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This presentation summarizes a proposed study looking at the effects of communication patterns on OsteoArthritis pain. Though my proposed study is not identical with the pain study I researched during ...

This presentation summarizes a proposed study looking at the effects of communication patterns on OsteoArthritis pain. Though my proposed study is not identical with the pain study I researched during my 2008-2009 academic year, it reflects the depth of my understanding and my ability to develop an effective and innovative research proposal.

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  • 33.6% = conservative estimate Numbers differ depending on whether collecting radiographic OA (70%), or symptomatic OA [explain diff.]
  • Dr. diagnosed arthritis, ages 18+ on graph. This is all types of arthritis, including rheumatoid and other forms. But OA is most prevalent, and will account for most of this increase. Notice that women are more severely affected than men in every graph:
  • Couples Therapy equally effective and economical as antidepressants in relieving depression (Leff, Vearnals et al. 2000)
  • It’s okay just to hypothesize on these factors and ignore the mechanisms by which they happen, right? (for instance, I don’t need to hypothesize whether self-efficacy for pain communication or quality of marriage is a byproduct of the intervention or something mediated by the level of patient pain, right?)
  • -50+ because standard diagnostic age 50+ is American College of Rheumatology criteria for some classifications of OA. -33% of individuals over 65 have osteoarthritis, and risks of side effects from pharm. Treatment are higher in elderly pop. Thus, more likely that a psychosocial intervention would be used in this age group. To Confirm OA: doctor reviews x-ray taken in last 6 months of affected area; if one hasn’t been taken, takes one. X-ray determines stage of severity. Not well correlated w/pain, so patients complete pain and disability subscales of AIMS. Must have chronic pain AND radiographic evidence of OA. Exclusion: will administer revised Symptom Checklist 90 [SCL-90-R], a self-report measure, to screen for current psychiatric illness and will ask participants to report any previous diagnoses. Established validity (cite), use in other studies with arthritic patients (KEEFE). Exclude other forms of RA in attempt to keep pain-related discussion to OA-specific pain. [RA is usually primary cause of pain in RA+OA patients]
  • -AIMS=Arthritis Impact Measurement Scale, measures HR-QoL in patient: two of the areas completed in screening (disability and pain, now complete final subscale on psychol. Status) -Both complete BDI and BAI in order to have comparable measurements of Dep. and Anxiety -Measuring Caregiver Strain rather than Caregiver QoL b/c no OA-specific caregiver measure, one accepted caregiver QoL index but includes different aspects of life than AIMS, not comparable (includes measure of material/resourches, social well-being, etc.). Caregiver Strain is an important measure within Caregiver-QoL, found to be correlated with overall QoL.
  • Therapists in both group will tape-record conversations to insure reliability among therapists, to be reviewed weekly by supervisor.
  • Lorig et al (2005) found that self-administered pain management/educational materials predicted decrease in pain compared to controls, so we DO expect decrease in patient pain within control group here. -HR-QoL is composite of pain, physical disability, and psychological distress. Since pain is decreasing and psychological stress is expecting to decrease as well, we can expect to see an increase in this composite measure of quality of life, esp. in intervention group.
  • -Changes we see in control group in Patient disability and pain are due to behavioral modifications from education intervention (increased exercise, better pain monitoring, etc.) -patient psychological distress could be because of beneficial effects of conversation with spouse--even unrelated to pain, can increase intimacy and strengthen marital satisfaction (which is associated with psy. distress); plus regression to the mean phenomenon
  • Caregiver strain yields score from 0 to 13
  • Self eff. Scale is from 1-100, Marriage satisfaction = 0 to 10 -Expect no within-group differences between caregiver and patient for marriage satis. Or self-eff., but as we predict higher levels of psychological distress to begin with, we also expect that intervention-patient would receive increased benefit from the counseling and would have more decrease in psy. Distress - marriage satisfaction increases for all due to intimacy of sharing thoughts/feelings and setting aside time to talk. B/c intervention requires sharing of personal concerns and feelings, increased sense of intimacy and satisfaction.
  • Chart from U.S. Bureau of the Census, rural population is aging and will need these types of interventions more accessible.

