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A tailored-guided internet-based cognitive-behavioral intervention for patients with rheumatoid arthritis as an adjunct to standard rheumatological care: results of a randomized controlled trial
Open accessAbstract
For patients with chronic pain conditions such as rheumatoid arthritis (RA), who experience elevated levels of distress, tailored-guided internet-based cognitive-behavioral treatment may be effective in improving psychological and physical functioning, and reducing the impact of RA on daily life. A multicenter, randomized controlled trial was conducted for RA patients with elevated levels of distress as assessed by a disease-specific measure. The control group (n = 71) received standard care and the intervention group (n = 62) additionally received an internet-based tailored cognitive-behavioral intervention. Main analyses were performed using a linear mixed model estimating differences between the intervention and control groups in scores of psychological functioning, physical functioning, and impact of RA on daily life at preassesment and postassessment, and at 3, 6, 9, and 12 months. Patients who received the internet-based intervention reported a larger improvement in psychological functioning compared with the control group, indicating less depressed mood (P< 0.001,d= 0.54), negative mood (P= 0.01,d= 0.38), and anxiety (P< 0.001,d= 0.48) during the course of the 1-year follow-up period. Regarding physical functioning, a trend was found for the intervention group reporting less fatigue than the control group (P= 0.06,d= 0.24), whereas no effect was found on pain. No effects were found for the impact of RA on daily life, except for the intervention group experiencing fewer role limitations due to emotional problems (P< 0.001,d= 0.53). Offering guided internet-based cognitive-behavioral therapy is a promising development to aid patients with psychological distress particularly in improving psychological functioning. Further research on adherence and specific intervention ingredients is warranted.
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“depression in five out of six studies that included this outcome [Ferwerda et al., 2017; Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Simister et al., 2018; Peters et al., 2017]”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Ferwerda et al., 2017
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“anxiety in three out of four studies [Ferwerda et al., 2017; Hedman-Lagerlöf et al., 2018; Peters et al., 2017]”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Ferwerda et al., 2017
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“Regarding detection bias, one study was at a low risk of bias (Simister et al., 2018) and two other studies were at an unclear risk of bias, since blinding of outcome assessment was insufficiently described (Ferwerda et al., 2017; Shigaki et al., 2013).”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Ferwerda et al., 2017
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“Concerning selection bias, more than half of the included studies (Ferwerda et al., 2017; Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Simister et al., 2018; Vallejo et al., 2015) reported a proper randomization method and allocation concealment (e.g., via a random number generator).”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Ferwerda et al., 2017
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EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis
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“The tailoring for the other two treatments, which were both Internetbased, once again included an assignment of one or more modules, based on participant ‘goals and characteristics’ (Ferwerda et al., 2017), or their ‘reported type of distress’ (Gasslander et al., 2022), from an intake session.”
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Mariano, T. Y., Wan, L., Edwards, R. R., & Jamison, R. N. (2021) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x19871746 · Cited by 52
“with arthritis.(51) Most of the studies offered an online Web-based course (75%), while two studies used videoconferencing alone(53,55) and one used telephonedelivered CBT alone.”
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Self-citationShen, B., Li, Y., Du, X., Chen, H., Xu, Y., Li, H., & Xu, G.-Y. (2020) · Psychology Health & Medicine · doi:10.1080/13548506.2020.1736312 · Cited by 54
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InfluentialSantos, E. J. F., Farisoğulları, B., Dures, E. K., Geenen, R., & Machado, P. (2023) · RMD Open · doi:10.1136/rmdopen-2023-003350 · Cited by 45
Tao, T. J., Lim, T. K., Yeung, E. T. F., Liu, H., Shris, P. B., Lawrence, K., Lee, T. M. C., & Hou, W. K. (2023) · npj Digital Medicine · doi:10.1038/s41746-023-00809-8 · Cited by 52
Web-based rehabilitation interventions for people with rheumatoid arthritis: A systematic review
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(2020) · Deakin Research Online (Deakin University) · Cited by 41
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ResultSelf-citationNagy, Z., Szigedi, E., Takács, S., & Császár-Nagy, N. (2023) · Life · doi:10.3390/life13030849 · Cited by 39
“It helps patients improve their problem solving skills; achieve behavioral changes; and further reveal the relationship between beliefs, thoughts, and feelings, as well as the behaviors that stem from these factors [38].”
