Impact of an arthritis self-management programme with an added exercise component for osteoarthritic knee sufferers on improving pain, functional outcomes, and use of health care services: An experimental study

Results At 16 weeks, there were significant mean changes between groups in four outcome measures: reduction in arthritis pain ( p = 0.0001) and fatigue ( p = 0.008), and increased duration of weekly light exercise practice ( p = 0.0001) and knee flexion ( p = 0.004). The ability to perform daily activities and the number of unplanned arthritis-related medical consultations show statistically significant improvements between three time-points within the intervention group only ( p = 0.0001 and p = 0.005, respectively), but not between-groups ( p = 0.14 and p = 0.86, respectively). Both groups apparently had no changes in muscle strength. Conclusion Our findings suggest that the intervention had a positive effect in reducing pain, fatigue, knee range of motion, the practice of exercise routines, the number of medical consultations and in improving functional status and over a 16-week period. Practice implications The self-management programme we applied took into account the local context and the ethnicity of the group. This process is worth further exploration and testing in different groups. Keywords Arthritis pain Experimental study Functional status Osteoarthritic knee Self-management and exercise component 1 Introduction Osteoarthritis is one of the most prevalent activity-limiting conditions among older people in developed countries [1] . A local general household survey [2] reported that about 30% of Hong Kong people aged over 65 had been diagnosed with osteoarthritis and about 11% of the interviewed population with arthritis required long-term follow-up [3] . Arthritis of the knee is particularly common among Hong Kong Chinese and is responsible for most of the disablement of the elderly in Hong Kong [4] . Another local survey reported that of people aged 50 and over, 13% of women and 7% of men were diagnosed with osteoarthritis of the knee [5] and that 24% of women and 17% of men had persistent knee pain. Because of its common and chronic nature amongst the local population, effective management lies heavily on those with osteoarthritic knee problems to self-manage their own symptoms on a day-to-day basis. Patient education needs to focus on preventing exacerbation of the condition, inspiring in them the confidence to learn and empowering them to manage their every day lives within the culture [6,7] . Self-efficacy, developed by Bandura [8] as part of social learning theory, can be enhanced through four sources of information: performance accomplishments, vicarious learning, verbal persuasion, and physiological information. By adopting this self-efficacy theory, self-management programmes enhance the participants’ perception of control of their illness and enable them to apply more effective self-management strategies on a day-to-day basis. It empowers participants and moves away from the traditional passive patient role. Experimental studies of the Arthritis Self-Management Programme (ASMP) originally developed by Lorig and Gonzalev [7] suggest that activating effective self-management of arthritis is important in achieving good outcomes, such as decreased levels of patient's arthritis pain [9–12] . However, other research indicates conflicting results [15,16] . Most studies of arthritis education programmes have been conducted in Western countries [10,12–14,16,17] . Despite the steep increase of osteoarthritis prevalence with age [18] , there is a paucity of self-management education programmes for older adults with osteoarthritis in Asian countries. Evidence-based health education programmes are needed to develop, implement and test the effectiveness of programmes with different cultures [9] . A pilot study carried out by us previously [19] showed that a self-management programme was effective in reducing arthritic pain among old aged residents in long-term care settings. As in a similar study on rheumatoid arthritis [20] , we found that most local Chinese participants wished to emphasize learning exercise routines rather than learning coping strategies. Talbot et al. [21] found that participants in self-management programmes may independently follow exercise regimes but that it varied on an individual basis. Most of the time, osteoarthritic sufferers only exercise if they feel relatively pain-free. Stenstrom [22] further found that rather than letting individuals decide on when to exercise, specific goal increases in a regular goal-directed exercise programme was of benefit for arthritis sufferers. As exercises were found to be an important component of the first line non-pharmacologic treatment of knee osteoarthritis [23] , we modified the ASMP used previously to give emphasis to light exercise routines. The current experimental study evaluates the effectiveness of the adopted ASMP intervention with an added exercise component among Chinese osteoarthritic knee sufferers. This article reports the results of clinical outcome measures on improving pain, function, and on the use of health care services. 