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地域在住高齢者における教室終了後の郵送プログラムが長期的な運動継続に与える効果：ランダム化比較試験のデザイン
大久保善郎１，２，３，鄭松伊４，大須賀洋祐２，重松 良祐５，清野
小林 裕幸１，７，宮地 元彦８，竹中 晃二９，田中喜代次４

諭６，

Effect of post-exercise class mailing program on long-term
exercise adherence among community-dwelling older adults:
A study design for a randomized controlled trial
Yoshiro OKUBO １，２，３，Songee JUNG ４, Yosuke OSUKA ２，４，６,
Ryosuke SHIGEMATSU ５, Satoshi SEINO ６, Hiroyuki KOBAYASHI ４，７,Motohiko MIYACHI ８, Koji TAKENAKA ９, Kiyoji TANAKA ４
抄録
背景：高齢者における運動教室終了後の運動継続率は依然低い．本稿では，高齢者の長期的な運動継続のための運動教室と郵送支援の有効性を検証するランダム化比較試験の研究デザインを報告する．
方法：本研究では，地域在住高齢者 230 名を，ランダム化された２群（郵送支援の有無）と補足的な非ランダム化（無介入）対照群に割付ける．全 27 ヵ月間の本研究には，３ヵ月間の運動教室，12 ヵ月間の郵送支援，12 ヵ月間の追跡が含まれる．運動教室では，３軸加速度計，目標設定とセルフモニタリングのための運動日誌を利用し，速歩，筋力運動，柔軟性運動の実践を学ぶ．教室修了後に，参加者を郵送支援（MP）群または非郵送支援（NMP）群にランダムに割付け，MP 群は運動日誌と運動新聞の郵送を受ける．運動新聞は，運動の知識と社会的支援の提供，友人の運動実
践による動機づけを狙いとしている．MP 群は切手付き封筒を用いて月末に運動日誌を指導者に郵送する．15 ヵ月
および 27 ヵ月時の追跡時に，運動実践率に加え，身体機能，社会・心理・生理的評価項目を測定する．
考察：郵送支援による長期的な運動継続が実現すれば，習慣的な運動実践による高齢者の持続的な健康増進に繋がると考えられる．
臨床試験登録：UMIN Clinical Trials Registry（UMIN 000015099）

１

筑波大学大学院人間総合科学研究科

２

日本学術振興会

３

神経科学研究オーストラリア 転倒バランス研究班

４

筑波大学体育系

Faculty of Health and Sport Sciences, University of Tsukuba

Kiyoji Tanaka

Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, JAPANGraduate School of Comprehensive Human Sciences, University of Tsukuba

The Japan Society for the Promotion of Science

Phone: 029-853-2655 Fax: 029-853-2986

Falls and Balance Research Group, Neuroscience Research Australia

E-mail: tanaka@taiiku.tsukuba.ac.jp

５

三重大学教育学部６

東京都健康長寿医療センター研究所

７

筑波大学附属病院 水戸地域医療教育センター

Mito Medical Center, Tsukuba University Hospital

８

国立研究開発法人医薬基盤・健康・栄養研究所

健康増進研究部

Faculty of Education, Mie University
Tokyo Metropolitan Institute of Gerontology
National Institutes of Biomedical Innovation, Health and Nutrition, Department

of Health Promotion and Exercise
９

早稲田大学人間科学学術院

Faculty of Human Sciences, Waseda University

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Backgroundadequately examined. Therefore, this study will assess

Various health benefits of regular exercise among thethe effect of a mailing program on long-term exercise

older population, including reductions in mortality,

adherence among community-dwelling older adults.

cardiovascular disease, and physical frailty, have been
demonstrated over the past several decades 1）. Howev-

Methods

er, approximately 48 % of older adults cease exercising
within six months after the initiation of an exercise
2）

. To

controlled trial with a supplemental, non-randomized

overcome the increasing health issues affecting aging

control arm. The 27 -month long study consists of aprogram, leading to a loss of training effects

The study design is a two-arm, parallel, randomized

3）

4）

populations around the globe , effective ways for main-

three-month exercise class, 12 -month mailing program,taining long-term exercise adherence are warranted.

and 12 -month follow-up period without any support.

