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63

Chapter 5

Applying the biopsychosocial model to the


management of rheumatic disease
Sarah Ryan RGN PhD MSc BSc FRCN Staffordshire Rheumatology Centre, Haywood Hospital, Stoke on Trent NHS Primary
Care Trust, Stoke on Trent, UK

Alison Carr PhD Nottingham University, City Hospital, Nottingham, UK

CHAPTER CONTENTS Patient health beliefs about disease and


treatment 71
Introduction 63 The clinical consultation 72
Questionnaires for assessing adherence
Section 1: The biopsychosocial model and its
and concordance 72
importance in arthritis management 64
Conclusion 73
Section 2: The impact of rheumatological
conditions 64
Work 64
Leisure 65 KEY POINTS
Mood 65 ■ Living with a rheumatological condition has the
Social support 65 potential to impact on physical, psychological and
Sexuality and body image 66 social function.
■ Adopting a biopsychosocial approach can provide a
Section 3: Pain 66
framework to identify the impact of illness.
Pain mechanisms 66
■ Chronic pain is a multifaceted experience with
Pain receptors 66
sensory, affective and cognitive components.
Peripheral and central sensitization 67 ■ Psychological models help to explain health behaviour.
Section 4: Health behaviour, coping and ■ Understanding health behaviour can enhance
concordance 67 adherence with treatment and improve outcome.
The health belief model 68
Health locus of control 68
Social cognitive theory 69 INTRODUCTION
Theory of planned behaviour 69
The self-regulatory model and illness beliefs 69
Living with a chronic condition, such as rheumatoid
Commonalities between the social cognition arthritis (RA), impacts all functional domains.
models (SCMs) 70 Health professionals help patients develop coping
Health behaviours (coping, concordance, skills to minimise the condition’s effects on physical
health beliefs) 70 and psychological wellbeing. To do this effectively
Coping 70 health professionals must understand why and how
Concordance 71 people adopt or reject certain health behaviours.
By utilising the biopsychosocial model of care,

© 2010 Elsevier Ltd


DOI: 10.1016/B978-0-443-06934-5.00005-X
64 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

illness impact on physical, psychological and social to pace their activities, this may be perceived as
aspects of function is addressed and a wider range ‘laziness’ and lead to family conflict. Spouses of
of therapeutic options offered that have meaning patients attending an education programme to
and relevance to the individual. increase their knowledge of RA experienced a
This chapter is divided into four sections change in their perceptions towards the condition,
addressing: the biopsychosocial model; the impact which were largely negative before the programme
of arthritis; pain; and social cognition models that (Phelan et al 1994). The importance of the family on
help explain health behaviour. outcome was illustrated in a study of the benefits
of behavioural interventions to minimise pain in
patients with RA. Intervention incorporating family
SECTION 1: THE BIOPSYCHOSOCIAL support was more effective in reducing pain than
MODEL AND ITS IMPORTANCE IN the intervention with the family alone (Radojenic
ARTHRITIS MANAGEMENT et al 1992). Adopting a biopsychosocial model of care
ensures all factors influencing a patient’s ability to
Recognition that understanding patient’s beliefs, manage and cope with their condition can be iden-
feelings, thoughts and health behaviour is neces- tified and, where possible, addressed.
sary to aid our understanding of the patient’s con-
dition has led to a move from a disease model to a
biopsychosocial model of care, which acknowledges SECTION 2: THE IMPACT OF
the importance of psychological and social factors RHEUMATOLOGICAL CONDITIONS
as well as the physical impact of living with arthri-
tis. For example, physical impact can include symp- Patients are individuals with a life history, beliefs,
toms of pain, stiffness and fatigue. Psychological standards and expectations (Bendor 1999). RA can-
effects may include feelings of frustration, low not be considered solely in terms of its physical
mood and give rise to concerns about the future, consequences. The potential psychological, social
whilst social implications can include concerns and economic impact must be considered.
about work, role within the family and continuing
to engage in valued leisure activities.
Adopting a biopsychosocial approach to care
WORK
has increased the range of therapeutic options for Work disability can occur early in arthritis (Fex et al
patients. Cognitive behavioural therapy (CBT), which 1998). People with a musculoskeletal condition are
aims to identify and change maladaptive patterns of more likely to stop working if they:
thought and behaviour, is of benefit in patients with ● are older
RA. In newly diagnosed RA patients, CBT improves ● are female
a patient’s sense of control regarding their condition
● have fewer years in education
and prevents development of negative illness per-
● have pain and co-morbidity
ceptions (Sharpe et al 2003). CBT is also useful for
patients with depression (Parker et al 2003). ● have limitations in function.
Other psychological interventions involve improv- (Yelin 1995)
ing confidence in carrying out specific behaviours, i.e. Cox (2004), focusing on the needs of newly
self efficacy, which will be discussed in Section 4. If a diagnosed RA patients, found that being able to
person believes they can play an active role in man- continue working was a major concern: ‘The only
aging some of the impact of their condition, through question I could think of, is the question I really
employing strategies such as pacing, goal setting and want answering - am I going to get back to work
exercise, they are more likely to do so than a patient full-time?’. A National Rheumatoid Arthritis Society
with little or no such confidence. Active self-manage- (2003) survey showed 54% of participants attrib-
ment is associated with higher levels of adherence. uted not being in full-time work to RA and 30% of
Even if the intended goal is not achieved, the process employed participants worked part-time because
of striving for it leads to better outcomes (Jerant 2005). of RA. Mancuso et al (2000) found those seem-
Involving significant others in care management ingly successfully employed still faced major chal-
can also have a positive effect on outcomes. If the lenges, made major adaptations in order to stay at
family is unaware why an individual is encouraged work and still perceived their jobs to be in jeopardy.
Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease 65

