S YS T E M AT I C R E V I E W

Effectiveness of non-pharmacological and non-surgical

interventions for rheumatoid arthritis: an umbrella review
Eduardo J.F. Santos 1,2,3  Cátia Duarte 1,4  Andréa Marques 1,3  Daniela Cardoso 3  João Apóstolo 3 
José A.P. da Silva 1,4  Maria Barbieri-Figueiredo 3,5,6
1
Rheumatology Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal, 2Abel Salazar Institute of Biomedical Sciences,
University of Porto, Porto, Portugal, 3Portugal Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence, 4Coimbra Institute
for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal, 5Nursing School of Porto, Porto,
Portugal, and 6CINTESIS – Center for Health Technology and Services Research, University of Porto, Porto, Portugal

ABSTRACT

Objective: This umbrella review aimed to determine the effectiveness of non-pharmacological and non-surgical
interventions on the impact of rheumatoid arthritis.
Introduction: Patients with rheumatoid arthritis have identified seven major domains of the impact of disease: pain,
functional disability, fatigue, sleep, coping, emotional well-being and physical well-being. This impact persists in many
patients even after inflammatory remission is achieved, requiring the need for adjunctive interventions targeting the
uncontrolled domains of disease impact. Several systematic reviews have addressed non-pharmacologic interventions,
but there is still uncertainty about their effectiveness due to scarce or conflicting results or significant methodological flaws.
Inclusion criteria: This review included studies of adult patients with rheumatoid arthritis in any context.
Quantitative systematic reviews, with or without meta-analysis, that examined the effectiveness of non-pharmaco-
logical and non-surgical interventions of any form, duration, frequency and intensity, alone or in combination with
other interventions designed to reduce the impact of disease, were considered. The outcomes were pain, functional
disability, fatigue, emotional well-being, sleep, coping, physical well-being and global impact of disease.
Methods: A comprehensive search strategy for 13 bibliometric databases and gray literature was developed. Critical
appraisal of eight systematic reviews was conducted independently by two reviewers, using the Joanna Briggs
Institute critical appraisal checklist for systematic reviews and research syntheses. Data extraction was performed
independently by two reviewers using a standard Joanna Briggs Institute data extraction tool, and data were
summarized using a tabular format with supporting text.
Results: Eight systematic reviews were included in this umbrella review, with a total of 91 randomized controlled trials
and nine observational studies (6740 participants). Four systematic reviews examined the effects of multicomponent or
single exercise/physical activity interventions, two examined the effects of hydrotherapy/balneotherapy, two examined
the effects of psychosocial interventions, and one examined the effects of custom orthoses for the foot and ankle.
Multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses
appeared to be effective in improving pain and functional disability. Fatigue also improved with the implementation of
multicomponent or single exercise/physical activity interventions and psychosocial interventions. Only exercise/physical
activity interventions appeared to be effective in reducing the global impact of disease and quality of life. None of the
included systematic reviews reported on emotional well-being, sleep, coping or physical well-being as an outcome
measure. Other types of interventions were not sufficiently studied, and their effectiveness is not yet established.
Conclusions: Of the included interventions, only multicomponent or single exercise/physical activity interventions,
psychosocial interventions and custom orthoses seem to reduce the impact of rheumatoid arthritis. Future evidence
should be sought and synthesized in the domains identified as knowledge gaps, namely, emotional well-being, sleep,
coping and physical well-being. Further examination of the effects of interventions that have not been assessed
sufficiently is suggested in order to establish their effectiveness so decisions and recommendations can be made.
Keywords Health impact assessment; non-pharmacological interventions; review; rheumatoid arthritis
JBI Database System Rev Implement Rep 2019; 17(7):1494–1531.

Correspondence: Eduardo J.F. Santos, [email protected]

There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-D-18-00020

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SYSTEMATIC REVIEW E. Santos et al.

Summary of Findings

Effectiveness of non-pharmacological and non-surgical interventions for rheumatoid arthritis

Bibliography: Santos JF, Duarte C, Marques A, Cardoso D, Apóstolo J, da Silva JAP, et al. Effectiveness of
non-pharmacological and non-surgical interventions for rheumatoid arthritis: an umbrella review. JBI Database
System Rev Implement Rep 2019; 17(7):1494–1531.
Outcomes Impact № of Certainty of the evidence
participants (GRADE)
(studies)

1. Multicomponent or single exercise/physical activity interventions

Pain Effective improvement with small positive effects* 545 (2 reviews)
Several instruments were used to MODERATE
measure this outcome due to inconsistency (due to
significant heterogeneity)

Functional disability Effective improvement with small positive effects* 1384 (2 reviews)
Several instruments were used to MODERATE
measure this outcome due to inconsistency (due to
significant heterogeneity)

Fatigue Effective improvement with small positive effects* 628 (2 reviews)

Several instruments were used to HIGH
measure this outcome

Global impact of disease Effective improvement with small positive effects* 586 (1 review)
Several instruments were used to MODERATE
measure this outcome due to inconsistency (due to
significant heterogeneity)

2. Hydrotherapy/balneotherapy interventions
Pain No effect or difference compared to a control 998 (2 reviews)
Several instruments were used to treatment VERY LOW
measure this outcome due to inconsistency (due to
significant heterogeneity),
imprecision (due to non-significant
effect sizes) and publication bias
(due to not having been being
assessed)

Functional disability No effect or difference compared to a control 998 (2 reviews)

Several instruments were used to treatment VERY LOW
measure this outcome due to inconsistency (due to
significant heterogeneity),
imprecision (due to non-significant
effect sizes) and publication bias
(due to not having been being
assessed)

Global impact of disease No effect or difference compared to a control 419 (1 review)

Several instruments were used to treatment VERY LOW
measure this outcome due to inconsistency (due to
significant heterogeneity),
imprecision (due to non-significant
effect sizes) and publication bias
(due to not having been being
assessed)

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3. Psychosocial interventions
Pain Effective improvement with small positive effects* 1316 (1 review) ⨁⨁⨁⨁
Several instruments were used to HIGH
measure this outcome

Functional disability Effective improvement with small positive effects* 1180 (1 review)
Several instruments were used to MODERATE
measure this outcome due to inconsistency (due to
significant heterogeneity)

Fatigue Effective improvement with small positive effects* 1556 (1 review)

Several instruments were used to MODERATE
measure this outcome due to inconsistency (due to
significant heterogeneity)

4. Custom orthoses
Pain Effective improvement with moderate positive 340 (1 review)
Several instruments were used to effects** LOW
measure this outcome due to inconsistency (due to
significant heterogeneity) and
publication bias (due to not having
been being assessed)

Functional disability Effective improvement with small positive effects* 220 (1 review)
Several instruments were used to LOW
measure this outcome due to inconsistency (due to
significant heterogeneity) and
publication bias (due to not having
been being assessed)
*The effect is interpreted as small positive because it is less than 0.40
**The effect is interpreted as moderate positive because it is greater than 0.40 and less than 0.80
GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a
possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Introduction and physical well-being. Disease impact is assessed and

heumatoid arthritis (RA) is an auto-immune targeted through treatment, parallel with the biological
R systemic condition characterized mainly by
joint inflammation, which causes pain, swelling and
disease process.5,6
There have been dramatic improvements in the
stiffness. The inflammatory process leads, in the long treatment of RA in recent years, not only through
term, to irreversible destruction of joints, with conse- new drugs (such as biological drugs) but also new
quent disability, incapacity and increased mortality.1 It treatment strategies (such as ‘‘Treat-to-Target
affects 0.5% to 2% of the world population, represent- [T2T]’’ strategy).7-9 Remission of the disease, i.e.
ing a significant socio-economic burden.2 The disease complete abrogation of inflammatory activity, has
is associated with negative consequences in almost all become a viable option for most patients with a
domains of well-being, both physical and emotional, recent diagnosis,7,8 which provides an opportunity
causing high levels of fatigue, sleep disturbances, anxi- for them to reduce their suffering, stop joint damage,
ety and depression.3-6 According to patients, this prevent disability and improve long-term quality of
impact is felt mainly in seven domains: pain, functional life (QoL).7 This supports the current paradigm of
disability, fatigue, emotional well-being, sleep, coping RA treatment, epitomized by the so-called T2T

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SYSTEMATIC REVIEW E. Santos et al.

strategy,7-9 which establishes that remission is the management.20,29 In fact, the criteria for classifying
core therapeutic target and should be achieved as the disease have changed over time to encompass
early and as permanently as possible. Remission is earlier disease classifications, and modern treat-
currently defined as the control of three inflamma- ments and strategies have changed the face of RA
tory indicators (number of painful and swollen and patients’ needs.30,31 Furthermore, several
joints, and acute phase reactants) and by the Patient domains of the impact of the disease elected by
Global Assessment (PGA) of disease activity.8-10 patients, such as emotional well-being and physical
Effective control of inflammation through immu- well-being, have not been addressed.
nosuppressive therapy, which is the pillar of current An umbrella review of the available information,
medical intervention, has a markedly positive impact its quality and its limitations is needed by patients,
on patient well-being.8,9,11-14 However, a consider- healthcare professionals and researchers in order to
able proportion (14% to 38%) of those who are in improve clinical practice, set priorities for research
biological remission, i.e. without objective signs of and foster development in this field. The only
relevant inflammation, still report significant levels umbrella review available had a limited scope (pain,
of disease impact, similar to those with active dis- function and patient global assessment) and was
ease.4,15-18 This so called ‘‘near-remission’’ is at least published in 2007,28 well before the updated classi-
as frequent as remission and typifies a common fication criteria for RA31 and the T2T strategy were
failure of the disease process strategy to achieve in place.32
the ultimate goal of therapeutic intervention: to A preliminary search of the JBI Database of
enable the patient to fully enjoy his/her life.19 These Systematic Reviews and Implementation Reports,
patients will not have their condition improved by the Cochrane Database of Systematic Reviews,
additional immunosuppressive therapy, but rather PROSPERO, PubMed and CINAHL revealed that
require adjunctive interventions targeting the uncon- there was no other umbrella review published or in
trolled domains of disease impact. Optimal care of progress. Therefore, an umbrella review was con-
patients with RA therefore requires an integrated ducted to uncover the best available evidence, eval-
approach including both pharmacologic and non- uate its quality and provide an up-to-date synthesis
pharmacologic interventions,20 ideally with the help to inform healthcare professionals.
of a multidisciplinary team.19,21,22 Many options are
available for this purpose, such as patient counsel- Review questions
ling, advice and support,20,23-25 occupational ther- The review questions are:
apy,26 cognitive behavioral therapy and other i) What is the effectiveness of non-pharmacologi-
psychological interventions,27 physical interventions cal and non-surgical interventions on pain, func-
(exercise, physical activity, psychotherapy), and tional disability, fatigue, emotional well-being,
others.28 sleep, coping and physical well-being in patients
Several systematic reviews have summarized with RA?
available evidence on the effect of non-pharmaco- ii) What is the effectiveness of non-pharmacologi-
logical interventions on patients with RA. However, cal and non-surgical interventions for reducing
insufficient evidence, conflicting results and knowl- the global impact of disease and QoL of patients
edge gaps indicate the need for an umbrella review to with RA?
better understand and evaluate the effectiveness of
available interventions and identify priorities for Inclusion criteria
research.23,24,28 The information on implemented Participants
and evaluated interventions, their characteristics, This umbrella review included existing systematic
contexts of application, and healthcare professionals reviews involving:
responsible for their application lacks systematisa-  Patients satisfying current RA criteria.30,31 If at
tion, which hinders the implementation of the inter- least one of these criteria was fulfilled, the review
ventions in practice. Additionally, most of the was included.
reviews were poorly reported, had significant meth-  Adult patients aged 18 years or over.
odological flaws and predated very significant devel- Patients with other concomitant musculoskeletal
opments in the definition of the disease and in its diseases were excluded.

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SYSTEMATIC REVIEW E. Santos et al.

Interventions Types of studies

This umbrella review included systematic reviews This umbrella review considered quantitative sys-
that evaluated the effectiveness of non-pharmaco- tematic reviews with or without meta-analysis, com-
logical and/or non-surgical interventions in adult prehensive systematic or mixed methods (only
patients with RA with the aim of reducing its impact, quantitative elements) reviews.
used either as a single intervention or as part of Additionally, systematic reviews needed to meet
multiple non-pharmacological and/or non-surgical the following criteria:
interventions. Non-pharmacological interventions  A clear, articulated and comprehensive search
included, but were not limited to, any treatment that strategy using multiple databases.
is not a registered drug,23 such as physical activity  Critical appraisal and assessment of risk of bias.
and exercise; hydrotherapy and balneotherapy; In case of doubt, due to unclear inclusion
occupational therapy; electro-physical modalities criteria, authors were contacted for clarification
such as thermotherapy, electrotherapy, and others; before exclusion. General literature reviews,
manual therapies such as massage, orthoses, aids, primary research and qualitative reviews were also
devices and adaptations of the physical environment excluded.
and others; and psychosocial interventions. Non- Systematic reviews published and unpublished in
surgical interventions were considered to be all English, French, Spanish and Portuguese, from 2010
interventions not related in any way to surgery. to the present, were considered for inclusion. The
No limitations regarding frequency/intensity/who criteria for classifying the disease were changed in
delivered the intervention were applied. Patients 2010 to include patients in earlier stages of the
only received pharmacological treatment targeting disease, and the impact of disease has changed dra-
the control of inflammation, according to interna- matically in recent years due to more effective drug
tional guidelines.32 treatment.20,31

Comparator Methods
This umbrella review considered systematic reviews
that compared the intervention to placebo, usual The review was conducted according to the Joanna
care or other non-pharmacological and non- Briggs Institute methodology for umbrella reviews,34
surgical interventions. following a previously published protocol35 and
prepared using the Preferred Reporting Items for
Outcomes Systematic Reviews and Meta-analyses (PRISMA)
The primary outcomes were quantitative measures guidelines.36
of impact of disease, measured individually, in at
least one of the following domains: pain, functional Search strategy
disability, fatigue, emotional well-being, sleep, cop- The search strategy aimed to find both published and
ing and physical well-being by validated instruments unpublished systematic reviews. A three-step search
(e.g. Visual Analog Scale [VAS], Health Assessment strategy was performed.
Questionnaire [HAQ], Functional Assessment of An initial search limited to PubMed and CINAHL
Chronic Illness Therapy [FACIT], Rheumatoid has been undertaken to identify articles on this topic,
Arthritis Impact of Disease (RAID]). followed by analysis of the text words contained in
The secondary outcomes were quantitative mea- the titles or/and abstracts, and of the index terms
sures of global impact of the disease, measured by used to describe these articles. This informed the
the Rheumatoid Arthritis Impact of Disease development of a search strategy including identified
(RAID),5,6 and/or global QoL, measured by vali- keywords and index terms, which were tailored for
dated instruments (e.g. 36-Item Short Form Survey each information source. A second search using all
[SF36], EuroQol-5 Dimension [EQ5D]).33 identified keywords and index terms was undertaken
across all included databases, after appropriate
Context adaptation to each information source. Finally, the
There were no context limitations in this reference lists of all studies selected for critical
umbrella review. appraisal were searched for additional studies.

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SYSTEMATIC REVIEW E. Santos et al.

