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Psychologic Interventions and Lifestyle Modifications for Arthritis Pain Management

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Abstract

This article provides an overview of self-management interventions used to manage pain in patients who have arthritis. The article is divided in two major sections. The first section reviews psychologic interventions used to manage arthritis pain, including pain-coping skills training and cognitive behavioral therapy for pain management, emotional disclosure interventions, and partner-assisted interventions. The second section addresses lifestyle behavioral weight loss interventions used to reduce arthritis pain. In each section, the authors briefly describe the rationale and nature of the interventions, present data on their efficacy, and highlight potential future research directions.

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... The current evidence-based, and most commonly implemented intervention in the United Kingdom is an interdisciplinary pain management programme, incorporating both cognitive and behavioural strategies (Scottish Intercollegiate Guidelines Network (SIGN), 2013; British Pain Society (BPS), 2013). Despite this, the National Pain Audit carried out by the Chief Medical Officer for England (Price et al, 2012) reported only 40% of pain services in England met these interdisciplinary requirements Relaxation skills, such as progressive muscle relaxation (Benson et al, 1974), are commonly taught as a component of these programmes (Keefe et al, 2008;Hasset and Gevirtz, 2009;Jensen 2011). However, on inspection of the findings from Savigny et al (2009) and the Cochrane collaboration (Henschke, 2010), who inform clinical guidelines in this area, there appears to be minimal evidence as to why these have traditionally been included, nor is there clarity as to which method of relaxation is most effective (Jensen, 2011). ...
... Patients suffering from chronic non-malignant pain have reported changes in social status, job loss and a resultant impact on their finances, which can have a negative effect on both them and their families, leading to an estimated 49% of these patients in the UK experiencing depression (Donaldson 2008). This impahas contributed to a need for rehabilitation to become both multifaceted and multidisciplinary, to address the physical, psychological and social impact of the condition (Keefe et al, 2008;Hassett and Gevirtz, 2009). ...
... Interdisciplinary pain management programmes have been shown to be the most effective intervention for the management of chronic non-malignant pain (Keefe et al, 2008;BPS, 2013;SIGN, 2013). ...
Article
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Background/Aims: Chronic non-malignant pain is a global condition with a complex biopsychosocial impact on the sufferers. Relaxation skills are commonly included as part of a pain management programme, which is currently the recommended evidence-based intervention for this group of patients. However, there is little evidence behind the choice of relaxation method implemented, or their effectiveness. The aim of this study was to investigate the effectiveness of relaxation skills in the management of chronic non-malignant pain, related to pain intensity and health-related quality of life. Methods: A systematic literature review was conducted using MEDLINE, CINAHL, AMED, PEDro and PsycARTICLES. The Cochrane, DARE and Trip databases were also accessed, and searches were carried out using the terms (relaxation OR relaxation therapy OR relaxation training) AND (pain OR chronic pain). Findings: Following critical appraisal, ten studies met the inclusion criteria. Three studies reported a decrease in pain intensity as a result of the relaxation intervention, while only one study reported an improvement in health-related quality of life. Progressive muscle relaxation was the most commonly implemented method throughout, although its method of delivery differed between studies. Conclusions: There is little evidence for the use of relaxation as a stand-alone intervention for pain intensity and health-related quality of life for patients with musculoskeletal chronic non-malignant pain. More research is needed to determine its effectiveness.
... We piloted an mHealth behavioral cancer pain intervention that capitalizes on the advantages of technologies by increasing the reach of the intervention and potentially enhancing intervention efficacy. Our work builds on and extends work done by Keefe et al. 18,19 that has developed and tested pain coping skills training (PCST) protocols for patients with chronic disease. PCST was designed to help patients with persistent pain acquire mastery of skills that can enhance their pain management. ...
... After the intervention, participants reported significantly decreased pain severity (t ¼ 2.92, P ¼ 0.009), physical symptoms (t ¼ 3.84, P ¼ 0.001), psychological distress (t ¼ 4.31, P < 0.001), and pain catastrophizing (t ¼ 3.15, P ¼ 0.005). There were no statistically significant changes in pain self-efficacy; however, the mean score on pain self-efficacy did increase (M ¼ 58.08, SD ¼ 17.17 vs. M ¼ 62.57, SD ¼ 13.82, t ¼ À1.34, P ¼ 0. 19). ...
Article
Pain coping skills training (PCST) interventions have shown efficacy for reducing pain and providing other benefits in patients with cancer. However, their reach is often limited because of a variety of barriers (e.g., travel, physical burden, cost, time). This study examined the feasibility and acceptability of a brief PCST intervention delivered to patients in their homes using mobile health (mHealth) technology. Pre-to-post intervention changes in pain, physical functioning, physical symptoms, psychological distress, self-efficacy for pain management, and pain catastrophizing also were examined. Patients with a diagnosis of breast, lung, prostate, or colorectal cancer who reported persistent pain (N=25) participated in a four-session intervention delivered using mHealth technology (video-conferencing on a tablet computer). Participants completed measures of pain, physical functioning, physical symptoms, psychological distress, self-efficacy for pain management, and pain catastrophizing. We also assessed patient satisfaction. Participants completed an average of 3.36 (SD=1.11) of the four intervention sessions for an overall session completion rate of 84%. Participants reported that the program was of excellent quality and met their needs. Significant pre- to post-intervention differences were found in pain, physical symptoms, psychological distress, and pain catastrophizing. The use of mHealth technology is a feasible and acceptable option for delivery of PCST for patients with cancer. This delivery mode is likely to dramatically increase intervention access for cancer patients with pain compared to traditional in-person delivery. Preliminary data also suggest that the program is likely to produce pre- to post-treatment decreases in pain and other important outcomes. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
... Self-efficacy beliefs of patients (that they can manage their pain) and the actual use of pain-coping strategies influence pain experiences and also the impact of pain on physical function and psychological distress (Keefe et al., 2008). Several studies have shown that pain-coping skills training and cognitive behavioral therapy can be successful in reducing pain. ...
... Several studies have shown that pain-coping skills training and cognitive behavioral therapy can be successful in reducing pain. Furthermore, it has been shown that these interventions also lead to improvements in anxiety, depression, and physical function (Keefe et al., 2008). ...
Article
Rheumatoid Arthritis (RA) is a chronic inflammatory disease, which is accompanied by swollen and painful joints, fatigue and limitations in physical functioning. Psychological reactions to disease symptoms and related attitudes and psychological characteristics of patients clearly influence the impact of disease symptoms on psychological distress and well-being, on daily activities and on social participation. In addition to pharmacological treatment of disease activity, regular monitoring of patient-reported symptoms and timely psychological stepped care approaches seem the best way to support and empower patients to successfully adapt to RA and to live a meaningful life with RA.
... The gating of pain signals is thought to be controlled by both peripheral input and the neural centers that govern thoughts, emotions and behaviors [1]. Gate-control theory explains why certain factors such as depression and anxiety worsen the experience of pain, while other factors like active coping, positive affect, and social support moderate the experience of pain [2]. ...
Article
Because of the dynamic and complex nature of chronic pain, successful treatment usually requires addressing behavioral, cognitive, and affective processes. Many adjunctive interventions have been implemented in fibromyalgia (FM) treatment, but few are supported by controlled trials. Herein, some of the more commonly used nonpharmacologic interventions for FM are described and the evidence for efficacy is presented. Clinical observations and suggestions are also offered, including using the principles outlined in the acronym ExPRESS to organize a comprehensive nonpharmacologic pain management approach.
... This strong evidence dissects organic beliefs from psychological beliefs for their respective influence on functioning. Furthermore, this study's contribution is consistent with the current literature that the transition from acute to persistent pain is associated with cognitive-affective factors (such as negative beliefs and low self-efficacy)56575859. Beliefs contribute to the formation of an individual's perception of reality. ...
Article
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Pain beliefs influence understanding of pain mechanisms and outcomes. This study in rheumatologic conditions sought to determine a relationship between beliefs about pain and functioning. Participants in Arthritis New Zealand's (ANZ) exercise and education programmes were used. Demographic data and validated instruments used included the Arthritis Impact Measurement Scale 2nd version-Short Form (AIMS2-SF) to measure functioning, and two scales of organic and psychological beliefs in Pain Beliefs Questionnaires (PBQ) to measure pain beliefs. 236 Members of ANZ were surveyed anonymously with AIMS2-SF and PBQ, with a 61% response rate; 144 responses were entered into the database. This study used α of 0.05 and a 1-β of 0.8 to detect for significant effect size estimated to be r = 0.25. Analysis revealed a significant relationship between organic beliefs scale of PBQ and functioning of AIMS2-SF, with an r value of 0.32 and P value of 0.00008. No relationship was found between psychological beliefs scale of PBQ and AIMS2-SF. Organic pain beliefs are associated with poorer functioning. Psychological pain beliefs are not. Beliefs might have been modified by ANZ programmes. Clinicians should address organic pain beliefs early in consultation. Causal links between organic pain beliefs and functioning should be clarified.
... Research has found that patients' capacity to manage their own pain is directly related to how they perceive their own ability to control their pain. Keefe et al. (2008) concluded that self-management of pain succeeds in part because patients believe that they can control their own pain. The National Institute of Medicine stated in 2011 that "Pain beliefs correlate with outcomes." ...
Article
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The argument is made that design does not stop when the fixed architectural and acoustical components are in place. Spaces live and breathe with the people who reside in them. Research and examples are presented that show that noise, auditory clutter, thrives on itself in hospitals. Application of the Lombard reflex studies fit into the hospital setting, but do not offer solutions as to how one might reduce the impact. In addition, the basis for looking at the noise component as a physical as well cultural dynamic will be addressed. Whether the result of the wrong conversation in the wrong place or the right conversation in an unfortunate place, talk mixed with sounds of technology is shown to cause its own symptoms. From heightened anxiety and stress to medical errors, staff burnout, or HIPAA violations, the case is made that noise is pandemic in hospitals and demands financial and operational investment. An explanation of how to reduce noise by design of the dynamic environment - equipment, technology, staff protocols is also provided.
... Psychological interventions and lifestyle modifications in arthritis have recently been reviewed. 45 An example of an effective biobehavioural intervention in chronic pain is Mindfulnessbased stress reduction (MBSR). An eight week out-patient programme teaching patients mindfulness practices to enhance self-regulation has been used effectively for symptom reduction in chronic pain conditions, with 3-year follow up showing maintenance of gains. ...
Article
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Chronic musculoskeletal disease is one of the most common causes of disability worldwide with considerable economic impact in health care. Osteoarthritis (OA) is the most common chronic musculoskeletal disease affecting a large proportion of the population with an increasing predicted prevalence in the next two decades. Regular physical exercise, nutritional intervention, psychological support and other lifestyle interventions are very important components of the non- pharmacological management of patients with OA. The main rationale to include regular exercise as part of a lifestyle intervention programme for OA is to improve muscle strength and proprioception, and to promote the other general health benefits of participating in regular physical activity. Nutritional intervention should focus on weight reduction while basic nutrients that are required for healthy joints should be provided. Glucosamine and chondroitin supplemention is commonly used and may reduce pain, improve function and reduce or arrest disease progression. Psychological intervention has a particular role in assisting with pain management.
... There are some interesting emerging data with respect to specific therapeutic interventions, especially with RA which are worthy of brief mention. (For a review of psychological interventions and lifestyle modifications in arthritis see Keefe et al 2008).41 Research has demonstrated that writing about emotionally traumatic experiences (usually for 20 minutes a day for four days) has a surprisingly beneficial effect on symptoms and immune parameters. ...
