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Evaluation of a multi-component group exercise program for adults with arthritis: Fitness and Exercise for People with Arthritis (FEPA)
Disability and Health Journal 5 (2012) 305e311 www.disabilityandhealthjnl.com
Brief Report
Evaluation of a multi-component group exercise program for adults with arthritis: Fitness and Exercise for People with Arthritis (FEPA) Susan S. Levy, Ph.D.a,*, Caroline A. Macera, Ph.D., M.P.H.b, Jennifer M. Hootman, Ph.D.c, Karen J. Coleman, Ph.D.d, Ruby Lopezb, Jeanne F. Nichols, Ph.D.a, Simon J. Marshall, Ph.D.e, Barbara A. Ainsworth, Ph.D., M.P.H.f, and Ming Ji, Ph.D.b a
San Diego State University, School of Exercise and Nutritional Sciences, 5500 Campanile Drive, San Diego, CA 92182-7251, USA b San Diego State University, Graduate School of Public Health, San Diego, CA, USA c Centers for Disease Control and Prevention, Division of Adult and Community Health, Atlanta, GA, USA d Kaiser Permanente, Department of Research and Evaluation, Pasadena, CA, USA e University of California, San Diego, Family and Preventive Medicine, San Diego, CA, USA f Arizona State University, College of Nursing and Health Innovation, Mesa, AZ, USA
Abstract Background: Research supports the favorable effects of exercise on physical and psychosocial outcomes in those with arthritis. Few easily disseminated, multi-component, arthritis-specific programs have been evaluated using both physical function and psychosocial measures. Fitness and Exercise for People with Arthritis (FEPA) is a new community-based, 3-month, instructor supervised multicomponent exercise program for individuals with arthritis designed to increase strength, flexibility, balance, and aerobic conditioning, while emphasizing joint-protection and proper biomechanics. Purpose: To conduct a preliminary evaluation of the effects of the FEPA program on physical function and arthritis-related outcomes in individuals with arthritis. Method: Middle-aged (n 5 31, Mage 5 54.8 6 7.2) and older (n 5 79, Mage 5 76.0 6 6.6) adults with arthritis completed the instructor led FEPA program in community senior centers, churches, and adult education settings. Changes in physical function, measured using the arm curl, back-scratch test, 8-foot up-and-go, and 6 min walk and self-reported arthritis-related pain, perceived physical function, affect, and self-efficacy for symptom management were assessed using RM ANOVA. Results: Significant improvements (ps ! .05) in all physical function measures were found in the older group. In the middle-aged group, significant improvements ( ps ! .05) were found in the 8-foot up-and-go and 6 min walk. Self-reported physical function, pain perceptions, and self-efficacy for pain management significantly improved ( ps ! .05) in middle-aged participants, while only selfreported pain perceptions significantly improved in the older group. Conclusions: FEPA shows promise for improving health-related outcomes in those with arthritis, and has potential for sustainability in community settings. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Community programs; Intervention effects; Physical activity; Physical function
‘‘This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) (gs1) Grant Number U36/ CCU300430-23. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.’’ CDC disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Initial study findings were a poster presentation at the Society of Behavioral Medicine Annual Meeting; San Diego, CA, 2008. * Corresponding author. Tel.: þ1 619 594 5672; fax: þ1 619 594 6553. E-mail address: [email protected] (S.S. Levy). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.07.003
Introduction Arthritis is the most common cause of disability in adults living in the U.S.1 Recent estimates indicate that 46.4 million (21.6%) individuals report receiving a doctor diagnosis of arthritis.2 Arthritis impact is underscored at both individual and public health levels. Arthritis is related to reduced quality of life,3 and research indicates that arthritis negatively impacts work productivity through lost time and diminished physical function.4,5 While pharmacological treatment of arthritis is standard, research and clinical evidence support the favorable effects of arthritis-appropriate exercise on
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physical function, pain, quality of life, and arthritis management self-efficacy.6e8 Despite recent U.S. federal guidelines recommending both aerobic (2.5 h per week) and muscle strengthening (2 days per week) exercise for adults with arthritis,9 37% of adults with arthritis are sedentary.10 The two most common approaches to community-based arthritis exercise programs are aquatic and land-based. Aquatic programs, such as the Arthritis Foundation Aquatics Program11 are effective, but may not appeal to all people and widespread dissemination is limited by the availability and expense of pool facilities. The 8-week Arthritis Foundation Exercise Program (AFEP, formerly People with Arthritis Can Exercise, PACE) is the most widely disseminated land-based group arthritis-specific exercise program.12 AFEP focuses on building strength, balance, and flexibility and has been effective in improving physical function, and self-reported performance of activities of daily living.13 However, the program does not focus on aerobic conditioning. Aerobic exercise may be particularly important, as it has shown greater efficacy than resistance exercise in reducing depressive symptom in individuals with arthritis.14 Depression and mood disturbance are commonly reported symptoms in those with arthritis15,16 and are important aspects of quality of life.17 Combining aerobic and muscle strengthening exercises into one program may produce even better outcomes for arthritis patients. Randomized trials of combined aerobic and resistance exercise programs significantly improved physical function, activities of daily living, and reduced in pain in obese individuals with osteoarthritis of the knee6 and in older adults with arthritis.3 Currently there are few multi-component (i.e., aerobic, strengthening, flexibility and balance) arthritis-specific exercise programs that can be feasibly disseminated (e.g., minimal, low-cost equipment/few storage requirements) through community-based and public health agencies with sufficient evidence of effectiveness and infrastructure for dissemination on a large scale.18 To address these gaps, we evaluated the Fitness and Exercise for People with Arthritis (FEPA) program, a new multi-component program that combines aerobic conditioning with upper, lower, and core muscle strengthening, balance, and flexibility exercises, teaching joint-protection strategies through proper biomechanics during exercise.
