Compliance in rheumatoid arthritis and the role of formal patient education

A longitudinal, qualitative study exploring sustained adherence to a hand exercise programme for rheumatoid arthritis evaluated in the SARAH trial

PURPOSE

This study explores the experience of participants taking part in a hand exercise programme for people with rheumatoid arthritis with a focus on adherence. The exercise programme was tested in a randomised controlled trial. This parallel qualitative study will inform future implementation into clinical practice.

METHOD

Twenty-seven semi-structured interviews from 14 participants were undertaken at two time points (4 and 12 months after randomisation). We collected data of participants' experiences over time. This was guided by an interview schedule. Interview data were analysed using interpretative phenomenological analysis which is informed by phenomenological and hermeneutic theory. We recruited participants from National Health Service rheumatology and therapy departments.

RESULTS

At 4 months, 11/14 participants reported continuing with the exercises. By 12 months, 7/13 participants still reported exercising. The ability to establish a routine determined whether participants adhered to the exercise programme. This was sometimes influenced by practical issues. We also identified facilitators and barriers to regular exercise in the themes of the following: the therapeutic encounter, perceived benefit of exercises, attitude of mind, confidence, and unpredictability.

CONCLUSIONS

Establishing a routine was an important step towards participants being able to exercise independently. Therapists provided participants with skills to continue to exercise while dealing with changes in symptoms and schedules. Potential barriers to long-term exercise adherence need to be taken into account and addressed for successful implementation of this programme. Implications for Rehabilitation Behavioural change components such as the use of an exercise planner (stating intentions of where, when and how), daily diary sheets, and joint goal setting enhance adherence to a hand exercise programme for RA by helping to establish routines. Exercise routines need to be flexible enough to fit in with life and symptom changes whilst delivering a sufficient dosage. Therapists facilitate this process by using behavioural components alongside more commonly used aspects of care (assessment, education, advice, and encouragement) to enable people with RA to become independent exercisers.

Patient participation in decisions about disease modifying anti-rheumatic drugs: a cross-sectional survey

BACKGROUND

Involvement of patients in decision-making about medication is currently being advocated. This study examined (the concordance between) inflammatory arthritis patients' preferred and perceived involvement in decision-making in general, and in four specific decisions about Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Furthermore, this study examined how patients' involvement is related to satisfaction about decision-making and which factors are related to preferred roles, perceived roles and concordance.

METHODS

Using a cross-sectional survey, 894 patients diagnosed with Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis were sent a questionnaire which focused on medical decisions in general and on four specific decisions: (a) starting with a traditional DMARD; (b) starting to inject methotrexate; (c) starting a biological DMARD; and (d) decreasing or stopping a DMARD. For each decision preferred and perceived involvement in decision-making was assessed using the Control Preference Scale. Concordance was calculated by subtracting the scores for perceived role from scores for the preferred role. Furthermore, satisfaction with the decision process and socio-demographic, health-related, patient-related and physician-related variables were assessed.

RESULTS

The response rate was 58%. For all decisions, most patients (59%-63%) preferred Shared Decision-Making (SDM). SDM was perceived frequently (26%-55%) and patients' preferences were met in 54% of the respondents. Yet, in some specific decisions, 26% to 54% of patients would have liked more participation. Perceiving less participation then preferred was associated with less satisfaction with the decision-process, but perceiving more participation than preferred was not. Our results did not reveal any meaningful models to predict preferred or perceived participation in decision-making in general or with reference to specific decisions about DMARDs.

CONCLUSIONS

Most arthritis patients prefer to be involved in decisions about their medication and SDM is perceived frequently. Yet, in some specific decisions patient participation can be further improved. Patients especially prefer more participation in decision-making regarding starting a first traditional DMARD, which occurs most commonly in newly diagnosed patients. Whereas perceiving too little participation was associated with decreased satisfaction, perceiving too much participation was not. Therefore, rheumatologists should urge patients to participate in every medical decision.

