Research Paper

British Journal of Occupational Therapy

2017, Vol. 80(7) 417–422

Long-term improvement in activities ! The Author(s) 2017

Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
of daily living in women with systemic DOI: 10.1177/0308022617698167
journals.sagepub.com/home/bjot
sclerosis attending occupational therapy

Elisabetta Zanatta1, Francesca Rodeghiero2, Erika Pigatto3, Paola Galozzi4,

Pamela Polito1, Maria Favaro5, Leonardo Punzi6 and Franco Cozzi7

Abstract
Introduction: Systemic sclerosis often affects hand function, leading to severe disability in many subjects. There is little data
available on the effects of occupational therapy in systemic sclerosis in current literature. The aim of our study was therefore to
evaluate the effects of a cycle of occupational therapy on performing activities of daily living in a group of women with systemic
sclerosis.
Method: Twenty women with systemic sclerosis were included in the study: 10 followed a cycle of occupational therapy; 10 were
enrolled as controls. An occupational therapy cycle consisted of six meetings of 90 minutes each over a 3-week period. All women
were evaluated by the Health Assessment Questionnaire and Evaluation of Daily Activity Questionnaire at baseline and after 24
weeks. The use of devices and alternative strategies was also assessed.
Results: We observed a significant reduction in the Health Assessment Questionnaire and Evaluation of Daily Activity Questionnaire
scores in occupational therapy subjects after 6 months compared to controls. There was also evidence of significant improvement
in four dimensions of the Evaluation of Daily Activity Questionnaire: eating; indoor mobility; outdoor mobility; and communication.
The number of devices in the occupational therapy group increased significantly.
Conclusion: Our findings suggest a relevant role for occupational therapy in improving activities of daily living in women with
systemic sclerosis. The use of strategies learned during occupational therapy sessions allows for long-lasting beneficial effects.

Keywords
Systemic sclerosis, ADL, activities of daily living, occupational therapy

