Journal of Physical Education and Sport ® (JPES), 16(3), Art 129, pp. 816 - 822 , 2016
online ISSN: 2247 - 806X; p-ISSN: 2247 – 8051; ISSN - L = 2247 - 8051 © JPES

Original Article
Effect of increased daily physical activity on lower-extremity physical function
during an exercise program for older adults
TAKASHI JINDO1,2; KEISUKE FUJII1; KENJI TSUNODA3; YUYA FUJII4; SONTHAYA SRIRAMATR5;TOMOHIRO OKURA6
1
Doctoral Program in Physical Education, Health and Sport Sciences, Graduate School of Comprehensive
Human Sciences, University of Tsukuba, JAPAN
2
Research Fellow of the Japan Society for the Promotion of Science, JAPAN3
Faculty of Social Welfare, Yamaguchi Prefectural University, JAPAN4
Master’s Program in Health and Sport Sciences, Graduate School of Comprehensive Human Sciences,
University of Tsukuba, JAPAN School of Health and Physical Education, University of Tsukuba, JAPAN5
Faculty of Physical Education, Srinakharinwirot University, THAILAND
6
Faculty of Health and Sport Sciences, University of Tsukuba, JAPANPublished online: September 26, 2016
(Accepted for publication August 14 2016)
DOI:10.7752/jpes.2016.03129
Abstract:
During an exercise program for older adults, it is important that participants exercise not only in theexercise classroom but also in their daily lives. The present study investigated how goal-setting aimed atincreasing daily physical activity by 1,000 steps per day, influenced lower-extremity physical function during theexercise program. The participants were non-randomly allocated to two groups: with goal-setting (n = 19, mean
age: 68.9 ± 3.3 years) and without goal-setting (n = 13, mean age: 69.9 ± 4.2 years). Participants in the groupwith goal-setting were encouraged to increase their physical activity by 1,000 steps/day above their baseline step
counts. All of the subjects in both groups participated in a square-stepping exercise program for 90 min once aweek for 9 weeks. To determine the lower-extremity physical function benefits of the program, six types of test
were performed before and after the program. There was a significant group-by-time interaction on daily
physical activity (p < 0.001). The group with goal-setting significantly increased their physical activity, and thegroup without goal-setting did not change their physical activity. There were significant time effects in the 5-m
habitual walk, choice stepping reaction time, and 6-min walk. There was a significant group-by-time interactionin the five-repetition sit-to-stand test (p = 0.006), and only the group without goal-setting improved theirperformance. Although we successfully increased daily physical activity using goal-setting, we could notconfirm the effect of goal-setting on lower-extremity physical function.
Key words: square-stepping exercise, step counts, feedback, goal-setting
Introduction
Care needs due to lower levels of physical function in older adults are a global health issue. Maintaining
lower-extremity physical function (LEPF) is a key factor in helping older adults to prevent care needs and tomaintain the quality of life (Guralnik et al., 1995; Moreland et al., 2004; Shinkai et al., 2000). Exercise programsfor improving LEPF have been conducted across many fields of research (Howe et al., 2007; Liu & Latham,2009).
On the other hand, exercise training in elderly individuals has been reported to cause a compensatory
decline in non-training physical activity (PA) (Meijer et al., 1999, 2001). Furthermore, another study reported
that effects can only be expected when participants maintain their daily PA during an exercise program (Jindo etal., 2016). Therefore, it is important for participants to perform exercise not only in the classroom but also intheir daily lives. To maintain the participants’ daily PA during the program, PA enhancement, such as goalsetting (GS), self-monitoring, and feedback, is an effective method for increasing PA (Baker et al., 2008; Kolt etal., 2012; Petersen et al., 2012). Petersen et al. (2012) reported that combining the use of a pedometer with GS
increased PA in older adults. However, it is still unclear as to whether the combination of exercise programs withthe encouragement of daily PA by GS is linked to an increase in daily PA and improvement in LEPF.
Previous studies have reported that increased PA may induce falls in older adults (Ebrahim et al., 1997;
Lawton et al., 2008) and have suggested that PA enhancement should include a fall prevention component(Tiedemann et al., 2015). In the present study, we used a fall prevention exercise program called the squarestepping exercise (SSE), which is effective in improving LEPF (Shigematsu & Okura, 2006). The combinationof SSE with the encouragement of daily PA by GS may represent a multi-component solution for health issues inolder adults. The purpose of the present study was to investigate the effects of GS aimed at increasing daily PA
816 --------------------------------------------------------------------------------------------------------------------------------Corresponding Author TAKASHI JINDO, E-mail: takashi.jindo@gmail.com

