Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 61, No. 11, November 15, 2009, pp 1522–1530

DOI 10.1002/art.24563
© 2009, American College of Rheumatology
ORIGINAL ARTICLE

Functional and Work Outcomes Improve in

Patients With Rheumatoid Arthritis Who Receive
Targeted, Comprehensive Occupational Therapy
ALYSSA M. MACEDO,1 STEPHEN P. OAKLEY,2 GABRIEL S. PANAYI,2 AND BRUCE W. KIRKHAM3

Objective. Work disability is a serious consequence of rheumatoid arthritis (RA). We conducted a 6-month, prospective
randomized controlled trial comparing assessments of function, work, coping, and disease activity in employed patients
with RA receiving occupational therapy intervention versus usual care.
Methods. Employed patients with RA with increased perceived work disability risk were identified by the RA Work
Instability Scale (WIS; score >10). Patients were stratified into medium- (score >10 and <17) and high-risk (>17) groups,
then randomized into occupational therapy or usual care groups. Assessments were conducted at baseline and 6 months.
The primary outcome was the Canadian Occupational Performance Measure (COPM), a standardized patient self-report
of function. Other outcomes included the disability index (DI) of the Health Assessment Questionnaire (HAQ); Disease
Activity Score in 28 joints (DAS28); RA WIS; EuroQol Index; visual analog scales (VAS) for pain, work satisfaction, and
work performance; and days missed/month. Independent sample t-tests and Mann-Whitney U tests were used.
Results. We recruited 32 employed patients with RA. At baseline the groups were well matched. At 6 months the
improvement in the occupational therapy group was significantly greater than that in the usual care group for all
functional outcomes (COPM performance P < 0.001, COPM satisfaction P < 0.001, HAQ DI P ⴝ 0.02) and most work
outcomes (RA WIS [P ⴝ 0.04], VAS work satisfaction [P < 0.001], VAS work performance [P ⴝ 0.01]). Additionally,
Arthritis Helplessness Index (P ⴝ 0.02), Arthritis Impact Measurement Scales II pain subscale (P ⴝ 0.03), VAS pain (P ⴝ
0.007), EuroQol Index (P ⴝ 0.02), EuroQol global (P ⴝ 0.02), and DAS28 (P ⴝ 0.03) scores significantly improved.
Conclusion. Targeted, comprehensive occupational therapy intervention improves functional and work-related out-
comes in employed RA patients at risk of work disability.

INTRODUCTION the first 3 years of the disease (3). Approximately one-third

Work disability, a measure of absenteeism defined as days
lost from work or completely stopping work, is a serious
adverse outcome of rheumatoid arthritis (RA) (1). Work
disability begins early after diagnosis and increases
steadily (1). Although some patients may have work dis-
ability prior to diagnosis (2), the greatest increase occurs in
Supported by a grant from the Guy’s and St. Thomas’
Charitable Foundation.
1
Alyssa M. Macedo, BSc OT, MSc OT, Guy’s & St. Thomas’
National Health Service Foundation Trust, London, UK;
2
Stephen P. Oakley, MBBS, FRACP, Grad Dip Clin Epi, PhD,
Gabriel S. Panayi, ScD, MD, FRCP: Guy’s & St. Thomas’
National Health Service Foundation Trust and King’s Col-
lege, London, UK: 3Bruce W. Kirkham, BA, MBChB, MD,
FRACP, FRCP: St George Clinical School, University of New
South Wales, Sydney, New South Wales; Australia.
Address correspondence to Bruce W. Kirkham, BA, MB-
ChB, MD, FRACP, FRCP, Department of Rheumatology, St
George Hospital, Gray Street, Kogarah, New South Wales
2217, Australia. E-mail: brucekirkham@btinternet.com.
Submitted for publication October 15, 2007; accepted in
revised form June 24, 2009.
of people with RA will leave employment prematurely (1).
Several studies have been published reporting high rates
and ranges of work disability. Therefore, a substantial
focus of RA management has been on reducing work dis-
ability.
A paradigm shift is warranted given the advent of more
effective biologic therapies, the lack of success with re-
turn-to-work initiatives, and the increased economic bur-
den of poor productivity while at work (presenteeism)
(4 –7). Presenteeism refers to the time of impaired perfor-
mance while at work due to health reasons resulting in
productivity loss (6). It has been suggested that greater
focus be placed on maintaining employment to prevent
work loss (8,9). Patient self-report of presenteeism mea-
sures, such as the RA Work Instability Scale (WIS) (10) and
the Canadian Occupational Performance Measure (COPM)
(11), have been recommended to screen for employed in-
dividuals at risk of work disability while they are at work
(1). Both assessments focus on measuring a mismatch be-
tween a person’s abilities and the demands of a task lead-
ing to functional impairment.