Received: 4 July 2016; accepted: 9 February 2017

Introduction flexor tendons, resulting in a progressive ankylosis of the

Many systemic rheumatic diseases cause a high level of
disability, which compromises many activities of daily
living (ADL). Occupational therapy can be very helpful,
providing affected subjects with personalized strategies to
carry out ADL and have a better quality of life (Hand
et al., 2011; Yasuda and Hanten, 1985). Occupational
therapy plays a well-defined role in the global therapeutic
program of those affected by rheumatoid arthritis (RA)
and the effectiveness of multidisciplinary team care in
this chronic, disabling disease has been consistently
demonstrated (Viliet Vilietland, 2004).
Systemic sclerosis (SSc) is an autoimmune disorder of
the connective tissue, characterized by diffuse microangio-
pathy and immune dysregulation which leads to an abnor-
mal fibroblast function and increased extracellular matrix
production, with a diffuse fibrosis of skin and internal
organs (lung, kidney, and heart) (Gabrielli et al., 2009).
The hand is seriously affected even in the early stages of
SSc. The fibrosis of the hand causes a retraction of both
the cutaneous and subcutaneous tissues as well as the
fingers also known as ‘‘claw hand’’ (Cuomo et al., 2009;
Erre et al., 2008). Moreover, subjects with SSc often pre-
sent very painful digital ulcers, caused by chronic and
1
Resident, Rheumatology Unit, Department of Medicine – DIMED, University
of Padova, Italy
2
Occupational Therapist, ‘Domus Salutis’ Rehabilitation Clinic, Brescia, Italy
3
PhD Fellow in Clinical and Experimental Science, Department of Medicine
– DIMED, University of Padova, Italy
4
Post-doc Researcher, Rheumatology Unit, Department of Medicine –
DIMED, University of Padova, Italy
5
Outpatient Clinician, Department of Medicine – DIMED, University of
Padova, Italy
6
Professor, Rheumatology Unit, Department of Medicine – DIMED,
University of Padova, Italy
7
Associated Professor, Rheumatology Unit, Department of Medicine –
DIMED, University of Padova, Italy
Corresponding author:
Prof. Franco Cozzi, Rheumatology Unit, Department of Medicine – DIMED,
via Giustiniani 2, 35128 Padova, Italy.
Email: franco.cozzi@unipd.it
418
recurring ischemia, that further hamper hand mobility and
function. Digital ulcers have a severe negative impact on a
subject’s ability to work and this often leads to anxiety and
depression (Mouthon et al., 2010). The hand mobility and
the ADL do not change significantly during the first year
of disease, whereas digital flexion/extension and supin-
ation are very impaired in the latter stages, with progres-
sive difficulties in ADL (Sandqvist et al., 2009). The main
impediment relating to reduced articular range is the abil-
ity to grab big objects, for example a glass (Poole, 1994).
These limitations highlight the importance of developing
rehabilitation programs to support the articular range
mobility, prevent contractures, and promote the best
grasp patterns (Sandqvist et al., 2004). The ability to
achieve different ADL is strictly related to hand function.
Sandqvist et al. (2008) underlined that 50% of subjects
with SSc were restricted in their working ability. The
most arduous activities included doing chores, shopping,
cooking, walking, and sports activities (Sandqvist
et al., 2005). A considerable worsening of work disability
was noted 3 years after disease onset (Sandqvist et al.,
2015). Subjects with SSc and work disability also experi-
ence less overall satisfaction as well as more physical exer-
tion and strain (Bérezné et al., 2011; Sandqvist et al.,
2010).
Despite similarities with patients suffering from RA,
there is little evidence of the actual effectiveness of occu-
pational therapy in SSc subjects. Schouffoer et al. (2011)
reported that a 12-week multidisciplinary team care pro-
gram leads to a significant improvement in the Health
Assessment Questionnaire (HAQ), grip strength, and limi-
tations in daily activities. A systematic review on the
effectiveness of non-pharmacological therapies in SSc
included studies about interventions focused on one symp-
tom or one characteristic (such as hand function or mouth
opening), but not on the ability to perform daily activities
(Willems et al., 2015). A recent paper suggested that occu-
pational therapy integrated with a self-administered
stretching program may be effective to improve and main-
tain hand function in SSc (Stefanantoni et al., 2016).
We decided to perform a controlled study to assess the
efficacy of an occupational therapy program on disability
and quality of life in a group of SSc women with severe
hand impairments. We enrolled in this study our Day
Hospital Unit subjects who received monthly infusions
of Iloprost (a prostacyclin analogous), the only effective
treatment for digital ulcers (Wigley et al., 1992, 1994). The
effects of occupational therapy were evaluated after 6
months by determining whether the women continued to
use strategies and devices, thus obtaining long-term
benefits.
Method
Subjects
Among 36 women affected by SSc and receiving monthly
intravenous administrations of Iloprost for digital ulcers
at the Rheumatology Unit of the University-Hospital of
British Journal of Occupational Therapy 80(7)
Padova, 27 agreed to participate in the study. All fulfilled
the classification criteria for SSc proposed by the
European League against Rheumatism (EULAR) and
the American College of Rheumatology (ACR) (Van den
Hoogen et al., 2013). Four were excluded because of
infected digital ulcers and three for severe lung/heart dys-
function (NYHA class III–IV). The remaining 20 were
allocated into two groups: 10 in the intervention group
(occupational therapy group) and 10 in the control
group. The study design is reported in Figure 1.
The mean age of the subjects was 50.8  9.6 years and
mean disease duration was 12.9  8.1 years. Seven women
presented the limited cutaneous form of SSc (affecting the
face and the extremities) and 13 presented the diffuse form
(with proximal cutaneous sclerosis and trunk fibrosis)
(LeRoy et al., 1988). All had positive antinuclear antibo-
dies (ANA), with specific anti-topoisomerase I antibodies
(Scl70) and anti-centromere antibodies (ACA) in eight and
five cases, respectively. The demographic and clinical char-
acteristics of these women are summarized in Table 1.
All women signed a written consent form and none had
participated in an occupational therapy program prior to
this. The study was conducted in compliance with the
Good Clinical Practices protocol and Declaration of
Helsinki principles. A formal approval from our ethical
committee was not required for this study.
Occupational therapy
A cycle of occupational therapy consisted of a preliminary
informative meeting and six sessions of 90 minutes each
over a 3-week period. A rheumatologist sat in on the ini-
tial meeting explain to participants the importance of a
multidisciplinary care program for improving disability
due to hand involvement in SSc. In the following sessions,
an occupational therapist illustrated the basics of occupa-
tional therapy and the movements that are less damaging
to the hands. The more difficult activities were recorded in
order to elaborate different strategies or explore new
devices to carry them out. Each session was based on a
Eligible patients n=36
Patients not interested n=4
Too busy n=2
Hospital too far away n=3
Screening n=27
Patients excluded n=7
Infected digital ulcers n=4
Lung/Heart dysfunction n=3
Included n=20
Allocated to Day Hospital n=10 Allocated to Day Hospital and
occupational therapy n=10
24-week assessment n=20 (no lost to follow-up)
Figure 1. Flow-chart of women with systemic sclerosis included in
the study.
Zanatta et al. 419

