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DOCTORA L T H E S I S

2008:01

Department of Health Sciences, Division of Health and Rehabilitation, Luleå University of Technology, Sweden

in collaboration with the Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Sweden.

EFFECTS AND EXPERIENCES OF

HIGH-INTENSITY FUNCTIONAL EXERCISE PROGRAMMES

AMONG OLDER PEOPLE WITH

PHYSICAL OR COGNITIVE IMPAIRMENT

Nina Lindelöf

From the Department of Health Science, Division of Health and Rehabilitation, Luleå University of Technology, Sweden,

and the Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Sweden

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EFFECTS AND EXPERIENCES OF

HIGH-INTENSITY FUNCTIONAL EXERCISE PROGRAMMES

AMONG OLDER PEOPLE WITH

PHYSICAL OR COGNITIVE IMPAIRMENT

Nina Lindelöf

From the Department of Health Science, Division of Health and

Rehabilitation, Luleå University of Technology, Sweden

and the Department of Community Medicine and Rehabilitation, Geriatric

Medicine, Umeå University, Sweden

.

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All previously published papers are reproduced with permission from the publisher. Print office Universitetstryckeriet, Luleå

Copyright Nina Lindelöf

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CONTENTS

ABSTRACT 7

SVENSK SAMMANFATTNING (SUMMARY IN SWEDISH) 8

LIST OF ORIGINAL PAPERS 10

ACRONYMS AND ABBREVIATIONS 11

DEFINITIONS 12

INTRODUCTION 14

AGING 14

Frailty 15

CONSEQUENCES OF PHYSICAL INACTIVITY AND PHYSICAL IMPAIRMENT 16

Consequences of inactivity 16

Consequences of physical impairment 16

Associations between physical impairments and functional limitations 17

PHYSICAL ACTIVITY AND EXERCISE 18

Exercise principles and modes 18

Recommendations and contraindications for exercise among older people 20

Effects of physical activity and exercise in old age 20

Nutrition and exercise 22

FACTORS THAT INFLUENCE EXERCISE BEHAVIOUR 23

Motivation for exercise 23

Barriers toward exercise 23

Positive and negative influences on exercise participation 24

Self-efficacy 24

Attitudes and beliefs 25

Exercise experiences 25

RATIONALE AND AIMS 26

RATIONALE OF THE THESIS 26

AIMS OF THE THESIS 27

Specific aims 27

METHODS 28

SETTINGS AND PARTICIPANTS 28

STUDY DESIGN OF PAPER I 36

Exercise intervention 36

STUDY DESIGN OF THE FOPANU STUDY (PAPERS II-IV) 38

Screening and randomisation 38

Exercise intervention 38

Control activity 41

Nutrition intervention and placebo 41

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ASSESSMENTS AND DATA COLLECTION 41

Outcome variables and interview data 41

Descriptive characteristics in the FOPANU Study 44

ANALYSES 44 Paper I 44 Paper II 44 Paper III 45 Paper IV 46 RESULTS 47 PAPER I 47 PAPER II 51

Between-group effects of interventions 51

Adverse events and drop-outs 51

Attendance and compliance 51

PAPER III 54

PAPER IV 57

Sub-themes 59

Theme 59

DISCUSSION 60

PERFORMING HIGH-INTENSITY EXERCISE AMONG FRAIL OLDER PEOPLE 60

SHORT-TERM EFFECTS 61

LONG-TERM EFFECTS AND PERFORMANCE IN DAILY LIFE 62

NUTRITION INTERVENTION TO INCREASE EXERCISE EFFECTS 64

INCENTIVES AND DISINCENTIVES FOR EXERCISING 64

INTERACTION WITH OTHER PARTICIPANTS, SUPERVISORS AND STAFF 66

SELF-EFFICACY BELIEFS 68 ATTITUDE 69 WILL TO BE ACTIVE 69 METHODOLOGICAL CONSIDERATIONS 70 ETHICAL CONSIDERATIONS 74 CLINICAL IMPLICATIONS 75

IMPLICATIONS FOR FUTURE RESEARCH 76

CONCLUSIONS 78

ACKNOWLEDGEMENTS 79

REFERENCES 82

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EFFECTS AND EXPERIENCES OF HIGH-INTENSITY EXERCISE PROGRAMMES AMONG OLDER PEOPLE WITH PHYSICAL OR COGNITIVE IMPAIRMENT

Nina Lindelöf, the Department of Health Science, Division of Health and Rehabilitation,

Luleå University of Technology and the Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Sweden.

A

BSTRACT

Exercise programmes with functional exercises improve lower-limb strength, balance, and gait ability in older people. Exercising at high intensity produce better results than low-intensity training. Perceptions and experiences of exercise impact on motivation to and attendance in exercise programmes. An intake of protein immediately before or after exercising has shown an increase of the exercise effects on muscle mass and strength. However, there are few studies investigating the effects, perceptions or experiences of high-intensity physical exercise in older people with pronounced physical or cognitive impairment.

The aims of the thesis were to evaluate the effects on physical performance of high-intensity functional exercise programmes among older people with physical or cognitive impairments, to evaluate the perceptions and describe the experiences of participating, and to investigate whether an intake of protein-enriched energy supplement immediately after the exercises increases the effect of the training.

In a single subject experimental design, three frail older women with residual problems after hip fracture performed a functional exercise programme using a weighted belt. Visual and statistical analyses of graphs showed improvements in dynamic balance and in comfortable and maximum gait speed for all three participants. The results were difficult to interpret for isometric knee extension strength and indicated no or very small improvements.

One hundred and ninety-one older people with a Mini Mental State Examination (MMSE) score of 10, dependent in activities of daily living, and living in residential care facilities, participated in a randomized controlled trial. They were randomized to exercise intervention or control activity, both of which included 29 sessions over three months, and to protein-enriched energy supplement or placebo taken immediately after each session. At a three-month follow up the exercise group had improved significantly regarding comfortable gait speed. At six months comfortable gait-speed, Berg Balance Scale, and one repetition maximum in leg press, all improved compared with the control group. The intake of protein-enriched energy supplement did not increase the effects of the exercise.

Participants with an MMSE score of 21 from the exercise group (n=20), and from the control group (n=28), answered a questionnaire. The perceptions of having participated in the activities were reported in a similarly positive way in both groups. However, significantly more respondents in the exercise group prioritized the exercise above other activities, had had positive outcome expectations, and felt encouraged during the sessions. They reported that, as a result of the exercise, they felt less tired and perceived improvements in lower-limb strength, balance, and safety and security when mobile, to a significantly greater degree than the participants in the control group.

The experience of participating in the high-intensity functional exercise programme was described in interviews conducted with nine of the exercise participants. The interviews were analysed using qualitative content analysis. The findings show that the informants believed in positive effects and had a strong will to be active in order to avoid decreased capacity. They were struggling with failing bodies that constituted barriers to exercise. The support from the supervisors and belief in personal success facilitated performance of the exercise. The informants told of improvements in body and soul and that exercising in groups created a sense of togetherness.

