Chapter 7: Exercises

Staying Healthy Through Education and Prevention (STEP)

Woman jogging

Overview

Physical activity in the STEP program involves aerobic fitness, strength training, flexibility (stretching), and balance. The goal of the STEP program is to have participants gradually build to a target of 150 minutes of moderate physical activity each week over a period of about 2 months. Some of this activity is conducted in group classes that focus on lower body strength and balance, but most of the activity in the STEP program consists of walking and is done outside the class setting, either individually or in groups.

Objectives

Chapter 7 provides the information needed to conduct the strength training and flexibility exercises in STEP classes. It also provides instruction on how to engage participants in independent walking in a way that helps them meet the goals of the STEP program.

After reading this chapter, you will:

  • Understand the difference between the aerobic and strength training components of STEP.
  • Know how to set up and maintain interest in the walking component.
  • Understand the strength exercises and how to lead these exercises.
  • Know the stretching exercises used during the warmup and cool-down periods.

Terms

  • STEP classes: Regular, prescheduled time slots—often held multiple times per week—in which STEP participants meet in groups to engage in strength and flexibility exercises. For the first 9 weeks of the STEP program, these classes are also the setting for the behavioral coaching curriculum.
  • Aerobic exercise: Activities that involve or improve oxygen use in the body. Aerobic exercise is often performed at moderate levels of intensity for extended periods of time.
  • Strength training exercise: Activities that use resistance and weights to develop muscles.
  • Flexibility exercises: Activities that improve the ability of joints to move through a full range of motion.

Key Points

  • The STEP program consists of aerobic activity such as walking, as well as lower body strength training and balance exercises.
  • Walking should be done at an intensity of 11 to 13 on the Rating of Perceived Exertion (RPE) Scale.
  • Strength training should be done at an intensity of 15 to 16 on the RPE scale.
  • Attendance at the STEP strength classes does not mean participants have satisfied the program requirements: Participants must also walk regularly at a moderate level on most days to benefit fully from STEP. Both strength classes and walking are important.
  • The goals of the program are to exercise 150 minutes per week at the appropriate intensity to help increase strength, flexibility, and balance. And, of course, to be healthy.

Components of the STEP Physical Activity Program

The STEP program includes aerobic, strength, flexibility, and balance activities.

  • Aerobic: Walking is the primary mode of aerobic activity in the STEP program because it is popular, cheap, and easy to do in senior housing communities. Walking can be done independently or in groups at a moderate level of exertion on the RPE scale.

    Alternatives to Walking

    The STEP Program focuses on walking for aerobic exercise but we realize walking is not always an option for certain people. If a pool is available, water aerobics, lap swimming, and "water walking" are acceptable alternatives to walking. For people with painful joints, the buoyancy of the water will take pressure off the joints and make people "weigh" less. If people usually use walkers on land, they should hold onto a pool noodle for balance and safety when walking in the water.
    Note: Everyone, regardless of physical condition, should wear pool shoes with grip soles for safety.

  • Strength and flexibility: STEP involves instructor-led classes that teach strength and flexibility exercises and focus on the lower body. Strength exercises involve ankle weights and body weight. Some are conducted sitting while others are done standing. Flexibility exercises are done after strength exercises to loosen the muscles and prevent injury.
  • Balance: Balance exercises are done by participants at home. Staff train participants in these exercises during class and provide an illustrated handout that participants can use when exercising at home.

As STEP program staff, you should be available for ongoing consultation, encouragement, and guidance in all aspects of the STEP program. Participants often need reminders about the goals of the program and target intensity levels. They may also need help solving problems, such as lack of motivation.

The first 9 weeks of the STEP program involve a lot of coaching and emphasis on behavioral strategies to help participants achieve their short-term strength goals AND to ensure long-term compliance with STEP program goals: 150 minutes of exercise each week. These aspects of the program are discussed in Chapter 8.

Walking Program

In the initial behavioral coaching sessions, explain to participants that walking is the major aspect of physical activity in the STEP program. Guides for coaching sessions can be found in Chapter 9. The guide includes class instructions for staff and handouts for participants to take home to familiarize themselves with STEP. Handouts review the schedule for building to 150 minutes of exercise per week, the strength exercises, and the number of minutes they should walk each week in their first months with the program.

Setting Up the Walking Program

The first session is also the time to introduce participants to the Rating of Perceived Exertion (RPE) Scale to help them target an appropriate level of intensity during their exercises. When walking, they should target their intensity at 11 to 13 ("somewhat hard"). Discourage them from exercising at levels that are too hard (15 or greater) or not hard enough (below 11).

