Staying Healthy Through Education and Prevention (STEP)
Chapter 6: Exercise Principles
Regular physical activity can improve an individual's mental health and cognitive function, as well as physical well-being and quality of life. The Surgeon General recommends that older adults engage in moderate-intensity physical activity for at least 30 minutes 5 days per week. The STEP program is an approach to achieving this recommended activity level in congregate housing settings.
Before offering the STEP program to participants, it is important that the program leader become knowledgeable about several exercise programming principles and practices that underpin the program. These principles and practices will help to ensure that STEP program participants have fun in a safe environment while being challenged in a way that improves their overall physical well-being.
After reading this chapter, you will be able to:
- Explain the FITT concept to participants.
- Understand and use the Borg Rating of Perceived Exertion (RPE) to guide participants.
- Provide an exercise program that both challenges participants and promotes safety.
FITT Principle: Guidelines developed for exercise prescription. FITT is an acronym for Frequency, Intensity, Time, and Type.
Rating of Perceived Exertion (RPE): A way of measuring the intensity of physical activity based on individuals' perception of how hard they feel their body is working.
- The STEP program should be fun, safe, and effective.
- Program staff need to identify individual abilities and help participants set goals and solve problems.
- The FITT principle helps staff and participants think about exercise goals in terms of Frequency, Intensity, Time, and Type.
- The Rating of Perceived Exertion (RPE) helps participants target their exercise at an appropriate level.
- Staff should be familiar with a number of safety guidelines and tips to ensure that participants achieve maximum benefit from the program without being injured.
Elements of an Effective Exercise Program
All exercise programs should be fun, safe, and effective.
- If participants are having fun, they will return to your program, and they may encourage others to join.
- If participants become sore or injured during or as a result of an exercise program, they may not return to the program once they have recovered.
- If participants feel that the exercise program has made a difference in their physical abilities, then they will continue to participate in the program.
Key Approaches to Offering an Effective Physical Activity Program
Identify Individual Abilities
Use a validated instrument to determine each participant's baseline abilities. It will help you identify areas of strength and weakness that may lead to loss of functional ability and can also serve as a target in the STEP program, if you so choose. The Senior Fitness Test is one such instrument (refer to the Resources section at the end of this chapter). Once baseline data are established, you can readminister the test at a predetermined interval (e.g., quarterly, biannually) to measure the impact of your program on each individual's function.
If participants define reasonable goals, they are more likely to see improvements. Goals should be specific to each individual's ability and could relate to any aspect of the exercise program (frequency of attendance, amount of time spent in moderate-intensity activity, etc.). Use STEP tracking sheets to assess each participant's progress toward his or her individual goal. (go to Session 1.) Detailed guidance on goal setting is available in Behavior Coaching Session 9, but please review all behavior coaching session materials for a complete understanding of the strategies recommended by STEP.
Coach and Problem Solve
Use the behavior coaching materials provided to facilitate the behavior coaching sessions. These sessions will assist seniors in developing behavior strategies and skills that will help them adopt and maintain an active lifestyle. There may be times when participants need additional support or when class time is insufficient to provide everyone with individual feedback on an exercise or behavior session activity. Supply additional support on an individual basis outside of class and at your discretion.
It is essential to help participants deal with the emotional and physical challenges they encounter during STEP, but it is equally important to accomplish as much as possible during class. That way, all participants can benefit from the group discussions and you as leader do not become overburdened providing excessive amounts of outside consultation.
Build Social Support
Encourage new behaviors and physical activity program participation through peer and staff support. Behavior Coaching Session 8 discusses the importance of social support and presents formal strategies to build it. Informally, remind participants to ask for help, support, and encouragement, and remind staff (even those not involved in STEP) to supply help, support, and encouragement. Emphasize the importance of walking groups or buddies for motivation and good friends whom participants can talk to when they need it.
The FITT Principle
FITT is an acronym for Frequency, Intensity, Time, and Type and is a useful tool to help participants set goals and achieve the most from their STEP activities.
