A Novel Exercise Initiative for Seniors to Improve Balance and Physical Function

Abstract

Objective: To investigate the feasibility, effectiveness, and short-term effects of an exercise intervention using a novel exercise park in improving seniors’ balance, physical function, and quality of life. Method: Randomized controlled trial with pre- and post-intervention design (baseline and 18-week intervention) was used. Outcome measures included measures of balance, strength, and function, as well as quality of life and fear of falling. MANCOVA was used to assess differences between groups (control and exercise intervention) over time. Results: Intervention group showed significant improvement on single leg stance (p = .02, 95% confidence interval [CI] = [−8.35, −0.549]), knee strength (p < .01, 95% CI = [−29.14, −5.86]), 2-min walk (p = 0.02, 95% CI = [−19.13, −0.859]), and timed sit to stand (p = .03, 95% CI = [−2.26, −0.143]) tests. Discussion: The exercise park program improved physical function and had high adherence and participation rate. Such intervention has been shown to be safe and therefore might enhance participation in exercise programs for older adults.

Keywords

balance physical function exercise exercise adherence sustained participation

Introduction

Preventing falls, improving muscle strength, balance, and physical function among older adults are key public health priorities. Falls are significantly associated with reduction in quality of life of older adults as well as functional decline (Granacher, Muehlbauer, Gollhofer, Kressig, & Zahner, 2011), with 30% to 35% of older people living in the community and aged above 65 years falling at least once a year (Granacher et al., 2011). After having a fall or being fearful of falling, older people tend to develop depression, anxiety, reduce social contact, decrease activity and mobility, increase use of medications, and lose independence and autonomy in their lives (Yardley, Donovan-Hall, Francis, & Todd, 2006). These factors may also be responsible for affecting daily functioning in older adults by promoting further reductions in muscle strength, balance, and gait speed (Van Kan et al., 2009).

Randomized controlled trials focusing on reducing the risk factors of falls, falls prevention, and improvement of muscle strength, balance, and mobility in older adults have shown that exercise interventions slow down functional losses expected with increased age (Paterson, Jones, & Rice, 2007). Consequently, exercise interventions are able to improve quality of life and maintain functional independence in older adults (Paterson et al., 2007). However, participation in these exercise or falls prevention interventions are rather low (Yardley et al., 2006), suggesting that older people may be reluctant to participate, or do not feel that interventions are sufficiently appealing or beneficial for them to take part in.

To increase exercise participation and adherence for older adults in a community setting, a unique purpose-built outdoor exercise park was designed to provide a fun but still physically challenging environment for older adults (https://www.youtube.com/watch?v=lO6jz_w5vcg&;feature=youtube). With this novel concept, older adults might feel more inclined to exercise and to adopt a healthier lifestyle given that these playful and purposeful activities are also functional and practical to what they do in their daily living activities (McMahon, Talley, & Wyman, 2011). Furthermore, older adults tend to partake in initiatives that can help them to maintain independence, autonomy, and confidence, and, consequently promoting a more positive self-identity (Evron, Schultz-Larsen, & Fristrup, 2009). The social interaction and support associated with this type of an exercise park could make the sessions more enjoyable given that some older adults show preference to exercise in groups (Yardley et al., 2008). Moreover, exercising outdoors has been shown to contribute to significant improvements in mood, self-esteem, and reduce levels of depression among older adults (Barton, Griffin, & Pretty, 2012). Therefore, the aims of this study were to investigate the feasibility, and short-term effectiveness of an exercise intervention using a novel outdoor exercise park designed for seniors in improving their balance, physical function, and quality of life.

Method and Design

The full description of this study’s methods, design, randomization process, exercises, and tests performed can be found on the full trial protocol previously published (Sales, Polman, Hill, Karaharju-Huisman, & Levinger, 2015).

Design

This study was a parallel randomized controlled trial with pre- and post-intervention design (outcome assessments at baseline and at 18 weeks after participation commencement, and number of falls measured over a 12-month period from enrolment in this study) comparing two groups: an exercise park intervention program (EPIG) for older people and a control group (CG).

Participants

One hundred twenty community-dwelling people aged between 60 and 90 years were sought via community health promotion events and advertisement in local newspapers, magazines, and online social networking media. Participants were also from diverse settings such as local senior organizations, retirement villages, community centers, senior clubs, and associations in Melbourne.

