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Research Article
Issue Date: November/December 2016
Published Online: October 10, 2016
Updated: January 01, 2021
Systematic Review of Educational Interventions for Rheumatoid Arthritis
Author Affiliations
  • Kristine Carandang, OTR/L, is PhD Candidate, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles; kcaranda@usc.edu
  • Elizabeth A. Pyatak, PhD, OTR/L, CDE, is Assistant Professor, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
  • Cheryl L. P. Vigen, PhD, is Research Assistant Professor, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
Article Information
Arthritis / Evidence-Based Practice / Musculoskeletal Impairments / Rheumatoid Arthritis / Rehabilitation, Disability, and Participation
Research Article   |   October 10, 2016
Systematic Review of Educational Interventions for Rheumatoid Arthritis
American Journal of Occupational Therapy, October 2016, Vol. 70, 7006290020. https://doi.org/10.5014/ajot.2016.021386
American Journal of Occupational Therapy, October 2016, Vol. 70, 7006290020. https://doi.org/10.5014/ajot.2016.021386
Abstract

OBJECTIVE. In this study, we systematically reviewed the effectiveness of educational interventions falling within the scope of occupational therapy practice for people with rheumatoid arthritis (RA). These interventions included disease education, joint protection and energy conservation, psychosocial techniques, pain management, and a combination category.

METHOD. Two databases, MEDLINE and CINAHL, and select journals were searched for randomized controlled trials published between January 2002 and June 2015. Qualitative synthesis was used for between-study comparisons.

RESULTS. Twenty-two studies, with approximately 2,600 participants, were included. The interventions were found to have strong evidence for constructs that dealt with increasing coping with pain and fatigue as well as maintaining positive affect. There was limited or no evidence supporting the effectiveness of these interventions on most other measured constructs.

CONCLUSION. Interventions in which a combination of educational techniques is used may complement pharmacological therapies in the care of people with RA. Future research is needed to identify specific mechanisms of change.

Rheumatoid arthritis (RA) is one of the most common rheumatic diseases, with an estimated prevalence of 1.5 million people diagnosed in the United States (Myasoedova, Crowson, Kremers, Therneau, & Gabriel, 2010) and annual societal costs reaching $39.2 billion (Birnbaum et al., 2010). Because of recent advancements in medical treatments, including the emergence of biologic drugs and aggressive therapy early in the disease course, medical remission is now an attainable target of treatment of some people with RA (e.g., Combe, 2009). Despite this progress, people continue to express concerns surrounding their abilities to fully participate in desired activities, such as social functions and paid employment, thus adversely affecting quality of life (e.g., Kristiansen, Primdahl, Antoft, & Hørslev-Petersen, 2012). Therefore, nonpharmacological interventions may complement medical prescriptions by targeting the psychosocial aspects of living with a chronic disease (Sanderson, Morris, Calnan, Richards, & Hewlett, 2010).
Because of its focus on enhancing daily functioning, occupational therapy is uniquely positioned to address this issue. Indeed, qualitative literature suggests the importance of health professionals assisting with treatment areas including occupational balance and lifestyle adaptation (e.g., McDonald et al., 2012; Stamm et al., 2009). However, two past systematic reviews noted a limited ability to adequately assess the effectiveness of occupational therapy interventions because of the low methodological quality of individual trials and lack of consensus on outcome measures and intervention components (Hammond, 2004b; Steultjens et al., 2002). In the current study, we sought to assess the current state of occupational therapy intervention for RA by analyzing the most current interventions being taught within the occupational therapy field and by evaluating the evidence base of these interventions. In this article, we present the findings of a systematic review of educational approaches to the treatment of RA within the scope of occupational therapy practice.
Educational Approaches of Occupational Therapy in Rheumatology
The education process is defined in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014) as the “imparting of knowledge and information about occupation, health, well-being, and participation that enables the client to acquire helpful behaviors, habits, and routines that may or may not require application at the time of the intervention session” (p. S30). Occupational therapy interventions that are based on educational processes aim to increase patient participation and independence in chronic disease management. Because of their diverse applications and content, these interventions have the potential to produce positive outcomes for people with RA, regardless of disease duration and symptom presentation.
Two systematic reviews and one scoping review have included patient education within the scope of occupational therapy interventions for RA (Hammond, 2004a, 2004b; Steultjens et al., 2002). Steultjens et al. (2002)  reported on seven mechanisms for occupational therapy intervention for RA. Among these seven mechanisms, limited evidence was found for the categories of “instruction on joint protection” and “advice/instruction in the use of assistive devices,” and no high-quality studies were found for the categories of “counseling” and “training of skills.” The authors concluded that this finding was in direct opposition with how frequently occupational therapy practitioners use these techniques in practice. Similarly, Hammond (2004b)  concluded that evidence for occupational therapy–specific psychological interventions (e.g., coping and relaxation skills) was limited but found emerging potential for the use of cognitive–behavioral interventions targeting people who were motivated for change (Hammond, 2004a). Although these reviews provided a comprehensive assessment of the state of research at the time of their publication, the health care environment has changed significantly to include the wide use of new prescription drugs, such as tumor necrosis factor inhibitors, and the implementation of new diagnostic criteria released by the American College of Rheumatology in 2010 (Aletaha et al., 2010), both of which have made clinical remission a more attainable treatment target. A more updated review is needed in light of these advances to incorporate intervention trials conducted within the past decade.
Method
The data presented in this article are part of a larger study evaluating the full spectrum of occupational therapy interventions for RA (including remediation, adaptive and preventive therapies, and educational approaches) that aimed to address the following question: What evidence exists to support occupational therapy intervention approaches for RA?
A large volume of varied intervention approaches was identified, including didactic, psychosocial, remediative, adaptive, compensatory, and preventive interventions. Because the evidence base for these intervention approaches was so diverse, the systematic review was divided into two parts: educational interventions versus remediation and adaptation interventions (e.g., strengthening, range of motion, and provision of orthoses). In this article, we evaluate the evidentiary base for the former category.
Study Design
To identify search terms for this systematic review, the first author (Carandang) conducted a comprehensive search of occupational therapy textbook content for intervention categories for the treatment of RA. Textbooks were selected from a list of the most commonly used textbooks in entry-level occupational therapy programs in the United States (list available from the National Board for Certification in Occupational Therapy [NBCOT], 2013). After excluding four categories of textbooks with a strictly administrative focus, textbooks within the remaining 10 categories were searched for the terms “rheumatoid arthritis,” “arthritis,” and “juvenile arthritis.” The following data were extracted from the qualifying textbooks: title, edition, page numbers, and descriptions of occupational therapy interventions in the text that pertained to RA. The first author synthesized the intervention modalities identified in the textbooks into 12 categories, which were then grouped according to the five broad types of interventions described in the Occupational Therapy Practice Framework (AOTA, 2008). This step was performed prior to the release of the third edition of the Framework (AOTA, 2014). The advocacy category was not represented among any of the occupational therapy interventions identified through the textbook search and was therefore excluded from this review; the remaining categories and subcategories are outlined in Table 1.
Table 1.
