Effect of a Positive Psychological Intervention on Pain and Functional Difficulty Among Adults With Osteoarthritis: A Randomized Clinical Trial

Leslie R M Hausmann, Ada Youk, C Kent Kwoh, Rollin M Gallagher, Debra K Weiner, Ernest R Vina, D Scott Obrosky, Genna T Mauro, Shauna McInnes, Said A Ibrahim, Leslie R M Hausmann, Ada Youk, C Kent Kwoh, Rollin M Gallagher, Debra K Weiner, Ernest R Vina, D Scott Obrosky, Genna T Mauro, Shauna McInnes, Said A Ibrahim

Abstract

Importance: Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited.

Objective: To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis.

Design, setting, and participants: The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017.

Interventions: The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists.

Main outcomes and measures: The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction.

Results: The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P < .001; functional difficulty: χ23 = 22.11, P < .001), differences were small and did not vary by treatment group or race. Exploratory analyses suggested that the intervention had counterintuitive effects on secondary outcomes.

Conclusions and relevance: The results of this randomized clinical trial do not support the use of positive psychological interventions as a stand-alone treatment for pain among white or African American veterans with knee osteoarthritis. Adaptations are needed to identify intervention components that resonate with this population, and the additive effect of incorporating positive psychological interventions into more comprehensive pain treatment regimens should be considered.

Trial registration: ClinicalTrials.gov Identifier: NCT02223858.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Gallagher was the National Director for Pain Management in the Veterans Health Administration until November 1, 2016. There was no involvement of his duties in this role with the research study. Dr Kwoh reported receiving grants and personal fees from EDM Serono, grants from Abbvie, and personal fees from Astellas, Fidia, and Thuane outside the submitted work. Dr Hausmann reported receiving grants from the Department of Veterans Affairs during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram for the…
Figure 1.. CONSORT Flow Diagram for the Staying Positive With Arthritis Study
aReasons for ineligibility are provided in eTable 1 in Supplement 2. bRandomization was at the patient level, stratified by site and self-reported race. cDetails on reasons for missing data points are provided in eTable 2 and eTable 3 in Supplement 2.
Figure 2.. Mean Affect Balance by Race…
Figure 2.. Mean Affect Balance by Race and Treatment Arm Over Time
These means are provided to aid in interpretation of the significant interaction between treatment group, race, and time for affect balance (positive − negative affect scores), χ23 = 8.64; P = .03. Among white participants, affect balance decreased from baseline to 1 month in the positive group, but increased over the same time in the control group. Among African American participants, affect balance decreased slightly at 1 month in the control group, and steadily declined over each time point in the positive group.

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