Rheumatic Diseases - Treatment  Beyond Medicines.

Dr Mohini Ganu, M.D.FICP. Latur.

Introduction -
Rheumatological disorders are characterised by pain in joints as well as soft tissues. Their chronic nature mandates long term and at times lifelong treatment for most of the patients. These diseases cause not only the structural changes in the body but also alter the psychology of the patient thus having immense effect on the outcome of the disease.

Many factors contribute to psychological trauma set in by these disorders.

1. Chronicity- Chronic nature of the disease mandates long term / life long treatment  for most of these diseases. By chronicity  we mean that the diseases can be controlled and not totally cured. Intermittent flares, immobility due to extreme stiffness creates anxiety and depression in patients mind affecting quality of life.

2. The diseases are common in females and in child bearing age. In developing country like India, many females are dependent on male partners economically giving them a sense of burden to family. Recurrent abortions as seen in APLA syndrome, SLE related pregnancy morbidity, inability to look after children or family well affects their emotional status negatively.

3.  Diseases like discoid Lupus cause disfigurement and Rheumatoid arthritis causes deformities. These are difficult to accept especially in those where disease onset is in adolescence or in childbearing age. Disabilities limit the physical activities affecting daily life adversely giving patients sense of dependence and feeling of helplessness.

4. Susceptibility to infections is increased due to disease induced compromise in immune system functioning .Drugs like corticosteroids and immunosuppressant that are needed to control the disease add to the problem. Unexpected flares increase economic burden as well as mental agony.

5. In addition these inflammatory disorders are characterised by chronic pain which is very frustrating. There is bidirectional relationship between pain and psychological distress.

Pain may originate locally at inflamed /damaged joints, muscles, back. It may be a chronic pain due to altered pain perception/ sensitization in the brain. Conditions like fibromyalgia are characterised by widespread pain and accompany many of the rheumatological disorders like Rheumatoid arthritis  and SLE  .There may be multiple tender points over the body.

Patients may in addition have sleep disorders with poor sleep quality, headaches and bowel disturbances.Genetic factors may predispose individuals to fibromyalgia / chronic widespread pain so also the psychological factors like anxiety , stress and chronic depression, mood disturbances.Patients have difficulty in doing tasks due to problems with attention.Chronic fatigue is an important complaint adversely affecting quality of life.

There are no specific laboratory tests for diagnosis Neuroimaging ie. Magnetic resonance imagimg(MRI), functional MRI may provide insight into the mechanisms of central pain but are still used for research purposes.

How mind and body are related in the context of pain?

Psychological factors alter the body physiology and have direct influence on the disease process.

Hypothalamus (a part of brain), endocrine system especially pituitary and adrenal glands and sympathetic nervous system are directly involved in body response to stress.

Actual physical or mental stress activates hypothalamo-pituitary- adrenal (HPA) axis . Various neuroendocrine hormones are secreted which activate inflammation. Chronic inflammatory conditions compromise stress regulatory system of the body and also amplify pain sensitization.

Proinflammatory Cytokines (small proteins regulating immune system) in addition to inducing inflammation alter the process of psychological adjustment .Physical , social, psychological wellbeing is affected culminating in sickness behaviour.

How to tackle this menace?

Pain is an unavoidable part of rheumatic diseases.

Personality characteristics like self sacrificing defense style perpetuate pain and reduce health related quality of life.

Controlling the disease process through appropriate medications is most important. Adherence to treatment helps control the disease early. Discussing the disease and mode of treatment with treating doctor is very essential to alleviate anxiety. It also helps patients to fare well during stressful times.

Exercises and guided self help are useful in overcoming milder depression. Moderate to severe depression needs pharmacological intervention.

Cognitive behavioral therapy (CBT) consisting of thought manipulation to reduce symptoms of anxiety, depression is helpful to tackle milder depression. It has beneficial effect on pain reduction as well. It is now included in the treatment of fibromyalgia.

Fear of pain leads to tendency to avoid of exercises. Resuming exercises under the guidance of physiotherapist is beneficial. It reduces muscle deconditioning, improves joint mobility improving functional status. It boosts self confidence and quality of life. For those who are unable to do routine exercises due to disability, advanced age or postural imbalance, chair yoga provides a viable alternative.

Patients should take adequate sleep/ rest. Fatigue and sleep influence one another. Avoiding continuous prolonged work is essential. Same amount of work can be done in different time slots with a period of rest in between to avoid fatiguability.

Indulgence in recreational activities and spending time with friends and family is beneficial. It elevates the mood.MAI is doing a very good job by providing such platform to the patients.

Family support plays very important role in coping with pain. Quality of life in patients having supportive families is definitely better. However patients should be allowed to do the work that they can still do. Overprotective behaviours from spouses and family members may contribute to maintenance of pain behaviours in the patients and hence should be avoided.

Encouragement to remain in work is important part of patient care and should be done.

In nut shell, psychological flexibility ie. behavioural adaptation as per one’s own core values, thoughts , feelings and bodily sensationsis important. This can be achieved by indulging in meaningful activities. For any treatment to be effective adherence to treatment is very important. Enjoy your exercise schedules, adhere to medical treatment, set smaller goals and try to achieve them through self help programmes and CBT. Take help of treating doctors, family and friends to improve your coping strategies.