|Older adults; Long-term pain; Musculoskeletal pain;
Home; Nursing; Home health care; Qualitative content analysis
|Musculoskeletal pain is the most common long-term pain for
older adults living in their homes [1-3]. There is an increase worldwide
in musculoskeletal conditions accompanied with this type of pain.
The pervasiveness and global nature of this problem led the World
Health Organization (WHO) to declare 2000-2010, “The Bone and
Joint Decade” in an effort to raise awareness and understanding of its
significance for the individual, health care system and society at large
|There is an extensive literature about long-term musculoskeletal
pain as a major health problem among older adults [1-3,6-14]. The
prevalence of this type of pain tends to increase with increasing age
[3,15]. Musculoskeletal pain is associated with lower level of physical
activity , increased risk of disabilities in daily living [6,17-23]
including sleeping difficulties , increasing risk of falls [25,26],
depressive symptoms [27,28] and impaired quality of life in relation to
health and well-being [28-31].
|To-date researchers have focused primarily on the prevalence
and nature of the pain, its treatment and impact rather than on how
community dwelling older adults actually experience living with the
pain at home. How do older adults endure long term musculoskeletal
pain that have lasted at least for 6 months in their daily life at home?
This question needs to be addressed in order to help health care
providers tailor individualized care to preserve and promote health and
well-being in this population.
|Qualitative studies that focus on how older adults (65 and older) actually live with musculoskeletal pain at home are highly limited.
Most studies have been quantitative and the focus has been mainly
on older adults in assisted living facilities, although a few have
included community dwelling older adults. Recently a small group of
researchers have begun to use qualitative research methods to explore
the perceptions and experiences of community dwelling older adults
living with long-term pain. Sofaer et al.  interviewed 63 older adults
living in their homes or assisted living facilities about the limitations
they faced because of long-term pain and the strategies they used to deal
with them. These older adults strived for independence and control and
tried to adapt to a life with pain. They used aids and adaptations to the
home and garden to help maintain their independence and they spoke
of “pacing oneself, helping other people,” prayer and “looking good
and feeling good” in trying to adapt. Seomun et al.  interviewed
16 older adults in their home as part of a concept analysis of coping
with long term pain while living with arthritis. They identified five
coping strategies, including tuning (controlling the body movement
until the pain goes away), attention diversion, exercise, medical regime and giving up control. Blomqvist and Edberg  interviewed 90 older
adults about their experience of living with long term pain at home
or in a sheltered accommodation and dependent on home health care
providers in daily life. Some of the older adults expressed satisfaction
in their situation in spite of pain and viewed themselves, their pain and
significant others positively whereas others expressed dissatisfaction
with a negative connotation in life. The authors concluded that health
care providers need to be sensitive to and acknowledge the individual’s
experience of pain in the specific situation. The need for additional
research has been argued by Helme and Gibson . They have argued
the need to more deeply and more fully understand the problems
caused by pain in the older adult’s life. They highlighted the difficulty
in obtaining in depth data of this experience with the commonly used
designs and questionnaire format. Furthermore, Miaskowski  and
Gartrell  have stated that researchers need to be attentive to how
older adults experience of pain and the distress and disabilities in life
related to this health problem. Cleary, one can assume that there is a
need to conduct further research aimed at clarifying and gaining an
in-depth understanding of the older adults’ experiences of living with
long-term musculoskeletal pain.
|In response and in an effort to expand this body off work, the
authors designed a study to address the older adult’s experience of
living with long-term musculoskeletal pain at home. Face-to-face
interviews were completed with 19 community dwelling older adults
living with long-term musculoskeletal pain in their home. The overall
aim was to obtain a more in-depth understanding of older adults’
experiences of living with long-term musculoskeletal pain at home. The
goal was to capture this experience as fully as possible in regard to both
variations and commonalities. An initial phenomenographic analysis
was completed in order to describe the different ways in which older
adults deal with daily life while living with long-term musculoskeletal
pain at home. The result of this analysis has been published . The
wide ranging categories ignore, struggle, adjust and resign reflected the
distinctly different ways the older adults’ dealt with daily life at home
while living with this type of pain.
|Despite these extreme variations, it became obvious during the
initial analysis of the data that there were commonalities in the older
adults’ experiences of living with this type of pain. Daily life for all the
adults was an act of endurance and there were important commonalities
in how they endured the pain. The penetrating sense of endurance
throughout the data motivated the following analysis, one that focused
on the commonalities in the older adults’ experiences. Based on the
studies reviewed and the conducted analysis the aim of this analysis
was to describe commonalities in how older adults endure long-term
musculoskeletal pain in their daily life at home.
|Qualitative face to face interviews were chosen to collect data
since it gave an opportunity to obtain a description of the participants’
experiences in a situation where the researcher momentarily could
obtain confirmation of the participants’ verbal and non-verbal
expressions [39,40]. Graneheim and Lundman’s  approach to
qualitative content analysis was chosen to identify commonalities
in how 19 older adults endured the pain in their daily life at home.
Content analysis as a research method was developed originally as a
quantitative research method in several disciplines during the 20th
century. More recently a qualitative type of content analysis was added
. Graneheim and Lundman  developed a qualitative style of
content analysis that is interpretive in nature and used to describe
or illuminate a phenomenon by identifying both the manifest (the obvious) and latent (underlying meaning) content in a text. This
approach remains close to the languages used by participants, rather
than the more traditional, realist approach which focuses on single
words and phrases .
|The inclusion criteria for this study were community dwelling older
adults aged 65 or above, who for at least the past six months, had lived
with long-term (persistent or regularly recurring) musculoskeletal pain
at home and had received home health care services. In addition they
had to be willing to participate in the study and be able to understand
and answer questions. The older adults who met the inclusion criteria
were identified by the home health care providers in their community.
They were given an informational letter about the study and asked if
they would be willing to be contacted by the first author. Each potential
participant was contacted by the first author by phone to answer any
questions and to give more detailed information. Additional written
information and a letter for informed consent were sent to those older
adults who were interested and a time was set up for an interview in the
older adult’s home for those who decided to participate in the study.
|A sample of 19 older adults, 18 women and one man, aged 66 to 88
years, (mean 79 years), from three different communities in Sweden
participated in the study. Five were married, 12 widowed and two were
divorced. The older adults had lived with long-term musculoskeletal
pain ranging from two to 50 years and one woman had lived with this
type of pain for about 75 years, almost her entire lifetime.
|Semi-structured, face to face interviews were conducted and
carried out as a conversation by the first author in the year of 2006.
This researcher is an experienced registered nurse with a post graduate
diploma as a public health specialist in nursing, and family nurse
practitioner with a master of science in nursing and doctoral prepared
in qualitative research method. The researcher had no personal relation
with the participants. An interview guide was used to frame the
conversation while also allowing the dialogue to develop in relation to
the participant’s responses. The interview, conveyed as a conversation
allowed the older adults to reflect upon and articulate their experiences
in their situation and to choose what content to share with the
researcher. The interview guide consisted of open ended questions with
subsequent follow up questions used to explore and describe how each
participant lived with long-term musculoskeletal pain in their daily life.
