The development and assessment of the Worry About Pain Questionnaire.

BACKGROUND: Worry can be conceptualized as a cognitive-affective automatic process initiated in order to address uncertainty and potential personal inadequacies that could result in negative outcomes. The purpose of the current study was to develop a measure of pain-specific worry - the Worry About Pain Questionnaire (WAPQ). METHOD: In study 1, responses of 335 pain-free participants were used to complete an item analysis and exploratory factors analysis to develop and assess the internal structure of the WAPQ. Study 2 included 224 pain-free participants who completed the WAPQ in order to confirm its factor structure, and to examine its relation to the experience of acute experimental pain. In study 3, 137 individuals with persistent pain were asked to complete the WAPQ as well as measures of pain and depressive symptoms. RESULTS: The resulting 15-item measure assesses uncertainties and potential negative outcomes related to the experience of pain. The results of the exploratory and confirmatory factor analyses showed a two-factor structure. Across all studies, the WAPQ was found to be related to measures of pain in clinical and non-clinical samples, acute experimental pain stimuli, as well as pain anxiety, pain catastrophizing, fear of pain, rumination and depressive symptomatology. CONCLUSIONS: The results suggest that the WAPQ is a reliable and valid measure for the assessment of worry about pain that can be used to understand how pain-specific worries are related to the experience and impact of pain across different populations. SIGNIFICANCE: Worry has been assessed in pain populations using measures that assess worry in general. The current study shows a relationship between pain-specific worry and the experience of pain. Further, worry about pain is related to but not synonymous with pain catastrophizing.

Exploratory secondary analyses of a cognitive-behavioral intervention for knee osteoarthritis demonstrate reduction in biomarkers of adipocyte inflammation.

OBJECTIVE: To investigate the effects of pain coping skills training (PCST) and a lifestyle behavioral weight management (BWM) program on inflammatory markers and biomarker associations with pain and function in the OA LIFE study. METHOD: Serum samples were available from a subset (N = 169) of the overweight or obese knee OA participants in the OA LIFE study that evaluated: PCST, BWM, combined PCST + BWM, or standard care (SC). Inflammatory markers (hsCRP, IL-1ra, IL-1ß, IL-6, IL-8, TNF-α, TNFRI, TNFRII, and hyaluronic acid (HA)), and adipokines (leptin and adiponectin) were measured before and after the 24-week treatment period. Biomarkers were assessed for effects of treatment and for associations with change in weight, pain and disability (unadjusted and adjusted for age, race, sex, baseline body mass index (BMI), and baseline biomarker concentration). RESULTS: PCST + BWM was associated with significant reductions in hsCRP (P = 0.0014), IL-6 (P = 0.0075), and leptin (P = 0.0001). After adjustment, there was a significant effect of PCST + BWM on changes in leptin (b = -0.19, P = 0.01) and IL-6 (b = -0.25, P = 0.02) relative to SC. Reductions in leptin and IL-6 were significantly correlated with reductions in weight, BMI and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain; reductions in IL-6 were correlated with improvements in WOMAC and Arthritis Impact Measurement Scales (AIMS) physical function. By mediation analyses, weight loss was responsible for 54% of the change in IL-6 and all of the change in leptin. CONCLUSIONS: OA-related inflammatory markers were reduced by a 24-week combined PCST + BWM intervention. This suggests that the inflammatory state can be successfully modified in the context of a readily instituted clinical intervention with a positive clinical outcome.

Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping.

