Fit & Strong!

Osteoarthritis is the most common chronic condition affecting older adults, and osteoarthritis-related lower-extremity joint impairment is known to be a major mechanism through which disability develops. Pain caused by osteoarthritis can be a major barrier to mobility and participation in physical activity. Persons with osteoarthritis, particularly in their large lower-extremity weight-bearing joints, minimize movement to reduce exposure to pain. The condition is therefore associated with both reduced lower-extremity strength and reduced aerobic functioning. Persons with osteoarthritis also experience depression and may become socially isolated, possibly due to increased pain and decreased mobility.

Several exercise interventions have been developed and tested over the past 20 years among older adults with osteoarthritis. Most studies have found short-term positive effects for various types of exercises, both alone and in combination with social support and patient education, on pain, stiffness, functional exercise capacity, aerobic functioning, and physical activity. Mixed findings have been found on longer-term exercise adherence and related outcomes. However, no studies address the effects of a single, multi-component intervention that incorporates range of motion, aerobic conditioning, strength training, and education for behavior change.

Fit and Strong! is a multi-component physical activity/behavior change intervention for older adults with mild to moderate lower-extremity osteoarthritis. Fit and Strong! sessions are delivered to groups of up to 15 participants in a facility such as a senior center. The intervention consists of 90-minute sessions held three times per week for 8 weeks (24 sessions total) and is led by physical therapists or certified exercise instructors trained in geriatrics. In the first hour of each session, participants engage in a multiple-component exercise program that incorporates flexibility/balance, aerobic walking and/or low-impact aerobics, and lower-extremity strength training using elastic exercise bands and adjustable ankle cuff weights. All exercises are accompanied by music. The sessions begin and end with 10-minute warm-up and cool-down periods, during which static and dynamic sitting and standing balance exercises are used. Over time, fitness walking progresses in duration, complexity, and balance. Strengthening exercises for the lower extremities and trunk utilize a graded task-specific approach (sit to stand and postural stabilization). The resistance is progressively increased throughout the program by adding weight to the ankle cuff weights. The last 30 minutes of each session are devoted to group problem solving and education using a curriculum designed to facilitate arthritis symptom management, self-efficacy for exercise, and commitment to lifestyle changes. Group and individual sessions are used to inform participants about opportunities to maintain exercise within the community or in an individual's home. Participants develop individualized post-intervention exercise plans that incorporate flexibility, aerobic activity (usually walking), and strength training a minimum of 3 days per week for a total of 30 minutes per day at a "moderate" to "strong" level of perceived exertion.

Fit and Strong! is offered in 90-minute sessions held three times per week for 8 weeks.  Physical therapists and certified exercise instructors attend an 8-hour training to become a certified Fit and Strong! instructor.

Fit and Strong! is intended for adults aged 60 and older with mild to moderate lower extremity osteoarthritis.

Fit & Strong! can be implemented in senior centers, senior housing residences, and other community settings.

All resources to implement Fit & Strong! can be obtained from the program website. These include participant and instructor manuals, ankle weights, elastic exercise bands, CD player, exercise music CDs, and mats (optional). A certified exercise instructor or physical therapist is needed to implement the program.

For costs associated with this program, please contact the developer, Susan Hughes. (See products page on the EBCCP website for developer contact information.)

To evaluate the effectiveness of Fit & Strong!, older adults with hip or knee osteoarthritis were randomized to intervention or control group using a stratified randomized block design with blocks consisting of 30 participants (15 intervention and 15 control), stratified by arthritis severity. Participants were recruited by newsletter, announcements in the local media, and presentations to local senior groups.  Control group participants received a copy of The Arthritis Helpbook and a list of exercise programs in the community. They also received a variety of self-care materials and handouts at each follow-up (2, 6, and 12 months after baseline). The control group was offered the opportunity to participate in the intervention at the conclusion of the study.

The study included 215 participants, 115 in the intervention group and 100 in the control group. Participants were aged 60 years and older with an average age of 73. The sample was 83.1% female and 72.0% White/Caucasian, 22.5% African American, 2.6% Hispanic, 2.0% Asian/Pacific Islander, and 1.0% other.

Outcomes were assessed through in-person interviews at baseline and 2 months (i.e., at the end of the 8-week program), 6 months, and 12 months after baseline. All analyses controlled for arthritis severity. The outcomes included maintenance of physical activity, pain, stiffness, self-efficacy for physical activity, and self-efficacy for ongoing exercise adherence.

Maintenance of physical activity was measured using the Lorig Exercise Behaviors Scale, a six-item measure that includes type of exercise (e.g., walking, swimming, biking), duration, and frequency. The total number of minutes of exercise per week was calculated for each participant.

Pain was measured using two scales. The five-item pain scale of the Western Ontario and McMasters University Osteoarthritis Index (WOMAC) measures lower extremity pain. The scale ranges from 0 ("none") to 4 ("extreme"), and scores are summed for the five items in the subscale, for a possible range of 0 to 20, with higher scores indicating more pain. The four-item Geri-AIMS Pain Scale assesses usual level of arthritis pain, frequency of severe arthritis-related pain, duration of morning stiffness from waking, and frequency of pain in two or more joints at the same time. The scale ranges from 0 to 10, with higher scores indicating less pain.