The strategies utilized to promote exercise adherence involve the use of telephone 5）, mass media 6）, community-wide campaigns 7）, home visits 8）, the internet

The study protocol was developed in accordance with

9）

. The ad-the guidelines proposed in the Declaration of Helsinki（using electronic devices） , and mailings

10）

vantages of internet- and mail-based approaches include

and was approved by the Research Ethics Committee ofthe ability to distribute information to a wide or specificthe Faculty of Health and Sport Sciences of the Univer-target population. In contrast, an in-person approach,sity of Tsukuba, Japan（TAI 26 - 38 , 7 -Aug- 2014）. The

such as a traditional exercise class, is useful for the ini-

protocol was registered with the UMIN Clinical Trials

tial adoption of an exercise routine, which often requires

Registry（UMIN 000015099）. The trial began in Decem-

not only cognitive awareness ‒ which the internet andber 2014 and will continue until March 2017 . We held

mailings can provide ‒ but also physical assistance anda meeting for all potential participants to explain thehands-on training 11）. However, short-term exercise

study purpose, measurements that would be used andclasses often lack structured long-term support to gen-

27 -month study design and to obtain written informed

eralize the exercise behaviors learned in the supervisedconsent.

environments to non-supervised contexts. After individuals successfully incorporate an exercise routine into
their daily lives, less intensive support and information

A flow diagram of the study participants is presented

delivered through mailings are useful for maintaining

in Figure 1 . The study participants were recruited

12）. In terms of an immediate appli-

through advertisements in a community newspaper.

cation for the current older population who may have

The eligibility criteria were as follows: aged 65 years

difficulty using technology 13）, a mail-based approachor older; not care-dependent or support-dependent on

may be advantageous compared to an internet-based

the Japanese long-term care insurance system; not re-approach using electronic devices.

stricted from exercising by a doctor; able to walk with-the exercise routine

We developed a structured, exercise-promoting

out a walking aid; and no regular exercise habits. The

mailing program following initial exercise classes. The

exclusion criteria were as follows: participation in mod-classes specifically focus on guiding older participants toerate-intensity（ 3 . 5 metabolic equivalents（METs））

acquire “habitual exercise” by developing self-regulato-

exercise  150 min/week or strength exercise  2 days/ry skills, including goal setting, exercising in their daily

week 1 , 14） or participation in another clinical trial.

lives, and self-monitoring. The acquired habitual exer-

Physical activity is known to positively inﬂuencecise routine will then be supported indirectly throughhealth and well being 1）. Thus, it was considered unethi-

the mailing program, which includes exercise newslet-

cal to randomize inactive older adults who were willingters and diaries. Although such coordinated approaches

to participate in a physical activity program into a con-involving the use of a mailing program have the poten-

trol group and then ask them to continue their seden-

tial to promote maintenance of long-term exercise ad-tary lifestyle. Therefore, we asked applicants who would

herence among the older population, they have not been

be excluded due to a high frequency of regular exercise
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and who agreed not to change their current exercise

Recruitment (n = 230)

routine during the intervention period（3 months）tobe included in the active control（AC）group. The AC

Eligibility assessment

group participated in all study assessments but not the
Exclude (n = 50)
Already exercising regularlyintervention programs.

Pre-intervention assessment

After the post-intervention assessment, the participants
were allocated into either the MP or non-mailing pro-

Exercise class(n = 180)- 90 min, 1 day/week, 3 months

gram（NMP）group using the permuted block method,with stratification by exercise adherence during the

Active control(n = 50)- Continue exercisingintervention（high/low）, age（< 75 years/ 75 years）
Post-intervention assessment (month 3)

and gender at an allocation ratio of 1 : 1（Figure 1）. A
researcher（who is not a co-author）performed the random group allocations using computer-generated ran-Randomization

dom numbers and sent the assignments to a researcher
via email. Then, this researcher notified the participants

Mailing program(n = 90)- Exercise diaries- Exercise newsletters- Feedback

by mail. Each participant was instructed not to disclose
their allocation or contents of the letter to the otherparticipants.

