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Arthritis Pain Management – A Course for Coping

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By Deborah Cooper • • October 17, 2000

With the many resources available today, arthritis patients need not suffer with endless pain and the disruption it causes. There are many avenues available to help patients manage their pain and to prevent it from dominating their lives.

One of the oldest and well- known programs in the country is the Arthritis Self-Management Program run by Stanford University. The Chronic Disease Self-Management Program teaches all the essentials of successful pain management, such as exercise and nutrition. More importantly, this program recognizes the emotional and coping issues involved in dealing with a chronic disease. Techniques are introduced for dealing with frustration, fatigue, and isolation, as well as ways to more effectively communicate with friends, family and health professionals.

But if the thought of sitting in a classroom makes you want to stay in bed, the program leaders emphasize that the way the classes are taught is non-traditional and have a high level of patient participation. The focus is on providing mutual support to build patients’ confidence in their ability to manage their health and maintain active and fulfilling lives.

What follows is an interview with Kate Lorig, DrPH, an associate professor in the Stanford University School of Medicine and director of the Stanford Patient Education Research Center. She and her colleagues developed the Arthritis Self-Management Program at Stanford University. The program is now offered nationwide by Arthritis Foundation chapters and replicated in Canada, Great Britain, Australia, and New Zealand. Lorig co-authored The Arthritis Helpbook (Addison-Wesley, 1995), a companion to the program.

Q: Tell us about the Arthritis Self-Management Program.

Lorig: It differs from most patient education programs in a number of ways. First, it is taught by lay people - people with arthritis teaching other people with arthritis. Second, we don't teach a topic of the week. We teach a little bit each week about exercise, pain management, or problem-solving techniques and then have people practice these skills. We are trying to give people confidence in their ability to manage the disease.

We started the program in the late 1970s. Over the years, we've studied 3,000 to 4,000 people - some for as long as four years. At four years, we find people who have taken the course have a 19 percent reduction in pain and their disability has increased by just 9 percent - which is less than the 12 percent to 20 percent increase we'd expect over that period of time.

And they have 43 percent fewer visits to physicians. Assuming $45 per physician visit, we calculated a savings of $647 for each patient in the program who had rheumatoid arthritis and $189 for each patient with osteoarthritis.

Q: Why is exercise important?

Lorig: For a number of reasons. If you are inactive, you end up having weak, tense muscles; and weak, tense muscles cause pain. Stronger muscles also help protect weaker joints. Exercise obviously keeps you fitter, and it helps with weight maintenance, which is important to people with arthritis. Exercise also is one of the things that is really good to help fight depression.

We don't teach people a specific exercise program. We teach people the skills they need to develop their own program. People come in with different activity levels and different things that they want to do and can do. Also, since arthritis changes over time, we want people to have the skills to modify their exercise programs as necessary, rather than just drop the whole thing.

Q: You also teach pain and stress management techniques?

Lorig: We teach two different forms of relaxation techniques. One is progressive muscle relaxation, in which individuals relax one set of muscles at a time and continue throughout the body. The second is guided imagery, where we basically just tell them a story and have them imagine, for example, that they are on a walk through a garden and the woods and they see running water and it is pleasant.

We also teach people about their "self talk" - the stuff we talk about in our heads all the time, which to a great extent determines our behavior. If you tell yourself, "I don't really want to get up this morning. It's too cold. I'll stay in bed and won't exercise," that's probably what you'll do.

We make people more aware of these self-defeating messages and give them techniques for changing them.

Q: How do you teach problem solving?

Lorig: We first have patients identify a problem: "I can't go upstairs." Well, why can't you go upstairs? "I'm afraid I'm going to fall." Then we have them make a list of solutions, try one, and if it doesn't work, try another. We teach people this procedure and go through it with them lots of times.

And anytime anybody in the class has a problem - and the problem may be, "I wasn't able to take my walk on Thursday because it was raining" - the leader will then say, "Does anybody in the group have any suggestions?" We always get the solutions generated in the group, rather than the leader saying, "Why don't you do this?"

Q: Why do people with arthritis teach the course rather than health

Lorig: For one, it makes it hard for people in the group to say to the instructor, "You don't know what it feels like," when in fact the instructors do know. Second, having a role model is a strong way of building self-confidence. Health professionals also tend to tell people what they should be doing rather than lead them through the problem-solving
and other techniques that we emphasize in the course.

In one study we compared people who took the course taught by a health professional with people who took the course taught by a lay instructor. From the health professionals, people learned a lot more, but with lay instructors, people did a lot more.

Another advantage is a systems thing. If we are talking about an intervention that is going to reach even 5 or 10 percent of the people with arthritis in this country, there are not anywhere near enough health professionals to teach that many courses.

The above interview is used with the permission of the Center for Advancement of Health Studies

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