is a broad term that covers a group of over 100 diseases. It has everything to
do with our joints-the places where bones connect such as wrist, knees or
fingers. But some types of arthritis can also affect other connective tissues
and organs, including skin. There are different type of arthritis-Degenerative
arthritis, inflammatory arthritis, Infectious arthritis and metabolic
arthritis. Rheumatoid arthritis is an example of inflammatory arthritis.
Rheumatoid arthritis is a chronic inflammatory
disease that causes significant pain and daily dysfunction (Mulligan &
Newman, 2007).The word arthritis means inflammation of joint (“artho” meaning
joint and “itis” meaning inflammation). RA is an autoimmune disease, causes
pain, swelling and stiffness. If one knee or hand has RA, usually the other
does too. Although its cause is still unknown, but it is believed to be the
result of a malfunctioning immune system. The symptoms and progression of RA
vary widely from person to person. RA affects women two to three times more
often than men. The disease strikes all ages, but the first signs are
predominately observed between the ages of 20 and 50 years. The male – female
ratio is 1:3, respectively (Anderson, Bradley, Young & Mc Daniel; 1985).
There is no cure for RA, but medical treatments are useful for reducing
pain at a normal level. Medical treatment is aimed at the reduction of symptoms
by attacking the inflammation and at maximum prevention of joint damage.
Medical management of RA involves the use of analgesics, nonsteroid anti-
inflammatory agents, corticosteroids injectable gold.Besides medical treatments
there are some physical exercise, yoga, aerobics, imagery therapy, cognitive
behaviour therapy type therapies, which together enhance the functional ability
as well as their quality of life, well- being, physical and mental health also.
RA affects cognitive functioning
involved various complex mental processing which include attention (mentally
focusing on some stimulus); perception (interpreting sensory information to
yield meaningful information); memory (the
storage and retrieval processes of cognition) and so on. Researchers have found
that various cognitive aspects are affected in arthritis group. Cognitive
impairment is described as when a person has trouble in remembering, learning
new things, problem-solving, concentrating or making decisions that affects
their everyday life. It ranges from mild to severe. Attentional functioning
involves a complex cognitive function and attentional control, which is
essential for human behaviour. It is a selection process of internal and
external event which has to be maintained at a certain level of awareness.
Cognitive functioning is also affected in Rheumatoid Arthritis.
Bartolini et. al. (2002) observed that cognitive
dysfunction was common in RA patients with prevalence rates ranging from 38%
(divided /sustained attention and mental flexibility) to 71% (visuo – spatial
and planning functions).
Dick, Eccleston and Crombez (2002) have worked on
attentional functioning in RA and its comparison with FM and musculoskeletal
(MSK) pain patients and revealed that all 3 groups of chronic pain patients had
impaired cognitive functioning on an ecological sensitive neuropsychological
test of everyday attention. This study supports previous findings by reporting
that many chronic pain patients have significant attentional dysfunction. In
this study, they found that FM patients showed a significantly higher level of
anxiety than the other 3 groups, but this study did not reveal that FM patients
had more severe attentional problems than other chronic pain patients.
Furthermore, FM patients did not show poorer performance than patients with RA
or MSK in any of the investigated domains of attentional and cognitive
functioning. There are some contrast studies on FM patients that attentional
deficits were found in FM patients compared with healthy controls on 2
standardized attention tests (Sletvold et. al.; 1995). Grace et. al. (1999)
also reported that compared with matched healthy controls, FM patients showed
significant attentional and memory deficits on a neuropsychological test
Dick and Rashiq (2007) worked on disruption of
attention and memory accompanied by chronic pain and found that 2/3 of
participants with chronic pain had found impaired on attentional task and they
had significantly greater difficulties in maintaining a memory trace during a
challenging test of working memory.This disruption was not found to be
associated with sleep problems, psychological distress or age. This study also
suggests that cognitive function was not improved by short-term local
Abeare et. al. (2010) also confirmed the negative
association between pain and performance on task requiring selective attention,
inhibition and working memory. In detailed, according to their result pain was
inversely related to executive functioning tasks, with higher pain levels
associated with poorer performance on executive functioning tasks. This
relationship was not moderated or mediated by negative affect; however positive
affect moderated the relationship between pain and executive functioning. For
patients high in positive affect there was a significant inverse relationship
between pain and executive functioning, whereas there was no such relationship
for patients low in positive affect. But this negative affect was not a
predictor of cognitive performance (Brown et. al., 2002).
