Program
Description
Evidence-base
Instructor qualifications
Availability
For information
Active Living Every Day (ALED)
Small group educational behavior change program focused on incorporating exercise into daily life
At 12 months:
One instructor per course
Available in nearly every state
Developed by the Cooper Institute
All exercise done outside of class
↑ physical activity with no increase in arthritis symptoms. (Callahan et al., 2014)
Online preparatory course followed by 2-day web-based or in-person training. Competency test before certification
Online version available but no evaluation data available
Program locator:
Dissemination support provided by Active Living Partners
Offered as weekly class in 12 or 20 week series
↓ depression, perceived stress. (Baruth & Wilcox, 2011)
Arthritis Foundation Aquatic Program (AFAP)
Low impact water exercise program developed for people with arthritis
↑ flexibility, strength, and aerobic fitness. (Patrick et al., 2001)
Health and fitness staff or volunteers with fitness experience who complete online training
Available in multiple locations across the U.S.
Developed by the Arthritis Foundation
Includes range of motion, muscle strengthening and conditioning exercise
Better outcomes among participants who attended 2+ classes per week. (Belza et al., 2002)
Program locator:
Dissemination support provided by Aquatic Exercise Association
Conducted in a warm water pool; offered 2–3 times per week in 8–12 week sessions or ongoing
Arthritis Foundation Exercise Program (AFEP)
Low impact recreational exercise program developed for people with arthritis. Includes range of motion, strengthening, balance, and aerobic condition exercise. Includes a health education component
upper extremity
Health and fitness staff or volunteers with fitness experience who complete online training
Available in multiple locations across the U.S.
Developed by the Arthritis Foundation
Offered 2–3 times per week in 8–12 week sessions or ongoing
↓ pain, fatigue (Callahan et al., 2008)
Program locator:
Dissemination support provided by Aquatic Exercise Association
EnhanceFitness (EF)
Small group exercise program originally developed for older adults
↑ physical function
Certified fitness instructor with 12 h of specialized EF training
Available in more than 25 states
Developed by the University of Washington
Includes flexibility, strengthening, balance, and conditioning exercise
↓ depression (Wallace et al., 1998)
Program locator:
Dissemination support provided by project enhance located at senior services
Offered three times per week on ongoing basis
↑ strength, mobility, self-rated health (Belza et al., 2006)
Fit & Strong! (F&S!)
Small group program that combines exercise and self-management education in each session. Developed for people with lower extremity osteoarthritis. Includes flexibility, strength training and aerobic working. Meets 3 times per week for 8 weeks. Concludes with participants developing a maintenance plan
↑ ability to exercise, adherence to exercise (Hughes et al., 2004)
Certified fitness instructor or physical therapist; 8 h of specialized training
Available in Illinois, North Carolina and west Virginia
Developed by the University of Illinois
↑ self-efficacy, strength, function
Program locator:
Dissemination support provided by the University of Illinois
↓ pain, stiffness (Seymour et al., 2009)
↑ physical activity, strength, function
↓ pain, stiffness , depression, anxiety (Hughes et al., 2010)
Walk with Ease (WWE)
Walking program designed for people with arthritis. Offered as small group instructor led program 3 times per week for 6 weeks or as a self-directed program. Includes educational modules on walking related topics
↑ strength, balance, walking pace, self-efficacy’
3–4 h of specialized online training. Must pass an online quiz to become certified
Available in many states; self-directed program can be done anywhere
Developed by the University of North Carolina
Online tools available to support participants
↓ pain, stiffness, fatigue, disability
Program locator:
Dissemination support provided by the Arthritis Foundation
More benefits maintained at 12 months in self-directed format (Callahan et al., 2011)
While the available programs have similar sets of exercises, they also have some important differences. The Arthritis Foundation Aquatic Program (AFAP) (Patrick et al., 2001) is performed in water, in contrast to the Arthritis Foundation Exercise Program (AFEP) (Callahan et al., 2008), EnhanceFitness (EF) (Wallace et al., 1998), and Fit & Strong! (F&S!) (Hughes et al., 2004), which are all done on land. Walk with Ease (WWE) (Callahan et al., 2011) focuses solely on walking, although it does include some warm-up stretching. Active Living Every Day (ALED) (Callahan et al., 2014) is a behavior change program focused on physical activity, but participants do not exercise in class. ALED class sessions focus on developing plans to incorporate exercise into daily routines and address barriers to regular exercise; all exercise is done outside of class.
