Pain in Arthritis and Musculoskeletal Disorders: The

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Pain in Arthritis and Musculoskeletal Disorders: The Role of Coping Skills Training and Exercise Interventions '

)ulie Opiteck, MS Elizabeth Hage, BS

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on December 28, 2015. For personal use only. No other uses without permission. Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Francis ). Keefe, PhD Susmita Kashikar-Zuck, PhD *

Susmita Kd9hikar-Zuck

lorien Dalrymple lames A. Blumenthal, P ~ D

There is growing recognition of the limitations of conventional, biomedical approaches to the management of pain in individuals having arthritis and musculoskeletal disorders. This article provides an overview of newly developed biopsychosocial approaches to the management of pain in this population. The presentation is divided into three sections. In the first section, a biopsychosocial model of pain is presented. This model highlights the role that biological factors (eg., disease severity, comorbid conditions), cognitive-behavioral bctors (eg., thoughts, emotions, and behaviors), and environmental factors (eg., spouse or family responses to pain behavior) can play in influencing the pain experience. In the second section, we provide an overview of two newly developed treatment protocols based on the biopsychosocial model of pain: a pain coping skills training protocol and an exercise training protocol. Practical aspects of implementing these protocols are illustrated by highlighting how they are applied in the management of patients having persistent osteoarthritic pain. In the final section of the article, we pinpoint several important future directions for research in this area. Future studies need to explore the utility of combining pain coping skills and exercise training protocols. In addition, there is a need to identify variables that predict patients' response to biopsychosocial treatments.

Key Words: biopsychosocial, musculoskeletal pain, coping skills training

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Professor, Duke University Medical Center, Durham, NC; Associate Professor, Department of Psychology, Duke University, Durham, NC. Address for correspondence: Department o i Psychiatry, PO Box 3 159, Duke University Medical Center, Durham, NC 27710. Clinical Associate, Duke University Medical Center, Durham, NC Senior Exercise Physiologist, Duke University Medical Center, Durham, NC '' Exercise Technician, Duke University Medical Center, Durham, NC Undergraduate Student, Department o i Psychology, Duke University, Durham, NC Proiessor, Duke University Medical Center, Durham, NC; Proiessor, Department of Psychology, Duke University, Durham, NC Preparation o i this manuscript was supported by grants No. AR35270 and AR42261 from the National Institute o i Arthritis and Musculoskeletal and Skin Diseases, by NlMH Grant Number MH 49679, and by NHLBl Grant Number HL 49572 to Dr. Blumenthal.

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ain is a major problem for individuals having arthritis and mr~scr~loskeletal disorders (16,26,41). For many, pain is a dailv experience th;~tnot only affects their performance at work and home, hut also has a negative impact o n their mood and the way that they view themselves. others. and the future. Traditionally, pain in muscdoskeletal disorders has been viewed as a sensonT

event that signals the presence of underlying disease o r in.jun (26). In some patient5, pain may be d u e to musculoskeletal in.juries, such as sprains, strains, o r muscle soreness resulting from unaccustomed activity. Treatment in such cases seeks to eliminate pain by addressing its underlying cause. Although such in-jurics may require a carefid interplay between rest and physical therapy.

the pain typically resolves in a relatively short period of time. Unfortunately, the view of pain as a simple sensory phenomenon has only limited utility when applied to patient5 with chronic arthritic and musculoskeletal disorders. Patients with osteoarthritis and rheumatoid arthritis, for example, often suffer from persistent joint pain, despite having multiple trials with conven-

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FIGURE 1. A biopsychosocial model of pain.

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The view of pain as a simple sensory phenomenon has only limited utility when applied to patients with chronic arthritic and musculoskeletal disorders. tional medical or surgical intewentions. Individuals having fibromyalgia, a diffuse musculoskeletal pain condition accompanied by fatigue, stiffness, and sleep disturbances, also typically have long histories of pain and repeated failure to respond to medical treatments. Over the past two decades, new biopsychosocial approaches to the conceptualization and treatment of persistent pain have been developed and refined (25.39). These a p proaches have two major hallmarks. First, they view persistent pain as a complex experience that is affected not only by sensory input, but also by behavioral, cogni tive-affective, and environmental factors. Second, they

maintain that, for many patients, the most effective approach to pain management involves combining medical treatments with training in self-control methods, such as paincoping skills training or exercise regimens. The purpose of this paper is to provide an introduction to the biopsychosocial approach to the management of persistent arthritic or musculoskeletal pain. The paper is divided into three sections. In the first section, we present a conceptual model that serves to guide the assessment and treatment of pain in arthritis and musculoskeletal disorders. In the second section, we discuss how coping skills training and exercise training can be applied to the management of persistent arthritic pain. In the final section, we discuss important future directions for research in this area.

A BIOPSYCHOSOCIAL MODEL OF PERSISTENT PAIN The biopsychosocial model provides a comprehensive perspective on the pain experience (13). The model, depicted in Figure 1, draws attention to three sets of variables that can affect persistent pain: biological variables, cognitive-behavioral variables, and environmental variables. The model depicts a system in which

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changes in one set of variables can influence and be influenced by changes in another set of variables. A rheumatoid arthritis patient, for example, who is depressed (a cognitivebehavioral variable) may be unwilling to take a disease-modifling drug that can reduce disease activity (a biological variable), become much more dependent on family members and friends (an environmental variable), and, as a result of all of these factors, experience high levels of pain. To understand persistent pain, one must examine each of the factors depicted in the model and understand how these factors influence and interact with each other.

Biological Variables Biological variables affecting pain include underlying tissue pathology due to disease or injury, comorbid medical conditions, and the overall physical status/conditioning of the patient. Biomedical assessment and treatment efforts are primarily designed to influence the biological variables affecting pain. Clinical o b sewations and numerous research studies have found that biological factors alone fail to explain pain and pain treatment response in many patients having arthritis and musculoskeletal disorders (6,21). For example, two rheumatoid arthritis patients having nearly identical disease evidence of disease activity may report very different levels of pain. Alternatively, two patients having persistent low back pain may vary greatlv in response to a trial with the same antiinflammatory medication. There is growing recognition that one must extend the analysis of persistent pain beyond biological variables to a broader model that considers potentially important psvchosocial variables (13).

