Testing the Effectiveness of the Exercise Plus Program in Older ...

Testing the Effectiveness of the Exercise Plus Program in Older Women Post–Hip Fracture Barbara Resnick, Ph.D., CRNP University of Maryland School of Nursing

Denise Orwig, Ph.D. University of Maryland School of Medicine

Janet Yu-Yahiro Union Memorial Hospital, Baltimore, Maryland

William Hawkes, Ph.D., Michelle Shardell, Ph.D., and J. Richard Hebel, Ph.D. University of Maryland School of Medicine

Sheryl Zimmerman, Ph.D. University of North Carolina Chapel Hill

Justine Golden, M.S., Michele Werner, B.S., and Jay Magaziner, Ph.D. University of Maryland School of Medicine

it was possible to engage these women in a home-based exercise program and that the plus only, exercise only, and the exercise plus groups all increased exercise.

ABSTRACT Background: Exercise is an important strategy with potential to improve recovery in older adults following a hip fracture. Purpose: The purpose of this study was to test the impact of a self-efficacy based intervention, the Exercise Plus Program, and the different components of the intervention, on self-efficacy, outcome expectations, and exercise behavior among older women post–hip fracture. Methods: Participants were randomized to one of four groups: exercise plus, exercise only, plus only (i.e., motivation), or routine care. Data collection was done at baseline (within 22 days of fracture), 2, 6, and 12 months post–hip fracture. Results: A total of 209 women were recruited with an average age of 81.0 years (SD ¼ 6.9). The majority was White (97.1%), was widowed (57.2%), and had a high school education (66.7%). Generalized Estimating Equations were used to perform repeated measures analyses. No differences in trajectories of recovery were observed for self-efficacy or outcome expectations. A statistically significant difference in the overall trajectory of time in exercise was seen (p < .001), with more time spent exercising in all three treatment groups. Conclusions: The study demonstrated that

(Ann Behav Med

2007, 34(1):67–76)

INTRODUCTION In 2003 there were more than 309,500 hospital admissions for hip fractures, and by the year 2030 over 650,000 hip fractures will occur annually in older adults (1). In the 1st year of their fracture, approximately 30% of these individuals will die (1), 25% will have significant functional decline in activities of daily living such as bathing and dressing (2), 20% will need help with lower extremity dressing, and 90% will require help climbing the stairs (3). Individuals who have had a hip fracture are noted to be impaired in their ability to independently rise from an armless chair or to step symmetrically (4), and approximately 38% to 50% need assistance to walk or are unable to walk at 12 months post–hip fracture (5). An important strategy with potential to improve recovery in older adults following a hip fracture is exercise training. Regular exercise, even at low levels of intensity, can improve mental and physical health in older adults (6). Despite the well-documented benefits of exercise, only 23% to 35% of men engage in regular exercise, and this is even lower in women ranging from 17% to 32% (7,8). Developing successful interventions to help motivate individuals after a hip fracture to adhere to regular exercise programs has the potential to improve recovery and overall quality of life.

Support for this project was provided by National Institute on Aging grants R37 AG09901, R01-AG18668, R01 AG17082, and the Claude D. Pepper Older Americans Independence Center P60-AG12583. We thank Thera-Band Academy for their generous contribution of Thera-Band1 resistive bands used by study participants, hospitals and personnel participating in the Baltimore Hip Studies, and research staff who worked with study patients and their families. We also thank hip fracture patients and their families for volunteering their time and information for this work. Reprint Address: B. Resnick, Ph.D., CRNP, University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201. E-mail: [email protected]

Theoretical Basis of the Intervention Social cognitive theory, based on triadic reciprocity suggesting that behavior, cognitive, and other personal

