**1. Introduction**

A 2015 research report stated that 90% of the global burden of disease lies in Low- and Mid- Income Countries [1]. A different report in the same year stated that over 24% of global disease burden lies in Africa, has access to only 3% health workers and less than 1% of the world's financial resources [2–4]. Healthcare system in Africa has estimated medical personnel (physician) to patient ratio of 2.7:10,000 compared to 5.9 South East Asia, 12.7 Eastern Mediterranean, 15.5 Western Pacific, 21.5 Americas, and 32.1 European region [3]. Generally, Africa is heavily burdened by non-infectious diseases and health conditions (e.g., diabetes, cancer, cardiovascular disease, pregnancy and childbirth related problems, musculoskeletal diseases, road accidents, etc.) and these are also the major causes of mortality and disability in the African population [3, 5–7]. Arthritis belongs to this category and is a major reason for adult disability in the continent. Rheumatoid arthritis was reported to

have worldwide prevalence of 1%, while between 1990 and 2010 prevalence in Africa seem to have increased from 0.36 to 0.42% [8]. In a more recent review, the prevalence of Rheumatoid arthritis was recorded as follows: 0.40% in South Asia, 0.37% in Eastern Mediterranean, 0.62% in Europe, 1.25% in America and 0.42% in Western Pacific, no information was provided on the African burden of Rheumatoid arthritis [7]. However, a study reported a 0.13% prevalence of Rheumatoid Arthritis in urban Barika Algeria, North Africa in 2013 with an estimated 0.15% prevalence for the general population [9].

Major challenges to arthritis management in Africa include the fact that its' economic/health import is downplayed in favor of communicable or infectious diseases. Consequently, research in this area is minimal with small sample population & clinic-based studies that are not representative of the true situation of arthritis disease (prevalence, treatment burden and resulting disability) in the African population. Also, little is known about causes and types of arthritis disease; and the psychosocial challenges patients face especially with regards to gender, ethnic or tribal dichotomies in the continent. However, these issues are beyond the scope of this chapter. This paper is focused on providing information about the state of psychological interventions in the management of arthritis pain in Africa and what can be done to improve the situation so as to offer more effective pain management protocols to arthritis patients. This review covers the use of psychological interventions in arthritis treatment in general drawing from clinical practices and studies conducted across gender and outside Africa.

#### **2. Arthritis disease: Types, symptoms and prevalence**

Arthritis is widely recognized as a leading cause of pain and disability among the aged (adults 50 years and above) across the globe. Its burden is well noted in developed nations like the United States and measures are taken to care for sufferers. The case is different in African countries, starting with under-diagnosis due to little or no presentation of cases at orthodox hospitals, misconceptions about the disease, poverty, expensive (unaffordable) medical care, inadequate medical facility and distractions by heavy burden of infectious diseases in the health sectors, as such little attention is given to arthritis disease in these countries. South Africa with on 85 rheumatologists is reported to have the largest number of rheumatologists in Africa [3].

Arthritic disease has been described as a chronic inflammatory disorder that affects joints of the body [10]. It has painful, debilitating and detrimental [5, 11] effects on the health and well-being of those affected. While it is assumed to be more common among the elderly (65+ years), it afflicts people of all age brackets including children, male and female alike. Over a hundred type of arthritis have been recorded [11, 12] overtime and across the globe. Studies in Africa have noted the existence of seven types of arthritis- 1) Rheumatoid arthritis 2) Osteoarthritis (Mseleni Joint Disease) 3) Ankylosing Spondylitis 4) juvenile idiopathic arthritis 5) juvenile chronic arthritis 6) psoriatic arthritis 7) Gout 8) Osteoarthritis. Literature showed that most studies on arthritis were conducted with non-African populations. Majority of the studies conducted in African Nations were centered on Rheumatoid Arthritis (RA) a few on osteo arthritis. Some meta-analytic reviews were on the prevalence of various types of arthritis in Africa. Both genetic and environment have been reported to contribute to the onset or arthritic conditions (e.g. aging, obesity, injury). The arthritis conditions identified among Africans will be briefly discussed.

*Rheumatoid Arthritis (RA):* RA is described as an autoimmune disease in which the immune system attacks the lining of joints and connected tissues [8, 7] causing

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in Cameroun.

*Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa*

inflammation of small joints of the hand, wrist, knee and feet. It is a chronic condition that if left untreated leads to extensive erosion on cartilage causing deformity and disability [13]. Its symptoms include daily pain, morning stiffness, fatigue, swelling of joints, generalized weakness, loss of weight, and low-grade fever. This is the most studied arthritic condition in Africa [6]. Generally, RA is reported to have 1–2% prevalence in western world and 1% worldwide [14]. Another report showed an increasing incidence of RA across African Nations including Uganda, Kenya, Nigeria and South Africa [6]. Report reveals a prevalence rate range of 0.1% to 2.5% in various urban and rural settings of Democratic Republic of the Congo (DRC), Lesotho and South Africa [10]. RA is most prevalent in South Africa with a prevalence ratio of 2:3 for men to women [8]. The report on Nigeria and Liberia with the next highest occurrences of RA showed greater incidence in men with a prevalence range of 3:1 for men to women. However, two studies that used the American College of Rheumatology (ACR) 1987 rheumatic arthritis criteria for diagnosis

*Osteoarthritis* (OA): Osteoarthritis occurs among older people of 65+ years. It is

*Degenerative joint disease that can affect any bodily joint but typically affects the hands, hips, kneel and spine. OA causes degradation of articular cartilage overtime resulting in bones rubbing up against one another leading to pain, joint swelling,* 

It has also been affirmed that the degenerative nature of osteoarthritis affects cartilage and its surrounding tissues, remodels the subarticular bone, causes osteophyte formation, ligamentous laxity, weakening of particular muscles and at times synovial inflammation [13]. Mseleni Joint Disease is a type of osteoarthritis common among people in Northern Kwazulu Natal province of South Africa and locally known as unyonga, meaning a disease of the joints [15]. It affects large joints in mid childhood. Some symptoms include joint pain, morning stiffness and stiffness on resumption of activity, limited mobility, bone enlargement, joint instability and severe physical disability. OA disease progresses slowly, and knee OA is reported as the most prevalent compared to hand and hip OA. People who are above age 50, obese, inactive, who smoke and who have joint injury are at greater risk of developing OA. The incidence of OA increases with age and it is reported more in women than males aged over 50 years. Osteoarthritis is recorded as the most prevalent form of arthritis in Africa with a prevalence range of 55.1% to 82.7% in urban and rural South Africa respectively [10]. However, it is not as extensively studied as RA. *Juvenile Arthritis:* This includes Juvenile Idiopathic Arthritis (JIA) and Juvenile Chronic Arthritis (JCA) among others that afflict children of 15 years and younger. Juvenile arthritis is a progressive inflammatory autoimmune disease that may affect multiple joints (e.g., knee, hand, elbow, ankle, wrists, etc.) in the body by the time the child becomes an adult resulting in restricted mobility [12]. The symptoms include swelling, joint pains and stiffness. JIA is reported as the most prevalent arthritis in this class [10]. Reported records of the prevalence of JIA among African children (10–15 years) are as follows: 0.003–0.33% prevalence in Egypt and 00.1%

*Psoriatic Arthritis*: It is described as a chronic inflammatory join disease with negative test for rheumatoid factors and cutaneous psoriasis [16]. The symptoms include morning stiffness, joint pain, skin flaking, intermittent swelling, fatigue and itching. This type of arthritis has also been noted to be incident in Africa with a 4.4% prevalence rate in urban South Africa, 1% & 0.1% in Uganda and Cameroun

respectively. In Africa records of its incidence is linked to HIV infection.

*DOI: http://dx.doi.org/10.5772/intechopen.93633*

found no incidence of RA in Botswana and Nigeria.