2 Materials and methods 2.1 Study design and participants This was an experimental study. Between December 2002 and May 2003 patients with osteoarthritis of the knee were recruited in the specialist out-patient clinic of the Orthopaedic Department of a local hospital, the general out-patient clinic of a local hospital and the Telehealth clinic. The study protocol was reviewed and approved by the human subjects committee of the School of Nursing, The Hong Kong Polytechnic University and the local hospitals. Patients who met the inclusion criteria were those capable of completing the questionnaire verbally, and with either self-reported osteoarthritis affecting the knee, or from their medical record. The diagnosis of osteoarthritis of knee was confirmed by the patient's medical history and a physical examination performed by either a registered nurse or physiotherapist based on the clinical criteria of the American College of Rheumatology 1991 [24–26] . The clinical criteria consisted of pain in the knee and three of the following: (1) aged at least 50 years of age; (2) less than 30 min of morning stiffness; (3) crepitus on active motion; (4) bony tenderness; (5) bony enlargement; and (6) no palpable warmth of synovium. Excluded were those patients who: were bed bound, were wheelchair bound, experienced loss of balance while standing, had knee replacements, could over-exert in exercise compliance, e.g. those currently undergoing active physiotherapy, such as hydrotherapy or strengthening exercises; and those currently receiving acupuncture treatments, since acupuncture is a traditional and popular treatment for joint pain among Chinese people. The patients who met the inclusion criteria were given detailed information about study procedures and provided written consent before being assigned to an intervention or control group by reference to a random number table. 2.2 The ASMP intervention The ASMP developed by Lorig and Fries [27] at Stanford University, is based on Bandura's [28] concept of self-efficacy and behaviour change. The ASMP intervention consisted of six 2-h classes held once a week, with 10–15 participants, led by registered nurses trained in small group leadership and basic principles of self-management. The classes were conducted according to a structured protocol. The programme focused on the use of an action plan and on teaching participants how to cope with, and manage, common knee osteoarthritic consequences, such as arthritis pain, fatigue, daily activity limitations, and stress. It was designed to give participants skills they could use to optimise their ability in managing their condition. The topics covered were (1) an overview of self-management principles; (2) medical aspects and pain management; (3) joint protection; (4) physical activity and exercise; (5) available treatments; (6) managing stress; (7) nutrition; and (8) communication skills and the availability of community resources. Based on the results of our pilot study [19] where many participants expressed their desire to learn more about exercise or motion to reduce their knee pain, three types of exercises were taught and promoted in the programme. The participants were asked to set their goal on exercise practice and received positive feedback by a nurse every week. The three types of exercises were, stretching, walking, and Tai Chi types of movement – fluid, gentle, relaxed, and slow in tempo – aimed at enhancing exercise on the affected joints. The stretching and walking exercises were based on those of Lorig and Fries [27] . A lay-person tutor who suffered from knee osteoarthritis and who had 3 years experience in teaching Tai Chi coached the third aspect of the exercises. The eight Tai Chi movements (‘eight basic movements’ developed by Professor Cheung, Beijing Sports University and produced by the Li Fai Centre of Wushu in August 2001) were chosen as being culturally relevant and specifically suited to the OA knee participants. Originally, the eight Tai Chi movements were developed for low back and large joint pains such as neck, shoulder, knee and lower limb. They consist of eight series of fluid, slow tempo, continuous graceful, dance-like movements involving: (1) head and neck rotations; (2) shoulder and wrist flexions; (3) trunk turning; (4) waist bending and rotation; (5) knee bending and rotation; (6) trunk turning and hip tapping with the fist; (7) trunk turning and knee bending; and (8) wrist bending and standing with weight bearing on one leg. The movements are integrated by mind concentration, balance, shifting of body weight, and breath control. The exercises take around 15 min to execute. In addition, a pedometer (OTO model DM-700) was given to the intervention group for 3 days (2 weekdays and 1 weekend) to act as a reinforcer for walking, but this was not used as an outcome measure. The control group received routine orthopaedic treatment (treatment prescribed by orthopaedic doctors or out-patient clinic) with no other treatment. 