Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy

Occupational impacts of early inflammatory arthritis: results from the National Early Inflammatory Arthritis Audit

OBJECTIVES

Inflammatory arthritis causes significant work disability. Studies regarding this frequently fail to report important contextual information such as employment type. Our objective was to explore work participation, by gender and occupation type, in early inflammatory arthritis.

METHODS

Data are from the National Early Inflammatory Arthritis Audit for 2018-2020. At diagnosis, clinicians collected information on demographics, inflammatory arthritis disease activity, and working status. Participants completed patient-reported outcomes at baseline, 3 months and 12 months, including occupation and Work Productivity and Activity Impairment (WPAI). Descriptive analyses of work participation and WPAI scores by occupational class at all time points were performed. Regression models were used to examine associations between WPAI score and occupation.

RESULTS

In all, 12 473 people received a diagnosis of inflammatory arthritis and reported employment status, among whom 5999 (47%) were in paid work for at least 20 hours/week. At diagnosis, the working cohort had statistically significant lower measures of disease activity (P < 0.001). Occupational data were available for 3694 individuals. At diagnosis, 2793 completed a WPAI; 200 (7.2%) had stopped work and 344 (12.3%) changed jobs because of inflammatory arthritis symptoms. There was a high burden of absenteeism (30%) and presenteeism (40%). Compared with managerial or professional workers, the burden of work disability was greater among those in routine (manual) occupations. During follow-up, 9.4% of WPAI completers stopped work and 14.6% changed roles. Work drop-out occurred almost entirely among people doing routine jobs.

CONCLUSION

It is easier to retain work in certain employment sectors. Participation in routine jobs is more affected, which may widen health inequalities.

Protocol for a pragmatic randomised controlled feasibility study of MS WorkSmart: an online intervention for Australians with MS who are employed

INTRODUCTION

Multiple sclerosis (MS) causes a wide variety of symptoms. Loss of income due to sickness and early retirement comprise one-third of the total cost of MS in Australia. An intervention that maximises work productivity and keeps people with MS in the workforce for longer could provide a large societal cost saving and improve quality of life. The aim is to test the feasibility of delivering and evaluating a 10-week digitally delivered intervention called 'MS WorkSmart'. Findings will provide insights into participant profiles and address key methodological and procedural uncertainties (recruitment, retention, intervention adherence and engagement, and selection of primary outcome) in preparation for a subsequent definitive trial.

METHODS AND ANALYSIS

A parallel-arm randomised controlled feasibility study, comparing those randomised to receive the MS WorkSmart package plus usual care (n=20) to those receiving usual care only (n=20). Australians with MS, aged 18-60 years, who are employed, and self-report work instability will be recruited from the Australian MS Longitudinal Study. Online surveys, at baseline and 1-month postintervention, will include MS-related work productivity loss and risk of job loss, MS work behaviour self-efficacy, health-related quality of life, fatigue severity, MS symptom impact on work, intention to retire due to MS, MS-related work difficulties, and awareness and readiness for change at work. Qualitative feedback will be obtained via a semistructured survey following the intervention (for participants) and via interviews (coaches). Analyses will be primarily descriptive and focus on the feasibility and acceptability of the intervention and study procedures. Progression criteria will guide decisions around whether to progress to a full trial.

ETHICS AND DISSEMINATION

The study has been approved by the University of Tasmania Human Research Ethics Committee (H0024544). Findings will be disseminated via publication in peer-reviewed journals, conference presentations and community presentations.

TRIAL REGISTRATION NUMBER

ACTRN12622000826741.

Predictors of Remission or Combined Remission and Low Disease Activity in Rheumatoid Arthritis Patients in Taiwan: A Prospective Cohort Study

Objectives: This study aimed to identify predictors of remission or low disease activity (LDA) in patients with rheumatoid arthritis (RA) and low-ultrasound inflammation. Methods: A total of 80 patients with RA who fulfilled the 1987 ACR criteria for RA with a disease activity score of 28 joints (DAS28) > 3.2 were recruited. Over 1 year of therapy, we conducted blood tests every 6 months to examine erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), monocyte chemotactic protein-1 (MCP-1), neuraminidase 3 (Neu3), and α-2,3-sialyltrasnferse I (ST3Gal-1) levels in B cells and monocytes. Additionally, we evaluated physical function by using the Health Assessment Questionnaire-Disability Index (HAQ-DI). Data on demographic and clinical parameters were collected, and musculoskeletal ultrasonography was performed twice a year on 12 specific joints to assess synovial changes. One year later, we compared all collected data and laboratory or ultrasound results between patients achieving remission or LDA and those who did not in order to determine the predictors. Results: Age, the presence or absence of rheumatoid factor, and the number of conventional disease-modifying anti-rheumatic drugs used were not correlated with remission or LDA for DAS28 or Simplified Disease Activity Index formulas. However, male sex, low CRP levels, low ESR levels, and low HAQ-DI scores were associated with a higher likelihood of achieving remission or LDA for DAS28-ESR. Negative anticyclic citrullinated peptide (CCP) and low HAQ-DI scores were predictors of remission or LDA for DAS28-MCP-1. Interestingly, having less than two comorbidities is a good predictor of a combined remission/low disease activity state for SDAI and DAS28-MCP-1. Furthermore, Neu3 and ST3Gal-1 levels and ST3Gal-1/Neu3 ratios in B cells and monocytes had no significant correlation with total ultrasound scores. Nevertheless, monocyte ST3Gal-1 and Neu3 correlated significantly with DAS28-ESR >5.1 and DAS-MCP-1 >4.8 (both categories belong to high disease activity), respectively (rho = 0.609 with p = 0.012, and rho = 0.727 with p = 0.011, respectively). Monocyte ST3Gal-1/Neu3 ratios connected with DAS28-ESR >5.1 and 3.3 < SDAI ≦ 11 (low disease activity), respectively (rho = 0.662 with p = 0.005, and rho = 0.342 with p = 0.048, respectively). Conclusions: In patients with RA in Taiwan, male sex, low CRP levels, low ESR levels, and low HAQ-DI scores are predictors of remission or LDA for DAS28-ESR, which differ from the predictors for DAS28-MCP-1. Moreover, monocyte ST3Gal-1, Neu3, and their ratios correlated with different disease activity categories of DAS28-ESR, DAS28-MCP-1, and SDAI scores.

The Impact of Occupational Therapy on the Self-Management of Rheumatoid Arthritis: A Mixed Methods Systematic Review

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 support 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.

Development of a Multimodal, Physiotherapist-Led, Vocational Intervention for People with Inflammatory Arthritis and Reduced Work Ability: A Mixed-Methods Design Study

PURPOSE

Work ability of people with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) is reduced, but underexamined as a clinical treatment target. The evidence on vocational interventions indicates that delivery by a single healthcare professional (HCP) may be beneficial. Physiotherapist (PT)-led interventions have potential because PTs are most commonly consulted by RA/axSpA patients in the Netherlands. The aim was to develop a PT-led, vocational intervention for people with RA/axSpA and reduced work ability.

METHODS

Mixed-methods design based on the Medical Research Council (MRC) framework for developing and evaluating complex interventions, combining a rapid literature review and six group meetings with: patient representatives (n = 6 and 10), PTs (n = 12), (occupational) HCPs (n = 9), researchers (n = 6) and a feasibility test in patients (n = 4) and PTs (n = 4).

RESULTS

An intervention was developed and evaluated. Patient representatives emphasized the importance of PTs' expertise in rheumatic diseases and work ability. The potential for PTs to support patients was confirmed by PTs and HCPs. The feasibility test confirmed adequate feasibility and underlined necessity of training PTs in delivery. The final intervention comprised work-focussed modalities integrated into conventional PT treatment (10-21 sessions over 12 months), including a personalized work-roadmap to guide patients to other professionals, exercise therapy, patient education and optional modalities.