Some of these more widely disseminated physical activity interventions, such as AFAP, AFEP, F&S!, and WWE, were all designed specifically for people with arthritis and include some educational components as well as the group exercise. In contrast, EF and ALED were developed to meet a more broad target population, but are also appropriate for people with arthritis.
While the majority of currently available physical activity programs require participants to meet together with a trained leader several times per week, WWE is designed to also accommodate self-directed participants—participants who conduct the program on their own by reading the book and gradually progressing the time or distance they walk. In an evaluation of both the group and self-directed formats of WWE, the participants in the self-directed WWE had 6-week improvements that were fairly equivalent to the group format and retained more of those benefits at 1 year follow-up than did the group participants (Callahan et al., 2011). Online tools are also available to support group and self-directed participants of WWE.
These physical activity programs are conveniently available at local fitness facilities, YMCAs, and community and senior centers. All of the physical activity programs identified in Table 15.1 are offered in multiple states across the country, although there is variability in availability. In 2014, EnhanceFitness was offered in more than 30 states, while Fit & Strong! was offered at multiple locations but in just three states (Illinois, North Carolina, and West Virginia). All of the small group exercise programs are led by trained instructors, with fitness or exercise training as well as 4–15 h of training in the specific intervention program. All of the interventions were developed at academic research centers or non-profit organizations, and all are offered at low cost (ranging from $2 to $3 dollars per session or $30 to $40 for an 8–12 week series of classes).
Self-Management Education Programs
The OA Public Health Agenda defines SME as interactive educational interventions specifically designed to enhance patient self-management. SME is patient-driven and focuses on building generalizable skills such as goal-setting, decision-making, problem-solving, and self-monitoring (Arthritis Foundation and Centers for Disease Control and Prevention, 2010). Self-management education differs from more traditional patient education in its focus on building those generalizable skills and helping people learn to solve the inevitable challenges of living with arthritis and make wise decisions about how to care for themselves, rather than a focus on disease information and compliance with healthcare professional directions (Bodenheimer, Lorig, Holman, & Grumbach, 2002). Seven SME interventions meet the criteria identified by the CDC Arthritis Program for interventions that are arthritis-appropriate, with an adequate evidence-base, and have the infrastructure to support widespread implementation (Brady, Jernick, et al., 2009). These programs are described in Table 15.2.
