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Perceived exercise barriers enablers and benefits among exercising and nonexercising adults with arthritisResults from a qualitative study.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 55, No. 4, August 15, 2006, pp 616 – 627
DOI 10.1002/art.22098
© 2006, American College of Rheumatology
ORIGINAL ARTICLE
Perceived Exercise Barriers, Enablers, and Benefits
Among Exercising and Nonexercising Adults With
Arthritis: Results From a Qualitative Study
SARA WILCOX,1 CHERYL DER ANANIAN,1 JILL ABBOTT,2 JOELLEN VRAZEL,1 CORNELIA RAMSEY,1
PATRICIA A. SHARPE,1 AND TERESA BRADY3
Objective. Rates of participation in regular exercise are lower among individuals with arthritis than those without
arthritis. This study examined perceived exercise barriers, benefits, and enablers in exercising and nonexercising adults
with arthritis.
Methods. Twelve focus groups were conducted with 68 adults with arthritis. Groups were segmented by exercise status,
socioeconomic status, and race. Focus group discussions were transcribed verbatim and coded. NVivo software was used
to extract themes for exercisers and nonexercisers.
Results. A wide range of physical, psychological, social, and environmental factors were perceived to influence exercise.
Some of these factors were similar to those in general adult samples, whereas others were unique to individuals with
chronic disease. Symptoms of arthritis were barriers to exercise, yet improvements in these outcomes were also seen as
potential benefits of and motivations for exercise. Exercisers had experienced these benefits and were more likely to have
adapted their exercise to accommodate the disease, whereas nonexercisers desired these benefits and were more likely
to have stopped exercising since developing arthritis. Health care providers’ advice to exercise and the availability of
arthritis-specific programs were identified as needs.
Conclusion. This study has implications for how to market exercise to individuals with arthritis and how communities
and health care professionals can facilitate the uptake of exercise. These implications are discussed.
KEY WORDS. Arthritis; Exercise; Barriers; Benefits.
INTRODUCTION
Arthritis, the leading cause of disability in the United
States, has a negative impact on health-related quality of
life (1). In total, the treatment of arthritis, its complications, and resulting disability cost the United States an
The views expressed in this report are not the official
views of the Centers for Disease Control and Prevention or
the Association of Schools of Public Health.
Supported by a grant from the US Centers for Disease
Control and Prevention and the Association of Schools of
Public Health (project S2109-22/22).
1
Sara Wilcox, PhD, Cheryl Der Ananian, PhD, JoEllen
Vrazel, PhD, Cornelia Ramsey, PhD, MSPH, Patricia A.
Sharpe, PhD: University of South Carolina, Columbia; 2Jill
Abbott, DrPH: The Ohio State University Comprehensive
Cancer Center, Columbus; 3Teresa Brady, PhD: US Centers
for Disease Control and Prevention, Atlanta, Georgia.
Address correspondence to Sara Wilcox, PhD, Department of Exercise Science, Arnold School of Public Health,
University of South Carolina, 1300 Wheat Street (Blatt),
Columbia, SC 29208. E-mail: swilcox@sc.edu.
Submitted for publication June 14, 2005; accepted in revised form November 3, 2005.
616
estimated $86 billion per year (1997 US dollars), and this
number is expected to increase as the US population ages
(2).
The National Arthritis Action Plan (3) and Healthy People 2010 (4) underscore the importance of exercise among
persons with arthritis. Exercise is a critical component of
disease management (5–7). In randomized clinical trials,
exercise (aerobic and resistance training) has been shown
to reduce pain; delay disability; improve physical function, postural sway, quality of life, aerobic capacity, and
muscle strength; and reduce the risk of other chronic conditions among individuals with arthritis (8 –17).
Despite the well-documented benefits of exercise for
arthritis management, rates of inactivity are higher in persons with arthritis than in those without (18). Although
much research has focused on the correlates of exercise
among adults in general (19), few studies have focused on
unique factors for individuals with arthritis (20). Understanding these factors among exercisers and nonexercisers
may help researchers and practitioners develop programs,
tailor recruitment and retention strategies, and implement
health communication messages more effectively. There-
Exercise and Arthritis
617
Figure 1. Recruitment of participants. The boxes at the bottom of the figure indicate the segmentation of
focus groups that were completed. Two groups were conducted for each population subgroup. The
numbers in parentheses indicate the number of persons. Ex ⫽ exercise; FG ⫽ focus group; PI ⫽ private
investigator; SES ⫽ socioeconomic status.
fore, the major goal of this project was to understand the
barriers, enablers, and motivations for exercise, as well as
the perceived benefits and outcomes of exercise most
meaningful to persons with arthritis. Special attention was
given to factors that differentiated exercisers from nonexercisers.
MATERIALS AND METHODS
Participants. This study was approved by the University of South Carolina Institutional Review Board. Participants responded to advertisements in local newspapers,
on local radio stations whose target audience is African
Americans, and in flyers posted throughout community
establishments. Recruitment was ongoing from May 2003
through March 2004.
Participants expressing an interest in the study were
screened via telephone after providing oral consent. Eligible participants were ages ⱖ18 years with any type of
diagnosed arthritis and were classified as either exercisers
or nonexercisers. All but one participant resided in Lexington or Richland County (i.e., greater metro area of Columbia, SC). Groups were segmented by exercise status,
socioeconomic status (operationalized as education less
than or equal to high school versus greater than high
school), and race/ethnicity (Figure 1). Two focus groups
were conducted for each group. Segmentation creates homogeneity along participant characteristics that are potentially related to the topic of interest and helps participants
feel comfortable and willing to talk openly (21).
Procedures. Eleven experts in exercise and/or arthritis
convened via teleconference and provided input on factors
that influence exercise, personally meaningful outcomes
among persons with arthritis, types of questions to ask
participants, how to segment groups, and how to recruit a
representative sample. As a result of these calls and a
review of the literature (20), 2 moderator’s guides were
developed, 1 for exercisers and 1 for nonexercisers. The
moderator’s guides were pilot tested to determine how
well the questions were understood by participants and
captured participants’ experiences with exercise. At the
conclusion of each pilot group, participants provided feedback on the questions. Because significant changes were
made to the moderator’s guide for exercisers, participants
from this pilot group were not included in any analyses.
Minimal changes were made to the moderator’s guide for
nonexercisers.
Focus groups were moderated by 3 white women with
masters degrees who had training and experience conducting focus groups and indepth interviews (10 groups were
moderated by 1 person). All focus groups were audio recorded and transcribed verbatim, and transcripts were reviewed for accuracy.
All individuals directly involved in coding and analysis
attended 3 training sessions. All read the 12 focus group
transcripts and generated a list of themes that were then
organized into a code book with definitions. Two of 5
coders were randomly assigned to code each of the 12
focus groups, ensuring that coding pairs differed across the
focus groups. Each person independently coded the transcript, and the pair met to review all codes and come to a
618
consensus. Consensus codes for all focus groups were
entered into NVivo (QSR International, Doncaster, Victoria, Australia). Throughout the coding process, new codes
and their definitions were discussed, added as needed,
and shared with all coders, and previously coded transcripts were recoded to reflect these changes.
The focus group (rather than individual participants)
was the unit of analysis. In focus groups, participants often
express agreement with one another by nodding and shaking their heads, thus an analysis of simple frequency
counts of themes is not a good indicator of the importance
of a theme. Results are reported according to how many
groups of exercisers and nonexercisers expressed the
theme. One limitation of focus groups is that some members may not feel comfortable expressing contradictory
views. To minimize this potential, we recruited homogeneous groups to prevent acquiescence to opinions of individuals with higher status, and the moderators were
trained to prompt individuals who did not respond to
questions or who did not nod in agreement.
Additional measures. Sociodemographics and background information. Participants reported their age, sex,
race, educational attainment, income, and employment
status. Participants also reported their arthritis type (based
on a physician’s diagnosis) and duration (years).
Physical activity. A modified version of the 2001 Behavioral Risk Factor Surveillance System physical activity
module was administered during the telephone screening
(22). The questions were modified to obtain information
on structured exercise only. Participants reported the type,
frequency, and duration of their moderate-intensity, vigorous, and strengthening structured activities.
Participants were classified into 1 of 2 groups. Exercisers
participated in moderate activities on at least 3 days per
week for ⱖ30 minutes per day, vigorous activities on at
least 3 days per week for ⱖ20 minutes per day, or strength
training on at least 3 days per week for ⱖ20 minutes per
day. Participating in exercise at this level has been shown
to yield health benefits in individuals with arthritis. Nonexercisers were those who exercised (any amount) on 0 or
1 day per week, or who exercised for ⱕ10 minutes on 2
days per week. Those who did not fall into one of these 2
groups were ineligible.
RESULTS
Characteristics of participants. The flow of participants
through the recruitment process is shown in Figure 1. Of
the 75 participants who took part in a focus group (including the 7 who took part in the pilot group of exercisers), the
most common recruitment sources were newspaper advertisements (n ⫽ 26) and fitness and community-based wellness facilities (n ⫽ 14). Characteristics of the 68 focus
group participants retained in the analyses are shown in
Table 1.
Focus group findings: barriers to exercise. Participants
discussed barriers to exercise as well as factors that made
Wilcox et al
exercise more difficult. Themes and illustrative quotations
for barriers are listed in Tables 2 and 3.
Physical barriers. Pain. Pain was described as a barrier
to exercise in all focus groups and was the single most
discussed topic. Pain was described in 3 ways: the occurrence of pain prevented a person from exercising, experiencing pain during exercise made a person not want to
exercise, and pain experienced after exercise decreased a
person’s willingness to participate in future exercise. Although similar themes emerged for exercisers and nonexercisers, exercisers were more likely to make adaptations
to their exercise (e.g., modify type or intensity, take a
respite during arthritis flares) and work through pain to
attain benefits, whereas nonexercisers were more likely to
give up exercise altogether.
Fatigue. Exercisers and nonexercisers described fatigue
as being a barrier to exercise or making exercise more
difficult. Although both groups were willing to modify
their activities in response to fatigue, nonexercisers more
often decreased frequency, whereas exercisers were more
likely to adjust other aspects of their exercise, such as
intensity. Participants attributed their fatigue to a variety
of factors, including medication, insomnia, and depression.
Mobility. Most commonly, exercisers and nonexercisers
described impaired mobility as a major challenge to exercise. Nonexercisers also discussed decreased mobility after engaging in exercise.
Comorbid conditions. Comorbid conditions were described as barriers to exercise more often among exercisers
than nonexercisers. These conditions ranged from musculoskeletal to cardiovascular ailments. Nonexercisers and
exercisers experienced similar comorbidities; however,
only nonexercisers described asthma (2 groups).
Psychological barriers. Attitudes and beliefs. Lack of
time, motivation, and enjoyment of exercise and the sentiment that “I should but I don’t” were cited by exercisers
and nonexercisers alike. Whereas nonexercisers described
these factors as barriers to exercise, exercisers described
them as factors that made exercise more difficult.
Exercisers were also more likely than nonexercisers to
talk about how other life activities took priority over exercise, making it difficult to fit in exercise. Nonexercisers
were much more likely than exercisers to describe their
belief that they were physically unable to exercise and
unskilled to exercise.
Fear. Among nonexercisers, participants’ fear of water
and fear of experiencing pain were barriers. The fear of
water prevented them from participating in water aerobics,
an exercise they believed to be safe and effective for individuals with arthritis.
