Arthritis injectable gold.Besides medical treatments there are some physical

is a broad term that covers a group of over 100 diseases. It has everything to
do with our joints-the places where bones connect such as wrist, knees or
fingers. But some types of arthritis can also affect other connective tissues
and organs, including skin. There are different type of arthritis-Degenerative
arthritis, inflammatory arthritis, Infectious arthritis and metabolic
arthritis. Rheumatoid arthritis is an example of inflammatory arthritis.Rheumatoid arthritis is a chronic inflammatory
disease that causes significant pain and daily dysfunction (Mulligan &
Newman, 2007).The word arthritis means inflammation of joint (“artho” meaning
joint and “itis” meaning inflammation). RA is an autoimmune disease, causes
pain, swelling and stiffness. If one knee or hand has RA, usually the other
does too. Although its cause is still unknown, but it is believed to be the
result of a malfunctioning immune system. The symptoms and progression of RA
vary widely from person to person. RA affects women two to three times more
often than men. The disease strikes all ages, but the first signs are
predominately observed between the ages of 20 and 50 years. The male – female
ratio is 1:3, respectively (Anderson, Bradley, Young & Mc Daniel; 1985). There is no cure for RA, but medical treatments are useful for reducing
pain at a normal level. Medical treatment is aimed at the reduction of symptoms
by 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 treatments
there are some physical exercise, yoga, aerobics, imagery therapy, cognitive
behaviour therapy type therapies, which together enhance the functional ability
as well as their quality of life, well- being, physical and mental health also.RA affects cognitive functioningCognition
involved various complex mental processing which include attention (mentally
focusing on some stimulus); perception (interpreting sensory information to
yield meaningful information); memory  (the
storage and retrieval processes of cognition) and so on. Researchers have found
that various cognitive aspects are affected in arthritis group. Cognitive
impairment is described as when a person has trouble in remembering, learning
new things, problem-solving, concentrating or making decisions that affects
their everyday life. It ranges from mild to severe. Attentional functioning
involves a complex cognitive function and attentional control, which is
essential for human behaviour. It is a selection process of internal and
external 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 cognitive
dysfunction was common in RA patients with prevalence rates ranging from 38%
(divided /sustained attention and mental flexibility) to 71% (visuo – spatial
and planning functions). Dick, Eccleston and Crombez (2002) have worked on
attentional functioning in RA and its comparison with FM and musculoskeletal
(MSK) pain patients and revealed that all 3 groups of chronic pain patients had
impaired cognitive functioning on an ecological sensitive neuropsychological
test of everyday attention. This study supports previous findings by reporting
that many chronic pain patients have significant attentional dysfunction. In
this study, they found that FM patients showed a significantly higher level of
anxiety than the other 3 groups, but this study did not reveal that FM patients
had more severe attentional problems than other chronic pain patients.
Furthermore, FM patients did not show poorer performance than patients with RA
or MSK in any of the investigated domains of attentional and cognitive
functioning. There are some contrast studies on FM patients that attentional
deficits were found in FM patients compared with healthy controls on 2
standardized attention tests (Sletvold et. al.; 1995). Grace et. al. (1999)
also reported that compared with matched healthy controls, FM patients showed
significant attentional and memory deficits on a neuropsychological test
battery.Dick and Rashiq (2007) worked on disruption of
attention and memory accompanied by chronic pain and found that 2/3 of
participants with chronic pain had found impaired on attentional task and they
had significantly greater difficulties in maintaining a memory trace during a
challenging test of working memory.This disruption was not found to be
associated with sleep problems, psychological distress or age. This study also
suggests that cognitive function was not improved by short-term local
analgesia.Abeare et. al. (2010) also confirmed the negative
association between pain and performance on task requiring selective attention,
inhibition and working memory. In detailed, according to their result pain was
