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Self-care behaviors for muscle pain
Self-Care Behaviors for Muscle Pain Erin A. Dannecker,* Christine M. Gagnon,† Rebecca L. Jump,‡ Jennifer L. Brown,‡ and Michael E. Robinson‡ Abstract: This investigation examined self-care behaviors for muscle pain because of the prevalence of musculoskeletal pain and the substitution of self-care for formal medical care. In Study 1, university students (N ⴝ 187) completed a retrospective questionnaire about self-care for muscle pain. In Study 2, muscle pain was experimentally induced in university students (N ⴝ 79) with subsequent measurement of self-care. In both studies, stretching and massaging were the most frequently performed behaviors, and consuming medication was the least frequently performed. In Study 1, the perceived effectiveness of behaviors and level of pain required to perform self-care accounted for 12% to 32% of the variance in behavior frequency. In Study 2, pain ratings and pain during activities were higher among those who performed self-care (ds ⴝ .59 to 1.00). These studies indicated that self-care behaviors are performed for both naturally occurring and experimentally induced muscle pain. However, both studies determined that the performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness for muscle injuries. Unique opportunities for future investigations of self-care behavior models and interventions are permitted by muscle pain induction. Perspective: Self-care for pain reduction is an understudied behavior. This report describes 2 studies of self-care behaviors for naturally occurring and experimentally induced muscle pain. The most frequent types of self-care behaviors are similar for the types of pain, and the perceived effectiveness of behaviors and pain level influence performance of the behaviors. © 2004 by the American Pain Society Key words: Self-management, self-treatment, delayed-onset muscle soreness.
M
usculoskeletal disorders are the most prevalent cause of chronic health problems, disabilities, and health care utilization, and they are the second most common reason for restricting activity and consuming medication.3 Musculoskeletal pain is the most frequently reported type of pain,24,34 the most common type of chronic/recurrent pain,1,7 and a primary determinant of disability.20,31 A recent study found that 38% to 57% of people reporting non–injury-related musculoskeletal pain had constant or daily pain, and 12% to 34% waited more than a year to seek medical treatment for their pain.40 During this period, individuals often use self-care strategies, which are defined as behaviors for health promotion and disease prevention, detection, and treatment.21 Such self-care behaviors Received July 28, 2004; Revised September 15, 2004; Accepted September 23, 2004. From the *Department of Physical Therapy, University of Missouri, Columbia, Missouri; †Pain Management Center, St Margaret Mercy Healthcare Centers, Hammond, Indiana; and ‡Center for Pain Research and Behavioral Health, Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida. Support for this research was provided from grant 5F32 (AR08623-01) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (E.A.D.). Address reprint requests to Erin A. Dannecker, PhD, ATC, University of Missouri–Columbia, Department of Physical Therapy, 106 Lewis Hall, Columbia, MO 65211-4250. E-mail: [email protected] 1526-5900/$30.00 © 2004 by the American Pain Society doi:10.1016/j.jpain.2004.09.003
have been found to substitute for formal medical care.16,38 Formal self-management programs are used to treat numerous chronic diseases.26,39 These programs improve health status and substantially reduce health care costs.22,23 An important component of self-management programs is patient education.4 For example, Hammond15 found that patients with rheumatoid arthritis tended to use self-management strategies they thought were beneficial rather than techniques with established efficacy. This failure to use established techniques was related to lack of knowledge regarding their proper use. It is not surprising that a patient’s beliefs about a strategy influence his or her use of the strategy. Indeed, several investigations have supported the importance of perceived treatment effectiveness for the performance of self-care.32,33,37 However, it is disconcerting when inaccurate beliefs lead to less than optimal and potentially dangerous self-management strategies. For example, both heat and cold are strategies for treating muscle pain. However, determining when and how to use heat or cold depends on several variables of which the general public might not be aware.35 Such uninformed decisions can lead to poor outcomes. In fact, Graham and Stevenson14 reported a case of severe frostbite from the improper use of ice for treating nonspecific pain. Another self-care behavior for musculoskeletal pain is massage. However, Ernst11 found that serious adverse
The Journal of Pain, Vol 5, No 9 (November), 2004: pp 521-527
521
522
Self-Care Behaviors for Muscle Pain
Mean Ratings of Self-Care Behaviors on Frequency, Effectiveness, Required Intensity, and Required Unpleasantness in Response to Muscle Pain
Table 1.
SELF-CARE BEHAVIOR Stretching Massaging Resting Over-the-counter medication Cold Heat
FREQUENCY OF PERFORMANCE
PERCEIVED EFFECTIVENESS
REQUIRED INTENSITY
REQUIRED UNPLEASANTNESS
76.2 (26.4) 74.8 (24.9) 60.8 (30.7) 24.5 (29.7)
71.9 (22.7) 71.6 (22.1) 71.2 (26.7) 58.3 (27.3)
30.4 (22.3) 30.0 (20.4) 47.8 (26.3) 63.7 (26.8)
28.1 (23.2) 29.1 (21.4) 43.8 (27.6) 63.6 (25.7)
26.1 (27.8) 32.0 (30.5)
54.1 (26.6) 53.7 (25.8)
52.6 (23.8) 44.8 (24.1)
50.8 (23.9) 42.6 (24.1)
NOTE. Scores are based on 0 to 100 numeric rating scales; group means and SDs are presented.
events might be associated with massage performed by laymen and unusual forms of massage. Three cases resulted in pulmonary embolism, hematoma, and embolization of the left kidney, respectively. There is also a wide body of literature showing that misuse of over-thecounter medications by headache sufferers can result in daily or rebound headaches,12,25,36 and there is literature showing that consumption of nonsteroidal anti-inflammatory medication for muscle injury can inhibit muscle regeneration.5,27 Thus, not only is it important for people to know which strategies to use for their pain and when to use them, but also how to use them properly. This report includes 2 studies that examined the use of 6 self-care behaviors for naturally occurring and experimentally induced muscle pain. Participants’ beliefs about the effectiveness of the self-care behaviors and the pain intensity and unpleasantness required for performance of the self-care behaviors were assessed. The self-care behaviors included in the study (ie, rest, massage, heat, cold, stretching, over-the-counter medications) are common treatments for muscle injury along with compression and elevation.6,9,17,28
Study 1 Material and Methods Participants Participants were 187 university students (62% women) with an average age of 19 years (SD, 1.52). Sixtynine percent of participants were white, 13.4% were African American, 10.2% were Hispanic, and 5.9% were Asian American.
