Effects of spouse-assisted coping skills training and exercise training
in patients with osteoarthritic knee pain: a randomized controlled study
Francis J. Keefea,*, James Blumenthala, Donald Baucomb, Glenn Affleckc, Robert Waugha,David S. Caldwella, Pat Beauprea, Susmita Kashikar-Zucka,
Katherine Wrighta, Jennifer Egerta, John Lefebvred
aDuke University Medical Center, Box 3129, Durham, NC 27710, USAbUniversity of North Carolina at Chapel Hill, Chapel Hill, NC, USA
cUniversity of Connecticut, Storrs, CT, USAdWofford College, Spartanburg, SC, USA
Received 6 June 2003; received in revised form 21 January 2004; accepted 4 March 2004
Abstract
This study tested the separate and combined effects of spouse-assisted pain coping skills training (SA-CST) and exercise training (ET) in a
sample of patients having persistent osteoarthritic knee pain. Seventy-two married osteoarthritis (OA) patients with persistent knee pain and
their spouses were randomly assigned to: SA-CST alone, SA-CST plus ET, ET alone, or standard care (SC). Patients in SA-CST alone, together
with their spouses, attended 12 weekly, 2-h group sessions for training in pain coping and couples skills. Patients in SA-CST þ ET received
spouse-assisted coping skills training and attended 12-weeks supervised ET. Patients in the ET alone condition received just an exercise
program. Data analyses revealed: (1) physical fitness and strength: the SA-CST þ ET and ET alone groups had significant improvements in
physical fitness compared to SA-CST alone and patients in SA-CST þ ET and ET alone had significant improvements in leg flexion and
extension compared to SA-CST alone and SC, (2) pain coping: patients in SA-CST þ ET and SA-CST alone groups had significant
improvements in coping attempts compared to ET alone or SC and spouses in SA-CST þ ET rated their partners as showing significant
improvements in coping attempts compared to ET alone or SC, and (3) self-efficacy: patients in SA-CST þ ET reported significant
improvements in self-efficacy and their spouses rated them as showing significant improvements in self-efficacy compared to ET alone or SC.
Patients receiving SA-CST þ ET who showed increased self-efficacy were more likely to have improvements in psychological disability. An
intervention that combines spouse-assisted coping skills training and exercise training can improve physical fitness, strength, pain coping, and
self-efficacy in patients suffering from pain due to osteoarthritis.
q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Pain coping skills; Osteoarthritis; Spouse-assisted coping skills training
Osteoarthritis (OA) is the most common rheumatic disease
affecting up to 70% of older adults (Felson et al., 1987;
Hochberg et al., 1989; Lawrence, 1960; Lawrence et al.,
1966). Medical treatments (e.g. aspirin, nonsteroidal anti-
inflammatory drugs, steroid injections) benefit some OA
patients but may have significant side effects (gastrointes-
tinal changes, potential for accelerating the disease) that
limit their long-term use (Schnitzer, 1993). With recog-
nition of the limitations of medical treatment has increased
interest in self-management approaches to OA (Brandt,
2000; Buckwalter et al., 2001; Creamer, 2000; Felson et al.,
2000; Hochberg et al., 1995; Parker et al., 1993).
Over the past 15 years, two approaches to the self-
management of OA pain have been developed. The first
approach, developed by health psychologists and arthritis
educators, is based on biopsychosocial theories of pain
(Keefe et al., 2002). The goal of this approach is to enhance
patients’ abilities to cope with pain and other arthritis
symptoms through systematic training in pain coping skills.
An example of this approach is a study testing the efficacy of
a spouse-assisted pain coping skills training protocol for
OA (Keefe et al., 1996a,b, 1999). In this protocol,
patients attended treatment sessions with their spouses
0304-3959/$20.00 q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2004.03.022
Pain 110 (2004) 539–549
www.elsevier.com/locate/pain
* Corresponding author. Tel.: þ1-919-668-2806; fax: þ1-919-668-2850.
E-mail address: [email protected] (F.J. Keefe).
and the training not only included instruction in pain coping
skills, but also instruction in couples skills designed to
supplement and reinforce learned pain coping skills. Results
revealed a consistent pattern in which patients who received
spouse-assisted coping skills training had the best outcomes,
those in the conventional pain coping skills training
condition (patients treated on their own) the next best
outcomes, and patients in an arthritis education-social
support control condition (patients and spouses attending
informational/support group sessions) had the poorest
outcomes (Keefe et al., 1996a,b, 1999). This study suggests
that spouse-assisted coping skills may be particularly
beneficial for patients having OA.
