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The Efficacy of the ROM Dance Program for Adults With Rheumatoid Arthritis Julia Van Deusen, Diane Harlowe Key Words: exercise therapy. health education. relaxation techniques This study examined the efficacy of an exercise and relaxation program fOl adults with rheumatoid arthritis. The program integrates principles of occupational therapy and rai-Chi Ch 'uan and was expected to be more effective than traditional exercise and rest regimens because of its expressive and pleasurable elements. There were Significant differences between 17 experimental and 16 control subjects on two categories of dependent variables after the former group's participation in the experimental program. These dependent variables were range of motion measures and subject self-reports offrequency, enjoyment, and benefits of home exercise and rest routines. Pretest, posttest, and 4-month follow-up data were analyzed. Program participants showed signz/icantly greater upper extremity range of motion 4 months after completing the program although the reported frequency of exercise and rest was greater in the control group. Postprogram reports of enjoyment were Significantly higher for experimental than for control subjects. If these initial results are confirmed in further studies, the efficacy of the use ofpurposeful activity for exercise and rest will be supported. This study also supports the integration of Eastern and Western frames of reference in the treatment of patients with chronic illness. c Julia Van Deusen. PhD, OTR, is Associate Professor, De· partmenr of Occupational Therapy, College of Health Related Professions, Box J -164, J. HiJlis MiJler Health Center, University of Florida, Gainesville, Florida 32610 Diane Harlowe, JVIS, OTR, is Director, Occupational Therapyand Speech Services, Sr. Marys Hospital Medical Center, Madison, Wisconsin. T herapists and physicians typically recommend a balance between rest and exercise to patients with rheumatoid arthritis (Harlowe & Yu, 1982; Melvin, 1982), but the research on the efficacy of exercise and rest programs is sparse. Nordemar (Nordemar, 1981, ordemar, Ekblom, Zachrisson, & Lundquist, 1981) found better disease outcomes for rheumatoid arthritiS patients in long-term physical training programs than for control subjects Achterberg, MacGraw and Lawlis (1981) obtained positive results on the effectiveness of relaxation and biofeedback training for patients with rheumatoid arthritis. Nonpharmacological relaxation procedures have been shown to promote relaxation, increase pain tolerance, and reduce stress. Harlowe and Yu (1984) cited a variety of these studies. A review of the literature showed no studies on adherence to home rest programs, but three studies described compliance of arthritis patients with home exercise regimens (Carpenter & Davis, 1976; Parker & Bender, 1957; Treusch & Krusen, 1943). Treusch and Krusen (1943) found 67% of 216 patients complied with home exercise programs for 3 months with a drop to only 25% after 1 year. Parker and Bender (1957) found that 50% of their 56 patient sample complied for 1 year, and Carpenter and Davis (1976) reported only 555% of their sample of 54 were compliant at 4-month follow-up. These compliance rates are low relative to the 65% compliance rate found by investigators for other types of self-administered medical treatment (Davis, 1966; Davis, 1967; Feinberg & Brandt, 1981; Maddock. 1967: Oakes, Ward, Gray, Kauber, & Moody, 1970). A number of explanations have been offered for the lower compliance rate for exercise programs: the dearth of efficacy information, pain, interference with daily routine, and boredom (Harlowe & Yu, 1984; Blach.rwell, 1973). The question of how to facilitate increased involvement in daily exercise and rest regimens for individuals with rheumatoid arthritis is worthy of investigation. Mayo reported in 1978 that patient education has been studied as a means to increase compliance with medical recommendations. Although education was found to increase patients' knowledge about their diseases and treatment, it did not have an effect on compliance _ The later literature does not negate the continuing need for increasing compliance (Dimonte & Hollis, 1982; Feinberg & Brandt, 1984; Lenker, Lorig, & Gallagher, 1984; Lorig, Laurin, & Gines, 1984; Parker et a!, 1984; Robinson, Haldeman, Imrie, & Neubauer, 1980). Program Description Harlowe and Yu (1984) hypothesized that adults