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Keywords:

  • Rheumatoid arthritis;
  • Coping;
  • Self management;
  • Self care

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

Objective

To examine self-management behaviors used to cope with 5 rheumatoid arthritis (RA)-related stressors (pain, fatigue, physical limitations, joint changes, and symptom unpredictability) and the relationship between use of self-management behaviors and ability to perform life activities.

Methods

Data were from telephone interviews of 511 persons with RA. Participants were presented with lists of self-management behaviors for each stressor and asked to indicate which they had used in the past year. Performance of life activities was assessed concurrently (baseline) and 1 year later (followup). The number of activities affected (difficulty performing or unable to perform) and the number that individuals were completely unable to perform were calculated. Multiple regression analyses were used to examine the association of perceived stressor impact and arthritis education with strategy use and the association of self-management behaviors with performance of life activities.

Results

Four self-management strategies were identified: accommodation, active remediation, social, and perseverance. Greater perceived impact of stressors was associated with use of more self-management strategies in total for each stressor (β = 0.43–0.73, all P < 0.0001) and with use of accommodation (β = 0.26–0.29, P < 0.0001), social (β = 0.23–0.43, P < 0.0001), and perseverance (β = 0.29–0.46, P < 0.0001) strategies. Greater use of accommodation strategies at baseline was associated with an increase in the number of activities affected at followup (β = 0.11, P < 0.05); greater use of perseverance strategies was associated with a decrease in activities unable to perform (β = −0.13, P < 0.01).

Conclusion

Self-management behaviors are commonly used and may help prevent loss of the ability to perform life activities.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

There has been a substantial amount of research on both self management of rheumatoid arthritis (RA) and coping with RA. Self management has been defined as the day-to-day tasks individuals undertake to control or reduce the impact of disease and to deal with the psychosocial problems generated or exacerbated by disease (1). Arthritis self-management behaviors commonly reported have included taking medications, using other treatments (e.g., heat, exercise), rest, and talking with friends and family for support or advice (2–6). Coping has been defined as “cognitive and behavioral efforts to manage specific external and/or internal demands appraised as taxing or exceeding the resources of the individual” (7). Self-management behaviors would appear to fall within this definition of coping. For example, Blalock and colleagues (8) identified a number of behavioral coping strategies for problems with daily and leisure activities, work, and social relationships that might be construed as self-management behaviors, including modification (changing something about a situation or behavior), perseverance (attempting to continue despite problems), and material resources (using special equipment or devices). Two scales used to assess coping with pain, the Coping Strategies Questionnaire (9) and the Vanderbilt Pain Management Inventory (10), assess specific behaviors in addition to emotions and cognitions used to cope with pain, and van Lankveld and colleagues include behaviors in their Coping with Rheumatic Stressors scale (11). However, the construct of self management is rarely included in the assessment of coping, nor does coping research refer to self management, and the neglect of the behavioral aspect of coping in coping research has been cited (12). Recently, there has been a shift toward examining ways of coping with disability, particularly toward looking at behavioral strategies of adapting to disability (13–16). These recent studies suggest that behavioral strategies are commonly used to adapt to, or cope with, disability.

This study attempts to assess the extent to which self-management behaviors are used to cope with RA. Most research on coping with RA has focused on coping with pain (10, 12, 17–20), although RA clearly presents other challenges (18, 21, 22). Because there were no existing measures of self management in coping with a variety of stressors, the first goal of the study was to identify how individuals with RA dealt with 5 aspects, or stressors, of the disease: pain, fatigue, physical limitations, changes in joint structure or appearance, and unpredictability of symptoms.

There is evidence that use of coping strategies tends to be stable over time (23), but there is little evidence about whether the strategies used are consistent across different aspects of disease. Therefore, the study examined whether individuals tended to use different self-management behaviors for different stressors, or whether use was consistent across stressors. The study also attempted to identify predictors of performance of self-management behaviors, focusing on 2 factors, perceived impact and participation in arthritis education programs. The perceived impact of a stressor has been shown to affect the way individuals respond to stressors (24, 25), and individuals who have attended arthritis education or self-management classes may respond to the stressors with different self-management behaviors than individuals who have not.

Finally, there is some evidence that pain coping strategies may influence future functioning, and that arthritis self-management programs may result in small reductions in pain and perhaps functional limitations (26–30). However, there is less information on how coping or self management affects disability, i.e., the ability to perform life activities. Therefore, this study examined the association of self-management coping behaviors with concurrent and subsequent disability, as measured by the ability to perform life activities.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

Data source.

