Original Papers

Perceptions of joint pain and

feeling well in older people who
reported being healthy:
a qualitative study
Janet Grime, Jane C Richardson and Bio Nio Ong

INTRODUCTION
ABSTRACT Joint pain is widespread in people after middle age,
Background and osteoarthritis is the most common cause of this
Older people often view osteoarthritis as a part of symptom. Most older people with chronic peripheral
normal ageing and see themselves as healthy despite joint pain do not consult a doctor,1 a major reason
painful joints. Professionals have mixed views about
being that joint pain and stiffness are seen as an
this. One concern is that seeing osteoarthritis as a
result of ‘wear and tear’ leads to restricting exercise in inevitable part of ageing for which the doctor can do
order to avoid further wear. little.2,3
Aim Paradoxically, from a biomedical perspective,
To explore lay perceptions of wellness and joint pain, osteoarthritis has been transformed from a natural
and their implications for consulting healthcare
part of ageing — the result of ‘wear and tear’ and of
professionals and taking exercise.
little interest to clinicians — to a medical condition,
Design of study
Qualitative, longitudinal study`. which has an active disease process.4 In spite of this,
Setting there are conflicting views among healthcare
General practice in the North Midlands. professionals about the advantage of medicalising
Method joint pain in older people. Dieppe argues that most
Semi-structured interviews with 27 older people who people with osteoarthritis are not seriously affected,
reported a joint problem but rated themselves as
and in only a few will joint damage progress.5 He
healthy. Diary sheets were sent for 11 consecutive
months to record changes in health and questions the benefit of seeing milder cases of
circumstances. Thematic data analysis was facilitated osteoarthritis as a medical problem. Woolf, on the
by NVivo 8. other hand, advises that not only those with early
Results signs of a musculoskeletal condition but also those
A key element of wellness was being able to continue
who are deemed to be at risk should receive
with everyday roles and activities. ‘Wear and tear’ was
used to categorise arthritis that is a normal part of old appropriate healthcare interventions.6
age. New joint symptoms that came on suddenly and In practice, older people who consult with chronic
severely were not necessarily attributed to ‘wear and pain often say that their doctor attributed joint pain to
tear’ arthritis, and were likely to lead to a professional
growing old,7 and advised them to put up with it.3
consultation. Physical activity was not restricted to
prevent further wear of affected joint(s). Keeping joints Wear and tear — the wearing away of joints with use
mobile was important in order to maintain
independence.
J Grime, MMedSci, research fellow; JC Richardson, PhD,
Conclusion senior lecturer in health services research; BN Ong, PhD,
Professionals should explore patients’ ideas and professor of health services research, Keele University, Arthritis
concerns about their joint problem, in order to
Research UK Primary Care Centre, Keele.
individually tailor explanations and advice. Patients are
likely to be receptive to recommendations that promote
Address for correspondence
independence, but advice needs to be set into
Mrs Janet Grime, Keele University, Arthritis Research UK
patients’ existing ways of living and coping with joint
pain. Primary Care Centre, Keele, Staffs,
ST5 5BG. Email: [email protected]
Keywords
Health; joint pain; elderly; osteoarthritis; primary care.
Submitted: 14 September 2009; Editor’s response: 23
November 2009; final acceptance: 5 January 2010.
©British Journal of General Practice 2010; 60: 597–603.

