Exercicios Funcionais Em Idosos

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Journal of Strength and Conditioning Research, 2005, 19(3), 647651 2005 National Strength & Conditioning Association

THE BENEFITS OF AFUNCTIONALEXERCISE CIRCUITFOR OLDER ADULTS

MICHAEL A. WHITEHURST,1 BEVERLYL. JOHNSON,2 CHERIEM. PARKER,2 LEEE. BROWN,3 AND

ALLISON

M. FORD

1

1Department of Exercise Science and Health Promotion, Florida Atlantic University, Davie, Florida 33314;2DeVos-Blum Family YMCA of Boynton Beach, Boynton Beach, Florida 33435; 3FACSM Division of Kinesiologyand Health Promotion, California State University, Fullerton, California 92834.

ABSTRACT. Whitehurst, M.A., B.L. Johnson, C.M. Parker, L.E.Brown, and A.M. Ford. The benefits of a functional exercise cir-cuit for older adults. J. Strength Cond. Res. 19(3):647651.

2005.The physical benefits of a functional exercise circuit arenot well known in an elderly population. The purpose of thisstudy was to evaluate the effect of a functional exercise circuiton mobility and perceived health in the elderly. Subjects were119 men and women (aged 74 [4.2] years) who received pre-and posttests of mobility (e.g., sit to stand, get up and go, timed

walk), flexibility (sit and reach), and balance (standing reach)and who completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). A supervised functional exercisecircuit that included 10 different upper- and lower-body exercis-es performed under time constraints was performed 3 times perweek for 12 consecutive weeks. Paired t-tests showed significantdifferences at posttest for the get up and go (p 0.001), standingreach (p 0.001), sit and reach (p 0.001), and selected itemsfrom the SF-36, including physical functioning (p 0.001), pain(p 0.001), vitality (p 0.001), and number of doctor visits (p 0.001). A functional exercise circuit such as the one employedin this study may offer promise as an effective means of pro-moting mobility and perceived health in older adults.

KEYWORDS. enhanced mobility, perceived health

INTRODUCTION

While resistance exercise has been used exten-sively during the past decade to promotestrength, muscle hypertrophy, and mobilityin the elderly (6, 7, 10, 17), few if any studieshave reported using a functional approach in

which movement patterns common to activities of dailyliving (ADL) were employed as the primary exercise stim-ulus. The idea that exercise should be strict linear move-ments typical of resistance machines and free weightsmay be impractical for many older adults. Rather, a func-tional exercise, particularly one performed in a circuitfashion, may be well suited to older persons wishing to

improve function and mobility.Using an exercise circuit to induce physiological stress

in an effort to promote health-related fitness is not new.For example, circuit weight training has been shown toimprove strength and, to a lesser extent, cardiorespira-tory endurance in young, healthy subjects (8, 19). Simi-larly, circuit or workstation exercise interventions havebeen used to improve function and physical work capacityin stroke patients (4, 12) and cardiac patients (5). In arecent study, Nelson et al. (13) exposed older adults to ahome-based exercise program that included progressiveresistance exercise and mobility challenges. Nelson andcolleagues found significant improvements in dynamic

balance, whereas strength and gait speed did not differbetween exercise and control groups. Although the authors concluded that a home-based exercise program of-fers benefits, it could be argued that their failure to findsignificant results across all outcome measures resultedfrom the older subjects inability to perform exercises correctly in the absence of feedback and/or sustain an ap-propriate intensity throughout the exercise session.

Our intention was to develop a functional exercise circuit that required movement patterns and mobility challenges common to ADL. In doing so, we sought to providea supervised exercise setting and effectively eliminate theneed for specialized equipment while providing physicallydemanding exercise performed in a group setting. We hypothesized that the functional exercise circuit would provide an exercise stimulus suitable for improving function-al mobility in older adults. In addition, considering thata psychologic benefit is often attributed to regular exer-cise (1), we examined the influence of the functional ex-ercise circuit on perceived health. Again, consistent withother forms of exercise, we hypothesized that the benefitsof the functional exercise circuit would extend beyond the

physical.