The study drew upon data from the Rheumatoid Arthritis Panel Study at the University of California, San Francisco. The RA Panel has been previously described in detail (31). Briefly, panel members were recruited from the offices of rheumatologists in northern California. Participating rheumatologists listed all patients with RA who presented to their offices over a specified 1-month period. Of the 847 patients who were identified, 822 (97%) agreed to participate. Additional recruitments in 1989 and 1995 yielded 203 and 131 new panel members, respectively. A total of 511 persons responded to the interview in the baseline year for this study, and 463 individuals responded to the subsequent (followup) year's interview.

Structured telephone interviews are conducted annually with panel members, covering topics such as symptoms, disease history, function, comorbidities, demographics, and psychosocial characteristics. An average of 93% of the panel members from the previous year have been reinterviewed each year. Study sample characteristics are presented in Table 1.

Table 1. Rheumatoid arthritis panel characteristics (n = 511)*
CharacteristicValue
  • *

    Values are the number (percentage) unless otherwise indicated. RA = rheumatoid arthritis; HAQ = Health Assessment Questionnaire.

  • Unless otherwise noted, all disease-related variables are from baseline. All symptom measures are self reported.

  • Reference group in multivariate analyses.

Sociodemographic 
 Age, mean ± SD years60.5 ± 13.4
 Female417 (81.6)
 White race423 (82.9)
 Education, years 
  <1264 (12.5)
  12180 (35.2)
  ≥13267 (52.3)
 Live alone114 (22.3)
Disease-related 
 Any comorbidity259 (50.7)
 Duration of RA, mean ± SD years18.6 ± 10.7
 No. painful joints (range 0–17), mean ± SD5.2 ± 4.6
 Pain rating (range 0–100, ref. 50), mean ± SD33.9 ± 28.9
 Fatigue rating 
  None, very mild, mild169 (33.1)
  Moderate222 (43.4)
  Severe, very severe120 (23.5)
 HAQ score (range 0–3, ref. 50), mean ± SD1.17 ± 0.7
 Changes in appearance of hands438 (85.7)
 Changes in appearance of feet345 (67.5)
 Can predict when symptoms will get worse 
  No269 (52.6)
  Sometimes132 (25.8)
  Most of the time110 (21.5)
 Perceived impact (range 0–10), mean ± SD 
  Pain5.1 ± 3.0
  Fatigue4.9 ± 2.9
  Physical limitations4.7 ± 3.1
  Changes in joint appearance3.7 ± 3.2
  Symptom unpredictability3.8 ± 3.1
Ever participated in arthritis education program140 (30.2)
Number of life activities, mean ± SD 
 Affected at baseline4.5 ± 3.8
 Affected at followup6.1 ± 4.4
 Unable to perform at baseline1.4 ± 2.0
 Unable to perform at followup1.6 ± 2.4

Variables.

Self-management behaviors.

The 5 RA-related stressors chosen for the study were pain, fatigue, physical limitations, changes in joint appearance, and unpredictability of symptoms. Studies assessing the importance of educational or psychosocial issues to individuals with RA or the degree of distress induced by these issues provide evidence that these aspects of the disease are problematic (21, 22). In the 2 years prior to the baseline year of this study, panel members were asked open-ended questions about how they dealt with each stressor (“What are the things you do to deal with your RA-related [stressor, e.g., pain]?”). Responses were reviewed by the author, and categories were developed to represent the responses. Two research staff members then independently reviewed the responses and assigned each response to one of the categories, or noted that they could not make an assignment. All raters then reviewed each response assignment and adjudicated conflicting assignments, including modifying definitions of categories, and developed a list of self-management behaviors for each stressor. The most common behaviors used to deal with each stressor were presented to panel members in the baseline and followup interviews in the following checklist form: “I'm going to read a list of things that people could do to deal with RA-related [stressor]. Tell me if you have done any of these things to help you deal with the [stressor] from your RA in the past year.” Response options were “no,” “sometimes,” and “often,” and were collapsed into dichotomous (use/no use) categories for these analyses. A list of 10 behaviors was presented for dealing with pain, 7 for fatigue, 10 for physical limitations, 9 for joint changes, and 8 for symptom unpredictability (Table 2). For each stressor, panel members were also given the opportunity to offer other coping activities (e.g., “Are there other things you do to deal with your [stressor]?”). Very few panel members offered additional coping behaviors. The entire list of self-management strategies for each stressor could not be included in the interview because of concerns about interview length.

Table 2. Frequency of use of self-management behaviors by stressor*
Stressor/behaviorValue
  1. a

    Values are the percentage, unless otherwise indicated. Letters in parentheses denote strategy in which item is included. PER = perseverance; ACC = accommodation; SOC = social; ACT = active remediation.