Table 15.2
Self-management education programs meeting CDC arthritis program screening criteria
Program | Description | Evidence-base | Instructor qualifications | Availability | For information |
|---|---|---|---|---|---|
Arthritis Self-Management Program (ASMP) | Interactive in-person small group workshop offered for 2–2.5 h per week for 6 weeks. Focuses on healthy behaviors such as physical activity, cognitive stress management, and communication with health care providers and generalizable skills such as problem-solving, decision-making, and action planning. Developed specifically for people with arthritis and all participants have arthritis | Meta-analysis of 19 studies demonstrated | Pair of leaders, preferably at least one who has arthritis; successful completion of CDSMP 4.5 day training followed by 4 h online arthritis-specific cross-training | Organizations in 15–20 states are licensed to offer ASMP; some are using CDSMP instead | |
Developed by Stanford University | ↑ self-efficacy, cognitive symptom management | Program locator: | |||
Dissemination support provided by Stanford University | ↓ depression, anxiety, health distress and fatigue, all sustained at 12 months | ||||
↑ exercise present at 6 months but not sustained at 12 months (Brady et al., 2010) | |||||
The Arthritis Toolkit (Toolkit) | Same content as the ASMP provided in a self-study format. Toolkit includes a self-assessment to direct user to most relevant content, The Arthritis Helpbook, tip sheets to address common problems, exercise and relaxation CDs. Available in English or Spanish | ↑ self-efficacy, role function | No leader required | Available by mail order nationwide | |
Developed by Stanford University | ↓ pain, fatigue, disability, depression, health distress (Goeppinger et al., 2009) | Program locator: | |||
Disseminated by Bull Publishing | Order toolkit through Bull Publishing | ||||
Better Choices, Better Health (BCBH) | Interactive online small group workshop covering the same content as the in-person CDSMP | ↑ stretch/strength exercise | Experience as a CDSMP leader, additional training to moderate online discussions | Available to members of contracted organizations | |
Developed by Stanford University | ↓ pain, fatigue, health distress, shortness of breath (Lorig et al., 2006) | Program locator: | |||
Disseminated by National Council on Aging/Canary Health | Information available through contracted organizations. | ||||
Better Choices, Better Health for Arthritis (BCBH-A) | Interactive online small group workshop covering the same content as the in-person ASMP | ↑ self-efficacy, self-reported health | Experience as a CDSMP leader, additional training to moderate online discussions | Available nationwide | |
Disseminated by National Council on Aging/Canary Health | ↓ pain, disability, health distress, all sustained at 12 months (Lorig et al., 2008) | Program locator: | |||
Chronic Disease Self-Management Program (CDSMP) | Interactive in-person small group workshop offered for 2–2.5 h per week for 6 weeks. Focuses on healthy behaviors such as physical activity, cognitive stress management, and communication with health care providers and generalizable skills such as problem-solving, decision-making, and action planning. Developed for people with a variety of chronic conditions; participants can have a variety of chronic conditions | Meta-analysis of 18 studies demonstrated | Pair of leaders, preferably at least one who has a chronic condition; 4.5 day training program | Organizations licensed to offer the program in all 50 states in the United States and well as internationally | |
Developed by Stanford University | ↑ self-efficacy, cognitive symptom management, aerobic exercise | Program locator: | |||
Dissemination support provided by Stanford University | ↓ depression, health distress, social/role limitations, pain, shortness of breath, all sustained at 12 months (Brady et al., 2013) | ||||
CDSMP Tool Kit for Active Living (CDSMP Toolkit) | Same content as the CDSMP provided in a self-study format. Toolkit includes a self-assessment to direct user to most relevant content, living a healthy life with chronic conditions book, tip sheets to address common problems, exercise and relaxation CDs | ↑ communication with doctor, self-rated health, muscle strength/stretch | No leader required | Available by mail order nationwide | |
Developed by Stanford University | ↓ depression, role limitations, unhealthy days (Lorig et al., 2015) | Program locator: | |||
Disseminated by Bull Publishing | Order toolkit through Bull Publishing | ||||
Programa de Manejo Personal la Artritis | Same content and format as ASMP, delivered in Spanish, developed to be culturally and linguistically appropriate for people of Hispanic origin | ↑ self-efficacy, exercise, self-reported health | Pair of leaders, preferably at least one who has a arthritis; 4.5 day training program conducted in Spanish | Organizations in five states (Florida, Massachusetts, Minnesota, Rhode Island, Wisconsin,) and several Spanish-speaking countries licensed to offer the program | Related posts: Sleep Disturbance in Rheumatic Disease
Mechanisms of Arthritis Pain
 Socioeconomic Disparities in Arthritis
The Importance of the Biopsychosocial Model for Understanding the Adjustment to Arthritis
 Physical Activity and Psychosocial Aspects of Arthritis
 The Nature, Efficacy, and Future of Behavioral Treatments for Arthritis
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