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In other words, pain and disease status variables are insufficient to explain work status; rather, it is an individualized combination of factors within and external to the person that supports or hinders their work participation. Coping styles have been investigated with regard to work loss secondary to arthritis pain [ 13 ]. Those who left the work force were engaged in fewer activities and more likely to use attention diverting and activity pacing coping strategies to deal with their pain [ 13 ]. These two types of coping behaviors significantly contributed to a model predicting work loss above and beyond work-related factors, when adjusted for age, sex, disease duration and disease activity.

In a prospective, longitudinal study of employed people with arthritis, lack of support in the workplace and work limitations were predictors of future depression [ 14 ]. There was also an association between greater pain catastrophizing, considered a maladaptive coping style, and future depressive symptoms.

Not only does pain interfere with work, but it restricts participation in other roles, including those integral to family life, such as being a parent, managing a household or maintaining intimate relationships [ 15 ]. Difficulties caring for children are frequently reported by parents with arthritis [ 5 , 11 , 16 ].

Evans and colleagues [ 16 ] compared the psychosocial functioning and coping of mothers with chronic pain including mothers with arthritis to mothers without pain, with regard to their ratings of parenting efficacy. There was a significant association between the level of psychological distress and parenting difficulties. While mothers with chronic pain reported using both problem-focused and emotion-focused coping strategies, the use of emotion-focused coping was associated with greater psychological distress [ 16 ].

Mental health status emerged as the most significant predictor of parenting efficacy. Elsewhere, social support from family members has been identified as a contributor to performance of household work and parenting [ 11 ]. In studies of pain, marital functioning and psychological distress, there are mixed results regarding the contribution of spousal support to their partner's experience of pain and psychological distress [ 17 ].

The most consistent finding is that negative responses or problematic forms of spousal 'support' are significantly associated with psychological distress [ 17 - 19 ] and pain severity [ 17 ]. Interestingly, the presence of positive forms of support does not consistently demonstrate an association to either psychological well-being or pain [ 18 ]. Marital satisfaction may have an inverse relationship to the presence of depressive symptoms [ 18 ]. A study exploring how couples shared the management of one partner's arthritis indicates the potential for conflict that adversely affects both the relationship and health outcomes [ 20 ].

Compared to controls from the general population, people with RA engage in fewer types of leisure activities, but this difference appears statistically significant only among people with lower educational attainment [ 21 ]. Given that result, it was hypothesized that people with less education may also have fewer resources and opportunities to explore leisure interests.

Arthritis and pain. Psychosocial aspects in the management of arthritis pain

As leisure is more discretionary by nature, especially when one juggles the demands of family, work, and self management of a chronic illness, there may be a tendency to set aside leisure interests in order to fulfill more obligatory responsibilities. Alternatively, in the presence of pain and physical limitation, it may seem daunting to engage in active recreational pursuits. Pain and fatigue are both independent predictors of loss of participation in activities such as recreation and hobbies [ 5 ].

Studies of valued life activities demonstrate that declining ability to engage in recreational activities, hobbies and social interactions appear to significantly increase the risk of new depressive symptoms, even more so than activity losses in other domains [ 22 ]. The role of leisure in maintaining or restoring psychological well-being in the presence of arthritis pain warrants further study.

Search terms included combinations of pain, pain management, psychosocial, and arthritis, and the search was limited to studies of adults and the English language. Studies needed to measure pain as an outcome and employ a specific psychosocial intervention to be included in the review. Because prior reviews have summarized literature through the s [ 4 ] this review focuses on papers published from January through August , inclusive of early on-line editions.

Psychosocial approaches to managing arthritis pain include educational programs, coping skills training CST , and cognitive behavioral therapy CBT. As a group of interventions, the focus is the provision of information necessary to understand the rationale for the approach selected, and techniques to enhance self efficacy, manage stress, decrease helplessness and catastrophizing, and perhaps most importantly, develop and practice specific skills, applied to the person's unique life situation.

While most people with arthritis are able to access basic medical care, timely, comprehensive care regarding psychosocial aspects of living with arthritis is limited [ 3 ]. A widely known educational intervention is the community-based Arthritis Self Management Program [ 23 ], typically a series of six weekly group sessions led by trained lay leaders, which specifically targets self efficacy skills in the management of arthritis symptoms, including pain. Other individualized or group specific educational programs may be designed by health care providers to match the needs of their audience, and may include elements similar in nature to the Arthritis Self Management Program or CST and CBT approaches.

