Arthritis or joint pain, is a leading cause of disability, poor physical function, and decreased quality of life, affecting an estimated 54 million US adults (Barbour et al., 2017). In Wisconsin, 26% of adults (1.1 million) reported a diagnosis of arthritis (CDC, 2019). Existing guidelines recommend exercise to manage arthritis symptoms and decrease the severity of pain and physical limitations (CDC, 2018a), yet only 26% of men and 19% of women with arthritis engage in sufficient physical activity (PA) (Piercy et al., 2018). Likewise, individuals with arthritis who meet PA guidelines can lower their risk for premature death by 33% (Vagnoni et al., 2018). Nationwide, arthritis contributes approximately $81 billion to medical costs annually (Barbour et al., 2017). Notably, participants with arthritis randomised to an exercise programme noted a decrease in average drug costs (Vagnoni et al., 2018). Thus, improving activity may improve arthritis management, survival, and health costs, but significant barriers persist for connecting patients to walking exercise programs, particularly in smaller communities (Hanson et al., 2022). In the US, a higher prevalence of arthritis is seen in rural communities (33%) compared to urban areas (21%). Furthermore, 43% of rural patients have arthritis-attributable activity limitation, affecting regular exercise participation. PA and self-management education programs could help reduce these limitations and improve physical function and health outcomes (CDC, 2018b). Unfortunately, many non-urban communities lack evidence-based activity programs for patients with arthritis, limiting arthritis prevention and functional improvement opportunities. Walk With Ease (WWE) is one of five evidence-based, CDC-endorsed programs to improve PA and self-management in patients with arthritis (Callahan et al., 2011; CDC, 2018b). WWE is readily accessible with training materials and resources that can be found on the Arthritis Foundation website and tailored to an individual's fitness level (Arthritis Foundation, 2018). Of the five CDC-endorsed programs, WWE is appealing for its low cost and ease of implementation across diverse settings and contexts (Conte et al., 2016). However, barriers exist to implementing WWE in smaller communities, including few partner organisations delivering such programs (Callahan et al., 2011; Chevan et al., 2022; Conte et al., 2016, 2021; Sheikh et al., 2019; Silverstein et al., 2018; Vilen et al., 2022). The objectives of this study were to (1) implement WWE in a community YMCA fitness centre; (2) examine physical function and self-reported health outcomes in participants with arthritis; and (3) examine the feasibility and sustainability of implementing WWE by strategically pairing with community partners. In this open pilot intervention study, partners included a Midwest community health system, two rheumatologists, two physical therapists, and a local YMCA. Health system rheumatologists and clinic staff facilitated patient recruitment using posters and flyers. Two health system physical therapists helped train two consecutive YMCA exercise leaders for programme evaluation by assisting with pre-post evaluations in 2 h-long WWE sessions. YMCA fitness staff completed online WWE training, helped with community recruitment, led classes, and performed the programme evaluations. The study's principal investigator, a rheumatologist with implementation expertise, provided system outreach for referrals and facilitation coaching for both the health system evaluators and YMCA trainers during two in-person sessions and quarterly calls. The project recruited adults with self-reported arthritis who met the programme requirements of being able to stand on their feet unassisted for at least 10 min. One of two WWE-trained YMCA staff members conducted six cohorts of 6-week cycles that met 3 days per week for 1 h, for a total of 18 sessions per cycle per the Arthritis Foundation curriculum (Arthritis Foundation, 2018). Patient recruitment and data collection occurred between August 2016 and December 2017 with subsequent data analysis. Physical and self-reported evaluations were performed at baseline and at 6-week follow-up. Physical measurements were documented by a physical therapist or a trained YMCA staff member and included seven data points: fast and normal walking speed measurements over a 20-foot distance, 2-min step counts, bidirectional turn tests, leg stance, and chair stands (Callahan et al., 2011). Evaluations also included pre- and post-surveys that were distributed to all registered participants. Surveys included 25 items consisting of a 10-point visual analogue scale (VAS) for arthritis pain, mood, fatigue, and global health, a validated multi-dimensional health assessment questionnaire (MD-HAQ) (Pincus, 2007), and an exercise plan assessing participants' weekly exercise frequency. Post-programme surveys also assessed the planned frequency of continued exercise in the next 30 days. Results were compared pre-post within and across subjects using