Cognitive-Behavioral Variables The cognitive-behavioral variables that can influence pain can be Volume 24 Number 4 October 19% JOSIT

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Interestingly, interventions designed to enhance perceived control over pain are often effective in reducing pain in patients with arthritis and musculoskeletal disorders (22.23). A third cognitive variable known to influence persistent pain is the patient's beliefs about pain (43). Patients suffering from arthritis o r milsculoskeletal disorders have certain belief5 about the cause and futtrre trajectory of their pain that can influence their adaptations to pain and response to treatment. For example, MTilliamsand Thorn (43) f o r d that low back pain patients who viewed their pain as likely to persist were

grouped into thrcc scts: I) cognitivc variables involving patterns of thinking o r ;~ppraisal,2) cmotion;d \.;wi;ibles s~ich21s mood, and 3) bchav ioral \.;~ri;~blcs srich ;is pattc.rns of daily activity and beh;niol-al responses to pain. Thc identification of' cognitivc ~ i r i a b l c safrccting persistent p i n has hccn o n c of the most active areas of psychologic;il pain rcscwcli over the past dcc;~tlc(2.5). Many studies have undcrscorcd the import;~nccof patients' use of cognitive coping strategies (20.21 ,XI). M'hcn filccd with pain, indivitlu;ils develop certain cognitive strategies t o copc with, de;il with, o r ~ninimizctheir pain. These strategies may incluck distracting oneself by counting h;~ckw;ird,using

plcasant imagcry, o r using calming sc~lflstatcmcntsto r c d ~ ~ ;inxiety cc and cmotion;d distress. Individr~alswho clcvclop and apply adaptive coping strategies may he ;iblc to live active ;ind c~i,jo!';~hlclives despite 1l;iving pcrsistcnt pain (2 1 ) . Those who rcly on maladaptive strategies, however, may become physically inactive and cxpcriencc significant problems with dcprcssion, fmr, and anxiety ( 19). Pcrccivctl control over pain is ;inotIicr cognitive variable that has a major impact on pain and functioning. 1ndividri;ds who pc.rceive thcmsclvcs as ~ i n a h l cto control pain and \vho h;~vca v c n low sense of sclf-efic;wy ha\^ bccn fhr~nrlto have much higher Icvcls of pain, psychological disability, and physical disabilitv (32).

1ow back pain patients who viewed their pain as likely to persist were more likely to be psychologically distressed and to show poor compliance with physical therapy and cognitive-behavioral interventions. niorc likelv to bc psychologically distressed and to show poor compliance with physical therapy and cognitivebehavioral interventions. Emotions also can have a major influence on pain. Studies of low back pain patients, for example, have shown that patients who are dcpressed report much higher levels of pain (40) and show more pain-related behaviors during physical examination than those who are not depressed (28). Negative mood has also been associated with higher levels of daily pain in rher~matoidarthritis patients (2). Patient5 who are exccs-


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sively anxious about pain often report higher levels of pain (33,34) and are often reluctant to engage in exercise or phvsically demanding work activities, even though they appear to be physically able to do so (30). Many individuals having persis tent pain develop maladaptive behavioral responses ( 12). Patients who experience increased pain during activity or exercise, for example, may limit their activities and spend much of their day sitting or reclining. Over time, these patients may develop an overly sedentary and restricted lifestyle that provides few distractions from pain. Behavioral interventions such as graded activation and exercise programs can be quite useful in helping these patients regain a more functionally effective lifestyle (31) . Another behavioral problem experienced by some patients is dependence on habit-forming medications or alcohol. In some patients, addiction to drugs or alcohol is serious enough to warrant a formal detoxification program. Overt, nonverbal pain behavior patterns such as guarded movement, pain avoidant posturing, and facial grimacing (12) often are evident in patients with persistent pain. Recent studies have demonstrated that these pain behaviors can be reliably o h served in patients having musculoskeletal in-juries such as low back pain (18) as well as osteoarthritis (24), rheumatoid arthritis ( 5 ) ,and fibre mvalgia (8). When such nonverbal pain behaviors become entrenched, they can exacerbate pain. The osteoarthritis patient, for example, who moves in an excessively stiff and guarded fashion or who reacts to knee or hip pain with increased u p per body tension may develop other pain complaints, such as neck pain or muscle tension headaches. Interventions designed to reduce such nonverbal pain behaviors, such as exercise or relaxation training, can be helpfill in decreasing pain.

Environmental Factors The environmental factors that can influence pain include both the patient's immediate environment and the broader social environment. When an arthritis patient exhibits pain behavior, he or she communicates pain to others and thus may elicit a response from a spouse or other family members (12,25). A concerned spouse may react by questioning the patient about pain, offering support and assistance, or taking over duties that the patient is actually capable of doing. Overly solicitous responses may reinforce dependency on the part of the patient. The broader environmental context of pain can also affect how patient.. adjust to pain. There is growing evidence, for example, that the work environment is an important risk factor influencing the occurrence of musculoskeletal in-juries. Individuals who rate their job happiness as low have been shown to be more likely to develop work-related back injuries (7). In some individuals, access to workers' compensation and disability benefit5 may also serve as disincentives to full recovery from a muscule skeletal injury. The biopsvchosocial model is not only important in understanding pain, it also serves to direct treatment efforts. Interventions, such as paincoping skills training and exercise training, reduce pain and disability by addressing one or more of the components of the biopsychosocial model.

COPING SKILLS TRAINING AND EXERCISE INTERVENTIONS FOR MANAGING PAlN In this section, we consider two newly developed interventions that can be used to manage pain in patients having arthritis and musculoskeletal disorders. For each of the interventions, we present a rationale, provide an outline of a treatment protocol, and discuss special issues. Although these interventions can be

applied to many arthritic and musculoskeletal disorders, we will illustrate their application in patient- having persistent pain due to osteoarthritis. Osteoarthritis is a particularly a p p r e priate disease upon which to focus because it is common, cannot be definitively treated medically or surgically, and appears to respond to biopsychosocial interventions (21).