The second approach to OA self-management, developed
by specialists in physical medicine and rehabilitation,
involves exercise training (van Baar et al., 1999; Chard
and Dieppe, 2001; Clyman, 2001; Petrella, 2000). The
primary rationale for exercise training is that it reduces the
effect of deconditioning seen in many patients with
persistent OA pain and increases muscular strength to
provide greater support for the affected knee. Recent studies
have shown that isometric exercise training focused on
strengthening the quadriceps muscles (Gur et al., 2002;
Petrella and Bartha, 2000), supervised walking (Toda,
2001), or general aerobic conditioning (van Baar et al.,
2001; Penninx et al., 2001) can lead to improved
functioning in OA patients.
The present study compared the separate and combined
effects of spouse-assisted coping skills training and exercise
for OA. Prior studies have shown that arthritis patients vary
considerably in how well they respond to these treatments,
with patients showing increases in self-efficacy over the
course of treatment experiencing much greater improve-
ments (van Baar et al., 2001; Keefe et al., 1996a,b). Thus, a
secondary goal was to examine how changes in self-efficacy
occurring over treatment relate to the separate and
combined effects of spouse-assisted coping skills training
and exercise interventions.
1. Methods
1.1. Participants
Participants and their spouses were recruited from
rheumatology clinics and advertisements placed in news-
papers. Patients underwent a physical examination by a
board-certified rheumatologist (DSC). Patients were
excluded if they had comorbid medical conditions that
could affect their health status over the course of the trial (e.g.
a recent myocardial infarction), an abnormal cardiac
response to exercise (e.g. exercise-induced ventricular
tachycardia, abnormal blood pressure response), or other
known organic disease that would contraindicate safe
participation in the study (e.g. chronic obstructive
pulmonary disease, congestive heart failure, or cancer).
Of the individuals who volunteered for the study, 30 were
disqualified during the initial evaluation process due to the
following: cardiac problems ðn ¼ 7Þ; high blood pressure
ðn ¼ 2Þ; multiple medical problems ðn ¼ 8Þ; a positive stress
test ðn ¼ 4Þ; osteopororis ðn ¼ 2Þ; fibromyalgia ðn ¼ 1Þ;
severe depression ðn ¼ 1Þ; death of their spouse ðn ¼ 1Þ; lack
of agreement for participation from their primary physician
ðn ¼ 1Þ; not having osteoarthritis ðn ¼ 1Þ; and joining an
exercise club ðn ¼ 1Þ: Sixteen of the patients meeting criteria
for study entry withdrew prior to treatment due to inability to
make sessions at the scheduled times ðn ¼ 13Þ and other
reasons ðn ¼ 3Þ: The final study sample consisted of 72
married patients having persistent knee pain due to OA
and who were diagnosed as having OA of the knees and their
respective spouses. Over the course of the study, five subjects
dropped out of the study, two from the spouse-assisted
coping skills training condition, one from the spouse-assisted
coping skills training plus exercise training condition, and
two from the standard care control condition.
1.2. Procedure
Informed consent was obtained and patients were
provided with an Arthritis Foundation pamphlet providing
basic information about OA. The protocol was approved by
the Institutional Review Board at Duke Medical Center.
Patients completed a baseline evaluation (see below) and
were then randomly assigned to one of four conditions: (1)
spouse-assisted CST (SA-CST), (2) spouse-assisted CST
plus exercise training (SA-CST þ ET), (3) exercise training
alone (ET), or (4) standard care (SC). Following the
treatment program, participants completed a second assess-
ment battery identical to the baseline evaluation.
1.3. Assessment measures
Aerobic fitness and strength measures. Participants
underwent bicycle ergometry and strength testing before
and after the 12-week treatment program. Each participant
performed a maximal effort bicycle ergometry exercise test
following an initial practice test on a Corival 400 cycle
ergometer. The graded exercise protocol consisted of 3-min
stages starting at 150 kpm and increasing 150 kpm at each
stage. Participants maintained a pedaling rate of 50 rpm and
exercised until exhaustion. This is a standard exercise
testing protocol that has been used in our previous research
with older individuals (Blumenthal et al., 1991). Heart rates
were recorded every minute. Blood pressure was measured
automatically with an automated blood pressure monitor.
Respiratory and oxygen consumption measurements were
obtained and measurements of VO2K were obtained every
15 s. Participants were retested with an identical protocol at
the end of the 12-week treatment phase of the study.
