Use of cognitive-behavioural arthritis education programmes in newly diagnosed rheumatoid arthritis

Physical Exercise and Occupational Therapy at Home to Improve the Quality of Life in Subjects Affected by Rheumatoid Arthritis: A Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that affects synovial membranes and typically causes joint pain and swelling. The resulting disability of RA is due to the erosion of cartilage and bone from the inflamed synovial tissue. Occupational therapy is a strategy and technique to minimize the joints' fatigue and effort. At the same time, physical exercise reduces the impact of systemic manifestations and improves symptoms in RA. This study investigates the role of a 30-day joint economy intervention (integration of physical exercise and occupational therapy) at home on the quality of life of subjects with RA.

METHODS

One hundred and sixty outpatients with RA were enrolled in a single-center trial with PROBE design and were divided into the intervention group (IG), which combined joint protection movements and physical exercise to maintain muscle tone at home, and the control group (CG). Both groups included 80 patients. In all patients, data from the disease activity score (DAS 28), health assessment questionnaire (HAQ), and short-form health survey (SF-12) "Italian version" were collected. In addition, to IG, a brochure was distributed, and the joint economy was explained, while to CG, the brochure only was distributed. The comparison between groups was made using Fisher's exact test for contingency tables and the z-test for the comparison of proportions. The non-parametric Mann-Whitney U test was used to compare quantitative variables between groups. The Wilcoxon signed-ranked test was used for post-intervention versus baseline comparisons.

RESULTS

Among the recruited patients, 54% were female. The mean age was 58.0 (42.4-74.7) for the CG and 54.0 (39.7-68.3) for the IG. Patients included in the IG had a higher cumulative illness rating scale for the evaluation of severity and comorbidity index (2.81 vs. 2.58; 2.91 vs. 2.59, respectively), as well as morning stiffness (33.8 vs. 25.0), even if not significant compared with CG patients. Our results indicate that, after 30 days of joint economy intervention at home, the DAS28 erythrocyte sedimentation rate (esr) and DAS28 C-reactive protein (crp), HAQ, and SF-12 mental component score were significantly improved (p = 0.005, p = 0.004, p = 0.009, and p = 0.010, respectively).

CONCLUSIONS

Our findings show that the combination of physical exercise and occupational therapy positively affects patients' quality of life with RA considering disease activity, global health status, and mental health.

Effectiveness of self-management interventions in inflammatory arthritis: a systematic review informing the 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Objective

To perform a systematic review (SR) on the effectiveness of self-management interventions, in order to inform the European League Against Rheumatism Recommendations for its implementation in patients with inflammatory arthritis (IA).

Methods

The SR was conducted according to the Cochrane Handbook and included adults (≥18 years) with IA. The search strategy was run in Medline through PubMed, Embase, Cochrane Library, CINAHL Plus with Full Text, and PEDro. The assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. A narrative Summary of Findings was provided according to the Grading of Recommendations, Assessment, Development and Evaluation.

Results

From a total 1577 references, 57 were selected for a full-text review, and 32 studies fulfilled the inclusion criteria (19 randomised controlled trials (RCTs) and 13 SRs). The most studied self-management components were specific interactive disease education in ten RCTs, problem solving in nine RCTs, cognitive–behavioural therapy in eight RCTs, goal setting in six RCTs, patient education in five RCTs and response training in two RCTs. The most studied interventions were multicomponent or single exercise/physical activity in six SRs, psychosocial interventions in five SRs and education in two SRs. Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes.

Conclusions

The findings confirm the beneficial effect of the self-management interventions in IA and the importance of their implementation. Further research should focus on the understanding that self-management is a complex intervention to allow the isolation of the effectiveness of its different components.

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Background

An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard.

Objectives

To develop recommendations for the implementation of self-management strategies in IA.

Methods

A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations.

Results

Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients.

Conclusion

These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.

Effectiveness of Occupational Therapy Interventions for Adults With Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

We reviewed the efficacy of occupational therapy-related interventions for adults with rheumatoid arthritis.

METHOD

We examined 51 Level I studies (19 physical activity, 32 psychoeducational) published 2000-2014 and identified from five databases. Interventions that focused solely on the upper or lower extremities were not included.

RESULTS

Findings related to key outcomes (activities of daily living, ability, pain, fatigue, depression, self-efficacy, disease symptoms) are presented. Strong evidence supports the use of aerobic exercise, resistive exercise, and aquatic therapy. Mixed to limited evidence supports dynamic exercise, Tai Chi, and yoga. Among the psychoeducation interventions, strong evidence supports the use of patient education, self-management, cognitive-behavioral approaches, multidisciplinary approaches, and joint protection, and limited or mixed evidence supports the use of assistive technology and emotional disclosure.

CONCLUSION

The evidence supports interventions within the scope of occupational therapy practice for rheumatoid arthritis, but few interventions were occupation based.

Getting Evidence into Practice: Implementing a Behavioural Joint Protection Education Programme for People with Rheumatoid Arthritis

Researchers must disseminate their research findings, but this alone is often insufficient to change practice. To improve research implementation by rheumatology occupational therapists, a 2-day training course for changing joint protection practice was developed. This aimed to improve understanding of joint protection, patient education and health behaviour research; develop skills in delivering a group joint protection programme; and reduce potential barriers to changing practice. To evaluate the course's effectiveness, a postal survey with attendees was conducted.

Of the 48 respondents, 45 subsequently changed individual patient education practice; 13 implemented the group programme, 25 contemplated doing so and 10 did not (precontemplators). The implementers and contemplators rated the joint protection programme as significantly more effective (p = 0.02) and relevant (p = 0.001) in practice than the precontemplators. The barriers to change were limited staffing, access to facilities, time to make practice changes, funding for programme costs and clinical time to deliver the programme. The implementers considered that supportive managers and teams helped to overcome these.

Changing practice needs clinicians, researchers and managers to work together. This research implementation strategy helped most of the participating clinicians to make practice changes that were readily within their control (that is, individual patient education). Group education requires greater organisational change and manager support is important to facilitate this.

Systematic Review of Educational Interventions for Rheumatoid Arthritis

OBJECTIVE

In this study, we systematically reviewed the effectiveness of educational interventions falling within the scope of occupational therapy practice for people with rheumatoid arthritis (RA). These interventions included disease education, joint protection and energy conservation, psychosocial techniques, pain management, and a combination category.

METHOD

Two databases, MEDLINE and CINAHL, and select journals were searched for randomized controlled trials published between January 2002 and June 2015. Qualitative synthesis was used for between-study comparisons.

RESULTS

Twenty-two studies, with approximately 2,600 participants, were included. The interventions were found to have strong evidence for constructs that dealt with increasing coping with pain and fatigue as well as maintaining positive affect. There was limited or no evidence supporting the effectiveness of these interventions on most other measured constructs.

CONCLUSION

Interventions in which a combination of educational techniques is used may complement pharmacological therapies in the care of people with RA. Future research is needed to identify specific mechanisms of change.

Immune responses to stress after stress management training in patients with rheumatoid arthritis

Introduction

Psychological stress may alter immune function by activating physiological stress pathways. Building on our previous study, in which we report that stress management training led to an altered self-reported and cortisol response to psychological stress in patients with rheumatoid arthritis (RA), we explored the effects of this stress management intervention on the immune response to a psychological stress task in patients with RA.

Methods

In this study, 74 patients with RA, who were randomly assigned to either a control group or a group that received short stress management training, performed the Trier Social Stress Test (TSST) 1 week after the intervention and at a 9-week follow-up. Stress-induced changes in levels of key cytokines involved in stress and inflammatory processes (for example, interleukin (IL)-6 and IL-8) were assessed.

Results

Basal and stress-induced cytokine levels were not significantly different in patients in the intervention and control groups one week after treatment, but stress-induced IL-8 levels were lower in patients in the intervention group than in the control group at the follow-up assessment.

Conclusions

In line with our previous findings of lower stress-induced cortisol levels at the follow-up of stress management intervention, this is the first study to show that relatively short stress management training might also alter stress-induced IL-8 levels in patients with RA. These results might help to determine the role of immunological mediators in stress and disease.

Trial registration

The Netherlands National Trial Register (NTR1193)

The Elizabeth Casson Memorial Lecture 2014: Changing ways; changing times

The Elizabeth Casson Memorial Lecture 2014, given on 4th June at the 38th Annual Conference and Exhibition of the College of Occupational Therapists, held at the Brighton Centre, Brighton.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial

OBJECTIVE

Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.

METHOD

We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.

RESULTS

Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.

CONCLUSIONS

The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Educational group visits for the management of chronic health conditions: a systematic review

OBJECTIVE

Review the effectiveness of group visits (appointments of multiple patients) on quality of life, function, self-efficacy, utilization, and biophysical outcomes in randomized controlled trials of patients with chronic conditions.

METHODS

We searched MEDLINE(®), Cochrane, CINAHL, and PsycINFO to January 2013 for English-language trials of educational group visits led by non-prescribing facilitators (e.g., peer educators).

RESULTS

We report on 80 arthritis/falls (n=22), asthma/COPD (n=10), CHF/hypertension (n=12), diabetes (n=29), multiple conditions (n=4), and pain (n=4) studies. We found moderate evidence of improved short-term self-efficacy in patients with arthritis (10 studies) and diabetes (10 studies). We found no consistent evidence of improved quality of life; however a moderately strong body of evidence suggests peer-led community-based programs might improve quality of life and utilization in patients with multiple chronic conditions. Meta-analyses found short- (14 studies; mean change HbA1c=-0.27, CI=-0.44, 0.11) and long-term (10 studies; mean change HbA1c=-0.23, CI=-0.44, -0.02) glycemic improvement.

CONCLUSIONS

Group visits may improve self-efficacy and glycemic control. There was little consistent evidence of improved quality of life, functional status, or utilization.

PRACTICE IMPLICATIONS

Group visits represent a reasonable alternative for educating patients with chronic illness, though varied participation/retention suggests they should not be the sole alternative.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

OBJECTIVES

To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

DATA COLLECTION AND ANALYSIS

Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

MAIN RESULTS

Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Osteoarthritis and rheumatoid arthritis: conservative therapeutic management

Hand therapists need to understand the basic science behind the therapy they carry out and the current evidence to make the best treatment decisions. The purpose of this article was to review current conservative therapeutic management of patients with rheumatoid arthritis (RA) or osteoarthritis (OA) of the hand. Treatment interventions such as orthotics, exercise, joint protection, modalities, and adaptive equipment are discussed from a basic science and evidence-based practice perspective.

The role of social reinforcement in the maintenance of short-term effects after a self-management intervention for frail housebound seniors with arthritis

Following the program I'm Taking Charge of My Arthritis!, study participants reported fewer functional limitations, less helplessness, and better coping effectiveness than did controls. This study examined the maintenance of these effects and the role of social reinforcement in maintaining benefits eight months post-intervention. The study collected information (1) at baseline (n=125); (2) two months later, before randomization (pre-intervention); (3) two months post-randomization (post-intervention 1); and (4) ten months post-randomization (post-intervention 2) (n=80). We conducted a randomized controlled trial comparing three groups: a control group, intervention group without social reinforcement, and intervention group with social reinforcement after the program. A multilevel analysis revealed that intervention participants with social reinforcement following the program continued to report significantly fewer functional limitations and greater coping effectiveness compared to intervention group participants without social reinforcement. This research provides preliminary evidence for the value of additional contact with frail housebound seniors post-intervention for maintaining the intervention benefits.

Therapeutic foot health education for patients with rheumatoid arthritis: a narrative review

PURPOSE

Foot health interventions such as foot orthoses for people with rheumatoid arthritis (RA) reduce pain, improve function and improve overall quality of life. Additionally, patient education (PE) is considered essential in achieving good outcomes with interventions such as foot orthoses, footwear and self-care. The aim of this literature review was to identify evidence in relation to the content, use and delivery of PE in the management of RA foot problems.

METHODS

An electronic search of the following databases was performed: PubMed, CINAHL, AMED, Medline and the Cochrane Library, between March 2000 and March 2010. In order to be included, studies had to be published in English, involve adults (>18 years) with RA, and assist in answering the research question. No publications regarding PE for the management of foot health-related problems in RA were found. However, other key terms emerged that embraced PE for people with RA and informed a further search. Thirty-two papers met the inclusion criteria and were reviewed with regard to the subject area, content of the paper, methodological issues and their key findings.

RESULTS

The present review provides evidence for the effectiveness of PE for people with RA delivered via a staged approach, with the content and timing of education provision being driven by the needs of the patient.

CONCLUSIONS

The effect of PE delivered from a podiatric context needs to be explored, and the nature and requirements of PE for individuals with RA-related foot problems from a patient and practitioner perspective requires investigation. Alternative and innovative ways of providing PE and, potentially, self-management need to be investigated and defined.

Self-efficacy as an outcome measure and its association with physical disease-related variables in persons with rheumatoid arthritis: a literature review

BACKGROUND

Studies have demonstrated a positive impact of patient education on self-efficacy in persons with rheumatoid arthritis (RA). However, the relationship between self-efficacy, physical disease-related variables and educational interventions has not yet been reviewed.

AIM

The aims of this study, in relation to persons with RA, were: 1) to provide an overview of the existing research into the association between self-efficacy and physical disease-related variables and, with this knowledge, 2) to provide an overview of the existing research on the effect of different types of educational interventions on self-efficacy.

METHOD

A systematic literature search was performed using eight databases, based on the terms 'rheumatoid arthritis' AND 'self-efficacy'. In total, 74 studies reporting associations between self-efficacy and physical disease-related variables and using self-efficacy as an outcome measure in educational interventions were included.

RESULTS

The scores obtained by the most commonly used questionnaire, the Arthritis Self-Efficacy Scale (ASES), was highly associated with physical disability, pain, fatigue and disease duration. If educational activities had a positive impact on self-efficacy, disease-related variables usually improved as well. Evidence is scarce as to whether disease-related variables affect patients' self-efficacy or vice versa and whether individual consultations can affect patients' self-efficacy.

CONCLUSION

The scores attained by the ASES is highly associated with physical disease-related variables. This relationship requires further research using a specific study design to restrict bias when evaluating the impact of interventions on self-efficacy in persons with RA. Research is needed on whether individual consultations can affect patients' self-efficacy. Disease-related variables do not affect the Rheumatoid Arthritis Self-Efficacy (RASE) questionnaire but this needs further exploration.

Perceived benefits and barriers to joint protection among people with rheumatoid arthritis and occupational therapists. A mixed methods study

BACKGROUND

Deciding whether or not to perform a health behaviour is an active decision-making process which has an impact on current and future behaviour and can be influenced by the beliefs both of patients and their healthcare professionals. The aim of this study was to explore rheumatoid arthritis (RA) patients' and occupational therapists' (OTs) perceptions of the benefits of and barriers to performing joint protection (JP).

METHODS

A mixed methods design was used. Questionnaires applied a theoretical framework of key themes to assess the relevance of JP benefits and barriers both to people with RA and OTs. Focused interviews with people with RA then enabled data triangulation. Investigator triangulation was used to check the validity of data interpretation.

FINDINGS

Ten people with RA and nine OTs participated. From the questionnaires, both groups agreed that highly relevant key themes for JP benefits were physical well-being, potential benefit and personal control. By contrast, the three key themes for JP barriers - negative attitude of others, negative impact on others and taking time from other things - were relevant for the majority of the OTs but not patients. The interviews enabled an understanding of the meaning behind RA patients' ratings, particularly their differences from OTs. People with RA explained JP benefits, and disease acceptance had altered some initial barriers into perceived benefits over time.

CONCLUSIONS

Emphasizing benefits and identifying individually relevant barriers could be an important communication strategy for OTs in understanding patients' rationale for whether or not to adopt JP methods.

Psychosocial interventions as adjunct therapy for patients with rheumatoid arthritis: a systematic review

AIM

To identify the psychological interventions for which there is consistent, high quality evidence of efficacy in the treatment of patients with rheumatoid arthritis (RA).

METHOD

A computer-aided search and manual screening of identified papers was conducted. Randomised controlled trials published in English in peer-reviewed journals, assessing the use of psychological interventions in adult patients with RA were included.

RESULTS

Thirty-four papers published between 1981 and 2009 encompassing 31 studies with 2021 patients were included. There is consistent supportive evidence for the efficacy of disclosure therapy (four studies) and cognitive behavioural therapy (CBT) with maintenance therapy (five studies). There is supportive evidence for improvement with CBT of greater than 6 weeks duration (six studies) in the short-term but conflicting evidence for its long-term efficacy. There is some evidence for improvement with biofeedback-based interventions (two studies). There is conflicting evidence for the benefits of counselling (three studies), psychotherapy (two studies) mindfulness and meditation (two studies), and CBT of less than 6 weeks duration (six studies). There is limited evidence regarding relaxation therapy (two studies). Methodological limitations of the reviewed literature included failure of allocation concealment, blinding and conduction of intention-to-treat analysis, as well as the heterogeneity and choice of outcome measures.

CONCLUSIONS

This review shows consistent supportive evidence for the use of disclosure therapy, and CBT with maintenance therapy as adjunct therapies in patients with RA. It also highlights methodological limitations in the current literature and the need for future research in this area.

Non-drug therapies in early rheumatoid arthritis

Non-pharmacological treatment modalities are often used as an adjunct to drug therapy in patients with rheumatoid arthritis (RA). The aim of this overview is to summarize the available evidence on the effectiveness of these modalities in early RA. The few available randomized controlled trials that have specifically investigated patients with early RA support the effectiveness of dynamic exercise and cognitive behavioural interventions, and to a lesser extent of joint protection programmes and foot orthoses. The effectiveness of multidisciplinary team-care programmes, specialist nurse care, electro-physical modalities (including passive hydrotherapy), wrist orthoses, and dietary interventions have not been studied in patients with early RA. Current recommendations on the usage of non-pharmacological treatment modalities in sets of guidelines on the management of early RA vary with respect to their scope, strength and level of detail. The results of this review indicate a need for further investigation into the most clinically effective and cost-effective strategies to deliver non-pharmacological treatment modalities as well as comprehensive arthritis care models in early RA.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic review has been published since 1999.

OBJECTIVES

To evaluate the effectiveness of psychological therapies on pain, disability, and mood.

SEARCH STRATEGY

Randomised controlled trials (RCTs) of psychological therapy were identified by searching MEDLINE, EMBASE and Psychlit and CENTRAL from the beginning of each abstracting service until January 2008. A further search was undertaken from January 2008 to August 2008. Additional studies were identified from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. Studies were excluded if the pain was primarily headache, or was associated with a malignant disease. Studies were also excluded if the number of patients in any treatment arm was less than 10.

DATA COLLECTION AND ANALYSIS

Fifty-two studies were examined with a quality rating scale specifically designed for use with these studies. Data were extracted from 40 studies (4781 participants) by two authors. Two main classes of treatment (Cognitive Behavioural Therapy (CBT) and Behaviour Therapy (BT)), were compared with two control conditions (Treatment as Usual (TAU) and Active control (AC)), at two assessment points (immediately following treatment and six months following treatment), giving eight comparisons. For each comparison, treatment effectiveness was assessed on three outcomes: pain, disability, and mood giving a total of 24 analyses.

MAIN RESULTS

Overall there is an absence of evidence for BT, except for pain immediately following treatment compared with TAU. CBT has some small positive effects for pain, disability and mood. At present there is insufficient data on quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.

UK self-care support initiatives for older patients with long-term conditions: a review

OBJECTIVES

Supporting self-care for people with long-term conditions is an aim of UK health policy. As many with long-term conditions are older it is of interest to explore which self-care support interventions have positive impacts for this group. This review explores what types of intervention have been reported in the UK and their impact upon older people.

METHODS

Studies were identified using existing reviews, electronic databases and through hand searching journals. After inclusion and exclusion criteria were applied data were extracted from 18 studies. These were summarized in a narrative synthesis supported by summary tables.

RESULTS

All studies described interventions to support self-care, many targeted at people with arthritis. All used patient education, usually delivered to groups by a range of professionals. The majority of studies reported some significant positive outcomes, most frequently changes in physical functioning, illness knowledge and increased self-efficacy. The average age of participants was 60.

DISCUSSION

This review shows that self-care interventions have had positive effects for older participants but it remains unknown how best to support self-care in participants over 75, a group of people with long-term conditions who may have different needs.

[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.

Sensitivity to change of the Rheumatoid Arthritis Self-Efficacy scale (RASE) and predictors of change in self-efficacy

OBJECTIVES

Patient education in rheumatoid arthritis (RA) aims to improve health outcomes by prompting people to adopt self-management behaviours. One precursor for initiating behaviour change is self-efficacy (SE), a belief that you can do a task. This study tested the sensitivity to change of a new scale to measure SE for self-management in people with RA, the Rheumatoid Arthritis Self-Efficacy scale (RASE). Exploratory analysis examined potential predictors of change in SE.

METHODS

People with RA at 11 rheumatology centres, who had accepted an education programme as part of clinical care, completed questionnaires at baseline, and two and eight weeks after their programme end. Programmes were not standardized, as this was a pragmatic study in clinical practice.

RESULTS

A total of 128 patients participated. After controlling for baseline scores, the RASE showed small but significant improvements in SE from baseline (RASE 107.57, CI 105.42-109.72) to two weeks after programme end (RASE 110.80, CI 108.60-112.99), and eight weeks (RASE 110.62, CI 108.40-112.85, p<0.001). Standardized response means, calculated both by absolute and percentage change, were 0.339 and 0.371 at two weeks after programme end, and 0.321 and 0.352 at eight weeks. Changes in the RASE were associated with behaviour initiation at two and eight weeks (r=0.419, r=0.342, p<0.001). No substantial predictors of change in SE could be identified.

CONCLUSIONS

The RASE is sensitive to change in a cohort of people with RA in the UK receiving education programmes as routine clinical care. Exploratory analysis did not identify clinical or psychological factors that predict change in SE, suggesting that programmes should not be restricted to particular patients.

Is dynamic exercise beneficial in patients with rheumatoid arthritis?

INTRODUCTION

Dynamic exercise therapy as defined by the American College of Sports Medicine for healthy individuals is of unclear relevance to patients with rheumatoid arthritis (RA). No recommendations on this issue are available. Few studies have evaluated the optimal program, frequency, or target population; furthermore, there is no consensus about the best assessment tools for monitoring clinical, functional, and structural parameters during dynamic exercise therapy in patients with RA.

METHODS

We conducted an extensive review of the literature published between 1964 and 2005. We identified nine randomized controlled studies that provided a high level of proof regarding the effects of dynamic exercise therapy in RA patients older than 18 years of age.

RESULTS

Dynamic exercise programs improve aerobic capacity and muscle strength in patients with RA. Their effects on functional capacity are unclear, and many sources of bias influenced the study results. The clinical and laboratory safety profiles were good. The structural impact of dynamic exercise remains to be determined.

Arthritis and pain. Psychosocial aspects in the management of arthritis pain

The purpose of this review is to summarize psychosocial factors associated with arthritis pain and highlight recent evidence for psychosocial approaches to managing arthritis pain. By definition, psychosocial factors refer to two dimensions of experience: the psychological (cognitive, affective) and social (interacting with others, engaging in life activities). Psychosocial factors influence the perception of pain and the presence of pain influences psychological well-being and social participation. After discussing the impact of arthritis pain on participation in work, family life, and leisure, evidence for psychosocial interventions is summarized, emphasizing reviews and studies published from January 2000 to August 2006.

Development and validation of a German version of the joint protection behavior assessment in patients with rheumatoid arthritis

OBJECTIVE

Joint protection (JP) is an important part of the treatment concept for patients with rheumatoid arthritis (RA). The Joint Protection Behavior Assessment short form (JPBA-S) assesses the use of hand JP methods by patients with RA while preparing a hot drink. The purpose of this study was to develop a German version of the JPBA-S (D-JPBA-S) and to test its validity and reliability.

METHODS

A manual was developed through consensus with 8 occupational therapist (OT) experts as the reference for assessing patients' JP behavior. Twenty-four patients with RA and 10 healthy individuals were videotaped while performing 10 tasks reflecting the activity of preparing instant coffee. Recordings were repeated after 3 months for test-retest analysis. One rater assessed all available patient recordings (n = 23, recorded twice) for test-retest reliability. The video recordings of 10 randomly selected patients and all healthy individuals were independently assessed for interrater reliability by 6 OTs who were explicitly asked to follow the manual. Rasch analysis was performed to test construct validity and transform ordinal raw data into interval data for reliability calculations.