Article
Full-text available
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disorder that causes symmetrical polyarthritis of large and small joints. RA affects about 0.5–1% of the population and is more common in females than males. In recent years, it has been increasingly recognised that early diagnosis and management of RA is important to prevent joint destruction, which has been shown to occur early on in the disease process. The primary effects of the disease on joints and muscles, together with physical inactivity, usually result in diminished joint range of motion, muscle weakness, decreased endurance performance, depression, poor cardiovascular health and osteoporosis. The principles of management of RA should include non-pharmacological and pharmacological management. Non-pharmacological modalities (including lifestyle interventions) are well recognised as important components of the treatment of early arthritis, including RA. The main lifestyle interventions for RA are physical exercise, dietary intervention, psychological intervention and education. The guidelines for these lifestyle interventions in patients with RA are reviewed.
... For example, cardiovascular complications are the leading contributor to mortality in RA, [44] accounting for approximately one half of all deaths, [45] and osteoporosis resulting in bone fractures represents a major source of morbidity in RA. [46] Indeed, lifestyle behavioral modification is considered to be critical in preventing RA-associated comorbidities and their complications. [47] Tai Chi exercise may be beneficial to patients with RA as a result of its effects on muscle strength, stress reduction, cardiovascular and bone health as well as improved health-related quality of life. ...
Article
Tai chi is a complex multicomponent mind-body exercise. Many studies have provided evidence that tai chi benefits patients with a variety of chronic disorders. This form of mind-body exercise enhances cardiovascular fitness, muscular strength, balance, and physical function and seems to be associated with reduced stress, anxiety, and depression and improved quality of life. Thus, despite certain limitations in the evidence, tai chi can be recommended to patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia as a complementary and alternative medical approach. This article overviews the current knowledge about tai chi to better inform clinical decision making for rheumatic patients.
... Such non-pharmacological treatments may include cognitive behavioral therapy strategies which can assist with achieving three main components for successfully coping with pain: 1) an educational approach documenting the influence of patients' thoughts, feelings, and behaviors upon pain and pain coping; 2) training in cognitive and behavioral-coping strategies, such as with relaxation, setting appropriate goals, and cognitive restructuring; and 3) education for home-coping skills. 60 There are a number of limitations associated with our results. First, this was a small patient cohort treated at one interdisciplinary clinic -outcomes may not be generalizable to primary care clinics or other tertiary clinics. ...
Article
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Objective Catastrophizing may be a negative predictor of pain-related outcomes. We evaluated the impact of catastrophizing upon success of first-line pharmacotherapy in the management of neuropathic pain (NeP) due to peripheral polyneuropathy. Methods Patients with confirmed NeP with NeP Visual Analog Scale (VAS) pain severity score ≥4 (0–10 scale) completed the Coping Strategies Questionnaire (CSQ) catastrophizing subscale at baseline. Pharmacological therapy consisting of first-line agents gabapentin, pregabalin, or a tricyclic antidepressant was initiated. Other measures examined included the Karnofsky Performance Scale, Beck Depression Inventory, EuroQol Quality of Life Health Questionnaire, and Modified Brief Pain Inventory. At 3 and 6 months, questionnaires were repeated and adverse effect reporting was completed. Outcome measures assessed were pharmacotherapy success (≥30% relief of NeP) and tolerability over 6 months of follow-up. Bivariate relationships using Pearson product-moment correlations were examined for baseline CSQ catastrophizing subscale score and the change in the NeP VAS scores and medication discontinuation. Results Sixty-six patients were screened, 62 subjects participated, and 58 subjects (94%) completed the final follow-up visit. Greater catastrophizing was associated with poor pain relief response and greater likelihood of discontinuation of pharmacotherapy, reports of greater disability, and impaired quality of life. Duration of pain was negatively associated with likelihood of pharmacotherapy success. Conclusion Catastrophizing exerts maladaptive effects on outcomes with pharmacotherapy in NeP patients. Detection of catastrophizing during clinical visits when pharmacological therapy is being considered can be a predictive factor for patient outcomes.
... Keefe et al. [17] ...
Article
Cognitive behavioural therapy offers a good approach for the treatment of chronic pain in physiotherapy. In contrast to conventional physiotherapy the technique is short-term and goal-oriented. This review analyses and discusses the results of a single or combined cognitive behavioural therapy programme from 9 articles. As psychotherapeutic method cognitive behavioural therapy achieves a worth-while improvement of pain-related behaviour, self-efficacy, coping strategies and general physical functions. There exists moderate evidence for an additional treatment benefit when cognitive behavioural therapy aspects are part of physiotherapy intervention. A more goal-oriented and more efficient physiotherapy treatment in patients with chronic pain calls for further research.
... 602). Keefe, Somers, and Martire (2008) identified cognitive-behavioral therapy as a commonly utilized and well-evidenced treatment for chronic pain associated with arthritis. In light of the multidimensional (i.e., biopsychosocial) nature of pain, and the shortcomings of strictly biologically based approaches to treatment, it is likely that psychological interventions will be utilized with greater frequency to address chronic pain more effectively in the future. ...
Article
Researchers have begun to evaluate interventions intended to enhance hope in various populations. Chronic pain is a pervasive problem with significant psychosocial consequences. This article presents studies that examined the extent to which a hope-focused group counseling intervention enhances hope and well-being in two community-based samples of participants (N =10 and N = 24) experiencing chronic pain. A pilot study (Study 1a) and a main study (Study 1b) both used a one-group, pretest-posttest design to determine whether participants experienced changes regarding their hope, well-being, acceptance of pain, and catastrophizing of pain. Both studies showed that participants experienced numerous and significant changes from pre- to post-intervention, including improvements in well-being and pain acceptance in Study 1a and improvements in hope, well-being, and catastrophizing cognitions in Study 1b. Self-reported pain severity, assessed only in Study 1a, did not change. We discuss implications for practice, study limitations, and potential lines of hope-related inquiry for future research.
... However, several patients still experience limitations in performing daily life activities and participating in social life (Vliet Vlieland, 2003). To address such limitations, drugs are often complemented with non-pharmacological approaches, such as patient education, life-style modifications, therapeutic exercise and vocational rehabilitation (Keefe et al., 2008;Vliet Vlieland, 2003;Vliet Vlieland et al., 2009). As multiple approaches can be needed in the rehabilitation of rheumatic diseases, the best clinical practice is assumed to be delivered by a multidisciplinary team including physicians and healthcare professionals with different specialized skills and expertise (Crossland et al., 2015). ...
Conference Paper
Background Patients with rheumatic autoimmune diseases are often offered rehabilitation services by a multidisciplinary team including for example rheumatologists, nurses, dieticians, psychologists, occupational therapists (OTs), physiotherapists (PTs) and social workers (SWs). The collaboration between the team members can be challenging as professional groups may not agree about what should be emphasized or how it is best approached. Presently, we wanted to examine differences or overlaps between the rehabilitation needs identified by OTs, PTs and SWs in a clinical setting. Objectives To examine the characteristics of patients referred to OTs, PTs, and SWs and the rehabilitation needs that the health professional groups identified. Methods Consecutive hospitalized patients at a rehabilitation unit at a rheumatism hospital were recruited by the health professionals at their first encounter with the patients. They filled in a standardized questionnaire about their patients' characteristics, as well as open-ended responses to questions about what each patient said they wanted to improve, what the health professional considered needed to be emphasized and how to approach it. Descriptive statistics were used to analyze patient characteristics, and the health professionals free-text responses about rehabilitation needs were coded by the WHO's International Classification of Functioning, Disability, and Health (ICF). Results The patients were rather heterogeneous; their age varied from 20 to 89 years, disease duration varied from being newly diagnosed to have had diagnosis for 54 years, they were classified within all four categories of disability levels according to the ACR Classification of Functioning scale, they could have common and rather rare rheumatic diagnoses, and several patients had comorbidities. Together the health professional groups identified rehabilitation needs were classified within all three components of the ICF. Within the Body Function component the needs fell mostly under Chapter 7: Neuromusculoskeletal and Movement-Related Functions (OTs and PTs) and Chapter 2: Sensory Functions and Pain (PTs). Within the Activity and Participation component, needs were mostly under Chapter 2: General Tasks and Demands (OTs), Chapter 4: Mobility (OTs), Chapter 5: Self-Care (PTs), and Chapter 8: Major Life Areas (SWs). For the Environmental Factor component, all needs were classified under Chapter 1: Products of Technology (OTs) and Chapter 5: Services, Systems, and Politics (SWs). Conclusions The patients were heterogeneous with respect to personal characteristics, diagnoses, and disability levels. The most prominent concerns met by the health professionals were pain, joint and muscle function, self-care in carrying out daily routines and health promotion activities, and work-related issues. Both OTs and PTs identified rehabilitation needs classified as muscle power function, otherwise there were distinctive differences between the health professional groups. Acknowledgements Thanks to the health professionals for taking the time to collect data from their clinical practice. Disclosure of Interest None declared
... O aumento da compreensão de uma perspetiva biopsicosocial na área das doenças tem alertado para métodos de intervenção biopsicosociais, onde a farmacologia se combina com a intervenção psicológica. Por exemplo, os modelos biopsicosociais da dor crónica defendem a hipótese que as respostas de coping são variáveis chave na compreensão do modo como as pessoas se ajustam à dor (Ferreira-Valente, Pais-Ribeiro, Jensen, & Almeida, 2011; Keefe, Somers, & Martire, 2008). Podemos considerar diversos tipos variáveis passíveis de ser abordadas pela psicologia com o objectivo de reduzir a dor: variáveis psicológicas relativamente estáveis (traço). ...
... A major source of morbidity in RA is osteoporosis, which results in bone fractures. Indeed, lifestyle behavioral modification is considered to be critical in preventing RA-associated comorbidities and their complications [23]. Tai Chi exercise may be beneficial to patients with RA due to its positive effects on muscle strength, stress reduction, cardiovascular, and bone health, as well as health-related quality of life. ...
Article
Rheumatologic diseases (e.g., fibromyalgia, osteoarthritis, and rheumatoid arthritis) consist of a complex interplay between biologic and psychological aspects, resulting in therapeutically challenging chronic conditions to control. Encouraging evidence suggests that Tai Chi, a multi-component Chinese mind-body exercise, has multiple benefits for patients with a variety of chronic disorders, particularly those with musculoskeletal conditions. Thus, Tai Chi may modulate complex factors and improve health outcomes in patients with chronic rheumatologic conditions. As a form of physical exercise, Tai Chi enhances cardiovascular fitness, muscular strength, balance, and physical function. It also appears to be associated with reduced stress, anxiety, and depression, as well as improved quality of life. Thus, Tai Chi can be safely recommended to patients with fibromyalgia, osteoarthritis, and rheumatoid arthritis as a complementary and alternative medical approach to improve patient well-being. This review highlights the current body of knowledge about the role of this ancient Chinese mind-body medicine as an effective treatment of rheumatologic diseases to better inform clinical decision-making for our patients.
... The progression of RA is variable [65,66]. Although the advent of biologic therapy has improved patients prognosis substantially, patient management remains a multidisciplinary approach with lifestyle modifications playing a major role [67,68]. ...
