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Pedometer Use Increases Daily Steps and Functional Status in Older Adults
Pedometer Use Increases Daily Steps and Functional Status in Older Adults Allison Snyder, MD, Bryanne Colvin, MD, and Julie K. Gammack, MD
Objective: The benefits of increased physical activity in adults of any age are many. It is hypothesized that wearing a pedometer can motivate older adults to increase and sustain a higher level of ambulatory activity and improve measures of functional status. Design: A prospective observational walking program using pedometers, goal orientation, and educational materials. Participants were given pedometers with the screen covered to measure baseline steps. The pedometer screen was then uncovered for 4 weeks and participants encouraged to increase daily steps by 5% weekly. The pedometers were removed for 2 weeks and then returned with the screen covered to measure maintenance of activity. Setting: Six senior-living facilities in the Saint Louis area. Participants: A total of 36 ambulatory adults aged 65 or older.
Gait and Balance Evaluation, functional reach, 2-minute walking distance, 30-second leg-lift repetitions, grip strength, Geriatric Depression Scale (GDS), and Quality of Life Scale. Results: The average number of daily steps increased from 2992 to 3670 over a 4-week period, a 22.7% increase (P 5.035). The average daily steps were not sustained once the pedometer was removed for 2 weeks. The Timed Up and Go decreased from 12.1 to 11.2 seconds (P 5.014), 30-second leg lifts increased from 22.7 to 26.3 repetitions (P \ .001), and 2-minute walking distance improved from 313.7 to 330.3 feet (P 5 .014) at study completion. No improvement was seen in grip strength, functional reach, GDS, or quality of life. Conclusion: Pedometers are a successful motivational tool to increase ambulatory activity in older adults with a secondary benefit in functional status measures. (J Am Med Dir Assoc 2011; 12: 590–594)
Measurements: The primary outcome measurement was average daily steps. Secondary outcomes included scores on the “Timed Up and Go,” Tinetti
Keywords: Pedometer; walking; functional status; elderly
According to the Department of Health and Human Services US Physical Activity Guidelines, “older adults should be as physically active as their abilities allow” and “some activity is better than none.”1 There is strong evidence that physical activity lowers the risk of heart disease, stroke,
type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, and some cancers. For older adults, there is also evidence that physical activity prevents falls, reduces depression, and improves cognitive function.2e4 With so much evidence supporting physical activity, it is important to try to change the sedentary lifestyle of so many seniors in the United States. In a review of physical activity promotion strategies that targeted healthy adults, walking was by far the most successful strategy used to increase physical activity. Walking is thought to be most helpful because it is a widely accessible activity, easily maintainable, and associated with a low rate of injury.5 To maximize the effectiveness of a walking routine, it is important to identify strategies that can motivate an older population. Pedometers are inexpensive step-counting devices that can motivate greater physical activity through increased daily ambulation. A prospective observational study showed that sedentary workers (mean age 43 years) could increase their daily steps from 7029 to 10,480 over 12 weeks through the use of a pedometer.6 This study reported significant decreases in body mass index (BMI), waist girth and resting heart rate, which positively correlated with increasing step rates.
Saint Louis University Health Sciences Center, St Louis, MO (A.S., B.C., J.K.G.); Gateway Geriatrics Education Center, St Louis VA Medical Center, St Louis, MO (J.K.G.). Allison Snyder, MD, received funding from the American Federation for Aging Research through the Medical Student Training in Aging Research Program. Julie K. Gammack, MD, is supported by a Geriatric Academic Career Award through the Bureau of Health Professions, Health Resources and Services Administration. This research protocol was approved by the academic institutional review board and written consent was obtained from all participants. These funding agencies have had no involvement in the planning, implementing, or evaluation of the study or in writing/reporting the results of this study. None of the authors have any financial conflicts of interest. Address correspondence to Julie K. Gammack, MD, Saint Louis University Health Sciences Center, Division of Geriatric Medicine, 1402 S. Grand Boulevard, M238, St Louis, MO 63104. E-mail: [email protected]
Copyright Ó2011 American Medical Directors Association DOI:10.1016/j.jamda.2010.06.007 590 Snyder, Colvin, and Gammack
JAMDA e October 2011
Most randomized controlled trials (RCTs) of pedometers focus on middle-aged adults and measure specific health outcomes such as blood pressure and BMI. Two recent studies reported an increase in physical activity of 47% to 69% in subjects who used a pedometer.7,8 Health outcomes such as BMI and blood pressure were measured in these studies but the outcomes were not consistently positive. A meta-analysis of 26 pedometer studies (mean age 49 years, n 5 277) demonstrated a reduction in BMI of 0.38 (P 5 .03) with pedometer use, as well as a decrease in systolic blood pressure of 3.8 mm Hg (P \ .001) but no improvement in fasting glucose or lipid levels.9 A second meta-analysis that included 307 participants reported a 1.3-kg weight loss over a median of 16 weeks with pedometer use.10 The purpose of our study was to evaluate the use of pedometers in motivating adults aged 65 and older to increase physical activity and measure the impact of this intervention on health outcomes of upper and lower limb functioning. It was hypothesized that a pedometer-based exercise intervention would motivate a 5% weekly increase in average daily steps for a total improvement of 20% in 4 weeks. It was also postulated that participants would maintain this increase in physical activity once the pedometers were removed. METHODS This study was approved by the Saint Louis University Institutional Review Board and the participating sites. The study included male and female adults aged 65 and older from 6 senior-living communities in the Saint Louis