Effectiveness of nonpharmacological and nonsurgical interventions for patients with rheumatoid arthritis: an overview of systematic reviews.

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease of unknown etiology. It is present in 0.5% to 1% of the general population, twice as often in women, and the age at disease onset is mainly between 45 and 65 years. (1) The clinical picture of RA is characterized by pain, fatigue, disability, and reduced quality of life. The course of the disease is often unpredictable, and the symptoms may vary from day to day.

The main goals of treatment for RA are to prevent or control joint damage, prevent loss of function, and decease pain. (2) Despite substantial progress in the pharmacological and surgical interventions over the last decade, many patients with RA will still experience disability, pain, psychological distress, fatigue, and poor quality of life. (3)

Besides pharmacological and surgical interventions, conventional therapies such as physical therapy, occupational therapy, and comprehensive rehabilitation and self-management programs are commonly and frequently used interventions. Not surprisingly, given the chronic and persistent nature of the disease, patients with RA tend to be particularly high users of complementary and alternative medicine (CAM) therapies. (3) Complementary medicine is used together with conventional medicine, whereas alternative medicine is used in place of conventional medicine. Research indicates that people with RA use a broad range of CAM therapies, such as dietary supplements (herbs and vitamins), movement therapies (yoga and tai chi) and manual therapy, homeopathy, and acupuncture.

Decisions on the provision and reimbursement of health care are increasingly based on the available evidence. Thus, purchasing organizations and policymakers in health care are in need of information on the effectiveness of interventions. Similarly, patients, health care professionals, and researchers are in need of this information to improve self-management strategies, to improve clinical practice, and to set priorities for research, respectively. Conclusions based on a systematic review of randomized controlled trials (RCTs) are considered to provide the highest level of evidence about the effectiveness of an intervention.

While systematic reviews summarize the effectiveness of a specific treatment for a specific condition, an overview of overviews (sometimes called an "umbrella review") typically summarizes the evidence from several systematic reviews on different treatment options for the same condition. Because the number of systematic reviews is rapidly increasing, there might be a need to provide patients and health care providers with synthesized and easily accessible information on different treatment options for a particular condition.

The aim of this overview is to summarize the available evidence from systematic reviews on the effect of nonpharmacological and nonsurgical interventions for patients with RA.

Methods

Systematic reviews were considered if they were published from January 2000 to January 2007 and had the primary aim of investigating the effects of nonpharmacological and nonsurgical interventions for people with RA (aged > 18 years). More specifically, the following inclusion criteria were used:

* Participants: People with RA according to the American College of Rheumatology criteria (4) or other acceptable diagnostic criteria. Reviews including participants with various rheumatic diagnoses were accepted only if results for RA could be extracted separately.

* Interventions: All types of nonpharmacological and nonsurgical interventions. Excluded were interventions such as gene therapy, all types of invasive interventions (eg, injections, arthroscopy), therapeutic apheresis, or interventions related to pharmacological or surgical interventions (ie, therapeutic exercises after total joint replacement).

* Outcomes: For the purpose of this overview, the primary outcome measures were function, pain, and patient global assessment. The concept of "function" is based on the International Classification of Functioning, Disability and Health (ICF), (5) where "function" is an umbrella term for body function, body structure, activities, and participation. As secondary outcome variables, we considered the rest of the outcomes in the preliminary core set recommended by the International League of Associations for Rheumatology (ILAR)/Outcome Measures for Arthritis Clinical Trials (OMERACT). (6)

Search Strategy

The following databases were searched from January 2000 to January 2007: MEDLINE, CINAHL, AMED, EMBASE, PsycINFO, The Cochrane Library, and PEDro.

The search strategy was formulated in Ovid (MEDLINE, CINAHL, EMBASE, and AMED) in cooperation with a medical librarian to make it applicable to all the databases. A broad computerized search strategy was developed (Appendix 1).

Retrieved hits were assessed by one of the authors (AC), who screened the titles and abstracts to identify relevant studies. If there was doubt about a study's relevance, one of the other authors (KBH) was consulted.

Relevant full-text articles were read by 2 authors (AC, KBH).

Assessment of Methodological Quality

The methodological quality of included reviews was independently assessed by 2 reviewers (AC, KBH) using a modified version of a previously validated checklist consisting of 9 criteria (7) (Appendix 2). Disagreement was resolved by discussion. Based on a summary of the 9 criteria, an overall scientific quality was applied to each review, as follows: "minor limitations" (at least 7 of the criteria were met), "moderate limitations" (at least 4 of the criteria were met), and "major limitations" (fewer than 4 of the criteria were met). Reviews with major limitations were excluded.

Data Extraction and Synthesis

Data were extracted by one of the authors (AC). If doubt occurred, one of the other authors (KBH) was consulted. The following criteria were applied when data on effects were extracted:

* Adequate quantitative pooling of data in reviews was regarded as more valid than a qualitative data synthesis approach.

* If no direct comparisons between treatments were undertaken or no quantitative pooling of data was done, the results are reported as "no quantitative pooling," and the authors' statements were reported.

* When we found that the results were reported inconsistently in different sections of a review, the effects were extracted from the main results section.

* If possible, the 3 primary outcomes were collected and presented in the result tables. The secondary outcomes were collected ff the primary outcomes were not reported. A maximum of 3 outcomes are reported.

Finally, principles from Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were used to assess an overall quality of evidence for each intervention and outcome. (8) The quality of evidence indicates the extent to which a person can be confident that the estimate of effect is correct. Based on judgments considering quality of primary studies, design of primary studies, consistency (similarity of estimates of effect across studies), and directness (the extent to which people, interventions, and outcome measures were similar to those of interest), the evidence for each intervention was classified as "high," "moderate," "low," or "no evidence from systematic reviews." The definitions are listed in Table 1. In the summary of findings (Tab. 2), the following statements were used to indicate direction of effect: improves (function) or reduces (pain) (ie, beneficial effects), no difference, and unclear (inconsistent or unclear evidence of effect).

Results

The literature search identified 1,189 references, which were first examined on the basis of titles and abstracts. Of these, 1,078 references were clearly not relevant, and 111 references were retrieved in full text. Eighty-three reviews were excluded: 41 because of major limitations (Appendix 3), 6 because of duplicate publications, 16 because of mixed populations, 9 because of use of nonrelevant interventions, and 11 were not reviews or mixed review and single studies. Twenty-eight reviews were included in this overview (Fig. 1).

Acupuncture

Two reviews (9,10) reported the effect of acupuncture (Tab. 3). The reviews described the intervention as "a kind of herbal acupuncture (bee venom acupuncture)" (9(p79)) and as "a technique based on Chinese medical practice whereby needles are inserted into specific exterior body locations to relieve pain and for other therapeutic purposes." (10) Study populations were "adult patients with classic or definite rheumatoid arthritis."

The methodological quality of the primary studies either was not assessed or was of low to moderate quality. One review (9) included 1 RCT and 2 uncontrolled studies and reported a significant decrease in pain, but did not report on function or patient global assessment. Casimiro et al (10) found conflicting results regarding pain, but no significant improvements in function or patient global assessment. Both reviews concluded that there is little evidence that acupuncture relieves RA symptoms, but underscored that this conclusion is limited by methodological flaws. We find this conclusion to be reasonable and conclude that the effect of acupuncture is unclear (Tab. 2). One of the reviews reported no harmful side effects, while the other concluded that a greater understanding of the risks and benefits of bee venom acupuncture is needed.

