Fit and Strong!: An evidence-based exercise/behavior change program for older adults with lower-extremity osteoarthritis

Arthritis is the number-one cause of disability among the growing population of older adults in the United States. In particular, lower extremity joint impairment among older adults with osteoarthritis (OA) is a known risk factor for future disability and institutionalization (Guralnik, et al. 1995; Dunlop, et al. 1997; Jette, et al. 1999). Arthritis currently affects 20 million persons aged 65 and over in the United Sates. and is projected to increase to affect approximately 40 million by 2030 (Centers for Disease Control and Prevention, 2006). Older adults who have OA in their lower extremity, weight-bearing joints tend to limit movement of these joints because of pain. This limitation of movement leads to the development of a sedentary lifestyle, which is associated with significantly reduced aerobic capacity and muscle strength (Minor et al. 1989; Semble et al. 1990). Thus, as older adults with lower extremity OA progressively limit their activity over time, they become unable to climb stairs, get in and out of a car, and perform other tasks of daily living that require the involvement of lower extremity, weight-bearing joints and that are necessary for independent functioning in the community. Although several exercise interventions have been tested with persons with OA, few have been designed to specifically reinforce long-term adherence to a regular multiple component program of physical activity designed for this high risk group.

To address this urgent public health problem, we developed Fit and Strong! Fit and Strong! is the first program of which we are aware to combine flexibility/balance, aerobic walking, and strength training with health education for disease management and sustained behavior change among older adults with OA (Hughes et al., 2004). The program meets for 90 minutes, three times a week for eight weeks. The first 60 minutes are devoted to physical activity, which incorporates flexibility/balance exercises, fitness walking and low impact aerobics, and lower extremity strength training. The last 30 minutes are devoted to group discussion/problem-solving to enhance disease management and self-efficacy for adherence to physical activity over time.

Efficacy Trial. We originally tested the impact of Fit and Strong! using a randomized trial with 215 older adults with lower extremity OA in Chicago. The trial was funded by the National Institute on Aging as part of our Edward R. Roybal Center. We assessed outcomes at two months (the end of the formal program) and also examined the maintenance of program effects at six months and 12 months. Relative to the control group, Fit and Strong! participants experienced statistically significant improvements in self-efficacy for exercise, exercise adherence, and lower extremity stiffness at two months (Hughes et al., 2004). These benefits were maintained at six months, at which time participants also experienced a significant increase in self-efficacy for adherence to exercise over time, a significant decrease in lower extremity joint pain, and a marginally significant increase in self-efficacy for arthritis pain management. At 12 months, significant treatment group effects were maintained on self-efficacy for exercise and exercise adherence that were accompanied by marginally significant reductions in lower extremity stiffness and pain (Hughes et al., 2006). No adverse health effects were seen.

Although the formal program ends at two months, effect sizes for self-efficacy for exercise and for exercise adherence at six and 12 months in the treatment group were large, at 0.798 and 0.713, and 0.905 and 0.669, respectively. Furthermore, treatment group participants maintained a 55.6 percent increase in participation in physical activity relative to their baseline levels at 12 months. This rate is approximately double the rate observed among control group members at 12 months. These findings indicate that this low-cost, eight-week intervention demonstrated substantial efficacy as a health promotion intervention and is ready to be replicated broadly.

Effectiveness Trial. We are currently testing different ways of reinforcing long term maintenance to the multiple physical activity components included in Fit and Strong! at five senior centers run by the Chicago Department on Aging through an R01 from NIA. All participants enroll in the eight-week Fit and Strong! program and are assigned to two different post Fit and Strong! maintenance strategies: negotiated vs. mainstreamed, with and without follow-up telephone reinforcement. Participant evaluations from new enrollees in the program show that 73 percent described their overall reaction to Fit and Strong! as ‘excellent’, 99 percent agreed that they had benefited from it, and 98 percent agreed that they would recommend the program to friends and family members.

The original efficacy trial of Fit and Strong! used licensed physical therapists to develop and test an exercise program that was safe for older adults with lower extremity OA. Since the program components demonstrated safety and efficacy during that trial, during our current R01 we transitioned to a model using certified exercise instructors in order to reduce program costs and disseminate the program broadly as a cost-effective health promotion intervention for older adults with OA. Evaluations from more than 400 participants in the follow-up R01 described above have ranked the program as equally effective under both physical therapist and certified exercise instructors, and no adverse events have occurred, indicating that the program is ready for wide-scale adoption.

Awards. Fit and Strong! was selected by the Healthcare and Aging Network (HAN) of the American Society on Aging, in collaboration with Pfizer Inc., as one of only six recipients of the 2008 Healthcare and Aging Awards. The review committee for the Health Care and Aging Award found Fit and Strong! to be innovative with a significant impact on community. The committee strongly believes that the field and practice of health care and health promotion is advanced by sharing Fit and Strong! with others in the field. The Fit and Strong! team received the Award at the American Society on Aging-National Council on Aging Joint Conference in Washington, D.C., in March 2008.

