Arthritis and pain. Psychosocial aspects in the management of arthritis pain

The purpose of this review is to summarize psychosocial factors associated with arthritis pain and highlight recent evidence for psychosocial approaches to managing arthritis pain. By definition, psychosocial factors refer to two dimensions of experience: the psychological (cognitive, affective) and social (interacting with others, engaging in life activities). Psychosocial factors influence the perception of pain and the presence of pain influences psychological well-being and social participation. After discussing the impact of arthritis pain on participation in work, family life, and leisure, evidence for psychosocial interventions is summarized, emphasizing reviews and studies published from January 2000 to August 2006.     

Hypothalamic-pituitary-adrenal stress axis function and the relationship with chronic widespread pain and its antecedents

In clinic studies, altered hypothalamic-pituitary-adrenal (HPA) axis function has been associated with fibromyalgia, a syndrome characterised by chronic widespread body pain. These results may be explained by the associated high rates of psychological distress and somatisation. We address the hypothesis that the latter, rather than the pain, might explain the HPA results. A population study ascertained pain and psychological status in subjects aged 25 to 65 years. Random samples were selected from the following three groups: satisfying criteria for chronic widespread pain; free of chronic widespread pain but with strong evidence of somatisation ('at risk'); and a reference group. HPA axis function was assessed from measuring early morning and evening salivary cortisol levels, and serum cortisol after physical (pain pressure threshold exam) and chemical (overnight 0.25 mg dexamethasone suppression test) stressors. The relationship between HPA function with pain and the various psychosocial scales assessed was modelled using appropriate regression analyses, adjusted for age and gender. In all 131 persons with chronic widespread pain (participation rate 74%), 267 'at risk' (58%) and 56 controls (70%) were studied. Those in the chronic widespread pain and 'at risk' groups were, respectively, 3.1 (95% CI (1.3, 7.3)) and 1.8 (0.8, 4.0) times more likely to have a saliva cortisol score in the lowest third. None of the psychosocial factors measured were, however, associated with saliva cortisol scores. Further, those in the chronic widespread pain (1.9 (0.8, 4.7)) and 'at risk' (1.6 (0.7, 3.6)) groups were also more likely to have the highest serum cortisol scores. High post-stress serum cortisol was related to high levels of psychological distress (p = 0.05, 95% CI (0.02, 0.08)). After adjusting for levels of psychological distress, the association between chronic widespread pain and post-stress cortisol scores remained, albeit slightly attenuated. This is the first population study to demonstrate that those with established, and those psychologically at risk of, chronic widespread pain demonstrate abnormalities of HPA axis function, which are more marked in the former group. Although some aspects of the altered function are related to the psychosocial factors measured, we conclude that the occurrence of HPA abnormality in persons with chronic widespread pain is not fully explained by the accompanying psychological stress.     

A multidisciplinary cognitive behavioural programme for coping with chronic neuropathic pain following spinal cord injury: the protocol of the CONECSI trial

Background  

Most people with a spinal cord injury rate neuropathic pain as one of the most difficult problems to manage and there are no medical treatments that provide satisfactory pain relief in most people. Furthermore, psychosocial factors have been considered in the maintenance and aggravation of neuropathic spinal cord injury pain. Psychological interventions to support people with spinal cord injury to deal with neuropathic pain, however, are sparse. The primary aim of the CONECSI (COping with NEuropathiC Spinal cord Injury pain) trial is to evaluate the effects of a multidisciplinary cognitive behavioural treatment programme on pain intensity and pain-related disability, and secondary on mood, participation in activities, and life satisfaction.     

What lies beyond the pain? A case report

The majority of people have back pain at some point in their lives and most are cured without any intervention. However, some patients develop chronic back pain and persistent disability. There is strong evidence that psychological factors significantly correlate with the development of chronic back pain. Back pain has also emerged as the strongest predictor of major depression. Assessing and treating patients in a manner that integrates psychosocial and biological aspects of care is the essence of excellent family medicine. This case illustrates the importance for primary care physicians of screening for depression and other psychosocial factors in assessing patients with persistent back pain.     

