This is the current release of the guideline.

Rheumatoid arthritis

Management
Rehabilitation
Treatment

Family Practice
Internal Medicine
Orthopedic Surgery
Physical Medicine and Rehabilitation
Rheumatology

Advanced Practice Nurses
Allied Health Personnel
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians

To promote appropriate use of electrotherapy and thermotherapy in the management of rheumatoid arthritis (RA)

Adult patients (18 years of age) with a diagnosis of rheumatoid arthritis (RA) according to the 1987 American Rheumatism Association (ARA) criteria.

A patient was said to have RA if he or she satisfied at least 4 of the following 7 ARA criteria:

• Morning stiffness
• Arthritis of 3 or more joints
• Arthritis of the hand joints
• Symmetric arthritis
• Rheumatoid nodules
• Serum rheumatoid factor
• Radiologic changes

Electrotherapy and Thermotherapy

1. Low-level laser therapy (LLLT)
2. Therapeutic ultrasound
   • Pulsed
   • Continuous
3. Thermotherapy
   • Paraffin baths
   • Cryotherapy
4. Transcutaneous electrical nerve stimulation (TENS)
   • High frequency
   • Low frequency
   • Acupuncture-like

Interventions Considered But Not Recommended

• Electrical stimulation of muscle
• Exercise

Organ Systems and Impairment

• Number of inflamed joints
• Number of acute phase reactants (e.g., erythrocyte sedimentation rate)
• Radiological damage
• Side effects

Abilities and Disabilities

• Pain reduction
• Muscle force
• Range of motion (ROM)
• Postural status
• Duration of morning stiffness

Life Habits and Handicap Situation

• Global physician assessment
• Global patient assessment
• Gait status
• Walking speed
• Walking distance
• Cadence
• Stride length
• Functional status
• Patient adherence
• Patient satisfaction
• Length of stay
• Discharge disposition
• Quality of life
• Return to work

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

The library scientist developed a structured literature search based on the sensitive search strategy for randomized controlled trials (RCTs)-a strategy recommended by The Cochrane Collaboration with modifications to that strategy. The Cochrane Collaboration method minimizes bias through a systematic approach to the literature search, study selection, and data extraction and synthesis. The search was organized around the condition and interventions rather than the outcomes because it was an a priori search. Thus, there was no control over the outcomes the authors decided to measure.

The library scientist expanded the search strategy to identify case-control, cohort, and nonrandomized studies and conducted the search in the electronic databases of MEDLINE, EMBASE, Current Contents, the Cumulative Index to Nursing and Allied Health (CINAHL), and the Cochrane Controlled Trials Register up to December 2002. Also searched were the registries of the Cochrane Field of Rehabilitation and Related Therapies, the Cochrane Musculoskeletal Group, the Physiotherapy Evidence Database (PEDro), and the University of Ottawa Evidence-Based Clinical Practice Guidelines (EBCPGs) Web site. Finally, reference lists of all of the included trials were searched for relevant studies and content experts were contacted for additional studies.

In the first round of study inclusion or exclusion, 2 independent reviewers, trained and experienced occupational therapist or physical therapist students, appraised the titles and abstracts of the literature search using a checklist with the a priori–defined selection criteria. More junior students were paired with fourth-year occupational therapist or physical therapist students who were experienced with the Philadelphia Panel methodology. Each pair of reviewers was assigned to a specific intervention. Within each pair of reviewers, individuals independently read the title and abstract of each article and created an individual list of all of the articles of the database with a reason for including or excluding each article. If the reviewers were uncertain about a particular article after having read the abstract, they ordered the article and read it in full before making a determination. Before deciding whether to include or exclude the article, a comparison of their individual lists was performed. A senior reviewer who is a methodologist and a clinical expert in arthritis checked the 2 independent lists of articles and the reason for inclusion or exclusion to determine potential inconsistencies. Eleven percent of the abstracts reviewed needed the consultation of the senior reviewer. For the second round of inclusion and exclusion, the pairs of reviewers retrieved articles selected for inclusion from the first round and independently assessed the full articles for inclusion or exclusion in the study.

