Effect of two programs of physical exercise in the motor fitness of sedentary elderly subjects

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1 Original Article Effect of two programs of physical exercise in the motor fitness of sedentary elderly subjects Efeitos de dois programas de exercícios físicos nos determinantes de aptidão motora em idosos sedentários Fernanda Varkala Lanuez 1, Wilson Jacob Filho 2 ABSTRACT Objective: To evaluate the effects of exercise in motor abilities of elderly subjects undergoing two different exercise programs: Group A, aerobic exercise program (n = 18); and Group B, flexibility and balance exercise program (n = 19). Methods: This is a one-year randomized controlled interventional trial of correlate samples. Subjects: Forty individuals aged 60 to 90 years, of both genders, referred from the Outpatient Geriatrics Clinic of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, with a sedentary lifestyle, or at least, not practicing regular physical activity in the last six months. Results: All determinants of motor fitness showed statistically significant improvement in Group B. The same occurred in Group A, except for flexibility parameters. Conclusions: The results of this study strengthen the relevance of the practice of physical exercise for sedentary elderly subject and demonstrate the need of specific exercise programs aimed at defined goals, optimizing their results in this Health Promotion tool for the Elderly. Keywords: Aged; Exercise; Pliability; Musculoskeletal equilibrium RESUMO Objetivo: Avaliar o efeito dos exercícios na aptidão motora por meio de dois diferentes programas: o grupo dos exercícios aeróbios (Grupo A, n= 18) e o grupo que realizou exercícios de flexibilidade e equilíbrio (Grupo B, n = 19). Métodos: Este foi um estudo casualizado, ensaio controlado, no qual cada amostra foi controle dela mesma. Foram sujeitos dessa pesquisa 40 idosos, idade entre 60 e 90 anos, ambos os sexos, encaminhados dos ambulatórios do Serviço de Geriatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, sedentários ou que não tivessem praticado atividade física por pelo menos seis meses. Resultados: Todos os determinantes de aptidão motora apresentaram melhora significativa no grupo de exercícios de flexibilidade e equilíbrio, como no grupo dos exercícios aeróbios, com exceção dos parâmetros de flexibilidade. Conclusões: Os resultados desta investigação reforçam a relevância da prática de exercícios físicos pelos idosos sedentários, mas demonstra a necessidade de dirigir a programação para objetivos definidos, o que pode otimizar os resultados deste instrumento de Promoção de Saúde do Idoso. Descritores: Idoso; Exercício; Maleabilidade; Equilíbrio musculosquelético IntroduCTION According to a World Health Organization (WHO) publication of 1984, elderly individuals are defined as those aged 60 years or over in some Eastern European and developing countries, such as Brazil. In these regions, when individuals reach this age, they will display anatomical and physiological characteristics, associated to social, economic and cultural factors (1). Being sedentary, very common in the elderly population, is characterized as a lifestyle in which physical activity, including the activities of working, leisure, daily life and locomotion entail energy expenditure below 500 kilocalories per week (kgcal/week) (2). Physical activity is described as any body movement produced by skeletal muscles (voluntarily), which results in energy expenditure above the resting levels (3-4). In 2000, the Instituto Brasileiro de Geografia e Estatística (IBGE) recorded a total of 14,512,803 inhabitants older than 60 years. The growth of this population is so impressive and it is estimated that, compared to 1940, it will triple in 2025, ranking Brazil as the sixth country of the world (4) as related to this population. All major causes of morbidity and mortality in elderly people are preventable. When reaching 65 years, the Study carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo USP, São Paulo (SP), Brazil. 1 Master s degree, Geriatrics Department of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo USP, São Paulo (SP), Brazil. 2 Post-doctorate degree; Full professor of Faculdade de Medicina da Universidade de São Paulo USP, São Paulo (SP), Brazil. Autor correspondente: Fernanda Varkala Lanuez Rua das Cascatas Vila Nivi CEP São Paulo (SP), Brasil Tel.: fervarkala@hotmail.com Received on Sep 7, 2007 Accepted: Jan 16, 2008

2 Effect of two programs of physical exercise in the motor fitness of sedentary elderly subjects 77 mean life expectancy is of 15 years more for men and 19 years for women. However, if preventable measures are established, life expectancy may increase as well as the quality of life, so that they may reach the age of 80 years in more satisfying conditions (5). In most countries, including Brazil, over 60% of adults living in urban areas are not involved in enough physical activity. The 2000 census revealed that 80% of the Brazilian population living in cities has greater chance of developing illnesses associated to a sedentary lifestyle, considering that the lack of physical activity is prevalent in the elderly women, in subjects of low social level and in people with disabilities (6). With the ageing process, some physiological manifestations favor the difficulty in performing physical activity, increasing the rate of sedentary people. On the other hand, the lack of physical activity puts these changes into evidence and may render the elderly in unsatisfactory functional conditions (7). Reduced flexibility along the ageing process is