523493 research-article2014
WJNXXX10.1177/0193945914523493Western Journal of Nursing ResearchPowell-Cope et al.
Article
Perceived Benefits of Group Exercise Among Individuals With Peripheral Neuropathy
Western Journal of Nursing Research 2014, Vol. 36(7) 855–874 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914523493 wjn.sagepub.com
Gail Powell-Cope1, Patricia A. Quigley1, Karen Besterman-Dahan1, and Jason D. Lind1
Abstract Exercise and training programs improve strength, functional balance, and prevent falls in a variety of populations. This article presents the qualitative findings related to the perceived benefits of participants in a randomized controlled trial that compared the effectiveness of group exercise on gait and balance in persons with peripheral neuropathy (PN). Participants with moderately severe PN were randomized into groups that received 10-week classes of Functional Balance Training (FBT) or Tai Chi or education alone. Perceptions of the intervention were overwhelmingly positive regardless of the study group. Perceived benefits reported by participants in the FBT and Tai Chi groups included awareness of how to deal with the effects of neuropathy by implementing balance strategies and a heightened sense of walking to prevent falls. This study offers a guide to design future exercise studies that promote simple balance exercises that can be performed in group settings. Keywords perception, health benefits, peripheral neuropathies, Tai Chi
1HSR&D/RR&D
Center of Innovation on Disability and Rehabilitation Research (CINDRR)
Corresponding Author: Gail Powell-Cope, PhD, ARNP, FAAN; HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); James A. Haley Veterans' Hospital, 8900 Grand Oaks Circle, Tampa, FL 33637, USA. Email: [email protected]
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
856
Western Journal of Nursing Research 36(7)
Evidence suggests that exercise programs can effectively improve gait and balance in fall risk populations and reduce falls and fall-related injuries (Baker, Atlantis, & Fiatarone Singh, 2007; Hanley, Silke, & Murphy, 2011; Herwaldt & Pottinger, 2003; Rose & Hernandez, 2010; Skelton & Beyer, 2003). While exercise interventions come in various forms, the most common are functional balance exercise training and Tai Chi (Alfieri, 2010; Bulat et al., 2007; Chin & Paw, 2008; Liu-Ambrose et al., 2004; Yau, 2008). Researchers are beginning to document that exercise interventions positively influence a person’s fall self-efficacy by promoting self-confidence to avoid a fall, an important factor in understanding and examining a person’s behaviors related to fall risks (Gillespie et al., 2003; Jahnke, Larkey, & Rogers, 2010; Jung, Lee, & Lee, 2009; Kumar, Vendhan, Awasthi, Tiwari, & Sharma, 2008; Moylan & Binder, 2007; Sattin, Easley, Wolf, Chen, & Kutner, 2005). However, adults are reluctant to value and perform routine exercises. Regular exercise is an important therapeutic intervention for successful aging for persons to maintain strength, range of motion, and endurance (Baraff, Penna, Williams, & Sanders, 1997). Healthy People 2000 (Department of Health and Human Services [DHHS], 1992), and Healthy People 2010 (DHHS, 2001), related that most people, including older people, do not engage in regular exercise despite its known benefits. Healthy People 2020 established goals and objectives for older people to improve their health, function, and quality of life, and addressed falls and fall-related injuries for the first time (DHHS, 2010). We examined functional balance versus Tai Chi, compared with a control group that only received education, as part of a clinical trial to test the effectiveness of group exercises on gait and balance in persons with peripheral neuropathy (PN) (Quigley et al., 2014). We used qualitative methods to examine the perceived benefits of exercise by asking the question: What are the immediate (10-week) and long-term (6-month) patient-perceived benefits for the Tai Chi and Functional Balance Training (FBT) groups? The use of peer volunteers to enhance activity has been reported in various population groups in the literature. Peer support has been used for chronic disease prevention involving nutrition, exercise, and smoking in indigenous urban populations (Adams, Paasse, & Clinch, 2011); pedometry in ethnic populations (Thomas et al., 2012); cardiovascular fitness in persons with mental illness (Gill, 2012); and diabetics using the mobile phone buddy system (Rotheram-Borus et al., 2012). Peer mentors are being studied as an alternative to paid staff which can escalate the cost of interventions such as exercise (Buman et al., 2011). Buman et al. (2011) conducted a randomized controlled trial (RCT) involving sedentary participants more than 50 years old who were matched with peers. Participants were randomized to two
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
857
16-week programs either involving peer support (n = 7) for behavioral changes in physical activity, or standard community resources (e.g., gym; n = 81). Participants were followed for 16 weeks (retention 85%) and followedup at 18 months (retention 61%). Self-reported moderate-to-vigorous physical activity (MVPA) was increased significantly in both the peer support group and the control group at 16 weeks, but the group with peer support had significantly more MVPA behavior at 18-month follow-up. In a 4-month exercise program, Jerome et al. (2012) conducted a trial, Activating Consumers to Exercise (ACE) Through Peer Support, involving persons (n = 93) with serious mental illness and the effect of peer support leaders from the community (n = 18). There were no differences in demographics and between the groups and average fitness levels were similar in that 95% of the sample scored below average on metabolic equivalent level (participants 5.9, SD = 2.2; peer leaders 6.2, SD = 2.3). The 6-min walk and treadmill fitness test (r2 = .36, p < .001) as well as an elevated basal metabolic index and lower metabolic equivalent levels (r2 = −.36, p < .001) were associated. Allet and colleagues (2010) conducted a RCT with participants who had diabetic neuropathy (n = 35) who received gait, balance, and strengthening exercises twice a week for 12 weeks; the control group (n = 35) received no training. These researchers found that, unlike the control group, the treatment arm increased their walking speed by 0.149 m/s (p < .001), reduced their time to walk over a beam, improved their balance sway index and mobility, decreased their concern about falling, and increased their hip and ankle plantar flexor strength and their hip flexion mobility. At 6-month follow-up, all gains in the interventional group remained significant except for the sway index and ankle plantar flexor strength. In a similar diabetic population with mild to moderate neuropathy, Morrison, Colberg, Mariano, Parson, and Vinik (2010) compared patients in an intervention group (n = 16) who were agematched with adults 50 to 75 years of age in a control group (n = 21). After a 6-week exercise program, the intervention group demonstrated significant gains in leg strength, had faster reaction times, and decreased falls and sway. In another RCT examining balance in sedentary diabetic patients with PN, however, Kruse, LeMaster, and Madsen (2010) conducted a 12-month study in a physical therapy office and subsequently in the community. The intervention group (n = 79) underwent leg strengthening and balance exercises, followed a walking regimen, and received follow-up phone calls. The intervention group, and control (n = 38) group, received foot care information and had eight physical therapy sessions. Although no significant differences were found in strength, balance, and number of falls at 12 months, participants in the intervention group could stand with their eyes closed on one leg longer but this was not statistically significant.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
858
Western Journal of Nursing Research 36(7)
For the qualitative portion of our study, embedded in the RCT, we were interested in patient-perceived significance of the interventions, that is, the immediate (within 6 weeks) coping mechanisms the individual uses to achieve adaptational outcomes in the areas of improved gait and balance (Lazarus & Folkman, 1984). According to Strauss (1984), any given disease can potentially cause multiple problems with activities of daily living (ADL) for the person, including the control of symptoms, carrying out prescribed regimens (e.g., performance of exercise and Tai Chi), prevention or living with social isolation (perhaps exacerbated by physical symptoms), adjustment to changes in the course of the illness, attempts to normalize interactions with others and style of life, dealing with funding to pay for the illness, and confronting attendant psychological, marital, and familial problems. From this perspective, gait and balance problems were conceptualized as components of aging and chronic illness that required coping adjustments in how that individual carried out his or her life, engaged in ADL and instrumental ADL, organized care, and adjusted to new social arrangements with caregivers, health care providers, and family members. Qualitative researchers have reported on participants' experiences and perceived benefits of exercise programs, which are critical in the design, implementation, participation, and success of interventions. Qualitative interviews of 100 patients with cancer undergoing chemotherapy, participating in a 6-week multidimensional exercise program found positive attitudes toward physical capacity tests following the intervention (Knutsen, Quist, Midtgaard, Rorth, & Adamsen, 2006). Physical, psychological, and social benefits of a 10-week progressive resistance strengthening program were noted in participants with multiple sclerosis. Participants reported reduced fatigue as a result of the program. Intrinsic factors for program completion included enjoyment, determination, seeing signs of progress, and previously held positive attitude about the benefits of exercise; extrinsic factors included leaders' encouragement and knowledge and group aspects of the program (Dodd, Taylor, Denisenko, & Prasad, 2006). Focus groups with adults with arthritis, grouped according to exercise status, were conducted to determine perceived barriers, benefits, and enablers for exercising. Although arthritis symptoms such as pain, stiffness, and fatigue were described as barriers to exercise, improvements in these symptoms were viewed as potential benefits of and motivations for exercise. The role of exercise in promoting independence was a significant and highly motivating benefit, particularly among exercisers; nonexercisers, however, had doubts that they would benefit from exercise and were unsure if increased pain would be worth the benefits (Wilcox et al., 2006). Perceived benefits of exercise and the factors that influence participation were explored in a qualitative study with focus groups of older and
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
859
younger people. Findings indicated that older people were not likely to participate in exercise for its own sake, but were motivated by social benefits of exercise. Furthermore, different strategies were suggested depending on the physical activity level of the intended participant (Stead, Wimbush, Eadie, & Teer, 1997).
Method We used a mixed methods research design in which the qualitative portion of the study was embedded into the primary focus, the quantitative RCT (Creswell & Plano Clark, 2011). The quantitative data set was primary, and the qualitative data were used to answer a different research question. Data were collected during 2006-2008 at the James A. Haley Veterans’ Hospital in Tampa, Florida.