METHODS

Subjects

This study sought to determine whether elderly subjectscould improve their mobility and perceived health from anontraditional functionally (i.e., movement patterns common to ADL) based exercise program. This study was approved by Florida Atlantic Universitys Institutional Re-view Board for Human Subjects Research. Subjects were119 (aged 73 [4.6] years) volunteers from Palm BeachCounty, Florida. Upon phone inquiry, subjects werescheduled for a physical examination (an informed con-sent and a detailed medical history were also obtained)

Subjects whose medical history and/or physical examination showed more than 2 major coronary heart diseaserisk factors and/or who presented with an unstable condition (e.g., heart disease, high blood pressure, abnormalevels of blood lipids) within the last 12 months and/orwho had mobility issues were referred to their physicianfor follow-up (n 3) and deemed unfit for participationin this study.

Immediately following the physical examination, sub-jects completed the Medical Outcomes Study 36-ItemShort-Form Health Survey (SF-36) and a battery of teststhat targeted mobility (e.g., sit to stand, get up and gotimed walk), flexibility (sit and reach), and balance


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FIGURE 1. Layout of functional exercise circuit.

(standing reach). The SF-36 (numeric responses, e.g., 1 all of the time; 6 none of the time) dealt with generalhealth, physical functioning, mental state, social activity,pain, and vitality. Subjects were also asked to provide thenumber of falls, emergency room visits, hospitalizations,and doctor visits, where pretest was defined as 12 monthsprior to their participation in this study. All tests wererepeated within 1 week following the conclusion of the 12weeks of continuous exercise.

Procedures

The sit-to-stand maneuver was electronically timed andrequired the subject to rise from a seated to a standingposition, without the aid of the arms, as quickly as pos-sible. The best of 3 trials was recorded. A detailed de-scription of this test may be found elsewhere (18).

The get-up-and-go test required the subject to risefrom a seated position, walk 8 ft (2.44 m), turn, and re-turn to the seated position as quickly as possible (14).

The timed walk test was an aerobic endurance testlasting 6 minutes. Briefly, the subject walked a rectan-gular course (13.4 3.35 m) for 6 minutes, covering asmuch distance as possible (14).

Flexibility was measured in the sit-and-reach positionusing a standard sit-and-reach box, and the best of 3 tri-als was recorded (9).

The standing-reach test was a field test of balance andprovided a measure of the subjects stability and risk offalling. Subjects stood with the shoulder of the dominantarm next to a wall. Affixed to the wall was a slide. Thestart position was defined as the subject grasping thehandle of the slide mechanism, arm in front of the bodyand parallel to the floor. The subject moved the slidemechanism forward by leaning forward as far as possibleor just prior to the point that a step was necessary toavoid falling. The distance from the start position (mea-sured from the handle on the slide mechanism) to thestopping point was recorded. Each subject received 3 tri-als, and the greatest reach was recorded. All tests wereadministered in the order described.

Functional Exercise CircuitOverview

A functional exercise circuit was performed 3 times perweek for 12 consecutive weeks. The circuit consisted of 10exercises or stations performed consecutively, each last-ing 60 seconds, with 3 circuits completed each session.During the 60 seconds, participants were able to complete1030 repetitions before transitioning (1520 seconds) tothe next station. A total of 1530 subjects participated ineach session. Subjects were monitored at all times to en-sure safety and adherence to good form and were in-structed to avoid the Valsalva maneuver while perform-

ing the different exercises in the circuit. Subjects werenot allowed to complete more than several repetitions ateach station of the circuit for the first week. More repe-titions and hence difficulty were introduced slowly duringsubsequent weeks (weeks 23). A timer called out times(e.g., 15, 30, 45 seconds) during the 60-second interval.Finally, subjects wore a heart rate monitor while exercis-ing and were instructed to monitor their intensity bychecking their monitor periodically (training heart rate 7080% predicted maximum heart rate) as well as usingthe Borg scale (1314). Periodic inspections by the inves-tigators showed that subjects were at or just below 70%of their THR during the functional exercise circuit. Of the

36 possible sessions, subjects averaged slightly more than30 sessions or 83% of all possible sessions.

