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Rheumatology Advance Access originally published online on September 24, 2008
Rheumatology 2008 47(11):1712-1718; doi:10.1093/rheumatology/ken380
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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

A. Hammond1,2, J. Bryan3 and A. Hardy4

1Centre for Rehabilitation and Human Performance Research, University of Salford, Salford 2Department of Rheumatology, Derbyshire Royal Infirmary, Derby 3Department of Occupational Therapy, Ripley Hospital, Ripley and 4Department of Physiotherapy, Derbyshire Royal Infirmary, Derby, UK.

Correspondence to: A. Hammond, Centre for Rehabilitation & Human Performance Research, Brian Blatchford Building, University of Salford, Frederick Road, Salford M6 6PU, UK. E-mail: a-hammond{at}salford.ac.uk


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
Objectives. Rheumatology guidelines recommend people with RA receive behavioural self-management education. This study developed a modular behavioural group programme and evaluated its longer term effects on pain, physical and psychological status.

Methods. People with RA or PsA were randomized to a modular behavioural or standard information-focused education programme, both delivered by experienced rheumatology health professionals at one large district general hospital. Outcome measures were pain, self-efficacy, fatigue, functional ability, psychological status and use of health behaviours (exercise, joint protection, fatigue and cognitive symptom management). Using an intent-to-treat analysis outcomes were compared at 6 and 12 months with analysis of covariance.

Results. Out of 498 referred patients, 218 agreed to participate, met entry criteria and were randomized; 51 withdrew before education. Of the remaining patients, 86 attended the behavioural and 81 the standard programmes. Participants were aged 55.4 yrs (S.D. 12.42) with disease duration of 7.39 (S.D. 6.88) yrs (53% <5 yrs). At 6 months, the behavioural group had better pain (P = 0.01), fatigue (P = 0.01), functional ability (P = 0.05) and self-efficacy (P = 0.01) scores and greater use of health behaviours. At 12 months, they continued to have better pain (P = 0.03), self-efficacy (P = 0.001) and psychological status (P = 0.0001) scores and greater use of some health behaviours.

Conclusion. Attending a modular behavioural education programme is effective for at least 1 yr in enabling people with RA and PsA to reduce pain, improve psychological status and self-manage their condition.

KEY WORDS: Rheumatoid arthritis, Patient education, Randomized controlled trial


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
People with arthritis have to learn to successfully manage its impact on their physical, functional, social and psychological status, a process termed self-management. This is the ability to monitor one's condition and effects the cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life [1]. Patient education aims to enable people to improve self-management, appropriately employ lifestyle changes (e.g. exercise) and help shift the responsibility for day-to-day disease management from health professionals to the individual [2]. The Arthritis and Musculoskeletal Alliance (ARMA) Standards of Care for Inflammatory Arthritis emphasize that people should have access to advice and training promoting self-management [3].

Delivery mode influences patient education effectiveness. A systematic review-identified behavioural group interventions for people with RA result in significantly better short-term (6 month) outcomes for functional disability, affect and patient global assessment, with a trend to improved pain, in comparison with information-focused group programmes, which primarily improve understanding [4]. Longer term (i.e. 12 month) benefits of behavioural interventions vary depending on programme structure, content and delivery, but in many benefits were not sustained. Strategies to preserve effects over time need developing [4].

People with arthritis need access to a variety of effective education modes and delivery methods, as no one approach meets all patients’ needs all the time [5]. In the United Kingdom, a widely available standardized group behavioural programme is the Arthritis Self-Management Programme. This is effective with community volunteers with a range of arthritis diagnoses [6, 7] and is delivered by trained lay leaders with arthritis. Within UK rheumatology services, health professionals provide a variety of arthritis education programmes, usually developed in-house. There is varying application of health behaviour and patient education theory and research guiding programme development dependent on the skills and training of rheumatology team members. Information-focused group programmes are often provided, such as that described by Helliwell et al. [8]. Usually, different multidisciplinary team members lead each session, discussing the key strategies each is most responsible for (e.g. physiotherapists and exercise). These improve knowledge but do not significantly impact on health behaviours and health status. Some include goal-setting and may use behavioural approaches. The British Society of Rheumatology/British Health Professionals in Rheumatology guidelines for the management of early RA recommend that people should be offered a cognitive–behavioural approach to patient education, delivered at the appropriate time, to promote long-term adherence to management strategies [9].

