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What are the goals and principles of management in the early treatment of rheumatoid arthritis?

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The management of patients with new-onset rheumatoid arthritis (RA) requires an awareness of the potential issues and needs that are unique to each patient with regards to their perceptions of their disease, physical needs and nutritional issues. Arthritis specialists should have a clear approach to the goals of management that are specific to patients with early rheumatoid arthritis (ERA). In this chapter, evidence for the goals and principles of management in the early treatment of RA is discussed. Patient education, the role of self-management, physical therapies, exercise, diet and drug management are addressed. This chapter aims to provide clinicians with a clear understanding of which interventions have supporting evidence and where further research is required. Where evidence for patients with ERA is lacking, evidence from patients with established RA is reviewed.

Section snippets

What are the goals of management—disease remission or control, maintaining function, maintaining quality of life?

The impact of RA can be devastating. Up to 50% of patients with ERA will be unable to do their job after 3 years of disease.1 It is not uncommon for job loss to occur even before the patient has seen a rheumatologist. Patients who lose their job and function experience secondary loss of self-esteem and depression. The primary goal of therapy is to achieve early remission of the disease with sustained therapy, as sustained remission in patients with longstanding disease if medications are

What is the role of patient education?

The goals of education for patients with new-onset RA are improved patient-physician communication, increased understanding of their condition, better adherence to treatment and a change in behavior to improve pain, disability and psychosocial wellbeing. Patient education programmes should compliment medical treatments by providing strategies and tools to make the necessary decisions to better cope with the patient's illness. A better comprehension of the disease process, possible outcomes,

What is the role of self-management?

RA is known to have an unpredictable course and prognosis, and a negative psychosocial impact. Barlow8 performed an RCT of a psycho-educational intervention known as the Arthritis Self-Management Program (ASMP) in 544 patients with osteoarthritis. The ASMP was found to be effective in terms of improving perceptions of control (i.e. arthritis self-efficacy), use of self-management techniques such as communication with physicians, cognitive symptom management, exercise, and health status in terms

Occupational therapy (OT)

OT for patients with RA can include training of skills, counseling, education about joint protection, prescription of assistive devices, provision of splints, advice/instruction in the use of assistive devices, training in self-care activities, and training in productivity activities. Steultjens11 reviewed the efficacy of OT interventions for RA. Seven different intervention categories were identified (comprehensive OT, training of motor function, training of skills, instruction on joint

What is the role of exercise?

The goal of exercise for any individual is to maintain or improve physical fitness. In order to achieve this, patients need to participate in exercise programmes over a prolonged period. For this reason, Hakkinen et al evaluated the impact of a 2-year home-based strength-training programme on physical function in patients with ERA after a subsequent 3-year follow-up.14 They randomized 70 patients with ERA to perform either strength training [experimental group (EG)] or range-of-motion exercises

What is the role of diet?

When patients are first diagnosed with RA, they must deal with the new sense of loss of control over their health. They frequently ask what they can do to help manage their disease, and inherent in this are questions about how they should modify their diet and whether dietary modifications can control or even cure their RA. There are now a number of studies of dietary interventions that have shown some benefit in RA. These are discussed below to provide healthcare providers with an

What is the role of drug management?

At this point in the evolution of disease management of ERA, drug therapy remains the most critical aspect of treating this disease. Pharmacological and biological therapies have been shown to be the most rapid acting and have the largest effect on controlling the inflammatory process in this disease. At the present time, no therapy can cure the disease. No drug can be withdrawn once the disease is in remission without a significant risk of the disease returning.

The main goal of drug management

Summary

Evidence has been presented that a diet high in anti-oxidants (vegetables, olive oil) and PUFAs (fish oils) is likely to have a moderating effect on RA. Psycho-educational interventions have only shown short-term benefit, but it is likely that these have not been evaluated for the appropriate specific outcome measures (i.e. adherence, depression). Physical exercise such as dynamic strength training has been shown to improve function and reduce disease activity in patients with ERA. Although the

References (41)

  • R. Panush

    Preface

    Rheumatic Disease Clinics of North America

    (1999)
  • M.J. James et al.

    Dietary polyunsaturated fatty acids and inflammatory mediator production

    Am J Clin Nutr

    (2000)
  • M.J. James et al.

    Dietary n-3 fatty acids and therapy for rheumatoid arthritis

    Semin Arthritis Rheum

    (1997)
  • W. Felts et al.

    The economic impact of the rheumatic diseases in the United States

    J Rheumatol

    (1989)
  • P.D.M. de Buck et al.

    A multidisciplinary job retention vocational rehabilitation programme for patients with chronic rheumatic diseases: patients’ and occupational physicians’ satisfaction

    Ann Rheum Dis

    (2004)
  • K.R. Lorig et al.

    Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs

    Arthritis and Rheumatism

    (1993)
  • A. Hammond et al.

    A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis

    Ann Rheum Dis

    (2004)
  • R.P. Riemsma

    Patient education for adults with rheumatoid arthritis (Cochrane Review)

  • R.P. Riemsma

    Group education for patients with rheumatoid arthritis and their partners

    Arthritis Care & Research

    (2003)
  • K. Freeman

    Use of cognitive-behavioral arthritis education programmes in newly diagnosed rheumatoid arthritis

    Clinical Rehabilitation

    (2002)
  • J.H. Barlow

    A randomized controlled trial of arthritis self management programme in the UK

    Health Education Research

    (2000)
  • A. Warsi

    Arthritis self-management education programs

    Arthritis and Rheumatism

    (2003)
  • E. Badamgarav et al.

    Effects of disease management programs on functional status of patients with rheumatoid arthritis

    Arthritis and Rheumatism

    (2003)
  • E.M.J. Steultjens

    Occupational therapy for rheumatoid arthritis

    Cochrane Database of Systematic Reviews

    (2004)
  • A. Verhagen et al.

    Balneotherapy for rheumatoid arthritis

    Cochrane Database of Systematic Reviews

    (2004)
  • E.M. Bartels et al.

    Pool exercise therapy of rheumatoid arthritis

    Ugeskr Laeger

    (2001)
  • A. Hakkinen et al.

    A home-based two-year strength training period in early rheumatoid arthritis led to good long-term compliance: a five-year followup

    Arthritis Care Res

    (2004)
  • A. Hakkinen et al.

    A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis

    Arthritis and Rheumatism

    (2001)
  • M. Munneke

    Adherence and satisfaction of rheumatoid arthritis patients with a long-term intensive dynamic exercise program (RAPIT Program)

    Arthritis & Rheumatism

    (2003)
  • K.K. Banerjee et al.

    Influence of cigarette smoking on vitamin C, glutathione and lipid peroxidation status

    Indian Journal of Public Health

    (1998)
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