The relationship of self-reported pain and functional impairment to gait mechanics in overweight and obese persons with knee osteoarthritis.

OBJECTIVE: To examine the degree to which 2 commonly used measures of pain and disability, the Arthritis Impact Measurement Scales (AIMS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), relate to objective gait measurements. DESIGN: A descriptive study of the influence of self-reported pain and perceived functional impairment on gait mechanics in osteoarthritic adults. SETTING: A university clinical research laboratory. PARTICIPANTS: Overweight/obese adults with radiographic knee osteoarthritis (OA) as well as pain and disability associated with the disease (N=179). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The AIMS and WOMAC were administered to determine self-report measures of pain and disability. Speed, stride length, support time, knee angle, and peak vertical force (PVF) were determined from 3-dimensional kinematic and kinetic data collected on subjects walking at self-selected normal and fast speeds. Anthropometric data and radiographic levels of OA were also collected. RESULTS: Pearson correlation analysis showed that the AIMS physical disability score was inversely correlated with speed, stride length, and knee range of motion at both speeds and PVF at the fast speed. The WOMAC function score was inversely correlated with speed and stride length at both speeds and with PVF at fast speed. The WOMAC pain score was inversely correlated with speed and PVF at the fast speed. Regression analysis revealed that the AIMS physical disability score and body mass index accounted for the greatest variation in speed at the normal speed. Overall, AIMS physical disability and WOMAC function explained a larger proportion of variance in gait mechanics than radiographic measures of OA disease severity. CONCLUSIONS: Taken together, the results suggest that the AIMS physical disability and WOMAC function scores are associated with some important measures of gait impairment.

Self-Efficacy for Pain Communication Moderates the Relation Between Ambivalence Over Emotional Expression and Pain Catastrophizing Among Patients With Osteoarthritis.

Pain catastrophizing (ie, the tendency to focus on and magnify pain sensations and feel helpless in the face of pain) is one of the most important and consistent psychological predictors of the pain experience. The present study examined, in 60 patients with osteoarthritis pain who were married or partnered: 1) the degree to which ambivalence over emotional expression and negative network orientation were associated with pain catastrophizing, and 2) whether self-efficacy for pain communication moderated these relations. Hierarchical multiple linear regression analyses revealed a significant main effect for the association between ambivalence over emotional expression and pain catastrophizing; as ambivalence over emotional expression increased, the degree of pain catastrophizing increased. In addition, the interaction between ambivalence over emotional expression and self-efficacy for pain communication was significant, such that as self-efficacy for pain communication increased, the association between ambivalence over emotional expression and pain catastrophizing became weaker. Negative network orientation was not significantly associated with pain catastrophizing. Findings suggest that higher levels of self-efficacy for pain communication may help weaken the effects of ambivalence over emotional expression on pain catastrophizing. In light of these results, patients may benefit from interventions that target pain communication processes and emotion regulation. PERSPECTIVE: This article examines interpersonal processes involved in pain catastrophizing. This study has the potential to lead to better understanding of maladaptive pain coping strategies and possibly better prevention and treatment strategies.

A comparison of conventional pain coping skills training and pain coping skills training with a maintenance training component: a daily diary analysis of short- and long-term treatment effects.

UNLABELLED: Pain coping skills training (PCST) has been shown to produce immediate improvements in pain and disability in rheumatoid arthritis (RA). However, some patients have difficulty maintaining these gains. This study compared a conventional PCST protocol with a PCST protocol that included maintenance training (PCST/MT). Patients with RA (n = 167) were randomly assigned to either conventional PCST, PCST/MT, arthritis education control, or standard care control. Daily data were collected on joint pain, coping, coping efficacy, and mood. Multilevel analyses showed that at posttreatment, conventional PCST was superior to all other conditions in joint pain, coping efficacy, and negative mood, whereas PCST/MT was superior to all other conditions in emotion-focused coping and positive mood. At 18 months follow-up, both PCST conditions were superior to standard care in joint pain and coping efficacy. Interpretation of follow-up outcomes was limited by higher dropout rates in the 2 PCST groups. For RA, a maintenance training component does not appear to produce significant improvements over conventional PCST. PERSPECTIVE: This article reports a trial evaluating a conventional pain coping skills training protocol and a similar protocol that included a maintenance training component. Overall, results indicate similar results for both the conventional and the modified protocols.