area between September 2007 and December 2008. Participants were recruited using postings placed in common areas of the complexes. An informational meeting was held in each building, and potential subjects volunteered for study screening. Written informed consent was obtained from all participants. Potential subjects were screened for cognitive impairment using the 30-point Saint Louis University Mental Status Examination (SLUMS).11 Those who scored in the range of probable dementia (\ 20 points for 12 or more years of education; \15 points for fewer than 12 years of education) were excluded from the study because of potential difficulty in correctly using a pedometer. Other exclusion criteria included the need for a walker or wheelchair for ambulation, individuals whose steps could not be measured accurately by the pedometer, a medical condition that would prevent daily walking, noneEnglish-speaking individuals, and the inability to meet weekly with the researchers. Outcome Measurements The primary outcome was average daily steps calculated from the total weekly steps measured by an Accusplit Eagle 120XL pedometer (ACCUSPLIT, Livermore, CA) worn on the hip. The hip has been shown to be the most accurate site for step measurements.12 To prevent loss of data, the pedometers were altered by the researchers so participants could view the step counter but not reset the pedometers. Secondary outcomes included functional and quality of life measures. Gait and mobility was measured by the “Timed Up ORIGINAL STUDIES
and Go” test and recorded as the average of 3 sequential trials.13 Walking speed was measured in feet over a 2-minute period. Balance and gait were measured with the Tinetti Balance and Gait Evaluation.14 Leg endurance was recorded as the number of repetitions of full knee extension from 90degree flexion in 30 seconds with a 5-pound weight attached to the ankle. Grip strength was measured in kilograms using a handgrip dynamometer and flexibility was measured in inches using upper extremity functional reach. Mood was assessed with the 15-point Geriatric Depression Scale (Short Form) (GDS) and quality of life was measured on a 100-point continuous scale from poor to excellent.15,16 Study Design The timeline for the study can be viewed in Table 1. At study initiation (T 1), demographic information, medical history, and social history were gathered from each participant. Functional status, mood, and quality of life were then measured. The following week (T0), participants were given a pedometer with the screen covered so that the steps could not be viewed on the counter. To establish baseline daily steps, participants were asked to walk normally for 1 week while wearing the pedometer on their hip or belt. During the following 4 weeks, (T1e4) the pedometer screen was uncovered and each participant was given an individualized step goal, to achieve a weekly increase of 5%. Educational materials and weekly meetings were provided to encourage an increase in physical activity. Each week, the total steps were recorded by the researchers and the pedometer reset to zero. During the second and fourth weeks, Timed Up and Go, Tinetti Balance and Gait, functional reach, 2-minute walk, leg-lifts, and grip strength were measured. After 4 weeks of walking with the screen uncovered, the pedometer was removed for 2 weeks and the participants were asked to maintain their walking habits. The pedometer was returned for a final week (Tf) with the screen covered, after which daily steps, functional status, mood, and quality of life were measured. Statistical Analysis With a confidence level set at 95%, and power of 80%, it was determined that a sample size of 30 was needed to detect a 20% improvement in average daily steps over a 4-week period. Data analysis was performed using chi-square and paired sample t test with the Statistical Package for the Social Sciences version 13.0 (SPSS Inc., Chicago, IL). A “last value carried forward” approach was used in analyzing data for all subjects who enrolled in the study. RESULTS A total of 46 potential subjects were screened, after which 36 eligible subjects enrolled in this study. The mean age was 81.6 years (range 65e98), 75% were female, and 89% were white. The mean SLUMS score was 23.6 points (range 15e30). Participant demographics are given in Table 2. At baseline, almost two thirds of subjects reported engaging in at least 15 minutes of exercise daily and 19% reported no regularly exercise activity; 46% of participants had a prior history of falling. Snyder, Colvin, and Gammack 591
Table 1. Study Timeline of Pedometer Step Measurements and Measured Outcomes Time
Week
T
1
1
Steps Measured
Functional Evaluation*
Mood and QOL Evaluation†
O
O
O (Covered Screen)
T0
2
T1
3
T2
4
T3
5
T4
6
T5e6
7e8
Tf
9
O (Uncovered Screen)
O Fig. 1. Percent change in average daily steps at weekly study time points compared to baseline and to previous week.
O O (Covered Screen)
O
O
* Timed Up and Go, 2-minute walking distance, Tinetti Gait and Balance Scale, leg lift repetitions, grip strength, functional reach. † Quality of Life 100-point continuous scale; Geriatric Depression Scale Short Form. Check marks represent activity that occurred during that time frame.
Seven participants (19%) did not complete the entire protocol, however 5 of these continued through at least the midpoint of the study. Three subjects each missed 1 data collection point but completed the remainder of the study protocol. Compliance with pedometer use was good; 9 subjects reported forgetting to use the pedometer for at least 1 day (range 0e9 days) with an average study noncompliance rate of 0.6 days per person. Three subjects were noted to have technique-related inaccuracy with pedometer measurement, which was subsequently corrected. At baseline (T0), the average number of daily steps was 2992, which increased by 22.7% to 3670 at T4 (P 5 .035). The average steps increased each week while the pedometer was uncovered. The greatest weekly improvement of 7.2% was measured between T2 and T3, and the smallest weekly improvement of 2.1% occurred between T3 and T4 (see Figure 1). During the final week of walking with the screen covered (Tf) the average daily step count dropped by 4.8% to 3526 steps. This was not statistically different from the average steps at T4 or from baseline. Compared with baseline, the Timed Up and Go decreased by 8.0% from 12.1 to 11.6 seconds (P 5 .014), leg-lift repetiTable 2.
