Francis Keefe, PhD, professor of health psychology at Ohio University, Athens, directs a research program exploring new strategies for assessing and treating pain. The former director of a pain management program at Duke University, Keefe has studied psychological approaches to pain control in arthritis and other chronic conditions for more than two decades.

Q: How do psychological factors contribute to arthritis?

A: We have strong evidence that psychosocial factors contribute to pain and psychological disability, and to some extent to physical disability in people who have arthritis.[5]

What's controversial is the relationship between stress and the onset of arthritis. Many rheumatoid arthritis patients believe that a major life event predated the onset of their symptoms. If you actually look at studies, however, it is not a consistent relationship.

Others have explored the relationship between personality and the development of rheumatoid arthritis. At one time, investigators thought there might be a particular personality type predisposed to arthritis, but we now know that that's not the case. There is no "arthritic personality."

Q: What are some of the factors that contribute to the course of the disease?

A: Self-efficacy is one of the biggest - the degree to which people feel confident that they can manage their arthritis pain and other symptoms. People with arthritis vary substantially in their levels of self-efficacy. You can have two people with a moderate degree of arthritis affecting the hand joints, for example. One will feel very confident in his or her ability to manage the pain and the other won't. Studies show that the patient with greater self-efficacy will likely report less pain and better adjustment to arthritis than the patient with lower self-efficacy.[7]

Q: How can people improve their self-efficacy?

A: They do it by learning skills for controlling arthritis pain and other aspects of the disease. We often train them in group sessions where they work with other people with arthritis. There's a lot of emphasis on practicing the skills during the sessions. And people not only learn the skill through this rehearsal procedure, they also learn they can effectively manage their pain and other aspects of their disease. And that enhances their self-efficacy.

Q: What non-drug techniques are effective?

A: Relaxation training is one of the best. We do a lot of work with very brief applied relaxation. We teach people how to do a body scan, to quickly scan through muscles that are tense and let the excess tension go. We have them do this for 30 seconds perhaps 20 to 30 times a day, and we give them some little adhesive-backed colored dots and have them paste them around as reminders. One woman recently got these little smiling faces and put them up all over her home and office. She used them as way to prompt herself, "I'm going to take 30 seconds and let the tension go."

Q: Are any other behavioral tools effective?

A: Many people with arthritis have trouble balancing their daily activities. They tend to overdo and then their symptoms flare up, and then they cut back on activities. We teach people to identify systematically the things they overdo and show them how to balance activity by using periods of moderate activity and limited rest.

Many people with chronic conditions like arthritis do the obligatory things that have to be done every day, but the pleasant things that might serve as distractions from pain and other symptoms seem to fall by the wayside. We do a lot of work helping people get in touch with what they like to do, developing goals they'd like to work on. They start with a minimum number of goals and gradually build up so that the daily activities they engage in become much more varied and pleasurable.

Q: How important is support from friends and family?

A: We know from many studies that, where there is higher perceived social support, people seem to do much better with their arthritis. In fact, we've done some studies that demonstrate that it is helpful for both the patients and their partners to learn pain control and other coping techniques.[6]

When the partners also learn the coping techniques, it helps enhance their understanding that the symptoms are there, that they vary. It also helps them avoid interfering with the goals of treatment. Sometimes you want to maintain activities in people with arthritis and a spouse might be saying, "No, no. That's the last thing my wife should be doing." And spouses, just by going through the training, benefit from knowing when the person is hurting, and what their needs are.

Interview #2:'The Self-Management Course'

Kate Lorig, DrPH, is an associate professor in the Stanford University School of Medicine and director of the Stanford Patient Education Research Center. She and her colleagues developed the Arthritis Self-Management Program now offered nationwide by Arthritis Foundation chapters and replicated in Canada, Great Britain, Australia, and New Zealand. Lorig co-authored The Arthritis Helpbook (Addison-Wesley, 1995), a companion to the program.

Q: Tell us about the Arthritis Self-Management Program.

A: It differs from most patient education programs in a number of ways. First, it is taught by lay people - people with arthritis teaching other people with arthritis. Second, we don't teach a topic of the week. We teach a little bit each week about exercise, pain management, or problem-solving techniques and then have people practice these skills. We are trying to give people confidence in their ability to manage the disease.

We started the program in the late 1970s. Over the years, we've studied 3,000 to 4,000 people - some for as long as four years. At four years, we find people who have taken the course have a 19 percent reduction in pain and their disability has increased by just 9 percent - which is less than the 12 percent to 20 percent increase we'd expect over that period of time. And they have 43 percent fewer visits to physicians. Assuming $45 per physician visit, we calculated a savings of $647 for each patient in the program who had rheumatoid arthritis and $189 for each patient with osteoarthritis.[9]

Q: Why is exercise important?

A: For a number of reasons. If you are inactive, you end up having weak, tense muscles; and weak, tense muscles cause pain. Stronger muscles also help protect weaker joints. Exercise obviously keeps you fitter, and it helps with weight maintenance, which is important to people with arthritis. Exercise also is one of the things that is really good to help fight depression.