widely reported. However, it is not defined whether this finding is due to the biological process or a consequence of some degenerative disease or to the frequently observed sedentary lifestyle in this age group (8). With ageing, instability and loss of balance occur due to several deficits in components of postural control (9). Aerobic resistance is also reduced in sedentary elderly subjects (10). When compared to young subjects, there is a drop by 50%, manifesting itself as impaired stress tolerance, fundamental for completing daily life activities (1,9,11-13). Frequent and systematic practice of physical activity is known as a beneficial factor in the process of ageing, easing situations of reduced muscle strength, aerobic resistance, balance and flexibility (14). Recent studies demonstrated a positive association between physical activity, physical fitness and risk factors for cardiovascular diseases, suggesting that physical activity has a protective effect in this population (14-15). The significant impact of physical activity in the prevention and treatment of chronic degenerative disease in elderly subjects is also true regarding improvement in functional abilities (14). A five-month program consisting of dancing, swimming and gymnastics, assessing muscle strength, coordination, balance, reaction time and flexibility in 59 men and women aged from 60 to 89 years demonstrated that, regardless of the activity performed, systematic and regular training has led to improvement in the variables studied, especially in neuromuscular functions (16). However, no study has assessed training programs with specific types of exercises, but an association of different modalities. Taking this into account, we acknowledge the need to perform a study assessing different types of physical exercise independently, in order to establish better methods of physical treatment in this situation. OBJECTIVE Considering the changes in balance, flexibility and aerobic resistance seen in an elderly population, the objectives of this study are: 1. to assess motor parameters of an elderly population; 2. to assess the effects of two different exercise programs in two randomized groups. METHODS This is a randomized controlled interventional trial with correlate samples, in which each group was its own control. It began in February 2002 and ended in February 2003; it was approved by the Research Ethics Committee of the Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP). Forty elderly subjects aged between 60 and 90 years, of both genders, with sedentary habits or not practicing any regular physical activity in the past six months, were referred from the Outpatient Geriatrics Clinic of HC- FMUSP. The subjects were randomized in two different groups: A. Aerobic training: training in this group consisted of monitored walks in athletic field (400 m), using the subjective scale of stress for interruption. Every two weeks, the stepping velocity increased, as well as the number of laps, and at the end of the study it reached 12 laps around the field; B. Flexibility and balance training: consisted of active stretching exercises of the lower and upper limbs (biceps brachii, triceps brachii, pectoralis major, quadriceps, triceps surae, iliotibial, gluteus maximus stretching) and exercises with progressive changes of the standing base and of the visual condition (tiptoeing with wide base and later reduced, lateralization of the body, squatting with wide base and later reduced and exercises performed with the eyes closed). Every two weeks, one repetition of each series was added, and the number of series, increased, totaling up to three series and twelve repetitions at the end of the study. Before the series, both groups warmed up (for five minutes), by performing circular movements of the extremities of the lower and upper limbs, rotation movements of the cervical spine and slow lap around the field, and cooled off after the series (for five minutes), performing respiratory exercises according

3 78 Lanuez FV, Jacob Filho W to respiratory patters associated to raising the upper limbs and self massage, when a circle was made and each elderly performed massages the subject in front. The activities were done at the Academic Athletic Association (Associação Atlética Acadêmica Osvaldo Cruz, AAAOC), in a closed gymnasium (Caveirinha) and in the athletic field (400 m), three times per week (Monday, Wednesday and Friday), lasting 50 minutes each, for 12 months. All elderly subjects signed an informed consent form of HC-FMUSP, as authorized by the Comissão de Ética para Avaliação de Projetos e Pesquisa (CAPPesq). Balance was assessed by means of the tests: modified Romberg: functional test assessing balance, with changes in the standing base, body posture and visual status, with the subjects remaining in the established posture for, at most, ten seconds with the total scores of 10 points (17-18) ; lower extremity function test: a performance test that assesses balance during changes in the standing base, walking speed and skill, with a maximum score of 12 points (19) ; Balance Scale or Berg test: it considers the functional performance in 14 tasks and is designed to outline decreased balance, as well as the potential for falls, with a maximum score of 56 points (20-21). The tolerance for stress was assessed by means of the six-minute test, in which the subject is told to continuously walk in a flat ground for six minutes (if possible). In case any discomfort occurred during the test, the subject was told to reduce the speed until the symptoms improve. The score obtained by the elderly subject is the result of the