Perceived negative outcomes. This theme emerged as a
barrier for both exercisers and nonexercisers. Almost all of
the comments were based on actual experiences. The general consensus was that individuals were going to “pay for
it” afterwards, although the outcomes mentioned were
varied and sometimes nonspecific. For some, the potential
negative outcomes were accepted as part of the exercise
Exercise and Arthritis
619
Table 1. Sociodemographic and physical activity–related characteristics of the sample
by exercise status*
Characteristic
Type of arthritis (selfreported as physician
diagnosed), no.†
Osteoarthritis
Rheumatoid arthritis
Fibromyalgia
Gout
Other (includes those not
sure of type)
Years with arthritis, no.
(mean ⫾ SD)
Age, no. (mean ⫾ SD years)
Education, no. (mean ⫾ SD
years)
Sex‡
Female
Male
Marital status§
Married
Widowed
Divorced or separated
Not married
Living with partner
Race or ethnicity§
White
Black/African American
Hispanic
American Indian
Not specified
Occupational status§
Employed
Full time
Part time
Retired
Unemployed
Homemaker
Student
Income
0–$29,999
$30,000–$59,999
ⱖ$60,000
Minutes of physical activity
per week, mean ⫾ SD
Total minutes¶
Strength minutes¶
Moderate minutes¶
Vigorous minutes‡
Percentage meeting the
physical activity
recommendations†
Strength
Moderate
Vigorous
Exercisers
(N ⴝ 36)
Nonexercisers
(N ⴝ 32)
36
31
16 (44.4)
14 (38.9)
6 (16.7)
1 (2.8)
8 (22.2)
16 (51.6)
8 (25.8)
11 (35.5)
2 (6.4)
6 (19.4)
31 (12.50 ⫾ 10.71)
28 (12.57 ⫾ 8.24)
36 (58.8 ⫾ 15.0)
36 (13.6 ⫾ 3.0)
32 (56.9 ⫾ 10.6)
32 (13.1 ⫾ 2.2)
36
27 (75.0)
9 (25.0)
36
13 (36.1)
8 (22.2)
7 (19.5)
6 (16.7)
2 (5.6)
36
23 (63.9)
13 (36.1)
0 (0)
0 (0)
0 (0)
36
32
30 (93.8)
2 (6.2)
30
16 (53.3)
4 (13.3)
7 (23.3)
2 (6.7)
1 (3.3)
32
15 (46.9)
13 (40.6)
1 (3.1)
1 (3.1)
2 (6.3)
31
11 (30.5)
3 (8.3)
13 (36.1)
6 (16.7)
2 (5.6)
1 (2.8)
31
13 (42.0)
9 (29.0)
9 (29.0)
36
5 (16.1)
3 (9.7)
13 (41.9)
6 (19.3)
2 (6.5)
2 (6.5)
25
16 (64.0)
6 (24.0)
3 (12.0)
32
230.6 ⫾ 124.7
54.9 ⫾ 66.1
146.1 ⫾ 89.9
33.6 ⫾ 70.4
9.22 ⫾ 20.2
0.8 ⫾ 3.2
5.8 ⫾ 13.9
2.8 ⫾ 15.9
12 (33.3)
29 (83.0)
6 (16.7)
–
–
–
* Values are the number (percentage) unless otherwise indicated.
† Categories are not mutually exclusive; therefore, the percentages can add up to greater than 100%.
‡ Groups differ significantly (P ⬍ 0.05).
§ Due to the small sample size in some cells, differences between groups were examined for the
percentage of participants who were white versus nonwhite, employed versus not employed, and married
or partnered versus neither married nor partnered. No significant differences were found.
¶ Groups differ significantly (P ⬍ 0.001).
Illustrative quotations
3 “When you have a flare-up and your joints become swollen and
inflamed . . . then you really can’t exercise.”
6 “I would love to be able to walk much of the mall . . . but I can walk
a little while and sit down on one of those benches and rest and let
the worst of the pain calm down, and I can walk a little bit more to
another bench, and I make it that way.”
5 “I do love to dance . . . and I will do my best to hang in there with
everybody else, knowing the consequences the next day . . . You
know you are going to hurt.”
5 “I have fibromyalgia, and my problem more than pain, I mean, I have
pain, but to me, the problem is more fatigue, and I used to ride
bikes and do more vigorous exercise, and once I got fibromyalgia, I
just have to push myself to make myself exercise.”
n
Exercisers
Lack of positive
outcomes
Perceived outcomes
Negative outcomes
Fear
I’m not skilled enough
I physically can’t
Not a priority
Lack of enjoyment
I should but I don’t
Psychological/behavioral
Attitudes and beliefs
Lack of time
Comorbid conditions
Illustrative quotations
5 “My house is always in front of me like a mountain to climb, and I do what I can and
then I got to sit down again . . . After a while, sometimes you just give up, and you
go to bed, and I’m supposed to be exercising.”
5 “The reason I have not made an attempt to go into an exercise class because, well, I
hurt so bad.”
5 “[Arthritis] is what made it so painful now to do the same thing I use to do, but I was
on an exercise program to strengthen my muscles and joints because the orthopedic
told me to do it, and then now when I do it, it’s like you are straining your
muscles, and you hurt more.”
6 “Well, exercise for me definitely causes the pain.”
n
Nonexercisers
5 “Cause I find . . . that if I really do go out, I like to walk at least 3
6 “If I want to . . . if I feel like I really want to do something . . . to have fun with
miles. If I . . . sometimes if I do 3 miles, I’m going to pay for it, so I
exercising, I do it, and I suffer the consequences later.”
have to back off. I can’t do as much, and I have to get that in my
head.”
0
4 “I have been swimming and aerobics, but none of that helped me at all. Nothing. Not
a thing. I still have that pain.”
5 “I don’t have the time to really walk every day and that’s what I
3 “If I had the time and were able to do those exercises, they would help.”
would like to do, and that’s one of the barriers for me is the time.”
