UNIVERSITI PUTRA MALAYSIA

EFFECTS OF A MULTICOMPONENT EXERCISE TRAINING PROGRAM ON FUNCTIONAL CAPACITY AND QUALITY OF LIFE OF OLDER PERSONS IN RUMAH SERI KENANGAN NEGERI SEMBILAN

MARIA JUSTINE @ STEPHANY IG 2010 1

EFFECTS OF A MULTICOMPONENT EXERCISE TRAINING PROGRAM ON FUNCTIONAL CAPACITY AND QUALITY OF LIFE OF OLDER PERSONS IN

RUMAH SERI KENANGAN NEGERI SEMBILAN

By

MARIA JUSTINE @ STEPHANY

Thesis Submitted to the School of Graduate Studies, Universiti Putra Malaysia, in Fulfilment of the Requirements for the Degree of

Doctor of Philosophy

February 2010

ii

Abstract of thesis presented to the Senate of Universiti Putra Malaysia in fulfilment of the requirement for the degree of Doctor of Philosophy

EFFECTS OF A MULTICOMPONENT EXERCISE PROGRAM ON FUNCTIONAL CAPACITY AND QUALITY OF LIFE OF OLDER PERSONS IN RUMAH SERI KENANGAN NEGERI SEMBILAN

By

MARIA JUSTINE @ STEPHANY

FEBRUARY 2010

Chair: Associate Professor Dr. Tengku Aizan Hamid, PhD Faculty: Institute of Gerontology The purpose of this study was to measure the effects of a 12-week

multicomponent exercise program on functional capacity (physical functioning

and psychological functioning) and quality of life of older persons residing in a

public funded shelter home in Seremban, Negeri Sembilan. Forty-three

subjects with mean age 70.88 7.82 years (exercise = 23, control = 20)

participated in this quasi-experimental (pretest-posttest design study). The

exercise sessions were carried out group-based three times a week,

comprised of aerobic training, strength training, flexibility and balance

training. Physical functioning outcome measures were cardiorespiratory

endurance (6MWT), right and left armcurl strength (30-sec armcurl), right and

left handgrip strength (handgrip dynamometer), lower limb strength (30-sec

chairrise), right and left upper limb flexibility (backscratch), right and left lower

limb flexibility (chair-sit and reach), balance performance (postural

iii

control(FRT), dynamic mobility and agility (TUG)). Psychological functioning

was measured based on level of depression (12-item GDS). Quality of life

was measured based on life satisfaction (Cantril’s ladder), and physical and

mental component summaries of the SF-12 health survey. No significant

differences were noted in all variables during the baseline measurements. At

the end of the intervention, results for the exercise group revealed significant

increases in cardiorespiratory endurance (41.79%), right armcurl strength

(25%), left armcurl strength (30.79%), right handgrip strength (13.65%), left

handgrip strength (9.93%), lower limb strength (46.19%), postural control

(49.58%), dynamic balance and agility (26.37%), and physical health

component summary (8.4%) (all, p < .05). The exercise group also presented

with improvement in flexibility of right lower limb (63.57%), left lower limb

(44.17%), right upper limb (36.67%), left upper limb (63.1%), as well as life

satisfaction score (10.74%), and mental health component summary (2.95%),

but all did not reach significant level ( p > .05). The control group did not

improve significantly in all the measured variables. In terms of psychological

functioning, both the exercise and control groups showed increase in

depression scores by 1.64% and 17.7% respectively (p > .05). This study

suggests that multicomponent exercise program may improve physical

functioning and quality of life of institutionalized older persons.

iv

Abstrak tesis yang dikemukakan kepada Senat Universiti Putra Malaysia sebagai memenuhi keperluan untuk ijazah Doktor Falsafah

KESAN PROGRAM SENAMAN PELBAGAI KOMPONEN TERHADAP KAPASITI KEFUNGSIAN DAN KUALITI HIDUP

WARGA TUA DI RUMAH SERI KENANGAN NEGERI SEMBILAN

Oleh

MARIA JUSTINE @ STEPHANY

FEBRUARI 2010

Pengerusi: Prof Madya Dr. Tengku Aizan Hamid, PhD Fakulti: Institut Gerontologi Tujuan kajian ini adalah untuk menilai kesan senaman pelbagai komponen

yang dijalankan selama 12 minggu terhadap kapasiti kefungsian (fungsi

fizikal dan psikologi) dan kualiti hidup (kepuasan hidup dan kualiti hidup

berdasarkan kesihatan) dalam kalangan warga tua yang menetap di

institusi kerajaan, di Seremban, Negeri Sembilan. Seramai 43 subjek

(senaman = 23, kawalan = 20) dengan purata umur 70.88 7.82 tahun

telah menamatkan kajian kuasi-eksperimental (ujian sebelum dan selepas)

ini. Senaman ini dijalankan berkumpulan, 3 kali seminggu dan melibatkan

kombinasi latihan aerobik, rintangan, kelenturan dan keseimbangan.