Procedures After providing written informed consent to the protocol, which was approved by the university’s institutional review board, participants answered questions pertaining to their performance of certain self-care behaviors for muscle pain, the pain levels required for them to engage in these self-care behaviors, and the effectiveness of these self-care behaviors.
Measures Performance of Self-Care Behaviors Participants rated the frequency with which they engaged in the following 6 behaviors when they experi-
enced muscle pain: stretching, massaging, resting, consuming an over-the-counter medication, applying heat, and applying cold. Frequency estimates were made on a 0 to 100 numeric scale in which 0 represents “never” and 100 represents “always.”
Pain Ratings First, participants rated how intense their muscle pain would have to be for them to engage in each of the 6 self-care behaviors listed above. The pain intensity scale ranged from 0 “not at all” to 100 “most intense imaginable.” Second, participants rated how unpleasant the muscle pain would have to be for them to engage in each of the self-care behaviors. The pain unpleasantness scale ranged from 0 “not at all” to 100 “most unpleasant imaginable.”
Effectiveness of Self-Care Behaviors Participants rated how effective they thought each of the self-care behaviors were in reducing muscle pain by using a 0 “not at all” to 100 “completely” numeric scale.
Data Analyses Differences among self-care behaviors in (1) the recalled frequency of performance for muscle pain, (2) the levels of muscle pain required for participants to perform the behavior, and (3) the perceived effectiveness of the behaviors were evaluated with one-way repeated measures analyses of variance (ANOVAs). Main effects for differences between the self-care behaviors were followed with Bonferroni corrected pairwise comparisons. In addition, the influence of both required muscle pain levels and perceived effectiveness of self-care behaviors on the tendency to perform the behaviors was assessed with forced entry regression analyses.
Study 1 Results Significant differences in the performance of self-care behaviors for muscle pain were found (F5,930 ⫽ 178.02, P ⬍ .01, 2 ⫽ .49), with stretching and massaging being the most frequently performed and consuming an overthe-counter medication and applying cold or heat being
ORIGINAL REPORT/Dannecker et al
523
Frequency of Self-Care Behaviors Predicted by Perceived Effectiveness of Behavior and Levels of Muscle Pain Intensity and Unpleasantness Required to Engage in Self-Care Behaviors
Table 2.
SELF-CARE BEHAVIOR Stretching Effectiveness Required intensity Required unpleasantness Massage Effectiveness Required intensity Required unpleasantness Resting Effectiveness Required intensity Required unpleasantness Over-the-counter medication use Effectiveness Required intensity Required unpleasantness Cold application Effectiveness Required intensity Required unpleasantness Heat application Effectiveness Required intensity Required unpleasantness
R2
 COEFFICIENT
T
VALUE
P VALUE
.24 .470 ⫺.161 .140
7.29 ⫺1.71 1.50
.000 .087 .136
.333 ⫺.137 .002
4.78 ⫺1.48 .02
.000 .140 .983
.474 ⫺.037 ⫺.119
7.41 ⫺.46 ⫺1.49
.000 .646 .139
.276 ⫺.191 ⫺.329
4.53 ⫺2.13 ⫺3.66
.000 .035 .000
.327 ⫺.091 ⫺.202
4.91 ⫺.90 ⫺1.99
.000 .367 .048
.419 ⫺.122 ⫺.058
6.38 ⫺1.23 ⫺.59
.000 .221 .559
.12
.26
.32
.21
.22
NOTE. Dependent variable ⫽ frequency ratings of respective self-care behaviors on a 0 to 100 scale.
the least frequently performed. The self-care behaviors also differed significantly on perceived effectiveness (F5,930 ⫽ 29.85, P ⬍ .01, 2 ⫽ .14), with stretching, massaging, and resting perceived as most effective and consuming an over-the-counter medication and applying cold or heat perceived as least effective. In addition, the pain level required for self-care behaviors to be performed varied for both intensity (F5,930 ⫽ 74.64, P ⬍ .01, 2 ⫽ .29) and unpleasantness (F5,930 ⫽ 90.15, P ⬍ .01, 2 ⫽ .33). Consuming an over-the-counter medication required the highest pain levels, whereas stretching and massaging required the lowest pain levels. See Table 1 for means and SDs. The amount of variance in the frequency of performing self-care behaviors explained by required muscle pain levels and perceived effectiveness of the self-care behaviors ranged from 12.1% for stretching to 32.3% for consuming an over-the-counter medication (Table 2). Perceived effectiveness made significant independent contributions to each of the self-care behaviors (ts ⫽ 4.58 to 7.29, Ps ⬍ .05). In addition, required pain intensity (t ⫽ ⫺2.13, P ⫽ .04) and pain unpleasantness (t ⫽ ⫺3.66, P ⬍ .01) significantly influenced the frequency of consuming over-the-counter medications, such that participants generally were hesitant to consume medications unless their pain level was high. A similar relationship was observed between pain unpleasantness and applying cold (t ⫽ ⫺1.99, P ⬍ .05).