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factors and environmental influences all operate interactively as determinants of each other, incorporates the factors that most consistently influence exercise behavior (9–11). Social cognitive theory considers (a) self-efficacy expectations, which are the individuals’ beliefs in their capabilities to perform a course of action to attain a desired outcome, and (b) outcome expectations, which are the beliefs that a certain consequence will be produced by personal action. Exposure to enactive mastery experiences, such as participation in an exercise class, is the most common intervention used to strengthen efficacy expectations in older adults (12–15). Verbal encouragement from a trusted, credible source in the form of counseling and education has been used alone, and with enactive mastery, to strengthen efficacy expectations (16,17). Less frequently, vicarious experience (15,18), self-modeling (19), or implementation of interventions to decrease the unpleasant sensations or augment the pleasant sensations associated with exercise have been used to strengthen self-efficacy and increase adherence to exercise (18,20,21). Behavior can also be altered by the outcome expectations the individual maintains, with expected outcomes being physical or mental health changes, social effects, or personal evaluations of behavior. In cross-sectional studies with older adult samples, outcome expectations related to exercise have had a significant influence on exercise behavior (22–24) and seem to be particularly important to the prediction of exercise behavior over time (25,26). Several researchers (15,16,18,27) have utilized a variety of sources of efficacy information to increase exercise among older adults. These included verbal encouragement, education about the benefits of exercise, social support, manipulation of affective states, self-modeling, and cueing. McAuley et al. (15,27) noted that the social environment and affective states of the participants directly and indirectly influence self-efficacy expectations and exercise behavior, beyond the effects of enactive mastery. Cumulatively, these studies suggest that in healthy community dwelling older adults there may be some benefit to adding sources of efficacy information, in addition to enactive mastery, when trying to strengthen the individuals’ beliefs about their ability to exercise and increase exercise behavior. It is not clear, however, if exposing older individuals who have sustained an acute medical event (i.e., a hip fracture) to multiple sources of efficacy information will strengthen self-efficacy and outcome expectations or increase time spent in exercise over the first 12 months post–hip fracture. The purpose of this study, therefore, was to test the Exercise Plus Program and the separate components of the Exercise Plus Program (exercise only and plus only components) using a four-group repeated measure design. Specifically, the following was hypothesized: 1. Participants who were exposed to exercise only (exercise trainer exercising with the individual) spent more time in

exercise and had stronger self-efficacy and outcome expectations related to exercise compared to those who received routine care. 2. Participants who were exposed to plus only (verbal persuasion to exercise through education and goal setting, self-modeling, and manipulation of affective states) spent more time in exercise and had stronger selfefficacy and outcome expectations related to exercise compared to those who received routine care. 3. Participants who were exposed to exercise plus (exercise trainer exercising with the individual and verbal persuasion, self-modeling, and manipulation of affective states) spent more time in exercise and had stronger self-efficacy and outcome expectations related to exercise compared to those who received routine care.

METHODS Study Design This study was a randomized controlled trial using a repeated measure design with participants randomized to one of four groups: exercise plus, exercise only, plus only, or routine care. Baseline testing was conducted within the first 22 days post–hip fracture and random assignment was done after baseline testing was complete. Follow-up data collection was done at 2, 6, and 12 months post–hip fracture. Sample Participants were recruited from nine hospitals in the greater Baltimore area (see Figure 1). Eligible participants were female, were 65 years of age or older, were community dwelling at the time of fracture, had a nonpathologic fracture within 72 hr of admission, had surgical repair of the hip fracture, and were free of medical problems that would potentially put them at particular risk for falls when exercising alone at home alone (e.g., neuromuscular conditions). Participants also had to be walking without human assistance prior to the fracture and score 20 or higher on the Folstein Mini Mental State Examination (28). Institutional Review Board approvals were obtained from the University of Maryland School of Medicine as well as the study hospitals, and all enrolled participants provided their own informed consent. Recruitment was initiated in August 2000, and data collection on the final participant was completed in September 2005. A Data and Safety Monitoring Board met quarterly and reviewed all adverse events and safety reports. The Intervention: The Exercise Plus Program The Exercise Plus Program incorporates the exercise only and plus only components of the intervention (described next). The theoretical premise of the Exercise Plus Program has been described in detail elsewhere (29,30).

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FIGURE 1 Flow of participants through the trial: Testing the effectiveness of the Exercise Plus Program.

In all treatment groups, visits from the trainer were initially twice a week and then decreased to once a month in the final 4 months of the program, with weekly telephone calls for those exposed to the plus component of the intervention during the weeks when no visit was scheduled. All visits lasted 1 hr. The goal was to initiate the intervention as soon as Medicare-covered rehabilitation services were completed. Assuming that the participant completed all Medicare-covered rehabilitation services by 1 month postfracture, the maximum number of anticipated visits was 38.

Exercise plus intervention. The exercise component exposes the participant to an exercise session with an exercise trainer. The exercise sessions incorporated aerobic exercise using a Stairstep (a specially designed 4-in. stair step with handles on either side for support and balance) (29–31), a comprehensive strengthening program that covers the main muscle groups relevant to hip fracture recovery, and stretching exercises (these were part of the warm up and cool down periods).