Table 1. Demographic and clinical characteristics of the 20 Table 2. HAQ and EDAQ scores in the occupational therapy group
women with SSc. and in the control group at baseline (T0).
Occupational Occupational
therapy group Control group therapy group Control group
(mean  SD) (mean  SD)
N 10 10
Age (years) 54.1  7.4 47.9  12.7 HAQ 14.9  11.3 13.3  13.1
SSc duration (years) 11.3  6.7 13.9  5.9 EDAQ total 66.7  42.9 72.4  73.0
ANA / Anti-Scl70 / ACA 10/5/2 10/3/3 Eating/drinking 10.8  5.9 8.8  8.6
Diffuse/limited form 7/3 6/4 Moving/transfer 0.8  1.1 1.3  1.8
mRSS (mean  SD) 13.9  6.9 12.2  11 Personal care 3.9  2.8 6.1  6.9
Digital ulcers 10 9 Getting dressed 6.4  4.0 8.8  7.9
ILD 6 4 Bathing/showering 7.7  8.0 9.2  9.9
PAH 1 2 Cleaning the house 5.9  5.0 5.8  5.4
G-I involvement 10 9 Cooking 6.7  6.3 7.6  8.8
Cardiac involvement 3 2 Moving indoors 3.6  2.8 4.2  5.6
Moving outdoors 9.2  3.7 9.2  8.6
SSc: systemic sclerosis; mRSS: modified Rodnan skin score; ILD: inter-
Clothes care 9.1  5.9 8.5  8.5
stitial lung disease; PAH: pulmonary arterial hypertension; G-I: gastro-
intestinal involvement; ANA: antinuclear antibodies; anti-Scl70: anti- Communication 1.9  1.9 2.5  2.6
topoisomerase I antibodies; ACA: anti-centromere antibodies HAQ: Health Assessment Questionnaire; EDAQ: Evaluation of Daily
Activity Questionnaire

specific topic of the program: cooking; getting dressed;