Article
Physical activity, by definition, is any skeletal muscle body movement that results in energy expenditure. In the last few decades, a plethora of scientific evidences have accumulated and confirmed the beneficial role of physical activity as a modifiable risk factor for a wide variety of chronic diseases including cardiovascular diseases (CVDs), diabetes mellitus and cancer, among others. Autoimmune diseases are a heterogeneous group of chronic diseases, which occur secondary to loss of self-antigen tolerance. With the advent of biological therapies, better outcomes have recently been noted in the management of autoimmune diseases. Nonetheless, recent research highlights the salient role of modifiable behaviors such as physical inactivity on various aspects of the immune system and autoimmune diseases. Physical activity leads to a significant elevation in T-regulatory cells, decreased immunoglobulin secretion and produces a shift in the Th1/Th2 balance to a decreased Th1 cell production. Moreover, physical activity has been proven to promote the release of IL-6 from muscles. IL-6 released from muscles functions as a myokine and has been shown to induce an anti-inflammatory response through IL-10 secretion and IL-1β inhibition. Physical activity has been shown to be safe in most of autoimmune diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), multiple sclerosis (MS), inflammatory bowel diseases (IBD), as well as others. Additionally, the incidence of RA, MS, IBD and psoriasis has been found to be higher in patients less engaged in physical activity. As a general trend, patients with autoimmune diseases tend to be less physically active as compared to the general population. Physically active RA patients were found to have a milder disease course, better cardiovascular disease (CVD) profile, and improved joint mobility. Physical activity decreases fatigue, enhances mood, cognitive abilities and mobility in patients with MS. In SLE patients, enhanced quality of life and better CVD profile were documented in more physically active patients. Physically active patients with type 1 diabetes mellitus have a decreased risk of autonomic neuropathy and CVD. Both fibromyalgia and systemic sclerosis patients report decreased disease severity, pain, as well as better quality of life with more physical activity. Further, SSc patients improve their grip strength, finger stretching and mouth opening with increased level of exercise. The purpose of this paper is to review the clinical evidence regarding the safety, barriers to engagement, and impact of physical activity on autoimmune diseases.
... In addition, with the move away from the traditional biomedical model, which has been proven to be inadequate with poor concordance between pain, disability and pathology [9], towards a biopsychosocial model [10], there has been a greater recognition of the psychosocial factors in knee OA [11,12]. As a result, the use of psychosocial interventions in the management of OA has gained popularity over the past two decades with many multidisciplinary knee OA programs now including psychosocial elements in combination with lifestyle interventions, augmenting traditional pharmacological and surgical treatments [13]. A substantial variation exists in the delivery of such programs including the mode (face-to-face, telephone, internet), audience (group, individual), duration, frequency and personnel delivering the intervention. ...
Article
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Knee osteoarthritis (OA) causes pain, disability and poor quality of life in the elderly. The primary aim was to identify and map out the current evidence for randomised controlled trials (RCTs) on complex lifestyle and psychosocial interventions for knee OA. The secondary aim was to outline different components of complex lifestyle and psychosocial interventions. Our scoping review searched five databases from 2000 to 2021 where complex lifestyle or psychosocial interventions for patients with knee OA were compared to other interventions. Screening and data extraction were performed by two review authors independently and discrepancies resolved through consensus and in parallel with a third reviewer. A total of 38 articles were selected: 9 studied the effectiveness of psychological interventions; 11 were on self-management and lifestyle interventions; 18 looked at multifaceted interventions. This review highlights the substantial variation in knee OA interventions and the overall lack of quality in the current literature. Potential areas of future research, including identifying prognostic social factors, stratified care models, transdisciplinary care delivery and technology augmented interventions, have been identified. Further high-quality RCTs utilizing process evaluations and economic evaluation in accordance with the MRC guidelines are critical for the development of evidence-based knee OA programs globally.
... Despite advances in the pharmacologic and interventional management of arthritis, there still remains a large role for adjunctive, behavioral strategies to improve self-efficacy, physical function, and HRQOL [83]. Self-management strategies, MBIs, and CBTs are evidenced-based treatments that may be implemented in those with arthritis and are offered in a variety of formats including office-and Internet-based settings. ...
Article
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Purpose of review There is increasing evidence that adjunctive, non-pharmacologic treatment programs are beneficial in the management of arthritis when added to traditional disease-modifying medications. This review focuses on non-pharmacologic management strategies that impact pain and affect, with a focus on self-efficacy, for those with osteoarthritis (OA) and rheumatoid arthritis (RA). Recent findings We reviewed both office-based and internet-based self-management strategies, mindfulness-based interventions (MBIs), and cognitive behavioral therapies (CBTs) for patients with arthritis. These behavioral strategies have shown to improve pain, mood disturbance, and physical function in those with both osteoarthritis and rheumatoid arthritis. Improvements in self-efficacy and coping capacity are associated with improvements in patient-reported outcomes (PROs) related to pain and functioning. Summary Self-management programs, MBIs, and CBTs are more effective at improving pain and mood disturbance compared to usual care for patients with arthritis although high-quality randomized controlled trials are lacking. Non-pharmacologic management programs are increasingly available via the Internet and mobile applications.
... Research has found that patients' capacity to manage their own pain is directly related to how they perceive their own ability to control their pain. Keefe et al. (2008) concluded that self-management of pain succeeds in part because patients believe that they can control their own pain. The National Institute of Medicine stated in 2011 that "Pain beliefs correlate with outcomes." ...
Article
Full-text available
With the continuing opioid epidemic, there is an urgent call for alternatives to narcotics and other addictive medications. Historically, pain theories have moved through the many stages of medicine, predating the scientific method and following through past Descartes declaration that the mind and the body do not influence each other. This article reviews pain theories and practices moving into the era of the Patient Experience, multi-modal strategies for mitigating suffering, and the impact of the patient's environment and social/cultural milieu informing and supporting the patient's own capacity to cope and manage pain. Methods: A broad review was done of studies and critiques that bring together the historic and current attitudes and beliefs about pain, social-ethnic-racial assumptions, to evaluate the state of pain management as medication-driven solutions begin to fail as first options. In addition, the dominant role of mean-making and caregiver beliefs is discussed as they become more relevant in seeking alternatives to opioids. Conclusion: I). The debate regard what exactly pain is continues to be between the physical or biochemical domain and the mental-emotional-cognitive domain that brings meaning to the experience. II) The Patient Experience of pain is lived rather than theorized, and is known fully only by the patient and is a private experience informed by the unique circumstances and history of each patient. III) The merging of neurological and psychological factors in pain management is well documented but not optimized in strategizing effective pain control methods. IV) Additional studies are needed to better understand the balance between psychological-social-and-clinical factors to arrive at more effective strategic processes in pain reduction. Keywords: patient experience, pain management, placebo and nocebo response, the meaning response, biopsychosocial factors in pain management, distraction therapy PAIN EXPERIENCE 77 REVIEW
... The rapidly growing numbers of older adults with persistent pain disorders (e.g., painful arthropathies and back pain) may be a particularly appropriate target population (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002) for intervention studies. Environmental volunteering could be tested as a method of addressing the social isolation that often occurs as a consequence of pain (Smith, Hopton, & Chambers, 1999), as well as helping to preserve physical functioning (Reid, Williams, & Gill, 2005) and mitigate pain levels via distraction and increased social support (Keefe, Somers, & Martire, 2008). ...
Article
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This study tested the hypothesis that volunteering in environmental organizations in midlife is associated with greater physical activity and improved mental and physical health over a 20-year period. The study used data from two waves (1974 and 1994) of the Alameda County Study, a longitudinal study of health and mortality that has followed a cohort of 6,928 adults since 1965. Using logistic and multiple regression models, we examined the prospective association between environmental and other volunteerism and three outcomes (physical activity, self-reported health, and depression), with 1974 volunteerism predicting 1994 outcomes, controlling for a number of relevant covariates. Midlife environmental volunteering was significantly associated with physical activity, self-reported health, and depressive symptoms. This population-based study offers the first epidemiological evidence for a significant positive relationship between environmental volunteering and health and well-being outcomes. Further research, including intervention studies, is needed to confirm and shed additional light on these initial findings.
... 4 The use of analgesics, either steroid or non-steroid, is associated with such adverse side effects as gastrointestinal complications. 5 Therefore, non-medicinal treatments including psychological and lifestyle interventions, 6 as well as cognitive-behavioral therapy 7 have been considered for pain management in patients with RA. ...
Article
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Objective: Previous studies reported the reduction of pain following eye movement desensitization and reprocessing (EMDR) and guided imagery; however, the effectiveness of these modalities was not compared. The current study aimed to compare the effects of EMDR and guided imagery on pain severity in patients with rheumatoid arthritis. Material and methods: In this randomized controlled trial, 75 patients were selected using non-random method, and then allocated into two intervention groups and one control group. Interventions were conducted individually in six consecutive sessions for the intervention groups. The Rheumatoid Arthritis Pain Scale was used for data collection before and after the interventions. Collected data were analyzed with descriptive and inferential statistics in SPSS. Significance level was considered at P<0.05. Results: The post-intervention mean scores of physiological, affective, sensory-discriminative, and cognitive pain sub-scales for patients in guided imagery group were 16.3±2.2, 13.9±2.2, 30.6±3.4, and 23.2±3, respectively. The post-intervention mean scores of these sub-scales in the EMDR group were 22±1.5, 18.1±1.8, 39.6±2.8, and 29±1.8, respectively. A significant difference was observed in the mean pain score between EMDR and guided imagery groups, and also between each intervention group and the control group (P=0.001). Conclusion: Guided imagery and EMDR could reduce pain in rheumatoid arthritis, but pain reduction was more following the EMDR than guided imagery.
... However, several patients still experience limitations in performing daily life activities and participating in social life (Vliet Vlieland, 2003). To address such limitations, drugs are often complemented with non-pharmacological approaches like patient education, life-style modifications, therapeutic exercise, and vocational rehabilitation (Keefe et al., 2008;Vliet Vlieland, 2003;Vliet Vlieland et al., 2009). As multiple approaches can be needed in rehabilitation of rheumatic diseases, the best clinical practice is assumed to be delivered by a multidisciplinary team including physicians and health care professionals with different specialized skills and expertise (Crossland et al., 2015). ...
Article
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Objective: The aim of the present study was to examine the characteristics of patients referred to occupational therapists (OTs), physiotherapists (PTs) and social workers (SWs) at a rehabilitation unit in a hospital specializing in rheumatology, and the rehabilitation needs that clinicians and patients agreed should be addressed in the encounters with the particular health professional groups. Methods: Consecutive hospitalized patients at a rheumatism hospital were recruited by the health professionals. Questions about patient characteristics and rehabilitation needs were posed. Free-text responses to questions about rehabilitation needs were coded by the International Classification of Functioning, Disability, and Health (ICF). Results: The patients varied considerably in age distribution, disease duration, disability level and diagnoses, and several patients had comorbidities. The rehabilitation needs classified under the component Body Function fell into the chapters: Sensory Functions and Pain (PTs), Functions of Cardiovascular System (PTs), Neuromusculoskeletal and Movement-Related Functions (OTs, PTs); under the Activity and Participation component, these were: General Tasks and Demands (OTs), Mobility (OTs), Self-Care (PTs), Interpersonal Interactions and Relationships (SWs) and Major Life Stress (SWs); and under the Environmental Factors component these were: Products and Technology (OTs) and Services, Systems and Politics (SWs). Conclusions: The patients were fairly heterogeneous. The needs identified in the encounters with the different professional groups fell into all three components of the ICF, and there was only a minor overlap between the health professionals at the chapter level of the ICF.
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OBJECTIVE:: There is relatively little research on important patient-reported outcomes that affect quality of life in systemic sclerosis (SSc) and even less research on psychological, behavioral, and educational intervention strategies. The objective was to review existing evidence and to develop a consensus research agenda for behavioral health and psychological research in SSc. METHODS:: An international panel of recognized experts in behavioral and psychological health in SSc, rheumatologists, patients, and patient advocates was convened to identify areas of concern for patients with SSc and to develop a research agenda. As part of this process, the PubMed and PsychInfo databases were searched from inception for the keywords "scleroderma" in conjunction with keywords related to each identified topic area. All relevant original and review articles were examined. RESULTS:: Key areas where behavioral health and psychological approaches may be useful to assess and improve quality of life in SSc include depression, fatigue, pain, pruritus, body image distress, and sexual function. Less researched areas that warrant attention include sleep, fear of disease progression and dependency, family and couples relationships, and healthcare factors. CONCLUSION:: Qualitative and quantitative studies are needed to (1) develop and evaluate assessment tools for SSc patient-reported outcomes; (2) assess potential causal and maintaining factors, as well as trajectories, of important problems faced by patients; and (3) develop and test psychological, behavioral, and educational interventions to reduce distress and increase overall well-being. Collaborative approaches that include multiple centers and that actively involve patients and patient advocates in the research process are needed.
