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Physical Exercise and the Prevention of Disability in Activities of Daily Living in Older Persons With Osteoarthritis
Brenda W. J. H. Penninx, PhD;
Stephen P. Messier, PhD;
W. Jack Rejeski, PhD;
Jeff D. Williamson, MD, PhD;
Mauro DiBari, MD, PhD;
Chiara Cavazzini, MD;
William B. Applegate, MD;
Marco Pahor, MD
Arch Intern Med. 2001;161:2309-2316.
ABSTRACT
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Background The prevention of disability in activities of daily living (ADL) may
prolong older persons' autonomy (older persons are defined in this study as
those aged  60 years). However, proved preventive strategies for ADL disability
are lacking. A sedentary lifestyle is an important cause of disability. This
study examines whether an exercise program can prevent ADL disability.
Methods A 2-center, randomized, single-blind, controlled trial was conducted
in which participants were assigned to an aerobic exercise program, a resistance
exercise program, or an attention control group. Of the 439 community-dwelling
persons aged 60 years or older with knee osteoarthritis originally recruited,
the 250 participants initially free of ADL disability were used for this study.
Incident ADL disability, defined as developing difficulty in transferring
from a bed to a chair, eating, dressing, using the toilet, or bathing, was
assessed quarterly during 18 months of follow-up.
Results The cumulative incidence of ADL disability was lower in the exercise
groups (37.1%) than in the attention control group (52.5%) (P = .02). After adjustment for demographics and baseline physical function,
the relative risk of incident ADL disability for assignment to exercise was
0.57 (95% confidence interval, 0.38-0.85; P = .006).
Both exercise programs prevented ADL disability; the relative risks were 0.60
(95% confidence interval, 0.38-0.97; P = .04) for
resistance exercise and 0.53 (95% confidence interval, 0.33-0.85; P = .009) for aerobic exercise. The lowest ADL disability risks were
found for participants with the highest compliance to exercise.
Conclusions Aerobic and resistance exercise may reduce the incidence of ADL disability
in older persons with knee osteoarthritis. Exercise may be an effective strategy
for preventing ADL disability and, consequently, may prolong older persons'
autonomy.
INTRODUCTION
INCREASES IN life expectancy and the subsequent growth of the elderly
population have a marked effect on the proportion of persons with a disability.
Approximately 20% of the persons aged 70 years or older report difficulty
with performing essential activities of daily living (ADL), referred to as
ADL disability.1 This type of disability is
the most severe form of disability that limits older persons' autonomy and
introduces dependence. It marks a serious decline in functional health and
increases the risk of outpatient care, hospitalization, nursing home admission,
and death.2-5
The number of elderly people with ADL disability will continue to increase
in the future, which highlights the urgent need to develop effective strategies
to prevent ADL disability in old age.
Observational studies6-9
suggest that regular physical exercise may be one of the most important preventive
factors for the onset of late-life disability. Clinical trials among older
persons have shown that exercise programs improve objective indexes of physical
performance (aerobic capacity, walking speed, and muscle strength)10-20
and self-reported functional scores.10 These
previous studies provide strong evidence for the benefits of physical exercise.
Nevertheless, it is still unclear whether exercise interventions can be sustained
for a sufficient duration and if the beneficial effects are strong enough
to actually prevent a clinically significant disability outcome and thereby
prolong autonomy. To our knowledge, no randomized trials have shown that physical
exercise can prevent the onset of ADL disability. The Fitness Arthritis and
Seniors Trial (FAST)10 was a randomized controlled
trial on resistance and aerobic exercise among community-dwelling older adults
with knee osteoarthritis, one of the leading causes of disability.21 We used data from FAST to assess whether a physical
exercise intervention can prevent the incidence of ADL disability.
PARTICIPANTS AND METHODS
STUDY SAMPLE
FAST was a 2-site, single-blind, randomized controlled trial of resistance
or aerobic exercise. Details of the design and methods of FAST have been described
before.10 Briefly, older adults with knee osteoarthritis
were recruited from the community through local advertisements and mailings.
