Physiotherapy February 2000/vol 86/no 2

85

IntroductionThe world’s elderly population, defined as65 years of age and over, is currently growingat a rate of 2.5% per year, faster than theoverall total population (Suzman et al,1992).

Within this diverse group of people,individuals may be diagnosed as frail. Frailtyis defined as the state of reduced physiologicreserve associated with an increasedsusceptibility to functional decline anddisability (Buchner and Wagner, 1992).Functional decline and the impairment ofmobility increase the risk of falls, fractures

and functional dependency (Fiatarone et al,1990). Fall-related injuries and loss ofindependence mean that a rapidly ageingpopulation poses an enormous economicand social burden upon society. Identifying ameans of decreasing frailty and prolongingindependence makes sound economic sensein the current UK climate of financialconstraint, particularly within healthcare(Chandler and Hadley, 1996). Governmentpolicy documents have identified this as anarea to target in order that the health costburden may be contained or reduced (DoH,1993, 1998).

Bortz (1982) suggested that a proportionof the changes that are commonly attributedto ageing are in reality caused by physicalinactivity and, as such, can be reversed withexercise.

Exercise is a very important factor inpromoting long life and good health and is often under-estimated or ignored.Individuals who have engaged in regularphysical activity throughout their lives tendto maintain a higher level of function andexperience less decline in functional status(Rikli, 1986). It is postulated that exerciseintroduced to inactive individuals may slow or halt many of the changes associatedwith ageing. This premise begs the develop-ment of a national exercise campaign as a means of promoting health. However, in considering this some fundamentalquestions must be addressed. At whomshould such an exercise campaign betargeted in order to ensure maximum healthcost savings in exchange for the costs of thecampaign? Would an exercise schemetargeting an elderly population proveeconomical or would it be dogged by poormotivation and adherence? If such acampaign were developed who should mostappropriately do this, co-ordinate it, anddeliver it?

This paper aims to highlight the health

Life Begins at Forty! Should the route to promoting exercise in elderlypeople also start in their forties?

Summary Exercise has many health benefits, including reducingcholesterol levels, reducing obesity, improving cardiovascularfunction, reducing the risks of coronary heart disease, improvingmuscle endurance and flexibility, reducing risk of injury andosteoporosis, and preserving function and mobility. In addition, itpreserves reaction times and neurological functioning and canimprove self-esteem and reduce depression and stress.

The cost of managing the world’s health is rising as the globalpopulation ages. The UK Department of Health report The Healthof the Nation (1993) suggests one way of reducing health-relatedcosts, through specifically addressing the problem of falls andinjuries of the elderly. Because exercise has the capacity to reducefalls, fractures, accidents and some medical conditions, and thushelps to avoid hospitalisation and associated institutionalisation,this paper suggests that an education and exercise promotioncampaign may provide a means to this end.

There are strong arguments in favour of targeting such anexercise campaign at the 40- to 50-year-old age group. It wouldmaintain people’s exercise capacity as they age (Shephard, 1987),it would help to reduce falls and morbidity in later years, andbestow enhanced recovery from accidents and illness (Bird, 1992).Ultimately it would offer a means of achieving a reduction in theassociated health costs of ageing described above.

This paper offers the suggestion that physiotherapists have a roleto play in developing and delivering such a health promotioncampaign; encouraging people to find convenient, enjoyable, andvaried exercise within safe programmes of activity.

Key WordsExercise, elderly, physiotherapy, healtheducation, health promotion.

by Naomi Carter Marie-Luce O’Driscoll

Carter, N and O’Driscoll,M-L (2000). ‘Life beginsat forty! Should the routeto promoting exercise inelderly people also startin their forties?’Physiotherapy, 86, 2, 85-93.

Physiotherapy February 2000/vol 86/no 2

86

benefits of exercise and the associatedpotential health cost savings. It will explorewhy an exercise promotion package mightbest be targeted at 40- to 50-year-olds ratherthan older people. It will considerappropriate exercise prescription, andpresent the role that might be taken byphysiotherapists in such a campaign. Finally,it will briefly state ways in which such anexercise campaign might be funded andimplemented.

Why Bother to Exercise?Exercise has been shown to have numeroushealth benefits (Pert, 1997). The benefits of exercise to the whole population,irrespective of age, include reducing the riskof cardiopulmonary problems, improvingcardiovascular function, and strengtheningthe musculoskeletal system (Pert, 1997).Exercise is also linked with improvingpsychological well-being (RCP, 1991).Regular aerobic exercise is thought topromote a great increase in life expectancyas it helps preserve neurological functioningor enhance it in those who have beensedentary (Foley and Gregg, 1994).