- F = Frequency (how often to exercise)
- Seniors should aim to walk or perform other aerobic exercise at least 5 times a week and attend a STEP strength training class at least once a week.
- The frequency of both walking and strength training can gradually increase over time, as tolerated by participants and as their abilities improve.
- I=Intensity (how hard to exercise)
- Use the RPE to help participants target moderate intensity (explanation below). link to RPE
- STEP participants should aim for an RPE of 11 to 13 for aerobic activity such as walking.
- For strength training, STEP participants should maintain an RPE of 15 or 16.
- T=Time (how long to exercise)
- STEP participants should aim for about 30 minutes of aerobic physical activity on most days of the week.
- Participants, especially inactive ones, can increase the amount of time based on how they feel and as their abilities improve.
- Participants may choose to perform physical activity in short bouts, such as five 10-minute walks, if that suits them better than fewer, longer episodes of activity.
- Participants should take a few minutes to warm up and cool down before and after their aerobic activities. This can take the form of activities such as seated stretches or walking in place.
- T=Type (what kind of exercise to do)
- STEP emphasizes two types of exercise: walking and lower extremity strength training.
- At the end of 3 months, the goal is for participants to be exercising a total of 150 minutes each week, with the majority of that time being independent or group walking at a moderate level of intensity. The rest of the time should be spent in the STEP strength classes.
Rating of Perceived Exertion Scale
Proper intensity maximizes the benefit of exercise, so it is important to remind participants not only of the importance of engaging in regular exercise, but also of challenging themselves in terms of intensity. The STEP program aims to have seniors walking and doing strength training exercises at more than a "light" level of intensity.
The Borg Rating of Perceived Exertion (RPE) Scale is a subjective method of measuring exercise intensity based on how the participant perceives his or her own level of exertion. The scale runs from a minimum of 6 to a maximum of 20, with midrange targets for walking and strength training. Participants should think about and evaluate their own "exertion" based on their experience of muscle fatigue, breathlessness, and emotions or "sense" of how hard they are exercising.
Because RPE is assessed through perception, not weights, speed, time, or distance, this rating is entirely individual and it may take time for participants to understand. It will require practice and a level of honesty from participants. They must rate the difficulty as they subjectively perceive it, and only they will know if they are overchallenging or underchallenging themselves.
The target intensity for walking is an RPE of 11 to 13. Exercising at this level, participants should perceive the exercise as "not especially hard." They are exerting themselves but are comfortable and have no problem continuing (RPE 11), or "somewhat hard" (they are tired but not excessively tired and they do not have great difficulty continuing to exercise (RPE 13).
The target intensity for strength exercises is 15 or 16, meaning that exercise should feel "hard." They can still go on, but they have to push themselves to continue and they do feel tired. For example:
- An individual who wants to walk at a moderate intensity level would aim for an RPE of "somewhat hard" (13). If he describes his muscle fatigue and breathing as very light (RPE of 8), he would want to increase his movements. Conversely, if he describes his intensity level as "very, very hard" (RPE of 19), then he should slow down in order to achieve his targeted intensity level and to ensure safety.
As part of the introduction to the STEP program, the program leader will work with participants to teach them about the RPE scale and how it relates to exercise targets in the STEP program. [link to behavior session 1] When you present the RPE handout to participants, it is important to emphasize these key points:
- Perceived intensity is how strenuous the exercise feels to them. Have them think about the strain and fatigue of their muscles and their sense of breathlessness and describe how it feels.
- It is important for participants to think about the intensity of exercise in terms of what they perceive, not what they think the program leader wants to hear. Participants should be encouraged to be honest and not overestimate or underestimate the intensity of their activity. The program is ongoing and there is ample time to "ramp up" their abilities. They should assess their honest level based on what is challenging but not unsafe or upsetting.
- Targeted intensity is important. Staff should consistently remind participants about the importance of engaging in physical activity that they perceive is challenging, a level above "light."
- Insufficient RPE intensity does not produce the desired effect. In order to improve in their functional abilities, participants MUST exercise at a sufficient RPE. They will not receive the same benefits from exercise done at lower RPEs.
