DOI: 10.1111/ajag.12008

Research Living Longer Living Stronger™: A community-delivered strength training program improving function and quality of life Freda Vrantsidis, Keith Hill*, Betty Haralambous, Emma Renehan, Kay Ledgerwood† and Jaya Pinikahana‡ National Ageing Research Institute, Parkville, Victoria, Australia

Stephanie Harper§ and Mitsuko Penberthy Council on the Ageing, Melbourne, Victoria, Australia

Aim: This study investigated changes in function and quality of life for older adults participating in Living Longer Living Stronger™, a community-delivered strength training program for people aged over 50. Methods: Assessments were conducted at baseline, 4 and 8 months using measures of function, balance, mobility, strength, mental health and quality of life. Results: Thirty-five participants (mean age 66 years, 69% female) completed 4 months of the program; 24 completed 8 months. Using repeated-measures ANOVA, significant improvements were found at 4 and 8 months for step test, gait stride length, 6-minute walk test, timed sit to stand, physical performance test and reported health transition (SF-36). At 4 months (n = 35), vitality (SF-36), quality of life and left shoulder abductor strength significantly improved; at 8 months (n = 24), role physical and mental health (SF-36) and gait velocity significantly improved. Conclusion: The program appears to be an effective community-delivered strength training program. Key words: exercise, older people, physical function, quality of life.

Introduction Strength training can improve muscle strength and endurance, maintain fat-free mass (often lost with age) and preserve and improve older people’s ability to perform activities of daily living [1–4]. However, it remains to be shown whether the many benefits found in ‘controlled’ research studies are translatable when delivered in the community. Living Longer Living Stronger™ (LLLS™) is an affordable (participants pay around $5 per session and $40 for the initial assessment) community-based strength training program for people aged 50 and over. The Council on the Ageing Victoria (COTA) endorses strength training Correspondence to: Ms Freda Vrantsidis, National Ageing Research Institute. Email: [email protected] *Present affiliations: Curtin University and the National Ageing Research Institute. †Present affiliation: Masters (in Genetic Counselling) student, University of Melbourne. ‡Present affiliation: Rajarata University of Sri Lanka. §Present affiliation: Shire of Macedon Ranges. 22

program providers as LLLS™ providers. Providers agree to deliver progressive strength training in accordance with the evidence-based endorsement scheme criteria. This unique study investigated in a real life context the effectiveness of the LLLS™ program in improving function and quality of life for older adults participating in this community-delivered program.

Method Recruitment Recruitment occurred through selected LLLS™-endorsed centres in Victoria: fitness/leisure centres, community health services, rehabilitation and other community centres/ facilities, and via COTA’s newsletter. Centre staff obtained expressions of interest from new LLLS™ clients; the research team contacted them, provided further information, obtained written consent and arranged a baseline assessment. Ethics approval was obtained from Melbourne Health Research Directorate Human Research Ethics Committee. Study participants were aged ⱖ50, living in the community, able to speak English and provide informed consent, had no major concurrent physical illnesses or medical contraindications to regular exercise, and were new clients of the LLLS™ program (commenced the program within 2 weeks of baseline assessment). This period was extended to 5 weeks due to low recruitment rates and the time lapse between initial interest and initial contact with participants. Participants commenced LLLS™ of their own accord and paid for the program. Participants completing all three assessments received a summary of their physical performance changes. Assessment Baseline, 4- and 8-month assessments were conducted at the project research facility or the participant’s fitness centre, and took 60–90 minutes. Assessments included: demographic and physical activity information, the Physical Performance Test (PPT)[5], Medical Outcomes Survey Short Form 36 (SF-36) [6], 6-minute walk test [7], sit to stand (five times) [8], Nicholas Hand Held Manual Muscle Tester (MMT) [9], step test [10], 6-m walk [11], Assessment of Quality of Life Scale (AQoL) [12], Geriatric Depression Scale (GDS) [13] and Physical Activity Scale for the Elderly (PASE) [14]. All measures have good reliability, internal consistency and/or concurrent validity [5,8–10,12–14]. Australasian Journal on Ageing, Vol 33 No 1 March 2014, 22–25 © 2013 Council on the Ageing Victoria Australasian Journal on Ageing © 2013 ACOTA