Balneotherapy 

Two reviews (11,12) included balneotherapy, reporting on interventions as "bathing in water containing minerals (added or natural)" (11) or "any type of balneotherapy (mud packs, sulphur baths, Dead Sea baths)." (12) Patients were included if they had "clinically confirmed RA" (11) or "only RA." (12) Again, the methodological quality of the primary studies was low to moderate. One review (12) provided quantitative pooling of results (Tab. 3). The pooled results (mudpacks versus control) were based on 2 studies with small sample sizes and showed no statistically significant improvements in pain or patient global assessment. Results from single primary studies showed conflicting evidence related to pain and function (grip strength [force-generating capacity]). Both reviews concluded that firm conclusions on the effectiveness of balneotherapy for people with RA cannot be drawn, mainly because of the heterogeneity of the interventions and the poor methodological quality of the included studies. We conclude, therefore, that the effect of baineotherapy is unclear (Tab. 2). Possible harmful aspects of balneotherapy, such as cardiac problems or risk of bacterial contamination, were not reported in any of the reviews.

Diets

One review (13) reported on the effect of fasting followed by a vegetarian diet for at least 3 months (Tab. 4). Patients included were diagnosed with RA. The primary studies were of mixed quality, but the pooling of data from 2 RCTs showed significant improvement in pain. However, based on one review of moderate quality, we conclude that there is low-quality evidence that fasting followed by a vegetarian diet (3 months) reduces pain (Tab. 2). Diets might have a negative effect on nutritional status, but the review did not report on this issue.

Electrical Stimulation (ES)

One review (14) based on 1 RCT of low quality reported the outcome of ES (Tab. 4). The review defined the intervention as "electrical stimulation applied to the motor point of a muscle and is used to recruit motor units that are not activated at a given moment by voluntary recruitment." The patient population (age=30-75 years) had RA affecting the metacarpophalangeal joint. The authors concluded that the evidence for the use of ES to improve muscle strength and resistance to fatigue is limited. The study included 6 participants in the intervention group and 3 participants in the control group. The Ottawa Panel excluded the RCT because: "Evidence with acceptable research design, interventions, group comparisons, or outcomes could not be identified." (15(p1026)) Thus, we conclude that the effect of ES is unclear (Tab. 2). The review did not comment on safety and possible harmful effects.

[FIGURE OMITTED]

Herbal Therapy

Effect of herbal therapy was reported in 3 reviews (16-18) (Tab. 4), defining the interventions as "Ayurvedic medicines as usually complex mixtures of multiple plants administered orally," (8(p705)) "any whole plant extract except homeotherapy, aroma therapy or any preparation of synthetic origin or consisting only of plant derivates," (16(p2)) or "herbal preparations administered orally or topically for RA." (17(p652)) Patient populations included were "RA patients" (17,18) or "all persons diagnosed with RA." (16)

All reviews found conflicting evidence for the effect of herbal therapy on pain and function. When reporting on the effect of gammalinolenic acid (GLA) specifically, 2 reviews (16,17) found statistically significant improvement in pain and patient global assessment based on pooled results from 3 RCTs of moderate quality, but they emphasized that further studies are needed to examine the efficacy, safety, and potential drug interactions. We conclude, therefore, that there is moderate-quality evidence that herbal therapy (GLA) reduces pain and improves patient global assessment, while the evidence for other herbals is unclear (Tab. 2). Frequently reported adverse events from ayurvedic medicines included anorexia, nausea, diarrhea, constipation, and abdominal pain, but in general the reviews concluded that the adverse effects reported were few and minor. Thus, the reviews concluded that further research is needed, not only research on the efficacy of herbal interventions but also research on safety and potential drug interactions.

Occupational Therapy Interventions

One review, (19) including 38 studies, explored several occupational therapy intervention categories for RA (Tab. 5). Occupational therapy interventions either were classified into 6 specific intervention categories (training of motor function, training of skills, instruction on joint protection and energy conservation, counseling, advice and instruction in the use of assistive devices, or provision of splints and hand orthoses) or were regarded as "comprehensive occupational therapy" (when all 6 interventions were part of the evaluated occupational therapy treatment). The review found no studies concerning the interventions training of skills and counseling. Studies with patients who fulfilled a clinical diagnosis of RA were included. Each intervention category is presented separately below.

Advice and instruction in the use of assistive devices. Two studies (non-RCTs) evaluated advice and instruction in the use of assistive devices versus alternative treatment. Only one study reported function as an outcome variable and found no statistically significant improvement. The 2 studies reported conflicting results regarding pain. Based on the conflicting results and the low quality of the primary studies, we conclude that the effect of advice and instruction in the use of assistive devices is unclear (Tab. 2). No safety or side effects were assessed in the included studies.

Comprehensive occupational therapy. Four studies evaluated comprehensive occupational therapy versus no treatment or alternative treatment. Comprehensive occupational therapy was defined as "when all 6 interventions (training of motor function, training of skills, instruction on joint protection and energy conservation, counseling, advice and instruction in the use of assistive devices, and provision of splints and hand orthoses) were part of the evaluated occupational therapy treatment." One RCT of high quality reported a statistically significant positive effect on functional ability, whereas 3 low-quality studies reported no effect. No statistically significant results were found for pain. Based on conflicting results, we conclude that there is low-quality evidence that comprehensive occupational therapy improves function and makes no difference in pain (Tab. 2).

Instruction on joint protection and energy conservation. Eight studies evaluated instruction in joint protection versus no treatment or alternative treatment. Two RCTs of high quality found statistically significant improvements in functional ability, and the findings were supported by 2 studies of lower quality. Two RCTs of high quality found no statistically significant improvement in pain. There was insufficient information about the results from the low-quality studies. The authors concluded that there is strong evidence that instruction on joint protection leads to an improvement of functional ability. We support this conclusion and conclude that there is high-quality evidence for a positive effect on function, but no difference in pain (Tab. 2). Only one of the included studies reported decreases in grip strength and range of motion (ROM) as possible effects, but the authors questioned whether this was due to improved joint protection behavior or a determinant of increased joint protection behavior.

Provision of splints and hand orthoses. Sixteen studies related to provision of splints (hand, finger, or wrist) versus other types of splints or no treatment. Three non-RCTs found a statistically significant decrease in pain while participants were wearing working splints, whereas the effects on pain after splinting were conflicting. Only 2 of the studies were RCTs of high quality and reported no difference in pain. Statistically significant improvements in grip strength while wearing a splint were reported (2 non-RCTs), whereas 2 RCTs of high quality reported no statistically significant increase in grip strength after a period of time. The authors concluded that there are indicative findings that splints are effective in reducing pain. Furthermore, they stated that there are indicative findings for a gain in grip strength immediately after provision of the splints.

Egan et al (20) included 12 studies assessing the same interventions versus placebo or alternative interventions. Splints and orthoses were defined as "any medical device added to a person's body to support, align, position, immobilize, prevent or correct deformity, assist weak muscles, or improve function." The primary studies were of low to moderate quality. The studies showed conflicting results regarding pain and function, and the authors concluded that there is insufficient evidence to make firm conclusions about the effectiveness of working splints or resting splints on pain and function. Based on the conflicting results in both of the reviews, (19,20) we conclude that the effect of splints (hand, finger, or wrist) is unclear (Tab. 2). Twelve of the included studies reported on safety or side effects, (19) and both reviews (19,20) concluded that there were some indicative findings that splinting has a negative effect on dexterity.

Training of motor function. Six studies evaluated training of motor function versus no treatment or alternative treatment. One RCT with high methodological quality reported no significant differences between groups on pain and functional ability after training of hand function. The other studies were of low quality, showed conflicting results, and did not report sufficient data to calculate effect sizes. The authors concluded that there is no evidence for the effectiveness of training of motor function on pain or function. Based on the conflicting results, we conclude that there is unclear evidence for the effect of motor function training on pain and function (Tab. 2). One study reported problems with the upper extremity after resistance exercises.

Foot orthoses. Effects of foot orthoses and special shoes versus placebo, no intervention, or other intervention were reported in 2 reviews, (20,21) with 4 and 11 studies included, respectively (Tab. 5). Foot orthoses are prescribed by clinicians as a form of intervention for the symptomatic foot in patients with RA to relieve forefoot, midfoot, and rear-foot pain and to normalize the pain pattern. (21) All patients included Had a confirmed diagnosis of RA. one review (20) reported that 2 lowquality Studies found significant improvements in pain, but not in function, and 2 high-quality studies found no significant changes in either pain or function (up to 3 years of orthosis wear). Clark et al (21) reported conflicting results on both pain and function, but no exact results were presented. Thus, we conclude, based on the 2 reviews, that the effect of orthosis is unclear (Tab. 2). Safety or side effects were not reported in any of the reviews.

Patient education. Four reviews (3,22-24) reported on the effects of patient education for patients with RA (Tab. 6), describing the interventions as "any set of planned educational activities designed to improve patients health behavior or health status," "a multidisciplinary intervention delivered by a team of health care professionals, providing a systematic approach to care, and including a patient education component," and "psychosocial interventions." Patients included had either "a clinical confirmation of RA" or "adult RA."

Riemsma et al (22) included 31 RCTs. The interventions were patient education interventions versus control and were categorized into 3 groups: "information only," "counseling," and "behavioral treatment." No significant effects of information only or counseling were reported. Significant effects on disability, patient global assessment, and depression were found for behavioral treatment interventions after treatment. The authors concluded that patient education had small short-term effects on disability, joint counts, patient global assessment, psychological status and depression, but there was no evidence of long-term benefits.

Niedermann et al (23) concluded that the results on physical health status are conflicting, and no long-term changes in disability and physical function were found in any study. Badamgarav et a1 (24) reported that pooled effect sizes were small and nonsignificant, but studies with interventions of greater than 5 weeks' duration showed significant differences in functional status. Astin et al (3) concluded that there are small, but statistically significant, effect sizes for pain, functional disability, depression, coping, and self-efficacy after treatment.

All included reviews concluded that different types of patient education interventions have small short-term effects on different health outcomes, but there is no evidence for the long-term benefits. Based on the many studies with consistent results, we conclude that there is high-quality evidence that patient education improves function and patient global assessment (Tab. 2).

Physical Therapy Interventions

Exercises. Five reviews (25-29) reported the effects of therapeutic exercises (Tab. 7), including "tai chi instructions," "any form of exercise for the hand," "therapeutic exercises, with an emphasis on the intensity of exercise program," and "aerobic activities." Target populations were ambulatory adults with a diagnosis of RA or clinically confirmed RA. Generally, the methodological quality of the primary studies was low or not reported, and the interventions were heterogeneous. One of the included reviews (28) provided quantitative pooling of results based on 2 primary studies of very low quality. Most of the reviews stated that further studies were needed, but the results indicated that exercises may have some beneficial effects on pain and function. One review (25) rated the evidence on pain and overall function as "good," but the conclusion is based on studies with conflicting results and no quantitative pooling. Patient global assessment was not statistically significant in the studies that reported this outcome. Based on the conflicting results, we conclude that there is low-quality evidence that exercises reduce pain and improve function and that there is no difference in patient global assessment (Tab. 2).

Tai chi instructions caused some joint and muscle pain complaints that diminished during the course of the study, but it did not cause withdrawals. One review (29) found that aerobic fitness activities do not exacerbate disease activity or accelerate joint damage, whereas another review (25) concluded that, although no harmful side effects were reported in the original studies, the effects of high-intensity exercise on pain raise concern.

Low-level laser therapy (LLLT). Two reviews were identified, (15,30) defining low-bevel laser therapy as "a light source that generates extremely pure light, of a single wavelength." All patients included had clinically confirmed RA. The methodological quality of the primary studies varied from low to good, and both reviews provided quantitative pooling of results (Tab. 7). Three RCTs of moderate quality showed statistically significant improvements in pain, and 2 RCTs of moderate quality found significant improvements in function (ie, ROM, flexibility). Patient global assessment was not reported. The reviews agreed on the conclusion that LLLT could be considered for relief of pain and rated the evidence to be of "silver" quality (30) and "good" quality, (15) respectively. We conclude, therefore, that there is moderatequality evidence that LLLT reduces pain and improves function (Tab. 2). None of the reviews reported on possible side effects and safety.

Therapeutic ultrasound. Two reviews (15,31) reported the effect of therapeutic ultrasound (pulsed or continuous), including 1 and 2 primary studies, respectively (Tab. 7). Patients included had clinically confirmed RA. Results from the 2 primary studies could not be combined in a meta-analysis. One RCT of moderate quality showed statistically significant improvements in pain (tender or painful joints) and function (grip strength, ROM). Patient global assessment was not reported. Based on one primary study of moderate quality, therefore, we conclude that there is low-quality evidence that therapeutic ultrasound reduces pain and improves function (Tab. 2). Neither of the reviews reported side effects.

Thermotherapy. Three reviews (15,32,33) reported the effects of thermotherapy (Tab. 7), including the interventions "melted paraffin wax applications" and "superficial moist heat and cryotherapy." All patients included had clinically confirmed RA. The methodological quality of the primary studies was low, and none of the included reviews provided quantitative pooling of the results. One primary study of low quality reported statistically significant improvements in pain and function (grip strength). The study was included in all 3 reviews, and the results were obtained in the group that received a combination of paraffin wax and exercise therapy. When paraffin wax alone was compared with a control, there were no significant differences in any of the outcomes. All 3 reviews agreed that thermotherapy is more effective as an adjunct therapy than it is alone. Patient global assessment was not reported as an outcome in any of the included studies. On these grounds, we find it reasonable to conclude that the effect of thermotherapy alone is unclear (Tab. 2). No side effects were reported.

Transcutaneous electrical nerve stimulation (TENS). Two reviews, (15,34) including the same primary studies, assessed the outcomes of TENS (low frequency, high frequency) (Tab. 7). All patients included had clinically confirmed RA. Based on a large variation in patients and methodological issues in the included studies, the results were not combined in a meta-analysis. Results regarding pain were conflicting. Two studies, one of low quality and one of moderate quality, found statistically significant improvement in pain (visual analog scale score, joint tenderness), whereas one study of moderate quality found no significant improvement in pain (visual analog scale score). Because of the inconsistent results, we conclude that the effect of TENS is unclear (Tab. 7). No side effects were reported.

Discussion

Based on the evidence from 28 systematic reviews, our overview indicates that the quality of evidence for the effectiveness of most of the interventions was low, except for patient educational programs, joint protection, LLLT, and GLA (herbal therapy).

Although our intention with the present overview was to provide useful information to patients, clinicians, researchers, and policymakers, it surely has several limitations. First, the results from this overview cannot be interpreted as treatment recommendations. Recommendations for practice are normally parts of clinical guidelines, and guideline recommendations should be based on both research evidence and clinical experience. Recommendations should be developed through a process involving both methodologists and clinicians and taking other factors, such as resources and culture, into account. This overview summarizes the empirical evidence, and the bottom line is what is known from systematic reviews. Thus, this overview could be the core element of a clinical guideline, but not a guideline in itself.

Second, based on our results, it is not possible to make conclusions regarding the effects of modalities on patients with various classes of disease because none of the included re views were distinct on these topics. An overview summarizes results of existing reviews. It does not review the literature or add more outcomes or studies. The results of an overview are dependent on the number of high-quality, updated systematic reviews and the quality of the primary studies included. Systematic reviews usually give us the answers in general terms, due to the primary studies' heterogeneity in diagnosis, interventions, and outcomes, and seldom help the clinician who wants to know what type of intervention is most effective in treating a specific patient in a clinical practice. Given these limitations, an overview might be more valuable for policymakers than for clinicians.

Third, possible harmful effects or side effects of the interventions were seldom reported, and no conclusions were drawn in any of the included reviews. This is in accordance with Ethgen et al, (35) who found that harm was less often described in reports of nonpharmacological treatment trials than in reports of pharmacological treatment trials. This might partly be explained by a presupposed lower degree of harmful effects; however, most therapy might imply the risk of adverse effects. Unexpected side effects can only be detected if data on all events are systematically collected.