Effects of a brief coping skills training intervention on nociceptive flexion reflex threshold in patients having osteoarthritic knee pain: a preliminary laboratory study of sex differences.

Studies have documented the efficacy of coping skills training (CST) for managing pain, distress, and disability in persons with arthritis. However, no laboratory studies have examined the effects of CST on descending modulation of nociception. This study used the nociceptive flexion reflex (NFR) to document pain and nociceptive responding among 62 men and women with osteoarthritis of the knee (mean age=63.3+/-7.5 years). Before and after a 45-minute CST session, participants completed laboratory assessments of NFR threshold and questionnaires evaluating pain and state anxiety. Results indicated significantly increased NFR thresholds and decreased pain ratings following CST for men and women. A significant time by sex interaction was observed for state anxiety, with women reporting greater decreases in anxiety following CST than men. This is the first study to demonstrate effects of a CST protocol on a measure of descending inhibition of nociception among patients with osteoarthritic knee pain.

Cognitive behavioral therapy for chronic pain is effective, but for whom?

Moderator analyses are reported for posttreatment outcomes in a large, randomized, controlled effectiveness trial for chronic pain for hip and knee osteoarthritis (N = 256). Pain Coping Skills Training, a form of cognitive behavioral therapy, was compared to usual care. Treatment was delivered by nurse practitioners in patients' community doctors' offices. Consistent with meta-analyses of pain cognitive behavioral therapy efficacy, treatment effects in this trial were significant for several primary and secondary outcomes, but tended to be small. This study was designed to examine differential response to treatment for patient subgroups to guide clinical decision-making for treatment. Based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified a priori as potential moderators. Trial outcome variables (N = 15) included pain, fatigue, self-efficacy, quality of life, catastrophizing, and use of pain medication. Results yielded 5 significant moderators for outcomes at posttreatment: pain coping style, patient expectation for treatment response, radiographically assessed disease severity, age, and education. Thus, sex, race/ethnicity, body mass index, and depression at baseline were not associated with level of treatment response. In contrast, patients with interpersonal problems associated with pain coping did not benefit much from the treatment. Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited. Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.

Automated Internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial.

Osteoarthritis (OA) places a significant burden on worldwide public health because of the large and growing number of people affected by OA and its associated pain and disability. Pain coping skills training (PCST) is an evidence-based intervention targeting OA pain and disability. To reduce barriers that currently limit access to PCST, we developed an 8-week, automated, Internet-based PCST program called PainCOACH and evaluated its potential efficacy and acceptability in a small-scale, 2-arm randomized controlled feasibility trial. Participants were 113 men and women with clinically confirmed hip or knee OA and associated pain. They were randomized to a group completing PainCOACH or an assessment-only control group. Osteoarthritis pain, pain-related interference with functioning, pain-related anxiety, self-efficacy for pain management, and positive and negative affect were measured before intervention, midway through the intervention, and after intervention. Findings indicated high acceptability and adherence: 91% of participants randomized to complete PainCOACH finished all 8 modules over 8 to 10 weeks. Linear mixed models showed that, after treatment, women who received the PainCOACH intervention reported significantly lower pain than that in women in the control group (Cohen d = 0.33). Intervention effects could not be tested in men because of their low pain and small sample size. Additionally, both men and women demonstrated increases in self-efficacy from baseline to after intervention compared with the control group (d = 0.43). Smaller effects were observed for pain-related anxiety (d = 0.20), pain-related interference with functioning (d = 0.13), negative affect (d = 0.10), and positive affect (d = 0.24). Findings underscore the value of continuing to develop an automated Internet-based approach to disseminate this empirically supported intervention.

Gender differences in patient-spouse interactions: a sequential analysis of behavioral interactions in patients having osteoarthritic knee pain.