3 “I probably would not go if it were left up to me, but now I know it’s 4 “ . . . I don’t know what’s in my mind that’s keeping me from it. One doctor told me,
good for me.”
he says, ‘It may mean your life if you exercise.’ Now, you think that would be
enough motivation. I’m still not doing it. It bugs me that I’m such a failure at that.”
3 “The doctor has just ordered me into an exercise class, and I’m, you 3 “I hate exercise. I just hate it. It’s the most boring thing in the world to go to a club
know, fighting and kicking it all the way . . . I got to tell you, for the
and pick up little weights, and I’ve done it, and it just bored me to
last 10 years of my life, I would do pretty much anything rather
tears . . . boredom . . . even tried the treadmill in front of the TV. It’s a waste of
than exercise.”
time. You don’t accomplish anything.”
4 “You have to take time. I have to be able to go down there and do
2 “And here I am at home by myself and when I do start feeling better, you know, I
this if I didn’t have to stay home and cook, but you know, it’s just
think I’m maybe I need to exercise. . . . You know, I’ll procrastinate for, I mean, I’ll
time consuming, and it just takes away from being at home . . . By
even cook which I don’t do. I’ll even do that before I’ll exercise.”
the end of the day, I’ve had enough. . . .”
1
4 “I did aerobics, and I loved it, but I can’t do aerobics. I can’t do step because I can’t
step up and step back because of my feet and my knees. I can’t run. I can’t stoop. I
can’t squat. I can’t get down on the floor. If I get on the floor, I can’t get up.”
1
4 “Everybody else is good, so I don’t want to be around them, you know, and I’m a
hermit.”
0
3 “I’ve been told to try water aerobics, but I’m not a water person. I’m terrified of water,
so that doesn’t work with me.”
3 “Now I can’t walk that far because my knee will not allow me to walk, and I mean I
can’t keep up with my husband.”
3 “ . . . and I don’t get the exercise like I would like to because, when I walk a certain
distance, I get to where I can’t hardly go . . . and if it gets real severe, I usually end
up in the bed.”
5 “But exercise he wanted me to do . . . he said it would make it worse 3 “Well, should I go and try the aquatics and get exercise, or should I go out and try to
because I had psoriasis on my knees and my feet and legs . . . they
walk again? But I have asthma, so I don’t want to go out in this heat and walk. So,
would crack and was real sore, and he said the exercise that he
it’s like a catch-22. Where do you go?”
would want me to do would make it worse.”
Impaired mobility
Impediment to exercise 3 “When it flares up . . . I can’t turn over in the bed. I can’t get out to
walk. I’m like a 90-year old person that really can’t walk.”
Result of exercise
1
Fatigue
After exercise
During exercise
Physical
Pain
Before exercise
Key themes and
subcategories
Table 2. Summary of physical and psychological barriers to exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each)
620
Wilcox et al
n
Illustrative quotations
n
Illustrative quotations
Nonexercisers
2 “My husband, he knows what I go through, what I’ve had done to me and he’ll 3 “ . . . I don’t have anybody that cares what I do. I mean, I live
say, ‘you ain’t got no business doing that. You know, you know how you
by myself, and I would imagine if I had a man or if I had a
are, you know.’ So he doesn’t encourage me, because he doesn’t want the
child or something that said, ‘Come on, go, Mom’ . . . You
aftermath of it. But my daughter is truly my cheerleader.”
know, my bird doesn’t care what I do . . . Nobody really
cares, so why should I . . . You know, I don’t have anybody
saying, ‘Go, gal, go.’ ”
Lack of acknowledgment of arthritis 1
2 “When I do walk with my husband, he’s about 3 steps ahead
of me, and he keeps getting farther and farther ahead of me,
and he doesn’t understand why I can’t keep up with him.
That’s why I am just glad that he’s got the ladies in the
neighborhood he can walk with. Now, I don’t have to go
out and try to walk.”
Doctor did not mention exercise
3 “They never mentioned it. The first thing they say is, ‘We do a blood test. Oh, 3 “My doctor never told me nothing about it because I be
you’ve got rheumatoid arthritis. Here, take this.’ Okay, that makes me sick.
fussing with him all the time about me. I can’t walk, and
‘Okay, take this.’ That gave me a rash. ‘Okay, take this.’ That gives me the
he ain’t never tell me nothing about what to do or no place
hives. ‘Okay, take 2 of these.’ Oh, that’s making me swell. ‘Well, take a shot
to go, you know what I mean . . . nothing like that.”
of this.’”
Doctor did not refer to programs
0
3 “I will say this . . . there is very little being passed around
that’ll tell you, ‘You can go here, or you can go there.’ It’s
sort of a word-of-mouth thing.”
Doctor did not give exercise
2 “He gave me a pamphlet that had movement in it. Stretching exercise and sit- 0
instruction
ups and rolling in a ball and doing all that to stretch your back out, and he
didn’t really show me how to do any. He just give me this piece of paper
and said, ‘Here.’ ”
No one to exercise with
3 “I think if I had somebody to exercise with . . . sometimes when I do want to
5 “If I had someone, you know, a partner that I was doing it
go, I don’t have enough motivation . . . like if I want to walk . . . Sometimes I
with, that motivates me more to walk and exercise . . . ”
don’t have anybody to do anything with. That gets in the way.”
Competing role responsibilities
2 “If you’re working and have a family, it’s really extra, extra hard and then if
4 “[Exercising] exhausts me. I mean, it was bad enough . . . I do
you’re hurting besides, I can imagine it’s even more difficult.”
the laundry and taking care of the kids and cooking and
working and every . . . I’d be da’goned if I was gonna go,
you know, jog for a mile, you know. No, no, no. Not for
me.”
