| | Effect of a Virtual Pain Coach on Older Adults' Pain Communication: A Pilot StudyReceived 27 February 2009; received in revised form 7 October 2009; accepted 15 October 2009. published online 31 May 2010.
Corrected Proof Abstract A randomized posttest-only double blind design was used to pilot test the effect of a virtual practitioner pain communication coach on older adults' communication of their osteoarthritis pain. Baseline pain intensity and pain interference with activities were measured using the Brief Pain Inventory Short Form. Thirty older adults watched a video of a practitioner describing important osteoarthritis pain information followed by either a virtual practitioner coach, a video practitioner coach, or no coach. Participants were next asked, via a videotaped health care practitioner, to orally describe their pain as if speaking to their own practitioner. The amount of important distinctive pain information described by the older adults was audiotaped, transcribed, content analyzed, and summed using a priori criteria from the American Pain Society osteoarthritis pain management guidelines. Older adults described M =6.3 (SD=3.17), M=3.0 (SD=2.08), and M=5.2 (SD=2.40) items of important pain information as a result of the virtual coach, video coach, and no coach conditions, respectively; F(2,25)=3.17, p=.06, η2=.01. Older adults who practiced talking with the virtual coach described more than one additional item of important pain information. The clinically significant group difference supports the need to test the intervention in a randomized clinical trial. The virtual coaching and education intervention might enable older adults to communicate their pain management information more effectively to their practitioners. Osteoarthritis afflicts an estimated 27 million Americans (Lawrence et al., 2008), and is associated with debilitating pain (Caporali et al., 2005). To prescribe effective pain treatment, practitioners need to first elicit from their patients important information for osteoarthritis pain management. Only a few pain studies have tested communication content or techniques (Aiarzaguena et al., 2007, Chassany et al., 2006), and the results have not supported clinically significant cost-effective interventions to improve pain outcomes. Coaching interventions including individual coaching before an office visit (Oliver, Kravtiz, Kaplan, & Meyers, 2001) and combinations of written scripts and individual coaching (Miaskowski, et al., 2004) demonstrated significant pain reduction, however. The coaching effect suggests that patients can be assisted to effectively communicate their pain and receive interventions that significantly reduce their pain. The two coaching studies included only patients with cancer pain. Patients with other types of pain, such as chronic osteoarthritis pain, also need to be tested to determine the effect of coaching on their pain relief. A more serious limitation to the coaching studies is the cost of the individual person-to-person coaching, which limits its widespread use. A gap remains for feasible cost-effective interventions to enhance patient and practitioner communication about pain. The aim of the present study was to pilot test a cost-effective virtual pain communication coaching intervention for the effect on older adults' communication of their osteoarthritis pain and pain management needs. The Bayer Institute for Health Care Communication literature review on health care practitioner and patient communication identified only six medical studies that examined eliciting patients' agenda (White & Bonvicini, 2003). All six were limited to descriptive medical studies. Primary care physicians interrupted opening statements by their patients during 77% of the visits, and patients completed only 1 out of 52 interrupted statements (Beckman & Frankel, 1984). Physician communication remained virtually unchanged 12 years later when physicians were again found to interrupt 72% of the opening statements (Marvel, Epstein, Flowers, & Beckman, 1999). Physicians starting off with an open-ended question to delineate the patient's problem identified significantly more patients with emotional distress than physicians not taught problem-defining skills. Six months later, patient distress remained significantly reduced for patients of physicians using problem-defining communication skills (Roter et al., 1995). Patients' ability to describe information important for their pain management can be limited by the way health care practitioners communicate with them. Teaching patients how to enhance their pain communication might allow patients to engage in more productive pain discussions with their health care practitioners. Practitioner pain management education has been the major means for improving pain outcomes, but medical and nursing curricula have generally not included education about pain communication beyond pain assessment (Giamberadino, 2002), even though experts have identified pain communication skills as an essential component of training in medical education (Turner & Weiner, 2002). The benefit of increased education in pain communication was provided by a recent study with pediatric residents (Roter et al., 2004). An 18-hour educational intervention teaching physicians a more patient-centered approach when communicating about pain problems with patients with fibromyalgia found that patients felt that they were allowed to fully discuss their pain (Moral, Alamo, Jurado, & Torres, 2001), perhaps because of a Hawthorne effect for the physicians, or low expectations by patients. This resource-intensive intervention supported increased pain communication between patients and practitioners, but the specific communication strategies that promoted the full discussion remain unclear, and the effect on patient pain outcomes was not measured. Further research is needed to test specific pain communication strategies essential for practitioner pain management education. The theoretic framework guiding the present study was communication accommodation theory (CAT). CAT describes the motivations and behaviors of people as they adjust their communication in response to their own needs and the perceived behavior of the person (Fox & Giles, 1993). Interpretability and discourse management are specific attuning strategies that people can use to enhance communication (Coupland, Coupland, Giles, & Henwood, 1988). Interpretability strategies involve use of terminology that clearly and explicitly relates important information to the practitioner. Examples of strategies to increase interpretability include older adults' use of the 0-10 pain intensity scale, their description of how the pain interferes with their daily living, or their description of current pain treatments and the effectiveness of the treatments. Discourse management involves selecting the topic, contributing to the discussion by taking your turn, and maintaining topic focus. Older adults who introduce the topic of their pain management problems are more likely to discuss their pain problems with their practitioner. The more skillful older adults are in using communication strategies, the more likely they will be to convey important osteoarthritis pain information to the practitioners and to be prescribed more effective pain management treatments. The addition of a coaching component has assisted cancer patients to obtain improved pain outcomes, but a serious gap remains for effective, feasible interventions that assist older adults to communicate with their health care practitioners about their chronic nonmalignant pain. The following hypothesis was tested: Older adults in the videotape education/virtual pain coach condition will describe more pain information than older adults in the videotape education/videotaped practitioner pain coach condition or the videotape education only condition. Methods  Design A randomized posttest-only double-blind pilot test design was used to compare older adults' pain communication response after watching a video of a practitioner describing important osteoarthritis pain information followed by either a virtual practitioner coach, a video practitioner coach, or no coach. Randomization was achieved via use of the current clock and a Mersenne Twister random number generator program (Matsumoto & Nishimura, 1998). Sample The sample consisted of 30 community-dwelling adults aged ≥60 years with self-reported pain from osteoarthritis but no malignant pain. Participants were also required to speak and understand English. Power analysis was not conducted, owing to the exploratory nature of the pilot study. Procedure The study was approved for human subjects' protection by the university Institutional Review Board. Participants were recruited from two older adult independent living congregate housing sites located in the northeastern United States. After obtaining informed consent, the trained research assistant orally administered the Brief Pain Inventory Short Form (BPI-SF) to measure two covariates: pain intensity and functional interference with pain. Older adults were then randomly assigned via the computer randomization program to view one of the three communication conditions, and practice responding out loud in the two coaching conditions. Immediately following the respective intervention, participants were asked via a videotaped health care practitioner to respond to the question, “Tell me about your pain, aches, soreness, or discomfort,” as if responding to their own health care practitioner. Participant responses were audio-taped. Demographic information was obtained by the research assistant before questioning each participant for hypothesis guessing, debriefing participants about the specific purpose of the study, and compensating participants for their time. Virtual Practitioner Coach The virtual practitioner coach intervention introduced two important discourse management strategies: practice in selecting personally relevant pain management topics to discuss with the practitioner, and practice in taking their turn. The virtual practitioner coach, a computer-generated and displayed representation of a practitioner, consisted of a professionally dressed virtual female practitioner appearing in an examination room. The virtual practitioner orally instructed older adults to practice talking with her about their pain. Female was used because female practitioners encourage significantly more communication from their patients (Roter, Hall, & Aoki, 2002). The coach asked older adults to talk about their pain, detected and responded to pauses by encouraging older adults to describe additional information, provided general positive feedback on the practice session, and concluded the coaching session by encouraging older adults to share their important pain information with their practitioner. Older adults orally interacted with the virtual practitioner coach as they practiced talking about their pain. The initial statement from the virtual coach was: “I am going to help you practice talking with your health care practitioner so you can be sure to say all the important information about your pain that you need to when you talk. Pretend that I am your health care practitioner and respond out loud to me. Hello. Tell me about your pain, aches, soreness, or discomfort.” The second statement was: “Very good. Is there anything else you would like to tell me about your pain, aches, soreness, or discomfort?” The third and final statement was: “You have shared lots of helpful information about your pain. It is very important that you now tell your health care practitioner your pain information so that you can get your pain reduced to a mild or lower level.” Before the study, the virtual practitioner pain communication coach was developed and tested with ten older adults with osteoarthritis pain who did not participate in the present study. The virtual practitioner coach was revised based on feedback. Video Practitioner Coach The video practitioner coach consisted of a videotaped practitioner verbalizing the same three main statements as the virtual practitioner. Separate video clips appeared in the same sequence as the virtual practitioner statements with each statement initiated after the participant touched the space bar. Unlike the virtual pain coach, the video coach was unable to detect pauses or encourage participants to continue talking about their osteoarthritis pain. Pain Communication Videotape The pain communication videotape increases interpretability by increasing older adults' understanding of important types of osteoarthritis pain information assessed by practitioners and of terminology familiar to the practitioners (e.g., “pain intensity of 7 on a 0-10 scale”). The intervention increases