Description of Interventions
Description of Interventions×
Intervention CategoryaSynthesis of Intervention Modalities Described in Occupational Therapy Textbooks
Education Process
Psychosocial educationEmphasizes that psychosocial factors are as important as physical factors
Encourages self-reflection, perspective transformation, and the use of coping skills
Joint protection and energy conservationUses guidelines that include techniques such as balancing rest and activity and the use of large joints
Disease educationStresses education about disease, symptoms, and prognosis (especially effects of synovitis); incorporates family and routine
Includes community resources, such as websites, organizations, written materials, and exercise programs
Pain managementHas a goal to maintain control of pain experience through coping skills and distraction techniques, including in social interactions (communication skills, distraction techniques)
Emphasizes person’s description of own pain
Preparatory Methods
Range of motion and strengtheningEmphasizes joint instability (use of PROM to avoid contractures) rather than strength (only isometric and only used in remission)
Includes postoperative considerations for hand surgeries
Includes resistive and aerobic exercise (pool exercise)
Provision of orthosesHas goals to reduce inflammation and to stabilize joints, prevent deformities, and prevent undesirable motion
Occurs at all stages of disease progression (including postoperative)
Physical agent modalitiesIncludes, but is not limited to, thermal (superficial heat, hot packs) and cryotherapy (cold packs), paraffin wax, fluidotherapy, whirlpool, ultrasound, contrast baths, iontophoresis
Cognitive rehabilitationRequires monitoring of cognitive effects from medications and fatigue
Includes protocols modified for RA and other chronic illnesses; however, research remains primarily in stroke
Does not include disease-specific guidelines, which were not found
Consultation Process
Environmental adaptationAssists people to choose environment in which they can perform and maintain safety
Includes fall prevention and safety management in the home
Provision of adaptive equipmentHas a goal to increase ease and independence and minimize stress on joints
Assists person to see value in consistent use of adaptive equipment
May be fabricated or purchased
Includes recommendation to have samples for trial use at facility
Occupation-Based Intervention and Purposeful Activity
Maintaining activities (ADLs)At diagnosis, encourages person to continue engaging in fundamental ADLs, such as feeding and hygiene; as person increases in physical capability, encourages “usual life”
Maintaining activities (Other)Assists person to choose work and leisure activities in suitable environments that are appropriate to physical capabilities
Includes sexual dysfunction, such as reevaluation of positions and time of day
Table Footer NoteNote. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.
Note. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.×
Table Footer NoteaIntervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).
Intervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).×
Table 1.
Description of Interventions
Description of Interventions×
Intervention CategoryaSynthesis of Intervention Modalities Described in Occupational Therapy Textbooks
Education Process
Psychosocial educationEmphasizes that psychosocial factors are as important as physical factors
Encourages self-reflection, perspective transformation, and the use of coping skills
Joint protection and energy conservationUses guidelines that include techniques such as balancing rest and activity and the use of large joints
Disease educationStresses education about disease, symptoms, and prognosis (especially effects of synovitis); incorporates family and routine
Includes community resources, such as websites, organizations, written materials, and exercise programs
Pain managementHas a goal to maintain control of pain experience through coping skills and distraction techniques, including in social interactions (communication skills, distraction techniques)
Emphasizes person’s description of own pain
Preparatory Methods
Range of motion and strengtheningEmphasizes joint instability (use of PROM to avoid contractures) rather than strength (only isometric and only used in remission)
Includes postoperative considerations for hand surgeries
Includes resistive and aerobic exercise (pool exercise)
Provision of orthosesHas goals to reduce inflammation and to stabilize joints, prevent deformities, and prevent undesirable motion
Occurs at all stages of disease progression (including postoperative)
Physical agent modalitiesIncludes, but is not limited to, thermal (superficial heat, hot packs) and cryotherapy (cold packs), paraffin wax, fluidotherapy, whirlpool, ultrasound, contrast baths, iontophoresis
Cognitive rehabilitationRequires monitoring of cognitive effects from medications and fatigue
Includes protocols modified for RA and other chronic illnesses; however, research remains primarily in stroke
Does not include disease-specific guidelines, which were not found
Consultation Process
Environmental adaptationAssists people to choose environment in which they can perform and maintain safety
Includes fall prevention and safety management in the home
Provision of adaptive equipmentHas a goal to increase ease and independence and minimize stress on joints
Assists person to see value in consistent use of adaptive equipment
May be fabricated or purchased
Includes recommendation to have samples for trial use at facility
Occupation-Based Intervention and Purposeful Activity
Maintaining activities (ADLs)At diagnosis, encourages person to continue engaging in fundamental ADLs, such as feeding and hygiene; as person increases in physical capability, encourages “usual life”
Maintaining activities (Other)Assists person to choose work and leisure activities in suitable environments that are appropriate to physical capabilities
Includes sexual dysfunction, such as reevaluation of positions and time of day
Table Footer NoteNote. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.
Note. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.×
Table Footer NoteaIntervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).
Intervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).×
×
Systematic review methods were used to evaluate the evidentiary base for occupational therapy interventions identified within the textbook search. The study protocol, including methods of analysis and study inclusion criteria, was specified in advance and translated into instructions to ensure replicability among reviewers and arbitrators involved in the study. This article follows PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines (Liberati et al., 2009).
Eligibility Criteria
A PICOS (Problem, Intervention, Comparison, Outcomes, and Setting) strategy was used to identify study inclusion criteria and search terms. We chose to include studies published after 2002 for two reasons: First, two systematic reviews have already been conducted to examine educational interventions published before 2002. Second, beginning in 1998 with the U.S. Food and Drug Administration approval of etanercept, the increasing availability of biologic medications for RA has significantly altered the medical management of RA. Because of this shift in the backdrop for educational interventions for RA, including only studies published after these agents were introduced gives a more realistic appraisal of intervention effects in the current medical disease management setting.
Studies that met the following criteria were eligible: (1) study was published in English; (2) all participants were adults age ≥18 yr diagnosed with RA1; (3) primary outcomes targeted symptoms of RA; and (4) the study protocol specified random allocation of participants to treatment and control groups, in which the treatment group received at least one of the previously identified occupational therapy interventions, and the comparison group was clearly identified by the study authors as a control group. Trial reports were excluded if the treatment under study targeted additional diagnoses or focused on comorbidities rather than symptoms of RA. Trial reports were also excluded if the intervention included both educational and remedial approaches because our aim was to identify the unique contribution of educational intervention, an occupational therapy mechanism that had previously been labeled as underresearched (Steultjens et al., 2002). To avoid multiple publication bias, if multiple publications had been generated from one study, we included only the publication reporting on the main study outcomes.
Search Strategy
We searched two electronic databases, MEDLINE and CINAHL, on two dates (the first on November 7, 2013, and an updated search on June 18, 2015) using search terms and strategies listed in Supplemental Appendix 1 (available online at http://otjournal.net; navigate to this article, and click on “Supplemental”). In addition, the first author hand-searched the most frequently used peer-reviewed journals in U.S. occupational therapy academic programs for the keyword “rheumatoid arthritis” (NBCOT, 2013). These journals included the American Journal of Occupational Therapy; British Journal of Occupational Therapy; Australian Journal of Occupational Therapy; Journal of Hand Therapy; Journal of Occupational Science; and OTJR: Occupation, Participation and Health. Titles, abstracts, and full-text PDFs of all eligible articles were imported into a citation manager.
Articles were excluded in five steps, as shown in Figure 1. The first author and the second author (Pyatak) independently reviewed all articles and completed Steps 1 and 2 to eliminate studies that were outside the realm of occupational therapy or that did not target symptoms of RA. The first author independently completed Steps 3–5 to obtain the final articles to be included within the study. To ensure replicability and accuracy, a graduate research assistant independently completed the same steps for 50% of the articles. In case of disagreement, the full-text article was reviewed by the second author, who made the final determination regarding categorization.