In conclusion, among older people with physical or cognitive impairments, high-intensity exercise programmes resulted in improved physical performance, both when measured by physical tests and when reported as subjective perceptions. A protein-enriched energy supplement, however, did not increase the exercise effects. Although bodily limitations could constitute barriers to exercise, the respondents communicated positive perceptions and experiences of participating in the high-intensity exercise programmes and reported a low rate of discomfort.

Key words: Balance, Exercise, Exercise experience, Frail elderly, Gait, Interviews, Muscle strength,

Qualitative content analysis, Questionnaire, Randomised controlled trial, Residential facilities, Single subject experimental design

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SVENSK SAMMANFATTNING

(SUMMARY IN SWEDISH)

Bland äldre människor som är friska eller har måttliga funktionsnedsättningar har funktionell fysisk träning visat goda resultat på benmuskelstyrka, balans- och gångförmåga. Träning med hög intensitet ger bättre resultat än lågintensiv träning och ett proteinintag i direkt anslutning till styrketräning kan öka effekterna på muskelmassa och muskelstyrka. Upplevelse av och uppfattning om träning har visat sig påverka motivation till träning och träningsnärvaro. Få studier har dock undersökt effekter, uppfattningar och upplevelserna av högintensiv, funktionell träning bland äldre människor med uttalade fysiska eller kognitiva nedsättningar.

Syften med denna avhandling var att utvärdera högintensiva, funktionella träningsprogram avseende effekterna på benmuskelstyrka, balans- och gångförmåga och att utvärdera om ett proteinintag direkt efter träningspassen ökade träningseffekterna. Ytterligare syften var att undersöka uppfattningar och beskriva upplevelser av att delta i programmen.

I en mindre studie, en så kallad single subject experimental design, undersöktes effekterna av ett träningsprogram hos tre äldre kvinnor med tidigare höftfraktur. Träningsprogrammet var intensivt med funktionella och kombinerade benstyrke- och balansövningar. Deltagarna bar ett viktbälte runt midjan under hela träningspassen för att öka belastningen på benmuskulaturen. Resultaten visade förbättringar av självvald och maximal gånghastighet samt av dynamisk balans både vid visuella analyser, illustrerade med grafer, och vid statistiska analyser. I statisk lårmuskelstyrka var resultaten svårtydda och visade inga eller mycket små förbättringar.

I en randomiserad kontrollerad studie, FOPANU studien (the Frail Older People - Activity and Nutrition Study in Umeå), deltog 191 äldre personer boende på servicehus. De var alla beroende av hjälp i aktiviteter i det dagliga livet, hade ett Mini Mental Test (MMT) på 10 poäng eller över och klarade att resa sig från en stol med högst en persons hjälp. De lottades till att delta i ett träningsprogram eller en kontrollaktivitet. Inom dessa grupper lottades deltagarna till att få proteinberikad dryck eller placebodryck. Tränings- och kontrollaktivitet utfördes under tre månader, totalt 29 tillfällen. Protein- och placebodryck intogs direkt efter varje aktivitets- och träningspass. Vid tremånadersuppföljning, direkt efter aktivitetsperioden, hade självvald

gånghastighet förbättrats signifikant mer i träningsgruppen än i kontrollgruppen.

Träningsgruppen visade även statistiskt säkerställda förbättringar i jämförelse med kontrollgruppen, i självvald gånghastighet, balans och benstyrka, efter ytterligare tre månader. Proteintillskottet ökade inte effekterna av träningen.

Deltagare utan eller med små kognitiva nedsättningar (MMT 21 poäng) från träningsgruppen (n=20) och kontrollgruppen (n=28) svarade på en enkät om deltagandet i aktiviteterna. Frågorna handlade om hur man uppfattade deltagandet, inställning till aktiviteten samt upplevda effekter av träning respektive kontrollaktivitet. I båda grupperna var uppfattningen av att delta i aktiviteterna positiv. Signifikant fler i träningsgruppen prioriterade denna träningen framför andra aktiviteter,

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hade positiva förväntningar på effekter och hade känt uppmuntran under träningspassen jämfört med deltagarna i kontrollgruppen. De svarade också i högre grad än kontrollgruppen att deras trötthet hade minskat, att deras benmuskelstyrka och balans förbättrats och att de kunde röra sig tryggare och säkrare. Svaren om förbättringar i fysisk funktionsförmåga avspeglade sig i utförandet i fysiska funktionstester.

Nio av deltagarna i träningsgruppen deltog i intervjuer där de beskrev sina upplevelser av att delta i den högintensiva funktionella träningen. Intervjuerna analyserades med kvalitativ innehållsanalys. Analysen av intervjuerna visade att träningen innebar övervinnelse av begränsningar för att få ökad vitalitet i både kropp och själ. Informanternas drivkrafter var att de trodde på positiva effekter av träningen och att de ville vara aktiva för att undvika försämrad fysisk funktionsförmåga. De berättade att stöd från tränarna liksom tilltro till den egna förmågan att lyckas underlättade genomförandet av träningen. Informanterna beskrev att de fick kämpa med kroppsliga svagheter vilka begränsade möjligheterna till att delta i träningen och utgjorde hinder för genomförandet av träningen. De upplevda effekterna visade på stor bredd, från förbättrad fysisk kapacitet och förbättrad tankeverksamhet till ökat självförtroende och en känsla av gemenskap med de andra i gruppen.

De olika studierna kompletterar varandra genom att bidra med uppmätta och upplevda effekter och genom kunskap av hur äldre personer med funktionsnedsättningar kan uppfatta och uppleva deltagande i träningen. Fynden visar att deltagarna vill, kan och föredrar att träna. Träningen medförde fördelar avseende effekter på benmuskelstyrka, balans och gångförmåga samt upplevda förbättringar av fysiska och mentala förmågor och av ökad social gemenskap. Ett proteinberikat energitillskott ökade inte effekterna av träningen. Deltagarna har uppgett en låg grad av obehag orsakade av träningen, men kroppsliga begränsningar kan upplevas som ett hinder för träningen. Vid sidan av kunskaper om träningens effekter och deltagarnas fysiska förmågor är även kunskaper om deras upplevda obehag, drivkrafter och hinder för träning viktiga aspekter för att utföra individualiserad och effektiv träning. De positiva fynden innebär att äldre personer med fysiska eller kognitiva nedsättningar bör ges möjlighet att delta i intensiv funktionell träning.

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LIST OF ORIGINAL PAPERS

I Lindelöf N, Littbrand H, Lindström B, Nyberg L. Weighted belt exercise for frail older women following hip fracture – A single subject design. Advances in Physiotherapy. 2002;4:54-64.

II Rosendahl E, Lindelöf N, Littbrand H, Yifter-Lindgren E, Lundin-Olsson L,

Håglin L, Gustafson Y, Nyberg L. High-intensity functional exercise program and protein-enriched energy supplement for older persons dependent in activities of daily living: A randomised controlled trial. Australian Journal of Physiotherapy 2006;52:105-113.

