Research Article: A Systematic Critical Appraisal of Non-Pharmacological Management of Rheumatoid Arthritis with Appraisal of Guidelines for Research and Evaluation II

Date Published: May 19, 2014

Publisher: Public Library of Science

Author(s): Lucie Brosseau, Prinon Rahman, Stéphane Poitras, Karine Toupin-April, Gail Paterson, Christine Smith, Judy King, Lynn Casimiro, Gino De Angelis, Laurianne Loew, Sabrina Cavallo, Jessica Mc Ewan, Adrian V. Hernandez.


Clinical practice guidelines (CPGs) have been developed to summarize evidence about the management of rheumatoid arthritis (RA) and facilitate the uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of this review was to assess the quality of CPGS on non-pharmacological management of RA with a standardized and validated instrument – the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and summarize the key recommendations from these CPGs. Scientific literature databases from 2001 to 2013 were systematically searched and a total of 13 CPGs for RA was identified. Only a minority of AGREE II domains were effectively addressed by the CPGS. Scope and purpose was effectively addressed in 10 out of 13 CPGs, stakeholder involvement in 11 CPGs, rigor of development in 6 CPGs, clarity/presentation in 9 CPGs, editorial independence in 1 CPGs, and applicability in none of the CPGs. The overall quality of the included CPGs according to the 7-point AGREE II scoring system was 4.8±1.04. Patient education/self-management, aerobic, dynamic and stretching exercises were the commonly recommended for the non-pharmacological management of RA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. CPGs creators should use the AGREE II criteria when developing guidelines. Innovative and effective methods of CPGs implementation to users are needed to ultimately enhance the quality of life of arthritic individuals. In addition, it was difficult to establish between strongly recommended, recommended and weakly recommended, as there is no consensus between the strength of the recommendations between the appraised CPGs.

Partial Text

Rheumatoid arthritis (RA) is an autoimmune pathology characterised by inflammation at the joints and in tissues surrounding other organs, which is usually accompanied by severe pain [1]. The prevalence of RA in the US in 2007 was about 1.5 million adults [2], and women were affected three times more than men [3]. The incidence is highly variable between nations, but is typically around 40 cases per 100,000 [4]. RA carries a great economic impact due to higher incidence in adults during their peak productivity years and the fact that long term treatment is required [5]. The estimated medical expenses for arthritis and rheumatism (excluding cost of time lost from paid or unpaid work) were estimated to be between $1.7 billion and $2.5 billion [6].

The PRISMA statement [18] was used to report this systematic review (Checklist S1) and the Cochrane methodology ( [19] was used to identify, select and analyze the data.

Of the 1136 citations systematically searched, duplicates were eliminated leaving 827 residual citations for title and abstract review (Figure S1). Based on the title and abstract, 811 citations were subsequently excluded because they did not address a CPG related to non-pharmacological management of RA and twelve CPGs were included (Figure S1). One additional CPG was identified and included after consulting the reference list of the included publications (Figure S1).

This systematic review identified a total of 13 CPGs, of which 7 were more general and comprised a larger proportion of pharmacological compared to non-pharmacological recommendations [30]–[33], [37], [43]–[44]. Only 6 CPGs were entirely devoted to non-pharmacological interventions for RA [34]–[36], [38]–[43]. Based on the AGREE II quality scoring instrument 6 CPGs [34], [36], [38]–[43] were considered high quality CPGs (adequately addressed rigor of development >60% in addition to addressing two or more domains effectively) and recommended for the non-pharmacological management of RA and the remaining CPGs were recommended for practice but with modifications. The majority of the 13 CPGs [30]–[44] recommended that non-pharmacological interventions be combined with pharmacological interventions in the global management of RA. Only two CPGs distinguish specific recommendations for the management of RA during the first two years since onset [31], [34] and after the two first years [32]. Foot orthosis/insoles, joint protection, patient education/self-management, multidisciplinary team approach, aerobic, dynamic, stretching, strengthening and whole body exercises were the common non-pharmacological interventions recommended by majority of the selected CPGs.

In summary, the literature search yielded 13 CPGs that targeted non-pharmacological interventions for RA. Six CPGs were found to be of high quality based on the AGREE II instrument and the non-pharmacological interventions that were recommended were: patient education/self-management, aerobic, dynamic and stretching exercises. The authors found that the recommendations presented in the CPGs provided insufficient information on the mode of delivery, dosage, intensity, frequency and duration. Future CPG developers should focus more on addressing all six AGREE II domains, in particular rigor of development and applicability to ensure the recommendations presented can easily be implemented in daily health care practice.