Arthritis patient education: a review of the literature

Evaluation of Iris Kashmiriana Baker plant extracts against nociception and rheumatoid arthritis in experimental rats: A concept proof by In-silico model

ETHNOPHARMACOLOGICAL RELEVANCE

Iris Kashmiriana Baker, a traditional medicinal plant, is native to Asia, found in India, Nepal, Afghanistan, Pakistan, as name indicates majorly it's found in Kashmir region of India. Ethnopharmacologically this plant has been used there for the management of joint pain, but there was no scientific literature available. This species also comes under critically endangered species.

AIM OF THE STUDY

The current study aims to evaluate the effect of Iris kashmiriana Baker against nociception and rheumatoid arthritis in experimental rats with In-silico model.

MATERIAL AND METHODS

Various extracts of the plant were investigated for their in-vitro antioxidant activity. Acute inflammation and FCA induced in rat model, then acetic acid-induced writhing in mice were used. These anti-rheumatic results were justified by the computational method.

RESULTS

The total phenolic and flavonoid concentration of HE extracts were found to be 95.30 ± 2.80 mg/g and 18.18 ± 5.88 mg/g respectively. IC50 and maximum inhibition of HE extracts against DPPH and H2O2 were also effective. Among different doses, 400 mg/kg of HE extracts showed significant (p<0.001) reduction in acute inflammation (16.42 %), in analgesic activity, the HE extract was found statistically (p<0.001) reduced (60.15 %) and in arthritis model, maximum inflammation reduced (25.9%) was found with hydro ethanol extract and statistical significant (p<0.001). and the paw thickness was reduced (27.4 %). Antioxidant activity of HE extract was found to be optimum (37.01%, p<0.001), Superoxide dismutase concentration was found to be optimum (65.12%, p<0.001). In Histopathology, HE 400 mg/kg showed mild inflammation only. The weight of the thymus and spleen were also determined and the HE 400 mg/kg extract inhibited the increase in weight of these organs compared with positive group (28.26 %, and 25.11 %), respectively.

CONCLUSION

Among all the different extracts and various doses, the iris kashmiriana Baker hydro-ethanolic (60:40) 400 mg/kg extract showed the best response among all different extracts.

Peer-led education or booklet for knowledge transfer about disease: A randomized-controlled trial with ankylosing spondylitis patients

Objectives

This study aims to investigate whether peer-led group education + booklet is superior to booklet only to increase ankylosing spondylitis (AS) patients’ knowledge about their disease.

Patients and methods

A total of 56 patients (46 males, 10 females; mean age 41.9±9.2 years; range, 22 to 58 years) with a definite diagnosis of AS who were under follow-up in our outpatient clinic between August 2010 and January 2012 were included in this study. The patients were randomly allocated to the peer-led education + booklet (education group, n=27) and booklet only (control group, n=29). To assess the level of patients’ knowledge, a patient knowledge questionnaire containing four domains was used. Evaluations were made at baseline, four weeks, and six months. The variables were “number of correct choices” (NoCC), “number of correct items” (NoCI) and percent of correct choices for each domain; the later one was resembled by the name of that domain (area A, area B, etc.).

Results

The variables that improved in both groups were NoCC, NoCI, and “pharmacotherapy and physical therapy area” (area C). These improvements were similar between the groups (respectively, p=0.915, p=0.830, p=0.791).

Conclusion

Reading a booklet alone is as successful as peer-led education + booklet for knowledge transfer about their disease in patients with AS. In this study, the most knowledge gain was achieved in “drug treatment and physical therapy” area.

Construction and validation of the Lebanese Osteoporosis Knowledge Scale among a representative sample of Lebanese women

Our study aimed at constructing and validating the Lebanese Osteoporosis Knowledge Scale adapted for use among Lebanese women and to assess factors associated with the poorest knowledge of osteoporosis definition, risk factors, and preventive measures. This scale showed adequate psychometric properties; higher knowledge scores were reached in women who already heard about the disease and had a formal education. As a result, the LOKS-19 can be used to measure knowledge of osteoporosis and help assess osteoporosis-related interventions.

INTRODUCTION

The primary objective of this study was to describe the construction of the Lebanese Osteoporosis Knowledge Scale (LOKS) and assess its psychometric properties in a representative sample of Lebanese women aged 40 years and above. Secondary objectives were to explore factors associated with this knowledge score.

METHODS

A cross-sectional study carried out between March and June 2018, enrolled 560 women over the age of 40 years living in the community. This proportionate sample was randomly selected from all Lebanese governorates to cover the entire Lebanese area. A survey was developed and adapted to the Lebanese population based on preexisting scales. Personal interviews were conducted to collect data.

RESULTS

The items of the LOKS were distributed across seven factors with an Eigenvalue over 1 solution, outlining an overall value of 55.89% of the variance. A high Cronbach's alpha was found for the full scale (0.725). Individuals having a university level of education (beta = 1.62; compared to illiteracy), having heard of osteoporosis (beta = 2.62), taking supplements of calcium and vitamin D compared to none (beta = 0.77), and having had Crohn's disease (beta = 1.71) had significantly higher knowledge scores of osteoporosis; oppositely, having diabetes (beta = - 1.17), currently taking chemotherapy (beta = - 2.25), and ever having had a fracture (beta = - 0.74) were significantly correlated with lower awareness of osteoporosis.

CONCLUSIONS

Our findings suggest that the LOKS-19 can be used to measure knowledge of osteoporosis and help assess osteoporosis-related interventions. A better knowledge seems to be associated with more preventive measures and less risk of fracture.

Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty: A Multisite Randomized Clinical Trial

BACKGROUND

Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education.

METHODS

A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure.

RESULTS

Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), -0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, -0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups.

CONCLUSIONS

Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Brief Report: Predicting Functional Disability: One-Year Results From the Scottish Early Rheumatoid Arthritis Inception Cohort

OBJECTIVE

To identify baseline prognostic indicators of disability at 1 year within a contemporary early inflammatory arthritis inception cohort and then develop a clinically useful tool to support early patient education and decision-making.

