Abstract
These AOTA Practice Guidelines provide strategies for occupational therapy practitioners to help people with osteoarthritis and rheumatoid arthritis live well with their chronic condition.
Approximately 20% of U.S. adults report a diagnosis of arthritis (Elgaddal et al., 2024; Fallon et al., 2023). Many of these adults have related activity limitations, contributing to a high personal and societal burden (Theis et al., 2021). Co-occurring psychological distress, which further exacerbates pain and creates barriers to managing the condition, is common (Price et al., 2020). Therefore, people with arthritis need to build knowledge, confidence, and skills so they can actively engage in occupations, including health management (American Occupational Therapy Association [AOTA], 2020; Packer, 2013). However, in one study fewer than 20% of adults with a diagnosis of arthritis attended a self-management class, highlighting gaps in care, especially for those with lower education (Duca et al., 2021). In addition, the proportion of adults with arthritis who engage in nonwork physical activity, which is associated with improved health, is lower in those with lower income and education (Guglielmo et al., 2021). Given the functional and psychosocial impact of arthritis, combined with disparities in overall health and access to specialist physicians, occupational therapy practitioners can play a key role in supporting individuals so they can live well with these chronic conditions (Barnabe, 2020; Desilet et al., 2025; Rabah et al., 2020). For example, occupational therapy practitioners can support the management of pain and fatigue and address barriers to engaging in meaningful daily activities. Although there are more than 100 types of arthritis and related rheumatic diseases, this document focuses on the two most common forms of arthritis: osteoarthritis (OA) and rheumatoid arthritis (RA).
OA has historically been perceived as aging-related mechanical wear and tear of the cartilage; however, it is now recognized instead as a complex multifactorial condition that includes inflammatory components (Dobson et al., 2018). OA can affect one or multiple joints, most commonly the knee joint, with other common sites including the hip, spine, interphalangeal, and thumb carpometacarpal (CMC) joints (Badley et al., 2020; Nelson, 2024). The disease usually causes pain, swelling, and stiffness in the involved joints, which can lead to limitations in activity and participation (Clynes et al., 2019). The incidence, prevalence, and societal burden of OA are increasing (Chen et al., 2023; GBD 2021 Osteoarthritis Collaborators, 2023). Although the incidence of the condition increases with age, OA can affect adults of all ages, impacting varied occupations, such as parenting and paid employment, and increasing costly health care utilization (He et al., 2024; Wang et al., 2017; Wilfong et al., 2024). Although OA is often discussed as an isolated musculoskeletal condition, those living with the disease may experience sleep disturbance, fatigue, and symptoms of depression or anxiety, supporting the need for holistic, person-centered care (Stebbings et al., 2010). In addition, OA has a high burden of coexisting chronic conditions, such as diabetes and hypertension, further challenging health management (Kamps et al., 2023; Li et al., 2024).
RA is an inflammatory autoimmune condition that affects multiple joints. It often starts with synovitis in bilateral smaller joints, with key symptoms including joint pain, tenderness, swelling, and stiffness. Although RA can occur at any age, adult onset most often occurs in young or middle-aged women. A high burden of multimorbidity has been documented in RA, and the disease itself can have extra-articular presentations, such as cardiac or interstitial lung disease (Bartels et al., 2010; Figus et al., 2021). Its prevalence has increased because of decreasing disease-associated mortality (GBD 2021 Rheumatoid Arthritis Collaborators, 2023). Given improvements in the medical management of RA, many individuals can achieve clinical remission with biologic or synthetic disease-modifying antirheumatic drugs, and joint deformities are now less common in this population (Brown et al., 2024). However, some individuals continue to have active disease, and unpredictable flares can still occur after remission (Ajeganova & Huizinga, 2017; Doumen et al., 2024). In addition, people may have challenges adhering to these medications because of side effects and financial toxicity (Berthelsen et al., 2025). Given the systemic and inflammatory nature of the disease, fatigue that substantially interferes with daily activities is common (Pope, 2020). Pain, fatigue, and psychosocial distress may cluster together (Lindqvist et al., 2022; Pope, 2020), and psychosocial distress may be present even in those with well-controlled disease (DiRenzo et al., 2020). The unpredictability of the disease can limit the ability to plan and engage in valued daily activities.
Occupational therapy practitioners may encounter people with OA or RA across practice settings. These conditions may be primary reasons for referral or co-occurring conditions that increase the complexity of care for another primary condition. In addition, many rheumatic conditions co-occur (e.g., RA and fibromyalgia), which can complicate prognosis and management (Mülkoğlu & Ayhan, 2021). When OA or RA is the primary reason for referral, management may be postoperative (e.g., after a total hip or thumb CMC arthroplasty) or a component of nonoperative management. Occupational therapy is an essential component of the interdisciplinary treatment of individuals with OA and RA, but it is often underused, especially for nonoperative management in the early stages of diagnosis (Baker et al., 2023). AOTA previously published Practice Guidelines for occupational therapy practitioners to use with individuals with arthritis and other rheumatic conditions (Poole et al., 2017). The present Practice Guidelines more narrowly focus on occupational therapy’s nonoperative management of OA and RA in adults, although some intervention strategies may also be relevant for other rheumatic conditions or postoperative care. These guidelines position OA and RA as chronic conditions, which places the emphasis of occupational therapy services on self-management support—building knowledge, confidence, and skills to manage daily activities, symptoms, emotions, and treatments—to promote outcomes such as improved occupational performance, role competence, participation, and quality of life (AOTA, 2020).
