Structured Exercise
in Older Adults With Limited Functional Ability Abstract The authors of this study examined the effects of a 16-week exercise program designed to increase aerobic capacity, muscular strength, and muscular endurance in older adults who reported and exhibited limited functional ability. Participants were randomly assigned to either an exercise (n = 39) or a control (n = 34) group. Dependent variables tested included measures of fitness (aerobic exercise capacity and isokinetic strength testing of the legs and arms) and measures of functional capacity (time to and off the floor, stair test, chair stand, and bicep curl). At the end of the program, there were significant differences between the exercise and control groups in arm strength, chair stand, and biceps curl. The results of this study indicate functionally limited older adults who maintain a structured exercise program for 16 weeks exhibit increased functional ability.
32
Assessing the Benefits of an Aerobic Plus Resistance Training Program
C
urrent estimates predict the population of the United States older than age 85 will reach approximately 6 million by the year 2010 and 16 million by the year 2050 (Haber, 2004). One of the goals outlined in Healthy People 2010 (U.S. Department of Health and Human Services, 2000) is successful aging, specifically “to increase the quality and years of healthy life.” Successful aging is dependent on a number of factors, including decreased probability for disease, high levels of functional capacity, and an active engagement in life (Topp, Fahlman, & Boardley, 2004). Functional ability, which is defined as having the physiologic capacity to perform normal everyday activities safely and without undue fatigue (Rikli & Jones, 2001), is widely recognized as important to maintaining independence as individuals age and is inversely associated with morbidity and mortality (Hurley & Hagberg, 1998). Older individuals require a sufficient level
of functional ability to conduct activities of daily living, endure acute illness and injury without declines in chronic health status, and reduce the risk of future health problems. Declining functional ability, including the ability to carry out activities of daily living, has been associated with declines in health and increased dependency among older adults (Gill, Allore, Holford, & Guo, 2004; Murtagh & Hubert, 2004). Functional ability also has been inversely correlated with the need for assisted living and short-term morbidity among older adults. Guralnik et al. (1994) reported strength, postural control, and the functional abilities of rising from a chair and gait speed were independent predictors of short-term mortality and nursing home admissions among a sample of 5,000 community-dwelling older adults. Chen and Wilmoth (2004) reported a significant relationship between a decline in the ability to perform activities of daily living and an increased likelihood of the need
Mariane M. Fahlman, PhD; Robert Topp, PhD; Nancy McNevin, PhD; Amy L. Morgan, PhD; and Debra J. Boardley, PhD June 2007
performance, functional ability, and general mobility among older adults of all levels of function (Kohrt, Snead, Slatopolsky, & Birge, 1995; Seeman et al., 1995). Regular exercise benefits older adults through overall health and physical fitness, lower rates of mortality, and fewer years of disability in later life. Exercise is effective in reversing, or at least slowing, certain age-related declines in motor performance. Because independence in daily living is an important goal for older adults, exercise is recognized as a major factor influencing independence
through the maintenance of mobility (Daley & Spinks, 2000). It has been postulated moderate levels of physical activity, which promote muscular strength and aerobic endurance, are associated with improved levels of functioning, even among older adults with existing chronic disease (Dipietro, Caspersen, Ostfeld, & Nadel, 1993). The purpose of this study was to determine the effects of a 16-week exercise program designed to increase aerobic capacity, muscular strength, and muscular endurance in older adults with limited functional ability.