III Lindelöf N, Rosendahl E, Gustafsson S, Nygaard J, Gustafson Y, Nyberg L Perceptions of participating in high-intensity functional exercise among older people with disability. Submitted

IV Lindelöf N, Karlsson S, Nyberg L, Lundman B. Experiences of and motives for a

high-intensity functional exercise programme among older people dependent in activities of daily living. Submitted.

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ACRONYMS AND ABBREVIATIONS

ACSM American College of Sports Medicine

ADL Activities of Daily Living

ANCOVA Analysis of Covariance

ANOVA Analysis of Variance

BBS Berg Balance Scale

BMI Body Mass Index

CI Confidence Interval

CONSORT Consolidated Standards of Reporting Trials

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4thedition

ES Effect Size

FAC Functional Ambulation Categories

FOPANU Study Frail Older People - Activity and Nutrition Study in Umeå

GDS Geriatric Depression Scale

HIFE Program High-Intensity Functional Exercise Program

ICC Intra-Class Correlation

MMSE Mini Mental State Examination

MNA Mini Nutritional Assessment

OT Occupational Therapist

PT Physiotherapist

RCT Randomised Controlled Trial

RM Repetition Maximum

SCT Social Cognitive Theory

SD Standard Deviation

SE Standard Error

SSED Single Subject Experimental Design

TPB Theory of Planned Behaviour

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DEFINITIONS

Balance

has been defined as a multidimensional concept, referring to the ability of a person not to fall1,2.

Balance, also referred to as postural stability, is the ability to control the centre of mass (a point that is at the centre of the total body mass) in relationship to the base of support (the area of the body that is in contact with the support surface)3.

Disability

Difficulty carrying out activities on one’s regular environment, in any domain of life. Disability is the gap between personal capability and environmental demands and is measured by self-reports or proxy reports about degree of difficulty4.

Exercise

A physical activity that is planned structured, repetitive, and purposive, i.e. done with the intention of improving or maintaining physical fitness. However, exercise is not synonymous with physical activity5.

Functional capacity

Basic physical and mental actions, such as, to ambulate, reach, stoop, climb stairs, produce intelligible speech, see standard print etc.6.

Functional limitation

Restrictions in performing fundamental task-oriented physical and mental actions used in daily life. Physical actions include overall mobility, discrete motions and strengths, and trouble seeing, hearing, and communicating. Mental actions include cognitive and emotional functions4.

Functional threshold

A hypothetical threshold after which enhancements in, for instance, strength, will no longer contribute to continued improvements in functional capacity, however, they may add to reserves of strength. This presupposes that the relation between impairments and functions is

curvilinear7,8.

Health

A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity9.

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Impairment

Dysfunctions and significant structural abnormalities in specific body systems, that can have consequences for physical, mental, or social functioning4.

Physical activity

Has been defined as any bodily movement produced by contractions of skeletal muscles that increase energy expenditure5,10. Leisure-time physical activity is a broad description of activities pursued during free time, based on personal interests and needs, e.g. exercise programmes as well as walking, hiking, gardening, sports, and dance5,10.

Physical fitness

A set of attributes (e.g. skeletal muscle strength and balance) that people have or achieve that relates to their ability to perform physical activity10.

Repetition maximum (RM)

The weight which requires maximum exertion to perform one repetition is one repetition maximum (1 RM) and the maximum weight that can be lifted with five or ten repetitions are 5 RM and 10 RM, respectively11.

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INTRODUCTION

Aging involves physical or cognitive decline. Physical activity decreases with increasing age, which is in turn associated with further physical decline. Since physical activity and exercise can improve physical capacity even among older people, the physical activity level should preferably be increased in the oldest age groups. High-intensity exercise programmes produce better results than lower intensity programmes. However, there are few high-intensity exercise studies among older people with severe physical or cognitive impairments. Accordingly, the evidence concerning the benefits of high-intensity physical exercise among older people with severe physical or cognitive impairment is weak. Attitudes, perceptions and experiences concerning exercise have an impact on motivation and attendance in exercise programmes but there are few studies that have investigated this among frail, older people. To substantiate the evidence and increase our knowledge about the effects and experience of high-intensity exercise there is a need for studies that evaluate various perspectives of participating in high-intensity exercise among older people with physical or cognitive impairment. This thesis comprises four papers that, using different methods, investigate the effects, perceptions, and experiences of high-intensity functional exercise programmes among older people with varying levels of physical or cognitive impairments.

AGING

In this thesis older people are defined as aged 65 years and older since this is the most common definition in Swedish studies, as well as the retirement age in Sweden. Older people constitute 17% of the Swedish population12and are projected to account for 25% in 2030. The proportion

of the very old, aged 80 and over, is increasing even more 13. As women live longer, the

proportion of women in Sweden 2005 was 57% in the group of people aged 65 years and over and 64% of those over 80 years14.

Increased age is associated with decline in the physiological systems and in physical ability, for example in muscle strength, balance, and gait ability15-17. With increasing age cognitive function

also declines18,19, and the prevalence of diseases increases 20. Common diagnoses among the

oldest old are sleeping problems, constipation, stroke, hypertension, impaired vision, dementia, heart failure, 21, depression 21,22, and fatigue 23,24. Having had a hip fracture and urinary tract

infection are also common among women, as is malignancy among men21. However, normal

aging does not result in significant impairment and healthy, old people should still have some reserve capacity in most physiological systems7,16. The aging process is not only a result of the

chronological age. Age-related physical decline can be determined by many factors, such as, diseases, inactivity or aging itself 25. The increase in average life span and associated physical

decline implies that also the group of older people with physical or cognitive impairments and multiple diseases is growing.

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There are also positive aspects to growing old. Aging involves gains and losses, health and ill health, and strength and weakness. The concepts good aging, successful aging, active aging, and healthy aging describe aging as a positive experience26. Active aging is a term used by the World

Health Organization (WHO) and involves maintained autonomy, independence and quality of life for all people, including those who are frail, disabled, and in need of care. Mental health and social contacts are as important as physical health27. Older people’s own perceptions of what it

means to be old can be quite optimistic, for example, they often rate their health as good or very good despite disease 20,21,28. However, the ability to be active and independent is perceived as

important for life satisfaction29.

There are several theories of aging that try to explain how people adapt to aging and those that describe how older people relate to activities are of interest for this thesis. According to the

disengagement theory of aging, it is a natural process for older people to be more self-centred, less involved with other people and to reject social roles and activities30. The theory of gero-transcendence

has been developed by Tornstam31, who describes gero-transcendence as a characteristic change

where the old individual moves from a materialistic and rational to a cosmic and spiritual world view, normally followed by increased satisfaction. The individual becomes less self–centred, more selective in their choice of activities, less interested in superficial social relations and material things, and in increased need of private meditation 31. In contrast, in the activity theory one

assumption is that old people who are active will be more satisfied and well-adapted than those who are sedentary and conditions during aging are better if the older person remains active32-34.

According to the continuity theory of aging, a key concept for older people is continuity, in spite of the life changes following the aging process35,36. Continuity is the maintenance of general internal

and external patterns of thoughts and actions. Many older people show consistency over time concerning life arrangements, familiar activities, activity profiles, and social patterns despite obvious changes in health, physical dependency and social circumstances36. When aging involves

functional impairment it is more difficult to create continuity since continuity of the self, as well as the feeling of competence and self-esteem, is affected negatively36.

