Agmr 22 0073
Agmr 22 0073
Agmr 22 0073
Corresponding Author:
Damayanti Tinduh, MD, PhD Background: Aging causes locomotive syndrome (LS), which is characterized by difficulty in
Department of Physical Medicine and walking. The present study determined the effects of locomotion training and regular aerobic ex-
Rehabilitation, Dr Soetomo General ercise programs on the aerobic capacity of older nursing home residents with LS stage 1. Meth-
Academic Hospital, Faculty of ods: This randomized controlled trial included 24 participants aged 60-80 years with LS stage 1
Medicine, Airlangga University, Jalan
residing in a single nursing home in Surabaya, Indonesia. The participants were randomly as-
Mayjen. Prof. Dr. Moestopo No. 6-8,
signed to either the locomotion training group (LTG) or the control group (CG). Both the groups
Surabaya, Jawa Timur 60286, Indonesia
performed 30 minutes of a daily group-based aerobic exercise program for 8 weeks. The LTG per-
E-mail: damayanti.tinduh@fk.unair.ac.id
formed additional locomotion training three times weekly, with three sets per session, gradually
ORCID: increasing to five sets per session according to the participant’s tolerance. Two-minute walking
https://orcid.org/0000-0001-6604-8152 test (2MWT) values before and after the 8-week intervention were determined in both the groups
and converted to maximum oxygen consumption (VO2max) values. Results: After 8 weeks of inter-
Received: July 7, 2022 vention, a significant increase in VO2max was observed in both the groups (both p<0.05). The LTG
Revised: September 17, 2022 showed a more significant improvement in VO2max (p<0.05) compared to the CG. Conclusion: The
Accepted: September 27, 2022 study results demonstrated the positive effect of 8 weeks of locomotion training and regular aer-
obic exercise programs in improving the aerobic capacity of older adult nursing home residents
with LS stage 1.
Key Words: Older adult, Locomotion, Mobility limitation, Aerobic exercise, Physical Fitness, Nurs-
ing home
sessed by measuring exercise capacity using maximal and submax- MATERIALS AND METHODS
imal exercise tests to measure maximum oxygen consumption
(VO2max).4) The 2-minute walk test (2MWT) is a shorter and rela- Study Design and Study Population
tively safer submaximal training test, especially for frail older This randomized clinical trial was conducted at Jambangan Nurs-
adults. These tests are safe and simple, provide the same informa- ing Home from December 2020 to February 2021. The study
tion on mobility, and are valid and reliable for the measurement of population consisted of older adults residing in the nursing home.
aerobic capacity in older adults.5,6) The inclusion criteria were older adults aged 60–80 years with LS
Physical exercise can improve physical function, reduce inflam- stage 1—a positive Indonesian version of the loco-check12) and a
mation, and delay dependence in older adults.7-9) The recommend- 25-question Geriatric Locomotive Function Scale (GLFS-25)
ed physical exercise program for older adults is multicomponent score of 7–15.13) The exclusion criteria were loss of sight, hearing,
exercises that include strength, flexibility, balance, and aerobic ex- and other senses that affected communication; previous diagnosis
ercise.10) The locomotion training developed by the Japanese Or- of dementia or cognitive impairment; unstable hemodynamics;
thopedic Association is a combination of strengthening and bal- any acute metabolic disorder; heart failure (New York Heart Asso-
ance exercises that are proven safe, simple, and effective for im- ciation [NYHA] class II, III, and IV); uncontrolled hypertension
proving the physical function of older adults.2,3) (systolic blood pressure > 180 mmHg, diastolic blood pressure
Nursing homes in Indonesia are funded mainly by the govern- > 100 mmHg); uncontrolled arrhythmia; stable or unstable angi-
ment, private companies, and charity organizations. Usually, only na pectoris; and any pain or physical disability that prevented exer-
