Aspects of exercise with person-centred guidance influencing the transition to independent exercise: a qualitative interview study among older adults with rheumatoid arthritis

Exercise is commonly known to enhance health in all ages and the World Health Organization recommends regular physical activity and exercise to maintain health and prevent disease [1]. Besides disease prevention, exercise also is recommended, with good evidence, as treatment for several chronic conditions [2, 3].

Rheumatoid arthritis (RA) is an inflammatory joint disease that can cause cartilage damage and disability [4]. Today more than 50% of people with RA are above 65 years old [5]. Exercise is suggested as an important part of the management of RA [6, 7], and for older adults the need for disability-preventing physical activity increases with age regardless of diagnosis [8, 9]. However, older adults with RA are less physically active than healthy older adults and do not reach the level of physical activity recommended by international guidelines for health-enhancing physical activity [10, 11]. Several diagnosis-specific barriers for adopting and participating in regular exercise have been reported, such as pain, fatigue, and reduced functional abilities, in addition to general barriers, such as lack of time or motivation [12]. Besides adopting exercise habits, sustaining exercise habits over a long time is known to be challenging and motivation plays an important role in that [13]. Persons with RA partaking in structured exercise interventions have expressed worry about moving on to independent exercise [14], and sustaining independent exercise over time is known to be troublesome for this group of patients [15].

To manage barriers for exercise in older adults with RA, a person-centred approach in the introduction of exercise has been proposed [7]. The person-centred approach emanates from the personal narrative of the person about who she is [16], and the individual is seen as capable and unique [17]. In a person-centred approach, an exercise routine is planned together with the individual, whose resources and wishes are taken in to consideration [16].

There is, to our knowledge, a lack of qualitative studies examining experiences of exercise among older adults with RA. To maintain health benefits from exercise over time it is valuable to increase knowledge about what affects and facilitates the transition to independent exercise. Therefore, the aim of this qualitative study was to explore aspects of participation in moderate- to- high-intensity exercise with person-centered guidance influencing the transition to independent exercise for older adults with RA.

A qualitative interview study was performed. Participants were recruited from the intervention arm of a randomized controlled trial evaluating moderate- to- high-intensity exercise intervention with person-centred guidance in 2015–2016 [7]. Recruitment and data collection were performed between January and November 2016. The exercise intervention consisted of 20 weeks of aerobic and resistance exercise at moderate- to- high-intensity. The intervention was led by a physiotherapist according to a person-centred approach, in which the narrative of each person was important for jointly, in partnership, developing an individual exercise routine tailored to that person’s limitations and goals. Through person-centred guidance, the exercise was continuously progressed and adapted to the needs of each person. Exercise was performed according to an individually tailored program where the participants attended a gym at a time of day of their choosing. Several participants attended the gym at the same time, resembling a group session. During 7 months following the intervention, the participants were encouraged to sustain their exercise routine independently and the physiotherapist offered telephone support one to two times during that time period. The intervention had been conducted in three consecutive groups, at two different sites with different intervention leaders, one of which was the first author. Participants were recruited from all three study groups.

Inclusion criteria were: RA according to the American College of Rheumatology 1987 [18] or European League Against Rheumatism 2010 criteria [19], age ≥ 65 years, disease duration > 2 years, DAS28 (Disease activity score 28 joints) below 5.1 indicating a low-to-moderate disease activity (DAS28 range 2.0–10.0), and participation in the underlying exercise study. Exclusion criteria were: ongoing exercise of moderate-to-high intensity ≥2 times/week prior to the start of the exercise study, and inability to understand or speak Swedish.

Data analysis

Data were analysed using qualitative content analysis [20]. The analysis was performed by the first two authors in collaboration and was validated by the last author, experienced in qualitative research. The interviews were read repeatedly to obtain a sense of the whole. Meaning units were identified based on the objective, condensed, and coded. In the subsequent steps, the meaning units were developed into categories and subcategories (Table 2) with results derived from data. Both manifest and latent content were sought; the manifest content being close to data and the latent content being more abstract descriptions [20, 21]. The analysis moved continuously between the parts and the whole text [20]. Fig. 1 shows an example of the analysis. In the final stage of the analysis process, the authors discussed the categories and subcategories and agreed on the result.

