Study Overview
Objective. To compare the effectiveness of a group exercise program focusing on the timing and coordination of movement (ie, On the Move [OTM]) with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability in older adults.
Design. Cross-sectional pilot study.
Setting and participants . Participants were community-dwelling older adults who were residents or members of 32 independent living facilities, senior apartment buildings, and community centers in the greater Pittsburgh, Pennsylvania, area. Participants were recruted between April 2012 and January 2014. Inclusion criteria included age 65 years or older, ability to walk independently with a gait speed of at least 0.60 m/s, and ability to follow 2-step commands. Individuals were excluded if they were non-English speaking, medically unstable, planning to leave the area for an extended time period, or had abnormal blood pressure or heart rate following a 6-minute walk test. The 32 participating facilities were randomly assigned to the OTM intervention (16 sites, 152 participants) or usual care (16 sites, 146 participants). The OTM and usual care exercise programs had the same frequency and duration (50 minutes per session, twice weekly for 12 weeks), and all exercise sessions were held on site at the facilities. The usual care program was a strength, flexibility, and endurance program based on programs that were being conducted in the participating facilities. It included a warm-up (range-of-motion exercises and stretching), upper and lower extremity strength exercises, aerobic activities, and a cool-down and was conducted with the participants sitting.
Intervention. The OTM program consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and cool down exercises, with most of the exercises conducted in a standing position (40 minutes) and the remainder (10 minutes) sitting. The stepping and walking patterns were designed to promote the timing and coordination of stepping, integrated with the phases of the gait pattern.
Main Results. The average participant age was 80.0 (SD, 8.1) years, most participants were female (84.2%) and white (83.65%), and the average number of chronic conditions was 2.8 (SD, 1.4). The 2 groups were similar except for small differences in facility type. 142 (93.4%) OTM participants and 139 (95.2%) usual care participants completed post-intervention testing. The OTM group had significantly greater mean (SD) improvements than the usual care group in gait speed (0.05 [0.13] m/s versus −0.01 [0.11] m/s; adjusted difference 0.05 [0.02] m/s; P = 0.002) and 6MWD (20.6 [57.1] m versus 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = 0.03). Class attendance was lower in the OTM group than in the usual care group (76 [50.0%] OTM participants versus 95 [65.1%] usual care participants attended at least 20 classes; P = 0.03). There were no other significant differences between the groups in primary or secondary outcomes.
Conclusion. The OTM intervention was more effective at improving mobility than a usual care exercise program.
Commentary
The ability to walk is fundamental to maintaining a high quality of life and living independently in the community. Walking difficulty is a common problem among older persons and is linked to higher rates of loss of independence, morbidity, disability, and mortality in this population [1,2]. Walking difficulty associated with aging is often reflected in reduced gait speed and walking distance. A decline in gait speed of as little as 1 m/s is associated with a 10% decrease in ability to perform activities of daily living [3,4].
According to the authors, previous studies that explored the impact of structured exercise programs on walking ability in older individuals have had mixed results. These studies typically used exercise interventions focused on improving lower extremity muscle strength, flexibility, and general conditioning. In this study, the authors examined a community-based group exercise program (OTM) that incorporated exercises targeting the timing and coordination of movement important for walking in addition to flexibility and strengthening exercises. The results showed that the OTM program was more effective at improving walking ability than usual care. This intervention produced changes in gait speed (0.5 m/s) and 6MWD (16.7 m) that met or nearly met the clinically meaningful change criteria established for research use (0.5 m/s and 20 m, respectively) [5].
The authors pointed out several strengths of this study. First, the OTM program was compared to a usual care exercise program taught by trained exercise professionals, making it more difficult to demonstrate a difference between the 2 interventions. Similar prior studies have used nonexercise controls as the comparator. In addition, the effectiveness of the OTM program was demonstrated in 3 different community settings, suggesting that it can be implemented in various settings. Finally, the study participants were frail, older-old adults, who typically are not included in exercise studies. An important limitation of this study is that because outcomes were measured only at the conclusion of the intervention, it is not known whether the walking improvements persist over time or what effects the intervention has on mobility, function, and disability over the long term.
Applications for Clinical Practice
This study adds to the current literature on group exercise programs for improving mobility among community-dwelling older adults and supports incorporation of timing and coordination exercises into such programs. As the authors note, however, follow-up studies exploring the impact of the OTM intervention on long-term disability outcomes are needed before routine implementation in clinical practice can be recommended.
—Ajay Dharod, MD, Wake Forest School of Medicine, Winston-Salem, NC