Frailty

One aspect of aging and physical decline is frailty, which is a term commonly used in studies about older people without the meaning being defined. According to the MeSH database frail individuals are lacking in general strength and are unusually susceptible to disease or to other infirmities37. Campbell & Buchner38discuss the lack of an adequate definition of frailty. They

define frailty as the risk of loss, or further loss, of function. They also state that frailty is best regarded as “a condition or syndrome, which results from a multi-system reduction in reserve capacity to the extent that a number of physiological systems are close to, or past, the threshold of symptomatic clinical failure”. The consequences of this are increased risk of disability and death from minor external stresses 38. Similarly, Rockwood et al. 39 describe frailty as a

multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health) that gives rise to vulnerability. The clinical characteristics of frailty are, according to Strandberg40

aneroxia, sarcopenia, osteoporosis, fatigue, risk of falls, and poor physical health and according to Chin A Paw et al.41 unintentional weight loss, self-reported exhaustion, muscle weakness, slow

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walking speed, and low level of physical activity. The natural course of frailty is progressive, increasing the risk of comorbidity and disability over time40. However, frailty is considered to be an appropriate focus for prevention, rehabilitation, and public-health programmes among older people38.

CONSEQUENCES OF PHYSICAL INACTIVITY AND PHYSICAL IMPAIRMENT Consequences of inactivity

Most old people live a sedentary life and a progressive decline in physical activity is observed with increasing age42,43. This is most apparent among women and those with physical impairments and

diseases 43-45. Sedentary lifestyle is a major health problem and lack of physical activity is

detrimental to one’s health43,46,47. Physical inactivity and its consequences have been described as

a public-health problem comparable to high blood cholesterol, hypertension, and smoking46,47.

Reductions in physical activity are associated with significant impairments, functional limitations, disablement, and chronic illness7. There is a hypothesized, causal relationship between inactivity,

functional limitations, and disability in older people that has been supported by longitudinal studies 16,48. Symptoms that are associated with sedentary lifestyle are, for example, type 2

diabetes, hypertension16,47, depression, low self-efficacy, sarcopenia, reduced endurance capacity,

reduced muscle strength, and impaired gait and balance16,45.

Consequences of physical impairment

Regardless of whether physical decline during aging is a result of aging itself, inactivity or disease, it implies consequences that can have a great impact on life for the older individual. The consequences of physical decline, such as impaired lower limb strength, balance, and gait ability, can be dependency in activities of daily living (ADL)42,49,50and admission to a residential care

facility51. In 2006, 6% of Swedish people aged over 65 years, i.e. 99 000 individuals, were living in

residential care facilities and of those 70% were women52. Most of those living in residential care

facilities are dependent in ADL, have cognitive or physical impairments, and a high prevalence of diseases 53. Common diagnoses and symptoms among older people living in residential care

facilities are vision and hearing impairment, dementia, depression, heart disease, previous stroke, previous fractures, delirium episodes and urinary incontinence 53. Sixty-five percent of those living in residential care facilities suffer from dementia14. Dementia is associated with physical

impairments and reduced function54-56, increased risk of falling53,54,57, and declining basic motor

performance, such as walking and mobility, during the course of the disease54,58,59.

The consequences of impaired mobility and balance, can be falls60and fractures51. Among older people living in ordinary housing one third fall each year61 and among older people living in

residential care facilities 60% fall60. Ninety-five percent of all hip fractures are fall-induced62. In

Sweden fall incidents result in 19 000 individuals sustaining a hip fracture annually63, 70% of

those are women and the average age is 83 years64. The consequences of hip fracture are e.g.

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reasons for being permanently institutionalized66,69,70, and mortality71,72. Half of the people who

sustained a hip fracture suffered substantial decline in physical function even after two years65,68.

Association between physical impairments, functional limitations, and disability

Older people require a level of fitness that enables them to perform daily activities, develop a reserve of energy, to recover faster and more completely from illness, to minimise risks of future ill health, and to promote a sense of well-being42. Mobility is an important goal for older people because the maintenance of mobility is central to a certain level of functional independence and essential for the ability to perform ADL42. From older people’s own point of view, the abilities

to move and walk can be seen as prerequisites for valued activities, as personal care and the ability to keep in touch with others29.

Gait speed is an indicator of overall functional ability and relates strongly, for example, to falls, use of walking aids, extent of personal mobility73, balance, and lower-limb strength73,74.

Lower-limb strength and balance are basic conditions for standing, transferring, and walking75.

Muscle strength plays a significant role in the ability to function on a day-to-day basis, as well as to the ability to participate in recreational activities47. There is an association between impaired

strength and decline in functional performance76-78. Strength in the leg extensors has been shown

to be important for mobility and gait performance, for example, for the ability to rise from a chair and for gait speed79-82. Muscle power in the lower limbs has also been shown to be a

predictor for physical performance, e.g. stair-climbing time, gait speed and chair-stand time, in older people with mild to moderate mobility limitations. Muscle power is the product of force and velocity while muscle strength is the ability to exert force7. Compared to strength, the power

in the lower limbs appears to exert a greater influence on function 7,79,83,84. There is also a

relationship between muscle strength and aerobic capacity among older people, where 50 percent of the loss in aerobic capacity is linked to an age-related reduction in muscle strength85. The

nature of the relationship between impairments and function, for example between impaired lower-limb strength and gait speed, is supposedly curvilinear. This means that, for people with severe muscle weakness, small increases in strength may produce large increases in functional capacity. For people at or above a functional threshold, strength improvements may lead to no or very small improvements in function7,86. There are only a few established threshold values for older people, for instance between leg extension power and gait speed81and between lower limb

power and ability to mount step heights87. An explanation for the difficulty in finding a threshold

is that impairments in one determinant can be compensated for by physiological reserves in other determinants and, thus the threshold varies from person to person8.

Women are more vulnerable to physical decline because they have poorer physical performance than men28,88,89. Females have higher rates of ADL limitations than males at all ages28,42,88. The

muscle strength of women is generally lower than the muscle strength of men, which means that women can more easily fall below the threshold for the performance of functional tasks 90.

Rantanen & Avela 81 conclude that one explanation of the greater prevalence of mobility

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women. Consequently, women have probably large functional gain from small improvements in strength.

In a socio-medical model of disability, the Disablement Process, Verbrugge & Jette4describe how

different conditions affect functioning in, for example, specific body systems and activities of daily living. The personal and environmental factors that speed up or slow down disablement is also described. The Disablement Process includes a main pathway that links the concepts pathology,

impairment, functional limitations, and disability4. The main pathway was further developed by Jette6,

using both negative and positive wording, to include pathology, impairment, functional (in)capacity, and

social/role (dis)ability.

The relationships between physical impairments and functional limitations and the consequences of declines indicate the importance of maintained or improved physical performance and capacities. There is a need to design exercise programmes aimed at improving impaired lower-limb strength, balance, and gait ability among older people because, as mentioned above, these impairments are both well-known fall-risk factors that can lead to dramatic consequences and are common problems that are crucial for functional independence42,75.

