InterventionEffectiveness of individual resource-oriented joint protection education in people with rheumatoid arthritis. A randomized controlled trial
Introduction
Hand joint protection (JP) education is a standard occupational therapy intervention in the multidisciplinary management of people with rheumatoid arthritis (RA) [1]. Hand involvement is one of the major problems from the patients’ perspective [2] and limits them in relevant activities and social participation [3]. The JP concept has developed to a self-management approach ‘to improve daily tasks and role performance through the use of alternative working methods and assistive devices, which may thus enhance perceptions of control and improve psychological status’ [4].
The development of JP aims also implied use of other teaching methods. Traditional teaching methods such as use of written information, demonstrations, supervised practice and visual aids were successful in providing knowledge and skills [5]. However the aims of behavioural change and self-management require other strategies [6]. Various studies demonstrated the effectiveness of JP as a self-management strategy, provided that psycho-educational interventions are applied as they facilitate behavioural change with respect to JP use more successfully [4], [7], [8]. JP is often provided in a one-to-one setting, however it is currently unclear, whether the effects of psycho-educational JP education in group settings are applicable to an individual approach.
Self-management requires the patients’ involvement and responsibility for the day-to-day management of their illness [9]. There is evidence that individual beliefs and attitudes of patients are better predictors of patients’ abilities to cope with the illness than disease severity, age or gender [10]. Unsuccessful coping results in suffering that is thus determined less by the disease itself than by its meaning to the individual [11].
The Pictorial Representation of Illness and Self Measure (PRISM) is a brief interactive hands-on tool, requiring simple instructions and little time. The standard PRISM task was developed to quantitatively and qualitatively assess a person's suffering caused by an illness and/or pain [12], [13]. This perceived impact of disease is related to restrictions or losses in aspects of life that are most salient for that person [14]. An extension of the tool (PRISM+ task) visually summarises relationships between illness and other important aspects of the patient's life (e.g. work, family, hobbies, friends) [15]. This stimulates therapeutic focus shift from illness to the individual and his/her strengths and perception of important life aspects as resources. The PRISM+ task refers to Hobfoll's resource conservation model, which related the ability to cope with stress to the ability to conserve or substitute resources of one's life [16].
In this study, PRISM was used to guide an individualised JP intervention, as typical practice in Switzerland is one-on-one JP education. In routine clinical care PRISM has demonstrated high therapeutic potential. The PRISM tasks apply a client-centred approach and help to identify meaningful occupations [3]. It was assumed that this would have a strong effect on patients’ learning motivation and on improving transfer of JP education to daily life [17].
The study aim was to evaluate whether individualised, resource-oriented JP education (PRISM-JP) in RA patients facilitates JP acquisition and adherence more successfully, compared to conventional JP education (C-JP).
Section snippets
Patients
Patients were recruited by rheumatologists of four rheumatology departments in German-speaking regions of Switzerland. They were eligible when: diagnosed with RA according to ACR (American College of Rheumatology) guidelines [18]; in ACR functional class II (limited in avocational activities), III (limited in vocational and avocational activities) or IV (limited in usual self-care, vocational, and avocational activities) [19] associated with difficulties and/or pain in hands, justifying
Results
A total of 54 participants were recruited over a period of approximately 2 years. The distribution over the hospitals was 14 (7 randomized to C-JP, 7 to PRISM-JP), 13 (6 C-JP, 7 PRISM-JP) and 26 (12 C-JP, 13 PRISM-JP). One hospital recruited only 1 patient (C-JP) within 6 months and stopped study participation when the trained OT changed job. As one patient (PRISM-JP) dropped out after randomization but before assessments, 53 patients remained available for analysis. The participants of the two
Discussion
This study demonstrated that individualised, resource-oriented psycho-educational JP education (PRISM-JP) supported the acquisition and maintenance of JP behaviour more successfully than C-JP. Both treatment groups increased the use of JP methods after only four OT sessions, however, more people improved in the experimental group within this time period and the data 2 months after the fourth session detected that their learning was more sustained, i.e. in contrast to the controls, they managed
Practice implications
PRISM-JP more effectively supported learning of JP methods, with meaningful occupations, resource activation and self-efficacy acting as important mediators. PRISM improved patient–clinician communication and is feasible for occupational therapy.
Conflict of interest
No conflicts of interests to declare.
Acknowledgements
This study was supported by grants of the Zurich Rheumatology Foundation and the Swiss League Against Rheumatism.
The authors thank the rheumatologists recruiting patients; the OTs Claudia Gerber, Lucia Illi, Sylvia Lutukaite, Charles Mayor, Brigitte Rausch, Juliane Stöcker, Hanna Trelenberg for providing JP education; the head OTs Michael Breuer, Christine Meier and Verena Schweizer for supporting the study within their institutions; Esther Rudischhauser, Research Patient Partner, for her
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