paired t-tests. Sample size precluded multivariable analysis. The project received an exemption and a waiver of informed consent from the Gundersen Health System institutional review board. Of 35 registered participants, 31 attended one of the six cycles (Figure 1), ranging between 2 and 10 participants per cycle. Participants were predominantly 65 years or older (78%), female (77%) and White (100%) (Table 1). Of the 10 participants who provided referral details, half were referred by a provider, and the other half were self-referred. Attendance was documented only for two cycles (n = 14 participants) with an average of 13 out of 18 total sessions attended (72%). All 31 participants had either pre- or post-data, and 74% of participants (n = 23) had paired assessment data. Four lacked all baseline physical measures, and eight lacked any follow-up questionnaire data. All missing data were from patients more than 65 years old; similar frequency for men (28.6%) and women (25%). Flow diagram of Walk With Ease implementation pilot with a local YMCA. Table 2 shows the results of the pre- and post-outcome measures with mean and standard deviation at baseline and 6-week follow-up. Improvement occurred in all physical measures of mobility and balance. In the paired data, normal and fast walking speeds increased an average of 0.53 ft/s (p = 0.02) and 0.67 ft/s (p = 0.01), respectively. The 2-min step count increased an average of 48.5 steps (p < 0.01). The timed chair stands dropped an average of 2 s (2.2 s, p = 0.01). A description of the physical measures is outlined in the Supporting Information S1. Self-reported quantitative items, including the 10-item-MD-HAQ and 10-point VAS pain scores, improved an average of 2.84 (p < 0.01) and 1.43 (p = 0.01). Global health scores improved an average of 1.43 (p < 0.01). Baseline exercise frequency increased an average of 1.7 times per week. Overall, 100% of participants reported a plan to continue to exercise three or more days per week. Of these, 81% felt very confident that they would continue to exercise, and 57% planned to exercise more than 30 min daily (Table 3). A description of the self-reported measures is outlined in the Supporting Information S1. All resources, including the certified leader training, were available through the Arthritis Foundation website. Partnering with the community YMCA proved optimal because their model supports the adoption and delivery of new fitness programs with minimal resource additions. Upon pilot completion, YMCA partners planned to continue to enrol in two WWE cycles annually, serving a new demographic of individuals with arthritis and little exercise background. Lastly, the average programmatic system cost to the YMCA was $208 per participant for the entire 6-week programme, or $12 per participant per session, which could be lessened with greater enrolment. Cost to participants was waived by the grant funding for this study. Consistent with previous studies (Callahan et al., 2011; Conte et al., 2016; Sheikh et al., 2019; Silverstein et al., 2018; Wyatt et al., 2014), WWE programme implementation showed improvements in physical measures and self-reported outcomes. All physical measures improved, suggesting that community-led WWE activity programs are effective for improving physical function (Table 2). Self-reported outcomes also largely improved (Table 3). Although mood and fatigue improved modestly, changes were not significant, possibly due to the small sample size. However, the average change in fatigue fell within the previously established range of 0.6–1.7, consistent with existing literature (Wells et al., 2007); MD-HAQ and pain score average improvements were both greater than the minimal clinically important difference (MCID) of 0.25 and 0.8, respectively (Maska et al., 2011; Olsen et al., 2017). Significant decreases in pain scores of 1.4 points (14 mm) on a 10-point VAS (MCID is 1.0–1.4 = 10–14 mm) occurred, consistent with prior studies (Callahan et al., 2011; Hawker et al., 2011). Although our study was observational, measured improvements were similar to the reported efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in arthritis pain management (da Costa et al., 2017). Lastly, self-reported exercise frequency (three or more times per week) increased from 20% to 70% of participants. Based on our pilot results, WWE programing can help individuals meet PA guidelines, which could ultimately lead to reduced healthcare costs and risks of premature death. Additionally, all participants reported that they would continue to exercise after the programme ended, with most being 'very confident', demonstrating that WWE may change behaviour. Of those missing paired data, there was no difference seen in the participant demographics, showing that age and sex do not impact attendance rates. To our knowledge, this is the first non-CDC-funded WWE pilot that (1) strategically paired a local YMCA and a community health system, and (2) addressed previously documented WWE implementation barriers, including staff