PAlN COPING SKILLS TRAINING Rationale Pain is the most common symp tom of osteoarthritis and usually the major concern of the patient (16). Recent studies indicate that osteoarthritis patients vary in their ability to cope with pain: some patients appear to cope well, whereas others cope very poorly. In the mid 1980s, we conducted a study of paincoping strategies in osteoarthritis patients having persistent knee pain (21). In this study, each patient completed the Coping Strategies Questionnaire (42), an instrument that measures the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping skills. Data analysis revealed that osteoarthritis patients who scored high on a pain control and rational thinking factor derived from the Coping Strategies Questionnaire (ie., those who rated their coping skills as effective in controlling and decreasing pain and who avoided irrational or catastrophizing responses) had significantly lower levels of pain and psychological disability. Patients scoring high on the pain control and rational thinking factor also reported lower levels of physical disability, walked a 5-meter course more quickly, and moved more quickly from a sitting to a reclining position. What made these results particularly interesting was that they were obtained even after controlling for demographic (age, gender, obesity status) and disease severity variables (X-ray grading of osteoarthritic changes) widely consid\'olnme 24 Number 4 October 19% JOSPT


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ered important in explaining pain and f~inctioningin osteoarthritis patients. Based on the findings from our initial pain coping study, we developed a treatment protocol designed to enhance the perceived effectiveness of pain coping and to reduce the use of maladaptive, catastrophizing responses. The protocol was evaluated in a randomized, controlled study (22.23) that compared three treatment conditions: pain coping skills training, arthritis education, or a standard medical care control condition. Patients in the pain coping skills training condition attended a series of weekly group sessions that provided training in cognitive and behavioral strategies for managing pain. Patients in the arthritis education condition also attended weekly group sessions, but the sessions were informational in nature, providing detailed descriptions of methods used in the assessment and medical treatment of osteoarthritis. Patient. in the standard care condition continued to receive their routine medical care. At the end of the 10-week treatment phase of the study, data analyses revealed that patient. in the pain coping skills training exhibited significant reductions in pain and psychological disability when compared with the patients in the arthritis education and standard medical care control conditions. To evaluate the maintenance of treatment effects, all patients were evaluated 6 months after completing treatment. Although patients in the pain coping skills training group had difficulty maintaining their initial gains in pain relief, they were able to maintain gains in psychological disability and showed significant improvements in phvsical disability relative to the arthritis education condition. For patients in the coping skills training condition, there was a clear relationship between changes in pain coping skills and long-term outcome. Those who showed the largest pre- to posttreatment increases on the pain control and rational thinking factor of the JOSPT \'ohme 24 0 Number 4 Octoher 1996

Coping Strategies Questionnaire had the best outcomes in terms of pain relief, physical disability, and psychological disability. In sum, there is research evidence that an analysis of pain coping skills is useful in understanding pain and disability in osteoarthritis patients, and that svstematic training in pain coping skills may enhance pain control and patient functioning.

A Protocol for Pain Coping Skills Training The protocol developed in our osteoarthritis research program provides a good example of practical methods that one can use to train patients in pain coping skills. This protocol has been described in detail elsewhere (17); for purposes of this paper, we provide only a brief overview of it.. kev features. Our pain coping skills training program is conducted in group sessions that meet for 90 minutes once a week for 10 consecutive weeks. The groups are small, consisting of four to eight patients and membership is closed, ie., all patients start and end the group together. The groups are led by a team consisting of a doctoral-level psychologist and nurse-educator. There are several advantages of carrying out coping skills training in small group sessions (17). First, members of the group are exposed to other individuals with similar problems and learn from their shared experiences. Second, the group provides an ideal setting for providing concrete examples of the application of a variety of coping skills used by the group members in different life situations. Third, the group format is eficient in that several patients can be treated at the same time. This significantly reduces the costs of treatment and makes it easier to treat the large number of patients who suffer from osteoarthritis or other pain conditions. The content of each session is standardized and the group leaders

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follow a manual that provides a detailed outline, a recommended time line, and patient handouts. Table 1 provides a listing of the major topics addressed in each of the sessions. The first session of coping skills training focuses on providing patients with a clear and credible rationale. The rationale has several components. The first component is a presentation of an adaptational model of pain. The major tenet of this model is that persistent pain changes the way that people act, feel, and behave on a daily basis. Patient. are asked to discuss how their lives have been affected bv chronic pain and how these adjustments to pain have, in turn, affected the pain itself. Maladaptive reactions to pain are identified and discussed. A key point in the discussion is that patients' adjustments to pain are learned patterns that are acquired over a period of time. Patients are told that new patterns of adaptation and coping can also be learned. The second component of the rationale is a simplified explanation of the gate control theory of pain (37). This theory maintains that there is a gating mechanism in the spinal cord that controls the flow of pain signals from the periphery to the brain. The theory also posits that descending influences from centers of the brain responsible for thoughts and feelings can influence whether the gate is open or closed. Patients are asked to provide concrete examples of how thought., feelings, and behaviors have influenced their own pain (such as experiencing higher levels of pain while tense or anxious). Pain coping skills are introduced as methods that can provide control over thoughts, feelings, and behaviors that affect pain. The third component of the treatment rationale is the introduction of a skills model. Patients are told that they will develop a "menu" of coping skills that includes a variety of cognitive and behavioral strategies. These skills, like any new skill, need to be rehearsed and practiced fre-

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Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10

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Rationale, overview, progressive relaxation Progressive relaxation, mini-relaxation practices Activity rest cycling Pleasant activity scheduling Distraction techniques: pleasant imagery Distraction techniques: focal point and counting techniques Cognitive restructuring: identifying negative thoughts Cognitive restructuring: altering negative thoughts Problem solving Review and feedback


TABLE 1. Coping skills training protocol.

quently if they are to be effective. Patients are given basic instruction in the skills in the treatment sessions and have the opportunity in the grorlp setting to rehearse the skills and get feedback from the therapist. T h e skills, however, can only be mastered by practicing and applying them at home and in dailv situations in which pain is likely to be a problem. T h e first coping skills taught are relaxation skills. Two relaxation techniques are introduced in the first two sessions: progressive muscle relaxation and mini-relaxation practices. Progressive muscle relaxation training in\,olves the alternate tensing and relaxing of groups of major muscles, starting with those in the feet and legs and progressing to those in the trunk, neck, and face. Progressive muscle relaxation is designed to improve awareness of areas of muscle tension in the bodv, reduce mr~scle tension, and reduce emotional arousal. T o facilitate home practice, patients are given an audiotape of the progressive relaxation training exercises and asked to listen to it twice daily. Mini-relaxation exercises are then introduced to help patients generalize relaxation skills to daily situations in which pain is a problem. In the mini-relaxation exercises, the patient stops, takes a deep breath, and then, while exhaling, focuses on sensations of relaxation flowing downward from the head and neck to the shoulders, trunk, and rest of the bodv. T h e mini-relaxation practice is brief (takes only 30-45 seconds) and can be readily used in a

