Physical & Occupational Therapy in Geriatrics, 31(3):268–279, 2013 C 2013 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potg DOI: 10.3109/02703181.2013.796583 Impact of Exercise Frequency on Hand Strength of the Elderly Bryan Guderian, MOT, OTR/L 1 , Ashley Johnson, MOT, OTR/L 2 , & Virgil Mathiowetz, PhD, OTR/L, FAOTA 3 1 Mayo Clinic, Rochester, MN, USA, 2 University ofMinnesota Medical Center, Fairview, Minneapolis, MN, USA, 3 Program in Occupational Therapy, University of Minnesota, Minneapolis, MN, USA ABSTRACT. Purpose: To determine if an every other day exercise program achieves comparable results to an everyday program, and to compare participants’ adherence to each program. Study Design: Randomized controlled trial. Methods: Thirty-six indepen- dent living individuals age 55 and older were randomly assigned to one of two groups. Group A performed grip and pinch therapy putty exercises daily. Group B performed the same exercises every other day. Participants were also assessed for program adher- ence. Results: There was no significant difference (p = 0.05) in grip strength change scores between the low- and high-frequency groups over the 8-week training period. Six out of eight pinch strength change scores indicated no significant difference between groups. Adherence data were better for the low-frequency group. Conclusion: For the most part, results indicated no significant difference between the hand-strengthening protocols when measuring hand strength over an 8-week period. Level of Evidence: 1b. KEYWORDS. Exercise frequency, hand exercise, grip strength, pinch strength, el- derly, program adherence, compliance Regular exercise and activity are crucial to the overall health of individuals who are aging (Nied & Franklin, 2002). As the elderly population ages, there is a decline in hand strength and function (Mathiowetz et al., 1985; Ranganathan, Siemionow, Shagal & Yue, 2001). Thus, programs are needed to guide the elderly in maintain- ing and/or increasing hand strength, specifically pinch and grip strength (Nied & Franklin, 2002). The optimum frequency for strength training of large muscle groups has been established in most research as three days per week or every other day (Nelson et al., 2007). However, there is currently a lack of evidence on whether the same frequency is appropriate for strengthening small muscle groups, such as the muscles involved in hand movements. The purpose of this study is to determine whether Address correspondence to: Bryan Guderian, MOT, OTR/L, 5879 Kingsbury Drive NW, Rochester, MN 55901, USA (E-mail: [email protected]). (Received 10 November 2012; accepted 14 April 2013) 268 Phys Occup Ther Geriatr Downloaded from informahealthcare.com by Dalhousie University on 07/15/14 For personal use only.
1Mayo Clinic, Rochester, MN, USA, 2University of Minnesota Medical Center, Fairview,Minneapolis, MN, USA, 3Program in Occupational Therapy, University of Minnesota,
Minneapolis, MN, USA
ABSTRACT. Purpose: To determine if an every other day exercise program achievescomparable results to an everyday program, and to compare participants’ adherence toeach program. Study Design: Randomized controlled trial. Methods: Thirty-six indepen-dent living individuals age 55 and older were randomly assigned to one of two groups.Group A performed grip and pinch therapy putty exercises daily. Group B performedthe same exercises every other day. Participants were also assessed for program adher-ence. Results: There was no significant difference (p = 0.05) in grip strength changescores between the low- and high-frequency groups over the 8-week training period.Six out of eight pinch strength change scores indicated no significant difference betweengroups. Adherence data were better for the low-frequency group. Conclusion: For themost part, results indicated no significant difference between the hand-strengtheningprotocols when measuring hand strength over an 8-week period. Level of Evidence: 1b.
KEYWORDS. Exercise frequency, hand exercise, grip strength, pinch strength, el-derly, program adherence, compliance
Regular exercise and activity are crucial to the overall health of individuals who areaging (Nied & Franklin, 2002). As the elderly population ages, there is a declinein hand strength and function (Mathiowetz et al., 1985; Ranganathan, Siemionow,Shagal & Yue, 2001). Thus, programs are needed to guide the elderly in maintain-ing and/or increasing hand strength, specifically pinch and grip strength (Nied &Franklin, 2002).