Figure 1.
Exclusion steps.
Note. RA = rheumatoid arthritis.
Figure 1.
Exclusion steps.
Note. RA = rheumatoid arthritis.
×
Data Extraction
The first author and the graduate research assistant classified all eligible trials into the previously identified occupational therapy intervention categories. The first author and the graduate research assistant extracted data from each trial into a lab-created table, including study title, methodology (including number of participants, measures of assessment, control group, and intervention content), and outcomes. Afterward, the first author checked 100% of extracted study data, and the graduate research assistant checked 50% of the data extracted in the table against the original article sources to ensure accuracy of data entry.
Quality Assessment
Risk of bias for individual studies was evaluated in accordance with Cochrane’s quality checklist for randomized studies, in which each study is evaluated on six criteria (as listed in Higgins & Green, 2011). After the second author completed an assessment of each study across these six criteria, overall risk of bias was developed in consensus by the first and second authors.
Best Evidence Synthesis
After consultation with a biostatistician (Vigen), the range of clinical outcomes was determined to be too wide to conduct a quantitative meta-analysis. Therefore, a qualitative review (best evidence synthesis) was used to determine levels of effectiveness of each intervention category. Levels of effectiveness were determined with criteria developed by van Tulder, Cherkin, Berman, Lao, and Koes (1999) . Their terminology (i.e., low-, unknown-, and high-quality studies) was adapted to reflect the language used within the quality assessment (i.e., high risk, unknown risk, and low risk of bias).
After piloting the best evidence synthesis instructions within two intervention categories, the following guidelines were developed. Between-groups statistics for all primary outcomes were included in the best evidence synthesis. Among studies reporting on secondary outcomes, we included only secondary outcomes with statistically significant results (whether in favor of the intervention or control group) in the best evidence synthesis because null findings may reflect Type II error because of the lack of statistical power. Among studies not designating primary versus secondary outcomes, all measured outcomes were included in the best evidence synthesis. For studies analyzing more than one intervention, the between-groups results for each intervention condition, compared with the control group, were counted as separate findings. The first and second authors independently conducted a full best evidence synthesis to ensure accuracy of data entry and interpretation.
Results
Fifty-seven textbooks were screened for inclusion. Of these, four textbooks were excluded as secondary because of their focus on assessments (n = 2) or use as reference guides (n = 2) rather than intervention, and 38 textbooks did not include the search terms “rheumatoid arthritis,” “arthritis,” or “juvenile arthritis” in their indexes. Descriptors of RA interventions from the remaining 15 textbooks were extracted and synthesized into 12 intervention approaches. These approaches were grouped according to the four categories from the Framework (see Table 1): Education Process, Preparatory Methods, Consultation Process, and Occupation-Based Intervention and Purposeful Activity. Four intervention strategies fell under the “Education Process” of occupational therapy intervention—psychosocial intervention, joint protection and energy conservation, disease education, and pain management—and were included in the current systematic review.
Study Selection
The first database search conducted in November 2013 yielded a total of 375 articles. Using the exclusion process detailed in Figure 1, we found 19 articles that fell within the scope of this review. The second search in June 2015 yielded a total of 59 articles published between 2013 and 2015, three of which also met inclusion criteria. We therefore categorized a total of 22 articles into the appropriate strategy categories under “Education Process” according to the primary intervention approach being evaluated. A “combined education” category was added for trials in which interventions were tested that combined these approaches.
Risk of Bias Within Studies
Twelve studies were determined to have low risk of bias, three studies had high risk of bias, and seven studies had unknown risk of bias. These results are detailed in Table 2.
Table 2.
Study Quality and Risk of Bias
Study Quality and Risk of Bias×
StudyRandom Sequence GenerationAllocation ConcealmentBlinding of Outcome AssessmentComplete Outcome Data (Attrition Bias)Nonselective Outcome ReportingOtherOverall Risk of Bias
Disease education
Hill & Bird (2003) +?+?++?
Lovisi Neto et al. (2009) ?++?++?
Walker et al. (2007) ??-?++?
Pain management
Carson et al. (2006) +++-+++
Psychosocial intervention
Broderick et al. (2004) ++-++--
Lumley et al. (2011) +-+++++
Shadick et al. (2013) +?+++++
Wetherell et al. (2005) ??--++-
Joint protection and energy conservation
Hammond et al. (2002) ??++++?
Masiero et al. (2007) ??+-++?
Niedermann et al. (2011) +++++++
Combination
Barsky et al. (2010) +?+++++
Evers et al. (2002) +??+++?
Freeman et al. (2002) ??+-+--
Giraudet-Le Quintrec et al. (2007) +++++++
Hewlett et al. (2011) +?+++-+
John et al. (2013) ++-++++
Núñez et al. (2006) +?+++++
Sharpe & Schrieber (2012) +++++++
Shigaki et al. (2013) ??-+++?
Zautra et al. (2008) +-+++++
Zwikker et al. (2014) ++-++++
 Total15 low risk8 low risk15 low risk15 low risk22 low risk19 low risk12 low risk
7 unknown2 high risk6 high risk4 high risk3 high risk3 high risk
12 unknown1 unknown3 unknown7 unknown
Table Footer NoteNote. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.
Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.×
Table 2.
Study Quality and Risk of Bias
Study Quality and Risk of Bias×
StudyRandom Sequence GenerationAllocation ConcealmentBlinding of Outcome AssessmentComplete Outcome Data (Attrition Bias)Nonselective Outcome ReportingOtherOverall Risk of Bias
Disease education
Hill & Bird (2003) +?+?++?
Lovisi Neto et al. (2009) ?++?++?
Walker et al. (2007) ??-?++?
Pain management
Carson et al. (2006) +++-+++
Psychosocial intervention
Broderick et al. (2004) ++-++--
Lumley et al. (2011) +-+++++
Shadick et al. (2013) +?+++++
Wetherell et al. (2005) ??--++-
Joint protection and energy conservation
Hammond et al. (2002) ??++++?
Masiero et al. (2007) ??+-++?
Niedermann et al. (2011) +++++++
Combination
Barsky et al. (2010) +?+++++
Evers et al. (2002) +??+++?
Freeman et al. (2002) ??+-+--
Giraudet-Le Quintrec et al. (2007) +++++++
Hewlett et al. (2011) +?+++-+
John et al. (2013) ++-++++
Núñez et al. (2006) +?+++++
Sharpe & Schrieber (2012) +++++++
Shigaki et al. (2013) ??-+++?
Zautra et al. (2008) +-+++++
Zwikker et al. (2014) ++-++++
 Total15 low risk8 low risk15 low risk15 low risk22 low risk19 low risk12 low risk
7 unknown2 high risk6 high risk4 high risk3 high risk3 high risk
12 unknown1 unknown3 unknown7 unknown
Table Footer NoteNote. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.
Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.×
×
Outcome of Interventions
Characteristics of the 22 individual studies are described in Supplemental Table 1 (available online at http://otjournal.net; navigate to this article, and click on “Supplemental”). Levels of best evidence are presented in Table 3. Six studies included an occupational therapy practitioner within delivery of the intervention, either as an independent practitioner or as part of a multidisciplinary team.
Table 3.
