This quasiexperimental study aimed to measure the effects of 12-week multicomponent exercise training on physical functioning among institutionalized elderly. Forty-three participants (age = 70.88 ± 7.82 years) were self-assigned to an intervention (
Physical functioning is widely recognized as a crucial component of quality of life (QOL) and perhaps the most universally accepted indicator of health status in older persons [
A number of recommendations suggest that physical activity should focus on improving functional fitness by engaging in cardiorespiratory, flexibility, strength, and balance training 3 to 5 days per week [
According to the American College of Sports Medicine (ACSM) and other literatures, recommendation for exercise interventions should consist of aerobic activities, strength training, balance, and flexibility [
Forty-three institutionalized elderly (female = 21, male = 22) aged above 60 years old volunteered to participate in this quasiexperimental study. The inclusion criteria were as follows: able to walk six meters or more with or without any walking devices, free from medical conditions that would prohibit safe participation in low to moderate intensity exercise independently, able to comprehend the study procedures and instructions, not currently involved in a regular exercise program of >30 minutes per day for three times a week, and independent in basic activities of daily living. The purpose and design of the study were fully explained to each subject before they gave written informed consent. The study was approved by the Ethics committee of the Faculty of Medicine, Universiti Putra Malaysia.
The multicomponent exercise training was conducted 3 times per week on every Monday, Wednesday, and Friday over a period of 12 weeks, and each session lasted for 1 hour. The exercises were conducted in the physiotherapy department by a physiotherapist with a staff nurse on standby to assist the older persons in case of any emergency.
The exercise program consisted of: (1) Five to 10 minutes of warm-up exercise, including mobilizing exercises (neck, trunk, upper and lower limb) and breathing exercises; (2) Aerobic exercises involving upper and lower limbs alternately in seated position, starting at low intensity (40–50% maximal heart rate) for first 2 weeks for 20 minutes, progressed to moderate intensity of exercise at slight breathlessness which is equivalent to 50–70% of maximal heart rate [
The subjects in the control group received a session of briefing on health education, at the beginning of the study. The education session highlighted the importance of regular physical activity and exercise. Subjects were followed up by the researcher once in two weeks and advised to continue with their previous lifestyle.
The variables measured in this study included cardiorespiratory or aerobic endurance, muscular function, flexibility, balance, and mobility. The instruments to measure the outcome of the intervention had been described as practical, valid, and reliable for older person [
Aerobic endurance was measured using the 6 min walk test. The subject was asked to walk as fast as possible for 6 minutes throughout the test. The score was the total distance walked in 6 minutes along a 45.72 m rectangular course, which was marked in every 4.57 m.
The chair stand test was used to assess the limb lower muscle endurance particularly the knee extensor. The subject was instructed to sit on a firm straight-backed chair (height approximately 17′′) with arms folded across the chest with arms remained in this position for the entire test. The subject was instructed to rise to a full stand and return back to a fully seated position after the signal “go” was given. The subject was encouraged to complete as many full stands as possible within a 30-second time. After a demonstration by the researcher, the subject completed a practice trial of two repetitions, followed by one 30-second test trial. The number of stands performed within 30 seconds was recorded as the subject’s score for the lower limb muscle endurance.
The grip strength was measured using a hand dynamometer (Lafayette Instrument J00105 JAMAR Hydraulic Hand Dynamometer). The subject was asked to hold the dynamometer in the hand, with the shoulder adducted, elbow flexed to 90 degrees, forearm pronated, slight wrist extension, and ulnar deviation position. The subject was instructed to squeeze the dynamometer with maximum isometric effort, maintained for about 2 to 5 seconds. The researcher demonstrated the procedure before the test was conducted, and then the subject performed three test trials with 60-second rest given between trials. The average of the three readings was recorded as grip strength.
The arm curl endurance was measured based on the number of arm curl movement in 30 seconds using a dumbbell [
The chair sit-and-reach test (CSR) was used to assess lower limb flexibility particularly of the hamstrings and lower spinal extensors. Subjects were asked to sit on the edge of a chair; one leg was flexed at 90 degrees with the foot flat on the floor while the other leg was extended straight in front of the hip with heel on the floor and foot flexed at 90 degrees. The subject was instructed to bend forward at the hip while sliding hands down (overlapping each other) the extended leg as far as possible, holding the position for 2 seconds and the distance was measured from the middle fingers to the toes using a ruler. This was repeated 3 times, and the best of the 3 distances was taken.
