Grow Strong, Live Long

 

Fitness Study with Elderly Retirement Home Independent Living Residents - Part 3

 

Robert Simons, Ph.D., CHES, MS

 

Results

 

Results of the exercise training programs were determined by analyzing the subjects' changes in functional ability, muscle strength, joint flexibility, and health knowledge. Post-testing took place precisely 16 weeks after the pre-testing.

 

Functional Ability

The subjects' functional abilities were assessed by means of the AAHPERD Functional Fitness Assessment for Adults Over the Age of 60 Years, which included a) Ponderal Index, b) Flexibility, c) Endurance (cardiovascular) 880-yard walk, d) Strength test, e) Coordination test, and the f) Agility test. The strength group far surpassed the results of either other group.

The strength groups analysis of results revealed an average improvement of 33% in strength, an 18% improvement in coordination, a 14% improvement in agility, a 7% increase in endurance, a 10% increase in flexibility, and a 1% improvement in ponderal index.

The cardiovascular/walking groups results indicated this group on the average became 11% more flexible, 13% more coordinated, 12% stronger, 6% better endurance, 9% more agile, and a 1% improvement in ponderal index.

The control groups positive results indicated this group on the average became 12% stronger, 13% more coordinated, 2% more flexible, and a 1% improvement in ponderal index. However, negative results also revealed a 21% reduction in agility, and a 6% reduction in endurance. The functional ability results are displayed in Table 1.

Table 1. Functional Ability

Key: PICHG- Ponderal Index change, FLEXCHG-Flexibility change, CORDCHG-Coordination change, STRCHG-Strength change, ENDCHG-Endurance change, ABCHG-Agility Balance change, HTCHG-Health Test change

Table 2. 

Mean changes in functional ability measures over the 16-week training period for the Strength (N=21) and Walking Group (N=18).

*Statistically significant difference (p<0.05)  

 

Muscle Strength

Both body strength and upper body strength improved as a result of the 16-week training program for both the strength and Cardiovascular/walking groups. These were measured by comparing the pre and post Keiser strength machine one-repetition maximum test scores.

As shown in Table 3 for the Strength Group, the strength group subjects' mean 1RM leg extension increased 18.57 pounds from 29.76 to 48.33 pounds, the subjects' mean 1RM leg curl increased 16.00 pounds from 45.24 to 61.24 pounds. Their mean 1RM leg press increased 30.48 pounds, from 183.81 to 214.29 pounds.

Table 3. 

Mean changes for the strength group in lower body strength and upper body strength over the 16-week strength training period.(N=21).

*Statistically significant difference (p<0.05).

Table 4. 

Mean changes for the Cardiovascular/walking group in lower body strength and upper body strength over the 16-week strength training period.(N=18).

*Statistically significant difference (p<0.05).

 

Joint Flexibility

All joint flexibility measures improved over the 16-week training period. The exercise group subjects increased their shoulder abduction by an average of 11.1 degrees (8.62 and 13.62 degrees), and their hip flexion by an average of 3.45 degrees (4.85 to 2.05 degrees). The joint flexibility changes are presented in Table 5.

Table 5. 

Mean changes in flexibility measured for the Strength group (N=21), as compared to the control group(N=21), at the shoulder joint and hip joint (seated) over the 16-week training period.

*Statistically significant difference (P<0.05).

 

Health Knowledge

All participants were administered the same written examination before and after the health series lecture intervention. All three groups similarly improved their health knowledge test scores. The strength group scores, on the average improved by 13%, the walking group by 15%, and the control group by 16%, for an overall average of approximately 15%. This improvement was statistically significant, especially when you consider that 15% represents an improvement of over 8 correct questions on a 55-question test. The health benefit attained with this increased health knowledge is intangible at this time, but could be expected to pay dividends in the future.

Quality of life, social inter-activeness, energy levels, as well as strength and functional ability status soared through the roof in just sixteen short weeks! The abstract psychosocial and psychological benefits were tremendous and were repeatedly acknowledged by the researcher during the majority of the post study consultations with the exercise group participants. The enhanced mood-state, social inter-activeness, and individual energy levels, were perhaps the greatest success of the fitness study. Some of these views will be provided at the end of this review. The health gains were so apparent in the exercise groups in the second half of the study that the control group and other Fountains residents not involved in the study were begging to begin another fitness study so they could begin their exercise programs. A phase two similar study is planned to commence soon, with great support of all involved, residents, families, and staff alike. The next study will combine the benefits of several modes of physical activity and exercise.

 

Discussion

The physician-cleared residents who participated in fitness study were mostly non-ambulatory individuals who initially required considerable encouragement to participate in a study that they perceived as possibly harmful to themselves. Nonetheless, after the pretesting and introductory exercise sessions (for the exercise groups), they followed the designed exercise training protocols with diligence and a sense of commitment. A significant percentage of each group was unable to complete successfully some aspect of pre-testing, such as the 880-yard endurance walk or the agility test. Some members of the strength-training group had to be assisted on and off the Keiser strength machines, and some members of the walking group had to either sit and rest during their assigned walks or had to utilize a cane or walker to complete it (which for some, constituted a near maximal upper and lower body workout). All participants were encouraged to put forth their best effort, but never pushed beyond their individual capabilities.

