This document is designed to provide arthritis health professionals, educators, and potential employers of health-care providers with guidelines for the competent practice of occupational therapy for persons with rheumatologic disorders. The competencies are intended for all registered occupational therapists (OTR) inexperienced in rheumatology. They do not apply to certified occupational therapy assistants (COTA).
These competencies are considered to be the minimum necessary for a therapist working without supervision. Items that are considered to be necessary but that may need to be acquired with experience, education, and/or supervision by persons experienced in rheumatology are in bold.
Basic Knowledge
The occupational therapist involved in care of the individual with rheumatic disease should be able to:
- Discuss the pathophysiology of the following rheumatic diseases from a multisystem
focus, including etiology, epidemiology, course, and pathogenesis.
- Most commonly seen rheumatic diseases
a. Rheumatoid arthritis
b. Degenerative joint disease/osteoarthritis
c. Systemic lupus erythematosus
d. Fibromyalgia
- Additional rheumatic diseases
a. Spondylarthropathies
b. Juvenile rheumatoid arthritis
c. Reflex sympathetic dystrophy
d. Systemic sclerosis
e. olymyositis/dermatomyositis
f. Psoriatic arthritis
g. Gout
- Most commonly seen rheumatic diseases
- Discuss medications commonly used with rheumatic diseases.
- Purpose of medication
- Side effects that may alter function
- Timing of administration to affect function
- Describe the pathomechanics of deformity, including the nature of periarticular and articular destruction.
- Define the following surgical interventions for patients with rheumatic disease,
including the process of healing, precautions, and postoperative treatment.
- Synovectomy
- Joint replacement
- Arthrodesis
- Arthroscopy
- Osteotomy
- Resection
- Explain basic diagnostic techniques, such as laboratory tests and x-rays, and their purpose.
- Describe the process of activity analysis for purposes of treatment and/or adaptation.
- Describe the following occupational therapy modalities.
- Functional adaptation, such as adaptive procedures for activities of daily living, work, and leisure
- Therapeutic activities
- Availability and uses for a wide range of activity of daily living equipment
- Orthotics
- Psychosocial interventions
- Describe joint protection and energy conservation techniques related to rheumatic diseases.
- Discuss the impact of rheumatic disease.
- Interrelationship between the patient’s motivation, daily routines, roles, and performance
- Environment and family interaction
- Common emotional reactions to chronic disease
- Factors that influence adaptation
- Describe the influence of cultural differences and values in approach to health care for common daily living activities.
- Explain how the following factors are associated with patient adherence to treatment
programs.
- Depression
- Fatigue
- Powerlessness (perception of external control)
- Secondary gains
- Responsibility for self
- Relationship with and role in family
- Knowledge and acceptance of disease
- Describe the roles of other health professionals who treat patients with rheumatic disease
Patient Evaluation
- Evaluate the patient’s knowledge of his or her rheumatic disease, treatment regimen, and goals for treatment through verbal interaction and observation.
- Evaluate and interpret the patient’s functional status through interview,
assessment procedures, and/or skilled observation in the following areas.
- Physical abilities
a. Self-care tasks, such as dressing, household activities, and transfers
b. Strength and range of motion
c. Dexterity
d. Pain
e. Sensation
f. Fatigue and endurance
g. Stiffness in the morning or following periods of inactivity
h. Cognitive screening
i. Leisure activities, such as sports and hobbies
- Occupational behaviors
a. Habits and routines
b. Values and priorities
c. Occupational history
d. Home, work, school, and community environment
- Physical abilities
- Perform a physical evaluation and assessment, including recognition and assessment
of the following items.
- Swelling/synovitis
- Tendon integrity
- Joint Stability
- Ligamentous laxity
- Soft tissue involvement
a. Tenosynovitis
b. Tendinitis
c. Bursitis
d. Subcutaneous nodules
e. Trigger finger
- Common hand deformities
a. Swan neck
b. Boutonniere
c. Malleet
d. Ulnar deviation
e. Thumb deformity
f. Subluxation
g. Dislocation
h. Wrist/hand zigzag deformity
i. Flexion/extension contracture
j. Mutilans
k. Heberden’s nodes
l. Bouchard’s nodes
m. Carpometacarpal squaring
- Intrinsic/extrinsic tightness
- Range of motion lag
- Crepitus
- Ankylosis
- Skin integrity
- Vascular involvement
- Sensory involvement
- Muscle strength
- Ambulation
- Transfers
- Posture and positioning
Develop a Treatment Plan
- Consolidate information from the evaluations and prioritize intervention strategies
by considering patients’ priorities and addressing problems identified.