Participants can walk indoors, outdoors, or on treadmills, if these are available. Participants may want to simply walk in the hallways or outdoors but you can find ways to make walking easier, more motivating, and more fun for them. For example, you might want to:

  • Establish indoor walking courses and make participants familiar with these courses.
  • Mark indoor courses with bright tape or another "trail marker."
  • Establish walking groups at various times during the day and week to promote group walking.
  • Encourage participants to find a "walking buddy" they enjoy walking with and socializing with.
  • Establish a "walking log": a 3-ring binder with a page for each participant to track his or her walking times.
  • Present participants with certificates for reaching key milestones (e.g., 500 minutes of total walking or one month with 120 minutes of walking each week).
  • Make announcements in resident newsletters highlighting walkers' achievements.

The more support you can provide (such as courses and walking buddies), the easier it will be for participants to reach their STEP goals and the more fun they will have doing it. You may also find that when your participants see results, other residents become interested. With any luck, over time walking and exercise will become part of the culture of your facility, and residents will motivate each other to maintain good habits.

Maintaining the Walking Program

As the program progresses, participants may focus their efforts on strength training because it is more structured. They may concentrate less on the walking portion because it is done independently of staff. Help them avoid this bias toward strength training.

Encourage Walking

You know what the heart doctors say: "Walk your dog twice a day, even if you don't have one." Use the weekly strength training sessions as an opportunity to remind participants how important walking is, to encourage them to use the walking log (if one is being used), to promote the achievements of "super walkers," and to encourage all participants to remain actively engaged in walking. This encouragement can take place outside of class as well, such as when staff members see participants at meals or other activities.

Problem-Solve

If you realize that some participants are only attending STEP strength classes and are not walking much, intervene and problem solve with them to identify strategies to get them walking. We will discuss some helpful strategies in Chapter 8 and 9.

Keep It Fresh

Some people enjoy routine but others get bored walking the same "courses" and may lose interest in walking altogether. Consider changing the indoor courses from time to time to keep things fresh. If you have space for multiple courses, change one (the "blue course") every month or two for those who like variety and keep one (the "yellow course") the same for those who prefer routine. Pedometers are also an excellent way to help participants set goals, keep track of their walking (especially when the courses change), and stay motivated by striving to improve their walking time and intensity. Remember that the number one goal is minutes of walking but it is fun to note that approximately 2,000 steps equal a mile.

Take a "Road Trip"

Add a pedometer program focused on a destination. As a community, or as individuals, choose a destination like the Grand Canyon or San Francisco. Tally up how many miles it would take to walk there and plot out a route to get there. Then set goals to get everybody where they want to go. You can even plan "stops" along the way, as if people were on a road trip. Stops will keep the sense of fun and motivation alive. Track everyone's progress with a map on the wall and turn it into a party at the finish to celebrate the journey and the destinations.

Strength Training

Starting Equipment

The STEP strength training program involves lower body movements, some of which use ankle weights. We recommend that you purchase ankle weights with multiple "slots" so that weights can be added or taken away in increments of ½ lb (for 10 lb weights) and ¼ lb (for 5 lb weights). We also recommend ankle weights or "cuffs" with Velcro rather than buckles, which can be uncomfortable and difficult to use.

Cuffs

Your first meeting should be more of an orientation session than an exercise session. Most participants won't have used ankle weights before, so be sure to give them time to get comfortable with the equipment. Teach them how to put the cuff on and take it off. Allow them to wear the cuffs without any weight in them in order to become accustomed to the feel.

Weights

Only after participants are comfortable wearing the cuffs should actual weights be inserted into the slots. You can add weights during the initial meeting or at Session #2, depending on how your participants react to the equipment. If they seem comfortable, this could be a good time to determine the appropriate weight each person should use for each exercise.

Exercise Movements

When participants seem comfortable with the ankle cuffs and how to add and subtract weight, move on to an exercise practice session (you may have time in Session #1 but may need to wait until Session #2). Teach them the exercises one at a time and allow them to practice the movements until they feel confident. Encourage them to wear the ankle cuffs (without weight) during the practice session—after all, they will be wearing the cuffs during class.

During the practice session, don't worry about performing a certain number of repetitions or about the targeted RPE intensity. Focus on perfecting the movements with good form. In subsequent strength training sessions when "it counts," start monitoring and recording repetitions and RPE on the tracking sheet.

