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. 2021 Winter;73(1):56–65. doi: 10.3138/ptc-2019-0037

Joint Protection Programmes for People with Osteoarthritis and Rheumatoid Arthritis of the Hand: An Overview of Systematic Reviews

Pavlos Bobos *,†, Joy C MacDermid ‡,§,, Goris Nazari *, Emily A Lalone **, Louis Ferreira §, Ruby Grewal §
PMCID: PMC8774950  PMID: 35110824

Abstract

Purpose: Joint protection has been introduced as a self-management strategy for people with rheumatoid arthritis (RA) and osteoarthritis (OA) of the hand. The purpose of this study was to conduct an overview of systematic reviews (SRs) and critically appraise the evidence to establish the current effectiveness of joint protection for people with hand RA and OA. Method: A comprehensive search was conducted of six databases from January 2008 to May 2018. SRs that evaluated the effectiveness of joint protection for people with hand arthritis were eligible for inclusion. The A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 checklist was used to assess the methodological quality of each SR. Results: Nine SRs were included: two were rated as high quality, and seven were rated as low quality. Seven of the nine did not take into account risk of bias when interpreting or discussing their findings, six did not assess publication bias, and five did not register their protocol. The high-quality reviews found no clinically important benefit of joint protection for pain, hand function, and grip strength levels. The low-quality reviews reported improvements in function, pain, grip strength, fatigue, depression, self-efficacy, joint protection behaviours, and disease symptoms in people with RA. Conclusions: High-quality evidence from high-quality reviews found a lack of any clinically important benefit of joint protection programmes for pain, hand function, and grip strength outcomes, whereas low-quality evidence from low-quality reviews found improvements in these outcomes.

Key Words: arthritis, hand, joint protection, osteoarthritis, systematic reviews as topic

Clinical manifestations of rheumatoid arthritis (RA) can be unpredictable, but pain, disability, fatigue, joint deformities, and poor quality of life are common features.1 Although medications such as biological agents and drugs are increasingly effective,1,2 arthritis currently has no cure. Conservative management aims to prevent or control joint deformities, reduce pain and swelling, increase hand function, and improve quality of life.3 Numerous studies investigating various hand pathologies have demonstrated that hand function is an important factor.4–8 Joint protection was first introduced in the 1960s as a self-management strategy for people with RA, and the indications were later extended to other arthritic conditions, such as hand osteoarthritis (OA) and soft-tissue rheumatic disorders.9 Joint protection consists of a wide range of strategies such as education for strengthening or stretching exercises, joint protection education for activity and pacing, use of proper body mechanics, and assistive devices to improve pain, reduce inflammation, lower additional risk of deformities, and enhance performance.9,10

Systematic reviews (SRs) are a recognized approach to synthesizing research evidence on the effectiveness of therapeutic interventions.11 Because the number of SRs is rapidly increasing, there is a need to summarize the evidence and inform health care professionals about conflicting or inconsistent evidence. Although the aim of these SRs in facilitating evidence-based practice is commendable, poor-quality SRs may contain significant bias that can mislead readers. An overview of SRs can summarize a large body of evidence and identify conflicting or inconsistent results and the potential reasons for them. For example, a 2007 overview that examined non-pharmacological and non-surgical joint protection interventions for people with hand RA reported high-quality evidence for a positive effect on function and no difference in pain.12 A subsequent overview in 2009 that examined non-pharmacological and non-surgical interventions for people with hand OA found insufficient high-quality evidence for these types of intervention.13 Still another overview published in 2014 that examined the effectiveness of occupational therapy interventions for adults with RA found that the evidence to support the use of joint protection was sufficient.14

These overviews had some limitations that justify the need to conduct another overview of SRs. The first limitation is that those reviews are outdated because they are based on SRs that were published between 2000 to 2013. The second relates to how the SRs were evaluated. Ekelman and colleagues based their quality assessment on guidelines that had been described by Stern,14,15 and they categorized the included SRs according to the levels of evidence for SRs established by the Oxford Centre for Evidence-Based Medicine in 2009.16 Although SRs and randomized controlled trials (RCTs) are considered high-quality evidence in that categorization, this way of rating methodological quality is imprecise because it does not consider how an SR or RCT was conducted. Christie and colleagues assessed the quality of SRs using a nine-item checklist that had been developed from Oxman and Guyatt in 1991.12,17 Moe and colleagues assessed the methodological quality of the first version of the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) checklist.13 Although these instruments do assess SR methods, they have been superseded by tools that more thoroughly consider risk of bias.12,13

Therefore, we set out to conduct an overview of SRs to establish the current state of evidence evaluating the effectiveness of joint protection for people with hand RA and OA.