While the stations of the circuit required specificmovement patterns, the circuit was designed to empha-size level changes, directional changes, and the negoti-ating of obstacles. In this way, the circuit was more thanjust a repetitive process. Rather, the configuration of thecircuit and its inherent obstacles placed cognitive and at-tentional demands on the subjects at all times. The sta-tions were labeled by number and name while the sub-jects rotated through the circuit numerically (12 . . . .101). See Figure 1 for a layout of the exercise circuit.

Functional Exercise Circuit

Wall Exercise. The subject stood with his or her back tothe wall. A large rubber ball (1.06 m) was placed betweenthe midback and the wall. While leaning against the ball,the subject flexed the knees, trying to attain a 90 bendbefore returning to the straight-legged starting position.

Single Leg Balance. With a foam cushion (5.08 cm)positioned near a wall, the subject balanced on 1 leg whilestanding on the foam cushion. This task will was repeatedon both legs, approximately 30 seconds per leg.

Cross-Legged Seated Torso. The subject assumed aseated cross-legged position (back straight) on the floor toperform a series of 4 gentle stretches. With the arms out-stretched and the hands resting on the knees, the first


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movement included bending forward at the waist andthroughout the spine, in order to move the head towardthe floor, and then returning to the straight-back posi-tion. The second and third movements required the sub-ject to maintain the straight back while rotating the torsoposition (arms were allowed to follow the torso but didnot provide assistance) as far as possible in one directionand then in the opposite direction. The fourth and finalmovement required the subject to place the hands behindthe buttocks for support while arching the back such thatthe chest moved toward the ceiling. Each position washeld for 310 seconds and repeated several times in se-quence.

Modified Push-Up. From a kneeling position, thehands were placed on the floor, shoulder width apart, andarms straight. The goal was to lower the chest to the floorand return to the straight-arm position. Subjects whocould not perform the modified push-up performed wallpush-ups in which their feet were shoulder width andparallel and as far from the wall as could be toleratedwhile they were still able to flex the arms and move thechest as close to the wall as possible.

Crunch. While lying on the back, arms crossed against

the chest and knees bent so the feet were flat on the floor,the subject tucked the chin against the sternal notch andraised the back from the floor as far as possible while, atthe same time, contracting the abdominal muscles suchthat the back rounded and the chest moved toward thebent knees. The subject held the upright position for 1count before returning the back to the floor and repeatingthe movement.

Superman. While lying facedown on the floor witharms outstretched overhead, the subject lifted the thighsand chest off the floor simultaneously. At the top, the sub-ject paused for 1 count before lowering the chest andthighs to the floor.

V-Sit. The subject assumed a seated position with thelegs outstretched, the back straight (some subjects placed

their hands on either side of the hips to assist in main-taining a straight back), and the feet spread 0.61.2 m,depending on individual capability. Alternating betweenlegs, the subject leaned toward an outstretched leg as faras possible. Upon stretching to a comfortable limit, thesubject paused and held the stretch for 510 seconds be-fore returning to the start position. The subject thenstretched toward the other leg. This process was repeatedseveral times for each leg.

Stretch and Balance. Standing with feet shoulderwidth apart and arms at the sides of the body, the subjectreached overhead with the right arm while simultaneous-ly abducting the left leg such that that foot left the floor.In the outstretched position, the arm and leg formed a

diagonal line that was held for as long as 10 seconds. Thesame action was repeated for the other side of the body.These movements were repeated 24 times per side. Sub-jects were allowed to hold a chair with the uninvolvedhand for support.