Our overview shows that the evidence for effects of the most common nonpharmacological and non-surgical interventions for patients with RA is of low quality. Low-quality evidence is not the same as the intervention does not have effect, rather that there is insufficient evidence to draw firm conclusions with regard to the effectiveness of many of the interventions usually offered to patients with RA. The overall methodological quality of the primary studies was frequently relatively weak. However, there are probably better conducted newly published RCTs not captured in the included reviews, which might enhance the quality of evidence for the effects of the interventions. This is possibly the case especially for exercise therapy.

Exercise therapy is considered to be a cornerstone in the treatment of RA in all stages of the disease. (36) The American College of Rheumatology (2) underscores the necessity of an interdisciplinary approach to the comprehensive management of RA. They recommend patient education, instruction in joint protection, conservation of energy, and a home program of ROM and strengthening exercises as important in achieving the treatment goals. Furthermore, the American College of Rheumatology reports that regular participation in dynamic and aerobic conditioning exercise programs improves joint mobility, muscle strength, aerobic fitness, and function as well as psychological well-being without increasing fatigue or joint symptoms. Apart from the recommendations of patient education and joint protection, their strong recommendations of exercise therapy are not supported by the present overview, which found low-quality evidence for exercise therapy.

Our results are supported by Smidt et al, (37) who conducted a best-evidence summary of systematic reviews on the effectiveness of exercise therapy. They concluded that there was insufficient evidence to support or refute the effectiveness of exercise therapy for patients with RA. The Ottawa Panel, (25) however, recommend the use of exercise therapy for RA in their guidelines, but they emphasize that their guidelines are limited by generally poorly reported descriptions of therapeutic exercise programs and the outcomes in the included studies.

The latest Cochrane review on exercise therapy for RA (38) was conducted in 1998. It concluded that dynamic exercise therapy had positive effects, but that research on long-term effects was needed. Lately, many high-quality studies have been cartied out and concluded that exercise is both effective and safe in patients with RA. (39-43) Thus, it is likely that an updated, high-quality review on exercise therapy for patients with RA will make it possible to draw firmer conclusions on the effect of exercise therapy for this group of patients.

As pointed out earlier, better conducted primary studies are necessary to draw firm conclusions on the effectiveness of nonpharmacological and nonsurgical interventions for patients with RA. Foley et a1 (44) assessed the quality between pharmacological and nonpharmacological studies. They found that the greatest difference was for subject masking, in which virtually all drug trials succeeded, whereas only a small percentage (35%) of non-drug trials succeeded. It is obvious that masking the patients is difficult in most of the interventions in our study, but masking of the assessors is possible in most cases and should be carried out. Blinding is particularly important when the outcome measures involve patient-reported symptoms such as pain. (45) Outcome measures also should be standardized, using valid and reliable tools, and follow-up should be of sufficient length to assess long-term effects.

The summarized evidence may be used by patients, health care practitioners, policymakers, and researchers. The policymakers need research-based evidence to guide their budget decisions on which interventions to reimburse and what kind of research to fund. For the researchers, our overview might identify areas where research is missing and improvements are needed. Clinicians and patients are usually interested in what type of intervention is the most effective in a specific context. An overview of systematic reviews will most often not add new evidence for a single intervention, but rather synthesize available evidence on different interventions for the same condition and thus provide clinicians and patients with an overview of the evidence for the most commonly used interventions. Because the overview gives the answers in general terms, it might be more valuable for policymakers and researchers than for clinicians and patients.

The increasing need for valid, relevant health care information emphasizes the need for rigorous clinical research to guide health care decisions. In the present overview, we found that the quality of evidence for most nonpharmacological and nonsurgical interventions for patients with RA is low. This does not mean that most of the interventions are ineffective, but rather that the quality of research evidence is low. As long as the primary studies have serious limitations, our confidence in the estimate of effect is low. Better conducted primary studies are warranted to provide stakeholders with high-quality information needed in their health care decisions.

Appendix 1.

Search Strategy

(A) Study type: systematic reviews

1. controlled.ab. [ab.=all searchable words from the abstract]

2. design.ab.

3. evidence.ab.

4. extraction.ab.

5. randomized controlled trials/[MESH]

6. meta-analysis.pt. [pt.=publication type]

7. review.pt.

8. sources.ab.

9. studies.ab.

10. OR/1-9

11. letter.pt.

12. comment.pt.

13. editorial.pt.

14. OR/11-13

15. 10 NOT 14

(B) Participants: rheumatoid arthritis

Arthritis, rheumatoid/OR (arthritis adj2 rheumat$).tw. [Textword]

(C) Interventions: nonpharmacological and nonsurgical

exp "Therapeutics"/(exploded MESH term] OR therap$.tw. OR dh.fs.
  [Diet Therapy as floating subheading to a MESH term]

exp "behavior and behavior mechanisms"/OR exp "psychological
  phenomena and processes"/OR exp "mental disorders"/OR exp
  "behavioral disciplines and activities"/

The following MESH terms and floating subheading were excluded from
the search result with NOT:

exp "Specialties, Surgical"/OR su.fs [Surgery as floating subheading
  to a MESH term]

exp "inorganic chemicals"/OR exp "organic chemicals"/OR exp
  "heterocyclic compounds"/OR exp "polycyclic compounds"/OR
  exp macromolecular substances/OR exp "hormones, hormone substitutes,
  and hormone antagonists"/OR exp "enzymes and coenzymes"/
  OR exp "carbohydrates/OR exp lipids"/OR exp "amino acids, peptides,
  and proteins"/OR exp "nucleic acids, nucleotides, and
  nucleosides"/OR exp "complex mixtures"/OR exp "biological factors"/OR
  exp "biomedical and dental materials"/OR exp
  "pharmaceutical preparations"/OR exp "chemical actions and uses"/

(D) Language restrictions: English or Scandinavian language

(E) Publication year from 2000 to January 2007

Appendix 2.

Quality Assessment Checklist for Systematic Reviews

The following 9 criteria was rated as "met," "unclear/partly met,"
  or "not met" according to a criteria list modified
  from a previously validated checklist (7):

1. Is the search strategy described in enough detail for the search
  to be reproducible?

2. Was the search for evidence reasonably comprehensive?

3. Were the criteria used for deciding which studies to include in
  the review reported?

4. Was bias in the selection of articles avoided?

5. Were the criteria used for assessing the validity of the studies
  that were reviewed reported?

6. Was the validity of all of the studies referred to in the text
  assessed using appropriate criteria in analyzing the
  studies that are cited?

7. Were the methods used to combine the findings of the relevant
  studies (to reach a conclusion) reported?

8. Were the findings of the relevant studies combined (or not combined)
  and analyzed appropriately relative to the primary question the
  review addresses and the available data?

9. Were the conclusions made by the author(s) supported by the data
  and/or the analysis reported in the review?

Appendix 3.

Excluded Reviews (n=41)

Barrels EM, Lund H, Nneskiold-Samsoe B. Pool exercise therapy of
  rheumatoid arthritis [in Danish]. Ugeskrift for
  Laeger. 2001;163:5507-5513.
  [Review] [49 references]

Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a
  treatment for rheumatologic conditions. Rheum Dis Clin
  North Am. 2000;26:103-115. [Review] [54 references]

Cleland LG, James MJ, Proudman SM. The role of fish oils in the
  treatment of rheumatoid arthritis. Drugs. 2003;63:845-853. [Review]
  [47 references]

Clyman B. Sports, exercise, and arthritis. Bull Rheum Dis. 2001;50:1-3.
  [Review] [22 references]

de Jong Z, Vlieland TP. Safety of exercise in patients with rheumatoid
  arthritis. Curr Opin Rheumatol. 2005;17:177-182. [Review] [43
  references]

Ernst E. Chinese herbal medicines for consumers in the West. Focus on
  Alternative & Complementary Therapies. 2005;10:94-97.