METHODS

The Scottish Early Rheumatoid Arthritis (SERA) inception cohort is a multicenter, prospective study of patients with newly presenting RA or undifferentiated arthritis. SERA data were analyzed to determine baseline predictors of disability (defined as a Health Assessment Questionnaire [HAQ] score of ≥1) at 1 year. Clinical and psychosocial baseline exposures were entered into a forward stepwise logistic regression model. The model was externally validated using newly accrued SERA data and subsequently converted into a prediction tool.

RESULTS

Of the 578 participants (64.5% female), 36.7% (n = 212) reported functional disability at 1 year. Functional disability was independently predicted by baseline disability (odds ratio [OR] 2.67 [95% confidence interval (95% CI) 1.98, 3.59]), depression (OR 2.52 [95% CI 1.18, 5.37]), anxiety (OR 2.37 [95% CI 1.33, 4.21]), being in paid employment with absenteeism during the last week (OR 1.19 [95% CI 0.63, 2.23]), not being in paid employment (OR 2.36 [95% CI 1.38, 4.03]), and being overweight (OR 1.61 [95% CI 1.04, 2.50]). External validation (using 113 newly acquired patients) evidenced good discriminative performance with a C statistic of 0.74, and the calibration slope showed no evidence of model overfit (P = 0.31).

CONCLUSION

In the context of modern early inflammatory arthritis treatment paradigms, predictors of disability at 1 year appear to be dominated by psychosocial rather than more traditional clinical measures. This indicates the potential benefit of early access to nonpharmacologic interventions targeting key psychosocial factors, such as mental health and work disability.

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.

Self-Management of Heart Disease by Older Adults

A randomized, controlled trial involving 636 older individuals was conducted to evaluate an intervention to enhance self-management of heart disease. Program participants experienced less impact of illness on their psychosocial functioning (p <.05), especially their emotional behavior (p < .05) and alertness (p < .01). Compared to controls, male program participants experienced improvements in their physical functioning, specifically their ability to ambulate (p < .05) and the frequency and severity of their symptoms. Female program participants did not experience gains in physical functioning. Most group differences emerged by 12 months and decayed by the 18-month final evaluation. To accurately assess the pattern of change associated with a program of this type, evaluation over at least 18 months following program completion may be needed. Separate interventions for older men and women with heart disease appear warranted, as do follow-up activities at strategic points in time to sustain program effects.

Patient School as a Way of Creating Meaning in a Contested Illness: The Case of CFS

Creating meaning in a situation of contested illness like Chronic Fatigue Syndrome (CFS) is an interactive process. As an example of how meaning is created, a CFS patient school organized by a hospital clinic in Sweden is discussed. This school can be seen as both a school and a medically oriented activity. The presence of different frameworks provides an opportunity to use different perspectives to understand CFS. It makes it possible for the participating men and women to regard the illness both from the outside as a social object, from the inside through personal experiences and to put the diagnosis and suffering in a larger ‘sickness’ perspective. Consequently, a number of different interpretations are brought up and used to create meaning in a situation of illness. The patients/students are thus learning discursively to manage the illness at the same time as they examine different ways to interpret their experiences through this discursive activity.

Self-management education programmes for osteoarthritis

BACKGROUND

Self-management education programmes are complex interventions specifically targeted at patient education and behaviour modification. They are designed to encourage people with chronic disease to take an active self-management role to supplement medical care and improve outcomes.

OBJECTIVES

To assess the effectiveness of self-management education programmes for people with osteoarthritis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PyscINFO, SCOPUS and the World Health Organization (WHO) International Clinical Trial Registry Platform were searched, without language restriction, on 17 January 2013. We checked references of reviews and included trials to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials of self-management education programmes in people with osteoarthritis were included. Studies with participants receiving passive recipients of care and studies comparing one type of programme versus another were excluded.

DATA COLLECTION AND ANALYSIS

In addition to standard methods we extracted components of the self-management interventions using the eight domains of the Health Education Impact Questionnaire (heiQ), and contextual and participant characteristics using PROGRESS-Plus and the Health Literacy Questionnaire (HLQ). Outcomes included self-management of osteoarthritis, participant's positive and active engagement in life, pain, global symptom score, self-reported function, quality of life and withdrawals (including dropouts and those lost to follow-up). We assessed the quality of the body of evidence for these outcomes using the GRADE approach.