personal care; cleaning the house; and leisure time.
The control group only participated in the preliminary
informative meeting. Women in this group were offered
the opportunity to participate in an occupational therapy
program at the end of the study.
Outcome assessment
All women were evaluated with the HAQ and Evaluation
of Daily Activity Questionnaire (EDAQ), administered at
baseline (T0) and after 24 weeks (T1). The use of devices
and alternative strategies was also assessed at the same
time points.
The HAQ score is a good measurement of the func-
tional impairment, as previously confirmed in SSc subjects
(Poole and Steen, 1991). The HAQ assesses disability and
highlights any changes occurring in these subjects
(Khanna et al., 2005; Merkel et al., 2002). The HAQ
score also shows a good correlation with the Cochin
Hand Function Scale, a functional disability questionnaire
about daily activities, validated both in RA (Poiraudeau
et al., 2000) and in SSc (Brower and Poole, 2004).
The EDAQ is a detailed assessment of self-reported
proficiency in daily activities performed by subjects
with RA (Nordenskiold et al., 1996). Its reliability
and validity have been recently confirmed (Hammond
et al., 2015).
The EDAQ consists of 102 items relating to daily activ-
ities, divided into 11 dimensions: eating; moving and
transfer; personal care; dressing; bathing; cleaning the
house; cooking; moving indoors; moving outdoors; clothes
care; communication. The women from the occupational
therapy group provided an overall evaluation of the occu-
pational therapy sessions, giving a score from 0 to 10 on
appreciation for the initiative, the session program, and
usefulness in daily life.
Statistical analysis
The subjects’ characteristics were described using mean
values and standard deviation for continuous data and
as percentages for qualitative data. Results are reported
as mean  standard deviation.
HAQ and EDAQ scores were analyzed by Wilcoxon’s
non-parametric statistic tests. The variations T0–T1 within
each group were assessed by the ‘signed-ranks test,’ while
the comparison between the occupational therapy and the
control group at T0 and in the time variation of each
parameter was investigated by the ‘two-sample tank test.’
Results
The HAQ and the EDAQ scores at baseline are reported
in Table 2. No significant differences were observed
between the occupational therapy group and controls.
Changes in the HAQ and EDAQ scores six months after
the cycle of occupational therapy are summarized in
Table 3. Subjects in the occupational therapy group
showed a lower HAQ score, though this was not statistic-
ally significant. The total score and the three dimensions of
the EDAQ (eating, moving indoors, and moving out-
doors) significantly decreased (p < 0.05). In the control
group, only a minimal improvement of the HAQ and
EDAQ scores was observed at T1, with no statistical sig-
nificance in comparison to T0. Comparing the two groups
of women, both the HAQ and the EDAQ scores signifi-
cantly improved in the occupational therapy group
(p < 0.05). Four dimensions of the EDAQ (eating,
indoor mobility, outdoor mobility, and communication)
significantly decreased (p < 0.05).
Concerning the use of devices, four women in the occu-
pational therapy group and three controls were already
using ‘assistive devices’ in daily activities at baseline.
After 6 months, nine women in the occupational therapy
420 British Journal of Occupational Therapy 80(7)

Table 3. HAQ and EDAQ scores in the occupational therapy group and in controls at baseline (T0) and after 6 months (T1).
Occupational therapy group Control group

T0 T1 T0 T1
(mean  SD) (mean  SD) (mean  SD) (mean  SD) p

HAQ 14.9  11.3 11.8  7.1 13.3  13.1 13.9  13.5 <0.05
EDAQ total 66.7  42.9 50.3  33.5* 72.4  73.0 71.5  72.3 <0.05
Eating 10.8  5.9 6.4  5.2* 8.8  8.6 9.7  7.8 <0.05
Moving/transfer 0.8  1.1 0.6  0.89 1.3  1.8 1.5  1.9
Personal care 3.9  2.8 4.9  2.7 6.1  6.9 3.9  3.3
Dressing 6.4  4 4.9  4.4 8.8  7.9 8.3  7.7
Bathing/showering 7.7  8 6.1  6.6 9.2  10.9 9.3  10.9
Cleaning the house 5.9  5 4.7  3.7 5.8  5.4 5.2  5.0
Cooking 6.7  6.3 6.5  6.3 7.6  8.8 8.6  9.8
Moving indoors 3.6  2.8 1.6  1.6* 4.2  5.6 4.3  6.0 <0.05
Moving outdoors 9.2  3.7 5.7  3.5* 9.2  8.6 9.5  8.8 <0.05
Clothes care 9.1  5.9 8.2  5.8 8.5  8.5 8.8  8.5
Communication 1.9  1.9 1.7  1.3 2.5  2.6 3.5  2.6 <0.05

HAQ: Health Assessment Questionnaire; EDAQ: Evaluation of Daily Activity Questionnaire

* ¼ p-value < 0.05; comparison between T0 and T1 means.
p ¼ comparison of the variations between the occupational therapy group and the control group.

