Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program

Authors


  • The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Abstract

Objective

To evaluate the effects of a revised 6-week walking program for adults with arthritis, Walk With Ease (WWE), delivered in 2 formats, instructor-led group or self-directed.

Methods

In an observational pre-post study design, 462 individuals with self-reported arthritis selected either a group format (n = 192) or a self-directed (n = 270) format. Performance and self-reported outcomes were assessed at baseline and at 6 weeks. Self-reported outcomes were assessed at 1 year. Adjusted mean outcome values for group and self-directed participants were determined using regression models, adjusting for covariates.

Results

At 6 weeks, significant adjusted mean improvements (P < 0.05) were seen for nearly all self-report and performance measures in both formats. Modest to moderate effect sizes (ES) were seen for disability (ES 0.16–0.23), pain, fatigue, and stiffness (ES 0.21–0.40), and helplessness (ES 0.24–0.28). The Arthritis Self-Efficacy (ASE) pain and symptom scales had modest improvements (ES 0.09–0.21). The performance measures of strength (ES 0.29–0.35), balance (ES 0.12–0.36), and walking pace (ES 0.12–0.32) all showed modest to moderate improvements. No adverse events were reported for either format. At 1 year, both formats showed modest improvement in ASE pain, but there were 5 outcomes where self-directed participants showed significant improvement, while the group participants did not.

Conclusion

The revised WWE program decreases disability and improves arthritis symptoms, self-efficacy, and perceived control, balance, strength, and walking pace in individuals with arthritis, regardless of whether they are taking a group class or doing the program as self-directed walkers. At 1 year, some benefits are maintained, particularly among the self-directed. This is a safe, easy, and inexpensive program to promote community-based physical activity.

INTRODUCTION

Arthritis is the most common cause of disability among adults in the US and is a highly prevalent chronic condition (1). A growing body of work has demonstrated that moderate aerobic exercise is safe and beneficial for people with arthritis (2–5). Regular moderate-intensity physical activity can decrease the severity of arthritis and its symptoms of pain, fatigue, and stiffness. As a result, various physical activity programs have been developed and tested specifically for people with arthritis.

Walking is a low-impact activity that is inexpensive, safe, and acceptable to people with arthritis. It can be done almost anywhere and anytime. Walking has been shown to improve functional status in individuals with arthritis, without exacerbating pain (2). In fact, a meta-analysis of 32 land-based exercise trials, including walking studies, in people with arthritis revealed beneficial treatment effects for pain (standardized mean difference [SMD] 0.40; 95% confidence interval [95% CI] 0.30, 0.50) and function (SMD 0.37; 95% CI 0.25, 0.49) (5). Adults with arthritis are less active than adults without arthritis (6) and struggle with disease-specific barriers to being physically active, such as episodic pain and fear of making their condition worse (7, 8). Despite this, people with arthritis know being physically active is important and that physical activity can help improve arthritis-related symptoms (7, 9). However, many adults with arthritis do not know how much walking they should do or how to start an exercise program safely (8). Therefore, there is a need to develop and evaluate a standardized walking program that can be easily accessed and distributed widely.

Walk With Ease (WWE), a 6-week community-based walking group program for adults with arthritis, was developed ∼10 years ago by the Arthritis Foundation (AF) (10). The program included a book and instructor-led group walks and was based on the stages of change behavioral theory, which encourages participants to tailor chapter readings and the overall program to their unique needs. Previously, the WWE program was evaluated in a nonrandomized pilot study of 102 adults with arthritis. The control group participated in an educational seminar on the pain cycle. The WWE group participants were less depressed, had less pain and health distress, and had increased arthritis self-efficacy at the end of the 6-week program; however, significant gains in walking endurance were not maintained at 4 months (11). Despite these initial positive findings, WWE was not widely used. In addition, not all persons with arthritis have access to, or a desire to participate in, group programs. This suggests a need to expand the delivery options (e.g., self-directed) for physical activity intervention programs for adults with arthritis.

In 2006, our research team evaluated and revised the existing WWE program to be suitable for both group and self-directed formats (12). We conducted a formative evaluation of the program by querying former WWE leaders and participants in order to identify participant preferences and determine needed modifications to the program structure and materials.

