Rehabilitation in rheumatoid arthritis: a critical review

Abstract

This article considers the evidence for effectiveness and timing of rehabilitation for people with rheumatoid arthritis (RA). The Cochrane Library, DARE, Medline, Embase, CINAHL and AMED were searched to identify systematic reviews and randomized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis. Many trials identified had methodological limitations (e.g. short follow-up periods, small sample sizes). Evidence to date is that symptomatic relief results from thermotherapy, laser therapy, acupuncture and assistive devices. In the short-term, comprehensive occupational therapy (in established rheumatoid arthritis), orthoses, and mind-body approaches can help maintain function. Over at least a one-year period, the following are effective in reducing pain and maintaining function: patient education and joint protection training using behavioural approaches; dynamic exercise therapy, hand exercises and hydrotherapy; and cognitive-behavioural therapy (in people with poorer psychological status). Many trials have recruited people with moderate to severe, established RA and relatively little is known about the long-term effectiveness of early rehabilitation, although this is becoming much more common in practice. Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Further well-designed clinical trials are needed recruiting people with early disease using patient-centred outcomes.

Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation

“…13,14 The three most common components of physiotherapy/occupational therapy for RA hands are exercise therapy, joint protection (JP) advice and provision of functional splinting and assistive devices, 15 although we are not aware of any research describing current clinical practice in the NHS.…”

“…According to surveys of current practice, the three most common components of therapy currently provided for people with RA of the hands are exercise therapy, JP advice and functional splinting. 15,[65][66][67] Hence, current treatment is a balance between the provision of strategies to support and protect joints (including symptomatic relief) and exercise to improve or maintain strength, flexibility and functional ability. However, little guidance is available as to the specifics of any exercise programme.…”

“…This type of 'intermittent support' splinting has more evidence of effectiveness than the 'immobilisation' resting splint approach. 92,93 The provision of functional wrist splints is common practice in the UK 15 and, therefore, was not restricted in the SARAH trial as we expected their use to be similar in both arms of the study. In contrast, resting splints were not included as a treatment modality owing to some evidence suggesting little benefit from their use.…”

Potential of the HAQ score as clinical indicator suggesting comprehensive multidisciplinary assessments: the Swedish TIRA cohort 8 years after diagnosis of RA

“…Disability also depends on other factors such as personal coping strategies and environmental factors [3,6,20,21]. Using an interactional model that pays attention to the individual as well as environmental factors, the WHO broadly defines disability as a condition that may require medication as well as multidisciplinary rehabilitative interventions [20,[22][23][24][25][26]. However, the effectiveness and mechanisms of these interventions are poorly understood with respect to how they address the most significant components of an individual patient's disability [22,24,26].…”

“…Using an interactional model that pays attention to the individual as well as environmental factors, the WHO broadly defines disability as a condition that may require medication as well as multidisciplinary rehabilitative interventions [20,[22][23][24][25][26]. However, the effectiveness and mechanisms of these interventions are poorly understood with respect to how they address the most significant components of an individual patient's disability [22,24,26]. In an individual patient, disabilities are difficult to predict because of complex interactions between genetic predispositions, age, other health conditions, disease activity, coping strategies, and environmental factors [2,4,6,[19][20][21][22]27].…”