Evaluation of the Coping Strategies Used by Knee Osteoarthritis Patients for Pain and Their Effect on the Disease-Specific Quality of Life

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1 January Aril 2016 Volume 9 Issue 1 Page 80 Original Article Evaluation of the Coing Strategies Used by Knee Osteoarthritis Patients for Pain and Their Effect on the DiseaseSecific Quality of Life Semra Aciksoz RN, PhD Gulhane Military Medical Academy, School of Nursing, Etlik, Ankara, Turkey Senay Uzun RN, PhD Associate Professor Yeditee University Faculty of Health, Deartment of Nursing and Health Services, Atasehir, Istanbul, Turkey Servet Tunay MD Professor Gulhane Military Medical Academy, Deartment of Orthoaedics and Traumatology, Etlik, Ankara, Turkey Corresondence: Semra Aciksoz, Gulhane Military Medical Academy, School of Nursing, Etlik, Ankara, Turkey semraaciksoz@yahoo.com Abstract Background: Analyses of ain coing strategies in atients with osteoarthritis are imortant for minimizing the imact of symtoms and establishing aroriate disease management. Objective: The aim of this study is to evaluate the strategies that atients with knee osteoarthritis use to coe with ain and effect of these strategies on diseasesecific quality of life. Methods: The study is a descritive one. Nonrandom samle included 145 atients with knee osteoarthritis, who resented to the orthoedics outatient clinic during one year. This study was erformed at a training and research hosital in Ankara, Turkey. The institutional consent was obtained for the study. Data collected with the atient information form, ain definition and coing strategies evaluation form, and Arthritis Imact Measurement Scale 2. Collected data were analysed by descritive and analytical statistics using SPSS 15.0 software. Results: With increasing severity of ain, quality of life was being affected unfavorably. The mostly exerienced roblem was within the area of symtom status (ain of arthritis) ( X =7.06±1.94). The average scores of areas of quality of life were more favorable in atients who were using nonharmacological and alternative strategies comared to atients who were using harmacological and traditional strategies. Conclusion: A ain management lan, which includes nonharmacological and alternative strategies that have favorable effects on quality of life areas, should be reared and imlemented with an organized education and counseling. Key words: Osteoarthritis; ain; coing strategy; quality of life; nursing Introduction Osteoarthritis (OA) is the most common joint disorder. It is estimated that, by 2030, close to 70 million ersons aged 65 and older will be at risk for OA (Regier & Parmelee, 2015). OA, is often associated with ain, al imairment, activity limitations and decreased indeendence in activities of daily living, deressed mood, and a reduction in quality of life. Pain is frequently identified as the most distressing symtom of OA (Tanimura et al., 2011; Regier & Parmelee, 2015). The rimary aim in OA treatment is to control the ain and imrove the quality of

2 JanuaryAril 2016 Volume 9 Issue 1 Page81 life (Rubin, 2005; Seomun et al., 2006). Studies emhasize that ain control is effective in imroving quality of life (Algıer et al., 2005; Jakobsson and Hallberg, 2006). The combination of harmacological and nonharmacological strategies is reorted to rovide the best ain management in the treatment rograms (Rubin, 2005). Nonharmacological strategies enable individuals to lay an active role in coing with ain and to be in control. They also decrease the amount of analgesic used, and therefore, drug side effects and associated financial burden (Seomun et al., 2006; Perrot et al., 2008; Tsai et al., 2008). It was emhasized that ensuring individuals stayed active by being ermitted to select a strategy by themselves was imortant both for decreasing symtoms and making them hay with the rocedure (Benyon et al., 2010). The develoment of effective coing skills may be a crucial determinant of wellbeing in older adults with this disease. While the existing literature on coing secifically with OA in the older oulation is relatively small (Regier & Parmelee, 2015). There have not been any studies on OA atients use to coe with ain and effects of these strategies on diseasesecific quality of life in Turkey. This study focuses on OA of the knee, as this is the single most common site of OA; additionally, the fact that the knee is a weightbearing joint bears strong imlications for al activities (Regier & Parmelee, 2015). Therefore, the urose of this study was to evaluate the effect of the strategies knee OA atients use to coe with ain on the diseasesecific quality of life. The result of this study will underline ain management; hel develo effective interventions for knee OA atients to coe with ain. Methods Setting and samles The study oulation comrised a total of 145 atients with knee OA and data were collected for one year. This study was conducted at the orthoedics outatient units of a training and research hosital in Ankara, Turkey. Patients fulfilled the classification criteria of American Rheumatism Association for OA of the knee. Inclusion criteria were; being diagnosed with knee OA, having exerienced knee ain in the ast 6 months or more, aged 40 years or older, absence of a surgical intervention in the ast month, did not have any other roblems that could affect the musculoskeletal system, absence of mental confusion or any other sychiatric condition and voluntary consent of articiation. Instruments The questionnaire used to collect data consisted of three forms. Patient Information Form: This 23question form, develoed by the investigator following a literature search, queries the sociodemograhic characteristics, health status and health behavior of the individuals. Pain Definition and Pain Coing Strategies Evaluation Form: The form consists of two sections: (1) The ain definition section is develoed by McCafery and Boobe and translated into Turkish by Algology Deartment of Istanbul University School of Medicine. In this form, the severity (in a numerical scale), the duration, the quality, accomanying feelings and symtoms, decreasing and increasing factors of the ain are questioned.(2) Pain coing strategies section includes questions is develoed by the investigators according to oinions of the exerts (orthoedist, clinical secialist nurse, educator nurse) and literature search. In this section, the coing strategies are interrogated. These strategies are classified as harmacological methods (analgesic treatment, intraarticular medical treatment, toical medical treatment), nonharmacological methods (hysical theray, exercise, weight control, ancillary devices, resting, raising the leg with ain, skin stimulation techniques, cognitivebehavioural methods), alternative medical methods (acuuncture, ayurveda and others)

