Abstract. Key words: Rehabilitation, rheumatoid arthritis, evidence-based practice. Introduction

Musculoskeletal Care Volume 2 Number 3 Whurr Publishers 2004 135 Main article Rehabilitation in rheumatoid arthritis: A critical review Alison Hammond PhD MSc BSc(Hons) DipCOT Senior Research Therapist, Derbyshire Royal Infirmary, Derby Abstract This article considers the evidence for effectiveness and timing of rehabilitation for people with rheumatoid arthritis (RA). The Cochrane Library, DARE, Medline, Embase, CINAHL and AMED were searched to identify systematic reviews and randomized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis. Many trials identified had methodological limitations (e.g. short follow-up periods, small sample sizes). Evidence to date is that symptomatic relief results from thermotherapy, laser therapy, acupuncture and assistive devices. In the short-term, comprehensive occupational therapy (in established rheumatoid arthritis), orthoses, and mind body approaches can help maintain function. Over at least a one-year period, the following are effective in reducing pain and maintaining function: patient education and joint protection training using behavioural approaches; dynamic exercise therapy, hand exercises and hydrotherapy; and cognitive-behavioural therapy (in people with poorer psychological status). Many trials have recruited people with moderate to severe, established RA and relatively little is known about the long-term effectiveness of early rehabilitation, although this is becoming much more common in practice. Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Further well-designed clinical trials are needed recruiting people with early disease using patient-centred outcomes. Key words: Rehabilitation, rheumatoid arthritis, evidence-based practice Introduction Rehabilitation is concerned with managing the consequences of disease. As no drug therapies at present lead to long-term remission for everyone with rheumatoid arthritis (RA), people will continue to experience physical, psychological, functional, social and role consequences, which could benefit from rehabilitation (Vliet Vlieland, 2003a). To provide best care, rehabilitation standards and services

136 Hammond should be based on the best available evidence. This article will review: why rehabilitation is needed in RA; which groups of people with RA need rehabilitation as a priority; the importance of early provision of specialist rheumatology care, patient education and promotion of self-management; and the evidence for the effectiveness of therapeutic interventions and multidisciplinary care. Future research directions will also be recommended. Method The following databases were searched to identify the available evidence: the Cochrane Library; Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effectiveness, Medline (1989 2003), EMBASE (1988 2003), CINAHL (1982 2003) and AMED (1985 2003). The search was limited to articles published in English and initially to randomized controlled trials, meta-analyses and systematic reviews, but was extended to narrative reviews and clinical trials for some topics if few or no articles were identified. The search combined the term rheumatoid arthritis with the MeSH headings and/or keywords shown in Table 1. Articles were also hand searched for further relevant references. The summaries of evidence provided below were obtained from systematic reviews and high quality randomized controlled trials unless otherwise stated. TABLE 1: MeSH headings and keywords used in the literature search Rehabilitation Physiotherapy, physical therapy Occupational therapy: hand Podiatry: foot Vocational rehabilitation, work Nursing Cognitive-behavioural therapy Multi-modal therapy Comprehensive care, team care Patient education, self-care and self-management Assistive technology, assistive devices Splint, orthoses Joint protection, energy conservation Exercise, hydrotherapy Relaxation The impact of RA and the need for rehabilitation RA is chronic, unpredictable and can cause persistent joint pain, joint damage (especially in the hands and feet) and long-term disability. Five years after diagnosis, while 40% still have relatively normal function (13% in remission), 44% have mild to moderate and 16% marked functional disability (Young et al., 2000). In working people 15% are work disabled at one year, 27% by five years, rising to over 50% by 10 years, leading to serious financial consequences for the person and his or her family and increased social security costs (Young et al., 2000). In the longer term, 80% are moderately or severely disabled by 20 years. The annual cost of treating RA is 0.8 1.3 billion (Scott et al., 1998). Most costs come