Do weather changes influence pain levels in women with fibromyalgia,and can psychosocial variables moderate these influences?

The aim of this study was to examine the association between fibromyalgia pain and weather, and to investigate whether psychosocial factors influence this relationship. Women with chronic widespread pain/fibromyalgia (N?=?50) enrolled in a larger study, were recruited from a 4-week inpatient rehabilitation program in Norway ( 2009–2010), and reported their pain and psychological factors up to three times per day (morning, afternoon, evening) for 5 weeks. These ratings were then related to the official local weather parameters. Barometric pressure recorded simultaneously impacted pain significantly while temperature, relative humidity, and solar flux did not. No psychological variables influenced the weather–pain interaction. No weather parameter predicted change in the subsequent pain measures. The magnitude of the inverse association between pain and barometric pressure was very small, and none of the psychological variables studied influenced the association between pain and barometric pressure. All in all, the evidence for a strong weather–pain association in fibromyalgia seems limited at best.     

Does suprascapular nerve block reduce shoulder pain following stroke: a double-blind randomised controlled trial with masked outcome assessment

Background  

Shoulder pain is a common complication of a stroke which can impede participation in rehabilitation programs and has been associated with poorer outcomes. The evidence base for current medical and therapeutic management options of hemiplegic shoulder pain is limited. This study will evaluate the use of suprascapular nerve block injection as part of an interdisciplinary approach to the treatment of shoulder pain following stroke. The technique has previously been proven safe and effective in the treatment of shoulder pain associated with rheumatoid arthritis and degenerative shoulder conditions but its usefulness in a stroke population is unclear.     

疼痛的性别差异

目前已有许多临床流行病学研究和实验研究证实了人类的疼痛存在性别差异。临床迹象表明疼痛存在性别差异,许多慢性疼痛疾病（偏头痛、颞下颌关节痛、纤维肌痛、风湿痛等）的发生率女性明显高于男性。女性对一些实验性疼痛（机械刺激痛、电刺激痛、热刺激痛等）更加敏感,痛阈和对疼痛的耐受性比男性低,而且女性月经周期与疼痛有关。啮齿动物实验研究也发现存在疼痛的性别差异。但是在不同动物研究或不同实验性疼痛刺激下雌雄性别的反应不完全相同,这些差异可能是由很多影响因素所导致的。目前许多研究对疼痛存在性别差异的解释也有所不同,机制尚不清楚,可能的因素包括：生物因素（性激素、内源性镇痛、基因等）、社会心理因素以及两者的相互作用等。     

Back pain--individual and genetic factors.

BACKGROUND: In research, back pain can be classified in several ways. This presentation will deal with 'self-reported back pain', which is a proxy measure of 'having back pain'. The terms 'individual factors' cover many aspects of human life. They also interact with external factors, such as work and environment. Back pain is prevalent at all ages, although the incidence (onset) probably is highest in the early teens. Causative and modifying factors may differ throughout life and it is not sure that the etiology of 'back pain' remains the same. If we are to prevent and treat back pain in an efficient way, it is essential that we understand the circumstances that bring it on or prevent it from getting better. The mode of action would depend on whether the responsibility lies mainly with the individual, for example through a change of life-style, or with others, for example by altering the work place. METHOD: My presentation will consist of three elements, evidence obtained from: (1). systematic literature reviews, (2). epidemiologic studies, and (3). genetic epidemiologic studies. All the information presented is based on own work and pertains to children/adolescents and adults, mostly in relation to low back pain (LBP). The evidence will be reviewed in the light of 'the weight of evidence' on the topics of: genetics, sedentary life-style, type of work and imaging findings. Also factors relating to social class and physical/psychological robustness will be discussed. RESULTS: There is evidence for a relatively strong genetic component to LBP, both in the young and in adults. Hard work is strongly linked to LBP and there is a moderate link with abnormal imaging findings (spinal pathology in the young and discal degeneration in both the young and the adults). In addition, a weak psychological and psychological constitution appears to be of interest, at least in the young. However, there is no evidence for a causal link between a sedentary life-style and LBP, neither in the young nor in the adults. CONCLUSIONS: Some myths in the area of back pain are dispelled by the evidence in relation to personal and genetic factors and some new elements need considering. It is suggested that we should look for populations at risk, rather than looking for risk factors. Populations at risk would consist of people with a weak psychological and physiological constitution, who more easily than others may develop long lasting back pain as well as other CLINICAL SIGNIFICANCE: Early identification of high risk populations will allow for a selective primary and secondary preventive approach.     

