Clinical Rehabilitation 1999; 13: 392–400

The effect of a joint protection education

programme for people with rheumatoid arthritis
Alison Hammond School of Health and Community Studies, University of Derby, Derby and Nadina Lincoln University
of Nottingham, Nottingham, UK

Received 16th October 1998; returned for revisions 28th December 1998; revised manuscript accepted 4th February
1999.

Objective: To evaluate the effects of an education programme in improving

adherence with joint protection by people with rheumatoid arthritis (RA).
Design: A repeated measures design. Subjects were assessed at six weeks
and one week before and six and twelve weeks after education.
Setting: Rheumatology unit in a large district general hospital.
Subjects: Twenty-one people diagnosed with RA (mean age 48.95 years
(SD 12.54) and disease duration of 6.43 years (SD 7.7) ).
Intervention: An 8-hour arthritis education programme delivered over four
sessions, including two hours of joint protection education designed to be
typical of current UK practice.
Main outcome measures: The Joint Protection Behaviour Assessment
(JPBA), an observational assessment of hand joint protection methods used
during kitchen activities, to measure adherence with education. Other
assessments included a joint protection knowledge questionnaire, hand joint
counts, hand pain visual analogue scale, the Health Assessment Questionnaire
(HAQ) and HAQ Pain scale to identify any short-term changes in hand pain,
pain on activity and functional status. At the beginning and end of the study
subjects were interviewed to obtain their self-report of joint protection
behaviours and reasons for following or not following the advice given.
Results: Median JPBA scores did not improve pre- to posteducation (18.4%
to 23.7%; p = 0.65) and neither did hand joint count, hand pain, HAQ and
HAQ Pain scores. However, joint protection knowledge improved significantly
(p = 0.01) and the majority of people believed joint protection to be a
beneficial strategy. Reasons for not changing behaviour included problems
recalling information; joint protection being considered inappropriate as ‘hands
were not that bad yet’; lack of skill; and difficulties changing habits.
Conclusion: The joint protection education programme improved knowledge
but not use of taught methods. Educational strategies being used by
therapists need to be focused on enhancing adherence.