inversely related to executive functioning tasks, with higher pain levels
associated with poorer performance on executive functioning tasks. This
relationship was not moderated or mediated by negative affect; however positive
affect moderated the relationship between pain and executive functioning. For
patients high in positive affect there was a significant inverse relationship
between pain and executive functioning, whereas there was no such relationship
for patients low in positive affect. But this negative affect was not a
predictor of cognitive performance (Brown et. al., 2002).Melo and Silva
studied on 3 groups rheumatoid
arthritis (RA), fibromyalgia (FM), systemic lupus erythematasus (SLE) to assess
the possible existence of cognitive disorder associated with these disease and
finally found that FM and SLE group showed significantly higher means of the
neuropsychiatric symptoms of anxiety, irritability and hallucinations than the
RA group in the neuropsychiatric inventory. In this study, young adults
performed better in all tests as compared with the elderly. This study showed a
reduced cognitive performance mainly in the operational memory sphere in the
low 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 (global
attention/working memory, language, visual and verbal memory, visuo-spatial
process and executive function) among them. Result showed that FM and RA
patients performed poorly on most cognitive measurements compared with healthy
controls and much similar to each other in performance. Comparison of patients
with FM and RA revealed no significant differences except for the executive
functions. Cognitive symptoms may be exacerbated by the presence of fatigue,
sleep problems, and pain, but the relationship of these factors to cognitive
problems in FM patients is unclear.There is another study on FM patients of
Katz, Heart, Mills & Leavitt; 2004 and Glass, Park & Minear; 2005).
According to them, memory impairment, poor concentration and difficulty in
performing mental tasks are frequent complaints in patient with FM. This
condition is so – called affected in “fibro-fog”.   Recent study of Gunnarsson,
Grahn and Agerstrom (2016) worked with 3 group as acute pain, regularly
recurrent pain and persistent pain to assess three cognitive function
(sustained attention, cognitive control and psychomotor ability). Result
indicated that patients with persistent pain showed significantly worse on
sustained attention and psychomotor ability compared with healthy controls. The
acute pain group showed a significant decrement in psychomotor ability and
regularly current pain group showed decrement in sustained attention. Age and
education level did not have any significant relation to the performance on
sustained attention. But age and education level were significantly related to
the performance on cognitive control and psychomotor ability. Patients with RA
or in other chronic pain disease, cognitive functioning is related to physical
functioning. Because it is assumed that cognitive impairment leads to decrease
performance in physical activity and other executive functioning. Simos (2016) worked on RA using
neuropsychological tests battery (for assessment of long-term verbal episodic
memory, verbal fluency, processing speed and set- shifting ability) and found
that 20% of RA patients were cognitively impaired.In a study, low cognitive function was significantly associated with the
subsequent loss of physical function in daily activities. It is also found a
significant relationship between cognitive function and functional limitation
in older adults (Greiner, Snowdon and Schmitt; 1996 and Wong, Van Belle and
Larson; 2002). Shin, Julian and Katz (2013) also investigated the relationship between
cognitive function and physical function in RA, using 12 standardized
neuropsychological measures and revealed that cognitive impairment was significantly
associated with greater functional limitations in patients with RA and
suggesting that cognitive impairment play a role in poor functional status in
RA and this decrement was associated with performance- based and self reported
measures. Cognitive difficulties in RA may have enough impact
on daily functioning treatment management and adaption to illness (Dunlop 2005; Shin, Julian & Katz, 2013). Above studies have shown that Rheumatoid Arthritis
is a disease having pain and physical symptoms but there is an psychological
aspects regarding this disease. Not only Rheumatoid Arthritis but also other
types of arthritis have their psychological consideration. Thus, Cognitive
processing is also affected in this disease.Factors
affecting of cognitive functioning in Rheumatoid Arthritis