Key Benefits of Exercise for Older PeopleStaying active appears to help minimisesome of the problems of ageing whichinclude increased body fat, reducedmuscular strength and flexibility, loss ofbone mass, lower metabolic rate and slowerreaction times (Foley and Gregg, 1994).However, the benefits gained from anexercise programme depend upon thenature and amount of exercise undertaken,as will be discussed later. It is suggested thatan exercise promotion package aimed at anageing population may produce benefits insix broad areas:

■ Maintaining well-being.

■ Reducing the risk of falls

■ Preserving functional ability.

■ Reducing the risk of fractures.

■ Reducing medical problems.

■ Saving healthcare costs.

Maintaining Well-beingExercise is postulated to prevent or slowdown intellectual decline (Spirduso, 1975).It is thought to enhance mood, memory andpsychological function and also to reducestress and depression, all of which areimportant for maintaining well-being and

health (RCP, 1991). This is particularly thecase when exercise is undertaken in groups.For example, the majority of the ‘Exerciseon Prescription’ schemes* show that justbeing a member of a scheme has a widerange of positive social and psychologicaleffects (Riddoch et al, 1998). It is thoughtthat group cohesiveness exerts a positivetherapeutic influence upon attendance,participation and the impact of an exerciseprogramme upon individuals (Yalom, 1975).It is believed that such group activities are beneficial in mental illness throughreducing social isolation and improving self-confidence (PATF, 1995). ‘Exercise onPrescription’ programmes have been foundparticularly effective for anxious or de-pressed individuals and for those who reportill health, but in whom no illness can bedetected (Riddoch et al, 1998).

Reducing the Risk of FallsInsufficient exercise is associated with weakmuscles, poor balance and gait, as well asaccelerated bone loss (NIH, 1996). Theseare key risk factors accountable for falls in elderly people. It has been estimated that approximately half of older adultshospitalised for fall-related injuries areultimately discharged to nursing homes(Sattin et al, 1990) and so the costs of falls, to society and the health service, aresubstantial.

It has been shown that exercise offerspotential benefits in reducing the risk of falls(NIH, 1996) by improving balance, strengthand flexibility (Province et al, 1995; Rikli andEdwards, 1991). Exercise has been seen toincrease muscle strength and endurance(Pert, 1997; Fiatarone et al, 1990), andtendon strength and flexibility (Pert, 1997),and to reduce static sway (Judge et al, 1993).Where these benefits of exercise are reaped,so falls may be prevented and subsequenthospitalisation avoided (Shephard, 1987).

The psychological benefits of exercise mayalso contribute to a reduction in the risk offalls in older people. There is a significantassociation between falls and the use ofhypnotic and antidepressant drugs (Blake et al, 1988). If exercise helps to reducedepression and stress, as previouslysuggested, fewer drugs may be taken andfalls may be less frequent.

Preserving Functional AbilityAs has been described, compromisedexercise tolerance and functional ability inolder people can increase the risk of falls. It

* The 'Exercise onPrescription' schemes arepart of the nationalpromotional campaign ledby the Health EducationAuthority. It is a physicalactivity strategy toenhance the nation'shealth, whereby doctorsprescribe exercise as partof treatment to help avoidheart disease, strokes andmental issues.

Physiotherapy February 2000/vol 86/no 2

87Professional articles

can also decrease the ability to get up after afall, making individuals fearful of falling andso reluctant to mobilise. This may contributeto a spiral of physical, functional and socialdecline through reducing activity, limitingsocial interaction and constraining activitiesof daily living (Walker and Howland, 1991).This loss of functional ability and indep-endence may culminate in hospitalis-ation or institutionalisation (Tinetti et al,1993).

Exercise may help to restore people’sconfidence in their ability to move aboutsafely and get up after falls. It can helpreduce the physiological and psychologicalchanges due to inactivity. Ultimately exerciseoffers a means of retaining or restoringsufficient fitness, physically and mentally, to enable everyday tasks to be donecomfortably, easily and efficiently (Bortz,1982; Fentem et al, 1988).

Reducing the Risk of FracturesExercise has been shown to decrease the riskof bony injury (Pert, 1997). It is suggestedthat exercise can reduce the risk ofosteoporosis (Pert, 1997), possibly evenreversing the process (McArdle et al, 1991;Dargie and Grant, 1991). This in turn mayreduce the number of fractures when fallsdo occur. It has been suggested that regularexercise may reduce the risk of fractures byas much as half, thereby preventing some20,000 hip fractures each year (Law et al,1991).