DOI: 10.3399/bjgp10X515106

British Journal of General Practice, August 2010 597

 J Grime, JC Richardson and BN Ong

responders who had reported osteoarthritis/pain in

How this fits in peripheral joints and who had agreed to further
contact were assessed, in order to find responders
There are concerns that older people normalise osteoarthritis by seeing it as from across the age range 50 to 90 years, who rated
wear and tear; as a consequence, they do not seek medical help and they limit their health as good/very good, or as fair if they had
exercise in order to prevent further wear of the affected joint. This study found
moderate/severe pain and physical limitations. Those
that older people were able to distinguish between ‘wear and tear-type’ joint
who reported no health problem and/or no limitation
pain and other joint pain that they did not consider to be normal for their age.
and/or mild pain were excluded. From the 60 people
They were likely to consult with the latter type of joint pain. Responders did not
limit physical activity to prevent further wear of the joint; on the contrary, approached, 27 agreed to take part. In only two
keeping joints mobile was considered essential for maintaining independence instances were reasons given for declining to
and a sense of wellness. participate — bereavement and being very elderly
(90 years).
An in-depth interview was carried out at baseline,
— is commonly held to be the factor that mediates using the life-grid approach.10 Responders talked
ageing as a cause of osteoarthritis, by both about family, work, leisure, and health throughout
healthcare practitioners and patients.3 their life course. In addition, they were asked about
Musculoskeletal professionals are concerned that the their current daily life, the impact of joint pain, how
wear and tear explanation leads to patients limiting they saw their present and future health (and why),
physical activity in order to avoid further ‘wearing’ of their use of health and social services, and any
the affected joint(s).8 advice they might have for others with similar joint
Many people with long-term conditions rate their pain/osteoarthritis in order to stay well and healthy.
health as good.9 Therefore, older people’s view of Interviews were digitally recorded and fully
joint pain as being normal is likely to be set within a transcribed.
general context of self-perceived good health. A Each responder was sent a monthly diary sheet for
qualitative study was undertaken to explore why older 11 months following the interview. The sheet asked
people who had joint pain perceived themselves to be about changes to their health (for example, whether
healthy, and what might compromise or increase their they were feeling more or less well than normal), their
sense of feeling well, resilience, and use of healthcare problem joint(s), and personal circumstances that
services. This paper will draw on only a small part of affected how they were coping or felt in themselves.
the data, focusing on why responders felt healthy A thematic analysis was carried out. Using the
despite having joint pain, their perception of their joint qualitative software package NVivo 8, a coding
problem, and the implications for consulting framework was drawn up and refined following
healthcare professionals and being physically active. independent coding. The authors then met to
Future papers will explore resilience. organise the codes into themes, which categorised
the data so that conceptual analysis could be
METHOD developed.
This was a qualitative longitudinal study. Responders
were interviewed at baseline and then sent a monthly RESULTS
diary sheet for 11 months — making a total Twenty seven people aged between 56 and 87 years
participation time of 12 months. Responders agreed to participate in the study (Table 1). Five
indicated on the diary sheet if they wanted further withdrew or were not contactable after the first
contact with a researcher. interview, and one withdrew after 6 months because
Responders were recruited from a cohort study her husband was seriously ill. Most were born within
(NorStOP — North Staffordshire Osteoarthritis a few miles of their current address. Nearly all had
Project), in which they complete a general health and worked, or were working, in local manufacturing or
joint pain questionnaire. The questionnaires of cohort service industries. Six had undertaken higher
education.
Table 1. Age and sex of responders. Despite purposefully sampling from a cohort study
to include only those who had long-standing
Age at first interview Males Females Total peripheral joint pain/osteoarthritis of at least medium
50s 1 1 2 intensity, the baseline interview revealed that
60s 4 8 12 responders reported a range of conditions. These
70s 5 6 11 were categorised as shown in Table 2.
80s 2 — 2
Total 12 15 27 Ageing and perceptions of wellness
Responders often assessed their health in terms of

598 British Journal of General Practice, August 2010

 Original Papers

Table 2. Type of joint problem (as described by responder).

Musculoskeletal problem Age, years Males Females Total

Uncertain diagnosis 50s 1 – 1
Immune disease/childhood problem 60s and 70s – 3 3
Sudden/recent ‘osteoarthritis’ 60s, 70s, and 80s 2 2 4
Gradual onset from middle age 50s, 60s and 70s 5 4 9
Very minor joint problem 60s and 80s 1 1 2
Osteoarthritis + motor nerve problem 70s 2 — 2
Long-standing back problem 60s and 70s — 4 4
Trauma 70s 1 1 2

what might be expected for someone of their age: ‘I mean, lots of people do slow down [physically]
anyway, but I tend to think I’m 40!’ (Gwen, early
‘At the moment, I class myself as very healthy for 70s)
my age. I feel a lot younger than I actually am,
and hopefully act a lot younger.’ (Anne, mid-60s) Nevertheless, being independent — being able to
get out and about, and fulfil everyday roles and
Physical decline was seen as a normal part of activities — was also an important factor in enabling
growing older and as such did not necessarily wellness. Being independent required a degree of
interfere with a self-perception of being well. Being physical capability, at least to be able to walk and/or
mentally alert and not having memory problems were drive:
considered more important:
Interviewer: ‘What do you think it is that makes
‘I feel well, yes. I don’t know if I give the you say, “Yes, I’m a well person”?’
impression but I feel that my mind is clear, my
memory’s okay. So, my body is not as good as it ‘Well, I suppose, it’s because I’ve got my
was, I’m aware of that, but all in all, putting independence if you like — two eyes, two ears,
everything, you know, into perspective, being 80 which are a bit dicky, and two legs, which still
next month, I feel pretty good.’ (Lewis, late 70s) go.’ (Vida, late 70s)

