PHYSICAL FRAILTY is complex, characterized by declines

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1 960 Low-Intensity Exercise as a Modifier of Physical Frailty in Older Adults Marybeth Brown, PhD, PT, David R. Sinacore, PhD, PT, Ali A. Ehsani, MD, Ellen F. Binder, MD, John O. Holloszy, MD, Wendy M. Kohrt, PhD ABSTRACT. Brown M, Sinacore DR, Ehsani AA, Binder EF, Holloszy JO, Kohrt WM. Low-intensity exercise as a modifier of physical frailty in older adults. Arch Phys Med Rehabil 2000;81: Objective: To examine the effects of a 3-month low-intensity exercise program on physical frailty. Design: Randomized clinical trial. Setting: Regional tertiary-care hospital and academic medical center with an outpatient rehabilitation fitness center. Participants: Eighty-four physically frail older adults (mean age, 83 4yrs). Intervention: Three-month low-intensity supervised exercise (n 48) versus unsupervised home-based flexibility activities (n 36). Main Outcome Measures: Physical performance test, measures of balance, strength, flexibility, coordination, speed of reaction, peripheral sensation. Results: Significant improvement was made by the exercise group on our primary indicator of frailty, a physical performance test (PPT) (29 4 vs 31 4 out of a possible 36 points), as well as many of the risk factors previously identified as contributors to frailty; eg, reductions in flexibility, strength, gait speed, and poor balance. Although the home exercise control group showed increases in range of motion, the improvements in flexibility did not translate into improvements in physical performance capacity as assessed by the PPT. Conclusions: Our results suggest that physical frailty is modifiable with a program of modest activities that can be performed by virtually all older adults. They also indicate that exercise programs consisting primarily of flexibility activities are not likely to reverse or attenuate physical frailty. Although results suggest that frailty is modifiable, it is not likely to be eliminated with exercise, and efforts should be directed toward preventing the condition. Key words: Exercise; Activities of daily living; Frail elderly; Rehabilition by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Claude Pepper Older Adult Independence Center, Division of Geriatrics and Gerontology, Washington University School of Medicine, St. Louis, MO. Submitted August 23, Accepted October 11, Supported by the Washington University Claude D. Pepper OAIC (AG13629) and grants AR40705 (WMK) and AG00585 (MB). Presented in part at the annual Gerontological Society Association meeting, Cincinnati, OH, November No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Marybeth Brown PhD, PT, Box 8502, Program in Physical Therapy, Washington University School of Medicine, 4444 Forest Park Blvd, St. Louis, MO /00/ $3.00/0 doi: /apmr PHYSICAL FRAILTY is complex, characterized by declines in multiple domains including strength, balance, flexibility, reaction time, coordination, and muscular and cardiovascular endurance. 1,2 The cumulative effect of these declines is a reduction in the ability to independently accomplish instrumental activities of daily living. 3,4 Evidence that exercise training can reduce physical frailty is accumulating For example, recent evidence has shown that exercise training can induce significant improvements in balance, 5 strength, 6 range of motion, 7 and tasks such as stair-climbing, getting up from the floor, and rising from a chair 8 in frail older individuals. Unclear from these studies, however, is the effect that one form of exercise intervention, such as strength training, might have on another domain, such as flexibility or speed of reaction. Although one aspect of frailty may predominate (eg, strength), other domains are likely also affected, suggesting that a comprehensive exercise approach should be the most effective for modifying frailty. 