Environmental
Programs or facilities: lack of arthritis- 5 “There are some of the other health clubs and spas and so forth that do water
6 “I don’t know nothing like that around here. I haven’t heard.
specific facilities
aerobics, but they don’t key to arthritis or fibromyalgia or joint replacement
If it is, I haven’t heard about it, you know. It might be, but I
like they do there, and it’s not working out well with them because I had
haven’t heard about it.”
one friend . . . there was a place . . . that was a little closer to her house, and
she tried them, and she could not do the exercises there. They were not
keyed toward a person who had joint problems or anything like that, and
you just couldn’t do them without damaging yourself.”
Environmental conditions
5 “[Rain] messes up your knees. It messes up your back. You don’t feel like
4 “But I have asthma so I don’t want to go out in this heat and
getting up and doing anything really.”
walk. So it’s like a catch-22. Where do you go?”
Cost
2 “The other one was at the Y and number one the Y is just too darned
3 “Every place I’ve checked, even at churches, you know, I
expensive anymore.”
cannot afford it being on disability.”
Transportation
0
3 “Well, I didn’t have transportation for a while either.”
Social
Lack of support
Lack of encouragement for exercise
Key themes and subcategories
Exercisers
Table 3. Summary of social and environmental barriers to exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each)
Exercise and Arthritis
621
622
Wilcox et al
experience. Both exercisers and nonexercisers concurred
that negative outcomes generally resulted from pushing
beyond one’s limits.
Nonexercisers expressed the theme that exercise might
not be “worth it” if it did not help their symptoms. Participants questioned the need for exercise when it did not
seem to positively affect their arthritis symptoms.
come and sometimes described being uninsured or underinsured, often due to disability.
Transportation. Among nonexercisers, lack of transportation to facilities or programs was a barrier. It was unclear
whether the respondents did not have access to transportation or were not capable of driving because of their
arthritis.
Social barriers. Lack of support. Not having support
from family, friends, and health care providers was expressed in different ways. Some exercisers and nonexercisers stated that although their significant others did not
discourage them from exercise, no one really encouraged
them to do so. Other participants, more commonly nonexercisers, expressed the notion that significant others did
not acknowledge their physical limitations and were not
sympathetic to their struggles.
Exercisers and nonexercisers also described their health
care providers’ emphasis on medication and failure to
mention exercise. Whereas nonexercisers said that their
physicians did not refer them to helpful exercise programs, exercisers were more likely to discuss how their
physicians did not instruct them on how to exercise properly.
No one to exercise with. Although both groups described how the lack of an exercise partner was a barrier,
this theme was more common among nonexercisers. Without exercise partners, frequency of exercise decreased. For
both groups, ideal exercise partners were those who preferred similar exercise schedules and who lived close by.
Nonexercisers also desired exercise partners with similar
abilities.
Competing role responsibilities. Feelings of responsibility to one’s family emerged as a barrier to exercise, especially among nonexercisers. Nonexercisers reported less
energy as a result of their competing roles, whereas exercisers described how they were left with less time to engage in exercise.
Focus group findings: exercise benefits and enablers.
Participants discussed the advantages and benefits that
may result or have resulted from exercise, identified the
single outcome that made or would make exercise worth
doing, and described what would motivate them or make it
easier for them to start or continue an exercise program.
The themes and illustrative quotations are listed in Tables
4 and 5.
Environmental barriers. Lack of programs or facilities.
In almost all groups, the lack of exercise programs or
facilities specifically for persons with arthritis emerged as
a barrier. Although participants acknowledged nearby fitness clubs, there were few programs or facilities that met
their specific needs. Some participants were aware of facilities and programs but said they were too far away to
attend regularly. Others described a lack of qualified instructors, particularly those who understood physical limitations.
Environmental conditions. Weather, including hot and
cold weather and rain, was the most common environmental barrier cited by exercisers and nonexercisers. Both cold
weather and damp, rainy weather were barriers in part
because they aggravated symptoms of arthritis. Other environmental conditions that impeded exercise included
congested parking, concrete surfaces, presence of dogs,
and lack of sidewalks.
Cost. Cost of programs emerged as a barrier to exercise
among both groups, but cost seemed to be especially prohibitive among nonexercisers who lived on a limited in-
Physical benefits and enablers. Symptom management.
In all groups, participants described how exercise could
reduce pain. Although some participants quickly noted
that exercise did not stop pain, many stated that it decreased the severity and intensity of pain enough to make
it more manageable. Those who exercised were generally
more positive because they had experienced pain reduction and other benefits. In contrast, nonexercisers expressed more doubt that exercise would reduce their pain.
Approximately half of the responses from nonexercisers
resulted from being asked to identify the one outcome that
would make exercise worth doing or would motivate them
to start exercising.
Reduced stiffness was described similar to pain reduction among exercisers and nonexercisers, although it was
more commonly cited by exercisers. Exercisers also cited
increased energy more often than nonexercisers. Fewer
groups described improved sleep, the prevention of disease progression, and decreased use of medications as
benefits.
Mobility and function. Participants in all groups stated
that exercise gave them the ability to move and function,
not necessarily at a normal level, but at least at a level that
allowed them to function in life and conduct everyday
activities. Mobility was a critical outcome for enabling
them to cope with arthritis. Exercisers repeatedly expressed the theme of “use it or lose it.” There was an
important distinction between groups. Nonexercisers described wanting to return to the life they had before arthritis when they were able to function normally, whereas
exercisers discussed how exercise enabled them to live a
more normal life. Many exercisers added that if they did
not move, they would “lock up,” “freeze up,” or “shut
down.” Several participants stated that they would be
“crippled” if they did not exercise. Nonexercisers often
used phrases such as “this is what I hear,” “I don’t know
but maybe,” or “this is what I understand” to describe the
mobility and function benefits or desired outcomes.
