Arthritis Education Research Articles

Monitoring Progress in Arthritis Management—United States and 25 States, 2003

Arthritis is a chronic disease affecting an estimated 43 million (20.8%) U.S. adults and is the leading cause of disability in the United States. Arthritis results in activity and work limitations, decreased quality of life, and substantial burden to the U.S. health-care system. Promotion of arthritis self-management through weight counseling, physical activity counseling, and arthritis education can reduce pain, improve function and quality of life, and delay disability among persons with arthritis. To encourage arthritis self-management, three objectives were added to the national health objectives for 2010. To monitor progress toward achieving these objectives and assess that progress by selected characteristics, CDC analyzed data from the 2003 National Health Interview Survey (NHIS) and the state-based 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of those analyses, which indicated no statistically significant progress toward reaching the targets for weight counseling, physical activity counseling, and arthritis education. To meet these targets by 2010, public health and health-care agencies should increase efforts to improve awareness of these three factors among both health-care providers and patients. Such interventions will enable persons with arthritis to better self-manage their disease.

Good teachers: substainable models

Dr Azer (February 2005, JRSM1) lists the qualities of a good teacher but is less persuasive on how these can be developed and sustained. In the UK, for example, teaching is just one of seven duties of a doctor. Other duties are to provide good clinical care, maintain good working relationships with patients and colleagues and maintain high standards of probity.2 What if one duty conflicts with another—for example, what if you are called to a patient or to a team meeting in the middle of a tutorial? There are no right or wrong answers but there is much to be said for involving patients in the education of medical students. This can reduce the workload for ourselves. In one study, students who had been taught pelvic examination by specially trained laywomen showed better skills than students taught in the conventional way.3 Similarly, patients trained in arthritis education can teach musculoskeletal examination skills.4 Perhaps more importantly, such patient-educators can encourage medical students to realize the impact of chronic arthritis on daily life.4 Colleagues from other disciplines can also be recruited, to increase the resources and support available, though time is needed to surmount the traditional barriers and provide an integrated programme.5

Clinical and psychological outcomes of patient education in rheumatoid arthritis

Evidence that patient education improves outcome in self-selected patients is often based on studies using patients with a mixture of diagnoses (primarily osteoarthritis) and where the education is delivered in a community setting. This study explored whether hospital outpatients with rheumatoid arthritis (RA) who were offered a self-management programme showed a similar response. A randomized controlled trial was undertaken of either observation or observation plus an educational intervention of five sessions (12.5 hours) designed to enhance self-management. Pain and self-efficacy for pain were the primary outcome measures. These and other standardized assessments were made at 0, 4, 8 and 36 weeks for a variety of psychological and disease states. Knowledge of RA and its treatment was measured at 0 and 4 weeks using a multiple-choice questionnaire. Sixty-eight of 79 randomized patients provided adequate data. In those randomized to be offered education, knowledge of RA and its treatment increased by 18% compared to 9% in controls (p = 0.058). Self-efficacy for pain improved between weeks 0 and 4 by 10.3% (p = 0.015) in those offered education, and by 14.1% in those who were offered and accepted education (p = 0.001) but the difference from controls was not maintained after four weeks. There were no significant differences between groups in pain or in any of the remaining variables. Most patients reported that the education had been helpful. Patients offered education gained knowledge and reported personal benefit, but only improved in self-efficacy for pain and only for a short time. RA patients drawn from hospital outpatient clinics and allocated to an educational intervention may not gain changes in health status as measured by the instruments employed in this study.