Address for correspondence: Alison Hammond, School of

Health and Community Studies, University of Derby, c/o
Radiography Education, Devonshire House, Derbyshire
Royal Infirmary, London Road, Derby DE1 2QY, UK.
© Arnold 1999 0269–2155(99)CR270OA
 A joint protection education programme for people with RA
Introduction
Joint protection is a concept underlying all reha-
bilitation of persons whose joints are at risk from
arthritis.1 It includes a wide variety of strategies,
such as exercise, orthoses and energy conserva-
tion, but is usually defined more specifically by
occupational therapists as ergonomic measures,
i.e. alternative actions to perform activities, task
restructuring and using assistive devices. Joint
protection aims to reduce pain, inflammation,
external and internal joint loading and help pre-
serve joint integrity.2–5 Most rheumatology occu-
pational therapists provide joint protection
education as part of their treatment for people
with rheumatoid arthritis (RA).6 Usually this
lasts 11/2 hours over two treatment sessions,
although over half of therapists provide this for
less than one hour in one session. Typically it
includes information about RA; a description of
normal joint structure and the effect of RA on
joints; hand and wrist deformities; biomechanical
and ergonomic factors influencing development
of these; and a discussion of joint protection prin-
ciples. Two-thirds of therapists demonstrate
examples of joint protection methods, half
include supervised practice of some of these and
almost all provide written information.6
Joint protection education does improve
knowledge of these methods. Studies using ques-
tionnaires and requesting demonstrations of cor-
rect methods before and after education have
identified significant improvement.7–9 Self-
reported increases in joint protection following
arthritis education programmes have also been
identified. Changes in work methods (such as
using both hands when lifting), attitudes (e.g.
being more active and asking for help) and
increasing use of splints and assistive devices10;
significantly ‘less difficulty in complying’ with the
use of assistive devices and joint protection
advice11; and using significantly more ‘number of
reported ways of using joint protection’ than peo-
ple in a control group (although this was a rela-
tively small difference)12 have been reported. In
contrast, other studies have identified no self-
reported or observed changes in joint protec-
tion.13–17
There is conflicting evidence of the effective-
ness of joint protection education in improving
393
adherence. Previous studies have used a variety
of educational methods, including self-instruction
using manuals, computer lessons and video pro-
grammes, with or without therapist support, and
group programmes lasting between 1 and 13
hours. This study was therefore conducted to
evaluate joint protection education typical of that
currently being provided by occupational thera-
pists in the UK. Both self-report and an objec-
tive observational assessment of hand joint
protection behaviours were used to evaluate
adherence. In addition, as there have been few
studies evaluating the outcomes of joint protec-
tion, several measures of pain and functional sta-
tus were also included to identify any short-term
benefits which might result.
Method
Subjects
People diagnosed with rheumatoid arthritis
(RA) by a consultant rheumatologist, attending
an arthritis education programme conducted as
part of a large district general hospital’s rheuma-
tology outpatient service, were invited to partic-
ipate. Inclusion criteria were that subjects had
wrist and/or metacarpophalangeal joint involve-
ment, no other medical condition affecting hand
function and had difficulty with kitchen tasks.
This was to ensure that the advice being provided
was appropriate for all subjects.
Design and intervention
A repeated measures design was used to eval-
uate a standardized joint protection education
programme of 2 hours duration over two ses-
sions. This was incorporated into sessions 3 and
4 of a group arthritis education programme, of 8
hours duration over four sessions. This research
design has limitations because of the lack of a
control group. A control phase was therefore
included prior to education to control for the
effects of time and the additional attention from
attending the first two education programme ses-
sions. Assessments were conducted six weeks and
one week before the joint protection education,
and six and twelve weeks after education. Ethi-
cal approval was obtained for this study.
The two sessions on joint protection were
394 A Hammond and N Lincoln
designed to be typical of that provided in the UK6
and closely modelled on that included in the
SPIRE arthritis education programme developed
by Unsworth.18 They consisted of the following
sessions:
• Session 1 Information about RA, normal
joint structure, the effect of RA on joints and
factors contributing to the development of
hand deformities; the benefits of using joint
protection in daily life; joint protection and
energy conservation principles; some exam-
ples of hand joint protection methods; and a
homework task to identify problem activities
and problem solve how principles could be
applied to make these easier.
• Session 2 Discussion of the homework task
and problem-solving of alternative tech-
niques in housework, gardening and work
activities; a repetition of joint protection and
energy conservation principles with a discus-
sion of examples practically applying these; a
demonstration of joint protection methods
applied to making a cup of tea; and group
practice of these with the opportunity to try
out kitchen assistive devices.
Patients were encouraged to use joint protec-
tion methods all of the time at home, not just
when experiencing hand pain, and to continue to
use the problem-solving approach to identify
and modify painful activities. The two other
education sessions included information about
drug therapy and management of RA, exercise,
resting positions, relaxation methods, diet, alter-
native therapies and the opportunity to ask
questions of staff.
Measures
Use of hand joint protection methods was eval-
uated using the Joint Protection Behaviour
Assessment (JPBA). People were asked to make
a hot drink and snack meal, structured so that 20
tasks had to be completed in order to make these.
Tasks assessed include, for example, turning a
tap, opening a jar, opening a can, lifting a full ket-
tle and carrying a pan. The JPBA manual pro-
vides details of assessment and scoring
procedures in full.19 The JPBA is video-recorded
to allow for detailed analysis later. Tasks are
