National physical activity recommendations for older Australians: Discussion Document

9.3 Disability

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 disability can occur at any age and has a multidimensional aetiology. Amongst older people, physical disability has been reviewed from several perspectives. For example, in their review, Latham and colleagues (2005) concentrated on the decline in muscle strength with ageing as a source of physical disability. Their review thus sought to determine whether progressive resistance training (PRT), as a single exercise intervention, reduces physical disability in older people. Measures of physical disability included measures of daily activities and measures of physical domains of health-related quality of life.

Whilst there is clear evidence that physical activity creates physical health and function improvements for older people, the current evidence base does not provide strong support for physical activity as a means of reducing disability across its domains. Nor does it indicate that physical activity can assist in the restoration of capacity in disabled people: rather it can prevent exacerbation of problems (Latham, Anderson et al. 2003).

A review of the outcomes associated with physical, social, emotional and overall disability was conducted by Keysor and Jette (2001). With the exception of osteoarthritis, they excluded people with pre -existing conditions, which has implications for their findings. With regard to impairment, the majority of studies assessed strength (23/26) and showed that physical activity participants improved strength compared with controls. Similar proportions of positive findings were reported for studies assessing aerobic capacity and flexibility. Functional limitation studies commonly reported walking and standing balance improvements. This in part reflects the common use of these as outcome measures. The findings for other physical, social, emotional and overall disability outcomes were limited in scope (obtained from far fewer studies) and equivocal. For example, only five out of 14 studies assessing physical disability reported improvements, with effect sizes ranging from 0.23 to 0.88. The largest effect size was found by Kovar et al. (1992) in a trial of 40-89 year olds (mean age 69 years) with osteoarthritis. Mueleman et al. (2000) only found a positive effect amongst those with greater disability.

Neurological disorders contribute to disability and participation restriction in older people. They can be categorised as a) event related, such as stroke, and b) progressive, such as Parkinson’s disease, multiple sclerosis and post-polio syndrome. Improved survival means that more people are entering old age with these conditions. The implications of neurological disorders for older people’s health require consideration, and there is limited but growing evidence concerning the potential benefits of physical activity for people with these conditions. Common symptoms that may be ameliorated by physical activity training are gait and balance impairments, function, and fatigue. In a commentary review of studies including both adults and children (Eldar and Marincek 2000) concluded that there was insufficient evidence to support promotion of physical activity for those with Parkinson’s disease and Guillain-Barre syndrome. A review of physical therapy for Parkinson’s disease, which primarily included exercise interventions, identified benefits in function and gait (de Goede, Keus et al. 2001).
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In stroke patients, aerobic exercise training (Pang, Eng et al. 2006), and task oriented exercise training targeting balance and gait have both been shown to improve functional and mobility related outcomes relative to standard rehabilitation / usual care, particularly in the earlier stages after stroke (van Peppen, Kwakkel et al. 2004). There is some level IV evidence from small studies that indicates that physical activity - walking, swimming and cycle ergometry - is useful for producing functional gains in stroke survivors, at later stages post stroke. The reviewers noted that whilst stroke rehabilitation is effective in promoting functional status, physical deconditioning may not be addressed. A systematic review of PRT following stroke reported some reduction in musculoskeletal impairment, but noted that there was insufficient evidence to date regarding improved performance of functional activities or social participation (Morris, Dodd et al. 2004). Further, gains made during rehabilitation are lost if people have a sedentary lifestyle on discharge. There has been limited trialling of home-based programs for people discharged from hospital, with short term benefits to neurological impairment and lower extremity function (Duncan, Richards et al. 1998). More community and home-based interventions to promote continued physical activity are needed.

Limited level II and IV evidence indicated that people with multiple sclerosis and post-polio syndrome have functional gains, but none of the studies included those over 65 years. The review identified only three studies of physical activity for adults with disabilities: chronic low back pain, chronic obstructive pulmonary disease (COPD) and osteoarthritis. No studies were found for para-or quadriplegia, mental retardation, multiple sclerosis or poliomyelitis. Sutherland and Anderson (2001) reviewed several controlled trials of aerobic exercise in multiple sclerosis and found some improvements in cardiovascular fitness. A small trial of yoga and cycling exercise for adults (mean age 48 years) with multiple sclerosis reported reductions in fatigue after 6 months of weekly classes and home practice (Oken, Kishiyama et al. 2004). No significant changes for cognitive outcomes such as attention, nor for mood state were attained.

Keysor and Jette noted the methodological limitations of existing studies and comment on the theoretical limitations of the biomedical disability model commonly underpinning existing studies (Keysor and Jette 2001). There is a need for contextual, behavioural and social factors to be considered when assessing the uptake of physical activity in older people. Future trials need to address an individual’s beliefs and self efficacy and the influences of the person’s physical and social environment. Outcome measures need to closely reflect the area of disability and participation restriction (handicap) that the intervention is intended to affect.

To quote Taylor et al:
‘In intervention studies, the basic challenges are a theoretical framework, valid and reliable measures, a strong experimental design, an effective intervention and minimum attrition. In all of these areas, physical activity interventions in… populations with disabilities require more rigorous development and study’ (Taylor, Baranowski et al. 1998)(pg 341).
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