3 JanuaryAril 2016 Volume 9 Issue 1 Page82 and traditional methods (herbal medicine, raying, worshi). Arthritis Imact Measurement Scale 2 (AIMS2): The AIMS2 was develoed by Meenan et al. (Meenan et al., 1992). A Turkish translation and validity and reliability studies were carried out by Atamaz et al. (Atamaz et al., 2005). The scale is comosed of 78 questions and 5 quality of life asects in 12 subscales; hysical status (motion level, walking and bending, hand and finger s, arm s, self care, housework), mood (anxiety level, emotional status), symtoms/signs status (arthritis ain), social interaction (social activity, family suort) and role (emloyment status). These subscales evaluate the associated quality of life within a range of 010 oints with 0 oint indicating good and 10 oints oor health status (Atamaz, Heguler & Oncu, 2005). Ethical considerations Informed written consent to articiate in the study was obtained from the articiants. The study was aroved by the Ethics Committee of the Gulhane Military Medical Academy Hosital, Turkey. Data analysis The Statistical Package of Social Sciences version 15.0 ackage rogram (SPSS, Inc., Chicago, IL, USA) was used for the evaluation of the data. Descritive statistics: the numerical variables were exressed as numbers and ercentages (%), and the quantitative variables were exressed as mean (standard deviation), median and minimum maximum (min max) value. Normality of continuous variables were assessed grahically with ShairoWilk analysis. For dual comarison of arametric variables, Student s t test, and of nonarametric continuous variables MannWhitney U test was used. For comarison of three or more variables, oneway analysis of variance (ANOVA) for arametric variables and KruskalWallis test for nonarametric variables. In comarison of categorical variables, cross tables and chi square test is used. Relation between arameters was tested by analysis of correlation. A value of was regarded as statistically significant. Results In the study samle of 145 atients with knee OA, most were female (80%), mean age of 59.14±8.55 years, rimary school graduate (47.6%) and a housewife (62.8%). Diseasesecific characteristics, ain status and coing characteristics of the atients. Patients average duration of disease was 7.02±5.38 (027) years. The average duration of ain was 7.02±5.38 years and the ain was accomanied by decreased hysical activity, lack of slee and decreased social activity, in addition to feelings of anger and agitation. Pain was increased by fatigue in 41.7% and movement in 33.2% of the atients and decreased by analgesics in 40.0% and rest in 28.9%. The harmacological strategies were the most common method used to coe with ain (37.5%), and analgesic usage was the most referred (54.0%) harmacological strategy. Rest, a nonharmacological strategy, was referred by 40.3% of the atients. Most of the atients stated that the strategies of coing rovided artial relief and were used when ain was resent. There was a statistically significant relation between the age and educational level of the individuals and the ain severity ( ²=34.468;, ²=25.469; =0.002). It was observed that the ain severity increased with increasing age while it decreased with increasing educational level. We observed that disease duration had an effect on ain severity and that ain severity increased with increasing disease duration (r=0.317; ). Educational status ( ²=23.542; ), occuation ( ²=21.365; =0.011) and emloyment status