Participant Demographics
Age (total) n; mean ± SD Age (female) n; mean SD Age (male) n; mean SD Race, n (%) White Black/African SLUMS (total) n; mean ± SD SLUMS (female) n; mean SD SLUMS (male) n; mean SD
36; 82.0 8.6 27; 81.6 8.8 9; 80.3 7.4 32 (89) 4 (11) 36; 23.4 5.3 27; 23.6 3.9 9; 23.6 5.5
SLUMS, Saint Louis University Mental Status Examination.
592 Snyder, Colvin, and Gammack
tions increased 5.9% from 22.7 to 26.3 (P \ .001), and the 2-minute walking distance improved 5.5% from 313.7 to 330.3 feet (P 5 .014, see Table 3). At Tf, the Tinetti Gait and Balance score improved compared with baseline (24.1 versus 24.8 points, P 5 .027). Grip strength, functional reach, GDS, and quality of life rating were unchanged during the study: 21.1 versus 21.6 kg (P 5 .370), 2.43 versus 2.41 feet (P 5 .671), 2.17 versus 2.38 points (P 5 .594), and 79.1 versus 79.9 (P 5 .721) respectively. The participants responded very positively to the program, and several asked to purchase the pedometer at the study conclusion to continue with the walking program. Of the participants reporting reasons for study disenrollment, 1 was not able to achieve accurate pedometer step recordings, 3 reported inadequate time for study participation, and 1 reported health limitations. During the study, 1 subject without a falls history sustained a hip fracture as result of a fall. Five subjects reported soreness in the muscles or joints, which may have been related to increased exercise, but which did not result in loss of study days. Only one participant reported inclement weather (1 day) that prevented walking. One subject had an infectious illness that resulted in a brief study absence but not disenrollment. DISCUSSION These data demonstrate that wearing a pedometer, along with goal setting and regular coaching of older adults, can improve daily ambulatory activity nearly 25% over 4 weeks and can result in functional benefits. About two thirds of the step increase occurred in the first 2 weeks of uncovered pedometer use. Improvement continued to a lesser degree during the second 2 weeks, but study duration was not sufficient to determine when a plateau effect on ambulation might take place. The average daily steps in this study population were considerably lower than the 10,000 steps per day goal that has gained popular support, but which has not been validated scientifically. The literature does suggest that this target may be unrealistic for an older population.17 For this reason, our study used goal setting based on individual baseline steps rather than a population-based average. When the pedometer was removed, the participants did not maintain their increased level of physical activity despite JAMDA e October 2011
Table 3.
Comparison of Baseline and Final Average Daily Steps and Measured Functional Outcomes
Pedometer Outcomes
Group Average Baseline (T
Timed Up and Go, seconds Leg lifts, reps Tinetti Gait and Balance Evaluation 2-minute walk, ft Functional reach, ft Grip strength, kg Geriatric Depression Scale (0e15) Quality of Life scale (0e100) Average daily steps, no.
11.2 3.9 22.7 7.1 24.1 3.7 313.7 97.0 2.43 0.36 21.1 7.7 2.17 2.53 79.1 18.9 2992 1975
1)
Group Average Final (Tf)
P Value*
10.6 3.9 26.3 7.0 24.8 3.1 330.3 101.0 2.41 0.33 21.6 6.7 2.29 2.70 79.9 19.0 Tf: 3526 2716 T4: 3670 2624
.014 \0.001 .027 .014 .671 .370 .594 .721 .070 T0 vs Tf .035 T0 vs T4
* Paired-sample t test.