Improvements in aerobic fitness were determined by
F.J. Keefe et al. / Pain 110 (2004) 539–549540
comparisonsof pre-and post-training peak VO2K(in mlkg/min).
To assess muscle strength, each participant performed a set
of maximal effort leg extensions, leg flexions, and bicep
curls following an initial practice test. This is a standardized
procedure for documenting strength that has been used in
our previous work (Blumenthal et al., 1988).
Pain coping. To assess pain coping, patients completed
the Coping Strategies Questionnaire (CSQ) (Rosenstiel and
Keefe, 1983). The CSQ is a 44-item instrument that asks
patients to report on the frequency that they use seven
coping strategies when they feel pain (coping self-
statements, praying or hoping, ignoring pain sensations,
reinterpreting pain sensations, increasing behavioral activi-
ties, catastrophizing, and diverting attention). Factor
analytic studies have identified two coping factors that
explain the majority of variance in arthritis patients’
responses on the CSQ: (a) Coping Attempts and (b) Pain
Control and Rational Thinking (Keefe et al., 1987a,b;
Parker et al., 1989). The spouse version of the Coping
Strategies Questionnaire was used to evaluate spouses’
perceptions of the patient’s coping strategies (Keefe et al.,
1996a,b). This instrument is identical to the patient version
with the exception that spouses are asked to rate how
frequently they believed their partners were using each of
the coping strategies to cope or deal with pain.
Self efficacy. The Arthritis Self-Efficacy Scale (Lorig
et al., 1989) was used to assess self-efficacy. This instrument
includes three subscales that assess self-efficacy for control
of three important areas: (1) pain management, (2) physical
function, and (3) other arthritis symptoms. Scores on these
subscales were combined to form a composite self-efficacy
measure (total self-efficacy) (Keefe et al., 1996a,b, 1999).
Prior studies have supported both the reliability and validity
of the Arthritis Self-Efficacy Scale (Lorig et al., 1989; Lorig
and Gonzalez, 1992; Schiaffino et al., 1991).
A spouse version of the Arthritis Self-Efficacy Scale was
used to evaluate spouses’ perceptions of the patients’ self-
efficacy. This instrument, used in prior studies (Keefe et al.,
1996a,b, 1997, 1999), was identical to the patient version
with the exception the spouses were asked to rate how
confident they were that their partners could engage in
behaviors to control pain, physical function, and other
arthritis symptoms. Alpha coefficients were conducted on
data collected on spouse total self-efficacy at pre-treatment
and post-treatment and were found to be high (alpha (pre-
treatment) ¼ 0.92; alpha (post-treatment) ¼ 0.95) support-
ing the internal consistency of this measure. The validity of
the spouse version of this measure is supported by prior
research in osteoarthritis patients that showed that spouses’
scores on self-efficacy are significantly related to patient
ratings of pain intensity and reports of use of pain coping
strategies (Keefe et al., 1997).
Marital adjustment. The Dyadic Adjustment scale
(Spanier, 1976) was used to assess marital adjustment.
This 32-item instrument was administered to patients. This
measure is one of the most widely used marital adjustment
measures and shows strong evidence of internal consist-
ency, test–retest reliability, and validity (Gotmman and
Krakoff, 1989).
Pain and psychological disability. The Arthritis Impact
Measurement Scales (AIMS) was used to assess pain and
psychological disability (Meenan et al., 1980). The AIMS
pain scale includes four items that assess the severity of
pain, frequency of severe pain, duration of morning
stiffness, and frequency of pain in multiple joints. The
AIMS psychological disability scale includes two individ-
ual scales (anxiety and depression). The AIMS is widely
used in studies of rheumatic disease patients and prior
research has provided strong support for its reliability and
validity (Kazis et al., 1983; Meenan et al., 1980; Meenan
et al., 1982).
1.3.1. Treatment conditions
1.3.1.1. General aspects. Patients in the spouse-assisted
CST conditions (SA-CST plus ET or SA-CST alone) met in
small groups (three to five couples) for 12 weekly, 2-h group
sessions. These group sessions were conducted by PhD level
psychologists who had been trained in spouse-assisted CST
and who followed a detailed treatment manual. The sessions
were audiotaped and the audiotapes were reviewed and
discussed in weekly supervision sessions. Patients in the
exercise training conditions (SA-CST plus ET, ET alone)
attended 60 min exercise sessions in small groups (three to
five patients) three times a week for 12 weeks. The exercise
sessions were run by BA level or above exercise physiol-
ogists who followed a treatment manual. Thus, the total
number of hours of treatment exposure was 24 for the
SA-CST alone condition, 26 h for the ET alone condition,
and 50 h for the SA-CST plus ET condition. Attendance by
patients and spouses at the treatment sessions was good
(range ¼ 85–92%). There were no significant differences in
patient or spouse attendance among the treatment conditions.
