R. Gooberman-Hill

Understanding the pain experience in hip and knee osteoarthritis – an OARSI/OMERACT initiative

OBJECTIVEnTo examine the pain experience of people with hip or knee osteoarthritis (OA), particularly changes over time and most distressing features.nnnMETHODnFocus groups in individuals aged 40+ years with painful hip or knee OA obtained detailed descriptions of OA pain from early to late disease. A modified Patient Generated Index (PGI) was used to assess the features of OA pain that participants found most distressing. Content analysis was performed to examine response patterns; descriptive statistics were used to summarize PGI responses.nnnRESULTSnMean age of the 143 participants (52 hip OA; 91 knee OA) was 69.5 years (47-92 years); 60.8% were female and 93.7% Caucasian. Participants described two distinct types of pain - a dull, aching pain, which became more constant over time, punctuated increasingly with short episodes of a more intense, often unpredictable, emotionally draining pain. The latter, but not the former, resulted in significant avoidance of social and recreational activities. From PGI responses, distressing pain features were: the pain itself (particularly intense and unpredictable pain) and the pains impact on mobility, mood and sleep.nnnCONCLUSIONSnTwo distinct pain types were identified. Intermittent intense pain, particularly when unpredictable, had the greatest impact on quality of life.

The assessment of persistent pain after joint replacement

SUMMARY This study used ‘think aloud’ to explore issues around using a standardised questionnaire to assess persistent pain after joint replacement. Twenty participants with moderate–extreme persistent pain in their replaced hip or knee completed the Chronic Pain Grade (CPG) while ‘thinking aloud’. The interviews were audio-recorded, transcribed and analysed using thematic analysis. Completion of the CPG by patients was influenced by four issues: challenges with the question wording or response options on the CPG items; the fluctuating nature of pain and functional limitations; the need to account for co-morbidities and pain elsewhere; and adjustment to pain. These issues reflect those that have arisen previously in patients with musculoskeletal pain, and need to be considered when assessing persistent joint pain, both before and after joint replacement.

Locomotor disability: Meaning, causes and effects of interventions

This paper provides a synopsis of a long-term programme of MRC-funded work on locomotor disability in older people. Specifically it describes the meaning and experience of disability, examines the risk factors for disability and systematically reviews the evidence from randomized trials of complex interventions for disability. We undertook a national prospective study of a representative sample of 999 people aged 65 years or more plus in-depth interviews with a small subsample and a selected sample obtained from hospital sources. Secondary analysis of several large prospective studies was carried out and a systematic review and meta-analysis of published randomized controlled trials of the effects of complex interventions for disability. Very few participants subscribed to the constructs of longstanding illness, disability or infirmity that surveys often use. A wide range of social and psychological factors, independently of chronic diseases, were strongly associated with disability. People with greater functional reserve capacity and those with greater self-efficacy were generally less likely to suffer from catastrophic decline in ability and had better quality of life in the face of disability. In reviewing 89 trials (over 97,000 participants) of complex interventions for disability, evidence of benefits was found although no relationship with intensity of intervention was apparent. Our findings on the meaning and experience of disability suggest the need for modifications to routinely used survey questions and for different ways of understanding the need for and receipt of care among older people with disabilities. The diverse risk factors for disability suggest that novel approaches across social, psychological as well as more traditional rehabilitation and behavioural risk factor modification would be worth exploring. Complex interventions appeared to help older people to live independently and limit functional decline irrespective of age and health status.