Arthritis: What, Why, and Moving Forward

There are four main types of arthritis. They are known as rheumatoid arthritis, osteoarthritis, fibromyalgia, and gout (CDC, 2018). Each is unique, but they all have many similarities with their major commonalities being joint pain, stiffness, and chronic pain (CDC, 2018). Based on the research gathered in this paper, it’s purpose is to educate on the background of each type of arthritis and suggest possible interventions while working with patients suffering from each condition. Throughout the process of gathering data, studies highlighting interventions on topics related to body functionality, body image, self image, self efficacy, self management, perseverance, and other psychological factors affecting the studies’ described patients were intentionally sought out. This was because these factors are not actually condition specific, meaning the intervention in the study could potentially be applied to the treatment of those with a different variety of arthritis.

The Illness and Treatments

Rheumatoid Arthritis (RA)

Rheumatoid arthritis is an autoimmune disease that attacks the joints in the patient’s body. An autoimmune disease is characterized by the way the immune system mistakenly attacks healthy cells in the patient’s body. RA is known to be an autoimmune disease, and it is unclear what actually causes the immune system to attack these healthy cells. This disease can present itself at any time in life, although it is more heavily associated for those of an older age (CDC, 2018). Rheumatoid arthritis causes painful swelling in the joints, most often in multiple pairs of joints at once. In fact, joint pain and swelling is symmetrical with RA (Uni. of WI, 2017). For example, if the patients left knee is affected, so is the right. Tissue damage can also spread to other parts of the body such as the lungs, heart, and eyes (CDC, 2018). The joints most commonly affected by RA are the hands, wrists, and knees (CDC, 2018). There are several additional symptoms such as fatigue, weight loss, obesity, and weakness (CDC, 2018). RA being an autoimmune disease has other unique treatments than other types of arthritis. The names of these drugs are disease-modifying antirheumatic drugs (DMARDs), biologic response modifiers, and corticosteroids (MFMER, 2018). These drugs are meant to slow down or suppress the immune system to stop attacking joints (MFMER, 2018). If left untreated, RA could potentially be fatal (CDC, 2018).

Osteoarthritis (OA)

Osteoarthritis is a type of arthritis formed repetitive damage on the joints over the course of several years (CDC, 2018). Known as a degenerative disease, the condition worsens over time as the joint cartilage in between the bones continues to breakdown (CDC, 2018). The symptomology for OA includes much pain and stiffness, decrease in mobility/flexibility, and possible swelling (CDC, 2018).

Fibromyalgia

There is a form of arthritis that causes pain all over the body, known as fibromyalgia. It is caused by abnormal pain perception processing, making patients with fibromyalgia more sensitive than those without it (CDC, 2018). The symptoms of fibromyalgia include pain/stiffness all over their body, fatigue/tiredness along with sleep problems, depression/anxiety, tingling in hands or feet, headaches/migraines, and problems with thinking, memory, and concentration (CDC, 2018). Fibromyalgia also presents other illness-like symptoms such as temporomandibular joint syndrome (TMJ); characterized by pain in the face or jaw and also presents in conjunction with digestive problems such as abdominal pain, bloating, constipation, and irritable bowel syndrome (IBS) (CDC, 2018). Fibromyalgia can also be developed at anytime, starting as early as childhood, although most cases present themselves over many years and are eventually diagnosed when the patient reaches middle age (CDC, 2018).

Gout

Gout, which is arthritis flare-ups caused by hyperuricemia, is an overabundance of uric acid in the body which then forms uric acid crystals in the joints (CDC, 2018). Most flare-ups occur in the toes, ankles, or knees with symptoms presenting as intense pain, redness, swelling, and heat (CDC, 2018).

Common Treatments

Despite the differences between the different forms of arthritis, the treatments are very similar. There are two main goals in the treatment of arthritis, improving joint function/mobility and alleviating pain (MFMER, 2018). The medications for pain relief include analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and counterirritants (MFMER, 2018). Analgesics are painkillers such as Tylenol or Oxycodone (MFMER, 2018). NSAIDs are both painkillers and anti-inflammatory drugs such as Aleve or Advil (MFMER, 2018). Counterirritants are creams or gels containing menthol or capsaicin, both of which are thought to hinder the transmission of pain signals from the joint to the brain (MFMER, 2018). Surgery is another option for treatment which includes joint fusion, repair, and replacement (MFMER, 2018).