Systematic review of rheumatoid arthritis patient education

Rheumatoid arthritis (RA) is a common chronic condition characterized by uncertain disease progression and an unpredictable course of exacerbations and remissions. Approximately 1–3% of the population in Western countries is affected by RA (1). Various interventions may alleviate its course, and patients come into contact with a large number and variety of health professionals. For many patients, pain, disability, deformity, and reduced quality of life persist in spite of treatment. There is room for new approaches to enhance current treatment effectiveness. Patient education is one such approach that is thought to be beneficial in helping patients cope with their disease and cooperate with its complex management (2,3). As with other chronic diseases, there is no cure for most types of arthritis, including RA. Furthermore, the disease course is often unpredictable and the symptoms that patients experience can vary from day to day or even from hour to hour. Because of the nature of pain and disability, the partial and inconsistent effects of treatment, and the unpredictability people with arthritis face on a daily basis, patient education programs have become a complement to traditional medical treatment (4). Thus, patient education programs have given people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease (5,6). Patient education has been defined as “any set of planned educational activities designed to improve patients health behaviors and/or health status” (7). Lorig has further stated “the purpose of patient education is to maintain or improve health, or, in some cases, to slow deterioration” (7). The focus of arthritis patient education programs is to teach patients to adjust their daily activities as dictated by disease symptoms. In other words, in addition to teaching patients what they should do, patients are also instructed on how to approach situations and to make adjustments that are appropriate for each individual and his or her own needs. There has been increasing research in the field of patient education, and major reviews of published studies have been conducted on the value of education in general (8) and, more recently, on education in arthritis (5,6,9,10). Two reviews on arthritis patient education reported combined effect estimates on main outcome measures, such as pain, functional disability, and psychological outcomes (9,10). Hawley reviewed 34 rheumatic disease patient education clinical trials performed between 1985 and 1995 (9). She reported average effect sizes for treatment groups compared with nonintervention controls for RA patient pain, functional ability, and depression at postintervention of 0.13, –0.16, and 0.01, respectivley; effect sizes for osteoarthritis (OA) patient pain, functional ability, and depression at postintervention were 0.44, 0.28, and 0.56, respectively (confidence intervals were not reported). These data show a trend to greater improvement for OA compared with RA patients (9). Superio-Cabuslay et al compared the effects of 19 patient education trials and 28 nonsteroidal antiinflammatory drug trials between 1966 and 1993 among patients with OA and RA (10). They found an average effect size for treatment compared with nonintervention controls for RA patient pain and funcThis article is a summary of a Cochrane systematic review: Riemsma R, Kirwan J, Taal E, Rasker J. Patient education for adults with rheumatoid arthritis. Cochrane Database Syst Rev 2002;(3):CD003688. An editorial discussing the main results of the review has been published: Riemsma RP, Taal E, Kirwan JR, Rasker JJ. Patient education programmes for adults with rheumatoid arthritis [editorial]. BMJ 2002;325:558–9. The results of a Cochrane review can be interpreted differently, depending on people’s perspectives and circumstances. Please consider the conclusions presented carefully. They are the opinions of review authors, and are not necessarily shared by the Cochrane Collaboration. The views expressed in this report are those of the authors and not necessarily those of the Dutch Arthritis Association. Any errors are the responsibility of the authors. Supported by a grant from the Dutch Arthritis Association. Robert P. Riemsma, PhD: Centre for Reviews and Dissemination, University of York, York, United Kingdom; Erik Taal, PhD: University of Twente, Enschede, The Netherlands; John R. Kirwan, BSc, MD: Bristol Royal Infirmary, Bristol, United Kingdom; Johannes J. Rasker, MD, PhD: University of Twente and Medisch Spectrum Twente, Enschede, The Netherlands. Address correspondence to Robert P. Riemsma, PhD, Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK. E-mail: rpr1@york.ac.uk. Submitted for publication July 4, 2003; accepted in revised form November 30, 2003. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 51, No. 6, December 15, 2004, pp. 1045–1059 DOI 10.1002/art.20823 © 2004, American College of Rheumatology

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

To evaluate the long-term effects of joint protection on health status of people with early rheumatoid arthritis (RA). A four-year follow-up of a randomized, controlled, assessor-blinded trial was conducted. Two rheumatology outpatient departments. People with rheumatoid arthritis less than five years since diagnosis. 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. 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. 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). 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.