Arthritis and pain. Current approaches in the treatment of arthritic pain

Current evidence suggests that although persistent arthritic pain is initiated and maintained by articular pathology, it is also heavily influenced by a range of other factors. Strategies for treating arthritic pain are therefore different from those adopted for acute pain. Although published guidelines offer general assistance, the complexity of underlying mechanisms requires that measures designed to relieve pain must take into account individual biological, psychological and societal factors. It follows that a combination of both pharmacological and non-pharmacological approaches offers the best opportunity for therapeutic success, although determining the effectiveness of such complex interventions remains difficult. Pharmacological therapy is often prolonged, and safety and tolerability issues become as important as efficacy over time.     

Neuropathic-like pain features and cross-sectional associations in rheumatoid arthritis

IntroductionIncreasing evidence indicates that features suggestive of neuropathic pain may also be present in patients with common rheumatic conditions. The objective of this study was to examine neuropathic-like pain symptoms and associated factors in patients with rheumatoid arthritis.MethodsWe used the painDETECT screening tool to identify possible or likely neuropathic pain in 159 outpatients with rheumatoid arthritis. Patients additionally completed other self-reported measures, while clinical measures were assessed to calculate the 28-joint Disease Activity Score. Univariate analyses and multivariable logistic regression were used to identify factors associated with neuropathic pain features.ResultsAccording to the painDETECT, 27 patients (17.0 %) were classified as having likely neuropathic pain and 34 patients (21.4 %) as having possible neuropathic pain. Besides reporting more severe pain, patients with likely or possible neuropathic pain were more likely to meet the diagnostic criteria for fibromyalgia, to use analgesics, and to have more tender joints and a worse physical and mental health status as measured by the 36-item Short-Form health survey. In multivariable analysis, physical (P < 0.001) and mental health status (P = 0.006) remained significantly associated with neuropathic pain features, even after controlling for pain severity.ConclusionsThese findings suggest that a sizeable proportion of patients with relatively well-controlled rheumatoid arthritis report symptoms suggestive of neuropathic pain. Neuropathic-like pain symptoms are independently associated with worse self-reported physical and mental health.     

Psychological characteristics of Japanese patients with chronic pain assessed by the Rorschach test

Background  

The increasing number of patients with chronic pain in Japan has become a major issue in terms of the patient's quality of life, medical costs, and related social problems. Pain is a multi-dimensional experience with physiological, affective, cognitive, behavioral and social components, and recommended to be managed via a combination of bio-psycho-social aspects. However, a biomedical approach is still the dominant method of pain treatment in Japan. The current study aimed to evaluate comprehensive psychological functions and processes in Japanese chronic pain patients.     

Neural and psychosocial contributions to sex differences in knee osteoarthritic pain

People with osteoarthritis (OA) can have significant pain that interferes with function and quality of life. Women with knee OA have greater pain and greater reductions in function and quality of life than men. In many cases, OA pain is directly related to sensitization and activation of nociceptors in the injured joint and correlates with the degree of joint effusion and synovial thickening. In some patients, however, the pain does not match the degree of injury and continues after removal of the nociceptors with a total joint replacement. Growth of new nociceptors, activation of nociceptors in the subchondral bone exposed after cartilage degradation, and nociceptors innervating synovium sensitized by inflammatory mediators could all augment the peripheral input to the central nervous system and result in pain. Enhanced central excitability and reduced central inhibition could lead to prolonged and enhanced pain that does not directly match the degree of injury. Psychosocial variables can influence pain and contribute to pain variability. This review explores the neural and psychosocial factors that contribute to knee OA pain with an emphasis on differences between the sexes and gaps in knowledge.     

