A systematic review of non-invasive manual therapy in the management of rheumatoid arthritis patients

Abstract

Background: Rheumatoid arthritis (RA) is a common, chronic, and progressive autoimmune condition manifesting in a polyarticular pattern, with an agnogenic pathophysiology. The progressive effect on physical function (e.g., pain, quality of life, funcaitonal impairment and disability) and the side effects of pharmaceutical interventions, have led to patients seeking adjunctive therapy. Complementary and alternative medicine (CAM) therapy, is thought to reduce pain, increase range of motion, and improve quality of life. Yet, the evidence base for CAM therapies is vague. This systematic review of studies relating to non-invasive manual therapy (vis. exercise, manipulation, mobilisation, and massage), determined the level of evidence available for their use, and provided a summation of the available evidence to support evidence-based clinical practice. Finally, the study provides recommendations for further investigations. Method: This mixed methods systematic review complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and Cochrane Collaboration guidelines, required an electronic literature search (viz: Google Scholar and DUT Summons) using key terms including rheumatoid arthritis and variable combination one or more of the following: treatment, management, chiropractic, osteopathy, physiotherapy, physical therapy, massage, mobilization, manipulation, joint oscillation, and exercise. This along with hand search strategies and reviewer input produced 65 articles that were incorporated into the review (40 RCTs. 15 nRCTs, and 10 Cases). All selected articles were available in English in electronic format and represented RCTs, nRCTs and CR/CS (not limited to peer reviewed studies) and reflected interventions applied to adult, human subjects. The articles were reviewed by 13 reviewers, using as appropriate the PEDro, Newcastle-Ottawa or Liddle scales, to evaluate the methodological rigour (internal validity) of the studies, while qualitatively contextualizing these outcomes (external validity) to determine the impact of bias on the reported clinical outcomes. Thereafter an analysis of evidence per modality was completed utilising published grading systems. Results: The above evaluations and aggregated evidence available was then determined for the modalities. It was found that there is limited evidence available for manipulation, mobilisation, massage, and exercise in the treatment of the RA patient. The notable exceptions were the use of aerobic exercise with acetaminophen; exercise as part of an intervention programme in the treatment of the hands; and mixed exercise programme to improve bone mineral density and attaining muscular strength gains. Conclusion: Thus, excluding the exceptions, the reviewed interventions should be used cautiously in practice and patients should not be provided with expectations that are not confidently supported by available literature. The evidence suggests that for the most part, intervention by means of manipulation, mobilisation, soft tissue manipulation and massage, along with exercise, requires further research efforts to provide sufficient high-quality evidence for the practitioner to implement in clinical practice with confidence