Occupational Therapy and Rheumatoid Arthritis, Research Paper Example

Introduction

I recently had the opportunity to spend some time with ____, an Occupational Therapist and Certified Hand Therapist. As I reflected on that experience and considered what I would write about in this paper, I began to realize how much the brief visit had affected me. I went into the visit unsure of what to expect; still, what I experienced was unexpected. While I may not have had very specific ideas about what I would encounter, I did expect the interaction between the therapist and the patient to be more “clinical” than it turned out to be. I suppose I expected it to be similar to a typical doctor visit, but with the addition of time spent doing a combination of examinations and exercises of the hand. While both examinations and exercises were involved in the visit, the overall experience was much less clinical, and much more personal, than I could have anticipated.

In writing this paper, I hope to accomplish several things. The first is simply to provide a thorough, detailed, and accessible account of the experience as a means of developing the skills necessary to continue creating such reports in the future. Extrapolating from that premise, I am writing as detailed and specific report as I am able as an exercise in memory recall. It is my hope that the act of writing this paper will help me to recall the details of the encounter in the future. Finally, I anticipate that I may receive feedback on this report from several sources. I look forward to such feedback, as it will hopefully reinforce those things I did well and remind of which areas I need to work on for the future.

Patient Assessment and Treatment

The patient is a 53 year-old African-American woman; for this paper, I will refer to her as “Ms. Johnson.” She had been asked if I could sit in on the session, and she agreed to allow me to participate. As _____ spoke with Ms. Johnson, I took notes on the session; the following information is taken from those notes.

Ms. Johnson is a single mother with a ten-year-old son, and she is suffering from Stage-2 Rheumatoid Arthritis. She listed some of her favorite activities, including knitting, cooking, and playing games with her son, and she noted that her condition was beginning to interfere with her daily life. Her work does not require her to make much use of her hands, but she has been unable to spend time on her hobbies, and is having difficulty doing all the things that she needs to do to take care of her son, such as cooking, cleaning, and doing laundry.

Ms. Johnson’s hands showed clear signs of her disease, with her right hand displaying more obvious signs. The fingers of both hands appeared swollen at the outer joints, and the fingertips of her right hand appeared as if they were bent inward towards her palm in an unnatural manner. When asked, Ms. Johnson indicated that she had stiffness and pain in both hands, primarily in the joints. She indicated that the pain in her right hand was usually worse than  the pain in her left hand; when asked if she ever experienced numbness or tingling in either of the affected hands, Ms. Johnson indicated that she did not.

The session began with ______ conducting a series of stretching exercises with Ms. Johnson. Together they went through about ten or twelve different stretches as _____ explained to us that the stretches helped Ms. Johnson warm up for the treatments and activities to come, while also giving _____ a sense of Ms. Johnson’s limitations. After the stretching was over, the session moved on to a series of treatment activities that were primarily based on an OT framework.

For the first activity, Ms. Johnson was given two pieces of string; one was carefully tied into a fairly intricate knot while the other was just jumbled and twisted up. The exercise had several steps: first, Ms. Johnson had to untangle the jumbled string, which she was able to do fairly easily. Next she was asked to use the untied string to tie a knot that was a copy of the other knotted string. The last exercise was supposed to involve Ms. Johnson taking apart both knots. Unfortunately Ms. Johnson was unable to tie the string into such a complicated knot; in fact, she had difficulty tying even a simple knot. I could see that Ms. Johnson was goring frustrated, and so could_____; they soon moved on to the next exercise.

This exercise used the same tool for two different activities. A small weighted disc, which looked like an over-sized hockey puck, was placed on the table. Using one hand and then the other, Ms. Johnson was asked to place her palm face down on top of the weight and then grip it with her fingers. She was then instructed to raise the weight up one foot from the table, pause for five seconds, and then lower the weight. She was asked to repeat this activity ten times with one hand and then ten with the other. Ms. Johnson had less difficulty with this activity than she did with the first one. When _____ asked her how she felt after completing the tasks, she said that she felt fine, and that the pain in her hands was no worse than it had been.

