Self management of arthritis in primary care: randomised controlled trial

Letter to the editor,

We are delighted by the trial of Buszewizc et al.(1) on Self
Management of Arthritis in Primary Care, because it is well-designed and
offering opportunities for discussions and further study for the benefit
of the enormous population of people suffering osteoarthritis.

We would like to commend on several points. We think it might be
helpful to compare the available trials on self management of arthritis in
primary care, looking for differences, overlap, and remaining questions.

First, this is actually the third RCT (not the second as the authors
stated) to evaluate self management of arthritis in primary care (2,3).
Our trial was designed in order to assess the efficacy of a self-
management programme in a primary health care setting in middle-aged
patients with osteoarthritis. This also was a two-group randomized
controlled trial. The experimental intervention was compared with care-as-
usual. Duration of follow-up was 21 months after start of the
intervention. Recruitment of participants, treatments and follow-up
measurement all were performed in a general health care setting and was
done by GPs and via advertisements. Self-management was instructed by
physiotherapists. Primary outcome measures were pain severity in hip(s)
and/or knee(s) (VAS) and functional limitations (WOMAC). Second outcome
measures were SF36 and the TSK (tapping into fear-avoidance).

We found that the self-management programme positively influenced
knee pain and self-reported functional level in this sample of
osteoarthritis patients. Interestingly, the differences between the groups
increased during follow-up in favour of the intervention group(3.

There is overlap as well as there are some interesting differences (1
-3:
The self management interventions in all three trials are based on the
work of Kate Lorig. The format seems rather the same: 6 sessions guided by
two instructors. In our trial self management was offered by
physiotherapists, especially trained for this purpose.

Buszewizc et al claim that strength of their study is -in contrast
with previous studies- the application of validated questionnaires.
However, the same holds for our study as there is considerable overlap in
the measurements used (SF36, WOMAC). The presentation of outcomes differs
somewhat between the studies: Buszewizc et al have chosen quality of life
(SF36) as primary outcome. In our trial pain (VAS) and self-reported
functioning (WOMAC) were primary outcomes. Quality of life (SF36) was a
secondary outcome in our trial. Buszewizc et al did not find effects on
pain and physical functioning, while our study demonstrated some
beneficial effects in this regard. This might be due to the different
characteristics of the outcome measurements. It is likely that the SF36 is
less responsive than the VAS-pain and WOMAC with regard to changes in pain
and physical functioning. Nevertheless, there is considerable overlap in
the use of standardized measurement scales between the studies which makes
comparison possible and worthwhile.

Duration of follow up differed in the three studies: 4 months(2), 12
months(1) and 21 months (3). This is important because the long term
results appear to be better in the self management group than in the
control group(1,3).

In sum, in our trial the effects of the current self-management
interventions administered in a primary health care setting showed
improvement in pain and self-reported daily functioning, while the control
group deteriorated. At long term follow up (3) the differences between the
groups increased during follow-up in favour of the self-management group.
This seems to be an important finding since arthritis is a chronic
condition.
Buszewizc reported the trend of improvement over time, though not
statistically significant. Probably this is due to the shorter period of
follow up.

In the discussion paragraph Buszewizc and colleagues argue that
participants in their study had been diagnosed with osteoarthritis and
included by their general practitioner rather than applying formal
assessment criteria. In our study participants were included in 2 ways.
First, like in Buscewizc’ trial by the general practitioner and
additionally we recruited via advertisements. In both groups the diagnosis
was checked with formal criteria: in the GP-group we used the ICPPH-2, in
the advertisement group both ICPPH-2 and the ACR-criteria. All
participants matched these criteria-sets.
We also looked for possible differences between the participants recruited
via general practitioners and via advertisement. We found one relevant
finding, namely differences on a scale measuring “readiness-to-
change”(4,5). We did not find differences in outcome effects between the
population recruited via GPs or via advertisement. The claim by Buszewizc
that larger effects of the self management programme are likely in
volunteers with high levels of motivation and morbidity is interesting but
warrants further research. The question remains whether participants not
recruited via GPs but via advertisements might benefit more from self
management.

We thank Buszewizc c.s. for their interesting work.

Peter HTG Heuts, MD, PhD.
Caroline HG Bastiaenen, PhD, PT.

References:

1. Buszewizc M, Rait G, Griffin M, Nazareth I, Patel A, Atkinson A, et al.
Self management of arthritis in primary care: randomised controlled
trial. BMJ 2006;333:879-882.

2. Solomon DH, Warsi A, Brown-Stevenson T, Farrell M, Gauthier S, Mikels
D, et al. Does self-management education benefit all populations with
arthritis? A randomized controlled trial in primary care physician
network. J Rheumatol 2002;29:362-8.

3. Heuts PH, Bie de RA, Drietelaar M, Aretz K, Hopman-Rock M, Bastiaenen
CH, et al. Self-Management in Osteoarthritis of Hip or Knee: A Randomized
Clinical Trial in a Primary Healthcare Setting. J Rheumatol 2005;32:543-
49.

4. Heuts PH, Bie de RA, Dijkstra A, Aretz K, Vlaeyen JW, Schouten HJ, et
al. Assessment of readiness to change in patients with osteoarthritis.
Development and application of a new questionnaire. Clin Rehabil
2005;19(3):290-99.

5. Kerns R, Rosenberg R, Jamison R, Caudill M, Haythornthwaite J.
Readiness to adopt a self-management approach to chronic pain: The Pain
Stages of Change Questionnaire (PSOCQ). Pain 1997;72:227-234.

Competing interests:
None declared