Rehabilitation in rheumatoid arthritis 137 from long-term care and hospital admissions, with drug therapy, including monitoring and management of toxicity, accounting for 15% of costs (Gray and Muirie, 2002). This is estimated to rise by 55 75 million per year with the increased use of the new biologic therapies, even though these are only applicable to a small minority of severely ill patients (6 8%) (ARMA, 2003). Joint damage progresses constantly over the first 20 years of RA. Avoiding or reducing joint damage in both early and established/late RA is likely to maintain function and thus reduce costs (Scott et al., 1998). Risk factors for poorer functional outcome and morbidity are: 1. Moderate functional disability already evident at diagnosis (ACR, 2002; Scott et al., 1998; Young et al., 2000). 2. Requiring hospital admission early (ACR, 2002; Scott et al., 1998; Young et al., 2000). 3. Poorer psychological status, i.e. poor self-efficacy, greater helplessness, passive coping (e.g. excess rest, decreasing social, leisure and work activities, relying on health professionals to affect symptoms), and depression (Covic et al., 2000; Uhlig et al., 2000). 4. Younger or older than peak age of onset (45 65 years) at disease onset (ACR, 2002; Young et al., 2000). 5. Socio-economic deprivation, possibly due to co-morbid disease, lifestyle factors (e.g. poorer diet, smoking), poorer self-management skills, later presentation with disease and poorer access to services (McEntegart et al., 1997). People with the above risk factors for poor outcome, in particular, should be identified and referred for rehabilitation early. Overall, the statistics indicate that, at some stage, two-thirds of people with RA could benefit from rehabilitation services to reduce disability. At least half of those of working age could benefit from vocational rehabilitation to prevent work disability. Early referral to specialist rheumatology care Specialist secondary care from dedicated rheumatology teams gives better outcomes in RA than general or primary care services (Solomon et al., 1997). All people suspected of having RA should be referred rapidly to a consultant rheumatologist. Any of the following should trigger rapid referral: more than three swollen joints; metacarpophalangeal/metatarsal (MCP/MTP) involvement; and/or morning stiffness for longer than 30 minutes (Emery et al., 2002). People suspected of having RA must be seen within 12 weeks (preferably six) of referral for diagnosis and to start disease modifying anti-rheumatic drug (DMARD) therapy as soon as possible.

138 Hammond Delaying DMARDSs adversely affects functional outcome, although symptoms and disease activity can be controlled (Scott et al., 1998; ACR, 2002). A longitudinal study identified adherence with drug therapy was about 60%, and was influenced by the quality of contact with the health professional and information provided (Viller et al., 1999). All allied health professionals (AHPs) should therefore emphasize the benefits of concordance with DMARD therapy. Following diagnosis, rheumatology nurse practitioner (RNP) follow-up is more effective than junior doctor and consultant care in providing patient education, maximizing concordance with drug therapy (essential to gain long-term functional benefits), referral to other health professionals for rehabilitation, and improvements in disease and functional and psychological status (Hill et al., 1994, 2001, 2003). Drug management Sulphasalazine and methotrexate have more favourable efficacy/toxicity profiles, but within 2 4 years over 50% of patients change to a second DMARD, as the first is no longer effective (SIGN, 2000; ACR, 2002). Biologic therapies are currently available for those with severe disease, who have already failed on two DMARDs (including methotrexate). Biologic therapies markedly improve functional ability but are expensive and provision varies considerably throughout the UK (ARMA, 2003). As drug therapy does not provide a cure, rehabilitation is essential. Effectiveness of rehabilitation interventions Patient education and self-management evidence The person with RA is an integral part of the team. Patients must be fully informed about their disease and treatment options to make decisions about their long-term care. Early education from the RNP aims to increase understanding of the condition, drug therapy, the role of the multidisciplinary team and shape motivation to use selfmanagement (Brady et al., 2000). The effect on the family and the social impact of the disease must be taken into account. People with RA should be informed of arthritis organizations locally and nationally. Written information must be provided as this significantly improves knowledge and provides reassurance (Barlow and Wright, 1998), e.g. Arthritis Research Campaign, Arthritis Care and National Rheumatoid Arthritis Society (NRAS) booklets on the disease, drug therapy, selfmanagement, availability of self-management programmes locally, as well as Internet sites and recommended book lists (Rowan et al., 1997). Patient education programmes significantly improve use of self-management, disability, pain and psychological status in the short-term (Superio-Cabuslay et al.,