Inclusion and Exclusion Criteria

Older adults who had one or more falls in the previous 12 months or who were concerned about having a fall were recruited for this study. Volunteers who were generally active and independent in the community with no more than a single point stick used for regular outdoors walking (at least three times per week) were included. More details about inclusion and exclusion criteria are detailed on the study protocol (Sales et al., 2015).

Randomization

Participants were randomly allocated to one of the following groups: (a) exercise park intervention group (EPIG) or (b) control (CG). Assessors and participants were not blind to their respective group allocation (EPIG or CG). Block randomization stratification by gender using opaque envelopes was undertaken, so that blocks of 12 participants (six for intervention group and six for CG) were randomized at a time. To accommodate couples (e.g., partners/married couples) participation, randomization by couple also took place.

Participants from the EPIG underwent an 18-week exercise intervention with no cost to the participants. Participants in the CG were advised to continue with their usual daily activities and met the research team every 2 weeks to take part in some social activities (nine meetings of 2-hr duration over 18 weeks of participation).

Treatment/Group Preference

Each participant’s group preference was documented (i.e., as CG, exercise intervention group, or no preference) to identify whether differences exist between those who received their preferred allocation and those who did not.

Study Protocol

All participants were fully informed about the nature of the study and signed a consent form. This study was approved by the Human Research Ethics Committee of Victoria University, Melbourne (Application ID HRE13-215). The study was designed according to the Consolidated Standard of Reporting Trials (CONSORT) guidelines and publications associated with the trial were reported according the CONSORT 2010 Statement (Moher et al., 2010; Schulz, Altman, & Moher, 2010).

Measures

Sociodemographic factors (such as age and gender), medical conditions, medications currently prescribed, past history of surgeries and medical procedures, smoking habits, as well as alcohol consumption were obtained via a structured questionnaire. Anthropometry measures including body weight and height were measured using digital scales and a stadiometer, respectively, and body mass index was calculated (weight [kg] / height² [m²]).

Primary Outcome: The Balance Outcome Measure for Elder Rehabilitation (BOOMER)

The BOOMER battery test was used as the primary outcome to assess the effectiveness of the novel purpose-built exercise park in improving balance. This test is a multi-item balance measure, which comprises four well-validated clinical measures: step test (Hill, Bernhardt, McGann, Maltese, & Berkovits, 1996), timed up and go (TUG; Shumway-Cook, Brauer, & Woollacott, 2000), functional reach (FRT; Duncan, Weiner, Chandler, & Studenski, 1990), and static standing balance (Anacker & Di Fabio, 1992; Kuys, Morrison, Bew, Clarke, & Haines, 2011).

Secondary Measures—Strength and Physical Function

The following secondary measures were used to assess balance, muscle strength, mobility, and physical function in older adults. The single leg stance test standing on the dominant leg with eyes open was used to measure static balance (Springer, Marin, Cyhan, Roberts, & Gill, 2007). The average hand grip strength of both hands using a TTM digital hand dynamometer (Mentone Educational Centre, Melbourne, Victoria, Australia; Tromp et al., 2001) was taken to measure physical strength. The 2-min walk test was used to assess exercise tolerance (Butland, Pang, Gross, Woodcock, & Geddes, 1982) and functional mobility (Gijbels, Eijnde, & Feys, 2011).

Lower limb strength was assessed via the 30-s sit-to-stand test (Csuka & McCarty, 1985) and measurement of the strength of the knee extensor muscles using a purposely built force transducer (Lord, Menz, & Tiedemann, 2003). Finally, the assessment of gait speed was performed with the use of the GaitRite® system (CIR System, Inc., Harverton, PA) instrumented walkway system.

Secondary Measures—Feasibility

Feasibility was defined as the number of participants recruited and retained over the recruitment period, overall attendance and seasonal attendance, safety and adverse effects. Overall attendance to the exercise program was defined by the number of sessions attended: 100% attendance if an EPIG participant attended 35 sessions. EPIG participants’ participation and attendance was recorded via a spreadsheet diary and was collected, respectively, by the exercise supervisor of that participant on each specific session or by the principal researcher.