1.3.1.2. Spouse-assisted CST alone condition. Patients in the
SA-CST alone condition attended 12 weekly, 2-h group
sessions along with their spouses. The training was similar
to that used in our study of spouse-assisted CST (Keefe et al.,
1996a,b). Couples were provided with a rationale that
emphasized that: (1) pain is a complex experience, which as
the Gate Control Theory (Melzack and Wall, 1965)
suggests, can be influenced by thoughts, feelings, and
behaviors; (2) patients and their spouses can acquire and
maintain skills for managing pain through frequent practice;
and (3) because OA is a couples issue that affects each
partner and their relationship, involving the spouse in
training can be quite helpful.
The training sessions emphasized active learning. Thus,
participants were not only instructed in coping skills, but
also were encouraged to practice the skills alone and with
their partners both in the group and also at home. The group
leaders provided feedback and suggestions to enhance the
efficacy of skills practice. Each session involved two major
F.J. Keefe et al. / Pain 110 (2004) 539–549 541
components: (1) training in pain coping skills, and (2)
training in couples skills designed to supplement and
reinforce the patient’s pain coping skills. During the pain
coping skills component, patients were encouraged to
develop a menu of pain coping skills. To assist them,
systematic training was provided in attention diversion
skills (relaxation, imagery, and distraction), activity-based
skills (activity-rest cycling, pleasant activity scheduling),
and cognitive coping strategies (cognitive restructuring and
self-instructional methods for dealing with severe pain.)
During the couples skills training component, each couple
was encouraged to develop a menu of couples skills. To
achieve this goal, training was provided in wide range of
couples skills including communication skills, behavioral
rehearsal, mutual goal setting, joint home practice, and in
vivo practice.
1.3.1.3. Exercise training alone condition. Patients in the ET
alone condition attended three supervised group exercise
sessions per week for 12 consecutive weeks. Their spouses
did not attend the exercise sessions. A detailed description of
the ET protocol used in this study is provided elsewhere
(Keefe et al., 1996b.) Briefly, the exercise program included:
(1) cardiopulmonary endurance training, (2) strength train-
ing, and (3) flexibility/range of motion training. The data
gathered during the bicycle ergometry assessment and
maximum strength test were used to establish a baseline
level and to develop an individualized training program.
Patients participated in 30 min of aerobic training three days
per week. The intensity of aerobic training started at 50–70%
of heart rate reserve and gradually increased to 70–85% over
12 weeks. The aerobic training sessions included a warm up,
low intensity biking or walking, 30 min of continuous
aerobic activity (walking, biking, or water aerobics)
performed at or above patient’s prescribed training range,
and a cool down period. Patients also participated in 30 min
of strength training two days per week.
1.3.1.4. Spouse-assisted CST plus exercise training. Patients
in this condition attended 12 weekly 2-h SA-CST group
sessions along with their spouses and participated in the ET
intervention. Each weekly SA-CST session was held just
prior to one of the weekly ET sessions. The pain coping
skills and couples skills training methods used in this
condition were similar to those used in the SA-CST
condition. The major differences were: (1) more emphasis
was placed on the role that pain coping skills and couples
skills can play during exercise, and (2) the spouse attended
one exercise session with the patient each week where their
role was to coach the patient in applying pain coping skills
during exercise.
1.3.1.5. Standard care condition. The SC condition was
designed to serve as a routine treatment control. Patients
assigned to this condition continued to receive their routine
care. Neither they nor their spouses attended coping skills
training sessions or exercise sessions. These patients and
their spouses completed all measures at time intervals
corresponding to the beginning and end of the treatment
period.
2. Results
Data analysis was carried out in three steps: (1) an
evaluation of pre-treatment differences among the four
groups, (2) an evaluation of post-treatment differences
among the four groups, and (3) analysis of how changes in
self-efficacy related to improvements in the outcome
measures.
2.1. Pre-treatment comparisons among groups
Table 1 displays the unadjusted pre-treatment means
(and SDs) for each of the measures for patients in each of the
treatment groups. To examine pre-treatment differences
among these groups a series of analyses of covariance was
conducted. Covariates in these analyses were identical to
those used in our prior outcome studies of osteoarthritis
patients and included age, gender, and obesity status. These
three variables were used as covariates because they have
been found in our prior studies (Keefe et al., 1990a,b) to be
important in explaining pain and disability in patients
having osteoarthritis of the knees.