Penilaian kesan fungsi fizikal melibatkan ujian ketahanan kardiorespiratori

(6MWT), kekuatan lengan kanan dan kiri (30-sec armcurl), kekuatan

genggaman tangan kanan dan kiri (handgrip dynamometer), kekuatan

anggota bawah (30-sec chairrise), kelenturan anggota bawah dan atas

v

(back scratch, chair-sit and reach), kawalan postur (FRT), serta

keseimbangan dinamik dan ketangkasan (TUG). Penilaian fungsi psikologi

menggunakan skala tahap kemurungan (12-item GDS). Penilaian kualiti

hidup adalah berdasarkan skala kepuasan hidup (Cantril’s ladder) dan

ringkasan komponen kesihatan fizikal dan mental menggunakan skala SF-

12. Penilaian awal bagi semua ujian tidak menunjukkan perbezaan yang

signifikan bagi kumpulan senaman dan kawalan. Pada akhir intervensi

kumpulan senaman menunjukkan peningkatan signifikan pada ketahanan

kardiorespiratori (41.79%), kekuatan lengan kanan (25%) dan lengan kiri

(30.79%), kekuatan genggaman kanan (13.65%) dan genggaman kiri

(9.93%), kekuatan anggota bawah (46.19%), kawalan postur (49.58%),

keseimbangan dinamik dan ketangkasan (26.37%), serta ringkasan

komponen kesihatan fizikal (8.4%) (semua, p < .05). Kumpulan senaman

juga menunjukkan peningkatan kelenturan anggota bawah kanan (63.57%)

dan kiri (44.17%), anggota atas kanan (36.67%) dan kiri (63.1%), serta skor

kepuasan hidup (10.74%) dan ringkasan komponen kesihatan mental

(2.95%), tetapi kesemuanya tidak mencapai tahap signifikan (p > .05).

Kumpulan kawalan tidak menunjukkan perubahan signifikan pada semua

variabel yang diuji. Bagi fungsi psikologi, kumpulan senaman dan kawalan

menunjukkan peningkatan tahap kemurungan dengan masing-masing

1.64% dan 17.7% (p > .05). Hasil kajian ini mencadangkan bahawa

senaman pelbagai komponen boleh meningkatkan fungsi fizikal dan kualiti

hidup warga tua yang tinggal di institusi.

vi

ACKNOWLEDGEMENTS

I, gratefully acknowledge the contributions of many individuals and groups in the

conduct of this study. Without the help of these people, the process of creating,

carrying out, and completing this project would not have been possible.

I would first like to thank all the residents of Rumah Seri Kenangan, Seremban,

Negeri Sembilan who willingly volunteered to participate in this study. Without

their cooperation this project would not have been possible.

Secondly, I express gratitude to my supervisors, Assoc. Prof Dr Tengku Aizan

Hamid, Dr Tengku Fadilah Tengku Kamalden, and Dr Zaiton Ahmad who

supported me through this long process whether it was assistance in the

suitability of the exercise program or feedback on the dissertation.

I am also thankful to my ex-students, especially Che NorHaslindar, Hazila, Asiah,

Norashikin, and Sofinah who helped in the implementation of this exercise

program. I would also wish to thank Munayati, Saiful Adli, Norazebah, and

Salwana who conducted the evaluations. This work could not have been

successful without their invaluable help, cooperation and support.

Many thanks are also extended to the support staffs of Rumah Seri Kenangan.

They were at all times, helpful and cooperative. Their assistance in the

recruitment of study subjects is much appreciated.

vii

My sincere thanks are extended to the Dean of the Faculty of Health Sciences,

Unviersiti Teknologi MARA, Prof Dr Abdul Rahim, Head of Physiotherapy

program, Puan Kamaria Kamaruddin, other colleagues, Aslinda, Dr Rozana, and

Madam Thum Hoe Hoe for their understanding and confidence in my abilities to

complete this research.