PHYSICAL ACTIVITY AND EXERCISE Exercise principles and modes

Older people benefit from regular physical activity or exercise through overall improved health and physical fitness, increased opportunities for social contacts, gains in cerebral function, lower rates of mortality, and fewer years of disability in later life 42. However, if the purpose is to

achieve specific benefits the exercise also has to be specific. The purpose of the exercise will determine the type of exercises chosen. There are some principles for exercise that the exercise programmes in this thesis follow.

Exercise intensitydescribes, in relative or absolute terms, the effort associated with the exercise and is expressed in a wide variety of ways depending on the kind of exercise it relates to10. There is

no consensus in the literature about how to best describe exercise intensity. One useful way is in relation to the individuals’ capacity, which implies that high-intensity exercise is training near the individuals’ maximum capacity. Intensity can be described in relative terms, i.e. percentage of maximal capacity. In resistance training this is the percentage of maximal voluntary contraction for isometric strength, or percentage of one repetition maximum (1 RM)11for dynamic strength.

Intensity can also be described in absolute terms, which means, for example, a specified RM, that is, e.g. doing one set of 8-10 RM. Estimates of the level of intensity and number of repetitions that can be done at a fixed percentage of 1 RM has been suggested and are, for example, that high-intensity resistance training should be performed at 8-12 RM (70-84% of 1 RM), and very high intensity at 4-6 RM (



85% of 1 RM

)

10. However, the percentages are only estimates and

there is inconsistency between studies in the estimates of the percent of 1 RM91. In this thesis

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people 45,92. The intensity, or difficulty, of balance exercises can be described in terms of the

extent to which postural stability is challenged. In high intensity balance exercises postural stability is fully challenged i.e. the exercises are performed near the limits of maintaining postural stability by reducing the base of support, reducing sensory input, or by perturbation of centre of mass45.

A rational for determining duration of exercise periods is that most successful studies using resistance or functional exercises are performed over a period of 8-12 weeks93. The duration for

each exercise session is in most cases between 30 and 60 minutes94. The frequency recommended

is to exercise at least 2-3 times a week45,95with 2-3 sets of each exercise96. Mode or type of exercise

is, for example, resistance or strength training, aerobic training or functional training.

Dose-responserefers to the relationship between increasing levels (doses) of physical activity and changes in the levels of a defined health parameter. The characteristics of intensity, frequency, duration, and mode are used to describe the dose of physical activity or exercise needed to bring about a particular response10. For example, a strong dose-response relationship has been shown

to exist between the intensity of resistance training and strength gains after resistance training97.

Exercise specificity means that the nature of the applied stimulus determines the nature of the physical change concerning, for example, movement patterns, intensity, or volume of training

7,92,98. The most effective exercise programmes are those that are designed to target specific goals,

e.g. tasks or activities 92. The exercises are performed in the same movement patterns that are

targeted for improvement. In studies that build on the concept of specificity of training, the exercises used are very similar to the tasks an individual is training to achieve e.g. if the exercise goal is to achieve functional independence the exercises can be rich in functionally specific exercises2,7.

Since the purposes of the exercise interventions in this thesis were to improve lower-limb strength, balance, and gait ability the programmes were, in accordance with the specificity principle, targeted on those functions. The mode of exercise chosen is functional and weight-bearing

exercise, meaning exercises performed in standing or walking positions that comprise everyday tasks, e.g. rising from a chair or climbing stairs. The programmes offer the possibility of combining lower-limb strength, balance, and gait exercises in functional movement patterns and of progressively increasing the intensity to achieve high intensity for each individual. This is an exercise method which also seems suitable for frail, older people in residential care facilities, including those with severe cognitive impairment, because the exercises are easy to follow and there is no need for special exercise facilities. It may also be a sensible way to regain physical functions and to prevent further falls after a hip fracture. Because the exercises focus on everyday tasks they might influence performance in daily life tasks positively through carry-over effects. The group of older people, especially those with impairments, is very heterogeneous in many respects, including physical capacity, and this has to be taken into consideration in exercise interventions by individualising the exercise programmes to ensure that they are sufficiently specific

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and intense. One important aspect is that the exercise programmes also have to be adapted to the individual’s exercise goals and physical and cognitive capacity.

Recommendations and contraindications for exercise among older people

According to the American College of Sports Medicine (ACSM) position stand 1998 99, all

exercise programmes for frail and very old people should include progressive resistance training of the major muscle groups, two or preferably three times per week. Balance training should be incorporated, either as part of strength training or as a separate modality. They recommend higher intensity strength exercise because it is more beneficial than lower intensity programmes and just as safe, nevertheless supervision is mandatory for safety and for progression to be made. In 2001, the recommendations include a concern that higher training intensities can lead to greater gains but may increase the risk of musculoskeletal injuries100. Walking is a preferred mode

of aerobic training because of its direct functional nature. High-intensity aerobic training interventions for frail older people have not been described and are unlikely to be feasible in this population99,100.

The principles for exercise are similar for both older and younger people and so are the contraindications. For many conditions the danger associated with not exercising is greater than that associated with exercising7,101. However, there is more to take into account when prescribing

exercise for older people because health conditions become more common whit age. Therefore, it is recommended that exercise supervisors, e.g. physiotherapists, have an adequate knowledge about the participants and their health problems and about common health problems among older people. It is also recommended that participants with disease or impairment have a physicians’ approval to exercise99,101. Instead of suspending exercise the training can be modified,

for example, when pain conditions are present and lowering the fall risk if a participant has osteoporosis or avoiding valsalva-like manoeuvres in older people 45,100or with people with

diabetes101.

Effects of physical activity and exercise in old age

The vicious circle of deterioration caused by physical decline, inactivity and their consequences can be broken because age-related physical decline is reversible through physical activity and exercise7,42,47,102. Physical activity and regular exercise is crucial for older people since it implies great health benefits7,45,47,99,100. Regular participation in physical activity or planned exercise has

been shown to retard age-related physiological changes, so while increased physical activity slows down the consequences of the aging process, physical inactivity speeds it up16,42,45,47. Longitudinal

studies have shown that reduced activity level is associated with decreased muscle strength and increased activity with maintained or increased strength 42,102. Physically active people outlive those who are inactive7,45. Regular physical activity or exercise reduces the risk of functional

dependency among older people42,45,103,104, contributes to psychological well-being, and is useful

as a protection against and treatment of certain chronic diseases such as type 2 diabetes, hypertension16,47, and depression or depressive symptoms16,45,47.

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Physical exercise also improves most bodily functions, strengthens the musculoskeletal system, and reduces the likelihood of physical dysfunction7,16,45. Exercise is an important means of both preventing and treating chronic diseases and exercise therapy is a fundamental aspect of rehabilitation 7, i.e. exercise can be used for the purpose of both primary and secondary

prevention.

