Sense of helplessness contributes to rheumatoid arthritis pain levels

Sense of helplessness contributes to rheumatoid arthritis pain levels

Psychological factors can be as important as physical factors in explaining pain intensity, according to a long-term University of Queensland study.

For her PhD, Physiotherapy Department lecturer in pain management Dr Pat Roche studied 120 Royal Brisbane Hospital outpatients who had ?progressive' rheumatoid arthritis and pain for an average of 15 years.

She said her study showed such enduring pain could produce a sense of helplessness - feelings of loss of control over adverse situations. This feeling was as important as the clinical severity of disease in producing pain levels, she said.

"Emotional distress is a natural, normal, human response to enduring pain," she said.

The progressive form of rheumatoid arthritis is an incurable, inflammatory disease of joints which can be more serious and debilitating than the more common osteoarthritis. Rheumatoid arthritis affects people in their 40s and 50s and the pain can last for decades.

Dr Roche's study found a sense of helplessness was a common psychological response to pain in people with rheumatoid arthritis. The stronger the sense of helplessness, the worse the pain, she said.

Her study is believed to be the first in Australia to examine both clinical and psychological effects of the disease in building a profile of the course, average intensity and average nature of the pain experienced by the patients over a six-year period.

It also achieved a place on the Health Sciences Faculty Executive Dean's Commendation List for Outstanding PhD theses in 1998.

Dr Roche's results suggest that evaluation and management of feelings of poor control over pain could be as important a part of the overall management of pain in long-term, incurable
conditions such as rheumatoid arthritis as drug therapies

"Health teams treating rheumatoid arthritis patients are becoming more aware of the need to treat patient's feelings and reactions of distress to pain, as well as treating the disease," she said.

"The study's results support arthritis care strategies such as physical therapy and hydrotherapy which improve patients' sense of control over problems such as pain."

The research is based on the 1965 Gate Control Theory developed by Emeritus Professor of Physiology at St Thomas' Hospital and editor of Pain journal, Patrick Wall and Professor Ron Melzack of McGill University in Canada.

"This theory says that the experience of arthritic pain is a result of the integration and processing at the spinal cord of at least two factors - the painful stimuli in the joint or muscles as well as the individual's own psychological responses to long-term pain," Dr Roche said.

"In other words, equating pain with the severity of chronic disease or injury is no longer an adequate explanation of pain.

Pain is also the product of constant (usually unconscious) analysis and appraisal by the sufferer of the meaning and difficulties of the pain to their daily and future lives.

"Feelings of distress are a natural response to pain, and particularly to long-term pain. It is because the joints, spinal cord and brain are all involved in processing ?pain' that the feeling of being constantly vulnerable to pain can heighten the level of pain."

Dr Roche, who is a qualified psychologist as well as physiotherapist, interviewed each outpatient about feelings of anxiety, depression and helplessness associated with pain. Measures of inflammation in the joints and the patient's physical function were also taken.

She found that psychological factors explained 20 percent of patients' pain intensity with disease severity explaining a further 18 percent.

"A 20-dimensional pain vocabulary found that patients with rheumatoid arthritis typically described their pain using words such as ?constrictive', ?gnawing', ?pulling' and ?penetrating'. The emotional response it triggered in them was described as ?tiring', ?troublesome' and occasionally as ?cruel'," Dr Roche said.

Another main finding of the study was that on average, the level of the disease, the pain and mental distress from the disease remained stable over the six years because of modern drug management, she said.

"This finding is a heartening indication that the progress of rheumatoid arthritis may have stabilised rather than become worse as it invariably did in previous years. This finding may allow patients to feel more in control of the outcome of the disease and help health carers and patients to develop pain management programs in a prospective way so that pain may become better controlled over time," Dr Roche said.

She said the study's results had implications for pain management across the wider field of chronic rheumatic and musculoskeletal diseases.

For more information, contact Dr Roche (telephone 07 3365 2095).