older adults with comorbidities and poor financial support move cise. Fig. 1 shows a flowchart of the study participants. This study
to nursing homes.11) Due to the lack of funds and staff, many of was approved by the Research Ethics Committee of Airlangga
these nursing homes cannot provide comprehensive and multi- University School of Medicine Health (No. 207/EC/KEPK/
modal exercise programs to their residents. Thus, short-duration, FKUA/2020). All procedures followed the principles of the 1964
low-to-moderate-intensity aerobic exercise has become a staple in Declaration of Helsinki and its later amendments or comparable
most nursing homes in Indonesia. ethical standards. The patients were informed about the study pro-
The present study aimed to assess the effect of locomotion train- tocol, and they provided their written informed consent. This
ing and regular aerobic exercise programs on the aerobic capacity study complied the ethical guidelines for authorship and publish-
of older adults with LS stage 1 living in nursing homes. We hypoth- ing in the Annals of Geriatric Medicine and Research.14)
esized that older adults who participated in the intervention
groups would show significantly improved outcomes compared to Randomization
their peers in the control group (CG). This randomized controlled trial included 24 older adults aged
Allocation
Allocated to locomotion training addition group (n=12) Allocated to aerobic exercise group (n=12)
Follow-up
10 Participants assessed lost to follow-up (n=2) 10 Participants assessed lost to follow-up (n=2)
• Lower extremity pain (n=2) • Drop out (n=1)
• Knee pain during assessment (n=1)
Analysis 8 week
Analyzed (n=10) Analyzed (n=10)
Fig. 1. Flowchart of the study procedure. GLFS-25, 25-question Geriatric Locomotive Function Scale.
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Exercise on Older Adult with Locomotive Syndrome 325
60–80 years residing in a single nursing home in Surabaya, Indone- pate in any other intervention-based training program during the
sia. The participants were randomly assigned to the intervention/ 8-week study period. To meet the ethical principles, the CG was
locomotion training group (LTG) or CG. This trial was not blind- provided knowledge of the concepts of the locomotion training
ed for participants and investigators because the intervention could program and its applications after completing the research data.
not be blinded. The sample size for the present study was calculat-
ed15) based on a previous study examining the effects of a multi- Assessments
component exercise intervention on frail older adults,16) with alpha We obtained written informed consent from all participants after
error rate (α) = 5% and beta error rate (β) = 20%. The research providing them with necessary information about the study. The
sample comprised 10 older adults in each group. The sample size participants then completed the research forms, which allowed the
was increased by 20% to account for participant dropout during collection of data on sociodemographic characteristics including
follow-up. The final sample size was 24 older adults, who were age, sex, education, and use of walking aids. The participants re-
equally distributed between the two groups (12 participants in corded their body weight, body height, body mass index (BMI),
each group). and submaximal exercise testing with 2MWT in 30-m courses.
The distance was recorded and converted to VO2max using equa-
Interventions tion6):
The participants in both the groups performed mild-to-moderate
aerobic exercise daily (40%–70% maximal heart rate) for 30 min- VO2max (mL/kg BB/min) = 2.809 + (0.868 × age) – (0.0412 ×
utes per session. The aerobic exercise included movements to im- body weight) – (0.382 × body height) – (0.474 × walking speed)
prove cardiorespiratory and muscle endurance and maintain joint
flexibility. The LTG received additional locomotion training three Note: Age (y), body weight (kg), body height (cm), walking speed
times per week; the three sets per session were gradually increased (m/min), estimation of error standard = 0.119.