Star Exercise.Six rubber cones (height 0.07 m) werepositioned in a circle around the subject, with each coneapproximately 0.094 m from the subject. While balancingon 1 leg, the subject flexed the knee, reached down, andtouched the top of a cone. The subject returned to theupright posture (starting position) before attempting totouch another cone. It should be pointed out that the sub-jects used opposing limbs (e.g., right leg as the base and

left arm to touch the cone). Additionally, the subject wasoriented in a constant direction during the task. Thismeant that touching a cone in the rear required bendingand flexing the knee and blindly reaching back. The long-term goal for each subject was for him or her to touch the6 cones with all combinations of balanced leg and outreached arm. However, not all subjects could touch alcones at all times without temporarily losing balance andhaving to temporarily stabilize themselves with the otherfoot.

Weight Transfer. The subject picked up tote bags, onein each hand, representing approximately 20% of his orher body weight. With the arms at the sides, the subjectwalked around the outside of the exercise circuit andthrough or around obstacles that included stepping overbarriers (there were 3 to choose from: 4.7, 7.0, and 9.4cm), reversing direction, and walking backward while carrying the tote bags.

Statistical Analyses

Mean and standard deviation were calculated for eachvariable. Paired t-tests were used to determine differences over time for each variable. The p 0.05 was used. Al

data analysis was completed using SPSS version 11.0(SPSS Inc., Chicago, IL).

RESULTS

As shown in Table 1, paired t-tests detected significantdifferences in pre- and posttests for get up and go ( p 0.000), standing reach (p 0.000), sit and reach (p 0.000), self-reports of physical functioning (p 0.001)pain (p 0.001), vitality (p 0.001), and doctor visits(p 0.000). The initial alpha level ofp 0.05 was corrected (0.05 per number of paired t-tests or 18).

DISCUSSION

This study sought to evaluate the relative value of a functional exercise circuit as a means of promoting mobilityand perceived health in an elderly population. On the ba-sis of the results obtained in the get-up-and-go test, itappears that the functional exercise circuit interventionpromoted mobility. Although not significant (0.006), thetimed walk test, indicative of cardiorespiratory endurance and mobility, improved by 7.4%. These findings areconsistent with other studies in which mobility improvedin an elderly population following exercise training (6, 710). However, unlike previous studies, the current studyemployed movements common to ADL, with resistanceprovided by the subjects body weight. Given the natureof the circuit (e.g., directional changes, obstacles) and thetime limit imposed at each station, we speculate that aprogressive overload was produced that manifested itsel

as improved mobility.Standing reach, a field measure of stability and fall

risk, improved 12.9%. This improvement may be a product of the dynamic nature of the training regimen. A dy-namic exercise intervention in the form of agility trainingwas employed in a recent investigation by Liu-Ambroseet al. (11). Using body sway as a measure of fall riskthese authors reported a 29.6 and 30.6% reduction insway following agility and resistance training. Given thatthere was no significant difference in body sway followingagility or resistance training, it could be argued that themore functionally based agility exercise is at least as goodas traditional resistance exercise at reducing the risk o


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TABLE 1. Changes in mobility and perceived health following 12 weeks of functional exercise (mean SD).

Variable Test 1 Test 2 % change Significance

Get up and goSit to standStanding reach (m)Timed walkSit and reach (m)

