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Three Part Question

In [adults with Rheumatoid Arthritis] what [physiotherapy management] results in [improvement to patient function]

Clinical Scenario

A 45 year old female with a diagnosis of Rheumatoid Arthritis (RA) presents to the physiotherapy department requesting the current best physiotherapy treatment and advice for her chronic, multiple joint pains and stiffness.

Search Strategy

Amed 1985-June 2013, EMBASE 1980-June 2013, MEDLINE 1946-June 2013, CINAHL 1981-June 2013 using the Athens interface. Limit to written in English

[Rheumatoid AND Arthritis] AND [Physiotherapy OR Physical AND Therapy OR Exercise OR Group OR Class OR Strengthening OR Hydrotherapy OR Aquatic OR Acupuncture OR TNS OR TENS OR Transcutaneous AND Nerve AND Stimulation OR Mobilisations OR Mobilisation OR Stretching OR Aerobic OR Education OR Pacing OR Goal AND Setting OR Heat OR Ice OR Advice OR Electrotherapy] AND [Visual AND Analogue AND Scale OR VAS OR Numerical AND Rating AND Scale OR Short AND Form AND McGill OR Timed AND Up AND Go OR Single AND Leg AND Stand OR Berg AND Balance AND Scale OR Balance OR Rhombergs OR 100m AND Walk AND Test OR Sit AND To AND Stand OR MyMop OR Strength OR Dynamometre OR Force OR Grip OR Oxford OR Quality AND Of AND Life OR SF36 OR Swelling OR Meter OR Sickness AND Impact AND Profile OR Functional AND Limitations AND Profile OR Nottingham AND Health AND Profile OR SEIQoL OR EuroQoL]

Search Outcome

316 papers were found of which 295 were irrelevant to the study question. The remaining 21 papers were distributed between the authors. Each paper was then read separately by two authors and data was extracted using a standardised extraction table. The two people then discussed the paper and created a common extraction table. Any disagreements were discussed and if no agreement reached, a third person mediated the discussion until an agreement was reached.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ahlstrand I, Bjork M, Thyberg I, Borsbo B, Falkmer T 2012 Sweden	Recruited from 3 rheumatology units in south east Sweden. Inclusion: Seropositive Rheumatoid Arthritis(RA) < 4years and pain intensity > 40mm on Visual analogue scale (VAS) as reported in the last 2 visits. Participants with co-morbid pain, cognitive impairments and limited Swedish were excluded. Stratified sampling was used in order to select potential participants based on their age and gender.	Data was obtained by 7 semi-structured group discussions focusing on pain, activity, occupational, balance and consequences of pain on activity and participation. Data was analysed by content analysis. The social interaction and participation in the group discussion provided opportunities to express individual experiences of pain. Questions included ‘how does the pain affect your activities of daily living (ADLs’) Focus group lasted 80 minutes and notes were taken. Written up and showed to each patient and they then agreed or disagreed with them. Control Group: N/A Study Type: 1. Qualitative hierarchy	The transcribed texts were analysed with respect to content. Meaning units were identified, condensed, abstracted and coded. These were compared based on differences and similarities and sub categorised. These were then reviewed and revised until consensus.	Focus groups resulted in the generation of 5 categories: 1. Activity as a mediator of pain. Distraction through activities and pain was related to fatigue, stress and mood. 2. Moderating activity levels. Difficulty in finding a suitable level of activity. Imbalance in daily activities. 3. Pain causing activity limitations. Barriers and adapted performance and environment. 4. Attitudes as a mediator of participation restriction. Support participation through understanding and in turn lack of support causing participation restriction.5. Dependence on others. Altered allocation of activities in the home.	Does not look at what each patient’s activity levels or social situations are. Unclear why they split women and men into groups. Aim was to describe pain which it did but did not look into the relationship with daily activities
Arvidsson S, Bergman S, Arvidsson B, Fridlund B, Tingstrom P 2013 Sweden	Participants attending a rheumatology clinic. One or more diagnosis of rheumatic disease for more than a year and had Musculoskeletal pain, sleep disturbance and/or fatigue for +3months. They had to want to participate in the problem based learning programme. Only exclusion was a poor understanding of Swedish.	1-year self-care promoting problem-based learning programme. Groups divided in to 7 tutorial groups of 7-8 participants and 1 tutor. Each tutorial group met for 1.5 hours, 10 times in 1 year. The experimental group had the opportunity to find approach to self-care and to be able to handle Musculoskeletal pain, sleep disturbances and fatigue. Each wrote targets in a work book. Curriculum: self-awareness and self-confidence, relationships to other, stress and relaxation, physical activity and rest, medicines and herbal remedies, tobacco and alcohol, and food and drink. Control group: Standard care at a Rheumatology department. No explanation as to what their management involved. Study Type: 1c. Randomised controlled trial.	1.Health-related quality of life was assessed by the Short Form-36 Health survey (SF-36)2.Empowerment was assessed by the Swedish Rheumatic Disease Empowerment Scale (SWE-RES 23) 3.Self-Care was assessed by the Appraisal of Self-Care Agency Scale (ASA-A) 4.Sense of Coherence was assessed by the Sense of coherence (SOC-questionnaire ) with 13 questions 5.Chronic Musculoskeletal pain and fatigue was assessed by the Visual analogue scale (VAS ) 6.Quality of sleep was assessed by four questions used in previous studies7.Demographic variable – sex, age, civil status, education, residence, socioeconomic status and rheumatic disease 8. Health related quality of life (HRQL)	There was statistically significant difference at 6 months post-intervention in the SWE-RES-23 total score CI= 0.0 -0.4, p<0.038.The participants in the experimental group scored that they had belonged to a tutorial group that worked well together to a fairly high degree (n=15) or to a sufficient degree (n=10). The participants of the intervention group had implemented lifestyle changes to a fairly high degree (n=8), to a sufficient degree (n=17) or to a fairly small degree (n=9). No statistically significant difference in HRQL between the experimental group and the control group. Participants in the experimental group had concrete goals for life-style changes to a fairly high degree (n=8, 21.1%, to a sufficient degree (n=17, 28.9%), or to a fairly small degree (n=9, 23.7%) during the 1 year PBL-program.	Large drop out of patients that are more disabled and have advanced disease. Differences in size of experimental (n=54) and control group (n=148). The mean improvements in the SF=36 subscales in the groups were 2.6-12.5 and if these changes are of clinical significance are controversial – effects larger than 12% of the baseline value in SF-36 are assumed to be the MCID, in this study they are all >12%.
Barsky AJ, Ahern DK, Orav EJ, Nestoriuc Y, Liang MH, Berman IT, Kingsbury JR, Sy JT, Wilk KG 2010 USA	Subjects had a diagnosis of Rheumatoid arthritis (according to American college of rheumatology criteria) and had visited the clinic in the last year. They were identified from the hospital computer registry and had on-going care at an academic medical centre. A small number responded to public announcements and adverts. Aged between 20 and 75 years old and fluent in English Exclusion criteria: fibromyalgia, serious medical co-morbidity that was likely to progress or cause death in the next 12 months, currently receiving psychological treatment for Rheumatoid arthritis	Subjects completed a baseline interview and were assigned to one of three groups. 1. Cognitive behavioural therapy (CBT): 12 weekly sessions, 60-75 minute sessions- techniques taught including problem solving, goal setting, relabeling and reframing of symptoms, enhanced awareness of pain behaviours, activity pacing, and distraction and attention refocusing. Homework was given. 2.Relaxation response training: 8 weekly sessions, 50-60 minute sessions – the relaxation response-psycho-physiological and cognitive aspect, diaphragmatic breathing, progressive muscle relaxation and generalised relaxation. 3. Arthritis Education: 8, 50 minute scripted talks and printed material. Including Rheumatoid arthritis pathophysiology, arthritis medication and therapies, physical exercise and activity, nutrition and diet and the nature of stress. Baseline was their self-reported questionnaires, grip strength test, walking time test, standardised joint examination and blood sample. Once they had 5 subjects they then randomly assigned by computer to 1 of the 3 groups. They had to assign patients to specific group at the end of the 127 patients as there was an unequal number in each group. Control Group: 3 groups – CBT, relaxation response, and arthritis education Study Type:1c.Randomised Controlled Trial	Outcomes were assessed with in-person interviews immediately following treatment, 6 and then 12 months later. 1.Rheumatoid Arthritis and symptoms questionnaire (RASQ). 2. The arthritis impact measurement scale (AIMS-2) 3.Erythrocyte sedimentation rate (ESR ) and a standardised physician rating scale for joint swelling – rated on a 4 point scale and over 28 joints 4.Grip strength with a hydraulic hand dynamometer and a timed walk over 65 feet 5. Psychological stress: the Rand Mental health inventory. 6.Medications – arranged in classes of strength	Pain improved significantly with Relaxation response and arthritis education and non-significant change for CBT. No change with function or depression and anxiety, arthritis meds. Walk times and grip strength did not change which was expected following a psychological intervention.The results were aggregated across the groups and this was when the findings became significant. The effect size for pain ranged between 0.26 and 0.35. For AIMS social activities at 12 months – in the CBT and the relaxation response treatment arms with effect size of 0.21 and 0.37, respectively.	Patients that missed their last RASQ had their last score carried forward – missed data may affect analysis. Limited demographic of patient used – white, middle aged female. Most subjects were +13 years post diagnosis which may affect the prognosis of treatment. High dropout rate for the CBT group. No waiting list control group as paper stated that ethically patients should receive education.
Breedland I, Van Scheppingen C, Leijsma M, Verheij-Jansen N P, Van Weert E 2011 USA	A medical diagnosis of Rheumatoid arthritis (RA) according to the American College of Rheumatology (ACR) criteria. Aged 18-66. Participants were independent, living at home. Participants were excluded if they had: 1. Disease Activity Score(DAS-28) Severe disease activity. 2. Cardiac or pulmonary diseases resulting in restrictions in their ability to follow a physical exercise program. 3. a Steinbrocker classification of functional capacity <=3. 4. No stable medication for the RA. 5. Intra-articular injections during the time of the study.	8-week, multidisciplinary group therapy programme, consisting of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) together with an educational programme: cardiovascular training (CV) 60min/week, sport training 60min/week, aqua jogging 2x30min/week – total participation 3 hours on 2 separate days – all supervised. And a one hour weekly multidisciplinary team(MDT) group session. Control Group: Waiting list Study Type: 1c. Randomised Controlled Trial	1.VO2 max using cycle ergometry. 2.Muscle strength of the elbow and knee flexors and extensors using hand held dynamometry. 3. Health Status using Arthritis Impact Measurement Scales-2 limiting analysis to the physical functioning, psychological functioning, and social interaction subscales.4.Perceived self-efficacy using the Arthritis Self-Efficacy Scale.	No negative impact upon disease. VO2 max 12.1% improvement in intervention group over time with Effect Size (ES) =0.35. Significant difference between groups. No significant difference between group difference in strength although some trivial improvements over time in the intervention group for upper limb(ES=0.15) with moderate improvement in lower limb (ES=0.43). No differences in psychological function or social interaction. Physical health improved in intervention group over time but no between group differences (ES=-0.6). No change to self-efficacy.	Small population (n=34), not sure what is required for adequate power. No information about exercise that participants did outside of the group. Some missing VO2max data not accounted for in analysis is likely to bias result. It is questionable how realistic this is to transfer to NHS case loads and demands.
Brorsson S, Hilliges M, Sollerman C, Nilsdotter A 2009 Sweden	36 Female patients with Rheumatoid arthritis (RA) visiting an outpatient’s clinic. Inclusion: disease duration of at least one year, to be able to fully extend their fingers, RA diagnosis based on the American College of Rheumatology (ACR) criteria Exclusion: Inflammatory or muscle disease, and previous hand or arm injury	Study period was 18 weeks, subjects examined at 6 week intervals. The exercise programme was performed for 12 weeks, 5 times per week. Each task was repeated 10 times, held for 3-5 seconds at max effort, with 20 sec rest. At least one day rest was between each exercise session. Participants used therapeutic putty (85 g) for finger resistance. The participants were free to choose soft, medium or firm putty. The participants kept diaries during this training period in which all hand Exercise occasions were declared. Control Group: 20 Healthy women, mean age of 59 years. Exclusion criteria for the controls were: Inflammatory or muscle disease, or previous hand or arm injuries. They completed the same exercise routine as the intervention group. Study Type: 2b. Case control study with healthy controls.	All participants kept diaries, other outcomes were:1.Force measurements: used two devices – EX-it for finger extension force and Grippit for finger flexion force2. Visual Analogue Scale (VAS) for pain3. Grip ability test (GAT)4.Disabilities of Arm, Shoulder and Hand questionnaire (DASH)5.Short-form- 36 (SF-36)6.Ultrasound measurements of Extensor digitorum commumis (EDC) at rest and during maximal contraction.	Force measurement and hand function: both increased significantly after 6 and 12 weeks in both groups, and both showed an improvement in GAT score but showed no significant change in pain – RA group, median values of 1.5 (0 weeks), 2.5 (6 weeks) and 2.0 (12 weeks). DASH was the only questionnaire that significantly improved in the RA group at 12 weeks, median 39.2 (6.7-47.5) p=<0.01. At 6 weeks, the cross sectional area(CSA) of the EDC muscle in the RA group increased, at 12 weeks the CSA had significantly increased in both groups (median increase in the RA group of 1.9 (0.9-2.5) p=<0.01.	The authors report that the study is underpowered and only recruited female patients, therefore we may not be able to generalise results to the general population. The data was not normally distributed. No adverse effects of the hand exercises were noted.