Guided by the formative evaluation feedback, we drafted a standardized WWE group and self-directed program structure and materials. The revised WWE workbook standardized the program, and the new leader training and manual allowed the leaders to maintain better fidelity to the program protocol. We replaced the Stages of Change (Transtheoretical Model) (13) approach in the original WWE workbook with Social Cognitive Theory (SCT) as the conceptual framework (14). We felt the SCT approach was a better choice for an intervention with both group and self-directed options. Specifically, we focused the WWE program content on having all participants engage in motivational strategies, including goal setting, setting up action plans, monitoring progress, identifying rewards, and using social supports. After these changes were made, we conducted a small pilot of the revised WWE program and further refined the materials based on feedback. The purpose of the current study was to conduct a large community-based evaluation of the revised WWE program in both group and self-directed formats.

Significance & Innovations

  • The revised Walk With Ease program is a safe, easy, and inexpensive program that can promote community-based physical activity, decrease disability, and improve arthritis symptoms.

  • Physical activity opportunities traditionally do not include both a group and a self-directed option. Offering both options may allow more people to benefit from the program and incorporate walking into their lifestyle.

PARTICIPANTS AND METHODS

Participants.

To be eligible for the community trial, participants had to self-report joint pain, stiffness, or any type of doctor-diagnosed arthritis, be age ≥18 years without a serious medical condition, be able to speak English, and have no cognitive impairments. The WWE program was publicized in newspaper advertisements, mass e-mails, and flyers sent to senior centers, aging councils, public health departments, medical centers, rheumatology clinics, fitness/wellness centers, retirement communities, colleges and universities, churches, recreation centers, and various employers across rural and urban counties throughout North Carolina.

Upon enrollment into the study, participants selected either the instructor-led group or self-directed format of the 6-week program. Group participants were led by an instructor and met 3 times a week for 1 hour. Self-directed participants followed the program on their own, using the WWE workbook as their guide.

Participants who enrolled in the group format of WWE were taught by trained WWE leaders who were recruited from senior centers and fitness/wellness centers across North Carolina. The leaders attended a 1-day certification course led by a senior behavioral scientist (MA) using the newly created AF WWE Leader Training Guide. Leaders were also required to obtain cardiopulmonary resuscitation certification. At the time of the training, leaders received a WWE workbook and a leader's guide, which included a script, a syllabus, and instructional tools for each of the group sessions.

All participants completed self-report and performance-based assessments at baseline and at the end of the 6-week program. Participants also completed self-report assessments 1 year after completion of the program; no performance-based assessments were conducted at that time. All study methods were approved by the University of North Carolina at Chapel Hill Biomedical Institutional Review Board.

Baseline and followup assessments.

Baseline assessments took place from June to September 2008 and were performed at community sites ∼1 week before the group classes began. Group and self-directed participants attended the assessments and provided informed consent, completed a self-report questionnaire (paper or computer-based), and underwent a series of performance-based tests administered by a trained research team member. The computer-based questionnaires were completed at the the facilities of the Assessment Center (www.assessmentcenter.net), part of the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) initiative, and allowed participants to directly enter their data. The paper forms were entered into the same system and stored on the Assessment Center servers for later retrieval. All participants received a WWE workbook at the time of the baseline assessment. Group classes began within a week of the baseline assessments, and self-directed participants were able to begin the program immediately following the baseline assessments. The 6-week followup assessments were conducted at each site from August to November 2008. At the time of the followup assessment, participants completed the performance-based physical function tests, the self-report survey, and a written satisfaction survey composed of closed and open-ended questions about their experience in the program. One year after completing the WWE program, group and self-directed participants were mailed followup surveys (self-reported outcomes only) to assess the long-term effect of the program.

Primary outcome measures.

Primary outcomes included physical function (performance based and self-report) and arthritis symptoms (pain, fatigue, stiffness). These outcomes were obtained through physical performance tests and self-reported measures. Physical performance tests were completed on the same day as the self-report instruments. Participants completed 5 performance-based physical function measures: timed chair stands, timed 360° turn test, single-leg stance, walking speed test, and the 2-minute step test (15–18). All measures have established reliability.

Timed chair stands.

The timed chair stands assess lower extremity strength (17, 18). Participants sit in a standardized armless chair with their backs against the chair and arms folded across the chest. The participant stands up and sits back down as quickly as possible 1 time, and then 3 times in a row without stopping. There was 1 trial for each of the chair stands with the measurement in seconds.

Turn tests.

The 360° turn test measures turning ability and balance (17, 18). Participants stand with arms at their side and feet comfortably apart and turn in a full circle to the right, and then in a full circle to the left. There were 2 trials for each direction and the times (in seconds) were averaged.

Single-leg stance.

This test measures balance (16). Participants stand next to a chair, wall, or raised surface and stand on one leg, and then the other, while placing their arms across their chest. There was 1 trial on each leg, and the measurement is the number of seconds of balance up to a maximum of 30 seconds.

Walking speed.