CONCLUSION

A mixed-methods design with stakeholder involvement produced a PT-led, vocational intervention for people with RA/axSpA and reduced work ability, tested for feasibility and ready for effectiveness evaluation.

Occupational therapy in the management of haemophilia patients: A scoping review

BACKGROUND

Haemophilia is a haematological disease, although most haemorrhages occur in the locomotor system. Patients are physically disabled from an early age and have a poorer perception of quality of life. In the day-to-day lives of patients and their families, psychosocial well-being, the disease's physical, personal, and social impact, as well as work-related problems are the most complicated aspects of the disease that need to be addressed.

OBJECTIVE

To identify the role of occupational therapy in managing patients with haemophilia and to analyse the therapeutic potential of occupational therapy in treating these patients.

METHODS

A scoping review was conducted to identify the role of occupational therapy in managing patients with haemophilia and to analyse the therapeutic potential of occupational therapy in treating these patients. The review was registered in the international registry PROSPERO (Id: CRD42022319637). The databases consulted were SCOPUS, PubMed, PsycINFO, Web of Science and Science Direct, including all studies published until 14 August 2023.

RESULTS

No single study was found that specifically developed an occupational therapy intervention for patients with haemophilia. Measurement instruments have been identified, specific for patients with haemophilia and generic, that can be useful for the functional evaluation of these patients in the occupational therapy approach. Different studies showed the importance of multidisciplinary treatment, including occupational therapy.

CONCLUSIONS

The use of occupational therapy could be effective in improving autonomy and quality of life in haemophilia patients. Therefore, it is of paramount importance to conduct research studies within the field of occupational therapy.

Effectiveness and cost-effectiveness of a multimodal, physiotherapist-led, vocational intervention in people with inflammatory arthritis: study protocol of the Physiotherapy WORKs trial

BACKGROUND

Although reduced work ability is a substantial problem among people with inflammatory arthritis (IA), work ability is an underexposed area in clinical practice. Evidence on vocational interventions in IA is limited, but favourable results of delivery by a physiotherapist (PT) warrant the need for further research. Therefore, we aim to evaluate the (cost-)effectiveness of a multimodal, PT-led, vocational intervention in (self-)employed people with IA compared to usual care.

METHODS

This randomized controlled trial will include 140 people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) who are (self-)employed and have reduced work ability (Work Ability Index - Single Item Scale (WAS) ≤ 7/10) and/or RA/axSpA related sick leave (≤ 6 months). Participants will be randomized 1:1 to the intervention or control condition (usual care). The intervention, delivered by primary care PTs, will be personalized to each patient, consisting of 10 to 21 sessions over 12 months. The intervention will be multimodal, comprising of 1) exercise therapy and a physical activity plan, 2) education/self-management support, 3) work-roadmap to guide participants in finding relevant other care, with optionally 4) online self-management course and 5) workplace examination. Assessments will be performed at baseline and after 3, 6, and 12 months. The primary outcome measure of effectiveness is work ability, as measured with the WAS at 12 months. For the cost-effectiveness analysis, the EuroQol (EQ-5D-5L), self-reported healthcare use, sick leave and productivity while at work will be used to estimate the trial based cost-utility from a societal perspective. A process evaluation, including assessments of adherence and treatment fidelity, will be undertaken using the registrations of the PTs and semi-structured interviews at 12 months follow-up in a random sample of the intervention group.

DISCUSSION

The results of this study will provide insights in the (cost-)effectiveness of a multimodal, PT-led, vocational intervention in people with IA and a reduced work ability.

TRIAL REGISTRATION

This study is registered in the International Clinical Trial Registry Platform (ICTRP) under number NL9343.

Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVE

To identify the best evidence on the efficacy of non-pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs.

METHODS

Systematic review of randomised controlled trials (RCTs) including adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. Data were pooled in meta-analyses.

RESULTS

From a total of 4150 records, 454 were selected for full-text review, 82 fulfilled the inclusion criteria and 55 RCTs were included in meta-analyses. Physical activity or exercise was efficacious in reducing fatigue in rheumatoid arthritis (RA) (standardised mean differences (SMD)=-0.23, 95% CI=-0.37 to -0.1), systemic lupus erythematosus (SLE) (SMD=-0.54, 95% CI=-1.07 to -0.01) and spondyloarthritis (SMD=-0.94, 95% CI=-1.23 to -0.66); reduction of fatigue was not significant in Sjögren's syndrome (SMD=-0.83, 95% CI=-2.13 to 0.47) and systemic sclerosis (SMD=-0.66, 95% CI=-1.33 to 0.02). Psychoeducational interventions were efficacious in reducing fatigue in RA (SMD=-0.32, 95% CI=-0.48 to -0.16), but not in SLE (SMD=-0.19, 95% CI=-0.46 to 0.09). Follow-up models in consultations (SMD=-0.05, 95% CI=-0.29 to 0.20) and multicomponent interventions (SMD=-0.20, 95% CI=-0.53 to 0.14) did not show significant reductions of fatigue in RA. The results of RCTs not included in the meta-analysis suggest that several other non-pharmacological interventions may provide a reduction of fatigue, with reassuring safety results.

CONCLUSIONS

Physica activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

Physical Exercise and Occupational Therapy at Home to Improve the Quality of Life in Subjects Affected by Rheumatoid Arthritis: A Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that affects synovial membranes and typically causes joint pain and swelling. The resulting disability of RA is due to the erosion of cartilage and bone from the inflamed synovial tissue. Occupational therapy is a strategy and technique to minimize the joints' fatigue and effort. At the same time, physical exercise reduces the impact of systemic manifestations and improves symptoms in RA. This study investigates the role of a 30-day joint economy intervention (integration of physical exercise and occupational therapy) at home on the quality of life of subjects with RA.

METHODS

One hundred and sixty outpatients with RA were enrolled in a single-center trial with PROBE design and were divided into the intervention group (IG), which combined joint protection movements and physical exercise to maintain muscle tone at home, and the control group (CG). Both groups included 80 patients. In all patients, data from the disease activity score (DAS 28), health assessment questionnaire (HAQ), and short-form health survey (SF-12) "Italian version" were collected. In addition, to IG, a brochure was distributed, and the joint economy was explained, while to CG, the brochure only was distributed. The comparison between groups was made using Fisher's exact test for contingency tables and the z-test for the comparison of proportions. The non-parametric Mann-Whitney U test was used to compare quantitative variables between groups. The Wilcoxon signed-ranked test was used for post-intervention versus baseline comparisons.

RESULTS

Among the recruited patients, 54% were female. The mean age was 58.0 (42.4-74.7) for the CG and 54.0 (39.7-68.3) for the IG. Patients included in the IG had a higher cumulative illness rating scale for the evaluation of severity and comorbidity index (2.81 vs. 2.58; 2.91 vs. 2.59, respectively), as well as morning stiffness (33.8 vs. 25.0), even if not significant compared with CG patients. Our results indicate that, after 30 days of joint economy intervention at home, the DAS28 erythrocyte sedimentation rate (esr) and DAS28 C-reactive protein (crp), HAQ, and SF-12 mental component score were significantly improved (p = 0.005, p = 0.004, p = 0.009, and p = 0.010, respectively).

CONCLUSIONS

Our findings show that the combination of physical exercise and occupational therapy positively affects patients' quality of life with RA considering disease activity, global health status, and mental health.

Completing an interdisciplinary outpatient intervention improves patient rehabilitation goals following a mild traumatic brain injury

BACKGROUND

Individualized and interdisciplinary rehabilitation programs are recommended following a mild traumatic brain injury (mTBI), but often have long waitlists. Accordingly, innovative evidence-based programs are needed.

OBJECTIVES

The first objective of this study was to determine the number and types of rehabilitation goals chosen by individuals completing an interdisciplinary outpatient rehabilitation intervention (BrainEx90) for persisting symptoms following an mTBI. The second objective was to investigate whether completing BrainEx90 or choosing specific types of goals influenced performance and satisfaction ratings of these goals.

