National physical activity recommendations for older Australians: Discussion Document

8.2 Types of physical activity

The National Ageing Research Institute was commissioned by The Department of Health and Ageing to review the evidence and develop physical activity recommendations for older people.

Page last updated: 01 February 2011

Physical activity encompasses exercise and incidental activity. Activities for older people can be broadly categorised as i) aerobic, endurance, ii) resistance or iii) mobility promoting and balance. A wide range of activities has been trialled with older people, from aquarobics through to yoga. The current guidelines recommend integration of physical activity into everyday life. Encouraging more ‘incidental activity’ is an approach that appears well suited to older people, who may prefer this to structured exercise programs (Dunn, Marcus et al. 1999). The following sections provide an overview of the different types of physical activity. The current consensus amongst physical activity experts is that a multidimensional program that includes all types of physical activity is optimal for functional and health benefits for older people in general (Cress, Buchner et al. 2005). Programs often employ multi-purpose exercises. There is a degree of specificity in some of the health benefits associated with particular types of physical activities. For example, it appears that physical activities with a balance component are more likely to improve balance and decrease falls, relative to other types of physical activity (Province, Hadley et al. 1995). Where a particular health outcome is required, a more specific program of exercises may be implemented. Each of the types of physical activity described below may be undertaken as:

  • structured activities such as strength training, tai chi or other group exercise activities, walking groups, hydrotherapy classes (exercise in water) and yoga. Many of these activities can be done in a group setting, or can be done alone at home;
  • leisure pursuits that involve physical activity, including golf, lawn bowls, bocce, and various types of dancing (for example, ballroom dancing, line dancing);
  • incidental activity, which includes all the routine activities which can be performed as part of everyday lifestyle, that are of a moderate intensity, for example housework, walking to the local shop instead of driving, gardening and raking leaves, and vacuuming;
  • supervised physical activity (for example, supervised by a physiotherapist or exercise physiologist), which may be of benefit for older people with moderate health problems, at least when starting out. Examples of older people who may benefit from supervision at least when commencing physical activities are those with heart problems, including following heart surgery; people with neurological problems such as stroke and Parkinson’s disease; people with moderately severe arthritis; and those with high risk of falls.

Chapter 9 provides examples of physical activity options that have been successful with different groups of older people.

Table 8.2 Illustrative Components of Fitness and Physical Activity Programs.
Lifestyle/IncidentalEndurance2StrengthFlexibilityBalance
Frequency (days/wk)5 – 75 – 72 – 32 – 31 – 7
IntensityModerate12 – 14 RPE, somewhat hard; 40 – 60% estimated HrmaxResistance to movement that overloads with greater resistance has a greater effect.To point of resistance or mild discomfort.Progress difficulty by decreasing support as competence increases.
VolumeAt least 30 min accumulated in bouts of 10 min or longerAt least 30 min2-3 sets, 10-12 repetitions; 4 upper (biceps, shoulder flexion, chest press, back row) and 4 lower body (hamstrings, quadriceps, leg press, calves).10-30s, progressing longer if desired. Repeat 3-4 times for each stretch. Areas to include: chest, neck ROM; hands, triceps, hamstrings, quadriceps, and hip flexors; calf soleus, gastrocnemius.Dynamic, focus on mobility; static, focus on 1-leg stance. 4-10 different exercises are available.
Special instructionsIncorporated into or added to the endurance volume for long-term adherence.Weight bearing encouraged. Increase duration (≥ 30 min) before increasing intensity up to moderate.Sets separated by 1 min, sessions separated by 1 day. Options: free weights, machines, elastic resistance bands, and callisthenics.No bouncing. PNF technique. Incorporate into lifestyle, e.g., gardening and putting away dishes on high and low shelves.Incorporate into lifestyle, e.g., balance exercise while standing in line, performing other tasks. Environmental safety important.

Note. HR = heart rate; ROM = range of motion; PNF – proprioceptive neuromuscular facilitation; RM = repetition maximum; RPE = rate of perceived exertion.

