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Activation to Self-Management and Exercise in Overweight and Obese Older Women With Knee Osteoarthritis Jennifer Kawi, Sue Schuerman, Patricia T. Alpert and Daniel Young Clin Nurs Res published online 30 July 2014 DOI: 10.1177/1054773814544167 The online version of this article can be found at: http://cnr.sagepub.com/content/early/2014/07/28/1054773814544167
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CNRXXX10.1177/1054773814544167Clinical Nursing ResearchKawi et al.
Article
Activation to Self-Management and Exercise in Overweight and Obese Older Women With Knee Osteoarthritis
Clinical Nursing Research 1–17 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814544167 cnr.sagepub.com
Jennifer Kawi, PhD, MSN, APRN, FNP-BC1, Sue Schuerman, PT, PhD, GCS1, Patricia T. Alpert, DrPH, MSN, APRN, FNP-BC, PNP-BC, CNE, FAANP1, and Daniel Young, PT, DPT1
Abstract Knee osteoarthritis (OA) affects approximately 1 in 10 adults in the United States, with higher prevalence in women, aggravated by increased weight. This quasi-experimental pilot study implemented an online selfmanagement (SM) program for older overweight and obese women with knee OA combined with a two-arm progressive exercise trial (walking and stepping groups). After the 10-week intervention using an interprofessional approach, activation to SM scores were significantly higher in all participants (N = 16) and between groups, with a higher increase in the stepping group. Those with higher activation scores pre-intervention obtained higher scores post-intervention. Activation levels also increased significantly among all participants with majority at the highest activation level. Follow-up data at 6 weeks and 6 months showed sustained SM and health-directed behaviors. 1University
of Nevada, Las Vegas, USA
Corresponding Author: Jennifer Kawi, Assistant Professor, Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-3018, USA. Email: [email protected]
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These findings, although preliminary, highlight the value of combined SM and progressive exercise intervention using an interprofessional approach. Further investigations are essential toward potential practice and policy changes. Keywords knee osteoarthritis, overweight, obesity, self-management, activation, exercise
Worldwide, knee osteoarthritis (OA) affects approximately 250 million individuals (Vos et al., 2012) with an estimated 1 in 10 adults afflicted in the United States (Lawrence et al., 2008). Knee OA is the most common form of OA, affecting 6.7% to 16.7% of adults 45 years of age and older; the prevalence is higher in women than men, especially among those 50 years and above (Lawrence et al., 2008). Another primary risk factor for OA is weight; two out of three individuals who are overweight or obese will develop knee OA in their lifetime prompting interventions that address selfmanagement (SM), activity, and weight (Murphy et al., 2008). The American Academy of Orthopaedic Surgeons (AAOS; 2013) released evidence-based guidelines for the management of knee OA. The AAOS strongly recommended patient participation in SM programs, strengthening exercises, physical activity, and weight loss for those with a body mass index (BMI) ≥ 25 kg/m2, often requiring interprofessional collaboration (United States Bone and Joint Initiative [USBJI], 2011). SM refers to health-directed tasks and skills with self-efficacy; individuals activated in SM are able to make appropriate decisions and engage in positive behaviors to allow adequate management of their chronic illnesses (Lorig & Holman, 2003). Hence, patient activation, referring to the individuals’ capacity to manage their health, is necessary in the SM of knee OA; those at higher levels of activation are more likely to self-manage by engaging in positive health behaviors (Hibbard & Mahoney, 2010). This interprofessional pilot study, involving the partnership of nursing and physical therapy, evaluated the impact of a combined SM program and exercise on activation to SM and activation levels in older women with knee OA and a BMI ≥ 25. Activation to SM represents individuals’ measure of their knowledge, skills, behaviors, and confidence toward SM, while activation levels indicate the degree of individuals’ capabilities to initiate and engage in health-directed behaviors (Hibbard, Stockard, Mahoney, & Tusler, 2004).
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Problem Although SM and strengthening exercises were highly recommended in clinical practice for knee OA (AAOS, 2013), there is a lack of research studies investigating activation to SM and the combined impact of an online SM program and progressive exercises focusing on older overweight or obese women with knee OA. This is a critical area of research considering the prevalence of knee OA in this population. Lifestyle changes to improve disease state and quality of life are essential in knee OA. Health improving behavioral changes (i.e., exercise) occur at a more successful rate if individuals are activated in SM (Hibbard & Mahoney, 2010).
Background OA is a chronic degenerative joint disease where progressive damage to the cartilage occurs resulting in symptoms of pain, swelling, and stiffness; it is the most common type of arthritis and has no cure (USBJI, 2011). Symptomatic OA leads to activity limitations that are higher among women (USBJI, 2011). Perpetuating this activity limitation is a BMI ≥ 25; weight is a strong contributory but modifiable risk factor for knee OA (USBJI, 2011). A BMI from 25 to 29.9 is considered overweight and a BMI ≥ 30 is categorized as obese (Centers for Disease Control and Prevention [CDC], 2011b). There are 68.8% of adults who are overweight and obese, with a greater percentage of obesity in women compared to men (Flegal, Carroll, Kit, & Ogden, 2012). Consequently, the management of OA is costly with 11.3 million outpatient visits a year (AAOS, 2013). This does not include health care visits related to hospitalizations, procedures, surgeries, and indirect costs like missed workdays. The global burden of knee OA is extensive and its management is challenging. Physical activity has been shown to help decrease the burden of OA through improving strength and function, reducing pain, and promoting fitness and healthy joints (Semanik, Chang, & Dunlop, 2012). However, older individuals commonly have weak muscles in the lower extremity causing knee instability, leading to further degenerative changes and reduced activity (Hassan, Mockett, & Doherty, 2001). Consequently, studies have reported that walking and single leg step-up, and strengthening exercises were successful in reducing pain and improving strength and self-reported disabilities in individuals with knee OA (McQuade & de Oliveira, 2011; Roddy, Zhang, & Doherty, 2005). Further, studies from a meta-analysis of knee OA exercise programs noted that stepping and mini-squat exercises facilitated muscle strengthening to improve pain and function (Fransen & McConnell, 2009). However, promoting physical activity and exercise in older overweight or
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obese individuals with knee OA can be challenging. Progressive walking and stepping exercises allowing gradual increase in activity individualized to patient needs, and supervised treatment sessions can facilitate exercise and improve outcomes (Fransen & McConnell, 2009). In addition, a combined intervention protocol of a SM program with the progressive exercise sessions can facilitate improved OA outcomes and lead to long-term adherence of a sustained, independent, and self-managed home exercise program. SM interventions in OA have resulted in improved levels of pain, functional disability, depression, anxiety, self-efficacy, SM skills, and healthdirected behaviors (CDC, 2011a; Harvey et al., 2008; Wu, Kao, Wu, Tsai, & Chang, 2011). For example, a widely used SM program called the Arthritis Self-Management Program was developed in 1979 and evaluated in several randomized controlled studies (Stanford School of Medicine, 2013). This online SM program is consistent with the concept of SM described by Lorig and Holman (2003), the theoretical foundation used in this study. The Arthritis Self-Management Program was made available online to increase patient access through a partnership between the National Council on Aging (NCOA) and Arthritis Foundation (2012). Online groups are kept small and manageable with no more than 25 participants. The online program is convenient to participants and accessible anytime. Information is kept private and confidential. There are also minimal technical requirements for ease of use that is especially helpful for older individuals. Evaluation of this online version showed reduction in pain, fear, frustration, worry, and improved activity and SM (NCOA & Arthritis Foundation, 2012). However, SM alone has not been found sufficient in managing OA (Kroon et al., 2014). In the past years, some studies have looked at the effects of combined SM and exercise programs in OA (Devos-Comby, Cronan, & Roesch, 2006; McKnight et al., 2010; Yip et al., 2007; Yip, Sit, Wong, Chong, & Chung, 2008). Overall, reductions in pain and disability, and improvement in self-efficacy, physical health, and psychological outcomes were appreciated. However, there is a lack of research studies evaluating activation to SM and the impact of combined online SM program and progressive walking or stepping exercises on older, overweight, or obese women with knee OA. Patient activation is essential in SM as this has been shown to improve disease outcomes, experiences in patient care, and health care costs (Hibbard & Greene, 2013).