CST or CBT include cognitive and behavioral exercises, conducted individually or in groups over several weeks. A typical program might introduce a simplified overview of a theory of pain control, attention diversion techniques such as relaxation or guided imagery, changing cognitions recognizing and reducing negative thoughts , changing activity patterns pacing, choosing pleasurable activities and the provision of homework to apply new techniques outside the treatment setting [ 3 , 4 , 24 ].

Some pain management techniques, such as relaxation, may be taught in isolation, but this in itself does not comprise a program of CST or CBT. The list of psychosocial factors potentially associated with pain management is daunting. Keefe and colleagues [ 25 ] have organized these into two general categories: While this schema is generally supported in the literature, the evidence from cross-sectional and longitudinal studies remains muddled with regard to the precise mechanism by which psychosocial factors might influence the pain experience.

Passive coping [ 29 ], feelings of helplessness [ 30 ], and catastrophizing [ 31 - 33 ] appear to be associated with more pain and poorer health outcomes, while active coping [ 33 , 34 ] and self efficacy [ 33 ] appear to decrease pain. Increasingly, clinical trials are being reported that examine various intervention protocols. A systematic review and meta-analysis of cognitive-behavioral and psychoeducational interventions found 25 trials of sufficient quality to analyze for pooled effects on 6 outcomes of interest pain, disability, tender joints, psychological status, coping and self efficacy [ 35 ].

Results indicated small effect sizes for reducing pain and disability over the short term, an effect that unfortunately was not sustained in the studies that employed a follow-up assessment. With regard to psychological status, the most frequently measured outcome was depression. Across trials, there was a small average effect size for reducing symptoms of depression, and this change was maintained in those studies that included a follow-up assessment.

Small but significant average effect sizes for coping and self-efficacy suggested that interventions were successful in improving skills. Not all studies provided enough information to calculate effect sizes, and when reviewed at the individual study level, the authors report a number of inconsistencies that could be due to lack of statistical power most studies used relatively small samples , variation in the treatments used, or characteristics of the patients studied. Inconsistencies across studies have been reported in another systematic review of group interventions for adults with RA or osteoarthritis OA [ 34 ].

The types of group interventions provided were self-management education or cognitive behavioral therapy for stress management. One of three studies demonstrated an improvement in coping skills, one of four studies demonstrated improved social contacts, and six of thirteen studies showed improvement in functional status. More research is required to tease out the circumstances under which positive outcomes occur. Beyond methodological limitations, there is the likelihood that some interventions are successful for some people but not others, and these characteristics need to be delineated to better inform clinical practice.

In a trial of CBT compared to sympathetic attention to arthritis symptoms and usual care control groups in adults with lupus, the experimental group demonstrated significant improvement in pain following treatment while the changes for both control conditions did not significantly differ from baseline [ 36 ]. However, improvements in pain were not sustained at the nine-month follow-up assessment. Similar results were obtained for psychological and physical functioning. If desirable outcomes are achieved in the short term but not sustained in the long term, it is reasonable to hypothesize that some type of maintenance program may resolve this problem.

One such trial compared conventional pain CST to a CST program enhanced with a maintenance component and two control conditions: A comprehensive daily diary was used to monitor pain variables. Although participants were randomized 38 to 46 in each group , just 95 completed the trial, and the attrition was greatest in the two pain CST groups 19 and 18, respectively, completing the study , which threatens the strength of the conclusions.

Unexpectedly, the conventional pain CST was superior to the maintenance-enhanced program and both control conditions in reducing pain and negative mood and increasing coping efficacy; however, the maintenance-enhanced pain coping skills group was superior in enhancing positive mood. An month follow-up study assessed the longer-term efficacy of CBT for adults with recently diagnosed RA [ 37 ]. The original intervention compared a series of eight individual sessions of CBT with a psychologist to routine care. In the intent-to-treat analysis, the changes in pain and coping were not statistically significant at follow up.

However, while depression and anxiety increased in the routine care group, they decreased in the cognitive behavioral treatment group. In contrast to that favorable outcome, another small but well-designed trial of cognitive-behavioral education with newly diagnosed RA patients, compared to standard care, found no significant improvements in functional status, helplessness, or self efficacy and no between-group differences at six months post-intervention [ 38 ].

The treatment in this trial was group sessions of two hours duration, once per week for four weeks. Could the different outcomes in the two trials be attributed to the intensity of the intervention eight individual versus four group sessions? The 'dose-response' relationship for most psychosocial interventions has not been fully investigated.

