Occupational Therapy and self-management for people with arthritis
Submitting InstitutionUniversity of Salford
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
With one in five of the adult population in the UK living with arthritis,
self-management education is a key approach used by occupational
therapists (OTs) to support people with arthritis. University of Salford
research has improved the tools available to OTs to deliver more effective
self-management education, demonstrating the following impact:
- Improving patients' quality of life through supporting them in:
- Managing their pain and fatigue;
- Improving their psychological resilience;
- Remaining in work and engaged in leisure activities.
- Supporting occupational therapists to deliver effective
- Developing evidence informed policy and strategy focused on improving
the availability of self management services for people with arthritis.
The key researchers and positions they held at the institution at the
time of the research are as follows: Professor Alison Hammond in
Rheumatology Rehabilitation (from 2011), Reader in Rheumatology
Rehabilitation, School of Health Sciences (2007-2011). The impact of this
case study is underpinned by the following research:
2009-13: Psychometric testing of the Evaluation of Daily
Activities Questionnaire (EDAQ) Valued Life Activities Scale (VLAS)
and Measure of Activity Performance —Hand (MAP-HAND): Patients are
referred to Rheumatology Occupational Therapy (OT) to address
difficulties with everyday activities, social roles and/or hand
function. In three studies, Hammond revised 3 assessments for clinical
and research use in OT in common musculoskeletal conditions (eg
rheumatoid arthritis (RA), osteoarthritis (OA), chronic pain).
Assessments were translated, revised to be culturally appropriate for
the UK and based on what patients' (not health professionals) considered
most important to include, then tested as reliable and valid. The EDAQ
is now available to facilitate patients and therapists in identifying
ergonomic solutions to daily problems.
2012: Foot health education for people with rheumatoid
arthritis: the practitioner's perspective: Patient education is a
key role for podiatrists in RA, leading to improved clinical outcomes.
This study identified the nature and content of podiatrists' foot health
education, the importance of the role of the podiatrist in management of
foot health, provision of foot health information, and self-management
strategies, delivered according to individuals' needs. Barriers to foot
health education, including financial constraints and difficulties
establishing effective therapeutic relationships, were shown to strongly
influence foot health education provision.
2011: Self-management of fatigue in rheumatoid arthritis: a
randomised controlled trial of group cognitive-behavioural therapy:
This study investigated the effect of group cognitive behavioural
therapy (CBT) for fatigue self-management, compared with receiving
fatigue information alone, for people with RA. A range of health
benefits resulted from group CBT for RA fatigue. Embedding such an
intervention within the clinical rheumatology team was found to be
essential and improving access to psychological therapies is
2010-13: Work Rehabilitation in Inflammatory Arthritis:
Effectiveness and cost effectiveness of an occupational therapy (OT)
job retention intervention: Hammond developed a feasibility study
for a future randomised controlled trial evaluating vocational
rehabilitation (VR) provided by occupational therapists for employed
people with inflammatory arthropathies. Patients were recruited from 6
Rheumatology departments in England and randomly allocated to receive VR
or a stay at work information pack only. Participants, employers,
therapists and therapy managers were also interviewed to identify their
views of the feasibility of the intervention. The study identified the
most appropriate primary work outcome measure, feasibility of
recruitment procedures and VR provision, which led to a
moderate-to-large effect size indicating trialling VR in IA is
warranted. During this a work assessment tool and work solutions manual
were developed — now freely available.
and Clinical Impact of the Lifestyle Management for ArthritisProgramme
(LMAP): This study developed a modular behavioural group arthritis
education programme (the LMAP) and evaluated its longer term effects on
pain, physical and psychological status. Hammond undertook a randomised
controlled trial of the LMAP versus an information-based group arthritis
education programme (AEP), similar to typical UK practice. The trial
identified, at 12-month follow-up, that the LMAP was significantly more
effective in reducing pain and improving self-efficacy Further research
- The longer-term effects of the LMAP and typical AEP on health status
by following up trial participants, identifying the LMAP led to
persistent behavioural and psychological benefits; and,
- LMAP effectiveness in an uncontrolled setting in a 12 month
observational study, identifying similar benefits to the trial.
