o

Q.

U
D

to

Exercise Adherence Following

Physical Therapy Intervention in
Older Adults With Impaired Balance
Background and Purpose. This study looked at adherence, and factors
affecting adherence, to a prescribed bome exercise program (HEP) in
older adults witb impaired balance following discbarge from physical
therapy. Subjects. The subjects were 556 older adults (^65 years of
age) who were discharged from physical therapy during the period
2000 to 2003. Methods. A survey was developed to determine participation in a HEP. Univariate logistic regressions identified speciftc
barriers and motivators that were associated with exercise participation
following discharge from physical therapy. Results. Ninety percent of
respondents reported receiving a HEP; 37% no longer performed it.
Change in health status was the primary reason for poor adherence to
a HEP. Eight barriers (no interest, poor health, weather, depression,
weakness, fear of falling, shorttiess of breath, and low outcomes
expectation) were associated with a lack of postdischarge participation
in exercise. Discussion and Conclusions. Exercise adherence following
discharge from a physical therapy program is poor among older adults.
Barriers, not motivators, appear to predict adherence. [Forkati R,
Pumper B, Smyth N, et al. Exercise adherence following physical
therapy intervention in older adults with impaired balance. Phys Ther.
2006;86:401-410,]

Key Words:

Barriers, Exercise.

Rebecca Forkan, Breeanna Pumper, Nicole Smyth, Hilary Wirkkala, Marda A Ciol, Anne Shumway-Cook

Physical Therapy , Volume 86 , Number 3 , March 2006

401

he benefits of exercise in older adults are well

established. Research has shown that for older
adults (S65 years of age) exercise can reduce
frailty,' increase walking speed,^'^ improve the
ability to live independently,* and increase life expectancy.^'' Exercise significantly reduces the risk for cardiovascular disease,^ adult-onset diabetes, and osteoporosis,'*'^'^ and it is associated with a reduction in health care
costs.^'3 In addition, participation in regular exercise can
significantly improve balance and reduce the risk of falls
in older
"'-^* have identified a variety of factors that
determine adherence to exercise in older adults. Some
of these factors increase adherence (motivators),
whereas others decrease adherence (barriers). For
example, one of the strongest motivators affecting exercise adherence in older adults is self-efficacy (the concept that a person is capable of controlling his or her
own behavior).'8-20 A second motivator is outcome
expectation, which is the belief that specific consequences will result from specific personal actions.'^'^
Resnick and Spellbring'^' examined factors that facilitated adherence to a walking program in a group of 23
older adults (^65 years of age) in a continued care
retirement community. They concluded that older
adults who adhered to exercise were characterized by an
inner motivation to exercise, a belief that they were able
to exercise safely (self-efficacy), a recognition of the
benefits of exercise (outcome expectation), the ability to
set specific activity-related goals, and an enjoyment of
walking.
Barriers shown to decrease adherence to exercise in
older adults include insufficient time, lack of social
support, no place to exercise, no transportation to an
exercise site, and insufficient money to either buy exercise equipment or join an exercise facility.^'^^^s Fear of
falling and fear of injury while exercising also are

significant barriers.''^^'^^ Finally, researchers'^"^'''^* have

found that increased stress and depression levels,
increased age, decreased health status, and lack of
enjoyment while exercising are associated with poor
exercise adherence.
According to the American Physical Therapy Association's Guide to Physical Therapy Practice (Guide), physical

therapists should strive to "restore, maintain, and promote not only optimal physical function but optimal
wellness and fitness and optimal quality of life as it
relates to movement and health."^''(P^') Prescribing and
promoting exercise, and educating patients on the
importance and value of exercise are key responsibilities
of the physical therapist. Several studies"'"'^^''''^ have
shown the benefits of participation in a multidimensional physical therapist-supervised exercise program on
balance, walking, and fall risk among older adults.
However, there is limited information on the degree to
which benefits are sustained after participating in a
physical therapy program. Some studies^-'''^'' have shown
that benefits of exercise gained during physical therapy
often are not maintained after discharge. Lack of sustained benefits from physical therapy may be the result
of poor adherence to a prescribed home exercise program (HEP) that is designed to promote the maintenance of improved function following discharge.
Little is known about adherence to a HEP prescribed by
a physical therapist in older adults following discharge
or about the factors that affect postdischarge adherence.
Thus, the purpose of this study was to develop an
instrument to survey older adults following discharge
from a physical therapy balance-training program in
order to: (1) determine postdischarge adherence and
factors that limit adherence to a prescriljed HEP and
(2) to characterize overall participation in exercise,
including both prescribed and nonprescribed exercise,
as well as factors influencing exercise participation.