to five sets per session according to the participants’ tolerance. In This equation was developed by Pratiwi et al.6) in 2019 for older
both LTG and CG, measurements were performed before and af- adults with frailty. The VO2max value obtained from this equation
ter 8 weeks of intervention and compared statistically. was calculated using confirmatory factor analysis. The calculation
of the Pearson correlation coefficient revealed a strong correlation
Locomotion Training (r = 0.791; p < 0.001) with the 2MWT and a significant correlation
The locomotion training included strengthening and balancing ex- with VO2max values during the 6-minute walking test (6MWT)
ercises. The four exercises included one-leg stand, half-squat, heel submaximal training test. The 2MWT has shown very good
raise, and forward lunge. All exercises were performed in six-mem- test-retest reliability (intraclass correlation coefficient [ICC] =
ber groups under the supervision of a physician, two physiothera- 92.5%). This result demonstrated that the 2MWT submaximal
pists, and nursing home medical staff on pre-programmed days training test was reliable for the assessment of aerobic capacity.6)
and hours in the Jambangan Nursing Home multipurpose room. A
physiotherapist provided examples of the movements to ensure Statistical Analyses
the correctness of the movements during locomotion training. IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Ar-
The participants were also provided with a booklet and video de- monk, NY, USA) was used to analyze the data. Categorical vari-
scribing the locomotion training. The details of each set of loco- ables are expressed as numbers and percentages, while continuous
motion training exercises and instructions were as follows: sin- variables are expressed as means and standard deviation (SD). In
gle-leg standing with eyes open (1 minute for each leg), squats (six the statistical evaluations of the variables, we assessed the normali-
repetitions), heel raises (10 repetitions), and forward lunges (five ty of the variable measurements using Shapiro-Wilk tests. Indepen-
repetitions for each leg). Further details are available from the Jap- dent- and paired-sample t-tests were used in pairwise comparisons
anese Orthopedic Association (https://locomo-joa.jp/assets/ and within- and between-group evaluations because they were
pdf/index_english.pdf). consistent with the normal distribution. Statistical significance was
set at p < 0.05.
Control Group
The CG received routine health care at Jambangan Nursing Home, RESULTS
including monthly physician visits, tests, prescription medications,
and daily activities. The CG participants were asked not to partici- The mean ages of the LTG and CG (75.40 ± 4.88 and 72.30 ± 4.30
years, respectively) were similar, and most participants in both the groups also showed a significant difference in the mean VO2max val-
groups were female (70% in both the groups). The other demo- ues after the 8-week intervention (p = 0.016) (Table 3).
graphic characteristics of the two groups were also similar (Table
1). We observed no significant differences in the mean and SD of DISCUSSION
baseline body weight, height, BMI, GLFS-25, 2MWT, and VO2max
between the LTG and CG (Table 1). Two participants each in the The present study assessed the effect of locomotion training and
LTG and CG dropped out of the study. Hence, the study was com- regular aerobic exercise programs on older adults with LS stage 1
pleted by 10 participants each in the LTG and CG. The outcomes who were nursing home residents. LS is a condition of reduced
of within- and between-group assessments after calculating the mobility due to impairment of the locomotive organs. Because up-
median and mean values for each scale before and after the 8-week right bipedal walking involves minutely controlled movement pat-
intervention were also performed. The mean 2MWT score before terns, it can be adversely affected by the impairment of any aspect
and after the 8-week intervention differed significantly in the LTG of the locomotive organs. The progression of these impairments
(p = 0.001). The mean and SD of 2MWT before the intervention, eventually results in limitations in ADL, reduction in quality of life,
91.70 ± 20.90, increased to 107.00 ± 21.38 after the intervention, and the necessity for care support. Based on the 2020 LS criteria,
indicating the effectiveness of the additional locomotion training LS can be classified into three stages based on the total GLFS-25
on improving mobility in older adults with LS. However, we ob- score, with scores ≥ 7 to < 16, ≥ 16 to < 24, and ≤ 24 categorized
served no significant changes in the CG (p = 0.249). The mean as LS stages 1, 2, and 3, respectively. A higher score indicates lower
2MWT values differed significantly between the two groups after locomotive function, and physical performance test results differ
the 8-week intervention (p = 0.004) (Table 2). The mean VO2max significantly between LS stages 2 and 3, while muscle strength dif-
differed significantly before and after the 8-week intervention in fers significantly between LS stages 1 and 2.2,3,13)
the LTG and CG (p < 0.001 and p = 0.022, respectively). The Functional mobility and independence are the main objectives
mean and standard deviation of VO2max before the intervention, of rehabilitation programs. Functional capacity reflects an individ-
28.9 ± 6.9, increased to 33.4 ± 8.3 after the intervention in the LTG. ual’s aerobic capacity.6) The current concept of LS focuses on
Moreover, the mean and SD of the VO2max before the intervention, strength and balance impairments in determining decreased func-
34.6 ± 8.6, increased to 36.6 ± 8.8 after the intervention. The two tional capacity and mobility in older adults.2,3) The lower limb
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Exercise on Older Adult with Locomotive Syndrome 327
Table 2. Within-group and between-group comparisons of 2MWT scores before and 8 weeks after the intervention
Locomotion training group Control group
p-value (between-group)
Score p-value (within-group) Score p-value (within-group)
Pre-intervention 91.7 ± 20.90 0.001* 90.0 ± 14.50 0.249 0.004*
Post-intervention 107.0 ± 21.38 92.7 ± 10.84
Values are presented as mean±standard deviation.