1522
Occupational Therapy and Functional and Work Outcomes in RA
Functional impairment is one of the most important
predictors of work disability (12). It has been proposed
that a work intervention should focus on maintaining or
improving function (13). Occupational therapists (OTs) are
key players involved in assisting people with remaining in
work by enhancing functional ability. OTs specialize in
maximizing the person-environment-occupation fit across
a lifespan (14). However, there have been no prospective
studies evaluating the role of OTs specifically in enhanc-
ing work retention with patients with RA. Our objective
was to conduct a randomized controlled trial (RCT) to
determine the impact of comprehensive occupational ther-
apy with employed RA patients at risk of work loss. The
primary goal was to determine if a targeted, comprehen-
sive occupational therapy intervention improved overall
occupational performance as assessed by the COPM. The
secondary goal was to determine if targeted, comprehen-
sive occupational therapy intervention resulted in im-
provements in physical function, work productivity,
coping, or disease activity.
PATIENTS AND METHODS
Trial design. This was a 6-month prospective RCT com-
paring assessments of function, work, coping, and disease
activity in employed patients with RA receiving occupa-
tional therapy intervention versus usual care. Ethical ap-
proval was obtained from the Bexley and Greenwich Re-
search Ethics Committee, UK.
Patients and eligibility criteria. Employed patients
with RA meeting the American College of Rheumatology
(formerly the American Rheumatism Association) criteria
(15) were recruited from the Rheumatoid Arthritis Center
clinics, Guy’s and St. Thomas’ National Health Service
Foundation Trust, to ensure similar medical management.
Within the Rheumatoid Arthritis Center clinics, the goal of
medical treatment is achievement of remission (a Disease
Activity Score in 28 joints [DAS28] ⬍2.6). Patients do not
routinely receive OT reviews. Participants were eligible if
they had a confirmed diagnosis of RA, were involved in
full-time/part-time work or were self-employed, were flu-
ent in English, lived locally, had medium or high work
disability risk on the RA WIS, and if they provided in-
formed consent. Participants were excluded if they were
participating in other research studies, had other major
comorbidities (e.g., cancer), were pending major surgery,
and/or had received an occupational therapy intervention
within the past 18 months.
Recruitment and stratification. Employed patients with
RA completed the RA WIS during their routine clinic
appointments. Those who scored ⱖ10, indicating medium
to high work disability risk, were invited to participate in
the study. Patients were stratified into medium-risk (RA
WIS score ⱖ10 and ⬍17) or high-risk (RA WIS score ⱖ17)
groups (16). Then within these strata, patients were ran-
domly allocated in equal numbers to the occupational
therapy or usual care group. The allocation procedure was
1523
completed in a blinded manner by an independent re-
search nurse, using a sealed envelope method.
Sample size and power calculations. Power calcula-
tions were based on the COPM with the following: range
1–10, SD (␴2) 1.5, clinically significant difference ⌬ 2.0,
statistical significance (␣) ⫽ 0.05, and power (1 – ␤) ⫽ 0.90.
According to the power calculation, 17 participants were
required per group.
Intervention. The occupational therapy group was pro-
vided with 6 months of comprehensive occupational ther-
apy, as well as usual rheumatology care. All patients were
seen by the same OT (AMM) with specialized training in
rheumatology and vocational rehabilitation. Due to the
nature of the intervention, blinding of the patient or OT
was not possible. The case management role of the OT
incorporated a biopsychosocial model stemming from the
COPM (11). Comprehensive occupational therapy con-
sisted of an individualized assessment of the patient’s
medical history, a work assessment, a functional assess-
ment, and a psychosocial assessment. An individualized
treatment plan of 6 – 8 sessions was then formulated. Oc-
cupational therapy interventions were conducted within
the rheumatology or occupational therapy department, the
home, or the workplace. Each session lasted from 30 min-
utes to 2 hours; work visits required the greatest amount of
time.
Typical interventions included provision of education
on RA, medications, compliance and management within
the Rheumatoid Arthritis Center clinics, self-advocacy,
work place rights and responsibilities, ergonomic reviews,
discussions with employers regarding reasonable accom-
modations, posture advice, pacing, activities of daily liv-
ing, stress management, assertiveness, sleep posture and
hygiene, exercises, footwear, splinting, and assertive com-
munication. Patients were referred to multidisciplinary
team members and community services as required.
Usual care in the Rheumatoid Arthritis Center clinics in-
volved routine reviews by the rheumatologist. The focus of
treatment was on early, aggressive medical management with
a goal of achievement of remission (DAS28 score ⬍2.6).
There was no OT involvement with these patients. Medical
management and rheumatology clinic visit schedules were
not changed from normal practice for either group.
Demographic details. Biographic details included age,
sex, disease duration, ethnic group, marital status, number
of children, educational level, current occupation, disclo-
sure to employers, employed or self-employed status, and
duration in current job.
Outcome measures. Outcome measures were com-
pleted at recruitment and at 6 months. A combination of
rheumatology and occupational therapy outcomes were
chosen to assess 4 main domains: function, work produc-
tivity, coping, and RA disease activity. The occupational
therapy outcome measures were completed by the patients
or the treating OT, and the disease activity measures were
completed by the treating rheumatologist who was blinded
to the treatment group.
1524
Measures of function. The COPM was the primary out-
come measure. The COPM is a well-known, standardized,
self-reported, semistructured interview tool designed for
