The relationship between health-related quality of life, pain and coping strategies in juvenile idiopathic arthritis

OBJECTIVES: To investigate the relationship between health-related quality of life (HRQL), experience of pain and pain coping strategies in children with juvenile idiopathic arthritis (JIA). To compare reports describing these variables obtained from children and their parents. METHODS: Participants were 59 children aged 8 to 18 yr with JIA and their parents. Parents and children completed the PedsQL generic core scales and arthritis module, the visual analogue scale of the Varni-Thompson Pediatric Pain Questionnaire, and the Waldron/Varni Pediatric Pain Coping Inventory. Parents rated children's functional disability using the Childhood Health Assessment Questionnaire. RESULTS: Parents reported significantly lower scores (indicating worse HRQL) than children on five of the eight PedsQL scales rating children's HRQL. Parents and children reported a significant negative relationship between pain levels and the PedsQL scores assessing children's physical, emotional and social functioning. They also reported a significant negative relationship between scores on several pain coping scales and scores on the PedsQL scales. However, the pattern of these relationships varied for reports from parents and children. CONCLUSIONS: Pain intensity and pain coping strategies have a significant and independent relationship with several domains that comprise the HRQL of children with JIA. However, parents and children have differing perceptions of the nature of these relationships. The differences emphasize the importance of clinicians obtaining information about children's HRQL, pain levels and pain coping strategies from both parents and children.     

Primary juvenile fibromyalgia. Psychological adjustment,family functioning,coping, and functional disability

Objectives. 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. Methods. Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. Results. All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. Conclusion. The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.     

Relationship of pain-coping strategies and pain-specific beliefs to pain experience in children with juvenile idiopathic arthritis

OBJECTIVE: To examine whether pain-specific beliefs and coping strategies of patients with juvenile idiopathic arthritis (JIA) independently predict their reported pain, while controlling for relevant demographic variables, disease activity, and parent-rated disability. To compare use of pain-coping strategies and pain-related beliefs of a selected subgroup of patients with high pain and low disease activity (high pain group) with the remaining patients. METHODS: Children with JIA (n = 56) completed the Pain Coping Questionnaire, a revised version of the Survey of Pain Attitudes, and a 3-week pain diary. The parents completed the Childhood Health Assessment Questionnaire (CHAQ). Second order principal component analyses were conducted in order to reduce the number of independent variables. Regression analyses of the dependent measure were performed. The use of coping strategies and health beliefs were compared using t-tests for independent samples. Pearson's correlation coefficients were calculated to examine the direct associations between each individual coping and belief scale, and the pain measure. RESULTS: Only the CHAQ and the cognitive belief composite factor score made statistically significant contribution to the prediction of pain after controlling for other variables. Significant differences were found between the scores of high pain patients and the rest of the group for the health belief subscale of disability (mean +/- SD 2.0 +/- 0.6 and 1.2 +/- 0.7, respectively), and for the health belief subscale of harm (mean +/- SD 2.7 +/- 0.6 and 1.8 +/- 0.7, respectively). Significant correlations were obtained between the pain measure and the pain-coping subscale of catastrophizing, the pain belief subscales of disability, harm, solicitude (inverse), control, and medical cure. CONCLUSION: These results support a model of pain experience in patients with JIA where psychological factors are strongly influential. It may be efficient to focus behavioral interventions on a subgroup of children where the pain experience seems to be in discordance with the disease activity.     

Weather,beliefs about weather,and disease severity among patients with fibromyalgia

Objective. This investigation 1) examined the relationships among actual weather, disease severity, and symptoms for individuals with fibromyalgia, 2) assessed subjects' beliefs about weather affecting their symptoms, and 3) examined differences between individuals with high and low “weather sensitivity.” Methods. Eighty-four individuals meeting Yunus' criteria for the diagnosis of fibromyalgia participated. Subjects completed the Weather and Pain Questionnaire (WPQ), the Arthritis Impact Measurement Scales (AIMS), the Symptom Checklist-90-Revised (SCL-90-R), and a Visual Analog Scale (VAS) assessing pain. A tender point index and a myalgic score were also obtained. Results. Subjects reported that weather affected musculoskeletal symptoms predominantly. The strongest relationship was found between weather beliefs and self-reported pain scores. Subjects with high weather sensitivity tended to have more functional impairment and psychological distress. Conclusions. Individuals with fibromyalgia believe that weather worsens their symptoms, but it is unlikely that physiologic changes are associates with actual weather.     

The impact of passive coping on rheumatoid arthritis pain

OBJECTIVE: To determine the ability of coping to predict pain. METHODS: Data on 111 rheumatoid arthritis (RA) patients (86 women and 25 men) were gathered from a mail survey. Statistical analyses were conducted on a range of clinical and psychological variables: physical disability, disease duration, pain, depression, helplessness, and passive and active coping. Pain was measured with both the pain subscale of the Arthritis Impact Measurement Scales and a visual analogue scale, and coping was measured with the Vanderbilt Pain Management Inventory. RESULTS: A series of multiple regression analyses revealed that the optimal predictors of pain in RA were physical disability and passive coping, which accounted for 40% of the variance associated with pain. Path analysis revealed that passive coping mediates between the physical disability and pain, and between physical disability and depression. CONCLUSION: The results of this study have implications for the overall management of RA. In addition to the medical treatment, the experience of pain and depression in RA should be addressed through an intervention programme designed to enhance coping strategies.     

Analysis of disability in knee osteoarthritis. Relationship with age and psychological variables but not with radiographic score.

Sixty-one women with symptomatic knee osteoarthritis were given the Italian version of Arthritis Impact Measurement Scale which showed a good construct through the factorial analysis. The disability index was then related to the body mass index, the anatomical/radiographic damage, to the severity of pain assessed either through the McGill Pain Questionnaire or a visual analog scale, and finally to the degree of anxiety and depression as obtained from the Zung depression and anxiety inventory scores. A statistically significant relationship was found between radiographic damage and body weight, while disability correlated with the degree of psychological involvement and with the age of the patients. Through the stepwise multiple regression analysis we demonstrated that the pain experience and disability scores are strongly influenced by psychological impact. Our data may have important therapeutic implications.     

Relationship of pain‐coping strategies and pain‐specific beliefs to pain experience in children with juvenile idiopathic arthritis

Objective

To examine whether pain‐specific beliefs and coping strategies of patients with juvenile idiopathic arthritis (JIA) independently predict their reported pain, while controlling for relevant demographic variables, disease activity, and parent‐rated disability. To compare use of pain‐coping strategies and pain‐related beliefs of a selected subgroup of patients with high pain and low disease activity (high pain group) with the remaining patients.

Methods

Children with JIA (n = 56) completed the Pain Coping Questionnaire, a revised version of the Survey of Pain Attitudes, and a 3‐week pain diary. The parents completed the Childhood Health Assessment Questionnaire (CHAQ). Second order principal component analyses were conducted in order to reduce the number of independent variables. Regression analyses of the dependent measure were performed. The use of coping strategies and health beliefs were compared using t‐tests for independent samples. Pearson's correlation coefficients were calculated to examine the direct associations between each individual coping and belief scale, and the pain measure.

Results

Only the CHAQ and the cognitive belief composite factor score made statistically significant contribution to the prediction of pain after controlling for other variables. Significant differences were found between the scores of high pain patients and the rest of the group for the health belief subscale of disability (mean ± SD 2.0 ± 0.6 and 1.2 ± 0.7, respectively), and for the health belief subscale of harm (mean ± SD 2.7 ± 0.6 and 1.8 ± 0.7, respectively). Significant correlations were obtained between the pain measure and the pain‐coping subscale of catastrophizing, the pain belief subscales of disability, harm, solicitude (inverse), control, and medical cure.

Conclusion

These results support a model of pain experience in patients with JIA where psychological factors are strongly influential. It may be efficient to focus behavioral interventions on a subgroup of children where the pain experience seems to be in discordance with the disease activity.