© Corbis
for a dependent living environment. Other investigations also support the contention that threshold levels of strength and functional ability are necessary for older men and women to maintain independence in their later years (Cress & Meyer, 2003; Landers, Hunter, Wetzstein, Bamman, & Weinsier, 2001). These studies indicate declines in functional ability in later life are associated with an increased need for assisted living and greater short-term morbidity. A number of epidemiologic studies have concluded physical activity is a significant predictor of physical
Journal of Gerontological Nursing
33
until week 3 when participants were walking a total of 25 minutes. ParParticipant Characteristics (Mean 6 SEM) Study participants were ticipants were instructed Exercise Control recruited from a large to walk with an intensity (n = 39) (n = 34) midwestern city and the that was equal to a rating Age (years) 75.5 6 0.9 75.7 6 1.3 surrounding area. Fliers of 11 to 16 on the Borg inviting individuals who Rating of Perceived ExHeight (cm) 163.1 6 2.2 161.3 6 1.5 were having trouble with ertion (RPE) scale. Weight (kg) 83.0 6 2.5 76.9 6 3.1 activities of daily living The strength trainand who were interested ing protocol consisted in beginning an exercise signed by number to either an exof one set of 10 repetiprogram to call the university were ercise or a control group. tions during weeks 1 and 2, and placed in churches, senior centers, Control group. Participants in two sets of 12 repetitions during older adult apartment complexes, the control group were instructed to weeks 3 through 16. Participants and doctors’ offices. A preliminary maintain normal activity throughused a Thera-Band® (Akron, Ohio), telephone conversation screened out the 16-week study period. At which provides a color-coded sysparticipants who identified limitathe 9- and 17-week follow-up sestem of determining resistance, with tions in their functional capacity. sions, participants were questioned force production dependent on the Participants who scored 24 or to ensure they were compliant with color and percent elongation. Parless on the 10-item Physical Functhe instructions to maintain their ticipants were instructed to select tioning scale (PF-10) of the Medicurrent level of activity and not bethe color that provided sufficient cal Outcomes Study 36-item Short gin an exercise program during the resistance to produce mild fatigue Form Health Survey (MOS SF-36) study period. following the last repetition. (McHorney, Ware, Lu, & SherAs an incentive to remain in the For the resistance training, parbourne, 1994) were invited for final study, participants were informed ticipants completed 13 exercises screening. During the final screenthey were merely “delaying” their designed to provide a whole body ing, participants completed a selfparticipation in the exercise proprogram. These exercises included: l Chair squats. reported health history and undergram. At the completion of the 17l Hip flexion. went a physical examination that week data collection, participants l Hip extension. included a resting 12-lead electrocarin the control group were offered 4 l Standing abduction. diogram. weeks of the exercise intervention. l Standing abduction. Participants who were cleared Exercise group. Participants in l Chest press. by the physician were eligible to the exercise group were requested l Lateral shoulder raises. undergo baseline testing. During to report to the university once l Seated rows. baseline screening, participants who per week for group exercise and to l Abdominal curl ups. were able to climb 26 stairs in less exercise at home on 2 other days. l Biceps curl. than 12.6 seconds (the mean time of Training logs were completed and l Triceps extension. individuals age 65 and older) (Topp, contained information regarding l Calf raise. Mikesky, & Thompson, 1998) were the independent exercise sessions l Toe raises. excluded from the study. and any physical problems that The final sample consisted of 73 prohibited participants from exerThe training period lasted 16 weeks, participants with an average age of 75 cising. These forms were returned with testing occurring during weeks 6 5 years (age range = 65 to 92) who to the investigators at the weekly 0 (pre), 9 (mid), and 17 (post). were able to participate in moderate group exercise session. exercise training but were not curAll exercise sessions began with Functional Ability Measurement rently doing so (Table 1). The approa 5-minute warm-up consisting of Functional ability was operapriate university Human Investigalight stretching designed to increase tionalized to include a variety of tion Committee approved the study, flexibility. All sessions ended with a measures that affect activities of and all participants signed informed 5-minute cool-down similar to the daily living, morbidity, and mortalconsent forms. warm-up. ity in older adults including upper In the first week, participants and lower body strength and aeroExercise Intervention walked for a total of 10 minutes. bic endurance. All of the tests have Participants who qualified for The walking distance was inbeen shown to be valid and reliable the program were randomly ascreased by 4 minutes each session for assessing the performance areas Method
Screening and Exclusion Criteria
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Table 1
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Strength training Isokinetic strength testing (legs and arms)
Chair stand
Isokinetic strength of the legs and arms was measured on the right side using a Kin Com Cybex Isokinetic Dynamometer. A warm-up of five submaximal contractions was performed. Participants completed three trials with a rest period of 30 seconds between trials. The concentric force curve demonstrating the greatest average force for each exercise was chosen to represent maximal strength.