Rehabilitation in rheumatoid arthritis 139 1996; Riemsma et al., 2002). People who use more active coping strategies have less functional disability long-term (Uhlig et al., 2000). The following factors should be considered in self-management patient education: Who: People with arthritis who are starting to lose movement and function. When: Early but timed to when people are psychologically ready to make lifestyle changes. Later education is still effective. What: Behaviourally based interventions (i.e. including goal-setting, contracting and feedback) are significantly more effective in improving health status than information and/or counselling alone (Superio-Cabuslay et al., 1996; Riemsma et al., 2002). Programmes should emphasize healthy lifestyle management and provide quality skills training in exercise, joint protection, pain and fatigue management, cognitive symptom management, effective communication, and should include disease and drug therapy education. How: Group behavioural programmes are more effective than individual education and use resources more efficiently. Flexibly timed and locally based patient education services maximize opportunities to attend. However, a survey found only 50% of people with RA consider attendance at group education useful and many prefer one-to-one education from health professionals and self-study programmes (Hammond and Badcock, 2002). To date, the limited evidence is that individual education is less effective improving knowledge and patient satisfaction but not self-efficacy, health behaviours or health status (Riemsma et al., 1997, 2002). Self-study programmes are effective when individualized but require health professional input to support people through change (Goeppinger et al., 1989; Fries et al., 1997). Why: The potential long-term benefits to the person and society of taking responsibility for self-management must be emphasized from an early stage, so that people attend effective group programmes. Community-based trained user-led self-management programmes are effective ( Challenging Arthritis, run by Arthritis Care: Barlow et al., 2000) and are currently being rolled out in the UK Expert Patient Programme. Informing people about the availability of these is essential. NRAS is also establishing a national expert patient programme providing individual education and support from people with arthritis. Patient education is a foundation of all rehabilitation interventions. If a person is not yet psychologically ready to change, motivational interviewing and brief educational interventions are more appropriate, with repeat opportunities to attend programmes. The most effective programmes improving outcomes use cognitivebehavioural strategies.

140 Hammond Occupational therapy (OT) evidence Joint protection/fatigue management: a randomized controlled trial (RCT) has demonstrated this reduces pain, early morning stiffness, maintains functional ability, improves grip and reduces number of visits to a doctor for arthritis one year after education in early RA (Hammond and Freeman, 2001). These improvements occurred only after a behavioural group programme, and education based on typical practice did not improve adherence or outcomes. An RCT of a behavioural energy conservation programme resulted in a better balance of rest and activity and overall levels of physical activity compared to typical teaching methods (Furst et al., 1987). Activities of daily living and assistive devices: in the short-term some assistive devices do significantly reduce pain, but designs have in general been poorly evaluated (Hass et al., 1997; Nordenskiold, 1994). A significant percentage of devices are abandoned if appropriate designs are not recommended to suit individual users needs (Eckloff and Thornton, 2002). A retrospective study identified that altered working methods, environmental modifications and assistive devices significantly reduce self-reported difficulty in activities of daily living (ADL) (Nordenskiold et al., 1998). Splinting: Hand and wrist splints reduce pain and improve grip and functional ability while being worn, and resting splints reduce pain at night (Steultjens et al., 2002). There is no evidence as yet that splinting maintains function long-term or prevents deformity. Adherence with splint wearing is highly variable and often associated with beliefs about splint efficacy. Government recommendations for medical device use are that splint provision should ensure correct design choice and fit, with clear instructions (written and verbal) in their use and care. Regular (e.g. six monthly) monitoring must be provided to ensure maximum therapeutic efficacy is continuing (Medical Devices Agency, 2000). Hand exercises: (provided by both occupational and physiotherapists). A combination of range of motion and strength exercises is more effective than range of motion or wax therapy alone in improving grip and pinch strength, reducing pain and maintaining hand function (Hurley et al., 2002, Dellhag et al., 1992, Brighton et al., 1993). Hand function deteriorates early in RA suggesting most people might benefit from following a maintenance range of motion and strengthening hand exercise programme at an early stage. Relaxation/mind body approaches: A combination of Tai Chi, relaxation and stress management improves range of motion and disability in the short-term (Van Deusen and Harlow, 1987). Work and leisure interventions: although included in therapy programmes no trials of the effectiveness of these interventions provided by occupational therapists were identified. Comprehensive OT programmes: These include ADL assessment and training,

