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Key Words:
Barriers, Exercise.
Rebecca Forkan, Breeanna Pumper, Nicole Smyth, Hilary Wirkkala, Marda A Ciol, Anne Shumway-Cook
401
therapists should strive to "restore, maintain, and promote not only optimal physical function but optimal
wellness and fitness and optimal quality of life as it
relates to movement and health."^''(P^') Prescribing and
promoting exercise, and educating patients on the
importance and value of exercise are key responsibilities
of the physical therapist. Several studies"'"'^^''''^ have
shown the benefits of participation in a multidimensional physical therapist-supervised exercise program on
balance, walking, and fall risk among older adults.
However, there is limited information on the degree to
which benefits are sustained after participating in a
physical therapy program. Some studies^-'''^'' have shown
that benefits of exercise gained during physical therapy
often are not maintained after discharge. Lack of sustained benefits from physical therapy may be the result
of poor adherence to a prescribed home exercise program (HEP) that is designed to promote the maintenance of improved function following discharge.
Little is known about adherence to a HEP prescribed by
a physical therapist in older adults following discharge
or about the factors that affect postdischarge adherence.
Thus, the purpose of this study was to develop an
instrument to survey older adults following discharge
from a physical therapy balance-training program in
order to: (1) determine postdischarge adherence and
factors that limit adherence to a prescriljed HEP and
(2) to characterize overall participation in exercise,
including both prescribed and nonprescribed exercise,
as well as factors influencing exercise participation.
R Forkan, B Pumper, N Smyth, and H Wirkkala were physical therapist students in the Division of Physical Therapy, Department of Rehabilitation
Medicine, University of Washington, Seattle, Wash.
MA Ciol, PhD, is Research Assistant Professor, Department of Rehabilitation Medicine, University of Washington.
A Shumway-Cook, PT, PhD, is Associate Professor, Division of Physical Therapy, Department of Rehabilitation Medicine, University of Washington.
Address all correspondence to Dr Shumway-Cook at Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Box
356490, Seattle, WA 98195-6490 (USA) (ashumway@u.washington.edu).
All authors provided concept/idea/research design, writing, and data analysis. Ms Forkan, Ms Pumper, Ms Smyth, Ms Wirkkala, and Dr
Shumway-Cook provided data collection. Dr Shumway-Cook provided project management, stibjects, facilities/equipment, and instittitional
liaisons.
The University of Washington Institutional Review Board reviewed and approved this sttidy.
The results of this sttidy were presented as a platform presentation the Combined Sections Meeting of the American Physical Therapy Association;
Februaiy 23-27, 2005; New Orleans, La.
This article zuas received May 25, 2005, and was accepted September 26,
402 . Forkan et al
2005.
Method
Subjects
Forkan et al . 403
exercise program. Outcomes expectation has been identified as an important factor in determining long-term
adherence to an exercise program among older adults,'^"
Survey Instrument
404 , Forkan et al
Table 1.
Demographic and Health-Related Characteristics of Survey
Respondents"
Strong
SAGE
and
Steady
81.93
6.00
68-99
81.04
7.08
65-91
.54
25.41
4.37
16.68-40.44
25.24
4.04
18.34-35.95
.85
70.77
69.23
.87
52.24
48.15
.70
Characteristic
Age, y (n=168)
X
SD
Range
BMI, kg/m^ (n=164)
X
SD
Range
Health status
No. of prescription
drugs (n=162)
0-3 (%)
4-6 (%)
7-10 (%)
>10(%)
.21
31.39
43.07
18.98
6.57
52.00
36.00
8.00
4.00
.66
No. of comorbidities
(n=175)
X
SD
3.10
1.87
0-7
2.93
1.92
0-7
Depression (n=154)
Yes (%)
16.79
4.35
62.96
13.33
23.70
66.67
16.67
16.67
91.7
80.8
Range
.12
.22
Forkan et al . 405
Table 2.
Reported Postdischarge Participation in a Prescribed Home Exercise
Program (HEP)
%
90.0
153
36.6
12.4
22.9
19.0
56
19
35
29
14
Duration (n=104)
<15 min
15-30 min
45 min
60 min
Mode (n= 103)
Strength
Balance
Flexibility
Aerobic
Mode combination (n=103)
All 4
Combination of 3
Combination of 2
Only 1 mode
9.2
31.7
56.7
9.6
1.9
33
59
10
2
70.9
69.9
52.4
45.6
73
72
54
47
12.6
28.2
44.7
14.6
13
29
46
15
respondents participating in their HEP reported performing more than one mode of exercise.
Adherence to exercise was independent of time since
discharge (chi-square test for independence of the
2 variables, P=.553). This finding is shown in Table 5,
which compares the distribution of subjects who
reported some participation in a prescribed HEP versus
those who reported no participation in a prescribed
HEP as a function of time since discharge (categorized
as <12 months, 12-48 months, and >48 months).
The most frequently reported reason given for poor
adherence to a prescribed HEP was a change in health
status (30.7%, 31/101). Table 4 lists other reasons
reported for lack of adherence among survey respondents.
Participation in Nonprescribed Physical Activity
Table 3.
Effect of Time Since Discharge on Adherence to a Prescribed Home Exercise Program (HEP)
Cohort Based on Time Since Discharge
<12 mo
HEP
None
Some
Total
n
% within cohort based on time since discharge
n
% within cohort based on time since discharge
19
30,2
44
69,8
n
% within cohort based on time since discharge
63
100
12-48 mo
9
40,9
13
59,1
22
100
>48 mo
Total
5
26,3
14
73,7
19
100
33
31,7
71
68,3
104
100
Table 4.
Table 5.
(n=101)
% (No.)
30,7(31)
11,9(12)
11,9(12)
7,9 (8)
7,9 (8)
5,9 (6)
4,0 (4)
2,0 (2)
4,0 (4)
3,0 (3)
2,0 (2)
2,0 (2)
2,0 (2)
1,0(1)
1,0(1)
1,0(1)
1,0(1)
1,0(1)
A major responsibility of physical therapists is to prescribe, promote, and educate patients on the importance and value of exercise as it relates to optimal
physical function, wellness, and quality of life.^* Ideally,
if a patient was given a physical therapy HEP, he or she
would adhere to the exercise program over the long
term. We found that following discharge from a balance
training physical therapy program, 90% of survey participants reported receiving a HEP; however, 36% of older
adults were no longer participating in their prescribed
HEP, and less than 10% participated 5 or more days per
week.
Physical Therapy , Volume 86 , Number 3 , March 2006
% (No.)
Strengthening (n=142)
<1
1
2-3
4-5
>5
61,3(87)
9,2(13)
17,6(25)
7,0(10)
4,9 (7)
>5
48,0(71)
12,2(18)
21,6(32)
14,2(21)
4,1 (6)
Aerobic (n=145)
<1
1
2-3
4-5
>5
66,2 (96)
11,0(16)
11,7(17)
5,5 (8)
5,5 (8)
Surprisingly, time since discharge did not affect adherence to a prescribed HEP, Adherence was not greater
among older adults discharged from physical therapy
within 12 months compared to those had been discharged for more than 48 months. Change in health
status was the most commonly reported reason for lack
of participation in a HEP, Burton et al'* reported that
current state of health was a predominant factor in
initiating or maintaining physical activity: This finding
suggests that physical therapists need to educate patients
and physicians that a return to physical therapy for
modification of a HEP may be necessary following a
change in health status.
An additional reason reported for nonadherence to a
prescribed HEP was participation in other forms of
physical activity, which may explain poor postdischarge
HEP adherence. However, in this study, older adults
most frequently reported performing additional physical
activity less than one time per week, suggesting that
participation in additional physical activity was not a
Forkan et al , 407
Table 6.
Univariate Logistic Regressions"
Proportion of
Endorsements
Item
Nonexercise
Group
Motivators
Exercising regularly is beneficial to health
Prefer to be in scheduled exercise program
1 feel better when 1 am active
Exercising gives me more energy
Exercising gives sense of accomplishment
Exercise keeps my mind active
Exercise is good for my heart
Exercise helps my spirits
1 exercise to keep myself healthy
1 want to exercise when 1 want
1 prefer to exercise with others
100
68.4
100
75.0
95.5
90.0
100
100
94.4
75.0
57.9
Barriers
1 feel the same whether 1 am active or not
Concerned will strain/hurt if physically active
Gets tightness in chest when exerting
1 do not have the strength to exercise
If health were better, 1 would be more active
1 am not interested in exercise
It is difficult to exercise when 1 ache
It is difficult to exercise when 1 feel
Exercise
Group
98.4
59.7
97.6
90.2
95.1
91.7
100
95.0
97.5
67.2
47.4
Odds Ratio
No. of
Missing
Values'*
29
37
30
33
30
35
40
34
35
39
42
30
Estimate
90% Confidence
Interval
0.68
0.24-1.92
3.06
0.93
1.22
0.94-9.89
2.33
0.68
0.65
0.23-23.73
.050
.147
.621
.011
.333
.004
.158
0.40
0.16-1.00
2.33
1.34
0.74-7.34
0.42-4.28
0.28
0.11-0.75
0.53
0.15-1.92
0.21
0.08-0.61
0.23
0.03-1.78
.032
0.28
0.09-0.90
.999
.469
.999
.062
.947
.806
.999
.A7A
.493
.398
O.n-8.11
0.25-6.04
0.23-2.02
0.24-1.75
95.0
28.5
34.1
23.0
16.2
77.9
10.9
81.1
78.9
51.0
depressed
Lack of transportation limits exercise options
Bad weather prevents me from
33.3
57.1
25.2
39
0.25-1.83
38
.440
.005
0.67
25.0
0.25
0.10-0.65
exercising
1 get short of breath vrhen 1 exercise
Fear of falling prevents me from
70.0
50.0
40.9
22.8
40
41
.020
.015
0.30
0.29
0.11-0.83
0.11-0.79
65.0
30.1
42
.004
0.23
0.09-0.63
exercising
In the past 4 wk, my health status
affected my ability to exercise on a
regular basis
50.0
18.2
18.2
40.9
87.0
36.4
30
31
36
39
34
33
60
" hems in boldface are barriers associated witli decreased parlicipation in exercise following discharge from a physical therapy program.
'' Missing wilties in the logistic regression; either the otitcome or the item was missing.
' Uni\'ariate logistic regression.
participation than motivators. No motivator was significantly associated with exercise participation in our analysis. Eight barriers were significantly associated with a
decreased adherence to exercise following discharge
from physical therapy. Barriers found to decrease adherence to exercise following discharge from physical therapy included the following: lack of interest, poor health,
bad weather, depression, lack of strength, fear of falling,
shortness of breath, and low outcomes expectation.
These findings are consistent with those of other studies
demonstrating a relationship between barriers and exercise participation.'^'^o^'
Limitations of the Study
Forkan et al . 409
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32 Tu W, Stump TE, Damush TM, Clark DO, The effects of health and
24 Guide to Physical Therapist Practice. 2nd ed, Alexandria, Va: American enWronment on exercise-class participation in older, urban women.
Physical Therapy Association; 200t,
Aging Phys Act. 2004;12:480-496,
35 US Preventive Services Task Force, Screening for depression: rec27 Portney L, Watkins M, Foundations of Glinical Research: Applications to ommendations and rationale, Ann Intern Med. 2002;136:760-764,
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