URC

Effects of Arthritis Exercise Program Participation on Arthritis Management Self-efficacy and Arthritis Pain Levels

Kaitlyn McManus

Truman State University

Keywords: Arthritis, Self-Efficacy, Group Exercise, Elderly, Pain Management

Abstract

Arthritis self-efficacy has emerged as one of the most important variables in understanding pain in people with arthritis. A convenience sample of senior adults participating (experimental) and not participating (control) in an Arthritis Foundation Exercise Program was compared to determine if there was a difference in self-efficacy and arthritis pain due to participating in the 8-week program. The results of an independent samples t-test revealed a statistically significant difference in the total mean scores of the experimental and control group for the Rheumatoid Arthritis Pain Scale, t(25) = 2.42, p = 0.02; and although the experimental group scored higher than the control group for the Arthritis Self-Efficacy Scale, t(25) = -1.40, p = 0.18, that difference was not significant. Results reinforce the importance of exercise in arthritis pain management and the need to improve patient self-efficacy to improve patient outcomes.

Introduction

Arthritis is the most common cause of disability in the United States, limiting the activities of nearly 21 million adults and projected to increase to 67 million by 2030 (Centers for Disease Control and Prevention [CDC], 2012). For millions of Americans who have some form of arthritis or a related disease, pain is chronic or long lasting. The term arthritis describes more than 100 rheumatic diseases and conditions that affect joints and other connective tissues (CDC, 2011), resulting in such problems as kidney disease, blindness, and premature death (Missouri Regional Arthritis Centers, n.d.).

Arthritis pain is chronic and potentially disabling and has pervasive adverse effects on the physical, mental, and social well-being of affected individuals. The course of chronic arthritis pain may be influenced by several factors, including the use of disease-modifying drugs, circumstances that are not controlled by doctors, social deprivation, formal education, helplessness, and social support (Brekke , Hjortdahl & Kvien, 2001). Chronic pain makes performing daily activities like cleaning the house, dressing, or looking after children more difficult and painful (Arthritis Foundation, 2012). Anxiety was more common than depression (31% and 18%, respectively); overall, one-third of respondents reported at least 1 of the 2 conditions. Most (84%) of those with depression also had anxiety (Murphy, Sacks, Brady, Hootman & Chapman, 2012).

Pain varies from person to person. Different kinds of pain can be due to different effects of arthritis on different parts of the joint (Arthritis Research UK Pain Centre, The University of Nottingham, 2012). Studies have focused on assessing individual pain in attempt to understand a common pain level. It seems that pain levels for those with arthritis tend to score a 2.91 on a 1-5 scale with a standard deviation of 1.00 (Somers, Wren, & Shelby, 2012; Somers, Shelby, Keefe, Godiwala, Lumley, & Mosley-Williams, 2010).

Group exercise classes that focus on aerobic endurance and muscle strengthening have been proven beneficial for decreasing pain and improving physical function in people with arthritis (Binnell & Hinman, 2011). Benefits of physical activity for those with arthritis are clear, yet physical activity is difficult to initiate and maintain. Existing physical activity programs for people with arthritis appear to be beneficial but they are very underutilized; only 1 percent of those who can benefit participate in the programs. Due to these daily restrictions, nearly 44 percent of adults with arthritis report no leisure-time physical activity (compared with about 36% of adults without arthritis) (Centers for Disease Control and Prevention [CDC], 2012). Some are afraid that exercise will be too difficult for them, that physical activity will harm them, or that they have to have special equipment (National Institute for Health: Senior Health, 2012). A potential barrier to exercise participation for people with arthritis suggested by the literature is low self-efficacy (Boutaugh, 2003).

Self-efficacy is a key modifiable psychosocial determinant of maintaining physical activity levels. It is concerned not with the skill one has, but with the judgment of what one can do with whatever skills one possesses (Brekke, Hjortdahl & Kvien, 2001). It assesses one's confidence to perform a task like manage arthritis pain rather than a global sense of control or mastery. Arthritis self-efficacy has emerged as one of the most important variables in understanding pain in people with arthritis. However, most rheumatologists do not focus efforts on improving patient self-efficacy (Somers, Shelby, Keefe, Godiwala, Lumley & Mosley-Williams, 2010). Arthritis patients' confidence (i.e., self-efficacy) has been related to numerous important outcomes, including pain intensity, pain-related disability, disease severity, and psychological distress. Thus, many people who could benefit from exercise programs may lack the self-efficacy to perform behaviors (like join an exercise program) that could control their arthritis pain. Self-efficacy for managing pain and other symptoms is an important construct in understanding the context of pain in patients with arthritis (Somers, Wren & Shelby, 2012). Therefore, the purpose of this study was to determine if there was a difference in self-efficacy and arthritis pain between people with arthritis participating in a group exercise program and those not participating in a group exercise program.

Methods

Sample

A convenience sample of 13 senior adults with arthritis from a rural, Northeast Missouri senior center who regularly participated in an 8-week long Arthritis Foundation Exercise Program (AFEP) class (experimental group) and a convenience sample of 14 senior adults with arthritis from a rural Northwest Missouri senior center who were not participating in an Arthritis Foundation Exercise Program class (control group) were asked to volunteer for the study. All (100%) elected to participate in the study. All were White, between the ages of 55-81 years, and female.