Category	Subcategory
A feasible opportunity to adopt exercise	Person-centred introduction, advancement and adjustments made the exercise feasible
	A new experience of exercise
	A fortunate opportunity to start exercising
	Exercise feasible despite negative elements
Experiencing positive effects of exercise	Positive effects manifested both physically and mentally
	Positive effects manifested in everyday life
	A positive, fun and healthy experience
Contextual factors affect the experience of exercise	Guidance as a security and a driving force
	The possibilities and inadequacies of a loosely connected group
	The facilities influence the experience
Developing knowledge and thinking	Learning about exercise
	New thoughts about exercise and oneself
	The gym as a new arena
Finding one’s way	Fitting exercise into everyday life
	Making the protocol your own
	Transition to independent exercise
	Using tools for motivation
	Access to support
Managing barriers for exercise	Facing barriers for exercise
	Various strategies to overcome barriers
	The importance of determination

Three of the authors are physiotherapists and one is a rheumatologist, three are PhD and all are female. The first author had been engaged as intervention leader in the underlying exercise study which could result in bias but also give valuable insight on the intervention. An attempt to bridle the preunderstanding of the authors was strived for, where the preunderstanding was discussed and made visible and a consciousness about how the preunderstanding could intertwine with the analysis was balanced against a curiosity for the expressed experiences of the interview persons [22]. Quotes are given to support that the results are derived from data. For systematic reporting of the methods section the Consolidated criteria for reporting qualitative research [23] was used.

The analysis resulted in six main categories and 21 subcategories, presented in Table 2. The exercise with person-centred guidance was experienced as a feasible opportunity to start exercising. The transition to independent exercise was further influenced by a positive experience of exercise, contextual factors, developing knowledge and thinking, finding one’s way and managing barriers for exercise.

The results of the study described aspects of participation in moderate- to high-intensity exercise with person-centred guidance that influenced the transition to independent exercise. Older adults with RA described experiences that where both facilitating and hindering.

The person-centred introduction to exercising at low intensity, followed by careful progression, might have contributed to making the exercise manageable by avoiding pain and physical problems related to the joint disease. The introduction also appeared to support performance accomplishment which is important for recognising personal abilities and for developing self-efficacy [24]. Perceived self-efficacy refers to a person’s beliefs about her capability to perform in certain events and is important for thinking, behavior and motivating oneself. A stronger sense of efficacy facilitates performance accomplishment and well-being and at the same time could be developed through personal experience of mastery, of seeing others succeed and through persuasion [25]. To expect a certain outcome is important for motivation [25] and experiencing positive effects of the exercise, both physically and mentally, appears to have contributed to the participants’ overall positive experience of exercise also increasing their self-efficacy for management of independent exercise in new settings. Experienced positive effects, also acknowledged by others, could be viewed as confirmation of the effectiveness of the intervention. Increased knowledge, through experience, of the effects of exercise has been suggested to add to motivation for exercise [14].

In addition to increased knowledge, the participants described how their thoughts about exercise and about themselves, as someone exercising with a diagnosis, had developed. This new way of thinking about oneself and a revised belief of what is possible can be interpreted as increased self-efficacy [26]. When the participants expressed that they had entered the gym as a new arena, it might be a response to a new confidence in their ability to exercise and a feeling of security in an environment to which they might have previously been unaccustomed. Developing self-efficacy during an exercise intervention seems to be important for sustaining independent exercise [27] and it could have an even more important role as mediator for exercise in older adults where age-related physical decline is present [28].