R Forkan, B Pumper, N Smyth, and H Wirkkala were physical therapist students in the Division of Physical Therapy, Department of Rehabilitation
Medicine, University of Washington, Seattle, Wash.
MA Ciol, PhD, is Research Assistant Professor, Department of Rehabilitation Medicine, University of Washington.
A Shumway-Cook, PT, PhD, is Associate Professor, Division of Physical Therapy, Department of Rehabilitation Medicine, University of Washington.
Address all correspondence to Dr Shumway-Cook at Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Box
356490, Seattle, WA 98195-6490 (USA) (ashumway@u.washington.edu).
All authors provided concept/idea/research design, writing, and data analysis. Ms Forkan, Ms Pumper, Ms Smyth, Ms Wirkkala, and Dr
Shumway-Cook provided data collection. Dr Shumway-Cook provided project management, stibjects, facilities/equipment, and instittitional
liaisons.
The University of Washington Institutional Review Board reviewed and approved this sttidy.
The results of this sttidy were presented as a platform presentation the Combined Sections Meeting of the American Physical Therapy Association;
Februaiy 23-27, 2005; New Orleans, La.
This article zuas received May 25, 2005, and was accepted September 26,

402 . Forkan et al

2005.

Physical Therapy . Volume 86 . Number 3 . March 2006

Method
Subjects

Survey questionnaires were mailed to a convenience

sample of 630 adults aged 65 years and older who had
completed a physical therapist-supervised balancetraining program at either the University of Washington
Medical Center (Strong and Steady program) or the
Northwest Hospital (Safety and Gait Enhancement
[SAGF] program) between the years of 2000 and 2003.
The SAGE and Strong and Steady programs are hospitalbased outpatient physical therapy programs and were
developed by the same individual using a model for
improving balance and reducing fall risk through the
use of multidimensional exercises, including cardiovascular fitness, strength (muscle force-generating
capacity) and flexibility exercises, and balance and
mobility training, i"*
Older adults are referred to the Strong and Steady or
SAGE program by a physician because of balance and
gait impairments with a history of falls or near falls, an
increased risk of falls, or restricted activity levels due to
fear of falling. The majority of patients have impaired
balance and gait associated with chronic health conditions such as arthritis, diabetes, and hypertension; however, a limited number are referred with neurological or
degenerative pathology. Once admitted into the program, patients are examined by a hcensed physical
therapist who is trained in the special examination and
treatment procedures for these programs, and an individualized exercise program is developed following standardized treatment algorithm. Patients are treated 1 to 3
times per week for 4 to 6 weeks depending on the
severity of the balance problems.
An integral part of both programs is the establishment of
an individualized, home-based exercise program that
includes resistance strength training, flexibility exercises, cardiovascular fitness (usually a progressive walking program), and balance exercises, which are to be
performed on most days of the week. Patients are
provided with an exercise log to track adherence.
Patients are discharged with an individualized HEP, with
the instructions to continue this lifelong exercise program on a regular basis. Records of the duration of each
individualized session were not obtained for this study.
Patients from these 2 programs were selected to participate in the survey because both programs emphasize
lifelong exercise as an integral part of the discharge
plan. In addition, both programs keep computerized
demographic records of patients completing the program. Demographic information was used to conduct
the survey research.