group and only four controls were using devices or alter-
native strategies. The number of devices or alternative
strategies increased from 35 to 114 in the occupational
therapy group and from 28 to 34 in the control group,
with a significant difference between the two groups
(p < 0.05).
The attendance rate in the occupational therapy group
was an estimated 96%. At the end of the sessions’ cycle,
the involved subjects seemed to appreciate the initiative
(score 8.5  1.2), the schedule of the sessions (score
8.9  0.9), and the usefulness in daily life (score 8.0  0.7).
Discussion and implications
SSc is a chronic autoimmune disease characterized by pro-
gressive disability and reduced quality of life. Among the
clinical features that are deleterious to ADL and quality of
life, hand involvement is the most common: cutaneous,
subcutaneous, and tendon fibrosis as well as the painful
digital ulcers and the flexion contracture of the fingers
cause deformities that lead to a severe disability and limi-
tation in ADL (Hudson et al., 2009). Sandqvist and col-
leagues previously investigated hand involvement in SSc,
confirming dexterity limitations in daily activities through
the HAMIS (Hand mobility in Scleroderma) test
(Sandqvist and Eklund, 2000). Difficulties in ADL can
be ascribed not only to gripping abilities but also to
Raynaud’s phenomenon as well as digital ulcers
(Sandqvist et al., 2004).
The functional impairment of the hand is a major com-
ponent of global disability in SSc and therefore should be
systematically evaluated. In a group of 50 SSc subjects, the
level of disability explained 75% of the variance of the
HAQ (Rannou et al., 2007).
The severe limitation in ADL highlights the importance
of rehabilitative programs for SSc subjects, providing
some strategies and assistive devices to reduce difficulties
in many areas of daily living. The effectiveness of a multi-
disciplinary program has been well demonstrated in
rheumatoid arthritis, in addition to pharmacological and
surgical treatments (Viliet Vilietland, 2004). The hand
function is often seriously compromised in this disease,
with a high level of disability perceived by the affected
subjects (Poiraudeau et al., 2000). Only a few studies
have evaluated the effectiveness of a multidisciplinary
team care program in SSc, even though it has been well
demonstrated that the disability caused by hand involve-
ment is as severe as that observed in subjects with RA with
a comparable disease duration. A pilot study performed
on six women with SSc demonstrated the positive effects of
an educational program on subjective symptoms, disabil-
ity, and psychological function (Samuelson and Ahlmén,
2000). Schouffoer and colleagues observed a significantly
greater improvement in the grip strength and the HAQ
score in 28 SSc subjects after a 12-week multidisciplinary
care program, including individual treatments, group exer-
cises, and group education (Schouffoer et al., 2011).
The SSc prevalence is higher in women, who usually do
housework. This is the reason why, for the purpose of this
study, we enrolled a group of 20 women with SSc char-
acterized by a severe hand involvement with fibrotic
retraction and digital ulcers.
We chose HAQ and EDAQ as evaluation parameters
as we believe they are the most accurate instruments for
detecting and following global disability in SSc and RA
patients. Our results showed that SSc women in both the
control group and the intervention group had comparable
ADL affection levels at baseline.
We observed a significant improvement of HAQ scores
in women from the occupational therapy group compared
to controls. Similar results were observed for the EDAQ
total score and some of its items: eating; communication;
Zanatta et al.
moving indoors; and moving outdoors. Eating includes, for
example, using cutlery, slicing bread or cheese; communica-
tion includes using a computer/phone, holding a book,
taking money from a wallet. These are all daily activities in
which hand function and grip, as well as the various strate-
gies and devices employed during the occupational therapy
sessions, are called into action. So it is not unexpected that
these items would show the most significant improvement.
Likewise, indoor and outdoor mobility includes activities