Rehabilitation in rheumatoid arthritis 141 splinting, joint protection, assistive devices and environmental modification, fatigue and pain management, counselling, patient education and work and leisure rehabilitation. Comprehensive OT is effective in the short-term in improving functional ability in people with moderate to severe established RA (Helewa et al., 1991). Longer term follow-up studies have not been conducted as yet in people with established RA. In early RA (less than 2.5 years post-diagnosis), an average 7.5 hour secondary preventative programme of typical OT (i.e. education, exercise, joint protection, orthoses, and ADL, work and leisure advice) led to some increase in selfmanagement but after two years, had no significant effect on physical, functional or psychological status (Hammond et al., 2004). Qualitative interviews indicated those with milder disease may have considered the programme too early and selfmanagement was inappropriate to their needs. Additionally, behavioural approaches, now known to be more effective, were not included in the OT programme. In early RA, specific interventions relevant to functional needs is most relevant (SIGN Guidelines, 2000) combined with self-management education, if the person is ready to make these changes (NAROT Guidelines, 2003). A recent systematic review concluded there is limited but encouraging evidence that OT has a positive effect on functional ability and pain (Steultjens et al., 2002). Although OTs emphasize the holistic nature of their interventions in improving psychological status and increasing role participation (as well as improving physical function), very little research has been directed at evaluating the effectiveness of OT in these domains (Hammond, in press). Exercise and physical therapies evidence Aerobic and strengthening exercise: two systematic reviews conclude this leads to significant improvements in physical (muscle strength, aerobic capacity, endurance and function) and psychological status (self-efficacy and well-being) and does not exacerbate disease activity (Van den Ende et al., 2003; Stenstrom and Minor, 2003). However, both studies concluded that the long-term effects are as yet unclear. A recent trial of intensive exercise over two years has demonstrated continued significant improvements in functional ability without detrimental effects on disease activity (De Jong et al., 2003). All people with arthritis should be taught and supported in following an effective exercise programme, i.e. of moderate (60 85% of maximum heart rate) aerobic exercise three times a week for between 30 and 60 minutes cumulatively, combined with moderate strengthening (50 80% of maximal voluntary contraction) two to three times a week (Stenstrom and Minor, 2003). Behavioural based exercise education, supporting people in increasing their use of exercise over a number of weeks or months is most likely to enable people to achieve this, rather than simple provision of short training and education sessions, supported by leaflets, as is common practice in the UK at present. Considerably more resources

142 Hammond need to be put into helping people with RA increase their use of exercise. Exercise on Prescription schemes (i.e. free/reduced rate exercise facilities available in leisure centres following referral by a GP for health reasons) may be a means of helping achieve this. Hydrotherapy: intensive dynamic training once a week for the person as a whole can improve grip and activity levels for up to two years. Long-term therapy can reduce the rate of hospital admission (Stenstrom et al., 1991). Thermotherapy: there are no significant benefits from heat and ice pack applications, cryotherapy or faradic baths apart from short-term relief of symptoms. Paraffin wax baths combined with exercises have beneficial short-term effects for arthritic hands (Hurley et al., 2002; Robinson et al., 2002). Electrical stimulation (ES): this aids muscle strength and endurance training in people unable voluntarily to recruit muscles actively. Only one small good quality study shows ES aids grip strength and fatigue resistance in the hand. Other uses are inadequately studied (Pelland et al., 2003). Low level laser therapy and acupuncture: these are beneficial in reducing pain in the short-term but have no other effects. However, trials are few and small in size (Casimiro et al., 2002; Brosseau et al., 2003). Comprehensive physiotherapy (PT): a combination of education, exercise and pain relief modalities significantly improves knowledge, self-efficacy and early morning stiffness for up to one year (Bell et al., 1998; Lineker et al., 2001; Hurley et al., 2002). Surprisingly little research has focused on evaluating the functional effects of comprehensive physiotherapy programmes. Foot care evidence Podiatry provides a combination of patient education, exercise, foot joint protection, splinting and footwear advice. Semi-rigid foot orthoses are more effective in reducing metatarsalgia than soft orthoses or supportive shoes alone (Chalmers et al., 2000). Extra-depth shoes or off-the-shelf orthopaedic footwear combined with moulded insoles decrease pain in standing, walking and stairclimbing, physical function, gait velocity, and gait stride length (Woodburn et al., 2002; Egan et al., 2003). Multidisciplinary foot care services (podiatry, orthotics, PT and OT) are an important component of service delivery to ensure foot problems are identified early and appropriate therapy, orthoses and footwear provided. Psychological interventions evidence Multimodal cognitive-behavioural therapy (CBT) (i.e. relaxation, imagery, stress management, cognitive coping skills, biofeedback, psychotherapeutic interventions group and individual) significantly improves pain and functional disability in the short-term. Anxiety, depression, self-efficacy and coping skills are improved both