The optimum frequency for strength training of large muscle groups has beenestablished in most research as three days per week or every other day (Nelsonet al., 2007). However, there is currently a lack of evidence on whether the samefrequency is appropriate for strengthening small muscle groups, such as the musclesinvolved in hand movements. The purpose of this study is to determine whether
Address correspondence to: Bryan Guderian, MOT, OTR/L, 5879 Kingsbury Drive NW, Rochester, MN55901, USA (E-mail: [email protected]).
(Received 10 November 2012; accepted 14 April 2013)
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an every other day hand-strengthening program achieves comparable outcomesto an everyday program in elderly persons and whether the frequency of exerciseeffects exercise program adherence of participants.
REVIEW OF LITERATURE
Exercise Frequency
Frequency of exercise has been identified by the American College of SportsMedicine (ACSM) as one of the exercise program variables that determines theeffectiveness of a strength training program (Bird, Tarpenning & Marino, 2005).For strength to increase, muscles must be overloaded at an appropriate level andfrequency (Franklin, Whaley & Howley, 2000). Frequency refers not only to thenumber of training sessions completed in a set time frame, but also to “the recov-ery ability of the individual” (Bird et al., 2005, p. 846).
Strength training three times per week or every other day is often recommendedfor programs targeting large muscle groups. The ACSM general guidelines suggestscheduling workouts with at minimum 1 day of recovery between sessions (Weir &Cramer, 2006). For older adults, the ACSM recommends strength training 2 daysper week at minimum on nonconsecutive days using major muscle groups (Nelsonet al., 2007). Bird et al. (2005) and Nichols, Hitzelberger, Sherman, and Patterson(1995) further support the frequency of 2 days per week as effective in promotingsignificant strength improvements in beginning strength trainers and elderly menand women, respectively. This frequency is believed to provide time for musclesto recover and develop. Rest periods may alleviate the potential for overtraining,which results from exercise prescriptions that exceed an individual’s recovery ca-pacity. This may lead to muscle fatigue and decrease in muscle strength due to in-sufficient metabolic recovery (Kuipers, 1998).
However, recommended training protocols for small muscle groups have notyet been determined through research. In a comprehensive review of literature onthe dose-response relationship between different training variables, including fre-quency, on forearm flexors, Wernbom, Ausgustsson, and Thomee (2007) revealeda variety of frequencies are being utilized to increase muscle hypertrophy, varyingfrom two to six times per week. Overall, findings suggested a training frequencyof four or more times per week can result in rapid muscle hypertrophy. However,it is unknown if continued high-frequency strength training would have resulted incontinued increases in muscle hypertrophy as many of the reviewed studies lastedonly between 2 and 4 weeks. The studies reviewed did not explore the effectsof strength-training frequency on any muscles smaller than the forearm flexors.Some studies specific to hand strength indicate daily hand exercise is effective inincreasing grip strength (Brighton, Lubbe & Van Der Merwe, 1993; Hoenig, Groff,Prat, Goldberg & Franck, 1993). Conversely, studies from O’Brien, Jones, Mullis,Mulherin, and Dziedzic (2005) and Keogh, Morrison & Barrett (2007) indicateprotocols utilizing only 2 days per week of hand exercises can lead to significantincreases in finger pinch strength. This highlights the need for continued researchto determine the optimal strength-training protocols to improve strength in smallmuscle groups such as those of the hand.
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Exercise Program Adherence
Exercise program adherence, or following through with a prescribed exercise rou-tine, must also be addressed in any hand-strengthening program. For elderly adults,program adherence will ultimately lead to an increased ability to perform theirmeaningful activities of daily living without the need of assistance (Mazzeo &Tanaka, 2001). There are unfortunately barriers that must be addressed to enhanceexercise program adherence. Barriers include: lifestyle habits, decrease in cogni-tion, fatigue, and even fear of injury (Nied & Franklin, 2002). However, they sug-gested that these barriers could be counterbalanced and overcome by designingsimple exercises in which the elderly adults have been thoroughly educated. Theyalso reported that beginning an exercise routine worked best when started out slow,as this builds self-efficacy (Nied & Franklin, 2002).
