Origin of Guide

Table of Contents

  1. Recommended Physical Activity
  2. Physical activity among adults with arthritis
  3. Unique barriers for adults with arthritis
  4. Evidence-based programs
  5. Environmental and policy strategies
  6. References

In 2010, the Arthritis Foundation (AF), the Centers for Disease Control and Prevention (CDC), and partners col­laborated to produce A National Public Health Agenda for Osteoarthritis.

The agenda outlined a blueprint for recommended environmental and policy intervention strategies to reduce the burden of this important public health issue.

Physical activity was one of the intervention strategies outlined in the agenda. As a result, the Arthritis Foundation convened professionals representing areas of expertise related to physical activity and arthritis, as well as various sectors that can influence physical activity levels, to outline key environmental and policy strategies that might facilitate physical activity.

The resulting report—Environmental and Policy Strategies to Increase Physical Activity Among Adults With Arthritis—focuses on the benefits of physical activity and ways to make it more convenient and acces­sible for adults with arthritis. The report also addresses the long-established benefits physical activity has for co-occurring chronic conditions such as obesity, diabetes, and heart disease. It was released at an event in Washington, DC on May 16, 2012. Priority strategies are arthritis specific and intended to supplement more comprehensive strategies. They should be implemented in compliance with the Americans with Disabilities Act (ADA), the National Physical Activity Plan, the 2008 Physical Activity Guidelines for Americans, and other general evidence based physical activity recommendations and applicable laws.

The report serves as a call to action for each of six key sectors to collaborate and focus more attention on helping people live well with arthritis and remain active and involved in society.  This implementation guide, Boosting Physical Activity Among Adults with Arthritis, is designed to assist the sectors in working independently and as partners to translate the report’s recommendations into specific, effective action.

To learn more:

To read the complete report, click here.

Recommended physical activity

Recommendations for the management of arthritis—from clinical treatment guidelines to A National Public Health Agenda for Osteoarthritis—have included physical activity among the interventions proven effective for improving the lives of adults with arthritis (CDC, 2010; Zhang et al., 2009; Arthritis Foundation & CDC, 2010).

Although adults with arthritis have disease-specific barriers to being physically active as well as high rates of comorbidities, physical activity is an important intervention that decreases pain, delays the onset of disability, improves physical functioning, mood and independence, and enhances quality of life, aerobic capacity, and muscle strength.

Evidence-based physical activity programs for adults with arthritis are available, and can improve the quality of life for adults with arthritis.1  The CDC Arthritis Program provides a list of recommended2 and promising3 evidence-based interventions that promote physical activity. The CDC Arthritis Program also offers criteria for determining if other interventions may be deemed “arthritis-appropriate.”3

Familiarize yourself with appropriate types and amounts of physical activity needed for adults with arthritis.

To learn more:

CDC’s Physical Activity for Arthritis Fact Sheet
On barriers:
Brittain DR, Gyurcsik NC, McElroy M, Hillard SA. General and arthritis-specific barriers to moderate physical activity in women with arthritis. Womens Health Issues. 2011 Jan-Feb;21(1):57-63. PubMed PMID: 20833069.

Gyurcsik NC, Brawley LR, Spink KS, Brittain DR, Fuller DL, Chad K. Physical activity in women with arthritis: examining perceived barriers and self-regulatory efficacy to cope. Arthritis Rheum. 2009 Aug 15;61(8):1087-94. PubMed PMID: 19644901.

Wilcox S, Der Ananian C, Abbott J, Vrazel J, Ramsey C, Sharpe PA, Brady T. Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: results from a qualitative study. Arthritis Rheum. 2006 Aug 15;55(4):616-27. PubMed PMID: 16874785.

Der Ananian C, Wilcox S, Saunders R, Watkins K, Evans A. Factors that influence exercise among adults with arthritis in three activity levels. Prev Chronic Dis. 2006 Jul;3(3):A81. Epub 2006 Jun 15. PubMed PMID: 16776882; PubMed Central PMCID: PMC1636716.