     

Gender and age differences in pain, coping and health status among children with chronic arthritis

OBJECTIVE: To investigate pain, coping and health status in children with chronic arthritis. Additional aims were to explore gender variations in pain, coping and health status, and the same factors in children under 16 years versus children 16 years or older. METHODS: For 125 children (43 boys) with a median age of 14.1 years (range 10.3-17.8) disability and discomfort were assessed (Childhood Health Assessment Questionnaire, CHAQ). Pain, coping, fatigue, sleeping and satisfaction with life were evaluated (Visual Analogue Scales). The Pain Intensity Scale was used to assess the variation in pain intensity during one week. RESULTS: The CHAQ disability index (DI) was 0.63. In the total sample, girls had larger numbers of affected joints in upper extremities (p = 0.028) and more days with morning pain (p = 0.025) than boys. Boys reported greater perceived ability to reduce pain than girls (p = 0.020). Compliance with treatment was more frequent in girls than in boys (p = 0.029). In children 16 years of age and older, boys reported greater perceived ability to control pain (p = 0.032) and to reduce pain than girls (p = 0.001) and fewer days with worst pain in the mornings (p = 0.013), as well as less pain variations over the period of a day (p = 0.014) and over a period of a week (p = 0.035). CONCLUSIONS: As a group, the children were clearly affected by their arthritis. Pain was related to the severity of disease. Some significant gender and age differences were highlighted, which should be considered in clinical pain management.     

Juvenile primary fibromyalgia syndrome

Juvenile primary fibromyalgia syndrome (JPFS) is a common musculoskeletal pain syndrome of unknown etiology characterized by widespread persistent pain, sleep disturbance, fatigue, and the presence of multiple discrete tender points on physical examination. Other associated symptoms include chronic anxiety or tension, chronic headaches, subjective soft tissue swelling, and pain modulated by physical activity, weather, and anxiety or stress. Research and clinical observations suggest that JPFS may have a chronic course that impacts the functional status and psychosocial development of children and adolescents. In addition, several factors have been implicated in the etiology and maintenance of JPFS including genetic and anatomic factors, disordered sleep, psychological distress, and familial and environmental influences. A multidisciplinary approach to treatment of JPFS is advocated, including pharmacologic and nonpharmacologic interventions (eg, psychotherapy, aerobic exercise, sleep hygiene).     

Family factors, emotional functioning, and functional impairment in juvenile fibromyalgia syndrome

OBJECTIVE: Family factors and emotional functioning can play an important role in the ability of adolescents with juvenile primary fibromyalgia syndrome (JPFS) to cope with their condition and function in their everyday lives. The primary objectives of this study were to determine 1) whether adolescents with JPFS and their caregivers differed from healthy age-matched comparison peers and their caregivers in terms of emotional distress and functional impairment; 2) whether there were any differences in the family environment of adolescents with JPFS compared with healthy comparison peers; and 3) which individual-, caregiver-, and family-level variables were associated with functional impairment in adolescents with JPFS. METHODS: Participants were 47 adolescents with JPFS recruited from a pediatric rheumatology clinic and 46 comparison peers without chronic illness matched for age, sex, and race. Participants and their caregivers (all mothers) completed a battery of standardized measures administered in their homes. RESULTS: Adolescents with JPFS had greater internalizing and externalizing symptoms than healthy comparison peers. Mothers of adolescents with JPFS reported twice as many pain conditions and significantly greater depressive symptoms than mothers of comparison peers. The JPFS group also had poorer overall family functioning and more conflicted family relationships. In adolescents with JPFS, maternal pain history was associated with significantly higher functional impairment. CONCLUSION: Increased distress and chronic pain are evident in families of adolescents with JPFS, and family relationships are also impacted. Implications for child functional impairment and the need for inclusion of caregivers in treatment are discussed.     

