The Gerontologist
Cite journal as: The Gerontologist Vol. 54, No. 4, 611–623
doi:10.1093/geront/gnt039
© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America.
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Advance Access publication May 15, 2013
Effect of Ecological Walking Training in
Sedentary Elderly People: Act on Aging Study
Daniele Magistro, PhD,*,1 Monica Emma Liubicich, PhD,1
Filippo Candela, PhD,2 and Silvia Ciairano, PhD2
1
Motor Science Research Center, University School of Motor and Sport Science (SUISM), University of Torino, Italy.
2
Department of Psychology, University of Torino, Italy.
*Address correspondence to Daniele Magistro, PhD, Motor Science Research Center, University School of Motor and Sport Science, University of Turin,
Piazza Bernini 12, 10143 Torino, Italy. E-mail: [email protected]
Received August 11, 2012; Accepted April 5, 2013
Decision Editor: Rachel Pruchno, PhD
Purpose of the Study: This study aims to investigate the effects of a walking program on aerobic
endurance and function in a sample of sedentary
elderly people. Design and Methods: For this
study, 126 sedentary individuals were recruited: 63
individuals (mean age = 74.1 ± 6.0 years) for the
control group and 63 (mean age = 72.0 ± 4.5 years)
for the intervention group. The intervention consisted
of walking training including balance exercises and
lower limb strength activities twice a week for 4
months. We collected baseline and post-test measurements of aerobic endurance, lower limb strength,
and mobility. We also measured aerobic endurance
at increments of 4, 8, and 12 weeks between the
baseline and the post-test. We used analyses of
covariance with baseline value, gender, age, and
body mass index scores as covariates (p < . 05) and
calculated the effect size for the effects of the intervention. The changeover time of aerobic endurance
was also analyzed with the repeated analysis of variance (p < .05). Results: The intervention group
showed steady and significant improvements with
respect to the 6-min walk (aerobic endurance) from
447.89 m (SD 73.87) to 561.51 m (SD 83.96), as
well as the 30-s chair stand (lower limb strength) from
10 (SD 3) to 13 (SD 3) number of times and the Timed
Up and Go Test (mobility) from 8.53 s (SD 2.86) to
7.13 s (SD 1.76) at the post-test, whereas the control
group showed significant decrease in all measurements. Implication: These results underline that
an ecological walking training program can be used
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to improve physical functioning among sedentary
elderly people.
Key Words: Physical activity, Intervention
Population in developed countries are getting
older. Aging is considered a primary risk factor for
the progression of most chronic degenerative diseases and is associated with an increase in disability and frailty (Stenzelius, Westergren, Thorneman,
& Hallberg, 2005; WHO, 2002). Furthermore,
reduced physical function in elderly people is
a risk factor relating to comorbidities, physical
and psychosocial health problems, environmental
and social frail conditions, inadequate nutrition,
and unhealthy lifestyles (Beswick et al., 2008).
Therefore, one of the priorities of risk prevention
among the elderly people is to delay or to avoid
risks related to aging by structuring specific interventions that aim at maintaining physical function,
limiting disability, and promoting independence
for as long as possible.
In particular, advancing age is associated with
physiological changes that result in the reductions
of functional and motor ability and skills, such
as strength, endurance, and mobility (Shea, Park,
& Braden, 2006). These age-related physiological
changes can have an impact on activities of daily
living (ADLs) and undermine the preservation
of the elderly people’s physical independence
(Guralnik et al., 2000; Spirduso & Cronin, 2001).
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For example, aging is accompanied by a progressive
loss of muscle mass that has been associated with
both lower muscle force production capacity and
an inability to perform ADL (Rockwood et al.,
2004; Wallerstein et al., 2012).
These impairments can affect walking, one of
the most common and important human movements related to living an active and independent
life. With aging, walking performance starts to
decline in terms of a decrease in speed and shorter
stride length, whereas the double-limb support
duration increases (Chodzko-Zajko et al., 2009).
Walking difficulties result in reduced activity, loss
of independence, and an increased number of falls
and other injuries (Van Swearingen et al., 2009).