Ernst E. Complementary medicine. Curr Opin Rheumatol. 2003;15:151-155.
  [Review] [19 references]

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This article was submitted January 31, 2007, and was accepted July 17, 2007.

DOI: 10.2522/ptj.20070039

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Ms Jamtvedt and Dr Hagen provided concept/idea/project design. All authors provided writing and data analysis. Ms Christie, Ms Dahm, Ms Moe, Dr Haavardsholm, and Dr Hagen provided data collection. Ms Christie and Dr Hagen provided project management. Ms Jamtvedt and Dr Hagen provided consultation (including review of manuscript before submission).

This work was inspired by the CARE III and CARE IV International Conferences.

A Christie, PT, MSc, is Research Fellow, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, PO Box 23 Vindern, 0319 Oslo, Norway. Address all correspondence to Ms Christie at: [e-mail].

G Jamtvedt, PT, MPH, is Researcher, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.

KT Dahm, PT, MSc, is Research Assistant, Norwegian Knowledge Centre for the Health Services.

RH Moe, PT, is Research Fellow, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital.

EA Haavardsholm, MD, is Research Fellow, Department of Rheumatology, Diakonhjemmet Hospital.

KB Hagen, PT, PhD, is Researcher, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital.

[Christie A, Jamtvedt G, Dahm KT, et al. Effectiveness of nonpharmacological and nonsurgical interventions for rheumatoid arthritis: an overview of systematic reviews. Phys Ther. 2007;87:1697-1715.]

Table 1.
Quality of Evidence

Level              Based on

High-quality       one or more updated, high-quality systematic
evidence             reviews that are based on at least 2 high-quality
                     primary studies with consistent results

Moderate-          One or more updated systematic reviews of high or
quality evidence     moderate quality
                      * Based on at least 1 high-quality primary study
                      * Based on at least 2 primary studies of
                          moderate quality with consistent results

Low-quality        One or more systematic reviews of variable quality
evidence             * Based on primary studies of moderate quality
                     * Based on inconsistent results in the reviews
                     * Based on inconsistent results in primary
                       studies

Table 2. Summary of Findings

Intervention         Comparison            Results

Acupuncture          Control/placebo       Unclear
Balneotherapy        Different types of    Unclear
                       balneotherapy/
                       other
                       interventions/
                       placebo/no
                       intervention
Diets                Control/usual diet    Reduces pain
Electrical           Control               Unclear
  stimulation

Herbal therapy       Placebo/              Reduces pain
                       alternative           and patient
                       herbal                global
                       intervention          assessment
Occupational
 therapy

  Advice/            Usual care/           Unclear
    instruction        no control
    about
    assistive
    devices

  Comprehensive      No intervention       Improves function,
    occupational                             no difference
    therapy                                  in pain

  Joint protection   Alternative           Improves function,
                       intervention/         nodifference
                       no intervention       in pain

  Provision of       No intervention/      Unclear
    splints            control/different
                       types of splints

  Training of        No intervention/      Unclear
     motorfunction     alternative
                       intervention

  Hand/foot          Placebo/no            Unclear
    orthosis           intervention/
                       other
                       intervention

  Patient            No intervention/      Improves function
    educational        usual care/            and patient
    intervention       other educational      global
                       intervention/          assessment
                       waiting list
                       controls

  Exercise           No intervention/      Reduces pain and
                       alternative           improves
                       intervention/         function, no
                       different             difference
                       types of              inpatient global
                       exercises             assessment

  Low-level          Alternative           Reduces pain and
    laser therapy      intervention/         improves function
                       placebo

  Therapeutic        Placebo/              Reduces pain and
     ultrasound        alternative           improves function
                       intervention

  Thermotherapy      Placebo/no            Unclear
                       intervention/
                       alternative
                       interventions

  Transcutaneous     Placebo/              Unclear
    electrical         alternative
    nerve              interventions
    stimulation

                     Quality of
Intervention         Evidence

Acupuncture          Low
Balneotherapy        Low
Diets                Low
Electrical           Low
  stimulation
Herbal therapy       Moderate
Occupational
 therapy
   Advice/           Low
    instruction
    about
    assistive
    devices
  Comprehensive      Low
    occupational
    therapy
  Joint protection   High
  Provision of       Low
    splints
  Training of        Low
     motorfunction
  Hand/foot          Low
    orthosis
  Patient            High
    educational
    intervention
  Exercise           Low
  Low-level          Moderate
    laser therapy
  Therapeutic        Low
     ultrasound
  Thermotherapy      Low
  Transcutaneous     Low
    electrical
    nerve
    stimulation

Table 3.
Description of Included Reviews: Acupuncture/Balneotherapy (a)

Reference                     No. of Included
                              Studies and
                              Participants

An overview of bee            1 RCT
  venom acupuncture in        2 CTs
  the treatment of            (152
  arthritis (Lee                participants)
  et al) (9)

Acupuncture and               2 RCTs
  electroacupuncture for        (84
  the treatment of              participants)
  rheumatoid arthritis
  (Casimiro et al) (10)

Balneotherapy for             6 RCTs
  rheumatoid arthritis          (355
  and osteoarthritis            participants)
  (Verhagen et al) (11)

Efficacy of balneotherapy     7 RCTs
  for rheumatoid arthritis:     (374
  a meta-analysis               participants)
  (Brosseau et al) (12)

Reference                     Methodological Quality
                              of Review and Primary
                              Studies

An overview of bee            Review
  venom acupuncture in        Moderate limitations
  the treatment of            Primarv studies
  arthritis (Lee              Mean quality score (1 RCT)=4
  et al) (9)                    (Jadad scale: 0-5)
                              2 CTs: not assessed

Acupuncture and               Review
  electroacupuncture for      Minor limitations
  the treatment of            Primary studies
  rheumatoid arthritis        Mean quality score=3 (Jadad
  (Casimiro et al) (10)         scale: 0-5)

Balneotherapy for             Review
  rheumatoid arthritis        Minor limitations
  and osteoarthritis          Primary studies
  (Verhagen et al) (11)       Mean quality score=4.8
                                (Delphi list: 0-9)

Efficacy of balneotherapy     Review
  for rheumatoid arthritis:   Minor limitations
  a meta-analysis             Primary studies
  (Brosseau et al) (12)       Mean quality score= 2.4 (Jadad
                                scale: 0-5)

  Reference                   Results

An overview of bee            No quantitative pooling
  venom acupuncture in        "Due to paucity and methodological flaws
  the treatment of               in the existing clinical studies, it
  arthritis (Lee                 is premature to draw any firm
  et al) (9)                     conclusions at this time. However,
                                 the effectiveness of bee venom
                                 acupuncture for arthritis is likely
                                 to be a promising area of future
                                 research."

Acupuncture and               No quantitative pooling
  electroacupuncture for      "With a silver level of evidence, we
  the treatment of              conclude that there is little evidence
  rheumatoid arthritis          that acupuncture relieves RA symptoms."
  (Casimiro et al) (10)

Balneotherapy for             No quantitative pooling
  rheumatoid arthritis        "One cannot ignore the positive findings
  and osteoarthritis            reported in most trials. However, the
  (Verhagen et al) I            scientific evidence is insufficient
                                because of the poor methodological
                                quality, the absence of an adequate
                                statistical analysis, and the absence,
                                for the patient, of most essential
                                outcome measures. Therefore, the
                                noted 'positive findings' should be
                                viewed with caution. Because of the
                                methodological flaws, an answer
                                about the apparent effectiveness of
                                balneotherapy cannot be provided at
                                this moment. A large, methodological
                                sound trial is needed."