Casimiro L, Barnsley L, Brosseau L, Milne S, Welch V, Tugwell P, Wells GA 2010 Ottawa, Canada	Adults with classic or definite Rheumatoid Arthritis (RA) treated with acupuncture or electroacupuncture. Excluded trials that used same patients as own control.	Acupuncture or electroacupuncture. Control Group: Sham acupuncture or application of acupuncture in incorrect points. Study Type: 1a.Systematic review.	Methodological quality was assessed using a validated assessment tool (Jadad 1996) – assessed using four levels: platinum, gold, silver and bronze. Primary outcome measure was pain.Secondary measures from the core set identifies by the OMER-ACT (conference on outcome measures used in rheumatoid arthritis clinical trials, 1993) conference on RA outcomes:1: Number of tender joints per patient2: Number of swollen joints per patient3: Physician global assessment4: Patient global assessment5: Functional status.	Two studies met the inclusion criteria: they were given a silver level of evidence. David 1999: No significant difference between groups. Man 1974:significant decrease in knee pain was reported in the experimental group 24 hours post treatment, weighted mean difference (WMD) -2.00, CI3.60 to -0.40, with a relative improvement of 66.6% when compared to placebo. At 4 months, WMD -.02, confidence interval(CI) -0.36 to -0.04.	This review included Randomised control trials and controlled trials. It excluded trials using the subject as their own control. None of the studies included range of motion, strength or physiological outcomes such as skin and joint temperature, which might have provided more clinically relevant information. Man 1974 study has the positive outcome but scored the lowest in the quality rating. No heterogeneity of the data therefore pooling not possible.
Crowley L 2009 Ireland	Included patients with a definitive diagnosis of Rheumatoid Arthritis(RA) both active and non-active; that included exercises performed in the home environment (HEP). Different methods of disease classifications of RA were included. The population also included other rheumatic diseases. Articles were included that were Randomised control trials, they were excluded if they involved community based physiotherapy, review articles or self-management programme involving multiple treatments.	Eight reviews were deemed suitable. All interventions in the studies were carried out at home. Intervention included: 1) Hand exercises 2) Dynamic strength training 3) Cardiopulmonary conditioning 4) Shoulder exercises Control Group: Papers in the review did have control groups but there was no full description as to what they did. Control group interventions included: No programme, relaxation training, and range of motion stretching exercises. Study Type: 1a.Systematic Literature review.	Each study had various outcomes: 1.Grip strength.2.Range of motion3. Proximal interphalangeal joint circumference 4.Hand deformities5.Nine hole peg test questionnaire6. Medication 7.Pincher grip strength8. Exercise motivation, The arthritis impact measurement scale(AIMS-2)9.Nottingham Health Profile10.Ritchie articular index11. 500m walk test12.Muscle function index13.Shoulder arm movement impairment assessment 14.Strength and endurance15.Bone mineral density16. Health Assessment Questionnaire ( HAQ )17.Erythrocyte Sedimentation Rate (ESR)18. Morning stiffness19. Joint radiology 20. Pain 21. Nottingham Health Profile – part 1 22. Arthritis self-efficacy scale 23.Functional disability of the Standford health assessment questionnaire24. Joint mobility 25. Six functional tasks with Visual analogue scale(VAS) 26. Systemic lupus activity measure(SLAM) 27. American college of rheumatology(ACR) 28. Glossary joint count. 29. National Institute of Health CES-depression scale 30. Profile of mood status(POMS)31. Fatigue scale. 32. Arthritis Helplessness index 33. Graded exercise test 34.Sub maximal exercise test 35. Functional movements – hand to neck and hand to scapula 35. Pain at rest 36.Night and, Endurance activities of daily living (ADLs).37. Compliance with exercise.	The study concluded that there was a high risk of bias within the papers reviewed because of the methodological quality. The authors reported that intension to treat analysis was not included.Hand exercise programmes (HEP): HEP for hands can improve hand strength. At two year follow up improvements were still observed. Dynamic strength training programmes demonstrate mixed results: 1. Minimal improvement in physical impact and work ability at 9 months. 2. Reduction in perceived exertion on walking with no change to the control group. 3. Significant increase in muscle strength and decreased morning stiffness. A positive impact on self-efficacy for other symptoms, pain in all functional tasks except maximal walking speed, Ritchie articular index and joint mobility. Cardiopulmonary conditioning programmes demonstrated no significant difference between the groups. Shoulder exercise programme: a HEP can increase shoulder function and decrease pain. Compliance in HEP: sessions performed each week ranged from 2.7/3 and 1.5/2; one study reported a 98% adherence. Reported Bottom Line: HEP for RA may produce beneficial effects.	The participants included in the review varied according to the diagnosis of rheumatological disease and American Rheumatoid Association functional class. Not all just RA diagnosis – included System lupus erythrocyte. Only one study looked at cardio pulmonary intervention and was flawed with recruitment bias and a sample attrition rate that may have affected the results. Difference in outcome measures and patient classification made combining results from the papers impossible Most improvement was found in patients with functional class I and II. Some studies only included female subjects Limited documentation of exact treatment interventions. Only two studies examined validity and reliability of their outcome measures.
Field T, Diego M, Delgado J, Garcia D, Funk CG 2013 USA	42 adults with Rheumatoid arthritis(RA) with symptoms in the upper limbs. Mean of 51 years of age. Middle socioeconomic status.	15 minutes of moderate pressure massage to the wrist and shoulder, once a week for 4weeks. Techniques used were stroking, milking, friction and skin rolling. All participants were taught self-massage. They were called weekly to encourage daily massage. Control Group: 15 minutes of light pressure massage to the wrist and shoulder, once a week for 4weeks. Techniques used were stroking, milking, friction and skin rolling. All participants were taught self-massage. Study Type: 1c.Randomised controlled trial	Assessments were carried out before and after the massage session. On the first and last days of the 4 weeks. Outcomes used were:1.VITAS – which is a pre and post session pain assessment using Visual Analogue Scale (VAS) anchored with five faces. 2.Percieved grip strength 3.The State Anxiety Inventory (STAI) 4. Profile of Mood Status (POMS) 5. The Sleep Disturbance Scale 6.Grip strength was measured using a talking digital exerciser 7. Range of motion of the wrist (flexion), the elbow (flexion) and the shoulder (abduction) using a goniometer. Compliance was noted using a daily diary.	Differences were seen between the two groups in the following1.Moderate massage decreased pain. 2.Moderate massage increased perceived pain. 3. Moderate massage decreased anxiety. 4. Moderate massage decreased depression. 5. Moderate massage increase range of motion of wrist and elbow flexion and shoulder abduction. No other differences were found.	No evidence of blinding Under powered, 42 adults needed but only 32 completed. The authors fail to clarify the results of within and between tests. This makes it difficult to draw conclusions from the results. The authors do not report effect size.