Best Evidence Analysis
Best Evidence Analysis×
InterventionLevel of EvidenceaConstruct
Disease educationLevel IIIGeneral health quality of life
Level IVDisease-specific knowledge
Medication-specific knowledge
Pain managementLevel ICoping efficacy
Joint pain
Problem-focused coping
Level IVNumber of high pain days
Emotion-focused coping
Negative mood
Positive mood
Psychosocial educationLevel IAffective pain
Level IIITotal mood disturbance
Physical function
Fatigue
Tension
Anger
Self-reported general pain
Self-compassion
Level IVDisease activity
Sensory pain
General health quality of life
Joint protection and energy conservationLevel IIJoint protection behaviors
Level IIIPain rating
Patient health status
Physical function
Self-reported symptoms
Social interaction
Joint protection self-efficacy
Arthritis self-efficacy
Level IVDisease activity
CombinationLevel IPain coping efficacy
Pain catastrophizing
Positive affect
Disease activity (tender joints)
Helplessness
Level IIIPsychological functioning
Cardiovascular disease knowledge
Quality of life
Arthritis self-efficacy
Disease activity (painful joints)
Disease activity (swollen joints)
Physical functioning
Fatigue impact
Fatigue severity
Fatigue coping
Sleep quality
Attitudes, perceived control, and behavioral intention toward exercise and healthy eating
Patient satisfaction
Disease knowledge
Diastolic blood pressure
Level IVPain rating
Symptoms
Social functioning
Negative affect
Patient health status
Anxiety
Depression
Beliefs about medications
Loneliness
Disease activity (RADAR)
Pain control
Well-being and functional status
Erythrocyte sedimentation rate
C-reactive protein
Interleukin-6 (Cytokine)
General affect
Table Footer NoteNote. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.
Note. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.×
Table Footer NoteaCriteria for level of best evidence, as adapted from van Tulder et al. (1999) .
Criteria for level of best evidence, as adapted from van Tulder et al. (1999) .×
Table 3.
Best Evidence Analysis
Best Evidence Analysis×
InterventionLevel of EvidenceaConstruct
Disease educationLevel IIIGeneral health quality of life
Level IVDisease-specific knowledge
Medication-specific knowledge
Pain managementLevel ICoping efficacy
Joint pain
Problem-focused coping
Level IVNumber of high pain days
Emotion-focused coping
Negative mood
Positive mood
Psychosocial educationLevel IAffective pain
Level IIITotal mood disturbance
Physical function
Fatigue
Tension
Anger
Self-reported general pain
Self-compassion
Level IVDisease activity
Sensory pain
General health quality of life
Joint protection and energy conservationLevel IIJoint protection behaviors
Level IIIPain rating
Patient health status
Physical function
Self-reported symptoms
Social interaction
Joint protection self-efficacy
Arthritis self-efficacy
Level IVDisease activity
CombinationLevel IPain coping efficacy
Pain catastrophizing
Positive affect
Disease activity (tender joints)
Helplessness
Level IIIPsychological functioning
Cardiovascular disease knowledge
Quality of life
Arthritis self-efficacy
Disease activity (painful joints)
Disease activity (swollen joints)
Physical functioning
Fatigue impact
Fatigue severity
Fatigue coping
Sleep quality
Attitudes, perceived control, and behavioral intention toward exercise and healthy eating
Patient satisfaction
Disease knowledge
Diastolic blood pressure
Level IVPain rating
Symptoms
Social functioning
Negative affect
Patient health status
Anxiety
Depression
Beliefs about medications
Loneliness
Disease activity (RADAR)
Pain control
Well-being and functional status
Erythrocyte sedimentation rate
C-reactive protein
Interleukin-6 (Cytokine)
General affect
Table Footer NoteNote. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.
Note. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.×
Table Footer NoteaCriteria for level of best evidence, as adapted from van Tulder et al. (1999) .
Criteria for level of best evidence, as adapted from van Tulder et al. (1999) .×
×
Disease Education.
Three studies focused on providing people with information about mechanisms of RA and possible treatment options. Providing educational materials that had verbal or pictorial components was no more effective to increase knowledge about disease or medications than standard pamphlets (Hill & Bird, 2003; Walker et al., 2007). One study included an intensive, weekly educational program that increased disease-specific knowledge and health quality of life (Lovisi Neto, Jennings, Barros Ohashi, Silva, & Natour, 2009). Overall, limited (Level III) evidence was found that these interventions increased general health quality of life.
Pain Management.
Carson et al. (2006)  aimed to evaluate the effectiveness of a pain management intervention with an added maintenance component to address long-term carryover. Both the intervention alone and the intervention with maintenance component significantly improved coping efficacy, joint pain, and problem-focused coping. Overall, strong (Level I) evidence was found for these three outcomes.
Psychosocial Intervention.
Interventions involving the written or spoken disclosure of traumatic events decreased affective pain (Broderick, Stone, Smyth, & Kaell, 2004; Lumley et al., 2011; Wetherell et al., 2005). One study entailed an intervention emphasizing mindful thinking and self-compassion, which was found to improve disease activity, self-compassion, physical function, and pain (Shadick et al., 2013). Overall, strong (Level I) evidence was found for a decrease in affective pain.
Joint Protection and Energy Conservation.
Joint protection and energy conservation interventions were delivered with two modalities: an educational–behavioral approach (Hammond, Jefferson, Jones, Gallagher, & Jones, 2002; Masiero et al., 2007) or an approach emphasizing personal goals and available resources (Niedermann et al., 2011). Overall, moderate (Level II) evidence was found for an increase in joint protection behaviors.
Combination of Educational Techniques.
Eleven studies were conducted to assess a combination of the aforementioned educational techniques (Barsky et al., 2010; Evers, Kraaimaat, van Riel, & de Jong, 2002; Freeman, Hammond, & Lincoln, 2002; Giraudet-Le Quintrec et al., 2007; Hewlett et al., 2011; John, Hale, Treharne, Kitas, & Carroll, 2013; Núñez et al., 2006; Sharpe & Schrieber, 2012; Shigaki et al., 2013; Zautra et al., 2008; Zwikker et al., 2014). Eight of these studies included a cognitive–behavioral intervention. A diverse array of outcomes was studied, including physical symptoms, various measures of disease activity, three domains of functioning, and psychological constructs. Of the 11 studies, 4 studies did not show that the intervention was superior to the control condition for the primary outcome. The remaining 7 studies showed positive effects for the primary outcome, and some or all secondary outcomes, in favor of the intervention groups. Overall, strong (Level I) evidence was found for the constructs of tender joints, pain catastrophizing, positive affect, helplessness, and pain coping efficacy.
Discussion
This review provides an update of the evidence base for occupational therapy interventions, as previously described in Steultjens et al. (2002)  and Hammond (2004a, 2004b) more than a decade ago. There was strong evidence found for the following outcomes: Pain management interventions improved joint pain, coping efficacy, and problem-focused coping; psychosocial education interventions improved affective pain; and combination interventions improved pain coping efficacy, pain catastrophizing, positive affect, disease activity (tender joints), and helplessness. Moderate evidence was found for joint protection and energy conservation interventions improving joint protection behaviors. There was limited or no evidence for other outcomes.
