Open Collections

UBC Graduate Research

The Effectiveness of Comprehensive Physiotherapy in the Treatment of Adults with Rheumatoid Arthritis:.. Batada, Shazeen; Elfring, Nicole; Gris, Mel; Martin, Mikayla; Webb, Julia 2008-08-21

You don't seem to have a PDF reader installed, try download the pdf

Item Metadata


07.pdf [ 717.79kB ]
sound file - Final.mp3 [ 47.85MB ]
JSON: 1.0081218.json
JSON-LD: 1.0081218+ld.json
RDF/XML (Pretty): 1.0081218.xml
RDF/JSON: 1.0081218+rdf.json
Turtle: 1.0081218+rdf-turtle.txt
N-Triples: 1.0081218+rdf-ntriples.txt
Original Record: 1.0081218 +original-record.json
Full Text

Full Text

The Effectiveness of Comprehensive Physiotherapy in the Treatment of Adults with Rheumatoid Arthritis: A Systematic ReviewShazeen BatadaNicole ElfringMel GrisMikayla MartinJulia WebbOutline?BACKGROUND?METHODS?RESULTS?DISCUSSION?IMPLICATIONS FOR RESEARCH?CONCLUSION?IMPLICATIONS FOR PRACTICEBACKGROUNDRheumatoid Arthritis?Definition:?Chronic inflammatory autoimmune disease that affects synovial joints and other organs1?Characterized by:?Joint inflammation, joint damage, pain,               stiffness, decreased muscle strength                        and ROM, difficulties with ADLs2Rheumatoid Arthritis?Epidemiology:?affects ~ 1-2% of the population3?women 2-3 x?s more affected than men3-4?Disease implications:?Body structure/function ?activity and participation5What do we know??Previous systematic reviews evaluating the efficacy of single physiotherapy interventions6-16?Physiotherapy improves outcomes for individuals with RA11-18?Multidisciplinary care is optimal19?Number of alternative methods of care are emerging19Comprehensive Physiotherapy?Combination of therapeutic interventions delivered by a PT based on client?s needs20?Various levels of rheumatology trainingWhy do this review??No systematic review on comprehensive physiotherapy and managing RA?The most effective and efficient method of physiotherapy delivery has yet to be determined21?Evidence based practiceObjectiveTo evaluate the effectiveness of comprehensive physiotherapy for adults with RA compared to waitlist control or a single non-pharmacological interventionMETHODSSearch Strategy?Electronic search:?EMBASE       ?Medline        ?CINAHL?PEDro?Cochrane?DARE?Proquest?Hand search:?Arthritis Care and Research (1998-2008)?Reference lists of included studiesSelection Protocol ?Stage 1?2 reviewers independently screened titles and abstracts?Selection criteria:1.Kept if ?rheumatoid arthritis?present & ?physical therapy or physiotherapy?or ?rehabilitation?2. Excluded if ?osteoarthritis, juvenile arthritis, or ankylosing spondylitis?present without ?rheumatoid arthritis?3. Kept if title or abstract ambiguous4. Kept if article available in EnglishSelection Protocol ?Stage 2?Full text articles divided among reviewers?2 reviewers independently examined each article for inclusion criteriaPDiagnosis of RA and ?16 years of ageIComprehensive PT (?2 types of PT tx)CWaitlist or medical treatment control or single non-pharmacological interventionOOutcomes fit into at least one category of the ICFSelection Protocol ?Stage 3?Common trends emerged?2 subgroups created?Post entry-levelrheumatology trained physiotherapy (PERPT)?Entry-level rheumatology trained physiotherapy (ERPT)Methodological Quality?2 reviewers independently scored each article using PEDro scale?PEDro designed to assess RCTs for PT interventions22?High quality = >50% of criteria met22-23?6/10 a prioriData Extraction?Data extraction form made for review?Pilot tested 3x to achieve inter-rater reliability?2 reviewers independently extracted data?Disagreements resolved                                         by discussionOutcomes?Primary Outcomes?Pain?Functional Ability?Health Related Quality of Life (HRQoL)?Disease Knowledge?Self-efficacy??REASON: Important tx goals ID by ppl with arthritis24?Secondary Outcomes?Any other outcome measures utilized in included studies??REASON: Multiple variables measured in tx of RAOutcomes & ICF?ICF used to classify outcome measures ?Inclusive nature?Globally agreed upon frameworkPainBody Structure & FunctionFunctional AbilityActivity & ParticipationHRQoLActivity & ParticipationDisease KnowledgeContextual FactorsSelf EfficacyContextual FactorsData Analysis?Comparison groups:1. PERPTvs. ERPT or wait-list control2. ERPTvs. single non-pharmacological intervention or wait-list control?Heterogeneity = no meta-analysis?Effect Sizes (Hedge?s g)reported as SMD & 95% CIBest Evidence Synthesis (BES)Strong EvidenceStatistically significant findings in outcome