Arthritisis a broad term that covers a group of over 100 diseases. It has everything todo with our joints-the places where bones connect such as wrist, knees orfingers.
But some types of arthritis can also affect other connective tissuesand organs, including skin. There are different type of arthritis-Degenerativearthritis, inflammatory arthritis, Infectious arthritis and metabolicarthritis. Rheumatoid arthritis is an example of inflammatory arthritis.Rheumatoid arthritis is a chronic inflammatorydisease that causes significant pain and daily dysfunction (Mulligan &Newman, 2007).The word arthritis means inflammation of joint (“artho” meaningjoint and “itis” meaning inflammation). RA is an autoimmune disease, causespain, swelling and stiffness. If one knee or hand has RA, usually the otherdoes too.
Although its cause is still unknown, but it is believed to be theresult of a malfunctioning immune system. The symptoms and progression of RAvary widely from person to person. RA affects women two to three times moreoften than men. The disease strikes all ages, but the first signs arepredominately observed between the ages of 20 and 50 years. The male – femaleratio is 1:3, respectively (Anderson, Bradley, Young & Mc Daniel; 1985). There is no cure for RA, but medical treatments are useful for reducingpain at a normal level. Medical treatment is aimed at the reduction of symptomsby 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 treatmentsthere are some physical exercise, yoga, aerobics, imagery therapy, cognitivebehaviour therapy type therapies, which together enhance the functional abilityas well as their quality of life, well- being, physical and mental health also.RA affects cognitive functioningCognitioninvolved various complex mental processing which include attention (mentallyfocusing on some stimulus); perception (interpreting sensory information toyield meaningful information); memory (thestorage and retrieval processes of cognition) and so on. Researchers have foundthat various cognitive aspects are affected in arthritis group. Cognitiveimpairment is described as when a person has trouble in remembering, learningnew things, problem-solving, concentrating or making decisions that affectstheir everyday life. It ranges from mild to severe.
Attentional functioninginvolves a complex cognitive function and attentional control, which isessential for human behaviour. It is a selection process of internal andexternal 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 cognitivedysfunction was common in RA patients with prevalence rates ranging from 38%(divided /sustained attention and mental flexibility) to 71% (visuo – spatialand planning functions). Dick, Eccleston and Crombez (2002) have worked onattentional functioning in RA and its comparison with FM and musculoskeletal(MSK) pain patients and revealed that all 3 groups of chronic pain patients hadimpaired cognitive functioning on an ecological sensitive neuropsychologicaltest of everyday attention. This study supports previous findings by reportingthat many chronic pain patients have significant attentional dysfunction.
Inthis study, they found that FM patients showed a significantly higher level ofanxiety than the other 3 groups, but this study did not reveal that FM patientshad more severe attentional problems than other chronic pain patients.Furthermore, FM patients did not show poorer performance than patients with RAor MSK in any of the investigated domains of attentional and cognitivefunctioning. There are some contrast studies on FM patients that attentionaldeficits were found in FM patients compared with healthy controls on 2standardized attention tests (Sletvold et. al.; 1995). Grace et. al. (1999)also reported that compared with matched healthy controls, FM patients showedsignificant attentional and memory deficits on a neuropsychological testbattery.
Dick and Rashiq (2007) worked on disruption ofattention and memory accompanied by chronic pain and found that 2/3 ofparticipants with chronic pain had found impaired on attentional task and theyhad significantly greater difficulties in maintaining a memory trace during achallenging test of working memory.This disruption was not found to beassociated with sleep problems, psychological distress or age. This study alsosuggests that cognitive function was not improved by short-term localanalgesia.Abeare et. al. (2010) also confirmed the negativeassociation between pain and performance on task requiring selective attention,inhibition and working memory. In detailed, according to their result pain wasinversely related to executive functioning tasks, with higher pain levelsassociated with poorer performance on executive functioning tasks. Thisrelationship was not moderated or mediated by negative affect; however positiveaffect moderated the relationship between pain and executive functioning.
Forpatients high in positive affect there was a significant inverse relationshipbetween pain and executive functioning, whereas there was no such relationshipfor patients low in positive affect. But this negative affect was not apredictor of cognitive performance (Brown et. al., 2002).Melo and Silva(2012)studied on 3 groups rheumatoidarthritis (RA), fibromyalgia (FM), systemic lupus erythematasus (SLE) to assessthe possible existence of cognitive disorder associated with these disease andfinally found that FM and SLE group showed significantly higher means of theneuropsychiatric symptoms of anxiety, irritability and hallucinations than theRA group in the neuropsychiatric inventory.
In this study, young adultsperformed better in all tests as compared with the elderly. This study showed areduced cognitive performance mainly in the operational memory sphere in thelow 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 (globalattention/working memory, language, visual and verbal memory, visuo-spatialprocess and executive function) among them. Result showed that FM and RApatients performed poorly on most cognitive measurements compared with healthycontrols and much similar to each other in performance. Comparison of patientswith FM and RA revealed no significant differences except for the executivefunctions. Cognitive symptoms may be exacerbated by the presence of fatigue,sleep problems, and pain, but the relationship of these factors to cognitiveproblems in FM patients is unclear.
There is another study on FM patients ofKatz, Heart, Mills & Leavitt; 2004 and Glass, Park & Minear; 2005).According to them, memory impairment, poor concentration and difficulty inperforming mental tasks are frequent complaints in patient with FM. Thiscondition is so – called affected in “fibro-fog”. Recent study of Gunnarsson,Grahn and Agerstrom (2016) worked with 3 group as acute pain, regularlyrecurrent pain and persistent pain to assess three cognitive function(sustained attention, cognitive control and psychomotor ability). Resultindicated that patients with persistent pain showed significantly worse onsustained attention and psychomotor ability compared with healthy controls. Theacute pain group showed a significant decrement in psychomotor ability andregularly current pain group showed decrement in sustained attention. Age andeducation level did not have any significant relation to the performance onsustained attention. But age and education level were significantly related tothe performance on cognitive control and psychomotor ability.
Patients with RAor in other chronic pain disease, cognitive functioning is related to physicalfunctioning. Because it is assumed that cognitive impairment leads to decreaseperformance in physical activity and other executive functioning. Simos et.al. (2016) worked on RA usingneuropsychological tests battery (for assessment of long-term verbal episodicmemory, verbal fluency, processing speed and set- shifting ability) and foundthat 20% of RA patients were cognitively impaired.In a study, low cognitive function was significantly associated with thesubsequent loss of physical function in daily activities.
It is also found asignificant relationship between cognitive function and functional limitationin older adults (Greiner, Snowdon and Schmitt; 1996 and Wong, Van Belle andLarson; 2002). Shin, Julian and Katz (2013) also investigated the relationship betweencognitive function and physical function in RA, using 12 standardizedneuropsychological measures and revealed that cognitive impairment was significantlyassociated with greater functional limitations in patients with RA andsuggesting that cognitive impairment play a role in poor functional status inRA and this decrement was associated with performance- based and self reportedmeasures. Cognitive difficulties in RA may have enough impacton daily functioning treatment management and adaption to illness (Dunlopet.al. 2005; Shin, Julian & Katz, 2013). Above studies have shown that Rheumatoid Arthritisis a disease having pain and physical symptoms but there is an psychologicalaspects regarding this disease.
Not only Rheumatoid Arthritis but also othertypes of arthritis have their psychological consideration. Thus, Cognitiveprocessing is also affected in this disease.