Research on RA interventions within the scope of occupational therapy has increased significantly: from 15 randomized controlled trials (RCTs) studying occupational therapy interventions for RA before 2002 (Steultjens et al., 2002) to 22 RCTs focused on the educational process of occupational therapy published in the past 13 yr. Although this increase demonstrates promising growth of the evidence base for occupational therapy intervention for people with RA, a majority of the constructs assessed continue to remain in Level III or Level IV of evidence. Because search terms were obtained from occupational therapy textbooks, this raises the question of whether there is a disconnect between the continuously changing base of evidence in rheumatology and what is being highlighted in occupational therapy textbooks and educational programs. Therefore, this article, combined with similar evidence-based reviews, may serve to guide areas of future research to support current guidelines of occupational therapy practice.
When interpreting the findings of this review, outcomes falling within Levels III and IV of evidence may indicate that few methodologically sound studies evaluated these constructs or that evidence was conflicting across studies. One explanation for these results stems from the inconsistency of target outcomes between trials. The interventions assessed in this review targeted a wide range of constructs, including disease activity, function and participation, and quality of life. Although interventions may have used similar mechanisms (i.e., cognitive–behavioral approach), their content was targeted toward specific symptoms or behavioral goals (i.e., increasing disease knowledge vs. decreasing fatigue). Therefore, disagreement between trials may not stem from the ineffectiveness of intervention mechanisms but rather may reflect differences in the primary outcomes targeted by the intervention content.
In research in which replication is a goal, it is important to establish a core set of target outcomes to determine effectiveness across trials. To address this issue, attendees at the Outcome Measures in Rheumatology (OMERACT) conference ratified a core set of outcomes in 1994 for use in rheumatology clinical trials. Despite an overall increase of researchers using this set of outcomes within rheumatology trials, their use remains low within nonpharmacological studies. Explanations for the lack of uptake of these core outcomes include researchers’ lack of awareness or consciously choosing against their use because of their poor fit with rehabilitation interventions (Kirkham, Boers, Tugwell, Clarke, & Williamson, 2013). The importance of developing and using a core set of outcomes continues to be discussed, with emphasis shifting to include patient perspectives on what is important to their well-being (e.g., Kirwan et al., 2005).
Another explanation for conflicting evidence is varying patient responsiveness because of the unpredictable course of RA and range of medical regimens prescribed to people with RA. Some people are greatly affected by symptoms that are absent in others or have a more severe presentation during symptom flare-ups. Therefore, people may not show significant improvements if provided with interventions incompatible with their current symptoms and needs. In addition, medical treatment of RA varies widely by type of medication (e.g., nonsteroidal anti-inflammatory drugs, oral corticosteroids, biologics) and dosage, which may affect a person’s response to nonpharmacological programs. Although properly conducted RCTs substantially reduce the potential for confounding by individual variation in symptoms and medication use, identifying people likely to respond to a given intervention is particularly challenging in RA research.
In future studies, researchers may benefit from analyzing the participant cohort for unique factors that contribute to intervention responsiveness. Tailoring interventions to address people’s current symptoms and interest and ability to adopt health-promoting behaviors has been established as a potential strategy to optimize the effectiveness of health behavior interventions while maintaining a patient-centered approach (Prochaska, DiClemente, & Norcross, 1992). By targeting interventions to people experiencing certain clusters of symptoms, researchers may have increased statistical power to discern effectiveness of interventions in specific populations. Current research is already moving in this direction. For example, post hoc analyses by Zautra et al. (2008)  demonstrated that mindfulness education was significantly more beneficial for participants with a history of recurrent depression than for other groups. Although in the current review we analyzed the main effects of each intervention, such subgroup analyses have the potential to shed greater insight on which populations benefit most from a given intervention.
Limitations
Limitations are reported at both the level of the included studies and the level of the review. Three methodological issues made it difficult to draw inferences from the included RCTs. First, several studies noted difficulty both recruiting and retaining people because of lack of interest or motivation, hospitalization, changes in medication, distance from hospital or clinic, and severity of illness. These factors warrant concern for selection bias, particularly because of people with a higher burden of illness being less likely to participate. In practice, it is imperative to review not only the needs and interests of the patient population but also the feasibility and cost-effectiveness of providing educational services for a population at high risk for attrition. Second, 6 of the 22 included studies did not designate a primary outcome. This information is necessary to determine the overall hypothesis of the study and whether the study has sufficient statistical power to test this hypothesis.
Finally, many of the studies included in this review were relatively small, and thus an inability to find a statistically significant effect for the intervention may be more a result of lack of statistical power than a lack of intervention efficacy. Lack of statistical power is likely to be a particular problem when secondary analyses are involved. Nevertheless, several small studies showed that their interventions produced statistically significant results and thus support the potential of educational occupational therapy approaches for RA. Even when small studies produce statistically significant results, their effect estimates may be very unstable, and thus we have refrained from discussion of effect size estimates. In addition, small samples are frequently the result of convenience and thus may not be representative of the populations to which we wish to draw inferences.
With respect to the limitations of the systematic review, the methodology included all RCTs within the educational scope of occupational therapy; however, studies were not limited to interventions provided by occupational therapy practitioners. Although all of the interventions being evaluated were within the scope of occupational therapy practice, it is possible that unspecified aspects of the interventions departed from the occupational therapy scope of practice, thus limiting their potential relevance to the field. In addition, the methods to obtain intervention categories through textbooks, and subsequently search terms, may have limited the scope of the intervention categories. Although the selected textbooks were identified as the most used within occupational therapy programs (NBCOT, 2013), there may be nontextbook resources describing occupational therapy treatment approaches for RA that were not captured in this review.
Conclusion
Our review demonstrates that occupational therapy practitioners who use interventions with the educational approach assist people with RA to increase coping skills for symptoms such as pain and fatigue as well as increase positive affect. Given that rheumatology is continuously progressing with medical advancements, occupational therapists and other health professionals should continue to evaluate the medical landscape to develop best practices in RA intervention. In future research, investigators should incorporate methodological changes, such as using a core set of outcomes and targeting interventions toward specific symptoms, to demonstrate effectiveness across studies.
Implications for Occupational Therapy Practice
The findings of the study have the following implications for occupational therapy:
  • Given people’s interest in improving psychosocial aspects of managing chronic illness, educational approaches should be incorporated along with other evidence-based approaches, such as remediation, within occupational therapy’s scope of practice.

  • Strong evidence exists for the effectiveness of various educational occupational therapy approaches to improve pain, tender joints, affect, and coping of people with RA. Joint protection and energy conservation approaches are moderately effective in increasing joint protection behaviors.

  • People with RA demonstrate heterogeneity across symptoms in response to medications. Tailoring interventions to each person, including symptoms, resources, and readiness to change, may increase applicability to everyday functioning and behaviors.

Acknowledgments
We thank Florence Clark for her review and valuable feedback on drafts of this article. This article was written in partial fulfillment of the requirements for the Doctor of Philosophy degree in occupational science at the University of Southern California, Los Angeles.
*Indicates article included in the scoping review.
Indicates article included in the scoping review.×
1Although the line between the age of diagnosis of RA and juvenile arthritis is blurred, age 18 yr was chosen to maintain consistency with diagnostic statistics of the Centers for Disease Control and Prevention (2016) .