Such walking difficulties are also associated with
weakness in the lower extremity muscles, poor
balance, and deconditioning from lack of muscle
use (Chodzko-Zajko et al., 2009). In general, leg
weakness is associated with impaired gait function
in terms of slow speed and small steps (Barrett,
Mills, & Begg, 2010). In particular, a decrement in
lower extremity strength may be associated with
the occurrence of falls. Besides this, declines in gait
speed might be seen as a relevant component of
preclinical disability (Guralnik et al., 2000; Protas
& Tissier, 2009). We know that the maintenance of
walking skills can be obtained by promoting regular physical activity (Chodzko-Zajko et al., 2009).
Generally speaking, regular physical activity
increases the average life expectancy by decreasing the chance of chronic disease development
and progression (Olshansky, Hayflick, & Carnes,
2002). In fact, regular physical activity can mitigate the effects of age-related biological changes
(Huang, Shi, Davis-Brezette, & Osness, 2005)
and the decline in health and well-being (Darren,
Crystal, & Shannon, 2006). Moreover, regular
physical activity affects the physical and psychological capabilities of elderly people (Colcombe &
Kramer, 2003). This is part of a healthy lifestyle
that contributes toward successful aging (Nelson
et al., 2007).
Traditionally, walking improvement training
focuses on walking practice and the remediation of
deficits in strength, balance, and endurance, under
the assumption that gains in physiological capacity
will contribute to improved walking performance
(LIFE Study Investigators et al., 2006; Mian et al.,
2007). Furthermore, an increase in the walked
distances indicates an overall improvement of the
functional capacity that can be used as a relevant
indicator of the efficacy of an intervention and/or
of a rehabilitation program (Poole-Wilson, 2000).
The elderly people’s walking performance can
be improved by enhancing the strength of lower
extremity muscles (Protas & Tissier, 2009). The
improvements in gait speed are associated with the
improvements in the strength of lower extremity
muscle and an increased mobility function
(Binder et al., 2002; Liubicich, Magistro, Candela,
Rabaglietti, & Ciairano, 2012). Moreover, a
moderate walking training may result in the
increments of muscle thickness and strength in
the elderly people’s lower limb muscles (Liu &
Latham, 2009).
The problem is that most of the aforementioned
studies investigate the effects of physical training
organized in traditional gyms with sports equipment (i.e., bike and treadmill) and/or in a laboratory. However, it is well known that promoting the
participation of sedentary elderly people in physical
trainings implemented in places such as traditional
gyms with specific facilities can be problematic,
particularly in Italy (National Institute of Statistics,
2010). There are two important factors affecting
the initiation and maintenance of physical activity: social and structural barriers (Dunlap & Barry,
1999). Social barriers include societal stereotypes
regarding activity in aging, social isolation, and
judgment from younger people. Structural barriers
include access to appropriate venues for activities,
neighborhood safety, transportation, and socioeconomic disadvantage (Dunlap & Barry, 1999).
For these reasons, many elderly people remain
sedentary.
Sedentary living is defined as a way of living or a
lifestyle that requires minimal physical activity and
that encourages inactivity through limited choices,
disincentives, and/or structural or financial barriers (Chodzko-Zajko et al., 2009). Furthermore,
according to Wahl, Iwarsson, and Oswald (2012),
many elderly people desire to “age in place” by
remaining in their familiar home environment
or in an environment of their choice for as long
as possible. An ecological intervention signifies a
health promotion program at the community level
that is based on emphasizing the individual and
contextual systems and the interdependent relations between the two. It also consists of a combination of educational, organizational, regulatory,
and economic components aimed at achieving specific objectives for a given population (McLaren &
Hawe, 2005).
In this study, we focused our attention on a different kind of physical training that is based on
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the ecological perspective of health promotion at
the community level. To do so, we created a new
ecological walking training program that includes
balance and strengthening exercises. These can
be performed not only in a gym but also in other
environments without specific facilities for physical activity. Our walking training can be, in fact,
practiced in such places as any meeting point, club,
or public environment already attended by elderly
people in their daily life. The advantage of these
spaces is that they are within the elderly people’s
own neighborhood and easily accessible, especially
for those sedentary elderly people who are not
willing to put a great deal of effort into a gym.
Moreover, the participants can practice this physical activity in a familiar social context with other
elderly people. This training combines functionfocused aerobic endurance and resistance lower
limb training including specific tasks commonly
performed in daily life among sedentary elderly
people aged more than 65.