There is a lack of standardized, evaluated health professional-led, arthritis patient education programmes available to enable UK rheumatology departments to deliver evidence-based cognitive–behavioural approach interventions more easily. This study sought to develop such a programme with accompanying course materials and provide pilot training for rheumatology health professionals in patient education methods and integrating cognitive–behavioural approaches into education practice. Following programme evaluation, if effective, this could contribute to the availability of evidence-based arthritis education interventions for rheumatology health professionals to use in practice.

The Lifestyle Management for Arthritis Programme (LMAP) builds on from a joint protection programme already proven effective (the Looking After your Joints Programme (LAJP) [10, 11] and disseminated nationally [12]. The LMAP incorporates cognitive, behavioural and educational approaches to promote self-management. Content and relative emphasis was based on a survey of people with RA priority concerns and interests [13]. Theoretical models supporting LAJP and LMAP development include adult education principles and methods to enhance recall (e.g. repetition, explicit categorization, advance organizers), social cognitive theory [14, 15] the Health Belief Model [16, 17], self-management cognitive–behavioural therapy [18] and the Transtheoretical Model of Behaviour Change [19]. The theoretical basis and application is described elsewhere [5]. The programme includes gradual skills mastery of self-management strategies (each practiced weekly for 3–4 weeks), modelling, persuasion, reinterpreting physiological status and individualized goal-setting to enhance self-efficacy and enable behavioural change [15, 20]. A modular structure with review was developed to promote sustained change.

The aim of this study was to evaluate the short- and long-term (i.e. 6 and 12 month) effects of this modular behavioural programme (the LMAP) on the physical, functional and psychosocial status of people with RA and early inflammatory arthritis (IA).


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
Design
The parallel-group randomized controlled trial evaluated a group modular cognitive–behavioural approach programme (the LMAP) compared with a group information-focused (or standard) programme. It was not ethically possible to have a usual care-only control group, as the standard programme had been part of the rheumatology service for over 10 yrs. Prior to entry, all participants received individual education about arthritis and its management from rheumatology nurse practitioners during clinic appointments and relevant Arthritis Research Campaign booklets about their condition.

Participants
Participants were aged ≥18 yrs diagnosed by rheumatology consultants with RA or early IA (i.e. insufficient diagnostic criteria present to diagnose RA). It was normal practice for team members to refer patients early to the existing information-focused programme. People with PsA could also attend as their self-management needs are similar to those of RA. People were not referred if deemed by team members to have: severe psychological difficulties or currently receiving mental health care; any medical condition that might prevent them from safely exercising (e.g. history of more severe heart, lung or cerebrovascular disease) or previously attended an education programme. After referral, they were screened and excluded if they had a Modified Health Assessment Questionnaire score >2 (score range 0–3), that is severe functional problems [21].

Procedures
Derbyshire Research Ethics Committee approval was obtained. Over a 21-month period, rheumatology team members at one large district general hospital were asked to refer all patients meeting entry criteria to education. Patients were mailed an education programme and study invitation letter, screening, reply and consent forms. The letter emphasized that education was an important part of treatment and was signed by the rheumatology consultants. The study was described as comparing two types of group education programme with similar content, but using different teaching approaches. Participants could not be blinded to programme allocation but programme differences were not discussed during the study. Patients could attend the standard education programme as part of normal treatment without study participation. Those indicating willingness to participate were telephoned by a research administrator, the study discussed and opportunity to ask questions provided. The consent procedure was explained and participants’ written consent obtained by mail.