Participants were told to perform aerobic activity at least 3 days per week and strength training 2 days per week for 30 min. Each participant started at her own individual level with regard to the time spent in aerobic activities and the amount of repetitions and resistance used in the strengthening program. Strength training consisted of a series of 11 exercises for the upper and lower extremities using Thera-band products (The Hygenic Corporation, Akron, OH) and=or ankle and wrist cuff weights. Generally, the duration of each exercise was increased until the participant could do three sets of 10 repetitions on the right and left sides. Intensity was then augmented by increasing the resistance of exercise bands or tubes and=or adding ankle and wrist cuff weights according to a standard protocol (30). These exercises are available from the first author upon request. The plus component of the Exercise Plus Program was implemented by the exercise trainer as part of the same visit and included education about the benefits of exercise post– hip fracture using an investigator-developed booklet Exercise After Your Hip Fracture, verbal encouragement through goal setting and positive reinforcement, exposure

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to interventions to decrease the unpleasant sensations associated with exercise such as relieving or decreasing pain with prescribed medications or use of heat=ice treatment, and cueing with posters describing the exercises, a Goal Form, and a calendar of daily exercise activities (29). A detailed description of the plus component is available from the first author upon request.

exercising. In this study there was evidence of internal consistency with an alpha coefficient of .91. The Outcome Expectations for Exercise Scale (34) is a nineitem measure (range ¼ 1–5) that focuses on the perceived consequences of exercise for older adults and likewise there was evidence of internal consistency with an alpha coefficient of .88.

Plus only intervention. Participants in the plus only group did not exercise with the trainer. Rather the sessions focused only on the plus components (i.e., education about exercise, verbal encouragement, removal of unpleasant sensations, and cueing).

Exercise behavior. Exercise behavior was measured based on the Yale Physical Activity Survey (35) and the Step Activity Monitor (SAM). The Yale Physical Activity Survey is an interviewer-administered questionnaire focusing on five major categories of common groups of activities such as work, exercise, and recreational activities that older adults engage in. In this study the Exercise subscale was the only data reported as this was the focus of the intervention. The SAM provides a count of the number of steps taken at specified intervals (36–38) and was placed on the participant for 48 hr at the 2-, 6-, and 12-month follow-up period.

Exercise only intervention. Participants in the exercise only group exercised with the trainer during the session but were not exposed to the plus components of the intervention and were not provided with any education about exercise, verbal feedback, interventions to decrease unpleasant sensations, or encouragement to exercise post–hip fracture. Routine care group. Those randomized to routine care received no intervention-related visits. Routine care for older adults post–hip fracture involved rehabilitation services based on Medicare guidelines. This generally included inpatient physical and occupational therapy based on the functional needs of the individual and in most cases a single home therapy evaluation for safety. Randomization Randomization was performed using a freeware computer program (32). Patient assignment was blocked by hospital to assure equal probabilities within each hospital being assigned to each of the four study groups. Patients were assigned to groups at random with forced balancing of treatment groups within hospital. The resulting randomization scheme was given to the project coordinator and patients assigned as they became available at the indicated hospital. The study nurses involved with recruitment and data collection were blind to randomization. Study participants were not informed of what specific arm of the intervention they were randomized to (i.e., exercise only, plus only, or exercise plus). Study Outcomes Study outcomes focused on self-efficacy and outcome expectations related to exercise and time in exercise activities. Efficacy expectations. The Self-efficacy for Walking= Exercise Scale (33) is a nine-item measure (range ¼ 0–10) that focuses on self-efficacy expectations related to the ability to continue to exercise in the face of barriers to

Descriptive Variables Age, marital status, educational level, and living situation prior to hip fracture (whether they live alone or with others) were obtained. Chart reviews were done to describe medical history, surgical intervention, and hospital course (see Table 1). Statistical Analysis The intention-to-treat principle was followed in all analyses used for assessing the effect of treatment on outcome, that is, all participants who were randomized were included. Generalized Estimating Equations (39) (GEEs) were used to perform repeated measures analyses with the outcome measures described previously as dependent variables. The independent variables included dummy variables to indicate the exercise plus, exercise only, and plus only interventions (the control condition serving as the reference). Additional dummy variables were used to indicate the 2-, 6-, and 12-month time points (baseline serving as the reference). Interactions between the intervention and time variables were also included as fixed effects in the longitudinal model. This model was used to estimate the mean and standard error of the outcome measure at each time point for each of the four treatment groups. Robust standard error estimates were obtained using a technique described by Huber (40). A global p value for the differences in longitudinal trajectories among the four groups was obtained from a test of the null hypothesis that all the Intervention
Time interaction coefficients in the model are simultaneously zero. Time-specific between-group contrasts were tested at the 5% level using Wald statistics derived from the linear combination of model coefficients used to estimate the dif-

