September/October 2014

Fit and Strong! Improves Arthritis Symptoms
By Susan Hughes, PhD; Renae Smith-Ray, PhD; Amy Shah, MPH; and Gail Huber, PhD
Today’s Geriatric Medicine
Vol. 7 No. 5 P. 20

The specialized program, combining structured physical activity with health education to build self-efficacy and effect behavior change, helps to reduce lower extremity joint pain.

Recent data from the Centers for Disease Control and Prevention (CDC) demonstrate that arthritis is the most common condition affecting older adults in the United States and the No. 1 cause of disability among them.1 Our study team first became aware of the prominence of arthritis in 1981 when we conducted an evaluation of a model long-term home care program for older adults in Chicago. We learned at that time that arthritis was the most common chronic condition reported by homebound clients.

In fact, when we queried these homebound clients, we heard time after time that arthritis is the condition that interferes most with daily function. To learn more about the connection between arthritis and disability, we obtained funding from the National Institutes of Health (NIH) to conduct a prospective longitudinal study in Chicago of 600 older adults. Again we found that arthritis was the most common condition reported by study participants and the No. 1 cause of disability when they were contacted after two and four years.

We measured participant joint impairment at baseline and conducted an analysis to try to determine which joints were causing the problem. Analyses clearly indicated that osteoarthritis (OA) in the lower extremity joints was the culprit, a scenario that makes sense considering that people use these large weight-bearing joints to perform most activities of daily living such as transferring, climbing stairs, and toileting.2

We conducted the longitudinal study in order to understand the association between the presence of OA and the development of disability. Once we understood the pivotal role of lower extremity OA in the causal chain, it became clear that we needed to develop an intervention to interrupt it.

Seeking a Solution
We examined the OA physical activity literature and found that people with OA have two significant problems: they are aerobically deconditioned and have weaker muscles than age-matched controls.3,4 People with OA have significant joint pain, and the natural tendency for most people with painful swollen joints is to stop moving around. As we all now know, this is the worst thing people can do.
A sedentary lifestyle leads to further joint stiffening, pain, muscle weakness, aerobic deconditioning, and weight gain, potentially setting the stage for the onset of comorbid conditions such as heart disease and diabetes. Given the presence of aerobic and strength deficits in this population, we decided that an intervention should entail a multiple-component physical activity program that includes aerobic walking and strength training.

Understanding that behavioral adherence is a challenge, we aimed to design a short-term (eight weeks) program with long-term results. This meant that we needed to include a program component that would help motivate participants to continue exercising on their own after the formal training program ends. Therefore, we included a health education/behavior change component. We borrowed heavily from the self-efficacy literature to design a behavior change component geared to help people gain mastery over their OA through an active lifestyle.5

Successful Model
The resulting program, Fit and Strong!, is a group/facility-based program that consists of three 90-minute sessions per week over eight weeks. The first hour of each session is devoted to exercise (flexibility, aerobic, and lower extremity strengthening), and the last 30 minutes are devoted to a structured health education/group problem-solving curriculum.

Random testing in an efficacy trial found differential significant benefits for participants randomly assigned to Fit and Strong! compared with those who were randomly assigned to a control arm. Fit and Strong! participants engaged in significantly more physical activity, had higher self-efficacy for physical activity, and experienced less lower extremity joint stiffness at eight weeks.

At six months, Fit and Strong! participants had maintained those gains, benefited from a reduction in lower extremity joint pain, and developed confidence in their ability to adhere to a physical activity program over time. Several of these gains (participation in physical activity, self-efficacy for physical activity, decreased joint stiffness) were maintained at 12 months with large effect sizes of .7 or .9 demonstrating a clear and measurable difference on these indicators of health between older adults who completed Fit and Strong! and those who did not.6

The efficacy trial sought to demonstrate not only that Fit and Strong! works to increase physical activity and improve other aspects of health, but also to show that a structured program of aerobic exercise and resistance training would not harm individuals with painful lower extremity joints. Therefore, the program was delivered by trained physical therapists who had experience working with older adults with OA, but this was an expensive model and not practical for national dissemination. The efficacy trial enabled the development of an exercise regimen that is safe and works. As a next step, we obtained follow-up funding to examine the impact of different types of instructors and different ways of bolstering physical activity maintenance following the termination of Fit and Strong!.