measures in ?2 high quality RCTs Moderate EvidenceStatistically significant findings in outcome measures in ?1 high quality RCT & ?1 low quality RCT Limited EvidenceStatistically significant findings in outcome measures in?1 high quality RCT Indicative FindingsStatistically significant findings in outcome measures in ?1 low quality RCT No EvidenceNo statistically significant findingsfor the outcome measures of this review or in the case of conflicting resultsamong included studiesAdapted from Van Tulder et al, 200225RESULTSArticle SelectionTotal Studies Retrieved N=702Studies Retrieved for Full Text Analysis N=25Studies Retrieved for Data Extraction N=6Excluded by Title / Abstract N=677Excluded by evaluating Full Text N=19Studies Retrieved from Hand Searching N=1Included Studies N=7Studies?Post Entry-LevelRheumatology Trained Physiotherapy (PERPT)4 Studies?Entry-LevelRheumatology Trained Physiotherapy (ERPT)3 StudiesQuality of StudiesPost Entry-LevelRheumatology Trained Physical Therapy (PERPT)Primary Author (Year)TitlePEDro ScoreBell (1998)A randomized control trial to evaluate the efficacy of community based physical therapy in treatment of people with rheumatoid arthritis8Helewa (1994)Can specifically trained physical therapists improve the care of patients with rheumatoid arthritis? A randomized control trial8Li (2005)Outcomes in home-based rehabilitation provided by primary therapists for patients with rheumatoid arthritis: A pilot study6Li (2006)Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: A randomized control trial4Quality of StudiesEntry-LevelRheumatology Trained Physical Therapy (ERPT)Primary Author (Year)TitlePEDro ScoreBuljina (2001)Physical and exercise therapy for the treatment of the rheumatoid hand6O?Brien (2006)Conservative hand therapy treatments in rheumatoid arthritis-A randomized control trial7van den Berg (2006)Using internet technology to deliver a home-based physical activity intervention for patients with RA: A randomized control trial8Effect SizesPrimary Author (Year)Effect Sizes [95% confidence interval] PAINFunctional AbilityHRQoLDisease KnowledgeSelf EfficacyERPTvs. single non-pharmacological  or waitlist control O?Brien(2005)Not measured0.03[-0.64, 0.70]-0.21[-0.89, 0.48]0.12[-0.55,0.80]-0.27[-0.93,0.40] -0.01[-0.96,0.68]0.04[-0.63,0.71] Not measuredNot measuredNot measuredVan den Berg(2006)Not measuredNot estimableNot estimableNot measuredNot measuredBuljina (2001)2.19[2.69,1.69]0.81[0.40, 1.22]Not measuredNot measuredNot measuredEffect SizesAuthor (Year)Effect Sizes [95% confidence interval] PAINFunctional AbilityHRQoLDisease KnowledgeSelf EfficacyPERPTvs. ERPT or waitlist control Li (2005)0.34[1.67, -0.99]-0.06[-1.38,1.25]0.18[-0.65, 1.00]0.29[-0.54, 1.12]0.60[0.77,1.96]Not measuredLi (2006)0.01[0.41,-0.39]0.03[-0.37,0.43]Not measured0.23[-0.17,0.64]0.24[-0.19,0.67]-0.03[-0.46,0.39]-0.19[-0.24,0.62]Bell (1998)0.27[0.62,-0.08]Not measuredNot measured0.34[-0.02,0.69]0.29[-0.06,0.64]Helewa (1994)Not measuredNot estimableNot measuredNot measuredNot measuredBES Results for Primary OutcomesERPT vs. single non-pharmacological intervention or wait list controlPainFunctional AbilityHRQoLDisease KnowledgeSelf EfficacyLimited evidenceNo evidence Not estimableNot measuredNot measuredPERPTvs. ERPT or waitlist control PainFunctional AbilityHRQoLDisease KnowledgeSelf EfficacyNo evidenceNo evidenceNo evidenceNo evidenceNo evidence*Based on our effect size calculationsBES Results for Secondary OutcomesERPTvs. single non-pharmacological intervention or wait list control?Key Grip Strength?Ability to perform mod-intense PA?ROM?Joint TendernessStrong evidenceLimited evidenceNo evidenceNo evidencePERPTvs. ERPT or waitlist control ?Medication Compliance?Coping Efficacy?Morning StiffnessLimited evidenceIndicative findingsNo evidence*Based on findings reported by authors of included studiesOverall Findings?Limited evidencesupporting treatment provided by entry-levelrheumatology trained PTs vs. waitlist control for reducing pain?No evidencefor the effectiveness of treatment provided by PTs with post entry-levelrheumatology training vs. ERPT or waitlist control for our primary outcomesDISCUSSIONDISCUSSION1.Counterintuitive Results2.  Findings for PERPT3.Findings for ERPT4.  Strengths & Limitations5.  