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Running Head: PHYSICAL PERFORMANCE AND QUALITY OF LIFE 1

Physical Performance and Health Related Quality of Life in Older Adults

Wendy Santos-Modesitt, BA

CSPP-Alliant International University

San Francisco

March 31, 2011


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PHYSICAL PERFORMANCE QUALITY OF LIFE

2

Physical Performance and Health Related Quality of Life in Older Adults

As of the 2009 Census, almost 40 million adults are 65 years and older.

It is estimated that by the year 2020 the number of Americans who will be 65years or older is estimated to be 55 million and about 72 million by 2030 (A

Profile of Older Americans: 2008). The 2009 Profile of Older Americans

stated that only 39% of older persons reported being in excellent or very

good health, suggesting that approximately 60% of the older adult

population suffers from at least one (or more) of the most prevalent health

conditions affecting older adults. As the older adult population increases, so

does the number of individuals reporting less than favorable health, thus

reflecting a need for exploring efficacious physical and mental health

interventions.

In an attempt to understand how to reduce the risks of poor health in

older adults, prior studies have consistently found that physical activity and

better physical performance are associated with better health outcomes in

older adults (Seeman et al., 1994; Nelson et al., 2007). A 2007 report by the

American College of Sports Medicine and the American Heart Association

suggests (based on their study of the literature) that regular and increased

physical activity has a whole host of beneficial implications. The report

states that physical activity plays a role in reducing the risk of many of the

most prevalent ailments and diseases suffered by older adults including

physical and mental health complaints. In addition to the beneficial effects

to physical and mental health, physical activity has also been found to

improve health related quality of life (HRQoL) (Abell, Hootman, Zack,Moriarty & Helmick, 2005; Park, Park, Shephard & Aoyagi, 2010). In order to

develop and test effective intervention strategies, it is crucial to develop a

detailed understanding of the associations between aspects of physical

performance and quality of life outcomes, specifically the mental health and

physical health aspects of quality of life.


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Physical activity refers to any activity that causes the body to exert

itself above and beyond what is typical for an individual, including aerobic

and muscle strengthening activities not necessarily done in a gym or as part

of an exercise program (e.g., hiking or strenuous gardening) ( Physical

Activity Guidelines Advisory Committee, U.S. Department of Health and

Human Services, 2008). Physical performance, often referred to as physical

fitness, describes, objectively, an individuals ability to perform a desired

task or the safety and speed at which tasks can be completed (Resnik,

Baker, Holmquist, & Ntuen, 2002). Measured performance includes walking

speed, chair stand, grip strength, postural balance, etc. In a randomized

control trial (RCT), Pahor et al (2006) found that 70- to 89-year-old subjects,

at risk for disability based on sedentary lifestyles, in a structured physical

activity intervention group significantly improved their physical performance

scores compared to the control group. In addition those in the physical

activity group showed a decrease in mobility disability, suggesting a

beneficial improvement of physical performance across time. Another

assessment of the same cohort found a relationship between subjects who

engaged in more vigorous physical activity and their physical performance

scores (Chale-Rush, et al. 2010). Thus older adults who engage in more

intense physical activity show better performance or score better on physical

performance measures.

Physical performance has been found to have direct benefits on

individuals reports and perceptions of HRQoL. Wolin, Glynn, Coditz, Lee and

Kawachi (2007) explored data collected by the Nurses Health Study (data

from 121,700 female registered nurses, started in 1976) and found that,

when comparing women who had maintained a stable physical activity

regimen across time to those who had increased their level of physical

activity, the latter group reported higher HRQoL. In a RCT, Groessl (2007)

found that physical performance was more strongly associated with HRQoL

than was subjects index of co-morbidity (e.g., having diabetes and


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hypertension). Takata et al. (2009) found that among 80- and 85-year-old

Japanese older adults, those who performed better in measures of physical

performance also reported higher HRQoL.