This test was used to assess participants’ functional ability to raise themselves from a seated position and return to sitting. Participants were instructed to rise and be seated in a straight-backed chair (seat = 17 inches or higher) as many times as possible in 30 seconds. The test began with participants seated with their feet flat on the floor and their arms crossed at the chest. On the signal “Go,” participants rose to a full stand and then returned to a fully seated position. The stopwatch was started on the signal “Go,” and participants were instructed to stop when the stopwatch reached 30 seconds. The score for this test was the number of complete stands finished in the 30 seconds, as counted by the test administrator.
Time to and off the floor This test began with participants in an upright standing position with their hands at their sides and ended with participants in a supine position with their hands at their sides. At the first signal of “Go,” participants safely got into the floor position. At the second signal of “Go,” participants were required to get off the floor and back into the starting position. The stopwatch was started on the “Go” signal and stopped when participants reached the intended position. Each trial was measured to the nearest tenth of a second using a stopwatch.
Stair test This test was used to assess participants’ functional ability to ascend and descend a flight of 21 steps with a 7 inch riser. In the starting position, participants stood facing the stairs, no further than 12 inches from the first step, with their hands at their sides. Participants then were instructed to ascend and descend the stairs as quickly and safely as they could. The stopwatch was started on participants’ first movement and stopped when both feet reached either the top (upstairs) or the bottom (downstairs) of the stairs. The trial was measured to the nearest tenth of a second.
affecting physical mobility in older adults (Guralnik et al., 1994; Harada, Chiu, & Stewart, 1999; Rikli & Jones, 2001). These include aerobic exercise capacity and strength testing. Aerobic exercise capacity. Aerobic exercise capacity was assessed by the distance participants were able to traverse during a 6-minute walk. The 6-minute walk test has been demonstrated to be a valid and reliable test in older adults with respiratory disease (Aurthur, 1982) and chronic heart failure (Peeters & Mets, 1996) as well as in healthy older adults (Harada et al., 1999). A submaximal exercise test was selected for three reasons. First, it closely approximated the exercise
Biceps curl This test was used to assess participants’ functional ability of upper body strength, which is accepted as a standardized test for older adults. Participants were asked to curl a 5 lb (women) or 8 lb (men) dumbbell through the full elbow range of motion starting from a fully extended arm position as many times as possible in 30 seconds. Participants sat in a straight-backed chair, slightly toward the edge of the chair associated with their dominant hand. Participants held the appropriate dumbbell at the side in a handshake position, perpendicular to the floor. On the signal “Go,” participants curled the weight through the full range of motion as many times as possible. The stopwatch was started on the signal “Go,” and participants were instructed to stop when the stopwatch reached 30 seconds. The score for this test was the number of curls completed in the 30 seconds, as counted by the test administrator.