METHODS

217 individuals (44.4 ± 13.5 years old) with persisting symptoms following an mTBI completed BrainEx90, a 16-session interdisciplinary group outpatient rehabilitation intervention at Parkwood Institute between November 2013 and September 2019. Performance and satisfaction ratings of self-identified goals before and after BrainEx90 were assessed using the Canadian Occupational Performance Measure, and changes in ratings were analyzed using a linear mixed effects model.

RESULTS

1008 goals were identified and categorized as: productivity (45%); leisure (37%); and self-care (18%). Satisfaction ratings were significantly higher for all goal types following BrainEx90. Satisfaction with self-care goals improved significantly more than leisure [t(151) = 3.24, p < .01] and productivity [t(144) = 2.97, p < .01] goals. Performance ratings were also significantly greater following BrainEx90 [2.4, 95% CI [2.27, 2.53], p < .01)].

CONCLUSION

Performance and satisfaction of self-identified rehabilitation goals significantly improved following BrainEx90. Satisfaction with self-care goals demonstrated the greatest improvements, yet the most identified goal type was productivity.

Association of vocational interventions and work-related factors with disease and work outcomes in people with RMDs: A systematic review

OBJECTIVE

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours amongst people with rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on work-related factors and disease-specific outcomes for people with osteoarthritis, rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis (SSc) and gout.

METHODS

Two separate systematic literature reviews (SLRs) were conducted. The first identified SLRs, published between 01/2013 and 09/2018. The second identified original observational and intervention studies published before 05/2019. Manuscripts were included if they assessed the effects of vocational interventions on disease-specific outcomes (i.e. clinical outcomes, patient-reported outcomes, and work outcomes) or if they assessed the association between work-related factors and these outcomes. Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases were searched.

RESULTS

Two SLRs were identified including individuals with SSc and inflammatory arthritis. Subsequently, 23 original manuscripts were identified, with most of them (43.5%) including people with RA and no manuscripts on gout. Most observational studies evaluated the association between work-related factors and work outcomes while limited information was available on the impact of work on clinical outcomes. A few studies suggested that physically demanding jobs have a small detrimental effect on radiographic progression in axSpA and PsA. Intervention studies showed beneficial effects of vocational interventions for disease-specific outcomes, but with small effect sizes.

CONCLUSION

Many studies indicated that work participation is not likely to be detrimental and, in some cases, may be beneficial for RMD-specific outcomes and should therefore receive attention within healthcare consultations.

Workplace barriers among people with rheumatic and chronic back pain: Results from the work experience survey for rheumatic conditions

BACKGROUND

The Work Experience Survey for Rheumatic Conditions (WES-RC) is a prominent feature of an evidence-based intervention to prevent premature job loss among people with arthritis. The WES-RC is used to identify client perceived barriers related to work performance. The degree to which people with arthritis and rheumatic conditions report barriers on the WES-RC has not been reported.

OBJECTIVE

The purpose of this study was to characterize the barriers reported on the WES-RC.

METHODS

Data from participants who completed the WES-RC in the Work It study trial were included (N = 143). Descriptive statistics were used to characterize the sample and the frequency with which barriers on the WES-RC were reported. Responses to the top three bothersome barriers to study participants were summed.

RESULTS

The mean age of the sample was 50.3 years; 73% were female, and 66% white. All WES-RC items were checked as a barrier by at least two participants; less than 10 participants checked 34 items. Barriers in the 'getting ready for work and traveling to and from, or for work' domain, were frequently reported. The most bothersome barriers were 'standing or being on feet too long' and 'prolonged sitting'.

CONCLUSION

The WES-RC is a self-reported checklist that captures a wide breadth of work-related barriers that could be experienced by people with arthritis who are currently employed.

Non-drug and surgical treatment algorithm and recommendations for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis-secondary publication

OBJECTIVES

The aim of this study was to update the Japan College of Rheumatology (JCR) clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) and prepare an algorithm for non-drug and surgical treatments. This article is a digest version of the guidelines.

METHODS

The Japanese Ministry of Health, Labour and Welfare's research group, in collaboration with the JCR, used the Grading of Recommendations, Assessment, Development, and Evaluation method to update the 2014 JCR CPG for RA. The consensus was formed by CPG panel members.

RESULTS

We raised 19 clinical questions regarding non-drug and surgical treatments for RA and developed recommendations. The treatments included exercise therapy; occupational therapy; joint injection of corticosteroids; and orthopaedic surgeries including cervical spine surgery, wrist and foot arthroplasty, ankle arthrodesis, and replacement arthroplasty of the shoulder, elbow, finger, hip, knee, and ankle. Recommendations regarding the risks of surgery and perioperative discontinuation of medications have also been developed. Based on these recommendations, we created an original algorithm for the non-drug and surgical treatment of RA.

CONCLUSIONS

These recommendations are expected to serve rheumatologists, health care professionals, and patients with RA as tools for shared decision-making to treat residual limb joint symptoms and functional impairment.

Non-pharmacological interventions to promote work participation in people with rheumatic and musculoskeletal diseases: a systematic review and meta-analysis from the EULAR taskforce on healthy and sustainable work participation

OBJECTIVE

To summarise the evidence on effectiveness of non-pharmacological (ie, non-drug, non-surgical) interventions on work participation (sick leave, work status and presenteeism) in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

A systematic review of randomised controlled trials (RCTs) and longitudinal observational studies (LOS) was performed. Qualitative (RCTs/LOS) and quantitative (RCTs) evidence syntheses were conducted. Mixed-effects restricted maximum likelihood models were used to combine effect estimates, using standardised mean differences (SMDs) as the summary measure for each outcome domain separately, with a negative SMD favouring the intervention over comparator. Subgroup analyses were performed for type of RMD, risk status at baseline regarding adverse work outcomes and intervention characteristics.

RESULTS

Of 10 153 records, 64 studies (37 RCTs and 27 LOS; corresponding to k=71 treatment comparisons) were included. Interventions were mostly conducted in clinical settings (44 of 71, 62%). Qualitative synthesis suggested clear beneficial effects of 7 of 64 (11%) interventions for sick leave, 1 of 18 (6%) for work status and 1 of 17 (6%) for presenteeism. Quantitative synthesis (37 RCTs; k=43 treatment comparisons) suggested statistically significant but only small clinical effects on each outcome (SMD_{sick leave} (95% CI)=-0.23 (-0.33 to -0.13; k=42); SMD_{work status}=-0.38 (-0.63 to -0.12; k=9); SMD_presenteeism=-0.25 (-0.39 to -0.12; k=13)).

CONCLUSION

In people with RMDs, empirical evidence shows that non-pharmacological interventions have small effects on work participation. Effectiveness depends on contextual factors such as disease, population risk status, intervention characteristics and outcome of interest, highlighting the importance of tailoring interventions.

The Workwell trial: protocol for the process evaluation of a randomised controlled trial of job retention vocational rehabilitation for employed people with inflammatory arthritis

Background

The Workwell trial is a multi-centre randomised controlled trial with the aims of evaluating the effectiveness and cost-effectiveness of job retention vocational rehabilitation for employed people with inflammatory arthritis, who are experiencing work difficulties due to their arthritis. Vocational rehabilitation is delivered by health service occupational therapists, who have received additional training in providing this Workwell intervention. A process evaluation will be undertaken alongside the main trial to investigate implementation fidelity; understand key stakeholders’ perspectives of the intervention and the social and structural context in which the intervention is provided; and explore issues related to future implementation in clinical practice. This protocol describes the aims, objectives, and methodology of the Workwell trial process evaluation.