*tenderness and limited mobility ([12], p. 5-6).*

described as a

*Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa DOI: http://dx.doi.org/10.5772/intechopen.93633*

inflammation of small joints of the hand, wrist, knee and feet. It is a chronic condition that if left untreated leads to extensive erosion on cartilage causing deformity and disability [13]. Its symptoms include daily pain, morning stiffness, fatigue, swelling of joints, generalized weakness, loss of weight, and low-grade fever. This is the most studied arthritic condition in Africa [6]. Generally, RA is reported to have 1–2% prevalence in western world and 1% worldwide [14]. Another report showed an increasing incidence of RA across African Nations including Uganda, Kenya, Nigeria and South Africa [6]. Report reveals a prevalence rate range of 0.1% to 2.5% in various urban and rural settings of Democratic Republic of the Congo (DRC), Lesotho and South Africa [10]. RA is most prevalent in South Africa with a prevalence ratio of 2:3 for men to women [8]. The report on Nigeria and Liberia with the next highest occurrences of RA showed greater incidence in men with a prevalence range of 3:1 for men to women. However, two studies that used the American College of Rheumatology (ACR) 1987 rheumatic arthritis criteria for diagnosis found no incidence of RA in Botswana and Nigeria.

*Osteoarthritis* (OA): Osteoarthritis occurs among older people of 65+ years. It is described as a

*Degenerative joint disease that can affect any bodily joint but typically affects the hands, hips, kneel and spine. OA causes degradation of articular cartilage overtime resulting in bones rubbing up against one another leading to pain, joint swelling, tenderness and limited mobility ([12], p. 5-6).*

It has also been affirmed that the degenerative nature of osteoarthritis affects cartilage and its surrounding tissues, remodels the subarticular bone, causes osteophyte formation, ligamentous laxity, weakening of particular muscles and at times synovial inflammation [13]. Mseleni Joint Disease is a type of osteoarthritis common among people in Northern Kwazulu Natal province of South Africa and locally known as unyonga, meaning a disease of the joints [15]. It affects large joints in mid childhood. Some symptoms include joint pain, morning stiffness and stiffness on resumption of activity, limited mobility, bone enlargement, joint instability and severe physical disability. OA disease progresses slowly, and knee OA is reported as the most prevalent compared to hand and hip OA. People who are above age 50, obese, inactive, who smoke and who have joint injury are at greater risk of developing OA. The incidence of OA increases with age and it is reported more in women than males aged over 50 years. Osteoarthritis is recorded as the most prevalent form of arthritis in Africa with a prevalence range of 55.1% to 82.7% in urban and rural South Africa respectively [10]. However, it is not as extensively studied as RA.

*Juvenile Arthritis:* This includes Juvenile Idiopathic Arthritis (JIA) and Juvenile Chronic Arthritis (JCA) among others that afflict children of 15 years and younger. Juvenile arthritis is a progressive inflammatory autoimmune disease that may affect multiple joints (e.g., knee, hand, elbow, ankle, wrists, etc.) in the body by the time the child becomes an adult resulting in restricted mobility [12]. The symptoms include swelling, joint pains and stiffness. JIA is reported as the most prevalent arthritis in this class [10]. Reported records of the prevalence of JIA among African children (10–15 years) are as follows: 0.003–0.33% prevalence in Egypt and 00.1% in Cameroun.

*Psoriatic Arthritis*: It is described as a chronic inflammatory join disease with negative test for rheumatoid factors and cutaneous psoriasis [16]. The symptoms include morning stiffness, joint pain, skin flaking, intermittent swelling, fatigue and itching. This type of arthritis has also been noted to be incident in Africa with a 4.4% prevalence rate in urban South Africa, 1% & 0.1% in Uganda and Cameroun respectively. In Africa records of its incidence is linked to HIV infection.

*Pain Management - Practices, Novel Therapies and Bioactives*

estimated 0.15% prevalence for the general population [9].

conducted across gender and outside Africa.

**2. Arthritis disease: Types, symptoms and prevalence**

have worldwide prevalence of 1%, while between 1990 and 2010 prevalence in Africa seem to have increased from 0.36 to 0.42% [8]. In a more recent review, the prevalence of Rheumatoid arthritis was recorded as follows: 0.40% in South Asia, 0.37% in Eastern Mediterranean, 0.62% in Europe, 1.25% in America and 0.42% in Western Pacific, no information was provided on the African burden of Rheumatoid arthritis [7]. However, a study reported a 0.13% prevalence of Rheumatoid Arthritis in urban Barika Algeria, North Africa in 2013 with an

