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## Complete Summary

#### GUIDELINE TITLE

Ottawa Panel evidence-based clinical practice guidelines for
electrotherapy and thermotherapy interventions in the management of
rheumatoid arthritis in adults.

#### BIBLIOGRAPHIC SOURCE(S)

Ottawa Panel evidence-based clinical practice guidelines for
electrotherapy and thermotherapy interventions in the management of
rheumatoid arthritis in adults. Phys Ther 2004 Nov;84(11):1016-43. \[118
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15509188)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Rheumatoid arthritis

#### GUIDELINE CATEGORY

Management\
Rehabilitation\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Orthopedic Surgery\
Physical Medicine and Rehabilitation\
Rheumatology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Occupational Therapists\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To promote appropriate use of electrotherapy and thermotherapy in the
management of rheumatoid arthritis (RA)

#### TARGET POPULATION

Adult patients (18 years of age) with a diagnosis of rheumatoid
arthritis (RA) according to the 1987 American Rheumatism Association
(ARA) criteria.

A patient was said to have RA if he or she satisfied at least 4 of the
following 7 ARA criteria:

-   Morning stiffness

-   Arthritis of 3 or more joints

-   Arthritis of the hand joints

-   Symmetric arthritis

-   Rheumatoid nodules

-   Serum rheumatoid factor

-   Radiologic changes

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Electrotherapy and Thermotherapy**

1.  Low-level laser therapy (LLLT)

2.  Therapeutic ultrasound

    -   Pulsed

    -   Continuous

3.  Thermotherapy

    -   Paraffin baths

    -   Cryotherapy

4.  Transcutaneous electrical nerve stimulation (TENS)

    -   High frequency

    -   Low frequency

    -   Acupuncture-like

**Interventions Considered But Not Recommended**

-   Electrical stimulation of muscle

-   Exercise

#### MAJOR OUTCOMES CONSIDERED

**Organ Systems and Impairment**

-   Number of inflamed joints

-   Number of acute phase reactants (e.g., erythrocyte sedimentation
    rate)

-   Radiological damage

-   Side effects

**Abilities and Disabilities**

-   Pain reduction

-   Muscle force

-   Range of motion (ROM)

-   Postural status

-   Duration of morning stiffness

**Life Habits and Handicap Situation**

-   Global physician assessment

-   Global patient assessment

-   Gait status

-   Walking speed

-   Walking distance

-   Cadence

-   Stride length

-   Functional status

-   Patient adherence

-   Patient satisfaction

-   Length of stay

-   Discharge disposition

-   Quality of life

-   Return to work

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The library scientist developed a structured literature search based on
the sensitive search strategy for randomized controlled trials (RCTs)-a
strategy recommended by The Cochrane Collaboration with modifications to
that strategy. The Cochrane Collaboration method minimizes bias through
a systematic approach to the literature search, study selection, and
data extraction and synthesis. The search was organized around the
condition and interventions rather than the outcomes because it was an a
priori search. Thus, there was no control over the outcomes the authors
decided to measure.

The library scientist expanded the search strategy to identify
case-control, cohort, and nonrandomized studies and conducted the search
in the electronic databases of MEDLINE, EMBASE, Current Contents, the
Cumulative Index to Nursing and Allied Health (CINAHL), and the Cochrane
Controlled Trials Register up to December 2002. Also searched were the
registries of the Cochrane Field of Rehabilitation and Related
Therapies, the Cochrane Musculoskeletal Group, the Physiotherapy
Evidence Database (PEDro), and the University of Ottawa Evidence-Based
Clinical Practice Guidelines (EBCPGs) Web site. Finally, reference lists
of all of the included trials were searched for relevant studies and
content experts were contacted for additional studies.

In the first round of study inclusion or exclusion, 2 independent
reviewers, trained and experienced occupational therapist or physical
therapist students, appraised the titles and abstracts of the literature
search using a checklist with the a priori--defined selection criteria.
More junior students were paired with fourth-year occupational therapist
or physical therapist students who were experienced with the
Philadelphia Panel methodology. Each pair of reviewers was assigned to a
specific intervention. Within each pair of reviewers, individuals
independently read the title and abstract of each article and created an
individual list of all of the articles of the database with a reason for
including or excluding each article. If the reviewers were uncertain
about a particular article after having read the abstract, they ordered
the article and read it in full before making a determination. Before
deciding whether to include or exclude the article, a comparison of
their individual lists was performed. A senior reviewer who is a
methodologist and a clinical expert in arthritis checked the 2
independent lists of articles and the reason for inclusion or exclusion
to determine potential inconsistencies. Eleven percent of the abstracts
reviewed needed the consultation of the senior reviewer. For the second
round of inclusion and exclusion, the pairs of reviewers retrieved
articles selected for inclusion from the first round and independently
assessed the full articles for inclusion or exclusion in the study.