MAIN RESULTS

We included twenty-nine studies (6,753 participants) that compared self-management education programmes to attention control (five studies), usual care (17 studies), information alone (four studies) or another intervention (seven studies). Although heterogeneous, most interventions included elements of skill and technique acquisition (94%), health-directed activity (85%) and self-monitoring and insight (79%); social integration and support were addressed in only 12%. Most studies did not provide enough information to assess all PROGRESS-Plus items. Eight studies included predominantly Caucasian, educated female participants, and only four provided any information on participants' health literacy. All studies were at high risk of performance and detection bias for self-reported outcomes; 20 studies were at high risk of selection bias, 16 were at high risk of attrition bias, two were at high risk of reporting bias and 12 were at risk of other biases. We deemed attention control as the most appropriate and thus the main comparator.Compared with attention control, self-management programmes may not result in significant benefits at 12 months. Low-quality evidence from one study (344 people) indicates that self-management skills were similar in active and control groups: 5.8 points on a 10-point self-efficacy scale in the control group, and the mean difference (MD) between groups was 0.4 points (95% confidence interval (CI) -0.39 to 1.19). Low-quality evidence from four studies (575 people) indicates that self-management programmes may lead to a small but clinically unimportant reduction in pain: the standardised mean difference (SMD) between groups was -0.26 (95% CI -0.44 to -0.09); pain was 6 points on a 0 to 10 visual analogue scale (VAS) in the control group, treatment resulted in a mean reduction of 0.8 points (95% CI -0.14 to -0.3) on a 10-point scale, with number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 5 to 23). Low-quality evidence from one study (251 people) indicates that the mean global osteoarthritis score was 4.2 on a 0 to 10-point symptom scale (lower better) in the control group, and treatment reduced symptoms by a mean of 0.14 points (95% CI -0.54 to 0.26). This result does not exclude the possibility of a clinically important benefit in some people (0.5 point reduction included in 95% CI). Low-quality evidence from three studies (574 people) showed no signficant difference in function between groups (SMD -0.19, 95% CI -0.5 to 0.11); mean function was 1.29 points on a 0 to 3-point scale in the control group, and treatment resulted in a mean improvement of 0.04 points with self-management (95% CI -0.10 to 0.02). Low-quality evidence from one study (165 people) showed no between-group difference in quality of life (MD -0.01, 95% CI -0.03 to 0.01) from a control group mean of 0.57 units on 0 to 1 well-being scale. Moderate-quality evidence from five studies (937 people) shows similar withdrawal rates between self-management (13%) and control groups (12%): RR 1.11 (95% CI 0.78 to 1.57). Positive and active engagement in life was not measured.Compared with usual care, moderate-quality evidence from 11 studies (up to 1,706 participants) indicates that self-management programmes probably provide small benefits up to 21 months, in terms of self-management skills, pain, osteoarthritis symptoms and function, although these are of doubtful clinical importance, and no improvement in positive and active engagement in life or quality of life. Withdrawal rates were similar. Low to moderate quality evidence indicates no important differences in self-management , pain, symptoms, function, quality of life or withdrawal rates between self-management programmes and information alone or other interventions (exercise, physiotherapy, social support or acupuncture).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence indicates that self-management education programmes result in no or small benefits in people with osteoarthritis but are unlikely to cause harm.Compared with attention control, these programmes probably do not improve self-management skills, pain, osteoarthritis symptoms, function or quality of life, and have unknown effects on positive and active engagement in life. Compared with usual care, they may slightly improve self-management skills, pain, function and symptoms, although these benefits are of unlikely clinical importance.Further studies investigating the effects of self-management education programmes, as delivered in the trials in this review, are unlikely to change our conclusions substantially, as confounding from biases across studies would have likely favoured self-management. However, trials assessing other models of self-management education programme delivery may be warranted. These should adequately describe the intervention they deliver and consider the expanded PROGRESS-Plus framework and health literacy, to explore issues of health equity for recipients.

A qualitative and quantitative analysis of the characteristics of gout patient education resources

Patient education is an important aspect of gout management, but there is evidence that many patients lack adequate knowledge of their condition. Our aim was to examine the characteristics of gout patient education resources. Ten gout patient information resources were examined for readability (Flesch-Kincaid reading level, the Simple Measure of Gobbledygook measure and the Flesch Reading Ease Score), qualitative characteristics such as figure and jargon use and whether they included information on the major points of gout. The median readability grade level of the examined resources was 8.5. The difference in readability grade level between the highest and the lowest education resource was 6.3 grade levels. The information content of the resources was high with an average of only 3.9 proposed criteria of 19 (19 %) absent from the resources. Jargon use was low and concepts were usually explained. However, important information regarding acute flare prophylaxis during urate-lowering therapy initiation and titration and treating serum uric acid to target was absent from 60 % of the patient education resources. There was poor use of key messages at the start. Gout patient resources have a wide range of readability. Thirty percent of resources were above the average reading level of rheumatology outpatients reported in previous studies. Sixty percent of gout patient resources omit education items that could impact on patient adherence and in turn patient outcomes. Further research is needed into the literacy levels and education requirements of patients with gout.

Sexual dysfunction in rheumatoid arthritis: a hot but sensitive issue

Rheumatoid arthritis (RA) has considerable personal impact for sufferers and their families. Those with RA suffer from pain, restricted joint movements, and fatigue, and can have problems with self-esteem and body image. It is also possible that medication causes sexual problems. Research on the subject is limited, and shows a divergent picture. Assessment for sexual dysfunction in clinical practice might be another hurdle, as patients and health professionals are reluctant to discuss this issue face to face. The aim of the work carried out and described in this article was to study the possibility of implementing sexual dysfunction assessment into standard rheumatology clinical practice. Results revealed that the multidimensional patient-reported outcome measures questionnaire offered the opportunity to assess the disease activity parameters, functional disability, quality of life, sexual dysfunction, and self-helplessness in one format. The patients appeared willing to complete questionnaires and this may be an acceptable tool for assessment. Improving patient education, as well as nurse-patient communication, through discussions about available options may minimize patients' feelings of isolation in addressing the problem and could help compensate for negative effects resulting from the disease.

Online self-management in rheumatoid arthritis: a patient-centered model application

OBJECTIVE

The aim of this study was to describe the online transformation of an empirically validated, clinic-based, self-management (SM) program for rheumatoid arthritis.

MATERIALS AND METHODS

A cognitive-behavioral framework served as the theoretical basis for the intervention. As with the clinic-based approach, the psychoeducational program included educational modules, weekly homework assignments, and self-evaluation. The dynamic online environment included secure communication tools to support a virtual community for the participants to garner peer support. In addition to peer support, weekly follow-up support was provided by a trained clinician via telephone. We describe the process and structure of the online self-management (OSM) intervention. Administrative issues including clinical monitoring and management, data collection, and security safeguards are considered. Utilization and management data are provided and explored for 33 initial subjects.

RESULTS

Individuals who volunteer to participate in an online modality are eager to receive this home-based programming. They readily engaged with all aspects of the OSM program and experienced few difficulties navigating the environment.

CONCLUSION

An OSM site provides a convenient, effective, and securely maintained health service, once restricted to clinic settings. The OSM application can be used to extend the benefits of SM programs to broad target audiences and serves as a model for the emerging generation of Internet-based clinical management/delivery systems.

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.