Methods Participants Participants were an ethnically diverse (Caucasian, 57%, Hispanic, 34%, other 9%) sample of men (n 5 25, 16%) and women (n 5 129, 84%) who volunteered for participation (Mage 5 67.74 years, SD 5 12.95) and met study inclusion criteria of a self-reported doctor diagnosis of arthritis (n 5 110) or self-reported joint pain (n 5 44) within the past three months, age of 18 and older, and the ability to
participate in the exercise program, as measured by the Physical Activity Readiness Questionnaire (PAR-Q19). Participant recruitment was conducted in collaboration with community partners serving constituents most likely to meet study inclusion criteria, or who delivered programs within which the FEPA program could be integrated. All participants completed an informed consent document in accordance with the University Institutional Review Board. Measures A pilot study confirmed the psychometric soundness of all study measures and the quality of data collection procedures, using individuals from a senior center (Mage 5 81.64 years, SD 5 7.55) and a YMCA (Mage 5 56.4 years, SD 5 5.66) who met the main study inclusion criteria. All questionnaires demonstrated acceptable internal consistency reliability (Cronbach alpha coefficients O .74) except the arm function and self-care task subscales of the AIMS2, whose alpha coefficients fell below the generally acceptable .70,20 likely due to the small sample size in the pilot. Test-retest reliability coefficients for the functional fitness measures, examined in the middle-aged group for whom the measures were not originally developed, were deemed acceptable (R 5 .89e.95). Physical performance measures Measures of physical performance were selected based on their appropriateness and their acceptable psychometric characteristics (convergent validity values above 6.70, and test-retest reliability values above .80) in the target population and samples similar to the current study.21 The 8-foot up-and-go assessed mobility, which reflects a combination of lower extremity strength, power, and dynamic balance. The participant starts by sitting in a chair, then stands up without the use of hands, walks 8 feet to and around a cone, and returns to a seated position in the chair. The score is total time to complete the test, using the fastest of two recommended trials. The 6 min Walk Test assessed aerobic endurance. The test is a measure of the distance walked in six minutes, and indicates one’s minimal aerobic endurance to complete common daily activities, such as walking and shopping. The test is well-tolerated by older adults and when compared to other functional walk tests is better related to activities of daily living.22 Number of arm curls performed in 30 s was used to assess arm strength and endurance, important for activities of daily living, such as house and yard work and lifting and carrying. The back-scratch test was used to assess shoulder flexibility. This over the shoulder reach attempting to touch fingers of the opposing arm reaching up behind the back is scored in distance between fingers. The test is considered by orthopedic experts to be the best overall measure of shoulder flexibility.23
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Self-reported arthritis-specific outcomes Self-reported measures of arthritis-specific outcomes were chosen based on their appropriateness and favorable psychometric characteristics (internal consistency and test-retest reliability coefficients above .70) with the target population. Arthritis-specific outcomes were assessed using nine subscales of the Arthritis Impact Measurement Scales 2 (AIMS224), a widely used measure of perceived health status, and health-related quality of life for individuals with arthritis. As recommended, subscales scores were combined to derive a 3-component model of health status comprised of self-reported physical functioning, affect, and pain frequency. The sensitivity of the measure’s components to changes in perceived health has also been demonstrated.25 Arthritis pain intensity was assessed using the Numerical Rating Scale for Pain (NPS). Participants reported their current level of pain on a numbered (0e10) horizontal line, 100 mm in length, with the left end of the line labeled ‘‘no pain’’ and the right end labeled ‘‘worst possible pain.’’ The NPS has shown sensitivity to changes over a 3-month period in individuals with osteoarthritis and rheumatoid arthritis.25 Confidence in managing arthritis-related symptoms was measured using pain and other symptoms subscales of the Arthritis Self-Efficacy Scale (ASE26). Participants indicated the degree to which they felt confident in managing their arthritis-related pain and other symptoms (e.g., fatigue, frustration). Procedures FEPA program FEPA is a 3-month, instructor supervised exercise program for adults with arthritis or joint pain, designed to increase strength, flexibility, balance, and cardiovascular health. Exercises in the program are designed to be lowimpact, safe, and joint-protective, with a focus on teaching proper body mechanics. The program is progressive, based on the exercise training principles of specificity and overload. A minimal amount of durable, low-cost equipment (e.g., dumbbell weights, balance trainers, stability balls) designed to be easily stored, was used. Classes were led by qualified instructors (previous group exercise leadership experience, some training in exercise science or physical therapy) who were trained by study staff and observed periodically to maintain intervention fidelity. Classes were conducted in a variety of community settings, including residential and non-residential senior centers, churches, and adult education centers. Program materials and training are available. Classes met twice weekly, were approximately one-hour in length, and combined a variety of exercises focusing on core strength and balance, flexibility, upper and lower body strength, agility, and aerobic conditioning. Exercises were
