The role of purpose in life in recovery from knee surgery

Abstract

This study examined the role of a sense of purpose in life (PIL) in recovery from knee replacement surgery in 64 surgery patients. Each of the surgery patients had been diagnosed with severe osteoarthritis of the knee. Regression analyses were conducted predicting changes in health 6 months after surgery. When considered alone, PIL was related to less anxiety, depression, negative affect, functional disability, stiffness, and more positive affect. When optimism, pessimism, and emotionality were controlled, PIL was still related to less negative affect, depression, and anxiety, and more positive affect. The results suggest that PIL may be an important positive personal characteristic and target for interventions.

Full text

The Role of Purpose in Life in Recovery from Knee Surgery
Bruce W. Smith and Alex J. Zautra
This study examined the role of a sense of purpose in life (PIL) in recovery from knee
replacement surgery in 64 surgery patients. Each of the surgery patients had been di-
agnosed with severe osteoarthritis of the knee. Regression analyses were conducted
predicting changes in health 6 months after surgery. When considered alone, PIL was
related to less anxiety, depression, negative affect, functional disability, stiffness, and
more positive affect. When optimism, pessimism, and emotionality were controlled,
PIL was still related to less negative affect, depression, and anxiety, and more positive
affect. The results suggest that PIL may be an important positive personal character-
istic and target for interventions.
Key words: purpose in life, knee surgery, osteoarthritis.
The examination of the effects of positive personal
characteristics on health has received increasing atten-
tion. Seligman (1999) has emphasized psychology’s
role in identifying these positive qualities and building
them through interventions. Several studies have ex-
amined the role of dispositional optimism and found
that it is often related to better mental or physical
health (Andersson, 1997). Other researchers have be-
gun to examine pathways by which positive affect may
improve coping with stress and enhance health
(Aspinwall, 1998; Fredrickson, 1998).
One of the positive characteristics that is frequently
mentioned but has received less attention than charac-
teristics such as optimism is a sense of meaning and
purpose in life. Viktor Frankl (1992) believed that a
sense of meaning and purpose was the distinguishing
feature between those who did and did not survive
World War II concentration camps. Wong and Fry
(1998) have asserted that “meaning seeking is a key to
unlocking the mysteries of optimal functioning at the
psychological, behavioral, and physiological levels”
(p. xxv).
Ryff and Singer (1998) have reviewed the philo-
sophical and psychological literature regarding mean-
ing and purpose in life. They tied it to research on sense
of coherence (Antonovsky, 1987) and personal mean-
ing (Baumeister, 1991). Ryff and Keyes (1995, p.720)
have defined a sense of purpose in life simply as “the
belief that one’s life is purposeful and meaningful.” In-
dividuals possessing a sense of purpose in life have
goals in living, a sense that their lives have a direction,
and beliefs that give their lives a sense of meaning.
Scheier and Carver (2001) provided a conceptual
framework for understanding the significance of a
sense of purpose in life. They believe that both a sense
of purpose in life (PIL) and positive outcome expectan-
cies (POE; e.g., hope and optimism) are essential for
attaining valued goals. First, an individual must iden-
tify a goal or set of goals that are valued and worthy of
being sought. Valued goals provide the purpose in liv-
ing. Second, an individual must believe that it is possi-
ble to attain one’s valued goals and find a measure of
fulfillment in their sense of purpose in living. The hope
of attaining one’s goals enables one to stay engaged in
trying to attain them.
Within this framework, it is not difficult to see how
both PIL and POE may play important roles for indi-
viduals facing challenges to their health and survival.
The sense of having valued goals (e.g., PIL) can pro-
vide the motivation for maintaining mental and physi-
cal health in the midst of adversity. The sense of being
able to attain valued goals (e.g., POE) makes it possi-
ble to stay engaged and committed to reaching these
goals.
Despite the potential value of both PIL and POE,
surprisingly few studies have examined PIL or both
PIL and POE together. In addition, the few studies that
have included measures of PIL have examined only
cross-sectional relationships and only in relation to
mental health. In these studies, PIL has been related to
less neuroticism, negative affect, and depression and
more positive affect and life satisfaction (Addad, 1987;
Baum & Boxley, 1983; Ryff & Keyes, 1995). However,
PIL may be more a result than a cause of good mental
health, may be associated with it because of third vari-
International Journal of Behavioral Medicine
2004, Vol. 11, No. 4, 197–202
Copyright © 2004 by
Lawrence Erlbaum Associates, Inc.
197
Bruce W. Smith, Department of Psychology, University of New
Mexico Albuquerque,New Mexico, USA; Alex J. Zautra, Department
of Psychology, Arizona State University, Tempe, Arizona, USA.
This research was supported by biomedical grants from the Ar-
thritis Foundation, and the National Institute for Arthritis and Mus-
cular-Skeletal Diseases, 5 RO1 AAR41687-03 (Alex J. Zautra, Prin-
cipal Investigator).
Correspondence concerning this article should be addressed to
Bruce W. Smith, Department of Psychology, University of New
Mexico, Albuquerque, NM 87131. E-mail: XXXXX@XXXX.com

ables, or may merely indicate the absence of
neuroticism.
The primary purpose of this study was to examine
PIL as a prospective predictor of health in the context
of a stressor in which PIL might play an important role
and where POE was also assessed. Both positive and
negative outcome expectancies were assessed because
of evidence of their independence (Chang,
Maydeu-Olivares, & D’Zurilla, 1997). Participants
were older adults who had severe osteoarthritis of the
knee and elected to have total replacement surgery
(TKR). Osteoarthritis is the most common form of ar-
thritis and joint replacement is a frequent alternative
for individuals with severe cases (Callahan, Drake,
Heck, & Dittus, 1994).
TKR was chosen because (a) it involves the common
expectation of improvement in physical health and (b)
the attainment and enjoyment of this health may depend
on having a sense of purpose in living. Because TKR al-
ready provides a basis for hope that improvement in
physical health can occur, PIL might be expectedto play
a critical role in providing the desire and motivation for
recovery and living a more satisfying life.
Emotional arousability was also assessed because it
is a central feature of neuroticism (Braithwaite, 1987)
and neuroticism has frequently been related to health
and symptom reports (Watson & Pennebaker, 1989).
Past studies have sometimes found that the relationship
between positive personal characteristics and health
disappears when neuroticism is controlled (Hart,
Hittner, & Paras, 1991; Smith, Pope, Rhodewalt, &
Poulton, 1989). Therefore, emotional arousability was
controlled to rule out the possibility that negative
affectivity might account for any relationship found
between PIL and health.
Changes in mental and physical health were exam-
ined as indicators of recovery. Mental health measures
included indicators of both psychological distress
(e.g., negative affect, anxiety symptoms, depressive
symptoms) and psychological well-being (e.g., posi-
tive affect). Physical health measures included were
those that are specifically relevant to individuals with
osteoarthritis on the knee (e.g., functional disability,
pain, stiffness).
The primary question addressed by this study was
whether PIL would predict recovery in the surgery
group, both alone and when controlling for outcome
expectancies and emotional arousability. It was ex-
pected that PIL would be related to improved health
because it may provide the incentive to recover and live
a satisfying life. PIL might be important beyond out-
come expectancies because it is important to actually
have valued goals as well as the belief that one can
reach them. Finally, it was expected that PIL would be
important beyond neuroticism because PIL is not just
the lack of negative affectivity but involves the belief
that there is a reason to live.
Methods
Participants
The sample consisted of 64 older adults who had se-
vere osteoarthritis of the knee and elected to have total
knee replacement surgery (TKR). Originally, there
were 72 participants, but 8 left the study for various
reasons (postponed surgery = 3; request to be discon-
tinued from the study = 3; out-of-state move = 1;
change to a nonparticipating surgeon = 1). The sample
was 52% women and the mean age was 67.2 (SD =
8.3). The mean level of education was 1 to 3 years of
college and 79% were married. The majority was
White (95%) and not employed (77%).
Procedure
Nurses in rheumatologists’ offices recruited pa-
tients who had been diagnosed with osteoarthritis and
referred for TKR. Participants completed question-
naires at two points in time: 2 weeks prior to surgery
(T1) and 6 months after surgery (T2). The question-
naires at T1 included measures of PIL, other personal
characteristics, and of mental and physical health.
The questionnaires at T2 included the measures of
mental and physical health that had been adminis-
tered at T1.
Measures
Purpose in life. Purpose in life (PIL) was as-
sessed at T1 using a 14-item scale developed to mea-
sure the belief that one’s life is purposeful and mean-
ingful (Ryff & Keyes, 1995). The scale consists of
items such as “I have a sense of direction and purpose
in my life” and “I enjoy making plans for the future
and working to make them a reality.” Cronbach’s α
was .83.
Optimism and pessimism. Optimism and pessi-
mism were assessed at T1 using the Life Orientation
Test–Revised (LOT–R; Scheier, Carver, & Bridges,
1994). The LOT–R includes 3 items measuring opti-
mism and 3 items measuring pessimism. Cronbach’s α
was .70 for optimism and .75 for pessimism.
Emotionality. Emotionality was assessed at T1
using the general emotionality subscale of the Scale
of Emotional Arousability (Braithwaite, 1987). The
emotionality subscale was designed to tap the emo-
tionally labile facet of neuroticism. The items assess
the tendency to experience negative affect (e.g., “I
frequently get upset”). It consists of 6 items and
Cronbach’s αwas .75.
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SMITH AND ZAUTRA

Positive and negative affect. Positive and nega-
tive affect were measured at T1 and T2 with the Posi-
tive and Negative Affect Schedule (Watson, Clark, &
Tellegen, 1988). It consists of 10 positive affect items
and 10 negative affect items. Cronbach’s αwas .88 for
positive affect and .89 for negative affect.
Mental health inventory. Anxiety and depres-
sive symptoms were assessed at T1 and T2 using the
Mental Health Inventory (Veit & Ware, 1983). The
anxiety subscale consists of 10 items and the depres-
sion subscale consists of 9 items. Cronbach’s αwas .90
for anxiety and .90 for depression.
Western Ontario and McMaster University
Osteoarthritis Index (WOMAC). Functional dis-
ability, pain, and stiffness due to osteoarthritis of the
knee was assessed at T1 and T2 by the WOMAC
(Bellamy, Buchanan, Goldsmith, Campbell, & Stitt,
1988). The WOMAC includes 17 items for functioning
disability, 5 items for pain, and 2 items for stiffness.
Cronbach’s αwas .96 for functional disability, .88 for
pain, and .81 for stiffness.
Results
Table 1 displays the means and standard devia-
tions for the personal characteristics and the health
measures before surgery (T1) and at 6 months follow-
ing surgery (T2). Paired samples ttests were con-
ducted to compare the health measures at T1 and T2.
There was a significant decrease in functional disabil-
ity, t(63) = –10.26, p< .001; stiffness, t(63) = –8.12,
p< .001; pain, t(63) = –11.44, p< .001; and negative
affect, t(63) = –3.74, p< .001; and an increase in pos-
itive affect, t(63) = 3.45, p< .01.
Table 2 displays the correlations between the per-
sonal characteristics and health measures at T1. PIL
was positively related to optimism and negatively re-
lated to pessimism and emotionality. As for the health
measures, PIL was significantly related (ps < .05) to
more positive affect and less anxiety, depression, and
negative affect. Although the correlations between PIL
and these mental health measures were substantial,
r(62) = .317–.585, they were not strong enough to sug-
gest multicollinearity problems (Tabachnick & Fidell,
1996).
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PURPOSE IN LIFE AND KNEE SURGERY
Table 1. Means and Standard Deviations of Personal Characteristics and Health Measures at Baseline and 6 Months
Baseline 6 Months
MSDMSDScale Range
Purpose in life 5.09 .67 — — 1–6
Optimism 3.11 .62 — — 0–4
Pessimism .86 .80 — — 0–4
Emotionality 2.70 .79 — — 1–5
Anxiety 2.26 .84 2.12 .83 1–6
Depression 1.70 .74 1.74 .89 1–6
Negative affect 1.91 .76 1.59 .78 1–5
Positive affect 3.22 .74 3.55 .89 1–5
Functional disability 2.19 .63 1.12 .77 0–4
Pain 2.15 .67 .87 .75 0–4
Stiffness 2.40 .93 1.39 .86 0–4
Note. N = 64.
Table 2. Correlations Between Personal Characteristics and Baseline Health Measures at Baseline
1234567891011
1. Purpose in life —
2. Optimism .437*** —
3. Pessimism –.585*** –.382*** —
4. Emotionality –.300** –.306** .311** —
5. Anxiety –.425*** –.265** .409*** .572*** —
6. Depression –.464*** –.268** .456*** .456*** .796*** —
7. Negative affect –.317** –.162 .212*.392*** .611*** .692*** —
8. Positive affect .379*** .175 –.165 –.222*–.233*–.188 –.240*—
9. Functional disability –.125 –.261** .031 .068 .290** .319** .477*** –.307** —
10. Pain –.081 .108 –.044 .159 .290** .295** .430*** –.312** .790*** —
11. Stiffness –.060 .176 –.040 .107 .151 .234*.343*** –.274** .638*** .580*** —
Note. N = 64.
*p< .10. **p< .05. ***p< .01.

Table 3 displays the partial correlations between the
personal characteristics and health measures at 6
months partialling out the corresponding T1 health
measure. PIL was significantly related to less anxiety,
depression, negative affect, functional disability, stiff-
ness, and more positive affect at 6 months. Of the other
personal characteristics, pessimism was related to
more negative affect, functional disability, and stiff-
ness, emotionality was related to more anxiety and less
positive affect, and optimism was related to less nega-
tive affect.
The hypotheses regarding the relationship between
PIL and improvements in mental and physical health
were tested using regression analyses predicting the
T2 health outcomes controlling for the corresponding
T1 outcomes. For each analysis, PIL was first entered
as the sole predictor and then entered with optimism,
pessimism, and emotionality. In addition, sex and ed-
ucation level were controlled because they were the
demographic variables that were related to the per-
sonal characteristics or health measures. Women re-
ported more positive affect, r(31) = .299, p< .05;
functional disability, r(31) = .416, p< .01; pain, r(31)
= .315, p< .05; and stiffness, r(31) = .388, p< .01.
Education was related to less functional disability,
r(62) = –.269, p< .01; and pain, r(62) = –.367, p<
.01. Age was not related to the personality character-
istics or health measures.
Table 4 displays the results for the regression analy-
ses for the mental health outcomes. When entered
alone, PIL was related to an increase in positive affect
and a decrease in anxiety, depression, and negative af-
fect. When entered with optimism, pessimism, and
emotionality, PIL was still related to an increase in pos-
itive affect and a decrease in anxiety, depression, and
negative affect. Thus, PIL explained a significant vari-
ance beyond the other personal characteristics. The ad-
justed R2for PIL was 2.3% for anxiety, 7.9% for de-
pression, 14.3% for negative affect, and 12.0% for
positive affect.
Table 5 displays the results for the regression analy-
ses for the physical health outcomes. When entered
alone, PIL was related to a decrease in functional dis-
ability and a decrease in stiffness. However, when en-
tered with optimism, pessimism, and emotionality, PIL
was no longer related to any of the physical health out-
comes. Thus, PIL did not make a contribution to physi-
cal health beyond the other personal characteristics. In-
deed, when considered together, none of the personal
characteristics were related to any of the physical
health measures.
Finally, because the optimism and pessimism mea-
sures were originally designed to be a part of the
same scale, the analyses using optimism and pessi-
mism were repeated substituting the combined scores
of the two scales combined into one score (pessimism
items were coded negatively). The results showed
that there were no differences in whether PIL was a
significant predictor of outcomes or in the direction
of the predictions.
200
SMITH AND ZAUTRA
Table 3. Partial Correlations Between Personal Characteristics and Change in Health Measures
Anxiety Depression Negative Affect Positive Affect Functional Disability Pain Stiffness
Purpose in life –.347*** –.393*** –.627*** .422*** –.288** –.093 –.308**
Optimism –.210*–.112 –.303** .107 –.135 –.021 –.164
Pessimism .235*.137 .463*** –.172 .356*** .155 .289**
Emotionality .334*** .206 .207 –.292** .246*.129 .180
Note. N = 64. The corresponding health measure at T1 was partialled out for each partial correlation coefficient.
*p< .10. **p< .05. ***p< .01.
Table 4. Standardized Beta Weights for Purpose in Life and Other Personal Characteristics Predicting Mental Health
Outcomes at Six Months
Anxiety Depression Negative Affect Positive Affect
βtpβtpβtpβtp
Simple regressiona
Purpose in life –.254 –2.64 .011 –.330 –3.16 .003 –.573 –6.23 < .000 .407 3.64 .001
Multiple regressionb
Optimism –.020 –.21 .838 .050 .49 .630 –.039 –.38 .705 –.096 –.82 .416
Pessimism .027 .25 .806 –.080 –.67 .504 .099 .84 .405 .159 1.19 .239
Emotionality .265 2.40 .020 .165 1.45 .154 .034 .30 .766 –.243 –2.07 .043
Purpose in life –.238 –2.04 .046 –.398 –3.11 .003 –.521 –4.10 < .000 .486 3.37 .001
Note. N = 64. Sex and education level were controlled in all analyses. The corresponding pre-surgery health measure was controlled in all
analyses.
aPurpose in life was the sole predictor. bPurpose in life was entered with optimism, pessimism, and emotionality.

Discussion
The results indicate that PIL played an important
role in recovery for individuals electing to have TKR.
When considered alone, PIL was related to improved
mental and physical health. Even when controlling for
optimism, pessimism, and emotionality, PIL was still
related to improved mental health.
These findings make several contributions to our
understanding of PIL. First, PIL was a prospective pre-
dictor of improvement in mental and physical health
when entered alone and mental health when control-
ling for other personal characteristics. Past studies
have examined the concurrent relationship between
PIL and health or used PIL as a dependent variable
(Addad, 1987; Ryff & Keyes, 1995). This study dem-
onstrates that PIL may be related to positive changes in
health over time.
Second, the effects of PIL on improved mental
health were not accounted for by negative affectivity.
Controlling for emotionality did not completely erase
the effects of PIL as they have on occasion with other
negative characteristics (Hart et al., 1991; Smith et al.,
1989). The implication is that PIL is more than just the
absence of negative affectivity. Whereas having a
sense of purpose in living may result in less negative
affect, and vice versa, they are not merely opposite
ends of the same continuum.
Third, the effects of PIL on all four mental health
outcomes held when controlling for both optimism and
pessimism. PIL appears to represent a unique positive
personal feature and plays an important role beyond
that of outcome expectancies. While POE may be nec-
essary to be engaged in one’s valued goals, there may
first have to be the sense that one has valued goals and a
purpose for living. TKR may have provided hope and
the expectation for improved physical functioning.
However, the opportunity for improved functioning
may not have resulted in improved emotional health
unless there was a sense of purpose in life to help moti-
vate recovery.
Future research may do well to examine the role of
both PIL and POE to learn more about how they may
complement each other and when one may be more im-
portant than the other. It appears that the recent empha-
sis on positive personal characteristics needs to encom-
pass both the ability to identify value goals (e.g.,
finding a purpose in life) and the belief that these goals
can be reached. It is possible that while modern behav-
ioral science has concentrated on engendering hope,
confidence, and optimism as a means, it has neglected
the need to first identify and foster valued goals as an
end.
This study has several limitations. First, it was
based on a relatively small sample. Thus, this should be
considered a preliminary study requiring replication
with a larger sample. Second, the mental and physical
health measures were self-report and not obtained
through interviews or clinician assessments. Third, it
would have been useful to acquire more information
about differences in the surgery procedure between
participants and on compliance to recovery regimens.
Each of these could have also helped to account for dif-
ferences in health outcomes. Examining compliance
could be particularly instructive because it may be a
partial mediator of the beneficial effects of PIL.
Despite these limitations, this study strongly sug-
gested that PIL is an important positive personal char-
acteristic and that it has implications for individuals
facing challenges that present opportunities for better
health. While some positive characteristics may be dif-
ficult to alter, there is evidence that interventions can
increase PIL. For example, logotherapy was developed
by Frankl (1992) and has been shown to increase the
sense of meaning and purpose in living. The findings
of this study suggest that interventions that enhance
PIL may help individuals successfully meet health
challenges and live a more fulfilling and satisfying life.
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PURPOSE IN LIFE AND KNEE SURGERY
Table 5. Standardized Beta Weights for Purpose in Life and Other Personal Characteristics Predicting Physical Health
Outcomes at Six Months
Functional Pain Stiffness
βtpβtpβtp
Simple regressiona
Purpose in life –.297 –2.42 .018 –.131 –1.02 .310 –.279 –2.33 .023
Multiple regressionb
Optimism .103 .70 .488 .104 .70 .485 .002 .01 .989
Pessimism .254 1.61 .113 .092 .55 .586 .148 .94 .354
Emotionality .196 1.35 .182 .211 1.37 .176 .083 .57 .568
Purpose in life –.118 –.73 .468 –.056 .32 .747 –.166 –1.06 .319
Note.N= 64. Sex and education level were controlled in all analyses. The corresponding pre-surgery health measure was controlled in all
analyses.
aPurpose in life was the sole predictor. bPurpose in life was entered with optimism, pessimism, and emotionality.

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