Compliance with treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, progressive, debilitating disease that demands continuous therapy with multiple medications. Noncompliance with disease-modifying drugs may cause disease flares, preventable functional impairment, unnecessary treatment changes, and loss of health care resources. The aim of the current study was to explore self-reported compliance with treatment and the factors contributing to this compliance using a representative sample of an RA patient population in Estonia. Two thousand patients diagnosed with RA were randomly selected from the Estonian Health Insurance Fund database. The eligible response rate of the study was 60%. Using prestructured questionnaires, the following information about the disease and treatment was evaluated: self-reported compliance with treatment, reasons for noncompliance, disease history, sociodemographic variables, health care utilization, and satisfaction with health care providers. The self-reported compliance rate was 80.3%, reflecting the percentage of patients who reported that they always took their medications exactly as described. The most often reported reasons for noncompliance were side effects and fear of side effects. Compliance was found to be the lowest in a group of younger and active patients with higher income. Higher frequency of visits to the rheumatologist, satisfaction with health care providers, and sufficient information about RA treatment correlated with better compliance.

Translating patient education theory into practice: developing material to address the cardiovascular education needs of people with rheumatoid arthritis

OBJECTIVE

This paper describes the rationale and design of a theory-informed patient education programme addressing cardiovascular disease for people with rheumatoid arthritis (RA) to illustrate how theory can explicitly be translated into practice.

METHODS

A steering group of rheumatologists and psychologists was convened to design the programme. The Common Sense Model, the Theory of Planned Behaviour and the Stages of Change Model were used to underpin the topics and activities in the programme. User involvement was sought. The programme was formatted into a manual and the reading age of the materials was calculated.

RESULTS

A small group 8-week programme was designed. The structure of the patient education programme, including topics, underlying psychological theory as well as behaviour change techniques, is described.

CONCLUSION

This patient education programme addresses a currently unmet educational need for patients with RA and uses theory to design, not just evaluate, the programme. This will allow both enhanced interpretation of the results when the programme is implemented and replication by other units if successful.

PRACTICE IMPLICATIONS

The actual design and detail of education programmes merit wider dissemination to facilitate progress in the process of development and application.

Psychological interventions for rheumatoid arthritis: examining the role of self-regulation with a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To examine the efficacy of psychological interventions for rheumatoid arthritis (RA), and to determine whether self-regulation interventions demonstrate efficacy superior to that of other psychological treatments.

METHODS

Only randomized controlled trials testing a face-to-face psychological intervention among patients with RA were included. Two independent investigators extracted pertinent study data, rated each study on a scale of methodologic quality, and assessed each treatment condition for its inclusion of 5 behavior-change techniques derived from self-regulation theory (goal setting, planning, self-monitoring, feedback, and relapse prevention).

RESULTS

Twenty-seven trials were included, and cumulative effect sizes were calculated for the 5 outcomes. Significant effect sizes (Hedges' g) were found at posttreatment for physical activity (0.45), pain (0.18), disability (0.32), depressive symptoms (0.23), and anxiety (0.17). At followup (range 2-14 months), significant effect sizes were obtained for physical activity (0.36), pain (0.13), disability (0.15), and depressive symptoms (0.32). Comparative analyses revealed that interventions utilizing more self-regulation techniques reduced depressive symptoms and anxiety significantly more than interventions utilizing fewer such techniques. Additionally, depressive symptoms were reduced significantly more among recently diagnosed RA patients than among those with longstanding RA.

CONCLUSION

Psychological interventions are beneficial for many patients with RA, particularly when it comes to increasing physical activity levels. Intervention techniques derived from self-regulation theory appear to play a role in reducing depressive symptoms and anxiety among patients with RA.

Adherence to therapeutic splint wear in adults with acute upper limb injuries: a systematic review

Introduction

Non-adherence with therapeutic splinting in acute hand injury can reduce treatment benefits, increase risk of disability and bias assessment of treatment efficacy. This systematic review aims to critically analyse the literature on splinting of acute upper limb injuries to identify key factors that could influence patient adherence with splint wear.

Methods

Trials were identified from searches of EMBASE, MEDLINE, CINAHL (to June 2009) and reference lists of articles and relevant reviews. Search terms used were patient compliance/adherence behaviour, splint/s, othosis/es and brace. Where possible, randomized controlled trials or prospective cohort studies were sought, and then cross-sectional and retrospective studies if the former were not available. Studies specifically addressing chronic conditions were excluded. All relevant trials were assessed for methodological quality by the author using explicit criteria. Data were extracted using a standardized form designed by the author.

Results

Six studies (one randomized controlled trial, two cross-sectional analytic surveys and three retrospective file reviews) involving 490 people were included. Owing to the heterogeneity of studies synthesis is narrative rather than quantitative. There was no consistent correlation between adherence and age or gender. One study found a correlation with patient perception of positive effect, and one found negative correlations with agitation and brain injury severity.