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Large descriptive studies of pain in systemic sclerosis (SSc) are lacking. The present study estimated prevalence, severity, and associations between SSc clinical variables and pain in all patients with SSc and in limited cutaneous (lcSSc) and diffuse cutaneous (dcSSc) subsets. Patients enrolled in a multicenter SSc registry (n = 585) completed a standardized clinical assessment and questionnaires about their physical and psychosocial health, including a pain severity numerical rating scale (NRS; range 0-10). Pain prevalence and severity were estimated with descriptive statistics. Crude and adjusted associations between specific SSc clinical variables and pain were estimated with linear regression for the entire group and by SSc subtype. Of the patients, 484 (83%) reported pain (268 [46%] mild pain [NRS 1-4], 155 [27%] moderate pain [NRS 5-7], and 61 [10%] severe pain [NRS 8-10]). More frequent episodes of Raynaud's phenomenon, active ulcers, worse synovitis, and gastrointestinal (GI) symptoms were associated with pain in multivariate analysis adjusting for demographic variables, depressive symptoms, and comorbid conditions. Patients with dcSSc reported only slightly higher mean +/- SD pain than those with lcSSc (dcSSc 3.9 +/- 2.8 versus lcSSc 3.4 +/- 2.7; Hedges's g = 0.18, P = 0.05). Regression estimates did not differ significantly between SSc subsets. Pain symptoms were common in the present study of patients with SSc and were independently associated with more frequent episodes of Raynaud's phenomenon, active ulcers, worse synovitis, and GI symptoms. Subsetting by extent of skin involvement was only minimally related to pain severity and did not affect associations with clinical variables. More attention to pain and how to best manage it is needed in SSc.
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To systematically review the research findings regarding the associations between psychosocial factors and adjustment to chronic pain in persons with physical disabilities. A key word literature search was conducted using articles listed in PubMed, PsychInfo, and CINAHL up to March 2010, and manual searches were made of all retrieved articles to identify published articles that met the review inclusion criteria. To be included in the review, articles needed to (1) be written in English, (2) include adults with a physical disability who report having pain, (3) include at least 1 measure of a psychosocial predictor domain, (4) include at least 1 criterion measure of pain or patient functioning, and (5) report the results of associations between the psychosocial factors and criterion measures used in the study. Twenty-nine studies met the inclusion criteria. Three reviewers tabulated study details and findings. The disability groups studied included spinal cord injury (SCI), acquired amputation, cerebral palsy (CP), multiple sclerosis (MS), and muscular dystrophy (MD). Psychosocial factors were shown to be significantly associated with pain and dysfunction in all disability groups. The psychosocial factors most closely associated with pain and dysfunction across the samples included (1) catastrophizing cognitions; (2) task persistence, guarding, and resting coping responses; and (3) perceived social support and solicitous responding social factors. Pain-related beliefs were more strongly associated with pain and dysfunction in the SCI, CP, MS, and MD groups than in the acquired amputation group. The findings support the importance of psychosocial factors as significant predictors of pain and functioning in persons with physical disabilities. Clinical trials to test the efficacy of psychosocial treatments for pain and dysfunction are warranted, as are studies to determine whether psychosocial factors have a causal influence on pain and adjustment in these populations.
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Stress reduction interventions can have a positive therapeutic effect in autoimmune disease patients. Physicians and patients must recognize the potential for stress to impact autoimmune diseases and how stress management should be considered in a multidimensional treatment approach. This article evaluates the effects of stress as a trigger and a modulator, and stress reduction as a treatment option in rheumatoid arthritis.
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Musculoskeletal problems are the most common cause of restriction in daily life in most countries. Most health care for musculoskeletal problems is provided in primary care settings, and back pain and joint problems together represent the largest workload of cases of chronic disease seen and managed there. This article reflects on aspects of the occurrence, natural history, prognosis, and management of common joint problems in primary care. Although the biomedical model has contributed to major advances, a model that embraces chronic pain management and its psychological and social components is needed. In particular, primary care is the ideal arena to achieve high-impact secondary prevention of pain and disability in people with osteoarthritis. Physical therapists are in a crucial position in primary care to provide support for self-management of this condition, especially for interventions related to exercise and behavioral change.
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Arthritis pain has traditionally been evaluated from a biomedical perspective, but there is increasing evidence that psychological factors have an important role in patients' adjustment to arthritis pain. The evolution of pain theories has led to the development of models, such as the cognitive-behavioral model, which recognize the potential involvement of psychological factors in pain. Emotional, cognitive, behavioral and social context variables are useful in understanding pain in patients with arthritis, and have led to the development of psychological approaches for treating arthritis pain. These include pain coping skills training, interventions that include patients' partners, and emotional disclosure strategies.
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The incidence of depression accompanying medical pathologies is elevated and have prognostic importance. To determine the frequency of depression in patients with systemic autoimmune diseases (SAD), as well as to determine the frequency of pain, fatigue and sleep disorders in these patients and their relation with depression. We performed a descriptive, prospective study on 88 patients with AID. The CES-D depression questionnaire, FSS fatigue questionnaire and the Pittsburgh sleep quality index were administered. 69% (n=61) of patients were depressed. Pain was found in 97% (59/61) of depressed patients and in 62% (17/27) of non-depressed patients (P=.0006). Sleep disorders were found in 95% of depressed patients, whereas 60% of non-depressed patients presented them (P=.00008). Depression was associated with fatigue: 80% (49/61) for depressed and 44% for non-depressed (p=0,001) persons. A very elevated prevalence of depression was found in SAD: 69%; constituting the most frequent comorbidity. Depression was significantly associated with pain, fatigue and sleep disorders.
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Unlabelled: Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain; and 2) learning to manage pain through actions and thoughts. Perspective: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing.
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The past 60 years has witnessed major changes in the way that pain is conceptualized and treated. In the 1950s, pain was generally conceptualized using a sensory model that maintained that pain is a simple sensory event that warned of tissue damage. Treatments for pain were biomedical and consisted mainly of attempts to identify underlying tissue damage and treat it medically or surgically. In the 1960s, clinicians and researchers expressed growing dissatisfaction with the sensory model of pain. In particular, it became increasingly clear that the sensory model failed to explain phenomena often seen in patients experiencing chronic pain: pain persisting despite multiple medical and surgical treatments aimed at correcting underlying tissue damage, reports of pain showing poor correlation with underlying evidence of tissue damage, pain being modified by psychosocial factors such as anxiety, social support, or expectations. Melzack and Wall’s gate control theory was one of the first to maintain that pain was complex in that it not only had a sensory component but also affective, ­cognitive, and behavioral components (Science 150(699):971–979, 1965). A key tenet of the gate control theory was that the brain could play a major role in modulating nociceptive signals at the spinal cord, through descending pathways from brain areas thought to be involved in affect, cognition, and behavior. The gate control theory also led to renewed interest in expanding pain treatments beyond traditional medical and surgical approaches to a wide array of ­interventions that could alter pain by modifying sensation (e.g., ­transcutaneous nerve stimulation, massage), or affective (e.g., antianxiety and antidepressant medications), cognitive (e.g., cognitive therapy, distraction techniques), and behavioral processes (e.g., exercise, graded activation).
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Despite the clinical importance of pain in patients with rheumatic diseases, rheumatologists have not delegated a proportionate amount of effort to its investigation and treatment. Some of the assumptions that have hindered progress in pain management for rheumatologists include a preference for immunologic research over pain research, a reluctance to provide opioid therapy, and inadequate compensation. Contrary to these assumptions, pain management is becoming an area of increasing research and clinical effort in the field of rheumatology. This article discusses how the barriers to effective pain management can be overcome, although the relative differential compensation for psychosocial versus interventional therapy remains a concern. In the future, rheumatologists will need to expend greater time and effort in the study of pain management to remain pertinent to the needs of their rheumatic disease patients.
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Background: Non-pharmacological interventions such as education, exercise, and weight loss (if necessary) are core to the management of Osteoarthritis (OA). The role of nurses in managing symptomatic knee OA has been advocated but whether nurses can deliver such interventions as a complex package of care is unknown. The overall aim of this research was to develop and test the feasibility of a nurse-led complex intervention for knee pain comprising non-pharmacological and pharmacological components. The specific objectives of this thesis were to: 1) Systematically review the literature evaluating complex interventions for knee pain due to OA, 2) Evaluate fidelity of delivery of a nurse-led non-pharmacological complex intervention for knee pain, 3) Assess the acceptability of the non-pharmacological component of the intervention, issues faced in delivery, and resolve possible challenges. Methods: Systematic review and meta-analysis of complex interventions for knee pain due to OA: A systematic literature search was conducted on MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL up until September 29th, 2020. Randomised Controlled Trials (RCTs) comprising at least patient education, exercise, and weight loss interventions were searched. Data were extracted by a single reviewer and cross-checked by two others. Standardised mean differences (SMD) and 95% confidence intervals (CI) were calculated using the random-effects model. The risk of bias was assessed with the Revised Cochrane risk-of-bias tool, and intervention reporting with the template for intervention description and replication (TIDieR) checklist. The primary outcome of interest was knee pain. Package development phase: 18 participants with knee pain (five with mild severity, eight with moderate, and five with severe) participated in a single-arm study. The fidelity and acceptability of a nurse-led non-pharmacological intervention comprising assessment, education, exercise, use of hot/cold treatments, footwear modification, walking aids, and weight-loss advice (if required), delivered in 4 sessions over 5 weeks were evaluated. Fidelity of delivery of intervention: Each intervention session with every participant was video recorded and formed part of the fidelity assessment. Self-reported fidelity checklists were completed by the research nurse after each session and by an independent researcher, after viewing the video recordings blinded to nurse ratings. Fidelity scores (%), percentage agreement, and 95% Confidence Intervals (CI) were calculated. Two semi-structured interviews were conducted with the research nurse. Acceptability assessment of the non-pharmacological components: Eighteen adults with chronic knee pain (defined as pain for longer than three months) were recruited from the community. The intervention comprised holistic assessment, education, exercise, weight- loss advice (where appropriate), and advice on adjunctive treatments such as hot/cold treatments, footwear modification, and walking aids. Participants had one-to-one semi- structured interviews at the end of the intervention. The nurse was interviewed after the last visit of the last participant. These were audio-recorded and transcribed verbatim. Themes were identified by one author (PAN) using framework analysis of the transcripts and cross-checked by another (AF). Results: Systematic review ad meta-analysis of complex interventions: We reviewed 2,649 titles and abstracts in the systematic search. The screening process identified twenty RCTs recruiting 3,069 participants with knee OA. Twelve RCTs were included in the meta- analysis. More than half of the studies were judged to be of high quality. The completeness of intervention reporting was poor. Complex interventions for OA produced moderate benefit for pain relief (-0.47, 95% CI -0.77, -0.16) and physical function (-0.49, 95% CI -0.72, -0.25). However, studies delivering non-pharmacological interventions for knee OA rarely reported both fidelity of delivery and acceptability of non-pharmacological interventions. Fidelity of delivery of intervention: Fourteen participants completed all visits. 62 treatment sessions took place. Nurse self-report and assessor video rating scores for all 62 treatment sessions were included in the fidelity assessment. Overall fidelity was higher on nurse self- report (97.7%) than on objective video-rating (84.2%). The percentage agreement between nurse self-report and video-rating was 73.3% (95% CI: 71.3 - 75.3). Fidelity was lowest for advice on footwear and walking aids. The nurse reported difficulty advising on thermal treatments, footwear, and walking aids, and did not feel confident negotiating achievable and realistic goals with participants. The nurse found the discussion of goal setting to be challenging. Acceptability assessment of the non-pharmacological components: Most participants found the advice from the nurse easy to follow and were satisfied with the package, though some felt that too much information was provided too soon. The intervention changed their perception of managing knee pain, learning that it can be improved with self-management. However, participants thought that the most challenging part of the intervention was fitting the exercise regime into their daily routine. Conclusion: A non-pharmacological package of care comprising patient education, exercise, and weight loss advice is more beneficial than usual care or any other single non- pharmacological component. A trained research nurse could deliver such a non- pharmacological package of care with high fidelity and acceptability for the participants and the nurse delivering the intervention. Future research should consider measuring the fidelity of delivery of intervention and acceptability in a real-world primary-care setting before evaluating it further in a multicentre RCT. Measuring the extent to which components are delivered as intended across different settings and populations, fidelity research may assist to understand which intervention components are effective and in which situations.
