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Guided Imagery for Arthritis and Other Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials
Abstract
Many individuals suffering from arthritis and other rheumatic diseases (AORD) supplement pharmacologic treatments with psychosocial interventions. One promising approach, guided imagery, has been reported to have positive results in randomized controlled trials (RCTs) and is a highly scalable treatment for those with AORD. The main purpose of this study was to conduct a systematic review of RCTs that have examined the effects of guided imagery on pain, function, and other outcomes such as anxiety, depression, and quality of life in adults with AORD. Ten electronic bibliographic databases were searched for reports of RCTs published between 1964 and 2013. Selection criteria included adults with AORD who participated in RCTs that used guided imagery as a partial or sole intervention strategy. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Instrument. Results were synthesized qualitatively. Seven studies representing 306 enrolled and 287 participants who completed the interventions met inclusion criteria. The average age of the participants was 62.9 years (standard deviation = 12.2). All interventions used guided imagery scripts that were delivered via audio technology. The interventions ranged from a one-time exposure to 16 weeks in duration. Risk of bias was low or unclear in all but one study. All studies reported statistically significant improvements in the observed outcomes. Guided imagery appears to be beneficial for adults with AORD. Future theory-based studies with cost-benefit analyses are warranted.
Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
... (4) Emotional disclosure (ED). In general, emotional disclosure consists of instructing patients to write and reflect individually and in private about their deepest thoughts and feelings regarding the most emotional event that they have experienced [42,43]. (5) Hypnotherapy (HY). ...
... In the selected articles, a few mixed psychological interventions also appeared [21,23], but most studies focused on one method, such as CBT [40,41] or emotional disclosure [42]. Our findings align with prior studies describing psychological interventions' positive impact on RA [2,23,43]. ...
Rheumatoid arthritis (RA) is a long-term disorder that significantly impairs somatic, emotional, and psychological functioning. The objective of this review is to identify, appraise, and synthesize the effects of psychological interventions (e.g., cognitive behavioral therapy (CBT), emotional disclosure (ED), group therapy (GT), mindfulness (M), patient education (PE), and relaxation (R)) on biopsychosocial outcomes in the treatment of rheumatoid arthritis (RA). A systematic search of all relevant existing randomized clinical trials (RCTs) was conducted using the following online bibliographic databases: JSTOR, PubMed, PsycNET, and The Cochrane Library. Reference lists were searched for additional reports. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias in the included studies. After the selection process, 57 articles were included and 392 were excluded. Three separate meta-analyses were conducted involving psychological interventions as the main variables, showing: (1) significant positive medium effect sizes for average values (Hedges-g = 0.399, Z = 0.399, p = 0.009); (2) significant positive large effect sizes for maximum values (Hedges-g = 0.856, Z = 4.223, p < 0.001); and (3) non-significant results for minimum values (Hedges-g = −0.047, Z = −0.335, p = 0.738). These results demonstrate that, when grouped, psychological interventions are, on average, moderately effective in treating RA. Overall, this review shows consistent, supportive evidence that psychological interventions can significantly contribute to the standard medical care of RA patients. However, more high-quality, large-sample RCTs still need to confirm these findings.
... Por tanto, es necesario enfocar el manejo del dolor de manera integral, incorporando TnoF efectivas y haciendo partícipe al paciente en su autocuidado. En la tabla 1 se exponen las características de algunas TnoF que, según distintos autores [3][4][5][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] , pueden mejorar la salud. Los estudios encontrados abordan la efectividad de estas terapias desde una metodología cuantitativa y, generalmente, de manera individualizada. ...
... Los pacientes hicieron especial mención también a las técnicas que trabajan el autoconcepto, el amor propio, la compresión de los propios sentimientos y la motivación (mensajes ante el espejo, técnica del Ho'oponopono), que facilitan la aceptación y el compromiso y que han demostrado mejorar los resultados en el manejo del DC 3,18,31 . También se utilizaron la musicoterapia y las imágenes guiadas que producen efectos positivos en el manejo del dolor y la ansiedad, disminuyendo el consumo de fármacos 10,20,21 . ...
Background:
The prevalence of chronic pain in Spain is 17%. There is a need for more scientific data on non-drug treat-ments that can be effectively used to treat chronic pain. The aim of this study is to analyze how patients with chronic non-malignant pain perceive non-drug approaches.
Method:
Mixed, descriptive and phenomenological study. Nineteen patients enrolled in a workshop on pain management and non-drug treatments that consisted of four sessions (one session a week). Each session lasted four hours. The patients then participated in a reflective writing activity about their personal experiences. Data from this activity was then ana-lyzed. Atlas.ti 8 software was used for the qualitative data analysis.
Results:
Sixteen participants tried an alternative therapy and fourteen assessed its benefits. The participants' expecta-tions were divided into three groups of similar size: relief from physical pain, emotional pain management and tools for use in daily life. All the participants were satisfied with the workshop. Perceived personal benefits were better pain and sleep management, reduced fatigue, reduced drug consumption; a more positive approach to life, better mood, more positive energy, more motivation and improved capacity to cope.
Conclusions:
The participants commented that the workshop had helped them to reduce pain levels and consume to fewer analgesics, and had reduced other symptoms associated with chronic disease, thus improving their perceived health. They also expressed great satisfaction with the organization and teachers.
... Both acupuncture and imagery have long been used in medical practice, including the treatment of chronic pain [6][7][8][9]. However, the mechanisms that mediate acupuncture and imagery efficacy remain poorly understood. ...
... These results support the potential of VGAIT as a novel pain management method. Both acupuncture [20,[32][33][34] and guided imagery treatment [7,35,36] have demonstrated efficacy as methods for pain management. We found that VGAIT, a combination of the two methods, not only relieved pain bothersomeness in patients with cLBP but also produced a marginally significant greater reduction in anxiety level compared to sham acupuncture treatment. ...
Background:
Research suggests that imagined experiences can produce brain responses similar to those produced by actual experiences. Shared brain responses that support both imagination and perception may underlie the functional nature of mental imagery. In a previous study, we combined acupuncture and imagery to develop a new treatment method, video-guided acupuncture imagery treatment (VGAIT). We found that VGAIT significantly increased pain thresholds in healthy subjects. The aim of this study is to extend our previous finding by investigating whether VGAIT can relieve symptoms in patients with chronic low back pain.
Methods:
We first performed a single-arm study in which we administered video-guided acupuncture imagery treatment (VGAIT) on patients with chronic low back pain (cLBP) (Study 1, n = 18, 12 females). We then compared our findings to those from a recently published study in which real or sham acupuncture treatment was applied on patients with cLBP (Study 2, n = 50, 31 females) using a similar protocol. All patients in Studies 1 and 2 received 6 treatments over 4 weeks.
Results:
All three treatments (VGAIT, real, and sham acupuncture) significantly reduced pain severity as measured by a low back pain bothersomeness score. VGAIT produced similar effects to real acupuncture (p = 0.97) and nonsignificantly greater pain bothersomeness relief compared to sham acupuncture (p = 0.14). Additional analysis showed that there was no significant difference on the sensations evoked by different treatment modalities.
Conclusion:
These findings support VGAIT as a promising method for pain management.
... 337,338 A more recent systematic review of guided imagery in fibromyalgia, arthritis and rheumatologic disorders found statistically significant improvement in pain and function, with several trials demonstrating reduction in medication use. 339 Mindfulness, meditation and relaxation therapy safety The body of research evidence has shown mindfulness-based practices, hypnosis, suggestive therapies, guided imagery, CBT, ACT and progressive relaxation techniques are utilized across diverse patient populations. These approaches are safe, with rare adverse reactions in psychiatric patients, people with epilepsy or those who have suffered abuse or trauma where relaxation may trigger a rare paradoxical reaction. ...
... These approaches are safe, with rare adverse reactions in psychiatric patients, people with epilepsy or those who have suffered abuse or trauma where relaxation may trigger a rare paradoxical reaction. 141,324,339,340 Biofeedback chronic pain Biofeedback utilizes techniques in which a signal generated by a device trains the patient to manipulate an aspect of their physiology not typically directed (e.g., heart rate variability and muscle tension) and provides a self-care tool for physiologic modulation. A meta-analysis of biofeedback for chronic low back pain (cLBP) found pain reduction, reduced depression, disability, and muscle tension and improved coping. ...
Medical pain management is in crisis: from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care has prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC.
There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in post-surgical pain with opioid sparing, acute nonsurgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components, and self-care/self-efficacy strategies.
Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.
The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short and long term therapeutic and economic impact of comprehensive care practices.
... GI has been widely used in various medical diseases too. A systematic review of seven studies has successfully used GI to treat arthritis and other rheumatic disorders [22]. Another systematic review of 11 randomized controlled trials (RCTs) showed a significant reduction of non-musculoskeletal pain with GI [23]. ...
Mind-body techniques, including Guided Imagery (GI) or Progressive Muscle Relaxation (PMR), may effectively manage bloating. The current study aimed to develop and validate (psychometric and psychological responses) audio-based GI and PMR techniques for bloating. Audio scripts were first developed from literature reviews and in-depth interviews of participants with bloating diagnosed based on the Rome IV criteria. Scripts were validated using psychometric (content & face validity index) and physiological approaches (brain event-related potentials & heart rate variability). 45/63 participants completed the in-depth interview, and ‘balloon’ emerged as the synonymous imagery description for bloating, of which inflation correlated with a painful sensation. The final tools consisted of narrated audio scripts in the background of a validated choice of music. Overall, the content and face validity index for PMR and GI ranged from 0.92 to 1.00. For ERP and HRV, 17/20 participants were analyzed. For ERP, there was a significant difference between GI and PMR for alpha waves (p = 0.029), delta waves (p = 0.029), and between PMR and control for delta waves (p = 0.014). For HRV, GI and PMR exhibited similar autonomic responses over controls (overall p<0.05). The newly developed GI and PMR audio-based tools have been validated using psychometric and physiological approaches.