The objective of this preliminary study was to evaluate more fully the role of daily spiritual experiences and daily religious/spiritual coping in the experience of individuals with pain due to rheumatoid arthritis (RA). Thirty-five individuals with RA were asked to keep a structured daily diary for 30 consecutive days. The diary included standardized measures designed to assess spiritual experiences, religious and spiritual pain coping, salience of religion in coping, religious/spiritual coping efficacy, pain, mood, and perceived social support. The participants in this study reported having spiritual experiences, such as feeling touched by the beauty of creation or feeling a desire to be closer or in union with God, on a relatively frequent basis. These participants also reported using positive religious and spiritual coping strategies much more frequently than negative religious and spiritual coping strategies. Although most of the variance in these measures was due to differences between persons, each measure also displayed a significant variability in scores from day to day. Indeed, there was just as much (or more) variability in these measures over time as there was variability in pain. Individuals who reported frequent daily spiritual experiences had higher levels of positive mood, lower levels of daily negative mood, and higher levels of each of the social support domains. Individuals who reported that religion was very salient in their coping with pain reported much higher levels of instrumental, emotional, arthritis-related, and general social support. Coping efficacy was significantly related to pain, mood, and social support in that on days that participants rated their ability to control pain and decrease pain using spiritual/religious coping methods as high, they were much less likely to have joint pain and negative mood and much more likely to have positive mood and higher levels of general social support. Taken together, these results suggest that daily spiritual experiences and daily religious/spiritual coping variables are important in understanding the experience of persons who have RA. They also suggest that newly developed daily diary methods may provide a useful methodology for studying religious and spiritual dimensions of living with arthritis.

Spouse-assisted coping skills training in the management of knee pain in osteoarthritis: long-term followup results.

OBJECTIVE: To evaluate the long-term effects of a spouse-assisted coping skills intervention in patients with osteoarthritis (OA) of the knees, and to evaluate how pre- to posttreatment changes in marital adjustment and self-efficacy relate to long-term improvements in pain, psychological disability, physical disability, pain coping, and pain behavior. METHODS: A followup study was conducted with 88 OA patients who had been randomly assigned to 1 of 3 treatment conditions: 1) spouse-assisted coping skills training (spouse-assisted CST), 2) a conventional CST intervention with no spouse involvement, and 3) an arthritis education-spousal support (AE-SS) control condition. To evaluate long-term outcome, comprehensive measures of self-efficacy, marital adjustment, pain, psychological disability, physical disability, pain coping, and pain behavior were collected from these individuals at 6 and 12 months posttreatment. RESULTS: Data analysis revealed that, at 6-month followup, patients in the spouse-assisted CST condition scored higher on measures of coping and self-efficacy than those in the AE-SS control group. At 6-month followup, patients who received CST without spouse involvement showed a significantly higher frequency of coping attempts and reported higher levels of marital adjustment than those in the AE-SS control group. At 12-month followup, patients in the spouse-assisted CST condition had significantly higher overall self-efficacy than those in the AE-SS control condition. In addition, patients in both the spouse-assisted CST and CST only conditions tended to show improvements in physical disability at the 12-month followup. Individual differences in outcome were noted at the 12-month followup. Patients in the spouse-assisted CST condition who reported initial (pre- to posttreatment) increases in marital adjustment had lower levels of psychological disability, physical disability, and pain behavior at 12-month followup. However, for patients in the conventional CST and AE-SS control conditions, increases in marital adjustment occurring over the initial phase of treatment were related to increases in pain and decreases in scores on the Pain Control in Rational Thinking factor of the Coping Strategies Questionnaire. Finally, patients in the spouse-assisted CST condition who showed pre- to posttreatment increases in self-efficacy were more likely to show decreases in pain, psychological disability, and physical disability at 12-month followup. CONCLUSIONS: These findings suggest that spouse-assisted CST can enhance self-efficacy and improve the coping abilities of OA patients in the long term. Individual differences in the long-term outcome of spouse-assisted CST were noted, with some patients (those showing increases in marital satisfaction and self-efficacy) showing much better outcomes than others.

The relationship of arthritis self-efficacy to daily pain, daily mood, and daily pain coping in rheumatoid arthritis patients.

There is an increasing awareness in the medical community that psychosocial variables such as beliefs in self-efficacy are important determinants of treatment outcome. However, before measures of self-efficacy are widely incorporated into clinical practice, there needs to be a better understanding of how they relate to daily pain, mood and coping. In the present study 128 rheumatoid arthritis patients completed diaries for 30 days in which they provided daily ratings of joint pain, negative and positive mood, the use of pain coping strategies, and coping efficacy. The patients then participated in an evaluation session during which measures of self-efficacy (the Arthritis Self Efficacy Scale (ASES)), demographic variables, and medical status were collected. A series of hierarchical regression analyses was conducted to determine the degree to which self-efficacy measures collected at the time of the evaluation session were related to daily diary measures collected during the 30 preceding days. The results revealed that self-efficacy was significantly related to daily ratings of pain, mood, coping and coping efficacy. Interestingly, the findings regarding self-efficacy were obtained even after taking into account the effects of important demographic and medical status variables. Taken together, these results suggest that self-efficacy ratings collected from arthritis patients at the time of an evaluation session may well be related to recent experiences of daily pain and mood, as well as the daily use and perceived effectiveness of pain coping strategies.