Rehabilitation in rheumatoid arthritis 143 short- and long-term. Interventions seem more effective in people with shorter disease duration (less than 11.5 years). CBT is most applicable for people at risk, i.e. with severe pain, little social support, who feel helpless about coping with their disease and become disabled even though seemingly having mild to moderate disease (Astin et al., 2002). Work rehabilitation evidence The prevalence of work disability is high, job problems arise quickly and job loss can often occur before the person is referred to rheumatology departments or started on DMARD therapy. Factors affecting work disability are primarily work factors (e.g. physical demands of the job, degree of autonomy) and employee factors (e.g. age, education, work motivation). Disease factors (e.g. disability, flare-up frequency, degree of pain and fatigue) are less important. Work loss is common in those with physically demanding jobs unable to change to lighter work and with little control over work pace (Frank et al., 2001). A recent evidence-based report summarized that there is good evidence that work rehabilitation can reduce sickness absence and early retirement, increase productivity, continue payment of taxes and reduce state benefits payments (BSRM, 2000). Key strategies to maintain people in work include rapid communication with employers and the employee with arthritis at disease onset and flare-up, openness between the two parties, job modification, re-organizing work schedules, reducing access barriers, enabling people to stay in their current workplace and changing to more appropriate duties if necessary (Frank and Chamberlain, 2001). Occupational therapists or physiotherapists trained in ergonomics and work rehabilitation can provide structured work rehabilitation programmes. Disability employment advisers at Job Centres assist financially and practically. Vocational retraining or intensive work rehabilitation is effective for people needing to change jobs or after extended sick leave (De Buck et al., 2002; BSRM, 2000; Gilworth et al., 2001). A trial evaluating a job retention rehabilitation programme demonstrated positive effects (Allaire, 2002). However, structured vocational rehabilitation and retention programmes are generally insufficiently available and almost completely lost in the UK National Health Service (BSRM, 2000). Good evidence indicates that introducing a simple work problem-screening tool into rheumatology clinics assists early identification of work problems. Early work assessment reduces work problems, maintains people in work and results in high levels of satisfaction from workers with RA (Barlow et al., 2001). Multidisciplinary rehabilitation evidence Co-ordinated intensive multidisciplinary rehabilitation programmes are important for people with active RA or moderate to severe RA and multiple functional

144 Hammond problems. Systematic reviews conclude that in-patient programmes are more beneficial for up to a year longer than outpatient rehabilitation and those of longer duration (more than five weeks) are most effective (Vliet Vlieland and Hazes, 1997; Badamgarav et al., 2003). One high quality trial demonstrated intensive medical treatment and rehabilitation provided in well-structured, co-ordinated day care (10 a.m. 4 p.m. daily) and in-patient rehabilitation are similarly beneficial, with day care being slightly cheaper (Lambert et al., 1998). It is likely that local geographical and service factors influence the most effective method of providing multidisciplinary care for those with more severe problems. Availability of rheumatology rehabilitation A recent survey of members by the National Rheumatoid Arthritis Society (NRAS) identified only 63% had access to an RNP, 57% to PT, 48% to OT and 39% to podiatry (NRAS, 2003). This is likely to be an optimistic picture of UK provision. Barriers to effective rehabilitation A primary barrier is adherence with self-management strategies, which are major constituents of rehabilitation programmes, requiring active participation and lifestyle changes from the individual. For example, unsupervised exercise and splinting adherence rates are between 18% and 57% (Lorish, 1998). Self-efficacy (i.e. belief in the effectiveness of treatment and ability to follow a treatment regime) is known to be a major determinant of medication adherence (Brus et al., 1999). Strategies designed to enhance self-efficacy can significantly improve adherence and outcome (Marks, 2001). Patient education research concludes group cognitivebehavioural approaches are most effective in improving adherence with selfmanagement (Riemsma et al., 2002). Traditional education approaches, of education, demonstration, brief supervised practice and written information in timelimited therapy interventions, may not be optimally effective in facilitating behaviour change, and thus rehabilitation costs are unnecessarily increased. Allied health professionals need increased training opportunities in applying behavioural approaches and motivational methods in daily practice to facilitate adherence. Future research Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Better quality trials of single interventions are needed to identify effective elements of therapy, and trials based on pragmatic and accessible

