Model Research Essay


Because arthritis is chronic, painful, and currently uncurable, it is important that patients understand the limitations of medicine and take responsibility for the ways in which they can improve their condition. Historically, arthritis was not a focus of medical concern; however, it is now considered a major public health problem. The two most common forms of arthritis are osteoarthritis and rheumatoid arthritis, which act through different mechanisms to cause joint damage, pain, and reduced function. Conventional medicine, surgery, and alternative therapies are available to treat arthritis; however, assessing the effectiveness of these treatments can be confusing for doctors and patients, due to the inconsistent pain patterns of arthritis and the psychological effects of treatment on the perception of pain. People with arthritis can learn ways to take care of their joints and manage pain. The Arthritis Self-Help Course has been shown to be effective in improving participants’ health by teaching adaptive behaviors and fostering self-efficacy.

Improving Life with Arthritis

By Heidi Aandahl

July 23, 2002

About five years ago, I shared in the popular misconception that “arthritis” simply describes natural aches and pains associated with aging. By volunteering with physical therapists, I became aware of the two most common forms of arthritis, which are osteoarthritis and rheumatoid arthritis. It wasn’t until I did some research that I found out that “arthritis” encompasses over 100 separate diseases. I was surprised that I could have been so misinformed about a household word. However, I found that my misconceptions had a strong historical basis.

In medical investigations through the early nineteenth century, the diseases that are now called arthritis were not considered very important. For example, post-mortem examinations in London addressed only the cause of death, and therefore did not include opening arthritic joints (1, 95). In Paris, the aged and crippled were placed in an asylum with other "unwanteds" such as prostitutes and beggars; serious attempts to differentiate the diseases afflicting people within the asylum were not made until the mid to late nineteenth century (1, 96-97). Osteoarthritis and rheumatoid arthritis were not commonly differentiated until the early twentieth century (1, 98).

Today, arthritis is a significant public health concern. The Centers for Disease Control and Prevention report that nearly one in six Americans have arthritis. They estimate that the annual "cost of medical care for arthritis is $15 billion, and the total estimated cost, including lost productivity, exceeds $65 billion" (2). Medicine and surgical interventions are used to reduce the symptoms or slow the progress of the disease; however, the causes of the disease are not fully understood, and there is no cure for arthritis. Since arthritis is a chronic and painful disease, it is crucial for people who have arthritis to understand what they can do to improve their condition, within the limitations of the medical treatments available.

Rheumatoid arthritis and osteoarthritis are both experienced by the patient as joint pain, and either may result in joint deformity or restricted movement. Pain is acute during the first year after the onset of disease, but then it may subside to some degree. Patients with osteoarthritis may experience further pain only after overusing the arthritic joint, whereas patients with rheumatoid arthritis will experience unpredictable cycles of flares and remission. Rheumatoid arthritis is characterized by swollen joints, and it tends to affect many joints on both side of the body. Rheumatoid arthritis may also cause fatigue, and severe cases cause swelling in bodily tissues other than the joints.

The differing symptoms associated with these two forms of arthritis result from the differing mechanisms of disease. When a healthy joint moves, the articular ends of the bone roll or slide against each other, but bone damage is prevented by a smooth cartilage covering on articular bone surfaces. The cartilage functions to reduce friction. A synovial membrane encapsulates the space between the bones and secretes slippery, lubricating fluid into it, which also protects the bones. In osteoarthritis, the articular cartilage wears away, leaving the bone susceptible to damage. Bony spurs may appear next to the joint, as an extension of the body’s repair of the damaged bone. In rheumatoid arthritis, an autoimmune attack causes inflammation of the synovial membrane. Proteins released during the inflammation damage the surrounding bone, cartilage, ligaments, and tendons.

Basic medical treatments for osteoarthritis and rheumatoid arthritis are similar: medications are prescribed to reduce pain and inflamation, and joints are surgically replaced if they become severely damaged. Depression is often associated with chronic, painful diseases, and may be treated with antidepressant mediation. An additional class of medications called "disease- modifying antirheumatic drugs" (DMARDs) is used to slow down rheumatoid arthritis and prevent permanent damage in some of the tissue. For patients with severe rheumatoid arthritis, a Prosorba column may be used to filter certain antibodies (immune chemicals) from the blood to prevent them from contributing to the pain and inflammation at the joints and muscles (5).