ongoing coaching activities. One fifth of the overall gain in steps was lost over 3 weeks when this device was removed. This suggests that the pedometer itself was the motivating factor rather than the support process. A study in younger adults also demonstrated that pedometer use with support materials was no better than pedometer use alone in increasing physical activity. These authors concluded that pedometers were the primary motivational tool and that behavioral support mainly served to affect attitudes toward pedometer use.18 As might be expected from a walking exercise program, lower body but not upper body functional status improved as a result of the increased activity. Walking speed improved as measured by the Timed Up and Go and the 2-minute walk distance. Leg endurance significantly improved as measured by the number of leg extension repetitions performed in 30 seconds. Gait and balance improved as measured by the Tinetti score; however, the upper body functional measures of grip strength, and dynamic trunk flexibility (functional reach) did not improve as a result of the increased ambulation. The combined Tinetti gait and balance score improved, but may have been a result of improvement in the gait component and not the balance component. This would potentially explain why improvement was not seen in functional reach as a test dynamic balance as a walking program would be expected to improve gait more so than balance. Grip strength was not expected to improve as a part of a walking program and served as a negative control parameter. Mood and global quality of life score also did not change over the course of the study. As in other pedometer studies, we found that the device was easy to use and a safe means of increasing physical activity. The study completion rate of 81% was similar to other pedometer trials.9 Few individuals had difficulty using the device and failure to wear the pedometer occurred on less than 2% of the measured days. Illness, poor weather conditions, and exercise-associated symptoms infrequently affected study participation. Recent data indicate these are the most common barriers cited by older adults in walking programs, along with concerns of safety and lack of a walking partner.19e21 Although one serious fall occurred during the study, serious walking-related adverse events are rare. A walking study of adults with multiple medical comorbidities showed only 1 serious activity-related event in 1110 person-months of obserORIGINAL STUDIES
vation and less than 1 nonserious activity-related event per 100 person-months.22 Only a few studies have evaluated the use of pedometers in an older population. In a 12-week feasibility study of 54 women with a mean age of 76 years, 83% completed a pedometer protocol, but no significant increase in daily steps was seen.20 A 12-week RCT of a pedometer-based walking program in older adults (mean age 73 years) showed an increase in physical activity of 21% to 34% over baseline. This study was not designed to measure clinical health outcomes.23 Our results are very similar to those reported by Talbot et al,24 who measured both activity and functional status in older adults. In that 12-week RCT of 34 adults (mean age 70 years) with knee osteoarthritis, a 23% (P 5 .04) increase in daily steps was reported. The treatment group also demonstrated a 20% (P 5 .04) increase in quadriceps strength as measured by knee extension and a 12% to 15% improvement in timed walk and stair climbing. Our study demonstrated a 17% improvement in lower limb endurance based on leg lift repetitions, but showed a less robust 5% to 8% improvement in walking time and walking distance. Our study was limited most in its design and its duration. Participants were self-identified and were not randomized into a study protocol. Most subjects self-reported a daily exercise routine at baseline, which would imply a healthier and more motivated study population. These data may not be generalizable to the more sedentary or community-dwelling population. Despite these limitations, participants were able to demonstrate improvement in activity and achieved an improvement in function compared with baseline. Study results indicated that increases in physical activity continued over 4 weeks, but it was not clear when a walking plateau was reached and how long this level of activity could be sustained. The study duration was also insufficient to determine a trajectory of loss in daily steps and function once the pedometer was removed. A longer study is needed to determine if using a pedometer imparts a lifestyle change, or if interest and physical benefits wane over time. CONCLUSION A pedometer is a simple and affordable device that is useful in improving daily activity and functional outcomes in older adults. Compliance was high in the walking program, but Snyder, Colvin, and Gammack 593
activity decreased once the pedometers were removed and the screen covered from view. Pedometers are an effective means of motivating positive lifestyle change in older adults.
REFERENCES 1. Physical Activity Guidelines for Americans. Chapter 5: Active Older Adults. Washington, DC: U.S. Department of Health and Human Services; updated October 16, 2008. Available at: http://www.health.gov/ paguidelines/guidelines/chapter5.aspx. Accessed May 7, 2010. 2. Mead GE, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Syst Rev 2009 (3):CD004366. 3. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009 (2):CD007146. 4. Angevaren M, Aufdemkampe G, Verhaar HJ, et al. Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev 2008 (3):CD005381. 5. Hillsdon M, Thorogood M. A systematic review of physical activity promotion strategies. Br J Sports Med 1996;30:84e89. 6. Chan CB, Ryan DAJ, Tudor-Locke C. Health benefits of a pedometerbased physical activity intervention in sedentary workers. Prev Med 2004;39:1215e1222. 7. Baker G, Gray S, Wright A, et al. The effect of a pedometer-based community walking intervention “Walking for Wellbeing in the West” on physical activity levels and health outcomes; a 12-week randomized control trial. Int J Behavioral Nut Physical Act 2008;5:44. 8. Araiza P, Hewes H, Gashetewa C, et al. Efficacy of a pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism 2006;55:1382e1387. 9. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA 2007;298:2296e2304. 10. Richardson CR, Newton TL, Abraham JJ, et al. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med 2008;6:69e77.
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11. Banks WA, Morley JE. Memories are made of this: Recent advances in understanding, cognitive impairment, and dementia. J Gerontol A Biol Sci Med Sci 2003;58:314e321. 12. Cyarto E, Myers A, Tudor-Locke C. Pedometer accuracy in nursing home and community-dwelling older adults. Med Sci Sports Exerc 2004;36:205e209. 13. Podsiadlo D, Richardson S. The Timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39: 142e148. 14. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 1986;80:429e434. 15. Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression. Clinical Gerontologist 1982;1:37e44. 16. The EuroQol Group. EuroQoldA new facility for the measurement of the health-related quality of life. Health Policy 1990;16:199e208. 17. Tudor-Locke C, Bassett D. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004;34:1e8. 18. DeCooker K, DeBourdeaudhuij I, Cardon G. The effect of pedometer use in combination with cognitive and behavioral support materials to promote physical activity. Patient Educ Couns 2008;70:209e214. 19. Croteau KA, Richeson NE, Farmer BC, Jones DB. Effect of a pedometerbased intervention on daily step counts of community-dwelling older adults. Res Q Exerc Sport 2007;78:401e406. 20. Sugden J, Sniehotta F, Donnan P, et al. The feasibility of using pedometers and brief advice to increase activity in sedentary older womenda pilot study. BMC Health Serv Res 2008;8:169. 21. Jones DB, Richeson NE, Croteau KA, Farmer BC. Focus groups to explore the perceptions of older adults on a pedometer-based intervention. Res Q Exerc Sport 2009;80:710e717. 22. Goodrich DE, Larkin AR, Lowery JC, et al. Adverse events among highrisk participants in a home-based walking study: a descriptive study. Int J Behav Nutr Phys Act 2007;4:20. 23. Farmer B, Croteau K, Richeson N, Jones D. Using pedometers as a strategy to increase the daily steps of older adults with chronic illness: From research to practice. Home Healthc Nurse 2006;24:449e456. 24. Talbot LA, Gaines JM, Huynh TN, Metter EJ. A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study. J Am Geriatr Soc 2003;51:387e392.
