Walking back to good health

Article taken from Arthritis Today | Summer 2015 | Issue 168

You’ve got painful osteoarthritis. You’re getting older and maybe heavier. You’re aware that you should be more physically active but you also have a number of concerns – won’t exercise make the pain worse and wear out your joints? Isn’t it too late to make a difference? 

Unfortunately, lots of older people living with pain have these concerns.

The Health Survey for England shows that walking drops dramatically in people over the age of 65, and in the 85-plus age group hardly anyone exercises according to recommended guidelines. 

At the same time, musculoskeletal pain is very common in older people, is often caused by osteoarthritis and accounts for 20% of all GP consultations. 

These two facts are directly related. It’s been known for some time that regular physical activity improves both pain and quality of life in people with arthritis and musculoskeletal pain. However, encouraging older people to be less sedentary and become more active has proved to be problematic.

There are big challenges in shifting older people’s mindsets about exercise. For many people of a certain generation who were told to rest or take to their beds when they had a bout of back pain, exercising to reduce pain can be an alien concept. There’s the common misconception that exercise will further damage their joints and make their pain worse. Older people can be worried about going out in the winter or falling and are often not used to exercising at their age.

Walking is the key 

However, help is at hand. Dr John McBeth and his team at the Arthritis Research UK Primary Care Centre at Keele University are keen to help older people with chronic musculoskeletal pain to become more active. They want to make it easier for this age group reduce their pain and also improve their overall health. And the key is…walking.

Their plan is simplicity itself – to increase the time that older people with chronic pain spend on their feet. Described as the ’near-perfect exercise’ by researchers in the field, walking is the most common form of exercise enjoyed by older people and also has the advantage of being familiar, convenient and free.

With £250,000 of funding from Arthritis Research UK, the research team is planning to conduct a pilot clinical trial, called the iPOPP study, to find out what older people (aged 65 years and over) with chronic musculoskeletal pain think of the iPOPP ‘walking intervention’. They also hope to establish whether the use of pedometers and pep talks with a healthcare assistant – will offer sufficient motivation to encourage them to increase their current level of walking and maintain it over time. 

The pilot clinical trial aims to recruit 150 people and split them into three randomised groups. One group will receive ‘usual care,’ the second a pedometer to motivate them to walk and the third group will receive the iPOPP walking intervention. All three groups will be given a pain toolkit – written information about pain and how to manage it, pacing and the value of exercise as treatment.

People receiving the iPOPP walking intervention will have two initial face-to-face appointments with a healthcare assistant at GP surgeries in Stoke-on-Trent, North Staffordshire and Cheshire, and will then receive a number of motivational prompts via text, postcard or email, based on the participants’ preferred choice of contact.

“The first session will be broken down into two stages, a motivational stage and an action-planning stage,” explains Dr Emma Healey, an exercise scientist and principal investigator for the pilot trial.

“We’ll find out what they want to achieve in terms of their daily activities and use walking as a way of getting them there. They may want to be able to play with their grandchildren, for example. So we’ll use walking as a means to getting them more physically active and build up their fitness to allow them to do that. It’s a first step to get them where they want to be.”

Overcoming barriers 

The healthcare assistants will be trained to deal with any barriers or concerns that people with chronic pain may have regarding increasing their levels of walking. 

So if someone says their pain is preventing them from walking, the healthcare assistant will be able to tell them that walking can actually help their pain. If they say they’re having a flare-up, they will be encouraged to pace themselves and build up slowly. If they worry that walking will make their pain worse, the healthcare assistant will hopefully ease these concerns by letting them know that walking can prevent muscle wasting by strengthening the muscles, which in turn can reduce pain.

Dr Healey adds: “If people are afraid of walking or find it makes their pain flare, it’s about addressing those concerns and problems. People could take some pain medication or use heat before they walk, or maybe have a bath or apply a cold pad after a walk. 

“People may not be aware that it’s normal for the pain to get a little bit worse at first and that they’re not necessarily making their problem worse. If this happens, it may knock a person’s confidence to walk, so this is the sort of thing the healthcare assistant will discuss."“It’s normal for the pain to get a little bit worse at first and that they’re not necessarily making their problem worse."Exercise scientist Dr Emma Healy 

Together, the patient and the healthcare assistant will then set some specific, realistic and achievable walking goals – what Dr Healey calls ‘shifting the intention into action’.

“It could just be walking around the house or garden. Anything over and above what they’re currently doing is a bonus, and everything counts,” she adds. “Even if they’re just doing a minimal amount of walking, achieving that may build their confidence in their ability to walk.”

Once the participants have clipped on their pedometers and started their eight weeks of walking, they’ll receive eight weekly follow-up prompts from the healthcare assistants. Patients can choose whether these are provided on the phone, or via text, email or postcard. The research team are keen to find out whether this age group are happy to use new technology, given the growth of telemedicine.

The follow-ups will be brief, light-touch chats asking how they’re getting on, whether they need any help, what’s stopping them from walking, and so on. An important part of the study is to find out whether this simple approach to getting people walking is acceptable to those taking part, and will it get buy-in? If it does, the expectation is that it will lead to a full randomised controlled trial, which will more thoroughly assess the impact of walking on participants’ musculoskeletal health.

Recruiting older adults 

 Unusually for a clinical trial, people over the age of 85 will be targeted to take part. “Recruiting older individuals into trials can be difficult,” concedes Dr McBeth. “However, we feel that these individuals have the most to gain from being physically active, so we’ll work hard in our recruitment phase to ensure that this age group is represented within the study.”

He adds: “Older people in pain face many barriers to taking part in physical activity. But fortunately a lot of these can be overcome and everyone can benefit from being physically active. We’re hoping this simple approach to walking will work. What’s really brilliant is that the patients are excited and enthused by it.”

Ruth Haines, a patient adviser to the primary care centre at Keele and the iPOPP study, has severe osteoarthritis, mainly in her feet. She knows all too well how hard it can be to walk to when experiencing a lot of pain.

Ruth’s feet are basically held together by screws, and her arthritis now affects her ankles, knees, hips and back. She says: “I’m a motivated person, and I’d probably have been in a wheelchair if I’d just given up. But even so I don’t go for walks because of the pain.”

A former auxiliary nurse, Ruth, 65, believes that many older people in pain from their arthritis simply don’t believe that walking and movement will help them. “But if this study can prove it and get that message across, maybe they’ll take more notice,” she says.

“There are a lot of lonely older people out there who have lost their motivation; they’re in pain and they don’t go out. If we can reach these people and help them get over their pain and their loneliness, that would be fantastic.”

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Do you have osteoarthritis?

A team of researchers at the University of the West of England in Bristol are trying to find out what motivates people with osteoarthritis to exercise and continue with physical activity in the long term.

The team, including Dr Nicki Walsh, Arthritis Research UK career development fellow, hope to identify common motivating factors, and use these to create a website that helps people to remain active by providing personalised motivational support.

If you'd like to take part in the study, complete a 20-minute survey.

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