Early intervention through liaison with employ- (Dickens & Creed 2001, Lowe et al 2004, Sheehy
ers, consideration of alternative ways of working, et al. 2006).
work place assessment and if necessary retraining If depression is suspected it must be assessed and
is important to keep patients at work (see Ch. 9: treated. It is not acceptable to acknowledge it is asso-
Occupational therapy). Vocational issues that may ciated with RA and not treat it. In Stoke-on-Trent in
need considering are shown in Box 5.1. the UK, a combined liaison psychiatry clinic run
by a liaison psychiatrist and a rheumatology nurse
consultant assesses for mental health problems and
LEISURE
advises on appropriate treatment. For depression
Engaging in a specific leisure activity will be influ- this involves anti-depressants and/or CBT.
enced by the individual’s level of motivation, and
the belief participation can be done to a reasonable
standard. The physical and psychological impact SOCIAL SUPPORT
of arthritis, such as pain, reduced muscle strength, Interpersonal relationships contribute to physical,
fatigue and reduced self esteem, may hinder both psychological and social state wellbeing. Through
the desire and ability to partake in leisure. Many our social support systems we validate beliefs, emo-
difficulties are faced participating in leisure (Fex tions, action and seek information and advice. Core
et al 1998, Hakkinen et al 2003, Wikstrom et al 2005). activities carried out within social networks include:
Inaccessible facilities, lack of transport, absence of
● Instrumental activities–cooking, cleaning,
support or negative attitudes from others may all
financial management and shopping.
impact negatively on leisure (Specht et al 2002).
● Nurturing activities–making family
arrangements, maintaining family ties, looking
MOOD after family members and listening to others.
Depression in RA is 2–3 times higher than in the Ryan et al (2003) demonstrated that patients wanted
general population (Dickens & Creed 2001). Data to remain active in both domains. Aspects of social
from baseline co-morbidity levels in over 7,000 support enhancing control perceptions include:
patients starting biologic treatments found 19% had ● remaining active in family activities
a formal diagnosis of depression at any one time ● receiving ongoing support from family members
(Hyrich et al 2006). (and not just at the time of increased activity
Depression in RA is linked to: such as a ‘flare’ of the condition)
● pain ● achieving a balance between support needs and
● functional disability: support provision.
● work disability Many inflammatory conditions are characterised
● poor adherence to treatment by unpredictability regarding symptom occurrence,
● lack of social support treatment efficacy and overall prognosis. Different
● low confidence in the ability to manage symptoms levels of support will be required from health profes-
sionals related to patients’ identified needs (Box 5.2).
● high daily stresses