Goals of These Practice Guidelines
With these Practice Guidelines AOTA aims to assist occupational therapy practitioners, educators, and researchers in applying evidence-based clinical recommendations within the scope of occupational therapy for people with OA and RA. These guidelines also can serve as a reference for people with arthritis looking for information on occupational therapy interventions that are supported by evidence. The guidelines can also serve as a reference for other health care professionals, health care managers, regulators, policymakers, third-party payers, and managed-care organizations to advance arthritis care and to manage, reimburse, and set related policy.
These Practice Guidelines were developed on the basis of the ADAPTE methodology (ADAPTE Collaboration, 2009) for clinical practice guideline (CPG) adaptation, which is supported by the Guidelines International Network (https://g-i-n.net/). The methodology was selected because of the proliferation of existing evidence-based CPGs on topics relevant to the practice of occupational therapy. Other professional associations and health care societies produce high- quality evidence-based CPGs that include interventions within the scope of occupational therapy, and these can be used to inform occupational therapy practice. We searched for existing CPGs on arthritis using the U.S. National Guideline Clearinghouse, Guidelines International Network, MEDLINE, Google and Google Scholar, CINAHL, and websites from related health societies. Figure 1 illustrates the selection process of the CPGs. More information about the methodology is available in the Appendix.
Selection of existing clinical practice guidelines.
AOTA supported the development of these Practice Guidelines as part of its Evidence-Based Practice (EBP) program. This program is based on the principle that the EBP of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research (Sackett et al., 1996). In these guidelines we present a comprehensive list of evidence-based recommendations derived from existing, high-quality CPGs. The recommendations are focused on interventions within the scope of occupational therapy for people with OA and RA across practice settings.
This Practice Guidelines document was commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. It was financially supported entirely by AOTA and was developed without any involvement from industry. All authors completed conflict-of-interest disclosure forms, with no conflicts noted. The content was reviewed and revised on the basis of feedback from external reviewers representing varied areas of expertise, including lived experience (see the Appendix for details). Reviewers who agreed to be identified are listed in the Acknowledgments.
Occupational therapy practitioners should not consider these Practice Guidelines to be a source of comprehensive information about OA or RA or about the application of the occupational therapy process. The occupational therapy practitioner makes the ultimate clinical judgment regarding the appropriateness of a given intervention, taking into consideration a specific client’s or group’s circumstances, needs, and response to intervention as well as the evidence available to support the intervention. Examples of how evidence-based clinical recommendations can inform practice with people with OA and RA are included in the “Occupational Therapy Interventions for People With OA and RA” section and the two case study sections.
Clinical Recommendations for Interventions for People With OA and RA
The included clinical recommendations are derived from the existing CPGs that are the basis of these guidelines. These clinical recommendations are based on findings from systematic reviews and are given a grade that is based on how confident a practitioner can feel using the recommendation to improve outcomes for their clients. The grade is based on the specificity of the intervention, number of studies supporting the intervention, levels of evidence of the studies, quality of the studies, and significance of the studies’ findings. Clinical recommendations that serve as the basis for these Practice Guidelines were developed by the American College of Rheumatology (England et al., 2023; Kolasinski et al., 2020), the European Alliance of Associations for Rheumatology (EULAR; Dures et al., 2024; Geenen et al., 2018; Kloppenburg et al., 2019; Nikiphorou et al., 2021), and the American Academy of Orthopaedic Surgeons (AAOS; 2021).
The original CPG developers reviewed and analyzed each research paper included in their CPG to assess the quality and strength of the underlying evidence supporting the recommendation. Different CPG developers used different methods to assign a strength to the recommendation, with some using an “ABC”–type of grading and some using qualitative descriptors, such as strong and conditional (Guyatt et al., 2008). For those who used descriptors, not all the CPGs incorporated a “moderate” category, and some used the term limited instead of conditional. To ensure the terminology regarding the strength of recommendations was consistent across the CPGs, we have chosen to make a minor revision and label all recommendations as strong, moderate, or conditional in a way that reflects the CPG developers’ original strength-of-recommendation assessment. For the EULAR recommendations, we mapped A to strong, B or C to moderate, and D to conditional (van der Heijde et al., 2015). The grades are defined as follows: ▪ Strong: There is compelling evidence of efficacy to support the intervention. The benefits of the intervention clearly outweigh the harms and burdens. Most clients should receive the recommended intervention, and it can be adopted in most situations. ▪ Moderate: There is moderate evidence or certainty to support the efficacy of the intervention. The benefits of the intervention clearly outweigh the harms and burdens. Many clients could receive the recommended intervention, and it can be adopted in many situations. ▪ Conditional: Further research findings will affect the certainty of whether to use the intervention. The current evidence is not sufficient to assess the benefits and harms of the intervention. The available evidence could be of poor quality. Practitioners should engage in shared decision-making with clients and diligently document progress and outcomes when trialing this type of intervention.