Methods

This mixed methods process evaluation will follow the Medical Research Council’s Guidance on process evaluations for complex interventions. It will be underpinned by the conceptual framework for implementation fidelity (CFIF) and normalisation process theory (NPT). We will analyse treatment records, work assessments, and treatment notes to ascertain implementation fidelity. Semi-structured interviews with trial participants, their employer/line managers, treating therapists, and their therapy service managers will be undertaken to explore perceptions of the intervention, contextual factors, and potential for future implementation in practice. Interview topic guides will be informed by NPT. Therapists’ views about Workwell training will be explored via questionnaires following training, and interviews and focus groups following treatment delivery to inform future implementation. Quantitative data will be analysed descriptively. Qualitative data will be analysed using thematic analysis. NPT will guide data analysis and interpretation. Findings from the different elements of this embedded design process evaluation will be reported separately and then the elements integrated. The process evaluation data will be analysed independently of the Workwell trial outcome evaluation. The process evaluation data will then be reviewed in the light of the trial findings.

Discussion

Few trials of job retention vocational rehabilitation in arthritis have included process evaluations. This process evaluation will assist in understanding factors influencing trial outcomes and identifying potential contextual barriers and facilitators for the potential implementation of Workwell vocational rehabilitation into clinical services.

Trial registration

ClinicalTrials.gov NCT03942783. Registered on 08 May 2019. ISRCTN Registry ISRCTN61762297. Registered on 13 May 2019. Retrospectively registered.

Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

'You don't want to be seen as a burden' experiences of working with early inflammatory arthritis: a qualitative study

PURPOSE

To describe the impact of early inflammatory arthritis on work participation.

MATERIALS AND METHODS

Thirty individuals (24 women) of working age (age 18-69 years) with inflammatory arthritis (<2 years duration) who were in paid employment or fulltime education were interviewed using qualitative description methodology. Data was analysed using thematic analysis.

RESULTS

Half of participants (n = 15) reported work disability within the first two-years of diagnosis. Five descriptive themes were identified that explained the early impact of IA on participation in paid employment. These themes were: (i) altered capacity for work; (ii) work comes first; (iii) the invisible burden; (iv) the disclosure effect; and (v) a reconstructed work future.

CONCLUSION

The scale of early work disability appears to be higher than previously understood. Although early medical intervention has improved disease management, significant work-based restrictions requiring intervention remain. Internalised and invisible work-related anxieties present early in the disease and need to be acknowledged and addressed by healthcare providers.IMPLICATIONS FOR REHABILITATIONEarly inflammatory arthritis causes significant challenges in work ability, and early work-based participation restrictions are present despite early use of drug therapy.Assessment of the client's subjective experience, including understanding the invisible burden, is an important aspect in determining the types of work interventions required.Disclosure of diagnosis in the work environment is associated with anxiety and fear, however, disclosure is influential in supporting capacity to retain work participation and should be included in work interventions.Routine healthcare should include early interventions to address work-based restrictions and supporting work retention to avoid work disability.

(Re-)Defining ergonomics in hand therapy: Applications for the management of upper extremity osteoarthritis

STUDY DESIGN

Invited literature review BACKGROUND: Arthritis is the leading cause of disability in adults, and research shows that people living with arthritis experience work instability, loss of independence, financial difficulties, and overall decreased quality of life. Current nonpharmacological treatments can be beneficial for short term relief; however, the evidence on these long-term treatments is limited. Ergonomic modifications have been used in the workplace to address musculoskeletal conditions to ensure proper fit of one's environment, and research shows that these modifications can decrease pain and injury and increase work productivity. A broader perspective on ergonomic approaches may be important to supporting individuals with arthritis within hand therapy.

PURPOSE OF THE STUDY

This review proposes an expanded perspective on ergonomic approaches within hand therapy and explores published literature to identify potential benefits of applying ergonomic approaches for individuals with upper extremity arthritis.

METHODS

A systematic search and screening process was conducted to identify articles that implemented an ergonomic approach for the support of individuals with upper extremity osteoarthritis or rheumatoid arthritis.

RESULTS

A total of 34 articles described interventions that employed ergonomics including task-based or general ergonomics (n = 17), contextualized supports (n = 8), or holistic, lifestyle approaches (n = 9). Only one study focused solely on individuals with osteoarthritis, whereas interventions for individuals with rheumatoid arthritis showed positive outcomes across these categories. Situational learning, building of patient self-efficacy, and development of new habits and routines are vital for carryover and implementation to support performance in daily life.

CONCLUSION

There is an opportunity for hand therapists to extend the scope of interventions provided as part of an ergonomic approach to supporting patients. Specifically, therapists can consider use of emerging technologies and telehealth that promote contextualization and follow-up for long-term outcomes.

The Effects of Patient Education on Psychological Status and Clinical Outcomes in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Background

Rheumatoid arthritis (RA) is a common systemic inflammatory autoimmune disease. The disease has a serious impact on mental health and requires more effective non-pharmacological interventions.

Objective

This study aims to systematically evaluate the effectiveness of patient education on psychological status and clinical outcomes in rheumatoid arthritis.

Methods

This systematic review and meta-analysis was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Library, EMBASE database, and Web of Science database were screened for articles published until November 2, 2021. Randomized controlled trials (RCTs) of patient education for RA were included. Outcomes measures included pain, physical function, disease activity, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anxiety, depression, Arthritis Self-Efficacy (pain, other symptoms, total), and General health. For each outcome, standardized mean differences or mean differences and 95% confidence intervals (CIs) were calculated.

Results

A total of 24 RCTs (n = 2,276) were included according to the inclusion and exclusion criteria. Meta-analysis revealed a statistically significant overall effect in favor of patient education for physical function [SMD = -0.52, 95% CI (-0.96, -0.08), I 2 = 93%, P = 0.02], disease activity [SMD = -1.97, 95% CI (-3.24, -0.71), I 2 = 97%, P = 0.002], ASE (pain) [SMD = -1.24, 95% CI (-2.05, -0.43), I 2 = 95%, P = 0.003], ASE (other symptoms) [SMD = -0.25, 95% CI (-0.41, -0.09), I 2 = 25%, P = 0.002], ASE (total) [SMD = -0.67, 95% CI (-1.30, -0.05), I 2 = 90%, P = 0.03], and general health [SMD = -1.11, 95% CI (-1.36, -0.86), I 2 = 96%, P < 0.00001]. No effects were found for anxiety [SMD = 0.17, 95% CI (-0.64, 0.98), I 2 = 82%, P = 0.68], depression [SMD = -0.18, 95% CI (-0.52, 0.15), I 2 = 52%, P = 0.28], pain [SMD = -0.37, 95% CI (-0.80, 0.05), I 2 = 89%, P = 0.08], and CRP [SMD = -0.27, 95% CI (-0.57, 0.02), I 2 = 0%, P = 0.07].

Conclusions

Patient education may be effective in improving clinical outcomes and psychological status in patients with rheumatoid arthritis. Considering the methodological limitations of the included RCTs, more high-quality and large-sample RCTs are needed to confirm this conclusion in the future.

Systematic Review Registration

http://www.crd.york.ac.uk/prospero, identifier: CRD42021250607.

A Systematic Review of Job Loss Prevention Interventions for Persons with Inflammatory Arthritis

Purpose To present an overview of the evidence of the effect of job loss prevention interventions, aiming to improve work ability and decrease absenteeism and/or job loss in persons with inflammatory arthritis (IA). Method A systematic literature search in the databases PubMed, EMBASE, CINAHL, PsycINFO and the Cochrane Library was conducted. A search strategy used in a review from 2014 was copied and additional keywords were added with no time restriction. The Cochrane Risk of Bias Tool (RoB 1) was used for quality assessment and the overall quality of each study was determined using predetermined cut-off criteria, categorising studies to be of good-, acceptable- or low quality. Results were summarised narratively. Results Six randomised controlled trials (published in seven articles) were included, one of good quality and five of acceptable quality. One study identified significant improvements in work ability, while three found no significant difference between groups. One study identified significant difference in absenteeism, while two studies identified no difference between the intervention and control groups. Two studies identified significant reduction in job loss, while two studies identified no group difference. The inconsistent results may be due to heterogeneity in interventions and outcome measures used, and the results should therefore be interpreted with caution. Conclusion The results indicate that job loss prevention interventions may have an effect on work ability, absenteeism and in particular job loss among persons with IA. Further good-quality studies regarding job loss prevention interventions for people with IA are still recommended.