TAKASHI JINDO; KEISUKE FUJII; KENJI TSUNODA; YUYA FUJII; SONTHAYA SRIRAMATR;
TOMOHIRO OKURA--------------------------------------------------------------------------------------------------------------------------------------by 1,000 steps/day on LEPF during a SSE exercise program. We hypothesized that increasing daily PA would
augment the effects of the exercise program on LEPF in older adults.
Material and methods
Participants
We conducted the present study from May to August 2015 in Ibaraki prefecture, rural Japan.
Participants comprised 35 independently living older adults aged 65 years and older who were recruited throughlocal advertisements or leaflets, which were distributed to participants who attended a health promotion event.
The participants were non-randomly allocated to two groups: with GS (n = 20) and without GS (n = 15). The two
programs were conducted at different times, and the participants selected the program based on the desired time.
To avoid selection by program content, the participants had not been informed of the difference between the two
programs by the end of the program. The participants were required to meet the following inclusion criteria forthe study: (1) aged 65 years or older, (2) able to walk, and (3) living independently. Two participants who did
not attend the post-test measurements and one participant who did not attend more than half of a session were
excluded. The remaining 19 participants in the group with GS (mean age: 68.9 ± 3.3 years) and 13 participants in
the group without GS (mean age: 69.9 ± 4.2 years) were included in the analysis.
All participants provided a signed, informed consent. The Ethics Committee of University of Tsukuba
approved the present study (registration no. tai 26-131).
Exercise program
All subjects participated in an exercise program, which utilized SSE (Shigematsu & Okura, 2006). This
program was conducted separately for the group with GS and that without GS. The program was conducted at a
community center once a week for 90 min over a total of 9 weeks. Experienced instructors supervised theexercise program. SSE is performed on a thin felt mat (250 × 100 cm), which is divided into 40 small squares(25 × 25 cm). The exercise technique includes forward, backward, lateral, and oblique steps, with a progressive
increase in the step pattern complexity. SSE has been applied as the main exercise in voluntary exercise salons
for healthy elderly individuals (Mitsuishi et al., 2013), exercise programs that are aimed at preventing care needsfor older adults (Jindo et al., 2015), and rehabilitation programs for post-stroke patients (Túbero et al., 2014).
The SSE program consisted of a warm-up activity (15 min), SSE (40 min), a recreational activity (20 min), and acool-down period (15 min). Short breaks were taken between each activity and at halftime. A previous study has
described this program in detail (Jindo et al., 2016).
Measurement variables
Measurement testing was performed before and 1 week after the exercise program period. The
demographic variables included age, gender, clinical history, and body mass index. In addition, the fall history
during the last year and during the exercise program was evaluated. To determine the LEPF benefits of the
program, we measured six physical function tests: single-leg balance with eyes open (balance) (Rikli & Busch,
1986) five-repetition sit-to-stand (muscle strength; STS) (Guralnik et al., 1994), timed up and go (mobility)(Shumway-Cook et al., 2000), 5-m habitual walk (walking ability, HW) (Shinkai et al., 2000), choice stepping
reaction time (reaction speed; CSRT) (Lord & Fitzpatrick, 2001), 6-min walk (endurance power; 6MW) (ATSstatement, 2002).
Physical activity
The participants daily PA during the exercise program was measured using pedometers (Kenz
Lifecorder; Suzuken, Nagoya, Japan), and they were instructed to wear the pedometer on their waists at all times
while they were awake, except when swimming or bathing (non-wear time). All of the participants began to wear
the pedometer when they had finished the pre-test, and they were asked to maintain their usual lifestyles for aweek to ascertain their regular PA (regular step counts).
For the group with GS, the first session of the program was extended by 45 min, and a GS session was
conducted. The aim of GS was to increase the mean step count of the first week by 1,000 steps/day. For physicalactivity motivation, two visual goal-setting sheets were made. The first was a line graph that confirmed whether
the participants’ PA had increased or not based on the mean step counts of the first week (Fig. 1). The usage was
as follows: (1) put the regular step counts into the middle brackets, (2) put ±7,000 steps/week and ±14,000
steps/week above or below the regular step counts, and (3) confirm a weekly total step count and put it on thegraph. The participants were encouraged to reach or surpass the line of the goal (+1,000 steps/day), i.e., above
the middle line. The second was a map to confirm the progress of GS (Fig. 2). This was a real map of Japan(SHIROTIZU KenMap, Ver 9. 11, http://www5b.biglobe.ne.jp/~t-kamada/CBuilder/kenmap.htm), and the scaleon the map indicated approximately 10 km for each division (e.g., Point 1 indicates 50 km from the starting
point). Each participant’s step length was supposed to be 60 cm, and the individual goal was set as when aparticipant increased the step count by 1,000 steps/day based on the mean steps count of the first week. The
participants selected a preferred map out of the three maps. The instructor painted the scales according to the---------------------------------------------------------------------------------------------------------------------------- 817
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TOMOHIRO OKURA--------------------------------------------------------------------------------------------------------------------------------------participant’s weekly total step counts. At that time, the instructor provided feedback as to whether their step
counts were enough to accomplish the goal. Before each session, the PA enhancement techniques were provided
on an individual basis by an experienced instructor. To reevaluate GS, it was conducted again half way throughthe program.
Fig. 1 and 2 show the visual representation of GS. The aim of GS was to increase the mean step countof the first week (regular step counts) by 1,000 steps per day. Fig. 1 can confirm whether there is an increase in
the participants’ PA or not based on the regular step count. Fig. 2 shows the progress of GS on a real map ofJapan.