- Excessive intensity can lead to injury and diminished interest in the program. It is important to emphasize that "too much too soon" is NOT the goal of the STEP program. The goal is to determine the appropriate intensity based on one's abilities and then strive for improvement over time.
Create a large poster-size copy of the RPE scale and post it in the room in which you lead the physical activity intervention so that you can refer to it throughout the program. Also provide a copy to participants in the first behavior session. Refer to this scale frequently throughout the program to help participants pace themselves and build strength.
Rating of Perceived Exertion (RPE) Scale
|7||Very, Very Light
This requires minimal effort. It is easy and comfortable.
Like walking slowly at your own pace for several minutes.
Not especially hard. It feels fine and is no problem to continue.
|Walk (11 to 13)||12|
You can still go on but you have to push yourself and you feel tired
|Strength (15 to 16)||16|
You are so tired that you cannot continue much longer.
|19||Very, Very Hard
This is as hard as you have ever experienced.
Exercise Program Format
The STEP exercise program consists of independent walking and group classes focusing on lower extremity strength training. This section provides information on how to organize the strength training classes.
Strength Class Content
Each class is composed of three parts:
- Warmup (5 to 10 minutes).
- Exercises (10 to 30 minutes).
- Cool-down and stretching activity (10 to 15 minutes).
Since participants will start the program with varying abilities (explained below), you will need to tailor these activities to individual abilities. The warmup period should last 5 to 10 minutes, the strengthening exercises 10 to 30 minutes, and the cool-down and stretching activity 10 to 15 minutes.
Duration of Strength Class
Most strength classes will range from 30 to 60 minutes. Typically, the classes are longer when the program is newly established and when new participants join. As participants become familiar with the routine and use of the ankle weights, the strength training will run more quickly.
In addition, as participants become fitter, the time distribution for each segment will gradually change. Early in the program, participants may be shifting from sedentary to active lifestyles. This means your initial classes may need to include shorter bouts of strength exercises (10 minutes) and longer periods of warmup and cool-down (10 to 15 minutes of each). As participants become stronger and more confident, you should increase your focus on strength exercise (30 minutes) and adjust the warmup and cool-down periods (5 to 10 minutes each).
During the first 9 weeks, most facilities hold the strength classes and behavior coaching sessions back to back. This arrangement often results in higher participation by minimizing the number of separate activities participants need to remember and motivate themselves to attend. It also allows you flexibility to schedule additional sessions if you have a large group of interested participants, if you want to hold makeup sessions, or if your program leader's availability varies. Ultimately, scheduling should be done according to the needs of your individual facility. It is up to the program coordinator and leaders to assess these needs and determine the best way to meet them.
For safety and to enhance participants' experience, limit the number of participants to 12 to 16 per instructor. If you are team teaching, then you can increase the number of participants accordingly.
It's good practice to offer your physical activity program in blocks of classes. Many communities offer classes in a 3-month or quarterly time block. Having definite start and end dates has several advantages:
- It creates an opportunity for celebrating goals such as regular class participation or increases in the amount of ankle weight used.
- It provides logical timing for recruiting and encouraging new participants to join.
- It provides a logical time for you to change or modify your program.
There are a number of forms that you can introduce to participants in conjunction with the physical activity program. Participants should be strongly encouraged, but not required, to use these forms. Forms serve multiple purposes, monitoring progress and adherence to program goals, facilitating goal setting, and supporting other behavior change strategies that are critical to success in the program.
Realistically, participants may feel the paperwork burden is too heavy between the logs for strength class and the handouts and homework they receive in the behavior coaching sessions. The Physical Activity Tracking Sheet is the most important, given that it allows them to track both walking and strength training minutes and reminds them of the overarching STEP goal (150 minutes of exercise a week). The behavior coaching sessions will reinforce the use of this log by asking participants to reflect on their exercise minutes.
Encourage participants to complete all or as many logs and handouts as they are willing; however, any amount of tracking or homework they do is a step in the right direction.