Another issue is the number of prescribed days, as program adherence may de-crease when the number of days of exercise increases throughout a given week(Mazzeo & Tanaka, 2001). Elderly individuals can potentially build more strengththe more days an exercise is performed, but loss of adherence to the program mayresult (Mazzeo & Tanaka, 2001). Nied and Franklin (2002) found that incorporat-ing exercises into a daily routine, such as completing exercises in front of the televi-sion, leads to better program adherence. LeLieuvre and Waggoner (1981) reportedthat visual display of the number of exercises completed increased the number ofpatients who adhered to the program. In addition, one of the more common meth-ods of promoting adherence consisted of participants keeping diaries at home toreport and keep track of all hand exercise occasions (Brorsson, Hilliges, Sollerman& Nilsdotter, 2009). Further research is needed to investigate the relationship be-tween prescribed program frequency and program adherence.
Purpose and Hypothesis
This study compared a low frequency every other day exercise program to a highfrequency every day exercise program using Rolyan@ ProgressiveTM Putty to de-termine if both programs achieve comparable results in elderly persons. It was hy-pothesized that the participants in the lower frequency exercise program wouldhave no significant greater improvements in grip- and pinch-strength performancecompared to persons participating in the higher frequency program. A secondarypurpose is to determine if participants adhere to one exercise program more con-sistently than the other. The findings from this study will further educate occupa-tional therapists and clients on the optimum frequency necessary in a hand exerciseprogram.
METHODS
Design
A two-group, pretest-posttest design was used. Each participant was randomly as-signed to either Group A or Group B by flip of the coin. Group A received 8 weeksof the high-frequency exercise protocol (X1) involving exercise every day. GroupB received 8 weeks of the low-frequency exercise protocol (X2) involving exerciseevery other day (Figure 1). Grip and pinch strength were evaluated at the beginning
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_______________________________________________
Group A R O1 X1 O2
Group B R O1 X2 O2
________________________________________________
Note: R = random assignment to groups; O = grip and pinch strength measurements; X = strength training frequency protocol.
FIGURE 1. Two-group pretest-posttest design used in the study.
of the study and on a biweekly basis for the duration of the study. Participants inboth groups performed the same hand-strengthening exercises.
Participants
Volunteers were recruited from four independent and assisted living senior centersin the Midwest. Inclusion criteria included:
1. Able to use both right and left hands2. Living independently3. Age 65 or older
Exclusion criteria included:
1. Grip strength of 70 pounds or above2. Presence of injury or impairments of the upper extremities3. Current participation in physical or occupational therapy4. Hospitalization or admittance into a care facility for three or more days during
the study5. Pain during hand-strengthening exercises
This study was approved by the Institutional Review Board of the University ofMinnesota.
Exercise Protocol
The study included low- frequency and high-frequency exercise protocols. Par-ticipants in the low-frequency group used the therapy putty during their hand-strengthening exercises every other day. The participants in the high-frequencygroup used the therapy putty every day. Three specific grip- and pinch-strengthening exercises, taught during the initial meeting, were performed by allparticipants.
The first exercise, gripping, involved placing the therapy putty in the palm of thehand and bending the fingers into the putty to create a fist. The second exercise keypinch, which consisted of placing the ball of therapy putty between the side of theindex finger and the pad of the thumb and squeezing until the index finger and thethumb touched. The third exercise, the 3-point pinch, consisted of placing the ball of
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therapy putty between the pad of the thumb and pads of the index and long fingers.The fingers then squeeze through the therapy putty until the pads of the thumb andfingers touched. Each exercise was performed for 30 repetitions each exercise day.Every 3 weeks during the study, resistance of the therapy putty was assessed andadjusted by adding a catalyst at the discretion of the investigators based on inputfrom the participants and observation of the participant’s use of the therapy putty.