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Participants were given calendars to record program attendance (adherence). LLLS™ program Staff at participating LLLS™-endorsed centres (trained to provide strength training to older people) individually assessed participants and devised individually tailored progressive strength training programs, which they regularly modified. The individualised 1-hour sessions included a warm-up (aerobic activity, e.g. bike, treadmill), a progressive resistance component targeting each of the main muscle groups (free and/or machine weights, e.g. leg press, lateral pull down, cable seated row, tricep push down), balance and flexibility exercises (e.g. tandem stance, single leg balance, grapevine side steps, stretching). Participants were encouraged to attend a minimum of twice weekly, working by themselves or in small groups, and accessing trained staff as required. Statistical analysis Power analysis indicated 60 participants were required to detect an effect size of 20% improvement; 85 participants were sought, allowing for a 30% dropout rate. Analysis, using Statistical Package for the Social Sciences (spss), included: repeated measures analysis of variance (rm-anova), for normally distributed continuous variables, to determine change over time; paired Student t-tests, for continuous variables, to compare changes in the first 4 months with changes at 8 months; and frequency and c2-analyses for nominal or ordinal variables.

Results Participants Sixty-six individuals were recruited. Four were ineligible (>5 weeks strength training prior to assessment) and 27 (41%) withdrew before the 4-month assessment. Eleven (17%) participants withdrew after 4 months, and 24 completed all three assessments (35 participants in total). Withdrawals primarily related to health issues and family and time commitments. Most participants said they might return to the program in the near future. There were no significant differences in baseline demographic or activity profiles between participants who only completed the 4-month assessment and those who also completed the 8-month assessment (Table 1), or those who withdrew after the baseline assessment. Baseline physical activity was high compared with community data for older Australians [3,15,16]. Outcome measures Program adherence was based on completed activity calendars, or estimates based on the number of sessions (selfreported during assessment) attended/per week less the reported number of sessions or weeks missed. At 4 months, Australasian Journal on Ageing, Vol 33 No 1 March 2014, 22–25 © 2013 Council on the Ageing Victoria Australasian Journal on Ageing © 2013 ACOTA

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Table 1: Baseline demographics and brief activity profiles of participants with a 4- and/or 8-month assessment Participants who Participants who completed remained to complete an 8-month the 4-month assessment assessment (n = 24) (n = 35) Age Mean (SD) Range Sex: n (%) female Marital status: n (%) Married Widowed Single Divorced Other Living arrangements: n (%) Alone With family Number of health issues Mean (SD) Range Number of medications (includes herbal supplements) Mean (SD) Range Height (cm) Mean (SD) Range Weight (kg) Mean (SD) Range LLLS attendance prior to baseline assessment: n (%) Had not started Between 1 and 3 weeks Between 4 and 5 weeks Moderate physical activity (without LLLS™ program) (hours/week) Mean (SD) Range Moderate physical activity (with LLLS™ program) (hours/week) Mean (SD) Range

66.4 (7.6) 53–83 24 (68.6)

65.7 (7.3) 53–83 16 (66.7)

22 (62.8) 7 (20.0) 1 (2.9) 4 (11.4) 1 (2.9)

16 (66.6) 4 (16.7) 1 (4.2) 2 (8.3) 1 (4.2)

10 (28.6) 25 (71.4)

7 (29.2) 17 (70.8)

2.5 (1.9) 0–7

2.4 (2.0) 0–7

4.1 (3.6) 0–15

4.3 (4.2) 0–15

168.3 (7.2) 155–184

169.4 (6.5) 155–183

78.2 (15.0) 52–115

79.5 (14.2) 59–115

7 (20.0) 23 (65.7) 5 (14.3)

7 (29.2) 16 (66.7) 1 (4.2)

7.3 (4.4) 2–21

7.9 (4.6) 2–21

9.0 (4.3) 4–23

9.5 (4.4) 4–23

LLLS™, Living Longer Living Stronger™.

