Among People Presenting for Musculoskeletal Specialty Care, Is There an Association of Accommodation of Aging and Other Mindset Factors With Levels of Comfort and Capability?

Background: Many musculoskeletal symptoms arise from the natural decline of cells and tissues with age (senescence). Among patients seeking care for those conditions, symptom intensity often corresponds more with thoughts and feelings about bodily sensations than with the severity of any pathophysiology. Population studies suggest that a large percentage of people manage to live with (accommodate) symptoms from these conditions without seeking care, and that as people age, healthy attitudes toward sensations from musculoskeletal senescence may help them accommodate these kinds of symptoms; to our knowledge, however, this has not been specifically studied.

Questions/purposes: In a cross-sectional study of patients presenting for musculoskeletal specialty care, we asked: (1) Are there factors associated with accommodation of aging, including mindsets measured as levels of unhelpful thoughts, feelings of distress, and intolerance of uncertainty? (2) Are there any factors associated with pain intensity, including comfort with aging and mindset measures? (3) Are there any factors associated with level of capability, including comfort with aging and mindset measures?

Methods: One hundred fifty-six English-speaking adults (age 18 to 89 years) presenting for initial or return specialist evaluation of a musculoskeletal problem (largely an unselected sample of patients with common lower and upper extremity problems) in a single large urban city in the United States agreed to participate. Among the 98% (153) who completed the survey and were analyzed, 57% (87) were women, the mean age was 53 ± 17 years, 69% (105) were non-Hispanic White, and 47% (72) had private insurance. Participants completed an 11-point ordinal measure of pain intensity, a measure of level of capability (a person's perception of the level of difficulty of specific activities, distinct from objective impairment or incapacity), intolerance of uncertainty (that is, a negative regard for uncertainty), unhelpful thoughts (unhealthy misinterpretations) regarding sensations, feelings of distress (worry or despair) regarding sensations, and attitudes toward aging (quantified positive or negative regard for aging), all using instruments with evidence supporting their ability to measure these constructs. Factors associated with levels of accommodation of aging, pain intensity, and incapability were analyzed using multivariable regression models, limiting the models to a single mental health variable because of concerns about collinearity and selecting the best performing model based on the Akaike information criterion. To account for known and anticipated collinearity of the mental health measures, we also performed a k-means cluster analysis to identify statistical groupings of unhelpful thoughts regarding sensations, distress regarding sensations, and intolerance of uncertainty and tested for differences in attitudes toward aging, pain intensity, and capability using analysis of variance.

Results: Accounting for potential confounders such as age, marital status, income status, unhelpful thoughts regarding symptoms, feelings of distress regarding symptoms, and intolerance of uncertainty that were associated in bivariate analysis, we found a small association between lower accommodation of aging and greater feelings of distress regarding symptoms (regression coefficient [RC] -0.17 [95% confidence interval (CI) CI -0.23 to - 0.11]; p < 0.01). Higher pain intensity had a modest association with greater feelings of distress (RC 0.4 [95% CI 0.2 to 0.5]; p < 0.001) and Medicaid insurance (RC 2.2 [95% CI -0.1 to 4.5]; p = 0.04) and a small inverse association with postcollege graduate education (RC -1.7 [95% CI -3.2 to -0.3]; p = 0.02). Higher levels of capability had a large association with less distress (RC -0.8 [95% CI -1.4 to -0.1]; p = 0.001), a small association with younger age (RC -0.2 [95% CI -0.3 to -0.1]; p = 0.005), and a medium association with postcollege graduate education (RC 5.9 [95% CI 0.4 to 11]; p = 0.04). The cluster analysis identified five statistical groupings of levels of unhelpful thoughts, feelings of distress, and intolerance of uncertainty that were associated with greater levels of healthier attitudes toward aging, pain intensity, and levels of capability.

Conclusion: The observation that people are less accommodative of aging to the degree that they experience greater intolerance of uncertainty, feelings of distress, and unhelpful thoughts about their body's sensations-and that these factors are also associated with greater levels of discomfort and incapability-points to the importance of cultivating and maintaining a healthy mindset as we age. To help guide patients to a healthier regard for the aging body, musculoskeletal specialists and all clinicians can transition away from concepts of inflammation (tendinitis), injury (tear), or breakdown (bone-on-bone) toward more accurate and healthful words and concepts, such as those that emphasize expected changes in people's bodies, that even painful activities are not off limits, and the importance of evolving one's identity to match one's body.

Level of evidence: Level III, prognostic study.