Ottawa panel evidence-based clinical practice guidelines for electrotherapy and thermotherapy interventions in the management of rheumatoid arthritis in adults.Introduction Rheumatoid arthritis rheumatoid arthritis Chronic, progressive autoimmune disease causing connective-tissue inflammation, mostly in synovial joints. It can occur at any age, is more common in women, and has an unpredictable course. (RA) affects a large proportion of the population. The Arthritis Foundation This article or section needs sources or references that appear in reliable, third-party publications. Alone, primary sources and sources affiliated with the subject of this article are not sufficient for an accurate encyclopedia article. reported that more than 2.1 million Americans have the disease. (1) The prevalence of RA is increasing with the aging population in industrial countries. (2) Rheumatoid arthritis is recognized as an important source of disability and handicap, which leads to considerable socioeconomic so·ci·o·ec·o·nom·ic adj. Of or involving both social and economic factors. socioeconomic Adjective of or involving economic and social factors Adj. 1. costs resulting from medical and surgical interventions and from frequent absences from work. (2,3) A patient is said to have RA if he or she satisfies at least 4 of the following 7 American Rheumatism rheumatism (r  `mətĭzəm), general term for a number of disorders that cause inflammation and pain in muscles, bones, joints, or nerves. Association (ARA Ara or Arrah (both: ŭ`rə), city (1991 pop. 157,082), Bihar state, NE India, on the Son Canal. A major road and rail junction, it is the administrative center for a district that produces grain, sugarcane, and oilseed. ) criteria: (1)
morning stiffness, (2) arthritis of 3 or more joints, (3) arthritis of
the hand joints, (4) symmetric No difference in opposing modes. It typically refers to speed. For example, in symmetric operations, it takes the same time to compress and encrypt data as it does to decompress and decrypt it. Contrast with asymmetric. (mathematics) symmetric - 1. arthritis, (5) rheumatoid nodules rheumatoid nodule n. A subcutaneous nodule occurring most commonly over bony prominences in some patients with rheumatoid arthritis. rheumatoid nodule , (6) serum rheumatoid factor rheumatoid factor n. Abbr. RF Any of the immunoglobulins found in the serum of individuals with rheumatoid arthritis that enhance the agglutination of suspended particles that are coated with pooled human gamma globulin and that are used , or (7) radiologic radiologic Radiological adjective Referring to radiology changes. (4) A classification of functional capacity frequently used in patients with RA is described as: (I) complete functional capacity with ability to carry out all usual duties without handicaps, (II) functional capacity adequate to conduct normal activities despite handicap of discomfort or limited mobility of one or more .joints, (III) functional capacity adequate to perform only a few or none of the duties of usual occupation or of self-care, or (IV) largely or wholly incapacitated in·ca·pac·i·tate tr.v. in·ca·pac·i·tat·ed, in·ca·pac·i·tat·ing, in·ca·pac·i·tates 1. To deprive of strength or ability; disable. 2. To make legally ineligible; disqualify. with patient bedridden bed·rid·den or bed·rid adj. Confined to bed because of illness or infirmity. or wheelchair-bound, permitting little or no self-care. (5) The rehabilitation rehabilitation: see physical therapy. approach to the management of RA (5) has 9 goals: (1) to decrease pain, (2) to decrease effusion effusion /ef·fu·sion/ (e-fu´zhun) 1. escape of a fluid into a part; exudation or transudation. 2. effused material; an exudate or transudate. (joint swelling swelling /swell·ing/ (swel´ing) 1. transient abnormal enlargement of a body part or area not due to cell proliferation. 2. an eminence, or elevation. ), (3) to decrease stiffness, (4) to correct or prevent joint deformity Deformity See also Lameness. Calmady, Sir Richard born without lower legs. [Br. Lit.: Sir Richard Calmady, Walsh Modern, 84] Carey, Philip embittered young man with club foot seeks fulfillment. [Br. Lit. , (5) to increase range of motion (ROM), (6) to increase muscle force, or decrease weakness, (7) to improve mobility and walking, (8) to increase physical fitness or reduce fatigue, and (9) to increase functional status. Electrotherapeutic modalities Modalities The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors. and thermotherapy ther·mo·ther·a·py n. Medical therapy involving the application of heat. thermotherapy physical agents are used as part of a rehabilitation program Noun 1. rehabilitation program - a program for restoring someone to good health program, programme - a system of projects or services intended to meet a public need; "he proposed an elaborate program of public works"; "working mothers rely on the day care offered mainly for pain and inflammation inflammation, reaction of the body to injury or to infectious, allergic, or chemical irritation. The symptoms are redness, swelling, heat, and pain resulting from dilation of the blood vessels in the affected part with loss of plasma and leucocytes (white blood relief in the management of various musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. conditions. (2,6,7) The electrotherapeutic modalities and thermal agents have been used primarily to reduce pain, effusion, and stiffness in RA. These therapeutic interventions also indirectly contribute to increased ROM, muscle force, mobility, walking ability, functional status, and physical fitness. Thus, electrotherapy electrotherapy /elec·tro·ther·a·py/ (-ther´ah-pe) treatment of disease by means of electricity. e·lec·tro·ther·a·py n. Medical therapy using electric currents. and thermotherapy are promising interventions, especially for inflammatory polyarthritis such as RA, which could present subacute subacute /sub·acute/ (-ah-kut´) somewhat acute; between acute and chronic. sub·a·cute adj. Between acute and chronic. and chronic inflammatory symptoms depending on the stage of the disease (eg, chronic stage >1 year). Electrotherapy and thermotherapy offer several advantages. They are noninvasive non·in·va·sive adj. 1. Not penetrating the body, as by incision. Used especially of a diagnostic procedure. 2. Not invading healthy tissue. interventions that present very few adverse side effects Side effects Effects of a proposed project on other parts of the firm. and contraindications compared with a large number of pharmacologic pharmacologic /phar·ma·co·log·ic/ (-kah-loj´ik) pertaining to pharmacology or to the properties and reactions of drugs. pharmacological, pharmacologic pertaining to pharmacology. interventions. Electrotherapy and thermotherapy are rapid to administer and are convenient for community-based settings; the modalities and agents either can be found at home (eg, ice packs) or are portable (for instance, the electrotherapy devices for transcutaneous electrical nerve stimulation transcutaneous electrical nerve stimulation n. TENS. Transcutaneous electrical nerve stimulation (TENS) A method for relieving the muscle pain of TMJ by stimulating nerve endings that do not transmit pain. [TENS] or low-level laser therapy [LLLT LLLT Low Level Laser Therapy ]). The effectiveness of electrotherapy and thermotherapy in the management of RA has been reported in systematic or literature reviews. (8-18) Trials on the efficacy of LLLT have been systematically reviewed for RA. (12,13) The experimental and placebo placebo (pləsē`bō), inert substance given instead of a potent drug. Placebo medications are sometimes prescribed when a drug is not really needed or when one would not be appropriate because they make patients feel well taken care of. groups in the reviewed studies showed a significant difference (P<.05), suggesting that LLLT is effective for reducing pain and morning stiffness and increasing ROM. (12,13) However, other reviews (8,9) that were not conducted systematically did not yield reports of any effect of LLLT for musculoskeletal pain relief. To our knowledge, only one systematic review (17) exists on the efficacy of therapeutic ultrasound Therapeutic ultrasound is a technique that uses high-frequency sound waves (ultrasound) to speed healing in injured joint or muscle tissue. The frequency used is typically 1-3 Mhz. in the management of RA. The review, involving RA of the hand, found a significant difference (P<.05) between experimental and control groups on reduced number of painful and swollen joints. However, ultrasound ultrasound or sonography, in medicine, technique that uses sound waves to study and treat hard-to-reach body areas. In scanning with ultrasound, high-frequency sound waves are transmitted to the area of interest and the returning echoes recorded combined with an exercise program was not effective for these outcome measures. Four other meta-analyses on the effects of therapeutic ultrasound (19-22) showed no evidence of clinically important or statistically significant results to support the effectiveness of therapeutic ultrasound in reducing musculoskeletal pain. However, these meta-analyses related to musculoskeletal or heel heel (hel) calx; the hindmost part of the foot. cracked heels pitted keratolysis. heel n. 1. pain and not specifically to RA. They also have not been updated. For thermotherapy for RA, the results of a systematic Review (15) showed that the application of hot packs or ice packs had no effect on measures of disease activity, including joint swelling, pain, medication intake, ROM, grip force, and hand function compared with a control (no intervention). However, paraffin baths paraffin bath, n dip treatment of hot paraffin wax; commonly used to encourage relaxation, relieve pain, and increase circulation in the hands and feet. See also thermotherapy. combined with therapeutic exercises for arthritic hands showed positive results on measures of pain on nonresisted motion, ROM, and stiffness, but not on grip force and pinch pinch, n a small amount of chewing tobacco (snuff) an individual takes to use the substance for its desired effect. A “pinch” is called a quid in Britain. function, compared with a control after 4 consecutive weeks of intervention. No beneficial effects were observed for an application of paraffin paraffin, white, more-or-less translucent, odorless, tasteless, waxy solid. It melts between 47°C; and 65°C; and is insoluble in water but soluble in ether, benzene, and certain esters. alone compared with a control for any of these measures. In a recent systematic review on the efficacy of TENS in the management of RA, (16) statistically significant results were observed for pain relief at rest for acupuncture-like (low frequency combined with high intensity) TENS compared with placebo. Conventional (high frequency combined with low intensity) TENS showed statistically significant benefit over a placebo for tenderness intensity. Similar results were obtained in previous review articles on pain management in musculoskeletal conditions (23,24) and in rheumatology rheumatology /rheu·ma·tol·o·gy/ (-tol´ah-je) the branch of medicine dealing with rheumatic disorders, their causes, pathology, diagnosis, treatment, etc. rheu·ma·tol·o·gy n. conditions. (16,25) A systematic review conducted by Pelland et aL (18) showed that electrical stimulation had effects on muscle force and endurance Endurance See also Longevity. Atalanta feminine name denotes power of endurance. [Gk. Myth.: Jobes, 148] Boston marathon famous 26-mile race held annually for long-distance runners. [Am. Pop. Culture: Misc. of the first dorsal dorsal /dor·sal/ (dor´s'l) 1. pertaining to the back or to any dorsum. 2. denoting a position more toward the back surface than some other object of reference; a synonym of posterior interosseous interosseous /in·ter·os·se·ous/ (-os´e-us) between bones. in·ter·os·se·ous or in·ter·os·se·al adj. Connecting or lying between bones. muscle when compared with a control group that received no intervention. To our knowledge, only 4 evidence-based clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. (EBCPGs) have been published specifically on electrotherapy and thermotherapy interventions for RA: The RA Management Protocol, (5) the American College American College is the name of:
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. , (26) the American Pain Society's guidelines, (27) and guidelines for occupational Therapists occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL. (28) (Appendix 1). Because it offers no specific recommendations for practitioners, the RA Management Protocol (5) can be categorized cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat as somewhere between an exhaustive literature review and a guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. for each specific physical agent mentioned in this article. Regardless, the 4 sets of guidelines have several drawbacks: (1) they were developed for limited clinical practice areas; (2) although the EBCPGs were based on the current scientific literature, a nonstandardized approach was used to synthesize To create a whole or complete unit from parts or components. See synthesis. the scientific results, meaning that the evidence of intervention efficacy was not clear or precise, especially when conflicting results were present; (3) the raw data of each article were not analyzed an·a·lyze tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es 1. To examine methodically by separating into parts and studying their interrelations. 2. Chemistry To make a chemical analysis of. 3. and synthesized syn·the·sized adj. 1. Relating to or being an instrument whose sound is modified or augmented by a synthesizer. 2. Relating to or being compositions or a composition performed on synthesizers or synthesized instruments. using Cochrane Collaboration The Cochrane Collaboration was developed in response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of health care. systematic methods; (4) the studies reviewed were not based on a systematic literature search; (5) the scientific results of each study were reviewed, but no synthesis was carried out; (6) no rigorous grading system was used to assess the evidence; and (7) no recent updating has been completed for most of the guidelines. The generally positive results from the recent meta-analyses and the lack of up-to-date and rigorously developed EBCPGs oil electrotherapy and thermotherapy suggest a need for the development of better-quality EBCPGs for these interventions. Evidence suggests that quality of care can be improved through the use of EBCPGs. (29-32) The aim of developing these guidelines was to promote appropriate use of electrotherapy and thermotherapy in the management of RA. These guidelines are aimed at various users, including physical therapists, physicians, and patients. This article discusses only LLLT, therapeutic ultrasound, TENS, electrical stimulation, and thermotherapy (including, for the purposes of this article, both cryotherapy Cryotherapy Definition Cryotherapy is a technique that uses an extremely cold liquid or instrument to freeze and destroy abnormal skin cells that require removal. and heat therapy). Methods For this project, we used the same methods that were used in a previous study conducted by the Ottawa Panel on therapeutic exercises. (33) The methods have been explained in full in a previous article, (33) which discusses all relevant areas: population, trial designs, outcomes, theoretical framework, literature search, selection criteria, statistical analysis, and guideline review. Briefly, an a priori a priori In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. protocol was defined, and it guided separate systematic reviews for each intervention. Positive recommendations were sent to 5 practitioners--a physical therapist, an occupational therapist, a physiatrist physiatrist /phys·iat·rist/ (-trist) a physician who specializes in physiatry. phys·i·at·rist n. 1. A physician who specializes in physical medicine. 2. , a family physician, and a rheumatologist--for comments. Results of Literature Search The literature search identified 14,111 potential RA-related articles for electrotherapy and thermotherapy. Of these, several publications were considered potentially relevant based on the selection criteria checklist: (1) for LLLT, 11 articles (34-44) (Tabs. 1 and 2) were initially considered relevant and 5 randomized controlled trials A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. (RCTs) involving 204 patients with RA (34-38) were ultimately included; (2) for therapeutic ultrasound, 8 studies (45-52) (Tabs. 3 and 4) were initially included and 1 RCT RCT Randomized Controlled Trial RCT Regimental Combat Team (infantry regiment with their own artillery, engineers, medical and tanks) RCT Rollercoaster Tycoon RCT Randomized Clinical Trial RCT Rhondda Cynon Taff involving 50 patients (45) was ultimately included; (3) for thermotherapy, 23 trials were initially included (47,49,53-74) (Tabs. 5 and 6) and 2 RCTs involving 76 patients (53,54) were ultimately included; and (4) for TENS, 9 articles were initially included (50,75-82) (Tabs. 7 and 8) and 3 RCTs involving 78 patients (75-77) were ultimately included (Appendixes 2-5). Low-Level Laser Therapy (LLLT) LLLT applied to the foot, knee, or hand versus a placebo, level I (RCT): grade A for pain at 3 months (clinically important benefit); grade C for function, tender joints, muscle force, and ROM at 3 and 6 months (no benefit). Patients with chronic RA. Summary of trials. Five placebo-controlled RCTs were included (Tab. 1). (34-38) In these RCTs, the LLLT treatment schedule ranged from 2 to 3 sessions a week and from 4 to 10 consecutive weeks. The dosage dosage /dos·age/ (do´saj) the determination and regulation of the size, frequency, and number of doses. dos·age n. 1. Administration of a therapeutic agent in prescribed amounts. ranged between 2.7 and 8.1 J/[cm.sup.2]. All RCTs used a gallium gallium (găl`ēəm), metallic chemical element; symbol Ga; at. no. 31; at. wt. 69.72; m.p. 29.78°C;; b.p. 2,403°C;; sp. gr. 5.904 at 29.6°C; (solid), 6.095 at 29.8°C; (liquid); valence +2 or +3. aluminum-arsenide laser medium, (34-37) except for that of Walker et al, (38) who used a helium-neon type of laser. Walker et al (38) also used LLLT to irradiate irradiate /ir·ra·di·ate/ (i-rad´e-at) to treat with radiant energy. ir·ra·di·ate v. 1. To expose to radiation, as for diagnostic or therapeutic purposes. 2. both painful RA joints and the appropriate superficial superficial /su·per·fi·cial/ (-fish´al) pertaining to or situated near the surface. su·per·fi·cial adj. 1. Of, affecting, or being on or near the surface. 2. nerve, whereas other investigators (34-37) treated only the RA joints (Appendix 2). Four trials (39-42) were excluded because of the lack of an appropriate control group, one trial (43) was excluded because the abstract did not provide enough statistical data to be analyzed, and one trial (44) was excluded because it was a duplicate DUPLICATE. The double of anything. 2. It is usually applied to agreements, letters, receipts, and the like, when two originals are made of either of them. Each copy has the same effect. of an included study (Tab. 2). Efficacy. A clinically important benefit was demonstrated for pain relief. Four RCTs (34-36,38) (n = 169) demonstrated a significant difference (weighted mean difference [WMD WMD white muscle disease. ]=-1.05 cm on a 10-cm visual analog scale [VAS vas (vas) pl. va´ sa [L.] vessel.va´sal vas aber´rans 1. a blind tubule sometimes connected with the epididymis; a vestigial mesonephric tubule. 2. ], 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI]=-1.58 to 0.53 cm) and percentage reductions in pain relative to a control group. Relative reductions in pain were -28% in patients with RA affecting 2 or more groups of joints, (34) -25% in patients at a chronic stage, (35) -19% in patients with RA according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. ARA criteria, (38) and -22% in patients with active RA (36) (Tab. 9, Fig. 1). For consistency in Figures 1 through 4, the results obtained for the intervention groups are presented on the left of the central vertical line representing no difference (value 0) between groups compared and the results obtained for the control or placebo groups are presented on the right of the central vertical line representing no difference (value=0) between groups compared. Two RCTs (36,37) (n=57) demonstrated a difference in favor of upon the side of; favorable to; for the advantage of. See also: favor LLLT compared with a placebo (WMD=-1.26 cm, 95% CI=-1.72 to -0.85 cm) in increasing ROM in the band (-76% to -142% relative difference). The trial by Palmgren et al, (37) involved only patients with RA. However, the tip-to-palm distance measurement was not considered a valid outcome according to the American Society of Hand Therapists (83) (Tab. 10, Fig. 1). No clinically important benefit was shown for tender joints (Ritchie Articular articular /ar·tic·u·lar/ (ahr-tik´u-ler) pertaining to a joint. ar·tic·u·lar adj. Of or relating to a joint or joints. articular pertaining to a joint. Index) or function (Fig. 1), and the results for grip force conflicted (Tab. 11, Fig. 1). [FIGURE 1 OMITTED] Strength of published evidence compared with other guidelines. The Ottawa Panel found good evidence (level I, RCT) suggesting that LLLT alone in the management of RA of the foot, knee, or hand is beneficial for pain relief The strength of evidence has not been assessed by other RA guidelines (Appendix 1). Clinical recommendations compared with other guidelines. The Ottawa Panel believes that the evidence supports the inclusion of LLLT applied to the foot, knee, or hand as an intervention for the reduction of pain associated with RA (grade A for pain). Low-level laser therapy has not been assessed by other RA guidelines (Appendix 1). Practitioners' response to Ottawa Panel guidelines. All surveyed practitioners found the Ottawa Panel's recommendation for LLLT clear. Two practitioners agreed with the recommendation, and 1 practitioner disagreed with the recommendation (although the Ottawa Methods Group sent the recommendations to 5 practitioners, only 3 practitioners responded in this case). Therapeutic Ultrasound Therapeutic ultrasound performed on the hand in water versus a placebo, level I (RCT): grade A for tender joints at 10 weeks (clinically important benefit); grade C for swollen joints and morning stiffness at 10 weeks (no benefit). Patients with RA involving the hand (functional class I or II, chronic stage). Summary of trials. One placebo-controlled RCT of therapeutic ultrasound (45) (n=50) was included (Tab. 3, Appendix 3). One trial (47) was excluded because the sample contained both subjects with RA and subjects without known pathology pathology, study of the cause of disease and the modifications in cellular function and changes in cellular structure produced in any cell, organ, or part of the body by disease. or impairments, one trial (46) was excluded because it contained subjects without known pathology or impairments, and the other trials (48-52) were excluded for various reasons (Tab. 4). Continuous-wave ultrasound was applied in water to the dorsal and palmar aspects of the hand at 0.5 W/[cm.sup.2]. The therapeutic session lasted 10 minutes on alternate days for 3 weeks for a total of 10 sessions (Appendix 3). Efficacy. Pain relief demonstrated a clinically important difference (-19% relative difference [Tab. 12]) and statistically significant benefits (WMD=1.20 for change in number of tender joints, 95% CI=0.45-1.95). (45) No clinically important difference was shown for swollen joints (-3% [Tab. 12]). A clinically important difference could not be calculated for grip force or ROM in patients with RA of the hand (functional class I or II, chronic stage). No clinically important difference was found for reduction of morning stiffness (-41% [Tab. 12], Fig. 2) because morning stiffness was not measured using a validated val·i·date tr.v. val·i·dat·ed, val·i·dat·ing, val·i·dates 1. To declare or make legally valid. 2. To mark with an indication of official sanction. 3. scale. (84,85) Strength of published evidence compared with other guidelines. The Ottawa Panel found good evidence (level I, RCT) of the effects of therapeutic ultrasound for RA of the hand. The strength of evidence has not been graded in other guidelines (Appendix 1). Clinical recommendations compared with other guidelines. The Ottawa Panel believes there is good evidence that therapeutic ultrasound alone performed on the hand in water should be included as an intervention for RA (grade A for tender joints, grade C for swollen joints and morning stiffness). To our knowledge, no EBCPGs in the scientific literature have dealt with therapeutic ultrasound (Appendix 1). Practitioners' response to Ottawa Panel guidelines. All surveyed practitioners agreed with the Ottawa Panel's recommendation for therapeutic ultrasound and found it clear. Thermotherapy Cryotherapy applied to the knee joint versus a control, level I (RCT): grade C for thermographic index (measurement [in degrees Celsius] obtained using infrared An invisible band of radiation at the lower end of the visible light spectrum. With wavelengths from 750 nm to 1 mm, infrared starts at the end of the microwave spectrum and ends at the beginning of visible light. thermography thermography (thûr'mŏg`rəfē), contact photocopying process that produces a direct positive image and in which infrared rays are used to expose the copy paper. of the joint) at 5 days (no benefit). Patients with chronic RA, and with obvious effusion of joints. Wax applied to the hand and wrist versus a control, level I (RCT): grade C for pain, ROM, muscle force, and function at 1 month (no benefit). Patients with functional class I or II with hands affected. Wax applied to the hand or wrist and hand exercises versus a control, level I (RCT): grade A for ROM at 1 month (clinically important benefit), grade C+ for pain and stiffness at 1 month (clinical benefit), grade C for muscle force and function at 1 month (no benefit). Patients with functional class I or II with hands affected. Summary of trials. Two RCTs (53,54) (n=76) evaluated controls versus 3 different types of thermotherapy for PA-affected upper- and lower-extremity joints: (1) cryotherapy (n=24), (2) wax (n=52), and (3) wax combined with exercise (n=52) (Tab. 5, Appendix 4). The treatment duration ranged from 5 consecutive days to 3 times a week for 4 weeks. The treatment session ranged from 10 to 20 minutes (Appendix 4). Eight RCTs were excluded for the following reasons: the absence of a control group, (58,62) the inclusion of patients postsurgery, (70) the use of patients as their own controls, (67) or the use of individuals without known pathology or impairments as controls. (47,68,69,73) Two other studies (57,63) were excluded because they had no numerical data Numerical data (or quantitative data) is data measured or identified on a numerical scale. Numerical data can be analysed using statistical methods, and results can be displayed using tables, charts, histograms and graphs. to be analyzed. Four head-to-head studies (involving comparison of 2 groups of subjects receiving active treatments; no placebo or control group) (49,65,66,74) were not accepted, and other studies (55,56,59-61,64,67,71,72) were excluded