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TABLE 1 Descriptive Data for Participants by Treatment Group Variable No. Age Race White African American Marital status Never married Married Widowed Divorced Separated Education None Elementary High (7–12) College Postgraduate Fracture site Intertrochanteric Subcapital Subtrochanteric Other Anesthesia risk rating Physical Therapy (PT) sessions Length of hospital stay Charlson Co-Morbidity Index Residence at discharge Community Skilled nursing Rehabilitation Nursing home: No rehab Unknown

Exercise Only

Plus Only

Exercise Plus

Routine Care

All Participants

51 82.4  7.9

54 80.6  6.9

52 81.4  5.8

51 79.7  6.7

208 81.0  6.9

51 (100.0%) 0

51 (94.4%) 3 (5.6%)

50 (96.2%) 2 (3.9%)

50 (98.0%) 1 (2.0%)

202 (97.1%) 6 (2.9%)

1 (2.0%) 17 (33.3%) 30 (58.8%) 2 (3.9%) 1 (2.0%)

1 (1.9%) 20 (37.0%) 31 (57.4%) 1 (1.9%) 1 (.9%)

4 (7.7%) 19 (36.5%) 27 (51.9%) 2 (3.9%) 0

1 (2.0%) 15 (29.4%) 31 (60.8%) 3 (5.9%) 1 (2.0%)

7 (3.4%) 71 (34.1%) 119 (57.2%) 8 (3.9%) 3 (1.4%)

0 2 (4.0%) 32 (64.0%) 12 (24.0%) 4 (8.0%)

0 0 37 (68.5%) 13 (24.1%) 4 (7.4%)

0 2 (3.9%) 33 (63.5%) 11 (21.2%) 6 (11.5%)

0 2 (3.9%) 36 (70.6%) 10 (19.6%) 3 (5.9%)

0 6 (2.9%) 138 (66.7%) 46 (22.2%) 17 (8.2%)

23 (45.1%) 22 (43.1%) 5 (9.8%) 1 (2.0%) 2.5  .5 4.3  3.2 3.8  .9 .7  1.3

16 (29.6%) 38 (70.4%) 0 0 2.7  .6 4.9  6.4 4.2  1.1 1.3  1.3

22 (42.3%) 27 (51.9%) 2 (3.9%) 1 (1.9%) 2.6  .6 5.1  4.6 4.3  1.6 1.1  1.1

27 (52.9%) 22 (43.1%) 1 (2.0%) 1 (2.0%) 2.6  .6 6.0  5.9 4.4  1.5 1.6  1.6

88 (42.3%) 109 (52.4%) 8 (3.9%) 3 (1.4%) 2.6  .6 5.1  5.2 4.2  1.3 1.2  1.4

4 (7.8%) 29 (56.9%) 18 (35.3%) 0 0

4 (7.4%) 25 (46.3%) 24 (44.4%) 1 (1.9%) 0

1 (1.9%) 22 (42.3%) 29 (55.8%) 0 0

1 (2.0%) 20 (39.2%) 29 (56.9%) 0 1 (2.0%)

10 (4.8%) 96 (46.2%) 100 (48.1%) 1 (.5%) 1 (.5%)

Note. Patients with angina, myocardial infarction, stroke, transient ischemic attack, deep venous thrombosis, seizures, and gastrointestinal hemorrhage in the 6 months before admission were not eligible for the study.