Fig. 1. Goal-setting: a line graphFig. 2. Goal-setting: maps
The participants in the group without GS were able to see their daily step counts; however, they did notreceive feedback on their step counts, and they were not provided with any supporting tools such as GS. The
exercise program, which included a baseline test and post-test period, was divided into four periods as follows:
baseline (1st week) early (2nd–4th session), middle (5th–8th session), and late (9th–11th session), and theaverage daily step counts were calculated for each period (Jindo et al., 2016). Lifelyzer05 Coach ver. 2.1(Suzuken) was used to analyze the downloaded data.
Statistical analysis
Data were analyzed using mean and standard deviation. The participants’ characteristics were compared
between the two groups using independent t-tests and chi-square tests. Two-way analysis of variance was used toconfirm the interaction between the two groups and the time effects before and after the program. A post-hoc test
was used on the variables that showed a significant group-by-time interaction to determine which groups had
more improvement. Regarding PA, the time factors for two-way analysis of variance were the four points. To
calculate effect sizes, Cohen’s d (Cohen, 1988) was used with 0.30 indicating a small effect, 0.50 a medium
effect, and 0.80 or greater a large effect (Cohen, 1988). IBM SPSS Statistics 23 for Windows was used for thestatistical analysis, and the level of statistical significance was set at p < 0.05.
Results
As shown in Table 1, there were significant differences at baseline in the fall history in the last year and
HW between the two groups. The participants in the group with GS had a fewer number of falls and better scoreson HW. The mean percentages of classes that were attended were 95.9% ± 8.5% (range: 77.8%–100.0%) for the
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TOMOHIRO OKURA--------------------------------------------------------------------------------------------------------------------------------------group with GS and 94.0% ± 10.7% (range: 66.7%–100.0%) for the group without GS, without a significant
group difference (p = 0.582).
Table 1. Comparison of baseline characteristics between two groups
SSE with GS (n = 19)