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adapted for an individual’s capabilities, and precautions were taken for any movement restrictions (e.g., performed in chair, holding on to chair back). Equipment such as medicine balls, small hand-held weights, and in more advanced classes, stability balls and balance trainers were used. Walking and dance movements were the mainstay of aerobic conditioning exercises. Classes were designed to progressively advance participants in each of the areas of fitness addressed, while being cautious and jointprotective at all times. Data analysis As prior research has identified significant differences in performance of the physical performance measures, with gradient decreases seen by decade,21 data were analyzed separately for those under 65 years of age (n 5 31), and those 65 years and older (n 5 79). This approach was taken, rather than entering age as a covariate, due to the greater number of participants in the older group, and resulting disproportionate effect on the age-adjusted dependent variable values. Repeated measures analyses of variance (RM ANOVA) were conducted in order to examine the effects of the FEPA program on physical function and the self-reported measures of arthritis-specific outcomes. Alpha was set to .05 for all tests of significance. Results Of the 154 participants who began the FEPA program, 110 completed the post-intervention assessment (completers were defined as those attending O50% of classes) and were included in the main data analysis. Among completers, on average attendance was high (Mattendance 5 75.2% classes 6 20.1%). Chi-square tests and independent samples t-tests, where appropriate, revealed no significant differences ( p O 0.05) between completers and non-completers based on self-report of doctor diagnosed arthritis vs. joint pain, or selfreported severity of arthritis pain, or in any of the demographic variables (i.e., sex, ethnicity, marital status, education), except age (dropouts were significantly ( p ! 0.05) younger than completers). When examining the composition of two groups, the dropouts were equally comprised of older (O65 years) adults and middle-aged adults. Descriptive statistics for completers and non-completers are found in Table 1. Physical performance measures Means, standard deviations, and 95% CID for all functional fitness measures are found in Table 2. Based on age-adjusted normative scores for older adults,27 at baseline, participants fell just below the 50% percentile on physical function measures. Mobility, as measured by the 8-ft up-and-go, significantly improved in older participants [F (1,78) 5 16.5,
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Table 1 Demographics for FEPA completers and dropouts Variable Completers (n 5 110) Age Older adults (n 5 79, 72%)a Middle-aged adults (n 5 31, 28%)a Sex Women (n 5 89, 81%) Men (n 5 21, 19%) Arthritis diagnosis (self-reported) Doctor diagnosis (n 5 79, 72%) Joint pain (n 5 31, 28%) Arthritis type (self-reported)c Osteoarthritis (n 5 61, 56%) Rheumatoid (n 5 17, 16%) Fibromyalgia (n 5 6, 5%) Gout (n 5 4, 4%) Unknown (n 5 7, 6%) Ethnicity Caucasian (n 5 65, 59%) Hispanic (n 5 32, 29%) Filipino (n 5 10, 9%) Other (n 5 27, 25%) Marital status Married (n 5 65, 59%) Single (n 5 9, 8%) Divorced/sep (n 5 5, 5%) Widowed (n 5 31, 28%) Highest level of education Grammar school (n 5 12, 11%) High school (n 5 15, 14%) Some college (n 5 16, 15%) Completed college (n 5 36, 33%) Prof/graduate school (n 5 25, 23%) Vocational/tech school (n 5 2, 2%) Physical activity self-report Walking (YES) (n 5 95, 86%) Days/week (Median 5 5) Min/time (77.6 6 91.5) Strength train (YES) (n 5 50, 46%) Days/week (Median 5 3) Flexibility train (YES) (n 5 60, 55%) Days/week (Median 5 3)
Dropouts (n 5 44) (n 5 21, 48%)b (n 5 23, 52%)b (n 5 89, 81%) (n 5 21, 19%) (n 5 31, 71%) (n 5 13, 29%) (n (n (n (n (n
5 5 5 5 5
23, 52%) 5, 11%) 3, 7%) 0, 0%) 4, 9%)
(n (n (n (n
5 5 5 5
20, 46%) 20, 46%) 2, 5%) 21, 48%)
(n (n (n (n
5 5 5 5
21, 48%) 6, 14%) 9, 21%) 8, 18%)
(n (n (n (n (n (n
5 5 5 5 5 5
6, 14%) 8, 18%) 13, 30%) 10, 23%) 3, 7%) 2, 5%)
(n 5 37, 84%) (Median 5 5) (98.8 6 103.8) (n 5 15, 34%) (Median 5 3) (n 5 19, 43%) (Median 5 3)
Middle-aged 5 !65 years, Older 5 >65 years. Older adults Mage 5 76.0 6 6.6 years, Middle-aged adults Mage 5 54.8 6 7.2 years. b Older adults Mage 5 73.7 6 7.1 years, Middle-aged adults Mage 5 51.4 6 9.9 years. c Some participants self-reported more than one type. a
p ! 0.001, h2 5 .18]. No significant improvement was seen in the middle-aged participants [F (1,30) 5 3.13, p ! 0.09, h2 5 .09], however speed improvement in these individuals was similar to that seen in the older group. Aerobic endurance, as measured by the 6 min walk test, significantly improved from baseline to post-intervention in both the middle-aged [F (1,30) 5 10.55, p ! 0.004, h2 5 .26], and older participants [F (1,76) 5 43.04, p ! 0.001, h2 5 .36]. Improvements in both groups (28.47 and 23.57 m, respectively) equate to approximately 1/3 of a city block. Arm strength and endurance, as measured by number of arm curls performed, significantly improved in the middle-
aged [F (1,30) 5 16.7, p ! 0.001, h2 5 .36], and older participants [F (1,78) 5 19.2, p ! 0.001, h2 5 .20]. Middle-aged participants were able to perform about 3 more arm curls post-intervention, while older participants were able to perform about 2 more arm curls. These changes may be particularly meaningful for individuals whose arm strength is compromised and who experience difficulty in the performance of daily tasks involving lifting or moving objects.28,29 Upper body flexibility, as measured by the back-scratch test, significantly improved in older participants [F (1,76) 5 5.27, p ! 0.03, h2 5 .07]. Participants increased flexibility by about 3/4 .’’ No significant improvement in flexibility was found in the middle-aged participants [F (1,30) þ .13, p ! 0.72, h2 5 .004], with increases in flexibility about ¼’’. Self-reported arthritis-specific outcomes Means, standard deviations, and 95% CID for arthritisspecific outcomes are found in Table 3. Physical function, significantly improved post-intervention in middle-aged participants [F (1,30) 5 9.74, p ! 0.006, h2 5 .25]. No significant differences were found for older participants [F (1,77) 5 2.08, p ! 0.16, h2 5 .03]. Variability for the older group was high at both baseline and postintervention for this factor. Affect, improved but was not statistically significant in middle-aged participants [F (1,30) 5 3.53, p ! 0.08, h2 5 .10] or older participants [F (1,78) 5 2.01, p ! 0.17, h2 5 .03]. Pain symptoms were assessed by both the AIMS2 pain subscale and the NPS, which were significantly correlated at both baseline (r 5 .65, p ! 0.001) and at postintervention (r 5 .67, p ! 0.001). As measured by the AIMS2, pain symptoms were significantly reduced in middle-aged participants [F (1,30) 5 7.25, p ! 0.02, h2 5 .20] and in older participants, [F (1,78) 5 5.70, p ! 0.02, h2 5 .07]. As measured by the NPS, reductions in pain were significant for the older participants [F (1,78) 5 3.94, p ! 0.006, h2 5 .10] but were not statistically significant for the middle-aged participants [F (1,30) 5 1.62, p ! 0.22, h2 5 .05]. Self-efficacy for arthritis pain management significantly improved post-intervention for middle-aged participants [F (1,30) 5 6.32, p ! 0.02, h2 5 .17], but not for older participants [F (1,78) 5 1.93, p ! 0.17, h2 5 .02]. No significant differences were found in self-efficacy for management of other arthritis symptoms in the middle-aged [F (1,30) 5 .14, p ! 0.71, h2 5 .005], or older participants [F (1,77)e.62, p ! 0.44, h2 5 .008].
