2 July 2018

Psychosocial issues key to future disability

Patients Psychology Rheumatology

Addressing psychological and social issues early in arthritis disease is vital to preventing secondary disability, yet clinicians likely overestimate how much attention is paid to them. 

A biomedical model of disease still dominated practice despite serious shortcomings, Professor Robert Smeets, a rehabilitation medicine expert at Maastricht University, Netherlands, told clinicians at the European League Against Rheumatism conference in Amsterdam. 

“There is a low correlation between biomedical factors and pain severity,” he said.

In contrast, pain beliefs have been shown to have moderate effects on pain severity, as had affective distress on functional impairment. 

“In fact, the relationship between psychosocial factors and functional impairment is higher than damage to the joint and functional impairment. Often we think patients want us to get rid of the pain,” Professor Smeets said. 

“Of course, that’s what they want. But they [also] want a lot more. They want help to deal with the pain, to deal with fatigue and to manage emotional consequences of living with RA or OA and its impacts on work and leisure activities.”

He said that while most in the room probably thought they paid attention to those other factors, research suggested that only one in four rheumatologists ever asked about psychological or social issues. Given relief from pain might only ever be partly achieved, it was vital for clinicians to be able to identify predisposing, provoking and maintaining factors for pain and risk factors for secondary disability “ASAP”, he said. 

Predisposing and provoking factors include genes and early development, which contribute to stress sensitivity, in conjunction with psychologically or physically stressful events, which may even include an infection. These can develop into dysregulation, such as hypersensitive stimulus processing. 

Cognitive factors to watch out for included catastrophising, misinterpreting symptoms, depression, poor coping with stress and fear of movement. 

These factors were all independent of the diagnosis of OA or RA, age, gender and pain duration in general, research indicated. 

While patients could misinterpret the meaning of stimuli such as mild pain, increased sweating, and clicking or cracking sounds while moving as potentially dangerous, Professor Smeets also drew attention to the ways in which clinicians often inadvertently contributed to the fear. 

“We tell them about what has been seen on the MRI or X-rays, although we know that the relationship between the MRI or X-ray findings and pain severity is not that high,” he said, which could easily lead to patients fearing loss of work or being in a wheelchair. 

This meant that it was important for clinicians to be vigilant that their attitudes and beliefs, and how they communicated them, would not cause the patient to have a less active lifestyle, Professor Smeets said. 

The first step was to be quite clear about “red zones” of activity that patients needed to be aware of, and similarly be precise about what safe levels of activity were, he said. 

“Don’t say, ‘Just see, and when the pain increases, just stop performing activities’.”

On the other hand, job satisfaction, support from coworkers, ability to get social support, the right kind of spousal support were all protective factors, he added. 

So focusing on these factors known to contribute to long-lasting arthritis pain, and clearly communicating them to patients, was a key aspect to daily practice.

This was helped by incorporating self-management of aspects such as sleep, weight and exercise with multidisciplinary care. 

Cognitive behaviour therapy, particularly early in a disease progression, looked to be helpful, he added.