Virtual Pain Coach and Older Adults' Pain Communication
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, η=.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.
Abstract and Introduction
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, η=.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.
Introduction
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.