Hand Splinting for Reumatoid ilness

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Please cite this article in press as: de Almeida PHTQ, et al. Occupational therapy in rheumatoid arthritis: what rheumatologists need to know? Rev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008 ARTICLE IN PRESS RBRE-148; No. of Pages 9 r e v b r a s r e u m a t o l . 2 0 1 4; x x x(x x) :xxx–xxx REVISTA BRASILEIRA DE REUMATOLOGIA w ww.reumatologia.com.br Review article Occupational therapy in rheumatoid arthritis: what rheumatologists need to know? Pedro Henrique Tavares Queiroz de Almeida a,, Tatiana Barcelos Pontes a , João Paulo Chieregato Matheus a , Luciana Feitosa Muniz b , Licia Maria Henrique da Mota b a Universidade de Brasília - Brasilia, DF, Brazil b Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil a r t i c l e i n f o Article history: Received 11 April 2014 Accepted 10 July 2014 Available online xxx Keywords: Rheumatoid arthritis Rehabilitation Activities of daily living Occupational therapy a b s t r a c t Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of inter- vention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient’s functionality. Occupational ther- apy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupa- tional therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and cop- ing with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and indepen- dence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA. © 2014 Elsevier Editora Ltda. All rights reserved. Institution: Faculdade de Ceilândia Course of Occupational Therapy; Hospital Universitário de Brasília Rheumatology Outpatient Clinic of Early Rheumatoid Arthritis. Corresponding author. E-mail: [email protected] (P.H.T.Q. de Almeida). http://dx.doi.org/10.1016/j.rbre.2014.07.008 2255-5021/© 2014 Elsevier Editora Ltda. All rights reserved.

description

Artigo que versa sobre a utilização de órtese para a correção de deformidades provenientes da artrite reumatóide

Transcript of Hand Splinting for Reumatoid ilness

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    ARTICLE IN PRESSBRE-148; No. of Pages 9r e v b r a s r e u m a t o l . 2 0 1 4;x x x(x x):xxxxxx

    REVISTA BRASILEIRA DEREUMATOLOGIA

    w ww.reumato logia .com.br

    eview article

    ccupational therapy in rheumatoid arthritis: whatheumatologists need to know?

    edro Henrique Tavares Queiroz de Almeidaa,, Tatiana Barcelos Pontesa,oo Paulo Chieregato Matheusa, Luciana Feitosa Munizb,icia Maria Henrique da Motab

    Universidade de Braslia - Brasilia, DF, BrazilHospital Universitrio de Braslia, Universidade de Braslia, Braslia, DF, Brazil

    r t i c l e i n f o

    rticle history:

    eceived 11 April 2014

    ccepted 10 July 2014

    vailable online xxx

    eywords:

    heumatoid arthritis

    ehabilitation

    ctivities of daily living

    ccupational therapy

    a b s t r a c t

    Interventions focusing on education and self-management of rheumatoid arthritis (RA) by

    the patient improves adherence and effectiveness of early treatment. The combination of

    pharmacologic and rehabilitation treatment aims to maximize the possibilities of inter-

    vention, delaying the appearance of new symptoms, reducing disability and minimizing

    sequelae, decreasing the impact of symptoms on patients functionality. Occupational ther-

    apy is a health profession that aims to improve the performance of daily activities by the

    patient, providing means for the prevention of functional limitations, adaptation to lifestyle

    changes and maintenance or improvement of psychosocial health. Due to the systemic

    nature of RA, multidisciplinary follow-up is necessary for the proper management of the

    impact of the disease on various aspects of life. As a member of the health team, occupa-

    tional therapists objective to improve and maintaining functional capacity of the patient,

    preventing the progression of deformities, assisting the process of understanding and cop-

    ing with the disease and providing means for carrying out the activities required for the

    engagement of the individual in meaningful occupations, favoring autonomy and indepen-

    dence in self-care activities, employment, educational, social and leisure. The objective of

    this review is to familiarize the rheumatologist with the tools used for assessment and

    intervention in occupational therapy, focusing on the application of these principles to thetreatment of patients with RA.Please cite this article in press as: de Almeida PHTQ, et al. Occupational therapy in rheumatoid arthritis: what rheumatologists need to know?Rev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    2014 Elsevier Editora Ltda. All rights reserved.