All stressors 
 Respondents who used at least 1 self-management behavior98.3
 Number of self-management behaviors used, mean ± SD24.8 ± 10.2
 Proportion of self-management behaviors used, mean ± SD56.3 ± 23.3
Pain 
 Respondents who used at least 1 self-management behavior95.0
 Number of pain self-management behaviors used, mean ± SD6.6 ± 2.5
 Proportion of pain self-management behaviors used, mean ± SD66.1 ± 25.0
  Take medicine, either prescription or non-prescription, for pain (PER)86.5
  Try to prevent pain by avoiding or limiting certain activities, or not overdoing things (ACC)82.0
  Rest to help your pain (ACC)79.3
  Try to think about something else or do something else to take your mind off your pain (ACC)79.1
  Push yourself and try to keep on as usual in spite of your pain (PER)76.3
  Exercise or do joint exercises to help your arthritis pain (PER)64.2
  Talk to others about your pain (SOC)54.2
  Use heat or cold on your joints to help with your arthritis pain (ACT)52.8
  Ask others for help because of your pain (SOC)46.2
  Use a joint brace or splint because of arthritis pain (ACT)33.1
Fatigue 
 Respondents who used at least 1 self-management behavior91.4
 Number of self-management behaviors used, mean ± SD4.5 ± 2.0
 Proportion of self-management behaviors used, mean ± SD64.3 ± 28.3
  Rest because of your fatigue (ACC)84.2
  Pace yourself or your activities according to your energy level (ACC)78.9
  Try to prevent fatigue by avoiding or limiting certain activities, or not overdoing (ACC)75.3
  Try to think of something else or do something to take your mind off your fatigue (PER)67.7
  Push yourself and try to keep on as usual in spite of fatigue (PER)67.5
  Talk to others about your fatigue (SOC)40.5
  Ask others for help because of your fatigue (SOC)37.2
Physical limitations 
 Respondents who used at least 1 self-management behavior87.0
 Number of self-management behaviors used, mean ± SD6.1 ± 3.1
 Proportion of self-management behaviors used, mean ± SD61.5 ± 30.6
  Take more time to perform certain activities because of limitations (ACC)79.8
  Avoid or limit certain activities because of physical limitations (ACC)74.6
  Rest to help with your physical limitations (ACC)73.0
  Make other changes in the way you perform certain activities because of limitations (ACC)69.9
  Push yourself and try to keep on as usual in spite of your physical limitations (PER)64.2
  Try to think about something else or do something to take your mind off limitations (PER)64.0
  Ask others for help because of your physical limitations (SOC)59.7
  Exercise or do joint exercises to help your physical limitations (PER)54.0
  Talk to others about your physical limitations (SOC)45.8
  Use a joint brace or splint because of your physical limitations (ACT)25.6
Joint changes 
 Respondents who used at least 1 self-management behavior for joint changes73.2
 Number of self-management behaviors used, mean ± SD3.4 ± 2.7
 Proportion of self-management behaviors used, mean ± SD37.9 ± 30.2
  Take more time to perform certain activities because of changes in your joints (ACC)60.5
  Make other changes in the way you perform certain activities because of changes in your joints (ACC)52.6
  Wear certain types of clothing (ACC)52.5
  Exercise or do joint exercises to help with the changes in your joints (PER)37.2
  Talk to others about the changes in your joints (SOC)32.9
  Ask others for help because of changes in your joints (SOC)31.3
  See another physician or health professional, such as a surgeon or podiatrist, because of changes in your joints (ACT)25.2
  Try to cover parts of your body (PER)23.7
  Use a joint brace or splint because of changes in the shape of your joints (ACT)20.7
Symptom Unpredictability 
 Respondents who used at least 1 self-management behavior73.4
 Number of self-management behaviors used, mean ± SD4.1 ± 2.9
 Proportion of self-management behaviors used, mean ± SD51.1 ± 35.7
  Try to make your symptoms less unpredictable by taking good care of yourself in general (ACC)68.7
  Take medicine to make your symptoms less unpredictable (ACC)64.2
  Rest to deal with the unpredictability of your symptoms (ACC)60.3
  Pace yourself or your activities to make your symptoms less unpredictable (ACC)56.4
  Try to make your symptoms less unpredictable by avoiding or limiting certain activities, or by not overdoing   things (ACC)55.6
  Keep your schedule flexible or not plan too far in advance because of unpredictable RA symptoms (ACC-2)48.7
  Talk to others about the unpredictability (SOC)29.9
  Not make plans or commitments because of unpredictable symptoms (ACC-2)23.3
Life activities.