discourse management by teaching older adults to select pain management as a topic to discuss with practitioners. The pain communication videotape consisted of a video of a female health care practitioner describing the types of osteoarthritis pain information important to share with health care practitioners. Content for the pain communication education portion of the intervention was based on the American Pain Society (2002) Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. The 3-minute pain communication education videotape was professionally produced and displayed on a laptop computer. All three groups viewed the pain communication videotape. The videotape was also developed and tested with the 10 previously mentioned older adults, and revised based on their feedback. Instruments Brief Pain Inventory Short Form (BPI-SF) Pain Measure The BPI-SF was used to obtain baseline osteoarthritis pain information. The BPI-SF consists of 15 questions that measure pain location, intensity, pain treatment, and functional interference of pain on mood and every day activities. Cronbach alpha for the overall BPI-SF has been reported as 0.77-0.87 (McDonald et al., 2005, Zalon, 1999). Validity of the BPI-SF has been evidenced by a correlation of r=61 and p < .001 with the Short Form McGill Pain Questionnaire (SF-MPQ) (Zalon, 1999). Demographic Form Older adults' demographic information was measured for age, gender, race, ethnic group, marital status, highest completed education, and if they were currently followed by a health care practitioner for their osteoarthritis and for their osteoarthritis-related pain. Content Analysis The audio-taped responses to the final video clip of the practitioner asking each participant to “Tell me about your pain, aches, soreness, or discomfort” were transcribed, and content analyzed (using 15 a priori criteria from the American Pain Society (2002) Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. The 15 criteria included type of pain (nociceptive/neuropathic), quality of pain, source, location, intensity, duration/time course, affect, effect on personal lifestyle, functional status, current pain treatments, effectiveness of prescribed treatments, prescription analgesic side effects, weight management to ideal body weight, exercise regimen or physical therapy and/or occupational therapy, and indications for surgery. Krippendorff's (2004) components for content analysis were used to content analyze transcripts of the responses to the virtual coach. The unit of analysis was any word or phrase that described one of the a priori criteria. One point was given for each word or phrase describing a criterion. Repeated use of the same word or phrase was counted only the initial time. Each distinctly different word or phrase about the same criterion was credited with one point. The type and amount of pain communication content was summed for each participant. Results The full sample, virtual coach, video coach, and no coach group frequencies for gender, education, receiving treatment for arthritis from a practitioner, and receiving treatment for pain from a practitioner are presented in Table 1. All of the participants were non-Hispanic and White. Means and standard deviations for age, percentage of pain relief from treatment, pain intensity, and functional interference from pain are presented in Table 2 for the full sample, virtual coach, video coach, and no coach groups. | ∗ Pain relief percentage was measured on the BPI-SF 0-100 scale. †Pain intensity was computed as the mean of the four BPI-SF 0-10 pain intensity items. ‡Functional pain was computed as the mean of the seven BPI-SF 0-10 functional interference items. |
Groups were compared regarding gender, education, receiving treatment for arthritis from a practitioner, receiving treatment for pain from a practitioner, age, percentage of pain relief from treatment, pain intensity, and functional interference from pain. There were no significant differences between the groups for any of these variables. The internal consistency for the BPI-SF pain intensity scale was α=0.81. The internal consistency for the BPI-SF functional interference from pain scale was α=0.83. The groups were compared reagrding the amount of pain information participants communicated in response to the question “Tell me about your pain, aches, soreness, or discomfort” after the respective intervention. Pain intensity and functional interference from pain were used as covariates. The amount of pain information was slightly skewed at 1.98. Square root transformation resulted in the normally distributed pain information variable used in the analysis of covariance. For the purpose of clarity, means and standard deviations are reported using the untransformed variable. Older adults described M=6.3 (SD=3.17), M=3.0 (SD=2.08), and M=5.2 (SD=2.40) items of important pain information as a result of the virtual coach, video coach, and no coach conditions, respectively; F(2,25)=3.17, p=.06, η2=.01. Mean pain intensity was significant as a covariate (F(1,25)=6.10, p=.02), as was mean functional interference from pain (F(1,25)=4.42, p=.05). Table 3 presents frequencies for the pain content communicated by the full sample and the virtual coach, video coach, and no coach groups. Discussion Older adults who viewed the pain communication videotape and responded to the virtual pain coach described on average one additional item of pain information than older adults who viewed the pain communication videotape and responded to the videotaped practitioner pain coach or who viewed only the pain communication videotape. The pilot results cautiously suggest that the virtual pain communication coach along with the pain communication videotape might assist some older adults to communicate more information about their osteoarthritis pain. One additional item of important pain information could indicate pain management changes that result in reduced pain. Practice in talking about the pain and taking turn in a pain discussion might be an important discourse management communication strategy for increasing older adults' pain communication with their practitioners. Older adults in the virtual coach group and the no coach group responded with more pain information than older adults who during a previous study responded to the identically presented pain question but did not view the pain communication