variety of situations to reduce muscle tension and emotional arol~sal.Patients are encouraged to start by doing five mini-practices a day and then to gradually build up to 20 mini-practices per day. They are also encow-aged to identify environmental cues (eg., stopping at it red light, waiting in line at the store, walking rlp and down stairs) that can senre as reminders to d o a mini-practice. T h e second set of coping skills, introduced in sessions 3 and 4, are designed to help patients gain better control over pain by changing thcir daily activities. Two skills are taught: activity-rest cycling and p1eas;lnt activity scheduling. Activity-rest cvcling is a way of teaching patients how to pace their daily activities. Some patients with osteoarthritis tend to bc overactive and have periodic pain flares as a result. Other patients are inactive and may become physically deconditioncd d u e to a highly sedentary lifestyle. Activityrest cycling teaches patients to pace their activities so that they ncithcr overdo physical activity nor rest excessively. Patients are encouraged to pace their activities by breaking activities u p into periods of moderate activitv and limited rest. T o teach patients how to use activitv-rcst cycling, we help them identifv specific problem activities, such as trying to complete household chores in a brief time period, gardening for several hours withor~ta break, o r shopping until o n e rcachcs the point of intolel-;~blepain. Recornmendations for pacing these activities (dcpending on each person's abilities) are then developed. These recom-

mendations, for example, might include resting for 10 minutes after vacuuming each room o r working in the garden o r shopping for 20minute periods interspersed with 5-minute rest breaks. Over time, patients are encow-aged to increase the duration of their activities and to gradually reduce the length of their rest breaks. This enables many patients to gradually return to activities that they thought they could not tolerate because of pain. Pleasant activity scheduling is a second behavioral skill for coping with pain. Many patients having persistent pain decrease their involvcnient in plcasant activities and, as a result, get less en,joyment from life and have fewer distractions from pain. In plcasant activity scheduling, patients are taught to identifv activity goals and then plan and set time aside for these activities each week. Patients rise brainstorming during a group session to develop a list of pleasant activities that are reasonable in light of their current abilities. These activities can range from going out on a day trip, to walking the dog. baking cookies, o r engaging in a favorite hobby. M'cekly activity goals are set and progress in completing these goals is monitored and reinforced by the therapist. T h e third set of skills, distraction techniques, are designed to enhance pain control by di\,erting attention away from pain. In sessions 5 and 6 of the protocol, patients are svstematically taught how to use pleasant irnage? (visl~alizinga relaxing, pleasant scene), a focal point (concentrating all their attention on an object o r event in their environment). and a counting strategy (slowly counting backward from 100 to 1) to control pain. Patients also learn how to combine these techniques with mini-relaxation practices to deal with particularly painful or difficult sitr~ations. In scssions 7 and 8, patients are taught how to use cognitive restructuring to deal with overly negative and ma1;ldaptive thoughts. Cognitive


restructuring helps patients change negative, catastrophizing thoughts that may contribute to pain. Group members are trained to identify negative thoughts that occur during periods of increased pain. These thoughts may include negative thoughts about oneself ("I am worthless when I hurt like this"), about others ("No one really cares o r understands"), and about the future ("I will never be able to d o anything I enjov"). Special efforts are made to identify catastrophizing and irrational thoughts that are maladaptive in c o p ing with pain. Patients are then taught how to challenge and dispute these negative thoughts and how to replace them with more rational, calming, and adaptive thoughts. For example, rather than reacting to pain by thinking "With pain this bad, I'll never be able to d o anything I really enjov," the patient may try to calm himself by thinking "I may not be able to d o ALL the things I en.joyed in the past, there are still many things I can d o that provide me great pleasure." The final coping skill introduced in the training program is problem solving. Problem solving teaches patients how to best apply the skills they have learned in diff~culto r challenging situations. Problem solving involves three steps. First, the patient is asked to describe the problem, eg., having an unexpected guest arrive for dinner. Second, the difficulties that are likely to be experienced in this situation are identified, eg., time pressure, stress, negative thoughts, fatigue, and increased pain. Third, the patient is asked to choose an a p propriate combination of coping skills that would be beneficial in this situation, eg., mini-relaxation practices, pacing activities through activity-rest cycling, and calming self statements. Patients discuss a number of life situations where they can use problem-solving techniques and receive suggestions and feedback from the group members and the therapists. JOSPT \'olrrme 24 Nrrmkr 4 Ortokr lW6

T h e last session of the training program consists of a review of the coping skills and a discussion of each patient's personal home practice plan. This session provides a good opportunity to help patients discuss how coping skills can be applied to particularly difficult o r challenging situations that might be coming u p in the future. It also provides an excellent time to give patients feedback on their progress.

Special Clinical Issues in Pain Coping Skills Training There are a number of important clinical issues that arise when one is carrying out coping skills training with osteoarthritis patients. Two of the most important issues are involving the spouse o r family members in treatment and maintenance of treatment effects. The biopsychosocial model emphasizes the importance of environmental factors in understanding pain. Persistent pain is not only an issue for the patient, but also an issue for the patient's spouse o r family members. We have recentlv developed a protocol for systematically involving spouses of osteoarthritis patients in the pain coping skills training. The spouse-assisted coping skills training program has three important features. First, spouses attend each training session with the patient and actually learn and practice the coping skills along with the patient. This helps the spouse gain a better understanding of each coping skill and enables them to be more eff'ective in prompting the patient to use coping skills. Patients also report that they en.joy having their spouse as a partner in home practice sessions. Second, behavioral rehearsal is used in group sessions to teach couples how to apply coping skills in daily situations in which pain is likely to be a problem. During behavioral rehearsal, the therapist takes on the role of the spouse and demonstrates how one can prompt a patient to use a

particular pain coping skill (eg., relaxation) during a difficult activity (eg., climbing a long flight of stairs). The patient's actual spouse is then asked to rehearse this role while the patient engages in the activity. The therapist and other group members provide the spouse and patient with feedback, and the couple repeats the activity once again. This type of rehearsal is much more effective than verbal instn~ctionsin teaching couples how to apply pain coping methods. It also provides many concrete examples of effective coping techniques. The final component of spouse-assisted training is training in communication skills. Patients and spouses are given instructions on the best ways to communicate about newly learned pain coping skills. They are encouraged to spend time frankly discussing their reactions to working with each other after many of their joint practice sessions. Effective communication is important in providing the spouse with guidance about what is helpful and what is not. It also can prevent the spouse from unwittingly becoming too solicitous o r overcontrolling in their interactions with the patient. Research suggests that arthritis patients who are able to maintain frequent use of learned pain coping skills have the best long-term outcomes (27). We have recently developed a maintenance enhancement protocol designed to bolster the longterm effects of coping skills training (27). In this protocol, maintenance training is introduced early in the sessions and continues to be emphasized throughout the treatment. The training includes four major cornponents. The first, awareness training, consists of teaching the patients to identify opportunities for practicing the coping skills they have learned in group sessions. The second component involves identifying natural prompts, ie., environmental cues (such as a waiting in line at the grocery store o r approaching a long walkway o r stairway) that can be used

