Abstract
Objective
To assess therapeutic education program impact for lower limb osteoarthritis (OA) at both the medical and surgical stage. Factors limiting efficiency and implementation of these programs such as patients’ beliefs will be highlighted.
Method
A non systematic literature review on Medline and Cochrane Library databases from 1966 to 2009 using following key words “knee/hip osteoarthritis”, “self-care/therapeutic education”, “total hip/knee replacement/arthroplasty”, “patients’ beliefs” is conducted. Clinical trials and randomized clinical trials, as well as literature reviews and practice guidelines, published in English and French will be analysed.
Results
Therapeutic education is part of the non-pharmacological management of chronic illnesses such as OA. The aim of education at an early stage of OA is to change patients’ lifestyle, especially the regular practice of physical activity and weight reduction. Fears and avoidance assessment is necessary before patients’ education process. When a surgical option is considered, the aim of education is to hasten patient recovery, improve autonomy after surgery, facilitate the return home and reduce the rate of transfer to a rehabilitation unit.
Conclusion
The efficacy of therapeutic education could be optimised for the management of OA with use of standardized rules and methods to deliver information and education. One way to improve therapeutic education in the management of OA could be to propose dedicated continuing medical education programs supported by specific economic sources for health care professionals.
Résumé
Objectif
Évaluer l’impact des programmes d’éducation thérapeutique dans la prise en charge de l’arthrose des membres inférieurs à la phase médicale et chirurgicale avec une attention particulière portée aux facteurs limitant la mise en place et l’efficacité de ces programmes et en particulier les croyances des patients.
Méthode
Revue non systématique de la littérature par interrogation des bases de données Medline et Cochrane Library pour les années 1966 à 2009 utilisant les mots-clés « knee/hip osteoarthritis », « self-care/therapeutic education », « total hip/knee replacement/arthroplasty », « patients’ beliefs ». Les essais cliniques et les études contrôlées randomisées en langue anglaise ou française ainsi que les revues de la littérature et les recommandations pour la pratique sont analysés.
Résultats
L’éducation thérapeutique fait partie intégrante de la prise en charge de l’arthrose autant à la phase médicale que chirurgicale. L’éducation à la phase médicale a pour objectif une véritable modification du mode de vie des patients en particulier en ce qui concerne la pratique d’une activité physique ou la réduction pondérale. L’évaluation des peurs et croyances des patients est un préalable indispensable à cette démarche. L’éducation à la phase chirurgicale a pour objectif de préparer la récupération et d’améliorer l’autonomie après l’intervention afin de faciliter le retour direct à domicile et diminuer les transferts en service de rééducation.
Conclusion
L’impact de l’éducation thérapeutique dans la prise en charge de l’arthrose des membres inférieurs pourrait être amélioré en standardisant les méthodes et les règles de délivrance des informations. Afin de promouvoir la prise en charge éducative des patients porteurs d’arthrose, une formation spécifique des professionnels de santé ainsi que des financements adaptés sont nécessaires.
1
English version
1.1
Introduction
The World Health Organization (WHO) considers that in 2020, chronic diseases will be the main cause of disability because of the improvement in medical technologies and the increasing life expectancy. Twenty percent of the French population has a chronic disease . Osteoarthritis (OA) is the most frequent chronic joint abnormality and contributes to functional disability and loss of autonomy in elderly people . The hip and knee joints are the joints most frequently affected by degenerative arthritis, and about 40 % of the population aged 65 years and older has symptomatic OA . Resistance to medical management and severity of functional disability often lead to surgical treatment . Every year, about 70,000 total hip and 45,000 total knee replacements are performed in France. The prevalence of prosthetic surgical indications has been amplified exponentially because of the aging population and the increasing indications for surgery .
The WHO mentions that “the aim of therapeutic education (TE) is to teach the patient the adequate know-how. The patient’s TE is a permanent process, which is part of medical care. It includes sensitization, information, learning and psychosocial support, which are all related to the pathology and its treatments. The education should allow the patient and his family to have a better collaboration with the health care professionals” . Thus, TE helps chronically ill patients have a better knowledge of their disease and its management and become actors in maintaining their health. The main aim of TE is to improve the prognosis of illness by decreasing both morbidity and complications. One of the secondary aims concerns public health costs. TE should lead to better self-management of OA and therefore require less medical care, thus reducing direct and indirect costs. Although some of these arguments are supported by previous medical reports and reviews, more studies are needed to demonstrate a significant impact of TE on medical costs .
