Research in Gerontological Nursing

Empirical Research 

The Reciprocal Relationship of Pain and Movement in African American Older Adults With Multi-Joint Osteoarthritis

Staja Q. Booker, PhD, RN; Keela Herr, PhD, RN, AGSF, FGSA, FAAN; Roger B. Fillingim, PhD

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

Pain with movement is a common issue for older adults with osteoarthritis; however, there has been insufficient attention within populations at increased risk for disabling pain, such as African American older adults. Accordingly, using a mixed methods approach, the purpose of the current study is to describe the nature of chronic joint pain and movement and its impact on physical function in African American older adults with symptomatic osteoarthritis. The authors accrued a sample of 110 African American older adults who completed cross-sectional surveys; from this sample, the authors interviewed 18 participants. Findings suggest that patterns of movement are uniquely influenced by pain. Specifically, three dynamic themes emerged: The Impact of Pain on Movement; The Importance and Impact of Movement on Pain; and The Adaptation of Personal Behaviors to Minimize Pain With Movement. Function-focused nursing care rests on addressing challenges and opportunities that African American older adults face in maintaining healthy movement when managing osteoarthritis pain. [Research in Gerontological Nursing, 13(4), 180–190.]

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

Pain with movement is a common issue for older adults with osteoarthritis; however, there has been insufficient attention within populations at increased risk for disabling pain, such as African American older adults. Accordingly, using a mixed methods approach, the purpose of the current study is to describe the nature of chronic joint pain and movement and its impact on physical function in African American older adults with symptomatic osteoarthritis. The authors accrued a sample of 110 African American older adults who completed cross-sectional surveys; from this sample, the authors interviewed 18 participants. Findings suggest that patterns of movement are uniquely influenced by pain. Specifically, three dynamic themes emerged: The Impact of Pain on Movement; The Importance and Impact of Movement on Pain; and The Adaptation of Personal Behaviors to Minimize Pain With Movement. Function-focused nursing care rests on addressing challenges and opportunities that African American older adults face in maintaining healthy movement when managing osteoarthritis pain. [Research in Gerontological Nursing, 13(4), 180–190.]

Research on the global burden of disease established that musculoskeletal conditions are the number one cause of disability worldwide, accounting for 21.3% of the total years lived with disability (Briggs et al., 2016; GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017). Specifically, osteoarthritis (OA) is the leading cause of persistent musculoskeletal pain and disability in older adults and has a profound effect on changes in mobility, functional health, and quality of life (Blyth & Noguchi, 2017; Cruz-Almeida, Rosso, et al., 2017). One of the most significant contributors of OA-related disability is pain with movement (Booker et al., 2019; Corbett et al., 2019). Recent pain studies show that African American older adults described their movement patterns as a means to remain mobile and functional (Park, Manotas, & Hooyman, 2013; Robinson-Lane & Vallerand, 2018). Although the literature has addressed the impact of OA on older adults (Blyth & Noguchi, 2017), the current authors' scientific premise is that pain and movement as interacting and intersecting issues are understudied yet critical components to understanding disparities in pain-related disability outcomes in high-risk populations, such as aging African Americans with OA.

Pain explains a large proportion of total variance in self-reported function in African American and Caucasian Americans with OA (Allen et al., 2009). Despite similar prevalence rates of OA between African American and Caucasian American individuals, OA-related pain and disability are disproportionately worse in African Americans. African Americans have more severe joint pain, pronounced immobility, functional and activity limitations, and greater disability (Barbour, Boring, Helmick, Murphy, & Qin, 2016; Parmelee et al., 2012; Vina, Ran, Ashbeck, & Kwoh, 2018). In older African Americans, these patterns of pain and functional limitation are more notable (Park, Engstrom, Tappen, & Ouslander, 2015), and progressively lead to disability and dependence. Studies comparing racial differences (African American vs. Caucasian American individuals) in severity of OA pain and functional disability show inconsistent findings: equal pain and disability (Burns, Graney, Lummus, Nichols, & Martindale-Adams, 2007; Onubogu, 2014), equal disability but greater pain (Bruce, Fries, & Murtagh, 2007), and greater pain and disability (Allen et al., 2009; Parmelee et al., 2012), but no studies show less pain and less disability.

