Measuring the value of program adaptation: a comparative effectiveness study of the standard and a culturally adapted version of the arthritis self-help program.

BACKGROUND: Arthritis remains an important public health problem. QUESTIONS/PURPOSES: This study aims to determine the effects of an adapted (vs. the original) Arthritis Self-Help Program (ASHP) among older adults. Specifically, this study sought to determine (1) whether the adapted ASHP improved attendance, retention, and adherence with the use of self-management exercises, and (2) if the original ASHP's beneficial outcomes were maintained following program adaptation. PATIENT AND METHODS: Individuals age ≥60 with self-reported arthritis were recruited from eight New York City senior centers. Participants were assessed at baseline to assess their demographic and clinical status and at 6 and 24 weeks to ascertain study outcomes using validated measures. RESULTS: Two-hundred-one participants (64 non-Hispanic African Americans, 86 Hispanics, and 51 non-Hispanic Whites) enrolled. Participants in the adapted (vs. original) ASHP had better average attendance in the six session program (4.7 vs. 3.2 classes attended, p < 0.01) and program retention (93% vs. 74%, p < 0.01). Adherence with use of the self-management exercises (number of days using endurance, stretching, and relaxation exercises) was similar in both groups. Significant positive physical/psychosocial outcomes were documented in both the adapted and original program. CONCLUSION: The adapted ASHP improved program attendance and retention while maintaining improvements in physical and psychosocial functions. These results support future efforts to employ controlled designs to quantify the benefits of adapted evidence-based programs to ensure that adaptation maintains program effectiveness.

Meeting the public health challenge of pain in later life: what role can senior centers play?

Interest in nonpharmacologic approaches for managing pain continues to grow. The aim of this study was to determine the types of pain-relevant programs offered by senior centers and whether the programs varied by clients' race/ethnicity status and center size. A telephone survey was conducted. Respondents were presented with a list of 15 programs and the option to choose "other" and asked (1) whether the activity was offered and, if so, how often; (2) if they believed the programs had value for seniors with pain; and (3) whether the classes were advertised as a means of achieving pain relief. Of 204 center staff contacted, 195 (95.6%) participated. The most common programs offered were movement-based, including exercise (by 91.8% of the centers), dance (72.3%), walking clubs (71.8%), yoga (65.6%), and Tai Chi (53.3%) classes. Creative arts programs were also frequently offered, including music (58.5%) and fine arts (47.7%). Programs such as stress management (27%) and relaxation (26%) classes were less commonly offered. Most respondents identified movement-based programs as helpful for seniors with pain, but few identified creative arts classes as potentially beneficial. The programs/classes offered were infrequently advertised as a means of helping seniors manage pain and varied by clients' race/ethnicity status and center size. Programs that have potential utility for older adults with pain are commonly offered by senior centers. Future research should determine optimal strategies for engaging older adults in these programs in the senior center setting.

Complementary therapies for osteoarthritis: are they effective?

Increasing interest has focused on complementary management modalities, including tai chi, acupuncture, yoga, and massage therapy, as treatments for osteoarthritis (OA). This review article synthesizes evidence from randomized controlled trials (RCTs) and systematic reviews (SRs) that examined one or more of the above as treatments for OA. Medline, Pubmed, and Cinahl databases were searched to identify English-language articles using an RCT design or that conducted a SR of published studies and presented data on symptom or functional outcomes. Two authors independently abstracted relevant information (e.g., study sample, intervention characteristics, treatment effects, safety data). Retained articles (n = 29) included those that evaluated tai chi (8 RCTs, 2 SRs), acupuncture (11 RCTs, 4 SRs), yoga (2 RCTs), and massage therapy (2 RCTs). Available evidence indicates that tai chi, acupuncture, yoga, and massage therapy are safe for use by individuals with OA. Positive short-term (≤6 months) effects in the form of reduced pain and improved self-reported physical functioning were found for all 4 treatments. Limited information exists regarding the relative effectiveness of the therapies (e.g., yoga vs. tai chi vs. acupuncture), as well as treatment effects in persons with joint involvement besides the knee and in distinct patient subgroups (e.g., older vs. younger adults, persons with mild vs. moderate vs. advanced disease). Complementary therapies can reduce pain and improve function in adults with OA. Research is needed to evaluate long-term benefits of the treatments, as well as their relative effects among diverse patient subgroups.