such as opening the door, driving a car, and shopping. Our
findings support the favorable impact of occupational ther-
apy on performing ADL and on the overall quality of life.
Another important observation was the significant
increase in the number of devices used and of alternative
strategies in daily activities in the occupational therapy
group, in comparison to controls. During the occupational
therapy sessions, the women were invited by the occupa-
tional therapist to implement these strategies in daily
activities at home as well. The appreciation for the pro-
gram at the end of the cycle of occupational therapy ses-
sions was very high and the continued use of the devices in
the following months secured a long-term benefit in carry-
ing out daily activities.
Conclusion
Our findings suggest the importance of occupational ther-
apy in improving the ability of women with SSc to carry
out ADL, with advantages to their quality of life. The use
of strategies acquired during the occupational therapy ses-
sions provides beneficial effects in daily life, lasting long
after the cycle of occupational therapy.
Key findings
. Hand functional impairment is the major component of
global disability in systemic sclerosis.
. An improvement in performing activities of daily living
has been observed after occupational therapy.
. Strategies acquired during occupational therapy pro-
vide long-term beneficial effects.
What the study has added
To our knowledge, this is the only study that demon-
strated the efficacy of a group education program in
women with systemic sclerosis.
Acknowledgment
The authors would like to acknowledge Irene Benetton, occupational
therapist, who contributed to planning the study.
Research ethics
The study was conducted in compliance with the Good Clinical
Practices protocol and Declaration of Helsinki principles. All subjects
signed a written consent form. A formal approval from our ethical
committee was not required for this study. All participants provided
written informed consent.
421
Declaration of conflicting interests
The authors confirm that there is no conflict of interest.
Funding
This research received no specific grant support from any funding
agency in the public, commercial, or not-for-profit sectors.
References
Bérezné A, Seror R, Morell-Dubois S, et al. (2011) Impact of
systemic sclerosis on occupational and professional activity
with attention to patients with digital ulcers. Arthritis Care
and Research 63(2): 277–285.
Brower L and Poole J (2004) Reliability and validity of the
Duruoz Hand Index in persons with systemic sclerosis (sclero-
derma). Arthritis and Rheumatology 51(5): 805–809.
Cuomo G, Zappia M, Abignano G, et al. (2009)
Ultrasonographic features of the hand and wrist in systemic
sclerosis. Rheumatology 48(11): 1414–1417.
Erre G, Marongiu A, Fenu P, et al. (2008) The ‘sclerodermic
hand’: A radiological and clinical study. Joint Bone Spine
75(4): 426–431.
Gabrielli A, Avvedimento EV and Krieg T (2009) Scleroderma.
The New England Journal of Medicine 360(19): 1989–2003.
Hammond A, Tennant A, Tyson S, et al. (2015) The reliability
and validity of the English version of the Evaluation of Daily
Activity Questionnaire for people with rheumatoid arthritis.
Rheumatology (Oxford) 54(9): 1605–1615.
Hand C, Law C and McColl M (2011) Occupational therapy
interventions for chronic diseases: A scoping review.
American Journal of Occupational Therapy 65(4): 428–436.
Hudson M, Thombs B, Steele R, et al. (2009) Health-related
quality of life in systemic sclerosis: A systematic review.
Arthritis and Rheumatology 61(8): 1112–1120.
Khanna D, Furst D, Clements P, et al. (2005) Responsiveness of
the SF-36 and the Health Assessment Questionnaire
Disability Index in a systemic sclerosis clinical trial. Journal
of Rheumatology 32(5): 832–840.
LeRoy EC, Black C, Fleischmajer R, et al. (1988) Scleroderma
(systemic sclerosis): Classification, subsets and pathogenesis.
Journal of Rheumatology 15(2): 202–205.
Merkel P, Herlyn K, Martin R, et al. (2002) Measuring disease
activity and functional status in patients with scleroderma and
Raynaud’s phenomenon. Arthritis and Rheumatology 46(9):
2410–2420.
Mouthon L, Mestre-Stanislas C, Bérezné A, et al. (2010) Impact
of digital ulcers on disability and health-related quality of life