Given their results, the authors of the latter study recommend re-examining the trend to offer cognitive behavioral treatment early in the disease course with a larger sample and longer follow up [ 38 ]. In a non-randomized trial of a seven-week educational program addressing pain and stress management, coping skills, goal-setting and exercise, compared to a wait-list control group in Korea, the intervention group showed significant improvement in the outcomes of pain and depression, but not functional status [ 39 ].

Additionally, there were significant associations between pain management skills, coping skills and the outcome measures, supporting the theory that training improves skills, which, in turn, improve outcomes. In another paper with a similar purpose, examining the mechanism by which stress management may mediate pain and depression in adults with RA, Rhee and colleagues [ 40 ] conducted a secondary analysis of their earlier clinical trial. Comparing a group of 47 who received comprehensive stress management training to 45 receiving standard rheumatologic care, they found support for the hypothesis that stress management based on CBT indirectly improves pain and depression via cognitive-behavioral variables efficacy, coping and helplessness.

Only one study was found comparing psychosocial and medical interventions, although the primary outcome was depression rather than pain. This randomized controlled trial [ 41 ] compared three groups in the management of depression: CBT plus medication, attention plus medication, and medication only. Outcomes were measured at baseline, post-treatment 10 weeks , and 6 and 15 month follow-up assessments.

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Participants were 54 adults with RA and major depression. Unfortunately, after drop outs, only 13 or 14 participants remained in each group. There were no significant between-group differences on the main outcome of depression, nor for most secondary outcomes, including pain, self efficacy, helplessness, or coping. One of the possible explanations for sometimes conflicting results across studies is the characteristics of the sample. What is 'right' for a young adult with early RA is likely not appropriate for an older adult with OA. In a study of homebound older adults experiencing moderate to severe symptoms of stiffness, fatigue and pain from RA or OA, more than half reported depression [ 42 ].

Those with RA reported less pain and limitations and greater self efficacy and social interactions than those with OA, suggesting that their arthritis had been better managed over the course of their illness. Self-management programs intended to address pain and psychosocial issues should consider the unique needs of different populations such as this one [ 42 ].

In another study of older women with RA or OA, Zautra and Smith [ 43 ] also found similarities and differences between the two disease-groups. While depression was related to pain in both groups it was associated with elevated stress and increased reactivity to stress in older women with RA but not those with OA, raising another set of immunological-related questions.

There may also be gender differences in selecting the best therapeutic approach. Hirsh and colleagues [ 15 ] report a significant relationship between pain-related disability in life activities and negative mood and that this relationship is stronger among women with chronic pain than in men. After controlling for negative mood, pain remains a predictor of overall disability in men, but is no longer a significant predictor of disability for women.

Findings such as these may suggest different approaches for men and women. Personal preferences and personality may also play a part, but that moves beyond the scope of this review. People also vary in their ability to cope and their health beliefs.

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It has been hypothesized that small beneficial effects from psychosocial interventions may result in part from heterogeneous samples with regard to their risk for psychosocial dysfunction. Patients were randomly assigned to CBT or standard care. Using an individualized approach to CBT, where patients chose their priority topics for therapy during ten biweekly sessions plus a 'booster' follow-up session four weeks later, results demonstrated generally improved physical, psychological and social function, but no direct, significant effect on pain.

However, only 11 patients in the CBT group chose pain management as a priority topic for intervention. This suggests CBT must be specifically applied to targeted symptoms and behaviors in order to have a measurable effect. Because the psychosocial interventions reviewed above are, to some degree, individualized, they are likely to address how to manage pain in specific situations or when fulfilling certain roles. That is, patients learn to apply the general strategies to their own priorities, such as better managing pain at work, family activities, or social situations.

However, sometimes programs are designed to enhance performance of specific roles, appealing to a specific group of individuals based on the role first, and secondarily incorporating psychosocial approaches to pain management into program content. Given the stage set earlier in this paper, where the psychosocial impact of arthritis pain was related to social roles at work, family life, and leisure pursuits, this more contextual approach to organizing and delivering intervention may appeal to different audiences. Two examples are briefly cited here: The intervention used in a randomized trial of vocational rehabilitation counseling for people with RA at risk for job loss included a review of the nature of work, positive messages about each participant's ability to work and skills training on how to request and implement job accommodations.

The control group received printed information alone. The result was significantly less job loss in the intervention group, demonstrating that job loss can be delayed or prevented [ 9 ]. The pain experience is influenced by interactions with significant others; therefore, some studies have investigated interventions involving family members [ 3 ].

