Original research| Volume 97, ISSUE 9, SUPPLEMENT , S201-S209, September 2016

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Pain, Fatigue, and Physical Activity in Osteoarthritis: The Moderating Effects of Pain- and Fatigue-Related Activity Interference



      To examine how self-reported pain- and fatigue-related activity interference relates to symptoms and physical activity (PA) in daily life among people with knee or hip osteoarthritis.


      Cross-sectional study with a 7-day repeated-measures assessment period.


      General community.


      Participants (N=154; mean age, 65y; 60% women [n=92]) with knee or hip osteoarthritis and pain lasting ≥3 months.


      Not applicable.

      Main Outcome Measures

      Pain- or fatigue-related activity interference items on the Brief Pain Inventory or Brief Fatigue Inventory, respectively, from baseline survey, momentary pain and fatigue severity (measured 5times/d for 7d), and PA measured with a wrist-worn accelerometer over 7 days. We hypothesized that perception of pain- and fatigue-related activity interference would moderate the association between symptoms (pain or fatigue) and PA. People with higher pain- or fatigue-related activity interference were thought to have stronger negative associations between momentary ratings of pain and fatigue and PA than did those with lower activity interference.


      Pain-related activity interference moderated the association between momentary pain and PA, but only in the first part of the day. Contrary to expectation, during early to midday (from wake-up time through 3 pm), low pain-related interference was associated with stronger positive associations between pain and PA but high pain-related interference was associated with a small negative association between pain and PA. Fatigue-related activity interference did not moderate the relation between fatigue and activity over the course of a day.


      Depending on a person's reported level of pain-related activity interference, associations between pain and PA were different earlier in the day. Only those with high pain-related activity interference had lower levels of PA as pain increased and only in the morning. High pain-related activity interference may be important to address, particularly to maintain PA early in the day despite pain.


      List of abbreviations:

      BFI (Brief Fatigue Inventory), BMI (body mass index), BPI (Brief Pain Inventory), MLM (multilevel modeling), OA (osteoarthritis), PA (physical activity)
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        • Bennell K.L.
        • Hinman R.S.
        A review of the clinical evidence for exercise in osteoarthritis of the hip and knee.
        J Sci Med Sport. 2011; 14: 4-9
        • Messier S.P.
        • Loeser R.F.
        • Miller G.D.
        • et al.
        Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the arthritis, diet, and activity promotion trial.
        Arthritis Rheum. 2004; 50: 1501-1510
        • Uthman O.A.
        • van der Windt D.A.
        • Jordan J.L.
        • et al.
        Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis.
        BMJ. 2013; 347: f5555
        • Murphy S.L.
        • Smith D.M.
        • Clauw D.J.
        • Alexander N.B.
        The impact of momentary pain and fatigue on physical activity in women with osteoarthritis.
        Arthritis Care Res. 2008; 59: 849-856
        • Shih M.
        • Hootman J.M.
        • Kruger J.
        • Helmick C.G.
        Physical activity in men and women with arthritis: National Health Interview Survey, 2002.
        Am J Prev Med. 2006; 30: 385-393
        • Dunlop D.D.
        • Song J.
        • Semanik P.A.
        • et al.
        Objective physical activity measurement in the osteoarthritis initiative: are guidelines being met?.
        Arthritis Rheum. 2011; 63: 3372-3382
        • Grotle M.
        • Hagen K.B.
        • Natvig B.
        • Dahl F.A.
        • Kvien T.K.
        Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up.
        BMC Musculoskelet Disord. 2011; 9: 132
        • Nüesch E.
        • Dieppe P.
        • Reichenbach S.
        • Williams S.
        • Iff S.
        • Jüni P.
        All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study.
        BMJ. 2011; 342: d1165
        • Petursdottir U.
        • Arnadottir S.A.
        • Halldorsdottir S.
        Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study.
        Phys Ther. 2010; 90: 1014-1025
        • White D.K.
        • Neogi T.
        • Zhang Y.
        • et al.
        The association of obesity with walking independent of knee pain: the multicenter osteoarthritis study.
        J Obes. 2012; 2012: 261974
        • Der Ananian C.
        • Wilcox S.
        • Saunders R.
        • Watkins K.
        • Evans A.
        Factors that influence exercise among adults with arthritis in three activity levels.
        Prev Chronic Dis. 2006; 3: A81
        • Power J.D.
        • Badley E.M.
        • French M.R.
        • Wall A.J.
        • Hawker G.A.
        Fatigue in osteoarthritis: a qualitative study.
        BMC Musculoskelet Disord. 2008; 9: 63
        • Murphy S.L.
        • Smith D.M.
        Ecological measurement of fatigue and fatigability in older adults with osteoarthritis.
        J Gerontol A Biol Sci Med Sci. 2010; 65: 184-189
        • Zautra A.
        • Fasman R.
        • Parish B.
        • Davis M.
        Daily fatigue in women with osteoarthritis, rheumatoid arthritis, and fibromyalgia.
        Pain. 2007; 128: 128-135
        • Schneider S.
        • Junghaenel D.U.
        • Keefe F.J.
        • Schwartz J.E.
        • Stone A.A.
        • Broderick J.E.
        Individual differences in the day-to-day variability of pain, fatigue, and well-being in patients with rheumatic disease: associations with psychological variables.
        Pain. 2012; 153: 813-822
        • Schepens S.L.
        • Kratz A.L.
        • Murphy S.L.
        Fatigability in osteoarthritis: effects of an activity bout on subsequent symptoms and activity.
        J Gerontol A Biol Sci Med Sci. 2012; 67: 1114-1120
        • Kratz A.L.
        • Schepens S.L.
        • Murphy S.L.
        Effects of cognitive task demands on subsequent symptoms and activity in adults with symptomatic osteoarthritis.
        Am J Occup Ther. 2013; 67: 683-691
        • Stubbs B.
        • Hurley M.
        • Smith T.
        What are the factors that influence physical activity participation in adults with knee and hip osteoarthritis? A systematic review of physical activity correlates.
        Clin Rehabil. 2015; 29: 80-94
        • Eggermont L.H.
        • Leveille S.G.
        • Shi L.
        • et al.
        Pain characteristics associated with the onset of disability in older adults: the maintenance of balance, independent living, intellect, and zest in the elderly Boston study.
        J Am Geriatr Soc. 2014; 62: 1007-1016
        • Donovan K.A.
        • Jacobsen P.B.
        • Small B.J.
        • Munster P.N.
        • Andrykowski M.A.
        Identifying clinically meaningful fatigue with the fatigue symptom inventory.
        J Pain Symptom Manage. 2008; 36: 480-487
        • HajGhanbari B.
        • Garland S.J.
        • Road J.D.
        • Reid W.D.