The Haute Autorité de santé (HAS) in France have defined general and specific goals of TE . In general, TE should improve patient health and patients’ and relatives’ quality of life. The specific goals of TE are the acquisition and maintenance of self-care competency or the ability to adapt competency depending on the patient’s background and experience. The HAS defined quality criteria for the content and delivery of TE. Educational programs should consider data from evidence-based medicine, as well as recommendations from evidence-based practice. The HAS focuses on the pivotal role of patients in the execution of the educational process, the need for a multidisciplinary team to deliver the program, and the need to assess the quality and efficacy of these programs.
Strong arguments for the development of educational programs for OA include the disease’s chronic, potentially disabling nature; its treatment involving a complex association of pharmacological and non pharmacological therapy, which implies several caregivers without an option for cure; and lifestyle modifications that may modify the severity and evolution of the disease. The educational process must start at the first medical visit, from the diagnosis, and continue after surgical therapy, with rehabilitation being an optimal period to begin or re-enforce a self-care program.
1.2
Objective
The main objective is to assess TE program impact for lower limb OA at both the medical and surgical stage. Factors limiting efficiency and implementation of these programs such as patients’ beliefs will be highlighted. We aimed to describe current TE programs for OA and their impact on patients, focusing on the role of patients’ fears and beliefs for such programs.
1.3
Method
A non systematic literature review on Medline and Cochrane Library databases from 1966 to 2009 using following key words “knee/hip osteoarthritis”, “self-care/therapeutic education”, “total hip/knee replacement/arthroplasty”, “patients’ beliefs” is conducted. Clinical trials and randomized clinical trials, as well as literature reviews and practice guidelines, published in English and French will be analysed. A focus is made on papers treating the following fields: state of the art on patients’ knowledge and beliefs, impact of TE programs at the medical and surgical stage, barriers in TE programs for OA in every day practice.
1.4
Osteoarthritis at the medical stage
1.4.1
State of the art on patients’ knowledge and beliefs
1.4.1.1
Patients’ knowledge of and misconceptions about osteoarthritis
A specific OA patient knowledge questionnaire (PKQ-OA) has recently been validated and used to assess patients’ knowledge of their disease, treatments and appropriate management ( Table 1 ) . In assessing the questionnaire, the authors found a wide range of knowledge levels among patients with established OA, scores ranging from 8 to 26 out of 30. Knowledge was not correlated with disease duration or patient’s age or sex; however, the number of years spent in formal education was correlated with high test scores. Many patients knew the symptoms of their disease, but many reported mixed methods of joint protection and energy conservation. The usual erroneous beliefs identified were “OA is caused by cold damp weather” and “blood tests are useful in OA diagnosis”. Knowledge about analgesics was poor: less than one-third of patients knew that analgesics should be taken prophylactically or that they should be taken when pain appears. Patients who ignored the maximal authorized doses of their analgesics were more likely to experience insufficient pain relief and to more rapidly take non-steroidal inflammatory drugs than were those who were aware of the maximal authorized doses. Muscle tightening and strengthening exercises were known suitable forms of exercise, but 13 % of patients thought that housework was part of these exercises. Only 71 % of patients knew that maintaining a recommended weight according to their height and age was the suitable method of reducing OA progression.
| Reference | Design | Population | Intervention | Follow-up | Outcomes measured | Results |
|---|---|---|---|---|---|---|
| Keefe et al. (1996) | RCT | 88 married patients diagnosed with knee OA | I1: spouse-assisted pain-coping skills training (CST) I2: conventional CST intervention C: arthritis education-spousal support (AE-SS) for control group | 10 weeks | Arthritis Impact Measurement Scales (AIMS) (pain, psychological and physical disability) Pain coping (Coping Strategies Questionnaire [CSQ]) Pain behaviour: videotaped behavioural observation protocol Medication use | The results suggest that spouse-assisted CST could reduce pain and disability in OA patients |
| Mazzuca et al. (1999) | Controlled clinical trial | 211 patients with radiographic evidence of knee OA | I: education ( n = 105) C: video ( n = 106) | Evaluations at 4, 8 and 12 months. Phone contact for the education group 1 week and 1 month after intervention | Cost of health services per subject Frequency of primary care visits | 80 % of the cost of delivering effective self-care education to the knee OA patients was offset within 1 year by the reduced frequency and costs of primary care visits |
| Keefe et al. (2004) | RCT | 72 married patients with knee OA | I1: spouse-assisted coping skills training (SA-CST) ( n = 18) I2: SA-CST plus exercise ( n = 20) I3: exercise ( n = 16) C: standard care ( n = 18) | Evaluation at baseline and at 12 weeks | Bicycle ergonometry and strength testing Post-training peakVO 2 K CSQ The arthritis self-efficacy scale The AIMS | An intervention combining spouse-assisted coping skills training and exercise training can improve physical fitness, strength, pain coping, and self-efficacy in patients with osteoarthritis knee pain |
