People Prefer to Continue with Painful Activities Even if They Lead to Earlier Surgery
Authors: Amiri Mahsa Mohammadian , Ring David , Fatehi Amirreza 
Published: March 2021

Abstract

Background
The degree to which physical activity results in arthritis progression is unknown, but it probably is less than most people believe. But the belief that painful activity is harmful has notable associations both with greater pain intensity and greater activity intolerance among people seeking care for painful conditions such as osteoarthritis. If there were evidence that people not seeking care would prefer to accommodate a painful cherished activity, even if such accommodation is harmful, this might remind surgeons that many people seeking their care also hold this value. Care strategies could be designed to help people reconnect with this value by guiding them to an appropriate weighting of the potential benefits and the potential harms of painful activity.

Questions/purposes
(1) What degree of harm (measured as a decrease in the number of years before reconstructive surgery) are people willing to trade to continue a cherished activity? (2) What factors are associated with the chosen number of years? (3) What percentage of patients is willing to trade harm to the joint (presented as surgery 3 years earlier) to continue their cherished activity? (4) What factors are associated with the choice to trade harm for continued activity?

Methods
We performed an online, survey-based, time trade-off experiment using a crowdsourcing website that allows users to pay volunteers to complete surveys. The survey was closed when the prespecified number of surveys was obtained. The experiment measured personal and psychological factors associated with the willingness to accommodate harmful painful activity to continue cherished activities among people not currently troubled by the condition, an approach favored in trade-off studies. Large crowdsourcing survey studies may not represent the general population, but they have sufficient diversity to determine factors associated with responses. Participants (539 total, 289 men and 250 women with a mean age of 33 ± 11 years) completed validated measures of symptoms of anxiety and depression, activity tolerance, an 11-point ordinal measure of pain intensity, and three validated questionnaires addressing common misconceptions about pain. To answer our first and second questions, we calculated the harm (measured as a decrease in the number of years before reconstructive surgery) that people were willing to trade to continue their cherished activity, and then we used multiple linear regression to identify factors associated with the number of years. To answer the third and fourth questions, we calculated the percentage of patients who would choose to trade harm to the joint (surgery 3 years earlier) to continue their cherished activity and then we used multiple logistic regression to identify factors associated with the choice to trade harm for activity.

Results
Participants were willing to trade harm in the form of more rapid disease progression leading to surgery a mean of 4.5 ± 3.6 years earlier to continue a cherished activity. Controlling for personal and psychological factors, a greater number of years people were willing to trade was associated with slightly greater bodily pain intensity (r = 0.11; p = 0.01). Seventy-six percent (410 of 539) of participants were willing to trade harm in the form of needing surgery 3 years earlier to continue their cherished activity. Controlling for personal and psychological factors, a choice to trade earlier surgery for continued activity was associated with an income greater than USD 50,000 per year (odds ratio 2.07 [95% confidence interval 1.17 to 3.65]; p = 0.01) and greater fear of painful movement (OR 1.07 [95% CI 1.01 to 1.15]; p = 0.04).

Conclusion
People are relatively willing to accommodate pain to continue a cherished activity, even if it causes harm.

Clinical Relevance
Musculoskeletal specialists can incorporate strategies to help people seeking care to revitalize their inherent level of willingness to accommodate painful activity. One strategy might be to attend to an appropriate weighting of the potential benefits and the potential harms of painful activity.

Level of Evidence
Level II, prognostic study.