Award-winning Research Papers From the American Academy of Family Physicians ... From the College of Osteopathic Medicine (Ms Hessert and Dr Gugliucci) and BodyWISE Center for ..... Philadelphia: Lippincott, Williams. & Wilkins, 2000.
Award-winning Research Papers From the American Academy of Family Physicians 2004 Annual Scientiﬁc Assembly
Functional Fitness: Maintaining or Improving Function for Elders With Chronic Diseases Mary Josephine Hessert; Marilyn R. Gugliucci, PhD; Heath R. Pierce, MEd Objective: This study’s objective was to prove or disprove four hypotheses, three addressing physical function and a subjective measure of self-perceived well-being from participating in an elder functional ﬁtness program. Methods: Participants included 17 chronically ill residents from an assistedliving center in Maine. Measures on mobility, metabolic equivalent estimation (MET) levels, resting heart rate, blood pressure, oxygen saturation, muscular strength, ﬂexibility, and body weight were conducted at three intervals—baseline, 6 months, and 1 year. SAS software was used for analysis of means and paired t test. Results: Increases in or maintenance of function proved signiﬁcant. The subjective hypothesis also proved signiﬁcant. Discussion: Research on elder exercise focuses on one or two components, rather than the beneﬁts of a thorough ﬁtness program. This study illustrated improvements in physical function and well-being from participating in a comprehensive elder ﬁtness program. (Fam Med 2005;37(7):472-6.) Old age is often accompanied by functional status decline associated with biological aging, medical problems, inactivity, and malnutrition. Unﬁt or deconditioned older adults have a greater likelihood of becoming dependent and succumbing to acute or chronic diseases than do physically ﬁt older adults.1-3 As a cohort, elders are relatively physically inactive. Even those who do not have a diagnosed medical problem are more likely than younger individuals to be weak, fatigue easily, have impaired ability to walk, and suffer from frequent falls—all of which culminate in further limitations in activity.4 While these problems are sometimes accepted as a concomitant of “normal aging,” in reality they are a constellation of symptoms that results from disuse.5,6 Mazzeo et al7 investigated older adults’ physical activity and found that regular physical activity is effective as an intervention to diminish the risk factors for, and possibly completely avoid, functional deterioration associated with aging.7 Indeed, exercise has been shown to improve health status and contribute to an increase in life expectancy.8,9 Healthy and chronically ill elders can combat negative physiological and functional changes with exercise.2,3,10 Exercise can improve cardiovascular function, postural stability,11 ﬂexibility/range of motion, cognitive abilities, depres-
From the College of Osteopathic Medicine (Ms Hessert and Dr Gugliucci) and BodyWISE Center for Health and Fitness (Mr Pierce), University of New England.
sive symptoms,12 strength/muscle mass,13 functional status,14 musculoskeletal ﬁtness,15 perceived health,10 bone density,16,17 muscular strength,16 cardiorespiratory endurance,14 body fat, total cholesterol levels,14 and may reduce pain and disability, leading to increased walking speed, distance, or ability.12 In addition, engagement in physical activity has been shown to affect psychosocial well-being by reducing symptoms of depression.12 It may also increase psychological comfort, cognitive function, self-conﬁdence in the ability to live independently,9 and quality of life.7 To date, much of the research on elder ﬁtness has focused on one or two components of ﬁtness, such as strength or balance,3,5,11,12,15 rather than the beneﬁts of a comprehensive ﬁtness program. The project reported in this paper focused instead on multiple components of ﬁtness. Speciﬁcally, it deals with mobility, exercise capacity measured in metabolic equivalent estimation (MET) levels, resting heart rate, blood pressure, oxygen saturation, muscular strength, ﬂexibility, and body weight. Each of these parameters was tested at baseline and retested to measure change over time. The study’s objective was to test four speciﬁc hypotheses related to the effect on a variety of physiological parameters of a functional ﬁtness program offered at an assisted-living center to elders with chronic health conditions. Our ﬁrst hypothesis was that as a result of exercising for 6 months, average resting heart rate (RHR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body weight would signiﬁcantly decrease. The second hypothesis was that as a result
Vol. 37, No. 7
Award-winning Research Papers From the AAFP 2004 Annual Scientiﬁc Assembly of exercising for 6 months, the average outcome measures for ﬂexibility, grip strength, oxygen saturation, estimated METs, and mobility would signiﬁcantly increase. The third hypothesis was that as a result of exercising for 1 year the outcome measures for the parameters listed in hypotheses 1 and 2 would be maintained or continue to improve during the second 6 months of exercise. The fourth hypothesis was that participants in the program would self-report through a survey/evaluation an increase in satisfaction in quality of life and functional ability at 1 year after beginning the program. Methods Subjects Seventeen residents (15 female, 2 male) of an assisted-living center in Portland, Maine, participated in this study. Participants ranged in age from 64 to 94, with a mean age of 83. Participant information and medical diagnoses are shown in Table 1. There was no control group. Participation was voluntary, and solicitation of participants was achieved by presenting information about the study to residents and then accepting volunteers. An institutional review board-approved informed consent provided participants with information about the research, the exercise program, and their right to terminate the program at any time. Funding for the exercise program was initially provided by a local grant from the assisted living facility’s board of directors and later paid for by the facility’s operating budget.