| Buszewicz et al. (2006) | RCT | 812 patients aged ≥50 years with hip or knee OA (or both) and pain or disability (or both) | I: six sessions of self-management of arthritis and an education booklet C: education booklet | Data were collected at baseline and 4 and 12 months | Primary outcome: quality of life (SF-36) Secondary outcomes: WOMAC OA scale, hospital anxiety and depression scale, arthritis self-efficacy scale | The intervention improves participants’ ability to manage their symptoms and leads to a sustained reduction in anxiety but does not substantially affect their quality of life |
| Coleman et al. (2008) | Observational study Quality assurance program | 79 participants with established knee OA | Specific self-management education program | Baseline, 8 weeks and 6 and 12 months | WOMAC SF-36 | This self-management education program improved health status of people with knee OA in the short and medium-term |
| Ravaud et al. (2009) | Open pragmatic cluster RCT | 336 French patients | I: standardized consultation ( n = 154) C: usual care ( n = 182) | Baseline evaluation and at 4 and 12 months | Change in body weight and in time spent on physical exercises (Baecke index) at 4 months | A structured consultation program for patients with knee OA resulted in short-term improvement in weight loss and time spent on physical activity |
These data suggest that although information is freely available in handbooks, in drug information leaflets or in formal educational sessions provided in primary or secondary care settings, patients still need further diffused, standardized information. One inexpensive but effective way to inform patients about drug therapy could be the “30-second intervention” in office visits .
1.4.1.2
Patients’ fears and beliefs
According to Leeuw et al., fear is an emotional reaction to a specific, identifiable threat that may increase arousal of the sympathetic nervous system and induce defensive or escape behaviour to remove the specific threat . Fear and anxiety may both contribute to the fear-avoidance model in musculoskeletal disorders; that is, how a person interprets pain may lead to one of two pathways:
- •
an adaptive response, whereby the patient deals with the pain and is more likely to manage it and maintain daily activities that will help achieve functional recovery;
- •
a non-adaptive response that leads to maladaptive behaviours, including pain-related fear, avoidance, and hypervigilance.
Avoidance behaviours have been associated with disability in various musculoskeletal conditions, especially low back pain, in which fear-avoidance beliefs have been shown to predict disability changes . Fear is thought to lead to avoidance of the activities believed to be painful or harmful, which may lead to increased disability through the detrimental effects of physical inactivity and weakening of the musculoskeletal system.
Pain-related fear and fear of movement have been shown in patients with knee OA and associated with decreased knee function . In addition, a cross-sectional survey demonstrated that fear-avoidance beliefs are associated with poor self-reported indicators of function.
A qualitative interview study of OA patients and caregivers suggested that patients often believe that knee OA is associated with age and has an unavoidable evolution, that treatments are of little help, and that practitioners do not have many therapies to propose. Patients also expressed unrealistic fears about the impact of knee OA on daily and social life. A 25-item questionnaire assessing the fears and beliefs of patients with knee OA was proposed from analysis of the qualitative data by a Delphi method.
Then, patients’ fears and beliefs assessment is a compulsory step before entering any TE process contributing to a better involvement of the patient (i.e. exercise program).
1.4.1.3
Do patients’ perceptions about osteoarthritis vary by ethnic group?
A cross-sectional study performed in 2003 among African Americans and white American male veterans with chronic knee or hip complaints revealed that these patients perceive the same degree of pain and functional disability whatever the severity of OA. Similarly, the perception of symptoms regardless of clinical OA severity as defined by Lequesne index did not vary by ethnic group. In the Johnston County OA Project, Jordan et al. found no significant difference between African Americans and white Americans in scores for difficulty performing tasks or activities of daily living. Coulton et al. also reported that pain and overall physical disability as measured by the Arthritis Impact Measurement Scales were similar among African Americans, Whites, and Hispanics. However, ethnic disparities in joint replacement have been reported .
Recently, results were published of a large cross-sectional study comparing pain and function among African Americans and Caucasians with radiographic evidence of hip or knee OA. The two groups with only hip OA or with both hip and knee OA did not differ in self-reported pain or function, but among participants with only knee OA, African Americans had greater self-reported pain and functional disabilities than did Caucasians. These differences were mainly explained by clinical factors such as pain for differences in function, and body mass index and depressive symptoms for both pain and function.