Information sources quality of each eligible review was based on the

The following electronic databases/sources were following cut-offs: 0–3 was considered a very low-
broadly searched for published systematic reviews: quality score; 4–6 was considered a low-quality score;
CINAHL Plus with Full Text, PubMed, Cochrane 7–9 was considered a moderate-quality score; and
Database of Systematic Reviews, Scopus, Embase, 10–11 was considered a high-quality score. A mini-
PsycINFO, PEDro, Epistemonikos, JBI Database of mum score of 4 was pre-established as a criterion for
Systematic Reviews and Implementation Reports, inclusion in this umbrella review.
the PROSPERO register, Campbell Collaboration
Library of Systematic Reviews. Data extraction
The search for unpublished studies and gray lit- Data were extracted from the selected reports by two
erature included: RCAAP – Repositório Cientı́fico independent reviewers (ES and AM) using the stan-
de Acesso Aberto de Portugal; OpenGrey – System dardized JBI data extraction tool in JBI SUMARI.37
for Information on Grey Literature in Europe. The following information was extracted from each
The final search strategy is included in Appendix I. included review: i) type of review; ii) countries where
the primary studies were conducted; iii) databases;
Study selection iv) search timeframes; v) number of studies included
Following the search, all identified citations were in the review; vi) participants (number, age, comor-
uploaded into EndNote VX7 (Clarivate Analytics, bidities); vii) type(s) of intervention(s) (including
PA, USA) and duplicates removed. Titles and abstracts duration and frequency); viii) outcomes of signifi-
were screened by two independent reviewers (ES and cance (types and characteristics); ix) outcome mea-
AM) to assess eligibility according to the inclusion sures; x) inclusion/exclusion criteria; xi) methods of
criteria for the review. The full articles were retrieved analysis; xii) heterogeneity; xiii) effect size and
for all studies that, clearly or probably, met these confidence intervals.
inclusion criteria and their citation details imported Any disagreements between the reviewers were
into the JBI System for the Unified Management, resolved through discussion or with a third reviewer
Assessment and Review of Information (JBI SUMARI; (CD). Authors of papers were contacted to request
Joanna Briggs Institute, Adelaide, Australia). Based on missing or additional data, when needed.
full texts, two reviewers (ES and AM) independently
examined whether the studies conform to the inclusion Data synthesis
criteria. Any disagreements that arise between the The studies were analyzed in separate categories
reviewers were resolved through discussion, or with based on the domain of outcome measure. Findings
a third reviewer (CD). were tabulated and subjected to a narrative synthesis
Full-text studies that did not meet the inclusion to address the review objective and specific questions.
criteria were excluded, and reasons for exclusion The overall effect sizes and a clear description of the
were provided in Appendix II. non-pharmacological intervention(s) were presented
The results of the search were reported in full in for interpretation of consistency. The previous
the final report and presented in a flow diagram.36 referred tables included a high level of detail for each
systematic review, such as the number of studies, total
Assessment of methodological quality number of participants and its specificities, assess-
Reviews selected for retrieval were assessed by two ment tool, heterogeneity and complete information
independent reviewers (ES and AM) for methodolog- about the non-pharmacological intervention(s). The
ical validity prior to inclusion in this review, using a overlap of original research studies included in sys-
standardized critical appraisal instrument (JBI Criti- tematic reviews was rigorously checked to avoid
cal Appraisal Checklist for Systematic reviews and double counting. Where possible, the review’s find-
Research Syntheses). Authors of reviews were con- ings were considered based on its quality, as assessed
tacted to request missing or additional data for clar- by critical appraisal, to explore the consequences of
ification, where required. Any disagreements between synthesizing reviews of differing quality. The results
the reviewers were resolved through discussion, or of the umbrella review were provided in an ‘‘Evidence
with a third reviewer (CD). The results of critical Summary’’ table that includes the intervention, the
appraisal were reported in a narrative form. The included systematic review(s) and a simple visual

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SYSTEMATIC REVIEW E. Santos et al.

indicator of the effectiveness of the intervention using included in this umbrella review. See Figure 1 for
the three colors of the traffic light: a beneficial or the process described above.36
effective intervention (green), no effect or difference
compared to a control treatment (orange) and a Methodological quality
detrimental intervention or one that is less effective The critical appraisal results for each of the eight
than a control treatment (red).34 systematic reviews are summarized in Table 1.
An overall assessment of the quality of the evi- There was agreement among the reviewers to
dence for each comparison using The Grading of include all studies appraised. Based on the JBI critical
Recommendations, Assessment, Development and appraisal checklist for systematic reviews and research
Evaluation (GRADE)38 approach for grading the syntheses,47 five of the eight systematic reviews selected
certainty of evidence and the creation of a Summary for inclusion were deemed of high quality23,27,41-43 and
of Findings (SoF) was performed using GRADEPro three were of moderate quality.44-46 The minimum
GDT software. A four-point rating scale was used to number of criteria met was nine and the maximum
rate the quality of the evidence: high, moderate, low was 11 out of 11. Criteria 1 through 5 and criteria 11,
and very low. The quality of evidence was classified relating to the review question, search strategy and
according to the following criteria: risk of bias, critical appraisal, were met by all included systematic
inconsistency, imprecision, indirectness and publica- reviews. Only one systematic review46 had critical
tion bias. A narrative SoF form was preferred due to appraisal of studies and extraction performed by one
the differences in metrics used by the included sys- reviewer (criteria 6 and 7). Finally, four systematic
tematic reviews (standard mean difference [SMD], reviews assessed the likelihood of publication bias
weighted mean difference [WMD], Hedges’ g effect (criteria 9).23,27,42,46 No reviews were excluded on
size [g], narrative synthesis) which did not allow the the basis of methodological quality criteria.
calculation of a pooled effect size. The significant In terms of risk of bias assessment, the inter-rater
heterogeneity between the reviews in terms of char- agreement between the two reviewers was strong39
acteristics of interventions, settings of conducted (k ¼ 0.88; 95% CI ¼ 0.651–1.0; p < 0.005). No
studies, differences in time points of the outcome intervention by a third reviewer was needed.
measurements also contributed to this decision.
Characteristics of included studies
Results The eight systematic reviews included a total of 103
Review selection randomized controlled trials (RCTs) and nine obser-
The literature search identified a total of 1140 vational studies, but only 91 RCTs were considered
records, of which 1084 records were from biblio- to be relevant to this review as 12 RCTs (11.7%)
metric databases and 56 from gray literature. After were duplicated in the systematic reviews. Specific
removing duplicates (n ¼ 367), titles and abstracts of information and characteristics from these system-
773 records were screened independently by two atic reviews were extracted and are summarized in a
reviewers and 681 were excluded as they were irrel- table (Appendix III).
evant to the umbrella review. Full-text reviews The number of participants involved was 6740 but
assessing the eligibility of the remaining 92 records one review27 did not report the number of participants
were conducted by two reviews independently, and and their characteristics. The mean age ranged from 18
84 failed to meet at least one of the four eligibility to 80 years and two studies did not report the mean
criteria (participants, interventions, outcomes and age.27,41 Four systematic reviews reported on the gen-
study design). See Appendix II for reasons for their der of the participants from included studies42,43,45,46
exclusion. The interrater agreement was strong39 and the majority were female, ranging from 46.7% to
(kappa statistic [k] ¼ 0.851; 95% CI ¼ 0.631–1.0; 100%. Regarding the classification of the disease (RA
p < 0.005) and consensus could always be achieved criteria), all included systematic reviews used the 1987
without intervention of the third reviewer. Only one ACR (American College of Rheumatology) criteria30
contact to the authors of a review was undertaken to and four of them used the ARA (American Rheuma-
request missing or additional data for clarification.40 tism Association) criteria,48 two used the Steinbrocker
Finally, the remaining eight records were critically criteria49 and one used the 2010 ACR/EULAR (Euro-
appraised by two reviews independently and pean League Against Rheumatism)31 criteria.

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Idenficaon

Records idenfied through Gray literature

database searching (n = 1084) (n = 56)

Records idenfied Duplicates removed

(n = 1140) (n = 367)
Screening

Records screened for retrieval Records excluded based on tle and

(n = 773) abstract (n = 681)

Full-text arcles excluded (n = 84):

Other rheumatoid arthris criteria or
musculoskeletal diseases (n = 31)
Full-text arcles assessed for Other intervenons (n = 3)
eligibility (n = 92) Other outcomes (n = 3)
Eligibility

Not a systemac review or did not have

comprehensive criteria (n = 37)
Publicaon date (n = 10)

Studies assessed by crical Studies excluded by crical appraisal

appraisal (n = 8) (n = 0)
Included

Studies included in the umbrella

review (n = 8)

Figure 1: Flowchart of the study selection and inclusion process36

The included studies were from a diversity of coun- reviews (n ¼ 91) were conducted in or after 2000
tries, namely, Australia, Austria, Bosnia, Canada, (n ¼ 49; 53.8%), 34 RCTs were conducted between
Denmark, Finland, France, Germany, Israel, The 1990 and 2000, and only eight RCTs (8.8%) were
Netherlands, Sweden, Turkey, United Kingdom and dated 1990 or earlier. With observational studies, six
United States of America. Three systematic reviews did were conducted in or after 2000 (66.7%), two in 1999
not provide information about the countries where the (22.2%) and only one in or before 1990 (11.1%).
included studies were conducted.23,41,44 The reviews All included systematic reviews performed meta-
were published between 2010 and 2015. The majority analysis and calculated heterogeneity in addition to a
of the individual RCTs included in the systematic narrative synthesis, with the exception of one.45

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Table 1: Critical appraisal results of eligible systematic reviews

Citation Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Quality

23
Cramp et al. Y Y Y Y Y Y Y Y Y Y Y High
44
Hennessy et al. Y Y Y Y Y Y U Y N Y Y Moderate
41
Rongen-van Dartel et al. Y Y Y Y Y Y Y Y N Y Y High
45
Al-Qubaeissy et al. Y Y Y Y Y Y Y U N Y Y Moderate
42
Baillet et al. Y Y Y Y Y Y Y Y Y U Y High
46
Baillet et al. Y Y Y Y Y N N Y Y Y Y Moderate
27
Knittle et al. Y Y Y Y Y Y Y Y Y Y Y High
43
Verhagen et al. Y Y Y Y Y Y Y Y N Y Y High
% 100 100 100 100 100 88 75 88 50 88 100
Y ¼ Yes, N ¼ No, U ¼ Unclear.
JBI critical appraisal checklist for systematic reviews and research syntheses: Q1 ¼ Is the review question clearly and explicitly stated? Q2 ¼ Were the inclusion
criteria appropriate for the review question? Q3 ¼ Was the search strategy appropriate? Q4 ¼ Were the sources and resources used to search for studies adequate?
Q5 ¼ Were the criteria for appraising studies appropriate? Q6 ¼ Was critical appraisal conducted by two or more reviewers independently? Q7 ¼ Were there
methods to minimize errors in data extraction? Q8 ¼ Were the methods used to combine studies appropriate? Q9 ¼ Was the likelihood of publication bias assessed?
Q10 ¼ Were recommendations for policy and/or practice supported by the reported data? Q11 ¼ Were the specific directives for new research appropriate?
0-3 ¼ very low-quality score; 4-6 ¼ low-quality score; 7-9 ¼ moderate-quality score; 10-11 ¼ high-quality score.

Intervention characteristics The remaining systematic review44 only evaluated

Type the effects of custom orthoses for the foot and ankle
Four systematic reviews examined the effects of compared to no orthoses or placebo orthoses in 17 trials.
multicomponent or single exercise/physical activity All these interventions were performed by differ-
interventions23,41,42,46 compared with no exercise, ent healthcare professionals, namely, medical doc-
usual care, non-aerobic exercises, range of motion tors, nurses, physical therapists, psychologists,
exercises or education. With these interventions, occupational therapists, counselors, dieticians, clin-
four trials included multi-component exercises ical psychologists and other professionals, namely,
involving resistance, strengthening, aerobic exer- yoga teachers, PhD students and laypersons (infor-
cises and flexibility. The remaining trials (n ¼ 31) mation stated only in two systematic reviews).23,27
examined the effects of single modalities of exer- Although most of the settings were not stated, it was
cise. reported that the interventions were supervised by
Two systematic reviews examined the effects of health professionals. Some interventions were under-
hydrotherapy/balneotherapy interventions43,45 com- taken in temperate pools, fitness centers and homes.
pared with usual care, home exercises, land-based
exercises, relaxation and other types of baths or Frequency/duration/intensity
mudpacks. The interventions included were based All of the included systematic reviews reported on
on aquatic exercises in six of the included trials and the frequency of interventions with a range of one to
different types of baths in nine trials. five sessions per week,23,27,41-43,45,46 with the excep-
The other two systematic reviews evaluated the tion of one review.44
effects of psychosocial interventions in 51 trials,23,27 The total duration ranged from 10 minutes to
which included expressive writing, cognitive skills 4.5 hours per session. One systematic review reported
training, cognitive behavioral therapy, mindfulness, a treatment duration of two to four weeks.43
lifestyle management, education, energy conservation, The intensity of the interventions (exercise/physi-
self-management, group education and counseling, cal activity) can be measured by ‘‘how hard the heart
relaxation, contracting/goal setting, coping, guided is working’’. This was only reported in two system-
imagery, self-instruction and others, compared to edu- atic reviews41,42 and ranged from 30–100% or 50–
cation or usual care. 90%. Some studies, as examined in two systematic

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SYSTEMATIC REVIEW E. Santos et al.

reviews,23,45 reported a moderate intensity; however Six systematic reviews23,27,42,44-46 involving 82

these definitions were presented without further relevant trials evaluated the effectiveness of non-
clarification. Usually, low-intensity exercises raise pharmacological and non-surgical interventions on
the heart rate to 40–50% of an individual’s maxi- functional disability. Two of these systematic
mum heart rate (MHR). Moderate-intensity exer- reviews showed small positive effects of multicom-
cises increase the heart rate to 50–70% of the MHR, ponent or single exercise/physical activity interven-
while vigorous-intensity exercises elevate the heart tions (n ¼ 1384).42,46 Two systematic reviews did
rate to above 70% of the MHR. The remaining not perform meta-analysis and for this reason
systematic reviews did not include any information showed insufficient effects/power of hydrotherapy/
about this phenomenon.27,43,44,46 balneotherapy interventions43,45 or multicomponent
or single exercise/physical activity and psychosocial
Review findings
interventions.23 One systematic review (n ¼ 1180)
Effects on impact of disease per domain
showed small positive effects of psychosocial inter-
Pain
ventions27 and finally one systematic review44
Pain was measured using the Visual Analog Scale for
(n ¼ 220) showed small positive effects of custom
Pain (VAS Pain), the Numerical Rating Scale (NRS),
orthoses.
the McGill Pain Questionnaire, the Impact Measure-
With overall effect, multicomponent or single
ment Scales Health Status Questionnaire (AIMS2),
exercise/physical activity interventions, psychosocial
the Impact of Rheumatic Diseases on General Health
interventions and custom orthoses appeared to be
and Lifestyle (IRGL), the Pain Disability Index, the
the most effective in improving functional disability.
Bodily Pain subscale of the SF-36, and the Man-
chester Foot Pain Disability Questionnaire.
Fatigue
Seven systematic reviews23,27,42-46 involving 86 rel-
Fatigue was measured using the Multidimensional
evant trials evaluated the effectiveness of non-pharma-
Assessment of Fatigue (MAF), the Visual Analog
cological and non-surgical interventions on pain. Two
Fatigue Scale (VAFS), the Functional Assessment
systematic reviews showed small positive effects (effect
of Chronic Illness Therapy (FACIT), the Checklist
size is < 0.40) of multicomponent or single exercise/
Individual Strength (CIS), the Profile of Mood States
physical activity interventions42,46 (n ¼ 545) and one
(POMS), the Short Form 36 Vitality subscale and the
did not perform meta-analysis either because it was not
perception of change in fatigue from baseline using a
possible and/or because there were no statistically
four-point Likert scale.
significant differences between the trial arms.23 Two
Only two systematic reviews evaluated the effect
systematic reviews showed insufficient effects/power
of non-pharmacological and non-surgical interven-
(no statistically significant differences or the inability to
tions on fatigue.23,41 These two reviews (n ¼ 628)
provide an overall effect size) of hydrotherapy/balneo-
showed small positive effects of multicomponent or
therapy interventions43,45 against usual care, exercise,
single exercise/physical activity interventions but
mudpacks or relaxation therapy. One systematic
one41 demonstrated that the benefits of these effects
review showed small positive effects of psychosocial
were more frequent in the short term (defined as <
interventions27 (n ¼ 1316) and one did not perform
12 weeks; n ¼ 257). Only one systematic review
meta-analysis for the reasons mentioned previously.23
(n ¼ 1556) reported on psychosocial interventions23
The remaining systematic review44 (n ¼ 340) showed
also showing small positive effects.
moderate positive effects (effect size is > 0.40 and <
With overall effect, multicomponent or single
0.80) of custom orthoses.
exercise/physical activity interventions and psycho-
With overall effect, multicomponent or single
social interventions appeared to be the most effective
exercise/physical activity interventions, psychosocial
in improving fatigue.
interventions and custom orthoses appeared to be
the most effective in alleviating pain.
Emotional well-being, sleep, coping or physical
Functional disability well-being
Functional disability was measured using the Health None of the included systematic reviews reported on
Assessment Questionnaire (HAQ), the Foot Func- emotional well-being, sleep, coping or physical well-
tion Index (FFI), the IRGL and the AIMS2. being as an outcome measure.

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SYSTEMATIC REVIEW E. Santos et al.

Table 2: Impact of rheumatoid arthritis disease domains or global dimension as assessed by the
included systematic reviews

Functional Emotional Physical Global impact

Pain disability Fatigue well-being Sleep Coping well-being of disease
Cramp et al.23 x x x
44
Hennessy et al. x x
Rongen-van x
Dartel et al.41
Al-Qubaeissy et al.45 x x x
Baillet et al.42 x x
Baillet et al.46 x x x
Knittle et al.27 x x
Verhagen et al.43 x

The summary of the disease domains or global Only two systematic reviews evaluated the effec-
dimension of the impact of disease as assessed by the tiveness of non-pharmacological and non-surgical
included systematic reviews are presented in Table 2. interventions on the global impact of disease.45,46
Of these, one systematic review45 did not perform
Effects on global impact of disease and quality meta-analysis and showed insufficient effects/power
of life (hydrotherapy/balneotherapy interventions). The
The global impact of disease and QoL were mea- other systematic review46 (n ¼ 586) showed small
sured using the 36-Item Short Form Survey (SF-36), positive effects of multicomponent or single exercise/
the EuroQol-5 Dimension (EQ-5D), the Notting- physical activity interventions on QoL.
ham Health Profile (NHP), the Rheumatoid Arthri- With overall effect, only multicomponent or single
tis Quality of Life (RAQol) questionnaire, the exercise/physical activity interventions appeared to be
Arthritis Impact Measurement Scales (AIMS) health effective in reducing the global impact of disease.
status questionnaire and the McMaster Toronto The interventions assessed by the included sys-
Arthritis Patient Preference Disability Question- tematic reviews and the summary of evidence are
naire (MACTAR). presented in Tables 3 and 4, respectively.

Table 3: Interventions for rheumatoid arthritis assessed by the included systematic reviews
Systematic Number of
Interventions reviews participants Outcomes Effects
Multicomponent or Baillet et al.42 545 Pain WMD¼4.13; 95% CI¼-11.0 to 2.7; p¼0.24;
single exercise/physical I2¼57%
activity interventions Baillet et al.46 SMD¼0.31; 95% CI¼0.06 to 0.55; p¼0.02;
I2¼30%
Baillet et al.42 1384 Functional WMD¼-0.22; 95% CI¼-0.35 to -0.10;
disability p < 0.001; I2¼36%
Baillet et al.46 SMD¼0.24; 95% CI¼0.10 to 0.38;
p ¼ 0.0009; I2 ¼ 29%
Cramp et al.23 628 Fatigue SMD ¼ -0.36; 95% CI ¼ -0.62 to -0.10;
p ¼ 0.0066; I2 ¼ 27%
Rongen-van Dartel SMD ¼ -0.31; 95% CI ¼ -0.55 to -0.06;
et al.41 p ¼ 0.02; I2 ¼ 0%
Baillet et al.46 586 Global impact SMD ¼ 0.39; 95% CI ¼ 0.23 to 0.56;
of disease p ¼ 0.0001; I2 ¼ 45%

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SYSTEMATIC REVIEW E. Santos et al.

Table 3. (Continued)
Systematic Number of
Interventions reviews participants Outcomes Effects
Hydrotherapy/ Al-Qubaeissy 998 Pain Not calculated
balneotherapy et al.45
interventions Verhagen et al.43 Mudpacks versus placebo: MD ¼ 0.50; 95%
CI ¼ -0.84 to 1.84; p ¼ 0.47; I2 ¼ 0%
Additional radon in carbon dioxide baths:
MD ¼ 9.6; 95% CI ¼ 1.6 to 17.6; p ¼ 0.019;
I2 ¼ 0%)
Al-Qubaeissy 998 Functional Not calculated
et al.45 disability
Verhagen et al.43 Not calculated
Al-Qubaeissy 419 Global impact Not calculated
et al.45 of disease
Psychosocial Knittle et al.27 1316 Pain g ¼ 0.18; 95% CI ¼ 0.08 to 0.29; p ¼ 0.006;
interventions I2 ¼ 0%
Knittle et al.27 1180 Functional g ¼ 0.32; 95% CI ¼ 0.13 to 0.51; p ¼ 0.001;
disability I2 ¼ 60.26%
Cramp et al.23 1556 Fatigue SMD ¼ -0.24; 95% CI ¼ -0.40 to -0.07;
p ¼ 0.0044; I2 ¼ 55%
Custom orthoses Hennessy et al.44 340 Pain SMD ¼ 0.45; 95% CI ¼ 0.00 to 0.90;
p ¼ 0.05; I2 ¼ 77%
Hennessy et al.44 220 Functional SMD ¼ 0.07; 95% CI ¼ 0.41 to 0.55;
disability p ¼ 0.78; I2 ¼ 66%

WMD, weighted mean difference; CI, confidence interval; SMD standard mean difference.

Table 4: Summary of evidence

Included Outcomes
Interventions systematic
reviews Pain Functional Fatigue Emotional Sleep Coping Physical Global
disability well-being well- impact of
being disease
Multicomponent Cramp et al.23
or single Baillet et al.42
exercise/physical Rongen-van
activity Dartel et al.41
interventions Baillet et al.46
Hydrotherapy/ Al-Qubaeissy et
balneotherapy al.45
interventions Verhagen et al.43
Psychosocial Cramp et al.23
interventions Knittle et al.27
Custom orthoses Hennessy et
al.44

Overall effective; Overall no effect or difference compared to a control treatment; No data reported.
All significant effects identified by systematic reviews had a small magnitude. The variability among the included studies precludes a detailed evaluation of effect
sizes as well as separate comparisons against the individual interventions. The transposition of this evidence into practice should be based on the assumption that
each of these interventions was effective against placebo or some other form of clinical acceptable intervention.

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SYSTEMATIC REVIEW E. Santos et al.

Discussion interventions are widely recommended for patients

With the introduction of biological drugs, the man- with RA23,27,52,53 due to the benefits highlighted in
agement of RA has recently incorporated a more this review. On the other hand, adherence and
targeted and aggressive pharmacological acceptance rates of exercise and physical activity
approach.32 However, not all patients achieve full can also be improved through the use of psychosocial
inflammatory remission, and a significant propor- interventions, suggesting that their combined use can
tion of those who do describe continued impact of provide better overall outcomes.23
the disease in different health domains. Both these With custom orthoses, several reviews previously
groups of patients require adjunctive non-pharma- showed its benefits for reducing pain and its poten-
cological interventions targeting the uncontrolled tial to reduce functional disability,44,54,55 which also
domains of disease impact.19,20 This umbrella corroborates our results.
review provides important knowledge in this field Most of the included systematic reviews stated an
because it appraises and brings together the available average exercise frequency of one to five sessions per
evidence on the effectiveness of non-pharmacologi- week, with a duration of 10 minutes to 4.5 hours per
cal and non-surgical interventions on RA (both session and an intensity of 30–100%. However, the
globally and by domain). This review summarized optimal parameters and components of these inter-
evidence from eight systematic reviews and included ventions have not yet been established,23 but these
four major groups of interventions: multicomponent findings provide an important practice guide which
or single exercise/physical activity interventions can be replicated and adjusted to the individual
(n ¼ 4 reviews), hydrotherapy/balneotherapy inter- patient’s condition, abilities and preferences.50 Fur-
ventions (n ¼ 2 reviews), psychosocial interventions thermore, no evidence on the superiority of inter-
(n ¼ 2 reviews), and custom orthoses (n ¼ 1 review). vention delivery or setting over other were found.
Overall, the results showed that non-pharmacologi- The delivery modes varied considerably and were
cal and non-surgical interventions were effective in described as ‘‘land-based’’, water-based’’, ‘‘super-
reducing the impact of RA in some health domains. vised and individualized’’ and most of them were
not even reported.
Type of interventions and effects on impact of
disease per domain Type of interventions and effects on global
Multicomponent or single exercise/physical activity impact of disease and quality of life
interventions can be recommended for people with Multicomponent or single exercise/physical activity
RA to reduce pain, functional disability and fatigue. interventions are the only interventions that can be
Psychosocial interventions were also suggested as recommended for people with RA to reduce the global
being beneficial for reducing pain, functional dis- impact of disease and QoL. This may be due to the fact
ability and fatigue, and custom orthoses for reducing that few studies reported measures of global impact of
pain and functional disability. disease and/ or QoL. Although there were many
Other types of interventions were not sufficiently studies that evaluated QoL in patients with RA in
examined and their effectiveness is not yet estab- general in relation to efficacy/intervention studies, we
lished, namely, hydrotherapy/balneotherapy inter- found that more specific endpoints were most fre-
ventions due to its overall non-significant effect in quently used (e.g. pain, fatigue).
most of the studies, which generally had significant
limitations and were of low quality. Strengths and limitations
None of the included systematic reviews reported The strengths of this umbrella review included the
on emotional well-being, sleep, coping or physical comprehensiveness of the search strategy, the strict
well-being as outcome measures. inclusion criteria that allowed the selection of qual-
These findings support current recommendations ity systematic reviews conveying a large number and
stressing the benefits of exercise and physical activity variety of RCTs and patients. We used a rigorous
for RA.50 However, health professionals do not process of data extraction and synthesis leading to
often recommend exercise to patients and even when the development of well supported recommenda-
they do, the acceptance and adherence rates are tions. We were able to identify important knowledge
not of expected levels.42,51 Also, psychosocial gaps that warranted investigation, with emphasis on

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SYSTEMATIC REVIEW E. Santos et al.

domains of impact that had not been (sufficiently) the global impact of disease. These interventions are
addressed by research. performed up to five times per week for 10 minutes
A limitation of this umbrella review was the lack to 4.5 hours per exercise session, at a moderate to
of patient characterization in the included systematic high intensity, and according to the patient’s pref-
reviews, namely, the definition/criteria used for RA erences. Other interventions such as hydrotherapy/
diagnosis and other demographic information such balneotherapy interventions fail to demonstrate
as age and gender. In some cases, the interventions effectiveness.
and their characteristics were also poorly described,
namely, the intensity of exercise interventions Recommendations for practice
(reported only in two systematic reviews). This Multi-component or single exercises/physical activ-
has limited the recommendations for each of the ity interventions involving resistance, strengthening
interventions. A consistent characterization of and aerobic exercises, and flexibility are an effective
patients and interventions would be required to strategy to reduce pain, functional disability, fatigue
allow for systematic examination of the effects. and global impact of disease in people with RA
Although we were able to summarize the evidence (GRADE B: JBI Grades of Recommendation).47
on four of the eight domains (pain, functional dis- Psychosocial interventions involving cognitive skills
ability, fatigue and global impact of disease), this training, cognitive behavioral therapy, mindfulness,
only represents 50% of the domains. The four unad- lifestyle management, education, self-management,
dressed domains (physical and emotional well-being, contracting/goal setting, coping, guided imagery,
sleep and coping) are interrelated with and influence self-instruction, among others, are an effective strat-
the four domains. This limits the ability to ‘‘fully’’ egy to reduce pain, functional disability and fatigue
address these four domains (pain, functional disabil- in people with RA (GRADE B: JBI Grades of Rec-
ity, fatigue and global impact of disease), since we ommendation).47 Custom orthoses for the foot and
were unable to account for the interrelationships ankle are an effective strategy to reduce pain and
between domains. functional disability in people with RA (GRADE B:
Another limitation was the heterogeneity of the JBI Grades of Recommendation).47
proposed interventions, including different types of
exercise, whether they were performed single or mul- Recommendations for research
ticomponent, different psychosocial interventions, and Future evidence should be generated and synthesized
different hydrotherapy/balneotherapy protocols. in the areas identified as a knowledge gap, namely,
Faced with these constraints, we had to adopt the interventions targeting emotional well-being, sleep,
comparisons provided by the systematic reviews coping or physical well-being. Furthermore, system-
(grouped interventions). Furthermore, there was not atic reviews should clearly adopt a RA diagnosis
enough evidence from which we could draw conclu- definition/criteria and identify the specifics of their
sions regarding the effectiveness of several types of target population. Information about the character-
interventions and the comparison between them. istics of the intervention (such as frequency, inten-
sity, duration and type) should always be provided to
Conclusion allow for more specific recommendations on differ-
To the best of our knowledge, this is the first ent types of exercises. The effectiveness of several
umbrella review examining the effects of non-phar- types of interventions (such as hydrotherapy/balneo-
macological and non-surgical interventions on the therapy interventions) is not yet established and
impact of RA, with individual analysis by impact warrant research in order to allow more specific
domain and globally. Our results suggest that mul- recommendations.
ticomponent or single exercises/physical activity
interventions, psychosocial interventions and cus- Acknowledgments
tom orthoses are the only interventions with dem- The authors would like to acknowledge the support
onstrated efficacy in reducing the impact of RA. This provided by Health Sciences Research Unit: Nursing
effectiveness is mainly perceived by patients as (UICISA: E), hosted by the Nursing School of Coim-
reduction in pain, functional disability, fatigue and bra (ESEnfC).

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SYSTEMATIC REVIEW E. Santos et al.