        Pain and physical performance in people with COPD.
        Respir Med. 2013; 107: 1692-1699
        • Kaleth A.S.
        • Slaven J.E.
        • Ang D.C.
        Does increasing steps per day predict improvement in physical function and pain interference in adults with fibromyalgia?.
        Arthritis Care Res. 2014; 66: 1887-1894
        • Dworkin R.H.
        • Turk D.C.
        • Wyrwich K.W.
        • et al.
        Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.
        J Pain. 2008; 9: 105-121
        • Murphy S.L.
        • Lyden A.K.
        • Clary M.
        • et al.
        Activity pacing for osteoarthritis symptom management: study design and methodology of a randomized trial testing a tailored clinical approach using accelerometers for veterans and non-veterans.
        BMC Musculoskelet Disord. 2011; 12: 177
        • Bellamy N.
        • Buchanan W.
        • Goldsmith C.
        • Campbell J.
        • Stitt L.
        Validation study WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis.
        J Orthop Rheumatol. 1988; 15: 95-108
        • Goggins J.
        • Baker K.
        • Felson D.
        What WOMAC pain score should make a patient eligible for a trial in knee osteoarthritis?.
        J Rheumatol. 2005; 32: 540-542
        • Kellgren J.
        • Lawrence J.
        Radiological assessment of osteo-arthrosis.
        Ann Rheum Dis. 1957; 16: 494-501
        • Callahan C.
        • Unverzagt F.
        • Hui S.
        • Perkins A.
        • Hendrie H.
        Six-item screener to identify cognitive impairment among potential subjects for clinical research.
        Med Care. 2002; 40: 771-781
        • Murphy S.L.
        Review of physical activity measurement using accelerometers in older adults: considerations for research design and conduct.
        Prev Med. 2009; 48: 108-114
        • Swartz A.M.
        • Strath S.J.
        • Bassett D.R.
        • O'Brien W.L.
        • King G.A.
        • Ainsworth B.E.
        Estimation of energy expenditure using CSA accelerometers at hip and wrist sites.
        Med Sci Sports Exerc. 2000; 32: S450-S456
        • Patterson S.M.
        • Krantz D.S.
        • Montgomery L.C.
        • Deuster P.A.
        • Hedges S.M.
        • Nebel L.E.
        Automated physical activity monitoring: validation and comparison with physiological and self-report measures.
        Psychophysiology. 1993; 30: 296-305
        • Westerterp K.R.
        Physical activity assessment with accelerometers.
        Int J Obes Relat Metab Disord. 1999; 23: S45-S49
        • Gironda R.J.
        • Lloyd J.
        • Clark M.E.
        • Walker R.L.
        Preliminary evaluation of reliability and criterion validity of Actiwatch-Score.
        J Rehabil Res Dev. 2007; 44: 223-230
        • Keller S.
        • Bann C.M.
        • Dodd S.L.
        • Schein J.
        • Mendoza T.R.
        • Cleeland C.S.
        Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain.
        Clin J Pain. 2004; 20: 309-318
        • Mendoza T.R.
        • Wang S.
        • Cleeland C.S.
        • et al.
        The rapid assessment of fatigue severity in cancer patients.
        Cancer. 1999; 5: 1186-1196
        • Williams V.S.
        • Smith M.Y.
        • Fehnel S.E.
        The validity and utility of the BPI interference measures for evaluating the impact of osteoarthritic pain.
        J Pain Symptom Manage. 2006; 31: 48-57
        • Shuman-Paretsky M.J.
        • Belser-Ehrlich J.
        • Holtzer R.
        Psychometric properties of the Brief Fatigue Inventory in community-dwelling older adults.
        Arch Phys Med Rehabil. 2014; 95: 1533-1539
        • Radloff L.S.
        The CES-D scale: a self-report depression scale for research in the general population.
        App Psychol Measure. 1977; 1: 385-401
        • Brummett C.M.
        • Hassett A.L.
        • Brummett K.A.
        • Clauw D.J.
        • Williams D.A.
        The Michigan Body Map and its use in assessing the American College of Rheumatology survey criteria for fibromyalgia.
        Arthritis Rheum. 2011; 63 ([abstract]): 939
        • Butland R.J.
        • Pang J.
        • Gross E.R.
        • Woodcock A.A.
        • Geddes D.M.
        Two-, six-, and 12-minute walking tests in respiratory disease.
        Br Med J (Clin Res Ed). 1982; 284: 1607-1608
        • West S.G.
        • Finch J.F.
        • Curran P.J.
        Structural equation models with nonnormal variables: problems and remedies.
        in: Hoyle R. Structural equation modeling: concepts, issues and applications. Sage, Newbury Park1995: 56-75
        • Enders C.
        • Tofighi D.
        Centering predictor variables in cross-sectional multilevel models: a new look at an old issue.
        Psychol Methods. 2007; 12: 121-138
        • Murphy S.L.
        • Kratz A.L.
        • Williams D.A.
        • Geisser M.E.
        The association between symptoms, pain coping strategies, and physical activity among people with symptomatic knee and hip osteoarthritis.