Specific aspects of physical performance, including muscle strength

and body flexibility, are associated with HRQoL. A few studies have found

relationships between specific aspects of physical performance, such as

muscle strength, and benefits or improvements in HRQoL. Tomas-Carus, et

al. (2009), in a RCT of 30 women with fibromyalgia, found that women in the

intervention group, with improved lower body muscle strength, predicted

improvements in HRQoL. Eyigor, Karapolat and Durmanz (2007) found that

women, 65 years and over, who participated in an 8-week exercise group,designed to improve muscle strength, not only significantly improved in

physical performance scores but also significantly improved in HRQoL at

follow-up compared to baseline. Finally, another RCT (King, Pruitt, Phillips,

Oka, Rodenburg & Hasken. 2000) investigating the effects of different types

of physical activity revealed different aspects of physical performance being

associated with different aspects of quality of life. Subjects in this study

were randomly assigned to one of two exercise groups; either a Fit and

Firm class, focusing on aerobic, muscle strength and toning or a Stretch

and Flex class, focused on stretching and flexibility exercises. A main effect

for group found a relationship between improvements in body flexibility (an

aspect of physical performance) and reported improvements in bodily pain

(an aspect of quality of life). HRQoL improvements over time included,

significant improvements at 12-month follow-up in the energy/fatigue scale

of their HRQoL measure in the Fit and Firm group. And significant

improvements in the emotional well-being scale at 12-month follow-up for

the Stretch and Flex group (King, Pruitt, Phillips, Oka, Rodenburg & Hasken.

2000).

Physical performance has also been found to be associated with

mental health. Depression and anxiety are among the more prevalent


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mental health concerns among older adults. Prior studies have suggested

that physical activity is related to a decreased risk of mental health issues

(Nelson, et al., 2007). Deschamps, Onifade, Decamps and Buordel-

Marchasson (2009) compared two different types of exercise interventions,

Tai Chi vs. Cognitive Action Exercise, in which frail institutionalized older

adults were randomly assigned. While there were no significant differences

between the two groups, at follow up the researchers found all subjects

showed significant improvements in physical performance, HRQoL and

depression. A RCT, studying the effects of aerobic exercise on sedentary

males aged 60-75, found significantly decreased scores in depression and

anxiety and significantly improved HRQoL at six-month follow-up as

compared to the control group (Atunes, Stell, Santos, Bueno & de Mello,

2004). A review of the literature conducted by Fox (1999) found that there

was a significant amount of evidence suggesting that physical activity

improves depression, anxiety and mental wellbeing. An alternative

explanation may be that poor physical performance may increase

dependence on others which may increase symptoms of depression and

anxiety and decrease HRQoL; however, existing literature has not adequately

addressed this.

While there are many studies exploring physical activity and its influence

on health and quality of life, to date, there are not many randomized control

trials (Atuens, Stell, Santos, Bueno & de Mello, 2004; Devereux, Robertson, &

Briffa, 2005; King, et al., 2002) exploring these relationships, particularly

effects of physical performance on HRQoL. In order to explore causal effects,

more RCTs are needed. In addition, the majority of studies are long term

studies ranging from six months to three years. With the number of older

adults predicted to benefit from exercise treatment programs increasing,

shorter term programs will be more efficient and cost effective. Finally,

understanding the relationship between aspects of physical performance and

how these might differently influence aspects of quality of life will help


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clinicians design more effective exercise programs that more accurately

target specific impairments. The objective of this study was to determine

whether an intervention designed to improve physical performance was

associated with improvements in health-related quality of life in a relatively

shorter period of time compared to other studies and to examine the cross-

sectional correlations between specific aspects of physical performance

(strength vs. flexibility) and health-related quality of life (mental vs. physical)

in older adults. Studies tend to simply explore the relationship between

physical performance and HRQoL as a single variable. While other studies

have explored the various domains of quality of life, very few have

associated these with aspects of physical performance. Other studies might

explore physical performance and dichotomize HRQoL to further explore the

relationship to physical and mental quality of life. This study further explores

which aspects of physical performance (upper body strength vs. flexibility)

might influence mental health aspects of quality of life. In other words,

would individuals who might have difficulty getting up out of a chair have

lower score in the mental health quality of life vs. an individual who has

more difficulty with touching his/her toes? We were interested to see:

1. In this 12-week intervention, was there a significant improvement in

physical performance as measured by the Senior Fitness Test among

the four MAX Trial physical activity and mental activity groups?

2. Was there a significant improvement in physical performance as

measured by the Senior Fitness Test among the physical activity

intervention and control group?