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as signals to apply coping skills. Next. patients are taught to identify and deal with high-risk situations (eg., a pain flare o r stressful interpersonal encounter) that might lead to a setback o r relapse. Finally, patients are instructed how to use a daily d i a n to monitor their progress and reinforce the frequent use of coping skills.


EXERCISE TRAINING AND PAIN MANAGEMENT An alternative biopsvchosocial intervention for managing persistent arthritic pain is exercise training. Exercise has particular advantages in reducing physical disability and in improving physical function outcomes that have been difficult to achieve through pain coping skills training.

Rationale Ostcoarthritis can have a major impact on a patient's abilities to perform simple daily tasks. Because osteoarthritis affects the major weightbearing joints, many patients have difficulty walking o r performing routine activities of daily life. Walking, stair climbing, getting in and out of a chair, car, o r bathtub, shopping, o r gardening may be painful and difficult. Many osteoarthritis patients avoid these physically demanding activities because they are painful and, as a result, become significantly deconditioned. Deconditioning further contributes to problems with mobility and muscle weakness that make attempts at resuming activity even more painful. Previous research has shown that the degree of physical disability is related to the amount and severity of the underlying disease (10,14). Ettinger and Afable (1 1) also suggest that decreased aerobic capacip may be a cause of disability in older people with osteoarthritis. T h e low fitness levels of persons with osteoarthritis may be the result of selfinitiated activity restrictions to avoid pain rather than a result of the dis-

ease activity of arthritis. Exercise training provides a method for increasing muscle strength, overall physical conditioning, and enhancing a patient's ability to initiate and to tolerate daily activities. There is evidence that aerobic exercise can reduce pain and disability in arthritis patients (1,0,36,38). A variety of therapeutic exercises has been used in the treatment of osteoarthritis. The majority of modalities to date have included range of motion/flexibility, isometric o r resistancc training, and low intensity/low duration dynamic cxcrcise. Morc aggressive exercise programs produce greater improvements in muscnlar strength and cardiopulmonan endurance.

stable joint. Flexibility training is designed to increase an individr~al's range of motion. Passive stretching exercises increase flexibility, which also can reduce the risk of milsculoskeletal il!july. T h e osteoarthritis exercise studies to date have selected moderate aerobic training ranges and/or have predominately utilized isometric strength training instead of dynamic training (29.38). T h e exercise treatment protocol offered through the Duke University Osteoarthritis Program is described below and is crirrently being utilized as part of a research study at o w treatment center investigating the impact of pain coping skills training and/or exercise on pain and frlnctioning in osteoarthritis patients having persistent knee pain. T h e proThe Duke Exercise Training Protocol gram involves two phases: assessment and training. T h e major components of an During the assessment phase, all ideal, comprehensive exercise propatients are given a history and physigram include: I) i~crobic/cardiowscu- cal examination by a rheumatologist. lar endurance training, 2) strength T o be included in the training protraining, and 3) flexibility/range of gram, all patients mrlst have radiomotion training. Aerobic training graphic evidence of osteoarthritis afimproves an individuals' functional t h i n g o n e o r both knees, comcapacity by increasing endrlrancc plaints of knee pain persisting for 6 through adaptations of the cardiovasmonths o r longer, and n o other macular, respiraton, and musc~~loskele- jor weight-bearing joint affected by tal systems. Following the completion osteoarthritis. Patients are excluded if of exercise training, individuals are they have significant medical condiable to perform more work at lower tions that would expose them to inheart rates and report less subjective creased risk of an adverse event durfatigue after a bout of exercise o r ing the course of the trial (eg., intense physical activity. Recarlse unstable angina, acute myocardial there are age-related declines in carinfarction, cardiomvopathy, o r condiovascular and musculoskeletal frinc- gestive heart failure, etc.). tion, the inclusion of strength trainAn important component of the ing in an osteoarthritis exercise assessment phase of the program is program is also important. In addibicycle ergometn testing. Subjects tion to changes in muscle strength as perform a maximum eflort exercise a result of normal aging, muscles betest following an initial practice test come even weaker its a resrllt of diso n a cycle ergometer. A graded exerrlse d u e to the disease, leading to cise protocol is used in which pafurther difficulties in performing actients gri~drlallpincrease the intensity tivities of'daily living. Although musof exercise until they reach exhauscle strength declines with decreased tion o r standard clinical endpoints. use, strength can also improve with Patients found to have an abnormal increased use. An appropriate procardiac response to exercise, such as gram of resistance training can procsercise-induced ventricular tachycarduce increased strength and ;I more dia o r ;~bnormalblood pressure re-

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Week

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Aerobic Training (Percent of Heart Rate Reserve)

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Aerobic Training (minutes)

Resistance Training (minutes)

Pool Pool Pool Pool Pool Pool Pool Pool BikNalk Bikewalk Bikewalk Bikewalk


TABLE 2. Overview o i Duke Universitv Osteoarthritis (DUOPJ Exercise Protocol.

