Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Occupational therapy home service improved rheumatoid arthritis

ACP J Club. 1991 Nov-Dec;115:77. doi:10.7326/ACPJC-1991-115-3-077


Source Citation

Helewa A, Goldsmith CH, Lee P, et al. Effects of occupational therapy home service on patients with rheumatoid arthritis. Lancet. 1991 Jun 15;337:1453-6.


Abstract

Objective

To determine the efficacy of an occupational therapy home service (OTHS) in patients with rheumatoid arthritis.

Design

Randomized controlled trial of 6 weeks duration, with an additional 6 weeks during which control patients also received the intervention.

Setting

Referrals to the Toronto Arthritis Society home service.

Patients

Patients aged 18 to 70 years, who met the American Rheumatism Association criteria for definite or classical rheumatoid arthritis, and had limitations in physical function, stable clinical status and drug therapy, and no recent intraarticular treatment or surgery. 155 of 427 patients met these criteria. 96% were assessed after 12 weeks.

Intervention

53 patients were randomized to OTHS and 52 to the control group. At ≤ 10 days after referral and an independent baseline assessment, patients in the OTHS group were evaluated by an experienced occupational therapist. The evaluation included medical and social history; assessment of active and damaged joints, grip strength, and morning stiffness; and evaluation of activities of daily living (e.g., personal care, communication, locomotion, homemaking). Treatment to achieve optimal functioning included aids and adaptations, education, and counseling. The control group received the same intervention after 6 weeks, whereas the intervention group continued to receive less intensive OTHS.

Main outcome measures

A global measure of functional ability, scored on a prevalidated scale, was designated as the primary outcome. Secondary outcomes were the "pooled index"; pain, as assessed on a visual analog scale; the Beck depression scale; and the Stanford Health Assessment Questionnaire (HAQ).

Main results

At 6 weeks, mean functional score had risen about 10 points for the OTHS group and remained almost unchanged for the control group (difference in improvement, 8.1, 95% CI 1.7 to 15.8, P = 0.012). The OTHS group improved on the "pooled index" (P = 0.04), but no difference existed between the groups in pain assessment scores, Beck depression scores, or HAQ scores. Similar improvements occurred in the control group after 6 weeks of OTHS. At 12 weeks no difference existed between groups on any measure.

Conclusion

Occupational therapy home service, for a period of 6 weeks, improved the day-to-day functioning of patients with rheumatoid arthritis.

Sources of funding: The Ontario Ministry of Health and the Conn Smythe Foundation.

Address for article reprint: Professor A. Helewa, Department of Physical Therapy, Elborn College, University of Western Ontario, London, Ontario N6G lH1, Canada.


Commentary

Establishing the benefit of occupational therapy (OT) for rheumatoid arthritis by rigorous scientific methods has been plagued by the lack of reliable instruments to quantify outcomes as well as by the difficulty in controlling such studies.

In the last decade, the authors of this study and other researchers have developed and refined instruments that measure functional status, quality of life, and utility in rheumatoid arthritis (1). A common feature of these instruments, which include the Arthritis Impact Measurement Scales (AIMS), the Health Assessment Questionnaire (HAQ), and the authors' open functional assessment device, is their administration by questionnaire. They measure the subjective response of the patient.

Although this study was conducted in a manner intended to blind the investigators, it could not blind the patients who received the intervention. These patients, by subsequently completing the questionnaire, judged the primary outcome. The placebo effect inherent in this study design is too powerful to ignore. The attention given in the intervention limb is obvious. Even a seemingly objective measure of grip strength is subject to patient effort. Although the authors argue to the contrary, their discussion indicates their recognition of this difficulty.

Despite the previous comments, much of the advice and therapy offered to our patients is empiric. Who can possibly argue against the apparent benefits of patient education, instruction in joint preservation, and aids to daily living, especially in the absence of associated risk?

This study shows the feasibility of using advanced techniques in assessing functional outcomes in the treatment of rheumatoid arthritis. Further refinement of methods to control for placebo effects will make the utility of future studies more powerful.

Robert A. Hawkins, MD
Wright State UniversityDayton, Ohio, USA


Reference

1. Bell MJ, Bombardier C, Tugwell P. Measurement of functional status, quality of life, and utility in rheumatoid arthritis. Arthritis Rheum. 1990;33:599-601.