Strength and flexibility. Increased strength was viewed
as an important component to improving mobility and
functioning by exercisers and nonexercisers alike. Several
nonexercisers noted that building muscles around a joint
or strengthening muscles would enhance mobility. Increased flexibility was a similar theme. In general, both
5
3
Behavioral enablers
5
Weight loss
Enjoyment
4
Strength and flexibility
6
4
Activities of daily
living
Emotional
6
Mobility and function
5
3
Increased energy
Attitudes and beliefs
6
Reduced stiffness
6
6
Physical
Symptom management
Reduced pain
Psychological/behavioral
Independence
n
Key themes and
subcategories
“ . . . and to me it’s just come down to it’s got to be a personal goal.
So I’ve been setting time limits, as you stated [name], in my daily
planner about when to make it a priority, when I can put it in,
trying to work my life around it.”
“ . . . because before I started doing this [exercise] my doctor was
trying to schedule me in a nursing home and I said, I said I would
not go . . . .after about 3 weeks I could begin to see the difference.
And now 2 years later I’m feeling just great compared to what I
was.”
“ . . . through exercise and, I mean, the medication too, but I have a
whole different outlook on having fibromyalgia. Like 2 years ago I
was like ‘I don’t know how I’m going to live the rest of my life
doing this. . . . I don’t know how I’m gonna ever have the life I
used to have before.’ And now I’m not 100% but I’m making
progress getting back to where I was before. I know I’m never
gonna be the same person as before but I think I can get pretty
close now.”
“Makes you feel good when you get through with it. Makes you more
energetic or . . . your state of mind. It makes you feel like you’ve
done something good for yourself.”
“I like everything about exercise.”
“ . . . if I lose weight maybe I’ll feel better, maybe I won’t hurt so
much . . . ”
“To bend down to pick green beans or something my legs were
just . . . there’s no strength there and there’s a big tremendous
difference with the weight machines. So I go 3 times a week for
about an hour each time and it just keeps the muscles from
deteriorating.”
“It’s beginning to feel better. Not hurting as bad as you did and being
able to do things that you couldn’t do before. I’m still limited but
man it’s so different now. And that’s why I go religiously . . . ”
“It’s just that if I don’t keep exercising, then every morning I’m stiffer
longer in the morning than if I don’t exercise . . . I think pretty
soon I’d just be sitting in a chair not able to go.”
“ . . . the more I pushed myself to do something like step class, I
couldn’t believe how much energy I had. And when I sleep now I
don’t usually wake up. I sleep through the night and I can get 9
hours and be a lot more functional.”
“The exercise that I do, I push myself to do it. Because I know that if
I didn’t do something that I will eventually be crippled. I’ve been
to the point to where I, you know, was either had to be in a wheel
chair, had to use a walker, or, you know, just you couldn’t do
nothing. You couldn’t make a fist. You couldn’t walk or anything.”
“My biggest motivation I think is that I want to be able to continue to
do things myself. When I first came down with my arthritis there
were so many things I couldn’t do. Like a zipper or do a
button . . . .and the more I exercise and stay mobile the more I can
do for myself.”
Illustrative quotations
Exercisers
1
5
6
4
3
4
4
3
6
1
4
6
n
“ . . . if I feel like I really want to do something that’s, you
know, to have fun with exercising, I do it and I suffer the
consequences later.”
“Yeah it did make me feel better but it makes me feel better
but yet it bothers me. It hurts me.”
“I think I’ve done something. So it gives me a mental boost,
and then when my wife comes home, I say, ‘Hey, I rode
the bike today, I did some exercise today.’ . . . It’s
nothing to someone else, but to me to be able to take that
one pound weight and do it like barbells and to ride that
bike for 10 minutes, it just really makes me feel like I did
something.”
“But I thought gosh if I don’t do something. I don’t want to
be . . . I don’t want to be disabled.”
“But I did find that my orthopedic told me to exercise as
far as doing leg lifts and things and that would to build
the muscles up around my knees and once I built the
muscles up around my knees, that would help me not to
be in such pain or be able to walk and be more mobile.”
“I would like to get back in the life that I used to have, to
be able to get out and do things with my children that I
used to do and go places I used to go and not worry
about hurting later. Everyday things. . . . I’d like to get out
one day and just clean my whole house. It’s just totally
impossible. . . .”
“I think that exercise that strengthens your body . . . like
with arthritis and with age you start losing your posture,
and I think if you could do exercises maybe like weightbearing exercises that you do with weights and things
that would strengthen some of the parts of your body
that would help you hold your body . . . .”
“If I lost weight my arthritis wouldn’t be as bad.”
“And so with the movement it relieves some of the
stiffness.”
“Stop the pain. If I could get some of the results I used to
get before the pain, that would make me keep going.”
Illustrative quotations
Nonexercisers
Table 4. Summary of perceived physical and psychological benefits and enablers of exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each)
Exercise and Arthritis
623
3
4
3
Programs for people with arthritis
Low cost
Availability of equipment
5
5
Someone to exercise with
Environmental
Water exercise
6
4
Social
Enjoyment of exercising with others
Encouragement
n
Key themes and subcategories
“ . . . I did hear something about there is a heated
pool over at Harbison and they have water
workouts for people with arthritis but I don’t
know if that’s still going on or not.”
“ . . . with arthritis, and yes, you can go to regular
classes, but I think you really need instructors
who are going to understand not so much the
exercise, but the limitations what we have and
that is what’s missing.”
“ . . . The yoga once a week is $15 a month and
you’ve got to join [name] for $35, and I think it’s
the biggest bargain around.”
“So I bought me one of those walkers, where I can
walk in the house. So I do that often.”
“It helps me mentally. It helps me physically.
It . . . I meet a lot of different people at the gym
and it’s amazing how quick you can form a
relationship with people that you have never
met before. And it’s a great way to share time
with other friends. You can get them to come to
the gym with you.”