9 The purpose of this study was to examine the effects of physical therapy exercises on many of the elements identified as factors associated with frailty. These include impairments in gait and decreases in flexibility, strength, balance, sensation, speed of response time, and coordination. METHODS Sample Sedentary men and women over the age of 78 years who were living independently but with difficulty and were interested in participating in an exercise intervention study were invited for a pre-enrollment evaluation. During this initial evaluation, potential subjects underwent a detailed medical assessment, chest x-ray, cognitive screening, blood and urine chemistry analyses, a screening treadmill exercise test with electrocardiogram and blood pressure monitoring, measurement of VO 2 max or VO 2 peak, and an objective evaluation of frailty, described below. Volunteers eligible for participation in the study were invited to an orientation, where details of the study were outlined and questions were answered. After orientation, informed consent was obtained. This research was approved by the Human Studies Committee of the Washington University School of Medicine. Forty-eight volunteers, 20 men and 28 women with an average age of 83 4 years, were enrolled in the supervised exercise program (EXER). Comparisons were made to 39 other volunteers (17 men, 22 women) who were randomized into a home exercise control group (HOME). HOME subjects also averaged 83 4 years of age. Defining Frailty As part of baseline screening, all subjects underwent a physical performance test (PPT) that correlates well with nursing home admission and mortality 11,12 (table 1). This nine-item examination requires subjects to complete seven functional tasks within a specified time frame; the two remaining items are descriptive. Each item is worth a maximum of 4 points and, therefore, a perfect score (no frailty) is 36. To be

2 EXERCISE EFFICACY FOR FRAIL ELDERS, Brown 961 Table 1: Modified Physical Performance Test 1. Lift a 7lb book from waist level to a shelf overhead. 2. Put on and take off a lab coat. 3. Pick a penny up from the floor. 4. Walk 50ft, 25ft out and back. 5. Turn Timed ascent of one flight of stairs. 7. Climb 4 flights of stairs. 8. Chair rises 5 times from a 16-in chair. 9. Progressive Romberg: eyes open condition. Items 1 through 7 are from the Physical Performance Test published by Reuben and Siu. 11 Items 8 and 9 are from Guralnik and colleagues. 12 admitted into the study, participants had to score less than 32 points on the PPT. Volunteers whose PPT scores were 17 or less were considered too frail to participate in the program. Those with scores over 31 points had no observable frailty. Physical Measures Subjects underwent tests of strength, balance, range of motion, sensation, speed of movement, and a detailed gait analysis to define further the deficits associated with physical frailty and to understand better the role of exercise as a modifier of these potential contributors to frailty. Strength. For testing of the knee extensors and flexors, subjects were seated on a Cybex a isokinetic dynamometer with the back supported and hips at 120 of flexion. 13 The dynamometer was set at the desired speed of motion (0 /sec, 60 /sec, 180 /sec), and subjects were asked to press against the fixed bar as hard as possible or to move against the movement arm as hard and fast as they were able. For the isometric component, the arm of the dynamometer was fixed at approximately 45 of flexion. For testing of the ankle plantar and dorsiflexors, subjects were placed in the supine position with the knee at 90 of flexion. The ankle was tested at speeds of 0 /sec, 60 /sec, and 120 /sec. Hand-held dynamometry was used for strength testing of the upper extremities and proximal musculature of the lower extremities. The standard break test was used, and two repetitions of each action were recorded. For shoulder flexion, the arm was placed at 90 of sagittal flexion (sitting position), and a Micro-Fet b dynamometer was placed on the arm, just above the elbow. For shoulder abduction, the arm was moved to 90 of abduction, and resistance was again applied just above the elbow. Elbow flexion was tested while the subject was seated with the forearm placed at 90 of flexion, and resistance applied at the wrist. Grip strength was obtained using a hand-held dynamometer, which was adjusted to accommodate differences in hand size. Hip extension was measured while the subject was prone. Once the hip was extended, the dynamometer was placed on the distal thigh, just above the popliteal fossa. Subjects were next asked to roll onto the side, and the thigh was passively placed in 20 of abduction with a slight amount of external rotation and hip extension. Once the thigh was positioned, the examiner slowly released the thigh to ensure the subject could hold the test position. If the test position was maintained, the dynamometer was placed on the lateral thigh, just above the knee. Both left and right hip abductors were tested. Range of motion. Range of motion measures were obtained using standard goniometric measures of passive shoulder flexion, shoulder external rotation, hip flexion with the knee extended (straight-leg raising), hip internal rotation, knee flexion, and ankle dorsiflexion. 