Efficacy of balneotherapy     Pain
  for rheumatoid arthritis:   Swollen/tender joints (Ritchie Index
  a meta-analysis               Scale): WMD = -7.07, 95% CI = -11.98
  (Brosseau et al)'z            to 2.19 (2  RCTs)
                              Patient global assessment
                                VAS: WMD=0.2, 95% CI=-1.08 to 1.8 (2
                                 RCTs)

(a) RCT=randomized controlled trial, CT=clinical trial,
RA = rheumatoid arthritis, WMD = weighted mean difference,
CI = confidence interval, VAS = visual analog scale.

Table 4.
Description of Included Reviews: Diets/Electrical
Stimulation/Herbal Therapy (a)
                                                 Methodological
Reference                   No. of               Quality of
                            Included Studies     Review
                            and Participants     and Primary
                                                 Studies

Fasting followed by         2 RCTs               Review
  vegetarian diet in        2 CCTs               Moderate
  patients with             (143 participants)     limitations
  rheumatoid arthritis: a                        Primary studies
  systematic review                              Not reported
  (Muller et al)13

Electrical stimulation for  1 RCT                Review
  the treatment of          (15 participants)    Minor limitations
  rheumatoid arthritis                           Primary studies
  (Brosseau et al) (14)                          Mean quality
                                                   score = 2
                                                   (Jadad
                                                   scale: 0-5)

Herbal therapy for          11 RCTs              Review
  treating rheumatoid       (398 participants)   Minor limitations
  arthritis (Little and                          Primary studies
  Parsons) (16)                                  Mean quality
                                                   score=3.4
                                                   (Jadad
                                                   scale: 0-5)

Herbal medicines for the    14 RCTs              Review
  treatment of              (493 participants)   Moderate
  rheumatoid arthritis: a                          limitations
  systematic review                              Primary studies
  (Soeken et al) (17)                            Mean quality
                                                   score= 3.9
                                                   (Jadad
                                                   scale: 0-5)

Ayurvedic medicine for      7 RCTs               Review
  rheumatoid arthritis: a   (508 participants)   Minor limitations
  systematic review (Park                        Primary studies
  and Ernst) (18)                                Mean quality
                                                   score = 2.1
                                                   (Jadad
                                                   scale: 0-5)
Reference                   Results

Fasting followed by         Pain
  vegetarian diet in        Effect size=0.58, r=.28,
  patients with               P<.01 (2 RCTS)
  rheumatoid arthritis: a
  systematic review
  (Muller et al)13

Electrical stimulation for  No quantitative pooling
  the treatment of          "ES was shown to have a clinically
  rheumatoid arthritis        beneficial effect on grip strength
  (Brosseau et al) (14)       and fatigue resistance for RA
                              patients with muscle atrophy of
                              the hand. However, these conclusions
                              are limited by the low
                              methodological quality of the
                              trial included. More  well-designed
                              studies are therefore needed to
                              provide further evidence
                              of the benefits of ES in the
                              management of RA."

Herbal therapy for          Pain
  treating rheumatoid       VAS: WMD=-32.83, 95% CI=-56.25
  arthritis (Little and       to -9.42 (3 RCTs)
  Parsons) (16)             Pain scale (0-4): WMD=-25.88, 95% CI=
                              -46.73 to -5.02 (3 RCTs)
                            Patient global assessment
                            Scale (0-4): WMD=-20.87, 95% CI=-39.43
                              to -2.31 (3 RCTs)

Herbal medicines for the    Pain
  treatment of              VAS: WMD=0.76, 95% CI=0.37
  rheumatoid arthritis: a     to 1.15 (3 RCTs)
  systematic review
  (Soeken et al) (17)

Ayurvedic medicine for      No quantitative pooling
  rheumatoid arthritis: a   "There is a paucity of RCTs of
  systematic review (Park     Ayurvedic medicines for RA. The
  and Ernst) (18)             existing RCTs fail to show
                              convincingly that such treatments
                              are effective therapeutic options
                              for RA."

(a) RCT=randomized controlled trial, CCT=controlled clinical trial
ES=electrical stimulation, RA=rheumatoid arthritis,
VAS=visual analog scale, WMD=weighted mean difference,
CI=confidence interval.

Table 5.
Description of Included Reviews: Occupational Therapy/Orthosis (a)

                                          Methodological
Reference               No. of Included   Quality of
                        Studies and       Review and Primary
                        Participants      Studies

Occupational            16 RCTs           Review
  therapy for           6 CCTs            Minor limitations
  rheumatoid            16 ODs            Primary studies
  arthritis             (1,789            Mean quality
  (Steultjens           participants)       score (RCT/CCT)=
  et al) (19)                               9.3 (van Tulder
                                            scale, 1997)6
                                          Mean quality
                                            score (OD)=8.1
                                            (adapted van
                                            Tulder scale)

A critical              6 RCTs            Review
  review of foot        5 CCTs            Moderate limitations
  orthoses in the       (419              Primary studies
  rheumatoid            participants)     Criteria used to assess
  arthritic                               methodological quality
  foot (Clark                             reported
  et al) (21)

Splints and             12 studies        Review
  orthoses for          (RCT/CCT/OD)      Minor limitations
  treating rheumatoid                     Primary studies
  arthritis                               Mean quality
  (Egan et al) (20)                         score = 2.3 (jadad
                                            scale: 0-5)

Reference               Results

Occupational            No quantitative pooling
  therapy for           "We found strong evidence for the efficacy
  rheumatoid              of instruction of joint protection on
  arthritis               functional ability. Studies that
  (Steultjens             evaluated comprehensive OT showed
  et al) (19)             limited evidence for the effectiveness
                          on functional ability. Studies that
                          evaluated splint interventions reported
                          indicative findings for the effectiveness
                          on pain."

A critical              No quantitative pooling
  review of foot        "From the review there is limited and
  orthoses in the         conflicting evidence upon which to base
  rheumatoid              clinical practice. The suggestion is
  arthritic               that foot orthoses may reduce pain
  foot (Clark             and improve ability, but these
  et al) (21)             outcomes are not achieved by
                          all studies."

Splints and             No quantitative pooling
  orthoses for            "There is insufficient evidence to make
  treating rheumatoid     firm conclusions about the effectiveness
  arthritis               of working wrist splints in decreasing
  (Egan et al) (20)       pain or increasing function for people
                          with RA.... There is evidence that
                          extra-depth shoes and molded insoles
                          decrease pain during weight-bearing
                          activities such as standing, walking,
                          and stair climbing. Extra-depth shoes
                          with semi-rigid insoles provide better
                          pain relief than extra-depth shoes
                          alone."

(a) RCT=randomized controlled trial, CCT=controlled clinical trial,
OD = other designs, OT = occupational therapy, RA = rheumatoid
arthritis.

(b) Van Tulder MW, Assendelft Wjj, Koes BW, Bouter LM. Method
guidelines for systematic reviews in the Cochrane Collaboration
Back Review Group for Spinal Disorders. Spine. 1997;22:2323-2330.

Table 6.
Description of Included Reviews: Patient Education
Intervention (a)

Reference                        No. of Included
                                 Studies and
                                 Participants

Psychological interventions      25 RCTs (1,676
  for rheumatoid arthritis:        participants)
  a meta-analysis of
  randomized controlled
  trials (Actin et al) (4)

Effects of disease management    8 RCTs
  programs on functional         3 CCTs
  status of patients with        (701 participants)
  rheumatoid arthritis
  (Badamgarav et al) (24)

Gap between short- and long-     11 RCTs (931
  term effects of patient          participants)
  education in rheumatoid
  arthritis patients: a
  systematic review
  (Niedermann et al) (23)

Systematic review of             31 RCTs
  rheumatoid arthritis           No. of included
  patient education                participants: not
  (Riemsma et al) (22)             possible to assess
                                   (8,632
                                   participants?)