Self-efficacy for arthritis pain: relationship to perception of thermal laboratory pain stimuli.

OBJECTIVE: To examine how self-efficacy for arthritis pain relates to the perception of controlled laboratory pain stimuli. METHODS: Forty patients with osteoarthritis completed self-report measures of self-efficacy for arthritis pain. They then participated in a single experimental session in which measures of thermal pain threshold and tolerance were collected, as well as measures of the perceived intensity and unpleasantness of a range of thermal pain stimuli. RESULTS: Correlational analyses revealed that patients reporting high self-efficacy for arthritis pain rated the thermal pain stimuli as less unpleasant than those reporting low self-efficacy. When subjects scoring very high and very low in self-efficacy were compared, it was found that subjects scoring high on self-efficacy for arthritis pain had significantly higher pain thresholds and pain tolerance than those scoring low on self-efficacy. CONCLUSIONS: These results indicate that self-efficacy for arthritis pain is related to judgments of thermal pain stimuli. Implications for the understanding of arthritis pain and for future laboratory research are discussed.

Cognitive behavioral control of arthritis pain.

Cognitive-behavioral approaches appear to offer a viable alternative for the management of arthritis pain. Controlled studies have documented the efficacy of CBT protocols for managing pain in individuals having OA and RA. Preliminary studies examining the efficacy of CBT for FM patients have also yielded encouraging results. A number of clinical and research issues need attention if CBT is to be incorporated into rheumatology practice settings. These issues include identifying the most important components of CBT, developing strategies for matching CBT interventions to patients' readiness for behavior change, testing the efficacy of different therapy formats (e.g., individual versus group), broadening the scope of CBT to address issues other than pain, and insurance reimbursement.

Pain coping strategies and coping efficacy in rheumatoid arthritis: a daily process analysis.

Data from daily diaries were used to analyze pain coping processes in rheumatoid arthritis patients. For 30 consecutive days, 53 individuals described the pain coping strategies they used that day and rated the efficacy of their coping, joint pain, and positive and negative mood. Relations among variables were examined across-persons and within-persons over time. At the across-persons level of analysis, (i) daily coping efficacy was unrelated to pain coping or pain intensity, and (ii) the more frequent daily use of a wide variety of pain coping strategies was correlated with greater pain. Within-person analyses provided unique information about the relations among coping, pain, and mood not apparent in the across-persons results. Specifically, these analyses showed that increases in daily coping efficacy were not only related to decreases in pain, but also to decreases in negative mood and increases in positive mood. Time-lagged effects of coping and coping efficacy were also found. Individuals who reported high levels of coping efficacy on one day had lower levels of pain on the subsequent day. The daily use of pain reduction efforts and relaxation strategies also contributed to an improvement in next-day pain and an enhancement of positive mood. The implications of these findings for the assessment of pain and coping in rheumatoid arthritis patients are discussed.

Spouse-assisted coping skills training in the management of osteoarthritic knee pain.

OBJECTIVE: To evaluate the effects of a spouse-assisted pain-coping skills training intervention on pain, psychological disability, physical disability, pain-coping, and pain behavior in patients with osteoarthritis (OA) of the knees. METHODS: Eighty-eight OA patients with persistent knee pain were randomly assigned to 1 of 3 conditions: 1) spouse-assisted pain-coping skills training, (spouse-assisted CST), 2) a conventional CST intervention with no spouse involvement (CST), or 3) an arthritis education-spousal support (AE-SS) control condition. All treatment was carried out in 10 weekly, 2-hour group sessions. RESULTS: Data analysis revealed that at the completion of treatment, patients in the spouse-assisted CST condition had significantly lower levels of pain, psychological disability, and pain behavior, and higher scores on measures of coping attempts, marital adjustment, and self-efficacy than patients in the AE-SS control condition. Compared to patients in the AE-SS control condition, patients who received CST without spouse involvement had significantly higher post-treatment levels of self-efficacy and marital adjustment and showed a tendency toward lower levels of pain and psychological disability and higher scores on measures of coping attempts and ratings of the perceived effectiveness of pain-coping strategies. CONCLUSION: These findings suggest that spouse-assisted CST has potential as a method for reducing pain and disability in OA patients.