Article
This review discusses several health behaviours associated with the progression and impact of osteoarthritis (OA) and rheumatoid arthritis (RA), including weight management, physical activity, medication adherence and smoking. An overview of current theories of behaviour-change is provided in terms of principles that can guide medical practice. Finally, evaluation studies of interventions targeting weight loss, physical activity and medication adherence in patients with OA or RA are presented and discussed. Of existing behaviour-change interventions in this population, few have taken a comprehensive theory-based approach to behaviour-change. Practitioners who provide lifestyle or behavioural advice to patients would do well to adopt a less prescriptive and more patient-centred approach in which they, or other health professionals to whom they refer the patient, assist the patient in formulating personal change goals, in translating good intentions into specific action plans and in closely monitoring their progress towards self-chosen goals.
Pain that accompanies musculoskeletal conditions should be regarded as an illness entity in its own right and deserves treatment in parallel with the management of the underlying condition. Recent understanding of the pathophysiology of rheumatic pain invokes interplay of the nociceptive mechanisms driven by local tissue factors and the neurogenic responses that sustain chronic pain. In line with other pain conditions, ideal treatment of rheumatic pain should be through a multimodal approach, integrating nonpharmacologic as well as pharmacologic treatments. In the light of this new concept of pain mechanisms, future pharmacologic treatment options may encompass a wider scope than the use of traditional analgesics and nonsteroidal anti-inflammatory drugs. There is currently limited experience for use of pharmacologic treatments that act primarily on neurogenic mechanisms in rheumatic conditions. Drug combination studies are lacking, but this strategy seems clinically reasonable to allow for an approach to treating pain from different mechanistic perspectives. An added advantage would be the opportunity to use lower doses of individual drugs and thereby reduce the side effect profile. Ideal pain management must also include attention to the important co-associates of pain such as effects on sleep, mood and energy, which all have an impact on the global burden of suffering. Although complete relief of pain is still an unrealistic objective, reasonable outcome goals for symptom relief should be accompanied with an improvement in function.
Resilience can be defined as the capacity for resistance, recovery, and rebound of psychological health after a challenge, such as chronic illness or acquired disability (Szanton & Gill, 2010). Older adults as a group not only confront more challenges of this nature but evidence suggests that they exhibit more resilience in the face of these types of challenges, particularly in the domains of resistance and recovery of psychological well-being. Various coping theories have been developed to account for age-related resilience, including stress inoculation resulting from exposure to lifelong stressors, illness and disability occurring on-time, enhanced coping skills, smaller but richer social networks, and more effective emotional regulation. Age-related psychological growth, including increased wisdom, body and ego transcendence, increased social competency, selective optimization with compensation, and increased spirituality have also been implicated as protective factors. Lastly, positive psychological factors that assist older adults in adapting to chronic conditions include positive reframing, optimism, and hope. We conclude by presenting evidence that interventions can and should be used to enhance resilience in older adults facing chronic illness and disability, and they may, in fact, be an age group ideally positioned to benefit from such interventions.
Article
Objective: The authors explored whether demographic and psychosocial variables predicted differences in physical activity for participants with arthritis in a trial of Active Living Every Day (ALED). Method: Participants (N = 280) from 17 community sites were randomized into ALED or usual care. The authors assessed participant demographic characteristics, self-efficacy, outcome expectations, pain, fatigue, and depressive symptoms at baseline and physical activity frequency at 20-wk follow-up. They conducted linear regression with interaction terms (Baseline Characteristic × Randomization Group). Results: Being female (p ≤ .05), less depressed (p ≤ .05), or younger (p ≤ .10) was associated with more frequent posttest physical activity for ALED participants than for those with usual care. Higher education was associated with more physical activity for both ALED and usual-care groups. Discussion: ALED was particularly effective for female, younger, and less depressed participants. Further research should determine whether modifications could produce better outcomes in other subgroups.
Article
IntroductionThe incidence of depression accompanying medical pathologies is elevated and have prognostic importance.
Article
Background International guidelines recommend educational intervention to treat knee osteoarthritis. However, they do not specify the type of intervention and the effectiveness of group educational intervention for knee pain is unclear. Objectives We aimed to examine the effectiveness of group educational interventions for people over 50 years old with knee pain compared with a control group. Design A systematic review and meta-analysis of randomized controlled trials (RCTs). Method We searched Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature and screened for RCTs involving participants over 50 years old that reported the effects of group education on knee pain. We performed meta-analyses and evaluated the methodological quality and evidence quality using the Physiotherapy Evidence Database scale and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, respectively. Results The search retrieved 1,177 studies. Seven RCTs were ultimately included, four of which were subjected to meta-analysis, showing standardized mean differences of −0.22 (95% confidence interval [CI]: −0.42 to −0.02, n = 423; I² = 0% GRADE: low). All studies included in the meta-analysis involved exercise without individualized instruction in addition to group educational intervention. Conclusions Group education, when delivered in addition to exercises, significantly reduces knee pain in people over 50 years old.
Article
Research has indicated physical activity and exercise can effectively attenuate biopsychosocial osteoarthritis-related symptoms in adults, more so than other management strategies; however, both leisure and structured physical activity are scarcely recommended by health care providers, and remain rarely adopted and adhered to in this patient population. Using qualitative interviews, the present study investigated potential facilitators and barriers to physical activity for adults with osteoarthritis. Fifteen participants (30-85 years of age) with osteoarthritis engaged in semi-structured interviews, which focused on experiences with physical activity/exercise, daily osteoarthritis management, and experiences with health professionals' recommendations. Analysis of the interview transcripts revealed that pain relief, clear health-related communication, and social support facilitated physical activity. Physical pain, psychological distress, and inadequate medical support were the most frequently expressed barriers. The present study supports the biopsychosocial nature of osteoarthritis, which may have important implications for advancing exercise as an effective and long-term intervention strategy in aging adults with osteoarthritis. © The Author(s) 2015.
Article
This study examined the effectiveness of iRest meditation for chronic pain in veterans with moderate traumatic brain injury (TBI). Veterans were randomly assigned to iRest (n = 4) or treatment as usual (n = 5) for eight weeks. Patient-reported pain intensity and interference were assessed at baseline, end point, and four-week follow-up. Veterans receiving iRest reported clinically meaningful reductions in pain intensity (23% to 42%) and pain interference (34% to 41%) for most outcome measures and time points. Effect sizes were large for pain interference (g = 0.92–1.13) and medium to large for intensity (g = 0.37–0.61). We conclude that iRest is a promising self-management approach for chronic pain in veterans with moderate TBI.
Article
The next few years in medicine will be a time of incredible change, and the organizational structure (e.g., task force) overseeing the pain initiative should regularly monitor the activities of the initiative, survey members, and report back to the BOD. The initiative has an impact on the identity of the specialty of rheumatology and it is essential that it is supported by the members and has the resources, both intellectual and financial, to assure its success.
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This chapter presents the rationale of innovative exercise modalities that integrate behavioral and self-management strategies into exercise therapy treatments. Three programs are presented which illustrate these interventions.
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In this chapter we focus on understanding pain coping in arthritis pain, what factors impact patients’ abilities to cope with arthritis pain, how coping can be enhanced in patients with arthritis pain, and how clinicians can apply this information to help patients improve their arthritis pain and other outcomes. First, we discuss what coping with pain is in relation to a chronic disease like arthritis. Then, using a biopsychosocial framework, we describe factors that have empirical support as being important in impacting how patients cope with their arthritis pain. Second, we describe psychosocial intervention strategies that have been studied and shown efficacy for improving patients’ abilities to cope with their arthritis pain. We present interventions that focus on the patient, on the patient and caregiver, and on treating patients with significant pain and comorbid medical problems (e.g., obesity). Finally, we discuss the practicalities of assessing pain coping, including what measurement tools to use, and using these assessments to implement intervention strategies that can lead to improved pain coping and overall arthritis outcomes. We complete this chapter with a discussion of what is unknown about coping with arthritis pain and suggest several areas that warrant future research.
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This chapter attempts to address lifestyle considerations, habits, and behaviors that can influence rehabilitation outcomes across the care continuum. This chapter suggests methods for treatment and prevention of pain.
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Operant theory has guided theoretical and empirical developments in the field of chronic pain for decades. This model has been the primary perspective from which behavioral interventions for chronic pain have been drawn. Recent evidence suggests that there is a need to expand upon the operant model with conceptual models found in the interpersonal, empathy, and pain communication literature. Although they each have a unique focus (e.g., communication, empathy), they each highlight the interpersonal dynamics that can impact the experience of pain for patients. Evidence is needed to know the extent to which treatment can intervene on these influential relationship variables and further, to elucidate the unique interplay between the communication of spouses in the context of pain and behavioral responses of close others. The theoretical models found in the interpersonal, empathy, and pain communication literature provide a way to view pain expressions in the context of the relationship and the deeper idiosyncratic meaning that these may have for an individual with chronic pain (ICP). These models provide a richer understanding of the motivations and antecedents that lead an observer to respond to a loved one’s pain behaviors and the effects of different observer responses on an ICP’s subjective rating of pain. Addressing communication, empathy, and intimacy correlates of observer responses to pain and gathering a better understanding of the communicative role of pain behaviors is necessary, as this is likely the direction that treatments for chronic pain are headed.
Article
Objective To investigate the effectiveness of pain coping skills training in pain, function, and psychological outcomes for patients with osteoarthritis, compared to the control group; and to compare the effectiveness of pain coping skills training between the intervention involving and without involving exercise. Data sources PubMed, Embase, the Cochrane Library, PEDro, Clinical Trials, and the WHO Clinical Trials Registry Platform (to 30 September 2020). Review methods To calculate the results, we used standardized mean difference, and mean difference for the outcomes of continuous variables, risk difference for the risk of adverse events. Heterogeneity was identified with I ² test, and publication bias was identified with Egger’s test. Results A total of 1195 patients with osteoarthritis underwent ten trials were included. The intervention group had significant differences in pain (SMD = −0.18; 95% CI −0.29 to −0.06), function (SMD = −0.19; −0.30 to −0.07), coping attempts (SMD = 0.37; 0.24 to 0.49), pain catastrophizing (SMD = −0.16; −0.29 to −0.02), and self-efficacy (SMD = 0.27; 0.07 to 0.46) than the control group. Between-group differences measured by the McMaster Universities Osteoarthritis Index subscales of pain (MD = −0.62; −1.48 to 0.24) or function (MD = −3.01; −6.26 to 0.24) were not statistically significant and did not reach the minimal clinically important differences that have been established. Subgroup analyses revealed no significant subgroup differences. Besides, no specific intervention-related adverse events were identified. Conclusion Our results supported the effectiveness and safety of pain coping skills training for managing osteoarthritis in pain, function, and psychological aspects. Besides, exercise could not add benefits when combined with pain coping skills training.