More specifically, it consisted of a series of questions covering older
adults general description of their pain, how they lived with it in daily
life, its influence on their daily lives, how they dealt with daily life while
living with this type of pain, contacts and support from health care
providers and significant others and their thoughts about the future.
Interviews lasted from 35 to 115 minutes. They were audio-recorded
and transcribed verbatim.
|There were six major steps in the analysis. First the transcripts of all
the interviews were read by the first author to become familiar with the
text and to reflect upon the content. The second reading was done to
confirm the aspect of enduring long-term musculoskeletal pain in daily
life at home which constituted the foundation for the research question:
What are the commonalities in how older adults endure long-term
musculoskeletal pain in their daily life at home? The notion of enduring
while living with pain was reflected upon throughout the whole text,
both implicitly and explicitly as the focal point in the older adult’s situation. Thirdly, each interview was read and re-read to identify the
content relevant to the research question. As a fourth step, meaning
units consisting of words, sentences or paragraphs related to the aim
were identified in the interviews. The meaning units constituted the
foundation for condensation and abstraction into codes conducted
separately for each interview. In the fifth step, the meaning units were
condensed and the essential contents in the condensed meaning units
were abstracted and labeled with a code. One example of text that
constituted a meaning unit answering the research question was “...
there is no one that can do anything…I have to continue and have this
pain as I have…one learns, that’s the only word I can say, that one has
to learn…” This meaning unit was condensed to “Realizes that no one
can help her with the pain and that there is nothing else to do other than
to learn to live with the pain” and further abstracted to the codes Learn
to live with pain, Tries to control her situation and Bear the pain alone.
|In the sixth step, the codes were compared for similarities and
differences in content and sorted into five preliminary themes: learning
to endure and get through the day; controlling oneself and daily
life; self talk; not be a burden; meaning and pleasure in life that had
emerged during the analysis. Each code, explicitly (manifest content)
or implicitly (latent content), reflected the theme it was sorted into. The
codes in the preliminary theme: learning to endure and get through the
day reflected the learning with a day by day focus. The codes: “learn to
live with pain to endure”, “take the unpredictable pain as it come” and
“take it day by day” were explicit codes (manifest content). Others as
“keep habits and routines”, “tries to live life despite pain, tries to endure”
were codes that reflected the theme more implicitly (latent content).
During the analysis the component learning to endure pain, in one of
the preliminary themes was interpreted as an underlying thread across
all the five preliminary themes. Based on this interpretation, learning to
live with pain was labeled as the main theme under which the remaining
five preliminary themes were subsumed. The older adults’ experiences
in their situation can be viewed in light of the main theme which in
combination with the sub-themes, as being the parts, constitutes the
coherent whole of how older adults endure long-term musculoskeletal
pain in their daily lives at home. The first and second author, an
experienced professor and researcher on the topic of pain in hospital
and home settings and an expert in qualitative methods, analyzed the
first interview separately, compared, discussed and reached consensus
about codes and potential themes. The first author continued to analyze
the following interviews and each analysis (condensations, codes and
preliminary themes) were discussed. There was close communication
between the first and second author in the phase of labeling codes,
sorting them into preliminary themes and naming final themes. The
analysis was an iterative process back and forth across the steps and not
in a linear process as might be understood from the description above.
|The study was approved by the Ethics Committee at the University
of Gothenburg, (034-06). In addition, approvals were given by
the heads of the social welfare and home health care services in the
communities of concern for the study. Furthermore, the older adults
consented to participate in the study both verbally and in writing.
Several reminders were given prior to the interview that participation
in the study was voluntary. The data were treated as confidential to
protect each participant’s identity.
|The community dwelling older adults in this study felt that they
were forced to endure pain in their daily lives at home. They felt that their pain could not be eliminated, controlled nor managed. Instead,
the question was how to endure living with it? In the interviews many
of the older adults referred explicitly, others implicitly that they had
to learn to live with the pain. Thus learning to live with pain became
the main theme. The five sub-themes reflected how these adults had
learned to endure pain in their daily life, continue with daily activities
and find meaning in life. These included:
|• taking the pain as it comes, one day at a time;
|• balancing the pain with activity, thoughts and emotions;
|• self talking;
|• trying to be less of a burden to family and others;
|• capturing, enjoying and valuing moments of pleasure
|Main and sub-themes are described below and illuminated with
quotes from the interviews. The quotes collectively stem from 10
interviews. These were the most illustrious. However, every interview
was reread to make sure that the illustrious quote was synonymous
with the text in the interviews.
|Learning to Live with Pain
|For the older adults in this study, the pain was continuously
ongoing and no one expressed any belief in the possibility that it could
be eliminated or controlled. They had come to believe that they just had
to learn how to endure.
|It varies, one just has to go along with how the body reacts because
it just comes, and one can’t decide about that oneself, the pain comes…
when it comes…I said at the hospital; could you give me something that
could make me almost well?...They say; ’you have to be happy for what
we do for you. We help you as much as we can’….I have no more wish,
not for me at least, one just has to endure.
|The older adults could not recall ever having been taught how to
endure. They spoke of varying degrees of support from health care
providers in their homes, although still more often alone with their
pain. They felt that they had to endure primarily on their own. Not
infrequently, health care providers seemed to unwittingly reinforce
the idea of having to deal with it on one’s own. Below is one woman’s
description of a conversation she had with one of her physicians.
|… it is so violently painful that I don’t think I can endure it, I
can’t handle this. ‘Yes, but you will’ said the doctor ‘because you are so
mentally strong, you will be able to manage this’.
|Several of the older adults brought up the need for additional,
individually tailored advice and support from health care providers
both now and in the future.
|Earlier I had one doctor for many years and that felt so good, we
knew each other….one needs someone that, so to speak, someone that
pays a little attention….One wishes that…there was a pain unit that
one, at least could consult....to at least hear if there could be anything
available to try….it’s always good to hear a little…but it’s not available
so it’s no use thinking about it.
|In summary the older adults in this study were pretty much on
their own when trying to figure out how to learn to endure living with
long-term musculoskeletal pain in daily life. There was no learner’s
guide, even though others told them that they could endure. In this
continual process of learning, they drew from what they had learned
in life while at the same time being open to new aspects that could
help. There was this underlying expectation that pervaded in the older adults’ lives about pulling themselves together and figuring out on
their own. This expectation was established within themselves, but was
also felt to be present among family, friends and health care providers.
They did their best to guide and coach themselves in the effort to meet
this expectation. Each older adult had some kind of support but the
extent and content of it varied individually in relation to the current
situation. The older adults felt that they had to learn how to endure on
their own despite the fact that they had people around them at different
point of times during a day. They had various support from health
care providers regarding their medication but none were fully satisfied
with the relief of their pain. They just tried their best to adjust their
medication in relation to their pain.
|Taking the Pain as it Comes, One Day at a Time
|The older adults in this study had learned that to take the pain as it
came and get through the day, one day at a time, helped them endure
the pain and continue with their daily lives. Many of them declared that
they were old now and circumstances like pain were a part of aging.