You can use the participation roster in several ways. Posted on the wall, it can serve as a motivational tool for class participants to track adherence to the goal of participating in the STEP class weekly. It also lets the STEP program leader see at a glance if an individual has missed multiple classes, which might prompt you to contact the participant and offer support and encouragement to rejoin the program.
On the other hand, you do not want to introduce an element of competition or shame that might discourage some participants or undermine the supportive environment you are trying to create. If you anticipate these issues or sense them once class has begun, there is no need to post the participation roster. Simply keep the roster with your program records and encourage participants to track their attendance individually.
Physical Activity Tracking Sheet
Participants should complete the Physical Activity Tracking Sheet or log on a weekly basis. Here, participants will record the number of minutes they spend exercising each week. There are separate lines for them to record time spent in STEP strength classes and time spent outside of class doing an aerobic activity, such as walking. The tracking sheet is a great tool to help participants monitor their progress every week and motivates them to continue their involvement in the STEP program. You should introduce the tracking log in the first coaching session so that they can start keeping track of their exercise time immediately. (go to Coaching Session 1)
Weight Training Log
The purpose of the weight training log is to record the ankle weight participants use in each strength class and to track individual progress. Recording this information provides another means for participants to monitor changes in their physical abilities. In addition, if your STEP classes are led by different staff members, the weight training logs ensure that residents know what weight to use to continue building their lower extremity strength. Log sheets can be stored in a simple 3-ring binder that contains a sheet for each participant, dates of class attendance, the weight used for each exercise, and the number of repetitions. Also remember to print the log in large type so that both residents and trainers can refer to this important resource. (link to Weight Training Log)
Group Facilitation Tips
Leading a physical activity group is an art. Here are some suggestions that will help you monitor and engage your participants:
- Greet people by name as they arrive at the class and thank them when they leave.
- Make sure each participant can see and hear your instructions and demonstrations.
- Watch every participant perform the exercises and ensure they are using proper technique. It is important for safety, but they will also appreciate your attention.
- Ask participants how they are doing with the current weight in their ankle weights and make sure the weight is appropriate.
- Remind your participants about exercising at the targeted RPE.
- Foster a social atmosphere—get group members to chat, tell jokes, etc.
- Be enthusiastic. If you're not having fun, your participants probably aren't either.
- Make eye contact with each participant during class.
- Keep it interesting (e.g., use music, have a theme day, change the props you use, post trivia questions and fitness quotes).
- Acknowledge accomplishments big and small.
- Remind participants about the "big picture" and that the STEP program is more about the "long haul" than short-term gains.
- Think about incentives (e.g., t-shirts, water bottles, pedometers), which are a great way to encourage and motivate your participants.
Safety Techniques and Guidelines
Determine Readiness for Physical Activity
In spite of the benefits of physical activity, not all interested residents will be healthy enough to participate in STEP. Residents should consider the state of their health and assess whether STEP is right for them. A number of online resources can aid them in this decision. One popular online tool is the Physical Activity Readiness Questionnaire (PAR-Q). The PAR-Q provides a series of questions that participants answer to determine if they should contact their physician regarding their involvement in an exercise program. You will find the link below in the References and Resources section.
Obtain Medical Clearance To Exercise
Ideally, your participants will contact their physician before starting any exercise or physical activity regimen. This allows the physician to communicate any limitations or contraindicated movements specific to that individual. However, many senior communities do not require clearance for participation. Staff should follow local procedures that govern residents' participation in exercise programming.
Always Have a Warmup and Cool-Down at Each Session
Make sure participants understand the importance of warmup and cool-down at each STEP strength training session and as part of their regular walking routines.
Discuss Proper Breathing Techniques
Proper breathing techniques are essential for the safe and appropriate performance of strength training exercises. It is fairly common for people to hold their breath during weight training. Direct their attention toward their breathing and guide them to breathe through their mouths continuously and regularly throughout the exercises. This can be done in one of two ways.
- Counting aloud to keep the pace of the exercises. Talking (counting) ensures they are not holding their breath.