Eligibility criteria were as follows: (1) age 60 years or older; (2) pain
in the knee(s) on most days of the month; (3) difficulty with at least one
of the following because of knee pain: walking 0.4 km; climbing stairs; getting
in and out of a car, bath, or bed; rising from a chair; or performing shopping,
cleaning, or self-care activities; and (4) radiographic evidence of knee osteoarthritis.
Exclusion criteria were as follows: (1) the presence of a medical condition
that precluded safe participation in an exercise program (eg, recent myocardial
infarction or stroke, severe chronic obstructive pulmonary disease, or congestive
heart failure); (2) inflammatory arthritis; (3) regular exercise participation
(>1 time per week for at least 20 minutes); and (4) inability to walk on a
treadmill or walk, unassisted, 128 m in 6 minutes.
Of the 4575 persons screened by telephone for the first 3 eligibility
criteria, 1402 came in so that a knee x-ray film could be obtained; 1164 of
these persons had radiographically evident osteoarthritis. Of these 1164 persons,
323 (27.7%) scored on one or more of the exclusion criteria and 402 (34.5%)
declined to participate. The remaining 439 persons were enrolled at baseline
and were, based on the randomization assignment generated by computer at the
biostatistics core, assigned to 1 of the 3 intervention arms: 144 to the attention
control group, 146 to the resistance exercise program, and 149 to the aerobic
exercise program. To examine the incidence of ADL disability, 178 participants
(40.5%) with baseline ADL disability were excluded for the present study.
The presence of baseline ADL disability was not significantly associated with
group assignment ( 22 = 3.4, P = .12). In addition, 11 participants (1 in the attention control
group, 2 in the resistance exercise group, and 8 in the aerobic exercise group)
were excluded because they had no follow-up data. The remaining 250 persons
(80 in the attention control group, 82 in the resistance exercise program,
and 88 in the aerobic exercise program) formed the present study sample.
INTERVENTIONS
Attention Control Group
To give subjects in the control group adequate study attention, they
attended, during the first 3 months, monthly group sessions on education related
to arthritis management, including time for discussions and social gathering.
Later, participants were called bimonthly (months 4-6) or monthly (months
7-18) to maintain health updates and provide support.
Aerobic Exercise Program
This intervention consisted of a 3-month facility-based walking program
and a 15-month home-based walking program. The facility-based program took
place at an indoor track under the supervision of exercise leaders, master's-degree
exercise scientists with training in exercise therapy, and was scheduled 3
times per week for 1 hour (leader-participant ratio, 2:20). Each session consisted
of a 10-minute warm-up and cool-down phase, including slow walking and flexibility
stretches, and a 40-minute period of walking at an intensity equivalent to
50% to 70% of the participants' heart rate reserve, as determined from their
screening exercise treadmill test. Subjects progressed at different rates,
with the emphasis placed on continued participation. For example, during disease
flare-ups, some subjects could not walk continuously for 40 minutes; hence,
short rest periods were interspersed within the 40-minute exercise phase.
During months 4 to 6, the exercise leader visited participants 4 times and
called them 6 times to offer assistance and support in the development of
a walking exercise program in their home environment. Most participants chose
to walk on sidewalks along streets or in nearby parks, but some walked in
a nearby facility such as a gymnasium or shopping mall. For the remainder
of the exercise program, telephone contacts were made every 3 weeks (months
7-9) or monthly (months 10-18). Attendance at the facility-based exercise
sessions was registered by exercise leaders. In the home-based phase, participants
maintained exercise logs in which they mentioned how many exercise sessions
were conducted. To assess compliance, the percentage attendance was calculated
by dividing the number of sessions completed by the total number of sessions
prescribed multiplied by 100.