“My daughter is my cheerleader. She has always
encouraged me. Cause sometimes she’ll call and
she, more than anyone can tell when I’m having
a bad day. She’ll say ‘Ma, you might need to
just get up and go for a little walk. Just go out in
the yard Ma.’ You know, just whatever, she’s
my cheerleader.”
“I probably wouldn’t go but my husband goes so I
go with him. I would probably be very bad
about exercising if I weren’t going like that.”
Illustrative quotations
Exercisers
3
2
4
6
6
6
5
n
“And so now it’s (the bike) on the back porch and it
faces the woods and so I sit up there and I ride it and
I have a little timer that I found and I set it for 15
minutes, then I walk for 10 minutes. I’ve been doing
that like I say a month or so now.”
“That’s why a water class and something like that where
you’ve got an instructor. Somebody there that can
lead you and give you 10 exercises for your particular
body.”
“ I think it’s like several of them said, finding a place to
go to do the exercise and having instructors there that
know your limitations to what you can do and what
you can’t do and how it’s going to affect your joints in
the certain exercises that you do.”
“Yeah. And it’s 3 times a week and it’s $30 for 3 times a
week which is really good.”
“Words don’t mean as much as go. You know let’s go,
let’s do it together.”
“I get a lot of general support in that area. Nobody
pushes me to exercise hard, but everybody supports
me to do whatever I can to exercise.”
“Yeah, I think like the others said I think it’s being with
other people when you exercise in a group, it’s more
like a social thing for you to get to be with other
people. And the fact that it gives you more energy.
You feel healthier.”
Illustrative quotations
Nonexercisers
Table 5. Summary of perceived social and environmental benefits and enablers of exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each)
624
Wilcox et al
Exercise and Arthritis
exercisers and nonexercisers talked about needing to be
“more flexible” and described the importance of staying
“limber” and “loose.” Exercisers said that an activity such
as swimming “limbers you up,” and yoga “increases your
flexibility.” Several comments related to flexibility also
related to the benefit of reduced stiffness described earlier.
Weight loss. Exercisers and nonexercisers described exercise as a way to “keep the weight down” or noted that it
was beneficial to managing the weight that they had gained
over the years. Exercisers perceived that losing weight
would make them feel better or noted that weight loss had
actually helped with their arthritis. Nonexercisers said
that they wanted weight loss results from exercise and that
it would help them be more motivated to exercise.
Other less common themes. Exercisers described improvements in comorbid conditions or their symptoms.
Several said that they began exercising because of heart
conditions, but that it also had a positive impact on their
arthritis. Diabetes and osteoporosis were also raised as
comorbid conditions that prompted them to exercise. Finally, in 2 groups, exercisers described how regular exercise decreased the amount of medication needed to manage the symptoms of arthritis.
Psychological benefits and enablers. Independence. Independence was a theme for exercisers and nonexercisers,
although it was cited more often by exercisers. Exercisers
reported compelling reasons as to why they were motivated to exercise regularly, including avoiding becoming
“an invalid” or having to be in a wheelchair, fear of having
to go into a nursing home, and, most importantly, being
able to remain “self-sufficient.”
Attitudes and beliefs. Exercisers and nonexercisers described how exercise improved their attitudes and beliefs.
Exercisers noted improvements in self-confidence and an
overall improved attitude toward their disease. Nonexercisers, in contrast, liked the feeling of being able to accomplish something, no matter how small. Whereas exercisers
described participating in sufficient exercise to attain benefits, nonexercisers struggled to be active but felt that even
the simplest of efforts were “a really big deal.”
Emotional benefits. All groups described the emotional
benefits of exercise. Exercisers reported that it made them
“feel better” or “feel good” during and after the activity. In
addition to feeling good, many exercisers described the
link between exercise and both “stress relief” and relaxation, and said that exercise helped them to forget about
their pain. Although many nonexercisers also reported
that exercise made them “feel good,” there was a distinct
difference in how some viewed this benefit. Some nonexercisers implied that the emotional benefit might not outweigh the pain that exercise caused. Most nonexercisers
who described emotional benefits from exercise referred to
exercise experiences before rather than after arthritis.
Enjoyment. In groups of both exercisers and nonexercisers, participants described liking exercise or having fun
while exercising, including exercising in a group, with a
significant other, or by themselves. Among nonexercisers,
the theme of enjoyment surfaced primarily from discussions about their exercise before arthritis. Although some
625
still described enjoying exercise, they often “paid for it
later” with pain or fatigue.
Behavioral enablers. Exercisers expressed specific behavioral enablers for exercise, whereas no clear themes
emerged for nonexercisers. Exercisers stated that they
were internally motivated to exercise and underscored the
importance of self-regulatory skills, including making exercise a priority, scheduling exercise, and setting goals.
Social benefits and enablers. Exercisers and nonexercisers described the enjoyment of exercising with others
and the positive social interaction of being around others
who exercise. Exercisers mentioned that being in or
around groups of exercisers was a positive social outcome.
Social benefits among nonexercisers were typically described in relation to their exercise experiences before
arthritis. Nonexercisers described the social benefits of
exercise and thought it was a motivating factor.
Exercisers and nonexercisers identified similar social
enablers, including having important others (e.g., friends,
family, health care providers) encourage them to exercise
and having someone to exercise with. Exercisers often said
that they had someone to exercise with, whereas nonexercisers said that they did not have this type of support but
desired it. Likewise, nonexercisers expressed the need to
receive external cues or reminders from important others
for exercise. Having an exercise group of similar others
was viewed as important for nonexercisers because of the
emotional support it provided.
Environmental enablers. Both exercisers and nonexercisers stated that a water-based exercise program would
make it easier for them to exercise. They also described the
need for programs and instructors who understood issues
related to arthritis and exercise. Exercisers were more
likely than nonexercisers to say that low-cost programs
enabled them to exercise. Finally, having exercise equipment such as a treadmill or a stationary bicycle within
one’s immediate physical environment (i.e., a person’s
home or a relative’s home) was perceived as making exercise more likely among exercisers and nonexercisers.
