Jo Adams

EULAR recommendations for patient education for people with inflammatory arthritis

Objectives The task force aimed to: (1) develop evidence-based recommendations for patient education (PE) for people with inflammatory arthritis, (2) identify the need for further research on PE and (3) determine health professionals’ educational needs in order to provide evidence-based PE. Methods A multidisciplinary task force, representing 10 European countries, formulated a definition for PE and 10 research questions that guided a systematic literature review (SLR). The results from the SLR were discussed and used as a basis for developing the recommendations, a research agenda and an educational agenda. The recommendations were categorised according to level and strength of evidence graded from A (highest) to D (lowest). Task force members rated their agreement with each recommendation from 0 (total disagreement) to 10 (total agreement). Results Based on the SLR and expert opinions, eight recommendations were developed, four with strength A evidence. The recommendations addressed when and by whom PE should be offered, modes and methods of delivery, theoretical framework, outcomes and evaluation. A high level of agreement was achieved for all recommendations (mean range 9.4–9.8). The task force proposed a research agenda and an educational agenda. Conclusions The eight evidence-based and expert opinion-based recommendations for PE for people with inflammatory arthritis are intended to provide a core framework for the delivery of PE and training for health professionals in delivering PE across Europe.

Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial.

BACKGROUND Disease-modifying biological agents and other drug regimens have substantially improved control of disease activity and joint damage in people with rheumatoid arthritis of the hand. However, commensurate changes in function and quality of life are not always noted. Tailored hand exercises might provide additional improvements, but evidence is lacking. We estimated the effectiveness and cost-effectiveness of tailored hand exercises in addition to usual care during 12 months. METHODS In this pragmatic, multicentre, parallel-group trial, at 17 National Health Service sites across the UK we randomly assigned 490 adults with rheumatoid arthritis who had pain and dysfunction of the hands and had been on a stable drug regimen for at least 3 months, to either usual care or usual care plus a tailored strengthening and stretching hand exercise programme. Participants were randomly assigned with stratification by centre. Allocation was computer generated and unmasked to participants and therapists delivering treatment after randomisation. Outcome assessors and all investigators were masked to allocation. Physiotherapists or occupational therapists gave the treatments. The primary outcome was the Michigan Hand Outcomes Questionnaire overall hand function score at 12 months. The analysis was by intention to treat. We calculated cost per quality-adjusted life-year. This trial is registered as ISRCTN 89936343. FINDINGS Between Oct 5, 2009, and May 10, 2011, we screened 1606 people, of whom 490 were randomly assigned to usual care (n=244) or tailored exercises (n=246). 438 of 490 participants (89%) provided 12 month follow-up data. Improvements in overall hand function were 3·6 points (95% CI 1·5-5·7) in the usual care group and 7·9 points (6·0-9·9) in the exercise group (mean difference between groups 4·3, 95% CI 1·5-7·1; p=0·0028). Pain, drug regimens, and health-care resource use were stable for 12 months, with no difference between the groups. No serious adverse events associated with the treatment were recorded. The cost of tailored hand exercise was £156 per person; cost per quality-adjusted life-year was £9549 with the EQ-5D (£17,941 with imputation for missing data). INTERPRETATION We have shown that a tailored hand exercise programme is a worthwhile, low-cost intervention to provide as an adjunct to various drug regimens. Maximisation of the benefits of biological and DMARD regimens in terms of function, disability, and health-related quality of life should be an important treatment aim. FUNDING UK National Institute of Health Research Health Technology Assessment Programme (NIHR HTA), project number 07/32/05.

Development and delivery of an exercise intervention for rheumatoid arthritis: Strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial

This paper describes the development and implementation of a hand exercise intervention for rheumatoid arthritis (RA) as part of a large multi-centred randomised controlled trial in a U.K. National Health Service (NHS) setting. Participants are eligible if diagnosed with RA according to American College of Rheumatology criteria, have a history of disease activity, functional deficit or impairment in the hand and/or wrist, and have been on a stable medication regime for at least 3 months. The intervention development was informed by the current evidence base, published guidelines, clinician and expert opinion, and a pilot study. The exercise programme targets known, potentially modifiable physical impairments of the hand with 5 exercise sessions and a home exercise component over a 12 week period. The intervention will be provided to 240 participants along with usual care. A further 240 will receive usual care only as part of the control arm. Specific details of the treatments delivered are described. [ISRCTN no: 89936343].

Proximal interphalangeal joint replacement in patients with arthritis of the hand: A meta-analysis

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications. Original studies were selected if they reported clinical outcome with a minimum of one years follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37). We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence. We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry.