Older adults are mobile too!Identifying the barriers and facilitators to older adults' use of mHealth for pain management.

BACKGROUND: Mobile health (mHealth) is a rapidly emerging field with the potential to assist older adults in the management of chronic pain (CP) through enhanced communication with providers, monitoring treatment-related side effects and pain levels, and increased access to pain care resources. Little is currently known, however, about older adults' attitudes and perceptions of mHealth or perceived barriers and facilitators to using mHealth tools to improve pain management. METHODS: We conducted six focus groups comprised of 41 diverse older adults (≥60 years of age) with CP. Participants were recruited from one primary care practice and two multiservice senior community day-visit centers located in New York City that serve older adults in their surrounding neighborhoods. Focus group discussions were recorded and transcribed, and transcriptions were analyzed using direct content analysis to identify and quantify themes. RESULTS: Focus group discussions generated 38 individual themes pertaining to the use of mHealth to help manage pain and pain medications. Participants had low prior use of mHealth (5% of participants), but the vast majority (85%) were highly willing to try the devices. Participants reported that mHealth devices might help them reach their healthcare provider more expeditiously (27%), as well as help to monitor for falls and other adverse events in the home (15%). Barriers to device use included concerns about the cost (42%) and a lack of familiarity with the technology (32%). Facilitators to device use included training prior to device use (61%) and tailoring devices to the functional needs of older adults (34%). CONCLUSIONS: This study suggests that older adults with CP are interested and willing to use mHealth to assist in the management of pain. Participants in our study reported important barriers that medical professionals, researchers, and mHealth developers should address to help facilitate the development and evaluation of age-appropriate, and function-appropriate, mHealth devices for older persons with CP.

Tailoring evidence-based interventions for new populations: a method for program adaptation through community engagement.

Evidence-based interventions (EBIs) are an important tool for community health practitioners, but there is often a mismatch between the population in which the EBI was validated and the target population in which it will be used. Methods of planned adaptation identify differences in the new target population and attempt to make changes to the EBI that accommodate these differences without diluting the program's effectiveness. This article outlines an innovative method for eliciting ideas for program modifications and deciding on program changes. The Method for Program Adaptation through Community Engagement (M-PACE) uses systematic and detailed feedback from program participants to guide adaptation. The authors describe procedures for obtaining high-quality participant feedback and adjudicating recommendations to decide on program changes. M-PACE was developed as part of the adaptation of an evidence-based, arthritis self-management program for older adults. The application and results of the M-PACE method are presented using this case as an example.

Implementing a cognitive-behavioral pain self-management program in home health care, part 1: program adaptation.

BACKGROUND AND PURPOSE: Pain is highly prevalent among older adults receiving home care, contributing to disability, increased health care utilization, nursing home placement, and diminished quality of life. Pain is a particular problem in the home care setting, where current approaches are often inadequate, resulting in persistent high levels of pain and disability in this vulnerable population. Cognitive-behavioral approaches to pain management have demonstrated effectiveness in reducing pain intensity and associated disability but have not been systematically implemented in home health care. The purpose of this project was to adapt a community-based, cognitive-behavioral pain self-management program designed for patients with persistent back pain for implementation by physical therapists (PTs) to use with patients with activity-limiting pain in the home care setting. METHODS: In this observational study, 2 groups of PTs practicing in home care were trained in the community-based program and completed surveys and participated in discussions during the training workshops to gather input on the program components perceived to be most helpful for their patients with pain; modifications to the program and the patient education materials for use in home care; and recommendations concerning program training and support required for successful implementation. Data collected during the workshops were summarized and presented to 2 expert panels for additional input and final decisions regarding program adaptations. RESULTS: Seventeen PTs with an average of 16.6 years of practice as a PT received the training and provided input on the community-based program. Program modifications based upon PT and expert panel review included reduction in the number of sessions, deletion of content, modification of the exercise component of the program, revision of patient materials, and modification of therapist training. DISCUSSION/CONCLUSIONS: This study successfully adapted a group-based pain management program for implementation by health care providers in a home care setting. The process described here may be useful for other groups planning to implement evidence-based programs in new settings. Part 2 of this study, a companion article in this issue, describes the field-testing of this home-care adapted program.

Participatory adaptation of an evidence-based, arthritis self-management program: making changes to improve program fit.