Physical Therapy . Volume 86 . Number 3 . March 2006

Development of the Survey

A survey questionnaire was the selected method of data

collection in order to ensure subject anonymity, to
provide a standard form to decrease potential bias, and
to reach a large population inexpensively in a short
period of time.^^ The MEDLINE database was used to
review research examining factors affecting adherence
to exercise in community-dwelling older adults. In addition, research focused on developing instruments that
measure factors affecting adherence to exercise in older
adults were identified. Based on the outcomes of this
literature search, an initial survey instrument was developed that included 43 questions divided into 7 sections
to determine adherence to a prescribed HEP, participation in additional forms of physical activity excluding a
HEP, factors affecting adherence to a prescribed HEP,
barriers to and motivators for physical activity, fall history, general health status, and demographics.
A pilot survey was administered to 5 older adults and 3
physical therapists to reveal any limitations in the design
and sequence of questions and to clarify operational
definitions. The 5 older adults were selected from
among those volunteering to participate in a geriatric
physical therapy class. Of the 3 physical therapists
selected, one had extensive experience in survey
research, one was the coordinator of the Strong and
Steady program, and one was a therapist in the SAGE
program. A feedback questionnaire containing questions regarding time to complete the survey, clarity of
the survey questions, and difficulty in completing the
survey accompanied the pilot survey instrument. Revisions to the survey instrument included changes to the
sequence and layout of the survey, clarifications of
questions, and corrections to punctuation or spelling
errors. Because minimal revisions were made, a second
pilot survey instrument was not necessary.^''
The final survey instrument was a self-administered,
43-item questionnaire composed predominantly of
closed-ended questions. Closed-ended questions were
developed to provide uniform answers and to simplify
coding for data analysis.2'' One open-ended question was
included to give respondents an opportunity to describe
any new medical problems that had been diagnosed
since discharge from either the SAGE or Strong and
Steady program. Three questions included an "other"
category with prompts and lines provided to further
describe their response. Neutral and interesting questions were included in the beginning to establish curiosity and subject trust, whereas demographics and more
sensitive questions (eg, fall history, barriers and motivators, depression level) were placed at the end.^'' Questions were grouped according to topic, resulting in 7
sections. The subjects' answers were numerically coded

Forkan et al . 403

and analyzed using SPSS version 11.5.28* Nonresponses

were coded as missing.

exercise program. Outcomes expectation has been identified as an important factor in determining long-term
adherence to an exercise program among older adults,'^"

Survey Instrument

Section 1 began witb a question to determine wbetber

the subject received a HEP upon discbarge; if so, subjects were directed to answer questions that queried
participation in the prescribed HEP over tbe previous 4
weeks. Continuotis scale questions were used to quantify
behavior in terms of frequency of participation and
duration of each exercise bout, A closed-ended multiplechoice question regarding mode of exercise was
included in this section. The modes of exercise included
in the list of options were consistent with those that were
an integral part of the multidimensional HEP incorporated in the SAGE and Strong and Steady programs. The
fmal question in this section queried barriers associated
with the subject's HEP,
Due to lack of literature regarding barriers specific to
HEP adherence, literature on barriers shown to decrease
adherence to general exercise in older adults was
reviewed,''''^-2022,'2,s xhose barriers that appeared most
relevant to a HEP were selected and included in a "check
all that apply," multiple-choice question to determine
the reason or reasons for nonadherence to the HEP. An
open-ended opportunity for providing other reasons
that were not included in the multiple-choice answer was
provided.
Section 2 determined participation in exercise other
than the prescribed HEP, including frequency of participation in muscle strengthening, flexibility, and aerobic activity of at least 30 minutes in duration. These
modes of exercise and the duration for aerobic activity
are consistent with those prescribed for older adults by
American College of Sports Medicine and the Centers
for Disease Control and Prevention,''2-' Examples of
modes were provided to help the subject determine
participation acctirately. Section 3 consisted of questions
regarding availability of social support associated with
any physical activity and the location at which physical
activity was performed. These questions were included
because previous literature has shown these 2 items can
be associated with exercise participation,''''''^'^''' Section 4
included 2 subscales from a published survey instrument
examining factors affecting adherence to exercise in
community-dwelling older adults,^" The barrier subscale
contained 13 questions, and the motivator subscale
contained 11 questions.
In addition, a published single-question instrument'^'
was used to examine the subject's perception regarding
the expected outcome for participating in a home-based

Section 5 addressed fall frequency in the previous 3

months, fall-related injuries requiring medical attention,
and reasons for falls. Questions on fall history were
included because previous research has shown that
among older adults, falls can affect participation in
exercise.''''''^^'' Section 6 included questions related to
current health status. Previous research'^^"-'*'' has shown a
relationship between the presence of adverse health
conditions and exercise participation, A checklist of
common comorbidities was included to determine number and type of comorbidities. An opportunity for subjects to report other comorbidities was provided. Participants listed current prescription medications. Finally
a 2-question instrument was used to screen for depression,'''' Section 7 was composed of dichotomous and "fill
in the blank" questions to determine subject demographics, including the following: date of discharge from
physical therapy, age, weight, height, sex, and current
living status, to compile a subject profile.
Procedure

A cover letter explaining the purpose of the survey and

a self-addressed stamped envelope were included with
the survey questionnaire. Survey questionnaires were
returned anonymously; however, they were color-coded
for each program. Reminder postcards were sent out 4
weeks after the initial mailing. Completion of the questionnaire implied informed consent to participate in the
survey.
Data Collection and Analysis

Descriptive statistics coded and analyzed in SPSS'*'*' were

used to summarize demographic and health status data
in the 2 groups (SACE and Strong and Steady), Differences in baseline characteristics were analyzed using the
t test and chi-square test as appropriate to assess the
statistical difference between the 2 groups.
The number of people who reported receiving a prescribed HEP on discharge was analyzed. Mode, frequency, and duration of participation in the prescribed
HEP was described, and the most frequently reported
combinations of exercises were determined. For nonprescribed physical activity, percentages were calculated to
determine the frequency of participation in strengthening, flexibility, and aerobic activity.
Survey respondents reported on motivators and barriers
using a 4-point ordinal scale. Barriers were scored as
follows: l=strongly agree, 2=agree, 3 = disagree, and
4=strongly disagree; motivators were scored as follows:
4=strongly agree, 3 = agree, 2 = disagree, and l=strongly

* SPSS Inc, 23,S S Wackcr Dr, Chicago, IL, 60606,

404 , Forkan et al

Physical Therapy , Volume 86 , Number 3 , March 2006

disagree. A barrier subscale score was calculated by

summing all of the barrier scores for an individual
(0-52). Motivator subscale scores (0-44) were calculated in the same manner. The 4-point ordinal scale was
dichotomized with "strongly agree" or "agree" responses
combined and coded as "item endorsement," while the
"disagree" or "strongly disagree" responses were combined and coded as "no endorsement." Using the dichotomous scoring system, the total number of endorsed
motivators (0-11) and barriers (0-13) was calculated.
A t test was used to test for differences among the 2
groups (adults who reported participating in some exercise versus those who did not participate) in total
number of barriers or motivators. Univariate logistic
regressions were used to study the specific barriers and
motivators that predicted continued participation in
exercise following discharge from physical therapy. Participants were grouped into 1 of 3 categories based on
time since discharge: <12 months, 12-48 months, and
>48 months. Chi-square analysis was used to determine
whether adherence to exercise (either to a prescribed
HEP or nonprescribed physical activity) was associated
with time since discharge. All statistical tests were performed at the .05 significance level.
Results

Table 1.
Demographic and Health-Related Characteristics of Survey
Respondents"
Strong

SAGE

and
Steady

81.93
6.00
68-99

81.04
7.08
65-91

.54

25.41
4.37
16.68-40.44

25.24
4.04
18.34-35.95

.85

Sex, female (%) (n=156)

70.77

69.23

.87

Social, living alone (%)

(n=161)

52.24

48.15

.70

Characteristic
Age, y (n=168)

X
SD
Range
BMI, kg/m^ (n=164)

X
SD
Range

Health status
No. of prescription
drugs (n=162)
0-3 (%)
4-6 (%)
7-10 (%)
>10(%)

From January 2004 to March 2004,179 completed sui-vey

questionnaires were returned. Seventy questionnaires
were returned as undeliverable and 4 questionnaires
were excluded from the study (2 sui-vey participants were
<65 years of age and 2 survey participants were discharged prior to 2000). The final response rate for the
total survey was 31.5% (175/556); however, because not
all respondents answered all questions, sample size varied by question.
There were no statistically significant differences in age,
sex, or health status between the SAGE and Strong and
Steady respondents. As shown in Table 1, the average
age was 81.9 years (SD=6.0) for the SAGE respondents
and 81.0 (SD = 7.1) for the Strong and Steady respondents; the majority were female (70.8% of the SAGE
respondents, 69.2% of the Strong and Steady respondents); and the average number of comorbid health
conditions reported was 3.1 (SD = 1.9) for the SAGE
respondents and 2.9 (SD = 1.9) for the Strong and Steady
respondents. Finally, the percentage of respondents who
reported receiving a prescribed HEP was similar for botb
programs (SAGE=91.7%, Strong and Steady=80.8%).
Because demographic characteristics were comparable
between both groups they were combined for subsequent data analysis.

Physical Therapy . Volume 86 . Number 3 . March 2006

.21
31.39
43.07
18.98
6.57

52.00
36.00
8.00
4.00
.66

No. of comorbidities
(n=175)

X
SD

3.10
1.87
0-7

2.93
1.92
0-7

Depression (n=154)
Yes (%)

16.79

4.35

Falls in the last 3 months

(%)(n=159)
0 falls
1 foil
>1 fall

62.96
13.33
23.70

66.67
16.67
16.67

Received HEP (%)

91.7

80.8

Range

Characteristics of Survey Respondents

.12

.22

"SAGE=Sai'eiy and Gait Enhancement program, BMI=body mass index,

HEP=liome exercise program.

Characterizing Participation in a Prescribed HEP

Ninety percent (153/170) of survey respondents

reported receiving a HEP as a part of their physical
therapy program. Data on characterization and adherence to a prescribed HEP is shown in Table 2. Frequency
of participation in the prescribed HEP in the past 4
weeks was low, 36.6% (56/153) of the respondents
reported no exercise, and only 9.2% (14/153) of the
respondents reported adherence on 5 or more days per
week. Duration of HEP was most often reported as 30
minutes or less. The 2 most frequently reported modes
of exercise were strength training (70.9%, 73/103) and
balance training (69.9%, 72/103). Flexibility exercises
were preformed by 52.4% (54/103) of the respondents,
and 45.6% (47/103) of the respondents reported some
form of aerobic exercise. As shown in Table 2, most

Forkan et al . 405

Table 2.
Reported Postdischarge Participation in a Prescribed Home Exercise
Program (HEP)
%

Prescribed HEP (n= 170)

90.0

153

Frequency in past 4 wk (n=153)

Never
1 time per wk
2-3 times per wk
4-5 times per wk
>5 times per wk

36.6
12.4
22.9
19.0

56
19
35
29
14

Duration (n=104)
<15 min
15-30 min
45 min
60 min
Mode (n= 103)
Strength
Balance
Flexibility
Aerobic
Mode combination (n=103)
All 4

Combination of 3
Combination of 2
Only 1 mode

9.2

31.7
56.7
9.6
1.9

33
59
10
2

70.9
69.9
52.4
45.6

73
72
54
47

12.6
28.2
44.7
14.6

13
29
46
15

respondents participating in their HEP reported performing more than one mode of exercise.
Adherence to exercise was independent of time since
discharge (chi-square test for independence of the
2 variables, P=.553). This finding is shown in Table 5,
which compares the distribution of subjects who
reported some participation in a prescribed HEP versus
those who reported no participation in a prescribed
HEP as a function of time since discharge (categorized
as <12 months, 12-48 months, and >48 months).
The most frequently reported reason given for poor
adherence to a prescribed HEP was a change in health
status (30.7%, 31/101). Table 4 lists other reasons
reported for lack of adherence among survey respondents.
Participation in Nonprescribed Physical Activity

