Search strategy
The EBSCOhost platform was used to search PsycInfo and CINAHL databases, and the search was repeated using the PubMed database. Search terms included combinations of pain, pain management, psychosocial, and arthritis, and the search was limited to studies of adults and the English language. Studies needed to measure pain as an outcome and employ a specific psychosocial intervention to be included in the review. Because prior reviews have summarized literature through the 1990s [4] this review focuses on papers published from January 2000 through August 2006, inclusive of early on-line editions.
Psychosocial approaches
Psychosocial approaches to managing arthritis pain include educational programs, coping skills training (CST), and cognitive behavioral therapy (CBT). As a group of interventions, the focus is the provision of information necessary to understand the rationale for the approach selected, and techniques to enhance self efficacy, manage stress, decrease helplessness and catastrophizing, and perhaps most importantly, develop and practice specific skills, applied to the person's unique life situation. While most people with arthritis are able to access basic medical care, timely, comprehensive care regarding psychosocial aspects of living with arthritis is limited [3]
A widely known educational intervention is the community-based Arthritis Self Management Program [23], typically a series of six weekly group sessions led by trained lay leaders, which specifically targets self efficacy skills in the management of arthritis symptoms, including pain. Other individualized or group specific educational programs may be designed by health care providers to match the needs of their audience, and may include elements similar in nature to the Arthritis Self Management Program or CST and CBT approaches. CST or CBT include cognitive and behavioral exercises, conducted individually or in groups over several weeks. A typical program might introduce a simplified overview of a theory of pain control, attention diversion techniques such as relaxation or guided imagery, changing cognitions (recognizing and reducing negative thoughts), changing activity patterns (pacing, choosing pleasurable activities) and the provision of homework to apply new techniques outside the treatment setting [3, 4, 24]. Some pain management techniques, such as relaxation, may be taught in isolation, but this in itself does not comprise a program of CST or CBT.
The list of psychosocial factors potentially associated with pain management is daunting. Keefe and colleagues [25] have organized these into two general categories: factors associated with poor pain control (catastrophizing, anxiety and fear, helplessness) and factors associated with effective pain control (self efficacy, pain coping strategies, readiness to change). While this schema is generally supported in the literature, the evidence from cross-sectional and longitudinal studies remains muddled with regard to the precise mechanism by which psychosocial factors might influence the pain experience. Some investigations [26, 27] have found improved coping skills to be associated with decreased psychological distress and/or pain reduction, but others have failed to find a significant effect for coping as a mediator of the relationships between life stresses and psychological well-being [28]. Passive coping [29], feelings of helplessness [30], and catastrophizing [31–33] appear to be associated with more pain and poorer health outcomes, while active coping [33, 34] and self efficacy [33] appear to decrease pain. Increasingly, clinical trials are being reported that examine various intervention protocols.
Clinical trials of psychosocial interventions and arthritis pain
A systematic review and meta-analysis of cognitive-behavioral and psychoeducational interventions found 25 trials of sufficient quality to analyze for pooled effects on 6 outcomes of interest (pain, disability, tender joints, psychological status, coping and self efficacy) [35]. Results indicated small effect sizes for reducing pain and disability over the short term, an effect that unfortunately was not sustained in the studies that employed a follow-up assessment. With regard to psychological status, the most frequently measured outcome was depression. Across trials, there was a small average effect size for reducing symptoms of depression, and this change was maintained in those studies that included a follow-up assessment. Small but significant average effect sizes for coping and self-efficacy suggested that interventions were successful in improving skills. Not all studies provided enough information to calculate effect sizes, and when reviewed at the individual study level, the authors report a number of inconsistencies that could be due to lack of statistical power (most studies used relatively small samples), variation in the treatments used, or characteristics of the patients studied.
Inconsistencies across studies have been reported in another systematic review of group interventions for adults with RA or osteoarthritis (OA) [34]. The types of group interventions provided were self-management education or cognitive behavioral therapy for stress management. One of three studies demonstrated an improvement in coping skills, one of four studies demonstrated improved social contacts, and six of thirteen studies showed improvement in functional status. More research is required to tease out the circumstances under which positive outcomes occur. Beyond methodological limitations, there is the likelihood that some interventions are successful for some people but not others, and these characteristics need to be delineated to better inform clinical practice.
In a trial of CBT compared to sympathetic attention to arthritis symptoms and usual care control groups in adults with lupus, the experimental group demonstrated significant improvement in pain following treatment while the changes for both control conditions did not significantly differ from baseline [36]. However, improvements in pain were not sustained at the nine-month follow-up assessment. Similar results were obtained for psychological and physical functioning.
If desirable outcomes are achieved in the short term but not sustained in the long term, it is reasonable to hypothesize that some type of maintenance program may resolve this problem. One such trial compared conventional pain CST to a CST program enhanced with a maintenance component and two control conditions: arthritis education and usual care [24]. A comprehensive daily diary was used to monitor pain variables. Although 167 participants were randomized (38 to 46 in each group), just 95 completed the trial, and the attrition was greatest in the two pain CST groups (19 and 18, respectively, completing the study), which threatens the strength of the conclusions. Unexpectedly, the conventional pain CST was superior to the maintenance-enhanced program and both control conditions in reducing pain and negative mood and increasing coping efficacy; however, the maintenance-enhanced pain coping skills group was superior in enhancing positive mood.