use by OTs to detect change in a patient’s self-perception
of occupational performance. Occupational performance
is defined as the individual’s experience of being engaged
in self-care, productivity, and leisure (11). Occupational
performance is maximized by enhancing the fit between a
person, their occupation, and their environment. Occupa-
tional performance was used as the primary measure of
functional status.
Patients identified their most important occupational
performance issues and rated their level of satisfaction and
performance on a scale of 1–10. The total average COPM
performance and the average COPM satisfaction score
were calculated at recruitment and at 6 months to detect
change in functional status. During the followup appoint-
ment, the COPM was completed without knowledge of the
previous scores. A clinically significant change has been
defined as an increase in 2.0 points (11).
The Health Assessment Questionnaire (HAQ) disability
index (DI) is a standardized, self-administered, written
questionnaire developed to assess a patient’s functional
ability (17). The scale takes into account the patient’s use
of aids or assistance. The highest score for each category is
summed (range 0 –24) and divided by 8 to yield a contin-
uous score (0 –3). A higher score indicates greater func-
tional disability. Clinically significant change has been
defined as a decrease of 0.2 points (18).
Measures of work productivity. The RA WIS (10) is a
self-administered, written, validated questionnaire used to
screen for work disability. The questionnaire takes ⬍5
minutes to complete by checking “yes” or “no” boxes. A
score is achieved by counting all the yes responses, result-
ing in a range of scores between 0 and 23. A higher score
indicates a higher risk of work disability. Based on the
scoring criteria, the medium work disability risk group
was indicated by a score ⱖ10 but ⬍17, and the high work
disability risk group by a score ⱖ17. No consensus has
been reached regarding clinically significant changes in
RA WIS score. Patients who moved from a medium- or
high-risk group to a low-risk group were identified accord-
ing to the above criteria. The number of days missed at
work due to illness was also recorded.
A self-developed Modified Health Economics Question-
naire combined measures of presenteeism and absentee-
ism. This is a written self-report questionnaire that
includes the number of days/hours spent at work per
week, the number of days missed from work in the past
month due to RA, and 100-mm visual analog scales (VAS)
for work performance and work satisfaction affected by RA
in the past week.
Measures of coping. The Arthritis Impact Measurement
Scales II (AIMS2) (19) is a standardized outcome for ar-
thritis. The subscales of mood, tension, and pain were
administered to obtain a summed raw score from 5–25.
Through a process of normalization, scores were obtained
from 2.5–12.5. A higher score indicates poorer health.
The Arthritis Helplessness Index (AHI) (20) assesses
self-perception of helplessness across 15 items related to
managing arthritis. This questionnaire uses an ordinal
Macedo et al
scale that ranges from 1– 6, where 1 ⫽ strongly disagree
and 6 ⫽ strongly agree, to assess different beliefs toward
arthritis. To compute the helplessness score, responses to
specific questions are reversed and a total score is
summed. A higher score indicates greater perceived help-
lessness.
The EuroQol (EQ-5D) Index is a questionnaire that clas-
sifies the patient into one of 243 health states (5 dimen-
sions, each with 3 categories), and a VAS on which
patients rate their own health between 0 and 100 (21). A
weighted index score is achieved from the 243 health
states, where full health ⫽ 1.0 and unconsciousness ⫽
⫺0.402. On the VAS for health, best imaginable health ⫽
100 and death ⫽ 0, based on UK norms.
Measures of RA disease activity. Disease activity was
measured using a standard set of outcomes: 100-mm pain
VAS score in the past week, fatigue measured on an ordi-
nal scale (where 0 ⫽ none, 1 ⫽ mild, 2 ⫽ moderate, and
3 ⫽ severe) over the past week, duration of morning stiff-
ness measured on a VAS from 0 minutes to ⱖ2 hours over
the past week, and DAS28 score (22,23). The DAS28 as-
sesses 28 joints, measuring tender joints, swollen joints,
and erythrocyte sedimentation rate (ESR), and also includ-
ing a patient global assessment of disease activity scored
on a VAS. The DAS28 scores range from 0 –10, indicating
the current activity of RA. By convention, a DAS28 score
⬎5.1 is regarded as indicating high disease activity,
whereas a DAS28 score ⬍3.2 indicates low disease activ-
ity. Remission is defined as a DAS28 score ⬍2.6. Clinically
significant change has been defined as a change ⬎1.2
(22,24 –26).
Statistical analysis. The changes over 6 months in the
occupational therapy group were compared with those in
the usual care group by independent sample t-test. The
results were then evaluated according to clinically mean-
ingful cutoffs for measures where there was some consen-
sus. Comparisons were made of the proportion of patients
with clinically significant improvements in HAQ score
(⌬HAQ ⬎0.2), COPM score (⌬COPM ⬎2.0), and DAS28
score (⌬DAS28 ⬎1.2), and of the proportion of patients
gaining low HAQ scores (⬍1.0) and low RA WIS scores
(⬍10). These proportions in the occupational therapy ver-
sus usual care groups were compared with binomial prob-
ability testing. Limited post hoc analysis was performed
using multiple linear regression modeling to determine the
influence of therapy (occupational therapy versus usual
care) on changes in COPM performance, COPM satisfac-
tion, HAQ, RA WIS, and DAS28 scores, taking into ac-
count changes in disease activity (DAS28 or ESR) and the
baseline score. Analyses were performed using Stata, ver-
sion 6.0 (StataCorp, College Station, TX) and SPSS, ver-
sion 13.0 (SPSS, Chicago, IL).
RESULTS
Recruitment. During the 14-month recruitment period,
136 employed patients completed the RA WIS. Of these,
67 patients had a score ⱖ10, indicating medium to high
work disability risk. Within this group, 32 patients pro-
Occupational Therapy and Functional and Work Outcomes in RA 1525