Following consent, participants were immediately randomized by a research administrator to the modular or standard programme using computer-generated random numbers in pre-prepared sealed, opaque, numbered envelopes. No stratification was used. Participants were then telephoned by a research administrator to arrange attendance to either the modular or standard programme as allocated. Options of course start dates, times and locations (at either the district general or a community hospital) were given and the participant booked to a convenient course for them. Confirmatory letters were sent, with reminder 1 week prior to the course start. Three weeks prior to the agreed course, the trial questionnaire was mailed. If not returned within 10 days, postal and telephone reminders were provided. Courses for the two interventions were available over an 18-month period. Follow-up questionnaires were mailed 6 and 12 months after initial questionnaires. Two reminders were sent to maximize return. All participants continued to receive usual care.

Treatment interventions
Programme providers could not be blinded to group allocation.

Standard programme
This was provided by rheumatology team members experienced in programme delivery. No additional training was needed. A programme manual was developed from observation of the existing programme. Team members reviewed and revised content and audiovisual aids, and used the manual throughout the trial. The programme consisted of five 2-h meetings including talks each week from a different member of the team and group discussion. Meeting 1 included: what is arthritis, how it affects joints and other parts of the body, drug treatments and tests, managing arthritis (rheumatology nurse and consultant rheumatologist); Meeting 2: exercise (including stretch programme with 30 min demonstration and practice), rest, posture and pain management [using heat and cold, transcutaneous electrical stimulation (TENS), massage] [physiotherapist (PT)]; Meetings 3 and 4: joint protection (including 45 min demonstration and practice), managing fatigue, aims of splinting, managing stress and relaxation (45 min practice), foot care [occupational therapist (OT)]; Meeting 5: healthy diet, complementary therapies, Social Security benefits and open discussion (nurse, OT, PT, social worker). Usually the same OT attended each week to facilitate discussion and programme management. Relevant Arthritis Research Campaign and Arthritis Care booklets were provided. Eight to 12 people were invited to attend each programme.

The LMAP
This included two modules, each with four 2.5 h meetings, and one 2-h review meeting. The first author wrote manuals for each module, which were piloted and revised following patient feedback. Three experienced therapists (one rheumatology OT, one community OT and one rheumatology PT) delivered modules. To standardize programme delivery, a two-day training course for each module (led by A.H.) was completed by therapists. This explained: evidence for programme interventions; patient education and behavioural change methods; tips for good teaching practice (e.g. voice modulation, eye contact, open questions, reflecting back, positive feedback); programme structure; and role play of sessions emphasizing group processes, teaching techniques and skills teaching. A.H. delivered a programme observed by the therapists. The therapists were then observed delivering a programme and given feedback on performance. Module manuals enabled adherence to programme content.

Participants could attend the two LMAP modules and review meeting over a 3- to 9-month period, as convenient to them. Six people could attend module 1 (‘Looking After Your Joints’), 7–10 module 2 (‘Keeping Mobile and Managing Pain and Mood’) and up to 12 the review meeting. Each meeting included self-monitoring, skills training with individualized feedback and advice, goal-setting and action planning to follow individually determined home activity and exercise programmes working towards recommended frequency targets. Module 1 was developed from a behavioural joint protection programme [10]. Meeting 1 discussed RA and PsA, health beliefs, personal impact of arthritis, understanding multiple factors affecting symptoms, attitudes (self and others), personal experiences of what helps, self-management methods and motivating for change. These themes recurred throughout. Meetings 2–4 focused on applying ergonomic approaches to reduce pain (45–60 min weekly skills practice), hand exercises (flexibility and strengthening: 20–30 min weekly practice), fatigue management (e.g. activity pacing, microbreaks, planning, posture) and benefits of splints. This module had already been modified following feedback from previous participants and therapists [10, 12]. An example of part of the LMAP workbook (meeting 1) is provided in supplementary data available at Rheumatology Online. In Module 2, initial discussions focused on participants’ exercise beliefs, barriers and problem-solving these. Exercise included: a flexibility and strengthening exercise programme (30 min weekly practice); a graded home walking programme [22] (increasing over time to at least 30 min 5 days per week); and the warm-up and first 6 moves of the Tai Chi for Arthritis programme (30 min weekly practice) [23]. Tai Chi was selected as it improves lower limb movement, is enjoyable [24] and is becoming more widely available. Experiencing a group physical leisure activity could also increase confidence in attending community classes. Information on local exercise and swimming facilities were promoted to encourage continuing exercise. Footwear and foot care advice were given to facilitate mobility and podiatry referral if needed. Cognitive symptom management included stress management and coping with automatic negative thoughts. Pain management included use of heat and cold massage, TENS, distraction and relaxation practice (deep breathing and progressive neuromuscular facilitation 10–30 min weekly for three meetings). The review meeting included progress with goals, drug therapy, investigations, communicating with health professionals, team care and topics of participants’ choice (e.g. diet, complementary therapies, work support services, Social Security Benefits). See supplementary figure 2, available as supplementary data at Rheumatology Online for an LMAP summary. Module B and the review meeting were piloted and changes made following participant feedback. These included spending more time on practising exercise, foot care, explaining about drug therapy and blood tests and providing information on appropriate community-based physical leisure activities.