Psychologische Aspekte des Diabetes in Kindheit und Adoleszenz

The intensified insulin therapy of type 1 diabetes imposes considerable demands in everyday life of children, adolescents and their families that often interfere with normal developmental tasks. Accordingly current guidelines on paediatric diabetes stated that psychosocial factors are the most important influences affecting the care and management of the chronic illness. This article reviews the main research findings from studies on psychological coping, family burden and dynamics, neurocognitive functioning, stress, psychosocial risk factors, psychological health and psychiatric disorders. In addition psychological support, age-appropriate educational and behavioural interventions as an integral part of every type 1 diabetes long-term therapy are described. Finally the vital role and the current situation of psychologists and social workers as members of the interdisciplinary paediatric diabetes teams especially in the context of the German Disease –Management Program for type 1 diabetes are discussed.     

Psychological assessment of factors affecting pain

Use of traditional stimulus-response models of pain leads to differentiation between organic and psychogenic pain, which is often not helpful, if not dangerous, in treating chronic pain. Pain does not simply reflect bodily damage but also complex psychological malfunctioning. Viewing chronic pain as an obsessional state may often help in treating the entire patient and prevent the physician from being obsessed with the patient''s obsession. Psychological assessment of pain should focus on the role of psychological processes in the multifactorial causation of the illness causing the pain, notably their role in illness-proneness in general. Also, iatrogenic psychological distress, associatively precipitated psychological conflict and illness-perpetuating psychological processes should be looked for. A serious obstacle to progress with pain problems is not lack of hard data but conceptual confusion. Before medicine can meaningfully assess psychological factors in pain problems it must first learn to perceive psychological disturbances in medical and surgical patients.     

Psychosocial Mechanisms Linking the Social Environment to Mental Health in African Americans

Resource-poor social environments predict poor health, but the mechanisms and processes linking the social environment to psychological health and well-being remain unclear. This study explored psychosocial mediators of the association between the social environment and mental health in African American adults. African American men and women (n = 1467) completed questionnaires on the social environment, psychosocial factors (stress, depressive symptoms, and racial discrimination), and mental health. Multiple-mediator models were used to assess direct and indirect effects of the social environment on mental health. Low social status in the community (p < .001) and U.S. (p < .001) and low social support (p < .001) were associated with poor mental health. Psychosocial factors significantly jointly mediated the relationship between the social environment and mental health in multiple-mediator models. Low social status and social support were associated with greater perceived stress, depressive symptoms, and perceived racial discrimination, which were associated with poor mental health. Results suggest the relationship between the social environment and mental health is mediated by psychosocial factors and revealed potential mechanisms through which social status and social support influence the mental health of African American men and women. Findings from this study provide insight into the differential effects of stress, depression and discrimination on mental health. Ecological approaches that aim to improve the social environment and psychosocial mediators may enhance health-related quality of life and reduce health disparities in African Americans.     

“Just Get on with It”: Qualitative Insights of Coming to Terms with a Deteriorating Body for Older Women with Osteoarthritis

Objective

To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease.

Methods

Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women’s Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework.

Results

The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic ‘day to day’ process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management.

Conclusion

The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.     

Arthritis and pain. Future targets to control osteoarthritis pain

Clinical presentation of osteoarthritis (OA) is dominated by pain during joint use and at rest. OA pain is caused by aberrant functioning of a pathologically altered nervous system with key mechanistic drivers from peripheral nerves and central pain pathways. This review focuses on symptomatic pain therapy exemplified by molecular targets that alter sensitization and hyperexcitability of the nervous system, for example, opioids and cannabinoids. We highlight opportunities for targeting inflammatory mediators and their key receptors (for example, prostanoids, kinins, cytokines and chemokines), ion channels (for example, NaV1.8, NaV1.7 and CaV2.2) and neurotrophins (for example, nerve growth factor), noting evidence that relates to their participation in OA etiology and treatment. Future neurological treatments of pain appear optimistic but will require the systematic evaluation of emerging opportunities.     