assessed as applying a correct (score = 2), par-
tially correct (score = 1) or incorrect (score = 0)
joint protection method. The score range is from
0 to a maximum of 40, if all 20 tasks are per-
formed correctly. Scores are converted to per-
centages to allow between- and within-subject
comparisons, in case some subjects omit per-
forming some tasks. Validity testing has been
conducted with a panel of seven rheumatology
occupational therapists and reliability testing
conducted with 20 subjects with RA.20 During
test–retest reliability evaluation, there was no sig-
nificant change in JPBA scores over on average
an 8-week period (z = –0.42; p = 0.67). The
median JPBA score on test 1 was 23.10% (IQR
6.48–31.88%) and 20.00% on test 2 (IQR
10.63–33.48%). The mean score change over this
period was 0.79% (SD 10.01%). From this, a sig-
nificant score change in the JPBA was deter-
mined as being 20%, i.e. either more or less than
two standard deviations of the mean JPBA score
change.
Joint protection knowledge was evaluated
using a 20-item multiple choice questionnaire
developed for this study. Subjects were asked to
identify which of three options they consider is
the ‘best method, i.e. puts less strain on the hand
joints’, for a range of daily activities, e.g. vacu-
uming, ironing, shopping, organizing household
chores, turning taps and preparing vegetables.
Items are scored as ‘0 = most stressful method’ to
‘2 = least stressful method’. Thus a high score
indicates greater ability to identify preferred joint
protection methods. Scores are converted to per-
centages. Reliability and validity testing has been
conducted.21
In order to confirm that people met the entry
criteria and to investigate if any short-term ben-
efits resulted from using joint protection meth-
ods, a variety of pain and functional measures
were collected. Hand pain during activity was
assessed using a 10 cm line with end points of ‘no
pain’ to ‘pain as bad as it can be’. Subjects were
asked to assess the amount of hand pain they usu-
ally experienced during the past week in every-
day activities (such as cooking, housework or
lighter gardening activities). Hand joint pain was
assessed bilaterally using tender hand joint
counts (11 joints in each hand: wrist, thumb and
finger metacarpophalangeal joints, thumb inter-
phalangeal joint and finger proximal interpha-
 A joint protection education programme for people with RA
langeal joints). A four-point scaling system was
used (0 = none, 3 = severe), based on the ARA
Co-operating Clinics Articular Index.22 Func-
tional status was evaluated using the Health
Assessment Questionnaire (HAQ). This 20-item
self-administered questionnaire consists of eight
subscales evaluating physical function during
activities of daily living and yields a total score
ranging between 0 (no or minimal dysfunction)
to 3 (severe dysfunction).23 The HAQ Pain scale
is an eight-item scale derived from the HAQ.
Subjects are asked to rate their perceived pain
during performance of eight activities on a 0 (no
pain) to 3 (severe pain) scale.24
Subjects were also interviewed pre- and post-
education, incorporating a number self-report
items used in previous studies. This included atti-
tudes towards the benefits of joint protection:
‘How important do you believe it is to reduce
stress/strain on joints during daily activities?’
(very important = 4; some = 3; a little = 2; not at
all = 1); and ‘Has the care taken to protect your
joints altered in the last three months?’
(increased = 2; not changed = 1; decreased = 0).15
People were asked: whether they had ‘altered
how they did kitchen or household activities in
any way to reduce stress/strain on their hands in
the last three months?’ ( a lot = 4; some = 3; a lit-
tle = 2; not at all = 1); in what ways they had done
so10; and to give practical examples of everyday
tasks they had altered. At post-test only, their
views on why change had or had not occurred
were sought. Data were recorded verbatim.
Sample size analysis
Based on data obtained from the earlier JPBA
reliability testing,20 a minimum of 14 subjects
were needed to detect a significant JPBA score
change of 20% (based on a mean JPBA score of
23%, SD 18%, power of 0.8 and significance level
of 0.05).
Procedure
The JPBA was conducted at six weeks and one
week before joint protection education, and six
and twelve weeks after education. All were con-
ducted in patients’ homes, apart from some at
one week, which were conducted in an occupa-
tional therapy kitchen. JPBA reliability testing
had previously identified that performance is not
395
significantly different in occupational therapy
kitchens to people’s own homes.20 Subjects were
not informed of the true purpose of the JPBA in
order to avoid social desirability effects. Light
conversation was continued during video-record-
ing to distract subjects’ attention from the activ-
ity in order to promote the use of habitual
actions. All other information was recorded at
baseline and 12 weeks posteducation only.
Data analysis
Nonparametric statistics were used as most
data were either ordinal or not normally distrib-
uted. The Wilcoxon test and Friedman’s analysis
of variance were used to analyse for differences
between pre- and post-test scores and performed
using the Statistical Package for the Social Sci-
ences (SPSS) for Windows software. Content
analysis was used to identify themes in the inter-
view data.
Results
Of the 43 patients agreeing to attend the seven
education programmes held during the one-year
study period, 30 met the entry criteria, 25 of
whom agreed to participate in the trial. Four of
these withdrew and did not complete all assess-
ments (two did not attend and two came to only
one or two sessions). All had been previously
assessed by an occupational therapist, expressed
interest in learning more about joint protection
and other self-management strategies and were
considered as appropriate to receive such educa-
tion by rheumatology staff. Seventeen women
and four men took part. Their average age was
48.95 years (range 22–70 years) and average dis-
ease duration was 6.43 years (SD 7.7). Ten had
been diagnosed less than two years. All subjects
experienced hand pain on activity and identified
difficulty with kitchen activities on the Health
Assessment Questionnaire (see Table 1).
Before education, all subjects were using some
joint protection methods (JPBA range 5–45%,
see Table 2). Seven stated they could recall pre-
viously receiving joint protection advice from a
rheumatology team member. There was no sig-
nificant difference in JPBA scores between those
who recalled (median 27.5%, IQR 10.5–42.5%)
396 A Hammond and N Lincoln