27 (of 35) participants fully/partially completed activity calendars; at 8 months 19 (of 24) participants completed calendars. Recommended minimum adherence equated to 8.5 sessions/month (two LLLS™ sessions/week). Of the 35 participants, 28% completed 8.5 or more sessions/month at 4 months; for the 24 participants who completed an 8-month assessment, the figures were 33% at 4 months and 21% at 8 months (4- and 8-month mean and median sessions attended = 7.0/month). Significant changes (rm-anova) from baseline were found at both 4 (n = 35; table not included) and 8 months (n = 24; Table 2) for the step test (more steps on/off a 7.5-cm block in 15 seconds) indicating improved balance; cardiovascular fitness (walked significantly further in 6 minutes); stride length (6-m walk); physical performance test (seven- and nine-item scores); and leg muscle strength (faster five times sit 23

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Table 2: Participant (with an 8-month assessment) assessment scores (n = 24) (repeated-measures ANOVA)†

SF-36 (self-reported health survey): mean (SD) Physical functioning§ Role – physical§ Bodily pain§ General health§ Vitality§ Social functioning§ Role – emotional§ Mental health§ Reported health transition¶ AQoL: mean (SD)¶ GDS: mean (SD)¶ PASE: mean (SD) PPT (physical performance measure): mean (SD) Seven items Nine items (n = 17) Distance (m) (6-minute walk) (cardiovascular fitness measure): mean (SD) Six-metre walk: mean (SD) Velocity (m/minute) Stride length Step test – worse leg (number of steps) (dynamic balance measure): mean (SD) Sit to stand (seconds) (leg strength measure): mean (SD) Weight (kg)

Baseline

4-month follow-up

8-month follow-up

P-value

% change: baseline & 4 months

% change: 4 months & 8 months

% change: baseline & 8 months

82.9 (17.6) 82.3 (34.2) 77.2 (16.6) 82.9 (12.8) 66.9 (17.9) 94.8 (10.4) 95.8 (14.9) 82.7 (14.6) 2.9 (0.7) 6.4 (3.3) 0.6 (0.9) 140.4 (58.3)

86.3 (15.1) 85.4 (27.5) 78.0 (20.1) 80.3 (12.7) 72.1 (15.3) 95.3 (11.5) 90.3 (25.0) 83.7 (12.1) 2.1 (0.7) 6.0 (3.2) 0.3 (0.6) 140.9 (47.3)

87.9 (14.4) 95.8 (20.4) 77.0 (13.8) 85.3 (12.7) 72.1 (17.2) 94.3 (13.3) 93.1 (24.0) 87.0 (12.2) 2.1 (0.6) 6.0 (3.5) 0.5 (0.8) 139.7 (44.2)

0.2 0.0 0.9 0.2 0.1 0.6 0.2 0.0 0.001 0.5 0.1 1.0

4 4 1 3‡ 8 1 6‡ 1 28 7 48 0

2 12 1‡ 6 0 1‡ 3 4 0 1 39 1‡

6 16 0 3 8 1‡ 3‡ 5 28 7 27‡ 0

25.6 (1.8) 32.7 (2.2) 443.4 (93.0)

26.4 (2.1) 33.8 (2.8) 482.6 (84.9)

27.0 (1.4) 34.6 (1.8) 501.0 (78.0)

0.0 0.0 0.001

3 3 9

2 2 4

5 6 13

79.2 (12.5) 1.3 (0.2) 16.9 (3.6)

84.7 (12.9) 1.5 (0.2) 19.1 (4.1)

96.0 (15.0) 1.6 (0.3) 20.8 (4.1)

0.0 0.0 0.0

7 16 13

13 8 9

21 25 23

10.9 (3.2) 79.5 (14.3)

9.1 (2.0) 77.7 (15.4)

8.3 (2.8) 77.4 (14.1)

