Effectiveness of non-pharmacological and non-surgical interventions for rheumatoid arthritis: an umbrella review
Authors: Santos Eduardo J.F. , Duarte Cátia , Marques Andréa , Cardoso Daniela , Apóstolo João , da Silva José A.P. , Barbieri-Figueiredo Maria 
Published: June 2019

ABSTRACTObjective:This umbrella review aimed to determine the effectiveness of non-pharmacological and non-surgical interventions on the impact of rheumatoid arthritis.Introduction:Patients with rheumatoid arthritis have identified seven major domains of the impact of disease: pain, functional disability, fatigue, sleep, coping, emotional well-being and physical well-being. This impact persists in many patients even after inflammatory remission is achieved, requiring the need for adjunctive interventions targeting the uncontrolled domains of disease impact. Several systematic reviews have addressed non-pharmacologic interventions, but there is still uncertainty about their effectiveness due to scarce or conflicting results or significant methodological flaws.Inclusion criteria:This review included studies of adult patients with rheumatoid arthritis in any context. Quantitative systematic reviews, with or without meta-analysis, that examined the effectiveness of non-pharmacological and non-surgical interventions of any form, duration, frequency and intensity, alone or in combination with other interventions designed to reduce the impact of disease, were considered. The outcomes were pain, functional disability, fatigue, emotional well-being, sleep, coping, physical well-being and global impact of disease.Methods:A comprehensive search strategy for 13 bibliometric databases and gray literature was developed. Critical appraisal of eight systematic reviews was conducted independently by two reviewers, using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research syntheses. Data extraction was performed independently by two reviewers using a standard Joanna Briggs Institute data extraction tool, and data were summarized using a tabular format with supporting text.Results:Eight systematic reviews were included in this umbrella review, with a total of 91 randomized controlled trials and nine observational studies (6740 participants). Four systematic reviews examined the effects of multicomponent or single exercise/physical activity interventions, two examined the effects of hydrotherapy/balneotherapy, two examined the effects of psychosocial interventions, and one examined the effects of custom orthoses for the foot and ankle. Multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses appeared to be effective in improving pain and functional disability. Fatigue also improved with the implementation of multicomponent or single exercise/physical activity interventions and psychosocial interventions. Only exercise/physical activity interventions appeared to be effective in reducing the global impact of disease and quality of life. None of the included systematic reviews reported on emotional well-being, sleep, coping or physical well-being as an outcome measure. Other types of interventions were not sufficiently studied, and their effectiveness is not yet established.Conclusions:Of the included interventions, only multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses seem to reduce the impact of rheumatoid arthritis. Future evidence should be sought and synthesized in the domains identified as knowledge gaps, namely, emotional well-being, sleep, coping and physical well-being. Further examination of the effects of interventions that have not been assessed sufficiently is suggested in order to establish their effectiveness so decisions and recommendations can be made.