Rehabilitation in rheumatoid arthritis 145 interventions are required (Hurley et al., 2002). Long-term studies of comprehensive therapy programmes are needed. Most trials have recruited people with established, moderate to severe RA. With earlier referral to rheumatology, rehabilitation and patient education is being provided earlier in the disease course, but there has been little evaluation of the effectiveness of this at this early stage. Medical treatment has improved and the potential gain from rehabilitation is therefore probably limited at this early stage (Vliet Vlieland, 2003b). People with relatively mild disease, reasonably controlled by drug therapy, may find self-management interventions interesting, but feel they are not that bad yet. Secondary preventative self-management education provided too early for an individual s needs may, in fact, be a waste of resources if the person is not yet ready to act upon it. Research into the effectiveness of screening methods to identify who is psychologically ready to benefit from self-management education and rehabilitation, motivational interviewing on increasing preparedness to self-manage, and programmes incorporating cognitive-behavioural approaches may assist in targeting rehabilitation more cost-effectively. There is also a need for consensus in what rehabilitation outcomes to use in trials, as this would allow for comparisons between patient groups and interventions, in particular including patient relevant outcomes (Vliet Vlieland, 2003a). A review of relevant measures has recently been published (Katz et al., 2003). Conclusion Primary care and rheumatology health professionals should emphasize the importance of self-management from an early stage and help motivate people to use this. Early screening for at risk factors is needed (e.g. for work disability, severe psychological distress, early hand and foot problems, early development of functional difficulty) and rehabilitation services should be targeted early at these groups, as they are most likely to have increased disability long-term. The following interventions improve function, self-efficacy, physical and psychological status and reduce pain: 1. Patient education using behavioural approaches. 2. Joint protection and energy conservation training using behavioural methods. 3. Dynamic exercise therapy and hydrotherapy. 4. Orthoses and supportive footwear. 5. Psychological interventions (cognitive-behavioural therapy) in people with poorer psychological status. 6. Intensive co-ordinated in-patient or day patient rehabilitation for people with active or severe RA. A summary pathway for the management of rheumatoid arthritis is given in Appendix 1.

146 Hammond Rehabilitation can improve function and psychological status, but relatively little is known about its longer-term effects, its efficacy in preventing or maintaining function when provided at an early stage, or who benefits most. AHPs need to ensure they are effectively implementing approaches enhancing adherence in order to reduce costs. Acknowledgements This review was supported by the Rheumatology Charitable Trust Fund, Derbyshire Royal Infirmary. Many thanks to the following for their comments on earlier drafts of this article: Drs RA Williams, MR Regan, GD Summers, LJ Badcock, S O Reilly, consultant rheumatologists, Derbyshire Royal Infirmary; Krysia Dziedzic, Candy McCabe, Paul Creamer, Sarah Ryan, Robert Field (members of the British Health Professionals in Rheumatology Committee); Ailsa Bosworth, Chair, National Rheumatoid Arthritis Society; and Sophie Edwards, Chief Executive, Arthritis and Musculoskeletal Alliance. References ACR: American College of Rheumatology Subcommittee on RA Guidelines (2002). Guidelines for the Management of Rheumatoid Arthritis: 2002 Update. Arthritis and Rheumatism 46(2):328 46. Allaire SH (2002). A randomised trial with 3.5 year follow-up shows job retention vocational rehabilitation services reduce job loss. Arthritis and Rheumatism 46: S580 1. ARMA: Arthritis and Musculoskeletal Alliance (2003). Anti-TNFa survey. Available from ARMA, 41 Eagle Street, London WC1R 4LT. Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B (2002). Psychological interventions for rheumatoid arthritis: A meta-analysis of randomised controlled trials. Arthritis and Rheumatism (Arthritis Care and Research) 47(3): 291 302. Badamgarav E, Croft JD, Hohlbauch A, Louie JS, O Dell J, Ofman JJ, Suarez-Almazor ME, Weaver A, White P, Katz P (2003). Effects of disease management programs on functional status of patients with rheumatoid arthritis. Arthritis and Rheumatism (Arthritis Care and Research ) 49(3): 377 87. Barlow JH, Turner AP, Wright CC (2000). A randomised controlled study of the arthritis selfmanagement programme in the UK. Health Education Research. 15(6): 665 80. Barlow JH, Wright CC (1998). Knowledge in patients with rheumatoid arthritis: A longer-term follow-up of a randomised controlled study of patient education leaflets. British Journal of Rheumatology 37: 373 6. Barlow J, Wright C, Kroll T (2001). Overcoming perceived barriers to employment amongst people with arthritis. Journal of Health Psychology 6(2): 205 16. Bell MJ, Lineker SC, Wilkins AL, Goldsmith CH, Badley EM (1998). A randomised controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis. Journal of Rheumatology 25: 231 7. Brady TJ, Sniezek JE, Conn DL (2000). Enhancing patient self-management in clinical practice. Bulletin of the Rheumatic Diseases 49(7): 1 4. Brighton SW, Lubbe JE, van der Merwe CA (1993). The effect of a long-term exercise programme