Reducing Medical Problems A loss of physical endurance may lead to thedevelopment of medical complicationsrequiring costly healthcare. Exercise hasbeen shown to prevent common conditionsexperienced in old age, such as non-insulin-dependent diabetes mellitus, peripheralvascular disease, hypertension and ischaemicheart disease (Young and Dinan, 1994).Additionally, the benefits of regular exerciseinclude dramatically reducing the risk ofcoronary heart disease, reducing bloodpressure (Duncan et al, 1985), and helpingto lower cholesterol levels (Heath et al,1983). It is also possible to facilitate weightcontrol due to changes in metabolicfunctioning, thus also helping to reduceobesity and obesity-related disease (Pert,1997).

Providing Health Cost SavingsThe reduced morbidity from medicalconditions, accidents, falls and fractures

associated with exercise may result in health-care cost savings. Where exercise results in maintained or recovered function and reduced need for medication, furthersavings are possible (Brechue and Pollock,1996). It is estimated that the health benefitsand consequent cost savings would becomeevident soon after exercise programmes areimplemented for middle-aged people, andmuch more than offset the costs due toinjury from exercise (Nicholl et al, 1994).

Why Promote Exercise for 40- to 50-year-olds?There has been a shift of emphasis inhealthcare policy away from responding toillness towards preventing the onset ofillness by actively promoting lifestylechanges, including regular physical exercise(Nicholl et al, 1994). Such policy changes aresupported by findings that primary healtheducation directed at ‘healthy’ people hasbeen shown to help prevent health problemsfrom arising (Ewles and Simnett, 1995). Ifwe educate adults in their 40s then there is achance that we can prevent some of thecommon conditions experienced in old age,which we have described in the previoussection.

It is possible that an improved quality oflife and a small extension of lifespan may begained through pursuit of an enduranceexercise programme started at or before theage of 40. This suggestion is supported byresearch in rats where exercise before theage of 400 days, corresponding to about 40years in humans, was shown to have thesehealth gains (Shephard, 1987). Additionally,Shephard (1987) discovered that whenmiddle-aged men trained regularly, theusual 10-15% decline in exercise capacityand aerobic fitness was forestalled. Theseactive men maintained the same values forblood pressure, body mass and maximumVO2 as men of 45.

It has been suggested that individuals whoexercise regularly in midlife may regainfunctional ability more quickly followinghospitalisation (Bird, 1992). This additionalbenefit of exercise is particularly significantin the current climate of ever-shorteningperiods of time available for rehabilitationfollowing acute admissions (Smith et al,1995).

Psychologically there may be advantages totargeting exercise programmes at individualsin their middle years. It is postulated thatwhen people reach the age of 40 years, theyare hit by the powerful images of morbidity

Authors

Naomi Carter MCSP BSc is a juniorphysiotherapist at SellyOak Hospital,Birmingham. This articlewas developed from partof her final yearcoursework towards herdegree.

Marie-Luce O’DriscollBSc GradDipPhys MCSPis a lecturer inphysiotherapy at theUniversity of East Anglia.She edited and advisedthroughout thedevelopment of this workfor publication.

Address forCorrespondence

Miss N CarterPhysiotherapyDepartment Selly Oak HospitalRaddlebarn Road Selly OakBirmingham West Midlands B29 6JD.

Physiotherapy February 2000/vol 86/no 2

88

and mortality through experiences and themedia. Facing physical ailments for the firsttime, such as the first experiences of lowback pain; facing physical inadequacies -- forinstance seeing their children display greaterstrength, speed or stamina than theirparents; and watching previously healthyparents advance into old age, are allexperiences which may coincide with theoutset of the fifth decade.

Added to this cocktail, individuals arebombarded with images from the mediawhere energy and youth are portrayed asglamorous and desirable. There arerelatively few positive role models for theover-40s, and where they do exist they areusually inextricably bound up with trying toappear and behave in a youthful manner.Consequently the fifth decade is often onein which people choose to consider theirfuture, re-evaluating their lives, health andhabits.

In the ‘Exercise on Prescription’ schemesthe studies that targeted participants in anappropriate state of readiness to changehave had the most encouraging results(Riddoch et al, 1998). It therefore seemsideal to promote exercise to this age group,harnessing the fear of ageing to achieve apositive end. Furthermore it has beensuggested that younger people may be moreenthusiastic to learn and less resistant tochange of habit than elderly individuals(Simpson and Mandelstam, 1995). Theexperiences of Chandler and Hadley (1996)substantiate such a suggestion; they foundthat exercise programmes for frail subjectssuffered from poor recruitment and largedrop-out rates. Consequently it may be morecost-effective to channel resources into acampaign aimed at younger people, whenrecruitment, retention and impact uponindividuals can be expected to be greater.