... 14,15 Currently, it is commonly used as a therapeutic method for addressing many disorders, such as chronic pain. [16][17][18][19] A large body of literature suggests that common brain areas are activated during direct and vicarious (observational) experiences. 20 For example, observing others' experience of pain can activate a network similar to the one that is activated when one experiences pain directly. ...
Background: Healing is a complicated process that can have several components including the self-healing properties of the body, the nonspecific effects of treatment (e.g., the power of the mind), and the specific effects of an intervention. This article first discusses the brain imaging studies on placebo acupuncture analgesia and the modulation effects of expectancy on real acupuncture in healthy subjects. Then, it introduces some attempts to translate findings from healthy subjects to patient population using power of the mind as a way to enhance acupuncture's treatment effects on chronic pain. After that, a new alternative method which merges acupuncture and imagery, while also drawing on power of the mind, is presented. Finally, the specific effects of acupuncture are discussed. Conclusions: Elucidating the mechanism underlying power of the mind would provide new opportunities for boosting the therapeutic effect of acupuncture treatment and furthering the development of new alternative interventions.
... Guided imagery uses the imagination to focus one"s attention on a specific image to achieve health-related goals. Empirical studies support its wide-ranging application, including for stress-management, BI disturbance, depression, sports performance, and pain management 28,[31][32][33] . For ReBIC, the specific words and phrases are tailored to explore personal identity, BI and intimacy. ...
Objectives:
Body image remains a significant survivorship challenge among breast cancer (BC) survivors. We describe an eight-week group intervention-Restoring Body Image after Cancer (ReBIC) developed to target body image distress for BC survivors.
Methods:
The intervention was informed by interviews with BC survivors and by a descriptive, exploratory approach which adapted guided imagery exercises to address body image (BI). Educational material was selected to address sociocultural factors that may contribute to BI distress and affect adjustment. Videotape reviews and content analyses further refined the intervention.
Results:
The intervention incorporates three active components: psychotherapeutic group principles; guided imagery exercises to address BI; and psychoeducation on relevant socialization factors and gender-based messages internalized by women in Western society. The therapeutic group was a supportive and effective way to assist BC survivors to gain insight on BI impacts, their histories and relevant sociocultural factors contributing to BI distress. The group also facilitated the working through of grief over multiple losses. Guided imagery was well-received, and appeared to help survivors identify negative and emerging self- schema, as well as facilitate new self-views. Specific themes included: negative emotions associated with an altered body and self, grief and loss, isolation, difficulties with sexual intimacy, relationship challenges and uncertainty around sense of self and future.
Conclusion:
An empirically tested group therapy intervention is described and has implications for survivorship programs to help address body image related challenges. Future work could consider testing a similar approach tailored for other cancer populations. This article is protected by copyright. All rights reserved.
... Mental Imagery is increasingly being recognized via research and theory as playing an important role in mental health treatment including stress/anxiety and insomnia treatment [67] [69] [70] [71] [72]. Guided imagery therapy has also shown effectiveness in treating chronic pain [73], fatigue [70] [74], food cravings [75] [76], arthritis [77], hypertension [78], and even fibromyalgia [79]. Positive mental imagery (imagining a nice place) has been reported by patients as the most effective relaxation technique and the most likely to be used at home [80]. ...
Excessive distress and insomnia are much too common in the modern world and often lead to a myriad of detrimental effects including loss of cognitive ability and even physical ailments such as cancer. Current pharmaceutical treatments can be addictive, detrimental to health, and in the case of insomnia don’t produce naturalistic sleep. We present a viewpoint on a potential adjunctive treatment of distress and insomnia that harnesses specific mental imagery as a component of mind/body relaxation technique. Via our perspective on the modern nature of stress and insomnia, our theoretical perspective on how specific guided mental imagery can be used to treat these ailments, and our review on the current literature on treatment with mental imagery, we hope to stimulate further research into mental health treatment with mental imagery which has traditionally been neglected. This perspective on the pathology of insomnia and distress is founded in prevailing “dysevolution” and hyper-arousal theories. Hyper-arousal is characterized in part by a vicious cycle of chronic physiological and emotional stimulation/distress. We argue for spatially based mental imagery in the form of nighttime-sky imagery to attenuate such pathology by breaking one away from a vicious cycle of stimulation and distress and discuss neuropsychological bases for its potential treatment mechanisms which include the autonomic nervous system and a phenomenal foundation of conscious cognition.
... Significant differences regarding trait anxiety, sleep quality, and tenderness at some points along with alleviation of pain intensity, fatigue and depression reported with audio-recorded guided imagery (one component of CBT) relaxation on people with FM [64][65][66][67]. Fear of pain leads to depression, social isolation, disability or reduced participation in daily life activities [68]. ...
... There is encouraging (although inconclusive) systematic evidence that positive imagery strategies benefit patients with various causes of chronic pain (for example [66][67][68]), including in children [69]. Guided imagery has reduced mobility difficulties related to the painful condition [70] and improved self-reported capacity to cope with pain [71]. ...
Pain imagery is “like having a picture in your head [of your pain] which may include things you can imagine seeing, hearing or feeling.” Pain imagery may offer a unique insight into a patient’s pain experience. This chapter summarises findings from international pain imagery research in women with endometriosis-associated pain. Endometriosis is a chronic inflammatory condition associated with debilitating pain that affects 5–10% of women of reproductive age worldwide. Our international research has found that pain imagery is experienced by around half of women suffering from endometriosis-associated pain, and is associated with higher levels of catastrophising, depression, and anxiety. However, coping imagery is also reported, and prevalent, at 30%. Pain imagery in women with endometriosis falls into themes: sensory qualities of pain; loss of power or control; attack (by someone, “something,” or self); pathology or anatomy envisaged; past or future catastrophe; pain as an object; and abstract images. Imagery content may therefore reveal the meanings of pain or endometriosis to these women. This chapter explores pain imagery content and its personal significance to patients, both for women with endometriosis-associated pain and for patients with other chronic pain conditions. The chapter concludes by discussing the clinical application of imagery, with example patient cases to contextualise the practicalities and therapeutic potential of imagery techniques.
... Significant differences regarding trait anxiety, sleep quality, and tenderness at some points along with alleviation of pain intensity, fatigue and depression reported with audio-recorded guided imagery (one component of CBT) relaxation on people with FM [64][65][66][67]. Fear of pain leads to depression, social isolation, disability or reduced participation in daily life activities [68]. ...
There is no clear specific pathophysiological therapeutic target of fibromyalgia (FM) management. 85%-90% fibromyalgia (FM) patients are middle aged women. In France, work productivity loss contributed almost 90% of the total costs incurred by patients with FM, with an economic cost of 13000 million euros annually which is around $100 billion in US. Chronic tension type headache was endorsed by 50-80% of treatment-seeking FM patients. A nearly 75% FM patients have issues of pain-non-pain symptoms, psychological distress, social security and work disability. Treatment failure is pain arising from dysfunctions within the brain and spinal cord. NSAIDs and opioids are widely used in FM, despite being considered not to be effective. Evidence for effectiveness of cannabinoids are there but chances of abuse limits their use. Transient, burning and pricking, skin irritation, dizziness, nausea, dry mouth, drowsiness, constipation and insomnia were some of the side effects associated with herbal medicines. A nearly 70% German FM patients used thermal baths, 35.2% use alternative interventions such as homeopathy, dietary supplements, and 18.4% use meditative exercises such as yoga or Tai chi. Low FODMAP was found be effective in QoL, quality of sleep, anxiety and depression and inflammatory biomarkers in FM patients. CBT interventions may reverse cortical gray matter atrophy, reduces circulating pro-inflammatory cytokines (IL-6, IL-8, and TNF-α level) of FM patients, pain symptoms and pain perceptions, helps FM patient having fear of pain, anxiety, depression and insomnia. An average 12-minute exposure to a therapy dog reduces anxiety in 34% of FM patients, together with reductions in pain and improvements in mood. A coordinated multidisciplinary team approach including physicians, mid-level practitioners, nursing staff, and where needed, pharmacists and physical therapists will produce the best results.
... Interestingly, it would appear that once Sally accepted this injured area of her body, she seemed to note improved pain perception. [13] found that by encouraging individual's to distance themselves from their private events, acceptance methods may help reduce the use of emotional reasons to explain behaviour and hence shift concern from moderating thoughts and feelings to experiencing the consequences of one's action. ...
... 111,112 Guided imagery, used as a relaxation strategy, encourages the patient to focus on a calming scene. 113 Mindfulness is a state in which the patient can live in the moment and observe his or her thoughts or feelings. 114,115 Similarly, biofeedback, a technique performed by a trained professional, attempts to help patients reduce stress by allowing them to actively participate in their own response. ...
Pharmacists are in a unique position to contribute knowledge and insight on chronic pain management. Our knowledge about mechanisms of action, drug–drug interactions, and evidence-based treatment gives us an invaluable familiarity with both medications and disease pathophysiology. When selecting appropriate treatment for managing chronic pain syndromes, we must also consider patients’ comorbid conditions. Through consideration of these other conditions, the most safe and effective medication for patients can be initiated and monitored.
... However available studies do suggest it may be of benefit, with early work by Baird and Sands (2004) indicating that guided imagery linked to progressive muscle relaxation could result in a significant reduction in pain in those suffering from osteoarthritis, with similar findings indicated in a 2010 follow-up study (Baird et al. 2010). Giacobbi et al. (2015) undertook a systematic review which identified seven previous RCTs that has used guided imagery and progressive relaxation on a range of arthritic conditions; although there was a high range of variation in the techniques used and length of exposure to participants, all studies reported statistically significant improvements in a range of outcomes including pain, anxiety, depression and quality of life. ...
There will be increased numbers of older adults in society in the next few decades. Older adults are more likely to have pain problems and other co-morbidities. Generally, pain is poorly managed in older adults, and this becomes worse when cognitive impairment exists. The impact of chronic pain on older adults will be greater than that of their younger counterparts in terms of social isolation. Attitudes and barriers to improved pain management exist in both the older adults themselves and their younger counterparts
... This scoping review represents a secondary analysis from a previously published study. [20] The steps for the current scoping review included the following: (1) identification of the research questions; (2) identification of relevant studies; (3) study selection; (4) charting of the data; (5) collating, summarizing, and reporting the results; and (6) receiving practitioner feedback from a practicebased research network (PBRN) in West Virginia. [19] The last step, as suggested by Levac et al. [19] was conducted for the purpose of encouraging wider dissemination and use of guided imagery. ...
