Self-perceived burden, social support and pain, and kinesiophobia correlates in Chinese older adults with knee osteoarthritis: a cross-sectional survey

Abstract

Background: The health of the elderly has always been the focus of attention in various countries, and how to better enable the elderly to enjoy a good quality of life has become a major focus of our research. This study was conducted to increase knowledge on the actuality of social support and pain, self-perceived burden, and kinesiophbia in elderly patients with knee osteoarthritis in China to provide evidence for disease recovery.

Methods: Cross-sectional survey using a general demographic questionnaire, social support and pain scale(SPQ), self-perceived burden scale and scale(SPBS), and Tampa Scale of Kinesiophobia(TSK-11) were administered.

Results: The results showed a prevalence of 57.89% for kinesiophobia in elderly patients with knee osteoarthritis. Social support and pain was negatively correlated with self-perceived burden scores and kinesiophobia scores（（r=-0.297,p＜0.01；r=-0.368,p＜0.01）, the self-perceived burden was positively correlated with kinesiophobia（r=0.605,p＜0.01）. The marital status, education, degree of understanding of the condition, pain degree, SPQ, and SPBS were associated with kinesiophobia, counting for 43.2% of the variance in kinesiophobia.

Conclusions: The prevalence of kinesiophobia in elderly patients with knee osteoarthritis is very high. Medical works should take early intervention measures to improve pain social support and reduce the self-perceived burden, and help promote disease recovery.

Background

Knee osteoarthritis (KOA) is a chronic degenerative disease prevalent in the elderly population [1], characterized by cartilage destruction in the knee joint. Patients may experience joint pain, stiffness, and joint deformities, and have a high disability rate [2-3]. Evidence-based data show that the number of older people over 60 in China has reached 264.02 million, accounting for 18.70% of China's total population. China has entered the age of aging ahead of schedule. For decades, one of the most popular ideas in knee osteoarthritis research is of how to identify, summarize, and find the risk factors [4].

Currently, approximately 28% of older adults worldwide have osteoarthritis of the knee[5]. In the UK, the prevalence increased 1.3-fold from 1998 to 2017 [6]. The incidence of KOA in the Chinese elderly population is 11.1%~21.9% [7]. In addition to causing damage to the patient’s body structure and function, KOA can also cause mobility impairments. Some studies suggest that KOA is associated with aging and overburdening of the body[8]. Risk factors for osteoarthritis of the knee are also closely related to gender, occupation, and activity. Therefore, the incidence of KOA is gradually increasing under the trend of gradual aging in China. In previous studies, it has been shown that KOA patients have a higher likelihood of anxiety and depression[9-10] due to chronic pain and poor physical condition, which can lead to reduced sleep quality[11-12].

Patients often choose conservative treatment due to concerns about side effects from surgery and medications[13-14]. The main treatment measures for KOA patients are currently non-pharmacological, such as diet and exercise [15-17]. Through data analysis and integration, we found that appropriate exercise has a positive effect on the recovery and regression of diseases in the elderly, relieving the painful feelings caused by pain and improving the role of physical function [18-19].

The burden of KOA on patients and families is increasing year by year [20]. Self-perceived burden (SPB) [21]can not only make patients feel guilt, anxiety, feeling of burden, and other emotions[22], but also some researchers have suggested that social support may affect patients’ self-perceived burden [23]. SPB not only includes physical burdens, but it also includes physical and psychological burdens, etc. The study found that nearly 50% of KOA patients in different countries have a pain burden [24]. The financial burden is also one of the most important factors affecting the self-perceived burden of patients with osteoarthritis of the knee [25-26].

Social support plays an essential role in the treatment and management of chronic diseases. At present, the main concern for the social support of patients at home and abroad is the support from a person and daily life [27-28], but social support and pain (SPQ) is more concerned about the patient’s satisfaction with external support [29]. Higher social support can reduce the degree of fear of disease in KOA patients, thereby promoting recovery [30]. High-quality, comprehensive, and effective social support from the medical sector and state agencies can reduce the negative attitude of elderly patients towards the disease [31-33].

Kinesiophobia refers to a psychological fear of secondary bodily damage caused by activities or function exercises when the patient is worried about pain [34]. The degree of KOA patients has a significant impact on the level of kinesiophobia and the quality of rehabilitation [35]. Recent theoretical developments have revealed that kinesiophobia is related to education level[36]. Timely and adequate social support and pain play an essential role in reducing the degree of panic disorder. Regular exercise is one of the aims of patient self-management. However, due to the presence of pain, the patient's compliance with exercise gradually decreases [37-38], leading to exercise avoidance beliefs. Studies have shown that older patients with osteoarthritic knees develop a fear of falling after surgery[39], and this psychology enhances the onset of Kinesiophobia and prolongs the patient's recovery time.

