184 Arthritis and Musculoskeletal Conditions
metaanalysis of common treatments for FM demonstrated that
nonpharmacological interventions are often more ef“cacious
than pharmacological treatments at treating the pain of FM
(Rossy et al., 1999).
Psychosocial Treatment
Given that biological, psychological, and social factors all
contribute to the experience of RA, OA, and FM, numerous
psychosocial interventions have been developed. Cognitive-
behavioral therapy (CBT) has emerged as one of the most
common forms of psychosocial treatment. Common ele-
ments of CBT include biofeedback, relaxation exercises,
education, mastery, modeling, and cognitive appraisal (for re-
views, see K. Anderson, Bradley, Young, McDaniel, & Wise,
1988; Nicassio & Greenberg, 2001). CBT is directed toward
the goal of improving targeted aspects of health status such as
pain tolerance, mobility, self-management, and self-ef“cacy.
In the treatment of RA, CBT has been found to decrease pain,
lower disease activity, decrease depression, and reduce health
care utilization (K. Anderson et al., 1988; McCracken, 1991;
Nicassio & Greenberg, 2001). Other common components
of CBT therapy, recently researched in OA patients, include
exercise treatments (Rejeski, Ettinger, Martin, & Morgan,
1998) and enhancing coping skills and spousal support
(Keefe et al., 1987). These studies found signi“cant improve-
ments in health status and enhancement of self-ef“cacy.
Interventions that succeeded in increasing self-ef“cacy and
the health of individuals with RA and OA have also been
studied in samples of FM patients (Burckhardt & Bjelle,
1994). These interventions utilized elements such as graded
exercise programs and cognitive-based psychoeducation.
Furthermore, these techniques have been shown to increase
self-esteem and various aspects of health in individuals with
FM (Gowans, deHueck, Voss, & Richardson, 1999).
Self-help groups have also been shown to effectively
increase arthritis knowledge, improve compliance with
health behaviors, increase self-ef“cacy, and reduce pain and
health care utilization in individuals with RA and OA
(Nicassio & Greenberg, 2001). For example, the Arthritis
Self-Management Program has traditionally focused on im-
proving knowledge and increasing health behaviors in indi-
viduals with arthritis and musculoskeletal conditions (Lorig,
Gonzalez, Laurent, Morgan, & Laris, 1998). In addition,
these programs increase self-ef“cacy by including experi-
ences of mastery (successfully controlling psychological or
physiological responses), modeling (observing others suc-
ceed), and cognitive appraisal (reducing negative thoughts)
(for review, see Nicassio & Greenberg, 2001). While self-
help management programs have recently been applied to
FM patients, further research is needed to demonstrate the
effectiveness of these programs in FM.FUTURE DIRECTIONSThe unique contributions from biological, psychological, and
social factors have been illustrated separately for RA, OA,
and FM. However, despite the unique experience of these
factors in each disorder, psychosocial treatment has yet to be
individualized to address the different needs of people with
various forms of chronic pain. Future treatments of these
conditions must consider the speci“c biopsychosocial quali-
ties unique to each condition. For example, RA is a condition
with many known pathophysiological features and some ef-
fective pharmacological treatments. As a result, psychosocial
interventions that in”uence biological processes that underlie
RA may be especially effective. It may also be helpful to
research the psychosocial factors that in”uence compliance
with pharmacological treatment. Furthermore, interventions
that utilize existing social systems (i.e., family, peers, and
health care providers) to address barriers to compliance may
be especially bene“cial.
Although new pharmacological treatments of OA (e.g.,
Celebrex, Vioxx) have been developed, many treatments of
OA are not pharmacological. Furthermore, the fact that many
treatments of FM do not involve medications underscores the
importance of compliance with nonpharmacological treat-
ment recommendations. For example, the development of
OA is often dependent on preventable factors such as exer-
cise and obesity. Therefore, treatments addressing compli-
ance with exercise regimens would be especially useful in
this population. Similarly, compliance with lifestyle changes
would also be a useful target for FM interventions. Interven-
tions promoting exercise initiation in individuals with FM
must recognize the speci“c need for close supervision by
trained health care professionals with this population.
Future treatments should also consider how each condi-
tion may engender unique sources of stress. For instance, we
have reviewed how unpredictable and uncontrollable events
are perceived as the most stressful. OA, characterized by rel-
atively predictable symptom exacerbation from variables
such as overexertion and climate changes, may be less stress-
ful than FM and RA, which are known for unpredictable
exacerbations. Similarly, FM•s relative lack of symptom re-
lief may be an additional source of stress that might not be as
pronounced as in OA, where pharmacological agents provide
some relief. Thus, treatments may maximize their effective-
ness by considering the controllability and predictability of
stressors and devising ways to affect these qualities.