14 In addition, trunk rotation was measured while subjects were seated to fix the pelvis, and while subjects were standing, the distance from their fingertips to the floor was measured with a ruler after forward bending and side bending. Hip flexor tightness was assessed using the Thomas test and measuring with a goniometer. Balance. Multiple measures of balance (static, dynamic, weight-shift) were obtained. Static balance was evaluated by having subjects stand on one leg for a maximum of 30 seconds on each side. No practice sessions were given. In addition, forward displacement of the center of mass was assessed using the functional reach test. 15 The ability to maintain static balance under conditions of reduced base of support was measured using the Romberg test. This staged test requires subjects to balance for 10 seconds in each of three test positions: feet together, semi-tandem, and full-tandem postures. Dynamic balance was assessed using a balance beam, obstacle course, and fast gait speed. The balance beam consisted of a board 5.5in in width, 1.5in in height, and 16ft in length. The time that it took to walk the middle 12ft of the beam was recorded. The number of times balance was lost was also noted. Successful performance of the obstacle course consisted of rising from a standard 18-in chair (without using arms if possible), walking forward approximately 6ft, stepping over a 2in 2in piece of wood, walking forward another 6ft, ascending a 7-in curb, turning around, stepping down off the curb, and returning to the chair as quickly as possible, safely. The obstacle was stepped over on the return trip as well. Finally, the Berg balance test was used. This 14-item examination requires subjects to accomplish static, dynamic, and weight-shifting activities, which can be scored from 0 (unable) to 4 (done safely), according to specific criteria, yielding both a test score and individual item performance data. 16 Gait analysis. Pressure-sensitive foot switches c were applied to the soles of each subject s shoes. Wires from the foot switches were connected to a waist pack that contained a module that recorded data in real time from the foot switches. With the aid of computer software, c signals from the waist pack were analyzed to provide gait velocity, cadence, stride length, swing and stance time, double support time, and percentages of the gait cycle spent in each phase. 17 Two trials for preferred gait speed were obtained and two trials at a self-selected fast gait speed were also recorded. Coordination and speed of response. Coordination was assessed using the Purdue peg board, d which requires subjects to pick up one peg at a time from a cup located at the top of the board and place each peg in a hole in the board. The goal is to place as many pegs into the board as possible, consecutively from top to bottom, in 30 seconds. Response time was determined by having subjects respond to a visual stimulus, the changing of a green to a red light, by moving the right foot from a gas pedal to a brake pedal. A stop watch triggered the green-to-red light change and stopped as soon as the subject s foot hit the brake pedal. Five trials were performed, and the scores from trials 2 and 4 were recorded in milliseconds. Sensation. To determine if lack of sensory input was a contributor to functional deficits, two forms of sensory testing were performed. Light touch and pressure sensation were evaluated using Semmes-Weinstein monofilaments. 18,e To begin the test, shoes and socks were removed, and subjects were asked to close their eyes. Filaments were pressed against the plantar surface of the great, middle, and small toes; the first, third, and fifth metatarsals; and the heel. The 4.17, 5.02, and 6.1W monofilaments were applied perpendicular to the surface of the skin with enough pressure to bend the filament. Individuals with normal sensation feel the 4.17W filament, the lightest