‘Thankfully, I’m mentally alert. Until these ankles ‘I think if you’re walking and getting about a bit,
flared up in May, I was, for my age, I would say I you’ve got a good life haven’t you?’ (Keith, mid-
was very active.’ (Miles, mid-80s) 60s)

Several people distinguished between how they ‘If I’ve been in most of the day I’ll just get in the car
felt inside their bodies and how they might outwardly and I’ll go sailing up the bypass. I might be only
appear to others, or even to themselves when they out of the house 10 minutes, quarter of an hour,
looked in a mirror: but I’ve enjoyed that drive ...’ (Lucy, mid-60s)

‘You know you look older and people say you It was hard for these responders to imagine losing
can tell you’re getting older now and all this — their mobility and feeling well. Thus, although the
but you don’t feel old in your mind, you still feel importance of the physical body for wellness was
about 18, 20 odd. Don’t you?’ (Peter, early 70s) downplayed, a certain level of functioning was
necessary.
‘If I didn’t look at myself occasionally in the mirror,
I wouldn’t think that there was anything wrong.’ Normalising joint pain in later life
(Arthur, late 70s, who is severely disabled) Seeing joint pain as a normal part of ageing ran
through the interviews like a leitmotif:
Thus, even those who had a significantly changed
external appearance were not necessarily conscious ‘And mine [joint pain] comes with age, so no,
of it from day to day. Some used comparisons with you just accept it.’ (Kath, early 60s)
others as an indicator of their degree of fitness and
wellness: Wear and tear of the body was the main

British Journal of General Practice, August 2010 599

 J Grime, JC Richardson and BN Ong

explanatory model: ‘I said to the doctor [her GP who had diagnosed

osteoarthritis], “How is it that it [knee] went like
‘It’s [osteoarthritis] wear and tear really isn’t it? that [suddenly]?” ... I went to the Nuffield [private
And probably, all the cleaning that I’ve done for hospital] at first because nobody could convince
like the last 18 years can’t have helped much can me [that it was osteoarthritis] with it happening
it, so, you know, that’s probably why it’s come on so quick. I wasn’t convinced ... This nice doctor
... I don’t look at it as an illness or a disease.’ there [Nuffield], he put my legs up, he twisted my
(Carol, mid-50s, portfolio of domestic cleaning knees, he twisted my legs and he said did I want
jobs over a 6-day week) cortisone injections. I said, “No thank you”. And
he said, “I know they’re [injections are] painful,
‘But my thumbs started aching, I thought it was it’s better than the pain”. I said, “Well, if you gave
just old age, wear and tear ... it’s just par for the me cortisone, and this could go on forever, I’d
course of living that is, the type of job you do.’ have them, but not if it’s going to come back
(Phil, early 60s, lorry driver, previously a miner) every 3 months”.’ (Beryl, early 70s)