Continuing Research
Conducted on the South Side of Chicago, the effectiveness trial enabled us to expand our reach into largely black communities. We used this study as an opportunity to conduct a natural experiment. We used the physical therapist instructor model with the first 161 enrollees, and then taught the remaining 190 enrollees using certified exercise instructors, an instructor model that is more practical for broad dissemination. Certified exercise instructors are physical activity instructors who have met the training requirements of any of 10 national programs, such as the American College of Sports Medicine. Participant gains in physical activity levels were very strong at eight weeks and at six months with both types of instructors, attendance was high, and participant evaluations were glowing.7 So we moved forward with the certified exercise instructor model. 

Overall participant outcomes from this trial were very strong, including significant gains in engagement in physical activity over 18 months of follow-up that were accompanied by improved lower extremity OA symptoms (joint pain, stiffness, and function), observed performance gains in lower extremity strength (sit-stand test), and mobility (six-minute distance walk), as well as reductions in anxiety and depression.8 The maintenance of effects on lower extremity strength and mobility after program completion were particularly important because of their association with other health outcomes.

Diminished mobility at advanced age is not only a risk factor for falls but is also associated with higher mortality.9,10 Older adults with arthritis have a greater risk of multiple falls and fall-related injuries compared with older adults without arthritis, at 2.4 and 2.5 times higher, respectively. As a result of these recent statistics, the CDC has called for evidence-based programs for older adults with arthritis that focus not only on self-management, but also on physical activity, including lower extremity strength training and fall prevention.11

Productive Partnership
Next we received CDC funding to test the translation of Fit and Strong! in partnership with Area Agencies on Aging in Illinois and North Carolina. This work with community partners enabled development of a license and fee structure, fine tuning of instructor and master instructor program trainings, and development of materials, including a program implementation guide and participant and instructor manuals. Development of an interactive website, http://fitandstrong.org, enables us to track participant attendance, program evaluations, and collect a reduced set of health outcome measures for all participants at baseline and immediately postprogram.

Outcomes, including BMI, lower extremity joint pain and stiffness, self-efficacy for exercise, engagement in physical activity, and energy/fatigue, are tracked across sites. These data are analyzed to ensure that the program continues to benefit participants as it is rolled out nationally. Benchmark reports, which can be provided to sites that offer the program, are being developed. Some sites find it more practical to offer the program twice per week. We allow providers to make this adaptation to the program when necessary, providing they cover the full complement of 24 sessions, which extends the program to 12 weeks in length.

Recently, we have developed and tested a new Hispanic version of the program, ¡Fuerte y en Forma!, in Chicago and Phoenix. The pilot study showed that there is a broad range of formal education among older Latinos who have immigrated to the United States, with a subset that has low levels of formal education. Our participant manuals are written for eighth-grade literacy levels. To accommodate the educational range among this population, we are revising the Hispanic manual to a fourth-grade level and will supplement the text with more pictures and stories to help better communicate the information. We obtained participant baseline, eight-week, and six-month outcomes for this pilot. Preliminary analyses show strong results at both time points and research findings are currently under review for future publication.12

Program Enhancements
Participants in the program offered on the South Side of Chicago asked for more information in the program manual about diet and weight management. Research on this issue solidified our understanding of the close relationship between overweight/obesity and knee OA.13-15 Funding from the National Institute on Aging has enabled us to compare the effectiveness of the initial version of Fit and Strong! with a new version, Fit and Strong! Plus, which includes physical activity and an explicit dietary change/weight management component.

The new program consists of 24 sessions but has been adapted to include dietary behavior change information intended to facilitate participant weight loss. Early returns from this study have been positive.16 Most recently we were invited to participate in a congressionally mandated evaluation of the appropriateness of the program, and a small set of others like it, to be reimbursed by Medicare. The evaluation is scheduled to take place over a 12-month period starting in September 2014.