Until recently, arthroscopic surgery was believed to be an effective treatment for osteoarthritis of the knee. The procedure involves "cleaning out" the knee cavity, either by using fluid to wash out enzymes and debris, or by scraping away rough cartilage and debris. Researchers in Houston tested both types of arthroscopic surgery against a placebo procedure, and found that patients in all three groups showed similar improvement in arthritis pain and total body pain, and none of the groups showed signficant improvement in the ability to walk and climb steps (6). This study illustrates two important points; the medical community still has much to learn about arthritis, and patients’ perception of pain is highly influenced by whether they believe appropriate action has been taken to combat the pain.

The inconsistency of arthritis patients’ pain can make it difficult for them to discern whether medical treatments or good personal habits are helping. In addition to trying treatments sanctioned by the medical community, many people will try alternative therapies. Carolyn Strange, a medical writer for the FDA, noted that "people with arthritis are among the prime targets for fraud and spend nearly a billion dollars annually on unproved remedies, largely diets and supplements" (7, 146). She explains that because arthritis has unpredictable cycles of pain and remission, people may readily attribute a remission to a dietary change that preceded it. However, there is insufficent evidence that specific dietary changes truly help arthritis patients. A balanced diet that keeps off excess weight is widely recommended. Although some of the alternative approaches to treating arthritis may seem harmless, they may cause patients to discontinue conventional treatment that would be helpful in the long run.

Derrick Brewerton, a clinical rheumatologist, shows a particular interest in the psychological experience of rheumatoid arthritis. He presents evidence that emotional threats may precipitate the onset of rheumatoid arthritis, and notes that hospitalization helps patients by removing them from daily stresses, allowing them to think and ask questions. Sometimes patients experience immediate pain relief and reduced swelling during their hospital stay. Furthermore, Brewerton emphasizes the need for mutual trust between the doctor and patient. He sees it as the doctor’s role to inform the patient that early interventions may not be effective, so that they will stay engaged in their treatment in spite of setbacks. Also, the doctor may be able to learn of daily activities or emotional events that tend to trigger flares, and suggest alternatives to medicine such as modified activities or psychological counseling (1, 181-184).

Brewerton's points of view were published only ten years ago, but it is interesting to note that more current literature emphasizes the importance of the patient’s self-care and disease management, partly as a means of reducing the number of doctor visits. Self-care techniques that help control arthritis include controlled exercise that isn't strenuous to tender joints, weight control, relaxation techniques, and doing daily activities in ways that put the least stress on individual joints.

A specific self-managment education program called the Arthritis Self-Help (ASH) Course has been used successfully since its development began in 1977. It is a twelve-hour course taught primarily by laypersons over the course of six weeks. The Centers for Disease Control and Prevention (CDC) report that the ASH Course reduces arthritis pain by 20% and physician visits by 40%. However, less than 1% of those with arthritis participate in the program, and the courses are not offered in all areas. One of the CDC's goals is to increase participation in programs such as the ASH Course (2).

The ASH Course teaches arthritis patients to manage three types of tasks, including disease-related tasks, such as exercising and using adaptive equipment; adapting their roles in families, work, and activities; and coping with negative emotions related to the uncertainty of the future (3, 63). A study of experimental versions of the ASH Course suggested that patients’ increased self-efficacy resulting from the course was a more important determinant of their improved health than specific behaviors that the course taught (3, 58- 60). Therefore, subsequent versions of the ASH Course were structured to emphasize self-efficacy. Kate Lorig, a public health nurse who was involved in the early studies of the ASH Course, summarizes the critical points of Albert Bandura's Self-efficacy theory that were applied in the course’s development:

Self-efficacy theory states that 1) the strength of belief in one's capability is a good predictor of motivation and behavior; 2) one's self-efficacy beliefs can be enhanced through performance mastery, modeling, reinterpretation of physiological symptoms, and social persuasion; and 3)enhanced self-efficacy leads to improved behaviors, motivation, thinking patterns, and emotional well-being (66).

Each of the elements in the second point of the theory is reflected in the structure of the ASH Course. General skills are introduced during the course, but it is the responsibility of the participants to tailor the skills to their specific needs and master them outside of the class. Doing so constitutes “performance mastery.” For example, people might be taught how to build a suitable exercise program, monitor it, judge their pain levels, and respond accordingly, rather than learning about specific exercises. Since the course material is general, The Arthritis Help Book is provided as reference material (63-69).