The financial arguments for targeting the40- to 50-year-old age group are alsoconvincing. Shephard (1987) states that anemployee fitness programme improvedperceived health to the point that individualworkers were using about 0.5 fewer hospitalbed-days per year and making fewer visits totheir doctors. It is estimated that 187 millionworking days are lost every year in the UKdue to sickness, resulting in a £12 billion taxon business (DoH, 1998). In addition to thehealth cost savings to be made throughimproving the health of an ageingpopulation, targeting exercise programmesat a pre-retirement population may alsoaffect statistics regarding lost work.

Campaign IssuesAdherence to ExerciseAdherence to exercise programmes isnotoriously poor. There is a typical drop-outrate from exercise programmes of around50% within six months of starting, possiblydue to lack of motivation, time andconvenience (Robison and Rogers, 1994).However, long-term participation in exerciseprogrammes is essential to obtain theassociated health benefits (ACSM, 1990) andways of promoting this need to beinvestigated (NIH, 1996). It has beenpostulated that images of morbidity andmortality perceived in the fifth decade may contribute to exercise uptake andadherence, but these alone may not be enough. Within the ‘Exercise onPrescription’ schemes other factors havebeen identified which may improveadherence. These include easy access tofacilities, a wide variety of settings,supportive and safe non-‘sporty’ environ-ments, flexibility of activities such as home-based or lifestyle-based exercises, low-costalternatives, promotion by the media, familysupport, extrinsic motivational techniquessuch as mileage allowances for cycling towork, counselling, supervision andmonitoring by exercise specialists, andindividual exercise programmes tailored toeach patient’s needs (Riddoch et al, 1998).The latter point was also emphasised byThomas (1995) who believed thatinteraction with a healthcare professionalhelped increase compliance levels byproviding a realistic and enthusiastic rolemodel. The ‘Exercise on Prescription’schemes showed that an importantmotivating factor for some patients washaving an ‘expert’ on hand (Riddoch et al,1998).

What Type of Exercise?It has been recommended that the emphasisfor a sedentary population should be upondeveloping the habit of regular physicalactivity (ACSM, 1986). Generally, it has beenrecommended that people should exercisethree times a week (Verdery, 1997; Thomas,1995; ACSM, 1990) with a minimum of 20-30minutes aerobic activity (Thomas, 1995;ACSM, 1990). However, the proposal fromThe Health of the Nation (DoH, 1993) andrecent research (Riddoch et al, 1998; PATF,1995) is to encourage people to build up totaking 30 minutes of moderate activity a day,five days a week.

The intensity of exercise prescribed

Physiotherapy February 2000/vol 86/no 2

89Professional articles

should be dictated by the person partic-ipating. An initial stress test can be used toascertain the level of exercise a client cansafely undertake (Finlayson, 1997; Thomas,1995). However, many authors believe it ispreferable to use a lower exercise intensity(Thomas, 1995; Williams, 1994; ACSM,1990). This is because higher intensitiespresent a greater risk of musculoskeletalinjury, can cause patients discomfort and, insome, may carry a greater cardiovascular risk(Williams, 1994). Moreover, a gentleexercise programme has been seen to be animportant factor in maintaining adherencelevels (Epstein et al, 1984). The AmericanCollege of Sports Medicine (1990) believesthat the intensity needs to be enough toproduce an increase in heart rate, sweatingand rate of respiration, which Thomas(1995) recommends is 50% of VO2 max.

To achieve all-round fitness, strengthtraining with resisted exercise should also beconsidered (Finlayson, 1997). Circuittraining may be advantageous as it enablesvariety in modes of exercise, while exercisingmost large muscle groups (Finlayson, 1997).An exercise programme which increasesmuscle strength is correlated with improvedfunction and independence (Verdery, 1997).Recent research has shown that interventionwhich uses balancing exercises, strengthtraining and low impact aerobic exercisesappears to be the most promising atreducing the risk of falls (NIH, 1996).However, there is also some evidence tosuggest that short bursts of high intensityactivity such as brisk walking or stairclimbing can be equally beneficial, providedthey are repeated several times a day (PATF,1995; Shephard, 1992; Fletcher et al, 1990).Indeed, Kerr (1999) suggests that partakingin physical activity which already forms partof normal daily life, such as walking to thenext bus stop or using the stairs, provides anindividualised approach requiring less of amajor change in behaviour and is thereforemore likely to be maintained over time.Paley (1997) states that improvements inaerobic capacity could be achieved by simplebrisk walking programmes because walkingcan improve cardiovascular fitness, lowerextremity strength and joint mobility(Walker and Howland, 1991). Worcester etal (1993), who prescribed twice weeklyformal exercises with daily walking on theremaining days, also support this.