Discussion

Studies found were generally of varied quality and may be susceptible to bias. This is a field with little published scientific evidence, and future research should measure adherence relationships with socioeconomic, health-care system, therapy- and patient-related characteristics.

Anti-inflammatory effect of Sanshuibaihu decoction may be associated with nuclear factor-kappa B and p38 MAPK alpha in collagen-induced arthritis in rat

Sanshuibaihu decoction (SSBH) is an anti-arthritic Chinese herbal formula which has been used in the treatment of rheumatoid arthritis (RA) for many years. We herein aimed to confirm its anti-arthritic effect and explore the potential mechanism of action on collagen-induced arthritis (CIA) in rats. CIA was induced by immunizing 50 female Wistar rats with bovine type II collagen. 13 days following the immunization rats with CIA were treated with SSBH (50mg/kg), leflunomide (LEF) (10mg/kg) and physiological saline for 30 days, and rats without CIA were left untreated. After the treatment, paw edema was obviously improved in SSBH-treated rats, with the significant difference of arthritis score (F=6.032, P=0.006) observed between the three treated groups. In pathological observation, SSBH-treated rats showed a significant improvement of inflammatory infiltration, synovial hyperplasia, cartilage and bone destruction and joint fusion. After the treatment of SSBH, radiological score of knee (t=11.504, P=0.000) and ankle joints (t=9.250, P=0.000) was decreased significantly. In situ hybridization on joint tissue section indicated only slight synovial hyperblastosis and expression of NF-kappaB in SSBH-treated rats. Image analysis indicated a significant difference of means of integrated optical density (MIOD) (F=3.956, P=0.040) and means of stained area (MSA) (F=3.867, P=0.032) of NF-kappaB between the three treated groups. MIOD and MSA of SSBH-treated group were significantly lower vs control. Enzyme linked immunosorbent assay (ELISA) showed a significant difference (F=10.167, P=0.000) of the amount of p-p38 MAPKalpha in the three treated groups. The detected amount of p-p38 MAPKalpha in SSBH-treated group was significantly lower vs control. These results show SSBH has an inhibiting effect on CIA, which may be associated with NF-kappaB and p38 MAPKalpha.

A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management

OBJECTIVE

Test the efficacy of educational interventions to reduce literacy barriers and enhance health outcomes among patients with inflammatory arthritis.

METHODS

The intervention consisted of plain language information materials and/or two individualized sessions with an arthritis educator. Randomization was stratified by education level. Principal outcomes included adherence to treatments, self-efficacy, satisfaction with care, and appointment keeping. Secondary outcomes included health status and mental health. Data were collected at baseline, six, and twelve months post.

RESULTS

Of the 127 patients, half had education beyond high school and three quarters had disease duration greater than five years. There were no differences in the primary outcome measures between the groups. In mixed models controlling for baseline score and demographic factors, the intervention group showed improvement in mental health score at six and twelve months (3.0 and 3.7 points, respectively), while the control group showed diminished scores (-4.5 and -2.6 points, respectively) (p=0.03 and 0.01).

CONCLUSION

While the intervention appears to have had no effect on primary outcomes, further studies with continued attention to literacy are warranted. Study site and disease duration must be considered as participants in this study had higher than average health literacy and had established diagnoses for years prior to this study.

PRACTICE IMPLICATIONS

The study offers insight into an application of many of the protocols currently recommended to ameliorate effects of limited literacy.

Determinants of the use of wrist working splints in rheumatoid arthritis

OBJECTIVE

To gain insight into the determinants of the use of wrist working splints among patients with rheumatoid arthritis (RA).

METHODS

A qualitative descriptive study was performed among 18 patients with RA who recently received a fabric wrist working splint because of pain due to arthritis of the wrist. Patients were interviewed at home using semistructured in-depth interviews. Interviews were audiotaped and transcribed verbatim and analyzed using the framework approach.

RESULTS

The majority of patients indicated that their splint use was dependent on the seriousness of the symptoms (pain, swelling, or tingling feelings) they perceived. Important reasons to wear the splint were reduction of symptoms, wrist support, and immobilization of the wrist. Important reasons to stop wearing the splint were reduced functional abilities using the splint and the performance of dirty or wet activities.