Sample Three hundred seventy-one persons responded for the initial telephone screening for the study between March 2005 and December 2008. Study inclusion criteria were men or women over the age of 60, no vision impairments (no worse than 20/50 vision), mild or moderate level of neuropathy based on the Michigan Diabetic Neuropathy Test, self-reported as ambulatory, no cognitive impairments based on the Mini-Mental State Examination, no diagnosis of metastatic cancer, no diagnosis of a central nervous system disease, no lower limb impairment or abnormality, and no impaired skin integrity. One hundred forty nine failed to meet admission criteria or were not interested in the study during the screening interview. One hundred twenty two persons were invited to take a physical exam of which 21 failed and were thus excluded from the study. The remaining 101 subjects were subsequently enrolled and randomized into three groups: FBT (n = 33), Tai Chi (n = 34), and Education Control Group (n = 34). Baseline demographics (M, SD) for the enrolled subjects by study group are presented in Table 1. Based on bivariate analyses, there were no differences in the basic demographic characteristics among the three groups. Study subjects were older adults, with a mean age of 67.8 years, predominantly male (85%), with similar body mass index (30.0), mostly Caucasian (82%), and 59.7% reported being actively engaged in physical activity in the last 6 months. More than 50% of the subjects in each group had at least some college education. On average, participants presented with moderate severity of neuropathy based on the Michigan Diabetic Neuropathy Test and were prescribed just over one medication that could potentially increase the patients’
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
860
Western Journal of Nursing Research 36(7)
Table 1. Demographics of Participants by Study Group. Education Only (Control)
Tai Functional Chi Balance Training (Intervention) (Intervention)
n = 33 (SD)
n = 34 (SD)
n = 34 (SD)
Age in years Gender (male) Body mass index Education (%) Some school HS diploma/GED Some college College degree % White % Physical activity Michigan Diabetic Neuropathy score Number of comorbidities Session attendance
67.5 (10.2) 80.7 30.3 (6.0)
68.4 (9.3) 85.3 30.4 (5.3)
67.6 (10.6) 88.2 29.2 (4.5)
19.4 16.1 38.7 25.8 83.8 64.5 14.6 (5.4) 10.1 (5.4) 5.7 (3.7)
35.3 2.9 50.0 11.8 88.2 55.9 16 (5.6) 7.9 (4.2) 5.5 (3.9)
41.2 5.9 35.3 17.7 73.5 58.8 16.1 (5.4) 8.0 (4.8) 5.9 (4.1)
Note. HS = high school; GED = General Educational Development.
fall risk. Finally, participants reported having on average 8.6 comorbidities (SD = 5.4) and attended 5.6 out of 10 classes in each group.
Intervention and Control Groups Each group was comprised of six subjects who attended a 1-hr session per week for 10 weeks. Two trained mobility assistants were present for all exercise groups to ensure safety of subjects. All participants received a handout and their homework on a weekly basis. This homework assignment was generally a single activity that was assigned during the group session. Subjects were also provided with a binder to organize assignments so they would have the entire content when they completed the sessions. The class facilitator reviewed the homework assignment prior to each weekly session. Intervention—FBT. A physical therapist led the FBT group, which included strengthening, coordination, multitasking, hand-eye coordination, visualperceptual conflict, and compensatory exercises. The primary goal of each class corresponded to an element of FBT. These elements generally increased
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
861
progressively in difficulty over the 10-week class period with postural balance being the primary goal of Class 1, progressing through various levels of mobility, and ultimately concluding with multitasking and complex movement coordination. Various elements of balance control were incorporated throughout the curriculum, including center of gravity control, anticipatory mechanisms, involuntary postural strategies, and ability to respond to various environmental conditions. Each class consisted of a light warm-up with one flexibility exercise and one functional strength exercise prior to the initiation of balance maneuvers. Intervention—Tai Chi. A 1-hr Tai Chi class was administered once per week for 10 weeks. All classes were taught by a Tai Chi instructor who was supervised by a Tai Chi Master. Each class consisted of a 10-min warm-up period, a 45-min supervised exercise session that included slow movements, unilateral to bilateral body weight shifting, trunk/motion rotations, and a 5-min cool-down period. The instructor closely monitored exercise intensity so that all participants maintained a standardized activity level. Two trained mobility assistants were present to ensure safety of subjects. The intensity of the exercise routine was consistent during the 10-week period. All study participants were provided with a Tai Chi video for their home practice sessions in addition to an instructional manual for each of the Tai Chi movements. Control—Education only. For participants who were enrolled in the control group, 1-hr educational classes were held once per week for 10 weeks. All classes were coordinated by a clinical pharmacist who specialized in falls and aging, and taught by a multidisciplinary team that had expertise in specific course content. Subjects were given homework assignments. No exercises were conducted during these classes. The classes consisted of general healthrelated course content for each week: (a) medication safety, (b) nutrition, (c) home safety, (d) injury prevention, (e) health maintenance strategies, (f) osteoporosis prevention, (g) general fitness strategies, (h) how and what to report to your doctor, (i) vision screening and health, and (j) hearing screening and health.
Focus Group Interviews and Individual Interviews Following the final sessions of each 10-week class, we used focus group interviews to collect descriptive data from study participants of all three groups. Each focus group consisted of a semistructured session made up of four to eight study participants. These were led by an experienced moderator and cofacilitator who were part of the study team; questions and interview
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
862
Western Journal of Nursing Research 36(7)
Table 2. Number of Focus Groups and Individual Interviews by Group.
Group Education Only Tai Chi Functional Balance Training Total
Number of Focus Groups
Number of Focus Group Participants
Number of 6-Month FollowUp Interviews
5 6
19 17
4 6
6 17
19 55
4 14
prompts were used to ensure a free flowing group discussion (Krueger & Casey, 2000). Focus group interview questions were designed by study personnel experienced in qualitative research design to elicit data to answer research questions. The questions focused on participant satisfaction and perceived benefits of participating in the assigned study group. For example, we asked participants to share their perspectives on whether they felt the classes helped them recover from or prevent gait and balance disturbances. Participants were also asked questions about what facilitated or impeded compliance with the intervention and whether the classes had changed their perspectives for the future. The focus group guide was modified for individual interviews at 6 months. Later, individual interviews were conducted with study participants who completed the 6-month follow-up study protocol. Questions were modified from the focus group guide and were designed to elicit perceived long-term benefits of study participation. Individual interviews were conducted by an experienced interviewer and were conducted in a face-to-face format. Table 2 shows the number of focus groups, individual interviews, and participants by group. Analysis of focus groups and individual interviews were conducted using qualitative text analysis techniques (Bernard & Ryan, 2010), separate from the quantitative data generated from the clinical trial. We used “The Ethnographic V5.0” qualitative data analysis software to analyze focus group and interview transcripts. Three team members experienced in qualitative data analysis created a codebook and coded all transcripts to ensure intercoder reliability. Researchers then identified and developed categories of participant experiences. These categories were compared and contrasted across each of the three study groups. Categories were then further analyzed into thematic structure that described the data set. Finally, exemplar quotes were extracted and presented to characterize qualitative themes. Of the 101 subjects randomized into the three study groups, 55 participants attended the final class session of each 10-week class and participated
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
863
Powell-Cope et al. Table 3. Demographics of Focus Group Participants by Study Group.
Age in years Gender (male) Body mass index Education (%) Some school HS diploma/GED Some college College degree % White % Physical activity Number of comorbidities Attendance in sessions
Education Only (Control)
Tai Chi (Intervention)
Functional Balance Training (Intervention)
n = 19 (SD)
n =17 (SD)
n = 19 (SD)
67.8 (10.1) 94.7 29.8 (5.3)
70.8 (9.1) 82.4 28.5 (4.9)
71.3 (9.3) 78.9 29.3 (4.4)
5.3 26.3 26.3 42.1 94.7 68.4 11.4 (5.7) 8.0 (1.6)
— 41.2 5.9 52.9 94.1 64.7 8.7 (4.8) 8.3 (2.3)
10.5 31.6 15.8 42.1 84.2 78.9 8.2 (6.9) 8.6 (2.1)
Note. HS = high school; GED = General Educational Development.