3 962 EXERCISE EFFICACY FOR FRAIL ELDERS, Brown of those applied; those with impaired or absent sensation can sense filaments that are heavier in weight or not feel the filaments at all. 18 Those able to sense the 4.17, 5.02, and 6.1W filaments were assigned scores of 3, 2, and 1, respectively. Those with absent sensation received a score of 0. A tuning fork was used to obtain an indirect assessment of proprioception. Subjects closed their eyes, and a tuning fork vibrating at 126Hz was placed on the dorsum of the foot, the first metatarsal head (plantar surface), and heel in random order. If the vibration of the tuning fork was felt for 5 seconds or longer, sensation was recorded as present. If the vibration was not felt at all or felt for less than 5 seconds, proprioception was graded as absent. Exercise Program Exercises were designed to challenge all major muscle groups and to enhance flexibility, balance, body handling skills, speed of reaction, coordination, and, to a modest extent, strength. Twenty-two exercises formed the basis of the activity program. There were three levels of difficulty associated with each exercise, and exercises were changed monthly to provide new levels of challenge. For example, sit-to-stand was performed during the first month, with subjects using hands if need be. During the second month, sit-to-stand was performed without using the hands, and subjects held the partial standing position for several seconds before fully rising to the upright. During the third month, sit-to-stand was performed without hands, and subjects held the partial standing position for several seconds during the ascend, and very slowly descended back to the chair. More repetitions of each activity were required each month. Theraband f was used to provide a small amount of resistance for the hip musculature and knee flexors and extensors, and occasionally, 1 to 2lb hand-held weights were used during upper extremity activities. Frequent position changes were required of exercise participants; these included moving from chair-sitting to floor-sitting, rolling from supine-lying to side-lying and prone, standing, and returning to sitting. As progress was made, more positional changes were added. Exercise classes were held 3 times per week, and once 36 sessions for EXER subjects were completed (about 3mo), retesting was done. HOME subjects came in for retesting after 3 months of home activity. HOME participants performed nine of the same 22 core exercises as those in the supervised exercise program; they performed only those activities that challenge range of motion. HOME subjects were invited to exercise on-site under supervision once a month. A complete list of exercises for the HOME and supervised EXER groups is provided in the appendix. Data Analysis Data were analyzed using a 2 2 analysis of variance to evaluate group (EXER vs HOME) and time (T1 vs T2) differences. For EXER subjects, data also were evaluated using paired t tests to determine if significant changes occurred in response to exercise. All results are presented as mean standard deviation, and data were considered significant when p.05. RESULTS Physical Performance Test The exercise training resulted in a significant improvement in physical performance capacity, as evidenced by scores on the PPT. PPT scores increased from 29 4to31 4 points in the EXER group, while scores for the HOME group remained unchanged (29 6vs29 6). The two groups were comparable at initial testing, but after 36 exercise sessions the difference between the two groups was significant ( p.05). Individual items on the PPT that showed a significant trainingrelated improvement were the chair rise, putting on and taking off a coat, picking up a penny, and the Romberg (balance) test. Strength Group time comparisons revealed that some significant changes in strength occurred in response to training in the knee extensors (60 /sec) and knee flexors (60 /sec) (table 2). Only the shoulder abductors showed an exercise-related change in strength in the upper extremities. The average increase in Table 2: Strength Values Exercise Group Home Exercise Controls p Values T1 T2 T1 T2 Group Time Group Time Knee extension (ft/lb) Isometric /sec * 180 /sec Knee flexion (ft/lb) Isometric /sec * 180 /sec Dorsiflexion (ft/lb) Isometric /sec /sec Plantar flexion (ft/lb) Isometric /sec /sec Hip abduction (lb) Hip extension (lb) Values reported as mean SD. Abbreviations: T1, time before exercise program; T2, time after exercise program. * Significant interaction effect.