CONCLUSION

The reasons for patients to wear and not wear wrist working splints are related to intentional decisions of the patients, which are primarily based on perceived benefits and barriers of splint wearing. The results of this study have been used to develop educational and behavioral strategies to increase adherence to wearing wrist working splints.

Medication adherence in patients with chronic non-malignant pain: is there a problem?

Health care providers, treating patients with chronic non-malignant pain, often experience that medication is not as effective as expected. It is important to realize that the effectiveness of a pharmacological treatment can be influenced by the way the medication is taken. Medication adherence is a topic that gains more attention, especially in chronic conditions, because it affects treatment outcome. A systematic review of studies on medication adherence in patients with chronic non-malignant pain was performed to gain insight in the prevalence of the problem, the impact on treatment outcome, influencing variables and interventions. Searching several electronic databases (Medline, CINAHL, Psychinfo and Cochrane), 14 relevant articles were found. The results indicate that medication non-adherence is common in patients with chronic non-malignant pain. Both overuse and underuse of medication occurs. However, due to the scarce literature and important methodological limitations, it is not possible to make firm conclusions concerning the impact on outcome, influencing variables and optimal intervention strategies. This review highlights some important gaps in the adherence literature in a chronic non-malignant pain population and sets the stage for future research.

Medication adherence of patients with selected rheumatic conditions: a systematic review of the literature

OBJECTIVE

Nonadherence with medication treatment has been found to occur in large proportions of patients with a broad range of chronic conditions. Our aim was to perform a systematic review of the literature examining adherence with treatments for inflammatory rheumatic conditions to assess the magnitude of the problem in this patient population.

METHODS

A MEDLINE search of English language literature was performed to identify studies published between January 1, 1985 and November 30, 2007 that evaluated adherence with chronic medications needed in the treatment of rheumatic conditions.

RESULTS

A total of 20 articles met the criteria for evaluation, the majority of which focused on the treatment of rheumatoid arthritis. Most of the studies examined the use of nonsteroidal anti-inflammatory medications and disease-modifying antirheumatic drugs. Adherence was assessed based on self-report, pill counts, pharmacy dispensings, openings of pill containers using electronic devices, laboratory assays, and physician assessment. Adherence varied greatly based on the adherence measure used, arthritic condition evaluated, and medication under study. Overall, the highest rates of adherence were based on self-reports for a wide variety of medications and conditions (range of persons reporting adherence was 30 to 99%), while the lowest adherence rates were for allopurinol based on pharmacy dispensings (18-26%).

CONCLUSIONS

Adherence has not been widely examined for most chronic inflammatory rheumatic conditions and the few studies that exist used different definitions and populations, thus limiting any conclusions. However, the current literature does suggest that nonadherence is a substantial problem.

Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review

This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.

Patients' Representations of Antidepressants: A Clue to Nonadherence?

OBJECTIVES

Antidepressants are prescribed frequently to chronic pain patients due to their pain relief effects. This medication raises major adherence issues. Despite the adverse effects, little is known about the factors that may jeopardize adherence in chronic pain patients. We carried out a qualitative study to investigate chronic pain patients' representations of antidepressants as compared with pain-free controls.

METHODS

One hundred thirteen chronic pain patients recruited in a multidisciplinary pain clinic and 62 matched controls were questioned with standardized semistructured interviews. The interviews were submitted to content analysis.

RESULTS

Ambivalence emerged as an important aspect of "patients" and controls' views about antidepressants. Antidepressants were described as potent chemicals acting in the brain, possibly causing effects on cognition, emotions, and personality, and inducing dependence and loss of control. Positive effects were mentioned, but when respondents related their own views and experiences, the statements became less favorable. Another key point was that neither the representations of the patients and nor those of the controls comprised the analgesic properties of antidepressants.

DISCUSSION

Chronic pain patients' representations differed only little from those of controls. Antidepressants were not considered as addressing somatic problems. Thus, the prescription of antidepressants for chronic pain may be mistaken for a denial of the "reality" of pain. Although this study did not assess medication adherence, it is possible that patient representations have a bearing on adherence. Clinically, this suggests that these representations should be elicited and addressed, taking into account the patients' own models of pain.

Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial

STUDY DESIGN

Three-group, randomized, single blinded, controlled trial.