Seasonal adherence was recorded as adherence over summer (December to end of February), fall (March to end of May), winter (June to end of August), and spring (September to end of November). Also, the number of sessions that were canceled due to rainy, windy, and excessively hot days (above 37 °C) were recorded given that these conditions potentially put participant’s safety and health at risk. Safety and adverse effects were measured by the number of fall incidents during exercise sessions and muscle/joint injuries or strains reported after undertaking the exercise session.

Secondary Outcomes—Health-Related Quality of Life and Psychological Measures

The Short Form (12) Health Survey Version 2 (SF-12v2™) was used to evaluate the individual health status (Ware, Kosinski, & Keller, 1996). Physical Composite Scores and Mental Health Composite Scores (PCSs and MCSs) were computed using the scores of 12 questions and range from 0 to 100, where a zero score indicates the lowest level of health measured by the scales and 100 indicates the highest level of health (Ware et al., 1996).

The Short Falls Efficacy Scale–International (Short FES-I) questionnaire was used to record fear of falling (Kempen et al., 2008). The total score ranges from 7 (not concerned) to 28 (severe concern) where higher scores are associated to a greater fear of falling (Kempen et al., 2008).

Secondary Measures—Physical Activity and Number of Falls Over 12 Months

Physical activity calendars were used to monitor whether EPIG or CG participants have participated in any other physical activities during their participation in the study and to monitor whether the participants had falls over the 12 months from commencing involvement in the project. Calendars were returned using pre-paid envelopes and participants were followed up with a phone call in the cases their calendars were not returned within 2 weeks of the end of each month.

The Exercise Park Intervention Program

The senior exercise park used in this project was provided in-kind by Lappset (Lappset Group Ltd., Rovaniemi, Finland; Figure 1) and was installed at St Bernadette’s Community Respite House in Sunshine North, Victoria, Australia. The exercise park consists of a number of components and stations that aim to work on the following aspects of physical performance: upper body mobility and fine motor skills, balance and coordination, lower limb and upper limb strength, stretching and flexibility (as detailed in this study protocol; Sales et al., 2015). The exercise sessions were provided two times a week (each class approximately 1-1.5 hr duration) and were supervised by an accredited exercise physiologist. Each session consisted of 5 to 10 min of warm-up exercises, followed by 45 to 75 min on the equipment stations, and concluded with 5 to 10 min of cool-down exercises. The exercise classes contained a maximum of six participants and were circuit based with the warm-up and cool-down exercises being performed in a group and the core part of the session being carried out in training pairs. Exercisers were paired in stations and an exercise session could include up to eight stations (Table 1).

Figure 1.

Lappset’s exercise park for senior population.

Table 1.

Exercise Stations.

Station number	Exercise 1	Exercise 2
1	Push-ups	Taps on platform
2	Modified pull-ups	Gangway
3	Balance stool	Calf raises + Finger steps
4	Sit to stand	Round snake pipe
5	Ramp + Net + Climb through	Sharp snake pipe
6	Balance beam	Hip extension
7	Steps	Screws/turners
8	Step-ups	Hip abduction

Data Management and Statistical Analysis

Power analysis was undertaken using previously published discharge data on the primary outcome measure—the BOOMER measure (Kuys et al., 2011), and assuming an improvement of 3 points (reported as the minimum detectable difference; Kuys et al., 2011) and an effect size of 0.5. A sample size of 48 participants per group would be required for a power of 0.80 and alpha of .05. A 20% dropout rate was anticipated based on previous exercise programs with older people. Therefore, this study aimed to recruit 60 participants per group.

All analyses were completed using SPSS version 22.0 and a p value less than .05 was considered statistically significant. Effect size (η_p²) from SPSS was used to determine effect size as follows: η_p² value greater than 0.14 was considered a large and significant effect size whereas 0.01 and 0.06 were considered small and medium, respectively (Cohen, 1988). For the primary outcome, the BOOMER test, repeated measures ANCOVA univariate analysis was performed to examine the difference between groups (baseline vs. 18-week assessment) and between groups over time (group by time interaction) while controlling for age. Repeated measures ANCOVA were performed to evaluate the differences between groups (baseline vs. 18-week assessment) and between groups over time on the individual components of BOOMER test, on the secondary physiological and quality of life and psychological outcomes. Ninety-five percent confidence interval (95% CI) was calculated for the differences between the two groups over time. Age was included as a covariate given the decline of many physiological functions, which occurs with increasing age (Whitbourne, 2012). Prior to the conduct of the main analysis, data were grouped based on group preference (preferred and non-preferred group) and analyzed to identify any possible effect of group allocation preference on the outcomes.

A mixed modeling analysis and the associated intention-to-treat approach were not used in the present study due to the following reasons: (a) for some participants, only one data point was available beyond baseline due to missing data (dropout); and (b) a disproportionately high number of participant dropouts from the CG as a result of not being allocated to the exercise intervention group. Furthermore, there is no adequate recommendation for replacement of missing values greater than 20% (Unnebrink & Windeler, 2001) and imputation of values for the missing data in similar cases to this study (dropout >10%) is likely to produce biased estimates of treatment effect (Simons-Morton, Obarzanek, & Cutler, 2006). Therefore, a “per protocol” approach has been used in the analysis of the data. By using per protocol analysis, the risk of having the treatment effect underestimated or overestimated due to missing data is reduced (Baron, Boutron, Giraudeau, & Ravaud, 2005), which will allow a more accurate representation of the actual effectiveness of the present exercise intervention (Armijo-Olivo, Warren, & Magee, 2009). Similarly, only the data of participants assigned to the exercise intervention who actually received, complied with, and completed the treatment have been used (Armijo-Olivo et al., 2009). As it has been previously showed that older adults need to attend exercise programs at least once weekly to achieve muscle strength gains and improve neuromuscular performance (Taaffe, Duret, Wheeler, & Marcus, 1999), participants from EPIG who did not comply with the exercise intervention and failed to attend at least one session per week (i.e., total attendance less than 50%) were excluded from the statistical analysis.

Results

Sixty-two older people (M age = 71.4 ± 6.7 years; 44 females, 18 males) living in the community volunteered to be part in the study. Challenges with recruitment meant that this final sample of 62 older people was lower than planned. More than 60% of participants of both groups had a history of at least one fall in the last 12 months. The mean age of participants in both groups was 70.2 years ± 8.2 and 75.1 years ± 7.9 for CG and EPIG, respectively, with the majority of participants being females (77% and 64% in CG and EPIG, respectively). Participants’ characteristics are provided in Table 2. No significant differences were observed at baseline between the two groups. Seventy percent of the total dropout from the CG was due to participants not being allocated to the EPIG, further details about dropout and exclusion are provided in Figure 2. Table 3 provides information about the primary and secondary outcome measures.

Table 2.

General Characteristics of the Participants of This Study.

Characteristic	Control group (n = 21)	Exercise intervention group (n = 27)
Age (years)	70.2 ± 8.2	75.1 ± 7.9
Gender (females, %)	77	64
BMI (kg/m²)	28.1 ± 5.0	28.9 ± 5.3
Current smoker (%)	6	3
Ex-smoker (%)	29	42
Daily alcohol consumption (%)	52	41
Average number of medications	3	3
Previous falls history (≥1 fall, %)	61.9	62.9
Follow-up falls over 12 months (%)	47.6	40.7

Note. BMI = body mass index.

Figure 2.

Consort flow diagram of recruitment and randomization.

Table 3.

Primary and Secondary Outcome Measures Before and After the 18-Week Participation for the CG and EPIG (Values Are M ± SD).