3. Which aspects of physical functioning (upper body strength, lower

body strength, upper body flexibility, lower body flexibility, endurance

and agility/balance) are related to HRQoL, specifically the mental vs.

physical aspect of quality of life?


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4. Does a 12-week physical and mental activity intervention result in

improvements in physical performance and health related quality of

life among all participants?

5. Are changes/improvements in physical performance related to

change/improvements in HRQoL at follow up?

Methods:

Procedures

Intervention. The Mental Activity and Exercise (MAX) Trial study is a

randomized control trial (RTC) in which older adults (65 and over), who self-

reported a recent decline in memory or thinking, were randomly assigned

into one of four possible groups. Recent decline in memory and thinking was

assessed by self report. The potential participant was asked: Do you feel

your memory and thinking have recently gotten worse? If the potential

participant did not perceive having some difficulty in these aspects of

cognition, the individual would not be eligible for the study. If participant

self-reported having been diagnosed with Alzheimers disease or any other

form of dementia or neurological disorder, the participant was excluded fromparticipating in the study (e.g. Has a doctor ever told you that you have).

To confirm this report, the Telephone Interview for Cognitive Status-modified

(TICS-m) was administered as the last step in the telephone screening

process. Potential participants who scored in the dementia range, 0-18

points, would not be eligible to participate in the study. For the purposes of

this study, recent decline in memory and thinking may include forgetting

names, word finding difficulties, and difficulty with concentrating and

organization. The primary goal of the larger study was to explore the impact

of a physical and mental activity intervention on the primary outcome of

cognitive functioning. This secondary data analysis reports on the outcomes

of physical performance, health-related quality of life and their associations

with each other.


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Eligible participants were randomly assigned to one of four groups in a

two-by-two design: (1) mental activity control + physical control group, (2)

mental activity control + physical intervention group, (3) mental activity

intervention + physical control group, or (4) a mental activity intervention +

physical intervention group, resulting in approximately equal number of

participants in each group. Participants in the mental activity intervention

group used the Posit Science Brain fitness program, installed on computers

and laptops assigned to participants, for one hour a day, three days a week,

for twelve weeks. Participants in the mental activity control group were

asked to view educational DVDs one hour a day, three days a week, for

twelve weeks. The physical activity intervention consisted of participants

enrolling in a structured aerobics and strength building class, while the

physical activity control group consisted of a structured stretching and

toning class. Both physical activity regimens were designed for this age

group. Participants commitment consisted of attending classes held at a

local YMCA for one hour a day, three days a week, for twelve weeks.

Subjects/Participants:

Study participants were recruited primarily through direct mailing toolder adults in the zip codes surrounding the local YMCA. Additional

strategies included recruitment from databases of several university memory

clinics and from other medical clinics, advertisement in local newspapers,

postings in various sites including places of worship, pharmacies and

shopping centers, and referrals from current study participants. Individuals

who showed interest in participating in the study, by either calling the MAX

Trial phone line or mailing back a post card attached to a study brochure,

were first screened for eligibility over the phone by a research assistant.

Inclusion criteria stated individuals had to be 65 years or older, inactive,

endorse self reported recent decline in memory or thinking, able to commit

to the time restrictions of the study and able to get permission to participate

in the study from a physician or general practitioner. Exclusion criteria


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included self-report diagnosis of any form of dementia or any other

neurological disorder; recent brain injury (within the past year); psychiatric

disorder such as major depression or bipolar disease; heart disease; lung

disease; history of substance or alcohol abuse; physical disabilities such as

tremor, hearing or vision impairment; dependence on cane, walker or similar

device; or currently enrolled in another study. Eligible participants verbally

consented during the telephone screening and were scheduled for a formal

consent visit. Participants were also scheduled for a baseline visit, where

their mental and physical functioning was evaluated. After the twelve-week

intervention, a follow-up visit was scheduled, where mental and physical

functioning was re-evaluated. Six hundred and thirty-eight potential

participants showed interest. Of this, 360 were found ineligible, typically due

to being too active (engaging in moderately intense physical activity at least

once per week for one hour or more per week), 151 refused resulting in 127

eligible participants. Of the 127 eligible participants, 31 withdrew (due to

either medical reasons or time constraints) after the baseline visit, leaving

96 participants who successfully completed the study, meaning the

participants completed baseline evaluations, successfully completed the

exercise and mental activity training program and completed follow up

evaluations. Of the 31 participants who withdrew, four participants

volunteered to undergo 12 week follow up evaluations.