    Institution: Faculdade de Ceilndia Course of Occupational Therapy; Hospital Universitrio de Braslia Rheumatology Outpatientlinic of Early Rheumatoid Arthritis. Corresponding author.E-mail: [email protected] (P.H.T.Q. de Almeida).

    ttp://dx.doi.org/10.1016/j.rbre.2014.07.008255-5021/ 2014 Elsevier Editora Ltda. All rights reserved.

    dx.doi.org/10.1016/j.rbre.2014.07.008dx.doi.org/10.1016/j.rbre.2014.07.008http://www.reumatologia.com.brmailto:[email protected]/10.1016/j.rbre.2014.07.008

  • ARTICLE IN PRESSRBRE-148; No. of Pages 92 r e v b r a s r e u m a t o l . 2 0 1 4;x x x(x x):xxxxxx

    Terapia ocupacional na artrite reumatoide: o que o reumatologista precisasaber?

    Palavras-chave:

    Artrite reumatoide

    Reabilitaco

    Atividades cotidianas

    Terapia ocupacional

    r e s u m o

    Intervences voltadas para a educaco e o autogerenciamento da artrite reumatoide (AR)

    pelo paciente aumentam a adeso e a eficcia da abordagem precoce. A combinaco de trata-

    mento medicamentoso e tratamento de reabilitaco visa a potencializar as possibilidades de

    intervenco, retardar o aparecimento de novos sintomas, reduzir incapacidades, minimizar

    sequelas e reduzir o impacto dos sintomas sobre a funcionalidade do paciente. A terapia

    ocupacional uma profisso da rea da sade que objetiva a melhoria do desempenho

    de atividades pelo paciente e fornece meios para a prevenco de limitaces funcionais,

    adaptaco a modificaces no cotidiano e manutenco ou melhoria de seu estado emocional

    e participaco social. Devido ao carter sistmico da AR o acompanhamento multidisciplinar

    necessrio para o adequado manejo do impacto da doenca sobre os mais diversos aspetos

    da vida do paciente. Como membro da equipe de sade, o terapeuta ocupacional objetiva

    a melhoria e manutenco da capacidade funcional do paciente, prevenir o agravamento de

    deformidades, auxiliar o processo de compreenso e enfrentamento da doenca, fornecer

    meios para as atividades necessrias para o engajamento do indivduo em ocupaces signi-

    ficativas, favorecer sua autonomia e independncia em atividades de autocuidado, laborais,

    educacionais, sociais e de lazer. O objetivo desta reviso familiarizar o reumatologista com

    as ferramentas de avaliaco e intervenco usadas na terapia ocupacional, com enfoque na

    aplicaco desses princpios para o tratamento de pacientes com diagnstico de AR.

    2014 Elsevier Editora Ltda. Todos os direitos reservados.Introduction

    Rheumatoid arthritis (RA) is a systemic autoimmune diseasecharacterized by impairment of the peripheral joints, espe-cially hands and feet.1 A prevalence of up to three times higheramong women is observed, with increasing incidence afterthe age of 25 years, with greater involvement of populationsbetween 35 and 55 years.2

    Although there is no consensus on the etiology of RA, it isobserved that the combination of inflammation and synovialhypertrophy favor cartilage and bone destruction, promot-ing joint damage and instability,3 predominantly affecting thejoints of the wrist and metacarpophalangeal and proximalinterphalangeal joints of upper limbs.4 For these reasons, thetreatment of patients diagnosed with RA should be started assoon as possible, aiming to reduce the inflammatory activityof the disease and even to obtain remission of symptoms.5

    Despite advances in the pharmacological treatmentachieved in the last 30 years, especially with the adventof disease-modifying anti-rheumatic drugs (DMARDs),6 thechronicity of RA implies interventions aimed to the edu-cation and self-management of the disease to favor thetreatment, increasing the adherence and effectiveness of anearly approach.7,8

    The combination of drug treatment and rehabilitationtherapy aims to maximize the possibilities of intervention,9

    delay the onset of new symptoms, reduce disability, minimizesequelae and diminish the impact of symptoms on function-ality of the patient.10,11Please cite this article in press as: de Almeida PHTQ, et al. Occupational thRev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    Occupational therapy (OT) is a health care profession whichaims at improving the performance of activities by the patient,providing a means for the prevention of functional limitations,adaptation to lifestyle changes and maintenance or improve-ment of his/her emotional state and social participation.12

    The aim of this review is to familiarize the rheumatologistwith the assessment and intervention tools used in occupa-tional therapy, focusing on the application of these principlesto the treatment of patients diagnosed with RA.

