Pain and physical activity in rheumatoid arthritis : A cognitive approach in physical therapy

Abstract: A gradual shift towards more active patient involvement has taken place during the past few decades. It is thus important for physical therapists to understand individuals’ cognitive appraisals of health states. Patients with rheumatoid arthritis (RA) are frequently referred to physical therapy for treatment of pain and activity limitation. Little is known about how their cognition, i.e. thoughts, feelings, and beliefs about their health, are related to physical therapy evaluation and what the effects of cognitive treatment given by physical therapists are. The overall aim of the present work was to investigate pain and physical activity in patients with RA, from a physical therapy perspective and a cognitive approach. The present work comprises four studies: one randomized, controlled study of progressive relaxation training; one methodological study of the measurement properties of a Swedish version of the Multidimensional Health Locus of Control Scales, form C (MHLC-C); and two cross-sectional studies on relations between pain and physical activity on the one hand, and health locus of control, beliefs about relationships between pain and impairment, and fear-avoidance, on the other. A total of 585 patients with RA were recruited from different rheumatology clinics. Assessments were performed with laboratory and clinical tests, rating scales, and questionnaires that were all valid and reliable for patients with RA and/or long-standing pain. A relaxation training program was performed with taped instructions two days a week for ten weeks. The results indicate that relaxation training improved certain aspects of self-rated health and observed muscle function at post-intervention and at a six-month follow-up, while no effects remained after 12 months. The translated, revised Swedish MHLC-C possessed satisfactory content validity, construct validity, test-retest stability, and internal consistency. High-intensity pain was related, in patients with early RA, to low attribution of health locus of control either to themselves or to doctors; and moderate/high levels of physical activity were related to low internal control. No relations between self-rated health and the MHLC-C sub-scales were found. Among patients with long-standing RA, pain and physical activity were not related to health locus of control, and no relations were found between physical activity and either fear-avoidance beliefs or beliefs about relationships between pain and impairment. However, high pain intensity was strongly related to fear-avoidance beliefs and to beliefs about relationships between pain and impairment in long-standing RA. In conclusion, the present work provides knowledge about individuals’ cognitive appraisals of health states and how a cognitive approach contributes in physical therapy.