2.3 Data collection procedures Both groups were assessed at baseline (T0), and then 1 week (T1) and 16 weeks (T2) after finishing the programme. The outcome measures, selected after an extensive review of the literature, were assessed in a structured face-to-face interview, which also included a physical assessment of the affected joints. A panel of seven experts in the musculo-skeletal field was invited to verify the content validity of the outcome measures by a content validity index. The content validity of the outcome measures was 0.89 (content validity index). The inter-rater reliability ranged from 0.84 (Kappa statistics) to 1.00 (correlation co-efficient) and the 1-week test and re-test reliability ranged from 0.9 (Pearson co-efficient) to 0.95 (Spearman correlation). 2.4 Outcome measures 2.4.1 Demographic information Demographic information (e.g. age, gender, education and pre-retirement occupation) and arthritis-related information (e.g. type of arthritis, duration of disease and treatment for current arthritis condition) were collected at T0 only. 2.4.2 Arthritis pain and fatigue intensity Standard 100 mm horizontal visual analogue scales (VAS) were used to assess current pain and fatigue. Scores ranged between 0 and 100. Respondents were asked to place a mark on a line representing their level of pain or fatigue. On the pain VAS, the line was anchored by ‘no pain’ and ‘pain as bad as it could be’. A similar format was used in the measurement of fatigue, the line was anchored by ‘no fatigue’ and ‘constantly fatigued’. 2.4.3 Duration of practice of light exercise, physical functioning and number of unplanned arthritis-related medical consultations The frequency and duration of leisure-time light exercise (including stretching types of exercise, walking exercise and Tai Chi movements) were noted on weekly basis. The ability to perform a range of daily activities such as dressing and grooming, walking, hygiene, arising, eating and reaching was measured by the modified Health Assessment Questionnaire (HAQ) [29] . Scores ranged from 0 to 3 (0 = ‘without any difficulty’ and 3 = ‘unable to do’), with higher scores indicating greater physical impairment. The range of motion for both knee joints flexion was measured with a goniometer. Muscle strength of the Hamstrings (knee flexion) and Quadriceps (knee extension) were assessed by a score from 0 to 5 (5 = normal muscle strength in active movement against full resistance without evident fatigue; 4 = active movement against gravity and some resistance; 3 = active movement against gravity; 2 = active movement of the body part with gravity eliminated; 1 = a barely detectable flicker or trace of contraction; while 0 = nil muscular contraction detected [30] ). The numbers of unplanned arthritis-related medical consultations in the 16 weeks prior to course commencement were noted at T0, those during the course duration (6 weeks) at T1, and again at T2 (16 weeks after completion of the course). 2.5 Analysis Normality checking of the outcome data was examined by the Kolmogorov-Smirnov test, with p < 0.05 indicating that data were not normally distributed and that non-parametric statistics should be performed. Baseline characteristics of participants from the control and intervention groups were compared using Mann–Whitney U -test or chi-square tests according to the types of variable. Analyses of intervention effects with and without an intent-to-treat basis were done and compared. As the results were similar the analysis of intervention effects with an intent-to-treat basis is presented. To determine whether groups of participants improved in outcome measures, we calculated a mean change using the formula: mean change = X 2 − X 0 , where X 2 was the mean score at T2 and X 0 was the mean score at T0. The between-group mean changes were compared using the Mann–Whitney U -test and the effect size of the outcome measures were calculated by nQuery Advisor 4.0 (Statistical Solutions, Belfast). Since most of the outcome data were not normally distributed, the Friedman test was used to compare the within-group outcome measures at T0, T1, and T2. The level of significance was 0.025 (one-tailed) for all tests. All of the analyses were completed using the Statistical Package for Social Sciences, version 9.0 (SPSS Inc., Chicago, IL). 3 Results 3.1 Enrolment, group allocation and follow-up By assuming an effect size of 0.5 with an alpha level of 0.05 and a beta error tolerance of 20%, a minimum of 51 participants would be needed for each group [31] . Of the 182 participants enrolled in this study at T0, 149 (81.90%) completed T1, and 130 completed T2 (65.56%) (see Fig. 1 for details). 