The next activity used the same weight, and was intended to build on the first activity. This time Ms. Johnson was instructed to stand at the table, and repeat the lifting motion with the weights. The difference this time was that when she paused, she now had to twist the weight back and forth, similar to the motion involved in removing a lid from a jar. Ms. Johnson said she noticed significantly more pain with this activity than she had when she was simply lifting the weight, though the pain was not in the wrists where the twisting motion happened, but was mostly in her fingers.

As Ms. Johnson was going through her exercise treatments, _____ was very encouraging. They talked about how the movements used in the exercises were based on the kinds of movements that Ms. Johnson makes as she goes about her daily routine. I could see that as _____ was listening to Ms. Johnson describe her daily activities, she was paying close attention. Ms. Johnson seemed to be very comfortable in this setting, and was eager to do her best with each exercise.

The next step involved a pegboard with patterns printed on it in different colors. Ms. Johnson had to remove the right color of pin from a box of mixed-up colored pins, and complete one of the designs on the pegboard. ______ timed Ms. Johnson as she filled in a design, and explained that she would be expected to improve her time in future visits. As was the case with the first task, this was clearly intended to address Ms. Johnson’s fine motor skills; also like the first one she had some difficulty completing the task even without a set time limit. She did eventually complete it, thought she was clearly frustrated. The exercises concluded with Ms. Johnson kneading a ball of putty into different shapes as instructed by _____. Periodically she was asked to roll the putty up into a ball and start over again. This exercise seemed like it was less about testing the limits of her fine motor skills, and more about simply flexing and using the muscles and tendons of her hands. Of all the treatments for Ms. Johnson’s hands, I thought the activity with the string was the most interesting, primarily because it was the most challenging.

Conceptual Analysis

The first activity in which Ms. Johnson engaged was the one involving the two sections of string, one tied in a knot, and one slightly tangled. It seemed clear to me (and was confirmed later) that _____ presented these activities to Ms. Johnson not just to help her RA symptoms improve, but also as a means of assessing Ms. Johnson’s capabilities. This activity consisted of several steps, each of which would call upon Ms. Johnson’s fine motor skills. Ms. Johnson had explained that one of her favorite hobbies is knitting, and she had been doing less and less knitting as her symptoms grew worse in recent months.

As she attempted to carry out the instructions for the task, I began to consider the predicament that Ms. Johnson was in. She had explained that her RA was interfering with the very things that she most enjoyed; besides knitting, she had also mentioned that she liked to play games with her son. Losing the full use of one’s hands must be devastating, and I can imagine that Ms. Johnson had high hopes for a positive outcome from her visits to an OT. A study of RA and OT therapy conducted in 2000 discussed the importance of the human hand, referring to it as a “perceptual entity” and an “information-seeking organ” (Cooper, 2008). That is a good way to describe the hand; it is through our hands that we interact with the world around us. Even the slightest impairment of the hand can be limiting and frustrating; I can only imagine the frustration of an RA sufferer.

The activity of tying and untangling knots may seem very simple, yet it meets several criteria of effective therapy. Studies have shown a link between therapies that focus on fine motor skills and the positive outcome for many RA sufferers. While this activity is appropriate on a clinical level, it also helps in areas of daily life, from shoe-tying to knitting, which are things that Ms. Johnson is likely to do on a regular basis. By connecting the exercise in the clinical setting with activities that are part of Ms. Johnson’s routine, the therapist reinforced the idea that this therapy was effective on a personal level.

The next activity involved the use of the disc-shaped weight that looked like an oversized hockey puck. As was the case with all of the treatments, _____ explained to Ms. Johnson exactly what she was expected to do, and she also explained how this particular activity was connected to some part of her daily routine. Many OTs report that the most important aspect of their job is to ensure that their therapies and treatments are client-based (Cooper, 2010). While there are theoretical models for all different treatments, and a clinician could likely assess a patient and then decide on a course of action based on the clinician’s ideas about the theoretical models, studies have shown that client-based approaches help to generate enthusiasm and participation on the part of the client.

This exercise was quite simple; it simply involved sitting at a table and raising the weight up, holding the weight, and then lowering it back to the table; this was done in reps of ten for each hand. Though it did not look like any particular part of someone’s daily life, ____ explained that the muscle groups being worked mimicked the same muscles the average person uses while working in a seated position, though it concentrates the usage into a shorter time frame. In addition, this exercise involves the hand’s ability to grip and grasp, which are both functions that are compromised in RA patients (Kasch, 2010).