BOX 5.2 Support that health professionals can


BOX 5.1 Vocational issues (Gordon et al 1997) provide
■ Flexible hours ■ Cognitive-discussing the individual’s thoughts about
■ Self paced activities the situation
■ Shortened working weeks ■ Affective-exploring the emotions connected to the
■ Working at home situation
■ Rest/work schedule ■ Instrumental-e.g. arranging for a home assessment
■ Equipment and modifications to aid employment and OT to evaluate and discuss problems in situ
■ Work space design and adaptation of the work ■ Informational-providing advice on how to manage a
environment specific symptom, such as pain.
66 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

SEXUALITY AND BODY IMAGE and pain experienced. But this does not explain the
variation in pain experience for a given stimulus or
Sexuality is an individual self-concept expressed as injury. Why do some patients take longer to recover
feelings, attitude, beliefs and behaviour (RCN 2000). from whiplash than others? Why does pain persist
RA features which impact negatively on sexual- beyond the time of tissue healing?
ity and body image include joint pain and stiffness, Melzack and Wall’s gate control theory of pain
fatigue, low mood, physical changes and treatment (1965) revolutionised understanding of pain mecha-
visibility, including splints (Hill et al 2003). Patients nisms (Fig. 5.1). This demonstrated that the trans-
indicate they would like the opportunity to discuss mission of pain messages could be modulated
sexuality concerns with healthcare professionals (Hill within the spinal cord via descending messages
et al 2003) but due to a lack of privacy, time, knowl- from the brain (our cognitions and emotions) or
edge and skills, this often does not occur. Many types altered by activating another source of sensory
of arthritis extensively affect people’s lives. Living receptor (e.g. exercise to release endorphins).
with chronic pain considerably contributes to this.

PAIN RECEPTORS
SECTION 3: PAIN Sensory receptors are situated in the tissues of the
skin, synovium of joints and arterial walls. These
Pain is an unpleasant sensory and emotional expe- are activated by various stimuli including:
rience associated with actual or potential tissue ● mechanical changes: increased synovial fluid in
damage, or described in terms of such damage the joint cavity and proliferation of the inflamed
(International Association for the Study of Pain synovial tissues causes pain by distension and
(IASP) 1994). It is a common symptom across rheu- stretching of the capsule
matic conditions. It is a unique, subjective and unver-
● temperature changes
ifiable person experience (Turk & Melzack 1992).
Acute pain is often transient and the source of pain is ● inflammatory changes: the release of
identifiable and treatable, e.g. active synovitis of the prostaglandin, bradykinin, histamine and
knee. Chronic pain is an ongoing experience associ- serotonin.
ated with a plethora of other symptoms including Peripheral sensory nerves transmit signals from
anxiety, depression and sleep disturbance. the peripheries to the central nervous system ena-
Patients with RA cite pain as their most impor- bling stimulus identification. Alpha delta fibres
tant symptom (Minnock et al, 2003). Pain is associ- (thin and myelinated) transmit the sharp pain of
ated with impaired quality of life, depression and an acute injury and slower C-fibres (unmyelinated)
disability in both RA and OA (Spranglers et al 2000). produce the dull aching pain of a more persistent
Chronic pain in fibromyalgia results in reduced phys- problem or the burning quality of neuropathic pain
ical activities, increased mood symptoms, withdrawal (McCabe 2004).
from the workplace and increased use of health care Sensory nerves deliver information from the
services (Hughes et al 2006). When helping patients peripheries to the dorsal horn where they terminate.
manage their pain, a biopsychosocial model aids
fully comprehending the pain experience and enables
planning care that is meaningful for the patient. Descending
messages Spinal
from the brain
cord
PAIN MECHANISMS
A Delta and C fibres
The ‘specificity theory’ attributed to Descartes in (excitatory)
Pain gate
1664 reflects early understanding of pain mecha-
A Beta fibres
nisms. In this model, skin pain receptors are acti- (inhibitory)
vated by a painful stimulus and messages conveyed
to the brain enabling action to be taken, e.g. remov-
ing the hand from a fire. Pain is purely a physical
phenomenon with a direct relationship between Figure 5.1 A simplified diagram of the gate control theory
the amount of stimulation (damage) to nociceptors of pain.
Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease 67