BackgroundAnxiety Disorders in Patients With Somatic Diseases
Henning, M., Subič-Wrana, C., Wiltink, J., & Beutel, M. E. (2020) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000779 · Cited by 34
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Walrabenstein, W., van der Leeden, M., Weijs, P. J. M., van Middendorp, H., Wagenaar, C. A., van Dongen, J. M., Nieuwdorp, M., de Jonge, C. S., van Boheemen, L., & van Schaardenburg, D. (2021) · Trials · doi:10.1186/s13063-021-05682-y · Cited by 32
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“[54,59,61,64,70,72,73,75,77,78,82,85,90,93,95,97–103], basic education (pamphlet, online information) (2, 4%)[79, 84], access to a discussion forum (5, 9”
Fatigue in inflammatory arthritis
Dures, E. K., Cramp, F. L., Hackett, K., & Primdahl, J. (2020) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2020.101526 · Cited by 24
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“Electronic CBT approaches have been demonstrated to improve psychological distress in RA, which can also extend to anxiety and quality of life, as seen in psoriasis [105,106].”
Backgroundvan der Vaart, R., Worm-Smeitink, M., Bos, Y., Wensing, M., Evers, A. W. M., & Knoop, H. (2019) · Internet Interventions · doi:10.1016/j.invent.2019.100290 · Cited by 19
“The interventions were found to be effective regarding outcome measures on psychological functioning and fatigue (Janse et al., 2018; Worm-Smeitink et al., 2019a; Worm-Smeitink et al., 2019b; Van Koulil et al., 2010; Ferwerda et al., 2017).”
BackgroundSelf-citationTerpstra, J. A., van der Vaart, R., Ding, H. J., Kloppenburg, M., & Evers, A. W. M. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100444 · Cited by 19
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“Completion rates Completion rates (defined as finishing all or a predetermined percentage of modules) were reported across six studies.(44,45,48,52,53,58) Intervention group completion rates ranged from 49% to 100%, while the control groups ranged from 63% to 100% completion.”
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“ments in depressed mood and other mood symptoms compared to control condition participants over a 1year follow-up period.(38) Interestingly, Ferwerda et al.”
BackgroundBecoming an eCoach: Training therapists in online cognitive-behavioral therapy for chronic pain
Terpstra, J. A., van der Vaart, R., Spillekom-van Koulil, S., van Dam, A., Rosmalen, J. G. M., Knoop, H., van Middendorp, H., & Evers, A. W. M. (2018) · Patient Education and Counseling · doi:10.1016/j.pec.2018.03.029 · Cited by 17
Self-citationCardol, C. K., van Middendorp, H., Dusseldorp, E., van der Boog, P. J. M., Hilbrands, L. B., Navis, G. J., Sijpkens, Y. W. J., Evers, A. W. M., van Dijk, S., & on behalf of the E-GOAL Study Group (2022) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001163 · Cited by 20
Self-citationWirken, L., van Middendorp, H., Hooghof, C. W., Bremer, T. E., Hopman, S. P. F., der Pant, K. A. M. I. V. D., Hoitsma, A. J., Hilbrands, L. B., & Evers, A. W. M. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-020906 · Cited by 17
Self-citationCardol, C. K., Tommel, J., van Middendorp, H., Ciere, Y., Sont, J. K., Evers, A. W. M., & van Dijk, S. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18063292 · Cited by 14
“Since the lifestyle modules were embedded within the existing iCBT intervention E-coach [30,31], the researchers only partly had to engage in this step.”