Implications for Research and PracticeWhy were the results counterintuitive?1.Heterogeneity of outcomes measures and  interventionsInability to pool dataNo meta-analysisSmall sample sizesInsufficient powerWhy were the results counterintuitive?2.Not all studies provided necessary dataLimited calculation of effect sizes* This resulted in exclusion of some studies in the analysis of the primary outcomesWhy were the results counterintuitive?3.Methodological limitations of included studiesNo control for participants?concurrent medical treatmentChanges in participant outcomes from medical treatment or PT interventions?Deterioration in Coping Efficacy??Indicative findings for deterioration in coping efficacy from one PERPTstudy (Li 2006)WHY?Increasing disease knowledge linked with changing expectations about prognosis31?Decrease in coping efficacyFindings for PERPT ?Discrepancy around disease knowledge for PERPT ?Original studies found statistical significant improvements (Li et al 2006 & Bell et al 1998)?No significant results found in our effect size calculationWHY?Reasons for Discrepancy1.Type of statistical analysis used??Authors used change scores??We used point estimates2.Sample size required to reach significance??Li et al (2006) used dichotomous variables??We used continuous measuresFindings for ERPT?Limited evidence found for use of ERPTto decrease pain?Chronic pain common in RA and is shown to increase over time26-28?Strong positive association between pain & depression29-30?Pain & depression can further increase personal suffering, health service utilization & societal costs29-30Findings for ERPT?No evidence to support ERPTfor improvement in functional ability due to conflicting resultsBuljina 2001O?Brien 2006Result:Strong effectOutcome Measure:ADL scaleResult:No effectOutcome Measure:Jebsen-Taylor Hand Fxn Test & AIMS II subscalesLimitations & Strengths of Included StudiesL:Small sample sizes ??low power to detect clinically important differencesS:Majority of outcomes measures were reliable and valid ??change can be attributed to interventionLimitations of Review?Overestimation of quality of included studies ??use of PEDro scale?Language bias ??only English articles?Overestimation bias ??potential unpublished negative studies ?Did not evaluate cost-effectiveness ??possibly excluded studies that had clinical measures of HRQoLStrengths of Review?External validity ??interventions & outcome measures applicable to clinical practice32?Internal validity ??rigorous review process?All RCTs ??most reliable form of scientific evidence in healthcare33?ICF ??internationally recognized classification system & allows for comprehensive representation of RA patients?experiencesIMPLICATIONS for RESEARCHWhat does future research need? ?This review limited by heterogeneity of interventions and outcome measuresWe Recommend:1) Core set of outcome measures that encompass all categories of ICF2) Clear description of interventions including amount of rheumatology trainingIncreases possibility of a meta-analysisWhat does future research need? ?Length of interventions as well as presence and length of follow-ups varied among included studiesWe Recommend:3) Future studies conduct follow-up measurements and track participants for longer periods post-dischargeCONCLUSIONPositive resultswere found for the effectiveness of entry-level rheumatology trained physiotherapy for the secondary outcomes, key pinch strengthand ability to perform moderate to intense physical activityLimited evidencewas found for effectiveness of treatment provided by an entry-level rheumatology trained PT versus waitlist control for reducing painin adults with RAResults were found for the effectiveness of post entry-level trained physiotherapy in terms of increased patient medication complianceand decreased coping efficacyInconclusive evidencewas found for the effectiveness of treatment provided by PTs with post entry-level rheumatology training for our primary outcomesImplications for Practice?Evidence to support entry-level rheumatology trained PTs providing comprehensive physiotherapy?Inconclusive evidence to support that PTs with additional training will produce better outcomes than PTs with entry-level trainingAcknowledgementsLinda Li BSc(PT), MSc, PhDAngela BuschDip (PT), BPT, MSc, PhDCharlotte Beck UBC Reference LibrarianQUESTIONS ?References1.Engel A, Roberts J, Burch TA. Rheumatoid arthritis in adults. Vital Health Stat [1 ] 1966; 11(17):1-43.2.Lindquist B, Unsworth C. Occupational therapy-reflections on the state of the art. WFOT-bulletin. 1999;39:26-30. 3.Marra C. Rheumatoid arthritis: A primer for pharmacists. Am J Health Syst Pharm. 2006;63:S4-10. 4.Symmons DP, Barrett EM, Bankhead CR, Scott DG, Silman AJ. The incidence of rheumatoid arthritis in the united kingdom: Results from the norfolk arthritis register. Br J Rheumatol. 