training prescription of the exercise group. Second, submaximal exercise has been shown to be effective in detecting a training effect in older adults following aerobic training (Stevenson & Topp, 1990). Third, it posed less of a health risk to the older adults than a maximal exercise test. All walks were conducted on a flat, indoor 200 m track marked off in 5 m segments. Participants were tested individually to promote individual pacing and to discourage walking in pairs. Participants were instructed to cover as much distance as possible without pushing themselves beyond what they considered safe. Elapsed time was announced each minute. The total distance walked after 6 minutes
Journal of Gerontological Nursing
constituted participants’ scores. Strength testing. Strength testing was assessed using isokinetic strength testing (legs and arms), time to and off the floor, stair test, chair stand, and biceps curl (see the Sidebar on this page). Results Statistical Analysis
The dependent variables of aerobic exercise capacity, isokinetic strength testing of the legs and arms, time to the floor, time off the floor, stair test, 30-second timed sit-to-stand trials, and 30-second timed biceps curls were analyzed separately using a 2 (groups: exercise, control) 3 3 (time: baseline, mid, post) analysis of variance with repeated measures on the second
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Table 2 significant effect after 16 weeks of training (Mean 6 SEM) Strength Training Item
Baseline
17-week
Change
Significance
Exercise
1339.4 6 59.2
1503.1 6 67.6
164 (12%)
Time: p , .05
Control
1269.4 6 71.3
1404.7 6 71.6
135 (11%)
Exercise
54.8 6 3.3
59.7 6 3.3
4.9 (9%)
Control
53.2 6 3.3
54.4 6 4.2
1.2 (2%)
Exercise
30.1 6 1.9
31.9 6 1.9
1.8 (6%)
Time: p , .05
Control
28.1 6 1.8
26.9 6 1.6
–1.2 (–4%)
G 3 T: p , .05
Exercise
5.7 6 0.6
5.3 6 0.6
0.4 (7%)
Time: p , .05
Control
5.9 6 0.6
5.9 6 1.0
0 (0%)
Exercise
7.3 6 0.7
6.1 6 0.5
1.2 (16%)
Control
8.2 6 0.8
7.7 6 0.9
0.5 (6%)
Exercise
18.9 6 2.2
15.6 6 1.6
3.3 (17%)
Control
17.9 6 1.6
15.9 6 1.2
2.0 (11%)
Exercise
17.9 6 1.5
15.1 6 1.2
2.8 (16%)
Control
19.6 6 2.2
17.8 6 2.4
1.8 (9%)
Exercise
10.8 6 0.6
13.7 6 0.8
2.9 (27%)
Time: p , .05
Control
9.4 6 0.8
11.9 6 0.7
2.5 (27%)
G 3 T: p , .05
Exercise
15.9 6 0.7
20.7 6 0.6
4.8 (30%)
Group: p , .05
Control
14.6 6 0.8
16.9 6 0.8
2.3 (16%)
G 3 T: p , .05
Aerobic exercise capacity (feet)
Isokinetic leg strength (peak torque in pounds) Time: p , .05
Isokinetic arm strength (peak torque in pounds)
Time to the floor (seconds)
Time off the floor (seconds) Time: p , .05
Time up the stairs (seconds) Time: p , .05
Time down the stairs (seconds) Time: p , .05
Chair stand (number)
Time: p , .05
Biceps curl (number)
factor. All statistical decisions were based on a = .05. Post hoc analysis of significant effects was performed using a modified Bonferroni’s post hoc procedure (with adjusted a = .02, c = 3) (Table 2). The Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL) version 13.0 was used for all statistical analyses. Aerobic exercise capacity. Only the main effect of time (F [2, 140] = 25.256, p , .05) reached statistical significance, indicating an increase in aerobic capacity for both groups
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as a function of the 16-week protocol. Both the main effect of group and the group 3 time interaction failed to reach significance (F , 1). Isokinetic strength testing (legs and arms). Analysis of leg extension and flexion data revealed a main effect of time (F [2, 136] = 6.105, p , .05) for leg extension data only. Neither the main effect of group nor its interaction with time reached significance (F , 1). Leg flexion analysis revealed no main effects or interaction (F , 1). For upper body isokinetic
strength data, analysis failed to identify main effects for time or group for arm extension data (F , 1). However, there was a significant interaction between these factors (F [2, 134] = 3.288, p , .05), indicating that for the 16week protocol, the exercise group showed significant improvements in strength compared to the control group. A different pattern of results emerged when arm flexion data were analyzed; only the main effect of time (F [2, 134] = 91.569, p , .05) was significant, with both
June 2007
16
Chair Stand
14
Number
12 10 8 Exercise
6
Control
4 2 0
PRE
MID
POST
Figure 1. Chair stand across time for exercise and control groups. A significant interaction was noted (p < .05). 25
Biceps Curls
20
Number