The results of the study suggest that finding your own personal way of exercising is important both for adopting exercise and sustaining independent exercise habits. Besides practicalities in developing the protocol and fitting exercise into everyday life, the participants also described a mental process of making the protocol their own. The participants often developed an individual idea about what amount of time that was reasonable to set aside for exercise. Some developed strict routines for their independent exercise to be able to coordinate exercise with other activities, whereas others valued flexibility in when to perform their independent exercise for the same reason. Flexibility and independence have been mentioned as one of the benefits of home exercise [29], but our study suggests this to be achievable also in exercising at a facility under the right conditions. Although flexibility provides a certain freedom, the establishment of routines has been described as important for maintenance of exercise [30]. Keeping to the routines was described in this study as one strategy to overcome different barriers.

One considerable barrier for exercise was perceived to be reduced physical health. Because this is a known barrier both for persons with RA [29] and for older persons [31], the results of this study could be interpreted as physical health being an even more important barrier to address for older persons with this type of chronic disease. In order to recover from this barrier and to manage independent exercise there could be an increased need for temporary support.

Different participants had their experience of exercise affected by contextual factors in various ways. It is interesting to note that there was a rich diversity in experiences of the same factors among the participants. In view of this diversity, the person-centred approach might be helpful to understand and adjust these different contextual factors to fit the individual’s needs and wishes, in order to facilitate the transition to independent exercise.

The moderate- to high-intensity exercise was performed in a loosely connected group, and the participants described both possibilities and inadequacies related to that structure. The participants described the benefits of a diagnosis-specific group, where the diagnosis itself shifts from being a factor that differentiates the individual from others to a factor common with others. Ricoeur [17] describe likeness and unlikeness at the same time as specifically human, as one needs to be open for differences in other people and confirm these differences in order to confirm oneself. The diagnosis-specific group enabled the participants to be confirmed as individuals and humans based on their unique qualities other than the diagnosis, because the diagnosis was part of the sameness in this context. Sharing experiences in a diagnosis-specific group emphasises understanding of each other’s symptoms [32], and has been described as being part of a community [33].

In addition to the benefits of sharing a diagnosis, the participants in this study also highlighted the benefits of being of the same age. The social interaction of persons of the same age is particularly important in providing a sense of security [34] and groups too heterogeneous regarding age have been described as problematic [14]. Socialisation itself may also encourage physical activity [35]. Comparisons during exercise may motivate a higher exercise effort and could also stimulate peer learning [29], while watching someone with the same attributes as oneself succeed with a task, may increase self-efficacy [24, 25].

The participants of this study described different needs and expectations of being part of a group. As a professional it is important to know that some individuals decline any form of group participation while others prefer a facilitated group introduction. Many participants acknowledged that being part of a group might not be for everyone; a finding that has previously been reported [35]. The design of the exercise intervention in the current study, which allowed participants to perform individual exercise collaterally, provided a good opportunity to either seek or reject contact with other group members.

The participants described the physiotherapist as providing security and at the same time being a pushing driving force. The person-centred approach might be a key factor in managing the balance between being a security offering help, and pushing to greater achievements and supporting independence. The person-centred approach entails an establishment of a partnership between the patient and the professional [16] which is desired since patients have been reported to want to be seen as experienced experts in the partnership for managing a rheumatic disease [36]. In addition to the value of a personal partnership, the competence of the person recommending exercise seems to be important [35], which aligns with this study’s expressions of competence as an assurance for quality and safety in exercise. The support from a physiotherapist as a knowledgeable professional has previously been described as facilitating the step to independent exercise [29].

The participants in this study described several aspects of participating in exercise that influenced and facilitated their transition to independent exercise. The demanding exercise was experienced as manageable and positive despite their age and diagnosis, by careful introduction and development of an individual exercise routine in partnership with a physiotherapist. This seems to have favored the development of self-efficacy, which had importance for future independent exercise. Reduced physical health, both temporary and permanent, was described as a considerable barrier for exercise. The personal process of trying to make the exercise one’s own, and developing knowledge about exercise and new thoughts about oneself, seemed to prepare the participants for managing independent exercise and overcoming barriers.