[Patient education in rheumatologic care--a review]

Patient education is a medical intervention for patients with chronic diseases to increase knowledge of their disease, self-efficacy, self-management and consumer behaviour. The goal is to improve their disease outcome, social participation and quality of life. This article reviews concepts, modalities and knowledge on effectiveness of patient education. The results of different studies in different rheumatic diseases on efficacy will be summarized including a small number of cost-benefit analyses. Most studies report on significant and relevant improvements of knowledge, self-efficacy and health status. With respect to disease specific outcomes low to moderate effect sizes with a short duration have been observed. Especially good results have been reported when physical training or other methods of rehabilitation were included. There are marked improvements in consumer behaviour of health measures and sickness leave. A better understanding of information needs and baseline characteristics of patients is necessary to develop more appropriate educational interventions focussed on relevant outcomes that can be improved by educational measures.

Management of knee osteoarthritis in primary care: pain and depression are the major obstacles

OBJECTIVES

Osteoarthritis (OA) management is a challenge, as OA consists of a spectrum of pathologies requiring a multifaceted treatment approach. Patient education programmes (PEP) are attractive, as they may be cost effective and potentially efficacious. The goals of the study were to determine what may hinder the efficacy of a PEP for knee OA by determining the relevance of depression, pain, disease knowledge and physical ability in patients to their response to a PEP.

METHODS

Clinical and demographic data relating to 170 patients who completed a trial of a PEP were analysed to determine how they interrelate during patient management.

RESULTS

All patients showed a progressive decrease in mental health over the duration of the study (P<.001). Greater pain was associated with reduced coping, increased depression and reduced physical ability (P<.05). Women were more likely to experience disability (P<.05). Disability was associated with reduced ability to cope, increased depression and the experience of more pain (P<.05). Subjects with a Caucasian background were significantly (P<.05) more likely to possess knowledge of OA than other ethnic groups. The lowest knowledge group experienced more pain; the highest knowledge group was coping better and had less depression (P<.05).

CONCLUSION

A complex interrelationship between depression, pain, disease knowledge, and physical ability in patients with knee OA has been demonstrated. Specifically, the treatment of depression and pain may be paramount to the successful treatment of knee OA, and these factors should be considered in each patient and management priorities made.

Theory-based programme development and evaluation in physiotherapy

PURPOSE

Programme evaluation has been defined as "the systematic process of collecting credible information for timely decision making about a particular program." Where possible, findings are used to develop, revise, and improve programmes. Theory-based programme development and evaluation provides a comprehensive approach to programme evaluation.

SUMMARY OF KEY POINTS

In order to obtain meaningful information from evaluation activities, relevant programme components need to be understood. Theory-based programme development and evaluation starts with a comprehensive description of the programme. A useful tool to describe a programme is the Sidani and Braden Model of Program Theory, consisting of six programme components: problem definition, critical inputs, mediating factors, expected outcomes, extraneous factors, and implementation issues. Articulation of these key components may guide physiotherapy programme implementation and delivery and assist in the development of key evaluation questions and methodologies. Using this approach leads to a better understanding of client needs, programme processes, and programme outcomes and can help to identify barriers to and enablers of successful implementation. Two specific examples, representing public and private sectors, will illustrate the application of this approach to clinical practice.

CONCLUSIONS

Theory-based programme development helps clinicians, administrators, and researchers develop an understanding of who benefits the most from which types of programmes and facilitates the implementation of processes to improve programmes.

Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial

The aim of this study was to asses the effects on pain, disability, and health status of an educational-behavioral joint protection program in a group of moderate-severe rheumatoid arthritis (RA) patients. Eighty-five subjects with RA in treatment with anti-tumor necrosis factor alpha (TNFalpha) drugs (infliximab) were enrolled into the study and randomized into either an experimental group (46, EG) or a control group (39, CG). We organized four EG meetings, which included information on pathophysiology and evolution of RA, joint protection during normal activities of daily living, suggestions on how to adapt the surrounding environment, and self-learning exercises to perform at home. Sociodemographic characteristics and degree of knowledge of the disease, measured by the Health Service Interview (HSI), were recorded at baseline. The outcome measures included the Visual Analogue Scale (VAS), the Arthritis Impact Measurement Scale 2 (AIMS2), and the Health Assessment Questionnaire (HAQ), which were administered at the beginning and end of the trial. Thirty-six patients from the EG (7 men and 29 women; mean age 54.2 years) and 34 from the CG (6 men and 28 women; mean age 52.2 years) completed the trial. No statistical differences in baseline evaluations were found between the two groups. According to the answers given on the HSI, the majority of our patients had poor knowledge of RA and its consequences. After a mean time of 8 months, the patients receiving educational training displayed a significant decrease, compared to the CG, in the VAS (p = 0.001), HAQ (p = 0.000), and physical (p =0.000), symptoms (p = 0.049), and social interaction (p = 0.045) scores on the AIMS2, but not in other items. Our study showed that 8 months after attending an educational-behavioral joint protection program, subjects with moderate-severe RA presented less pain and disability and thus an enhanced health status. This approach may efficiently complement drug therapy in these patients.

Patient Satisfaction with Rheumatology Practitioner Clinics: Can We Achieve Concordance by Meeting Patients’ Information Needs and Encouraging Participatory Decision Making?

Introduction: The objective of this study was to determine if patient information needs are being met and the level of patient satisfaction with rheumatology practitioners in participatory decision-making and thereby indirectly explore whether concordance was achieved. Materials and Methods: The design was a cross-sectional postal questionnaire survey of 420 patients attending outpatient clinics at the Norfolk and Norwich University Hospital who were taking disease modifying anti-rheumatic drugs (DMARDs) or a biological treatment. The population served is ethnically homogeneous and predominantly Caucasian. Results: The response rate was 76%. Most respondents (79%) had inflammatory arthritis while 66% had rheumatoid arthritis. Seventy-seven per cent of patients reported that the rationale behind commencing treatment was explained and that they were given ample opportunities to ask questions. Eighty-two per cent said they were given an appropriate amount of information. Sixty-four per cent of patients were satisfied with their level of participation in the decision-making process, although a substantial number (25%) said that information from different sources was conflicting. There was no correlation between concern about side effects and patients’ perceptions of the effectiveness of medication. Females were more concerned than males about possible side effects; P =0.009, using the Mann-Whitney U test. One third of the patients altered their medication in response to whether their arthritis felt better or worse. Conclusion: The majority of patients were satisfied that their information needs were met and with the care provided in the practitioner clinic. Participatory decision-making was sub-optimal despite patient satisfaction with the amount of time allocated to meeting their information needs. We found that patients exercise autonomy in managing their arthritis by regulating their medications through an active decision-making process, which is informed by their previous experience of medication, and how well controlled they felt their arthritis was. Research into this decision-making process may hold the key to achieving concordance. Key words: Compliance, Concordance, Decision-making, Satisfaction, Side effects