Theory and research suggest that spousal responses to displays of pain behavior can vary markedly. To our knowledge, observational research on spousal responses to pain behavior has been carried out only in chronic low back pain patients, but not in other populations. In this study systematic observations were conducted of interactions occurring between 50 married osteoarthritis patients (25 male and 25 female) and their respective spouses. Observations were conducted as the patient and spouse performed three common household tasks: sweeping the floor, folding laundry, and carrying small, artificial logs from one side of the room to the other. Contrary to prior research on chronic low back pain this study found that in osteoarthritis patients spouse facilitative behavior preceded and followed patient pain behavior significantly more often than did spouse solicitous behavior. A gender difference in spousal responding to pain behavior also was observed in that wives were significantly more likely to show facilitative behavior preceding and following patient pain behavior than were husbands. The implications of these findings for future research and clinical interventions focused on patient-spouse interactions are discussed.

Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery.

This study used the Coping Strategies Questionnaire (CSQ) to investigate pain coping strategies in 52 rheumatoid arthritis patients who reported having knee pain 1 year or more following knee replacement surgery. Data analysis revealed that, as a group, these patients were active copers in that they reported frequent use of a variety of pain coping strategies. Pain coping strategies were found to be related to measures of pain and adjustment. Patients who rated their ability to control and decrease pain high and who rarely engaged in catastrophizing (i.e., who scored high on the Pain Control and Rational Thinking factor of the CSQ) had much lower levels of pain and psychological disability than patients who did not. Coping strategies were not found to relate to age, gender, obesity status or disability/compensation status. Taken together, these results suggest that an analysis of pain coping strategies may be helpful in understanding pain in arthritis patients who have pain following joint replacement surgery.

Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy.

The present study examined catastrophizing in rheumatoid arthritis (RA) patients. Subjects were 223 RA patients who were participants in a longitudinal study. Each patient completed the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ) on 2 occasions separated by 6 months (time 1, time 2). The Catastrophizing scale is designed to measure negative self-statements, castastrophizing thoughts and ideation (sample items = 'I worry all the time about whether it will end,' 'It is awful and I feel that it overwhelms me'). Data analysis revealed that the Catastrophizing scale was internally reliable (alpha = 0.91) and had high test-retest reliability (r = 0.81) over a 6 month period. Correlational analyses revealed that catastrophizing recorded at time 1 was related to pain intensity ratings, functional impairment on the Arthritis Impact Measurement scale (AIMS), and depression at time 2. Predictive findings regarding catastrophizing while modest were obtained after controlling for initial scores on the dependent variables, demographic variables (age, sex, socioeconomic status), duration of pain, and disability support status. Taken together, these findings suggest that catastrophizing is a maladaptive coping strategy in RA patients. Further research is needed to determine whether cognitive-behavioral interventions designed to decrease catastrophizing can reduce pain and improve the physical and psychological functioning of RA patients.

Understanding the adoption of arthritis self-management: stages of change profiles among arthritis patients.

Clinical observations and recent studies suggest that arthritis patients vary considerably in their involvement in self-management efforts. In the literature on health promotion, there is growing recognition that patients may be at different stages of change with respect to the adoption of self-management strategies. The major goal of the present study was to examine whether cluster analysis could be used to identify homogeneous subgroups of patients having persistent arthritis pain based on their responses to a stages of change questionnaire. Participants in this study (103 patients having rheumatoid arthritis and 74 patients having osteoarthritis) completed a stages-of-change measure specific to adoption of a self-management approach to their arthritis. A cluster analysis identified five distinct subgroups of arthritis patients: (1) precontemplation - 44% of the sample; (2) contemplation - 11% of the sample; (3) preparation - 22% of the sample; (4) unprepared action - 6% of the sample; and (5) prepared maintenance - 17% of the sample. These subgroups are generally consistent with what might be expected based on the transtheoretical model of stages of change by Prochaska and DiClemente (Prochaska JO, DiClemente CC. Towards a comprehensive, transtheoretical model of change: states of change and addictive behaviors. In: Miller WR, Heather N, editors. Applied clinical psychology, 2nd ed. Treating addictive behaviors, New York: Plenum Press, 1998. pp. 3-24.), and may have important clinical implications. For example, it is possible that the arthritis subgroups identified may predict arthritis patients' participation in and responsiveness to pain-coping skills training, exercise interventions, or other formal self-management training programs. Also, one may be able enhance the outcomes of self-management interventions for arthritis by tailoring treatment to the patient's particular stage.