Although the line between the age of diagnosis of RA and juvenile arthritis is blurred, age 18 yr was chosen to maintain consistency with diagnostic statistics of the Centers for Disease Control and Prevention (2016) .×
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*Núñez, M., Núñez, E., Yoldi, C., Quintó, L., Hernández, M. V., & Muñoz-Gómez, J. (2006). Health-related quality of life in rheumatoid arthritis: Therapeutic education plus pharmacological treatment versus pharmacological treatment only. Rheumatology International, 26, 752–757. http://dx.doi.org/10.1007/s00296-005-0071-6 [Article] [PubMed]
*Núñez, M., Núñez, E., Yoldi, C., Quintó, L., Hernández, M. V., & Muñoz-Gómez, J. (2006). Health-related quality of life in rheumatoid arthritis: Therapeutic education plus pharmacological treatment versus pharmacological treatment only. Rheumatology International, 26, 752–757. http://dx.doi.org/10.1007/s00296-005-0071-6 [Article] [PubMed]×
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102–1114. http://dx.doi.org/10.1037/0003-066X.47.9.1102 [Article] [PubMed]
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Sanderson, T., Morris, M., Calnan, M., Richards, P., & Hewlett, S. (2010). ‘It’s this whole picture, this well-being’: Patients’ understanding of ‘feeling well’ with rheumatoid arthritis. Chronic Illness, 6, 228–240. http://dx.doi.org/10.1177/1742395310377672 [Article] [PubMed]
Sanderson, T., Morris, M., Calnan, M., Richards, P., & Hewlett, S. (2010). ‘It’s this whole picture, this well-being’: Patients’ understanding of ‘feeling well’ with rheumatoid arthritis. Chronic Illness, 6, 228–240. http://dx.doi.org/10.1177/1742395310377672 [Article] [PubMed]×
*Shadick, N. A., Sowell, N. F., Frits, M. L., Hoffman, S. M., Hartz, S. A., Booth, F. D., . . . Schwartz, R. C. (2013). A randomized controlled trial of an internal family systems-based psychotherapeutic intervention on outcomes in rheumatoid arthritis: A proof-of-concept study. Journal of Rheumatology, 40, 1831–1841. http://dx.doi.org/10.3899/jrheum.121465 [Article] [PubMed]
*Shadick, N. A., Sowell, N. F., Frits, M. L., Hoffman, S. M., Hartz, S. A., Booth, F. D., . . . Schwartz, R. C. (2013). A randomized controlled trial of an internal family systems-based psychotherapeutic intervention on outcomes in rheumatoid arthritis: A proof-of-concept study. Journal of Rheumatology, 40, 1831–1841. http://dx.doi.org/10.3899/jrheum.121465 [Article] [PubMed]×
*Sharpe, L., & Schrieber, L. (2012). A blind randomized controlled trial of cognitive versus behavioral versus cognitive–behavioral therapy for patients with rheumatoid arthritis. Psychotherapy and Psychosomatics, 81, 145–152. http://dx.doi.org/10.1159/000332334 [Article] [PubMed]
*Sharpe, L., & Schrieber, L. (2012). A blind randomized controlled trial of cognitive versus behavioral versus cognitive–behavioral therapy for patients with rheumatoid arthritis. Psychotherapy and Psychosomatics, 81, 145–152. http://dx.doi.org/10.1159/000332334 [Article] [PubMed]×
*Shigaki, C. L., Smarr, K. L., Siva, C., Ge, B., Musser, D., & Johnson, R. (2013). RAHelp: An online intervention for individuals with rheumatoid arthritis. Arthritis Care and Research, 65, 1573–1581. http://dx.doi.org/10.1002/acr.22042 [PubMed]
*Shigaki, C. L., Smarr, K. L., Siva, C., Ge, B., Musser, D., & Johnson, R. (2013). RAHelp: An online intervention for individuals with rheumatoid arthritis. Arthritis Care and Research, 65, 1573–1581. http://dx.doi.org/10.1002/acr.22042 [PubMed]×
Stamm, T., Lovelock, L., Stew, G., Nell, V., Smolen, J., Machold, K., . . . Sadlo, G. (2009). I have a disease but I am not ill: A narrative study of occupational balance in people with rheumatoid arthritis. OTJR: Occupation, Participation and Health, 29, 32–39. http://dx.doi.org/10.1177/153944920902900105 [Article]
Stamm, T., Lovelock, L., Stew, G., Nell, V., Smolen, J., Machold, K., . . . Sadlo, G. (2009). I have a disease but I am not ill: A narrative study of occupational balance in people with rheumatoid arthritis. OTJR: Occupation, Participation and Health, 29, 32–39. http://dx.doi.org/10.1177/153944920902900105 [Article] ×
Steultjens, E. M., Dekker, J., Bouter, L. M., van Schaardenburg, D., van Kuyk, M. A., & van den Ende, C. H. (2002). Occupational therapy for rheumatoid arthritis: A systematic review. Arthritis and Rheumatism, 47, 672–685. http://dx.doi.org/10.1002/art.10801 [Article] [PubMed]
Steultjens, E. M., Dekker, J., Bouter, L. M., van Schaardenburg, D., van Kuyk, M. A., & van den Ende, C. H. (2002). Occupational therapy for rheumatoid arthritis: A systematic review. Arthritis and Rheumatism, 47, 672–685. http://dx.doi.org/10.1002/art.10801 [Article] [PubMed]×
van Tulder, M. W., Cherkin, D. C., Berman, B., Lao, L., & Koes, B. W. (1999). The effectiveness of acupuncture in the management of acute and chronic low back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine, 24, 1113–1123. http://dx.doi.org/10.1097/00007632-199906010-00011 [Article] [PubMed]
van Tulder, M. W., Cherkin, D. C., Berman, B., Lao, L., & Koes, B. W. (1999). The effectiveness of acupuncture in the management of acute and chronic low back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine, 24, 1113–1123. http://dx.doi.org/10.1097/00007632-199906010-00011 [Article] [PubMed]×
*Walker, D., Adebajo, A., Heslop, P., Hill, J., Firth, J., Bishop, P., & Helliwell, P. S. (2007). Patient education in rheumatoid arthritis: The effectiveness of the ARC booklet and the mind map. Rheumatology, 46, 1593–1596. http://dx.doi.org/10.1093/rheumatology/kem171 [Article] [PubMed]
*Walker, D., Adebajo, A., Heslop, P., Hill, J., Firth, J., Bishop, P., & Helliwell, P. S. (2007). Patient education in rheumatoid arthritis: The effectiveness of the ARC booklet and the mind map. Rheumatology, 46, 1593–1596. http://dx.doi.org/10.1093/rheumatology/kem171 [Article] [PubMed]×
*Wetherell, M. A., Byrne-Davis, L., Dieppe, P., Donovan, J., Brookes, S., Byron, M., . . . Miles, J. (2005). Effects of emotional disclosure on psychological and physiological outcomes in patients with rheumatoid arthritis: An exploratory home-based study. Journal of Health Psychology, 10, 277–285. http://dx.doi.org/10.1177/1359105305049778 [Article] [PubMed]
*Wetherell, M. A., Byrne-Davis, L., Dieppe, P., Donovan, J., Brookes, S., Byron, M., . . . Miles, J. (2005). Effects of emotional disclosure on psychological and physiological outcomes in patients with rheumatoid arthritis: An exploratory home-based study. Journal of Health Psychology, 10, 277–285. http://dx.doi.org/10.1177/1359105305049778 [Article] [PubMed]×
*Zautra, A. J., Davis, M. C., Reich, J. W., Nicassario, P., Tennen, H., Finan, P., . . . Irwin, M. R. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76, 408–421. http://dx.doi.org/10.1037/0022-006X.76.3.408 [Article] [PubMed]
*Zautra, A. J., Davis, M. C., Reich, J. W., Nicassario, P., Tennen, H., Finan, P., . . . Irwin, M. R. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76, 408–421. http://dx.doi.org/10.1037/0022-006X.76.3.408 [Article] [PubMed]×
*Zwikker, H. E., van den Ende, C. H., van Lankveld, W. G., den Broeder, A. A., van den Hoogen, F. H., van de Mosselaar, B., . . . van den Bemt, B. J. (2014). Effectiveness of a group-based intervention to change medication beliefs and improve medication adherence in patients with rheumatoid arthritis: A randomized controlled trial. Patient Education and Counseling, 94, 356–361. http://dx.doi.org/10.1016/j.pec.2013.12.002 [Article] [PubMed]
*Zwikker, H. E., van den Ende, C. H., van Lankveld, W. G., den Broeder, A. A., van den Hoogen, F. H., van de Mosselaar, B., . . . van den Bemt, B. J. (2014). Effectiveness of a group-based intervention to change medication beliefs and improve medication adherence in patients with rheumatoid arthritis: A randomized controlled trial. Patient Education and Counseling, 94, 356–361. http://dx.doi.org/10.1016/j.pec.2013.12.002 [Article] [PubMed]×
Figure 1.
