheumatoid nodules
the presence of rheumatoid factor
radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints

The American College of Rheumatology¹⁶ notes that additional tests that help with diagnosing RA may include:

Anemia
Increased rate of erythrocyte sedimentation (confirms level of inflammation in joints)
Antibodies to cyclic citrullinated peptides (CCP)
X-rays may also aid diagnostics of RA if disease progression is beyond first 3-6 months; may also aid in determining rate of progression
Rating the severity of RA is completed via use of Ultrasounds and MRI’s

Implications for Occupations

RA can have a significant impact on an individual’s occupational performance. The Canadian Association of Occupational Therapists defines occupations as the “activities and tasks of everyday life”.^{17 p34} Occupations may be grouped into three main categories: self-care, productivity, and leisure. Self-care tasks are those that involve taking care of oneself, such as bathing or feeding. Productivity includes occupations that allow an individual to make an economic or social contribution to a community. This might include paid employment, childcare, or being a student. Leisure includes activities that people do for enjoyment or recreation.¹⁷

Because the symptoms and joints involved in RA are so variable, the impact of the disease on daily life also varies from person to person. However, the pain, stiffness, limited range of motion, joint deformity and fatigue that typically accompany RA can cause a variety of functional problems with everyday activities.³ Backman, Fairleigh, and Kuchta¹⁸ note that RA symptoms can significantly affect daily routines. For example, an individual may struggle to get to work on time due to morning stiffness or may spend their weekend recovering from a busy workweek and may consequently be unable to engage in their usual housework or leisure activities.

Gueskens, Burdorf, and Hazes¹⁹ add that the effects of RA may range from difficulty with simple tasks, such as brushing one’s hair to more complex occupations, such as maintaining paid employment. In their research, Lutze and Archenholtz²⁰ found that patients with RA reported needing to adjust their activities according to their energy level. They reported that if they did too much in a day, they often had difficulty doing things in the days following. Participants also reported giving up valued activities because they caused pain, stiffness, or fatigue. Activities they had given up were mostly leisure or work-related. In their research, Reinseth and Espnes⁴ found that women with RA reported a significant decrease in engagement in non-vocational activities (which included leisure and household activities) over the last 10 years of their life.

Self-Care

People with RA may have difficulty with various self-care tasks, ranging from being able to use the toilet to feeding themselves. Backman, Fairleigh, and Kuchta¹⁸ provide the following examples:

Difficulty washing or styling hair due to shoulder pain, limited ROM, and weakness
Unable to get in and out of bathtub due to hip or knee pain, limited ROM, and weakness.
Unable to button shirts, due to unstable hand joints.

In their research, Lutze and Archenholtz²⁰ found that participants commonly reported difficulty in performing self-care tasks, such as managing their personal hygiene, and also commonly reported having to depend on others for help. Research has also indicated that those with RA tend to spend more time engaged in self-care tasks and less time in paid work and child-care occupations than individuals without chronic illness.²¹ This shift in time use may also increase with the severity of RA. Katz and Morris²² found that severity of RA was associated with spending more time in self-care activities than in areas of productivity or leisure.

Productivity

RA may affect various aspects of productivity. Some examples, provided by Backman, Fairleigh, and Kuchta¹⁸ include:

Difficulty using a keyboard and mouse for extended periods of time at work due to wrist pain.
Difficulty with tasks involved in preparing a meal (for example, lifting pots, handling utensils) due to pain in hands and weak grip strength.
Difficulty opening the car door and turning the ignition key due to thumb pain.

Research indicates that adults with RA work significantly less hours of both paid and unpaid work than healthy controls.²³ Backman, Kennedy, Chalmers, and Singer²⁴ note that estimates of employment disability in individuals with RA have ranged from 22-38%. In their research, they found that a group of participants with RA reported working on average eight hours fewer per week than has been reported for the general of Canada for the same age. Thirty percent of the participants in research by Forhan and Backman²¹ reported that the number of hours they participated in their main occupation, which was usually paid or unpaid work, was limited by their RA.

As noted, RA affects not only paid employment but also unpaid work. Backman, Kennedy, et al²³ found that more than half of the participants in their research reported difficulty with cleaning, laundry, and shopping. Of those who had young children in this research, 29% reported that their childcare abilities were limited due to their RA.

Work limitations appear to depend on the severity of RA. Women with more severe RA have reported more limitation in performing household work than women with mild or no RA.²³ Backman, Kennedy, et al²³ found that participants who reported work limitations due to RA reported more active disease, more pain, and more fatigue than those with RA who reported no work limitations.

Leisure

As noted, RA may have a significant effect on the leisure activities individuals engage in. Some examples of RA’s effect on leisure activities provided by Backman, Fairleigh, & Kuchta¹⁸ include:

Difficulty Gardening, related to fatigue, limited ROM, and decreased grip strength
Difficulty reading, due to neck pain and weakness
Difficulty playing golf, due to ankle pain.

Research indicates that following a diagnosis of RA, the number of leisure activities individuals engage in tends to decrease. In their research, Wikstrom, Isacsson, and Jacobsson²⁴ considered the leisure interests of individuals before and after their diagnosis of RA. They found that:

Leisure activities that individuals engaged in decreased following a diagnosis of RA. Participants reported an average of 3 leisure activities before their diagnosis and an average of 1 leisure activity after their diagnosis. On average, participants had given up two thirds of their leisure activities.
Morning stiffness was significantly correlated with the loss of leisure activities.
Participants reported giving up leisure activities mainly that required strength (for example, going to the gym) and those that required fine motor dexterity (for example, sewing). The activities that they had remained in were typically more passive ones, such as watching television or visiting with friends.