Panel members were presented with a list of 16 activity domains (e.g., housework, social events, recreational activities) (32–34) and were asked whether RA had affected their ability to perform activities that were important to them in each domain. Response options were “no problems,” “had trouble but continued to do it [perform the activity],” “had trouble but changed the way you did it,” “unable to do it,” “did not do it for reasons other than RA,” and “not important to you.” Activities were defined as affected by RA if individuals had trouble with the activities and continued to perform them, changed the way they performed them, or were unable to perform them. For each individual, the number of activities affected and the number of activities unable to perform were calculated.

Statistical analysis.

Descriptive statistics for self-management behaviors were calculated. Consistency of behavior use across stressors was examined using chi-square analyses. Factor analyses were conducted to determine if self-management strategies for coping with the 5 stressors could be identified. Examination of the preliminary factor analysis of the pain strategies, using varimax rotation, revealed 1 factor with a high eigenvalue (later defined as the accommodation factor) and 3 other factors with eigenvalues slightly above or below 1.0. The 4 factors were interpretable; therefore, 4-factor solutions with varimax rotation were specified for joint changes and physical limitations, and similar factor structures emerged. The 4 self-management strategies identified were accommodation (e.g., avoiding or limiting activities, resting, taking more time to perform activities), active remediation (e.g., using heat or cold, using a splint/brace), social (e.g., asking for help or talking to others), and perseverance (e.g., pushing oneself to keep going). Factor names were assigned after examination of behaviors loading on each factor.

Because of the way the self-management behavior lists were developed, items representing each of the 4 factors were not included for fatigue and symptom unpredictability. Based on the strategies included in the checklist for fatigue, a 3-factor solution was specified (omitting the active factor) and was consistent with the results of the previous analyses. A 4-factor solution was initially specified for symptom unpredictability; however, three 1-item factors emerged, 2 of which were related to making plans (keeping one's schedule flexible and not making plans). A 3-factor solution was then attempted. The 2 planning items loaded on the same factor, and the 3-factor solution was retained. Both the initial 5-item factor and the 2-item planning factor were consistent with accommodations to the stressor.

All strategies were retained in the factor in which they had the highest factor loading, regardless of cross-loading. In a few cases, this resulted in similar behaviors being included with different factors for different stressors. For example, taking medicine loaded on the perseverance factor for pain, but loaded on the accommodation factor for symptom unpredictability. The strategy in which each self-management behavior is included is shown in Table 3. Details of factor loadings are shown in Appendix A.

Table 3. Summary of self-management strategy use
StrategiesNo. behaviors presented in interviewRespondents who used at least 1 behavior, %No. behaviors used, mean ± SDProportion behaviors used, mean ± SD
  • *

    α = 0.91; item-total correlations 0.39–0.68.

  • α = 0.74; item-total correlations 0.23–0.68.

  • α = 0.87; item-total correlations 0.49–0.69.

  • §

    α = 0.73; item-total correlations 0.23–0.52.

Accommodation strategies*    
 Total1596.710.0 ± 4.169.3 ± 28.1
 For specific stressors    
  Pain389.01.6 ± 0.780.6 ± 33.8
  Fatigue389.42.4 ± 1.079.5 ± 33.4
  Physical limitations485.53.0 ± 1.474.3 ± 36.1
  Joint changes362.01.1 ± 0.937.7 ± 31.2
  Unpredictability of symptoms-1573.43.1 ± 2.161.8 ± 41.4
  Unpredictability of symptoms-2249.50.7 ± 0.835.1 ± 39.5
Active remediation strategies    
 Total570.81.6 ± 1.632.4 ± 31.3
 For specific stressors    
  Pain262.60.9 ± 0.844.0 ± 39.1
  Fatigue
  Physical limitations126.30.3 ± 0.426.3 ± 44.1
  Joint changes237.60.5 ± 0.723.9 ± 33.7
  Unpredictability of symptoms
Social strategies    
 Total984.23.8 ± 2.942.2 ± 31.9
 For specific stressors    
  Pain267.21.0 ± 0.850.1 ± 41.1
  Fatigue250.80.8 ± 0.838.1 ± 41.6
  Physical limitations267.21.1 ± 0.953.5 ± 42.5
  Joint changes245.80.7 ± 0.832.6 ± 39.3
  Unpredictability of symptoms129.80.3 ± 0.529.8 ± 45.8
Perseverance strategies§    
 Total1097.86.1 ± 2.561.2 ± 25.2
 For specific stressors    
  Pain394.42.3 ± 0.976.5 ± 28.8
  Fatigue282.51.4 ± 0.868.1 ± 38.2
  Physical limitations381.91.9 ± 1.161.7 ± 36.8
  Joint changes246.00.6 ± 0.730.7 ± 36.9
  Unpredictability of symptoms

Factor scores representing the number of self-management behaviors individuals used within each strategy were calculated. The internal consistency of the self-management strategy scores was examined by calculating the Cronbach's alpha for each strategy score and examining the item-total correlations.