The walking speed test measures functional mobility (17, 18). Participants walk a premeasured 20-foot distance on flat ground, with 6-foot acceleration and deceleration zones at each end, at both a normal and a fast walking pace. There were 2 trials for each pace, and the times (in seconds) to complete the distance were averaged. The average speed was calculated in units of meters/second for use in the analysis.

2-minute step test.

The 2-minute step test measures aerobic endurance (15). Participants march in place for 2 minutes, taking as many steps as possible in that time and raising both knees to a predetermined height (based on the height of the participant) as marked on the wall next to them. There was 1 trial for this test.

Self-reported physical function: PROMIS Health Assessment Questionnaire (HAQ).

The disability scale of the PROMIS HAQ (19) assesses self-report function. The PROMIS HAQ differs from the standard HAQ disability index in that it has 5 responses (0–4), instead of 4 (0–3), for 20 questions that remain virtually the same. The item scores are adjusted for assistance by people or devices, averaged, and then multiplied by 25 to give the total score on a scale of 0–100. A higher score on the PROMIS HAQ indicates more disability. For brevity, going forward the PROMIS HAQ will be referred to as the HAQ.

Arthritis symptoms: pain, stiffness, and fatigue.

A visual analog scale (VAS) was used to measure arthritis symptoms of pain, stiffness, and fatigue (20, 21). The participants marked a spot on a 100-mm line corresponding to their pain experience over the last 7 days. For pain, the VAS is anchored with the descriptors “no pain” and “pain as bad as it could be.” Stiffness and fatigue were measured similarly. The VAS is measured in millimeters from the left anchor to the point marked by the respondent. Higher VAS scores indicate more pain, fatigue, or stiffness.

Secondary outcome measures.

Three psychosocial instruments were administered as part of the self-report survey.

Arthritis Self-Efficacy (ASE) pain and symptom scales.

The ASE measure characterizes an individual's confidence in managing their arthritis pain and symptoms (22). This 11-item instrument has 2 subscales; one for pain (5 items) and one for other symptoms (6 items). Each item is scored as an integer (1–10) and averaged over the subscale. Higher scores express greater confidence for managing arthritis.

Rheumatology Attitudes Index (RAI).

The 5-item helplessness subscale of the RAI measures perceived helplessness (23). The items are scored from 1–5 (least to greatest amount of helplessness), and the average of the 5 items is used for analysis.

Self-Efficacy for Physical Activity (SEPA).

The 5-item SEPA scale assesses the respondents' confidence in their ability to be physically active despite barriers (24). A summary score (range 1–5) is calculated by averaging the 5 items. Higher scores reflect higher levels of self-efficacy.

Covariates.

Demographic data included age, sex, race, education, and body mass index (BMI; kg/m2) calculated from self-reported height and weight. In the modeling analyses, age was trichotomized as <60 years, 60–74 years, and ≥75 years. Race was classified as white, African American, or other. Education was dichotomized as either greater than high school or less than or equal to high school. Finally, BMI was dichotomized as <30 kg/m2 or ≥30 kg/m2, and sex was female or male.

Satisfaction surveys.

Individuals in both group and self-directed study arms were queried regarding their overall satisfaction with the WWE program, the extent to which they were satisfied with the length of the program and program topics, whether the program increased their knowledge about walking in a safe and comfortable manner, and whether they would recommend the program to a friend.

Statistical analysis.

The baseline mean values of all variables were calculated separately for self-directed and group format, and the differences were examined with either t-tests or chi-square tests, as appropriate. Approximately 42% of the participants enrolled in the group format and 58% enrolled in the self-directed format.

Repeated-measure linear regression models for each outcome, using data from all the participants in both formats, were formulated to assess changes in an outcome measure through multiple time points, either baseline to 6 weeks or baseline to 6 weeks and 1 year. Model outputs include adjusted mean outcomes for each format at all time points, and adjusted mean outcomes at baseline vary by format. Results are displayed as differences from the values at baseline, e.g., 6 weeks minus baseline or 1 year minus baseline. Modeling each outcome measure controlled for the baseline outcome value, age, sex, BMI, race, and education. A positive difference indicates that the measure of outcome has increased from baseline to the followup. Depending on the scale of the particular outcome, the increase may be viewed as either beneficial or detrimental in terms of the participant's well-being. For example, an increase in the HAQ score would be detrimental (more disability), while an increase in the leg stance measure would be beneficial (increased time maintaining balance).