Table 1. Demographic variables at baseline for the

occupational therapy and usual care groups*

Occupational
therapy Usual care
(n ⴝ 16) (n ⴝ 16)

Age, mean ⫾ SD years 48.63 ⫾ 11.56 52.56 ⫾ 7.65

Sex, women:men 15:1 15:1
Disease duration, mean 11.63 ⫾ 9.95 8.38 ⫾ 6.21
⫾ SD years
RA WIS scores
Medium (ⱖ10 and 11 10
⬍17)
High (ⱖ17) 5 6
Primary treatment
medication at start
of study
Figure 1. Consort diagram. RA ⫽ rheumatoid arthritis; WIS ⫽ Biologic agents 2 3
Work Instability Scale; WD ⫽ work disability; OT ⫽ occupational DMARDs 14 13
therapy/therapist.
Days missed from 3.25 ⫾ 6.23 2.13 ⫾ 5.05
work, mean ⫾ SD
vided consent and remained in the study. There were no days/month
dropouts. The remaining 35 patients did not meet the Work status, no. (%)
inclusion/exclusion criteria (Figure 1). Full time (⬎35 15 (94) 119 (6,956)
hours/week)
Demographic data. The mean ⫾ SD age of the entire Part time (ⱕ35 1 (6) 57 (3,144)
sample was 50.6 ⫾ 9.85 years, 93% of the patients were hours/week)
Disclosure of diagnosis,
women, and the mean ⫾ SD disease duration was 10.0 ⫾
no. (%)
8.32 years (Table 1). The occupational therapy and usual Yes 14 (88) 16 (100)
care groups did not differ with regard to age, sex, disease No 2 (12) 0 (0)
duration, function, work performance, coping, or disease Self-employed, no. (%) 1 (6) 3 (19)
activity. There were more full-time workers in the occu- Ethnic group
pational therapy group (94% versus 56%). White 9 11
Asian 1 1
Occupational therapy received. An initial assessment African American 5 3
was completed by all 16 patients in the occupational ther- Other 1 1
Marital status
apy group. Fourteen patients had disclosed their diagnosis
Single 2 4
to their employer, of whom half had a work visit com- Married 6 6
pleted and recommendations provided to their employer. Divorced/separated 5 3
The other patients were primarily seen in their homes or in Other 3 3
the occupational therapy/rheumatology department. Most Educational level
patients (n ⫽ 15) had approximately 6 – 8 occupational Primary school 0 2
therapy sessions (30 –120 minutes) to review work, home, Secondary school 4 6
and social needs on a one-to-one basis or in a group format. College/university 10 8
The remaining patient had a single consultation session Postgraduate 2 0
due to poor attendance. Six patients attended the group Socioeconomic status
Managers and 11 10
education program run by the OT. The COPM was used for
professionals
goal setting and intervention planning, which focused pre- Administrative and 5 4
dominantly on self-care and productivity. Occupational skilled trades
performance issues regarding leisure occupations were Customer service and 0 2
ranked as less important by these patients and therefore sales
were rarely incorporated in the standardized scoring pro- Process and machine 0 0
cedure. operators
Function. Improvements in the occupational therapy Duration in job, years
group were significantly better than those in the usual care ⬍1 3 2
group for all assessments of function (mean ⌬COPM satis- 1–3 4 1
3–5 1 1
faction 4.08 and 0.25 for the occupational therapy and
⬎5 8 12
usual care groups, respectively, t-test P ⫽ 0.001; mean
⌬COPM performance 3.10 and ⫺0.28, respectively, t-test * Values are the number of patients unless otherwise indicated.
P ⫽ 0.001; mean ⌬HAQ ⫽ ⫺0.27 and 0.17, respectively, RA ⫽ rheumatoid arthritis; WIS ⫽ Work Instability Scale;
DMARDs ⫽ disease-modifying antirheumatic drugs.
t-test P ⫽ 0.02).
A greater proportion of the occupational therapy group
1526
Table 2. Measures of function in the usual care versus occupational therapy groups*
Baseline
Occupational
Usual care therapy Usual care
Assessment (n ⴝ 16) (n ⴝ 16) P† (n ⴝ 16)
HAQ DI 1.39 ⫾ 0.46 1.36 ⫾ 0.84 0.90 1.55 ⫾ 0.55
COPM satisfaction 3.66 ⫾ 1.65 3.71 ⫾ 1.85 0.94 3.91 ⫾ 2.05
COPM performance 4.35 ⫾ 1.45 4.49 ⫾ 1.67 0.81 4.08 ⫾ 1.98
* Values are the mean ⫾ SD unless otherwise indicated. HAQ ⫽ Health Assessment Questionnaire; DI ⫽ disability index; COPM ⫽ Canadian
Occupational Performance Measure.
† By independent sample t-test.
had clinically significant improvements (⌬ ⬎2.0) in COPM
performance (12 of 16 patients versus 1 of 16 in the usual
care group; ␹2 ⫽ 15.7, P ⫽ 0.001) and COPM satisfaction
(13 of 16 patients versus 1 of 16; ␹2 ⫽ 18.3, P ⫽ 0.001). The
proportion of occupational therapy patients with clini-
cally meaningful improvements in HAQ score (⌬HAQ
⬎0.2) was not significantly greater than that of the usual
care group (7 of 16 patients versus 4 of 16; ␹2 ⫽ 1.25, P ⫽
0.26). The proportion of the occupational therapy group