This review will contribute towards a PhD in 14. Matcham F, Scott IC, Rayner L, Hotopf M, Kingsley GH, Norton
Nursing Sciences for ES. S, et al. The impact of rheumatoid arthritis on quality-of-life
assessed using the SF-36: a systematic review and meta-
References analysis. Semin Arthritis Rheum 2014;44(2):123–30.
1. Gabay C, Nissen MJ, van Laar JM. Rheumatoid arthritis: 15. Vermeer M, Kuper HH, van der Bijl AE, Baan H, Posthumus MD,
Phatogenesis and clinical features. In: Bijlsma JWJ, Hachula Brus HL, et al. The provisional ACR/EULAR definition of
E, editors. Textbook on rheumatic diseases. 2nd ed. London, remission in RA: a comment on the patient global assessment
UK: BMJ Publishing Group Ltd, 2015;229–64. criterion. Rheumatology (Oxford) 2012;51(6):1076–80.
2. Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. The 16. Studenic P, Smolen JS, Aletaha D. Near misses of ACR/EULAR
Lancet 2016;388(10055):2023–38. criteria for remission: effects of patient global assessment in
3. Boonen A, Severens JL. The burden of illness of rheumatoid Boolean and index-based definitions. Ann Rheum Dis
arthritis. Clin Rheumatol 2011;30(Suppl 1):S3–8. 2012;71(10):1702–5.
4. Ferreira RJO, Dougados M, Kirwan JR, Duarte C, de Wit M, 17. Balogh E, Madruga Dias J, Orr C, Mullan R, Harty L, FitzGerald
Soubrier M, et al. Drivers of patient global assessment in O, et al. Comparison of remission criteria in a tumour
patients with rheumatoid arthritis who are close to remis- necrosis factor inhibitor treated rheumatoid arthritis longi-
sion: an analysis of 1588 patients. Rheumatology (Oxford) tudinal cohort: patient global health is a confounder. Arthri-
2017;56(9):1573–8. tis Res Ther 2013;15(6):R221.
5. Gossec L, Dougados M, Rincheval N, Balanescu A, Boumpas 18. Ferreira RJO, Duarte C, Ndosi M, de Wit M, Gossec L, da Silva
DT, Canadelo S, et al. Elaboration of the preliminary Rheu- JAP. Suppressing Inflammation in Rheumatoid Arthritis:
matoid Arthritis Impact of Disease (RAID) score: a EULAR Does Patient Global Assessment Blur the Target? A Prac-
initiative. Ann Rheum Dis 2009;68(11):1680–5. tice-Based Call for a Paradigm Change. Arthritis Care Res
6. Gossec L, Paternotte S, Aanerud GJ, Balanescu A, Boumpas (Hoboken) 2018;70(3):369–78.
DT, Carmona L, et al. Finalisation and validation of the 19. Santos EJF, Duarte C, Ferreira RJO, Pinto AM, Geenen R, da
rheumatoid arthritis impact of disease score, a patient- Silva JAP, et al. Determinants of happiness and quality of life
derived composite measure of impact of rheumatoid arthri- in patients with rheumatoid arthritis: a structural equation
tis: a EULAR initiative. Ann Rheum Dis 2011;70(6):935–42. modelling approach. Ann Rheum Dis 2018;77(8):1118–24.
7. Anderson J, Caplan L, Yazdany J, Robbins ML, Neogi T, 20. Vliet Vlieland TP, van den Ende CH. Nonpharmacological
Michaud K, et al. Rheumatoid arthritis disease activity treatment of rheumatoid arthritis. Curr Opin Rheumatol
measures: American College of Rheumatology recommen- 2011;23(3):259–64.
dations for use in clinical practice. Arthritis Care Res (Hobo- 21. van Eijk-Hustings Y, van Tubergen A, Bostrom C, Braychenko
ken) 2012;64(5):640–7. E, Buss B, Felix J, et al. EULAR recommendations for the role
8. Smolen JS, Landewe R, Breedveld FC, Buch M, Burmester G, of the nurse in the management of chronic inflammatory
Dougados M, et al. EULAR recommendations for the man- arthritis. Ann Rheum Dis 2012;71(1):13–9.
agement of rheumatoid arthritis with synthetic and biolog- 22. Zangi HA, Ndosi M, Adams J, Andersen L, Bode C, Bostrom C,
ical disease-modifying antirheumatic drugs: 2013 update. et al. EULAR recommendations for patient education for
Ann Rheum Dis 2014;73(3):492–509. people with inflammatory arthritis. Ann Rheum Dis 2015;
9. Castrejon I, Pincus T. Patient self-report outcomes to guide a 74(6):954–62.
treat-to-target strategy in clinical trials and usual clinical 23. Cramp F, Hewlett S, Almeida C, Kirwan JR, Choy EH, Chalder
care of rheumatoid arthritis. Clin Exp Rheumatol 2012;30(4 T, et al. Non-pharmacological interventions for fatigue in
Suppl 73):S50–5. rheumatoid arthritis. Cochrane Database Syst Rev 2013;(8):
10. Smolen JS, Aletaha D. The assessment of disease activity in CD008322.
rheumatoid arthritis. Clin Exp Rheumatol 2010;28(3 Suppl 24. Cunningham NR, Kashikar-Zuck S. Nonpharmacologic Treat-
59):S18–27. ment of Pain in Rheumatic Diseases and Other Musculoskel-
11. Gossec L, Dougados M, Dixon W. Patient-reported out- etal Pain Conditions. Curr Rheumatol Rep 2013;15(2):306.
comes as end points in clinical trials in rheumatoid arthritis. 25. Ndosi M, Vinall K, Hale C, Bird H, Hill J. The effectiveness of
RMD Open 2015;1(1):e000019. nurse-led care in people with rheumatoid arthritis: a sys-
12. Boers M, Kirwan JR, Wells G, Beaton D, Gossec L, d’Agostino tematic review. Int J Nurs Stud 2011;48(5):642–54.
MA, et al. Developing core outcome measurement sets for 26. Steultjens EM, Dekker J, Bouter LM, van Schaardenburg D,
clinical trials: OMERACT filter 2.0. J Clin Epidemiol van Kuyk MA, van den Ende CH. Occupational therapy for
2014;67(7):745–53. rheumatoid arthritis. Cochrane Database Syst Rev 2004;(1):
13. Curtis JR, Shan Y, Harrold L, Zhang J, Greenberg JD, Reed CD003114.
GW. Patient perspectives on achieving treat-to-target goals: 27. Knittle K, Maes S, de Gucht V. Psychological interventions
a critical examination of patient-reported outcomes. Arthri- for rheumatoid arthritis: examining the role of self-regula-
tis Care Res (Hoboken) 2013;65(10):1707–12. tion with a systematic review and meta-analysis of

JBI Database of Systematic Reviews and Implementation Reports ß 2019 THE JOANNA BRIGGS INSTITUTE 1508

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

SYSTEMATIC REVIEW E. Santos et al.

randomized controlled trials. Arthritis Care Res (Hoboken) 41. Rongen-van Dartel SA, Repping-Wuts H, Flendrie M, Bleijen-
2010;62(10):1460–72. berg G, Metsios GS, van den Hout WB, et al. Effect of Aerobic
28. Christie A, Jamtvedt G, Dahm KT, Moe RH, Haavardsholm EA, Exercise Training on Fatigue in Rheumatoid Arthritis: A Meta-
Hagen KB. Effectiveness of nonpharmacological and nonsurgical Analysis. Arthritis Care Res (Hoboken) 2015;67(8):1054–62.
interventions for patients with rheumatoid arthritis: an overview 42. Baillet A, Vaillant M, Guinot M, Juvin R, Gaudin P. Efficacy of
of systematic reviews. Phys Ther 2007;87(12):1697–715. resistance exercises in rheumatoid arthritis: meta-analysis
29. Vliet Vlieland TP. Non-drug care for RA–is the era of evidence- of randomized controlled trials. Rheumatology (Oxford)
based practice approaching? Rheumatology (Oxford) 2012;51(3):519–27.
2007;46(9):1397–404. 43. Verhagen AP, Bierma-Zeinstra SM, Boers M, Cardoso JR,
30. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Lambeck J, de Bie R, et al. Balneotherapy (or spa therapy)
Cooper NS, et al. The American Rheumatism Association for rheumatoid arthritis. Cochrane Database Syst Rev
1987 revised criteria for the classification of rheumatoid 2015;(4):CD000518.
arthritis. Arthritis Rheum 1988;31(3):315–24. 44. Hennessy K, Woodburn J, Steultjens MP. Custom foot ortho-
31. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham ses for rheumatoid arthritis: A systematic review. Arthritis
CO 3rd et al. 2010 Rheumatoid arthritis classification criteria: Care Res (Hoboken) 2012;64(3):311–20.
an American College of Rheumatology/European League 45. Al-Qubaeissy KY, Fatoye FA, Goodwin PC, Yohannes AM. The
Against Rheumatism collaborative initiative. Arthritis Rheum effectiveness of hydrotherapy in the management of rheu-
2010;62(9):2569–81. matoid arthritis: a systematic review. Musculoskeletal Care
32. Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados 2013;11(1):3–18.
M, Emery P, et al. Treating rheumatoid arthritis to target: 46. Baillet A, Zeboulon N, Gossec L, Combescure C, Bodin LA,
2014 update of the recommendations of an international Juvin R, et al. Efficacy of cardiorespiratory aerobic exercise in
task force. Ann Rheum Dis 2015;75(1):3. rheumatoid arthritis: meta-analysis of randomized controlled
33. Herdman M, Gudex C, Lloyd A, Janssen MF, Kind P, Parkin D, trials. Arthritis Care Res (Hoboken) 2010;62(7):984–92.
et al. Development and preliminary testing of the new five- 47. Aromataris E, Munn Z (Editors). Joanna Briggs Institute
level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011; Reviewer’s Manual [Internet]. Adelaide: Joanna Briggs Insti-
20(10):1727–36. tute; 2017 [cited 15 November 2018]. Available from:
34. Aromataris E, Fernandez R, Godfrey C, Holly C, Khalil H, https://reviewersmanual.joannabriggs.org/.
Tungpunkom P. Chapter 10: Umbrella Reviews. In: Aroma- 48. Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA. 1958
taris E, Munn Z (Editors). Joanna Briggs Institute Reviewer’s Revision of diagnostic criteria for rheumatoid arthritis. Bull
Manual: The Joanna Briggs Institute; [internet]. 2017 [cited Rheum Dis 1958;9(4):175–6.
15 November 2018]. Available from https://reviewersma- 49. Steinbrocker O, Traeger CH, Batterman RC. Therapeutic
nual.joannabriggs.org/. criteria in rheumatoid arthritis. Journal of the American
35. Santos E, Duarte C, Marques A, Cardoso D, Apóstolo J, da Medical Association 1949;140(8):659–62.
Silva JAP, et al. Effectiveness of non-pharmacological and 50. Rausch Osthoff A-K, Niedermann K, Braun J, Adams J, Brodin
non-surgical interventions on the impact of rheumatoid N, Dagfinrud H, et al. 2018 EULAR recommendations for
arthritis: an umbrella review protocol. JBI Database Systemc physical activity in people with inflammatory arthritis and
Rev Implement Rep 2019;17(1):22–7. osteoarthritis. Ann Rheum Dis 2018;77(9):1251.
36. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred report- 51. Sokka T, Hakkinen A, Kautiainen H, Maillefert JF, Toloza S, Mork
ing items for systematic reviews and meta-analyses: the Hansen T, et al. Physical inactivity in patients with rheumatoid
PRISMA statement. PLoS Med 2009;6(7):e1000097. arthritis: data from twenty-one countries in a cross-sectional,
37. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, international study. Arthritis Rheum 2008;59(1):42–50.
Tungpunkom P. Summarizing systematic reviews: method- 52. Sharpe L. Psychosocial management of chronic pain in
ological development, conduct and reporting of an patients with rheumatoid arthritis: challenges and solu-
umbrella review approach. Int J Evid Based Healthc tions. Journal of pain research 2016;9:137–46.
2015;13(3):132–40. 53. Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B.
38. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso- Psychological interventions for rheumatoid arthritis: A
Coello P, et al. GRADE: an emerging consensus on rating meta-analysis of randomized controlled trials. Arthritis
quality of evidence and strength of recommendations. BMJ Rheum 2002;47(3):291–302.
2008;336(7650):924–6. 54. Clark H, Rome K, Plant M, O’Hare K, Gray J. A critical review of
39. McHugh ML. Interrater reliability: the kappa statistic. Bio- foot orthoses in the rheumatoid arthritic foot. Rheumatol-
chemia medica 2012;22(3):276–82. ogy 2006;45(2):139–45.
40. Carandang K, Pyatak EA, Vigen CL. Systematic Review of 55. Farrow SJ, Kingsley GH, Scott DL. Interventions for foot
Educational Interventions for Rheumatoid Arthritis. Am J disease in rheumatoid arthritis: a systematic review. Arthri-
Occup Ther 2016;70(6). 7006290020p1-p12. tis Rheum 2005;53(4):593–602.

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Appendix I: Search strategies

CINAHL Plus with Full Text: searched on 30th July, 2018

Search ID # Search terms Results

S28 S4 AND S25 AND S26 AND S27 60
Limiters - Published Date: 20100101
Language: English, French, Portuguese, Spanish
S27 S2 OR S13 341,951
S26 S3 OR S23 324,685
S25 S1 OR S24 45,658
S24 MH Arthritis, Rheumatoid 18,137
S23 S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR 144,531
S22
S22 (MH ‘‘Phototherapy’’) 2675
S21 (MH ‘‘Acupunctureþ’’) 13,114
S20 (MH ‘‘Exerciseþ’’) 90,721
S19 (MH ‘‘Hyperthermia, Inducedþ’’) 3349
S18 (MH ‘‘Transcutaneous Electric Nerve Stimulation’’) 1796
S17 (MH ‘‘Massageþ’’) 13,015
S16 (MH ‘‘Occupational Therapyþ’’) 21,489
S15 (MH ‘‘Balneology’’) 460
S14 (MH ‘‘Tai Chi’’) 1689
S13 (S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12) 113,460
S12 MH Asthenia 151
S11 MH Adaptation, Psychological 25,563
S10 MH Sleep 14,397
S9 MH sleep deprivation 3090
S8 MH Pain 60,836
S7 MH Fatigue (NANDA) 0
S6 MH Fatigue (Saba CCC) 0
S5 MH Fatigue 14,256
S4 (MH ‘‘Systematic Review’’) OR (MH ‘‘Meta Analysis’’) OR TI 91,130
‘‘systematic review’’ OR TI ‘‘meta analysis’’ OR TI metaanalysis OR
AB ‘‘systematic review’’ OR AB ‘‘meta analysis’’ OR AB metaanalysis

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SYSTEMATIC REVIEW E. Santos et al.