Introduction:
Guided imagery involves the controlled visualization of detailed mental images. This integrative health technique is used for healing, health maintenance, or the treatment of specific conditions. Guided imagery is an integral part of mindfulness meditation, hypnosis, and various relaxation exercises. However, evidence to support the widespread use and dissemination of guided imagery interventions has been lacking. The purposes of this scoping review were to document the scope of health outcomes and disease processes examined by guided imagery researchers and the journal outlets where this work has been published. Secondary purposes were to review the efficacy of guided imagery, risk of bias from studies published in selected integrative health journals, and gain feedback from clinicians in a practiced-based research network (PBRN) about potential barriers for use in clinical settings.
Methods:
Ten bibliographic databases were searched for randomized controlled trials (RCTs) published between 1960 and 2013 that included adult participants. Descriptive and analytic methods were employed to document the journal outlets, diseases, and health outcomes investigated.
Results:
320 RCTs that included more than 17,979 adult participants were reviewed. The published studies appeared in 216 peer-reviewed journals from diverse disciplines largely representing psychology, the sport sciences, rehabilitation, nursing, and medicine. Major outcomes observed were coping with pain, stroke recovery, anxiety, coping with stress, and sport skills. Practitioner feedback from the PBRN revealed some interest but skepticism and time constraints were discussed as barriers.
Conclusions:
Ongoing research and creative dissemination techniques are warranted.
... These findings are in line with previous studies that experimentally induced pain and optimism and found a reduction in situational and dimensional pain catastrophizing in healthy participants [40,41]. Although previous BPS studies have not included quality of life as an outcome measure, these results suggest that positive imagery is capable of improving the functional status in FMS, coinciding with guided imagery studies for rheumatic diseases that found improvements in psychological well-being [85,86]. ...
Objective:
Previous studies have demonstrated the effects of positive psychological factors on pain adjustment. Specifically, optimism has been linked to better physical functioning and less psychological distress. Until recently, these beneficial effects have mostly been examined in correlational studies or laboratory settings. The aim of this study was to test the efficacy of the Best Possible Self intervention using information and communication technologies with fibromyalgia patients.
Methods:
Seventy-one patients were randomly allocated to the Best Possible Self intervention or a Daily Activities control condition. The Best Possible Self intervention used an interactive multimedia system with the support of an Internet platform to practice the guided imagery exercise online.
Results:
Intent-to-treat analyses showed that, compared with the control condition, Best Possible Self patients showed significant improvements in depression, positive affect, and self-efficacy at postintervention. Moreover, at three-month follow-up, patients who received the intervention improved their optimism and negative affect significantly more than participants in the control condition.
Conclusions:
This study shows how a technology-supported intervention aimed at augmenting positive affect and promoting positive functioning works in the case of fibromyalgia, expanding the intervention's efficacy data in clinical populations and adding knowledge about the role that positive psychological factors play in pain experience. Moreover, it demonstrates the specific effects of the Best Possible Self intervention in order to incorporate this exercise in pain treatment protocols.
... These approaches are safe, with rare adverse reactions in psychiatric patients, people with epilepsy or those who have suffered abuse or trauma where relaxation may trigger a rare paradoxical reaction. 141,324,339,340 Biofeedback chronic pain Biofeedback utilizes techniques in which a signal generated by a device trains the patient to manipulate an aspect of their physiology not typically directed (e.g. heart rate variability, muscle tension) and provides a self-care tool for physiologic modulation. ...
Medical pain management is in crisis: from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care has prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC.
There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in post-surgical pain with opioid sparing, acute nonsurgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components, and self-care/self-efficacy strategies.
Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.
The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short and long term therapeutic and economic impact of comprehensive care practices.
... Guided imagery is a quasi-perceptual, multisensory, and a conscious experience that closely resembles the actual perception of some scene, event, or object, but occurs in the absence of an external stimuli (Thomas, 2016). This cognitive technique has been used by psychologists to help individuals cope with pain, stress or anxiety, and may be an effective treatment or adjunct for those with arthritis and other rheumatic diseases (Giacobbi et al., 2015;Verkaik et al., 2014). Separate lines of scientific inquiry have shown that guided imagery can be an effective intervention strategy to help individuals increase physical activity (Chan & Cameron, 2012;Duncan et al., 2012), modify food consumption and cravings (E. ...
The purpose of this randomized wait-list controlled trial was to test the feasibility and preliminary efficacy of a guided imagery based multi-behavior intervention intended to address psychological stress, food cravings, and physical activity. Personalized guided imagery scripts were created and participants were instructed to practice guided imagery every day for 35 consecutive days. Of 48 women who enrolled, we report comparisons between 16 randomized to treatment with 19 who were wait-listed (overall Mage = 45.50; Mbodymassindex = 31.43). Study completers reported 89% compliance with practicing guided imagery during the intervention. A significant time-by-group interaction was observed with reductions in food cravings and increases in physical activity compared with wait-list controls. Telephone-based multi-behavior interventions that utilize guided imagery to address food cravings and exercise behavior appear to be acceptable for overweight and obese women. Future phone-based guided imagery research testing this skill to address multiple health behaviors is justified.
... Guided imagery uses the imagination to focus one"s attention on a specific image to achieve health-related goals. Empirical studies support its wide-ranging application, including for stress-management, BI disturbance, depression, sports performance, and pain management 28,[31][32][33] . For ReBIC, the specific words and phrases are tailored to explore personal identity, BI and intimacy. ...
Several alternative treatments cannot logically be put in any of the previously discussed categories. They form a mixed bunch and include, for instance, mind–body therapies as well as energetic healing methods. These modalities will be evaluated in this chapter.
Objective:
Both acupuncture and guided imagery hold promise for treating pain. The mechanisms underlying these alternative interventions remain unclear. The reported study aimed to comparatively investigate the modulation effect of actual and imagined acupuncture on the functional connectivity of descending pain modulation system and reward network.
Methods:
Twenty-four healthy participants (mean [SE], 25.21 [0.77] years of age; 66.67% female) completed a crossover study that included five sessions, a training session and four intervention sessions administered in randomized order. We investigated the modulation effect of real acupuncture, sham acupuncture, video-guided acupuncture imagery treatment (VGAIT) and VGAIT control on the resting state functional connectivity (rsFC) of periaqueductal gray (PAG) and ventral tegmental area (VTA). These are key regions of the descending pain modulatory system (DPMS) and dopaminergic reward system, respectively.
Results:
Compared with sham acupuncture, real acupuncture produced decreased PAG-precuneus (Pcu) rsFC and increased VTA-amygdala/hippocampus rsFC. Heat pain threshold changes applied on the contralateral forearm were significantly associated with the decreased PAG-Pcu (r = 0.49, p = 0.016) and increased VTA-hippocampus rsFC (r = -0.77, p < 0.001).Compared to VGAIT control, VGAIT produced decreased PAG-paracentral lobule (PCL)/posterior cingulate cortex/Pcu, middle cingulate cortex (MCC), and medial prefrontal cortex rsFC, and decreased VTA-caudate and MCC rsFC.Direct comparison between real acupuncture and VGAIT showed that VGAIT decreased rsFC in PAG-PCL/MCC, VTA-caudate/anterior cingulate cortex/nucleus accumbens, and VTA-MCC.
Conclusions:
Results suggest that both actual and imagined acupuncture can modulate key regions in DPMS and reward networks, but through different pathways. Identification of different pain-relief mechanisms may facilitate the development of new pain management methods.
Background
The use and impact of guided imagery in the acute care setting is limited.
Aims
The purpose of this quality improvement project was to evaluate the feasibility of a guided imagery intervention to change pain scores, anxiety scores, and opioid analgesia usage among hospitalized adults in an acute care setting.
Design
Quality improvement project using three measurements (baseline, 24 hours, and 48 hours).
Settings
Acute care hospital.
Participants/Subjects
Adult inpatients referred to an APRN-led pain management service.
Methods
The intervention was the use of a 30-minute guided imagery recording delivered via MP3 player which patients used twice daily.
Results
Limited changes were seen in pain scores, with no statistically significant results (p = .449). Statistically significant reductions were found in both anxiety scores (p < .001) and opioid analgesia usage (p = .043).
Conclusions
Findings from this quality improvement project support the impact of guided imagery on anxiety and opioid analgesia use. Changes in pain scores were not demonstrated in this project. Additional research with a rigorous design is needed to determine cause and effect conclusions.
Clinical Implications
The use of guided imagery as an adjunctive intervention for pain control may engage and empower the patient in self-care activities, which may have an impact on how care is perceived. Guided imagery is a low-cost, easily implemented approach that can be incorporated into patient care to reduce anxiety and, potentially, opioid analgesia use.
Autogenes Training wurde in den 1920er-Jahren von dem deutschen Psychiater Johannes Heinrich Schultz (1884–1970) entwickelt. Es handelt sich um eine auto-hypnotische Entspannungstechnik, die in Deutschland, aber weniger in anderen Ländern, sehr beliebt ist.
Complementary and integrative health approaches are becoming more widely used by patients with pain in the United States and the rest of the Western world. Growing body of evidence point to potential benefit and complementary roles they can play in managing patient's pain. Further research evaluating efficacy of many of these approaches is indicated.
Physical medicine providers work to cure organic aspects of disease while simultaneously enhancing quality of life and well-being. Mind-body interventions are evidence-based, cost-effective approaches to serve these aims. This article enhances provider knowledge and acceptance of the most effective and prevalent mind-body modalities: meditation, guided imagery, clinical hypnosis, and biofeedback. The scientific evidence is strongest for mind-body applications for chronic pain, primary headache, cardiac rehabilitation, and cancer rehabilitation, with preliminary evidence for traumatic brain injury and cerebrovascular events. Mind-body interventions are well-tolerated by patients and should be considered part of standard care in physical medicine and rehabilitation settings.