There is a suggestion that involving family members in psychosocial interventions, such as cognitive behavioral approaches or CST, is beneficial for reducing arthritis symptoms, enhancing self efficacy, and improving social support for the person with arthritis, but the effect on family members is largely unmeasured [ 45 ]. A phenomenological study of women living with lupus reported participants felt that health care professionals did not fully appreciate the psychosocial impact of the illness, and consequently did not provide information to meet those needs [ 46 ], a finding supported by other women with RA, ankylosing spondylitis and lupus [ 47 ].

Reports like this are reason to carefully consider the psychosocial aspects of arthritis and discover interventions that not only alleviate arthritis pain, but ensure people are able to participate in valued life activities, as much as possible maintaining physical and psychological well-being.

Psychosocial approaches enhance medical regimes of care [ 2 , 3 ]. There is evidence that psychosocial interventions improve coping and self efficacy, reduce psychological distress, and reduce pain, at least in the short term. While there is a body of literature examining psychosocial approaches, the volume addressing any one specific approach or research question is not large enough to draw confident conclusions.

More studies into their effectiveness are required, with adequate sample sizes and careful attention to study populations in order to identify which strategies work best for which groups of people, based on their own priorities as well as factors such as pain experience, diagnosis, age, gender, income and vocation. Cost-effectiveness has yet to be adequately assessed. The acceptability, availability, and applicability of programs for different patient populations should also be further explored in order to inform decisions regarding the allocation of health care resources.

Truly interdisciplinary collaborations may advance the understanding between physiological and psychological processes [ 48 ], and advance the rather sparse evidence for efficacy of biopsychosocial approaches [ 49 ]. Engaging the patient as a research collaborator may also foster innovation. Clinical guidelines for managing arthritis pain recognize the importance of thoughts, feelings and emotions, and recommend CBT to reduce pain, psychological distress, and improve coping [ 50 ]. Additional clinical research will clarify the most effective therapeutic approaches.

This review is part of a series on Arthritis and pain edited by Jason McDougall. Other articles in this series can be found at http: The author acknowledges Linda Del Fabro Smith for assistance with searching and retrieving literature. The author's participation in a workshop on pain and arthritis hosted by the Canadian Arthritis Network January 27—29, , influenced the development of this paper.

Over 10 weeks, participants learn, practice and receive feedback on their newly acquired skills, which serves to improve self-efficacy for self-management behaviors. Feedback on goal achievement further strengthens participants' self-efficacy. PACE-Ex is comprised of twenty 2-hour group sessions held twice weekly.

The program is delivered and supported by two trained health professionals. In Baycrest's model, a physiotherapist serves as the primary facilitator and program coordinator and an occupational therapist serves as the second facilitator. The role of program coordinator includes intake and overall administrative processes. The first hour of each session is an interactive participatory discussion session facilitated by the program facilitators on the topics as listed in Table I.

Psychological Interventions and Lifestyle Modifications for Arthritis Pain Management

The principles and strategies of self-management are incorporated into each of the discussion sessions. Participants engage in discussing issues, brainstorming ideas, sharing experiences and finding solutions to meet personal goals. A PACE-Ex program graduate also volunteers in the program acting as a role model to enhance the experiential learning. Each participant receives a comprehensive PACE-Ex resource manual, with information on each discussion topic and related community resources. A key program component is goal setting and focuses on lifestyle changes, physical activity and condition management rather than on impairments.

Over the course of the program, individuals have the opportunity to set both short-term goals STGs and long-term goals LTGs. At the start of each session, participants set personal STGs in a group format. During subsequent sessions, STG achievements are reviewed. Group feedback discussions on barriers and facilitating factors to goal achievement and problem solving are integral to the goal review process.

In addition, each participant sets a LTG to be achieved by program completion. To support this, each participant has one minute individual appointment with one of the program facilitators, outside of the group sessions, within the first 3 weeks of the program. During the individual goal setting appointment, participants are guided in the development of a personal goal attainment plan for their LTG. Over the course of the program, the aerobic workout is progressed from 5 to 15 min. The overall emphasis of the water exercise sessions is to prepare participants for community exercise programs after completing PACE-Ex.

An early pilot review of PACE-Ex completed in revealed that after program completion, participants showed statistically significant improvements in health status, pain scale, self-efficacy for pain reduction and self-efficacy for performing activities of daily living but not in disability, joint count or knowledge [ 1 ]. The purpose of this review is to examine the impact of this long-running arthritis SMP, which incorporates warm water exercise and goal setting practice on the participants' self-efficacy to manage their arthritis, self-management behaviors, goal achievement levels and self-reported disability, pain and health status.