Measure	CG (n = 21)		EPIG (n = 27)		p value group by time interaction (95% CI)	η_p ²	p value between groups
Measure	Pre	Post	Pre	Post	p value group by time interaction (95% CI)	η_p ²	p value between groups
BOOMER—total score (of 16)	13.5 ± 1.7	13.9 ± 1.4	13.6 ± 1.4	13.7 ± 1.3	.6 [−0.354, 0.830]	0.00	.4
Physical measures
Single leg stance (s)	18.7 ± 11.1	16.0 ± 9.2	15.6 ± 11.0	17.3 ± 11.3	<.01* [−8.35, −0.549]	0.11^a	.4
Knee strength (N.m)	83.7 ± 33.1	78.5 ± 33.8	84.2 ± 36.5	96.4 ± 44.4	<.01* [−29.1, −5.86]	0.15^b	.1
Hand grip strength (kg)	20.6 ± 7.2	20.9 ± 7.1	26.3 ± 10.6	26.5 ± 9.6	.4 [−1.52, 1.88]	0.02^c	.01**
2-min walk (m)	149.0 ± 29.5	150.4 ± 22.5	140.6 ± 30.5	152.1 ± 28.7	<.01* [−19.1, −0.859]	0.12^a	.7
TUG fast (s)	7.0 ± 2.0	7.0 ± 1.4	7.4 ± 1.8	7.1 ± 1.4	.6 [−0.315, 0.913]	0.01^c	.8
Sit to stand (reps)	11.0 ± 2.2	11.5 ± 2.5	10.5 ± 3.0	12.1 ± 2.7	<.01* [−2.26, −0.143]	0.10^a	.6
Gait speed (m/s)	1.34 ± 0.20	1.36.5 ± 0.16	1.31 ± 0.19	1.33 ± 0.17	.8 [−6.11, 4.30]	0.00	.8
Fear of falling and quality of life
Short FES-I	11.3 ± 4.0	10.9 ± 3.7	10.3 ± 3.4	9.3 ± 2.5	.4 [−1.10, 2.05]	0.02^c	.1
SF-12-PCS	49.1 ± 7.91	48.9 ± 7.6	46.9 ± 7.56	49.6 ± 8.29	.2 [−7.24, 1.37]	0.03^c	.8
SF-12-MCS	51.4 ± 6.1	51.6 ± 7.9	53.1 ± 9.8	54.5 ± 7.0	.6 [−5.76, 3.22]	0.01	.4

Note. CG = control group; EPIG = exercise park intervention group; TUG = timed up and go; BOOMER = Balance Outcome Measure for Elder Rehabilitation; FES-I = Falls Efficacy Scale–International; SF-12-PCS and SF-12-MCS = Physical and Mental Component scores of the Short Form (12) Health Survey (SF-12), respectively.

Medium effect size.

Large effect size.

Small effect size.

Significant at p < .05 for group by time interaction. **Significant between groups at the follow-up assessment.

Treatment/Group Preference

Ninety-six percent (n = 26) and 43% of participants from the intervention and CG, respectively, received their group preference. The difference between pre- and post-values for all outcome measures (delta change) based on participant preference was calculated and compared. As only one participant from the intervention received their non-preferred group allocation, analysis was conducted only for the CG. Multivariate analysis showed no differences between preferred and non-preferred group allocation (p > .05).

The Exercise Program

All participants allocated to EPIG program performed all exercises as per description on the study protocol (Sales et al., 2015) with minimal adjustment based on individual abilities. All participants were able to perform all exercises as per the study protocol. These exercises were paired up in exercise stations as shown on Table 1. In addition, an average of 35 sessions were run for each group of participants with the objective of reaching 50 hr of cumulative exercise previously suggested to be effective in reduction of falls risks for older adults (Sherrington et al., 2008).

Primary Outcome: BOOMER Test

No significant difference was found between the groups at baseline and after 18-week participation for the BOOMER test or the BOOMER individual components (p > .05). No significant differences were found for the BOOMER test between the groups over time (p = .46, 95% CI = [−0.354, 0.830]; Table 3). The component tests of BOOMER test were also analyzed individually and no significant differences were observed between the groups over time (p > .05).

Secondary Outcomes—Strength and Physical Function

Participants from EPIG showed significant improvement on single leg stance (p = .02, 95% CI = [−8.35, −0.549]), knee strength (p < .01, 95% CI = [−29.14, −5.86]), 2-min walk (p = .02, 95% CI = [−19.13, −0.859]), and timed sit to stand (p = .03, 95% CI = [−2.26, −0.143]) tests following the 18-week intervention compared with the CG (Table 3). A significant difference was found between the groups only for the hand grip strength (p = .01, Table 3). Univariate t test revealed greater strength for the EPIG at the follow-up assessment (p = .04, 95% CI = [−10.39, −0.11]).

Secondary Outcomes—Feasibility

Twenty-seven participants (87%) from EPIG completed the 18-week intervention with mean attendance to the sessions of 79.6%. However, only 14% of participants in the CG attended to the social meetings offered. Summer and autumn were the seasons that demonstrated the highest levels of attendance with participants, respectively, attending 86.1% and 72.7% (Figure 3). Two falls during exercise sessions were reported with two participants. One participant missed the seat during the sit-to-stand exercise and the other lost balance when stepping down from a platform. No injuries or adverse events were reported from these two episodes or during the research trial. Only 9.6% of sessions had to be canceled due to rain. Also, no participants in the exercise intervention group reported experiencing uncomfortable delayed muscle soreness or fatigue post-exercise that limited them from doing their daily tasks.

Figure 3.

Participant’s attendance throughout the different seasons.

Secondary Outcomes—Fear of Falling and Quality of Life

No significant differences were found for fear of falling (Short FES-I, p = .4, 95% CI = [−1.10, 2.05]) and quality of life (SF-12 PCS and MCS, respectively, p = .2, 95% CI = [−7.24, 1.37]; p = .6, 95% CI = [−5.76, 3.22]) between EPIG and CG over time.

Secondary Measures—Number of Falls Over 12 Months

No significant difference was found for the number of falls between EPIG and CG after 12 months (p = .78); although there was a reduction of 35.2% in the number of fallers among EPIG participants (Table 2) and 23.1% among CG participants.

Discussion

Participation in the 18-week exercise program using the purpose-built exercise park resulted in improvement in muscle strength, balance, and physical function in older adults. Furthermore, given the relatively high attendance and retention rates observed among participants allocated to the exercise intervention group and the absence of major adverse events, which could compromise the safety of participants, this novel concept might be a feasible option to improve participation and adherence to exercise programs aiming to reduce falls among older adults.

The importance of balance in preventing falls among older adults is well established (Howe, Rochester, Neil, Skelton, & Ballinger, 2011). As balance is multi-dimensional, the BOOMER, a test battery that incorporates a number of key domains of balance (static and dynamic balance, including measures of stepping, reaching, and turning, that are commonly involved in falls) was used in this present study. Our results showed no significant improvements in the BOOMER test among participants from the intervention group across time. Participants of both groups, at baseline, nearly reached the maximum BOOMER score value of 16 (CG mean = 13.4, EPIG mean = 13.5) and the same was observed when evaluating each component test individually suggesting that only minimal improvement can be achieved. Hence, the lack of improvement could be a reflection of a ceiling effect and that this chosen primary outcome measure may not be sensitive enough to be used on a sample of independent and mostly healthy community-dwelling seniors. Previous research on the BOOMER has only used older adults in geriatric and rehabilitation units (Haines et al., 2007).

Exercise interventions targeting improvement in muscle strength, balance, mobility, agility, and functional tasks have been reported to be effective in reducing risk of falls and the number of falls among older adults (Karlsson, Vonschewelov, Karlsson, Cöster, & Rosengen, 2013). In the present study, significant improvements in knee strength, balance (single leg stance), 2-min walk test and sit to stand were demonstrated following the 18-week exercise intervention with light to moderate but still challenging exercises. A non-significant reduction in the number of falls by 35.2% for the exercise intervention group was also reported, although this sample is underpowered for identifying a significant difference on this outcome. The ability to walk and function is important to reduce disability and promote independent living among older adults (Seidel, Brayne, & Jagger, 2011). Similarly, muscle strength and balance have been reported to be critical elements responsible for maintaining physical function, mobility, and vitality in old age (Haines et al., 2007). Given the prescribed exercises were similar to tasks required in daily life, the functional and translational aspect of the exercises proposed might have contributed to the positive outcome on the physical and mobility measures, which can positively affect confidence and self-efficacy (Lee, Arthur, & Avis, 2008). Interventions that particularly target exercise self-efficacy, perceived exercise enjoyment, confidence, and satisfaction are more prone to promote behavioral change in older adults (Lee et al., 2008). A further investigation with a larger sample size is now needed to evaluate whether using the senior exercise park would also result in reduction in the number of falls among older adults.

Despite the improvements in physical performance and function, no significant improvements in quality of life and falls efficacy were found between the groups of the present study. Participants from both groups were more independent and physically capable with relatively high baseline values for the quality of life measures compared with the reported Australian population aged 70+ (Table 3; Tucker, Adams, & Wilson, 2010). Similarly, although presenting some concern about the possibility of having a fall or a history of fall, current participants of this study showed relatively low fear of falling (Table 3) when compared with the average value expected for older adults between 70 and 80 years (Kempen et al., 2008). Therefore, older people with lower levels of quality of life and with greater fear of falling might result in greater improvement in these domains when accessing the senior exercise park intervention; however, this would require further investigation.