Acupuncture and imagery interventions for pain management have a long history. The present study comparatively investigated whether acupuncture and video-guided acupuncture imagery treatment (VGAIT, watching a video of acupuncture on the participant's own body while imagining it being applied) could modulate brain regional connectivity to produce analgesic effects. The study also examined whether pre-intervention brain functional and structural features could be used to predict the magnitude of analgesic effects. Twenty-four healthy participants were recruited and received four different interventions (real acupuncture, sham acupuncture, VGAIT, and VGAIT control) in random order using a cross-over design. Pain thresholds and magnetic resonance imaging (MRI) data were collected before and after each intervention. We first compared the modulatory effects of real acupuncture and VGAIT on intra- and inter-regional intrinsic brain connectivity and found that real acupuncture decreased regional homogeneity (ReHo) and functional connectivity (FC) in sensorimotor areas, whereas VGAIT increased ReHo in basal ganglia (BG) (i.e., putamen) and FC between the BG subcortical network and default mode network. The altered ReHo and FC were associated with changes in pain threshold after real acupuncture and VGAIT, respectively. A multimodality fusion approach with pre-intervention ReHo and grey matter volume (GMV) as features was used to explore the brain profiles underlying individual variability of pain threshold changes by real acupuncture and VGAIT. Variability in acupuncture responses was associated with ReHo and GMV in BG, whereas VGAIT responses were associated with ReHo and GMV in the anterior insula. These results suggest that through different pathways both real acupuncture and VGAIT can modulate brain systems to produce analgesic effects.
Introduction
Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.
Objective
In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.
Methods
Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.
Results
Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.
Conclusion
This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.
When acute pain persists beyond the expected healing time following an injury, important neurological changes occur that allow pain to transition from adaptive to maladaptive. Spine pain has become an important global problem, with significant increases in prevalence, disability, and subsequent healthcare costs over the past several decades. Low back pain is now the number one cause of disability in the world. Because of the magnitude of the effect of low back pain, and especially chronic low back pain, it has become imperative that we embrace the best available evidence and clinical sensibilities as we work with patients to find appropriate solutions. Intrinsic to the successful care of persons with spine pain is the acknowledgment that the experience of pain is a biopsychosocial one. There is no universal experience of pain and thus our solutions must accommodate variation in the meanings of pain. Experiential (qualitative, subjective) knowledge of spinal pain can be integrated with our understanding of spinal pain neurobiology (quantitative, objective) in rehabilitation contexts to improve health outcomes. Ultimately, the rehabilitation of persons with spine pain exists at the intersection of the objective and subjective goals of care.
Experiential evidence shows that pain is associated with common meanings. These include a meaning of threat or danger, which is experienced as immediately distressing or unpleasant; cognitive meanings, which are focused on the long-term consequences of having chronic pain; and existential meanings such as hopelessness, which are more about the person with chronic pain than the pain itself.
This interdisciplinary book - the second in the three-volume Meanings of Pain series edited by Dr Simon van Rysewyk - aims to better understand pain by describing experiences of pain and the meanings these experiences hold for the people living through them. The lived experiences of pain described here involve various types of chronic pain, including spinal pain, labour pain, rheumatic pain, diabetic peripheral neuropathic pain, fibromyalgia, complex regional pain syndrome, endometriosis-associated pain, and cancer-related pain. Two chapters provide narrative descriptions of pain, recounted and interpreted by people with pain.
Language is important to understanding the meaning of pain since it is the primary tool human beings use to manipulate meaning. As discussed in the book, linguistic meaning may hold clues to understanding some pain-related experiences, including the stigmatisation of people with pain, the dynamics of patient-clinician communication, and other issues, such as relationships between pain, public policy and the law, and attempts to develop a taxonomy of pain that is meaningful for patients. Clinical implications are described in each chapter.
This book is intended for people with pain, their family members or caregivers, clinicians, researchers, advocates, and policy makers.
“It is my opinion that this ... work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” - Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword
(related modalities: hypnotherapy, meditation, mind-body therapies, mindfulness, progressive muscle relaxation, transcendental meditation).
Objective:
This umbrella review aimed to determine the effectiveness of non-pharmacological and non-surgical interventions on the impact of rheumatoid arthritis.
Introduction:
Patients with rheumatoid arthritis have identified seven major domains of the impact of disease: pain, functional disability, fatigue, sleep, coping, emotional and physical well-being. This impact persists in many patients even after inflammatory remission is achieved, requiring the need for adjunctive interventions targeting the uncontrolled domains of disease impact. Several systematic reviews have addressed non-pharmacologic interventions, but there is still uncertainty about their effectiveness due to scarce or conflicting results or significant methodological flaws.
Inclusion criteria:
This review included studies of adult patients with rheumatoid arthritis in any context. Quantitative systematic reviews, with or without meta-analysis, that examined the effectiveness of non-pharmacological and non-surgical interventions of any form, duration, frequency and intensity, alone or in combination with other interventions designed to reduce the impact of disease, were considered. The outcomes were pain, functional disability, fatigue, emotional well-being, sleep, coping, physical well-being and global impact of disease.
Methods:
A comprehensive search strategy for 13 bibliometric databases and grey literature was developed. Critical appraisal of eight systematic reviews was conducted independently by two reviewers, using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research syntheses. Data extraction was performed independently by two reviewers using a standard Joanna Briggs Institute data extraction tool and data was summarized using a tabular format with supporting text.
Results:
Eight systematic reviews were included in this umbrella review, with a total of 91 randomized controlled trials and nine observational studies (6740 participants). Four systematic reviews examined the effects of multicomponent or single exercise/physical activity interventions, two the effects of hydrotherapy/balneotherapy, two the effects of psychosocial interventions, and one the effects of custom orthoses for the foot and ankle. Multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses appeared to be effective in improving pain and functional disability. Fatigue also improved with the implementation of multicomponent or single exercise/physical activity interventions and psychosocial interventions. Only exercise/physical activity interventions appeared to be effective in improving the global impact of disease and quality of life. None of the included systematic reviews reported on emotional well-being, sleep, coping or physical well-being as an outcome measure. Other types of interventions were not sufficiently studied and their effectiveness is not yet established.
Conclusions:
Of the included interventions, only multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses seem to reduce the impact of rheumatoid arthritis. Future evidence should be sought and synthesized in the domains identified as knowledge gaps, namely, emotional well-being, sleep, coping and physical well-being. Further examination of the effects of interventions that have not been assessed or sufficiently is suggested in order to establish their effectiveness so decisions and recommendations can be made.
This study compared the effect of eye movement desensitization and reprocessing (EMDR) therapy versus guided imagery on insomnia severity in patients with rheumatoid arthritis (RA). In this randomized controlled trial, 75 patients with RA were selected via convenience sampling before using block randomization to assign patients into three groups comprised of (a) six sessions of EMDR, (b) six sessions of guided imagery, and (c) a control group. The Persian version of the Insomnia Severity Index was implemented at preintervention and 2 weeks' postintervention as the outcome measure. The EMDR group obtained respective pre-and postintervention mean scores of 23.5 ± 5.2 and 11±2.1, whereas the guided imagery group obtained scores of 24 ± 3 and 15.3 ± 2.3, and the control group obtained scores of 24.2 ± 3.3 and 23.6 ± 3. Pairwise comparisons showed statistically significant differences in insomnia severity between patients from each group, with the EMDR group experiencing a greater reduction in insomnia severity than guided imagery. EMDR and guided imagery were both effective in reducing insomnia severity in RA patients, although the degree of insomnia reduction for patients from the EMDR group was greater than that of the guided imagery group.
Despite the plethora of treatments available for patients with fibromyalgia, there is insufficient evidence to date as to what the ideal treatment approach is. This study sought to determine the effectiveness of a home program of audio-recorded guided imagery relaxation on people with fibromyalgia. This experimental 8-week longitudinal trial design was undertaken with 60 people diagnosed with fibromyalgia who were randomly assigned to either a guided imagery intervention group or a control group. Pain at tender points, anxiety, self-efficacy, quality of sleep, quality of life, and the impact of the fibromyalgia were determined at baseline, at 4 weeks, and at 8 weeks. After the guided imagery intervention, we found significant differences regarding trait anxiety, sleep quality, and tenderness at some of the tender points. There is a need, therefore, to develop and evaluate interventions that may enhance the quality of life of those affected by this disorder.
Integrative medicine emphasizes the care of the whole person and employs both conventional and complementary therapeutic approaches. Techniques such as mind-body therapies, therapeutic art, music and writing, biofield therapies, and emotional freedom technique can be used to support family members of patients in the ICU. Complementary and integrative modalities have been shown to improve perceived stress, anxiety, depression, and PTSD and enhance quality of life, resilience, and sleep.
Pain in the elderly is an increasing problem with increasing life expectancy resulting in many people living for longer with a range of age-related debilitating and painful conditions. Management of pain in the elderly can be complex due to increasing fragility, cognitive impairment and the presence of comorbidities and polypharmacy. Non-pharmacological methods of pain relief would appear to offer a solution to many of these problems. Overall the evidence for the effective use of many non-pharmacological therapies in pain management for the elderly is limited. Most effective measures appear to be those which support self-help, those which provide distraction and promote exercise and the use of superficial heat/cold. There is limited evidence to support the use of most complementary and alternative medicines (CAMs) including dietary supplements, and the role of psychological therapy is limited to improvements in mood states such as anxiety and depression. However due to the low incidence of adverse events, any non-pharmacological therapy which is perceived as offering some relief from suffering by the individual may have personal value.
Although pain is widely recognized by clinicians and researchers as an experience, pain is always felt in a patient-specific way rather than experienced for what it objectively is, making perceived meaning important in the study of pain. The book contributors explain why meaning is important in the way that pain is felt and promote the integration of quantitative and qualitative methods to study meanings of pain. For the first time in a book, the study of the meanings of pain is given the attention it deserves. All pain research and medicine inevitably have to negotiate how pain is perceived, how meanings of pain can be described within the fabric of a person's life and neurophysiology, what factors mediate them, how they interact and change over time, and how the relationship between patient, researcher, and clinician might be understood in terms of meaning. Though meanings of pain are not intensively studied in contemporary pain research or thoroughly described as part of clinical assessment, no pain researcher or clinician can avoid asking questions about how pain is perceived or the types of data and scientific methods relevant in discovering the answers.
