Nivelreumapotilaille suositellaan annettavaksi potilasohjausta. Suositus on vahva, koska potilaalle annettu tieto on myös edellytyksenä sille, että potilas voi tehdä punnitun hoitopäätöksen yhdessä hoitavan lääkärin kanssa.
Katsauksessa «Riemsma RP, Taal E, Kirwan JR ym. Systematic revie...»1 vuodelta 2003 arvioitiin potilasohjauksen vaikutusta nivelreumaa sairastavien terveydentilaan. Katsaukseen valikoitui 31 satunnaistettua kontrolloitua tutkimusta. Ohjausinterventiot olivat hyvin erityyppisiä ja tutkimusten potilasryhmät erilaisia.
Potilasohjauksella todettiin olevan merkitsevä edullinen vaikutus toimintakykyyn, arkojen ja tulehtuneiden nivelten määrään, potilaan kokonaisarvioon nivelreuman vaikeudesta, psykologiseen statukseen ja masennuksen ilmenemiseen ensimmäisellä seurantakäynnillä eli 3 viikosta 9 kuukauteen kestäneiden interventioiden jälkeen. Ero kontrolliin oli selvin Behavioral treatment tutkimuksissa, joissa interventiot suuresti vaihtelivat sisällöltään (fyysinen harjoittelu, rentoutus, kivun hallinta, biofeedback). Ahdistuksen ja taudinaktiviteetin osalta merkitseviä muutoksia ei todettu. Viimeisellä seurantakäynnillä tilastollisesti merkitseviä eroja ei todettu, joskin trendi toimintakyvyn eduksi.
Kommentti: Tutkimusten laatu ei ollut keskimäärin kovin korkea.
In a randomized controlled trial «Grønning K, Rannestad T, Skomsvoll JF ym. Long-ter...»2, patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to a nurse-led hospital-based patient education programme combining group and individual education (the intervention group) (n = 71) or a waiting list (n = 70).
After 12 months, the intervention group had a statistically significant higher global well-being than the controls, mean change score 8.2 (95 % CI 1.6–14.8; p-value = 0.015). DAS28–3 showed a statistically significant improvement in, mean change -0.3 (95 % CI -0.5 – -0.1; p-value = 0.001), in the intervention group from baseline to 12 months, but not in the controls. The controls had a statistically significant deterioration in the Arthritis Self-Efficacy Other Symptoms Subscale, mean change -5.0 (95 % CI -8.6 – -1.3; p-value = 0.008), Arthritis Impact Measurement Scales - 2 Social, mean change 0.3 (95 % CI 0.1–0.5; p-value = 0.008), and Hospital Anxiety and Depression Scale total, mean change 1.4 (95 % CI 0.3–2.5; p-value = 0.013).
Kommentti: Lyhyt seuranta-aika vähensi tutkimuksen näytönastetta.
A randomized controlled trial «Arvidsson S, Bergman S, Arvidsson B ym. Effects of...»3 was performed to evaluate the effects of a self-care promoting problem-based learning programme for people with rheumatic diseases in terms of health-related quality of life, empowerment, and self-care ability. The participants were randomly assigned to either the experimental group (n = 54) or the control group (n = 148). The programme was running alongside the standard care the participants received at a rheumatology unit. The participants in the experimental group had statistically significant stronger empowerment after participation in the self-care promoting problem-based learning programme compared with the control group, at the 6-month post-intervention.
Kommentti: Lyhyt seuranta-aika vähensi tutkimuksen näytönastetta.
In a non-blinded randomized controlled trial «John H, Hale ED, Treharne GJ ym. A randomized cont...»4with a delayed intervention arm. A total of 110 participants were randomly assigned to receive the cognitive behavioural education intervention to address the cardiovascular aspects of rheumatoid disease (n = 52) or a control information leaflet (n = 58).
At 6 months, those in the intervention group had significantly higher knowledge scores (P < 0.001); improved behavioural intentions to increase exercise (P < 0.001), eat a low-fat diet (P = 0.01) and lose weight (P = 0.06); and lower mean diastolic blood pressure by 3.7 mmHg, whereas the control group's mean diastolic blood pressure increased by 0.8 mmHg. There was no difference between the groups on actual behaviours.