(Continued)

Search ID # Search terms Results

 
S3 TI (non-pharmacological OR non-surgical intervention OR ‘‘physical 243,857
activity’’ OR Exercise OR ‘‘occupational therapy’’ OR ‘‘electro-physical
modalities’’ OR ‘‘thermotherapy’’ OR ‘‘electrotherapy’’ OR ‘‘manual
therapies’’ OR massage OR orthoses OR aids OR devices OR ‘‘adapta-
tions of physical environment’’ OR ‘‘psychosocial interventions’’ OR
balneotherapy OR ‘‘tai chi’’ OR acupuncture OR electroacupuncture
OR ‘‘low level laser therapy’’) OR AB (non-pharmacological OR non-
surgical intervention OR ‘‘physical activity’’ OR Exercise OR ‘‘occupa-
tional therapy’’ OR ‘‘electro-physical modalities’’ OR ‘‘thermotherapy’’
OR ‘‘electrotherapy’’ OR ‘‘manual therapies’’ OR massage OR orthoses
OR aids OR devices OR ‘‘adaptations of physical environment’’ OR
‘‘psychosocial interventions’’ OR balneotherapy OR ‘‘tai chi’’ OR
acupuncture OR electroacupuncture OR ‘‘low level laser therapy’’)
S2 TI (pain OR ‘‘functional disability’’ OR fatigue OR tired OR wear OR 296,940
exhaust OR ‘‘emotional well-being’’ OR sleep OR coping OR ‘‘physical
well-being’’ OR asthen) OR AB (pain OR ‘‘functional disability’’ OR
fatigue OR tired OR wear OR exhaust OR ‘‘emotional well-being’’
OR sleep OR coping OR ‘‘physical well-being’’ OR asthen)
S1 TI (rheumat OR reumat OR arthrit OR artrit) OR AB (rheumat 42,107
OR reumat OR arthrit OR artrit)

PubMed: searched on 30th July, 2018

Search ID # Search terms Results

#27 Search (((((((((non-pharmacological[Title/Abstract] OR non-surgical interven- 221
tion[Title/Abstract] OR ‘‘physical activity’’[Title/Abstract] OR exercise[Title/
Abstract] OR ‘‘occupational therapy’’[Title/Abstract] OR ‘‘electro-physical
modalities’’[Title/Abstract] OR ‘‘thermotherapy’’[Title/Abstract] OR ‘‘electro-
therapy’’[Title/Abstract] OR ‘‘manual therapies’’[Title/Abstract] OR massage[Ti-
tle/Abstract] OR orthoses[Title/Abstract] OR aids[Title/Abstract] OR
devices[Title/Abstract] OR ‘‘adaptations of physical environment’’[Title/
Abstract] OR ‘‘psychosocial interventions’’[Title/Abstract] OR balneotherapy[Ti-
tle/Abstract] OR ‘‘tai chi’’[Title/Abstract] OR acupuncture[Title/Abstract] OR
electroacupuncture[Title/Abstract] OR ‘‘low level laser therapy’’[Title/Abstract]
OR ‘‘tai ji’’[Title/Abstract] OR ‘‘Low-Level Light Therapy’’[Title/Abstract])) OR
(((((((((Tai Ji[MeSH Terms]) OR Acupuncture Therapy[MeSH Terms]) OR Low-
Level Light Therapy[MeSH Terms]) OR Balneology[MeSH Terms]) OR Occupa-
tional Therapy[MeSH Terms]) OR Massage[MeSH Terms]) OR Electric Stimu-
lation Therapy[MeSH Terms]) OR Hyperthermia, Induced[MeSH Terms]) OR
Exercise[MeSH Terms]))) AND ((((pain[Title/Abstract] OR ‘‘functional disabil-
ity’’[Title/Abstract] OR fatigue[Title/Abstract] OR tired[Title/Abstract] OR
wear[Title/Abstract] OR exhaust[Title/Abstract] OR ‘‘emotional well-being’’[-
Title/Abstract] OR sleep[Title/Abstract] OR coping[Title/Abstract] OR ‘‘physi-
cal well-being’’[Title/Abstract] OR asthen[Title/Abstract]))) OR
(((((Asthenia[MeSH Terms]) OR Adaptation, Psychological[MeSH Terms]) OR
Sleep[MeSH Terms]) OR Pain[MeSH Terms]) OR Fatigue[MeSH Terms])))
AND ((((rheumat[Title/Abstract] OR reumat[Title/Abstract] OR arthrit[Title/
Abstract] OR artrit[Title/Abstract]))) OR arthritis, rheumatoid[MeSH Terms])))
AND systematic [sb] Sort by: Best Match Filters: Publication date from 2010/
01/01; English; French; Portuguese; Spanish

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(Continued)
Search ID # Search terms Results

#26 Search (((((((((non-pharmacological [Title/Abstract] OR non-surgical interven- 301
tion[Title/Abstract] OR ‘‘physical activity’’[Title/Abstract] OR exercise[Title/
Abstract] OR ‘‘occupational therapy’’[Title/Abstract] OR ‘‘electro-physical
modalities’’[Title/Abstract] OR ‘‘thermotherapy’’[Title/Abstract] OR ‘‘electro-
therapy’’[Title/Abstract] OR ‘‘manual therapies’’[Title/Abstract] OR massage[Ti-
tle/Abstract] OR orthoses[Title/Abstract] OR aids[Title/Abstract] OR
devices[Title/Abstract] OR ‘‘adaptations of physical environment’’[Title/
Abstract] OR ‘‘psychosocial interventions’’[Title/Abstract] OR balneotherapy[Ti-
tle/Abstract] OR ‘‘tai chi’’[Title/Abstract] OR acupuncture[Title/Abstract] OR
electroacupuncture[Title/Abstract] OR ‘‘low level laser therapy’’[Title/Abstract]
OR ‘‘tai ji’’[Title/Abstract] OR ‘‘Low-Level Light Therapy’’[Title/Abstract])) OR
(((((((((Tai Ji[MeSH Terms]) OR Acupuncture Therapy[MeSH Terms]) OR Low-
Level Light Therapy[MeSH Terms]) OR Balneology[MeSH Terms]) OR Occupa-
tional Therapy[MeSH Terms]) OR Massage[MeSH Terms]) OR Electric Stimu-
lation Therapy[MeSH Terms]) OR Hyperthermia, Induced[MeSH Terms]) OR
Exercise[MeSH Terms]))) AND ((((pain[Title/Abstract] OR ‘‘functional disabil-
ity’’[Title/Abstract] OR fatigue[Title/Abstract] OR tired[Title/Abstract] OR
wear[Title/Abstract] OR exhaust[Title/Abstract] OR ‘‘emotional well-being’’[-
Title/Abstract] OR sleep[Title/Abstract] OR coping[Title/Abstract] OR ‘‘physi-
cal well-being’’[Title/Abstract] OR asthen[Title/Abstract]))) OR
(((((Asthenia[MeSH Terms]) OR Adaptation, Psychological[MeSH Terms]) OR
Sleep[MeSH Terms]) OR Pain[MeSH Terms]) OR Fatigue[MeSH Terms])))
AND ((((rheumat[Title/Abstract] OR reumat[Title/Abstract] OR arthrit[Title/
Abstract] OR artrit[Title/Abstract]))) OR arthritis, rheumatoid[MeSH Terms])))
AND systematic [sb]
#25 Search (((((((non-pharmacological[Title/Abstract] OR non-surgical interven- 2702
tion[Title/Abstract] OR ‘‘physical activity’’[Title/Abstract] OR exercise[Title/
Abstract] OR ‘‘occupational therapy’’[Title/Abstract] OR ‘‘electro-physical
modalities’’[Title/Abstract] OR ‘‘thermotherapy’’[Title/Abstract] OR ‘‘electro-
therapy’’[Title/Abstract] OR ‘‘manual therapies’’[Title/Abstract] OR massage[Ti-
tle/Abstract] OR orthoses[Title/Abstract] OR aids[Title/Abstract] OR
devices[Title/Abstract] OR ‘‘adaptations of physical environment’’[Title/
Abstract] OR ‘‘psychosocial interventions’’[Title/Abstract] OR balneotherapy[Ti-
tle/Abstract] OR ‘‘tai chi’’[Title/Abstract] OR acupuncture[Title/Abstract] OR
electroacupuncture[Title/Abstract] OR ‘‘low level laser therapy’’[Title/Abstract]
OR ‘‘tai ji’’[Title/Abstract] OR ‘‘Low-Level Light Therapy’’[Title/Abstract])) OR
(((((((((Tai Ji[MeSH Terms]) OR Acupuncture Therapy[MeSH Terms]) OR Low-
Level Light Therapy[MeSH Terms]) OR Balneology[MeSH Terms]) OR Occupa-
tional Therapy[MeSH Terms]) OR Massage[MeSH Terms]) OR Electric Stimu-
lation Therapy[MeSH Terms]) OR Hyperthermia, Induced[MeSH Terms]) OR
Exercise[MeSH Terms]))) AND ((((pain[Title/Abstract] OR ‘‘functional disabil-
ity’’[Title/Abstract] OR fatigue[Title/Abstract] OR tired[Title/Abstract] OR
wear[Title/Abstract] OR exhaust[Title/Abstract] OR ‘‘emotional well-being’’[-
Title/Abstract] OR sleep[Title/Abstract] OR coping[Title/Abstract] OR ‘‘physi-
cal well-being’’[Title/Abstract] OR asthen[Title/Abstract]))) OR
(((((Asthenia[MeSH Terms]) OR Adaptation, Psychological[MeSH Terms]) OR
Sleep[MeSH Terms]) OR Pain[MeSH Terms]) OR Fatigue[MeSH Terms])))
AND ((((rheumat[Title/Abstract] OR reumat[Title/Abstract] OR arthrit[Title/
Abstract] OR artrit[Title/Abstract]))) OR arthritis, rheumatoid[MeSH Terms])

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SYSTEMATIC REVIEW E. Santos et al.

(Continued)
Search ID # Search terms Results
 
#24 Search ((((non-pharmacological [Title/Abstract] OR non-surgical intervention [Ti- 851,679
[Title/Abstract] OR ‘‘physical activity’’[Title/Abstract] OR exercise[Title/Abstract]
OR ‘‘occupational therapy’’[Title/Abstract] OR ‘‘electro-physical modalities’’[Ti-
tle/Abstract] OR ‘‘thermotherapy’’[Title/Abstract] OR ‘‘electrotherapy’’[Title/
Abstract] OR ‘‘manual therapies’’[Title/Abstract] OR massage[Title/Abstract] OR
orthoses[Title/Abstract] OR aids[Title/Abstract] OR devices[Title/Abstract] OR
‘‘adaptations of physical environment’’[Title/Abstract] OR ‘‘psychosocial inter-
ventions’’[Title/Abstract] OR balneotherapy[Title/Abstract] OR ‘‘tai chi’’[Title/
Abstract] OR acupuncture[Title/Abstract] OR electroacupuncture[Title/Abstract]
OR ‘‘low level laser therapy’’[Title/Abstract] OR ‘‘tai ji’’[Title/Abstract] OR
‘‘Low-Level Light Therapy’’[Title/Abstract])) OR (((((((((Tai Ji[MeSH Terms]) OR
Acupuncture Therapy[MeSH Terms]) OR Low-Level Light Therapy[MeSH
Terms]) OR Balneology[MeSH Terms]) OR Occupational Therapy[MeSH Terms])
OR Massage[MeSH Terms]) OR Electric Stimulation Therapy[MeSH Terms]) OR
Hyperthermia, Induced[MeSH Terms]) OR Exercise[MeSH Terms])
#23 Search ((non-pharmacological[Title/Abstract] OR non-surgical intervention[Ti- 673,194
[Title/Abstract] OR ‘‘physical activity’’[Title/Abstract] OR exercise[Title/
Abstract] OR ‘‘occupational therapy’’[Title/Abstract] OR ‘‘electro-physical
modalities’’[Title/Abstract] OR ‘‘thermotherapy’’[Title/Abstract] OR ‘‘electro-
therapy’’[Title/Abstract] OR ‘‘manual therapies’’[Title/Abstract] OR massage[Ti-
tle/Abstract] OR orthoses[Title/Abstract] OR aids[Title/Abstract] OR
devices[Title/Abstract] OR ‘‘adaptations of physical environment’’[Title/
Abstract] OR ‘‘psychosocial interventions’’[Title/Abstract] OR balneotherapy[Ti-
tle/Abstract] OR ‘‘tai chi’’[Title/Abstract] OR acupuncture[Title/Abstract] OR
electroacupuncture[Title/Abstract] OR ‘‘low level laser therapy’’[Title/Abstract]
OR ‘‘tai ji’’[Title/Abstract] OR ‘‘Low-Level Light Therapy’’[Title/Abstract]
#22 Search systematic [sb] 371,216
#21 Search (((pain[Title/Abstract] OR ‘‘functional disability’’[Title/Abstract] OR 1,159,280
fatigue[Title/Abstract] OR tired[Title/Abstract] OR wear[Title/Abstract] OR
exhaust[Title/Abstract] OR ‘‘emotional well-being’’[Title/Abstract] OR
sleep[Title/Abstract] OR coping[Title/Abstract] OR ‘‘physical well-being’’[Title/
Abstract] OR asthen[Title/Abstract]))) OR (((((Asthenia[MeSH Terms]) OR
Adaptation, Psychological[MeSH Terms]) OR Sleep[MeSH Terms]) OR Pain[-
MeSH Terms]) OR Fatigue[MeSH Terms])
#20 Search (((rheumat[Title/Abstract] OR reumat[Title/Abstract] OR arthrit[Title/ 256,361
Abstract] OR artrit[Title/Abstract]))) OR arthritis, rheumatoid[MeSH Terms]
#19 Search ((((Asthenia[MeSH Terms]) OR Adaptation, Psychological[MeSH Terms]) 567,264
OR Sleep[MeSH Terms]) OR Pain[MeSH Terms]) OR Fatigue[MeSH Terms]
#18 Search ((((((((Tai Ji[MeSH Terms]) OR Acupuncture Therapy[MeSH Terms]) 316,995
OR Low-Level Light Therapy[MeSH Terms]) OR Balneology[MeSH Terms])
OR Occupational Therapy[MeSH Terms]) OR Massage[MeSH Terms]) OR
Electric Stimulation Therapy[MeSH Terms]) OR Hyperthermia, Induced[MeSH
Terms]) OR Exercise[MeSH Terms]
#17 Search Asthenia[MeSH Terms] 1614
#16 Search Adaptation, Psychological[MeSH Terms] 118,125
#15 Search Sleep[MeSH Terms] 72,405
#14 Search Pain[MeSH Terms] 361,100
#13 Search Fatigue[MeSH Terms] 26,820
#12 Search Exercise[MeSH Terms] 167,783
#11 Search Hyperthermia, Induced[MeSH Terms] 28,980

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(Continued)
Search ID # Search terms Results
#10 Search Electric Stimulation Therapy[MeSH Terms] 71,976
#9 Search Massage[MeSH Terms] 5684
#8 Search Occupational Therapy[MeSH Terms] 12,217
#7 Search Balneology[MeSH Terms] 12,055
#6 Search Low-Level Light Therapy[MeSH Terms] 4772
#5 Search Acupuncture Therapy[MeSH Terms] 21,769
#4 Search Tai Ji[MeSH Terms] 895
#3 Search arthritis, rheumatoid[MeSH Terms] 105,847
#2 Search (pain[Title/Abstract] OR ‘‘functional disability’’[Title/Abstract] OR fati- 906,123
gue[Title/Abstract] OR tired[Title/Abstract] OR wear[Title/Abstract] OR
exhaust[Title/Abstract] OR ‘‘emotional well-being’’[Title/Abstract] OR
sleep[Title/Abstract] OR coping[Title/Abstract] OR ‘‘physical well-being’’[Title/
Abstract] OR asthen[Title/Abstract])
#1 Search (rheumat[Title/Abstract] OR reumat[Title/Abstract] OR arthrit[Title/ 232,101
Abstract] OR artrit[Title/Abstract])

