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Keywords:

  • Nonpharmacologic treatment;
  • Rheumatoid arthritis;
  • Osteoarthritis;
  • Treatment utilization;
  • Survey

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information

Objective

To examine the use of nonpharmacologic treatment by patients with osteoarthritis (OA) and rheumatoid arthritis (RA).

Methods

Patients were recruited from physicians' offices in Ontario, Canada. All participants completed questionnaires that asked about their health status, use of medications and nonpharmacologic treatments, and use of health care resources.

Results

A total of 326 patients with OA and 253 patients with RA completed the survey on the use of nonpharmacologic treatment. Only 73% of patients with OA had been told to use nonpharmacologic modalities, but 98.8% had tried at least 1 type of treatment. About 97% of those with RA had been told to use and had tried at least 1 type of treatment. Most patients continued to use a treatment once they had tried it.

Conclusion

The use of nonpharmacologic modalities is common among patients with arthritis. It is important that clinicians address with their patients the appropriate use of and barriers to continuing these treatments.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information

Recent updates of guidelines for the management of osteoarthritis (OA) and rheumatoid arthritis (RA) emphasize the use of nonpharmacologic modalities in addition to the use of pharmacologic agents (1, 2). Traditionally, nonpharmacologic modalities involve treatments provided by physical and occupational therapists. These include exercise, patient education, thermotherapy (i.e., application of ice and heat), electrotherapy, proper footwear, foot orthoses, splints, braces, aids for ambulation, and assistive devices for activities of daily living (ADL) (3–8).

Although much has been written about the roles of nonpharmacologic modalities for managing OA and RA, limited information is available on how often these treatments are recommended and used by patients. A literature search using Medline (1999–2003) was conducted by mapping the following terms with article titles, abstracts, and medical subject heading terms: “arthritis,” “non-pharmacologic,” “non-pharmacologic treatment,” “non-drug,” “physical modalities,” and “survey.” The term “arthritis” was then combined with the remaining ones. Of the 433 citations retrieved by this search strategy, only 6 presented utilization data on nonpharmacologic modalities (9–14). All except 2 (10, 14) were from the physicians' perspective (see Appendix A, available at the Arthritis Care & Research Web site at http:/www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html).

The reported use of nonpharmacologic treatments varied among the published studies. This might be due to the difference in participating physicians' medical specialties, their perceptions on the effectiveness of different types of nonpharmacologic modalities, and the accessibility of treatment in different geographic locations. Also, the lack of consistency in the definition of the state of arthritis in the surveys might have affected physicians' decisions. For example, although “early” and “late” presentations of RA were used by Glazier et al (11), Rush and Shore (12) asked about treatment for “acute arthritis.”

There are also limitations in the prior studies. First, these survey data mainly reflect the recommendations by specialists and family physicians. Physicians who referred their patients to physical or occupational therapy might rely on the therapists for subsequent recommendation of treatments, such as exercise and thermal modalities. Hence, the use of nonpharmacologic treatments by patients might have been underestimated. Second, the relationship between physician's prescription and the actual use of treatments by patients is unclear. Some patients might not have followed the recommendations, whereas others might have tried treatments that had not been suggested by their physicians. Therefore, the use of data from physician surveys as a surrogate for patient utilization of treatment is questionable. Third, hypothetical cases were used in 1 of the surveys asking physicians about their prescribing patterns (11). It was possible that participants over- or underestimated what they would actually recommend in practice.

Finally, these studies addressed a narrow range of modalities, especially in the OA population. The use of braces, foot orthoses, and assitive devices for ADL by patients with OA is currently unclear.

To address these limitations, we conducted a survey with OA and RA patients in Ontario, Canada. The purpose of this study was threefold: 1) to determine the use of nonpharmacologic treatment by OA and RA patients who consulted their family physicians and rheumatologists, respectively; 2) to investigate the reasons for patients stopping a treatment; and 3) to investigate the factors associated with the use of nonpharmacologic modalities.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information

Patient recruitment.

