A randomized controlled trial
Introduction: An essential public health goal is to reduce age-related disabilities in the elderly. The present study aimed to investigate the effect of exercise program on health-quality of life (HQL) in older adults.
Methods: Subjects were sixty healthy adult volunteers over the age of 55 years. None of the subjects had any experience in exercise programs but were physically active and able to perform activities of daily living independently. The subjects were randomly assigned into one of two groups each with 30 people: test (exercise) group and control (no exercise) group. The test group was taken into a 12-week aerobic exercise program. The exercises included a 5-10 minute circulatory warm-up, a 15 minute walking and a 5-10 minute stretching/cool-down period. The exercises were performed three times per week under supervision of an experienced instructor. No exercise program was prescribed for the control group. Both groups were assessed before and after the exercise program. The LEIPAD questionnaire was used to measure HQL.
Results: The results showed significant improvements in all domains of the LEIPAD questionnaire whilst the level of HQL did not change and none of the scores obtained by the LEIPAD was significant. Measures of HQL improved with exercise so that there were no HQL changes in the control but significant changes were observed in the exercise group.
Conclusion: This study suggests that an exercise program has resulted in a significant improvement in HQL in older adults (NCT00999674).
An essential public health goal is to reduce age-related disabilities in the elderly. In the next 20 years, the number of people over 60 years of age will double , raising the issue of finding feasible means for their independent living . In fact, the aging populations are those who are in need of specific encouragement to engage in physical activity . Exercise and physical activity have been suggested as effective means to maintain independent living in old age [4, 5]. Health-related quality is defined as optimum levels of physical, mental, role, social functioning involving occupational and life roles, relationships, and personal perceptions of health, fitness, life satisfaction and well-being . The elderly are more prone to experiencing various adverse events. Consequently, physical, social, economic well-being issues tend to be interrelated to a much greater extent than among other age groups .
Exercise can improve and maintain health-quality of life (HQL) and increasing the HQL is one of the primary goals for health improvement in older persons . Various modes of exercise have been offered to improve physical functions and HQL in older adults. The goal of exercise for older adults is to increase their reserve capacities and therefore maintain the ability to perform daily activities . As HQL is related to body function and structure, activity and participation [10, 11], exercise programs may lead to significant improvement in strength, endurance and body mechanics in older adults .
Many HQL instruments have been developed (e.g. studies of reactions to such diseases as cancer, cardiovascular disorder, AIDS and surgery), however, the LEIPAD questionnaire is a subjective assessment specifically designed to determine HQL in the elderly as it takes cognitive function into consideration . This instrument is valid, reliable and also very practical. Its name is an acronym deriving from the first two of the three involved universities namely, LEIden (the Netherlands), PADua (Italy), and Helsinki (Finland). The present study aimed to investigate the effects of exercise program on HQL in older adults.
This was a semi-experimental trial conducted in Shahrekord, Iran (NCT00999674). We assessed 69 subjects for eligibility. Sixty healthy volunteers over the age of 55 years were asked to participate in this study (Cochran’s formula with a 99% confidence level, t = 2.326; d = 0.03; p = 0.869). The study subjects were recruited among those who responded to advertisements in outpatient clinics . Subjects were randomly assigned into one of two groups each with 30 people: test (exercise) group and control (no exercise) group. Following Avlund et al , the sixty subjects were equally distributed between the two groups, but otherwise randomly selected by taking every second participant from a randomly organised computer file.
None of the subjects had any experience in exercise programs but were physically active and able to perform activities of daily living independently . Exclusion criteria were: neurological disorder (paresis, stroke, Parkinson’s disease), acute heart impairment (hypertension, congestive heart failure), unstable chronic illness (diabetes mellitus, malignancies), severe musculo-skeletal impairment (inability to participate in the programs) . Ethics approval was obtained from the university’s medical research ethics committee. All subjects agreed to participate by providing written informed consent. The test group was taken into a 12-week aerobic exercise program. The exercises included a 5-10 minute circulatory warm-up, a 15 minute walking, and a 5-10 minute stretching/cool-down period. The exercises were performed three times per week at the rehabilitation unit under supervision of an experienced instructor. No exercise program was prescribed for the control group. Both groups were assessed before and after the exercise program. The same questionnaire was used for the subjects in both groups.