No group differences were found on any of the pre-
treatment measures except for the AIMS Pain measure
(Fð3; 67Þ ¼ 4:52; P ¼ 0:006). Post hoc analyses using
Tukey’s LSD revealed that patients in the spouse-assisted
CST alone and spouse-assisted CST plus exercise con-
ditions had higher pre-treatment levels of pain than those in
the two other conditions. Because of this difference, each
participant’s pre-treatment score on the AIMS Pain measure
was used as an additional covariate in all subsequent
outcome analyses.
2.2. Post-treatment differences among the groups
Table 1 presents the unadjusted post-treatment group
means (and SDs) for each of the measures. A series of
ANCOVAs was conducted to examine the effects of
treatment on these measures. In each ANCOVA, partici-
pants’ pre-treatment score on the relevant measure was used
as a covariate.
Effects of treatment on aerobic fitness and muscle
strength. An ANCOVA for Peak VO2K revealed a
significant post-treatment group (Fð3; 53Þ ¼ 4:67;
P ¼ 0:006) (Fig. 1). Paired comparisons between treatment
group means were made using Tukey’s LSD. These
analyses revealed that patients in the SA-CST plus ET
group showed significantly higher post-treatment Peak
VO2K than patients in the SC condition. Patients in the
SA-CST plus ET group and patients in the ET alone group
F.J. Keefe et al. / Pain 110 (2004) 539–549542
showed significantly higher post-treatment Peak VO2K than
patients in the SA-CST alone condition.
ANCOVAs were also conducted to examine post-treat-
ment group differences on the measures of muscle strength.
Significant group differences were found for the leg extension
(Fð3; 44Þ ¼ 7:02; P ¼ 0:001), leg flexion (Fð3; 49Þ ¼ 9:00;
P , 0:001), and bicep curl measures (Fð3; 46Þ ¼ 3:93;
P ¼ 0:014). Paired comparisons between treatment group
means were made using Tukey’s LSD. As can be seen in
Table 2, patients in the SA-CST plus ET group and patients in
the ET alone group showed significantly higher post-
treatment scores on leg extension and leg flexion than those
in the SA-CST alone and SC conditions. As can be seen in
Table 2, participants in the ET alone condition had
significantly higher bicep curl values compared to those in
the SC and SA-CST alone conditions and participants in
Table 1
Demographic data and pre- and post-treatment means of measures for patients in each of the treatment groups exercise
Variable Treatment group
Spouse-assisted CST Spouse-Assisted
CST þ exercise
Exercise Standard
care control
Age 60.00 (12.15) 60.20 (9.09) 60.25 (8.74) 57.56 (14.27)
Sex
Male 9 7 10 7
Female 9 13 6 11
Pre Post Pre Post Pre Post Pre Post
Peak VO2K 20.36
(6.77)
20.40
(7.21)
20.42
(5.48)
24.03
(5.88)
21.37
(5.74)
24.35
(5.97)
21.86
(6.16)
21.94
(7.99)
Coping factors
Coping attempts 69.36
(26.33)
78.18
(23.96)
55.19
(32.27)
73.76
(25.78)
49.35
(26.61)
47.44
(20.29)
57.22
(16.98)
51.01
(21.16)
Pain control and
rational thinking
1.17
(4.89)
3.56
(3.28)
1.39
(3.68)
3.81
(2.71)
0.72
(4.54)
1.50
(4.67)
3.39
(2.25)
2.62
(3.57)
Self-efficacy 201.93
(45.69)
234.13
(37.43)
196.68
(41.68)
238.71
(31.61)
215.42
(36.95)
220.46
(44.66)
224.08
(39.75)
224.17
(54.26)
Dyadic adjustment
scale
112.67
(15.55)
111.70
(18.04)
112.49
(14.51)
111.54
(12.04)
108.54
(21.34)
110.24
(23.41)
121.11
(17.37)
116.81
(18.48)
AIMS
Pain 5.44
(1.88)
4.00
(1.56)
5.20
(1.20)
4.26
(1.45)
3.91
(1.64)
3.19
(1.85)
3.91
(1.73)
4.03
(2.08)
Psychological
disability
2.83
(1.64)
2.38
(1.38)
2.57
(1.14)
2.21
(1.21)
2.36
(1.22)
1.88
(0.87)
1.85
(0.33)
1.80
(1.04)
Fig. 1. Adjusted post-treatment means for peak VO2K (with effect size) by treatment condition.