Purpose
The clinical response to traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) varies substantially. The objective of this study was to describe physicians’ and patients’ perceptions of response to tNSAIDs as measured by satisfaction with control of patients’ osteoarthritis (OA).
Patients and methods
A cross-sectional survey was undertaken in 2009 in Germany, Spain, and the UK. Linked physician and patient questionnaires collected data on OA management, degree of pain and disability, and satisfaction with OA control.
Results
The study included 363 treating physicians and 713 patients receiving tNSAIDs. Patient mean (standard deviation) age was 65.5 (11.0) years (range 36–94 years); 60% were women; 86% were white; and one-quarter were obese. Dissatisfaction with control of patients’ OA was expressed by physicians or their patients, or both, for 51% of patients, including 208 patients (31%) with mild OA and 478 patients (60%) with moderate or severe OA. Overall, 37% of patients reported dissatisfaction and 34% had a physician who reported dissatisfaction. Patient and physician assessments were the same in 70% of cases; Cohen’s κ coefficient was 0.34 (95% confidence interval 0.26–0.41), indicating fair agreement. Of those reporting dissatisfaction, most physicians (79%) and patients (64%) believed that the current control was the best that could be achieved. The most common reasons for which physicians reported dissatisfaction were inadequate response (56%), side effects (11.1%), and poor tolerance (7.8%).
Conclusion
One-half of patients or their treating physicians were dissatisfied with the control of OA provided by tNSAID therapy; moreover, most believed it was the best control that could be achieved.
Objectives
The purpose of this study was to examine the effects of a peer-based mental imagery intervention on the self-determined motivation and cardio-respiratory fitness of university enrolled women.
Design
Randomized controlled trial.
Method
43 university enrolled women were randomized to peer-mentored or peer-mentored plus mental imagery conditions while 32 completed three meetings with peer-mentors and post-testing (Mage = 19.91; SD = 1.70).
Results
Significant improvements in cardio-respiratory endurance, ratings of perceived endurance, and self-determined motivation to exercise were observed across both study conditions. Participants assigned to the peer mentored plus mental imagery condition reported significantly greater increases in self-determined motivation to exercise at post-test compared to those in the peer-mentored condition.
Conclusions
Peer-based interventions are a viable way to improve fitness and health outcomes while mental imagery appears to be associated with increases in autonomous forms of exercise motivation.
Experimental studies have shown that administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to susceptible individuals can lead to the development of congestive heart failure (CHF). There have been few epidemiological investigations of the importance of this adverse effect.
To estimate the relative risk of first admission to a hospital with CHF in recent users of NSAIDs, compared with nonusers, and to determine whether the estimated relative risk was increased in those with a history of heart disease and the extent to which the level of risk varied with the dose and half-life of the drugs consumed.
We conducted a matched case-control study of the relationship between recent use of NSAIDs and hospitalization with CHF. Cases (n = 365) were patients admitted to hospitals with a primary diagnosis of CHF. Controls (n = 658) were patients without CHF who were admitted to the same hospitals as case patients. Structured interviews were used to obtain information on several study factors, including recent use of aspirin and other NSAIDs.
Use of NSAIDs (other than low-dose aspirin) in the previous week was associated with a doubling of the odds of a hospital admission with CHF (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.3). Use of NSAIDs by patients with a history of heart disease was associated with an odds ratio of 10.5 (95% confidence interval, 2.5-44.9) for first admission with heart failure, compared with 1.6 (95% confidence interval, 0.7-3.7) in those without such a history. The odds of a first admission to a hospital with CHF was positively related to the dose of NSAID consumed in the previous week, and was increased to a greater extent with long half-life than with short half-life drugs. Assuming these relationships are causal, NSAIDs were responsible for approximately 19% of hospital admissions with CHF.
The burden of illness resulting from NSAID-related CHF may exceed that resulting from gastrointestinal tract damage. NSAIDs should be used with caution in patients with a history of cardiovascular disease.
In this clinical, randomized trial three cognitive behavioural coping techniques were compared for their efficiency of relieving fibromyalgia pain and anxiety symptoms: (1) a patient education programme (2) a general pleasant guided imagery program (3) Self disclosure of pain talk, freely and emotionally about their fibromyalgia problems. The study tested a 30 minutes post intervention effect. A total of 58 fibromyalgia patients participated, where22 were in the patient education group, 17 in the pleasant guided imagery group and 19 in the pain talk self disclosure group. Visual analogue scale (VAS) results indicate that patient education and guided imagery reduced both the patients current pain and anxiety, while the pain talk self disclosure group showed unchanged outcomes, although the patients expressed relief while talking. This study may have clinical relevance about how to approach chrinic pain patients.
While it is recognised that depression is prevalent in Rheumatoid Arthritis (RA), recent studies have also highlighted significant levels of anxiety in RA patients. This study compared two commonly used scales, the Depression Anxiety and Stress Scale (DASS) and the Hospital Anxiety and Depression Scale (HADS), in relation to their measurement range and cut points to consider the relative prevalence of both constructs, and if prevalence rates may be due to scale-specific case definition.
Patients meeting the criteria for RA were recruited in Leeds, UK and Sydney, Australia and asked to complete a survey that included both scales. The data was analysed using the Rasch measurement model.
A total of 169 RA patients were assessed, with a repeat subsample, resulting in 323 cases for analysis. Both scales met Rasch model expectations. Using the 'possible+probable' cut point from the HADS, 58.3% had neither anxiety nor depression; 13.5% had anxiety only; 6.4% depression only and 21.8% had both 'possible+probable' anxiety and depression. Cut points for depression were comparable across the two scales while a lower cut point for anxiety in the DASS was required to equate prevalence.
This study provides further support for high prevalence of depression and anxiety in RA. It also shows that while these two scales provide a good indication of possible depression and anxiety, the estimates of prevalence so derived could vary, particularly for anxiety. These findings are discussed in terms of comparisons across studies and selection of scales for clinical use.
Overwhelming evidence shows the quality of reporting of randomised controlled trials (RCTs) is not optimal. Without transparent reporting, readers cannot judge the reliability and validity of trial findings nor extract information for systematic reviews. Recent methodological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects. Such systematic error is seriously damaging to RCTs, which are considered the gold standard for evaluating interventions because of their ability to minimise or avoid bias.
Recent systematic reviews on psychological therapies of fibromyalgia syndrome (FMS) did not consider hypnosis/guided imagery (H/GI). Therefore we performed a systematic review with meta-analysis of the efficacy of H/GI in FMS.
We screened http://ClinicalTrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS (through December 2010). (Quasi-) randomized controlled trials (CTs) comparing H/GI with controls were analyzed. Outcomes were pain, sleep, fatigue, depressed mood and health-related quality of life (HRQOL). Effects were summarized using standardized mean differences (SMD).
Six CTs with 239 subjects with a median of 9 (range 7-12) H/GI-sessions were analysed. The median number of patients in the H/GI groups was 20 (range 8-26). Three studies performed follow-ups. H/GI reduced pain compared to controls at final treatment (SMD -1.17 [95% CI -2.21, -0.13]; p = 0.03). H/GI did not reduce limitations of HRQOL at final treatment (SMD -0.90 [95% CI -2.55, 0.76]; p = 0.29) compared to controls. Effect sizes on fatigue, sleep and depressed mood at final treatment and follow-up and on pain and HRQOL at follow-up were not calculated because of limited data available. The significant effect on pain at final treatment was associated with low methodological and low treatment quality.
Further studies with better treatment quality and adequate methodological quality assessing all key domains of FMS are necessary to clarify the efficacy of H/GI in FMS.
Overwhelming evidence shows the quality of reporting of randomised controlled trials (RCTs) is not optimal. Without transparent reporting, readers cannot judge the reliability and validity of trial findings nor extract information for systematic reviews. Recent methodological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects. Such systematic error is seriously damaging to RCTs, which are considered the gold standard for evaluating interventions because of their ability to minimise or avoid bias.
(1) To investigate the effects of a 6-week intervention of guided imagery on pain level, functional status, and self-efficacy in persons with fibromyalgia (FM); and (2) to explore the dose-response effect of imagery use on outcomes.
Longitudinal, prospective, two-group, randomized, controlled clinical trial.
The sample included 48 persons with FM recruited from physicians' offices and clinics in the mid-Atlantic region.
Participants randomized to Guided Imagery (GI) plus Usual Care intervention group received a set of three audiotaped guided imagery scripts and were instructed to use at least one tape daily for 6 weeks and report weekly frequency of use (dosage). Participants assigned to the Usual Care alone group submitted weekly report forms on usual care.
All participants completed the Short-Form McGill Pain Questionnaire (SF-MPQ), Arthritis Self- Efficacy Scale (ASES), and Fibromyalgia Impact Questionnaire (FIQ), at baseline, 6, and 10 weeks, and submitted frequency of use report forms.
FIQ scores decreased over time in the GI group compared to the Usual Care group (p = 0.03). Ratings of self-efficacy for managing pain (p = 0.03) and other symptoms of FM also increased significantly over time (p = < 0.01) in the GI group compared to the Usual Care group. Pain as measured by the SF-MPQ did not change over time or by group. Imagery dosage was not significant.
This study demonstrated the effectiveness of guided imagery in improving functional status and sense of self-efficacy for managing pain and other symptoms of FM. However, participants' reports of pain did not change. Further studies investigating the effects of mind-body interventions as adjunctive self-care modalities are warranted in the fibromyalgia patient population.
To describe the impact of musculoskeletal pain (MP); to compare management of MP by the population and by primary care physicians; and to identify misconceptions about treatment.