Cochrane Database of Systematic Reviews: searched on 31th July, 2018

Search ID # Search terms Results

   
#1 rheumat or reumat or arthrit or artrit :ti,ab,kw (Word variations 19,604
have been searched)
#2 non-pharmacological or non-surgical intervention or ‘‘physical activ- 151,048
ity’’ or Exercise or ‘‘occupational therapy’’ or ‘‘electro-physical modali-
ties’’ or ‘‘thermotherapy’’ or ‘‘electrotherapy’’ or ‘‘manual therapies’’ or
massage or orthoses or aids or devices or ‘‘adaptations of physical
environment’’ or ‘‘psychosocial interventions’’ or balneotherapy or ‘‘tai
chi’’ or acupuncture or electroacupuncture or ‘‘low level laser therapy’’:-
ti,ab,kw (Word variations have been searched)
#3 pain or ‘‘functional disability’’ or fatigue or tired or wear or exhaust 180,971
or ‘‘emotional well-being’’ or sleep or coping or ‘‘physical well-being’’
or asthen:ti,ab,kw (Word variations have been searched)
#4 MeSH descriptor: [Arthritis, Rheumatoid] explode all trees 5772
#5 #1 or #4 19,817
#6 MeSH descriptor: [Tai Ji] explode all trees 380
#7 MeSH descriptor: [Acupuncture Therapy] explode all trees 4399
#8 MeSH descriptor: [Low-Level Light Therapy] explode all trees 834
#9 MeSH descriptor: [Balneology] explode all trees 563
#10 MeSH descriptor: [Occupational Therapy] explode all trees 767
#11 MeSH descriptor: [Massage] explode all trees 1050
#12 MeSH descriptor: [Electric Stimulation Therapy] explode all trees 6660
#13 MeSH descriptor: [Hyperthermia, Induced] explode all trees 1657

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(Continued)

Search ID # Search terms Results

#14 MeSH descriptor: [Exercise] explode all trees 21,440
#15 #2 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 159,087
#16 MeSH descriptor: [Fatigue] explode all trees 3085
#17 MeSH descriptor: [Pain] explode all trees 45,049
#18 MeSH descriptor: [Sleep] explode all trees 5187
#19 MeSH descriptor: [Adaptation, Psychological] explode all trees 5121
#20 MeSH descriptor: [Asthenia] explode all trees 71
#21 #3 or #16 or #17 or #18 or #19 or #20 189,737
#22 #5 and #15 and #21 1462
#23 #5 and #15 and #21 in Cochrane Reviews 59

Scopus: searched on 30th July, 2018

Search strategy Results

(TITLE-ABS-KEY (‘‘systematic AND review’’ OR ‘‘meta AND analysis’’ OR metaanalysis)) 98
AND (TITLE-ABS-KEY (pain OR ‘‘functional disability’’ OR fatigue OR tired OR wear
OR exhaust OR ‘‘emotional well-being’’ OR sleep OR coping OR ‘‘physical well-being’’
OR asthen)) AND (TITLE-ABS-KEY (rheumat OR reumat OR arthrit OR artrit))
AND ((TITLE-ABS-KEY (non-pharmacological OR non-surgical AND intervention OR
‘‘physical activity’’ OR exercise OR ‘‘occupational therapy’’ OR ‘‘electro-physical modali-
ties’’ OR ‘‘thermotherapy’’ OR ‘‘electrotherapy’’ OR ‘‘manual therapies’’)) OR (TITLE-
ABS-KEY (massage OR orthoses OR aids OR devices OR ‘‘adaptations of physical
environment’’ OR ‘‘psychosocial interventions’’ OR balneotherapy OR ‘‘tai chi’’ OR
acupuncture OR electroacupuncture OR ‘‘low level laser therapy’’))) AND (LIMIT-TO
(PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016)
OR LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO
(PUBYEAR, 2013) OR LIMIT-TO (PUBYEAR, 2012) OR LIMIT-TO (PUBYEAR, 2011)
OR LIMIT-TO (PUBYEAR, 2010)) AND (LIMIT-TO (LANGUAGE, ‘‘English’’) OR
LIMIT-TO (LANGUAGE, ‘‘Spanish’’) OR LIMIT-TO (LANGUAGE, ‘‘French’’))

Embase: searched on 31th July, 2018

Search ID # Search terms Results

#14 #12 AND (2010:py OR 2011:py OR 2012:py OR 2013:py OR 2014:py 307
OR 2015:py OR 2016:py OR 2017:py OR 2018:py) AND ([english]/lim
OR [french]/lim OR [portuguese]/lim OR [spanish]/lim)
#13 #12 AND (2010:py OR 2011:py OR 2012:py OR 2013:py OR 2014:py 312
OR 2015:py OR 2016:py OR 2017:py OR 2018:py)
#12 #10 AND #11 458
#11 ‘systematic review’/syn OR ‘meta analysis’/syn 347,084
#10 #7 AND #8 AND #9 6,692

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(Continued)

Search ID # Search terms Results

#9 #3 OR #6 2,050,079
#8 #2 OR #5 1,078,842
#7 #1 OR #4 396,381
#6 ‘fatigue’/exp OR ‘pain’/exp OR ‘sleep’/exp OR ‘coping behavior’/exp 1,566,255
OR ‘asthenia’/exp
#5 ‘tai chi’/exp OR ‘acupuncture’/exp OR ‘phototherapy’/exp OR ‘balneology’/ 504,905
exp OR ‘occupational therapy’/exp OR ‘massage’/exp OR ‘transcutaneous
electrical nerve stimulation’/exp OR ‘thermotherapy’/exp OR ‘exercise’/exp
#4 ‘rheumatoid arthritis’/exp 202,714
#3 ‘pain’:ab,ti OR ‘functional disability’:ab,ti OR ‘fatigue’:ab,ti OR 1,337,530
‘tired’:ab,ti OR ‘wear’:ab,ti OR ‘exhaust’:ab,ti OR ‘emotional
well-being’:ab,ti OR ‘sleep’:ab,ti OR ‘coping’:ab,ti OR ‘physical
well-being’:ab,ti OR ‘asthen’:ab,ti
#2 ‘non-pharmacological’:ab,ti OR ‘non-surgical intervention’:ab,ti OR 841,643
‘physical activity’:ab,ti OR ‘exercise’:ab,ti OR ‘occupational therapy’:ab,ti
OR ‘electro-physical modalities’:ab,ti OR ‘thermotherapy’:ab,ti OR ‘elec-
trotherapy’:ab,ti OR ‘manual therapies’:ab,ti OR ‘massage’:ab,ti OR
‘orthoses’:ab,ti OR ‘aids’:ab,ti OR ‘devices’:ab,ti OR ‘adaptations of
physical environment’:ab,ti OR ‘psychosocial interventions’:ab,ti OR
‘balneotherapy’:ab,ti OR ‘tai chi’:ab,ti OR ‘acupuncture’:ab,ti OR ‘elec-
troacupuncture’:ab,ti OR ‘low level laser therapy’:ab,ti
#1 ‘rheumat’:ab,ti OR ‘reumat’:ab,ti OR ‘arthrit’:ab,ti OR ‘artrit’:ab,ti 353,974

PsycINFO: searched on 2nd September, 2018

Search terms Results

    
AB (rheumat OR reumat OR arthrit OR artrit ) AND AB (non-pharmacological OR non- 116
surgical intervention OR ‘‘physical activity’’ OR Exercise OR ‘‘occupational therapy’’ OR
‘‘electro-physical modalities’’ OR ‘‘thermotherapy’’ OR ‘‘electrotherapy’’ OR ‘‘manual thera-
pies’’ OR massage OR orthoses OR aids OR devices OR ‘‘adaptations of physical environment’’
OR ‘‘psychosocial interventions’’ OR balneotherapy OR ‘‘tai chi’’ OR acupuncture OR
electroacupuncture OR ‘‘low level laser therapy’’) AND AB (pain OR ‘‘functional disability’’
OR fatigue OR tired OR wear OR exhaust OR ‘‘emotional well-being’’ OR sleep OR coping
OR ‘‘physical well-being’’ OR asthen)
Limiters - Published Date: 20100101
Language: English, French, Portuguese, Spanish

PEDro: searched on 30th July, 2018

Search terms Results

Abstract & Title: rheumatoid arthritis 54
Method: systematic review
Published Since: 2010

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SYSTEMATIC REVIEW E. Santos et al.

Epistemonikos: searched on 30th July, 2018

Search terms Results

(title:(‘‘rheumatoid arthritis’’) OR abstract:(‘‘rheumatoid arthritis’’)) AND (title:(non- 48
pharmacological OR non-surgical intervention OR ‘‘physical activity’’ OR Exercise OR
‘‘occupational therapy’’ OR ‘‘electro-physical modalities’’ OR ‘‘thermotherapy’’ OR
‘‘electrotherapy’’ OR ‘‘manual therapies’’ OR massage OR orthoses OR aids OR devices
OR ‘‘adaptations of physical environment’’ OR ‘‘psychosocial interventions’’ OR bal-
neotherapy OR ‘‘tai chi’’ OR acupuncture OR electroacupuncture OR ‘‘low level laser
therapy’’) OR abstract:(non-pharmacological OR non-surgical intervention OR ‘‘physical
activity’’ OR Exercise OR ‘‘occupational therapy’’ OR ‘‘electro-physical modalities’’ OR
‘‘thermotherapy’’ OR ‘‘electrotherapy’’ OR ‘‘manual therapies’’ OR massage OR orthoses
OR aids OR devices OR ‘‘adaptations of physical environment’’ OR ‘‘psychosocial
interventions’’ OR balneotherapy OR ‘‘tai chi’’ OR acupuncture OR electroacupuncture
OR ‘‘low level laser therapy’’))
Publication year: 2010-2018
Publication type: Systematic review
Systematic Review Question: interventions

JBI Database of Systematic Reviews and Implementation Reports: searched on 30th July, 2018

Search terms Results

rheumatoid arthritis 26

The PROSPERO register: searched on 30th July, 2018

Search terms Results

(rheumatoid arthritis):TI AND (Intervention OR Systematic Review OR Meta-Analysis):RT 95

Campbell Collaboration Library of Systematic Reviews: searched on 30th July, 2018

Search terms Results

rheumatoid arthritis 0

RCAAP – Repositório Cientı́fico de Acesso Aberto de Portugal: searched on 30th July, 2018

Search terms Results

Full-text: ‘‘rheumatoid arthritis’’ AND review 49

OpenGrey – System for Information on Grey Literature in Europe: searched on 30th July, 2018

Search strategy Results

rheumatoid arthritis AND Review 7
Publication date from 2010

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SYSTEMATIC REVIEW E. Santos et al.

Appendix II: List of excluded studies after full-text eligibility assessment

Akyuz G, Kenis-Coskun O. The Efficacy of Tai Chi and Yoga in Rheumatoid Arthritis and Spondyloar-
thropathies: A narrative biomedical review. Rheumatology International. 2018;38(3):321–30.
Reason for exclusion: Ineligible participants.
Alkabeya HA, Adams J, Hughes A-M. Factors associated with hand functional disability in patients with
rheumatoid arthritis: a systematic review. 2017.
Reason for exclusion: Ineligible study type.
Balsamo S, Diniz LR, dos Santos-Neto LL, da Mota LM. Exercise and fatigue in rheumatoid arthritis. Isr
Med Assoc J. 2014;16(1):57–60.
Reason for exclusion: Ineligible participants.
Bearne LM, Byrne AM, Segrave H, White CM. Multidisciplinary team care for people with rheumatoid
arthritis: a systematic review and meta-analysis. Rheumatol Int. 2016;36(3):311–24.
Reason for exclusion: Ineligible intervention.
Bergstra SA, Murgia A, Te Velde AF, Caljouw SR. A systematic review into the effectiveness of hand exercise
therapy in the treatment of rheumatoid arthritis. Clin Rheumatol. 2014;33(11):1539–48.
Reason for exclusion: Ineligible participants.
Brosseau L, Welch V, Wells GA, de Bie R, Gam A, Harman K, et al. Low level laser therapy (Classes I, II and
III) for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2005(4).
Reason for exclusion: Ineligible publication date.
Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA, et al. Transcutaneous electrical nerve
stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database of Systematic
Reviews. 2003(2).
Reason for exclusion: Ineligible publication date.
Bryer C, Srikesavan C, Williamson E. Effects of web-based interventions on physical function and activity,
pain and quality of life in patients with rheumatoid arthritis: A systematic review. Rheumatology (Oxford).
2017;56:ii204.
Reason for exclusion: Ineligible study type.
Camacho-Bautista K, Orjuela-Rodrı́guez A, Vargas-Pinilla O. Intervención fisioterapéutica en el manejo de
pacientes con artritis reumatoide: una revisión sistemática. Fisioterapia. 2017;39(4):174–80.
Reason for exclusion: Ineligible participants.
Carandang K, Pyatak E. A systematic review of the educational approach of occupational therapy for
rheumatoid arthritis. Arthritis and Rheumatology. 2014;66:S1014-S5.
Reason for exclusion: Ineligible study type.
Carandang K, Pyatak EA, Vigen CL. Systematic Review of Educational Interventions for Rheumatoid
Arthritis. Am J Occup Ther. 2016;70(6):7006290020p1-p12.
Reason for exclusion: Ineligible study type.
Casimiro L, Barnsley L, Brosseau L, Milne S, Welch V, Tugwell P, et al. Acupuncture and electroacupuncture
for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2005(4).
Reason for exclusion: Ineligible publication date.
Casimiro L, Brosseau L, Welch V, Milne S, Judd M, Wells GA, et al. Therapeutic ultrasound for the
treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2002(3).
Reason for exclusion: Ineligible publication date.

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Chen J, Chen T, Xu J. Efficacy of probiotics on rheumatoid arthritis (RA): a systematic review and meta-
analysis. PROSPERO. 2017.
Reason for exclusion: Ineligible study type.
Chou P-C, Chu H-Y. Clinical Efficacy of Acupuncture on Rheumatoid Arthritis and Associated Mecha-
nisms: A Systemic Review. Evidence-Based Complementary and Alternative Medicine. 2018;2018:21.
Reason for exclusion: Ineligible participants.
Conceicao CS, Gomes Neto M, Mendes SM, Sa KN, Baptista AF. Systematic review and meta-analysis of
effects of foot orthoses on pain and disability in rheumatoid arthritis patients. Disabil Rehabil.
2015;37(14):1209–13.
Reason for exclusion: Ineligible participants.
Cramp F, Berry J, Gardiner M, Smith F, Stephens D. Health behaviour change interventions for the
promotion of physical activity in rheumatoid arthritis: a systematic review. Musculoskeletal Care.
2013;11(4):238–47.
Reason for exclusion: Ineligible participants.
DiRenzo D, Crespo-Bosque M, Bingham C, Gould N, Finan P, Nanavati J. Systematic review: mindfulness-
based interventions for rheumatoid arthritis (protocol). PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Efthimiou P, Kukar M. Complementary and alternative medicine use in rheumatoid arthritis: proposed
mechanism of action and efficacy of commonly used modalities. Rheumatol Int. 2010;30(5):571–86.
Reason for exclusion: Ineligible intervention.
Egan M, Brosseau L, Farmer M, Ouimet MA, Rees S, Tugwell P, et al. Splints and Orthosis for treating
rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2001(4).
Reason for exclusion: Ineligible publication date.
Ekelman BA, Hooker L, Davis A, Klan J, Newburn D, Detwiler K, et al. Occupational therapy interventions
for adults with rheumatoid arthritis: an appraisal of the evidence. Occup Ther Health Care.
2014;28(4):347–61.
Reason for exclusion: Ineligible study type.
Ernst E, Posadzki P. Complementary and alternative medicine for rheumatoid arthritis and osteoarthritis: an
overview of systematic reviews. Curr Pain Headache Rep. 2011;15(6):431–7.
Reason for exclusion: Ineligible participants.
Giacobbi PR, Jr., Stabler ME, Stewart J, Jaeschke AM, Siebert JL, Kelley GA. Guided Imagery for Arthritis
and Other Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials. Pain Manag Nurs.
2015;16(5):792–803.
Reason for exclusion: Ineligible participants.
Gijon-Nogueron G, Ramos-Petersen L, Ortega-Avila AB, Morales-Asencio JM, Garcia-Mayor S. Effective-
ness of foot orthoses in patients with rheumatoid arthritis related to disability and pain: a systematic review
and meta-analysis. Qual Life Res. 2018.
Reason for exclusion: Ineligible participants.
Guillot X, Tordi N, Mourot L, Demougeot C, Dugue B, Prati C, et al. Cryotherapy in inflammatory
rheumatic diseases: a systematic review. Expert Rev Clin Immunol. 2014;10(2):281–94.
Reason for exclusion: Ineligible participants.
Hammond A, Jones V, Prior Y. The effects of compression gloves on hand symptoms and hand function in
rheumatoid arthritis and hand osteoarthritis: a systematic review. Clin Rehabil. 2016;30(3):213–24.
Reason for exclusion: Ineligible participants.