Purpose The purposes of this interprofessional pilot study were to (a) provide training in two low-to-moderate exercise strategies that gradually advance in intensity
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(progressive walking or progressive stepping) for older overweight or obese women with knee OA, toward independence in performing the exercise in their own homes and (b) implement an online SM program to enhance adherence, progression, and sustainability of exercise. The following were the specific research questions: Research Question 1: Were there significant differences in mean activation scores to SM comparing pre- to post-intervention for the full sample, and the walking and stepping groups separately? Research Question 2: Were there significant differences in the change in mean activation scores to SM in the full sample and between the two exercise groups? Research Question 3: Were there significant differences in activation levels for the full sample and between the two exercise groups?
Methods This pilot study utilized a quasi-experimental design with a two-arm exercise trial: progressive walking or progressive stepping. Both groups received an online SM program. This study was carried out in five phases: recruitment and screening, allocation into two groups and pre-testing, implementation, post-testing, and follow-ups at 6 weeks and 6 months. An interprofessional approach was used with physical therapy managing the exercise program while collaborating with nursing in overseeing the online SM program.
Sample and Setting Participants were recruited using flyers posted at senior centers and primary care offices throughout Clark County, Nevada. Blast emails were also sent through university announcements and to members of a university program for retired and semi-retired individuals. Inclusion criteria were (a) female, (b) 50 years of age or older, (c) BMI of 25 and over, and (d) OA in one or both knees confirmed by radiologists through X-rays. Exclusion criteria were (a) history of joint replacement or major trauma to lower extremities; (b) history of rheumatoid arthritis, osteoporosis, or uncontrolled high blood pressure; (c) use of opioid-based pain relievers or corticosteroid injections in the past 30 days; (d) currently enrolled in a rehabilitation program; or (e) having been advised by a health care provider not to participate in any exercise due to heart disease or other medical condition. A total of 26 participants were screened; 7 did not meet the inclusion criteria and 3 did not proceed to the implementation phase (no show, personal reasons).
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After Institutional Review Board approval, informed consent was obtained from each participant. A convenience sample of participants were alternately assigned as they were enrolled in the study to a progressive walking group (n = 8) or a progressive stepping group (n = 8). Demographic information was gathered (age, race, height, weight, BMI). Incentives were given which included steps for the stepping group, exercise shoe vouchers for the walking group, and a monetary incentive given to all participants.
Patient Activation Measure (PAM), Short Version The PAM was given to all participants prior to the start of this study and after completion. The PAM evaluates patient activation to SM (Hibbard et al., 2004). It is a unidimensional, cumulative survey, with a 4-point Guttman scale (“strongly agree” to “strongly disagree”). Using Rasch methodology, raw ordinal level data are converted to a 0 to 100 interval scale representing scores of patient activation to SM (Hibbard et al., 2004). These scores indicate the knowledge, skills, behaviors, and confidence of individuals in selfmanaging their chronic illnesses (Hibbard et al., 2004). Subsequently, these scores are categorized into four specified cut-off points that represent four levels of activation to SM in a hierarchical order (Hibbard et al., 2004). Level 1 describes a participant beginning to take part in SM (activation score of 47 or lower). Level 2 indicates a growing confidence in and knowledge of SM (47.1 to 55.1). Level 3 involves taking direct action in SM (55.2 to 67). Level 4 is the highest activation to SM (67.1 or above) and includes the ability to maintain health-directed behaviors and to stay within course of adequately managing one’s chronic illness. The short version 13-item PAM facilitates completion of surveys and has demonstrated item conformity with infit values of 0.92 to 1.05 and outfit values of 0.85 to 1.11 (Hibbard, Mahoney, Stockard, & Tusler, 2005). These were consistent with the fit values of the original, conceptually validated 22-item version (Hibbard et al., 2004). Stability was demonstrated in those without or with various chronic conditions (.90 to .91) and between variable responses to self-rated health (.87 to .91). Construct validity was supported by Hibbard and colleagues where those having higher activation reported significantly better health when correlated with the Short Form 8 Health Survey (SF-8), r = .38, p < .001, and lower rates of health care utilization (r = −.07, p < .01).
Procedures After all participants were screened based on the inclusion and exclusion criteria with knee X-rays completed, they were enrolled in the study, assigned
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Figure 1. Exercise protocols for the walking and stepping groups.
into two groups, pre-tested with the PAM, and scheduled to attend their respective exercise programs. Participants exercised for 10 weeks at 3 days a week of their choice: 2 days at the research facility and 1 day at their homes with written instructions provided. Four days of exercise sessions with two different time slots were made available at the research facility for the participants’ convenience facilitating adherence. The exercise protocols for the walking and stepping groups are presented in Figure 1. The duration of the walking sessions and height of the steps were progressed as long as knee pain intensity was no more than 4 on a scale of 1 to 10 during or within 1 hr after exercise. Heart rates and blood pressures were evaluated, and participants were also assessed for shortness of breath or difficulty speaking during the exercise sessions. Participants unable to progress were maintained at their present walking level or step height until they were able to advance. Participants were monitored by at least two trainers and supervised by one of the researchers. Trainers (health sciences students) were adequately trained on safety measures and on the two exercise protocols to facilitate integrity of the intervention. Along with the exercise sessions, all participants received an email from NCOA at Week 1 to register for the online SM program that was hosted in the NCOA website. Simple, easy, step-by-step instructions were provided for accessing the website and creating screen names. The screen names facilitated privacy and confidentiality especially when posting on the discussion boards or communicating with online NCOA-trained workshop facilitators for content questions.
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Participants committed to online static and dynamic modules for approximately 2 hr every week for 6 weeks at days and times of their convenience. Pre-set weekly modules with topics covered included (a) managing pain, (b) dealing with difficult emotions, (c) problem solving, (d) fitness and healthy eating, (e) conserving energy, (f) working and communicating with the health care team and significant others, and (g) other SM principles. An interactive discussion board was provided to encourage group support while individualized tailored care is enhanced through personalized tools (i.e., nutrition, exercise, pain diary). This was facilitated by trained NCOA staff who offered support to the research team. Every week for 6 weeks, participants received email reminders to complete their 2-hr weekly sessions. The researchers communicated with the NCOA staff regularly to ensure completion of the weekly sessions. Additional reminders were given to the participants as needed. A free SM book was also sent to the participants’ home addresses to augment the online information. Six weeks and 6 months following the combined SM and 10-week exercise program, all participants were contacted by telephone or email for follow-up. Participants were asked if they continued to exercise and if not, why not. They were also asked how many times they exercised each week, what type(s) of exercise, whether they managed their health adequately, and if they were able to maintain positive health behaviors (i.e., healthy eating, physical activity) to indicate continued SM. Throughout the study, effective interprofessional consultations among the researchers were maintained. The physical therapists and the nurses/nurse practitioners met regularly to facilitate the online SM program, progressive exercises, and staff training. A collaborative approach was employed during implementation of the combined SM and exercise program. Recruitment, data collection, and data analysis were also conducted with interprofessional participation.
Data Analysis Data were analyzed using the SPSS, version 19. Participant data were deidentified. Descriptive statistics, paired t tests, and ANOVA were conducted to analyze pre- and post-test data for within and between group differences in activation scores to SM.