5803 people with MP and 1483 primary care physicians, randomly selected, in eight European countries were interviewed by telephone. A structured questionnaire was used to ask about usual management of MP and perceived benefits and risks of treatment. Current health status (SF-12) was also assessed.
From primary care physicians' perceptions, MP appears to be well managed. All presenting patients are offered some form of treatment, 90% or more doctors are trying to improve patients' quality of life, and most are aware and concerned about the risks of treatment with NSAIDs. From a population perspective, up to 27% of people with pain do not seek medical help and of those who do, several wait months/years before seeing a doctor. 55% or fewer patients who have seen a doctor are currently receiving prescription treatment for their pain. Communication between doctors and patients is poor; few patients are given information about their condition; and many have misconceptions about treatment.
Management of MP is similar across eight European countries, but there is discordance between physician and patient perspectives of care. Some people with pain have never sought medical help despite being in constant/daily pain. Those who do seek help receive little written information or explanation and many have misperceptions about the benefits and risks of treatment that limit their ability to actively participate in decisions about their care.
Objective. To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time. Methods. Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables. Results. Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations. Conclusion. The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.
Background: While it is recognised that depression is prevalent in Rheumatoid Arthritis (RA), recent studies have also highlighted significant levels of anxiety in RA patients. This study compared two commonly used scales, the Depression Anxiety and Stress Scale (DASS) and the Hospital Anxiety and Depression Scale (HADS), in relation to their measurement range and cut points to consider the relative prevalence of both constructs, and if prevalence rates may be due to scale-specific case definition. Methods: Patients meeting the criteria for RA were recruited in Leeds, UK and Sydney, Australia and asked to complete a survey that included both scales. The data was analysed using the Rasch measurement model. Results: A total of 169 RA patients were assessed, with a repeat subsample, resulting in 323 cases for analysis. Both scales met Rasch model expectations. Using the 'possible+probable' cut point from the HADS, 58.3% had neither anxiety nor depression; 13.5% had anxiety only; 6.4% depression only and 21.8% had both 'possible+probable' anxiety and depression. Cut points for depression were comparable across the two scales while a lower cut point for anxiety in the DASS was required to equate prevalence. Conclusions: This study provides further support for high prevalence of depression and anxiety in RA. It also shows that while these two scales provide a good indication of possible depression and anxiety, the estimates of prevalence so derived could vary, particularly for anxiety. These findings are discussed in terms of comparisons across studies and selection of scales for clinical use.
Objective. —To determine if inadequate approaches to randomized controlled trial design and execution are associated with evidence of bias in estimating treatment effects. Design. —An observational study in which we assessed the methodological quality of 250 controlled trials from 33 meta-analyses and then analyzed, using multiple logistic regression models, the associations between those assessments and estimated treatment effects. Data Sources. —Meta-analyses from the Cochrane Pregnancy and Childbirth Database. Main Outcome Measures. —The associations between estimates of treatment effects and inadequate allocation concealment, exclusions after randomization, and lack of double-blinding. Results. —Compared with trials in which authors reported adequately concealed treatment allocation, trials in which concealment was either inadequate or unclear (did not report or incompletely reported a concealment approach) yielded larger estimates of treatment effects ( P P =.01), with odds ratios being exaggerated by 17%. Conclusions. —This study provides empirical evidence that inadequate methodological approaches in controlled trials, particularly those representing poor allocation concealment, are associated with bias. Readers of trial reports should be wary of these pitfalls, and investigators must improve their design, execution, and reporting of trials. ( JAMA . 1995;273:408-412)
Objective. This study examines the determinants of patients' side effects from arthritis medication. Proposed predictors were patients' beliefs about medications, objective disease activity, treatment regimen, and psychiatric and rheumatoid arthritis symptoms. Methods. In a longitudinal design, 100 rheumatoid arthritis outpatients were investigated at baseline and again at 6 months after receiving both pharmacologic and psychosocial treatment. Results. Multivariate analyses showed no influence of disease status, type of treatment, or psychiatric or arthritis symptoms on side effects. Heightened concerns about arthritis medication at baseline predicted side effects at baseline (partial correlation r 0.37, P < 0.001) and at 6 months (partial correlation r 0.25, P < 0.001) after controlling for relevant disease-and treatment-related variables. In a cross-lagged panel analysis, prior experience with side effects from arthritis medication was ruled out as a cause of heightened concerns, indicating that negative beliefs genuinely contribute to side effects. A comparison of patients who did and did not start new medications showed no difference in side effects in patients with positive beliefs about medications, but led to significantly more side effects in patients with negative beliefs. Conclusion. Patients' beliefs about arthritis medications were stable and consistently associated with side effects. Patients with greater concerns about their arthritis medications are at higher risk for developing side effects, especially when starting new drugs. Identifying those patients is important to avoid premature drug discontinuation. Research into cause and preventability of negative attitudes to prescribed medicines is needed.
Objective.
—To determine if inadequate approaches to randomized controlled trial design and execution are associated with evidence of bias in estimating treatment effects.Design.
—An observational study in which we assessed the methodological quality of 250 controlled trials from 33 meta-analyses and then analyzed, using multiple logistic regression models, the associations between those assessments and estimated treatment effects.Data Sources.
—Meta-analyses from the Cochrane Pregnancy and Childbirth Database.Main Outcome Measures.
—The associations between estimates of treatment effects and inadequate allocation concealment, exclusions after randomization, and lack of double-blinding.Results.
—Compared with trials in which authors reported adequately concealed treatment allocation, trials in which concealment was either inadequate or unclear (did not report or incompletely reported a concealment approach) yielded larger estimates of treatment effects (P<.001). Odds ratios were exaggerated by 41% for inadequately concealed trials and by 30% for unclearly concealed trials (adjusted for other aspects of quality). Trials in which participants had been excluded after randomization did not yield larger estimates of effects, but that lack of association may be due to incomplete reporting. Trials that were not double-blind also yielded larger estimates of effects (P=.01), with odds ratios being exaggerated by 17%.Conclusions.
—This study provides empirical evidence that inadequate methodological approaches in controlled trials, particularly those representing poor allocation concealment, are associated with bias. Readers of trial reports should be wary of these pitfalls, and investigators must improve their design, execution, and reporting of trials.(JAMA. 1995;273:408-412)
Objectives: To review studies on relaxation treatment for chronic musculoskeletal pain. Methods: Searches in the databases PubMed, PEDro, CINAHL, Amed, the electronic library information navigator (ELIN), and the British Medical Journal and Science Direct, found 12 relevant studies. Inclusion criteria were: randomised controlled trials (RCTs); studies including a total of at least 25 subjects at the end of intervention; relaxation techniques as single treatment, or combined with education, with the participants being active in the treatment. Results: A total of 12 studies fulfilled all inclusion criteria and were reviewed. Quality assessment showed that all studies were of medium quality. The relaxation techniques used were: progressive muscle relaxation ad modum Jacobson (most common), autogenic training ad modum Schultz, hypnosis, guided imagery and biofeedback. Positive effects were found regarding decreases in pain intensity, anxiety, depression, and fatigue (in fibromyalgia). Even decreases in medication and health costs were seen. Increased mobility and use of coping strategies were also reported. Conclusion: Relaxation training could be effective for patients with chronic musculoskeletal pain. The experimental study designs need to be of improved scientific quality and should, for example, include clear self-training relaxation protocols and suitable control groups. RCTs of high quality are necessary.
To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.
A list of pharmacologic and nonpharmacologic modalities commonly used to manage knee, hip, and hand OA as well as clinical scenarios representing patients with symptomatic hand, hip, and knee OA were generated. Systematic evidence-based literature reviews were conducted by a working group at the Institute of Population Health, University of Ottawa, and updated by ACR staff to include additions to bibliographic databases through December 31, 2010. The Grading of Recommendations Assessment, Development and Evaluation approach, a formal process to rate scientific evidence and to develop recommendations that are as evidence based as possible, was used by a Technical Expert Panel comprised of various stakeholders to formulate the recommendations for the use of nonpharmacologic and pharmacologic modalities for OA of the hand, hip, and knee.
Both “strong” and “conditional” recommendations were made for OA management. Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical nonsteroidal antiinflammatory drugs (NSAIDs), tramadol, and topical capsaicin. Nonpharmacologic modalities strongly recommended for the management of knee OA were aerobic, aquatic, and/or resistance exercises as well as weight loss for overweight patients. Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self management programs, and psychosocial interventions. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. Opioid analgesics were strongly recommended in patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed medical therapy. Recommendations for hip OA were similar to those for the management of knee OA.
These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.
There has been limited characterization of the burden of anxiety and depression, especially the former, among US adults with arthritis in the general population. The study objective was to estimate the prevalence and correlates of anxiety and depression among US adults with doctor-diagnosed arthritis.
The study sample comprised US adults ages ≥ 45 years with doctor-diagnosed arthritis (n = 1,793) from the Arthritis Conditions Health Effects Survey (a cross-sectional, population-based, random-digit-dialed telephone interview survey). Anxiety and depression were measured using separate and validated subscales of the Arthritis Impact Measurement Scales. Prevalence was estimated for the sample overall and stratified by subgroups. Associations between correlates and each condition were estimated with prevalence ratios and 95% confidence intervals using logistic regression models.
Anxiety was more common than depression (31% and 18%, respectively); overall, one-third of respondents reported at least 1 of the 2 conditions. Most (84%) of those with depression also had anxiety. Multivariable logistic regression modeling failed to identify a distinct profile of characteristics of those with anxiety and/or depression. Only half of the respondents with anxiety and/or depression had sought help for their mental health condition in the past year.
Despite the clinical focus on depression among people with arthritis, anxiety was almost twice as common as depression. Given their high prevalence, their profound impact on quality of life, and the range of effective treatments available, we encourage health care providers to screen all people with arthritis for both anxiety and depression.