    Multidisciplinary treatment practice ofoccupational therapy

    Due to the characteristic joint impairment of RA, the function-ality of the patient is reduced not only by the painful condition,but also by those motor constraints associated.13 The diffi-culty in performing daily tasks is one of the main complaintsof patients with the disease14,15 causing restrictions in most oftheir areas of performance16: from simple activities related toself-care and home maintenance to complex work tasks, thepatient presents limitations in doing many of his/her activitiesof daily living (ADLs).17

    It is observed that such restrictions affect not only the per-formance of the activities independently and autonomously,but has a negative impact on the emotional state, social rela-tionships and quality of life of the patient.7,18

    Given the participation constraints and the importanceof engaging in productive activities for the maintenance ofphysical and psychosocial health of this population, the occu-pational therapist is an integral part of the multidisciplinaryteam of care for patients with RA, being concerned with theperformance of ADLs and the inclusion of the patient in mean-erapy in rheumatoid arthritis: what rheumatologists need to know?

    ingful occupations for his/her everyday life.19,20

    Due to the multiplicity of involvements motivated by thedisease and the singularity represented by the daily activities

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    Table 1 Standardized instruments for the functional assessment of patients with RA.

    Assessment tool Objective Data collection method

    Disabilities of Arm, Shoulder andHand (DASH)

    Measures the level of functional impactresulting from the impairment of theupper limb to perform activities of dailyliving related to self-care, mobility, homemaintenance and recreation. The devicehas optional modules specific to assessthe impairment of work activities and thepractice of sport and musical activities.

    Structured, self-administeredquestionnaire. Score from 0 to 100 points,indicating increasing disability due toinvolvement of upper limbs.24,25

    Sequential Occupational DexterityAssessment (SODA)

    Assesses the patients performance ontwelve tasks, performed unilaterally andbilaterally, including writing, handlingobjects and pieces of clothing and handhygiene.

    Structured test. Scored by the therapist,according to the patients performance onthe tasks described.26,27

    Health Assessment Questionnaire(HAQ)

    Measures the level of functionality basedon the difficulty reported by the patient toperform activities in eight areas,including reaching, self-care, mobilityand object holding.

    Standardized questionnaire consisting of20 questions, scored from 0 to 3,indicating increasing disability.28,29

    Canadian OccupationalPerformance Measure (COPM)

    Assesses the patients perception of theimportance of ADLs in self-care,productivity and leisure areas, as well ashis/her satisfaction on theimplementation and performance ofthese tasks.

    Qualitative questionnaire in a format ofsemi-structured interview. Provides twoscores (for performance and satisfaction),allowing the patients pre- andpost-intervention evaluation.30,31

    Handgrip dynamometry JAMAR

    DynamometerAssesses handgrip strength by measuringthe maximum force exerted by thepatient when pressing a hydraulicdynamometer.

    Standardized test, measured in pounds orkg/F. Requires standardization of posturesand grip forms utilized during theevaluation.32,33

    Digital pinch dynamometry Pinch Gauge Dynamometer

    Measures the digital pinch strength of thepatient with three types of tweezers,using the fingers I, II and III, representingboth fine movement (opposition betweenfingers I and II) and grip strength (lateralgrip).

    Standardized test, measured in pounds orkg/F. Requires standardization of posturesand grip forms utilized during theevaluation.32,33

    Manual Dexterity and FunctionTesting

    Measure manual dexterity through themanipulation of objects and utensilscommon to ADLs. Examples:JebsenTaylor function test, PurduePegboard, OConnor Finger Dexterity.