4 EXERCISE EFFICACY FOR FRAIL ELDERS, Brown 963 Table 3: Range of Motion Exercise Subjects Home Exercise p Values T1 T2 T1 T2 Group Time Group Time Shoulder flexion External rotation Forward bend (cm) *.07 Trunk rotation *.10 Straight leg raise *.24 Hip flexor tightness Hip internal rotation *.17 Knee flexion Dorsiflexion *.75 Except where noted, measures are given in degrees (mean SD) according to the methods adopted by the American Academy of Orthopedic Surgeons. 14 Abbreviations: T1, time before exercise program; T2, time after exercise program. * Significant time effect. Significant interaction effect. There were no group differences. lower extremity strength (total percentage change in all strength measures) for the EXER group was approximately 9% in contrast to a 1% change for the HOME control group. Range of Motion Flexibility increased with exercise in both the EXER and HOME groups. Specific range of motion values are provided in table 3. Balance Significant improvements in balance occurred for the EXER group for the obstacle course. Times do not reflect data for 5 6 of the EXER subjects who were unable independently to complete the obstacle course prior to activity intervention but were able to negotiate the obstacle course after exercise. Significant improvements were also noted in the full-tandem portion of the Romberg test, the Berg balance test, and one-limb standing time. For HOME control subjects, there were no significant changes in any of the balance measures (table 4). Gait Although there was a trend toward normalization of gait characteristics in the EXER group, only the change in preferred walking cadence was significant (group time comparisons). Fast velocity, preferred velocity, and temporal events (eg, Table 4: Balance Measures Exercise Subjects Home Exercise Controls T1 T2 T1 T2 Obstacle course (sec) * Functional reach (in) Romberg (sec) Feet together Semi-tandem Full tandem * * One-limb stand (sec) * Balance beam (sec) No. of Errors * Berg test * Values are reported as mean SD. Abbreviations: T1, time before exercise program; T2, time after exercise program. * Significant group time differences (p.05). Significant time differences. There were no significant group differences. stance time, double stance) did not reach statistical significance (table 5). No significant change in gait was observed for HOME control subjects. Coordination/Response Time Coordination scores (pegboard task) for the EXER group improved ( pegs vs at T2) while scores for the HOME control group ( vs ) stayed unchanged, so that the difference between groups at T2 was close to significant ( p.08). Response time remained unchanged for both the EXER ( vs msec) and HOME ( vs msec) groups. Sensation Differences in sensation were not apparent between groups. In general, both groups exhibited mild sensory loss when tested using monofilaments, with an average score of on a 3-point system. Approximately half of all subjects in each group were unable to perceive vibration. Thus, differences between Table 5: Gait Measures Before and After Exercise Exercise Subjects Home Exercise Controls T1 T2 T1 T2 Preferred gait velocity (m/min) * Fast walk (m/min) * Cadence * Stride (m) Right stance time (sec) Left stance time (sec) Swing as % of gait cycle Stance as % of gait cycle Double stance % Values reported as mean SD. Abbreviations: T1, time before exercise program; T2, time after exercise program. * Significant time effects (p.05). Significant group time difference.

5 964 EXERCISE EFFICACY FOR FRAIL ELDERS, Brown groups in balance could not be attributed to differences in sensory input from the periphery. DISCUSSION The findings in this study indicate that women and men over the age of 78 years with some degree of frailty are capable of improvements in strength, balance, and flexibility with a low-intensity program of physical therapy types of exercise. More important, these changes in strength, flexibility, and balance are associated with a significant improvement in functional capability. These results underscore the importance of physical activity for the maintenance and enhancement of independence for older adults. Although the elderly men and women in this study were not markedly debilitated all were community dwelling they were compromised in their abilities to accomplish routine daily physical tasks. Difficulty in functional activity was associated with decreased range of motion, strength, ability to balance, speed of reaction, coordination, and sensory processing. Exercises were designed to remediate many of these deficiencies, and thus, the positive outcomes from this exercise program are likely attributable to the exercises that were designed to improve more than one of the contributors to frailty. The program for HOME subjects consisted primarily of range-of-motion activities. Self report by the participants and the significant improvements in range-of-motion values indicate that home exercises were done by subjects, but the findings also indicate that this approach is insufficient to enhance physical capacity in older adults. In general, the HOME participants lost a small amount of strength and balance in just 3 months, even though flexibility improved. It is important to find strategies for older adults at risk for loss of independence to improve their situation in the home setting. Clearly, a flexibility program for home participants is not the