Discussion The purpose of this investigation was to examine the effects of FEPA, a multi-component arthritis-specific
S.S. Levy et al. / Disability and Health Journal 5 (2012) 305e311 Table 2 Means, standard deviations, pre- post-differences, and 95% CID of physical performance measures Variable n Baseline Post-intervention Mobility e 8-ft up-and-go (sec) Middle-aged 31 Older 79 Aerobic endurance e 6 min walk (m) Middle-aged 31 Older 79 Strength e arm curl (repetitions) Middle-aged 31 Older 79 Flexibility e back-scratch test (in) Middle-aged 31 Older 77
309
Pre-post D
95% CID
6.35 6 2.42 7.17 6 1.59y
e.58 e.56
e.09 to 1.24 e.29 to .84
460.59 6 90.02* 426.03 6 80.98y
28.47 23.57
10.57 to 46.36 16.41 to 30.73
11.68 6 4.47 11.72 6 3.35
14.81 6 6.55y 13.44 6 4.07y
3.13 1.72
1.57 to 4.69 .94 to 2.50
4.34 6 3.25 4.95 to 4.79
4.13 6 5.19 4.35 6 4.54*
.21 .60
e.97 to 1.39 .08 to 1.12
6.93 6 1.59 7.73 6 2.02 432.13 6 72.13 402.46 6 75.26
Middle-aged 5 !65 years, Older 5 >65 years. Lower scores indicate more positive outcomes for mobility and flexibility. Higher scores indicate more positive outcomes for aerobic endurance and strength. Negative scores for flexibility indicate distance between fingers not touching, while positive scores indicate amount of finger overlap. *p ! 0.05, yp ! 0.001.
exercise program. In general, statistical and clinically meaningful improvements were seen in physical function and arthritis-specific outcomes. The functional and arthritis-specific changes observed are important to a comprehensive understanding of the benefits of physical activity to those who suffer from chronic disease.17 Understanding their role in the exercise e quality of life/work productivity relationship gives practitioners some guidance in providing exercise recommendations for those with arthritis. Research suggests that improvements in physical function may be a critical mediator in the exercise and quality of life relationship.17 Aerobic endurance improvements have been reported in exercise programs lasting 18 months,6 while shorter programs (i.e., 8 weeks) reported no significant improvements.4 Current findings suggest that
a 12-week time frame may be effective in bringing about desired results. Aerobic fitness is important as it is associated with a reduced risk of the co-morbidities often found in individuals with arthritis, who are often inactive.30,31 Encouraging individuals to engage in appropriate aerobic activities may lead to general health improvements and improve endurance needed for daily activities, such as climbing stairs and household work. Other physical function improvements observed may benefit those with arthritis through improved healthrelated quality of life at home and work. Increases in upper body strength are associated with improvements in performing many activities of daily life, such as self-care tasks, dressing, cleaning and household work, and preparing meals and relate to greater independence and
Table 3 Means, standard deviations, pre- post-differences, 95% CIdifference, and alpha coefficients of arthritis specific outcomes Variable n a Baseline Post-intervention Pre-post D Physical function e (AIMS2) Middle-aged 31 Older 78 Affect e (AIMS2)a Middle-aged 31 Older 79 Pain e (AIMS2)a Middle-aged 31 Older 79 Self-efficacy e pain managementb Middle-aged 31 Older 79 Self-efficacy e other symptomsb Middle-aged 31 Older 78
95% CID
a
.66e.93c .63e.79c
1.23 6 1.44 .87 6 .82
.62 6 .88y .78 6 .80
.61 .09
.21 to 1.01 e.03 to .21
.78e.80c .82e.92c
3.60 6 1.48 2.39 6 1.70
3.11 6 1.53 2.24 6 1.58
.49 .15
e.04 to 1.01 e.06 to .34
.86 .82
4.33 6 2.41 3.59 6 2.20
3.35 6 2.16* 3.05 6 2.02*
.98 .54
.24 to 1.72 .09 to .99
.71 .72
7.20 6 1.71 7.62 6 1.55
7.91 6 1.29* 7.91 6 1.75
.71 .29
.13 to 1.28 e.69 to .12
.85 .82
7.55 6 1.66 8.44 6 1.38
7.63 6 1.63 8.55 6 1.21
.08 .11
e.48 to .33 e.39 to .17
*p ! 0.05, yp ! 0.01. Scores range from 1 to 5. Lower scores indicate more positive outcomes. b Scores range from 1 to 10. Higher scores indicate greater self-efficacy. c Cronbach alpha coefficients for subscales comprising measure component. a
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quality of life. Similarly, improved mobility and upper body flexibility may improve work productivity associated with arthritis.32 Pain perceptions (frequency and intensity) and the reductions observed are important due to their relationship with quality of life,17 work productivity,5 and general health perceptions.31 Our findings suggest that pain intensity may be a critical piece of pain perception among older adults with arthritis, and is responsive to exercise intervention. Middle-aged participants reported significant improvements in the all self-reported arthritis-specific outcomes except for self-efficacy for management of symptoms other than pain, which only approached significance, perhaps due to the small sample size of this age group. For older adults, only self-efficacy for pain management significantly improved. Other studies have also reported non-significant changes in self-reported physical function and mental health, but significant improvements in physical measures of function.6,33 This suggests that measuring physical function by performance of specific tasks, like the 8-foot up-andego test, may be necessary to evaluate changes in older adults. Moreover, because physical self-perceptions are strong predictors of actual behavior and performance34,35 practitioners may need to highlight achieved physical improvements to help older adults improve these self-perceptions. Based on this preliminary evaluation, FEPA appears to be effective for reducing pain and improving function for adults with arthritis and has potential for sustainability in community settings. Four sites were able to continue offering the program after the research project ended. Future considerations for successful community dissemination might include offering separate classes based on age and/or exercise intensity, as this may reduce the dropout rate of younger participants seen here. Inclusion of a control group in future studies will strengthen the fidelity of the current findings. Future studies should also compare the effects of various programs and delivery mechanisms on intermediate and longer term outcomes, such as medical care visits, and regional arthritis-related health care costs.
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S.S. Levy et al. / Disability and Health Journal 5 (2012) 305e311 27. Rikli R, Jones J. Functional fitness normative scores for communityresiding older adults, ages 60e94. J Aging Phys Act. 1999;7:162e 181. 28. Avlund K, Schroll M, Davidsen M, Løvborg B, Rantanen T. Maximal isometric muscle strength and functional ability in daily activities among 75-year-old men and women. Scand J Med Sci Sports. 1994;4:32e40. 29. Mihalko SL, McAuley E. Strength training effects on subjective wellbeing and physical function in the elderly. J Aging Phys Activity. 1996;4:56e68. 30. Mikuls TR. Co-morbidity in rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2003;17:729e752. 31. Eurenius E, Stenstr€ om CH, The Para Study Group. Physical activity, physical fitness, and general health perception among individuals with rheumatoid arthritis. Arthritis Rheum. 2005;53:48e55.