Many different psychosocial treatments for pain have been described in the literature. All of these treatments have at least some evidence supporting their efficacy. However, each treatment is based on a theory or model that is most useful only for that particular intervention. An overarching model or framework that includes all of the factors hypothesized to play a role in the effects of these treatments would be useful for (1) understanding the similarities and differences between existing and future psychosocial pain treatments, (2) guiding the psychosocial evaluation of patients with chronic pain, and (3) giving clinicians greater flexibility for including psychosocial interventions that have proven efficacy, but that may not be explained by their preferred (but perhaps limited) model. This article proposes an initial version of such a framework, with the hope that it will increase our understanding of the role that psychosocial factors play in the experience of pain and its negative effects on functioning, and informs future research seeking to identify the common and specific factors associated with psychosocial pain treatments.
Supporting safe self-management interventions for symptoms of osteoarthritis (OA) may reduce the personal and societal burden of this increasing health concern. Self-management interventions might be even more beneficial if symptom control were accompanied by decreased medication use, reducing cost and potential side effects. Guided imagery with relaxation (GIR) created especially for OA may be a useful self-management intervention, reducing both symptoms and medication use. A longitudinal randomized assignment experimental design was used to study the efficacy of GIR in reducing pain, improving mobility, and reducing medication use. Thirty older adults were randomly assigned to participate in the 4-month trial by using either GIR or a sham intervention, planned relaxation. Repeated-measures analysis of variance revealed that, compared with those who used the sham intervention, participants who used GIR had a significant reduction in pain from baseline to month 4 and significant improvement in mobility from baseline to month 2. Poisson technique indicated that, compared with those who used the sham intervention, participants who used GIR had a significant reduction in over-the-counter (OTC) medication use from baseline to month 4, prescribed analgesic use from baseline to month 4, and total medication (OTC, prescribed analgesic, and prescribed arthritis medication) use from baseline to month 2 and month 4. Results of this study support the efficacy of GIR in reducing symptoms, as well as in reducing medication use. Guided imagery with relaxation may be useful in the regimen of pain management for clinicians.
This study examines the determinants of patients' side effects from arthritis medication. Proposed predictors were patients' beliefs about medications, objective disease activity, treatment regimen, and psychiatric and rheumatoid arthritis symptoms.
In a longitudinal design, 100 rheumatoid arthritis outpatients were investigated at baseline and again at 6 months after receiving both pharmacologic and psychosocial treatment.
Multivariate analyses showed no influence of disease status, type of treatment, or psychiatric or arthritis symptoms on side effects. Heightened concerns about arthritis medication at baseline predicted side effects at baseline (partial correlation r = 0.37, P < 0.001) and at 6 months (partial correlation r = 0.25, P < 0.001) after controlling for relevant disease- and treatment-related variables. In a cross-lagged panel analysis, prior experience with side effects from arthritis medication was ruled out as a cause of heightened concerns, indicating that negative beliefs genuinely contribute to side effects. A comparison of patients who did and did not start new medications showed no difference in side effects in patients with positive beliefs about medications, but led to significantly more side effects in patients with negative beliefs.
Patients' beliefs about arthritis medications were stable and consistently associated with side effects. Patients with greater concerns about their arthritis medications are at higher risk for developing side effects, especially when starting new drugs. Identifying those patients is important to avoid premature drug discontinuation. Research into cause and preventability of negative attitudes to prescribed medicines is needed.
To assess the value of searching for unpublished data by exploring the extent to which Cochrane reviews include unpublished data and by evaluating the quality of unpublished trials.
We screened all 2,462 completed Cochrane reviews published since 2000 in the Cochrane Database of Systematic Reviews Issue 3, 2006. In a random sample (n=61) of 292 reviews, including unpublished trials, we studied all 116 references.
Unpublished trials make up 8.8% of all included trials in our sample. Thirty-eight percent of the "unpublished" trials have in fact been published. Allocation concealment was "unclear" or not adequate in 54.3% and 61.3% reported blinding. In 47.2% reported withdrawal rates were >20%. Trials that were eventually published had larger mean population sizes (P-value, 0.02). Of the reported sponsors, 87.3% were drug companies. Methodological quality and publication bias are mentioned in half of the reviews and explored in a third. Quality ratings did not have consequences for pooling, because 82.8% was included in the forest plots.
A minority of Cochrane reviews include "unpublished trials" and many of these are eventually published. Truly unpublished studies have poor or unclear methodological quality. Therefore, it may be better to invest in regular updating of reviews, rather than in extensive searching for unpublished data.
( This reprinted article originally appeared in Science, 1977, Vol 196[4286], 129–236. The following abstract of the original article appeared in PA, Vol 59:1423. ) Although it seems that acceptance of the medical model by psychiatry would finally end confusion about its goals, methods, and outcomes, the present article argues that current crises in both psychiatry and medicine as a whole stem from their adherence to a model of disease that is no longer adequate for the work and responsibilities of either field. It is noted that psychiatrists have responded to their crisis by endorsing 2 apparently contradictory positions, one that would exclude psychiatry from the field of medicine and one that would strictly adhere to the medical model and limit the work of psychiatry to behavioral disorders of an organic nature. Characteristics of the dominant biomedical model of disease are identified, and historical origins and limitations of this reductionistic view are examined. A biopsychosocial model is proposed that would encompass all factors related to both illness and patienthood. Implications for teaching and health care delivery are considered.
This article presents the basic elements of Rogers' science of unitary human beings. It defines science, explicates nursing as a science and an art, addresses the meaning of the principles of hemodynamics, and discusses the building blocks of these principles. Several theories arising from the science of unitary human beings are elaborated, and noninvasive therapeutic modalities are discussed as part of nursing practice.
15 chronic low back pain patients, 11 chronic respiratory patients, and 11 nonpatient controls (mean ages 47–56 yrs) were studied using a standard radiant heat signal detection methodology. Following determination by ascending limits of each S's stimulus detection and faint pain thresholds, 26 randomized trials at each of 5 stimulus levels were administered. Ss rated each stimulus on a 6-point subjective rating scale ranging from no pain to severe pain. Results indicate that the back pain Ss and respiratory Ss had higher radiant heat pain thresholds than the controls, and the back pain Ss had a discrimination deficit for mildly painful stimuli. Results fit the predictions of an adaptation model of pain perception in chronic pain patients as opposed to a hypochondriasis model. (9 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To compare the use of randomized controls (RCTs) and historical controls (HCTs) for clinical trials, we searched the literature for therapies studied by both methods. We found six therapies for which 50 RCTs and 56 HCTs were reported. Forty-four of 56 HCTs (79 percent) found the therapy better than the control regimen, but only 10 of 50 RCTs (20 percent) agreed. For each therapy, the treated patients in RCTs and HCTs of the same therapy was largely due to differences in outcome for the control groups, with HCT control patients generally doing worse than the RCT control groups. Adjustment of the outcomes of the HCTs for prognostic factors, when possible, did not appreciably change the results. The data suggest that biases in patient selection may irretrievably weight the outcome of HCts in favor of new therapies. RCTs may miss clinically important benefits because of inadequate attention to sample size. The predictive value of each might be improved by reconsidering the use of p less than 0.05 as the significance level for all types of clinical trials, and by the use of confidence intervals around estimates of treatment effects.
To determine if inadequate approaches to randomized controlled trial design and execution are associated with evidence of bias in estimating treatment effects.
An observational study in which we assessed the methodological quality of 250 controlled trials from 33 meta-analyses and then analyzed, using multiple logistic regression models, the associations between those assessments and estimated treatment effects.
Meta-analyses from the Cochrane Pregnancy and Childbirth Database.
The associations between estimates of treatment effects and inadequate allocation concealment, exclusions after randomization, and lack of double-blinding.
Compared with trials in which authors reported adequately concealed treatment allocation, trials in which concealment was either inadequate or unclear (did not report or incompletely reported a concealment approach) yielded larger estimates of treatment effects (P < .001). Odds ratios were exaggerated by 41% for inadequately concealed trials and by 30% for unclearly concealed trials (adjusted for other aspects of quality). Trials in which participants had been excluded after randomization did not yield larger estimates of effects, but that lack of association may be due to incomplete reporting. Trials that were not double-blind also yielded larger estimates of effects (P = .01), with odds ratios being exaggerated by 17%.
This study provides empirical evidence that inadequate methodological approaches in controlled trials, particularly those representing poor allocation concealment, are associated with bias. Readers of trial reports should be wary of these pitfalls, and investigators must improve their design, execution, and reporting of trials.
To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time.
Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables.
Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations.
The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and used, especially to treat patients with osteoarthritis and rheumatoid arthritis. Since their introduction as a therapeutic class, a large body of literature has accumulated on the side-effects of these drugs. NSAIDs, through their inhibition of prostaglandin synthesis, can affect the renal and cardiovascular systems. However, the majority of reported side-effects are related to the gastrointestinal (GI) system, and the occurrence of these GI events adds significantly to the disease burden. Several factors have been identified that contribute to the risk of an NSAID-associated GI event. However, when considering risk, especially in clinical trials or observational studies, it is necessary to distinguish between baseline risk and NSAID-attributable risk, since this distinction can affect the results and conclusions of the study; NSAID-attributable risk is present in subjects who have few or no risk factors for upper GI toxicity. Safer NSAIDs, such as the new specific cyclooxygenase-2 inhibitors, when targeted to the appropriate patient (i.e. those with NSAID-attributable risk), should lead to improved outcomes and reduced costs.
The effectiveness of an attention distracting and an attention focusing guided imagery as well as the effect of amitriptyline on fibromyalgic pain was studied prospectively.
Fifty-five women with previously diagnosed fibromyalgia were monitored for daily pain (VAS) in a randomized, controlled clinical trial. One group received relaxation training and guided instruction in "pleasant imagery" (PI) in order to distract from the pain experience (n=17). Another group received relaxation training and attention imagery upon the "active workings of the internal pain control systems", "attention imagery" (AI) (n=21). The control group (CG) received treatment as usual (n=17). Patients were also randomly assigned to 50-mg amitriptyline/day or placebo. Some psychological and socio-demographic variables were also measured initially. The slopes of diary pain ratings over a 4-week period were used as the outcome measures.