We also included recommendations against using a certain intervention. This is not common given that interventions within the scope of occupational therapy tend to be less invasive than in other medical fields. However, if recommendations do come out against interventions, this is important information to share with practitioners. The grades are the same in terms of level of evidence or certainty but are framed as not supporting the efficacy of the intervention (i.e., it can cause harm, or the burdens outweigh benefits).
We evaluated the quality of each of the seven CPGs that are the basis of these Practice Guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II (Brouwers et al., 2010; https://www.agreetrust.org). In addition, we evaluated the overall quality and relevance of the recommendations from each of the CPGs using AGREE–Recommendations Excellence (AGREE-REX; Brouwers et al., 2020). Each author completed the review independently, and an average score was calculated (see the Appendix). AGREE II and AGREE-REX scores range from 1 (lowest) to 7 (highest). The quality of the CPG influences the quality of the recommendations. All included recommendations were extracted from CPGs with an average AGREE II score of 5 or above. We included one CPG with an average AGREE II score of 6 but an AGREE-REX score of 4 (AAOS, 2021). Although the scores reflect decreased relevance of the composite body of recommendations in that CPG for occupational therapy practice, specific recommendations were considered relevant by the context experts, warranting inclusion. The AGREE II and AGREE-REX scores can be found in Appendix Tables A.2 and A.3.
The included clinical recommendations, with text taken directly from the original CPGs, are presented in Tables 1–6. They are organized as recommendations related to (1) client education and self-management interventions, (2) psychosocial interventions, (3) lifestyle management interventions, (4) physical activity and exercise interventions, (5) interventions to support occupation, and (6) interventions for work participation. Several recommendations could be classified in multiple tables, but they were assigned to a single table on the basis of iterative discussions by the Practice Guidelines team. The strength of each recommendation and the target population are based on the source CPG. Some recommendations likely have relevance for other target populations but were not specifically examined. For example, the recommendations in Table 6 related to work participation are attributed only to RA per the original CPGs but likely have practical relevance for clients with OA.
Clinical Recommendations for People With OA and RA Related to Client Education and Self-Management Interventions
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. AAOS = American Academy of Orthopaedic Surgeons; ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Clinical Recommendations for People With OA and RA Related to Psychosocial Interventions
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Clinical Recommendations for People With OA and RA Related to Lifestyle Management Interventions
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. AAOS = American Academy of Orthopaedic Surgeons; ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Clinical Recommendations for People With OA and RA Related to Physical Activity and Exercise Interventions
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. AAOS = American Academy of Orthopaedic Surgeons; ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Clinical Recommendations for People With OA and RA Related to Interventions to Support Occupation
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Clinical Recommendations for People With OA and RA Related to Interventions for Work Participation
Note. The text of the recommendations is taken directly from the existing clinical practice guidelines. Readers should refer to the original sources to identify more information that may be useful to contextualize the recommendations. ACR = American College of Rheumatology; OA = osteoarthritis; RA = rheumatoid arthritis.
Occupational Therapy Interventions for People With OA and RA
The Practice Guidelines team developed action statements to align the evidence-based clinical recommendations in Tables 1–6 with the fourth edition of the Occupational Therapy Practice Framework (AOTA, 2020). These action statements guide occupational therapy practitioners on how to use these clinical recommendations to inform interventions for people with OA and RA. The case studies in later sections of this document illustrate how occupational therapy practitioners can use these action statements to guide practice when collaborating with people with OA and RA.
Although OA and RA are discussed together because of overlapping occupational performance limitations and related interventions, occupational therapy practitioners should use their clinical reasoning to identify personalized care solutions that align with condition-specific needs as well as the client’s preferences and personal, environmental, and occupational factors. Decisions about the frequency and duration of occupational therapy interventions are client specific and vary according to the client’s clinical presentation, including coexisting rheumatological conditions, comorbidities, health literacy, and access to resources. The chronicity of OA and RA may warrant care over an extended period or recurring episodes of care corresponding to disease fluctuations.
Action Statement 1: Provide Client Education and Self-Management Interventions to People With OA and RA
Individually tailored interventions should increase clients’ knowledge about their condition and build their confidence and skills to address symptoms (e.g., pain, fatigue, swelling) and promote participation in valued occupations. A thorough occupational profile is needed to identify clients’ occupational needs and priorities and align interventions with clients’ occupations, performance patterns, environmental factors, and personal factors (e.g., health beliefs, culture). Education and self-management interventions are well suited to take place via telehealth, which can reduce barriers to accessing services for some individuals. However, client preferences, digital literacy, and digital resources should be considered in choosing the format of occupational therapy services.