2MWT, 2-minute walking test.
*p<0.05.
Table 3. Within-group and between-group comparisons of VO2max scores before and 8 weeks after the intervention
Locomotion training group Control group
p-value (between-group)
Score p-value (within-group) Score p-value (within-group)
Pre-intervention 28.9 ± 6.9 < 0.001* 34.6 ± 8.6 0.022* 0.016*
Post-intervention 33.4 ± 8.3 36.6 ± 8.8
Values are presented as mean±standard deviation.
VO2max, maximum oxygen consumption.
*p<0.05.
muscle strength is strongly positively correlated with body balance program for 8 weeks resulted in a significant increase in 2MWT in
in older adults.17) Strength and balance are often significant con- the LTG (15.3 ± 9.8 m). In contrast, we observed no significant
tributors to mobility limitations, and aerobic capacity, often mea- change between the baseline and post-exercise periods in the CG.
sured as maximal oxygen uptake (VO2max) or peak oxygen uptake Connelly et al.5) reported that the minimum change value for the
(VO2peak), also correlates with self-reported difficulty and disability 2MWT to show the effect of exercise on the aerobic capacity of
and timed functional performance in older adults.18) older adults in nursing homes was 15 m, with a time between mea-
Aerobic capacity is generally assessed by measuring VO2max. surements of at least 1 week.
However, this measurement requires complex equipment and lab- The walking test for measuring aerobic capacity indicates the ca-
oratories, specific and expensive equipment, supervision of a pro- pacity for independent mobility, defined as the ability to adjust
fessional medical team, and consideration of the motivation and body position independently, strength for vertical and horizontal
physical effort of the subject to undergo the training test. There- transitions, and aerobic fitness. Tests based on runs have limita-
fore, an alternative test is required to estimate VO2max using a sub- tions for use in older individuals with multisystem disorders.5)
maximal training test.6,19) Walking test results are also highly correlated with other mobility
The 6MWT is a standardized test developed by the American measures, including balance and strength.21) LS is characterized by
Thoracic Society in 2002 to measure VO2max. However, this test decreased balance and strength. Locomotion training combines
has limitations in older adults, especially those with frailty. The strengthening and balance exercises; therefore, regular locomotion
6MWT is too tiring, takes longer, and increases the risk of falling training can improve these factors, including the mobility ability of
in frail older adults; therefore, the 2MWT may be an alternative in patients with LS.2,3) This improved mobility capability is evident in
this population. The 2MWT has good validity, as anthropometric the 2MWT results.
parameters of weight, height, age, sex, and walking speed in the Comparisons of mean VO2max values before and after the 8-week
2MWT were significantly correlated with VO2max during the intervention showed a significant difference between the LTG and
6MWT submaximal training test. The 2MWT also has excellent CG (p = 0.016). Both the groups showed significantly increased
test-retest reliability in frail older adults.6) VO2max; however, the difference was greater in the LTG than in the
In older adults, physical activity is associated with many health CG. A meta-analysis by Hurst et al.22) concluded that for the same
benefits and functional abilities, including ADL mobility and inde- duration, a combination of aerobic and strengthening exercises
pendence. Physical activity also promotes better outcomes in older provided a better benefit in increasing VO2max compared to aerobic
adults with chronic diseases. Physical exercise reduces the risk of exercise alone in a population aged > 50 years. This is because ag-
falls and improves physical function, particularly in frail older ing simultaneously affects several physiological systems. Therefore,
adults with limited mobility.7,20) physical exercise in older adults should include resistance training,
In this study, locomotion training and a regular aerobic exercise aerobics, balance, and flexibility exercises.23)
This study had several limitations. First, this study was per- 4. Jones S, Tillin T, Williams S, Coady E, Chaturvedi N, Hughes
formed during the coronavirus disease 2019 pandemic and includ- AD. Assessment of exercise capacity and oxygen consumption
ed a relatively small number of participants in a single study area. using a 6 min stepper test in older adults. Front Physiol 2017;
Owing to the small number of participants, we could not assess the 8:408.