Major challenges to arthritis management in Africa include the fact that its' economic/health import is downplayed in favor of communicable or infectious diseases. Consequently, research in this area is minimal with small sample population & clinic-based studies that are not representative of the true situation of arthritis disease (prevalence, treatment burden and resulting disability) in the African population. Also, little is known about causes and types of arthritis disease; and the psychosocial challenges patients face especially with regards to gender, ethnic or tribal dichotomies in the continent. However, these issues are beyond the scope of this chapter. This paper is focused on providing information about the state of psychological interventions in the management of arthritis pain in Africa and what can be done to improve the situation so as to offer more effective pain management protocols to arthritis patients. This review covers the use of psychological interventions in arthritis treatment in general drawing from clinical practices and studies

Arthritis is widely recognized as a leading cause of pain and disability among the aged (adults 50 years and above) across the globe. Its burden is well noted in developed nations like the United States and measures are taken to care for sufferers. The case is different in African countries, starting with under-diagnosis due to little or no presentation of cases at orthodox hospitals, misconceptions about the disease, poverty, expensive (unaffordable) medical care, inadequate medical facility and distractions by heavy burden of infectious diseases in the health sectors, as such little attention is given to arthritis disease in these countries. South Africa with on 85 rheumatologists is reported to have the largest number of rheumatologists in

Arthritic disease has been described as a chronic inflammatory disorder that affects joints of the body [10]. It has painful, debilitating and detrimental [5, 11] effects on the health and well-being of those affected. While it is assumed to be more common among the elderly (65+ years), it afflicts people of all age brackets including children, male and female alike. Over a hundred type of arthritis have been recorded [11, 12] overtime and across the globe. Studies in Africa have noted the existence of seven types of arthritis- 1) Rheumatoid arthritis 2) Osteoarthritis (Mseleni Joint Disease) 3) Ankylosing Spondylitis 4) juvenile idiopathic arthritis 5) juvenile chronic arthritis 6) psoriatic arthritis 7) Gout 8) Osteoarthritis. Literature showed that most studies on arthritis were conducted with non-African populations. Majority of the studies conducted in African Nations were centered on Rheumatoid Arthritis (RA) a few on osteo arthritis. Some meta-analytic reviews were on the prevalence of various types of arthritis in Africa. Both genetic and environment have been reported to contribute to the onset or arthritic conditions (e.g. aging, obesity, injury). The arthritis conditions identified among Africans will

*Rheumatoid Arthritis (RA):* RA is described as an autoimmune disease in which the immune system attacks the lining of joints and connected tissues [8, 7] causing

**70**

be briefly discussed.

Africa [3].

*Gout*: This particular type of arthritis is considered to have significant genetic underlining as it is found to run in families [12]. Its symptoms include acute joint pain, swelling in the knees, foot and big toe. It is more prevalent in males than females. The prevalence of gout is reported as 0.70% among white South African and 0.30% among HIV-infected population in Burkina Faso.

*Ankylosing Spondylitis*: It is a chronic, progressive arthritic condition that leads to severe disability. It occurs in early adulthood with symptoms like pain in the mid and lower back, heel, eyes, shoulder, ankle, and knee, reduced flexibility in the spine, sleep disorder, inflammatory bowel disease, and abnormal bone formation. Some occurrences of this type of arthritis are recorded in South Africa, Cameroun and Egypt [10, 17].

#### **2.1 Arthritis pain experience**

Pain often contributes to dramatic reduction in a patient's quality of life. Like every other pain, arthritis pain is multidimensional [18]. It has physical, social, psychological and economic dimensions and how each person perceives these dimensions influences their treatment outcome. Despite the obvious, treatment of pain and arthritis pain in particular is usually and largely based on the biomedical procedures like medication, surgery and physical therapy. Traditionally, arthritis disease known as a musculoskeletal disorder is classified as a biological and physiological condition. As such, its epidemiology, pathogenesis as well as treatment efforts have been majorly focused on and drawn from the biomedical field. This has largely served to under-prioritize the potential contributions of other approaches especially psychological approaches to the treatment and care of arthritis patients. It has also indirectly suppressed the understanding of pain, in this context arthritic pain, as a psychological experience with cognitive, emotional and behavioral components.