moving into the low HAQ score range (⬍1.0) was no dif-
ferent than that of the usual care group (2 of 16 patients
versus 1 of 16; ␹2 ⫽ 0.37, P ⫽ 0.54) (Table 2, Figure 2).
Work productivity. The reduction in RA WIS in the
occupational therapy group was significantly greater than
that of the usual care group at 6 months (mean ⌬RA WIS
⫺5.33 and ⫺2.53 for the occupational therapy and usual
care groups, respectively; t-test P ⫽ 0.04) (Table 3, Figure
2). The proportion moving into the low RA WIS range
showed a positive trend in the occupational therapy group
(8 of 16 patients versus 3 of 16 in the usual care group; ␹2 ⫽
3.46, P ⫽ 0.06). The improvement in VAS work satisfac-
tion and VAS work performance scores were significantly
greater in the occupational therapy group than in the usual
care group (mean ⌬VAS work satisfaction 36.87 and
⫺10.06 for the occupational therapy and usual care
groups, respectively, t-test P ⫽ 0.001; mean ⌬VAS work
performance ⫺43.20 and ⫺4.69, respectively, t-test P ⫽
0.01). There were no significant differences between the
two groups for work days missed per month or percentage
of days missed per month.
Coping. The majority of coping outcomes significantly
improved in the occupational therapy group compared
with the usual care group. The reductions in the AHI
scores, AIMS2 pain subscale scores, and the scores of the
quality of life measures EQ-5D Global and EQ-5D Index in
the occupational therapy group were significantly greater
than those in the usual care group (mean ⌬AHI ⫺3.63 and
3.13 for the occupational therapy and usual care groups,
respectively; mean ⌬AIMS2-pain ⫺2.31 and ⫺0.66, re-
spectively; mean ⌬EQ-5D Global 20.60 and ⫺6.69, respec-
tively; mean ⌬EQ-5D Index 0.13 and ⫺0.15, respectively;
t-test P ⬍ 0.05). There were no significant differences
between the 2 groups for the AIMS2 tension or AIMS2
mood scores (Table 4, Figure 2).
RA disease activity. The reductions in VAS pain and
DAS28 scores in the occupational therapy group were
Macedo et al
Change in mean scores over
6 months 6 months
Occupational
therapy ⌬Usual ⌬Occupational
(n ⴝ 16) P† care therapy P†
1.10 ⫾ 0.70 0.05 0.17 ⫾ 0.51 ⫺0.27 ⫾ 0.49 0.02
7.79 ⫾ 1.26 0.001 0.25 ⫾ 2.16 4.08 ⫾ 2.41 0.001
7.59 ⫾ 1.34 0.001 ⫺0.28 ⫾ 1.44 3.10 ⫾ 2.01 0.001
significantly greater than that of the usual care group
(mean ⌬DAS ⫺0.94 and 0.11, respectively, t-test P ⫽ 0.03;
mean ⌬VAS pain ⫺25.31 and ⫺1.13, respectively, t-test
P ⫽ 0.007) (Table 4, Figure 2). The proportion of occupa-
tional therapy patients with clinically meaningful im-
provements in DAS score (⌬DAS score ⬎1.2) was not
significantly greater than that in the usual care group (5 of
16 occupational therapy patients versus 2 of 16 usual care
patients; ␹2 ⫽ 1.64, P ⫽ 0.20). The other disease status
outcomes, fatigue and early morning stiffness, did not
reach significance.
The medical management of patients was similar
throughout the study. Two patients in each group started
on anti–tumor necrosis factor (anti-TNF) therapy during
the study, resulting in a total of 5 patients in the usual care
group and 4 in the occupational therapy group receiving
anti-TNF therapy. All the other patients remained on com-
bination disease-modifying antirheumatic drugs or mono-
therapy, and received the same medical management
process in the Rheumatoid Arthritis Center clinics.
Post hoc analyses. Occupational therapy was signifi-
cantly better than usual care in all models (P ⬍ 0.01) except
the RA WIS (P ⫽ 0.11). Poorer baseline scores were associ-
ated with larger improvement for all measures (P ⬍ 0.05)
except the RA WIS (P ⫽ 0.271). Change in DAS28 score or
ESR had low correlation (⬍0.3) with changes in COPM per-
formance, COPM satisfaction, HAQ, or RA WIS scores.
DISCUSSION
This study has shown that timely, comprehensive occupa-
tional therapy intervention significantly improves func-
tional assessments in employed patients with RA at risk of
work loss. Post hoc multivariate analyses confirmed this
effect for the COPM and HAQ but not for the RA WIS,
showing that the largest benefits occurred in subjects with
the worst baseline function and that these differences were
not explained by changes in disease activity.
Work loss or poor performance at work is a serious
adverse outcome of RA. There have been few prospective
studies examining the effectiveness of medical treatments,
and even fewer assessing interventions specifically aimed
at improving work ability (28). This novel study evaluated
the benefit of comprehensive occupational therapy in em-
Occupational Therapy and Functional and Work Outcomes in RA 1527