One women declared “I get older and older so I don’t have much time
left, I can die any day…one hangs on, day by day, that’s how it is and
one has to take one day at a time, one has to live…I live with this pain,
one has this pain in the body.” The unending pain had become a natural
part of daily life. Some even came to view the pain as a friend in life.
One women said “…it aches all the time. One finally becomes, so to
speak friends with the pain when it’s aching, aching and aching always,
always, always”. The older adults had become used to the presence of
pain with all its differing levels of frequency and intensity and locations
that could not be predicted on any given day. One woman said:
|One lives with the pain, one certainly does. Sometimes one feels
better and sometimes one feels worse….there is nothing one can do about
it....now one has that crap so it’s nothing else to do but to live with it….
one has to take it day by day.
|The older adults lived with daily pain which caused various degrees
of difficulty in their effort to continue their daily lives. They felt that
they had no other choice in their situation then to learn to endure and
incorporate the unpredictable pain into their lives. They had concluded
that the only way to be able to endure was to learn to live with their
pain. One component in the learning to live with pain was to take the
pain as it comes, one day at a time to get through each day for the rest
of their lives.
|Balancing the Pain with Activities, Thoughts and
|The learning to live with pain in daily life was a continuous ongoing
balancing act where the older adults tried their best to balance their
pain with activities, thoughts and emotions in order to endure the pain.
Balancing daily life was a matter of learning through the use of trial and
error, with varying levels of success.
|Clearly, there comes certain times when you do things and it doesn’t
work but one is so, it’s so routine that one tolerates it anyhow….one
becomes both morose and willful sometimes but it pays off poorly when
one is alone…there are many times when one has to rethink and do
something else instead.
|Movements of the body were painful for the older adults but they
wanted to maintain their ability to move about. They tried their best
to balance their movements and positioning of their body to make the
pain as tolerable as possible in the effort to find a good position or move
about as intended.
|I go where I’m heading….if I for example want to go to the bathroom
and sit on the toilet I would need to do this very, very carefully…sit
down very carefully because if I sit down sloppily or too fast then it hurts
terribly, to the point that it makes me scream.
|Furthermore, holding on to habits and routines helped the older
adults stay as active as they desired and endure the pain. One woman
described her day from the morning when she got up until bedtime.
“That’s how my day works…and then I start the next day with the same
routines, so goes my day….if I would lie in bed and sense how bad the
pain is then I might not get up. I don’t feel like doing that so I get up and
do the old routines that I’ve always done”. In addition, the maintenance
of daily activities distracted the older adults, which in turn helped to
lower their awareness of the pain. The woman continued to say “When
I start doing something else I forget about the darn pain…I sit down with
my crossword puzzle….Then I’ve forgotten about the pain. Don’t think
about the pain. It’s difficult but it works”.
|A major part of balancing the pain involved using medication as
prescribed by the physician on a regular basis and taking extra when
needed. The older adults felt that their medication to some extent
relieved their pain, even though they did not become free of pain. The
pain varied which made it difficult to foresee in advance the extent
to which their medication would relieve their pain or if they would
need to take more. In times when the prescribed medication was not
enough there was a wish for something else to help them to endure.
One woman said:
|I take Paracetamol and then after half an hour or so it usually starts
to help I think, I feel a little better but it doesn’t help every time....It comes
in periods…it moves about in the body and can’t be ordered when to
come but it comes when it comes and then one has to try to help and have
something to take….If only one could get help to get a more tolerable
situation when one gets these periods when one feels really bad and has
|In addition, some of the older adults considered aspects such as the
dose and its effect on their body in the long-run. One woman said she
had been told by health care providers “that I can’t take too much since
that tablet won’t help either”. There was a fear of becoming dependent
on the medication and concerns about possible effects on the body
and the relief of pain. The woman continued, “I’m scared to become
dependent on them so that I would need more and more…and I’m scared
that I would become dizzy from them, a little crazy. It might not help in
the end anyway if I take more and more pain medication….Maybe it will
get worse….I don’t take more than absolutely necessary”.
|The older adults also balanced their thoughts and emotions to
endure their pain in daily living. They tried their best to direct their
thinking to stay as positive as possible in their current situation. One
woman said “I have a fairly good attitude and I want to believe that; oh
I must be able to handle this. No one else can take the pain away from
me, for me, this I need to deal with by myself”. The older adults tried
to dismiss thoughts of pain like expressed by one woman “I’m always
in pain…but I dismiss it. I try to think that: No, I’m not going to pay
attention to it, I don’t feel it”. They also tried to keep the pain from
effecting their mood which was described in words like “I try to avoid
crying, getting sad and feeling distressed” even though sometimes “the
tears are never far away, but I know I can’t let them come….the worst
you can do is to sit there and cry and be sad….It is the worst you can
do to give up on yourself”. Furthermore, some of the older adults had
found out that their state of mood influenced their notion of pain. One
woman said “I mustn’t be too sad, if anyone makes me very sad you know, then it’s as certain as amen in the church that I feel pain. It’s like
what the soul can’t stand, the body has to bear”.
|This balancing of pain with activity, thoughts and emotions helped
the older adults to endure their pain in daily life while trying to make
the best they could out of their current situation. The balancing to
endure their pain was permeated by learning on their own through
trial and error.
|The older adults carried on an active dialogue with themselves
about their situation and how to endure pain in their daily life. This was
different from when they were channeling their thoughts and emotions
in a specific direction in order to keep themselves balanced and positive.
The self talking was a purposeful cognitive way they had learned could
help them endure their pain. The self talk theme shows the purposeful
thinking, discussion, arguing and negotiation with self that was going
on in the older adult’s daily life when living with pain. It shows the
conscious active dialogue that was going on with themselves in their
situation about how to live with and endure their pain. This is different
from the theme taking the pain as it comes, which constitutes more of a
description of what they actually did to learn to endure living with pain,
and not how they reached what they intended as in this self talk theme.
It is also different from the balancing theme which illuminates that the
older adults were channeling their thoughts and emotions in specific
directions to keep themselves balanced and positive. The presence and
intensity of this self talking varied. For those who had decided to not
pay so much attention to the continuously ongoing pain, the self talk
was less extensive than for those who described the influence of pain in
their daily lives as challenging to capitulating.
|One woman described how she had argued with herself about
whether or not anything could be done about the pain since she wanted
to remain in her home as long as possible rather than go to a nursing
home. She declared to herself “…and hasn’t it helped by now during
these two years, then there is no one that can do anything”. She then
goes on to tell herself:
|…so then I have to continue and have this pain as I have…one
learns, that’s the only word I can say… And I’m not the kind that is illtempered
and angry and so on, I’m not, I’m just, I’m just reasoning so
that there is nothing to do about it, that will have to be that. And if I get
very much so that I become totally confined to bed then they, someone
has to take care of that. That’s just the way it is. I would rather live here
and have this pain as I have then to come to a nursing home among all
who have pain….As long as I can manage by myself, I want to do that.
|For others, the self talking was more like an on-going dialogue or a
constant companion, throughout the day. It helped them to endure by
learning to live with pain in a way that they could keep on living a daily
life. For the following woman, it was almost like she was her own coach,
telling herself to put up with the pain, not be passive, move and fight to
do what can be done. She declared:
|One has to put up with everything…there are things that are much
worse so to speak…sometimes one thinks it is unbearable…but that’s
how it is…one tries to move about and take care of the little one can do,
one doesn’t sit passive…one just has to submit to it and do the little one
|Sometimes the older adults actually negotiated with themselves
in order to gather the strength needed to just exist and get through
the day. Below one woman talked about how she talks herself into
getting up and into the kitchen to make coffee. This was associated with difficulties and pain but sometimes she negotiated with herself to try
anyhow. She told herself that she needed to make coffee and that it
would cheer her up once she has had this cup of coffee.
|Sometimes when I’m about to make coffee…I have difficulty with
that but sometimes I try since I feel it will cheer me up, and then one
fights to get that water and coffee going and to get that cup of coffee and
then it feels a little better. One has to fight like that many times with
|This self talk was used to guide the older adults through the pain
and daily living. They discussed how to proceed, convinced themselves
to fulfill their intensions and negotiated when they needed to pull
themselves together to do what they intended to endure by learning to
live with long-term musculoskeletal pain in daily living.
|Trying to be Less of a Burden to Family and Others
|The older adults in this study tried their best to not burden their
family and others while learning to endure pain in daily living. They
continuously tried to be less of a burden and had learned by thinking
in certain ways and using various behaviors to accomplish the intended
the best they could. They did not ask for more help than absolutely
necessary and had learned to find ways to do things themselves and
by that, delay the day when there was nothing else to do but to allow
others to help. When that time came, they tried their best to alleviate
the situation for their family and other caregivers. One man said “I do
what I can and the wife does the rest and it works very well….I’m so
afraid that it will be too much, too much for her….I try to be as neutral
as possible to not put a burden on her since I know that she has much
to do and that it becomes burdensome, it has worked very well so far.”
|The older adults did not want to complain and bother family and
friends with their problems. They endured and carried their thoughts
and emotions inside themselves as much as they possibly could and
avoided talking about their pain with others. They wanted to convey
the message to family and friends that the pain was not so bad and that
they were doing pretty well or even good in their situation.
|I think that I never want to complain you know, so I carry it within
me….I think that it doesn’t get any better if I keep on talking about it…
On the contrary, I want to be happy, so I don’t show anything...I never
talk about that I have any pain.
|Several of the older adults had learned that nothing good came from
complaining, for themselves nor in relation to others. One woman said
that her son had told her “don’t nag mother because then I won’t come
and visit you”. She continued:
|We know exactly where we stand so there’s no hard feeling. I have
said that I will never do anything that will make the children suffer
because of me. I know what they have to do and they should have some
pleasure in their life, the free time they have….But the children tells me
now that; ‘mother if there is anything you know you can call, if you are
feeling alone and want to get out and so on’. But then, if one doesn’t feel
like one has the strength, it’s no fun for either one of us.
|Clearly, the older adult did not want their families to worry about
them, since they felt that their children and their families had enough
to deal with themselves. They wanted them to find joy and have a good
time whenever they had a chance. In the interviews it was as though
the older adults knew that they their families cared about them and
that they could ask for help when needed. The notion of caring families
however, did not change the older adults need to learn to endure living
with pain on their own.
|The older adults stayed home or avoided visitors when they felt that
the pain was too difficult. They wanted their family and friends to have
a good time and not focus on and attend to the older adults’ needs.
However, when participating in family events and the pain became
worse, some of the older adults pretended that the pain was not so bad
even though they in fact found it almost unbearable. Sometimes they
went hiding for a moment to pull themselves together and get hold
of the situation. However, how successful the older adults were in
convincing their families and friends that they did not need to worry
varied. As one woman said:
|I want to be seen as being happy, first by my family and then by my
children…When they come to visit I absolutely do not want them to see
that I’m in so much pain. But they hear me when I moan and groan and
am sad….I don’t want to be a burden to them…they have enough to
deal with themselves, they have difficulties with pain and suffering and
they also have to have enough strength for their families….But they tell
me that they see it, that I pretend to feel so good. ‘You’re just pretending
mom’, and I said let me pretend. Because I feel better myself when I’m
|The older adults had learned how to think and used certain
behaviours in their effort to be less of a burden to family and others.
With varying degrees of success, they tried to conceal their pain and
how they felt by not complaining and even at times pretending in front
of families and friends. They wanted their children to have a good life
and tried to facilitate that by trying their best to endure and to be less
of a burden in their lives.
|Capturing, Enjoying and Valuing Moments of Pleasure
|The older adults consciously tried to capture, enjoy and value
moments of pleasure. They had learned that it helped them to endure
pain in daily life since such moments alleviated their pain, added
meaning in life and gave them strength to carry on.
|Occasions as when being asked to participate in social events and
to spend time with family and friends to the extent that was possible in
each older adult’s life, made their day and life lighter. One woman said:
|They do so much for me, clearly I value that and I think it makes
me happy. This winter we had bingo down in the basement every other
Thursday and then this woman came up to get me and said: ‘You will
come even if I have to carry you, you’ll come’. It lightened up the situation
only that she said those words and that I could participate down there
and then she followed me back up here to make sure that everything
worked out well for me.
|When the older adults had the strength to meet with family and
friends, they felt that their pain was alleviated for a moment and they
even could forget about it for a while. This is illustrated by the following
quote: “It eases a little, clearly I’m always in pain but definitely it comes
to be in a totally different way when I’m among people. I don’t sense it
quite so hard”.
|For these older adults, their families were a major source for
bringing joy and meaning into their lives. Their families called, visited
and were many times the ones to see that the older adults got outside
their home. The older adults were curious about and wanted to follow
what happened in the lives of their families. As shown in the quote
below, there were older adults that considered themselves to be living
on overtime, but even those had learned to keep trying to capture and
value things they found good about their life.
|I’m so curious and I love my son so I don’t want to leave him, that’s why I got to be so old. I have lived 6 years too long….But I have a very
wonderful son, he comes and does the shopping and then he takes me out
sometimes…that is such an elixir and I live many days on that.
|Memories from the past, but also more recent memories from life
with family and friends were something that the older adults valued.
These memories gave them something to hold onto and live for the
current day and in the days to come. When evaluating their lives,
many of them thought that they could not expect much more of life
and realized that it was as good as it possibly could be, when taken
into account the circumstances of their current situation. One woman
|Many times I think that I’ve lived my life so I have to be grateful
for what I’ve got....I think that everything works so well so I think I
require no more….Yes we have had a good home in every way, family
circumstances and everything. I think that one lives on that one has had
such a good life....Many times one sits and think back upon life. I sure
have pleasant memories and that one lives on.
|For these older adults capturing, enjoying and valuing moments
of pleasure was a way they had learned helped them to endure pain in
their daily life since it to some extent alleviated their pain and helped
them to keep their spirits up, gave strength and meaning in life.
|Clearly, it is a challenge to alleviate the older adults’ suffering and
meet their individual needs while living daily life with pain at home.
The older adults’ overall orientation and first priority was to continue
daily living despite pain and not the pain itself. They focused on how to
live with musculoskeletal pain and had realized that there was no other
way out than to endure and learn to live with this pain in their daily
lives, an orientation which contrasts with much of the existing literature
on pain. Undoubtedly, musculoskeletal pain has been recognized as
global and increasing health problem overtime. However, the existing
literature predominantly focuses on prevalence, causes, management,
associated disabilities (physical, psychological and social) and the
burden on society with reference to economic costs [4,5,9,22,29,44-46]. Unfortunately, there is limited literature about how community
dwelling older adults actually live with this type of pain, which would
be valuable knowledge for health care providers. The image in the
literature does not reflect the fluctuating nature of the pain nor provide
a detailed description or guide for how to live with this kind of pain in
one’s daily life. In this study, the older adults’ pain was anything but
constant and they had to work hard to figure out how to endure it on a
daily basis. The learning had become integral to life itself like described
by Berglund . The notion of learning as a component in life with
pain was illuminated Sofaer et al. . However, the predominant focus
on learning in the act of enduring pain has not been found in earlier
studies. Neither has the constraint associated with this learning among
the older adults in their effort to fulfill expectations and demands from
self, relatives and health care providers.
|Clearly, endurance by learning to live with pain without any
established guidelines was a challenge for these older adults. They used
trial and error and overtime learned that balancing activities, thoughts
and emotions was a necessary element in daily life. Fagerhaugh and
Strauss  referred to balancing as a process of making choices to
control actions and argued that it might be the most important process in
relation to understanding interactions involving pain. The participants
in this study deliberately balanced their pain and disability in relation
to planned activities for the day [48,49] and evaluated the advantages
versus disadvantages of any one activity [33,34,47]. The balancing was not only related to physical activities and certain moments during
the day. It also was a continuous ongoing process with deliberate
choices being made throughout the day, including not just the physical
dimension of balancing but also a psychological dimension, one related
to the balancing of thoughts and emotions. The balancing was oriented
both internally (balance within self) and externally (balance towards
the surrounding world) similar to that described by Lipworth et al.
. Berglund  described this act of balancing as “the way to learn”
which constitutes one of the components in “the essential meaning of
learning to live with long-term illness” (p. 189).
|Furthermore, little attention has been given in the literature to
expectations and demands of health care providers and others on the
older adult’s ability to be independent. The older adults in this study
had learned to endure living with their pain pretty much on their own
even though they had received various degrees of support from health
care providers. There were no detailed descriptions or any guidelines
available on how to live with pain in daily life, so trial and error was
used until something was found that worked. The demands placed on
patients by health care providers were similar to that found by Wiener
 in a study of participants who described the uncertainty they had to
contend with in relation to the pain associated with rheumatoid arthritis.
The adults in Wiener’s study faced the demands in managing their life
with an incurable chronic disease associated with unpredictable pain
and were often told by physicians that “You’re going to have to learn to
live with it” (p. 98). The need of improved information, empathy and
guidance by health care providers to manage pain as acknowledged by
the older adults in this study is similar to findings in a study among
adults 40 to 65 years by Dewar et al. .
|The management of pain was not satisfactory for the older adults
in this study. This experience might be associated with research
where long-term pain among community dwelling older adults is
found to be frequently unrecognized, underestimated, underreported
and undertreated  which might lead to older adults` suffering in
silence [52,53]. The older adults in the study had to endure continuous
and fluctuating pain daily and had concerns about their pain and its
relief now and in the future. It seemed that the health care providers
recognized the lack of satisfying pain relief but were not able to provide
any more help. Patients reported that they did talk to their health care
providers about their concerns and that they felt they could take the
pain anymore and needed help. In turn, the health care providers
tried to encourage the patients by saying that “they could do it” and
that they needed to be satisfied with the help they had received. The
older adults in this study had a feeling of being on their own while
learning to endure pain in daily living. This experience contradicts the
prevailing centrality in nursing to help individuals live in their context
and the existing guidelines for management of long-term pain among
older adults aimed at preserving the older adult’s dignity, function and
overall quality in life [54-57]. It can be assumed that the experienced
lack of pain management and support might be associated with the
tendency documented in the literature where pain is expected as an
inevitable and natural part of aging . Thus, this notion has been
refuted in the literature . However, the opinion of this type of pain
as a natural part in the process of aging was prevailing among the older
adults in this study. From their experiences one might assume that the
healthcare providers involved tended to assume the same.
|The difficulty for older adults living with musculoskeletal pain, to
achieve adequate pain relief has also been acknowledged by Von Korff
. Yu et al.  addressed the limited literature about the strategies
used by community dwelling older adults to relief long-term pain. The authors argued that nurses need to acknowledge this problem
and provide older adults with guidance about strategies for effective
pain relief. This was clearly the case for the older adults in this study.
They acknowledged the need of improved information, empathy and
guidance by health care providers to manage pain in daily living based
on each individual’s experience. However, this need can be understood
as not being dependent of age since it is similar to findings in a study
among adults 40 to 65 years, by Dewar et al. . Furthermore, Von
Korff  highlighted the need for health care providers to tailor the
pain care and promote self-management based on each individuals’
experience to improve quality of life. Spiers  emphasized that a
central role for nurses in the management of the older adult’s pain is
to listen, communicate and respond to the expression of pain with a
specific focus on the experience in each individual’s current situation.
|However, there is a well-known existence of stoic attitudes among
older adults result in a reticence to report pain [58,62,63]. This stoic
attitude may in part explain why older adults used self talk, where they
discussed, argued and negotiated with self and their environment to get
themselves to do what they felt they needed and their effort to be less of
a burden to family and others. The reluctance to complain about pain
and not disturb others has been recognized in other studies [64,65]. In
addition, findings from research studies have shown that older adults
want to spare and not upset their relatives , nor involve or burden
their families with their health care needs . Not being a burden
can also be viewed in light of Wagstaff and Rowledge’s  concept
of stoicism which includes three measurable characteristics: “lacking
of emotional control or endurance”, “lacking in emotional expression”
and “exercising emotional control or endurance” (p. 181). The force to
not complain, disturb or be a burden to family and others was strong
among the older adults in this study. The reluctance to talk about their
pain can be understood in light of findings in the studies above. The
purposeful act of pretending to not be in pain can be understood as
novel in the older adult’s endurance of pain. This conscious action
to give a false impression about the experience of pain has not been
recognized by the authors in earlier studies.
|It may be that the older adults in this study were to various degrees
stoic while learning to endure pain in daily living. However, reasons
behind this stoicism may not only be intrapersonal. It might also be
influenced by external factors, such as expectations embedded in
ongoing interaction and negotiation with others and the environment.
In fact, the stoicism might be an effort by older adults to prevent
becoming distanced from others. From the perspective of the negotiated
order , older adults live within a mutual negotiated order which
most often is implicit and involves tacit agreements or understandings.
