updated revisions - capstone11.26.11 by fanzhongqing


									           A cognitive-behavioral approach to

     promote functional independence and

wellness in community dwelling older adults

 Adam J. Bockey candidate for Doctor of Physical Therapy Degree Class of 2011

David C. Grinnell candidate for Doctor of Physical Therapy Degree Class of 2011

David M. Pieschel candidate for Doctor of Physical Therapy Degree Class of 2012

                         Dr. Tony Brosky PT, DHS, SCS
       Aging and associated physical changes are an inevitable change in one’s life.

Particularly as modern medicine continues to evolve, individuals are living longer,

and with an extended life expectancy come age related physical and cognitive

changes that require a growing amount of attention. Recently, there has been a

push for overall wellness and preventative medicine to coincide with and prevent

the need for traditional medicine. This is especially true for the older adult. Our

search of the literature on all the aspects that pertain to older adult health, wellness,

and functional independence led us to the following PICO question:

       In the aging adult population who are at risk for falls, does an exercise
program that is geared toward fall reduction/prevention/agility training have a
higher success rate (i.e. reduction of falls, postural sway) when individuals
participate in a group setting vs. independently, and does the setting (i.e. group vs.
individual exercise) have an effect on an individual’s overall confidence in one’s
balance and fear of falling?

       While it is said that old age brings wisdom, it can often bring a plethora of

medical issues. Despite changes in physical capabilities and cognitive function many

elderly individuals desire to remain as independent as possible. Age related

changes in strength, balance, sensation, coordination and agility puts one at an

increased risk for a fall.

       A fall can be one of the most debilitating events that an older adult can

experience, and this has to led a great deal of publicity 5,6. It has been estimated

that 1 out of 3 people aged 65 and older will fall once per year6. Falls can result in a

range of minor injuries of soft tissue (contusions) to more serious injuries such as

fracture, traumatic brain injury and even death. Not only are falls physically

disabling to the individual impacting their quality of life, falls also have significant
economic costs to the individual and society5. In a study by Rizzo et al., the average

financial costs for an individual over the age of 72 for treatment after a fall reached

$19,400 5. In 2000, falls among the older adult population cost the US health care

system approximately $19 billion, and it has been reported to increase to an

estimated $28.2 billion in 2010. As the aging population continues to grow, it is

expected that the cost of falls will increase as well. Without encouraging proper

preventative techniques, it is estimated that by 2020, fall related injury costs could

possibly rise to $54.9 billion5.

        Ongoing research investigates what causes a fall, risk factors, and what

preventative measures can decrease the risk of a fall6, 7,36,37. A number of intrinsic

factors increase fall risk such as muscle weakness, as well as decreased agility,

balance, flexibility, vision and hearing6-10. Extrinsic factors can also play a role, such

as pets, poor footwear, medication, use of an assistive device and a fear of falls, 7,36,37.

Sir Francis Bacon once stated, “Knowledge is power 1.” In an effort to prevent falls

and related injuries many caregivers and health care associates have begun to

inform elderly individuals about the intrinsic and extrinsic risk factors associated

with falls as well as the importance of remaining active. Interestingly, studies

suggest that elderly patients who continue to remain socially active often have

better quality of life17, 38,39 .

        Educating elderly adults may improve self-efficacy, an important factor in

improving quality of life and management of their environments. Psychologist

Albert Bandura has led the way in research regarding self-efficacy. Bandura’s social

cognitive theory is the pinnacle of self-efficacy:
        “Perceived self-efficacy is defined as people's beliefs about their capabilities
to produce designated levels of performance that exercise influence over events that
affect their lives. Self-efficacy beliefs determine how people feel, think, motivate
themselves and behave. Such beliefs produce these diverse effects through four
major processes. They include cognitive, motivational, affective and selection

       Self-efficacy research has long been integrated into health care research on

chronic conditions affected by daily decisions. Arthritis is one prevalent condition

in which an individual’s behavior and daily decisions impact their condition, and a

great deal of self-efficacy research has been conducted on those facing arthritic

changes3, 4,45. Patients are often referred to physical therapy to help treat the

physical impairments of arthritis, as well as to receive further education about

managing this debilitating condition. While physical therapy is not a cure for the

condition, it can aid in the management of arthritis as well as provide education

regarding activity modification for participating individuals.

       Historically, group-based educational programs pertaining to arthritis

management have had favorable outcomes that have been attributed to Bandura’s

theory of self-efficacy3. Early interventions geared toward improving self-efficacy

have had significant and sustained clinical improvements in an individual’s self-

management of chronic arthritis. Individuals who have participated in these

programs have reported improved ability to manage pain, depression, as well as an

increased frequency of exercise, relaxation, and self-management activities3.

       Kovar et al. conducted a randomized, controlled self-efficacy trial to further

evaluate the connection self-efficacy plays in relation to one’s condition and

improving one’s overall function3, 4. In this study researchers assessed the safety

and efficacy of a supervised walking program for subjects with osteoarthritis of the
knee. Resulting in statistically and clinically significant outcomes, this study

confirmed the hypothesis that supports self-efficacy in the management of knee

osteoarthritis 2.

       It has long been understood that engaging in routine, moderate physical

activity and exercise produces a number of physiological health benefits such as a

reduced incidence of coronary artery disease11, 12, hypertension11, 13, non-insulin

dependent diabetes mellitus11, 14, colon cancer11, 15, depression and anxiety11, 16.

Structured physical activity and exercise have been promoted more as our society

has a tendency to become more sedentary with age. Due to the fact that the

majority of studies in the literature are done in the younger population, we

currently have a strong understanding of the physiology of exercise in young

healthy adults. However, the older adult population is currently the most rapidly

growing population of individuals17. In the U.S. alone, there are approximately 35

million adults over the age 65, and it has been estimated that number will double in

years to come17. Unfortunately, far less research has been done in this population.

       A common form of exercise for the older adult is walking. Walking has been

previously shown to produce many physical and psychosocial benefits21.

Community-based mall walking programs have been able to address some of the

common barriers to exercise adherence within the aging population such as safety,

support, access and health concerns. Malls are generally wide open, well lit and free

of the common home dwelling obstacles that often can cause a fall. Previous

research on this topic has supported mall walking with significant improvements in

physical activity levels21. While mall walking may be a viable exercise to increase
one’s cardiovascular endurance, it may not suffice if the participant’s overall goal is

to increase strength and balance to reduce their fall risk. Additionally, although mall

walking is sufficient at providing a relatively safe environment for elderly exercise,

little research has been done on the benefits that mall walking may provide in self-


       Another popular exercise practice that has been found to reduce one’s fall

risk is Tai Chi. Tai Chi is “a form of mind-body exercise, [which] originated as a

martial art in China. It utilizes slow, gentle movements along with deep breathing

and relaxation to build strength and flexibility22”. To date, there are numerous

studies that have found positive effects on one’s balance and fall risk reduction after

participation in Tai Chi23, 24. Other model exercise programs have been created to

specifically address health, wellness, exercise and fall risk reduction in the older

adult population. Three well-known programs are Matter of Balance, Stepping On,

and Healthways SilverSnearkers Fitness.

       The Matter of Balance program was initially created for community dwelling

older adults interested in improving balance, flexibility and strength, and reducing

fall risk18. Individuals participating in the Matter of Balance program are age 60 and

over, have experienced a fall in the past, are considered ambulatory and able to

problem solve18. Engaging in the program, participants learn to understand that

falls are preventable, set goals for increasing physical activity, modify their home to

reduce fall risk, and engage in exercise that helps to increase strength and balance18.

       The Stepping On program, created by an Australian occupational therapist,

Dr. Lindy Clemson, is another balance oriented exercise program19, 20. It is a
multifaceted community-based program that utilizes a group environment to reduce

one’s fall risk, improve fall self-efficacy, and encourage behavior change19, 20. The

program encourages individuals to take control, explore with coping behaviors and

encourage safety in an individual’s everyday life.

           The Stepping On program utilizes a total of seven sessions. Throughout the

course of the program participants are educated about different aspects of fall risk

each session. Session one includes an introduction, overview and risk appraisal. The

second session of the program focuses on exercise safe movement. Session three

covers home hazards and problem solving solutions. Session four is about

community safety and footwear. Session five includes information about vision and

falls, the importance of vitamin D and the use of hip protectors. Session six is geared

toward medication management and mobility mastery experiences. This session

identifies medication risks and falls, and how to reduce the risk of falls due to

medication side effects or misuse. The seventh and final session of the program is

for review and planning ahead. In a study completed by Dr. Lindy, the creator of the

Stepping On program, the program was effective for community-residing elderly in

overall fall reduction, and therefore supported previous findings that cognitive-

behavioral learning in a group environment can be effective in the reduction of


           Another credible program is Healthways SilverSneakers Fitness, where

Healthways, Inc. offers free basic memberships in local participating fitness centers

throughout the country 46. This nationally known program is run by certified

SilverSneakers instructors, and is understood to be of high-value for the aging
population. Through this program, older adults have access to exercise instruction,

equipment, pool facilities, and sauna46. A number of leading health plans include

SilverSneakers participation for interested individuals. Medicare has over 40

different health care plans that include SilverSneakers as a benefit under an

individual’s plan46.

       The previously stated exercise programs are group-based where participants

exercise in a group setting under the direction of a fitness instructor. And while

much of the research conducted indicates that many Americans do participate in

some group-exercise activities, other research contends that most Americans

choose to exercise independently 25,26,27.

       Additionally, mental well-being is often considered to be equally as

important, if not more important, than physical well-being in any age group28.

Among the numerous documented health benefits of physical fitness, there are also

psychological benefits from engaging in regular physical activity. Physical activity

has been shown to enhance mood, perceived quality of life, give a sense of self-

satisfaction, provide opportunities for social interaction, improve self-concept, self-

confidence, cognitive functioning, self-esteem, and decrease levels of stress, anxiety,

and depression28.

       It has been proposed that social interaction and physical activity in elderly

adults may promote functional independence29. Further benefits of social

interaction include increased access to health information and care, decreased risk

of mortality, decreased incidence of cardiovascular disease, and improved cancer

survival rates29. It has also been concluded that social interaction and physical
activity differ between men and women. Previous research has found that older

women tend to be more depressed, live alone and report more functional limitations

than males30. It has been suggested that elderly men tend to be more physically

active than women, and that social support and widowhood have stronger effects

for men than women31-34.

       Furthermore, recent research has also described a correlation between

idiopathic motor decline and reduced social interaction35. In 2009, Bruchman et al.

concluded there is an association between a decline in motor function and engaging

in less social activity35. The data collected during this longitudinal study supported

the hypothesis that late life social activity is related to the rate of change in motor

function with increasing age 35.

       The topic of self-efficacy and preventative health care continues particularly

as the relatively healthy, older adult population continues to age, presenting with a

myriad of chronic issues. Bandura and others provided the following suggestions to

improve self-efficacy:

   a.) Identify and reinforce the patients past and present successes and
   b.) Direct patients to observe successful behaviors and coping mechanisms of
       similar others, even if this involves having them alter or expand their social
   c.) Provide positive feedback for the patient’s efforts or encourage people in the
       patient’s social network, such as family members or friends, to do this.
   d.) Facilitate the patient in adopting new health behaviors by ensuring that
       patients do not interpret incorrectly how they are feeling2.

Our project aims to take these ideas a step further, not only encouraging the patient

effort but also providing them with social support in the form of a group setting.
Methods: Description of Community Partner Project

       Highlands Court apartments were created in 1984 to provide a place for

older adults typically over the age of 62 who need minimal assistance for the

activities of daily living. Highland Court has 100 one-bedroom apartments,

including one set aside for a live-in maintenance person. It also has smaller rooms

held for entertaining, an arts and crafts room, a beauty shop, laundry facilities, a

large common room with kitchen facilities, and has recently added a fitness room

with new exercise equipment. Highlands Court also has amenities they can provide

for their residents such as, transportation, Mid-City Mall shopping, grocery

shopping, basic health screening, and religious services.


       After talking to members on the board of directors at Highland Court and a

few of the residents, we noticed a need to develop an exercise program as well as

provide exercise education in order for the residents to utilize their new exercise

equipment appropriately. With a basic literature review, we noted an increase in the

risk of falls in the community-based elderly individual. As previously mentioned,

falls are one of the biggest reasons for emergency room visits in this population and

a major healthcare cost. Through an education and exercise program, we hope to

prevent falls, and maintain an independent lifestyle for residents at Highland Court.

Research suggests general strengthening, balance and Tai Chi exercise programs

decrease the risk of falls. By developing this exercise program, our aim is to reduce

falls, and fall risk in the individual residing at Highlands Court.
       We also noticed the need for education on illnesses that are commonly

associated with the community-dwelling aging population. By developing an

educational program that would address these issues, our expectation is to improve

the residents’ understand of issues such as falls, arthritis, and stroke. Our goal is to

establish a continued exercise and education program at Highlands Court.


       It was originally planned for only the residents that were evaluated and

cleared by the first session to partake in the exercise portion. 14 total residents

were screened by four student physical therapists and one licensed physical

therapist. After the initial screening, other residents showed an increased interest in

participating in the program. All of the residents had medical clearance from their

medical provider to engage in activity, the Highlands Court manager approved open

enrollment of all the residents. Twenty-one Highlands Court residents, ranging in

age from 65-88, volunteered to participate in the Bellarmine University Community

Partner Project. Twenty of the participants were female with only one male

participant. Average demographic age and prior fitness level were not obtained due

to having an inconsistent number of participants at each session.


       In November 2010, three Bellarmine University Doctor of Physical Therapy

students sent a proposal to the Highlands Court administrator. The proposal

involved a program to work with the Highlands Court community to provide them

with education and general exercises to promote wellness and increase regular
physical activity. In January 2011, a survey administered to determine the areas of
interest revealed that the individuals were primarily interested in: arthritis, balance

and falls, signs and symptoms of stroke and heart attack, cardiac disease,

osteoporosis, and cognitive disorders. The project’s main focus was to establish

general health education sessions and an exercise program utilizing existing
equipment and activities that could be performed safely within the facility.


          The project consisted of a series of 40-minute discussions followed by a 20 -

minute interactive exercise component that addressed: flexibility, strength and

balance. A total of six sessions were conducted. On the initial starting date we

performed a general physical therapy screen and collected a subjective medical

history. Participants filled out a Physical Activity Readiness Questionnaire (PAR-Q),

to help determine if they were medically eligible to partake in physical activity. For

those residents eligible, a baseline battery of common functional tests was given.

The baseline tests included the four square step test40, time get up and go test (TUG)
41,   sit to stand test42, and the standing functional reach test43.

          The remaining five sessions addressed the residents’ specific areas of

interest: arthritis, balance and falls, signs and systems of a stroke and heart attack,

heart disease, osteoporosis, and cognitive disorders. Each of the exercise sessions

were composed of a five minute warm up, ten minute exercise portions, and a five

minute cool down. The five-minute warm up was composed of sitting or standing

exercises. The ten-minute exercise portions were similar in nature and addressed:

balance, strength, flexibility and active range of motion. The five-minute cool down

was a group of exercises and stretches. After our weekly discussion and exercise

sessions came to a close, a brief post intervention survey was provided to the
residents who participated. The purpose of the survey was to receive feedback on
our performance, and determine what could be done to improve the program in the
future. A copy of this survey can be found in the appendices section.


      Out of the twenty-one total participants at Highlands Court that took part in

our community partner project, we received fourteen survey responses. All surveys

were handed out to the rehab director at Highlands Court and distributed to the

residents. The surveys were collected by the rehab director and then returned to us.

The results were then analyzed for all of the Likert scale results to our questions

ranging from highly disagree to highly agree. See Table 1 below.

Question #                          Highly       Disagree    Neutral    Agree Highly
                                    disagree                                  Agree
Provided vital information          0            1           0          5     8
Appropriate exercise intensity      1            0           0          5     8
Renewed interest in exercise        0            0           2          6     6
Enjoyed exercising with peers       0            0           1          4     9
Enjoyed exercising alone            0            7           4          1     2
Request additional independent      1            0           7          3     3
Instructor provided motivation      0            0           2          4         8
 Table 1. Results of post-intervention survey. Participants responded favorably
to the program, preferring exercising in an instructor-led group to exercising alone.

      57% of the total participants highly agreed and 36% agreed the Bellarmine

students provided vital education about conditions that can have an effect on the

aging population. 57% highly agreed and 36% agreed the exercise sessions at the

end of the lecture portion were appropriate for their fitness level. 43% highly

agreed and 43% agreed that after participating in this community partner project

they now have a new interest in exercise. 64% highly agreed they enjoyed
exercising with peers. 50% of the participants indicated that they disliked individual

exercise. 50% were neutral that we have provided more information about

exercises they can perform on their own. 57% highly agreed and felt they needed an

exercise instructor to show and motivate them to exercise.

       Our survey ended with four open-ended questions regarding our overall

performance in exercise instruction and our discussions that dealt with conditions

that may have an impact on the older adult’s quality of life and functional

independence. The following 4 questions were asked at the conclusion:

       A.)“Would you rather have exercised by yourself or as part of a group? Please
       state why”.
       B.) “What was most beneficial about exercising in a group?”
       C.) “How will you personally benefit from the information/exercise we
       provided to assist you in your independent living at Highland Court?”
       D.) “Do you have any other suggestions as to how we could improve the
       delivery of the material and or improve the exercise portion of our

       In summary, the residents all responded that they would rather exercise in a

group. They felt more motivated in a group setting, it was fun, and the feelings of

overall safety and security. The residents thought that social interaction, fun and

motivation were the most beneficial aspects of group exercise. The residents had

varied responses about how they personally benefited from the program to assist

with their continued independence at the facility. Overall, the responses showed

improved recognition of the importance of exercise and physical activity. The

activities director informed us how appreciative the residents were of our

engagement with them, and hope that Bellarmine doctor of physical therapy
students will continue to work with this group in the future. Detailed responses of

the open-ended questions can be found in the appendices.


       Previously, King et al. specifically investigated a home-based individual

exercise program in comparison to a group-based exercise program of higher and

lower intensities among healthy, sedentary older adults25. Individuals between the

ages of 50 and 65 where prescribed a high or low intensity exercise regimen for

endurance training25. Researchers aimed to evaluate if there was a difference in the

reduction of cardiac disease risk factors, and overall improved fitness25. The

studies’ findings suggest that community-based training improved fitness but not

cardiac disease risk factors. Their findings also showed that home-based exercise

was as effective as group exercise25. At first glance this appears to contradict our

own findings, however the individuals in this study were younger than those used in

our own study, as well as having different exercise goals.

       Research that specifically looked at older adults at risk for falls compared

individual home-based exercise and group-based exercise in fall risk reduction6.

Individuals in this study resided in a nursing home, and were all at risk for a fall.

Both groups showed a significant improvement in their balance, functional mobility,

and flexibility post intervention6. In addition to the previous findings, the

supervised exercise group displayed significant improvements in strength and

proprioception. Similar to our own findings, researchers concluded that overall

group exercise is more effective than solo exercise with regards to fall risk reduction

for older adults living in a nursing home, suggesting that age and exercise type may
be important reasons for the differences between our survey results and the

findings of King et al6. Given that Highlands Court is an independent-living facility

we believe the information we obtained along with that of previous studies presents

vital information for the community-dwelling older adult, suggesting the

importance of group exercise particularly in this setting.

       Our data is indicative of the need to reinforce the importance of self-efficacy

and education, as well as the benefits of moderate exercise. Interestingly, while

previous studies suggest that exercising alone is preferred28, our study appears to

show the opposite. The responses from our satisfaction survey suggested that this

cohort prefers group exercise. This may be due to the relatively small number of

participants, specific demographics of this cohort, or the fact that these individuals

knew one another prior to engaging in the group exercise. There is the possibility

that if the residents had not known each other prior to participation in our program

responses to our post survey may have differed.

       Our survey and general discussions with the Highlands Court residents over

the course of our six-week program indicated they received great benefit from our

intervention. They enjoyed the social benefits of exercise, and our educational

seminars. The perceived benefits of group exercise were safety, a diminished fear of

falling, and overall fun. Working with this population presents challenges due to the

wide variety of co-morbidities and complex medical histories of the residents.

However, a majority of these individuals are relatively healthy. One problem we

encountered was inconsistency in attendance for our discussion and exercise

program, as well as varying levels of participation and interaction from residents.
       Further research is warranted in order to fully understand if the overall

aging population living in independent living facilities such as Highlands Court will

benefit more from formal group exercise and informational sessions or from

individualized attention in order to promote their functional independence. A

majority of those who attended the weekly discussion and exercise sessions were

women. On occasion a male would be present, but the regular attendees were

female. Future research could compare gender differences in exercise compliance

when exercising alone compared to in a group setting.

       The physical therapy profession has numerous offerings for individuals of

advancing age. In conjunction with the care individual’s primary care physician, a

physical therapist can improve and maintain overall mobility in older adults

enabling a greater quality of life. Physical therapists can also educate this

population regarding the normal process of aging, as well as address specific

conditions the older adult is prone to and provide information that will help them

be as functionally sound as possible.


       Students involved in this program are thankful to have had such a positive

impact on the lives of the residents at Highlands Court. It became obvious as the

weeks progressed how much the residents enjoyed our presence in the facility.

Trust and a sense of comfort developed between the residents and us. Each weekly

discussion involved more residents, and ignited more in depth conversation.

Unfortunately, we had to cut discussions short in order to allow enough time for the
scheduled exercise. Due to conflicting busy schedules, we were only able to meet

with our participants on a weekly basis for approximately 60 minutes.

       The American College of Sports Medicine recommends 30 minutes/day of

moderate-intensity exercise to reduce disease risk47. Although our exercise sessions

were approximately 10 minutes short of the suggested 30 minutes, some exercise is

better than none. If we had the opportunity to do this again, we would have

included more time devoted to exercise, and tried to include more resident

participation. We would also have liked to incorporate various types exercise to

avoid boredom, as well as provide a home exercise program to keep our participants

active on the days were we not present. In addition, we wish we constructed a pre-

test/post-test design to see if our exercise intervention had a positive impact in fall

risk reduction.

       Overall, we believe the physical therapy profession can provide a great deal

to the aging population. A physical therapist’s background and knowledge of

pathology has an enormous impact in the creation a safe, effective, exercise program

for the this cohort. Historically, physical therapists have been able to spend more

time with patients in comparison with their primary care physician. This has

allowed us to provide vital education about a condition they may face. In

conclusion, by educating our patients, and focusing on exercise specifically geared

toward the impairments of aging, we can bolster their functional independence, and

enhance their quality of life.

       We would like to thank Janet Lee and the residents of Highlands Court for

inviting us into their lives, and agreeing to participate in our project. We would also

like to thank David Pieschel, Doctor of Physical Therapy candidate, class of 2012 for

the assistance he provided during the course of our time at Highlands Court. Our

discussions and exercises sessions with the residents would not have been the same

without his presence. In addition, we would also like to thank Edward Foring,

Doctor of Physical Therapy candidate class of 2011 for his help in conducting our

initial health screen prior to the discussion and exercise sessions of the project. We

hope that the Bellarmine PT program will stay in close contact with the Highland

Court residents and director in the future because this was a great opportunity to

utilize skills gained in the classroom, and will and help prepare future students of

Bellarmine’s Doctor of Physical Therapy Program in working with a population with

multiple co-morbidities and complex medical backgrounds.

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Standford/Lockheed exercise survery.” Health Educ Q. 1990; 17:269-285

28. Unger JB, Johnson CA, Marks G. “Functional Decline in the Elderly:
Evidence for Direct and Stress Buffering Protective Effects of Social
Interactions and Physical Activity.” Ann Behav Med 1997, 19(2):152-160)

29. Leppin A, Schwarzer R: Social support and physical health: An updated
meta-analysis. In Schmidt LR, Schwenkmezger P, Weinman J, Maes S (eds),
Theoretical and Applied Aspects of Health Psychology. Chur: Harwood
Academic Publishers, 1990,185-202.

30. Cox HG: Later Life: The Realities of Aging. Englewood Cliffs, NJ: Prentice
Hall, 1993.

31. Berkman LF, Leo-Summers L, Horwitz RI: Emotional support and survival
following myocardial infarction: A prospective population-based stud of the
elderly. Annals of Internal Medicine. 1992, 117:1003-1009.

32. Seeman TE, Berkman LF, Blazer D, Rowe JW: Social Ties and support and
neuroendocrine function: The MacArthur studies of successful aging. Annals
of Behavioral Medicine. 1994, 16:95-106

33. Rowe JW, Kahn RL: Human aging: Usual and successful. Science. 1987,
34. Umberson D, Wortman CB, Kessler RC: Widowhood and depression:
Explaining long-term gender differences in vulnerability. Journal of Health
and Social Behavior. 1992, 33:1-24

35. Buchman AS, Boyle PA, Wilson RS, Fleischman DA, Leurgans S, Bennett
DA: “Association Between Late-Life Social Activity and Motor Decline in
Older Adults.” Arch Intern Med Vol 169 (No 112), June 22,2009

36. American Geriatrics Society, British Geriatrics Society, and American
Orthopedic Surgeons Panel on Falls Prevention. Guideline for the Prevention
of falls in older persons. J Am Geriatr Society 2001; 49:664-672

37. Bloem BR, Steijins JAG, Smits-Engelsman BC, An Update on Falls. Curr
Opin Neurol 2003; 16: 15-26

38. Rejeski WJ, Elvasky S: Physical activity, aging, and quality of life in older
adults. Journals of Gerontology. Series A. Biological Sciences and Medical
Sciences. 2001, 56(2):23-25

39. Schechtman KB, Ory MG: The effects of exercise on the quality of life of
frail older adults: A preplanned meta-analysis of the FICSIT trials. Annals of
Behavioral Medicine. 2001, 23: 186-197

40. Temple W. A clinical test of stepping and change of direction to identify
multiple falling older adults. Archives of Physical Medicine & Rehabilitation.

41. Podsiadlo, D., Richardson, S. The timed ‘Up and Go’ Test: a Test of Basic
Functional Mobility for Frail Elderly Persons. Journal of American Geriatric
Society. 1991; 39:142-148

42. Senior’s Chair Stand Test. Available URL at:
http://www.exrx.net/Calculators/SeniorChairStand.html. Accessed
November 9, 2011

43. Duncan, P. W., D. K. Weiner, et al. Functional reach: a new clinical
measure of balance. J Gerontol 1990. 45: M192-197.

44. Meeks, Sara. Walk Tall! 2nd Edition. An Exercise Program for the
Prevention and Treatment of Back Pain, Osteoporosis, and the Postural
Changes in Aging. Triad Publishing.
45. Lorig, K., Chastain, R., Ung, E., Shoor, S., & Holman, H. (1989).
Development and evaluation of a scale to measure perceived self- efficacy in
people with arthritis. Arthritis and Rheumatism, 32, 37- 44

46. Silver Sneakers Exercise Program. Available at URL:
www.silversneakers.com/Default.aspx. Accessed November 14, 2011

47. Heyward, Vivian H. Advanced Fitness Assessment and Exercise
Prescription 5th Edition. Champaign: Human Kinetics, 2006

     Copy of Survey

            We are students in the doctor of physical therapy program from Bellarmine

     University who are dedicated to improving the health and wellness of our local

     community. We would like to learn more about potential interests the residents of

     Highlands Court have regarding mini-educational sessions on health related issues

     as well as the possibility of offering some limited exercise programming using the

     gym equipment at Highlands Court. Please take a few minutes to complete this
     survey, as we are very interested in your responses.

     Please rate your interest for sessions on the following topics by circling a

     number on a scale of 0-5. (0= not at all interest, 1= very little interest, 2= little
     interest, 3= some interest, 4= interested, 5= very interested)

1.   Osteoporosis                                0 1 2 3 4 5

2.   Balance and Falls Prevention                0 1 2 3 4 5

3.   Diabetes                                    0 1 2 3 4 5

4.   Arthritis                                   0 1 2 3 4 5

5.   Heart Disease                               0 1 2 3 4 5

6.   Stretching/Flexibility                      0 1 2 3 4 5

7.   Strength Training                           0 1 2 3 4 5

8.   Responsible Medication Management            0 1 2 3 4 5
9.    COPD/Emphysema, Chronic Bronchitis                 0 1 2 3 4 5

10.      Signs and Symptoms of a Stroke                  0 1 2 3 4 5

11.     Tai Chi (Meditation in Motion)                   0 1 2 3 4 5

12.     Relaxation Techniques                            0 1 2 3 4 5

13.     Other: Please list any other topics or concerns_______________


      Please circle your response regarding your current frequency that you
      perform the following types of exercise:


              -Never      1-2 times/week        3-4 times/week          5 or more times/week

      Strengthening Exercises (example: Lifting weights)

              -Never    Once a week       2 times/week       3 times/week      4 times or

      Do you do any other form of exercise?

              -Never    1-2 times/week        3-4 times/week          5 or more times/week
If so, what types of exercise do you

do? ___________________________________________________________________________________________

What other recreational activities do you enjoy doing? List any/all.

Has your physician or other healthcare provider ever told you that you should NOT

        Yes    No    I don’t know

Are you interested in participating in a five weeklong educational and interactive

program where we will discuss health topics and instruct in general health

Yes    No

How often would you be interested in participating in an educational and interactive
program to discuss health topics and instruct in general exercise?

One hour one day/week for 5 weeks                   One hour 2 days/week for 5 weeks

2 hours one day/week for 5 weeks                    30 minutes 2days/week for 5

Thank you for taking the time to fill out this survey. Please return this survey to

Exercise Program

Session 1: March 16, 2011

Screen participants.

       -Medical Doctor Clearance (Note: Highlands Court, residents currently
       participating in group exercise activities have these on file)

       -General subjective/medical history

       -Physical Activity Readiness Questionnaire or PAR- Q

       -Physical Therapist Community Screening Form for Aging Adults

Session 2: March 23, 2011

       -40-minute information/discussion session on Balance and Falls.

       -20-minute Balance Exercise Session

              5-minute warm-up

                       -Deep Breathing

                       -Good Morning Stretch

                       -Cervical ROM

                       -Flexion, extension, side bending, and rotation

                       -Shoulder Rolls

                       -Seated Knee Raises (marching)

                       -Ankle circles

              20-minute Exercise

                       -Diagonal arm press across the body and toward the floor
           -Diagonal arm press across the body and slightly overhead

           -Rowing exercise

           -Seated leg extensions

           -Toe Stands

           -Alternating Steps (marching in place)

           -Side Stepping

           -The box step (waltz)

           -Standing Hip Extension

           -Standing Hip Abduction

           -Wrist Flexion/Extension

           -Touch Elbows Stretch – scapular protraction/retraction

           -Arm Chair Push

           -Standing Hip circles

           -Standing Foot Circles

           -Heel Cord Stretch

     (All exercises will be performed 15-30 seconds each and will have a
     chair with an armrest to provide support to participant) Referenced
     from “A Matter of Balance”

5-minute Cool-down

           -Ear to Shoulder

           -Cervical ROM

           -Flexion, extension, side bending, and rotation

           -Good Morning Stretch

           -Giant Bear Hug Stretch
Session 3: March 30, 2011

      -40-minute information/discussion session on Osteoporosis

      -20-Minute Balance Exercise Session

             5-minute Warm-up

      Simulation and educational on body mechanics

                    -Will have participants demonstrate proper down mechanics of
                    squatting, push objects, lifting objects, and carrying objects44

             20-minute Exercise

                    -Diagonal arm press across the body and toward the floor

                    -Diagonal arm press across the body and slightly overhead

                    -Rowing exercise

                    -Seated leg extensions

                    -Toe Stands

                    -Alternating Steps (marching in place)

                    -Side Stepping

                    -The box step (waltz)

                    -Standing Hip Extension

                    -Standing Hip Abduction

                    -Wrist flexion and extension

                    -Touch Elbows Stretch scapular protraction/retraction

                    -Arm Chair Push

                    -Standing Hip circles

                    -Standing Foot Circles
                     -Heel Cord Stretch

              (All exercises will be performed 15-30 seconds each and will have a
              chair with armrest to provide support to participant) Referenced from
              “A Matter of Balance”

       5-minute Cool-down

              Simulation and educational on body mechanics

                     - Participants will demonstrate proper down mechanics of
                     squatting, push objects, lifting objects, and carrying objects44.

Session 4: April 6, 2011

       40-minute information/discussion session on Signs and Symptoms of a
Stroke and Heart Attack

       20-Minute Balance Exercise Session

              5-minute Warm-up

                     -Seated Walking/marching in place with arm swing

                     -Mini squats

                     -Side stepping

                     -Heel Raises

                     -Standing walking/marching in place

              20-minute Exercise

                     -Diagonal arm press across the body and toward the floor

                     -Diagonal arm press across the body and slightly overhead

                     -Rowing exercise

                     -Seated leg extensions
      -Toe Stands

      -Alternating Steps (marching in place)

      -Side Stepping

      -The box step (waltz)

      -Standing Hip Extension

      -Standing hip abduction

      -Wrist Flexion and Extension

      -Touch Elbows Stretch scapular protraction/retraction

      -Arm Chair Push

      -Standing Hip circles

      -Standing Foot Circles

      -Heel Cord Stretch

(All exercises will be performed 15-30 seconds each and will have a
chair with armrest to provide support to participant) Referenced from
“A Matter of Balance”

5-minute Cool-down

      -Seated Walking/marching in place with arm swing

      -Mini squats

      -Side stepping

      -Heel Raises

      -Standing walking/marching in place
Session 5: April 13, 2011

       -40-minute information/discussion session on Arthritis

       -20-Minute Balance Exercise Session

              5-minute Warm-up

                     -Seated hamstring stretch

                     -Standing Quad stretch

                     -Standing gastrocnemius stretch

                     -Seated piriformis stretch

                     -Standing marching in place

              20-minute Exercise

                     -Diagonal arm press across the body and toward the floor

                     -Diagonal arm press across the body and slightly overhead

                     -Rowing exercise

                     -Seated leg extensions

                     -Toe Stands

                     -Alternating Steps (marching in place)

                     -Side Stepping

                     -The box step (waltz)

                     -Standing Hip Extension

                     -Standing Hip Abduction

                     -Wrist Flexion and Extension

                     -Touch Elbows Stretch scapular protraction/retraction

                     -Arm Chair Push
                     -Standing Hip circles

                     -Standing Foot Circles

                     -Heel Cord Stretch

              (All exercises will be performed 15-30 seconds each and will have a
              chair with armrest to provide support to participant) Referenced from
              “A Matter of Balance”

              5-minute Cool-down

                     -Seated hamstring stretch

                     -Standing Quad stretch

                     -Standing gastrocnemius stretch

                     -Seated piriformis stretch

                     -Standing marching in place

Session 6: April 20, 2011

       -40-minute information/discussion session on Alzheimer’s/Wii sports

       -20-Minute Balance Exercise Session

              5-minute warm-up

                     -Seated Walking/marching in place with arm swing

                     -Mini squats

                     -Side stepping

                     -Heel Raises

                     -Standing walking/marching in place

              20-minute Exercise

                     -Diagonal arm press across the body and toward the floor

                     -Diagonal arm press across the body and slightly overhead
      -Rowing exercise

      -Seated leg extensions

      -Toe Stands

      -Alternating Steps (marching in place)

      -Side Stepping

      -The box step (waltz)

      -Standing Hip Extension

      -Standing Hip abduction

      -Wrist Flexion and Extension

      -Touch Elbows Stretch (scapular protraction/retraction

      -Arm Chair Push

      -Standing Hip circles

      -Standing Foot Circles

      -Heel Cord Stretch

(All exercises will be performed 15-30 seconds each and will have a
chair with armrest to provide support to participant) Referenced from
“A Matter of Balance”

5-minute Cool-down

      -Seated Walking/marching in place with arm swing

      -Mini squats

      -Side stepping

      -Heel Raises

      -Standing walking/marching in place
Highland Court Questionnaire

Please rate your experience with the Bellarmine Physical therapy students (Adam,
David and David) based on their content and quality of the education in which they
provided during the engagement with you, the residents of Highland Court.

Please circle one of the following numbers after each question
1= highly disagree
3= neutral
4= agree
5=highly agree

Overall, the Bellarmine students provided vital education about common conditions
that can have an effect on the aging population.

       1       2       3       4      5

The exercise sessions at the end of the lecture/discussion portion of our weekly
presentation was appropriate for your fitness level.

       1       2       3       4      5

After participating in the discussion/exercise program, did you have a new interest
in exercise or want to take up a new form of exercise?

       1       2       3       4      5
During our group exercise session did you enjoy exercising with peers?
      1      2      3      4      5

If you exercised previously, did you enjoy exercising alone?

       1      2      3      4      5

Do you wish we had provided more information about exercise you can perform on
your own?
      1      2     3      4     5

Do you feel you need an exercise instructor to show you and or motivate you to
       1      2      3     4       5

Please respond in your own words to the following questions:

Would you rather have exercised by yourself or as part of a group?


What was the most beneficial about exercising in a group?
(for example: demonstration, social interaction, motivation)

How will you personally benefit from the information/exercise program we
provided to assist in your independent living at Highland Court?

Do you have any other suggestions as to how we could improve our delivery of the
material and or improve the exercise portion of our presentation?
Additional Comments – Quotations from our satisfaction survey

Would you rather have exercised by yourself or as part of a group? And Why?
        -“A group, I feel more motivated being with a group.”
        -“Part of a group socializing and doing it with other makes it more fun and you
tend to do it when it’s a scheduled time with the group.”
        -“Part of a group, less likely to stop between session completed.”
        -“Part of a group, because some will be present in case I fall”
        -“Group, its more fun”
        -“Group, you feel motivated whereas not so much alone”
        -“Part of a group, most likely I would not exercise alone”

What was the most beneficial about exercising in a group?
(for example: demonstration, social interaction, motivation)
       -“Social interaction, and motivation”
       -“The fun of being with other trying to do the exercise”

How will you personally benefit from the information/exercise program we
provided to assist in your independent living at Highland Court?
         -“Being able to do things we have not done until we were shown correctly.
         -“Recognizing the importance of exercise.”
         “Knowledge, keeping more active more.”
         “Strength, weight loss, happier, motivated”
         -“You have the tools and information to take better care of yourself and continue
to live independently”

Do you have any other suggestions as to how we could improve our delivery of the
material and or improve the exercise portion of our presentation?
       -“ As activity director, I felt the Bellarmine students did a great job and the
residents love having them. They listen and they we do what they suggest. I personally
appreciate your coming.”
       -“No change, just please continue”

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