Finally, not forgetting my dear family, Haslanoor and Muhd Adlan, and close

friends, for their love, understanding and support that kept me going during my

studies. Thank you for being there for me, I know I owe my time with you all.

viii

APPROVAL

I certify that a Thesis Examination Committee has met on 25 February, 2010 to conduct the final examination of Maria Justine @ Stephany on her thesis entitled “Effects of a Multicomponent Exercise Training Program on Functional Capacity and Quality of Life of Older Persons in Rumah Seri Kenangan Negeri Sembilan in accordance with Universities and University Colleges Act 1971 and the Constitution of the Universiti Putra Malaysia [P.U.(A) 106] 15 March 1998. The Committee recommends that the student be awarded the Degree of Doctor of Philosophy. Members of the Thesis Examination Committee were as follows: Zanariah Bte Othman Senior Medical Lecturer Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Chairman) Muhammad Nazrul Hakim Bin Abdullah, PhD Associate Professor Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Internal Examiner) Soh Kim Geok, PhD Associate Professor Faculty of Educational Studies Universiti Putra Malaysia (Internal Examiner) Keith D. Hill, PhD Professor Division of Allied Health LaTrobe University Australia (External Examiner)

___________________________________ BUJANG KIM HUAT, PhD

Professor and Deputy Dean School of Graduate Studies

Universiti Putra Malaysia

Date:

ix

This thesis was submitted to the Senate of Universiti Putra Malaysia and has been accepted as fulfilment of the requirement for degree of Doctor of Philosophy. The members of the Supervisory Committee were as follows: Tengku Aizan Hamid, PhD Associate Professor Institute of Gerontology Universiti Putra Malaysia (Chairman) Tengku Fadilah Tengku Kamalden, PhD Department of Sport Studies Faculty of Educational Studies Universiti Putra Malaysia (Member) Zaiton Ahmad, MD Department of Community Health Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Member)

___________________________________ HASANAH MOHD GHAZALI, PhD

Professor and Dean School of Graduate Studies

Universiti Putra Malaysia

Date:

x

DECLARATION

I declare that the thesis is my original work except for quotations and citations which have been duly acknowledged. I also declare that it has not been previously, and is not concurrently, submitted for any other degree at Universiti Putra Malaysia or at any other institution.

__________________________________

MARIA JUSTINE @ STEPHANY

Date:

xi

TABLE OF CONTENTS

Page ABTRACT ii ABSTRAK iv ACKNOWLEDGEMENTS v APPROVAL vi DECLARATION vii LIST OF TABLES xvi LIST OF FIGURES xvii LIST OF ABBREVIATIONS xviii

CHAPTER

1 INTRODUCTION

1.1 Introduction 1

1.2 Problem Statement 3

1.3 Research Objectives 8

1.4 Research Hypotheses 8

1.5 Significance of the Study 9

1.6 Delimitations 10

1.7 Limitations 11

1.8 Definition of Terms 12

2 LITERATURE REVIEW

2.1 Introduction 14

2.2 Theoretical and Conceptual Model 14

2.2.1 Component of exercise 22

2.2.2 Component of physical functioning 24

2.2.3 Component of psychological functioning 27

2.2.4 Component of quality of life 30

2.3 Exercise Recommendation for Older Persons 34

2.3.1 Type or mode of activity 35

2.3.2 Duration of exercise 40

2.3.3 Frequency of exercise 42

2.3.4 Intensity of exercise 44

2.3.5 Progression of exercise 48

2.4 Benefits of Exercise for Older Persons 50

2.4.1 Cardiorespiratory training for older persons 53

2.4.2 Resistance training for older persons 61

xii

2.4.3 Flexibility training for older persons 77

2.4.4 Balance training for older persons 81

2.4.5 Multicomponent exercise training for older

persons 88

2.5 Summaries of the Literature Review 94

3 METHODOLOGY

3.1 Introduction 96

3.2 Design of the Study 96

3.3 Preliminary Study 98

3.4 Description of Subjects 100

3.5 Ethics 101

3.6 Sampling Procedures 102

3.7 Determination of Sample Size 103

3.8 The Study Flow Chart 104

3.9 Instrumentations 107

3.9.1 Demographic and health history

information 107

3.9.2 Study variables 108

3.10 The Procedures 119

3.10.1 Ethical considerations 119

3.10.2 The intervention group 121

3.10.3 The control group 127

3.10.4 Data collection 128

3.11 Data Analysis 129

4 RESULTS AND DISCUSSION

4.1 Introduction 131

4.2 Baseline Characteristics of Samples 131

4.2.1 Demographic and health characteristics of

study population 132

4.2.2 Physical function, psychological function

and QOL at baseline 137

4.3 Hypotheses Testing 140

4.3.1 Cardiorespiratory endurance 141

4.3.2 Muscle strength 147

4.3.3 Flexibility 160

4.3.4 Balance performance 169

4.3.5 Psychological function 175

4.3.6 Quality of life 181

xiii

5 SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Summary 193

5.2 Conclusion 195

5.3 Recommendations 196

5.3.1 Clinical practice 196

5.3.2 Future research 198

REFERENCES APPENDICES

A Permission to conduct study at Rumah Seri Kenangan Seremban Negeri Sembilan

B Ethical approval for study involving human subjects C Information sheet (English and Bahasa Malaysia versions) D Consent form (English and Bahasa Malaysia versions) E Medical clearance form F Demographic data, health history, falls history, and mental

status questionnaires (English and Bahasa Malaysia versions)

G Performance-based measures of physical functioning H Skala kemurungan geriatric / Geriatric depression scale

(English and Bahasa Malaysia versions) I Cantril’s self-anchored scale (English and Bahasa Malaysia

versions) J SF-12 Health-related QOL questionnaire (English and

Bahasa Malaysia versions) K The exercise intervention L Physical activity log book

BIODATA OF STUDENTS LIST OF PUBLICATIONS

xiv

LIST OF TABLES

Table Page

1. Measurements of outcome conducted during baseline,

week 6, and week 12 97

2. Reliability and validity of outcome measures used in the study 110

3. Demographic characteristics of study population 134

4. Health characteristics of study population 136

5. Baseline differences between exercise and control groups in

functional capacity and QOL 139

6. Changes (%) in cardiorespiratory endurance after 12 weeks of

intervention 142

7. Changes (%) in right arm curl strength after 12 weeks intervention 148

8. Changes (%) in left arm curl strength after 12 weeks intervention 149

9. Changes (%) in right handgrip strength after 12 weeks intervention 150

10. Changes (%) in left handgrip strength after 12 weeks intervention 151

11. Changes (%) in lower limb strength after 12 weeks intervention 152

12. Changes (%) in right lower limb flexibility after 12 weeks intervention 162

13. Changes (%) in left lower limb flexibility after 12 weeks intervention 163

14. Changes (%) in right upper limb flexibility after 12 weeks intervention 164

15. Changes (%) in left upper limb flexibility after 12 weeks intervention 165

16. Changes (%) in postural control balance after 12 weeks intervention 170

17. Changes (%) in dynamic balance after 12 weeks intervention 171

18. Changes (%) in level of depression after 12 weeks intervention 176

19. Changes (%) in life satisfaction after 12 weeks intervention 183

20. Changes (%) in physical health component summary after 12 weeks

intervention 184

21. Changes (%) in mental health component summary after 12 weeks

intervention 185

xv

LIST OF FIGURES

Figure Page

1. Conceptual framework explaining how intervention targeted

on impairment factors contributes to physical and psychological

functioning, and QOL based on the model of ICF (WHO, 2002) 21

2. The flow chart of the study 106

xvi

LIST OF ABBREVIATIONS

ACSM American College of Sports Medicine BRMS Bech-Rafaelsen Melancholy Scale BS Back scratch test CES-D Center for Epidemiologic Studies Depression Scale CR 30-sec chairrise CSAS Cantril’s self-anchored scale CSR Chair Sit-and-reach test FRT Functional reach test GDS Geriatric Depression Scale HRE Hydraulic-resistance exercise HRSD Hamilton Rating Scale for Depression ICF International Classification of Functioning, Disability and Health MCS Mental health component summary PACE Program circuit exercise PCS Physical health component summary QOL Quality of life RCT Randomized controlled trial SDM Statistics Department of Malaysia TUG Time up and go test USDHHS US Department of Health and Human Services WHO World Health Organization 6MWT Six-minute walk test

1

CHAPTER I

INTRODUCTION

1.1 Introduction

The older population in Malaysia is growing rapidly. In 2007, they were

1,195,480 people aged 65 years and above which represented 4.41% of the

total population (Statistics Department of Malaysia [SDM], 2008). It was

projected that by the year 2019, older persons population aged 65 and above

would reach 7% and would double to 14% in 2043 (Tengku Aizan, Zaiton,

Shariffah Norazizan, & Mohmad, 2006). In 2006, the life expectancy at birth

for female and male were 76.4 years and 71.9 years respectively (SDM,

2008), and this could further increase in the years to come due to

improvement in the health care system.

The rapid changes in the number of aged population posed a serious

implication as extended years of life often involved increased incidence of

chronic diseases and development of functional limitations (Nakasato &

Carnes, 2006; Seguin & Nelson, 2003; Singh, Chin, Bosscher, & Mechelen,

2006). In America it was estimated that 80 to 85% of people over age 65

have at least one chronic illness and nearly half of the older people reported

that chronic illness limited their activity to some degree (Jamshidi,

Oppenheimer, Lee, Lepar, & Espenshade, 1992), while in Malaysia, in the

year 2002, chronic diseases were cited as the major causes of death and

2

disability, accounting for 71% of all deaths and 69% of the total burden of

disease (as cited in Ramli & Taher, 2008). However, the gradual

physiological aging process would still affect all the major organ systems

even if the older person was not suffering from any diseases (Brennan,

2002).

In addition, the recent changes in the social systems such as migration,

urbanization, increased participation of females in the labour force and

changes in the family structure had heightened the need for

institutionalization for some older persons (Arokiasamy, 1997).

Institutionalized older persons presented with declining quality of life over

time due to deterioration of the physical and psychological functioning

(Degenholtz, Rhee, & Rosen, 2004). As such one major issue that challenges

the public health policy is in terms of health care provision for the

institutionalized older persons due to their dependency on government

subsidy. Dependency with reduce quality of life was considered as a concern

of older adults and a burden on the funding of health care (Noro & Aro, 2004;

Paterson, Govindasamy, Vidmar, Cunningham, & Koval, 2004). Aljunid

(1997) had highlighted this issue and suggested that the health care system

needed improvement to ensure comprehensive and integrated health

services were provided to address the physical, social and mental health of

the older persons.

3

Recently, there was an increasing interest among researchers in

implementing exercise programs as one of the health care strategies to

improve and maintain the functional capacity of older people (Guralnik,

Ferrucci, Simonsick, Salive, & Wallace, 1995; Ritchie, Trost, Brown, & Armit,

2005). According to the American College of Sports Medicine ([ACSM],

1998a), the goals of an exercise program for frail older individuals included

maintenance of functional capacity for independent living, reduction in the risk

of cardiovascular disease, retardation of the progression of chronic diseases,

promotion of psychological well-being, and provision of opportunities for

social interaction. However, to date, research on the effects of exercise

intervention have tended to focus on the community older persons rather than

the institutionalized older persons. As such, the aim of this study was to

evaluate the effects of an exercise intervention on the functional capacity

(physical functioning and psychological functioning) and health-related quality

of life of institutionalized older persons.

1.2 Problem Statement

Institutionalized older persons were found to be high-risk people not only due

to the aging process, but partly due to the sedentary lifestyle (Au-Yeung et

al., 2002; Bastone & Filho, 2004; Evans, 1999). Aging led to a decline in

physical and psychological functioning (Kawamoto, Yoshida, & Oka, 2004)

that caused high level of dependency (Chin, van Poppel, Twisk, & van

Mechelen, 2006a; Noro & Aro, 1996; Singh et al., 2006).

4

In Malaysia, it was reported that 27.2% of the older persons aged 60 and

above living in the government shelter homes (Rumah Seri Kenangan) were

dependent in at least one activity of daily living (ADL) (Zaiton, Nor Afiah, &

Latiffah, 2006). In terms of psychological well-being among older persons in

Malaysia, the prevalence of depression was reported to be at 22.2% for

institutionalized older persons (Mohd Aznan & Samsul, 2007), and 7.6% for

community living older persons (Sherina, Rampal, & Mustaqim, 2004).

Therefore, it is particularly important that the institutionalized older persons

are introduced to exercise intervention in view of their high prevalence of

functional decline.

Health care professionals need to promote exercise intervention that can

benefit the overall functional capacity and enhancement of quality of life of

institutionalized older persons (Csapo, Gormasz, & Baron, 2009;

Deschamps et al. 2010; Deschamps, Onifade, Decamps & Bourdel-

Marchasson, 2009; Evans, 1995). Burbank, Reibe, Padula, and Nigg

(2002) argued that even in advanced old age, one could improve strength,

decrease the risk of falls, improve cardiorespiratory fitness and improve

ability to live independently. As such a comprehensive exercise intervention

should be able to address the physical and psychological well-being of

institutionalized older persons.