This information is then interpreted by transmis- PERIPHERAL AND CENTRAL


sion cells (T-cells) transmitting information to the SENSITIZATION
local reflex circuits and the brain. When the Alpha
delta and C fibres are stimulated T cells are acti- The gate theory of pain is portrayed as a hard-
vated resulting in the substantia gelatinosa (SG) wired system but we know this is not the case
being suppressed so that the ‘pain gate’ opens and (McCabe 2004). If persistent stimulation occurs the
messages pass to the brain to be perceived as pain. Alpha delta and C fibres will be activated by weak
When large fibres become activated (Alpha beta) non-noxious stimuli (Devor & Seltzer 1999). This
they suppress T cell activity and close the gate. sensitization occurs in the peripheries due to tissue
Alpha beta fibres transmit the sensation of touch. damage or release of chemical inflammatory media-
Acupuncture and electrical nerve stimulation work tors (e.g. substance P) into the skin from damaged
on the same principle and excite large fibre activity. C fibres and the increase in the activity of calcium
Nerve impulses descending from the brain can also channels within the spinal cord. The presence of
operate ‘the gate’. allodynia (pain from a non noxious stimuli) and
hyperalgesia (increased response to a painful stim-
ulus) can occur due to a lowering in the Alpha beta
threshold so that pain now becomes a painful stim-
ulus (McCabe 2004).
CASE STUDY 5.1 POSSIBLE PAIN PATHWAYS IN Pain is affected by many physical, psychologi-
A CASE STUDY OF A PATIENT WITH RA (BASED ON cal and social factors. Effective pain control using a
AN EXAMPLE BY McCABE 2004) variety of approaches is thus essential in biopsycho-
social management of arthritis. These approaches
Mrs Jones is a 44-year-old women diagnosed with
are discussed in subsequent chapters.
RA 5 years ago. She works as a legal assistant in a
busy law firm. She has had to take time off which is
worrying her. Mrs Jones is married with no children.
Over the last 3 months she has experienced more early SECTION 4: HEALTH BEHAVIOUR,
morning stiffness (from 30 minutes to 2 hours) and COPING AND CONCORDANCE
has pain and inflammation in both wrists and her right
knee. Mrs Jones describes her pain as ‘burning and Health behaviour refers to the ways in which peo-
tender to touch’. The pain disturbs her sleep and she ple with arthritis perceive, understand and man-
has difficulty with mobility. age their condition. Understanding factors affecting
health behaviours, coping and concordance helps
Peripheral mechanisms
maximise effective biopsychosocial management.
The inflammatory process (demonstrated by swelling, Influences on health behaviours include:
pain and stiffness) has generated peripheral
● demographic factors, e.g. age, gender, culture,
sensitization. Reporting burning pain indicates
socio-economic
activation of the C fibres or changes in the dorsal
● social and environmental factors: e.g. access
horn resulting in central sensitization. Problems with
to care and societal attitudes to illness and
mobility may be due to changes in knee intra-articular
treatment
pressure.
● personal factors, e.g. personality, emotions and
Central mechanisms cognitions.
Generalised tenderness indicates a lowering of There are several psychological models, known
the Alpha beta fibre threshold and may have been as social cognition models, developed to predict
induced by the duration of symptoms. Changes in and explain health behaviour. The most commonly
proprioception due to knee swelling may create a used are:
mismatch in the motor and sensory systems. This ● Health belief model (HBM)
mechanism has been proposed as an explanation for
● Health locus of control (HLC)
the perception of stiffness in RA (Haigh et al 2003).
● Social cognitive theory
Other factors that may influence Mrs Jones’ pain are
her lack of sleep and work concerns. ● Theory of planned behaviour (TPB)
● Self-regulatory model (SRM)
68 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

Perceived susceptibility

Demographic
variables Perceived severity
Class, gender, age etc.
Health motivation Action
Psychological
characteristics
Personality, peer group Perceived benefits
pressure etc.

Perceived barriers Cues to action

Figure 5.2 The health belief model (adapted from Abraham and Sheeran 2005).