0.0 0.1

17 2

8 0

24 3

†This table does not include the MMT measures (a portable device assessing muscle strength); ‡Deterioration in performance/score; §higher = better score; ¶lower = better score. AQoL, Assessment of Quality of Life Scale; GDS, Geriatric Depression Scale; MMT, Nicholas Hand Held Manual Muscle Tester; PASE, Physical Activity Scale for the Elderly; PPT, Physical Performance Test; SF-36, Medical Outcomes Survey Short Form 36.

to stand). However, this improvement in leg muscle strength was not evident in the MMT lower limb strength measures (hip, knee and ankle). Reported health transition (SF-36) also significantly improved, changing the mean score from participants reporting their health being ‘about the same as last year’ to a score closer to ‘somewhat better now than 1 year ago’. This improvement occurred by 4 months and was maintained at 8 months. The only other significant difference between the two time periods (paired Student t-tests, n = 24, P = 0.005) was right ankle dorsiflexion strength (P = 0.002) (6% reduction at 4 months, 8% improvement at 8 months). At 4 months, self-reported vitality (SF-36) (7% improvement, P = 0.04), quality of life (AQoL) (10%, P = 0.02) and left shoulder abductor strength (13%, P = 0.008) had also significantly improved (n = 35; table not included). At 8 months (Table 2) these improvements were maintained with no further gains. At 8 months, mental health and role physical (SF-36 domains) and gait velocity had significantly improved. There were no significant improvements in the MMT strength measures and one significant reduction, the right hip abductor strength.

Discussion Several significant improvements in physical and well-being measures were found at 4 and 8 months, some of which were 24

clinically and functionally meaningful. Perera et al. [17] estimated a change of 0.05 m/second (3 m/minute) for gait speed and 20 m for the 6-minute walk distance indicated a small meaningful change in performance; substantial change was estimated to be approximately 0.1 m/second (6 m/minute) for gait speed and 50 m for the 6-minute walk distance. At 4 months (n = 35), a 26.8-m improvement (table not included) was achieved in distance walked; at 8 months (n = 24) there was a 57.6-m improvement and gait velocity improved by 16.8 m/minute. Where measures did not significantly improve, performance was generally maintained, an important outcome in itself given the risk of functional decline as people age. There was only one significant improvement (at 4 months; n = 35) in strength measures using the MMT. Potential problems with rater variability, particularly with strong participants, and ceiling effects, suggest a more sensitive measure may be required. All baseline MMT scores were high compared with reported scores for healthy older people [18]. Additionally, this study assessed a ‘real life’ program delivered across various facilities. The percentage of the participants’ program dedicated to weight training (compared with stretching and treadmills, for example), the number of repetitions completed and the weights used were not reported. In the real world, programs are not prescriptive and need to be adapted to individual’s needs and abilities. Study limitations include small sample size, high dropout rate, assessment delays, and that some participants Australasian Journal on Ageing, Vol 33 No 1 March 2014, 22–25 © 2013 Council on the Ageing Victoria Australasian Journal on Ageing © 2013 ACOTA

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completed 4–5 weeks of the program prior to baseline assessment. The latter two factors affect the timing of change not the outcome. Recruitment and retention in this ‘real life context’ study reflects the real world; participants paid for classes, provided their own transport and had multiple commitments and health issues (theirs/their families’). Studies tracking program (not exercise) adherence report that older people leave, rejoin and switch exercise classes as commitments and interests change [19,20]. Programs need to consider strategies to re-engage participants who have withdrawn. Understanding why participants withdraw and their attitudes towards strength training will help improve longterm adherence in this age group. Study participants were also generally healthy, active older people and may not be representative of the broader older-aged population, or the broader LLLS™ population.

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Acknowledgements The project team wishes to acknowledge the study participants for their time and support of the project and the facilities for their assistance in the recruitment process and the use of their facilities to conduct some of the assessments. Other acknowledgements include: Sarah Taraquino and Natalie El Haber who were involved in assessments in the early part of the study, Sue Hendy (COTA) for her contribution to the study proposal and the William Buckland Foundation (ANZ Charitable Services) for funding the study. The LLLS™ program is available in Victoria, South Australia and Western Australia. For more information about the LLLS™ program, see http://www.cotavic.org.au/ programs-events/physical-education/strength-training/. For more details regarding the LLLS™ endorsement scheme, contact COTA (Victoria): [email protected]

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Although this study was not a randomised control trial it is unique as it evaluated an existing community-based strength training program in a real life context. Significant improvements were evident in balance, gait, strength, function, self-reported health and well-being for these older people involved in the LLLS™, a widely available local community program.