Participation in nonprescribed pbysical activity was

examined to determine whether this was a factor in low
adherence to a prescribed HEP. Table 5 summarizes
the frequency of participation by mode of exercise. For
all modes, including strengthening, aerobic, and flexibility exercises, the highest percentage of respondents
reported participating less than one time per week.
Older adults were grouped according to participation in
exercise. Categorization was determined either through
participation in a prescribed HEP or through participa406 . Forkan et a I

tion in other forms of physical activity. Respondents who

reported exercising at least one time per week in the past
4 weeks were classified as exercisers (83.3%), whereas
respondents reporting no exercise in the past 4 weeks
were categorized as nonexercisers (16.7%). Participation in nonprescribed physical activity was not associated
with time since discharge (chi-square test for independence of the 2 variables, P=.185).
Factors Affecting Participation in Exercise

The exercise and the nonexercise groups differed

{P<.OOl) in the number of barriers to exercise, with the
nonexercise group reporting more barriers (X=7.2,
SD = 1.8) compared with the exercise group (X=4.6,
SD=2.6). The number of motivators did not differ
between the 2 groups (P=.65). A series of univariate
logistic regressions was performed on individual barriers
and motivators to determine wbich were most associated
with adherence to exercise following discharge from a
physical therapy program.
Table 6 shows the results for the logistic regressions. This
table summarizes the proportion of participants from
each group (exercisers versus nonexercisers) who
endorsed the item and the number who did not answer
the question (missing data), which is followed by the P
for a specific motivator or barrier in the model and its
odds ratio and 95% confidence interval. For example,
among respondents, 68.4% of the nonexercisers and
59.7% of the exercisers endorsed the motivator "prefer
to be in scheduled exercise program" (second motivator
in the table), while 37 participants did not answer that
item. Additionally, the P of .469 implies that this motivator was not statistically significant (ie, this motivator
does not explain why a person becomes an exerciser or
why he or she does not). Odds ratios and confidence
intei"vals were calculated for all items for which the
calculation was possible. The odds ratio is the odds that
a person who endorses an item is an exerciser when
compared to a person who did not endorse the item. For
example, for the first barrier in the table, a person wbo
is not interested in exercise is 0.21 times less hkely to be
an exerciser than a person who did not endorse that
item.
In the models, none of the motivators were associated
with exercise participation. Eight barriers were associated (P<.05) with decreased participation in exercise
following discharge from a physical therapy program
and are shown in Table 6 in boldface. The barrier most
associated with reduced adherence was "I am not interested in exercise," followed in order by "In the past 4
weeks my health status affected my ability to exercise
regularly," "Bad weather prevents me from exercising,"
"I do not have the strength to exercise," "It is difficult to
exercise when I feel depressed," "Fear of falling prevents

Physical Therapy . Volume 86 . Number 3 . March 2006

Table 3.
Effect of Time Since Discharge on Adherence to a Prescribed Home Exercise Program (HEP)
Cohort Based on Time Since Discharge
<12 mo
HEP

None
Some

Total

n
% within cohort based on time since discharge
n
% within cohort based on time since discharge

19
30,2
44
69,8

n
% within cohort based on time since discharge

63
100

12-48 mo
9
40,9
13
59,1
22
100

>48 mo

Total

5
26,3
14
73,7
19
100

33
31,7
71
68,3
104
100

Table 4.

Table 5.

Reported Reasons for Nonadherence to Prescribed Home Exercise

Program (HEP)

Reported Frequency of Participation in Exercise (by Mode), Not

Prescribed in the Home Exercise Program (HEP)

Reason for Nonadherence to Exercise

(n=101)

% (No.)

Change in health status

Doing other forms of exercise
Lack of motivation
It is too long
It is uncomfortable
It is too hard
Do not have equipment needed
Do not know how to do it
Other:
Lack of energy
Time/scheduling problems
Disinterest in exercise
Boring
HEP did not help
Forgot
No one to exercise with
Depression
Exercise not stressed by physical therapist
No reason given

30,7(31)
11,9(12)
11,9(12)
7,9 (8)
7,9 (8)
5,9 (6)
4,0 (4)
2,0 (2)
4,0 (4)
3,0 (3)
2,0 (2)
2,0 (2)
2,0 (2)
1,0(1)
1,0(1)
1,0(1)
1,0(1)
1,0(1)

me from exercising," "I get short of breath when I

exercise," and "I feel the same whether I am active or
not," Their associated odds ratios were all less than 1,
indicating that for all those items, endorsement would
decrease likelihood of exercise participation.
Discussion