Long-term effectiveness of a patient and family pain education program on overcoming barriers to management of cancer pain

The purpose of this research was to investigate the effectiveness of a patient and family pain education program on reducing cancer patients' and their families' barriers to (i.e., concerns or misconceptions about) cancer pain management, on increasing patients' adherence to a prescribed analgesic regimen, and on decreasing pain intensity and pain interference with daily life. An experimental and longitudinal design was used. The experimental group consisted of 31 pairs of cancer outpatients and their family carers, while the control group consisted of 30 patient-family pairs (N=122). Patients and their family carers in the experimental group simultaneously received a pain management education program. Both groups had pretest data collection and after-test follow-ups on the second and fourth weeks at the outpatient clinics. Comparisons between those two groups were made using the Generalized Estimating Equations (GEE) method. Results revealed that at both the second and fourth weeks, patients and family carers in the experimental group showed a significantly greater reduction in barrier scores than did patients and family carers in the control group. At the second and fourth weeks, patients in the experimental group reported significantly better adherence to a scheduled analgesic regimen than did patients in the control group. In the fourth week, patients in the experimental group reported significantly lower levels of worst pain intensity and pain interference than did patients in the control group. This research provides evidence of the effectiveness of a patient and family pain education program.

The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study

OBJECTIVE

To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR).

METHODS

Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months.

MAIN RESULTS

Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline.

CONCLUSIONS

The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.

Health-related quality of life in rheumatoid arthritis: therapeutic education plus pharmacological treatment versus pharmacological treatment only

OBJECTIVE

To determine whether therapeutic education added to conventional drug therapy reduced disability and pain in patients with early rheumatoid arthritis (RA).

METHODS

Fourty-three patients with RA, 29F/14 M, were included in a randomized, controlled trial and assigned to a control group receiving conventional pharmacological treatment only (n=21), or an intervention group receiving therapeutic education added to conventional pharmacological treatment (n=22). The main outcome variable was self-reported disability on the Stanford health assessment questionnaire (HAQ).

RESULTS

At 18 months, patients in the intervention group had less disability (HAQ), pain intensity, number of tender and swollen joints, and patient's and physician's global assessments (p=0.003, 0.031, 0.003, 0.001, 0.014, and 0.004, respectively) compared with baseline, and improvements in disability and number of tender and swollen joints (p=0.024, 0.040, and 0.003, respectively), compared with controls.

CONCLUSIONS

Patients receiving pharmacological treatment and therapeutic education had a better evolution than those receiving only pharmacological treatment.

The unstable metacarpophalangeal joint in rheumatoid arthritis: anatomy, pathomechanics, and physical rehabilitation considerations

The metacarpophalangeal (MCP) joints bestow important strength to the longitudinal and transverse arch systems of the hand. In addition, these joints guide active movements of the fingers in 2 degrees of freedom, while allowing sufficient laxity for passive accessory motions. Both stability and mobility functions are attained in the healthy hand by a complex interaction among the muscles and the joints' periarticular connective tissues. Rheumatoid arthritis (RA) often causes destruction of the MCP joints' connective tissues, which leads to weakness of the tissues and an imbalance of active and passive forces, and subsequently, instability, pain, and deformity. The 2 most common deformities of the MCP joints associated with RA and instability are palmar subluxation and ulnar "drift." Therapists and physicians often collaborate to treat these conditions through a combination of surgical and nonsurgical interventions. Two of the more conservative nonsurgical interventions typically involve a combination of splinting and education on joint protection. Additional nonsurgical treatment may include the judicious use of exercise and methods for relieving pain and reducing inflammation. Surgical intervention is often indicated when the more conservative treatments fail to arrest the progression of the pain or deformity. Regardless of the specific approach, effective intervention for instability of the MCP joint requires that the clinician possess a sound knowledge of the anatomy and the pathomechanical influences that predispose or cause the instability. This clinical commentary is intended to provide this information, as well as offer treatment guidelines based on our clinical experience. Whenever possible, research will be cited to support clinical interventions. This paper is especially geared to the therapist who may not currently specialize in the treatment of instability of the MCP joint but may require basic information on this important topic.

Lack of benefit of a primary care-based nurse-led education programme for people with osteoarthritis of the knee

Osteoarthritis (OA) is the commonest cause of locomotor disability and forms a major element of the workload of the primary care team. There is evidence that patient education may improve quality of life, physical functioning, mental health and coping as well as reducing health service use. The aim of this study was to evaluate the effectiveness of a primary care-based patient education programme (PEP) using a randomised controlled trial. A cluster randomised controlled trial, involving 22 practices, was used to determine the efficacy of a nurse-led education programme. The programme consisted of a home visit and four 1-h teaching sessions. Patients were assessed at baseline and then 1, 3, 6 and 12 months post intervention using 36-item Short Form (SF-36), Western Ontario and McMaster Universities Arthritis Index (WOMAC), arthritis helplessness index and a patient knowledge questionnaire. Direct interviews were used at baseline and at the 12-month follow-up. There were no differences in depression, OA knowledge, pain or physical ability at either 1 month or 1 year between the two groups. Control practices (65 patients from 12 practices) recruited significantly fewer patients than intervention practices (105 patients from ten practices, p = 0.02). Control practices had more doctors (p = 0.02), more non-white patients (p = 0.007), fewer patients living alone (p = 0.005) and lower levels of disability (p = 0.008). We detected a lack of benefit of PEP for people with OA of the knee. This was thought to be due in part to the short intervention time employed and the heterogeneous nature of the disease and the population studied.