in systemic sclerosis. Annals of the Rheumatic Diseases 69(1):
214–217.
Nordenskiold U, Grimby G, Hedberg M, et al. (1996) The struc-
ture of an instrument for assessing the effects of assistive
devices and altered working methods in women with rheuma-
toid arthritis. Arthritis Care and Research 9(5): 358–367.
Poiraudeau S, Lefevre-Colau M, Fermanian J, et al. (2000) The
ability of the Cochin rheumatoid arthritis hand functional
scale to detect change during the course of disease. Arthritis
Care and Research 13(5): 296–303.
Poole J (1994) Grasp pattern variations seen in the scleroderma
hand. American Journal of Occupational Therapy 48(1): 46–54.
Poole J and Steen V (1991) The use of the Health Assessment
Questionnaire (HAQ) to determine physical disability in sys-
temic sclerosis. Arthritis Care and Research 4(1): 27–31.
Rannou F, Poiraudeau S, Berezné A, et al. (2007) Assessing dis-
ability and quality of life in systemic sclerosis: Construct
validities of the Cochin hand function scale, Health
Assessment Questionnaire (HAQ), Systemic Sclerosis HAQ,
422
and medical outcomes study 36-item short form health survey.
Arthritis and Rheumatology 57(1): 94–102.
Samuelson U and Ahlmén E (2000) Development and evaluation
of a patient education program for persons with systemic
sclerosis (scleroderma). Arthritis Care and Research 13(3):
141–148.
Sandqvist G and Eklund M (2000) Validity of HAMIS: A test of
hand mobility in scleroderma. Arthritis Care and Research
13(6): 382–387.
Sandqvist G, Eklund M, Akesson A, et al. (2004) Daily activities
and hand function in women with scleroderma. Scandinavian
Journal of Rheumatology 33(2): 102–107.
Sandqvist G, Hesselstrand R and Eberhardt K (2009) A longitu-
dinal follow-up of hand involvement and activities of daily
living in early systemic sclerosis. Scandinavian Journal of
Rheumatology 38(4): 304–310.
Sandqvist G, Hesselstrand R, Petersson I, et al. (2015) Work
disability in early systemic sclerosis: A longitudinal popula-
tion-based cohort study. Journal of Rheumatology 42(10):
1794–1800.
Sandqvist G, Scheja A and Eklund M (2005) Daily occupations
and well-being in women with limited cutaneous systemic scler-
osis. American Journal of Occupational Therapy 59(4): 390–397.
Sandqvist G, Scheja A and Eklund M (2008) Working ability in
relation to disease severity, everyday occupations and well-
being in women with limited systemic sclerosis. Rheumatology
47(11): 1708–1711.
Sandqvist G, Scheja A and Hesselstrand R (2010) Pain, fatigue
and hand function closely correlated to work ability and
employment status in systemic sclerosis. Rheumatology
49(9): 1739–1746.
Schouffoer A, Ninaber M, Beaart-van de Voorde L, et al. (2011)
Randomized comparison of a multidisciplinary team care
British Journal of Occupational Therapy 80(7)
program with usual care in patients with systemic sclerosis.
Arthritis Care and Research 63(6): 909–917.
Stefanantoni K, Sciarra I, Iannace N, et al. (2016) Occupational
therapy integrated with a self-administered stretching pro-
gram on systemic sclerosis patients with hand involvement.
Clinical and Experimental Rheumatology 100(Suppl. 5):
157–161.
Van den Hoogen F, Khanna D, Fransen J, et al. (2013) 2013
classification criteria for systemic sclerosis: An American
College of Rheumatology/European League against
Rheumatism collaborative initiative. Arthritis and
Rheumatology 65(11): 2737–2747.
Viliet Vilietland T (2004) Multidisciplinary team care and out-
comes in rheumatoid arthritis. Current Opinion in
Rheumatology 16(2): 153–156.
Wigley FM, Seibold JR, Wise RA, et al. (1992) Intravenous ilo-
prost treatment of Raynaud’s phenomenon and ischemic
ulcers secondary to systemic sclerosis. Journal of
Rheumatology 19(9): 1407–1414.
Wigley FM, Wise RA, Seibold JR, et al. (1994) Intravenous
iloprost infusion in patients with Raynaud phenomenon
secondary to systemic sclerosis. A multicenter, placebo-
controlled, double-blind study. Annals of Internal Medicine
120(3): 199–206.
Willems L, Vriezekolk A, Schouffoer A, et al. (2015)
Effectiveness of nonpharmacologic interventions in systemic
sclerosis: A systematic review. Arthritis Care & Research
67(10): 1426–1439.
Yasuda Y and Hanten D (1985) Occupational therapy care of
rheumatic disease patients. Occupational Therapy in Health
Care 2(1): 73–80.