Study 1 Discussion According to this investigation, individuals perform self-care behaviors in response to naturally occurring muscle pain, and some behaviors (eg, stretching, massaging) are performed more often than others (eg, consuming over-the-counter medication, applying heat or cold). The infrequently completed behaviors (eg, consuming medication) were also described as requiring higher pain levels before completion, which suggests a consistent hesitancy to perform them. The primary predictor of performing the behaviors was perceived effectiveness, which indicated that beliefs about the effectiveness of a particular self-care strategy do indeed predict use of the strategy. The performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness.6,9,17,28 For example, the application of cold and heat was infrequent, despite recommendations that ice be applied early after injury and heat be applied several days after injury.17,28 In addition, over-the-counter medications were infrequently taken, despite the usefulness of nonsteroidal anti-inflammatory medications (eg, aspirin, ibuprofen) for the first few days after injury.17,28 Although the self-care behaviors evaluated in this investigation are considered routine treatments for muscle injury, their effectiveness is not adequately supported,6,9 and these self-care behaviors might not be relevant to all types of muscle pain. In addition, the time and manner of
524 the behaviors are important to consider for determination of whether appropriate behaviors are performed at appropriate times in appropriate ways. Furthermore, the retrospective recall of pain and behaviors would benefit from the application of laboratory models using controlled pain stimuli that produce self-care behaviors outside the laboratory. Therefore, the purpose of Study 2 was to examine the utility of a model of exercise-induced muscle pain within this context.
Study 2 Material and Methods Participants Participants were 61 university students (61% women) with an average age of 21 years (SD, 2.33) who were part of a larger investigation comparing exercise-induced muscle pain to typical laboratory pain. Seventy-three percent (72.9%) of participants were white, 6.8% were African-American, 8.5% were Hispanic, and 6.8% were Asian-American. Participants met the following restrictions: (1) had not engaged in upper body strength training on a regular basis (ie, 2 times per week) for consecutive weeks within the previous 6 months, (2) were not currently experiencing arm pain, and (3) had no history of upper arm injury within the previous 6 months. In addition, participants were screened for potential risk factors of a heightened response to the exercise protocol (eg, excessive swelling, loss of range or motion, exertional rhabdomyolysis).29
Procedures Participants provided written informed consent to the protocol, which was approved by the university’s institutional review board. As part of a larger investigation, participants completed a strength test and muscle pain induction procedure in physical therapy clinics operated by Shands Hospital at the University of Florida. Seventytwo hours later, they called a telephone data collection system (VoiceGuide; Katalina Technologies, Sydney, Australia) and responded to questions that are described below.
Eccentric Strength Test Participants were positioned in an isokinetic apparatus according to the manufacturer’s recommendations (Biodex System 3; Biodex Medical Systems, Shirley, NY). Such isokinetic devices use a computer to control the speed of the contractions. After completing 6 to 10 submaximal familiarization repetitions, participants performed a strength test that consisted of 5 consecutive maximal eccentric repetitions, which are contractions in which the muscle lengthens. Participants completed all repetitions through active range of motion at a velocity of 90°/s in the eccentric phase.
Muscle Pain Stimulus Muscle pain was induced in the elbow flexors of the dominant arm by having participants complete 3 sets of 12 eccentric repetitions. Participants were provided a
Self-Care Behaviors for Muscle Pain minimum peak torque target of 75% of eccentric strength for each repetition, and they were permitted to observe their torque output throughout the range of motion on the display screen of the isokinetic device. Participants completed the repetitions in the same manner as described for the strength test. However, a rest phase of 60 seconds was provided between each set. The average percentage of eccentric strength completed across the 3 sets of contractions was 67.7% (SD, 0.08).
Measures Eccentric Strength The peak torque that participants produced during 5 eccentric contractions was defined as the 1 repetition maximum (1 RM; ie, eccentric strength). Unpublished pilot data determined that the between session test-retest reliability of eccentric strength measured with this device by using the same muscle group (ie, elbow flexors) was excellent (intraclass correlation coefficient ⫽ .97).
Pain Ratings To measure exercised-induced muscle pain, ratings of pain intensity and pain unpleasantness were collected by using 0 to 100 numeric scales. The pain intensity scale anchors were “no pain” and “most intense pain sensation imaginable,” and the pain unpleasantness scale anchors were “not at all unpleasant” and “most unpleasant imaginable.” Participants made pre-exercise ratings in person and postexercise ratings via the telephone data collection system.
Frequency of Muscle Pain With the telephone data collection system, participants rated the frequency of feeling pain in the exercised arm during normal daily activities during the previous 24 hours on a 0 to 100 numeric scale. The anchors for the scale were “never” and “constantly.”
Performance of Self-Care Behaviors With a “yes” or “no” response format, participants rated their performance of 5 self-care behaviors for the purpose of relieving arm muscle pain. The 5 self-care behaviors were based on Study 1 and included stretching, massaging, resting, consuming medication, and applying heat or cold. Again, participants made their responses via a telephone data collection system.
Data Analyses Paired samples t tests were conducted to assess the induction of muscle pain by comparing preinduction pain scores to the scores obtained at 72 hours after exercise. The performance of self-care behaviors and the perception of pain during normal daily activities were evaluated by the calculation of frequencies and descriptive statistics. Differences in the completion of self-care behaviors were examined with the Fisher exact test. In addition, independent t tests were used to compare the groups that did and did not perform each self-care behavior. The groups were compared on pain ratings and
ORIGINAL REPORT/Dannecker et al the perception of pain during normal daily activities to determine if those participants performing behaviors had higher pain ratings and more frequent perception of pain during normal daily activities.
525
Percentage of Participants (N ⴝ 61) Performing Self-Care Behaviors 72 Hours After Exercise
Table 3.
SELF-CARE BEHAVIOR
Study 2 Results Compliance with the telephone procedures on each of these days was 77.2% (N ⫽ 61), so the analyses were conducted on this sample. Significant increases in muscle pain intensity (t ⫽ ⫺10.19, P ⬍ .01, d ⫽ 2.52) and unpleasantness (t ⫽ ⫺10.79, P ⬍ .01, d ⫽ 2.65) were observed from pre-exercise to postexercise, indicating the exercise protocol was successful. The baseline levels of muscle pain intensity and unpleasantness were mean of 0.36 (SD, 1.08) and mean of 0.54 (SD, 1.67), respectively. The levels of muscle pain intensity (mean, 36.38; SD, 27.54) and unpleasantness (mean, 44.82; SD, 31.76) obtained by 72 hours after exercise were sufficient to produce pain that is routinely felt during daily activities (mean, 53.02; SD, 37.86), and 19.7% to 83.6% of the participants performed self-care behaviors in response to the pain. Stretching and massaging were the most frequently performed behaviors, and consuming medication was the least frequently performed behavior (Table 3). As expected, higher pain ratings and more frequent perception of pain during normal daily activities were observed for participants who performed self-care behaviors (Table 4). More specifically, when comparing participants who did and did not perform self-care behaviors, the pain intensity reported by performers was significantly higher for all behaviors (ts ⫽ 2.14 to 3.30, Ps ⬍ .05, ds ⫽ .59 to .78) except applying heat or cold and consuming medication. Pain unpleasantness was significantly higher for all behaviors (ts ⫽ 2.45 to 3.05, Ps ⬍ .05, ds ⫽ .84 to 1.00) except applying heat or cold. Similarly, the frequency of pain perception with activity was significantly higher for all behaviors (ts ⫽ 2.19, Ps ⬍ .05, ds ⫽ .64 to .98) except stretching, but this difference approached significance (P ⫽ .06) and had a large effect size (d ⫽ .68).
Study 2 Discussion The exercise-induced muscle pain model used in this study was sufficient to produce self-care behaviors and pain that are perceived during normal daily activities. Consistent with Study 1, stretching and massaging were the most frequently performed self-care behaviors, and consuming medication was the least frequently performed self-care behavior. Higher pain ratings and more frequent perception of pain during normal daily activities were observed for those who performed self-care behaviors. Because the delayed-onset muscle pain produced by exercise might last for up to 10 days,8 the exercise stimulus could be used to assess change in the performance of self-care behaviors across time. Investigations could test the predictive efficacy of models of and interventions for self-care.10,18 Pain ratings and the frequency of
Stretching Massage Resting Over-the-counter medication Applying cold/heat
FREQUENCY
PERCENTAGE
51 51 42 16 12
83.6 83.6 68.9 26.2 19.7
pain perception during normal daily activities should be included into models because of the differences in their levels between those who did and did not perform selfcare behaviors.
General Discussion As stated previously, the self-care behaviors included in the study (ie, rest, massage, heat, cold, stretching, over-the-counter medications) are common treatments for muscle injury along with compression and elevation.6,9,17,28 Studies 1 and 2 determined that the performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness for muscle injuries. One potential reason for this contradiction is that participants were specifically asked about self-care behaviors for relieving muscle pain, whereas investigations of treatment effectiveness for muscle injury typically evaluate muscle pain or soreness along with range of motion, weakness, inflammation, etc. However, both the application of ice and consumption of antiinflammatory medications, which were infrequently performed, are specifically recommended for pain or soreness.6,9,28 Study 1 supported the importance of perceived effectiveness for the performance of self-care behaviors. This finding has been reported by other authors in other samples.32,33,37 However, Study 1 was limited by a reliance on retrospective recall by using questionnaires. In Study 2, induced pain with a controlled stimulus also produced self-care behaviors, and the pain differentiated between those who completed self-care and those who did not. Because the induced pain can last for more than a week, this methodology permits experimental designs with repeated measures across time. Thus, future tests of selfcare models and interventions can be conducted, and these investigations could examine a larger number of self-care behaviors in both healthy and clinical samples. Such investigations are important because of evidence that self-care behaviors substitute for formal medical care16,38 and that health care costs impact self-care behaviors.13,19 It is noteworthy that exercise-induced muscle damage causes weakness, reduced range of motion, stiffness, swelling, and altered proprioception, and biomechanics in addition to pain.30 Such muscle pain affects normal daily activities as reported in Study 2. However, the meaning of this muscle pain is likely to be different
526
Self-Care Behaviors for Muscle Pain
Comparison of Pain Frequency During Daily Activities, Intensity, and Unpleasantness Between Users and Nonusers of Self-Care Behaviors at 72 Hours After Muscle Pain Induction
Table 4.
PAIN FREQUENCY
PAIN INTENSITY COHEN
SELF-CARE BEHAVIOR Stretching Massage Resting Over-the-counter medication use Heat/ice application
COHEN
N
MEAN
SD
SIGNIFICANCE
D
MEAN
SD
SIGNIFICANCE
51 10 51 10 42 19 16
57.1 32.1 58.8 23.7 61.1 35.1 70.3
35.1 16.4 35.1 39.8 34.1 40.1 33.7
.055
.68
.006
.98
.012
.72
.033
.64
39.8 19.0 41.2 12.0 41.3 25.5 46.5
26.8 26.1 30.0 15.1 25.5 26.0 26.6
N 45 Y 12 N 49
46.9 79.5 46.5
37.7 27.5 37.4
.002
.92
32.8 39.6 35.6
27.3 31.7 26.7
Y N Y N Y N Y
PAIN UNPLEASANTNESS COHEN
D
MEAN
SD
SIGNIFICANCE
.028
.78 1.14
.036
.59
.087
.51
29.8 34.0 30.5 26.7 28.1 33.3 24.8
.017
.000
49.1 23.2 49.8 19.7 52.6 27.5 63.3
.657
.14
38.2 31.6 51.17 31.6 43.3 31.9
.005
D
.85 1.0
.036
.84
.003
.84
.444
.23
NOTE. Scores are based on 0 to 100 numeric rating scales; group means and standard deviations (SDs) are presented. Abbreviations: Y, yes; N, no.
than that of chronic or recurrent clinical muscle pain. In addition, the meaning of muscle pain is likely to be different, depending on the age and health status of the sample. Because the meaning of pain (eg, tissue-
damaging) influences the perception of pain2 and might influence the performance of self-care behaviors, additional investigations evaluating these issues are warranted.
