Self-management education programmes for osteoarthritis

This review shows that in people with osteoarthritis:

Self-management education programmes may not improve self-management skills, osteoarthritis symptoms, function, quality of life and dropout rates but may reduce pain modestly compared with attention control. Active and positive engagement in life was not reported.

Self-management education programmes may slightly improve self-management skills, pain and function but may not improve active and positive engagement in life, osteoarthritis symptoms, quality of life and dropout rates compared with usual care.

Self-management education programmes probably do not improve outcomes compared with provision of information alone or compared with other interventions (exercise, physiotherapy, social support or acupuncture).

What is osteoarthritis and what are self-management education programmes?

Osteoarthritis (OA) is a disease of the joints, such as your knee or hip, or the joints in your hands. The joint cartilage that lines the joint gradually thins, narrowing the joint space. In severe cases, no cartilage remains between the bones, and the bones rub together when the joint is moved, making the joint painful and sometimes unstable.

Self-management education programmes are behavioural interventions designed to encourage people with chronic disease to take an active role in the management of their own condition. These programmes aim to improve outcomes for patients by supporting, not replacing, medical care. The content used to educate patients about their condition and to explain how they can best manage their symptoms varies between programmes.

Best estimate of what happens to people with osteoarthritis who undergo self-management programmes:

People who completed a self-management programme rated their self-management skills to be 0.4 points better (0.4 points worse to 1.2 points better) on a scale of 1 to 10 (higher score means better self-management) after 12 months (4% absolute improvement; 4% worse to 12% better).

- People who completed a self-management programme rated their self-management skills as 6.2 points on a scale of 1 to 10.

- People who received attention control rated their self-management skills as 5.8 points on a scale of 1 to 10.

People who completed a self-management programme rated their pain to be 0.8 points lower (0.3 to 0.14 points lower) on a scale of 0 to 10 (lower score means less pain) after 12 months (8% absolute improvement).

- People who completed a self-management programme rated their pain as 5 points on a scale of 0 to 10.

- People who received attention control rated their pain as 5.8 points on a scale of 0 to 10.

People who completed a self-management programme rated their osteoarthritis symptoms to be 0.14 points lower (0.54 points lower to 0.26 points higher) on a scale of 0 to 10 (lower score means fewer symptoms) after 12 months (1% absolute improvement).

- People who completed a self-management programme rated their symptoms as 4.1 points on a scale of 0 to 10.

- People who received attention control rated their symptoms as 4.2 points on a scale of 0 to 10.

People who completed a self-management programme rated their function to be 0.04 points lower (0.02 points lower to 0.10 points higher) on a scale of 0 to 3 (lower score means better function) after 12 months (4% absolute improvement).

- People who completed a self-management programme rated their function as 1.25 points on a scale of 0 to 3.

- People who received attention control rated their function as 1.29 points on a scale of 0 to 3.

People who completed a self-management programme rated their quality of life to be 0.01 points lower (0.03 points lower to 0.01 points higher) on a scale of 0 to 1 (higher score means better quality of life) after 12 months (1% absolute worsening).

- People who completed a self-management programme rated their quality of life as 0.56 points on a scale of 0 to 1.

- People who received attention control rated their quality of life as 0.57 points on a scale of 0 to 1.

One more person out of 100 dropped out of self-management programmes (1% absolute improvement).

- 13 out of 100 people who received a self-management programme dropped out.

- 12 out of 100 people who received attention control dropped out.

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.

Read the full abstract...
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 strategy: 

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).

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