BackgroundMethodInfluentialSelf-citationCuenca‐Martínez, F., López, L., Suso‐Martí, L., Varangot‐Reille, C., Calatayud, J., Herranz‐Gómez, A., Romero-Palau, M., & Casaña, J. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11071806 · Cited by 15
“3%) diagnosed with chronic back pain [64,75,82,85,86,95,96], chronic low back pain [80,91,97,109,116,117], unspecific chronic pain [63,65–67,70,73,76,81,92–94,99,102,106, 108,114,115,118,119], fibromyalgia [69,77,83,98,104,110,111,113], headache [79,100,101,107], rheumatic disorders [68,74,84,88,89,104,112], or others…”
BackgroundInfluentialBetz, L. T., Jacob, G. A., Knitza, J., Köhm, M., & Behrens, F. (2024) · npj Mental Health Research · doi:10.1038/s44184-024-00085-8 · Cited by 17
Ferwerda, M., van Beugen, S., van Middendorp, H., VISSER, H. K. A., Vonkeman, H. E., Creemers, M. C. W., van Riel, P. L. C. M., Kievit, W., & Evers, A. W. M. (2018) · Journal of Medical Internet Research · doi:10.2196/jmir.9997 · Cited by 14
“In a recent randomized controlled trial (RCT), we demonstrated that a therapist-guided internet-based cognitive behavioral therapy intervention (ICBT) that was tailored to specific problems of individual patients with rheumatoid arthritis with elevated levels of distress led to improvements in their psychological func…”
BackgroundResultInfluentialSelf-citationImplementation of an eHealth self-management care path for chronic somatic conditions
Ciere, Y., van der Vaart, R., Jong, A. E. V. D. M., Maljaars, J., van Buul, A. R., Koopmans, J. G., Snoeck-Stroband, J. B., Chavannes, N. H., Sont, J. K., & Evers, A. W. M. (2019) · Clinical eHealth · doi:10.1016/j.ceh.2019.04.001 · Cited by 13
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“Participants in the intervention group received a guided ICBT intervention for 6 weeks [23], which was based on an ICBT intervention for chronic somatic diseases developed in our research group [25,26].”
Self-citationKoulil, S., Ferwerda, M., Beugen, S., Middendorp, H., Kerkhof, P., Riel, P., & Evers, A. (2018) · Acta Dermato Venereologica · doi:10.2340/00015555-2803 · Cited by 12
“The value of case reports is increasingly being recognized in addition to RCTs, as this design incorporates unique features, such as an in-depth description of the course and content of the intervention and the exploration of factors contributing to possible treatment effectiveness (42).”
BackgroundInfluentialSelf-citationMind-body practices in chronic inflammatory arthritis
Sibilia, J., Berna, F. S., Bloch, J.-G., & Scherlinger, M. (2023) · Joint Bone Spine · doi:10.1016/j.jbspin.2023.105645 · Cited by 11
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Computer-Assisted Cognitive-Behavior Therapy in Medical Care Settings
Wright, J. H., McCray, L. W., Eells, T. D., Gopalraj, R. K., & Bishop, L. B. (2018) · Current Psychiatry Reports · doi:10.1007/s11920-018-0947-2 · Cited by 9
Nonpharmacologic Pain Management in Inflammatory Arthritis
Martin, A. M., Chopra, R., & Nicassio, P. M. (2021) · Rheumatic Disease Clinics of North America · doi:10.1016/j.rdc.2020.12.009 · Cited by 9
Tse, C. S., Lewis, J. D., Horst, S., Saha, S., Taleban, S., Shah, S. A., Lutz, M. K., Fiske, H. W., Brown, L. A., Kuehnel, R. H., et al. (2025) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000003681 · Cited by 8
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Azizoddin, D. R., Olmstead, R., Anderson, K.-A. S., Hirz, A. E., Irwin, M. R., Gholizadeh, S., Weisman, M. H., ISHIMORI, M. L., Wallace, D. J., & Nicassio, P. M. (2024) · BMC Rheumatology · doi:10.1186/s41927-024-00416-4 · Cited by 7
Cuenca‐Martínez, F., Suso‐Martí, L., Herranz‐Gómez, A., Varangot‐Reille, C., Calatayud, J., Romero-Palau, M., Blanco‐Díaz, M., Salar-Andreu, C., & Casaña, J. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19063231 · Cited by 6
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BackgroundInfluentialVolkmar, A., von der Decken, C., Kleinert, S., Karberg, K., Gauler, G., Klennert, M., Klennert, J., Aries, P. M., Froschauer, S., Wildenhain, S., et al. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1617151 · Cited by 5
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Rothmann, M. J., Mouritsen, J. D., Ladefoged, N. S., Jeppesen, M. N., Lillevang, A. S., Laustrup, H., & Ellingsen, T. (2022) · JMIR Human Factors · doi:10.2196/30829 · Cited by 6
“In line with previous studies using web-based tools [22-25,28,38,39] we found the module to be feasible and accepted by the patients.”