Psychosocial mechanisms for the transmission of somatic symptoms from parents to children

AIM: To examine familial aggregation of irritable bowel syndrome(IBS) via parental reinforcement/modeling of symptoms, coping, psychological distress, and exposure to stress.METHODS:Mothers of children between the ages of8 and 15 years with and without IBS were identified through the Group Health Cooperative of Puget Sound.Mothers completed questionnaires,including the Child Behavior Checklist(child psychological distress),the Family Inventory of Life Events(family exposure to stress),SCL-90R(mother psychological distress),and the Pain Response Inventory(beliefs about pain).Children were interviewed separately from their parents and completed the Pain Beliefs Questionnaire(beliefs about pain),Pain Response Inventory(coping)and Child Symptom Checklist[gastrointestinal(GI)symptoms].In addition,health care utilization data was obtained from the automated database of Group Health Cooperative.Mothers with IBS(n=207)and their 296 children were compared to 240 control mothers and their 335 children,while controlling for age and education.RESULTS:Hypothesis 1:reinforcement of expression of GI problems is only related to GI symptoms,but not others(cold symptoms)in children.There was no significant correlation between parental reinforcement of symptoms and child expression of GI or other symptoms.Hypothesis 2:modeling of GI symptomsis related to GI but not non-GI symptom reporting in children.Children of parents with IBS reported more non-GI(8.97 vs 6.70,P0.01)as well as more GI(3.24 vs 2.27,P0.01)symptoms.Total health care visits made by the mother correlated with visits made by the child(rho=0.35,P0.001 for cases,rho=0.26,P0.001 for controls).Hypothesis 3:children learn to share the methods of coping with illness that their mothers exhibit.Methods used by children to cope with stomachaches differed from methods used by their mothers.Only 2/16 scales showed weak but significant correlations(stoicism rho=0.13,P0.05;acceptance rho=0.13,P0.05).Hypothesis 4:mothers and children share psychological traits such as anxiety,depression,and somatization.Child psychological distress correlated with mother’s psychological distress(rho=0.41,P0.001 for cases,rho=0.38,P0.001 for controls).Hypothesis 5:stress that affects the whole family might explain the similarities between mothers and their children.Family exposure to stress was not a significant predictor of children’s symptom reports.Hypothesis 6:the intergenerational transmission of GI illness behavior may be due to multiple mechanisms.Regression analysis identified multiple independent predictors of the child’s GI complaints,which were similar to the predictors of the child’s non-GI symptoms(mother’s IBS status,child psychological symptoms,child catastrophizing,and child age).CONCLUSION:Multiple factors influence the reporting of children’s gastrointestinal and non-gastrointestinal symptoms.The clustering of illness within families is best understood using a model that incorporates all these factors.     

Development of an instrument to measure disability in parenting activity among women with rheumatoid arthritis

OBJECTIVE: To develop a method of assessing and summarizing parenting function and disability, and to use that method to describe parenting disability among a group of women with rheumatoid arthritis (RA). METHODS: The study group comprised 231 women with RA who are members of the University of California, San Francisco RA Panel Study. Parenting disability scales were developed by first asking open-ended questions and then, based on the responses, constructing closed-ended questions. Separate sets of questions were asked concerning young (ages 0-5 years) and older (ages 6-18 years) children. Parenting disability indices (PDIs), scored in a manner similar to that for the Health Assessment Questionnaire (HAQ) (range 0-3), were developed (total, and for young and older children). Associations of PDIs with demographic, health, and symptom measures were assessed. RESULTS: Substantial proportions of women with RA experienced disability in parenting activities. Greater disability was reported for activities related to parenting young children. Doing less of parenting functions because of RA was commonly reported. The mean total PDI of women who currently had children under age 18 years, taking into account "doing less" of activities because of RA, was 0.76 (range 0-2.08). Greater parenting disability was associated with poorer general function (HAQ; P < 0.0001), more severe pain (P = 0.002), greater fatigue (P = 0.0005), greater parenting stress (P = 0.005), and greater psychological distress (depressive symptoms; P < 0.0001). DISCUSSION: The PDI appears to be valid. This method can provide the means of assessing parenting disability, its risk factors, and its effects, which may assist in identifying ways of helping individuals with RA cope more effectively with parenting.     

