- Top of page
- PATIENTS AND METHODS
- 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.
- Top of page
- PATIENTS AND METHODS
- 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.