Cyclosporin A therapy for Wegener's granulomatosis.

Five patients with active Wegener's granulomatosis were treated with the immunosuppressive agent Cyclosporin A, along with low dose prednisone. All five patients had previously taken cyclophosphamide, but further treatment with this agent was not desired, either due to patient choice, drug toxicity or malignancy. In initial doses of up to 5mg/kg/day, CyA showed efficacy but when lowered to 1-2mg/kg/day, mild disease flares occurred. CyA may provide an alternative to traditional therapy in selected patients with WG.

Disease severity in rheumatoid arthritis: relationships of plasma tumor necrosis factor-alpha, soluble interleukin 2-receptor, soluble CD4/CD8 ratio, neopterin, and fibrin D-dimer to traditional severity and functional measures.

Rheumatoid arthritis is a complex inflammatory disease of unknown cause. Although various laboratory and clinical measurements are useful in managing these patients, there is a need for better tests to quantitatively assess disease activity. The purpose of this study was to investigate the association of certain immune and inflammation (I-I) parameters with four traditional disease severity measures and a functional measure in rheumatoid arthritis patients. A single set of patient blood samples was analyzed, and four traditional disease severity measures and patient functional statuses were determined from 64 consecutive outpatients with rheumatoid arthritis. Plasma tumor necrosis factor-alpha (TNF), soluble interleukin-2 receptor (sIL-2R), sCD4 and sCD8 (and the sCD4/sCD8 ratio), neopterin, and fibrin D-dimer were analyzed in relationship to Westergren erythrocyte sedimentation rate (ESR), physician assessment of disease activity, joint pain count, grip strength, and Arthritis Impact Measurement Scale (AIMS) scores. Rheumatoid arthritis patients had higher mean levels of all I-I measures (except sCD4) compared to healthy subjects. Initial significant correlations between TNF, sIL-2R, and D-dimer and several disease severity and functional measures were detected. When we controlled for the covariates age, gender, race, and medications, regression analyses indicated that, as a group, the I-I measures were significantly related to grip strength, physician disease severity rating, ESR, and total joint pain. When the predictive values of the I-I measures were tested controlling for the covariates and ESR, D-dimer was independently and significantly associated with variability in grip strength, physician disease severity, and AIMS physical disability, while TNF was associated with a significant amount of variability in total joint pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of methotrexate, rheumatoid arthritis and lymphoma: report of 2 cases and literature review.

We describe 2 Caucasian men with rheumatoid arthritis (RA) who developed non-Hodgkin's lymphoma of identical histological type during treatment with low dose oral weekly methotrexate (MTX). Both patients had longstanding RA and had been treated with MTX for over 2 years at time of tumor diagnosis; neither had secondary Sjögren's syndrome. The oncogenic potential of MTX and RA arthritis is reviewed.

Psoriatic arthritis of the foot and ankle: analysis of joint involvement and diagnostic errors.

Forty-two patients with psoriatic arthritis arthritis who were referred to a tertiary medical center from 1983 to 1987 were reviewed. The foot and/or ankle was the most common site of joint or bone involvement, (N = 36, 86%). Twenty-six of these patients demonstrated bilateral involvement. The foot and ankle was the most common site of initial arthritis (N = 23, 55%). Errors in patient diagnosis were noted and analyzed. Eight patients with foot and ankle involvement were diagnosed and treated for either gout or compression of a digital nerve. Major causes for misdiagnosis included failure to identify psoriatic skin lesions and failure to associate foot and ankle symptoms with psoriatic arthritis.

Biofeedback as a means to alter electromyographic activity in a total knee replacement patient.