walking time divided by the distance covered, expressed in meters (22). Flexibility was assessed by the sitting and reaching test or modified Wells bench, a functional test in which the trunk and lower limb flexibility is assessed. The subject sits on the floor, with the back against the wall, lower limbs 30 cm apart and on top of a box (50 x 90 x 30 cm). The subject is told to extend the upper limbs and flex the trunk. The score obtained is recorded in centimetres (23-24). The exclusion criteria were the parameters recommended by the American College of Sports Medicine (ACSM): subjects with history of a recent myocardial infarction, severe aortic stenosis, dissecting aneurism of the aorta, uncompensated congestive heart failure, unstable angina, myocarditis, pulmonary embolism or ventricular tachycardia (25). The elderly subjects missing three consecutive sessions with no justification were also excluded. Statistical analysis was done using the SigmaStat 3.0 for Windows package, within groups and for intragroup comparison a variance analysis was utilized (one-way ANOVA). For the intergroup analysis, the Tukey and Dunn tests were used. The level of significance adopted was p < RESULTS Table 1 depicts the demographic data of the 37 elderly subjects who completed the study: one of them quitted and two were removed due to surgeries. The results are expressed as means ± standard deviations. Table 1. Demographic data of patients who completed the study Data Group A Group B p Subjects (37) n = 18 n = 19 Age (years) 69.8 ± ± Minimum-maximum (years) Sex, M/F 02/16 02/ In the Figures 1, 2, 3, 4 and 5, Group A is depicted in black and Group B, in white. Figure 1. Six-minute test: A and B. Box Plot illustrates the six-minute test performed five times during the study in both groups. A significant difference was observed both at univariate (Group A, p = < and Group B, p = 0.01) and at intergroup analyses (p < 0.001). Note that after three and six months of exercises, both groups presented improvement in this parameter; after this period, only Group A showed a marked increase Figure 2. Modified Romberg test: A and B. Box Plot displays the modified Romberg test. At univariate analysis, only Group B had a significant difference (p = < 0.001). Note that after three months of training, both groups displayed improvement and the parameters were maintained until the end of the program.

4 Effect of two programs of physical exercise in the motor fitness of sedentary elderly subjects 79 Figure 3. Berg test or Balance Scale: A and B. Box Plot shows the Balance Scale, in which both univariate analysis (Groups A and B p = < 0.001) and intergroup analysis presented a significant improvement (p = < 0.001). Group A had an increment after three, six and nine months of training, and the parameters were maintained until completing 12 months. Group B presented improvement after three and nine months of training Figure 4. Lower extremity function test: A and B. Box Plot illustrates the lower extremity function test or Guralnik test. At univariate analysis, Group A presented a significant improvement in the parameters (p = < 0.001), by comparing the initial assessment and the evaluation after three, six and nine months, as shown by the median. Group B presented a significant improvement in the parameters only when comparing the initial assessment and the evaluation after 12 months (p = 0.03). At the intergroup analysis, a significant difference was observed -(p = 0.001) Figure 5. Sit and reach test: A and B. Box Plot depicts the flexibility test, in which at the univariate analysis, Group A demonstrated improved parameters only after six and 12 months, as shown by the median. Group B presented a significant improvement at all moments (p = < 0.001). The intergroup analysis demonstrated a significant difference when comparing the initial assessment and evaluation after three months (p = 0.001) DISCUSSION The literature does not portray sufficient evidence for designing systematic exercise programs and their cost effectiveness in improving flexibility (12). Of all the motor fitness determinants, flexibility is the least studied, but the few existing studies show positive effects, with the use of specific stretching programs (14). In the present study, it was shown that lower and upper limbs stretching exercises associated to balance training (Group B) were able to improve flexibility parameters in elderly subjects. This was not seen in Group A, which only performed walking exercises. In a study of 26 obese 63-year-old women (± 4), that were subjected to a training program (aerobic and strength) lasting 40 minutes daily for 12 weeks, 13 performed exercises, 13 were controls and it was observed that the group who performed exercises obtained satisfactory results in the walking test, in reducing systolic blood pressure, when compared to the control group. However, it did not show significant difference in the sitting and reaching test (26). This effect did not occur in Group B, what demonstrates the positive effect of training for 12 months. Training composed by flexibility and balance exercises (Group B) demonstrated significant increase of flexibility in sedentary elderly subjects in all stages of the assessment. In Group A, there was an increase in flexibility after six to 12 months, as shown by the median, but this increase was not significant. Several authors state that regardless of the type of physical activity, systematic training has important physiological effects in the balance component (14-18). On the other hand, other studies report that most investigations have used broad intervention programs (associating strength, balance, flexibility and aerobic training), which does not allow to identify which of the program components promoted the observed changes in balance, and that exercise programs, such as Tai Chi Chuan, or flexibility exercises using postural changes and slow movements are able to increase, besides of balance and flexibility, the capacity of postural control, muscle strength and aerobic resistance (12,27). In the present study, an improvement of balance was observed with less risk for falls both in Group A and in Group B. In the latter, such increase was greater, as described in the literature. An interesting observation was that in Group A, balance improved in the tests Balance Scale and the lower extremity function test, both after three months of training, which remained until the end of the study. Such finding was not described in the literature. Regarding aerobic resistance, several studies have shown that it only increases with specific aerobic exercises, such as walking, running and swimming. But it was shown that both in the group subjected to walking and in the group who performed gymnastics, there was an increase in these parameters. This is due to the fact that the group performing balance and flexibility

5 80 Lanuez FV, Jacob Filho W exercises improved these parameters which, in turn, improved their performance in walking and tolerance to stress. The magnitude of the improvement in aerobic resistance is determined by the intensity, frequency and duration of the exercise and of the initial level of fitness (1). The aerobic exercises increase the cardiovascular reserve, with the optimization of the mechanic performance of the heart and improvement of the distribution of peripheral oxygen (28). Investigators state that aerobic training is beneficial to elderly subjects, for improving their cardiovascular system and by reducing the proportion of body fat, and that strength training would be the ideal one, because it improves all aspects of motor fitness (29-30). In the present study, it was demonstrated that walking, besides improving the cardiovascular parameter and the aerobic resistance, was also important to improve balance, and it did not show influence in flexibility. On the other hand, Group B displayed improvement in all parameters, including aerobic resistance, even though this group had not performed strength training, contradicting the literature. Regarding the lower extremity function test, Group A showed improvement in scores up to nine months, when compared to baseline results, displaying small reduction after twelve months of training. Group B, on the other hand, showed improvement in the score after three months of training, which remained stable until completing nine months; only after twelve months of training, there was an expressive increase of this parameter, which suggests that this type of training is more efficacious, because it remains stable, and shows marked improvement after one year. In the modified Romberg test, both groups displayed improvement in balance, and the parameters were maintained until the end of the study. In the Balance Scale, a test that assesses balance and the risk of falls, both groups showed score increments; however, Group A had a more expressive increase. Perhaps this is due to the fact that walking was done in open environment and on uneven ground, recruiting several sensorial information; also, walking contributes to increasing muscular strength of the lower limbs, which is related with reduction in the rate of falls. In a randomized trial comparing resistance training (n = 20) with flexibility training (n = 20), in which the activities were performed for one hour, twice weekly, for ten weeks, it was observed that strength training produced excellent effects in strength, gait and balance, compared to the flexibility training (31). Balance, as already mentioned, was more expressive in the Group performing specific exercises for this function; however, walking had a cumulative effect, with Group A remaining stable until the end of the study, and not showing increases at single assessments, in the modified Romberg test. Perhaps, this occurred because walking was performed in an open, uneven ground, stimulating several systems committed with postural control. What became clear in the present study was that both groups improved determinants of motor fitness (Group B had an increase in all parameters assessed and Group A, only in aerobic resistance and balance) and that the association of these two types of training would be ideal for the elderly subjects. According to WHO, for every dollar spent in programs of physical activity for the elderly, there is a 4.5 dollar savings in Health services (32). This estimate demonstrates the importance of studies and projects that use physical training as means of Health promotion for the elderly. CONCLUSION With the analysis of the results, it was possible to conclude that aerobic training featured in the study, such as walking, promotes, beside the expected increase in aerobic resistance, the improvement of parameters of balance, which is contrary to what is reported in the literature. Improvement in balance in the group of aerobic training is due to the fact that walking was perfomed on open and uneven ground, therefore, stimulating several systems responsible for postural control. Training consisting of balance and flexibility exercises has shown to be more complete for this age group, enhancing all parameters studied, including aerobic resistance, which has not demonstrated in recent studies. 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