direction to pursue. The results suggest that the more comprehensive the exercise intervention, the greater the likely scope of improvement in frailty. Although strength increased to a modest extent, it is not clear whether this small enhancement directly improved function. More likely, the improvements in balance, flexibility, and strength together were responsible for the enhancement in function. Possibly, the improvements in strength or balance alone resulted in functional change, but this needs to be determined. Regardless of the mechanism, a low-intensity program designed to improve multiple risk factors associated with frailty can help to modify the condition. Range of motion did not appear to change in all of the joints that received flexibility exercise. Examination of the results show that range-of-motion increases ranged from 0 to as much as 20. Rotator cuff problems, the presence of significant osteoarthritic changes (particularly at the knee), and the high percentage of total hip and knee joint replacements apparently precluded improvements in range of motion at various sites in many of the subjects. Similar findings were noted for strength, where increases ranged from 0% to 100%. Some of the study participants had too much pain or joint instability to allow them to exercise hard enough for increases in strength to occur in some muscle groups. For a few individuals, residual weakness from polio, war injuries, or stroke precluded appreciable change in strength. Nonetheless, as evidenced by an approximate 9% improvement overall (all strength measures combined), strength increases are likely to occur even with low-level activity. Not all measures of balance responded to the exercise program, suggesting that some of the measures may be too insensitive to detect modest changes. The balance tests required subjects to respond to a static challenge with eyes open and closed, reduce their base of support, weight-shift left and right, and hold balance under dynamic conditions. Static balance improved the most (one-legged stand, Romberg), dynamic balance (obstacle course) improved to a modest extent; and the functional reach test did not change at all. Given the complex nature of balance and the need for information from at least three separate systems (vestibular, visual, somato-sensory) to succeed at balancing, 19 it is important to understand better factors leading to improvements in this important domain. It is also important to evaluate the causes of impaired balance in the elderly and the mechanisms by which training improves balance. One element involved in functioning safely and independently in the community is the ability to recover from loss of balance. None of the balance tests used in this study provided information regarding the effectiveness of protective reactions. Some of the participants in this study had excellent balance, as determined by the Berg test, 16 functional reach, 15 and singlelimb stance, but seemed to lack the ability to catch themselves if balance was lost. This aspect of balance and the potential for falling warrants future examination. About 60% of the men and women in this study had sensory deficits as determined by vibration sense and the ability to feel the Semmes-Weinstein monofilaments. Nonetheless, these individuals showed improvements in balance function, which suggests that balance is modifiable even though peripheral sensation is not fully intact. There is evidence to indicate that older adults enjoy the type of exercise program provided in this study and feel better afterward. 20 A sense of enjoyment and a perceived improvement in well-being are likely to have a positive effect on exercise continuation and adherence. The exercises used in this study are easy to accomplish and can be performed without special equipment or sophisticated instructions and supervision. Thus, this exercise approach may have a greater impact on frailty over time than exercises that require direct assistance and sophisticated equipment. Even though strength deficiencies play a major role in frailty, not all elders are capable of participating in conventional strengthening exercise. A very low VO 2peak has also been associated with diminished ability to accomplish activities of daily living and instrumental activities of daily living, but there are not many older adults who are capable of undergoing vigorous cardiovascular conditioning. Low-intensity exercise, such as the program employed in this study, has the potential to enhance and maintain function in men and women with significant physical compromise without untoward effects. In summary, a 3-month program of low-intensity exercise designed to challenge balance and speed of movement, enhance flexibility, and improve strength to a modest extent was found to be effective for improving physical function as reflected in tests of balance, range of motion, and strength. In contrast, a home exercise program consisting of stretching exercises resulted in some improvements in flexibility but did not improve balance, strength, or the score on a PPT used to quantify frailty. Although exercise was found to improve functional capacity, frailty was not eliminated with training. Findings suggest that the prevention of physical frailty may be a more important goal than the modification of this condition. Acknowledgment: We are appreciative of the support given by the entire technical staff.