THE HEALTH BELIEF MODEL HEALTH LOCUS OF CONTROL


This model is based on two aspects of health behav- The Health Locus of Control model is based on
iour (Fig. 5.2): Rotter’s Social Learning Theory (Rotter 1954). It
1. The perception of threats to health based on an proposes that health behaviours are predicted by
estimation of perceived susceptibility to illness the extent to which an individual believes they can
and severity of illness consequences. perform the behaviour and that it will be effective.
Individuals with an internal locus of control (LOC)
2. An evaluation of the behaviour required to avoid/
are more likely to take action to manage their symp-
reduce these threats including the benefits, efficacy
toms than an individual with more external LOC
and costs of engaging in health behaviours.
who believes their symptoms are a result of chance
Cues to action can trigger performance of health and looks to other sources, such as the doctor, to
behaviours if the underlying beliefs about threat manage their symptoms. However, this model has
perception and behavioural evaluation are favour- been tested in a wide range of therapeutic areas
able (Becker et al 1977). with conflicting results.
Take, for example, a patient whose RA is affect- The most widely used measure is the Multiple
ing ability to work. They believe that without some Health Locus of Control (MHLC) Scale (Wallston
form of drug treatment they will become progres- et al 1978), evaluating beliefs about health behaviours
sively disabled (high threat). They know there are in general, and the variance in results might relate
several treatment options. Despite concerns about to individuals holding different beliefs depending
medications (costs) they believe some are very on the situation. For example, an individual might
effective (benefits). Media reports of a new wonder have a high internal LOC for weight loss (i.e. they
treatment for RA may prompt them to seek treat- believe they are responsible and have the ability to
ment (cues to action). reduce their weight) but a high external LOC for
The HBM has been used as a basis for the Beliefs managing their arthritis, believing this is the doc-
about Medicine Questionnaire (Horne et al 1999). tor’s responsibility. Ryan et al (2003) found that
This focuses on the perceived threat of illness and within a medical consultation, contrary to the HLC
medication and the consequences of taking or not model, an external LOC increased the patient’s per-
taking medication. It has been used to explain/ ceived control over their ability to live with their
predict adherence to medication. For example, if arthritis. This may be because patients view their
arthritis pain is perceived as severe and medica- condition as too unpredictable and mutifacted to
tion is perceived as effective and relatively safe, manage without external professional support and
patients are more likely to take it to manage their view the consultation as a partnership where their
pain (Horne, Mitchell, Weinman, 2001 personal issues could be voiced and management appropri-
communication). ate to their needs provided.
Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease 69