The back scratch test (BS) was used to assess the upper limb flexibility [
The functional reach test (FRT) was used to measure balance that is required for postural control during perturbed movement [
The time up-and-go test (TUG) was used to measure functional mobility [
Descriptive statistics were performed on demographic characteristics, baseline and post-intervention results and data were reported as means (M) ± standard deviations (SD). Baseline and posttest data were found to be normally distributed using Kolmogrov and Shapiro tests. Improvements were reported in percentage for all physical functioning tests. A two-way repeated measures ANOVA were used to compare differences between groups. The within-group changes between baseline and posttest were determined using paired
The demographic data for the subjects are illustrated in Table
Demographic characteristics of study population at baseline.
Characteristics ( | Exercise ( | Control ( | |
---|---|---|---|
Mean age, years ( | 70.19 (8.84) | 71.80 (6.88) | .506 |
Female, | 11 (47.8) | 10 (50.0) | |
Male, | 12 (52.2) | 10 (50.0) | |
Mean height, m ( | 1.53 (0.08) | 1.53 (0.07) | .979 |
Mean weight, kg ( | 53.18 (9.11) | 55.30 (10.34) | .480 |
Mean BMI, kg/m2 ( | 22.93 (4.17) | 23.95 (5.23) | .479 |
Ethnicity | |||
Malay | 14 (60.9) | 13 (65.0) | |
Chinese | 5 (21.7) | 4 (20.0) | |
Indian | 3 (13.0) | 3 (15.0) | |
Others | 1 (4.3) | — | |
Length of residency, years ( | 3.14 (2.82) | 4.56 (3.97) | .165 |
Table
Means, SD and % changes in all measures before and after intervention for the exercise and control groups.
Variables | Exercise group | Control group | ||||
Baseline | 12-week | % change | Baseline | 12-week | % change | |
CRE (m) | 208.92 ± 87.62 | 296.22 ± 110.53 | 41.79* | 238.26 ± 130.73 | 213.11 ± 129.70 | −10.56 |
RAC (rep) | 12.91 ± 4.92 | 16.13 ± 6.18 | 24.95* | 13.83 ± 4.25 | 13.15 ± 3.25 | −4.92 |
LAC (rep) | 13.04 ± 5.50 | 17.04 ± 5.20 | 30.7* | 13.10 ± 5.39 | 12.65 ± 4.22 | −3.44 |
RHG (kg) | 14.61 ± 7.86 | 16.58 ± 8.10 | 13.55* | 15.59 ± 11.59 | 16.63 ± 9.14 | 6.67 |
LHG (kg) | 13.33 ± 6.87 | 15.99 ± 7.29 | 19.93* | 15.67 ± 8.13 | 15.47 ± 8.88 | −1.29 |
LL (rep) | 9.22 ± 4.04 | 13.48 ± 3.23 | 46.19* | 9.40 ± 4.06 | 9.05 ± 3.52 | −3.72 |
RLL (cm) | −5.27 ± 11.42 | −1.92 ± 8.08 | 63.57 | −5.07 ± 11.16 | −6.01 ± 11.32 | 18.54 |
LLL (cm) | −3.78 ± 10.23 | −2.09 ± 7.81 | 44.71 | −4.56 ± 9.40 | −5.30 ± 9.68 | 16.23 |
RUL (cm) | −8.10 ± −18.56 | −11.07 ± 14.19 | 36.67 | −15.67 ± 15.79 | −17.32 ± 12.78 | 10.53 |
LUL (cm) | −12.48 ± 19.9 | −20.35 ± 14.77 | 63.1 | −21.12 ± 11.91 | −22.04 ± 10.68 | 4.36 |
BAL (in) | 7.06 ± 2.28 | 10.56 ± 2.64 | 49.58* | 7.13 ± 2.47 | 6.62 ± 2.17 | −7.15 |
MOB (sec) | 13.69 ± 5.95 | 10.08 ± 3.75 | 26.37* | 13.59 ± 6.78 | 14.83 ± 7.66 | 9.12 |
Note: CRE: cardiorespiratory endurance, RAC: right arm curl strength, LAC: left arm curl strength, RHG: right handgrip strength, LHG: left handgrip strength, LL: lower l limb strength, RLL: right lower limb flexibility, LLL: left lower limb flexibility, RUL: right upper limb flexibility, LUL: left upper limb flexibility, BAL: balance, MOB: mobility.