sponses, are excluded from the study. T h e data gathered during the cycle ergometn assessment are used to assess baseline aerobic fitness to e s t a b lish an individualized aerobic training program. T h e training phase of the program begins within 1 week of the conclusion of the assessment phase. T h e frequencv, intensity, and duration of the exercise training program is outlined in Table 2. T h e program involves a combination of aerobic training, consisting of pool exercises, walking, and biking, and strength training carried out in sessions that meet three times per week. Aerobic training requires a person to exercise at an intensity that will elevate heart rate at o r above a predetermined level during endurance exercises. This form of exercise involves the major muscle groups in activities siich as walking, cvcling, rowing, and water aerobics. T h e Nordic Track also has been found to be a good exercise modality that is well accepted and tolerated by this population. Participants engage in 30 minutes of aerobic training 3 days pcr week. T h e intensitv is based on a percentage of the maximum heart rate achieved during the exercise test. Each participant is started at 50-70% of heart rate reserve ([HR max HR rest] X .70 - .85 + HR rest) and JOSPT \'olume 24 Sumhcr 4 October lW6

gradually increased to 70-85% over the 12-week training program (Table 2). Each aerobic training session begins with a 10-minute series of warm-up exercises, consisting of gentle stretching followed by 5 minutes of low intensity biking o r walking. Warm-up is critical for increased blood flow to prepare the heart, muscles, and connective tissues for increased activity. Participants then perform 30 minutes of continuous aerobic activity within their training range (Figure 2). Immediately after the aerobic component, participants cool down for .%I0 minutes of low intensitv aerobic exercise (eg., slow walking) followed by a 10-minute series of stretches. T h e stretches focus on the major miiscle groups of the upper and lower extremities. T h e Duke University Osteoarthritis Program protocol also t~tilizesresistance training, which is comprised of both miometric (muscle shortcning) and pliometric (muscle lengthening) components. Because dynamic resistance training involves the use of various weights, it has the ability to produce greater strength gains when compared with isometric training. This is because muscle and connective tissue adaptation is v e v much dependent 11po11 the load placed on the system. T h e greater the challenge to the system, the greater the adapta-

tion to meet the demand; therefore, muscles, tendons, and ligaments exhibit a greater response to a more intense resistance training protocol (15,35). In the Duke University Osteoarthritis Protocol, each participant is assessed initially to determine maximum strength capacity for eight specific lifts: leg press, toe press, knee flexion, knee extension, bench press, latissimus dorsi pull-dow!i, biceps curl, and triceps extension. Following the initial assessment, participants engage in regular 30-minute resistance training sessions in which they perform two sets of 12 repetitions. starting at 30% of their o n e repetition maximum for each lift and progressing to 70% by the end of the 12-week program (Table 2). T h e resistance training immediately follows the cool-down/stretching phase. T h e combination of aerobic and resistance training is tolerated very well by most participants. For all types of training, the more deconditioned a person, the greater potential for improvement. Indeed, patients who are severely deconditioned may demonstrate improvements of more than 20% over a .3-4 month training period. At Duke University, Durham, NC, the exercise program is conducted on alternate days with the aerobic and flexibility training on Monday,


M'ednesdav, and Friday, and strength training on Monday and Friday. It is important to sequence the exercise sessions so that the body has time to recover for the next session, especially in reference to the strength training component. A minimum of 48 hours should be given for the muscle to recover between weight lifting days. For the first 8 weeks, aerobic activity is land-based (walking, cycling, rowing, and Nordic Track) on Monday and pool-based on Wednesday and Friday. For the last 4 weeks, participants move o u t of the pool and perform land-based activities on MTednesdavs.The rationale for shifting out of the pool is the assumption that the majority of people will not have access to a pool once they leave the Duke University Osteoarthritis Program protocol, but will have more opportunity to walk and cycle outside the fitness center.

Special Clinical Issues in Exercise Training There are a number of clinical issues that are particularly relevant for patients having osteoarthritis. One of the most important is screening of participants. Before beginning any exercise program, it is highly recommended that persons be seen by a physician and have a complete medical history and phvsical examination. T h e American College of Sports Medicine (ACSM) states that initial screening of participants is necessary for both the apparently healthy and those with chronic diseases in order to optimize safeh during exercise testing and training and to permit the development of a sound and effective exercise prescription (4). Recause most osteoarthritis patients are older adults who are at a higher risk for coronary artery disease, appropriate screening and evaluation is especiallv. important. . A graded exercise test is recommended, especially in sedentary men over age 40 o r women over age 50

with multiple o r severe cardiac risk factors (eg., hypertension, hyperlipidemia, o r cigarette smoking), in order to determine optimal exercise training regimens and to identify individuals for whom exercise may be contraindicated. In osteoarthritis patients, especially those with severe disease, it may be difficult to adequately test individuals due to orthopaedic limitations. To optimize this situation, a nonweight-bearing bike protocol should be utilized with small increases in workload (10 to 20 W) every 1-2 minutes. It is very important to allow for adequate warm-up prior to testing. Afternoon testing is typically better for the majority of osteoarthritis participants since many of them experience the most stiffness and pain in the first part of the day. There are certain contraindications to exercise in osteoarthritis patients that should be observed. If a patient has excessive inflammation, swelling, pain, o r has symptoms that are out of the ordinary, it is advised that the individual abstain from exercise until the increased symptoms subside. If the symptoms persist for more than 1 to 2 weeks, patients are advised to see a physician for consultation before proceeding with any further activity. Patients are also advised to report any unusual pain o r symptoms to the exercise staff at any time during their training program. They are asked to pay special attention to the time of occurrence and the duration of the symptoms experienced, noting whether it be muscular, joint, o r possibly connective tissue in origin. If a person has increased symptoms, the intensity and/or duration of both aerobic and strength components may need to be decreased. It is important to note that the exercise program presented in Table 2 is flexible and should be individualized to patients' particular needs. Each person possesses different levels and severity of disease and pain. Each case must be treated individually and modified accordingly to ensure a safe and ef-

fective progression and optimal benefit for the participant. A second common concern about rigorous exercise intervention is whether it can be detrimental to a preexisting arthritis condition. Although data are limited, as most studies have been too short in duration to answer this question definitively, there are n o data to suggest that exercise worsens o r exacerbates the symptoms of knee osteoarthritis. Although musculoskeletal injury is the major adverse effect for regular exercise, regular physical activity has not been shown to predispose individuals to arthritis. It is well known that a normal healthy joint is designed to withstand repetitive loads inherent to physical activities and activities of daily living.