A recent meta-analysis demonstrated that OA pain and disability are greater in African Americans compared to Caucasian Americans (Vaughn, Terry, Bartley, Schaefer, & Fillingim, 2019). The drivers for these differential outcomes are multifactorial, including socioeconomic inequities, environmental dynamics, perceived stress, and other biobehavioral factors, particularly pain processing (Cruz-Almeida, Cardoso, et al., 2017; Booker et al., 2019). Cruz-Almeida et al. (2014) found that African American older adults, as compared to Caucasian older adults, have greater OA pain and disability but also more impaired pain modulatory systems (i.e., decreased pain inhibition) to regulate function-related pain. Differences in pain inhibition may also support why severe functional impairment in African Americans is also associated with other types of pain, such as cancer pain (Hazard Vallerand, Hasenau, Robinson-Lane, & Templin, 2018). Despite these differences, there are limited data beyond quantitative measurement to support how pain with movement specifically impacts objective function and perception of function in African American older adults.

Pain and movement are strongly interrelated, sometimes paradoxically so. Although pain often discourages movement and movement exacerbates pain, the importance of movement and activity in managing pain are also well recognized (Chimenti, Frey-Law, & Sluka, 2018). Research on pain with movement has recently increased among pain scientists, particularly with greater national emphasis on understanding and reducing high-impact chronic pain, which is characterized as persistent pain that significantly interferes with functional ability (e.g., mobility, basic daily activities, social activities) (Pitcher, Von Korff, Bushnell, & Porter, 2019). The neural and motor pathways by which movement induces pain are beginning to receive empirical and theoretical attention (Butera, Fox, & George, 2016; Corbett et al., 2019; Cote & Hoeger Bement, 2010; Cruz-Almeida, Rosso, et al., 2017; Hodges & Tucker, 2011), although important questions remain unanswered about the relationship between movement and pain-related functional outcomes especially in people with chronic conditions associated with movement restrictions such as OA (Corbett et al., 2019) and post–total knee replacement (Rakel et al., 2012).

Even with an increase in research investigating movement-evoked pain, the relationship between pain and movement remains understudied, although some recent evidence shows that middle-aged and older African Americans with knee OA experience greater movement-evoked pain than Caucasian Americans (Cruz-Almeida, Cardoso, et al., 2017; Booker et al., 2019). Furthermore, in a previous qualitative analysis, the current authors observed that pain was a major barrier to movement, physical activity, and exercise; however, many African American older adult participants also revealed that movement and regular physical activity also improved pain (Booker, Herr, & Tripp-Reimer, 2018). This parallel phenomenon reveals the dueling effects of pain aggravation and pain relief, whereby pain negatively impacts movement and movement positively impacts pain, respectively. The latter observation was frequently overshadowed by the negative impact.

Limited research has explored the real-life experience of pain with movement from the voices of African American older adults. Thus, understanding their experience of OA and the pain-related factors that affect movement are critical to reducing arthritis-attributable limitations in function and mobility and improving their quality of life and well-being. In the current a posteriori mixed-methods analysis, the aim is to describe the nature of chronic joint pain and movement and its impact on physical function in African American older adults with symptomatic OA.

Method

Design

The current study is a descriptive analysis from a convergent parallel mixed methods study (Booker et al., 2018). Participants completed surveys on pain and self-management practices, and concurrently completed in-person, semi-structured interviews. Findings on self-management practices are published elsewhere (Booker et al., 2018). In the current study, qualitative data were given greater weight, and analyses are supplemented by quantitative survey data specific to function.

Sample and Setting

Qualitative participants (N = 18) were selected from the quantitative strand's convenience sample (N = 110) using a purposive stratified sampling approach based on pain severity level, educational attainment, age group, and gender (Booker et al., 2018). African American adults were recruited from metropolitan and rural communities in Louisiana. Study criteria required African Americans to identify as non-Hispanic/Latin(x), be age ≥50 years, have joint pain for approximately ≥3 months, have clinical signs of OA, live independently, and be without major cognitive impairment (Booker et al., 2018). Clinical symptoms of OA included: intermittent swelling in any joint, stiffness in the morning (<30 minutes) or after periods of inactivity, crepitus or grading sound or feel when walking or bending a joint, and pain that gets better with rest but worse with activity (Abhishek & Doherty, 2013).

Research Ethics

Study approval was granted by the Institutional Review Board (IRB) from a flagship midwestern (U.S.) university. Participants were informed that all audio recordings of interviews would be kept confidential, securely stored, and only shared though aggregated data in presentations and publications.

