Non-Pharmacologic Management
- Physical Inactivity: #1 Public Health Enemy
- Enhancing Exercise Adherence
- Facilitating Well-Being Among Patients
- Facilitating Behavior Change: What Really Works in Patient Education
Physical Inactivity: #1 Public Health Enemy
ARHP Keynote Address
Speaker:
Steven N. Blair PED
When inviting Dr. Blair to speak about exercise, there is little doubt that benefits of physical activity will be high on the list. After all, he was the scientific editor of the Surgeon General's landmark report on Physical Activity and Health. However, Dr. Blair's 2000 AHRP 2000's Keynote Address conveyed a more urgent tone regarding the dangers of inactivity.
Low levels of fitness are epidemic in the U.S. As noted in the SG report, more than 60 percent of American adults are not regularly active, and 25 percent of the adults are not active at all. For persons with arthritis, regular physical activity can help control joint swelling and pain and has not been shown to cause osteoarthritis. Regular physical activity is also important for individuals with rheumatic diseases because it increases stamina and muscle strength, enhances psychological well-being and quality of life and by increases the ability to perform activities of daily life.
The major cause of poor cardiorepiratory fitness is inactivity. Blair argued that throughout more than 99% of human history, physical labor was necessary for survival. Only recently has inactivity become commonplace.
Inactivity is deadly. A sedentary lifestyle is ranks highly among among the top predictors of mortality (e.g., overweight, smoking, hypertension, hyperlipidemia, age and genetics). Blair presented new data from the Aerobics Center Longitudinal Study while followed 891 women and 2,135 men from 1970 through 1994. The concept of Population Attributable Risk (PAR) takes into account both the strength of the factor and the prevalence of the factor in the population. PAR can be used to estimate the proportion of deaths that could be prevented by getting people to be more physically active (i.e., eliminating poor cardiorespiratory fitness.) The PAR for inactivity ranged 10% among normal weight men to 44% among obese men. Among hypertensive men, low fitness accounted for more risk of death (19%) than smoking, hypercholesterolemia and obesity combined.
In summary, low fitness is primarily caused by a sedentary lifestyle. A sedentary lifestyle is highly prevalent in the US. Poor fitness is as strong or stronger a predictor or mortality than other well-established risk factors and ranks as the most important public health problem in many countries around the world. Encouraging regular physical activity is included in the guidelines for treating osteoarthritis, and should be integrated into the routine care of most individuals with rheumatic diseases.
Editorial Comment: Below is an excerpt from the Surgeon Generals Report on Physical Activity and Health
HOW PHYSICAL ACTIVITY IMPACTS HEALTH
Regular physical activity that is performed on most days of the week reduces the risk of developing or dying from some of the leading causes of illness and death in the United States. Regular physical activity improves health in the following ways:
- Reduces the risk of dying prematurely.
- Reduces the risk of dying prematurely from heart disease.
- Reduces the risk of developing diabetes.
- Reduces the risk of developing high blood pressure.
- Helps reduce blood pressure in people who already have high blood pressure.
- Reduces the risk of developing colon cancer.
- Reduces feelings of depression and anxiety.
- Helps control weight.
- Helps build and maintain healthy bones, muscles, and joints.
- Helps older adults become stronger and better able to move about without falling.
- Promotes psychological well-being.
HEALTH BURDENS THAT COULD BE REDUCED THROUGH PHYSICAL ACTIVITY
Millions of Americans suffer from illnesses that can be prevented or improved through regular physical activity.
- 13.5 million people have coronary heart disease.
- 1.5 million people suffer from a heart attack in a given year.
- 8 million people have adult-onset (non-insulin-dependent) diabetes.
- 95,000 people are newly diagnosed with colon cancer each year.
- 250,000 people suffer from a hip fractures each year.
- 50 million people have high blood pressure.
- Over 60 million people (a third of the population) are overweight.
Enhancing Exercise Adherence: What Happens Outside the Pool Matter Too
Regular exercise in the pool is helpful for most persons with arthritis. Despite this, up to 74% of those begin an aquatic exercise program drop out within a few months. Kang and colleagues used a structural model to evaluate indicators of aquatic exercise adherence. They conducted interviews with 249 patients with arthritis who completed a 6-week program. First beliefs and expectations about oneself and the value of exercise were evaluated. Second, social (group support) and environmental (i.e., barriers) were added into the model. Principles of Social Learning Theory were used in developing the theoretical model.
As shown in the path diagram below, the factors most directly associated with exercise adherence were both psychological [self-efficacy and self evaluation] and social [group cohesion] [Self-efficacy is confidence in ones ability to exercise and adhere over time; self-evaluation is a measure of how well you think you are doing. Group cohesion is an indicator of how emotionally close you feel to other group members.]
Two factors were negatively associated with exercise adherence. Barriers to exercise as well as outcome expectancy (beliefs about the likely results of aquatic exercise). There were several indirect pathways as well. While group cohesion enhanced self-efficacy , barriers to exercise had an equally important but negative effect. Self-efficacy, had positive effects that differed in magnitude on both outcome expectancies and self-evaluation.
What does all this mean? In essence, these results strengthen the notion that exercise adherence is a complex behavior with multiple determinants. When developing aquatic exercise programs, several factors can be incorporated that may help patients to remain active exercisers. These include:
- Creating a supportive and safe atmosphere, as well as opportunities to socialize. These factors are known to increase group cohesion.
- Providing participants with the opportunities to talk about their expectations about exercise and how they view themselves and their progress. Groups discussions (facilitated by an exercise instructor) offer unique opportunities to enhance self-evaluations and ensure expectations are realistic.