In sum, the first objective of this research is to
test the effects of an ecological physical activity
program on walking function, particularly with
regards to endurance, mobility, and lower limb
strength, which are strictly related to walking. We
hypothesized that our ecological walking training would improve aerobic endurance, lower limb
strength, and mobility performance among sedentary elderly people. The second aim of the study
was to monitor the change of aerobic endurance of
the elderly people who participated in the training.
In fact, we wanted to detect the time required to
observe a first significant change in aerobic endurance. These data could be useful to improve the
protocol of the training for future intervention.
The proposed intervention is addressed at specific
subgroup of the population: elderly people who
are at high risk of loss of autonomy and/or diseases
because of their sedentary lifestyle.
Design and Methods
An experimental research design was utilized in
this study in which one experimental group and one
control group were used to determine the effects of
walking training on aerobic endurance, mobility,
and strength of lower limbs. The experimental
condition consisted of the participation in an
ecological 16-week physical training implemented
in halls of elderly people residential centers.
All participants were tested before and after the
16-week training. Aerobic endurance was also
Vol. 54, No. 4, 2014
tested every 4 weeks during the 16 weeks of training,
but only within the experimental group. Control
group participants were advised to maintain their
normal daily routines. This research belongs to a
larger in-progress longitudinal “Act on Ageing”
project of Piedmont Region, Italy, the main aim of
which is to evaluate the effect of various physical
and cognitive interventions on the physical and
cognitive status of sedentary elderly people.
Participants
The sedentary elderly people were recruited
from a list of 400, offered by the Health Office of
the Piedmont Region and general medical practitioners. The participants were recruited by phone
and did not receive any incentive for participation.
The Consolidated Standards of Reporting Trials
(Figure 1) summarizes the recruitment and attendance information of our study sample.
First, participants were classified as leading a
sedentary lifestyle if they did not report participating in regular moderate or vigorous physical
activity for the last 5 years. Second, the eligibility criteria for participation were being 65 years
or older, having an ability to walk 500 m without
assistance and a Mini-Mental State Examination
(MMSE) score higher than 25 (a score ≥25 of 30
indicates the absence of cognitive impairment).
People were excluded if they had a myocardial
infarction and/or coronary bypass surgery within
1 year, uncontrolled diabetes or hypertension,
orthopedic impairment, or upper or lower extremity fracture within the past 6 months and/or if
they were currently participating in another study,
even if of a different scope. Such conditions were
thought to present a potential negative effect on the
participant’s participation in our intervention and
potentially impend on his/her health and safety.
Elderly people meeting the inclusion criteria (126
of the 400 from the original list) received written
approval from their primary-care physician to be
eligible for the study.
After baseline testing, participants were randomly assigned to the walking training or the
control group using a computerized randomization. Descriptive characteristics of the participants
are presented in Table 1. All the participants were
retired and independent. A total of 126 elderly
people participated in the study: 42 (33%) men
(16 in the control group and 26 in the experimental group) and 84 (67%) women (47 in the
control group and 37 in the experimental group).
613
Figure 1. Consolidated Standards of Reporting Trials of participants through the study.
The mean age was 74.1 years (SD = 6.0) for the
control group and 72.0 years (SD = 4.5) for the
experimental group.
At the beginning of the 16-week study, one participant from the experimental group withdrew
after the introductory training session, and subsequent attempts to contact him for an explanation
were unsuccessful. Besides this, two women in the
experimental group and two men and five women
in the control group were dropped from the analyses because they were unable to attend the final
data collection. In sum, we had an 8% attrition
rate for the study. The remaining 60 experimental
group participants attended 90% of the total possible workouts. Data were also collected at both
waves from the 56 remaining control participants.
All the elderly people completed every session of
training.
The Ethical Committee of the University of
Torino approved the study, and all participants
were informed that participation in the study was
voluntary and confidential. All the selected individuals agreed to participate and gave their written
informed consent in accordance with Italian law
and the ethical code of the American Psychological
Association (2002).
Measures
The demographic data (age, gender, family condition, and level of education) were self-reported.
Each participant was assessed at the baseline for
height, weight, body mass, and cognitive function (MMSE, Folstein, Folstein, & McHugh,
1975). Height was assessed by anthropometer
(International Standard ISO/TR 7250-2, 2010).
Weight and body mass index (BMI) were assessed
by Tanita Body Composition Analyzer BF-350.
We tested for aerobic endurance, strength of
lower limb, and mobility. All tests were performed
in the same day, with an hour break between
each test.