A variety of exercise is also a crucial aspectto staying fit, as it helps reduce themonotony of exercise, while increasing the

number of muscle groups being worked.Familiarity with a variety of exercises is alsoimportant when illness or injury interferewith exercise participation. Exercising maythen be sustained by substituting the usualactivity for another familiar one, forexample swimming instead of running whenrecovering from running injuries (Buchnerand Wagner, 1992).

While we have stated that the long-termcost savings associated with exercise faroutweigh the costs of sports-related injurieswhich might be sustained, it still remainsimportant that this group of people beeducated to warm-up and cool-downcorrectly when exercising to reduce the riskof sports-related injury.

Overcoming Barriers to Exercise Some of the personal or intrinsic barriers to exercise were identified earlier and it was indicated that professionals mightcontribute significantly in enablingindividuals to overcome these. If success is tobe achieved in the long term, however,multiple levels of intervention are required.These interventions need to be organ-isational, environmental and societal as wellas personal (PATF, 1995; Robison andRogers, 1994; Yoshida et al, 1988). It isimportant to help overcome barriers, whichinclude ageism and views about what isappropriate activity for later life. Lack offacilities, lack of transport, limited financialresources, and lack of knowledge aboutalternative forms of effective exercise allneed to be addressed (O’Brien andVertinsky, 1991). However, it must beacknowledged from the start that even if allthese problems can be overcome nocampaign will achieve unified attendanceand satisfy all participants (Riddoch et al,1998).

Possible strategies to promote long-termexercising include:

■ Marketing the exercise campaign throughthe media – newspapers, billboards,advertisements on public transport,Internet and magazines. Television can beused to promote exercises throughcommercials and editorial and dedicatedprogrammes.

■ National and local government subsidy oftransport to leisure centres and crèchefacilities. Priority for funding of increasedlighting in parks, more cycle paths,possibly even consideration of funding

Physiotherapy February 2000/vol 86/no 2

90

more radical schemes such as cyclingallowances. Central government financeto support community schemes andfitness awards for local communities ordistricts.

■ Drawing upon the experience and workof the ‘Exercise on Prescription’ schemes,it is important that a variety of physicalactivities is available to the community,catering for many tastes. A structuredexercise programme for independentperformance should be defined at initialintrerview, with follow-up dates, groupclasses, ideas of how to exercise at home,community walks, cycle rides, localdances, etc.

■ Leisure centres should offer incentives toexercise such as reduced prices andpromotional packages to encourageadherence, for example 10 hours ofphysical activity giving entitlement to halfan hour of massage without charge, orone free swimming session.

■ Professionals such as physiotherapists inthe workplace promoting a more activelifestyle to those working in a sedentaryenvironment, using simple strategies suchas encouraging them to use the stairs,walk to the corner shop or possibly cycleto work, as well as offering to holdexercise classes in the workplace toaddress motivation and time barriers(Pert, 1997).

■ Educational leaflets and videos in doctors’surgeries in association with localphysiotherapists, offering talks orintroduction to exercise groups within thesurgery.

Evaluation of these and other strategies isessential before it is possible to identify themost successful and cost-effective means ofpromoting exercise and adherence toexercise in the long term. A cohort study isalso needed to ensure that exercise uptakewill be maintained in people reaching their50s and 60s after an exercise promotionaland educational campaign in their 40s to50s.

Are Physiotherapists Most Appropriate? The ‘More People, More Active, More

Often’ paper (PATF, 1995) suggests thathealth professionals should develop theirrole in promoting physical activity. It seems

that physiotherapists are appropriatelyskilled and ideally suited to taking on suchactivities. We have identified thatprofessional involvement in exerciseschemes may improve adherence toexercise. Physiotherapists recognise thephysical and psychological benefits ofexercise and are well versed in the art ofmotivating people. The results from exerciseprogrammes have demonstrated that whendesign and delivery are firmly rooted inphysiological and psychological theory theoutcomes are better (Pert, 1997; Riddoch etal, 1998). Physiotherapists operate out of astrong theoretical base, and understand theimportance of communicating this to theirclients. They are skilled at calling upon thisknowledge to tailor exercise appropriately toa cross-section of people with diverse healthneeds in group and one-to-one settings.

Dislike of sport, fear of injury and lack ofexperience of enjoyment in exercise may allbe intrinsic barriers to participation inexercise. Wills and Campbell (1992) believethat people should be given guidance toovercome their perceived barriers toexercise and be encouraged to set their owngoals. Physiotherapists are highly skilled inmotivating patients in healthcare settings,taking a holistic view of the individuals theymeet and involving their clients in settinggoals for treatment. Such skills would beeasily transferred to exercise programmesfor healthy adults. Furthermore, physio-therapists involved in such programmeswould then be ideally placed to advise uponand treat any musculoskeletal injuriesshould they arise during the course ofexercise, as well as giving advice on foot-wear and exercise activities outside the class.