videotape or pain coach (McDonald, 2009). Older adults in the previous study responded with M=3.6 (SD=2.46) items of important osteoarthritis pain information. The greater amount of information described in the present study suggests that the pain communication videotape might assist older adults to communicate more about their osteoarthritis pain. Identifying important pain information for older adults to describe to practitioners eases interpretability during pain discussion. Older adults responded with the least pain information in response to the video pain coach. The video pain coach consisted of clips of the practitioner from the pain communication video. Older adults might have been unable to distinguish the transition from the education component to the coaching component of the intervention, and as a result responded less. The noninteractive nature of the video coach also might explain why older adults responded less. The video coach could not detect pauses or encourage participants to describe more pain information as was done by the virtual coach. In either case older adults responding to the virtual coach described more than twice the pain information, indicating a greater ability to elicit pain information. The type of pain information communicated by participants might be more important than the amount of pain information. All of the communicated pain content identified through the content analysis was important pain information, according to the a priori criteria from the American Pain Society (2002). Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. Some information, however, might have greater clinical relevance depending on the older adults' clinical presentation. The most frequently described pain information in descending order of frequency was pain location, timing, intensity, functional interference from pain, and pain treatments, similar to findings from previous research with more than 300 community-dwelling older adults with osteoarthritis pain (McDonald, 2009). The pilot sample was too small to test for group differences in types of pain content. In general, participants in the virtual coach and no coach groups described similar amounts of the different types of pain information, as might be expected after both groups viewed the pain communication education videotape. Cautious interpretation is warranted owing to the pilot nature of the pain communication and virtual pain coach intervention. The pilot results might not support significant group differences with a larger sample powered to detect group differences. Randomization resulted in the virtual group with 12 participants and the no coach group with 11, but the video coach group with only 7 participants, which reduced power but did not affect group differences. The pilot took place in elderly congregate housing sites. Older adults might respond differently when the intervention is used by patients in an examination room immediately before discussions with their health care practitioners or in other settings. The authors are currently pilot testing the virtual pain coach in the primary care setting. The homogeneous sample of non-Hispanic White older adults does not indicate how older adults from other ethnic and racial backgrounds might respond. The intervention was in English, limiting use of the current version of the intervention to English speakers. To control for potential response bias, a videotaped practitioner was used to ask the older adults to describe their pain, but older adults might respond differently when their own practitioner asks them about their pain. Older adults were not screened for impaired visual or auditory acuity which could reduce the ability to respond to the intervention. The volume was individually adjusted to each participant's comfort level before proceeding with the intervention, reducing the likelihood of auditory difficulty. All information presented in the three conditions was presented orally, thereby reducing the potential for differences due to visual impairments. Increased usefulness and ease of technology use have been suggested as important factors increasing older adult computer use (Czaja & Sharit, 1998). Older adults trained to use an interactive computer program teaching them about medication interactions reported that the information was useful and that the program was easy to use (Neafsey, Strickler, Shellman, & Chartier, 2002). The present study provides further evidence that when given brief instructional support, older adults are able to use computers to access health information. This pilot study provides preliminary evidence that a virtual pain communication coach along with a brief pain communication videotape assists older adults with osteoarthritis pain to communicate a clinically significant greater amount of information about their pain. The virtual nature of the coaching intervention avoids the resource-intensive nature of individual coaching interventions (Miaskowski et al., 2004, Oliver et al., 2001). A recent randomized trial of a 6-week internet-based arthritis self-management program revealed a clinically nonsignificant 0.65 point greater pain reduction on a single 0-10 pain intensity scale with adults in the treatment and control groups continuing to report moderately intense pain (Lorig, Ritter, Laurent, & Plant, 2008). Interventions are needed to assist older adults to communicate with their practitioners about their pain in ways that result in significant pain reduction. The present pilot study cautiously suggests that the virtual pain communication coach along with the brief pain communication videotape assists older adults to describe important pain information. A randomized clinical trial is needed to test the virtual coach intervention for the effect on pain communication and long-term pain outcomes for older adults with osteoarthritis pain. References Aiarzaguena et al., 2007. 1.Aiarzaguena J, Grandes G, Gaminde I, Salazar A, Sanchez A, Arino J. 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Supported with funds from the School of Nursing, University of Connecticut; University of Connecticut Research Foundation; Mu Chapter Sigma Theta Tau; and the McDonald Family Trust. PII: S1524-9042(09)00121-0 doi:10.1016/j.pmn.2009.10.001 © 2009 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. | |
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