5

It had been widely recommended that an exercise intervention for the older

persons should consist of aerobic activities, strength training, balance and

flexibility (ACSM, 1998a; Bird, Smith, & James 1998; Heath & Stuart, 2002;

Mazzeo & Tanaka 2001; McDermott & Mernitz, 2006; Nelson et al., 2007;

Newman, 1995; Nied & Franklin, 2002; Nitz & Hourigan, 2004; Skinner,

1993). Exercise recommendations should also be incorporated with regular

motivation as well as education on the benefits and barriers of exercise

(Hughes, Prohaska, Rimmer, & Heller, 2005; McDermott & Mernitz, 2006).

However, there is lack of evidence on the effectiveness of such a

comprehensive program or the so-called multicomponent exercise program in

improving the functional capacity and quality of life among institutionalized

older persons.

Previous studies on exercise interventions for institutionalized older persons

were mainly emphasizing on one or two fitness components such as strength

alone or combination of strength and aerobic training. Aerobic and strength

training had been shown to operate through different mechanisms in

promoting health in the older persons (Madden, Blumenthal, Allen, & Emery,

1989). Strength training improved muscle mass, muscle strength and muscle

quality (Cassilhas et al., 2007; Seguin & Nelson, 2003) while aerobic training

mainly affected cardiovascular fitness, blood pressure and plasma lipoprotein

profiles (Rydwik, Frandin, & Akner, 2004). Takeshima et al. (2007) had

shown that improvement in cardiorespiratory fitness was limited to aerobic

6

training, whereas improvement in upper and lower body strength were

outcomes of resistance and balance training, and that there was no

improvement in flexibility from cardiorespiratory, resistance, and balance

exercises. The evidence for balance training or flexibility training alone on the

improvement of functional capacity of older persons was also inconclusive

(Nied & Franklin, 2002). Previous studies had shown that strength training

improved balance in older persons (Barret & Smerdely, 2002; Nelson et al.,

1994). More recently, it has been identified that balance component is a key

element in exercise programs aiming to reduce risk of falls among older

persons (Sherrington, Whitney, Lord, Herbert, Cumming, & Close, 2008).

However, it should be noted that the majority of the information available on

benefits of exercise for older persons across the strength, balance,

cardiovascular fitness and flexibility domains has been derived from

community living.

Therefore, based on international exercise recommendations, and the

differing physical benefits associated with different exercise types, an

exercise intervention or recommendation for older persons must be

multicomponent that includes aerobic, strength, balance and flexibility

training, to maximize potential functional outcomes. In addition, an exercise

program for older persons must be functionally-oriented that emphasizes

coordination and postural control to gain overall effects on functional

capacity. Bastone and Filho (2004) argued that it would be more beneficial to

7

train using movements that closely mirror daily activities rather than to train to

increase strength and the power of individual muscle group per se. Similarly,

group-based activity could also boost the older person‟s adherence to regular

exercise and be beneficial to mental health (Helbostad, Sletvold, & Moe-

Nilssen, 2004). Mauk (2005) have highlighted that group exercise and health

educations have the added benefit of increasing opportunities to socialize.

Research on group-based multicomponent exercise training that is

functionally oriented as well as emphasizing education on the benefits of

exercise program are still lacking, and especially in Malaysia insufficient

study is available.

Therefore, this study introduced a multicomponent and well-structured

exercise intervention for older persons living in institutions with the purpose of

maintaining their overall functioning and quality of life. The exercise program

incorporated all the components of fitness required by older persons, which

included strength, aerobic, flexibility, and balance training, and based on low

frequency, low- to moderate-intensity, and using very few and inexpensive

equipment. Each activity or movement was implemented to mimic functional

tasks in order to train functions required in a real-life situation that is directed

towards actual daily activities, for example strengthening the knee extensors

while getting up and progressing to holding an object from sitting to standing.

8

1.3 Research Objectives

The primary objectives of this study were to measure the effects of

participation in a 12-week multicomponent exercise program on:

i. Physical functioning (cardiorespiratory endurance, muscle strength,

flexibility, & balance performance).

ii. Psychological functioning (level of depression).

The secondary objectives of this study were to measure whether the

intervention influences well-being directly or through changes in disability

status (Ferrucci et al., 2004), i.e., whether the intervention has an effect on:

i. Life satisfaction.

ii. Health-related quality of life (physical and mental health)

1.4 Research Hypotheses

Based upon the prior research and the research objectives, the following

alternative hypotheses were tested at the 0.05 level of significance:

i. There will be a significant effect of participation in a 12-week

multicomponent exercise program on physical functioning

(cardiorespiratory endurance, muscle strength, flexibility, and balance

performance).