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Hartman-Stein P, Potkanowicz E. Behavioural determinants of healthy aging: Good news for the baby boomer generation. Online Journal of Issues in Nursing 2003; 8: 127–146. Nelson ME, Rejeskit WJ, Blair SN et al. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007; 116: 1094–1105. Sims J, Hill K, Hunt S, Haralambous B. Physical activity recommendations for older people. Australasian Journal on Ageing 2010; 29: 81–87. Liu C, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews 2009; (3): CD002759. Reuben DB, Siu AL. An objective measure of physical function of elderly outpatients. The Physical Performance Test. Journal of the American Geriatrics Society 1990; 38: 1105–1112. Stewart A, Hayes R, Ware J. The MOS short form general health survey reliability and validity in a patient population. Medical Care 1988; 26: 724–735. Guyatt GH, Pugsley SO, Sullivan MJ et al. Effect of encouragement on walking test performance. Thorax 1984; 39: 818–822. McCarthy EK, Horvat MA, Holtsberg PA, Wisenbaker JM. Repeated chair stands as a measure of lower limb strength in sexagenarian women. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 2004; 59: 1207–1212. Wang CY, Olson SL, Protas EJ. Test–retest strength reliability: Hand-held dynamometry in community-dwelling elderly fallers. Archives of Physical Medicine and Rehabilitation 2002; 83: 811–815. Hill K, Bernhardt J, McGann A, Maltese D, Berkovits D. A new test of dynamic standing balance for stroke patients: Reliability, validity, and comparison with healthy elderly. Physiotherapy Canada 1996; 48: 257– 262. Hill K, Ellis P, Bernhardt J, Maggs P, Hull S. Balance and mobility outcomes for stroke patients: A comprehensive audit. Australian Journal of Physiotherapy 1997; 43: 173–180. Hawthorne G, Richardson J, Osborne R. The Assessment of Quality of Life (AQoL) instrument: A psychometric measure of health-related quality of life. Quality of Life Research 1999; 8: 209–224. Yesavage J, Brink T, Rose T et al. Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research 1983; 17: 37–49. Washburn R, Smith K, Jette A, Janney C. The Physical Activity Scale for the Elderly (PASE): Development and evaluation. Journal of Clinical Epidemiology 1993; 46: 153–162. Brownie S. The physical activity patterns of older Australians. Australian Journal of Primary Health 2005; 11: 79–87. Australian Institute of Health and Ageing. Older Australia at a Glance, 4th edn. Canberra: AIHW, 2007. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. Journal of the American Geriatrics Society 2006; 54: 743–749. Hill K. Studies of Balance in Older People. Melbourne: The University of Melbourne, 1998. Ecclestone NA, Myers AM, Paterson DH. Tracking older participants of twelve physical activity classes over a three year period. Journal of Aging and Physical Activity 1998; 6: 70–82. Stiggelbout M, Hopman-Rock M, Tak E, Lechner L, van Mechelen W. Dropout from exercise programs for seniors: A prospective cohort study. Journal of Aging and Physical Activity 2005; 13: 409–421.

• LLLS™, as delivered in the community, can result in significant improvements to function and quality of life for older people participating in the program. • A better understanding of program adherence/ withdrawals and older people’s attitudes towards strength training is needed to maximise participation and sustainability of outcomes.

Australasian Journal on Ageing, Vol 33 No 1 March 2014, 22–25 © 2013 Council on the Ageing Victoria Australasian Journal on Ageing © 2013 ACOTA

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Living Longer Living Stronger™: a community-delivered strength training program improving function and quality of life.

This study investigated changes in function and quality of life for older adults participating in Living Longer Living Stronger™, a community-delivere...
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