The MAX Trial study has been approved by the University of California,

San Franciscos Committee on Human Research and by the San Francisco

Veterans Affairs Medical Center Research Committee. The secondary data

analyses conducted for this study has been approved by the Institutional

Review Board of the California School of Professional Psychology at Alliant

International University.

Measures


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DemographicsParticipants were asked demographic information

such as age, gender, level of education, income, veteran status, race and

ethnicity.

Physical PerformanceThe Senior Fitness Test (SFT), developed by

Rikli and Jones (2001), was used to assess functional fitness of older adults.

The SFT measures functional fitness by assessing physical parameters.

Lower body strength was measured by counting how many times, in 30

seconds, the participant could stand from sitting position and return to a

seated position (Chair Stand); upper body strength was measured by

counting how many times, in 30 seconds the participant could lift a weight,

do an arm curl, using a five pound weight for women and an eight poundweight for men (Arm Curl). Aerobic endurance was measured by counting

how many steps the participant could take in two minutes, while raising both

knees to a specified height (the specified height was based on the distance

halfway between the participants hip bone and knee bone; 2-Minute Step

Test). Lower body flexibility and upper body flexibility were measured by

taking distance from the participant middle finger reaching towards or going

past their toes (Sit and Reach), and placing their preferred hand over the

same shoulder, palms facing down, and the other hand around their back,

palms facing out, in an attempt to touch middle fingers and measuring the

distance between their middle fingers or overlap (Back Scratch). And motor

ability/agility balance were measured by timing how quickly the participant

could stand from a chair, walk eight feet, go around a marker (a cone) and

walk back another eight feet, returning to the chair and sitting down (8 Foot

Up & Go). Norms have been established by assessing over 7,000 men and

women ages 60-94 (Jones & Rikli, 2002).

Health Related Quality of LifeThe Short Form 12 Health Survey

(SF-12; Ware, Kosinski & Keller, 1995; Ware, Kosinski & Keller, 1996) was

used to assess HRQoL. The SF-12 was developed from the longer version

Short Form 36 Health Survey and measures eight domains resulting in a


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Mental Component Summary (MCS) Score and a Physical Component

Summary (PCS) Score. The specific domains measured include mental

health, social functioning, energy/vitality, role emotional, general health,

physical functioning, role physical and bodily pain. The scores have been

standardized based on general population norms as well as gender and age

based norms. These have been established using a US sample of over 2300

subjects, ages 18 to over 75 years (Ware, Kosinski & Keller, 1995). The SF-

12 has been validated in the US as well as many European countries

(Gandek, et al., 1998). All participants were asked to read and answer all

questions on the form.

The Short Form-12 Health Survey (SF-12) and Senior Fitness Test (SFT)were administered as part of a comprehensive neuropsychological battery

administered to MAX Trial participants at baseline and after a twelve-week

intervention. The cognitive and physical evaluations were administered

according to a protocol, which was developed for the MAX Trial, by a

doctorate level graduate student. All interviewers underwent an extensive

training prior to administering the battery.

Analysis

Study data were analyzed using Stata 10.1 statistical software. The

distributions of all continuous variables were examined using means,

medians, standard deviations (SD) and histograms/box plots. One way

ANOVA analyses were used to determine if the difference or change

observed in SFT item scores, from baseline to follow up, were significantly

different among 1) the four identified groups and 2) more specifically the two

physical activity groups (intervention vs. control). In addition, the

researchers were interested in exploring which aspects of physical

performance correlated with the mental aspects of quality of life versus the

physical aspects of quality of life. Pairwise correlations were used to

determine relationships among SFT items and PCS and MCS scores.


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Significance level was set at .05. Paired T-tests were used to determine

significant differences in SFT performance and PCS and MCS scores from

baseline and post intervention. Change in performance on the SFT and the

change in the MCS and PCS scores was analyzed using pairwise correlations.