Pain is described as an unpleasant experience signaled by behavioral expressions such as crying, screaming, withdrawal, change in posture, gait or facial expression [19] which limits, hinders or alters the bearer's behavior. Pain was defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage [14]. The relationship between the incidence of pain and possible cell damage or existence of disease provides clear evidence or support for the biomedical understanding of pain. Nevertheless, this connection is not able to explain why two individuals with the same level of cell damage or disease activity would have varying degrees of pain. The biomedical perspective is considered as being weak due to its inability to explain the differentials in pain responses of patients with similar disease activity [20], neither is it able to address psychological factors in the experience of pain. Again, the biomedical drug treatment approach to the management of arthritis in Africa with recourse to non-pharmacological or surgical treatments may have increased the likelihood for self-medication among sufferers. This is most likely because of the problems of inaccessible, unavailable or expensive healthcare services in Africa (especially among rural women dwellers). A situation that may explain the seemingly low prevalence rates arthritis disease reported by studies originating from Africa. Therefore, the argument that pain sensation is not merely a biological process but mostly a psychological experience forms the basis for this call to fully adapt psychological techniques in the management of arthritis pain among Africans and all people in general. The importance of this call for the use of psychological techniques in the treatment of arthritis pain, relates to the bio-psychosocial model of [21] which postulated that no particular factor can account for health outcome. Rather, that health outcome depends on the synergistic and reciprocal interactions

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*Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa*

of various factors that relates to a patient's disease experience. In this paper, it is argued that because the perception of pain depends on a lot of factors including but not limited to age, sex, wellbeing, cognition, belief, learning, emotional stability, culture, economic status, etc., The insistence or rigidity that sustains the biomedical model of pain management has to be revaluated in light of new knowledge and best practices across the globe. When adopted, psychological methods [21–23], would

b.Improving patients' adherence to treatment protocols and life style changes

d.Addressing ethno-cultural factors contributing to illness experience and illness

e.Addressing issues of interpersonal relationship, communication, and social

f. Addressing gendered issues that may be hindering positive health outcome or

g.Assessing and treating pre- or co-morbid psychological problems like drug

There is a clear challenge of limited empirical studies on arthritis in Africa. A report [10] showed that between 1975 and 2014, about fifty studies relating to arthritis were published across Africa. However, none of those studies and none that was found in the course of writing this chapter were focused on African women or arthritis treatment. Instead, most were on prevalence and the remaining, either studied risk factors or are meta-analytic reviews of others. Meanwhile, information on women experience of arthritis pain and its treatment is lacking. Studies from other parts of the world including United States of America, United Kingdom and France point to the use of non-drug treatments in the management of arthritis pain. A meta-analytic study that assessed the efficacy of psychosocial interventions in the management of arthritic pain in the United States, reported that patients who received psychosocial interventions displayed significantly lower post-treatment anxiety, depression and psychological disability [23, 24]. Reported the use of non-pharmacological treatments as depending on disease progression, personality, environment and objectives of the patient [25]. Some identified non-pharmacological treatments include physiotherapy, balneotherapy, spa therapy, psychological

h.Teaching patients effective selfcare and pain management protocols.

interventions, therapeutic patient education, dietetics and acupuncture.

Attempts to explain pain and human experience of pain dates back to the time of Descartes in the 17th century, with pain described and understood as a sensory

**3. Psychological theories on pain and pain management**

misuse/abuse, depression, anxiety, sleep problems, etc.

*DOI: http://dx.doi.org/10.5772/intechopen.93633*

mostly enhance patients' health outcome by:

c.Improving level of acceptance of the illness

support relating to patient care.

hinder access to health services.

**2.2 Arthritis pain treatment options in Africa**

sustenance

a.Improving patients' understanding of perceived illness

#### *Review of Psychological Interventions in the Management of Arthritic Pain: The Case of Africa DOI: http://dx.doi.org/10.5772/intechopen.93633*

of various factors that relates to a patient's disease experience. In this paper, it is argued that because the perception of pain depends on a lot of factors including but not limited to age, sex, wellbeing, cognition, belief, learning, emotional stability, culture, economic status, etc., The insistence or rigidity that sustains the biomedical model of pain management has to be revaluated in light of new knowledge and best practices across the globe. When adopted, psychological methods [21–23], would mostly enhance patients' health outcome by:

