Psychosocial Factors & Pain in Hand Osteoarthritis

A recent longitudinal study of hand pain in osteoarthritis (OA) indicates a variable course, with some patients showing pain stability or even improvement over time.¹ As researchers learn more about the biopsychosocial factors that influence pain course, the data may help shape more targeted interventions in specific patient subsets.

Multifactorial Nature of Hand OA

Multiple processes are thought to underlie pain in chronic hand OA, which may be present in patients to differing degrees. Traditional therapeutics target nociceptive pain in the joint, pain derived directly from the stimulation of pain receptors. For a condition such as hand OA, nociceptive pain may have both inflammatory and more mechanical components, and this is where much previous research has focused.^1,2

Other causes may also play a role in pain, and a patient’s ultimate pain course. Sensitization of nerves can contribute to nociplastic-type pain, and actual nerve damage may lead to neuropathic pain in some patients. Incomplete response to standard therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs), may partly derive from non-nociceptive causes such as these.^1,2

Patients’ emotional and mental states can also powerfully influence the perception of pain, both chronic pain generally and in hand OA specifically. Previous studies have demonstrated that differences in patients’ sociocultural environments, coping styles and self-perception, illness perception and expectations, as well as levels of anxiety and depression, can all influence the subjective experience of pain in hand OA.^3-5

For example, a recent study out of Norway demonstrated that patients with hand OA that was scored the least severe radiographically but who have higher burdens of psychosocial factors experienced more pain than patients with worse radiographic findings.⁶ Other studies have often found discrepancies between pain and radiographic joint findings, although these better correlate when analyzed at the individual joint level.⁷

One of the authors of the recent longitudinal pain course study in hand OA is Coen van der Meulen, MD, a current PhD student at Leiden University Medical Center, The Netherlands. He notes that the pain field has been moving from a purely nociceptive, biological model of pain toward a broader model that also incorporates other factors, including centrally mediated pain mechanisms, social factors and psychological factors.⁸

Study Design & Selected Outcomes

Some patients and clinicians conceptualize hand pain from OA as inevitably worsening over time. Some previous work indicated that, analyzed as a group, pain levels tend to stay relatively stable over long periods, although individuals’ pain may vary greatly from day to day.¹ This includes a recent report by Dr. van der Meulen and colleagues utilizing data from HOSTAS (Hand OSTeoArthritis in Secondary care), an observational cohort of patients with a clinical diagnosis of hand OA from the Leiden University Medical Center rheumatology outpatient clinic.⁹

In the follow-up study, which also tapped data from HOSTAS, the researchers chose to examine the data from another angle, looking at 356 patients more individually. To do so, they utilized the Australian/ Canadian hand osteoarthritis index (AUSCAN) pain subscale, initially and for four years annually. They categorized patients with deteriorated pain, stable pain or improved pain using patient reports via the Minimal Clinically Important Improvement (MCII) measure.¹

Pain Course

At an individual level, pain course seemed variable. Four years after the initial assessment, pain had worsened in 30% of patients, but had remained stable for 32% and had improved in 38%. Using the patient acceptable symptom state (PASS) patient-reported outcome, which describes the highest level of symptoms at which patients regard the symptom as acceptable, 44% met PASS levels at baseline and 49% at follow-up.¹ Dr. van der Meulen notes that overall pain scores were consistent with what had previously been found in the literature.

Illness Perceptions & Coping Styles

The investigators used the Illness Perception Questionnaire (IPQ), which measures eight different domains in which patients may perceive their disease and their level of control over it.¹⁰ They found that patients with less perceived understanding of the disease (the illness coherence category of the IPQ) were more likely to experience improvements in their pain. Patients with a higher perception of negative disease consequences from hand OA (via the IPQ) were less likely to experience improvement in their pain over the period.¹

Although the general literature on patient education suggests increased health literacy may be associated with less pain intensity, it’s possible in this case that some patients had a darker view of their prognosis than is fully warranted, influencing their pain course through a sort of nocebo effect.¹¹

“The expectations people have of their disease may influence how they experience it,” explains Dr. van der Meulen. “I think that’s where the importance of proper patient education comes in. If you always tell patients that their pain is only going to get worse, you may bias them toward a more negative experience of their symptoms.”

The investigators also used the Coping with Rheumatic Stressors (CORS) questionnaire, a tool developed for use in rheumatic diseases that categorizes eight different coping styles—different ways to think about and manage the impact of the disease. They identified one particular coping style that was more likely to be associated with pain worsening over a four-year period.¹

Comorbidities

The group also used the Hospital Anxiety and Depression Scale (HADS) to measure signs of anxiety and depression.¹² Participants with fewer signs of depression and anxiety at initial assessment were more likely to have pain improvement four years later, reinforcing previous findings of the effects of mental health on pain perception.^1,3

Depression is a common comorbidity in osteoarthritis, and patients with major depressive disorder are more likely to experience chronic pain than those in the general population. It’s possible that underlying features, such as increased chronic inflammation, may be partly driving the association of osteoarthritis pain with depression and anxiety.¹³

Higher initial body mass index (BMI) was also associated with pain deterioration longitudinally. This is consistent with previous crosssectional reports, and some have speculated the association stems from the increased inflammation triggered by adipokines from excess adipose tissue.¹⁴

Future Directions

Dr. van der Meulen

Given the limits of observational studies, Dr. van der Meulen emphasizes the need for replication in other longitudinal hand OA cohorts, such as the Nor-Hand cohort or DIGICOD cohort.^6,15 Theoretically, further studies may help identify specific targets for interventions in certain populations of patients with hand OA. For example, teaching specific coping styles or targeting mental health issues may prove useful for some patients.

“For everyone dealing with patients who are experiencing chronic pain, such as from some kind of rheumatic disease, we may need to start looking more at the biopsychosocial model in its entirety,” says Dr. van der Meulen. “That would mean the paradigm has to shift.”

Dr. van der Meulen acknowledges that it is hard to know how to apply these results and the overall biopsychosocial pain model to patients at present. Current ACR guidelines acknowledge that interventions to improve mood, reduce stress and manage weight may improve patients’ overall well-being. Cognitive behavioral therapy, one mode of working with patient beliefs and perceptions, is already conditionally recommended as a potential component of hand OA treatment for some patients.¹⁶

“The main thing right now is to have an open mind and see where rheumatology connects to this larger model of pain,” adds Dr. van der Meulen. “And make sure patients know that increasing pain in hand OA is not a given, that it’s often stable or might even improve.”

Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.

References

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