Study Inclusion/Exclusion Criteria

The inclusion/exclusion criteria were based on previous criteria used by the Philadelphia Panel. This list of criteria, which had been created for multiple diagnoses, including back and neck pain, was adapted and approved by the Ottawa Methods Group (OMG) for use with rheumatoid arthritis (RA).

All original comparative controlled studies that evaluated the specific intervention in a sample of patients with RA were included: RCTs, controlled clinical trials (CCTs), cohort studies, and case-control studies. (Controlled clinical trials are the same as RCTs except that, according to the Jadad scale, CCTs are either not randomized or poorly randomized.) Crossover studies were included, and, to avoid potential confounders, the data from only the first part of the study (before crossing) were analyzed. (Data from the first part are more specific than data from the second part because once the study patients change from the intervention group to the placebo group, the outcome could be due to either the intervention or the placebo. Thus, such results are not useful for measuring the special effect of each intervention.)

Uncontrolled cohort studies (studies with no comparison group) and case series were excluded, as were eligible studies with greater than 20% dropout rates or a sample size of less than 5 patients per group. Abstracts were excluded because none of the abstracts found had sufficient data for analysis and the full studies of the abstracts could not be obtained from the authors. Trials published in languages other than French and English were not analyzed because of the time and cost involved in translation. Head-to-head studies (that is, the comparison of 2 active interventions, such as therapeutic exercises versus transcutaneous electrical nerve stimulation) were generally excluded in these recommendations.

For low-level laser therapy (LLLT), 11 articles were initially considered relevant and 5 randomized controlled trials (RCTs) involving 204 patients with rheumatoid arthritis were ultimately included.

For therapeutic ultrasound, 8 studies were initially included and 1 RCT involving 50 patients was ultimately included.

For thermotherapy, 23 trials were initially included and 2 RCTs involving 76 patients were ultimately included.

For transcutaneous electrical nerve stimulation (TENS), 9 articles were initially included and 3 RCTs involving 78 patients were ultimately included.

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

The methodological quality of the trials was assessed using the Jadad scale, a 5-point scale with reported reliability and validity that assigns 2 points each for randomization and double blinding and 1 point for description of withdrawals.

Meta-Analysis
Systematic Review with Evidence Tables

Expert Consensus

The development process of these evidence-based practice guidelines (EBCPGs) was similar to that of the Philadelphia Panel, except that a different target population was used. Briefly, the Ottawa Methods Group (OMG), a group of 9 methodologists with experience in developing EBCPGs, asked professional associations interested in the care of people with rheumatoid arthritis (RA) for suggestions of individuals with both clinical expertise in the management of the disease and familiarity with EBCPGs. From among the suggestions given, the OMG chose 9 experts to serve as panel members. These experts in RA were a rheumatologist, a physiatrist, a physician with experience in evidence-based medicine, a family physician, 3 physical therapists (including one who practiced acupuncture and one involved in clinical research), an occupational therapist, and a patient with RA. The Ottawa Panel consisted of these 9 experts and all members of the OMG.

One OMG member assembled a research and support staff with expertise in meta-analyses, rheumatology rehabilitation interventions, research methods, or the development and assessment of EBCPGs. The OMG then established a priori a set of inclusion criteria for the study designs, subject samples, interventions, and outcomes to allow the research staff to select the most relevant material as evidence of the effectiveness of therapeutic exercise and manual therapy. The OMG also reviewed the inclusion criteria to ensure that the approach to the study selection was reproducible and systematic. This a priori protocol guided separate systematic reviews of the literature for each intervention. The research staff reviewed articles and created evidence tables for them, which the 9 clinical experts received in preparation for their meeting with the OMG. These tables were used as the basis for making the recommendations.

The recommendations were graded by their level (I for randomized controlled trials [RCTs], II for nonrandomized studies) and strength (A, B, C+, C, or D) of evidence.