Arthritis: a broader approach

Arthritis: a broader approach

Patient education in arthritis: helping people change

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

Physical Therapist-Based Group Exercise/Education Program to Improve Functional Health in Older Health Maintenance Organization Members with Arthritis

Purpose: The purpose of this research was to investigate the effects of a group education/low to moderate intensity exercise intervention on the health status of older health maintenance organization (HMO) members with arthritis. Methods: 36 individuals (11 males, mean age = 76.8 ± 5.1 yrs; 25 females, mean age = 71.8 ± 6.4 yrs) with moderate to severe osteoarthritis or rheumatoid arthritis participated in the study. Participants had multiple comorbidities (mean =1.8 ± 1.0) and were taking multiple medications (mean = 4.2 ± 2.1). Participants were pretested and post-tested using the Physical Performance Test (PPT) and the Short Form (SF)-36 health status questionnaire. The intervention consisted of 90-minute classes held twice weekly for 9 weeks. The classes encompassed arthritis education and an exercise program (stretching, strengthening, endurance, and balance). Standing and sitting dynamic balance exercises were emphasized, including use of large therapy balls in sitting. Results: The PPT mean total scores improved significantly from pretest to post-test (p < .001). Scores on 7 of 9 PPT items improved significantly (p < .05). Scores improved on all 8 SF-36 scales, but the changes did not reach significance (p > .05) on the physical component scales. Significant improvement occurred on 3 of 4 of the mental health component scales of the SF-36 (p < 05). Conclusion: A group program of education and exercise led by physical therapists and an arthritis educator had a positive impact on physical performance and mental health in older persons with arthritis. The class may be a worthwhile adjunct to medical management of patients with arthritis.

Provision of Internet‐based rheumatology education (http://rheuma.bham.ac.uk)

The Internet is becoming an important way of delivering medical information, and if used appropriately may assist in improving patients' self-management of their disease. We have established an arthritis education website ('Arthritis Help') and investigated its use over the last 2 yr. Computer-generated log-file analysis and on-line questionnaires were used to create user profiles of our website. An average of 288 people visited our site each day, predominantly from America and the UK (49% of users). The typical questionnaire respondent (n = 770) was an American female with arthritis, aged 30+ yr, accessing the Internet from home. Typically, respondents had previously obtained information from medical staff or in written form, but were now more likely to use the Internet. One hundred and sixty-seven out of 585 respondents found our site to be useful, prompting them to seek more information (29%), change their behaviour or engage in more effective discussions with their physician (15%). These data indicate that it is possible to use the Internet to deliver medical information to its target audience, and that this process can have some impact on the way disease is self-managed. This information may aid more focused website design to maximize the use and potential benefits of such a resource.

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

To evaluate the effects of an education programme in improving adherence with joint protection by people with rheumatoid arthritis (RA). A repeated measures design. Subjects were assessed at six weeks and one week before and six and twelve weeks after education. Rheumatology unit in a large district general hospital. Twenty-one people diagnosed with RA (mean age 48.95 years (SD 12.54) and disease duration of 6.43 years (SD 7.7) ). An 8-hour arthritis education programme delivered over four sessions, including two hours of joint protection education designed to be typical of current UK practice. The Joint Protection Behaviour Assessment (JPBA), an observational assessment of hand joint protection methods used during kitchen activities, to measure adherence with education. Other assessments included a joint protection knowledge questionnaire, hand joint counts, hand pain visual analogue scale, the Health Assessment Questionnaire (HAQ) and HAQ Pain scale to identify any short-term changes in hand pain, pain on activity and functional status. At the beginning and end of the study subjects were interviewed to obtain their self-report of joint protection behaviours and reasons for following or not following the advice given. Median JPBA scores did not improve pre- to posteducation (18.4% to 23.7%; p = 0.65) and neither did hand joint count, hand pain, HAQ and HAQ Pain scores. However, joint protection knowledge improved significantly (p = 0.01) and the majority of people believed joint protection to be a beneficial strategy. Reasons for not changing behaviour included problems recalling information; joint protection being considered inappropriate as 'hands were not that bad yet'; lack of skill; and difficulties changing habits. The joint protection education programme improved knowledge but not use of taught methods. Educational strategies being used by therapists need to be focused on enhancing adherence.