JAMDA e October 2011
Objective: The benefits of increased physical activity in adults of any age are many. It is hypothesized that wearing a pedometer can motivate older adults to increase and sustain a higher level of ambulatory activity and improve measures of functional status. Design: A prospective observational walking program using pedometers, goal orientation, and educational materials. Participants were given pedometers with the screen covered to measure baseline steps. The pedometer screen was then uncovered for 4 weeks and participants encouraged to increase daily steps by 5% weekly. The pedometers were removed for 2 weeks and then returned with the screen covered to measure maintenance of activity. Setting: Six senior-living facilities in the Saint Louis area. Participants: A total of 36 ambulatory adults aged 65 or older.
Gait and Balance Evaluation, functional reach, 2-minute walking distance, 30-second leg-lift repetitions, grip strength, Geriatric Depression Scale (GDS), and Quality of Life Scale. Results: The average number of daily steps increased from 2992 to 3670 over a 4-week period, a 22.7% increase (P 5.035). The average daily steps were not sustained once the pedometer was removed for 2 weeks. The Timed Up and Go decreased from 12.1 to 11.2 seconds (P 5.014), 30-second leg lifts increased from 22.7 to 26.3 repetitions (P \ .001), and 2-minute walking distance improved from 313.7 to 330.3 feet (P 5 .014) at study completion. No improvement was seen in grip strength, functional reach, GDS, or quality of life. Conclusion: Pedometers are a successful motivational tool to increase ambulatory activity in older adults with a secondary benefit in functional status measures. (J Am Med Dir Assoc 2011; 12: 590–594)
Measurements: The primary outcome measurement was average daily steps. Secondary outcomes included scores on the “Timed Up and Go,” Tinetti
Keywords: Pedometer; walking; functional status; elderly
According to the Department of Health and Human Services US Physical Activity Guidelines, “older adults should be as physically active as their abilities allow” and “some activity is better than none.”1 There is strong evidence that physical activity lowers the risk of heart disease, stroke,
type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, and some cancers. For older adults, there is also evidence that physical activity prevents falls, reduces depression, and improves cognitive function.2e4 With so much evidence supporting physical activity, it is important to try to change the sedentary lifestyle of so many seniors in the United States. In a review of physical activity promotion strategies that targeted healthy adults, walking was by far the most successful strategy used to increase physical activity. Walking is thought to be most helpful because it is a widely accessible activity, easily maintainable, and associated with a low rate of injury.5 To maximize the effectiveness of a walking routine, it is important to identify strategies that can motivate an older population. Pedometers are inexpensive step-counting devices that can motivate greater physical activity through increased daily ambulation. A prospective observational study showed that sedentary workers (mean age 43 years) could increase their daily steps from 7029 to 10,480 over 12 weeks through the use of a pedometer.6 This study reported significant decreases in body mass index (BMI), waist girth and resting heart rate, which positively correlated with increasing step rates.
Saint Louis University Health Sciences Center, St Louis, MO (A.S., B.C., J.K.G.); Gateway Geriatrics Education Center, St Louis VA Medical Center, St Louis, MO (J.K.G.). Allison Snyder, MD, received funding from the American Federation for Aging Research through the Medical Student Training in Aging Research Program. Julie K. Gammack, MD, is supported by a Geriatric Academic Career Award through the Bureau of Health Professions, Health Resources and Services Administration. This research protocol was approved by the academic institutional review board and written consent was obtained from all participants. These funding agencies have had no involvement in the planning, implementing, or evaluation of the study or in writing/reporting the results of this study. None of the authors have any financial conflicts of interest. Address correspondence to Julie K. Gammack, MD, Saint Louis University Health Sciences Center, Division of Geriatric Medicine, 1402 S. Grand Boulevard, M238, St Louis, MO 63104. E-mail: [email protected]
Copyright Ó2011 American Medical Directors Association DOI:10.1016/j.jamda.2010.06.007 590 Snyder, Colvin, and Gammack
JAMDA e October 2011
Most randomized controlled trials (RCTs) of pedometers focus on middle-aged adults and measure specific health outcomes such as blood pressure and BMI. Two recent studies reported an increase in physical activity of 47% to 69% in subjects who used a pedometer.7,8 Health outcomes such as BMI and blood pressure were measured in these studies but the outcomes were not consistently positive. A meta-analysis of 26 pedometer studies (mean age 49 years, n 5 277) demonstrated a reduction in BMI of 0.38 (P 5 .03) with pedometer use, as well as a decrease in systolic blood pressure of 3.8 mm Hg (P \ .001) but no improvement in fasting glucose or lipid levels.9 A second meta-analysis that included 307 participants reported a 1.3-kg weight loss over a median of 16 weeks with pedometer use.10 The purpose of our study was to evaluate the use of pedometers in motivating adults aged 65 and older to increase physical activity and measure the impact of this intervention on health outcomes of upper and lower limb functioning. It was hypothesized that a