FUTURE DIRECTIONS Future studies need to explore the utility of the biopsychosocial a p proach for both pain assessment and treatment. O n e of the most important directions for future research is identifying variables that predict treatment response. Clinical obsenations suggest that patients vary in their response to pain coping skills training and exercise training interventions. Several variables may be especially important in understanding these individual differences in treatment outcome (27). First. selfefficacy, o r the belief that one has the ability to engage in actions sufficient to attain a desired outcome, appears to be important in explaining outcome. As noted earlier, patients who report high levels of selfefficacy report an enhanced sense of control over pain and lower levels of pain and disability. Changes in selfeffkacy following coping skills training o r exercise may well be associated with long-term improvement5 in pain and disability. Few studies, however, have examined how changes in selfefficacy are related to the long-term outcome of coping skills o r exercise interventions. Second, aerobic fitness \'olume ?4 Nrlmher 4 Ocroher 19% oJOSPT


CLINICAL

may influence the outcome of these interventions. Patients who show improvements in fitness over the course of treatment may regain a more functionally effective lifestyle and become more involved in dailv physical and leisure activities. Little is known, however, about how coping skills training affects fitness o r how changes in acrobic fitness relate to the long-term outcomes of exercise interventions. Finally, interventions s w h as coping skills training and exercise may have a mqjor impact on how patients cope with pain on a dailv basis. Recently, researchers have begun to use intensive daily diary measures to gather information on coping, pain, and mood in arthritis patients (3). These studies have shown that patients who report a high frequency of coping cflbrts are likely to show a decline in pain intensity over a 7.i-ciay recording period. Frequent use of relaxation strategies has been found to relate to lower levels of pain, and the use of a wide range of coping strategies has been found to relate to iniprovements in mood. These results are interesting and support the utility of intensive dailv measures. These measures have not yet been incorporated into treatment outcome studies, but could yield important new insights in to how biopsychosocial in tenrentions work. O n e of the most important directions for biopsychosocial trcatment research is investigating the effectivcness of multimodal interventions that combine coping skills training with exercise. There are a number of reasons to believe that such a treatment combination will have synergistic effects. First, patients with musculoskeletal in,jwies o r arthritis often expect to h a w increased pain d r ~ r i n gexercise and are anxious about beginning an exercise program. Coping skills training can help reduce anticipatory anxiety and avoidance of activitv. Further, during excrcise sessions, pain may limit a patient's ability to exercise to the target training range and cause some patients to stop prema-

turely. Coping skills training methods, such as relaxation, activity pacing, and distraction, however, provide a means for controlling pain during exercise and allow patients to complete individual exercise sessions. Finally, a flare-up of pain may be one of the major reasons that patients stop exercising after completing a stn~ctured,supervised exercise program. In coping skills training, patients are taught cognitive and hehavioral skills for coping with pain flares and enhancing the long-term use of pain coping skills. Although biopsvchosocial a p proaches have only recently been a p plied to patients having arthritis and musculoskeletal disorders, they a p pear to have promise (25). New and creative applications of these a p proaches are likely to emerge in the coming years. By integrating interventions, such as coping skills training and exercise, into clinical practice, we not only may be able to significantly reduce pain, but also improve function and enhance the quality of life of individuals who have arthritis and musculoskeletal in.juries.

COMMENTARY

ery, activity pacing, and problem solving). T h e efficacy of pain coping skills training has been evaluated in a number of controlled research studies. A second intervention approach to pain management is exercise training. Following a careful assessment, many patients with musculoskeletal o r arthritic pain can benefit from a comprehensive exercise program. Basic elements of such a program include aerobic/cardiovascular training, strength training, and flexibility/ range of motion training. There are several important future directions for research on pain management interventions for mi~sculoskeletaland arthritic disorders. Patients vary in their response to coping skills training and exercise interventions and it is important to identifv variables that might explain these variations (eg., patient's sense of selfeficacy, aerobic fitness). Future s t ~ ~ d i also e s need to explore the benefit5 of treatment protocols that combine coping skills training with exercise interventions. ]OSrr

REFERENCES SUMMARY T h e biopsvchosocial model of pain emphasizes the role that biological variables (eg., tissue p a t h o l o p d u e to disease and in,jury, physical dcconditioning), cognitive-behavioral variables (eg., coping strategies, perceived control over pain, and patient beliefs), and environmental factors (eg., presence of a w~pportive spouse) can play in influencing the pain experience. In the past two decades, researchers have developed new interventions for managing pain in arthritic and musculoskeletal disorders based on the biopsychosocial model. O n e intervention approach is pain coping skills training. This type of training emphasizes the role that patients can play in controlling their own pain and provides systematic training in a variety of pain coping skills (eg., relaxation training, imag-

1. Afable RF, Bailey E, Woodard M : Comparison of aerobic and strength training in persons with osteoarthritis of the knee. ] Am Gerontol Soc 40:SA17, 1992 2. Affleck G, Tennen H, Urrows P: Individual differences in the day-to-day experience of chronic pain: A prospective daily study of rheumatoid arthritis patients. Health Psycho1 l O:4 19-426, 1992 3. Affleck G, Urrows S, Tennen H, Higgins P: Daily coping with pain from rheumatoid arthritis: Patterns and correlates. Pain 5 1 :22 1-229, 1992 4. American College of Sports Medicine: Guidelines for Exercise Testing and Prescription (5th Ed), Baltimore: Williams & Wilkins, 1995 5. Anderson KO, Bradley LA, McDaniel LK, Young LD, Turner RA, Agudelo CA, Keefe F], Pisko El, Snyder RM, Semble EL: The assessment of pain in rheumatoid arthritis. Validity of a behavioral observation method. Arthritis Rheum 30:36-43, 1987 6. Beckham ]C, Keefe F], Caldwell DS, Roodman AA: Pain coping strategies in