for various reasons (Tab. 6). Efficacy. For cryotherapy versus a control (n=24), (53) no statistically significant difference or clinically important benefits were observed for thermographic index for patients with chronic RA and obvious effusion of joints (Tab. 13, Fig. 31). No other outcomes were reported. No statistically significant difference or clinically important benefit was shown for patients with functional class I or II with hands affected for reducing pain or for improving ROM, muscle force, or function (Tab. 14) in wax versus a control (n=26). (54) Wax combined with exercise versus a control (n=26) (54) demonstrated a clinically important benefit for improving ROM in finger flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. (21% relative difference [Tab. 15]) in patients with pain resulting from the latter type of RA. Clinically important benefits without statistical significance were shown for pain and stiffness (44% and -23%, respectively [Tab. 15, Fig. 3b]). No clinically important benefit was shown for muscle force or the pinch function test. No statistical difference was observed in any outcome measured except for ROM in finger flexion (WMD=8.30[degrees], 95% CI-0.44[degrees]-16.16[degrees]). Strength of published evidence compared with other guidelines. The Ottawa Panel found good evidence (level 1, RCT) showing that thermotherapy, especially wax combined with exercise, benefits ROM, pain, and stiffness in the management of RA. The strength of evidence has been either not graded by or not reported in other RA guidelines (Appendix 1). Clinical recommendations compared with other guidelines. The Ottawa Panel found good evidence (grade A for ROM; grade C+ for pain and stiffness) that thermotherapy, especially wax combined with exercise for the hand and wrist, should be included as an intervention for patients with RA. This recommendation concurs with all existing guidelines (Appendix 1). (5,25,27) Practitioners' response to Ottawa Panel guidelines. All practitioners surveyed agreed with the recommendations for thermotherapy and found them clear. Transcutaneous Electrical Nerve Stimulation (TENS) Low-frequency TENS applied to the hand and wrist versus no stimulation, level I (RCT): grade A for pain at 3 weeks (clinically important benefit), grade C+ for power at 3 weeks (clinical benefit), grade C for work at 3 weeks (no benefit). Patients with chronic RA. High-frequency TENS applied to the hand and wrist versus placebo, level I (RCT): grade C for pain and joint tenderness, same day (no benefit). Patients with chronic RA. High- versus low-frequency TENS applied to the hand and wrist, level I (RCT): grade C+ for global patient (patient's assessment of overall disease activity or improvement) (33) at 2 weeks (clinical benefit). Patients with chronic RA. Summary of trials. Three placebo-controlled RCTs involving TENS (n=78) (75-77) were included (Tab. 7, Appendix 5). Three types of TENS were prescribed pre·scribe v. pre·scribed, pre·scrib·ing, pre·scribes v.tr. 1. To set down as a rule or guide; enjoin. See Synonyms at dictate. 2. To order the use of (a medicine or other treatment). : (1) low-frequency (0-70 Hz), acupuncture-like TENS versus no stimulation (n=26), (75) (2) high-frequency (70-100 Hz), conventional TENS versus a placebo (n=33), (76) and (3) high- versus low-frequency TENS (n=19). (77) Thus, both high-frequency TENS (76,77) and low-frequency TENS (75,77) were provided to patients with RA. The therapeutic application of TENS ranged from 5 to 20 minutes a session and from 1 to 15 consecutive sessions for up to 3 consecutive weeks (Appendix 5). One trial (79) with a sample size of fewer than 5 patients per group was excluded. One trial (80) was excluded because the enrolled patients were the control, one trial (78) was excluded because it involved a sample of patients with total knee replacement who had preoperative pre·op·er·a·tive adj. Preceding a surgical operation. preoperative preceding an operation. preoperative care the preparation of a patient before operation. osteoarthritis osteoarthritis or osteoarthrosis or degenerative joint disease Most common joint disorder, afflicting over 80% of those who reach age 70. It does not involve excessive inflammation and may have no symptoms, especially at first. or RA of the knee, another trial (82) was excluded because it offered no numerical data to be analyzed, and other trials (50, 81) were excluded for different reasons (Tab. 8). Efficacy. For low-frequency TENS versus no stimulation, (75) a clinically important benefit was demonstrated for pain relief (-67% relative difference [Tab. 16]), and this outcome was statistically significant (WMD=-59.50 mm on a 100-mm VAS, 95% CI = -76.58 to -42.42 mm; Fig. 4a) for patients with chronic RA. Power (in watts) was improved by 55% compared with baseline. This outcome, however, was not statistically significant in TENS compared with a placebo at 3 weeks. Work (in joules) scores showed little difference between TENS and a control (Tab. 17, Fig. 4a). Neither statistical significance nor a clinically important benefit was found in high-frequency TENS versus a placebo for pain relief in patients experiencing the aforementioned a·fore·men·tioned adj. Mentioned previously. n. The one or ones mentioned previously. aforementioned Adjective mentioned before Adj. 1. type of RA (Fig. 4b). (76) A statistically significant result was obtained for the reduction of joint tenderness, but no clinically important benefit was found (Tab. 18, Fig. 4b). (76) For high- versus low-frequency TENS, no statistically significant difference in patient assessment of overall disease improvement was determined, but a clinically important benefit (21% risk difference) was observed in patients with RA, in favor of high-frequency TENS (Tab. 19, Fig. 4C). (77) Strength of published evidence compared with other guidelines. The Ottawa Panel found good evidence (level I, RCT) of the effects of TENS for management of RA in the hand and wrist. The strength of evidence has been graded by the American Pain Society, (26) which also reported good-quality evidence for TENS (Appendix 1). Clinical recommendations compared with other guidelines. According to the Ottawa Panel, there is good evidence (grade A for pain, grade C+ for global patient and power) suggesting that TENS alone should be included as an intervention for management of RA in the hand and wrist. The Ottawa Panel partially agrees with The Arthritis Society, (5) which recommends the use of TENS for pain and joint swelling in patients with RA. The American Pain Society (26) gives TENS a fair recommendation for pain relief (Appendix 1). Practitioners' response to Ottawa Panel guidelines. All practitioners surveyed agreed with the Ottawa Panel's TENS recommendations and found them clear. Electrical Stimulation of Muscle Evidence with acceptable research design, interventions, group comparisons, or outcomes could not be identified to guide the development of recommendations for electrical stimulation of muscle. To our knowledge, no EBCPGs exist on electrical stimulation for RA conditions. Discussion In the area of rehabilitation for RA, evidence-based practice is gaining popularity. (5,7,25-27,86,87) The Ottawa Panel's systematic review revealed that one or more controlled clinical trials controlled clinical trial, n a research strategy that calls for two samples: an experimental sample of patients receiving a pharmaceutical, and a second sample of control patients receiving a placebo. (CCTs) demonstrated some clinically important benefits of electrotherapy and thermotherapy interventions for patients with RA. The Ottawa Panel developed several EBCPGs (n=8 with grade A, B, or C+ recommendations) for these interventions. However, other current clinical interventions for RA still need this evidence to prove their effectiveness (n=16 with grade C recommendations and n=4 with insufficient data). Credibility of Guidelines The Ottawa Panel's EBCPGs on electrotherapy and thermotherapy (grouped together in Appendix 6) for the management of RA are generally in accordance Accordance is Bible Study Software for Macintosh developed by OakTree Software, Inc.[] As well as a standalone program, it is the base software packaged by Zondervan in their Bible Study suites for Macintosh. with other EBCPGs (Appendix 1). An earlier expert panel (the Philadelphia Panel) agreed on a systematic grading of the evidence for EBCPGs, and the Ottawa Panel's EBCPGs were based on this grading system. The evidence for the Ottawa Panel's EBCPGs came from systematic reviews and meta-analyses that used Cochrane Collaboration methods or similar methods. To ensure that the guidelines were applicable and easy for clinicians to use, several practitioners sat on the Ottawa Panel. Their involvement supports the credibility of the guidelines. The development of the draft EBCPGs was done in accordance with Appraisal of Guidelines Research and Evaluation (AGREE) criteria. (88) On dimensions 1 (purpose), 2 (stakeholder stakeholder n. a person having in his/her possession (holding) money or property in which he/she has no interest, right or title, awaiting the outcome of a dispute between two or more claimants to the money or property. involvement), 4 (clarity), and 6 (editorial independence), the guidelines received excellent scores. Dimensions 3 (rigor rigor /rig·or/ (rig´er) [L.] chill; rigidity. rigor mor´tis the stiffening of a dead body accompanying depletion of adenosine triphosphate in the muscle fibers. of development) and 5 (applicability) received lower scores. Inadequate reporting of side effects and risks, which were not reported in the primary trials and therefore not included in the guidelines, lowered the rigor of development score. In identifying cost implications, potential organizational barriers, and methods of applying and monitoring the guidelines, the EBCPGs' applicability was low. Exact scores and a decision aid tool are available on the University of Ottawa LLLT According to the Ottawa Panel, there is good evidence suggesting that LLLT should be included as an intervention for reducing RA-related pain. The use of this modality modality /mo·dal·i·ty/ (mo-dal´i-te) 1. a method of application of, or the employment of, any therapeutic agent, especially a physical agent. 2. fulfills one intervention goal of the RA Management Protocol. (5) The Ottawa Panel's position agrees with those of previous systematic reviews. (12, 13) Several physiological physiological /phys·i·o·log·i·cal/ (-loj´i-kal) pertaining to physiology; normal; not pathologic. phys·i·o·log·i·cal or phys·i·o·log·ic adj. Abbr. phys. 1. studies confirm the pain relief observed among patients with RA managed with LLLT. Low-level laser therapy irradiation irradiation /ir·ra·di·a·tion/ (i-ra?de-a´shun) 1. radiotherapy. 2. the dispersion of nervous impulse beyond the normal path of conduction. 3. positively modifies the peripheral nerve activity and provides a reduction in the sensation of the pain, (7) particularly in long-standing pain such as that associated with RA. (89) One proposed animal model theory is that LLLT enhances the action of superoxide dismutase superoxide dismutase n. An enzyme that catalyzes the decomposition of a superoxide into hydrogen peroxide and oxygen. superoxide dismutase , which prevents the proliferation proliferation /pro·lif·er·a·tion/ (pro-lif?er-a´shun) the reproduction or multiplication of similar forms, especially of cells.prolif´erativeprolif´erous pro·lif·er·a·tion n. of prostaglandin E Prostaglandin E is a family of naturally occurring prostaglandins. Types include:
1. absence of sensibility to pain. 2. the relief of pain without loss of consciousness. . This beneficial physiological effect was observed in humans both at the end of intervention and at 1- and 3-month follow-up examinations. (94) Physiological studies concerned with the inflammatory process suggest that exposure to LLLT results in anti-inflammatory and analgesic analgesic (ăn'əljē`zĭk), any of a diverse group of drugs used to relieve pain. Analgesic drugs include the nonsteroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, narcotic drugs such as morphine, and synthetic drugs effects, (95) normalization In relational database management, a process that breaks down data into record groups for efficient processing. There are six stages. By the third stage (third normal form), data are identified only by the key field in their record. of the permeability permeability /per·me·a·bil·i·ty/ (per?me-ah-bil´i-te) the property or state of being permeable. per·me·a·bil·i·ty n. 1. The property or condition of being permeable. 2. of the synovial membrane synovial membrane n. The connective-tissue membrane that lines the cavity of a synovial joint and produces the synovial fluid. Also called synovium. , (95) enhancement of regional microcirculation microcirculation /mi·cro·cir·cu·la·tion/ (-sir?ku-la´shun) the flow of blood through the fine vessels (arterioles, capillaries, and venules).microcirculato´ry mi·cro·cir·cu·la·tion n. , reduction of exudative exudative of or pertaining to a process of exudation. exudative diathesis a disease of young pigs and chickens caused by a nutritional deficiency of vitamin E. Characterized by severe edema of the subcutaneous tissues. and infiltrative infiltrative /in·fil·tra·tive/ (in´fil-tra?tiv) pertaining to or characterized by infiltration. Infiltrative fluids, increased synovial membrane fibrosis fibrosis /fi·bro·sis/ (fi-bro´sis) formation of fibrous tissue.fibrot´ic congenital hepatic fibrosis , (96) and increased protein synthesis Protein synthesis is the creation of proteins using DNA and RNA. Biological and artificial methods for creation of proteins differ significantly.