Analytical and clinical validation of an RNA sequencing-based assay for quantitative, accurate evaluation of a molecular signature response classifier in rheumatoid arthritis

OBJECTIVES

This study reports analytical and clinical validation of a molecular signature response classifier (MSRC) that identifies rheumatoid arthritis (RA) patients who are non-responders to tumor necrosis factor-ɑ inhibitors (TNFi).

METHODS

The MSRC integrates patient-specific data from 19 gene expression features, anti-cyclic citrullinated protein serostatus, sex, body mass index, and patient global assessment into a single score.

RESULTS

The MSRC results stratified samples (N = 174) according to non-response prediction with a positive predictive value of 87.7% (95% CI: 78-94%), sensitivity of 60.2% (95% CI: 50-69%), and specificity of 77.3% (95% CI: 65-87%). The 25-point scale was subdivided into three thresholds: signal not detected (<10.6), high (≥10.6), and very high (≥18.5). The MSRC relies on sequencing of RNA extracted from blood; this assay displays high gene expression concordance between inter- and intra-assay sample (R² > 0.977) and minimal variation in cumulative gene assignment diversity, read mapping location, or gene-body coverage. The MSRC accuracy was 95.8% (46/48) for threshold concordance (no signal, high, very high). Intra- and inter-assay precision studies demonstrated high repeatability (92.6%, 25/27) and reproducibility (100%, 35/35).

CONCLUSION

The MSRC is a robust assay that accurately and reproducibly detects an RA patient's molecular signature of non-response to TNFi therapies.

[Rehabilitation in rheumatic diseases and osteoporosis-a multidisciplinary task]

Advances in medications and changes in therapeutic options have significantly reduced limitations in functional capacity and quality of life for patients with rheumatic diseases and osteoporosis, but there is still a large number of patients in whom the diseases do not take the desired course. Older rheumatic patients also often have comorbidities that require a multidisciplinary and multimodal approach to therapy. Rehabilitation measures are, therefore, an important part of the treatment concept for these patients in order to maintain their functional health, social participation, and, in the case of those who are still working, in particular their gainful employment. They can help to limit sequelae, preserve existing functions, reduce pain, and maintain the quality of life of those affected. The article aims to provide an overview of the rehabilitative therapy concept and the level of evidence for individual forms of therapy.

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVE

To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).

METHODS

An EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.

RESULTS

Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).

CONCLUSIONS

These PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVES

To summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA.

METHODS

PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.

RESULTS

Two hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias.

CONCLUSIONS

This SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.

The effect on work presenteeism of job retention vocational rehabilitation compared to a written self-help work advice pack for employed people with inflammatory arthritis: protocol for a multi-centre randomised controlled trial (the WORKWELL trial)

Background

Work problems are common in people with inflammatory arthritis. Up to 50% stop work within 10 years due to their condition and up to 67% report presenteeism (i.e. reduced work productivity), even amongst those with low disease activity. Job retention vocational rehabilitation (JRVR) may help prevent or postpone job loss and reduce presenteeism through work assessment, work-related rehabilitation and enabling job accommodations. This aims to create a better match between the person’s abilities and their job demands. The objectives of the Workwell trial are to test the overall effectiveness and cost-effectiveness of JRVR (WORKWELL) provided by additionally trained National Health Service (NHS) occupational therapists compared to a control group who receive self-help information both in addition to usual care.

Methods

Based on the learning from a feasibility trial (the WORK-IA trial: ISRCTN76777720), the WORKWELL trial is a multi-centre, pragmatic, individually-randomised parallel group superiority trial, including economic evaluation, contextual factors analysis and process evaluation. Two hundred forty employed adults with rheumatoid arthritis, undifferentiated inflammatory arthritis or psoriatic arthritis (in secondary care), aged 18 years or older with work instability will be randomised to one of two groups: a self-help written work advice pack plus usual care (control intervention); or WORKWELL JRVR plus a self-help written work advice pack and usual care. WORKWELL will be delivered by occupational therapists provided with additional JRVR training from the research team. The primary outcome is presenteeism as measured using the Work Limitations Questionnaire-25. A comprehensive range of secondary outcomes of work, health, contextual factors and health resource use are included. Outcomes are measured at 6- and 12- months (with 12-months as the primary end-point). A multi-perspective within-trial cost-effectiveness analyses will also be conducted.

Discussion

This trial will contribute to the evidence base for provision of JRVR to people with inflammatory arthritis. If JRVR is found to be effective in enabling people to keep working, the findings will support decision-making about provision of JRVR by rheumatology teams, therapy services and healthcare commissioners, and providing evidence of the effectiveness of JRVR and the economic impact of its implementation.

Trial registration

Clinical Trials.Gov: NCT03942783. Registered 08/05/2019 (https://clinicaltrials.gov/ct2/show/NCT03942783); ISRCTN Registry: ISRCTN61762297. Registered:13/05/2019 (http://www.isrctn.com/ISRCTN61762297). Retrospectively registered.

Effectiveness and characteristics of interventions to improve work participation in adults with chronic physical conditions: a systematic review

PURPOSE

Chronic physical conditions often negatively affect work participation. The objective of this systematic review is to investigate the effectiveness and characteristics of vocational rehabilitation interventions for people with a chronic physical condition.

METHODS

Searches in five databases up to April 2020 identified 30 studies meeting our inclusion criteria. Two reviewers independently assessed and extracted data. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) framework was used to evaluate quality of evidence for three outcome measures related to work participation.

RESULTS

All vocational rehabilitation interventions consisted of multiple components, but their characteristics varied widely. Analysis of 22 trials yielded a moderate positive effect with moderate certainty of interventions on work status; analysis of five trials with low risk of bias showed a large positive effect with moderate certainty (risk ratio 1.33 and 1.57, respectively). In addition, in eight studies we found a moderate to small positive effect with low certainty on work attitude (standardized mean difference = 0.59 or 0.38, respectively). We found no effect on work productivity in nine studies.

CONCLUSION

The systematic review of the literature showed positive effects of vocational rehabilitation interventions on work status and on work attitude; we found no effect on work productivity.Implications for rehabilitationIn rehabilitation, addressing work participation of persons with a chronic physical condition using targeted interventions is beneficial to improve or sustain work participation, irrespective of the intervention characteristics and diagnosis.Interventions that include multiple components and offer individual support, whether or not combined with group sessions, are likely to be more effective in improving work participation in persons with a chronic physical condition.The overview of vocational interventions in this systematic review may assist healthcare professionals in making informed decisions as to which intervention to provide.Vocational rehabilitation, as well as studies on work participation in chronic disease, should include a long follow-up period to explore if work participation is sustainable and contributes to health and wellbeing.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.

[What is certain in the treatment of rheumatoid arthritis?]

Rheumatoid arthritis (RA) is the most important chronic inflammatory joint disease with a prevalence of 1%. When untreated the disease leads to joint destruction and therefore to functional restrictions of the patients and also to increased rates of cardiovascular and malignant diseases. After the pathophysiology of rheumatoid arthritis was better understood, in the last 20 years biologics could be developed, which are directed against targets involved in the inflammatory process in RA. Since then the remission rates of RA have substantially increased. In 2017 Janus kinase (JAK) inhibitors were additionally approved for the treatment of RA in Germany. They further broaden the therapeutic options and, in contrast to biologics, are administered orally. The response rates to therapy are better the earlier the disease is diagnosed and treated. Patients in whom RA is suspected due to a new onset of polyarthritis, should therefore be promptly referred to a rheumatologist.