Patients with OA or RA were recruited from medical practices in Ontario, Canada between May 1999 and May 2000 for the Community Hypertension and Arthritis Project (CHAP). We approached 1,936 family physicians and all rheumatologists in the area (n = 154) to participate in the study. The former sample was randomly selected from the Ontario database of College of Family Physicians of Canada (n = 4,510). Of the 123 family physicians who agreed to participate, 76 subsequently recruited patients with OA. Sixty-nine rheumatologists agreed to participate; of those, 53 recruited patients with RA.

Participants with OA were required to have a physician diagnosis of OA and be older than 55 years. Those with RA had to have a valid diagnosis according to the American College of Rheumatology (formerly American Rheumatism Association) diagnostic criteria of 1987 (15) and be older than 18 years. We excluded all patients with a joint replacement in the 3 months prior to the baseline interview. All patients were required to communicate in English and to provide consent. The study protocol was approved by the Research Ethics Board, University Health Network.

Data collection.

Patients with OA participated in telephone interviews at baseline and 3 months later. Two-thirds of the patients with RA were randomly assigned to complete the survey by telephone interview and the remaining one-third completed at least the baseline questionnaire by mail. The purpose of this arrangement was to evaluate the difference in response between the 2 modes of questionnaire administration; the findings will be published separately. At baseline we inquired about each patient's demographic characteristics, including age, sex, marital status, and educational attainment. We asked for the presence of 23 specific comorbid conditions and whether treatment was received in the year preceding the interview. Patient's use of mainstream nonpharmacologic treatment and complementary and alternative medicine was captured by the Allied Health Professional and Alternative Therapy (AHPAT) questionnaire. In addition, a battery of disease-specific and generic health status questionnaires, including the Health Assessment Questionnaire (HAQ), Short Form 36 (version 1), Western Ontario and McMaster Universities Osteoarthritis Index (OA group only), and Australian/Canadian Hand Index (AUSCAN) (OA group only), were administered at baseline and 3 months. Details of these results will be reported in a separate manuscript.

Definitions.

In this study, nonpharmacologic treatment was defined as treatment that had been commonly prescribed or specifically recommended by physicians, physical therapists, or occupational therapists but did not involve the use of drugs or surgical interventions. Some of these treatments, such as exercise (16) and patient education (17, 18), have shown evidence of benefits for the management of OA and RA. Others, including the use of heat and cold, have demonstrated limited benefits but have been recommended by guidelines for the management of OA (1).

Instrument.

The nonpharmacologic treatment portion of the AHPAT questionnaire consisted of 12 items. They included land exercise (i.e., exercise in home or group settings), pool exercise, the use of heat or ice, knee braces, foot orthoses, proper footwear, mobility aids, methods for managing body weight, patient education programs, energy conservation principles, and joint protection principles. The latter 2 were defined as pacing oneself while continuing with ADL and methods for avoiding excessive stress on the involved joints by modifying ways to perform ADL. Participants were asked if they had been told to use and if they had tried the treatment. For those who had tried a specific treatment, they were then asked if they were still using it. If not, they were asked to state the reasons for stopping the use. Finally, they were asked about any other nonpharmacologic treatments for OA or RA that they had used in the past or that they were using currently. Content inclusiveness of the questionnaire was examined by 3 physical therapists and 2 occupational therapists practicing in the rheumatology field.

Statistical analysis.

Descriptive analyses, based on frequency distributions and percentages, were employed to describe the use of and the advice received by patients regarding each type of nonpharmacologic modality. The reasons for discontinuing a treatment were coded by 1 of the investigators (LCL). For the first 20 interviews, the coder performed open coding, and subsequently, created a coding scheme. The codes were then placed into broad categories that were summarized by the frequency of occurrences.