    Standardized tests, generally using as aparameter for evaluation the timerequired for manipulation of objectsduring the course of systematic tasks.27

    Hospital Anxiety and DepressionScale (HADS)

    Evaluates the occurrence of symptoms ofanxiety and depression among patients.

    Standardized questionnaire containingseven questions to assess anxiety andseven for depression, scored from 0 to 3.The final score is the sum of the points;

    fetTitr

    A

    Teoph

    or each patient, the first step toward the realization of anffective therapeutic intervention is to obtain relevant data onhe state of the disease and its impact on the patients ADLs.he evaluation is an ongoing process, which enables the mon-toring of treatment and the interventions needed, as well ashe modification of these during periods of exacerbation andemission.21

    ssessment in occupational therapy

    he evaluation aims at obtaining data relating to the physical,Please cite this article in press as: de Almeida PHTQ, et al. Occupational thRev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    motional and social state of the patient, as well as the impactf the disease on his/her ADLs, providing objective data on theatients occupational performance that allow monitoring ofis/her evolution during treatment.22results >7 suggest states of anxiety and/ordepression.18

    Historically, occupational therapists combine the use ofsemi-structured interviews and standardized tools for gather-ing information to enable the establishment of a baseline forthe therapy: disease status and functional limitations, expan-sion of the understanding of the contexts of a patients life,identification of his/her priorities, monitoring of the diseaseand the effectiveness of proposed interventions.21 The selec-tion of assessment methods should take into considerationthe main complaints of the patient and their relevance to theclinical presentation.23 Table 1 illustrates some of the stan-dardized assessment tools that comprise the evaluation ofpatients with RA by the occupational therapist.

    Independent of the choice of instruments for assessment,erapy in rheumatoid arthritis: what rheumatologists need to know?

    is important that the information obtained is related to theoccupational performance of the patient, i.e., the data mustaim not only to measure the intensity of a particular symptom

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    Table 2 Principles of joint protection and energyconservation.

    Joint protectionRespect the pain Use it as a sign to change the activityDistribute the load on more than one jointReduce the strength and the effort required to perform someactivity, changing the way to perform it, using assistive devicesor reducing the weight of utensilsUse each joint in its most stable and functional anatomical planeAvoid positions or forces in directions that favor deformitiesAlways use the stronger and larger joint to workAvoid staying in the same position for a prolonged timeAvoid holding objects with excessive forceAvoid awkward postures and inappropriate ways to pick up andhandle objectsMaintain muscle strength and range of motion

    Energy conservationAdjust your day balancing moments of activity and rest,alternating light and heavy tasks and performing activities at aslower pacePlan the conduction of your activities: prioritize important tasks,use equipment to reduce the effort and delegate tasks whennecessaryWhen tired, avoid starting tasks that cannot be interruptedimmediately4 r e v b r a s r e u m a t o

    (fatigue, pain, functional capacity), but also the influence ofthis on the patients ability to engage and perform tasksrelevant to his/her day-to-day.12,21

    Interventions of occupational therapy

    Patient guidance and education changing habits to copewith illness

    The transmission of knowledge and the understanding of thepatient about his/her condition do not guarantee, by itself, anychange of attitudes necessary for the management of compli-cations arising from a chronic disease; so that OT has as mainobjective the voluntary change of habits, extended to all areasof the patients performance and not only to those activitiesafflicted by pain or biomechanical imbalances driven by thedisease.24

    The multidisciplinary interventions for patients with RAaim to control pain and fatigue, aiming their functionalimprovement by combining different modalities of treatment.

    Among some of the interventions focused on patientadjustment and empowerment concerning the disease, thetechniques of joint protection and energy conservation areexamples of changes in habits, by the way of conducting ADLs,which promote changes not only on functional capacity, butalso on the psychological well-being, personal control andself-acceptance fundamental concepts for improving thequality of life of the patient.34

    Joint protection and energy conservation

    Joint protection techniques are a set of guidelines and preven-tive strategies used in the management of pain and fatigue,35

    associated with other symptoms in patients with RA, whichaim to apply ergonomic and biomechanical principles whileperforming ADLs to protect joint structures of normal andabnormal forces that may contribute to the installation ofdeformities or aggravate deformities already present.36,37