Findings The participants (N = 16) were between 52 to 72 years old with a mean age of 60.9, and predominantly Caucasian (87.5%) with two Asians (12.5%). BMIs ranged from 25.1 to 51.4 with a mean BMI of 34.1. No significant
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Kawi et al. Table 1. Activation Scores to Self-Management and Activation Levels (N = 16). Pre-intervention Participants
Activation scores
Stepping group (n = 8) 1 91.6 2 86.3 3 49.9 4 75.3 5 66.0 6 49.9 7 70.8 8 68.5 Walking group (n = 8) 1 56.4 2 47.4 3 68.5 4 63.2 5 40.1 6 52.9 7 70.8 8 49.9
Post-intervention
Activation levels
Activation scores
Activation levels
4 4 2 4 3 2 4 4
100 86.3 60.0 77.5 100 60.0 80.0 100
4 4 3 4 4 3 4 4
3 2 4 3 1 2 4 2
70.8 56.4 80.0 66.0 70.8 75.3 82.8 45.2
4 3 4 3 4 4 4 1
baseline differences were noted between those assigned to the walking group or stepping group. All 16 participants completed the 10-week progressive exercise program. Of these, 11 completed all six sessions of the online SM program, 3 completed five sessions, and 2 completed four sessions. Participants were required to finish four or more sessions of the online SM program to be considered complete (NCOA & Arthritis Foundation, 2012). Activation scores to SM and activation levels are shown in Table 1.
Research Question 1: Activation Scores to SM The mean activation scores for all participants (n = 16) before and after intervention were 62.97 ± 14.44 and 75.69 ±16.15, respectively, r = .726, p = .001. The mean difference between activation scores before and after intervention for the full sample was 12.72 ± 11.43, t(15) = 4.45, p < .001. For the stepping group (n = 8), the mean activation scores before and after intervention were 69.79 ± 15.06 and 82.98 ±16.79, respectively, r = .689,
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p = .05. The mean difference between activation scores before and after intervention was 13.18 ± 12.65, t(7) = 2.947, p = .021. In the walking group (n = 8), the mean activation scores before and after intervention were 56.15 ± 10.69 and 68.41 ±12. 47, respectively, r = .564, p = .145. The mean difference between activation scores before and after intervention was 12.26 ± 10.92, t(8) = 3.174, p = .016.
Research Question 2: Change in Activation Scores to SM Using a 2 × 2 mixed between (Group)–within (Time) ANOVA, we tested the Time by Group interaction effect, as well as the main effects of Time and Group. The nonsignificant Time by Group effect showed that the magnitude of change in mean activation scores were similar across the walking and stepping groups (p = .878). The significant main effect of Time, Wilks’s λ = .430, F = 18.54, p = .001, indicated a significant overall increase in activation scores post-intervention for all participants. There was a statistically significant main effect of Group, indicating difference between subjects in the walking and stepping groups before and after intervention, p = .043, with those in the stepping group scoring higher regardless of measurement time. Figure 2 shows the increase in mean activation scores before and after intervention for each group.
Research Question 3: Activation Levels When activation scores were converted to activation levels based on specified cut-off points, the difference in activation levels to SM before and after intervention among all participants was significant (p = .034). Before intervention, 7 of the 16 participants (43.75%) were at SM Level 4, 3 were at Level 3 (18.75%), 5 at Level 2 (31.25%), and 1 at Level 1 (6.25%). After the intervention, there were 11 (68.75%) participants at Level 4, 4 (25%) at Level 3, and 1 (6.25%) remained at Level 1. However, when evaluated according to exercise group, no significant differences in activation levels were noted between the stepping (p = .083) or walking group (p = .131) before and after intervention.
Follow-Up Data At 6 weeks post-intervention, 14 of the 16 total participants (87.5%) continued to exercise at an average of three times every week. Two (12.5%) participants were unable to continue exercising due to low back pain and family illness. The most common types of exercises were walking, followed by
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Figure 2. This shows the estimated marginal means of the increase in activation scores to self-management for each group (stepping and walking) from Time 1 (pre-intervention) to Time 2 (post-intervention).
stepping, and others (i.e., swimming, aerobics, cycling). There were 15 (93.75%) participants who agreed or strongly agreed that they managed their health adequately with 1 (6.25%) who felt unchanged. When asked about maintaining positive health behaviors, 14 (87.5%) agreed or strongly agreed that they were able, 1 (6.25%) felt unchanged, and 1 (6.25%) was not able to maintain positive health behaviors. At 6 months post-intervention, 10 participants (62.5%) continued to exercise at an average of four times every week with 2 (12.5%) exercising intermittently, while 4 participants (25%) did not continue to exercise (2 due to time limitations and 2 due to low back pain). The most common exercises were walking, followed by stepping, and others (i.e., aerobics, running, swimming). Fifteen out of the 16 participants (93.75%) agreed that they managed their health adequately with 1 (6.25%) stating that she is “somewhat” able. Fourteen (87.5%) agreed that they maintained positive health behaviors, while 2 (12.5%) stated they “try.” There were no significant differences on exercise and health behavior maintenance self-reports between the stepping and walking groups during the follow-ups. When considering activation scores to SM in relation to the
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follow-up data, those who scored higher in the stepping group exercised an average of 3 to 4 times every week while those who scored higher in the walking group exercised an average of 2 to 3 times every week.
Discussion Activation scores to SM were significantly higher after intervention in all participants and when evaluated according to exercise groups (stepping and walking). Overall, activation scores increased significantly by an average of 12.72 points after intervention. This average increase was slightly higher (13.18) for the stepping group than the walking group (12.26). However, this difference was not statistically significant, indicating that regardless of the assigned exercise group, activation scores increased. This is consistent with previous studies on adults with OA where improved outcomes on SM skills and self-efficacy were observed after combined SM and exercise programs were implemented (McKnight et al., 2010; Yip et al., 2007; Yip et al., 2008). Furthermore, participants with higher activation scores before intervention also obtained higher scores after the intervention in this study. It is likely that individuals who are self-directed and motivated at the onset become even more proficient in SM after a combined SM and exercise program. Attaining higher activation scores is beneficial because these individuals are more likely to consistently maintain health-directed behaviors (Hibbard et al., 2004). A meta-analysis of studies reviewing exercise and/or SM programs in OA showed that more significant physical health improvements were noted in programs that had an exercise component (Devos-Comby et al., 2006). In contrast, another study involving middle-aged adults with knee OA found no significant differences in physical function between three groups of participants (SM only, exercise only, and combined exercise and SM; McKnight et al., 2010). It is clear that further studies need to be conducted evaluating exercise and online SM programs involving older overweight and obese women with knee OA. For activation levels, the increase in levels following intervention was statistically significant only for the full sample. When evaluated according to groups, the significance was not appreciated. This may be related to the small sample size limitation in this study. It was also noted that before intervention, participants were at various activation levels. The majority progressed to Level 4 after the intervention which is the highest level (having the ability to maintain health-directed behaviors) while some progressed to Level 3 (taking action into SM). This was consistent with data gathered at follow-up where majority of the participants were managing their health adequately and maintaining positive health behaviors.
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The follow-up data at 6 weeks and 6 months were promising. A majority of the participants continued to exercise. Although there were fewer participants (10 at 6 months compared with 14 at 6 weeks) who continued to exercise, the frequency of their exercise days increased from 3 to 4 days at 6 months. In a recent study, Voelker (2011) reported that patients with knee OA did not meet national activity guidelines because of low levels of activity especially in women; in a 7-day period, 40.1% of males and 56.5% of females were inactive. Most of the participants in this study, however, reported that they continued to manage their health adequately and maintained positive health behaviors after the intervention period. Although these are self-reports, the data are consistent with a recent meta-analyses of the Arthritis SelfManagement Program where self-efficacy and health-directed behaviors improved and were maintained long term at 9 to 12 months (CDC, 2011a). Although there are limitations to this pilot study (small sample size, sample of convenience with participants allocated into groups, use of self-reports, dosing between the two exercise groups), the results provide relevant direction for future larger studies on patient activation combining progressive exercise programs with SM sessions for overweight and obese older women with knee OA. Furthermore, interprofessional collaborative efforts were reflected in this study with the combined efforts of nurses/nurse practitioners, physical therapists, and allied health science students.