Patients' socioeconomic characteristics and health status might have an effect on their use of nonpharmacologic treatments (19, 20). For this reason, associations between the use of nonpharmacologic modalities and the following patient demographic characteristics were examined using Spearman's correlation: diagnosis (RA = 1, OA = 0), sex (female = 1, male = 0), age, employment status (employed full time, part-time, or casual = 1, not employed or retired = 0), family income (Can $20,001 to >$80,000 = 1, <$6,000 to $20,000 = 0), disease duration, obesity (body mass index [BMI] ≥27 = 1, BMI <27 = 0], and HAQ score at baseline (range 0–3; 0 = best, 3 = worst]. The nonpharmagologic modalities were grouped into 7 categories: exercise in the home or group setting or in a pool program; thermal modalities; assistive devices; equipment assisting in walking, including knee braces and taping, supportive footwear, foot orthoses, or walking aids; methods for weight management; energy conservation or joint protection techniques; and patient education programs. Independent variables significantly associated with the use of a group of nonpharmacolgoic modalities (P < 0.05) were then entered into logistic regression analyses. The variables that remained significant (P < 0.05) in the logistic regression analyses constituted the final multivariable models.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information

Recruitment.

A total of 386 patients with OA were referred to the CHAP, 35 did not meet eligibility criteria, 3 declined participation, and 2 could not be contacted. Of the 346 eligible participants, 331 (95.7%) completed the interviews. Among the 292 patients with RA who volunteered for the study, 20 were ineligible or could not be contacted. Of the 272 eligible patients, 19 dropped out after the baseline interview and 253 (93.0%) completed the entire survey.

Demographic characteristics.

The average ± SD age of the patients with OA was 70.4 ± 8.1 years, compared with 57.0 ± 13.4 years in the RA group. The RA group consisted of a higher percentage of women (n = 202, 79.8%) and those who were employed (n = 104, 41.1%) compared with the OA group (72.8% women, 15.1% employed). About 70% of patients from either group reported family income higher than $20,000. Patients with RA tended to be more disabled (HAQ score = 1.2 ± 0.7 compared with 0.9 ± 0.6 in OA), scored worse in the patient global rating of general health (3.8 ± 1.2 compared with 2.9 ± 1.0 in OA), and had a lower BMI (26.1 ± 5.2, compared with 28.1 ± 5.3 in OA). Both groups had a median of 2 comorbid conditions that required treatment in the previous year (see Appendix B, available at the Arthritis Care & Research Web site at http://www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html).

Use of nonpharmacologic treatments.

A total of 326 patients with OA and all 253 patients with RA completed the questions on their use of mainstream nonpharmacologic treatments (Table 1). Of the patients with OA, 73% had been told to use at least 1 type of nonpharmacologic modality, but 98.8% reported they had tried at least 1 type. About 97% of those with RA had been told to use and had tried at least 1 type of nonpharmacologic treatment.

Table 1. Use of nonpharmacologic modalities by patients with osteoarthritis and rheumatoid arthritis
 Osteoarthritis n = 326Rheumatoid arthritis n = 253
Had been told to use treatment %Had tried treatment %Had been told to use treatment %Had tried treatment %
  • *

    Number of patients queried on these items was 252.

  • Number of patients queried on this item was 250.

At least 1 of the following72.798.896.897.6
Exercise at home or in a group33.473.075.183
Pool exercise12.615.357.754.9
Hot pack or ice pack for pain25.268.779.4*83.3
Knee brace or taping11.011.717.219.6
Supportive walking shoes13.816.657.354.9
Foot orthosis21.824.561.5*60.3
Cane, crutches, or walker27.331.332.431.2
Adaptive devices13.839.937.537.2
Weight management31.334.725.033.7
Joint protection11.412.354.8*56.3
Energy conservation16.953.452.256.9
Education, such as Arthritis Self Management Program4.93.736.832.4

Exercise at home or in a group setting (33.4%) and weight management (31.3%) were the most often recommended treatments to patients with OA, whereas the use of heat or cold (79.4%) and exercise (75.1%) were the most often suggested to those with RA. Furthermore, >50% of the participants with RA had been told to try pool exercise programs, use supportive shoes and foot orthoses, and practice joint protection and energy conservation principles.

