The 10 OA groups included 32 women and 21 men, and the 6 control groups included 21 women and 16 men (n = 90). Participants ranged in age from 39 to 88 years (mean ± SD age 57 ± 11 years). The sample included individuals of different racial and cultural backgrounds, education, and income levels. There were no significant differences between OA group participants and control participants in sex, education, income, or race. However, OA group participants were older than controls (mean ± SD age 59.8 ± 12.1 years versus 53.2 ± 7.5 years) and were more likely to report comorbidities (P < 0.01). Comorbid conditions were nondisabling and non–life threatening, such as high blood pressure, cholesterol problems, and minor vision problems. OA group participants reported an onset of symptoms ranging from a couple of months to several years. OA participants reported poorer physical functioning on the SF-36 and WOMAC; greater WOMAC pain and stiffness; and higher disability of the arm, shoulder, and hand (DASH questionnaire; P < 0.01). There were no significant differences in mental health (Table 2).
Overlap of signs and symptoms.
Participants in both groups mentioned a range of signs and symptoms. OA participants of all ages primarily discussed 5 physical symptoms: pain, stiffness, fatigue, joint cracking, and swelling. Although there was some overlap, the control groups emphasized a physical “slowing down” and cognitive and emotional changes. These changes were more evident with age. There was also greater variability in their discussions. The major signs and symptoms and descriptors of each group are presented in Table 3.
Table 3. Signs and symptoms of osteoarthritis and aging
|Osteoarthritis groups|| |
| Pain||Pain, shooting, throbbing, sharp, dull, burning, migratory, hot, achy, sore, hurts, excruciating, kills me, bursting, weakness, searing, cramping, tinges, pins and needles, tightness, tearing, nagging|
| Stiffness||Stiff, clumsiness, numbness|
| Fatigue||Fatigue, less energy, drained, tired, difficulty falling asleep/staying asleep, unrefreshing sleep|
| Joint cracking||Joints crack, joint locking, clicking, snapping, popping, grating|
| Swelling||Swelling, disfiguring|
|Healthy aging groups|| |
| Concentration||Concentration problems, forgetful, memory problems|
| Energy changes||Lack of energy, slowing down, less stamina, more sedate, more energy, sleep better, feel groggy, need to rest|
| Physical changes||Less flexible, less strong, less quick, slower reflexes, slower reaction time, short of breath, in better shape, weight gain, hair loss, eyesight problems, digestion problems|
| Emotional swings||Apathy, less patience, less ability to handle stress, less upset, quieter, calmer|
| Wisdom||Wisdom, acceptance, understanding, less tolerance of others, less maternal|
| Pain||Aching, pain, no pain|
| Sexual changes||Less sexual drive|
Pain was mentioned infrequently in the control groups regardless of the age of participants and was characterized as minor, transient, and associated with “overdoing it” in physical activity. Stiffness was mentioned by some control participants, but was described as infrequent and of short duration. In OA groups, fatigue was often described as debilitating and as occasionally restricting activity. Some individuals linked fatigue to pain and noted difficulties falling asleep or staying asleep, whereas others ascribed difficulties in sleeping to fatigue. In some cases, sleep disruption signaled that something was “not normal” and had resulted in individuals consulting a physician. Although some control participants noted more energy with age, most talked about “slowing down” and having “less stamina.” Physical changes included being less flexible, strong, and quick, but problems were not associated with pain or sleep.
Because OA participants were selected partly based on their reports of pain, differences between the groups in this symptom were not surprising. However, the breadth, depth, and complexity of the OA group discussions of pain were notable. Participants of all ages used a range of descriptors suggesting multiple dimensions including the quality of pain (e.g., sharp, throbbing) and intensity of pain (e.g., mild, severe) (Table 4). OA group members also described at length other dimensions that tempered the quality and intensity of their symptoms. In particular, they discussed a wide-ranging frequency, duration, and predictability of symptoms. Symptoms were sometimes associated with times of the day, weather conditions, or seasons, and some symptoms were absent when at rest. Some respondents reported a sudden onset of symptoms, whereas others reported a gradual, variable onset. The location of OA pain also varied. Many participants described a circumscribed area of pain (e.g., right knee), but some reported pain in several joints and a few noted that symptoms “migrated” and were not confined to one area. Pain in the extremities (i.e., fingers and feet) was reported as particularly intense and debilitating. Variability in descriptions of pain was not related to the age of participants or the location of their OA (i.e., knee, hand). Although discussions of pain were uncommon in the control groups, the dimensions used overlapped with those of the OA groups. Control participants mentioned pain intensity (mild), frequency and duration (rare and of short duration), and predictability (reliably linked to overexertion in physical activity).