4 JanuaryAril 2016 Volume 9 Issue 1 Page83 ( ²=17.407; =0.001) influenced the strategy used to coe. The ercentage of the atients with mild ain that used nonharmacological strategies was 66.7% while increased ain severity led to an increase in the use of both harmacological strategies together with nonharmacological strategies. The diseasesecific quality of life of the atients The walkingbending ( X =07.91±1.75), health status ercetion ( X =7.73±2.40) and ain ( X =7.06±1.95) subscale mean scores were high in the knee osteoarthritis atients. The most roblematic quality of life areas were symtom status ( X = 7.06±1.94) and mood ( X =4.91±1.55) while the hysical area was least effected ( X =4.12±1.93) (Table 1). The 4055 years age grou was doing best regarding quality of life related to hysical. There was a significant difference between the 4055 years age grou and the 66+ age grou (z=3.769; ) when the age grous creating a difference regarding hysical were evaluated. Increased age led to a more negative symtom status (arthritis ain) quality of life area. The hysical s (t=4.0; ), mood (t=7.0; ), symtom status (t=3.3; ) and social mean scores (t=4.9; ) were higher in the women than the men and the difference was statistically significant (Table 2). Educational status influenced the hysical (F=12.7; ), mood (F=7.7; ), symtom status (F=11.3; ) and social (F=6.6; ) areas and the difference was statistically significant. Low educational status was found to have a negative effect on the quality of life (Table 2).. Physical, mood and social area average scores and esecially symtom status were directly correlated with an increase in body mass index and these areas were negatively affected. There was a statistically significant relation between disease duration and hysical (r=0.550, ), mood (r=0.201, ), symtom status (r=0.520, ) and social (r=0.248, ) areas with the score increasing as the disease duration increased, with more negative effects on quality of life (Table 3). We found a strong, ositive and statistically significant relation between the ain severity and the scores from the hysical, mood, symtom status and social areas of the quality of life () (Table 4). The average score from the quality of life areas increased with increasing ain severity with the quality of life areas being negatively affected. We found that the quality of life mean scores were higher and the quality of life worse in atients using harmacological methods and traditional alications comared to atients using nonharmacological or alternative treatments where the quality of life mean scores were lower and the quality of life was better (Table 5). Currently erceived health status, their exectation in future and the health area in which they mostly wanted imrovement The health status was erceived as unfavorable by 46.9% while 50.3% felt that their health roblems were all due to OA and 66.9% believed that OA would become an imortant roblem in the next 10 years. Patients would most like an imrovement in ain (32.2%), mobility (25.3%) and walkingbending (24.5%) as the healthrelated areas.

5 JanuaryAril 2016 Volume 9 Issue 1 Page84 Table 1. Distribution of Mean Quality of Life Areas Scores (n=145) Quality of Life Areas X ±SD MinMax Physical 4.12± Mood 4.91± Symtom status 7.06± Social 4.45± Role 4.68± *a low score indicates good health status and a high score unfavorable health status Table 2. Distribution of Mean Quality of Life Areas Scores of Patients According to the Sociodemograhic Characteristics (n=145) QUALITY OF LIFE AREAS Sociodemograhic Characteristics Physical Mood Symtom status Social Role * Gender n X ±SD X ±SD X ±SD X ±SD X ±SD Female Male t Educational status Illitarete Primary school Secondary school High school F ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± *n=10 **a low score indicates good health status and a high score unfavorable health status 5.00± ± ± ± ±

6 JanuaryAril 2016 Volume 9 Issue 1 Page85 Table 3. The Relation between Disease Duration and Quality of Life Areas (n=145) Quality of Life Areas Physical Mood Symtom status Social Role * Disease duration (years) F Disease duration and correlation n X ±SD X ±SD X ±SD X ±SD X ±SD ± ± ± r= ± ± ± r= ± ± ± r= ± ± ± r=0.248 *n=10 **a low score indicates good health status and a high score unfavorable health status r=0.427 Table 4. The Relation between Pain Severity and Quality of Life Areas (n=145) Quality of Life Areas Physical Mood Symtom status Social Role Pain severity r=0.660 r=0.464 r=0.676 r=0.434 r=0.215