Only one-third of the OA group had been advised to try land exercise; 73% said they had tried it in the past. A similar trend was noticed in the use of heat or cold, use of assistive devices, and the practice of energy conservation principles, in which more than twice the number of participants reported they had tried the treatment compared with the number of those who had been advised to try them. Among those with RA, >50% of participants had tried at least 1 of the following treatments: land or pool exercises, heat or cold, proper footwear, foot orthoses, joint protection, and energy conservation.

Reasons for stopping treatments.

A majority of patients who had tried a specific treatment said they were still using it at the time of the interview, with the exception of pool exercise (OA: 22 of 50 patients stopped; RA: 71 of 139 patients stopped). The most-cited reason for discontinuing pool exercise was the lack of access to programs. Some patients stated that their local pool programs were closed for the winter months, whereas others said there were no affordable pool programs close to their home. The common reasons for stopping land exercise were the lack of motivation and an increase in joint pain. Patients with arthritis tended to continue the use of thermal modalities, braces, foot orthoses, proper footwear, mobility aids, and assistive devices until they no longer needed the treatment. Among patients with OA who used methods for weight management, the most often cited reason for stopping was poor compliance (see Appendix C, available at the Arthritis Care & Research Web site at (see Appendix C, available at the Arthritis Care & Research Web site at http://www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html).

Factors associated with the use of nonpharmacologic treatments.

Overall, high level of disability, as indicated by a high HAQ score at baseline, and the presence of RA were predictive of the use of most categories of nonpharmacologic treatment (Table 2). These included thermal modalities (HAQ: odds ratio [OR] 2.96, 95% confidence interval [95% CI] 2.07–4.25; RA: OR 1.98, 95% CI 1.30–3.03), the use of equipment assisting in walking (HAQ: OR 3.21, 95% CI 2.24–4.60; RA: OR 1.99, 95% CI 1.32-003.00), and the participation in patient education programs (HAQ: OR 1.69, 95% CI 1.19–2.40; RA: OR 11.27, 95% CI 5.94–21.40).

Table 2. Significant predictors of nonpharmacologic treatment use*
Independent variablesAdjusted OR95% CIP
  • *

    OR = odds ratio; 95% CI = 95% confidence interval; RA = rheumatoid arthritis; HAQ = Health Assessment Questionnaire; BMI = body mass index.

  • Compared with patients with annual family income between <$6,000 and $20,000.

  • Compared with patients with osteoarthritis (OA).

  • §

    For the OA group, only those with a diagnosis of OA of the hip or knee were included in the analysis (n = 242). All patients in the RA group were included (n = 253).

Tried exercise at home, in a group, or in a pool   
 Annual family income $20,001–>$80,0002.741.70–4.41<0.01
 Diagnosis of RA2.31.42–3.71<0.01
Tried the application of hot pack or cold   
 Baseline HAQ disability index score (0 = best, 3 = worst)2.962.07–4.25<0.01
 Diagnosis of RA1.981.30–3.03<0.01
Tried using assistive devices   
 Baseline HAQ disability index score (0 = best, 3 = worst)4.363.16–6.03<0.01
 Age1.041.02–1.05<0.01
Tried using knee braces or taping, supportive footwear, foot orthosis, or walking aids§   
 Baseline HAQ disability index score (0 = best, 3 = worst)3.212.24–4.60<0.01
 Diagnosis of RA1.991.32–3.000.01
Tried methods for weight management   
 Obese (BMI ≥27)5.443.68–8.06<0.01
 Baseline HAQ disability index score (0 = best, 3 = worst)1.511.12–2.030.01
 Age0.980.97–1.000.03
Tried energy conservation and joint protection principles   
 Female2.541.68–3.86<0.01
 Baseline HAQ disability index score (0 = best, 3 = worst)2.211.63–3.01<0.01
Attended education classes   
 Diagnosis of RA11.275.94–21.40<0.01
 Baseline HAQ disability index score (0 = best, 3 = worst)1.691.19–2.40<0.01