Grade A: Evidence from one or more RCTs of a statistically significant, clinically important benefit (>15%)

Grade B: Statistically significant, clinically important benefit (>15%) if the evidence was from observational studies or controlled clinical trials (CCTs)

Grade C+: Evidence of clinical importance (>15%) but not statistical significance

Grade C: An appropriate outcome was measured in a study that met the inclusion criteria but no clinically important difference and no statistical significance were shown

Grade D: Evidence from one or more RCTs of a statistically significant benefit favoring the control group (<0%: favors controls)

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review

Each recommendation is followed by recommendation grades (Level I or II and A, B, C+, C and D). Definitions of the recommendation grades are presented at the end of the "Major Recommendations" field.

Low-level Laser Therapy (LLLT)

LLLT applied to the foot, knee, or hand versus a placebo, level I (randomized controlled trial [RCT]): Grade A for pain at 3 months (clinically important benefit); grade C for function, tender joints, muscle force, and range of motion (ROM) at 3 and 6 months (no benefit). Patients with chronic rheumatoid arthritis (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 (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.

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) (Ottawa Panel, 2004) at 2 weeks (clinical benefit). Patients with chronic RA.

Definitions:

The recommendations were graded by their level (I for RCTs, II for nonrandomized studies) and strength (A, B, C+, C, or D) of evidence.

Grade A: Evidence from one or more RCTs of a statistically significant, clinically important benefit (>15%)

Grade B: Statistically significant, clinically important benefit (>15%) if the evidence was from observational studies or CCTs

Grade C+: Evidence of clinical importance (>15%) but not statistical significance

Grade C: Appropriate outcome was measured in a study that met the inclusion criteria but no clinically important difference and no statistical significance were shown

Grade D: Evidence from one or more RCTs of a statistically significant benefit favoring the control group (<0%: favors controls.)

None provided

The type of evidence is identified and graded for each recommendation (see "Major Recommendations")

Appropriate use of electrotherapy and thermotherapy for the treatment and rehabilitation of adults with rheumatoid arthritis

None stated

The Evidence-Based Clinical Practice Guidelines (EBCPGs) developed by the Ottawa Panel have some potential limitations due to methodological weaknesses. Although the included trials were selected based on well-established inclusion and exclusion criteria, selection was performed by occupational therapist and physical therapist students. Potential omission of studies due to reviewer inexperience could have led to selection bias. Consultation with a third reviewer and the use of the panel of senior clinical experts may have compensated in part for this potential methodological flaw. The EBCPGs also are limited by the inclusion and exclusion criteria for the included studies. For example, some reports of randomized controlled trials (RCTs) did not specify if the study sample included individuals in acute or chronic stages of rheumatoid arthritis (RA). Additionally, some studies lacked details about the specific characteristics of the exercise intervention such as intensity. This lack of specificity could be problematic for future clinical implementation of the guidelines, especially for the whole-body functional strengthening recommendation.

The Ottawa Panel is planning to implement these guidelines in the Arthritis Rehabilitation and Education Program of The Arthritis Society of Ontario.

Living with Illness

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2004 Nov

Ottawa Panel - Independent Expert Panel

This study was financially supported by an unrestricted educational grant from the Cigna Foundation, Philadelphia, PA USA.

Ottawa Panel

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, Director, Medical Library, Centre for Global Health, Institute of Population Health

External Experts: Mary Bell, MD (Rheumatologist), 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 Légaré, MD (Evidence-Based Practice in Family Medicine), University of Laval, Québec City, Québec, Canada; Catherine 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, MSc, Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation and Education Program, Ottawa, Ontario, Canada; Martha Hall, OT, MPA, Canadian Association of Occupational Therapists and Ottawa Arthritis Rehabilitation and Education Program; Paddy Cedar, patient with rheumatoid arthritis (named with her written permission)

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on March 10, 2005. The information was verified by the guideline developer on April 9, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.