and those who could not recall such advice
(median 14.1%, IQR 10–35%; U = 34.5; p = 0.28).
There was no significant change in JPBA
scores during the control phase before education
(z = 0.78; p = 0.43), indicating that behaviour is
stable over time and was not affected by the
attention effects of attending the earlier part
of the education programme (see Table 2).
There was no significant difference in scores
between baseline and 12 weeks after education
(F(r) = 1.64, df = 3; p = 0.65). Only two patients
improved JPBA scores by 20% or more at six
weeks after education. In both cases, scores
decreased to near baseline values at 12 weeks.
There was a significant increase in joint protec-
tion knowledge scores from baseline (mean
82.36%, SD 8.97) to 12 weeks after education
(mean 87.37%, SD 7.37) (z = 2.5; p = 0.01), with
11 patients improving scores. There were no sig-
nificant differences in hand pain, hand joint
counts, pain during activity (HAQ Pain) or func-
tional disability (HAQ) before and after educa-
tion (see Table 1).
During the pre-education interview, 17 people
stated they had already made some changes to
everyday activities (see Table 3). Five found
these ‘had come naturally’ but 11 reported these
had been difficult, mainly because of frustration
and difficulty accepting having to make changes
(n = 7) and remembering to make these (n = 4).
Ten made comments such as ‘it’s like losing your
sense of independence and achievement . . . when
you’ve done it all your life’. Twenty said the main
reason they had made changes was that some
tasks had become too painful or their grip was
too weak or they were too tired to do it normally:
‘I was forced to by the pain’, ‘not physically pos-
sible’.