When they are ready to practice, tell participants that the strength training component of the STEP program begins with a warmup and is followed by several lower body strength exercises. The strength exercises are followed by a brief cool-down consisting of flexibility exercises. Then demonstrate the following elements:

  • Warmup.
  • Wide leg squat.
  • Heel raise.
  • Seated leg extension (with ankle weights).
  • Standing leg curl (with ankle weights).
  • Side leg raise (with ankle weights).
  • Cool-down (stretching).

Warmup

The warm up session should last 5 to 10 minutes to adequately warm up the muscles and loosen the joints. We recommend that you do the following exercises for approximately 1 minute each:

  • Alternate stomping feet (marching or walking). Start slowly and increase speed.
  • Alternate moving feet in and out (gently extend leg and tap heel, bring back in).
  • Alternate knee lifts (as though walking through snow).
  • Alternate leg extensions (bend leg up and extend forward).
  • Alternate toe point and flex.
  • Alternate ankle rotations (foot only) clockwise and counterclockwise.
  • Both feet: heel lift to toe rocking.
  • Shoulder shrugs.
  • Backward shoulder rolls.
  • Seated leg stretch:
    • Sit on edge of chair, one leg out straight.
    • Bend ankle up, pointing toes toward ceiling.
    • Tighten muscles on top of thigh by pushing knee down toward floor.
    • Take a deep breath and hold stretch for 6 seconds.
    • Relax and switch legs.

Sets and Repetitions for Strength Exercises

For each strength exercise, participants should perform 10 repetitions (one set), rest for 1 minute, and then perform a second set. Some participants will find this routine easy, and others will find it extremely difficult. Once things get started, you may need to adjust participants' weights so that they begin at a comfortable level. Remind everyone to move at their own pace and make sure the leader or coach is aware of individual needs and accommodates them with sensitivity and positivity. Participants who get discouraged will be unlikely to return to subsequent classes, so spend the extra time to ensure that every participant feels successful in their efforts.

For the leg extension, leg curl, and side leg raise exercises, participants should alternate legs during the set, performing one repetition on the left leg, one repetition on the right leg, and so on. As noted earlier, target intensities of STEP program activities are measured using the RPE scale . Participants should do their strength exercises at an RPE of 15 to 16.

Summary

  • 2 sets of each exercise.
  • Wide leg squat—10 reps per set.
  • Heel raise—10 reps per set, both legs simultaneously.
  • Seated leg extension (with ankle weights)—alternate legs, 5 reps per leg, 10 total.
  • Standing leg curl (with ankle weights)—alternate legs, 5 reps per leg, 10 total.
  • Side leg raise (with ankle weights)—alternate legs, 5 reps per leg, 10 total.

Starting Weight and Progression

For exercises that use ankle weights (leg extension, leg curl, side leg raise), the instructor should determine the appropriate starting weight for each participant for each exercise. During the first strength training session, ankle weights should contain a small amount of weight (3 lb for men and 2 lb for women). Note that these are recommended weights to start the program. Some people will find this difficult while others will find it easy. Also remember to use the same amount of weight on each leg, even if one leg seems stronger.

During early strength training classes, staff should orient the participant to strength training with weight settings that are "very easy" for the participant to use. If the recommended weight is too much for a participant, the weight should be reduced.

  • When the weight is light, participants can safely learn proper technique for each exercise and take the time to learn to breathe properly.
  • After mastering proper technique and breathing, participants can start to progress and work toward meeting the target intensity for an effective workout.
  • Participants will experience a sense of accomplishment as they progress through the program, learn new skills, and develop new walking and strength training habits.

After the first week of strength training, participants should be encouraged to complete each physical activity with weights that they can lift at least 10 times with moderate difficulty (RPE rating of 15 to 16).

  • If one or more of the exercises seems too difficult (e.g., if the participant cannot complete 10 repetitions), then the weight is too heavy and should be reduced.
  • Work closely with participants during the early weeks of the program to ensure proper identification of the ideal starting weight.

Over time, as participants improve their lower body strength and become confident, instruct them to increase their weights to maintain an exercise intensity of 15 to 16. Retrain them regularly on the use and interpretation of the RPE scale to ensure their continued understanding of program targets for intensity.