Wear and tear was used as a form of shorthand for One important difference between the
normal bodily changes with ageing. Resulting joint consultations was that the second doctor offered her
pain was therefore also considered normal and not painkillers, and so she felt her (abnormal) degree of
an illness. Wear and tear was not seen to arise from pain was recognised. The physical examination of
abusing the body but rather from virtuous use, such her knees also reassured her about the accuracy of
as physical labour. the diagnosis. Towards the end of the study Beryl
developed pain in her shoulders. It came on slowly
Consulting and type of joint pain and related to doing specific activities, such as
All joint pain, however, was not automatically ironing. She talked about this pain as arthritis:
attributed to old age. The type of onset and severity
of the pain led some responders to question if their ‘... there’s no cure for arthritis, there’s nothing
joint pain was normal. they can do [medically] at all for it. The only thing
Miles, for example contrasted the cause of his they give you is perhaps rubbing stuff or
back pain — ‘the usual deterioration you find with old painkillers ... I was going to make an
age’ — with the pain in his ankles which came on appointment to go to the doctor’s, but I know
suddenly and severely — ‘when I was a boy I he’ll say its arthritis.’ (Beryl, early 70s)
continually twisted my ankles, and many years ago
my GP told me that I would suffer in later life’. He saw She decided not to consult the doctor, but that she
his ankle problem as a medical condition. would mention it to the nurse when she next had a
Brian summarised the significance of this lay blood pressure check.
nosological model for distinguishing between a pain
that you have to live with, and a pain that is The importance of physical activity for
potentially a sign of a medical problem: managing ‘wear and tear’ arthritis
None of the responders limited physical activity in
‘... if it’s a thing [a joint pain] that you know you’ve order to minimise further wear of their problem
got to live with, then I think you’ve got to carry on joint(s). On the contrary, several said they persevered
regardless. But, like I say, if a sudden pain comes with exercise as a form of therapy, even if their joint
on then it is a warning, what’s going on like, and pain was worsening:
you can see the doctor.’ (Brian, early 60s)
‘My husband and I walk 2 miles every morning
A pain that was judged to be abnormal was likely after breakfast; really to get my limbs going.’
to lead to a medical consultation. (Gwen, early 70s)
A responder, who consulted with what she
considered was not an age-related joint problem, ‘Well, they’ve [knees] gradually got worse. But, I
found it difficult to accept a diagnosis of can still walk a fair distance. Last Sunday, for
osteoarthritis. Beryl’s knee had suddenly given way instance, I walked for an hour and 20 minutes.’
without any previous symptoms. She thought that (Robert, mid-70s)
her doctor, in attributing the cause to loss of cartilage
through wear and tear, had misdiagnosed her with ‘I do like working with my hands and if it’s [finger]
old age ’rheumatics’, although she later accepted the really, really painful any particular day, if I’m
diagnosis following a private consultation: sitting, I’m moving it, I won’t just let it set, I just

600 British Journal of General Practice, August 2010

 Original Papers

move it about.’ (Lucy, mid-60s) The level of physical activity varied across
responders, often according to how much it had
Responders rarely said that medical advice was been an interest over the life course:
the reason for exercising. Two described how they
took the initiative: ‘I’ve always danced. My wife and I did ballroom
dancing. I struggled at times but then you just go
‘I have asked [my GP] if I can go to the gym ... to through the pain barrier and try to ignore it.’
get myself a bit fitter, because they said I was (Lewis, late 70s)
putting a lot of weight on. And nothing has come
of it. She [GP] just laughed, and said, “You’re all Some enjoyed walking, swimming, or other
right. What do you expect? You’ve just gone activities for their own sake, but others did not. The
through all that [had a lung removed], you’re availability of gyms had led some to take up exercise
bound to have put a bit of weight put on”.’ more formally in later life, though not necessarily to
(George, early 70s) continue with it:

After being told that his age and general health ‘I’ve never done much actual sporty activities at
meant he was unsuitable for knee replacement all. I have joined a gym on various occasions but
surgery, Miles explained how he had come to start a get very bored with that, you know ... I go quite
programme of knee exercises: enthusiastic [for] about 3 months and then
boredom sets in and I tend to fall by the wayside,
‘Ever since my wife died, my daughter has you know. So I’m not very good at committing to
adopted a very concerned attitude about my anything like that.’ (Anne mid-60s)
welfare [she lives a long distance away from me].
She, of her own volition, contacted the Arthritis However, many spoke of routine activities, such as
Society and obtained their literature ... My housework, shopping or gardening, as exercise.
impression is that the exercises are preventing
my knee problem from getting worse.’ DISCUSSION
(Miles, mid-80s) Summary of main findings
Study responders were selected because they
When explaining their rationale for exercising considered themselves to be healthy despite having
joints affected by osteoarthritis, some responders painful joints. They spoke of joint pain as a normal
drew on a different model from the wear and tear consequence of ageing and a result of wear and tear
one used to normalise joint pain. They used a model from virtuous use of their bodies over the life
of use it or lose it — using joints to prevent loss of course.11 An impaired body did not necessarily
function: compromise their sense of being well, as long as
their brain functioned and they could be as
‘I’m willing to try anything that will help me stay independent as possible. Physical activity was not
mobile and I keep, you know, exercising because restricted in order to prevent further wear of the
I think it’s important. It’s like anything, you’ve got affected joint(s). The opposite was the case —
to use it or you’ll lose it.’ (Jennifer, early 60s) keeping stiff and painful joints mobile was
considered important in order to conserve people’s
‘[I stay healthy by] keeping mobile, because independence.
even though we’re sort of disabled, it’s a case of However, not all joint pain was attributed to
use it or lose it. If you want to keep your mobility osteoarthritis; for example, new joint symptoms that
you’ve got to move, even if you’re in pain.’ came on suddenly and severely were of concern.
(Anne, mid-60s) Responders were more likely to seek medical help in
these circumstances.
Arthur, for example, who had little mobility and
lived in an adapted chair, refused the offer of a tape Strengths and limitations of the study
recorder to complete his monthly diary sheets, even The qualitative and longitudinal nature of the study
though writing was onerous. He wanted to preserve enabled experiences that affected responders’ sense
what physical capabilities he had: of wellness to be explored in real time. Leaving
decisions about follow-up contact to responders was
‘Similarly, I make myself fasten my shirt buttons a strength because it enabled investigation of the
or make myself write because I do not want to fluctuations experienced by people from month to
lose these abilities.’ (Arthur, late 70s) month. It was also a limitation. There were several