1994;33:735-739.5.Vlieland TPMV. CARE: International conference on multidisciplinary care in rheumatoid arthritis. International Journal of Advances in Rheumatology. 2003;1:34?366.Brosseau L, Robinson V, Wells G, et al. Low level laser therapy (classes I, II and III) for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1.7.Brosseau L, Yonge KA, Robinson V, et al. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database of Systematic Reviews. 2008;1. 8.Cardoso JR, Athala AN, Cardoso APRG, et al. Aquatic therapy exercise for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1 9.Casimiro L, Barnsley L, Brosseau L, et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1. 10.Casimiro L, Brosseau L, Robinson V, et al. Therapeutic ultrasound for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1.11.Pelland L, Brosseau L, Casimiro L, Robinson VA, Tugwell P, WellsG. Electrical stimulation for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1. 12.Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education for adults with rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1. 13.Robinson VA, Brosseau L, Casimiro L, et al. Thermotherapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1.14.Van den Ende CHM, Vliet Vlieland TPM, Munneke M, Hazes JMW. Dynamic exercise therapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1. 15.van der Giesen F, Vliet vlieland TPM, Schoones JW, Brosseau L. Exercise therapy for the rheumatoid hand. Cochrane Database of Systematic Reviews. 2008;1.16.Verhagen AP, BiermaZeinstra SMA, Boers M, et al. Balneotherapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2008;1. 17.Bell MJ, Lineker SC, Wilkins AL, Goldsmith CH, Badley EM. A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment ofpeople with rheumatoid arthritis. J Rheumatol. 1998;25:231-237.18.Glazier R. Managing early presentation of rheumatoid arthritis. Canadian Family Physician. 1996;42:913-922. 19.Vliet Vlieland TP, Li LC, MacKay C, Badley EM. Does everybody need a team? J Rheumatol. 2006;33:1897-1899.20.Cott CA, Boyle J, Fay J, Sutton D, Bowring J, Lineker S. Client-Centred Rehabilitation. 2001-03. 2001. Toronto, Arthritis Community Research & Evaluation Unit (ACREU).21.Li, LC, Iverson MD. Outcomes of patients with rheumatoid arthritis receiving rehabilitation. Curr.Opin.Rheumatol.2005;17:2 172-176 22.Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys.Ther.2003;83:8 71323.Scholten-Peeters , Verhagen AP, Bekkering GE, van der Windt DA, Barnsley L, Oostendorp RA, Hendriks EJ. Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies. Pain 2003;104:1-2 303-32224.Li LC, MacKay C. CARE III Local Planning Committee. CARE III Online Patient Survey -Summary of Preliminary Analysis. Available at: Accessed 07/15, 2008.25.van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the cochrane collaboration back review group. Spine. 1999;24:1113-1123.26.Yelin E, Callahan LF. The economic cost and social and psychological impact of musculoskeletal conditions. national arthritis data work groups. Arthritis Rheum. 1995;38:1351-1362.27.Felts W, Yelin E. The economic impact of the rheumatic diseases in the united states. J Rheumatol. 1989;16:867-884.28.Gabriel SE, Crowson CS, Campion ME, O'Fallon WM. Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol. 1997;24:43-48.29.Turner JA, Romano JM. Self-report screening measures for depression in chronic pain patients. J Clin Psychol. 1984;40:909-913.30.Kazis LE, Mcenan RF, Anderson JJ. Pain in the rheumatic diseases. Arthritis and Rheumatism.1983;26:1017-1022.31.Sprangers MA, Schwartz CE. Integrating response shift into health-related quality of life research: A theoretical model. Soc Sci Med. 1999;48:1507-1515.32.Rothwell PM. External validity of randomised controlled trials: "to whom do the results of this trial apply?". Lancet. 2005;365:82-93.33.Lachin JM. Randomization in clinical trials: Conclusions and recommendations. Controlled clinical trials[serial online]. 1988;9:365.


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics

Country Views Downloads
China 27 35
United States 19 6
Canada 17 6
Russia 5 0
Brazil 3 5
Germany 2 1
Poland 2 0
India 2 3
New Zealand 1 0
Netherlands 1 0
Japan 1 0
City Views Downloads
Shenzhen 18 35
Unknown 11 11
Beijing 9 0
Ashburn 7 0
Vancouver 7 0
Saint Petersburg 5 0
Burnaby 4 0
Richmond 4 0
Fort Worth 3 0
Kasigluk 2 0
University Park 2 0
Auckland 1 0
New Westminster 1 0

{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}
Download Stats



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items