Compared with our knowledge of self-perceived burden, little is known about social support and pain. Even less is known about kinesiophobia and their relationship. Although there are many types of treatment modalities for our KOA, we need to focus on the patient's influencing factors when we focus on its etiology, pathology, and efficacy. Therefore, this study explores the relationship between social support and pain, self-perceived burden, and kinesiophobia in elderly patients with knee osteoarthritis, and provides a basis for reducing kinesiophobia in patients and promoting the rehabilitation of patients with KOA.

Research questions

The research questions were as follows: What is the actuality of kinesiophobia patients with KOA in China? What is the relationship between social support and pain, self-perceived burden, and kinesiophobia with KOA by using the social support and pain scale（SPQ）, self-perceived burden scale and scale(SPBS), and Tampa Scale of Kinesiophobia(TSK-11)? Therefore, such results can provide evidence for medical works to facilitate patients’ life quality.

Methods

Study design and sample

This study is a cross-sectional study and no sample size calculation was performed. A random sample of 304 inpatients with KOA from two hospitals in Jinzhou City Liaoning province, China, was enrolled in this study from May-December 2021. The questionnaires are distributed in a face-to-face manner on-site, and patients are informed of the purpose, significance, and precautions of the survey before filling it out. It is required to fill it out truthfully. The patient inclusion criteria were as follows: (a) confirmed diagnosis of knee osteoarthritis and pain duration≥3months, (b) voluntary participation and have certain cognitive ability, (c) aged 60 years or older, (d) can understand the survey content correctly and answer the questions. The exclusion criteria were as follows: (a) those who have had major surgery recently and are in unstable condition, (b) diagnosis of cancer, heart, and cerebral vessels disease, (c) the patients could not normally communicate due to mental illness or other reasons, (d) those who dropped out during the investigation.

Measurement of variables

Demographic information

Information on gender, age, education, marital status, lifestyle, annual income of the family, BMI, number of combined chronic diseases, payment methods, degree of understanding of the condition, pain duration, pain degree, and primary caregiver for KOA were all collected.

Self-perceived Burden Scale

Self-perceived Burden(SPBS) was developed by Cousineau et al[21] in Canada. Cronbach's alpha coefficient of the scale is 0.85. It is currently the most used scale for evaluating SPB in patients with chronic diseases at home and abroad. This study uses the Chinese version of SPBS translated by Wu et al. [40], and the internal consistency reliability is 0.91. The scale is divided into three dimensions with a total of 10 items, using the Likert 5-level scoring method. A score of 0~20 is no significant self-perception burden, 20~30 is mild self-perception burden, 30~40 is moderate self-perception burden, and the score of over 40 is severe self-perception burden. In this study, Cronbach's alpha was 0.917. 

Social Support and Pain Questionnaire Scale

Social Support and Pain Questionnaire (SPQ) was developed by Amsterdam Dental Center[29] in the Netherlands to assess the satisfaction of chronic pain patients with pain social support. The scale contains six items and is single-dimensional. The Likert 5-level scoring method is used for scoring. The score ranges from 0 to 4 points. The higher the score, the more satisfied you are with social support. He et al. [41] translated it into Chinese. After testing, the Cronbach's alpha coefficient of the questionnaire is 0.926. Furthermore, the total score range is 0~24 points. Cronbach's alpha of SPQ in the present study was 0.908. 

Tampa Scale of Kinesiophobia Scale

Tampa Scale of Kinesiophobia(TSK-11), designed by Woby et al. [42] in the UK, mainly detects panic disorder in patients with chronic pain. In the Chinese version developed by Cai et al. [43], the Cronbach's alpha coefficient of the scale is 0.883, and the test-retest was 0.798. The Chinese version includes three dimensions and 11 items. Total score range 11-44 points. Kinesiophobia is defined as a score of ≥ 27. The higher the score, the higher the patient's level of panic disorder. At the same time, Cronbach's alpha of TSK-11 for the present study was 0.904.

Data collection

The researcher asked questions face-to-face and filled them in uniformly according to the responses of the research subjects. Before filling in, each participant who was requested to fill truthfully had been informed that the study was anonymous, and had known ed the purpose, significance, and precautions of the study. A secondary check was performed during data entry. In this study, a total of 310 questionnaires were distributed, of which 304 were valid, with an effective recovery rate of 98.1%.