Outcomes
Grip- and Pinch-Strength Assessments
Grip strength was assessed using a recently calibrated Jamar dynamometer, andpinch strength was assessed using a recently calibrated B & L Engineering pinchgauge. The Jamar dynamometer and B & L Engineering pinch gauge have evidenceof reliability and validity when used with standard positioning and instructions asdescribed by Mathiowetz, Weber, Volland, & Kashman (1984).
Exercise Program Adherence
Participants were provided a tracking sheet to record their completion of the ex-ercises throughout the 8-week period. Participants recorded the days of the weekthey performed the exercises, as well as whether they completed the exercises fully,partially, or not at all. If participants recorded partial exercises or did not performthe repetitions, they were asked to make comments as to why they were not com-pleted. Participants also made comments on the resistance of the device at the endof the week as being too easy, about right, or too hard.
The data recorded were analyzed using the PASW Statistics 18 statistical analysissoftware. Descriptive and inferential statistics were run on the following variables:right grip strength, left grip strength, right key pinch, left key pinch, right tip-pinch,left tip-pinch, right palmer pinch, and left palmer pinch. An independent samplet-test was run on each of these variables to compare the mean change scores ofhigh-frequency group to the low-frequency group. Effect sizes using Cohen’s d werecalculated by using the mean difference for each change variable divided by thestandard deviation of the difference (Portney & Watkins, 2000).
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Assessed for Eligibility (n=57)
Not Randomized (n=9) -Did not meet inclusion criteria (n=9)
Randomly Assigned (n=48)
High frequency group (n=27)Did not complete treatment (n=6)
Low frequency group (n=21)Did not complete treatment (n=6)
Four men and 44 women were randomly assigned to groups. Thirty six subjectscompleted the entire study: three men and 33 women. Twelve subjects droppedout of the study: four due to lack of interest in completing the study, three dueto scheduling conflicts, one due to arthritis flare up, one due to undisclosed illness,one due to not liking the way the putty felt in their hands, one for unknown reasons,and one subject died prior to the end of the study. The subjects were stratified byexercise group; either high- or low-exercise program (high n = 21, low n = 15).See Figure 2 for a flow chart of the participants through the study. See Table 1 forparticipant characteristics based on assigned frequency protocol. There were nosignificant differences in age or pretest grip strength between the two groups, butthere were clearly more men in the low-frequency group.
Comparison of Low- Versus High-Exercise Frequency
Table 2 is a comparison of the mean change scores between the low-frequencygroup and the high-frequency group for both grip measurements and all six pinch
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TABLE 1. Characteristics of Participants that Completed the Study (N = 36)
High Frequency (N = 21) Low Frequency (N = 15)
Men 0 3a
Age NA 81 (4.9)b
Right dominant NA 2Left dominant NA 1Women 21a 12a
Age 82.3 (6.8)b 82.3 (5.2)b
Right dominant 19 10Left dominant 2 2Pretest hand strengthRight grip strength 39.8 (12.0)b 35.4 (11.6)b
Left grip strength 38.0 (12.0)b 35.6 (16.3)b
Note. aN.bM (SD).
measurements. For the low-frequency group, the right and left grip strengths and theleft key pinch increased, while the remaining pinch strengths all decreased slightlyby the end of the 8-week program. For the high-frequency group, all variables in-cluding both grip measurements and all six of the pinch measurements increased asexpected.
The mean change score differences showed that the low-frequency group in-creased more in strength compared to the high-frequency group for the right andleft grip scores. For all six pinch scores, the high-frequency group increased morein strength compared to the low-frequency group. However, t-tests indicated thatthe differences were nonsignificant between groups on all variables, except left tippinch and right palmar pinch. In those two comparisons, the high-frequency groupdid significantly better than the low-frequency group.