Differences in self-management strategy use between individuals who had and those who had not participated in arthritis education were first assessed with t-tests. Multiple linear regression analysis was used to examine the association of perceived stressor impact and arthritis education with strategy use, controlling for covariates. In stressor-specific regression models, perceived impact of that stressor was included; in summary models, the average impact of all stressors was included.

Covariates were chosen for multiple regression analyses based on reported associations with disease characteristics or performance of self-management behaviors. Sociodemographic characteristics may be associated with either the tendency or ability to perform particular self-management behaviors (e.g., it may be more difficult for an individual who lives alone to ask someone else for help). In addition, some demographic characteristics (e.g., low levels of education, female sex) have been associated with more severe RA symptoms (35, 36), and both performance of self-management behaviors and functioning in life activities may be linked to the frequency or severity of disease symptoms (5, 6, 37). Characteristics included as covariates in multivariate analyses were age, race (white versus nonwhite), sex, educational attainment, and living arrangements (living alone versus living with another/others). Duration of RA and the number of comorbid conditions were included as covariates in regression models for each of the 5 stressors. Finally, stressor-specific variables (e.g., severity of pain or fatigue) were included as covariates. In regression models relevant to a single stressor, only covariates specific to that stressor were included. In summary models, all stressor-specific covariates were included. All covariates are shown in Table 1.

To examine the association of self-management behaviors with performance of life activities, multiple linear regression analyses were calculated, controlling for covariates. All 4 self-management strategy scores were included in the same regression models. For analyses of followup functioning, baseline functioning was also included as a covariate.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

Use of self-management behaviors.

Almost all (98%) participants reported using at least 1 self-management behavior (Table 2). An average of 24.8 behaviors (from a total of 44) were used. Self-management behaviors were most commonly reported for pain (95%) and fatigue (91%), and were least commonly reported for symptom unpredictability (73%) and joint changes (73%). Participants reported using approximately two-thirds of the self-management behaviors for pain, fatigue, and physical limitations (66%, 64%, and 62%, respectively); approximately half of those for symptom unpredictability; and only approximately one-third of those for joint changes.

Pain.

Most respondents (95%) used at least 1 self-management behavior for pain. Taking medicine was the most common behavior used to cope with pain (87%). Trying to prevent pain by avoiding or limiting activities (82%), resting (79%), distraction (79%), and pushing oneself to keep going (76%) were also behaviors reported by more than three-quarters of the panel. Only asking others for help (46%) and using a joint brace or splint (33%) were used by less than half of the panel members.

Fatigue.

Most (91%) panel members reported using at least 1 of the fatigue self-management behaviors, and 16% reported using all the behaviors. Resting was the most common way of dealing with fatigue (84%), followed by pacing oneself or one's activities (79%), trying to prevent fatigue by avoiding or limiting activities or not overdoing things (75%), distraction (68%), and pushing oneself to keep going in spite of fatigue (68%).

Physical limitations.

The majority (87%) of respondents reported using at least 1 of the self-management behaviors for physical limitations. All of the physical limitations self-management behaviors, except talking to others and using a joint brace or splint, were reported by more than half of the panel members. Activity accommodations (taking more time to perform activities [80%], avoiding or limiting certain activities [75%], resting [73%], and making other changes in the way activities were performed [70%]) were the most common behaviors reported.

Changes in joint structure and appearance.

Approximately three-quarters of respondents (73%) reported using at least 1 of the self-management behaviors to cope with joint changes. The most commonly reported behaviors were taking more time to perform activities (61%), making other changes in the way activities were performed (53%), and wearing certain types of shoes or clothing (53%). Overall, the panel members reported fewer of the self-management behaviors presented for this stressor than for any other stressor.

Unpredictability of RA symptoms.

Approximately three-quarters of participants used at least 1 self-management behavior for symptom unpredictability. The most commonly reported strategy was to take good care of oneself in general to make symptoms less unpredictable (69%), followed by taking medicine to make symptoms less unpredictable (64%); resting (60%); pacing oneself (56%); and avoiding, limiting, or not overdoing activities (56%).

Self-management strategies and consistency of use across stressors.