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150 Hammond Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, Gallivan S, Gough A, James D, Prouse P, Williams P, Winfield J (2000). How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology 39: 603 11. Correspondence should be sent to Alison Hammond, Senior Research Therapist, Rheumatology Department, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY. Fax: 01332 254989, E-mail: Alison.Hammond@derbyhospitals.nhs.uk Key to Appendix 1 ADL = Activities of daily living DMARD = Disease modifying anti-rheumatic drug ERP = Extended role practitioner GP = General practitioner MCP = Metacarpophalangeal MDT = Multidisciplinary team MTP = Metatarsophalangeal NRAS = National Rheumatoid Arthritis Society OT = Occupational therapist PT = Physiotherapist RNP = Rheumatology nurse practitioner

Rehabilitation in rheumatoid arthritis 151 Appendix 1: Summary pathway for rheumatoid arthritis GP: Early identification of inflammatory arthritis/ra: Any of the following must trigger rapid referral to a consultant rheumatologist 3 swollen joints; MCP/MTP involvement; morning stiffness 30 minutes. Rheumatology: appointment within 12 (preferably 6) weeks. Diagnosis, disease and drug therapy education from consultant/rnp/erp. Drug therapy (including DMARDs). Education: emphasizing benefits of self-management; counselling (if necessary) to support emotional adjustment to chronic disease; comprehensive information packs. Inform of NRAS expert patient programme for one-to-one support. Work problems identified: Early referral to OT for work screening/ advice/rehabilitation. Liaison with employers/disability employment adviser. Poor psychological status: Psychology: early referral for counselling or cognitive behavioural therapy as necessary. Mobility/function/psychosocial status beginning to be affected: RNP/ERP/doctor: evaluate readiness to use self-management. Motivational interviewing to enhance willingness to change. When psychologically ready refer to: Cognitive-behavioural approach group arthritis self-management programme. Provide programmes flexibly (day and evening/hospital and community). Individual cognitive-behavioural based self-management education: if person unwilling/ unable to attend group programme. Team: emphasize home exercise/activity: regular aerobic fitness exercise, e.g. Tai Chi, walking, swimming, keep fit (low impact), yoga etc. Increasing mobility, functional, psychosocial problems: RNP/ERP/doctor: regular monitoring for development of problems, with early referral to MDT. OT: joint protection, fatigue management, splinting (hand, neck, insoles), ADL/work/leisure rehabilitation; assistive devices, psychological interventions, e.g. relaxation, stress and pain management, counselling). Liaison with social services, mobility centre, employment if needed. PT: exercise therapy, hydrotherapy, pain management, gait and posture training, lower limb splinting, walking aids. Podiatry: foot/gait assessment advice/treatment; orthoses (co-ordinated with PT and orthotist as necessary for specialist footwear and orthoses). Social work: social services support, financial/benefits claims advice. Psychology: cognitive-behavioural therapy and counselling. Refer to Challenging Arthritis or Expert Patient Programme for continuing education and support. Multiple functional problems: Intensive multidisciplinary rehabilitation (day or in-patient as above). Regular monitoring (with case management if needed). Pain management services (if needed). Hand problems: joint clinics with hand surgeon; hand surgery and hand therapy. Referral to orthopaedic surgery if joint replacement/surgery indicated. Referral to OT/PT pre-operatively to maximize functional ability/fitness. Social services liaison: housing adaptation, environmental controls, home care support. Wheelchair provision and indoor/outdoor mobility adaptations/equipment.