Abordaje de terapia ocupacional en la discapacidad de miembros superiores, destreza manual, habilidades motoras finas y autoeficacia en pacientes reumáticos con dolor crónico

Abstract

ABSTRACT: Hand Osteoarthritis is described by a gradual damage of articular cartilage linked to degradation of subchondral bone, joint borders, and periarticular structures. Self-efficacy is a construct probably associated with health behaviors and health status. Greater self-efficacy should predict higher levels of functional performance with Osteoarthritis. However, the impact of upper limb disability, dexterity and fine motor skill of older adults with hand Osteoarthritis on self-efficacy is not well known yet. Effectiveness´ studies of rehabilitation treatments for improving fine motor abilities in patients with hand Osteoarthritis are also scarce. Selected activities, previously modified and graded by the occupational therapist, could reach the desired aims for fine motor abilities on upper limb disability, with no negative effect on joints or tissues. The main objectives of this thesis were: 1) to evaluate the self-efficacy and its relationship with upper limb function/disability in institutionalized elderly with hand Osteoarthritis; 2) to assess the effectiveness of a rehabilitation programme on upper limb disability, independence of activities of daily living, fine motor skills, functional independency, and general self-efficacy in this population. A cross-sectional study and a randomized clinical trial were performed according to the main objectives previously expressed. Institutionalized adults (n = 45) over the age of 65 years with hand Osteoarthritis were evaluated, to determine pinch strength, active range of motion of the hand, and upper limb dexterity and disability. Firstly, they were classified as self-efficacious or not based on their general self-efficacy level. The influence of upper limb function-disability on self-efficacy was statistically analyzed by using bivariate and multivariate regression analyses. Secondly, participants were randomly assigned to an experimental group for completing a rehabilitation intervention focused on fine motor skills (n=25) or a control group that received conventional occupational therapy (n=23). Both interventions were performed 3 times a week, 45 minutes each session, during 8-weeks. Main outcome measures were upper limb disability, performance in activities of daily living, pinch strength, manual dexterity, active and passive range of fingers motion, functional independency, and general self-efficacy. These variables were assessed at baseline, post-treatment and after two months’ follow-up. The results highlighted that self-effective older adults seem to show significantly lower scores in disability and higher scores in pinch strength, dexterity and motion of thumb than those who were classified as non-self-effective. Self-efficacy was associated with pinch strength (p ≤ 0.038), disability (p < 0.001) and dexterity (p ≤ 0.048). Multiple regression analyses showed that upper limb and hand disability explained almost 40% of the variability of self-efficacy. On the other hand, the rehabilitation treatment of fine motor skills of the hand evidenced significant higher improvements on manual dexterity (p ≤ 0.034, d ≥ 0.48) and range of index (p ≤ 0.018, d ≥ 0.58) and thumb motion (p ≤ 0.027, d ≥ 0.39) in comparison to the conventional occupational therapy treatment. Moreover, the participants in the conventional approach showed a significant worsening over time moderate to large for range of motion in some joints at the index (p ≤ 0.037, d ≥ 0.36) and thumb (p ≤ 0.017, d ≥ 0.55) fingers. The main conclusions were: firstly, institutionalized older adults classified as non-self-effective seem to have higher upper limb disability and less pinch strength, manual dexterity and thumb motion than those who are self-effective, suggesting a relationship between impairment and perceived ability. Secondly, a rehabilitation intervention by using a therapeutic activity for fine motor skills of the hand may improve manual dexterity and range of fingers motion, but its effects on upper limb disability, performance in activities of daily living, pinch strength, functionality, and self-efficacy remain uncertain. Conventional occupational treatment showed a certain worsening effect on range of motion. Thus specific treatments of the hand should be included for the upper limb rehabilitation of hand Osteoarthritis.