ASH Course groups are taught by a pair of laypersons, at least one of whom usually has arthritis and serves as the “model” recommended by the self-efficacy theory. Instead of teaching all of the course materials, the group leaders facilitate group exercises and rely on participants to answer as many of each other's questions as possible. These interactions serve as “social persuasion” (3, 66-67).

“Reinterpretation of physiological symptoms,” the remaining enhancer of self-efficacy, is presented as part of the ASH Course’s content. Myths about arthritis are exposed, and multiple causes of symptoms are presented so that the patients can look at multiple ways to relieve the symptoms. For example, sometimes fatigue is simply a symptom of rheumatoid arthritis, but other times it is caused by medication or factors that could influence anyone, such as diet or depression (3, 67).

We may hope that medical research will lead to preventions or cures for arthritis. Until that time, though, patients must accept that fluctuations in pain cannot always be explained or prevented. Even more importantly, their lives can be improved if they accept responsiblity for self-care and disease management. Not only can their joints be protected by their behaviors, but their sense of pain may be diminished by their proactive attitude.

Annotated Bibliography

  1. Brewerton, Derrick. All About Arthritis: Past, Present, Future. Cambridge, MA: Harvard University Press, 1992.
    This book is structured as a "detective story" showing the scientific discoveries that have helped build our knowlege about the causes of arthritis. I relied on this book to place arthritis in an historical context, and I found its discussion of arthritis's psychological aspects useful. It was difficult to use as a reference book on arthritis, due to its emphasis on the process of making scientific discoveries.
  2. Centers for Disease Control and Prevention. "Targeting Arthritis: Public Health Takes Action." Feb. 19, 2002. Http://
    This portion of CDC's website provides a brief discussion about arthritis and outlines the CDC's role in preventing and controling arthritis. This site had been updated recently, so I used it as a source of statics on arthritis and the ASH course. Most of this site’s content was not specifically relevant to this essay.
  3. Lorig, Kate. "Arthritis Self-Management: Elizabeth Swanson, Toni Tripp-Reimer, Kathleen Buckwalter," Health Promotion and Disease Prevention in the Older Adult. New York, NY: Springer Publishing Company, Inc., 2001, pp. 56-80.
    This chapter describes the ASH course, provides synopses of studies conducted during its development, and discusses its dissemination and future impact. It successfully highlights the importance of self-efficacy in an arthritis patient's health, and greatly impacted the direction I took in writing this essay. I would have liked more detailed synopses of the studies used to develop the ASH course; the presentation of their results appeared to be incomplete and/or unclear.
  4. Mayo Foundation For Medical Education and Research. "What is Osteoarthritis?" Feb. 11, 2002. Http://
    This site provides an overview of osteoarthritis at a level of detail suited to the more-than-casual layperson, such as someone who thinks they might have arthritis. This site is excellent reference material, because it is well-organized and concise, and it has useful pictures. Its strength is also its limitation -- it does not explore any one aspect of the disease in depth.
  5. Mayo Foundation For Medical Education and Research. "What is Rheumatoid Arthritis?" Mar. 4, 2002. Http://
    This site is structured the same as “What is Osteoarthritis?” (4), and is also a good reference.
  6. Okie, Susan. "Knee Surgery For Arthritis is Ineffective, Study Finds." Jul. 11, 2002. Http://
    This newspaper article reports the findings of a study that compared arthroscopic surgery to a placebo procedure for osteoarthritis patients. I used this article because the findings are interesting (the effects of surgery and the placebo were nearly equal) and relevant to this essay. The weakness of this article is that it only presents the point of view of people who conducted the study.
  7. Strange, Carolyn. "Coping with Arthritis in Its Many Forms," Disabilities Sourcebook: Health Reference Series, First Edition. Dawn Matthews. Detroit, MI: Omnigraphics, Inc., 2000, pp.141-148.
    This chapter describes the common features of the various forms of arthritis, discusses how patients can cope, and describes the medical treatments that are available. I found its discussion of patients’ susceptibility to fraud insightful and relevant. Although I used this chapter to reinforce my understanding of arthritis and its conventional treatments, it was not as comprehensive and organized as the Mayo Clinic websites (4 and 5).

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