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Table 1. Sociodemographic and Baseline Characteristics of Study Participants
Group
Control
Gender (N)
Women
Men
Level of education (N)
Low
High
Family condition
Never married
Married
Widow
Divorced
Past job
Manual labor
Nonmanual labor
Experimental
N
%
N
%
47
16
75
25
37
26
59
41
522
11
35
17
51
12
32
19
13
29
17
4
21
46
27
6
9
23
24
7
14
37
38
11
43
20
68
32
40
23
63
37
M (SD)
M (SD)
p
74.1 (6)
29.6 (5.3)
28.8 (1.5)
432.46 (47.31)
10 (2)
9.26 (2.14)
72.0 (4.5)
29 (5)
28.4 (3)
447.70 (73.96)
10 (3)
8.46 (2.81)
.06
.54
.32
.17
.12
.08
Age
Body mass index score
Mini-Mental State Examination (score 0–30)
Six-minute walk (time in minutes)
Thirty-second chair stand (N° of times)
Timed Up and Go Test (time in seconds)
Note: Level of education: low—corresponding to compulsory education (primary school); high—corresponding to
additional noncompulsory education.
Aerobic endurance is defined as the capacity
to perform large-muscle activity over an extended
period of time (Weineck, 2007). Aerobic
endurance was assessed using a 6-min walk (Rikli
& Jones, 2001). The test involves walking around
a course covering as much distance (m) as possible
within 6 min. On a timed test such as the 6-min
walk, scores were obtained for individuals of all
levels of ability starting with frail participant who
can only walk a few meters to the highly able
individual who can cover several hundred meters
within the allocated time. We also tested aerobic
endurance at increments of 4, 8, and 12 weeks
between the baseline and the post-test. The test
was performed 1 hr before the beginning of the
training session.
Strength is the ability to generate force to overcome inertia or a load (Zatsiorsky, 2008). Lower
limb strength is an important aspect of fitness in
elderly people because of its role in daily activity. It
was assessed using a 30-s chair stand (Jones, Rikli,
& Beam, 1999), consisting in counting the number of times a person could stand up from a sitting
position with arms folded across the chest within
a 30-s time frame. Chair-stand performance has
Vol. 54, No. 4, 2014
also been found to be effective in detecting normal
age-related declines (Bohannon, Shove, Barreca,
Masters, & Sigouin, 2007) and the effect of physical training in older adults (Carvalho, Marques, &
Mota, 2004).
Mobility is defined as the ability to independently move around in one’s environment (Webber,
Porter, & Menec, 2010; WHO, 2001) and is a fundamental expression of an individual’s autonomy.
This capacity was assessed using Timed Up and
Go Test (Rees, Murphy, & Watsford 2007), which
involves counting the number of seconds required
to stand from a seated position, walk as quickly
and as safely as possible across a line located 3 m
away, turn around, and finally return to the initial
sitting position. This test was completed twice and
the best score was recorded.
Training Protocol
The training consisted of a twice-weekly intervention of 75 min each session. The training was
organized in six groups composed of 10–11 participants and conducted by two qualified instructors. The instructors had a university degree in
615
physical education and sports-related fields and
specialized in physical activity for the elderly
people. Every training session was supervised by
the first author. For each intervention session, the
instructors followed a specific protocol that was
specifically designed for our research. The protocol specified the duration and the recovery time
between each exercise. It also gave the instructor the instructions for each sequence of every
exercise and the time of execution and rest. For
managing all the activity sections, the instructors followed an instruction sheet where all the
sequences and times of the exercises were specified. Also, the instructors used a stop watch to
manage the times of the exercises correctly. All
participants of the various groups performed the
same sequences and same times of the exercises.
Moreover, the instructor was asked to show the
exercise during the activity until all the participants learned the correct execution of the exercise. For the safety of all participants, heart rates
were monitored during the training with a personal heart rate system. The safety limit was
determined by calculation the maximum heart
rate following the method of Tanaka, Monahan,
and Seals (2001); the formula to predict the maximum heart rate is 208 − 0.7 × age.
The first 10 min of the exercise consisted of a
warm-up activity of walking around an indoor
track (a track was built along the perimeter of
the hall) at a slow pace/rhythm of low intensity,
followed by four accelerations of stride for 30
s, which were interspersed with 1 min of slow
strides up to 40%–45% of maximum heart rate.