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32. Chorus AM, Miedema HS, Wevers CW, van der Linden S. Work factors and behavioural coping in relation to withdrawal from the labour force in patients with rheumatoid arthritis. Ann Rheum Dis. 2001;60:1025e1032. 33. Belza B, Shumway-Cook A, Phelan EA, Williams B, Snyder SJ, LoGerfo JP. The effects of a community-based exercise program on function and health in older adults: the enhance fitness program. J Appl Gernontology. 2006;25:291e306. 34. Mak MKY, Pang MYC. Balance confidence and functional mobility are independently associated with falls in people with Parkinson’s disease. J Neurol. 2009;256:742e749. 35. Friedman SM, Munoz B, West SK, Rubin GS, Fried LP. Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. JAGS. 2002;50:1329e1335.
Brief Report
Evaluation of a multi-component group exercise program for adults with arthritis: Fitness and Exercise for People with Arthritis (FEPA) Susan S. Levy, Ph.D.a,*, Caroline A. Macera, Ph.D., M.P.H.b, Jennifer M. Hootman, Ph.D.c, Karen J. Coleman, Ph.D.d, Ruby Lopezb, Jeanne F. Nichols, Ph.D.a, Simon J. Marshall, Ph.D.e, Barbara A. Ainsworth, Ph.D., M.P.H.f, and Ming Ji, Ph.D.b a
San Diego State University, School of Exercise and Nutritional Sciences, 5500 Campanile Drive, San Diego, CA 92182-7251, USA b San Diego State University, Graduate School of Public Health, San Diego, CA, USA c Centers for Disease Control and Prevention, Division of Adult and Community Health, Atlanta, GA, USA d Kaiser Permanente, Department of Research and Evaluation, Pasadena, CA, USA e University of California, San Diego, Family and Preventive Medicine, San Diego, CA, USA f Arizona State University, College of Nursing and Health Innovation, Mesa, AZ, USA
Abstract Background: Research supports the favorable effects of exercise on physical and psychosocial outcomes in those with arthritis. Few easily disseminated, multi-component, arthritis-specific programs have been evaluated using both physical function and psychosocial measures. Fitness and Exercise for People with Arthritis (FEPA) is a new community-based, 3-month, instructor supervised multicomponent exercise program for individuals with arthritis designed to increase strength, flexibility, balance, and aerobic conditioning, while emphasizing joint-protection and proper biomechanics. Purpose: To conduct a preliminary evaluation of the effects of the FEPA program on physical function and arthritis-related outcomes in individuals with arthritis. Method: Middle-aged (n 5 31, Mage 5 54.8 6 7.2) and older (n 5 79, Mage 5 76.0 6 6.6) adults with arthritis completed the instructor led FEPA program in community senior centers, churches, and adult education settings. Changes in physical function, measured using the arm curl, back-scratch test, 8-foot up-and-go, and 6 min walk and self-reported arthritis-related pain, perceived physical function, affect, and self-efficacy for symptom management were assessed using RM ANOVA. Results: Significant improvements (ps ! .05) in all physical function measures were found in the older group. In the middle-aged group, significant improvements ( ps ! .05) were found in the 8-foot up-and-go and 6 min walk. Self-reported physical function, pain perceptions, and self-efficacy for pain management significantly improved ( ps ! .05) in middle-aged participants, while only selfreported pain perceptions significantly improved in the older group. Conclusions: FEPA shows promise for improving health-related outcomes in those with arthritis, and has potential for sustainability in community settings. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Community programs; Intervention effects; Physical activity; Physical function
‘‘This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) (gs1) Grant Number U36/ CCU300430-23. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.’’ CDC disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Initial study findings were a poster presentation at the Society of Behavioral Medicine Annual Meeting; San Diego, CA, 2008. * Corresponding author. Tel.: þ1 619 594 5672; fax: þ1 619 594 6553. E-mail address: [email protected] (S.S. Levy). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.07.003
Introduction Arthritis is the most common cause of disability in adults living in the U.S.1 Recent estimates indicate that 46.4 million (21.6%) individuals report receiving a doctor diagnosis of arthritis.2 Arthritis impact is underscored at both individual and public health levels. Arthritis is related to reduced quality of life,3 and research indicates that arthritis negatively impacts work productivity through lost time and diminished physical function.4,5 While pharmacological treatment of arthritis is standard, research and clinical evidence support the favorable effects of arthritis-appropriate exercise on
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physical function, pain, quality of life, and arthritis management self-efficacy.6e8 Despite recent U.S. federal guidelines recommending both aerobic (2.5 h per week) and muscle strengthening (2 days per week) exercise for adults with arthritis,9 37% of adults with arthritis are sedentary.10 The two most common approaches to community-based arthritis exercise programs are aquatic and land-based. Aquatic programs, such as the Arthritis Foundation Aquatics Program11 are effective, but may not appeal to all people and widespread dissemination is limited by the availability and expense of pool facilities. The 8-week Arthritis Foundation Exercise Program (AFEP, formerly People with Arthritis Can Exercise, PACE) is the most widely disseminated land-based group arthritis-specific exercise program.12 AFEP focuses on building strength, balance, and flexibility and has been effective in improving physical function, and self-reported performance of activities of daily living.13 However, the program does not focus on aerobic conditioning. Aerobic exercise may be particularly important, as it has shown greater efficacy than resistance exercise in reducing depressive symptom in individuals with arthritis.14 Depression and mood disturbance are commonly reported symptoms in those with arthritis15,16 and are important aspects of quality of life.17 Combining aerobic and muscle strengthening exercises into one program may produce even better outcomes for arthritis patients. Randomized trials of combined aerobic and resistance exercise programs significantly improved physical function, activities of daily living, and reduced in pain in obese individuals with osteoarthritis of the knee6 and in older adults with arthritis.3 Currently there are few multi-component (i.e., aerobic, strengthening, flexibility and balance) arthritis-specific exercise programs that can be feasibly disseminated (e.g., minimal, low-cost equipment/few storage requirements) through community-based and public health agencies with sufficient evidence of effectiveness and infrastructure for dissemination on a large scale.18 To address these gaps, we evaluated the Fitness and Exercise for People with Arthritis (FEPA) program, a new multi-component program that combines aerobic conditioning with upper, lower, and core muscle strengthening, balance, and flexibility exercises, teaching joint-protection strategies through proper biomechanics during exercise.