In 2006, Fit and Strong! also received an honorable mention for the Archstone Award in Program Innovation from the Gerontological Health Section.

Translation and Dissemination. Fit and Strong! is currently being replicated in Chicago, North Carolina and West Virginia. It is ready for broad, community-based diffusion to persons who can benefit from it. We have recently obtained funding from the Centers for Disease Control and Prevention under their new initiative, “Improving Public Health Practice Through Translation (R18)” to examine the effectiveness of partnering with existing Area Agencies on Aging (AAAs) in two states (Illinois and North Carolina) to translate and diffuse the program to providers within two AAA catchment areas per state. Our translation work is using Glasgow’s Re-Aim model and Greene et al.’s work on evaluation (Glasgow, Vogt and Bowles, 1999; Green and Glasgow, 2006) to identify facilitators and barriers to the reach, effectiveness, adoption, implementation and maintenance of Fit and Strong!. We will train a T-Trainer and Master Trainers and will work with them to train certified exercise instructors to conduct Fit and Strong at providers in four AAA catchment areas (target numbers = one T trainer, two master trainers, 30 sites, 30 certified instructors and a minimum of 1,200 participants). The study will use mixed qualitative and quantitative methods to examine barriers and facilitators to the reach, effectiveness, adoption, implementation and maintenance of Fit and Strong! Study funds are also being used to develop a Fit and Strong! Web site (www.fitandstrong.org) and an interactive, Web-based support hotline, to finalize training materials, to support the cost of the trainings and to provide financial incentives for participation among the first sites that sign up to participate.

Collaboration with the National Arthritis Foundation. We are also simultaneously working closely with the National Arthritis Foundation to translate and disseminate Fit and Strong! in four additional states through their local chapters beginning in Fall 2008. These locations include southern and northern New England, Michigan, Kansas and Northern California.

We anticipate that all of these activities will advance the development of Fit and Strong! as a high-quality, turnkey, evidence-based program, while advancing our understanding of factors that facilitate the adoption, implementation, and maintenance of effective physical activity programs for older adults.

References.

CDC. (2006). Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation, MMWR, U.S. 2003-2005, 55, 1089-1092.

Dunlop, D. D., Hughes, S. L., Manheim, L. M. (1997). Disabilities in Activities of Daily Living, Patterns of Change and a Hierarchy of Disability. American Journal of Public Health, 87, 378-383.

Glasgow, R.E., Vogt, T.M., Boles, S.M. (1999). Evaluating the Public Health Impact of Health Promotion Interventions: The RE-AIM Framework. American Journal of Public Health, 89,1322-1327.

Green, L.W., Glasgow, R.E. (2006). Evaluating the Relevance, Generalization, and Applicability of the Research: Issues in External Research and Translation Methodology. Evaluation and the Health Professions, 29, 126-153.

Guralnik, J. M., Ferrucci, L. Simonsick, E.M., Salive, M.E., Wallace, R.B. (1995). Lower-Extremity Function in Persons over the Age of 70 Years as a Predictor of Subsequent Disability. New England Journal of Medicine, 332, 556-561.

Hughes, S. L., Seymour, R. B., Campbell, R., Pollak, N., Huber, G., Sharma, L. (2004). Impact of the Fit and Strong Intervention on Older Adults with Osteoarthritis. The Gerontologist, 44, 217-228.

Hughes, S.L., Seymour, R.B., Campbell, R.T., Huber, G., Pollak, N., Sharma, L., Desai, P. (2006). Long-Term Impact of Fit and Strong! On Older Adults with Osteoarthritis. The Gerontologist, 46(6), 801-814.

Jette, A.M., Lachman, M., Giorgetti, M.M., Assmann, S.F., Harris, B.A., Levenson, C., Wernick, M., Krebs, D. (1999). Exercise--It's Never Too Late: The Strong-for-Life Program, American Journal of Public Health, 89, 66-72.

Minor, M.A., Hewett, J. E., Weber, R.R., Anderson, S.K., Kay, D.R. (1989). Efficacy of Physical Conditioning Exercise in Patients with Rheumatoid Arthritis and Osteoarthritis. Arthritis and Rheumatism, 32, 1396-1405.

Semble, E. L., Loeser, R. F., Wise, C.M. (1990). Therapeutic Exercise for Rheumatoid Arthritis and Osteoarthritis. Seminars in Arthritis and Rheumatism, 20, 32-40.

Contact Information

For more information, please contact:

Susan L. Hughes, DSW
Professor, Community Health Sciences
School of Public Health
Co-Director, Center for Research on Health and Aging Institute for Health Research and Policy
1747 W. Roosevelt Rd., Room 558, M/C 275 Chicago, IL 60608
Ph: (312) 996-1473 Fax: (312) 413-9835