Giraudet-Le Quintrec JS, Mayoux-Benhamou A, Ravaud P, Champion K, Dernis E, Zerkak D, Ouslimani A, C 2007 France	Between June 2001 and December 2002, all consecutive inpatients 208 patients with a diagnosis of Rheumatoid Arthritis (RA) according to the American College of Rheumatology (ACR) criteria. Inpatients and outpatients from the Institute of Rheumatology in a French hospital. Exclusion criteria: current juvenile chronic arthritis, steinbrocker class IV, pregnancy, presence of RA flare or patient not understanding information.	Multidisciplinary education in addition to usual medical care. 8 weekly, 6-hour sessions in groups of 8-10. 6 months later attended a 4 hour booster session. MDT included a rheumatologist, rehabilitation specialist, dietician, social assistant, 2 nurses, 2 physiotherapists, 2 Occupational therapists. Topic explored were: 1.General information about RA as well as specific information about the disease and treatment 2.Pain coping strategies 3.RA treatment 4.Nutritional advice 5.Rehabilitation The objective was to modify patient behaviour and encourage self-efficacy. Control Group: Usual medical care and 2 information leaflets written by the team. Study Type: 1c.Randomised controlled trial.	Outcomes were collected at the start, 6 months and 1 year.Health assessment questionnaires: 1.Disease activity score. 2.Hospital anxiety and depression scale (HAQ). 3.Arthtiis helplessness index (AHI). 4. Quality of life: Arthritis impact measurement scales. 5. Functional assessment of chronic illness therapy. 6. Physical activity scores. 7. Drug compliance. 8. Satisfaction with the program. 9. Knowledge of RA	After1 year there was no statistically significant difference between the 2 groups in change in HAQ score: -0.04±0.46 in the education group verses -0.06±0.47 in controls (p=0.79). Patient coping improved in the education group, assessed with AHI (-1.22±5.55 intervention group vs. -.022±3.81 controls; p=0.03). Knowledge of RA improved in the education group (3.42±4.73 vs. 0.73±3.78; p<0.0001).Patient’s satisfaction was achieved in the education group (10.07±11.70 vs. 5.72±13.77; p=0.02).	No homogeneity with other studies From 1242 potential subjects – only 189 suitable and completed. Subjects included had a long disease time (11.85±9.44) which may influence the effectiveness of the intervention.
Hurkmans E, Van der Giesen FJ, VlietVlieland TPM, Schoones J, Van den Ende ECHM 2009 Netherlands	A systematic review of Randomised control trials (RCT’s) including patients with classical or definitive rheumatoid arthritis (RA) according to the 1958 Arthritis research association criteria (ARC) or the 1987 ARC. Participants were required to be over 18 years, male and female. Exclusion criteria: Diagnosis of other types of arthritis.	Trials with an exercise programme assumed to be adequate enough to improve aerobic capacity, muscle strength, or both according to the following criteria: 1. Exercise frequency of a least 20 minutes twice per week 2. Duration of exercise programme at least 6 weeks 3. Exercise programme performed under supervision 4. Aerobic exercise intensity at least 55% of maximal heart rate, or intensity starting at 40% to 50% of the maximum oxygen uptake reserve (VO2R) or Heart rate maximum reserve (HRR), furthermore, the intensity is increased up to 85% during the intervention. 5. Progressively strengthening exercise loads starting at 30% to 50% and increasing to 80%of max voluntary contraction, max speed, or as maximal subjective exertion Control Group: Control groups were in all RCTs but no full description was given. Study Type: 1a. Cochrane systematic review.	Primary Outcomes: 1.Functional ability - McMaster Toronto Arthritis Patient Preference Interview (MACTAR) Health Assessment Questionnaire (HAQ) Arthritis Index Measurement ( AIMS) Quality of Life (QOL) Short-form- 36 (SF-36) The Fries Index. FSI. 2. Self-reported pain – Visual Analogue Scale (VAS) 3. Adverse effects Secondary Outcomes: 1. Aerobic capacity determined by a maximal or sub maximal ergometer test 2. Muscle strength of knee extensors 3. Disease activity, Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP),Disease activity Score (DAS) 4. Radiological joint damage of small or large, or both 5. Ratio of costs divided by the effectiveness, measured by the EuroQol (EQ-5D) , SF-6D, time trade off (TTO) method Standard Gamble (SG).	8 studies were included in the review that involved a total of 575 participants. Average age 52 years, average disease duration 5-14 years.2 studies found a significant positive effect on aerobic capacity immediately after the intervention (P<0.05). No differences in muscle strength, functional ability or aerobic capacity nine months after intervention were established. Short term effects: 1. Pooled data revealed a trend towards an improvement of functional ability (Effect size (ES) 0.03, 95% Confidence Interval (CI) -0.46 to 0.51) and aerobic capacity (ES 0.99, 95%CI 0.29 to 1.68) immediately after intervention 2. For the pooled effect of functional ability from 2 papers, there is a non-significant positive trend on functional ability (ES -0.40, 95%CI -0.86 to 0.06). From pooled effect of muscle strength there was a significant, medium positive effect on muscle strength (ES 0.47, 95%CI 0.01 to 0.93). 3. For water based exercise, data could only be pooled for aerobic capacity, resulting in a trend towards improvement (ES 0.47, 95%CI -0.04 to 0.98). 4. Long term aerobic capacity and muscle strength training resulted in a non-significant improvement of muscle strength (ES 0.49, 95%CI -0.06 to 1.04). Pooling data revealed a non-significant effect on disease activity (ES -0.16, 95%CI -0.39 to 0.06) and radiological damage (ES -.015, 95%CI -0.37 to 0.08) 5. Bottom line conclusion: short-term land based dynamic exercise programmes have a positive effect on aerobic capacity and muscle strength immediately after intervention, but not after a follow up period.	No studies compared short-term versus long-term exercise interventions so it is still unclear which program has the biggest effect on aerobic capacity and strength. Of the 8 studies included, 6 were more than 10 years old. 50 studies were excluded due to not meeting the exercise intervention criteria. Therefore other forms of exercise may have benefits for RA but where not explored within the inclusion criteria of the Review.
