Education, self-management, and upper extremity exercise training in people with rheumatoid arthritis: a randomized controlled trial

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Understanding the Self-Management Practices of Young Adults with Sickle Cell Disease

Because self-management is central to sickle cell disease (SCD) management, this descriptive study of 18 young adults with SCD, ages 19-39, was conducted to understand their pain experience and to identify the specific home activities they use for pain prevention and management prior to care-seeking. Participants completed two baseline surveys and one semi-structured, individual interview. Content analysis of the interview transcripts yielded two themes: difficulty in describing pain and living with pain. Participants used pharmacological and non-pharmacological strategies to alleviate pain and avoid disease complications but report barriers to using these strategies. Healthcare providers should use study findings to provide appropriate care to and improve pain outcomes for young adults with SCD. In addition, interventions aimed at addressing barriers and optimizing self-management are needed.

Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial

OBJECTIVES

The Stretching And strengthening for Rheumatoid Arthritis of the Hand (SARAH) randomised controlled trial evaluated the effectiveness of a hand exercise programme and demonstrated it was clinically effective and cost-effective at 12 months. The aim of this extended follow-up was to evaluate the effects of the SARAH programme beyond 12 months.

METHODS

Using postal questionnaires, we collected the Michigan Hand Questionnaire hand function (primary outcome), activities of daily living and work subscales, pain troublesomeness, self-efficacy and health-related quality of life. All participants were asked how often they performed hand exercises for their rheumatoid arthritis. Mean difference in hand function scores were analysed by a linear model, adjusted for baseline score.

RESULTS

Two-thirds (n=328/490, 67%) of the original cohort provided data for the extended follow-up. The mean follow-up time was 26 months (range 19-40 months).There was no difference in change in hand function scores between the two groups at extended follow-up (mean difference (95% CI) 1.52 (-1.71 to 4.76)). However, exercise group participants were still significantly improved compared with baseline (p=0.0014) unlike the best practice usual care group (p=0.1122). Self-reported performance of hand exercises had reduced substantially.

CONCLUSIONS

Participants undertaking the SARAH exercise programme had improved hand function compared with baseline >2 years after randomisation. This was not the case for the control group. However, scores were no longer statistically different between the groups indicating the effect of the programme had diminished over time. This reduction in hand function compared with earlier follow-up points coincided with a reduction in self-reported performance of hand exercises. Further intervention to promote long-term adherence may be warranted.

TRIAL REGISTRATION NUMBER

ISRCTN89936343; Results.

Effectiveness of an overall progressive resistance strength program for improving the functional capacity of patients with rheumatoid arthritis: a randomized controlled trial

Objective:

To evaluate the effectiveness of overall progressive resistance training in patients with rheumatoid arthritis.

Design:

Randomized controlled clinical trial with blinded assessor and intention-to-treat analysis.

Setting:

Outpatient clinics.

Subjects:

Sixty patients with rheumatoid arthritis according to the American College of Rheumatology criteria, aged between 18 and 65 years old, under stable medication and not performing regular physical activity were randomized into two groups: intervention group (IG) and control group (CG).

Interventions:

IG performed the progressive resistance strength training, twice a week, during 12 weeks. The training consists of exercising various muscle groups using a load of 50% and 70% of one repetition maximum. The load was reassessed and adjusted after six weeks of baseline. Both groups remained in conventional drug treatment during the study.

Main measures:

Patients were evaluated at baseline and after 6, 12, and 24 weeks, using HAQ and SF-36 questionnaires and strength.

Results:

Thirty-three patients in the CG and 27 in the IG were evaluated. The groups were homogeneous at baseline. Statistical and clinical improvement were found with better results for the IG in the HAQ questionnaire ( P=0.030), functional capacity (0=0.022) and pain ( P=0.027) domains of SF-36; and muscle strength for flexors of right and left knee ( P=0.005 and p=0.14), abductors of shoulder ( P=0.041) and extensors of right and left wrists ( P=0.003 and P= 0.005).

Conclusions:

This progressive resistance strength training improves physical function as well as grip and muscular strength of knee flexors, shoulder abductors and wrist extensors in patients with RA, without adverse effects.

Non-pharmacological and pharmacological interventions in patients with early arthritis: a systematic literature review informing the 2016 update of EULAR recommendations for the management of early arthritis

Objective

To perform a systematic literature review (SLR) on pharmacological and non-pharmacological treatments, in order to inform the European League Against Rheumatism (EULAR) recommendations for the management of early arthritis (EA).