We don't teach people a specific exercise program. We teach people the skills they need to develop their own program. People come in with different activity levels and different things that they want to do and can do. Also, since arthritis changes over time, we want people to have the skills to modify their exercise programs as necessary, rather than just drop the whole thing.

Q: You also teach pain and stress management techniques?

A: We teach two different forms of relaxation techniques. One is progressive muscle relaxation, in which individuals relax one set of muscles at a time and continue throughout the body. The second is guided imagery, where we basically just tell them a story and have them imagine, for example, that they are on a walk through a garden and the woods and they see running water and it is pleasant.

We also teach people about their "self talk" - the stuff we talk about in our heads all the time, which to a great extent determines our behavior. If you tell yourself, "I don't really want to get up this morning. It's too cold. I'll stay in bed and won't exercise," that's probably what you'll do. We make people more aware of these self-defeating messages and give them techniques for changing them.

Q: How do you teach problem solving?

A: We first have patients identify a problem: "I can't go upstairs." Well, why can't you go upstairs? "I'm afraid I'm going to fall." Then we have them make a list of solutions, try one, and if it doesn't work, try another. We teach people this procedure and go through it with them lots of times. And anytime anybody in the class has a problem - and the problem may be, "I wasn't able to take my walk on Thursday because it was raining" - the leader will then say, "Does anybody in the group have any suggestions?" We always get the solutions generated in the group, rather than the leader saying, "Why don't you do this?"

Q: Why do people with arthritis teach the course rather than health professionals?

A: For one, it makes it hard for people in the group to say to the instructor, "You don't know what it feels like," when in fact the instructors do know. Second, having a role model is a strong way of building self-confidence. Health professionals also tend to tell people what they should be doing rather than lead them through the problem-solving and other techniques that we emphasize in the course.

In one study we compared people who took the course taught by a health professional with people who took the course taught by a lay instructor. From the health professionals, people learned a lot more, but with lay instructors, people did a lot more.[10]

Another advantage is a systems thing. If we are talking about an intervention that is going to reach even 5 or 10 percent of the people with arthritis in this country, there are not anywhere near enough health professionals to teach that many courses.

How to Spell R-E-L-I-E-F:

Education programs can give arthritis patients up to 80 percent more relief from pain and joint tenderness than they can get from some medications alone.[14]

Kate Lorig, DrPH, of Stanford University, and colleagues examined 19 controlled trials of arthritis patient education and 28 placebo-controlled trials of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen, and indomethacin. They calculated that the education programs gave rheumatoid arthritis patients 20-40 percent more pain relief and decreased disability than what they received from NSAIDs alone, and 60-80 percent more relief from tender joints.

The findings "should encourage physicians and arthritis health professionals to incorporate formal education interventions in the treatment of patients with chronic arthritis," the investigators say.

Helping Kids Help Themselves

Children and adolescents with rheumatoid arthritis can also benefit from behavioral techniques to reduce pain and improve daily functioning.[8]

John V. Lavigne, PhD, and colleagues at Northwestern University enrolled eight children aged 9 to 17 years in a six-session program to reduce pain that combined relaxation training and biofeedback. The children studied progressive muscle relaxation. Biofeedback sensors that displayed changes in forehead muscle tension and skin temperature helped the children see when they had achieved the desired relaxation response.

Half of the children achieved a 25 percent reduction in pain (considered clinically significant) after completing the course. Almost two-thirds experienced a similar reduction in severe pain episodes, Lavigne and colleagues found. Half of the children displayed additional improvements in average pain and severely painful episodes six months after completing the program.

Family Stress and Arthritis Progression

Stress may be a key factor in the progression of arthritis. Stress in dealing with family members and others appears to exacerbate arthritis patients' reports of pain and joint tenderness, and these reports are supported by laboratory-measured physiological markers of increased disease activity.[15]

"How we deal with and adapt with various problems in our lives has a direct relationship with the course of illnesses that we may have," says Alex J. Zautra, PhD, of Arizona State University, Tempe. "People with a chronic illness like arthritis must learn not only to manage the negative emotional consequences of having a painful disease, they also need to preserve some positive engagement with activities that do not simply revolve around managing illness and pain. Both of these tasks are important, not only in terms of their quality of life but perhaps also in terms of affecting the course of the disease."

In one study, Zautra and his colleagues followed 41 women with rheumatoid arthritis for 12 to 20 weeks, interviewing them weekly about stressful events and encounters with family members and their overall pain and functioning. During particularly stressful weeks, clinicians drew blood from the women to assess immune system activity and inflammation, and rated the overall severity of their disease.

Stressful encounters with family members, particularly spouses, were the women's primary sources of stress. During the stressful periods, the women not only reported significantly more pain, the clinical exams revealed more joint tenderness and swelling. Their blood samples also had greater T-cell activity and levels of another immune system component, interleukin 2-receptors, signaling an increase in inflammation.