Cronbach's alpha coefficients for strategy scores were high (ranging from 0.73 to 0.91), and all item-total correlations except 3 were ≥0.35 (Table 3), supporting the consistency of responses within each strategy. Detailed examination of the use of specific behaviors for different stressors (e.g., resting to prevent pain and resting because of fatigue) using chi-square analyses, and correlations of strategy use among stressors (e.g., correlation of the number of accommodation strategies used for pain with the number of accommodation strategies used for other stressors) supported the consistency of strategy use across stressors (data not shown).

Accommodation and perseverance strategies were the most commonly used self-management strategies. The average proportion of the self-management behaviors performed within both of these categories was 69% and 61%, respectively; 97% and 98% of participants performed at least 1 self-management behavior included in each of these strategies, respectively.

Perceived stressor impact and arthritis education.

Greater perceived impact was consistently associated with use of more self-management behaviors, even after controlling for covariates (Table 4). In bivariate analyses, individuals who had participated in arthritis education also reported consistently greater use of all self-management strategies (data not shown). When controlling for covariates, however, the consistency of the association diminished, although some differences were still noted (Table 4). Individuals who had participated in arthritis education programs reported significantly more self-management behaviors for physical limitations and joint changes, and used more social and active remediation strategies.

Table 4. Relationship of perceived stressor impact and arthritis education on use of self-management strategies*
StressorsSelf-management strategies
TotalAccommodationActive remediationSocialPerseverance
βPβPβPβPβP
  • *

    Standardized parameter estimate and P value from multiple linear regression analysis. NS = not significant.

Perceived impact     
 Pain0.43< 0.00010.45< 0.00010.170.0030.25< 0.00010.37< 0.0001
 Fatigue0.53< 0.00010.57< 0.0001 0.23< 0.00010.36< 0.0001
 Physical limitations0.55< 0.00010.26< 0.00010.060.190.25< 0.00010.29< 0.0001
 Joint changes0.46< 0.00010.43< 0.00010.26< 0.00010.27< 0.00010.33< 0.0001
 Unpredictability0.71< 0.00010.69< 0.0001 0.43< 0.0001 
 All stressors0.54< 0.00010.58< 0.00010.080.180.37< 0.00010.46< 0.0001
Arthritis education          
 PainNS NS NS 0.090.03NS 
 FatigueNS NS  0.090.03NS 
 Physical limitations0.090.01NS 0.090.04NS NS 
 Joint changes0.090.04NS 0.120.02NS NS 
 UnpredictabilityNS NS  NS  
 All stressorsNS NS 0.090.030.070.05NS 

Self-management behaviors and life activities functioning.

Self-management strategies were associated with both concurrent and subsequent life activity functioning (Table 5). Individuals who used more social self-management behaviors reported more activities affected by RA at baseline, controlling for sociodemographic and disease-related factors. Greater use of accommodation strategies at baseline was associated with an increase in the number of activities affected at followup. In contrast, greater use of perseverance strategies was associated with individuals reporting fewer activities that they were unable to perform at baseline and a decrease in the number of activities unable to perform at followup.

Table 5. Effect of self-management strategies on valued life activities concurrently and in subsequent year*
Strategies used at baselineNo. activities affectedNo. activities unable
BaselineFollowupBaselineFollowup
  • *

    NS = not significant.

  • Standardized beta from multiple linear regression analysis adjusted for age, sex, race, education, duration of rheumatoid arthritis, baseline living arrangements, baseline clinical variables (pain rating, number of painful joint groups, joint changes in past year, fatigue severity, unpredictability of symptoms, and Health Assessment Questionnaire score), and baseline perceived impact. Followup regressions also included the baseline number of activities affected/unable. P = 0.05.

  • P = 0.01.

Accommodation strategiesNS0.11NSNS
Active remediationNSNSNSNS
Social strategies0.12NSNSNS
Perseverance strategiesNSNS−0.14−0.13

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

Studies examining self-care or self-management behaviors of persons with arthritis or other musculoskeletal conditions have found that most do engage in such behaviors, and that self-management strategies are extremely varied (2–5, 16, 38). Almost all of the participants in this study reported using at least 1 of the self-management behaviors. The extent of self-management efforts varied across stressors. Panel members were more likely to report self-management behaviors for dealing with pain, fatigue, and physical limitations than for joint changes and symptom unpredictability. This finding may reflect the perception that pain, fatigue, and physical limitations have a greater impact (22); that individuals perceive fewer options for dealing with joint changes or symptom unpredictability; or that individuals attribute fewer self-management behaviors specifically to these stressors. It may also indicate that joint changes and symptom unpredictability are experienced less often and thus require less management; however, the majority of panel members reported joint changes, and few felt that they could predict when their symptoms would flare. Self-management behaviors for symptom unpredictability seemed to be less consistent with the factor structure noted for the other stressors, and some of the self-management behaviors mentioned for symptom unpredictability were substantively different from those of the other stressors (e.g., flexible plans, taking care of self to avoid unpredictability). This may be because symptom unpredictability represents the appearance of a cluster of symptoms, and efforts are focused on prevention of symptom flares rather than coping with specific symptoms.