in the focus group interviews (Table 2). In addition, 14 individuals were interviewed after 6 months. We believe that the lack of participation in the final class session was representative as the average study participant attended just over half of the class sessions. Participants reported missing the class sessions due to personal reasons, including scheduling conflicts, illness, and transportation issues. The demographics (M, SD) for participants who participated in focus group interviews are presented in Table 3. Study subjects who participated in a focus group interview were older adults, with a mean age of 70 years, predominantly male (85.5%), with similar body mass index (29.2), mostly Caucasian (91%), and 71% reported being actively engaged in physical activity in the last 6 months (Table 3). More than 60% of the subjects in each group had at least some college education. On average, participants presented with moderate severity of neuropathy based on the Michigan Diabetic Neuropathy Test and were prescribed just over one medication that could potentially increase the patients’ fall risk. Finally, participants reported having on average 9.5 comorbidities (SD = 5.9) and attended 8 out of 10 classes in each group.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
864
Western Journal of Nursing Research 36(7)
Table 4. Summary of Major Themes at 6 Weeks and 6 Months. Short Term
Functional Balance Training
Perceived benefits Improved balance X Balance “tricks” X Heightened awareness of walking X Exposure to information X Camaraderie/social benefits X Improved outlook X Improved confidence and X control Acceptance X Motivation to improve health Barriers for complying with intervention Balance too poor to do X exercises X Information not new, not focused on peripheral neuropathy Memory too poor to remember
Tai Chi
Long Term
Functional Education Balance Control Training
X X X X
X X
Tai Chi
X
X
X X
X
X
X
X X X
X X
Education Control X X X
X X
X
X
Results Responses related to perceived benefits were grouped into nine categories, and barriers for complying with the intervention were grouped into three categories (Table 4). In general, participants engaged in focus groups, and many of the discussions were lively. Perceptions were overwhelmingly positive regardless of the study group. Participants from all study groups expressed that they appreciated the camaraderie and social benefits of group participation and reported that they had gradually learned to adapt to life with PN. Participants in the FBT and Tai Chi groups commented positively at 10 weeks and 6 months on being given tips to improve balance. Perceived benefits were greater than perceived barriers to exercise. A commonly perceived barrier in the intervention groups was that balance was too poor to exercise.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
865
Immediate Patient-Perceived Benefits at 6 Weeks At 6 weeks, study participants in all three groups identified numerous benefits to participation. Improvements in balance and stability were noted by the FBT and Tai Chi groups, specifically in learning strategies and exercises for improving balance. Many reported valuing the increased awareness of their movement and posture and “learning to walk” which in turn helped to improve balance and stability. The greatest thing I got out of it was very improved balance. And it started out very slowly, the techniques that we learned in the group to improve balance and my balance is like not a 100% better, but it is greatly improved. And we are given exercises to take home and I will continue to use those exercises. And I was given specific exercises for my particular problem to use to continue to use so that I can improve my area that I had the most problem. In fact, after our last group they kept me back just to show me specific, two specific exercises to work on: stair steps, stepping up and stepping back, which are two of my problem areas. And it was done, they were just great help. (FBT) I just use the [Tai Chi] posture when I’m standing in line or anywhere, use the posture like when I’m walking before I cross the street, I’m in the Tai Chi posture and rocking back and forth just to keep perpetual motion, and so the balance and the walk, learning to walk, has helped a great deal. I use it constantly ever since, you know, he first showed us and it has helped in my gait also because I now concentrate on my walking more than just haphazardly, you know, I concentrate on my steps, where I want to step, and I try to stay on level ground. I am concentrating more on where I’m placing my feet and being aware of the hip joint, the knee, the ankle. (Tai Chi)
Exposure to new information was an immediate benefit that was noted by both the Education and FBT group participants. This included learning new things, or reinforcing previously learned information, about balance and one’s body and informal learning that occurred as participants shared stories about the problems they experienced as a result of impaired balance. . . . I think it was so good for people to realize there is so much out there, things to be aware of are just a natural part of being more careful when you get older. A lot of sensory things including your balance and your numbness, you know, it makes you have to be more aware of safety things, things like diet, your environment. I think it is good for anybody. This class would be good for any person in assisted living or any place, you know, to hear this information. (Education)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
866
Western Journal of Nursing Research 36(7)
Another advantage of this . . . and the way the class was conducted. We had an opportunity to be with people that had several problems . . . and just having that interaction has helped an awful lot, and I’m sure it will with other classes too. Being able to be there with somebody that has similar problems, and um after 10 weeks you start to get loosened up and you talk a little more. And you start learning a lot of things that you would not have learned otherwise. (FBT)
Participants in all study groups identified the social aspect of the classes as a major benefit, and described a strong sense of camaraderie. They identified with each other, helped each other as needed, and enjoyed coming to class to see each other. Participants discussed how the class let them know that they were “not alone” with PN, gait, and balance problems. They found comfort in sharing experiences with others who had related problems. I think when you have a problem and sometimes you feel like you are the only one with it and then when you find that there are other people out there with that problem, like was mentioned before, it does kind of help because we are all in the same group, we are all trying to find out what we can do to better our situation, and in the end it just worked out very well. (FBT)
Similarly, a strong sense of camaraderie was discussed by participants in both the FBT and Tai Chi groups as a benefit that gave greater meaning to the classes. This sense of camaraderie not only provided participants with the feeling that there were other people who shared similar problems related to PN but was also related to increased motivation, self-confidence, and acceptance of their conditions. This sense of camaraderie encouraged participants to consistently come to the classes. . . . a lot of times in classes people just see the other person and they just go about their business. The class was run in such a way that we kind of motivated each other, so I think that was important. You don’t just sit there and go “okay.” We clapped for each other and supported each other, and I think that helped out quite a bit too. (FBT) It is amazing that a group of people that had no prior connection, come together; we’re all from different walks of life, and there is a tremendous sense of we’re in it together. (FBT) It is always good to get out and talk to other people that have similar problems . . . you know it gets you out of the house and gets you moving a little bit. (Tai Chi)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
867
I feel very happy here [in class] because I found some people that are in the same way like me and we are living, we are still living, we are trying to find something to better us. (Tai Chi)
Participants from all three groups reported improved outlooks as an immediate benefit of the classes. Participants reported having improved selfesteem and confidence because they felt that they were in more control of their balance and able to do something to improve their stability. Some participants related that the classes helped them to better understand and accept their abilities and limitations, which helped them to have more tolerance and patience with themselves. Some learned to accept the use of an assistive device as a result of class participation. Awareness that you can get better, you can improve your balance and you don’t have to live with it and know you are going to get worse and worse and worse. With using these exercises and everything you know you can slow down or stop the loss of balance and the neuropathy and so on and so forth. (FBT)
Participants from the Tai Chi and Education groups, but not the FBT group, noted motivation as an immediate benefit of their classes. Tai Chi participants reported that they were highly motivated to continuing balance and strengthening exercises. The Education Control Group said that they were motivated to continue making positive health changes such as becoming more active, eating right, and taking their medications without missing doses.
Long-Term Patient-Perceived Benefits at 6 Months Perceived benefits at 6 months continued to be reported by study participants. Although participants continued to apply specific things they had learned in the classes, few continued practicing Tai Chi and balance exercises. Several participants discussed “balance tricks” they had learned that continued to be beneficial. I picked up an awful lot from this class and I’m not enabling myself like I was before. I’ve learned to get up out of a chair without holding on instead of sitting back, pushing myself up because I couldn’t get out. I’ve worked on that and a few other things. My gait . . . I’m very conscious of the way I’m walking instead of waddling like a duck. I’m very conscious of going straight when I’m walking and these are the things that knock your balance out when you start to do them so I’ve been practicing everything that we learned here. So it has really been very helpful. (FBT)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
868
Western Journal of Nursing Research 36(7)
Sounds kind of weird to say you learned to put your weight on your back leg when you sort of put your left foot out and sort of like finding where you’re going. So not that I do it, but I think, you know, the more I had done that I would do it, you know, just learn how to shift weight rather than just go. (Tai Chi)
Participants in the Education Control Group continued to report the benefits of exposure to health promotion information. . . . it has given me more to think about, more knowledge on the subject, and now I’m going to have to live with it. It is going to be there the rest of my life. I don’t think the time was wasted; let me put it that way, even though it was reinforcement rather than new data.
While participants still related the benefits of camaraderie among class members, no one we interviewed stayed in touch with anyone from class. Participants in the FBT and Education groups related positive effects on their overall outlook, including confidence in gait and balance, and acceptance of their illness. Typical of acceptance, one said, “I’m going to have to live with it [PN]. It is going to be there the rest of my life.” About the lasting effects of PN on outlook, another participant related, Oh yes, I understand it [PN] a little bit and I know what is causing it now. I know that it is a disabling factor no matter who has it and you have to compensate for it. (FBT)
Another participant discussed the lasting increased confidence he had in preventing a fall: Well I do have a lot more confidence in balance than I did before. I think as far as learning, that is the main thing. Probably the confidence of . . . I don’t know whether I was ever afraid of falling over, but I’m less so now if that is possible. I’m not so afraid at night that I’m going to trip on my cat and fall in the dark. (FBT)
Finally, participants in both the Tai Chi and FBT groups discussed the long-term effects on their motivation to sustain the changes they had made. While few participants reported sustaining physical exercise programs, Tai Chi, and breathing exercises, those who did reported positive effects: I learned a lot from the class. I really enjoyed it and it has really motivated me to continue on to do exercise. I’m still going to aerobic class 3 times a week and I took a lot with me from that class. (FBT)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
869
And, specific to Tai Chi, another participant reported, Well the class started me on it . . . taking better care of myself. It has had some positive affects in my health, yes. I’m glad I took it. (Tai Chi)
Barriers to Realizing Benefits at 6 Months In general, participants reported fewer barriers at 6 months than they did immediately after the interventions; no barriers were reported at 6 months by participants of the FBT or Tai Chi groups. One participant in the Education group said that he did not remember most of what he had learned in the class. Another said that although the classes reinforced things he already knew, he did not find information useful over the long term. Other participants said that Tai Chi did not change their outlook on life in the long term nor improve their abilities in ADL and they did not keep up with exercise.
Discussion Patient-centered care is advocated by leading organizations and policy makers including but not limited to the Institute of Medicine (2001), the National Quality Forum (2013), the Department of Veterans Affairs (DVA) (2013), and the Joint Commission (2008); it is an orientation that incorporates patients’ perspectives, values, and attitudes in determining the course of care (International Alliance of Patients’ Organizations, 2007). Findings from qualitative research that document patients’ perspectives can be used to develop patient-centered interventions and translate these into care. Findings can be used to engage patients in discussions for overcoming barriers to adherence, to motivate them to engage in health promotion activities, and to specify features of interventions likely to succeed related to sequence, timing, method of delivery, audience, and language. Qualitative data shed new light on the experiential aspects of fall prevention interventions; management of these hurdles has not been well articulated to date. Problems with gait and balance, frequently resulting from PN, require coping strategies to adapt to the social, medical, and personal challenges related to compromised mobility. Sharing the illness experience with others is one way to cope with chronic illness such as PN (Jeon, Stefan, Tanisha, & Nicholas, 2010). This study demonstrated that FBT, Tai Chi, and Educational classes provided forums in which participants can share their experiences and obtain both social and practical support from peers. Qualitative findings indicated that, prior to the classes, many participants had feelings of social isolation related to having neuropathy. The realization that there are others who
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
870
Western Journal of Nursing Research 36(7)
suffer from the same illness produced a strong sense of camaraderie among participants and provided them with a way to cope with their illness by renewing their motivation and self-confidence. While most study participants expressed that they hoped to be in the Tai Chi or the FBT groups, the perceived long-term benefits of the Tai Chi and Education Control Groups were both equal in number while the FBT was only slightly higher. Perceived benefits of camaraderie and social support were reported across all study groups at 10 weeks and 6 months, although participants noted that this was related to being together in class. They did not keep in contact with each other long term, however, and the camaraderie may have been limited to the duration of the classes. However, a long-term social benefit was related to realizing they were not isolated in coping with PN. “Tricks” to improve balance were also a perceived benefit in both the Tai Chi and FBT groups at 10 weeks and 6 months; this also related to improving confidence in control and balance longer term and acceptance of PN across all groups at 10 weeks. Interestingly, only the Education Control Group perceived exposure to new information as a benefit both long term and short term despite having also expressed concerns over their memory being too poor to remember information. Few exercise trials have employed qualitative research methods to gain patients’ perspectives of participating in a group exercise program. Statistical significance of the results of exercise clinical trials is often compromised by methodological problems with inadequate sample sizes and high drop-out rates. The findings of this study provide insight into the complexity of adherence to exercise programs while examining the effects of exercise programs on gait and balance, core variables of fall risk programs. Many participants had suffered with PN for months or years and had been told by their physicians that nothing more could be done for pain. Many reported feeling hopeless about finding relief. Despite the informed consent, and repeated reminders about the goals of the parent study of improving balance and decreasing fall risk, many enrolled in the study hoping to learn more about the causes and treatments of PN. Many study participants sought pain relief and were disappointed that the interventions did not focus on pain management. This study offers guidance to design future exercise studies that promote adherence to simple balance exercises, progressive strengthening programs, multifaceted exercises, a modified functional balance, and a Tai Chi program that older adults can perform in group settings or individually at home. Efforts to improve health, strength, and function combine to increase the older adult’s quality of life, enhance confidence in their abilities, reduce fall risks, and promote independence. These efforts should also include having choices in exercise programs available to the older adult. Suitable exercises for static
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
871
and dynamic balance, muscle strength, sensory integration, and social support have the potential to reduce the burden, trauma, and fear associated with falls and fall-related injuries among older adults. Future research that engages older adults in identifying protective factors for fall prevention and that focus on positive outcomes may motivate them to integrate exercise into their daily lives. The perceived benefits of group exercise training in the short term can be used to translate effective interventions into community-based programs to ensure widespread adoption, a priority for an aging society (Stevens, Noonan, & Rubenstein, 2010). While the research offers direction for future research and implementation of best practices, limitations are noted. Because this study was conducted 5 years ago in a Veteran's Hospitaland the sample was predominantly male, Caucasian, and had many comorbidities, caution is recommended for applying findings to populations of other older adults. In addition, because only 14 follow-up interviews were conducted, findings related to long-term outcomes were not as rich as findings related to short-term outcomes. Acknowledgment The authors would like to thank Rosa Avila who was a research assistant on this project and participated in data collection and initial data analysis.
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 material is based upon work supported by the Office of Research and Development Rehabilitation Research and Development Service, Department of Veterans Affairs (O4-4006RA).
References Adams, K., Paasse, G., & Clinch, D. (2011). Peer-support preferences and readinessto-change behaviour for chronic disease prevention in an urban indigenous population. Australian Social Work, 64, 55-67. Alfieri, F. J. (2010). Functional mobility and balance in community-dwelling elderly submitted to multisensory versus strength exercises. Clinical Interventions in Aging, 5, 181-185. Allet, L., Arm, S., de Bie, R. A., Golay, A., Monnin, D., Aminian, K., . . . de Bruin, E. D. (2010). The gait and balance of patients with diabetes can be improved: A randomized controlled trial. Diabetologia, 53, 458-466.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
872
Western Journal of Nursing Research 36(7)
Baker, M. K., Atlantis, E., & Fiatarone Singh, M. A. (2007). Multi-modal exercise program for older adults. Age and Ageing, 36, 375-381. Baraff, L. J., Penna, R. D., Williams, N., & Sanders, A. (1997). Practice guideline for the ED management of falls in community dwelling elderly persons. Annals of Emergency Medicine, 30, 480-492. Bernard, H. R., & Ryan, G. W. (2010). Analyzing qualitative data: Systematic approaches. Los Angeles, CA: SAGE. Bulat, T., Hart-Hughes, S., Ahmed, S., Quigley, P., Palacios, P., Werner, D. C., & Foulis, P. (2007). Effect of a group-based exercise program on balance in elderly. Clinical Interventions in Aging, 2, 655-660. Buman, M. P., Giacobbi, P. R., Jr., Dzierzewski, J. M., Aiken Morgan, A., McCrae, C. S., Roberts, B. L., & Marsiske, M. (2011). Peer volunteers improve long-term maintenance of physical activity with older adults: A randomized controlled trial. Journal of Physical Activity & Health, 8, S257-S266. Chin, A., & Paw, M. J. (2008). The functional effects of physical exercise training in frail older people: A systematic review. Sports Medicine, 38, 781-793. Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods research. Los Angeles, CA: SAGE. Department of Health and Human Services. (1992). Healthy people 2000. Sudbury, MA: Jones & Bartlett. Department of Health and Human Services. (2001). Healthy people 2010. Sudbury, MA: Jones & Bartlett. Department of Health and Human Services. (2010). Healthy people 2020. Sudbury, MA: Jones & Bartlett. Department of Veterans Affairs. (2013). Patient Aligned Care Team (PACT). Retrieved from http://www.va.gov/primarycare/pact/ Dodd, K. J., Taylor, N. F., Denisenko, S., & Prasad, D. (2006). A qualitative analysis of a progressive resistance exercise programme for people with multiple sclerosis. Disability and Rehabilitation, 28, 1127-1134. Gill, K. (2012). New moves: Targeting physical and mental well-being in people with mental illness. Health Issues, 108, 18-23. Gillespie, L. D., Gillespie, W. J., Robertson, M. C., Lamb, S. E., Cumming, R. G., & Rowe, B. H. (2003). Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews, 2003(4), Article CD000340. Hanley, A., Silke, C., & Murphy, J. (2011). Community-based health efforts for the prevention of falls in the elderly. Clinical Interventions in Aging, 6, 19-25. Herwaldt, L., & Pottinger, J. (2003). Preventing falls in the elderly. Journal of the American Geriatrics Society, 51, 1175-1177. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. International Alliance of Patients’ Organizations. (2007). What is patient-centered healthcare? A review of definitions and principles. Retrieved from http://www .patientsorganizations.org/attach.pl/547/494/IAPO%20Patient-Centred%20 Healthcare%20Review%202nd%20edition.pdf
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
873
Jahnke, R. A., Larkey, L. K., & Rogers, C. (2010). Dissemination and benefits of a replicable Tai Chi and Qigong program for older adults. Geriatric Nursing, 31, 272-280. Jeon, Y. H., Stefan, K., Tanisha, J., & Nicholas, G. (2010). The experience of living with chronic heart failure: A narrative review of qualitative studies. BMC Health Services Research, 10(1), Article 77. Jerome, G. J., Dalcin, A. T., Young, D. R., Stewart, K. J., Crum, R. M., Latkin, C., . . . Daumit, G. L. (2012). Rationale, design and baseline data for the Activating Consumers to Exercise Through Peer Support (ACE trial): A randomized controlled trial to increase fitness among adults with mental illness. Mental Health and Physical Activity, 5, 166-174. Joint Commission. (2008). Health care at the crossroads: Guiding principles for the development of the hospital of the future. Retrieved from http://www.joint commission.org/assets/1/18/Hosptal_Future.pdf Jung, D., Lee, J., & Lee, S. M. (2009). A meta-analysis of fear of falling treatment programs for the elderly. Western Journal of Nursing Research, 31, 6-16. Knutsen, L., Quist, M., Midtgaard, J., Rorth, M., & Adamsen, L. (2006). Maximum physical capacity testing in cancer patients undergoing chemotherapy: Qualitative findings from an exercise program. Scandinavian Journal of Medicine & Science in Sports, 16, 403-411. Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research (3rd ed.). Thousand Oaks, CA: SAGE. Kruse, R. L., LeMaster, J. W., & Madsen, R. W. (2010). Fall and balance outcomes after an intervention to promote leg strength, balance, and walking in people with diabetic peripheral neuropathy: “Feet First” randomized controlled trial. Physical Therapy, 90, 1568-1579. Kumar, S., Vendhan, G., Awasthi, S., Tiwari, M., & Sharma, V. P. (2008). Relationship between fear of falling, balance impairment and functional mobility in community dwelling elderly. Indian Journal of Physical Medicine and Rehabilitation, 19, 48-52. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer. Liu-Ambrose, T., Khan, K. M., Eng, J. J., Janssen, P. A., Lord, S. R., & McKay, H. A. (2004). Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: A 6-month randomized, controlled trial. Journal of the American Geriatrics Society, 52, 657-665. Morrison, S., Colberg, S. R., Mariano, M., Parson, H. K., & Vinik, A. I. (2010). Balance training reduced falls risk in older individuals with type 2 diabetes. Diabetes Care, 33, 748-750. Moylan, K. C., & Binder, E. F. (2007). Falls in older adults: Risk assessment, management and prevention. American Journal of Medicine, 120, 493-497. National Quality Forum. (2013). Person- and family-centered. Retrieved from https:// www.qualityforum.org/Topics/Patient_and_Family_Engagement.aspx
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
874
Western Journal of Nursing Research 36(7)
Quigley, P., Bulat, T., Schulz, B., Friedman, Y., Hart-Hughes, S., & Richardson, J. (2014). Exercise interventions, gait and balance in older subjects with distal symmetric polyneuropathy: A 3-group randomized clinical trial. American Journal of Physical Medicine & Rehabilitation, 93, 1-16. Rose, D. J., & Hernandez, D. (2010). The role of exercise in fall prevention for older adults. Clinics in Geriatric Medicine, 26, 607-631. Rotheram-Borus, M. J., Tomlinson, M., Gwegwe, M., Comulada, W. S., Kaufman, N., & Keim, M. (2012). Diabetes buddies: Peer support through a mobile phone buddy system. Diabetes Educator, 38, 357-365. Sattin, R., Easley, K. A., Wolf, S. L., Chen, Y., & Kutner, M. H. (2005). Reduction in fear of falling through intense Tai Chi exercise training in older, transitionally frail adults. Journal of the American Geriatrics Society, 53, 1168-1178. Skelton, D. A., & Beyer, N. (2003). Exercise and injury prevention in older people. Scandinavian Journal of Medicine & Science in Sports, 13, 77-85. Stead, M., Wimbush, E., Eadie, D., & Teer, P. (1997). A qualitative study of older people’s perceptions of ageing and exercise: The implications for health promotion. Health Education Journal, 56, 3-16. Stevens, J. A., Noonan, R. K., & Rubenstein, L. Z. (2010). Older adult fall prevention: Perceptions, beliefs, and behaviors. American Journal of Lifestyle Medicine, 4, 16-20. Strauss, A. (1984). Chronic illness and quality of life. Philadelphia, PA: Mosby. Thomas, G. N., Macfarlane, D. J., Guo, B., Cheung, B. M., McGhee, S. M., Chou, K. L., . . . Tomlinson, B. (2012). Health promotion in older Chinese: A 12-month cluster randomized controlled trial of pedometry and “peer support.” Medicine & Science in Sports & Exercise, 44, 1157-1166. Wilcox, S., Der Ananian, C., Abbott, J., Vrazel, J., Ramsey, C., Sharpe, P., & Brady, T. (2006). Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Results from a qualitative study. Arthritis Care & Research, 55, 616-627. Yau, M. K. (2008). Tai Chi exercise and the improvement of health and well-being in older adults. Sport Science, 52, 155-165.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
WJNXXX10.1177/0193945914523493Western Journal of Nursing ResearchPowell-Cope et al.
Article
Perceived Benefits of Group Exercise Among Individuals With Peripheral Neuropathy
Western Journal of Nursing Research 2014, Vol. 36(7) 855–874 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914523493 wjn.sagepub.com
Gail Powell-Cope1, Patricia A. Quigley1, Karen Besterman-Dahan1, and Jason D. Lind1
Abstract Exercise and training programs improve strength, functional balance, and prevent falls in a variety of populations. This article presents the qualitative findings related to the perceived benefits of participants in a randomized controlled trial that compared the effectiveness of group exercise on gait and balance in persons with peripheral neuropathy (PN). Participants with moderately severe PN were randomized into groups that received 10-week classes of Functional Balance Training (FBT) or Tai Chi or education alone. Perceptions of the intervention were overwhelmingly positive regardless of the study group. Perceived benefits reported by participants in the FBT and Tai Chi groups included awareness of how to deal with the effects of neuropathy by implementing balance strategies and a heightened sense of walking to prevent falls. This study offers a guide to design future exercise studies that promote simple balance exercises that can be performed in group settings. Keywords perception, health benefits, peripheral neuropathies, Tai Chi
1HSR&D/RR&D
Center of Innovation on Disability and Rehabilitation Research (CINDRR)
Corresponding Author: Gail Powell-Cope, PhD, ARNP, FAAN; HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); James A. Haley Veterans' Hospital, 8900 Grand Oaks Circle, Tampa, FL 33637, USA. Email: [email protected]
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
856
Western Journal of Nursing Research 36(7)
Evidence suggests that exercise programs can effectively improve gait and balance in fall risk populations and reduce falls and fall-related injuries (Baker, Atlantis, & Fiatarone Singh, 2007; Hanley, Silke, & Murphy, 2011; Herwaldt & Pottinger, 2003; Rose & Hernandez, 2010; Skelton & Beyer, 2003). While exercise interventions come in various forms, the most common are functional balance exercise training and Tai Chi (Alfieri, 2010; Bulat et al., 2007; Chin & Paw, 2008; Liu-Ambrose et al., 2004; Yau, 2008). Researchers are beginning to document that exercise interventions positively influence a person’s fall self-efficacy by promoting self-confidence to avoid a fall, an important factor in understanding and examining a person’s behaviors related to fall risks (Gillespie et al., 2003; Jahnke, Larkey, & Rogers, 2010; Jung, Lee, & Lee, 2009; Kumar, Vendhan, Awasthi, Tiwari, & Sharma, 2008; Moylan & Binder, 2007; Sattin, Easley, Wolf, Chen, & Kutner, 2005). However, adults are reluctant to value and perform routine exercises. Regular exercise is an important therapeutic intervention for successful aging for persons to maintain strength, range of motion, and endurance (Baraff, Penna, Williams, & Sanders, 1997). Healthy People 2000 (Department of Health and Human Services [DHHS], 1992), and Healthy People 2010 (DHHS, 2001), related that most people, including older people, do not engage in regular exercise despite its known benefits. Healthy People 2020 established goals and objectives for older people to improve their health, function, and quality of life, and addressed falls and fall-related injuries for the first time (DHHS, 2010). We examined functional balance versus Tai Chi, compared with a control group that only received education, as part of a clinical trial to test the effectiveness of group exercises on gait and balance in persons with peripheral neuropathy (PN) (Quigley et al., 2014). We used qualitative methods to examine the perceived benefits of exercise by asking the question: What are the immediate (10-week) and long-term (6-month) patient-perceived benefits for the Tai Chi and Functional Balance Training (FBT) groups? The use of peer volunteers to enhance activity has been reported in various population groups in the literature. Peer support has been used for chronic disease prevention involving nutrition, exercise, and smoking in indigenous urban populations (Adams, Paasse, & Clinch, 2011); pedometry in ethnic populations (Thomas et al., 2012); cardiovascular fitness in persons with mental illness (Gill, 2012); and diabetics using the mobile phone buddy system (Rotheram-Borus et al., 2012). Peer mentors are being studied as an alternative to paid staff which can escalate the cost of interventions such as exercise (Buman et al., 2011). Buman et al. (2011) conducted a randomized controlled trial (RCT) involving sedentary participants more than 50 years old who were matched with peers. Participants were randomized to two
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
857
16-week programs either involving peer support (n = 7) for behavioral changes in physical activity, or standard community resources (e.g., gym; n = 81). Participants were followed for 16 weeks (retention 85%) and followedup at 18 months (retention 61%). Self-reported moderate-to-vigorous physical activity (MVPA) was increased significantly in both the peer support group and the control group at 16 weeks, but the group with peer support had significantly more MVPA behavior at 18-month follow-up. In a 4-month exercise program, Jerome et al. (2012) conducted a trial, Activating Consumers to Exercise (ACE) Through Peer Support, involving persons (n = 93) with serious mental illness and the effect of peer support leaders from the community (n = 18). There were no differences in demographics and between the groups and average fitness levels were similar in that 95% of the sample scored below average on metabolic equivalent level (participants 5.9, SD = 2.2; peer leaders 6.2, SD = 2.3). The 6-min walk and treadmill fitness test (r2 = .36, p < .001) as well as an elevated basal metabolic index and lower metabolic equivalent levels (r2 = −.36, p < .001) were associated. Allet and colleagues (2010) conducted a RCT with participants who had diabetic neuropathy (n = 35) who received gait, balance, and strengthening exercises twice a week for 12 weeks; the control group (n = 35) received no training. These researchers found that, unlike the control group, the treatment arm increased their walking speed by 0.149 m/s (p < .001), reduced their time to walk over a beam, improved their balance sway index and mobility, decreased their concern about falling, and increased their hip and ankle plantar flexor strength and their hip flexion mobility. At 6-month follow-up, all gains in the interventional group remained significant except for the sway index and ankle plantar flexor strength. In a similar diabetic population with mild to moderate neuropathy, Morrison, Colberg, Mariano, Parson, and Vinik (2010) compared patients in an intervention group (n = 16) who were agematched with adults 50 to 75 years of age in a control group (n = 21). After a 6-week exercise program, the intervention group demonstrated significant gains in leg strength, had faster reaction times, and decreased falls and sway. In another RCT examining balance in sedentary diabetic patients with PN, however, Kruse, LeMaster, and Madsen (2010) conducted a 12-month study in a physical therapy office and subsequently in the community. The intervention group (n = 79) underwent leg strengthening and balance exercises, followed a walking regimen, and received follow-up phone calls. The intervention group, and control (n = 38) group, received foot care information and had eight physical therapy sessions. Although no significant differences were found in strength, balance, and number of falls at 12 months, participants in the intervention group could stand with their eyes closed on one leg longer but this was not statistically significant.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
858
Western Journal of Nursing Research 36(7)
For the qualitative portion of our study, embedded in the RCT, we were interested in patient-perceived significance of the interventions, that is, the immediate (within 6 weeks) coping mechanisms the individual uses to achieve adaptational outcomes in the areas of improved gait and balance (Lazarus & Folkman, 1984). According to Strauss (1984), any given disease can potentially cause multiple problems with activities of daily living (ADL) for the person, including the control of symptoms, carrying out prescribed regimens (e.g., performance of exercise and Tai Chi), prevention or living with social isolation (perhaps exacerbated by physical symptoms), adjustment to changes in the course of the illness, attempts to normalize interactions with others and style of life, dealing with funding to pay for the illness, and confronting attendant psychological, marital, and familial problems. From this perspective, gait and balance problems were conceptualized as components of aging and chronic illness that required coping adjustments in how that individual carried out his or her life, engaged in ADL and instrumental ADL, organized care, and adjusted to new social arrangements with caregivers, health care providers, and family members. Qualitative researchers have reported on participants' experiences and perceived benefits of exercise programs, which are critical in the design, implementation, participation, and success of interventions. Qualitative interviews of 100 patients with cancer undergoing chemotherapy, participating in a 6-week multidimensional exercise program found positive attitudes toward physical capacity tests following the intervention (Knutsen, Quist, Midtgaard, Rorth, & Adamsen, 2006). Physical, psychological, and social benefits of a 10-week progressive resistance strengthening program were noted in participants with multiple sclerosis. Participants reported reduced fatigue as a result of the program. Intrinsic factors for program completion included enjoyment, determination, seeing signs of progress, and previously held positive attitude about the benefits of exercise; extrinsic factors included leaders' encouragement and knowledge and group aspects of the program (Dodd, Taylor, Denisenko, & Prasad, 2006). Focus groups with adults with arthritis, grouped according to exercise status, were conducted to determine perceived barriers, benefits, and enablers for exercising. Although arthritis symptoms such as pain, stiffness, and fatigue were described as barriers to exercise, improvements in these symptoms were viewed as potential benefits of and motivations for exercise. The role of exercise in promoting independence was a significant and highly motivating benefit, particularly among exercisers; nonexercisers, however, had doubts that they would benefit from exercise and were unsure if increased pain would be worth the benefits (Wilcox et al., 2006). Perceived benefits of exercise and the factors that influence participation were explored in a qualitative study with focus groups of older and
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
859
younger people. Findings indicated that older people were not likely to participate in exercise for its own sake, but were motivated by social benefits of exercise. Furthermore, different strategies were suggested depending on the physical activity level of the intended participant (Stead, Wimbush, Eadie, & Teer, 1997).
Method We used a mixed methods research design in which the qualitative portion of the study was embedded into the primary focus, the quantitative RCT (Creswell & Plano Clark, 2011). The quantitative data set was primary, and the qualitative data were used to answer a different research question. Data were collected during 2006-2008 at the James A. Haley Veterans’ Hospital in Tampa, Florida.
Sample Three hundred seventy-one persons responded for the initial telephone screening for the study between March 2005 and December 2008. Study inclusion criteria were men or women over the age of 60, no vision impairments (no worse than 20/50 vision), mild or moderate level of neuropathy based on the Michigan Diabetic Neuropathy Test, self-reported as ambulatory, no cognitive impairments based on the Mini-Mental State Examination, no diagnosis of metastatic cancer, no diagnosis of a central nervous system disease, no lower limb impairment or abnormality, and no impaired skin integrity. One hundred forty nine failed to meet admission criteria or were not interested in the study during the screening interview. One hundred twenty two persons were invited to take a physical exam of which 21 failed and were thus excluded from the study. The remaining 101 subjects were subsequently enrolled and randomized into three groups: FBT (n = 33), Tai Chi (n = 34), and Education Control Group (n = 34). Baseline demographics (M, SD) for the enrolled subjects by study group are presented in Table 1. Based on bivariate analyses, there were no differences in the basic demographic characteristics among the three groups. Study subjects were older adults, with a mean age of 67.8 years, predominantly male (85%), with similar body mass index (30.0), mostly Caucasian (82%), and 59.7% reported being actively engaged in physical activity in the last 6 months. More than 50% of the subjects in each group had at least some college education. On average, participants presented with moderate severity of neuropathy based on the Michigan Diabetic Neuropathy Test and were prescribed just over one medication that could potentially increase the patients’
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
860
Western Journal of Nursing Research 36(7)
Table 1. Demographics of Participants by Study Group. Education Only (Control)
Tai Functional Chi Balance Training (Intervention) (Intervention)
n = 33 (SD)
n = 34 (SD)
n = 34 (SD)
Age in years Gender (male) Body mass index Education (%) Some school HS diploma/GED Some college College degree % White % Physical activity Michigan Diabetic Neuropathy score Number of comorbidities Session attendance
67.5 (10.2) 80.7 30.3 (6.0)
68.4 (9.3) 85.3 30.4 (5.3)
67.6 (10.6) 88.2 29.2 (4.5)
19.4 16.1 38.7 25.8 83.8 64.5 14.6 (5.4) 10.1 (5.4) 5.7 (3.7)
35.3 2.9 50.0 11.8 88.2 55.9 16 (5.6) 7.9 (4.2) 5.5 (3.9)
41.2 5.9 35.3 17.7 73.5 58.8 16.1 (5.4) 8.0 (4.8) 5.9 (4.1)
Note. HS = high school; GED = General Educational Development.
fall risk. Finally, participants reported having on average 8.6 comorbidities (SD = 5.4) and attended 5.6 out of 10 classes in each group.
Intervention and Control Groups Each group was comprised of six subjects who attended a 1-hr session per week for 10 weeks. Two trained mobility assistants were present for all exercise groups to ensure safety of subjects. All participants received a handout and their homework on a weekly basis. This homework assignment was generally a single activity that was assigned during the group session. Subjects were also provided with a binder to organize assignments so they would have the entire content when they completed the sessions. The class facilitator reviewed the homework assignment prior to each weekly session. Intervention—FBT. A physical therapist led the FBT group, which included strengthening, coordination, multitasking, hand-eye coordination, visualperceptual conflict, and compensatory exercises. The primary goal of each class corresponded to an element of FBT. These elements generally increased
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
861
progressively in difficulty over the 10-week class period with postural balance being the primary goal of Class 1, progressing through various levels of mobility, and ultimately concluding with multitasking and complex movement coordination. Various elements of balance control were incorporated throughout the curriculum, including center of gravity control, anticipatory mechanisms, involuntary postural strategies, and ability to respond to various environmental conditions. Each class consisted of a light warm-up with one flexibility exercise and one functional strength exercise prior to the initiation of balance maneuvers. Intervention—Tai Chi. A 1-hr Tai Chi class was administered once per week for 10 weeks. All classes were taught by a Tai Chi instructor who was supervised by a Tai Chi Master. Each class consisted of a 10-min warm-up period, a 45-min supervised exercise session that included slow movements, unilateral to bilateral body weight shifting, trunk/motion rotations, and a 5-min cool-down period. The instructor closely monitored exercise intensity so that all participants maintained a standardized activity level. Two trained mobility assistants were present to ensure safety of subjects. The intensity of the exercise routine was consistent during the 10-week period. All study participants were provided with a Tai Chi video for their home practice sessions in addition to an instructional manual for each of the Tai Chi movements. Control—Education only. For participants who were enrolled in the control group, 1-hr educational classes were held once per week for 10 weeks. All classes were coordinated by a clinical pharmacist who specialized in falls and aging, and taught by a multidisciplinary team that had expertise in specific course content. Subjects were given homework assignments. No exercises were conducted during these classes. The classes consisted of general healthrelated course content for each week: (a) medication safety, (b) nutrition, (c) home safety, (d) injury prevention, (e) health maintenance strategies, (f) osteoporosis prevention, (g) general fitness strategies, (h) how and what to report to your doctor, (i) vision screening and health, and (j) hearing screening and health.
Focus Group Interviews and Individual Interviews Following the final sessions of each 10-week class, we used focus group interviews to collect descriptive data from study participants of all three groups. Each focus group consisted of a semistructured session made up of four to eight study participants. These were led by an experienced moderator and cofacilitator who were part of the study team; questions and interview
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
862
Western Journal of Nursing Research 36(7)
Table 2. Number of Focus Groups and Individual Interviews by Group.
Group Education Only Tai Chi Functional Balance Training Total
Number of Focus Groups
Number of Focus Group Participants
Number of 6-Month FollowUp Interviews
5 6
19 17
4 6
6 17
19 55
4 14
prompts were used to ensure a free flowing group discussion (Krueger & Casey, 2000). Focus group interview questions were designed by study personnel experienced in qualitative research design to elicit data to answer research questions. The questions focused on participant satisfaction and perceived benefits of participating in the assigned study group. For example, we asked participants to share their perspectives on whether they felt the classes helped them recover from or prevent gait and balance disturbances. Participants were also asked questions about what facilitated or impeded compliance with the intervention and whether the classes had changed their perspectives for the future. The focus group guide was modified for individual interviews at 6 months. Later, individual interviews were conducted with study participants who completed the 6-month follow-up study protocol. Questions were modified from the focus group guide and were designed to elicit perceived long-term benefits of study participation. Individual interviews were conducted by an experienced interviewer and were conducted in a face-to-face format. Table 2 shows the number of focus groups, individual interviews, and participants by group. Analysis of focus groups and individual interviews were conducted using qualitative text analysis techniques (Bernard & Ryan, 2010), separate from the quantitative data generated from the clinical trial. We used “The Ethnographic V5.0” qualitative data analysis software to analyze focus group and interview transcripts. Three team members experienced in qualitative data analysis created a codebook and coded all transcripts to ensure intercoder reliability. Researchers then identified and developed categories of participant experiences. These categories were compared and contrasted across each of the three study groups. Categories were then further analyzed into thematic structure that described the data set. Finally, exemplar quotes were extracted and presented to characterize qualitative themes. Of the 101 subjects randomized into the three study groups, 55 participants attended the final class session of each 10-week class and participated
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
863
Powell-Cope et al. Table 3. Demographics of Focus Group Participants by Study Group.
Age in years Gender (male) Body mass index Education (%) Some school HS diploma/GED Some college College degree % White % Physical activity Number of comorbidities Attendance in sessions
Education Only (Control)
Tai Chi (Intervention)
Functional Balance Training (Intervention)
n = 19 (SD)
n =17 (SD)
n = 19 (SD)
67.8 (10.1) 94.7 29.8 (5.3)
70.8 (9.1) 82.4 28.5 (4.9)
71.3 (9.3) 78.9 29.3 (4.4)
5.3 26.3 26.3 42.1 94.7 68.4 11.4 (5.7) 8.0 (1.6)
— 41.2 5.9 52.9 94.1 64.7 8.7 (4.8) 8.3 (2.3)
10.5 31.6 15.8 42.1 84.2 78.9 8.2 (6.9) 8.6 (2.1)
Note. HS = high school; GED = General Educational Development.
in the focus group interviews (Table 2). In addition, 14 individuals were interviewed after 6 months. We believe that the lack of participation in the final class session was representative as the average study participant attended just over half of the class sessions. Participants reported missing the class sessions due to personal reasons, including scheduling conflicts, illness, and transportation issues. The demographics (M, SD) for participants who participated in focus group interviews are presented in Table 3. Study subjects who participated in a focus group interview were older adults, with a mean age of 70 years, predominantly male (85.5%), with similar body mass index (29.2), mostly Caucasian (91%), and 71% reported being actively engaged in physical activity in the last 6 months (Table 3). More than 60% of the subjects in each group had at least some college education. On average, participants presented with moderate severity of neuropathy based on the Michigan Diabetic Neuropathy Test and were prescribed just over one medication that could potentially increase the patients’ fall risk. Finally, participants reported having on average 9.5 comorbidities (SD = 5.9) and attended 8 out of 10 classes in each group.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
864
Western Journal of Nursing Research 36(7)
Table 4. Summary of Major Themes at 6 Weeks and 6 Months. Short Term
Functional Balance Training
Perceived benefits Improved balance X Balance “tricks” X Heightened awareness of walking X Exposure to information X Camaraderie/social benefits X Improved outlook X Improved confidence and X control Acceptance X Motivation to improve health Barriers for complying with intervention Balance too poor to do X exercises X Information not new, not focused on peripheral neuropathy Memory too poor to remember
Tai Chi
Long Term
Functional Education Balance Control Training
X X X X
X X
Tai Chi
X
X
X X
X
X
X
X X X
X X
Education Control X X X
X X
X
X
Results Responses related to perceived benefits were grouped into nine categories, and barriers for complying with the intervention were grouped into three categories (Table 4). In general, participants engaged in focus groups, and many of the discussions were lively. Perceptions were overwhelmingly positive regardless of the study group. Participants from all study groups expressed that they appreciated the camaraderie and social benefits of group participation and reported that they had gradually learned to adapt to life with PN. Participants in the FBT and Tai Chi groups commented positively at 10 weeks and 6 months on being given tips to improve balance. Perceived benefits were greater than perceived barriers to exercise. A commonly perceived barrier in the intervention groups was that balance was too poor to exercise.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
865
Immediate Patient-Perceived Benefits at 6 Weeks At 6 weeks, study participants in all three groups identified numerous benefits to participation. Improvements in balance and stability were noted by the FBT and Tai Chi groups, specifically in learning strategies and exercises for improving balance. Many reported valuing the increased awareness of their movement and posture and “learning to walk” which in turn helped to improve balance and stability. The greatest thing I got out of it was very improved balance. And it started out very slowly, the techniques that we learned in the group to improve balance and my balance is like not a 100% better, but it is greatly improved. And we are given exercises to take home and I will continue to use those exercises. And I was given specific exercises for my particular problem to use to continue to use so that I can improve my area that I had the most problem. In fact, after our last group they kept me back just to show me specific, two specific exercises to work on: stair steps, stepping up and stepping back, which are two of my problem areas. And it was done, they were just great help. (FBT) I just use the [Tai Chi] posture when I’m standing in line or anywhere, use the posture like when I’m walking before I cross the street, I’m in the Tai Chi posture and rocking back and forth just to keep perpetual motion, and so the balance and the walk, learning to walk, has helped a great deal. I use it constantly ever since, you know, he first showed us and it has helped in my gait also because I now concentrate on my walking more than just haphazardly, you know, I concentrate on my steps, where I want to step, and I try to stay on level ground. I am concentrating more on where I’m placing my feet and being aware of the hip joint, the knee, the ankle. (Tai Chi)
Exposure to new information was an immediate benefit that was noted by both the Education and FBT group participants. This included learning new things, or reinforcing previously learned information, about balance and one’s body and informal learning that occurred as participants shared stories about the problems they experienced as a result of impaired balance. . . . I think it was so good for people to realize there is so much out there, things to be aware of are just a natural part of being more careful when you get older. A lot of sensory things including your balance and your numbness, you know, it makes you have to be more aware of safety things, things like diet, your environment. I think it is good for anybody. This class would be good for any person in assisted living or any place, you know, to hear this information. (Education)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
866
Western Journal of Nursing Research 36(7)
Another advantage of this . . . and the way the class was conducted. We had an opportunity to be with people that had several problems . . . and just having that interaction has helped an awful lot, and I’m sure it will with other classes too. Being able to be there with somebody that has similar problems, and um after 10 weeks you start to get loosened up and you talk a little more. And you start learning a lot of things that you would not have learned otherwise. (FBT)
Participants in all study groups identified the social aspect of the classes as a major benefit, and described a strong sense of camaraderie. They identified with each other, helped each other as needed, and enjoyed coming to class to see each other. Participants discussed how the class let them know that they were “not alone” with PN, gait, and balance problems. They found comfort in sharing experiences with others who had related problems. I think when you have a problem and sometimes you feel like you are the only one with it and then when you find that there are other people out there with that problem, like was mentioned before, it does kind of help because we are all in the same group, we are all trying to find out what we can do to better our situation, and in the end it just worked out very well. (FBT)
Similarly, a strong sense of camaraderie was discussed by participants in both the FBT and Tai Chi groups as a benefit that gave greater meaning to the classes. This sense of camaraderie not only provided participants with the feeling that there were other people who shared similar problems related to PN but was also related to increased motivation, self-confidence, and acceptance of their conditions. This sense of camaraderie encouraged participants to consistently come to the classes. . . . a lot of times in classes people just see the other person and they just go about their business. The class was run in such a way that we kind of motivated each other, so I think that was important. You don’t just sit there and go “okay.” We clapped for each other and supported each other, and I think that helped out quite a bit too. (FBT) It is amazing that a group of people that had no prior connection, come together; we’re all from different walks of life, and there is a tremendous sense of we’re in it together. (FBT) It is always good to get out and talk to other people that have similar problems . . . you know it gets you out of the house and gets you moving a little bit. (Tai Chi)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
867
I feel very happy here [in class] because I found some people that are in the same way like me and we are living, we are still living, we are trying to find something to better us. (Tai Chi)
Participants from all three groups reported improved outlooks as an immediate benefit of the classes. Participants reported having improved selfesteem and confidence because they felt that they were in more control of their balance and able to do something to improve their stability. Some participants related that the classes helped them to better understand and accept their abilities and limitations, which helped them to have more tolerance and patience with themselves. Some learned to accept the use of an assistive device as a result of class participation. Awareness that you can get better, you can improve your balance and you don’t have to live with it and know you are going to get worse and worse and worse. With using these exercises and everything you know you can slow down or stop the loss of balance and the neuropathy and so on and so forth. (FBT)
Participants from the Tai Chi and Education groups, but not the FBT group, noted motivation as an immediate benefit of their classes. Tai Chi participants reported that they were highly motivated to continuing balance and strengthening exercises. The Education Control Group said that they were motivated to continue making positive health changes such as becoming more active, eating right, and taking their medications without missing doses.
Long-Term Patient-Perceived Benefits at 6 Months Perceived benefits at 6 months continued to be reported by study participants. Although participants continued to apply specific things they had learned in the classes, few continued practicing Tai Chi and balance exercises. Several participants discussed “balance tricks” they had learned that continued to be beneficial. I picked up an awful lot from this class and I’m not enabling myself like I was before. I’ve learned to get up out of a chair without holding on instead of sitting back, pushing myself up because I couldn’t get out. I’ve worked on that and a few other things. My gait . . . I’m very conscious of the way I’m walking instead of waddling like a duck. I’m very conscious of going straight when I’m walking and these are the things that knock your balance out when you start to do them so I’ve been practicing everything that we learned here. So it has really been very helpful. (FBT)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
868
Western Journal of Nursing Research 36(7)
Sounds kind of weird to say you learned to put your weight on your back leg when you sort of put your left foot out and sort of like finding where you’re going. So not that I do it, but I think, you know, the more I had done that I would do it, you know, just learn how to shift weight rather than just go. (Tai Chi)
Participants in the Education Control Group continued to report the benefits of exposure to health promotion information. . . . it has given me more to think about, more knowledge on the subject, and now I’m going to have to live with it. It is going to be there the rest of my life. I don’t think the time was wasted; let me put it that way, even though it was reinforcement rather than new data.
While participants still related the benefits of camaraderie among class members, no one we interviewed stayed in touch with anyone from class. Participants in the FBT and Education groups related positive effects on their overall outlook, including confidence in gait and balance, and acceptance of their illness. Typical of acceptance, one said, “I’m going to have to live with it [PN]. It is going to be there the rest of my life.” About the lasting effects of PN on outlook, another participant related, Oh yes, I understand it [PN] a little bit and I know what is causing it now. I know that it is a disabling factor no matter who has it and you have to compensate for it. (FBT)
Another participant discussed the lasting increased confidence he had in preventing a fall: Well I do have a lot more confidence in balance than I did before. I think as far as learning, that is the main thing. Probably the confidence of . . . I don’t know whether I was ever afraid of falling over, but I’m less so now if that is possible. I’m not so afraid at night that I’m going to trip on my cat and fall in the dark. (FBT)
Finally, participants in both the Tai Chi and FBT groups discussed the long-term effects on their motivation to sustain the changes they had made. While few participants reported sustaining physical exercise programs, Tai Chi, and breathing exercises, those who did reported positive effects: I learned a lot from the class. I really enjoyed it and it has really motivated me to continue on to do exercise. I’m still going to aerobic class 3 times a week and I took a lot with me from that class. (FBT)
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
869
And, specific to Tai Chi, another participant reported, Well the class started me on it . . . taking better care of myself. It has had some positive affects in my health, yes. I’m glad I took it. (Tai Chi)
Barriers to Realizing Benefits at 6 Months In general, participants reported fewer barriers at 6 months than they did immediately after the interventions; no barriers were reported at 6 months by participants of the FBT or Tai Chi groups. One participant in the Education group said that he did not remember most of what he had learned in the class. Another said that although the classes reinforced things he already knew, he did not find information useful over the long term. Other participants said that Tai Chi did not change their outlook on life in the long term nor improve their abilities in ADL and they did not keep up with exercise.
Discussion Patient-centered care is advocated by leading organizations and policy makers including but not limited to the Institute of Medicine (2001), the National Quality Forum (2013), the Department of Veterans Affairs (DVA) (2013), and the Joint Commission (2008); it is an orientation that incorporates patients’ perspectives, values, and attitudes in determining the course of care (International Alliance of Patients’ Organizations, 2007). Findings from qualitative research that document patients’ perspectives can be used to develop patient-centered interventions and translate these into care. Findings can be used to engage patients in discussions for overcoming barriers to adherence, to motivate them to engage in health promotion activities, and to specify features of interventions likely to succeed related to sequence, timing, method of delivery, audience, and language. Qualitative data shed new light on the experiential aspects of fall prevention interventions; management of these hurdles has not been well articulated to date. Problems with gait and balance, frequently resulting from PN, require coping strategies to adapt to the social, medical, and personal challenges related to compromised mobility. Sharing the illness experience with others is one way to cope with chronic illness such as PN (Jeon, Stefan, Tanisha, & Nicholas, 2010). This study demonstrated that FBT, Tai Chi, and Educational classes provided forums in which participants can share their experiences and obtain both social and practical support from peers. Qualitative findings indicated that, prior to the classes, many participants had feelings of social isolation related to having neuropathy. The realization that there are others who
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
870
Western Journal of Nursing Research 36(7)
suffer from the same illness produced a strong sense of camaraderie among participants and provided them with a way to cope with their illness by renewing their motivation and self-confidence. While most study participants expressed that they hoped to be in the Tai Chi or the FBT groups, the perceived long-term benefits of the Tai Chi and Education Control Groups were both equal in number while the FBT was only slightly higher. Perceived benefits of camaraderie and social support were reported across all study groups at 10 weeks and 6 months, although participants noted that this was related to being together in class. They did not keep in contact with each other long term, however, and the camaraderie may have been limited to the duration of the classes. However, a long-term social benefit was related to realizing they were not isolated in coping with PN. “Tricks” to improve balance were also a perceived benefit in both the Tai Chi and FBT groups at 10 weeks and 6 months; this also related to improving confidence in control and balance longer term and acceptance of PN across all groups at 10 weeks. Interestingly, only the Education Control Group perceived exposure to new information as a benefit both long term and short term despite having also expressed concerns over their memory being too poor to remember information. Few exercise trials have employed qualitative research methods to gain patients’ perspectives of participating in a group exercise program. Statistical significance of the results of exercise clinical trials is often compromised by methodological problems with inadequate sample sizes and high drop-out rates. The findings of this study provide insight into the complexity of adherence to exercise programs while examining the effects of exercise programs on gait and balance, core variables of fall risk programs. Many participants had suffered with PN for months or years and had been told by their physicians that nothing more could be done for pain. Many reported feeling hopeless about finding relief. Despite the informed consent, and repeated reminders about the goals of the parent study of improving balance and decreasing fall risk, many enrolled in the study hoping to learn more about the causes and treatments of PN. Many study participants sought pain relief and were disappointed that the interventions did not focus on pain management. This study offers guidance to design future exercise studies that promote adherence to simple balance exercises, progressive strengthening programs, multifaceted exercises, a modified functional balance, and a Tai Chi program that older adults can perform in group settings or individually at home. Efforts to improve health, strength, and function combine to increase the older adult’s quality of life, enhance confidence in their abilities, reduce fall risks, and promote independence. These efforts should also include having choices in exercise programs available to the older adult. Suitable exercises for static
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
871
and dynamic balance, muscle strength, sensory integration, and social support have the potential to reduce the burden, trauma, and fear associated with falls and fall-related injuries among older adults. Future research that engages older adults in identifying protective factors for fall prevention and that focus on positive outcomes may motivate them to integrate exercise into their daily lives. The perceived benefits of group exercise training in the short term can be used to translate effective interventions into community-based programs to ensure widespread adoption, a priority for an aging society (Stevens, Noonan, & Rubenstein, 2010). While the research offers direction for future research and implementation of best practices, limitations are noted. Because this study was conducted 5 years ago in a Veteran's Hospitaland the sample was predominantly male, Caucasian, and had many comorbidities, caution is recommended for applying findings to populations of other older adults. In addition, because only 14 follow-up interviews were conducted, findings related to long-term outcomes were not as rich as findings related to short-term outcomes. Acknowledgment The authors would like to thank Rosa Avila who was a research assistant on this project and participated in data collection and initial data analysis.