Methods Participants Participants were an ethnically diverse (Caucasian, 57%, Hispanic, 34%, other 9%) sample of men (n 5 25, 16%) and women (n 5 129, 84%) who volunteered for participation (Mage 5 67.74 years, SD 5 12.95) and met study inclusion criteria of a self-reported doctor diagnosis of arthritis (n 5 110) or self-reported joint pain (n 5 44) within the past three months, age of 18 and older, and the ability to
participate in the exercise program, as measured by the Physical Activity Readiness Questionnaire (PAR-Q19). Participant recruitment was conducted in collaboration with community partners serving constituents most likely to meet study inclusion criteria, or who delivered programs within which the FEPA program could be integrated. All participants completed an informed consent document in accordance with the University Institutional Review Board. Measures A pilot study confirmed the psychometric soundness of all study measures and the quality of data collection procedures, using individuals from a senior center (Mage 5 81.64 years, SD 5 7.55) and a YMCA (Mage 5 56.4 years, SD 5 5.66) who met the main study inclusion criteria. All questionnaires demonstrated acceptable internal consistency reliability (Cronbach alpha coefficients O .74) except the arm function and self-care task subscales of the AIMS2, whose alpha coefficients fell below the generally acceptable .70,20 likely due to the small sample size in the pilot. Test-retest reliability coefficients for the functional fitness measures, examined in the middle-aged group for whom the measures were not originally developed, were deemed acceptable (R 5 .89e.95). Physical performance measures Measures of physical performance were selected based on their appropriateness and their acceptable psychometric characteristics (convergent validity values above 6.70, and test-retest reliability values above .80) in the target population and samples similar to the current study.21 The 8-foot up-and-go assessed mobility, which reflects a combination of lower extremity strength, power, and dynamic balance. The participant starts by sitting in a chair, then stands up without the use of hands, walks 8 feet to and around a cone, and returns to a seated position in the chair. The score is total time to complete the test, using the fastest of two recommended trials. The 6 min Walk Test assessed aerobic endurance. The test is a measure of the distance walked in six minutes, and indicates one’s minimal aerobic endurance to complete common daily activities, such as walking and shopping. The test is well-tolerated by older adults and when compared to other functional walk tests is better related to activities of daily living.22 Number of arm curls performed in 30 s was used to assess arm strength and endurance, important for activities of daily living, such as house and yard work and lifting and carrying. The back-scratch test was used to assess shoulder flexibility. This over the shoulder reach attempting to touch fingers of the opposing arm reaching up behind the back is scored in distance between fingers. The test is considered by orthopedic experts to be the best overall measure of shoulder flexibility.23
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Self-reported arthritis-specific outcomes Self-reported measures of arthritis-specific outcomes were chosen based on their appropriateness and favorable psychometric characteristics (internal consistency and test-retest reliability coefficients above .70) with the target population. Arthritis-specific outcomes were assessed using nine subscales of the Arthritis Impact Measurement Scales 2 (AIMS224), a widely used measure of perceived health status, and health-related quality of life for individuals with arthritis. As recommended, subscales scores were combined to derive a 3-component model of health status comprised of self-reported physical functioning, affect, and pain frequency. The sensitivity of the measure’s components to changes in perceived health has also been demonstrated.25 Arthritis pain intensity was assessed using the Numerical Rating Scale for Pain (NPS). Participants reported their current level of pain on a numbered (0e10) horizontal line, 100 mm in length, with the left end of the line labeled ‘‘no pain’’ and the right end labeled ‘‘worst possible pain.’’ The NPS has shown sensitivity to changes over a 3-month period in individuals with osteoarthritis and rheumatoid arthritis.25 Confidence in managing arthritis-related symptoms was measured using pain and other symptoms subscales of the Arthritis Self-Efficacy Scale (ASE26). Participants indicated the degree to which they felt confident in managing their arthritis-related pain and other symptoms (e.g., fatigue, frustration). Procedures FEPA program FEPA is a 3-month, instructor supervised exercise program for adults with arthritis or joint pain, designed to increase strength, flexibility, balance, and cardiovascular health. Exercises in the program are designed to be lowimpact, safe, and joint-protective, with a focus on teaching proper body mechanics. The program is progressive, based on the exercise training principles of specificity and overload. A minimal amount of durable, low-cost equipment (e.g., dumbbell weights, balance trainers, stability balls) designed to be easily stored, was used. Classes were led by qualified instructors (previous group exercise leadership experience, some training in exercise science or physical therapy) who were trained by study staff and observed periodically to maintain intervention fidelity. Classes were conducted in a variety of community settings, including residential and non-residential senior centers, churches, and adult education centers. Program materials and training are available. Classes met twice weekly, were approximately one-hour in length, and combined a variety of exercises focusing on core strength and balance, flexibility, upper and lower body strength, agility, and aerobic conditioning. Exercises were
307