References to the research
1. Hammond A, Bryan J, Hardy A (2008). Effects of a modular behavioural
arthritis education programme: a pragmatic parallel group randomized
controlled trial. Rheumatology 47(11):1712-1718. DOI
2. Iversen M, Hammond A, Betteridge N (2010). Self-management of
rheumatic diseases: state of the art and future directions. Annals of
the Rheumatic Diseases 69:955-963. DOI
3. Hewlett, S, Ambler, N, Almeida, C, Cliss, A, Hammond, A, Kitchen, K,
Knops, B, Pope, D, Spears, M, Swinkels, A and Pollock, J (2011),
`Self-management of fatigue in rheumatoid arthritis: a randomised
controlled trial of group cognitive-behavioural therapy', Annals of
the Rheumatic Diseases, 70 (6), pp. 1060-1067. DOI(REF2)
4. Graham, A, Hammond, A and Williams, A (2012), `Foot health education
for people with rheumatoid arthritis: the practitioner's perspective', Journal
of Foot and Ankle Research, 5 (2). DOI
5. Hammond A, Rayner J (2013). The Lifestyle Management for Arthritis
Programme in practice: results of an observational study. Rheumatology
52 (Suppl): i109(141) URL
6. 2012: Psychometric testing of the Valued Life Activities
Questionnaire and MAP-HAND in people with rheumatoid arthritis in the UK,
Arthritis Research UK, £80,342.00. Principal Investigator: A Hammond
7. 2010: Work Rehabilitation in Inflammatory Arthritis:
Effectiveness and cost effectiveness of an occupational therapy (OT) job
retention intervention: A randomised controlled trial, Arthritis
Research UK, £262,732.00. Principal Investigator: A Hammond
8. 2010: The UK-Evaluation of Daily Activities Questionnaire
(EDAQ) in musculoskeletal conditions, UK Occupational Therapy
Research Foundation, £84,753.00. Principal Investigator: A Hammond
9. 2009: Development of a Dutch and German version of the
Evaluation of Daily Activities Questionnaire (EDAQ) for use in
Rheumatoid Arthritis (RA), European League Against Rheumatism
(EULAR), £27,896.00. Principal Investigator: A Hammond (100%).
10. 2008: Development of a UK version of the Evaluation of
Daily Activities Questionnaire (EDAQ) for use in RA, Arthritis
Research Campaign, £51,915.00. Principal Investigator: A Hammond
11. 2007: Long-term impact of the Lifestyle Management for
Arthritis programme (LMAP), Arthritis Research Campaign, £47,552.00.
Principal Investigator: A Hammond (100%).
Details of the impact
- Rheumatoid arthritis (RA) affects 0.5-1.0% of the population and
causes significant pain, debilitating fatigue, joint deformity, and
psychological distress. It affects people's abilities to perform
everyday activities and causes work disability, which can reduce
financial status. "Approximately one third of people stop work
because of the disease within 2 years of onset, and this prevalence
increases thereafter. The total costs of RA in the UK, including
indirect costs and work-related disability, have been estimated at
between £3.8 and £4.75 billion per year." NICE
Clinical Guidance 79
- Supporting people with arthritis in managing their pain and fatigue,
and supporting Occupational Therapists (OTs) to develop effective
self-management and joint protection methods for people with arthritis
when taught using educational-behavioural approaches, significantly
reduces pain, improves functional ability, and in the long-term, limits
hand deformity development.
