Tom Age 48 Is Advised by His Family Physician
Tin can Fam Medico. 2010 May; 56(5): e191–e200.
Language: English | French
Improving aerobic fitness in older adults
Furnishings of a md-based exercise counseling and prescription programme
Améliorer la capacité aérobique des personnes âgées
Tom Overend, PhD
Acquaintance Professor and Acting Director of Physical Therapy at UWO
Abstruse
OBJECTIVE
To decide the effects of adding stages of change–based counseling to an practice prescription for older, sedentary adults in family practice.
Pattern
The Footstep Exam Practise Prescription Stages of change counseling study was a 12-month cluster randomized trial.
SETTING
Xl family unit practices in 4 regions of Canada.
PARTICIPANTS
Healthy, community-dwelling men (48%) and women (52%) with a mean (SD) age of 64.9 (seven.1) years (range 55 to 85 years). There were a full of 193 participants in the intervention grouping and 167 in the control group.
INTERVENTION
Intervention physicians were trained to deliver a tailored practise prescription and a transtheoretical behaviour change counseling plan. Control physicians were trained to deliver the do prescription lonely.
MAIN Result MEASURES
Predicted cardiorespiratory fitness, measured by predicted maximal oxygen consumption (pVO2max), and free energy expenditure, measured by 7-day physical activity recall.
RESULTS
Mean increase in pVO2max was pregnant for both the intervention (iii.02 [95% confidence interval ii.40 to 3.65] mL/kg/min) and control (2.21 [95% confidence interval 1.27 to 3.15] mL/kg/min) groups at 12 months (P < .001); however, there was no difference between groups. Women in the intervention group improved their fitness significantly more than women in the control group did (iii.20 vs ane.23 mL/kg/min). The intervention grouping had a 4–mm Hg reduction in systolic blood pressure, while the control group'southward mean reduction was 0.four mm Hg (P < .001). The mean (SD) free energy expended significantly increased and was higher in the intervention grouping than in the command grouping (69.06 [169.87] kcal/d vs −6.96 [157.06] kcal/d, P < .006). Exercise setting characteristics did not significantly affect the primary outcomes.
Decision
The Step Test Exercise Prescription Stages of change practice and behavioural intervention improved fitness and activity and lowered systolic blood pressure beyond a range of Canadian practices, but this was not significantly different from the control group, which received but the practise prescription. Women in the intervention group showed higher levels of fitness than women in the control grouping did; men in both groups showed similar improvement.
RÉSUMÉ
OBJECTIF
Déterminer 50'effet de l'ajout d'un counseling individuellement adapté à une prescription d'exercice pour des sujets âgés sédentaires dans un contexte de médecine familiale.
TYPE D'ÉTUDE
L'étude « Stride Examination Practise Prescription Stages of modify counseling » était united nations essai randomisé en grappe de 12 mois.
CONTEXTE
Quarante établissements de médecine familiale de 4 régions du Canada.
PARTICIPANTS
Hommes (48 %) et femmes (52 %) sains âgés de 55 à 85 ans (moyenne 64,9, DS 7,1) et vivant dans le milieu naturel.
INTERVENTION
Les médecins participants ont été formés à prescrire des exercices individuellement adaptés et à dispenser un programme de counseling transthéorique visant un changement comportemental. Les médecins du groupe témoin ont été formés uniquement pour la prescription d'exercices.
PRINCIPAUX PARAMÈTRES À L'ÉTUDE
La capacité cardiorespiratoire prédite, telle que mesurée par la consommation maximale d'oxygène estimée (pVO2max), et la dépense d'énergie, mesurée par le rappel des activités physiques sur une semaine.
RÉSULTATS
La pVO2max avait augmenté de façon significative après 12 mois, tant dans le groupe d'intervention (3,02 mL/kg/min [intervalle de confiance à 95 % ii,40 à 3,65]) que dans le groupe témoin (2,21 mL/kg/min [intervalle de confiance à 95 % one,27 à iii,15]) (P < ,001); il northward'y avait toutefois pas de différence entre les groupes. Les femmes du groupe d'intervention ont obtenu une augmentation de leur status physique significativement plus grande que celles du groupe témoin (3,20 vs i,23 mL/kg/min). Le groupe d'intervention a connu une baisse de pression systolique de 4 mm Hg contre une baisse de 0,4 mm Hg dans le groupe témoin (P < ,001). La dépense énergétique moyenne a augmenté de façon significative et était plus forte dans le groupe d'intervention que dans le groupe témoin (69,06 kcal/d [169,87] vs −6,96 kcal/d [157,06], P < ,006). Les caractéristiques du milieu de pratique n'avaient pas d'influence significative sur les bug principales.