A 50-min progressive endurance exercise period
followed the warm-up, consisting primarily in
walking with direction changes, accelerations
and decelerations, and changes of gait. More specifically, during the walk, two series of six accelerations of the gait speed were provided where
participants were walking at their maximum
speed. Between accelerations, there was a recovery
time where participants were walking at a slower
pace. After every acceleration, the participants
changed the direction of their walk. The walk’s
intensity increased with the time of acceleration
(from 30 s in the first month to 120 s in the fourth
month). The recovery time between accelerations
also decreased (from 180 s in the first month to
90 s in the fourth month). Moreover, after the
first and second series of accelerations, six balance
exercises were included during the walk (at a slow
speed). Our protocol specifically provided three
series of three different exercises (toe walk, balance walk, heel walk, tandem forward walk, heelto-toe walk, and cross-over walk). Each exercise
had a duration of 30 s and for each session the
sequence of these exercises changed. The sequence
of balance exercises had previously been defined
in the protocol of activity.
During this period, the heart rate ranged
between 45% and 60% of the maximum heart
rate. During the 16 weeks of training exercise,
intensity was increased to a 70% of the maximum
heart rate. After, in the same place, 10 min of
strength training provided closed kinetic chain
exercises using body weight as resistance for
all major muscle groups of the lower extremity
(half squat—knee flexion around 90°; quarter
squat—knee flexion around 120°; lunge—during
the lunge, the knee does not touch the floor; side
lunge; and calf raise). The participants did not
use any exercise equipment (i.e., free weights and
elastic bands) during these exercises. However, if
they felt or seemed insecure during the exercises,
the participants were able to use handrails or
chairs in order to support themselves. Overall,
the participants performed three sets for each
exercise. Their intensity was increased with the
number of repetition (from 8–10 for the first
month to 22–24 for the fourth month), whereas
the recovery time between series was decreased
(from 90 s in the first month to 30 s in the fourth
month). The last 5 min were used for cool down
and rest.
Statistical Analyses
First, we performed a t-test analysis for each
test score at the baseline between the experimental
and control group to see if there were any differences in the baseline values. Second, following the
work of Van Breukelen (2006), we tested the differences between experimental and control groups
by a series of analyses of covariance for each outcome (aerobic endurance, lower limb strength, and
mobility) with group as main effect (experimental
vs control) and the baseline value, gender (coded as
0 for women and 1 for men), age, and BMI scores
as covariates. As a dependent variable, we used
the post-test scores for each outcome variable. In
addition, we tested the effect size (Cohen’s d) of
walking training in order to quantify the effectiveness of an intervention (Derzon, Sale, Springer, &
Brounstein, 2005). The Cohen’s d was computed
with the following formula: training group (TG),
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Vol. 54, No. 4, 2014
617
Notes: Baseline value, gender, age, and body mass index were used as covariates. Relative percentage of improvement from baseline is the difference between post-test and
baseline in percent respect to baseline.
d = 3.39
d = 1.56
d = .75
F = 253.59; p < .0001; η = .697
F = 96.80; p < .0001; η2 = .470
F = 42.85; p < .0001; η2 = .282
26
33
13
561.51 (83.96)
13 (3)
7.13 (1.76)
447.89 (73.87)
10 (3)
8.53 (2.86)
−24
−6
−7
330.84 (100.91)
9 (2)
9.84 (2.49)
428.87 (46.96)
10 (2)
9.34 (2.19)
Six-minute walk
Thirty-second chair stand
Timed Up and Go Test
Effect size
Percentage
of change
Post-test,
M (SD)
Pretest, M (SD)
Percentage
of change
Post-test,
M (SD)
There were no baseline differences between the
two groups with respect to age (t(124) = 1.89;
p = .06), BMI score (t(124) = .62, p = .54), and MME
score (t(124) = .98, p = .33). At the pretest, the intervention group and the control group did not differ
in a statistically significant way with respect to aerobic endurance (t(124) = −1.38, p = .18), as well as
lower limb strength (t(124) = −1.56, p = .12), and
mobility (t(124) = 1.77, p = .08) (Table 1).
All participants attended 90% of the total possible workouts and reached the intensity range
required by the exercise program for each session.
Furthermore, all participants were able to complete every set of strength training exercises without difficulties.