pedometer-based exercise intervention would motivate a 5% weekly increase in average daily steps for a total improvement of 20% in 4 weeks. It was also postulated that participants would maintain this increase in physical activity once the pedometers were removed. METHODS This study was approved by the Saint Louis University Institutional Review Board and the participating sites. The study included male and female adults aged 65 and older from 6 senior-living communities in the Saint Louis area between September 2007 and December 2008. Participants were recruited using postings placed in common areas of the complexes. An informational meeting was held in each building, and potential subjects volunteered for study screening. Written informed consent was obtained from all participants. Potential subjects were screened for cognitive impairment using the 30-point Saint Louis University Mental Status Examination (SLUMS).11 Those who scored in the range of probable dementia (\ 20 points for 12 or more years of education; \15 points for fewer than 12 years of education) were excluded from the study because of potential difficulty in correctly using a pedometer. Other exclusion criteria included the need for a walker or wheelchair for ambulation, individuals whose steps could not be measured accurately by the pedometer, a medical condition that would prevent daily walking, noneEnglish-speaking individuals, and the inability to meet weekly with the researchers. Outcome Measurements The primary outcome was average daily steps calculated from the total weekly steps measured by an Accusplit Eagle 120XL pedometer (ACCUSPLIT, Livermore, CA) worn on the hip. The hip has been shown to be the most accurate site for step measurements.12 To prevent loss of data, the pedometers were altered by the researchers so participants could view the step counter but not reset the pedometers. Secondary outcomes included functional and quality of life measures. Gait and mobility was measured by the “Timed Up ORIGINAL STUDIES
and Go” test and recorded as the average of 3 sequential trials.13 Walking speed was measured in feet over a 2-minute period. Balance and gait were measured with the Tinetti Balance and Gait Evaluation.14 Leg endurance was recorded as the number of repetitions of full knee extension from 90degree flexion in 30 seconds with a 5-pound weight attached to the ankle. Grip strength was measured in kilograms using a handgrip dynamometer and flexibility was measured in inches using upper extremity functional reach. Mood was assessed with the 15-point Geriatric Depression Scale (Short Form) (GDS) and quality of life was measured on a 100-point continuous scale from poor to excellent.15,16 Study Design The timeline for the study can be viewed in Table 1. At study initiation (T 1), demographic information, medical history, and social history were gathered from each participant. Functional status, mood, and quality of life were then measured. The following week (T0), participants were given a pedometer with the screen covered so that the steps could not be viewed on the counter. To establish baseline daily steps, participants were asked to walk normally for 1 week while wearing the pedometer on their hip or belt. During the following 4 weeks, (T1e4) the pedometer screen was uncovered and each participant was given an individualized step goal, to achieve a weekly increase of 5%. Educational materials and weekly meetings were provided to encourage an increase in physical activity. Each week, the total steps were recorded by the researchers and the pedometer reset to zero. During the second and fourth weeks, Timed Up and Go, Tinetti Balance and Gait, functional reach, 2-minute walk, leg-lifts, and grip strength were measured. After 4 weeks of walking with the screen uncovered, the pedometer was removed for 2 weeks and the participants were asked to maintain their walking habits. The pedometer was returned for a final week (Tf) with the screen covered, after which daily steps, functional status, mood, and quality of life were measured. Statistical Analysis With a confidence level set at 95%, and power of 80%, it was determined that a sample size of 30 was needed to detect a 20% improvement in average daily steps over a 4-week period. Data analysis was performed using chi-square and paired sample t test with the Statistical Package for the Social Sciences version 13.0 (SPSS Inc., Chicago, IL). A “last value carried forward” approach was used in analyzing data for all subjects who enrolled in the study. RESULTS A total of 46 potential subjects were screened, after which 36 eligible subjects enrolled in this study. The mean age was 81.6 years (range 65e98), 75% were female, and 89% were white. The mean SLUMS score was 23.6 points (range 15e30). Participant demographics are given in Table 2. At baseline, almost two thirds of subjects reported engaging in at least 15 minutes of exercise daily and 19% reported no regularly exercise activity; 46% of participants had a prior history of falling. Snyder, Colvin, and Gammack 591
Table 1. Study Timeline of Pedometer Step Measurements and Measured Outcomes Time
Week
T
1
1
Steps Measured
Functional Evaluation*
Mood and QOL Evaluation†
O
O
O (Covered Screen)
T0
2
T1
3
T2
4
T3
5
T4
6
T5e6
7e8
Tf
9
O (Uncovered Screen)
O Fig. 1. Percent change in average daily steps at weekly study time points compared to baseline and to previous week.
O O (Covered Screen)
O
O
* Timed Up and Go, 2-minute walking distance, Tinetti Gait and Balance Scale, leg lift repetitions, grip strength, functional reach. † Quality of Life 100-point continuous scale; Geriatric Depression Scale Short Form. Check marks represent activity that occurred during that time frame.
