# Exercise as it relates to Disease/Arthritis Specific Exercise Programs: Do They Work?

Critique of Levy, S. S., Macera, C. A., Hootman, J. M., Coleman, K. J., Lopez, R., Nichols, J. F., Marshal, S. J., Ainsworth, B. A. & Ji, M. (2012). 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(4), 305-311. doi: 10.1016/j.dhjo.2012.07.003

## What is the background to this research?

Arthritis is a chronic condition characterised by joint inflammation causing pain and reduced mobility, and is one of the leading causes of pain and disability in Australia and the United States. Research suggests that exercise has a positive effect on physical and psychological outcomes for individuals with arthritis. Resistance training programs have proven to be an effective treatment method for restoring physical function, and aerobic training has proven beneficial to psychological well being. However, minimal research has been conducted on programs combining both resistance and aerobic components.

## Where is the research from?

Levy et al. (2012) evaluated the efficacy of Fitness and Exercise for People with Arthritis (FEPA), a multi-component group exercise program, which incorporates aerobic and full body resistance training, combined with biomechanical strategies for protecting joints. Development of FEPA was sponsored by the Centers for Disease Control and Prevention of the United States, and the research in question was carried out by members of the San Diego State University’s School of Exercise and Nutritional Sciences.

## What kind of research was this and what did the research involve?

The study was of an empirical design. An ethnically diverse sample of 154 arthritis afflicted volunteers participated in the 3 month FEPA program. The sampling method was described as a volunteer sample group, in which all participants were allocated to a single treatment group. Within the sample, 25 (0.16) of the participants were male, while 129 (0.84) were female. 100 (0.65) of the participants were older aged adults, the remaining 54 (0.35) were middle aged. While the sample size is suitable, the distribution of the sample is problematic. In particular, the low ratio of males to females makes it difficult to identify possible interactions between gender and program efficacy.
The physical outcome measures ustilised are evidenced based and provide a functional method of evaluating aerobic condition and muscular strength in older adults, as well as aiding practitioners in planning appropriate exercise interventions for this population. These measures included the 8-foot up-and-go test and the 6 minute walk test, testing mobility, leg strength and power as well as aerobic endurance; number of arm curls performed in 30 seconds to assess arm strength and endurance; and finally, the back-scratch test to indicate shoulder flexibility.
Self-reported outcome measures were utilised to enable researchers to investigate participant perception of the FEPA program’s effectiveness. The Arthritis Impact Measurement Scales 2 (AIMS2) used is an evidence based health questionnaire, which investigates physical function in arthritis sufferers.
Instructor led classes were conducted twice weekly over the 3 months, for a duration of one hour each. Classes were of a progressive nature and comprised of resistance techniques using medicine balls and small hand weights, and aerobic training utilising walking and dance movements.

## What were the basic results?

110 participants completed the study. As seen in table 1, older participants experienced significant improvement in mobility and upper body flexibility, while middle aged and older participants gained minor improvements in upper body strength. Both middle aged and older adults experienced a significant improvement in aerobic endurance.
Table 1. Physical performance improvements
| Physical performance measures | Middle aged | Older |
| Mobility | Not significant | Significant |
| Aerobic endurance | Significant | Significant |
| Arm strength and endurance | Significant | Significant |
| Upper body flexibility | Not significant | Significant |
Pain symptoms for both middle aged and older participants improved significantly, as seen in table 2. Middle aged adults showed improvement in physical function, but older adults did not. Neither middle aged or older adults experienced significant improvement in psychological state.
Table 2. Self-reported improvements
| Self-reported measures | Middle aged | Older |
| Physical function | Significant | Not significant |
| Psychological state | Not significant | Not significant |
| Pain symptoms | Significant | Significant |

## How did the researchers interpret the results?

Researchers found meaningful improvements in physical function and arthritis outcomes and believe these improvements are important in understanding the benefits of physical activity. The three month time frame is believed to be sufficient to bring about positive change. The researchers are of the opinion that arthritis sufferers should be encouraged to engage in aerobic activity in order to improve aerobic endurance and gain general health improvements. Increases in upper body strength are thought to improve quality of life by enabling individuals to maintain independence in self-care and work related tasks. Researchers found discrepancies between physical performance measures and self-reported measures, highlighting the need for professional practitioners to bring attention to measured performance outcome improvements in order to boost individual’s self-esteem and awareness.

## What conclusions should be taken away from this research?

From the research, it can be concluded that a multi-component group exercise program is an effective treatment intervention for individuals suffering with arthritis. Older adults especially may benefit from group exercise classes combining aerobic and strength training components. Efficacy of such programs appears to be best measured by assessing physical outcomes, rather than self-reported measures.

## What are the implications of this research?

This study highlights the need for further research in the area of arthritis specific exercise programs. While the study has merit, re-evaluating the experimental design will offer greater insight into the interaction between exercise and arthritis. Diversifying the sample by recruiting more men may make it possible to identify whether or not gender differences in regards to exercise response exist. Adding a control group and/or multiple treatment variables, rather than having a single treatment intervention with no control group, should increase the validity and reliability of the study. Focusing on a specific form of arthritis, such as osteo or rheumatoid, rather than grouping all arthritic conditions together in one study, may give a clearer picture of how exercise interacts with the condition in question, due to the fact that not all arthritic states share the same etiology. There is still much evaluation to be done, but it has been demonstrated that arthritis specific exercise programs are effective and have meaning potential for future arthritis treatment protocols.

## References

* ↑ Levy, S. S., Macera, C. A., Hootman, J. M., Coleman, K. J., Lopez, R., Nichols, J. F., Marshal, S. J., Ainsworth, B. A. & Ji, M. (2012). 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(4), 305-311. doi: 10.1016/j.dhjo.2012.07.003
* ↑ Australian Bureau of Statistics, (2011). Arthritis and osteoporosis in Australia: a snapshot, 2007-08. Retrieved from Australian Burea of Statistics: http://www.abs.gov.au/ausstats/abs@.nsf/productsbytopic/FB8447960065DC96CA2578DB0013243E?OpenDocument
* ↑ Centers for Disease Control and Prevention, (2009). Completed projects fitness: fitness and exercise for people with arthritis. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/arthritis/funded_science/completed/fitness.htm
* ↑ Rikli, R. E. & Jones, J. C. (2013). Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years. The Gerontologist, 53(2), 255-267. doi: 10.1093/geront/gns071
* ↑ Meenan, R. F., Mason, J. H., Anderson, J. J., Guccione, A. A. & Kazis, L. E. (1992). AIMS2. The content and properties of a revised and expanded arthritis impace measurement scales health status questionnaire. Arthritis and Rheumatism, 35(1), 1-10. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/1731806