Background In healthcare policy making reimbursement decisions are often made by using information from systematic reviews on the effectiveness of interventions. Since 2011 policy makers decided to not reimburse physiotherapy in Dutch persons with chronic arthritis anymore due to low evidence of beneficial effects. To date, several systematic reviews on effectiveness of physiotherapy in chronic arthritis, showed inconclusive results based on the methodological quality of RCTs. Improving methodological quality will only partially solve this inconclusiveness. Also, the quality of the intervention is important to consider when evaluating the quality and strength of evidence on the effectiveness of exercise therapy.
Objectives The purpose was to conduct a systematic review to evaluate therapeutic validity and methodological quality (risk of bias) of physiotherapy interventions on functional status, participation, and quality of life of people with chronic arthritis.
Methods A search was conducted in four databases to identify RCTs on the effect of supervised physiotherapy interventions for people with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and juvenile idiopathic arthritis (JIA). Outcome measures included functional status, participation, and/or quality of life. Two reviewers extracted data, and assessed therapeutic validity and the risk of bias. Therapeutic validity was assessed with a nine-itemed, expert-based rating scale (scores range from 0 to 9; score ≥6 reflecting good validity). Risk of bias was assessed by the Pedro scale (scores range from 0-10; score ≥6 reflecting low risk of bias). The degree of evidence was determined using the GRADE method.
Results Of the 1181 articles retrieved, 26 articles were included and described a total of 25 interventions (16 RA, 6 AS, 2 JIA). Only two studies demonstrated good therapeutic quality, and 14 showed low risk of bias. Low quality evidence suggests that therapeutic exercise has beneficial effects on short-term physical functioning for individuals with RA. For AS, low quality evidence suggests that therapeutic exercise has a short and long term beneficial effect on self-reported functional status. For JIA, insufficient evidence is available, despite the only one study with good therapeutic validity and good methodological quality. Even though all studies aimed to improve the functional status of people with chronic arthritis, only few studies specifically included individuals who were functionally impaired. Moreover, therapeutic validity domains like therapy monitoring, adequate dosing, and personalization and contextualization were hardly addressed in the programs.
Conclusions The few available studies on physiotherapy interventions for chronic arthritis demonstrated low evidence for beneficial effects on functional status and no effects on quality of life. None of the studies included participation. However, poor therapeutic validity of the interventions may have hampered potentially beneficial effects, since only two of the studies met the predetermined quality criteria. We therefore make an appeal to the international organization of applied researchers in the field of rheumatology to develop good quality physiotherapy interventions. Therapeutic validity should be taken into account to improve the quality of studies evaluating physiotherapy interventions for people with chronic arthritis.
Acknowledgements The authors thank Dr. Els van den Ende for her useful comments.
Disclosure of Interest None declared