Rimmer JH, Riley B, Wang E, Rauworth A. Accessibility of health clubs for people with mobility disabilities and visual impairments. Am J Public Health 2005;95(11):2022-8.

Rimmer JH, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med 2004;26(5):419-25.

Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P; American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465-74

Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010;18(4):476-99.

1 http://www.cdc.gov/arthritis/interventions.htm

2 http://www.cdc.gov/arthritis/interventions/physical_activity.htm

3 http://www.cdc.gov/arthritis/interventions/program_lists.htm

Recommended Physical Activity for Adults

  • 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.
  • Additional health benefits are provided by increasing to 5 hours (300 minutes) a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity
    physical activity, or an equivalent combination of both.
  • Muscle-strengthening activities that involve all major muscle groups performed on 2 or more days per week.

Special Considerations for People with Chronic Conditions (including Osteoarthritis)

  • Adults with chronic conditions obtain important health benefits from regular physical activity. When adults with chronic conditions do activity according to their abilities, physical activity is safe.
  • Adults with chronic conditions should be under the care of health-care providers. People with chronic conditions and symptoms should consult their health-care providers about the types and amounts of activity appropriate for them.

Source: Physical activity guidelines for Americans, available at: http://www.health.gov/PAGuidelines/guidelines

For specific research findings on physical activity for people with osteoarthritis, see: The Physical Activity Guidelines Advisory Committee Scientific Report available at: http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf

Physical activity among adults with arthritis

Despite the documented benefits of physical activity, adults with arthritis have higher rates of physical inactivity than those without arthritis (Shih et al., 2003; CDC, 2011; Dunlop et al., 2011).

Based on the 2012 National Health Interview Survey, 38.2 percent of adults with arthritis are considered inactive (defined as less than 10 minutes of aerobic physical activity per week) as compared to 27.1 percent of adults without arthritis (Shih et al, 2003). The highest rates of physical inactivity are among adults with arthritis and heart disease, arthritis and diabetes, and arthritis and obesity, when compared to adults with none of these conditions (CDC, 2008; CDC, 2009; CDC 2011a).

Rates of physical inactivity among adults with arthritis also vary considerably by state. Inactive adults with arthritis make up a substantial proportion of all inactive adults in each state (CDC, 2011b).

Source: Centers for Disease Control and Prevention. State-specific prevalence of no leisure-time physical activity among adults with and without doctor-diagnosed arthritis — United States, 2009. MMWR Morb Mortal Wkly Rep 2011;60(48):1641-70.

Adhering to national physical activity guidelines is directly related to improved quality of life for adults with arthritis. However—

  • Only 8-13% of adults with arthritis meet physical activity recommendations when assessed using direct measurement by motion sensors (Dunlop et al, 2011).
  • These inactive individuals experience more days when they are physically or mentally unhealthy (1.14 and 1.12, respectively) than those who follow the physical activity guidelines (Austin, 2011).
To learn more:

Shamly Austin S, Qu H, Shewchuk RM. Association between adherence to physical activity guidelines and health-related quality of life among individuals with physician-diagnosed arthritis. Qual Life Res 2012;21: 1347–1357. DOI 10.1007/s11136-011-0046-x  ArthritisPhysicalActivityGuidelinesHRQOL

Unique barriers for adults with arthritis

So why is this recommended intervention—physical activity—so underutilized by adults with arthritis?

A large part of the answer lies in the array of arthritis-specific barriers adults with arthritis face, compounded by barriers present in their physical and social environments. These barriers are both perceived and objective. Understanding these barriers can help shape new environmental and policy strategies specific to adults with arthritis or identify existing strategies that might be adapted.