Table 2 presents mean scores and standard
errors for the experimental and control groups
at pre- and postintervention. As for the effects of
the intervention (Figure 2), the difference between
the experimental and control group was statistically significant for aerobic endurance (F(5,
116) = 253.59, p < .0001, η2 = .697) with a huge
effect size (d = 3.39). In fact, aerobic endurance
Pretest, M (SD)
Results
Experimental
Range: negligible effect (≥−0.15 and <.15),
small effect (≥.15 and <.40), medium effect (≥.40
and <.75), large effect (≥.75 and <1.10), very large
effect (≥1.10 and <1.45), and huge effect (>1.45).
With respect to aerobic endurance, we checked
at which time point the change was statistically
significant by repeated measures analyses of variance
(ANOVA) for which we introduce the five waves
as the within-factor. We also used the Bonferroni
post hoc test to determine whether the difference
between each pair of waves was significant at p
value less than .05. In order to highlight the change
in experimental and control groups, we computed
the percentage of change by dividing the average
gain by the pretest mean of our measures (Thomas,
Nelson, Silverman, & Silverman, 2010). All data
were analyzed using the SPSS computer package
(SPSS V. 18.0; Chicago, IL).
Main effect group
2
(N TG − 1)SD2TG + (NCG − 1)SDCG
N TG + NCG − 2
Analysis of covariance
;
Group
SDpooled =
SDpooled
Control
(MTG, t 2 − MTG, t1 ) − (MCG, t 2 − MCG, t1 )
Table 2. Analysis of Covariance
ES =
2
control group (CG), pretest (t1), post-test (t2),
sample (N), standard deviation, and range:
Figure 2. Aerobic endurance.
decreased between the pre- and post-test in the
control group (from 432.46 to 330.84 m), whereas
it increased in the experimental group (from
447.70 to 561.51 m). Considering the baseline aerobic endurance score, the data of the experimental
group showed a relative increase of 26%, whereas
the control group showed a relative decrease
of 24%.
Regarding lower limb strength (Figure 3), the
difference between the experimental and control groups was statistically significant (F(5,
115) = 96.80, p < .0001, η2 = .470) together with
a huge effect size (d = 1.56). A small decrease
between the pre- and post-test was observed in the
control group (from 10 to 9 times). However, the
lower limb strength increased in the experimental
group (from 10 to 13 times). Based on the baseline
lower limb strength score, the data of the experimental group showed a relative increase of 33%,
and the control group showed a relative decrease
of 6%.
Finally, the difference between the experimental
and control groups was statistically significant for
mobility (F(5, 115) = 42.85, p < .0001, η2 = .282)
with a large effect size (d = .75). The control group
(Figure 4) remained stable in mobility performance
(from 9.25 to 9.84 s), whereas the intervention
group’s increased (from 8.47 to 7.13 s). The baseline mobility score data of the experimental group
showed a relative increase of 13% and the control
group showed a relative decrease of 7%.
Figure 5 presents mean scores and standard
errors for the experimental groups at pretest, three
midwaves, and post-test. Regarding aerobic endurance (Table 3), the Bonferroni post hoc test of the
ANOVA revealed a significant statistical difference
for every five waves of measures (F(1, 59) = 157.11,
p < .0001, η2 = .920).
Discussion
The aim of this study was to investigate the
effects of an ecological walking training, which
includes balance and strengthening exercise among
a group of sedentary elderly people in terms of aerobic endurance, lower limb strength, and mobility.
As for aerobic endurance, we wanted to
demonstrate whether participating in an ecological
physical activity training could improve this in
elderly people. Consequently, the data showed a
huge effect size of intervention. We found that the
participants of the experimental group increased
their aerobic endurance from the baseline by
26%. This improvement is similar to changes
reported in other studies that trained participants
in comparable tasks (Harber et al., 2009; LIFE
Study Investigators et al., 2006). Also noteworthy
is the fact that no physical or medical problems
occurred during training or aerobic endurance
testing, which is consistent with the literature and
confirms the idea that moderate aerobic training
is safe and effective even in the elderly people
(Bischoff & Roos, 2003; Garber et al., 2011).
In accordance with American College of Sports
Medicine (2000) (Chodzko-Zajko et al., 2009),
aerobic physical activity training can significantly
increase aerobic capacity and performance in older
adults. This finding is relevant because an adequate
level of aerobic endurance, which is the ability to
sustain large-muscle activity over time, is necessary
to perform many everyday activities (Garber et al.,
2011). In relation to aerobic endurance, our study
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Figure 3. Lower limb strength.