A major responsibility of physical therapists is to prescribe, promote, and educate patients on the importance and value of exercise as it relates to optimal
physical function, wellness, and quality of life.^* Ideally,
if a patient was given a physical therapy HEP, he or she
would adhere to the exercise program over the long
term. We found that following discharge from a balance
training physical therapy program, 90% of survey participants reported receiving a HEP; however, 36% of older
adults were no longer participating in their prescribed
HEP, and less than 10% participated 5 or more days per
week.
Physical Therapy , Volume 86 , Number 3 , March 2006

Times per week of:

% (No.)

Strengthening (n=142)
<1
1
2-3
4-5
>5

61,3(87)
9,2(13)
17,6(25)
7,0(10)
4,9 (7)

Flexibility (n= 148)

<1
1
2-3
4-5

>5

48,0(71)
12,2(18)
21,6(32)
14,2(21)
4,1 (6)

Aerobic (n=145)
<1

1
2-3
4-5
>5

66,2 (96)
11,0(16)
11,7(17)
5,5 (8)
5,5 (8)

Surprisingly, time since discharge did not affect adherence to a prescribed HEP, Adherence was not greater
among older adults discharged from physical therapy
within 12 months compared to those had been discharged for more than 48 months. Change in health
status was the most commonly reported reason for lack
of participation in a HEP, Burton et al'* reported that
current state of health was a predominant factor in
initiating or maintaining physical activity: This finding
suggests that physical therapists need to educate patients
and physicians that a return to physical therapy for
modification of a HEP may be necessary following a
change in health status.
An additional reason reported for nonadherence to a
prescribed HEP was participation in other forms of
physical activity, which may explain poor postdischarge
HEP adherence. However, in this study, older adults
most frequently reported performing additional physical
activity less than one time per week, suggesting that
participation in additional physical activity was not a
Forkan et al , 407

Table 6.
Univariate Logistic Regressions"
Proportion of
Endorsements
Item

Nonexercise
Group

Motivators
Exercising regularly is beneficial to health
Prefer to be in scheduled exercise program
1 feel better when 1 am active
Exercising gives me more energy
Exercising gives sense of accomplishment
Exercise keeps my mind active
Exercise is good for my heart
Exercise helps my spirits
1 exercise to keep myself healthy
1 want to exercise when 1 want
1 prefer to exercise with others

100
68.4
100
75.0
95.5
90.0
100
100
94.4
75.0
57.9

Barriers
1 feel the same whether 1 am active or not
Concerned will strain/hurt if physically active
Gets tightness in chest when exerting
1 do not have the strength to exercise
If health were better, 1 would be more active
1 am not interested in exercise
It is difficult to exercise when 1 ache
It is difficult to exercise when 1 feel

Exercise
Group

98.4
59.7
97.6
90.2

95.1
91.7
100
95.0
97.5
67.2
47.4

Odds Ratio

No. of
Missing
Values'*

29
37

30
33
30
35
40

34
35
39
42

30

Estimate

90% Confidence
Interval

0.68

0.24-1.92

3.06
0.93
1.22

0.94-9.89

2.33
0.68
0.65

0.23-23.73

.050
.147
.621
.011
.333
.004
.158

0.40

0.16-1.00

2.33
1.34

0.74-7.34
0.42-4.28

0.28

0.11-0.75

0.53

0.15-1.92

0.21

0.08-0.61

0.23

0.03-1.78

.032

0.28

0.09-0.90

.999
.469
.999
.062
.947
.806
.999
.A7A
.493
.398

O.n-8.11
0.25-6.04

0.23-2.02
0.24-1.75

95.0

28.5
34.1
23.0
16.2
77.9
10.9
81.1

78.9

51.0

depressed
Lack of transportation limits exercise options
Bad weather prevents me from

33.3
57.1

25.2

39

0.25-1.83

38

.440
.005

0.67

25.0

0.25

0.10-0.65

exercising
1 get short of breath vrhen 1 exercise
Fear of falling prevents me from

