People feel helpless when they believe they have little control over a situation and any efforts they make to resolve their problems will be unsuccessful. High levels of helplessness are associated with greater pain, depression, and disability. The chronic nature of OA, our poor understanding of its cause, and our inability to correct entrenched health beliefs about the prognosis and management of OA foster feelings of helplessness (3).
Self-efficacy is a person’s confidence in their ability to perform tasks that will achieve certain goals (1). People with high levels of self-efficacy are more active, less depressed, less anxious, report lower levels of pain, and are more willing to tackle and persevere longer at challenging tasks despite failures than people with low self-efficacy (12). Self-efficacy is closely linked to control and helplessness, but whereas helplessness is a consistent belief of a general loss of control, self-efficacy is task specific and can vary greatly within an individual. For example, a person’s self-efficacy in their ability to reduce pain by reinterpreting it may be high, whereas their belief in their ability to perform exercise that will reduce pain (termed exercise self-efficacy) may be low.
The efforts people make to deal with and minimize the effects of ill-health are described as coping strategies (8). There are many strategies and behavioral changes that help people cope with ill health and gain control of their condition. These strategies can be loosely divided into active coping strategies, such as increasing physical activity, diverting attention, and reinterpreting pain, and passive coping strategies, such as resting, avoiding activities, and relinquishing responsibility for pain control to others. People who deploy active coping strategies avoid catastrophizing and have better control of pain, less physical and psychological disability, and better treatment outcomes than people who deploy passive coping strategies. However, people deploy different pain coping strategies at different times, depending on their beliefs, past experience, their confidence in their ability to influence the pain, and their pain coping skills. Because musculoskeletal pain is so ubiquitous, most people initially cope with it by using simple, home remedies and analgesia, but unexplainable recurrent bouts of pain and unsuccessful attempts to cope with it raise worries about the cause, meaning, and prognosis of the problem and undermine people’s confidence in their ability to cope (5).
Interpersonal relationships with a spouse, family, and friends promote physical, social, and emotional well being and self-worth through emotional (promoting feelings of belonging and being valued) and informational (providing explanation of medical conditions and treatment) support (11). Although the size of people’s social network and the number and frequency of social contacts is important, the quality of support is vital, consequently people’s adjustment to ill health is poor if they have a wide circle of support but they are dissatisfied with the support provided. A particularly important source of social support is marital status. People with high levels of marital satisfaction and support display more effective coping strategies, greater psychological adjustment to illness, greater self-esteem, fewer depressive symptoms, and higher levels of life satisfaction. It may not be coincidental that the age-related increase in the incidence of OA may be associated with decrease in elderly people’s social support and increased social isolation resulting from bereavement of spouses, family, and friends; loosening family ties; mobility problems; loss of confidence; and perceptions of personal vulnerability and safety fears.
People with OA are more likely to display symptoms of depression, probably because of increased levels of pain and disability. Depressed people have increased feelings of helplessness, decreased social support, and lower levels of self-efficacy and physical activity (2,13).
COMPLEX INTERACTION BETWEEN OF PSYCHOSOCIAL TRAITS AND OSTEOARTHRITIS
Attempting to identify the relative importance of psychosocial traits is extremely difficult. Not only is the role of all psychosocial traits important, but also these traits are highly labile and their influence on people is likely to vary markedly with the specific trait, with the situation, between and within people, and over time. The variability will be determined by the initial strength of influence of the person’s psychological traits, external influences, and their experiences. Moreover, there are complex interactions between psychosocial traits, so a person’s beliefs about the harm or benefits of exercise is likely to influence their exercise self-efficacy, exercise behavior, and coping strategies (Fig. 2).
The relationship between psychosocial traits and clinical symptoms of OA adds to this complexity (Fig. 1B). The clinical symptoms of OA (pain, disability, perceived muscle weakness, and fatigue) can alter a person’s psychological traits, for example, their health beliefs, coping strategies, level of self-efficacy. However, people’s psychosocial traits determine their reporting of the clinical symptoms of OA and their reaction to these symptoms, by catastrophizing and adopting fear-avoidance behaviors. These can exacerbate physiological changes in muscle weakness and joint instability and lead to further joint degeneration (3). Thus there is a complex “reciprocally deterministic” relationship between clinical symptoms and psychological traits (Fig. 1B).
To illustrate this, exercise-induced improvements in the symptoms of OA have been suggested to be mediated by enhancement of exercise self-efficacy beliefs (14). In one study, when people stopped exercising, these self-efficacy beliefs declined but were elevated back to previous high levels during a single follow-up assessment (12). Such immediate improvement during a single assessment is much more likely to be attributable to improvements in psychological traits than physiological variables. These findings highlight not only the crucial role played by people’s psychological traits, but also the “plastic” and dynamic nature of these traits—successful implementation and positive mastery experiences facilitate appropriate health beliefs, self-efficacy, and behavior, whereas unsuccessful implementation or unhelpful experiences undermine these cognitions and traits.