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Hammond A, Prior Y. The effectiveness of home hand exercise programmes in rheumatoid arthritis: a
systematic review. Br Med Bull. 2016;119(1):49–62.
Reason for exclusion: Ineligible participants.
Han A, Judd M, Welch V, Wu T, Tugwell P, Wells GA. Tai chi for treating rheumatoid arthritis. Cochrane
Database of Systematic Reviews. 2004(3).
Reason for exclusion: Ineligible publication date.
Hernández-Hernández MV, Dı́az-González F. Role of physical activity in the management and assessment of
rheumatoid arthritis patients. Reumatologia Clinica. 2017;13(4):214–20.
Reason for exclusion: Ineligible study type.
Hurkmans E, van der Giesen FJ, Vliet Vlieland TPM, Schoones J, Van den Ende E. Dynamic exercise
programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane
Database of Systematic Reviews. 2009(4).
Reason for exclusion: Ineligible publication date.
Hurkmans EJ, Jones A, Li LC, Vliet Vlieland TP. Quality appraisal of clinical practice guidelines on the use of
physiotherapy in rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2011;50(10):1879–88.
Reason for exclusion: Ineligible study type.
Hurkmans EJ, Van Der Giesen FJ, Vlieland TPMV, Schoones JW, Van Den Ende CHM. Home-based
exercise therapy in patients with rheumatoid arthritis: A systematic review. Arthritis and Rheumatism.
2010;62:2283.
Reason for exclusion: Ineligible study type.
Jones GT, Paudyal P, MacPherson H, Sim J, Doherty M, Ernst E, et al. The effectiveness of practitioner-based
complementary and alternative therapies in the management of rheumatoid arthritis. Rheumatology
(Oxford). 2012;51:131–2.
Reason for exclusion: Ineligible study type.
Kelley GA, Kelley KS, Callahan LF. Aerobic Exercise and Fatigue in Rheumatoid Arthritis Participants: A
Meta-Analysis Using the Minimal Important Difference Approach. Arthritis Care Res (Hoboken). 2018.
Reason for exclusion: Ineligible participants.
Kelley GA, Kelley KS, Hootman JM. Effects of exercise on depression in adults with arthritis: a systematic
review with meta-analysis of randomized controlled trials. Arthritis Res Ther. 2015;17:21.
Reason for exclusion: Ineligible participants.
Kelley GA, Kelley KS, Hootman JM, Jones DL. Effects of community-deliverable exercise on pain and
physical function in adults with arthritis and other rheumatic diseases: a meta-analysis. Arthritis Care Res
(Hoboken). 2011;63(1):79–93.
Reason for exclusion: Ineligible participants.
Langdon K, Phie J, Thapa C, Biros E, Nagaraja H, Loukas A. Helminth-based therapies for rheumatoid
arthritis: a systematic review and meta-analysis of the CIA animal model literature. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Larkin L, Gallagher S, Cramp F, Brand C, Fraser A, Kennedy N. Behaviour change interventions to promote
physical activity in rheumatoid arthritis: a systematic review. Rheumatol Int. 2015;35(10):1631–40.
Reason for exclusion: Ineligible outcomes.
Larmer PJ, Bell J, O’Brien D, Dangen J, Kersten P. Hydrotherapy outcome measures for people with arthritis:
A systematic review. New Zealand Journal of Physiotherapy. 2014;42(2):54–67.
Reason for exclusion: Ineligible participants.

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Lee JA, Son MJ, Choi J, Jun JH, Kim JI, Lee MS. Bee venom acupuncture for rheumatoid arthritis: A
systematic review of randomised clinical trials. BMJ Open. 2014;4(11).
Reason for exclusion: Ineligible participants.
Li J YJ, Wu S, Wang M-R, Zhu J-M. Effects of acupuncture on rheumatoid arthritis: a systematic review and
meta-analysis African Journal of Traditional, Complementary, and Alternative Medicines 2016.
Reason for exclusion: Ineligible outcomes.
Lourenzi FM, Jones A, Pereira DF, dos Santos JHCA, Furtado RNV, Natour J. Effectiveness of an overall
progressive resistance strength program for improving the functional capacity of patients with rheumatoid
arthritis: A randomized controlled trial. Clinical Rehabilitation. 2017;31(11):1482–91.
Reason for exclusion: Ineligible study type.
Martinez-Calderon J Pt M, Meeus M Pt P, Struyf F Pt P, Luque-Suarez A Pt P. The role of self-efficacy in pain
intensity, function, psychological factors, health behaviors, and quality of life in people with rheumatoid
arthritis: A systematic review. Rheumatol Int. 2018:1–17.
Reason for exclusion: Ineligible participants.
McKenna S, Comber L, A. D, Kennedy N, Fraser A. The effectiveness of exercise on sleep in people who have
rheumatoid arthritis: a systematic review and meta-analysis. PROSPERO. 2015.
Reason for exclusion: Ineligible study type.
McKenna S, Comber L, Donnelly A, Kennedy N, Fraser A, Herring M. The effects of exercise on depression
and anxiety in people who have rheumatoid arthritis: a systematic review and meta-analysis.
PROSPERO. 2016.
Reason for exclusion: Ineligible study type.
Melainie C, Joel JG, Sigrun C. Herbal therapy for treating rheumatoid arthritis. Cochrane Database of
Systematic Reviews. 2011(2):CD002948.
Reason for exclusion: Ineligible intervention.
Mildner AR, Machado RS, Sbruzzi G. The use of hand splints on functionality in patients with rheumatoid
arthritis: systematic review. PROSPERO. 2017.
Reason for exclusion: Ineligible study type.
Nagel MA, Guendling PW. Effects of exercise therapy on patients with rheumatoid arthritis-A systematic
review. European Journal of Integrative Medicine. 2010;2(4):238–9.
Reason for exclusion: Ineligible study type.
Nasir, S. H., Troynikov, O., & Massy-Westropp, N. (2014). Therapy gloves for patients with rheumatoid
arthritis: a review. Ther Adv Musculoskelet Dis, 6(6), 226–237. doi: 10.1177/1759720x14557474
Reason for exclusion: Ineligible participants.
Oishi A, Prior M, Worley A. The use of foot orthoses in the management of the rheumatoid arthritis patient.
Internet Journal of Allied Health Sciences & Practice. 2011;9(2):11p-p.
Reason for exclusion: Ineligible participants.
Park Y, Chang M. Effects of rehabilitation for pain relief in patients with rheumatoid arthritis: a systematic
review. J Phys Ther Sci. 2016;28(1):304–8.
Reason for exclusion: Ineligible participants.
Pelland L, Brosseau L, Casimiro L, Welch V, Tugwell P, Wells GA. Electrical stimulation for the treatment of
rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2002(2).
Reason for exclusion: Ineligible study type.

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Peres D, Sagawa Y, Dugue B, Domenech SC, Tordi N, Prati C. The practice of physical activity and
cryotherapy in rheumatoid arthritis: systematic review. Eur J Phys Rehabil Med. 2017;53(5):775–87.
Reason for exclusion: Ineligible participants.
Prothero, L., Barley, E., Galloway, J., Georgopoulou, S., & Sturt, J. (2018). The evidence base for
psychological interventions for rheumatoid arthritis: A systematic review of reviews. Int J Nurs Stud,
82, 20–29. doi: 10.1016/j.ijnurstu.2018.03.008
Reason for exclusion: Ineligible participants.
Ramsey L, Winder RJ, McVeigh JG. The effectiveness of working wrist splints in adults with rheumatoid
arthritis: a mixed methods systematic review. J Rehabil Med. 2014;46(6):481–92.
Reason for exclusion: Ineligible participants.
Ranzani R, Souza D, Oliveira L. Mindfulness for rheumatoid arthritis patients. Systematic review of the
literature. PROSPERO. 2017.
Reason for exclusion: Ineligible study type.
Rueda-Vergara R, Sánchez-Pérez E. Efectividad de la terapia láser de baja intensidad en pacientes con artritis
reumatoide: una revisión sistemática de ensayos clı́nicos. Fisioterapia. 2016;38(3):152–8.
Reason for exclusion: Ineligible participants.
Santos I, Cantista P, Vasconcelos C. Balneotherapy in rheumatoid arthritis-a systematic review. Int J
Biometeorol. 2016;60(8):1287–301.
Reason for exclusion: Ineligible participants.
Salmon VE, Hewlett S, Walsh NE, Kirwan JR, Cramp F. Physical activity interventions for fatigue in
rheumatoid arthritis: a systematic review. Physical Therapy Reviews. 2017;22(1/2):12–22.
Reason for exclusion: Ineligible study type.
Scarvell J, Elkins MR. Aerobic exercise is beneficial for people with rheumatoid arthritis. Br J Sports Med.
2011;45(12):1008–9.
Reason for exclusion: Ineligible study type.
Seca S, Miranda D, Cardoso D, Greten H, Cabrita A, Rodrigues MA. The effectiveness of acupuncture on
pain, physical function and health-related quality of life in patients with rheumatoid arthritis: a systematic
review protocol. JBI Database System Rev Implement Rep. 2016;14(5):18–26.
Reason for exclusion: Ineligible study type.
Siegel P, Tencza M, Apodaca B, Poole JL. Effectiveness of Occupational Therapy Interventions for Adults
With Rheumatoid Arthritis: A Systematic Review. Am J Occup Ther. 2017;71(1):7101180050p1-p11.
Reason for exclusion: Ineligible participants.
Silva KN, Mizusaki Imoto A, Almeida GJ, Atallah AN, Peccin MS, Fernandes Moca Trevisani V. Balance
training (proprioceptive training) for patients with rheumatoid arthritis. Cochrane Database Syst Rev.
2010(5):Cd007648.
Reason for exclusion: Ineligible outcomes.
Sjöquist ES, Almqvist L, Åsenlöf P, Lampa J, Opava CH. Physical-activity coaching and health status in
rheumatoid arthritis: A person-oriented approach. Disability and Rehabilitation: An International, Multi-
disciplinary Journal. 2010;32(10):816–25.
Reason for exclusion: Ineligible study type.
Srikesavan C, Bryer C, Ali U, Williamson E. Web-based rehabilitation interventions for people with
rheumatoid arthritis: A systematic review. J Telemed Telecare. 2018:1357633x18768400.
Reason for exclusion: Ineligible participants.

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Steultjens E, Dekker JJ, Bouter LM, Schaardenburg DD, Kuyk M, Van den Ende E. Occupational therapy for
rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2004(1).
Reason for exclusion: Ineligible publication date.
Tenten-Diepenmaat M, Dekker J, Vliet Vlieland TPM, Roorda LD, van der Leeden M. A systematic review
on the comparative effectiveness of foot orthoses in patients with rheumatoid arthritis. PROSPERO. 2017.
Reason for exclusion: Ineligible study type.
Tenten-Diepenmaat M, Dekker J, Vliet Vlieland TPM, Roorda LD, van der Leeden M. The effectiveness of
therapeutic footwear in patients with rheumatoid arthritis: a systematic review and meta-analysis.
PROSPERO. 2016.
Reason for exclusion: Ineligible study type.
Tenten-Diepenmaat M, van der Leeden M, Vliet Vlieland TPM, Roorda LD, Dekker J. The effectiveness of
therapeutic shoes in patients with rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol-
ogy International. 2018;38(5):749–62.
Reason for exclusion: Ineligible participants.
Tuntland H, Kjeken I, Nordheim LV, Falzon L, Jamtvedt G, Hagen KB. Assistive technology for rheumatoid
arthritis. Cochrane Database of Systematic Reviews. 2009(4).
Reason for exclusion: Ineligible publication date.
Verhoeven F, Tordi N, Prati C, Demougeot C, Mougin F, Wendling D. Physical activity and rheumatoid
arthritis, a systematic review. Annals of the Rheumatic Diseases. 2015;74:416.
Reason for exclusion: Ineligible study type.
Welch V, Brosseau L, Casimiro L, Judd M, Shea B, Tugwell P, et al. Thermotherapy for treating rheumatoid
arthritis. Cochrane Database of Systematic Reviews. 2002(2).
Reason for exclusion: Ineligible publication date.
Yang K, Zeng L, Yu G. Effectiveness of coenzyme Q10 supplementation for rheumatoid arthritis patients.
PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of curcumin and turmeric extract for rheumatoid arthritis patients.
PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of probiotic for rheumatoid arthritis patients. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of probiotic supplementation for rheumatoid arthritis patients.
PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of quercetin for rheumatoid arthritis patients. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of sesamin supplementation for rheumatoid arthritis patients.
PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of vitamin D for rheumatoid arthritis patients. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Yang K, Zeng L, Yu G. Effectiveness of vitamin E for rheumatoid arthritis patients. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.

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Yang K, Zeng L, Yu G. Effectiveness of vitamin K for rheumatoid arthritis patients. PROSPERO. 2018.
Reason for exclusion: Ineligible study type.
Zhao X, Gao J, Li Y, Yu J, Lyu J, Xiang Y, et al. Efficacy of Chinese herbal fumigation for rheumatoid
arthritis (RA): a systematic review. PROSPERO. 2016.
Reason for exclusion: Ineligible study type.
Zhou B, Li G, Zhang Y, Zhao Z. Effects of nursing interventions on depression of patients with rheumatoid
arthritis: A meta-analysis of randomized controlled trials. Archives of Psychiatric Nursing. 2016;30(6):717–
21.
Reason for exclusion: Ineligible participants.
Zwolinska J, Gasior M, Sniezek E, Kwolek A. The use of magnetic fields in treatment of patients with
rheumatoid arthritis. Review of the literature. Reumatologia. 2016;54(4):201–6.
Reason for exclusion: Ineligible study type.