Figure 2. Change in mean functional, work, coping, and disease activity scores between the
usual care and occupational therapy intervention groups from baseline to 6 months. The bars
show the change in the mean values from the baseline assessment to the 6-month reassess-
ments. The error bars show ⫾2 SEM with t-test P values indicated. COPM ⫽ Canadian
Occupational Performance Measure; OT ⫽ occupational therapy; HAQ ⫽ Health Assessment
Questionnaire; VAS ⫽ visual analog scale; WIS ⫽ Work Instability Scale; DAS ⫽ Disease
Activity Score in 28 joints.

ployed patients with RA at risk of work disability. We used
functional assessments as surrogate measures of long-term
work outcomes because they are known to best predict
work disability (29).
The COPM and HAQ DI are widely used, standardized
self-report measures recommended by the international
working group for Outcome Measures in Rheumatology
Clinical Trials (30). Our results indicated that both COPM
and HAQ DI scores significantly improved in the occupa-
tional therapy group compared with the usual care group.
The improvements in the COPM measures were generally
above what is regarded as being clinically significant. In
addition, almost all of the secondary work outcomes sig-
nificantly improved.
The psychological and coping outcomes, including quality
of life, pain, and arthritis helplessness, also significantly im-
proved within the occupational therapy group. This is im-
portant because pain is the most common symptom of arthri-
tis, which may lead to a vicious cycle of fatigue and
depression. Depression, fatigue, stress, and pain have all
been linked to reduced productivity. As such, vocational
rehabilitation services focus on pain management to reduce
worker productivity loss associated with arthritis (31).
This increased sense of well-being probably contributed
1528 Macedo et al

to the slight improvement in DAS28 scores within the

occupational therapy group. Because VAS pain scores sig-

0.001
0.04

0.01

0.10

0.10
P†
nificantly decreased in the occupational therapy group
(P ⫽ 0.007), it would logically have influenced the tender
Change in scores over 6 months

joint count, which also decreased significantly (P ⫽ 0.01).

