Alison Hammond

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I–IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Self-management of rheumatic diseases: state of the art and future perspectives

Self-management interventions are patient-centred and designed to foster active participation of patients in order to promote well-being and to manage symptoms. Over the past two decades, the role of self-management in chronic diseases has gained momentum. Self-management programmes are now acknowledged as a key element of quality care. New modes of delivery allow greater access to information and are tailored to address patient needs. This systematic review presents data from clinical studies of self-management over the past decade, summarises the evidence for programme effectiveness, and suggests future research directions.

Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy

Objectives To investigate the effect of group cognitive behavioural therapy (CBT) for fatigue self-management, compared with groups receiving fatigue information alone, on fatigue impact among people with rheumatoid arthritis (RA). Methods Two-arm, parallel randomised controlled trial in adults with RA, fatigue ≥6/10 (Visual Analogue Scale (VAS) 0–10, high bad) and no recent change in RA medication. Group CBT for fatigue self-management comprised six (weekly) 2 h sessions, and consolidation session (week 14). Control participants received fatigue self-management information in a 1 h didactic group session. Primary outcome at 18 weeks was the impact of fatigue measured using two methods (Multi-dimensional Assessment of Fatigue (MAF) 0–50; VAS 0–10), analysed using intention-to-treat analysis of covariance with multivariable regression models. Results Of 168 participants randomised, 41 withdrew before entry and 127 participated. There were no major baseline differences between the 65 CBT and 62 control participants. At 18 weeks CBT participants reported better scores than control participants for fatigue impact: MAF 28.99 versus 23.99 (adjusted difference −5.48, 95% CI −9.50 to −1.46, p=0.008); VAS 5.99 versus 4.26 (adjusted difference −1.95, 95% CI −2.99 to −0.90, p<0.001). Standardised effect sizes for fatigue impact were MAF 0.59 (95% CI 0.15 to 1.03) and VAS 0.77 (95% CI 0.33 to 1.21), both in favour of CBT. Secondary outcomes of perceived fatigue severity, coping, disability, depression, helplessness, self-efficacy and sleep were also better in CBT participants. Conclusions Group CBT for fatigue self-management in RA improves fatigue impact, coping and perceived severity, and well-being. Trial registration: ISRCTN 32195100

EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis

Objectives The authors aim to develop European League Against Rheumatism recommendations for the role of the nurse in the management of patients with chronic inflammatory arthritis, to identify a research agenda and to determine an educational agenda. Methods A task force made up of a multidisciplinary expert panel including nurses, rheumatologists, occupational therapist, physiotherapist, psychologist, epidemiologist and patient representatives, representing 14 European countries, carried out the development of the recommendations, following the European League Against Rheumatism standardised operating procedures. The task force met twice. In the first meeting, the aims of the task force were defined, and eight research questions were developed. This was followed by a comprehensive, systematic literature search. In the second meeting, the results from the literature review were presented to the task force that subsequently formulated the recommendations, research agenda and educational agenda. Results In total, 10 recommendations were formulated. Seven recommendations covered the contribution of nurses to care and management: education, satisfaction with care, access to care, disease management, psychosocial support, self-management and efficiency of care. Three recommendations focused on professional support for nurses: availability of guidelines or protocols, access to education and encouragement to undertake extended roles. The strength of the recommendations varied from A to C, dependent on the category of evidence (1A–3), and a high level of agreement was achieved. Additionally, the task force agreed upon 10 topics for future research and an educational agenda. Conclusion 10 recommendations for the role of the nurse in the management of chronic inflammatory arthritis were developed using a combination of evidence-based and expert consensus approach.

Community patient education and exercise for people with fibromyalgia: a parallel group randomized controlled trial

Objective: To evaluate the effects of a community patient education -exercise programme, using a cognitive-behavioural approach, for people with fibromyalgia. Design: A randomized, parallel group trial with assessments at 0, 4 and 8 months. Setting: Community leisure centres. Subjects: People with fibromyalgia (n=183) attending a rheumatology outpatient department at a large district general hospital. Interventions: Participants were randomized to a patient education-exercise group (n=97) or relaxation (attention control) group (n=86). Main measures: The Fibromyalgia Impact Questionnaire (0-80; lower score means better health). Secondary outcomes included: the Arthritis Self-Efficacy Scale(pain and other symptoms subscales: 1 -10 scale; higher scores mean greater self-efficacy) and self-reported improvement. Results: Fifty participants withdrew or were unable to attend and 133 completed and returned baseline questionnaires: patient education group (n=71); relaxation group (n=62); 120/133 participants were women. Average age was 48. 53 (SD 10.89) years. Follow-up ranged between 73 and 82% of questionnaires returned. At four months, there was a difference in average changes in total Fibromyalgia ImpactQuestionnaire scores between the two groups: patient education group -3.38 (SD 9.35); relaxation group 0.3 (SD 8.85); P=0.02. Arthritis Self-Efficacy Scale scores were significantly higher in the patient education group: pain 0.59 (SD 1.45)compared to the relaxation group’s -0.12 (SD 1.22); P=0.003; other symptoms (patient education group 0.72 (SD 1.33); relaxation group 0.03 (SD 1.16); P=0.002). At eight months these differences were no longer apparent. Forty-seven per cent in the patient education group self-reported improvement compared with 13% in the relaxation group (ϰ=13.65; P=0.0001). Conclusion: Short-term improvements resulted from the education -exercise programme but were not sustained. Appropriate selection may improve efficacy.