Iversen MD, Brandenstein JS 2012	575 adults predominantly female with physician-diagnosed Rheumatoid arthritis (RA) meeting American college of rheumatology established criteria, with a low to moderate disease activity.	The review reported 4 different dynamic exercise interventions: 1.Short-term aerobic exercises performed on land 2.Short-term aerobic and strengthening exercises performed on land 3. Long-term aerobic and strengthening exercises 4.Short-term aquatic aerobic exercises Control Group: Not clearly indicated Study Type: 5. Expert opinion	Unclear listing of tests but the topics assessed were:1.Functional ability 2.Aerobic capacity 3. Muscle strength 4. Visual Analogue Scale (VAS) self-reported pain. 5. Disease activity 6. Radiological damage	Short-term, land-based aerobic exercise improves aerobic capacity (pooled Effect size (ES) 0.99, Confidence Interval (CI) 0.29 to 1.68) and strength (pooled ES -0.47, CI 0.01 to 0.93). However, only a trend towards improving functional ability (pooled ES -0.40, CI -0.86 to 0.06).Water-based aerobic exercise improved aerobic capacity (pooled ES 0.47, CI 0.04 to 0.98). Long-term land based combined exercise of greater than 3 months demonstrated a non-significant improvement of muscle strength (ES 0.49, CI 0.06 to 1.04). Bottom line: patients with moderate disease activity and limited joint erosions may benefit from short-term exercise including aerobic capacity and dynamic strength training.	The authors support the use of aerobic capacity training combined with muscle strengthening exercises for people with RA. No deleterious effects with respect to pain or increased disease activity were reported. This is a summary article.
Kennedy N 2006 Ireland	Patients with a definite diagnosis of Rheumatoid Arthritis (RA) using the Functional Classification in RA scale (class I-IV).. One study included people with stable RA, whilst three included patients using a stable disease-modifying anti-rheumatic drugs regimen for RA.	Interventions in the papers: 1. Strengthening and aerobic components to the exercise programs. 2. Safety and effectiveness of the RAPIT programs. A one hourly, biweekly group exercise program of 1.25h per session. Bicycle training, exercise circuits and sporting activity all for 20 minutes each. 3. Intensive exercise (usual care plus reciprocal isometric and isokinetic training on an isokinetic dynamometer) regimen. Control Group: Usual care received by a physiotherapist as a control. 1a. Systematic review.	A combination of the following:1. Disease activity score (DAS): comprises the number of swollen joints, number of tender joints, Erythrocyte Sedimentation Rate (ESR), and patient’s global assessment of disease2. DEXA scanRadiological damage to the small joints of the hands and feet were used as a measure of the safety of these exercise programs in response to the concerns over the possibility of damage to the joint from intensive exercise.	30 papers were found using the search criteria and 11 were reviewed. Intensive exercise did not exacerbate disease activity.In one study disease activity decreased over the study period (24 weeks) with improvements in Disease activity score – mean improvement of -1.4 for intervention group and -0.7 for the usual care group. Bone mineral density (BMD) measurement of the hip showed that the mean rate of decrease of hip BMD was smaller in patients in the RAPIT group than in the usual care group. A mean decrease in the RAPIT group was 1.6% (CI 1.10-2.90) over 1 year and 0.5% (CI 1.1-2.0) over 2 years. Another study focusing on disease activity found that there was no detrimental effect in terms of disease activity from the RAPIT, but no outcome measure was quoted. Radiological imagining of participants in the RAPIT program indicated significantly less radiological damage than in the usual care participants. Main conclusion: exercise programmes for patients with RA 1) does not increase disease activity 2) are safe to use in participants with RA 3) slow down the loss of BMD in the hip.	Little statistical data was reported.
Knittle KP, De Gucht V, Hurkmans EJ, VlietVlieland TPM, Peeters AJ, Ronday HK, Maes S 2011 The Netherlands	643 patients were recruited from 3 rheumatology outpatient clinics in the Netherlands. All participants had to fulfil the American College of Rheumatology criteria for Rheumatoid Arthritis (RA). They have attended the outpatient clinic in the last 12 months.	Questionnaires assessed 1.regulatory style (motivation) 2. self-efficacy for physical activity 3. physical activity 4. arthritis pain 5. Quality of life among patients with RA whether through physical activity or achievement of goals. Control Group: None Study Type: 2c. Population collated information from outcome measures	Results were compared and correlated over a 6 month period. 1.The Treatment Self-Regulation Questionnaire for physical activity (TSRQ) 2. Self-Regulatory Skills Battery 3.Visual analogue scale (VAS) for goal achievement - rating of degree they felt they have reached their goal using a 100-mm VAS 4.The Short Questionnaire to Assess Health-Enhancing Physical Activity 5.The Rheumatoid Arthritis Disease Activity Index (RADAI) 6. Short form-36(SF-36) 7. Goal setting	From the 217 patients initially sent questionnaires, 48% returned follow up questionnaires. At follow up 129 subjects returned the second questionnaire, 23 were excluded due to missing data. 106 patients were included in the analysis (39% of baseline) No differences found between men and women or between longstanding or recent onset of RA. VAS for goal achievement ranged from 3-100 (median 72; interquartile range 50-87), with 75% having rated their goal achievement as ≥50%. No significant relationship between physical activity and arthritis pain, but there is a significant indirect effect of self-efficacy upon arthritis pain through goal achievement.	The main flaw of the study is that the subjects recruited may not reflect the general RA population. Baseline and final motivation in non-participators may have been lower than those more motivated to participate. The study required patients to independently fill in questionnaire and post themselves. Those who did not complete the second questionnaire had significantly less physical activity and lower Quality of life at baseline then study completers. The authors discuss that those who have greater self-efficacy set more difficult physical goals which in turn have an indirect effect on arthritis pain. This is unsubstantiated by the research presented here. The content of the physical activity goals was not examined and the timeframes and specificity of interventions not explored.
Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Madison PJ 2009 U.K.	Eligible volunteers were recruited from a Rheumatology Department – 28 subjects completed the trial Criteria: 1. American College of Rheumatology (ACR ) criteria for Rheumatoid arthritis (RA) 2.Age ≥18 years 3.Functional class I or II 4.Not cognitively impaired 5.Antiinflammatory or Disease-modifying antirheumatic drugs (DMARDS) has been stable for 3 previous months 6.If on corticosteroids, maintained on a dosage <10 mg/day 7.Free of other cachectic diseases 8.Free from medical conditions contradicting regular high intensity exercise 9.Not taking drugs of nutritional supplements known to be anabolic 10.Not currently undertaking regular, intense physical training 11.Not pregnant	High intensity progressive resistance training: twice weekly for 24 weeks at a community gym under the supervision of exercise physiologists. The exercises consisted of 3 sets of 8 repetitions at 80% of the 1-rep max (1-RM) with 1-2 mins rest between each rest. Multi stack exercises: 1.leg press 2.chest press 3.leg extension 4.seated rowing 5.leg curl 6.triceps extension 7.standing calf raises 8.biceps curl To prevent muscle soreness, 1 set was performed in the first week and 2 sets in the second. Further, 15 repetition sets at 60% 1-RM for week 1-4 and 12 repetition sets at 70% of 1-RM in weeks 5-6 then up to the 80% 1-RM for 8-repetition sets. Each session was carried out with a warm up and cool down lasting 10 minutes of low-intensity range of motion (ROM) exercises. Control Group: Low-intensity ROM exercises twice weekly at home following instruction on performance – control subjects were called every 2 weeks. Study Type: 1c. Randomised controlled trial	All subjects kept a training diary, and monitored adverse effects. Assessment was carried out at baseline at immediately at 24 weeks following exercise. 1. Total and regional lean and fat masses –DEXA-scanner 2. Proxy measure of total skeletal body muscle mass – appendicular lean mass (kg/height(m2) 3. Relative skeletal muscle index and percentage body fat 4. Extracelllar water and total body fat 5. Estimated total body protein 6. Muscle strength – max voluntary contraction of knee extensor strength 7. Senior fitness test 8. Multidimentional Health assessment Questionnaire. 9. Habitual physical activity – pedometers 10. Muscle biopsies 11. Blood sampling 12. Insulin-like growth factor (IGF) system assays 13. Disease activity score (DAS-28) 14. Erythrocyte Sedimentation rate (ESR).	Progressive resistance training (PRT) programme in 24 weeks had an increase in training specific strength of 119% and did not exacerbate DAS when compared to the control group, p=0.471 for the interaction and ESR p=0.285 for the interaction.Body composition: PRT increased both in LBM (lean body mass)(mean ±SD1,536±1,471gm) and appendicular lean mass (ALM) (1,211±1,235gm). Controls lost ~400gm and ~160gm respectively. There was an increase in mean estimated total body protein (+1,796gm) following PRT contrasting with a numerical loss for the controls (-413gm). Seemingly large losses of total fat mass (-2,298gm and -1,326gm respectively). Changes in LBM correlated with change to 50-foot walk test (r= -0.613, p<0.0001), the chair test which is part of the Senior Fitness Test (r= 0.383, p<0.05), the arm curl test (r= 0.292, p=0.064), and knee extensor strength (r= 0.251, p=0.09). These improvements were not reflected in the Multidimensional HAQ scores (mean ±SD pretest and posttest: 0.914±0.680 versus 0.817±0.691 for the PRT group and 0.575±0.619 versus 0.575±0.590 for the control, p=0.513 for the interaction). IGF system: increases in muscle IGF-1 and IGFBP-3 levels (41% and 73%) were observed in the PFT group and in the control group these levels remained stable. Overall: Progressive resistance training increased LBM and ALM p < 0.01. Reduced trunk fat mass by 2.5kg,improved training-specific strength by 119%. Chair stands by 30%. Knee extensor strength by 25%. Arm curls by 23%, walk time 17%. Main conclusion: PRT is safe and effective at restoring muscle mass and functional capacity in patients with stable, established RA.	As 36 subjects are required for an appropriate power to assess appendicular lean mass, this data is underpowered.
Lineker SC, Bell MJ, Wilkins AL, Badley EM 2001 Canada	150 adult patients with moderate to severe rheumatoid arthritis (RA).	A home based Physical therapy (PT) program of exercise and education of the disease and individual goal setting. Treatment was provided by Arthritis Society physical therapists for 6 weeks (mean 4 hours). Control Group: No treatment for the same 6 weeks. The control group then had the same treatment from 6-12 weeks as required. All patients, therefore, had received PT by the 12 week review. Study type: 1c. Randomised Control trial	Blinded interviewers administered questionnaires at 0, 12 and 52 weeks. 1. the Stanford Arthritis Self-efficacy Scale (SES) 2. The arthritis Community Research and Evaluation Unit RA knowledge questionnaire (KQ). 3. Visual analogue scale (VAS) for pain 4. Arthritis impact scale 2 and impact profile (AIMS2) 5. Sickness Index Profile (SIP) 6. Disease activity – tender joints, grip strength, morning stiffness	127 completed the study protocol and 117 were available at the year follow up.For those that showed a significant improvement in SES, KQ and morning stiffness at 12 weeks were maintained at 52 weeks (p.0.010). Long-term measures of SIP and AIMS2 subscales (mobility, walking, and bending, hand and arm function, self-care and house hold activities, pain tension, mood, satisfaction, perception, disease impact, physical symptoms, affect) improved between baseline and 12 weeks (p≤0.001). At 52 weeks these improvements were maintained or continued to improve (AIMS2 pain subscale and the SIP). The VAS, grip strength, and number of tender joints were also improved at 12 weeks (p<0.001) and continued to improve over time.	No criteria for classification for classification of moderate/severe RA. Discussed the experience of the provider may have influence recovery – do we need specific training to implement effect treatment – not yet researched. No description of exactly what the PT at home involved.