In summary, from the evidence above, itseems that physiotherapists would be highlyappropriate professionals to educateindividuals, construct safe and effectiveexercise programmes, and within theseencourage ‘enjoyment, independence,personal choice and individual effort’ whichhave been identified as important toadherence (PATF, 1995). Nevertheless, while physiotherapists may be the idealprofessionals to lead exercise programmesin such a campaign, it is recognised thatlong-term success will depend on a wide co-ordinated multilevel approach (PATF, 1995).Physiotherapists will therefore need to bepart of a team of players to includeadministrators, assistants, occupationalhealth professionals, dieticians and

Physiotherapy February 2000/vol 86/no 2

91Professional articles

potentially psychologists. Good communic-ation between local GPs and the team wouldlead to a two-way stream of effectivereferrals. Members of the team could also support each other in providingmeasurements of health improvement,which are valid and objective. These are essential to encourage continuedinvolvement from individuals and fundingfrom government (Riddoch et al, 1998).

In addition to involvement in the field it issuggested that physiotherapists at aprofessional level are well placed to beinvolved in developing, launching and co-ordinating a national exercise campaignaimed at promoting health in the workplaceand the community. To some extentrudimentary steps have been taken in thisdirection; the Chartered Society ofPhysiotherapy has recently been consultedto evaluate existing referral schemes for the‘Exercise on Prescription’ programmes andhelp create safe and effective new ones(Tonkin, 1999).

The current funding of physiotherapy inthe National Health Service is directedtowards the treatment of pathophysiologicalproblems. Little support is provided forhealth education other than the advice given alongside treatment. This financialarrangement prevents physiotherapists fromdeveloping their role as promoters of health.Unfortunately this short-term view meansthat the existing physiotherapy work-force will continue to be stretched, treatingmany conditions that might otherwise beprevented.

Furthermore, while occupied in this way,the workforce and future physiotherapists intraining will continue to view their primaryrole as one which addresses and rehabilitatesspecific pathologies rather than one of promoting health and preventingpathologies. Kerr (1999) states: ‘Too often itseems that we are concerned only with thespecific problems which have necessitatedphysiotherapy, and ignore the total healthpicture.’ However, Kerr then goes on to saythat ‘perhaps we do not see ourselves ashaving a role in promoting health-relatedactivity. But who is in a better position, andindeed better qualified to do this thanphysiotherapists?’

If this cycle of events described above is tobe altered, a change in central fundingpolicy is necessary. For such policy changesto occur a long-term view of the nation’shealth, straddling the term of office for anyparticular government, is essential.

Funding Health Cost SavingsAn exercise campaign aimed at decreasingthe long-term health costs associated withageing would need funds to market,resource and administer it. Funds might be raised from government, private andpublic sector employers, and individualsthemselves. However, the difficulty offunding a campaign such as this is thatoutcomes are hard to measure because theyare prospective over a long term. Riddoch etal (1998) point out that this necessitatespatience, long-sightedness and a degree ofvision on the part of government andorganisations who find themselves requiredto bear the greater proportion of thefunding burden.

The motivation of raising funds atgovernment level would be to satisfy theaspirations laid out in The Health of the Nation(DoH, 1993) and in the long term achieve areduction in the health bill for an ageingpopulation. At organisational level incentivefor contributing to such a scheme may bederived from the potential to reduce thenumber of days of work lost through illhealth. Whether such incentives aresufficient can only remain to be seen. Thebest hope of strengthening the case forfunding a national exercise campaignremains the running of evaluated smallerschemes regionally.

ConclusionAn aim of The Health of the Nation (DoH,1993) is to reduce accidents and falls amongelderly people to help reduce health-relatedcosts. One possible way to achieve this isthrough primary education and targetingadults before they reach old age. Exercise isa key behaviour that promotes good healthand fitness. If adults in their 40s and 50sstarted to exercise, the vicious circle ofdecline which results from inactivity,reduced flexibility and strength might beprevented. Realistic individualised exerciseprogrammes could encourage independ-ence, strengthen the muscles and bones,and develop body awareness and balanceskills. Physiotherapists could assume theleading role in educating and initiating thisexercise campaign which might build afuture of improved function, and reduceaccidents and health-related costs for thegrowing elderly population.

Physiotherapy February 2000/vol 86/no 2

92

References

American College of Sports Medicine (1986).Guidelines for Graded Exercise Testing and ExercisePrescription, Lea and Febiger, Philadelphia.

