Arthritis and musculoskeletal patient education standards. Arthritis Foundation

Foot health education for people with rheumatoid arthritis - some patient perspectives

BACKGROUND

Patient education is an important component of foot health management for people with rheumatoid arthritis (RA). The content and strategies for delivery require investigation in relation to the patients' needs. This study explores patients' experiences of foot health education, to inform how the patients' needs could be identified in clinical practice and inform effective education delivery.

METHOD

A focus group was used to collect data. The dialogue was recorded digitally, transcribed verbatim and analysed using a structured thematic approach. Member checking and peer review added to credibility of the data.Six themes emerged; (i) content and purpose of patient education - what it should be, (ii) content of patient education - what it should not be, (iii) timing of information on foot health, (iv) method of delivery, (v) ability to engage with foot health education and (vi) the patient/practitioner relationship.

CONCLUSIONS

This study identified aspects of patient education considered important by this group of patients in relation to content, timing and delivery, forming the basis for further research on clinical and patient focussed outcomes of patient education.Identifying health education needs and provision of supportive verbal and written information can foster an effective therapeutic relationship, supporting effective foot health education for people with RA.

Prescription for Education: Development, Evaluation, and Implementation of a Successful Interprofessional Education Program for Adults with Inflammatory Arthritis

Objective.

To assess the feasibility of recruitment and standardize care delivery for an interprofessional program for inflammatory arthritis education (Prescription for Education, or RxEd), and to explore outcomes relevant to arthritis patient education.

Methods.

A patient-based needs assessment and ongoing patient feedback guided program development. An interprofessional team was involved in developing program content and delivering and adapting the program to patient needs. A quasiexperimental, waitlisted control with crossover design was used to evaluate the program. Data were collected at baseline, immediately following intervention, at 6 months (when the crossover control group received intervention), and at 1 year. Self-report measures included demographics, disorder-related data, Arthritis Self-efficacy Scale, arthritis knowledge, coping efficacy, and illness intrusiveness. Analysis included baseline comparisons and longitudinal trends; direct between-group comparison at 6 months; and generalized estimating equations (GEE) analysis to evaluate the main effect of the intervention on the primary outcome (arthritis self-efficacy) and secondary outcomes.

Results.

Program modifications based on patient input made recruitment possible. Forty-two persons participated (including 19 controls), with 93% followup at 1 year. Comparison of change shows moderate effect sizes (standardized effect size 0.5 to 0.7). GEE analysis showed significant main effect, before to after the program, in both groups for primary outcome (arthritis self-efficacy) and most secondary outcomes.

Conclusion.

Program feasibility was dependent on patient feedback. Our pilot study provides evidence that the RxEd program is feasible and improves arthritis self-efficacy and other outcomes.

Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine

Because of the dynamic and complex nature of chronic pain, successful treatment usually requires addressing behavioral, cognitive, and affective processes. Many adjunctive interventions have been implemented in fibromyalgia (FM) treatment, but few are supported by controlled trials. Herein, some of the more commonly used nonpharmacologic interventions for FM are described and the evidence for efficacy is presented. Clinical observations and suggestions are also offered, including using the principles outlined in the acronym ExPRESS to organize a comprehensive nonpharmacologic pain management approach.

[Patient education in rheumatologic care--a review]

Patient education is a medical intervention for patients with chronic diseases to increase knowledge of their disease, self-efficacy, self-management and consumer behaviour. The goal is to improve their disease outcome, social participation and quality of life. This article reviews concepts, modalities and knowledge on effectiveness of patient education. The results of different studies in different rheumatic diseases on efficacy will be summarized including a small number of cost-benefit analyses. Most studies report on significant and relevant improvements of knowledge, self-efficacy and health status. With respect to disease specific outcomes low to moderate effect sizes with a short duration have been observed. Especially good results have been reported when physical training or other methods of rehabilitation were included. There are marked improvements in consumer behaviour of health measures and sickness leave. A better understanding of information needs and baseline characteristics of patients is necessary to develop more appropriate educational interventions focussed on relevant outcomes that can be improved by educational measures.

The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study

OBJECTIVE

To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR).

METHODS

Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months.

MAIN RESULTS

Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline.

CONCLUSIONS

The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.

Health-related quality of life in rheumatoid arthritis: therapeutic education plus pharmacological treatment versus pharmacological treatment only

OBJECTIVE

To determine whether therapeutic education added to conventional drug therapy reduced disability and pain in patients with early rheumatoid arthritis (RA).

METHODS

Fourty-three patients with RA, 29F/14 M, were included in a randomized, controlled trial and assigned to a control group receiving conventional pharmacological treatment only (n=21), or an intervention group receiving therapeutic education added to conventional pharmacological treatment (n=22). The main outcome variable was self-reported disability on the Stanford health assessment questionnaire (HAQ).