British Journal of General Practice, August 2010 601

 J Grime, JC Richardson and BN Ong

instances when responders summarised a change in of it was conducted in order to get on with normal
the monthly diary sheet that seemed significant to life, and keep up valued roles and activities, including
the researchers, but they did not request contact, leisure pursuits.2,22
thus leaving the researchers unable to explore the The wear and tear osteoarthritis model was not
significance of reported change. used as a biomechanical basis for taking decisions
about exercise. Some responders invoked the model
Comparison with existing literature of ‘use it or lose it’, which, logically, is at odds with
Unsurprisingly, seeing osteoarthritis as a natural part wear and tear.
of growing older, not as an illness, means older
people manage their joint problem themselves rather Implications for future research and clinical
than seek professional help.12,13 Turner et al examined practice
the uptake of medical care for osteoarthritis in It is common for older people to normalise joint pain
relation to lay beliefs.14 They argued that patients who and not to consult a doctor. When people do consult
saw osteoarthritis as a normal part of ageing were they may have already worked up specific ideas and
fatalistic and unable to interpret symptoms as a sign concerns about their joint pain.16 Patients should be
of ill-health, and as a consequence were reluctant to encouraged to express these, so that clinical
consult. However, several older people in the present explanations and advice are individually tailored.
study evaluated their joint pain according to its While patients frequently see wear and tear as the
severity and type of onset, in order to establish if it cause of joint pain, practitioners should be careful
was likely to be ‘old age arthritis’ — to be lived with, how they use this as a diagnostic cause. A patient,
or something else not age related, with which it was for example, may be consulting because they do not
appropriate to consult. Tulle found that veteran think their joint pain is a result of wear and tear. Such
athletes created a typology of athletic injuries.15 The a lack of congruency in the consultation may affect
older runners distinguished between injuries caused patient ideas on prognosis.23
by ageing (wear and tear or overuse of the knee for a Responders had developed complex and
long period of time) and those, such as muscle tears, individualised ways of using physical activity to
that were not related to ageing. A GP advised one of manage joint pain and get on with their everyday
Tulle’s athletes to give up running and take up bowls, lives.22 They were receptive to suggestions that help
so he obtained private treatment for his ‘non-age- maintain independence, such as the role of exercise.
related knee problem’ and quickly returned to Exercise advice, though, needs to draw on patients’
running. In the present study, one responder, whose existing ways of managing, and to reflect personal
knee suddenly gave way, could not accept an abilities, preferences, and priorities.24 Motivational
osteoarthritis diagnosis. Her GP used the words interviewing uses this kind of approach to support
‘wear and tear’, and did not prescribe painkillers, so patient behaviour change.25
she felt that he had misdiagnosed her condition as Future research could explore the views of older
minor and age related. Thus, a lack of congruency in people who do not consider themselves to be
the consultation between patient and healthcare healthy.
professional over the nature of the joint problem
being presented may result in diagnosis and advice Funding body
being deemed inappropriate.2,16 This study was funded by the Economic and Social
Research Council (reference number RES-000-22-2812).
Older people often prioritise maintaining Ethical approval
independence over controlling pain,17,18 and The study was approved by South Staffordshire Research
conceptualise health as being able to carry out Ethics Committee (reference number 08/H1203/52).
everyday tasks, including self-care.9,19 There is Competing interests
The authors have stated that there are none.
conflicting evidence about lay perceptions of using
Acknowledgements
exercise to care for joint pain. Ross et al, for We would like to thank all those who participated in the
example, found that exercise was favoured as part of study.
a self-care strategy,13 and Lansbury found that it was Discuss this article
Contribute and read comments about this article on the
not.20 One reason for the contradictory findings in the
Discussion Forum: http://www.rcgp.org.uk/bjgp–discuss
literature is probably terminological. Some
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