Systematic review
Effect of multidisciplinary, team-based rehabilitation, including education, in rheumatoid arthritis
Systematic review
|Updated
The aim of this systematic review is to compare the effect of a multidisciplinary, team-based rehabilitation program, including education, specialised for patients with RA with treatment/training without a multidisciplinary team, or with no special follow-up.
Key message
Rheumatoid arthritis (RA) is a chronic rheumatic, autoimmune disease that causes inflammation of the joints and connective tissues. International research estimates that RA affects between 0.5 % and 1 % of the adult population. Although there have recently been large advances in pharmacological treatments, many patients still have a need for follow-up and rehabilitation. To best organize future rehabilitation service for patients with RA, there is a need for evaluating and comparing the effect of a specialised, multidisciplinary treatment with a non-multidisciplinary approach. The aim of this systematic review is to compare the effect of a multidisciplinary, team-based rehabilitation program, including education, specialised for patients with RA with treatment/training without a multidisciplinary team, or with no special follow-up.
We included eleven studies. Six studies were about patient education as sole intervention, and five studies were about multidisciplinary team-based rehabilitation. The main findings from these studies were:
- Patient education delivered as sole intervention, gives an improvement in symptoms, self-efficacy and knowledge about RA at one year follow-up in favour of the intervention group. For other outcomes, patient education showed small or no effects.
- Multidisciplinary team-based rehabilitation showed, for HAQ physical function, an improved score in favour of the control group at one year follow-up. At two years follow-up there still was a tendency towards better scores in the control group, but the difference was no longer significant. For other outcomes, multidisciplinary, team-based rehabilitation showed small or no effect.
The documentation about the effect of multidisciplinary team-based rehabilitation is insufficient, and the conclusions are based on findings from small studies with unclear or high risk of bias. It is important to emphasize that no evidence of effect is not the same as evidence of no effect.
Summary
Background
Rheumatoid arthritis (RA) is a chronic, autoimmune disease that causes inflammation of the joints and connective tissues. International research estimates that arthritis affects between 0.5 % and 1 % of the adult population. Although there have recently been large advances in pharmacological treatments, a large proportion of the patients still have a need for follow-up and rehabilitation.
To best organize future rehabilitation services for patients with RA, there is a need for evaluating and comparing the effect of a specialised, multidisciplinary treatment with a non-multidisciplinary approach. The aim of this systematic review is to compare the effect of a multidisciplinary team-based rehabilitation program, including education, specialised for patients with RA with treatment/training without a multidisciplinary team, or with no rehabilitation.
Method
We performed a literature search that was updated in August 2011 in the following databases: Cochrane Library, CRD, Medline, EMBASE, Ovid Nursing Database, British Nursing Index, PEDro and OT seeker.
The inclusion criteria were as follows:
- Study design: Systematic reviews, randomized controlled trials and controlled clinical trials
- Population: Adult patients with rheumatoid arthritis (ACR 1987 criteria/ 1958 ARA criteria).
- Intervention: multidisciplinary team-based rehabilitation targeted at patients with RA.
- Comparison: Treatment/training where a multidisciplinary team does not participate, or with no special follow-up.
- Outcomes : Patient reported and clinical outcomes
- Languages : No language restrictions in the search, but only publications in English and Scandinavian languages were considered for inclusion.
- Time span : 1987 until August 2011
Results
The literature search resulted in a total of 1441 unique hits. Eleven studies (described in 13 publications) fulfilled the inclusion criteria.
Effect of patient education as sole intervention
Six randomised controlled trials about patient education were included. A criterion for inclusion was that the patient education had to be delivered by a multidisciplinary team. The studies were published during 1997 to 2011. The follow-up duration was between 22 weeks and one year. Five studies had between 34 and 100 included patients, while one study included 208 patients. Three studies had high risk of bias and three had unclear risk of bias. The included studies used different methods for measuring outcomes. We therefore chose to divide the outcomes into different categories as follows: Physical function/ state of health, symptoms, disease activity, self-efficacy, depression and anxiety, and knowledge of rheumatoid arthritis. When patient education was delivered as sole intervention, there was a significant improvement in symptoms, self-efficacy and knowledge about RA at one year follow-up in favour of the intervention group. For other outcomes, patient education showed small or no effects.
Effect of other multidisciplinary rehabilitation
We included five studies in which the intervention was multidisciplinary team-based rehabilitation targeted at patients with RA, and in which patient education could be part of the intervention. Four studies had a randomised controlled study design, and one was a prospective cohort study. The latter was different from the others because multidisciplinary rehabilitation was offered on an individual basis. The studies were published during 1988 to 2011. The follow-up durations in the studies were from one to two years. Two studies (including the cohort study) had more than 200 included patients, while the other studies had between 59 and 115 included patients. Three studies had unclear risk of bias, and two studies (including the cohort study) had high risk of bias. In the same manner as in the paragraph about patient education, we divided the outcomes into different categories as follows: Physical function/ health state, symptoms, disease activity and quality of life. The results from the studies evaluating the effect of multidisciplinary team-based rehabilitation showed, for HAQ physical function, a significantly improved score in favour of the control group at one year follow-up. At two years follow-up there still was a tendency towards better scores in the control group, but the difference was no longer significant. For other outcomes, multidisciplinary team-based rehabilitation showed small or no effect.
Discussion
Multidisciplinary rehabilitation is a complex intervention, and in the quality assessment of each study it was difficult to judge whether the intervention group and the control group was treated equally, except from the intervention under evaluation. The interventions were insufficiently described in several studies, both regarding content and frequency. The complexity of the intervention also makes it difficult to know what parts of the treatment package that were effective.
There are several factors that weaken the conclusions in this report. First and foremost is the fact that the results are based on few and small studies with either unclear or high risk of bias. Multidisciplinary rehabilitative interventions are per definition composite and complex, which may make it difficult to demonstrate difference in effect between interventions in clinical studies This can result in an underestimation of effect or vague conclusions about how different elements of compound multidisciplinary rehabilitation programs work.
Conclusion
When patient education was delivered as sole intervention, there was a significant improvement in symptoms, self-efficacy and knowledge about RA at one year follow-up in favour of the intervention group. For other outcomes, patient education showed small or no effects. The results from the studies evaluating the effect of multidisciplinary team-based rehabilitation showed, for HAQ physical function, a significantly improved score in favour of the control group at one year follow-up. At two years follow-up there still was a tendency towards better scores in the control group, but the difference was no longer significant. For other outcomes, multidisciplinary, team-based rehabilitation showed small or no effect.
The documentation about effect of multidisciplinary team-based rehabilitation is insufficient, and all conclusions are based on findings from small studies with unclear or high risk of bias. It is important to emphasize that no evidence of effect is not the same as evidence of no effect. In order to assess the effect of multidisciplinary team-based rehabilitation for patients with RA, it will therefore be a need for more research in this field.
Need for further research
Ideally, the randomized controlled trial is the most appropriate study design to study the effect of different interventions, including rehabilitative interventions. Due to among others organizational causes, it might be difficult to conduct these kinds of studies. An alternative in future studies of rehabilitative interventions can be what is called a "stepped wedge randomised trial design", in which the intervention is sequentially introduced (in clusters) over time periods.