Correlates of Regular Participation in Sports Groups among Japanese Older Adults: JAGES Cross–Sectional Study

Background

Participation in a sports group is key for the prevention of incident functional disability. Little is known about the correlates of older adults’ participation in sports groups, although this could assist with the development of effective health strategies. The purpose of this study was to identify the demographic and biological, psychosocial, behavioral, social and cultural, and environmental correlates of sports group participation among Japanese older adults.

Methods

Data were obtained from the Japan Gerontological Evaluation study, which was a population–based cohort of people aged ≥65 years without disability enrolled from 31 municipalities across Japan (n = 78,002). Poisson regression analysis was used to determine the associations between the factors and participation in sports groups.

Results

Non-regular participation in sports groups was associated with lower educational level, being employed, and working the longest in the agricultural/forestry/fishery industry among the demographic and biological factors and poor self-rated health and depression among the psychosocial factors. Of the behavioral factors, current smoking was negatively associated and current drinking was positively associated with regular participation in sports groups. Among the social and cultural factors, having emotional social support and participating in hobby clubs, senior citizen clubs, or volunteer groups were associated with a high prevalence of participation in sports groups. Perceptions of the presence of parks or sidewalks, good access to shops, and good accessibility to facilities were positively associated with participation in sports groups among the environmental factors.

Conclusions

Our study suggests that the promotion of activities that could increase older adults’ participation in sports groups should consider a broad range of demographic and biological, psychosocial, behavioral, social and cultural, and environmental factors. Although future longitudinal studies to elucidate the causal associations are needed, encouraging participation in community groups through social networks might be effective for participation in sports groups.     

Glutamate receptors and pain

Pain is an important survival and protection mechanism for animals. However, chronic/persistent pain may be differentiated from normal physiological pain in that it confers no obvious advantage. An accumulating body of pharmacological, electrophysiological, and behavioral evidence is emerging in support of the notion that glutamate receptors play a crucial role in pain pathways and that modulation of glutamate receptors may have potential for therapeutic utility in several categories of persistent pain, including neuropathic pain resulting from injury and/or disease of central (e.g., spinal cord injury) or peripheral nerves (e.g., diabetic neuropathy, radiculopathy) and inflammatory or joint-related pain (e.g., rheumatoid arthritis, osteoarthritis). This review focuses on the role of glutamate receptors, including both ionotropic (AMPA, NMDA and kainate) and metabotropic (mGlu1-8) receptors in persistent pain states with particular emphasis on their expression patterns in nociceptive pathways and their potential as targets for pharmacological intervention strategies.     

Personal experiences of the psoriasis and its relation to the stressful life events

Psoriasis is a disease with a profound impact on the psychological and social aspects of the patient, particularly because of its visibility. Quality of life is impaired and different mental health disorders like depression, anxiety, alcoholism, posttraumatic stress disorder (PTSD) are found among persons suffering from psoriasis. Studies have shown the influence of stressful life events on onset, exacerbation and relapse of psoriasis. Rare studies explored prevalence of psoriasis during war times and relations between psoriasis and war provoked PTSD. Psoriasis is a disease with multiple possible causes and additional caution is necessary among medical professional to recognize all contributing factors. This report describes a case of a person whose first episode of psoriasis appeared six months after engaging in combat activities. He is diagnosed with psoriasis vulgaris, psoriatic arthritis and permanent personality changes after the traumatic experiences caused by war participation. His occupational history is burdened with additional causational factors; work with heavy metals and metal dusts. Cumulative effects of different aetiological factors can contribute to psoriasis with intensive trauma induced stressors serving as a trigger. His medical history indicates cognitive difficulties typical for early dementia which makes this case even more interesting. Research results suggesting common aetiology of psoriasis, autoimmune diseases and neurodegenerative diseases, indicate a need, as in the case of our patient, for multidisciplinary approach to studying aetiology of psoriasis.