- Inhaling before the lift, exhaling through the mouth while lifting, and inhaling through the nose during the lowering phase. Sometimes it takes a little practice, but this is a very effective technique called "exhale during exertion."
Additional guidance on strength training movements and breathing is provided in Chapter 7.
Emphasize That Strength Training Should Be on Alternate Days
A break between sessions gives muscles a chance to recover. If strength classes are held on consecutive days or multiple times in a single day, participants should be discouraged from attending classes on consecutive days or multiple times in a single day. Allowing for recovery time actually strengthens muscle and allows it to repair from the workout.
A rest day also prevents mental exhaustion and burnout, which is better for participants' short-term attendance and long-term goals. Participants can walk on "rest days," which will not cause them additional soreness and could help loosen and warm sore muscles. Walking is a critical component of the STEP program and should not be neglected.
Facilitate a Slow, Gradual Progression of Weights
While some participants might be wary of ankle weights and overexertion, others may be very enthusiastic during strength training exercises. The amount of weight that is appropriate for each individual will vary, as will the rate at which people increase their weights. Program staff must work with participants individually to determine an appropriate initial weight and to decide when it is time to increase weight. Regardless of their eventual progression, all participants should start at a low weight to ensure that they do the exercise movements correctly. This is the key to long-term success and safety.
Monitor Exercise Intensity
Using the RPE scale, remind participants frequently that the optimal target intensity is 11 to 13 for walking and 15 or 16 for strength training. Participants should be actively and regularly discouraged from exercising beyond the intensity levels designated for the STEP program.
Discourage a Competitive Atmosphere in the Group Setting
A competitive atmosphere can sometimes lead participants to overexert themselves in class, which can lead to safety issues. A competitive atmosphere can also be a turnoff to seniors who seek a more collegial group environment. The purpose of the STEP program is to improve each individual's functional ability, not to determine who can do more repetitions or weight. It is therefore important to ensure that group classes do not take on a competitive feel.
Emphasize general victories, such as increasing weight or repetitions, or maintaining strength from the previous week. Praise everyone who comes to class regardless of performance, because any workout is better than no workout when it comes to reaching long-term goals.
Be Aware of Environmental Hazards
Conditions such as excessive heat or cold or a slippery floor may have serious health consequences. Chairs that are too close together can cause participants to bump or jostle one another and lose their footing. Be aware of potential hazards in your particular classroom and take whatever steps are needed to minimize them. Always make sure your residents are safe and comfortable.
If people are out of town or take a break from the program for health reasons, remind them that they can rejoin STEP at any time. Similarly, if participants worry that they are not meeting the STEP goals (either in terms of time walking or class attendance), assure them that participation is paramount. Even if they fall short of the target goals, they are still succeeding in changing their health behaviors and they should continue to walk and attend class when they can.
References and Resources
Listed below are resources and references for additional information on planning an effective exercise program for older adults:
- Exercise & Physical Activity—Your Everyday Guide from the National Institute on Aging. Order from National Institute on Aging Information Center, P.O. Box 8057, Gaithersburg, MD 20898-8057; 800-222-2225 (toll free); 800-222-4225 (TTY/toll free); http://www.nia.nih.gov.
- Exercise for Frail Elders, Elizabeth Best-Martini and Kim A. Botenhagen-DiGenova, Human Kinetics; http://www.humankinetics.com.
- Exercise for Older Adults—ACE's Guide for Fitness Professionals, Richard T. Cotton, Editor, American Council on Exercise; http://www.humankinetics.com.
- Physical Activity Instruction of Older Adults, C. Jessie Jones and Debra J. Rose, editors; http://www.humankinetics.com.
- PAR-Q: Physical Activity Readiness Questionnaire: http://www.americanheart.org/downloadable/heart/1176844249407Phys%20Activity%20Questionnaire.pdf. [Plugin Software Help]
- For Fitness Resources, including the Senior Fitness Test Manual, call Human Kinetics at 1-800-747-4457. http://www.HumanKinetics.com.