Methods

Study design

We followed a standard methodology for overviews.18–21 This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration No. CRD42018094725).

Eligibility criteria

We included SRs of RCTs in our overview if they met the following criteria:

  • Population: patients with hand RA and hand OA

  • Interventions: joint protection programme with other treatments or joint protection alone

  • Comparison: other treatment or no treatment

  • Outcomes: pain, function, and grip and pinch strength.

Search strategy

A search for SRs that had been published between January 2008 and May 2018 was conducted on May 15, 2018, in the following databases with no language restriction set: MEDLINE, Embase, CINAHL, Cochrane Library, Physiotherapy Evidence Database (PEDro), and Latin American and Caribbean Health Sciences Literature (LILACS). The search strategy was designed to locate SRs that addressed the effectiveness of joint protection programmes on pain, function, and grip and pinch strength in patients with hand RA and hand OA. In addition, the PROSPERO database was searched to identify ongoing studies of joint protection. Reference lists of included studies were searched to identify and retrieve other eligible SRs. Our search strategy, which includes words and Boolean operators, is summarized in the Appendix.

Study selection

Two independent reviewers (PB and GN) screened relevant titles and abstracts. Relevant studies (SRs) were then screened at full-text review and included if the following criteria were met: (1) SR of the effectiveness of joint protection programmes (defined by Hammond9) plus other treatments or joint protection programmes compared with other treatment or no treatment; (2) studied population included patients with hand RA or hand OA; and (3) SR of RCTs. Studies were excluded if they (1) were narrative, critical, or scoping reviews; (2) were not written in English; or (3) described joint protection not as a whole intervention but only in part (e.g., assistive devices only).

Quality assessment

Three reviewers (PB, GN, and EAL) independently applied the AMSTAR 2 risk-of-bias tool to assess the risk of bias of each SR.22 Disagreements on the AMSTAR 2 rating were resolved by consensus with the help from a fourth reviewer (JCM) if needed. AMSTAR 2 is composed of 16 items and has adequate interrater reliability for measuring the risk of bias of SRs and for rating overall confidence in the results of an SR.22 For each SR, we considered the 16 items included on the AMSTAR 2 checklist along with the checklist guidelines and scored the SR as “yes,” “partial yes,” “no,” or, for some domains, “not applicable.” The AMSTAR 2 rating is based not on an overall score but on identification of the following critical domains:

  • Protocol registered before commencement of the review (Item 2)

  • Adequacy of the literature search (Item 4)

  • Justification for excluding individual studies (Item 7)

  • Review includes risk of bias of individual studies (Item 9)

  • Appropriateness of meta-analytical methods (Item 11)

  • Consideration of risk of bias when interpreting the results of the review (Item 13)

  • Assessment of presence and likely impact of publication bias (Item 15).

The overall AMSTAR 2 rating of confidence are as follow:22

  • High – no or one non-critical weakness: the SR provides an accurate and comprehensive summary of the results of the available studies that addresses the question of interest.

  • Moderate – more than one non-critical weakness: the SR has more than one weakness but no critical flaws. It may provide an accurate summary of the results of the available studies that were included in the SR.

  • Low – one critical flaw with or without non-critical weaknesses: the SR has a critical flaw and may not provide an accurate and comprehensive summary of the available studies that address the question of interest.

  • Critically low – more than one critical flaw with or without non-critical weaknesses: the SR has more than one critical flaw and should not be relied on to provide an accurate and comprehensive summary of the available studies.