Figure 4. Mobility.
Figure 5. Aerobic endurance (five repeated measures).
demonstrated that sedentary elderly people who
participated in walking training had a regular and
continuous increase in performance during the
16-week training. For each measurement at weeks
Vol. 54, No. 4, 2014
4, 8, 12, and 16, the participants improved steadily
(respectively by 9%, 10%, 4%, and 3%). The
participants of the control group, who remained
sedentary, decreased their aerobic endurance by
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Table 3. Repeated Measures Analyses of Variance
Experimental group
Wave 1
(baseline)
Wave 2 (4 weeks)
Wave 3 (8 weeks)
Wave 4 (12 weeks)
Wave 5 (16 weeks)
Percentage
Percentage
Percentage
Percentage Main effect
M (SD) M (SD), p of change M (SD), p of change M (SD), p of change M (SD), p of change
time
Six-minute
walk test
447.89
(73.87)
487.95
(74.15),
<.0001
9
534.13
(79.10),
<.0001
10
547.34
(81.20),
<.0001
4
561.51
(83.96),
<.0001
3
F = 157.11;
p < .0001;
η2 = .920
Notes: The statistical significance of the difference between the waves was calculated by the Bonferroni post hoc test. Relative
percentage of improvement fromF baseline is the difference between post-test and baseline in percent with respect to baseline.
24% during the same period. Therefore, our study
suggests that even in the shorter term physical
activity training can trigger positive and continuous
changes on individual physical functions that
are essential for maintaining independence and
reducing fatigue in daily activities.
A further outcome of our study was that we
found that our ecological training would specifically improve the lower limb strength of sedentary
elderly people. The participants in the experimental group increased lower limb strength by 33%
with respect to the baseline. The data show, also
in this case, a huge effect size. Our results, similar
to those reported in the meta-analysis by Liu and
Latham (2009), confirm that given a stimulus of
sufficient intensity, muscle strength may increase in
older adults. Moreover, the meta-analysis showed
that strength training had a significant benefit
compared with aerobic training on strength in
elderly people. Also, we found a similar positive
effect that was reported after a progressive resistance strength training (Latham, Bennett, Stretton,
& Anderson, 2004). However, physical activity
based on walking and resistance strength training does help to preserve and even improve the
lower limb strength of sedentary elderly people
(Lovell, Cuneo, & Gass, 2010). Limb strength is
directly related to one’s autonomous walking ability. Indeed, lower limb strength declined by 6%
among the control group participants. Moreover,
the ability to repeatedly produce muscular strength
through an extended period of time determines
the travel range and the functional independence
of the elderly people; the lack of strength is a reliable predictor of the onset of disability in later
years of life.
The third outcome this study demonstrated was
that a physical activity program based on walking
exercise that includes balance and strengthening
exercise can improve performance related to
mobility. In particular, the participants of the
experimental group registered an intermediatehigh improvement (13%) compared with the sedentary participants of the control group where
mobility decreased (7%). These results are similar
to changes reported by Malatesta, Simar, Saad,
Préfaut, and Caillaud (2010) who demonstrate
that walking training may be an effective way to
improve walking performance and delay mobility
impairment among elderly people. Indeed, maintaining a good level of mobility is very important
for elderly people with regards to walking and
managing dynamic balance, even in situations
that require speed, such as getting in and out of
a bus and/or car (Rikli & Jones, 2013). Mobility
includes the ability to perform complex motor
tasks, such as ambulatory supporting weights,
changing direction, and overcoming obstacles.
Shumway-Cook, Ciol, Yorkston, Hoffman, and
Chan (2005) already showed that older persons,
even if independent in mobility, have limitations
in the way they express themselves in complex
situations. Moreover, a good level of mobility
can promote an active lifestyle and participation at recreational activities in the elderly people
(Webber et al., 2010).
Moreover, we want to highlight that these positive results can be affected by the interaction of
walking training with lower body strength exercises and balance exercises. In fact, as already
shown by the literature, a combination of activities (i.e., aerobic and strength training) seems to be
more effective than training alone in counteracting the detrimental effects of a sedentary lifestyle
on health and physical function (Chodzko-Zajko
et al., 2009). Also, multimodal exercise, usually including strength and balance exercises, has
been shown to be effective in reducing the risk of
620
The Gerontologist
falling over and promote safer mobility (Pereira,
Vogelaere, & Baptista, 2008).