Resistance Exercise Program
This program also consisted of a 3-month supervised facility-based program,
with 3 one-hour sessions per week, and a 15-month home-based program. Each
session consisted of a 10-minute warm-up and cool-down phase and a 40-minute
phase consisting of 2 sets of 12 repetitions of 9 exercises: leg extension,
leg curl, step up, heel raise, chest fly, upright row, military press, biceps
curl, and pelvic tilt. Upper body exercises were performed with dumbbells
and lower body exercises with cuff weights. Beginning with a low resistance
(1.3 kg for the upper body and 1.1 kg for the lower body), weight was increased
in a stepwise fashion as long as participants could complete 2 sets of 12
repetitions. Once a self-imposed plateau was reached, weight was increased
after the participant performed 2 sets of 12 repetitions for 3 consecutive
workouts. However, because the emphasis was placed on continued participation,
during periods of disease flare-ups, subjects were allowed to reduce their
weight for exercises that exacerbated the pain. During the home-based phase,
participants continued their exercises at home. Weights were exchanged at
the participant's request or after a determination was made to increase the
weight during the face-to-face or telephone contact. As with the aerobic program,
compliance was assessed as the percentage attendance to exercise sessions
based on registrations by exercise leaders (months 0-3) and on exercise logs
(months 4-18).
Earlier articles10, 22 reported
on the findings of FAST, and showed that both exercise interventions resulted
in a lower score on a global disability questionnaire, improved physical performance,
decreased knee pain, and improved balance.
DATA COLLECTION
Incidence of ADL Disability
Self-reported disability was assessed every 3 months during the 18-month
follow-up period. At 3, 9, and 18 months postrandomization, participants were
invited for data collection visits, for which transportation was provided,
if necessary. At 6, 12, and 15 months postrandomization, telephone interviews
were conducted. For this study, a 30-item physical disability questionnaire
was developed that assessed self-reported difficulty with tasks in the following
domains: mobility, transferring from a bed to a chair, upper extremity, instrumental,
and basic ADL items.23 Each item was scored
from 1 (no difficulty) to 5 (inability). The basic ADL items included in the
questionnaire are the ADL items used and validated for the first time by Katz
et al24 in 1963, and since then used by many
others. ADL disability was defined as experiencing (yes or no) some or a lot
of difficulty or an inability in doing at least one of the following without
help: bathing, eating, dressing, transferring from a bed to a chair, or using
the toilet. All available data were used to determine whether persons developed
a new ADL disability during the 18 months of the trial. The primary analysis
was based on the first report of ADL disability at follow-up, which was considered
as the event of incident ADL disability.
Demographic and Clinical Variables
Demographics assessed at baseline were age, race, educational level,
and household income. Chronic comorbid conditions were considered to be present
if participants had ever been told by a health professional that they had
the following: coronary heart disease (diagnosed as having a myocardial infarction
or angina or having undergone angioplasty or coronary artery bypass surgery),
artery disease, diabetes mellitus, lung disease, cancer, or osteoarthritis
in joints other than the knee (hands, spine, hips, or feet). Hypertension
was defined as self-reported hypertension and concomitant use of antihypertensive
drugs or a blood pressure of 160/90 mm Hg or higher. The body mass index was
calculated as measured weight in kilograms divided by the square of measured
height in meters. To assess the baseline intensity of knee pain, participants
rated the intensity of knee pain during the past week for 6 different ADL
items on a Likert scale from 1 (no pain) to 6 (excruciating pain).25 A summary pain intensity score was calculated by
averaging the 6 scores for ambulation and transfer activities. Baseline aerobic
capacity was assessed by a graded exercise treadmill test during which ventilatory
and gas exchange responses were measured using a computerized system (CPX
system; Medical Graphics Corp, Vadnais Heights, Minn). Oxygen uptake is reported
as the volume of oxygen taken up in 1 minute per kilogram of body weight at
peak exercise. Two indicators for baseline physical function were used: the
average walking speed during a 6-minute test in which subjects were asked
to walk as far as they possibly could and the average score on the disability
questionnaire measuring perceived difficulty with mobility, transferring from
a bed to a chair, upper extremity function, and instrumental ADL items (basic
ADL items did not contribute to the score because those with baseline ADL
disability were excluded from the study).