Exclusion steps.
Note. RA = rheumatoid arthritis.
Figure 1.
Exclusion steps.
Note. RA = rheumatoid arthritis.
×
Table 1.
Description of Interventions
Description of Interventions×
Intervention CategoryaSynthesis of Intervention Modalities Described in Occupational Therapy Textbooks
Education Process
Psychosocial educationEmphasizes that psychosocial factors are as important as physical factors
Encourages self-reflection, perspective transformation, and the use of coping skills
Joint protection and energy conservationUses guidelines that include techniques such as balancing rest and activity and the use of large joints
Disease educationStresses education about disease, symptoms, and prognosis (especially effects of synovitis); incorporates family and routine
Includes community resources, such as websites, organizations, written materials, and exercise programs
Pain managementHas a goal to maintain control of pain experience through coping skills and distraction techniques, including in social interactions (communication skills, distraction techniques)
Emphasizes person’s description of own pain
Preparatory Methods
Range of motion and strengtheningEmphasizes joint instability (use of PROM to avoid contractures) rather than strength (only isometric and only used in remission)
Includes postoperative considerations for hand surgeries
Includes resistive and aerobic exercise (pool exercise)
Provision of orthosesHas goals to reduce inflammation and to stabilize joints, prevent deformities, and prevent undesirable motion
Occurs at all stages of disease progression (including postoperative)
Physical agent modalitiesIncludes, but is not limited to, thermal (superficial heat, hot packs) and cryotherapy (cold packs), paraffin wax, fluidotherapy, whirlpool, ultrasound, contrast baths, iontophoresis
Cognitive rehabilitationRequires monitoring of cognitive effects from medications and fatigue
Includes protocols modified for RA and other chronic illnesses; however, research remains primarily in stroke
Does not include disease-specific guidelines, which were not found
Consultation Process
Environmental adaptationAssists people to choose environment in which they can perform and maintain safety
Includes fall prevention and safety management in the home
Provision of adaptive equipmentHas a goal to increase ease and independence and minimize stress on joints
Assists person to see value in consistent use of adaptive equipment
May be fabricated or purchased
Includes recommendation to have samples for trial use at facility
Occupation-Based Intervention and Purposeful Activity
Maintaining activities (ADLs)At diagnosis, encourages person to continue engaging in fundamental ADLs, such as feeding and hygiene; as person increases in physical capability, encourages “usual life”
Maintaining activities (Other)Assists person to choose work and leisure activities in suitable environments that are appropriate to physical capabilities
Includes sexual dysfunction, such as reevaluation of positions and time of day
Table Footer NoteNote. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.
Note. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.×
Table Footer NoteaIntervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).
Intervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).×
Table 1.
Description of Interventions
Description of Interventions×
Intervention CategoryaSynthesis of Intervention Modalities Described in Occupational Therapy Textbooks
Education Process
Psychosocial educationEmphasizes that psychosocial factors are as important as physical factors
Encourages self-reflection, perspective transformation, and the use of coping skills
Joint protection and energy conservationUses guidelines that include techniques such as balancing rest and activity and the use of large joints
Disease educationStresses education about disease, symptoms, and prognosis (especially effects of synovitis); incorporates family and routine
Includes community resources, such as websites, organizations, written materials, and exercise programs
Pain managementHas a goal to maintain control of pain experience through coping skills and distraction techniques, including in social interactions (communication skills, distraction techniques)
Emphasizes person’s description of own pain
Preparatory Methods
Range of motion and strengtheningEmphasizes joint instability (use of PROM to avoid contractures) rather than strength (only isometric and only used in remission)
Includes postoperative considerations for hand surgeries
Includes resistive and aerobic exercise (pool exercise)
Provision of orthosesHas goals to reduce inflammation and to stabilize joints, prevent deformities, and prevent undesirable motion
Occurs at all stages of disease progression (including postoperative)
Physical agent modalitiesIncludes, but is not limited to, thermal (superficial heat, hot packs) and cryotherapy (cold packs), paraffin wax, fluidotherapy, whirlpool, ultrasound, contrast baths, iontophoresis
Cognitive rehabilitationRequires monitoring of cognitive effects from medications and fatigue
Includes protocols modified for RA and other chronic illnesses; however, research remains primarily in stroke
Does not include disease-specific guidelines, which were not found
Consultation Process
Environmental adaptationAssists people to choose environment in which they can perform and maintain safety
Includes fall prevention and safety management in the home
Provision of adaptive equipmentHas a goal to increase ease and independence and minimize stress on joints
Assists person to see value in consistent use of adaptive equipment
May be fabricated or purchased
Includes recommendation to have samples for trial use at facility
Occupation-Based Intervention and Purposeful Activity
Maintaining activities (ADLs)At diagnosis, encourages person to continue engaging in fundamental ADLs, such as feeding and hygiene; as person increases in physical capability, encourages “usual life”
Maintaining activities (Other)Assists person to choose work and leisure activities in suitable environments that are appropriate to physical capabilities
Includes sexual dysfunction, such as reevaluation of positions and time of day
Table Footer NoteNote. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.
Note. ADLs = activities of daily living; PROM = passive range of motion; RA = rheumatoid arthritis.×
Table Footer NoteaIntervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).
Intervention categories are from Table 8, Types of Occupational Therapy Interventions, in the second edition of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008).×
×
Table 2.
Study Quality and Risk of Bias
Study Quality and Risk of Bias×
StudyRandom Sequence GenerationAllocation ConcealmentBlinding of Outcome AssessmentComplete Outcome Data (Attrition Bias)Nonselective Outcome ReportingOtherOverall Risk of Bias
Disease education
Hill & Bird (2003) +?+?++?
Lovisi Neto et al. (2009) ?++?++?
Walker et al. (2007) ??-?++?
Pain management
Carson et al. (2006) +++-+++
Psychosocial intervention
Broderick et al. (2004) ++-++--
Lumley et al. (2011) +-+++++
Shadick et al. (2013) +?+++++
Wetherell et al. (2005) ??--++-
Joint protection and energy conservation
Hammond et al. (2002) ??++++?
Masiero et al. (2007) ??+-++?
Niedermann et al. (2011) +++++++
Combination
Barsky et al. (2010) +?+++++
Evers et al. (2002) +??+++?