CONCLUSION
Le programme « Stride Exam Exercise Prescription Stages of change » associé à united nations counseling comportemental a entraîné une augmentation de la condition physique et de fifty'activité ainsi qu'une baisse de la pression systolique dans plusieurs établissements médicaux à travers le Canada, mais cela ne différait pas significativement du groupe contrôle à qui on avait seulement prescrit l'exercice. Les femmes du groupe d'intervention ont obtenu des niveaux de status physique plus élevés que celles du groupe témoin; pour les hommes, l'amélioration était la même dans les two groupes.
Accumulating testify indicates that short- and long-termane , 2 exercise prescription programs improve aerobic fitness. Sedentary lifestyle is associated with an increased risk of coronary avenue disease, diabetes, hypertension, and osteoporosis3 – v; withal, many older adults remain inactive.
Estimates indicated that only 21% of Canadians—and just 17% of Canadians anile 55 years and older—were physically active in 2000 to 2001.six Similarly, the 2000 National Health Interview Survey indicated that just nineteen% of Americans and xv% of Americans aged 65 years and older accomplished the level of physical activity recommended in the Healthy People 2010 guidelines.7 Past 2025, the number of Canadians older than 65 years is expected to double,viii and the accented number of inactive older Canadians with related comorbidity could reach epidemic levels.
Community-based interventions are effective for promoting physical activity among older adults (aged 50 years and older).nine All the same, despite reasonable physical activity participation rates and relatively long study durations, few interventions have targeted specific behavioural- or plan-based (eg, do frequency, intensity, mode, and duration)1 , 2 , 5 strategies that promote physical action participation and adherence, and also prescribed dosing of activity to achieve health benefits. A particular challenge has been identifying the setting in which such coordinated, comprehensive interventions have the highest likelihood of success amid those at risk.
The average Canadian adult makes nigh iii.1 visits to his or her family physician annually. For those aged 45 to 65 years, the average number of visits increases to 3.3, and for those anile 65 years or older, it increases to almost vi visits per year.ten Similarly, Americans brand an average of one.6 visits to family unit physicians annually at age 15, compared with vi.iii per year for those older than 65.xi Hence, family unit physicians could potentially play a unique and important role in promoting healthy lifestyle changes in a large at-risk population. Further, organizations including the American Eye Association,12 the National Heart, Lung, and Blood Institute,13 the U.s. Centers for Disease Control and Prevention,xiv and the Canadian Chore Force on Preventive Health Care15 have recommended that physicians should advise and counsel their patients to exist physically active. In the United States, studies take shown that 28% of older adults reported receiving advice almost physical activity from their family unit physicians in the previous half-dozen months,16 and only 36%17 to 48%eighteen reported that they had e'er received such advice. In Canada, we found that 85% of family physicians reported asking patients about their physical activity levels, merely only 26% assessed fettle in their patients and a few (11%) referred patients to others for assessment; 70% provided exact counseling nearly exercise, and simply sixteen% wrote practise prescriptions.19 About family physicians do not prescribe physical activeness, resulting in a substantial care gap in a growing at-risk population.
Since we reviewed the literature betwixt 1985 and 1998 on the effects of chief care physical activity counseling on fitness,20 results of additional studies of such counseling have been made bachelor.2 , 21 – 23 Generally these have investigated behavioural theories (eg, social cognitive theories, transtheoretical model) and short-term (4 weeks to 6 months) monitoring of changes in concrete activity levels or stages of adoption for physical action. Although behavioural strategies have been found to increase physical activity participation, at that place is no prove to indicate that this is associated with an increase in fettle. Farther, most studies take used a range of physical action outcome variables (and not fitness), relying on patient self-reports. Few studies2 , 24 have measured aerobic fettle, simply those that did showed differing levels of improvement in fitness. The primary question in this study was whether the improver of behaviour counseling to an do prescription, tailored for family exercise, resulted in greater improvement in fitness and secondary clinical outcomes than an exercise prescription alone did.
METHODS
Design
The Pace Exam Practice Prescription Stage of alter counseling (STEPS) study was a stratified, cluster randomized25 clinical trial in which the clusters, or units of randomization, were family dr. practices. Eligible practices were stratified according to 2 variables: region (British Columbia, Alberta, Ontario, or Nova Scotia and New Brunswick) and setting (urban or rural). The 1:i urban-rural stratum was a reflection of current practise distribution in Canada, while sampling in the 4 regions ensured generalizability across Canada.
Family physicians
A local physician coordinator from each region was approached by the primary investigator (R.J.P.) before the study during a national family medicine continuing education meeting. Family physicians agreeing to participate were randomized to either the intervention or the command group. Those family physicians randomized to the intervention grouping, along with members of their role staff, attended a 3-hour training session conducted by the principal investigator and a research banana. The session was designed to increment physician and staff knowledge near the health benefits and risks of exercise amidst older patients; increase doctor and staff noesis virtually the stages of change model; and increase md skill in individualizing prescription and counseling techniques for older patients. Family physicians in the control group attended a workshop designed to provide cognition about handling of hypertension and the importance of lifestyle equally a foundation of treatment. For the purpose of the study, they were instructed to provide patients with exercise prescriptions co-ordinate to our previously described Step Test Practice Prescription intervention (practice prescription without behavioural counseling).2 Both groups were given training on how to collect study outcomes. Family physicians received continuing medical instruction credits for their participation in the written report and retained all study-related equipment and materials.
Patients
The study population consisted of good for you community-dwelling men and women aged 55 to 85 years who were patients at ane of the participating family practices. Recruitment took place betwixt Baronial 2000 and Jan 2002. Patients were included if they met the post-obit criteria: inactive lifestyle (energy expenditure less than 35 kcal/kg/d) determined using the seven-day physical activity call back (PAR) instrument26; readiness to increase their concrete action levels based on their stage of change (ie, not those in the maintenance phase); able to read and write English; and the absenteeism of exclusionary medical atmospheric condition, including recent myocardial infarction or stroke, New York Heart Association form Ii to Four congestive heart failure, atrial flutter, uncontrolled hypertension (greater than stage 2), unstable angina, astringent chronic obstructive pulmonary disease, uncontrolled diabetes mellitus, severe systemic or musculoskeletal disease preventing increased concrete activeness, or major psychiatric disease. During the recruitment phase of the study, office staff initiated recruitment with screening telephone calls to potential patients who were already scheduled to see the study physicians inside the next 3 months. At the baseline visit, informed consent was obtained by the family md, and questionnaires about psychosocial determinants of physical activity (ie, quality of life, self-efficacy, and stage of modify) were administered. Measures of clinical outcomes (ie, claret pressure and torso mass alphabetize [BMI]) were collected by trained staff members; then step tests, supervised by the family physicians, were performed to calculate predicted maximum oxygen consumption (pVO2max). Further data collection visits in the family exercise occurred at iii, half-dozen, ix, and 12 months after recruitment every bit well as through monthly staging done by telephone. The coordinating center likewise conducted PAR phone interviews at three, half dozen, 9, and 12 months. Subjects reported any agin events at each report visit. The study was canonical past the Review Lath for Wellness Sciences Inquiry at the University of Western Ontario and local review boards in the participating regions.
Intervention
Patients in the STEPS and control groups received individualized exercise prescriptions based on submaximal step test results,2 , 27 merely only patients in the STEPS group received counseling and back up based on their stages of exercise behaviour.28 Family physicians in both groups developed exercise prescriptions past determining pVO2max from step test results and using these information to prescribe training eye rate (THR) intensities for patients; they also provided communication about appropriate frequency, intensity, type, and duration of exercise. Family unit physicians' prescriptions for patients in the STEPS grouping were matched to patients' current stages of adoption for physical activity.28
Measures
Primary outcomes
Aerobic fettle: Aerobic fettle was the primary effect measure, determined past pVO2max using a pace examination protocol.27 Using a manus-held computer, the pace test data (age, weight, sexual activity, stepping fourth dimension, and maximum heart rate [Hourmax]) were used to predict VO2max using logistic regression, then to calculate a THR corresponding to 75% of pVO2max. Effort during the test was adamant using the rate of perceived exertion (RPE) calibration.29
Physical activity level: Physical activeness was assessed as total energy expenditure (kcal/kg/d), estimated by the 7-day PAR, a widely used and validated26 instrument that classifies activities into 5 categories according to their intensity expressed as metabolic equivalents (or kcal/kg/h). The full time spent in the light physical activity category was obtained by subtracting hours in other activities and in sleep from 24 hours. The caloric expenditure per twenty-four hour period was quantified past multiplying the total energy expenditure by the patient's torso weight in kilograms.
Secondary outcomes
Resting systolic (SBPrest) and diastolic (DBPremainder) blood pressures and heart charge per unit (60 minutesrest) were measured using standard procedures. Ii seated readings were taken 5 minutes apart and then averaged. Body mass index was calculated as body mass (in kilograms) divided by height (in metres squared).
Sample size calculation
We estimated that the sample size needed to be 320 patients from 4 regions, stratified past urban or rural practice setting within each region, based on our previous 12-month intervention2 of the exercise prescription program compared with command in sedentary older adults, which produced a 10% increase in pVO2max. We assumed a type I error charge per unit of 5%, fourscore% power, standard deviation (σ) in pVO2max of i.7 50/min, and a clinical divergence (δ) in pVO2max of two.5 Fifty/min. To account for the effect of clustering, we used an intracluster correlation coefficient (ρ) of 0.025 for pVO2max and an attrition charge per unit of 30%.
Statistical analyses
All analyses were performed with SAS for Windows. Analysis of variance (ANOVA) and χtwo tests were used to test for differences in baseline characteristics by treatment group. All patients were analyzed according to treatment group assignment. As patients were clustered past practice, and practices were randomized to treatment, nosotros adjusted the variance among practices for nonindependence. The dependent variable was pVO2max, and the alter from baseline to 12 months was analyzed with repeated-measures multifactorial ANOVA. Dropouts were not replaced, as we performed an intent-to-treat analysis. Post hoc secondary analyses were performed to examine the change in pVO2max by subgroups (sexual activity, age, BMI, setting, and region). All data were reported every bit means and standard deviations or means and 95% confidence intervals (CIs). Statistical significance was preset at P < .05 for all analyses.
RESULTS
Sample population
Xl family unit physicians were recruited to participate in the study. Simply ane dr. was recruited from a group practice setting. Xx-i family physicians were randomized to the STEPS group and 19 to the control group. Seventeen of the physicians were male. Hateful (SD) historic period of participating physicians was 48 (nine) years and years in exercise was eleven (6). Ten physicians were from British Columbia, viii were from Alberta, fourteen were from Ontario, and 8 were from Nova Scotia or New Brunswick, and there was an equal urban-rural distribution. The progress of patients through the study is shown in Figure ane. A total of 426 patients from these 40 family unit practices were screened for entry into the study betwixt August 2000 and Jan 2002. Of these, 42 patients were excluded because they were already agile and 24 declined participation. The last sample included 360 patients (84.5% of the screened sample). During the grade of the study, 2 patients died owing to complications not related to the study, and 29 patients withdrew. The most mutual reasons for withdrawing were failure to complete study requirements, perception of a failure to run into their physicians' expectations, and lack of time; 79% of patients who withdrew were from the STEPS grouping. Few agin events were reported (primarily muscle soreness), and there was no difference in such events between groups.
Flow of patients through the study
Demographic and clinical characteristics
All baseline characteristics and demographics, except for age, were similar between the STEPS and control groups (Table ane). Overall, mean (SD) age of participants was 64.9 (7.one) years (range 55 to 85 years).
Table 1.
Patient demographic and clinical characteristics at baseline: Comparisons of continuous ways were performed using ANOVA; comparisons of categorical variables were performed using χ 2 analysis.
| CHARACTERISTICS | STEPS (Due north= 193) | CONTROL (N = 167) | P VALUE |
|---|---|---|---|
| Mean (SD) age, y | 64.2 (7.4) | 65.8 (6.7) | .040 |
| • Men | 65.iii (seven.v) | 66.5 (vii.0) | .314 |
| • Women | 63.4 (7.three) | 65.2 (6.4) | .068 |
| Sex activity, n (%) | .750 | ||
| • Male | 81 (42.0) | 73 (43.vii) | |
| • Female | 112 (58.0) | 94 (56.three) | |
| Abode, northward (%) | .536 | ||
| • Alone | 33 (17.i) | 33 (19.8) | |
| • With spouse | 146 (75.vi) | 124 (74.three) | |
| • With other relative | 12 (vi.2) | 6 (3.6) | |
| • With friend | 0 (0) | one (0.half dozen) | |
| • With other person | 2 (ane.0) | 3 (1.8) | |
| Marital status, due north (%) | .945 | ||
| • Single | half-dozen (3.i) | v (3.0) | |
| • Married | 147 (76.2) | 129 (77.2) | |
| • Divorced | 15 (7.8) | 10 (6.0) | |
| • Widowed | 23 (eleven.9) | 22 (xiii.two) | |
| • Long-term companion | two (1.0) | 1 (0.half dozen) | |
| Education, n (%) | .400 | ||
| • Elementary | eight (four.1) | xxx (18.0) | |
| • Secondary | xc (46.vi) | 76 (45.5) | |
| • College | 35 (eighteen.1) | 27 (sixteen.ii) | |
| • University | 38 (19.vii) | 21 (12.half dozen) | |
| • Postgraduate | 22 (xi.4) | 13 (7.8) | |
| Employment status, n (%) | .062 | ||
| • Full-time | 52 (26.9) | 34 (xx.4) | |
| • Part-time | 26 (13.5) | 14 (eight.iv) | |
| • Retired | 108 (56.0) | 106 (63.5) | |
| • Unemployed | vii (three.half-dozen) | 13 (7.eight) | |
| Smoking behaviour, north (%) | .607 | ||
| • Never | 84 (43.five) | 64 (38.3) | |
| • Former | 18 (ix.3) | 17 (10.2) | |
| • Current | 91 (47.two) | 86 (51.5) | |
| Hateful (SD) BMI, kg/yardtwo | 26.62 (5.01) | 29.07 (five.sixty) | .414 |
| Mean (SD) Hrresiduum, beats/min | 71.ix (ten.3) | 72.9 (9.ix) | .356 |
| Mean (SD) SBPresidual, mm Hg | 133.2 (16.iii) | 133.6 (fourteen.nine) | .800 |
| Mean (SD) DBPrest, mm Hg | 77.5 (8.9) | 78.6 (9.3) | .254 |
| Mean (SD) EE, kcal/kg/d | 32.91 (1.02) | 33.08 (1.01) | .106 |
| Step test | |||
| • Mean (SD) pVO2max, mL/kg/min | xxx.fifty (7.82) | 31.02 (8.21) | .550 |
| • Mean (SD) HRmax, beats/min | 107.2 (18.vii) | 109.1 (20.three) | .591 |
| • Mean (SD) stepping time, s | 94.68 (23.54) | 92.03 (23.32) | .300 |
| • Mean (SD) RPE, Borg score | 3.5 (one.5) | 3.5 (1.8) | .815 |
Primary outcome
Change in fitness, pVO2max, and related exercise test variables are shown in Tabular array 2. In the STEPS group, pVO2max increased 9.9% (95% CI 7.9% to 12.0%) at 12 months, and it increased seven.1% (95% CI 4.one% to 10.2%) in the command group (P < .001). Nevertheless, the divergence in the change in pVO2max between the handling groups did not reach statistical significance. For the STEPS group, the greatest improvement in pVO2max (vi.vi%) occurred within the first iii months, with sequential increases from previous measurement of 3.9% at 6 months and 1.7% at 9 months; the terminal 3 months served every bit a maintenance phase. The control group showed an increment in pVO2max of 4.9% inside the beginning 3 months, with an boosted increase of 5.viii% at 6 months, followed by a slight decline of ane.0% in the concluding 6 months.
Table 2.
Hateful changes in primary and secondary outcome variables in the STEPS and control groups at 12 months
| VARIABLES | STEPS (N = 169*) MEAN Modify (95% CI) | Command (N = 160†) MEAN Change (95% CI) | DIFFERENCE Betwixt GROUPS IN Hateful Alter (95% CI) | P VALUE FOR THE Departure Betwixt GROUPS |
|---|---|---|---|---|
| pVO2max, mL/kg/min | iii.02 (ii.40 to iii.65) | ii.21 (1.27 to 3.15) | 0.81 (−0.29 to 1.91) | .147 |
| Hourmax, beats/min | eight.27 (5.70 to x.84) | 4.22 (0.91 to 7.54) | 4.05 (−0.09 to 8.xviii) | .055 |
| Stepping time, s | −19.05 (−21.35 to −sixteen.74) | −x.77 (−xiv.xx to −7.35) | −viii.28 (−12.32 to −four.24) | < .001 |
| RPE, Borg score | 0.93 (0.61 to one.25) | 0.50 (0.18 to 0.82) | 0.43 (−0.02 to 0.88) | .061 |
| BMI, kg/yard2 | 0.13 (−0.08 to 0.35) | −0.17 (−0.46 to 0.12) | 0.30 (−0.05 to 0.66) | .095 |
| Hourremainder, beats/min | 1.23 (−0.15 to two.61) | ane.70 (0.xviii to 3.23) | −0.47 (−2.52 to 1.57) | .648 |
| SBPresidual, mm Hg | −4.thirteen (−half-dozen.39 to −1.86) | −0.38 (−2.98 to ii.22) | −3.75 (−7.17 to −0.32) | .032 |
| DBPrest, mm Hg | −1.93 (−3.22 to −0.63) | −1.67 (−3.23 to −0.10) | −0.26 (−2.27 to 1.76) | .801 |
| EE, kcal/kg/d | 0.67 (0.43 to 0.91) | 0.25 (0.07 to 0.42) | 0.42 (0.12 to 0.72) | .006 |
At 12 months, 60 minutesmax and RPE significantly increased (P < .01) in both the STEPS and command groups, but there were no differences between groups. The stepping time significantly decreased (P < .001) in both treatment groups, but the STEPS group had a significantly greater decrease (P < .001) than the control grouping did.
Secondary measures
As shown in Table 2, at 12 months the control group's mean HRrest had significantly increased (P < .05) and the STEPS group had a nonsignificant increase. The STEPS group had a iv.ane–mm Hg reduction (P < .001) in systolic blood pressures compared with a 0.iv–mm Hg in the control group at 12 months. The DBPresidue significantly decreased (P < .05) in both the STEPS and control groups. Cocky-reported total energy expenditure (kcal/kg/d) significantly increased in both the STEPS and control groups; however, the STEPS group had a significantly greater increase compared with the control grouping (2.1% and 0.8%, respectively; P = .006). When mean (SD) free energy expenditure was adapted for trunk weight (kcal/d), at that place was notwithstanding a meaning increase (P < .001) at 12 months in the STEPS grouping (69.06 [169.87] kcal/d), whereas the control grouping did not change significantly (−6.96 [157.06] kcal/d).
Subgroup analyses
Sex differences
As seen in Table 3, the men in both treatment groups significantly increased (P < .001) pVO2max at 12 months, yet the change in pVO2max did not significantly differ between treatment groups. Amidst the women, only the STEPS group significantly increased pVO2max at 12 months (P < .001); therefore, the alter in pVO2max was significantly unlike between the STEPS and control groups.
Table 3.
Mean changes in the STEPS and control groups at 12 months
| Mean CHANGE IN PVO2MAX, ML/KG/MIN (95% CI) | ||
|---|---|---|
| CHARACTERISTICS | STEPS (N = 169*) | CONTROL (N = 160†) |
| Sex | ||
| • Men (n = 155) | 2.81 (1.80 to 3.82) | 3.38 (1.95 to four.eighty) |
| • Women (north = 174) | 3.20 (2.41 to iv.00) | 1.23 (0.00 to 2.46) |
| Age, y | ||
| • < 65 (n = 179) | 2.98 (ii.17 to 3.79) | 2.31 (0.77 to 3.87) |
| • ≥ 65 (north = 139) | 3.10 (2.09 to 4.10) | 2.11 (1.00 to 3.22) |
| BMI, kg/mtwo | ||
| • ≤ 24.ix (n = ninety) | 3.62 (ii.03 to 5.21) | 0.57 (−one.25 to 2.39) |
| • 25.0–29.9 (n = 129) | 2.99 (ii.11 to 3.87) | 2.82 (i.02 to 4.61) |
| • ≥ thirty.0 (n = 108) | 2.lx (one.57 to 3.63) | 3.03 (1.69 to 4.37) |
| Setting | ||
| • Urban (north = 166) | 2.74 (i.91 to three.58) | 2.03 (0.81 to 3.24) |
| • Rural (n = 163) | three.34 (2.39 to 4.29) | 2.35 (0.96 to 3.74) |
| Region | ||
| • British Columbia (northward = 101) | v.36 (iv.02 to 6.69) | one.67 (0.27 to 3.06) |
| • Alberta (n = 47) | 3.17 (i.33 to v.02) | 2.14 (−0.72 to v.00) |
| • Ontario (n = 118) | 2.sixteen (one.15 to 3.18) | 2.68 (i.14 to 4.23) |
| • Nova Scotia and New Brunswick (n = 62) | 2.22 (i.22 to 3.22) | ii.55 (−ane.12 to vi.22) |
Age differences
Those younger than 65 years of age (mean 59.4, SD 3.2 years) significantly increased pVO2max at 12 months (P < .001), yet there was no significant deviation in the change in pVO2max between the STEPS and control groups.
Body composition differences
When patients were classified based on their baseline BMI (mean 34 kg/10002), all cohorts in both treatment groups, except for the normal (≤ 24.9 kg/mtwo) control group, significantly increased pVO2max at 12 months (P < .001).
Setting differences
Among participants in the urban settings (Table 3), both those in the STEPS grouping and those in the control group significantly increased pVO2max at 12 months (P < .001), and there was no difference between treatment groups. Similarly, among the rural settings, both the STEPS and control groups significantly increased pVO2max at 12 months (P < .001), although over again the modify was not significantly different between treatment groups.
Regional differences
In Alberta and Nova Scotia or New Brunswick (Tabular array three), the STEPS grouping significantly increased pVO2max at 12 months (P < .01), compared with the control grouping. However, these differences were not significantly different for either region. In Ontario and British Columbia, both the STEPS and control groups also significantly increased pVO2max at 12 months (P < .001); the modify was not significantly different between intervention and control groups for Ontario, whereas British Columbia showed a significant difference between treatment groups (sixteen.3% and 5.5%, respectively; P = .003).
Give-and-take
In this study, family physicians from different regions beyond Canada were randomized to deliver an exercise prescription2 and behaviour counseling28 program (STEPS) amidst older adults compared with the exercise prescription (control) program alone.2 The primary finding from this report is that both the STEPS and control groups experienced pregnant and comparable improvement in pVO2max at 12 months compared with baseline measures. Examination of secondary outcomes revealed that SBPresiduum was reduced, while physical activity and energy expenditure levels were increased in both groups; these changes were significantly dissimilar betwixt groups, favouring the STEPS treatment grouping from baseline to 12 months. Furthermore, the change in pVO2max differed by sex activity between groups—the alter was greater among the women receiving the STEPS intervention—but not by historic period or between urban and rural customs settings. These results are provocative and advise that no overall divergence in fitness is observed on the chief effect when behaviour counseling is added to a tailored exercise prescription. However, changes in important secondary clinical variables such as systolic blood pressure, energy expenditure, and behaviour modify favoured STEPS in both men and women, suggesting that the added behaviour counseling in STEPS might have benefits in some individuals beyond fettle alone.
Our exercise prescription and counseling arroyo differs from previous doctor-based physical activeness interventionsii , 19 , 21 because we combined physiologic (exercise prescription) and behavioural (stages of modify) strategies. Further, the literature to appointment has largely focused on behavioural-based programs, cocky-reported physical action levels, and short-term follow-upward; few studies accept used individualized exercise prescriptions based on fitness.ii
At 6 months, pVO2max significantly improved in both groups; nonetheless, for the last six months, pVO2max appeared to go on to ameliorate in the STEPS grouping, while the control grouping started to reject. This is in dissimilarity to our previous study of the exercise prescription without behavioural counseling: although demonstrating an increase in pVO2max, similar to that identified in both groups in this study, the exercise prescription group in the initial written report had not begun to decline at 12 months. The study population might accept afflicted this outcome: the initial written report was conducted in an academic family exercise setting; this study was more than generalized and was conducted across academic and community practices in urban and rural regions. Academic practices might take more resources for preventive intendance compared with nonacademic practices, although this was not explored in our studies. However, follow-up visits within the STEPS group provided ongoing motivational support, suggesting that behaviour has an important issue on longer-term fettle change.
It has been suggested that continuity of care in family practice offers opportunities to sustain private motivation, appraise progress, provide feedback, and adjust behaviour modify plans30; therefore, the regular contact between physicians and patients might accept contributed to the improvements observed. In the U.s.a., telephone follow-upwardly is popular and has been shown to be effective for achieving longer-term do adherence.9 , 31
Previous studies24 take supported our finding of fitness interventions having different furnishings on men and women. Why women and not men appeared to benefit from the addition of behavioural support requires further investigation. Nosotros previously2 showed that pVO2max significantly increased following exercise prescription only, compared with a control group receiving regular care, at 12 months (14% and 3%, respectively). In the Action Counseling Trial,24 the addition of incentives (including electronic step monitors) and follow-upwards mailings or more intensive telephone counseling and classes resulted in smaller increases in pVO2max at 24 months for women (three.7% and 4.0%, respectively), compared with those who received only doc advice (−1.0%). For men in the Activity Counseling Trial, all intervention groups (advice, assistance, or counseling) increased their fettle levels at 6 months; however, this effect was no longer apparent at 24 months (−0.7%, i.6%, and −0.2% alter in pVO2max, respectively). Among the various strategies used to improve fitness, the practise advice strategy, which required the fewest resources, was by and large as constructive for men as the behaviour change strategies requiring more resource. This might be important when generalizing the results to exercise. Those who are most likely to benefit from more intervention (ie, women) could be triaged to receive this from centrolineal wellness professionals.
Secondary outcomes
The secondary aim of our study was to decide whether the intervention caused changes in clinical measures and concrete action levels. It is well established that SBPresidue and DBPresidue increase with age among adults in Northward America.32 Our findings showed that the STEPS group clinically and statistically decreased SBPresidual and DBPresidue by more than than 2 mm Hg. In a meta-analysis, Kelley and Kelley33 reported on the efficacy of aerobic exercise training programs, similar to this community-based fitness program in older adults, for reducing SBPrest. Reducing DBPrest past as piddling as ii mm Hg could lower the prevalence of hypertension by 17% and the risk of stroke and transient ischemic attack past xv%.34
Expending an additional 1000 kcal per week is associated with a twenty% to 30% reduction in take a chance of all-cause mortality compared with sedentary men and women.4 , 5 Our study showed that the mean (SD) increase in free energy expenditure in the STEPS group (483.45 [1189.06] kcal/wk) was greater than that in the command group (−48.69 [1099.45] kcal/wk) at 12 months. 4 previous primary intendance physical activity interventions21 – 24 have reported significant changes in self-reported physical activity for a follow-upward period greater than 6 months (P < .05); however, 3 of these studies did not measure changes in fettle. Overall, these beneficial changes in blood pressure, physical action levels, and physical fettle suggest that exercise prescription and counseling delivered past family physicians could increase the proportion of patients coming together physical activity goals to better cardiovascular health.
In Canada, a perception exists that living in urban environments or western provinces might be associated with better fitness and health.vi In this written report, delivery of practise prescription in either urban or rural settings improved pVO2max in both groups at 12 months, still there were no differences betwixt treatment groups. At the regional level, pVO2max improved in the STEPS grouping for all four regions, whereas the control group only showed improvements in Ontario and British Columbia. As well, British Columbia was the only region to show a significant difference between treatment groups at 12 months. Therefore, geographic location (region) might play a role in improvements in aerobic fitness; customs setting (urban vs rural) does not appear to play a office. This might corroborate observed differences in cardiovascular health and fitness in dissimilar parts of Canada, and could exist related to differences in socioeconomic, ecology, and health resources.eight
Report strengths and limitations
The primary strengths of this study include the fact that it was conducted in a range of Canadian principal care practices (making the findings more generalizable); the long duration of follow-up; utilize of a large, older population sample (with similar baseline characteristics in both groups); inclusion of both free energy expenditure and fettle outcome measures; and randomization cluster by exercise to reduce the risk of intervention contamination. The report is limited by the fact that it did not include a "no handling" control group, only rather compared the intervention with a previously described practise prescription delivered in a rather homogeneous setting. There were more than dropouts from the intervention group than from the control. Although this could relate to the greater time required to deliver the intervention (approximately 10 minutes more than per visit), we did not notice any other explanations for this discrepancy.
Gains in pVO2max in both groups might take been the result of the Hawthorne consequence. The fact that all patients initially consented to participate in a written report that would prescribe and counsel almost do with the goal of increasing concrete activeness and improving fitness might have biased the outcome. Farther, nosotros did non assess compliance with the intervention, equally THR achieved during exercise sessions and validation of proper pulse-palpation techniques were not quantified. Yet, nosotros did measure RPE (Borg score), PAR, phase of change, and pVO2max, which would likely just show improvements if patients were indeed exercising. Given that our exercise prescription intervention requires just minimal training and equipment and can exist completed within a typical 15-minute office appointment suggests that it could be implemented in a range of practices.
Conclusion
This study has shown that routine exercise prescription with or without behaviour counseling every 3 months by family physicians among sedentary, simply otherwise healthy, older adults tin brand substantial improvements in pVO2max for at to the lowest degree a twelvemonth. Addition of staged behavioural support to our practice prescription appeared to improve important clinical measures and might promote better long-term behaviour and outcomes amidst some patients. Thus, if implemented widely, STEPS could aid public health efforts to reduce the prevalence of sedentary lifestyles and might be a clinically effective and economical means of reducing cardiovascular risk.
Acknowledgments
This study was supported past an operating grant from the Center and Stroke Foundation of Canada. We are as well indebted to the physician coordinators, doc participants, their staff, and more important, their patients.
Notes
Footnotes
This commodity has been peer reviewed.
Cet article a fait l'objet d'une révision par des pairs.
The abstract of this study was previously published as Lattanzio CN, Petrella RJ, Shapiro South, Overend T. Effects of a physician-based exercise counseling plan for improving aerobic fitness in older adults. Med Sci Sports Exerc 2009;41(5 Suppl 1):364. Republished with permission.
Un résumé de cette étude a déjà été publié en anglais par Lattanzio CN, Petrella RJ, Shapiro, Southward et Overend T sous le titre : Furnishings of physician-based exercised counseling program for improving aerobic fettle in older adults. Med Sci Sports Exerc 2009;41 (5 Suppl i) :364. Publié à nouveau avec permission.
Contributors
Drs Petrella, Lattanzio, and Overend and Ms Shapiro contributed to concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Competing interests
None declared
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2868630/
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