Concerning physical exercise as a therapy in various chronic diseases, Pedersen & Saltin101have recently conducted an exhaustive review. They found that there is strong evidence that exercise improves symptoms specific to the diagnosis and enhances physical fitness, muscle strength, and quality of life in a number of diagnoses (type 2 diabetes, hypertension, chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication, osteoarthritis, and depression). In the case of osteoporosis and cancer there is moderate evidence that exercise will improve symptoms101. All these diagnoses are common among older people.

Studies show that exercise has a great potential to improve the physical function for healthy old people or for those with moderate physical impairments7,92,105-107. Early studies using endurance

or resistance exercise showed improvements in physiological outcomes that did not, however, always lead to functional improvements7. According to Bean7, one explanation might be that

endurance training alone does not improve function and another the curvilinear relation between impairments and function. Progressive resistance training has produced improved or maintained function among both community-dwelling and institutionalized older people 7,108,109. Resistance

training designed to enhance muscle power has also been shown to improve function 7,110. A

strong dose-response relationship has been demonstrated between the intensity of resistance training and strength gains as well as between strength gains and functional improvements after resistance training97. A review of aerobic and resistance exercise interventions showed effects on

strength, aerobic capacity, flexibility, walking, and standing balance, although few improvements were found in social, emotional and overall disability111.

Functional weight-bearing exercise has been shown to have wide-ranging effects on fall-risk factors such as impaired lower-limb strength, balance, and gait ability among both community-dwelling older people and those living in institutions 82,112-117. Other studies have reported

functional improvements after functional exercises 112,118-120. De Vreede et al. 98 found that functional task performance increased significantly more in a functional-task exercise group than in a resistance exercise group or a control group, among healthy older women. Other authors have had similar findings where resistance exercise has been shown to affect muscle strength and power, but limited functional benefit111,120,121. A recent study comparing functional and strength

exercise among older people with disability found that both groups improved lower-limb strength, but the functional training group improved significantly more regarding gait speed and chair rise performance120.

Functional, weight-bearing exercise has also been shown to have an effect on leg strength, weight-bearing test measures, and gait-speed among older people with hip fracture 82. An

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functional performance and was safe to perform 122. Other studies have also shown positive

results from exercise programmes after hip fracture117,123-125.

Among older people with no or only moderate impairments, high-intensity training programmes have produced better results concerning improvement of physical performance than exercising at low intensity45,105,106,113,126,127. High-intensity exercise has not been reported to cause complications 45,97,127

. However, adverse events arising from exercise are under-reported 93. Some of these studies involve older people living in residential care facilities97,105,113. One review shows that

there is strong evidence that exercise affects muscle strength and mobility in older people living in institutions but concludes that more studies are required because so many of the studies are of limited quality128.

Few studies involve people with cognitive impairment94,113,129,130as those with dementia or other

cognitive impairment are often excluded from exercise interventions 131. The potential for

exercise to improve the physical condition of older people with dementia is controversial132. In a

review of exercise among older people with cognitive impairment the conclusion is that the issue is clearly insufficiently studied and the reviewed randomised controlled trials (RCT’s) do not provide enough evidence and also partly lack methodological quality and research consensus132

Nevertheless, exercise can have positive effects on people with dementia and it is possible for such people to improve their motor performance through exercise94,133.

To my knowledge, there are only two studies that have used a high-intensity exercise programme among older people with severe cognitive and physical impairments129,130. In one of these the

exercise formed one part of a multifactorial fall-prevention programme in residential care facilities, making it difficult to evaluate it separately129. The other study by Morris et al. found a

reduction in decline in ADL but no improvements in physical function from high-intensity exercise among residents in nursing homes130.

Nutrition and exercise

Loss of muscle mass and strength, i.e. sarcopenia, with aging can be explained by insufficient nutritional intake, lack of physical activity, hormonal changes and resistance to the normal action of insulin 134. Exercise to preserve and increase muscle mass and strength, and appropriate nutrition, especially through an adequate protein intake, are suggested as first-line treatments in the early stages of frailty40. A meta-analysis concerning protein and energy supplementation in

older people concludes that oral nutritional supplements can improve nutritional status and seem to reduce mortality and complications for under-nourished older patients, but that there is no support for routine supplementation in well-nourished older people 135. The protein needs of older people who regularly perform resistance training are not yet established but in a brief review it is suggested that they require a little more protein than sedentary people to maintain muscle mass136.

Elevation of blood amino acid concentrations through intake of exogenous amino acids or protein stimulates protein synthesis, which is required for muscle hypertrophy 134. Strength

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exercising also stimulates muscle protein synthesis and an intake of protein after exercising has a synergistic effect134,137,138. The ability to increase protein synthesis after strength training decreases with time139. Therefore, an early intake of protein after training seems favourable as is shown in a

study among healthy, older men where an immediate intake of 10 g protein after strength exercising had an effect on muscle hypertrophy and strength 140. Among frail, older people,

combinations of strength training and protein-energy supplement have not shown any interaction effects on physical function 105,141. In these studies, however, the supplement was not taken in direct connection to the exercise.

FACTORS THAT INFLUENCE EXERCISE BEHAVIOUR

“Longer life expectancy, rapid population growth, well-documented benefits of exercise, the impact of physical inactivity on public health, and low exercise-participation rates among older people justify the need for better understanding of older adults’ exercise behaviour”104. Despite

the benefits associated with physical activity and exercise, most older people live a sedentary life

42,43. One study shows that in spite of the fact that many (89%) older people are aware of the

health benefits associated with physical activity, 69% of them do not engage in any physical activity142. At the eight-year follow up in a prospective study among older people in Finland it

was shown that the exercise levels had increased among men but decreased among women44.

Motivation for exercise

Motivation can be defined as the need, drive or desire to act in a certain way to achieve a certain goal143 or all the intrinsic processes and extrinsic factors that initiate and trigger actions 144,145.

Intrinsic motivation and goals for exercise may be feelings of well-being, enjoyment, pride, self-fulfillment, need of physical activity, or to feel independent and capable. Extrinsic motivation, for example, is reward, status, and appreciation or encouragement from others146,147. An important

factor in motivation is goal-oriented behaviour148.

Factors which act as motivators for exercise among older people are, for example, health benefits

149-151, enjoyment44,152, and social motives such as company and friends44,149,151,153, or psychological

benefits such as mental health, diversion and zest for life 44. The identification of goals is also important for the motivation needed to adhere to a physical training programme152,154,155. More

practical reasons reported as motivators are more time, better weather, and having an organized programme to attend149. Among active women reduced fitness levels, low bone density, more

leisure time, fear of poor healthcare, experiencing reduced pain, and reports of new exercise programmes and health benefits initiated activity152.

Barriers toward exercise

There are also a number of reasons for not exercising stated by older people. The barriers can constitute incentives for not starting to exercise or be reasons for discontinuing exercise. Commonly reported barriers, real or perceived, to exercise among older people include impaired

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health44,149,156-158, lack of interest or motivation44,148-150,159, fatigue149,150,160-162, or discomfort in the

form for example of pain148,149,154,158, fear of falling, and shortness of breath148.