Table 4. Dimensions of measurement
|Quality||e.g., “sharp,” “throbbing,” “aching,” “weakness,” “stiffness,” “drained,” “fatigued”|
|Intensity||“I've got a very severe pain on the inside of my knee” (group 2, 380); “I have a little pain here” (group 2, 406).|
|Frequency||“Two weeks bad and then 2 weeks good, and it's all like that” (group 1, 1080–1081); “It wakes me up during the night a lot” (group 4, 60).|
|Duration||“I find as the day goes on, things ease up” (group 3, 1253); “The pain gradually is disappearing” (group 3, 188).|
|Time of day or season||“In the evenings I'm in a lot of pain” (group 3, 381); “As the weather changes, my hand changes” (group 4, 214).|
|Regular versus sporadic/unpredictable||“[The pain] goes away, comes back, goes away, comes back” (group 6, 45–48); “Sometimes it comes suddenly” (group 2, 408).|
|At rest/upon movement||“When I'm sitting or laying down or anything like that, I have hardly any pain” (group 8, 100–102); “I got a pain only when I am walking” (group 8, 442).|
|Location||“One knee might hurt, the other knee might hurt at the same time or sometimes they take turns” (group 6, 150–152); “I have what is, what I call migratory osteo. It just travels around my body” (group 5, 282–284).|
Perceptions of the meaning of symptoms in individuals' lives.
Despite talking at length about symptoms, OA respondents often minimized or normalized their condition. One participant noted, “[I have] nothing much to complain [about], except for this stiffness and shooting pain” (group 3, transcript line numbers 1675–1676). Another younger participant said, “It is sort of a wake up call I suppose, that I am getting on [in] age” (group 6, 601–602). Although middle-aged respondents minimized their symptoms, this was more commonly done among older participants. Many OA participants reported that they had relayed their concerns to health professionals who either ignored symptoms or suggested that they were a normal part of aging. Comments included: “My doctor tells me all the time, ‘You’re just getting older'” (group 2, 660–661); “I have a family doctor who's a doll … But as far as diagnosing illnesses, I mean, he says, ‘What do you want, you’re getting on'” (group 4, 304–307); and “So I showed my family doctor and she said it's going to get worse you know. Get used to it” (group 8, 803–805). A middle-aged participant reported: “I saw the doctor who said, ‘Well … there’s nothing wrong with you. It's just old age. You're just, you know, you're just growing old.' And I refuse to believe that because a guy that's healthy and runs every day you know, shouldn't all of a sudden just stop doing the stuff he wants to do!” (group 9, 48–56).
Although some individuals in the control groups noted that they did not think about aging and health at all (e.g., “I am the same … it never occurred to me that I am getting older” [group 16, 470–471]), more common was the perception of the need to be aware of their limits: “As I get older, I'm more aware of maybe what's in store and just trying to be a little more careful” (group 11, 1212–1216).
There was a substantial difference in the discussions concerning coping responses and perceptions of the ability to control health changes. OA participants emphasized a lack of control and the need for acceptance of health difficulties. They discussed the need to persevere with activities despite the relative absence of effective strategies to manage symptoms: “I'm in pain; I'm suffering, you know. But you learn to live with that” (group 4, 812–813). Others noted:
Participant 1: [It's] mind over matter: I fight it, believe me I fight it …
Participant 2: It's just like the children's book, “The Little Engine That Could.” [laughter]
Participant 3: I think I can, I think I can (group 7, line 91 [participant 1] lines 806–809 [participants 2, 3]).
Rather than acceptance and perseverance, control group members perceived that they had significant control over their health and emphasized a healthy lifestyle to maintain or improve health. One man noted, “I am paying closer attention to my health … you're more aware, you know. I am eating better, getting lots of exercise, lots of sunshine, drinking lots of water and avoiding certain foods that are known to be, you know, detrimental. So I feel stronger now and I guess I have a strong belief that the body is able to heal itself if we get out of the way” (group 14, 173–182).
