Exercise and global well-being in community-dwelling adults with fibromyalgia: a systematic review with meta-analysis

Background

Exercise has been recommended for improving global-well being in adults with fibromyalgia. However, no meta-analysis has determined the effects of exercise on global well-being using a single instrument and when analyzed separately according to intention-to-treat and per-protocol analyses. The purpose of this study was to fill that gap.

Methods

Studies were derived from six electronic sources, cross-referencing from retrieved studies and expert review. Dual selection of randomized controlled exercise training studies published between January 1, 1980 and January 1, 2008 and in which global well-being was assessed using the Fibromyalgia Impact Questionnaire (FIQ) were included. Dual abstraction of data for study, subject and exercise program characteristics as well as assessment of changes in global well-being using the total score from the FIQ was conducted. Risk of bias was assessed using the Cochrane bias assessment tool. Random-effects models and Hedge's standardized effect size (g) were used to pool results according to per-protocol and intention-to-treat analyses.

Results

Of 1,025 studies screened, 7 representing 5 per-protocol and 5 intention-to-treat outcomes in 473 (280 exercise, 193 control) primarily female (99%) participants 18-73 years of age were included. Small, statistically significant improvements in global well-being were observed for per-protocol (g and 95% confidence interval, -0.39, -0.69 to -0.08) and intention-to-treat (-0.34, -0.53 to -0.14) analyses. No statistically significant within-group heterogeneity was found (per-protocol, Q_w = 6.04, p = 0.20, I² = 33.8%; intention-to-treat, Q_w = 3.19, p = 0.53, I² = 0%) and no between-group differences for per-protocol and intention-to-treat outcomes were observed (Q_b = 0.07, p = 0.80). Changes were equivalent to improvements of 8.2% for per-protocol analyses and 7.3% for intention-to-treat analyses.

Conclusions

The results of this study suggest that exercise improves global well-being in community-dwelling women with fibromyalgia. However, additional research on this topic is needed, including research in men as well as optimal exercise programs for improving global well-being in adults.

Differences in the prevalence and severity of arthritis among racial/ethnic groups in the United States, National Health Interview Survey, 2002, 2003, and 2006

We describe the prevalence of doctor-diagnosed arthritis and its impact on activities, work, and joint pain for 6 racial/ethnic groups: non-Hispanic whites, non-Hispanic blacks, Hispanics, American Indians/Alaska Natives, Asians and Pacific Islanders, and multiracial or "other" respondents. We combined data from the 2002, 2003, and 2006 National Health Interview Survey (n = 85,784) and, after adjusting for age, sex, and body mass index, compared racial/ethnic differences. Arthritis-attributable activity limitation, arthritis-attributable work limitation, and severe joint pain were higher for non-Hispanic blacks, Hispanics, and multiracial or other respondents with arthritis compared with non-Hispanic whites with arthritis. Our finding that arthritis disproportionately affects certain racial/ethnic minorities may be useful for planning interventions.

Public health interventions for arthritis: expanding the toolbox of evidence-based interventions

BACKGROUND

Since 1999, the Centers for Disease Control and Prevention's (CDC) Arthritis Program has worked to improve the quality of life for people with arthritis, in part by funding state health departments to disseminate physical activity (PA) and self-management education (SME) interventions. Initially, only one SME and two PA interventions were considered evidence-based and appropriate for people with arthritis. The purposes of this article are to describe the processes and criteria used to screen new or existing intervention programs and report the results of that screening, including an updated list of recommended intervention programs.

METHODS

A series of three sets of screening criteria was created in consultation with subject matter experts: arthritis appropriateness, adequacy of the evidence base, and implementability as a public health intervention. Screening interventions were categorized as Recommended, Promising Practices, Watch List, Future Possibility, or Unlikely to Meet criteria based on how well the intervention met the screening criteria.

RESULTS

A total of 15 packaged PA interventions and six SME interventions were screened. Three PA and three SME interventions met all three sets of criteria and were added to the list of recommended public health interventions for use by CDC-funded state arthritis programs. An additional two SME interventions are developing the infrastructure for public health dissemination and were categorized as Promising Practices, and six PA interventions have evaluations underway and are on the Watch List.

CONCLUSIONS

The CDC Arthritis Program identified arthritis-appropriate interventions that can be used effectively and efficiently in public health settings to improve the quality of life of people with arthritis. The screening criteria used offer a guide to intervention developers on necessary characteristics of interventions for use in public health settings. The expanded menu of interventions is beneficial to clinical care and public health professionals and, ultimately, to people with arthritis.