1. pertaining to a synovial membrane. 2. pertaining to or secreting synovia. synovial of, pertaining to, or secreting synovia. cells, a synthesis that indicates a regenerative re·gen·er·a·tive adj. 1. Of, relating to, or marked by regeneration. 2. Tending to regenerate. re·gen process in the damaged synovial membrane. (97,98) The evidence suggests that LLLT could be applied without the addition of other physical therapy interventions to solve a specific RA pain-related problem. Because LLLT is rapid to administer and portable devices are available, it offers advantages for community-based sex-vices such as the Arthritis Rehabilitation and Education Program of The Arthritis Society (Canada). Further studies are needed to determine the optimal LLLT wavelength, dosage, application techniques, and duration of intervention and to determine long-term effects in patients with RA. (99) Therapeutic Ultrasound According to the Ottawa Panel, therapeutic ultrasound without the addition of other physical therapy interventions is effective for reducing joint tenderness caused by RA. Our results do not seem to concur CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes", R.M. Salter et al, Comp Langs 5(3):163-189 (1981)]. fully with those of previous systematic reviews (19-22) conducted for all musculoskeletal conditions. Perhaps continuous ultrasound (100) is more effective for patients with RA whose condition is chronic and marked by a medium level of disease activity (45) than for individuals with acute musculoskeletal conditions. The use of continuous ultrasound is supported by its documented physiological effects. (7,100,101) The mechanical effect of both pulsed and continuous ultrasound increases skin permeability, thus decreasing inflammatory response, reducing pain, and facilitating the soft tissue healing Healing See also Medicine. Achilles’ spear had power to heal whatever wound it made. [Gk. Lit.: Iliad] Agamede Augeas’ daughter; noted for skill in using herbs for healing. [Gk. Myth. process. Furthermore, both pulsed and continuous ultrasound reduce nerve conduction nerve conduction n. The transmission of an impulse along a nerve fiber. Nerve conduction The speed and strength of a signal being transmitted by nerve cells. velocity of pain nerve fibers nerve fiber n. A threadlike process of a neuron, especially the axon that conducts nerve impulses. . Continuous ultrasound, however, has thermal effects that reduce muscle spasms muscle spasm n. Persistent increased tension and shortness in a muscle or group of muscles that cannot be released voluntarily. muscle spasm, n and pain. The thermal effects also cause vasodilation vasodilation /vaso·di·la·tion/ (-di-la´shun) 1. increase in caliber of blood vessels. 2. a state of increased caliber of blood vessels. , which enhances the excretion excretion, process of eliminating from an organism waste products of metabolism and other materials that are of no use. It is an essential process in all forms of life. In one-celled organisms wastes are discharged through the surface of the cell. of chronic inflammatory cells. (7,100) Thermotherapy The Ottawa Panel found good evidence that thermotherapy, especially paraffin baths combined with exercise, should be included as an intervention for patients with RA to improve ROM and decrease pain and hand stiffness. This recommendation agrees with all existing guidelines (5,25-27) on improving pain and is partially supported by Nicholas, (102) who concluded that the current literature in rheumatology does not provide clinicians with precise information on dosage or duration, or specific indications for heat or cold therapy in therapeutic application. The Ottawa Panel found insufficient evidence insufficient evidence n. a finding (decision) by a trial judge or an appeals court that the prosecution in a criminal case or a plaintiff in a lawsuit has not proved the case because the attorney did not present enough convincing evidence. on the efficacy of cryotherapy, although physiological studies have shown effects on circulatory circulatory /cir·cu·la·to·ry/ (ser´ku-lah-tor?e) 1. pertaining to circulation, particularly that of the blood. 2. containing blood. cir·cu·la·to·ry n. 1. and temperature responses, muscle spasms, and inflamed tissue. (9,103) Cryotherapy's mechanism of action has not yet been fully elucidated. (103) Whether these physiological effects translate to important clinical outcomes (such as pain and functional status) is unknown. The beneficial effects observed for paraffin baths combined with therapeutic exercises for arthritic hands-effects on measures of ROM, stiffness, and pain on nonresisted motion--concur with the physiological and therapeutic effects such as facilitation Facilitation The process of providing a market for a security. Normally, this refers to bids and offers made for large blocks of securities, such as those traded by institutions. of soft tissue healing, decrease of pain by reducing muscle spasms, and reduction of joint stiffness Joint stiffness may be either the symptom of pain on moving a joint, the symptom of loss of range of motion or the physical sign of reduced range of motion. Doctors prefer the latter two uses but patients often use the first meaning. . (7) Thermotherapy using paraffin baths combined with exercise for RA is more effective as an adjunct adjunct (aj´ungkt), n a drug or other substance that serves a supplemental purpose in therapy. adjunct therapy than it is alone. The combination of several concurrent therapies within the same treatment session reflects current physical therapist practice (6) where heat therapy is used for its reflex vasodilative effect, which increases cell metabolism Cell metabolism The sum of chemical reactions which transpire within cells. The cell performs chemical, osmotic, mechanical, and electrical work, for which it needs energy. and blood flow (7) for an optimal muscle preparation before hand exercises. The combination of wax and exercises can introduce confounders. Indeed, endorphin endorphin Any of a group of proteins occurring in the brain and having pain-relieving properties typical of opium and related opiates. Discovered in the 1970s, they include enkephalin, beta-endorphin, and dynorphin. and enkephalin enkephalin (ĕnkĕf`əlĭn), one of several naturally occurring morphinelike substances (endorphins) released from nerve endings of the central nervous system and the adrenal medulla. production is stimulated by exercise. (104) The reduction of arthritic pain also could be observed when exercise is combined with a thermotherapy modality. (15) TENS According to the Ottawa Panel, there is good evidence showing that acupuncture-like TENS alone should be included as an intervention for RA to decrease pain and improve power. However, patients with RA seem to prefer conventional TENS application compared with acupuncture-like TENS. (77) The Ottawa Panel partly agrees with The Arthritis Society, (5) which views TENS as beneficial for pain and joint swelling in patients with RA. Our results concur with the conclusions of several descriptive literature reviews. (16,23,24,102) The neuroregulatoly peripheral and central effects (89,105-107) of TENS have been proposed to be more effective with higher-intensity applications. (75) This effect was observed in the study involving acupuncture-like (higher-intensity) application compared with a placebo. (75) However, both conventional and acupuncture-like TENS excite (Excite.com, Irvington, NY, www.excite.com) One of the major search engines on the Web founded in 1995 and part of IAC Search & Media. Excite was acquired by Ask Jeeves, Inc. in 2004, which was acquired by IAC in 2005. See Web search engines. afferent fibers afferent fiber n. Any of the nerve fibers that convey impulses to a ganglion or to a nerve center in the brain or spinal cord. in the A-alpha-beta range. (108) The plausible effect is explained by the activation activation /ac·ti·va·tion/ (ak?ti-va´shun) 1. the act or process of rendering active. 2. the transformation of a proenzyme into an active enzyme by the action of a kinase or another enzyme. 3. of intrinsic pain-suppressive systems (109,110) and the concomitant concomitant /con·com·i·tant/ (kon-kom´i-tant) accompanying; accessory; joined with another. concomitant adjective Accompanying, accessory, joined with another release of opiate opiate /opi·ate/ (o´pe-it) 1. any drug derived from opium. 2. hypnotic (2). o·pi·ate n. 1. observed in both animals (111) and humans. (105) The importance of the stimulation parameters in TENS analgesia is shown in animal and human research. Changes in frequency recruit different opioid receptors Opioid receptors Receptors located in the brain and various organs that bind opiates or opioid substances. Mentioned in: Methadone opioid receptors, n.pl any of the several receptors to which opiates bind. , for example, and therefore an awareness of the parameters used during TENS treatments is essential. (112,113) Several investigators (114-116) have recommended that vibrator vibrator /vi·bra·tor/ (vi´bra-tor) an instrument for producing vibrations. vibrator an apparatus used in vibratory treatment. stimulation be part of TENS application, especially when TENS is being applied for relief of chronic pain. Electrical Stimulation of Muscle Electrical stimulation of muscle is one of the therapeutic interventions available to minimize the loss of joint mobility and function by enhancing muscle performance in patients with RA. (18,117) However, despite the potential benefits of electrical stimulation in RA management, only one CCT CCT Circuit CCT Commission Canadienne du Tourisme (Canadian Tourism Commission) CCT Correlated Color Temperature CCT Common Customs Tariff (EU) CCT Certificate of Completion of Training (117) was identified for this intervention, and the study was ultimately rejected because the control group included fewer than 5 patients, indicating a very low statistical power. This CCT (117) is also considered a head-to-head study because 2 methods of stimulation were compared. Clinically, electrical stimulation is used to facilitate effective muscle force and endurance in situations involving a decrease in the voluntary recruitment of the muscle. Electrical stimulation helps to increase this recruitment in subjects without known pathology, or impairments. However, patients with RA are not able to voluntarily recruit motor units to the level required for the performance of high-intensity exercises needed to enhance muscle function, (18) and electrical stimulation does not help these patients, who have chronic muscle weakness. Furthermore, the Ottawa Panel does not recommend high-intensity exercises for patients with RA. (33) Musculoskeletal dysfunction dysfunction /dys·func·tion/ (dis-funk´shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc´tional erectile dysfunction impotence (2). , including pain and muscle disuse atrophy disuse atrophy A generic term encompassing the degenerative changes that tissues undergo when they are functioning at suboptimal levels; involvement of the musculoskeletal unit is characterized by atrophy of muscles, contraction of tendons and osteoporosis; that are observed in patients with RA, may cause decreased voluntary recruitment. Although the biophysical actions of many physical therapy interventions are partially understood, further investigation needs to be undertaken in several areas of physical therapy research, particularly that involving rheumatology: the mechanism of action; the differential effects of dose, of wavelength, and of treatment duration (99); disease staging and treatment combinations; and the relationship of pain, impairment Impairment 1. A reduction in a company's stated capital. 2. The total capital that is less than the par value of the company's capital stock. Notes: 1. This is usually reduced because of poorly estimated losses or gains. 2. , and disability. To reproduce re·pro·duce v. 1. To produce a counterpart, an image, or a copy of something. 2. To bring something to mind again. 3. To generate offspring by sexual or asexual means. the results of published RCTs, it is crucial that details on various kinds of characteristics be systematically reported. Characteristics include those of the device (eg, size of the ultrasound head or temperature of the paraffin); those of the therapeutic application (eg, specific area of application or mode of application); duration of the intervention; and schedule of intervention. Characteristics of the population such as age, sex, concurrent interventions, and disease status (cg, acuity acuity /acu·i·ty/ (ah-ku´i-te) clarity or clearness, especially of vision. a·cu·i·ty n. Sharpness, clearness, and distinctness of perception or vision. and joint involvement) also must be reported. Conclusion Despite the fact that the scientific literature is limited in quantity, good-quality evidence exists to recommend and support the use of LLLT, ultrasound, thermotherapy, and TENS for the management of RA. Conversely con·verse 1 intr.v. con·versed, con·vers·ing, con·vers·es 1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak. 2. , evidence is lacking as to whether the use of electrical stimulation should be included or excluded in physical rehabilitation physical rehabilitation See Physical therapy. for RA management. The main difficulty in determining the effectiveness of rehabilitation interventions is the lack of well-designed prospective RCTs. Future research in physical therapy should adopt rigorous methods such as the use of an appropriate placebo (and double-blind procedure Noun 1. double-blind procedure - an experimental procedure in which neither the subjects of the experiment nor the persons administering the experiment know the critical aspects of the experiment; "a double-blind procedure is used to guard against both experimenter ), adequate randomization randomization (ranˈ·d  ·m , a homogeneous The same. Contrast with heterogeneous. homogeneous - (Or "homogenous") Of uniform nature, similar in kind. 1. In the context of distributed systems, middleware makes heterogeneous systems appear as a homogeneous entity. For example see: interoperable network. sample of patients based on rigorous selection and diagnostic criteria, and an adequate sample size to detect clinically important differences with confidence. Unfortunately, at present, there is insufficient evidence to recommend or not recommend the use of several modalities and physical agents in certain clinical circumstances CIRCUMSTANCES, evidence. The particulars which accompany a fact. 2. The facts proved are either possible or impossible, ordinary and probable, or extraordinary and improbable, recent or ancient; they may have happened near us, or afar off; they are public or . The main difficulty is the lack of studies available and the methodological weaknesses in those studies: the variation in the quality of the included trials (sometimes because the randomization procedure is not described properly), the difficulty of masking mask·ing n. 1. The concealment or the screening of one sensory process or sensation by another. 2. An opaque covering used to camouflage the metal parts of a prosthesis. patients to a physical agent or modality, (118) and the lack of standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. outcomes. (2,99)
Appendix 1.