Methods

The expert committee defined research questions concerning non-pharmacological interventions, patient information and education, non-steroidal anti-inflammatory drug, glucocorticoid (GC) and disease-modifying antirheumatic drugs (DMARDs) use, as well as on disease monitoring. The SLR included articles published after the last EULAR SLR until November 2015 found in the MEDLINE, EMBASE and Cochrane databases and abstracts from the 2014 and 2015 American College of Rheumatology and EULAR conferences.

Results

Exercise programmes may improve pain and physical function in patients with EA. Patients with EA treated within the first 3 months of symptoms have better clinical and radiological outcomes than those treated beyond 3 months. The clinical and radiological efficacy of GCs is confirmed, with similar efficacy of oral and parenteral administrations. Long-term data raise concerns regarding cardiovascular safety when using GCs. Step-up DMARD therapy is as effective as intensive DMARD therapy ‘ab initio’ for the long-term outcome of EA. Short-term superiority of intensive therapy with bDMARDs is not maintained on withdrawal of bDMARD. Patients with early psoriatic arthritis have better skin and joint outcomes when tight control is used compared to standard care.

Conclusions

The findings confirm the beneficial effect of exercise programmes and the importance of early drug therapy and tight control. They support the use of methotrexate and GCs as first-line drugs, although the long-term use of GCs raises safety concerns.

Participants' experiences of an Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis programme (EXTRA)

BACKGROUND

The Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis programme (EXTRA) is an individualized, upper limb, home exercise regimen supplemented by four supervised, group sessions, a handbook and exercise dairy which improves upper extremity disability and self-efficacy.

OBJECTIVE AND STUDY DESIGN

This qualitative interview study explored participants' experience of EXTRA to inform development and implementation of EXTRA into practice.

PARTICIPANTS

Adults with Rheumatoid Arthritis who completed EXTRA were purposively sampled to include a range of ages, upper extremity disabilities, self-efficacy for arthritis self-management and attendance at EXTRA sessions.

METHODS

Individual, semi-structured interviews were conducted with a single researcher until data saturation of themes was reached. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Twelve participants (10 females; 32 to 87 years) were interviewed. Four overarching themes were identified: (i) empowering self-management; (ii) influence of others and (iii) the challenge of sustaining exercise, which resonate with the Social Cognition Theory, and (iv) refining EXTRA: consistent and personalised.

CONCLUSIONS

EXTRA enhanced participants' confidence to manage their arthritis independently and was adaptable so it could be integrated with other life commitments. Whilst healthcare professionals, peers and family and friends influenced exercise uptake, sustaining exercise was challenging. Participants desired consistent and continuing contact with a familiar physiotherapist (e.g. via follow-up appointments, digital health technologies) which accommodated individual needs (e.g. different venues, session frequency). Implementation of EXTRA needs to appreciate and address these considerations to facilitate success.

The effectiveness of home hand exercise programmes in rheumatoid arthritis: a systematic review

INTRODUCTION

Rheumatoid arthritis (RA) commonly reduces hand function. We systematically reviewed trials to investigate effects of home hand exercise programmes on hand symptoms and function in RA.

SOURCES OF DATA

We searched: Medline (1946-), AMED, CINAHL, Physiotherapy Evidence Database, OT Seeker, the Cochrane Library, ISI Web of Science from inception to January 2016.

AREAS OF AGREEMENT

Nineteen trials were evaluated. Only three were randomized controlled trials with a low risk of bias (n = 665). Significant short-term improvements occurred in hand function, pain and grip strength, with long-term improvements in hand and upper limb function and pinch strength.

AREAS OF CONTROVERSY

Heterogeneity of outcome measures meant meta-analysis was not possible.

GROWING POINTS

Evaluation of low and moderate risk of bias trials indicated high-intensity home hand exercise programmes led to better short-term outcomes than low-intensity programmes. Such programmes are cost-effective.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research is required to evaluate methods of helping people with RA maintain long-term home hand exercise.

Randomised study versus control group of customised therapeutic education for patients in follow-up for rheumatoid arthritis

OBJECTIVE

We have evaluated customized objectives, predefined during a therapeutic education session for rheumatoid arthritis (RA).

METHODS

Fifty-four RA patients were randomised into patient therapeutic education (PTE) group versus waiting list (WL). The final comparative evaluation involved solving 3 predefined problems.

RESULTS

Fifty-four were evaluated after 6 months. The main criterion was defined for all three of the chosen themes at 76.9% in the PTE group and 42.4% in the WL group. Among the other positively evaluated criteria were: less corticotherapy, more occupational therapy, more demand for social aid, more physical activity, knowledge of the recognition of an RA attack and how to cope with it. On the other hand, knowledge of the treatments did not differ between the 2 groups nor did the RAPID scores, fatigue, stiffness, depression, compliance, number of consultations and hospitalisations. Patient satisfaction was excellent (between 85.3 and 93.9%).