Such interventions may include one or more of the following: ▪ Providing tailored education about the condition of OA or RA, taking into consideration each client’s personal factors, including health literacy. ▪ Providing pain education on nociceptive and centralized contributors to the OA or RA pain experience. ▪ Providing information about relevant assistive devices and adaptive equipment, ergonomic strategies, and joint protection principles, taking into consideration each client’s personal and environmental factors as well as joint deformities that may be present. ▪ Training clients in strategies to modify activities, protect joints, use assistive devices and adaptive equipment, and engage in energy conservation and pacing to reduce pain and fatigue and support participation in meaningful activity. ▪ Building clients’ self-efficacy to use strategies to manage their symptoms and daily activities by providing graded opportunities to experience successful performance, providing opportunities to learn from peers with similar experiences, and offering encouragement. ▪ Supporting clients in developing action plans, setting goals, making decisions, and problem-solving in daily life as well as developing methods to track and evaluate goal attainment related to occupational performance. ▪ Engaging in the codevelopment of routines that support the incorporation of condition-specific health management strategies in everyday life. ▪ Offering participation in structured individual or group self-management programs.
Action Statement 2: Provide Psychosocial Interventions to Clients With OA and RA
Interventions should be aimed at addressing psychosocial factors that contribute to the development or worsening of pain, fatigue, and stress that are barriers to occupational performance. In addition, psychosocial interventions should address the emotional distress associated with living with a chronic condition, including the need to discontinue or modify valued activities and the potential social stigma associated with using adaptive equipment or assistive devices. Occupational therapy practitioners should use the information collected in the occupational profile, such as that related to social drivers of health and clients’ beliefs and values, to develop individually tailored strategies.
Such interventions may include one or more of the following: ▪ Leveraging cognitive–behavioral techniques as part of other education and self-management interventions to reframe thoughts and change behaviors as a means of managing pain, fatigue, and stress and reducing fear of movement and activity. ▪ Incorporating mindfulness-based techniques into daily activities when such approaches align with clients’ personal factors. ▪ Integrating mind–body exercises into physical activity routines to manage pain, stress, and fear of movement. ▪ Providing education and training on stress management and coping strategies. ▪ Connecting clients with resources to address social drivers of health (e.g., food bank, housing assistance). ▪ Collaborating with interdisciplinary team members, including referring clients to licensed mental health counselors for psychotherapy, when needed, and referring clients to social workers to further address social health barriers.
Action Statement 3: Provide Lifestyle Management Interventions to Clients With OA and RA
Individualized lifestyle management interventions should address clients’ medical comorbidities. Such interventions may be designed and delivered in collaboration with interdisciplinary team members (e.g., physicians, dietitians). Occupational therapy practitioners should specifically evaluate clients’ health beliefs and routines and develop tailored action plans that address their lifestyle management goals (e.g., weight loss, tobacco cessation) in the context of daily life.
Such interventions may include one or more of the following: ▪ Providing education about the inflammatory component of arthritis and connection to diet and sleep. ▪ Leveraging occupationally informed lifestyle management approaches to build routines to manage intersecting chronic conditions (e.g., diabetes, obesity). ▪ Promoting sleep hygiene, including through strategies such as establishing healthy sleep routines and modifying environments to support rest and sleep.
Action Statement 4: Provide Physical Activity and Exercise Interventions to Clients With OA and RA
Physical activity and exercise interventions can manage pain and fatigue, improve physical function, support physical and mental wellness, and facilitate continued participation in valued occupations. Such interventions should be designed to align with clients’ general health status and other personal and environmental factors, including financial and geographic resources. Exercise programs may be designed in collaboration with other health care professionals (e.g., physical therapists), in particular for clients with spine or lower extremity arthritis. These physical activity and exercise interventions are often integrated with interventions for Action Statements 1–3, such as in self-management programs.
Such interventions may include one or more of the following: ▪ Providing structured hand therapy exercises to improve motion and strength for those with upper extremity involvement. ▪ Providing structured opportunities for supervised exercise that align with clients’ preferences and needs, including mind–body exercises (e.g., tai chi, yoga), resistance exercise and muscle strengthening (e.g., free weights), neuromuscular training (e.g., balance, agility, and coordination exercises), aerobic exercise (e.g., walking, cycling), or aquatic exercise (e.g., swimming). ▪ Providing education on the why and how of movement and building routines to engage in long-term physical activity and unsupervised but tailored exercise. This includes supporting clients in identifying safe and accessible environments for physical activity in their daily lives.
Action Statement 5: Provide Interventions to Clients With OA and RA That Support Occupation, Including Orthoses, Environmental Modifications, and Physical Agent Modalities
Interventions that support clients’ abilities to participate in their desired occupations may do so by reducing pain and fatigue or directly facilitating function. The selection of such strategies should align with clients’ general health and other personal and environmental factors. These interventions should generally be part of more comprehensive education and self-management interventions (Action Statement 1) so they are incorporated into daily life with a chronic condition.