1.4.2
Practitioners’ promoting or not self-management programs for people with osteoarthritis
A qualitative descriptive study to identify barriers to physicians’ referring patients to OA self-management programs was conducted in Australia. General practitioners (GPs) limiting knowledge about the availability of local programs and the types of services that these programs provide was a major barrier to referral for OA patients. Some GPs considered that self-management for OA was less favourable than that for other chronic conditions (e.g., diabetes, asthma) and questioned the clinical benefit of such programs for OA patients. The main patient-related factor was lack of motivation, whereas organizational and access issues (e.g., design and content of programs, location of programs, cost of attendance, waiting period) were the main program-related factors. Factors enabling referral included GPs’ knowledge about the content and availability of programs, positive attitudes about patient involvement in these programs, and patient awareness of the value and availability of these programs (i.e., patient-mediated referral).
1.4.3
Therapeutic education programs when surgery is not yet considered
1.4.3.1
Evidence-based data
For knee OA, TE may include individualised education packages, group sessions, regular phone calls, and assisted coping-skills training . A literature review identified many randomized controlled trials (RCTs), as well as systematic reviews and a meta-analysis of TE. Several RCTs and the meta-analysis concluded that educational strategies had positive effects on pain and coping but limited effects on functional disability . A site-specific self-management educational program improved health status, including indices of pain, mental health and physical functioning at 8 weeks and 6 and 12 months . A systematic review concluded that self-management programs do not significantly affect patient physical health as compared with exercise and suggested that effective educational programs for patients with knee OA should include exercises. Spousal-assisted coping-skills training could reduce pain and disability . When this training is associated with exercises, this intervention can improve physical fitness, pain coping and self-efficacy . Finally, TE could be cost-effective by reducing the frequency of primary care visits .
Concerning hip OA, a meta-analysis concluded no significant effect of education on pain and disability .
1.4.3.2
Self-care and international guidelines for the management of osteoarthritis
International guidelines advise the association of pharmacological and non-pharmacological therapy for optimal OA care . Among non-pharmacological therapies, TE is recommended. Nevertheless, the European League Against Rheumatism (EULAR) recommendations for hip and knee OA, gathered in a single item, concern patient’s education, as well as physical exercise, technical aids and diet, but do not sufficiently detail the non-pharmacological therapies . The lack of details on how to apply these recommendations leads to insufficient implementation of these measures, especially patient’s education. A French observational survey showed that only 48.7 % of GPs prescribe physical exercise for knee OA, whereas 95.8 % prescribe acetaminophen . Similar results concerning weight loss were found: less than half of patients with OA report ever being advised by a medical doctor or a health professional about the importance of losing weight . More recent recommendations by the Osteoarthritis Research Society International (OARSI) insist on the relevance of informing and educating patients with hip or knee OA, specifying the domains that TE must emphasize to patients . These domains involve explaining the goals of treatment and the importance of changing lifestyle, such as the importance of exercise, activity adaptations, weight loss and other measures to unload the damaged joint(s). Patients must become actors of their treatment, rather than adopt passive coping strategies. Simple information should be differentiated from a real educational process aiming to change the patient lifestyle, especially regarding exercise or diet.
Considering the clinical benefit of aerobic activity or exercise for lower-limb OA and the association of the effectiveness of an exercise program and compliance, recommendations established by the Société française de médecine physique et de réadaptation (SOFMER) et de rhumatologie (SFR) highlight the need for educational programs aimed at increasing the daily practice of an exercise program. Such educational programs should describe the expected results of exercise and propose a self-assessment tool such as an exercise diary. Reminders such as phone calls are also recommended .
No specific recommendations exist for TE about weight loss in OA. The recommendations established by the US National Institutes of Health for obesity treatment are often adopted for TE in OA. They emphasize a practical, patient-centered approach aimed at improving information about weight loss strategies according to patients’ ability to change their diet .
1.5
Osteoarthritis at the surgical stage
1.5.1
Preoperational therapeutic education
1.5.1.1
Self-care awareness
The preoperational period is favourable for developing TE strategies ( Table 2 ). These educational programs have the same objectives as those proposed earlier in the disease, such as practice of physical activity and weight loss. These educational approaches must also focus on preparing for surgery by proposing preoperational rehabilitation programs and analysing and discussing patients’ expectations about surgery results in order to detect unrealistic expectations associated with patients’ dissatisfaction with surgery .
