Effects of Self-Regulated Exercise Maintenance Program (SR-EMP) on Cognitive and Behavioral Changes and Musculoskeletal Health of Elderly Women with Osteoporosis

Purpose:   As Korea becomes an ageing society rapidly, geriatric diseases recently increased in the South Korean society. Especially, over the past decade, osteoporosis has drastically increased in the elderly women in their sixties and seventies (Ministry of Health and Welfare), so active social, economic and scientific attention should be paid. The osteoporosis is a disease which enhances a risk of fracture by weakening bone strength through bone mass reduction, bone tissue atrophy, and fine structure damage (Kotz, Deleger, Cohen, Kamigaki, & Kurata, 2004). The disease is treated by means of exercise, intake of calcium and vitamin, no alcohol, no smoking, weight control, medication etc. Among them, exercise therapy is effective for reducing facture, since it gives mechanical load to bone, thus preventing bone loss, increasing bone strength and improving muscular quantity and strength and sense of balance (Lewiecki, 2011). Therefore, continuous exercise should be strongly emphasized for elderly osteoporosis women. Six months or more are needed to make the temperament of bone formed again in response to the transformed load caused by exercise (Spirduso, Francis, & MacRae, 2005). Hence, elderly osteoporosis women should do continuous exercise in everyday life, not during a short term. However, there is a preceding study according to which 50% of the elderly stop exercise after 3-6 months of exercise (Resnick & Spellbring, 2000). This indicates that it is very difficult for old people to maintain their habit of exercise for a long time. The present study paid attention to Park et al. (2013)'s self-regulated exercise maintenance program (SR-EMP), a new strategic program to induce elderly osteoporosis women to do exercise continuously in everyday life and eventually to improve musculoskeletal health.  The SR-EMP was developed to lead elderly osteoporosis women into continuous exercise by using self-observation, goal setting, social and environmental support and reinforcement, time management and relapse prevention, which are sub-concepts of self-regulation, as the tactics of the intervention program, but the practical efficacy of the program should be verified among elderly osteoporosis women. Therefore, this study aims to determine the effects of the SR-EMP program on cognitive and behavioral changes and musculoskeletal health improvement by applying the program to the elderly women having osteoporosis.

Methods: The present study was performed using the pretest-posttest design with a comparison group at two silver schools in C and W cities for about six months from April 26 to October 22, 2012.  The subjects were the women of 65 to 74 years old who were diagnosed as osteoporosis and recommended to do regular exercise but did not take the drugs which are likely to affect osteoporosis without restricting physical activities. The study was joined by 19 subjects in the test group (C city) and 18 subjects in the control group (W city) to the end. There was no statistically significant difference in the demographic characteristics and study.

This study applied the SR-EMP and a general exercise program to the test group and the control group, respectively in order to check how effective the SR-EMP with reinforced self-regulated strategy were for study factors, as compared to the existing exercise programs. To determine self-regulation abilities, an intermediate test was performed after pretest and 12-week introduction and adaptation period, during which regular exercise was maintained by the investigator, and posttest was performed after 12-week maintenance period, during which the subjects maintained exercise (24 weeks after the prior test).

The SR-EMP was developed through the six steps of need assessment, goal setting, selection theory-based intervention methods and performance strategies, development of program application and performance schemes and development of program effect assessment methods, and consists of the health education using self-control strategy's sub-factors, self-observation, goal setting, social support, environmental aids, reinforcement and relapse prevention, and the strategic intervention methods, such as complex exercise, self-help meeting, exercise notebook and telephone consulting.  

In order to help elderly osteoporosis women exercise at home after completing intervention, the program is composed of one-time health education, complex exercise three times a week, self-help meeting once a week in the 8-week introduction period; complex exercise once a week, self-help meeting once a week and telephone consulting two times a week in the 4-week adaptation period; keeping and updating an exercise notebook in the 12-week period.

This study used the tools to measure self-efficacy, expected outcome, exercise frequency and time, osteoporosis, balance and muscular strength in order to determine the effects of the SR-EMP on cognitive and behavioral aspects and health aspects. For self-efficacy, 6 questions (Won In Sook, 2009) of 10 point VAS scale were used, and for expected outcome, 16 questions of 4-Likert scale (Kim Yul, 2009) were used. Higher average points mean greater self-efficacy and expected outcome. This study analyzed the exercise notebooks that the subjects kept during the study period to measure behavioral aspects, exercise frequency and time. For exercise frequency, average values were obtained by adding up the �› (exercise) and × (non-exercise) marks every week. Higher values mean higher exercise frequency. For exercise time, average values were obtained by adding up practical exercise hours among complex exercise hours (5-minute preparatory exercise, 25-minute aerobic exercise, 25-minute resistance exercise and 5-minute finishing exercise) every week. Higher values mean more exercise hours. For bone density, T scores were measured in the calcaneus at a simple test using a mobile bone density measurer for quantitative ultrasonometry. Higher T-score values mean higher bone density. For balance, static balance measurement was used. Higher values mean higher sense of balance. For back strength, a back muscle dynamometer was used. Higher values mean better back strength. The collected data was using the IBM SPSS Statistics version. A repeated measure ANOVA was used to analyze the differences in self-efficacy, expected outcome, exercise frequency and time, bone density, balance and muscular strength.  

Results: The effects of the SR-EMP on cognitive aspects are as follows. First, self-efficacy was no statistically significant difference between the test and control groups (F=0.72, p=.401), but there were statistically significant differences between periods (F=34.50, p<.001), and there was no statistically significant difference in interaction effect between groups and periods (F=3.07, p=.053). Second, the expected outcome was no significantly significant difference between the test and control groups (F=1.03, p=.318) and periods (F=0.72, p=.492). However, there were statistically significant differences in interaction effect between groups and periods (F=6.00, p=.004).

The effects of the SR-EMP on elderly osteoporosis women’s behavioral aspects are as follows. First, the exercise frequency were statistically significant differences between the test and control groups (F=4.43 p=.043) and periods (F=277.49, p<.001). However, there were no statistically significant difference in interaction effect between groups and periods (F=6.00, p=0.103). Second, the exercise time were statistically significant differences between the test and control groups (F=6.96, p=.012), periods (F=239.33, p<.001), in interaction effect between groups and periods (F=4.99, p=.024).

The effects of the SR-EMP on the musculoskeletal health of elderly osteoporosis women are as follows. First, the bone density was no significantly significant difference between the test and control groups (F=1.03, p=0.566) and periods (F=0.72, p=0.329). However, there were statistically significant differences in interaction effect between groups and periods (F=6.00, p=0.005). Second, the balance was no statistically significant difference between the test and control groups (F=0.17, p=.684), but significant differences between periods (F=12.12, p<.001). There was no statistically significant difference in interaction effect between groups and periods (F=6.00, p=0.130). Third, the muscular strength was no statistically significant difference between the test and control groups (F=3.01, p=.092), but significant differences between periods (F=34.77, p<.001). There were statistically significant differences in interaction effect between groups and periods (F=6.05, p=.004).

Conclusion: The present study was performed to determine the effects of the SR-EMP on the cognitive and behavioral changes and musculoskeletal health of elderly osteoporosis women. As a result, the SR-EMP proved to continuously promote expected outcome, a cognitive factor, and increase exercise time, a behavioral factor, and thus have positive effects on bone density and muscular strength. The SR-EMP is expected to be used in various fields as an intervention tool for elderly osteoporosis women to do effective and continuous exercise.