Measures

Qualitative Interviews. The qualitative procedures are detailed in a previous publication (Booker et al., 2018). A semi-structured interview guide was conducted with 22 questions regarding participants' practices, processes, and preferences for pain self-management within the context of their personal, cultural, and community environments. Interviews were conducted by the first author (S.Q.B.) and lasted approximately 70 minutes.

Brief Pain Inventory–Short Form. The Brief Pain Inventory Short–Form (BPI–SF), a self-report survey, assessed pain intensity and the degree in which pain interferes with seven physical, social, and psychological functional areas (Cleeland, 1991). The BPI–SF was completed by all 110 participants. Cronbach's alpha for internal consistency on the BPI-SF ranged from 0.88 to 0.96, and test–retest reliability ranged from 0.67 to 0.87, demonstrating validity in people with OA (Kapstad, Rokne, & Stavem, 2010; Mendoza, Mayne, Rublee, & Cleeland, 2006). Scores range from 0 to 10, and higher mean scores indicate greater pain intensity and interference on functioning (5 to 10), whereas lower scores (0 to 4) indicate less pain and interference. Descriptive statistics from the pain interference subscale are used to contextualize qualitative results.

Data Analysis and Integration

A deductive-inductive approach guided the qualitative content analysis to identify common themes, explanations, and patterns. Analysis was completed using qualitative description, as conceptualized by Sandelowski (2010), which enables a range of responses to a disparate phenomenon that is not commonly investigated, described, or understood (Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016).

Systematic data analysis occurred concurrently with data collection: after each interview, (a) field notes were processed; (b) audio recordings were professionally transcribed by an IRB–approved vendor, verified by the primary investigator (S.Q.B.) for verbatim linguistic accuracy, and transcripts were imported into HyperRESEARCHTM (version 3.7.3); and (c) an open coding template was developed and finalized by two researchers (S.Q.B. and other) and applied to all transcripts.

For the current analysis, the authors first examined previously analyzed transcripts to identify codes and categories labeled as movement-evoked pain, exercise causes pain thus prevents action, exercise/moving around helps pain and stiffness, mobility, and physical function. A focused rereading and key word search of all 18 transcripts were performed to review responses that made mention of the effect of pain on movement (e.g., walking, mobility, bending), function (e.g., pacing activities, basic/instrumental activities of daily living [ADLs], physical activity/exercise), and disability (e.g., assistive devices, inability to care for self or walk).

Demographic and BPI–SF data from the total sample (N = 110) were entered into IBM® SPSS version and summarized as mean (SD) and frequencies (n, %) to complement qualitative findings. At each step of analysis, the qualitative and quantitative data were compared to understand and verify findings. After individual analysis of all data sources, data triangulation was conducted to assess convergence and mutual corroboration. Steps to ensure trustworthiness of the data were taken, including triangulation methods, maintaining audit trails and memo notes, and regular research team meetings to discuss results and interpretation (Lincoln & Guba, 1985; Willis et al., 2016).

Results

Table 1 provides a comparison of participant characteristics between total sample and qualitative sample. The total sample (N = 110) was mostly female (80%) and retired (59%), and women (mean age = 68.58 [SD = 12.95]) were marginally older than men (mean age = 67.80 [SD = 9.52]). From the total sample, 84% of participants had a diagnosis of OA, but all participants demonstrated clinical symptoms consistent with OA. The most common sites for OA were knees (n = 85, 77.3%), hands (n = 41, 37.3%), lower back (n = 39, 35.5%), and hips (n = 25, 22.7%).

Participant Characteristics Stratified by Qualitative Sampling Criteria

Table 1:

Participant Characteristics Stratified by Qualitative Sampling Criteria

Qualitative participants' (N = 18) demographics and clinical characteristics closely matched those of the total sample, except that interviewees were equal in gender distribution—nine men and nine women. Interview participants' descriptions of pain and/or arthritis were often in reference to movement and function, signaling that these are major issues that African American older adults encounter and must manage daily. Fourteen participants mentioned movement/move/moving in the context of pain or joint symptoms approximately once during the interview, and two participants talked about lack of being active as a contributor to arthritis and the importance of staying active. Three qualitative themes characterized the dynamic nature of OA pain with movement: (a) Impact of Pain on Movement, (b) Importance and Impact of Movement on Pain, and (c) Adaptation of Personal Behaviors to Minimize Pain With Movement. Figure 1 illustrates the patterns of movement and pain.