Coping with pain in the hip or knee in relation to physical disability in community-living elderly people

Objective . To investigate the use of pain coping strategies by community-living older people with pain in the hip or knee and the mediating role of coping with pain in the relationship between the chronicity of pain and physical disability. Methods . A group of 157 people with pain “in the last month” was identified. Coping with pain was assessed with the Pain Coping Inventory, physical disability with the Sickness Impact Profile, and household and sport activities with a validated structured interview method. Results . People with chronic pain used relatively more “resting,” and “reducing demands” as pain coping strategies. Pain chronicity made a significant contribution to physical disability; however, when corrected for other variables in a regression model, no significant partial correlation was found. Conclusion . We conclude that pain coping has a mediating role in the relationship between pain chronicity and physical disability. Less use of “resting” and a physically active lifestyle are independently associated with less physical disability.     

Measuring the epidemiology of distress: the rheumatology distress index

OBJECTIVES: (1) To examine clinical and psychological variables to determine which are associated with psychologic and psychosocial severity or "distress"; (2) to investigate whether patients with the 2 major rheumatic disorders, rheumatoid arthritis (RA) and osteoarthritis (OA), differ in distress variables and distress; and (3) to develop and validate a simple, clinically acceptable index of distress suitable for routine care and research purposes. METHODS: A total of 2,403 patients were evaluated in 2 data sets (N = 1,399 and N = 1,490). The first data set was evaluated in the clinic by a routine clinical examination and administration of the Clinical Health Assessment Questionnaire (CLINHAQ). This instrument includes measures of pain, global severity, functional disability, anxiety, depression, sleep disturbance, fatigue, health satisfaction, and health status. The second data set was evaluated by a mailed questionnaire that included the CLINHAQ, but also coping scales, the Beliefs in Pain Control Questionnaire, the Self Performance Scale, and the Arthritis Helplessness Index. RESULTS: RA and OA groups had similar scores for the variables associated with distress: pain, global severity, functional disability, anxiety, depression, sleep disturbance, fatigue, health satisfaction, and health status. Patients with fibromyalgia (FM) had more abnormal scores for every variable, reflecting overall distress. Using patients with FM as a "gold standard" of distress, we developed an index in data set 2. the Rheumatology Distress Index (RDI), made up of 5 variables, anxiety, depression, global severity, fatigue, and sleep disturbance, that best identified patients with FM compared to other patients. We then validated the instrument on the distress severity clusters formed in data set 1. The correlation between RDI and distress severity cluster was 0.874 with all patients considered and 0.867 with FM patients excluded. In addition, RDI predicted 1,174 of 1,399 (83.9%) cluster memberships correctly. Compared with a battery of psychological and clinical tests that classified 74% of FM and non-FM patients correctly, the RDI and is only slightly less effective, classifying 70.3% correctly. CONCLUSION: Distress is a patient rather than a disease phenomenon. A simple, easy to administer self-report questionnaire can be used to classify patients according to their level of distress. The resulting index, the RDI. accurately identifies distressed and non-distressed patients. Such an index should be useful for patient care and research.     

A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia

PURPOSE: To assess the efficacy of fluoxetine in the treatment of patients with fibromyalgia. SUBJECTS AND METHODS: Sixty outpatients (all women, aged 21-71 years) with fibromyalgia were randomly assigned to receive fluoxetine (10-80 mg/d) or placebo for 12 weeks in a double-blind, parallel-group, flexible-dose study. The primary outcome measures were the Fibromyalgia Impact Questionnaire total score (score range, 0 [no impact] to 80) and pain score (score range, 0-10). Secondary measures included the McGill Pain Questionnaire, change in the number of tender points, and total myalgic score. RESULTS: In the intent-to-treat analysis, women who received fluoxetine (mean [+/- SD] dose, 45 +/- 25 mg/d) had significant (P = 0.005) improvement in the Fibromyalgia Impact Questionnaire total score compared with those who received placebo, with a difference of -12 (95% confidence interval [CI]: -19 to -4). They also had significant (P = 0.002) improvement in the Fibromyalgia Impact Questionnaire pain score (difference, -2.2 [95% CI: -3.6 to -0.9]), as well as in the Fibromyalgia Impact Questionnaire fatigue (P = 0.05) and depression (P = 0.01) scores and the McGill Pain Questionnaire (P = 0.01), when compared with subjects who received placebo. Although counts for the number of tender points and total myalgic scores improved more in the fluoxetine group than in the placebo group, these differences were not statistically significant. CONCLUSIONS: In a 12-week, flexible-dose, placebo-controlled trial, fluoxetine was found to be effective on most outcome measures and generally well tolerated in women with fibromyalgia.     