Biopsychosocial Factors

Rheumatoid Arthritis (RA)

RA is an autoimmune disease, so those with a family history of autoimmune diseases are more at risk than the average to develop RA (CDC, 2018). While RA can potentially present itself at any age, those who are in the age range of 60 and up are the most likely to develop the disease (CDC, 2018). Early life exposures such as breathing second hand smoke or being raised in a lower class family contributes to the disease’s development (CDC, 2018). Sex is also an important factor as men are more likely than women to have RA (CDC, 2018). Risk factors include smoking, women who have never given birth, and obesity (CDC, 2018).

Osteoarthritis (OA)

There are factors that put certain individuals at higher risk for OA including previous joint injury/overuse, advanced age, being obese, and genetics (CDC, 2018). Also, women and Asians are more likely to develop OA (CDC, 2018).

Fibromyalgia

There are several known risk factors of fibromyalgia such as being a woman (twice as likely to have fibromyalgia), stressful or traumatic events such as car crashes or PTSD, illness, repetitive injuries, family history, and obesity (CDC, 2018). It is also common for an individual with fibromyalgia to also have RA or lupus before developing fibromyalgia (CDC, 2018).

Gout

The biopsychosocial factors affecting the probability of developing gout include being male, being obese, certain medications, certain health conditions, eating or drinking things high in fructose, and drinking alcohol (CDC, 2018).

Psychological Reactions

An arthritis patient finds themselves in a day to day struggle with chronic pain which creates a circular cycle of negative emotions (Arthritis Foundation, 2016). Negative emotions and pain go hand and hand, with negative emotions leading to more pain and that pain leading to more negative emotions. In fact, individuals with RA, OA, or fibromyalgia actually have much higher rates of depression and anxiety than arthritis-free individuals (Arthritis Foundation, 2016). In addition to anxiety and depression, stress is also a common reaction to living with the disease as it makes daily functions difficult (CDC, 2018; Oh et al., 2018) Lastly, negative self-image is a major issue for individuals with arthritis (Oh et al., 2018). Men start to lose their sense of masculinity as the arthritis develops and the lose the ability to do certain activities that defined them (Flurey et al., 2017). Women also experience negative self image, specifically body image. It was actually mentioned by several women to researchers that they felt as though that body image is not discussed enough in therapy (Alleva et al., 2018). Fifty-four female patients were found in the hospital being treated with RA. They were given surveys in order to measure pain, positive effects, and negative effects (Kwissa-Gajewska & Graszczyrisja, 2017). The researchers had originally predicted that higher levels of optimism would ‘protect’ patients, enhancing the positive effects and decreasing the negative ones (Kwissa-Gajewska & Graszczyrisja, 2017). The opposite was found to be true, with low optimism actually decreasing positive effects and increasing negative effects (Kwissa-Gajewska & Graszczyrisja, 2017). More findings of the study were that lower optimism was far more common among patients and that higher optimism isn’t necessarily going to protect them from having more negative effects than positive ones (Kwissa-Gajewska & Graszczyrisja, 2017).

Interventions

A study was done to prove that psychological intervention help the management of RA. The study was done with intention to complete several objectives. Firstly, they wanted to see if there was any measurable difference in biopsychosocial outcomes post intervention (Prothero et al., 2016). Secondly, they wanted to determine if intensity of the intervention, number/duration of sessions, and duration of intervention had any effect on the outcome of the intervention (Prothero et al., 2016). Lastly, they wanted to see if other groups that received ‘usual care’ or education on their condition would have any impact on the outcome (Prothero et al., 2016). Along with at least one form of medication and one or more of several types of psychological intervention was used including the following: cognitive behavioral therapy (CBT), supportive counselling, psychotherapy, self-regulatory techniques, mindfulness-based cognitive therapy, and disclosure therapy (Prothero et al., 2016). The outcomes recorded were pain, fatigue, psychological status, functional disability, and disease activity (Prothero et al., 2016). The study concluded that there are measurable effects on the outcomes post psychological intervention, especially compared to those who didn’t receive an intervention (Prothero et al., 2016). There was a small improvement noted in the patient’s global assessment, functional disability, pain, fatigue, anxiety, and depression; higher levels of improvement were recorded in coping, self-efficacy, and physical activity (Prothero et al., 2016). In addition, the recorded improvements for depression, coping, and physical activity were maintained over 8.5 to 14 months (Prothero et al., 2016). Therefore, psychological intervention could be used as an extremely powerful tool in helping improve the condition of arthritis patients.