An 18-month follow-up study assessed the longer-term efficacy of CBT for adults with recently diagnosed RA [37]. The original intervention compared a series of eight individual sessions of CBT with a psychologist to routine care. In the intent-to-treat analysis, the changes in pain and coping were not statistically significant at follow up. However, while depression and anxiety increased in the routine care group, they decreased in the cognitive behavioral treatment group. The proportion of possible/probable clinical depression or anxiety was significantly lower in the treatment group than the control group. In contrast to that favorable outcome, another small but well-designed trial of cognitive-behavioral education with newly diagnosed RA patients, compared to standard care, found no significant improvements in functional status, helplessness, or self efficacy and no between-group differences at six months post-intervention [38]. The treatment in this trial was group sessions of two hours duration, once per week for four weeks. Could the different outcomes in the two trials be attributed to the intensity of the intervention (eight individual versus four group sessions)? The 'dose-response' relationship for most psychosocial interventions has not been fully investigated. Given their results, the authors of the latter study recommend re-examining the trend to offer cognitive behavioral treatment early in the disease course with a larger sample and longer follow up [38].
In a non-randomized trial of a seven-week educational program addressing pain and stress management, coping skills, goal-setting and exercise, compared to a wait-list control group in Korea, the intervention group showed significant improvement in the outcomes of pain and depression, but not functional status [39]. Additionally, there were significant associations between pain management skills, coping skills and the outcome measures, supporting the theory that training improves skills, which, in turn, improve outcomes. In another paper with a similar purpose, examining the mechanism by which stress management may mediate pain and depression in adults with RA, Rhee and colleagues [40] conducted a secondary analysis of their earlier clinical trial. Comparing a group of 47 who received comprehensive stress management training to 45 receiving standard rheumatologic care, they found support for the hypothesis that stress management based on CBT indirectly improves pain and depression via cognitive-behavioral variables (efficacy, coping and helplessness).
Only one study was found comparing psychosocial and medical interventions, although the primary outcome was depression rather than pain. This randomized controlled trial [41] compared three groups in the management of depression: CBT plus medication, attention plus medication, and medication only. Outcomes were measured at baseline, post-treatment (10 weeks), and 6 and 15 month follow-up assessments. Participants were 54 adults with RA and major depression. Unfortunately, after drop outs, only 13 or 14 participants remained in each group. There were no significant between-group differences on the main outcome of depression, nor for most secondary outcomes, including pain, self efficacy, helplessness, or coping.
One of the possible explanations for sometimes conflicting results across studies is the characteristics of the sample. What is 'right' for a young adult with early RA is likely not appropriate for an older adult with OA. In a study of homebound older adults experiencing moderate to severe symptoms of stiffness, fatigue and pain from RA or OA, more than half reported depression [42]. Those with RA reported less pain and limitations and greater self efficacy and social interactions than those with OA, suggesting that their arthritis had been better managed over the course of their illness. Self-management programs intended to address pain and psychosocial issues should consider the unique needs of different populations such as this one [42]. In another study of older women with RA or OA, Zautra and Smith [43] also found similarities and differences between the two disease-groups. While depression was related to pain in both groups it was associated with elevated stress and increased reactivity to stress in older women with RA but not those with OA, raising another set of immunological-related questions.
There may also be gender differences in selecting the best therapeutic approach. Hirsh and colleagues [15] report a significant relationship between pain-related disability in life activities and negative mood and that this relationship is stronger among women with chronic pain than in men. After controlling for negative mood, pain remains a predictor of overall disability in men, but is no longer a significant predictor of disability for women. Findings such as these may suggest different approaches for men and women. Personal preferences and personality may also play a part, but that moves beyond the scope of this review.
People also vary in their ability to cope and their health beliefs. It has been hypothesized that small beneficial effects from psychosocial interventions may result in part from heterogeneous samples with regard to their risk for psychosocial dysfunction. Evers and colleagues [44] recruited 64 patients with early RA with psychological profiles suggesting they were 'at risk', defined as scoring in the upper 30% of scores for anxiety or negative mood. Patients were randomly assigned to CBT or standard care. Using an individualized approach to CBT, where patients chose their priority topics for therapy during ten biweekly sessions plus a 'booster' follow-up session four weeks later, results demonstrated generally improved physical, psychological and social function, but no direct, significant effect on pain. However, only 11 patients in the CBT group chose pain management as a priority topic for intervention. This suggests CBT must be specifically applied to targeted symptoms and behaviors in order to have a measurable effect.
Role-specific interventions
Because the psychosocial interventions reviewed above are, to some degree, individualized, they are likely to address how to manage pain in specific situations or when fulfilling certain roles. That is, patients learn to apply the general strategies to their own priorities, such as better managing pain at work, family activities, or social situations. However, sometimes programs are designed to enhance performance of specific roles, appealing to a specific group of individuals based on the role first, and secondarily incorporating psychosocial approaches to pain management into program content. Given the stage set earlier in this paper, where the psychosocial impact of arthritis pain was related to social roles at work, family life, and leisure pursuits, this more contextual approach to organizing and delivering intervention may appeal to different audiences. Two examples are briefly cited here: vocational rehabilitation to maintain or facilitate return to employment, and programs aimed at enhancing social support and relationships.
The intervention used in a randomized trial of vocational rehabilitation counseling for people with RA at risk for job loss included a review of the nature of work, positive messages about each participant's ability to work and skills training on how to request and implement job accommodations. The control group received printed information alone. The result was significantly less job loss in the intervention group, demonstrating that job loss can be delayed or prevented [9].
The pain experience is influenced by interactions with significant others; therefore, some studies have investigated interventions involving family members [3]. There is a suggestion that involving family members in psychosocial interventions, such as cognitive behavioral approaches or CST, is beneficial for reducing arthritis symptoms, enhancing self efficacy, and improving social support for the person with arthritis, but the effect on family members is largely unmeasured [45].
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