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527 physical disability in a sample of community-dwelling senior citizens. J Gerontol 55A:M393-399, 2000 32. Skinner TC, Hampson SE: Personal models of diabetes in relation to self-care, well-being, and glycemic control: A prospective study in adolescence. Diabetes Care 24:828-833, 2001 33. Skinner TC, John M, Hampson SE: Social support and personal models of diabetes as predictors of self-care and well-being: A longitudinal study of adolescents with diabetes. J Pediatr Psychol 25:257-267, 2000 34. Sternbach RA: Survey of pain in the United States: The Nuprin Pain Report. Clin J Pain 2:49-53, 1986 35. Tepperman PS, Devlin M: Therapeutic heat and cold: A practitioner’s guide. Postgrad Med 73:69-76, 1983 36. Tonore TB, King DS, Noble SL: Do over-the-counter medications for migraine hinder the physician? Curr Pain Headache Rep 6:162-167, 2002 37. van de Kar A, Knottnerus A, Meertens R, Dubois V, Kok G: Why do patients consult the general practitioner? Determinants of their decision. Br J Gen Pract 42:313-316, 1992 38. Verbrugge LM, Ascione FJ: Exploring the iceberg. Med Care 25:539-569, 1987 39. Wheeler JR, Janz NK, Dodge JA: Can a disease self-management program reduce health care costs? The case of older women with heart disease. Med Care 41:706-715, 2003 40. Woolf AD, Zeidler H, Haglund U, Carr AJ, Chaussade S, Cucinotta D, Veale DJ, Martin-Mola E: Musculoskeletal pain in Europe: Its impact and a comparison of population and medical perceptions of treatment in eight European countries. Ann Rheum Dis 63:342-347, 2004
M
usculoskeletal disorders are the most prevalent cause of chronic health problems, disabilities, and health care utilization, and they are the second most common reason for restricting activity and consuming medication.3 Musculoskeletal pain is the most frequently reported type of pain,24,34 the most common type of chronic/recurrent pain,1,7 and a primary determinant of disability.20,31 A recent study found that 38% to 57% of people reporting non–injury-related musculoskeletal pain had constant or daily pain, and 12% to 34% waited more than a year to seek medical treatment for their pain.40 During this period, individuals often use self-care strategies, which are defined as behaviors for health promotion and disease prevention, detection, and treatment.21 Such self-care behaviors Received July 28, 2004; Revised September 15, 2004; Accepted September 23, 2004. From the *Department of Physical Therapy, University of Missouri, Columbia, Missouri; †Pain Management Center, St Margaret Mercy Healthcare Centers, Hammond, Indiana; and ‡Center for Pain Research and Behavioral Health, Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida. Support for this research was provided from grant 5F32 (AR08623-01) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (E.A.D.). Address reprint requests to Erin A. Dannecker, PhD, ATC, University of Missouri–Columbia, Department of Physical Therapy, 106 Lewis Hall, Columbia, MO 65211-4250. E-mail: [email protected] 1526-5900/$30.00 © 2004 by the American Pain Society doi:10.1016/j.jpain.2004.09.003
have been found to substitute for formal medical care.16,38 Formal self-management programs are used to treat numerous chronic diseases.26,39 These programs improve health status and substantially reduce health care costs.22,23 An important component of self-management programs is patient education.4 For example, Hammond15 found that patients with rheumatoid arthritis tended to use self-management strategies they thought were beneficial rather than techniques with established efficacy. This failure to use established techniques was related to lack of knowledge regarding their proper use. It is not surprising that a patient’s beliefs about a strategy influence his or her use of the strategy. Indeed, several investigations have supported the importance of perceived treatment effectiveness for the performance of self-care.32,33,37 However, it is disconcerting when inaccurate beliefs lead to less than optimal and potentially dangerous self-management strategies. For example, both heat and cold are strategies for treating muscle pain. However, determining when and how to use heat or cold depends on several variables of which the general public might not be aware.35 Such uninformed decisions can lead to poor outcomes. In fact, Graham and Stevenson14 reported a case of severe frostbite from the improper use of ice for treating nonspecific pain. Another self-care behavior for musculoskeletal pain is massage. However, Ernst11 found that serious adverse
The Journal of Pain, Vol 5, No 9 (November), 2004: pp 521-527
521
522
Self-Care Behaviors for Muscle Pain
Mean Ratings of Self-Care Behaviors on Frequency, Effectiveness, Required Intensity, and Required Unpleasantness in Response to Muscle Pain
Table 1.
SELF-CARE BEHAVIOR Stretching Massaging Resting Over-the-counter medication Cold Heat
FREQUENCY OF PERFORMANCE
PERCEIVED EFFECTIVENESS
REQUIRED INTENSITY
REQUIRED UNPLEASANTNESS
76.2 (26.4) 74.8 (24.9) 60.8 (30.7) 24.5 (29.7)
71.9 (22.7) 71.6 (22.1) 71.2 (26.7) 58.3 (27.3)
30.4 (22.3) 30.0 (20.4) 47.8 (26.3) 63.7 (26.8)
28.1 (23.2) 29.1 (21.4) 43.8 (27.6) 63.6 (25.7)
26.1 (27.8) 32.0 (30.5)
54.1 (26.6) 53.7 (25.8)
52.6 (23.8) 44.8 (24.1)
50.8 (23.9) 42.6 (24.1)
NOTE. Scores are based on 0 to 100 numeric rating scales; group means and SDs are presented.
events might be associated with massage performed by laymen and unusual forms of massage. Three cases resulted in pulmonary embolism, hematoma, and embolization of the left kidney, respectively. There is also a wide body of literature showing that misuse of over-thecounter medications by headache sufferers can result in daily or rebound headaches,12,25,36 and there is literature showing that consumption of nonsteroidal anti-inflammatory medication for muscle injury can inhibit muscle regeneration.5,27 Thus, not only is it important for people to know which strategies to use for their pain and when to use them, but also how to use them properly. This report includes 2 studies that examined the use of 6 self-care behaviors for naturally occurring and experimentally induced muscle pain. Participants’ beliefs about the effectiveness of the self-care behaviors and the pain intensity and unpleasantness required for performance of the self-care behaviors were assessed. The self-care behaviors included in the study (ie, rest, massage, heat, cold, stretching, over-the-counter medications) are common treatments for muscle injury along with compression and elevation.6,9,17,28
Study 1 Material and Methods Participants Participants were 187 university students (62% women) with an average age of 19 years (SD, 1.52). Sixtynine percent of participants were white, 13.4% were African American, 10.2% were Hispanic, and 5.9% were Asian American.