Neidermann K, Buchi S, Ciurea A, Kubli R, Steurer-Stey C, Villiger PM, De Bie RA 2012 The Netherlands	53 patients: 1.Diagnosed with Rheumatoid arthritis (RA) according to the American college of rheumatology (ACR) guidelines 2. In ACR functional class II, III or IV 3. Perceived difficulties and/or pain in the hands that justified Occupational Therapy(OT) 4. Sufficient German language skills Exclusion criteria: severe deformities of finger, hand and shoulder	Five 45 minute sessions, four over a three-week period and one booster session 2 months later. Sessions about Joint protection used “The Pictorial Representation of Illness and Self Measure based joint protection (PRISM)” – this includes theories on social learning and self-management, and individualised education (oral and written) on joint protection to aid motivation. Homework and tasks are carried out to improve their joint protection. Any other OT intervention was documented (home exercises, provision of assisted devices and splints). Control Group: Conventional joint protection. Patients received: 1. Oral and written information on RA and joint protection principles. 2. Demonstrations and supervised practice of hand joint protection methods. Sessions were summarised in a short manual. Study Type: 1c. Multicentre randomised controlled trial	Carried out on initial assessment, 6 months and 12 months1. Joint Protection Behavioural Assessment (D-JPBA-S) 2. Video assessment of a task: ‘preparing an instant coffee’ and it was assessed on a 9 task scale from 0-2. 3. Hand function: grip strength and pain on Visual analogue scale (AS) 4. Arthritis self-efficacy scale (A-SES-D) 5. Joint protection specific self-efficacy scale (JP-SES) 6. EUROHIS-QUOL 8 – this is an eight-item WHO quality of life questionnaire assessing general quality of life on a 0-4 Likert scale. 7. Hospital anxiety and depression scale (HADS-D) 8. Disease activity score (DAS28). The PRIMS-JP group completed a Self-Illness separation and a self-resource separation.	6 month follow up: 1. JP behaviour was significantly better in the PRISM-JP group (Effect size (ES) S 0.32, p=0.02) 2. Joint protection behaviours were significantly increased in both groups 12 month follow up: 1. Joint protection adherence was significantly better in the PRISM-JP group (ES 0.28, p=0.04) 2. the C-JP group had significantly better quality of life score. Within group analysis showed the C-JP group had significantly better quality of life, depression and disease activity scores at 12 months than the PRISM-JP group. The PRISM-JP group alternatively had improved hand grip strength and self-efficacy scores at 12 months.	Randomisation involved sequentially numbered concealed treatment allocations. Not the gold standard for randomisation. Patient group and treating OT’s were not blinded but the assessor of primary outcome was blinded. No subjects dropped out from Conventional JP group, 4 patients dropped out or did not receive the full PRISM-JP intervention. Those who dropped out where included in the final analysis. Participants in the C-JP group were significantly younger then the PRISM-JP group and had a significantly higher weekly working hours mean at baseline.
Oldfiled V, Felson DT 2008 USA	Patients with Rheumatoid Arthritis (RA) having undergone aerobic exercise of moderate intensity for 20mins for at least twice per week over a minimum of 6 Weeks. Exclusion: Studies using healthy volunteers as controls were excluded. Trials with participants with pathologies other than RA were included if the results were reported separately for each patient group	6 Randomised control trials (RCT’s) of land based exercise that included either aerobic exercise only, non-aerobic only and three combination studies. Class exercise included 60-80% maximum heart rate(MHR) or videotape based home exercise 60-80% MHR 1h 3x/week. 12 wk 2 RCT’s of exercise in water. 4 RCT’s of foot orthoses. 2 RCT’s of wrist splints Control Group: Variable: 1.Usual physical therapy activity 2.Joint protection leaflet 3.Usual care 4.Land-based home exercise programme Study Type: 1a. Review article	Exercise based 1. Disease activity score (DAS4) with four variables - Ritchie articular index, 44 swollen joint count, Erythrocyte Sedimentation Rate (ESR),C-reactive Protein (CRP) and Visual analogue scale (VAS) 2. Total joint count, ESR, CRP or swelling or tenderness or pain with pressure in 70 peripheral joints. 3. Health Rated Quality of life (HRQL) Rheumatoid Arthritis quality of life questionnaires 1. McMaster Toronto Arthritis patient preference disability questionnaire. 2. Health Assessment Questionnaire 3. Arthritis Impact measurement scale 4. modified functional capacity evaluation 5. Global fatigue index of multidimensional assessment of fatigue questionnaire 6. McGill Pain questionnaire 7. Centre for Epidemiological studies depression questionnaire Feet1.Foot functional index 2. Foot Health status questionnaire 3. Short form-36 (SF-36) 4. Health assessment questionnaire 5. VAS 6. Gait assessment Wrist 1.Grip pressure 2. 2 point and 3 point pinch weight 3. Peg dexterity	Overall symptoms decreased over 12 weeks in the class exercise group vs. controls ( p<0.04); there was no significant between-group difference with home exercise vs. control. Disease activity was unchanged over 12 weeks in all patients. Walk time and grip strength were significantly improved from baseline in both exercise groups vs. controls ( p<0.005). The aerobic exercise group achieved significantly better scores than the control group on HRQL questionnaire: physical (3.5 vs. 2.0), emotional/psychological (2.0 vs. 1.4), social function (3.0 vs. 1.6), self-recognised health status (2.0 vs. 0.0) and total (3.4 vs. 2.0) scores [all p<0.05] Land-Based exerciseNo statistical improvements or worsening in the number of involved joints. RAPIT programme – significantly less radiological damage (p=0.045) for patients undertaking regular exercise at 2 year follow up. The study did note that patients experiencing joint damage progression over 2 years were significantly higher in the exercise group with extensive damage to large joints. Compared with control, there were significantly greater improvements from baseline in symptoms; walk time and grip strength following a 12-week aerobic programme. And similar for hand strength and function in the study evaluating non-aerobic hand strengthening and mobilising exercises. Hydrotherapy produces similar benefits to land based exercise. Physical function and pain were significantly improved with the use of specialised foot orthoses. Significantly lower mean VAS score for pain in subjects using palliative orthoses in the single use study evaluating gait (18.87 vs. 42.06 without, p=0.008) Wrist splints were found to improve pain and functionality without compromising dexterity. Of the three splints used, there was no significant difference between them.	Well laid out and easy to follow.
Porter BJ, Brittain A 2012 Canada	Patients with rheumatoid arthritis (RA) who had developed certain hand deformities: ulnar drift deformity (UDD), swan neck deformity (SWD) and boutonniere deformity (BD).	Effectiveness of resting splints. 1. Splinting 2. Night splinting 3. Metacarpophalangeal blocking splinting Control Group: Variable . Some had usual occupational therapy care, some no treatment. Study Type: 5. Expert opinion paper	A range of outcomes were included such as: 1.Pinch and grip strength 2. Radiography and goniometry of the hand and wrist 3. Morning stiffness 4. Pain 5. Patient preference for splint type 6. Dexterity	UDD: Cochrane review found no evidence that wrist and hand splints improve pain, pinch or grip strength, but patients preferred wearing splints to not wearing splints.An RCT showed a significant decrease in morning stiffness (p=0.021 in the splinted group. Another RCT reported the splint group had a reduction (p=0.001) in hand pain and improvements in grip and pinch strength, upper limb function and functional status.Functional splint trials reported that wearing the splints significantly reduced ulnar drift in the middle (p=0.0002), ring (p=<0.0001) and little (p=<0.0001) fingers. An MCP blocking splint combined with exercise showed a significant improvement in dexterity (p=0.046) and pain (p=0.043).SND: several studies reported an improvement in dexterity (p=0.05 and p=0.026) and dexterity related pain (p=0.05).BD: very limited evidence on the effectiveness of splinting.Hand exercises: a systematic review showed no strong evidence for the use of exercise in the RA hand and no evidence of its effect on hand deformity. Consequently, no single approach can be directly applied to all patients. There is limited evidence to support or refute the role of splinting and hand exercise for these three hand deformities.	Unclear if the guidelines for whole body exercise can be transferred to application with exercise for RA hands. Poor methodological quality as only expert opinion. Also, detail about the outcome measures was not clearly documented, especially with how morning stiffness was assessed and dexterity measurements. No clear conclusions drawn – no clear evidence for any splinting and exercises for hand RA deformities. Management of RA hand deformities is complex.