Thus, there is a very complex, interdependent, and reciprocal relationship between people’s psychosocial traits, behavior, clinical symptoms, and physical consequences of OA (10). These relationships are very labile and impinge on the management of OA. However, they also present us with opportunities to enhance the effective management of OA.
ADDRESSING THE PSYCHOSOCIAL EFFECTS OF OSTEOARTHRITIS
Effective management of OA necessitates addressing its psychosocial consequences. Of major importance is challenging erroneous ill-health beliefs through cognitive behavioral restructuring. This involves explaining that although OA may be incurable it is not untreatable. In addition, because the raison d’être of a joint is movement, pain-related activity does not signal joint damage but rather that prolonged inactivity exacerbates muscle dysfunction and articular damage, leading to greater pain and disability. Correcting inappropriate health beliefs reduces anxiety, catastrophizing, depression, and the consequences of fear avoidance (8). Pain coping skills can be taught on self-management programs that enhance self-efficacy cognitions (9,15), enabling people to cope more effectively with OA and increasing their sense of control and reducing helplessness and social isolation by encouraging greater physical activity.
However, people’s beliefs, anxiety, fears, and confusion about OA and what they should (not) do often are so entrenched that didactically instructing them about the pathology, (in)appropriate behavior, and what they should (not) do is of limited value. To alter people’s health beliefs, to increase their confidence in their ability to control their condition, and to implement appropriate coping strategies and behavioral change, people need to experience the tangible, clinically meaningful benefits that implementing suggested strategies can produce.
EXERCISE AND PHYSICAL ACTIVITY IN MANAGING BIOPSYCHOSOCIAL SEQUELAE OF OSTEOARTHRITIS
As stated earlier, although exercise regimens improve physiological variables, these improvements are apparent so soon after beginning an exercise regimen that they are very unlikely to be due to solely physiological changes. The “added value” of exercise in the management of OA may be due to concurrent improvements in psychosocial variables achieved during participation on exercise regimens (Figs. 1B and 4) that are evident in healthy and patient populations (4) including those with OA (13).
Participation in regular exercise, consciously or subconsciously, addresses many deficits in psychosocial traits. Exercise promotes acceptance of appropriate health beliefs by challenging beliefs that activity causes pain and joint damage, thereby disrupting detrimental fear-avoidance behaviors. Regular exercise also helps control the symptoms of OA, providing people with an active coping strategy (7); through exercise, they learn how to implement these strategies, enhancing exercise self-efficacy and enabling them to do more for themselves, thereby reducing helplessness, disability, and social isolation.
To encourage regular participation in exercise regimens people must experience the benefits of a simple, practicable exercise regimen that they can implement. Exercise regimens that are complex or require expensive, specialized equipment, facilities, and supervision undermine self-efficacy and encourage passive coping strategies, feelings of helplessness, and dependency on others.
The effectiveness of simple, practicable exercise regimens can be enhanced by integrating into them explicit patient education and practical self-management advice (8,15). They can be further enhanced if people receive support, encouragement and frequent positive feedback from their spouses, close family, friends, and healthcare professionals. When this encouragement and support is not forthcoming, people perceive they are no longer benefiting from the regimen, their enthusiasm wanes, they stop exercising, and the hard-won physiological and psychological benefits are rapidly lost. This emphases the importance of social support
Such rehabilitation programs do not attempt to cure OA, which remains an incurable condition, but in line with the tenets of the biopsychosocial model of ill health, it encourages people to learn about, accept, adapt to, and cope with OA by providing knowledge, practical advice, and convincing positive experience of the meaningful improvements people can achieve to help themselves self-manage their problems.
Exercise has proven benefits in the management of OA, but the benefits attained cannot be explained solely by physiological improvement in muscle function. Exercise-induced improvements in psychosocial variables have not been widely appreciated, but are as important because they help people understand and live with chronic joint pain. The most important traits have not been identified, and it is likely that the most influential traits will vary from person to person, within people over time, and from situation to situation, depending on a person’s internal cognitions, external influences, and experiences. Disentangling what psychosocial traits are most influential, in whom, and when will not only be an extremely difficult and probably futile task because of the complex, reciprocal relationship between the various psychological traits and reported symptoms and consequences of OA. To date, most clinical trials have investigated only a limited number of psychosocial variables, which has limited our ability to gain a better understanding of the effects of OA. To understand the complex interactions between psychosocial traits and the condition requires careful measurement during large, well-designed, complex clinical trials. Addressing these issues and increasing our knowledge of this area will enable us to devise more effective interventions to lessen the impact of OA.
What is apparent is that the most effective rehabilitation programs integrate simple, practicable exercise regimens with cognitive behavioral restructuring interventions. These help people appreciate that exercise, far from being harmful, provides them with an active strategy that enables them to cope with and control the complex physical symptoms and psychosocial consequences of OA.
The authors thank arc, the Arthritis Research Campaign, for the financial support of their research, and the two reviewers for their constructive comments on the original manuscript.
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Keywords:©2003 The American College of Sports Medicine
osteoarthritis; exercise; sensorimotor physiological improvements; psychological benefits