Exercise and Health-Related Quality of Life in Older Community-Dwelling Adults

The authors used the meta-analytic approach to examine the effects of physical activity on health-related quality of life (HRQOL) in older community-dwelling adults. A random-effects model was used for all primary analyses. Of the 257 studies screened, 11 randomized controlled trials representing 13 groups and 617 men and women (324 physical activity, 293 control), all older than 50, were included. Overall, a significant (small to moderate) standardized effect size improvement was found for physical function as a result of physical activity (Hedges's g = 0.41, 95% confidence interval [CI] = 0.19, 0.64, p < .001). This was equivalent to a common language effect size of 62% and an odds ratio of 2.14 (95% CI = 1.42, 3.24). No significant differences were found for the other nine HRQOL outcomes. Although additional research is needed, results suggest that physical activity improves self-reported physical function, a component of HRQOL, in older community-dwelling adults.

US national prevalence and correlates of low back and neck pain among adults

OBJECTIVE

To estimate the US prevalence and psychological and health behavior correlates of low back pain and/or neck pain. No current US national prevalence estimates of low back and neck pain exist and few studies have investigated the associations between low back and neck pain, psychological factors, and health behaviors in a representative sample of US community dwellers.

METHODS

We analyzed data obtained from adults ages 18 years or older (n = 29,828) who participated in the 2002 National Health Interview Survey, a cross-sectional, population-based survey of US adults.

RESULTS

The 3-month US prevalence of back and/or neck pain was 31% (low back pain: 34 million, neck pain: 9 million, both back and neck pain: 19 million). Generally, adults with low back and/or neck pain reported more comorbid conditions, exhibited more psychological distress (including serious mental illness), and engaged in more risky health behaviors than adults without either condition.

CONCLUSION

Low back and neck pain are critical public health problems. Our study supports the idea of a multidimensional approach to examining low back and neck problems and suggests the need for further research to address potentially modifiable psychological factors and health behaviors in these populations.

Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18-64: 2002 National Health Interview Survey Data

OBJECTIVE

To estimate the national prevalence of arthritis-attributable work limitation (AAWL) among persons ages 18-64 with doctor-diagnosed arthritis and examine correlates of AAWL.

METHODS

Using the 2002 National Health Interview Survey, we estimated the prevalence of AAWL (limited in whether individuals work, the type of work they do, or the amount of work they do) and correlates of AAWL in univariable and multivariable-adjusted logistic regression analyses. Survey data were analyzed in SAS and SUDAAN to account for the complex sample design.

RESULTS

A total of 5.3% of all US adults ages 18-64 reported AAWL; in this age group, AAWL is reported by approximately 30% of those who report arthritis. The prevalence of AAWL was highest among people ages 45-64 years (10.2%), women (6.3%), non-Hispanic blacks (7.7%), people with less than a high school education (8.6%), and those with an annual household income <$20,000 (12.6%). AAWL was substantially increased among people with arthritis-attributable activity limitations (multivariable-adjusted odds ratio [OR] 9.1, 95% confidence interval [95% CI] 7.1-11.6). The multivariable-adjusted likelihood of AAWL was moderately higher among non-Hispanic blacks (OR 1.6, 95% CI 1.2-2.3), Hispanics (OR 1.8, 95% CI 1.2-2.6), and people with high levels of functional/social/leisure limitations (OR 1.8, 95% CI 1.4-2.3) and was decreased among those with a college education (OR 0.6, 95% CI 0.4-0.8).

CONCLUSION

AAWL is highly prevalent, affecting millions of Americans and one-third of adults with doctor-diagnosed arthritis. Findings suggest the need for more targeted research to better understand the natural history, success of interventions, and effects of policy on AAWL. Public health interventions, including self-management education programs, may be effective in countering AAWL.

Arthritis Burden and Impact are Greater among U.S. Women than Men: Intervention Opportunities

OBJECTIVES

To summarize arthritis burden and impact among women compared with men, using updated surveillance and impact measures; to describe public health approaches to arthritis; and to review effective, evidence-based arthritis self-management interventions.