3.2 Characteristics of participants Participants’ characteristics are presented in Table 1 . All participants had suffered from osteoarthritis of the knee for an average of 8 years. No difference was apparent between the groups with respect to age, gender, education, pre-retirement occupation, marital status and the outcome measures ( p -value range from 0.10 to 0.99). The participants and drop-out group were also comparable across most of the demographic characteristics and outcome variables except for arthritis pain intensity rating ( p = 0.02) and the number of unplanned medical consultations related to arthritis ( p = 0.0001) (see Table 2 ). The drop-out group suffered from higher arthritic pain [mean = 52.42 out of 100, standard deviation (S.D.) = 2.76] than the participant group (mean = 44.58 out of 100, S.D. = 2.11). During the previous 16 weeks the drop-out group had visited the doctor for unplanned arthritis-related problems more frequently (mean = 3.77, S.D. = 6.41) than those in the participant group (mean = 1.33, S.D. = 3.18). 3.3 Arthritis pain intensity and fatigue level The results are presented in Table 3 . The reduction in current arthritis pain rating was significantly higher for the intervention group (about 12 mm reduction in 100 mm VAS, p = 0.0001) at T2 compared with the control group (about 2 mm reduction in 100 mm VAS, p = 0.17). The effect size was 0.61. Comparing the between-groups on mean changes, participants in the intervention group demonstrated a significant decrease in current pain ( p = 0.0001) between T0 and T2. The current fatigue intensity was significantly reduced for the intervention group (about 8 mm reduction in 100 mm VAS, p = 0.0001) at T2 compared with the control group (about 2 mm in 100 mm VAS, p = 0.17). The effect size was 0.34. There was a significant difference in mean change in current fatigue intensity for between-group comparison ( p = 0.008). 3.4 Duration of light exercise practice, physical functioning and number of unplanned arthritis-related medical consultations For the intervention group, there was a significant increase in the duration of light exercise practice weekly from T0 (mean = 5.60 h, S.D. = 4.48) to T2 (mean = 7.17 h, S.D. = 5.18) but not for the control group (mean = 5.07 h, S.D. = 3.96 at T0, and mean = 5.41 h, S.D. = 4.20 at T2). The p -values for the intervention and the control groups were 0.0001 and 0.95, respectively. The effect size was 0.68 (refer to Table 4 ). The p -value for between-groups comparison was 0.0001. No significant changes were detected at T2 on knee flexion, right hamstring strength or right quadriceps strength (see Table 4 ). However, intervention group participants did show better knee flexion outcomes than the control group in between-groups comparison ( p = 0.004). Moreover, intervention group participants did show more favourable disability health outcomes than the control group, as assessed by the HAQ ( p = 0.0001 and p = 0.12, respectively). The effect size was 0.12. The number of unplanned arthritis-related medical consultation was significantly reduced in the intervention group (−0.73, S.D. = 3.13) compared with the control group (−0.34, S.D. = 1.49) at T2 ( p = 0.005 and p = 0.17, respectively). The effect size was 0.66 (see Table 4 ). However, there was no significant difference in disability health outcomes and number of unplanned arthritis-related medical consultation for between-groups comparison ( p = 0.14 and p = 0.86, respectively). 4 Discussion and conclusion 4.1 Discussion In this study, the design of the intervention was based on self-efficacy theory [28] , i.e. the individual's sense of his or her ability to self-manage their arthritis. The programme stressed an exercise component that was culturally relevant and fitted for the OA participants. Our results show that statistically significant changes between groups were achieved in four outcome measures: arthritis pain rating, fatigue rating, increased duration of weekly light exercise practice and knee flexion. Both HAQ and the number of unplanned arthritis-related medical consultations show a statistically significant improvement between three time-points within the intervention group but not between-groups. Both groups had no apparent changes in muscle strength. Our results are in line with previous findings suggesting a benefit from an ASMP course in pain reduction at a 16-week follow-up [9–11,17,20,32] . However, our results are in contrast to previous findings [12,16,33] , where the intervention group did not show a reduction. In this study, the reduction in arthritis pain may have been mediated by an improvement in the participants’ perception of control of their knee joint arthritis and related symptoms. Improvements in joint pain and fatigue level may be the sources of physiological information. Though we found significant effects in the reduction of joint pain, we did not explore whether the reduction was associated