Previous Clinical Practice Guidelines for Rheumatoid Arthritis (a)
Quality of
Scientific
Intervention Author Evidence Clinical Recommendations
LLLT ACR (26) N/C N/C
APS (27) N/C N/C
Yasuda (28) N/C N/C
Therapeutic ACR (26) N/C N/C
ultrasound APS (27) N/C N/C
Yasuda (28) N/C N/C
Thermotherapy ACR (26) N/R Heat is recommended,
especially just prior to
exercise
APS (27) N/C N/C
Yasuda (28) N/R Physical agents, including
paraffin bath, hot
packs, and pain
management techniques,
are recommended
TENS ACR (26) N/C N/C
APS (27) Good-quality TENS is given a fair
evidence recommendation for pain
relief
Yasuda (28) N/C N/C
Electrical ACR (26) N/C N/C
stimulation APS (27) N/C N/C
Yasuda (28) N/C N/C
(a) LLLT=low-level laser therapy, ACR=American College of Rheumatology,
N/C=not considered, APS=American Pain Society, N/R=not reported,
TENS=transcutaneous electrical nerve simulation.
Appendix 2.
Included Trials for LLLT (a)
Sample
Author/Year Size Population Details
Goats et al, (34) RCT Inclusion criteria: patients who
1996 Total: 35 were aged 16 y or over
Gr1 : 25 and had RA affecting 2 or
Gr2: 10 more of the following
groups of joints:
tibiofemoral, talocrural,
subtalar, midtarsol, or
metatarsophalangeal
Exclusion criteria: patients
receiving medication that
might distort the planned
assessments
Hall et al, (35) RCT Inclusion criteria: patients with
1994 Total: 40 definite RA and active
Gr1: 20 synovitis of all or some
Gr2: 20 MCP or PIP joints
Exclusion criteria: patients
who had had a recent drug
change (<30 d earlier) and
were incapable of joint
response (bony ankylosis,
joint replacement, or
tendon rupture)
Johannsen et al, (36) RCT Inclusion criteria: patients who
1994 Total: 22 were aged 18-85 y, had
Gr1: 10 active Steinbrocker
Gr2: 12 functional class I or II RA,
and had symmetrical
involvement of the MCP
joints
Exclusion criteria: patients
who had bony erosions or
osteoarthritis of the MCP or
PIP joints, were pregnant, or
had an inflammatory
rheumatic disease other
than RA
Palmgren et al, (37) RCT Inclusion criteria: patients with
1989 Total: 35 classical RA
Gr1: 19
Gr2: 16
Walker et al, (38) RCT Inclusion criteria: patients with
1987 Total: 72 RA (according to ARA
Gr1: 34 criteria)
Gr2: 38
Symptom
Author/Year Duration Age
Goats et al, (34) Gr1: [bar.X]=7.54 y, Gr1: [bar.X]=57 y,
1996 SD=6.86 y SD=14 y
Gr2: [bar.X]=9.8 y, Gr2 [bar.X]=64 y,
SD=10.11 y SD=8 y
Hall et al, (35) Gr1: [bar.X]=12.2 y, Gr1: [bar.X]=67.1 y,
1994 range=1-33 y range=55-84 y
Gr2: [bar.X]=9.3 y, Gr2: [bar.X]=60.9 y,
range=2-30 y range=43-77 y
Johannsen et al, (36) N/A Gr1: [bar.X]=59 y,
1994 range=36-76 y
Gr2: [bar.X]=62 y,
range=56-73 y
Palmgren et al, (37) Gr1: [bar.X]=13.4 y, Gr1: F: [bar.X]=61.1 y,
1989 range=1-45 y range=29-76 y
Gr2: [bar.X]=15.5 y, M: [bar.X]=66.0 y,
range=4-30 range=56-73 y
Gr2: F: [bar.X]=57.5 y,
range=39-70 y
M: [bar.X]=68.0 y,
range=66-70
Walker et al, (38) Gr1: [bar.X]=11 y, Gr1: [bar.X]=60 y,
1987 range=1-40 y range=23-74 y
Gr2: [bar.X]=6 y, Gr2: [bar.X]=61.5 y,
range= range=35-73 y
0.25-38 y
Author/Year Intervention
Goats et al, (34) Gr1: 5-kHz pulse repetition
1996 rate, spot size of 0.125
[cm.sup.2] in contact with the
skin and 8.1 J/[cm.sup.2]
applied to each aspect
of the joint, Ga-Al-As
LLLT
Hall et al, (35) Gr1: Go-Al-As LLLT in
1994 contact with the skin for
18 min, wavelength of
820 nm (cluster and
single), spot size of
0.1 [cm.sup.2]
Single-probe: pulsing
frequency of 5 kHz,
actual output of 40 mW,
irradiance of 400 mW/
[cm.sup.2], applied at the
radial, ulnar, and
ventral aspects of the
first to fifth MCP and PIP
joints of the most
affected hand,
90 s/joint (3.6 J/joint,
36 J/[cm.sup.2] for each joint)
Cluster probe: 31 diodes
(8x880 nm, 10x870
nm, 14x950 nm,
1x820 nm), total power
output of 60 mW,
applied over the dorsal
and ventral aspects of
the hand for 180 s
(minimal exposure=2.7
J/[cm.sup.2], maximal
exposure=4.5 J/[cm.sup.2])
Johannsen et al, (36) Gr1: Go-Al-As LLLT,
1994 wavelength of 830 nm,
continuous LLLT beam,
spot size of 0.07 [cm.sup.2],
effect of 21 mW, 23.2 J
applied per treatment
with 2.9 J on 4 points
(2 anterolateral and 2
posterolateral) around
each of the 2 most
painful MCP joints on
the most affected hand
Palmgren et al, (37) Gr1: LLLT, 820 nm,
1989 polarized, 15 mW,
narrow profile Go-Al-As
semiconductor LLLT
diode, continuous-wave;
diode area of 0.1256
[cm.sup.2], applied for 60 s
on each lateral side of
the second to fifth MCP
and PIP joints of the most
affected hand
Walker et al, (38) Gr1: helium-neon LLLT,
1987 632.5 nm, 1 mW, 20
Hz, maximal output of
0.95 mW at the fiber
optic tip (spot size of 4
[mm.sup.2]), actual output of
0.4776 mW, pulsed,
applied bilaterally for
20 s on each site on the
skin overlying the radial,
median, and saphenous
nerves, also applied on
the skin overlying the
painful joints (4 min total
joint exposure for the
first 4 wk, 6 min for the
next 3 wk, and 8 min for
the last 3 wk)
Concurrent
Author/Year Comparison Group Therapy
Goats et al, (34) Gr2: placebo (identical in Patient's regular
1996 external appearance medication
but having no output)
Hall et al, (35) Gr2: placebo Patient's regular
1994 medication
Johannsen et al, (36) Gr2: placebo Patient's regular
1994 medication
Palmgren et al, (37) Gr2: placebo Patient's regular
1989 medication
Walker et al, (38) Gr2: placebo N/A
1987
Frequency Follow-up Quality
Author/Year and Duration Duration (R, B, W)
Goats et al, (34) 2 times a week 3 and 6 mo 1, 2, 0
1996 for 4 wk
Hall et al, (35) 3 times a week 2 and 4 mo 1, 2, 1
1994 for 4 wk
Johannsen et al, (36) 3 times a week None 2, 2, 1
1994 for 1 mo
Palmgren et al, (37) 3 times a week None 1, 2, 1
1989 for 4 wk
Walker et al, (38) 3 times a week None 1, 2, 1
1987 for 10 wk
(a) LLLT=low-level laser therapy, R=randomization: 2 points maximum
(Jadad scale (33)), B=blinding: 2 points maximum (Jadad scale (33)),
W=withdrawals: 1 point maximum (Jadad scale (33)), RCT=randomized
controlled trial, Gr=group, RA=rheumatoid arthritis,
MCP=metacarpophalangeal, PIP=proximal interphalangeal,
Ga-Al-As=gallium-aluminum-arsenide, N/A=not available, F=female,
M=male, ARA=American Rheumatism Association.
Appendix 3.
Included Trials for Therapeutic Ultrasound (a)
Author/ Sample Symptom
Year Size Population Details Duration
Konrad, (45) RCT Inclusion criteria: Gr1: [bar.X]=4 y,
1994 50 patients with RA (onset SD=1.5 y
Gr1: 25 of disease at least 1 y Gr2: [bar.X]=5 y,
Gr2: 25 earlier, functional SD=1.75
class I or II, medium
activity of
RA-erythrocyte
sedimentation rate,
C-reactive protein)
Author/
Year Age Intervention
Konrad, (45) Gr1: [bar.X]=7.3 y, Gr1: US applied in water
1994 SD=9 y to the dorsal and
Gr2: [bar.X]=5.9 y, palmar aspects of the
SD=8.75 y hand, 0.5 W/[cm.sup.2],
continuous with circular
round head, 10 min on
alternate days for 3 wk
for a total of 10
sessions
Author/ Concurrent Frequency
Year Comparison Group Therapy and Duration
Konrad, (45) Gr2: placebo (inactive N/A 10 sessions
1994 US in water applied (3 wk)
to the palmar and
dorsal aspects of
the hand)
Author/ Follow-up Quality
Year Duration (R, B, W)
Konrad, (45) None 1, 1, 1
1994
(a) R=randomization: 2 points maximum (Jadad scale (33)), B=blinding: 2
points maximum (Jadad scale (33)), W=withdrawals: 1 point maximum
(Jadad scale (33)), RCT=randomized controlled trial, Gr=group,
RA=rheumatoid arthritis, US=ultrasound.
Appendix 4.