We employed community-based participatory research techniques to adapt an evidence-based self-management program called the Arthritis Self-Help Program for older African American, Hispanic, and non-Hispanic white adults. Participants and instructors provided multiple recommendations for program change (including content additions or augmentations as well as changes in program delivery) in telephone interviews and focus groups. Recommendations were implemented through a collaborative process involving diverse stakeholders. Changes implemented respond to the preferences and needs of participants, as well as the strengths and constraints of program instructors and host sites. Improved fit for participants may extend the program's reach and effectiveness for older adults of color. In addition, the adapted Arthritis Self-Help Program may make the program more feasible and therefore sustainable for the host sites.

Pharmacologic management of osteoarthritis-related pain in older adults: a review shows that many drug therapies provide small-to-modest pain relief.

OVERVIEW: Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements.Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Pharmacologic management of osteoarthritis-related pain in older adults.

OVERVIEW: Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements. Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

Pharmacologic Management of Osteoarthritis-Related Pain in Older Adults: A Review Shows that Many Drug Therapies Provide Small-to-Modest Pain Relief.

Because pain is a common and debilitating symptom of osteoarthritis in older adults, the authors reviewed data on the efficacy and safety of commonly used oral, topical, and intraarticular drug therapies in this population. A search of several databases found that most studies have focused on knee osteoarthritis and reported only short-term outcomes. Also, treatment efficacy was found to vary by drug class; the smallest effect was observed with acetaminophen and the largest with opioids and viscosupplements. Acetaminophen and topical agents had the best safety profiles, whereas oral nonsteroidal antiinflammatory drugs and opioids had the worst. Little data were available on patients ages 75 years old and older and on patients from diverse racial and ethnic groups. Most drug therapies gave mild-to-moderate pain relief; their long-term safety and efficacy and their effects in diverse populations (particularly older adults) remain undetermined.

A cognitive-behavioral plus exercise intervention for older adults with chronic back pain: race/ethnicity effect?

This pilot study examined the feasibility and potential efficacy of a self-management program for seniors with chronic back pain and assessed for possible race/ethnicity differences in program impact. Sixty-nine seniors (24 African Americans, 25 Hispanics, and 20 non-Hispanic Whites) enrolled in the 8-wk community-based program. Efficacy outcomes included pain-related disability as measured by the Roland Morris Disability Questionnaire (RMDQ), pain intensity, pain self-efficacy, depressive symptoms, social activity, and functional status. Eighty percent of enrollees completed the program. Clinically important decreases in RMDQ scores were found for non-Hispanic White (adjusted change score = -3.53), African American (-3.89), and Hispanic (-8.45) participants. Improvements in all other outcomes were observed, but only for Hispanic participants. Results confirm that implementation of the protocol in urban senior centers is feasible, and the program shows potential efficacy. The race/ethnicity differences observed in the current study merit further investigation.

A comparison of the arthritis foundation self-help program across three race/ethnicity groups.

OBJECTIVE: Despite high prevalence rates of pain among older adults, relatively few studies have examined the impact of the Arthritis Foundation Self-Help Program (ASHP) in this age group, particularly older minority groups. DESIGN: This study compared the effects of the ASHP on groups of Hispanic, African American and non-Hispanic White older adults. SETTING: Three senior centers in New York City. PARTICIPANTS: Data are presented for 112 (37 African American, 38 Hispanic and 37 non-Hispanic White) participants (mean age= 75 years) age 60 and over with diverse noncancer pain disorders. INTERVENTION: Participants enrolled in the 6-week Arthritis Self Help Course. MAIN OUTCOME MEASURES: Participants were surveyed before and after course completion (in person) and at 18 weeks (by telephone). Demographic and clinical data were collected at baseline; outcomes included pain, mood, self-efficacy, and number of days per week spent exercising. RESULTS: All three groups experienced significant decreases in pain intensity (P< or =.05). Significant improvements were also found in mood scores for non-Hispanic White (P=.01) and Hispanic participants (P=.03). Hispanic participants also evidenced significant improvement in their confidence to self-manage pain (P=.003) and reported fewer arthritis-related symptoms (P=.02). All three race/ethnicity groups reported substantial increases in the number of days spent doing stretching, endurance and relaxation exercises (P< or =.01). CONCLUSION: Positive results were noted for all three race/ethnicity groups, particularly in the areas of pain reduction and uptake of stretching, endurance and relaxation exercises. Our findings support efforts to disseminate broadly the ASHP in community settings that serve older African American, Hispanic and non-Hispanic white adults.