The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing.

One hundred and sixty-eight patients with osteoarthritis (OA) of the knees participated in this study. Of the participants, 72 were men and 96 were women. All participants completed the Arthritis Impact Measurement Scales (AIMS), underwent a 10 min standardized observation session to assess their pain behavior, and completed the Catastrophizing Scale of the Coping Strategies Questionnaire (CSQ) and the Depression Scale of the Symptom Checklist 90 Revised (SCL-90R). The study found that there were significant differences in pain, pain behavior, and physical disability in men and women having OA. Women had significantly higher levels of pain and physical disability, and exhibited more pain behavior during an observation session than men. Further analyses revealed that catastrophizing mediated the relationship between gender and pain-related outcomes. Once catastrophizing was entered into the analyses, the previously significant effects of gender were no longer found. Interestingly, catastrophizing still mediated the gender-pain relationship even after controlling for depression. These findings underscore the importance of both gender and catastrophizing in understanding the OA pain experience and may have important implications for pain assessment and treatment.

Osteoarthritic knee pain: a behavioral analysis.

This study used behavioral assessment techniques to analyze pain in osteoarthritis (OA) patients. Eighty-seven OA patients having chronic knee pain served as subjects. Pain behavior was evaluated using a standard observation method and functional impairment was assessed using the Arthritis Impact Measurement Scales. Data analysis revealed that pain and limitations in physical activities were the most common functional impairments and that the most frequently observed pain behavior was guarded movement. Predictive analyses indicated that disability support status and scores on a Pain Control and Rational Thinking factor of the Coping Strategies Questionnaire (CSQ) were predictive of functional impairment. Patients receiving disability support payments were much more functionally limited than those not receiving this financial support. Patients scoring high on the Pain Control and Rational Thinking factor of the CSQ were much less functionally impaired, walked a 5 m course more rapidly and moved from a standing to a sitting or reclining position more quickly than patients scoring low on this factor. The implications of these results for behavioral treatment of OA knee pain are discussed.

Effects of spouse-assisted coping skills training and exercise training in patients with osteoarthritic knee pain: a randomized controlled study.

This study tested the separate and combined effects of spouse-assisted pain coping skills training (SA-CST) and exercise training (ET) in a sample of patients having persistent osteoarthritic knee pain. Seventy-two married osteoarthritis (OA) patients with persistent knee pain and their spouses were randomly assigned to: SA-CST alone, SA-CST plus ET, ET alone, or standard care (SC). Patients in SA-CST alone, together with their spouses, attended 12 weekly, 2-h group sessions for training in pain coping and couples skills. Patients in SA-CST + ET received spouse-assisted coping skills training and attended 12-weeks supervised ET. Patients in the ET alone condition received just an exercise program. Data analyses revealed: (1) physical fitness and strength: the SA-CST + ET and ET alone groups had significant improvements in physical fitness compared to SA-CST alone and patients in SA-CST + ET and ET alone had significant improvements in leg flexion and extension compared to SA-CST alone and SC, (2) pain coping: patients in SA-CST + ET and SA-CST alone groups had significant improvements in coping attempts compared to ET alone or SC and spouses in SA-CST + ET rated their partners as showing significant improvements in coping attempts compared to ET alone or SC, and (3) self-efficacy: patients in SA-CST + ET reported significant improvements in self-efficacy and their spouses rated them as showing significant improvements in self-efficacy compared to ET alone or SC. Patients receiving SA-CST + ET who showed increased self-efficacy were more likely to have improvements in psychological disability. An intervention that combines spouse-assisted coping skills training and exercise training can improve physical fitness, strength, pain coping, and self-efficacy in patients suffering from pain due to osteoarthritis.

Everyday life with osteoarthritis or rheumatoid arthritis: independent effects of disease and gender on daily pain, mood, and coping.