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population

Objective: To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation). Design: Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments. Outcome measures: Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist. Results: Strong correlations (>0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side. Conclusion: In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.

Effects of a modular behavioural arthritis education programme: a pragmatic parallel-group randomized controlled trial

OBJECTIVES Rheumatology guidelines recommend people with RA receive behavioural self-management education. This study developed a modular behavioural group programme and evaluated its longer term effects on pain, physical and psychological status. METHODS People with RA or PsA were randomized to a modular behavioural or standard information-focused education programme, both delivered by experienced rheumatology health professionals at one large district general hospital. Outcome measures were pain, self-efficacy, fatigue, functional ability, psychological status and use of health behaviours (exercise, joint protection, fatigue and cognitive symptom management). Using an intent-to-treat analysis outcomes were compared at 6 and 12 months with analysis of covariance. RESULTS Out of 498 referred patients, 218 agreed to participate, met entry criteria and were randomized; 51 withdrew before education. Of the remaining patients, 86 attended the behavioural and 81 the standard programmes. Participants were aged 55.4 yrs (s.d. 12.42) with disease duration of 7.39 (s.d. 6.88) yrs (53% <5 yrs). At 6 months, the behavioural group had better pain (P = 0.01), fatigue (P = 0.01), functional ability (P = 0.05) and self-efficacy (P = 0.01) scores and greater use of health behaviours. At 12 months, they continued to have better pain (P = 0.03), self-efficacy (P = 0.001) and psychological status (P = 0.0001) scores and greater use of some health behaviours. CONCLUSION Attending a modular behavioural education programme is effective for at least 1 yr in enabling people with RA and PsA to reduce pain, improve psychological status and self-manage their condition.

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.

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

Objective: To identify the effect of attending a cognitive-behavioural arthritis education programme on the health status of participants with newly diagnosed rheumatoid arthritis (RA) compared with a control group. Design: Randomized controlled trial. Setting: Hospital based. Subjects: Newly diagnosed with RA. Intervention: Participation in either a cognitive-behavioural arthritis education programme or a standard arthritis education programme (control group). Sessions for both groups lasted for 2 hours per week for four weeks. Subjects were examined at home by an assessor blinded to group allocation, prior to and three and six months following attendance. Outcome measures: The main outcome measure was the Physical Function subscale of the Arthritis Impact Measurement Scale Two. Other outcome measures included erythrocyte sedimentation rate (ESR), joint count scores, assessments of pain and psychological status. Results: Fifty-four subjects (mean time since diagnosis 4.5 months) took part. Baseline analysis revealed that the control group had significantly better levels of functional ability (U = 185; p = 0.009) and lower levels of helplessness (U = 168; p = 0.002) prior to intervention. This difference remained unchanged three months later. Six months following the intervention no significant differences were noted between the groups for any measure of health status. There were no significant changes in health status over time in either group. Conclusion: Attending a cognitive-behavioural arthritis education programme had no significant effect on the health status of individuals newly diagnosed with RA. The move to early use of these programmes should be examined further, with a larger sample size and longer duration of follow-up.

Self-management approaches for osteoarthritis in the hand: a 2×2 factorial randomised trial

Background Osteoarthritis is the leading cause of disability in older adults. Evidence of effectiveness for self-management of hand osteoarthritis is lacking. Methods In this randomised, factorial trial, we evaluated the effectiveness of joint protection versus no joint protection, and hand exercise versus no hand exercise in adults, 50 years of age or older, with hand osteoarthritis. Following a population survey (n=12 297), eligible individuals were randomly assigned (1:1:1:1) to: leaflet and advice; joint protection; hand exercise; joint protection plus hand exercise. Joint protection and hand exercises were delivered by nine occupational therapists, over four group sessions. The primary outcome was the OARSI/OMERACT responder criteria at 6 months. Outcomes were collected blind to allocation (3, 6, 12 m). Analysis was by intention to treat. Results Of 257 participants randomised (65:62:65:65) (mean age (SD) 66 years (9.1); female 66%) follow-up was 85% at 6 m (n=212). Baseline characteristics and loss to follow-up were similar between groups. There were no reported treatment side effects. At 6 m 33% assigned joint protection were responders compared with 21% with no joint protection (p=0.03). Of those assigned hand exercises, 28% were responders compared with 25% with no exercises (n.s.). Differences in secondary outcomes were not statistically significant, except for improvement in pain self-efficacy with joint protection (3 m p=0.002; 6 m p=0.001; 12 m p=0.03). Conclusions These findings show that occupational therapists can support self-management in older adults with hand osteoarthritis, and that joint protection provides an effective intervention for medium term outcome. (Funded by the Arthritis Research UK ISRCTN 33870549).