In an attempt to make the HLC a stronger pre- has three subscales: belief in ability to control
dictor of health behaviour it has been adapted to pain, function and other symptoms.
include: the value the individual places on their ● Rheumatoid Arthritis Self-Efficacy Scale (RASE)
health and the extent to which an individual is con- (Hewlett et al 2001): evaluates individuals’
fident in carrying out behaviours they believe will beliefs in their ability to perform specific health
be effective. In other words, for an individual to behaviours rather than their actual ability or
engage in health behaviour, such as exercise, they their outcome expectancy.
need to value their health, believe they are responsi-
ble for it, be confident they can exercise and believe
exercise will be effective. THEORY OF PLANNED BEHAVIOUR
The Theory of Planned Behaviour (TPB) is an
SOCIAL COGNITIVE THEORY extension of the Theory of Reasoned Action (TRA)
(Fishbein & Ajzen 1975, Ajzen & Fishbein 1980).
In this model health behaviour is seen as the result Both models are based on the premise that indi-
of three sets of beliefs: viduals make logical, reasoned decisions to engage
1. Beliefs that there are consequences to threats or in specific behaviours by evaluating the informa-
events that occur without personal involvement tion available to them. The performance of a behav-
or action (situational-outcome expectancies). iour is determined by the individual’s intention to
This involves an evaluation of the health risk and engage in it (influenced by the value the individual
individual’s perception of their susceptibility to places on the behaviour, the ease with which it can
that risk. be performed and the views of significant others)
2. Beliefs that behaviour will result in specific and the perception that the behaviour is within his/
outcomes (action-outcome expectancies). her control. In RA a TPB model based on attitudes,
3. Beliefs that behaviours are within the social support, self efficacy and intention was mod-
individual’s control and they have the ability to erately successful in predicting and explaining self
perform the behaviour (self-efficacy). management of arthritis (Strating et al 2006). Whilst
no validated questionnaires are available, a com-
Self-efficacy (SE) has a direct effect on behaviour: prehensive guide to developing measures of TPB
an individual’s beliefs that he/she can perform components is given in Ajzen (1991). A challenge in
a behaviour predict performance of it. It can also TPB measurement is the difficulty in conceptualis-
influence intention to perform a behaviour. Studies ing and capturing attitudes.
have demonstrated individuals intend to perform
behaviours they are confident they can achieve
(Bandura 1992, Schwarzer 1992). THE SELF-REGULATORY MODEL AND
Self-efficacy has been widely applied in arthritis to: ILLNESS BELIEFS
1. Explain health behaviours: a high SE for
The Self-Regulatory model (SRM) (Leventhal et al
medication and exercise improves adherence to
1997) describes how biological, psychological and
medicines and leads to participation in exercise.
social factors interact to influence how individuals
2. Understand the relationship between physical
perceive their symptoms and illness and the health
and psychological factors e.g. a higher SE is
behaviours they subsequently adopt (Fig. 5.3).
related to less pain, joint stiffness and fatigue,
These perceptions, or illness representations, are
improved function and better mood.
a set of beliefs, emotions and disease experiences
3. As a basis for interventions to help patients which individuals use to evaluate information
manage or cope with their arthritis. about their disease and to regulate their subsequent
Questionnaire measures of self-efficacy include the behaviour. The SRM differs from the other social
● Generalised Self-Efficacy Scale (GSES) (Barlow cognition models in placing equal importance on
et al 1996): measures belief in ability across the emotional reaction to health threats.
a range of situations and is not specific to Studies of people’s illness representations have
musculoskeletal pain. identified five categories of illness beliefs:
● Arthritis Self-Efficacy Scale (Barlow et al 1997): ● Symptoms/identity (recognising the symptoms
assesses self-efficacy in people with arthritis and as associated with illness)
70 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

Health threat representations


• Identify – what is it?
• Cause – why did it happen?
• Timeline – how long will it last?
• Consequences – what will happen?
• Cure/control – what can be done?

Interpretation of Procedural ‘coping’ Outcome appraisal


information responses • Was response successful
• Symptom perception • Approach response or is a change needed?
• Social constructs • Avoidance response

Emotional representations e.g.


• Fear
• Depression
• Helplessness

Figure 5.3 The self-regulatory model (adapted from Hobro et al 2004).

● Timeline (beliefs about how long the illness COMMONALITIES BETWEEN THE SOCIAL
will last) COGNITION MODELS (SCMs)
● Consequences (beliefs about the outcome of the
Whilst there are many similarities between these,
illness)
the main differences are the underlying psycho-
● Control/cure (beliefs about the extent to which logical theory. There are specific patient-completed
the illness can be treated/controlled and the role questionnaires available to capture each construct
of the individual in managing the illness) and they can be, and often are, used in combina-
● Causes (beliefs about the causes of illness). tion. However, this is not always helpful. For exam-
The illness perceptions questionnaire (IPQ) ple, in a study of patients with either OA or RA
(Weinman et al 1996) was originally developed self-efficacy, but not locus of control, was associated
to quantify these. It has been used to understand with health status in patients with RA, whilst in
patients’ responses to illness and predict or explain patients with OA, locus of control was a better pre-
treatment adherence. It has since been revised to dictor of health status (Cross et al 2006). It is unclear
improve its psychometric properties (Moss-Morris how findings can be meaningfully interpreted in a
et al 2002) and consists of eight categories: clinical setting. Moreover, interventions aimed at
● symptoms/identity changing behaviour (such as promoting exercise,
● timeline acute/chronic
increasing medication adherence) may draw on
several SCMs. The most commonly applied theo-
● timeline cyclical
ries are Social Cognitive Theory and the Health
● consequences
Belief Model, with increasing interest in the Self-
● personal control Regulatory Model.
● treatment control
● emotional representations (emotional responses
HEALTH BEHAVIOURS (COPING,
to the illness)
CONCORDANCE, HEALTH BELIEFS)
● coherence (the extent to which patients
understand or comprehend illness).
Coping
In addition to use in research, it could be used in
practice to identify misperceptions of treatment/ Coping is the ability to generate and maintain psy-
illness or lack of understanding affecting adherence chological well-being despite living with a serious
to treatment/lifestyle advice that might be addressed condition (Folkman 1997) and is linked to better psy-
through educational interventions. chological adjustment outcomes (Smith et al 1997).
Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease 71