RESULTS

Arthritis continues to burden the U.S. population as the leading cause of physical disability and affects women disproportionately: women with arthritis report greater prevalence of activity and work limitations, psychological distress, and severe joint pain than their male counterparts. Three main public health interventions can reduce arthritis impact: self-management education, physical activity, and weight management. Self-management education programs are proven to reduce pain and depression, delay disability, improve self-efficacy, physical function, and quality of life, and reduce healthcare costs. Appropriate physical activity decreases pain, improves function, and delays disability. The American College of Rheumatology recommends maintaining a healthy weight to benefit patients with hip or knee osteoarthritis. Women appear more receptive to certain information delivery methods (i.e., physician counseling) than men, suggesting gender-specific targeting of interventions may be of use.

CONCLUSIONS

Effective interventions remain underused. The Centers for Disease Control and Prevention Arthritis Program and its partners, including state arthritis programs, continue their efforts to build the arthritis public health science base, monitor burden and impact, evaluate and disseminate evidence-based interventions, and work to decrease and delay disability, and increase quality of life among those with arthritis. As new approaches are developed, women and other disproportionately impacted groups merit particular consideration in tailoring and delivering programs to reduce arthritis burden.

Descriptive epidemiology of collegiate women's field hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003

OBJECTIVE

To review 15 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's field hockey and identify potential areas for injury prevention initiatives.

BACKGROUND

Field hockey is one of the most popular sports worldwide and is growing in participation in the United States, particularly among women. From 1988-1989 to 2002-2003, participation in NCAA women's field hockey increased 12%, with the largest growth among Division III programs. In 2002- 2003, 253 colleges offered women's field hockey and 5385 women participated.

MAIN RESULTS

Game injury rates showed a significant average annual 2.5% decline over 15 years, most likely fueled by drops in ankle ligament sprain, knee internal derangement, and finger fracture injuries. Despite this, ankle ligament sprains were common (13.7% of game and 15.0% of practice injuries) and a frequent cause of severe injuries (resulting in 10+ days of time-loss activity). Concussion and head laceration injuries increased over this same time, and the risk of sustaining a concussion in a game was 6 times higher than the risk of sustaining one during practice. Overall, injury rates were twice as high in games as in practices (7.87 versus 3.70 injuries per 1000 athlete-exposures, rate ratio = 2.1, 95% confidence interval = 2.0, 2.3). Most head/neck/face (71%) and hand/finger/thumb (68%) injuries occurred when the player was near the goal or within the 25-yd line and were caused by contact with the stick or ball (greater than 77% for both body sites); for 34% of head/neck/ face injuries, a penalty was called on the play.

RECOMMENDATIONS

Equipment (requiring helmets and padded gloves) and rule changes (to decrease field congestion near the goal) as well as evidence-based injury prevention interventions (eg, prophylactic ankle taping/bracing, neuromuscular balance exercise programs) may be viable prevention initiatives for reducing injury rates in women's collegiate field hockey players.

Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives

OBJECTIVE

To summarize 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for 15 sports and to identify potential modifiable risk factors to target for injury prevention initiatives.

BACKGROUND

In 1982, the NCAA began collecting standardized injury and exposure data for collegiate sports through its Injury Surveillance System (ISS). This special issue reviews 182 000 injuries and slightly more than 1 million exposure records captured over a 16-year time period (1988-1989 through 2003-2004). Game and practice injuries that required medical attention and resulted in at least 1 day of time loss were included. An exposure was defined as 1 athlete participating in 1 practice or game and is expressed as an athlete-exposure (A-E).

MAIN RESULTS

Combining data for all sports, injury rates were statistically significantly higher in games (13.8 injuries per 1000 A-Es) than in practices (4.0 injuries per 1000 A-Es), and preseason practice injury rates (6.6 injuries per 1000 A-Es) were significantly higher than both in-season (2.3 injuries per 1000 A-Es) and postseason (1.4 injuries per 1000 A-Es) practice rates. No significant change in game or practice injury rates was noted over the 16 years. More than 50% of all injuries were to the lower extremity. Ankle ligament sprains were the most common injury over all sports, accounting for 15% of all reported injuries. Rates of concussions and anterior cruciate ligament injuries increased significantly (average annual increases of 7.0% and 1.3%, respectively) over the sample period. These trends may reflect improvements in identification of these injuries, especially for concussion, over time. Football had the highest injury rates for both practices (9.6 injuries per 1000 A-Es) and games (35.9 injuries per 1000 A-Es), whereas men's baseball had the lowest rate in practice (1.9 injuries per 1000 A-Es) and women's softball had the lowest rate in games (4.3 injuries per 1000 A-Es).