Procedures After providing written informed consent to the protocol, which was approved by the university’s institutional review board, participants answered questions pertaining to their performance of certain self-care behaviors for muscle pain, the pain levels required for them to engage in these self-care behaviors, and the effectiveness of these self-care behaviors.
Measures Performance of Self-Care Behaviors Participants rated the frequency with which they engaged in the following 6 behaviors when they experi-
enced muscle pain: stretching, massaging, resting, consuming an over-the-counter medication, applying heat, and applying cold. Frequency estimates were made on a 0 to 100 numeric scale in which 0 represents “never” and 100 represents “always.”
Pain Ratings First, participants rated how intense their muscle pain would have to be for them to engage in each of the 6 self-care behaviors listed above. The pain intensity scale ranged from 0 “not at all” to 100 “most intense imaginable.” Second, participants rated how unpleasant the muscle pain would have to be for them to engage in each of the self-care behaviors. The pain unpleasantness scale ranged from 0 “not at all” to 100 “most unpleasant imaginable.”
Effectiveness of Self-Care Behaviors Participants rated how effective they thought each of the self-care behaviors were in reducing muscle pain by using a 0 “not at all” to 100 “completely” numeric scale.
Data Analyses Differences among self-care behaviors in (1) the recalled frequency of performance for muscle pain, (2) the levels of muscle pain required for participants to perform the behavior, and (3) the perceived effectiveness of the behaviors were evaluated with one-way repeated measures analyses of variance (ANOVAs). Main effects for differences between the self-care behaviors were followed with Bonferroni corrected pairwise comparisons. In addition, the influence of both required muscle pain levels and perceived effectiveness of self-care behaviors on the tendency to perform the behaviors was assessed with forced entry regression analyses.
Study 1 Results Significant differences in the performance of self-care behaviors for muscle pain were found (F5,930 ⫽ 178.02, P ⬍ .01, 2 ⫽ .49), with stretching and massaging being the most frequently performed and consuming an overthe-counter medication and applying cold or heat being
ORIGINAL REPORT/Dannecker et al
523
Frequency of Self-Care Behaviors Predicted by Perceived Effectiveness of Behavior and Levels of Muscle Pain Intensity and Unpleasantness Required to Engage in Self-Care Behaviors
Table 2.
SELF-CARE BEHAVIOR Stretching Effectiveness Required intensity Required unpleasantness Massage Effectiveness Required intensity Required unpleasantness Resting Effectiveness Required intensity Required unpleasantness Over-the-counter medication use Effectiveness Required intensity Required unpleasantness Cold application Effectiveness Required intensity Required unpleasantness Heat application Effectiveness Required intensity Required unpleasantness
R2
 COEFFICIENT
T
VALUE
P VALUE
.24 .470 ⫺.161 .140
7.29 ⫺1.71 1.50
.000 .087 .136
.333 ⫺.137 .002
4.78 ⫺1.48 .02
.000 .140 .983
.474 ⫺.037 ⫺.119
7.41 ⫺.46 ⫺1.49
.000 .646 .139
.276 ⫺.191 ⫺.329
4.53 ⫺2.13 ⫺3.66
.000 .035 .000
.327 ⫺.091 ⫺.202
4.91 ⫺.90 ⫺1.99
.000 .367 .048
.419 ⫺.122 ⫺.058
6.38 ⫺1.23 ⫺.59
.000 .221 .559
.12
.26
.32
.21
.22
NOTE. Dependent variable ⫽ frequency ratings of respective self-care behaviors on a 0 to 100 scale.
the least frequently performed. The self-care behaviors also differed significantly on perceived effectiveness (F5,930 ⫽ 29.85, P ⬍ .01, 2 ⫽ .14), with stretching, massaging, and resting perceived as most effective and consuming an over-the-counter medication and applying cold or heat perceived as least effective. In addition, the pain level required for self-care behaviors to be performed varied for both intensity (F5,930 ⫽ 74.64, P ⬍ .01, 2 ⫽ .29) and unpleasantness (F5,930 ⫽ 90.15, P ⬍ .01, 2 ⫽ .33). Consuming an over-the-counter medication required the highest pain levels, whereas stretching and massaging required the lowest pain levels. See Table 1 for means and SDs. The amount of variance in the frequency of performing self-care behaviors explained by required muscle pain levels and perceived effectiveness of the self-care behaviors ranged from 12.1% for stretching to 32.3% for consuming an over-the-counter medication (Table 2). Perceived effectiveness made significant independent contributions to each of the self-care behaviors (ts ⫽ 4.58 to 7.29, Ps ⬍ .05). In addition, required pain intensity (t ⫽ ⫺2.13, P ⫽ .04) and pain unpleasantness (t ⫽ ⫺3.66, P ⬍ .01) significantly influenced the frequency of consuming over-the-counter medications, such that participants generally were hesitant to consume medications unless their pain level was high. A similar relationship was observed between pain unpleasantness and applying cold (t ⫽ ⫺1.99, P ⬍ .05).