Statistical analyses

Data analysis was performed using the IBM SPSS26.0 statistical software. All data were collected and checked by two researchers independently. A descriptive study was conducted for demographic characteristics, and the scores of each scale were described using means and standard deviations. Univariate analyses were performed for each parameter by using a t-test. Pearson correlation analysis was used to determine the links among social support and pain, self-perceived burden, and kinesiophbia. Hierarchical regression analysis was conducted to find independent factors associated with kinesiophbia. In this study, differences were indicated as statistically significant when P＜0.05.

Results

Participant’s characteristics and their univariate analysis

Among the 304 participants with KOA, the KOA patient group consisted of 155 male participants (51%) and 149 female participants (49%). 41.4% were 60-69 years old, a large majority of the participants were married (62.5%). The results of the univariate analysis demonstrated that there was a significant difference in the total of kinesiophbia in KOA patients in terms of gender, education, marital status, annual income of the family, BMI, number of combined chronic diseases, payment methods, degree of understanding of the condition, pain duration, pain degree, and primary caregiver. The demographic characteristics of the respondents and their univariate analysis are shown in Table 1.( See the end of article)

Table 1 Participant’s characteristics and their univariate analysis（±s, n=304）

Discussion

This study revealed that the social support and pain score from KOA was 18.73 ± 5.65, which is higher than that of Ma et al.[44] on patients with infratemporal joint disorders. Spanish seniors also have a high level of social support[45–46]. The reason may be that the elderly have more time and energy to communicate with their friends and family after retirement, express their feelings, and get responses from others, thereby increasing their social support. Most older adults in Malaysia also perceive a higher level of social support [47]. However, in a study of Mexico, social support was found to be lower among older adults [48]. Literacy and lifestyle affect the social support of older adults in different countries. Therefore, when medical staff intervenes in clinical interventions on elderly pain patients, they should also interfere with their surrounding family members; not only should the health education of the patients be strengthened, but also the psychological care and communication skills of their family members should be strengthened. Good interaction and communication skills can make the patient feel happy and relieve the pain caused by the disease.

In this study, the self-perceived burden score of elderly KOA patients was 31.18 ± 8.70, which is at a moderate burden level, which is consistent with the research results of Ren et al. [49]. The high cost of medicine and the lack of social resources are among the factors that affect patients' self-perceived burden[50]. The reason may be that the disease brings not only the consumption of external substances to the patient but also the increasing physical and mental torture, which makes the patient suffer from an increase in self-burden during the diagnosis and treatment process. The self-perceived burden can regulate the quality of life of patients [51]. The study found that the use of Motivational Interviewing(MI) was effective in reducing patients' self-perceived burden[52]. From this point of view, medical workers should discover the patient’s negative emotions as early as possible in their work, provide timely help, unblock the patient’s thoughts, and reduce the burden of self-feeling.

TSK-11 is a concise scale with strong generalization ability and is widely used by the public. It has a similar evaluation function with TSK-17, but its accuracy is not lower than TSK-17. The survey showed that the kinesiophbia score of elderly KOA patients was 29.04 ± 7.11. The incidence of kinesiophbia was 57.89%, which was slightly higher than the survey results of Kocic et al. [53]on patients with total knee arthroplasty (21.8%), but lower than the results of the study of patients with degenerative cervical disc disease (81.5%) [54]. The prevalence of kinesiophbia in a survey of patients with ankylosing spondylitis in Turkey was 66.6% [55]. The reason may be that it may be different from the living environment at home and abroad, and the elderly are in a period of decline in life, their physical abilities are in a decline stage, and the fear of pain is transformed into a behavioral fear of activity, that is, kinesiophbia. Medical staff should pay attention to elderly patients with long-term pain, let them correctly understand the pain, positively respond to the pain, teach patients how to reduce pain, and take adequate measures to help patients reduce the occurrence of kinesiophbia.

The results of this study show that the pain social support scores of elderly KOA patients are significantly negatively correlated with the panic disorder scores(r=-0.368,p<0.01). That is, the higher the level of social support for pain, the lower the degree of panic disorder, which is consistent with the results of Luque et al. [56]. Social support and self-efficacy have a positive impact on patients and can improve health status[57]. After receiving support and encouragement from friends, elderly KOA patients can actively perform rehabilitation exercises and calmly overcome the fear of pain. The score of self-perceived burden is positively correlated with the score of kinesiophbia (r = 0.605, p < 0.01), that is, the heavier the burden of self-perceived, the higher the level of kinesiophbia, which is consistent with the results of Sun et al. [58]. When the patient's physical and mental burden is too heavy, it will further produce negative emotions and loss of confidence and motivation in life, which induces kinesiophbia. Pain social support is negatively correlated with the self-perceived burden (r=-0.297, p < 0.01), that is, the higher the satisfaction with social support, the lighter the patient’s self-perceived burden, which is consistent with the results of Hill et al. [23]. Adequate social support can enable patients to open up and communicate well with the outside world. Caregivers of the elderly are less burdened as social support increases[59]. Good feedback from relatives and friends can also help patients reduce their burden.