Use of both specific self-management behaviors and more general strategies was fairly consistent across stressors, although the frequency of use differed. In other words, individuals may or may not have used a self-management strategy for a particular stressor, but if they did use one, it was likely to be the same behavior or same type of strategy used for another stressor. This finding suggests that many self-management strategies are used to cope with multiple stressors. It is also possible that panel members did not or could not differentiate the reason for using some of the self-management strategies because the stressors were so closely intertwined. For example, because joint pain may lead to physical limitations, it may be difficult to disentangle the effects of pain and physical limitations, and the same self-management strategy could be reported for both stressors. This idea is supported by van Lankveld and colleagues (21), who noted that individuals with RA must cope simultaneously with pain, limitations, and dependence. Another possibility is that individuals may initially engage in a self-management strategy to cope with one stressor, and then recognize that the effects of another stressor are also moderated. Individuals could also have undertaken self-management strategies in a less focused attempt to “deal with their arthritis.” This consistency of self-management strategies across stressors contrasts with some other studies. For example, Tack (39) noted that patients reported different coping behaviors for fatigue than for other problems, and Blalock et al (8) noted little consistency in use of coping strategies for problems with daily activities, leisure activities, work, and social relationships (although Blalock et al did find that individuals were more likely to use behavioral strategies to cope with problems with functioning, i.e., daily activities, leisure activities, and work, than to cope with problems with social relationships).

Previous assessments of coping have categorized coping into a variety of styles, such as active versus passive coping; problem-focused versus emotion-focused coping; and optimistic cognitions, self-control, and behavioral coping (10, 19, 40–42). Four general self-management strategies were identified in this study: accommodation, active remediation, social, and perseverance strategies. Although the assessment of self management in this study was based primarily on behaviors, and previous assessments of coping have included emotions and cognitions as well as behaviors, the strategies identified in this study were similar to some of the previously identified coping strategies or styles. For example, seeking social support, which is similar to the social strategies identified in these analyses, is included in several coping typologies. Blalock et al found that individuals relied heavily on behavioral strategies, such as perseverance, decreasing activity, modifications, and help, in coping with functional problems (8). Gignac and colleagues identified 4 major types of “adaptation behaviors” among individuals with osteoarthritis and osteoporosis, including selection (e.g., performing behaviors less often, avoiding or limiting activities), optimization (e.g., spending more time on activities, resting or pacing), compensation (e.g., changing the way activities were performed, using assistive devices), and receiving help (15). Although Gignac et al's categorizations were based on adaptational processes described by Baltes and Baltes (43) and the categorizations for the current study were developed in a more empirical method, some of the same themes emerged. These conceptual and structural similarities suggest that regardless of the terminology used (behavioral adaptation, behavioral coping, or self management), these types of behaviors are commonly used and are important components of the way individuals cope with chronic conditions.

Perhaps the most important finding of this study was that self-management strategies were associated with functioning in life activities. Accommodation strategies such as resting, avoiding or limiting activities, and taking more time to perform activities were associated with an increase in the number of activities affected at followup, whereas perseverance strategies were associated with a decrease in the number of activities individuals were unable to perform at followup. These findings are consistent with previous coping and self-management studies, which have generally shown that passive coping strategies (e.g., rest, depending on others for help) are associated with worse outcomes (10, 12, 14, 17, 19, 20), and that programs designed to enhance self management are associated with improved outcomes (26–30, 44, 45). For example, van Lankveld et al (14) found that decreasing activity (an accommodation strategy) was associated with a subsequent loss of function, and Evers et al (20) found that resting (another accommodation strategy) was associated with a subsequent decrease in functioning.

This study found that individuals who had participated in arthritis education programs used more self-management strategies than those who had not. This finding may suggest that arthritis education programs increase participants' repertoires of self-management or behavioral coping behaviors, or, because seeking out arthritis education could be viewed as a coping strategy per se, individuals with larger self-management or behavioral coping repertoires may be more likely to attend arthritis education. Future research could further explore the association between arthritis education and use of specific types of behaviors to cope with arthritis, particularly behaviors that may be associated with maintenance of valued activities. Certain self-management or coping strategies may be more effective for individuals with particular sociodemographic, clinical, or psychological characteristics; therefore, future research could also focus on the interaction of individual characteristics and the likelihood or efficacy of certain self-management strategies. Such knowledge could enhance the effectiveness of arthritis education efforts.