For each format and each outcome, the differences from baseline were tested using the null hypothesis that the difference is zero, i.e., no change over time. This testing procedure addresses the primary question, “Does the WWE program improve physical function and arthritis symptoms?” In addition, for each outcome, the differences from baseline between the 2 formats were tested under the null hypothesis that they are the same. This procedure addresses the secondary question, “Were the effects of the WWE program the same for the self-directed and the group format?” For the results from baseline to 6 weeks, the effect size (ES) was calculated as the within-format difference in outcomes divided by the SD of the outcome at baseline. Positive ES indicates improvement in an outcome, and negative ES indicates deterioration in an outcome measure. Qualitatively, ES 0.1–0.3 will be termed “modest,” and ES 0.3–0.5 will be termed “moderate.”

RESULTS

A total of 462 participants enrolled into the study and entered self-report data at baseline (Figure 1). Data were collected at 33 sites located in communities throughout the state. Study sites included 9 senior centers (27.7% of participants), 4 churches (8.2% of participants), 4 employers (11.1% of participants), 4 community health/fitness/wellness centers (11.3% of participants), and 4 departments or councils on aging (11.6% of participants). Other venues included assisted-living and retirement communities, medical centers, and a service sorority. Ten sites offered the self-directed format only, 6 sites offered the group format only, and the remainder (17 sites) offered both formats. Groups ranged in size from 2 or 3 to 19 participants, with most groups in the range of 5–12 participants.

Figure 1.

Walk With Ease (WWE) Program participant flow chart.

A majority (n = 270, 58.4%) of the participants opted for the self-directed format and the remainder (n = 192, 41.6%) opted for the group format. Followup rates at 6 weeks were 83.3% and 92.7% for self-directed and group participants, respectively. Rates for performance-based assessments were lower than self-reported assessments for participants in both formats at the 6-week followup. Due to scheduling conflicts, a total of 38% self-directed participants and 22.6% group participants did not complete performance-based assessments. Followup rates at 1 year from baseline were 75.5% for self-directed and 82.3% for group participants. In both formats, ∼90% of those followed up at 6 weeks were also followed up at 1 year (Figure 1). No differences were found for 6-week followup rates by baseline demographic characteristics (data not shown).

The baseline demographics and scores by format of participation, either group or self-directed, are summarized in Table 1. Data are restricted to only those 403 participants (87%) who completed followup at 6 weeks. Of the 403 participants with 6-week data, 362 returned followup data at the 1-year point. The sample was mostly female (87.3%), most had continued education beyond high school (71%), and most were white (72%). On average, self-directed participants were younger than the group participants by 5.8 years, better educated, and had better baseline scores on all the performance tests except the step test. Although not statistically different, the self-directed participants at baseline reported less disability on the HAQ and were more confident in being able to exercise (SEPA). Group and self-directed participants had similar symptoms and psychosocial measures (except SEPA noted above) at baseline. The participants who completed the 6-week and 1-year followups were not significantly different in demographic makeup for the baseline characteristics of the samples. Also, there were no significant differences in the demographics between individuals who completed the performance-based assessments and those who did not.

Table 1. Baseline characteristics of both self-directed and group participants who completed the 6-week followup*
CharacteristicSelf- directedGroupPParticipants, no.
TotalSelf-directedGroup
  • *

    HAQ = Patient-Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS = visual analog scale; ASE = Arthritis Self-Efficacy scale for pain and symptoms; SEPA = Self-Efficacy for Physical Activity.

  • Analysis includes only participants who completed followup measures at 6 weeks (n = 403).

  • Result of t-test (continuous variables) or chi-square test (categorical variables) for determining if the group and self-directed participants means are significantly different.