Participant workbooks were provided for each module with key points, illustrations and diaries to record practising joint protection, pacing and exercise. A range of relevant Arthritis Research Campaign and Arthritis Care booklets were provided. Each module was delivered by one group leader to facilitate: continuing discussion of themes (e.g. adjusting to living with arthritis, coping, impact of arthritis on the family, managing at work), negotiating home programmes and weekly review of progress with goals. Flexibility and promoting group interaction allowed tailoring of content to participants’ needs (e.g. applying joint protection at work, coping with negative attitudes at work) and problem solving to generate solutions.

Outcome measures
All outcome measures were collected using self-report questionnaires. The primary outcome measure was change in scores at 12 months on a 0–100 mm pain visual analogue scale (VAS, ‘no pain’ to ‘pain as bad is it can be’). Secondary outcome measures included:

  1. Physical status: the modified HAQ assessing functional ability (0–3 scale) [21]; a 100 mm fatigue VAS (‘no problem’ to ‘a major problem’); a 0–100 mm VAS of perceived health (‘very bad’ to ‘very well’); duration of early morning stiffness (in minutes).
  2. Psychological status: the RA Self-efficacy (RASE) Scale, evaluated belief about using 28 self-management behaviours [25]; the Arthritis Self-efficacy Scale (ASES) evaluated belief in ability to manage pain and other symptoms [26]; the psychological distress scale of the multidimensional HAQ includes four questions on sleep, stress, anxiety and depression [27]; and the Helplessness and Internality sub-scales of the Arthritis Helplessness Index measuring perceived control [28].
  3. Self-management: the Arthritis Stages of Change Questionnaire evaluated readiness to change to manage arthritis, with four sub-scales of pre-contemplation, contemplation, action and maintenance [29]; use of self-management behaviours in the previous week: exercise (stretch, strengthening and aerobic); cognitive symptom management (e.g. relaxation, positive thinking, distraction) [30]; joint protection; and fatigue management.
  4. Health care use: self-reported number of visits to physicians during the last 6 months; current medication (whether taking DMARDs, NSAIDs or low-dose oral steroids).
  5. Biographical information on age, gender, marital status, disease duration, occupation and work status were recorded.

Sample size
Using pain VAS data derived from participants with RA in a trial evaluating an earlier version of Module 1 [mean score 53.4 (S.D. 23.75)] [10], assuming a 20% difference between groups, a power of 80% at the two-tailed 5% significance level, a minimum of 78 patients were needed in each group.

Statistical analysis
An intention-to-treat analysis was conducted. Differences in clinical and demographic variables at baseline between participants remaining in the trial vs lost to follow-up were assessed using {chi}2 or unpaired t-tests as appropriate. Mean change (S.D.) scores for outcome measures from 0 to 6 months and from 0 to 12 months were calculated. Scores were compared using analysis of covariance to identify whether any significant differences occurred. Analysis was conducted with baseline scores of the outcome variable as covariates. Data were analysed using SPSS version 12.1.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Supplementary data
 Acknowledgements
 References
 
Recruitment and retention
The trial flowchart is shown in Fig. 1. Of those referred, 65% (324/499) wished to attend a group education programme. However, only 44% overall (218/499) were willing to participate in the trial and met the entry criteria. Following randomization, 51 of the 218 (23%) withdrew: no longer wished to attend education (n = 40); unable to attend due to work or childcare commitments (n = 6) or too ill (n = 5). This was a similar withdrawal rate to non-trial patients attending the standard programme as part of usual treatment (27% non-attendance). There were no significant differences at baseline between participants remaining in the trial vs the 17% lost to follow-up (data not shown).