7 JanuaryAril 2016 Volume 9 Issue 1 Page86 Table 5. Distribution of Mean Quality of Life Areas Scores of Patients According to the Methods of Coing with Pain (n=145) Methods of Coing With Pain Pharmacological method Not using Using t Nonharmacological method Not using Using t Alternative medicine Not using Using t Traditional method Not using Using t Physical Mood Quality of Life Areas Symtom status Social Role * n X ±SD X ±SD X ±SD X ±SD X ±SD ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± = ± ± =0.001 *n=10 **a low score indicates good health status and a high score unfavorable health status 4.68± ± ± ± ± ± Discussion Pain limits s and negatively affects the quality of life in knee OA atients. The disorderrelated effects of knee OA, and esecially the ain, increase in individuals with advancing age (Jakobsson & Hallberg, 2006). We found a significant relation between age and ain severity, with the severity increasing and the hysical and symtom status areas of the quality of life more negatively affected with increasing age. We also found that the quality of life results were better in males. These finding agree in art with a revious reort that women have lower mean quality of life

8 JanuaryAril 2016 Volume 9 Issue 1 Page87 scores than men with a negative effect on the quality of life (Algıer et al., 2005). We found that increasing ain led to decreased hysical activity, insomnia and decreased social activity comlaints and accomanying emotions such as agitation and anger. Reorts state that negative mood has a negative effect on the coing strategies or individuals and therefore their ercetion of ain severity directing them towards assive coing strategies such as looking for medical hel, seeking hel from others or feeling helless, therefore increasing the erceived ain severity (Keefe et al., 1990; Ataoglu et al., 1998; Seomun et al., 2006; Tanimura et al., 2011). In terms of ain coing strategies, our results indicate that the atients used nonharmacological strategies at similar rates to harmacological strategies to coe with ain. It is reorted that better results are obtained when the drugs used for knee OA treatment are combined with diseasesecific nonharmacological strategies such as exercise and weight loss (Rubin, 2005). It is thought that harmacological strategies, with the side effects they may cause, can lead to a more negative effect on the quality of life, which has already been negatively affected in atients with knee OA due to the disease and its signs. Studies reort that ineffective individual coing leads to a lack of effective management of disease by the individual with a negative effect on the quality of life. It also shows that individuals who develo active coing strategies for ain can lead a more al lifestyle (Keefe et al., 1990; Burke & Flatherty, 1993; Seomun et al., 2006). Ataoglu et al. (Ataoglu et al., 1998) reorted that atients with OA mostly use active coing strategies to coe with ain. This was exlained by the atients observing the rominent OA effects and objective athology and assuming aindecreasing behavior to decrease it. The reason atients use active coing strategies often has been stated as the resultant increased selfconfidence and being less sychologically affected by this method. Perrot et al. (Perrot et al., 2008) have reorted that there is tendency to use assive methods, such as retreating and resting, in coing with ain in OA. We found that atients with mild ain used nonharmacological strategies while the rate of harmacological strategies use in addition to nonharmacological strategies increased with increasing ain severity. Tsai et al. (Tsai et al., 2008) reorted that most of the atients used harmacological coing strategies about half of the time and nonharmacological strategies about onequarter of the time. The lack of knowledge regarding nonharmacological strategies of knee OA atients and their inability to use these effectively indicates that nonharmacological strategies are inadequate in ain management and that atients therefore try harmacological strategies (Atamaz, Heguler & Oncu, 2006). It is emhasized that education ensures that atients have information regarding their disorder and its treatment and therefore increases their control of the disease and also has a ositive effect on ain and quality of life (Algıer et al., 2005; Seomun et al., 2006). Atamaz et al. (Atamaz, Heguler & Oncu, 2006) reort that OA atients with lower educational status do not use active coing strategies or use them less often and develo more comlications. It is reorted that women generally use assive coing strategies and choose harmacological strategies while men use active coing strategies and use nonharmacological strategies (Burke & Flatherty, 1993; Ataoglu et al, 1998). Most of our atients were women and mostly used harmacological strategies indicating that these reasons may also be valid for our study grou. The quality of life areas that were most negatively affected were walkingbending, ercetion of health status and ain. Meenan et al. (Meenan et al., 1992) have similarly reorted that the most roblematic area was