A detailed description of the program was provided to each participant’s primary care physician along with a request for the physician’s clearance. Participants’ physicians approved their enrollment in the functional ﬁtness program and provided a medical history on a standardized form. Measures and Instrumentation An initial ﬁtness evaluation determined the base level of ﬁtness/ability for each participant. This evaluation consisted of measurements of RHR using a 1-minute palpated radial pulse, oxygen saturation (O2 sat) measured by using a Nonin Onyx Pulse Oximeter, and left arm SBP and DBP obtained with a sphygmomanometer by auscultation. Exercise testing, to establish participant baseline values for study variables and to determine initial exercise intensities, consisted of the RHR, SBP/DBP, and O2 sat (described above), as well the measures shown in Table 2. Procedures Testing was performed prior to the start of the program and repeated at 8 weeks, 16 weeks, 6 months, and 1 year. Exercise classes were 1 hour per day, two times per week, and were comprised of seven components that are shown in Table 3.18 All 17 subjects participated in the exercise program and follow-up from the baseline evaluation until the 6-month evaluation. Thirteen participants were present
Table 1 Participants’ Physical Characteristics Subject
1 2 3 4 5 6 7 8 9 10 11 12 13
Female Female Male Female Female Female Female Female Female Female Female Male Female
14 15 16 17
Female Female Female Female
Average or Percent 88% female
Weight (lbs) 259 140 92 113 148 134 146 206 147 142 124 148 116
64 86 94 90 88 84 84 68 78 90 86 88 89
Height (cm) 170.2 165.1 165.1 157.5 160.1 151.1 154.9 165.1 160.1 162.6 167.6 175.3 149.9
X X X X X X X X X X X X X
X X X
78 76 82 93
160.1 162.6 167.6 162.2
189 150 149 148
X X X X
X X 64%
X X X X 48%
Other OB, MS, wheelchair bound MI, walker use Aﬁb
X X X
CAD, angina OB Aﬁb CA: skin and lung CA: lung and breast CAD Glaucoma, macular degeneration Hypothyroid Presbycusis Aﬁb
Key: AR=arthritis, DM=diabetes mellitus, CHF=congestive heart failure, HTN=hypertension, Chol=high cholesterol, CVA=prior cerebrovascular accident, OB=obese, MS=multiple sclerosis, MI=prior myocardial infarction, Aﬁb=atrial ﬁbrillation, CAD=coronary artery disease, CA=cancer
for the 1-year evaluation. Two participants were unavailable at 1 year for personal reasons, and two died (ages 94 and 86) from pneumonia and cancer, respectively. This research reports the changes from pretest to 6 months for the 17 participants, as well as pretest to 1 year and 6 months to 1 year for the remaining 13 participants. Data Analysis The data were analyzed using SAS quantitative computer software. Raw data were imported into SAS from an Excel ﬁle. All participants were assigned a subject number for anonymity. The baseline measures, identiﬁcation, gender, and ambulation status (need for a wheelchair, walker, or no assistance) comprised the ﬁrst 13 variables. Thirty new variables were created to survey the differences between the pretest, 6-month, and 1-year measures for RHR, SBP, DBP, right grip strength, left grip strength, ﬂexibility, mobility, MET level, body weight, and O2 sat. A procedural mean test was conducted on all the variables, pretest, 6-month, and 1-year test scores revealing the mean, standard deviation, upper and lower conﬁdence intervals, the t values, and the signiﬁcance level. Group results are reported, with some individual measures highlighted.