Other barriers are feeling too old, feeling no need to exercise or that one is active enough, lack of time44,148,150,157,163, lack of knowledge151, concerns about risks46, or social factors such as having

no friend to exercise with44. With increasing age lack of time becomes less frequent and impaired

health more frequent as the reason for not participating in physical exercise157. There are also a number of practical reasons for not exercising, e.g. insecure physical environment, limited access to exercise facilities158, a long way to travel to exercise44,149,159, bad weather149. Life course events

such as family illness159or onset of illness can also affect participation in exercise negatively163,164.

For women, life events, particularly interpersonal loss can also be reasons for not exercising165.

Positive and negative influences on participation in exercise

Motivation for and extent of participation in exercise among older people has been described as being influenced by previous exercise experience 148,154,166, attitudes and general beliefs about

exercise 156,161, social influences 152,155,156,161, personality 148,154, outcome expectations, outcome

realizations148,166,167, perceived control of the exercise behaviour156, and self-efficacy148,152,154-156,166.

These factors can impact both positively and negatively on motivation. What people in the environment, such as healthcare professionals, think and believe about exercise for older people can also constitute a barrier or a motive for exercising46,168.

Cohen-Mansfield et al. 149 have examined the relationship between barriers, motivators, and

participants’ characteristics and found that having no motivation to exercise was significantly related to higher scores for depressed affect, according to the Geriatric Depression Scale (GDS) and depressed affect in turn was highly correlated with reporting the most common barriers. There are some contrasts between barriers toward exercise behaviour among exercisers and non-exercisers. Lees et al.104have found that the principle barriers among exercisers were inertia, time

constraints, physical alignments and social barriers and among non-exercisers fear of falling, inertia, and negative affect. Depression was mentioned as one reason for discontinuing exercise. Gender differences concerning barriers were reported for adults, aged 55-70, where the primary barriers for women were pain and social discomfort and for men lack of motivation169.

Self-efficacy

Self-efficacy is an individual’s belief of their own ability, despite potential barriers, to be able to organise and perform actions to achieve a specific goal. Self-efficacy is a concept within Albert Banduras’ Social Cognitive Theory (SCT), according to which, there is a mutual interaction between the individual, behaviour, and environmental events. Self-efficacy and outcome expectations are seen as the most important concepts of behavioural motivation155. Self-efficacy is

a crucial factor in the initiation and maintenance of goal-oriented behaviour and is affected by the actual performance of an activity, by vicarious experience or role models, by reliable verbal encouragement or other social influence, and by physiological or emotional condition 155. The

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Self-efficacy has been shown to influence and be influenced by physical activity and has been identified as a determinant of exercise behaviour 99,156,170, as well as a factor that can reduce functional limitations171, among older people. During an exercise period of one year, positive

outcome realizations occurring between 0 - 6 months resulted in increased self-efficacy and exercise attendance between 7 – 12 months166. Another study showed that physical health,

self-efficacy, and outcome expectations directly influenced exercise behavior and that age and mental health indirectly influenced exercise through self-efficacy and outcome expectations172.

Attitudes and beliefs

The theory of planned behaviour (TPB) is a social cognitive model that analyses social behaviour in order to understand it and thereby be able to predict future behaviour173. The theory has also

been used in studies about physical activity and exercise behaviour among older people150,162,174,175.

According to TPB people act in accordance with their intentions and perceptions of control over their behaviour, while intentions in turn are influenced by attitudes toward the specific behaviour, personal and social norms, and perceptions of behavioural control. It is the experienced presence or absence of resources, possibilities or barriers, and the strength of these that facilitates or obstructs the accomplishment of the behaviour. Control of the behaviour is based on how easy or difficult it is perceived to be to adopt or perform the behaviour173.

Studies among older people using TPB to examine exercise behaviour have shown that attitude towards and perceived control of exercise are predictors for exercise attendance162,174. However,

there are contradictory results concerning the impact of social norms150,166,175,176.

Exercise experiences

Previous exercise experiences can form motives for or barriers to future exercise adherence

44,152,156,166,177. However, there are a few studies that investigate older people’s experience of their

actual participation in a specific exercise programme159,164,178-180. In these studies, the participants

were healthy or had only moderate health problems and the exercise was of low or medium intensity159or was not defined164,178-180. There were no studies found about exercise experience

among older people with physical or cognitive impairments.

Participants in exercise programmes have perceived that exercise helped them to improve and cope with medical conditions, to improve their fitness, and to maintain mobility and physical function and also that the exercise context was a good way to meet other people 159,178,180.

Professional help and psychological support from exercise specialists were valued highly159,164,180.

Exercise could also be perceived to relieve pain, enhance self-esteem, and create mental activity178.

Making a personal commitment and experiencing desirable changes in physical capacity were said to be important for the motivation to adhere to an exercise programme179. Discovering that they

could set and achieve goals generated feelings of accomplishment and success in older people participating in an exercise referral scheme 180. Among older people who were exercisers, the

proportion of those reporting satisfaction from exercising as a motive and those for whom advice from healthcare staff was a motive, increased over an eight-year period44.

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RATIONALE AND AIMS

RATIONALE OF THE THESIS

Functional weight bearing exercise programmes as well as high-intensity exercise programmes have positive effects among older people with no or only moderate physical impairments. However, those with the greatest need for improved or maintained function, i.e. older people with severe impairments, multiple diseases, or dementia, are often excluded from exercise interventions. In contrast to the evidence concerning older people who are healthy or moderately impaired, the evidence concerning high-intensity functional exercise for older people with more severe impairments is weak. There is also a lack of studies investigating the effect of an immediate intake of protein after strength exercises among older people with multiple diseases, physical and cognitive impairments, or malnutrition. It would therefore be important to investigate whether physical exercise combined with an immediate protein intake would increase the effects of exercise.

Research on perceptions and experiences of participation in high-intensity exercise among frail, older people is sparse. Investigating exercise experience is relevant since it is an important factor for motivation for and participation in exercise. A better knowledge about exercise perceptions and experiences would enable the development of feasible exercise programmes with high attendance and motivation among the participants. It is especially interesting to study the experience of high-intensity exercise because this training method is effective but also demanding and can be expected to more often constitute an impediment or discomfort, particularly in a group of older people where many have multiple diseases and a high prevalence of pain conditions and depression.

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AIMS OF THE THESIS

The overall aims were to evaluate the effects on physical performance of high-intensity functional exercise programmes among older people with physical or cognitive impairments and to evaluate the perceptions and describe the experiences of participating.

Specific aims

• To examine the possibility of increasing lower limb strength, dynamic balance, and gait speed in frail older women with residual problems after hip fracture, by using a functional exercise programme with a weighted belt (Paper I).

• To determine whether a high-intensity functional exercise programme improves lower-limb strength, balance, and gait speed in older people dependent in activities of daily living and living in residential care facilities, and if an intake of protein-enriched energy supplement immediately after the exercises increases the effect of the training (Paper II). • To evaluate how older people, dependent in activities of daily living and with mild or no

cognitive impairment, perceive their participation in a high-intensity functional exercise programme compared to the perceptions of those participating in a control activity, and whether perceived changes in physical functions were reflected in physical performance tests (Paper III).