CONCLUSION

This study is a good illustration of the position occupied and value of PTE in solving the problems specific to each RA case, the resulting high level of patient satisfaction and its independently complementary aspects relative to the purely medical treatment of RA. Customized PTE could better respond to specific patients problems in RA.

A Systematic Review Exploring the Social Cognitive Theory of Self-Regulation as a Framework for Chronic Health Condition Interventions

Background

Theory is often recommended as a framework for guiding hypothesized mechanisms of treatment effect. However, there is limited guidance about how to use theory in intervention development.

Methods

We conducted a systematic review to provide an exemplar review evaluating the extent to which use of theory is identified and incorporated within existing interventions. We searched electronic databases PubMed, PsycINFO, CENTRAL, and EMBASE from inception to May 2014. We searched clinicaltrials.gov for registered protocols, reference lists of relevant systematic reviews and included studies, and conducted a citation search in Web of Science. We included peer-reviewed publications of interventions that referenced the social cognitive theory of self-regulation as a framework for interventions to manage chronic health conditions. Two reviewers independently assessed articles for eligibility. We contacted all authors of included studies for information detailing intervention content. We describe how often theory mechanisms were addressed by interventions, and report intervention characteristics used to address theory.

Results

Of 202 articles that reported using the social cognitive theory of self-regulation, 52% failed to incorporate self-monitoring, a main theory component, and were therefore excluded. We included 35 interventions that adequately used the theory framework. Intervention characteristics were often poorly reported in peer-reviewed publications, 21 of 35 interventions incorporated characteristics that addressed each of the main theory components. Each intervention addressed, on average, six of eight self-monitoring mechanisms, two of five self-judgement mechanisms, and one of three self-evaluation mechanisms. The self-monitoring mechanisms ‘Feedback’ and ‘Consistency’ were addressed by all interventions, whereas the self-evaluation mechanisms ‘Self-incentives’ and ‘External rewards’ were addressed by six and four interventions, respectively. The present review establishes that systematic review is a feasible method of identifying use of theory as a conceptual framework for existing interventions. We identified the social cognitive theory of self-regulation as a feasible framework to guide intervention development for chronic health conditions.

Self-efficacy and arthritis disability: An updated synthesis of the evidence base and its relevance to optimal patient care

Self-efficacy, denoting the degree of confidence an individual has in carrying out a specific activity, was initially discussed in the 1970s as a potential correlate of disease outcomes. Drawn from 35 years of related research, this review provides an updated understanding of the concept of self-efficacy and its relevance for arthritis management. There is a consistent link between self-efficacy, arthritis pain and disability, and adherence to recommended therapeutic strategies. A wide variety of intervention strategies improve arthritis self-efficacy, as well as outcomes. Steps to assess and intervene thoughtfully to maximize self-efficacy beliefs are likely to impact arthritis disability outcomes quite favorably and significantly, regardless of disease type, duration, or sociodemographic factors.

Do inpatient multidisciplinary rehabilitation programmes improve health status in people with long-term musculoskeletal conditions? A service evaluation

BACKGROUND

Long-term musculoskeletal (MSK) conditions impair health and function. Guidelines recommend a multidisciplinary team (MDT) approach for the optimum management of people with long-term MSK conditions, but there is limited evidence for MDT care. This service evaluation investigates the short-term effectiveness of an inpatient MDT rehabilitation programme on self-reported function and disease status in people with long-term MSK conditions.

METHODS

A convenience sample of adults with rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP) and chronic widespread pain (CWP) participated in an inpatient MDT rehabilitation programme, consisting of needs assessment, collaborative goal setting and planning, exercise and self-management. The Routine Assessment of Patient Index Data (RAPID3) (primary outcome), the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS were assessed at baseline and immediately following MDT rehabilitation.

RESULTS

A total of 183 people [mean age 62 (standard deviation, 14.5) years, 145 females] with RA, OA, LBP or CWP were evaluated before and after inpatient MDT rehabilitation (median duration, ten days). Overall, there was a 28% improvement in RAPID3 (mean difference [95% confidence intervals] in effect size, 5.0 [4.3, 5.8], d=-0.98, p<0.05). Clinically relevant changes were found in people with RA (5.7 [4.4, 6.9], d=-1.08, p<0.05, 32%), OA 6.1 [3.4, 8.7], d=-1.07, p<0.05, 35%), LBP 4.0 [2.8, 5.2], d=-0.91, p<0.05, 22%), CWP 4.6 [2.7, 6.6], d=-0.84, p<0.05, 25%). These changes were reflected in all secondary outcomes.

CONCLUSION

This inpatient MDT rehabilitation programme provides short-term evidence of improved function and disease status in people with long term MSK conditions.