Although exercise has been shown to be an important and effective approach to preventing falls in older people (Sherrington et al., 2008), adherence to exercise programs remains a persistent problem (Chao, Foy, & Farmer, 2000). In this present study, a high retention rate of 87% and attendance rate of 79.6% were reported among participants in the exercise intervention group. The social context and support element of the EPIG program, which participants called “the get-together moment,” provided the sessions with a playful and relaxed atmosphere that probably camouflaged the physical challenge they were facing while exercising throughout different stations. Furthermore, offering physical sessions with high emphasis on social support (e.g., social support provided by exercise classmates and exercise team leader) is a key way to achieve success with the adherence and retention of older adults participating in exercise interventions (Brassington, Atienza, Perczek, DiLorenzo, & King, 2002). The high attendance and adherence observed might also be related to the sessions being run outdoors despite the unpredictability of Melbourne’s weather. Importantly, it has been shown that older adults tend to favor attending outdoor sessions over the indoor sessions (Barton et al., 2012), and that outdoor exercises greatly improve mood in older people (Barton et al., 2012).

Apart from the two minor fall episodes that happened during the exercise session delivery, no adverse events or muscle strains or injuries that needed further medical intervention were reported during the trial. However, it is important to note that participants were working in pairs and had one exercise physiologist closely accompanying and supervising them throughout the entire session. To allow for broader public use of the exercise park, a simplification of the exercise protocol might be required so that older participants would be able to exercise more independently, but safely. In addition, older adults could come and meet an allied health professional at a pre-established frequency (e.g., once a month) to proceed with establishing and progression of their exercise routine.

Limitations

Although this study provides useful information about the effectiveness of an exercise intervention using an outdoor senior exercise park, several limitations are acknowledged. First, we had an overall relatively modest sample size. The BOOMER test battery chosen as the primary outcome was not adequately sensitive to the population group studied. Furthermore, it is believed that the involvement, adherence, and attendance to this project could have been higher if the senior exercise park had been installed in a location accessible by public transport and in a more central suburb of Melbourne. For future trials, location of the exercise park needs to be considered to allow easy access. Moreover, to facilitate the attrition of participants in a CG and to minimize dropout rate (as observed in this study), the CG should be offered some other non-physical activities, which are perceived as meaningful for older people in combination with social activities rather than solely social activities.

Conclusion

The 18-week exercise program using a senior exercise park has been shown to be effective and safe in improving balance, muscle strength, and physical function among older adults, and, therefore, may reduce the risk of falling in older people living in the community. This initiative demonstrated high adherence and participation rate. However, further investigation with a larger sample size is now needed to evaluate whether the exercise park intervention would also be effective in reducing the number of falls among older adults.

Footnotes

Acknowledgements

The authors would like to thank all participants for volunteering to this study, Ms. Caitlin Dodd for assisting in the data collection, Mrs. Tuire Karaharju-Huisman for the conceptual design, and Associate Professor Charles Lawoko for helping with the statistical analyses. We would like to acknowledge Mr. William Kelly from Gateway Social Support Options, Mrs. Sherry-Ann Bailey and Mrs. Brenda Suva from St Bernadette’s Community Respite House—Villa Maria Catholic Homes for help with the logistic of this project at the site, Mr. John McAulay from Villa Maria Catholic Homes for his advice and support with regards to the site landscape and security of the exercise park area and Mr. Harri Makela from Lappset Australia for the advice, installation and maintenance of the exercise park equipment. Finally, we would like to thank Villa Maria Catholic Homes for providing the infrastructure and land for the equipment installation and for Lappset Australia for providing in-kind the exercise park equipment for this project.

Author Contributions

M.S., P.L., K.H., and R.P. participated in the design and conception of the project. M.S. and P.L. were involved in the project management planning and in community organization participation. P.L., R.P., and K.H. obtained the funding. R.P., P.L., and M.S. obtained the ethical approval. All authors have assisted to draft the article and have read and approved the final version.

Authors’ Note

This trial is registered with the Australian New Zealand Clinical Trials Registry—Registry No. ACTRN12614000700639. Data and the statistical code are available on request from the author at pazit.levinger@vu.edu.au.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Gandel Philanthropy.

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