Can interprofessional education make a difference in the care of people with chronic disease?

In recent years, there has been an increasing policy focus on the role of interprofessional education in healthcare. However, the literature emphasizes process rather than outcomes, with little that specifically relates interprofessional educational interventions to the care of people with long-term conditions. This article questions what we know about interprofessional interventions in the care of people with chronic disease, examines the evidence for and potential of interprofessional education in changing practice, and makes suggestions for further research.

Self-management interventions for chronic illness

An increasing number of interventions have been developed for patients to better manage their chronic illnesses. They are characterised by substantial responsibility taken by patients, and are commonly referred to as self-management interventions. We examine the background, content, and efficacy of such interventions for type 2 diabetes, arthritis, and asthma. Although the content and intensity of the programmes were affected by the objectives of management of the illness, the interventions differed substantially even within the three illnesses. When comparing across conditions, it is important to recognise the different objectives of the interventions and the complexity of the issues that they are attempting to tackle. For both diabetes and asthma, the objectives are concerned with the underlying control of the condition with clear strategies to achieve the desired outcome. By contrast, strategies to deal with symptoms of pain and the consequences of disability in arthritis can be more complex. The interventions that were efficacious provide some guidance as to the components needed in future programmes to achieve the best results. But to ensure that these results endure over time remains an important issue for self-management interventions.

Evaluation of a community rehabilitation service for people with rheumatoid arthritis

This study aims to evaluate the outcomes of a community rehabilitation service for people with rheumatoid arthritis, provided by the Community Rehabilitation Network (CRN) in Hong Kong. The three-phase community rehabilitation service consists of a number of standardized program elements, including orientation meeting, self-help course, stress management program, water exercises class, as well as informal social and recreational activities. Using a pre-, post-test non-equivalent groups design, the outcomes of 29 clients of the treatment group were compared with 16 clients of the comparison group at baseline and at the end of 9 months, using an 86-item self-completed questionnaire. The treatment group achieved significant more increases in self-efficacy of managing the illness, more increases in self-management behaviors, but no significant increases in the overall health status or health care utilization patterns, when compared with the comparison group.

A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus

OBJECTIVE

In a cross-sectional study, we previously identified 2 potentially modifiable risk factors for adverse outcomes in systemic lupus erythematosus (SLE): self-efficacy and social support. The goal of this study was to evaluate in a randomized controlled trial a theory-based intervention to improve patient self-efficacy and partner support to manage SLE.

METHODS

Patients with SLE ages 18 years and older who met the American College of Rheumatology criteria and were able to identify a partner (spouse or family member) were recruited from 2 academic medical centers and randomized into an experimental group or a control group. Patients in the experimental group and their partners received an intervention designed to enhance self-efficacy, couples communication about lupus, social support, and problem solving, in the form of a 1-hour session with a nurse educator followed by monthly telephone counseling for 6 months. Patients in the control group and their partners received an attention placebo, including a 45-minute video presentation about lupus, and monthly telephone calls. Measures of physical and mental health status, disease activity, and psychosocial factors were collected at baseline, 6 months, and 12 months. The effect of the intervention on physical and mental health and disease activity at 6 and at 12 months was modeled with linear regression and adjusted for baseline health status, disease activity, sociodemographic factors, treatment change, and psychosocial factors.

RESULTS

One hundred twenty-two patients (plus their partners) were enrolled and randomized as follows: 64 to the experimental intervention and 58 to the attention control group. The participants were predominantly white, approximately half were college educated, and the groups were balanced for sociodemographic factors. At 6 months, significantly higher scores for couples communication (P = 0.01) and problem-focused coping (P = 0.03) were seen in the experimental group compared with the control group. At 12 months (6 months after the intervention ended), social support was higher (4.4 versus 4.1; P = 0.03), self-efficacy was higher (7.2 versus 6.2; P = 0.02), couples communication was higher (3.5 versus 3.1; P = 0.03), and fatigue was lower (5.1 versus 6.3; P = 0.02) in the experimental group compared with the control group. Global mental health status at 12 months, as measured by the Short Form 36 survey, was 69 points in the experimental group compared with 58 points in the control group (P = 0.04). In multivariate models, adjusting for baseline covariates, scores for couple communication (P = 0.01) were significantly higher at 6 months, and scores for self-efficacy (P = 0.004) and global mental health status (P = 0.03) were significantly higher at 12 months in the experimental group compared with the control group, and the mean score for global physical function was higher by 7 points, which was a clinically meaningful change (P = 0.2). The mean score for fatigue was also significantly lower in the experimental group than in the control group (P = 0.05). SLE disease activity was unchanged by this intervention.

CONCLUSION

This randomized, controlled trial of a theory-based educational intervention in SLE demonstrated significantly higher scores for couple communication, self-efficacy, and mental health status, and lower fatigue scores in the experimental group compared with the control group. Because couple communication and self-efficacy appear to be modifiable risk factors, they may also be potential targets in more disadvantaged populations.

Clinical skills: evidence-based nursing care of people with rheumatoid arthritis

Rheumatoid arthritis is a complex inflammatory disease with an unknown cause, uncertain prognosis and no known cure. The physical symptoms of this chronic disease can impact on the patient's psychological state and also affect the family unit and social/economic viability. Nursing patients with such a multifaceted illness is a skilled and complex task and it is imperative that the care provided is optimal, timely and underpinned by patient education. Evidence-based nursing care founded on an in-depth knowledge of the disease and its treatments will help to achieve optimal patient outcome.

Gap between short- and long-term effects of patient education in rheumatoid arthritis patients: A systematic review

OBJECTIVE

To systematically review educational or psychoeducational interventions for patients with rheumatoid arthritis focusing on long-term effects, especially health status.

METHODS

Two independent reviewers appraised the methodologic quality of the included randomized controlled trials, published between 1980 and July 2002.

RESULTS

Validity scores of studies ranged from 3 to 9 (of 11). The 7 educational programs mainly improved knowledge and compliance in the short and long term, but there was no improvement in health status. All 4 psychoeducational programs improved coping behavior in the short term, 2 of them showing a positive long-term effect on physical or psychological health variables.