**Study Inclusion/Exclusion Criteria**

The inclusion/exclusion criteria were based on previous criteria used by
the Philadelphia Panel. This list of criteria, which had been created
for multiple diagnoses, including back and neck pain, was adapted and
approved by the Ottawa Methods Group (OMG) for use with rheumatoid
arthritis (RA).

All original comparative controlled studies that evaluated the specific
intervention in a sample of patients with RA were included: RCTs,
controlled clinical trials (CCTs), cohort studies, and case-control
studies. (Controlled clinical trials are the same as RCTs except that,
according to the Jadad scale, CCTs are either not randomized or poorly
randomized.) Crossover studies were included, and, to avoid potential
confounders, the data from only the first part of the study (before
crossing) were analyzed. (Data from the first part are more specific
than data from the second part because once the study patients change
from the intervention group to the placebo group, the outcome could be
due to either the intervention or the placebo. Thus, such results are
not useful for measuring the special effect of each intervention.)

Uncontrolled cohort studies (studies with no comparison group) and case
series were excluded, as were eligible studies with greater than 20%
dropout rates or a sample size of less than 5 patients per group.
Abstracts were excluded because none of the abstracts found had
sufficient data for analysis and the full studies of the abstracts could
not be obtained from the authors. Trials published in languages other
than French and English were not analyzed because of the time and cost
involved in translation. Head-to-head studies (that is, the comparison
of 2 active interventions, such as therapeutic exercises versus
transcutaneous electrical nerve stimulation) were generally excluded in
these recommendations.

#### NUMBER OF SOURCE DOCUMENTS

For low-level laser therapy (LLLT), 11 articles were initially
considered relevant and 5 randomized controlled trials (RCTs) involving
204 patients with rheumatoid arthritis were ultimately included.

For therapeutic ultrasound, 8 studies were initially included and 1 RCT
involving 50 patients was ultimately included.

For thermotherapy, 23 trials were initially included and 2 RCTs
involving 76 patients were ultimately included.

For transcutaneous electrical nerve stimulation (TENS), 9 articles were
initially included and 3 RCTs involving 78 patients were ultimately
included.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The methodological quality of the trials was assessed using the Jadad
scale, a 5-point scale with reported reliability and validity that
assigns 2 points each for randomization and double blinding and 1 point
for description of withdrawals.

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Data Extraction**

Using predetermined extraction forms, the pairs of reviewers
independently extracted data from included articles on the population
characteristics, details of the interventions, trial design, allocation
concealment, and outcomes. The pairs of reviewers assessed
methodological quality using the Jadad scale, a 5-point scale with
reported reliability and validity that assigns 2 points each for
randomization and double blinding and 1 point for description of
withdrawals.  The reviewers resolved differences in data extraction and
quality assessment through consensus with the senior reviewer. This
consensus served to support the reliability of data obtained with the
article selection process.

**Statistical Analysis**

Data were analyzed using Review Manager software. Continuous data,
\"data with a potentially infinite number of possible values along a
continuum,\" were analyzed using the weighted mean differences (WMDs)
between the intervention and control groups at the end of the study,
where the weight is the inverse of the variance. A WMD is \"a method of
meta-analysis used to combine measures on continuous scales (such as
weight), where the mean, standard deviation, and sample size in each
group are known.\" Dichotomous data, or data with only 2
classifications, were analyzed using relative risks. According to
Cochrane, the relative risk is \"the ratio of risk in the intervention
group to the risk in the control group. The risk (proportion,
probability, or rate) is the ratio of people with an event in a group to
the total in the group.\"

Heterogeneity (i.e., variability or difference between studies) was
tested using the chi-square statistic. Data heterogeneity was tested
among the results of different included studies to make sure that only
homogeneous data were pooled together. When heterogeneity was not
significant, fixed-effect models were used. A fixed-effect model is a
statistical model that stipulates that the units under analysis (e.g.,
participants in a meta-analysis study) are the ones of interest and thus
constitute the entire population of units. Fixed-effect models were used
to generalize data across the included studies.