RECOMMENDATIONS

In general, participation in college athletics is safe, but these data indicate modifiable factors that, if addressed through injury prevention initiatives, may contribute to lower injury rates in collegiate sports.

Serious psychological distress in U.S. adults with arthritis

BACKGROUND

Arthritis and mental health disorders are leading causes of disability commonly seen by health care providers. Several studies demonstrate a higher prevalence of anxiety and depression in persons with arthritis versus those without arthritis.

OBJECTIVES

Determine the national prevalence of serious psychological distress (SPD) and frequent anxiety or depression (FAD) in adults with arthritis, and in adults with arthritis, identify risk factors associated with SPD.

METHODS

Cross-sectional data from the 2002 National Health Interview Survey, an in-person household interview survey, were used to estimate the prevalence of SPD and FAD in adults with (n=6,829) and without (n=20,676) arthritis. In adults with arthritis, the association between SPD and sociodemographic, clinical, and functional factors was evaluated using multivariable logistic regression.

RESULTS

The prevalence of SPD and FAD in adults with arthritis is significantly higher than in adults without arthritis (5.6% vs 1.8% and 26.2% vs 10.7%, P<.001, respectively). In adults with arthritis, SPD was significantly associated with younger age, lower socioeconomic status, divorce/separation, recurrent pain, physical inactivity, having functional or social limitations, and having comorbid medical conditions. Adults aged 18 to 44 years were 6.5 times more likely to report SPD than those 65 years or older, and adults with recurrent pain were 3 times more likely to report SPD than those without recurrent pain.

CONCLUSIONS

Serious psychological distress and FAD affect persons with arthritis and should be addressed in their treatment. Younger adults with arthritis, and those with recurrent pain or either functional or social limitations, may be at higher risk for SPD.

Self-reported Injury and Physical Activity Levels: United States 2000 to 2002

PURPOSE

The aim of the study is to compare national estimates of the incidence of self-reported all-cause and activity-specific injuries in adults with differing leisure-time physical activity levels.

METHODS

Data were analyzed from the 2000 to 2002 National Health Interview Survey. Leisure-time physical activity levels were categorized as active, insufficiently active, and inactive.

RESULTS

Age-adjusted incidences of all-cause injury did not differ by leisure-time physical activity level (active, 89.3/1000; 95% confidence interval [CI], 81.8-96.8; insufficiently active, 81.6/1000; 95% CI, 73.1-90.1; and inactive, 86.3/1000; 95% CI, 78.6-93.9). Active respondents (29.4/1000; 95% CI, 25.2-33.6) had a greater incidence of injury related to sport and leisure-time activities than inactive respondents (15.2/1000; 95% CI, 12.1-18.3), whereas inactive respondents (71.1/1000; 95% CI, 63.9-78.2) had a greater incidence of injury related to nonsport and non-leisure-time activities than active respondents (59.9/1000; 95% CI, 53.6-66.2). Results were unchanged after multivariate control for confounding factors.

CONCLUSIONS

Although the incidence of sport and leisure-time injuries is associated with participation in leisure-time physical activity, no association was observed between leisure-time physical activity and overall injuries.

Physical activity in men and women with arthritis National Health Interview Survey, 2002

BACKGROUND

Regular physical activity in persons with arthritis has been shown to decrease pain, improve function, and delay disability. This study estimates the national prevalence of leisure-time physical activity and identifies factors associated with physical inactivity in adults with arthritis.

METHODS

Data from the 2002 National Health Interview Survey were analyzed in 2004-2005 to estimate the proportion of adults with arthritis meeting four physical activity recommendations put forward in Healthy People 2010 and one arthritis-specific recommendation established by a national expert panel in arthritis and physical activity. Multivariate logistic regression was used to evaluate the association between inactivity and sociodemographic factors, body mass index, functional limitations, social limitations, need for special equipment, frequent anxiety/depression, affected joint location, joint pain, physical activity counseling, and access to a fitness facility.

RESULTS

Adults with arthritis were significantly less likely than adults without arthritis to engage in recommended levels of moderate or vigorous physical activity, and 37% of adults with arthritis were inactive. In both men and women with arthritis, inactivity was associated with older age, lower education, and having functional limitations; having access to a fitness facility was inversely associated with inactivity. Among women, inactivity was also associated with being Hispanic, non-Hispanic black, having frequent anxiety/depression or social limitations, needing special equipment, and not receiving physical activity counseling. Among men, inactivity was also associated with severe joint pain.