STATISTICAL ANALYSES
2 Statistics (for categorical variables) and 1-way analyses
of variance (for continuous variables) were used to compare baseline characteristics
across the 3 assignment groups. Cox proportional hazards analyses were used
to evaluate the effect of assignment on time to incident ADL disability. Persons
who survived with no evidence of disability were censored at 18 months, and
those unavailable for follow-up were censored after their last interview.
Multivariate analyses were adjusted for race, site, sex, age, body mass index,
walking speed, volume of oxygen taken up in 1 minute per kilogram of body
weight at peak exercise, baseline disability, and pain. Primary analyses were
conducted by intention to treat using the data of all participants. Secondary
analyses were conducted to examine the effect of compliance with exercise
on ADL incidence. The assumption of proportionality of hazard was checked
with log minus log plots and by tests of the interaction of time with the
group assignment variable. In complementary analyses conducted to confirm
the findings from the Cox proportional hazards analyses, Markov logistic regression
models26 were used to examine all 3-month transitions
during the 18-month follow-up. For this purpose, the data of subjects without
ADL disability at the beginning of each 3-month interval were pooled across
subjects and across intervals. Using these pooled data, 3-month transition
probabilities for changing from the non–ADL-disabled to the ADL-disabled
state were calculated across all intervals. The Markov model adjusts for the
fact that not all observations are independent, but can still achieve more
statistical power than survival analyses because the number of transitions
studied is much higher. Finally, we conducted Cox proportional hazards analyses
with the onset of disability in each of the specific ADLs to assess which
of the 5 ADL items were affected by exercise assignment.
RESULTS
The mean age of the 250 participants who were free of ADL disability
at baseline was 69.1 years (SD, 5.5 years); 68.0% were women, 41.2% had 12
or less years of education, and 50.0% had an annual household income below
$20 000. Eighty persons were assigned to the attention control group,
82 to the resistance exercise group, and 88 to the aerobic exercise group.
Demographics, comorbidity, intensity of knee pain, walking speed, and disability
scores did not differ across the randomized groups (Table 1). The intervention dropout rate was 9.8% for the resistance
exercise group (2 dropouts between 0-3 months, 4 between 4-9 months, and 2
between 10-18 months) and 13.6% for the aerobic exercise group (2 dropouts
between 0-3 months, 6 between 4-9 months, and 4 between 10-19 months). Reasons
for dropping out were moving from the area (n = 1), increased severity of
knee osteoarthritis (n = 3), major illness (n = 5), and lost interest (n =
11). When dropouts were scored as having 0% compliance for their remaining
time in the study, the overall compliance with the exercise sessions was 61%
for resistance exercise and 56% for aerobic exercise. Compliance with exercise
declined over time, with an average of 85% compliance during the first 3 months,
61% for months 4 through 9, and 54% for months 10 through 18. There was no
statistically significant difference in compliance between the exercise groups
(t = 1.38; P = .17).
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Table 1. Baseline Characteristics of Randomized Participants*
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Of the 250 persons, 105 (42.0%) developed ADL disability during an average
follow-up of 13.1 months (SD, 6.1 months). The cumulative incidence of ADL
disability over 18 months was significantly higher (21 = 5.3, P = .02) among the 80 persons in the
attention control group than among the 170 persons in the exercise groups
(Table 2). Cumulative incidences
were similar for the resistance exercise program and the aerobic exercise
program. In the Cox proportional hazards model, the unadjusted relative risk
(RR) of incident ADL disability associated with exercise was 0.62 (P = .01). After adjustment for age, sex, site, race, body mass index,
walking speed, and disability and knee pain scores, the RR was 0.57 (P = .006). The adjusted risk was 0.60 (P = .04) for those in the resistance exercise program and 0.53 (P = .009) for those in the aerobic exercise program. Thus,
persons participating in either a resistance or an aerobic exercise program
had a significantly higher probability of remaining free of ADL disability
for 18 months (Figure 1).