Baseline characteristics

SSE without GS (n = 13)

Mean ± SD

Mean ± SD

p- value

Demographic items
Age, y68.9 ± 3.3

69.9 ± 4.2

0.470

Women, n (%)

15 (78.9)

11 (84.6)

0.687

Education, y12.0 ± 1.9

12.3 ± 1.3

0.623Heart disease, n (%)

1 (5.3)0 (0.0)0.401

Stroke, n (%)

0 (0.0)0 (0.0)-

Low back disease, n (%)

4 (21.1)

3 (23.1)

0.892

Knee disease, n (%)

1 (5.3)3 (23.1)

0.135

Fall in the last year, n (%)

0 (0.0)4 (30.8)

0.010

Fall during the exercise program, n (%)

1 (12.5)

0 (0.0)0.401

23.4 ± 3.1

24.3 ± 2.6

0.413

8,312 ± 3,759

7,796 ± 2,708

0.696

Single-leg balance with eyes open, sec

39.5 ± 19.9

47.1 ± 22.2

0.315

5 repetition sit-to-stand, sec

6.6 ± 0.6

7.2 ± 1.1

0.119

Timed up and go, sec

5.1 ± 0.5

5.5 ± 0.8

0.128

Body mass index, kg/m2
Physical activity
Daily step counts, steps/day
LEPF items

5 m habitual walk, sec

3.2 ± 0.5

3.6 ± 0.3

0.040

Choice stepping reaction time, msec

1,025 ± 105

1,027 ± 64

0.932

6-min walk, m

575 ± 72560 ± 62

0.534

GS: goal-setting, LEPF: lower-extremity physical function, SD: standard deviation, SSE: square-stepping exercise

As shown in fig. 3, there was a significant group-by-time interaction on PA (p < 0.001). The group withGS significantly increased their PA from baseline to the three other periods, whereas the group without GS did
not change their PA. There were significant time effects in HW, CSRT, and 6MW, with both groups improving
their performances (table 2). There was a significant group-by-time interaction in STS (p = 0.006) with only thegroup without GS improving performance. Although significant group-by-time interaction in STS was
confirmed, on post-hoc testing, there were no significant differences in the six physical function tests between
the two groups.
Table 2. Physical function items by group at baseline and post-test

Time effectp -value

Effect size
(Cohen's d )Baseline vs.
Post-test

Interaction
p -value

44.7 ± 19.7
47.4 ± 21.1

0.367

0.27
0.01

0.417

6.6 ± 0.6
7.2 ± 1.1

6.8 ± 0.9
6.7 ± 1.4

0.154

0.23
0.40

0.006

Timed up and go, sec
SSE with GS
SSE without GS

5.1 ± 0.5
5.5 ± 0.8

5.2 ± 0.6
5.6 ± 1.0

0.360

0.14
0.11

0.914

0.223

5 m habitual walk, sec
SSE with GS
SSE without GS

3.2 ± 0.5
3.6 ± 0.3

3.1 ± 0.5
3.3 ± 0.6

0.024

0.27
0.49

0.469

0.273

Choice stepping reaction time, msec
SSE with GS
SSE without GS

1,025 ± 105
1,027 ± 64

1,016 ± 83
984 ± 73

0.030

0.10
0.64

0.149

0.274

6-min walk, m
SSE with GS
SSE without GS

575 ± 72560 ± 62589 ± 86587 ± 60

0.035

0.17
0.44

0.477

0.939

Baseline-test

Post-test

Mean ± SD

Mean ± SD

Single-leg balance with eyes open, sec
SSE with GS
SSE without GS

39.5 ± 19.9
47.1 ± 22.2

5 repetition sit-to-stand, sec
SSE with GS
SSE without GS

Lower-extremiy physical function items

Comparison of
Post hocpost-test score
With GS vs. Without GS
test
p -value

0.717

0.241
0.007

0.750

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TOMOHIRO OKURA--------------------------------------------------------------------------------------------------------------------------------------GS: goal-setting, PA: physical activity, SD: standard deviation, SSE: square-stepping exercise
Fig. 3 presents physical activity (PA) by group during the three periods. Participants in the group withgoal-setting (GS) were encouraged to increase their PA by 1,000 steps/day above their baseline step counts. The
group with GS significantly increased their PA, whereas the group without GS did not change their PA.
p < 0.001(steps/day)Time effect p-value = 0.020
Interaction p-value < 0.001