Strengthening and stretching for rheumatoid arthritis of the hand (SARAH). A randomised controlled trial and economic evaluation

BACKGROUND The effectiveness of exercise for improving hand and wrist function in people with rheumatoid arthritis (RA) is uncertain. OBJECTIVES The study aims were (1) to estimate the clinical effectiveness and cost-effectiveness of adding an optimised exercise programme for hands and upper limbs to standard care for patients with RA; and (2) to qualitatively describe the experience of participants in the trial with a particular emphasis on acceptability of the intervention, exercise behaviours and reasons for adherence/non-adherence. DESIGN A pragmatic, multicentred, individually randomised controlled trial with an embedded qualitative study. Outcome assessors were blind to group assignment and independent of treatment delivery. SETTING Seventeen NHS trusts in England comprising 21 rheumatology and therapy departments. PARTICIPANTS Adults with RA who had pain and dysfunction of the hands and/or wrists and had been on stable medication for at least 3 months. Patients were excluded if they were under 18 years old, had undergone upper limb surgery/fracture in the last 6 months, were on a waiting list for upper limb surgery or were pregnant. INTERVENTIONS Usual care or usual care plus an individualised exercise programme. Usual care consisted of joint protection education, general exercise advice and functional splinting if required. The exercise programme consisted of six sessions of strengthening and stretching exercises with a hand therapist, daily home exercises and strategies to maximise adherence. MAIN OUTCOME MEASURES The primary outcome was the Michigan Hand Outcome Questionnaire (MHQ) overall hand function subscale score at 12 months. Secondary outcome measures included the full MHQ, pain, health-related quality of life (Short Form questionnaire-12 items), impairment (grip strength, dexterity and range of motion) and self-efficacy. European Quality of Life-5 Dimensions, medication and health-care use were collected for the health economics evaluation. Follow-up was at 4 and 12 months post randomisation. Analysis was performed on an intention-to-treat basis. RESULTS We randomised 490 patients (244 to usual care, 246 to exercise programme). Compliance with the treatments was very good (93% of usual care participants and 75% of exercise programme participants completed treatment). Outcomes were obtained for 89% of participants at 12 months (222 for usual care, 216 for exercise programme). There was a statistically significant difference in favour of the exercise programme for the primary outcome at 4 and 12 months [mean difference 4.6 points, 95% confidence interval (CI) 2.2 to 7.0 points; and mean difference 4.4 points, 95% CI 1.6 to 7.1 points, respectively]. There were no significant differences in pain scores or adverse events. The estimated difference in mean quality-adjusted life-years (QALYs) accrued over 12 months was 0.01 greater (95% CI -0.03 to 0.05) in the exercise programme group. Imputed analysis produced incremental cost-effectiveness ratio estimates of £17,941 (0.59 probability of cost-effectiveness at willingness-to-pay threshold of £30,000 per QALY). The qualitative study found the exercise programme to be acceptable and highlighted the importance of the therapist in enabling patients to establish a routine and incorporate the exercises into their lives. CONCLUSIONS The results of the Strengthening And stretching for Rheumatoid Arthritis of the Hand trial suggest that the addition of an exercise programme for RA hands/wrists to usual care is clinically effective and cost-effective when compared with usual care alone. No adverse effects were associated with the exercise programme. The economic analysis suggests that the intervention is likely to be cost-effective. STUDY REGISTRATION Current Controlled Trials ISRCTN 89936343.

What can handgrip strength tell the therapist about hand function

Power handgrip strength is recorded by clinicians as a quick and viable measure of hand impairment and function that can serve as a useful evaluation of hand status and treatment progress. This paper explores the procedure and reliability of measuring handgrip using different equipment. The extent of usefulness of grip strength as an indicator of structural impairment and ability measures in patient populations is questioned and the relevance of recording grip strength as part of a clinical assessment is summarised.

The educational needs of nurses and allied healthcare professionals caring for people with arthritis: results from a cross-sectional survey.

AIM The purpose of the present study was to identify the educational needs of rheumatology nurses and allied healthcare professionals (AHPs) working with people with osteoarthritis (OA) and rheumatoid arthritis (RA). METHODS A cross-sectional national online survey was carried out. RESULTS The survey was completed by 162 health care practitioners. Seventy-one per cent of respondents had the knowledge and skills to manage the care of a person with RA. The elements of care for which the respondents were either unsure or did not have the necessary knowledge and skills related to providing advice on exercise (37%) and pain medication (30%) to people with RA. There was a consistent tendency for respondents to be less confident in their knowledge and skills when caring for people with OA, with respondents reporting that they were either unsure or did not have the necessary knowledge and skills to advise on appropriate exercise (61%), or medication for the management of pain (45%) or the management of ongoing care (51%). CONCLUSIONS Current and future educational programmes on RA and OA management should provide nurses and AHPs with the opportunity to develop knowledge and skills in providing advice on exercise and pain medication.

Literacy levels required to complete routinely used patient-reported outcome measures in rheumatology

OBJECTIVE To assess the reading levels required to complete patient-reported outcome measures (PROs) commonly used in rheumatology clinical and research settings. METHODS Ten PROs written in English were evaluated. Four reviewers critiqued each measure blindly using two standardized readability indexes and a final readability score for each PRO was agreed. RESULTS Only six of the PROs met the recommended reading level for health education literature. CONCLUSION Many people completing PROs will not be able to understand what they are answering and will be unable to give an accurate perspective on their condition.

The effectiveness of musculoskeletal education interventions in people with lower literacy: a systematic review

To conduct a systematic review to assess the effectiveness of patient education interventions delivered or directed by health professionals for people with musculoskeletal conditions who also have lower levels of literacy.

Effectiveness of Musculoskeletal Education Interventions in People With Low Literacy Levels: A Systematic Review

To conduct a systematic review to assess the effectiveness of patient education interventions delivered or directed by health professionals for people with musculoskeletal conditions who also have lower levels of literacy.