These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Rheumatoid arthritis: national clinical guideline for management and treatment in adults [National Collaborating Centre for Chronic Conditions, 2009; NICE, 2009], and the British Society for Rheumatology and British Health Professionals in Rheumatology guidelines for the management of rheumatoid arthritis [Luqmani et al, 2006; Luqmani et al, 2009].

Multidisciplinary team work

• NICE reviewed good quality evidence (five randomized controlled trial [RCTs] and three case series) on the effectiveness of multidisciplinary team work in RA and concluded that there is a lack of evidence to show whether or not there is any benefit in the long term. NICE recognized that a multidisciplinary approach addresses issues beyond the purely medical problems, and complements the skills of the rheumatologist.

Physiotherapy

• NICE reviewed good quality evidence (five systematic reviews/meta-analyses and 17 RCTs) for the effectiveness of physiotherapy in RA and concluded that exercise (aerobic, joint flexibility, muscle strength) improves fitness, enhances psychological status, reduces pain and fatigue, and has a positive effect on functional capacity, without exacerbating RA or accelerating joint damage.

Occupational therapy

• NICE reviewed the evidence (two meta-analyses and five RCTs) on psychological interventions, or splints and orthoses, in RA and concluded:
• There was limited evidence of benefit for hand splints, although NICE recognized that many people find them beneficial.
• There was good evidence that psychological interventions (for example, relaxation, stress management, and cognitive coping skills) have a beneficial impact on pain and functional ability, and that stress reduction techniques and cognitive behavioural therapy could improve some aspects of psychological status.

Complications and comorbidities

• The inflammatory processes of RA can directly or indirectly affect most organs in the body, and result in premature death.
• Cardiovascular disease accounts for about half of all deaths in RA [van Doornum et al, 2002]. The risks of cardiovascular morbidity and mortality are approximately double those of the rest of the population.

Self-care advice and education

• NICE reviewed the evidence from observational and qualitative studies and concluded that people with RA felt that many issues (such as pain and fatigue, depression, sexual relationships, mobility, and inability to work or undertake activities) were not satisfactorily addressed, and they wanted more involvement in the management of their disease.
• A Cochrane systematic review and meta-analysis (31 RCTs) suggested that education had small, short-term effects on disability, psychological status, and depression. There was no evidence of long-term benefits or cost-effectiveness. However, due to the clear desire for education, NICE stated that a range of activities should be made available to people with RA until further research highlights the most appropriate educational methods.

Diet

• NICE reviewed the evidence (three meta-analyses and 14 RCTs) on diet and dietary supplements in RA and concluded there was no consistent evidence of benefit (in terms of symptoms, joint damage, or function and quality of life) of any one particular diet.
• NICE concluded that the principles of a Mediterranean diet should be highlighted if the person wishes to modify their diet, as people with RA are at an increased risk of cardiovascular disease compared with the general population.