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Knee Osteoarthritis Pain: Coping Strategies among Elderly Women

Mariam Riad Fahmy, Eman Mohamed Alsherbieny, Hanan Elzeblawy Hassan*

Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt

Abstract: Background: Coping is generally categorized into four major categories which are problem-focused, emotion-focused, meaning-focused and social coping. The patients with knee osteoarthritis can be coping with it by enjoy leisure activities, don't forget to pamper self, sometimes a change surroundings can help, even if it's just for a day trip. Aim: This study aimed to assess the coping strategies of elderly women suffering from knee osteoarthritis (OA) pain in Beni-Suef city. Design: A descriptive cross-sectional research design was utilized in the current study. Setting: the study was carried out at Beni-Suef university hospital in orthopedics outpatient clinic and the physiotherapy unit. Subjects: A non-probability consecutive sampling technique of a total 300 studied women was recruited in the current study. Tools: Visual Analog scale (VAS) and Pain Coping Inventory (PCI). Results: 70% of studied elderly women had severe pain, 62% almost always think of things that remain undone because of pain, 83.7% had low coping level regarding reducing demands. Conclusion: The active coping strategies that most often applied by the studied women were distraction and pain transformation. While concerning passive coping strategies applied by women were resting and retreat were the most utilized by the studied women. Recommendations: Increase public awareness about efficacy & tolerability of the coping in reducing pain and complications of osteoarthritis through directed program to persons in community.

Keywords: coping strategies, elderly, knee osteoarthritis, pain, women

Received March 12, 2023; Revised April 17, 2023; Accepted April 26, 2023

Citation: Mariam Riad Fahmy, Eman Mohamed Alsherbieny, Hanan Elzeblawy Hassan, Knee Osteoarthritis Pain: Coping Strategies among Elderly Women. American Journal of Public Health Research, 11 (3). 99-106. January 2023. doi:10.12691/ajphr-11-3-3

1. Introduction

Osteoarthritis (OA) is caused by damage or breakdown of joint cartilage between bones. Joint injury or overuse such as knee bending and repetitive stress on a joint, can damage a joint and increase the risk of OA in that joint. The risk of developing OA increases with age. Gender; women are more likely to develop OA than men, especially after age 50. Obesity; extra weight puts more stress on joints, particularly weight-bearing joints like the hips and knees. This stress increases the risk of OA in that joint. Obesity may also have metabolic effects that increase the risk of OA [1,2,3,4,5,6]. Genetics; people who have family members with OA are more likely to develop OA. People who have hand OA are more likely to develop knee OA. Race; some Asian populations have lower risk for OA [7,8,9,10,11].

Coping is defined as the thoughts and behaviors mobilized to manage internal and external stressful situations. Coping is generally categorized into four major categories which are problem-focused, emotion-focused, meaning-focused and social coping. For patients’ with knee osteoarthritis it can be difficult to cope with osteoarthritis symptoms that interfere with usual activities of daily living. The patients with knee osteoarthritis can be coping with it by enjoy leisure activities, don't forget to pamper self, sometimes a change surroundings can help, even if it's just for a day trip. A change of scenery is likely to spark a good mood and relieve stress, exercise and increase physical activity [11,12,13,14,15].

Symptomatic, slow-acting drugs for osteoarthritis (SYSADOA) such as hyaluronic acid, diacerein (DIA), glucosamine, chondroitin sulfate, and Piascledine (avocado/soybean unsaponifiable) are widely used for non-acute OA slow-acting treatment with a tolerable safety and potency to relieve pain and somehow to modify the joint functions [16]. Complementary and alternative medicine was used in OA to avoid the unwanted effects of other therapeutic opportunities and searching for more satisfactory results. Nutraceuticals and health supplements are always getting a broad acceptance between patients due to the nature-trust, seeking for safer alternatives than chemical drugs [17].

Treatment for knee osteoarthritis can be broken down into non-surgical and surgical management. Non-surgical management include patient education, activity modification, physical therapy, weight loss, knee bracing, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, glucosamine and chondroitin sulfate, corticosteroid injections and hyaluronic acid (HA) [18].

The role of the nurse in managing OA risk and progression has been evolving, for example, in primary care, teaching, research, and other tasks and settings. Nurses assist in diagnosing and assessing the disease’s functional and psychosocial impacts, provide medication and pain management, monitor disease progress, educate patients, and coordinate care with other providers (physical, occupational, and psychosocial therapists). Understanding the clinical manifestations of and the diagnostic criteria for OA provide the foundation for these activities [19,20,21,22,23].