In this study, the families and health care providers had implicit and
explicit expectations and demands that the older adult tried their best
to fulfill in order not to be a burden and become distanced. Language is
way to convey these expectations. Clearly, there is a need for health care
providers to reflect upon the language used in their conversations with
older adults. Language that might be intended to support can in fact be
a source that creates isolation and adds to the sense of being a burden.
|The importance of support and guidance over time based on the
individual’s context has been highlighted by Berglund and Källerwald
. Such guidance was seen as a prerequisite in the process of learning
to live with long-term illness involving both coping and conscious
reflection in everyday life. This aligns with Kim’s  emphasis on
nursing practice that “encompasses both the scientific problem-solving
orientation and the human practice orientation. Nurses are not only
dealing with and seeking solutions for clients’ health problems but also are concerned about how to help clients in their “living with” certain
health-related situations  (p.2). Kim [69,70] introduced the concept
of human living which encompasses the environment, interactions and
phenomena in the client’s life and argued that helping and supporting
individuals in finding ways to live their lives while dealing with a health
problem and within the health care system is central to nursing practice.
|Furthermore, nurses need to take into account that these older
adults, to varying degrees, live in a negotiated reality where they are
used to making agreements. Nurses need to take time and be there with
the older adult in the home and make collaborative decisions, even if
this includes some negotiation [61,71].
|The older adults tried to maintain the relations and support they
needed and valued from family, friends and health care providers in
order to learn to live with their pain and still remain at home. The older
adults, within the context of a negotiated reality [72,73] tried to focus
on things that gave meaning and strength in life, such as capturing,
enjoying and valuing moments of pleasure. The older adults in this
study had learned that moments of pleasure could be a distraction and
lessen the intensity of pain, similar to that reported in other studies
of individuals with long term pain [74-76] and often espoused as a
noninvasive method of pain control . However, for these adults,
these moments were more than simply a source of distraction. They
kept their spirits up, gave them strength and meaning in life, a finding
unrecognized in the literature on long term pain, although hinted at by Stenström et al. , Tollen et al.  and further described by
Lerdal et al.  in studies of individuals with disabilities and long term
illnesses. It would appear that learning how to endure living with longterm
pain in daily life is not limited solely to gaining knowledge and
skill in using pain management strategies. This is an important, novel
aspect that contributes to the existing literature since traditionally
health care providers have focused on older adults problems and
negatives in life. Sensitivity and an understanding of the things that
bring joy and give strength and meaning in the older adult’s life could
help to address the older adult’s experience and needs while learning to
endure pain in daily living.
|Similar to Lincoln and Guba , Graneheim and Lundman  use
the criteria trustworthiness to secure credibility, dependability and
transferability in their approach to establish what traditionally is called
validity and reliability in the quantitative paradigm. These criteria were
used in this study to secure and enhance the quality of findings in the
|Limitations in this study include the issue of trustworthiness.
The credibility can be questioned since the sample size in this study
was small, even though this is consistent with qualitative research in
general. In addition, the sample was homogenous in large part because
the majority of the participants were native speaking Swedish women
who lived alone in their homes in small to midsize communities.
Unfortunately, it was not possible to shed light over this experience
from an equal gender perspective, even though consistent with the
demography in this population. No member-check was performed;
however it was offered but denied.
|Despite the limitations above trustworthiness was focused on
throughout the study, as consistent with the chosen approach. The
face to face qualitative interviews with momentarily and continuous
confirmation of the participants’ verbal and nonverbal expressions,
gave a thick descriptions of the participants experiences which enhanced the credibility of the study [39,40]. Efforts to further enhance
the credibility were made when the participants were given time
to reflect upon if there was anything they wanted to add before the
interview was ended. Even though denied, each participant was offered
the opportunity to read the transcribed interview.
|Furthermore, the credibility was strengthened through that the
researcher stayed close to the text during the analysis to not lose the
core in the content. It was only those aspects of the text related to the
aim that were sorted out, condensed and abstracted into codes and
themes. The themes answered the research question and the experience
of enduring pain by learning to live with it permeated the five themes
as an underlying meaning, both explicitly and implicitly, which
strengthened the credibility of the themes. Additionally, examples
drawn from the data in each step of the analysis were presented to
enhance credibility. In addition, representative quotes were used to
illuminate the theme and sub-themes to strengthen the credibility of
the findings. Furthermore, the close communication between the first
and second author in the phase of labeling codes and creating themes
and sub-themes strengthened the credibility and dependability of the
|The transferability of the findings in terms of generalization to all
other adults in living under similar circumstances cannot be claimed by
the authors. Although, the obtained rich description of the older adults’
experiences give an understanding of how older adults endure living
with this type of pain in the context of home. Stake  argue that
the potential for qualitative findings to be transferred is determined
by the reader since it depends on how the findings can be related to
the readers’ context, knowledge and earlier experiences. This argument
support that these finding can be useful for health care providers
familiar with this population and context. The findings can be used to
guide the planning and provision of individualized care for older adults
living at home with musculoskeletal long-term pain. These findings can
also be used as a reference point and compared with findings in current
and future studies to confirm and further develop the understanding of
this experience in various contexts.
|The older adults in this study felt there was no other way out but
to endure and felt forced into learning to live with their pain. However,
their primary orientation was not the unpredictable pain itself. Their
primary focus was on learning how to endure daily life with pain and to
coach themselves, with a minimum of guidance, while still remaining
as independent as possible at home. The continuous interaction and
negotiation with self, others and their environment was useful in their
learning and coaching. The force to not complain, disturb or be a
burden was strong and the purposeful pretending to not be in pain can
be understood as novel in this context. Another important and novel
aspect was the older adults’ orientation towards seeking out things they
valued and moments of pleasure in life. This was important and since it
gave them meaning in life and strength to continue.
|The older adults in this study highlighted the lack of support
and guidance in learning how to endure and live daily life with pain.
This calls for increased sensitivity, empathy and willingness in the
interaction with the older adult. The care need to be oriented towards
not only each older adult’s needs in life related to the current health
problem. It also requires an orientation with focus on existential issues
as the older adults’ values and meaning in life. The overall orientation
in providing health care for older adults needs to be aimed at providing
tailored, holistic and individualized health care that preserves and promotes health and well-being with a maximum of care and a
minimum of intrusion.
|Implications for Research
|Further research is needed to bridge the gap in the literature
between existing writings that acknowledge the increasing burden of
this type of pain worldwide and the need to focus on how older adults
endure living with this type of pain in daily life at home. Furthermore,
research is needed to explore and describe the older adults need for
guidance in learning to endure pain in daily living and how that
guidance might be designed or conveyed. In addition, there is a need to
further explore the older adult’s seeking out moments of pleasure and
meaning in life.
|Thanks go to Professor Hesook Suzie Kim who, together with the late Professor
Björn Sjöström initiated the Joint PhD Program in Nursing between University of
Skövde, Sweden and The University of Rhode Island, USA. Acknowledgments
to the Skaraborg Institute for Research and Development and the School of Life
Sciences, University of Skövde, Sweden for grants and support. Thanks also go to
the older adults in the study.
- Soldato M, Liperoti R, Landi F, Finne-Sovery H, Carpenter I, et al. (2007) Non malignant daily pain and risk of disability among older adults in home care in Europe. Pain 129: 304-310.
- Tsang A, Von Korff M, Lee S, Alonso J, Karam E, et al. (2008) Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain 9: 883-891.
- Fors S, Lennartsson C, Lundberg O (2008) Health inequalities among older adults in Sweden 1991-2002. Eur J Public Health 18: 138-143.
- Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81: 646-656.
- Brooks P (2005) Issues with chronic musculoskeletal pain. Rheumatology (Oxford) 44: 831-833.
- Lihavainen K, Sipilä S, Rantanen T, Sihvonen S, Sulkava R, et al. (2010) Contribution of musculoskeletal pain to postural balance in community-dwelling people aged 75 years and older. J Gerontol A Biol Sci Med Sci 65: 990-996.
- Bergman S, Herrström P, Högström K, Petersson IF, Svensson B, et al. (2001) Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. J Rheumatol 28: 1369-1377.
- Grimby C, Fastbom J, Forsell Y, Thorslund M, Claesson CB, et al. (1999) Musculoskeletal pain and analgesic therapy in a very old population. Arch Gerontol Geriatr 29: 29-43.
- Woo J, Leung J, Lau E (2009) Prevalence and correlates of musculoskeletal pain in Chinese elderly and the impact on 4-year physical function and quality of life. Public Health 123: 549-556.
- Podichetty VK, Mazanec DJ, Biscup RS (2003) Chronic non-malignant musculoskeletal pain in older adults: clinical issues and opioid intervention. Postgrad Med J 79: 627-633.
- Loeser RF (2010) Age-related changes in the musculoskeletal system and the development of osteoarthritis. Clin Geriatr Med 26: 371-386.
- Gorevic PD (2004) Osteoarthritis. A review of musculoskeletal aging and treatment issues in geriatric patients. Geriatrics 59: 28-32.
- Von Korff M (2013) Tailoring chronic pain care by brief assessment of impact and prognosis: comment on "Point-of-care prognosis for common musculoskeletal pain in older adults". JAMA Intern Med 173: 1126-1127.
- Maxwell CJ, Dalby DM, Slater M, Patten SB, Hogan DB, et al. (2008) The prevalence and management of current daily pain among older home care clients. Pain 138: 208-216.
- Thiem U, Lamsfuß R, Günther S, Schumacher J, Bäker C, et al. (2013) Prevalence of self-reported pain, joint complaints and knee or hip complaints in adults aged â‰¥ 40 years: a cross-sectional survey in Herne, Germany. PLoS One 8: e60753.
- Stubbs B, Binnekade TT, Soundy A, Schofield P, Huijnen IP, et al. (2013) Are older adults with chronic musculoskeletal pain less active than older adults without pain? A systematic review and meta-analysis. Pain Med 14: 1316-1331.
- Buchman AS, Shah RC, Leurgans SE, Boyle PA, Wilson RS, et al. (2010) Musculoskeletal pain and incident disability in community-dwelling older adults. Arthritis Care Res (Hoboken) 62: 1287-1293.
- Leveille SG, Bean J, Ngo L, McMullen W, Guralnik JM (2007) The pathway from musculoskeletal pain to mobility difficulty in older disabled women. Pain 128: 69-77.
- Vogt MT, Simonsick EM, Harris TB, Nevitt MC, Kang JD, et al. (2003) Neck and shoulder pain in 70- to 79-year-old men and women: findings from the Health, Aging and Body Composition Study. Spine J 3: 435-441.
- Leveille SG, Ling S, Hochberg MC, Resnick HE, Bandeen-Roche KJ, et al. (2001) Widespread musculoskeletal pain and the progression of disability in older disabled women. Ann Intern Med 135: 1038-1046.
- Leveille SG, Fried L, Guralnik JM (2002) Disabling symptoms: what do older women report?. J Gen Intern Med 17: 766-773.
- Shah RC, Buchman AS, Boyle PA, Leurgans SE, Wilson RS, et al. (2011) Musculoskeletal pain is associated with incident mobility disability in community-dwelling elders. J Gerontol A Biol Sci Med Sci 66: 82-88.
- Dziedzic K, Thomas E, Hill S, Wilkie R, Peat G, et al. (2007) The impact of musculoskeletal hand problems in older adults: findings from the North Staffordshire Osteoarthritis Project (NorStOP). Rheumatology (Oxford) 46: 963-967.
- Chen Q, Hayman LL, Shmerling RH, Bean JF, Leveille SG (2011) Characteristics of chronic pain associated with sleep difficulty in older adults: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. J Am Geriatr Soc 59: 1385-1392.
- Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, et al. (2009) Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 302: 2214-2221.
- Leveille SG, Bean J, Bandeen-Roche K, Jones R, Hochberg M, et al. (2002) Musculoskeletal pain and risk for falls in older disabled women living in the community. J Am Geriatr Soc 50: 671-678.
- Reid MC, Williams CS, Gill TM (2003) The relationship between psychological factors and disabling musculoskeletal pain in community-dwelling older persons. J Am Geriatr Soc 51: 1092-1098.
- Nickel M.K, Lahmann C, Muehlbacher M, Nickel C, Pedrosa Gil F, et al. (2006) Change in instrumental activities of daily living disability in female senior patients with musculosceletal pain: A prospective, randomized, controlled trial. Arch Gerontol Geriatr 4: 247-255.
- Taylor W (2005) Musculoskeletal pain in the adult New Zealand population: prevalence and impact. N Z Med J 118: U1629.
- Tüzün EH (2007) Quality of life in chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 21: 567-579.
- Falsarella GR, Coimbra IB, Neri AL, Barcelos CC, Costallat LT, et al. (2012) Impact of rheumatic diseases and chronic joint symptoms on quality of life in the elderly. Arch Gerontol Geriatr 54: e77-82.
- Sofaer B, Moore AP, Holloway I, Lamberty JM, Thorp TA, et al. (2005) Chronic pain as perceived by older people: a qualitative study. Age Ageing 34: 462-466.
- Seomun GA, Chang SO, Lee PS, Lee SJ, Shin HJ (2006) Concept analysis of coping with arthritic pain by South Korean older adults: development of a hybrid model. Nurs Health Sci 8: 10-19.
- Blomqvist K, Edberg AK (2002) Living with persistent pain: experiences of older people receiving home care. J Adv Nurs 40: 297-306.
- Helme RD, Gibson SJ (2001) The epidemiology of pain in elderly people. Clin Geriatr Med 17: 417-431.
- Miaskowski C (2000) The impact of age on a patient's perception of pain and ways it can be managed. Pain Manag Nurs 1: 2-7.
- Gartrell M (2005) Expression and description of chronic pain by older people. Australas J Ageing 24: 33-37.
- Gillsjö C, Schwartz-Barcott D, Bergh I, Dahlgren LO, (2012) Older Adults’ Ways of Dealing With Daily Life While Living With Long-Term Musculoskeletal Pain at Home. J Appl Gerontol 31: 685-705.
- Kvale S (1983) The qualitative research in terview: A phenomenological anda hermeneutical mode of understanding. J Phenomenol Psychol 14: 171- 196.
- Kvale S (1997) Den kvalitativa forskningsintervjun [The qualitative research interview] Lund: Studentlitteratur.
- Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24: 105-112.
- Krippendorff K (2004) Content analysis: An introduction to its methodology. (2ndedn). Thousand Oaks: Sage Publications, Inc.
- Stemler S (2001) An overview of content analysis. Practical Assessment, Research & Evaluation 7: 12-27.
- Harkness EF, Macfarlane GJ, Silman AJ, McBeth J (2005) Is musculoskeletal pain more common now than 40 years ago?: Two population-based cross-sectional studies. Rheumatology (Oxford) 44: 890-895.
- Mallen CD, Peat G (2008) Screening older people with musculoskeletal pain for depressive symptoms in primary care. Br J Gen Pract 58: 688-693.
- Victorino C, Maxwell C, Hogan D, (2003) The prevalence and pharmacological management of pain among older home care clients. Stride 4-19.
- Berglund M (2011) Att ta rodret i sitt liv: Lärande utmaningar vid långvarig sjukdom [Taking charge of one´s life: Challenges for learning in long-term illness], No 47/2011, in Institutionen för hälso- och vårdvetenskap. Linnéuniversitet: Växsjö, Kalmar.
- Fagerhaugh SY, Strauss AL, (1977) Politics of pain management: Staffpatient interaction. Menlo Park, California: Addison-Wesley Publishing Co., Health sciences division.
- Wiener CL (1975) The burden of rheumatoid arthritis: tolerating the uncertainty. Soc Sci Med 9: 97-104.
- Lipworth WL, Hooker C, Carter SM (2011) Balance, balancing, and health. Qual Health Res 21: 714-725.
- Dewar AL, Gregg K, White MI, Lander J (2009) Navigating the health care system: perceptions of patients with chronic pain. Chronic Dis Can 29: 162-168.
- Cairncross L, Magee H, Askham J (2007) A hidden problem: Pain in older people Picker Institute Europe: Oxford.
- Gran SV, Festvåg LS, Landmark BT (2010) 'Alone with my pain-it can't be explained, it has to be experienced'. A Norwegian in-depth interview study of pain in nursing home residents. Int J Older People Nurs 5: 25-33.
- Gloth FM 3rd (2011) Pharmacological management of persistent pain in older persons: focus on opioids and nonopioids. J Pain 12: S14-20.
- Gloth FM 3rd (2000) Geriatric pain. Factors that limit pain relief and increase complications. Geriatrics 55: 46-48, 51-4.
- Gloth FM 3rd (2001) Pain management in older adults: prevention and treatment. J Am Geriatr Soc 49: 188-199.
- AGS Panel on Persistent Pain in Older Persons (2002) The management of persistent pain in older persons. J Am Geriatr Soc 50: S205-224.
- Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, et al. (2013) Guidance on the management of pain in older people. Age Ageing 42 Suppl 1: i1-57.
- Thielke SM, Whitson H, Diehr P, O'Hare A, Kearney PM, et al. (2012) Persistence and remission of musculoskeletal pain in community-dwelling older adults: results from the cardiovascular health study. J Am Geriatr Soc 60: 1393-1400.
- Yu HY, Tang FI, Yeh MC, Kuo BI, Yu S (2011) Use, perceived effectiveness, and gender differences of pain relief strategies among the community-dwelling elderly in Taiwan. Pain Manag Nurs 12: 41-49.
- Spiers J (2006) Expressing and responding to pain and stoicism in home-care nurse-patient interactions. Scand J Caring Sci 20: 293-301.
- Yong HH (2006) Can attitudes of stoicism and cautiousness explain observed age-related variation in levels of self-rated pain, mood disturbance and functional interference in chronic pain patients? Eur J Pain 10: 399-407.
- Yong HH, Gibson SJ, Horne DJ, Helme RD (2001) Development of a pain attitudes questionnaire to assess stoicism and cautiousness for possible age differences. J Gerontol B Psychol Sci Soc Sci 56: P279-284.
- Bruckenthal P, D'Arcy YM, (2007) Assessment and management of pain in older adults: A review of the basics. Topics in advanced practice nursing ejournal 7.
- Cahill E, Lewis LM, Barg FK, Bogner HR (2009) "You don't want to burden them": older adults' views on family involvement in care. J Fam Nurs 15: 295-317.
- Wagstaff GF, Rowledge AM (1995) Stoicism: its relation to gender, attitudes toward poverty, and reactions to emotive material. J Soc Psychol 135: 181-184.
- Strauss A (1978) Negotiations: Varieties, contexts, processes, and social order. (1stedn). San Francisco: Jossey-Bass Publishers.
- Berglund M, Källerwald S (2012) The Movement to a New Understanding: A Life- World-Based Study about How People Learn to Live with Long-Term Illness. J Nurs Care 1:25.
- Kim HS (2000) The nature of theoretical thinking in nursing. (2ndedn). New York: Springer.
- Kim HS (2000) An integrative framework for conceptualizing clients: a proposal for a nursing perspective in the new century. Nurs Sci Q 13: 37-40.
- Kim HS (1983) Collaborative decision making in nursing practice: A theoretical framework, in Advances in nursing theory development, P.L. Chinn, M. Anderson, Editors. Aspen systems corporation: Rockville.
- Ley D (1981) Behavioral geography and the philosophies of meaning, in Behavioral problems in geography revisited, K.R. Cox, R.G. Golledge, Editors. Methuen: New York.
- Gesler WM (1992) Therapeutic landscapes: medical issues in light of the new cultural geography. Soc Sci Med 34: 735-746.
- Ross MM, Carswell A, Hing M, Hollingworth G, Dalziel WB (2001) Seniors' decision making about pain management. J Adv Nurs 35: 442-451.
- Ong BN, Jinks C, Morden A (2011) The hard work of self-management: Living with chronic knee pain. Int J Qual Stud Health Well-being 6.
- Eccleston C, Crombez G (1999) Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol Bull 125: 356-366.
- Jeffrey JE, Lubkin IM (2009) Chronic Pain, in Chronic illness: Impact and intervention, Jones and Bartlett Publishers: Sudbury, Mass.
- Stenström CH, Bergman B, Dahlgren LO (1993) Everyday life with rheumatoid arthritis: A phenomenographic study. Physiother Theory Pract 9: 235-243.
- Tollén A, Fredriksson C, Kamwendo K (2008) Elderly persons with disabilities in Sweden: their experiences of everyday life. Occup Ther Int 15: 133-149.
- Lerdal A, Schwartz-Barcott D, Borg M (2010) The Experience and meaning of time among individuals with long-term health problems. Klin Sygepleje, 24: 16-25.
- Lincoln YS, Guba EG (1985) Naturalistic inquiry. Beverly Hills, Calif, Sage.
- Stake RE (2005) Qualitative case studies, in Hanbook of qualitative research, Thousand Oaks Sage: California.