The strength group, that is, performed one set of each exercise with a resistance/weight load that produced momentary muscle fatigue within 8 to 10 controlled repetitions. This required a relatively high exercise effort, as 8 to 10 repetitions to fatigue represents about 75 percent of maximum resistance.

Because there were no injuries associated with the strength training exercise program, it appears that standard strength training procedures are well tolerated by elderly retirement home residents. There was one injury during a walk from one participant in the walking group. This individual recovered well and resumed the program after a short convalesce. Unrelated to the exercise program, two individuals experienced unrelated illnesses during the course of the study that forced them to discontinue training. Two study participants dropped out due to personal reasons. The 39 subjects who completed the 16-week exercise training programs reported that is was a very positive experience and planned to continue their exercise sessions. According to the lead trainer, residents liked the challenge of serious strength training and saw much more improvement than they anticipated.

The six training exercises were selected specifically for non-ambulatory retirement home residents for the following reasons. The Leg Press machine involves the quadriceps, hamstrings, and gluteus maximus muscles used for moving between seated and standing positions, such as getting in and out of chairs or bed.  Strengthening these large corps stability muscles should therefore improve the residents' ability to lift and lower their bodies. Because these muscles are also essential for standing and walking, the leg press is the foundational exercise in our strength-training program. It is noted that the Keiser leg press exercise is performed with the torso fully supported and at a right angle to the line of force through the legs. This prevents resistance loading on the spinal column, which could be contraindicated for frail, elderly individuals.

The Keiser Chest Press machine targets the upper body pushing muscles, namely the triceps, pectoralis major, and anterior deltoid. These muscles are used in conjunction with the legs when rising from a chair or bed. Seniors typically lean forward, place their hands on the chair armrests, and push hard as they attempt to stand. Of course, they use these same muscles to control their lowering movement when getting back into a chair or bed.

Because it is important to attain balanced muscle development, our remaining 4 exercises were machines supplemented these strength functions. These exercises addressed the upper body pulling muscles (latisumus dorsi, teres major, biceps, and posterior deltoids), as well as the shoulder retraction muscles of the upper back (rhomboids and middle trapezius). An intended outcome of these exercises was improved breathing through better posture, reduced round-shoulderness, and learned adherence to the exercise breathing protocol. Other group participants, community staff members, as well as resident family members noticed the improved posture of the strength group participants. These observations were recorded early in the study and persisted throughout the duration of the 16 weeks.

According to the instructional staff, the six resistance exercises were relatively easy for the subjects to learn and perform. With only six minutes of actual exercise time, most of the strength group participants were able to do the strength-training program without assistance. Some strength group participants needed continued assistance in adjusting the seats and digital resistance device, due to eyesight challenges. Although transition time between exercises increased the session duration to 20 minutes for some subjects, the training program required a relatively small time commitment.

Training intensity appears to be the critical factor for stimulating strength development, as one set of 10 repetitions to momentary muscle fatigue produced significant strength gains in the program participants. A demand must be placed on the musculature for adaptation to take place. The 62%, 35%, , and the 17% increase in three leg 1RM represented an  overall 38% percent increase in lower body strength, and the 16%, 29%, and 19% increase in upper body 1RM represented a 21.3%  percent increase in upper body strength. The practical result for most residents in the strength-training group was improved mobility, ease in sitting down and standing up from chairs, and for several residents the ability to ambulate without a walker or even a cane.

Although the exercise subjects did not perform stretching exercises during the course of the study, their joint flexibility improved significantly in both upper body and lower body sites. The full-range of motion strength training instructed, it is believed, was responsible for increasing shoulder abduction by about 10 percent and hip flexion by about 50 percent. For retirement home patients with limited mobility, enhanced range of joint movement and strength can have important practical applications in the performance of daily tasks, such as putting on and taking off shoes and clothing. The majority of strength group participants noted this improvement.

These results speak for themselves, however, in a comparison of change per group the results are quite revealing. For example, in the comparison of change from the beginning of the study to the end, the strength training group had increases of the following over the control group:

• 338% Endurance improvement

• 312% Strength improvement

• 307% Flexibility improvement

• 210% Agility and balance improvement

• 104% Coordination improvement

In the comparison of change from the beginning to the end, the walking training group had increases over the control group, as follows:

• 333% Endurance improvement

• 133% Strength improvement

• 303% Flexibility improvement

• 153% Agility and balance improvement

In the areas of endurance, flexibility, and strength improvements of the strength group, these figures represent an improvement over the control group of over three times (3X). And for the walking group, increases in endurance and flexibility, were also three times as great.

It was most encouraging to see elderly residents improve their body composition, increase their muscle strength, increase their energy levels, and enhance their joint flexibility.

These physiological changes become more relevant if they result in greater functional capacity and personal independence in performing activities of daily living.