Included Trials for Thermotherapy (a)
Sample
Author/Year Size Population Details
Bulstrode et al, (53) RCT Inclusion criteria: patients who
1986 Total: 24 had chronic RA (<1 y) and
Gr1 : 15 clinically obvious effusion of
Gr2: 9 one or both knee joints
Dellhag et al, (54) RCT Inclusion criteria: patients had
1992 Total: 52 to reside in the city of
Grl: 13 Gothenburg, be no older
Gr2: 11 than 70 y, and have
Gr3: 15 functional class I or II
Gr4: 13 chronic RA, have hand
F: 33 problems defined as a
M: 19 decrease in ROM or grip
force
Symptom
Author/Year Duration Age Intervention
Bulstrode et al, (53) N/A N/A Gr1: ice packs
1986
Dellhag et al, (54) 6-10 y F: [bar.X]=51.8 y Gr1: wax bath
1992 M: [bar.X]=56.3 y and exercises
Gr2: exercises
only
Gr3: wax bath
only
Comparison Concurrent
Author/Year Group Therapy
Bulstrode et al, (53) Gr2: control Supervised regimen
1986 (no ice of static
packs) quadriceps
femoris muscle
exercises 3 times
daily
Dellhag et al, (54) Gr4: control None
1992 (unknown
intervention)
Frequency Follow-up Quality
Author/Year and Duration Duration (R, B, W)
Bulstrode et al, (53) Once a day for End of 1, 0, 0
1986 10 min intervention
after 5 d
Dellhag et al, (54) Five repetitions End of 1, 0, 0
1992 for the intervention
exercises after
(each session 4 wk
was 20 min)
Wax bath: both
hands dipped
5 times into
wax, wrapped
in paper, and
fitted in quilt
mittens for 20
min
Intervention 3
times a week
(a) R=randomization: 2 points maximum (Jadad scale (33)), B=blinding: 2
points maximum (Jadad scale (33)), W=withdrawals: 1 point maximum
(Jadad scale (33)), RCT=randomized controlled trial, Gr=group,
RA=rheumatoid arthritis, N/A=not available, F=female, M=male, ROM=range
of motion. The data in this table have been previously published in a
table in another article (Brosseau L, Robinson V, Pellaud L, et al.
Efficacy of thermotherapy for rheumatoid arthritis: a meta-analysis.
Physical Therapy Reviews. 2002;7:5-15) and are used here with
permission of the publisher.
Appendix 5.
Included Trials for TENS (a)
Sample
Author/Year Size Population Details
Abelson et a1, (75) RCT Inclusion criteria: patients
1983 34 with chronic RA
Gr1: 18 (according to ARA
Gr2: 16 criteria (4)) and chronic
wrist involvement
Langley et al, (76) RCT Inclusion criteria: patients
1984 22 with chronic RA
Gr1: 11 (according to ARA
Gr2: 11 criteria (4)), chronic hand
involvement, and pain
in one or both hands
Mannheimer RCT Inclusion criteria: patients
et al, (77) 1978 38 with RA (including
Gr1: 19 spontaneous pain or
Gr2: 19 pain on loading from
the wrist, the MCP
joints, and the PIP
joints)
Symptom
Author/Year Duration Age
Abelson et a1, (75) Gr1: [bar.X]=12 y, Gr1: [bar.X]=57 y,
1983 SD=8 y SD=8 y
Gr2: [bar.X]=13 y, Gr2: [bar.X]=55 y,
SD=6.75 y SD=7 y
Langley et al, (76) Gr1: [bar.X]=11.3 y, Gr1: [bar.X]=54.9 y,
1984 SD=7.5 y SD=15.3 y
Gr2: [bar.X]=10.7 y, Gr2: [bar.X]=53.4 y,
SD=10.7 SD=14.1 y
Mannheimer Range: 1-44 y Range: 20-69 y
et al, (77) 1978
Concur-
Comparison rent
Author/Year Intervention Group Therapy
Abelson et a1, (75) Gr1: one TENS Gr2: placebo N/A
1983 session a week for
3 wk
Langley et al, (76) Gr1: 20 min of high- Gr2: 20 min N/A
1984 frequency TENS of placebo
(continuous square TENS
wave pulses of
0.2 ms at 100
Hz), monophasic
pulses via 2
surface electrodes.
Electrodes were
wet pad type with
surface area of
9.08 [cm.sup.2].
Electrodes were
placed
immediately
proximal to the
patient's wrist,
with one electrode
on the volar
surface and the
other electrode on
the palmar surface.
Mannheimer Conventional HF/LF Placebo N/A
et al, (77) 1978 TENS, 5 min a controlled
day for 15 d, wrist
(dorsal and volar)
and back (either
side of the spinal
process),
0-120 V, 0.2 ms,
45-170 Hz,
electrodes had
area of 9 [cm.sup.2]
Frequency
and Follow-up Quality
Author/Year Duration Duration (R, B, W)
Abelson et a1, (75) 1 session a None 1, 1, 0
1983 week for
3 wk, 15
min per
session
Langley et al, (76) 1 session None 1, 2, 1
1984
Mannheimer 15 sessions None 1, 0, 0
et al, (77) 1978 (one daily
5-min
session)
(a) TENS=transcutaneous electrical nerve stimulation, R=randomization:
2 points maximum (Jadad scale (33)), B=blinding: 2 points maximum
(Jadad scale (33)), W=withdrawals: 1 point maximum (Jadad scale (33)),
RCT=randomired controlled trial, RA=rheumatoid arthritis, Gr=group,
N/A=not available, MCP=metacarpophalangeal, PIP=proximal
interphalangeal, HF=high frequency, LF=low frequency. The data in this
table have been previously published in a table in another article
(Brosseau L., Yonge K, Marchand S, et al. Efficacy of transcutaneous
electrical nerve stimulation (TENS) for rheumatoid arthritis: a
systematic review. Physical Therapy Reviews. 2003;7:199-208) and are
used here with permission of the publisher.
Appendix 6. Clinical Practice Guidelines Low-level Loser Therapy (LLLT) LLLT applied to the foot, knee, or hand versus a placebo, level I (RCT): grade A for pain at 3 months (clinically important benefit); grade C for function, tender joints, muscle force, and ROM at 3 and 6 months (no benefit). Patients with chronic RA. Therapeutic Ultrasound Therapeutic ultrasound performed on the hand in water versus a placebo, level I (RCT): grade A for tender joints at 10 weeks (clinically important benefit); grade C for swollen joints and morning stiffness at 10 weeks (no benefit). Patients with RA involving the hand (functional class I or II, chronic stage). Thermotherapy Cryotherapy applied to the knee joint versus a control, level I (RCT): grade C for thermographic index (measurement [in degrees Celsius] obtained using infrared thermography of the joint) at 5 days (na benefit). Patients with chronic RA, and with obvious effusion of joints. Wax applied to the hand and wrist versus a control, level I (RCT): grade C for pain, ROM, muscle force, and function at 1 month (na benefit). Patients with functional class I or II with hands affected. Wax applied to the hand or wrist and hand exercises versus a control, level I (RCT): grade A for ROM at 1 month (clinically important benefit), grade C+ for pain and stiffness at 1 month (clinical benefit), grade C for muscle force and function at 1 month (no benefit). Patients with functional class I or II with hands affected. Transcutaneous Electrical Nerve Stimulation (TENS) Low-frequency TENS applied to the hand and wrist versus no stimulation, level I (RCT): grade A for pain at 3 weeks (clinically important benefit), grade C+ for power at 3 weeks (clinical benefit), grade C for work at 3 weeks (no benefit). Patients with chronic RA. High-frequency TENS applied to the hand and wrist versus placebo, level I (RCT): grade C for pain and joint tenderness, same day (no benefit). Patients with chronic RA. High- versus low-frequency TENS applied to the hand and wrist, level I (RCT): grade C+ for global patient [(patient's assessment of overall disease activity or improvement).sup.33] at 2 weeks (clinical benefit). Patients with chronic RA.
Table 1.
Included Studies for Low-Level Laser Therapy (a)
Study
Study Design Population Outcomes
Goats et al (34) RCT RA affecting 2 Pain, function, knee
or more ROM, ankle ROM,
tibiofemoral, morning stiffness,
talocrural, rheumatoid factor
subtalar, or positive,
MCP joints; suprapatellor
mean age: swelling, and
Gr1=57 y, walking speed
Gr2=74 y
Hall et al (35) RCT RA class II or Pain, tender joints,
III; active function, MCP and
synovitis of PIP joint ROM,
some or all grip force, MCP
of the MCP and PIP joint
and PIP swelling, and
joints; mean morning stiffness
age: Gr1=67.1 duration
y, Gr2=60.9 y
Johannsen et al (36) RCT RA class I or Pain, flexibility
II; mean age: (fingertip-to-palm
Gr1=59 y, distance), morning
Gr2=62 y stiffness not
improved, and grip
force
Palmgren et al (37) RCT RA class I or Flexibility
II; mean age: (fingertip-to-palm
Gr1 males=66 distance), morning
y, Gr1 stiffness, grip
females=61.1 force, PIP joint
y, Gr2 swelling, and
males=68 y, morning stiffness
Gr2 duration
females=57.5
y
Walker et al (38) RCT RA; mean age: Pain
Gr1=61.5 y,
Gr2=60 7
(a) RCT=randomized controlled trial, RA=rheumatoid arthritis,
MCP=metacarpophalangeal, PIP=proximal interphalangeal, ROM=range
of motion, Gr1=group 1, Gr2=group 2.
Table 2.
Excluded Studies for Low-Level Laser Therapy (LLLT)
Study Reason for Exclusion
Asada et al (39) No control group
Bliddal et al (40) Subjects served as their own control--LLLT
potential systemic effect
Goldman et al (41) Subjects served as their own control--LLLT
potential systemic effect
Heussler et al (42) Subjects served as their own control--LLLT
potential systemic effect
Oyamada et al (43) The abstract did not provide enough
statistical data to be analyzed
Walker et al (44) Duplicate of Walker et al (38)
Table 3.
Included Studies for Therapeutic Ultrasound (a)
Study
Study Design Population Outcomes
Konrad (45) RCT Classical or Change in the following:
definite RA of ROM, grip force, number
both hands; pain, of painful
swelling, and articulations, number of
limitation of swollen articulations,
movement circumference of the PIP
joints, and duration of
morning stiffness
(a) RCT=randomized controlled trial, RA=rheumatoid arthritis,
PIP=proximal interphalangeal, ROM=range of motion.
Table 4.
Excluded Studies for Therapeutic Ultrasound
Study Reason for Exclusion
Berliner and Piegsa (46) Subjects without known pathology or
impairments
Bromley et al (47) Subjects without known pathology or
impairments
El-Hadidi and El-Garf (48) Measures effect of medication
Hawkes et al (49) Head-to-head study
Herrera-Lasso et al (50) No patients with rheumatoid arthritis
Kitchen and Literature review
Partridges (51)
Nykanen (52) No patients with rheumatoid arthritis
Table 5.
Included Studies for Thermotherapy (a)
Study
Study Design Population Outcomes
Bulstrode et al (53) RCT Classical or Swelling/
definite RA; inflammation and
effusion of 1 joint circumference
or both knee
joints
Dellhag et al (54) RCT RA class I and Flexion and extension
II and hand of the dominant
problems hand (ROM), grip
(decreased force, pain
ROM or grip (nonresisted motion
force); age: with both hands),
no older than and stiffness (both
70 y hands)
(a) RCT=randomized controlled trial, RA=rheumatoid arthritis, ROM-range
of motion.
Table 6.