Cycle of pain and movement.

Figure 1.

Cycle of pain and movement.

Impact of Pain on Movement: Minimize Moving

Total pain interference was relatively low (mean = 3.53 [SD = 2.58]) for the entire sample but slightly higher for the qualitative sample (mean = 4.21 [SD = 2.58]). Participants also reported high confidence in their ability to minimize pain interference with the things they want to do (mean = 7.07 [SD = 2.52]; mean = 7.86 [SD = 2.87] for total vs. qualitative sample, respectively). Nevertheless, qualitative participants reported that pain significantly impacts temporal variability in daily function, ADLs, mobility, and psychological well-being. As participants stated:

It takes hold of the body and gives you problems, no matter where it's located on in the body. (081: Male, age 84)

Even affects you physically and emotionally because you be in so much, you be in pain. It'll make you cranky, irritable. [Laughter] That's basically the only thing I really know about arthritis, that it affects you a lot. (018: Female, age 50)

Functional Limitations. OA resulted in limited range of motion and ability to perform basic and instrumental ADLs, engage in social activities, and sleep impairment. As evidence, one participant stated:

I know it affects you, especially your movement. Then it restricts you from doin' the things that you like to do and you used to do and that can cause problems. (018: Female, age 50)

As a result, participants were unable to “function quite like you ordinarily would” (108: Male, age 71), making certain tasks more challenging and unsafe. Thus, many found it difficult on some days to engage in leisure and pleasurable activities despite reporting low interference on enjoyment of life (mean = 3.63 [SD = 3.54]).

As one older adult woman said:

I sit and look back over my life and wonder. I didn't think this day would come when I was younger, but I say now, just look at me now. Things I used to could do, can't do 'em now. Yeah, I used to have a garden, beautiful garden. (030: Female, age 85)

Social relationships were compromised due to imposition of physical limitations; yet scores on the BPI–SF interference with social relationships item were extremely low (mean = 1.85 [SD = 3.01]). Although OA resulted in varying levels of disablement, participants were determined not to allow pain to stop them from moving, doing activities (e.g., leisure, household), and partaking in life.

…If I stop every time I was hurting, I wouldn't get much done. (009: Female, age 68)

I refuse to let arthritis stop me. That's my attitude toward—I'm not gonna let this just get me completely down! That's why I bought my car, so I could keep movin', at least on wheels, if not on my legs! (075: Female, age 81)

Mobility Limitations and Disability. There was great impairment in mobility, whereby “it [pain] puts a limitation on what I can do and my movements…. Long as I'm sitting or in a position where I'm comfortable, well, it doesn't bother me unless I move” (081: Male, age 84). Many qualitative participants reported altered mobility and walking ability, and some expressed fear of falling. As a result, they reported moving slower or eliminating usual household tasks to ensure personal safety. The interviewer (S.Q.B.) captured observable pain-related behaviors during interactions with participants and these behaviors were recorded and quantified on a data collection form. The most prominent behaviors were gathering their balance before walking (14.5%), limping (9.1%), restricting movement (7.3%), and using objects in their environment for additional stability (5.5%; e.g., holding on to the wall or chairs). Observations were confirmed by participant statements, such as, “When I stand up and get my balance, then I move” (099: Male, age 65).

Three participants specifically mentioned feeling self-conscious about their gait, walking with bowed legs and not “want[ing] anybody to see me limping around.” One participant even likened her walking to “Fred Sanford” (009: Female, age 68) from the syndicated television show Sanford and Son (Galton et al., 1972). Despite experiencing OA, participants noted the sadness of seeing others in much worse functional condition.

I see more cripple people. People that barely can walk, or people that have—and that, within itself, sort of—it sort of hurt your feelings to see so many people that's down. It's a lot of people down, baby. I promise you. (108: Male, age 71)

Importance and Impact of Movement on Pain: Keep Moving

When asked “What things would help you manage OA?,” many participants noted movement-based strategies such as “movement,” “moving,” “exercise,” and “staying active.” For example:

Well, it's like I was sayin', a person need to move around and do some exercise. He just need to stay active. (108: Male, age 71)

The need to move was even more important for individuals still employed:

Come to work, moving, mobility, that helps a lot. (008: Female, age 61)

Furthermore, several older adults referenced that moving each day is a necessary activity for pain self-management regimens and to help limit the impact of OA symptoms and the progression or worsening of arthritis pain. For example, as stated below:

Well, I take my medication, diclofenac [brand name redacted], and I take hot showers. I rub up with ointments you know like Icy Hot® or something. That's about the size of it. That's all I know to do for mine, and I move around as much as possible. (031: Female, age 85)

On a daily basis, some days probably my pain might would be at a—it might start out when you wake up. Maybe it's the way you moved or turned, or if you moved too quickly, something will happen within the body. Then, you notice that the pain is there. That's when you do something about it. You begin to take the pain medicine, rather than to wait until it's at a 10. Cuz if you want till it's at a 10, you're gonna have to stay in the bed…. At a 10, I'm not mobile…if I get up and I notice that, on my side, it's hurting down in my hip area…and my walking is not steady. I know I need to do something then… take some pain medicine. (075: Female, age 81)

African Americans held a strong belief that although it is painful and sometimes challenging to move, there is no alternative for regular movement.

Each day, if you can't move this hand, you gotta move this one. Always keep walking. …it's a learning process every day. (099: Male, age 65)

By strengthening the muscles around the joints, participants believed their stiffness was reduced and balance was improved.

You've got to, baby. There's just no other way around it. Exercising. Cuz generally, when I move these joints, that makes me feel better. I think those fluids that are around the joint, the synovial fluid that's within that tissue, I think it increases when we exercising, cause that friction on the inside, and move those joints. We've got to move these joints. I'm so used to pain until it just doesn't affect me the way it used to affect me when I was young…. But now that I'm older, I know how to handle it. I believe in walking. I believe in going to the pool, as I told you. When you do that, I think all of that help, and it builds up the muscles around those joints that help protect that. (007: Female, age 54)

Adaptation of Behaviors to Minimize Pain with Movement: Bracing and Pacing, The New Normal

When I was 78, I didn't have pain. After I was 78, seemed to begin to change. My structure, everything, mind, once upon a time I could do quick things. You can get up and move. If somebody said, “Go get that,” you could.... Now, you can't. I can't do that. I have to hold on to something, to get up, because number one, I don't wanna fall. (075: Female, age 81)

Changes in physical and mental function elevated the level of seriousness, causing an underlying fear of losing independence and some dispiritedness, although they were grateful to be alive and have enough function to remain living independently. Older adults had to learn to accept the limitations that OA brings, and in this “new stage” (031: Female, age 85) found themselves manipulating their environment or modifying behaviors to minimize pain and continue being active and independent. One woman stated:

It's very serious because it determines whether I take care of myself and life I would have. I mean it's a difference between bein' able to walk, bein' able to do things on your own. Because as I told you, 2 years of my life I was completely bedridden. I was just simply…symptoms were just to the severest that they could possibly be. Wracking pain all over my body at once. I couldn't do anything. Couldn't lift myself. Once you've been there and could not walk, I spent 6 years in a wheelchair...It's devastating.… Through God I know all things are possible. That's what I believe, baby. I wouldn't be walkin'. They don't understand to this day how blessed I am. (007: Female, age 54)

Using and Anticipating Use of Assistive and Orthotic Devices. In some homes, the interviewer observed walkers, canes, and wheelchairs, and these were typically used by those with severe cases of OA. Most times, these devices were used to help with walking, balance, and stabilization of joints especially during periods of severe pain. Compared to the general sample (49%), more qualitative participants (72%) owned and used an assistive and/or orthotic device, whereas the remaining 28% (and 51% of the total sample) were not using assistive devices and reported they would use them in the future if functional impairment worsened. For instance:

I hope I never have to use a walker, but I will if I do. I wanna just get a little bit more physically active, and there's a lot of things I can do. (061: Male, age 63)

For some, advancing severity of OA led to a progression in the types of assistive devices needed:

I really was getting to where I couldn't walk. When I actually ended up on canes or walkers and then gradually to a wheelchair, then they [family] saw the destruction of how all of it was happenin. (007: Female, age 54)

The decision to use assistive devices, along with consistency and/or frequency of use, lies in adjustment and acceptance of their condition as well as perceptions of need (e.g., pain severity, mobility level), bulkiness, and ease of use. When discussing her inconsistent use of assistive devices, one woman explained:

I try not to take it [cane] if I can. [Laughter] I got to stop that, though.…You're not ready for everybody to see that. You done got here. You still wanna be who you was. And you haven't accept the fact that you're not. (018: Female, age 50)