Kommentti: Vaikutus oli vähäinen. Lyhyt seuranta-aika vähensi tutkimuksen näytönastetta.
Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to an educational programme (n = 71) or usual care (n = 70). The programme consisted of three group educational sessions followed by one individual educational session «Grønning K, Skomsvoll JF, Rannestad T ym. The effe...»5.
After four months the intervention group had significantly better global well-being, 95 % CI (2.3–14.1), p = 0.01, and self-efficacy, 95 % CI (0.2–8.1), p = 0.04, than the control group. There were also trends for improved disease activity, and a statistically significant improvement in patient activation and pain in the intervention group.
Kommentti: Vain osalla potilaista oli nivelreuma. Lyhyt seuranta-aika vähensi tutkimuksen näytönastetta.
In a randomised, blind, controlled trial «Mathieux R, Marotte H, Battistini L ym. Early occu...»660 patients with early RA were divided into 2 groups. At baseline, group 1 received a full early occupational therapy information programme and group 2 received no information. In an extension phase, patients in group 2 received the full information programme at 3 months and were assessed at 6 months.
At 3 months, grip strength of the dominant and non-dominant hands increased more in group 1 than in group 2 (p = 0.021 and 0.047 respectively). HAQ score decreased more in group 1 than in group 2 (p < 0.001). In the extension phase, changes in grip strength and HAQ score in group 2 were similar to those seen in group 1 between baseline and 3 months.
Kommentti: Potilailla oli tuore nivelreuma. Lyhyt seuranta-aika vähensi tutkimuksen näytönastetta.
In this randomized, prospective, controlled trial «Giraudet-Le Quintrec JS, Mayoux-Benhamou A, Ravaud...»7104 patients with RA (ACR criteria) were allocated into an educational intervention consisted of 8 weekly ambulatory sessions, each lasting 6 hours and 104 to usual care. After 1 year, statistically significant differences in favour of the education group were found in patient coping (-1.22 ± 5.55 vs -0.22 ± 3.81; p = 0.03), knowledge (3.42 ± 4.73 vs 0.73 ± 3.78; p < 0.0001), and satisfaction (10.07 ± 11.70 vs 5.72 ± 13.77; p = 0.02. No difference was observed in change in HAQ score: -0.04 ± 0.46 (education group) vs -0.06 ± 0.47 (control group) (p = 0.79).
In a randomized controlled trial «Kirwan JR, Hewlett S, Cockshott Z ym. Clinical and...»8 79 RA patients drawn from hospital outpatient clinics were allocated in either observation or observation plus an educational intervention of five sessions (12.5 hours) designed to enhance self-management. Pain and self-efficacy for pain at 0, 4, 8 and 36 weeks were the primary outcome measures. Knowledge of RA and its treatment was measured at 0 and 4 weeks using a multiple-choice questionnaire.
Sixty-eight patients provided adequate data. In those randomized to education, knowledge of RA and its treatment increased by 18 % compared to 9 % in controls (p = 0.058). Self-efficacy for pain improved between weeks 0 and 4 by 10.3 % (p = 0.015) in those offered education, and by 14.1 % in those who were offered and accepted education (p = 0.001) but the difference from controls was not maintained after four weeks.
Kommentti: Potilaat olivat varsin pitkään sairastaneita.
In a randomized, controlled, assessor-blinded trial «Hammond A, Freeman K. The long-term outcomes from ...»9 65 patients with rheumatoid arthritis less than five years since diagnosis were allocated attend a joint protection and 62 a standard programmes. Both were 8-hour interventions. The standard arthritis education programme, included 2.5 hours of joint protection based on typical UK occupational therapy practice plus 5.5 hours on RA, exercise, pain management, diet and foot care; the joint protection programme used educational-behavioural training.
At four years, the joint protection group had significantly better: joint protection adherence (p = 0.001); early morning stiffness (p = 0.01); AIMS2 activities of daily living (ADL) scores (p = 0.04) compared with the standard group. The joint protection group also had significantly fewer hand deformities: metacarpophalangeal (MCP) (p = 0.02) and wrist joints (p = 0.04).
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Kommentti: Neljän vuoden seuranta-aika.