Emotion-focused coping strategies such as; letting off steam by venting to friends or family, keeping yourself busy to keep your mind off the stressor, seeking encouragement, moral support, sympathy, and understanding from others and turning to rigorous activities like sports to distract attention from the stressor. People are more likely to adopt emotion-focused coping when they don't think their actions can affect the stressor itself, so they alter their response to the stressor. This is like when a friend says something that hurts feelings. What was said may make person feel badly about self, and you may spend a lot of time and mental energy thinking about it [24].

Talking to other people about the situation or engaging in other activities may help person deal with the emotional stress of that encounter. Problem-focused coping is about trying to deal with the stressor itself so as to avoid the stress response it is causing. Problem-focused coping involves finding practical ways to deal with stressful situation such as put other activities on hold in order to concentrate on and cope with stressor, wait to act until the appropriate time and actively try to remove or work around the stressor. Some of these coping strategies are healthy, for example, applying problem solving skills, some are neither healthy nor unhealthy, for example, practicing some religious rituals, while some are unhealthy or maladaptive such as denying the existence of a stressful situation or escaping through use of drugs [25].

On the other hand, neuroendocrinology involving the level of activity of the hypothalamic-pituitary-adrenocortical axis, corticosteroids, and plasma catecholamines were unlikely to have a direct causal relationship with an individual's coping style. For osteoarthritis patients have behavioral strategies that relate to activity broadly reflect three dimensions: avoidance, persistence, and pacing. The fear-avoidance model describes how the pain experience can lead to a pathway where habitually avoiding activity promotes a cycle of disuse and disability. In essence, catastrophizing about pain and its potential consequences, or ruminating, feeling helpless, or exaggerating the threat of pain, leads to pain-related fear or anxiety, which causes avoidance behaviors and ultimately reinforces this negative cycle [23].

Consistent with the idea that avoidance behaviors are maladaptive coping strategies, research examining avoidance usually associates these behaviors to disability or other outcomes such as depressed mood or maintenance of pain. In OA, use of rest as a coping strategy has been associated with physical disability in cross-sectional studies as well as in longitudinal studies. In addition, rest and restricting activities have also been related to negative mood and pain at follow-up in people with OA. Another strategy considered being avoidant, Guarding as bracing, limping, flinching and stiffening, had the strongest independent association with disability [24].

Recent research studied pointed out that there is increasing evidence for the role of nurses in the management of patients with chronic inflammatory arthritis. Community health nurses help patients with OA achieve the ultimate goal of remission or low disease activity. Based on the patient’s individual needs, encourage and assist patient to establish health behaviors and activities that promote rest and exercise, reduce stress, and encourage independence [25]. So the aim of the current study was to evaluate assess the coping strategies of elderly women suffering from knee osteoarthritis (OA) pain in Beni-Suef city.

2. Aim of the Study

The aim of the current study is to assess the coping strategies of elderly women suffering from knee osteoarthritis (OA) pain in Beni-Suef city

2.1. Research Questions

What are the coping strategies utilized by elderly women suffering from knee osteoarthritis (OA) pain in Beni-Suef city?

3. Subjects and Methods

3.1. Research Design

A descriptive cross-sectional research design was utilized in the current study.

3.2. Subjects & Setting

3.2.1. Setting

The current study was conducted at Beni-Suef university hospital in orthopedics outpatient clinic and the physiotherapy unit.

3.2.2. Subjects

3.2.2.1. Sample Size

The sample size was calculated to determine the prevalence of any type of coping strategy of 50% or higher prevalence, with 5% absolute precision, at 95% level of conﬁdence. Using the Open-Epi software package for single proportion estimation for dichotomous variables with ﬁnite population correction, the estimated sample size is 278 subjects. This was increased to 300 to anticipate a non-response rate of about 10%.

3.2.2.2. Sampling Type

A non-probability consecutive sampling technique was used to recruit elderly women.

3.2.2.3. Sample Criteria

Any elderly women suffering from knee osteoarthritis (OA) pain and attended the study settings was selected in the study sample after fulﬁlled the following criteria. Elderly (age ≥65 years old) and Diagnosed as having knee osteoarthritis (OA) for at least one year; this will be confirmed by chart review or medical report and history.