We found significant differences of the pain-slopes between the three psychological conditions (P=0.0001). The pleasant imagery (P<0.005), but not the attention imagery group's slope, declined significantly when compared with the control group (P>0.05). There was neither a difference between the amitriptyline and placebo slopes (main effects, P=0.98) nor a significant amitriptyline x psychological interaction (P=0.76).
Pleasant imagery (PI) was an effective intervention in reducing fibromyalgic pain during the 28-day study period. Amitriptyline had no significant advantage over placebo during the study period.
Arthritis is the most prevalent chronic condition among persons age 65 and older in North America. Physical inactivity in this population is linked to functional limitations, increased risk for cardiovascular disease, diminished quality of life, and disability. The purpose of this study was to identify risk factors for inactivity.
National data for 6256 community-dwelling older adults with arthritis from the 1996-1997 Canadian National Population Health Survey were examined using logistic regression analyses. The independent variables included sociodemographic characteristics, health status, psychosocial factors, health behaviors, and medication use.
Inactive persons were significantly (P < 0.05) more likely to be women, older (75+), have functional limitations, be underweight (BMI < 20) or overweight (BMI > 25), have severe pain, or not have prescription drug insurance coverage. The same group was less likely to be unmarried, well educated, from western provinces, attend church frequently, consume alcohol infrequently, have higher levels of social support, have better self-rated health, or use pain medication.
The profile presented in this study should be fully considered by health care providers when educating patients with arthritis about the adverse health effects of sedentary behavior. Prescription drug insurance coverage may facilitate activity among elders with arthritis.
Using Martha Rogers' science of unitary human beings, changes in pain and power among 42 patients were examined in relation to the use of a guided imagery modality. Participants were randomly assigned to treatment and control groups and repeated measures MANCOVA was used to detect differences in pain and power over a 4-day period of time. The treatment group's pain decreased during the last 2 days of the study. No differences in power emerged. Guided imagery appeared to have potential as a useful nursing modality for chronic pain sufferers.
Osteoarthritis (OA) is a common, chronic condition that affects most older adults. Adults with OA must deal with pain that leads to limited mobility and may lead to disability and difficulty maintaining independence. A longitudinal, randomized clinical trial pilot study was conducted to determine whether Guided Imagery (GI) with Progressive Muscle Relaxation (PMR) would reduce pain and mobility difficulties of women with OA. Twenty-eight older women with OA were randomly assigned to either the treatment or the control group. The treatment consisted of listening twice a day to a 10-to-15-minute audiotaped script that guided the women in GI with PMR. Repeated-measures ANOVA revealed a significant difference between the two groups in the amount of change in pain and mobility difficulties they experienced over 12 weeks. The treatment group reported a significant reduction in pain and mobility difficulties at week 12 compared to the control group. Members of the control group reported no differences in pain and non-significant increases in mobility difficulties. The results of this pilot study justify further investigation of the effectiveness of GI with PMR as a self-management intervention to reduce pain and mobility difficulties associated with OA.
The purpose of this study is to determine how verbal descriptions of pain change with the use of a guided imagery technique. A mixed method, concurrent nested design was used. Participants in the treatment group used the guided imagery technique over a consecutive 4-day period, and those in the control group were monitored. Verbal descriptions of pain were obtained before randomization and at four daily intervals. A total of 210 pain descriptions were obtained across the five time points. Data were analyzed using content analysis. Six categories emerged from the data: pain is never-ending, pain is relative, pain is explainable, pain is torment, pain is restrictive, and pain is changeable. For participants in the treatment group, pain became changeable. The meaning of pain as never-ending was a prominent theme for participants before randomization to treatment and control groups. It remained a strong theme for participants in the control group throughout the 4-day study period; however, pain as never-ending did not resurface for participants in the treatment group.
To update the projected prevalence of self-reported, doctor-diagnosed arthritis and arthritis-attributable activity limitations among US adults ages 18 years and older from 2005 through 2030.
Baseline age- and sex-specific prevalence rates of arthritis and activity limitation, using the latest surveillance case definitions, were estimated from the 2003 National Health Interview Survey, which is an annual, cross-sectional, population-based health interview survey of approximately 31,000 adults. These estimates were used to calculate projected arthritis prevalence and activity limitations for 2005-2030 using future population projections obtained from the US Census Bureau.
The prevalence of self-reported, doctor-diagnosed arthritis is projected to increase from 47.8 million in 2005 to nearly 67 million by 2030 (25% of the adult population). By 2030, 25 million (9.3% of the adult population) are projected to report arthritis-attributable activity limitations. In 2030, >50% of arthritis cases will be among adults older than age 65 years. However, working-age adults (45-64 years) will account for almost one-third of cases.
By 2030, the number of US adults with arthritis and its associated activity limitation is expected to increase substantially, resulting in a large impact on individuals, the health care system, and society in general. The growing epidemic of obesity may also significantly contribute to the future burden of arthritis. Improving access and availability of current clinical and public health interventions aimed at improving quality of life among persons with arthritis through lifestyle changes and disease self-management may help lessen the long-term impact.
Regular physical activity in persons with arthritis has been shown to decrease pain, improve function, and delay disability. This study estimates the national prevalence of leisure-time physical activity and identifies factors associated with physical inactivity in adults with arthritis.
Data from the 2002 National Health Interview Survey were analyzed in 2004-2005 to estimate the proportion of adults with arthritis meeting four physical activity recommendations put forward in Healthy People 2010 and one arthritis-specific recommendation established by a national expert panel in arthritis and physical activity. Multivariate logistic regression was used to evaluate the association between inactivity and sociodemographic factors, body mass index, functional limitations, social limitations, need for special equipment, frequent anxiety/depression, affected joint location, joint pain, physical activity counseling, and access to a fitness facility.
Adults with arthritis were significantly less likely than adults without arthritis to engage in recommended levels of moderate or vigorous physical activity, and 37% of adults with arthritis were inactive. In both men and women with arthritis, inactivity was associated with older age, lower education, and having functional limitations; having access to a fitness facility was inversely associated with inactivity. Among women, inactivity was also associated with being Hispanic, non-Hispanic black, having frequent anxiety/depression or social limitations, needing special equipment, and not receiving physical activity counseling. Among men, inactivity was also associated with severe joint pain.
Although physical activity is a recommended therapy for people with arthritis, levels among adults with arthritis are insufficient, and those with arthritis have worse activity profiles than their peers without arthritis. Efforts to promote physical activity should include expanding access to evidence-based interventions and recreational facilities/programs. The importance of physical activity counseling and associated pain management measures by healthcare providers should be emphasized.
Osteoarthritis (OA) is the most common cause of disability in older adults, which, in turn, leads to poor quality of life (QOL). Disability is caused primarily by the joint degeneration and pain associated with OA. A randomized pilot study was conducted to test the effectiveness of guided imagery with relaxation (GIR) to improve health-related QOL (HRQOL) in women with OA. A two-group (intervention versus control) longitudinal design was used to determine whether GIR leads to better HRQOL in these individuals and whether improvement in HRQOL could be attributed to intervention-associated improvements in pain and mobility. Twenty-eight women were randomized to either the GIR intervention or the control intervention group. Using GIR for 12 weeks significantly increased women's HRQOL in comparison to the women who used the control intervention, even after statistically adjusting for changes in pain and mobility. These findings suggest that the effects of GIR on HRQOL are not limited to improvements in pain and mobility. GIR may be an easy-to-use self-management intervention to improve the QOL of older adults with OA.
To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by arthritis overall, rheumatoid arthritis, juvenile arthritis, the spondylarthritides, systemic lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. A companion article (part II) addresses additional conditions.
The National Arthritis Data Workgroup reviewed published analyses from available national surveys, such as the National Health and Nutrition Examination Survey and the National Health Interview Survey (NHIS). For analysis of overall arthritis, we used the NHIS. Because data based on national population samples are unavailable for most specific rheumatic conditions, we derived estimates from published studies of smaller, defined populations. For specific conditions, the best available prevalence estimates were applied to the corresponding 2005 US population estimates from the Census Bureau, to estimate the number affected with each condition.
More than 21% of US adults (46.4 million persons) were found to have self-reported doctor-diagnosed arthritis. We estimated that rheumatoid arthritis affects 1.3 million adults (down from the estimate of 2.1 million for 1995), juvenile arthritis affects 294,000 children, spondylarthritides affect from 0.6 million to 2.4 million adults, systemic lupus erythematosus affects from 161,000 to 322,000 adults, systemic sclerosis affects 49,000 adults, and primary Sjögren's syndrome affects from 0.4 million to 3.1 million adults.
Arthritis and other rheumatic conditions continue to be a large and growing public health problem. Estimates for many specific rheumatic conditions rely on a few, small studies of uncertain generalizability to the US population. This report provides the best available prevalence estimates for the US, but for most specific conditions, more studies generalizable to the US or addressing understudied populations are needed.
To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by osteoarthritis, polymyalgia rheumatica and giant cell arteritis, gout, fibromyalgia, and carpal tunnel syndrome, as well as the symptoms of neck and back pain. A companion article (part I) addresses additional conditions.
The National Arthritis Data Workgroup reviewed published analyses from available national surveys, such as the National Health and Nutrition Examination Survey and the National Health Interview Survey. Because data based on national population samples are unavailable for most specific rheumatic conditions, we derived estimates from published studies of smaller, defined populations. For specific conditions, the best available prevalence estimates were applied to the corresponding 2005 US population estimates from the Census Bureau, to estimate the number affected with each condition.
We estimated that among US adults, nearly 27 million have clinical osteoarthritis (up from the estimate of 21 million for 1995), 711,000 have polymyalgia rheumatica, 228,000 have giant cell arteritis, up to 3.0 million have had self-reported gout in the past year (up from the estimate of 2.1 million for 1995), 5.0 million have fibromyalgia, 4-10 million have carpal tunnel syndrome, 59 million have had low back pain in the past 3 months, and 30.1 million have had neck pain in the past 3 months.
Estimates for many specific rheumatic conditions rely on a few, small studies of uncertain generalizability to the US population. This report provides the best available prevalence estimates for the US, but for most specific conditions more studies generalizable to the US or addressing understudied populations are needed.
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
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