American College of Sports Medicine (1990).‘The recommended quantity and quality ofexercise for developing and maintainingcardiorespiratory and muscular fitness in healthyadults’, Medicine and Science in Sports and Exercise,22, 265-274.

Blake, A J et al (1988). ‘Falls by elderly people athome: Prevalence and associated factors’, Age andAgeing, 17, 365-372.

Bird, S R (1992). Exercise Physiology for HealthProfessionals, Chapman and Hall, London, page 269.

Bortz, W M (1982). ‘Disuse and aging’, Journal ofthe American Medical Association, 248, 10, 1203-08.

Brechue, W F and Pollock, M L (1996). ‘Exercisetraining for coronary artery disease in theelderly’, Clinics in Geriatric Medicine, 12, 1, 207-229.

Buchner, D M and Wagner, E H (1992).‘Preventing frail health’, Clinics in GeriatricMedicine, 8, 1, 1-17.

Chandler, J M and Hadley, E C (1996). ‘Exerciseto improve physiologic and functionalperformance in old age’, Clinics in GeriatricMedicine, 12, 4, 761-784.

Dargie, H J and Grant, S (1991). ‘Exercise’, British Medical Journal, 303, 910-912.

Department of Health (1993). The Health of theNation. Key Area Handbook: Accidents, HMSO.

Department of Health (1998). ‘Our HealthierNation: A contract for health: A consultationpaper’, HMSO.

Duncan, J J, Farr, J E, Upton S J, Hagan, R D,Oglesby, M E and Blair, S N (1985). ‘The effectsof aerobic exercise on plasma catecholaminesand blood pressure in patients with mild essentialhypertension’, Journal of the American MedicalAssociation, 254, 18, 2609-13.

Epstein, L H, Koeske, R and Wing, R R (1984).‘Adherence to exercise in obese children’, Journal of Cardiac Rehabilitation, 4, 185-195.

Ewles, L and Simnett, I (1995). Promoting Health:A practical guide, Scutari Press, London, page 24.

Fentem, P H, Bassey, E J and Turnbull, N B(1988). The New Case for Exercise, Health EducationAuthority, London.

Fiatarone, M A, Marks, E C, Ryan, N D, Meredith,C N, Lipsitz, L A and Evans, W J (1990). ‘High-intensity strength training innonagenarians: Effects on skeletal muscle’,Journal of the American Medical Association, 263, 22,3029-34.

Finlayson, J M (1997). ‘The role of exercise inrehabilitation after uncomplicated myocardialinfarction’, Physiotherapy, 83, 10, 517 - 524.

Fletcher, G, Froelicher, V F and Hartley, H L(1990). ‘Exercise standards: A statement forhealth professionals from the American HeartAssociation’, AHA, Dallas, Texas.

Foley, B and Gregg, G (1994). Bodyworks CD-ROM,Software Marketing Corporation, SoftkeyInternational, London.

Heath, G W, Ehsani, A A, Hagberg, J M,Hinderliter, J M and Goldberg, A P (1983).‘Exercise training improves lipoprotein lipidprofiles in patients with coronary artery disease’,American Heart Journal, 105, 6, 889-895.

Judge, J, Lindsey, C, Underwood, M andWinsemius, D (1993). ‘Balance improvements inolder women: Effects of exercise training’,Physical Therapy, 73, 4, 254-265.

Kerr, K (1999). ‘Exercise: No easy option’,Physiotherapy, 85, 3, 114-115.

Law, M R, Wald, N J and Meade, T W (1991).‘Strategies for prevention of osteoporosis and hipfractures’, British Medical Journal, 303, 453-459.

McArdle, W, Katch, F and Katch, V (1991).Exercise Physiology: Energy, nutrition and performance,Lea and Febiger, London, pages 706-708.

Nicholl, J P, Coleman, P and Brazier, J E (1994).‘Health and healthcare costs and benefits ofexercise’, PharmacoEconomics, 5, 109-122.

Nuffield Institute for Health (1996). ‘Preventingfalls and subsequent injury in older people’,Effective Health Care, 2, 4, 1-16.

O’Brien, S J and Vertinsky, P A (1991). ‘Unfitsurvivors: Exercise as a resource for ageingwomen’, Gerontologist, 31, 347.

Paley, C A (1997). ‘A way forward for determiningoptimal aerobic exercise intensity?’ Physiotherapy,83, 12, 620-624.

Pert, V (1997). ‘Exercise for health’, Physiotherapy,83, 9, 453-460.

Physical Activity Task Force (1995). ‘Morepeople, more active, more often: A consultationpaper’, Health Education Authority, London.