- Self-management education is a key approach used in Rheumatology by
OTs and other team members to help people with arthritis practically
manage symptoms, improve psychological outlook and maintain ability to
perform everyday home, work and leisure activities. The OT and
self-management education research led by Hammond, has addressed three
key areas helping:
- People with arthritis manage their symptoms and everyday activities
- Developing patient reported outcome measures, from the patients'
perspective, to enable patients and therapists identify problems and
find solutions together, and;
- OTs to deliver more effective OT and self-management education to
people with RA.
- The LMAP trial contributed to the evidence for effectiveness of OT,
included in the NICE RA Guidelines (2009.), Hammond was a member of the
NICE Guideline Development Group: The Management of rheumatoid
arthritis in adults, offering best practice evidence on the care
of adults with RA, which included the recommendation that people with RA
should have access to specialist Rheumatology OT for assessment,
provision of comprehensive OT and periodic review if they have problems
with either everyday activities and/or hand function; including joint
protection and hand exercises taught using educational-behavioural
approaches, not just simple advice. Rheumatology OT departments now set
standards of service delivery based on these guidelines.
- Hammond has trained over 200 OTs in delivery of LMAP modules in
practice. The programmes are provided in Rheumatology OT departments
across England, Scotland, the Republic of Ireland, the Netheralnds and
Turkey. OTs are provided with a detailed leader manual and audio-visual
resources to facilitate delivery; and patient workbooks support
learning. Course evaluations have consistently shown that the training
programme increased confidence in teaching using cognitive-behavioural
approaches. OTs also incorporate the training approaches when teaching
self-management to individual patients.
- Patients have found the LMAP highly beneficial. An independently
conducted focus group study at Wishaw Hospital (Scotland) included the
- "I had been terrified of damaging my joints and was scared to do
things — I got more confidence about what was safe/ unsafe to do, and
- "I went from trying to discover what I could do for myself, by
seeing how sore it was, to being shown other methods."
- "I get through more — I take micro-breaks and I am not so tired at
- "I accepted my limits but learnt how to work round them."
- "I was coming home from work exhausted, but now I can do ½ hour
ironing or go to the gym."
- "It got me walking again." "I started walking every morning."
- "Doing a little then a little more...... culminating in climbing
- "Through one of the discussions, I made an appointment with the
podiatrist and got insoles — my ankles are now behaving themselves."
"I am able to relax better."
- "When you've got information, you are in control more about what is
happening with the disease and that makes it easier to accept."
- "Information shared within the group and experiences. We learnt a
lot from each other."
- "Having a laugh about our ability or inability to do things, had a
therapeutic effect, it was fun."
- At Hairmyres Hospital, East Kilbride: "We use the LMAP and find the
outcomes that patients achieve excellent outcomes." Service
Manager (Jane-Marie Stobie)
- Prof Hammond was the lead author for the Arthritis Research UK advice
booklet "Looking after your joints when you have arthritis"
(2011) for people with inflammatory and osteoarthritis, provided free to
arthritis patients in the majority of Rheumatology and Rheumatology OT
departments in the UK. It is used as a key element of teaching joint
protection by OTs and one of the core information booklets provided to
people newly diagnosed with inflammatory arthritis in Rheumatology
departments and freely available as a download from the Arthritis
Research UK website.
Sources to corroborate the impact
a) National Institute of Clinical Excellence (2009). Guidelines for
the management of adults with RA. http://www.nice.org.uk/nicemedia/pdf/CG79NICEGuideline.pdf
b) Wishaw Hospital (2008) unpublished focus group study report. The
c) Arthritis Research UK (2011). Looking
after your joints - Arthritis Research UK www.arthritisresearchuk.org
Departments using the LMAP modules:
d) Occupational Therapist, Wishaw General Hospital
e) Occupational Therapy Team Leader, Occupational Therapy Department East
f) Specialist Occupational Therapist, Fife Rheumatic Diseases Unit,
Whytemans Brae Hospital
g) Co-ordinator, Community Traumatic Brain Injury Team, Blantyre Health
h) Clinical Specialist Occupational Therapist, Rheumatology Services,
Waterford Regional Hospital.