Reference                        Methodological Quality of
                                 Review and Primary Studies

Psychological interventions      Review
  for rheumatoid arthritis:      Minor limitations
  a meta-analysis of             Primary studies
  randomized controlled          Mean quality score=2.24 (Jadad
  trials (Actin et al) (4)         scale: 0-5)
                                 Mean quality score=5.84 (van
                                   Tulder scale: 0-10)

Effects of disease management    Review
  programs on functional         Moderate limitations
  status of patients with        Primary studies
  rheumatoid arthritis           Type of quality
  (Badamgarav et al) (24)          score not reported

Gap between short- and long-     Review
  term effects of patient        Moderate limitations
  education in rheumatoid        Primary studies
  arthritis patients: a          Mean quality score=5.6
  systematic review                (Cochrane/Amsterdam-
  (Niedermann et al) (23)          Maastricht, range= 0-11)

Systematic review of             Review
  rheumatoid arthritis           Minor limitations
  patient education              Primary studies
  (Riemsma et al) (22)           Mean quality score =
                                   2.6 (modified
                                   Jadad scale: 0-8)

Reference                        Results

Psychological interventions      Pain
  for rheumatoid arthritis:      Pooled effect size
  a meta-analysis of               (postintervention) = 0.22,
  randomized controlled            95% CI=0.07 to 0.37 (13 RCTs)
  trials (Actin et al) (4)       Pooled effect size (follow-up)=0.06,
                                   95% CI=-0.17 to 0.29 (6 RCTs)
                                 Function

                                 Pooled effect size
                                   (postintervention)=0.27,
                                   95% CI = 0.12 to 0.42 (12 RCTs)
                                 Pooled effect size (follow-up)=0.12,
                                   95% CI=-0.09 to -0.33 (7 RCTs)

                                 Self-efficacy
                                 Effect size (postintervention)=0.35,
                                   95% CI=0.11 to 0.59 (5 RCTs)
                                 Effect size (follow-up)=0.20,
                                   95% CI=-0.08 to -0.48

Effects of disease management    Function
  programs on functional         Effect size = 0.27, 95% CI = -0.01 to
  status of patients with          0.54 (7 RCTs/1 CCT)
  rheumatoid arthritis           Interventions lasting >5 wk: effect
  (Badamgarav et al) (24)          size=0.49, 95% CI=0.12 to 0.86
                                   (2 RCTs/1 CCT)

                                 Interventions lasting :55 wk: effect
                                 size=0.13, 95% CI=-0.25 to 0.52
                                 (4 RCTs)

Gap between short- and long-     No quantitative noolinn
  term effects of patient        "Methodologically better-designed
  education in rheumatoid          studies had more difficulties
  arthritis patients: a            demonstrating positive outcome
  systematic review                results. Short-term effects in
  (Niedermann et al) (23)          program targets are generally
                                   observed, whereas long-term
                                   changes in health status are not
                                   convincingly demonstrated."

Systematic review of             Pain
  rheumatoid arthritis           Posttreatment SMD=-0.08,
  patient education                95% CI=-0.16 to 0.00 (37 CTS) (b)
  (Riemsma et al) (22)           Follow-up SMD=-0.07,
                                   95% CI=-0.19 to 0.05 (19 RCTs)
                                 Function
                                 Posttreatment SMD=-0.17,
                                   95% CI=-0.25 to -0.09
                                   (37 RCTS) (b)
                                 Follow-up SMD=-0.09,
                                   95% CI=-0.20 to 0.02 (23 RCTs)
                                 Patient global assessment
                                 Posttreatment SMD=-0.28,
                                   95% CI=-0.49 to -0.07 (6 RCTs)
                                 Follow-up SMD=-0.06,
                                   95% Cl=-0.22 to 0.10 (7 RCTs)

(a) RCT=randomized controlled trial, CCT=controlled clinical trial,
CT = clinical trial, CI = confidence interval,
SMD = standardized mean difference.

(b) Some studies contained more than 2 comparative interventions
and were included as independent studies in the statistical
pooling.

Table 7.
Description of Included Reviews: Physical Therapy Interventions
(Exercises/Electrotherapy/Thermotherapy) (a)

Reference              No. of Included      Methodological
                       Studies and          Quality of Review
                       Participants         and Primary Studies

Ottawa Panel           6 RCTs               Review
  Evidence-Based       10 CCTs              Minor limitations
  Clinical Practice    (661 participants)   Primary studies
  Guidelines for                            Mean quality
  Therapeutic                                 score = 1.2
  Exercises in the                            (Jadad
  Management of                               scale: 0-5)
  Rheumatoid
  Arthritis in
  Adults (Ottawa
  Panel) (25)

Tai chi for treating   3 RCTs               Review
  rheumatoid           1 CCT                Minor limitations
  arthritis (Ham       (206 participants)   Primary studies
  et al) (28)                               Mean quality
                                              score=0.25 (Jadad
                                              scale: 0-5)

The effectiveness      9 CCPs or case       Review
  of hand                series (262        Moderate limitations
  exercises for          participants)      Primary studies
  persons with                              Mean quality score=28
  rheumatoid                                  (type of scale not
  arthritis: a                                reported: 0-48)

Training effects on    6 RCTs               Review
  pain in              Unknown number of    Moderate limitations
  rheumatoid             participants       Primary studies
  arthritis (Enger                          Quality score not
  et al) (27)                                 reported (Jamtvedt
                                              and Hilde, 2000) (b)

A health               11 RCTs              Review
  professional's       7 CCPs or            Moderate limitations
  guide to               pretest-posttest   Primary studies
  exercise               studies            Quality score not
  prescription for                            reported (Squires,
  people with                                 1989) (c)
  arthritis: a
Low level laser        6 RCTs               Review
  therapy (classes       (222               Minor limitations
  I, II and III) in      participants)      Primary studies
  the treament of                           Mean quality score:
  rheumatoid                                  3.0 (Jadad
  arthritis                                   scale: 0-5)

Ottawa Panel           Low-level            Review
  Evidence-Based         laser therapy      Minor limitations
  Clinical Practice    5 RCTs (204          Primary studies
  Guidelines for         participants)      Low-level laser
  Electrotherapy                              therapy:
  and                  Therapeutic            mean quality
  Thermotherapy          ultrasound           score=4.0 (Jadad
  Interventions in     1 RCT (50              scale: 0-5)
  the Management         participants)
  of Rheumatoid                             Therapeutic
  Arthritis in         TENS                   ultrasound:
  Adults (Ottawa       3 RCTs (94             mean quality
  Panel) (15)          participants)          score=3.0 (Jadad
                                              scale: 0-5)
                       Electrical
                       stimulation          TENS: mean quality
                       No reviews found       score=2.3 Qadad
                                              scale: 0-5)

Therapeutic            2 RCTs (80           Review
  ultrasound for       participants)        Minor limitations
  the treatment of                          Primary studies
  rheumatoid                                  Mean quality
  arthritis                                     score=2
  (Casimiro                                     (Jadad
  et al) (31)                                   scale: 0-5)

Transcutaneous         3 RCTs (78           Review
  electrical nerve     participants)        Minor limitations
  stimulation                               Primary studies
  (TENS) for the                            Mean quality
  treatment of                                score: 2.3
  rheumatoid                                  (Jadad scale: 0-5)
  arthritis in the
  hand (Brosseau
  et al) (34)

Efficacy of paraffin   4 RCTs (303          Review
  wax baths for        participants)        Moderate limitations
  rheumatoid                                Primary studies
  arthritic hands                           Mean quality score= 10
  (Ayling and                               (Beckerman et al,
  Marks) (32)                               1992: 0-25)"

Ottawa Panel           2 RCTs (76           Review
  Evidence-Based       participants)        Minor limitations
  Clinical Practice                         Primary studies
  Guidelines for                              Mean quality
  Electrotherapy                              score= 1 Qadad
  and                                         scale: 0-5)
  Thermotherapy
  Interventions in
  the Management
  of Rheumatoid
  Arthritis in
  Adults (Ottawa
  Panel (15))