Random effects models include both within-study sampling error
(variance) and between-studies variation in the assessment of the
uncertainty (confidence interval) of a meta-analysis\' results and are
more severe than fixed effect models. Such random-effects models were
used when heterogeneity was significant. All figures were created using
Cochrane Collaboration methodology
([www.cochrane.org](http://www.cochrane.org/)).

Based on previous studies in the musculoskeletal domain and on
consensus, clinical improvement for all interventions studied by the
Ottawa Panel was defined as 15% improvement relative to a control. This
figure can be justified because it was developed by the Philadelphia
Panel, whose members are experts in musculoskeletal practice, and
confirmed by another panel (the Ottawa Panel) whose members included
specialists in rheumatology and an expert biostatistician.

To determine clinical improvement, the absolute benefit and relative
difference in the change from baseline were calculated. Absolute benefit
was calculated as the improvement in the treatment group less the
improvement in the control group, maintaining the original units of
measurement. Relative difference was calculated as the absolute benefit
divided by the baseline mean (weighted for the intervention and control
groups). For dichotomous data, the relative percentage of improvement
was calculated as the difference in the percentage of improvement
between the intervention and control groups.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The development process of these evidence-based practice guidelines
(EBCPGs) was similar to that of the Philadelphia Panel, except that a
different target population was used. Briefly, the Ottawa Methods Group
(OMG), a group of 9 methodologists with experience in developing EBCPGs,
asked professional associations interested in the care of people with
rheumatoid arthritis (RA) for suggestions of individuals with both
clinical expertise in the management of the disease and familiarity with
EBCPGs. From among the suggestions given, the OMG chose 9 experts to
serve as panel members. These experts in RA were a rheumatologist, a
physiatrist, a physician with experience in evidence-based medicine, a
family physician, 3 physical therapists (including one who practiced
acupuncture and one involved in clinical research), an occupational
therapist, and a patient with RA. The Ottawa Panel consisted of these 9
experts and all members of the OMG.

One OMG member assembled a research and support staff with expertise in
meta-analyses, rheumatology rehabilitation interventions, research
methods, or the development and assessment of EBCPGs. The OMG then
established a priori a set of inclusion criteria for the study designs,
subject samples, interventions, and outcomes to allow the research staff
to select the most relevant material as evidence of the effectiveness of
therapeutic exercise and manual therapy. The OMG also reviewed the
inclusion criteria to ensure that the approach to the study selection
was reproducible and systematic. This a priori protocol guided separate
systematic reviews of the literature for each intervention. The research
staff reviewed articles and created evidence tables for them, which the
9 clinical experts received in preparation for their meeting with the
OMG. These tables were used as the basis for making the recommendations.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The recommendations were graded by their level (I for randomized
controlled trials \[RCTs\], II for nonrandomized studies) and strength
(A, B, C+, C, or D) of evidence.

**Grade A**: Evidence from one or more RCTs of a statistically
significant, clinically important benefit (\>15%)

**Grade B**: Statistically significant, clinically important benefit
(\>15%) if the evidence was from observational studies or controlled
clinical trials (CCTs)

**Grade C+**: Evidence of clinical importance (\>15%) but not
statistical significance

**Grade C**: An appropriate outcome was measured in a study that met the
inclusion criteria but no clinically important difference and no
statistical significance were shown

**Grade D**: Evidence from one or more RCTs of a statistically
significant benefit favoring the control group (\<0%: favors controls)

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were sent to the external experts for review. To judge
clinical usefulness, the positive recommendations also were sent to 5
practitioners for feedback. Practitioners were selected from clinical
settings in the Ottawa and Toronto regions and were a physical
therapist, an occupational therapist, a physiatrist, a family physician,
and a rheumatologist, all of whom were currently working with patients
with rheumatoid arthritis (RA). Practitioners were asked 4 questions for
each guideline: whether the recommendation was clear, whether the
practitioners agreed with the recommendation, whether they felt that the
literature search on therapeutic exercises and intensity of
rehabilitation was relevant and complete, and whether the results of the
trials in the guidelines were interpreted according to the
practitioners\' understanding of the data.