Nearly all OA participants had made changes to their lifestyle to try and minimize symptoms. Many were unwilling to use medication. Instead, by remaining vigilant and monitoring symptoms, they amassed information on activities and foods that they perceived were harmful. For these individuals, treating pain with medication was seen as masking rather than curing symptoms, and was seen as potentially harmful because of an increased risk of unwanted side effects. Unfortunately, unlike members of the control groups who reported a clear cause-effect relationship of activity to subsequent pain, OA participants were unable to guarantee relief from symptoms based on their lifestyle changes alone. This was linked to upset feelings, helplessness, and depression.
Because of their attention to lifestyle, respondents in the control groups often believed their health was better than others. They rarely expressed negative affect or concerns about the future: “I am quite pleased with my health … when I compare myself with my colleagues who are working with me, I don't have much complaints at all” (group 14, 1088–1093). In contrast, participants in the OA groups frequently expressed frustration, anxiety, and fear about the future. In particular, younger individuals were more upset by their OA than older respondents. This was mainly because OA was not seen as normative in this age group. OA was also viewed as more disruptive of current activities and threatening to future plans. A man in his late 40s whose job kept him standing for much of each work day said, “I started having problems when my son was 4 or 5 years old. He is now 14. I've missed out on all those years where I could have taught him how to catch … how to hit a ball … I've had to send them, to sign them up for different sports: to get somebody else's father to work with them and teach them to do that. … All of the things I had planned that I was going to do with my children, I couldn't do because of this. Really it was psychologically very difficult to accept” (group 9, 504–527).
Long delays between experiencing symptoms and an OA diagnosis made OA symptoms more difficult to deal with. Several younger participants attributed this delay to health professionals not considering OA as a possibility because participants were “too young” to have arthritis. In contrast, younger participants in the control groups were often more optimistic about their future than their older counterparts: “I've worked hard for the last 35, 40 years … so I really deserve another 50 years. I think that's possible … maybe with a bit of luck and careful management of my activities. I want to bank that. I deserve that” (group 12, 740–752).
Impact of health changes in OA and control groups.
OA participants reported that a range of important activities and roles were affected by their condition. Most frequently mentioned were leisure activities, social activities, close relationships, community mobility, employment, and heavy housework. (Personal care activities such as dressing, eating, and bathing were rarely mentioned.) Both middle- and older-age adults described the loss of valuable roles, although older participants were more likely to focus on leisure activities such as travel and less likely to discuss employment. Loss of many of these activities was described as extremely upsetting. For example, one woman noted that dancing was a particularly valued activity. She spoke to her physician, “I said, ‘well can I still take dance class?’… And he said, ‘no,’ and I went home and I cried. And I cried and cried because I was a very active person, very active” (group 8, 192–194).
The impact of symptoms on social activities and interpersonal relationships was discussed in all OA groups across all ages. Some participants noted that symptoms affected their mood and made them frustrated and annoyed with others. In response to the impact on leisure and social activities, family and friends were variously described as supportive or unsupportive. Two barriers to receiving support noted particularly by younger OA participants were the “invisibility” of symptoms and their unpredictable nature. Participants reported that others sometimes exhorted them to engage in activities when they were in pain, were disappointed when plans were unexpectedly canceled, or were suspicious about the inability of participants to engage in some activities: “She doesn't understand that someone that is in this type of pain cannot do things. You cannot do things. And you're not babying yourself. It's just that you can't do it” (group 4, 940–945). Another person commented: “Because nobody can see it … [but] it's a disease and that's what's causing me the pain. It's not just in my head and I'm not just trying to get out of having to clean out the locker room or do this or that or the next thing, which is what I got accused of for years and years” (group 9, 1362–1368).
Members of the control groups reported little impact of their health on activities and roles. Some respondents reported less interest in sexual activity. Others noted that energy and stamina changes had resulted in decisions to forgo some physical activities. However, these activities were generally replaced with new ones. Changes in energy also sometimes interfered with socializing. Typically, participants did not associate changes with health problems. Instead, changes were discussed as a natural progression of interests that comes with time and maturation.