CORR Insights®: A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population : Clinical Orthopaedics and Related Research®

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CORR Insights

CORR Insights®: A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population

Jain, Rina MD1

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Clinical Orthopaedics and Related Research ():10.1097/CORR.0000000000002558, January 19, 2023. | DOI: 10.1097/CORR.0000000000002558
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Where Are We Now?

Knee osteoarthritis is an enormous cause of pain and disability [3], but even among patients with similar radiographic severity, the amount of pain they experience varies widely. This may be related to biological factors, psychologic issues, and social challenges [1].

Cultural factors may shape a person’s perspective on pain and function [2, 4, 5]. Asian patients have not been studied as frequently in this area. It is important to be aware of psychosocial and cultural factors that may influence a patient’s perceptions because such factors can affect treatment and outcome. To quote Dr. Marvin Tile, my former attending physician who taught me as a resident, “Treat the patient, not the x-ray.” This means being aware of the patient’s disease state in the context in which they live.

In this month’s Clinical Orthopaedics and Related Research®, a qualitative study by Yang et al. [6] advances our knowledge in these areas in a few important ways. The study team interviewed patients who had participated in an earlier randomized trial assessing a multidisciplinary intervention program for patients with osteoarthritis in an urban, tertiary-care hospital in Singapore. Their patients had advanced arthritis and considerable pain and functional limitations, about two-thirds of them were women, and none had undergone knee arthroplasty. The authors found that three factors affected patient experience: loss of face (embarrassment with a diagnosis of knee osteoarthritis, change in gait or speed because of this condition, and having to use a walking aid), anticipation and avoidance of pain and suffering by reducing their activities such as walking, and vicious cycle of negative emotions that affected mood. Study participants also feared becoming a burden to others, and so they avoided seeking help; some isolated themselves. Patients expressed concerns about employment as well as challenges with walking in facilities that did not have accommodations for patients with physical limitations. Based on the information from this study, surgeons should consider an individual patient’s context in the management of osteoarthritis and the patient’s entire situation when discussing treatments (for example, use of crutches, a walker, or bracing). Having an awareness of these potential factors can open useful dialogue with patients.

Where Do We Need to Go?

This study evaluated Asian patients who lived in Singapore; however, in this community, there are diverse groups. Ethnically and culturally, these patients may have been of Chinese, Indian, Malay, or other backgrounds.

In addition, migration of ethnic groups to North America and Europe brings up the question of the degree to which cultural values and norms persist in individuals’ new countries after they emigrate from their places of origin. It would be interesting to ascertain whether the same findings observed here with respect to the patient experience [6] are still present in those contexts. Furthermore, although arthritis tends to affect older patients, it can occur in younger patients, and future studies might investigate this.

An important adjunct would be the perspective of family members who often provide care for patients with arthritis. Do family members and caregivers have similar concerns or different ones to patients who are experiencing the pain and limitations associated with knee osteoarthritis? Patients in this study expressed they felt they were a burden to the family [6]; I wonder whether family members felt differently. This would be important to know in order to best support patients with arthritis.

An added perspective would be a more formal assessment of mental health. Depression and anxiety sometimes complicate the management of somatic diagnoses like arthritis and potentiate pain. A future study could consider administering questionnaires that evaluate emotional distress and observe any correlations or patterns with the patient experience.

Moreover, what is the effect of financial security on the patient experience? Themes that were mentioned in this study included those related to employment. Do patients with financial security have the means and resources to support their care without experiencing loss of face, or is economic status irrelevant?

How Do We Get There?

Given the global village in which we live, a comparative qualitative study on Asian patients of various ethnicities in Asia as well as North America and Europe would be useful. Comparisons between those from Asia and the diaspora would yield data on whether cultural attitudes persist. It would be interesting to see whether second- and third-generation persons of Asian descent in North America hold values similar to those still residing in Asia or whether their experience has transformed into the typical Western themes. A practical way of conducting such a study would be to compare a specific ethnic group from Asia to the same ethnic group who immigrated to North America, which can also be subdivided into first-, second-, and possibly even third-generation groups. Further stratification can also be done by income levels, age, comorbidity, and mental health diagnoses. Qualitative comparisons can yield useful information to guide realistic discussions with patients in the management of their diseases.


1. Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosom Med. 2008;70:890-897.
2. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Associations between psychosocial factors and pain intensity, physical functioning, and psychological functioning in patients with chronic pain: a cross-cultural comparison. Clin J Pain. 2014;30:713-723.
3. Finan PH, Buenaver LF, Bounds SC, et al. Discordance between pain and radiographic severity in knee osteoarthritis: findings from quantitative sensory testing of central sensitization. Arthritis Rheum. 2013;65:363-372.
4. Thong ISK, Tan G, Lee TYC, Jensen MP. A comparison of pain beliefs and coping strategies and their association with chronic pain adjustment between Singapore and United States. Pain Med. 2017;18:1668-1678.
5. Thumboo J, Chew LH, Lewin-Koh SC. Socioeconomic and psychosocial factors influence pain or physical function in Asian patients with knee or hip osteoarthritis. Ann Rheum Dis. 2002;61:1017-1020.
6. Yang SY, Sheng EY, Griva K, Tan B. A qualitative study of psychosocial factors in patients with knee osteoarthritis: insights learned from an Asian population. Clin Orthop Relat Res. Published online December 27, 2022. DOI: 10.1097/CORR.0000000000002526.
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons