Characteristics of Participants in Water Exercise Programs Compared to Patients Seen in a Rheumatic Disease Clinic

Transcription

1 Characteristics of Participants in Water Exercise Programs Compared to Patients Seen in a Rheumatic Disease Clinic Cleda L. Meyer and Donna J. Hawley Purpose. To determine if community-based water exercise programs are serving people with significant levels of disability and pain. Methods. Eighty-seven participants in water exercise classes and 274 patients from a rheumatic disease clinic were matched for age, sex, and diagnosis and comparisons were made between the groups for the study variables. Results. Patients had significantly higher disability, pain, global disease severity, anxiety, and depression and lower grip strength than participants. Osteoarthritis [OA) patients (n = 226) compared to OA participants [n = 63) had similar significant differences for all variables. Rheumatoid arthritis (RA) patients (n = 48) scores were all more severe than RA participants scores (n = 24), and these differences were similar in magnitude to OA differences, but only global disease severity and grip strength were statistically significantly different. Conclusions. Water exercise classes are reaching persons with important levels of dysfunction and pain, but more severely affected patients are underrepresented in such programs. Key Words: Water exercise; Rheumatoid arthritis; Osteoarthritis; Community-based programs. Cleda L. Meyer, RN, MSN, is an Assistant Professor in the School of Nursing, Baker University, Topeka, Kansas: and Donna J. Hawley, RN, EdD, is a Professor of Nursing in the Department of Nursing, The Wichita State University, Wichita, Kansas Address correspondence to Donna J. Hawley, RN, EdD, Department of Nursing, Box 41, Wichita State University, Wichita, KS Submitted for publication May 19,1992; accepted September 20, by the Arthritis Foundation Water-based exercise has the potential to improve both physical and psychological well being for people with arthritis. Observational studies and controlled trials have documented the safety and efficacy of both land- and water-based aerobic exercise for people with arthritis (see review by Minor [l]). Participants in trials of water exercise programs have shown improvements in pain, grip strength, morning stiffness, tender joint counts, and mood [Z-41. The Arthritis Foundation has sponsored water exercise programs throughout the United States for almost a decade. These programs are accepted by both lay persons and professionals, with an estimated 12,000 people nationwide participating. Tork and Douglas [5] surveyed participants in community-based water exercise programs in Kansas. Respondents reported improvements in areas such as sleeping and relaxing, doing activities of daily living, and in general feeling better about themselves. Water exercise, according to these respondents, had psychological, social, and physical benefits. Thus, data from controlled clinical trials validate the efficacy of water exercise for individuals with substantial disease severity and disability, and anecdotal evidence indicates participant satisfaction with community-based programs. However, we do not know if participants in clinical trials and attendees of community-based programs have similar demographic and disease severity characteristics. In other words, are community-based programs serving people with varying disability levels or are these programs reaching only those with mild disease and disability? To address these questions, we compared 87 participants attending community-based water exercise programs at 6 sites in Kansas [hereafter called participants) with 174 age- and sex-matched patients attending a rheumatic disease clinic [hereafter called patients) /94/$

2 86 Meyer and Hawley Val. 7, No. 2, June 1994 in the same geographic area. We compared the two groups for functional disability, pain, grip strength, global severity of disease, anxiety, and depression. METHODS The water exercise participant group was recruited from 6 water exercise programs sponsored by the Arthritis Foundation in 5 communities in central Kansas. All attendees at each program site who indicated that they had arthritis were given the opportunity to participate in the study. A total of 136 people originally agreed to participate, with 104 returning questionnaires. Eighty-seven questionnaires had sufficient information for analysis. An overall response rate of 64% limits concern about response bias [6]. The final sample of participants included 24 people with rheumatoid arthritis (RA) and 63 people who reported 0steoarthritis (OA). All participants completed the Stanford Health Assessment Questionnaire (HAQ), functional disability scale, a visual analog pain scale, a visual analog scale measuring global disease severity, and the anxiety and depression scales of the Arthritis Impact Measurement Scales (AIMS]. In addition, they completed a demographic questionnaire and answered questions concerning medications taken, number of physician visits during the last 6 months, and number and type of joint replacement surgeries. Diagnosis of RA or OA was by self-report and was not confirmed by a physician. There is a potential for errors in diagnosis when using selfreport determinations, which may limit the generalizability of the findings. Grip strength was measured by the investigator (CM) on site. Due to time constraints, participants were permitted either to complete questionnaires on site or to return them by mail. The second group, the clinic patients, consisted of 2 patients matched to each water exercise participant by age within a decade, sex, and type of arthritis. All were patients at the Wichita Arthritis Clinic, a private rheumatic disease clinic, serving the southern and central areas of Kansas. The two-to-one matching was used to increase the sample size, thereby increasing power and minimizing bias. Matching was done for consecutively seen patients during essentially the same time of year as we were collecting data from the participants in the water exercise program. Questionnaires used for the participant group are those routinely completed by all patients at each visit to this clinic. All patient data including demographic information and clinical variables are stored in the computerized databank at the Wichita Databank using methodology and assessments developed by ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System). The RA patients met either the ARA 1958 criteria for definite or classic RA [7] or the ACR 1987 criteria [B]. OA patients had clinical and radiographic evidence of OA of the knee or hip. Instruments The HAQ was used to assess functional disability. This questionnaire measures 8 activities of daily living including dressing and grooming, arising, eating, walking, general hygiene (bathing), reaching for items, gripping objects, and general activities such as running errands and getting in and out of cars. Any activity that requires assistance from another individual or requires the use of an assistive device receives a score of 2. The highest score for each of the eight areas is summed (range = 0-24) and divided by 8 to yield a 0-3 functional disability index [9]. Reliability and validity of this instrument is well established in studies of rheumatic disease patients [ Pain during the last week and global disease severity were measured with visual analog scales (VAS). The VAS for pain is a 15-cm line double anchored and indexed to a scale of 0 = no pain to 3 = very severe pain. The reliability and validity of the VAS for measuring pain is well-established in studies of chronic pain patients and in arthritis patients [ Global severity was assessed with the question considering all the ways that your illness affects you, rate how you are doing. The analog scale ranges from 0 = very well to 100 = very poor. The 15-cm line is marked with increments of 20. The anxiety and depression instruments are two of the 9 scales of the AIMS [15]. Both scales are short: each scale has 6 questions. For each question patients have 6 choices ranging from 1, none of the time, to 6, all of the time. Scores are indexed on a scale of with increasing scores indicating worse status. Reliability and validity have been documented in various rheumatic disease samples [ Grip strength was measured using a folded blood pressure cuff inflated to 20 mm Hg. The highest value of three attempts for each hand was recorded and the measurements for the right and the left hands were averaged [20]. Statistical Analyses Data were analyzed with SAS Statistical Software version 6.04 for the PC [21]. Statistical significance was set at 0.05, and all tests were two-tailed. t-tests for independent groups were used to evaluate differences between the two groups for continuous variables and

3 Arthritis Care and Research Water Exercise Programs 87 chi-square for categorical data. Comparisons were made between participants and patients in total, followed by comparisons between patients and participants by diagnosis. RESULTS Both participants and patients were predominantly women (8Z%), married (70-73%), high school graduates ( , and retired with limited incomes (see Table 1). The participants did not differ from the patients in marital status, education, race, or length of disease (P > 0.05). Ethnic origins of both groups were consistent with those of the population of Kansas over age 60 [Z]. Nearly one-half (43.7%) of the water exercise group reporting total income (n = 65) indicated incomes at or below $15,000. The majority of the clinic sample (60.4%) reported incomes between $15,000 and $50,000. Average income in Kansas per household for 1989 was $43,700 [22]. Participants had been attending the water exercise classes for varying amounts of time, ranging from first time attendees to one person who had been involved for 22 years. One-half of those in the study (n = 47) had joined during the last 3 years. Average attendance was 8 sessions per month. As shown in Table 2, patients and participants differed significantly on all clinical variables studied, with the patient group reporting more significant disease. Specifically, patients reported more pain (1.5 vs 1.11, significantly higher HAQ functional disability scores (1.1 vs 0.81, higher global severity scores (46 vs 31). more anxiety (3.5 vs 2.81, and more depression (2.4 vs 1.8). In addition, the patients had significantly lower grip strengths (152 vs 181). Differences between patients and participants were also found when comparing the 2 groups using only those with OA. Table 3 illustrates that clinic patients with OA reported higher pain scores (1.6 vs 1.01, increased functional disability (1.0 vs 0.7). higher severity scores (46 vs 301, more anxiety (3.8 vs 3.0), and more depression (2.5 vs 1.8) than the community exercise group. Grip strength was also lower in the clinic sample (170 vs 190). All differences were significant with P values less than or equal to Table 3 also shows the mean values for each of the study variables for those with RA. Scores for the RA patients on all variables indicated higher disease severity for patients when compared to participants. Although the differences are not statistically significant, these differences have clinical importance. Pain is almost 7% higher for the patients than for the partici- TABLE 1 Demographic Characteristics of Study Participants Age (years) Sex (70 female) Married (70) Ethnic origin (70 Caucasian) Education (7' H.S. graduates) Income (%)u < $15,000 $ ,000 > $50,000 Retired (70) Disease duration (years) Water exercise Clinic participants patients (n = 87) (n = 174) Income levels, using chi-square analysis were statistically significantly different, P = Other demographic characteristics were not different between groups. pants, disability 1070, and depression 3%. Further, the magnitude of the differences between patients with RA and participants with RA was similar to differences noted when comparing the patients and participants with OA. For example, the differences in HAQ functional disability for the OA patients between patients and participants was 1.0 vs 0.7. The differences in the HAQ for the RA patients was 1.3 vs 1.0 for participants with OA. Both are differences of 0.3. The patients had a 10% higher rate of disability than the participants regardless of diagnosis. However, the smaller sample size for the RA groups yielded less statistical power, and statistical significance was reached only for global disease severity (35 vs 46) and grip strength (106 vs 160). TABLE 2 Comparison of All Water Exercise Participants and Clinic Patients for Outcome Variables Water exercise participants (n = 87) Mean (SD) Clinic patients (n = 174) Mean (SD) VAS pain ( (0.78) 1.5 (0.731 HAQ disability (0-3) 0.8 (0.66) 1.1 (0.72) VAS severity (0-100) 31.2 (19.97) 45.8 (24.34) AIMS anxiety (0-10) 2.8 ( (2.03) AIMS depression (0-10) 1.8 (1.04) 2.4 (1.63) Grip strength (0-300) (53.69) (59.58) All differences are statistically significant, P < 0.01.

4 88 Meyer and Hawley VO~. 7, No. 2, June 1994 TABLE 3 Comparison of Water Exercise Participants and Clinic Patients by Diagnosis Osteoarthritis Rheumatoid arthritis Water exercise Clinic patients Water exercise Clinic patients (n = 63) (n = 126) (n = 24) (n = 48) Mean (SD) Mean (SD) Mean (SD) Mean (SD) VAS pain (0-3) 1.0 (0.78) 1.6 (0.72)" 1.2 (0.78) 1.4 (0.73) HAQ disability (0-3) 0.7 (0.61) 1.0 (0.68)b 1.0 (0.75) 1.3 (0.79) VAS severity (0-100) 29.8 (25.12) 45.5 (25.221" 34.8 ( (22.411" AIMS anxiety (0-10) 3.0 (1.52) 3.8 (2.03)b 2.5 (1.37) 2.7 (1.80) AIMS depression (0-10) 1.8 (1.06) 2.5 (1.63)" 1.6 (0.99) 1.9 (1.55) Grip strength (0-300) (48.95) (53.59)b (59.78) (49.86)" 0 P < b P < P < DISCUSSION Several factors in the study limit generalizability of the findings. First, the data were collected in only one geographic area and the patient comparison groups were selected from one clinic. Second, we used only self-report diagnosis for the participants in the water exercise group. Some errors in diagnosis are possible. Last, not all people who attended the water exercise classes agreed to participate in the study, and not all who agreed returned usable questionnaires. However, the questionnaire return rate of 64% would indicate that response bias is probably minimal. The smaller representation of people with RA (27.6%) compared to those with OA (72.4%) limited the power in the study and lead us to suspect a Type I1 error. This higher representation for OA compared to RA is typical of community-based programs [23]. OA is common in the general population and has a prevalence certainly much higher than RA; therefore, one would expect that a community sample would likewise have a higher representation of those with OA than RA. The serious disability levels common in RA may also constrain attendance. Despite these limitations, this study makes an important point concerning who is really being served by community education and exercise classes. Programs are serving those with clinically important arthritis as evidenced by pain and disability scores reported by participants in the water exercise programs studied. However, these participants are less impaired than an age-, sex-, and disease-matched group from an arthritis clinic who are not known to engage in regular range of motion and/or aerobic exercise. The most severely affected people attending arthritis clinics are