OBJECTIVE

To test the effectiveness of physiotherapy-based rehabilitation starting 1 week after lumbar disc surgery. In addition, we tried to estimate the contribution of specific effects to the observed outcome (efficacy).

SUMMARY OF BACKGROUND DATA

Physiotherapy-based rehabilitation is usually recommended for patients following lumbar disc surgery. Few and conflicting data exist for the relative effectiveness of this intervention.

METHODS

A total of 120 patients following first-time, uncomplicated lumbar disc surgery were randomly assigned to "comprehensive" physiotherapy, "sham" neck massage, or no therapy. Before enrollment, all subjects completed a minimal physiotherapeutic intervention. Physiotherapy was administered by experienced physiotherapists and consisted of 20 sessions per patient over 12 weeks. Masseurs administered "sham massage" to the neck. The amount of treatment time was equal to that of physiotherapy. The main outcome measure was the Low Back Pain Rating Score (LBPRS) at 6 and 12 weeks, and 1.5 years after randomization. Secondary parameters were patients' overall satisfaction with treatment outcome and socioeconomic and psychologic measures.

RESULTS

At the end of therapy (12 weeks), the LBPRS revealed a significantly better improvement in the physiotherapy group than in the untreated group. LBPRS outcome, however, did not significantly differ between physiotherapy and "sham" therapy. There was a tendency toward significance between the sham therapy and no therapy. Within the 1.5-year follow-up, LBP rating scales remained significantly improved compared with baseline, but there were no significant outcome differences. No statistically significant between-group differences were found for the secondary outcome parameters.

CONCLUSION

As compared with no therapy, physiotherapy following first-time disc herniation operation is effective in the short-term. Because of the limited benefits of physiotherapy relative to "sham" therapy, it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery, but psychological factors may contribute substantially to the benefits observed.

Effects of home strength training and stretching versus stretching alone after lumbar disk surgery: a randomized study with a 1-year follow-up

OBJECTIVE

To assess the adherence to and effects of a 12-month combined strength and stretching home exercise regimen versus stretching alone, on patient outcome after lumbar disk surgery.

DESIGN

Randomized controlled trial.

SETTING

Departments of physical medicine and rehabilitation and orthopedics at a Finnish hospital.

PARTICIPANTS

Patients (N=126) were randomized into either a combined strength training and stretching group (STG, n=65) or a control group (CG, n=61).

INTERVENTION

The STG was instructed to perform strength training and both the STG and CG were instructed in the same stretching and stabilization exercises for 12 months.

MAIN OUTCOME MEASURES

Pain on the visual analog scale (VAS), the Oswestry and the Million disability indexes, isometric and dynamic trunk muscle strength, mobility in the lumbar spine, and straight-leg raising were measured.

RESULTS

The trial was completed by 71% and 77% of the patients from the STG and the CG, respectively. The mean strength training frequency decreased from 1.5 to 0.6 times a week in the STG during the intervention. The mean stretching frequency decreased from 3.7 to 1.6 times a week in both groups. Median back and leg pain varied between 17 and 23 mm (VAS), and the Million and Oswestry indices varied between 14 and 23 points 2 months postoperatively. No statistically significant changes took place in these outcome measures during the 12-month follow-up in both groups. The changes in isometric trunk extension favored the STG ( P =.016) during the first 2 months. However, during the whole 12-month training period, both dynamic and isometric back extension and flexion strength, as well as mobility of the spine and repetitive squat-test results, improved significantly in both groups, and no differences were found in any of the physical function parameters between the STG and CG.

CONCLUSIONS

At the 12-month follow-up, no statistically significant changes were found in the physical function, pain, or disability measures between the groups. In the STG, training adherence with regard to training frequency and intensity remained too low to lead to specific training-induced adaptations in the neuromuscular system. Progressive loading, supervision of training, and psychosocial support is needed in long-term rehabilitation programs to maintain patient motivation.

Use of mainstream nonpharmacologic treatment by patients with arthritis

OBJECTIVE

To examine the use of nonpharmacologic treatment by patients with osteoarthritis (OA) and rheumatoid arthritis (RA).

METHODS

Patients were recruited from physicians' offices in Ontario, Canada. All participants completed questionnaires that asked about their health status, use of medications and nonpharmacologic treatments, and use of health care resources.