| Reference | Design | Population | Intervention | Follow-up | Outcomes measured | Results |
|---|---|---|---|---|---|---|
| Giraudet-Le Quintrec et al. (2003) | Single-center RCT | 100 patients scheduled for THA | I: multidisciplinary collective information group, receiving verbal information and an information leaflet ( n = 48) C: control group receiving verbal information and an information leaflet ( n = 52) | 7 weeks of follow-up | The State Anxiety Inventory: one day before surgery and postoperatively (1 day and 7 days after intervention) A self-evaluation questionnaire about the use of analgesic drugs Rehabilitation and length of hospital stay Patient satisfaction score (0–100 %) | A collective multidisciplinary information session 2 to 6 weeks before surgery may decrease pain before surgery and prevent an increase in anxiety before THA |
| Crowe and Henderson (2003) | RCT | 133 patients with comorbidities or limited social support | I: preoperative rehabilitation C: preoperative usual care | Evaluation at discharge | Length of stay | Patients receiving rehabilitation achieved discharge criteria earlier ( R = 5.4, CI = 8 days) and had a shorter actual length of stay (R = 6.5, UC = 10.5 days) |
| Nuñez et al. (2006) | RCT | 100 consecutive outpatients | I: therapeutic education and functional readaptation (TEFR) + pharmacological treatment C: pharmacological treatment | 9 months | Quality of life (SF-36) WOMAC (pain, function) Treatment Number visits Cost visits | A program of TEFR during the period on the waiting list for TKA may reduce the negative impact of this situation WOMAC function of patients who received both pharmacological treatment and TERF improved as compared with the control group |
| Mancuso et al. (2008) | 2 RCTs | 178 patients undergoing THA 146 patients undergoing TKA | Standard education session plus additional information (i.e., module) focusing on expectations of recovery during the first 12 months after surgery (THA = 91, TKA = 71) Standard class (THA = 87, TKA = 75) | 1 year | Primary outcome: within-patient change in expectation scores (Hospital for Special Surgery Total Hip or Knee Replacement Expectations Survey, score range 0–100, higher score = greater expectations | Expectations of patients undergoing THA and patients undergoing TKA can be modified by pre-surgery education sessions. An educational module focusing on 12th month recovery decreased expectations in patients undergoing TKA and resulted in more patients having expectations that coincided with surgeons’ recommendations |
| Crotty et al. (2009) | RCT | 152 public hospital outpatients awaiting hip or knee replacement surgery | I: self-management program C: usual care | 6 months | Health Education Intervention Questionnaire (HeiQ) WOMAC The Centre for Epidemiologic Studies/Depression Scale (CES-D) | The arthritis self-management program improved health-directed behaviours, skill acquisition and stiffness in patients waiting for TJA, although the observed effects were of modest size effect No significant effect on pain, function or quality of life at 6 months Self-management programs can assist in maintaining health behaviours (particularly walking) |
| Lübbeke et al. (2009) | Cohort study | 2238 patients who underwent 2601 THA (Hardinge approach) | I: 3-hour preoperative multidisciplinary education session (advice on muscle strengthening exercises and postoperative restrictions of range of motion) 1 month before surgery ( n = 597 patients, 656 THA) C: non-participation ( n = 1641 patients, 1945 THA) | 6 months | Incidence of dislocation within 6 months of surgery | Findings suggest that participation in a preoperative patient education session may reduce the risk of dislocation within 6 months after THA |
GPs should discuss total joint arthroplasty (TJA) as a treatment option with patients who have severe OA. One study demonstrated that patients who reported discussing TJA as a treatment option with their GP were more likely to undergo TJA within the next year, but only 26 % reported having these discussions . Therefore, better communication is needed between patients and GPs about TJA.
1.5.1.2
Evidence-based data
Many studies have assessed preoperational interventions, especially educational ones. A systematic review of the Cochrane Library evaluated the impact of preoperational education alone before total hip or knee arthroplasty . Among the nine studies selected, only one showed a positive impact on hospital stay but no effect on functional disability . More complex interventions involving occupational therapy, physical therapy, or social worker intervention could be more effective. Optimal occupational sessions include counselling, technical aids suggestions, phone contacts, and possibly a home visit. Videos or booklets are also proposed in some educational programs. A high-quality RCT found patients waiting for total hip replacement with a significant reduction in pain as compared with a control group after both groups had received verbal and written information and the intervention group participated in educational group sessions with a multidisciplinary team .
1.5.1.3
International guidelines
The French College of Physical Medicine and Rehabilitation (SOFMER), combining evidence-based medicine and practice approaches, concluded that preoperational rehabilitation programs of at least physical therapy plus education should be proposed before total hip or knee arthroplasty . As well, the authors recommended a preoperative multidisciplinary rehabilitation program with occupational therapy and education for the most fragile patients who have major disability, co-morbidities, or social problems. The HAS recommend a preoperative physiotherapy program that combines analytic work, respiratory physiotherapy and TE before total knee arthroplasty. The educational program should address the use of technical aids, getting out of a chair and bed, and going up and down stairs .
Another objective of preoperative education is to address the postoperative orientation. According to the HAS recommendations for patients undergoing total knee arthroplasty, the postoperative way of life must be planned before surgery . Therefore, decision-making tools are needed for the postoperative orientation. The Risk Assessment and Prediction Tool is based on sociodemographic and functional criteria, as well patient’s expectations and preferences for postoperative discharge. The latter issue could be affected by targeted education. Preoperative rehabilitation, including education before total hip or knee arthroplasty, could reduce the hospital stay and favour a direct return home, which therefore would contribute to reducing the rate of transfer to a rehabilitation unit .
