Prevention of Disability with Exercise
Abstract & Commentary
Synopsis: Aerobic exercise (walking 1 hour 3 times a week) and resistance exercise (a set of 9 exercises for 1 hour 3 times a week) reduced the subsequent deterioration of activities of daily living in a group of people 60 years of age and older.
Source: Penninx BW, et al. Arch Intern Med. 2001;161:2309-2316.
This study is an interesting collaboration between the Center on Aging and the Department of Health and Exercise Sciences at Wake Forest University, along with 2 Italian Geriatrics groups. Penninx and colleagues set out to determine if exercise can prevent disability in activities of daily living (ADL) in a group of subjects recruited from the Fitness Arthritis and Seniors Trial (FAST).1 In brief, subjects included in the current report were older than 60 (mean age, 69.1), had pain and radiographic evidence of knee arthritis, lacked significant cardiopulmonary disease, lacked baseline ADL disability, and consented to participate. The 250 subjects were randomized into 3 groups: attention control (n = 80), resistance exercise (n = 82), and aerobic exercise (n = 88). Subjects were followed for 18 months. The attention control group served as the control group; they attended monthly group sessions on arthritis management for 3 months, then got phone calls at least for the remainder of the study period. The aerobic exercise group had a 3-month facility-based walking program followed by a 15-month home-based walking program. Walking comprised 40 minutes of the exercise, with a 10-minute warm-up and stretching period and a 10-minute cool-down period. They completed exercise logs as a measure of compliance, and received regular phone calls to encourage participation. The resistance exercise group had 3 months of facility-based exercises, then 15 months of at home exercises. This group did about 40 minutes of 9 different exercises, with a 10-minute warm-up and stretching period and a 10-minute cool-down period.
ADL disability was assessed by self-report every 3 months and by data collection visits at 6, 12, 15, and 18 months. Knee pain was assessed by a Likert scale applied to pain occurrence during 6 different ADL activities. Aerobic exercise capacity was also measured. The groups were matched by gender, body mass index (BMI), comorbid illness, socioeconomic status, ethnicity, pain intensity, oxygen uptake, and disability score. ADLs assessed in this study were bathing, eating, dressing, transferring from a bed to a chair, and using the toilet.
The dropout rate was 9.8% for the resistance exercise group and 13.6% for the aerobic exercise group. Compliance with exercise declined over time; it was 85% the first 3 months, and 54% for the last 8 months. Forty-two percent of the participants developed an ADL disability over the follow-up period, and the development of ADL disability was significantly greater in the attention control group than in the exercise groups (P < 0.2). Controlling for the usual variables, the adjusted relative risk (RR) of development of an ADL disability was 0.60 (P = 0.04) for the resistance exercise group, and 0.053 (P = 0.009) for those in the Aerobic Exercise Group. Compliance with exercise was inversely related to the risk of ADL disability. Those in the highest tertile of compliance were least likely to develop ADL disability.
Comment by Barbara A. Phillips, MD, MSPH
Just the other day, a patient told me her doctor had advised her not to walk because she has arthritis in her knees. While some clinicians may believe that exercise accelerates osteoarthritis and/or causes injury, the evidence actually indicates that moderate exercise improves knee pain and performance outcomes in patients with knee osteoarthritis.2,3 The current study shows that exercise protected patients with osteoarthritis from development of disability. We already know that moderate exercise improves performance outcomes in older people.4,5 As our population ages, we need to seriously examine strategies to prevent disability. This will mean discarding many old notions. Because behavior is so difficult to change, it is easier to prescribe the medication and give the reassuring pat. But smart patients want to know what they can do to safeguard their ability to function. We owe it to them to continue to talk about diet, exercise, sleep, smoking, and all that other stuff they should have learned in health class. Because we are physicians, we have tremendous credibility and authority.
Dr. Phillips, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, is Associate Editor of Internal Medicine Alert.
References
1. Ettinger WH, et al. JAMA. 1997;277:25-31.
2. Fisher NM, et al. Arch Phys Med Rehabil. 1993;74: 840-847.
3. Kovar PA, et al. Ann Intern Med. 1992;116:529-534.
4. Ades PA, et al. Ann Intern Med. 1996;124:568-572.
5. Cress ME, et al. J Gerontol A Biol Sci Med Sci. 1999; 54:M242-M248.
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