Melo and Silva
studied on 3 groups rheumatoid
arthritis (RA), fibromyalgia (FM), systemic lupus erythematasus (SLE) to assess
the possible existence of cognitive disorder associated with these disease and
finally found that FM and SLE group showed significantly higher means of the
neuropsychiatric symptoms of anxiety, irritability and hallucinations than the
RA group in the neuropsychiatric inventory. In this study, young adults
performed better in all tests as compared with the elderly. This study showed a
reduced cognitive performance mainly in the operational memory sphere in the
low educational level group.
Bilgici, Terzi, Guz and Kuro (2014)
worked on 3 groups i.e.
healthy controls, RA and FM patients to assess cognitive performance (global
attention/working memory, language, visual and verbal memory, visuo-spatial
process and executive function) among them. Result showed that FM and RA
patients performed poorly on most cognitive measurements compared with healthy
controls and much similar to each other in performance. Comparison of patients
with FM and RA revealed no significant differences except for the executive
functions. Cognitive symptoms may be exacerbated by the presence of fatigue,
sleep problems, and pain, but the relationship of these factors to cognitive
problems in FM patients is unclear.There is another study on FM patients of
Katz, Heart, Mills & Leavitt; 2004 and Glass, Park & Minear; 2005).
According to them, memory impairment, poor concentration and difficulty in
performing mental tasks are frequent complaints in patient with FM. This
condition is so – called affected in “fibro-fog”.
Recent study of Gunnarsson,
Grahn and Agerstrom (2016) worked with 3 group as acute pain, regularly
recurrent pain and persistent pain to assess three cognitive function
(sustained attention, cognitive control and psychomotor ability). Result
indicated that patients with persistent pain showed significantly worse on
sustained attention and psychomotor ability compared with healthy controls. The
acute pain group showed a significant decrement in psychomotor ability and
regularly current pain group showed decrement in sustained attention. Age and
education level did not have any significant relation to the performance on
sustained attention. But age and education level were significantly related to
the performance on cognitive control and psychomotor ability. Patients with RA
or in other chronic pain disease, cognitive functioning is related to physical
functioning. Because it is assumed that cognitive impairment leads to decrease
performance in physical activity and other executive functioning.
Simos et.al. (2016) worked on RA using
neuropsychological tests battery (for assessment of long-term verbal episodic
memory, verbal fluency, processing speed and set- shifting ability) and found
that 20% of RA patients were cognitively impaired.
In a study, low cognitive function was significantly associated with the
subsequent loss of physical function in daily activities. It is also found a
significant relationship between cognitive function and functional limitation
in older adults (Greiner, Snowdon and Schmitt; 1996 and Wong, Van Belle and
Shin, Julian and Katz (2013) also investigated the relationship between
cognitive function and physical function in RA, using 12 standardized
neuropsychological measures and revealed that cognitive impairment was significantly
associated with greater functional limitations in patients with RA and
suggesting that cognitive impairment play a role in poor functional status in
RA and this decrement was associated with performance- based and self reported
Cognitive difficulties in RA may have enough impact
on daily functioning treatment management and adaption to illness (Dunlop
et.al. 2005; Shin, Julian & Katz, 2013).
Above studies have shown that Rheumatoid Arthritis
is a disease having pain and physical symptoms but there is an psychological
aspects regarding this disease. Not only Rheumatoid Arthritis but also other
types of arthritis have their psychological consideration. Thus, Cognitive
processing is also affected in this disease.