Data extraction

Two review authors (PB and JCM) were trained and calibrated on the use of the data extraction form. Data extraction was performed by one author (PB) and checked by a second (JCM). The following descriptive characteristics were extracted from the eligible SRs: (1) author and year, (2) number of primary studies, (3) population, (4) risk-of-bias assessment, (5) quality-of-evidence assessment, (6) outcomes reported in the SR, and (7) conclusions drawn by the authors of the SR.

Data analysis and synthesis

A qualitative synthesis was conducted to summarize the findings across the multiple SRs. We synthesized the results on the basis of quality of evidence and on the populations studied. The risk of bias and the quality assessment of primary studies were extracted as reported in the included SRs. Rather than re-scoring the data from the primary studies included in each SR, we relied on the judgment and reporting of the SR authors.

Results

Selection process

Our literature search identified 14 SRs for a full-text review. Of these, 4 were excluded because they evaluated the effect of hand exercises,23,24 splints,25 or Web-based multi-modal interventions with no mention of joint protection.26 One SR was excluded because it did not include any study that had evaluated joint protection as an intervention or control.27 Overall, nine SRs met our inclusion criteria and were included in our analysis. A summary of the selection process is presented in Figure 1.

Figure 1 .

Figure 1

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Flow diagram showing the selection process.

Characteristics of the included systematic reviews

Five reviews evaluated the effectiveness of joint protection for people with hand OA,28–32 and three evaluated its effectiveness for people with hand RA;33–35 one review (Bobos and colleagues36) included studies for both hand OA and RA. Risk of bias was evaluated in six reviews: five used the Cochrane risk-of-bias tool,29,30,33,34,36 and one used a list recommended by VanTulder and colleagues.35,37 Quality of evidence was assessed in six reviews: two using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines,29,36 one using the Jadad scoring checklist,28 one using the PEDro scale,31 one using the Structured Effectiveness for Quality Evaluation Scale (SEQES) and levels of evidence,32 and one using a list recommended by VanTulder and colleagues.35,37 One review rated the evidence as strong, moderate, mixed, or limited on the basis of consistent or conflicting results from the RCTs,33 and Carandang and colleagues rated the evidence as low, unknown, or high quality to reflect the language used in the quality assessment (i.e., high risk, unknown risk, and low risk of bias).34 Six reviews assessed pain levels and function,29,30,32,33,35,36 four reviews examined grip strength as an outcome of interest,29,31,32,36,38 and two reviews assessed behavioural change.33,34 The characteristics of the included reviews are summarized and presented in Table 1.

Table 1 .

Characteristics of the Included Systematic Reviews

Author Population No. of studies of joint protection included Risk-of-bias tool Quality of evidence Reported outcomes for joint protection
Bobos et al.36 OA and RA 14 for RA, 3 for OA Cochrane GRADE Pain, function, grip strength
Siegel et al.33 RA 5 Cochrane Evidence was considered strong, moderate, mixed, and limited on the basis of consistent or conflicting results from RCTs Function, pain, fatigue, depression, self-efficacy, behaviour
Lue et al.28 OA 2 Not assessed Jadad’s scoring checklist (0–5) Unclear
Østerås et al.29 OA 1 Cochrane GRADE Pain, hand function, grip and pinch strength
Carandang et al.34 RA 3 Cochrane Low, unknown, and high quality; adapted to reflect the language used in the quality assessment (e.g., high risk, unknown risk, low risk of bias) Behavioural change
Aebischer et al.30 OA 1 Cochrane Unclear Pain, function
Ye et al.31 OA 1 Not assessed PEDro scale Grip strength, hand function
Valdes & Marik32 OA 1 Not assessed SEQES and LOE HAQ; VAS for pain and hand function; grip strength
Steultjens et al.35 RA 4 List recommended by VanTulder et al.37 Methodological quality of RCTs and CCTs rated using a list recommended by VanTulder et al.37 Pain, functional ability, knowledge
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OA = osteoarthritis; RA = rheumatoid arthritis; GRADE = Grading of Recommendations Assessment, Development and Evaluation; RCT = randomized controlled trial; PEDro = Physiotherapy Evidence Database scale; SEQES = Structured Effectiveness for Quality Evaluation of Study; LOE = levels of evidence; HAQ = health assessment questionnaire; VAS = visual analog scale; CCT = controlled clinical trials.