- Short and long term goals, including vocational and avocational considerations
- Need for adaptive and orthotic equipment
- Realistic consideration of available resources to the patient; including, but not
limited to the following areas
a. Physical and psychological capacities to benefit from rehabilitation
b. Family, community, and other environmental support
- Information from other health care providers working with the patient to enhance understanding of all problems that will affect setting functional goals
- Financial abilities/insurance
- Inpatient/outpatient options
- Select functional activities and exercise appropriate to the patient’s roles, interests, stage of disease, and activity level.
- Design a splinting program to address problems identified on the evaluations, including patient’s goals and willingness to wear splints. Identify realistic splinting outcomes. Identify and apply pathomechanics, select appropriate splint designs, prioritize splinting needs, select custom versus commercial splints, and train patient in use and care.
- Design an individualized education plan to provide training in energy conservation
and joint protection principles.
- Appropriate for the patient’s psychological readiness and acceptance level
- Appropriate to the educational and cognitive levels of the patient and family members
- Sensitive to and understanding of sociocultural issues
a. Cultural background
b. Level of education
c. Methods of learning to which the patient is responsive
- Ability to evaluate architectural barriers and recommend changes to modify the environment.
Implement a Treatment Plan
- Demonstrate the ability to perform activities of daily living training.
- Select appropriate equipment with regard to patient’s abilities/disabilities, needs, and resources
- Practice of daily activities using appropriate joint protection, energy conservation techniques, and adaptive equipment
- Provide effective patient education, including the following areas.
- Joint protection, energy conservation, and home exercise techniques
- Basic treatment principles
- Practice of specific techniques
- Use of audiovisual aids
- Follow-up to assess learning
- Instruction in posture and body positioning
- Implement functional activities designed to facilitate role activities and to improve strength, range of motion, dexterity, and endurance.
- Implement a graded activity program appropriate for rheumatic diseases that will
facilitate occupational therapy interventions.
- Select exercises appropriate to the problems identified on initial evaluation
a. Range of motion (passive or active)
b. Stretching exercises
c. Strengthening
- Identify boundaries of exercise program
a. Repetitions
b. Modification of program in response to changes in joint and disease status
- Select appropriate setting for exercise program to be carried out
a. Home exercise program
b. Outpatient, therapist-assisted exercise/treatment program
- Select exercises appropriate to the problems identified on initial evaluation
- Correctly fabricate the following splints.
- Resting hand
- Wrist cock-up
- Finger and thumb splints
- Ulnar deviation
- Dynamic outrigger
- Elbow extension
- Place treatment program appropriately for patient’s cognitive and fatigue levels and degree of disease activity.
- Provide consultation and training for mobility aids, including wheelchairs and power scooters.
- Provide assistance in modifying/redefining daily role involvement, environment, and exploring new interests in keeping with functional limitations, patients goals, and joint protection and energy conservation requirements.
- Demonstrate skills in postoperative management of related rheumatic diseases,
including the spine and upper and lower extremities.
- Adaptation during recovery
- Graded return to productive role activities
Modify a Treatment Plan
- Recognize and respond to changes in the patient’s status by making appropriate
modifications in the plan of care.
- Continuing/discontinuing treatment
- Modifying goals of treatment
- Refer patients to other healthcare professionals and community resources as appropriate.
Patient Education
- Write measurable learning objectives and evaluate the outcome of educational interventions.
- Use educational materials relevant to the patient’s social environment, taking into consideration family, work, school, and leisure activities.
- Identify arthritis resources for patient education, including printed materials, commercially available audiovisual aids, and facility and community resources.
Research
- Demonstrate knowledge of occupational therapy research literature related to rheumatology and patient care; also show ability to search that literature for relevant information.
- Apply research results and knowledge gained through continuing education to patient care.
- Collect and analyze outcome measures.
References
The American Occupational Therapy Association has an Arthritis Resource Guide that includes
- Names of resource personnel
- Organizational resources
- Databases/information centers/directories
- Journals and newsletters
- Key references
- An extensive topic-specific bibliography
- Audiovisual references
- Sample forms
The resource guide is available from:
American Occupational Therapy Association
4720 Montgomery Lane
PO Box 31220
Bethesda, MD 20824-1220
Phone (301) 652-2682
www.aoto.org