Table 1 Hand pain and functional status before and after education (n = 21)

Before education After education

Median IQR Median IQR p-value

HAQ Pain 1.00 0.69–1.69 1.13 0.50–2.00 0.74

HAQ 1.38 1.00–1.81 1.38 1.00–2.00 0.49
Hand joint count 16.00 4.00–30.00 12.00 2.50–31.50 0.63
Hand pain VAS 51.00 31.50–60.50 55.00 37.00–77.00 0.29

IQR, interquartile range.

Table 2 Joint Protection Behaviour Assessment (JPBA) scores before and after education ( n = 21)

Assessment Median JPBA score (%) Interquartile range (IQR, %)

6 weeks before education 18.40 10.25–35.55

1 week before education 23.70 11.90–34.30
6 weeks after education 22.50 14.40–38.15
12 weeks after education 23.70 15.35–37.45

Table 3 Self-reported strategies for reducing hand joint stress (n = 21)

Numbers self-reporting: Before education After education

Use assistive devices 17 14

Lift differently, e.g. two hands, with forearms 16 17
Ask for help/delegate 14 9
Avoid lifting/reduce weight of objects 7 13
Avoid positions of deformity, e.g. flat hands, straight wrists 5 2
Slow pace of activity/rest more often 5 8
Leave tasks/do less often 4 11
Reorganize tasks/work areas 2 5
 A joint protection education programme for people with RA
The majority of subjects both before (n = 17)
and after education (n = 15) stated that reducing
stress on joints during activity was ‘very
important’. After education, there was no signif-
icant difference in ‘care taken to protect joints’
(z = 0.28; p = 0.77) or ‘how much they had altered
everyday activities’ (z = 0.22; p = 0.82). When
asked to describe methods they were using, most
experienced difficulty and needed prompting. Of
the 51 methods cited, 39 were tasks included in
the JPBA. JPBA video-recordings were there-
fore analysed to identify if subjects were per-
forming these as self-reported. Only 17 of the 39
methods were observed being used in the post-
education JPBAs at either six or twelve weeks,
13 of which were observed as already used dur-
ing pre-education JPBAs. People were also asked
to describe strategies they were using to reduce
joint stress (see Table 3). On the whole, there
were few differences before and after education,
although subjects reported asking for help less,
doing tasks less frequently and avoiding lifting
more.
After education, nine subjects stated that they
believed they used more joint protection meth-
ods than previously. Of these, four considered
these had ‘soon became habitual’, and they were
‘much more conscious of it now’. The other five
wanted to use joint protection more but thought
they were doing so inconsistently because: some
methods were used ‘on bad days only’ (n = 4); it
was difficult to get used to the different actions
or it seemed more effort than normal (n = 4); and
it was difficult changing the habits of a lifetime
(n = 4). Other comments included were ‘I do it
when I am in pain. When I am better I tend to
forget about it’, ‘I am often too busy. It’s easier
to change by changing equipment than the
method . . . it’s remembering to do it’ and ‘I’ve
done this as a last resort . . . but if the disease had
gone away I would have reverted back to nor-
mal’.
Of those stating that they were not using any
methods taught after education (n = 12), this
was because they: could not recall any methods
(n = 6); considered it inapplicable to them as they
were ‘not that bad yet’ (n = 5); and one stated
that ‘I know the correct methods but I am not
using them’. One subject stated ‘it was helpful as
it confirmed what I was doing was right’.
397
Discussion
The primary focus of patient education has been
defined as including the acquisition of informa-
tion, beliefs, attitudes and skills which impact on
health status, quality of life and possibly health-
care utilization.25 The people with RA in this
study increased their knowledge of joint protec-
tion, although many were already able to gain
high scores on the questionnaire at the outset.
Most believed reducing joint stress during activ-
ity to be both important and beneficial before
and after education, yet a quarter thought it was
inapplicable to them. Despite these generally
positive beliefs and attitudes, behavioural change
did not occur, supporting the findings of some
previous studies.13–17 Subjects’ perceptions of
changes in their behaviour were not borne out
objectively. As in an earlier study,17 education
seemed to have helped people become more
aware of their actions, rather than changing these
much. The difficulties subjects had in identifying
joint protection methods they were using and the
honest response by over half that they were not
doing so, supports these objective findings. This
highlights the need to view the results of self-
reported joint protection adherence with caution,
as self-report can be prone to bias, reactivity
effects and difficulties of accurate recall,26 partic-
ularly when post-test only interviews are con-
ducted.
Before education, many already used some
joint protection methods because pain and weak-
ness had forced them to. Some saw this as a nat-
ural process of adaptation but many found it
difficult. Amongst those with lower JPBA scores
Clinical messages
• A joint protection education programme
based on current UK practice improved
knowledge but not use of joint protection,
despite attendees believing it to be benefi-
cial and important.
• No improvements in pain, joint swelling or