BackgroundResultA New Lens on Improving Physical Health with Psychological Interventions: A Systematic Review
Paddon, L., & Kampman, H. (2023) · Journal of Happiness and Health · doi:10.47602/johah.v3i2.46 · Cited by 6
“…(2015) Multiple positive psychology interventions (6 week) S Müller et al. (2016) Individually tailored positive psychology intervention (8 weeks) S Ferwerda et al. (2017) Tailored-guided internet-based cognitive behavioral intervention (26 weeks) NS Ferwerda et al. (2017) Tailored-guided…”
BackgroundInfluentialNon-Pharmacological Pain Management of Rheumatoid Arthritis
Pham, P., & Lee, Y. C. (2025) · Current Rheumatology Reports · doi:10.1007/s11926-025-01184-x · Cited by 5
Eather, C.-E., Sterling, M. M., Sullivan, C. M., & Elphinston, R. A. (2024) · Pain · doi:10.1097/j.pain.0000000000003441 · Cited by 3
Digital Psychological Intervention for Inflammatory Rheumatic Diseases
Knitza, J., Kraus, J., Krusche, M., Haase, I., Klemm, P., Hueber, A. J., Pfeil, A., Drott, U., Kühn, S., & Klein, J. P. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.29892 · Cited by 3
Isley, S., Johnson, E., Corrick, S., Hyde, A. M., Vandermeer, B., Dolgoy, N. D., Tabert, N., Pituskin, E., & Tandon, P. (2025) · PLOS Digital Health · doi:10.1371/journal.pdig.0000878 · Cited by 3
“Studies were published from 2010 [63] to 2024 [65] across 7 countries: United States (n = 4) [54,55,61,63], Netherlands (n = 4) [53,66–68], Germany (n = 4) [56,58,60,64], Canada (n = 2) [62,69], the United Kingdom (n = 1) [59], Switzerland (n = 1) [57] and Turkey (n = 1) [65].”
InfluentialZhang, L., Zhu, W., & Liu, S. (2025) · Psychology Health & Medicine · doi:10.1080/13548506.2025.2482949 · Cited by 2
“Given the great negative impacts of depression on RA patients, providing effective psychological interventions for them is of great importance (Ferwerda et al., 2017; Fogarty et al., 2019).”
Xie, Q., Goldberg, S. B., Jacobson, N. A., Rakel, D. P., & Quanbeck, A. (2025) · Journal of Pain Research · doi:10.2147/jpr.s568016 · Cited by 4
“86,87 However, empirical evidence regarding the effectiveness of personalized chronic pain interventions over non-personalized approaches appears inconclusive.”
Duarte, C. C. M., Spilker, R. L. F., Paiva, C., Ferreira, R. J. O., da Silva, J. A. P., & Pinto, A. M. (2023) · Trials · doi:10.1186/s13063-023-07692-4 · Cited by 3
“Adjunctive non-pharmacological interventions, including exercise, counselling, occupational therapy, cognitive behavioural therapy (CBT), and other psychological interventions, have been associated with positive results [24–26].”
BackgroundInternet-Delivered Cognitive Behavioural Therapy for the Management of Chronic Non-Cancer Pain
CADTH (2022) · Canadian Journal of Health Technologies · doi:10.51731/cjht.2022.462 · Cited by 1
Biopsychosocial conditions of patients in the rheumatology department of a university hospital
Kabul, E. G., Taskın, F., Çalık, B. B., & Çobankara, V. (2024) · Reumatologia/Rheumatology · doi:10.5114/reum/191793 · Cited by 1
“Additionally, it is believed that Pilates exercises, by activating the parasympathetic nervous system through respiratory control, may enhance over-all well-being and have positive effects on physical and mental fatigue [28].”