⌬Occupational

⫺43.20 ⫾ 35.01
36.87 ⫾ 39.81
All other DAS28 components did not show statistically

⫺5.33 ⫾ 3.24

⫺2.80 ⫾ 6.18

⫺0.13 ⫾ 0.29
significant change. In addition, the systemic outcomes
therapy

(early morning stiffness, fatigue, and ESR) did not signifi-

cantly improve, and therefore it is unlikely that actual
inflammatory disease status improved more in the occu-
pational therapy group. These findings support the hy-
pothesis that it was the comprehensive, client-centered
⫺4.69 ⫾ 43.91
⫺10.06 ⫾ 31.04

occupational therapy approach involving individualized

⫺2.53 ⫾ 3.74

0.63 ⫾ 4.86

0.05 ⫾ 0.30 screening that positively influenced overall functional sta-

⌬Usual
care
Table 3. Measures of work productivity in the usual care versus occupational therapy groups*

tus and work outcomes.

These findings were similar to an RCT that examined the
impact of vocational rehabilitation in 242 patients with a
range of arthritis diagnoses over 2 years (32). The majority of
* Values are the mean ⫾ SD unless otherwise indicated. RA ⫽ rheumatoid arthritis; WIS ⫽ Work Instability Scale; VAS ⫽ visual analog scale.

employed participants in that study had a diagnosis of RA

(n ⫽ 142), followed by knee osteoarthritis (n ⫽ 53), lupus
0.004
0.001
0.03

0.09

0.10
P†

(n ⫽ 36), ankylosing spondylitis (n ⫽ 8), and psoriatic arthri-

tis (n ⫽ 3). The mean age of the participants was 49.5 years,
the majority (81%) were women, and the mean HAQ score
11.20 ⫾ 18.14
84.33 ⫾ 20.85
Occupational

was 0.54. Participants were considered at risk of job loss if

9.00 ⫾ 5.39

0.33 ⫾ 1.29

0.02 ⫾ 0.06
(n ⴝ 16)
therapy

they answered positively to the screening question “Do you

6 months

have any concern about your health affecting your ability to

work now or over the next few years?” Participants in the
experimental group received brief intervention of an average
of two 1.5-hour sessions on job accommodations, vocational
counseling, education, and self-advocacy, delivered by reha-
43.00 ⫾ 34.73
42.38 ⫾ 35.20
13.67 ⫾ 5.46

2.75 ⫾ 5.17

0.15 ⫾ 0.30
Usual care

bilitation counselors. The control group received printed ma-

(n ⴝ 16)

terials about disability employment issues. The results

showed that from 12 to 42 months postintervention, a greater
percentage of the experimental group remained employed
with no job loss (P ⫽ 0.03 by log rank test). Participation in
the vocational rehabilitation intervention was protective
0.36

0.40
0.47
0.40

0.42

against either temporary or permanent job loss (odds ratio

P†

0.58, 95% confidence interval 0.34 – 0.99; P ⫽ 0.05 by pooled

logistic regression).
That study showed that timely, patient-centered voca-
57.25 ⫾ 31.02
44.50 ⫾ 30.91
Occupational

14.69 ⫾ 3.84

3.88 ⫾ 6.39

0.18 ⫾ 0.30

tional rehabilitation interventions can assist in promoting

(n ⴝ 16)
therapy

work retention and reducing work disability. Our study

Baseline

differed in that we restricted our intervention to patients

with RA formally screened with a validated measure of
work instability, the RA WIS. Our patients had substan-
tially higher functional disability and probably more truly
47.69 ⫾ 32.63
52.44 ⫾ 29.97

reflect the RA population seen in rheumatology practices.

15.88 ⫾ 3.34

2.13 ⫾ 5.05

0.10 ⫾ 0.24
Usual care
(n ⴝ 16)

Our study had several limitations. Due to limited OT staff-

ing and funding, the same OT conducted the interventions
who was involved in data collection. To ensure that all
patients received the same goal-oriented medical therapy,
† By independent sample t-test.

they were recruited from specialized inflammatory arthritis

clinics. Within these clinics, all rheumatologists work to-
Work performance

ward the goal of achieving DAS28 remission (score ⬍2.6).

Work satisfaction
Work days missed

Days missed/days

Screening patients with RA only from these clinics therefore

Assessment

worked per

limited the sample size and generalizability. However, this

per month

month, %

was necessary to ensure consistency in background medical

RA WIS

management between the two groups. The sample size was

VAS

not seen as a limitation because this was an initial proof-of-

concept study.
This preliminary study was small, of short duration, and
 Table 4. Measures of coping and RA disease activity in the usual care versus occupational therapy groups*

Baseline 6 months Change in scores over 6 months

Occupational Occupational
Usual care therapy Usual care therapy ⌬Occupational
Assessment (n ⴝ 16) (n ⴝ 16) P† (n ⴝ 16) (n ⴝ 16) P† ⌬Usual care therapy P†