O Astudypresentation O Astudypresentation Presentation Transcript

  • 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
  • Projected Increase in U.S. Arthritis Prevalence http://www.cdc.gov/arthritis/data_statistics/national_data_nhis.htm
  • Current standards of treatment
    • Pharmacological
      • Nonsteroidal Anti-inflammatory drugs
    • Behavioral
      • Exercise
      • Monitoring context surrounding pain flares 16
    • Surgical arthroplasty
  • Treatment Limitations
    • Pharmalogical 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 couples Baseline 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
  • Recruitment
    • Recruit from North Carolina Hospitals and Health Clinics in Piedmont (Hispanic and White) and Coastal areas (Af-Am.)
    • Screen for eligibility, collect demographics
    Source: US Bureau of the Census http://www.ncruralcenter.org/databank/trendpage_Population.asp
  • Baseline Measurements
    • PATIENT:
    • Arthritis Impact Measurement Scale
    BOTH: 1. Quality of Marriage Index 2. Self-Efficacy in Pain Communication Scale 3. Beck Depression and Anxiety Inventories
    • PARTNER:
    • Caregiver Strain Index
    • 2. 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
  • Intervention
    • 1/week, 5 weeks
    • Session lasts 40 minutes
    • Led by psychologist trained in
    • pain communication skills training.
    3 and 4 Psychologist-led Pain expression coping conversations, 2 pain topics discussed each session 6 final supervised pain conversation and wrap-up. 2 Introduction to pain communication & emotion expression skills. 20 min. intro conversation with psychologist coaching. 5 Psychologist may remind couples of skills, but does not actively coach conversation, 2 pain topics discussed
  • Control group
    • 1/week, 5 weeks
    • Session last 40 minutes
    • Supervised 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
  • PRIMARY OUTCOMES:
  •  
  • SECONDARY OUTCOMES
  • SECONDARY OUTCOMES 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?
  • References
    • Manek, N.J., and Lane, N.E. (2000). Osteoarthritis: Current Concepts in Diagnosis and Management. American Family Physician, 61, 1795-804.
    • Lawrence RC, Felson DT, Helmick CG, et al. (2008). Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis and Rheumatism 58(1), 26–35.
    • Pugner, K., Scott, D., Holms, J., and Kieke, K. (2000). The costs of rheumatoid arthritis: an international long-term view. Seminars in Arthritis and Rheumatism 29, 305-320.
    • Srikanth VK, Fryer JL, Zhai G, Winzenberg TM, Hosmer D, Jones G. (2005) A meta-analysis of sex difference prevalence, incidence and severity of osteoarthritis. Osteoarthritis and Cartilage 13 , 769–781.
    • Buckwalter JA, Saltzman C, Brown T. (2004). The impact of osteoarthritis. Clinical Orthopedics and Related Research 427S , S6-S15.
    • Dominick, K.L., and Baker, T.A. (2004). Racial and ethnic differences in osteoarthritis: prevalence, outcomes, and medical care. Ethnic Dis, 14(4), 608.
    • Tepper, S. and Hochberg, M.C. (1993). Factors associated with hip osteoarthritis: data from the first National Health and Nutrition Examination Survey (NHANES-I). American Journal of Epidemiology, 137, 1081–1088.
    • Forman, M.D., Malamet, R., and Kaplan D. (1983). A survey of osteoarthritis of the knee in the elderly. Journal of Rheumatology, 10, 282–287.
    • Schnitzer, T.J. (1993). Osteoarthritis treatment update: minimizing pain while limiting patient risk. Postgraduate Medicine 93 , 89-95.
    • Lin, Elizabeth H. B. (2008). Depression and Osteoarthritis. The American Journal of Medicine 121, S16-S19.
    • He, Y., Zhang, M., Lin, E.H.B., Bruffaerts, R., et al. (2008). Mental disorders among persons with arthritis: results from the World Mental Health Surveys. Psychological Medicine 38, 1639-1650.
    • Smith, B.W. and Zautra, A.J. (2008). The effects of anxiety and depression on weekly pain in women with arthritis. Pain 138 , 354-361.
    • Leonard, M.T., Cano, A., and Johansen, A.B. (2006). Chronic Pain in a Couples Context: A review and Integration of Theoretical Models and Empirical Evidence. The Journal of Pain, 7( 6), 377-390.
    • Keefe, F.J., Caldwell, D.S., Baucom, D., and Salley, A. (1996). Spouse-assisted coping skills training in the management of osteoarthritic knee pain. Artritis Care Research, 9, 279-291.
    • McDonald, D.D. and Molony, S.L. (2004). Postoperative pain communication skills for older adults. Western Journal of Nursing Research 26(8), 836-852.
    • Lorig, K., Lubeck, D., Kraines, R.G., Seleznick, M., and Holman, H.R. (1985). Outcomes of self-help education for patients with arthritis. Arthritis and Rheumatism, 28(6), 680-685.
    • Leonard, M.T., Cano, A., and Johansen, A.B. (2006). Chronic Pain in a Couples Context: A review and Integration of Theoretical Models and Empirical Evidence. The Journal of Pain, 7( 6), 377-390.
    • Canam, C. and Acorn, S. (1999). Quality of Life for Family Caregivers of People with Chronic Health Problems. Rehabilitation Nursing 24(5) , 192-196.
    • Regan Sterba, K., DeVellis, R.F., Lewis, M.A., DeVellis, B.M., Jordan, J.M., and Baucom, D.H. (2008). Effect of Couple Illness Perception Congruence on Psychological Adjustment in Women with Rheumatoid Arthritis. Health Psychology 27(2), 221-229.
  • References Cont’d
    • 20. Herbette, G., and Rime, B. (2004). Verbalization of emotion in chronic pain paients and their psychological adjustment. Journal of Health Psychology, 9, 661-676.
    • 21. Cano, A., Johansen, A.B., and Franz, A. (2005). Multilevel analysis of couple congruence on pain, interference, and disability. Pain, 118 , 369-379.
    • 22. Badr, H. and Carmack Taylor, C.L. (2006). Social constraints and spousal communication in lung cancer. Psycho-Oncology, 15, 673-683.
    • 23. Manne, S.L., Ostroff, J.S., Norton, T.R., Fox, K., Goldstein, L., and Grana, G. (2006). Cancer-related relationship communication in couples coping with early stage breast cancer. Psycho-Oncology, 15, 234-247.
    • 24. Badr, H., Acitelli, L.K., and Carmack Taylor, C.L. (2008). Does talking about their relationship affect couples’ marital and psychological adjustment to lung cancer? Journal of Cancer Survival, 2, 53-64.
    • 25. Cano, A., Gillis, M., Heinz, W., Geisser, M., and Fran, H. (2004). Marital functioning, chronic pain, and psychological distress. Pain, 107, 99-106.
    • 26. Waltz, M., Kriegel, W., van’t Pad Bosch, P. (1998). The social environment and health of rheumatoid arthritis: Marital quality predicts individual variability in pain severity. Arthritis Care and Research, 11, 356-374.
    • 27. Marks, R. (2009). Comorbid depression and anxiety impact hip osteoarthritis disability. Disability and Health Journal, 2, 27-35.