*Significance at 0.05 level.
The results of repeated measure ANOVA for cardiorespiratory endurance for both intervention and control groups revealed that there was no significant difference between groups after the 12-week duration (
In terms of muscular function, there were no significant differences between groups after 12-week duration for measures of right arm curl (
There were no statistical differences between the two groups for measure of right lower limb flexibility (
Balance measure was found significantly different between the two groups after 12 weeks (
The finding in cardiorespiratory endurance was consistent with previous RCT conducted among institutionalized older persons [
The subjects in the exercise group started the cardiorespiratory exercise in the sitting position in the first two weeks and progressed to standing. In the standing position, the movements involved walking on the spot, stepping backward, forward, sideways, and lifting the knees with movements of the arms. These activities could have facilitated the movement while carrying out the 6MWT in which it involved walking at their own pace. The exercises were started in the sitting position to develop confidence and were also meant to familiarize subjects with various movements as there were many changes of movement throughout the exercise session.
Changes in the muscular function were consistent with previous studies conducted to improve muscle strength and hand grip strength in older persons’ institutions using RCT [
Intensity of the exercise selected in this present study was from low to moderate in order to reduce adverse effect. This was well supported in an RCT (exercise versus control) by Littbrand et al. [
The protocol of the exercise to train the strength of the lower limb in this study was based on functional tasks of older persons. Previous studies that trained the lower limbs using a leg press machine did not produce significant improvement on knee strength [
It was also observed in this study that the rate of change in the improvement of muscle function was not consistent which was at 46.19%, 24.95%, 30.7%, 13.55%, and 19.93% for lower limb, right arm curl, left arm curl, right handgrip, and left handgrip, respectively. This is consistent with the argument by Gleberzon and Anis [
The observed findings of flexibility were not significant in the exercise group and are consistent with previous studies. Chin et al. [
The possible reason for the lack of improvement in flexibility is duration of sustaining the stretch. In this study, the protocol was to stretch all major muscle groups for 15 to 20 seconds for 5 times every session as part of warm-up and cool-down movement. Previous studies which included stretching alone showed that 15-second to 60-second stretch enhanced flexibility of the lower limb [
Longer holding times during stretching and daily performance might result in higher rate of gains in flexibility and a more sustained increase in flexibility in older persons. However, this was quite controversial as prolonging stretching causes increase in muscle length, and thus decreases the amount of passive force that it develops at certain points in the range of motion that the muscle crosses [
The results of functional mobility in this study were consistent with previous findings on older persons living in an institution [
The training in this study was incorporated with strength training, and the results in the measure of lower limb strength were significant in the exercise group. Thus, it can be concluded that it is associated with the improvement of the lower limb strength, as the relationship between leg strength and dynamic balance prior (
It is reasonable to believe that short-term studies conducted over a few weeks have certain limitations. According to the American College of Sports Medicine [
The exercise program incorporated all the components of fitness required by older persons, which included strength, aerobic, flexibility, and balance training, and based on low frequency, low to moderate intensity, and using easily administrable and cost-effective equipment. Each activity or movement was implemented to mimic functional tasks in order to train functions required in a real-life situation that is directed towards activities of daily living by means of sitting and standing.
The findings of this study support that exercise interventions which incorporate the elements of multicomponent exercise training improved cardiorespiratory endurance, muscle strength, and balance performance in institutionalized older persons. This shows that the majority of the frail older persons responded to the multicomponent exercise intervention. Therefore, the key clinical strategy is to support interventions that improve or maintain physical function. Thus, this might offer health care providers and practitioners the opportunity to develop exercise intervention which comprised the elements of multicomponent exercise training.
However, it is inconclusive as to which of the component of exercise was the actual cause of the outcome observed as the intervention used was a combination of cardiorespiratory, muscle strength, flexibility, and balance training. It is also not known that how much dosage or intensity of each component of this training had actually contributed to the improvement of each of the outcome that was observed. As such, future study is needed to compare a multicomponent exercise program with a single component of exercise intervention, for example, comparing a multicomponent exercise with aerobic training alone or with a combination of aerobic and strength training.
None of the authors have conflict of interests to disclose.
Acknowledgement goes to Faculty of Health Sciences, Universiti Teknologi MARA for providing research materials for the study. The authors also wish to thank the participants of this study for their valuable contribution and time spent in the intervention.