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Table 2. Incidence of Disability in Activities of Daily Living (ADL)
During 18 Months According to Intervention Assignment
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Survival probability without activities of daily living (ADL) disability
according to assignment group: results from adjusted Cox proportional hazards
analysis. For the resistance exercise group vs the control group, P = .03; for the aerobic exercise group vs the control group, P = .01; and for both exercise groups vs the control group, P = .006.
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We assessed whether differential study loss (due to unavailability)
could have biased our results. Overall, 129 (8.6%) of the total 1500 ADL disability
assessments were missing. Of the 250 participants, 36 (14.4%) had 1 missing
ADL disability assessment during 18 months and 26 (10.4%) had 2 or more missing
assessments. Those who missed 1 or more ADL disability assessments did not
differ from those with complete information for baseline sex, race, educational
level, income, comorbidity, and disability and knee pain scores. Also, unavailability
for follow-up was not associated with assignment group (22 = 0.96, P = .62), which illustrates that
study loss to follow-up was nondifferential. When analyses were repeated among
only those with complete data (n = 188), results were similar: the adjusted
RR was 0.55 (95% confidence interval, 0.34-0.90; P
= .02) for resistance exercise and 0.58 (95% confidence interval, 0.36-0.94; P = .03) for aerobic exercise.
Survival analyses examine the first onset of disability and ignore eventual
recovery and subsequent disability patterns after recovery, if present. In
complementary analyses, all 3-month transitions during 18 months (from no
disability to disability, and vice versa) were pooled and examined using first-order
Markov regression models. Pooling of the data across subjects and across intervals
resulted in 1048 three-month intervals starting from the non–ADL-disabled
state. During these intervals, 138 (13.2%) made a transition from the non–ADL-disabled
state to the ADL-disabled state, and 910 (86.8%) showed continuation of the
non–ADL-disabled state. When compared with the attention control group,
the adjusted RR for making a transition from a non–ADL-disabled state
to an ADL-disabled state was 0.53 for resistance exercise (95% confidence
interval, 0.31-0.91; P = .02) and 0.45 for aerobic
exercise (95% confidence interval, 0.26-0.78; P =
.004). Thus, the RRs associated with exercise assignment were even somewhat
lower than those derived from survival analyses, which strengthened our finding
of a significantly protective effect for exercise on onset of ADL disability
over time.
We examined the risk of incident ADL disability by tertiles of exercise
compliance, defined as the percentage attendance to exercise sessions (Table 3). These analyses showed that those
in the highest exercise compliance tertile had the lowest risk of incident
ADL disability. When compared with the attention control group, persons who
completed 81% or more of the resistance exercise sessions prescribed were
0.43 times as likely to develop ADL disability (P
= .04). This risk was 0.38 (P = .01) among those
in the most compliant tertile in the aerobic exercise program.
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Table 3. Effect of Compliance With an Exercise Intervention on the
Risk of Developing an Incident Activities of Daily Living (ADL) Disability
During 18 Months of Follow-up
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We examined which of the 5 ADL items were affected by exercise assignment
by conducting Cox proportional hazards analyses for each specific activity
(Table 4). Persons in the exercise
intervention groups had a significantly lower risk of developing a disability
in transferring from a bed to a chair (P = .007),
a disability in bathing (P = .002), and a disability
in dressing (P = .005). For a disability in eating,
the number of incident cases was too small to conduct Cox proportional hazards
analyses, but the cumulative incidence was significantly higher in the attention
control group than in the exercise groups (P = .02).