Source: Cress et al., 2005

2 For selected older adults for whom vigorous exercise is appropriate and desired, the guideline for vigorous activity is at least 20 min 3 times/week (U.S. Department of Health and Human Services, 1996)

Aerobic, endurance exercise

Aerobic or endurance exercise is defined as continuous movement involving large muscle groups that is sustained for a minimum of 10 minutes (Pate, Pratt et al. 1995). Aerobic activity such as cycling, swimming and walking has featured in a range of physical activity programs for older people. Household activities such as mowing lawns, cleaning floors and washing windows can also be classified as aerobic activities. Progression can be monitored by measuring exertion using a tool such as the Borg Rating of Perceived Exertion scale (Borg 1970) or by simply reducing intensity level when it becomes difficult to talk during the activity (although this test has limitations in those with respiratory impairments). Aerobic exercise may be unsuitable for some older people, for example where there are many comorbidities, or some unstable cardiovascular disorders such as recent myocardial infarction, unstable angina, uncontrolled arrythmias, third degree heart block and acute congestive heart failure (American College of Sports Medicine 1998).
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Progressive resistance training

Progressive resistance training (PRT) offers an alternative form of physical activity for older people. It has been particularly successful in ameliorating muscle weakness in older people. A decrease in muscle mass and muscle strength is a function of the ageing process, but can be exacerbated by chronic health problems. The weakness contributes to falls and fracture risk and overall disability. There has been substantial research into whether PRT can improve muscle strength and physiological function. An early trial in a sample of frail older nursing home residents achieved significant improvements in muscle strength, gait, and habitual activity level (Fiatarone, O Neill et al. 1994). The improved muscle strength findings in this seminal research have subsequently been confirmed in several other studies (Mihalko 1996, McMurdo 1994, Brill 1998). The evidence for strength training was recently reviewed by an Australian group (Dodd, Taylor et al. 2004) who identified 50 RCTs. A Cochrane review (Latham, Anderson et al. 2003) of PRT for physical disability contained 31 RCTs. Cyarto et al’s update (2004) identified four further papers and in our search we identified 2 recent papers. The interventions were largely held at external venues, although three were home based. Programs lasted from two weeks to two years.

The reported gains in muscle strength obtained via PRT can impact positively upon functional capacity, improving overall health. However, the evidence for functional health benefits from PRT is more equivocal, partly due to methodological weaknesses. In their review, Barry and Carson (2004) argue that the tasks undertaken in resistance training for older people need to closely match the functional tasks intended to be improved in the older person. The physiological arguments they forward are beyond the scope of this document. In general, due to reduced neuromuscular plasticity in older people, the physical skills learnt are not as generally transferable as in younger people. For functional health gains then, these authors argue that intensity is probably less important than frequency, so that muscles get used to working in a particular way. Intensity is more important for strength gains, so for tasks that particularly need strength, the dosage will be also be of relevance.

There are encouraging trends for balance, gait and ADL outcomes using PRT. Jette’s and colleague’s (1999) home based PRT trial involved 3 sessions/week with Therabands™ over 6 months. The program had good adherence (89%) and clinically significant improvements in leg strength, tandem gait and disability at six months. Simons and Andel (2006) trialled PRT in older people living in supported residential accommodation. Their mean age was 83.5 years and only five of the 64 participants were less than 75 years old. Compared to a control group, significant improvements in upper and lower body strength were reported, plus agility, balance and coordination. Few studies have focused on PRT’s impact on quality of life or disability outcomes, but the results have generally been favourable (Latham, Anderson et al. 2003). Further research is needed to extend this evidence base.

We have some evidence that physical activity intensity influences the outcome achieved with PRT programs. A small trial using PRT indicated that high intensity training was needed to optimise strength, power and functional gains in older men (Fatouros, Kambas et al. 2005). The authors reported that the higher intensity program aided maintenance of the benefits over time, whereas they disappeared with the lower intensity program. Nevertheless, lower intensity training produced strength gains that were maintained for 4 -8 months. Where this is the desired outcome, a lower intensity program may suffice. Intensity has also been shown to influence mental health outcomes. For depression management, higher intensity PRT may be necessary. For example, Singh et al. found a 50% reduction in depressive symptoms in most (61%) of their high intensity group (Singh, Stavrinos et al. 2005) (Rf Chapter 9) whereas the reduction in the lower intensity group was much smaller (29%). In contrast, both high intensity and variable intensity PRT were found to improve measures of mood amongst sedentary, healthy older people (McLafferty, Wetzstein et al. 2004). There were also gains in strength and lean body mass.