- Demonstrating problem-solving skills and reviewing barriers as a group. Facilitated discussion as a group about the challenges of becoming a regular exerciser may help participants to identify and reduce barriers and enhance self-efficacy.
These data are based on a sample of treatment completers in a relatively short (i.e., 6-week program), and need to be more closely evaluated and replicated. However, they add to the building volume of evidence that that in the long run, what is done out of the pool is perhaps more important that the swimming activity itself.
Facilitating Well-Being Among Patients
"Treatment is not just fixing what is broken: it is nurturing what is best."
By Mihaly Csikiszentmihalyi
Freshly minted health professionals quickly recognize the wide variability in emotional distress and functioning among persons with rheumatic diseases. While the role of POSITIVE FACTORS that predict enhanced coping, health status and quality of life among patients has been studied for nearly 20 years, there has been little translation and integration of this knowledge into clinical care.
In his ACR 2000 workshop "What Helps Individuals with Chronic Disease Flourish: The Determinants of Well-being", Dr. Stephen Wegener of the Department of Physical Medicine and Rehabilitation at Johns Hopkins provided an overview of research findings and challenged attendees to rethink traditional models of rheumatic disease assessment and care. Highlights included:
"Its not how bad your disease is, but how satisfied you are with what you can do" that really makes a difference. Blalock and colleagues have published a series of studies evaluating how patients' satisfaction with their physical abilities and the types of comparisons that patients make between themselves and other people (i.e., social comparisons) when evaluating their abilities. These types of patient self-assessments clearly influence physical and psychological functioning and help explain differences in psychological well-being noted among individuals with the same degree of physical impairment. Greater satisfaction with physical abilities is also associated with less negative affect. We spend a great deal of time diagnosing and monitoring structural changes and problems brought about by rheumatic diseases, but relatively little time learning how our patients see themselves, the yardsticks they use, and the impact the disease has on their lives.
Work characteristics profoundly alter the probability of remaining employed. Loss of employment is a major financial, social and emotional blow to many patients with rheumatic diseases. Persons with rheumatic diseases are forced to adapt to the environment, rather than creating environments that facilitate individuals with changing need. Those who remain employed tend to have jobs in which they have greater job control (i.e., discretion over the pace and activities of work) and are able to lessen the physical demands. Service workers are most vulnerable to job loss. While OT and social workers have long recognized the importance of helping patients to actively adapt work environments, rarely is this type of help systematically integrated into routine care.
Much can be done to improve mood and psychological health. Most comprehensive treatment plans will try to identify and treat depression, but few do little to enhance mood in non-depressed individuals. Two important but separate components of mood are positive and negative affect. Positive affect is very different than not being depressed. Examples include feeling interested, inspired, determined, enthusiastic; negative affect includes feelings of irritability, distress, shame, guilt, etc. Mood management skills can be taught to patients to increase positive mood. This area offers important and novel avenues to enhance well-being among all patients.
Dr. Wegener concluded by suggesting we view persons with rheumatic diseases not as victims, but active participants. While interventions that modify self-perceptions, mood and social support need to be developed and tested before they can be implemented, assessments of an individuals psychological, social and environmental are an important first step we can incorporate right now. New areas of research include understanding the adaptive value of benefit finding, hope, denial, personal control and spirituality. It behooves all of us to think more broadly about identifying and "nurturing what is best" as part of the treatment of our patients.
Facilitating Behavior Change: What Really Works in Patient Education
Few would dispute that Kate Lorig, RN, PH.D. at Stanford University is the consummate patient educator. Over the years, she has developed and refined methods in the self-management of arthritis and other chronic diseases. In her ARHP 2000 symposium, Patient Education 101, she reviewed how her thinking about patient education has evolved with experience. Whether youre planning your first patient educations groups or, like me, trying to refine 15 years of experience, here are some real pearls from Dr. Lorig, straight from the trenches.
Remember what youre trying to accomplish:
The goal of patient education is to improve health status (e.g., by reducing pain, disability, reducing body weight, increasing quality of life) and decrease health care utilization. Patient education should NOT be designed to increase knowledge, as knowledge does not translate into behavior change, improved health, or fewer doctor visits or hospitalizations!
Five Habits of Highly Effective Patient Education Programs
- Programs must be based on patients' perceived needs and problems. To understand patients needs, you need to ask the right questions, then listen carefully. Hold focus groups with patients and ask questions such as "When you think about arthritis, what do you think of? What is that a problem? What helps?" In subsequent focus groups, begin by saying "Other groups have told us...what do you think." Only when you no longer get any new material are you really ready to begin developing your patient education program.
- Be very clear about what the key messages are. Patients should not be told many many things. Rather tell them a few things very clearly, on many occasions. As a staff, you have to decide what are the key messages for your patients and then all agree to pass on the same 10 to 15 messages. Often patients are told different things by different people or are told so many things that they decide not to do anything. Hold staff meetings to distill what these key messages will be so everyone is sure to reinforce the same messages.
- Build problem-solving skills. The single most important gift you can give patients is the ability to problem solve. Problem solving skills are in short supply, as most people go directly from "I have a problem" to "Theres no solution." Problem-solving in a group format also allows patients to help each other - one of the most potent forms of medicine.
- "You cant hurt yourself by exercising, except by not doing it." The need to be active remains a key message that many people with arthritis are not hearing from their health care providers. Exercise is not helpful - its essential to maintaining physical and mental health.
- Stay away from the lecture of the week format. As mentioned earlier, knowledge does not change behavior or health status. Instead, use what Dr. Lorig refers to as the "Sesame Street approach;" in each session, focus on facilitating discussions on many subjects and patient problems. Look for opportunities to build on previous patient success stories and restate your key messages.