Demographics      
 Age, mean ± SD years64.9 ± 11.470.7 ± 9.8< 0.001403225178
 Education, less than/equal to high school, %25.134.30.039403225178
 Race      
  White, %72.970.8    
  African American, %23.125.80.790403225178
  Other, %4.03.4    
 Female, %88.985.40.295403225178
 Body mass index ≥30 kg/m2, %39.136.50.594403225178
Performance-based physical function, mean ± SD seconds      
 Lower-extremity strength      
  1 chair stand3.34 ± 1.853.70 ± 1.50.063305159146
  3 chair stands9.59 ± 3.7610.4 ± 3.50.069301156145
 Standing balance/turning ability      
  360° turn right3.16 ± 1.43.73 ± 1.2< 0.001306163143
  360° turn left3.14 ± 1.463.68 ± 1.2< 0.001306163143
 Balance      
  Right leg stance12.16 ± 10.928.6 ± 9.10.004276150126
  Left leg stance12.2 ± 11.258.3 ± 9.20.002286155131
 Functional mobility, mean ± SD meters/second      
  Normal walking speed1.12 ± 0.221.06 ± 0.200.008308163145
  Fast walking speed1.54 ± 0.311.44 ± 0.320.005307162145
 Aerobic endurance, mean ± SD step count      
  2-minute step test75.0 ± 23.775.6 ± 23.20.821286148138
Self-reported function, mean ± SD      
 HAQ (range 0–100)13.7 ± 12.815.8 ± 14.50.128394221173
Arthritis symptoms, mean ± SD mm      
 Pain, VAS (range 0–100)38.6 ± 23.637.6 ± 27.10.536387216171
 Fatigue, VAS (range 0–100)36.0 ± 27.538.2 ± 28.80.418388216172
 Stiffness, VAS (range 0–100)43.4 ± 25.740.8 ± 27.70.664388216172
Psychosocial, mean ± SD      
 Pain ASE (range 1–10)6.8 ± 2.056.6 ± 2.30.318390216174
 Symptom ASE (range 1–10)7.08 ± 1.936.9 ± 2.10.464389216173
 Rheumatology Attitudes Index (range 0–4)1.16 ± 0.871.22 ± 0.850.528368206162
 SEPA (range 1–5)2.82 ± 0.712.95 ± 0.750.061374210164

Pre-post test results after 6-week intervention.

The modeling results for performance-based physical function at 6-week followup are presented in Table 2. The model produces adjusted mean differences from baseline to 6 weeks separately for those in each format. Participation in the WWE program, both the self-directed and group formats, resulted in significant improvements in almost all performance-based physical measures. ES for lower extremity strength measures indicated moderate improvement (0.29–0.35), balance measures indicated modest to moderate significant improvement (0.12–0.37), and functional mobility measures indicated modest improvement (0.12–0.32). No significant improvement was seen in the 2-minute step test, which is a measure of endurance (Table 2). Although fast walking speed is improved from baseline in both formats (within format test), the improvement is significantly greater for group format (between- formats test).

Table 2. Differences in performance-based physical function test results from baseline to 6-week followup as determined from an adjusted repeated-measures regression model*
Physical function measureDifference from baseline (95% confidence interval)Effect sizeNo.
  • *

    Adjusted for baseline outcome value, age, sex, body mass index, race, and education.

  • P < 0.01 for test that difference from baseline is 0 (within format).

  • P < 0.05 for test that difference from baseline is 0 (within format).

  • §

    P < 0.05 for test that difference from baseline is 0 (within format) and for test that group and self-directed differences are the same (between formats).

  • P < 0.01 for test that difference from baseline is 0 (within format) and P < 0.05 for test that group and self-directed differences are the same (between formats).

Lower extremity strength, seconds   
 1 chair stand   
  Self-directed format−0.57 (−0.77, −0.37)0.31159
  Group format−0.52 (−0.73, −0.31)0.35146
 3 chair stands   
  Self-directed format−1.27 (−1.66, −0.88)0.34156
  Group format−1.02 (−1.42, −0.62)0.29145
Standing balance/turning ability, seconds   
 360° turn right   
  Self-directed format−0.30 (−0.43, −0.16)0.21163
  Group format−0.43 (−0.58, −0.29)0.36143
 360° turn left   
  Self-directed format−0.34 (−0.46, −0.21)0.23163
  Group format−0.43 (−0.57, −0.3)0.37143
Balance, seconds   
 Right leg stance   
  Self-directed format1.87 (0.39, 3.35)0.17150
  Group format2.78 (1.17, 4.4)0.31126
 Left leg stance   
  Self-directed format1.39 (−0.04, 2.83)0.12155
  Group format2.49 (0.93, 4.05)0.27131
Functional mobility, meters/second   
 Normal walking speed   
  Self-directed format0.048 (0.022, 0.074)0.22163
  Group format0.064 (0.037, 0.091)0.32145
 Fast walking speed   
  Self-directed format0.038 (0.005, 0.071)§0.12162
  Group format0.078 (0.043, 0.113)0.24145
Endurance, count   
 2-minute step test   
  Self-directed format−1.56 (−5, 1.88)−0.07148
  Group format−1.54 (−5.1, 2.02)−0.07138

Results from regression models for the self-reported outcomes are presented in Table 3. Similar to the performance-based measures, numerically, all differences represent improvements from baseline, and most are significant. Self-reported disability (HAQ) improved modestly (ES 0.16–0.23), arthritis symptoms of pain, fatigue, and stiffness improved moderately (ES 0.21–0.40), and the psychosocial measures improved modestly (ES 0.09–0.28). There were no significant differences in the amount of improvement for any variable between formats of intervention.