The questionnaire consisted of demographic data (such as age, gender, educational level, and employment) and the LEIPAD questionnaire used to measure HQL at week 0 and 12 . The 31-item LEIPAD questionnaire designed to measure seven main HQL dimensions or domains and each item in the instrument was scored from 0 (the worst condition) to highest (the best condition). The questionnaire was administered by the same instructor who was not informed about the protocol:
1) The physical function dimension, scores ranging 0-15; 2) the self-care dimension, scores ranging 0-15; 3) the depression and anxiety domain, scores ranging 0-12; 4) the cognitive functioning domain, scores ranging 0-15; 5) the social functioning domain, scores ranging 0-9; 6) the sexual functioning domain, scores ranging 0-6; and 7) the life satisfaction domain, scores ranging 0-18.
Scale instrument consisted of 31 questions which measured seven dimensions of HQL: self-perceived physical health, self-esteem, interpersonal and social functions, expectations for the future, recreational activities and activity of daily living. Test-retest for reliability was based on 30 questionnaires within two weeks of early assessment. The reliability level measured 83%. All data were gathered and analyzed using SPSS (version 14). Chi-square and t–test were performed to analyse demographic and HQL differences between the two groups. Statistical significance was accepted at p<0.05. Mann-Whitney test was used to compare the measurements of characteristics and dependent variables between the two groups.
All subjects had completed the study. Table 1 represents demographic details of both groups. Initially there was no significant difference between the two groups of test and control in terms of the demographic features (p >0.05, Chi-square and Mann-Whitney). However, after intervention (exercise), the overall level of HQL, measured by seven domains of the LEIPAD questionnaire, showed statistically significant improvement in the LEIPAD score in the test group (t-test, p <0.05). In contrast, the level of HQL did not change and neither of scores obtained by the LEIPAD was significant so that no improvement in the LEIPAD score was found in the control group (Table 2). The results clearly indicate that an exercise program has a positive effect on HQL in older adults.
This study demonstrates that an exercise program improves HQL in older adults and that after a regular exercise significant improvement in all components of HQL in the older adults is observed.
In the recent industrialised world, HQL in older adults is particularly important in view of the increasing number of over 65 year-olds . At this age physical abilities slow down and pharmacokinetic responses to treatment decline . The results of the current study are in agreement with Acree et al  who found that HQL of the elderly who exercise is higher than HQL of the elderly who do not, so that the adherence to exercise improves HQL . In fact, many studies have reported that the exercise interventions of any type (water, resistance and balance exercise) can lead to the improvement of HQL [14, 15]. Likewise, Barrett & Smerdely  suggested that progressive resistance training significantly improves strength, mobility and HQL in elderly people.
Many older people are reluctant to participate in the exercise programs because of medical obstacles such as poor health, fear of injury and transportation problems . For adults, there is substantial evidence documenting the health-benefits associated with physical activity [18-20]. Physical activity improves health even for chronically ill or frail older adults [21, 22].
Indeed, exercise is a tool to help older adults to overcome their disabilities and improve all aspects of HQL particularly to maintain their health conditions and perform activities of daily living. Meta-analytic reviews have proven that exercise is associated with a variety of health improvements such as decreased risk of coronary heart disease and stroke , improved cognition in sedentary older adults , a modest benefit in HQL for frail or older adults , and a positive association with successful aging .
Because of this, recommendation of current public health is that all adults should engage in at least 30 min. of moderate-intensity activity (4.0-5.9 metabolic equivalents) on most days of the week . Similarly, this study showed that a regular exercise has a positive effect on physical activity and improves HQL in older adults.
In addition, other investigations show that exercise interventions are able to modify physical risk factors for falls such as balance and mobility impairments and also reduced muscle strength [27-30], and as such the incidence of falls in older people reduces . Nevertheless, it must be noted that exercise outcomes for older adults should be achieved as efficiently as possible due to the fact that elderly people can less easily afford multiple exercise programs and often have difficulties to travel to venues for exercise . Therefore, further research should investigate specifically the best training exercise to improve HQL in older adults.
Correspondence:Ali Hassanpour Dehkordi, Faculty of Medical Science, Shahrekord University, Shahrekord, Iran. E-mail: email@example.com
Acknowledgement: The authors would like to thank Dr. L. Ward and Dr. J. Purser from Australia for their help.
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