Impact of a fatigue management in work programme on meeting work demands of individuals with rheumatic diseases: A pilot study

INTRODUCTION

Work disability and job loss are serious consequences of rheumatic diseases (RDs), and fatigue is a symptom of RDs commonly reported to have an impact on work performance. A FAtigue ManagEment in Work (FAME-W) programme was developed to facilitate the self-management of fatigue in work. The present pilot study explored if FAME-W could facilitate individuals with RDs to manage fatigue in work and improve their ability to meet work demands.

METHODS

Twenty-seven individuals with a variety of rheumatic diagnoses completed a 4-week, 2-h occupational therapy-led self-management programme. Each week focused on fatigue-related topics, including fatigue and activity management, pain management and joint protection, mental well-being, effective communication with employers and work colleagues, and employment legislation. Individual workplace ergonomic assessments were also offered. Study measures (work function, fatigue, pain, mood and self-efficacy) were completed prior to starting FAME-W, immediately post-intervention and 12 weeks post-intervention.

RESULTS

Participants (56% male) had a mean age of 43 years. No significant improvements were observed immediately post-programme. However, at the 12-week follow-up, significant improvements were reported in meeting work demands (scheduling [p = 0.046], output [p = 0.002], physical [p = 0.003], mental [p = 0.016]), fatigue [p = 0.001], pain [p = 0.01], anxiety [p = 0.001], depression [p < 0.001], self-efficacy [p < 0.001] and Arthritis Impact Measurement Scales 2-Short Form (physical: p = 0.005; symptoms: p = 0.010; affect: p = 0.010; social: p = 0.001).

CONCLUSIONS

Significant improvements were reported in participants' ability to meet various demands of their work 3 months post-FAME-W. These findings suggest that FAME-W has the potential to assist individuals with RDs to meet the demands of their work, although further research is required to test the effectiveness of this intervention.

A systematic review on workplace interventions to manage chronic musculoskeletal conditions

BACKGROUND AND PURPOSE

A review to investigate whether there are effective workplace interventions that manage chronic musculoskeletal disorders.

METHODS

The literature search included published articles between 2008 and 2017. The databases used in this search were MEDLINE, Scopus, CINAHL, AMED, PsycINFO, Academic Search Complete, Cochrane, and PEDro. A limited search on websites for relevant grey literature was also conducted.

RESULTS

The review included 12 studies that investigated effectiveness of a specific strength exercise programme or interventions provided by health professionals at the workplace when compared with controls or interventions not at the workplace. Seven studies were classified as high quality (>85% of criteria met) and five studies were classified as acceptable. Studies were heterogeneous preventing a meta-analysis. No intervention was clearly superior to another.

DISCUSSION

There was some consistency in the results of the selected studies, suggesting that workplace interventions such as high-intensity strength exercises and/or integrated health care can decrease pain and symptoms for employees who experience long-term musculoskeletal disorders. However, the current research is limited.

Efficacy of a Work Disability Prevention Program for People with Rheumatic and Musculoskeletal Conditions: A Single-Blind Parallel-Arm Randomized Controlled Trial

OBJECTIVE

Work disability rates are high among people with rheumatic and musculoskeletal conditions. Effective disability preventive programs are needed. We examined the efficacy of a modified vocational rehabilitation approach delivered by trained occupational therapists and physical therapists on work limitation and work loss over 2 years among people with rheumatic and musculoskeletal conditions.

METHODS

Eligibility criteria for this single-blind, parallel-arm randomized trial included ages 21-65 years, 15 or more hours/week employment, a self-reported doctor-diagnosed rheumatic or musculoskeletal condition, and concern about staying employed. The intervention consisted of a 1.5-hour meeting, an action plan, written materials on employment supports, and telephone calls at 3 weeks and 3 months. Control group participants received the written materials. The primary outcome was the Work Limitations Questionnaire (WLQ) output job demand subscale. The secondary outcome was work loss. Intent-to-treat analyses were performed.

RESULTS

Between October 2011 and January 2014, 652 individuals were assessed for eligibility. A total of 287 participants were randomized: 143 intervention and 144 control participants. In total, 264 participants (92%) completed 2-year data collection. There was no difference in the mean ± SD WLQ change scores from baseline to 2-year followup (-8.6 ± 1.9 intervention versus -8.3 ± 2.2 control; P = 0.93). Of the 36 participants who experienced permanent work loss at 2 years, 11 (8%) were intervention participants and 25 (18%) control participants (P = 0.03).

CONCLUSION

The intervention did not have an effect on work limitations but reduced work loss. The intervention can be delivered by trained rehabilitation therapists.

Job retention vocational rehabilitation for employed people with inflammatory arthritis (WORK-IA): a feasibility randomized controlled trial

BACKGROUND

Inflammatory arthritis leads to work disability, absenteeism and presenteeism (i.e. at-work productivity loss) at high cost to individuals, employers and society. A trial of job retention vocational rehabilitation (VR) in the United States identified this helped people keep working. The effectiveness of this VR in countries with different socioeconomic policies and conditions, and its impact on absenteeism, presenteeism and health, are unknown. This feasibility study tested the acceptability of this VR, modified for the United Kingdom, compared to written advice about managing work problems. To help plan a randomized controlled trial, we tested screening, recruitment, intervention delivery, response rates, applicability of the control intervention and identified the relevant primary outcome.

METHODS

A feasibility randomized controlled trial with rheumatoid, psoriatic or inflammatory arthritis patients randomized to receive either job retention VR or written information only (the WORK-IA trial). Following three days VR training, rheumatology occupational therapists provided individualised VR on a one to one basis. VR included work assessment, activity diaries and action planning, and (as applicable) arthritis self-management in the workplace, ergonomics, fatigue and stress management, orthoses, employment rights and support services, assistive technology, work modifications, psychological and disclosure support, workplace visits and employer liaison.

RESULTS

Fifty five (10%) people were recruited from 539 screened. Follow-up response rates were acceptable at 80%. VR was delivered with fidelity. VR was more acceptable than written advice only (7.8 versus 6.7). VR took on average 4 h at a cost of £135 per person. Outcome assessment indicated VR was better than written advice in reducing presenteeism (Work Limitations Questionnaire (WLQ) change score mean: VR = -12.4 (SD 13.2); control = -2.5 (SD 15.9), absenteeism, perceived risk of job loss and improving pain and health status, indicating proof of concept. The preferred primary outcome measure was the WLQ, a presenteeism measure.

CONCLUSIONS

This brief job retention VR is a credible and acceptable intervention for people with inflammatory arthritis with concerns about continuing to work due to arthritis.

TRIAL REGISTRATION

ISRCTN 76777720 . Registered 21.9.12.

Effectiveness of Occupational Therapy Interventions for Adults With Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

We reviewed the efficacy of occupational therapy-related interventions for adults with rheumatoid arthritis.

METHOD

We examined 51 Level I studies (19 physical activity, 32 psychoeducational) published 2000-2014 and identified from five databases. Interventions that focused solely on the upper or lower extremities were not included.

RESULTS

Findings related to key outcomes (activities of daily living, ability, pain, fatigue, depression, self-efficacy, disease symptoms) are presented. Strong evidence supports the use of aerobic exercise, resistive exercise, and aquatic therapy. Mixed to limited evidence supports dynamic exercise, Tai Chi, and yoga. Among the psychoeducation interventions, strong evidence supports the use of patient education, self-management, cognitive-behavioral approaches, multidisciplinary approaches, and joint protection, and limited or mixed evidence supports the use of assistive technology and emotional disclosure.

CONCLUSION

The evidence supports interventions within the scope of occupational therapy practice for rheumatoid arthritis, but few interventions were occupation based.