This activity, like the others, is both evidence-based, in the sense that working on these gripping functions has been shown to offer benefits to many RA patients, and is also occupation-based, as it is designed to mimic movements and function used in the average person’s daily routine.

The next exercise used the same weight, and added a bit more movement to the activity. In this exercise, the client stands at a table reaches forward to grasp the object, and raises it into the air. These steps test the same gripping and lifting capabilities as did the previous exercise, and adds a twisting motion that looks like the motion of removing a lid from a jar. Again, ____ explained how this exercise was directly inspired by the activities that Ms. Johnson undertakes in her day-to-day life.

Studies have shown that early intervention in RA patients can lead to improved outcomes (Dellhag, 2000), and _____ emphasized this to Ms. Johnson. Throughout the entire session she had been building rapport with Ms. Johnson as she learned about how RA had affected her life. Then, as each treatment was being implemented, ____ was able to connect it with some aspect of Ms. Johnson’s life. This approach would seem to help Ms. Johnson develop on a psychosocial level as well; she had made it clear that her RA was limiting her in ways that affected her entire life, and any treatment that could help her do some of the simple things she enjoyed would clearly have a larger benefit than just reducing pain in her hands.

This exercise, as it imitated the motion of opening a jar, was connected to one of Ms. Johnson’s favorite activities: cooking. As Ms. Johnson twisted the weight, ____ explained how the twisting weight could be anything from a jar of peanut butter for sandwiches to a jar of sauce for a spaghetti dinner. As Ms. Johnson was going through the steps of this routine, she began to jokingly pretend that she really was cooking a dinner. I could see that the activity was really connecting with her, and that kind of client-centered activity is exactly the kind of activity that the client will remember to do on her own.

The treatment with the pegboard was probably the least client-centered of all the activities, though it had been shown to be an important component of a larger set of OT-based treatments (Marcus-Johnson, 2005). While it was not necessarily client-centered, it did target the client’s fine motor skills, which have been shown to be seriously affected in many RA patients (Cooper, 2008). It is the deterioration of these fine motor skills that can indicate a serious level of RA, and RA sufferers often find themselves having difficulty buttoning buttons, picking up coins, tying shoelaces, and engaging in many other activities that the rest of us take for granted.

Because there is no cure for RA, the best treatments simply hope to slow its progression and to alleviate the worst of its symptoms. As ____explained to MS. Johnson, she was going to use information learned during their initial consultation, along with the observed and self-reported results of these treatments and exercises, to develop a treatment plan for Ms. Johnson. ____ further explained during the pegboard test that she would be coming at the problem from several angles. In the beginning of the session, _____ had examined Ms. Johnson’s hands, palpating them as she checked for tenderness and swelling, and checking and measuring the joints for swelling and stiffness. These examinations gave _____ information she needed to offer certain treatments, such as this pegboard treatment. It is not based on a specific occupational model; it is just a general tool for developing and maintaining fine motor control.

The other approach is the client-centered approach; ____ got the information she needed for that aspect of treatment from talking with Ms. Johnson. It was during their conversations that she was able to learn how RA had affected her personally –not just whether it made her joints swell or her fingers stiff, but what kinds of activities were disrupted because of RA, and how the disruption of RA made her feel not just physically, but emotionally, In that sense, all of the treatments, the pegboard included, had a psycho-social component. In heloping to treat Ms. Johnson’s RA, _____ was not just improving Ms. Johnson’s physical condition, she was also improving Ms. Johnson’s outlook on life.

The final treatment was a simple one, though it was perhaps the one that was most fun: squeezing and shaping a blob of putty. In general, RA sufferers can be helped by using their hands as much as possible (Cooper, 2010). This does not mean that they should “overdo” it; it simply means that moderate, appropriate levels of activity can be beneficial in slowing the progression of symptoms. There are no specific exercises or treatments that are the “best,” nor do all treatments help all RA patients equally 9or at all). In most cases, an OT working with an RA patient will do exactly as ____ did: conduct a thorough assessment of the patient’s condition, develop a working profile of the patient’s psycho-social needs, and formulate a treatment plan that addresses both the physical manifestation of the disease as well as the overall needs of the patient in a practical, real-world context.