Application The lifetime risk for knee OA that produces symptoms of pain and functional limitations was reported at 44.7%; this risk was higher among those with increased BMI (Murphy et al., 2008). The symptoms of OA often result in a decline of physical activity, and while previous studies showed that exercise improves outcomes among patients with knee OA, patients still commonly associate increased physical activity with greater pain and physical damage resulting in fear avoidance. Consequently, decreased physical activity leads to even more chronic health conditions where management necessitates further increase in physical activity and weight loss (Chronic Osteoarthritis Management Initiative [COAMI] Work Group, 2012). In addition, it remains a challenge in clinical practice to advise older overweight or obese patients with knee OA to initiate and increase their physical activity. Hence, SM programs are critical components of care especially in these patients so that they become empowered to make positive health-directed decisions and actions to manage their health adequately. Although there is an initial need for supervised individualized exercise sessions especially for older overweight or obese women, online SM programs can be valuable for patients to facilitate
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an independent and convenient home-based exercise program maintaining adherence and long-term sustainability. Nurses can lead the way to patient activation and implementation of SM programs. National and international evidence-based guidelines and calls to priority actions for knee OA management strongly recommended patient activation to SM of OA (AAOS, 2013; COAMI Work Group, 2012; National Collaborating Centre for Chronic Conditions, 2008). Continued education, awareness, use of evidence-based guidelines by health care providers, and proactive approach to management during follow-ups to include activating patients to OA SM are essential. Unfortunately, the efforts of health care providers in motivating patients and supporting programs that enhance SM are lacking (COAMI Work Group, 2012). The following sites can be accessed by providers and patients with arthritis to engage in SM: (a) arthritis SM program through Stanford University: http://patienteducation.stanford.edu/programs/asmp.html, (b) NCOA online arthritis program: http:// www.arthritistoday.org/arthritis-self-management-program/index.php, and (c) the Arthritis Foundation: http://www.arthritis.org/chaptermap/php Furthermore, interprofessional approaches to management have not been customary in treating OA (COAMI Work Group, 2012). Current focus on management remains on episodic care based on symptom exacerbation instead of a coordinated, interprofessional approach. The emphasis on interprofessional care is essential with collaborative efforts among health care providers. Collaboration with outside agencies (i.e., NCOA) also proved to be valuable in this study. Policy considerations are also indicated; it is challenging to engage patients in SM during a 15-min primary care visit. Health care system changes are required, prompting policy makers and insurers to provide reimbursement for evidence-based SM programs to supplement exercise interventions especially for those without online access to SM programs. In summary, this pilot study was found to be feasible, combining exercise sessions that allowed for individualized progression, and an online delivery format of a SM program that was convenient and accessible. The exercise sessions were manageable, patient-centered, and flexible according to participants’ capabilities, preventing attrition. Exercise progression facilitated increasing intensity while allowing for modifications as needed. The combined exercise and SM intervention in this study was also sustainable at home based on the data gathered at follow-up. The importance of activation to SM in facilitating adherence to the exercise sessions, progression, and sustenance of independent home exercise was notable. Although this is a pilot study, the preliminary findings are valuable in the care of older overweight and obese women with knee OA prompting the need for replication in a larger sample.
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Lastly, several research studies were conducted on single isolated interventions (i.e., exercise by itself or SM alone). Few have looked at a combined program and activation to SM that are essential in managing the complexity of knee OA. Future research efforts need to focus on comprehensive programs for knee OA with increasing interprofessional involvement, potentially including nutritionists especially for the overweight/obese population, as well as psychologists to address mental health concerns as needed. Evaluation of comprehensive programs will necessitate analysis of direct and indirect health care costs in comparison with standard care considering the enormous costs associated with knee OA. Acknowledgment The authors are grateful to Julie Kosteas (Director) and Simona Eldridge (Senior Coordinator) with the National Council on Aging, the Arthritis Foundation, and the physical therapy student research group.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was supported by a grant from the University of Nevada, Las Vegas, School of Nursing and Allied Health Sciences.
References American Academy of Orthopaedic Surgeons. (2013). Treatment of osteoarthritis of the knee: Evidence-based guideline (2nd ed.). Rosemont, IL: Author. Centers for Disease Control and Prevention. (2011a). Executive summary of ASMP/ CDSMP meta-analyses. Retrieved from http://www.cdc.gov/arthritis/docs/ ASMP-executive-summary.pdf Centers for Disease Control and Prevention. (2011b). Healthy weight—It’s not a diet, it’s a lifestyle: About BMI for adults. Retrieved from http://www.cdc.gov/ healthyweight/assessing/bmi/adult_bmi/index.html#Definition Chronic Osteoarthritis Management Initiative Work Group. (2012). A new vision for chronic osteoarthritis management. Rosemont, IL: United States Bone and Joint Initiative. Devos-Comby, L., Cronan, T., & Roesch, S. C. (2006). Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review. The Journal of Rheumatology, 33, 744-756.
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Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogden, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999-2010. Journal of the American Medical Association, 307, 491-497. Fransen, M., & McConnell, S. (2009). Land-based exercise for osteoarthritis of the knee: A metaanalysis of randomized controlled trials. The Journal of Rheumatology, 36, 1109-1117. Harvey, P. W., Petkov, J. N., Misan, G., Fuller, J., Battersby, M. W., Cayetano, T. N., . . . Holmes, P. (2008). Self-management support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes. Australian Health Review, 32, 330-338. Hassan, B., Mockett, S., & Doherty, M. (2001). Static postural sway, proprioception, and maximal voluntary quadriceps contraction in patients with knee osteoarthritis and normal control subjects. Annals of the Rheumatic Diseases, 60, 612-218. Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32, 207-214. Hibbard, J. H., & Mahoney, E. R. (2010). Toward a theory of patient and consumer activation. Patient Education & Counseling, 78, 377-381. Hibbard, J. H., Mahoney, E. R., Stockard, J., & Tusler, M. (2005). Development and testing of a short form of the Patient Activation Measure. Health Services Research, 40, 1918-1930. Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39, 1005-1026. Kroon, F. P., van der Burg, L. R., Buchbinder, R., Osborne, R. H., Johnston, R. V., & Pitt, V. (2014). Self-management education programmes for osteoarthritis. Cochrane Database of Systematic Reviews, 1, CD008963. Lawrence, R. C., Felson, D. T., Helmick, C. G., Arnold, L. M., Choi, H., & Deyo, R. A., . . . National Arthritis Data Workgroup. (2008). Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis & Rheumatism, 58, 15-25. Lorig, K. R., & Holman, H. R. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1-7. McKnight, P. E., Kasle, S., Going, S., Villanueva, I., Cornett, M., Farr, J., . . . Zautra, A. (2010). A comparison of strength training, self-management, and the combination for early osteoarthritis of the knee. Arthritis Care & Research, 62, 45-53. McQuade, K. J., & de Oliveira, A. S. (2011). Effects of progressive resistance training on knee biomechanics during single leg step-up in persons with mild knee osteoarthritis. Clinical Biomechanics, 26, 741-748. Murphy, L., Schwartz, T. A., Helmick, C. G., Renner, J. B., Tudor, G., Koch, G., . . . Jordan, J. M. (2008). Lifetime risk of symptomatic knee osteoarthritis. Arthritis & Rheumatism, 59, 1207-1213. National Collaborating Centre for Chronic Conditions. (2008). Osteoarthritis: The care and management of osteoarthritis in adults. London, England: National Institute for Health and Clinical Excellence.