Excluded Studies for Thermotherapy
Study Reason for Exclusion
Abramson et al (55) No clinical outcome
Amundson (56) Not a clinical trial
Bromley et al (47) Subjects without known pathology or
impairments
Curkovic et al (57) No sufficient statistical data
Devereaux et al (58) No control group
DonTigny and Sheldon (59) No subjects with rheumatoid arthritis
Feibel and Fast (60) Not a clinical trial
Haines (61) No subjects with rheumatoid arthritis;
survey to estimate the number of
hospitals that find it worthwhile to
use cold therapy
Halliday et al (62) No control group
Harris and Millard (63) No description of the statistical
procedure used, no P values, and no
standard deviations available
Hawkes et al (62) Head-to-head study
Hoyrup and Kjorvel (64) Subjects with traumas
Ivey et al (65) Head-to-head study
Kirk and Kersley (66) Head-to-head study
Mainardi et al (67) No control group; subjects served as
their own controls
Oosterveld et al (68) Subjects without known pathology or
impairments
Oosterveld and Rasker (69) Mixed population, with rheumatoid
arthritis in minority
Oosterveld and Rasker (70) Literature review
Rembe (71) Patients postsurgery
Weinberger et al (72) No clinical outcome
Whipple-Ellsworth et al (73) Subjects without known pathology or
impairments
Williams et al (74) Head-to-head study
Table 7.
Included Studies for Transcutaneous Electrical Nerve Stimulation (a)
Study
Study Design Population Outcomes
Abelson et al (75) RCT Chronic RA and Pain and muscle
chronic wrist force
involvement;
mean age:
Gr1: 57 y,
Gr2: 55 y
Langley et al (76) RCT Chronic RA with Pain, joint
hand tenderness score,
involvement and number of
and pain in 1 tender joints
or both
hands; mean
age: Gr1=54.9
y, Gr2=53.4 y
Mannheimer et al (77) RCT RA with Patient global
spontaneous (patient's
pain or pain assessment of
on resistance overall disease
from the activity or
wrist, MCP, improvement (33)):
and PIP number of patients
joints; age: improved
20-69 y
(a) RCT=randomized controlled trial, RA-rheumatoid arthritis,
MCP=metacarpophalangeal, PIP=proximal interphalangeal, Gr1=group 1,
Gr2=group 2.
Table 8.
Excluded Studies for Transcutaneous Electrical Nerve Stimulation
Study Reason for Exclusion
Angulo and Colwell (78) Majority of subjects had osteoarthritis
Bruce et al (79) Only 2 subjects per group
Herrera-Lasso et al (50) No subjects with rheumatoid arthritis
Kumar and Redford (80) Subjects served as their own control
Levy et al (81) Not rheumatoid arthritis
population--rabbit joints
Moystad et al (82) Data could not be used
Table 9.
Low-Level Laser Therapy (LLLT) Versus Placebo: Pain at 10 Weeks
Intervention No. of
Study Group Outcome Subjects
Goats et al (34) LLLT Pain 10-cm VAS 25
Placebo Pain 10-cm VAS 10
Hall et al (35) LLLT Pain on activity 20
10-cm VAS
Placebo Pain on activity 20
10-cm VAS
Walker et al (38) LLLT Pain 10-cm VAS 34
Placebo Pain 10-cm VAS 38
Johannsen et al (36) LLLT Pain: 0-12 scale 10
Placebo Pain: 0-12 scale 12
End-of-
Intervention Baseline Study Absolute
Study Group Mean Mean Benefit
Goats et al (34) LLLT 5.52 5.16 -1.47
Placebo 4.83 5.94
Hall et al (35) LLLT 5.20 4.00 -1.20
Placebo 4.30 4.30
Walker et al (38) LLLT 4.58 3.67 -0.91
Placebo 5.21 5.21
Johannsen et al (36) LLLT 7.00 4.50 -1.50
Placebo 6.50 5.50
Relative
Difference
in Change
Intervention From
Study Group Baseline
Goats et al (34) LLLT -28%
Placebo
Hall et al (35) LLLT -25%
Placebo
Walker et al (38) LLLT -19%
Placebo
Johannsen et al (36) LLLT -22%
Placebo
(a) VAS=visual analog scale.
Table 10.
Low-Level Laser Therapy (LLLT) Versus Placebo: Fingertip-to-Palm
Distance
Intervention No. of
Study Group Outcome Subjects
Johannsen et al (36) LLLT Fingertip-to-palm 10
distance (cm)
Placebo Fingertip-to-palm 12
distance (cm)
Palmgren et al (37) LLLT Finger pulp-to-palm 19
distance (mm)
Placebo Finger pulp-to-palm 16
distance (mm)
Intervention Baseline End-of-Study
Study Group Mean Mean
Johannsen et al (36) LLLT 0.25 0
Placebo 1 1.25
Palmgren et al (37) LLLT 7 0
Placebo 5 6
Relative
Difference
in Change
Intervention Absolute from
Study Group Benefit Baseline
Johannsen et al (36) LLLT -0.5 -76%
Placebo
Palmgren et al (37) LLLT -8.0 -142%
Placebo
Table 11.
Low-Level Laser Therapy (LLLT) Versus Placebo: Grip Force
Intervention No. of
Study Group Outcome Subjects
Palmgren et al (37) LLLT Grip force (kPa) at 19
10 wk
Placebo Grip force (kPa) at 16
10 wk
Hall et al (35) LLLT Grip force (mm Hg) 20
at 10 wk
Placebo Grip force (mm Hg) 20
at 10 wk
Johannsen et al (36) LLLT Grip force (kg) at 10
10 wk
Placebo Grip force (kgl at 12
10 wk
Intervention Baseline End-of-Study
Study Group Mean Mean
Palmgren et al (37) LLLT 2.5 3.3
Placebo 2.1 1.8
Hall et al (35) LLLT 80 86
Placebo 95 105
Johannsen et al (36) LLLT 6.2 7
Placebo 5.3 6.5
Relative
Difference
in Change
Intervention Absolute From
Study Group Benefit Baseline
Palmgren et al (37) LLLT 1.1 47%
Placebo
Hall et al (35) LLLT -4.0 -7% (favors
placebo)
Placebo
Johannsen et al (36) LLLT -0.4 -7% (favors
placebo)
Placebo
Table 12.
Ultrasound Versus Placebo: Grip Force, Range of Motion (ROM],
Swollen Joints, Tender Joints, and Morning Stiffness at 10 Weeks
Intervention No. of
Study Group Outcome Subjects
Konrad (45) Ultrasound Painful articulations 25
(tender joints)
Placebo Painful articulations 25
(tender joints)
Konrad (45) Ultrasound Swollen articulations 25
(swollen joints)
Placebo Swollen articulations 25
(swollen joints)
Konrad (45) Ultrasound Morning stiffness 25
(min)
Placebo Morning stiffness 25
(min)
Konrad (45) Ultrasound Dorsal flexion of wrist 25
(ROM in degrees)
Placebo Dorsal flexion of wrist 25
(ROM in degrees)
Konrad (45) Ultrasound Grip force 25
Placebo Grip force 25
Intervention Baseline End-of-Study
Study Group Mean Mean
Konrad (45) Ultrasound 6.2 4.8
Placebo 6.2 6.0
Konrad (45) Ultrasound 6.12 4.84
Placebo 6.12 5.86
Konrad (45) Ultrasound 69.6 31.4
Placebo 69.6 59.94
Konrad (45) Ultrasound Not available Not available
Placebo Not available Not available
Konrad (45) Ultrasound Not available Not available
Placebo Not available Not available
Relative
Difference
in Change
Intervention Absolute From
Study Group Benefit Baseline
Konrad (45) Ultrasound -1.20 -9%
Placebo
Konrad (45) Ultrasound -1.02 -3%
Placebo
Konrad (45) Ultrasound 28.54 -41
Placebo
Konrad (45) Ultrasound 1.90
Placebo
Konrad (45) Ultrasound 28.07
Placebo
Table 13.
Ice Packs Versus Control at 5 Days
Intervention No. of
Study Group Outcome Subjects
Bulstrode et al (53) Ice packs Thermographic index 15
Control Thermographic index 9
Relative
Difference
in Change
Baseline End-of-Study Absolute From
Study Mean Mean Benefit Baseline
Bulstrode et al (53) 5.0 4.6 -0.3 -6%
5.3 5.2
Table 14.
Wax Only Versus Control at 1 Month: Range of Motion (ROM), Grip,
Pain, Stiffness (a)
Intervention No. of
Study Group Outcome Subjects
Dellhag et al (54) E: Wax only ROM: flexion in dominant 15
hand (in millimeters)
C: Untreated ROM: flexion in dominant 13
hand (in millimeters)
Dellhag et al (54) E: Wax only Grip function test: 15
0-80 points
C: Untreated Grip function test: 13
0-80 points
Dellhag et al (54) E: Wax only Pinch function test: 15
0-32 points
C: Untreated Pinch function test: 13
0-32 points
Dellhag et al (54) E: Wax only Grip force (in newtons) 15
(average of dominant
hand)
C: Untreated Grip force (in newtons] 13
(average of dominant
hand)
Dellhag et al (54) E: Wax only Pain on nonresisted 15
motion: both hands,
0-100-mm VAS
C: Untreated Pain on nonresisted 13
motion: both hands,
0-100-mm VAS
Dellhag et al (54) E: Wax only Stiffness: both hands, 15
0-100-mm VAS
C: Untreated Stiffness: both hands, 13
0-100-mm VAS
Intervention Baseline End-of-Study
Study Group Mean Mean
Dellhag et al (54) E: Wax only 43.0 42.9
C: Untreated 59.4 62.0
Dellhag et al (54) E: Wax only 75.5 75.0
C: Untreated 75.2 75.0
Dellhag et al (54) E: Wax only 29.3 28.3
C: Untreated 29.5 29.2
Dellhag et al (54) E: Wax only 72.9 75.9
C: Untreated 82.6 85.4
Dellhag et al (54) E: Wax only 20.3 25.9
C: Untreated 27.7 33.1
Dellhag et al (54) E: Wax only 23.7 27.0
C: Untreated 36.0 30.2
Relative Difference
Intervention Absolute in Change From
Study Group Benefit Baseline
Dellhag et al (54) E: Wax only -2.7 -5%
C: Untreated
Dellhag et al (54) E: Wax only -0.3 -1%
C: Untreated
Dellhag et al (54) E: Wax only -0.7 -2%
C: Untreated
Dellhag et al (54) E: Wax only 0.2 0%
C: Untreated
Dellhag et al (54) E: Wax only 0.2 1%
C: Untreated
Dellhag et al (54) E: Wax only 9.1 31% (favors control)
C: Untreated
(a) E=experimental group, C=control group, VAS-visual analog scale.
Table 15.
Wax and Exercise Versus Control at 1 Month: Range of Motion (ROM),
Grip, Pain, Stiffness (a)
Intervention No. of
Study Group Outcome Subjects
Dellhag et al (54) E: Wax and exercise ROM: flexion 13
in dominant
hand (in
millimeters)
C: Untreated ROM: flexion 13
in dominant
hand (in
millimeters)
Dellhag et al (54) E: Wax and exercise Grip function 13
test: 0-80
points
C: Untreated Grip function 13
test: 0-80
points
Dellhag et al (54) E: Wax and exercise Pinch function 13
test: 0-32
points
C: Untreated Pinch function 13
test: 0-32
points
Dellhag et al (54) E: Wax and exercise Grip force 13
(in newtons)
(average of
dominant hand)
C: Untreated Grip force 13
(in newtons)
(average of
dominant hand)
Dellhag et al (54) E: Wax and exercise Pain on 13
nonresisted
motion: both
hands,
0-100-mm VAS
C: Untreated Pain on 13
nonresisted
motion: both
hands,
0-100-mm VAS
Dellhag et al (54) E: Wax and exercise Pain on 13
nonresisted
motion: both
hands,
0-100-mm VAS
C: Untreated Pain on 13
nonresisted
motion: both
hands,
0-100-mm VAS
End-of-
Intervention Baseline Study
Study Group Mean Mean
Dellhag et al (54) E: Wax and exercise 62.3 52.1
C: Untreated 59.4 62.0
Dellhag et al (54) E: Wax and exercise 72.3 74.8
C: Untreated 75.2 75.0
Dellhag et al (54) E: Wax and exercise 27.4 29.3
C: Untreated 29.5 29.2
Dellhag et al (54) E: Wax and exercise 72.4 79.2
C: Untreated 82.6 85.4
Dellhag et al (54) E: Wax and exercise 29.3 22.1
C: Untreated 27.7 33.1
Dellhag et al (54) E: Wax and exercise 39.3 24.9
C: Untreated 36 30.2
Relative
Diffe-
rence in
Change
Intervention Absolute From
Study Group Benefit Baseline
Dellhag et al (54) E: Wax and exercise -12.8 -21%
C: Untreated
Dellhag et al (54) E: Wax and exercise 2.7 5%
C: Untreated
Dellhag et al (54) E: Wax and exercise 2.2 8%
C: Untreated
Dellhag et al (54) E: Wax and exercise 4 5%
C: Untreated
Dellhag et al (54) E: Wax and exercise -12.6 -44%
C: Untreated
Dellhag et al (54) E: Wax and exercise -8.6 -23%
C: Untreated
(a) E=experimental group, C=control group, VAS-visual analog scale.