Article
Orthopaedic surgery successfully restores physical function and relieves pain in millions of Americans each year. In fact, orthopaedic surgery to treat arthritis of the knee and hip and lumbar spine conditions is among the top five surgical procedures by cost and volume in the United States. Despite the overwhelming success of orthopaedic procedures, functional improvement after surgery varies widely. Poor functional outcomes have been correlated with poor emotional health, such as anxiety, depression, poor coping skills, and poor social support1,2. The variation in functional outcomes exists despite state-of-the-art surgical techniques and is independent of postoperative complications. Furthermore, suboptimal functional outcomes associated with poor emotional health have been reported in a variety of orthopaedic specialties, including spine surgery, trauma care and/or fracture repair, rotator cuff repair, sports-related surgery (e.g., anterior cruciate ligament [ACL] reconstruction), total hip replacement, total knee replacement, and hand and upper extremities surgery. It is well established that the emotional health of the patient influences the outcome of many common orthopaedic surgeries.
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Objective: To examine the relation between adult weight change and the risk for clinical diabetes mellitus among middle-aged women. • Design: Prospective cohort study with follow-up from 1976 to 1990. • Setting: 11 U.S. states. • Participants: I'll 281 female registered nurses aged 30 to 55 years who did not have diagnosed diabetes mellitus, coronary heart disease, stroke, or cancer in 1976. • Outcome Measures: Non-insulin-dependent diabetes mellitus. • Results: 2204 cases of diabetes were diagnosed during 1.49 million person-years of follow-up. After adjustment for age, body mass index was the dominant predictor of risk for diabetes mellitus. Risk increased with greater body mass index, and even women with average weight (body mass index, 24.0 kg/m 2) had an elevated risk. Compared with women with stable weight (those who gained or lost less than 5 kg between age 18 years and 1976) and after adjustment for age and body mass index at age 18 years, the relative risk for diabetes mellitus among women who had a weight gain of 5.0 to 7.9 kg was 1.9 (95% CI, 1.5 to 2.3). The corresponding relative risk for women who gained 8.0 to 10.9 kg was 2.7 (CI, 2.1 to 3.3). In contrast, women who lost more than 5.0 kg reduced their risk for diabetes mellitus by 50% or more. These results were independent of family history of diabetes. • Conclusion: The excess risk for diabetes with even modest and typical adult weight gain is substantial. These findings support the importance of maintaining a constant body weight throughout adult life and suggest that the 1990 U.S. Department of Agriculture guidelines that allow a substantial weight gain after 35 years of age are misleading.
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Context The prevalence of obesity and overweight increased in the United States between 1978 and 1991. More recent reports have suggested continued increases but are based on self-reported data.Objective To examine trends and prevalences of overweight (body mass index [BMI] ≥25) and obesity (BMI ≥30), using measured height and weight data.Design, Setting, and Participants Survey of 4115 adult men and women conducted in 1999 and 2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population.Main Outcome Measure Age-adjusted prevalence of overweight, obesity, and extreme obesity compared with prior surveys, and sex-, age-, and race/ethnicity–specific estimates.Results The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-1994; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI ≥40) also increased significantly in the population, from 2.9% to 4.7% (P = .002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalences were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight.Conclusions The increases in the prevalences of obesity and overweight previously observed continued in 1999-2000. The potential health benefits from reduction in overweight and obesity are of considerable public health importance.
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This study investigated whether emotional expression of traumatic experiences influenced the immune response to a hepatitis B vaccination program. Forty medical students who tested negative for hepatitis B antibodies were randomly assigned to write about personal traumatic events or control topics during 4 consecutive daily sessions. The day after completion of the writing, participants were given their first hepatitis B vaccination, with booster injections at 1 and 4 months after the writing. Blood was collected before each vaccination and at a 6-month follow-up. Compared with the control group, participants in the emotional expression group showed significantly higher antibody levels against hepatitis B at the 4 and 6-month follow-up periods. Other immune changes evident immediately after writing were significantly lower numbers of circulating T helper lymphocytes and basophils in the treatment group. The finding that a writing intervention influences immune response provides further support for a link between emotional disclosure and health. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective: To determine whether a couple-oriented intervention for osteoarthritis (OA) was more efficacious than a patient-oriented intervention and whether each intervention was more efficacious than usual medical care. Research Design: 242 older adults with OA and their spouses were randomly assigned to patient-oriented education and support, couple-oriented education and support, or usual care. Results: Intent-to-treat analyses indicated no significant differences between the 3 study conditions in outcomes for individuals with OA or their spouses. Completers analyses showed that at the 6-month follow-up, contrary to prediction, individuals with OA who received the patient-oriented intervention reported greater reductions in pain and improvements in physical function than those who received the couple-oriented intervention. At the postintervention assessment, spouses who received the coupleoriented intervention reported greater reductions in stress and a trend toward less critical attitudes than spouses of individuals with OA who received the patient-oriented intervention. Moderator analyses indicated that female spouses and spouses with high marital satisfaction who received the couple-oriented intervention also experienced better outcomes in terms of depressive symptoms and caregiver mastery. Conclusions: A couples approach to education and support for OA may offer no advantage for individuals with OA but may prove helpful for spouses, thereby indirectly benefiting individuals with OA over time. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This study was undertaken to update and revise the estimate of the economic impact of obesity in the United States. A prevalence-based approach to the cost of illness was used to estimate the economic costs in 1995 dollars attributable to obesity for type 2 diabetes mellitus, coronary heart disease (CHD), hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis. Additionally and independently, excess physician visits, work-lost days, restricted activity, and bed-days attributable to obesity were analyzed cross-sectionally using the 1988 and 1994 National Health Interview Survey (NHIS). Direct (personal health care, hospital care, physician services, allied health services, and medications) and indirect costs (lost output as a result of a reduction or cessation of productivity due to morbidity or mortality) are from published reports and inflated to 1995 dollars using the medical component of the consumer price index (CPI) for direct cost and the all-items CPI for indirect cost. Population-attributable risk percents (PAR%) are estimated from large prospective studies. Excess work-lost days, restricted activity, bed-days, and physician visits are estimated from 88,262 U.S. citizens who participated in the 1988 NHIS and 80,261 who participated in the 1994 NHIS. Sample weights have been incorporated into the NHIS analyses, making these data generalizable to the U.S. population. The total cost attributable to obesity amounted to $99.2 billion dollars in 1995. Approximately $51.64 billion of those dollars were direct medical costs. Using the 1994 NHIS data, cost of lost productivity attributed to obesity (BMI> or =30) was $3.9 billion and reflected 39.2 million days of lost work. In addition, 239 million restricted-activity days, 89.5 million bed-days, and 62.6 million physician visits were attributable to obesity in 1994. Compared with 1988 NHIS data, in 1994 the number of restricted-activity days (36%), bed-days (28%), and work-lost days (50%) increased substantially. The number of physician visits attributed to obesity increased 88% from 1988 to 1994. The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States. The direct costs associated with obesity represent 5.7% of our National Health Expenditure in the United States.
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The purpose of this study was to determine whether a couple-oriented education and support intervention for osteoarthritis was more efficacious than a similar patient-oriented intervention in terms of enhancing spouses' support of patients and their positive and negative responses to patient pain. Repeated-measures analyses of covariance with the completers sample (N = 103 dyads) showed that at the postintervention assessment, patients in the couple-oriented intervention reported a greater decrease in their spouses' punishing responses (e.g., anger, irritation) than did patients in the patient-oriented intervention. In addition, a trend effect was observed in regard to the advantage of couple-oriented intervention for increasing spouses' attempts to distract patients from their pain. At the 6-month follow-up, patients in the couple-oriented intervention reported greater increased spouse support than those in the patient-oriented intervention. Findings illustrate the value of examining change in specific types of marital interactions targeted in a couples intervention, and the need to strengthen the impact of future couple-oriented interventions.
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On the basis of previous work, freshmen should evidence improved health after writing about their thoughts and feelings associated with entering college. One hundred thirty subjects were assigned to write either about coming to college or about superficial topics for 20 min on 3 days. One fourth of the subjects in each group wrote during the 1st, 5th, 9th, or 14th week of classes. Physician visits for illness in the months after writing were lower for the experimental than for the control subjects. Self-reports of homesickness and anxiety were higher in the experimental group 2-3 months after writing. By year's end, experimental subjects were either superior or similar to control subjects in grade average and in positive moods. No effects emerged as a function of when people wrote, suggesting that the coping process can be accelerated. Implications for comparing insight treatments with catharsis and for distinguishing between objective and self-report indicators of distress are discussed.
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Examined whether writing about traumatic events would influence long-term measures of health as well as short-term indicators of physiological arousal and reports of negative moods in 46 introductory psychology students. Also examined were aspects of writing about traumatic events (i.e., cognitive, affective, or both) that were most related to physiological and self-report variables. Ss wrote about either personally traumatic life events or trivial topics on 4 consecutive days. In addition to health center records, physiological measures and self-reported moods and physical symptoms were collected throughout the experiment. Findings indicate that, in general, writing about both the emotions and facts surrounding a traumatic event was associated with relatively higher blood pressure and negative moods following the essays, but fewer health center visits in the 6 mo following the experiment. It is concluded that, although findings should be considered preliminary, they bear directly on issues surrounding catharsis, self-disclosure, and a general theory of psychosomatics based on behavioral inhibition. (24 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The relationships among interpersonal stressors, depression, coping inefficiency, hormones (prolactin, cortisol, and estradiol), and disease activity were examined. The sample comprised 33 women with rheumatoid arthritis (RAs; age 37-78) and 37 women with osteoarthritis (OAs; age 47-91), who served as controls. In a regression analysis, interpersonal conflict events accounted for more than twice as much variance in depression in RAs than in OAs. In the RA patients, the immune-stimulating hormones prolactin and estradiol were significantly positively correlated with interpersonal conflicts, depression, coping inefficacy, and clinician ratings of disease activity, suggesting that RAs are more reactive to interpersonal stressors than are OAs, both psychologically and physiologically.
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Healthy Epstein-Barr virus (EBV) seropositive undergraduates (N = 57) completed a personality inventory, provided blood samples, and were randomly assigned to write or talk about stressful events, or to write about trivial events, during three weekly 20-min sessions, after which they provided a final blood sample. Individuals assigned to the verbal/stressful condition had significantly lower EBV antibody titers (suggesting better cellular immune control over the latent virus) after the intervention than those in the written/stressful group, who had significantly lower values than those in the written/trivial control group. Subjects assigned to the written/stressful condition expressed more negative emotional words than the verbal/stressful and control groups and more positive emotional words than the verbal/stressful group at each time point. The verbal/stressful group expressed more negative emotional words compared with the control group at baseline. Content analysis indicated that the verbal/stressful group achieved the greatest improvements in cognitive change, self-esteem, and adaptive coping strategies.
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This study examined the effects of dietary weight loss and exercise on the health-related quality of life (HRQL) of overweight and obese, older adults with knee osteoarthritis. A total of 316 older men and women with documented evidence of knee osteoarthritis were randomly assigned to 1 of 4 18-month interventions: dietary weight loss, exercise, dietary weight loss and exercise, or healthy lifestyle control. Measures included the SF-36 Health Survey and satisfaction with body function and appearance. Results revealed that the combined diet and exercise intervention had the most consistent, positive effect on HRQL compared with the control group; however, findings were restricted to measures of physical health or psychological outcomes that are related to the physical self.