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National Council on Aging & Arthritis Foundation. (2012). Better choices, better health, arthritis. Retrieved from http://www.arthritistoday.org/arthritis-selfmanagement-program/index.php Roddy, E., Zhang, W., & Doherty, M. (2005). Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systemic review. Annals of the Rheumatic Diseases, 64, 544-548. Semanik, P. A., Chang, R. W., & Dunlop, D. D. (2012). Aerobic activity in prevention and symptom control of osteoarthritis. PM & R: The Journal of Injury, Function, and Rehabilitation, 4(Suppl.), S37-S44. Stanford School of Medicine. (2013). Arthritis self-management (self-help) program. Retrieved from http://patienteducation.stanford.edu/programs/asmp.html United States Bone and Joint Initiative. (2011). The burden of musculoskeletal diseases in the United States (2nd ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons. Voelker, R. (2011). Few adults with knee osteoarthritis meet national guidelines for physical activity. Journal of the American Medical Association, 306, 1428-1430. Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., . . . Murray, C. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380, 2163-2196. Wu, S. F. V., Kao, M. J., Wu, M. P., Tsai, M. W., & Chang, W. W. (2011). Effects of an osteoarthritis self-management programme. Journal of Advanced Nursing, 67, 1491-1501. Yip, Y. B., Sit, J. W., Fung, K. K., Wong, D. Y. S., Chong, S. Y. C., Chung, L. H., & Ng, T. P. (2007). Effects of a self-management arthritis programme with an added exercise component for osteoarthritic knee: Randomized controlled trial. Journal of Advanced Nursing, 59, 20-28. Yip, Y. B., Sit, J. W., Wong, D. Y. S., Chong, S. Y. C., & Chung, L. H. (2008). A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee. Psychology, Health & Medicine, 13, 402-414.
Author Biographies Jennifer Kawi, PhD, MSN, APRN, FNP-BC, is an assistant professor at the University of Nevada, Las Vegas, School of Nursing, Department of Physiological Nursing. Sue Schuerman, PT, PhD, GCS, is an assistant professor and director of Clinical Education at the Department of Physical Therapy, University of Nevada, Las Vegas. Patricia T. Alpert, DrPH, MSN, APRN, FNP-BC, PNP-BC, CNE, FAANP, is an associate professor and chair of the Department of Physiological Nursing, University of Nevada, Las Vegas. Daniel Young, PT, DPT, is an associate professor at the University of Nevada, Las Vegas, Department of Physical Therapy.
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Activation to Self-Management and Exercise in Overweight and Obese Older Women With Knee Osteoarthritis Jennifer Kawi, Sue Schuerman, Patricia T. Alpert and Daniel Young Clin Nurs Res published online 30 July 2014 DOI: 10.1177/1054773814544167 The online version of this article can be found at: http://cnr.sagepub.com/content/early/2014/07/28/1054773814544167
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544167 research-article2014
CNRXXX10.1177/1054773814544167Clinical Nursing ResearchKawi et al.
Article
Activation to Self-Management and Exercise in Overweight and Obese Older Women With Knee Osteoarthritis
Clinical Nursing Research 1–17 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814544167 cnr.sagepub.com
Jennifer Kawi, PhD, MSN, APRN, FNP-BC1, Sue Schuerman, PT, PhD, GCS1, Patricia T. Alpert, DrPH, MSN, APRN, FNP-BC, PNP-BC, CNE, FAANP1, and Daniel Young, PT, DPT1
Abstract Knee osteoarthritis (OA) affects approximately 1 in 10 adults in the United States, with higher prevalence in women, aggravated by increased weight. This quasi-experimental pilot study implemented an online selfmanagement (SM) program for older overweight and obese women with knee OA combined with a two-arm progressive exercise trial (walking and stepping groups). After the 10-week intervention using an interprofessional approach, activation to SM scores were significantly higher in all participants (N = 16) and between groups, with a higher increase in the stepping group. Those with higher activation scores pre-intervention obtained higher scores post-intervention. Activation levels also increased significantly among all participants with majority at the highest activation level. Follow-up data at 6 weeks and 6 months showed sustained SM and health-directed behaviors. 1University
of Nevada, Las Vegas, USA
Corresponding Author: Jennifer Kawi, Assistant Professor, Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-3018, USA. Email: [email protected]
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These findings, although preliminary, highlight the value of combined SM and progressive exercise intervention using an interprofessional approach. Further investigations are essential toward potential practice and policy changes. Keywords knee osteoarthritis, overweight, obesity, self-management, activation, exercise
Worldwide, knee osteoarthritis (OA) affects approximately 250 million individuals (Vos et al., 2012) with an estimated 1 in 10 adults afflicted in the United States (Lawrence et al., 2008). Knee OA is the most common form of OA, affecting 6.7% to 16.7% of adults 45 years of age and older; the prevalence is higher in women than men, especially among those 50 years and above (Lawrence et al., 2008). Another primary risk factor for OA is weight; two out of three individuals who are overweight or obese will develop knee OA in their lifetime prompting interventions that address selfmanagement (SM), activity, and weight (Murphy et al., 2008). The American Academy of Orthopaedic Surgeons (AAOS; 2013) released evidence-based guidelines for the management of knee OA. The AAOS strongly recommended patient participation in SM programs, strengthening exercises, physical activity, and weight loss for those with a body mass index (BMI) ≥ 25 kg/m2, often requiring interprofessional collaboration (United States Bone and Joint Initiative [USBJI], 2011). SM refers to health-directed tasks and skills with self-efficacy; individuals activated in SM are able to make appropriate decisions and engage in positive behaviors to allow adequate management of their chronic illnesses (Lorig & Holman, 2003). Hence, patient activation, referring to the individuals’ capacity to manage their health, is necessary in the SM of knee OA; those at higher levels of activation are more likely to self-manage by engaging in positive health behaviors (Hibbard & Mahoney, 2010). This interprofessional pilot study, involving the partnership of nursing and physical therapy, evaluated the impact of a combined SM program and exercise on activation to SM and activation levels in older women with knee OA and a BMI ≥ 25. Activation to SM represents individuals’ measure of their knowledge, skills, behaviors, and confidence toward SM, while activation levels indicate the degree of individuals’ capabilities to initiate and engage in health-directed behaviors (Hibbard, Stockard, Mahoney, & Tusler, 2004).
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Problem Although SM and strengthening exercises were highly recommended in clinical practice for knee OA (AAOS, 2013), there is a lack of research studies investigating activation to SM and the combined impact of an online SM program and progressive exercises focusing on older overweight or obese women with knee OA. This is a critical area of research considering the prevalence of knee OA in this population. Lifestyle changes to improve disease state and quality of life are essential in knee OA. Health improving behavioral changes (i.e., exercise) occur at a more successful rate if individuals are activated in SM (Hibbard & Mahoney, 2010).