Seven participants (19%) did not complete the entire protocol, however 5 of these continued through at least the midpoint of the study. Three subjects each missed 1 data collection point but completed the remainder of the study protocol. Compliance with pedometer use was good; 9 subjects reported forgetting to use the pedometer for at least 1 day (range 0e9 days) with an average study noncompliance rate of 0.6 days per person. Three subjects were noted to have technique-related inaccuracy with pedometer measurement, which was subsequently corrected. At baseline (T0), the average number of daily steps was 2992, which increased by 22.7% to 3670 at T4 (P 5 .035). The average steps increased each week while the pedometer was uncovered. The greatest weekly improvement of 7.2% was measured between T2 and T3, and the smallest weekly improvement of 2.1% occurred between T3 and T4 (see Figure 1). During the final week of walking with the screen covered (Tf) the average daily step count dropped by 4.8% to 3526 steps. This was not statistically different from the average steps at T4 or from baseline. Compared with baseline, the Timed Up and Go decreased by 8.0% from 12.1 to 11.6 seconds (P 5 .014), leg-lift repetiTable 2.
Participant Demographics
Age (total) n; mean ± SD Age (female) n; mean SD Age (male) n; mean SD Race, n (%) White Black/African SLUMS (total) n; mean ± SD SLUMS (female) n; mean SD SLUMS (male) n; mean SD
36; 82.0 8.6 27; 81.6 8.8 9; 80.3 7.4 32 (89) 4 (11) 36; 23.4 5.3 27; 23.6 3.9 9; 23.6 5.5
SLUMS, Saint Louis University Mental Status Examination.
592 Snyder, Colvin, and Gammack
tions increased 5.9% from 22.7 to 26.3 (P \ .001), and the 2-minute walking distance improved 5.5% from 313.7 to 330.3 feet (P 5 .014, see Table 3). At Tf, the Tinetti Gait and Balance score improved compared with baseline (24.1 versus 24.8 points, P 5 .027). Grip strength, functional reach, GDS, and quality of life rating were unchanged during the study: 21.1 versus 21.6 kg (P 5 .370), 2.43 versus 2.41 feet (P 5 .671), 2.17 versus 2.38 points (P 5 .594), and 79.1 versus 79.9 (P 5 .721) respectively. The participants responded very positively to the program, and several asked to purchase the pedometer at the study conclusion to continue with the walking program. Of the participants reporting reasons for study disenrollment, 1 was not able to achieve accurate pedometer step recordings, 3 reported inadequate time for study participation, and 1 reported health limitations. During the study, 1 subject without a falls history sustained a hip fracture as result of a fall. Five subjects reported soreness in the muscles or joints, which may have been related to increased exercise, but which did not result in loss of study days. Only one participant reported inclement weather (1 day) that prevented walking. One subject had an infectious illness that resulted in a brief study absence but not disenrollment. DISCUSSION These data demonstrate that wearing a pedometer, along with goal setting and regular coaching of older adults, can improve daily ambulatory activity nearly 25% over 4 weeks and can result in functional benefits. About two thirds of the step increase occurred in the first 2 weeks of uncovered pedometer use. Improvement continued to a lesser degree during the second 2 weeks, but study duration was not sufficient to determine when a plateau effect on ambulation might take place. The average daily steps in this study population were considerably lower than the 10,000 steps per day goal that has gained popular support, but which has not been validated scientifically. The literature does suggest that this target may be unrealistic for an older population.17 For this reason, our study used goal setting based on individual baseline steps rather than a population-based average. When the pedometer was removed, the participants did not maintain their increased level of physical activity despite JAMDA e October 2011
Table 3.
Comparison of Baseline and Final Average Daily Steps and Measured Functional Outcomes
Pedometer Outcomes
Group Average Baseline (T
Timed Up and Go, seconds Leg lifts, reps Tinetti Gait and Balance Evaluation 2-minute walk, ft Functional reach, ft Grip strength, kg Geriatric Depression Scale (0e15) Quality of Life scale (0e100) Average daily steps, no.
11.2 3.9 22.7 7.1 24.1 3.7 313.7 97.0 2.43 0.36 21.1 7.7 2.17 2.53 79.1 18.9 2992 1975
1)
Group Average Final (Tf)
P Value*
10.6 3.9 26.3 7.0 24.8 3.1 330.3 101.0 2.41 0.33 21.6 6.7 2.29 2.70 79.9 19.0 Tf: 3526 2716 T4: 3670 2624
.014 \0.001 .027 .014 .671 .370 .594 .721 .070 T0 vs Tf .035 T0 vs T4
* Paired-sample t test.
ongoing coaching activities. One fifth of the overall gain in steps was lost over 3 weeks when this device was removed. This suggests that the pedometer itself was the motivating factor rather than the support process. A study in younger adults also demonstrated that pedometer use with support materials was no better than pedometer use alone in increasing physical activity. These authors concluded that pedometers were the primary motivational tool and that behavioral support mainly served to affect attitudes toward pedometer use.18 As might be expected from a walking exercise program, lower body but not upper body functional status improved as a result of the increased activity. Walking speed improved as measured by the Timed Up and Go and the 2-minute walk distance. Leg endurance significantly improved as measured by the number of leg extension repetitions performed in 30 seconds. Gait and balance improved as measured by the Tinetti score; however, the upper body functional measures of grip strength, and dynamic trunk flexibility (functional reach) did not improve as a result of the increased ambulation. The combined Tinetti gait and balance score improved, but may have been a result of improvement in the gait component and not the balance component. This would potentially explain why improvement was not seen in functional reach as a test dynamic balance as a walking program would be expected to improve gait more so than balance. Grip strength was not expected to improve as a part of a walking program and served as a negative control parameter. Mood and global quality of life score also did not change over the course of the study. As in other pedometer studies, we found that the device was easy to use and a safe means of increasing physical activity. The study completion rate of 81% was similar to other pedometer trials.9 Few individuals had difficulty using the device and failure to wear the pedometer occurred on less than 2% of the measured days. Illness, poor weather conditions, and exercise-associated symptoms infrequently affected study participation. Recent data indicate these are the most common barriers cited by older adults in walking programs, along with concerns of safety and lack of a walking partner.19e21 Although one serious fall occurred during the study, serious walking-related adverse events are rare. A walking study of adults with multiple medical comorbidities showed only 1 serious activity-related event in 1110 person-months of obserORIGINAL STUDIES
vation and less than 1 nonserious activity-related event per 100 person-months.22 Only a few studies have evaluated the use of pedometers in an older population. In a 12-week feasibility study of 54 women with a mean age of 76 years, 83% completed a pedometer protocol, but no significant increase in daily steps was seen.20 A 12-week RCT of a pedometer-based walking program in older adults (mean age 73 years) showed an increase in physical activity of 21% to 34% over baseline. This study was not designed to measure clinical health outcomes.23 Our results are very similar to those reported by Talbot et al,24 who measured both activity and functional status in older adults. In that 12-week RCT of 34 adults (mean age 70 years) with knee osteoarthritis, a 23% (P 5 .04) increase in daily steps was reported. The treatment group also demonstrated a 20% (P 5 .04) increase in quadriceps strength as measured by knee extension and a 12% to 15% improvement in timed walk and stair climbing. Our study demonstrated a 17% improvement in lower limb endurance based on leg lift repetitions, but showed a less robust 5% to 8% improvement in walking time and walking distance. Our study was limited most in its design and its duration. Participants were self-identified and were not randomized into a study protocol. Most subjects self-reported a daily exercise routine at baseline, which would imply a healthier and more motivated study population. These data may not be generalizable to the more sedentary or community-dwelling population. Despite these limitations, participants were able to demonstrate improvement in activity and achieved an improvement in function compared with baseline. Study results indicated that increases in physical activity continued over 4 weeks, but it was not clear when a walking plateau was reached and how long this level of activity could be sustained. The study duration was also insufficient to determine a trajectory of loss in daily steps and function once the pedometer was removed. A longer study is needed to determine if using a pedometer imparts a lifestyle change, or if interest and physical benefits wane over time. CONCLUSION A pedometer is a simple and affordable device that is useful in improving daily activity and functional outcomes in older adults. Compliance was high in the walking program, but Snyder, Colvin, and Gammack 593
activity decreased once the pedometers were removed and the screen covered from view. Pedometers are an effective means of motivating positive lifestyle change in older adults.
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11. Banks WA, Morley JE. Memories are made of this: Recent advances in understanding, cognitive impairment, and dementia. J Gerontol A Biol Sci Med Sci 2003;58:314e321. 12. Cyarto E, Myers A, Tudor-Locke C. Pedometer accuracy in nursing home and community-dwelling older adults. Med Sci Sports Exerc 2004;36:205e209. 13. Podsiadlo D, Richardson S. The Timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39: 142e148. 14. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 1986;80:429e434. 15. Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression. Clinical Gerontologist 1982;1:37e44. 16. The EuroQol Group. EuroQoldA new facility for the measurement of the health-related quality of life. Health Policy 1990;16:199e208. 17. Tudor-Locke C, Bassett D. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004;34:1e8. 18. DeCooker K, DeBourdeaudhuij I, Cardon G. The effect of pedometer use in combination with cognitive and behavioral support materials to promote physical activity. Patient Educ Couns 2008;70:209e214. 19. Croteau KA, Richeson NE, Farmer BC, Jones DB. Effect of a pedometerbased intervention on daily step counts of community-dwelling older adults. Res Q Exerc Sport 2007;78:401e406. 20. Sugden J, Sniehotta F, Donnan P, et al. The feasibility of using pedometers and brief advice to increase activity in sedentary older womenda pilot study. BMC Health Serv Res 2008;8:169. 21. Jones DB, Richeson NE, Croteau KA, Farmer BC. Focus groups to explore the perceptions of older adults on a pedometer-based intervention. Res Q Exerc Sport 2009;80:710e717. 22. Goodrich DE, Larkin AR, Lowery JC, et al. Adverse events among highrisk participants in a home-based walking study: a descriptive study. Int J Behav Nutr Phys Act 2007;4:20. 23. Farmer B, Croteau K, Richeson N, Jones D. Using pedometers as a strategy to increase the daily steps of older adults with chronic illness: From research to practice. Home Healthc Nurse 2006;24:449e456. 24. Talbot LA, Gaines JM, Huynh TN, Metter EJ. A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study. J Am Geriatr Soc 2003;51:387e392.
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