The effects of disease (form of arthritis) and gender on pain, mood, and pain coping strategies were examined in a prospective 30-day diary study of 71 patients with osteoarthritis (OA) and 76 with rheumatoid arthritis (RA). Diary instruments included joint pain ratings, POMS-B checklists for positive and negative mood, and the Daily Coping Inventory. Women's average daily pain was 72% greater than men's pain, and RA patients' average daily pain was 42% greater than OA patients' pain. Hierarchical Linear Models were estimated for (a) within-person associations between pain and next-day mood; coping and next-day pain; and coping and next-day mood; and (b) the independent effects of disease and gender on individual intercepts for pain, mood, and coping and on individual slopes for pain-coping-mood relations. Women, regardless of their disease, and RA patients, regardless of their gender, reported more daily pain. Women used more emotion-focused strategies each day than did men, regardless of their disease and even after controlling for their greater pain. Men were more likely than women to report an increase in negative mood the day after a more painful day. RA patients' pain worsened, but OA patients' pain improved, following a day with more emotion-focused coping. Implications for research and clinical practice are summarized.

Laboratory pain perception and clinical pain in post-menopausal women and age-matched men with osteoarthritis: relationship to pain coping and hormonal status.

The present study examined relationships between pain coping, hormone replacement therapy, and laboratory and clinical pain reports in post-menopausal women and age-matched men with osteoarthritis. Assessment of nociceptive flexion reflex threshold was followed by an assessment of electrocutaneous pain threshold and tolerance. Participants rated their arthritis pain using the Arthritis Impact Measurement Scales. To assess pain coping, participants completed measures of emotion-focused coping, problem-focused coping, and pain catastrophizing. Results indicated that women were more likely than men to report using emotion-focused pain strategies, and that emotion-focused coping was associated with more arthritic pain and lower electrocutaneous pain tolerance. Correlations between coping measures and pain reports revealed that catastrophizing was associated with greater arthritis pain and lower pain threshold and tolerance levels. However, catastrophizing was not related to nociceptive flexion reflex threshold, suggesting that the observed relationship between catastrophizing and subjective pain does not rely on elevated nociceptive input. A comparison of men (n=58), post-menopausal women receiving hormone replacement therapy (n=32), and post-menopausal women not receiving hormone replacement therapy (n=42) revealed no significant group differences in arthritis pain, electrocutaneous pain threshold or tolerance, or nociceptive flexion reflex threshold. Thus, older adults with osteoarthritis do not exhibit the pattern of sex differences in response to experimental pain procedures observed in prior studies, possibly due to the development of disease-related changes in pain coping strategies. Accordingly, individual differences in clinical and experimental pain may be better predicted by pain coping than by sex or hormonal differences.

Gender differences in pain, coping, and mood in individuals having osteoarthritic knee pain: a within-day analysis.

This study examined gender differences in prospective within-day assessments of pain, pain coping, and mood in men and women having OA, and analyzed gender differences in dynamic relations between pain, mood, and pain coping. A sample of 64 women and 36 men diagnosed as having pain due to osteoarthritis of the knee(s) rated their pain, pain coping, and mood two times each day (once in the afternoon and once in the evening) for 30 days using a booklet format. Two gender differences were found in between person-analyses: women used more problem focused coping than men, and women who catastrophized were less likely than men to report negative mood. Several within-day and across-day gender differences were noted. First, women were much more likely to show a significant increase in pain over the day. Second, men were more likely than women to experience an increase in coping efficacy over the day. Third, men were more likely than women to use emotion-focused coping when their mood was more negative. Finally, men were more likely than women to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain. Taken together, these findings underscore the importance of obtaining multiple daily assessments when studying gender differences in the pain experience.

Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis.

This article provides an overview of the emerging literature on biopsychosocial assessment and treatment for two of the most common forms of arthritis: osteoarthritis and rheumatoid arthritis. The article is divided into 3 parts. In the 1st part, the basic elements of the biopsychosocial approach to assessing and treating persons having arthritis is described. In the 2nd part, the authors evaluate studies of biopsychosocial approaches to the assessment of arthritis pain and disability. Six research areas are reviewed: learned helplessness, depression, stress, pain coping, self-efficacy, and the social context of arthritis. The 3rd part of the article reviews studies that testing the efficacy of biopsychosocial treatment approaches for persons having osteoarthritis and rheumatoid arthritis.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial.

A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients' doctors' offices (N=129 patients); the control group received usual care (N=127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.