3.2.3. Tools of Data Collection

A. Tool (1): Visual Analog scale (VAS):

It was adapted from (Hawker et al, 2011). It aimed to assess pain severity among elderly women with knee osteoarthritis and include numbers from 1 to 10 in box that described how much knee pain patient feel [26].

v The scoring system:-

The total score of this scale was 10 and classified into three categories based on the following:

B. Tool (2): Pain Coping Inventory (PCI):

It was adapted from (Kmaimaat and Evers, 2003) [27]. It aimed to assessment of the coping strategies used in dealing with the OA pain among elderly women with knee osteoarthritis. It included the following items:

• Part I: Pain transformation: it included pretend the pain is not present, pretend pain does not concern body, imagine pain to be less violent than it really is and think of other people’s difficulties (4 items with score 16).

• Part II: Distraction: it included take a bath or shower, think of pleasant things of events, distract by undertaking a physical activity and distract by reading, listening to music (5 items with score 20).

• Part III: Reducing demands: it included continue activities with less effort continue activities with a slower pace and continue activities less precisely (3 items with score 12).

• Part IV: Retreating: it included make sure that I don’t get upset, retreat into a restful environment, avoid bothering sounds and avoid light (7 items with score 28).

• Part V: Worrying: it included focus on the pain all the time, self-administration of other physical stimuli, think of things that remain undone because of pain and start worrying (9 items with score 36).

• Part VI: Resting: it included stop activities, confine self to simple activities, do not exert self physically and rest sitting or lying down (5 items with score 20).

v The scoring system:- Total global score of 132 for 33 sub items, were rated on four ranks as:

- Part I, II & III (rarely = 1, sometimes few = 2, sometimes a lot = 3 & almost always = 4).

- Part IV, V & VI (rarely = 4, sometimes few = 3, sometimes a lot = 2 & almost always = 1).

The total score of this scale classified into three categories based on the following:

- Low coping level ≤60% of total score (≤ 79.2 scores)

- Moderate coping level >60% - <80% of total score (> 79.2 - <105.6 scores)

- High coping level ≥ 80 % of total score (≥ 105.6 scores)

3.2.4. Validity and Reliability

• Content Validity: tools were examined by a panel of five experts in the field of community health nursing to determine whether the included items are comprehensive, understandable, applicable, clear and suitable to achieve the aim of the study. The modification was done based the opinion of the expertise.

• Reliability: In the present study, reliability was tested using Cronbach’s Alpha coefficients for Pain Coping Inventory was 0.784.

3.2.5. Pilot Study

A pilot study was carried out on 30 patients (10%) of the study subjects to test the clarity, applicability, feasibility and relevance of the tools used and to determine the needed time for the application of the study tools.

3.2.6. Field Work

The researcher explained the purpose of the study to elderly women included in the study. The actual work of this study started and completed within eight months from beginning of August (2021) to the end of March (2022). Patients’ oral consent to participate in the study obtained and every patient was informed that confidentiality was assured. Data were collected by the researcher two days per week (Saturday & Wednesday) at morning shifts in the previous mentioned setting.

3.2.7. Ethical Considerations

The research approval was obtained from the faculty scientific ethical committee before starting the study. The researcher clarified the objectives and aim of the study to the patients included in the study before starting. Researcher assured the anonymity and confidentiality of the patients included in the study. The patients in the study was informed that they are allowed to choose to participate or not in the study and they have the right to withdraw from the study at any time without any reasons.

3.2.8. Administrative Approval

An official written letter was issued from the faculty of Nursing in Beni-Suef University to the director of Beni-Suef University Hospital in which the study was conducted by which permission obtained for data collection and help in conducting the study in their facilities.

3.2.9. Statistical Analysis

The data were collected, coded and entered into a suitable excel sheet and analyzed using an appropriate statistical method. Data were analyzed using statistical program for social science (SPSS) version 26.0, quantitative data were expressed as a mean ± standard deviation (SD), and qualitative data were expressed as frequency and percentage.

4. Results

Figure 1 presents percentage distribution of study elderly women' regarding their total pain level. It shows that, more than two thirds (70%) of studied elderly women had severe pain and (30%) of them had moderate pain level.