Such interventions may include one or more of the following: ▪ Providing orthoses to stabilize the thumb CMC joint to reduce pain and improve participation. ▪ Providing orthoses for other joints to reduce pain and improve participation (e.g., immobilization orthosis for a painful distal interphalangeal joint). ▪ Providing elastic taping or compression, in combination with or in the place of rigid orthoses, to reduce pain and swelling and improve participation. ▪ Modifying clients’ environments to support activities and participation or providing recommendations for such modifications. ▪ Applying thermal modalities (cold or heat) to reduce pain, including the use of paraffin as a heat modality for hand OA. These modalities may be incorporated into client education and self-management programs for home use.
Such interventions should likely not include the use of electrotherapy with clients who have RA or iontophoresis with clients who have thumb CMC joint OA. Occupational therapy practitioners should consider avoiding these interventions because the burdens may outweigh the benefits.
Action Statement 6: Provide Interventions for Work Participation to Clients With OA and RA
Interventions for work participation may be valuable for those who are employed or who desire to engage in paid or unpaid work.
Examples of interventions may include one or more of the following: ▪ Completing worksite evaluations and individually tailored worksite modifications. ▪ Educating clients on ergonomics to decrease pain, increase function, and prolong work participation. ▪ Supporting clients to advocate for accommodations for optimal work participation. ▪ Connecting clients to resources (e.g., vocational rehabilitation) that extend beyond direct delivery of occupational therapy services, where needed.
Case Study 1: Manny
Clinical Case Overview
Manny is a 57-yr-old bilingual Hispanic man referred to occupational therapy with OA primarily affecting his knees and hands. He presents for an initial evaluation in a large outpatient practice located about 80 miles from his home. In addition to OA, Manny has an elevated body mass index of 27.3 (i.e., overweight), and his hemoglobin A1C is elevated, putting him at risk for diabetes. Manny reports that he has never been referred to any kind of therapy before and is very excited to learn about occupational therapy. However, he is concerned about the amount of travel time required for therapy visits. He reports that he prefers health care information, including written information, in English.
Occupational Therapy Initial Evaluation and Findings
At his initial evaluation, Manny’s occupational therapist used AOTA’s (2021) Occupational Profile Template to focus on Manny’s concerns: ▪ Manny’s primary concern is related to his knee pain and the effect that pain has had on his ability to walk and hike for exercise. He reports that his favorite pastime is hiking to a lake where he and his family frequently fish. Over the past few years, he has had knee pain during and sometimes after these hikes, and at times he has felt like he was at risk of falling. Thus, he does not go hiking to the lake as often, and he feels like this has contributed to his weight gain. ▪ Manny’s physician would like him to lose 10–15 lb, and Manny reports he has never had to diet before. He is interested in adding exercise to his daily routine, but he was told that he should exercise only in water, and he does not have access to a pool. He is also interested in weight loss ideas and strategies but is unsure where to get information. ▪ Manny lives in a three-bedroom home on land that has been in his family for many generations. He has three adult children: two sons and a daughter. His sons both built homes on the family land, and his daughter lives in a small town about a 10-min drive from the property. ▪ Manny and his family have a large garden and try to produce fruit and vegetables for their households. He mentions they can sometimes buy produce at roadside stands and that the closest grocery store is 90 min away by car. He shares that he and his family have a yearly competition to see who can create the best dish using only what they acquire from their gardens. He is the current salsa champion. ▪ Manny works in facilities management for a community school that is near his daughter’s home. In addition to doing maintenance work, Manny occasionally fills in as a bus driver. He reports that he has always really enjoyed his job but that the job is becoming more difficult because of knee and hand pain. He plans to stay in the job until retirement and describes his employer as being very supportive.
The Canadian Occupational Performance Measure (COPM; Law et al., 2019) was used to help define Manny’s satisfaction with and performance on activities and to help with goal setting. The Quick Disabilities of the Arm, Shoulder, and Hand (Wong et al., 2007) was used to measure the impact of OA on Manny’s arm and hand use. Pain in the thumb and knee was measured using the Numeric Rating Scale for Pain (Hawker et al., 2011), and Manny’s therapist used objective measures, such as the grind test to assess thumb CMC arthritis (Merritt et al., 2010) and a Jamar dynamometer to measure grip strength. Initial evaluation findings are summarized in Table 7.
Assessment Findings: Manny
Note. ADLs = activities of daily living; QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand.
aHigher scores indicate more importance and better performance and satisfaction Law et al. (2019).
bAverage for men ages 55–59: right, 97.2 lb; left, 90.4 lb (Bohannon et al., 2006).
cAverage for men ages 55–59: right, 24.2 lb; left, 23.0 lb (Mathiowetz et al., 1985).
dHigher scores indicate more pain.