1.5.1.4
How to assess patient’s expectations before joint replacement surgery?
Patient’s expectations before hip or knee arthroplasty contribute to postoperative satisfaction. These expectations could be assessed by standardized and validated methods before surgery, which would contribute to an “educational diagnosis” . These expectations could be changed by a preoperative educational intervention and could contribute to increasing the satisfaction rate, which is not always closely associated with outcomes such as disability or pain levels.
To improve the quality of life of patients on waiting lists for TJA, an OA self-management program has been proposed . This program showed improved health-related behaviours, skills acquisition and stiffness in patients waiting for TJA, although the effects were modest (Cohen’s d : 0.36–0.42), but had no significant effect on pain, function or quality of life. Self-management programs can help maintain health behaviours (particularly walking) in this patient group. Another study suggested that a TE program associated with functional restoration may reduce the negative impact of being on a waiting list for total knee arthroplasty .
1.5.2
Postoperative education
Multidisciplinary postoperative rehabilitation programs after hip or knee replacement may include information or education. Programs including education are more effective than is usual hospital care, when considering function, hospital stay, postoperative complications and medium-term cost as outcome measures . Educational programs may have a positive effect on surgical side effects, especially on the occurrence of dislocation after total hip replacement .
1.6
Specific difficulties in the systematic implementation of therapeutic education programs in osteoarthritis
For effectiveness, several messages developed in TE programs for patients with OA require patients’ willingness to change. Consequently, patients must be educated about their disease and understand the objectives of therapy . This kind of approach is difficult, time-consuming and hardly feasible during a traditional visit to GPs . The lack of application of guidelines regarding OA management is probably due to difficulties in informing patients about non-pharmacological therapies within a simple office visit. A pragmatic approach consisting in a single message given at each visit has been effective for weight loss and the practice of physical activity in patients with knee OA .
Other potential barriers are linked to medical culture and health insurance systems . Phone calls are effective but remain unconventional in many countries. Information booklets with validated scientific content are effective , but several educational interventions for OA, such as occupational therapy or dietician visits, are not covered by many health insurance systems.
1.7
Conclusion
According to the literature and international recommendations, TE should be considered in OA management. The main objective of education is a real change in patient lifestyle, especially regarding physical activity or weight loss. Education must address the early stage of OA, as well as the pre- and postoperative periods.
More studies are needed to better define effective educational programs for OA, alone or associated with other therapies, and assess their cost-effectiveness.
Conflict of interest statement
None.
2
Version française
2.1
Introduction
D’après l’Organisation mondiale de la santé (OMS), les maladies chroniques constitueront la principale source d’incapacité d’ici 2020. Cette évolution est liée à l’amélioration de la technicité médicale et à l’augmentation de l’espérance de vie. En France, 20 % de la population est atteinte de maladies chroniques . L’arthrose est la plus fréquente des pathologies articulaires chroniques et contribue largement à l’incapacité fonctionnelle et à la perte d’autonomie des sujets âgés . La hanche et le genou sont les articulations les plus souvent atteintes par cette arthropathie dégénérative. Ainsi, près de 40 % des plus de 65 ans sont porteurs d’une arthrose symptomatique . Dans un nombre important de cas, la résistance au traitement médical et le niveau d’incapacité fonctionnelle conduisent à proposer un traitement chirurgical . Près de 70 000 prothèses totales de hanche (PTH) et 45 000 prothèses totales du genou (PTG) sont actuellement posées par an en France. La prévalence de l’indication chirurgicale prothétique augmente de façon exponentielle en raison du vieillissement de la population et de l’élargissement des indications opératoires .
L’OMS–Europe a défini l’éducation thérapeutique (ETP) qui « a pour objet de former le malade pour qu’il puisse acquérir un savoir-faire adéquat, afin d’arriver à un équilibre entre sa vie et le contrôle optimal de sa maladie. L’ETP du patient est un processus continu qui fait partie intégrante des soins médicaux. L’ETP du patient comprend la sensibilisation, l’information, l’apprentissage, le support psychosocial, tous liés à la maladie et au traitement. La formation doit aussi permettre au malade et à sa famille de mieux collaborer avec les soignants » . Ainsi, l’ETP des patients contribue pour les malades chroniques à une meilleure connaissance de leur pathologie et de sa prise en charge, les faisant ainsi devenir acteur de leur propre santé. L’objectif principal de l’ETP est l’amélioration de la prise en charge de la pathologie via une diminution de la morbidité ou une réduction de la survenue de certaines complications ou incidents. L’un des objectifs secondaires est d’ordre médicoéconomique, l’amélioration de la prise en charge d’une pathologie par le patient diminuant le recours aux soins et pouvant de ce fait entraîner une réduction des coûts directs ou indirects. Cependant, s’il existe un certain nombre d’arguments dans ce sens dans la littérature, la démonstration définitive de l’impact significatif de l’ETP sur le plan médicoéconomique reste à faire .