Below is a list of common barriers to physical activity for adults with arthritis (some of the barriers listed are arthritis specific, while others are barriers that anyone would experience) (Brittain et al, 2011; Gyurcsik et al, 2009; Der Ananian et al, 2006; Wilcox et al., 2006; Rimmer et al, 2004; Rimmer et al, 2005):

Pysical barriers such as pain and fatigue, lack of mobility, or comorbid conditions.

  • Pain – including occurrence of pain preventing exercise, pain experienced during exercise, and pain experienced after exercise
  • Fatigue – including fatigue related to medication, insomnia, and depression
  • Mobility – impaired mobility is a major challenge to exercise
  • Comorbid conditions – including conditions ranging from musculoskeletal to cardiovascular ailments

Psychological barriers related to attitudes, beliefs, and fears.

  • Attitudes and beliefs – including lack of time, motivation, and enjoyment of exercise
  • Fear – including fear of experiencing or worsening pain and fear of water preventing participation in water aerobics
  • Perceived negative outcomes – including negative outcomes that might result from pushing beyond one’s limits

Social barriers such as lack of family support, no exercise partner, or competing responsibilities of job and family.

  • Lack of support – including not having support from family, friends, and health care providers (failure to mention exercise, not referring patients to helpful exercise programs, or not instructing patients how to exercise properly)
  • No one to exercise with – without exercise partners, frequency of exercise decreased
  • Competing role responsibilities – including feelings of responsibility to one’s family that relate to lack of time

Environmental barriers due to costly fees, no transportation, or lack of safe and accessible exercise sites.

  • Lack of programs or facilities – including few programs or facilities that meet specific needs and lack of qualified instructors
  • Environmental conditions – including hot and cold weather, rain, congested parking, concrete surfaces, and presence of dogs
  • Cost – such as membership fees to local exercise facilities
  • Transportation – including lack of transportation to facilities or programs
  • Exercise facility barriers – including inaccessible access routes, lack of elevators, slippery floors, absence of hand rails on stairs, lack of adaptive and/or accessible equipment, paying the same membership even though the facility is not fully accessible, and poor equipment maintenance
  • Lack of accessibility to parks and recreational centers – due to the challenge of complying with ADA guidelines while preserving the natural surroundings of parks and trails
  • Public space barriers – including damaged sidewalks, no sidewalks, terrain too steep a grade or slope, unsafe neighborhoods, poor weather causing slippery or impassible sidewalks, insufficient number of benches along a trail for people who need frequent rest periods, and poorly designated signage.
To learn more:

For more detail on barriers, visit Additional Resources (hyperlink) or read the following articles—
Brittain DR, Gyurcsik NC, McElroy M, Hillard SA. General and arthritis-specific barriers to moderate physical activity in women with arthritis. Womens Health Issues. 2011 Jan-Feb;21(1):57-63. doi: 10.1016/j.whi.2010.07.010. Epub 2010 Sep 15. PubMed PMID: 20833069.

Der Ananian C, Wilcox S, Saunders R, Watkins K, Evans A. Factors that influence exercise among adults with arthritis in three activity levels. Prev Chronic Dis. 2006 Jul;3(3):A81. Epub 2006 Jun 15. PubMed PMID: 16776882; PubMed Central PMCID: PMC1636716.

Gyurcsik NC, Brawley LR, Spink KS, Brittain DR, Fuller DL, Chad K. Physical activity in women with arthritis: examining perceived barriers and self-regulatory efficacy to cope. Arthritis Rheum. 2009 Aug 15;61(8):1087-94. doi: 10.1002/art.24697. PubMed PMID: 19644901.

Rimmer JH, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med 2004;26(5):419-25.

Rimmer JH, Riley B, Wang E, Rauworth A. Accessibility of health clubs for people with mobility disabilities and visual impairments. Am J Public Health 2005;95(11):2022-8.

Wilcox S, Der Ananian C, Abbott J, Vrazel J, Ramsey C, Sharpe PA, Brady T. Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: results from a qualitative study. Arthritis Rheum. 2006 Aug 15;55(4):616-27. PubMed PMID: 16874785.