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The authors used data from the United States first national Health and Nutrition Examination Survey of 1971–1975 (HANES I) to explore the cross-sectional associations between radiographic osteoarthritis of the knee and a variety of putative risk factors. A total of 5,193 black and white study participants aged 35– 74 years, 315 of whom had x-ray-diagnosed osteoarthritis of the knee, were available for analysis. After controlling for confounders, the authors found significant associations of knee osteoarthritis with overweight, race, and occupation, all of which have been suggested by smaller cross-sectional studies. They then focused specifically on those factors. For overweight, they found a strong association between current obesity and osteoarthritis of the knee, with a dose-response effect not previously assessed. This association was also seen for self-reported minimum adult weight, a proxy for long-term obesity, and was present in persons with asymptomatic osteoarthritis of the knee. These findings strongly suggest that obesity is causative. HANES I was the first study in which racial differences in osteoarthritis of the knee could be assessed within the same country. The black women who were studied had an increased risk of disease (odds ratio (OR) = 2.12, 95% confidence interval (Cl) = 1.39−3.23) after controlling for age and weight, although the black men did not. Finally, the authors used the US Department of Labor Dictionary of Occupational Titles to obtain characterizations of the physical demands and knee-bending stress associated with occupations and to study the relation between physical demands of jobs and osteoarthritis of the knee. They found for persons aged 55–64 years an association between knee-bending demands and osteoarthritis of the knee (men, OR = 2.45, 95% CI = 1.21−4.97; women, OR = 3.49, 95% CI = 1.22−10.52). Since such occupational physical demands are common, the authors conclude that they may be associated with a substantial proportion of osteoarthritis of the knee.
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Objective. To evaluate the effects of a spouse-assisted pain-coping skills training intervention on pain, psychological disability, physical disability, pain-coping, and pain behavior in patients with osteoarthritis (OA) of the knees. Methods. Eighty-eight OA patients with persistent knee pain were randomly assigned to 1 of 3 conditions: 1) spouse-assisted pain-coping skills training, (spouse-assisted CST), 2) a conventional CST intervention with no spouse involvement (CST), or 3) an arthritis education-spousal support (AE-SS) control condition. All treatment was carried out in 10 weekly, 2-hour group sessions. Results. Data analysis revealed that at the completion of treatment, patients in the spouse-assisted CST condition had significantly lower levels of pain, psychological disability, and pain behavior, and higher scores on measures of coping attempts, marital adjustment, and self-efficacy than patients in the AE-SS control condition. Compared to patients in the AE-SS control condition, patients who received CST without spouse involvement had significantly higher post-treatment levels of self-efficacy and marital adjustment and showed a tendency toward lower levels of pain and psychological disability and higher scores on measures of coping attempts and ratings of the perceived effectiveness of pain-coping strategies. Conclusion. These findings suggest that spouse-assisted CST has potential as a method for reducing pain and disability in OA patients.
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This study examined the effects of emotional disclosure of stressful events on the pain, physical and affective dysfunction, and joint condition of patients with rheumatoid arthritis (RA). Patients were randomly assigned to talk privately about stressful events (disclosure group, n = 36) or about trivial topics (control group, n = 36) for 4 consecutive days. Disclosure resulted in immediate increases in negative mood. At 2 weeks the 2 groups did not differ on any health measure, but at 3 months disclosure patients had less affective disturbance and better physical functioning in daily activities. There was no main effect of disclosure on pain or joint condition, but among the disclosure patients, those who experienced larger increases in negative mood after talking demonstrated improvements in the condition of their joints. This study concludes that, among RA patients, verbal disclosure and emotional processing of stressful life events induces an immediate negative mood followed by improved psychological functioning.
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Presents guidelines for the management of rheumatoid arthritis and monitoring of drug therapy.
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Background: Obesity increases the risk for hypertension, but the effects of modest long-term weight changes have not been precisely quantified. Objective: To investigate body mass index (BMI) and weight change in relation to risk for hypertension. Design: Cohort study. Setting: General community. Participants: Cohort of 82 473 U.S. female nurses 30 to 55 years of age followed every 2 years since 1976. The follow-up rate was 95%. Measurements: Primary risk factors examined were 1) BMI at age 18 years and midlife and 2) long-term and medium-term weight changes. The outcome was incident cases of hypertension. Results: By 1992, 16 395 incident cases of hypertension had been diagnosed. After adjustment for multiple covariates, BMI at 18 years of age and midlife were positively associated with occurrence of hypertension (P for trend < 0.001). Long-term weight loss after 18 years of age was related to a significantly lower risk for hypertension, and weight gain dramatically increased the risk for hypertension (compared with weight change <2 kg, multivariate relative risks were 0.85 for a loss of 5.0 to 9.9 kg, 0.74 for a loss 210 kg, 1.74 for a gain of 5.0 to 9.9 kg, and 5.21 for a gain ≥25.0 kg). Among women in the top tertile of baseline BMI at age 18 years, weight loss had a greater apparent benefit. The association between weight change and risk for hypertension was stronger in younger (<45 years of age) than older women (≥55 years of age). Medium-term weight changes after 1976 showed similar relations to risk for hypertension. Conclusions: Excess weight and even modest adult weight gain substantially increase risk for hypertension. Weight loss reduces the risk for hypertension.
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WADDEN, THOMAS A., DREW A. ANDERSON, AND GARY D. FOSTER. Two-year changes in lipids and lipoproteins associated with the maintenance of a 5% to 10% reduction in initial weight: some findings and some questions. Obes Res. Objective This study assessed whether a 5% to 10% reduction in initial weight would be associated with as favorable long-term (i.e., 100 weeks) changes in lipids and lipoproteins, as have been observed on a short-term basis (i.e., 8 weeks). Research Methods and Procedures This was a prospective evaluation of 25 obese women, each of whom had lost ≥5% of initial weight during 48 weeks of treatment and had maintained a weight loss of this magnitude at 1-year follow-up (week 100). Lipids and lipoproteins were obtained at baseline and at weeks 8, 24, 48, and 100. All participants had a baseline total cholesterol ≥5.17 mmol/L (200 mg/dL). Results At the end of the first 8 weeks, weight fell an average of 11.7±2.8%, total cholesterol 20.6±7.5%, low-density-lipoprotein (LDL) cholesterol 23.0±18.1%, and triglycerides 26.0±20.1%. At week 48, weight had fallen to 20.1±7.0% below baseline, but total cholesterol and LDL cholesterol were reduced only 11.5±10.4% and 12.0±14.0% below baseline, respectively. These latter reductions were significantly (p<0.05) smaller than those observed at week 8, despite the larger weight loss at week 48. High-density-lipoprotein cholesterol declined significantly (p<0.05) during the first 8 weeks, but returned to baseline values by week 24. Patients gained 7.4±7.4 kg from weeks 48 to 100, during which time total and LDL cholesterol (but not triglycerides) rose significantly (p<0.05). Patients who, at week 100, maintained losses >10% of initial weight had significantly greater reductions in total and LDL cholesterol values than did patients who maintained losses of only 5% to 10% of initial weight. Discussion Results of this study underscore the importance of assessing long-term changes in weight-related health complications when patients have lost weight but are no longer dieting (and exercising) as aggressively as they did during the initial months of treatment.
Article
A 15-year follow-up study of 74 female patients with definite or classic rheumatoid arthritis (RA) was performed with special focus on the association between life stress and clinical course of the illness. Two categories of RA could be classified: a disease form less connected with genetic factors and more influenced by major psychodynamic conflict situations (‘major conflict group’ MCG) and a second form more associated with hereditary predisposition and less influenced by environmental psychosocial changes (‘non-conflict group’, NCG).
Article
Objective. To determine if participation of the spouse of patients with rheumatoid arthritis in cognitive-behavioral oriented self-management training aimed at improving disease related cognitions and coping with pain has additional benefits for the patients. Methods. A total of 59 couples were randomly assigned to 2 conditions. In the experimental condition the couples participated in a group program aimed at restructuring disease related cognitions and decreasing passive coping. In the control condition, only the patient participated. Disease status, self-reported physical and psychological functioning, coping, disease related cognitions, and marriage characteristics were assessed prior to the intervention and 2 weeks and 6 months postintervention. A general linear model with repeated measures was used to test for differences between conditions. Results. In both conditions, similar positive changes in disease activity, cognitions, coping, and physical and psychological functioning were observed. Patients reported a decrease in potential support. There were no differences between conditions. However, at the followup assessment patients in the experimental condition reported more improvement of disease related communication with their spouse. Conclusion. No evidence was found for additional beneficial effects of spouse participation in the cognitive-behavioral oriented self-management group treatment.
Article
Research involving perceived internal vs external control of reinforcement as a personality variable has been expanding at a rapid rate. It seems clear that for some investigators there are problems associated with understanding the conceptualization of this construct as well as understanding the nature and limitations of methods of measurement. This article discusses in detail (a) the place of this construct within the framework of social learning theory, (b) misconceptions and problems of a theoretical nature, and (c) misuses and limitations associated with measurement. Problems of generality-specificity and unidimensionality-multidimensionality are discussed as well as the logic of predictions from test scores. (35 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objectives: To examine the moderating effects of wives' pain expression (verbal disclosure, nonverbal behavior) on the relationship between wives' pain and husbands' well-being and support provision. Design: Interviews were conducted with couples at baseline; questionnaires were mailed 6 months later. Setting: All women were patients at a rheumatology clinic. Participants: The sample included older women (n = 101) with a diagnosis of osteoarthritis (OA) and their caregiving husbands. Main Outcome Measures: Outcomes were husbands' psychological well-being (depressive symptoms, life satisfaction) and the quality of their support to wives (emotional support, critical attitudes). Results: Verbal and nonverbal expression of OA pain increased the likelihood that women experiencing severe pain would have husbands with poor psychological well-being. Moreover, verbal pain disclosure strengthened the association between the severity of wives' pain and less emotional support from husbands. Conclusions: Findings suggest that wives' verbal and nonverbal communications about their pain, especially about severe pain, have the potential to decrease the psychological well-being and support resources of their caregiving spouses. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
With the majority of adults involved in intimate relationships and chronic illness on the rise, the impact of illness on couples has become a significant area of psychological research and clinical practice. This book, representing the emerging field of the psychology of couples, examines the juncture of psychology and medicine. To begin to address how illness affects relationships, as well as how relationships influence illness, the book presents recent empirical data from psychologists who study and work with couples. Contributors explore biological and immunological research; specific illnesses, such as cancer; organ systems, such as the respiratory system; and health-related behaviors, such as smoking. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Data from 4225 persons from the National Health and Nutrition Examination Survey (HANES) was used to determine whether obesity was associated with osteoarthritis (OA) or joint pain. Subjects were divided into four groups on the basis of sex and race. We found that obesity was associated with OA of the knee for each sex/race group (p < 0.01). The association was strongest for women, and it was present even for subjects without evidence of knee pain on physical examination. Frame size was not significantly associated with OA of the knee. Relative weight was weakly associated with OA of the hips in white women and nonwhite men but not significantly associated with OA of the sacroiliac joint. Diabetes did not seem to be an important risk factor for OA. These results suggest that the additional mechanical stress resulting from obesity is the principal reason for the association between obesity and OA.