Description of joint protection programmes

Most joint protection programmes used guidelines that included an educational component that addressed disease and symptom severity (RA or OA) and techniques to influence behavioural change such as energy conservation, coping skills for pain management, assistive devices, and the use of large joints.36 Interventions included on average three to four 2-hour, face-to-face interventions and home programmes.33,36 In the majority of studies, an occupational or physical therapist was primarily responsible for delivering the programmes.36

Quality assessment

Two SRs29,36 were rated as high quality, seven as low quality.28,30–35 Regarding the critical domains of AMSTAR 2, five reviews did not perform a priori registration,28,31–34 two did not perform a comprehensive search,32,34 and three partially met the comprehensive search criterion.28,30,33 Three reviews did not provide justification for excluding studies,28,30,31 and four did not use a satisfactory technique to assess the risk of bias of the primary studies.30–32,35 Seven reviews did not take into account the risk-of-bias assessment in their interpretation or discussion,28,30–35 and six reviews28,30–34 did not assess publication bias of the included studies. The summary of AMSTAR 2 ratings is presented in Table 2.

Table 2 .

AMSTAR 2 Rating

Question Bobos et al.36 Siegel et al.33 Lue et al.28 Østerås et al.29 Carandang et al.34 Aebischer et al.30 Ye et al.31 Valdes & Marik32 Steultjens et al.35
1. Research question and inclusion criteria aligned with PICO + ?
No outcomes, comparator		 – + + ?
No comparator		 – + +
2. A priori protocol used* + – – + – + – – +
3. Study design selection explained + + + + + + + + +
4. Comprehensive search carried out* ?
Did not justify language restriction		 ?
Did not justify language restriction		 ?
Did not justify language restriction		 + – ?
Did not justify language restriction		 + – +
5. Duplicate study selection used + + + + + + + – +
6. Duplicate data extraction used + + + + + + – + +
7. List of excluded studies included, with justification* + + ?
No list of excluded studies		 + + ?
No list of excluded studies		 ?
No list of excluded studies		 – +
8. Included studies described in adequate detail + ?
No outcomes, comparator		 + + + + + + +
9. Satisfactory technique used for assessing risk of bias* + – ?
Lack of blinding		 + + – – – –
10. Sources of funding of included studies reported in review + – – + – – – – +
11. If meta-analysis, combination of data justified + N/A N/A + N/A + N/A N/A +
12. If meta-analysis, risk of bias of included studies taken into account + N/A N/A + N/A – N/A N/A –
13. Risk of bias taken into account in interpretation and discussion* + – – + – – – – –
14. Satisfactory explanation given for any heterogeneity + N/A N/A + N/A + N/A N/A –
15. Publication bias in included studies assessed* + – – + – – – – +
16. Review authors reported on any of their own conflicts of interest + – + + – + + + +
Overall quality High Low Low High Low Low Low Low Low
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*

Indicates a critical domain.

AMSTAR 2 = A MeaSurement Tool to Assess systematic Reviews; - = no; + = yes; ? = partial yes; N/A = not applicable; PICO = Patient Intervention Comparator Outcome.

Findings from high-quality reviews for hand osteoarthritis and rheumatoid arthritis

Two high-quality SRs reported the effects of joint protection versus usual care or control and hand exercises versus joint protection for pain, hand function, and grip strength outcomes for patients with hand RA and OA.29,36

The review by Bobos and colleagues reported results from 14 RCTs for people with hand RA and three RCTs for people with hand OA for pain, grip strength, and hand function.36 This review found very-low- to low-quality evidence (according to GRADE guidelines) that, compared with usual care or control, the effects of joint protection programmes on pain and hand function for people with hand arthritis are too small to be clinically important at short-, intermediate- and long-term follow-up. Pain levels were quantified by pooling the results from five low-quality primary studies for the short, mid-, and long term for people with hand RA. Pooling the results indicated that joint protection is no better than usual care or control at short-term follow-up (3–4 mo). For the mid- (6 mo) and long term (12 mo), joint protection was favored over usual care or control but did not exceed the cutoff scores for minimal clinically important difference. For hand function, joint protection was favored over usual care or control with small effects at mid- and long-term follow-up.