functional ability resulted.
• Current practice needs to change to im-
prove educational methods being em-
ployed.
398 A Hammond and N Lincoln
a common theme was ‘frustration’ at having dif-
ficulties with everyday tasks and anger at having
to accept making changes, which has been
reported elsewhere.27,28 In comparison, higher
JPBA scorers seemed to have adopted a more
pragmatic attitude and described having gone
through stages of acceptance. For example, ‘it’s
a matter of accepting . . . and then life improves.
It took a long time . . . at first I didn’t want to
accept . . . then you have to come to terms . . .
and then you’re finally prepared to be sensible
and do things differently.’ Both subjects who
improved scores at six weeks, expressed before
education that they had accepted making
changes. After education, half of the subjects said
that making changes in performing everyday
activities no longer seemed as frustrating or as
difficult as a result of attending the joint protec-
tion education, suggesting that it may have
helped them move through stages of acceptance,
even if significant behavioural change did not
result. Potentially, a person’s degree of accepting
making changes may indicate how successful joint
protection education will be in improving adher-
ence, and this aspect warrants further study.
The interview yielded other clues as to why use
of hand joint protection did not increase. Half
reported not using any methods taught either
because of poor recall, suggesting teaching meth-
ods may need improving, or that, whilst impor-
tant, it was not appropriate for them personally
as their ‘hands were not that bad’. Joint protec-
tion should theoretically be used as a preventa-
tive measure, not just when experiencing more
severe pain or when deformities are present. Half
of this group had not understood this concept,
suggesting it may not have been sufficiently
emphasized or explained. Among those self-
reporting increased use of joint protection, barri-
ers to change were identified as mainly a lack of
skill as these methods ‘felt awkward, clumsy and
slower’ and in forming new habits as ‘it’s hard to
change the things you do automatically, the
habits of a lifetime’.
The limitations of the study included the lack
of a control group, as change could occur with
the passage of time. As behaviour did not change,
this would seem not to have been disadvanta-
geous. Whilst a small sample size, analysis iden-
tified it was sufficient to detect a significant
change of 20% in the JPBA. Two-thirds of the
subjects’ posteducation scores lay within –10 to
+10% of their pre-education scores, which is
indicative of the natural variation that can occur
between test performances.20 Subjects were also
drawn from a group of volunteers attending the
education programmes and not randomly
recruited, questioning the generalizability of find-
ings to all people with RA. However, as volun-
teers, presumably this group were more
motivated than most to pay heed to advice given,
yet few changes were made. The JPBA only
assesses hand joint protection in kitchen activi-
ties, and so it is impossible to say how much the
advice provided was generalized to other activi-
ties not observed. However, the activities
assessed are those which people with RA find
most problematic and are commonly targeted in
joint protection education, indicating that if
change does not occur in these, it is less likely to
have occurred elsewhere. Follow-up was also rel-
atively short at three months, although this had
been thought long enough to allow practice and
adoption of new habits.
Joint protection adherence did not increase
following this education based on UK practice.
Neither were there any changes in hand pain,
swelling or functional ability. Treatment failure
can be due to two factors: either treatment meth-
ods are ineffective or the client fails to adhere
sufficiently.30 In this study, joint protection was
ineffective but clearly adherence was poor, so we
cannot yet determine whether or not joint pro-
tection is effective. Despite the limitations of this
study, the lack of change suggests much of the
joint protection education currently being pro-
vided in the UK may be ineffective and many
people with RA are not using joint protection
sufficiently after education, or spontaneously
before education, to allow its potential benefits
to be obtained.
These findings suggest that further evaluation
of joint protection education using objective
methods rather than self-report is needed, as
reporting on habitual daily activities is difficult.
Methods of teaching joint protection need to be
reconsidered. If the aim is simply to impart
advice, providing an information booklet has
been proven as effective as an education session
with a therapist in improving knowledge.8 If the
 A joint protection education programme for people with RA
aim is to help people change behaviour, then
educational-behavioural methods have proven
effective in increasing recall of and adherence
with other self-management strategies, such as
exercise and relaxation.11,29 These educational
approaches include: a greater time allocation to
the teaching of self-management skills; repeated
demonstrations; simplification and repetition of
information; modelling (watching others similar
to oneself perform the actions); supervised prac-
tice and feedback over several sessions to