Table 3. Differences in self-reported physical function, arthritis symptoms, and psychosocial from baseline to 6-week followup as determined from adjusted repeated-measures regression models for each outcome*
Self-reported measureDifference from baseline (95% confidence interval)Effect sizeNo.
  • *

    Adjusted for baseline outcome value, age, sex, body mass index, race, and education. HAQ = Patient-Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS = visual analog scale.

  • P < 0.01 for test that difference from baseline is 0 (within format).

  • P < 0.05 for test that difference from baseline is 0 (within format).

Function   
 HAQ (range 0–100)   
  Self-directed format−2.98 (−4.08, −1.87)0.23221
  Group format−2.26 (−3.51, −1.01)0.16173
Symptoms   
 VAS (range 0–100)   
  Pain   
   Self-directed format−8.4 (−11.65, −5.15)0.36216
   Group format−7.82 (−11.48, −4.17)0.29171
  Fatigue   
   Self-directed format−5.68 (−9.07, −2.3)0.21216
   Group format−6.33 (−10.12, −2.54)0.22172
  Stiffness   
   Self-directed format−10.27 (−13.67, −6.87)0.40216
   Group format−8.75 (−12.55, −4.94)0.32172
Psychosocial   
 Pain Arthritis Self-Efficacy (range 1–10)   
  Self-directed format0.19 (−0.11, 0.5)0.09216
  Group format0.49 (0.15, 0.83)0.21174
 Symptom Arthritis Self-Efficacy (range 1–10)   
  Self-directed format0.26 (−0.02, 0.54)0.13216
  Group format0.4 (0.09, 0.72)0.19173
 Rheumatology Attitudes Index (range 0–4)   
  Self-directed format−0.21 (−0.3, −0.11)0.24206
  Group format−0.23 (−0.34, −0.13)0.28162
 Self-efficacy for physical activity (range 1–5)   
  Self-directed format0.06 (−0.03, 0.15)0.09210
  Group format0.07 (−0.03, 0.18)0.10164

One-year followup data.

The model results out to the 1-year followup are presented in Table 4. All outcomes are self-reported since no site visits were made to include performance-based tests. The model requires data from all 3 time points. The results at 6 weeks are comparable, but not identical, to those found in Table 3, since the sample has decreased in size and the model includes the 1-year data. At 1 year, there are several measures where the difference from baseline is significant for the self-directed participants, the difference from baseline is nonsignificant for group participants, and the between-format results are significant (HAQ, pain VAS, stiffness VAS, and RAI). The self-directed participants held onto their gains or even improved, while the group participants lost ground (e.g., pain VAS, ASE pain and symptoms). The significant SEPA difference from baseline in group format is actually a loss of self-efficacy for physical activity.

Table 4. Differences in self-reported physical function, arthritis symptoms, and psychosocial outcomes from baseline to 6-week followup and baseline to 1-year followup as determined from a repeated-measures regression model for each outcome, for participants with 1-year data*
Self-reported measureDifferences from baseline (95% confidence interval)No.
6-week followup1-year followup
  • *

    HAQ = Patient-Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS = visual analog scale; RAI = Rheumatology Attitudes Index.

  • P < 0.01 for test that the difference from baseline is 0 (within format).

  • P < 0.01 for test that the difference from baseline is 0 (within format) and for test that the group and self-directed differences are the same (between formats).

  • §

    P < 0.01 for test that the group and self-directed differences are the same (between formats).

  • P < 0.05 for test that the difference from baseline is 0 (within format).

  • #

    P < 0.01 for test that the difference from baseline is 0 (within format) and P < 0.05 for test that the group and self-directed differences are the same (between formats).

  • **

    P < 0.05 for test that the group and self-directed differences are the same (between formats).

