O Astudypresentation

Pain Communication and Osteoarthritis:

A couples-based Approach

Georgia Hoyler

April 16, 2009

Research Methods in Psychology

PSY185cs

Overview of presentation

Define Osteoarthritis (OA)

Prevalence

Treatment and Limitations

Study Proposal

Methods

Anticipated Results

Future Directions

What is OA?Breakdown of cartilage in

affected joint 1

Symptoms: - Joint pain- Morning stiffness- Joint instability - Limited motion

Clinical signs:- Pain during motion- Crepitus- Boney enlargement- Joint deformity

Prevalence• 33.6-70% of Americans over 65 2,3,4

• Increases with age 4

• Women at higher risk, especially 50+ 4,5

• Increased rates of radiographic OA among ethnic minorities and risk of poor outcomes (pain, disability) 6,7,8

http://www.cdc.gov/arthritis/data_statistics/national_data_nhis.htm, [2006 data analysis, all arthritis types

Current standards of treatment

• Pharmacological– Nonsteroidal Anti-

inflammatory drugs

• Behavioral– Exercise– Monitoring context

surrounding pain flares 16

• Surgical arthroplasty

Treatment LimitationsPharmalogical concerns

– Risk of GI-bleeding, compromised renal blood flow– Long-term effects cartilage metabolism 9

High comorbidity rates of depression and anxiety unaddressed 10, 11

– Depression + anxiety predict current+future pain severity in OA patients 10, 12, 13

– depression and anxiety predict less effective pain treatment

Social context and effects of pain unaddressed– Interactions affect patient HR-QoL 25, 26

– Caregivers experience decrease in marital satisfaction and increase in psychological distress 17,18

– Marital Dissatisfaction also associated with depression and anxiety 13

Why Pain Communication?

In Chronic Pain Patients:

negative caregiver behaviors (critical, oversolicitous)

Withholding pain expression/communication

Increased pain and pain-related disability 21

Increased patient and partner psy. Distress 14, 19, 20

Positive Effects of Pain Communicat’n:Studies of couples with Cancer 22, 23, 24

OA Patient-Dr. pain communication 15

Study Proposal

Evaluate the Benefit of Couples-Based Pain Communication Skills Intervention on patient’s Health-

Related Quality of Life

Health-Related Quality of life: Pain severity, Pain-related Disability, and Psychological Functioning

Hypotheses:

HYP 2: Reduced pain and disability will be associated with reduction in Caregiver strain and

improved psychological well-being.

HYP 1: Patients in intervention group will have

higher HR-QoL scores than controls: lower pain, disability, and psychological distress.

HYP 3: intervention group couples also report

increased Marriage Satisfaction and Self-efficacy

for pain communication compared to controls.

Approach Patients

Patients who did not qualify to participate

N=400 eligible couplesBaseline Assessment

Randomization

Couples-therapy Pain Communication Skills Training

Control Group

Measures administered at 6 weeks, 6 and 12 month follow-ups

OA disease education session

Subjects

• 400 patients and their partners/spouses• > 50 years old • 50% women, 33% Latino, 33% African-

American, 33% White• OA confirmed by study-affiliated doctor• Exclusion criteria:

– Patient or caregiver has history of/current psychiatric illness other than Major Depression or General Anxiety Disorder

– Diagnosis of any other form of arthritis (RA, gout, fibromyalgia, lupus)

– Does not live with romantic partner

WhiteAfrican-AmericanHispanic

Baseline Measurements

PATIENT:1. Arthritis Impact

Measurement Scale BOTH:1. Quality of Marriage Index2. Self-Efficacy in Pain Communication Scale3. Beck Depression and Anxiety Inventories

PARTNER:1. Caregiver Strain Index2. Medical questionnaire to report general health and presence of chronic illness

Education session

• 40-minute session offered to 4-5 couples in group setting

• OA disease education, methods for self-management.– Includes suggestion for exercise– Monitoring context surrounding pain flares

• Question-and-answer session 10 minutes following 30 minute presentation

• Session run by psychologists trained in OA disease management

Intervention1/week, 5 weeks

Session lasts 40 minutesLed by psychologist trained in

pain communication skills training.

3 and 4Psychologist-led Pain expression

coping conversations, 2 pain topics discussed each session

6final supervised pain

conversation and wrap-up.

2 Introduction to pain communication &

emotion expression skills.20 min. intro conversation with

psychologist coaching.

5Psychologist may remind

couples of skills, but does not actively coach conversation, 2

pain topics discussed

Control group1/week, 5 weeks

Session last 40 minutesSupervised by psychologist who did not

get training in pain communication theory.

Each session identical:Opportunity to ask questions regarding OA pain

management.

Couple is provided list of general topics to discuss that are not pain-specific. (Finances, Relationship

Roles, Fears for future, Children etc.)

No input from psychologist unless words of understanding.

Anticipated results

0 weeks 6 weeks 26 weeks 52 weeks

ControlIntervention

HR-QoL

PRIMARY OUTCOMES:

0 weeks 6 weeks 26 weeks 52 weeks

ControlIntervention

Patient Disability

0 weeks 6 weeks 26 weeks 52 weeks

Control

Intervention

Patient Pain

0 weeks 6 weeks 26 weeks 52 weeks

ControlIntervention

Patient Psychological

Distress

0 weeks 6 weeks 26 weeks 52 weeks

ControlIntervention

Caregiver Strain

SECONDARY OUTCOMES

SECONDARY OUTCOMES

psychologicaldistress

marriagesatisfaction

self-efficacy forpain comm.

Intervention-CaregiverIntervention-Patientcontrol- caregiver

control- patient

Percent Difference, Post-Treatment

Clinical Significance

Augments treatment options for patients with OA– Improves relationship outcomes for couple and

improves caregiver health outcomes– Reduces depression and anxiety comorbidity in

patients

Future Directions

• Telephone-administered intervention

Source: U.S. Bureau of the Census

Future Directions Cont’d

• Similar interventions with other chronic pain patients (lower back, RA)

• Investigate efficacy of interventions administered by social workers, or trained health volunteers

Limitations• Reliance on self-report measures

• Control group is not ‘usual care’

• By targetting couples, not offering treatment to those widowed or with non-romantic caregivers (children, nurses, etc.)

• Self-selecting bias, better relationships/comm. skills may be more willing to participate

Feedback:

• Should I limit the population to OA patients with knee, hip, or hand? A minimum level of pain in order to qualify?

• Necessary to add an observational measure of pain-related disability or communication skills?

• Questions?

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