adapted for an individual’s capabilities, and precautions were taken for any movement restrictions (e.g., performed in chair, holding on to chair back). Equipment such as medicine balls, small hand-held weights, and in more advanced classes, stability balls and balance trainers were used. Walking and dance movements were the mainstay of aerobic conditioning exercises. Classes were designed to progressively advance participants in each of the areas of fitness addressed, while being cautious and jointprotective at all times. Data analysis As prior research has identified significant differences in performance of the physical performance measures, with gradient decreases seen by decade,21 data were analyzed separately for those under 65 years of age (n 5 31), and those 65 years and older (n 5 79). This approach was taken, rather than entering age as a covariate, due to the greater number of participants in the older group, and resulting disproportionate effect on the age-adjusted dependent variable values. Repeated measures analyses of variance (RM ANOVA) were conducted in order to examine the effects of the FEPA program on physical function and the self-reported measures of arthritis-specific outcomes. Alpha was set to .05 for all tests of significance. Results Of the 154 participants who began the FEPA program, 110 completed the post-intervention assessment (completers were defined as those attending O50% of classes) and were included in the main data analysis. Among completers, on average attendance was high (Mattendance 5 75.2% classes 6 20.1%). Chi-square tests and independent samples t-tests, where appropriate, revealed no significant differences ( p O 0.05) between completers and non-completers based on self-report of doctor diagnosed arthritis vs. joint pain, or selfreported severity of arthritis pain, or in any of the demographic variables (i.e., sex, ethnicity, marital status, education), except age (dropouts were significantly ( p ! 0.05) younger than completers). When examining the composition of two groups, the dropouts were equally comprised of older (O65 years) adults and middle-aged adults. Descriptive statistics for completers and non-completers are found in Table 1. Physical performance measures Means, standard deviations, and 95% CID for all functional fitness measures are found in Table 2. Based on age-adjusted normative scores for older adults,27 at baseline, participants fell just below the 50% percentile on physical function measures. Mobility, as measured by the 8-ft up-and-go, significantly improved in older participants [F (1,78) 5 16.5,
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Table 1 Demographics for FEPA completers and dropouts Variable Completers (n 5 110) Age Older adults (n 5 79, 72%)a Middle-aged adults (n 5 31, 28%)a Sex Women (n 5 89, 81%) Men (n 5 21, 19%) Arthritis diagnosis (self-reported) Doctor diagnosis (n 5 79, 72%) Joint pain (n 5 31, 28%) Arthritis type (self-reported)c Osteoarthritis (n 5 61, 56%) Rheumatoid (n 5 17, 16%) Fibromyalgia (n 5 6, 5%) Gout (n 5 4, 4%) Unknown (n 5 7, 6%) Ethnicity Caucasian (n 5 65, 59%) Hispanic (n 5 32, 29%) Filipino (n 5 10, 9%) Other (n 5 27, 25%) Marital status Married (n 5 65, 59%) Single (n 5 9, 8%) Divorced/sep (n 5 5, 5%) Widowed (n 5 31, 28%) Highest level of education Grammar school (n 5 12, 11%) High school (n 5 15, 14%) Some college (n 5 16, 15%) Completed college (n 5 36, 33%) Prof/graduate school (n 5 25, 23%) Vocational/tech school (n 5 2, 2%) Physical activity self-report Walking (YES) (n 5 95, 86%) Days/week (Median 5 5) Min/time (77.6 6 91.5) Strength train (YES) (n 5 50, 46%) Days/week (Median 5 3) Flexibility train (YES) (n 5 60, 55%) Days/week (Median 5 3)
Dropouts (n 5 44) (n 5 21, 48%)b (n 5 23, 52%)b (n 5 89, 81%) (n 5 21, 19%) (n 5 31, 71%) (n 5 13, 29%) (n (n (n (n (n
5 5 5 5 5
23, 52%) 5, 11%) 3, 7%) 0, 0%) 4, 9%)
(n (n (n (n
5 5 5 5
20, 46%) 20, 46%) 2, 5%) 21, 48%)
(n (n (n (n
5 5 5 5
21, 48%) 6, 14%) 9, 21%) 8, 18%)
(n (n (n (n (n (n
5 5 5 5 5 5
6, 14%) 8, 18%) 13, 30%) 10, 23%) 3, 7%) 2, 5%)
(n 5 37, 84%) (Median 5 5) (98.8 6 103.8) (n 5 15, 34%) (Median 5 3) (n 5 19, 43%) (Median 5 3)
Middle-aged 5 !65 years, Older 5 >65 years. Older adults Mage 5 76.0 6 6.6 years, Middle-aged adults Mage 5 54.8 6 7.2 years. b Older adults Mage 5 73.7 6 7.1 years, Middle-aged adults Mage 5 51.4 6 9.9 years. c Some participants self-reported more than one type. a
p ! 0.001, h2 5 .18]. No significant improvement was seen in the middle-aged participants [F (1,30) 5 3.13, p ! 0.09, h2 5 .09], however speed improvement in these individuals was similar to that seen in the older group. Aerobic endurance, as measured by the 6 min walk test, significantly improved from baseline to post-intervention in both the middle-aged [F (1,30) 5 10.55, p ! 0.004, h2 5 .26], and older participants [F (1,76) 5 43.04, p ! 0.001, h2 5 .36]. Improvements in both groups (28.47 and 23.57 m, respectively) equate to approximately 1/3 of a city block. Arm strength and endurance, as measured by number of arm curls performed, significantly improved in the middle-
aged [F (1,30) 5 16.7, p ! 0.001, h2 5 .36], and older participants [F (1,78) 5 19.2, p ! 0.001, h2 5 .20]. Middle-aged participants were able to perform about 3 more arm curls post-intervention, while older participants were able to perform about 2 more arm curls. These changes may be particularly meaningful for individuals whose arm strength is compromised and who experience difficulty in the performance of daily tasks involving lifting or moving objects.28,29 Upper body flexibility, as measured by the back-scratch test, significantly improved in older participants [F (1,76) 5 5.27, p ! 0.03, h2 5 .07]. Participants increased flexibility by about 3/4 .’’ No significant improvement in flexibility was found in the middle-aged participants [F (1,30) þ .13, p ! 0.72, h2 5 .004], with increases in flexibility about ¼’’. Self-reported arthritis-specific outcomes Means, standard deviations, and 95% CID for arthritisspecific outcomes are found in Table 3. Physical function, significantly improved post-intervention in middle-aged participants [F (1,30) 5 9.74, p ! 0.006, h2 5 .25]. No significant differences were found for older participants [F (1,77) 5 2.08, p ! 0.16, h2 5 .03]. Variability for the older group was high at both baseline and postintervention for this factor. Affect, improved but was not statistically significant in middle-aged participants [F (1,30) 5 3.53, p ! 0.08, h2 5 .10] or older participants [F (1,78) 5 2.01, p ! 0.17, h2 5 .03]. Pain symptoms were assessed by both the AIMS2 pain subscale and the NPS, which were significantly correlated at both baseline (r 5 .65, p ! 0.001) and at postintervention (r 5 .67, p ! 0.001). As measured by the AIMS2, pain symptoms were significantly reduced in middle-aged participants [F (1,30) 5 7.25, p ! 0.02, h2 5 .20] and in older participants, [F (1,78) 5 5.70, p ! 0.02, h2 5 .07]. As measured by the NPS, reductions in pain were significant for the older participants [F (1,78) 5 3.94, p ! 0.006, h2 5 .10] but were not statistically significant for the middle-aged participants [F (1,30) 5 1.62, p ! 0.22, h2 5 .05]. Self-efficacy for arthritis pain management significantly improved post-intervention for middle-aged participants [F (1,30) 5 6.32, p ! 0.02, h2 5 .17], but not for older participants [F (1,78) 5 1.93, p ! 0.17, h2 5 .02]. No significant differences were found in self-efficacy for management of other arthritis symptoms in the middle-aged [F (1,30) 5 .14, p ! 0.71, h2 5 .005], or older participants [F (1,77)e.62, p ! 0.44, h2 5 .008].