Coping scores
AHI 47.44 ⫾ 7.45 43.44 ⫾ 7.46 0.14 50.56 ⫾ 6.07 39.81 ⫾ 9.68 0.001 3.13 ⫾ 6.01 ⫺3.63 ⫾ 9.06 0.02
AIMS2
Tension 7.69 ⫾ 1.29 7.28 ⫾ 1.76 0.46 7.34 ⫾ 1.41 6.38 ⫾ 1.52 0.07 ⫺0.34 ⫾ 1.19 ⫺0.91 ⫾ 1.40 0.23
Mood 6.41 ⫾ 1.45 6.09 ⫾ 1.58 0.57 5.91 ⫾ 1.44 5.66 ⫾ 1.22 0.60 ⫺0.50 ⫾ 1.34 ⫺0.44 ⫾ 1.39 0.90
Pain 8.84 ⫾ 2.91 8.31 ⫾ 2.41 0.58 8.19 ⫾ 3.09 6.00 ⫾ 2.07 0.30 ⫺0.66 ⫾ 2.26 ⫺2.31 ⫾ 1.74 0.03
EuroQol
Global 60.69 ⫾ 22.74 54.87 ⫾ 26.65 0.54 51.69 ⫾ 24.94 76.56 ⫾ 17.33 0.003 ⫺6.69 ⫾ 25.46 20.60 ⫾ 31.53 0.02
Occupational Therapy and Functional and Work Outcomes in RA

Index 0.57 ⫾ 0.23 0.52 ⫾ 0.28 0.63 0.45 ⫾ 0.32 0.65 ⫾ 0.19 0.04 ⫺0.15 ⫾ 0.33 0.13 ⫾ 0.29 0.02
Disease activity
scores
DAS28 4.5 ⫾ 1.51 4.6 ⫾ 0.92 0.85 4.7 ⫾ 1.81 3.7 ⫾ 0.94 0.07 0.11 ⫾ 1.21 ⫺0.94 ⫾ 1.32 0.03
ESR 25.75 ⫾ 17.94 24.44 ⫾ 19.43 0.84 23.69 ⫾ 23.62 22.19 ⫾ 21.73 0.85 ⫺2.06 ⫾ 12.92 ⫺2.25 ⫾ 9.11 0.19
28 tender 6.50 ⫾ 7.85 6.13 ⫾ 4.63 0.87 9.88 ⫾ 11.2 3.50 ⫾ 3.37 0.04 3.38 ⫾ 6.50 ⫺2.63 ⫾ 5.24 0.01
joint count
28 swollen 4.06 ⫾ 3.66 5.31 ⫾ 4.59 0.40 4.50 ⫾ 5.34 2.75 ⫾ 2.44 0.24 0.44 ⫾ 3.90 ⫺2.56 ⫾ 4.75 0.06
joint count
Patient global 53.13 ⫾ 32.29 51.56 ⫾ 25.56 0.88 55.13 ⫾ 31.84 35.56 ⫾ 24.94 0.06 2.00 ⫾ 29.11 ⫺16.0 ⫾ 36.48 0.13
assessment
VAS pain 54.69 ⫾ 25.67 50.69 ⫾ 26.55 0.67 53.56 ⫾ 31.19 25.38 ⫾ 19.00 0.004 ⫺1.13 ⫾ 22.98 ⫺25.31 ⫾ 24.22 0.007
Fatigue 2.19 ⫾ 0.66 1.75 ⫾ 0.68 0.07 2.00 ⫾ 0.82 1.50 ⫾ 0.82 0.09 ⫺0.19 ⫾ 0.66 ⫺0.25 ⫾ 0.86 0.82

* Values are the mean ⫾ SD unless otherwise indicated. RA ⫽ rheumatoid arthritis; AHI ⫽ Arthritis Helplessness Index; AIMS2 ⫽ Arthritis Impact Measurement Scales II; DAS28 ⫽ Disease Activity
Score in 28 joints; ESR ⫽ erythrocyte sedimentation rate; VAS ⫽ visual analog scale.
† By independent sample t-test.
1529
1530
used surrogate assessments of function and work ability.
Future studies of true work loss, absenteeism, and presen-
teeism should be much larger, and more work is needed to
evaluate the comparative benefits of occupational therapy
and medical therapy, which is also known to reduce ab-
senteeism (13,33). In conclusion, timely comprehensive
occupational therapy significantly improves functional
and work-related outcomes in employed patients with RA
who are at risk of work loss.
ACKNOWLEDGMENTS
The authors thank Elizabeth Maclennan, Head Occupa-
tional Therapist, and Janine Kelleher, Research Nurse,
Guy’s and St. Thomas’ National Health Service Founda-
tion Trust, for their guidance and support.
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