The perception of how others would view them when using a walker or cane as well as how participants viewed themselves resulted in a negative self-image. Some African American older adults needed assistive aids daily, others used them as needed. The participant above added:

They [my kids] be fussin' at me, cuz I'm supposed to have my cane. If I'm hurting, I slow it down. I won't be as active. I use my cane, like I supposed to. If I'm in the kitchen cooking, like when I do my cakes and stuff, I know I'm gonna be in there a long time standin' on my feet. I have a walker with wheels on it and a seat on it. (018: Female, age 50)

Some kept their assistive devices (e.g., cane, walker) nearby in case the pain flared “Because I never know when I'm gonna need it” (081: Male, age 84). Others used publicly available motorized scooters when shopping, and this helped them maintain a sense of personal independence. Several African American older adults discussed using assistive and/or orthotic devices to try to improve knee stability and pain as an alternative to joint replacement surgery.

I know a lot of people who've had joint replacements and knee replacements, and they don't get any better. I might as well just ache and go on. Take my medicine and let it do what it's gonna do. Use my walker, and I'm okay. (031: Female, age 85)

If it got worse, they would talk about a knee replacement, but that's the last thing I wanna do. If I don't have to, I won't have that. They made me a sleeve. You pull it up, and it leaves your kneecap out, and it's got straps on it and it holds it in place cuz they said my patella was trying to move to the right. (061: Male, age 63)

Some participants believed that constant movement could help delay the need for surgical intervention, such as joint replacement. Others gauged the need for joint replacement by the degree to which pain interfered with their ability to walk and function normally.

I was almost at one point to where I couldn't walk. I've prayed about it, and I started doin' some stretches, and that helped me more than anything…because I'd probably be crippled by now if I wasn't doin' some. I thought I was goin' have to have some knee—a knee operation on both of 'em.… It's just I guess the movements that I do, and workin' all day long. (108: Male, age 71)

I don' seen and heard a lot of people say their knees and everything feel better after they had surgery. As long as I'm able to move around and still do things for myself, I'mma keep putting it off. If it ever comes down to the point where I can't move around or nothing unless I have surgery, then I'll consider that about going and having surgery. (097: Male, age 63)

Resting and Pacing Activities. Approximately 22% of the total sample, 67% of which were interviewees (n = 12 of 18), noted the importance of rest/relaxation and activity limitation, especially for individuals who also had other comorbidities, such as chronic obstructive pulmonary disease or heart failure. As noted by one participant, “'cause basically when I'm at home, I don't move it [knee]” (008: Female, age 61). Rest included: bedrest, elevating legs, relaxing in a chair, or simply limiting activities. Resting was a double-edged sword, and although helpful to relieve acute flare-ups, “if the pain is there and I sit too long, the pain will get worse” (075: Female, age 81). Rest was beneficial when participants believed they had overtaxed their body.

If I'm in a flare-up, I'm gonna rest…because generally if you're hurting real bad and it causes me sometimes not to be able to move as well and as fluid…you basically have to rest. ‘Cuz if you don't, it's just gonna tear you down even more. (007: Female, age 54)

Discussion

Painful musculoskeletal conditions, such as OA, can profoundly impact movement and activities, and compelling evidence shows that painful musculoskeletal conditions resulting in functional deterioration, frailty, and loss of independence are a global threat to healthy aging (Briggs et al., 2016). The current study found evidence for functional deterioration and subsequent frustrations with changing levels of independence, but also a concurrent optimism and resilience to continue moving despite pain and changes in mobility. Major themes from the current study illuminated several reciprocal relationships between pain and movement in African American older adults (Figure 1):

  • Pain changes movement patterns and movement changes pain patterns.
  • Pain can inhibit movement and movement can facilitate pain.
  • Pain can impair movement but movement can improve pain.
  • When pain is lower, movement is higher.
  • When pain is higher, movement is lower.