Patient and public health education in arthritis and musculoskeletal disorders: Challenges for the future

Patient and public health education in arthritis and musculoskeletal disorders: Challenges for the future

Musculoskeletal Rehabilitation

Musculoskeletal problems are common, disabling, and cause great suffering in older adults. Rehabilitation services are frequently indicated and can usually be offered in an outpatient setting. The role of the physician is to make an accurate diagnosis, recognize disability, and refer for rehabilitation services when indicated. There are many diagnostic tests available to assist the physician, but none is as useful and practical as the office examination, including the functional history. Treatment goals with musculoskeletal conditions often are modest and include reduced pain and improved function. Frequently, conditions can flare up or persist in smoldering forms, requiring recurrent interactions with the rehabilitation team. The primary care physician can make use of many of the following resources available to treat musculoskeletal pain and limitations: exercise, medication, physical modalities, adaptive equipment, and arthritis education, including self-help and support groups. Used in combination, these treatments can contribute to increased well-being. The key for the physician is knowing that these options exist and being familiar with their use.

Positive impact of an intervention by arthritis educators on retention of information, confidence, and examination skills of medical students

To determine whether an intervention by trained persons with arthritis could have a positive impact on retention of information, confidence, and examination skills of medical students. Second-year medical students were introduced to the musculoskeletal examination as part of their Introduction to Clinical Medicine course by viewing a video (n = 93) or were taught the joint examination by a trained arthritis educator after viewing the video (n = 88). Each group was tested before and after the intervention about arthritis information, confidence, and attitude about arthritis and also evaluated for the ability to carry out a musculoskeletal examination. Retention of information and confidence of both groups increased as a result of the intervention. However, students who received the arthritis educator intervention increased their scores significantly in comparison. Musculoskeletal examination skills of the students receiving the arthritis educator intervention were also significantly greater than the control group. An intervention by arthritis educators improved the retention of information, confidence, and examination skills of second-year medical students significantly compared with the standard educational approach. The impact of the intervention persisted for at least two weeks.

Joint Protection Education: What are We Doing?

Joint protection (JP) education is a standard part of rheumatology occupational therapy services. This survey was conducted to identify the duration, teaching methods and content of JP education. Over half of therapists responding (55%, n=86) provided education for less than one hour during one treatment session. Eighty-six per cent supported education with written information; 66% demonstrated JP methods to patients, commonly methods for opening Jars, chair transfers and tap turning; and 50% also asked patients to practise these under supervision. The SPIRE arthritis education programme seemed a common influence on the JP education provided. Previous research suggests that educational-behavioural approach based patient education programmes (of 8–12 hours' duration) facilitate health behavioural change. It would appear that much of the current JP education provided in the United Kingdom may not be achieving this goal.

The use of trained patient educators with rheumatoid arthritis to teach medical students.

To assess whether patients with rheumatoid arthritis (RA) trained as educators can enhance the integration of clinical and basic science education among second-year medical students during their rheumatology sequence. Twenty patients with RA and strong communication skills were extensively trained to teach students how to perform the whole-body joint examination. Each arthritis educator taught three 2-hour small group sessions and participated in a concluding 2-hour panel discussion with the entire class. Changes in student knowledge and attitudes were assessed in a pre-post evaluation design. There were statistically and educationally significant gains in knowledge, confidence, and attitudes related to psychosocial aspects of arthritis in each of the 2 years the program was implemented. One-year followup data indicated substantial retention of these gains. Patients trained in arthritis education can effectively teach fundamental musculoskeletal examination skills and encourage the development of sensitivity to the impact of chronic arthritis on the daily life of other patients.