Background OA is a chronic degenerative joint disease where progressive damage to the cartilage occurs resulting in symptoms of pain, swelling, and stiffness; it is the most common type of arthritis and has no cure (USBJI, 2011). Symptomatic OA leads to activity limitations that are higher among women (USBJI, 2011). Perpetuating this activity limitation is a BMI ≥ 25; weight is a strong contributory but modifiable risk factor for knee OA (USBJI, 2011). A BMI from 25 to 29.9 is considered overweight and a BMI ≥ 30 is categorized as obese (Centers for Disease Control and Prevention [CDC], 2011b). There are 68.8% of adults who are overweight and obese, with a greater percentage of obesity in women compared to men (Flegal, Carroll, Kit, & Ogden, 2012). Consequently, the management of OA is costly with 11.3 million outpatient visits a year (AAOS, 2013). This does not include health care visits related to hospitalizations, procedures, surgeries, and indirect costs like missed workdays. The global burden of knee OA is extensive and its management is challenging. Physical activity has been shown to help decrease the burden of OA through improving strength and function, reducing pain, and promoting fitness and healthy joints (Semanik, Chang, & Dunlop, 2012). However, older individuals commonly have weak muscles in the lower extremity causing knee instability, leading to further degenerative changes and reduced activity (Hassan, Mockett, & Doherty, 2001). Consequently, studies have reported that walking and single leg step-up, and strengthening exercises were successful in reducing pain and improving strength and self-reported disabilities in individuals with knee OA (McQuade & de Oliveira, 2011; Roddy, Zhang, & Doherty, 2005). Further, studies from a meta-analysis of knee OA exercise programs noted that stepping and mini-squat exercises facilitated muscle strengthening to improve pain and function (Fransen & McConnell, 2009). However, promoting physical activity and exercise in older overweight or
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obese individuals with knee OA can be challenging. Progressive walking and stepping exercises allowing gradual increase in activity individualized to patient needs, and supervised treatment sessions can facilitate exercise and improve outcomes (Fransen & McConnell, 2009). In addition, a combined intervention protocol of a SM program with the progressive exercise sessions can facilitate improved OA outcomes and lead to long-term adherence of a sustained, independent, and self-managed home exercise program. SM interventions in OA have resulted in improved levels of pain, functional disability, depression, anxiety, self-efficacy, SM skills, and healthdirected behaviors (CDC, 2011a; Harvey et al., 2008; Wu, Kao, Wu, Tsai, & Chang, 2011). For example, a widely used SM program called the Arthritis Self-Management Program was developed in 1979 and evaluated in several randomized controlled studies (Stanford School of Medicine, 2013). This online SM program is consistent with the concept of SM described by Lorig and Holman (2003), the theoretical foundation used in this study. The Arthritis Self-Management Program was made available online to increase patient access through a partnership between the National Council on Aging (NCOA) and Arthritis Foundation (2012). Online groups are kept small and manageable with no more than 25 participants. The online program is convenient to participants and accessible anytime. Information is kept private and confidential. There are also minimal technical requirements for ease of use that is especially helpful for older individuals. Evaluation of this online version showed reduction in pain, fear, frustration, worry, and improved activity and SM (NCOA & Arthritis Foundation, 2012). However, SM alone has not been found sufficient in managing OA (Kroon et al., 2014). In the past years, some studies have looked at the effects of combined SM and exercise programs in OA (Devos-Comby, Cronan, & Roesch, 2006; McKnight et al., 2010; Yip et al., 2007; Yip, Sit, Wong, Chong, & Chung, 2008). Overall, reductions in pain and disability, and improvement in self-efficacy, physical health, and psychological outcomes were appreciated. However, there is a lack of research studies evaluating activation to SM and the impact of combined online SM program and progressive walking or stepping exercises on older, overweight, or obese women with knee OA. Patient activation is essential in SM as this has been shown to improve disease outcomes, experiences in patient care, and health care costs (Hibbard & Greene, 2013).
Purpose The purposes of this interprofessional pilot study were to (a) provide training in two low-to-moderate exercise strategies that gradually advance in intensity
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(progressive walking or progressive stepping) for older overweight or obese women with knee OA, toward independence in performing the exercise in their own homes and (b) implement an online SM program to enhance adherence, progression, and sustainability of exercise. The following were the specific research questions: Research Question 1: Were there significant differences in mean activation scores to SM comparing pre- to post-intervention for the full sample, and the walking and stepping groups separately? Research Question 2: Were there significant differences in the change in mean activation scores to SM in the full sample and between the two exercise groups? Research Question 3: Were there significant differences in activation levels for the full sample and between the two exercise groups?
Methods This pilot study utilized a quasi-experimental design with a two-arm exercise trial: progressive walking or progressive stepping. Both groups received an online SM program. This study was carried out in five phases: recruitment and screening, allocation into two groups and pre-testing, implementation, post-testing, and follow-ups at 6 weeks and 6 months. An interprofessional approach was used with physical therapy managing the exercise program while collaborating with nursing in overseeing the online SM program.
Sample and Setting Participants were recruited using flyers posted at senior centers and primary care offices throughout Clark County, Nevada. Blast emails were also sent through university announcements and to members of a university program for retired and semi-retired individuals. Inclusion criteria were (a) female, (b) 50 years of age or older, (c) BMI of 25 and over, and (d) OA in one or both knees confirmed by radiologists through X-rays. Exclusion criteria were (a) history of joint replacement or major trauma to lower extremities; (b) history of rheumatoid arthritis, osteoporosis, or uncontrolled high blood pressure; (c) use of opioid-based pain relievers or corticosteroid injections in the past 30 days; (d) currently enrolled in a rehabilitation program; or (e) having been advised by a health care provider not to participate in any exercise due to heart disease or other medical condition. A total of 26 participants were screened; 7 did not meet the inclusion criteria and 3 did not proceed to the implementation phase (no show, personal reasons).
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After Institutional Review Board approval, informed consent was obtained from each participant. A convenience sample of participants were alternately assigned as they were enrolled in the study to a progressive walking group (n = 8) or a progressive stepping group (n = 8). Demographic information was gathered (age, race, height, weight, BMI). Incentives were given which included steps for the stepping group, exercise shoe vouchers for the walking group, and a monetary incentive given to all participants.
Patient Activation Measure (PAM), Short Version The PAM was given to all participants prior to the start of this study and after completion. The PAM evaluates patient activation to SM (Hibbard et al., 2004). It is a unidimensional, cumulative survey, with a 4-point Guttman scale (“strongly agree” to “strongly disagree”). Using Rasch methodology, raw ordinal level data are converted to a 0 to 100 interval scale representing scores of patient activation to SM (Hibbard et al., 2004). These scores indicate the knowledge, skills, behaviors, and confidence of individuals in selfmanaging their chronic illnesses (Hibbard et al., 2004). Subsequently, these scores are categorized into four specified cut-off points that represent four levels of activation to SM in a hierarchical order (Hibbard et al., 2004). Level 1 describes a participant beginning to take part in SM (activation score of 47 or lower). Level 2 indicates a growing confidence in and knowledge of SM (47.1 to 55.1). Level 3 involves taking direct action in SM (55.2 to 67). Level 4 is the highest activation to SM (67.1 or above) and includes the ability to maintain health-directed behaviors and to stay within course of adequately managing one’s chronic illness. The short version 13-item PAM facilitates completion of surveys and has demonstrated item conformity with infit values of 0.92 to 1.05 and outfit values of 0.85 to 1.11 (Hibbard, Mahoney, Stockard, & Tusler, 2005). These were consistent with the fit values of the original, conceptually validated 22-item version (Hibbard et al., 2004). Stability was demonstrated in those without or with various chronic conditions (.90 to .91) and between variable responses to self-rated health (.87 to .91). Construct validity was supported by Hibbard and colleagues where those having higher activation reported significantly better health when correlated with the Short Form 8 Health Survey (SF-8), r = .38, p < .001, and lower rates of health care utilization (r = −.07, p < .01).