        Front Psychol. 2012; 3: 326
        • Jinks C.
        • Jordan K.P.
        • Blagojevic M.
        • Croft P.
        Predictors of onset and progression of knee pain in adults living in the community: a prospective study.
        Rheumatology. 2008; 47: 368-374
        • Rustøen T.
        • Wahl A.K.
        • Hanestad B.R.
        • Lerdal A.
        • Paul S.
        • Miaskowski C.
        Age and the experience of chronic pain: differences in health and quality of life among younger, middle-aged, and older adults.
        Clin J Pain. 2005; 21: 513-523
        • Troiano R.P.
        • Berrigan D.
        • Dodd K.W.
        • Masse L.C.
        • Tilert T.
        • McDowell M.
        Physical activity in the United States measured by accelerometer.
        Med Sci Sports Exerc. 2008; 40: 181
        • Teychenne M.
        • Ball K.
        • Salmon J.
        Physical activity and likelihood of depression in adults: a review.
        Prev Med. 2008; 46: 397-411
        • Woo J.
        • Leung J.
        • Kwok T.
        BMI, body composition, and physical functioning in older adults.
        Obesity. 2007; 15: 1886-1894
        • Zhai G.
        • Blizzard L.
        • Srikanth V.
        • et al.
        Correlates of knee pain in older adults: Tasmanian older adult cohort study.
        Arthritis Care Res. 2006; 55: 264-271
        • Kamaleri Y.
        • Natvig B.
        • Ihlebaek C.M.
        • Bruusgaard D.
        Localized or widespread musculoskeletal pain: does it matter?.
        Pain. 2008; 138: 41-46
        • Murphy S.L.
        • Alexander N.B.
        • Levoska M.
        • Smith D.M.
        Relationship between fatigue and subsequent physical activity among older adults with symptomatic osteoarthritis.
        Arthritis Care Res. 2013; 10: 1617-1624
        • Aiken L.
        • West S.
        Multiple regression: testing and interpreting interactions.
        Sage, Thousand Oaks1991
        • WHO Expert Committee
        Physical status: the use and interpretation of anthropometry.
        World Health Organization, Geneva1995: 345-374 (WHO Technical Report Series 854)
        • Bohannon R.W.
        Six-minute walk test: a meta-analysis of data from apparently healthy elders.
        Top Geriatr Rehabil. 2007; 23: 155-160
        • Dansie E.J.
        • Turk D.C.
        • Martin K.R.
        • Van Domelen D.R.
        • Patel K.V.
        Association of chronic widespread pain with objectively measured physical activity in adults: findings from the National Health and Nutrition Examination survey.
        J Pain. 2014; 15: 507-515
        • Holla J.F.M.
        • Van Der Leeden M.
        • Knol D.L.
        • et al.
        Avoidance of activities in early symptomatic knee osteoarthritis: results from the CHECK cohort.
        Ann Behav Med. 2012; 44: 33-42
        • Steultjens M.P.M.
        • Dekker J.
        • Bijlsma J.W.J.
        Coping, pain, and disability in osteoarthritis: a longitudinal study.
        J Rheumatol. 2001; 28: 1068-1072
        • Huijnen I.P.J.
        • Verbunt J.A.
        • Peters M.L.
        • et al.
        Do depression and pain intensity interfere with physical activity in daily life in patients with chronic low back pain?.
        Pain. 2010; 150: 161-166
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
        Pain. 2000; 85: 317-332
        • Hasenbring M.I.
        • Verbunt J.A.
        Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice.
        Clin J Pain. 2010; 26: 747-753
        • Plaas H.
        • Sudhaus S.
        • Willburger R.
        • Hasenbring M.L.
        Physical activity and low back pain: the role of subgroups based on the avoidance-endurance model.
        Disabil Rehabil. 2014; 36: 749-755
        • Jensen M.P.
        • Turner J.A.
        • Romano J.M.
        • Karoly P.
        Coping with chronic pain: a critical review of the literature.
        Pain. 1991; 47: 249-283
        • Jensen M.P.
        • Turner J.A.
        • Romano J.M.
        • Strom S.E.
        The chronic pain coping inventory: development and preliminary validation.
        Pain. 1995; 60: 203-216
        • Tan G.
        • Jensen M.P.
        • Robinson-Whelen S.
        • Thornby J.I.
        • Monga T.N.
        Coping with chronic pain: a comparison of two measures.
        Pain. 2001; 90: 127-133
        • Perrot S.
        • Poiraudeau S.
        • Kabir M.
        • et al.
        Active or passive pain coping strategies in hip and knee osteoarthritis? Results of a national survey of 4,719 patients in a primary care setting.
        Arthritis Care Res. 2008; 59: 1555-1562
        • Jensen M.P.
        • Mardekian J.
        • Lakshiminarayanan M.
        • Boye M.E.
        Validity of 24-h recall of ratings of pain severity: biasing effects of “peak” and “end” pain.
        Pain. 2008; 137: 422-427