Format   
 HAQ   
  Self-directed format−2.97 (−4.31, −1.62)−2.63 (−3.97, −1.28)193
  Group format−2.5 (−4.04, −0.96)0.78 (−0.76, 2.32)§148
Arthritis symptoms, VAS (range 0–100)   
 Pain   
  Self-directed format−7.56 (−11.51, −3.6)−9.68 (−13.63, −5.73)186
  Group format−8.34 (−12.82, −3.87)−0.37 (−4.84, 4.11)§145
 Fatigue   
  Self-directed format−5.29 (−9.43, −1.16)−2.85 (−6.98, 1.29)185
  Group format−5.74 (−10.38, −1.1)0.90 (−3.74, 5.55)147
Stiffness   
  Self-directed format−9.1 (−13.0, −5.21)−9.73 (−13.62, −5.84)186
  Group format−8.98 (−13.38, −4.57)−1.54 (−5.95, 2.87)§145
Psychosocial   
 Pain Arthritis Self-Efficacy (range 1–10)   
  Self-directed format0.09 (−0.25, 0.43)§0.34 (0, 0.68)185
  Group format0.66 (0.28, 1.04)0.39 (0.01, 0.78)142
 Symptom Arthritis Self-Efficacy (range 1–10)   
  Self-directed format0.21 (−0.11, 0.52)0.42 (0.1, 0.73)186
  Group format0.53 (0.17, 0.89)0.36 (−0.01, 0.72)140
 RAI (range 0–4)   
  Self-directed format−0.19 (−0.3, −0.08)−0.24 (−0.35, −0.13)#176
  Group format−0.23 (−0.36, −0.1)−0.08 (−0.21, 0.05)**125
 Self-efficacy for physical activity (range 1–5)   
  Self-directed format0.07 (−0.05, 0.18)−0.04 (−0.16, 0.07)177
  Group format0.02 (−0.11, 0.16)−0.22 (−0.36, −0.09)130

Six-week satisfaction survey data.

Among the 232 self-directed participants who completed the satisfaction survey at the end of the 6-week program, 92% reported that they agreed or strongly agreed that they would recommend the WWE program to a friend or family member. The majority agreed or strongly agreed that the program motivated them to become more active (80%), were satisfied with the program (78%), benefited from the program (80%), and thought 6 weeks was an appropriate program length (82%). Approximately 84% reported that, as a result of the WWE program, they learned how to exercise safely and comfortably. At the end of the program, 47% of self-directed participants were extremely confident that they would continue walking or being physically active after WWE, and 35% were fairly confident. Of the 109 (of 178) group format participants who completed the satisfaction survey, 100% reported that they would recommend the WWE program to a friend. Nearly all participants (99%) stated that their WWE leader maintained their interest fairly or very well; 100% were satisfied with the way the leader presented the topics, with the length of the program (94%), with the extent to which the program fulfilled their expectations (99%), and with the program overall (100%). More than 99% reported that they increased their knowledge about walking in a safe and comfortable manner.

DISCUSSION

The revised AF WWE program appears to decrease disability and improve arthritis symptoms, self-efficacy and perceived control, balance, strength, and walking pace in individuals with self-reported arthritis, regardless of whether they are taking an instructor-led group class or doing the program on their own as self-directed walkers. At 1 year after completing WWE, both self-directed and group participants maintained some benefits. However, self-directed participants were more likely to continue walking and retained improvement in more self-reported physical function, symptoms, and psychosocial outcomes. Future study is needed to determine if there are successful motivational strategies to transition group format participants and/or those who are less healthy and older to continue in an independent walking lifestyle that produces ongoing benefits comparable to those experienced by our self-directed participants. WWE is a safe, easy, and inexpensive program for community-based physical activity delivery.

The WWE program is unique in that it offers both a group and a self-directed option, expanding traditionally offered opportunities for physical activity. This may allow more people to benefit from the program and incorporate walking into their lifestyle, since some individuals may not enroll in group-based physical activity programs for reasons such as dislike of groups or scheduling conflicts. In our study, the individuals who chose to do the self-directed format were younger and more likely to have a high school education or beyond. They also reported better status on most of the outcome measures at baseline, which may be attributable to the age difference. These findings suggest that the self-directed version of the program may be more desirable or marketable to younger working-age adults with arthritis, since it may help them fit walking into their daily routine.

In terms of meaningful change, several of the arthritis symptoms and physical function measures demonstrated statistically significant differences that are in line with meaningful change scores previously reported in the literature. In our study, change for the 100-mm pain VAS was found to be 8.4 (self-directed) and 7.8 (group), both above and within the previously established range (6.8–8.2) for meaningful changes (25). These meaningful changes in pain were obtained and maintained for those in the self-directed mode at 6 weeks and 1 year, i.e., 7.6 and 9.7, respectively; a meaningful change of 8.3 was obtained for those in the group format at the 6-week followup. In addition, changes for the 100-mm fatigue VAS were found to be 5.68 (self-directed) and 6.3 (group), which are slightly lower than the meaningful change range of 6.7–17.0 that has been established in patients with rheumatoid arthritis (26). Small meaningful change for gait speed has previously been estimated at 0.05 meter/second (27). We observed meaningful change for normal walking speed in both intervention formats, with a 0.05 meter/second (self-directed) and a 0.06 meter/second (group) observed difference from baseline.