This paper presents a single case controlled study of a 75-year-old male having bilateral total knee replacement. Baseline EMG recordings demonstrated differential levels of vastus medialis and vastus lateralis muscle activity in both knees during exercise, with increased vastus lateralis activity compared to vastus medialis activity. The purpose of the study was to use electromyographic (EMG) biofeedback training to train the patient to equalize vastus medialis and vastus lateralis EMG activity during exercise. After 11 and 13 training sessions for the left and right knees, respectively, differences between vastus medialis and vastus lateralis activity had markedly decreased. Following the termination of biofeedback training, EMG activity during exercise showed a return toward baseline levels. Several concomitant changes in psychological and physical function were noted. These results suggested that EMG biofeedback can be used to train vastus medialis and vastus lateralis activity in total knee replacement patients, and that biofeedback training may produce positive benefits in other functional areas.

Expression of autoantibodies to recombinant (U1) RNP-associated 70K antigen in systemic lupus erythematosus.

To determine the specificity of antibodies to the (U1) ribonucleoprotein antigen in systemic lupus erythematosus (SLE), patient sera were tested for binding to a recombinant human 70K antigen. By solid-phase immunoassay, we detected anti-70K reactivity in sera from 31 of 96 patients with systemic lupus erythematosus (SLE), demonstrating that anti-70K antibodies may occur in patients with SLE as well as other clinical diagnoses. In sequential sera from 2 of these patients, we found that anti-70K binding varied dramatically over the course of disease. The changes in anti-70K antibody levels did not correlate with clinical events nor evolving antibody reactivity with the Sm-specific antigens.

Dysphagia due to diffuse idiopathic skeletal hyperostosis.

Although diffuse idiopathic skeletal hyperostosis generally affects the lumbar spine, any segment of the spine may be involved. When the cervical spine is affected, dysphagia may occur. Diabetes mellitus is commonly present. A history of previous cervical trauma is an indication to obtain cervical spine radiographs. Barium swallow and endoscopy provide confirmation of etiology. Surgery is curative.

Methotrexate-associated hepatotoxicity: retrospective analysis of 210 patients with rheumatoid arthritis.

PURPOSE: Beginning in the 1980s, methotrexate has been used successfully to treat rheumatoid arthritis. The magnitude and severity of short- and long-term methotrexate toxicity, however, have not been adequately investigated. Our study was performed to determine the prevalence of hepatotoxicity in patients with rheumatoid arthritis receiving long-term methotrexate therapy. PATIENTS AND METHODS: We conducted a retrospective, computer-assisted review of all Duke University Medical Center patients undergoing liver biopsy for methotrexate monitoring from January 1979 to January 1988. A total of 538 biopsies were performed in 399 patients, 259 of whom had inflammatory arthritis (210 with rheumatoid arthritis, 47 with psoriatic arthritis, and two with seronegative spondyloarthropathy). RESULTS: No evidence of cirrhosis was defined in the cohort with rheumatoid arthritis; however, six patients with rheumatoid arthritis had histologic changes of fibrotic liver disease (prevalence of 2.9 percent in the group with rheumatoid arthritis) while taking methotrexate. Five of the six patients were obese and three had glucose intolerance or overt diabetes mellitus, and one person admitted to alcohol usage. Only one patient with fibrotic liver disease had elevated liver function test results, and no person showed a declining serum albumin level at the time of biopsy. Sixty-one patients with rheumatoid arthritis underwent multiple samplings (44 with two, 13 with three, and four with four biopsies). Fourteen of these patients showed progressive hepatic disease, whereas four patients improved. CONCLUSION: Although the prevalence of methotrexate hepatotoxicity in this large cohort of patients with rheumatoid arthritis was low, a small but definite risk of hepatic fibrosis, not predictable by laboratory screening, still exists.

Polymyositis after propylthiouracil treatment for hyperthyroidism.

An additional disorder in the spectrum of thyroid related muscle disease is presented. Hypothyroid and hyperthyroid disease are both associated with a variety of muscle abnormalities, from myalgias to myopathy. Polymyositis, however, has never been reported immediately after treatment for active hyperthyroidism. A patient is presented with typical hyperthyroidism, who developed a severe proximal muscle weakness and a raised creatine phosphokinase after treatment for hyperthyroidism with propylthiouracil (100 mg orally, three times a day). Electromyography, muscle biopsy, and the course of the patient's illness were consistent with polymyositis. Whether this represents a cause-effect association or a chance occurrence is unknown. Physician awareness of the occurrence of a variety of muscle disorders including polymyositis in thyroid disease is emphasised. A brief discussion of thyroid myopathy, thionamide drug reactions, and polymyositis is included.