Non-drug treatment (excluding surgery) in rheumatoid arthritis: clinical practice guidelines.
OBJECTIVE
Because drugs do not halt joint destruction in rheumatoid arthritis (RA), non-drug treatments are an important adjunct to drug treatment. Establishing rules governing their use is difficult because treatment is multidisciplinary, complex, and difficult to assess. The aims of these guidelines were to (a) establish the indications for physical therapies and for educational, psychological, and other non-drug interventions, (b) address social welfare, occupational, and organizational issues.


METHODS
A systematic literature search (MEDLINE, EMBASE, CINAHL, Pascal, Cochrane Library, HTA database) (1985-2006) was completed with information obtained from specialty societies and the grey literature. A review of the studies meeting inclusion criteria, with evidence levels, was used by a multidisciplinary working group (18 experts) to draft guidelines. Consensus was reached when evidence was lacking on key topics. The draft guidelines were scored by 60 peer reviewers, amended when necessary, and then validated by the HAS Board.


RESULTS
Of the 1819 articles retrieved, 817 were analysed and 382 cited in the report. Low-power randomized clinical trials constituted the highest level of evidence. Grade B guidelines (intermediate evidence level) concerned aerobic activities, dynamic muscular strengthening, and therapeutic patient education. Grade C (low evidence level) concerned use of rest orthoses or assistive devices, balneotherapy and spa therapy, self-exercise programmes, and conventional physiotherapy. Professional agreement (no scientific evidence) was reached for orthotic insoles and footwear, chiropody care, thermotherapy, acupuncture, psychological support, occupational adjustments, and referral to social workers.


CONCLUSIONS
Aerobic activities, dynamic muscular reinforcement, and therapeutic patient education are valuable in non-drug management of RA.
Forestier
Romain
R
Centre de recherche rhumatologique et thermal, 15, avenue Charles-de-Gaulle, 73100 Aix-les-Bains, France. romain.forestier@wanadoo.fr
André-Vert
Joëlle
J
Guillez
Pascal
P
Coudeyre
Emmanuel
E
Lefevre-Colau
Marie-Martine
MM
Combe
Bernard
B
Mayoux-Benhamou
Marie-Anne
MA
D001172:Arthritis, Rheumatoid / Q000503:physiopathology / Q000628:therapy*; D003245:Consensus Statements as Topic; D016206:Databases, Bibliographic; D015444:Exercise; D005602:France; D006801:Humans; D009989:Orthotic Devices; D010353:Patient Education as Topic; D026741:Physical Therapy Modalities; D017410:Practice Guidelines as Topic