F.J. Keefe et al. / Pain 110 (2004) 539–549 543
Table 2
Adjusted post-treatment means (with effect size) for treatment condition
CA, coping attempts; PCRT, pain control and rational thinking.
F.J. Keefe et al. / Pain 110 (2004) 539–549544
the SA-CST plus ET group had significantly higher bicep curl
values than participants in the SC.
Effects of treatment on pain coping. An ANCOVA
revealed significant between group differences for patients’
scores on the Coping Attempts factor (Fð3; 57Þ ¼ 6:18;
P ¼ 0:001) of the CSQ. As can be seen in Table 2, pairwise
comparisons among the means revealed that patients in the
SA-CST alone condition and the SA-CST plus ET condition
had significantly higher post-treatment scores on Coping
Attempts than patients in the ET alone and SC conditions.
The ANCOVA for the Pain Control and Rational Thinking
factor of the CSQ also showed a significant group effect
(Fð3; 57Þ ¼ 3:00; P ¼ 0:038). As shown in Table 2,
participants in the SA-CST plus ET condition showed
significantly higher post-treatment scores on Pain Control
and Rational Thinking compared to participants in the ET
alone and SC conditions.
An ANCOVA also revealed significant between group
differences for spouses’ ratings of patients’ coping on the
Coping Attempts factor of the CSQ-S (Fð3; 51Þ ¼ 2:91;
P ¼ 0:043). Table 2 shows the adjusted post-treatment
means for spouses’ ratings of patients’ Coping Attempts.
Pairwise comparisons among the adjusted means revealed
that spouses in the SA-CST plus ET group rated their
partners as scoring significantly higher post-treatment on
Coping Attempts than patients in the ET alone and SC
conditions. Spouses in the SA-CST alone condition also
rated their partners as scoring significantly higher post-
treatment on Coping Attempts than patients in the SC
condition. The ANCOVA for the spouses’ ratings of
patients’ Pain Control and Rational Thinking was also
significant (Fð3; 54Þ ¼ 3:83; P ¼ 0:015). Table 2 shows
spouses in the SA-CST alone and SA-CST plus ET groups
rated their partners as scoring significantly higher post-
treatment on the Pain Control and Rational Thinking factor
than spouses in the ET alone condition.
Effects of treatment on self-efficacy measures. An
ANCOVA conducted to analyze the effects of treatment
on patient’s ratings of overall self-efficacy revealed a
significant treatment group effect (Fð3; 57Þ ¼ 4:37;
P ¼ 0:008). Fig. 2 displays the adjusted post-treatment
means for self-efficacy. As can be seen, patients in the
SA-CST plus ET condition and the SA-CST alone condition
showed significantly higher levels of self-efficacy than
patients in the SC condition. Patients in the SA-CST plus ET
condition also tended to report significantly higher levels of
self-efficacy than patients in the ET alone condition.
An ANCOVA conducted to analyze the effects of
treatment on spouse’s ratings of the patients overall self-
efficacy was also significant (Fð3; 55Þ ¼ 3:47; P ¼ 0:022).
As can be seen in Fig. 3, spouses in the SA-CST plus ET
condition and the SA-CST alone condition rated their
partners as showing significantly higher levels of total self-
efficacy than spouses of patients in the ET alone and SC.
Effects of treatment on marital adjustment. The effect of
treatment on marital adjustment was not significant
(Fð3; 56Þ ¼ 0:158; P ¼ 0:92).
Effects of treatment on pain and psychological disability.
The effects of treatment on AIMS Pain (Fð3; 58Þ ¼ 0:80;
P ¼ 0:50) or Psychological Disability (Fð3; 57Þ ¼ 0:33;
P ¼ 0:80) measures were not significant.
2.3. Relationship of changes in self-efficacy to outcome
A series of correlational analyses was conducted to
examine how changes in patients’ ratings of self-efficacy
related to changes in the outcome measures. Change scores
for total self-efficacy were calculated by subtracting pre-
treatment from post-treatment values. For patients in the
SA-CST plus ET condition, the results of the correlations
revealed that patients who showed increases in self-efficacy
were more likely to have improvements in psychological
Fig. 2. Adjusted post-treatment means for patient coping attempts (with effect size) by treatment condition.
F.J. Keefe et al. / Pain 110 (2004) 539–549 545
disability (r ¼ 20:64; P ¼ 0:003) and in scores on the pain
control and rational thinking factor of the Coping Strategies
Questionnaire (r ¼ 0:48; P ¼ 0:038). For patients in the ET
alone condition, increases in self-efficacy were significantly
related to increases in peak VO2K (r ¼ 0:58; P ¼ 0:029).
Finally, for patients in the SC condition, increases in self-
efficacy were related to decreases in physical disability
(r ¼ 20:53; P ¼ 0:04), and increases in scores on the pain
control and rational thinking factor of the Coping Strategies
Questionnaire (r ¼ 0:52; P ¼ 0:047).
3. Discussion
To our knowledge, no prior controlled studies of OA
patients have directly compared the effects of spouse-
assisted pain coping skills training and exercise interven-
tions. Our results show that each of these interventions
appear to have very specific benefits. Spouse-assisted
training, either alone or in combination with exercise
training, was found to produce improvements in coping
and self-efficacy, whereas exercise training, either alone or
in combination with spouse-assisted coping skills training
produced improvements in physical fitness and muscle
strength. Clinicians working with OA patients should be
aware that spouse-assisted CST and exercise have specific
benefits and that, when the primary clinical goal is to
improve self-efficacy and pain coping, spouse-assisted
CST may be particularly beneficial. Whereas, when the
primary clinical goal is to improve physical fitness and
muscle strength, exercise training may be particularly
beneficial.
The findings regarding specificity of treatment effects
have potentially important implications for multidisciplin-
ary or multicomponent treatment programs for patients
suffering from persistent pain. Our results suggest that when
one combines coping skills training and exercise interven-
tions, then improvements can be obtained across a much
broader range of outcomes (i.e. in coping, self-efficacy,
physical fitness, and muscle strength) than can be achieved
through either intervention alone.
The results of the present study agree with prior studies
in showing that exercise interventions can produce signifi-
cant improvements in physical fitness and muscle strength
in patients suffering from OA (van Baar et al., 2001; Gur
et al., 2002; Penninx et al., 2001; Petrella and Bartha, 2000).
These findings are important for several reasons. First, many
OA patients respond to knee pain by decreasing their
physical activity, a response that can lead to an overly
sedentary lifestyle, weight gain, and muscle weakness all of
which, in turn, can increase pain and disability (Felson and
Chaisson, 1997). Second, there is a growing consensus that,
by increasing and maintaining physical fitness and muscle
strength, exercise interventions may play a role in prevent-
ing disability in OA (AGS Panel on Exercise and
Osteoarthritis, 2001). Finally, there is growing recognition
that strategies for maintaining physical fitness and muscle
strength are very important in maintaining independence
and quality of life in older adults (Brill et al., 1998;
Fiatarone et al., 1990).
One of the most interesting findings of this study was
how changes in self-efficacy related to treatment outcome.
Patients who showed improvements in self-efficacy over the
course of exercise training were much more likely to show
increases in physical fitness. Improvements in self-efficacy
were also related to decreases in psychological disability
and improvements in Pain Control and Rational Thinking in
patients receiving the combination of spouse-assisted CST
and exercise training. Taken together, these findings
underscore the importance of self-efficacy in understanding
adjustment to arthritis and add to a growing literature
showing that changes in self-efficacy are associated with
outcomes following behavioral treatments for arthritis.
The results of this study found that an intervention that
combines spouse-assisted training in pain coping skills and
exercise training can improve physical fitness and muscle
Fig. 3. Adjusted post-treatment means for patient pain control and rational thinking (with effect size) by treatment condition.
F.J. Keefe et al. / Pain 110 (2004) 539–549546
strength and enhance pain coping and self-efficacy in
patients with OA of the knees. The present study is the first
to systematically involve spouses of patients undergoing
exercise training in an intervention designed to enhance
pain coping skills. Interestingly, spouses who participated in
this intervention reported significant increases in their
confidence (self-efficacy) that the patient could cope with
arthritis. They also reported that their partners showed
significant improvements in coping, both in the frequency of
coping attempts and in the perceived effectiveness of
coping.