effect of locomotion training addition based on participant sex; 5. Connelly DM, Thomas BK, Cliffe SJ, Perry WM, Smith RE.
therefore, sex differences in locomotive performance could be pos- Clinical utility of the 2-minute walk test for older adults living in
sible. Moreover, most participants were women; therefore, the re- long-term care. Physiother Can 2009;61:78-87.
sults could not completely reflect the older population. Follow-up 6. Pratiwi N, Satyawati R, Tinduh D, Melaniani S, Mahmuddah M.
studies with larger sample sizes and geographical areas are warrant- Validity and reliability of 2 minutes walking test in frailty elderly.
ed. Second, long-term effects of locomotion training were not Proceedings of the 11th National Congress and the 18th Annual
monitored and the total exercise duration was longer in the LTG Scientific Meeting of Indonesian Physical Medicine and Reha-
than in the CG. These differences in exercise durations also affect- bilitation Association (KONAS XI and PIT XVIII PERDOSRI
ed the results of the locomotion training. The evaluation of the 2019); 2019 Nov 20-23; Jakarta, Indonesia. p. 242-7.
long-term effects and an increased duration of the CG is recom- 7. Gine-Garriga M, Roque-Figuls M, Coll-Planas L, Sitja-Rabert M,
mended in follow-up studies. Salva A. Physical exercise interventions for improving perfor-
In conclusion, the addition of locomotion training to a regular mance-based measures of physical function in communi-
aerobic exercise program in nursing homes showed positive effects ty-dwelling, frail older adults: a systematic review and meta-anal-
on improving mobility and aerobic capacity in older adults with ysis. Arch Phys Med Rehabil 2014;95:753-69.
LS stage 1. Locomotive training may be an effective intervention 8. Gde Agung Mahendra ID, Subadi I, Wardhani IL, Satyawati R,
to prevent and slow LS progression in older adults living in nursing Alit Pawana IP, Melaniani S. Effects of Otago Exercise Program
homes. on serum interleukin-6 level in older women. Ann Med Surg
(Lond) 2022;78:103733.
ACKNOWLEDGMENTS 9. Zheng G, Qiu P, Xia R, Lin H, Ye B, Tao J, et al. Effect of aerobic
exercise on inflammatory markers in healthy middle-aged and
CONFLICT OF INTEREST older adults: a systematic review and meta-analysis of random-
The researchers claim no conflicts of interest. ized controlled trials. Front Aging Neurosci 2019;11:98.
10. Theou O, Stathokostas L, Roland KP, Jakobi JM, Patterson C,
FUNDING Vandervoort AA, et al. The effectiveness of exercise interven-
This work was supported by a Riset Kolaborasi Mitra Luar Negeri tions for the management of frailty: a systematic review. J Aging
grant from Airlangga University (No. 346/UN3/2020). Res 2011;2011:569194.
11. Rizka A, Indrarespati A, Dwimartutie N, Muhadi M. Frailty
AUTHOR CONTRIBUTIONS among older adults living in nursing homes in Indonesia: preva-
Conceptualization: MP, DT, RS, DP, SMMW, YM; Data curation lence and associated factors. Ann Geriatr Med Res 2021;25:93-
and Formal analysis: MP, DT, SM; Investigation and Methodolo- 7.
gy: MP, DT, DP, RS, SMMW, YM; Project administration: MP; 12. Al Hayyan AJ, Mei Wulan SM, Masduchi RH, Nugraheni N, Po-
Supervision: DP, MP, RS, DT, SMMW, YM; Writing-original erwandari D, Melaniani S, et al. Validity and reliability of the lo-
draft: MP; Writing-review and editing: DP, RS, SMMW, DT, YM, co-check questionnaire after cross-cultural adaptation for Indo-
SM. nesia. J Orthop Sci 2021 Nov 17 [Epub]. https://doi.org/10.
1016/j.jos.2021.10.008.
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