DISCUSSION
By recruiting a relatively large sample of individuals with
arthritis, measuring exercise participation, and conducting
stratified recruitment to ensure a diverse sample of exercisers and nonexercisers, our qualitative study extends
what is known about the perceived barriers, benefits, and
enablers of exercise among persons with arthritis. Relatively few studies have examined these issues, and even
fewer have been specifically designed with this purpose in
mind (20). Furthermore, only 3 studies (all with small
samples) have used a qualitative approach (23–25), one of
which measured physical activity and stratified on the
basis of this measure (23).
Physical, psychological, social, and environmental barriers, benefits, and enablers were identified in this study,
consistent with social cognitive theory (26) and social
ecological models (27,28). While some influences were
626
similar to those reported in other general populations (19),
others appeared unique to individuals with a chronic disease. Consistent with other studies (25,29), symptoms of
arthritis, including pain, stiffness, fatigue, and mobility
problems, were perceived as barriers to exercise. Yet improvements in these outcomes were also seen as potential
benefits of and motivations for exercise. The role of exercise in promoting independence was a salient and highly
motivating benefit, especially among exercisers. Exercisers
had experience achieving many benefits, whereas nonexercisers described these potential benefits as outcomes that
would motivate them to exercise. Nonexercisers expressed
some doubt that they would benefit from exercise and
thought that increased pain, even if temporary, may not be
worth the benefits.
A number of our findings have direct implications for
how to market exercise to individuals with arthritis and
how communities and clinicians can facilitate participation in exercise. First, individuals with arthritis value the
information provided by health care providers (24,25).
Receiving such information has been shown to predict
higher levels of physical activity among adults with rheumatoid arthritis (30). The perceived lack of advice, instruction, and referrals was cited in our study as a barrier.
Providers may feel ill prepared to prescribe exercise (24)
and may need additional assistance to make exercise recommendations and specific referrals. In addition, results
from research trials take time to influence practice (31),
and the lack of advice, instruction, and referrals may reflect this lag in evidence-based practice.
Second, wider availability and awareness of arthritisspecific programs is needed for individuals with arthritis
and health care providers. The lack of arthritis-specific
programs and knowledgeable instructors was identified as
a major barrier, especially among nonexercisers. Considering the prevalence of arthritis, community programs and
facilities should be encouraged to expand their programming to individuals with arthritis and to publicize such
programs. Program characteristics that build self-efficacy,
facilitate social support, encourage individuals to work at
their own pace, and are led by quality instructors are
particularly important (29).
Third, exercisers and nonexercisers identified similar
barriers to exercise. What differentiated these groups was
that exercisers were less likely to allow these barriers to
prevent exercise and often modified their exercise to accommodate physical limitations. Nonexercisers were more
likely to have given up exercise altogether or to have
greatly reduced its frequency when faced with arthritisspecific barriers. Print and other forms of messages might
be more effective if they emphasize ways in which individuals with arthritis can modify exercise to accommodate
their disease.
Fourth, most exercisers and nonexercisers alike were
aware of the benefits of exercise, yet nonexercisers were
not engaging in it. These findings indicate that knowledgebased approaches alone are unlikely to affect behavior
(19,32), and techniques to increase self-efficacy (33), problem-focused coping, and self-regulatory skills are important for changing behavior.
Fifth, pain relief and improved mobility from exercise
Wilcox et al
were the major motivators for exercisers and nonexercisers. However, pain was the primary reason why nonexercisers had quit an exercise program. Pain is consistently
associated with lower rates of exercise across arthritis
types, despite the fact that a substantial number of controlled, randomized trials of exercise in persons with arthritis have reported reductions in pain (11,34,35). In one
intervention study (36), improvements in pain predicted
subsequent exercise participation, suggesting that this outcome may be critical to exercise adherence. Recruitment
and program messages might need to explain to persons
with arthritis that pain may increase during and immediately after exercise, but that overall pain management can
be enhanced. Many exercisers voiced this message. Interventions might also need to include pain management
strategies.
Finally, in addition to traditional outcome measures,
personally meaningful outcomes for individuals with arthritis (e.g., pain reduction, increased mobility, decreased
stiffness, independence) should be emphasized in intervention materials and assessed in research and practice
settings. These outcomes are what matter most to the individuals with arthritis and are likely to predict subsequent adherence.
As is common in qualitative research, a purposive sample of participants was recruited. Key stratification factors
expected to affect the discussion were used to structure the
composition of groups and to create homogeneous groups.
To increase the generalizability of findings, we used a
variety of recruitment strategies to reach the entire community. Nonetheless, participants who volunteer in such a
study may differ from those who do not volunteer along
potentially important variables such as disease severity,
attitudes about health and exercise, and sociodemographics. Furthermore, local communities vary widely in the
availability of resources and programs for individuals with
arthritis, and our findings may not be as applicable in
communities with more such resources or in rural areas
with substantially fewer resources. To limit the number of
groups conducted, groups were not segmented by age or
disease type. Also, we recruited a small number of men,
particularly those who were nonexercisers. It is likely that
barriers, attitudes, and beliefs differ by age (or generation),
sex, and disease type. Therefore, we are not able to make
sex-, age-, and disease-specific conclusions. Finally, not all
potentially pertinent characteristics of participants were
measured (e.g., personality traits).
Despite potential limitations, our findings provide useful information for understanding the experiences with
and beliefs about exercise among persons with arthritis
and informing recruitment and intervention strategies.
ACKNOWLEDGMENTS
We would like to thank Carol Rheaume for her assistance
in pilot testing the moderator’s guide and Billy Oglesby for
providing qualitative training and consultation. We also
gratefully acknowledge each of the individuals who took
part in our focus groups.
Exercise and Arthritis
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