2016 update of the EULAR recommendations for the management of early arthritis

Article Reviews
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Read Full Text: 2016 update of the EULAR recommendations for the management of early arthritis (Free to download)
Journal: Annals of the Rheumatic Diseases (Impact factor 12.5 in 2017)
Year Published: 2016
Ranked 14th on our 2014-2019 list of the 50 most influential articles

Article overview for OTs

This article lays out recommendations for diagnosing and managing early arthritis.

Early arthritis is defined as “early inflammatory joint disease” and this article looks at the recommended course of action for the initial months following the initial onset of any joint swelling associated with or stiffness.

Occupational therapy is among the recommended adjuncts to drug treatment! (It is recommended 10th on a list of 12.)

The article states “occupational therapy may improve functional ability and self-management but does not have a positive effect on disease activity.”

There have not been recent studies on the role of occupational and early arthritis, so this recommendation was based off of studies that looked at occupational therapy and established rheumatoid arthritis.

How the recommendations were established

These recommendations were put forth by the European League Against Rheumatism.

The recommendations were based on a combination of evidence in literature and expert opinion.

The committee that reviewed the guidelines included 20 rheumatologists, two patients and one healthcare professional.

The recommendations stop just short of being treatment guidelines, due to the degree of expert opinion that was involved, but are still intended to be widely disseminated to help improve the standards of care.

Takeaways for OT

Early arthritis intervention seems to have a “window of opportunity”

Like other conditions we have examined, there are distinct “windows of opportunity” in arthritis care. This means there are distinct time periods in which interventions are most effective for improving outcomes. While the ones covered below are not directly related to occupational therapy, I still think it is good to have this information on our radar so we can encourage patients to seek the appropriate treatment in the appropriate time frame.

  • Patients presenting with arthritis should be seen by a rheumatologist within six weeks of onset.
  • Patients at risk of developing persistent arthritis should be started on DMARDs (disease modifying anti-rheumatic drugs) as early as possible (ideally within three months), as introducing these early can lead to better outcomes.

Occupational therapists can play a role in supporting broader treatment goals

There are three other treatment recommendations that really stood out to me as opportunities for occupational therapists to lend support:

#9: Arthritis activity should be assessed at one-month to three-month intervals until treatment target has been reached. Radiographic and patient-reported outcome measures, such as functional assessments, can be used to complement disease activity monitoring.

#11: When working with early arthritis patients, the following elements should play into the overall patient care plan: smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities.

#12: Patient information concerning the disease, its outcome, and its treatment is important. Adjunct interventions should include educational programs aimed at coping with pain and disability, as well as maintaining the ability to work and remain socially active.

Shared Decision-Making (SDM) is a model for OTs to be aware of and watching

I wanted to highlight that this article advocates for management of arthritis be based on a “shared decision.” This is the first time that SDM has come up in our article reviews. SDM is a process of communication in which clinicians and patients work together to make optimal healthcare decisions that align with what matters most to patients. For a nice overview of SDM, check out this article.

Documentation

Example wording for your assessment section:

As this patient is presenting with joint pain that is compromising her participation in daily life, skilled OT is warranted. Skilled OT is a recommended adjunct treatment for early arthritis per the 2017 EULAR recommendations.

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What questions/thoughts does this article raise for you?

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This was a great article. I was excited to see OT recommended as an adjunctive therapy to drug treatment in early arthritis. I had worked with rheumatologists in India long ago as an OT. Some of the info in this article is new to me such as “DMARDs should be started as early as 3 months”. In the past, they waited longer to administer the disease modifying drugs. It makes sense to prevent adverse effects of joint erosion and facilitate clinical remission of the disease.
OT can play an important role in primary care (one of our emerging areas of practice) to teach simple exercises for strengthening, joint protection, and work simplification techniques in daily tasks as well as management of co-morbidities. Ideas for research mentioned in the main article for using non-pharmacologic interventions such as OT in early arthritis in the community setting could be a great topic for students. Thank you.

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Oh! I love that you have worked with a rheumatologist in the past, and that you’re now seeing the field evolve!

I agree that it makes sense that prevention of damage should be a priority. I love how the article stated it:

"Beyond doubt, the treatment goal of early arthritis should now be clinical remission and prevention of join destruction."

I was also thinking of how effective OT could be in primary care with these patients. I wish I knew more OTs that actually worked in these roles!

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In my previous job, it was heart breaking to see many invividuals with multiple comorbidities who had never received ANY intervention for their now advance arthritis. In many of their cases, it was something they “just lived with.” It is great to see that there is awareness awakening about prevention. OTs have the potential to play such a vital role in ergonomic assessment and adjustment/adapation in all daily activities incuding home and workplace environments!! In addition to that, as I was quickly reading a little more about this, I found this research article about nutrition prevention as well for RA.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682732/.

Can you imagine a holistic, preventative approach to arthritis including establishing healthy routines, ergonomic assessment and adapation, healthy lifestyle education, exercise prescription?

Can’t wait to see more research in these areas!!

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Yes, great point made about adding nutrition to the list. Rachel, you are right, OT has that holistic approach to tackle some of these chronic conditions. It is sad to see that many patients with RA or OA have never seen an OT till they have surgeries to correct their deformities.

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I know! If only our business models could shift towards prevention and early action…

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Yessssss! I love this vision @Rsaltzgaber! Makes me giddy to ponder:) And it’s so doable.

The main point that stuck out to me in the article was the piece about shared decision making, too. What a concept:) (And how grateful I am to be in such a powerful profession that is already using this model, or at least parts of it.)

What could/would it take to reach more people sooner with the impact that OT could have on their arthritis?

Thanks again @SarahLyon. Fascinating read.

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I am intrigued by the idea of OT’s in primary care. However, I feel like OT’s must be very enterprising to land such roles. If you or anyone here was pitching a doctor on why they should add an OT to their primary care practice, what are some things you’d say?

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Hey @andy! Like I said, I will occasionally see information about OTs in primary care, but have never been able to actually meet an OT who works in this practice area.

If I was talking to a primary care doctor about teaming up, I would definitely talk to them about a seemingly inevitable transition to value-base care (though the details of how get there are very murky!) In a value-based care model, prevention, holistic thinking, and interdisciplinary care all have way more value than they do in our fee-for-service models.

Here is some content that you might like on this subject:


(Thanks @monika for introducing me to ZDoggMD!)

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