CONCLUSIONS

Although physical activity is a recommended therapy for people with arthritis, levels among adults with arthritis are insufficient, and those with arthritis have worse activity profiles than their peers without arthritis. Efforts to promote physical activity should include expanding access to evidence-based interventions and recreational facilities/programs. The importance of physical activity counseling and associated pain management measures by healthcare providers should be emphasized.

Projections of US prevalence of arthritis and associated activity limitations

OBJECTIVE

To update the projected prevalence of self-reported, doctor-diagnosed arthritis and arthritis-attributable activity limitations among US adults ages 18 years and older from 2005 through 2030.

METHODS

Baseline age- and sex-specific prevalence rates of arthritis and activity limitation, using the latest surveillance case definitions, were estimated from the 2003 National Health Interview Survey, which is an annual, cross-sectional, population-based health interview survey of approximately 31,000 adults. These estimates were used to calculate projected arthritis prevalence and activity limitations for 2005-2030 using future population projections obtained from the US Census Bureau.

RESULTS

The prevalence of self-reported, doctor-diagnosed arthritis is projected to increase from 47.8 million in 2005 to nearly 67 million by 2030 (25% of the adult population). By 2030, 25 million (9.3% of the adult population) are projected to report arthritis-attributable activity limitations. In 2030, >50% of arthritis cases will be among adults older than age 65 years. However, working-age adults (45-64 years) will account for almost one-third of cases.

CONCLUSION

By 2030, the number of US adults with arthritis and its associated activity limitation is expected to increase substantially, resulting in a large impact on individuals, the health care system, and society in general. The growing epidemic of obesity may also significantly contribute to the future burden of arthritis. Improving access and availability of current clinical and public health interventions aimed at improving quality of life among persons with arthritis through lifestyle changes and disease self-management may help lessen the long-term impact.

Health-related quality of life, health risk behaviors, and disability among adults with pain-related activity difficulty

OBJECTIVES

We examined the association between pain-related activity difficulty (PRAD) in the past 30 days and health-related quality of life, health behaviors, disability indices, and major health impairments in the general US population.

METHODS

We obtained data from 18 states in the 2002 Behavioral Risk Factor Surveillance System, an ongoing, cross-sectional, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged 18 years or older.

RESULTS

Nearly one quarter of people in the 18 states and the District of Columbia reported at least 1 day of PRAD in the past 30 days. PRAD was associated with obesity, smoking, physical inactivity, impaired general health, infrequent vitality, and frequent occurrences of physical distress, mental distress, depressive symptoms, sleep insufficiency, and anxiety symptoms. Moreover, a general dose-response relationship was noted between increased days of PRAD and increased prevalence of impaired health-related quality of life, disability indices, and health risk behaviors.

CONCLUSION

Pain negatively influences various domains of health, not only among clinical populations, but also in the general community, suggesting a critical need for the dissemination of targeted interventions to enhance recognition and treatment of pain among adult community-dwellers.

Physical activity and health related quality of life among people with arthritis

STUDY OBJECTIVE

To assess the association between physical activity and health related quality of life (HRQOL) among persons with arthritis or chronic joint symptoms (CJS).

DESIGN

Cross sectional survey investigating the relation between physical activity level and HRQOL. HRQOL was estimated using the number of physically or mentally unhealthy days during the past 30 days. Physical activity was categorised as recommended, insufficient, or inactive according to federal activity recommendations. Persons with arthritis were defined as those with either self reported CJS or doctor diagnosed arthritis.

SETTING

Community dwelling, US adults residing in all 50 states and the District of Columbia.

PARTICIPANTS

Respondents (n = 212 000) in the 2001 behavioral risk factor surveillance system (BRFSS), an annual population based, telephone survey.

MAIN RESULTS

The 33% of BRFSS respondents with arthritis had a mean of 6.7 physically and 4.9 mentally unhealthy days during the past 30 days, compared with 1.8 and 2.7 among those without arthritis. Inactive men and women were 1.2-2.4 times more likely to report impaired HRQOL compared with those who met physical activity recommendations. Men and women who engage in insufficient physical activity also report variably reduced HRQOL.

CONCLUSIONS

Among people with arthritis, recommended levels of physical activity were associated with fewer mean physically and mentally unhealthy days and a decreased probability of having severely impaired physical or mental HRQOL.