ference in means and its standard error. To investigate the potential for bias due to missing outcome data, sensitivity analyses were performed using weighted estimating equations (WEEs) (41). Weights were the inverse estimated probabilities of being observed at each visit derived from a logistic regression of observed status (yes=no) on time, group, their interaction, and baseline factors (age, comorbidities, Geriatric Depression Scale (GDS), and prefracture Activities of Daily Living (ADLs). Results from GEEs are only unbiased when data are missing completely at random in the sense of Rubin (42). WEEs using the estimated weights will produce unbiased results if the data are missing at random (42). RESULTS Table 1 provides descriptive data for participants by treatment group. Overall, the average patient was 81.0

years old (SD ¼ 6.9), all were female, and 97.1% were White. The majority (57.2%) was widowed and had a high school education (66.7%). Of the 209 initially recruited into Testing the Effectiveness of the Exercise Plus Program, 165 women (79%) were available for 2month assessments, 169 (81%) were available for 6-month follow up, and 155 (75%) were available for the 12-month follow up visits. One case was deleted postrandomization due to being ineligible (no surgery was performed post– hip fracture). Reasons for loss to follow up are shown in Table 2. The time from fracture to first intervention visit from the trainer ranged from 28 to 200 days. Participants generally were not willing to have a visit occur prior to 60 days postfracture, and only 1 participant had her first visit at 28 days postfracture, 22 (31%) of the participants had their first visit by 60 days postfracture, 44 (62%) of the participants had their first visit by 90 days postfracture, and

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Resnick et al. TABLE 2 Reasons for Loss to Follow-up by Treatment Group

Follow-Up Point Two monthe Scheduling=unable to contact Illness Refusal of study (cumulative) Refusal of measures Death (cumulative) Other Six monthf Scheduling=unable to contact Illness Refusal of study (cumulative) Refusal of measures Death (cumulative) Other Twelve monthg Scheduling=unable to contact Illness Refusal of study (cumulative) Refusal of measures Death (cumulative) Other

Usual Carea 2 2 2 3 0 0

(4%) (4%) (4%) (6%) (0%) (0%)

4 0 3 0 1 0

(8%) (0%) (6%) (0%) (2%) (0%)

1 0 3 2 3 1

(2%) (0%) (6%) (4%) (6%) (2%)

Exercise Onlyb

Plus Onlyc

Exercise Plusd

0 (0%) 0 (0%) 4 (10%) 6 (15%) 0 (0%) 0 (0%) 0 (0%) 1 (3%) 10 (26%) 0 (0%) 0 (0%) 1 (3%)

2 0 2 5 1 0

(5%) (0%) (5%) (11%) (2%) (0%)

1 3 5 4 0 0

(3%) (8%) (13%) (10%) (0%) (0%)

0 0 2 3 1 2

(0%) (0%) (4%) (7%) (2%) (4%)

1 0 5 4 1 0

(2%) (0%) (12%) (10%) (2%) (0%)

2 (6%) 1 (3%) 10 (29%) 0 (0%) 2 (6%) 1 (3%)

3 0 2 4 1 1

(7%) (0%) (5%) (9%) (2%) (2%)

4 0 5 5 2 0

(11%) (0%) (14%) (14%) (5%) (0%)

a n ¼ 51. bn ¼ 51. cn ¼ 54. dn ¼ 52. eUsual care, n ¼ 42; exercise only, n ¼ 40; plus only, n ¼ 44; exercise plus, n ¼ 39. fUsual care, n ¼ 43; exercise only, n ¼ 39; plus only, n ¼ 46; exercise plus, n ¼ 41. gUsual care, n ¼ 41; exercise only, n ¼ 35; plus only, n ¼ 43; exercise plus, n ¼ 36.

58 (82%) of the participants had their first visit by 120 days postfracture. The mean number of intervention visits was 20.9 (SD ¼ 15.3), and the exercise only group participated in 17.3 (SD ¼ 15.6) visits, the plus only group participated in 24.4 (SD ¼ 14.5) visits, and the exercise plus group participated in 21.2 (SD ¼ 15.3) visits. Based on analysis of variance these differences were not statistically significant (F ¼ 2.8, p ¼ .06). Eighteen of the 51 individuals randomized to exercise only (35%), 15 of the 52 individuals randomized to exercise plus (29%), and 8 of the 54 individuals randomized to plus only (15%) were not willing to have any intervention visits. Results for outcome measures are presented in Table 3. No differences in trajectories of recovery were statistically significant at the .05 level for self-efficacy or outcome expectations. A statistically significant difference in the overall trajectory of time in exercise (in hours) was seen (p < .001) with all treatment groups spending more time in exercise than the control group (see Figure 2). The SAM also showed a statistically significant difference (p ¼ .03) in the trajectories of the groups (see Figure 3). At 12 months postfracture, the exercise only group showed higher activity levels (M ¼ 6,459 steps, SE ¼ 968 steps) as did the plus only group (M ¼ 6,994 steps, SE ¼ 1,012 steps) relative to the control group (M ¼ 4,060 steps, SE ¼ 623 steps). The exercise plus group did not show statistically significantly higher step activity

levels based on the SAM at the .05 level when compared to the control group. The estimated trajectories varied slightly when the data were estimated assuming missing at random using WEE; however, the directions of changes in the estimates were not consistent across outcomes (data not shown). The conclusions derived from the original GEE analyses did not change and hence are robust to departures from the missing completely at random assumption.