Study 1 Discussion According to this investigation, individuals perform self-care behaviors in response to naturally occurring muscle pain, and some behaviors (eg, stretching, massaging) are performed more often than others (eg, consuming over-the-counter medication, applying heat or cold). The infrequently completed behaviors (eg, consuming medication) were also described as requiring higher pain levels before completion, which suggests a consistent hesitancy to perform them. The primary predictor of performing the behaviors was perceived effectiveness, which indicated that beliefs about the effectiveness of a particular self-care strategy do indeed predict use of the strategy. The performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness.6,9,17,28 For example, the application of cold and heat was infrequent, despite recommendations that ice be applied early after injury and heat be applied several days after injury.17,28 In addition, over-the-counter medications were infrequently taken, despite the usefulness of nonsteroidal anti-inflammatory medications (eg, aspirin, ibuprofen) for the first few days after injury.17,28 Although the self-care behaviors evaluated in this investigation are considered routine treatments for muscle injury, their effectiveness is not adequately supported,6,9 and these self-care behaviors might not be relevant to all types of muscle pain. In addition, the time and manner of
524 the behaviors are important to consider for determination of whether appropriate behaviors are performed at appropriate times in appropriate ways. Furthermore, the retrospective recall of pain and behaviors would benefit from the application of laboratory models using controlled pain stimuli that produce self-care behaviors outside the laboratory. Therefore, the purpose of Study 2 was to examine the utility of a model of exercise-induced muscle pain within this context.
Study 2 Material and Methods Participants Participants were 61 university students (61% women) with an average age of 21 years (SD, 2.33) who were part of a larger investigation comparing exercise-induced muscle pain to typical laboratory pain. Seventy-three percent (72.9%) of participants were white, 6.8% were African-American, 8.5% were Hispanic, and 6.8% were Asian-American. Participants met the following restrictions: (1) had not engaged in upper body strength training on a regular basis (ie, 2 times per week) for consecutive weeks within the previous 6 months, (2) were not currently experiencing arm pain, and (3) had no history of upper arm injury within the previous 6 months. In addition, participants were screened for potential risk factors of a heightened response to the exercise protocol (eg, excessive swelling, loss of range or motion, exertional rhabdomyolysis).29
Procedures Participants provided written informed consent to the protocol, which was approved by the university’s institutional review board. As part of a larger investigation, participants completed a strength test and muscle pain induction procedure in physical therapy clinics operated by Shands Hospital at the University of Florida. Seventytwo hours later, they called a telephone data collection system (VoiceGuide; Katalina Technologies, Sydney, Australia) and responded to questions that are described below.
Eccentric Strength Test Participants were positioned in an isokinetic apparatus according to the manufacturer’s recommendations (Biodex System 3; Biodex Medical Systems, Shirley, NY). Such isokinetic devices use a computer to control the speed of the contractions. After completing 6 to 10 submaximal familiarization repetitions, participants performed a strength test that consisted of 5 consecutive maximal eccentric repetitions, which are contractions in which the muscle lengthens. Participants completed all repetitions through active range of motion at a velocity of 90°/s in the eccentric phase.
Muscle Pain Stimulus Muscle pain was induced in the elbow flexors of the dominant arm by having participants complete 3 sets of 12 eccentric repetitions. Participants were provided a
Self-Care Behaviors for Muscle Pain minimum peak torque target of 75% of eccentric strength for each repetition, and they were permitted to observe their torque output throughout the range of motion on the display screen of the isokinetic device. Participants completed the repetitions in the same manner as described for the strength test. However, a rest phase of 60 seconds was provided between each set. The average percentage of eccentric strength completed across the 3 sets of contractions was 67.7% (SD, 0.08).
Measures Eccentric Strength The peak torque that participants produced during 5 eccentric contractions was defined as the 1 repetition maximum (1 RM; ie, eccentric strength). Unpublished pilot data determined that the between session test-retest reliability of eccentric strength measured with this device by using the same muscle group (ie, elbow flexors) was excellent (intraclass correlation coefficient ⫽ .97).
Pain Ratings To measure exercised-induced muscle pain, ratings of pain intensity and pain unpleasantness were collected by using 0 to 100 numeric scales. The pain intensity scale anchors were “no pain” and “most intense pain sensation imaginable,” and the pain unpleasantness scale anchors were “not at all unpleasant” and “most unpleasant imaginable.” Participants made pre-exercise ratings in person and postexercise ratings via the telephone data collection system.
Frequency of Muscle Pain With the telephone data collection system, participants rated the frequency of feeling pain in the exercised arm during normal daily activities during the previous 24 hours on a 0 to 100 numeric scale. The anchors for the scale were “never” and “constantly.”
Performance of Self-Care Behaviors With a “yes” or “no” response format, participants rated their performance of 5 self-care behaviors for the purpose of relieving arm muscle pain. The 5 self-care behaviors were based on Study 1 and included stretching, massaging, resting, consuming medication, and applying heat or cold. Again, participants made their responses via a telephone data collection system.
Data Analyses Paired samples t tests were conducted to assess the induction of muscle pain by comparing preinduction pain scores to the scores obtained at 72 hours after exercise. The performance of self-care behaviors and the perception of pain during normal daily activities were evaluated by the calculation of frequencies and descriptive statistics. Differences in the completion of self-care behaviors were examined with the Fisher exact test. In addition, independent t tests were used to compare the groups that did and did not perform each self-care behavior. The groups were compared on pain ratings and
ORIGINAL REPORT/Dannecker et al the perception of pain during normal daily activities to determine if those participants performing behaviors had higher pain ratings and more frequent perception of pain during normal daily activities.
525
Percentage of Participants (N ⴝ 61) Performing Self-Care Behaviors 72 Hours After Exercise
Table 3.