the effect of group and the group 3 time interaction failing to reach significance (F , 1). Time to and off floor. Separate analysis of time to and time up from the floor revealed main effects for time only (F [2, 110] = 7.744, p , .05, and F [2, 112] = 14.914, p , .05, respectively). All other main effects and interactions failed to reach significance (F , 1). Once again, both groups improved their performances on this test despite differences in training. Stair test. The time taken to go up and down a series of stairs also failed to differentiate between the exercise and control groups (F , 1). The main effects of time for up and down stairs (F [2, 132] = 9.936 and F [2, 130] = 7.923, respectively) were significant; however, time did not interact with group (F , 1) for either set of data. As with the previous measure, the 16-week training protocol did not significantly improve participants’ ability to perform this task beyond that produced by the control group. Chair stand. Analysis of the sit-to-stand data revealed a significant main effect of time (F [2, 128] = 17.847, p , .05), which was qualified by its interaction with group (F [2, 128] = 3.172, p , .05). Post hoc analysis indicated that although performance between groups was equivalent during baseline and mid-training sessions, the exercise group demonstrated improved performance by week 16 compared to the control group (Figure 1). There was no main effect of group (F , 1). Biceps curls. This analysis revealed main effects for both group (F [1, 68] = 7.876, p , .05) and time (F [2, 136] = 39.539, p , .05). However, the main effects were qualified by their significant interaction (F [2, 136] = 4.057, p , .05) such that although both groups tended to show improvements for the 16week protocol, the benefits were more pronounced for the exercise
15 10
Exercise Control
5 0
PRE
MID
POST
Figure 2. Biceps curls across time for exercise and control groups. A significant group effect and interaction was noted (p < .05).
group compared to the control group (Figure 2). Discussion The most significant finding of this study is that moderate exercise conducted three times per week resulted in an improvement in performance on measures of fitness and functional ability. Many of these same components are linked to disability and loss of independence in older adults, thus clearly affecting one of the goals of Healthy People 2010, that is, healthy aging. The goal of the exercise program was to increase fitness variables, which
Journal of Gerontological Nursing
would then lead to increased functional ability, one of the components of healthy aging. In this study, participants in the exercise group increased their 6-minute walk distance by 12%. However, because the control group also increased their distance by 11%, this increase is most likely caused by familiarity with testing procedures. Aerobic capacity declines with age, and attenuating this progressive decline may attenuate the risk of decreased functional capacity in later life. Miller, Rejeski, Reboussin, Ten Have, and Ettinger (2000) found 1 mile of walking
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Keypoints
Structured Exercise Fahlman, M.M., Topp, R., McNevin, N., Morgan, A.L., & Boardley, D.J. Structured Exercise in Older Adults With Limited Functional Ability: Assessing the Benefits of an Aerobic Plus Resistance Training Program. Journal of Gerontological Nursing, 2007, 33(6): 32-39.
1
Because declining functional ability has been associated with a decline in activities of daily living and increased dependency, older adults are encouraged to add exercise to their daily routines.
2
This study examined the effects of a 16-week exercise program designed to increase aerobic capacity, muscular strength, and muscular endurance in older adults who reported and exhibited limited functional ability.
3
Participants in the exercise group walked for 25 minutes and then completed two sets of 12 repetitions of 13 different resistance exercises three times per week.
4
Findings demonstrated that a 16-week structured exercise program in older adults with limited functional ability leads to increased measures of functional ability such as strength and endurance.
exerted a strong independent protective effect on physical functioning. This was further supported by Binder et al. (2002), who demonstrated that even frail older adults maintain the ability to respond positively to endurance training and that the increased endurance as a result of training could, in turn, improve physical functioning. Although it is important to reverse the progressive decline in aerobic capacity that occurs with aging, it is clear the aerobic training component of this exercise program was insufficient to accomplish that goal. Although the exercise group walked for 25 minutes three times per week, the current recommendation to attenuate the age-related decline in aerobic capacity is to walk 60 minutes five times per week (Hawkins & Wiswell, 2003). Clearly, the aerobic portion of the exercise program must be increased to produce the desired results. An additional goal of the exercise program was to increase strength.