Our study recruited participants from multiple sources, including worksites, and it also includes individuals from rural and urban settings, therefore enhancing our generalizability. Benefits of the program were seen regardless of whether participants had been exercising before they began WWE, demonstrating that the program is appropriate for individuals of various physical activity backgrounds. Our study was limited in that we did not have a control group. However, previous randomized trials of physical activity among adults with arthritis have used walking as the main mode of exercise and have shown significant improvements in physical function and quality of life and reduced disability compared with controls, which is likely to apply to this walking intervention as well (28–31). Therefore, our primary interest was to examine the comparative effectiveness of the 2 modes of program administration; group and self-directed.

Our study was also limited by having a smaller percentage of participants complete the performance-based physical function measures. A total of 62% of self-directed participants and 77.4% of group participants completed performance-based assessments at the 6-week followup. Participants could not attend the followup assessment for various reasons. Those that did not attend were invited to complete a paper self-report survey by mail or over the phone soon after the followup assessment. There were no differences in the demographics between the participants who completed the performance-based physical function measures and those who did not. The self-directed participants were 1.8 times more likely not to have performance-based assessment data than the group participants, which we believe was largely due to scheduling conflicts. We held the group format assessments the day of the last WWE class, which helped to minimize attrition. Despite our lower followup rate among the self-directed participants, our sample size was still quite large and clinical, and significant effects were found. Another limitation of our study was the absence of a measure of physical activity levels. Finally, our study was limited in that we enrolled more female than male participants, but this demographic divide is reflective of differences in the prevalence of arthritis (more common in women) in the general population.

In summary, our study of more than 450 community-dwelling adults from urban and rural areas of North Carolina provides evidence that the revised AF WWE program modestly improves symptoms and function after a 6-week intervention, regardless of whether delivery format is instructional group or self-directed. Benefits were more likely to be maintained over time in self-directed walkers.

AUTHOR CONTRIBUTIONS

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Callahan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Callahan, Altpeter, Hootman.

Acquisition of data. Callahan, Shreffler, Schoster, Houenou, Martin.

Analysis and interpretation of data. Callahan, Shreffler, Hootman, Schwartz.

Acknowledgements

The WWE program would not have been possible without the coordinated efforts of the AF, the Centers for Disease Control and Prevention, the University of North Carolina Institute on Aging, and the Thurston Arthritis Research Center. We wish to thank Dr. Peter Blanpied of the University of Rhode Island and Rebecca Martinique from the Rhode Island region of the Northern and Southern New England chapter of the AF for sharing their experiences, research findings, and program materials from their implementation of the WWE program. We thank AF advisor Michele Boutaugh, Area Agency on Aging leaders Carolyn Tracy and Gayla Woody, as well as Thurston Arthritis Research Center team members Drs. Margaret Morse, Thelma Mielenz, Jean Goeppinger, and Ms. Katherine Buysse for their contributions to the revision of the WWE workbook. We thank Dr. Tiffany Shubert for assistance in training the assessment team. We also thank Dr. Kate Queen for supporting the leader trainings and assessments, Drs. Darren DeWalt and Robert DeVellis for loaning us assessment equipment, Janice Woodard, Sue Savage-Guin, and Lynn Joyner for their help with participant recruitment and assessments, and My-Linh Luong for assistance in manuscript preparation. We thank the Assessment Center (www.assessmentcenter.net) for the use of their data entry facilities. We thank the WWE group leaders Nancy Alton, Myra Austin, Sue Brooks, Gloria Brown, Judy Burnett, Adrienne Calhoun, Rebecca Chaplin, Lillian Corprew, Pam Doty, Peggy Evans, Madeline Fillman, Kacky Hammon, Ethel Hennessee, Jan Horton, Katelyn Irwin, Jamie Ives, Joy Jones, Jennifer Lanier, Marilyn Madden, Lauren Mangili, Sigrun Mapes, Laura Martelle, Jean Moncrief, Meaghan Morgan, Susan Musselman, Dana Oar, Lauren Scharf, Cherie Shaffer, Michele Skeele, Olivia Sweet, Alice Taylor, Theresa Thomas, Susan Whitley, and Anita Wilkins. We also thank the WWE assessment team of Jennifer Abramson, Kirsten Nyrop, Katherine Buysse, Brian Charnock, Amanda Cornett, Karl Eklund, Betsy Hackney, Brennan Martin, Diana McAllister, Michael Narveson, James Norris, John Shadle, Bonnie Shaw, Joan Phillips Trimmer, Robert Whitehill, Lauren Wood, and John Wright. Finally, we thank all of the WWE participants, whose generous donations of time and effort made this project a success.

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