The clinical utility of the Canadian Occupational Performance Measure in vocational rehabilitation: A qualitative study among occupational therapists in Slovenia

BACKGROUND

Few studies exist on the clinical utility of the Canadian Occupational Performance Measure (COPM) in vocational rehabilitation.

OBJECTIVE

The aim of this study was to explore how Slovenian occupational therapists working in vocational rehabilitation, perceived the usefulness of the COPM in their everyday practice.

METHODS

A qualitative study using two focus group discussions was conducted. The meaning condensation method was applied to analyze the data.

RESULTS

Analysis revealed the following key themes: (1) the COPM facilitates collaboration with the client; (2) the COPM is a source of evidence and empowerment for occupational therapists; (3) the challenges that arise when using the COPM; (4) the use of COPM requires training; and (5) using the COPM results and understanding their meaning.

CONCLUSIONS

The study reveals new insights into using the COPM results in occupational therapy, especially into the contextual factors that influence the meaning and importance of work for clients in vocational rehabilitation.

Development and reliability of a Turkish version of the Short Form-Joint Protection Behavior Assessment (JPBA-S)

STUDY DESIGN

Clinical measurement.

PURPOSE

To adapt the original JPBA-S to a Turkish version (TUR-JPBA-S) and to investigate its reliability in assessing patients with rheumatoid arthritis (RA).

METHODS

Twenty-two participants with RA and 21 healthy people were videotaped while performing tasks listed in the TUR-JPBA-S. Two raters scored the video recordings for to evaluate inter-rater reliability. One rater re-analyzed the recordings at a different time point for intra-rater reliability. Participants with RA were asked to perform the same tasks after three to four weeks which was also recorded to evaluate test-retest reliability.

RESULTS

Internal consistency (Cronbach's α value) was found to be high (0.89) for participants with RA. Our results demonstrate excellent intra-rater (ICC: 0.99, SEM 1.2) inter-rater (ICC: 0.99, SEM 1.7) reliability, apart from excellent test-retest reliability (ICC: 0.96).

CONCLUSION

The TUR-JPBA-S is a valid and reliable instrument for assessing JP behavior in patients with RA in Turkey.

LEVEL OF EVIDENCE

Level 2.

One Year Effects of a Workplace Integrated Care Intervention for Workers with Rheumatoid Arthritis: Results of a Randomized Controlled Trial

Purpose To evaluate the effectiveness of a workplace integrated care intervention on at-work productivity loss in workers with rheumatoid arthritis (RA) compared to usual care. Methods In this randomized controlled trial, 150 workers with RA were randomized into either the intervention or control group. The intervention group received an integrated care and participatory workplace intervention. Outcome measures were the Work Limitations Questionnaire, Work Instability Scale for RA, pain, fatigue and quality of life (RAND 36). Participants filled out a questionnaire at baseline, and after 6 and 12 months. We performed linear mixed models to analyse the outcomes. Results Participants were on average 50 years of age, and mostly female. After 12 months, no significant intervention effect was found on at-work productivity loss. We also found no significant intervention effects on any of the secondary outcomes. Conclusions We did not find evidence for the effectiveness of our workplace integrated care intervention after 12 months of follow up. Future studies should focus on investigating the intervention in groups of workers with severe limitations in work functioning, and an unstable work situation.

A qualitative evaluation of occupational therapy-led work rehabilitation for people with inflammatory arthritis: Patients' views

INTRODUCTION

This qualitative study, nested in a pilot feasibility randomised controlled trial, explored the views of working people with inflammatory arthritis on the impact of a work rehabilitation programme received.

METHOD

Thirty-two participants, drawn from the 55 participants in the associated randomised controlled trial, were recruited from secondary care in the United Kingdom. Semi-structured telephone and face-to-face interviews were conducted at six (n = 32) and nine months follow-up (n = 31). Interviews were audio-recorded, transcribed, and analysed using a constant comparative approach, under the theoretical framework of critical realism.

FINDINGS

Three overarching themes emerged: (1) intervention group participants valued the work rehabilitation programme received, and highlighted the benefits of occupational therapy; (2) control group participants reported no benefits in relation to the written work advice pack, and lacked future aspirations to stay employed; (3) the majority of participants reported not reading the written work advice pack provided, which was the only work advice received by the control group.

CONCLUSION

Working people with inflammatory arthritis highly valued the practical support received from the therapists, and emphasised the value of the therapeutic relationship in the rehabilitation process. A tailor-made work rehabilitation programme, which incorporates cognitive-behavioural strategies into patient education, may help to reduce work instability in people with inflammatory arthritis, and increase their perceived self-efficacy.

Integral strategy to supportive care in breast cancer survivors through occupational therapy and a m-health system: design of a randomized clinical trial

BACKGROUND

Technological support using e-health mobile applications (m-health) is a promising strategy to improve the adherence to healthy lifestyles in breast cancer survivors (excess in energy intake or low physical activity are determinants of the risk of recurrence, second cancers and cancer mortality). Moreover, cancer rehabilitation programs supervised by health professionals are needed due to the inherent characteristics of these breast cancer patients. Our main objective is to compare the clinical efficacy of a m-health lifestyle intervention system alone versus an integral strategy to improve Quality of Life in breast cancer survivors.

METHODS

This therapeutic superiority study will use a two-arm, assessor blinded parallel RCT design. Women will be eligible if: they are diagnosed of stage I, II or III-A breast cancer; are between 25 and 75 years old; have a Body Mass Index > 25 kg/m²; they have basic ability to use mobile apps; they had completed adjuvant therapy except for hormone therapy; and they have some functional shoulder limitations. Participants will be randomized to one of the following groups: integral group will use a mobile application (BENECA APP) and will receive a face-to-face rehabilitation (8-weeks); m-health group will use the BENECA app for 2-months and will received usual care information. Study endpoints will be assessed after 8 weeks and 6 months. The primary outcome will be Quality of Life measured by The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core and breast module. The secondary outcomes: body composition; upper-body functionality (handgrip, Disability of the Arm, Shoulder and Hand questionnaire, goniometry); cognitive function (Wechsler Adult Intelligence Scale, Trail Making Test); anxiety and depression (Hospital Anxiety and Depression Scale); physical fitness (Short version of the Minnesota Leisure Time Physical Activity Questionnaire, Self-Efficacy Scale for Physical Activity); accelerometry and lymphedema.

DISCUSSION

This study has been designed to seek to address the new needs for support and treatment of breast cancer survivors, reflecting the emerging need to merge new low cost treatment options with much-needed involvement of health professionals in this type of patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02817724 (date of registration: 22/06/2016).

The Work-It Study for people with arthritis: Study protocol and baseline sample characteristics

BACKGROUND

People with arthritis are at risk of work disability. Job accommodation and educational programs delivered before imminent work loss can minimize work disability, yet are not currently being widely implemented. The Work-It Study is a randomized controlled trial testing the efficacy of a problem solving program delivered by physical and occupational therapy practitioners to prevent work loss over a two-year period among people with arthritis and rheumatological conditions.

OBJECTIVE

The purpose of this paper is to describe the protocol of the randomized controlled trial, and describe the baseline characteristics of the subjects and their work outcomes.

METHODS

287 participants were recruited from the Boston area in Massachusetts, USA. Eligible participants were aged between 21-65, self-reported a physicians' diagnosis of arthritis, rheumatic condition, or chronic back pain, reported a concern about working now or in the near future due to your health, worked at least 15 hours a week, had plans to continue working, and worked or lived in Massachusetts. Subjects were recruited through community sources and rheumatology offices. Participants in the experimental group received a structured interview and an education and resource packet, while participants in the control received the resource packet only. The baseline characteristics and work related outcomes of the participants were analyzed.

