October, 2006

Definition of the Problem
Arthritis refers to a group of more than 100 conditions that cause pain, stiffness, and swelling in the joints. Occasionally there is damage to other structures as well. All the major forms of arthritis are chronic conditions, and most get worse over time. Osteoarthritis, the most common form, is a degenerative joint disease. Rheumatoid arthritis (RA), the second most common form, is considered an autoimmune condition.

Scope and Cost of Problem
According to the Centers for Disease Control (2006), arthritis is the most common chronic illness in the United States, with almost 43 million people in the United States have some form of arthritis or joint pain. Arthritis is also the leading cause of disability in this country. The CDC reports direct and indirect annual costs of arthritis is over $86 billion , accounting for 36 million physician visits per year and 750,000 hospital admissions.

Medical and Complementary Treatment
The main classes of arthritis medications are the non-steroidal anti-inflammatory drugs (NSAIDS). There are also many secondary treatments including methotrexate, gold compounds, d-penicillamine, hydroxychloroquine, sulfasalazine, and newer drugs such as Enbril (anti-tumor-necrosis factor). All of these medicines “help but do not cure,” according to rheumatologist Earl J. Brewer, Jr., MD (Brewer & Angel, 1998).

People also take a tremendous variety of nutritional supplements and herbal medications for arthritis, the most popular of which are glucosamine and chondroitin. The annual cost of prescription arthritis medications is $9.4 billion and money spent on herbal and other nonprescription medicines is $2 billion. Acupuncture has been found useful for some people with osteoarthritis (Berman, Singh, et al, 1999).

Arthritis Self-Management Programs
Self-care is vital in the management of chronic pain (Turner, Ersek & Kemp, 2005). The Arthritis Self-Management Program (ASMP), developed at Stanford and now presented at over 200 facilities worldwide, has been highly successful and cost-effective (Lorig, Mazonson & Holman, 1993; Mullen, Laville, et al, 1987; Young, Bradley, et al, 1995). The Arthritis Foundation now markets this course as the Arthritis Self-Care Program.

Along with education about arthritis, exercise, nutrition, and medication use, ASMP features practice with relaxation, guided imagery, other cognitive pain management techniques, communication skills, doctor-patient relationship skills, and group support (Young, Bradley & Turner). Imagery and relaxation exercises are used in five of the six ASMP sessions, and are considered important parts of the program’s success (Stanford Patient Education Research Center, 1999).

Benefits include better self-reported health, improved routine function and comfort levels, and decreased healthcare usage (Lorig, Mazonson & Holman, 1993). These benefits could not be adequately explained by improved health behaviors, and better self-self-care is considered a likely major contributor to the positive outcomes (Lorig, Selzenick, et al, 1989; Marks, 2001).

Imagery and Self-Hypnosis
Dozens of studies show moderate effectiveness for relaxation, hypnosis, and psychological support in arthritis. Both in Baird and Sands’ pilot study (2004) and in their later longitudinal study (2006), arthritis patients using guided imagery and progressive muscle had a significant improvement both in pain and morbidities (Baird & Sands, 2004; Baird & Sands, 2006).

A 2002 literature review of relaxation and psychotherapy in people with RA found significant reduction of pain and disability, and improvement on several psychological characteristics (Astin, Beckner, et al, 2002). The following year, the same author headed another review and concluded that there is at least “moderate evidence” for the use of mind-body therapies in arthritis (Astin, Shapiro, et al, 2003).

A study comparing hypnosis with relaxation in osteoarthritis showed that both had significant benefits in reducing pain and medication for pain, with hypnosis somewhat more effective (Gay, Philippot & Luminet, 2002). Varni and Gilbert (1982) published a case study showing self-hypnosis reduced pain medication use in an arthritic patient with hemophilia. Imagery, relaxation and self-hypnosis have proven effective in a number of chronic pain conditions (Mannix, Chandurkar, et al, 1999; Syrjala, Donaldson, et al, 1995).

Guided imagery and relaxation are valuable skills for increasing self-efficacy and self-management behavior. Used with appropriate medical treatment, a guided imagery program can help increase patients’ perceived well-being and self-management skills, and reduce consumption of medical resources.

Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B. Psychological interventions for rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheum. 2002 Jun 15;47(3):291-302.

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Mullen PD, Laville E, Biddle AK, Lorig K. Efficacy of psycho-educational interventions on pain, depression and disability with arthritic adults: a meta-analysis. J of Rheumatology. 198714(15):33-39.

Stanford Patient Education Research Center. The Chronic Disease Self-Management Workshop Leaders Manual. Stanford University. 1999.

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[no authors listed] Targeting Arthritis: Reducing disability for 16 million americans. At a glance 2006. National Center for Chronic Disease Prevention and Health Promotion.
Accessed October, 2006.

Varni JW, Gilbert A. Self-regulation of chronic arthritic pain and long-term analgesic dependence in a haemophiliac. Rheumatol Rehabil. 1982 Aug;21(3):171-4.

Young LD, Bradley LA, Turner RA. Decreases in health care resource utilization in patients with rheumatoid arthritis following a cognitive behavioral intervention. Biofeedback and Self-Regulation.1995 Sep;20(3):259-68.