It is likely that changes in functional patterns are a direct effect of pain or are mediated by fear of anticipatory pain and movement or their disability level. Yet, there was interesting divergence between BPI–SF pain interference responses and participants' narratives, highlighting the importance of qualitative methods in better understanding the lived experience of older adults with chronic pain. Overall pain interference scores for both samples were low compared to their narrative descriptions of substantial impact on function. Low scores were primarily driven by floor effects due to a large proportion of 0 of 10 ratings (i.e., no interference) on several individual items, such as mood and relations with others. However, when physical function items were analyzed separately for the entire sample, African American older adults had higher mean interference scores for walking (4.53 [SD = 3.80]), doing normal work (4.71 [SD = 3.81]), and sleep (4.25 [SD = 3.65]). Interviewees reported that pain interfered with performance of basic and instrumental ADLs, but they did not allow pain to stop them from doing general activities, which may have influenced lower perceived interference. Compared to the current study, others indicate marginally higher pain interference scores in African American older adults (Robinson-Lane & Vallerand, 2018). Typically, at higher levels of pain intensity, pain interference decreases with age, a likely function of enhanced coping skills and/or altered expectations regarding normal activities (Boggero, Geiger, Segerstrom, & Carlson, 2015). It is postulated that African Americans have developed stronger spiritual coping mechanisms in response to chronic pain (Booker, 2015; Meints, Miller, & Hirsh, 2016), which could frame African American older adults' perception and objective rating of pain interference.

Overall, declines in function and walking ability described by individuals with OA pain comprise a “disability trinity”: chronic pain, physical (dys)function, and mobility impairment. This tri-partite phenomenon highlights important pain-related factors that increase the risk of disability in older adults, especially ethnic minorities. Because the qualitative portion was small and exploratory, better understanding of this phenomenon may reveal critically important clinical intervention targets to reduce joint pain, reverse impaired function, and enhance perceived control over pain.

Implications

Healthy People 2020 (U.S. Department of Health and Human Services, 2010) set a goal to prevent and decrease disabling joint pain and preserve independence by reducing the proportion of older adults with arthritis-related limitations in specific joint-related activities. Qualitative findings reveal the challenges and opportunities that African American older adults face in maintaining healthy movement when managing OA. Notably, participants recognized the importance of movement in sustaining their health and quality of life, and they expressed a desire to develop strategies that will avoid mobility declines.

Nurses can provide support at all levels with proactive education, functional risk screening tools, function-focused care (Resnik, Galik, & Boltz, 2013), and introduction of nonpharmacological strategies, such as transcutaneous electrical nerve stimulation (TENS), which is shown to reduce movement-evoked pain associated with OA and joint replacement (Cherian et al., 2016; Chimenti et al., 2018; Rakel et al., 2014). It is important that nurses are engaged in preserving and enhancing the functional capacity of older adults and serve as advocates for quality comprehensive pain treatment.

Nurses with expertise in the care of older adults have an opportunity to work within an interdisciplinary team who can teach and motivate African American older adults on how to overcome pain and how to safely initiate activities, mainly through behavioral modification to break the cycle of fear and avoidance through perceived threat reduction, musculoskeletal strengthening, and safe biomechanics (Chimenti et al., 2018; Latham & Liu, 2010). A randomized controlled trial found evidence that nurse practitioners could effectively deliver pain coping skills training, which included teaching older adults how to alter activity and rest patterns as a way of increasing activity level (e.g., behavioral modification) and reducing negative pain-related thoughts and emotions (e.g., threat reduction) (Broderick et al., 2014). Furthermore, it may prove advantageous if nurses can convey that regular physical activity to reduce pain and improve function can also improve other chronic disease indicators that commonly affect African Americans, such as blood glucose levels and blood pressure (Tucker et al., 2019).

Other areas for nursing consideration include assessment of movement-evoked pain, fall risk, walking impairment and recovery, and safe use of assistive devices. The stigma of “getting old,” potential disability discrimination, loss of independence and control, and desire to remain fashionable and youthful are relevant concerns for African American older adults when deciding to use assistive aides (Copolillo, 2001; Resnik, Allen, Isenstadt, Wasserman, & Iezzoni, 2009). One woman from the current study delayed using a cane because “she was trying to be cute.” Identity and social perception may deter use of assistive devices, and providers may need to provide tailored recommendations for use. When geriatric and community health nurses consider cultural norms and values, pain interventions for ethnically diverse older adults can be optimized. Using a mixed methods approach allowed the authors to identify a significant concern and the cultural nuances therein that the quantitative survey otherwise did not elucidate or illuminate. Multiple levels of scientific inquiry are needed to develop evidence-based practices, but also more practice-based evidence is needed to guide population strategies aimed at reducing pain- and movement-related health disparities. More importantly, there is a desperate need for greater pain research engagement between scientists and African American communities.