    This approach was first described in 1965,38 through theanalysis of motor impairments motivated by the inflam-matory process common to RA and its combination withbiomechanical principles, aiming to minimize the action offorces that favored the development of joint deviations anddeformities during performing daily tasks,39 for example,hyperextension of the metacarpophalangeal joint of the fingerI, ulnar deviation of metacarpophalangeal joints of the fin-gers IIV and installation of deformity standards, such as swanneck, hammer toe or buttonhole toe, through involvement ofdistal interphalangeal joints.40

    Due to the importance and constancy necessary for theaccomplishment of ADLs, modifications in their performanceallow a significant reduction in joint stress and energy expen-diture, facilitating or enabling the participation of the patientin meaningful occupations.36,37 Table 2 illustrates the mainguidelines of the concepts of joint protection and energy con-Please cite this article in press as: de Almeida PHTQ, et al. Occupational thRev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    servation.By modifying work methods and environments, use of

    assistive devices (assistive technologies) and inclusion ofbreaks in the routine, the objective here is the reduction ofModify the environment according to practices of jointprotection and ergonomics

    pain at rest and during movement, by minimizing nocicep-tive stimuli on the inflamed joint capsules, decreasing theforce incident on the joints and controlling energy expendi-ture during daily activities, enabling joint preservation andimprovement or maintenance of the patients functionality.41

    Moreover, conducting activities to strengthen the periartic-ular muscles and maintain joint range of motion, especiallyin the upper limbs, are also resources that contribute tothe maintenance or improvement of the patients functionalcapacity,42,43 allowing a better performance and preservationof joint structures impaired by RA.

    Practical examples of some of the techniques of joint pro-tection and energy conservation44 are illustrated in Fig. 1.

    Randomized trials with high levels of evidence on theeffectiveness of methods of joint protection and energy con-servation showed significant improvement with respect topain reduction among patients receiving the guidelines forchanges in their ADLs.4547 Improvement in fatigue andincreased social participation,47 reduction of morning stiff-ness, lower incidence of deformities in the hands48 andimproved functionality49 were observed, even among patientswith severe RA state.50

    Modifying activities and work environments

    Although most functional assessments have focused on thedifficulty presented by the patient while performing self-careand mobility activities, dysfunctions related to work activitiesrepresent a serious consequence of RA.51

    The rate of retirement for reasons related to RA can varyerapy in rheumatoid arthritis: what rheumatologists need to know?

    from 7% of cases in the first year after diagnosis up to 39%of patients with over 15 years of diagnosis in the absence oftreatment targeted to labor difficulties51; with respect to NorthAmerican and European populations, is expected that up to

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    Fig. 1 Examples of modifications in performing activitiesof daily living. The items on the left indicate movementpatterns in which the position of the joints of the wrist andfingers enhance mechanical forces toward deformitiescommonly observed among patients with RA. Theillustrations on the right suggest modifications that favorthe use of other, more stable, joints, or the distribution ofthe load among multiple joints, avoiding painful andp

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    Although to date there is no conclusive evidence on theotentially harmful positions.

    ne third of patients will abandon the work during the firsthree years of the disease.52

    Abandonment of employment is a last resort, face to theimitations encountered by patients with RA: before retire-ent, increases of stress levels, job changes, restrictions onorkload, loss of promotion opportunities and greater fre-uency of absenteeism and of job changes are observedore often among this population.53 It is estimated that the

    eduction in productivity motivated by RA caused losses ofpproximately 7000 Euros/year per patient,54 and up to 25% ofhe working period may be affected by conditions related tohe disease.55

    The early treatment conducted by a multidisciplinary teams an effective method to minimize complications related toork, maintaining the work capacity of these patients for

    period of time similar to that found among the healthyopulation.51,55

    Given the multiplicity of situations and perceptions aboutork activity reported by patients, individualized strate-ies are indicated as the best approach to labor difficulties,ncluding a specific evaluation of the situation and of theorkplace.52

    Changes for a better performance of the activity maynclude the organization of the tasks that compose the workPlease cite this article in press as: de Almeida PHTQ, et al. Occupational thRev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    ctivity, changing shifts, and a fair division of the workloadhroughout the day56; ergonomic modifications such as newurniture and changes in the workplace, ensuring a proper 4;x x x(x x):xxxxxx 5

    joint positioning during activity, replacement of fixtures byother of smaller weight or with better handgrip57 and guidanceon stress management and acquisition of strategies (coping)to handle with the workload.58

    Although some review studies show no high level evidenceon the effectiveness of specific ergonomic interventions toreduce problems related to upper limbs,59 there is satisfac-tory evidence to support such interventions with respect topatients with RA,57 suggesting improvement in functionality,pain and satisfaction with the work in the long term, whencompared to individuals who did not get these interventions.