with rheumatoid arthritis would better adhere to a home exercise-rest program if it were enjoyable and per- February 1987, Volume 41, Number 2 90 Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms ceived to have intrinsic value. Therefore, they developed a health education program which employed the basic occupational therapy principle of addressing goals through the use of purposeful, meaningful activities which facilitate creativity and self-expression in a supportive environment. Their program was named the ROM Dance Program (ROM is pronounced ram and stands for range of motion). Program goals include the following: 1. To assist participants in following any medical recommendations provided by their personal physicians and therapists for involvement in daily exercise and rest routines 2. To increase the frequency, enjoyment, and perceived benefit of involvement in daily exercise and rest 3. To enhance the ability to cope with stress and pain through the use of relaxation techniques 4. To prOVide a forum for group interaction concerning personal health care management 5. To prOVide selected health education experiences 6. To improve body awareness 7. To promote an experience of well-being The program's use of an expressive dance form for maintaining range of motion reflects occu pational therapy principles more fully than does routine exercise It emphasizes the creative use of relaxation and pain management techniques during prescribed rest periods to increase the benefits and perceived value of rest as a claily activity The group instruction format was chosen for the program to proVide a forum for peer interaction and support. Brief occupational therapy patient education materials (Harlowe & Yu, 1984; Harlowe & Black, 1984) were included as a focus for discussion Topics covered included coping with arthritis, the relaxation response, energy conservation, work simplification, and the use of adaptive equipment and splints. The program was designed to be proVided in a series of eight, 90-minme, weekly health education classes with 15 to 25 participants. Each class included a repetition of the ROM Dance sequence, a gUided relaxation experience, and a group discussion] The ROM Dance sequence is a flOWing progression of dance-like movements, which incorporates joint motion in ranges usually recommended for persons with rheumatoid arthritis (Harlowe & Yu, 1984). The 7-minute sequence is accompanied by a poem and music, both of which are provided to participants in an audiotape cassette (ROM Dance, 1984) for home J Instructional materials for the ROM Dance Program (book, audio olape, and videotape) can be purchased from St Marys Services, 1011 Erin Street, Madison, WI 53715 (Telephone: 608-258-5700). use. Illustrated instructions are also provided (Harlowe & Yu, 1984) In a holistic approach to maintaining function, the occupational therapy principles and techniques described here were integrated with those from an ancient Chinese exercise form, Tai-Chi eh'uan, which stresses slow, relaxed movement together with an awareness of postural alignment and breathing. The ROM Dance routine differs from rai-Chi in that it presents pleasant images of warm water, sunshine, and friendship rather than being oriented to the martial arts A sample from the poetry to which the expressive movements are performed follows (Barlowe & Yu, 1984, p. 23) I gather the sun's warmth down over me Bathing me in a shining light My 11ands feel warm And a sunbeam shines between them Then shines back to the sun. The relaxation component of the ROM Dance Program includes a wide variety of methods (Harlowe & Yu, 1984), which are introduced in a graded sequence Emphasis is placed on individual experimentation with the presented techniques. Simple biofeed back devices are introduced, and relaxation audiotape cassettes are provided for home use (ROM Dance, 1984) Results of a pilot study by Harlowe and Yu (984) of 17 adults with rheumatoid arthritis showed an increase in the reported frequency of exercise, r'st, and perceived benefit after participation in the ROM Dance Program. Subjects also reported that the pro· gram was beneficial in increasing their ability to cop with arthritis. The purpose of the pI/'sent study was to ascertain if there were significant differences on the dependent variables between experimental subjects in the RO.! Dance Program and control subjects on traditional exercise and rest regimens (a) immediately after tbe 8 week program and (b) 4 months after the comple· tion of the program. The dependent variables were range of motion measures and subject self-reports of the frequency, enjoyment, and benefits of home e. ercise and rest programs as operationally defined by scores on the scales shown in Figure 1 Method Subjects Ambulatory adults with rheumatoid arthritis who had medical recommendations for home rest and exercise and no prior ROM Dance experience were recruJ(' :d. Of 110 potential subjects contacted 46 agreed to participate in the project and were randomly assigned to experimental and control groups with 23 subjects each. All control subjects were informed that they could participate in a future program as experimental The Americanjoumal a/Occupational Therapy Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms 91 Figure 1 Exercise-Rest Self-Report Scales Please complete the following statements by putting a check next Table 1 Demographic Data: 46 Subjects (Experimental and Control) Versus 32 Nonsubjects to the most appropriate response (choose only one). Please read all responses carefully since they are not in any particular order Exercise Scales A People often have difficulty following advice [0 schedule regular exercise periods during the day. On the whole, I do my recommended home exercises S daily - 4 - three [0 five times a week _3_ once or twice a week 1 less than once a week 2 once or twice a momh B~erms of enjoymem, I can say that 1 S almost always enjoy my exercise periods 4 usually enjoy my exercise periods _2_ get almost no enjoymem from my exercise periods _3_ occasionally enjoy my exercise periods _1_ hate haVing [0 take exercise periods C. I feel that my home exercise program is of 4 much benefit - 1 - no benefit -S- tremenl10us benefit ~ little benefit _3_ some benefit Rest Scales A I am able [0 sit qUietly and rest my joints S once or twice daily -4- three [0 five times a week - 2 - once or twice a month - 1 - less than once a month 3 once or twice a week B~el that rest periods are of 2 little benefit - 1 - no benefit -4- much benefit -S- tremendous benefit -3- some benefit C-:rnterms of enjoymem, I can say that I _3_ occasionally enjoy my rest periods 4 usually enjoy my rest periods - 2 - get almost no enjoyment from rest periods 1 hate having to take rest periods _S_ almost always enjoy my rest periods No/e. Numbers are for use in scoring and were not on forms filled out by subjects. subjects. A physician's permission to participate was obtained for all subjects. Demographic data collected on the 46 participams and on a random selection of 32 nonparticipants were comparable with the exception of age (see Table 1). The average age was greater for the nonpartiCipants than for the subjects. Instrumentation Exercise-rest rating scales (see Figure 1) were developed on the basis of the self-report scales in the pilat study questionnaire (Harlowe & Yu, 1984). These scales were used to obtain data on the reported frequency, benefits, and enjoyment of rest and exercise. Scale items were randomly placed to rule out position habits in response patterns. 92 Variable Number of medications Age Number of surgeries Sex Years since onset Whether or not devices are used Chi Square F 927 df S 469 020 036 0.17 180 1 1 1 1 1 P 009 0.03' 066 O.5S 0.68 0.18 , Significant at or beyond the .OS level. Standard goniometry as described by Trombly (1983) was used by four occupational therapists to measure selected joint ranges (see Table 2). Prior to the study, a generalizabi!ity coefficient (Berk, 1979) of 83 had been obtained for the four therapists' goniometry measurements shOWing a relatively high degree of agreement among the therapists' measurements. Procedures Using the instruments discussed above, we collected pretest data from all subjects in the experimental and control groups. Demographic data and medical histories were also obtained through questionnaires. Potentially confounding variables were examined by chi-square analyses and analysis of variance (F test) to determine if there were significant differences between the control and experimental subjects on variables that might influence the results of the study. The 23 experimental subjects were encouraged to practice the ROM Dance sequence on a daily basis at home in addition to any specific exercises recommended by their physician or therapist. They were also encouraged to practice relaxation techniques during daily periods of rest. All 23 control subjects received a brochure which