Discussion The purpose of this investigation was to examine the effects of FEPA, a multi-component arthritis-specific
S.S. Levy et al. / Disability and Health Journal 5 (2012) 305e311 Table 2 Means, standard deviations, pre- post-differences, and 95% CID of physical performance measures Variable n Baseline Post-intervention Mobility e 8-ft up-and-go (sec) Middle-aged 31 Older 79 Aerobic endurance e 6 min walk (m) Middle-aged 31 Older 79 Strength e arm curl (repetitions) Middle-aged 31 Older 79 Flexibility e back-scratch test (in) Middle-aged 31 Older 77
309
Pre-post D
95% CID
6.35 6 2.42 7.17 6 1.59y
e.58 e.56
e.09 to 1.24 e.29 to .84
460.59 6 90.02* 426.03 6 80.98y
28.47 23.57
10.57 to 46.36 16.41 to 30.73
11.68 6 4.47 11.72 6 3.35
14.81 6 6.55y 13.44 6 4.07y
3.13 1.72
1.57 to 4.69 .94 to 2.50
4.34 6 3.25 4.95 to 4.79
4.13 6 5.19 4.35 6 4.54*
.21 .60
e.97 to 1.39 .08 to 1.12
6.93 6 1.59 7.73 6 2.02 432.13 6 72.13 402.46 6 75.26
Middle-aged 5 !65 years, Older 5 >65 years. Lower scores indicate more positive outcomes for mobility and flexibility. Higher scores indicate more positive outcomes for aerobic endurance and strength. Negative scores for flexibility indicate distance between fingers not touching, while positive scores indicate amount of finger overlap. *p ! 0.05, yp ! 0.001.
exercise program. In general, statistical and clinically meaningful improvements were seen in physical function and arthritis-specific outcomes. The functional and arthritis-specific changes observed are important to a comprehensive understanding of the benefits of physical activity to those who suffer from chronic disease.17 Understanding their role in the exercise e quality of life/work productivity relationship gives practitioners some guidance in providing exercise recommendations for those with arthritis. Research suggests that improvements in physical function may be a critical mediator in the exercise and quality of life relationship.17 Aerobic endurance improvements have been reported in exercise programs lasting 18 months,6 while shorter programs (i.e., 8 weeks) reported no significant improvements.4 Current findings suggest that
a 12-week time frame may be effective in bringing about desired results. Aerobic fitness is important as it is associated with a reduced risk of the co-morbidities often found in individuals with arthritis, who are often inactive.30,31 Encouraging individuals to engage in appropriate aerobic activities may lead to general health improvements and improve endurance needed for daily activities, such as climbing stairs and household work. Other physical function improvements observed may benefit those with arthritis through improved healthrelated quality of life at home and work. Increases in upper body strength are associated with improvements in performing many activities of daily life, such as self-care tasks, dressing, cleaning and household work, and preparing meals and relate to greater independence and
Table 3 Means, standard deviations, pre- post-differences, 95% CIdifference, and alpha coefficients of arthritis specific outcomes Variable n a Baseline Post-intervention Pre-post D Physical function e (AIMS2) Middle-aged 31 Older 78 Affect e (AIMS2)a Middle-aged 31 Older 79 Pain e (AIMS2)a Middle-aged 31 Older 79 Self-efficacy e pain managementb Middle-aged 31 Older 79 Self-efficacy e other symptomsb Middle-aged 31 Older 78
95% CID
a
.66e.93c .63e.79c
1.23 6 1.44 .87 6 .82
.62 6 .88y .78 6 .80
.61 .09
.21 to 1.01 e.03 to .21
.78e.80c .82e.92c
3.60 6 1.48 2.39 6 1.70
3.11 6 1.53 2.24 6 1.58
.49 .15
e.04 to 1.01 e.06 to .34
.86 .82
4.33 6 2.41 3.59 6 2.20
3.35 6 2.16* 3.05 6 2.02*
.98 .54
.24 to 1.72 .09 to .99
.71 .72
7.20 6 1.71 7.62 6 1.55
7.91 6 1.29* 7.91 6 1.75
.71 .29
.13 to 1.28 e.69 to .12
.85 .82
7.55 6 1.66 8.44 6 1.38
7.63 6 1.63 8.55 6 1.21
.08 .11
e.48 to .33 e.39 to .17
*p ! 0.05, yp ! 0.01. Scores range from 1 to 5. Lower scores indicate more positive outcomes. b Scores range from 1 to 10. Higher scores indicate greater self-efficacy. c Cronbach alpha coefficients for subscales comprising measure component. a
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quality of life. Similarly, improved mobility and upper body flexibility may improve work productivity associated with arthritis.32 Pain perceptions (frequency and intensity) and the reductions observed are important due to their relationship with quality of life,17 work productivity,5 and general health perceptions.31 Our findings suggest that pain intensity may be a critical piece of pain perception among older adults with arthritis, and is responsive to exercise intervention. Middle-aged participants reported significant improvements in the all self-reported arthritis-specific outcomes except for self-efficacy for management of symptoms other than pain, which only approached significance, perhaps due to the small sample size of this age group. For older adults, only self-efficacy for pain management significantly improved. Other studies have also reported non-significant changes in self-reported physical function and mental health, but significant improvements in physical measures of function.6,33 This suggests that measuring physical function by performance of specific tasks, like the 8-foot up-andego test, may be necessary to evaluate changes in older adults. Moreover, because physical self-perceptions are strong predictors of actual behavior and performance34,35 practitioners may need to highlight achieved physical improvements to help older adults improve these self-perceptions. Based on this preliminary evaluation, FEPA appears to be effective for reducing pain and improving function for adults with arthritis and has potential for sustainability in community settings. Four sites were able to continue offering the program after the research project ended. Future considerations for successful community dissemination might include offering separate classes based on age and/or exercise intensity, as this may reduce the dropout rate of younger participants seen here. Inclusion of a control group in future studies will strengthen the fidelity of the current findings. Future studies should also compare the effects of various programs and delivery mechanisms on intermediate and longer term outcomes, such as medical care visits, and regional arthritis-related health care costs.
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8.
9.
10.
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16. 17. 18.
19. 20. 21.
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