Les recommandations de la Haute Autorité de santé (HAS) permettent de préciser l’intérêt de l’ETP . Elle participe à l’amélioration de la santé du patient (biologique, clinique) et à l’amélioration de la qualité de vie du patient ou de ses proches. Les finalités spécifiques de l’ETP sont l’acquisition et le maintien par le patient de compétences d’autosoins et la mobilisation ou l’acquisition de compétences d’adaptation qui s’appuient sur le vécu et l’expérience antérieure du patient, faisant partie d’un ensemble plus large de compétences psychosociales. La HAS a par ailleurs défini des critères de qualité concernant le contenu et la forme des informations délivrées qui doivent s’appuyer lorsqu’elles existent sur les données issues de la médecine fondée sur les preuves ou sur les recommandations pour la pratique. La HAS insiste également sur la place centrale du patient dans la démarche, la pluridisciplinarité des intervenants et la nécessité d’une évaluation du processus éducatif.
Ces recommandations s’appliquent tout à fait à l’arthrose qui est une pathologie chronique, potentiellement invalidante, dont la prise en charge associe des thérapeutiques pharmacologiques et non pharmacologiques. En l’absence de traitement curatif en dehors de la chirurgie prothétique, le recours aux thérapeutiques non pharmacologiques doit conduire à des modifications du mode de vie. De plus, cette prise en charge doit être pluridisciplinaire, mobilisant de multiples intervenants autour du patient, qu’ils soient médecins (généraliste, médecin physique et de réadaptation, rhumatologue), chirurgiens orthopédistes, rééducateurs (kinésithérapeute et ergothérapeute), diététiciens. Le processus éducatif dans l’arthrose débute lors de la prise en charge médicale initiale dès l’annonce du diagnostic et doit se poursuivre jusqu’à la prise en charge chirurgicale, en particulier au cours de la rééducation pré- et postopératoire qui est une période propice pour engager une démarche éducative.
2.2
Objectif
L’objectif de cet article est de faire une mise au point sur l’impact des programmes d’ETP dans la prise en charge de l’arthrose des membres inférieurs. Une attention particulière sera portée à l’évaluation des peurs et croyances des patients à la phase médicale ; ces croyances pouvant être assimilées à des facteurs contextuels personnels retentissant sur l’activité et la participation conformément à la classification internationale du fonctionnement, de la santé et du handicap (CIF). Les facteurs limitant la mise en place et l’efficacité de ces programmes à la phase médicale et chirurgicale seront également mis en évidence.
2.3
Méthode
Une revue non systématique de la littérature est réalisée par interrogation des bases de données Medline et Cochrane Library pour les années 1966 à 2009. Les références des articles retenus ont été prises en compte et les articles correspondant aux critères d’inclusion mais non présents dans la recherche initiale ont été sélectionnés. Les mots-clés utilisés sont « knee/hip osteoarthritis », « self-care/therapeutic education », « total hip/knee replacement/arthroplasty », « patients’ beliefs ». Les essais cliniques et les études contrôlées randomisées concernant des sujets adultes humains, rédigés en langue anglaise ou française ainsi que les revues de la littérature et les recommandations pour la pratique sont utilisés pour l’analyse. L’ensemble des articles permettant de répondre aux items suivants sont retenus : état des lieux des connaissances et des croyances des patients, contenu et impact des programmes d’ETP à la phase médicale et chirurgicale, facteurs limitant la mise en place et l’impact des programmes d’ETP dans l’arthrose.
