The multidisciplinary team has been shown to be effective in optimising management of patients with RA.38 All patients should have access to such a range of professionals, including general practitioner, rheumatologist, nurse specialist, physiotherapist, occupational therapist, dietitian, podiatrist, pharmacist, and social worker.

5.1 Occupational therapy

In everyday practice, the substantial impact of skilled occupational therapy (OT) intervention on quality of life for patients with RA is clear. Unfortunately, relatively few studies have been carried out and evidence from RCTs is often lacking. The OT approach is multifaceted and includes:

5.1.1 Activities of daily living

Facilitation of the activities of daily living (e.g. washing, toileting, dressing, cooking, eating, working), sometimes with the provision of equipment and adaptations, is fundamental to the management of RA.¹⁶⁷ Effective OT advice is crucial in helping patients to maximise function and improve their level of independence. Evidence level 1+

Skilled occupational therapy advice should be available to those experiencing limitations in function.

5.1.2 Joint protection

Joint protection aims to reduce pain and stress on joints whilst carrying out everyday activities. ¹⁶⁸ Evidence level 4

A range of strategies are employed including adapting movement patterns of affected joints to reduce strain, assistive devices, rest regimens, energy conservation techniques, exercise and splinting. These interventions are difficult to evaluate and formal studies are limited. Studies in patients with longer disease duration, have shown encouraging results.

5.2 Physiotherapy

The role of the physiotherapist in assessing and treating patients with RA is well recognised in clinical practice. Physiotherapy management has been shown to be effective in improving self-efficacy, knowledge and morning stiffness.¹⁶⁹ However, well-conducted studies evaluating the effectiveness of intervention are lacking and the formal evidence base is limited.

5.2.1 Dynamic exercise therapy

Exercise therapy is prescribed in an attempt to overcome the adverse effects of RA on muscle strength, endurance and aerobic capacity. Dynamic exercise therapy (i.e. exercises of low to moderate aerobic intensity) is effective in increasing aerobic capacity and muscle strength. No adverse effects on disease activity or pain are observed.¹⁷⁰ Limited evidence indicates that specific strength training programmes can reduce impairment.¹⁷¹ Evidence level 1++

Patients should be encouraged to undertake simple dynamic exercises.

5.2.2 Hydrotherapy

Hydrotherapy is one of the oldest forms of treatment for patients with arthritis. Despite this, formal evidence showing benefit is sparse. Limited evidence suggests that hydrotherapy can effect and maintain an improvement in self-efficacy in addition to some clinical and psychological gain.¹⁷²,¹⁷³ A recent systematic review of balneotherapy¹⁷⁴ (i.e. hydrotherapy or spa therapy) noted that no conclusion could be provided from the reviewed studies due to poor methodology. Further well-conducted trials are needed to assess the efficacy of this mode of treatment.

5.2.3 Other physical therapies

Evidence for other therapies such as the application of ice or heat,¹⁷⁵ TENS or laser therapy^{176,177,178,179} is conflicting or is insufficient to support their routine use. There is limited evidence showing symptomatic benefit from ultrasound.¹⁸⁰

5.3 Splinting

Splinting can be undertaken by occupational therapists, physiotherapists, or orthotists. Good evidence to support the use of resting hand splinting is sparse although two studies did report a significant reduction in pain when splints were applied.^181,182 Wrist working splints have been shown to decrease pain on activity^183,184 but do not improve function, grip strength or dexterity.^185,186 There is no good evidence to support the use of splints to correct ulnar deviation or any other deformity. Evidence level 1+

Resting and working splints can be used to provide pain relief.

5.4 Podiatry

The importance of appropriate footwear provision for comfort, mobility and stability is well recognised in clinical practice but there is little evidence-based research to support such observations in patients with early RA.

There is some evidence regarding the efficacy of foot orthoses in terms of both comfort level and stride speed and length.^{187,188 ,189}

The guideline development group could find no research regarding other podiatry interventions such as reduction of callosities and padding of the feet in those with early RA.

Podiatry referral should be offered to all patients.

5.5 Dietetics

Nutritional advice plays an important part in the management of a patient with RA. Enquiries about diet are amongst those most commonly received from patients.

5.5.1 Weight management

Weight reduction in obese individuals is important particularly when weight bearing joints are involved. Management should be as recommended in the SIGN guideline on obesity.¹⁹⁰

Cachexia may occur in those with severe active RA. The aetiology is likely to be multi-factorial. Several studies have shown that patients with low body mass index (BMI) do less well and have poorer functional status.^191,192 Whilst it is not clear whether dietary intervention improves outcome, for general health reasons, an adequate BMI should be maintained. Some patients will require diet supplements in addition to dietary advice.

5.5.2 Diet as therapy

Relatively few studies have been carried out to assess the effect of diet therapy on disease activity in RA.¹⁹³ Fasting has been shown to be of benefit in some patients.¹⁹⁴ Weight loss often occurs and this may not be beneficial in all patients. Practical difficulties have also been encountered in implementing and maintaining strict dietary changes. The evidence regarding food exclusion is often anecdotal and is inconclusive. Exclusion/elimination diets can be difficult to follow and if adhered to over a long period of time, may lead to the development of nutritional deficiencies.

5.5.3 Diet supplements

A meta-analysis of clinical trials of fish oil supplementation in RA concluded that there was a significant reduction in the number of tender joints and in duration of morning stiffness after three months of therapy. However, no effect was seen on indices of disease activity or progression of RA.¹⁹⁵ There are practical limitations to this approach, including the large quantities of fish oil required. The latter is expensive, difficult to take and not available on prescription.

The effect of other oils such as evening primrose oil¹⁹⁶ and blackcurrant seed oil¹⁹⁷ on disease activity in RA remains uncertain.