Thermotherapy for      7 RCTs (328          Review
  treating             participants)        Minor limitations
  rheumatoid                                Primary studies
  arthritis                                 Mean quality
  (Robinson                                   score= 1.6
  et al) (33)                                 (Jadad scale: 0-5)

Reference              Results

Ottawa Panel           No quantitative pooling
  Evidence-Based       "Good evidence (level I, RCT) exists that
  Clinical Practice      therapeutic exercises, including
  Guidelines for         functional strengthening and low- or
  Therapeutic            high-intensity exercises, relieve pain
  Exercises in the       and improve overall function."
  Management of
  Rheumatoid
  Arthritis in
  Adults (Ottawa
  Panel) (25)

Tai chi for treating   Function
  rheumatoid           ADL index: WMD=0.001, 95% CI=-2.94 to 2.97
  arthritis (Ham         (1 RCP/1 CCT)
  et al) (28)          50-ft walking test: WMD=0.35, 95% CI=-1.14
                         to 1.84 (1 RCP/1 CCT)

The effectiveness      No quantitative pooling
  of hand              "There is not strong research evidence for
  exercises for          or against the value of hand exercise in
  persons with           the treatment of persons with rheumatoid
  rheumatoid             arthritis, although results of this review
  arthritis: a           suggest that appropriate exercise might
  systematic             lead to long-term strength changes and
  review                 very short-term changes in stiffness."
  (Wessel) (26)

Training effects on    No quantitative pooling
  pain in              "The results indicate that exercise leads to
  rheumatoid             unchanged or reduced self-reported pain
  arthritis (Enger       and joint tenderness for patients with
  et al) (27)            rheumatoid arthritis. Further studies are
                         needed in order to demonstrate to what
                         extent and how different kinds of exercise
                         influence pain and joint tenderness in
                         rheumatoid patients."

A health               No quantitative pooling
  professional's       "Although more comprehensive evaluation is
  guide to               necessary, present evidence suggests that
  exercise               aerobic fitness activities have minimal to
  prescription for       short-term effects on arthritis-related
  people with            impairment, disease activity, or
  arthritis: a           accelerating] joint damage. The long-term
  review of              effects of aerobic exercise are less well
  aerobic fitness        understood. Available data do not suggest
  activities             that one mode of aerobic exercises is
  (Westby) (29)          better than another when comparing the
                         changes in aerobic capacity, disease
                         activity, pain, physical activity, and
                         depression."

Low level laser        Function
  therapy (classes     ROM: WMD=-18.03, 95% Cl=-31.80 to -4.27
  I, II and III) in      (2 RCPs)
  the treament of      Flexibility-tip to palm distance: WMD=-1.28,
  rheumatoid             95% CI=-1.72 to -0.85 (2 RCPs)
  arthritis            Pain
  (Brosseau            VAS: WMD=-1.10, 95% CI=-1.82 to -0.39
  et al)30               (3 RCPs)

Ottawa Panel           Low-level laser therapy
  Evidence-Based       Function
  Clinical Practice    ROM: WMD=-1.26, 95% CI=-1.72 to -0.85
  Guidelines for         (2 RCTs)
  Electrotherapy       Pain
  and                  VAS: WMD=-1.05, 95% Cl=-1.58 to -0.53
  Thermotherapy          (4 RCTs)
  Interventions in
  the Management       Therapeutic ultrasound
  of Rheumatoid        No quantitative pooling
  Arthritis in         "The Ottawa Panel found good evidence
  Adults (Ottawa         (level I, RCT) of the effects of
  Panel) (15)            therapeutic ultrasound for RA of
                         the hand."

                       TENS
                       No quantitative pooling "The Ottawa Panel
                         found good evidence (level I, RCT) on
                         the effects of TENS for management of RA
                         in the hand and wrist."

                       Electrical stimulation
                       Evidence with acceptable research design,
                         interventions, group comparisons, or
                         outcomes could not be identified.

Therapeutic            No quantitative pooling
  ultrasound for       "Ultrasound in combination with exercises,
  the treatment of       faradic current, and wax bath treatment
  rheumatoid             modalities is not supported and cannot
  arthritis              be recommended. Ultrasound alone can,
  (Casimiro              however, be used on the hand to increase
  et al) (31)            grip strength, and to a lesser extent
                         and based on borderline results, increase
                         wrist flexion, decrease morning stiffness,
                         reduce the number of swollen joints, and
                         reduce the number of painful joints. It is
                         important to note that these conclusions
                         are limited by methodological
                         considerations."

Transcutaneous         No quantitative pooling
  electrical nerve     "There are conflicting effects on pain
  stimulation            outcomes in patients with RA. AL-TENS is
  (TENS) for the         beneficial for reducing pain intensity and
  treatment of           improving muscle power scores over
  rheumatoid             placebo, while, conversely, C-TENS
  arthritis in the       resulted in no clinical benefit on pain
  hand (Brosseau         intensity compared with placebo. However,
  et al) (34)            C-TENS resulted in a clinical benefit on
                         patient assessment of change in disease
                         over AL-TENS. More well-designed studies
                         with a standardized protocol and adequate
                         number of subjects are needed to fully
                         conclude the effect on C-TENS and AL-TENS
                         in the treatment of RA of the hand."

Efficacy of paraffin   No quantitative pooling
  wax baths for        "A critical review of the literature
  rheumatoid             concerning the clinical efficacy of
  arthritic hands        paraffin wax as a treatment for hands
  (Ayling and            afflicted with RA has not revealed any
  Marks) (32)            study without serious bias. Thus, no
                         definitive evidence exists either in
                         support of this treatment approach.
                         In addition, studies suggesting that the
                         techniques of wax baths may be temporarily
                         useful, or not useful at all, did not
                         necessarily employ optimal application
                         methods. Related data do suggest, though,
                         that physiotherapists should avoid using
                         this modality when their patients' joint
                         disease is active."

Ottawa Panel           No quantitative pooling
  Evidence-Based       "The Ottawa Panel found good evidence
  Clinical Practice      (level 1, RCT) that thermotherapy,
  Guidelines for         especially wax combined with exercise,
  Electrotherapy         benefits ROM, pain, and stiffness in the
  and                    management of RA."
  Thermotherapy
  Interventions in
  the Management
  of Rheumatoid
  Arthritis in
  Adults (Ottawa
  Panel (15))

Thermotherapy for      No quantitative pooling
  treating             "The results of this systematic review on
  rheumatoid             thermotherapy in the treatment of RA found
  arthritis              that there was no significant effect of
  (Robinson              hot or ice pack applications or faradic
  et al) (33)            baths on objective measures of disease
                         activity, including joint swelling, pain,
                         medication intake, ROM, grip strength, or
                         hand function, when compared to a control
                         or alternate treatment."

(a) RCT=randomized controlled trial, SMD=standardized mean
difference, CI = confidence interval, CT = clinical trial,
ADL = activities of daily living, WMD = weighted mean difference,
ROM = range of motion, VAS=visual analog scale, TENS=transcutaneous
electrical nerve stimulation, RA=rheumatoid arthritis,
AL-TENS=acupuncture-like transcutaneous electrical nerve
stimulation, C-TENS =conventional transcutaneous electrical
nerve stimulation.

(b) Jamtvedt G, Hilde G. Evidence-based physiotherapy: critical
appraisal of a randomized controlled trial [in Norwegian].
Norwegian Physiotherapy Journal, 2000;67:7-12.

(c) Squires BP. Biomedical review articles: what editors want
from authors and peer reviewers. Can Med Assoc J. 1989;141:195-197.

(d) Beckerman H, de Bie RA, Bouter LM, et al. The efficacy of laser
therapy for musculoskeletal and skin disorders: a criteria-based
meta-analysis of randomized clinical trials. Phys Ther.
1992;72:483-491.