The practice of land or pool exercise was significantly associated with moderate to high family income ($20,001 to >$80,000; OR 2.74, 95% CI 1.70–4.41) and a diagnosis of RA (OR 2.30, 95% CI 1.42–3.71). The use of assistive devices for ADL was significantly associated with high HAQ scores (OR 4.36, 95% CI 3.16–6.03) and age (OR 1.04, 95% CI 1.02–1.05). It might not be surprising to find that the practice of weight management was significantly associated with obesity (OR 5.44, 95% CI 3.68–8.06), high HAQ scores (OR 1.51, 95% CI 1.12–2.03), and age (OR 0.98, 95% CI 0.96–1.00). Female sex (OR 2.54, 95% CI 1.68–3.86) and high HAQ scores (OR 2.21, 95% CI 1.63–3.01) were predictive of the practice of energy conservation and joint protection principles.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information

To our knowledge, this study is the first to assess the use of a wide range of nonpharmacologic treatment from the perspective of patients with OA or RA. We found almost all participants had used at least 1 type of treatment, although only 73% of those with OA had been told to try a nonpharmacologic treatment. More than twice the number of patients with OA said they had tried exercising, using assistive devices, using thermal agents, and practicing energy conservation principles compared with the number of patients who had been told to try these treatments. Those who chose to try the treatment independently might not have consulted physicians or therapists about their use. Although some treatments could be carried out efficiently by patients with minimal instruction from health care professionals, other treatments, such as exercise (21) and the use of knee braces or foot orthoses, might require some guidance from a physical or occupational therapist to achieve therapeutic benefits. Therefore, patients should not only be informed about the use of nonpharmacologic treatments, but should also be referred to the appropriate rehabilitation professional if further instructions are required.

Another major finding of this study is that a majority of respondents continued to use a treatment once they had tried it regardless of their arthritis diagnosis. Adherence to land exercise did not appear to be a big issue among the participants. However, because we did not differentiate among flexibility exercise, strengthening exercise, and aerobic exercise in the question regarding land exercise, it is uncertain whether the rates of use and abandonment were the same among the categories. Despite the limited evidence supporting the efficacy of thermal modalities (22), knee braces or taping (23–25), and assistive or mobility devices (26), many participants stopped using the modalities because they were no longer required, and not due to poor effectiveness or adverse effects. It should be noted that studies that assessed the use of assistive devices were mainly done with elderly patients (i.e., age 70 years) regardless of their diagnoses (27–30). Hence, they focused mainly on the use of walking aids and self-care devices. The use of other equipment, such as devices for gripping and reaching, by patients with OA and RA had not been thoroughly explored. Although additional research is required to understand the value of these devices, patients should be provided with the opportunity to try them because they have a low risk of adverse effects and may be helpful.

Our estimated percentages of OA participants who had been told to try a nonpharmacologic modality were lower than those from the previous rheumatologist survey (9). Hochberg et al (9) found that 41% and 54% of the community-based rheumatologists “always or frequently” recommended exercise to patients with hip or knee OA, respectively. Furthermore, ∼80% of the rheumatologists said they “always” or “frequently” recommended weight reduction to their patients. In our study, only 35% of the patients said they had been advised to try land or pool exercise and 31% had been told to try methods for weight control. This might be due to the fact that our patient population was recruited from family physicians' offices and many of them had not seen a rheumatologist (76.8%). Patients who consulted a rheumatologist might have received different advice on nonpharmacologic treatment as compared with those who were treated by family physicians (10). It is, therefore, important to take into account the source of report on treatment use (i.e., patients, family physicians, or specialists) when interpreting treatment utilization data.