Article
Objective To evaluate the effect of weight reduction on the rehabilitation of patients with knee osteoarthritis and obesity.MethodsA total of 126 patients with bilateral knee osteoarthritis and obesity were classified into 3 groups by their stages of osteoarthritis. Each group was divided into subgroups a, b, and c. The subjects in subgroup a received weight reduction treatment, those in subgroup b received weight reduction and electrotherapy modalities, and those in subgroup c received electrotherapy modalities to relieve pain.ResultsPain reduction, weight reduction, ambulation speed, and changes of Lequesne's index were greater in patients in subgroups a and b than in subgroup c after treatment. Although the last pain scores in subgroup b were less than those in subgroup a, as measured by a visual analog scale (VAS), there was no significant difference between their functional status. Significant pain relief (VAS < 2) and an acceptable functional status (Lequesne's index < 7) were indicated when weight reduction was more than 15% and 12%, respectively, of the initial body weight of the individual.Conclusion Weight reduction was found to be a practical adjuvant treatment in the rehabilitation of patients with knee osteoarthritis.
Article
Objective To examine changes in mobility-related self efficacy following exercise and dietary weight loss interventions in overweight and obese older adults with knee osteoarthritis (OA), and to determine if self efficacy and pain mediate the effects of the interventions on mobility task performance.Methods The Arthritis, Diet, and Activity Promotion Trial was an 18-month, single-blind, randomized, controlled trial comparing the effects of exercise alone, dietary weight loss alone, a combination of exercise plus dietary weight loss, and a healthy lifestyle control intervention in the treatment of 316 overweight or obese older adults with symptomatic knee OA. Participants completed measures of stair-climb time and 6-minute walk distance, self efficacy for completing each mobility task, and self-reported pain at baseline, 6 months, and 18 months during the trial.ResultsMixed model analyses of covariance of baseline adjusted change in the outcomes demonstrated that the exercise + dietary weight loss intervention produced greater improvements in mobility-related self efficacy (P = 0.0035), stair climb (P = 0.0249) and 6-minute walk performance (P = 0.00031), and pain (P = 0.09) when compared with the healthy lifestyle control intervention. Mediation analyses revealed that self efficacy and pain served as partial mediators of the beneficial effect of exercise + dietary weight loss on stair-climb time.Conclusion Exercise + dietary weight loss results in improved mobility-related self efficacy; changes in these task-specific control beliefs and self-reported pain serve as independent partial mediators of the beneficial effect of exercise + dietary weight loss on stair-climb performance.
Article
This study investigated the relation between stress and current disease activity in rheumatoid arthritis (RA). During a routine clinic appointment, subjects were given ratings of global disease status by their physicians and completed self-report measures of major stress and minor stress. In addition, each subject''s erythrocyte sedimentation rate was taken. After controlling for disease severity and major stress, minor stress accounted for a significant amount of the variance in inflammation level. These results suggest that minor stress is associated with current disease activity in RA.
Article
This study examines six months follow-up data obtained from osteoarthritic knee pain patients participating in a study comparing pain coping skills training, arthritis education, and a standard care control condition. At the time of follow-up, patients receiving pain coping skills training had: 1) significantly lower levels of psychological and physical disability than patients receiving arthritis education, and 2) marginally lower levels of psychological disability (p<.052) and physical disability (p<.13) than patients in the standard care control condition. Although patients receiving pain coping skills training showed deterioration in their initial gains in psychological disability from post-treatment to follow-up, it was the only treatment group that showed a strong trend (p=.051) towards improvements in physical disability over time. Variability in outcome was noted; some patients showed better maintenance of treatment effects than others. Correlational analyses revealed that patients' scores on the Pain Control and Rational Thinking (PCRT) factor of the Coping Strategies Questionnaire were related to outcome at six months follow-up. Patients receiving pain coping skills training who scored high on the PCRT factor at the end of treatment had lower levels of pain, physical disability, and pain behavior at six months follow-up. The implications of these findings for future research on cognitive-behavioral interventions for arthritis pain and disability are discussed.
Article
This investigation evaluated two cognitive behavioral interventions, one of which involved a contingent model of family support, in the management of pain and other symptoms in rheumatoid arthritis (RA). These conditions were compared with an education with family support group and a no-treatment group on measures of pain, disease activity, and psychological status over a six-week treatment period and a two-month follow-up. The behavioral interventions demonstrated significantly greater improvement in joint exam pain at follow-up, and reduced swelling severity and number of swollen joints at posttreatment and follow-up when contrasted with the two control conditions. The behavioral intervention with family support was superior to all other conditions combined on swelling measures at posttreatment, but did not differ from the behavior therapy without family group at follow-up. The results provide evidence for the effectiveness of brief behavioral interventions in reducing RA disease activity, and demonstrate the potential usefulness of including family members in pain treatment using a behavioral framework.
Article
The purpose of this study was to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability, psychological disability, and pain behavior in osteoarthritic knee pain patients. Patients in this study were older adults (mean age=64 years) having persistent pain (mean duration=12 years), who were diagnosed as having osteoarthritis of the knee on the basis of medical evaluation and x-rays. Patients were randomly assigned to one of three conditions: pain coping skills training, arthritis education, or a standard care control condition. Patients in the pain coping skills training condition (n=32) attended 10 weekly group sessions training them to recognize and reduce irrational cognitions and to use attention diversion and changes in activity patterns to control and decrease pain. Arthritis education subjects (n=36) attended 10 weekly group sessions providing them with detailed information on osteoarthritis. Standard care control subjects (n=31) continued with their routine care. Measures of coping strategies, pain, psychological disability, physical disability, medication use, and pain behavior were collected from all subjects before and after treatment. Results indicated that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education or standard care. Correlational analyses revealed that patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were more likely to have lower levels of physical disability post-treatment. Taken together, these findings indicate that pain coping skills training can reduce pain and psychological disability in osteoarthritis patients. Future studies should examine whether behavioral rehearsal or spouse training can strengthen the effects of pain coping skills training in order to reduce physical disability and pain behavior as well as pain and psychological disability.
Article
The medical effects of modest weight reduction (approximately 10% or less) in patients with obesity-associated medical complications were reviewed. The National Library of Medicine MEDLINE database and the Derwent RINGDOC database were searched to identify English language studies that examined the effects of weight loss in obese patients with serious medical complications commonly associated with obesity (non-insulin dependent diabetes mellitus (NIDDM or type II), hypertension, hyperlipidemia, hypercholesterolemia, and cardiovascular disease). Studies in which patients experienced approximately 10% or less weight reduction were selected for review. Studies indicated that, for obese patients with NIDDM, hypertension or hyperlipidemia, modest weight reduction appeared to improve glycemic control, reduce blood pressure, and reduce cholesterol levels, respectively. Modest weight reduction also appeared to increase longevity in obese individuals. In conclusion, a large proportion of obese individuals with NIDDM, hypertension, and hyperlipidemia experienced positive health benefits with modest weight loss. For patients who are unable to attain and maintain substantial weight reduction, modest weight loss should be recommended; even a small amount of weight loss appears to benefit a substantial subset of obese patients.
Article
This study sought to replicate previous findings that disclosing traumas improves physical health and to compare the effects of revealing previously disclosed versus undisclosed traumas. According to inhibition theory, reporting about undisclosed traumas should produce greater health benefits. Sixty healthy undergraduates wrote about undisclosed traumas, previously disclosed traumas, or trivial events. Contrary to expectations, there were no significant between-groups differences on longer term health utilization and physical symptom measures. However, Ss who disclosed more severe traumas reported fewer physical symptoms in the months following the study, compared with low-severity trauma Ss, and tended to report fewer symptoms than control Ss. Results suggest that health benefits occur when severe traumas are disclosed, regardless of whether previous disclosure has occurred.
Article
Forty rheumatoid arthritis (RA) patients diagnosed by rigid criteria were evaluated for alexithymic characteristics using the Beth Israel Hospital Psychosomatic Questionnaire (BIQ) and the Toronto Alexithymia Scale (TAS). 40 healthy subjects matched with RA patients on sociodemographic variables served as controls. RA patients scored significantly higher on the BIQ and TAS compared to controls. The two scales correlated in the expected direction. Using the TAS cutoff score of 74 and above, 11 RA patients (27.5%) were identified as alexithymic. RA patients with greater functional impairment showed significantly higher alexithymia scores.
Article
A randomized clinical trial was performed to evaluate a psychological treatment intervention and a social support program, compared with a control program in which no adjunct treatment was rendered, and their effects upon pain behavior, affect, and disease activity of 53 patients with rheumatoid arthritis. The psychological intervention produced significant reductions in patients' pain behavior and disease activity at posttreatment. Significant reductions were also observed in trait anxiety at posttreatment and 6-month followup. Relaxation training may have been the most important component of the psychological intervention. The social support program produced a significant reduction in trait anxiety only at posttreatment. This is the first well-controlled study to demonstrate reduced pain behavior, disease activity, and trait anxiety following psychological treatment.
Article
The authors used data from the United States first national Health and Nutrition Examination Survey of 1971-1975 (HANES I) to explore the cross-sectional associations between radiographic osteoarthritis of the knee and a variety of putative risk factors. A total of 5,193 black and white study participants aged 35-74 years, 315 of whom had x-ray-diagnosed osteoarthritis of the knee, were available for analysis. After controlling for confounders, the authors found significant associations of knee osteoarthritis with overweight, race, and occupation, all of which have been suggested by smaller cross-sectional studies. They then focused specifically on those factors. For overweight, they found a strong association between current obesity and osteoarthritis of the knee, with a dose-response effect not previously assessed. This association was also seen for self-reported minimum adult weight, a proxy for long-term obesity, and was present in persons with asymptomatic osteoarthritis of the knee. These findings strongly suggest that obesity is causative. HANES I was the first study in which racial differences in osteoarthritis of the knee could be assessed within the same country. The black women who were studied had an increased risk of disease (odds ratio (OR) = 2.12, 95% confidence interval (CI) = 1.39-3.23) after controlling for age and weight, although the black men did not. Finally, the authors used the US Department of Labor Dictionary of Occupational Titles to obtain characterizations of the physical demands and knee-bending stress associated with occupations and to study the relation between physical demands of jobs and osteoarthritis of the knee. They found for persons aged 55-64 years an association between knee-bending demands and osteoarthritis of the knee (men, OR = 2.45, 95% CI = 1.21-4.97; women, OR = 3.49, 95% CI = 1.22-10.52). Since such occupational physical demands are common, the authors conclude that they may be associated with a substantial proportion of osteoarthritis of the knee.
Article
Literature concerning rheumatoid arthritis (RA) was reviewed with regard to the empirical evidence for the widely held view that the onset and course of the disease are influenced by stress variables. Human studies yielded contradictory results; there are at least two large well-controlled investigations that were not able to find a preponderance of life stress variables prior to the onset of the disease in RA patients compared to other patients or healthy subjects. Findings of animal studies are inconsistent, too: Some kinds of stress seem to abrogate, whereas others may rather enhance the development of rheumatic symptoms. Possible pathogenetic models are discussed to explain the influence of stress on the disease. For further research, the use of more sophisticated methods to assess life events, and prospective longitudinal studies in RA patients are suggested to find out whether stressful events antedate relapses. Such correlations should be examined for patients with seronegative and seropositive RA separately.
Article
A 15-year follow-up study of 74 female patients with definite or classic rheumatoid arthritis (RA) was performed with special focus on the association between life stress and clinical course of the illness. Two categories of RA could be classified: a disease form less connected with genetic factors and more influenced by major psychodynamic conflict situations ('major conflict group' MCG) and a second form more associated with hereditary predisposition and less influenced by environmental psychosocial changes ('non-conflict group', NCG).
Article
A gate control system modulates sensory input from the skin before it evokes pain perception and response.
Article
In this study the efficacy of phentermine was studied for weight reduction in 22 patients. The significant correlation of loss of weight with clinical improvement after 6 months supports the generally held belief that obese patients with symptomatic osteoarthritis of hips or knees benefit from the loss. In particular, the improvement related more to the knee than to hip disease.