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Appendix III: Characteristics of included reviews

Al-Qubaeissy et al.45 Baillet et al.46

Databases searched and language AMED, CINAHL, the Cochrane PubMed, Embase, and the Cochrane
limits Library, EMBASE, MEDLINE, Central Register of RCTs
ProQuest, PubMed, Science Direct English, French or German
and the Web of Science
English
Range of included studies 1991–2007 1981–2009
Number, type of studies included 6 RCTs 14 RCTs
and countries of origin UK, Canada, Sweden, Finland Sweden, Netherlands, Canada, Turkey,
Denmark, USA, France, Sweden
Instruments used for bias appraisal Physiotherapy Evidence Database Jadad scale and the Checklist to
(PEDro) scale Evaluate A Report of a Non-Pharmaco-
logical Trial (CLEAR-NPT)
Bias appraisal rating 4  high quality Jadad scale with a mean score of 2.4
2  moderate quality 7  Jadad scale score<3
PEDro scale with a mean score of 2  7 CLEAR-NPT items
6.8
Participant characteristics (num- 419/ Female 78.3% 1040/ Female 46.7–100%
ber, age, RA criteria, details) Mean age 53 years Mean age 44–68 years
ACR criteria30 or the criteria of Disease duration 1–16 years
Steinbrocker49 RF-positive 59–93.3%
ACR criteria30 or defined by the ARA48
Intervention(s) 6  Aquatic exercises 9  Cardiorespiratory aerobic condition-
ing
5  Dynamic exercise programs
Intervention characteristics Frequency 1–3 times/week Frequency 1–5 times/week
Duration 30–60 mins Duration 10–90 mins
Intensity moderate (1 trial) other Intensity not stated
not stated
Professional that performed the Not stated Not stated
interventions
Intervention setting 2  Not stated 4  Home-based
4  Temperate pool (308-358C) 10  Not stated (supervised)
Control 3  Usual care 8  Usual care
1  Home exercise program 2  Education
2  Land-based exercise and relax- 3  Range of motion exercises
ation 1  Non-aerobic exercises
Outcomes of interest (types and Pain (VAS, McGill Pain Question- Pain (VAS)
measuring instruments) naire and pain subscales from a Functional disability (HAQ)
variety of self-reported question- Global impact of disease [Nottingham
naires) Health Profile (NHP), the Rheumatoid
Functional disability (HAQ) Arthritis Quality of Life (RAQol) ques-
Global impact of disease (EQ-5D, tionnaire, SF-36, the Arthritis Impact
SF-36) Measurement Scales Health Status Ques-
tionnaire (AIMS), and the McMaster
Toronto Arthritis Patient Preference Dis-
ability Questionnaire (MACTAR)]
Methods of analysis Narrative synthesis Meta-analysis þ Narrative synthesis

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(Continued)
Al-Qubaeissy et al.45 Baillet et al.46
2
Heterogeneity (I ) Not calculated HAQ 29% low
Quality of life 45% moderate
Pain VAS 30% low
Effect size Not calculated HAQ (n ¼ 771) SMD ¼ 0.24 small
Pain VAS (n ¼ 261) SMD ¼ 0.31 small
Quality of life (n ¼ 586) SMD ¼ 0.39
small
95% confidence intervals Not calculated HAQ 0.10 to 0.38
Quality of life 0.23 to 0.56
Pain VAS 0.06 to 0.55
P value Pain 0.05 in 3 trials and 0.05 HAQ 0.0009
in 1 trial Quality of life 0.0001
Functional disability 0.05 in 4 Pain VAS 0.02
trials and 0.05 in 1 trial
Global impact of disease 0.05 in
1 trial and 0.05 in 1 trial
Follow-up 6–48 weeks 2–104 weeks
Conclusions Hydrotherapy has a positive role in Cardiorespiratory aerobic conditioning
reducing pain and improving the in stable RA appears to be safe and
health status of patients with RA improves some of the most important
compared with no or other inter- outcome measures.
ventions in the short term.
Baillet et al.42 Cramp et al.23
Databases searched and language PubMed, Embase and the Cochrane Central Register of Controlled
limits Cochrane Central register of ran- Trials, MEDLINE, Embase, AMED,
domized controlled trials CINAHL, PsycINFO, Social Science
English or French Citation Index, Web of Science, Disser-
tation Abstracts International, Current
Controlled Trials Register (USA), The
National Research Register (NRR)
Archive (UK), The UKCRN Portfolio
Database (UK)
English (other languages are not stated)
Range of included studies 1997–2009 1985 - 2012
Number, type of studies included 10 RCTs 24 RCTs
and countries of origin UK, Sweden, Bosnia, USA, Finland, Countries not stated
Australia, Netherlands
Instruments used for bias appraisal Jadad scale Cochrane Collaboration appraisal tools
Bias appraisal rating Jadad scale with a mean score of Quality of the evidence ranged from
2.4 moderate quality for physical activity
7  score of 2 interventions and Mediterranean diet to
low quality for psychosocial interven-
tions and all other interventions.
Participant characteristics (num- 547/ Female 47.6–100% 2882
ber, age, RA criteria, details) Mean age 41–62 years Age 18–70 years
RF-positive 54.3–88.2% ACR criteria30
ACR criteria30 or defined by the
ARA48

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(Continued)
Baillet et al.42 Cramp et al.23
Intervention(s) 3  Quadriceps resistance exercises 6  Physical activity interventions (pool-
5  Upper and lower extremities based therapy, Yoga, strength training,
exercises stationary cycling, aerobic exercise, Tai
1  Shoulder strengthening Chi)
1  Hand resistance exercises 13  Psychosocial interventions (expres-
sive writing, cognitive skills training, 2
 cognitive behavioral therapy, mindful-
ness, lifestyle management, education
incorporating energy conservation, 3 
education incorporating self-manage-
ment, 3  group education)
1  Herbal medicine
1  Omega-3 fatty acid supplementation
1  Mediterranean diet
1  Reflexology
1  Health Tracker information
Intervention characteristics Frequency 2-daily Frequency 2–3 times a daily
Duration 15–60 min Duration 20 min-4.5 hours
Intensity 30–100% Intensity moderate (majority unstated)
Professional that performed the Not stated Yoga teachers, physiotherapists, occupa-
interventions tional therapists, clinical psychologists,
nurses, dieticians
Intervention setting 5  Not stated Class - at a fitness center, home, major-
5  Supervised ity unstated
Control 6  Usual care Not stated
1  Non-aerobic exercises
3  Range of motion exercises
Outcomes of interest (types and Pain (VAS or NRS) Fatigue [VAS, SF-36, the Multidimen-
measuring instruments) Functional disability (HAQ) sional Assessment of Fatigue (MAF),
Profile of Mood States (POMS), FACIT-
F, Checklist Individual Strength (CIS),
and the perception of change in fatigue
from baseline using a four-point Likert
scale]
Pain [VAS or NRS, Likert scale, short-
form McGill Pain Questionnaire,
AIMS2, the Impact of Rheumatic Dis-
eases on General Health and Lifestyle
(IRGL), Pain Disability Index, the Bodily
Pain subscale of the
SF-36, and the Manchester Foot Pain
Disability Questionnaire]
Functional disability (HAQ, IRGL and
the AIMS2)
Methods of analysis Meta-analysis þ Narrative synthe- Meta-analysis þ Narrative synthesis
sis
Heterogeneity (I2) HAQ 36% low Fatigue: Physical activity interventions
Pain VAS 57% moderate 27% low
Fatigue: Psychosocial interventions 55%
moderate

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SYSTEMATIC REVIEW E. Santos et al.

(Continued)
Baillet et al.42 Cramp et al.23
Effect size HAQ (n ¼ 613) WMD ¼ -0.22 Fatigue: Physical activity interventions
small (n ¼ 371) SMD ¼ -0.36 small
Pain VAS (n ¼ 284) WMD ¼ 4.13 Fatigue: Psychosocial interventions
small (n ¼ 1556) SMD ¼ -0.24 small
For the remaining interventions/ out-
comes meta-analysis was not possible
and there was either no statistically
significant difference between trial arms
or findings were not reported.
95% confidence intervals HAQ -0.35 to -0.10 Fatigue: Physical activity interventions
Pain VAS -11.0 to 2.7 0.62 to 0.10
Fatigue: Psychosocial interventions
0.40 to 0.07
P value HAQ <0.001 Fatigue: Physical activity interventions
Pain VAS 0.24 0.0066
Fatigue: Psychosocial interventions
0.0044
Follow-up 3–104 weeks 3 - 24 months
Conclusions Resistance exercise in RA is safe, Physical activity and psychosocial inter-
and the improvement in most out- ventions provide benefit in relation to
comes was statistically significant self-reported fatigue in adults with rheu-
and possibly clinically relevant for matoid arthritis. There is currently insuf-
RA disability. ficient evidence of the effectiveness of
other non-pharmacological interventions.

Hennessy et al.44 Knittle et al.27

Databases searched and language MEDLINE, Embase (1979 to PsycINFO, MEDLINE, the central cata-
limits March 2011), CINAHL, AMED, log of Dutch libraries
PEDro and the Cochrane Library English or Dutch
No language restrictions
Range of included studies 1984 - 2011 1981–2007
Number, type of studies included 8 RCTs and 9 observational stud- 27 RCTs
and countries of origin ies USA, UK, Netherlands, Canada, Sweden,
Countries not stated Austria
Instruments used for bias appraisal Adapted from the Cochrane Hand- Adapted 29-item version of the
book for Systematic Reviews of Cochrane Collaboration Depression
Interventions Anxiety, and Neurosis Review Group
scale
Bias appraisal rating 2  high quality for internal valid- Scores between 21–42
ity
3  high quality for external valid-
ity
No study had high quality for both
internal and external validity
Participant characteristics (num- 703 Number of participants and characteris-
ber, age, RA criteria, details) Age 18–80 years tics not stated
ACR criteria30 ACR criteria30 or defined by the ARA48

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SYSTEMATIC REVIEW E. Santos et al.

(Continued)
Hennessy et al.44 Knittle et al.27
Intervention(s) 17  Foot orthoses Relaxation, cognitive pain management
strategies, self-management program,
cognitive–behavioral therapy, education,
contracting, goal setting, provision of
feedback, cognitive restructuring, joint
protection, problem solving, exercise,
coping, group counseling, guided imag-
ery, self-instruction, range of motion
exercises, mindfulness
Intervention characteristics Not applicable Frequency 1–5 times per week
Duration 30 min-2.5 hours
Intensity not stated
Professional that performed the Not stated PhD student, layperson, psychologist,
interventions medical doctor, occupational therapist,
physical therapist, nurse, counsellor, die-
tician
Intervention setting Not stated Home, majority unstated
Control No orthoses or placebo orthoses Education or no intervention
Outcomes of interest (types and Pain (not stated) Pain (VAS)
measuring instruments) Functional disability (Foot Func- Functional disability (HAQ)
tion Index - FFI)
Methods of analysis Meta-analysis þ Narrative synthe- Meta-analysis þ narrative synthesis
sis
Heterogeneity (I2) Pain 77% high Pain 0% none
Functional disability 66% moder- Functional disability 60.26% moderate
ate
Effect size Pain (n ¼ 340) SMD ¼ 0.45 moder- Pain (n ¼ 1316) g ¼ 0.18 small
ate Functional disability (n ¼ 1180) g ¼ 0.32
Functional disability (n ¼ 220) small
SMD ¼ 0.07 small
The results of observational studies
maintain the trends of low effects
sizes.
95% confidence intervals Pain 0.00 to 0.90 Pain 0.08 to 0.29
Functional disability 0.41 to 0.55 Functional disability 0.13 to 0.51
P value Pain 0.05 Pain 0.006
Functional disability 0.78 Functional disability 0.001
Follow-up 1–32 months 2–16 weeks
Conclusions Custom orthoses may be beneficial Psychological interventions are beneficial
in reducing pain and elevated fore- for many patients with RA, particularly
foot plantar pressures in the rheu- when it comes to increasing physical
matoid foot and ankle. activity levels.

Rongen-van Dartel et al.41 Verhagen et al.43

Databases searched and language PubMed, Cochrane library, Embase Cochrane ‘Rehabilitation and Related
limits English (other languages are not Therapies’ Field Register, The Cochrane
stated) Central Register of Controlled Trials,
MEDLINE, Embase, CINAHL, AMED,
PsycINFO, PEDro
No language restrictions

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SYSTEMATIC REVIEW E. Santos et al.

(Continued)
Rongen-van Dartel et al.41 Verhagen et al.43
Range of included studies 2000–2012 1990–2007
Number, type of studies included 5 RCTs 9 RCTs
and countries of origin Countries not stated Israel, Germany, UK, Turkey
Instruments used for bias appraisal Cochrane Collaboration’s tool for Cochrane Collaboration’s tool for asses-
assessing risk of bias sing risk of bias
Bias appraisal rating 3  low risk of bias Most studies showed an unclear risk of
2  unclear risk of bias bias in most domains
Participant characteristics (num- 570 579, Age 39–62.4, Males 5–40%, ACR
ber, age, RA criteria, details) ACR criteria30 criteria30 or the criteria of Steinbrocker49
or the ARA criteria48 or the ACR/
EULAR criteria31
Intervention(s) 1  Bicycle þ muscle strength 1  Mineral-rich mud compresses
training 1  Mineral baths þ mudpacks
1  Bicycle þ circuit þ sport and 2  Radon þ carbon dioxide baths
game 1  Seated immersion
1  Low impact aerobics þ 1  Dead Sea salt baths
strengthening 1  Sulphur baths
1  Land-based (circuit) 1  Baths in Dead Sea
1  Walk on treadmill, cycle, row 1  Mineral baths
or hand ergometer
Intervention characteristics Frequency 2–3 times per week Frequency 1–5 times per week
Duration 15–85 min Duration 2–4 weeks
Intensity 50–90% Intensity not stated
Professional that performed the Not stated Not stated
interventions
Intervention setting Not stated Not stated
Control No exercise 1  Mineral-depleted mud compresses
1  Tapwater baths
2  Carbon dioxide baths only
1  Hydrotherapy or land exercise or
relaxation
1  Sodium chloride baths
1  Mudpacks or mudpacks þ sulphur
baths or no-treatment control
2  Sulphur baths or Dead Sea baths þ
sulphur baths or no-treatment control
Outcomes of interest (types and Fatigue [MAF, Short Form 36 Pain (VAS, the McGill Questionnaire)
measuring instruments) vitality subscale, or a VAS of
fatigue]
Methods of analysis Meta-analysis þ Narrative synthe- Meta-analysis þ Narrative synthesis
sis
Heterogeneity (I2) Difference in fatigue score (12 Pain (mudpacks versus placebo) 0%
weeks) 0% none none
Difference in fatigue score (24 Pain (additional radon in carbon dioxide
weeks) 2% low baths at 6 months) 0% none
Effect size Fatigue (12 weeks) (n ¼ 257) Pain (mudpacks versus placebo) (n ¼ 45)
SMD ¼ -0.31 small MD ¼ 0.50 mm
Fatigue (24 weeks) (n ¼ 523) Pain (additional radon in carbon
SMD ¼ -0.15 small dioxide baths at 6 months) (n ¼ 194)
MD ¼ 9.6 mm

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(Continued)
Rongen-van Dartel et al.41 Verhagen et al.43
95% confidence intervals Fatigue (12 weeks) -0.55 to -0.06 Pain (mudpacks versus placebo) -0.84 to
Fatigue (24 weeks) -0.33 to 0.02 1.84
Pain (additional radon in carbon dioxide
baths at 6 months) 1.6 to 17.6
P value Fatigue (12 weeks) 0.02 Pain (mudpacks versus placebo) 0.47
Fatigue (24 weeks) 0.09 Pain (additional radon in carbon dioxide
baths at 6 months) 0.019
Follow-up 4–104 weeks 12–24 weeks
Conclusions Aerobic exercise programs are Overall evidence is insufficient to show
effective in reducing fatigue among that balneotherapy is more effective than
patients with RA, especially in the no treatment, that one type of bath is
short term. more effective than another, or that one
type of bath is more effective than
mudpacks, exercise or relaxation
therapy.

ACR: American College of Rheumatology; ARA: American Rheumatism Association; EQ-5D: EuroQol-5 dimension; EULAR: European League Against Rheumatism; FACIT:
functional assessment of chronic illness therapy; g: Hedges’ g effect size; HAQ: health assessment questionnaire; MD: mean difference; mm: millimeters; NRS:
numerical rating scale; RA: rheumatoid arthritis; RAID: rheumatoid arthritis impact of disease; RCT: randomized controlled trial; RF: rheumatoid factor; SF-36: 36-item
short form survey; SMD: standard mean difference; UK: United Kingdom; USA: United States of America; VAS: visual analog scale.

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