The Cochrane review by Østerås and colleagues29 reported the effects of hand exercise versus no exercise (joint protection) for patients with hand OA from one study. The overall estimate effect was in favor of hand exercises for the short, mid-, and long term for hand pain and function and for grip and pinch strength. No specific recommendation was made for joint protection, only for hand exercises.

Findings from low-quality systematic reviews for hand osteoarthritis

Four SRs summarized findings of reported outcomes for pain, hand function, and grip strength for people with hand OA.28,30–32 Lue and colleagues reported the results from two high-quality RCTs (Jadad score > 3) for people with hand OA.28 This review did not report the effect on outcomes specifically for joint protection studies but concluded that joint protection was conditionally recommended. Aebischer and colleagues reported findings from one RCT (risk of bias not reported) for pain and function and found that joint protection improved solely pain, not function.30 Ye and colleagues reported findings from one high-quality RCT (PEDro scale > 6) and found that joint protection improved grip strength and hand function.31 Valdes and Marik32 reported findings from one high-quality RCT (SEQES scores for quality of research ) and found that the evidence to support joint protection for increased hand function was moderate.

Findings from low-quality reviews for hand rheumatoid arthritis

Three SRs provided summarized findings on reported outcomes of function, pain, fatigue, depression, self-efficacy, behavioural change, and knowledge.33–35 Siegel and colleagues reported the results from five high risk-of-bias RCTs and found strong evidence to support the use of psychoeducational interventions (joint protection) to improve function, pain, fatigue, depression, self-efficacy, and disease symptoms in people with RA.33 Carandang and colleagues reported findings from three RCTs (one with low risk of bias, two with high risk of bias) and found that the evidence for joint protection and energy conservation interventions to improve joint protection behaviours was moderate.34 Stueultjens and colleagues reported findings from four RCTs and found strong evidence to support the efficacy of joint protection.35

Discussion

Our overview shows that the majority of the evidence supporting the effects of joint protection for patients with hand arthritis is of low quality. The summarized findings from the high-quality reviews indicate that, when compared with usual care or control, joint protection does not improve pain by a clinically important amount at 6- and 12-month follow-up. Joint protection was superior to usual care or control in improving hand function but did not exceed the predefined cutoff scores. The majority of the included SRs had very poor overall methodological quality in the critical domains of AMSTAR 2. Seven of the nine reviews did not take risk of bias into account in the interpretation and discussion of findings, six reviews did not assess publication bias, and five reviews did not register their protocol. Another important finding is that differences in the risk-of-bias and quality assessment tools seemed to affect the SRs’ overall recommendations (Table 3).

Table 3 .

Summary of Recommendations Made for Joint Protection in Each Systematic Review

Author (Year) Quality of evidence Recommendations
Bobos et al.36 High Very-low- to low-quality evidence that the effects of joint protection programmes compared with usual care or control on pain and hand function are too small to be clinically important at short-, intermediate- and long-term follow-ups for people with hand arthritis
Siegel et al.33 Low Strong evidence to support the use of physical activity and psychoeducational interventions (joint protection) to improve function, pain, fatigue, depression, self-efficacy, and disease symptoms in people with RA
Lue et al.28 Low Joint protection conditionally recommended
Østerås et al.29 High No specific recommendation made for joint protection, only for hand exercises
Carandang et al.34 Low Moderate evidence for joint protection and energy conservation interventions improving joint protection behaviours
Aebischer et al.30 Low Main finding: moderate to high evidence that multimodal physiotherapy and occupational therapy–related interventions have beneficial effects on pain; no statistical evidence for improvement of function, only narrative; joint protection improved pain but not function
Ye et al.31 Low Evidence suggests that programmes of joint protection, advice, and home exercises are effective at improving grip strength and hand function
Valdes & Marik32 Low Moderate evidence to support joint protection education and providing adaptive equipment to increase hand function and reduce pain
Steultjens et al.35 Low Results of best-evidence synthesis show that there is strong evidence for the efficacy of instruction on joint protection (an absolute benefit of 17.5 to 22.5, relative benefit of 100%)
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RA = rheumatoid arthritis.