7.92 2.10.78 0.65

0.3432 0.087.5 1.8

0.248 0.14

7.25 2.00.74 1.5

0.386 0.068.1 2.2

0.289 0.13

8.45.1

12.97.4

14.0

0.000*0.8160.000*0.0060.000*

Physical functioningRole physicalPainGeneral health

Vitality

66.5 23.267.2 38.666.8 21.168.9 18.657.5 21.4

72.7 20.773.9 34.973.2 20.970.1 17.263.5 20.0

8.59.08.71.79.4

0.001*0.1100.001*0.4520.001*

Social functioningRole emotionalMental healthFalls

85.3 19.479.2 35.276.0 15.30.18 0.64

90.0 17.083.1 30.379.5 16.20.08 0.30

5.24.74.4

55.5

0.0060.2520.0080.131

Emergency department visitsHospitalizationsDoctor visitsNumber of medications

0.11 0.340.08 0.271.34 1.13.87 2.6

0.03 0.180.01 0.090.91 0.873.68 2.8

72.787.532.0

4.9

0.0380.0060.000*0.110

*p 0.002.

falling in older subjects. Using another form of dynamicexercise, Tai Chi, Wolf et al. (20) found that Tai Chi train-ing reduced the risk of multiple falls by 47% compared tothose of an education group. We would suggest that thefunctional exercise circuit employed in this study wassimilar to the aforementioned dynamic training interven-tions. Assuming as much, a functional or dynamic ap-proach may activate the centers for postural control (i.e.,somatosensory, vestibular, visual) (15) with the synapticplasticity occurring in the postural control centers as afunction of repetition and learning (18). Speculatively, anadditional benefit of the functional exercise circuit wastask complexity. That is, the required movement patternswere not always easy to remember or easy to produce.Hence, the functional exercise circuit represented a con-tinuum of perceptual, cognitive, and action challengesthat, over time, may have affected cognitive and cerebel-lum function as well (16).

The improved sit-and-reach performance was not un-expected. Again, given the dynamic nature of the exer-cise, including level changes and both static and dynamicmovements, improved hip and lower-back flexion was ex-pected and consistent with the findings of other studiesin which flexibility was targeted through specific exercis-es (2).

Perceptions of physical functioning, pain, and vitalitywere all significantly improved following training. As faras physical functioning is concerned, there appears to bea relationship between function and mobility, particularly

walking speed (3). Therefore, it is logical to conclude thatimproved mobility was associated with a high degree ofphysical functioning. Similarly, subjects in this study ap-peared to perceive less pain and feel more vital following12 weeks of exposure to a functional exercise circuit. Fi-nally, a reduction in the number of doctor visits wouldseem to go hand in hand with improved mobility as wellas a reduction in pain and a feeling of more vitality. Otherinvestigators have reported that older adults who reporta high level of physical functioning also perceived them-selves as being healthy (21). Hence, such subjects are lessapt to make scheduled visits to their doctor.

This study offers support for using a functional exer-

cise circuit as a safe and cost-effective alternative to tra-ditional exercise interventions for older adults. Subjectsdid appear to derive both functional and perceived healthbenefits from their participation in the functional exercisecircuit. Clearly, these finding must be interpreted withcaution. Without an experimental investigation, we maynot conclude a cause-and-effect relationship. However,considering the adherence rate of 83% and the fact thatno subjects sustained injury during the course of thestudy, the functional exercise circuit did appear to besuitable for older adults. Future investigations should fo-cus on comparing a traditional exercise intervention withthe functional exercise circuit.

PRACTICALAPPLICATIONS

A practitioner may find that a functional exercise circuitcan be both challenging and beneficial for an elderly sub-ject wishing to improve physical functioning and mobility.In addition, because the functional exercise circuit in-cludes a series of movement patterns that must be pro-duced under varying conditions (i.e., space negotiations,directional changes, level changes), the subject is affordedcognitive stimulation. Still, it is unclear at this timewhether better results could be expected from a function-al exercise circuit like the one employed here when com-pared to traditional exercise interventions. Nevertheless,considering that none of the subjects in this study wasinjured and that the participation is both time- and cost-effective, it seems logical to consider a functional exercisecircuit an alternative form of exercise for older adults.

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Acknowledgments

This study was supported by a grant from the QuantumFoundation, Inc., West Palm Beach, Florida.

Address correspondence to Dr. Michael [email protected].

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