explained the ROM Dance Program and the research project. They were not given any specific instructions concerning exercise and rest at home. Posttest data were collected with the same instruments immediately after the 8-week ROM Dance Program. By this time, because of illness, geographical move, or other reason, the number of experimental subjects had gone down to 22 and the number of control subjects to 17. Demographic data on these subjects are presented in Table 3. Data on range of motion measures and the selfreport scales were again collected 4 months after the cessation of the ROM Dance Program. These followup data were obtained for 17 experimental subjects and 16 control subjects. Scaled data were analyzed by the median test, range of motion data by analysis of variance (F test). On one variable (lower extremity February 1987, Volume 41, Number 2 Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms Table 2 Range of Motion: Differences Between 17 ROM Dance Participants and 16 Control Subjects Mean dl SD P Experimemal Control Experimental Control 0.11 073 0.02- 291 270 75 30 B. Shoulder internal and external rotation 3.22 Pretest Postlest 114 4-month follow-up 533 0.08 029 003- 290 248 81 65 C. Wrist extension Pretest Posttest 4-momh follow-up 0.81 082 046 899 843 232 96 Variable F A. Shoulder flexion Pretest Postlest 4-momh follow-up 2.64 013 565 006 005 056 D. TOlalupper extremity combined: Above ranges plus elbow flexion and wriSt l1exion 0.42 068 1 Pretest POStleSl 4-month follow-up 069 4.22 1 1 0.77 0.048- E. MetarcaL'pal phalangeal flexion-five digits Pretest (n = 34) 2.00 Posttest (11 = 32) 0 15 4-month follow-up 013 072 F. Ankle plamar flexion Pretest Posttest 4-month follow-up 039 003' 025 114 90 35 25 0.020.04051 487 453 36 32 G 017 0.70 076 496 135 Lower extremity flexion: Hip, knee. ankle dorsal flexion Pretest 5.83 1 POStleSl 4.79 1 4 -momh follow·up 0.45 1 • Significant at or beyond the 05 level. fleXion) significant pretest differences were observed and analysis of covariance was used to determine posttest and follow-up differences. To reduce the number of variables for appropriate statistical analYSiS, left and right limb range of motion scores were combined as well as various other scores (see Table 2) volvement in occupational therapy or physical therapy, number of medications currenrly taken, number of years since onset of the arthritiS, and current use of assistive devices. The only demographic variable shOWing significant differences was age, with control subjects being older (X = 60) than experimental subjects (X = 52) Pretest data were also compared for experimental and control subjects by the same methods See Tables 2 and 4 for differences Table 4 shows the results of the analyses for the Results The pmentially confounding variables examined were age, sex, number of arthritis-related surgeries, in- Table 3 Demographic Data on the 39 SUbjects at Posttest Variable No of SubjeGs Years since onset Number of surgeries Number of medications Age Sex Had OT HaJ PT Uses device 38 9 37 39 39 37 38 37 Mean SDof Mean Minimum Maximum 1092 268 2.14 55.91 217 88 .18 2.60 0 0 1 29 38 8 4 80 Frequencies Male = 7 Yes = 12 Yes = 27 Yes = 18 Tbe American Journal of Occupational Tberapy Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms Female No No No = 32 = 25 = 11 = 19 93 Table 4 Differences Between ROM Dance Participants and Control Subjects on Self-Reports for Exercise and Rest (Combined) Variable Frequency a Pretest b Posttest b 4-month follow-up Enjoyment a Pretest b Posttest b 4-month follow-up Benefit a Pretest b Posttest b 4-month follow-up Chi-~quare df p 1.59 0.24 374 021 062 0.05' 1.07 374 0.05 030 005" 083 0.18 0.94 0.40 0.67 033 0.53 Control group of 14 subjects and experimental group of 17 subjects. b Control group of 16 subjects and experimental group of 17 subjects. , Controls significantly greater at the 05 level. " Experimentals significantly greater at the .05 level. a self-report data. There were no significant differences on pretests between control and experimental subjects At the 4-month follow-up evaluation, the control subjects reported significantly higher frequencies of exercise and rest than did the experimental subjects_ The other significant difference in the 4-month evaluation was that the experimental subjects reported greater enjoyment than did control subjects immediately after the 8-week ROM Dance Program. More significant differences between experimental and control measures