enhance skill development; and the setting of
goals and homework programmes to facilitate
incorporating these into daily life. The joint pro-
tection programme evaluated was probably inef-
fective in increasing hand joint protection
behaviour because these strategies were insuffi-
ciently applied. As this programme was based on
current UK practice, this would suggest that
many occupational therapists need to review the
educational methods they are employing. Future
studies need to be conducted to evaluate both
methods of enhancing joint protection behaviour
and its outcomes.
Acknowledgements
This study was completed as part of a PhD,
Department of Psychology, University of
Nottingham. Grateful thanks to the rheumatol-
ogy team, and especially Anne Allen (lead
practitioner occupational therapist), at the
Derbyshire Royal Infirmary, Derby, UK for their
unstinting support in running the education pro-
gramme. This research was supported by a Post-
graduate Training Bursary generously provided
by the Arthritis Research Campaign, UK.
References
1 Cordery J, Rocchi M. Joint protection and fatigue
management. In: Melvin J, Jensen G (eds)
Rheumatological rehabilitation, Volume I: assessment
and management. Bethesda, MD: The American
Occupational Therapy Association, 1988.
2 Brattstrom M. Joint protection – rehabilitation in
chronic rheumatic disorders, second edition. London:
Wolfe Medical, 1987.
3 Melvin J. Rheumatic disease: occupational therapy
and rehabilitation, second edition. Philadelphia, FA
Davis, 1989.
4 Noaker JA. Enhancing functional ability: alternative
399
techniques, assistive devices and environmental
modification. In: Clinical care in the rheumatic
diseases. Atlanta, GA: American College of
Rheumatology, 1996.
5 Chamberlain MA, Ellis M, Hughes D. Joint
protection. Clin Rheum Dis 1984; 10: 727–42.
6 Hammond A. Joint protection education: what are
we doing? Br J Occup Ther 1997; 60: 401–406.
7 Barry MA, Purser J, Hazleman R, McLean A,
Hazleman BL. Effect of energy conservation and
joint protection education in rheumatoid arthritis. Br
J Rheumatol 1994; 33: 1171–74.
8 Maggs FM, Jubb RW, Kemm JR. Single blind
randomised controlled trial of an education booklet
for patients with chronic arthritis. Br J Rheumatol
1996; 35: 775–77.
9 Neuberger GV, Smith KV, Black SC, Hassanein R.
Promoting self-care in clients with arthritis. Arthritis
Care Res 1993; 6: 141–48.
10 Nordenskiold U. Evaluation of assistive devices after
a course of joint protection. Int J Technol Assess
Health Care 1994; 10: 293–304.
11 Taal E. Group education for patients with
rheumatoid arthritis. Patient Educ Counselling 1993;
20: 177–87.
12 Lindroth Y, Brattstrom M, Bellman I et al. A
problem based education program for patients
with rheumatoid arthritis: evaluation after three
and twelve months. Arthritis Care Res 1997; 10:
325–32.
13 Lindroth Y, Bauman A, Barnes C, McCredie M,
Brooks P. A controlled evaluation of arthritis
education. Br J Rheumatol 1989; 28: 7–12.
14 Lindroth Y, Bauman A, Brooks PM, Priestley D. A
5 year follow-up of a controlled trial of an arthritis
education programme. Br J Rheumatol 1995; 34:
647–52.
15 Wetstone S, Sheehan TJ, Votaw R et al. Evaluation
of a computer based lesson for patients with
rheumatoid arthritis. J Rheumatol 1985; 12: 907–12.
16 Cartlidge PJ, Higson NB, Stent G. Rheumatoid
arthritis: a pilot evaluation of an inpatient education
programme. Austr Occup Ther J 1984; 31: 14–19.
17 Hammond A. Joint protection behaviour in patients
with rheumatoid arthritis following an education
program: a pilot study. Arthritis Care Res 1994; 7:
5–9.
18 Unsworth H. The SPIRE arthritis education
programme. Nottingham: Nottingham Rehab, 1990.
19 Hammond A. Evaluating joint protection education
for people with rheumatoid arthritis. Unpublished
PhD thesis, University of Nottingham, 1994.
20 Hammond A, Lincoln N. Development of the Joint
Protection Behaviour Assessment. Arthritis Care Res
20: 200–207.
21 Hammond A, Lincoln N. The Joint Protection
Knowledge Assessment: reliability and validity. Br J
Occup Ther 62: 117–122.
400 A Hammond and N Lincoln
22 McCarty DJ. Clinical assessment of arthritis. In:
McCarty DJ ed. Arthritis and allied conditions: a
textbook of rheumatology. Philadelphia: Lea and
Febinger, 1979.
23 Fries JF, Spitz P, Kraines RG, Holman H.
Measurement of patient outcome in arthritis.
Arthritis Rheum 1987; 23: 137–45.
24 Callahan LF, Brooks RH, Sumney JA, Pincus T.
Quantitative pain assessment for routine care of
rheumatoid arthritis patients using a pain scale
based on activities of daily living and a visual
analogue pain scale. Arthritis Rheum 1987; 30:
630–35.
25 Burckhardt CS. Arthritis and musculoskeletal
patient education standards. Arthritis Care Res 1994;
7: 1–4.
26 Meichenbaum D, Turk DC. Facilitating treatment
adherence: a practitioner’s guidebook. New York:
Plenum Press, 1987.
27 Williams GH, Wood PN. Coming to terms with
chronic illness: the negotiation of autonomy in
rheumatoid arthritis. Int Disabil Studies 1988; 10:
128–33.
28 Ryan S. Living with rheumatoid arthritis: a
phenomenological exploration. Nurs Stand 1996; 10:
45–48.
29 Lorig K, Lubeck D, Kraines RG, Seleznick M,
Holman HR. Outcomes of self-help education for
patients with arthritis. Arthritis Rheum 1985; 28:
680–85.
30 Foa EB, Emmelkamp PMG eds. Failures in
behaviour therapy. New York: John Wiley, 1983.