training and buy-in and oversight by an experienced implementation scientist. WWE proved to be a feasible and sustainable programme when delivered through a community fitness organisation paired with a community healthcare system. Leader training resources were available online (Arthritis Foundation, 2018, <$100, 4 CEUs). Although the Arthritis Foundation guidebook was donated to our participants, local communities and individuals can purchase print copies ($11.95 online, less in bulk). In addition, partnering with the YMCA, an organisation that routinely disseminates new fitness programs to its members, provided expedient infrastructure. Readiness of the YMCA meant minimal additional start-up costs. Moreover, they were equipped to easily onboard new staff even with personnel changes during implementation. The YMCA's established infrastructure and the consultation of health system physical therapists are key elements that address many of the implementation barriers to scaling up WWE (Conte et al., 2017; Vilen et al., 2022). Therefore, partnership with local YMCAs can offer an effective means for scaling-up the implementation of arthritis interventions. WWE was also cost effective when compared to the national average cost for an initial physical therapy visit. In our study, costs were ∼$208 per participant (less than $12 per participant) per session for the 6-week programme; total cost of 18 sessions was less than an initial physical therapy visit (∼$241, MD Save). This addresses another WWE programme limitation outlined in prior evaluations (Conte et al., 2017). Despite the strengths of the study, including improvements in physical function and signals of decreased pain, we acknowledge limitations. This was a small, open pilot in patients with self-reported arthritis in a low-diversity health system and YMCA in the Midwest. Sample sizes were convenience samples (not a priori determined) and may not reflect those with more severe arthritis who were unable to participate in exercises, limiting generalisability. Additionally, self-reported surveys could introduce social desirability. Although women (77%) outnumbered men, demographics matched national arthritis visit data (Barbour et al., 2017). Furthermore, lack of controls, use of pre- and post- data, and variable attendance and data completeness were limitations. Not all participants attended each session, and asking community partners to collect data resulted in more missing data. Medical records were not reviewed nor were medications. Lastly, our study used pragmatic aggregate programme evaluations, which did not allow robust multivariable analysis. To improve recruitment and outcomes, future studies could examine ways to increase provider referral using electronic health record referrals and study the impact of staff versus provider referral. Our pilot study showed that WWE programme participation improves physical function and self-reported health outcomes in patients with arthritis. In addition, WWE appeared to be a feasible, sustainable, and cost-effective programme when implemented with well-suited community partners. Given observed improvements in function and diminished arthritis pain, health professionals should refer patients with arthritis to community-based programs that promote PA interventions to improve function, pain control, and behaviour change. The authors' contributions are as follows: substantial contributions to the concept or design of the work: Christie M. Bartels, Douglas W. White, Lee Walraven, Brock Polnaszek; substantial contributions to the acquisition of data: Christie M. Bartels, Chelsea Barnes, Lee Walraven, Amanda Perez; analysis and interpretation of data: Christie M. Bartels, Amanda Perez, Monica Messina, Kathryn A. Miller, Anupama T. Joseph, Kim Kies. All authors have contributed to the drafting, critical revision, and final approval of the work: Amanda Perez, Monica Messina, Brock Polnaszek, Douglas W. White, Kathryn A. Miller, Anupama T. Joseph, Kim Kies, Lee Walraven, Chelsea Barnes, Christie M. Bartels. Christie M. Bartels accepts full responsibility for the work. The Study was funded by a 2016 Wisconsin Medical Society Foundation grant (Bartels-PI). Funders played no role in the design, conduct, or interpretation of results. The authors would like to thank the physical therapists, Karen Amann and Sheryl Helstad, for program evaluation training and the YMCA staff for helping to conduct this study. C. Bartels has received unrelated grant support from Independent Grants for Learning and Change (Pfizer). D. White is supported by the Gundersen Medical Foundation. The manuscript content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. All other authors declare no financial disclosures or conflicts of interest. This manuscript does not contain clinical studies or patient data. The data that support the findings of this study are available from the corresponding author upon reasonable request. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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