Various factors are responsible for impairment in
cognitive functioning. Previous research has professed that chronic pain in
arthritis disrupts attention and that this break-down can lead to significant
functional impairment and decreased quality of life. Prevalence studies
indicate that as much as 44% of the population experience pain on a regular
basis and that in one-quarter of this group the pain is severe (Birse and
Lander; 1998 and Smith et. al. 2001). Patients with chronic pain experience disruption
of attention and memory (Jamison, Sbrocco and Parris; 1998 and Hart, Martelli
and Zasler; 2000). Chronic pain affects the ability to work, sleep and daily
life activities and these changes generally worsen over time. Although it is
clear that many individuals who suffers from chronic pain experience
attentional and other deficits, the cognitive mechanism that are affected by
chronic pain are not clear.

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Pain serves as a warning of actual
or potential harm. It is a negative indication. (Eccleston and Crombez, 1999). Closer
inspection of the influence of pain on attention indicates variable effects.
Individual differences are likely to account for some of the variability in
pain interference (e.g., age, sex, personality). In addition, features of the
stimulus (e.g., novelty), as well as top-down factors (e.g., motivation, threat
value), play a role (Legrain, Van, Eccleston, Davis, Seminowicz et. al.). Another
consideration is that attention is a compound term for a range of processes and
the effect of pain might be selective (Moore, Keogh, Eccleston, 2012, 2013;
Legrain, Crombez and Mouraux, 2011; Verhoeven, Van, Eccleston, Van, Legrain et.
al., 2011).

Eccleston and Crombez (1999) documented that patient
with chronic pain who reported higher levels of both pain and somatic awareness
showed significant performance decrements on an attentionally demanding
switching task compared with other chronic pain patients.

Pain has a cognitive component:
evaluation of the intensity and other qualities of the pain requires attention
be turned to the pain, and because of the biological importance of nociceptive
pain, pain demands attention. Pain is inherently salient and such demands
attention (Eccleston and Crombez 1999). The mechanism underlying the
interaction between pain and attention/cognitive function is not understood but
likely involves some common cortical elements because pain involves similar
attentional resources as other cognitive processes.

Drugs, which is used for treating pain in RA has
also their effect on cognition. Such as Corticosteroid responsible for their
effects on cognitive abilities, like memory (Wolkowitz et. al., 1990; Shin et.
al., 2012). Wolkowitz et. al. also found that even a single dose (1 mg dose of
dexamethosone)  or short – term use of
corticosteroids ( 80 mg dose of prednisone for 5 days ) was significantly
related to memory problems.

There are number of studies which support the factors
or predictors of cognitive impairment in RA, like depression is commonly
observed as a risk factor for cognitive decline in other population ( Chodosh ,
Kado, Seeman & Karlamangla; 2007 ) but did not emerge as a significant
predictor in Shin’s study. Martelli,; 2003). Disease symptoms such as chronic
pain and psychological distress have been linked to cognitive impairment (Hart,
Wade and Martelli; 2003). Shin found possible predictors through their
study that person with lower education, lower income, oral glucocorticoid use,
and increased (cardiovascular disease) CVD risk factors were more likely to be
cognitively impaired. Demographic factors, medical comorbities and steroid
treatment were identified in studies as potential risk factors for cognitive
dysfunction. Brown, Glass and Park (2002) documented negative impact of pain on
measures of processing speed, reasoning, working memory and verbal episodic
memory, which were largely mediated by depressive symptomatology. A 2010 study
in the clinical journal of pain found that people with RA who were in a lot of
pain scored poorly on the tests of planning, decision- making and working

The relationship between pain,
general cognitive functioning and depression has been examined in RA patients,
particularly with the goal of examining the potential mediating role of
depression in the relationship between pain and cognitive functioning. Brown,
Glass and Park (2002) found that pain was positively related to depression and
negatively related to cognitive functioning, and that depression mediated the
relationship between pain and cognitive functioning, suggesting that pain leads
to depression which leads to poorer cognitive functioning. Many studies have
reported that executive and attentional functions are affected in chronic pain
patients, presumably as a result of competing attentional demands of chronic
pain (Moriarty, McGuire and Finn, 2011; Eccleston, 1995; Grisart and Plaghki,

RA can be accompanied by cognitive dysfunction yet
there is very limited literature on their dynamics. To assess the cognitive
impairment, Deficits have been noted on short – term memory, visuospatial
processing, episodic memory and executive tasks (Appenzeller, Bertolo &
Castallat, 2004; Bartolini et. al., 2002). Shin, Katz, Wallhagen & Julian
(2012) also have worked on the same topic and revealed that proportion of
persons who were classified as cognitively impaired on each test ranged from
8-29%.More than 20% of subjects were found to be cognitively impaired in executive
function (28% on the design fluency test and 21% on the trail making test).29%
and 18% of subjects were cognitively impaired in visuo- spatial learning and
verbal learning/memory, respectively. These deficits are because of lower
levels of socioeconomic status (e.g. education and income), So it is well known
risk factors for poorer performance on cognitive tasks in individuals with or
without multiple chronic problems (Lynch, Kaplan and Shema, 1997; Cogney and
Lauderdale, 2002).