RESULTS

A total of 326 patients with OA and 253 patients with RA completed the survey on the use of nonpharmacologic treatment. Only 73% of patients with OA had been told to use nonpharmacologic modalities, but 98.8% had tried at least 1 type of treatment. About 97% of those with RA had been told to use and had tried at least 1 type of treatment. Most patients continued to use a treatment once they had tried it.

CONCLUSION

The use of nonpharmacologic modalities is common among patients with arthritis. It is important that clinicians address with their patients the appropriate use of and barriers to continuing these treatments.

Challenges to early prevention and intervention: personal experiences with adherence

OBJECTIVE

To describe potential adherence-related difficulties encountered in the implementation of a secondary prevention, early intervention study with acute low back pain patients. An additional goal is to provide recommendations, based on the authors' experience, on how best to overcome these potential obstacles for future research.

DESIGN

The study used a predictive algorithm, identified through previous research, to identify which patients presenting with acute low back pain were at risk for developing chronic problems. These subjects were then treated prophylactically with an interdisciplinary intervention. Specific difficulties initially encountered during the pilot stage of implementation of this intervention included securing adequate physician referrals to the study and helping patients to progress through treatment in the most efficient manner.

CONCLUSIONS

Potential difficulties are discussed in the contextual framework of treatment adherence and factors affecting it, including the impact of personality factors, satisfaction, comprehension, side effects, financial issues, length of treatment, type of regimen, social issues, patient beliefs, and biologic factors. It is hoped that the present authors' experience will enable future investigators to anticipate these common problems, and structure their research endeavors accordingly.

Advances with analgesics and NSAIDs for the treatment of spinal disorders

One of the major developments with regard to chronic non-malignant pain in these last few years has been a better understanding of the mechanisms that act to maintain pain, while inferences about the pathophysiology have facilitated therapeutic decision-making. This chapter reviews the strength of evidence for the therapeutic effect of pharmacological symptomatic approaches using non-steroidal anti-inflammatory agents, opioids and co-analgesics in acute and chronic back pain with an emphasis on the results of randomized controlled trials as well as on the need for long-term comparative trials of drug efficacy, toxicity and compliance.

Patient advocacy groups. A key prescription for dermatology

In addition to medical care, patient education and support is important to successful treatment of chronic dermatologic diseases. For assistance, dermatologists and patients should turn to patient advocacy groups, which provide educational materials, programs, support groups, and advocacy for patients with chronic skin diseases.

Physical activity in the life of the patient with rheumatoid arthritis

BACKGROUND AND PURPOSE

Physical activity is an important tool used by patients with rheumatoid arthritis (RA) in order to reduce inflammation and pain as well as preserve and improve function. The aim of this study was to investigate how patients with RA perceive and relate to physical activity in everyday life.

METHODS

Ten patients diagnosed with RA were interviewed. The data collected were transcribed and analysed for categories of meaning and main themes. Inter-judge reliability was tested and showed an 81.5% agreement.

RESULTS

Three themes were identified. The first represented a 'driving force' and included two positively loaded categories 'satisfaction' and 'support', and two negatively loaded categories 'keep at bay' and 'intimidation'. The second theme was 'hindrance' and included the categories 'internal barrier' and 'external barrier' and, finally, the third theme 'physical activity' included the categories 'organized activity' and 'everyday activity'.

CONCLUSION

Physical exercise was an important strategy for patients with RA and was promoted primarily by patients' own experiences, positive as well as negative. A salutogenic (explaining health) approach to patient education, as well as an increased use of everyday activities as additional exercise, is advocated.

Persistent functional and social benefit 5 years after a multidisciplinary arthritis training program

OBJECTIVE

To assess the sustainable benefits of a professional, multidisciplinary training program for patients with rheumatoid arthritis.

DESIGN

Two studies with different observation periods. Study I was a prospective, randomized trial for 1 year. Study II was a noncontrolled observation over 5 years.

SETTING

The 9-day program for eight patient groups encompassed a multidisciplinary cooperation between rheumatologists, orthopedists, physicotherapists, psychologists and social workers.

PATIENTS

Sixty-eight consecutive patients with rheumatoid arthritis participated in an arthritis training program either immediately after enrollment in the program or after 1 year.

INTERVENTIONS

The program covered the following fields: pathogenesis of rheumatoid arthritis, drug therapy, physicotherapy, practical exercise in remedial gymnastics, use of joint protection devices, orthopedic perspectives, psychological counseling, dietetics, information about unproven cures and social assistance.