RESULTS

At 18 months, patients in the intervention group had less disability (HAQ), pain intensity, number of tender and swollen joints, and patient's and physician's global assessments (p=0.003, 0.031, 0.003, 0.001, 0.014, and 0.004, respectively) compared with baseline, and improvements in disability and number of tender and swollen joints (p=0.024, 0.040, and 0.003, respectively), compared with controls.

CONCLUSIONS

Patients receiving pharmacological treatment and therapeutic education had a better evolution than those receiving only pharmacological treatment.

Educating patients: self-management approaches

PURPOSE

To review and evaluate approaches to educating patients with fibromyalgia syndrome (FMS).

METHODS

A narrative literature review was undertaken to summarize the published literature on patient education for FMS patients.

RESULTS

A number of studies contain specific education strategies while others are combined with exercise or movement therapies or cognitive-behavioural therapy.

CONCLUSIONS

Self-efficacy provides an effective theoretical model from which to understand how patients change as a result of education strategies that focus on self-management. Programmes that combine education with cognitive-behavioural techniques and exercise are most effective in enhancing self-efficacy and decreasing symptoms of FMS.

Gap between short- and long-term effects of patient education in rheumatoid arthritis patients: A systematic review

OBJECTIVE

To systematically review educational or psychoeducational interventions for patients with rheumatoid arthritis focusing on long-term effects, especially health status.

METHODS

Two independent reviewers appraised the methodologic quality of the included randomized controlled trials, published between 1980 and July 2002.

RESULTS

Validity scores of studies ranged from 3 to 9 (of 11). The 7 educational programs mainly improved knowledge and compliance in the short and long term, but there was no improvement in health status. All 4 psychoeducational programs improved coping behavior in the short term, 2 of them showing a positive long-term effect on physical or psychological health variables.

CONCLUSION

Methodologically better-designed studies had more difficulties demonstrating positive outcome results. Short-term effects in program targets are generally observed, whereas long-term changes in health status are not convincingly demonstrated. There is a need to find better strategies to enhance the transfer of short-term effects into gains in health status.

Patient education in arthritis: helping people change

Systematic reviews of education for arthritis patients have emphasized behavioural approaches are effective in facilitating behaviour change and improving psychological and health status. This article discusses how a range of patient education and motivational approaches could be integrated into clinical practice to help people make behavioural changes to benefit their health. These include information giving, counselling, motivational interviewing, behaviour-orientated self-management therapy and cognitive-behavioural approaches.

Nonpharmacologic management strategies in fibromyalgia

Clinicians using the results of the extant research base can take an optimistic view of the role of nonpharmacologic treatment strategies for fibromyalgia. There were no negative outcomes in any of the reviewed studies, although in a few studies the experimental treatment did not prove to be more effective than the attention control. Rather than viewing this negatively, one could look more closely at the attention control groups and attempt to better understand what they contained that worked as an active treatment. A number of trials include a follow-up component and all but one of them find maintenance of at least one outcome change. Maintenance of changes is more likely to occur when the patient continues to participate in the experimental activity long-term. Patients especially need strategies that help them continue in exercise regimens. Unlike cognitive skills strategies that once learned are likely to become part of a person's coping repertoire, both exercise and behavioral strategies, like progressive muscle relaxation, need to be performed on a consistent basis in order to have their effect. The goals of increased self-efficacy, symptom reduction, increased functional status and quality of life along with decreased inappropriate use of health care resources are realistic when patients persevere in their use of strategy combinations and receive support from their providers.

Education in the management of juvenile chronic arthritis. Changes in self-reported competencies among adolescents and parents of young children

OBJECTIVE

The purpose was to evaluate changes in self-reported competencies following an education program among parents of children with juvenile chronic arthritis (JCA) and among adolescents with JCA.

METHODS

The self-reported, 24-item MEPS questionnaire was used for evaluating the program. Fifty-five parents and 11 adolescents completed the questionnaire before, directly after, and four months after the eight-hour program.

RESULTS

Parents in the education program improved significantly concerning their self-reported competencies on medical, exercise, pain and social support issues, while the adolescents showed only minor improvement. The parents' positive development in some comparisons was also significant in relation to that of a non-educated group, whose responses remained mainly unchanged over the four months.

CONCLUSION

Given the advantages of the education program indicated in the study, parent education should be a self-evident part of the treatment in JCA.

How to use education as an intervention in osteoarthritis

Definitions of health education and patient education form the starting point for an overview of patient education interventions for people with osteoarthritis (OA). Recipients, tutors and the key messages that education can deliver are considered, followed by a review of the methods used and the typical content of current educational provision for OA. The theoretical and empirical basis for interventions is illustrated using examples from the somewhat limited field. The outcomes used to evaluate education and the evidence for effectiveness is presented. The issues of which patients benefit most, adherence, length of interventions, optimal timing and frequency are raised. The chapter concludes with a brief discussion of the best health care system is needed to underpin educational provision and suggestions for a research agenda that will go some way towards addressing the many questions that remain unanswered.

