Self-management for Inflammatory Arthritis Seems Effective but Needs More Research, Study Says

Self-management interventions can play an important role in treating inflammatory arthritis, but a new systematic review found that existing evidence into the effectiveness of specific interventions is lacking.

The analysis of the literature, looking at the chronic conditions included in the inflammatory category, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and axial spondyloarthritis, was published in the journal RMD Open.

A team of investigators including corresponding author Andréa Marques, RN, PhD, of the University of Coimbra, in Portugal, set out to see which types of interventions might be good candidates for the European League Against Rheumatism’s (EULAR) self-management recommendations. To do so, they looked for existing studies of self-management programs involving adults at least 18 years old. They found 32 studies that met inclusion criteria, of which 19 were randomized controlled trials and the remaining 13 were systematic reviews.

The studies covered a wide range of interventions, including interactive disease education (10 trials), patient problem-solving (9 trials), and cognitive behavioral therapy (8 trials). Also studied were goal setting and patient education programs.

“Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes,” Marques and colleagues wrote.

However, the investigators also said that it was hard to make strong recommendations based on the existing data, in part because the breadth and heterogeneity of specific interventions made it impossible to identify to points of convergence between the different types of programs, and most of the certainty of evidence in the studies was moderate or low.

“This is natural because self-management is a so-called ‘complex intervention,’” they noted. “In complex interventions, the efficacy of specific components is difficult to isolate.”

Marques and colleagues said a wide variety of people administered the interventions studied in the trials, including rheumatologists and nurses, but also therapists, social workers, and dieticians. Sometimes lay people, such as yoga teachers and counselors, provided the interventions, the authors said. However, none of the studies involved expert patients delivering the education or intervention, which Marques and colleagues said is in contrast to the practice of many patient organizations, which emphasize involving experienced patients as intervention leaders. The investigators said this may be due to the fact that most of the interventions in the studies took place in a health care setting, such as a hospital, or due to the strictures of a research trial.

Though self-management interventions were widely studied, Marques and her coauthors found most studies did not examine the effect of such interventions in patient adherence. Only one study used patient adherence as a primary outcome. Even among studies that tracked adherence, most did not attempt to draw a correlation between the intervention and potential improvements in adherence. What little evidence is available, though, suggests patient education has a beneficial role.

There was also a relative lack of studies looking at the cost-effectiveness of self-management interventions, the authors found. Two studies that were excluded from the review dealt with such questions, but the two had conflicting conclusions.

Marques and colleagues said self-management is an important issue, but it remains under-studied and warrants additional, carefully designed trials. The existing evidence supports the use of self-management interventions, but the investigators said certain types of intervention might work better on some patients than others, in part due to differences in disease status, and in part due to socioeconomic variables.

“Professionals should look out for ‘new ways’ that are more adjusted and closer to the patient needs, such as internet programs, which are proven to be effective in improving health status measures at 1 year,” Marques and colleagues concluded.

However, they added that that will be a difficult task, since it is not yet clear which measures should be used to qualify a program as effective.

Reference

Marques A, Santos E, Nikiphorou E, Bosworth A, Carmona L. Effectiveness of self-management interventions in inflammatory arthritis: A systematic review informing the 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis. RMD Open. 2021;7(2):e001647. doi:10.1136/rmdopen-2021-001647