Results:

Table 1 displays a summary of the demographic characteristics of the

participants in the Max Trial. A large proportion of the participants identified

as non-white, 35.7%, mean age was 73.4 years and 63% were female. The

mean level of education or the mean highest grade completed was 16

(graduate degree/some graduate work). Baseline performance on SFT and

SF-12 are also reported.

The four groups, (1) mental activity control + physical control group,

(2) mental activity control + physical intervention group, (3) mental activity

intervention + physical control group, or (4) a mental activity intervention +

physical intervention group, were compared based on physical performance

difference (e.g. T2-T1) on all the SFT items. Oneway ANOVA analyses

revealed that improvements in physical performance did not differ by

randomization group. The ANOVA analyses yielded the following results:

Chair Stand F(3,96)=.63,p=.6, Arm Curl F(3,96)=.31,p=.82, 2-Min Step Test

F(3,96)=.30,p=.82, Sit and Reach F(3,96)=1.34,p=.27, Back scratch

F(3,96)=.43,p=.73 and 8-Foot Up and Go F(3,96)=.73,p=.54. Oneway

ANOVA analyses, comparing all participants assigned to the physical activity

control group and the physical activity intervention group, revealed no

significant difference among the two groups when comparing the difference

on the SFT items: Chair Stand F(1,98)=.13,p=.72, Arm Curl F(1,98)=.46,

p=.50, 2-Min Step Test F(1,98)=.04,p=.85, Sit and Reach F(1,98)=.12,

p=.73, Back scratch F(1,98)=.58,p=.45 and 8-Foot Up and Go F(1,98)=.35,

p=.55. Therefore, all participants were combined in the remaining analyses.


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Improvements in HRQoL did not differ by randomization group.

Oneway Anova analyses of four groups, as described above, found no

significant difference among the PCS-12 and MCS-12 change scores, PCS-12

F(3, 96)=2.02,p=.12 and MCS-12 F(3, 96)=.42,p=.74. Likewise, no

significance found for HRQoL when comparing participants in the physical

activity control versus intervention group F(1, 98)=.30,p=.59, MCS-12 F(1,

98)=.01,p=.93.

Physical Performance and Health Related Quality of Life.

Table 2 displays the cross-sectional correlations between measures of

physical performance and mental versus physical aspects of quality of life at

baseline. The following SFT items were significantly correlated with PCS

scores: Chair Stand (r=.32,p


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Paired t-test analyses were conducted in order to determine improvement in

physical performance over time. At baseline participants completed an

average of 10.8 (SD=3.8) chair stands in 30 seconds and 12.2 (SD=4.8) arm

curls in 30 seconds; took 74.3 (SD=23.3) steps during the 2-Min Step Test;

were 1.2 (SD=4.6) inches away from touching their toes and 4.0 (SD=5.0)

inches away from touching their fingers behind their backs; and took 6.7

(SD=2.2) seconds to complete the 8 Foot Up and Go task. After the twelve

week intervention period, participants could complete 1.7 (SD=3.2,

p=


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Discussion:

The mean difference, that is the participants performance on a Senior

Fitness Test (SFT) items, at follow up, subtracted from their performance at

baseline, was compared among the main four groups of the study, as

described above. The analysis revealed there was no significant difference

in the change (or difference) scores among the four groups. The same mean

difference comparison (or mean change) of all the participants in the

physical activity control group versus the physical activity intervention group

yielded no significance as well. One possible explanation is that the control

group was not a true control, as they too received some form of exercise. It

is possible that for this sample, both forms of exercise, either aerobic or

flexibility and stretching, were equally beneficial in improving physical

performance in a 12-week intervention.

At baseline several aspects of the physical performance measure, theSFT, were significantly associated with the Physical Component Summary

Score (PCS) of our HRQoL measure, the SF-12. These included: Chair Stands,

which measures lower body strength; 2-min Step Test, which measures

endurance; and 8-foot Up & Go, which measures agility and balance. At

baseline we also found that Arm Curl (upper body strength) was significantly

related to the Mental Component Summary Score (MCS). While these

relationship remain constant at follow-up for PCS, arm curl is no longer

associated with MCS at follow up, neither is any other physical performance

item of the SFT.