Occupational Therapy Interventions
Manny participated in six occupational therapy sessions over a 12-wk period, including the initial evaluation, a progress report at the end of 30 days, and a discharge summary at the end of 12 wk. Two phone calls were initiated by Manny’s occupational therapist to check on progress during the weeks that Manny was unable to travel to therapy. Formal telehealth via video calls was not an option because Manny’s rural location has only limited broadband availability.
Physical Activity and Exercise and Related Client Education (Action Statements 1 and 4)
Manny’s occupational therapist explained that newer research has shown that people with knee OA have reduced pain completing exercise both in and out of the water, including exercises such as aerobic walking and weightlifting (Escalante et al., 2010). The therapist also explained that evidence has shown that weight loss can help decrease discomfort in people who have knee pain secondary to OA (Jenkinson et al., 2009). Manny was very interested in being able to participate in exercise and agreed to work with his therapist on what he hoped would become a daily program. To improve physical wellness, manage weight, and ultimately reduce knee pain, Manny and his therapist designed an exercise program. The program included walking for 30 min using lightweight hiking poles to help with balance and to involve his upper extremities in the activity. Manny initially participated in this exercise 3×/wk. He then added days, as he became more comfortable, until he was ultimately completing the activity daily. The program also encompassed chair-based exercises that included sit-to-stand to improve leg strength, shoulder range-of-motion exercises using one of his hiking poles, and resistive upper extremity exercises using resistance bands and light weights.
Lifestyle Management (Action Statement 3)
Manny also expressed interest in learning about weight loss resources. To help Manny achieve a healthier weight, which could help with his knee pain and function and reduce the risk of diabetes, the occupational therapist helped him set up a free one-time consultation with a nutritionist to get information on food choices to support weight loss. The therapist also provided Manny with a list of websites where he could obtain healthy recipes and provided him with a food diary and instructions on how to use the diary to set weekly goals to incorporate healthy eating into his daily life. Manny agreed to bring the diary and one new recipe to therapy at each subsequent visit.
Client Education, Self-Management, and Related Supportive Interventions for Managing Daily Activities and Pain (Action Statements 1 and 5)
Manny was also provided with information on adaptive equipment to help with work and leisure tasks. After viewing a video demonstration with the occupational therapist, Manny decided to order a wheeled garden stool with side rails for use at home, and he asked his employer to purchase one for him to use at work. In addition, Manny’s therapist provided him with instruction on joint protection and gave him a handout that listed online resources with additional ideas for adaptive devices to protect joints and reduce pain. Teach-back was used to ensure Manny’s understanding.
Manny’s occupational therapist created custom orthoses to support and reduce pain at the CMC joints of his thumbs overall and during activities such as gardening and using tools. The therapist provided wear-and-care instructions for the orthoses and reminded Manny to bring the orthoses with him to subsequent appointments for adjustments if needed. In addition to the custom orthoses, the therapist provided Manny with washable neoprene thumb supports to use as needed.
During therapy sessions, Manny was also introduced to physical agent modalities, such as hot and cold packs and paraffin, for pain management. Manny’s therapist carefully explained the rationale for, and precautions related to, the modalities and provided Manny with sources where he could purchase the modalities should he decide to continue use at home.
Manny’s Discharge Summary
At the end of 12 wk, Manny had attended six occupational therapy sessions. He reported weight loss of 9 lb and had a 2-point decrease in hand pain with heavy use and a 3-point decrease in knee pain with activity (Table 7). He felt his overall quality of life had improved, as had his satisfaction with work tasks and tool use. Manny told his therapist that he felt like he had the knowledge and skills he needed to be able to participate in and enjoy work and leisure activities, and he shared that his family had recently bought a home paraffin unit for him for his birthday.
Case Study 2: Kate
Clinical Case Overview
Kate is a 35-yr-old English-speaking non-Hispanic White woman who was diagnosed with RA at age 29 and was referred to occupational therapy by her rheumatologist. She presents for an initial evaluation in an urban outpatient private practice 4 mo after having given birth to her first child, a daughter named Sophie. She had a remission of RA during pregnancy but experienced a substantial flare that began 2 mo after delivery and has still not resolved. She has never received occupational therapy services.
Occupational Therapy Initial Evaluation and Findings
Using AOTA’s (2021) Occupational Profile Template as a guide, Kate’s occupational therapist conducted an initial evaluation, which identified the following: ▪ Kate’s primary concerns are severe fatigue and bilateral upper extremity pain, which are interfering with her role competence, participation, and well-being. Specifically, she wants to thrive in her new role as a mother. ▪ She lives in a three-bedroom apartment in a multistory building with an elevator. She resides with her husband of 2 years, who is emotionally supportive but works long hours and travels often for work. They have a housekeeper who comes weekly to do laundry and heavy cleaning. Although this level of household assistance was adequate before Sophie’s birth, some activities, such as laundry, now need to be done many times a week. She has two friends who live in the neighborhood who have been providing support with some activities (e.g., grocery shopping) since Sophie’s birth. ▪ Kate has a PhD in immunology and is employed as a scientist for a pharmaceutical company. Her job responsibilities require a substantial amount of fine motor activity, including precise repetitive or sustained prehension. She has taken an extended leave of absence related to persistent pain and fatigue after Sophie’s birth. Although being a scientist is an important part of her professional identity, she shares that returning to work is currently less of a priority for her than her parenting responsibilities. She has health insurance through her husband’s employer. ▪ Kate has been diagnosed with postpartum depression, which is resolving, but she continues to feel overwhelmed and tearful when unable to complete a simple task for Sophie. She is currently receiving counseling from a psychologist. She shares that her sense of loss reminds her of how she felt immediately after her RA diagnosis. Exercise, including regular participation in yoga, has been an important part of her self-care and social participation in recent years, but she has been unable to participate in this activity since Sophie’s birth.