Soreness

Although the warmup and cool-down should prevent excessive soreness, remind participants that it is okay to be a little sore. Soreness indicates muscle growth and progress being made. On the other hand, if the soreness is intense and long lasting, encourage participants to decrease their weights slightly. Remind them that they are always searching for balance—weights, repetitions, and intensity that are not too hard but not too easy. You will be an important advisor as they seek this balance.

Clothing

Everyone should wear comfortable clothing to STEP classes. A comfortable pair of socks is also advisable to prevent skin irritation where the ankle weights are secured. High-heeled shoes are not recommended for any STEP program activities.

Instructions for Strength and Flexibility Exercises

Wide Leg Squat

Starting Position:

Participants sit with their feet slightly greater than shoulder-width apart and about 6 to 8 inches in front of a chair. Their arms should be crossed in front of their chest and shoulders relaxed.

Exercise:

  • Participants pause for an inhale in the seated position.
  • Leaning slightly forward, they EXHALE to stand up, making sure to keep their knees directly above their ankles. While doing this, they should push up from their heels through their lower legs, thighs, hips, and buttocks, which will help keep their knees from moving in front of their feet.
  • Leaning slightly forward at the hip, participants aim their buttocks into the chair and slowly lower themselves back to a seated position. During this exercise, keep their chest up (lifted) and their back, neck, and head in a straight line.

Sets and Repetitions:

  • 2 sets, 10 reps per set, both legs simultaneously.

Complete 10 repetitions using both legs for the set. Rest for about 1 minute; then repeat for a second set of 10.

Make sure participants:

  • Lean just slightly forward when beginning the move.
  • Don't allow their knees to come in front of their toes.
  • Tighten their abdominal muscles.
  • Don't hold their breath.
  • Keep their chest lifted throughout the movement, so that the body doesn't curl forward.
  • Are looking straight ahead rather than down at the floor.

If participants experience any knee pain, check their technique: Their knees should not move forward past their toes during the movement. The thighs should stay parallel to each other; make sure the knees do not drift inward.

Wide Leg Squat video (Flash video, 1 min., 28 sec.; 10.0 MB) (Download Flash® Player )

Heel Raise (Without Ankle Weights)

The heel raise is an excellent physical activity that improves balance and ankle flexibility while strengthening the feet and calves to provide more power for our walking stride. As participants get stronger, they can progress from Level 1 to Level 2 of the exercise.

  • Level 1: Heel raise on both feet with hand support.
  • Level 2: Same as Level 1 but without hand support.

Start with Level 1.

If participants' calf muscles are weak, they may not be able to raise their heels very far. They can improve the strength of these muscles at Level 1 until they are better balanced and can lift their heels more easily. Then proceed to Level 2.

Starting Position:

Participants should stand 12 inches away from a wall (or back of a chair), with feet about 12 inches apart.

  • Level 1: Resting their fingertips lightly on a wall (or back of a chair) to help maintain balance.
  • Level 2: Standing in front of the wall (or chair) without touching it. For safety's sake, always perform this physical activity with a wall (or chair) in front of them.

Exercise:

  • Participants slowly rise on the balls of their feet.
  • They hold the position for a slow count of 3.
  • They slowly lower their heels back to the ground.

Sets and Repetitions:

  • 2 sets, 10 reps per set, both legs simultaneously.

Complete 10 repetitions using both legs for the set. Rest for about 1 minute; then repeat for a second set of 10.

Make sure participants:

  • Maintain good upright posture.
  • Do the heel raises slowly—many people have a tendency to raise and lower themselves too quickly.
  • Don't hold their breath.

Heel Raise video (Flash video, 1 min., 14 sec.; 8.0 MB) (Download Flash® Player )

Seated Leg Extensions (With Ankle Weights)

Starting Position:

The participants sit back in a chair with their feet shoulder-width apart and knees slightly separated and directly above their feet. If they are tall, you may need to make some adjustments so that their thighs are flat and their knees aren't raised above their thighs. Some suggestions are using a taller chair (or one with a higher seat), stacking two chairs to raise the seat, or placing a pillow or towel on the seat of the chair to raise the participant. However you choose to address the issue, it is important that participants start in the correct body position.

Exercise:

  • Keeping the thigh in contact with the chair and the foot flexed, participants Exhale and slowly straighten the left leg until it is fully extended, with the foot off the ground.
  • They then pause for a breath.
  • They slowly bend the knee and lower the left foot back to the ground.

Sets and Repetitions:

  • 2 sets, alternating legs, 5 reps per leg, 10 reps total.