• To describe the experience of participating in a high-intensity functional exercise programme among older people dependent in activities of daily living and living in residential care facilities (Paper IV).

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METHODS

This thesis is based on two main studies. The first was a single subject experimental design (SSED) study that was performed in 1999 to examine whether a high-intensity exercise programme with combined lower-limb strength and balance exercises in three older women who had sustained a hip fracture was practicable and could improve physical function (Paper I). The second, the Frail Older People –Activity and Nutrition Study in Umeå (the FOPANU Study) was an RCT, carried out in 2002 to study the effects on physical function of an exercise and a nutrition intervention in a sample of 191 older people dependent in ADL and living in residential care facilities (Paper II). Perceptions about participating in exercise were compared with the perceived participation of participants in the control activity, using a questionnaire among 48 participants (Paper III). The experiences of participating were described in a qualitative study in nine participants from the exercise group (Paper IV).

SETTINGS AND PARTICIPANTS

In Paper I the participants were selected from among patients who had completed a rehabilitation period at the outpatient clinic at the Geriatric Centre at Umeå University Hospital during the 12 months prior to the start of the study. Inclusion criteria were female sex, understanding simple instructions, a hip fracture at least six months earlier, and perceived mobility problems such as impaired lower-limb strength, balance or gait problems following the hip fracture. Exclusion criteria were severe pain that seriously affected the ability to participate in the assessments or training programme and motor impairment from neurological disease. The three women who participated lived in the community, were aged 78-82, and had suffered a hip fracture 10, 11 and 35 months, respectively, before the study start. They had previously completed an outpatient rehabilitation period for their hip fractures (4 to 9 months prior to study). Basic characteristics are shown in Table 1.

The FOPANU Study (Papers II-IV) was carried out in nine residential care facilities in Umeå, Sweden (Figure 1). All facilities comprised private flats with access to dining facilities, alarms, and on-site nursing and care. Four facilities also comprised units, with private rooms and staff on hand, for people with dementia. Inclusion criteria were aged 65 years or over, dependent on assistance from a person in one or more personal ADL according to the Katz Index181, able to

stand up from a chair with armrests with help from no more than one person, and a Mini-Mental State Examination (MMSE)182score of ten or more. One hundred and ninety-one people, aged

65–100 years, were included in the study. Age (p=0.84), sex (p=0.64), and Katz ADL Index score (p=0.66) did not differ between those included and those declining to participate (n=71).

Paper II included all participants in the FOPANU Study (n=191) (Figure 1). Ninety-two participants (48%) were categorised as having severe cognitive impairment and 81 (42%) as having severe physical impairment. One hundred and thirty participants (68%) had either severe

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cognitive or severe physical impairment. An MMSE score of  17 indicates severe cognitive impairment 183. Verbal supervision or standby help from one person without physical contact, and a score of 3 or less on the functional ambulation categories (FAC) 73,184, were chosen to

indicate severe physical impairment. When transferring in their flat or room, 108 participants (57%) normally used a walker and 27 (14%) used a wheel-chair. Basic characteristics are shown in Table 2.

In Paper III participants in the FOPANU Study who had participated in at least one exercise or control activity session and had an MMSE score of 21 or more responded to the inclusion criteria (n=55). Forty-eight of those, 20 from the exercise and 28 from the control group, answered a questionnaire (Figure 1). Basic characteristics are shown in Table 3.

In Paper IV nine participants, out of 91, from the exercise group were purposefully selected for participation in qualitative interviews (Figure 1). The informants were selected by the exercise supervisors in order to achieve variety regarding sex, degree of attendance in exercise sessions, and motivation for the training. They needed to have participated in at least three exercise sessions and have the ability to relate the questions to this exercise period and to verbally describe their experience of it. Basic characteristics are shown in Table 4.

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Week 1

Week 12

Week 14

Week 27

Figure 1. Flow chart of participants in the FOPANU Study, Papers II-IV

Assesed for eligibility (n=487)

Randomised (n=191)

Not included (n=296)

Failed to meet inclusion criteria (n=216) - Aged < 65 years (n=19)

- Independent in personal ADL (n=46) - Unable to stand up from a chair with help

from one person (n=69)

- Mini Mental State Examination < 10 (n=68) - Physician disapproved (n=14)

Not present at the facility (n=9) Declined participation (n=71) Exercise (n=91) Protein (n=46) / Placebo (n=45) Intervention start Paper II Control activity (n=100) Protein (n=50) / Placebo (n=50) Intervention start Paper II Discontinued (n=4) - Physician disapproval (n=1) - Died (n=1) - In another study (n=2) Not accessible (n=5) Discontinued (n=4) - Moved (n=1) - Declined to continue (n=1) - Died (n=1) - In another study (n=1) Not accessible (n=3)

Participated 1 session and MMSE 21 (n=24) Asked to answer questionnaire

Declined (n=4) Answered questionnaire

(n=20)

Paper III

Participated 1 session and MMSE 21 (n=31) Asked to answer questionnaire

Not accessible (n=3) Answered questionnaire

(n=28)

Paper III

Selected for interviews (n=9)

Paper IV Exercise (n=82) 3-month follow up physical performance Paper II Control activity (n=93) 3-month follow up physical performance Paper II Exercise (n=77) 6-month follow up physical performance Paper II Control activity (n=86) 6-month follow up physical performance Paper II Discontinued (n=9) - Declined to continue (n=2) - Died (n=7) Not accessible (n=1) Discontinued (n=5) - Moved (n=1) - Declined to continue (n=1) - Died (n=3) Not accessible (n=5)

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Table 1. Basic characteristics of the participants in Paper I

Characteristics Participant #1 Participant #2 Participant #3

Age 78 82 80

Diagnoses and medical conditions

Cervical hip fracture, left

Cervical hip fracture, left Pertrochanteric fracture, right Polymyalgia rheumatica Ischaemic heart disease

Previous hip fracture

Post tuberculosis Previous stroke Previous wrist

fractures Osteoarthrosis, right

knee

Patellectomy, left knee Malignancy

In-door walking aid Stick None Stick

Assessments

Pain Scale (0–4)185 3 3 1

Activity Scale (0–6)186 2 3 3

Berg Balance Scale (0–56)1,187,188 39 55 48

Gait speed, comfortable73, m/s 0.54 0.64 0.51

Gait speed, maximum73, m/s 0.60 0.91 0.63

1 RM, lower-limb strength11,115, kg:

Right leg 33 54 40

Left leg 34 42 43

Figure

Figure 1. Flow chart of participants in the FOPANU Study, Papers II-IV
Table 1. Basic characteristics of the participants in Paper I
Table 2. Basic characteristics of the participants in the FOPANU Study, Paper II Characteristic Total n = 191 Excercise&amp; Proteinn = 46 Excercise &amp; Placebon = 45 Control &amp;Proteinn = 50 Control &amp;Placebon = 50 p Age, mean ± SD 84.7 ± 6.5 85.0
Table 2. Continued Characteristic Total n = 191 Excercise&amp; Proteinn = 46 Excercise &amp; Placebon = 45 Control &amp;Proteinn = 50 Control &amp;Placebon = 50 p Assessments
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References

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