Table 2 Measures Collected at Baseline • Mobility—3-minute walk test around a 25-m loop, as tolerated, scored by number of laps. • Metabolic equivalent estimation (MET)—metabolic equivalence formula: meters ÷ seconds=m/s; m/s x 60 seconds=m/minute; m/minute x (0.1 + 3.5)=milliliters of O2/kg/minute of activity; ml O2/kg/min ÷ 3.5= MET. • Muscular strength—three trials with a Takei Kiki Kogyo grip dynamometer and a rest interval of 60 seconds between attempts, using the right and left hand, were performed. High score was recorded. • Flexibility—t test, measuring the distance from the participants’ ﬁngertips to the ﬂoor when reaching toward toes. The closest measurement from ﬁngertips to ﬂoor was recorded after three attempts, with a score of zero for those who could touch the ﬂoor. • Body weight—Calibrated Balance Arm Detecto medical scale.
weight after ≥90% attendance. Similarly, the result of exercising for 1 year further increased functional ﬁtness or maintained the improvements they attained at the 6-month evaluation.
Pretest to 6-month Evaluation As shown in Table 4, participants signiﬁcantly imResults proved RHR, SBP, grip strength, ﬂexibility, mobility, The three hypotheses addressing performance meabody weight, MET level, and O2 sat (P< .01 for all comsures were proven true. The results of exercising for parisons). Speciﬁcally, participants’ RHR decreased by 6 months revealed signiﬁcant positive changes for the 2.59 beats per minute, SBP decreased by 6.70 mmHg, participants’ RHR, SBP, ﬂexibility, grip strength (right and 3-minute walking distance increased by 3.53 laps. and left), O2 sat, MET capacity, mobility, and body Right and left grip strength increased by 7.17 and 6.88 kg. Flexibility increased by 3.64 inches. Participants lost 1.3 pounds on average while Table 3 maintaining similar eating habits. They increased their MET Components of the Exercise Program level by .9 METs or by 52% and increased their O2 sat by 1.88 Component Duration Purpose Warm up 5–10 minutes Facilitate the transition from rest to exercise with lowpoints or 2%. DBP increased intensity, rhythmic movements that incorporate large muscle 1.29 mmHg. groups, promote blood circulation, and gradually increase heart rate and body temperature.
Reduce susceptibility to musculoskeletal injury.
Coordinate the muscles and joints to develop ﬁne motor skills.
Resistance exercise/ weight bearing
Augment muscular strength and endurance with slow, controlled movements of 8–10 different exercises for the major muscle groups and one set of 10–15 repetitions per exercise.
Enhance the ability to maintain an upright position (orientation) through static (stationary) and dynamic (moving) equilibrium.
Facilitates the transition from exercise to rest by gradually decreasing heart rate and body temperature.
Maintains and/or increases joint range of motion and muscle ﬂexibility.
Pretest to 1-year Evaluation Table 5 shows that most of the signiﬁcant improvements seen at 6 months continued to be present at the 1-year evaluation. All differences remained statistically signiﬁcant, except for body weight and DBP. Seven participants had a total weight loss of 22 lbs, two maintained their same weight, and four gained weight. Although on average the DBP reading decreased by .62 mmHg, there was no signiﬁcant change from the pretest to 1 year.
Award-winning Research Papers From the AAFP 2004 Annual Scientiﬁc Assembly
Table 4 Pretest to 6-month Evaluation Variable Label RHR SBP DBP Right grip strength Left grip strength Flexibility Walking distance Weight in pounds Metabolic equivalent Oxygen saturation
n 17 17 17 17 17 17 15 17 15 17
Mean -2.5882353 -6.7058824 1.2941176 7.1764706 6.8823529 -3.6470588 3.5333333 -1.2941176 0.9066667 1.8823529
t Value -5.70 -10.87 1.31 15.75 47.28 -6.57 30.97 -4.40 17.11 16.00
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