There are number of factors for cognitive decline in
RA and have some mechanism involve in it. Studies show that mechanism of
systemic inflammation and cardiovascular disease (CVD) are linked with this
type of impairment in general population and have a particular relevance for
RA. In addition, the influence of glucocorticoid use and CVD may be
interconnected, with some studies suggesting that glucocorticoid use may also
confer a direct risk for CVD in RA (Mazzantini et. al.;2010 & Ponoulas et.
al,; 2008).

The mechanism for the decline in
attention and executive function in chronic pain patients remain largely
unclear. Several different hypotheses have been postulated to explain reduced
cognitive, and in particular attentional, functions in chronic pain patients.
It has been argued that patients have an attentional bias toward painful
sensation which may cause distraction from other stimuli. The experience of
pain may reduce the capacity to attend to another stimulus because it captures
attentional resources itself. In this perspective, it is expected that with
increasing task demands cognitive task performance decreases disproportionally
in chronic pain patients. Studies report the brain regions affected in cognitive impairment. Brain
areas such as the prefrontal cortex, the anterior cingulate cortex, and the
secondary somatosensory cortex have been implicated in pain status and play a
crucial role in controlled/higher-order cognitive processing involving
attention, cognitive control, and certain psychomotor abilities (Chen,
Babiloni, Ferreti et. al.; 2008 and Babiloni, Vecchio, Bares et. al.; 2008).

Attention is the process of selecting stimuli for active processing relating
to specific aspects of the physical environment (e.g. objects) or ideas that
stand in memory (Raz, 2004). Earlier research found
that people with RA had more trouble on tests of memory, speaking ability, and
attention than people who didn’t have RA. More recent theories suggest that attention is a
system of anomalous networks including alerting, orienting and selection (Fan 2002).

Thus, pain being central to
arthritis plays a crucial role among arthritis patients during their cognitive
performances. Several cognitive functions like selective and sustained
attention, executive functioning, visuospatial memory, set shifting ability are
found to be impaired among arthritis patients and its various types. A wide
range of studies revealed that arthritis pain affect various dimensions of
cognitive functioning in the patients.

So, through literature review, it has been clearly identified that
Rheumatoid Arthritis patients get affected on various aspects of cognitive
functioning and pain is a major factor involved in the decrement of
performance. There are varied factors that affect the functioning. Thus, the
primary aim of this review is to explore how pain and others factors affects
the performances of RA patients on various tasks related to cognitive
functioning. This work will provide a beneficial psychological outlook for the
RA patients in clinical setting.


Increasing pain severity has been previously found to be associated with
decreased cognitive task performance (Eccleston, 1995; Weiner, Ruddy, Morrow,
Slaboda and Lieber, 2006; Oosterman, Derksen, Van, Veldhuijzen and Kessels,

On the
basis of previous studies, it has been observed that cognitive functioning of
Rheumatoid Arthritis patients got affected by rheumatoid arthritis induced
pain. Moreover, these findings were only reported on executive functioning of
various types of arthritis patients.

the attention and executive function domains cover multiple aspects of
cognition, some of which were not addressed in the previous studies. For
example, working memory and set shifting have also been denoted as aspects of
executive function (Lezak, Howieson and Loring, 2004), while differentiation
among alerting, orienting and executive function of attentional network system
remains unclear.Therefore, this differential understanding of alerting,
orienting and executive functioning stands as area of future researches and
also for the better understanding of the effects of pain on others subcomponent
of attention in individuals suffering from Rheumatoid Arthritis.