The effectiveness of the First Step to Active Health in sedentary, community dwelling older adults

Pamela E. Toto, MS, OTR/L, BCG, FAOTA

Purpose: The purpose of this research is to evaluate the effectiveness of the First Step to Active Health (FSAH) program in increasing physical activity, physical performance and occupational performance in sedentary, community dwelling older adults. There are a multitude of physical activity programs currently being marketed for use with the older adult population. While the FSAH encompasses all of the key elements recognized by the 2008 Physical Activity Guidelines for Americans (U.S. Department of Health and Human Services) for best practice, there is limited published evidence regarding efficacy of the FSAH with a general older adult population. This study is being completed to fulfill the dissertation component of graduate studies in a doctoral program in Rehabilitation Science. The primary aim for this study is as follows: Evaluate the effect of participation of sedentary, community-dwelling older adults from low-income households in the First Step to Active Health (FSAH) program on physical activity, physical performance, and occupational performance.

Method: This research is being completed through a pre-post cohort study. The setting is a low-income suburban senior citizen high rise housing complex. Inclusion criteria for participation in this study includes: Permanent residency in the senior high rise, age 60 or older, no significant cognitive impairment and reported low levels of physical activity. Exclusion criteria includes: Recent hospitalization (6 months or less), current participation in a skilled physical therapy or occupational therapy rehabilitation program, current participation in a formal exercise program or presence of a health condition for which exercise is contraindicated. Interested residents will be screened through a brief interview through a face-to-face meeting. The intervention includes a 12 week program consisting of one hour exercise sessions held two times per week at the senior citizen high-rise in a large recreation room. Participants were asked to complete the exercise protocol independently one additional time per week. The FSAH protocol will be manualized and facility staff will be trained on program implementation to allow duplication of the program and carryover post completion of the intervention.

Outcome Measures: The primary outcome measures are the Yale Physical Activity Survey (YPAS) and the Activity Measure – Post Acute Care (AM-PAC). The YPAS is a self-report questionnaire administered by an interviewer to measure activity levels in a typical week during the previous month. Specifically designed for use with older adults, the tool is divided into two sections. The first section examines participation time spent performing instrumental activities of daily living (categorized as “work” in the survey), exercise and recreational tasks and is expressed as hours per week. Section two of the survey assesses intensity of activity participation through calculation of time spent performing activities in various intensity categories ranging from “vigorous” to “sitting”. Responses on the YPAS allow for a summary of eight indices to be calculated which include total time summary, energy expenditure expressed in kcals, five individual activity dimensions and an activity dimension summary. The AMPAC is an activity limitations measure that was designed using the World Health Organization’s 2001 International Classification of Functioning, Disability and Health (ICF) to measure post-acute activity functioning across inpatient and community settings (Boston University, 2007). AM-PAC examines a person’s perceived level of difficulty for performing the functional activities that most adults encounter in their typical daily routines. The tool examines perceived difficulty, level of assistance and limitations in three specific domain areas – Basic Mobility, Daily Activity and Applied Cognition. Physical performance will be evaluated using the Senior Fitness Test and change in occupational performance will be measured using the Canadian Occupational Performance Measure (COPM). Results: The criterion for significance (alpha) will be set at 0.05.Because of the pre-post cohort study design, the use of measures that supply quantitative data, and the expectation that subjects will improve as a result of the intervention, a one-tailed paired samples t-test will be completed for the YPAS, the SFT, COPM and AM-PAC measures. Effect sizes will be computed and reported as r values for all continuous variables with 95% confidence intervals calculated. A general overview will be provided outlining both the strengths and weaknesses of the FSAH for the community-dwelling, sedentary older adult population in the United States. A manual with specific steps for implementing the FSAH will be shared. Based on the results of this study, recommendations will be suggested on ways to further develop and strengthen this product for consumer use.

Clinical Impact: Despite numerous guidelines suggesting best practice programs to increase physical activity in older adults, no single turnkey program has demonstrated evidence-based results that make it the “program of choice”. The FSAH, with a multi-dimensional exercise program, personal goal setting measures, a focus on function and behavioral change strategies, includes all of the key components recommended for best practice. Published evidence of a well-designed study using the FSAH will significantly increase its marketability. Outcomes of this study will support further research using the FSAH in larger scale studies and through various distribution measures (i.e. physician offices