Treatment Fidelity Treatment fidelity was considered with regard to study design, training, delivery of treatment, and receipt of treatment (43). Training of the interventionists was completed as delineated in the procedure manual, and retraining was ongoing through monthly meetings of the trainers with the investigators who developed the exercise only and plus only interventions. The exercise only group on average received 45% of the total possible visits, the plus only group received 63% of the total possible visits, and the exercise plus group received 55% of the total possible visits. Seventy direct observations (five different interventionists) of the interventionists were completed by two of the investigators. Overall, there was a 90.8% adherence to delivery of the intervention across all of the treatment groups, and in 92% of the observed visits the participants

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TABLE 3 Predicted Means (SE) and Sample Sizes for Outcome Measures for Each Treatment Group Exercise Only Variable Self-efficacy expectations Baseline 2 month 6 month 12 month Outcome expectations Baseline 2 month 6 month 12 month Exercise time in hours Baseline 2 month 6 month 12 month

Plus Only

Exercise Plus

Routine Care

M

SE

n

M

SE

n

M

SE

n

M

SE

n

p

5.24 6.61 7.35 7.84

0.36 0.45 0.40 0.28

51 40 38 35

5.33 6.30 7.20 7.14

0.34 0.42 0.33 0.45

54 44 46 42

5.54 6.63 7.14 7.30

0.32 0.45 0.45 0.39

52 39 41 36

5.31 6.45 5.89 6.35

0.37 0.36 0.47 0.51

51 42 43 40

.28

3.92 3.91 3.97 4.07

0.10 0.11 0.09 0.09

51 40 39 35

3.99 3.84 3.93 3.89

0.10 0.11 0.09 0.11

54 44 46 42

3.92 4.07 3.86 3.94

0.10 0.09 0.10 0.10

51 39 41 36

3.95 3.88 3.84 3.73

0.08 0.09 0.10 0.10

51 42 43 40

.13

1.21 1.77 2.27 3.34

0.25 0.36 0.29 0.66

51 40 39 35

0.92 1.49 2.91 3.00

0.35 0.28 0.48 0.55

54 44 46 43

0.76 2.08 2.59 3.10

0.25 0.42 0.63 0.65

52 39 41 36

0.66 1.70 1.02 0.92

0.20 0.36 0.25 0.23

51 42 43 40

< .001

Note. n ¼ 208.

demonstrated evidence that they received the intervention as intended.

DISCUSSION Partially supporting the stated hypotheses, this study demonstrated that exposure to the full Exercise Plus Program, the exercise only component, or the plus only component increased reported time in exercise activities among older women post–hip fracture. This subjective report was further supported by the objective data from the SAM for the exercise only and motivation only interventions, but not for exercise plus. As has been suggested

FIGURE 2 Longitudinal trajectories of time (hours) spent exercising as measured by the Yale Physical Activity Survey.

in other exercise intervention studies (12,13,44,45), this study demonstrated that there is benefit to exposing individuals to sources of efficacy information as a way to increase exercise behavior. It is difficult to interpret the lack of a statistically significant increase in the number of steps noted in the exercise plus group. It is possible that these individuals were spending more time in resistive exercise activities that were not captured by the SAM. Conversely, it is possible that combined exercise and plus components in the same hour-long session resulted in a less intense exposure to either the exercise activity or the plus activities thus reducing the impact of the intervention.

FIGURE 3 Longitudinal trajectories of activity (steps) as measured by the Step Activity Monitor (SAM).