Seven of the nine SRs were rated as low quality, and the majority of the included SRs did not follow the recommended Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.39 Six of the nine SRs were published between 2015 and 2018, and only two followed the PRISMA guidelines. Not following these predefined guidelines may diminish the usefulness of the results when they are interpreted by clinicians or policymakers. It is important to note that low-quality evidence implies not that joint protection has no effect but that the high-quality evidence is insufficient to draw definite conclusions.

Our included SRs used a variety of risk-of-bias and quality assessment tools. The authors of the included reviews seemed to lack an understanding of what constitutes risk-of-bias and quality assessment. Authors have at their disposal a wide variety of tools to critically appraise and synthesize evidence, and which one they use is a matter of personal preference. However, the methodological quality of the included reviews may have a very important effect on estimates of the results and may affect the validity of the authors’ conclusions.40 For instance, a primary study (RCT) that had been rated with four separate approaches was reported as being high quality when using the PEDro scale, high quality when using SEQES, high risk when using only the Cochrane risk-of-bias tool, and very low quality when using the Cochrane risk-of-bias tool and the GRADE approach combined.

This overview had several limitations that need to be taken into account when interpreting our findings. First, the included SRs did not differ significantly in their eligibility criteria.20 Second, they did not clearly report potential harms. Third, there was minor overlap among the primary studies, although this is common for reviews.19,20,28 Next, we focused on SRs of RCTs and did not include SRs that included other study designs (i.e., prospective or retrospective observational designs), and it is possible that such inclusion criteria could lead to publication bias. However, our objective was to summarize the highest level of evidence available.

Conclusion

This overview provided high-quality evidence (AMSTAR 2) from two SRs that, compared with usual care or control, the effects of joint protection programmes on pain and hand function are too small to be clinically important at short-, intermediate- and long-term follow-up. It is important to note that the primary studies included in these SRs were graded as very-low-quality to low-quality evidence.

Key Messages

What is already known on this topic

Several systematic reviews (SRs) have been published on the effectiveness of joint protection programmes for patients with osteoarthritis or rheumatoid arthritis of the hand, but the quality of the evidence synthesized by these SRs varies.

What this study adds

Our review shows that the majority of the current evidence from systematic reviews that supports the effects of joint protection for patients with osteoarthritis or rheumatoid arthritis of the hand is of low quality. The summarized findings from the high-quality reviews indicate that, when compared with usual care or control, joint protection does not improve pain by a clinically important amount at 6- and 12-month follow-up.

APPENDIX: Search Strategy using Medline Ovid

No. Search(es)
1 osteoarthritis/
2 (arthritides or “degenerative arthritisor degenerative arthritides” or “degenerative arthritis” or “osteoarthritides” or “osteoarthritis” or “osteoarthroses” or “osteoarthrosis” or osteoarthrosis deformans).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
3 arthritis, rheumatoid/
4 “systematic review”/
5 (“systematic review” or systematic reviews as topic).pt.
6 (“systematic review*” or “systematic literature review” or “systematic scoping review” or “systematic narrative review” or “systematic qualitative review” or “systematic evidence review” or “systematic quantitative review” or “systematic meta-review”).ti. or “systematic critical review”.mp. or “systematic mixed studies review”.ti. or “systematic mapping review”.ti. or “systematic cochrane review”.ti. or “systematic search and review”.ti. or “systematic integrative review”.ti. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
7 or/4–6†
8 1 and 5
9 1 and 6
10 3 and 6
11 2 and 5
12 3 and 5
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*

In OvidSP, the main truncation symbol is an asterisk for any number of letters (e.g. “review*” for reviews)

†

Systematic review filter terms, adapted from PubMed.

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