Instruments

The Arthritis Self-Efficacy Scale 8-Item (ASES-8), derived from the original 20-item Arthritis Self-Efficacy Scale and less burdensome on the respondent, was used to assess perceived confidence in ability to perform behaviors that would control arthritis pain. With eight items and no subscales, the ASES-8 has been successfully used in previous intervention program evaluations. Sentence stems for each question asked respondents about how "certain" they were that they could perform tasks, and respondents rated themselves on a scale of 1 (very uncertain) to 10 (very certain) for each. Mean score of the eight item ratings was then calculated (Lorig, Brown, Ung, Chastain, Shoor, & Holman, 1989; Brady, 2011).

The Rheumatoid Arthritis Pain Scale (RAPS) a valid, reliable instrument for measurement of arthritis pain, pain severity, and pain interference based on the gate control and affective motivational theories of pain, was used to assess pain levels of both groups. The 24-item scale with high internal consistency for total scale included four subscales: physiological, affective, sensory-discriminative, and cognitive with moderate to high internal consistency for the subscales. There was also one numerical rating scale of pain severity and 1 total joint score. The 24 items were scored using a 7-point Likert scale ranging from "0 = never" to "6 = always," with a lower score representative of higher pain levels (range of 0-144). The numerical rating scale of pain severity used a Likert scale ranging from "0 = none" to "10 = severe " with a higher score representing higher pain levels, and 1 total joint score rated by a physician used only for scale validation and was not part of the scale. RAPS has previously shown strong internal consistency reliability (coefficient of .92); and the four subscales also indicated good reliability with Cronbach's coefficients of .65 to .86 (Anderson, 2001). 

Procedure

During fall 2013, after Institutional IRB approval and participant consent, both groups completed the instruments and placed them in a sealed clasp envelope. The envelope was given to the researcher for data input/analysis.

Analysis

An independent samples t test was conducted to evaluate the hypothesis that there was a difference in self-efficacy and arthritis pain between people with arthritis participating in a group exercise program and those not participating in a group exercise program.

Results

As seen in the table, there was a statistically significant difference in the total mean scores of the experimental and control group for the Rheumatoid Arthritis Pain Scale, t(25) = 2.42, p = 0.02.

Table 1 Measures of Tendency and Dispersion for RAPS and Arthritis Self-Efficacy Scales

Scales

n

Possible Scores

Mean

Std. Deviation

Variance

Range

Min

Max

RAPS Control Group

14

0-144

73.64

21.22

450.09

74.00

36.00

110.00

RAPS Experimental Group

13

0-144

49.46

30.24

914.44

111.00

15.00

126.00

Arthritis Self Efficacy Control Group

14

1-10

5.40

1.82

3.29

6.50

2.38

8.88

Arthritis Self Efficacy Experimental Group

13

1-10

6.48

2.22

4.92

7.75

2.25

10.00

When asked specifically to rate the level of their arthritis pain from none to severe, however, there was not a statistically significant difference in the mean score of the experimental (M = 4.77, s = 2.65) and control (M = 6.14, s = 1.92) groups for the overall pain rating on the Rheumatoid Arthritis Pain Scale, t(25) = 1.55, p = 0.13.

Although self-efficacy levels were higher in the experimental group than in the control group; there was not a statistically significant difference in the total mean scores of the experimental and control groups for the Arthritis Self-Efficacy Scale, t(25) = -1.40, p = 0.18.

Discussion/Conclusion

In regard to the statistically significant difference in the total mean scores of the experimental and control group for the Rheumatoid Arthritis Pain Scale, pain is the primary reason people with arthritis seek medical attention (Bernstein, 2012). When experimental and control group respondents were compared on physiologic, affective, sensory-discriminative, and cognitive components of pain, those in the experimental group noted significantly less frequent pain symptoms over the last week. Consistent with the literature, it seems participation in exercise classes such as these may help ease arthritis pain symptoms (Binnell & Hinman, 2011). Results reinforce the importance of exercise in arthritis pain management and the need to encourage people with arthritis to participate in exercise classes like these that focus on improving muscular strength and endurance to decrease some components of pain.

Pain levels limit function and movement of people with arthritis (Anderson, 2001). In regard to the overall pain rating on the Rheumatoid Arthritis Pain Scale; although the experimental group rated their level of arthritis pain lower than that of the control group; it is interesting to speculate on why the difference was not significant. It may be that pain levels and tolerance are unique to the individual. Pain is highly subjective and the evaluation of pain levels is complex and difficult to quantify (Anderson, 2001). In a multi-dimensional disease such as arthritis, it is just one symptom as people with arthritis experience many symptoms such as joint stiffness, swelling, and restricted motion (Bernstein, 2012). Results, therefore, are in contrast with emerging research. Those with arthritis tend to average a 2.91 on a 1-5 scale (Somers, Wren, & Shelby, 2012; Somers, Shelby, Keefe, Godiwala, Lumley, & Mosley-Williams, 2010). In this study, both experimental and control groups rated their levels of arthritis pain as '6' and '5', respectively. Both groups' pain level scores were on the high side - noted at or above the mid-point and higher than the average previously assessed in the literature.