Figure 1. Total pain level among studied elderly women (n=300)

Figure 2. frequency and percentage distribution of study elderly women' regarding their coping level with pain concerning positive adaptation

Figure 2 presents percentage distribution of study elderly women' regarding their coping level with pain concerning positive adaptation. It reveals that, more than half (27%) of studied elderly women rarely continue activities with a slower pace, (41%) of them were sometimes a few pretend pain does not concern my body, (47.0%) of them were sometimes a lot assume think of pleasant things of events and (24.4%) of them were almost always distract their selves by undertaking a physical activity.

Figure 3. frequency and percentage distribution of study elderly women' regarding their coping level with pain concerning negative adaptation

Figure 3 portrays percentage distribution of study elderly women' regarding their coping level with pain concerning negative adaptation. It reveals that, more than half (62%) of studied elderly women almost always Think of things that remain undone because of pain, (48.7%) of them were Sometimes a lot When outdoors they try to return home soon, (40.7%) of them were sometime Sometimes a few a lot assume rest sitting or lying down and (30.7%) of them were rarely do not exert their selves physically.

Figure 4. Frequency and percentage distribution of study elderly women' regarding their utilized coping strategies with pain (n= 300)

Figure 4 presents percentage distribution of study elderly women' regarding their utilized coping strategies with pain (n= 300) shows that, more than two third (83.7%) of studied elderly women had low coping level regarding reducing demands, (50.3%) of them had moderate coping level regarding distraction and (35.4%) of them had high coping level regarding resting coping.

5. Discussion

The treatment strategies for OA have been dramatically reformed during the last 20 years, through early diagnosis, timely use of disease-modifying anti-rheumatic drugs (DMARDs), and the introduction of new and effective “biological agents,” which have all led to reduced disease activity and fewer reported disabilities. However, despite these new treatment strategies, disabilities are still reported, which indicates the need for further no pharmacological multi-professional interventions to complement the medication [28,29,30,31,32].

There are two types of coping: a) “active coping” (strategies used to control pain or to function despite pain) versus “passive coping” (withdrawing and surrendering control over pain); b) “approach” (strategies of engaging with pain or its causes) versus “avoidance” (strategies of engaging efforts away from pain) [25].

Concerning the strategies that are adopted by the studied women at the current study, the present study revealed that studied women adopted different strategies to cope arthritis pain including; both positive adaptation, and negative adaptation; the positive adaptation strategies including; Pain transformation, distraction and reducing demand. The result of the current study indicated that distraction was one of the highest utilized copying strategies among studied women. These findings are agreed with Janiszewska et al., (2020) in the study to “evaluate Coping strategies observed in women with rheumatoid arthritis” and added that coping pain distraction strategy was highly utilized by the studied female patient with rheumatoid arthritis [33].

Moreover, Pain transformation was the second positive adaptation strategy that was utilized by the studied women, nearly 50% of them was utilized it in Sometimes a lot and almost always manner. This result was supported by Santos et al., (2020) who indicated that pain transformation is one of the most effective pain coping strategies that was adopted by the patient with rheumatoid arthritis pain [34].

Concerning adoption of the studied women of passive coping, the present study findings revealed that resting passive coping strategy was mainly utilized by more than half of the studied women, this may be due to that they almost always do not exert their selves physically, due to the physical disability that caused by the physiology of rheumatoid arthritis. These finding are agreed with Martinec et al., (2019) who added that studied patient affected with rheumatoid arthritis preferred resting in order to avoid increase intensity of pain [35].

Retreat is an integrative medicine modality that can be helpful in managing not just chronic pain, but also the associated depression and anxiety that comes along with the condition. More than that, it can improve cognitive function deficits associated with chronic pain. Recent research done at Stanford University suggests that retreat and breathing practices could be the solution to overcoming the opioid crisis.

Moreover, the retreating was the second utilized passive coping strategy by the studied women, as nearly half of them almost always retreat into a restful environment, the result of the current study came in the same line with Clynes et al., (2019) who added that Patients with OA seek immediate care from multiple traditional providers with a wide range of products and services with no gatekeeping [36]. The most significant concern expressed by practitioners, restful environment retreating as a safety and efficacy of traditional treatments.

6. Conclusion

The active coping strategies that most often applied by the studied women were distraction and pain transformation. While concerning passive coping strategies applied by women were resting and retreat were the most utilized by the studied women.

7. Recommendation

The important recommendations inferred from the study result was increase public awareness about efficacy & tolerability of the coping in reducing pain and complications of osteoarthritis through directed program to persons in community.

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