People with arthritis live with the physical, social Concordance


and economic consequences of the disease over
long periods and may have to cope with uncertainty Concordance describes a partnership between the
about long term outcome as well as unpredictabil- health professional and patient in which both work
ity of recurrent fluctuations in disease activity. How together to agree optimal treatment based on a bal-
people with RA cope has been shown to influence ance of treatment risks and benefits and compat-
current and long-term psychological and physical ibility with the patient’s goals and preferences.
adjustment (Burckhardt et al 1997, Smith & Wallston Concordance is increasingly used instead of ‘com-
1992, Smith et al 1997, Zautra & Manne 1992). pliance’ which is viewed as excluding patients from
Coping behaviours have been extensively stud- being equal partners in treatment decisions. It is
ied in chronic disease and are typically classified unclear how frequently concordance occurs in clini-
as active (good) coping strategies, such as infor- cal practice. It is limited by many factors including:
mation-seeking and self management, and passive ● Difficulties interpreting information about
(bad) coping strategies, such as catastrophising relative risks and benefits of treatment (for both
and wishful thinking. In arthritis studies, effective health professionals and patients)
coping has been equated with perceived control ● Lack of training for health professionals in
over arthritis and its impact on daily life (Felton & achieving concordance
Revenson 1984) and with self efficacy for pain and ● Lack of time and resources
other arthritis symptoms (Keefe et al 1997, Lefebvre ● Some patients do not want an active role in
et al 1999). Coping behaviours are influenced by the treatment decision making.
individual’s appraisal of the threat and the coping
Treatment decisions based on concordance may
options available. Whilst it is assumed that active
increase effective use of treatment.
coping behaviours are more effective in helping
Between 30–70% of patients take their medication
patients adapt to and manage their condition, there
according to the prescribed regimen (Conrad 1985,
is more evidence to support ineffectiveness of pas-
Donovan & Blake 1992, Hill et al 2001, Viller et al
sive coping.
1999). Figures are similar for non-pharmacological
Questionnaires which identify coping strategies:
interventions such as exercise (O’Reilly et al 1999).
● Ways of coping scale (Folkman & Lazarus 1988): Factors influencing how patients use treatments are
a 42-item questionnaire assessing three coping complex and often independent of age, gender or
domains: emotion-focused coping, problem- disease severity (Kraag et al 1994, Rejeski et al 1997).
focused coping and the seeking of social support They include:
(Felton & Revenson 1984).
● patients’ beliefs about disease and treatments
● Coping strategies questionnaire (Rosenstiel &
● patients’ expectations of treatment
Keefe 1983): a 44-item questionnaire with seven
● use of alternative healthcare (e.g. complementary
subscales and two effectiveness items assessing
therapies)
pain coping strategies. Subscales are grouped
into Active (coping self-statements, diverting ● interpretation of the risks of treatment
attention, ignoring pain sensations, interesting ● the quality of the relationship between patient
activity level and reinterpreting the pain and doctor
sensation) and Passive coping (catastrophising ● patients’ knowledge and understanding of
praying and hoping) treatment
● Arthritis Helplessness Index (Nicassio et al ● treatment factors such as the complexity
1985): a 15-item disease-specific measure of of the regimen e.g. adherence with weekly
coping measuring perceptions of ability to bisphosphonates in osteoporosis is higher than
control arthritis. with daily bisphosphonates (Carr et al 2006).
● London Coping with Rheumatoid Arthritis scale
(Newman et al 1990): has 36 coping strategy Patient health beliefs about disease and
items assessing frequency of use. Results are used treatment
to identify and group individuals with similar
coping patterns rather than pre-defining if each Many patients with RA and OA do not initially
coping strategy alone is helpful or unhelpful. interpret their symptoms as evidence of disease but
72 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