Evaluation of a community arthritis program in Australia: Dissemination of a developed program

To evaluate the effectiveness of a community-based arthritis education program conducted in a number of locations throughout the Sydney, Australia, metropolitan area. The program, based on earlier work, comprised 6 weekly sessions of 2.5 hours' duration. The study sample included 175 men and women with different types of arthritis, divided into intervention (n = 104) and control (n = 71) groups. Five outcome measures were selected to evaluate effectiveness of the program: pain perception, knowledge level, self-efficacy, disability index, and self-management behavior. The results indicated that the program was effective in increasing knowledge level (F[1,222] = 10.3, P = 0.001 at 6 weeks; F[1,108] = 7.8, P = 0.006 at 6 months), and a statistically significant difference was found in disability satisfaction 6 months after intervention (F[1,98] = 5.9, P = 0.01], but no statistically significant difference was found in pain perception, self-efficacy, and disability index. This research supports some of the successful outcomes which follow an arthritis education program: increased knowledge level and increased disability satisfaction.

Arthritis and musculoskeletal patient education standards

Arthritis and musculoskeletal patient education standards

Effect of energy conservation and joint protection education in rheumatoid arthritis.

As there is relatively little information about the effectiveness of occupational therapy (OT) in RA a questionnaire was devised to assess whether patient knowledge and performance of joint protection manoeuvres improved following OT intervention and, if improved, whether this was sustained over 6 months. A photographic multiple choice questionnaire was devised covering major categories of activities of daily living. The study population consisted of 55 patients with RA attending a rheumatology clinic who had not previously had OT treatment. Patients had a single instruction/treatment session with an occupational therapist of 1-h duration. Prior to treatment the questionnaire was administered by an independent assessor who re-administered the questionnaire 1 month and 6 months after the OT session. Following treatment there was a significant increase in scores at 1 month compared with pre-treatment (P < 0.001). There was no significant change in score at 6 months compared with 1 month. Qualitative analysis of age and sex showed no significant effects. OT leads to sustained improvement in patient knowledge and probably performance of joint protection manoeuvres in RA.

Cognitive‐behavioral treatment of rheumatoid arthritis pain maintaining treatment gains

This paper critically reviews research studies examining the long-term effects of cognitive-behavioral therapy interventions for managing pain in rheumatoid arthritis patients. The first section of the paper evaluates long-term results obtained in studies of cognitive-behavioral therapy, arthritis education interventions, and combined cognitive-behavioral therapy-arthritis education interventions. These studies show that although some rheumatoid arthritis patients are able to maintain initial improvements in pain and disability, other rheumatoid arthritis patients do not. In the second section of this review, a cognitive-behavioral model of maintenance of pain coping skills is presented. This model may be useful in increasing our understanding of the relapse process and in planning interventions to enhance and prolong cognitive-behavioral therapy treatment gains. The final section of this paper addresses important future directions for research. The need for empirical studies of relapse and maintenance processes is underscored. Controlled studies are needed to test the utility of new cognitive-behavioral interventions designed to enhance the long-term maintenance of treatment gains in RA patients. We suggest that a focus on issues of relapse and maintenance may be just as important for medical and surgical interventions for rheumatoid arthritis pain, as it is for cognitive-behavioral therapy interventions.

Arthritis education: opportunities and state of the art.

Health education research in arthritis and musculoskeletal disease experienced extraordinary growth in the 1980s. In this article we discuss opportunities for health education in arthritis and musculoskeletal disease, and the effectiveness of evaluated programs to influence knowledge, behavior, and health status of persons with arthritis. Additionally, we review developments in theory and trends in research that we expect to be influential in the next decade. Educational opportunities for primary prevention of arthritis are limited. However, a large variety of organized programs, planned according to commonly accepted principles of education, psychology, and psychotherapy, and applied consistently by personnel with some kind of training, have been able to produce desirable changes in knowledge, behavior, and health outcome in arthritis patients, over and above the medical treatment and incidental education to which they have already been exposed. As a result, national dissemination of programs and standards for arthritis patient education is in progress. In the next decade, researchers will increasingly turn to new populations and methods of delivery, investigation of conditions less well studied, such as osteoporosis, education of patients in generic communication and coping skills, and development of arthritis-specific applications of theory, especially in areas such as social support, control and helplessness, cognitive processing, and pain management.