The development of the draft Evidence-Based Clinical Practice Guidelines
(EBCPGs) prepared for the expert members was in concordance with
Appraisal of Guidelines Research and Evaluation (AGREE) criteria. Using
AGREE
([www.agreecollaboration.org](http://www.agreecollaboration.org/)), 2
trained physical therapists assessed the Ottawa Panel EBCPGs for
rheumatoid arthritis (RA). This tool consists of 6 dimensions measured
on a 4-point scale, where 1 represents \"strongly agree\" and 4
represents \"strongly disagree.\" The dimensions are: (1) purpose,
defined as overall objectives that described the potential impact of a
guideline on society and populations of patients; (2) stakeholder
involvement, defined as the extent to which the guideline represents the
views of its targeted users; (3) rigor of development, which deals with
the process used to gather and synthesize the evidence and with the
methods to formulate the recommendations and to update them; (4) clarity
and presentation, which refers to the language and format of the
guideline; (5) applicability, which relates to the likely
organizational, behavioral, and cost implications of applying the
guideline; and (6) editorial independence, which refers to the
independence of the recommendations and acknowledgment of possible
conflict of interest from the guideline development group.

The Ottawa Panel\'s evidence-based practice guidelines on electrotherapy
and thermotherapy for the management of rheumatoid arthritis are
generally in accordance with other evidence-based practice guidelines,
including those from the American College of Rheumatology, the American
Pain Society, and the American Occupational Therapy Association.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Each recommendation is followed by recommendation grades (**Level I or
II** and **A, B, C+, C and D**). Definitions of the recommendation
grades are presented at the end of the \"Major Recommendations\" field.

**Low-level Laser Therapy (LLLT)**

LLLT applied to the foot, knee, or hand versus a placebo, **level I**
(randomized controlled trial \[RCT\]): **Grade A** for pain at 3 months
(clinically important benefit); **grade C** for function, tender joints,
muscle force, and range of motion (ROM) at 3 and 6 months (no benefit).
Patients with chronic rheumatoid arthritis (RA).

**Therapeutic Ultrasound**

Therapeutic ultrasound performed on the hand in water versus a placebo,
**level I** (RCT): **Grade A** for tender joints at 10 weeks (clinically
important benefit); **grade C** for swollen joints and morning stiffness
at 10 weeks (no benefit). Patients with RA involving the hand
(functional class I or II, chronic stage).

**Thermotherapy**

Cryotherapy applied to the knee joint versus a control, **level I**
(RCT): **Grade C** for thermographic index (measurement \[in degrees
Celsius\] obtained using infrared thermography of the joint) at 5 days
(no benefit). Patients with chronic RA, and with obvious effusion of
joints.

Wax applied to the hand and wrist versus a control, **level I** (RCT):
**Grade C** for pain, ROM, muscle force, and function at 1 month (no
benefit). Patients with functional class I or II with hands affected.

Wax applied to the hand or wrist and hand exercises versus a control,
**level I** (RCT): **Grade A** for ROM at 1 month (clinically important
benefit), **grade C+** for pain and stiffness at 1 month (clinical
benefit), **grade C** for muscle force and function at 1 month (no
benefit). Patients with functional class I or II with hands affected.

**Transcutaneous Electrical Nerve Stimulation (TENS)**

Low-frequency TENS applied to the hand and wrist versus no stimulation,
**level I** (RCT): **Grade A** for pain at 3 weeks (clinically important
benefit), **grade C+** for power at 3 weeks (clinical benefit), **grade
C** for work at 3 weeks (no benefit). Patients with chronic RA.

High-frequency TENS applied to the hand and wrist versus placebo,
**level I** (RCT): **Grade C** for pain and joint tenderness, same day
(no benefit). Patients with chronic RA.

High- versus low-frequency TENS applied to the hand and wrist, **level
I** (RCT): **Grade C** for global patient (patient\'s assessment of
overall disease activity or improvement) (Ottawa Panel, 2004) at 2 weeks
(clinical benefit). Patients with chronic RA.

**[Definitions]{.underline}**:

The recommendations were graded by their level (I for RCTs, II for
nonrandomized studies) and strength (A, B, C+, C, or D) of evidence.

**Grade A**: Evidence from one or more RCTs of a statistically
significant, clinically important benefit (\>15%)

**Grade B**: Statistically significant, clinically important benefit
(\>15%) if the evidence was from observational studies or CCTs

**Grade C+**: Evidence of clinical importance (\>15%) but not
statistical significance

**Grade C**: Appropriate outcome was measured in a study that met the
inclusion criteria but no clinically important difference and no
statistical significance were shown

**Grade D**: Evidence from one or more RCTs of a statistically
significant benefit favoring the control group (\<0%: favors controls.)