70.0
50.0

40.9
22.8

40
41

.020
.015

0.30
0.29

0.11-0.83
0.11-0.79

65.0

30.1

42

.004

0.23

0.09-0.63

exercising
In the past 4 wk, my health status
affected my ability to exercise on a
regular basis

50.0
18.2
18.2

40.9
87.0

36.4

30
31
36
39

34
33
60

" hems in boldface are barriers associated witli decreased parlicipation in exercise following discharge from a physical therapy program.
'' Missing wilties in the logistic regression; either the otitcome or the item was missing.
' Uni\'ariate logistic regression.

major contributor to nonadherence to a prescribed

HEP.
The respondents reported that aerobic activity was the
least common mode of exercise in their HEP. This was
an unexpected finding, considering previous research-^'
has shown that older adults report walking as a preferred
form of activity. There are several possible explanations
for this finding. First, physical therapists within these 2
balance-training programs may emphasize strength
more than aerobics when prescribing a HEP. Alternately, in our study, one of the major barriers reported
by respondents to maintaining participation in physical
activity was weather. Strength training exercises may be
less affected by adverse weather becatise older adults can
perform strength training activities in their home.
Results from our study also suggested that barriers play
a greater role in determining postdischarge exercise
408 . Forkan et al

participation than motivators. No motivator was significantly associated with exercise participation in our analysis. Eight barriers were significantly associated with a
decreased adherence to exercise following discharge
from physical therapy. Barriers found to decrease adherence to exercise following discharge from physical therapy included the following: lack of interest, poor health,
bad weather, depression, lack of strength, fear of falling,
shortness of breath, and low outcomes expectation.
These findings are consistent with those of other studies
demonstrating a relationship between barriers and exercise participation.'^'^o^'
Limitations of the Study

There are several limitations associated with this study.

Sui'vey respondents were drawn from 2 physical therapy
programs targeting balance, training in older adults;
thus, the degree to which findings could be generalized
to a broader population of adults receiving physical
Physical Therapy . Volume 86 . Number 3 . March 2006

therapy is unknown. Were both groups of subjects

located in a cool climate? In addition, because we were
only able to use information gathered from the returned
surveys, we do not know to what extent these results are
representative of the entire survey population. Descriptions of HEP were self-reported by survey respondents,
and the accuracy of this information was not verified. In
addition, respondents did not report the prescribed
HEP as defined by their physical therapist, rather only
what they were currently doing. This limited our ability
to determine adherence to the prescribed HEP. We also
did not inquire about the length of the entire balance
training program, the time it took to complete the HEP,
or additional physical therapy received since discharge,
all of which could have affected adherence to the HEP.
The survey questionnaires were mailed after the winter
holidays, which may have affected participation in physical activity in the 4 weeks prior to receiving the survey
instruments. Missing values may reflect an individual's
perception that not answering the item was equivalent to
nonendorsement of that item. We chose to use available
data rather than assuming that missing data reflected
nonendorsement. Worthy of mention is the fact that the
question most frequently not answered was "It is difficult
to exercise when I am depressed," which may mean that
depression was not a condition that applied to the
person or that the respondent refused to answer because
this was a sensitive question. Finally, we did not collect
data on race or ethnicity; thus, the effect of these
variables on exercise adherence and factors affecting
adherence cannot be determined from this study.
Clinical Implications and Conclusions
This study has a number of implications for the practice
of physical therapy. In this study, barriers rather than
motivators were more likely to predict postdischarge
exercise participation. This finding suggests that physical
therapists may need to place a greater emphasis on
addressing patients' barriers when establishing postdischarge exercise programs. In addition, physical therapists need to address current as well as potential changes
in health status as they relate to long-term adherence
and participation in physical activity. Because of the
broad and significant benefits of exercise, increasing
physical activity in older adults to the level necessary to
achieve health benefits needs to be a key focus in
physical therapy. Further research should examine what
strategies help patients overcome their barriers and
increase adherence to a HEP or participation in additional physical activity.
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Physical Therapy , Volume 86 , Number 3 , March 2006