2.4
Arthrose à la phase médicale
2.4.1
État des lieux des connaissances et des croyances des patients
2.4.1.1
Connaissances des patients et idées reçues sur l’arthrose
Un questionnaire mesurant les connaissances des patients sur l’arthrose (osteoarthritis patient knowledge questionnaire [PKQ-OA]) a été récemment validé et utilisé pour évaluer les connaissances sur leur maladie, les traitements et la prise en charge adaptée ( Tableau 1 ) . Au cours de la validation de ce questionnaire, les auteurs ont trouvé des niveaux de connaissance très variable parmi les patients arthrosiques, les valeurs allant de 8 à 26 points sur 30. Les connaissances n’étaient pas corrélées avec la durée de la pathologie, l’âge ou le sexe du patient ; en revanche, le niveau d’éducation était corrélé à des valeurs élevées sur ce score. Alors que de nombreux patients connaissaient la symptomatologie clinique de l’arthrose, ils avaient recours à des stratégies d’économie articulaire et de réduction de leur activité. Les croyances erronées le plus souvent mises en évidence concernaient la relation entre l’arthrose et le mauvais temps qui n’a pas de véritable fondement scientifique et l’intérêt de réaliser des bilans sanguins pour faire le diagnostic d’arthrose. Les connaissances sur les antalgiques étaient faibles : moins d’un tiers des patients interrogés savaient que les antalgiques devaient être pris de façon préventive ou dès les premiers symptômes douloureux. Les patients ne connaissant pas les posologies maximales recommandées de leurs traitements antalgiques étaient les plus mal soulagés et les plus enclins à avoir recours aux anti-inflammatoires non stéroïdiens. Le bénéfice des exercices de renforcement musculaire était connu des patients mais 13 % d’entre eux pensaient que les travaux ménagers en faisaient partie. Seul 71 % des patients savaient que maintenir un poids en rapport avec leur taille et leur âge permettait de ralentir la progression de l’arthrose.
| Auteurs | Type d’étude | Population | Intervention | Suivi | Critères d’évaluation | Résultats |
|---|---|---|---|---|---|---|
| Keefe et al. (1996) | ECR | 88 patients mariés souffrant de gonarthrose | I1 : stratégies de coping impliquant l’épouse (CST) I2 : stratégies de coping conventionnelle C : éducation du conjoint | 10 semaines | Arthritis Impact Measurement Scales (AIMS) (douleur, handicap physique et psychologique) Gestion de la douleur (Coping Strategies Questionnaire) Comportement vis-à-vis de la douleur (analyse protocolisée d’un enregistrement vidéo) Consommation médicamenteuse | Les résultats suggèrent que l’apprentissage de stratégies de coping impliquant l’épouse peut diminuer la douleur et le handicap des patients gonarthrosiques |
| Mazzuca et al. (1999) | Étude contrôlée | 211 patients avec un diagnostic radiologique de gonarthrose | I : éducation + relance téléphonique ( n = 105) C : vidéo ( n = 106) | Évaluations à 4, 8 et 12 mois. Relance téléphonique pour le groupe éducation à une semaine et un mois après l’intervention | Consommation de soins Fréquence des consultations en soins primaires | 80 % du coût du programme éducatif est compensé en un an par la réduction de la consommation de soins et de la fréquence des consultations |
| Keefe et al. (2004) | ECR | 72 patients mariés souffrant de gonarthrose | I1 : stratégies de coping impliquant l’épouse ( n = 18) I2 : stratégies de coping impliquant le conjoint + exercice ( n = 20) I3 : exercice ( n = 16) C : soins usuels ( n = 18) | Évaluation à l’inclusion et à 12 semaines | Test sur ergocycle et mesure de la force musculaire VO 2-max Stratégies de coping (Coping Strategies Questionnaire) Arthritis Self-Efficacy Scale AIMS | L’intervention associant apprentissage des stratégies de coping impliquant l’épouse et un programme d’exercice peut améliorer la condition physique, la force musculaire, le coping et l’autoprise en charge pour des patients gonarthrosiques |
| Buszewicz et al. (2006) | ECR | 812 patients de plus de 50 ans souffrant de coxarthrose ou de gonarthrose | I : six sessions d’autoprise en charge de l’arthrose et livret d’éducation C : livret d’éducation | Évaluation à l’inclusion, 4 et 12 mois | Critère principal : qualité de vie (SF-36) Critères secondaires : WOMAC, anxiété-dépression (HAD), autogestion de l’arthrose (Arthritis Self-Efficacy Scale) | L’intervention améliore la capacité des patients à gérer leurs symptômes et réduit leur anxiété sans modification significative de leur qualité de vie |
| Coleman et al. (2008) | Étude observationnelle Programme d’assurance qualité | 79 sujets porteurs d’une gonarthrose | Programme éducatif d’autoprise en charge | Inclusion, 8 semaines, 6 et 12 mois | WOMAC SF-36 | Amélioration de l’état de santé à court et moyen termes |
| Ravaud et al. (2009) | ECR Pragmatique en cluster ouvert | 336 patients gonarthrosiques suivis par un rhumatologue | I : consultation standardisée ( n = 154) C : soins usuels ( n = 182) | Inclusion, 4 et 12 mois | Perte de poids et durée d’activité physique (indice de Baecke) à 4 mois | Un programme de consultations structurées auprès de patients gonarthrosiques améliore à court terme la perte de poids, la durée d’activité physique |
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