Standardized assessment findings for the initial evaluation are given in Table 8. Kate had no observable joint deformities. Her active bilateral shoulder flexion was moderately painful and limited to 90°; active bilateral shoulder external rotation was severely painful and limited to 30° in shoulder abduction. Active range of motion of other upper extremity joints was within normal limits but moderately painful. Kate contextualized her sleep disturbance as primarily associated with taking care of Sophie versus pain.
Assessment Findings: Kate
Note. PROMIS® = Patient-Reported Outcomes Measurement Information System.
aHigher scores indicate more importance and better performance and satisfaction (Law et al., 2019; Meesters et al., 2014).
b Bingham et al. (2019, 2021).
Occupational Therapy Interventions
Kate participated in 10 occupational therapy sessions over 24 wk, including 6 weekly in-person visits followed by 4 monthly telehealth visits. These sessions included the initial evaluation, a progress report at the end of each month, and a discharge summary at the end of the 24 wk. Care was initially expected to end at 16 wk, but discharge was postponed secondary to a symptom flare. Care was provided by an occupational therapist and occupational therapy assistant team, with the occupational therapy assistant providing care for 3 of the 6 in-person visits. Interim email check-ins with the occupational therapy practitioner team were initiated four times by Kate for support with problem-solving in relation to a parenting activity during a symptom flare. The focus of treatment included client education and self-management for symptoms, emotions, and daily activities; specifically, per Kate’s stated priorities, treatment objectives focused on improving participation in child care and home management.
Assistive Devices, Environmental Modifications, and Related Education and Training (Action Statements 1 and 5)
Kate was instructed on available assistive devices to support child care and meal preparation. She expressed anxiety about trialing strategies with Sophie and therefore initially trialed adaptive techniques for dressing, bathing, and feeding (incorporating assistive devices) in the clinic and at home with an infant-sized doll. An example of a strategy that she adopted was using a nursing pillow to assist with positioning during bottle feeding (Powell et al., 2019). Some devices that were trialed (e.g., a sling to assist with positioning Sophie during bottle feeding) were not adopted because they increased Kate’s shoulder pain. Kate brought in Sophie for one session at the end of the first month and practiced adaptive techniques on her daughter in a safe environment to build confidence. Kate also brought in photos and videos of her kitchen, and the occupational therapy practitioner recommended modifications to the setup to minimize the need to reach overhead. With guidance from the occupational therapy practitioner, Kate also purchased a stool with a back for the kitchen to conserve energy while completing meal preparation.
Individualized Self-Management for Symptoms and Emotions (Action Statements 1 and 2)
To manage fatigue and pain while participating in meaningful activities, Kate was educated on activity-pacing principles that encompassed the new tasks associated with motherhood, including how to problem-solve activity distribution on a daily and weekly basis. The occupational therapy practitioner and Kate collaborated on setting self-management goals and creating related action plans to complete motherhood-related tasks while managing pain and fatigue. Kate expressed interest in self-monitoring her progress and keeping herself accountable using a digital tool. She was introduced to a voice-activated smartphone app that would allow her to monitor levels of daily home management and child care activities, tolerance as indicated by changes in fatigue and pain, and facilitators of and barriers to activities. The occupational therapy practitioner provided feedback on the log at several time points during the treatment episode to increase Kate’s confidence with its use. Possible solutions to manage emotional distress were discussed, and Kate opted to use positive affirmations to reduce unhelpful negative thoughts about her self-worth as a mother before diapering Sophie. In addition, she selected a progressive muscle relaxation intervention to implement before going to bed and after bottle feeding Sophie during the night. When she expressed interest in joining a community of others experiencing similar challenges, she was directed to an online support group for parents with arthritis that could provide both practical guidance and a sense of social connectivity.
Physical Activity and Mind–Body Exercise (Action Statements 2 and 4)
During the second session, Kate participated in 15 min of adapted yoga poses, with modifications based on her symptoms. The goal was to increase confidence in physical movement without increasing pain and to begin restoring participation in a meaningful activity as a coping strategy. She was provided with a home program that incorporated yoga (i.e., mind–body movement) with light aerobic and resistive exercise. On the basis of Kate’s preferences, the home program had a digital format that allowed for the logging of exercise and tracking of symptoms as well as progressions and adaptations based on symptoms. Problem solving related to specific adaptations to physical activity was further discussed at a follow-up session given a symptom flare. In addition, Kate and the occupational therapy practitioner codeveloped a plan to gradually restore a regular physical activity routine, including strategies to incorporate movement into daily activities. For example, walking with Sophie to the coffee shop to meet a friend was framed as a way to get aerobic exercise.