RESULTS

Nine of the 10 tasks fit the Rasch model. The D-JPBA-S, consisting of 9 valid tasks, had an intraclass correlation coefficient of 0.77 for interrater reliability and 0.71 for test-retest reliability.

CONCLUSION

The D-JPBA-S provides a valid and reliable instrument for assessing JP behavior of patients with RA and can be used in German-speaking countries.

Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion

OBJECTIVE

To develop clinical practice guidelines for the use of nonpharmacological treatments in patients with early rheumatoid arthritis (RA), using the evidence-based approach and expert opinion.

METHODS

A scientific committee used a Delphi prioritization procedure to select five questions. Evidence providing answers to the five questions was sought in the literature and presented to a panel of rheumatologists. The panel developed five detailed recommendations, filling gaps in evidence with their expert opinion. The strength of each recommendation was determined.

RESULTS

Of the 565 publications retrieved by the literature review, 198 were included in the analysis. The five recommendations on nonpharmacological treatments for early RA were validated by a final vote among all participants. The recommendations are as follows: (1) physicians may decide to provide joint protection education to patients with potentially severe early RA, with the knowledge that structured joint protection programs have not been found effective; (2) physical exercise and sports can be recommended to patients with early RA; muscle strength exercises are advisable; (3) in patients with early RA, metatarsal pain and/or foot alignment abnormalities should be looked for regularly, and appropriate insoles should be prescribed if needed; (4) dietary measures and nutritional supplements are not indicated as part of the treatment of early RA; (5) elimination diets, particularly those with low intakes of dairy products, should be discouraged in patients with early RA.

CONCLUSION

These recommendations should help to improve practice uniformity and, ultimately, to improve the management of RA.

The long-term outcomes from a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis

OBJECTIVE

To evaluate the long-term effects of joint protection on health status of people with early rheumatoid arthritis (RA).

DESIGN

A four-year follow-up of a randomized, controlled, assessor-blinded trial was conducted.

SETTING

Two rheumatology outpatient departments.

PARTICIPANTS

People with rheumatoid arthritis less than five years since diagnosis.

INTERVENTIONS

Two 8-hour interventions were originally compared: a standard arthritis education programme, including 2(1/2) hours of joint protection based on typical UK occupational therapy practice (plus 5(1/2) hours on RA, exercise, pain management, diet and foot care); and a joint protection programme, using educational-behavioural training.

MAIN MEASURES

Adherence to joint protection, pain, hand pain on activity, Arthritis Impact Measurement Scales 2 and Arthritis Self-efficacy were recorded at 0 and 4 years.

RESULTS

Sixty-five people attended the joint protection and 62 the standard programmes. Groups at entry were similar in age (51 years; 49 years), disease duration (21 months: 17.5 months) and use of nonsteroidal anti-inflammatory and disease-modifying drugs. At four years, the joint protection group continued to have significantly better: joint protection adherence (p=0.001); early morning stiffness (p=0.01); AIMS2 activities of daily living (ADL) scores (p=0.04) compared with the standard group. The joint protection group also had significantly fewer hand deformities: metacarpophalangeal (MCP) (p =0.02) and wrist joints (p=0.04).

CONCLUSION

Attending an educational-behavioural joint protection programme significantly improves joint protection adherence and maintains functional ability long term. This approach is more effective than standard methods of training and should be more widely adopted.

Self-management interventions for chronic illness

An increasing number of interventions have been developed for patients to better manage their chronic illnesses. They are characterised by substantial responsibility taken by patients, and are commonly referred to as self-management interventions. We examine the background, content, and efficacy of such interventions for type 2 diabetes, arthritis, and asthma. Although the content and intensity of the programmes were affected by the objectives of management of the illness, the interventions differed substantially even within the three illnesses. When comparing across conditions, it is important to recognise the different objectives of the interventions and the complexity of the issues that they are attempting to tackle. For both diabetes and asthma, the objectives are concerned with the underlying control of the condition with clear strategies to achieve the desired outcome. By contrast, strategies to deal with symptoms of pain and the consequences of disability in arthritis can be more complex. The interventions that were efficacious provide some guidance as to the components needed in future programmes to achieve the best results. But to ensure that these results endure over time remains an important issue for self-management interventions.