Evidence-based programs

For the purposes of this Guide, EVIDENCE-BASED PROGRAMS are defined as interventions that:

  • are packaged so they can be delivered in the same way each time they are offered (i.e. maintaining fidelity); and
  • have an accumulation of data that show they have specific health benefits for people with arthritis. This includes data from well-conducted controlled trials and evaluation studies, published in scientific, peer-reviewed journals.

At least six programs have been proven to enhance the function and quality of life of adults with arthritis.

Tools
To learn more:

Environmental and policy strategies

Environmental and policy approaches tend to be broad in scope and affect underlying systems to provide opportunities, support, and cues to help people be more physically active.

Based on the definitions of environmental and policy changes, at times they involve:

  • The physical environment
  • Social networks
  • Organizational norms and policies
  • Laws
  • Involvement of multiple sectors: public health, community organizations, policymaking bodies, departments of parks and recreation, transportation and planning agencies, business and industry, and the media

The U.S. Preventive Services Task Force is charged with reviewing all available evidence and issuing recommendations for interventions that have been proven effective on a community-wide scale. Their recommendations, published in the Community Guide, have included some specific to physical activity. While none are specific to adults with arthritis, they lay the scientific foundation for the strategies in this Guide.

This table lists interventions reviewed by the Community Guide, with Task Force findings for each (definitions of findings). The Community Guide includes systematic reviews of interventions in the following areas:

Click on an underlined intervention title for a summary of the review and relevant recommended approaches.

Linking these approaches—environmental and policy strategies with informational outreach and the availability of individual behavior/social change programs—is key to increasing reach.

  • Some examples:Worksites build walking trails or provide walking maps to their employees (environmental/policy), disseminate Physical Activity. The Arthritis Pain Reliever materials to employees (campaigns/informational), and then have programs available that meet the needs of employees with arthritis such as the Arthritis Foundation’s group led Walk With Ease Program (behavioral/social)
  • Health plan wellness programs provide “incentive points” for participation in evidence-based programs (environmental/policy), disseminate health communications materials (campaigns/informational) through member guides and email, and link health plan members to programs such as the Arthritis Foundation’s self-directed Walk With Ease program (behavioral/social).
To learn more:

References

  • Arthritis Foundation, Centers for Disease Control and Prevention. A National Public Health Agenda for Osteoarthritis. www.cdc.gov/arthritis/docs/OAagenda.pdf. www.arthritis.org/osteoarthritis-agenda. Atlanta (GA): Centers for Disease Control and Prevention 2010.
  • Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activity among adults with obesity — United States, 2007 and 2009. MMWR Morb Mortal Wkly Rpt 2011a; 60(19);614-8.
  • Centers for Disease Control and Prevention. State-specific prevalence of no leisure-time physical activity among adults with and without doctor-diagnosed arthritis — United States, 2009. MMWR Morb Mortal Wkly Rep 2011b;60(48):1641-70.
  • Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007-2009. MMWR Morb Mortal Wkly Rep 2010;59(39):1261-5.
  • Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activity among adults with heart disease — United States, 2005 and 2007. MMWR Morb Mortal Wkly Rpt 2009;58(7):165-169.
  • Centers for Disease Control and Prevention. Arthritis as a Potential Barrier to Physical Activity Among Adults with Diabetes — United States, 2005 and 2007. MMWR Morb Mortal Wkly Rpt 2008;57(18):486-489.
  • Rimmer JH, Riley B, Wang E, Rauworth A. Accessibility of health clubs for people with mobility disabilities and visual impairments. Am J Public Health 2005;95(11):2022-8.
  • Rimmer JH, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med 2004;26(5):419-25.
  • Wilcox S, Der Ananian C, Abbott J, et al. Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: results from a qualitative study. Arthritis Rheum 2006;55(4):616-27.
  • Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010;18(4):476-99.