Freeman et al. (2002) ??+-+--
Giraudet-Le Quintrec et al. (2007) +++++++
Hewlett et al. (2011) +?+++-+
John et al. (2013) ++-++++
Núñez et al. (2006) +?+++++
Sharpe & Schrieber (2012) +++++++
Shigaki et al. (2013) ??-+++?
Zautra et al. (2008) +-+++++
Zwikker et al. (2014) ++-++++
 Total15 low risk8 low risk15 low risk15 low risk22 low risk19 low risk12 low risk
7 unknown2 high risk6 high risk4 high risk3 high risk3 high risk
12 unknown1 unknown3 unknown7 unknown
Table Footer NoteNote. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.
Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.×
Table 2.
Study Quality and Risk of Bias
Study Quality and Risk of Bias×
StudyRandom Sequence GenerationAllocation ConcealmentBlinding of Outcome AssessmentComplete Outcome Data (Attrition Bias)Nonselective Outcome ReportingOtherOverall Risk of Bias
Disease education
Hill & Bird (2003) +?+?++?
Lovisi Neto et al. (2009) ?++?++?
Walker et al. (2007) ??-?++?
Pain management
Carson et al. (2006) +++-+++
Psychosocial intervention
Broderick et al. (2004) ++-++--
Lumley et al. (2011) +-+++++
Shadick et al. (2013) +?+++++
Wetherell et al. (2005) ??--++-
Joint protection and energy conservation
Hammond et al. (2002) ??++++?
Masiero et al. (2007) ??+-++?
Niedermann et al. (2011) +++++++
Combination
Barsky et al. (2010) +?+++++
Evers et al. (2002) +??+++?
Freeman et al. (2002) ??+-+--
Giraudet-Le Quintrec et al. (2007) +++++++
Hewlett et al. (2011) +?+++-+
John et al. (2013) ++-++++
Núñez et al. (2006) +?+++++
Sharpe & Schrieber (2012) +++++++
Shigaki et al. (2013) ??-+++?
Zautra et al. (2008) +-+++++
Zwikker et al. (2014) ++-++++
 Total15 low risk8 low risk15 low risk15 low risk22 low risk19 low risk12 low risk
7 unknown2 high risk6 high risk4 high risk3 high risk3 high risk
12 unknown1 unknown3 unknown7 unknown
Table Footer NoteNote. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.
Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (-). More than one (-) merits a high overall risk rating; more than one (?) merits an unknown overall risk rating; none or one (-) and (?) merits a low-risk rating. Allocation Concealment = adequate concealment of group assignment before randomization; Blinding of Outcome Assessment = outcome evaluation is conducted by blinded assessors; Complete Outcome Data = complete data are reported for each outcome, including attrition and exclusions from analysis; Nonselective Outcome Reporting = outcomes are prespecified, and data for all outcomes are reported; Other = bias that is due to other methodological concerns not outlined above (Higgins & Green, 2011); Random Sequence Generation = adequate generation of a randomization sequence.×
×
Table 3.
Best Evidence Analysis
Best Evidence Analysis×
InterventionLevel of EvidenceaConstruct
Disease educationLevel IIIGeneral health quality of life
Level IVDisease-specific knowledge
Medication-specific knowledge
Pain managementLevel ICoping efficacy
Joint pain
Problem-focused coping
Level IVNumber of high pain days
Emotion-focused coping
Negative mood
Positive mood
Psychosocial educationLevel IAffective pain
Level IIITotal mood disturbance
Physical function
Fatigue
Tension
Anger
Self-reported general pain
Self-compassion
Level IVDisease activity
Sensory pain
General health quality of life
Joint protection and energy conservationLevel IIJoint protection behaviors
Level IIIPain rating
Patient health status
Physical function
Self-reported symptoms
Social interaction
Joint protection self-efficacy
Arthritis self-efficacy
Level IVDisease activity
CombinationLevel IPain coping efficacy
Pain catastrophizing
Positive affect
Disease activity (tender joints)
Helplessness
Level IIIPsychological functioning
Cardiovascular disease knowledge
Quality of life
Arthritis self-efficacy
Disease activity (painful joints)
Disease activity (swollen joints)
Physical functioning
Fatigue impact
Fatigue severity
Fatigue coping
Sleep quality
Attitudes, perceived control, and behavioral intention toward exercise and healthy eating
Patient satisfaction
Disease knowledge
Diastolic blood pressure
Level IVPain rating
Symptoms
Social functioning
Negative affect
Patient health status
Anxiety
Depression
Beliefs about medications
Loneliness
Disease activity (RADAR)
Pain control
Well-being and functional status
Erythrocyte sedimentation rate
C-reactive protein
Interleukin-6 (Cytokine)
General affect
Table Footer NoteNote. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.
Note. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.×
Table Footer NoteaCriteria for level of best evidence, as adapted from van Tulder et al. (1999) .
Criteria for level of best evidence, as adapted from van Tulder et al. (1999) .×
Table 3.
Best Evidence Analysis
Best Evidence Analysis×
InterventionLevel of EvidenceaConstruct
Disease educationLevel IIIGeneral health quality of life
Level IVDisease-specific knowledge
Medication-specific knowledge
Pain managementLevel ICoping efficacy
Joint pain
Problem-focused coping
Level IVNumber of high pain days
Emotion-focused coping
Negative mood
Positive mood
Psychosocial educationLevel IAffective pain
Level IIITotal mood disturbance
Physical function
Fatigue
Tension
Anger
Self-reported general pain
Self-compassion
Level IVDisease activity
Sensory pain
General health quality of life
Joint protection and energy conservationLevel IIJoint protection behaviors
Level IIIPain rating
Patient health status
Physical function
Self-reported symptoms
Social interaction
Joint protection self-efficacy
Arthritis self-efficacy
Level IVDisease activity
CombinationLevel IPain coping efficacy
Pain catastrophizing
Positive affect
Disease activity (tender joints)
Helplessness
Level IIIPsychological functioning
Cardiovascular disease knowledge
Quality of life
Arthritis self-efficacy
Disease activity (painful joints)
Disease activity (swollen joints)
Physical functioning
Fatigue impact
Fatigue severity
Fatigue coping
Sleep quality
Attitudes, perceived control, and behavioral intention toward exercise and healthy eating
Patient satisfaction
Disease knowledge
Diastolic blood pressure
Level IVPain rating
Symptoms
Social functioning
Negative affect
Patient health status
Anxiety
Depression
Beliefs about medications
Loneliness
Disease activity (RADAR)
Pain control
Well-being and functional status
Erythrocyte sedimentation rate
C-reactive protein
Interleukin-6 (Cytokine)
General affect
Table Footer NoteNote. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.
Note. Italic font signifies that the construct was measured as a secondary outcome exclusively. Level I = strong evidence (provided by generally consistent findings in multiple randomized controlled trials [RCTs] of low risk of bias); Level II = moderate evidence (provided by generally consistent findings in one low-risk and one or more high-risk or unknown-risk RCTs); Level III = limited evidence (provided by generally consistent findings in one or more high-risk or unknown-risk RCTs); Level IV = no evidence (if there were no RCTs or if the results were conflicting; conflicting evidence was defined as <2/3 of the trials reporting the same findings); RADAR = Rapid Assessment of Disease Activity in Rheumatology questionnaire.×
Table Footer NoteaCriteria for level of best evidence, as adapted from van Tulder et al. (1999) .
Criteria for level of best evidence, as adapted from van Tulder et al. (1999) .×
×
Supplemental Material