Cohen’s d calculations indicated that left tip pinch (d = .88) had a large effectsize; right tip pinch (d = .57) and right palmar pinch (d = .74) had a moderate effectsizes; right grip (d = −.38), left palmar pinch (d = .31), and right key pinch (d =.49) all had a small effect size; and left grip (d = −.04) and left key pinch (d = .15)
TABLE 2. Comparison of Mean Change Scores between Pretest and Eight-Week Posttestfor Low (n = 15) versus High (n = 21) Frequency Groups Using Independent t-test,probability (p) and Cohen’s d
Frequency High (n = 21) Low (n = 15) DifferenceMeasurement M (SD) M (SD) M (SD) t p d
Note. The negative value of the difference mean indicates the low-frequency group increased in strength comparedto the high-frequency group. Cohen d effect size = mean difference/pooled SD of the mean difference.
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FIGURE 3. Comparison of grip strength, mean scores between the low- and high-frequencygroups across the 8 weeks of the study.
had a negligible effect size. A negative effect size indicated that the low-frequencygroup had a greater increase in strength than the high-frequency group.
Figure 3 provides visual comparisons of mean scores of the low- and high-frequency group’s changes in grip strength during the 8-week study. This graph in-dicates that most of the increase in grip strength scores across time occurred duringthe first 2 weeks.
Exercise Program Adherence
This study collected program adherence data on participants to determine if partic-ipants adhered to one exercise protocol more completely than the other. Overall,results (Table 3) indicated program adherence was better in the low-frequency
TABLE 3. Adherence Percentage Based on Assigned Frequency Protocol for 8-WeekStudy
Frequency Full Adherence Partial Adherence Not Adherent Missing Data
Note: Full adherence indicates participants reported performing all exercises for the assigned days. Partial adherenceindicates participants reported performing 33–99% of the exercises for the assigned days. Not adherent indicatesparticipants reported performing <33% of the exercises for the assigned days. Missing data indicates data notrecorded or turned in by participants.
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exercise group than the high-frequency group. In addition, the low-frequencygroup had much less missing data.
DISCUSSION
We hypothesized there would be no significant difference between low- and high-frequency hand-strengthening protocols when measuring hand strength over an8-week period. For the most part, our results support this hypothesis. However,there is some inconsistency between grip- and pinch-strengthening data. The grip-strength data appeared to support the hypothesis, as there was no significant dif-ference in mean change of strength between the two groups. The pinch-strengthdata included four measures that showed no significant difference and two mea-sures which were significantly different: left tip pinch and right palmar pinch. Thehand-grip strength data especially provides some support for the conventional ev-ery other day strengthening guidelines for frequency of strengthening exercisesof larger muscle groups (Nelson et al., 2007). It also may lend some support toother studies finding significant improvements in strength with lower frequency ex-ercise protocols, 4 days or less per week, on forearm flexors (Wernbom et al., 2007),wrist extension and finger-pinch muscles (Keogh et al., 2007), and overall strength(Nichols et al., 1995). One mechanism, which may help make exercising every otherday sufficient, may include sufficient overload through the duration and intensityof the exercise (Franklin et al., 2000; Bird et al., 2005). Another mechanism, whichmay contribute to this, is the need for muscles to recover and develop (Bird et al.,2005), which supports the general ACSM guidelines of having at least 1 day of re-covery between strength-training sessions (Weir & Cramer, 2006).
The study by Wernbom et al. (2007) recommending 4 or more days per weekto train smaller muscle groups could help explain why the pinch-strength scoresincreased more in the high-frequency groups than in the low-frequency groups inour study. However, our study utilized hand strength, which utilizes smaller mus-cle groups than the forearm flexors tested in Wernbom et al. (2007). Additionally,hand-grip strength data in our study did not show this same trend. Hence, our find-ings may also suggest that exercise frequency has a different effect on even smallergroups of muscles in the hand used for pinch.