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 material is based upon work supported by the Office of Research and Development Rehabilitation Research and Development Service, Department of Veterans Affairs (O4-4006RA).
References Adams, K., Paasse, G., & Clinch, D. (2011). Peer-support preferences and readinessto-change behaviour for chronic disease prevention in an urban indigenous population. Australian Social Work, 64, 55-67. Alfieri, F. J. (2010). Functional mobility and balance in community-dwelling elderly submitted to multisensory versus strength exercises. Clinical Interventions in Aging, 5, 181-185. Allet, L., Arm, S., de Bie, R. A., Golay, A., Monnin, D., Aminian, K., . . . de Bruin, E. D. (2010). The gait and balance of patients with diabetes can be improved: A randomized controlled trial. Diabetologia, 53, 458-466.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
872
Western Journal of Nursing Research 36(7)
Baker, M. K., Atlantis, E., & Fiatarone Singh, M. A. (2007). Multi-modal exercise program for older adults. Age and Ageing, 36, 375-381. Baraff, L. J., Penna, R. D., Williams, N., & Sanders, A. (1997). Practice guideline for the ED management of falls in community dwelling elderly persons. Annals of Emergency Medicine, 30, 480-492. Bernard, H. R., & Ryan, G. W. (2010). Analyzing qualitative data: Systematic approaches. Los Angeles, CA: SAGE. Bulat, T., Hart-Hughes, S., Ahmed, S., Quigley, P., Palacios, P., Werner, D. C., & Foulis, P. (2007). Effect of a group-based exercise program on balance in elderly. Clinical Interventions in Aging, 2, 655-660. Buman, M. P., Giacobbi, P. R., Jr., Dzierzewski, J. M., Aiken Morgan, A., McCrae, C. S., Roberts, B. L., & Marsiske, M. (2011). Peer volunteers improve long-term maintenance of physical activity with older adults: A randomized controlled trial. Journal of Physical Activity & Health, 8, S257-S266. Chin, A., & Paw, M. J. (2008). The functional effects of physical exercise training in frail older people: A systematic review. Sports Medicine, 38, 781-793. Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods research. Los Angeles, CA: SAGE. Department of Health and Human Services. (1992). Healthy people 2000. Sudbury, MA: Jones & Bartlett. Department of Health and Human Services. (2001). Healthy people 2010. Sudbury, MA: Jones & Bartlett. Department of Health and Human Services. (2010). Healthy people 2020. Sudbury, MA: Jones & Bartlett. Department of Veterans Affairs. (2013). Patient Aligned Care Team (PACT). Retrieved from http://www.va.gov/primarycare/pact/ Dodd, K. J., Taylor, N. F., Denisenko, S., & Prasad, D. (2006). A qualitative analysis of a progressive resistance exercise programme for people with multiple sclerosis. Disability and Rehabilitation, 28, 1127-1134. Gill, K. (2012). New moves: Targeting physical and mental well-being in people with mental illness. Health Issues, 108, 18-23. Gillespie, L. D., Gillespie, W. J., Robertson, M. C., Lamb, S. E., Cumming, R. G., & Rowe, B. H. (2003). Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews, 2003(4), Article CD000340. Hanley, A., Silke, C., & Murphy, J. (2011). Community-based health efforts for the prevention of falls in the elderly. Clinical Interventions in Aging, 6, 19-25. Herwaldt, L., & Pottinger, J. (2003). Preventing falls in the elderly. Journal of the American Geriatrics Society, 51, 1175-1177. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. International Alliance of Patients’ Organizations. (2007). What is patient-centered healthcare? A review of definitions and principles. Retrieved from http://www .patientsorganizations.org/attach.pl/547/494/IAPO%20Patient-Centred%20 Healthcare%20Review%202nd%20edition.pdf
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
Powell-Cope et al.
873
Jahnke, R. A., Larkey, L. K., & Rogers, C. (2010). Dissemination and benefits of a replicable Tai Chi and Qigong program for older adults. Geriatric Nursing, 31, 272-280. Jeon, Y. H., Stefan, K., Tanisha, J., & Nicholas, G. (2010). The experience of living with chronic heart failure: A narrative review of qualitative studies. BMC Health Services Research, 10(1), Article 77. Jerome, G. J., Dalcin, A. T., Young, D. R., Stewart, K. J., Crum, R. M., Latkin, C., . . . Daumit, G. L. (2012). Rationale, design and baseline data for the Activating Consumers to Exercise Through Peer Support (ACE trial): A randomized controlled trial to increase fitness among adults with mental illness. Mental Health and Physical Activity, 5, 166-174. Joint Commission. (2008). Health care at the crossroads: Guiding principles for the development of the hospital of the future. Retrieved from http://www.joint commission.org/assets/1/18/Hosptal_Future.pdf Jung, D., Lee, J., & Lee, S. M. (2009). A meta-analysis of fear of falling treatment programs for the elderly. Western Journal of Nursing Research, 31, 6-16. Knutsen, L., Quist, M., Midtgaard, J., Rorth, M., & Adamsen, L. (2006). Maximum physical capacity testing in cancer patients undergoing chemotherapy: Qualitative findings from an exercise program. Scandinavian Journal of Medicine & Science in Sports, 16, 403-411. Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research (3rd ed.). Thousand Oaks, CA: SAGE. Kruse, R. L., LeMaster, J. W., & Madsen, R. W. (2010). Fall and balance outcomes after an intervention to promote leg strength, balance, and walking in people with diabetic peripheral neuropathy: “Feet First” randomized controlled trial. Physical Therapy, 90, 1568-1579. Kumar, S., Vendhan, G., Awasthi, S., Tiwari, M., & Sharma, V. P. (2008). Relationship between fear of falling, balance impairment and functional mobility in community dwelling elderly. Indian Journal of Physical Medicine and Rehabilitation, 19, 48-52. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer. Liu-Ambrose, T., Khan, K. M., Eng, J. J., Janssen, P. A., Lord, S. R., & McKay, H. A. (2004). Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: A 6-month randomized, controlled trial. Journal of the American Geriatrics Society, 52, 657-665. Morrison, S., Colberg, S. R., Mariano, M., Parson, H. K., & Vinik, A. I. (2010). Balance training reduced falls risk in older individuals with type 2 diabetes. Diabetes Care, 33, 748-750. Moylan, K. C., & Binder, E. F. (2007). Falls in older adults: Risk assessment, management and prevention. American Journal of Medicine, 120, 493-497. National Quality Forum. (2013). Person- and family-centered. Retrieved from https:// www.qualityforum.org/Topics/Patient_and_Family_Engagement.aspx
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
874
Western Journal of Nursing Research 36(7)
Quigley, P., Bulat, T., Schulz, B., Friedman, Y., Hart-Hughes, S., & Richardson, J. (2014). Exercise interventions, gait and balance in older subjects with distal symmetric polyneuropathy: A 3-group randomized clinical trial. American Journal of Physical Medicine & Rehabilitation, 93, 1-16. Rose, D. J., & Hernandez, D. (2010). The role of exercise in fall prevention for older adults. Clinics in Geriatric Medicine, 26, 607-631. Rotheram-Borus, M. J., Tomlinson, M., Gwegwe, M., Comulada, W. S., Kaufman, N., & Keim, M. (2012). Diabetes buddies: Peer support through a mobile phone buddy system. Diabetes Educator, 38, 357-365. Sattin, R., Easley, K. A., Wolf, S. L., Chen, Y., & Kutner, M. H. (2005). Reduction in fear of falling through intense Tai Chi exercise training in older, transitionally frail adults. Journal of the American Geriatrics Society, 53, 1168-1178. Skelton, D. A., & Beyer, N. (2003). Exercise and injury prevention in older people. Scandinavian Journal of Medicine & Science in Sports, 13, 77-85. Stead, M., Wimbush, E., Eadie, D., & Teer, P. (1997). A qualitative study of older people’s perceptions of ageing and exercise: The implications for health promotion. Health Education Journal, 56, 3-16. Stevens, J. A., Noonan, R. K., & Rubenstein, L. Z. (2010). Older adult fall prevention: Perceptions, beliefs, and behaviors. American Journal of Lifestyle Medicine, 4, 16-20. Strauss, A. (1984). Chronic illness and quality of life. Philadelphia, PA: Mosby. Thomas, G. N., Macfarlane, D. J., Guo, B., Cheung, B. M., McGhee, S. M., Chou, K. L., . . . Tomlinson, B. (2012). Health promotion in older Chinese: A 12-month cluster randomized controlled trial of pedometry and “peer support.” Medicine & Science in Sports & Exercise, 44, 1157-1166. Wilcox, S., Der Ananian, C., Abbott, J., Vrazel, J., Ramsey, C., Sharpe, P., & Brady, T. (2006). Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Results from a qualitative study. Arthritis Care & Research, 55, 616-627. Yau, M. K. (2008). Tai Chi exercise and the improvement of health and well-being in older adults. Sport Science, 52, 155-165.
Downloaded from wjn.sagepub.com at UNIV OF MASSACHUSETTS on April 9, 2015