Ethical approval for the retrospective review was received by the Baycrest Research Ethics Board file number A telephone screen is conducted by the program coordinator on all interested clients to determine eligibility to participate in PACE-Ex. Eligibility is based on the following inclusion criteria: A medical clearance form is completed by a physician indicating arthritic diagnosis and appropriate medical status for warm water exercise.

Demographic information relating to participant's age, gender, type of arthritis and living arrangements is collected preprogram. Attendance at each session is also recorded throughout the program. At the first and last sessions, a battery of self-administered outcome measures, as described below, is administered.

As this is a retrospective review over a 9-year period, based on ongoing reviews of the literature, the battery of outcome measures has changed over the years. Although this tool only has content relevance, it was adopted in as it measures self-efficacy for the key behaviors addressed in PACE-Ex. Items on the PRISM include dimensions of self-efficacy to manage pain, stress, diet, medications, utilizing relaxation, coping techniques, fitness and contacting the correct health care professional. Quality of life is measured on a scale from 0 to The score is then converted to a percentage, with higher scores indicating better quality of life.

The Health Assessment Questionnaire HAQ , with well-established reliability and validity, was developed as a comprehensive measure of outcome in patients with a wide variety of rheumatic diseases [ 32 ]. The HAQ was used to measure self-reported health status, pain, swollen and painful joint counts and disability.

The HAQ includes two indexes that measure self-reported disability, the standard disability index and the alternate disability index. The alternate disability index does not penalize participants from using assistive devices and since PACE-Ex participants were encouraged to use assistive devices, the alternative disability index was chosen as the measure of disability in this review. The alternate disability index consists of eight categories of disability. Self-reported health status and pain in the last week are measured as single items using a visual analogue scale.

The HAQ was administered throughout the 9-year period 24 programs. This measure contains eight subscales as shown in Table V , with each subscale having a range of one to six items. The SMB questionnaire was administered over a 6-year period 16 programs. Goal Attainment Scaling GAS is a well-established reliable and validated tool and was used as a standardized tool to measure participants' LTG attainment levels [ 34 ]. GAS includes five goal attainment levels: GAS was administered throughout the 9-year period.

Demographic information is summarized using descriptive statistics. Distribution of the data was visually inspected by histograms and Q—Q plots to examine normality. Goal attainment is summarized descriptively. The percentage of participants who attained or exceeded their goals is calculated. Attendance is defined as the percentage of sessions participants attended compared with total sessions offered.

Psychological Interventions

A participant was considered a non-completer if they withdrew from the program after attending the first session. The drop out rate was calculated as the percentage of non-completers compared with the total number of participants starting the program. Baseline characteristics of completers and non-completers are compared with either chi-square tests for categorical data or independent sample t -tests for continuous data.

Over the 9-year review period, a total of participants started the program with completing the 24 programs. The drop out rate was The majority of participants was female Reported diagnoses include OA Some individuals reported more than one arthritic condition. About half of the sample were married and retired. At baseline, completers and non-completers were similar in age, marital status, vocational category, education, diagnosis of fibromyalgia and living alone. Baseline pain ratings and self-rated health status for completers pain: The average attendance rate was calculated by dividing the total number of sessions participants attended by the total number of sessions offered and then multiplied by The SMB questionnaire was administered over a 6-year period for which there were complete pairs.

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Findings include improvements in self-efficacy to: Data were analyzed by paired t -tests ADLs, Plan daily activities. Data were analyzed by paired t -tests. Time spent exercising in the past week does not include the time spent performing the warm water exercise in PACE-Ex.

Although there was a mixture of arthritic diagnoses, OA was most prevalent. In addition, for a twice-weekly program, which spanned 10 weeks, a drop out rate of There were statistically significant differences between completers and non-completers in gender, type of arthritis and years living with the condition suggesting that these factors may influence participant retention in the program.

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However, further investigation is required to confirm these conclusions. As shown in Tables III—V , there were statistically significant improvements in almost all outcomes measures. After completing PACE-Ex, participants showed statistically significant improvements in their ratings of self-efficacy to manage their arthritis, quality of life and overall health status. It is noteworthy that this older adult population with long-standing arthritis reported improvements in these constructs. In addition, participants adopted a variety of SMBs such as spending more time exercising group and individual , increased utilization of community education and support groups and adoption of cognitive symptom management.