All types of arthritis are conditions that are chronic, meaning they will never be cured, and progressive, meaning the condition will continue to worsen as time passes. The treatment of arthritis requires a plan of action that is applied outside of the doctor’s office. The patient will have to be responsible for the management of their own condition. This can be an incredibly difficult process for some patients when they are first diagnosed and learning how to live with their new condition. The Arthritis Self-Management Assessment Tool (ASMAT) was developed in order to provide patients with a way to gauge how well they are doing in their attempts to manage their condition (Oh et al., 2018). The tool was comprised of three different ‘management tasks’ which were identified as medical, behavioral, and psycho-emotional. Medical management task was defined as “adherence to treatment: taking medications, symptom management, and hospital visits” (Oh et al., 2018, p. 26). Behavioral management task was defined as “adoption of general and health behaviors: stop smoking and drinking alcohol, exercise, and quality sleep.” (Oh et al., 2018, p. 26). And lastly, psycho-emotional management task was defined as “management of arthritis-induced depression, anxiety, emotional problems, stress, and negative self-image” (Oh et al., 2018, p. 26). Under each task is a series of sub-tasks. Patients referred to the list of 32 ‘management tasks’ to see which tasks they are routinely accomplishing to determine whether or not they are self-managing their condition effectively (Oh et al., 2018).

Arthritis can have a damaging effect on self image, both of men and of women. Physical strength, athleticism, paid work, and ability to provide for the home are just a few of the societal standards that men are expected to adhere to (Flurey et al., 2017). These ‘masculine’ roles may be too due to the chronic pain. Men can be forced into early retirement, to hide or disguise their condition, to withdraw from their favorite leisure activities, and may lose their social support network (Flurey et al., 2017). One study found that their patients choose one of three routes to coping with their RA (Flurey et al., 2017). They could try to maintain their original masculinity standards by pushing through the pain, they could change their masculine roles to replace the roles they are no longer suited to fit, or they could reject masculinity entirely, which was the least common of the coping mechanisms (Flurey et al., 2017). Since RA in a long term condition, the patient must learn to not only adapt to their condition but to also accept it. Some men have a very hard time with accepting their condition and require some assistance in transitioning to their new reality. In therapy, the best way to help a man with rheumatoid arthritis is to teach him how to “rewrite their masculinity scripts,” meaning they have to redefine their ideas of masculinity in life (Flurey et al., 2017, p. 115). For example, while a man may have been forced to retire, he still contributes to the family by helping out around his adult daughter’s house, providing valuable services to his kids and grandkids. Since he considers this role to be important, his masculine value has not been diminished.

Men aren’t the only patients who experience changes in self-image with the progression of arthritis. Women also experience difficulties with self-image, specifically body image. Negative body image is actually extremely common for women with RA. Unfortunately, this negativity can affect other aspects of the patient’s life. Despite how prominent of an issue body image is for female RA patients, the issue is rarely discussed in treatment and there was only one study had been conducted on an experimental intervention method (Alleva et al., 2018). This study proposed that the women affected by negative body image due to RA focus on ‘body functionality’ (Alleva et al., 2018). This means the women would direct their focus onto everything that their body is capable of achieving. These women saw improvements in several aspects of their body image. The areas improved included functionality appreciation, body appreciation, body satisfaction, and body-self alienation (Alleva et al., 2018). In addition to these improvements, the women experienced a decrease in depression that was maintained and documented at one week and one month check-ups (Alleva et al., 2018). The study thereby concludes that body functionality interventions are an effective method of positively influencing the patient’s body image.

A study was done with patients who experienced arthritis flare-ups to see the effects of each patients’ with differing levels of self-regulatory efficacy on their persistence to exercise despite their pain. The study of self-regulatory efficacy for managing arthritis flare symptoms (SRE-flare) recorded the levels of persistence to exercise and their self-efficacy in using coping strategies while exercising after the patient was given a random situation where flare symptoms pose a threat to their will to continue (Sessford, 2017). In the study the idea of pain willingness is presented; defined as the lengths to which the patient is willing to endure pain in order to be capable of performing the patient’s own valued activities (Sessford, 2017). Patients with higher pain willingness were the patients with higher SRE-flare levels (Sessford, 2017). In turn, those with lower levels of SRE-flares were far less likely to persist and continue to exercise (Sessford, 2017). The greater the pain, the greater the will to do their daily exercises.