Table 16.
Transcutaneous Electrical Nerve Stimulation (TENS) Versus
Control (No TENS): Pain at 3 Weeks (a)
Intervention No. of
Study Group Outcome Subjects
Abelson et al (75) TENS Pain VAS 100 mm 18
Placebo Pain VAS 100 mm 16
Intervention Baseline End-of-Study
Study Group Mean Mean
Abelson et al (75) TENS 60.5 18.5
Placebo 75.0 78.0
Relative
Difference
in Change
Intervention Absolute From
Study Group Benefit Baseline
Abelson et al (75) TENS -45 -67%
Placebo
(a) VAS=visual analog scale.
Table 17.
Transcutaneous Electrical Nerve Stimulation (TENS) Versus
Control (No TENS): Power and Work Scores
Intervention No. of
Study Group Outcome Subjects
Abelson et al (75) TENS Power (in watts) 18
for hand muscles
(not precise)
at 3 wk
Placebo Power (in watts) 16
for hand muscles
(not precise)
at 3 wk
Abelson et a1 (75) TENS Work score 18
(in joules) for
hand muscles
(not precise)
at 3 wk
Placebo Work score 16
(in joules) for
hand muscles
(not precise)
at 3 wk
Intervention Baseline End-of-Study
Study Group Mean Mean
Abelson et al (75) TENS 1.64 2.38
Placebo 1.91 1.67
Abelson et al (75) TENS 0.82 0.96
Placebo 0.69 0.67
Relative
Difference
in Change
Intervention Absolute From
Study Group Benefit Baseline
Abelson et al (75) TENS 0.98 55
Placebo
Abelson et al (75) TENS 0.16 5%
Placebo
Table 18.
High-Frequency Transcutaneous Electrical Nerve Stimulation (TENS)
Versus Placebo (No TENS): Joint Tenderness
Intervention No. of
Study Group Outcome Subjects
Langley et al (76) High-frequency TENS Joint tenderness 11
scale
(0-22) (a)
Placebo Joint tenderness 11
scale (0-22) (a)
Intervention Baseline End-of-Study
Study Group Mean Mean
Langley et al (76) High-frequency TENS 28 15
Placebo 48 35
Relative
Difference
in Change
Intervention Absolute From
Study Group Benefit Baseline
Langley et al (76) High-frequency TENS 0 0%
Placebo
(a) The scale from 0 to 22 is not consistent with baseline
and final scores >22.
Table 19.
High-Frequency Versus Low-Frequency Transcutaneous Electrical Nerve
Stimulation (TENS): Patient Global (Patient's Assessment of Overall
Disease Activity or Improvement (33) at 2 Weeks
No. of
Subjects
Author Group (a) Outcome Improved
Mannheimer et al (77) E: High-frequency TENS Patient 18
global;
number of
subjects
improved
C: Low frequency TENS Patient 14
global;
number of
subjects
improved
Total Risk
Author Group (a) N Occurrence
Mannheimer et al (77) E: High-frequency TENS 19 95
C: Low frequency TENS 19 74%
Risk
Author Group (a) Difference
Mannheimer et al (77) E: High-frequency TENS 21%
C: Low frequency TENS
(a) E=experimental group, C = control group.
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The region of the cerebral cortex influencing movements of the face, neck and trunk, and arm and leg. Also called excitable area, motor area, Rolando's area. induced by peripheral nerve stimulation in human subjects. Exp Brain Res. 2000;131:135-143. (107) Willer JC. Relieving effect of TENS on painful muscle contraction Noun 1. muscle contraction - (physiology) a shortening or tensing of a part or organ (especially of a muscle or muscle fiber) contraction, muscular contraction shortening - act of decreasing in length; "the dress needs shortening" produced by an impairment of reciprocal innervation René Descartes (1596-1650) was one of the first to conceive a model of reciprocal innervation (in 1626) as the principle that provides for the control of agonist and antagonist muscles. : an electrophysiological analysis. Pain. 1988;32:271-274. (108) Levin lev·in n. Archaic Lightning. [Middle English levene, levin; see leuk- in Indo-European roots.] MF, Hui-Chan CWY CWY Canada World Youth (International Youth Corps) CWY Clearway (aviation) . Conventional and acupuncture-like transcutaneous electrical nerve stimulation excites similar afferent fibers. Arch Phys Med Rehabil. 1993;74:54-60. (109) Cheng R, Pomeranz B. Electroacupuncture analgesia could be mediated me·di·ate v. me·di·at·ed, me·di·at·ing, me·di·ates v.tr. 1. To resolve or settle (differences) by working with all the conflicting parties: by at least two pain-relieving mechanisms: endorphin and non-endorphin systems. Brain. 1980;103:1957-1962. (110) Sjolund BH. Peripheral nerve stimulation suppression suppression /sup·pres·sion/ (su-presh´un) 1. the act of holding back or checking. 2. sudden stoppage of a secretion, excretion, or normal discharge. 3. of C-fiber-evoked flexion reflex in rats, part 1: parameters of continuous stimulation. J Neurosurg. 1985;63:612-616. (111) Gopalkrishnan P, Sluka KA. 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Blockades may be used to prevent shipping from reaching enemy ports, or they may serve purposes of coercion. The term is rarely applied to land sieges. of opioid receptors prevents the analgesia produced by TENS in arthritic rats. J Pharmacol Exp Ther. 1999;289:840-846. (113) Sluka KA, Judge MA, McColley MM, et al. Low-frequency TENS is less effective than high-frequency TENS at reducing inflammation-induced hyperalgesia in morphine-tolerant rats. Eur J Pain. 2000;4:185-193. (114) Lundeberg T. Long-term results of vibratory vibratory /vi·bra·to·ry/ (vi´brah-tor?e) vibrating or causing vibration. vibratory vibrating or causing vibration; vibritile. stimulation as pain relieving for chronic pain. Pain. 1984;20:13-23. (115) Guieu R, Tardy-Gervet MF, Roll JP. Analgesic effects of vibration and transcutaneous electrical nerve stimulation applied separately and simultaneously to patients with chronic pain. Can J Neurol Sci. 1991 ;18: 113-119. 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Ottawa Panel Members: Ottawa Methods Group: Lucie Brosseau, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada George A Wells, PhD, Department of Epidemiology and Community Medicine, University of Ottawa Peter Tugwell, MD, MSc, Centre for Global Health, Institute of Population Health, Ottawa, Ontario, Canada Mary Egan, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa Claire-Jehanne Dubouloz, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa Lynn Casimiro, MA, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa Vivian A Robinson, MSc, Centre for Global Health, Institute of Population Health Lucie Pelland, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa Jessie McGowan, MLIS MLIS Master of Library and Information Science MLIS Multilingual Information Society MLIS Molecular Laser Isotope Separation MLIS Masters of Library and Information Studies MLIS Medical/Legal Information Services , Director, Medical Library Centre for Global Health, Institute of Population Health External Experts: Mary Bell
Mary Flora Bell (born on May 26 1957 in Newcastle upon Tyne, England) was convicted in December 1968 of the murders of two boys, Martin Brown (four years old) and Brian Howe , MD (Rheumatologist rheumatologist /rheu·ma·tol·o·gist/ (roo?mah-tol´ah-jist) a specialist in rheumatology. rheu·ma·tol·o·gist n. A specialist in the diagnosis and treatment of rheumatic disorders. ), Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada Hillel M Finestone, MD (Physiatrist), Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, Canada France Legare, MD (Evidence-Based Practice in Family Medicine), University of Laval, Quebec Laval (pronounced  ) is a city and a region in southwestern Quebec, Canada in the Greater Montreal Area. It is located on Île Jésus, across the Rivière des Prairies from Montreal. City, Quebec, CanadaCatherine Caron, MD (Family Physician), Sisters of Charity of Ottawa Health Service Sydney Lineker, PT, MSc, The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto, Ontario, Canada Angela Haines-Wangda, PT, MSc, Ottawa Hospital, General Campus, Ottawa, Ontario, Canada Marion Russell-Doreleyers, PT who practices acupuncture acupuncture (ăk`y  pŭng'chər), technique of traditional Chinese medicine, in which a number of very fine metal needles are inserted into the skin at specially designated points. , MSC,
Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation
and Education Program, Ottawa, Ontario, CanadaMartha Hall, OT, MPA MPA medroxyprogesterone acetate. , Canadian Association of Occupational Therapists and Ottawa Arthritis Rehabilitation and Education Program Paddy Cedar cedar, common name for a number of trees, mostly coniferous evergreens. The true cedars belong to the small genus Cedrus of the family Pinaceae (pine family). , patient with rheumatoid arthritis (named with her written permission) Assistant Manuscript Writer: Marnie Lamb, MA, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa APTA APTA American Physical Therapy Association. is a sponsor of the Decade, an international, multidisciplinary mul·ti·dis·ci·pli·nar·y adj. Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. initiative to improve health-related quality of life for people with musculoskeletal disorders. Address all correspondence and requests for reprints to: Lucie Brosseau, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, 451 Smyth Rd, University of Ottawa, Ottawa, Ontario, Canada K1H 8MS(lbrossea@uottawama). This study was financially supported by The Arthritis Society (Canada); the Ontario Ministry of Health and Long-Term Care long-term care (LTC), n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. (Canada); the Career Scientist Salary Support Program, University of Ottawa for Dr Brosseau; the University Research Chair Program for Dr Brosseau; and the Ministry of Human Resources The fancy word for "people." The human resources department within an organization, years ago known as the "personnel department," manages the administrative aspects of the employees. , Summer Students Program (Canada). Acknowledgments: The Ottawa Panel is indebted in·debt·ed adj. Morally, socially, or legally obligated to another; beholden. [Middle English endetted, from Old French endette, past participle of endetter, to oblige to Ms Catherine Lamothe, Ms Shannon Rees, Mr Shaun Cleaver, Ms Lucie Lavigne, Mr Guillaume Leonard, Ms Marie-Andree Ouimet, Mr Martin Campbell, Ms Isabelle Blais Isabelle Blais is a Canadian actress. Born in 1975 in Trois-Rivières, Quebec, she is a graduate of the Montreal Conservatory of Dramatic Arts. She quickly charmed critics by her stage interpretation of Juliette in Romeo and Juliette, and in 2001, won their attention for her role in , Ms Simon Barsoum, Ms Judith Robitaille, and Ms Karin Phillips for their technical support and help in data extraction Data extraction is the act or process of retrieving (binary) data out of (usually unstructured or badly structured) data sources for further data processing or data storage (data migration). . |
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