The performance of warm water exercise at each session may contribute to the uptake of exercise behaviors at program completion. These results are in keeping with previously reported findings of improvements in self-efficacy, self-rated health status, cognitive symptom management and exercise frequency [ 4—10 , 13 , 15 , 16 ]. Interestingly, even though at program completion participants reported an increased number of joints as tender and swollen, they still perceived their pain and disability as less.

Participants also reported a statistically significant increase in their time spent exercising in addition to the exercise component of PACE-Ex. It is possible that while increased physical activity levels contributed to increased joint symptoms, participants were better able to manage these joint symptoms. Although participants reported a greater level of impairment, they perceived the impact of their arthritis as less in the areas of pain and disability. Previous reports have shown small reductions in pain [ 6 , 13 , 14 , 16 , 20 , 21 ] and disability [ 6 , 13 , 14 , 20 , 21 ] after completing SMP.

Yet these studies do not report on joint symptoms and differ from PACE-Ex as they include SMPs with no exercise component [ 6 , 13 , 14 ] or self-management combined with land exercise [ 16 , 20 , 21 ]. Sixty-eight percent of participants achieved or exceeded their LTGs. By practicing goal setting and goal review at each program session, participants gained knowledge and skills on setting realistic goals.

Goal setting results for generic or arthritis-specific SMPs have not been reported by other studies [ 5—11 , 19—21 ]. There are some limitations to this program review. The main outcomes are measured via self-administered questionnaires that were collected by the program facilitators. With this evaluation design, it is difficult to control for other factors that may have contributed to the success.

For example, participants could have benefited from any intervention or contact with health professionals. Validated self-administered questionnaires were chosen, as evaluation objectives were focused on measuring changes in self-perceptions. This is an accepted method for measuring these constructs, yet they do not provide an objective measure. Since these questionnaires were collected by the health care professionals delivering the program, it is possible that participants were trying to please the health care professionals and over rated post-program benefits.

However, it is unlikely that participants remembered their preprogram responses 10 weeks later. It is possible that those who completed the program were healthier, more motivated and had a larger social support network and thus were more likely to succeed. Type of arthritis, years living with condition and gender may have influenced the outcomes; however, further investigation is required to determine if and how any of these factors influenced the positive outcomes. This retrospective review does not examine the long-term impact of PACE-Ex and whether participants' skills, health behaviors and self-efficacy were sustained months or years after their participation in the program.

In addition, the HAQ disability index only provides an indirect measure of physical performance, as a physical performance measure was not included between and Since PACE-Ex involves twice-weekly warm water exercise over a week period, a physical performance measure would provide further information on the impact of the exercise component of the program. In particular, the literature suggests that land-based exercise alone improves physical health but not psychological outcome while self-management interventions without exercise improve psychological outcomes but not physical health [ 17 ].

The benefits of water exercise for OA of the hip and knee [ 22 ] have been reported and there may be some psychological benefit to water exercise over land exercise [ 23 ]. An objective measure of the impact of combining water exercise with arthritis self-management on physical performance and physical health would be of benefit.

This program review provides goal setting results that have not been reported by other studies. Goal setting is integral to the PACE-Ex program and provides participants with the skills to identify behaviors they wish to adopt and set realistic targets for achieving their goals. Feedback on goal achievement during the program helps to further develop this skill and builds participants' self-efficacy for SMBs and condition management.

The use of GAS in setting LTGs serves to reinforce that goal setting is a process and allows participants to measure progress toward achieving a goal rather than just whether a goal is met or unmet. By adopting and reporting on a formalized STG and LTG processes, this review provides evidence that participants were able to meet or exceed their goals. PACE-Ex is designed for open access by the public and not constrained by a medical model.

Experience shows that the optimum ratio of program facilitator to participants is 1: This ratio optimizes the facilitator's ability to facilitate group discussions, manage group dynamics, accommodate for LTG setting and lead group exercise. The program facilitator could be any health professional who received training on the delivery of PACE-Ex such as social workers, nurses, physiotherapists and occupational therapists.


A physiotherapist or kinesiologist is best suited to deliver the exercise component. At Baycrest, a program to train health professionals on the conceptual and theoretical foundation, skills and delivery of PACE-Ex have been developed to support replication in other jurisdictions. The cost of program delivery is dependent on local salary scale. An SMP consisting of 20 sessions will require a minimum of 80 paid hours of work from two health professionals.

This cost does not include printed materials, intake and administrative processes.