appeared in the goniometf)' data. (See Table 2.) There were no significant differences between control and experimental subjects on the finger measures. Three of the four analyses of upper extremity showed significant differences at the 4-month follow-up evaluation whereas lower extremity differences were significant only at the posttest. In all of these analyses where significant differences were observed, the ROM Dance Program participants showed better scores in range of motion than did the control subjects Discussion In analYZing results, it is important to consider the combined effect of all program elements that differ markedly from traditional approaches_ Since the ROM Dance incorporates a variety of occupational therapy and T'ai-Chi principles, it may be more satisfying than routine exercise. This notion is supported by the significantly greater enjoyment of exercise and rest reported by the experimental group immediately after the completion of the ROM Dance Program. That the reported differences in enjoyment were no longer evident at the 4-month follow-up may indicate that group involvement was the effective component. A number of explanations can be provided for 94 the significantly better upper extremity mobility status of the experimental groups 4 months after the completion of the program. The ROM Dance sequence involves "total body" range of motion, whereas subjects' prescribed exercises may have been limited to specific joints or to the lower extremities_ The emphasis placed on slow, relaxed movement in the ROM Dance may enhance the benefits of exercises for range of mOtion. The weekly instruction and reinforcement for learning proVided by the program may have affected the participants' ability to perform the motions accurately and to full range. It is interesting to note that the only reported upper extremity ranges that did not show significant differences at the 4-month follow-up test were wrist extension and metacarpal phalangeal flexion. One possible explanation for this finding is that these ranges are more likely to be affected by joint fusion than others reported in the study. Therefore, they may have been less likely to show changes in range. Another explanation for the lack of significant differences in these ranges is that both control and experimental subjects would tend to maintain wrist and finger range through their ordinary daily activities. The finding that the significant differences between groups for lower extremity ranges occurred only at the posttest is difficult to interpret. One possible explanation is that the ROM Dance sequence places more emphasis on upper extremity motion. During classes, however, the lower extremity motions are repeated frequently for instructional purposes, which could have had an initial influence That there were no lasting differences could be due to the fact that ambulatory adults perceive the maintenance of upper extremity ranges to be more essential to function and, consequently, intensify effofts in this area during home exercise. Another interesting finding is that control subjects reported a higher frequency of exercise and rest than did the ROM Dance participants at the 4-month follow-up. One possible explanation is that the program repeatedly emphasizes tbe daily practice of range of motion exercise. Control subjects may have thought that any exercise, such as walking, would qualify for frequency, whereas the experimental subjects, having been specifically oriented to the program, would have been more cognizant of the intent of the questions on the self-report scale. On the other hand, a basic initial assumption was that an increased frequency of exercise and rest would promote the desired results. If tbe self-report data are accurate, this could be a faulty assumption and hence it would not necessarily be true that more exercise and rest means better exercise and rest. If these initial results are confirmed in future studies, the efficacy of the ROM Dance Program and February 1987, Volume 41, Number 2 Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms the value of integrating Eastern and Western frames of reference 10 the treatment of some chronic disease patients will be supported. Limitations There were a number of limitations in this study. For ethical reasons, subjects had [0 sign either control or experimental consent forms, and the potentially motivating effects of study participation could not be avoided. Because of scheduling problems