Ronningen A, Kjeken I 2008 Norway	60 Inpatients with rheumatoid arthritis (RA) diagnosed according to the American college of rheumatology criteria (ACR), disease duration of >1 year, age between 18 and 70 years, ability to be able to communicate Norwegian and able to be recruited within the first two days after admission to the hospital. Exclusion: functional problems related to diseases other than RA, pregnancy, hand surgery 6 month before or during inclusion in the study, mental or cognitive deficits, or attendance at less than five training sessions during the hospital stay.	An intensive hand therapy programme (IEP) that comprised of 11 exercises repeated 10 times delivered In a daily group session led by an Occupational Therapist (OT) for 1 week and then continued independently. The exercises included gripping a ball and through range movements that were described in an appendix. When discharged, participants were instructed to continue with this exercise for a minimum for 5 days per week for 12 further weeks. Control Group: Conservative hand exercise programme (CEP), 11 exercises repeated 3 times. On discharge the patients were advised to exercise according to their normal exercise routine. Study Type: 2b. Clinical controlled trial.	Patients were evaluated at the start of their hospital stay, at discharge (approximately 2 weeks after admission) and 12 weeks after discharge.1.Grip strength 2. Three-pod pinch strength 3. Visual analogue scale (VAS) during Grippit recording of grip strength and pinch test 4. Joint mobility – goniometry for flexion deficit, extension deficit, opposition deficit, wrist mobility, palmar dorsal flexion 5. Grip Ability Test (GAT) 6. Self-estimated hand function (SEHF) recorded on a VAS 7. Modified version of the Stanford Health Assessment Questionnaire (MHAQ) 8. Patient experience assessed through interview following each intervention	Median of 7 sessions attended during 2 weeks in both groups. Median number of self-reported training sessions: 39 in CEP group and 49 in the IEP group. The increase in SEHF did not differ between groups (p = 0.71) There was no significant changes in disease variables within the groups from baseline to 14 weeks, or between the groups in the study period, except for the significant decrease in fatigue in the IEP group after 14 weeks (p=0.01)Joint mobility: Within each group revealed some significant improvements in the measures of joint mobility. There was no significant difference between the two groups at 2 or 14 weeks in the MHAQ, but the GAT score was statistically significantly improved in the IEG after 2 weeks (p= 0.001).No patients reported negative effects of the hand exercise programmes.	Cohort Study but authors call it clinical controlled trial. Query as to the control this isn’t a control but a comparator It may have been helpful to have had a group with waiting list control to see the effect of no exercise. Patients in the study were inpatients at a Rheumatology Centre and potentially results may not be applicable to an outpatient patient population. Other physiotherapy or medical interventions received during inpatient stay were not documented. The patients interviewed were not chosen randomly and may not reflect the results of the population. The patients interviewed reported that they struggled to comply with the recommended 5 times a week protocol on the IEP with an average of 4 times a week achieved. The study was not randomised and the assessors were not blinded to the exercise intervention which may have influenced the measurements. There were significant baseline differences between two groups regarding disease duration and extension deficit in the dominant hand. These differences where controlled for in the statistical analysis however randomisation could have prevented this. Of 60 that started the study, 50 completed. Paper discussed that the increase in strength gained in the IEP group may not be reflected in normal daily tasks and therefore subjective benefits from improved strength may be missed/undervalued. The programme is a non-specific/generic exercise programme - this may need to be adaptable to target patients’ specific impairments/dysfunctions.
Vliet Vlieland TPM, Van Den Ende CH 2011 The Netherlands	Patients with Rheumatoid arthritis (RA)	Discussion and summary of recently published reviewed: Cochrane review - >20 mins aerobic exercises at >55% max heart rate and/or muscle strengthening exercises starting at 30-50% maximal strength. Duration >6 weeks x 2 weekly. One Randomised control trial (RCT) – long-term land-based dynamic exercise programmes Meta-analysis of 14 RCT’s with aerobic exercise. Including an RCT 4-week dynamic exercise programme with Multidisciplinary team (MDT) intervention Control Group: Nil Study Type: 5. Review of recent literature.	Varied depending on the review. Outcome measures described include: 1. Compliance to exercise tools 2. Cardiorespirtory function 3. Funtional ability 4. Disease activity 5. Health Assessment Questionnaire 6. Muscle mass 7. Quality of patient education 8. Foot pain and function 9. Visual analogue scale (VAS) for pain	Paper’s conclusion: Exercise and physical activity programmes are consistently improving; however more research is needed on self-management. The benefits of wrist and finger splints have been consistently demonstrated. For dietary manipulation, there is a need for more appropriately designed studies	High level of bias.

Comment(s)

1. A group-based supervised exercise programme and high-intensity progressive resistance training have been shown to have a significant positive effect on aerobic capacity and muscle strength in the short term for patients with Rheumatoid Arthritis (RA). Evidence for long term benefits are inconclusive. 2. There were no reported negative impacts or adverse effects of exercise upon RA disease activity. 3. Home Exercise Programmes may benefit patients with RA when compared to no treatment. 4. Moderate massage may improve pain, anxiety, depression and joint range of motion for patients with RA in comparison to light massage. 5. There is are equal benefits to functional ability and aerobic capacity using either land based or water based exercise for patients with Rheumatoid Arthritis. 6. Intensive exercise (usual care plus reciprocal isometric and isokinetic training programmes) for patients with RA can slow down the loss of bone mineral density in the hip. 7. Joint protection advice can reduce Disease Activity Scores and increase Quality of Life outcomes for patients with RA.

Clinical Bottom Line

The current best physiotherapy treatment and advice for chronic, multiple joint pains and stiffness in patients with RA varies depending upon the goals that the patient would like to achieve.

References

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