Spouse-assisted coping skills training in the management of osteoarthritic knee pain

Objective . To evaluate the effects of a spouse-assisted pain-coping skills training intervention on pain, psychological disability, physical disability, pain-coping, and pain behavior in patients with osteoarthritis (OA) of the knees. Methods. Eighty-eight OA patients with persistent knee pain were randomly assigned to 1 of 3 conditions: 1) spouse-assisted pain-coping skills training, (spouse-assisted CST), 2) a conventional CST intervention with no spouse involvement (CST), or 3) an arthritis education-spousal support (AE-SS) control condition. All treatment was carried out in 10 weekly, 2-hour group sessions. Results. Data analysis revealed that at the completion of treatment, patients in the spouse-assisted CST condition had significantly lower levels of pain, psychological disability, and pain behavior, and higher scores on measures of coping attempts, marital adjustment, and self-efficacy than patients in the AE-SS control condition. Compared to patients in the AE-SS control condition, patients who received CST without spouse involvement had significantly higher post-treat- ment levels of self-efficacy and marital adjustment and showed a tendency toward lower levels of pain and psychological disability and higher scores on measures of coping attempts and ratings of the perceived effectiveness of pain-coping strategies. Conclusion. These findings suggest that spouse-assisted CST has potential as a method for reducing pain and disability in OA patients.     

Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study

OBJECTIVE: To evaluate the effects of 6 months of pool exercise combined with a 6 session education program for patients with fibromyalgia syndrome (FM). METHODS: The study population comprised 58 patients, randomized to a treatment or a control group. Patients were instructed to match the pool exercises to their threshold of pain and fatigue. The education focused on strategies for coping with symptoms and encouragement of physical activity. The primary outcome measurements were the total score of the Fibromyalgia Impact Questionnaire (FIQ) and the 6 min walk test, recorded at study start and after 6 mo. Several other tests and instruments assessing functional limitations, severity of symptoms, disabilities, and quality of life were also applied. RESULTS: Significant differences between the treatment group and the control group were found for the FIQ total score (p = 0.017) and the 6 min walk test (p < 0.0001). Significant differences were also found for physical function, grip strength, pain severity, social functioning, psychological distress, and quality of life. CONCLUSION: The results suggest that a 6 month program of exercises in a temperate pool combined with education will improve the consequences of FM.     

Development of an observation method for assessing pain behaviors in children with juvenile rheumatoid arthritis

Objective. To develop an observation method for assessing pain behaviors in children with juvenile rheumatoid arthritis (JRA). Methods. Thirty children with JRA performed a standardized sequence of activities for video recording, and correlations between the pain behaviors observed on the videotapes and established measures of pain, depression, and functional disability were determined. Results. Pain behaviors were reliably observed (kappa coefficients 0.53-0.79). Total pain behaviors were significantly correlated with subjective reports of pain (r = 0.50) and disability levels (r = 0.64). These behaviors were not significantly associated with children's depression ratings (r = 23). Conclusion. The results indicate that the behavioral observation method provides a reliable and valid measure of pain associated with JRA. Measurement of pain behaviors may be especially useful in treatment outcome studies because these behaviors are relatively independent of depression.     

Pain, disability, and pain/disability relationships in seven rheumatic disorders: a study of 1,522 patients.

We studied the pain, Stanford Health Assessment Questionnaire functional disability, pain/disability ratio, and psychological scores in 1,522 patients with rheumatic disease with 7 distinct disorders. Individual differences between patients were more striking than differences among diagnostic groups. Patients with rheumatoid arthritis (RA) had the greatest disability, least pain, lowest pain/disability ratio, and least abnormal psychological scores. Highest pain and psychological distress was noted in low back pain, neck pain, and fibromyalgia (axial disorders). Disability in activities of daily living was as high in fibromyalgia as in RA, but low in axial skeletal disorders. There appears to be a continuum for disability that begins with axial but not articular disease (neck and back pain) and ends with multiple articular and periarticular involvement (RA and fibromyalgia).