Translating Fit and Strong!: Lessons Learned and Next Steps

Fit and Strong! began in 1998. It grew out of the Hughes doctoral dissertation many years ago that examined the impact of a model long-term home care program for older adults. We learned at that time (1981) that arthritis was the most common chronic condition reported by homebound clients and the condition that was most frequently cited by them as interfering greatly with their function. To learn more about this story, we obtained funding from the National Institutes of Health (NIH) to conduct a prospective, longitudinal study in Chicago of 600 seniors who were unselected for presence of arthritis at baseline. We found again that arthritis was the most common condition reported and the number one cause of disability (1). We also measured participant joint impairment and conducted an analysis to try to determine which joints were causing the problem. Analyses clearly indicated that osteoarthritis (OA) in the lower extremity joints was the culprit, a scenario that makes sense when considering that people use these large weight bearing joints to perform most activities of daily living such as transferring, climbing stairs, and toileting (2). We conducted the longitudinal study in order to understand the links between presence of OA and development of disability. Once we understood the causal chain, it was clear that our next step should be the development of an intervention to interrupt it. We examined the OA physical activity literature and found that people with OA have two problems. They are aerobically de-conditioned and have weaker muscles than age-matched controls (3, 4). People who have OA have a lot of pain in their joints. For those with lower extremity joint pain, the natural tendency is to stop moving around, which is, of course, the worst thing that people can do. A sedentary lifestyle leads to further joint stiffening, pain, muscle weakness, aerobic de-conditioning, and weight gain; potentially setting people up for the onset of co-morbid conditions like heart disease and diabetes (5–9). So we decided that our intervention must consist of a multiple component physical activity program that included aerobic walking and strength training. We also wanted to design a short term (8 weeks) program that had long-term results. Therefore, we talked to experts in the field and learned that we needed to also include a health education/behavior change component. Like the evidence-based Chronic Disease SelfManagement Program (CDSMP), we borrowed heavily from the self-efficacy literature to design this piece that helps people gain mastery over their OA through an active lifestyle (10). The resulting program, Fit and Strong!, consists of three 90-min sessions per week over 8 weeks. The first hour of each session is devoted to exercise (flexibility, aerobic, and lower extremity strengthening) and the last 30 min is devoted to a structured health education/group problem solving curriculum. We tested the program in an efficacy trial that found differential benefits in the treatment group on physical activity, self-efficacy for exercise, and lower extremity stiffness at 8 weeks. At 6 months, those gains were maintained and we saw additional benefits on self-efficacy for adherence to physical activity over time and lower extremity pain. Several of these gains were maintained at 12 months with large effect sizes (11). TRANSLATION STEPS CHANGE IN INSTRUCTORS The efficacy trial sought to demonstrate that a structured program of aerobic exercise and resistance training would not harm persons with painful lower extremity joints. The program was delivered by trained physical therapists who had experience working with persons with OA, but this was an expensive model for translation. By this time, we had obtained funding to test different ways of bolstering maintenance of physical activity after Fit and Strong! ends. This effectiveness trial was conducted on the south side of Chicago, enabling us to expand the reach of the program into largely African American communities. We used this study as an opportunity to conduct a natural experiment. We used the physical therapist instructor model with the first 200+ enrollees and then taught the remaining 300 enrollees using certified exercise instructors. Outcomes were very strong at 8 weeks and 6 months with both types of instructors, attendance was high and participant evaluations glowing (12). Therefore, we decided to move forward with the certified exercise instructor model. Overall long-term effects from this trial were very strong, including significant gains in physical activity over 18 months of follow up that were accompanied by improved lower extremity OA symptoms, observed performance gains in lower extremity strength, and mobility (risk factors for falls), and anxiety and depression out to 18 months (13).