In regard to the total mean scores of the experimental and control groups for the Arthritis Self-Efficacy Scale, although self-efficacy levels were higher in the experimental group than in the control group there was not a statistically significant difference in the total mean scores. Arthritis self-efficacy is viewed as a key component in managing arthritis pain and symptoms (Somers, Shelby, Keefe, Godiwala, Lumley & Mosley-Williams, 2010). Respondents in this study reported higher than average pain levels possibly leading to less self-efficacy for pain management techniques such as group exercise class. Disease has been reported to have a direct relationship with self-efficacy; that is, arthritis patients with higher levels of disease severity would report lower self-efficacy across all self-efficacy domains (Somers, Shelby, Keefe, Godiwala, Lumley & Mosley-Williams, 2010). They feel so poorly that they cannot acquire the confidence to attempt to make a change. Disease severity has the strongest impact on self-efficacy to perform functional tasks and control arthritis symptoms (Somers, Shelby, Keefe, Godiwala, Lumley & Mosley-Williams, 2010). Study limitations, cross-sectional study design and small sample size, may also have led to this unexpected finding.

Higher levels of arthritis self-efficacy seem to lead to lessening of disease symptoms and pain, and work to improve patient self-efficacy like referral to health behavior specialists may improve outcomes (Somers, Shelby, Keefe, Godiwala, Lumley & Mosley-Williams, 2010). It is recommended that future research should examine the effect of bio-behavioral interventions to improve arthritis management self-efficacy and how this approach would affect exercise behavior.

References

Anderson, DL. (2001). Development of an instrument to measure pain in rheumatoid arthritis: Rheumatoid Arthritis Pain Scale (RAPS). Arthritis Rheumatology, 45(4), 317-23.

Arthritis Foundation. (n.d.).Safe and effective: Outcomes summary. Retrieved from:http://www.arthritis.org/media/programs/Evaluation_Summary_Exercise_HIGH.pdf

Arthritis Research UK Pain Center- The University of Nottingham. (2012, December). Arthritis pain affects people differently. Retrieved from http://www.nottingham.ac.uk/paincentre/pain-and-arthritis/index.aspx

Bernstein, S. (2012). Living with chronic pain. Arthritis Foundation, Retrieved from

Binnell, K., & Hinman, R. (2011). A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal of Science and Medicine in Sport. 14(1), 4-9.

Boutaugh, M. (2003). Arthritis Foundation community-based physical activity programs: Effectiveness and implementation issues. Arthritis Care & Research, 49(3), 463-470.

Brady, T. (2011). Measures of Self-Efficacy, Arthritis Self-Efficacy Scale (ASES), Arthritis Self-Efficacy Scale-8 Item (ASES-8),Children's Arthritis Self-Efficacy Scale (CASE), Chronic Disease Self-Efficacy Scale (CDSES), Parent's Arthritis Self-Efficacy Scale (PASE), and Rheumatoid Arthritis Self-Efficacy Scale (RASE). Arthritis Care & Research, 63 (S11), S473–S485.

Brekke , M., Hjortdahl, P., & Kvien, T. (2001). Self-efficacy and health status in rheumatoid arthritis: A two-year longitudinal observational study. Rheumatology, 40(4), 387-392.

Centers for Disease Control and Prevention [CDC]. (2012). Arthritis. Retrieved from: http://www.cdc.gov/arthritis/

Centers for Disease Control and Prevention [CDC]. (2011). Intervention programs. Retrieved from: http://www.cdc.gov/arthritis/interventions.htm

Lorig K., Brown B., Ung, E., Chastain, R., Shoor, S., Holman, H., (1989). Development and evaluation of a scale to measure the perceived self-efficacy of people with arthritis. Arthritis and heumatism, 32(1), 37-44.

Missouri Regional Arthritis Centers. (n.d.). About Arthritis. Retrieved from:      http://moarthritis.typepad.com/learn_about_arthritis/

Murphy, L., Sacks, J., Brady, T., Hootman, J., & Chapman, D. (2012). Anxiety and depression among us adults with arthritis: prevalence and correlates. Arthritis Care Research, 64(7), 968-76.

National Institute for Health: Senior Health. (2012, February). Being inactive can be risky. Retrieved from http://nihseniorhealth.gov/exerciseforolderadults/healthbenefits/01.htmlhttp://www.cdc.gov/arthritis/

Somers, T., Shelby , R., Keefe, M., Godiwala, N., Lumley, M., & Mosley-Williams, A. (2010). Disease severity and domain-specific arthritis self-efficacy: Relationships to pain and functioning in patients with rheumatoid arthritis. Arthritis Care & Research, 62(6), 848-856.

Somers, T., Wren, A., & Shelby, R. (2012). The context of pain in arthritis: Self-efficacy for managing pain and other symptoms. Current Pain & Headache Reports, 16(6), 52-508.


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