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This study further attempted to compare the impact of different components of the intervention. It should be recognized, however, that it is impossible to control exposure to sources of efficacy information in real-world settings. The plus only participants had mastery experiences if and when they did exercise, although this was not with the trainer. Likewise the exercise only participants, by virtue of the exercise program they were given, had goals they could establish for themselves and also received feedback (albeit not the same as the verbal persuasion provided through the plus component) about successfully or not successfully completing the exercise during the course of their exercise session. It is therefore impossible to conclude that mastery alone is sufficient or that verbal persuasion, vicarious experience, or altering unpleasant physiological and affective states is sufficient to motivate older women post–hip fracture to exercise. Future research is needed to replicate these findings as demonstrating the beneficial impact of the plus component alone has practical implications in clinical settings. On average the treatment group participants reported that they engaged in 2 to 3 hr of moderate intensity exercise each week, which approached the recommended 30 min of moderate intensity physical activity on most if not all days of the week (46). Conversely, the no-treatment control group demonstrated a decline in the amount of time they engaged in exercise activities between 2 and 6 months postfracture, and this remained at a low level of 1 hr weekly at the 12-month follow-up point. Clinically, the long-term impact of these differences in time spent exercising can’t be addressed given this study design. The benefits, however, may include a variety of physical and psychological factors such as improved blood pressure, mood, endurance, strength and=or bone mineral density. Although there were trends indicating that individuals in the treatment groups had a greater increase in their selfefficacy and outcome expectations when compared to controls, these differences were not statistically significant. This may, in part, be due to measurement issues. Given that these women volunteered to participate in an exercise intervention study they generally had strong self-efficacy and outcome expectations at baseline. It is also possible changes might have been noted if the participants engaged in all of the intended visits. In particular it is possible that intervening earlier (i.e., in the first 60 days postfracture), as was intended, may have resulted in a greater impact on selfefficacy and outcome expectations. In addition, we focused only on self-efficacy with regard to challenges associated with exercise, not confidence in the performance of the actual exercises prescribed which may have been strengthened given the intervention. The lack of a statistically significant improvement in self-efficacy and outcome expectations has, however, been previously reported (15,45,47–49). McAuley et al. (15) suggested that a decline in self-efficacy following exposure to an exercise intervention can also occur when there is a

Annals of Behavioral Medicine decrease in exposure to exercise classes (or in this case the trainer in the home setting), when exposed to a new exercise program, when there is a change in clinical condition or ability, or when the exercise program is progressively more challenging. The study presented here focused on older women who had just sustained an acute change in clinical condition due to the hip fracture. We believe these individuals may need time to accurately evaluate their self-efficacy related to exercise following the hip fracture. Their self-efficacy evaluations may have reflected prefracture self-efficacy expectations rather than a true reflection of their confidence related to exercise following the fracture. The findings from this study are limited in that the older women in this study were relatively healthy, lived in the community prior to fracture, and willingly participated in an exercise intervention study. In addition there was variability in terms of when the intervention was initiated (due to participant willingness to allow the trainer to come out to the home setting) and some group differences in number of visits to which the participant was exposed. A major concern in this study was the inability to truly control the type and amount of efficacy information that participants were exposed to, limiting our interpretation of the findings. There were also challenges to measurement as multiple measures were based on recall. Despite these limitations, the study demonstrated that it was possible to engage these women in a home-based exercise program and that the plus only, exercise only, or the combined exercise plus program resulted in the desired outcome of increased time in exercise. For practical purposes, replication studies are recommended to determine if the exposure of older women post–hip fracture to the plus component alone is sufficient to increase time spent in exercise as the plus only component only could be easily implemented during follow-up orthopedic visits, daily encounters with nursing assistants in assisted living and nursing home settings and by family members and friends in the home setting.

REFERENCES (1) National Center for Health Statistics, Centers for Disease Control and Prevention: Centers for Disease Control and National Nursing Home Survey (NNHS) Public-Use Data Files. Retrieved December 2006 from http://www.cdc.gov/ nchs/products/elec prods/subject/nnhs.htm (2) Cree M, Carriere KC, Soskolne CL, Suarez-Almazor M: Functional dependence after hip fracture. American Journal of Physical Medicine and Rehabilitation. 2001, 80:736–743. (3) Magaziner J, Hawkes WG, Hebel JR, et al.: Recovery from hip fracture in eight areas of function. Journal of Gerontology: Medical Sciences. 2000, 55A:M498–M507. (4) Fox KM, Hawkes WG, Hebel JR, et al.: Mobility after hip fracture predicts health outcomes. Journal of the American Geriatrics Society. 1998, 46:169–173. (5) Boonen S, Autier P, Barette M, et al.: Functional outcome and quality of life following hip fracture in elderly women:

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