Stiffness was rated by using the two-item Stiffness subscale of the WOMAC. The scale ranges from 0 ("none") to 4 ("extreme"), and scores are summed for the two items in the subscale, for a possible range of 0 to 8, with higher scores indicating more stiffness.

Self-efficacy for physical activity was measured using the Efficacy for Exercise subscale of the Lorig Exercise Efficacy Scale. This subscale includes three items: "How confident are you that you can do gentle exercises for muscle strength and flexibility 3 to 4 times/week (range of motion, using weights, etc.)?" "How confident are you that you can do aerobic exercise such as walking, swimming, or bicycling 3 to 4 times each week?" and "How confident are you that you can exercise without making symptoms worse?" Participants rated each item on a 10-point scale from 1 ("not at all confident") to 10 ("totally confident").

Self-efficacy for ongoing exercise adherence was measured using the McAuley "Time" Exercise Adherence scale, which includes six items related to participants' level of self-efficacy to continue participating in regular exercise over 6 months.

• At all three follow-ups, the intervention group reported significant increases from baseline in minutes of exercise per week compared with the control group (2 months: p<.001, 6 months: p=.001, and 12 months: p=.001). The mean minutes of exercise per week for the intervention group were 135.27 at baseline, 248.89 at 2 months (83.9% increase from baseline), 214.46 at 6 months (58.5% increase from baseline), and 210.52 at 12 months (55.6% increase from baseline). Values for the control group were 122.55 minutes per week at baseline, 126.67 at 2 months, 104.66 at 6 months, and 115.65 at 12 months.
   
• Although minutes of exercise per week declined slightly in the intervention group between 2 and 12 months, their levels of participation continued to be above the goal of 30 minutes three times per week.

• From baseline to 6 months, pain ratings on both measures improved significantly for the intervention group compared with the control group (WOMAC: p=.040, Geri-AIMS: p=.039). No between-group differences were found with either measure at 2 months or 12 months.
  
  
   

• From baseline to the first two follow-up, stiffness ratings decreased significantly in the intervention group relative to the control group (2 months: p=.018, 6 months: p=.032). There was no significant difference between groups at 12 months.
   
• Self-efficacy for physical activity scores increased in the intervention group from baseline to 2 months and remained slightly higher than baseline levels at 6 and 12 months. In contrast, in the control group, self-efficacy for physical activity scores declined steadily from baseline through 12 months. At each follow-up, intervention group scores were significantly higher than control group scores (2 months: p=.001, 6 months: p=.005, and 12 months: p=.006).
   
• While there were no group differences at 2 months on self-efficacy for ongoing exercise adherence over a 6-month period, the intervention group did show significant improvement over baseline relative to the control group at 6 months (p=.001) and 12 months (p=.010).
  
   

Additional Findings From Reviewed Study

• Lower extremity muscle strength and endurance was assessed with the Timed-Stands test, the amount of time it takes to complete five full stands from a sitting position. Functional exercise capacity was assessed with the 6-minute walk test, the distance walked within a 6-minute period. There were no significant group differences at any of the follow-up assessments for either of these outcomes.

 
Additional Findings From Maintenance Studies Not Rated by EBCCP
The findings reported above are from a 2006 study that analyzed data collected more than 10 years ago. EBCCP accepted the study for review based on the existence of two more recent studies of Fit and Strong! that reported significant findings. These two maintenance studies could not be rated in the EBCCP review because they did not utilize a quasi-experimental or experimental study design; however, key findings from these studies are described below.

2009 Study
Fit & Strong! was evaluated in a two-group, pretest-posttest design to compare the effectiveness of the program when delivered by certified exercise instructors versus physical therapists (PTs). Participants were assessed at baseline, 8 weeks (i.e., at the end of the program), and 6 months. Participants in both groups improved significantly with respect to exercise participation, caloric expenditure, lower-extremity stiffness, physical function, and lower-extremity strength and aerobic capacity. Significant differences favoring the PT-led classes were seen on two of five mediators, self-efficacy for exercise and barriers adherence efficacy.

2010 Study
A follow-up, multi-site study was conducted to assess the comparative effects of two different ways of bolstering long-term maintenance of physical activity after program participation: negotiated maintenance or mainstreaming. Half of each of the participants in the negotiated maintenance and mainstreamed groups were randomly assigned to receive telephone reinforcement that tapered off over time. Outcomes were assessed at baseline, 8 weeks (i.e., at the end of the program), and 6, 12, and 18 months. Analyses showed significant improvements at 2, 6, 12, and 18 months on physical activity maintenance, lower-extremity pain and stiffness, lower-extremity function, lower-extremity muscle strength and endurance, 6-minute distance walk, and anxiety/depression. Analyses by follow-up condition showed persons in the negotiated maintenance with telephone reinforcement group maintained a 21% increase in caloric expenditures over baseline at 18 months, with lesser benefits seen in the negotiated maintenance only, mainstreamed with telephone reinforcement, and mainstreamed only groups. Significant benefits of telephone dose were also seen on lower-extremity joint stiffness, pain, and function, as well as anxiety and anxiety/depression.