Zautra and colleagues also found that the effects of stress were not as severe for women who remained actively engaged with others, particularly spouses. For those who tended to withdraw, as people often do when they are also depressed, stress had a stronger effect on arthritis symptoms. "That kind of response may not only worsen arthritis patients' quality of life and their ability to adapt to the disease, but we suspect it may also affect the disease itself," Zautra says.

More recently Zautra and colleagues have been examining the effects of stress and depression in 100 patients with rheumatoid arthritis, 90 patients with osteoarthritis, and 90 healthy controls.[16]

Preliminary results show that both rheumatoid arthritis and osteoarthritis patients report more pain, joint tenderness, and swelling when stressed, Zautra says. Those who were depressed showed a greater reaction and more sustained increase in arthritis symptoms and activity in response to stress. Finally, rheumatoid arthritis patients seemed to get more depressed in response to stress than did osteoarthritis patients.

"We think there is an important difference between rheumatoid arthritis patients and osteoarthritis patients and how depression affects their reaction to stress," Zautra says. "And we suspect it is regulated through immune changes, both as a function of having depression and having an autoimmune disease."

43,000,000 and Rising

• Nearly 43 million Americans - one in every six - have arthritis, a collection of more than 100 different diseases that cause pain and swelling and limit movement in joints and tissue throughout the body.
• Arthritis is the leading cause of disability among Americans over age 15. More than half of those affected are under age 65.
• Arthritis costs the U.S. economy $65 billion a year in medical care and lost wages - equivalent to a moderate recession.
• Arthritis accounts for 39 million physician visits and more than half a million hospitalizations a year.

• The Centers for Disease Control and Prevention estimates that 59.4 billion Americans - one in five - will have arthritis by 2020.
• Half of all people with arthritis today believe nothing can be done to help them.

The Research:

1. Arthritis Foundation. (1999). "Arthritis Fact Sheet." Arthritis Foundation, P.O. Box 7669, Atlanta, GA 30357-0669

2. Bennett RM, et al. (March 1996). "Group Treatment of Fibromyalgia: A Six-Month Outpatient Program." Journal of Rheumatology, 23: 521-8.

3. Evers A, et al. (1998). "Psychosocial Predictors of Functional Change in Recently Diagnosed Rheumatoid Arthritis Patients." Behavior Research and Therapy, 36(2): 179-193.

4. Flor H and Turk DC. (1988). "Chronic Back Pain and Rheumatoid Arthritis: Predicting Pain and Disability from Cognitive Variables." Journal of Behavioral Medicine, 11:251.

5. Keefe FJ and Caldwell DS. (1997). "Cognitive Behavior Control of Arthritis Pain." Medical Clinics of North America, 81(1): 277-290.

6. Keefe FJ, et al. (1996). "Spouse-Assisted Coping Skills Training in the Management of Osteoarthritic Knee Pain." Arthritis Care and Research, 9(4): 279-291.

7. Keefe FJ, et al. (1997). "Pain Coping Strategies and Coping Efficacy in Rheumatoid Arthritis: A Daily Process Analysis." Pain, 69(1): 35-42.

8. Lavigne JV. (1992). "Evaluation of a Psychological Treatment Package for Treating Pain in Juvenile Rheumatoid Arthritis." Arthritis Care and Research, 5(2): 101-110.

9. Lorig K and Holman H. (1993). "Arthritis Self-Management Studies: A Twelve-Year Review." Health Education Quarterly, 20(1): 17-28.

10. Lorig K, et al. (1986). "A Comparison of Lay-Taught and Professional-Taught Arthritis Self Management Courses." Journal of Rheumatology, 13(4): 763-767.

11. NIH Technology Assessment Panel. (1996). "Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia." Journal of the American Medical Association, 276: 313-318.

12. Parker JC. (1995). "Effects of Stress Management on Clinical Outcomes in Rheumatoid Arthritis." Arthritis & Rheumatism, 38(12): 1807-1818.

13. Smyth JM, et al. (1999). "Effects of Writing about Stressful Experiences on Symptom Reduction in Patients with Asthma or Rheumatoid Arthritis." Journal of the American Medical Association, 281(14): 1304-1309.

14. Superio-Cabuslay E, et al. (1996). "Patient Education Interventions in Osteoarthritis and Rheumatoid Arthritis: A Meta-Analytic Comparison with Nonsteroidal Anti-inflammatory Drug Treatment." Arthritis Care and Research, 9(4): 292-301.

15. Zautra AJ, et al. (1997). "Examination of Changes in Interpersonal Stress as a Factor in Disease Exacerbation among Women with Rheumatoid Arthritis." Annals of Behavioral Medicine. 19(3): 279-286.

16. Zautra AJ, et al. (in press). "Field Research on the Relationship Between Stress and Disease Activity in Rheumatoid Arthritis." Annals of the New York Academy of Sciences.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

For more information contact:
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