6 EXERCISE EFFICACY FOR FRAIL ELDERS, Brown 965 References 1. Jette AL, Branch LG, Berlin J. Impairment and physical disability in the aged. J Chron Dis 1985;38: Buchner D, Wagner EH. Preventing frail health. Clin Geriatr Med 1992;8: Harris T, Kovar MG, Suzman R, Kleinman JC, Feldman JJ. Longitudinal study of physical ability in the oldest-old. Am J Public Health 1989;79: Guralnik JM, LaCroix AZ, Abbott RD, Berkman LF, Satterfield S, Evans DA, et al. Maintaining mobility in later life. I. Demographics characteristics and chronic conditions. Am J Epidemiol 1993; 137: Wolf SL, Barnhart HX, Kutner NG, McNeely E, Loogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. J Am Geriatr Soc 1996;44: Frontera WR, Meredith CN, O Reilly KP, Knuttgen HG, Evans WJ. Strength conditioning in older men: skeletal muscle hypertrophy and improved function. J Appl Physiol 1988;64: Raab DM, Agre JC, McAdam M, Smith EL. 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A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M Brown M, Holloszy JO. Effects of a low intensity exercise program on selected physical performance characteristics in 60- to 71-year olds. Aging: Clin Exp Res 1991;3: American Academy of Orthopedic Surgeons. Joint Motion. Method of measuring and recording. Chicago: American Academy of Orthopedic Surgeons; Duncan PW, Weiner DK, Chandler JM, Studenski SA. Functional reach: a new clinical measure of balance. J Gerontol Med Sci 1990;45:M Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil 1992;73: Perry J. Gait analysis. Normal and pathological function. Thorofare (NJ): Slack; p Mueller MJ. Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. Phys Ther 1996;76: Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: a review. Neurobiol Aging 1989;10: King AC, Taylor CB, Haskell WL. Effects of differing intensities and formats of 12 months of exercise training on psychological outcomes in older adults. Health Psychol 1993;12: Suppliers a. Cybex, Division of Lumex Inc, 2100 Smithtown Ave, Ronkonkoma, NY b. Hoggan Health Industries, Inc, 265 East South, PO Box 957, Draper, UT c. B&L Engineering, PO Box 3905, East Florence Blvd, Santa Fe Springs, CA d. Smith & Nephew, Inc, PO Box 1005, One Quality Dr, Germantown, WI e. Research Designs, Inc, 7520 Hillcroft, Houston, TX f. Theraband; The Hygenic Corp, Akron, OH APPENDIX: THE 22 CORE EXERCISES THAT SERVED AS THE BASIS FOR THE ACTIVITY PROGRAM The nine exercises marked with an asterisk are those that were performed by the home exercise participants. Sitting 1. Chin tucks (neck retraction).* 2. Trunk twists as far as possible left and right.* 3. Trunk side-bending as far as possible toward the floor.* 4. Lateral arm raises (shoulder abduction), possibly with small hand-held weights.* 5. Theraband diagonals (moving from shoulder extension/ internal rotation to shoulder abduction/external rotation). 6. Ball toss as quickly as possible. Standing 7. Back to wall. Arms are abducted to 90 and arms and elbows are brought back to the wall.* 8. Wall slides or partially sitting with knees flexed but supporting body weight. 9. Calf stretch: standing on an incline board and leaning forward. 10. Toe press: raising up and down on toes as far as possible. 11. Heel lift: rolling back on the heels and lifting the toes off the floor. Floor Exercise 12. Hands and knees: starting on all fours, bring buttocks to heels.* 13. Prone lying: raise head and shoulder up on elbows.* 14. Side lying hip abduction. 15. Side lying quadriceps stretch: simultaneous hip extension and knee flexion. 16. Prone lying: raise one arm and the opposite leg simultaneously. 17. Supine hamstring stretch: the thigh is held to the chest while the knee is extended.* 18. Supine with knees bent: one leg is allowed to fall out to the side to stretch adductors.* 19. Supine lower abdominal exercise: begin pelvic tilt and then impose lower extremity movement. 20. Upper abdominal exercise: sitting with legs extended, slowly lower trunk toward the floor. Standing Exercise 21. Tandem walking. 22. Standing balancing, initially with feet together and then on one leg.