Because the mean differences in grip strength were similar between the two fre-quency groups, this suggests that therapists may have more flexibility when pre-scribing hand-strengthening programs. The decision could be based more on whichprotocol would elicit better adherence with a specific client. If a client has a lot ofhome exercises, the every other day protocol would likely elicit better adherence.Unless one frequency protocol is proven more effective than another through fu-ture research, this may enable therapists to prescribe lower frequencies of exercisethat may appear more desirable to many clients.
The program adherence forms used in this study may have been difficult forparticipants to complete by the number of forms not completed or turned in (seeTable 3). The high-frequency group had a much higher percentage of missing dataas compared to the low-frequency group, indicating the time involved to completethe forms may have been too demanding for participants. Participants stated theyhad difficulty remembering to complete the forms and it was noted that many
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participants completed the forms during the biweekly meeting with the researchers,possibly affecting the accuracy of the program adherence data. There was no ob-jective way to determine the accuracy of the program adherence forms or proveparticipants completed the exercises as reported on the program adherence forms.Given the small increases in hand strength across the 8-week study, it is speculatedthat the program adherence rate reported might be inflated to some degree.
Limitations
One limitation in our study was that increases in the resistance of the putty after theinitial period were a subjective preference of the participant. This subjective pref-erence may have led to insufficient increases in the putty’s resistance to elicit largerstrength gain across the 8 weeks of our study. In addition, there was no controlgroup in our study, which limits our ability to compare our frequency groups to agroup that received no hand exercises during the 8-week period. Further, our studywas conducted using relatively healthy, potentially higher functioning individualsthat may have had higher beginning hand strength scores than the average olderadult. It is possible that this may have led to less motivation to improve their handstrength, resulting in poorer adherence and smaller changes. Additionally, there isa limitation in generalization to the populations that do have weak hand strength,lower functioning, and/or a disability. Lastly, our lack of complete and reliable pro-gram adherence data limited our ability to draw strong conclusions related to theeffect of exercise frequency on program adherence.
Further research is needed to identify the optimal way to develop muscle hy-pertrophy in small muscles, specifically extrinsic and intrinsic hand muscles. Lim-ited research is available that enables practitioners to understand the impact ex-ercise frequency has on small muscles groups. Other recommended questions forfuture research include the relationship between age and exercise protocols, long-term effects of hand-strengthening programs, and comparison of different hand-strengthening devices. Finally, further research is needed to explore the relationshipbetween exercise protocols and participant adherence. Improved methods need tobe developed allowing researchers to track adherence resulting in more accurateand reliable records.
CONCLUSION
For the most part, the results indicated there was no significant difference be-tween low- and high-frequency hand-strengthening protocols over an 8-week pe-riod. However, given the small changes in hand strength and uncertain accuracy ofthe adherence data, this conclusion must be taken with caution. Further research isnecessary to conclude that either protocol elicits larger gains in hand strength thanthe other.
ACKNOWLEDGMENTS
Thanks to participating investigators: Brenda Egger, Catherine Gerhart, ChadHarms, Erin Johnson, Matthew Johnson, Tastan Kulmeshkenov, Michael Olson,
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Miranda Pierce, Renee Wright, and Kimberlee Yost, and to those who assisted withdata collection & analysis, and/or writing the preliminary report.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors alone are responsible forthe content and writing of the paper.
ABOUT THE AUTHORS
Bryan Guderian, MOT, OTR/L, is an Occupational Therapist at the Mayo Clinic,Rochester, Minnesota, and was a graduate student in the University of MinnesotaMaster of Occupational Therapy Program at the time this research was conducted.Ashley Johnson, MOT, OTR/L, is an Occupational Therapist at the University ofMinnesota Medical Center, Fairview, Minneapolis, Minnesota, and was a graduatestudent in the University of Minnesota Master of Occupational Therapy Programat the time this research was conducted. Virgil Mathiowetz, PhD, OTR/L, FAOTA,is Associate Professor and Assistant Director, Program in Occupational Therapy,Center for Allied Health Professions, University of Minnesota, Minneapolis, MN.
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