CONCLUSIONS

To our knowledge, the Work-It Study is the largest and most diverse randomized controlled trial to date aiming to identify and problem solve work-related barriers, promote advocacy, and foster work disability knowledge among people with chronic disabling musculoskeletal conditions. Despite advances in medical management of arthritis and other rheumatological and musculoskeletal conditions, many people still have concerns about their ability to remain employed and are seeking strategies to help them sustain employment.

Self-Reported Barriers to Healthcare Access for Rheumatoid Arthritis Patients in Rural and Northern Saskatchewan: A Mixed Methods Study

OBJECTIVES

The aim of the present study was to identify potential barriers for access to medical and allied health services from the perspective of rural and Northern Saskatchewan rheumatoid arthritis (RA) patients.

METHODS

A total of 100 adults with established RA, residing in rural and Northern Saskatchewan, were recruited from two rheumatology practices. Structured interviews with standardized scripts solicited patient perspectives on appointment waiting times, travel required to access medical services and satisfaction with healthcare provision. Thematic analysis was employed for qualitative data.

RESULTS

Patients-reported concerns regarding waiting time for their first rheumatology appointment. There was reduced access to allied health professionals, with only 53% of the participants having seen a physiotherapist (PT), and only 26% an occupational therapist (OT). Patients had similar driving distances to their family physician, PT, pharmacy and laboratory services but commuted significantly further for rheumatologist and OT services. There were high levels of satisfaction with their rheumatologist and family physician appointments (8.96 and 8.04 on a ten-point scale). Patients with longer travel times had higher satisfaction with their health care appointments: Patients who travelled one, two and more than two hours had satisfaction scores of 0.93, 0.88 and 1.32 points higher on a ten-point scale (p < 0.03).

CONCLUSIONS

Access to medical services is a concern for this population. Patients were dissatisfied with the waiting time for their first specialist appointment and with decreased access to allied health professionals. Patients travelling longer distances were more satisfied with their health care provider's care, suggesting that good patient-care giver relationships helped to ameliorate the difficulties of travelling to their appointments. Copyright © 2016 John Wiley & Sons, Ltd.

Patients' Perspectives and Experiences Living with Systemic Sclerosis: A Systematic Review and Thematic Synthesis of Qualitative Studies

OBJECTIVE

Systemic sclerosis (SSc) is a chronic, progressive autoimmune disease with major end-organ involvement. Much attention has been focused on the management of physical and clinical manifestations; however, the effect of the disease and treatment on the patient's identity, relationships, functioning, and mental well-being are less known. We aimed to describe the patients' perspectives and experiences of living with SSc.

METHODS

Electronic databases were searched to October 2014. Thematic synthesis was used to analyze the findings.

RESULTS

We included 26 studies involving 463 patients. Six key themes were identified: distressing appearance transformation (disturbing facial changes, stigmatizing sickness, unrecognizable self), palpable physical limitations (bodily restrictions, frustrating mind-body disconnect, pervasive fatigue, disabling pain), social impairment (breaking intimacy, struggling to fulfill family responsibilities, maintaining work, losing independence), navigating uncertainty (diagnostic ambiguity, medically fending for oneself, unpredictable course of illness), alone and misunderstood (fearful avoidance of fellow patients, invisible suffering), and gradual acceptance and relative optimism (adapting to change and accepting limitations, taking a positive spin, cautious hoping, empowering relationships, valuing medical support).

CONCLUSION

SSc is a rare and unpredictable illness that undermines patients' sense of certainty and control and impairs their self-image, identity, and daily functioning. Patient-centered care that encompasses strategies to promote self-esteem, resilience, and self-efficacy may help to improve treatment satisfaction and health and quality of life outcomes for patients with SSc.

Effectiveness of an integrated care intervention on supervisor support and work functioning of workers with rheumatoid arthritis

PURPOSE

In this manuscript, we evaluated the effectiveness of an intervention programme consisting of integrated care and a participatory workplace intervention on supervisor support, work instability and at-work productivity after 6 months of follow-up among workers with rheumatoid arthritis (RA).

METHODS

We conducted a randomized controlled trial; we compared the intervention programme to usual care. Eligible patients were diagnosed with RA, had a paid job (> 8 h per week) and who experienced, at least, minor difficulties in work functioning. Supervisor support was measured with a subscale of the Job Content Questionnaire, work instability with the Work Instability Scale for RA, and at-work productivity with the Work Limitations Questionnaire. Data were analyzed using linear regression analyses.

RESULTS

A beneficial effect of the intervention programme was found on supervisor support among 150 patients. Analyses revealed no effects on work instability and at-work productivity.

CONCLUSION

We found a small positive effect of the intervention on supervisor support, but did not find any effects on work instability and at-work productivity loss. Future research should establish whether this significant but small increase in supervisor support leads to improved work functioning in the long run. This study shows clinicians that patients with RA are in need of efforts to support them in their work functioning. Implications for Rehabilitation Rheumatoid arthritis (RA) is a chronic inflammatory disease with a severe impact on work functioning, even when a patient is still working. It is important to involve the workplace when an intervention is put in place to support RA patients in their work participation. Supervisor support influences health outcomes of workers, and it is possible to improve supervisor support by an intervention which involves the workplace and supervisor.

Effects of rehabilitation for pain relief in patients with rheumatoid arthritis: a systematic review

[Purpose] The purpose of this study was to find evidence for the effectiveness of rehabilitation for pain relief in patients with rheumatoid arthritis. [Subjects and Methods] A systematic review was conducted of MEDLINE, The Cochrane Central Register of Controlled Trials (CENTRAL), and OVID, for studies published from July 2005 to July 2015. We extracted data regarding patients, intervention, comparison, and outcomes, and assessed the methodological quality of the data. [Results] Nine randomized controlled trials comparing the effects of pain relief in patients with rheumatoid arthritis were found. [Conclusion] Physical therapy and occupational therapy can reduce pain in rheumatoid arthritis.

Persistent musculoskeletal pain and productive employment; a systematic review of interventions

A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed. Databases of Medline, PsychINFO, CINAHL and Embase were searched using MeSH and other relevant terms. Studies that reported on interventions at, or involving, the workplace were included. Interventions were considered as either focused on the individual or multilevel. Outcome measures assessed included: job loss, productivity, sick leave, pain and cost benefit. A quality assessment was undertaken using GRADE criteria with development of impact statements to synthesise the results. Eighteen relevant articles (14 studies) were identified for inclusion in the review. No high-level evidence for workplace interventions to assist people with PMP were identified. Low numbers of participants and limited studies resulted in downgrading of evidence. However, individually focused interventions will probably reduce job loss and sick leave, but are unlikely to reduce pain. Multilevel focused interventions will probably result in decreased sick leave and provide some cost benefit. The evidence on productivity was limited and of poor quality. Further research is required because sustainable employment for individuals with PMP is important and understanding what works is necessary to ensure effective workplace interventions are developed.

Effectiveness of Client-Centered Occupational Therapy in Patients With Rheumatoid Arthritis: Exploratory Randomized Controlled Trial

Objectives

This study aims to examine the effectiveness of client-centered occupational therapy in patients with rheumatoid arthritis (RA).

Patients and methods

The study included 40 patients (2 males, 38 females; range 39 to 60 years) with RA. Patients were divided into two groups as intervention group (n=20) and control group (n=20) by random sampling method. Each group was given 10 sessions of physical therapy program. In addition, the intervention group received client-centered occupational therapy. Patients were evaluated with Turkish versions of Short-Form McGill Pain Questionnaire, Health Assessment Questionnaire, The Arthritis Impact Measurement Scales 2, RA Quality of Life Questionnaire, and Canadian Occupational Performance Measurement.

Results

Pain, activity limitation, and participation restriction scores decreased significantly more in the intervention group compared to the control group. Also, quality of life increased significantly in the intervention group (p<0.05).

Conclusion

Our findings suggest that occupational therapy intervention reduces activity limitation and participation restrictions in patients with RA. Therefore, such interventions may be generalized for this patient group.