Overall, the specific ADL disability risks for aerobic exercise tended to
be somewhat smaller than those for resistance exercise. Although the findings
were in the expected direction, exercise assignment was not significantly
(P = .13) associated with incident disability in
"using the toilet."
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Table 4. Incidence of Disability in the Individual Activities of Daily
Living (ADL) During 18 Months According to Intervention Assignment
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Finally, to examine whether the preventive effect of exercise was consistent
across demographic and clinical subgroups, we entered an interaction term
between demographic or clinical variable and assignment to (resistance or
aerobic) exercise in the analyses and checked its significance. The effect
of exercise on ADL disability appeared not to be significantly modified by
age, sex, race, body mass index, or baseline disability or knee pain score.
COMMENT
Our data suggest that an exercise program may significantly reduce the
18-month incidence of ADL disability in older persons with knee osteoarthritis.
When compared with the attention control group, persons assigned to an exercise
group had a 0.57 times decreased risk of developing ADL disability. The preventive
effect of the resistance exercise program was similar to that of the aerobic
exercise program. For both exercise programs, the most compliant persons with
the exercise program showed the largest reduction in their risk of incident
ADL disability. In addition, a consistently protective effect of exercise
was found in separate analyses examining the disability incidence in each
specific activity (transferring from a bed to a chair, bathing, using the
toilet, dressing, and eating), with significant results for 4 of the 5 specific
ADL items. Previous clinical trials10-20
have shown that exercise has beneficial effects on intermediate end points,
such as continuous disability scales, physical performance, or muscle strength.
Despite this evidence, there were still concerns as to whether physical exercise
interventions in older persons can be sufficiently sustained in duration and
intensity to actually improve clinically significant outcomes in the long-term.
To our knowledge, our study is the first to show that an exercise program
may be able to prevent major ADL disability in late life.
Various pathways may explain the preventive effect of exercise on ADL
disability in patients with knee osteoarthritis. First, as shown in previous
trials,11-14,16-17,20, 27
exercise has various beneficial physiological effects, such as improved muscle
strength and bone mass and increased aerobic capacity, flexibility, and balance.
In line with these findings, the exercise programs in our study resulted in
increased physical performance, aerobic capacity (for the aerobic exercise
program only), and muscle strength and in improved postural sway,10, 22 which may explain the reduced risk
for subsequent major disability. A second pathway for the preventive effect
of exercise may be through reduced knee pain, which was another result of
our study.10 Severity of knee pain has been
shown to be an independent risk factor for disability.28
Third, exercise may have favorable psychological consequences, such as a decreased
depressed mood and a reduced fear of falling,29
which influence the risk of ADL disability.30-31
Rejeski and colleagues32 reported that increased
self-efficacy beliefs mediate the effects of both exercise treatments in this
trial on performance-related function. Also, it is likely that the exercise
programs increase peer support and counseling and emphasize self-responsibility
for maintaining health, which, in turn, may have resulted in favorable health
effects. Fourth, greater weight loss in the exercise groups may be another
possible mechanism. A greater mean 18-month weight loss was found for the
aerobic exercise group (1.89 kg lost) compared with the attention control
group (0.40 kg lost) (P = .05), but not for the resistance
exercise group. This greater weight loss in the aerobic exercise group may
have been because of the exercise program, increased physical activity outside
of the prescribed exercise intervention, or other improved health behaviors
(nutrition). Finally, it is possible that part of the protective effect of
exercise is through preventing or favorably influencing the course of frequently
disabling other conditions, such as cardiovascular disease,33
respiratory diseases,34 diabetes mellitus,35 and osteoporosis.27
Because our trial was designed as an outcome study and in-depth exploration
of mediating mechanisms between exercise and ADL disability was beyond its
scope, future studies should be designed to address this important topic.