CONCLUSION

Methodologically better-designed studies had more difficulties demonstrating positive outcome results. Short-term effects in program targets are generally observed, whereas long-term changes in health status are not convincingly demonstrated. There is a need to find better strategies to enhance the transfer of short-term effects into gains in health status.

Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions

OBJECTIVE

The objective of this study was to test the effectiveness of a mail-delivered, tailored self-management intervention (SMART) and to compare it with the classic Arthritis Self-Management Program (ASMP).

METHODS

We performed 2 randomized controlled trials: 1) a study of 1090 participants randomized to SMART or USUAL CARE, and 2) a study of 341 participants randomized to SMART or ASMP. Dependent variables included disability, pain, depression, role function, global severity, doctor visits, and self-efficacy. SMART interventions were provided in months 0-18 and not reinforced. Results were assessed at 1, 2, and 3 years using analyses of covariance (ANCOVA).

RESULTS

Compared with USUAL CARE, SMART participants at 1 year had decreased disability, improved role function, and increased self-efficacy (all P <0.01). At 2 years, decreases in global severity, doctor visits, and increases in self-efficacy (all P <0.01) were noted. At 3 years without reinforcement, no statistically significant effects remained. Compared with ASMP, SMART at 1 year had greater decreases in disability (P = 0.02) and increases in self-efficacy (P = 0.01). There were no differences at 2 years. At 3 years, role function (P = 0.04) and doctor visit (P = 0.03) were improved in ASMP as compared with SMART. Improvements from baseline were seen for nearly all variables in both groups.

CONCLUSIONS

A mail-delivered arthritis self-management program, SMART, was similarly effective to the classic ASMP, with slightly better results in the first year and a slightly more rapid attenuation over the next 2 years. Results suggest that both programs are effective, and that the addition of a mail-delivered program could improve accessibility to arthritis self-management treatment.

Capturing lay perspectives in a randomized control trial of a health promotion intervention for people with osteoarthritis of the knee

Osteoarthritis (OA) is a common and often disabling condition that predominately affects older adults. It is the commonest cause of locomotor disability and forms a major element of the workload in primary care. Previous studies suggest that there are both deficits in the knowledge patients have about their disease and extensive 'unmet' information needs. This paper explores the patients' perspective on the meaning and significance of living with arthritis, identified through quantitative and qualitative approaches undertaken during a trial that evaluated the effectiveness of a primary care-based patient education programme. This paper draws on qualitative and quantitative data from: the baseline interview (knowledge of arthritis, satisfaction with services and support received in primary care); patient diaries (individual goals and reflections on treatment); and group teaching sessions (themes describing the patient's experience). The different data sources were interrogated for common and divergent themes. One hundred and ninety-four participants were identified and 170 completed baseline interviews. Participants were predominantly female (73%), with a mean age of 63 and arthritis of long-standing; 55% reported that they had had it for 5 years or more. Use of primary care services was high, with 41% consulting their GP in the 2 weeks before interview. Levels of information were low, with less than 25% receiving support/advice about the disease, pain management or its impact upon daily life. Set against negative perceptions of the quality of services, patients' personal priorities were for improved pain management and enhanced mobility/functional ability. The combined quantitative and qualitative data provide insight into the patients' perspective on the causes and impact of knee OA, individual goals desired from treatment and the quality of care. There is consistent evidence of unmet needs for information and support and the priority placed by patients on finding strategies to cope with OA and maintaining independence. Even within a tightly defined study sample participating in the intervention, a diversity of experience and goals were revealed, which highlights the importance of taking account of contextual factors and individual differences when evaluating complex interventions.

Systemic sclerosis: Patients' perceptions of their condition

OBJECTIVE

To examine patients' beliefs about systemic sclerosis (SSc) and to investigate the relationship between these beliefs, symptom report, and clinical and demographic variables.

METHODS

A total of 49 patients (7 male, 42 female) with SSc underwent clinical examination and completed the Revised Illness Perception Questionnaire. This measure assesses beliefs about symptoms, chronicity or recurrence of the condition, consequences, personal and treatment control, illness coherence, perceived causes of the condition, and patients' emotional response to their condition.

RESULTS

The symptoms patients most frequently associated with their SSc were stiff joints (79%), pain (75%), and fatigue (75%). The most commonly reported causes of SSc were stress (53%), altered immunity (49%), and chance or bad luck (46%). More than 96% of patients believed that their condition would be chronic and 78% believed that the condition had serious consequences on their lives. Patients with diffuse cutaneous SSc reported more significant consequences of the condition and less personal control of their SSc compared with patients with limited cutaneous disease. There were no significant differences in illness beliefs between patients with nonsevere and severe ischemia. Multiple regression analyses indicated that illness beliefs, in particular perceived consequences associated with the condition, accounted for a significant proportion of the variance in emotional response to the condition.

CONCLUSIONS

The beliefs held and symptoms experienced by patients with SSc are not ruled by disease subtype, skin score, functional ability, or severity of digital ischemia. This suggests patients' beliefs and emotional response are associated with the meaning they ascribe to their condition rather than its severity.

Group education for patients with rheumatoid arthritis and their partners

OBJECTIVE

To determine the effects of group education followed by booster sessions for people with rheumatoid arthritis (RA), and to determine whether participation of a significant other influenced the effects.

METHODS

A total of 218 RA patients, each of them with a partner, took part in the study. Two-thirds of the patients received a 5-week group self-management education program, with booster sessions after 3, 6, and 9 months; half of them received the intervention with a partner, and half without. One-third of the patients received the same educational materials without group sessions. Data were collected 1 week before the group sessions began and 2, 6, and 12 months later. The assessments included health behavior, arthritis self-efficacy, health status, and social interactions.

RESULTS

After 12 months, self-efficacy scores for coping with other symptoms were significantly higher for patients participating in the group education without a partner and significantly lower for patients participating in the group education with a partner. Fatigue increased in patients participating in the group education with a significant other and decreased in patients participating in the group education without a significant other. No other effects were found on health status, health behavior, or social interactions.