Figure 1
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  		FIG. 1. Trial flowchart.

 
Background characteristics, attendance and co-interventions
The two groups were similar in demographic and baseline variables (Tables 1 and 2). Similar numbers continued to take DMARDs at 1 yr (74 in the standard vs 74 in the LMAP group), with no significant differences between groups ({chi}2 = 0.28, P = 0.20). Similar numbers remained in employment throughout (P = 0.70).


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  		TABLE 1. Baseline characteristics of participants

 

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  		TABLE 2. Analysis of covariance: baseline scores and mean (S.D.) 6- and 12-month change scores for health and functional status outcomes

 
There was no significant difference in the average attendance rate between the two groups, with 4.09 (S.D. 1.09) per five meetings (average 81.72% attendance) for the standard and 7.73 (S.D. 1.96) per nine meetings (average 85.92% attendance) for the LMAP ({chi}2 = 85.39; P = 0.21), suggesting that both were popular. Nine people in the standard and 10 in the LMAP groups attended less than half of the meetings. In the LMAP group, average time to complete the whole programme was 4.93 (S.D. 2.23) months; with 66 (77%) taking up to 6 months; nine (10%) 7 months; 10 (12%) 8–9 months; and one (1%) 12 months. The majority (94%) completed the modules before returning the second questionnaire. There were no significant differences between good and poor attendees apart from the latter having significantly greater fatigue [63.53 (S.D. 27.55) vs 49.31 (S.D. 24.96), t = 2.31, P = 0.02]. Participants in both groups could continue to attend for occupational or physiotherapy as appropriate, with no significant difference between the groups (6 months: number of standard group therapy attendances to OT/PT = 1.98 (S.D. 5.10), LMAP = 1.50 (S.D. 5.56), t = 0.57, P = 0.57; 12 months: standard group OT/PT attendances = 1.04 (S.D. 3.38), LMAP = 1.07 (S.D. 3.90), t = –0.06, P = 0.95).

Outcome measures
There were significant differences between groups at 6 months. The LMAP, compared with the standard programme, led to significantly improved pain, fatigue, functional ability, perceived health, self-efficacy for self-management (RASE), self-efficacy for controlling arthritis symptoms (ASES) and perceived control of arthritis, alongside significant reductions in psychological distress and helplessness (Tables 2 and 3). Significantly more participants in the LMAP had moved into the Action stage of change. Use of exercise and joint protection were significantly higher, and recalled consultations with a GP or consultant about arthritis were also significantly lower (Tables 4 and 5). By 12 months, improvements had attenuated but improvements in pain, self-efficacy, perceived control, helplessness, being in the Action stage of change, use of joint protection and fatigue management techniques continued (Tables 2 and 5). Staffing, resource and course materials costs were: £149 per patient based on eight patients attending each standard programme; and £208 per patient based on six people in Module 1, nine in Module 2 and 12 in the review meeting for the LMAP (supplementary Table 6, available as supplementary data at Rheumatology Online). Calculations were based on 2006/07 data [31] and do not include facilities costs.


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  		TABLE 3. Analysis of covariance: baseline scores + mean (S.D.) 6- and 12-month change scores for psychological status outcomes

 

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  		TABLE 4. Analysis of covariance: baseline scores and mean (S.D.) 6- and 12-month change scores for the Arthritis Stages of Change Questionnaire sub-scales

 

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  		TABLE 5. Analysis of covariance: baseline scores and mean (S.D.) 6- and 12-month change scores for doctor consultations and use of self-management

 

   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Supplementary data
 Acknowledgements
 References
 