Although RA can clearly have an effect on an individual’s leisure activities, it does not mean that individuals are unable to engage in recreational activities. In their research, Mock, Fraser, Knutson, and Prier²⁵ found that despite limitations, most of the participants they studies engaged in some form of active leisure. The most common activities reported were walking, gardening, and home exercise.

How occupational therapy can help to address the identified occupational performance issues

Occupational therapy (OT) is a client-centred profession that can provide a variety of services to individuals with RA. The pain, stiffness, joint deformity, and fatigue that typically accompany RA often contribute to limitations in function. As noted, RA may affect one’s ability to independently perform activities of self-care or to engage in meaningful activities related to productivity, leisure, or important life roles (e.g. one’s role as a mother).²⁶ OTs are interested in enabling clients to do the activities that they need and want to do. For clients with RA, OT interventions are “directed at resolving functional limitations while managing symptoms such as pain and fatigue”.^{18 p432} The role of the OT is to assist clients in developing strategies and solutions for maintaining, restoring, or improving the skills and abilities required to engage in meaningful activities.²⁷ OTs can assist people with RA by providing education and support on subjects such as pain management, joint protection, and energy conservation; OTs may also suggest assistive devices or environmental modifications to compensate for a loss in function.²⁷ What is unique to OT is that client self-reflection is encouraged throughout intervention.²⁸ An OT might ask you to describe a typical day and identify the activities that are most challenging and most meaningful for you. Through collaboration and shared decision-making, the OT and client can work together to tailor the intervention to meet individual needs and personal goals. OT also involves assessment, intervention and ongoing evaluation for clients.

Education surrounding energy conservation and joint protection is a key component of OT services for clients with RA. For example, energy conservation techniques might involve planning, pacing, and prioritizing important activities in order to manage fatigue.¹⁸ The following examples of joint protection methods can also play an important role in reducing pain and fatigue²⁷:

Respect pain
Balance activity and rest
Maintain muscle strength and joint range of motion
Use each joint in its most stable position
Avoid positions of deformity
Use the strongest and largest joints available for the job (eg. Carry your purse on your forearm rather then in your hand)
Avoid activities that cannot be stopped immediately (in case you feel pain or fatigue)
Ensure correct patterns of movement
Avoid staying in one position for long periods of time
Use both hands whenever possible

Splinting is another method that an OT can use to assist clients with joint protection and pain management. A splint is a device that can immobilize, restrain, or support a joint.¹¹ Resting splints for the wrist, hand, and fingers are often custom-fit by OTs to reduce joint stress and provide rest and support to joints that may be painful and/or inflamed.²⁹ Although resting splints do not correct or prevent deformity caused by RA, they may assist in delaying the progression of deformity.¹¹ A splint may also be designed to provide stability, enhance function, and realign or reposition joints during activity.¹⁸

Splinting immobilizes the affected joints and protects them from further damage. While splinting can be an effective way to deal with rheumatic joints it is also very important to maintain joint mobility and range of motion. The loss of joint mobility and range of motion may have functional implications. An OT may recommend gentle exercises such as stretching, water aerobics, or bike riding to improve range of motion.¹¹

To encourage self-management an OT can also provide strategies and support. The role of an OT is to encourage individuals to take an active role in managing their condition.This often includes the development of new life skills in the areas of problem solving, self-monitoring, and communication (Radomski & Trombly, 2008). Because pain, fatigue, and morning stiffness are typical symptoms of RA, the OT will often recommend strategies for modifying daily routines.¹⁸ Together, the OT and the client can identify potential strategies, such as planning ahead and adjusting schedules and routines.¹⁸ The OT might also assist the client in identifying personal strengths, social support networks, and community resources.

Individuals with RA may also experience difficulty with sexual expression. For example, “pain and stiffness in joints can lead to avoidance or limited sex”.^{11 p1230} OT intervention might include the provision of resources and education about planning for more comfortable sex. For example, finding more comfortable positions or taking a warm bath before sex to relax are strategies that can help.^{11 p1230}

The OT might also recommend making changes to the client’s physical environment. A client’s living space might be arranged in such a way that it requires the client to use more energy than is necessary to complete certain tasks. For example, re-arranging the kitchen by moving dishes and frequently used food items to lower shelves may reduce unnecessary reaching and fatigue.⁴ An OT might perform a home visit to identify safety concerns and make further recommendations for change (e.g. installing a walk-in shower). Similarly, an OT can also visit the client’s workplace to propose alternative methods of performing tasks and to recommend physical changes that can “accommodate the client’s pain and/or functional limitations”.^{18 p432}

The OT might also recommend the use of assistive devices. An assistive device is “any product used to maintain or improve function”.^{18 p436} There are a variety of assistive devices that can help to reduce the amount of physical effort that a person must exert during daily tasks. For example, an individual with RA who has difficultly grasping objects might choose to adapt kitchen utensils, toothbrushes, and door handles by adding large grips that reduce the range of motion and force required and are easier to grasp.¹¹ Jar openers, long-handled reachers, raised toilet seats, and extended key handles are all examples of assistive devices that can help an individual with RA overcome physical limitations and improve their functional abilities.

Conclusion

Rheumatoid Arthritis is an inflammatory autoimmune disease that affects one out of one hundred Canadians.¹² Symptoms include inflammation, heat, and pain in joints. These symptoms are most prevalent in the wrist, PIP, MCP, elbow, MTP, and temporomandibular joints.¹¹ An individual with RA may experience various limitations in function. For example, RA may impact one’s ability to independently perform self-care, productivity, or leisure occupations. An occupational therapist can work with the client to develop strategies and solutions for managing symptoms and maintaining or improving functional abilities.

References

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