Effects of a coping intervention on patients with rheumatic diseases: results of a randomized controlled trial

OBJECTIVE

To test the effects (on coping, social interactions, loneliness, functional health status, and life satisfaction) of an intervention aimed at teaching people with rheumatic diseases to cope actively with their problems.

METHODS

A total of 168 patients with chronic rheumatic disorders affecting the joints were randomly assigned to a coping intervention group, a mutual support control group, or a waiting list control group. Measurements were by self-report questionnaires.

RESULTS

Post-intervention measurements showed that the coping intervention increased action-directed coping and functional health status, but these effects did not persist up to 6-months followup. In patients who attended at least half of the 10 sessions, the coping intervention contributed to decreased loneliness at post-intervention and to improvements in social interactions and life satisfaction at 6-months followup.

CONCLUSION

Teaching patients with rheumatic diseases to cope actively with their problems had positive impacts. Consequently it is recommended that the coping intervention be incorporated into regular care. Maintenance sessions are advisable.

The effect of a joint protection education programme for people with rheumatoid arthritis

OBJECTIVE

To evaluate the effects of an education programme in improving adherence with joint protection by people with rheumatoid arthritis (RA).

DESIGN

A repeated measures design. Subjects were assessed at six weeks and one week before and six and twelve weeks after education.

SETTING

Rheumatology unit in a large district general hospital.

SUBJECTS

Twenty-one people diagnosed with RA (mean age 48.95 years (SD 12.54) and disease duration of 6.43 years (SD 7.7) ).

INTERVENTION

An 8-hour arthritis education programme delivered over four sessions, including two hours of joint protection education designed to be typical of current UK practice.

MAIN OUTCOME MEASURES

The Joint Protection Behaviour Assessment (JPBA), an observational assessment of hand joint protection methods used during kitchen activities, to measure adherence with education. Other assessments included a joint protection knowledge questionnaire, hand joint counts, hand pain visual analogue scale, the Health Assessment Questionnaire (HAQ) and HAQ Pain scale to identify any short-term changes in hand pain, pain on activity and functional status. At the beginning and end of the study subjects were interviewed to obtain their self-report of joint protection behaviours and reasons for following or not following the advice given.

RESULTS

Median JPBA scores did not improve pre- to posteducation (18.4% to 23.7%; p = 0.65) and neither did hand joint count, hand pain, HAQ and HAQ Pain scores. However, joint protection knowledge improved significantly (p = 0.01) and the majority of people believed joint protection to be a beneficial strategy. Reasons for not changing behaviour included problems recalling information; joint protection being considered inappropriate as 'hands were not that bad yet'; lack of skill; and difficulties changing habits.

CONCLUSION

The joint protection education programme improved knowledge but not use of taught methods. Educational strategies being used by therapists need to be focused on enhancing adherence.

Group education for rheumatoid arthritis patients

This article reviews the effectiveness of group education programs in improving the knowledge, behavior, and health status of patients with rheumatoid arthritis (RA) and evaluates to what extent various programs fulfill certain criteria for educational self-management programs. Thirty-one studies are reviewed: in 12, patients with various rheumatic diseases including RA were included, and in 19, only RA patients were studied. Group education increased the knowledge of the participants, which was maintained over long intervals. Beneficial behavioral effects were found in mixed populations but less often found in RA patients. Group education often improved physical health status both in mixed and in RA populations, but seldom led to improved psychosocial health status. In general, the beneficial effects of group education were found more often in mixed populations than in strictly RA patients. Further investigations must examine which mechanisms make educational interventions effective and determine the types of interventions or combinations of interventions that are effective. Effects of group education on health status are almost never maintained over long intervals. More research is needed to develop strategies for maintaining and enhancing early gains from group education.

Education programmes for fibromyalgia patients: description and evaluation

A firm theoretical basis for patient education in rheumatic disease care has been built up over the past 10 to 15 years. Education in self-management has enabled patients to control symptoms and become partners in care with their health providers. Education for fibromyalgia patients has come to the foreground during the last 5 years as health professionals have come to understand the syndrome better and recognize the role that stress plays in the exacerbation of symptoms. A few controlled trials of various strategies, such as aerobic conditioning and cognitive-behavioural techniques, have been reported recently. All have shown significant benefits to patients with fibromyalgia. Only one controlled trial has studied the effects of a self-management education programme alone. The results of this programme were positive. Self-efficacy and life quality were enhanced. This programme and an uncontrolled programme that integrated many strategies have shown some of the first positive long-term indications that patients who are treated intensively for even a short time can continue to improve as they practice self-management techniques. There is still a need for further documentation of non-drug treatment strategies and especially further research into who is helped by which strategies, the optimal length of time for a programme, and the need for ongoing treatment.