The hierarchical regression results showed that when SPQ and SPBS were placed in the second layer, the adjusted R²16.7% was increased from 43.2–43.2%, and the degree of explanation of the regression equation for kinesiophbia increased by 26.5%. It suggests that the lower the patient's kinesiophbia level, the more social support the individual receives, and the less burden he bears, which is more conducive to later rehabilitation training.

The results of this study show that education level, marital status, understanding of the condition, and pain level are the influencing factors for the occurrence of kinesiophbia in elderly patients with KOA. The higher the education level, the lower the level of kinesiophbia, which is consistent with the research results of Cai et al. [60]. The reason may be that patients with a low level of education have insufficient understanding and cognition of knowledge about disease treatment and rehabilitation, and fear that activities will cause further physical harm. Therefore, medical staff should teach patients with lower education levels simply and clearly, so that they can better understand the importance of exercise for rehabilitation. Studies have shown that widowed patients have a higher level of panic disorder than married patients. It is possible that in life with the elderly, the primary companion is the spouse. The care and support provided by the spouse in life can reduce the patient's fear of activities and facilitate future recovery. The dynamic process of coping with agoraphobia in patients with myocardial infarction was found to include kin anxiety, and the presence of family members can lead to a different direction of disease development[61]. n clinical work, more attention should be paid to patients who lack long-term companions, and help and care should be given in life to reduce the level of kinesiophbia.

The more you understand the condition, the higher the level of panic disorder. After the patient understands his illness and physical condition, he can accurately assess his physical function, make behaviors in line with his abilities, and not excessively perform activities to aggravate the condition. It can be seen that medical staff should carry out different health education for different older people, and develop effective exercise plans for their physical conditions so that patients can recover as soon as possible. The more severe the pain, the higher the degree of kinesiophbia, which is consistent with the findings of Larsson et al. [62]. The possible reason is that the heavier the pain felt by the patient, which promotes the fear of movement and the deviation of the individual's behavioral cognition, resulting in a higher level of kinesiophbia. The study points out that pain and exercise, fear of injury are the antitheses[42]. Pain level has a strong relationship with the attendance of caregivers suffering from low back pain [63]. Therefore, medical workers should take intervention measures for patients with severe pain as soon as possible to reduce their fear of exercise, enhance their confidence in fighting pain, and improve their quality of life.

Limitations

This study only conducted a cross-sectional survey of two hospitals in Jinzhou City, Liaoning Province. The number and scope of the survey subjects have certain limitations. The survey scope can be expanded for further research in the future.

Conclusions

Current research shows that the kinesiophbia level of KOA patients should be increased, and SPQ and SPBS are the key factors affecting kinesiophbia. This study suggests that measures should be taken to improve the burden level of KOA patients, enhance the ability to cope with difficulties actively, and increase the use of social support and social support to strengthen the resilience of patients. Understanding the incidence of panic disorder in elderly patients with knee osteoarthritis suggests that medical staff should improve the patient’s awareness of rehabilitation and health education, build a bridge for nurse-patient communication, pay attention to the patient’s emotional and psychological changes, and continue to improve the patient’s old age Quality of life.

Abbreviations

Declarations

Ethics approval and consent to participate

Each object was willing to be enrolled, also informed consent before the study began. All participants gave informed consent for the research and that their anonymity was preserved. The Declaration of Helsinki was adhered to during this study. The study was approved by the Ethics Committee of the Jinzhou Medical University(NO.JZMULL2022008). Participants gave their written informed consent before the interviews took place.

Funding

This study was supported by the "Geriatric Health Promotion Action (2021-2025)" of the Chinese Society of Gerontology Foundation and Geriatrics, No. 2021-04-01

Acknowledgments

We are very grateful for the support and assistance of all the health care professionals and patients involved in this study.

Competing interests

No conflicts of interest in this study.

Authors’ contributions

LJY and LYP designed and conducted the study. TMY was a major contributor in drafting the manuscript. ZYL, ZYH, and JXF helped with data collection. LHY critically revised the manuscript. All authors read and approved the final manuscript.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the correspondence author.

Consent for publication

Not applicable.

Author details

School of Nursing, Jinzhou Medical University, No 40, Section 3, Songpo Road, 121001 Jinzhou, China.

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