Rheumatoid arthritis (RA) affects approximately 2% of the population and is more common in women than in men. The course of RA is variable and unpredictable but for a significant number of patients it is a severe disease resulting in persistent pain and stiffness, progressive joint destruction, functional decline and premature mortality. The multidisciplinary team has been shown to be effective in optimizing management of patients with RA.1 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.

1. 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.2,3 Wrist working splints have been shown to decrease pain on activity4 but do not improve function, grip strength or dexterity.5 There is no good evidence to support the use of splints to correct ulnar deviation or any other deformity.

2. 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.6

2.1 Assistive Devices- Fortunately there are hundreds of tools that can help. But before employing any assistive device, it should be sure to use own strength and range-of-motion first, the better to preserve both. A few all-purpose self-help tools in the house include:
• Fat rubber grips slip over everything from a toothbrush handle to a pen or potato peeler, reducing pressure on your joints and making it easier to hold small items.
• Doorknob adapters are lever handles that fit over standard round doorknobs; once installed you only need push the lever up or down to open a door
• Lamp adapters. Screw a lamp adapter into a light bulb socket and it converts any metal lamp into a touch lamp with three brightnesses.
• Leg extenders can lengthen the legs of your office chair, dining room table, kitchen island, or any piece of furniture that's too low to use comfortably.
• Spring-loaded scissors can save your hands from fatigue from garden to office.
• Key turners snap onto the heads of household keys, widening your gripping surface and making keys easier to turn.

3. 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:

3.1 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.7

4. 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.8 However, well-conducted studies evaluating the effectiveness of intervention are lacking and the formal evidence base is limited.

4.1 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.9

4.2 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.10 A recent systematic review of balneotherapy11 (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.

4.3 Other physical therapies
Evidence for other therapies such as the application of ice or heat,12 TENS or laser therapy13,14 is conflicting or is insufficient to support their routine use. There is limited evidence showing symptomatic benefit from ultrasound.15


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.
5.1 Weight management- 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.

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References
1. Vliet Vlieland TP, Breedveld FC, Hazes JM. The two-year follow-up of a randomized comparison of in patient multidisciplinary team care and routine out patient care for active rheumatoid arthritis. Br J Rheumatol 1997; 36: 82-5
2. Callinan NJ, Mathiowetz V. Soft versus hard resting han