It is possible that findings from the current study are limited by an incomplete list of self-management behaviors, particularly those used to deal with joint changes and symptom unpredictability. Obviously omitted is the use of equipment or assistive devices, with the exception of splints. Assistive devices have been noted to be effective in reducing disability (46), and their use for coping with disability is fairly common in some groups (15). However, in this study, devices were not identified by respondents in the developmental phase or when respondents were asked to add behaviors to the checklists. Another possible limitation is that, due to interview time constraints, the complete lists of self-management behaviors could not be administered.

The study population may not be representative of all persons with RA, particularly in terms of age and duration of disease. The RA panel has been in existence for 20 years, which explains its now higher than average age and disease duration. At its inception, however, the panel appeared to be fairly representative of persons with RA in the community, and the characteristics of panel members were similar to the characteristics of other panels of persons with RA (47). Nonetheless, these individuals may be more experienced in coping with RA, and the self-management behaviors they use may differ from those used by individuals who have not dealt with the disease for as long.

Although recent research has begun to integrate the perspectives of coping and self management, more complete integration of these bodies of research could perhaps lead to more effective and more widely generalizable results. Such integration may require a broader specification or interpretation of existing theoretical models of coping, modification of existing models, or even development of new models. Behaviors are not the only components of coping, but behavioral coping, or self management, may be the easiest form of coping to transmit through educational programs, support groups, or other means. For example, many of the active strategies, such as exercise or techniques to manage pain, are included in arthritis self-management education (48). Effective self-management behaviors may prevent loss of valued life activities. The ability to perform these valued life activities is the type of function that individuals value the most (49), and loss of the ability to perform life activities is associated with onset of depression (33, 34). Therefore, identification of factors that may enhance maintenance of life activities has important implications for patient education and for maintenance of quality of life for individuals with RA or other chronic conditions.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:

APPENDIX A:

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A:
Table  . Factor Loadings For Self-Management Strategies
PainAccommodationTreatmentSocialPerseverance
  1. Eigenvalues for factors 1–4: 4.34, 1.02, 0.91, 0.82. Cumulative variance accounted for: 0.71.

Variance explained by factor (rotated)1.851.501.441.35
 Limit0.85   
 Rest0.72   
 Distract0.620.35  
 Splint/brace 0.75  
 Heat 0.72  
 Talk  0.84 
 Help  0.72 
 Push   0.79
 Medicine   0.56
 Exercise 0.42 0.49
Eigenvalues for factors 1–4: 3.05, 1.10, 1.05, 0.94. Cumulative variance accounted for: 0.61.
Joint changesAccommodationTreatmentSocialPerseverance
Variance explained by factor (rotated)2.301.311.351.34
 More time0.84   
 Other performance changes0.81   
 Special clothing0.54   
 Splint/brace 0.79  
 See health professional0.370.70  
 Talk  0.87 
 Help0.52 0.63 
 Cover self   0.80
 Exercise0.46  0.60
Eigenvalues for factors 1–4: 3.73, 0.94, 0.83, 0.81. Cumulative variance accounted for: 0.70.
FatigueAccommodationSocialPerseverance
Variance explained by factor (rotated)2.081.551.27
 Limit0.81  
 Pace0.78  
 Rest0.77  
 Talk 0.88 
 Help 0.84 
 Push  0.91
 Distract0.40 0.64
Eigenvalues for factors 1–3: 2.68, 1.15, 1.08. Cumulative variance accounted for: 0.70.
Unpredictability of symptomsAccommodationAccommodation 2Social
Variance explained by factor (rotated)3.491.551.07
 Take care of self0.86  
 Medicine0.85  
 Pace0.80  
 Rest0.75  
 Limit0.690.38 
 No plans 0.93 
 Flexible plans0.540.62 
 Talk  0.97
Eigenvalues for factors 1–3: 4.35, 0.93, 0.82. Cumulative variance accounted for: 0.76.
Physical limitationsAccommodationTreatmentSocialPerseverance
Variance explained by factor (rotated)2.911.161.601.43
 Limit0.82   
 More time0.77   
 Other performance changes0.77   
 Rest0.71   
 Splint/brace 0.88  
 Talk  0.89 
 Help0.44 0.72 
 Push   0.82
 Exercise 0.51 0.60
 Distract0.46  0.49