Physician's Weekly Article - An Evidence-Based Self-Management Program for Arthritis

       Physical activity is an important aspect of self-managing arthritis, and the Arthritis Foundation Exercise Program has been shown to safely improve function and arthritic symptoms in elderly, sedentary patients.

      The Arthritis Foundation Exercise Program (AFEP), formerly known as People with Arthritis Can Exercise, or PACE, is part of the Arthritis Foundation’s Life Improvement Series. The program was developed to promote the self-management of arthritis through moderate physical activity. “AFEP is a land-based exercise program designed specifically for arthritic individuals to help decrease pain and stiffness and increase joint flexibility and range of motion,” says Leigh F. Callahan, PhD. “This is accomplished through gentle exercises designed to protect the joints. The primary goal of AFEP is to give people the tools and confidence to exercise safely and increase physical well-being.”

      Exercise is an important component in the management of arthritis. Results from several studies have demonstrated the benefits of appropriate exercise programs for persons with arthritis, including improvements in cardiovascular fitness, muscular strength, psychosocial status, and functional status. Increased physical activity also improves joint mobility, strength, fitness, and range of motion. “The Arthritis Foundation is continually trying to improve its menu of available exercises,” says Dr. Callahan, “and the AFEP offers individuals an alternative to water-based exercise programs, such as water aerobics.”

      Essential Program Components

      The AFEP program consists of two levels—a basic level and an advanced level—and is conducted over the course of 8 weeks. It is administered for 1 hour, twice a week, and offers several advantages over other generalized community exercise programs because it is designed specifically for arthritis sufferers (Table 1). “The integration of education within each exercise session is an essential component of the program to ensure safe performance of the exercises,” says Dr. Callahan. “AFEP instructors inform participants’ on basic principles of arthritis exercise, joint protection, correct body mechanics, and relaxation techniques in order to help them safely achieve the full benefits of the program. Individuals are taught the importance of warming up and cooling down, and are encouraged to progress gradually at their own pace.”

      According to Dr. Callahan, all AFEP exercises can be modified to meet participant needs and individual limitations. For example, individuals who are unable to balance and perform exercises while standing will be shown alternative techniques in a seated position. In order to further prevent disease exacerbations in patients with arthritis, participants are cautioned about the “2-hour pain rule.” Those who experience exercise-induced pain lasting more than 2 hours are encouraged to reduce their amount of exercise so that they do not aggravate their arthritis symptoms.

      Evaluating AFEP Benefits

      Although several exercise programs have been created to promote physical activity for arthritis self-management, there has been insufficient scientific evidence supporting their effectiveness. In a study published in the January 15, 2008 issue of Arthritis Care & Research, Dr. Callahan and colleagues conducted a fully randomized control trial that evaluated the basic 8-week AFEP level for improvements in primary outcomes (symptoms, functioning, and level of physical activity) and secondary outcomes (psychosocial). “Participants completed self-report and performance-based assessments at baseline and 8 weeks, as well as psychosocial outcomes measures,” Dr. Callahan explains. “The intervention group also completed self-report assessments 3 and 6 months after completing the program. Pain, stiffness, and fatigue—typical arthritis symptoms—were measured using visual analog scales, and physical function was measured via self-reporting as well as performance-based measures. Psychosocial outcomes were assessed using four different scales to measure self-efficacy, depression, and helplessness.”

      The program’s demonstrated benefits, Dr. Callahan says, included improvements in pain and fatigue and in self-efficacy for managing arthritis (Table 2). “People who participated in at least nine core classes were classified as ‘completers,’ receiving the full value of the course. In addition to improvements in pain, fatigue, and stiffness, ‘completers’ showed more significant gains in the strength of the upper and lower extremities. Moreover, those who continued the program independently had sustained improvements in pain, fatigue, and stiffness at 6 months.”

      Continue Promoting Physical Activity

      Self-management is essential for individuals with chronic diseases, and physical activity and education play important roles in achieving that goal. Dr. Callahan says her team’s study provides the first solid evidence that the basic 8-week AFEP program is a safe exercise program. “It appears to benefit sedentary, older individuals suffering from arthritis without exacerbating their condition. It should be noted, however, that many people will still be afraid of hurting themselves by exercising. As such, physicians must educate their patients about the importance of physical activity. An appropriate exercise program is a pain reliever that will not only improve arthritis symptoms, but also promote additionally important health-related outcomes.”

      Dr. Callahan has indicated to Physician’s Weekly that she has or has had no financial interests to report.