Province, M A, Hadley, E C, Hornbrook, M C etal (1995). ‘The effects of exercise on falls inelderly patients’, Journal of the American MedicalAssociation, 273, 1341-47.

Riddoch, C, Puig-Ribera, A and Cooper, A (1998).Effectiveness of Physical Activity Promotion Schemes inPrimary Care: A review, Health EducationAuthority, London.

Rikli, R (1986). ‘Function of age and physicalactivity’, Journal of Gerontology, 41, 5, 645-649.

Rikli, R G and Edwards, D J (1991). ‘Effects of athree-year exercise programme on motor functionand cognitive processing speed in older women’,Research Quarterly for Exercise and Sport, 62, 61-67.

Robison, J I and Rogers, M A (1994). ‘Adherenceto exercise programmes: Recommendations’,Sports Medicine, B, 1, 39-52.

Physiotherapy February 2000/vol 86/no 2

93Professional articles

Royal College of Physicians (1991). MedicalAspects of Exercise: Benefits and risks, RCP, London.

Sattin, R W, Lambert, H, Devito, C A et al (1990).‘The incidence of fall injury events among theelderly in a defined population’, American Journalof Epidemiology, 131, 1028-37.

Shephard R J (1987). Exercise Physiology, BC Decker Inc, Toronto, chap 10, 13, 18.

Shephard, R J (1992). ‘A critical analysis of work-site fitness programmes and their postulatedeconomic benefits’, Medicine and Science in Sportsand Exercise, 24, 3, 354-370.

Simpson, J M and Mandelstam, H (1995). ‘Elderlypeople at risk of falling: Do they want to betaught how to get up again?’ ClinicalRehabilitation, 9, 65-69.

Smith, S, Simpson, J M and Hastie, I (1995).‘Elderly in-patients need more exercise: A functional exercise system’, Physiotherapy, 81, 10, 605-610.

Spirduso, W W (1975). ‘Reaction time andmovement time as a function of age and physicalactivity’, Journal of Gerontology, 30, 435.

Suzman, R, Kinsella, K and Myers, G (1992).‘Demography of older populations in developedcountries’ in: Evans, G and Williams, F (eds)Oxford Textbook of Geriatric Medicine, OxfordUniversity Press, chap 1.1.

Thomas, S G (1995). ‘Exercise and activityprogrammes’ in: Pickles, B, Compton, A, Cott, C,Simpson, J and Vandervoort, A (eds) Physiotherapywith Older People, W B Saunders, London, chap 12.

Tinetti, M E, Liu, W L and Claus, E (1993).‘Predictors and prognosis of inability to get upafter falls among elderly persons’, Journal of theAmerican Medical Association, 269, 65-70.

Tonkin, J (1999). ‘CSP consultation forframework’, Physiotherapy Frontline, 5, 5, 20.

Verdery, R B (1997). ‘Clinical evaluation offailure to thrive in older people’, Clinics inGeriatric Medicine, 13, 4, 769-778.

Walker, J E and Howland, J (1991). ‘Falls and fearof falling among elderly persons living in thecommunity: Occupational therapy interventions’,American Journal of Occupational Therapy, 45, 2,119-122.

Williams, M A (1994). Exercise Testing and Trainingin the Elderly Cardiac Patient, Human Kinetics,Illinois.

Wills, J D and Campbell, L F (1992). ‘Exercisebehaviour: Exercise adherence’, ExercisePsychology, Human Kinetics, Champaign, Illinois.

Worcester, M C, Hare, D L, Oliver, R G, Reid, M A and Globe, A J (1993). ‘Early programmes ofhigh and low intensity exercise and quality of lifeafter myocardial infarction’, British MedicalJournal, 307, 11, 1244-47.

Yalom, I D (1975). The Theory and Practice of GroupPsychotherapy, New York Basic Books Inc, USA,chap 3.

Yoshida, K K, Alison, R R and Osborn, R W(1988). ‘Social factors influencing perceivedbarriers to physical exercise among women’,Canadian Journal of Public Health, 79, 104.

Young, A and Dinan, S (1994). ‘Fitness for olderpeople’, British Medical Journal, 309, 331-334.

Key Messages

■ Exercise can help improve your health.

■ The health benefits of exercise couldhelp to reduce health-related costs andsatisfy the aims and objectives of The Health of the Nation (1993).

■ The cost of managing the nation's healthis rising as the population ages.

■ Targeting an exercise campaign at the 40- to 50-year-old age group could beboth beneficial for the individual andgood for the nation's health and wealth.

■ Physiotherapists' unique training and skill mean we are ideally placed to co-ordinate and encourage an effectiveexercise campaign.