Arthritis pain

Authors:
YOON Eunkyung, DOHERTY John B.
Journal article citation:
Journal of Gerontological Social Work, 50(S1), 2008, pp.79-103.
Publisher:
Taylor and Francis
Place of publication:
Philadelphia, USA

Arthritic pain is a common and disabling condition for many older people in the USA, and is often under-treated despite its significant negative impact on quality of life. This systematic review examines the empirical literature on psychosocial interventions, including cognitive-behavioural treatments and psycho-educational interventions. The former has been shown to have a major positive impact on pain control, while the latter has contributed to better understanding and self-treatment. The paper concludes with a ‘treatment resource appendix’ directed at US practitioners. (Copies of this article are available from: Haworth Document Delivery Centre, Haworth Press Inc., 10 Alice Street,  Binghamton, NY 13904-1580).

Extended abstract:
Author

YOON Eunkyung; DOHERTY John B.;

Arthritis pain.

Journal citation/publication details

Journal of Gerontological Social Work, 50(supplement 1), 2008, pp.79-103.

Summary

A review of 21 studies, including three meta-analyses, finds that cognitive-behavioural therapy (CBT) and psycho-educational interventions can be effective in helping older people and their carers to cope with arthritic pain.

Context

Arthritic pain is a common, disabling and often under-treated condition, with major adverse effects on mental health and quality of life. There are limitations to surgical and drug treatments because of side-effects, and psychosocial approaches have been shown to be effective in treating disease-related pain.

Methods

What sources were used?
The following databases were searched: AgeLine; ERIC (Education Resources Information Center); Medline; PsycARTICLES; PsycINFO; and PubMed. ‘Further studies were subsequently identified by cross-referencing and manually checking abstracts.’

What search terms/strategies were used?
The terms used were: chronic pain; arthritis; rheumatology; chronic joint symptoms; older adults; evidence-based practice; intervention; meta-analysis; clinical trials; randomized controlled trials; patient education; cognitive behavioral therapy. The upper cut-off point for searching was May 2005.

What criteria were used to decide on which studies to include?
None are reported beyond those implied by the search terms.

Who decided on their relevance and quality?
This is not reported. All reviews in this issue of the Journal of Gerontological Social Work judged the quality of evidence on the basis of a common framework: meta-analysis or systematic review of all relevant randomised controlled trials (RCTs) (Level I); at least one properly designed RCT (Level II); well designed controlled but non-randomised studies (Level III); non-controlled studies (Level 4a); and consensus reviews of expert opinion based on clinical experience or reports of expert committees (Level 4b).

How many studies were included and where were they from?
Twenty-one studies (eight CBT, 13 psycho-educational) were reviewed and are summarised in Tables 1 and 2. Geographical origins are not reported.

How were the study findings combined?
The review is narrative.

Findings of the review

Cognitive-behavioural treatments
Eight CBT studies were identified. A meta-analysis conducted in 2002 showed that CBT was effective in reducing pain and functional disability, and increasing psychological status, coping and self-efficacy. Of the seven RCTs, one showed no difference in outcomes for depressed patients with rheumatoid arthritis who received instruction in depression management or a patient education intervention, as compared to those who simply received anti-depressants. However, the remainder demonstrated positive results, including two studies showing that family carers can also benefit from coping skills training.

Psycho-educational interventions
Two meta-analyses have suggested positive, although rather small, effect sizes for reductions in pain, depression and disability, while a third has concluded that patient education provides additional benefits that are 20-30% as great as the effects of pain relief using non-steroidal anti-inflammatory drugs. Several RCTs (as well as meta-analyses) have demonstrated the effectiveness of the Arthritis Self-Management Program, a standardised 12-session, cost-effective psycho-educational group intervention that can be delivered by professionals or trained lay leaders. An evaluation of a shorter version – the Chronic Pain Self Management Program – has also provided positive results for health care utilisation, health-related distress and self-efficacy.

Other brief, low cost psycho-educational interventions have also proved effective, including telephone, mail and internet-based approaches that include education alongside counselling or symptom monitoring.

Authors' conclusions

‘Based upon clinical evidence, cognitive-behavioral treatment models can have a major positive impact on pain treatment.’ The model is flexible, it integrates information about the varying influences (biological, psychological, social) on pain, and it teaches specific coping skills. Overall, the empirical support for CBT as a way of encouraging the adoption of a self-management approach to pain is ‘relatively strong’.

Psycho-educational approaches have also ‘gained support in the outcome literature’ as an adjunct to medical and physical therapies, and as a low cost, effective way of helping people find ways to manage their pain more effectively. There is good evidence in favour of coping skills training for both patients and their carers, while telephone and internet-based approaches (including moderated support groups) ‘are economically promising’.

Implications for policy or practice

When mobile older people are diagnosed with arthritis they should be offered access to education about the condition within six months. No particular recommendation is made about CBT, despite its empirical support, and the authors note that problems remain with the evidence on psychosocial treatments. Many of the interventions discussed are included as part of a multi-modal approach to treatment, and it is difficult to assess which components of such an approach are responsible for which observed effects. It is also impossible to assess the relative effectiveness of the treatments discussed, or their long term impact. Future research is needed and recommendations for study topics are outlined, although the authors note the difficulty of conducting RCTs with older people. The paper concludes with a ‘treatment resource appendix’ directed at American social workers.

Subject terms:
older people, outcomes, pain, psychosocial intervention, arthritis;
Content type:
systematic review
Link:
Journal home page
ISSN online:
1540-4048
ISSN print:
0163-4372

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