with the level of self-efficacy or the mastery of self-management practices [28] . Future studies should address the relationship of symptom relief with the level of self-management practices and as to whether intervention programmes such as ours promotes self-efficacy and alters the participants’ perception of control. Education programmes for arthritis management need to be customised by including culturally specific components. We considered all aspects of the 6-week ASMP intervention programme and we ascribe the success of the adopted version to being culturally in tune with this Chinese ethnic group. Unlike the original ASMP, cognitive training was not emphasized in this programme since most participants in our pilot study [19] stated that they were not particularly interested in emotional training but preferred to learn exercises to improve their physical health. Perhaps, this relates to Chinese culture. Traditionally, dreaming or playing is devalued in the learning process, whilst doing something or working hard is expected as the essence of adult learning or problem solving. Compared with cognitive training, exercise may be perceived as doing something by Chinese osteoarthritic sufferers. Also middle-aged and older Chinese are usually reluctant to talk about their problems with new acquaintances, so they opted to take exercise as a less stressful option. Getting the participants to exercise was a challenge. We found that Tai Chi was a popular and acceptable form of exercise within this ethnic group. We evaluated many styles of Tai Chi including Yang or Ng for their suitability for arthritis sufferers, and their ease of learning, so as to fit within a 6-week course. We found that the ‘eight basic movements’ programme were specially suited to OA sufferers, when taught within the 6-week ASMP by a local Tai Chi tutor. Participants in the intervention group reported significant improvement in practising light exercise weekly including stretching exercise, walking or Tai Chi exercise. This increase in the practice of light exercise among the intervention group was sustained at T2, in line with those of similar programmes [20,32–35] . In contrast, Fu and his team in Shanghai [36] found no significant increase. Compliance is a general problem with respect to exercise programmes for older adults with osteoarthritis [9] . Talbot et al. [21] pointed out that one limitation for self-management programmes is that the subjects in the intervention group may independently pursue exercise regimes or implement the information imparted. In this study, compliance to exercise was boosted by five factors. (1) It was an area in which the participants were ready to learn, they verbalized their interests in exercise in baseline assessment. (2) It built on current exercise habits and culture-acceptable type. (3) Periodic nurse supervision monitored safe implementation practices with feedback about individual accomplishments. (4) There were multiple enforcers including the loan of a pedometer and weekly group exercise practice in class. (5) There was a Tai Chi tutor as a role-model since she also suffered from an osteoarthritic knee. From our experience, the use of a pedometer as pioneered by Talbot et al. [21] was easily incorporated into daily life, providing an inexpensive alternative to encourage exercise for older adults with symptomatic osteoarthritis of the knee. The lower limb muscle strength was similar for both groups at T2. Those in the intervention group showed slight improvement in knee flexion in the lower limb, compared with a slight drop in the control group. Perhaps a more intense exercise component would have yielded better results, but we planned light, culture-specific, safe, simple and easily repeatable exercises to be performed by the osteoarthritic sufferer in their living environment, under periodic professional supervision. In contrast with the findings of previous studies [10,12,16] , the intervention group showed improvements in the ability to perform a range of daily activities. Our data are in agreement with other studies [21,37–39] which also found significant changes after individual exercise components or with an Arthritis Self-Management Programme with exercise components. The Philadelphia Panel [40] pointed out that when the outcome goals are pain relief and function, stretching, strengthening and functional exercises were the most effective treatment. Thus, this type of ASMP with added individual exercises is worth further exploration and testing. Similar to the findings to previous local studies [36,41] , the number of medical consultations for arthritis-related problem decreased at T2. The potential of this type of programme in reducing the reliance on the traditional medically oriented health care system and on the cost of medical care in the long run should not be underestimated. Therefore, it is worthwhile to carry out a long-term follow-up, e.g. at 12 months, to