Our sample consisted of a selected group of older persons with knee
osteoarthritis. Because this population is at a high risk for ADL disability,21 it forms an appropriate and efficient group to examine
preventive strategies for ADL disability. The cumulative incidence of ADL
disability in our sample may seem high (52.5% in the attention control group
and 37.1% in the exercise groups). However, this number is similar to previously
reported rates: among the initially moderately disabled (but not ADL-disabled)
older women in the Women's Health and Aging Study,36
the cumulative incidence of ADL disability was 48% in 1 years, and
in a study37 among hospitalized older persons
without ADL disability at discharge, the ADL disability incidence was 41%
in 1 year. Also, the hierarchical structure of the ADL disability incidence
is similar to that found in a previous longitudinal study by Dunlop and colleagues,38 with the highest cumulative incidences for transferring
from a bed to a chair and bathing and the lowest for eating.
In the past, there have been some concerns raised that exercise accelerates
the underlying osteoarthritis process or results in injury. However, as reported
in several studies,10, 18-19
moderate exercise improves knee pain and performance outcomes in patients
with knee osteoarthritis. In addition, our study shows that, although 2% of
the respondents had an injury related to the exercise program,10
the aerobic and the resistance exercise programs appear to be effective nonpharmacological
therapies for preventing major subsequent disability in older people with
knee osteoarthritis.
Our sample consisted of a selected group of patients with knee osteoarthritis
and, consequently, the results may not be completely generalizable to the
older population at large. However, in addition to knee osteoarthritis, favorable
effects of exercise on physiological or performance outcomes have consistently
been found for healthy older persons11-12,16
and for older persons with other conditions, such as cardiovascular disease,17, 39 pulmonary disease,40
osteoporosis,41 or frailty.13-15
Thus, the beneficial effect of exercise on the prevention of disability may
well be more broadly applicable across the spectrum of diseases typically
prevalent in older persons. Although this may suggest that exercise prevents
ADL disability in initially nondisabled older persons irrespective of disease
status, future studies are necessary to confirm the effect of exercise in
the general older population at large. Many of the older participants with
knee osteoarthritis in our study (41%) had other disabling comorbid conditions,
such as cardiovascular disease, diabetes mellitus, lung disease, or cancer.
Thus, our sample is not solely a sample of persons with knee osteoarthritis.
As the population ages, ADL disability in older persons will increasingly
affect quality of life and will considerably increase requirements for informal
and formal care. Consequently, there is an urgent need to develop effective
interventions that may increase the years of life spent without disability
and dependency. Besides minimizing the severity and functional impact of certain
diseases and preventing comorbidity, using appropriate exercise regimens may
be another valuable target in the prevention of disability. Several studies
have shown that it is possible and feasible to enroll older persons with and
without various chronic conditions in various exercise programs. Our study
suggests that a physical exercise program may be an effective strategy for
increasing the active life expectancy of older adults.
AUTHOR INFORMATION
Accepted for publication March 13, 2001.
This study was supported by grant P60AG10484-01 from the National Institute
on Aging, Bethesda, Md (Claude D. Pepper Older Americans Independence Center
of Wake Forest University, Winston-Salem, NC); by grant M01-RR00211 from the
General Clinical Research Center, Winston-Salem; and by the Brookdale Foundation,
New York, NY (Dr Penninx).
Corresponding author: Brenda W. J. H. Penninx, PhD, Sticht Center
on Aging, Wake Forest University School of Medicine, Medical Center Boulevard,
Winston-Salem, NC 27157 (e-mail: bpenninx{at}wfubmc.edu).
From the Sticht Center on Aging, Department of Internal Medicine, Wake
Forest University School of Medicine (Drs Penninx, Williamson, DiBari, Applegate,
and Pahor), and the Department of Health and Exercise Sciences, Wake Forest
University (Drs Messier and Rejeski), Winston-Salem, NC; and the Department
of Gerontology and Geriatrics, University of Florence and Azienda Ospedaliera
"Careggi," Florence (Dr DiBari), and the Section of Geriatrics, University
of Rome "Tor Vergata," Rome (Dr Cavazzini), Italy.
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