Kate’s Discharge Summary
At the end of the 10 sessions, Kate reported that her overall confidence to manage her disease and its impact on her daily life was continuing to increase, although it was not yet at the same level as before Sophie’s birth. Upper extremity range of motion was similar to that at the initial evaluation but was less painful. The results of the standardized assessments at discharge are summarized in Table 8. Kate’s average COPM performance score increased from 4.3 to 7.0, and her average satisfaction score increased from 3.0 to 6.7, exceeding a meaningful change threshold of 2 points (Law et al., 2019). Patient-reported fatigue improved by 19.2 points, pain interference improved by 10.8 points, and depression improved by 10.2 points, which likely all exceed meaningful change thresholds (Bingham et al., 2021; Norman et al., 2003). Although work participation was not directly addressed during occupational therapy in accordance with Kate’s priorities, she shared that her increased confidence in managing symptoms and daily activities should support a return to work. She was also now aware of the role of occupational therapy services to improve work participation if needed in the future.
Strengths and Limitations of These Practice Guidelines
Leveraging the ADAPTE methodology to adapt existing CPGs enabled a more efficient use of resources. In addition, this approach allowed us to include evidence-based clinical recommendations developed by other professional organizations that have direct relevance for occupational therapy but that may have been excluded in a more traditional CPG development process limited to interventions delivered by occupational therapy practitioners. A limitation of this approach is the heterogeneity of existing CPG methodology (e.g., grading of strength of recommendations), which required some minor modifications to support their synthesis for this document. In addition, the development of the action statements to align the clinical recommendations with occupational therapy practice was a subjective process, although we increased rigor by including two content experts, a research methodologist, and AOTA EBP staff in the development process, combined with an external review process. Note that we chose to include conditional clinical recommendations in this Practice Guidelines document. Although these may change with the addition of newer evidence, we felt that the benefits of including such recommendations with high relevance to support occupational performance in people with OA and RA outweighed any potential risks.
Furthermore, although the clinical recommendations and associated action statements cover a breadth of interventions, they are not intended to be fully inclusive of all possible interventions within the scope of occupational therapy practice. The lack of a specific clinical recommendation for an intervention generally reflects the absence of evidence. For example, limited evidence was available for technology, such as telehealth and mobile apps. In addition, recommendations in CPGs are often broad and do not provide specific guidance on intervention parameters and dosage or the tailoring of interventions to specific clinical or demographic subgroups. To advocate for the distinct contribution of occupational therapy in OA and RA care, more evidence generation is also needed for profession-specific interventions (e.g., occupation) and outcomes (e.g., occupational performance). Recommendations for assessment in OA and RA were outside the scope of these Practice Guidelines. Furthermore, because of the time it took to develop both the original CPGs and current Practice Guidelines, the recommendations synthesized in this document may not reflect the most up-to-date evidence.
Postoperative interventions, such as after total hip arthroplasty or wrist fusion, were not the focus of the current Practice Guidelines, although some recommendations in this document may be relevant. No recommendations were identified specific to glenohumeral OA despite it being a common condition seen by occupational therapy practitioners. In addition, the focus of this document was OA and RA, although some recommendations may be relevant for other types of arthritis (e.g., psoriatic arthritis). Similarly, some recommendations that were specifically formulated for one subgroup of people with arthritis (e.g., knee OA) may also be relevant for a different subgroup. Occupational therapy practitioners should use their clinical reasoning to evaluate potential benefits and risks in the new subgroup in combination with clients’ preferences and unique personal, occupational, and environmental factors. These Practice Guidelines also do not explicitly address health care delivery issues, such as out-of-pocket costs for clients, costs for payers, and intervention delivery and implementation costs.
Conclusion
Approximately 20% of U.S. adults live with arthritis, with the most common types being OA and RA. Arthritis has a substantial functional and psychosocial impact, and occupational therapy practitioners may encounter people who have OA and RA as primary or secondary conditions across practice settings. People with OA and RA benefit from occupational therapy services, including from the early stages of diagnosis. Occupational therapy practitioners can play a key role in supporting people with OA and RA to manage daily activities, symptoms, emotions, and treatments so they can live well with these chronic conditions. Practitioners can leverage the clinical recommendations synthesized in this document and the related action statements, in combination with clients’ preferences and personal, environmental, and occupational factors, to improve clients’ quality of life and address their occupational performance and participation needs.
Footnotes
*
Indicates existing clinical practice guidelines included in the current Practice Guidelines.
Acknowledgments
We thank the following individuals for their participation in the content review and development of this publication.