Strengths and Limitations

One strength of the current study includes the elicitation of diverse perspectives via multiple methods of data collection through surveys, interviews, and observations, which strengthens the credibility of findings. The sample was heterogeneous regarding pain severity and sociodemographic characteristics, which increases transferability (Booker et al., 2018); however, the specific cultural influences of the regional areas from which participants were recruited limits generalizability to African American/Black populations in other parts of the United States. From the outset of study design, a sample of 18 to 21 participants was predetermined, and although this yielded very rich and vivid data, the authors did not strive to achieve data saturation. However, many of the study themes reached saturation. In addition, limiting participation to African American older adults living independently in the community may have excluded a key population of participants (e.g., assisted living) who have significant pain and functional limitations due to OA. Despite these limitations, the knowledge gained from current findings adds a valuable voice to the limited literature on pain in African American older adults. This research, although incremental, demonstrates the importance of targeting pain-related function and supports a program of research focused on building the evidence of an increasingly recognized phenomenon, movement-evoked pain (Booker et al., 2019; Corbett et al., 2019).

Conclusion

OA is often dismissed as a disease of aging, and the current article is only one of a few studies to qualitatively examine the experience of living with chronic joint pain and movement limitations in African American older adults. African American older adults recognized and reported the reciprocal relationship between pain and movement. Therefore, interventions should focus not only on reducing pain but intentionally improving function and mobility.

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Participant Characteristics Stratified by Qualitative Sampling Criteria

Demographic Characteristic Total Sample (N = 110)<inline-graphic xlink:href="10.3928_19404921-20191202-01-inline1.jpg" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink"></inline-graphic> Qualitative Sample (N = 18)
Mild Pain n (%) Moderate Pain n (%) Severe Pain n (%) Mild Pain n (%) Moderate Pain n (%) Severe Pain n (%)
Sex
  Female 23 (20.9) 52 (47.3) 15 (13.6) 1 (5.6) 4 (22.2) 4 (22.2)
  Male 2 (1.8) 14 (12.7) 4 (3.6) 1 (5.6) 4 (22.2) 4 (22.2)
Education
  Less than high school 2 (1.8) 8 (7.3) 2 (1.8) 0 (0) 4 (22.2) 1 (5.6)
  High school/some college 7 (6.4) 36 (32.7) 12 (10.9) 0 (0) 4 (22.2) 4 (22.2)
  College degree 16 (14.5) 22 (20) 5 (4.5) 2 (11.1) 0 (0) 3 (16.7)
Agea
  50 to 64 11 (10) 27 (24.5) 6 (5.5) 2 (11.1) 3 (16.7) 3 (16.7)
  65 to 79 10 (9.1) 26 (23.6) 9 (8.2) 0 (0) 2 (11.1) 3 (16.7)
  80 to 94 3 (2.7) 13 (11.8) 4 (3.6) 0 (0) 3 (16.7) 2 (11.1)
Painb Characteristic Mean (SD) Mean (SD)
  BPI–total interference 3.53 (2.58) 4.21 (2.58)
  BPI–general activity 3.34 (3.58) 4.94 (3.70)
  BPI–mood 2.41 (3.17) 2.89 (3.53)
  BPI–walking ability 4.53 (3.80) 5.44 (3.63)
  BPI–normal work 4.71 (3.81) 4.39 (3.70)
  BPI–relations with other people 1.85 (3.01) 1.11 (1.97)
  BPI–sleep 4.25 (3.63) 5.33 (3.16)
  BPI–enjoyment of life 3.63 (3.54) 5.39 (3.20)
  Self-efficacyc: How confident are you that you can keep arthritis pain from interfering with the things you want to do? 7.07 (2.52) 7.86 (2.87)
Authors

Dr. Booker is Assistant Professor, College of Nursing, and Dr. Fillingim is Distinguished Professor, College of Dentistry, The University of Florida, and Pain Research and Intervention Center of Excellence, Gainesville, Florida; and Dr. Herr is Kelting Professor of Nursing, Associate Dean for Faculty, The University of Iowa, College of Nursing, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current study was supported by predoctoral and postdoctoral training grants from the National Institutes of Health (NIH) (T32NR011147; T32AG049673).

Address correspondence to Staja Q. Booker, PhD, RN, Assistant Professor, College of Nursing, The University of Florida, 1225 Center Drive, Gainesville, FL 32610; email: bookers@ufl.edu.

Received: July 05, 2019
Accepted: October 15, 2019
Posted Online: December 13, 2019

10.3928/19404921-20191202-01

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