Very few studies have systematically tested the effects of
involving spouses in coping skills training interventions for
patients with OA pain. In fact, the vast majority of pain
coping skills training studies conducted with persistent pain
conditions have focused on training the patient alone. There
is growing recognition that coping with painful diseases
such as OA takes place in a social context (Carr, 1999;
Reisine, 1995) and that many patients may prefer a
communal approach that involves them and their partner
in joint coping efforts (Sullivan et al., 2001). Patients with
OA engage in verbal and non-verbal behaviors commu-
nicating that pain is being experienced (Beaupre et al.,
1997) and these behaviors often provide a means of eliciting
spousal attention as well as instrumental and emotional
support (Sullivan et al., 2001). Couples-based training
programs that systematically engage partners in pain
management and provide opportunities for partners to
reinforce pain coping efforts can be helpful in meeting
patient’s interpersonal needs. As such, they represent a
potentially valuable addition to our treatment armementar-
ium. The findings of the current study agree with those
obtained in our prior work with OA in demonstrating that
spouse-assisted CST is effective in improve pain coping and
self-efficacy (Keefe et al., 1996a,b, 1999). Future studies
need to examine whether spouse-assisted CST is effective
for other pain conditions. Spouse- and partner-based
interventions may be particularly beneficial and appropriate
in clinical situations where the demands of pain on spouses
and caregivers are quite high (e.g. advanced cancer, brain
tumor patients, or in end-of-life care).
This study did not find evidence of treatment effects on
self-report measures of physical disability and psychologi-
cal disability. The fact that the exercise training produced
significant improvements in an objective measure of
physical fitness, but failed to show a significant effect on a
self-report measure of physical disability was surprising. It
is possible that the physical disability measure was less
sensitive to changes produced by the exercise training
intervention. Prior studies by our research team have shown
that interventions consisting of either coping skills training
alone (Keefe et al., 1990a) or SA-CST (Keefe et al., 1996a,b)
can produce significant improvements in psychological
disability in patients having OA of the knees. The present
study, however, did not find evidence SA-CST alone or
SA-CST plus ET produce changes in psychological
disability. One possible explanation for this discrepancy in
that the patients in this study were, prior to treatment,
experiencing somewhat lower levels of psychological
disability than patients in some of our prior studies.
Nevertheless, these SA-CST interventions tested in this
study (SA-CST alone, SA-CST plus ET) did produce
improvements in psychological outcomes such as self-
efficacy and pain coping. Considered overall, the findings of
this study suggest that additional research is needed to
determine the precise impact of SA-CST alone, ET, or SA-
CST plus ET on measures of physical disability and
psychological disability.
In terms of limitations, it should be noted that the patients
and spouses who participated were all volunteers with
generally high levels of marital satisfaction. The results, thus,
may not generalize to patients and spouses who have
significant marital problems. Future research needs to
examine the separate and combined effects of spouse-
assisted CST and exercise in couples who are more maritally
distressed. Based on research conducted in the marital
therapy area, it is possible that spouse-assisted interventions
would lead to even greater improvements in couples having
significant marital distress (Baucom et al., 1998).
The relatively small sample size of this study ðN ¼ 72Þ is
a limitation. This may have limited the ability of this study
to detect treatment effects that were potentially important,
but more moderate in magnitude. With a larger sample, for
example, we might have had sufficient power to detect
treatment effects on pain. Prior research conducted in our
lab has demonstrated that spouse-assisted pain coping skills
training can produce significant improvements in pain in
patients having OA of the knees (Keefe et al., 1996a,b).
Replication of the current study with a larger study sample
is warranted. However, the effect sizes in this study ranged
from 0.17 to 0.44 and thus generally fell in the range Cohen
(1988) considers as small (0.20) to medium (0.50)
suggesting that the treatment effects, in general, were not
as robust as other studies.
For purposes of experimental rigor and safety, volunteers
for this study were carefully screened. Of those who
volunteered, 30 were disqualified during the initial evalu-
ation process, mostly due to medical problems that
precluded their safe participation in exercise. This raises
concerns regarding the generalizability of the interventions
and findings to the broad population of patients with OA,
many of whom have medical problems and co-morbidities.
Careful medical screening and clearance, such as conducted
in this study, is considered to be the standard of care for
older adults who are candidates for formal exercise training.
Although persons who fail such screening may not be
appropriate for exercise interventions, they benefit from
other lifestyle interventions that reduce OA pain (e.g.
weight loss interventions). Furthermore, most of those
disqualified in this study could have safely participated in a
spouse-assisted coping skills training intervention so long as
this intervention was not combined with exercise training.
F.J. Keefe et al. / Pain 110 (2004) 539–549 547
Thus, the SA-CST intervention protocol used in this study
may be more easily adapted to treating a general population
of OA patients, than the exercise training intervention we
investigated.
Taken as a whole, the results of this study indicate that an
intervention combining spouse-assisted coping skills train-
ing and exercise can improve physical fitness, pain coping,
and self-efficacy in patients suffering from OA of the knees.
These results are interesting and support the need for further
research.
Acknowledgements
This research was supported by National Institute of
Arthritis and Musculoskeletal Diseases Grant No. AR-
35270.
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