p < 0.001

16,000p < 0.001

14,00012,00010,00010,109±4,170

10,513±4,778

10,632±4,441

8,312±3,759

SSE with GS group(n = 18)
SSE without GS group(n = 11)

8,000
6,000

7,796±2,708

7,965±3,372

Baseline(1st week)

Early period(2nd-4th weeks)

6,854±2,264

7,087±2,349

Middle period(5th-8th weeks)

Late period(9th-11th weeks)

4,000
2,000

GS: goal-setting, SSE: square-stepping exercise
Three participants had wearing times that did not reach the criteria for calculating step counts.

Fig. 3. Physical activity by group during the four periods
Discussion
In the present study, we conducted an exercise program and compared its effects on LEPF between
participants with GS aimed at increasing PA by 1,000 steps/day and those without GS. The graph and map,
which were used in the present study, were visually understandable and were able to motivate participants toachieve their goal. However, although the group with GS significantly increased their daily PA compared withthe group without GS, we were unable to confirm the effect of GS on LEPF.
Both groups significantly improved in HW, CSRT, and 6MW from baseline to post-testing. A previous
study has suggested that SSE, consisting of multidirectional steps in the forward, backward, lateral, and oblique
directions, led to a better LEPF (Shigematsu et al., 2008). This may explain why we were able to confirm
significant improvements in HW and CSRT. Moreover, regardless of the daily PA, it is possible that the SSE
program in itself is effective in improving 6MW in older adults. The SSE program may be as effective as
walking programs in improving endurance power (Okubo et al., 2015).
On the other hand, there was a significant group-by-time interaction in STS, and only the group without
GS improved their performance. A previous study showed that older adults with a low level of physical fitness atbaseline are more likely to improve their physical fitness with a period of exercise program (Arai et al., 2009). In
the present study, the without GS group had a comparatively lower level of physical performance than the groupwith GS. This indicates that the group without GS had greater room for improvement in their LEPF. In addition,
Aoyagi et al. (2009) reported that walking speeds were positively associated with daily step counts of up to
7,000–8,000 steps per day but that there was no association for more than 8,000 steps per day. The group without
GS maintained approximately 7,000 steps, whereas the group with GS exceeded 10,000 steps per day by the lateperiod. Although we successfully increased PA using GS, the participants in the group with GS may have had aceiling effect of increased PA for improving LEPF.
The present study had several limitations. First, it included only a small sample size and was not a
randomized controlled trial. Having only a few male subjects in each group was also a limitation. Secondly, PA
and LEPF of our study participants were equal or slightly higher than Japan’s general values (Seino et al., 2014).
Therefore, there may have been a ceiling effect for improving LEPF and step counts. We need to investigate
whether our findings apply to other populations, such as sedentary older adults or those with poorer LEPF.
Finally, the present study was a short-term program, and a long-term program is needed to confirm the effects of
GS in increasing daily PA.
Conclusion
We conducted the SSE program and compared its effects on LEPF between participants with GS aimed
at increasing PA by 1,000 steps/day and those without GS. The group with GS increased their PA; however, we
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TOMOHIRO OKURA--------------------------------------------------------------------------------------------------------------------------------------could not confirm the effect of GS on LEPF. A long-term program is needed to confirm the effects of GS in
increasing daily PA. Even so, because the without GS group tended to decrease the daily PA during the program,the GS techniques were useful to prevent decrease in daily PA due to the participation in an exercise program.
Acknowledgments
This study was supported by the KAKENHI Grant-in-Aid for JSPS Fellows number 15J00281, 2015–2017.
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