instead attribute them to stress, or more commonly, BOX 5.3 Stepwise model of a consultation to
normalise them in terms of their age and activities improve adherence (from Daltroy 1993)
(Goodwin et al 1999, Hampson 1994, Sakalys 1997).
Even where patients interpret their symptoms as evi- Step 1 The patient is encouraged to express all concerns
dence of underlying disease, their family, friends and Step 2 The patients’ concerns are discussed
even health professionals may not. In a study of newly Step 3 Doctor and patient share their models (beliefs)
referred patients with RA, more than 50% reported of disease and symptoms
that family, friends or doctors had normalised, mini- Step 4 Doctor and patient share their goals for
mised or disbelieved their symptoms (Sakalys 1997). treatment
RA patients’ beliefs have been associated with Step 5 Treatment goals are agreed and priorities
medication use (Neame & Hammond 2005). In gen- are set
eral, patients perform cost–benefit analyses on their Step 6 Doctor and patient share their models (beliefs)
prescribed medication (Donovan 1991) and are more of treatment
likely to take this when their perception of the neces- Step 7 Potential barriers to adherence are identified
sity for medication (effectiveness and the perceived Step 8 Plans are made to overcome these
consequences of untreated illness) outweighs con- Step 9 The doctor provides written information on
cerns about it (side-effects, addiction and develop- disease and the treatment regimen, annotated
ment of tolerance) (Horne & Weinman 1999, Neame with individual patients’ detail/concerns
& Hammond 2005). Sixty percent of patients with RA
report fear of side-effects is a major factor influencing
their decisions to alter dose or frequency (Donovan &
Blake 1992). Patients often allow themselves a ‘trial of STUDY ACTIVITIES
treatment’ during which they adhere to the treatment
regimen, evaluating its effectiveness against their ■ Take a case history from a patient with a
beliefs and expectations (Donovan & Blake 1992). rheumatological condition and identity its
Where outcome does not meet expectations, they may psychological and social impact using a
be more likely to change regimen or stop treatment. biopsychosocial approach.
■ Using the gate control theory of pain, record how
you would explain to a patient how their thoughts
THE CLINICAL CONSULTATION
can affect their perception of pain.
High levels of non-adherence may occur if interven- ■ After reading section 4, list the factors that may
tions have not addressed underlying health and treat- influence whether a patient will engage in a specific
ment beliefs driving patient behaviour. It would be health behaviour, such as exercise.
useful within the clinical consultation if patients’ beliefs
about illness and treatment are elicited, their expecta-
tions of treatment are identified and realistic treatment
goals negotiated (Carr & Donovan 1998, Horne 1999). promoting adherence is limited because they provide
A consultation guide has been developed based on the little information about why patients take their
evidence for factors influencing adherence (Daltroy medications in this way, or why they choose not
1993) but its effectiveness in promoting adherence or to follow their prescribed treatment regimen at all.
concordance has not been evaluated (Box 5.3). Established, validated questionnaires that elicit
Concordance, i.e. an equal partnership between some of the health beliefs underlying adherence can
patient and health professional in which treatment be used to identify misperceptions and reasons for
goals are negotiated on the basis of patient preference non-adherence. These include the IPQ and IPQ-R
and priorities, is promoted by addressing these. (Moss-Morris et al 2002, Weinman et al 1996) and
the Beliefs about Medication Questionnaire (Horne
et al 1999).
Questionnaires for assessing adherence and
Understanding theories of health behaviour
concordance
and factors influencing coping and concordance
Whilst useful in identifying how patients take their enhance effectiveness of treatment and planning
medicines (de Klerk et al 1999), their usefulness in and delivering effective patient education.
Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease 73

CONCLUSION patients will be able to cope more effectively with


the physical, psychological and social impact of
The ways in which people with arthritis perceive, their condition.
understand and manage their condition, how active
they are, which treatments they use, whether and
how they take their prescribed medication and how
USEFUL WEBSITES
they cope with the symptoms of their arthritis, are
influenced by a complex interaction of many factors. http://www.healthtalkonline.org
By increasing the health professional’s knowledge http://www.britishpainsociety.org/patienthome.htm
in this area a relationship based on concordance http://www.expertpatients.nhs.uk
principles can be introduced into clinical care and

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