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Het ontwikkelen en evalueren van het online zelfmanagementprogramma ‘Reuma zelf te lijf ’
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Roodenrijs, N. M. T. (2021) · Utrecht University Repository (Utrecht University) · doi:10.33540/573
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Effectiveness of Psychological Interventions in Patients with Musculoskeletal System Diseases
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Walrabenstein, W., van der Leeden, M., Weijs, P. J. M., van Middendorp, H., Wagenaar, C. A., van Dongen, J. M., Nieuwdorp, M., de Jonge, C. S., van Boheemen, L., & van Schaardenburg, D. (2021) · Figshare · doi:10.6084/m9.figshare.16829896
Walrabenstein, W., van der Leeden, M., Weijs, P. J. M., van Middendorp, H., Wagenaar, C. A., van Dongen, J. M., Nieuwdorp, M., de Jonge, C. S., van Boheemen, L., & van Schaardenburg, D. (2021) · Figshare · doi:10.6084/m9.figshare.16829902
Walrabenstein, W., van der Leeden, M., Weijs, P. J. M., van Middendorp, H., Wagenaar, C. A., van Dongen, J. M., Nieuwdorp, M., de Jonge, C. S., van Boheemen, L., & van Schaardenburg, D. (2021) · Figshare · doi:10.6084/m9.figshare.16829905
Walrabenstein, W., van der Leeden, M., Weijs, P. J. M., van Middendorp, H., Wagenaar, C. A., van Dongen, J. M., Nieuwdorp, M., de Jonge, C. S., van Boheemen, L., & van Schaardenburg, D. (2021) · Figshare · doi:10.6084/m9.figshare.16829899
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“Of these, six studies were conducted in the Netherlands [31,36,37,39,41,42], three in Denmark [29,30,33], two in China [18,34], two in France [40], two in United States [35,38],and one each in Canada [31], Spain [44], Switzerland [43].”
InfluentialTerpstra, J. A., van Beugen, S., van der Vaart, R., van Eersel, R. A., Dusseldorp, E., Kloppenburg, M., & Evers, A. W. M. (2026) · Internet Interventions · doi:10.1016/j.invent.2026.100908
“Master Your Pain was adapted from E-coach, a tailored iCBT for chronic somatic conditions showing positive effects in rheumatoid arthritis (Ferwerda et al., 2017) and psoriasis (van Beugen et al., 2016).”
InfluentialSelf-citationLi, C. J., & Hou, W. K. (2026) · Springer eBooks · doi:10.1007/978-3-032-08980-9_22
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“Randomized trials in patients with RA have reported improvements in pain interference, depression, mood, anxiety, and selected functional or psychological outcomes after online mindfulness or cognitive behavioral therapy, with some bene fi ts persisting for 12 months (100, 101).”
Metadata
- Authors
- Ferwerda, M., van Beugen, S., van Middendorp, H., Spillekom-van Koulil, S., Donders, A. R. T., Visser, H., Taal, E., Creemers, M. C. W., van Riel, P. C. L. M., & Evers, A. W. M.
- Affiliations
- Leiden University (NL)
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
- Medical Psychology and
- Radboud University Medical Center (NL)
- Rijnstate Hospital (NL)
- University of Twente (NL)
- Jeroen Bosch Ziekenhuis (NL)
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
- Corresponding author
- Ferwerda, Maaike
- ORCID
- Venue
- Pain
- Published
- 2017-01-12
- Volume
- 158
- Issue
- 5
- Pages
- 868-878
- ISSN
- 0304-3959 (ISSN-L)
- 1872-6623
- OpenAlex
- W2578268303
- Cited by
- 85
- References
- 47
- Citations by year
- 2026: 6 · 2025: 10 · 2024: 9 · 2023: 10 · 2022: 10 · 2021: 13 · 2020: 7 · 2019: 7 · 2018: 8 · 2017: 3
- FWCI
- 7.82
- Type
- journal article
- Language
- en
- Open access
- green
- research.utwente.nl
- Licence
- other-oa
- Locations
- Pain (publishedVersion)
- PubMed (publishedVersion)
- University of Twente Research Information (acceptedVersion, other-oa)
- Leiden Repository (Leiden University) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- University of Twente Research Information (submittedVersion, other-oa)
- Funders
- Pfizer (WS682746)
- ZonMw
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Rheumatology › Rheumatoid Arthritis Research and Therapies
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Keywords
- rheumatoid arthritis, internet-based cognitive behavioral therapy, psychological distress, depression, anxiety, fatigue, physical function, chronic pain
- MeSH terms
- Activities of Daily Living, Adult, Aged, Aged, 80 and over, Arthritis, Rheumatoid, Female, Follow-Up Studies, Humans, Male, Middle Aged, Netherlands, Pain Measurement, Physical Examination, Psychiatric Status Rating Scales, Time Factors, Cognitive Behavioral Therapy, Outcome Assessment, Health Care, Disease Management, Mood Disorders, Internet
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