Of the two programmes, the LMAP was significantly more effective. The standard group tended to stay the same or worsen across many outcomes, whilst the LMAP group improved or maintained status. There were no differences in self-reported use of medications between the two groups and thus gains were over and above those from medication. As in many other arthritis education trials, the short-term outcomes were better [4]. Pain, fatigue, functional disability, psychological status and use of lifestyle management improved, and were similar to those described from the UK study of the ASMP (6 x 2.5 h meetings), which included 35% of the participants with RA (OA 52%, and other forms of arthritis 13%) [7]. Longer term benefits were: a 14% improvement in pain, the primary outcome measure, compared with no change for the standard group; better self-efficacy and perceived control of the condition; and a trend to functional ability being maintained compared with deterioration in the standard group. Use of joint protection and fatigue management strategies continued to be increased, and thus the focus on enabling progressive changes and adequate skills practice was successful. Cognitive symptom management showed a strong trend to improvement at 6 but not 12 months. However, LMAP participants may not have needed to continue these in the longer term as their pain and psychological status improved. Exercise was increased at 6 but not 12 months. Exercise adherence has been difficult to maintain in other trials [32, 33]. Studies successfully doing so include either long-term supervised exercise training [34] or regular follow-up visits [35]. This suggests that further development of the LMAP exercise module is needed. For example, strategies to help people self-monitor their progress further (e.g. use of a pedometer with the walking programme) and continued longer term follow -up (telephone or attendance) to monitor progress. Aerobic exercise is beneficial in RA [36], thus some kind of longer term exercise support needs to be planned into services.

There is a continued need to research further into what aspects of arthritis education programme delivery facilitate change and improvements, who benefits most and what factors influence best timing for individuals of such behavioural programmes. This would help target patient education better. Whilst the LMAP includes topics common to many programmes it has some unique or less commonly provided features promoting sustained change. These were: the emphasis on motivating for change at the beginning of each module; participants’ self-monitoring behaviours to promote the decision to change (i.e. move through contemplation to action); the structured application of cognitive–behavioural approaches with protocolized programme delivery (whilst still allowing discussion of emotional issues and individuals’ goals); one group leader per module enabling continuity of discussion, individualized review and feedback; and longer intervention with greater skills practice to enable skills consolidation across a number of health behaviours, especially joint protection. For example, the LMAP includes this in three sessions rather than 1 h in the ASMP. The application of these techniques within Module 1 of the programme is further explained elsewhere [5]. Unusually amongst health professional led programmes, the LMAP has been developed to be a replicable package, with standardized leader manuals, teaching materials and participant workbooks.

Other health professional-led behavioural programmes including similar topics have all been delivered by several MDT members (which increases costs) but not had longer term effects on pain, although continuing benefits occurred in improved self-efficacy and some health behaviours. Examples of such programmes are: Taal et al. [37]: 10 h education, average disease duration 4.4 yrs; Lindroth et al. [33]: 20 h education, average disease duration 12 yrs; Brus et al. [32]: 10 h education, <3 yrs disease duration; Kirwan et al. [38]: 12.5 h education, average 14 yrs disease duration; Giraudet le Quintec et al. [39]: 52 h education, average 12 yrs disease duration. In this study, in contrast to several of these [33, 38, 39], just over half of the participants had the disease for <5 yrs.

Unlike the trials outlined above, this study compared the LMAP with another educational intervention, not usual care. Potentially its impact could be greater as it is unknown whether the standard programme led to any benefits in slowing deterioration in the absence of a usual care control group. As only one group leader is required for each module, it can be flexibly delivered in time (morning, afternoon and evening) and location (e.g. rheumatology department, community hospitals or centres with appropriate facilities) to meet patients’ needs. There is no need to coordinate a team to deliver the intervention.

The LMAP achieved these gains at a £59 per patient additional cost to the standard programme. The reduced number of doctor visits in the LMAP group may help off-set this additional NHS investment in staff time for patient education. However, if a department had no existing programme it would be a considerable investment. The cost of the LMAP is comparable with delivering the UK Arthritis Self-Management Programme (~£3000 per 12–20 attendees, i.e. £150–250 per person). This includes facilities and staff costs, but participants buy course materials (personal communication, Midlands ‘Challenging Arthritis’ Organiser, Arthritis Care, 2006).