 

Financial

The significantly higher functional ability scores attained by the exercising residents after the 16-week strength and cardiovascular training program was therefore an important finding. The increase represented approximately a 14 and 9 percent improvement in functional independence, respectively for the strength and walking groups. In a retirement home setting, this clearly indicates considerably less need for caregiver assistance.

While this is good news for both the senior residents and retirement community staff, a higher functional ability also has financial benefits. It is estimated that every percentage point increase in a resident's functional ability reduces cost of care by 50 cents a day. A 14% functional ability gain therefore represents a cost of care reduction of $7.00 per day. Multiplying this by the 21 subjects in the strength-training group, we get a daily cost of care reduction of $147.00. On a yearly basis, this represents a savings of $53,655. Because the strength training equipment costs a fraction of this amount, the program would appear to provide desirable financial dividends. Of course, if 100 residents were involved in the strength-training program, the annual cost of care reduction could easily exceed $255,000. The walking groups gains represented a savings of $29,565. Factors directly derived from the exercise training such as, maintaining autonomous, independent living, and delaying assisted living care would be hard to calculate, however, would also be very costly to the individual. As far as individual costs, this would be the most significant savings.

 

Falls

Another indicator of improved functional capacity was incidence of falls, which decreased by 61 percent. Recorded and reported falls for six month periods for the entire group went from 31 to 19 falls. All of these factors taken together attest to the practical benefits of the basic fitness training program, especially strength training.

Because this was one of the first studies conducted to examine functional benefits of exercise, both strength training and cardiovascular training, in a large retirement home facility, we interviewed several of the staff and a few of the participants to ascertain their perceptions of the fitness training program. The following information was obtained from one-on-one interviews with the lead researcher after the study concluded.

Peter Brooks

Executive Director, The Fountains at Boca Ciega Bay

 

Peter Brooks was extremely pleased with the residents' progress, especially their improved functional capacity for the activities of daily living and state of mind. According to Peter Brooks, the study participants exhibited much better physical mobility, energy levels, mental fitness, posture, more endurance, and less pain. What was most gratifying about the outcome of the study in Peters words was that is was very apparent that the quality of life of all involved improved tremendously. We never expected the results to be so significant. To compare the changes of abilities noted in the study from 338% to 210% in the strength group and from 333% to 133% in the walking group, was beyond our wildest dreams. We have established a precedent here at the Fountains and will continue to ride the wave of innovative fitness thinking!

 

Summary of On-Site Feedback

Personnel and Residents

 

All of the staff and participant interviews indicated a high level of satisfaction with the exercise programs, especially the strength-training program. The consensus was that the strength exercises were easy to learn, satisfying to perform, and productive from a performance perspective. Everyone agreed that the strength-training program was both safe and effective, and that it produced positive outcomes in addition to improved physical fitness and functional capacity. It was also noted that the entire facility couldnt wait to begin the next study that will include an exercise group that will combine strength training and walking.

 

Conclusion

It is a simple, successful, and time-efficient program that provides an excellent model for training older adults. It incorporated a strength, as well as a cardiovascular/walking program, with the strength training program outperforming the later.  However, there are other proven strength training programs for the elderly, such as the Tufts University model used in numerous research studies. Regardless of the training protocol utilized, the important point is that sensible and supervised strength exercise should be provided to residents in retirement centers. In a very real sense, these are the individuals who can benefit most from more muscle strength. While one is never too old to begin strength training, it is certainly advantageous to start sooner rather than later. We therefore recommend that independent living facilities also make well-designed strength training programs available to all residents. In addition to improving the participants' functional capacity, such programs should be instrumental in reducing health care costs, thereby benefiting society in general.

Based on the results of our 16-week fitness study at the Fountains at Boca Ciega Bay, we conclude that a basic program of progressive resistance exercise may be a safe and effective means for enabling elderly adults to attain:

• Increased muscle strength,

• Improved balance and stability

• Improved body composition,

• Enhanced joint flexibility,

• Increased functional capacity,

• Improved mobility,

• Enhanced Mood state

• Increased social interaction

Based on firsthand reports from medical staff and residents at the Fountains at Boca Ciega Bay, we further conclude that a supervised strength training program may be related to:

• Increased potential for resident independence,

• Improved cooperation between care givers, staff and residents,

• Improved cooperation among physical therapists, occupational therapists, speech therapists, and recreation specialists,

• Enhanced potential for recruiting new residents,

• Enhanced potential for recruiting new professional staff,

• Reduced health care costs.

PART 1    PART 2

The author wishes to express his sincere appreciation to the Executive Director of the Fountains at Boca Ciega Bay, Mr. Peter Brooks and all the administrators, professional staff, and residents whose leadership, cooperation, and participation made this study a tremendous success. Without the extraordinary vision and sincere desire of Mr Peter Brooks for the improvement in quality of life for so many residents this fitness study would not have been possible. The author also wishes to acknowledge the valuable assistance provided by Katherine Donigan, Susan Wright, and Tammy Makinen.

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