There are limitations to consider in this study,
especially regarding the age of participants and
duration and the frequency of activity. Concerning
the age of participants in our study between
experimental and control groups, there is no
difference (p = .06). If we take in account the
sample size, however, we cannot exclude that the
magnitude of our result is, in part, due to some
difference in the age of two groups. Moreover,
literature regarding training duration and
frequency suggests that in order to achieve more
effective results, training should be introduced
three times a week and last for 24–32 weeks.
In our study, it was not possible to use such a
protocol. In Italy, the majority of the elderly population (National Institute of Statistics, 2006),
although sedentary, is very socially active. In
fact, Italian elderly people are usually very much
involved in the care of their grandchildren and voluntary and cultural activities. There is often little
time left for other activities such as physical training. The literature focuses on interventions carried
out in northern European and North American
countries. These are not representative of the
Italian social context that is characterized by a different social and health care system. Furthermore,
the present generation of elderly people has not
developed the habit of participating in structured
physical activity and therefore to convince them
to participate in a training longer than the one we
used would have been virtually impossible. Finally,
we only measured lower limb strength and mobility before training and after the 16-week training.
Consequently, our results reflect only the amplitude
of the final change and not the rate of change over
the weeks of training. We think it is important to
continuously monitor the process of change during the activity, as we did for aerobic endurance,
because all changing aspects must be measured in
order to plan training phases and meet the elderly
people’s needs. Furthermore, future studies should
investigate the effects of our ecological walking
training on psychosocial and cognitive adjustment
and compare its effects with those of a different
kind of physical activity (i.e., strength training and
walking training with treadmill).
Despite these limitations, our study highlights
the importance of identifying protective factors
for health and independence among elderly population. Considering their involvement in physical
activity, many elderly individuals must confront
Vol. 54, No. 4, 2014
barriers to initiation and maintenance. These barriers are not only chronic diseases, disability, or fear
of doing new activities (Bruce, Devine, & Prince,
2002) but also social and structural. We think that
physical activity programs for elderly people have
to take into account environmental conditions
during the design of the intervention. Our ecological training was designed to meet these social and
structural barriers.
Most importantly, our study shows that is possible to obtain positive results through implementing
a physical training without any specific facility or
structure. According to Wiles, Leibing, Guberman,
Reeve, and Allen (2012), the elderly people wanting
to be “aging in place” need health-promoting services inside their daily community, such as physical
trainings. The increasing proportion of the elderly
population demands urgent implementation and
evaluation of the effectiveness of preventive programs that can reduce the costs of health care in
a frail population at risk of disability. Our findings suggest that a physical activity program may
play a protective role in elderly people autonomy.
Even ecological training can slow the aging process
and preserve motor abilities that are critical for
independent livelihood. In addition, our walking
training, owing to the possibility of implementing
this program within elderly residential communities, combined the organizational, regulatory, and
economic components representing an example of
an effective ecological intervention (McLaren &
Hawe, 2005).
We point out that, despite its ecological characteristics, our intervention was based on professional exercises recognized by literature (American
College of Sports Medicine, 2000; Weineck, 2007).
For this reason, it required a qualified instructor in
order to ensure the proper conduct of the activity
and the safety of the participants. Finally, the study
supports the possibility of introducing healthy
lifestyles at older ages, that is, lifestyles in which
movement becomes a relevant part of the elderly
people’s everyday life.
Conclusions
In summary, we found that 16 weeks of our
ecological walking training, which includes
balance and strengthening exercise, for sedentary
elderly people resulted in a significant increase
in aerobic endurance, lower limb strength, and
mobility. The decline of these parameters usually
has significant implications for the quality of life
621
and health of this age bracket. Physical training is
one of the most important instruments to combat
these declines. The study demonstrated that an
ecological training conducted by qualified trainers
could be used to improve physical functioning
in sedentary elderly people. Setting a training,
which reproduces movements of daily life, bearing
realistic goals, and taking scientific evidence into
consideration (with respect to type, intensity, and
frequency of the physical training) can allow for
active and successful aging.
Funding
Research presented in this article has been supported by Regione
Piemonte, Direzione e Innovazione Ricerca e Università, Bando Scienze
Umane e Sociali 2008 (ID 59), for their contribution to ACT ON AGEING
study.
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