Psychological aspects of persistent pain: current state of the science

This article provides an overview of current research on psychological aspects of persistent pain. It is divided into 3 sections. In section 1, recent studies are reviewed that provide evidence that psychological factors are related to adjustment to persistent pain. This section addresses research on factors associated with increased pain and poorer adjustment to pain (ie, pain catastrophizing, pain-related anxiety and fear of pain, and helplessness) and factors associated with decreased pain and improved adjustment to pain (ie, self-efficacy, pain coping strategies, readiness to change, and acceptance). In section 2, we review recent research on behavioral and psychosocial interventions for patients with persistent pain. Topics addressed include early intervention, tailoring treatment, telephone/Internet-based treatment, caregiver-assisted treatment, and exposure-based protocols. In section 3, we conclude with a general discussion that highlights steps needed to advance this area of research including developing more comprehensive and integrative conceptual models, increasing attention to the social context of pain, examining the link of psychological factors to pain-related brain activation patterns, and investigating the mechanisms underlying the efficacy of psychological treatments for pain.

PERSPECTIVE

This is one of several invited commentaries to appear in The Journal of Pain in recognition of The Decade of Pain Research. This article provides an overview of current research on psychological aspects of persistent pain, and highlights steps needed to advance this area of research.

Prevention research and rheumatic disease

PURPOSE OF REVIEW

Prevention may occur in clinical, community, or population settings and is often classified into primary, secondary, and tertiary types. To provide a context for this review, we define the three types and provide general and arthritis-specific examples of prevention strategies. Next, we highlight recently published longitudinal cohort and intervention studies that focus on arthritis prevention in the following topic areas: cognitive and behavioral strategies, obesity, exercise, and occupational injury prevention.

RECENT FINDINGS

Few studies examined primary prevention strategies. In one study, an educational intervention significantly changed tick-related knowledge and behaviors among a population at risk of Lyme disease. Another population-based study used a mailed, stage-based educational program to successfully increase physical activity levels; this intervention may have practical application as a primary or tertiary prevention strategy for arthritis. Tertiary prevention research received much attention: Recent studies extend the benefits of exercise and cognitive-behavioral interventions to persons with different rheumatic conditions (eg, neck pain, low back pain, systemic lupus erythematosus, fibromyalgia). Longitudinal cohort studies improve our understanding of the relationships between computer use and carpal tunnel syndrome among office workers, birth weight and hand osteoarthritis, and baseline balance and functional declines among older adults with knee pain.

SUMMARY

Prevention of arthritis and its complications is an active focus of investigation. Primary prevention research remains a challenge because of the prolonged time frame for disease expression. Scientific evidence continues to provide support for tertiary prevention strategies among people with documented rheumatic disease.

A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis

BACKGROUND

Occupational therapy (OT) aims at improving performance of daily living tasks, facilitating successful adjustments in lifestyle, and preventing losses of function.

OBJECTIVE

To evaluate the effects of a pragmatic, comprehensive OT programme on self management and health status of people with early rheumatoid arthritis (RA) (<2.5 years).

METHODS

A randomised, controlled "assessor blinded" trial was conducted with assessments made at entry, 6, 12, and 24 months. Main outcomes were AIMS2: physical function (PF), pain visual analogue scale (VAS), and Arthritis Self-Efficacy Scale (ASES).

RESULTS

Groups had similar disease duration (9 months OT (n = 162) v 10 months control (n = 164)). The OT group received 7.57 (SD 3.04) hours of therapy. Self management significantly increased in the OT group. Otherwise, there were no significant differences in any outcome measures, or between groups, by ACR functional class: AIMS2: PF (F = 0.04; p = 0.96); pain VAS (F = 0.29; p = 0.74); total ASES score (F = 0.93; p = 0.39).

CONCLUSIONS

OT improved self management but not health status in early RA. Functional ability remains reasonably good for many in the first five years, so preventive benefits of self management may not yet be apparent and longer follow up is needed. Although many considered the education and therapy useful, insufficient numbers in the OT group used self management sufficiently to make a difference. Behavioural approaches can improve adherence and, potentially, the long term benefits. Future research should evaluate OT as a complex intervention and develop programmes from a theoretical and evidence base.