underrepresented in community-based pro- grams we studied. Because previous studies have demonstrated the safety and efficacy of water exercise for individuals with significant disability, it is important to find out why such underrepresentation continues to exist. Although this study does not directly address the reasons people do or do not attend community-based programs, the data provide some clues. First, are the classes offered at times and places that are convenient? The majority of these programs were offered during the day, although a few sessions began at 6:30 pm. The higher rate of retired persons in the participant group versus the patient group (see Table 1) may be partially explained by the daytime class schedule. Perhaps those who are employed or who have significant disability do not have the time or energy to attend such classes regardless of scheduling. Secondly, those with high pain levels and significant mobility problems may not believe that they can benefit from classes or think that the classes may increase their pain. Conceivably those with more severe disability do not have the transportation necessary to get to the classes. Additional questions that could be addressed are: What motivates people to attend classes? Is there transportation to the pools? Is more advertising necessary? How do we get more information out to patients? Do physicians and nurse practitioners have sufficient information to make referrals to these types of programs? The questions and explanations about why some people with arthritis are not attending community exercise programs are speculative but illustrate the need for additional study. As stated previously, the efficacy of exercise for people with significant disability has been demonstrated by other researchers. This study has shown severely afflicted people attending arthritis

5 Arthritis Care and Research Water Exercise Programs 89 clinics are underrepresented in community-based programs. Thus an opportunity exists to determine why a segment of the arthritis population is not being served by community-based programs and then to plan ways to get more people with severe mobility limitations involved in these beneficial programs. Such efforts by health professionals would be appropriate and potentially beneficial for more people with arthritis. REFERENCES 1. Minor MA: Physical activity and management of arthritis. Ann Behav Med 13: , Danneskiold-Samsoe, B, Lynberg R, Risum T, Telling M: The effect of water exercise therapy given to patients with rheumatoid arthritis. Scand J Rehabil Med 19:31-35, Dial C, Windsor RA: A formative evaluation of a health education-water exercise program for class I1 and I11 adult rheumatoid arthritis patients. Patient Ed Counsel 7:33-42, Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR: Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum , Tork SC, Douglas V: Arthritis water exercise program evaluation. Arthritis Care Res , Dillman DA: Mail and Telephone Surveys. New York, John Wiley & Sons, Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA: 1958 Revision of diagnostic criteria for rheumatoid arthritis. Arthritis Rheum , Arnett FC, Edworthy SM, Bloch DA, et al: The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 31: , Fries JF, Spitz PW, Kraines RG: Measurement of patient outcome in arthritis, Arthritis Rheum 23: , Fries IF, Spitz PW, Young DY: The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol 9: , Brown JH, Kazis LE, Spitz PW, Gertman P, Fries JF, Meenan RF: The dimensions of health outcomes: a crossvalidated examination of health status measurement. Am J Public Health 74: , Huskisson EC: Measurement of pain. Lancet November: , Carlsson AM: Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analog scale. Pain 16:87-101, Scott J, Huskisson EC: Vertical or horizontal visual analog scales. Ann Rheum Dis 38:560, Meenan RF, Gertman PM, Mason JH: Measuring health status in arthritis: the arthritis impact measurement scales. Arthritis Rheum 23: , Mason JH, Weener JL, Gertman PM, Meenan RF Health status in chronic disease: a comparative study of rheumatoid arthritis. J Rheumatol 10: , Masson JH, Anderson JJ, Meenan RF: Applicability of a health status model to osteoarthritis. Arthritis Care Res 2:89-93, Mason JH, Anderson JJ, Meenan RF: A model of health status for rheumatoid arthritis: a factor analysis of the arthritis impact measurement scales. Arthritis Rheum 31: , Coulton CJ, Hyduk CM, Chow JC: An assessment of the Arthritis Impact Measurement Scales in 3 ethnic groups. J Rheumatol 16:lllO-1115, Decker JL, McShane DJ, Esdaile JM, Hathaway DE, Levinson JE, Liang MH, Medsger TA Jr., Meenan RF, Mills JA, Roth SH, Wolfe F: Dictionary of the Rheumatic Diseases, Volume 1. Signs and Symptoms. New York, Contact Associates International, Ltd, SAS Institute: SAWSTAT Guide for Personal Computers, Version Cary, SAS Institute, Helyar T [ed): Kansas Statistical Abstract. Lawrence, Institute for Public Policy, University of Kansas, Lorig K, Chastain RL, Ung E, Shoor S, Holman HR: Development and evaluation of a scale of measure perceived self-efficacy in people with arthritis. Arthritis Rheum ,1989.