We were interested in learning whether or not this 12 week exercise

intervention could significantly improve physical performance and HRQoL in


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community dwelling adults with self-reported cognitive complaints. After

analysis, we discovered that this sample did improve significantly in 4 of the

6 physical performance items measured by the SFT, including upper and

lower body strength, endurance and lower body flexibility. PCS also

significantly improved in the group from baseline to follow up. There were

no significant improvements in the MCS, however, this groups MCS mean of

52.5, at baseline ,was higher than that of the general US population mean

(51.3; Ware, Kosinski & Keller, 1995). It is possible that this group was

relatively well, in terms of mental health factors, as assessed by this

measure, thus improvements in HRQoL would more likely load on the PCS.

In addition, more SFT items correlated with PCS at baseline than MCS.

We also wanted to explore whether or not the physical performance

improvements observed would correlate to the improvements observed in

HRQoL. For this analysis we found that none of the changes or

improvements for the SFT correlated with changes on the MCS or PCS scores.

Limitations.

This study recruited community dwelling participants living in the Bay

Area, thus based on geographical nature of their residence and

demographics of this region, study participants were relatively healthy,

active and highly educated. Hence this study cannot be generalized to other

populations, such as institutionalized or disabled older adults. RCTs with a

more representative US sample may yield more improvements in physical

performance and HRQoL. Secondly, the intervention was for only twelve

weeks. While this was efficacious enough for this sample, in terms of

improvements in physical performance and PCS, and may be cost effective

for adult treatment programs, exploring longer interventions may also yield

significant improvements in all physical functioning domains and HRQoL. It

is possible some aspects of physical performance (e.g. upper body flexibility,

agility and balance) required a longer intervention to show significant


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improvement. Perhaps a combination of short-term programs coupled with

home based interventions may also yield positive results. Finally, this study

does not include a true control group, that is, a group receiving no form of

treatment. This studys physical activity control group participated in an

exercise program focusing on stretching and flexibility for twelve weeks. It is

possible that including a control group that receives no form of exercise may

shed some light on whether or not the improvements we see on the SFT

items are related to the exercise program or simply being tested twice.

In summary, this study found that a short twelve week intervention

was sufficient in providing improvements in specific aspects of physical

performance, such as lower body strength (standing up out of a chair), upperbody strength (carrying/lifting groceries), endurance (walking/climbing stairs)

and lower body flexibility (reaching for dropped keys). These are all crucial

in an individuals ability to maintain independence as they age. In addition,

participation in this short intervention also significantly improved

participants PCS scores which are related to the physical aspects of quality

of life. As the Baby Boomer generation begins to join the current older adult

population it is crucial for community centers and agencies, providing

services to help reduce risk of disability and to help older adults maintain

independence, implement efficacious exercise interventions.


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Table 2.

Relationships among Physical Performance Items and MCS

PCS SF-12 scores at Baseline

Baseline MCS-12

(r)

PCS-12

(r)

Chair Stand .12 .32***

Arm Curl .31*** .16

Step Test .05 .38***

Sit and Reach -.06 -.10

Back Scratch -.02 .13

8 Foot Up & Go .01 -.36***

***p


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Table 3.

Comparison of Physical Performance at Baseline and Follow up

Paired T-Tests

Baseline Follow-up

Senior Fitness Test

Items

n=100

Mean (SD)

n=100

Mean (SD) P-value

Chair Stand 10.8 (3.8) 12.6 (4.3)


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Table 4.

Relationship among change in physical performance (SFT)

and change in MCS and PCS SF-12 scores

ChangeMCS-12

(r)

PCS-12

(r)Chair Stand .19 -.02

Arm Curl .12 .04

Step Test .05 .10

Sit and Reach .03 -.11

Back Scratch .11 -.02

8 Foot Up & Go -.09 -.05

Note: none of the relationships were significant at a p < .05

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Figure 1. Comparison of MCS-12 and PCS-12 at baseline and follow up.

45

46

47

48

49

50

51

52

53

Mental Component Physical Component

Baseline Follow up

52.5 52.4

(7.8) (8.6)

P-Value= .99

47.5 49.0(8.8) (8.8)

*P-Value= .049

* P value significant at .05

20110331 Paper-Wendy TIET

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