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=6265)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is identified and graded for each recommendation
(see \"Major Recommendations\")

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of electrotherapy and thermotherapy for the treatment
and rehabilitation of adults with rheumatoid arthritis

#### POTENTIAL HARMS

None stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The Evidence-Based Clinical Practice Guidelines (EBCPGs) developed by
the Ottawa Panel have some potential limitations due to methodological
weaknesses. Although the included trials were selected based on
well-established inclusion and exclusion criteria, selection was
performed by occupational therapist and physical therapist students.
Potential omission of studies due to reviewer inexperience could have
led to selection bias. Consultation with a third reviewer and the use of
the panel of senior clinical experts may have compensated in part for
this potential methodological flaw. The EBCPGs also are limited by the
inclusion and exclusion criteria for the included studies. For example,
some reports of randomized controlled trials (RCTs) did not specify if
the study sample included individuals in acute or chronic stages of
rheumatoid arthritis (RA). Additionally, some studies lacked details
about the specific characteristics of the exercise intervention such as
intensity. This lack of specificity could be problematic for future
clinical implementation of the guidelines, especially for the whole-body
functional strengthening recommendation.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The Ottawa Panel is planning to implement these guidelines in the
Arthritis Rehabilitation and Education Program of The Arthritis Society
of Ontario.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ottawa Panel evidence-based clinical practice guidelines for
electrotherapy and thermotherapy interventions in the management of
rheumatoid arthritis in adults. Phys Ther 2004 Nov;84(11):1016-43. \[118
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15509188)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Nov

#### GUIDELINE DEVELOPER(S)

Ottawa Panel - Independent Expert Panel

#### SOURCE(S) OF FUNDING

This study was financially supported by an unrestricted educational
grant from the Cigna Foundation, Philadelphia, PA USA.

#### GUIDELINE COMMITTEE

Ottawa Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Ottawa Methods Group*: Lucie Brosseau, PhD, Physiotherapy Program,
School of Rehabilitation Sciences, Faculty of Health Sciences,
University of Ottawa, Ottawa, Ontario, Canada; George A Wells, PhD,
Department of Epidemiology and Community Medicine, University of Ottawa;
Peter Tugwell, MD, MSc, Centre for Global Health, Institute of
Population Health, Ottawa, Ontario, Canada; Mary Egan, PhD, Occupational
Therapy Program, School of Rehabilitation Sciences, Faculty of Health
Sciences, University of Ottawa; Claire-Jehanne Dubouloz, PhD,
Occupational Therapy Program, School of Rehabilitation Sciences, Faculty
of Health Sciences, University of Ottawa; Lynn Casimiro, MA,
Physiotherapy Program, School of Rehabilitation Sciences, Faculty of
Health Sciences, University of Ottawa; Vivian A Robinson, MSc, Centre
for Global Health, Institute of Population Health; Lucie Pelland, PhD,
Physiotherapy Program, School of Rehabilitation Sciences, Faculty of
Health Sciences, University of Ottawa; Jessie McGowan, MLIS, Director,
Medical Library, Centre for Global Health, Institute of Population
Health

*External Experts*: Mary Bell, MD (Rheumatologist), Sunnybrook and
Women\'s College Health Sciences Centre, Toronto, Ontario, Canada;
Hillel M Finestone, MD (Physiatrist), Sisters of Charity of Ottawa
Health Service, Ottawa, Ontario, Canada; France Légaré, MD
(Evidence-Based Practice in Family Medicine), University of Laval,
Québec City, Québec, Canada; Catherine Caron, MD (Family Physician),
Sisters of Charity of Ottawa Health Service; Sydney Lineker, PT, MSc,
The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto,
Ontario, Canada; Angela Haines-Wangda, PT, MSc, Ottawa Hospital, General
Campus, Ottawa, Ontario, Canada; Marion Russell-Doreleyers, PT who
practices acupuncture, MSc, Canadian Physiotherapy Association and
Ottawa Arthritis Rehabilitation and Education Program, Ottawa, Ontario,
Canada; Martha Hall, OT, MPA, Canadian Association of Occupational
Therapists and Ottawa Arthritis Rehabilitation and Education Program;
Paddy Cedar, patient with rheumatoid arthritis (named with her written
permission)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from Lucie Brosseau, PhD, Physiotherapy Program,
School of Rehabilitation Sciences, Faculty of Health Sciences, 451 Smyth
Rd, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5 (E-mail:
<LucieBrosseau@uottawa.ca>).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 10, 2005. The
information was verified by the guideline developer on April 9, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/10/2008