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Most functional tasks used to perform activities of daily living are short in duration and are related more to muscular strength than aerobic endurance (Hunter et al., 1995). Therefore, it is encouraging to note the increases in measures of strength that were achieved exclusively by the exercise group. Participants in the exercise group increased their isokinetic leg strength by 9%, arm strength by 6%, chair stands by 27%, and the number of biceps curls by 30%. For arm strength, chair stands, and biceps curls, the exercise group progressed much farther than the control group as evidenced by the group and interaction effect. These results are consistent with other studies of functional ability that involve training in older adults (Cavani, Mier, Musto, & Tummers, 2002; Cress et al., 1999; Toraman, Erman, & Agyar, 2004). These findings contribute to the growing body of evidence that regular physical exercise can
improve the functional ability of older adults. This evidence is beginning to direct the practice of health care providers by allowing them to prescribe specific physical exercise interventions for older adult patients. This study included functionally limited older adults, with only a few chronically ill individuals being excluded. Practitioners can use the same exclusion criteria by treating their older adult patients with regular exercise interventions. This study demonstrated that a 16week structured exercise program in older adults with limited functional ability leads to increased measures of functional ability such as strength and endurance. Previous research has indicated moderate intensity exercise is related to improvements in risk factors associated with cardiovascular disease (Mazzeo & Tanaka, 2001), premature death (Blair et al., 1995), independence in later life (Wolinsky, Stump, & Clark, 1995), and improved physical functioning (Binder et al., 2002). When previous research is combined with recent research indicating older adults who participate in planned exercise programs experience increased physical functioning capacity compared with those who participate in activities of similar caloric expenditure (Brach et al., 2004), it becomes evident that providing opportunities to exercise is crucial to the future functioning and independence of older adults. References
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chosocial predictors of physical performances: MacArthur studies of successful aging. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 50, M177-M183. Stevenson, J.S., & Topp, R. (1990). Effects of moderate and low intensity long-term exercise by older adults. Research in Nursing and Health, 13, 209-218. Topp, R., Fahlman, M., & Boardley, D. (2004). Healthy aging: Health promotion and disease prevention. Nursing Clinics of North America, 39, 411-422. Topp, R., Mikesky, A., & Thompson, K. (1998). Determinants of four functional tasks among older adults: An exploratory regression analysis. Journal of Orthopaedic and Sports Physical Therapy, 27, 144-153. Toraman, N.F., Erman, A., & Agyar, E. (2004). Effects of multicomponent training on functional fitness in older adults. Journal of Aging and Physical Activity, 12, 538-553. U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health (2nd ed.). Retrieved April 30, 2005, from http://www.healthypeople.gov/ Document/pdf/uih/2010uih.pdf Wolinsky, F.D., Stump, T.E., & Clark, D.O. (1995). Antecedents and consequences of physical activity and exercise among older adults. The Gerontologist, 35, 451462. About the Authors
Dr. Fahlman is Associate Professor, Kinesiology, Health, and Sports Studies, and Dr. McNevin is Assistant Professor, Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan. Dr. Topp is Professor and Shirley B. Powers Endowed Chair in Nursing Research, School of Nursing, University of Louisville, Louisville, Kentucky. Dr. Morgan is Associate Professor, School of Human Movement, Sport, and Leisure Studies, Bowling Green State University, Bowling Green, Ohio. Dr. Boardley is Associate Professor, Rehabilitation Services, University of Toledo, Toledo, Ohio. This project was supported by a grant from the National Institute for Nursing Research (#RO1 NR04929) and the Hygenic Corporation. Address correspondence to Mariane M. Fahlman, PhD, Associate Professor, Kinesiology, Health, and Sports Studies, Wayne State University, Matthaei 262, Detroit, MI 48202; e-mail:
[email protected].
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