Procedures After all participants were screened based on the inclusion and exclusion criteria with knee X-rays completed, they were enrolled in the study, assigned
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Figure 1. Exercise protocols for the walking and stepping groups.
into two groups, pre-tested with the PAM, and scheduled to attend their respective exercise programs. Participants exercised for 10 weeks at 3 days a week of their choice: 2 days at the research facility and 1 day at their homes with written instructions provided. Four days of exercise sessions with two different time slots were made available at the research facility for the participants’ convenience facilitating adherence. The exercise protocols for the walking and stepping groups are presented in Figure 1. The duration of the walking sessions and height of the steps were progressed as long as knee pain intensity was no more than 4 on a scale of 1 to 10 during or within 1 hr after exercise. Heart rates and blood pressures were evaluated, and participants were also assessed for shortness of breath or difficulty speaking during the exercise sessions. Participants unable to progress were maintained at their present walking level or step height until they were able to advance. Participants were monitored by at least two trainers and supervised by one of the researchers. Trainers (health sciences students) were adequately trained on safety measures and on the two exercise protocols to facilitate integrity of the intervention. Along with the exercise sessions, all participants received an email from NCOA at Week 1 to register for the online SM program that was hosted in the NCOA website. Simple, easy, step-by-step instructions were provided for accessing the website and creating screen names. The screen names facilitated privacy and confidentiality especially when posting on the discussion boards or communicating with online NCOA-trained workshop facilitators for content questions.
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Participants committed to online static and dynamic modules for approximately 2 hr every week for 6 weeks at days and times of their convenience. Pre-set weekly modules with topics covered included (a) managing pain, (b) dealing with difficult emotions, (c) problem solving, (d) fitness and healthy eating, (e) conserving energy, (f) working and communicating with the health care team and significant others, and (g) other SM principles. An interactive discussion board was provided to encourage group support while individualized tailored care is enhanced through personalized tools (i.e., nutrition, exercise, pain diary). This was facilitated by trained NCOA staff who offered support to the research team. Every week for 6 weeks, participants received email reminders to complete their 2-hr weekly sessions. The researchers communicated with the NCOA staff regularly to ensure completion of the weekly sessions. Additional reminders were given to the participants as needed. A free SM book was also sent to the participants’ home addresses to augment the online information. Six weeks and 6 months following the combined SM and 10-week exercise program, all participants were contacted by telephone or email for follow-up. Participants were asked if they continued to exercise and if not, why not. They were also asked how many times they exercised each week, what type(s) of exercise, whether they managed their health adequately, and if they were able to maintain positive health behaviors (i.e., healthy eating, physical activity) to indicate continued SM. Throughout the study, effective interprofessional consultations among the researchers were maintained. The physical therapists and the nurses/nurse practitioners met regularly to facilitate the online SM program, progressive exercises, and staff training. A collaborative approach was employed during implementation of the combined SM and exercise program. Recruitment, data collection, and data analysis were also conducted with interprofessional participation.
Data Analysis Data were analyzed using the SPSS, version 19. Participant data were deidentified. Descriptive statistics, paired t tests, and ANOVA were conducted to analyze pre- and post-test data for within and between group differences in activation scores to SM.
Findings The participants (N = 16) were between 52 to 72 years old with a mean age of 60.9, and predominantly Caucasian (87.5%) with two Asians (12.5%). BMIs ranged from 25.1 to 51.4 with a mean BMI of 34.1. No significant
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Kawi et al. Table 1. Activation Scores to Self-Management and Activation Levels (N = 16). Pre-intervention Participants
Activation scores
Stepping group (n = 8) 1 91.6 2 86.3 3 49.9 4 75.3 5 66.0 6 49.9 7 70.8 8 68.5 Walking group (n = 8) 1 56.4 2 47.4 3 68.5 4 63.2 5 40.1 6 52.9 7 70.8 8 49.9
Post-intervention
Activation levels
Activation scores
Activation levels
4 4 2 4 3 2 4 4
100 86.3 60.0 77.5 100 60.0 80.0 100
4 4 3 4 4 3 4 4
3 2 4 3 1 2 4 2
70.8 56.4 80.0 66.0 70.8 75.3 82.8 45.2
4 3 4 3 4 4 4 1
baseline differences were noted between those assigned to the walking group or stepping group. All 16 participants completed the 10-week progressive exercise program. Of these, 11 completed all six sessions of the online SM program, 3 completed five sessions, and 2 completed four sessions. Participants were required to finish four or more sessions of the online SM program to be considered complete (NCOA & Arthritis Foundation, 2012). Activation scores to SM and activation levels are shown in Table 1.
Research Question 1: Activation Scores to SM The mean activation scores for all participants (n = 16) before and after intervention were 62.97 ± 14.44 and 75.69 ±16.15, respectively, r = .726, p = .001. The mean difference between activation scores before and after intervention for the full sample was 12.72 ± 11.43, t(15) = 4.45, p < .001. For the stepping group (n = 8), the mean activation scores before and after intervention were 69.79 ± 15.06 and 82.98 ±16.79, respectively, r = .689,
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p = .05. The mean difference between activation scores before and after intervention was 13.18 ± 12.65, t(7) = 2.947, p = .021. In the walking group (n = 8), the mean activation scores before and after intervention were 56.15 ± 10.69 and 68.41 ±12. 47, respectively, r = .564, p = .145. The mean difference between activation scores before and after intervention was 12.26 ± 10.92, t(8) = 3.174, p = .016.
Research Question 2: Change in Activation Scores to SM Using a 2 × 2 mixed between (Group)–within (Time) ANOVA, we tested the Time by Group interaction effect, as well as the main effects of Time and Group. The nonsignificant Time by Group effect showed that the magnitude of change in mean activation scores were similar across the walking and stepping groups (p = .878). The significant main effect of Time, Wilks’s λ = .430, F = 18.54, p = .001, indicated a significant overall increase in activation scores post-intervention for all participants. There was a statistically significant main effect of Group, indicating difference between subjects in the walking and stepping groups before and after intervention, p = .043, with those in the stepping group scoring higher regardless of measurement time. Figure 2 shows the increase in mean activation scores before and after intervention for each group.
Research Question 3: Activation Levels When activation scores were converted to activation levels based on specified cut-off points, the difference in activation levels to SM before and after intervention among all participants was significant (p = .034). Before intervention, 7 of the 16 participants (43.75%) were at SM Level 4, 3 were at Level 3 (18.75%), 5 at Level 2 (31.25%), and 1 at Level 1 (6.25%). After the intervention, there were 11 (68.75%) participants at Level 4, 4 (25%) at Level 3, and 1 (6.25%) remained at Level 1. However, when evaluated according to exercise group, no significant differences in activation levels were noted between the stepping (p = .083) or walking group (p = .131) before and after intervention.
Follow-Up Data At 6 weeks post-intervention, 14 of the 16 total participants (87.5%) continued to exercise at an average of three times every week. Two (12.5%) participants were unable to continue exercising due to low back pain and family illness. The most common types of exercises were walking, followed by
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Figure 2. This shows the estimated marginal means of the increase in activation scores to self-management for each group (stepping and walking) from Time 1 (pre-intervention) to Time 2 (post-intervention).
stepping, and others (i.e., swimming, aerobics, cycling). There were 15 (93.75%) participants who agreed or strongly agreed that they managed their health adequately with 1 (6.25%) who felt unchanged. When asked about maintaining positive health behaviors, 14 (87.5%) agreed or strongly agreed that they were able, 1 (6.25%) felt unchanged, and 1 (6.25%) was not able to maintain positive health behaviors. At 6 months post-intervention, 10 participants (62.5%) continued to exercise at an average of four times every week with 2 (12.5%) exercising intermittently, while 4 participants (25%) did not continue to exercise (2 due to time limitations and 2 due to low back pain). The most common exercises were walking, followed by stepping, and others (i.e., aerobics, running, swimming). Fifteen out of the 16 participants (93.75%) agreed that they managed their health adequately with 1 (6.25%) stating that she is “somewhat” able. Fourteen (87.5%) agreed that they maintained positive health behaviors, while 2 (12.5%) stated they “try.” There were no significant differences on exercise and health behavior maintenance self-reports between the stepping and walking groups during the follow-ups. When considering activation scores to SM in relation to the
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follow-up data, those who scored higher in the stepping group exercised an average of 3 to 4 times every week while those who scored higher in the walking group exercised an average of 2 to 3 times every week.