As Ms. Johnson squeezed the putty, I noticed that she seemed to be enjoying herself. I took that as a good sign; if she had a pleasant experience today she would probably be more likely to return for further visits. While the putty exercise was probably the least “clinical” of all the treatments Ms. Johnson experienced during that session, it did address the psycho-social component of her condition, and did so in a positive manner. In speaking with her briefly after the session was completed, she indicated that she actually felt somewhat improved, despite the fact that she had used her hands so much. I presume that at least some of her positive outlook was generated by the positive environment created by _____, and the fact that Ms. Johnson now at least had some hope that her condition could improve.

Conclusion

Numerous studies have determined the efficacy of treatments such as this when applied to RA (Marcus-Johnson, 2005). While RA is progressive, studies have shown that consistent OT and Hand Therapy achieve positive outcomes for many patients (Dellhag, 2000). Because determinations about what constitutes “success” are inherently subjective, researchers attempt to measure function and abilities while also taking into consideration how a patient feels on a self-assessment level after undergoing hand therapy or OT therapy for the treatment of RA.

Time and again, studies have demonstrated positive outcomes for RA patients who undergo OT therapy. Along with the results of studies into the connection between RA and OT, there are innumerable anecdotal reports from therapists and patients who are clearly impressed with the way in which OT can aid those who suffer from RA (Cooper, 2010). An important step for those working in the field would be to develop a fundamental set of core competencies that can tie RA and OT together; the dissemination of information about these core competencies could provide direction both for future research and serve as guideposts for individuals interested in developing their abilities in this field (Kasch et al, 2010).

Of the treatments and exercises that I observed, I would say that the first one –the one involving the tying and untying of knots- was the most interesting. First, I could clearly understand the way that this activity addressed all of the significant dimensions of OT. The therapist had selected this activity specifically because of the client’s interest in knitting. While tying and untying string is not exactly a component of knitting, that activity does utilize the fingers to work with yarn, and to untangle and otherwise manipulate strands in different ways; in that regard, it was clearly a client-based activity. Because Ms. Johnson indicated that knitting had been a favorite hobby before her symptoms grew worse, anything the therapist can do to help her  return to that activity will aid Ms. Johnson’s psycho-social development as well.

I will admit that I had several unanswered questions after the session. I would have liked to spend more time with the therapist after the session, to ask questions about how she chose the treatments and exercises she chose, and also about how she will develop a future treatment plan for Ms. Johnson. I do not feel as if anything was left out of the session; I just wish I had more time there so I could better understand the nature of the therapist’s functions and responsibilities.

Before I attended the session with the OT, I did not have a firm opinion about the efficacy of OT for the treatment of RA. I did expect that there could be a positive association, but I did not expect to see such a strong positive outcome so quickly. It was clear to me that Ms. Johnson did not just experience some relief from her physical pain, but that the hope for even the slightest improvement also addressed her emotional pain. It is that promise of psycho-social efficacy that makes OT a welcome weapon in the fight against RA.

Bibliography

Anonymous. Rheumatoid Arthritis; Scientists at University of Pittsburgh, Department of Occupational Therapy publish research in rheumatoid arthritis.Biotech Business Week. 29 March 2010.

Cooper, Cynthia et al.Coordination Activities for Hand Therapy Patients. Journal of Hand Therapy. V21 N4. October-December 2008.

Cooper, Cynthia. Narratives in Hand Therapy. Journal of Hand Therapy. V24 N2. April-June 2011.

Dellhag, Berit. Hand Function in Rheumatoid Arthritis. Scandinavian Journal of Occupational Therapy. 27 November 2000.

Kasch, Mary et al.Competencies in Hand Therapy. Journal of Hand Therapy V16 N1. January-March 2003.

Malcus-Johnson, Pia et al. Occupational therapy during the first 10 years of rheumatoid arthritis. Scandinavian Journal of Occupational Therapy. V12 N3. September 2005.