    Assistive technologies orthotics and adaptations

    The concept of assistive technology includes devices, guide-lines and practices that aim to maintain, enhance or facilitatethe performance of self-care, instrumental, educational,employment or social activities.60

    Among the range of instruments available to patients withRA, the adaptations of utensils and the use of orthotics aresome of the major resources to promote improved grip, biome-chanical alignment and joint stress reduction, as well as toallow the development of activities and occupations, con-tributing to the patients functionality and autonomy.61

    The adaptation of utensils requires a thorough analysis ofthe activity performed by the patient, in order to determinewhat are the main challenges encountered and possible solu-tions to be proposed. Such modifications may include fromchanges in the way of conducting the activity (such as guid-ance on joint protection and energy conservation) to changesin the shape, weight and size of utensils.

    Thicker handles and adaptations to facilitate or replace thehandgrip strength, for example, elastic or neoprene strips,favor the handling of cutlery, writing instruments and per-sonal hygiene materials, such as toothbrushes and haircombs.

    The replacement of drinking glasses for mugs, the use ofmodified cutting boards, soap and detergent dispensers andclotting adaptations are examples of simple devices whichpromote important functional changes to the patient.6264

    Examples of adaptations to promote improvement in perform-ing ADLs are illustrated in Fig. 2.

    Orthoses (splints) are resources used by therapists to pro-mote better joint support, reduce pain and optimize functionalperformance of the patient.65 Although several models areavailable, clinical reasoning used for prescribing an orthosisinvolves the needs for each case; the same orthosis can beprescribed for multiple objectives.

    Among the most common indications, pain control,decreased morning stiffness, mechanical support for joints,encouragement of joint motion and functionality, and cer-tain postoperative situations (where the combination of jointalignment, immobilization and application of traction forcesis required) can be cited.6668 Some models of orthoses com-monly indicated are illustrated in Fig. 3.erapy in rheumatoid arthritis: what rheumatologists need to know?

    effectiveness of orthoses for improved functionality and hand-grip strength,65 some studies suggest that the use of orthoticsfor hands and wrists positioning during inflammatory phases

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    Fig. 2 Adapted utensils. The proposed adjustments are based on the principles of joint protection and energyconservation, with distribution of mechanical loads and promoting the use of larger joints during activities.

    er limFig. 3 Examples of orthoses for upp

    promote improvement in pain and morning stiffness for thepatient.68,69

    Braces used for stabilization of the interphalangeal jointsalso exhibit significant levels of evidence in reducing pain,although no significant changes on hand function or strengthduring its use have been observed.70

    Conclusions

    Due to the systemic nature of RA, a multidisciplinary follow-Please cite this article in press as: de Almeida PHTQ, et al. Occupational thRev Bras Reumatol. 2014. http://dx.doi.org/10.1016/j.rbre.2014.07.008

    up is necessary for the proper management of the impactof the disease on various aspects of life of the patient. Asa member of the health team, the occupational therapistaims to improve and maintain his/her patients functionalbs, suggested for patients with RA.

    capacity, preventing the worsening of deformities, aiding inthe process of understanding and coping with the disease,and providing means for carrying out the activities requiredfor the engagement of the individual in meaningful occupa-tions, contributing to his/her autonomy and independence inself-care, labor, educational, social and leisure activities.

    It is important that the rheumatologist become aware ofthe general principles of therapy, so that he/she can suggesttheir use more consciously, as an additional tool in the treat-ment of patients diagnosed with RA.erapy in rheumatoid arthritis: what rheumatologists need to know?

    Conflict of interest

    The authors declare no conflict of interest.

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