Complete 10 repetitions, alternating the right and left legs for the set. Rest for about a minute; then repeat for a second set of 10.

Make sure participants:

  • Don't arch their backs. Contracting the abdominal muscles should help stabilize the lower back and prevent discomfort.
  • Straighten their legs as far as possible at the end of the lift—the last part of the muscle contraction is the most important.
  • Don't hold their breath.

Seated Leg Extensions video (Flash video, 1 min., 26 sec.; 9.5 MB) (Download Flash® Player )

Standing Leg Curl(With Ankle Weights)

Starting Position:

Participants stand with their feet slightly apart behind a chair with their hands gently resting along the top of the chair back for balance. They should then shift their body weight to their left leg while keeping the knee slightly bent.

Exercise:

  • Keeping their thighs side by side and knees directly under their hips, participants slowly lift their right foot toward their buttocks until their upper and lower leg form a 90-degree angle.
  • They pause for a breath.
  • They slowly lower the right foot back to the ground, shift their weight to the right leg, and repeat the move with the left leg.

Sets and Repetitions:

  • 2 sets, alternating legs, 5 reps per leg, 10 reps total.

Complete 10 repetitions, alternating the right and left legs for the set. Rest for about a minute; then repeat for a second set of 10.

Make sure the participants:

  • Keep thighs parallel and hips and knees aligned.
  • Don't arch their backs as they do the exercise.
  • Don't let the knee or thigh move forward as the lower leg curls up.
  • Don't hold their breath.
  • Stay in a "pain-free range." The movement may be difficult but the knee should not hurt.

Standing Leg Curl video (Flash video, 1 min., 35 sec.; 10.3 MB) (Download Flash® Player )

Side Leg Raise (With Ankle Weights)

Starting Position:

Participants stand tall with feet parallel and hands gently resting on the back of a chair for balance.

Exercise:

  • Keeping their toes pointed straight ahead, they EXHALE and slowly lift their right leg out to the side until their foot is 5 to 8 inches off the ground. The knee on the supporting leg should not lock.
  • They pause for a breath.
  • They lower the right leg slowly back to the ground and repeat with the left leg.

Sets and Repetitions:

  • 2 sets, alternating legs, 5 reps per leg, 10 reps total.

Complete 10 repetitions, alternating the right and left legs for the set. Rest for about a minute; then repeat for a second set of 10.

Make sure participants:

  • Keep their bodies upright during this exercise, not leaning to one side.
  • Raise their legs no more than 12 inches off the ground.
  • Keep their fingertips on top of the chair for balance.
  • Keep their feet straight, not angled, and lead with the heel.
  • Don't hold their breath.

Side Leg Raise video (Flash video, 1 min., 26 sec.; 9.6 MB) (Download Flash® Player )

Cool-Down (Stretching)

Upper Back Stretch (Without Ankle Weights)
  • Participants stand (or sit) with their feet shoulder-width apart, their knees straight but not locked, and their hands clasped in front.
  • They rotate their hands so that their palms face the ground. Then they raise their arms to about chest height or until they feel a stretch.
  • They press their palms away from their body and feel a stretch in the neck, upper back, and along their shoulders.
  • They hold the stretch for a count of 20 to 30 seconds.

Upper Back Stretch video (Flash video, 1 min., 12 sec.; 7.8 MB) (Download Flash® Player )

Hamstring and Calf Stretch (Without Ankle Weights)
  • Participants stand facing a sturdy chair.
  • They slowly bend forward at the hip, keeping their legs straight without locking their knees. Resting their hands on the back or seat of the chair with their elbows slightly bent, they should feel a stretch in the back of their upper and lower legs. The back should be kept flat.
  • They hold the stretch for a count of 20 to 30 seconds.

Hamstring and Calf video (Flash video, 1 min., 6 sec.; 7.3 MB) (Download Flash® Player )

Chest and Arm Stretch (Without Ankle Weights)
  • Participants stand with their arms down by their sides.
  • Clasping their hands together, they extend both arms behind them. Make sure the arms are straight before lifting.
  • They should keep the chest forward and shoulders back during the stretch.
  • They hold the stretch for a count of 20 to 30 seconds.

Chest and Arm Stretch video (Flash video, 59 sec.; 6.4 MB) (Download Flash® Player )

Page last reviewed February 2011
Internet Citation: Chapter 7: Exercises: Staying Healthy Through Education and Prevention (STEP). February 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/stepmanual/step7.html