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rheumatoid arthritis: Relationships to maladaptive strategy. Pain 37:5 1-56, pain, disability, depression, and daily 1989 hassles. Behav Ther 22: 1 13- 124, 20. Keefe F], Caldwell DS, Martinez S, 1991 Nunley 1, Beckham 1, Williams DA: An7. Bigos Sl, Battie MC, Spengler DM, alyzing pain in rheumatoid arthritis paFisher LO, Fordyce WE, Hansson T, tients: Pain coping strategies in patients Nachemson AL, Zeh 1: A longitudinal who have had knee replacement surprospective study of industrial back ingery. Pain 46: 154- 160, 1 99 1 jury reporting. Clin Orthop 279:2 1-34, 2 1. Keefe F], Caldwell DS, Queen KT, Gil 1992 KM, Martinez S, Crisson JE, Ogden W, 8. Buckelew SP, Parker lC, Keefe Fl, Nunley 1: Pain coping strategies in osDeuser WE, Crews TM, Hewett ]E: Selfteoarthritis patients. ] Consult Clin Psyefficacy and pain behavior among subcho/ 55:208-2 12, 1987 jects with fibromyalgia. Pain 59:38522. Keefe F], Caldwell DS, Williams DA, 395, 1994 Gil KM, Mitchell 0, Robertson 0, Rob9. Bunning RD, Materson RS: A rational erston C, Martinez S, Nunley ], Beckprogram of exercise for patients with ham /C, Helms M : Pain coping skills osteoarthritis. Arthritis Rheum 2 1:33training in the management of osteoar43, 1991 thritic knee pain: A comparative study. 10. Davis MA, Ettinger WH, Neuhaus ]M, Behav Ther 21 :49-62, 1990 Mallon KP: Knee osteoarthritis and 23. Keefe F], Caldwell DS, Williams DA, physical functioning: Evidence from Gil KM, Mitchell 0, Robertson 0, Robthe NHANES I epidemiologic follow up erston C, Martinez S, Nunley ], Beckstudy. J Rheumatol l8:59 1-598, 1991 ham ]C, Helms M : Pain coping skills 1 1 . Ettinger WH, Afable RF: Physical distraining in the management of osteoarability from knee osteoarthritis: The thritic knee pain: Follow-up results. Berole of exercise as an intervention. Med hav Ther 2 1 :435-448, 1990 Sci Sports Exerc 26: 1435- 1440, 1994 24. Keefe F], Crisson lE, Snipes MT: Obser12. Fordyce WE: Behavioral Methods for vational methods for assessing pain: A Chronic Pain and Illness, St. Louis: C. V. practical guide. In: Blumenthal ]A, McMosby Company, 1976 Kee DC (eds), Applications in Behav13. Fordyce WE: The biopsychosocial ioral Medicine and Health Psychology, model revisited. Presented at the anpp 67-94. Sarasota, FL: Professional nual meeting of the American Pain SoResource Exchange, 1987 ciety, Los Angeles, CA, November, 1995 25. Keefe FJ, Dunsmore 1, Burnett R: Be14. Guccione AA, Felson DT, Anderson I]: havioral and cognitive-behavioral apDefining arthritis and measuring funcproaches to chronic pain: Recent adtional status in elders: Methodological vances and future directions. J Consult issues in the study of disease and physClin Psychol 60:528-536, 1992 ical disability. Am J Public Health 80: 26. Keefe FJ, Egert]: A cognitive-behavioral 945-949, 1990 perspective on patients with cumula15. Jones DA, Rutherford OM, Parker OF: tive trauma disorders. In: Sauter SL, Physiological changes in skeletal musMoon SO, Psychosocial Aspects of cle as a result of strength training. Q J Musculoskeletal Disorders in Office Exp Physiol74:233-256, 1989 Work, Durham, NC: Taylor R. Francis 16. Kazis LE, Meenan RF, Anderson 1: Pain (in press) in the rheumatic diseases: Investiga- 27. Keefe FJ, Van Horn Y: Cognitive-behavtions of a key health status component. ioral treatment of rheumatoid arthritis Arthritis Rheum 4(Suppl2):10- 13, 1983 pain: Understanding and enhancing 17. Keefe F], Beaupre PM, Gil KM: Group maintenance of treatment gains. Arthritherapy for patients with chronic pain. tis Care Res 6:2 13-222, 1993 In: Turk DC, Gatchel R] (eds), Psycho- 28. Keefe F], Wilkins RH, Cook WA, Crislogical Treatments for Pain: A Practitioson ]E, Muhlbaier LH: Depression, ner's Handbook, New York: Guilford pain, and pain behavior. ] Consult Clin Press (in press) Psychol 54:665- 669, 1986 18. Keefe F], Block AR: Development of an 29. Kovar PA, Allegrante JP, Mackenzie observation method for assessing pain CR, Peterson MGE, Gutin B, Charlson behavior in chronic low back pain paME: Supervised fitness walking in tients. Behav Ther l3:363-375, 1982 patients with osteoarthritis of the knee. 19. Keefe F], Brown GK, Wallston KA, Ann Intern Med 116:529-534, 1992 Caldwell DS: Coping with rheumatoid 30. Lentham J, Slade PO, Troup JOG, Bentarthritis pain: Catastrophizing as a ley G: Outline of a fear-avoidal model

of exaggerated pain perception. Behav Res Ther 2 1 :40 1-408, 1983 3 1. Linton S], Bradley LA, Jensen I, Spangfort E, Sundell L: The secondary prevention of low back pain: A controlled study with follow-up. Pain 36: 197-207, 1989 32. Lorig K, Chastain RL, Ung E, Shoor S, Holman HR: Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum 32:37-44, 1989 33. McCracken LM, Zayfert C, Gross RT: The Pain Anxiety Symptom Scale: Development and validation of a scale to measure fear of pain. Pain 50:67-73, 1992 34. McCracken LM, Zayfert C, Gross RT: The Pain Anxiety Symptom Scale (PASS):A multimodal measure of painspecific anxiety symptoms. Behav Ther 16:183-184, 1993 35. McDonagh MJN, Davies CTM: Adaptive response of mammalian skeletal muscle to exercise with high loads. Eur ] Appl Physiol52:139-155, 1984 36. McKeag KB: The relationship of osteoarthritis and exercise. Clin Sports Med 11:471-487, 1992 37. Melzack R, Wall P: Pain mechanisms: A new theory. Science 50:971-979, 1965 38. Minor MA, Hewett JE, Webel RR, Anderson SK, Kay OR: Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum 32: 1396- 1405, 1989 39. Parker ]C, Bradley LA, Devellis RM, Gerber LH, Holman HR, Keefe F], Lawrence TS, Liang MH, Lorig KR, Nicassio PM, Revenson TA, Rogers MP, Wallston KA, Wilson MG, Wolfe F: Biopsychosocial contributions to the management of arthritis disability: Proceedings from an NIDRR-sponsored conference. Arthritis Rheum 36:885-889, 1993 40. Parmalee PA, Katz IB, Lawton MP: The relation of pain to depression among institutionalized aged. J Gerontol 46: 15-21, 1991 41. Rodnan GP, McEwen C, Wallace SL: Primer on the rheumatic diseases. Arthritis Foundation 25-38, 1983 42. Rosenstiel A R, Keefe F]: The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain l7:33-40, 1983 43. Williams DA, Thorn BE: An empirical assessment of pain beliefs. Pain 361351-358, 1989

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