Study limitations were that it was conducted in one rheumatology department only, which provided good quality individual education about arthritis and drug therapy from rheumatology nurses. Its generalizability is unknown. We could not collect data from those people who withdrew before education, so were unable to identify any differences between them and programme attendees. This could help understand characteristics of persons for whom such programmes should be targeted at. Although there were no differences between groups, methodologically it would have been preferable to stratify the sample based on diagnosis, disease duration and gender. Periodic observation of programme delivery would also have checked programme leaders’ adherence to protocols. Additionally, we did not undertake any qualitative data collection to obtain participants’ views of the programme or the process whereby it helped people make changes.

Further research is needed to investigate whether findings can be replicated in a multi-centre trial by rheumatology therapists with training in programme delivery. We did not include a cost–effectiveness analysis. Determining whether LMAP costs are off-set by other direct and indirect costs savings needs investigating in a study comparing the LMAP with usual care. Qualitatively investigating participants’ perceptions of the programme, what they changed or did not change and why, could also provide further insight into the mechanisms through which patient education facilitates change. Few health professional-led education studies have evaluated whether effects are sustained beyond 1 yr and a longer term follow-up would be beneficial. Evaluating its implementation in clinical practice would also identify whether the programme is feasible and effective in an uncontrolled setting.

In conclusion, over a 1-yr period this modular behavioural arthritis education programme was effective in improving pain and self-efficacy. It was feasible to deliver this using a small team of rheumatology therapists following training and supervised practice. Its wider use should be considered. Further details of the programme are available from A.H.

Formula


   Supplementary data
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Supplementary data
Acknowledgements
 References
 
Supplementary data are available at Rheumatology Online.


   Acknowledgements
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
References
 
Many thanks are due to the Rheumatology Consultants at the Derbyshire Royal Infirmary for their support and study advice: Dr R. A. Williams, Dr M. R. Regan, Dr G. D. Summers, Dr C. Deighton, Dr L. J. Badcock and Dr S. O’Reilly. Thanks are also due to: Derby Hospitals NHS Foundation Trust statisticians for advice on statistical analysis; the therapists and nurses in the rheumatology team for assisting in programme delivery; rheumatology nursing staff for referring patients diligently; and to research administrators for support during the study.

Funding: Arthritis Research Campaign (project grant no. 13371); Derby Hospitals National Health Service Foundation Trust Rheumatology Charitable Trust Fund.

Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 

  1. Barlow JH. How to use education as an intervention in osteoarthritis. In: Osteoarthritis. Bailliere's Best Practice Research Clinical Rheumatology—Doherty M, Dougados M, eds. (2001) 15:545–58. 2001;15:545–58.[CrossRef]
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  3. Arthritis and Musculoskeletal Alliance. In: Standards of care for people with inflammatory arthritis (2004) http://www.arma.uk.net/pdfs/ia06.pdf (24 March 2007, date last accessed).
  4. Riemsma RP, Taal E, Kirwan JR, Rasker JJ. Systematic review of rheumatoid arthritis patient education. Arthritis Care Res (2004) 51:1045–59.[CrossRef][Web of Science]
  5. Hammond A. Patient education in arthritis: helping people change. Musculoskeletal Care (2003) 1:84–97.[CrossRef]
  6. Lorig K, Lubeck D, Kraines RG, Seleznick M, Holman HR. Outcomes of self help education for patients with arthritis. Arthritis Rheum (1985) 28:680–5.[Web of Science][Medline]
  7. Barlow JH, Turner AP, Wright CC. A randomized controlled study of the arthritis self management programme in the UK. Health Educ Res (2000) 15:665–80.[Abstract/Free Full Text]
  8. Helliwell P, O’Hara M, Holdsworth J, Hesselden A, King T, Evans P. A 12 month randomised controlled trial of patient education on radiographic changes and quality of life in early rheumatoid arthritis. Rheumatology (1999) 38:303–8.[Abstract/Free Full Text]
  9. Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British health professionals in rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology (2006) 45:1167–9.[Free Full Text]
  10. Hammond A, Freeman KE. One year outcomes of a randomised controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology (2001) 40:1044–51.[Abstract/Free Full Text]
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Submitted 7 May 2008; revised version accepted 26 August 2008.
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