CONCLUSION

Our findings suggest that participation of a significant other in psychoeducational programs does not have only positive effects. Instead of stimulating patients to adopt beneficial health behaviors and increase their self-efficacy expectations, participation of a significant other led in our program to decreases in self-efficacy and increased fatigue, whereas patients participating in group education without partners showed increases in self-efficacy and decreased fatigue. Booster sessions did not seem to influence results.

Psychoeducational interventions in rheumatic diseases: a review of papers published from September 2001 to August 2002

A large number of psychoeducational intervention studies have been developed for use with patients with rheumatic disease. The interventions vary considerably in the components they include and in the extent of the benefits they find. Recent meta-analyses of studies in rheumatoid arthritis (RA) report moderate short-term benefits, but it remains necessary to further examine which components are most important in bringing about change. A significant recent development in psychoeducational interventions is the move toward a generic intervention-the Chronic Disease Self-Management Program (CDSMP). A randomized controlled trial of this program has been performed, but statistical analysis for arthritis have not been reported separately.

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.

Overcoming patient-related barriers to cancer pain management for home care patients. A pilot study

The purpose of this pilot study was to explore the effectiveness of a pain education program to overcome patient-related barriers in managing cancer pain for Taiwanese home care patients with cancer. The pain education program was developed based on previous studies of Taiwanese patient-related barriers to cancer pain management. The Barriers Questionnaire-Taiwan form, the Brief Pain Inventory, the Medication Adherence Questionnaire, and a demographic questionnaire were used for data collection. The sample consisted of 18 patients in the experimental group and 19 patients in the control group. Descriptive statistics, tests, and paired tests were used to analyze the data. Results of this study revealed that patients who received the pain educational program had significantly greater reduction in Barriers Questionnaire-Taiwan form scores and more improvement in medication adherence compared with patients who did not participate in the program. When compared to pretest scores, patients scores after receiving the pain education intervention showed significant improvement on the Barriers Questionnaire-Taiwan form, medication adherence, pain intensity, and pain interference. The results of this study support the effectiveness of the pain education program on overcoming the barriers to cancer pain management for Taiwanese home care patients with cancer.

Health concerns of men with osteoarthritis of the knee

PURPOSE

The purpose of this study was to determine health concerns of men with osteoarthritis (OA) of the knee for use in the design of appropriate nursing interventions.

DESIGN/SAMPLE

A one-group, descriptive design was used with a convenience sample of 104 men with a clinical diagnosis of OA of the knee.

METHODS

All participants were recruited from a VA hospital/clinic located in Missouri. They were surveyed using the Arthritis Impact Measurement Scales 2 (AIMS2).

FINDINGS

The men in this sample were most concerned about pain, walking and bending, and mobility. They rated their present health as fair to good, but in 10 years they predicted their health would be worse and their arthritis would be a major problem.

CONCLUSIONS

Based on these findings, interventions for men with OA should focus on strategies to deal with pain and decreased mobility and on fostering hope for the future.

Patient education for adults with rheumatoid arthritis

BACKGROUND

Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.

OBJECTIVES

To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.

MAIN RESULTS

Twenty-four studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment and psychological status. Physician global assessment was not assessed in any of the included studies. The two separate dimensions of psychological status: anxiety and depression showed no significant effects, nor did the dimensions of pain and disease activity. At final follow up no significant effects of patient education were found.

REVIEWER'S CONCLUSIONS

Patient education as provided in the studies reviewed here had moderate short-term effects on patient global assessment, and small short-term effects on disability, joint counts and psychological status. There were no long-term benefits.

Promoting self-help strategies by sharing the lived experience of arthritis

A qualitative approach informed by the phenomenological concept of lived experience using semi-structured interviews explored the experience of living with arthritis. Audio-taped transcribed conversations were analysed using a computer-assisted thematic analysis procedure. Strategies were offered for managing mornings, ensuring personal comfort, keeping a positive attitude, doing housework, cooking and meals, getting exercise, existing in day-to-day life, living at a slower pace, acknowledging feelings, dealing with depression, trying alternative treatments, accepting illness, getting sleep and rest, getting help, using help and handy gadgets, having emotional support, having determination, managing pain relief using distractions, making adjustments, planning ahead, maintaining independence, having a social life, managing stress, adapting around young children, and facilitating self-awareness.

Development of a questionnaire (OPQ) to assess patient's knowledge about osteoporosis

OBJECTIVE

to develop a self-administered questionnaire (OPQ) to assess the patient's knowledge about osteoporosis.

METHODS

An initial item pool of 71 questions was developed with input from clinicians involved in the management of patients with osteoporosis. It was piloted in ten patients for face validity and comprehension. The questionnaire was then administered to 50 first-time attendees at a specialist osteoporosis unit. After item analysis using index of difficulty and index of discrimination, 20 items were selected for the final questionnaire (OPQ). These were in the areas of general information (5), risk factors (7), consequences and treatment (four each).

RESULTS

the average index of difficulty and index of discrimination (D) of the 20 items was 0.56 (>0.75 is suggestive of a poor discriminator) and 54.8% (D value of 50% is associated with highest level of item discrimination) respectively. This means that all the items actively discriminated between high and low scorers. The Flesch readability index was 74.3 (a score between 70 and 100 means a document is easily understood) and the reliability coefficient was 0.84 (acceptable range 0.8-0.9). Criterion validity (verification that the scale measures what it claims to measure) was confirmed by the method of contrasted groups where members of an osteoporosis awareness charity had a significantly higher score than the first time attendees (13.6 +/- 4.3 vs. 8.5 +/- 5.4; P=0.003).

CONCLUSIONS

we have developed a self-report, 20-item questionnaire (OPQ) to assess the patient's knowledge about osteoporosis. Psychometric analysis has shown that the items have a satisfactory index of difficulty and discrimination. The OPQ is internally reliable, valid and easily understandable. It can be used to identify individuals in need of educational interventions as well as assess the effectiveness of education efforts as a part of management of osteoporosis.