and the fact that experimental subjects talked about their involvement, the evaluators were occasionally aware of which subjects were in the experimental group and which were in the control group. This limitation could have affected the results of the study. Another limitation is the large drop-out rate of 28% at the 4-month follow-up. An added problem was that because of the low number of subjeCtS it was necessary to decrease the number of dependent variables for statistical reasons Therefore, groups of goniometry measures were made. A lack of data on the exact home exercise procedures used by the control subjeCts was a further limitation. A final limitation was the fact that measurement tools lacked rigorous validity and had not been tested with the population under consideration. The current study, however, can help alleviate this limitation by contributing reliability and construct validity data Acknowledgments We extend our appreciation to Kenneth Ottenbacher, PhD, OTR, for statistical consultatiOn, the occupational therapy students at the University of Wisconsin-Madison for reo search assistance, and the Sr. Marys Hospital Medical Center and professional participants Patricia Yu, Andrea Alder, Becky Black, Mary Jahnke-Hanson, and Nancy Walker for data collection The National Arthritis Foundation funded this research through an Arthritis Health Professional Research Grant. The development of the ROM Dance was funded in part by a grant from the Arthritis Foundation, Wisconsin Chapter References Achterberg,]., McGraw, P., & Lawlis, F. (1981) Rheumatoid arthritis: A study of relaxation and temperature biofeedback training as an adjunctive therapy. Biofeedback and Self-RegUlation, 6, 207-223. Berk, R. (1979). 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Allied health team management of rheumaroid arthritis patients. American journal 0/ Occupational Therapy, 38, 613-620. Harlowe, D., & Black, B (1984) [19-minute slide-tape] Helping hands: Splints for early rheumatoid arthritis. Madison, WI: St. Marys Hospital Medical Center. Harlowe, D., & Yu, P (1984) The ROM dance. Madi· son. WI: Board of Regents of the University of Wisconsin, Sr. Marys Hospital Medical CeOler. Lenker,S., Lorig, K., & Gallagher, D. (1984). Reasons for the lack of association between changes in health behavior and improved health status: An exploratory study. Patient Education and Counseling, 6, 69-72. Lorig, K., Laurin, J., & Gines, G. (1984) Arthritis selfmanagement, a five-year history of a patient education program. Nursing Clinics ofNorth America, 19,637-645 Maddock, R. (1967) Patient cooperation in taking medication. journal of tbe American Medical Association, 199,169-172 Mayo, N (1978). Patient compliance: Practical implications for physical therapists. Pbysical Tberapy, 58, 10831090 I\'lelvin, J (1982) Rheumatic disease. Occupational therapy and rehabilitation. Philadelphia: Davis. Nordemar, R (1981) Physical training in rheumatoid arthritis: A controlled long-term study: II. Functional capacity and general attitudes. Scandinavian Journal of Rheumatology, 10, 25-30 Norclemar, R, Ekblom, B., Zachrisson, & LundqUist, K. (1981). Physical training in rheumatoid arthritiS A controlled long-term study. Scandinavian journal of Rbeumatology, 10, 17-23 Oakes, T., Ward,], Gray, R.. Klauber, M., & Moody, P (1970) Family expectations and arthritis patient compliance to a hand resting splint regimen. journal of Cbronic Diseases, 22, 575-764 Parker, J C, Singsen, B. H, Hewett. J E, Walker, S. E., Hazelwood, S. E, Hall, P]., Halston, D. ], & Radon, C. M. (1984) Educating patients with rheumatoid arthritis A prospective analysis Arcbives of Pbysical Medicine and Rebabilitation, 65,771-774. Parker, L, & Bender, L. (957). Problem of home treatment in arthritis Arcbives of Pb)'sical Medicine and Rehabilitation, 38, 392-394. Robinson, H, Haldeman,]., Imrie, ], & Neubauer, P (1980) Evaluation of a province-wide physiotherapy monitoring service in an arthritis control program. journal of Rbeumatology, 3, 387-389 ROM Dance Audio-Cassettes. (1984) Madison, WI: University of Wisconsin, St Marys Hospital Medical Center. Treusch, j., & Krusen, F. (1943) Physical therapy applied at home for arthritis. Archives of Internal Medicine, 72, 231-238 Trombly, C. (Ed) (1983). Occupational therapy for physical dysfunction (2nd eeL) Baltimore: Williams & Wilkins. (p. 127) The American Journal of Occupational Therapy Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms 95