determine whether the changes in pain rating, fatigue level, practice of exercise and functional status are maintained over a longer time. Moreover, future studies should also include an equal attention control to account for non-specific effects. One limitation of this study was the high drop-out rate in this study especially in the control group. Although there were slight differences in the characteristics of drop-outs and the participants in terms of pain level and the number of unplanned medical consultations for arthritis-related problems, the major factor was due to the SARS outbreak where all hospitals and clinics discouraged the participants from attending follow-up. Although the research team did relocate the site for the class, this remedial measure failed to retain some participants. Since the non-participants suffered from higher pain and had a higher number of unplanned medical consultations, the possibility of a survival bias was unavoidable. Furthermore, it is possible that the improvements noted were simply a result of the participants behaving according to their expectations of what the researchers were looking for. We scaled down the cognitive training component in our intervention programme, as we found that the ethnic background of our Chinese participants did not initially admit such a component. Perhaps, this component could be introduced at a later stage when the group knows each other more, and feels ready to share and co-learn. 4.2 Conclusion Our findings suggest that a self-management programme with an added exercise component had a short term positive effect in reducing pain, fatigue, knee range of motion and the number of medical consultations, improving functional status and increasing the practice of exercise for osteoarthritic knee sufferers. 4.3 Practice implications In applying such a self-management programme, it is deemed advisable to be specific to the local context culturally and in tune with the ethnic group. These aspects are worth further exploration and testing in different cultural groups. Acknowledgements We would like to acknowledge the partial support of the SN Departmental Research Committee for this study. The authors would also like to thank the Li Fai Centre of Wushu, Ms. Shirley Chan and Ms. Ada Tam for their contributions to the production of educational materials and fieldwork for this study. The authors also gratefully acknowledge Dr. Tony Chan for his thoughtful discussion especially on the analysis and Mr. Ian Dunn for English proof-reading and suggestions on refinement of the manuscript. Additionally, the study would not have been possible without the co-operation of the arthritic participants I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. References [1] E.M. Badley P.P. Wang Arthritis and the aging population: projections of arthritis prevalence in Canada 1991 to 2031 J Rheumatol 25 1998 138 144 [2] J. Woo E. Lau C.S. Lau P. Lee J. Zhang T. Kwok C. Chan P. Chiu K.M. Chan A. Chan D. Lam Socioeconomic impact of osteoarthritis in Hong Kong: utilization of health and social services, and direct and indirect costs Arthritis Rheum 49 2003 526 534 [3] Hong Kong Government Census and Statistics Department. Thematic Household Survey (Report No. 3). Hong Kong: Hong Kong Government Census and Statistics Department; 1999. [4] G.L. Cheing C.W. Hui-Chan The motor dysfunction of patients with knee osteoarthritis in a Chinese population Arthritis Rheum 45 2001 62 68 [5] E.C. Lau C. Cooper D. Lam V.N.H. Chan K.K. Tsang A. Sham Factors associated with osteoarthritis of the hip and knee in Hong Kong Chinese: obesity, joint injury, and occupational activities Am J Epidemiol 152 2000 855 862 [6] A. Madigan O. FitzGerald Multidisciplinary patient care in rheumatoid arthritis: evolving concepts in nursing practice Best Pract Res Clin Rheumatol 13 1999 661 674 [7] K. Lorig V. Gonzalez The integration of theory with practice: a 12-year case study Health Educ Quart 19 1992 355 368 [8] A. Bandura Social foundations of thought and action 1986 Prentice Hall Englewood Cliffs (NJ) [9] O.R.W. De Jong M. Hopman-Rock E.C. Tak N.S. Klazinga An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip Health Educ Res 19 2004 316 325 [10] J.H. Barlow B. Williams C.C. Wright The reliability and validity of the arthritis self-efficacy scale in a UK context. Psychol Health Med 2 1997 3 17 [11] K. Lorig D. Lubeck R.G. Kraines M. Seleznick H.R. Holman Outcomes of self-help education for patients with arthritis Arthritis Rheum 28 1985 680 685 [12] E. Simeoni A. Bauman J. Stenmark J. Obrien Evaluation of a community arthritis program in Australia: dissemination of a development program Arthritis Care Res 8 1995 102 107 [13] W.M. Gonzalez A. Stewart P.L. Ritter K. Lorig Translation and validation of arthritis outcome measures in Spanish Arthritis Rheum 38 1995 1429 1446 [14] E. Taal R.P. Riemsma H.L.M. Brus E.R. Seydel J.J. Rasker O. Wiegman Group education for patients