Whilst many PRT programs have included healthy older people, benefits have also been seen for those with chronic disease (e.g. osteoarthritis and chronic heart failure) and disability (Latham, Anderson et al. 2005).
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Mobility promoting and balance exercises

Balance is the ability to maintain control of the body over the base of support so as to avoid falling (Cress, Buchner et al. 2005). Most of the evidence regarding balance programs comes from the falls prevention literature in the community setting. Some studies have used specific balance activities, although improvements in muscle strength and endurance can also improve balance. In a meta-analysis of the Frailty and Injuries: Cooperative Studies of Intervention Techniques, only those programs that incorporated a balance component were shown to reduce falls (Province, Hadley et al. 1995). More recently, a number of different approaches have been used to improve balance and reduce falls, including home exercise programs (Campbell, Robertson et al. 1997; Robertson, Campbell et al. 2002), group exercise programs (Day, Fildes et al. 2002; Barnett, Smith et al. 2003; Lord, Castell et al. 2003) and Tai Chi (Wolf, Barnhart et al. 1996; Li, Harmer et al. 2005). In all instances, these programs also incorporated some level of balance activity. These programs have usually resulted in improved balance, strength, gait and function, in addition to reducing falls.

Tai Chi is a form of physical activity that involves balance, strength, coordination, and flexibility. Tai Chi is becoming a more popular form of physical activity in Australia. There are a number of different types of Tai Chi, including variations in terms of the individual styles, the number of forms (movements) learnt, and the degree of physical difficulty involved. Tai Chi for Arthritis is a modified form of Tai Chi which appears more suitable for older people with arthritis and other health problems, which has been shown to improve balance and function (Song, Lee et al. 2003). Several reviews have reported on the effectiveness of various styles of Tai Chi in improving leg strength, trunk flexibility and static standing balance (cardiovascular fitness, pain and mood benefits have also been noted) (Li, Hong et al. 2001; Wu 2002). The generalisability of the findings is limited: most samples have been healthy older people and most of the research has been observational or quasi-experimental in design.

Other forms of physical activity that incorporate balance and mobility (eg dancing, yoga, lawn bowls, golf) may also achieve positive health outcomes, although there have been few randomised trials, particularly with older people, evaluating these approaches.

Decreased flexibility is involved in the aetiology of a range of physical impairments. Loss of flexibility occurs as we age, although to date no causal relationships have been determined. Degenerative changes are exacerbated by disuse and the development of osteoarthritis, osteoporosis and atherosclerosis. Age related changes in musculoskeletal tissue and increased incidence of joint pathology can negatively affect joint extensibility and stiffness. Flexibility exercises have been recommended to be performed at least twice a week, as unique exercises or as part of a physical activity program (Cress, Buchner et al. 2005). Overall, physical activity interventions emphasising flexibility have demonstrated positive effects on older people’s range of movement (ROM) and physical function, even in frail older people (McMurdo and Rennie 1993). A review of flexibility and physical function in older people noted the paucity of evidence about specific or general physical activity programs to improve joint flexibility (Holland, Tanaka et al. 2002). The authors provide an overview of the evidence, focusing on the range of motion (ROM) outcomes documented. In a physical activity calisthenics trial to influence spinal and knee flexion and knee extension ROM, no changes were seen for knee ROM, but spinal flexion improved by 7%, a clinically significant change. In a small RCT, supervised flexibility exercises three times a week for 10 weeks produced significant spinal flexion (25%) and extension (40%) improvements, compared to in the control group (Rider and Daly 1991). One additional benefit of stretching and flexibility exercises that has been reported is an improvement in pain (King, Pruitt et al. 2000), a symptom that impacts on many older people and clearly influences quality of life. The unique impact of this particular type of training cannot be readily established, since most programs use stretching as part of their warm-up and cool-down phases. However, more research of this nature is needed, using specific flexibility training protocols.

Summary

All three broad categories of activity - aerobic, resistance and mobility/balance - have demonstrated health benefits (Hillsdon, Foster et al. 2005) and can be promoted amongst older people. While much of the research evidence regarding health benefits relates to older people living at home, a small but growing research base indicates benefits can be achieved in frailer older people living at home or in residential care. Interventions to increase physical activity have varied in the amount of activity given and the duration of follow-up. Future research is needed to elucidate the types, frequency and intensity of exercises that provide optimal benefit.
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