SELF-CARE BEHAVIOR
Study 2 Results Compliance with the telephone procedures on each of these days was 77.2% (N ⫽ 61), so the analyses were conducted on this sample. Significant increases in muscle pain intensity (t ⫽ ⫺10.19, P ⬍ .01, d ⫽ 2.52) and unpleasantness (t ⫽ ⫺10.79, P ⬍ .01, d ⫽ 2.65) were observed from pre-exercise to postexercise, indicating the exercise protocol was successful. The baseline levels of muscle pain intensity and unpleasantness were mean of 0.36 (SD, 1.08) and mean of 0.54 (SD, 1.67), respectively. The levels of muscle pain intensity (mean, 36.38; SD, 27.54) and unpleasantness (mean, 44.82; SD, 31.76) obtained by 72 hours after exercise were sufficient to produce pain that is routinely felt during daily activities (mean, 53.02; SD, 37.86), and 19.7% to 83.6% of the participants performed self-care behaviors in response to the pain. Stretching and massaging were the most frequently performed behaviors, and consuming medication was the least frequently performed behavior (Table 3). As expected, higher pain ratings and more frequent perception of pain during normal daily activities were observed for participants who performed self-care behaviors (Table 4). More specifically, when comparing participants who did and did not perform self-care behaviors, the pain intensity reported by performers was significantly higher for all behaviors (ts ⫽ 2.14 to 3.30, Ps ⬍ .05, ds ⫽ .59 to .78) except applying heat or cold and consuming medication. Pain unpleasantness was significantly higher for all behaviors (ts ⫽ 2.45 to 3.05, Ps ⬍ .05, ds ⫽ .84 to 1.00) except applying heat or cold. Similarly, the frequency of pain perception with activity was significantly higher for all behaviors (ts ⫽ 2.19, Ps ⬍ .05, ds ⫽ .64 to .98) except stretching, but this difference approached significance (P ⫽ .06) and had a large effect size (d ⫽ .68).
Study 2 Discussion The exercise-induced muscle pain model used in this study was sufficient to produce self-care behaviors and pain that are perceived during normal daily activities. Consistent with Study 1, stretching and massaging were the most frequently performed self-care behaviors, and consuming medication was the least frequently performed self-care behavior. Higher pain ratings and more frequent perception of pain during normal daily activities were observed for those who performed self-care behaviors. Because the delayed-onset muscle pain produced by exercise might last for up to 10 days,8 the exercise stimulus could be used to assess change in the performance of self-care behaviors across time. Investigations could test the predictive efficacy of models of and interventions for self-care.10,18 Pain ratings and the frequency of
Stretching Massage Resting Over-the-counter medication Applying cold/heat
FREQUENCY
PERCENTAGE
51 51 42 16 12
83.6 83.6 68.9 26.2 19.7
pain perception during normal daily activities should be included into models because of the differences in their levels between those who did and did not perform selfcare behaviors.
General Discussion As stated previously, the self-care behaviors included in the study (ie, rest, massage, heat, cold, stretching, over-the-counter medications) are common treatments for muscle injury along with compression and elevation.6,9,17,28 Studies 1 and 2 determined that the performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness for muscle injuries. One potential reason for this contradiction is that participants were specifically asked about self-care behaviors for relieving muscle pain, whereas investigations of treatment effectiveness for muscle injury typically evaluate muscle pain or soreness along with range of motion, weakness, inflammation, etc. However, both the application of ice and consumption of antiinflammatory medications, which were infrequently performed, are specifically recommended for pain or soreness.6,9,28 Study 1 supported the importance of perceived effectiveness for the performance of self-care behaviors. This finding has been reported by other authors in other samples.32,33,37 However, Study 1 was limited by a reliance on retrospective recall by using questionnaires. In Study 2, induced pain with a controlled stimulus also produced self-care behaviors, and the pain differentiated between those who completed self-care and those who did not. Because the induced pain can last for more than a week, this methodology permits experimental designs with repeated measures across time. Thus, future tests of selfcare models and interventions can be conducted, and these investigations could examine a larger number of self-care behaviors in both healthy and clinical samples. Such investigations are important because of evidence that self-care behaviors substitute for formal medical care16,38 and that health care costs impact self-care behaviors.13,19 It is noteworthy that exercise-induced muscle damage causes weakness, reduced range of motion, stiffness, swelling, and altered proprioception, and biomechanics in addition to pain.30 Such muscle pain affects normal daily activities as reported in Study 2. However, the meaning of this muscle pain is likely to be different
526
Self-Care Behaviors for Muscle Pain
Comparison of Pain Frequency During Daily Activities, Intensity, and Unpleasantness Between Users and Nonusers of Self-Care Behaviors at 72 Hours After Muscle Pain Induction
Table 4.
PAIN FREQUENCY
PAIN INTENSITY COHEN
SELF-CARE BEHAVIOR Stretching Massage Resting Over-the-counter medication use Heat/ice application
COHEN
N
MEAN
SD
SIGNIFICANCE
D
MEAN
SD
SIGNIFICANCE
51 10 51 10 42 19 16
57.1 32.1 58.8 23.7 61.1 35.1 70.3
35.1 16.4 35.1 39.8 34.1 40.1 33.7
.055
.68
.006
.98
.012
.72
.033
.64
39.8 19.0 41.2 12.0 41.3 25.5 46.5
26.8 26.1 30.0 15.1 25.5 26.0 26.6
N 45 Y 12 N 49
46.9 79.5 46.5
37.7 27.5 37.4
.002
.92
32.8 39.6 35.6
27.3 31.7 26.7
Y N Y N Y N Y
PAIN UNPLEASANTNESS COHEN
D
MEAN
SD
SIGNIFICANCE
.028
.78 1.14
.036
.59
.087
.51
29.8 34.0 30.5 26.7 28.1 33.3 24.8
.017
.000
49.1 23.2 49.8 19.7 52.6 27.5 63.3
.657
.14
38.2 31.6 51.17 31.6 43.3 31.9
.005
D
.85 1.0
.036
.84
.003
.84
.444
.23
NOTE. Scores are based on 0 to 100 numeric rating scales; group means and standard deviations (SDs) are presented. Abbreviations: Y, yes; N, no.
than that of chronic or recurrent clinical muscle pain. In addition, the meaning of muscle pain is likely to be different, depending on the age and health status of the sample. Because the meaning of pain (eg, tissue-
damaging) influences the perception of pain2 and might influence the performance of self-care behaviors, additional investigations evaluating these issues are warranted.
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