MAIN OUTCOME MEASURES

Clinical outcome was assessed by self-report questionnaires: (1) Stanford Health Assessment Questionnaire, (2) Freiburg Questionnaire of Coping with Illness, (3) Beck Depression Inventory, and (4) a 21-point scale to evaluate cognitive-behavioral and environmental impact.

RESULTS

A significant and persistent improvement of all investigated parameters was demonstrated in the 1-year controlled trial. Between the end-point of the 1-year study and the 5-year evaluation, this improvement increased even more for functional status and coping with illness, whereas depression returned to baseline values. These effects were seen even without reinforcement of the training.

CONCLUSION

A professional, multidisciplinary approach to educate patients with rheumatoid arthritis leads to a significant and sustained improvement of the clinical outcome and is an approach that should be established as a part of conventional therapy.

A crossover trial evaluating an educational-behavioural joint protection programme for people with rheumatoid arthritis

Joint protection (JP) is a self-management technique widely taught to people with rheumatoid arthritis (RA). JP education aims to enable people with RA to reduce pain, inflammation, joint stress and reduce risks of deformity through using assistive devices and alternative movement patterns of affected joints to perform everyday activities. Previous studies evaluating JP education methods common in the UK have identified JP adherence is poor. A group education programme was developed using the Health Belief Model and Self-efficacy Theory. Strategies used to maximise JP adherence included goal-setting, contracting, modelling, homework programmes, motor learning theory, recall enhancing methods and mental practice. A crossover trial (n = 35) was conducted. Adherence with JP was measured using an objective observational test (the Joint Protection Behaviour Assessment). Significant improvements in use of JP were recorded at 12 and 24 weeks post-education (P < 0.01). No significant changes in measures of pain, functional disability, grip strength, self-efficacy or helplessness occurred post-education, although this may have been due to the small sample size recruited. In conclusion, JP adherence can be facilitated through the use of educational-behavioural strategies, suggesting this approach should be more widely adopted in clinical practice.

Determinants of compliance with medication in patients with rheumatoid arthritis: the importance of self-efficacy expectations

In this study we examine which factors are related to compliance with medication in patients suffering from rheumatoid arthritis (RA).

PATIENTS

persons suffering recently developed, active RA, who cooperated in a randomized study on the effect of patient education. We analyzed the relation between adherence to Sulphasalazine therapy and personal factors, environmental influences, demographic factors, disease-related factors, and barriers to compliance. Moreover, a logistical regression analysis was performed on these factors, considering > or = 80% a high compliance, both with compliance as dependent factor. Only self-efficacy correlated with compliance (r = 0.58; P < 0.001). The logistical regression analysis identified self-efficacy as the only factor determining > or = 80% adherence (P = 0.01). Self-efficacy regarding the use of prescribed medication is related to compliance with this treatment. Further study is needed to determine the test characteristics of self-efficacy as a predictor for compliance with medication.

Effects of patient education on compliance with basic treatment regimens and health in recent onset active rheumatoid arthritis

OBJECTIVES

To determine the effects of patient education on compliance and on health in patients with active, recent onset rheumatoid arthritis (RA).

METHODS

A randomised, controlled, assessor blinded, one year trial. The experimental group followed an education programme. All patients started on sulphasalazine therapy. Compliance with sulphasalazine was measured by pill counting. Compliance rates with regimens of physical exercise, endurance activities, and energy conservation were measured by questionnaires. Compliance with prescriptions of joint protection was scored using a test for joint protection performance. Health was measured by a Disease Activity Score (function of erythrocyte sedimentation rate, Ritchie score, and number of swollen joints), C reactive protein, Dutch-AIMS scores, and M-HAQ scores, range of motion of shoulder, elbow, and knee joints. Parameters were scored at baseline and after three, six, and 12 months.

RESULTS

Sixty of 65 patients gave informed consent, five of them withdrew from follow up. Compliance with sulphasalazine exceeded 80% with no differences between groups. Compliance with physical exercise (at three months), energy conservation (at three and at 12 months), and joint protection (at three months) improved significantly more in the experimental group. The improvements of health were not different in the groups.

CONCLUSION

Compliance with sulphasalazine among patients with active, recent onset RA is high, whether formal patient education is followed or not. Compliance with physical exercise, energy conservation, and joint protection was increased by patient education. Formal patient education did not improve health status.