9 JanuaryAril 2016 Volume 9 Issue 1 Page88 ain, followed by walking and bending. Tsai et al. (Tsai et al., 2008) have reorted that most atients with ain have coed with their ain by stoing activity. These findings indicate the imortance of interventions to decrease ain in individuals with knee OA. In our study, almost half of the atients erceived their current health status as unfavorable and stated that they felt their health would get worse in the next ten years. Other articles mention that "the erceived feeling of control over ain" among the factors that affect coing. It is emhasized that the ercetion of hoelessness regarding this control has a negative effect on coing (Seomun et al., 2006). Conclusion These findings indicate that the harmacological strategies were the most common method used to coe with ain, and increased severity of ain was associated with the use of harmacological strategies. The average score from the quality of life areas increased with increasing ain severity with the quality of life areas being negatively affected. The average scores of areas of quality of life were more favorable in atients who were using nonharmacological and alternative strategies comared to atients who were using harmacological and traditional strategies. The studies that investigated the other factors of using harmacological strategies should be carried on. A treatment lan, which includes nonharmacological and alternative strategies as well as harmacological and traditional strategies, should be reared and carried on with counseling. In order to enhance the adherence to the lan, individual characteristics, learning features and references should be taken into account. References Algıer, L., Dogan, N., Abbasoglu, A., Hanoglu, Z., & Beder, A. (2005). Quality of life in atients with rheumatic roblem. Health and Society, 15, Atamaz, F., Heguler, S., & Oncu, J. (2005). Translation and validation of the turkish version of the arthritis imact measurement scales 2 in atients with knee osteoarthritis. The Journal of Rheumatology, 32, Atamaz, F., Heguler, S., & Oncu, J. (2006). Factors associated with ain and disability in knee osteoarthritis. Turkish Journal of Physcical Medicine and Rehabilitation, 52, Ataoglu, S., Ataoglu, A., Ozkan, M., Sır, A., Erdogan, F., Nas, K., Gur, A., & Sarac J. (1998). Coing Strategies in Pain Control in Patients with Fibramyalgia and Osteoarthritis. Turkish Journal of Physcical Medicine and Rehabilitation, 1, Benyon, K., Hill, S., Zadurian, N., & Mallen, C. (2010). Coing Strategies and SelfEfficacy as Predictors of Outcome in Osteoarthritis: A Systematic Review. Musculoskeletal Care, 8(4), Burke, M., & Flatherty M.J. (1993). Coing strategies and health status of elderly artritic women. Journal of Advanced Nursing, 18, Jakobsson, U., & Hallberg, I.R. (2006). Quality of life among older adults with osteoarthritis: an exlorative study. Journal of Gerontological Nursing, 32, Keefe, F.J., Caldwell, D.S., Williams, D.A., Gil, K.M., & Mitchell, D. (1990). Pain coing skills training in the management of osteoarthritic knee ain: a comarative study. Behavior Theray, 21, Meenan, R., Mason, J., Anderson, J., Guccione, A., & Kazıs, I. (1992). AIMS2: The content and roerties of a revised and exanded arthritis imact measurement scales health status questionarie. Arthritis Rheumatism, 35, 110. Perrot, S., Poiraudeau, S., Kabir, M., Bertin, P., Sichere, P., Serrie, A., & et al. (2008). Active or assive ain coing strategies in hi and knee osteoarthritis? Results of a national survey of 4,719 atients in a rimary care setting. Arthritis Rheumatism, 59(11), Regier N.G., & Parmelee P.A. (2015). The stability of coing strategies in older adults with osteoarthritis and the ability of these strategies to redict changes in deression, disability, and ain. Aging & Mental Health, 6, 110.

10 JanuaryAril 2016 Volume 9 Issue 1 Page89 Rubin, B.R. (2005). Management of osteoarthritic knee ain. The Journal of the American Osteoathic Assocation, 4, Seomun, G., Chang, S., Pyoung, L., Lee, S.J., & Shin, H.J. (2006). Concet analysis of coing with arthritic ain by south korean older adults: develoment of a hybrid model. Nursing Health Science, 8, Tanimura, C., Morimoto, M., Hiramatsu, K., & Hagino, H. (2011). Difficulties in the daily life of atients with osteoarthritis of the knee:scale develoment and descritive study. Journal of Clinical Nursing, 20, Tsai, Y.F., Chu, T.L., Lai, Y.H., & Chen, W.J. (2008). Pain exeriences, control beliefs and coing strategies in Chinese elders with osteoarthritis. Journal of Clinical Nursing, 17,