Discussion Activation scores to SM were significantly higher after intervention in all participants and when evaluated according to exercise groups (stepping and walking). Overall, activation scores increased significantly by an average of 12.72 points after intervention. This average increase was slightly higher (13.18) for the stepping group than the walking group (12.26). However, this difference was not statistically significant, indicating that regardless of the assigned exercise group, activation scores increased. This is consistent with previous studies on adults with OA where improved outcomes on SM skills and self-efficacy were observed after combined SM and exercise programs were implemented (McKnight et al., 2010; Yip et al., 2007; Yip et al., 2008). Furthermore, participants with higher activation scores before intervention also obtained higher scores after the intervention in this study. It is likely that individuals who are self-directed and motivated at the onset become even more proficient in SM after a combined SM and exercise program. Attaining higher activation scores is beneficial because these individuals are more likely to consistently maintain health-directed behaviors (Hibbard et al., 2004). A meta-analysis of studies reviewing exercise and/or SM programs in OA showed that more significant physical health improvements were noted in programs that had an exercise component (Devos-Comby et al., 2006). In contrast, another study involving middle-aged adults with knee OA found no significant differences in physical function between three groups of participants (SM only, exercise only, and combined exercise and SM; McKnight et al., 2010). It is clear that further studies need to be conducted evaluating exercise and online SM programs involving older overweight and obese women with knee OA. For activation levels, the increase in levels following intervention was statistically significant only for the full sample. When evaluated according to groups, the significance was not appreciated. This may be related to the small sample size limitation in this study. It was also noted that before intervention, participants were at various activation levels. The majority progressed to Level 4 after the intervention which is the highest level (having the ability to maintain health-directed behaviors) while some progressed to Level 3 (taking action into SM). This was consistent with data gathered at follow-up where majority of the participants were managing their health adequately and maintaining positive health behaviors.
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The follow-up data at 6 weeks and 6 months were promising. A majority of the participants continued to exercise. Although there were fewer participants (10 at 6 months compared with 14 at 6 weeks) who continued to exercise, the frequency of their exercise days increased from 3 to 4 days at 6 months. In a recent study, Voelker (2011) reported that patients with knee OA did not meet national activity guidelines because of low levels of activity especially in women; in a 7-day period, 40.1% of males and 56.5% of females were inactive. Most of the participants in this study, however, reported that they continued to manage their health adequately and maintained positive health behaviors after the intervention period. Although these are self-reports, the data are consistent with a recent meta-analyses of the Arthritis SelfManagement Program where self-efficacy and health-directed behaviors improved and were maintained long term at 9 to 12 months (CDC, 2011a). Although there are limitations to this pilot study (small sample size, sample of convenience with participants allocated into groups, use of self-reports, dosing between the two exercise groups), the results provide relevant direction for future larger studies on patient activation combining progressive exercise programs with SM sessions for overweight and obese older women with knee OA. Furthermore, interprofessional collaborative efforts were reflected in this study with the combined efforts of nurses/nurse practitioners, physical therapists, and allied health science students.
Application The lifetime risk for knee OA that produces symptoms of pain and functional limitations was reported at 44.7%; this risk was higher among those with increased BMI (Murphy et al., 2008). The symptoms of OA often result in a decline of physical activity, and while previous studies showed that exercise improves outcomes among patients with knee OA, patients still commonly associate increased physical activity with greater pain and physical damage resulting in fear avoidance. Consequently, decreased physical activity leads to even more chronic health conditions where management necessitates further increase in physical activity and weight loss (Chronic Osteoarthritis Management Initiative [COAMI] Work Group, 2012). In addition, it remains a challenge in clinical practice to advise older overweight or obese patients with knee OA to initiate and increase their physical activity. Hence, SM programs are critical components of care especially in these patients so that they become empowered to make positive health-directed decisions and actions to manage their health adequately. Although there is an initial need for supervised individualized exercise sessions especially for older overweight or obese women, online SM programs can be valuable for patients to facilitate
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an independent and convenient home-based exercise program maintaining adherence and long-term sustainability. Nurses can lead the way to patient activation and implementation of SM programs. National and international evidence-based guidelines and calls to priority actions for knee OA management strongly recommended patient activation to SM of OA (AAOS, 2013; COAMI Work Group, 2012; National Collaborating Centre for Chronic Conditions, 2008). Continued education, awareness, use of evidence-based guidelines by health care providers, and proactive approach to management during follow-ups to include activating patients to OA SM are essential. Unfortunately, the efforts of health care providers in motivating patients and supporting programs that enhance SM are lacking (COAMI Work Group, 2012). The following sites can be accessed by providers and patients with arthritis to engage in SM: (a) arthritis SM program through Stanford University: http://patienteducation.stanford.edu/programs/asmp.html, (b) NCOA online arthritis program: http:// www.arthritistoday.org/arthritis-self-management-program/index.php, and (c) the Arthritis Foundation: http://www.arthritis.org/chaptermap/php Furthermore, interprofessional approaches to management have not been customary in treating OA (COAMI Work Group, 2012). Current focus on management remains on episodic care based on symptom exacerbation instead of a coordinated, interprofessional approach. The emphasis on interprofessional care is essential with collaborative efforts among health care providers. Collaboration with outside agencies (i.e., NCOA) also proved to be valuable in this study. Policy considerations are also indicated; it is challenging to engage patients in SM during a 15-min primary care visit. Health care system changes are required, prompting policy makers and insurers to provide reimbursement for evidence-based SM programs to supplement exercise interventions especially for those without online access to SM programs. In summary, this pilot study was found to be feasible, combining exercise sessions that allowed for individualized progression, and an online delivery format of a SM program that was convenient and accessible. The exercise sessions were manageable, patient-centered, and flexible according to participants’ capabilities, preventing attrition. Exercise progression facilitated increasing intensity while allowing for modifications as needed. The combined exercise and SM intervention in this study was also sustainable at home based on the data gathered at follow-up. The importance of activation to SM in facilitating adherence to the exercise sessions, progression, and sustenance of independent home exercise was notable. Although this is a pilot study, the preliminary findings are valuable in the care of older overweight and obese women with knee OA prompting the need for replication in a larger sample.
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Lastly, several research studies were conducted on single isolated interventions (i.e., exercise by itself or SM alone). Few have looked at a combined program and activation to SM that are essential in managing the complexity of knee OA. Future research efforts need to focus on comprehensive programs for knee OA with increasing interprofessional involvement, potentially including nutritionists especially for the overweight/obese population, as well as psychologists to address mental health concerns as needed. Evaluation of comprehensive programs will necessitate analysis of direct and indirect health care costs in comparison with standard care considering the enormous costs associated with knee OA. Acknowledgment The authors are grateful to Julie Kosteas (Director) and Simona Eldridge (Senior Coordinator) with the National Council on Aging, the Arthritis Foundation, and the physical therapy student research group.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was supported by a grant from the University of Nevada, Las Vegas, School of Nursing and Allied Health Sciences.
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Author Biographies Jennifer Kawi, PhD, MSN, APRN, FNP-BC, is an assistant professor at the University of Nevada, Las Vegas, School of Nursing, Department of Physiological Nursing. Sue Schuerman, PT, PhD, GCS, is an assistant professor and director of Clinical Education at the Department of Physical Therapy, University of Nevada, Las Vegas. Patricia T. Alpert, DrPH, MSN, APRN, FNP-BC, PNP-BC, CNE, FAANP, is an associate professor and chair of the Department of Physiological Nursing, University of Nevada, Las Vegas. Daniel Young, PT, DPT, is an associate professor at the University of Nevada, Las Vegas, Department of Physical Therapy.
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