Older adults who complain of pain or stiffness in the lower back, hip, knees, ankles, and/or feet are ideal candidates for Fit and Strong!. Physicians should ask patients whether they have any arthritis and, if so, whether it affects any of the aforementioned areas. Patients directed to our website can learn about the program, including states and sites where it is offered. Fit and Strong! is recognized by the CDC and the Administration on Aging of the Administration for Community Living, which is part of the US Department of Health and Human Services, as a top-tier evidence-based program for older adults. It is offered by YMCAs, health care systems, senior centers, and park and recreation facilities in Illinois, North Carolina, Florida, Arkansas, Texas, Arizona, and Oregon, with plans to disseminate Fit & Strong! to additional states.

Final Thoughts
The enduring hallmark of an evidence-based program is the capacity to produce the same results across different populations, geographic sites, and instructors. Fit and Strong! has demonstrated the capacity to produce nearly identical participant outcomes across six different evaluations with white, black, and Hispanic participants; across sites in Illinois, Michigan, North Carolina, Texas, and Arizona; and with two different types of instructors (physical therapists and certified exercise instructors).

The program, combining structured physical activity with health education for building self-efficacy and behavior change, is beginning to demonstrate similar positive outcomes with additional clinical populations, such as cancer survivors, and is being tested among individuals with symptoms of depression. The potential also exists for the new Fit and Strong! Plus program to not only promote a physically active lifestyle but also to simultaneously promote healthy eating and weight management. Additional program information is available at http://fitandstrong.org. The program can help to reverse the trajectory of disability in this high-risk older adult population.

— Susan Hughes, PhD, is a professor of community health sciences in the School of Public Health at the University of Illinois at Chicago (UIC) and directs the UIC Center for Research on Health and Aging.

— Renae Smith-Ray, PhD, is a research scientist at the UIC Center for Research on Health and Aging.

— Amy Shah, MPH, is a project manager at the UIC Center for Research on Health and Aging.

— Gail Huber, PhD, is an associate professor at the Northwestern University School of Physical Therapy.

References
1. Brault MW, Hootman J, Helmick CG, Theis KA, Armour BS. Prevalence and most common causes of disability among adults- United States, 2005. MMWR Morb Mortal Wkly Rep. 2009;58(16):421-426.

2. Dunlop DD, Hughes SL, Edelman P, Singer RM, Chang RW. Impact of joint impairment on disability-specific domains at four years. J Clin Epidemiol. 1998;51(12):1253-1261.

3. Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989;32(11):1396-1405.

4. Semble EL, Loeser RF, Wise CM. Therapeutic exercise for rheumatoid arthritis and osteoarthritis. Semin Arthritis Rheum. 1990;20(1):32-40.

5. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: W.H. Freeman and Company; 1997.

6. Hughes SL, Seymour RB, Campbell RT, et al. Long-term impact of Fit and Strong! on older adults with osteoarthritis. Gerontologist. 2006;46(6):801-814.

7. Seymour RB, Hughes SL, Campbell RT, Huber GM, Desai P. Comparison of two methods of conducting the Fit and Strong! program. Arthritis Rheum. 2009;61(7):876-884.

8. Hughes SL, Seymour RB, Campbell RT, Desai P, Huber G, Chang HJ. Fit and Strong!: bolstering maintenance of physical activity among older adults with lower-extremity osteoarthritis. Am J Health Behav. 2010;34(6):750-763.

9. Chang HJ, Lynm C, Glass RM. JAMA patient page. Falls and older adults. JAMA. 2010;303(3):288.

10. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50-58.

11. Barbour KE, Stevens JA, Helmick CG, et al. Falls and fall injuries among adults with arthritis—United States, 2012. Morb Mortal Wkly Rep. 2014;63(17):379-383.

12. Der Ananian C, Hughes SL, Miller A, Shah A. Six-month outcomes of ¡Fuerte y en Forma! in Latinos with arthritis. 2014; in review.

13. Koonce RC, Bravman JT. Obesity and osteoarthritis: more than just wear and tear. J Am Acad Orthop Surg. 2013;21(3):161-169.

14. Messier SP, Legault C, Mihalko S, et al. The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale. BMC Musculoskelet Disord. 2009;10:93.

15. Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum. 2004;50(5):1501-1510.

16. Smith-Ray RL, Fitzgibbon ML, Tussing-Humphreys L, et al. Fit and Strong! Plus: design of a comparative effectiveness evaluation of a weight management program for older adults with osteoarthritis. Contemp Clin Trials. 2014;37(2):178-188.