with rheumatoid arthritis Patient Educ Couns 20 1993 177 187 [15] J.H. Barlow L.A. Cullen I.F. Rowe Educational preferences, psychological well-being and self-efficacy among people with rheumatoid arthritis Patient Educ Couns 46 2002 11 19 [16] D.H. Solomon A. Warsi T. Brown-Stevenson M. Farrell S. Gauthier D. Mikels T.H. Lee Does self-management education benefit all populations with arthritis? A randomized controlled trial in a primary care physician network J Rheumatol 29 2002 362 368 [17] M. Alderson L. Starr S. Gow J. Moreland The program for rheumatic independent self-management: a pilot evaluation Clin Rheumatol 18 1999 283 292 [18] J. Hill S. Ryan M. Edwards Rheumatology: a handbook for community nurses 2000 Whurr Publishers Philadelphia [19] Y.B. Yip J.W.H. Sit D.Y.S. Wong A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong Psychol Health Med 9 2004 249 260 [20] A.M.H. Siu D.Y.Y. Chui Evaluation of a community rehabilitation service for people with rheumatoid arthritis Patient Educ Couns 55 2004 62 69 [21] L.A. Talbot J.M. Gaines T.N. Huynh E.J. Metter A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study J Am Geriatr Soc 51 2003 387 392 [22] C.H. Stenstrom Home exercise in rheumatoid arthritis functional class II: goal setting versus pain attention J Rheumatol 21 1994 627 634 [23] A. Pendleton N. Arden M. Dougados M. Doherty B. Bannwarth J.W. Bijlsma F. Cluzeau C. Cooper P.A. Dieppe K.P. Gunther H.J. Hauselmann G. Herrero-Beaumont P.M. Kaklamanis B. Leeb M. Lequesne S. Lohmander B. Mazieres E.M. Mola K. Pavelka U. Serni B. Swoboda A.A. Verbruggen G. Weseloh I. Zimmermann-Gorska EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT) Ann Rheum Dis 59 2000 936 944 [24] Hopkins J. Arthritis provides clinical classification criteria and management guidelines. Retrieved May 21 2002, from http://www.hopkins-arthritis.som.jhmi.edu . [25] R.D. Altman Criteria for the classification of osteoarthritis of the knee and hip Scand J Rheumatol—Suppl 65 1987 31 39 [26] R.D. Altman E. Asch D. Bloch G. Bole D. Borenstein K. Brandt W. Christy T.D. Cooke R. Greenwald M. Hochberg D. Howell D. Kaplan W. Koopman S. Longley III. H. Mankin D.J. McShane T. Medsger Jr. R. Meenan W. Mikkelson R. Moskowitz W. Murphy B. Rothschild M. Segal L. Sokoloff F. Wolfe Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee Arthritis Rheum 29 1986 1039 1049 [27] K. Lorig J.F. Fries The arthritis helpbook a test self-management program for coping with arthritis and fibromyalgia 5th ed. 2000 Perseus Books Cambridge [28] A. Bandura 1,2 Human agency in social cognitive theory Am Psychol 44 1989 1175 1184 [29] T. Pincus J.A. Summey S.A. Sooraci Jr. K.A. Wallston N.P. Hummon Assessment of patient satisfaction in activities of daily living using a modified Stanford Health Assessment Questionnaire Arthritis Rheum 26 1983 346 1353 [30] L.S. Brickley R.A. Hoekelman Bates’ guide to physical examination and history taking 7th ed. 1999 Lippincott Philadelphia p. 576–7 [31] L.G. Portney M.P. Watkin Foundations of clinical research applications to practice 1993 Appleton & Lange Norwalk [32] Y. Lindroth A. Bauman P.M. Brooks D. Priestley A 5-year follow-up of a controlled trial of an arthritis education programme Br J Rheumatol 34 1995 647 652 [33] J.H. Barlow A.P. Turner C.C. Wright A randomized controlled study of the Arthritis Self-Management Programme in the UK Health Educ Res 15 2000 665 680 [34] R. Song E.O. Lee P. Lam S.C. Bae Effects of 12-week Tai Chi exercise on pain, balance, muscle strength and perceived difficulties in physical functioning in older patients with osteoarthritis: a randomized clinical trial J Rheumatol 30 2001 2039 2044 [35] C.A. Hartman T.M. Manos C. Winter D.M. Hartman B. Li J.C. Smith Effects of T’ai Chi training on function and quality of life indicators in older adults with osteoarthritis J Am Geriatr Soc 48 2000 1553 1559 [36] D. Fu H. Fu P. McGowan Y.E. Shen L. Zhu H. Yang J. Mao S. Zhu Y. Ding Z. Wei Implementation and quantitative evaluation of chronic disease self-management programme in Shanghai China: randomized controlled trial B World Health Organ 81 2003 174 182 [37] R.C. Dias J.M. Dias L.R. Ramos Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee Physiother Res Int 8 2003 121 130 [38] M. Fransen E. Margiotta J. Crosbie J. Edmonds A revised group exercise programme for osteoarthritis of the knee Physiother Res Int 2 1997 30 41 [39] S.A. Mazzuca K.D. Brandt B.P. Katz M. Chambers D. Byrd M. Hanna Effects of self-care education on the health status of inner-city patients with osteoarthritis of the knee Arthritis Rheum 40 1997 1466 4174 [40] Philadelphia Panel Members. Philadelphia Panel evidence-based clinical practice: guidelines on selected rehabilitation interventions for knee pain. Phys Ther 2001;81:1675–1700. [41] D.Y.Y. Chui J.S.K. Lau I.T.Y. Yau An outcome evaluation study of the rheumatoid Arthritis Self-Management Programme in Hong Kong Psychol Health Med 9 2004 286 292