About 80% of our patients with RA had been advised to try land or pool exercise and to use thermal modalities. This percentage is substantially higher than that reported in the surveys of family physicians (11) and specialists (12). It should be noted that both studies were published in the mid-1990s and physicians' perceptions of the value of exercise and other nonpharmacologic modalities might have changed over the years. This speculation is supported by a recent survey of rheumatologists in Ontario, Canada, that found 95.6% of the respondents “strongly agreed” or “agreed” that exercise was effective in the management of RA (31). The differences in results might also be related to the different definitions of exercise, the time frame, and the disease severity used among studies. In this study, patients were asked if they were ever advised to try exercising, regardless of disease severity. We differentiated exercise as pool and land exercise, and the latter was defined as exercise in patients' homes or in a group setting. In contrast, Rush and Shore (12) asked about the use of “active” and “passive” exercise in patients with “acute arthritis,” and Glazier et al (11) asked about the use of exercise (with no specific definition) in “early” and “late” RA. These discrepancies might have contributed to the different findings.

Our regression analyses showed that patients' use of nonpharmacologic modalities was associated with a higher level of disability and a diagnosis of RA. Other factors that were significantly associated with the use of treatments include moderate to high family income (for exercise), higher age (for the use of assistive devices), obesity (for weight management), and being a woman (for energy conservation and joint protection principles). This study found that participants who had tried exercise were more likely to have higher family income and have a diagnosis of RA. It is possible that patients with low income might have limited resources for joining exercise programs, which often require a fee. However, financial barriers had not been explored in previous studies that examined determinants for patients to start or continue an exercise regime. Other factors that have been previously reported to have an influence on patients' decision to exercise include perceived benefits of exercise (32–34), perceived social support for exercise (33), willingness and ability to accommodate exercise regimens with everyday life, perceived severity of symptoms, and attitudes toward arthritis (35).

Another interesting finding is related to the use of education programs. Patients who attended education classes were highly associated with a diagnosis of RA (OR 11.27). This might be due to 2 reasons. First, patients with OA were found to receive less advice on education programs than their RA counterparts. We found 37% of patients with RA had been told to attend education classes, whereas only 5% of those with OA received the same advice. Reasons behind this discrepancy is unclear. However, Mazzuca et al (10) found a slightly higher percentage of patients with OA, who were medically managed by rheumatologists, had received formal instruction in self care compared with those who were managed by family physicians or general internists (3% each). Second, patients might have received information on the disease and its management during their visits with health professionals or from reading materials (36–38). These alternative methods for providing disease-specific information were not explored in this study. It should be noted that appropriate use of nonpharmacologic treatment could be enhanced through patient education (39). Hence, it should be regarded as a major component of OA and RA management.

There are some potential limitations of this survey. The observational design of this study does not permit identification of causal relationships. Hence, the degree to which factors associated with nonpharmacologic treatment use actually led to the use of treatment is uncertain. Some of the associations found to be statistically significant may represent chance or spurious relationships. Also, this study relied on patient self-reported data, which is an inherent limitation in most surveys examining chronic illnesses and treatment utilization. Information was obtained on whether patients had been told to try a treatment; however, we could not make a judgment on who provided the recommendation, nor on the quality of the advice. Hence, our findings should not be used to interpret the quality of care provided by physicians and rehabilitation health professionals.

This study contributes to our understanding of nonpharmacologic treatment use. Although medications are essential for the management of arthritis, clinicians should devote time to address the appropriate use of and barriers to continuing nonpharmacologic treatments with their patients. We believe that an exploration of the use of these modalities will improve both communication between patients and health care professionals, and the level of clinical care. As well, development of process measures, such as the effort undertaken by the Arthritis Foundation, will be valuable in understanding whether patients have received adequate advice regarding and have been provided with the appropriate nonpharmacologic treatment.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. Supporting Information
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suppmat_203.pdf28KSupporting Information file suppmat_203.pdf

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