No mailing program(n = 90)- Health newsletters

Activecontrol(n = 50)-Healthnewsletters

One-year follow-up assessment (month 15)

The participants participated in an exercise class focused on introducing a new exercise habit into their daily lives. This class consisted of twelve 90 min sessions

Self management (no support), 12 months

held at a university once per week for 12 weeks. Eachsession consisted of a warm-up（10 - 20 min）, brisk walk-Two-year follow-up assessment (month 27)

ing（30 - 50 min）, muscle strengthening（20 - 30 min）

Figure 1. Flow chart of the study participants.

and a cool-down（10 min）. The exercise program, which
is focused on improving endurance, gait, and muscle
strength 15）, was designed to be simple, to not require

to the weather conditions, a walking-related exercise 17）

the use of equipment, and to be feasible at any location,or cycling using stationary bikes were performed to en-so that long-term exercise adherence would be possible

sure that a similar amount of aerobic exercise was per-for all participants.

formed. Brisk walking for 30 to 50 min for 3 to 5 days

Brisk walking on a safe pedestrian road was per-was also be recommended as home-based exercise 1）.

formed by groups of people with similar fitness levels

Each participant received a tri-axial accelerometer toand trained exercise instructors who ensured for theirwear every day until the 27 -month follow-up assess-safety and proper walking forms. Brisk walking wasment. The participants were asked to manually record

defined as an exercise intensity of approximately 3 . 6

their brisk walking durations（min/day）in their exer-

METs 16） or higher, as determined using a tri-axial ac-

cise diaries for self-monitoring.

celerometer（Estyle- 2 , Suzuken Inc., Aichi, Japan）worn

Muscle strengthening of the lower extremities

according to the manufacturerʼ s instructions（placed inand trunk using body weight was also be performed.

a pant or chest pocket）. The duration of walking was

Muscle strengthening consisted of ankle dorsiflexions

extended from 30 min（approximately 3 km）during

and plantar flexions, hip abductions, squats, and sit-

the 1 st week to 50 min（approximately 5 km）by theups, with 10 to 20 repetitions using slow, consistent12thweek. When walking outside was not feasible due

movements to ensure for sufficient tension in the target
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muscle groups 18）. Stretching of the shoulder, back, hip,pleted; however, they were told that they could stop

calf, hamstrings, thighs, and ankles were performed asrecording and/or exercising any time that they wish. In

warm-up and cool-down exercises. Muscle strengthening

addition to the brisk walking, muscle strengthening, andand stretching for three to five days were also recom-

stretching exercises, the participants were permitted

mended as home exercises, and the participants wereto start other types of exercises but were asked not toasked to record their training in their exercise diaries.

participate in other research projects related to exercise

The exercise diaries were used to create exercise

or physical interventions.

habits based on planning, recording, monitoring, andself-evaluation（Figure 2）. Each exercise diary included
sections for goal setting, recording of daily exercises,

Participants allocated to the MP group received thereflection on exercises performed over the month, and12 -month mailing support program, including the ex-

feedback from an instructor. The participants were in-

ercise diaries and newsletters（Figures 2 and 3）. The

structed to set their monthly exercise goals considering

participants were asked to send their exercise diaries

the generally recommended standard（brisk walking,to the instructors at the end of each month using a

150 min/week; and muscle strengthening and stretch-stamped envelope. The instructors reviewed the diaries

ing, 2 sets/week）, their health conditions, daily and oc-

and provide brief feedback as previously described andcasional schedules, and recent exercise histories（an in-then returned them to the participants along with ancrease in 10 % from the last month was recommended）.

exercise newsletter within two weeks.

Brisk walking（minutes）, muscle strengthening（sets）,

The exercise newsletter consisted of sections con-stretching（sets）, and other exercises or physical ac-

taining a greeting from an exercise instructor, scientifictivities（blank space）were recorded as daily exercises.

information regarding exercise, a list of the participantsʼ

The participants were asked to calculate the weekly

names who achieved their exercise goals, comments

and monthly exercise amounts, determine whether theyfrom participants, and announcements. These newslet-

have achieved their monthly goals, evaluate themselves

ters were designed to promote long-term exercise ad-（0 to 100 points）, reflect on their exercise habits overherence by older people by expanding their knowledge

the month（achievements, positive efforts, problems, andabout exercise 19）, providing social support from thepossible solutions）（no more than 140 Japanese charac-

exercise instructors 20）, and strengthening their self-effi-ters or approximately 70 English words）, and submit

cacy by demonstrating that their friends are also exer-

the completed records. Then, the instructors reviewed

cising. The scientific topics covered included the proper

the exercise diaries and wrote brief feedback comments

walking form, ideal frequency, timing, duration, intensi-（no more than 70 Japanese characters or approximately

ty, and health benefits of exercise, goal setting, manag-

35 English words）. The feedback comments focused on

ing joint pain, and preventing falls and heat syndromes.

ensuring for effective self-monitoring and building exer-

Several comments from the participants（from theircise habits into the participantsʼ daily lives. These com-

exercise diaries）expressing positive efforts, successes,

ments included praise, suggestions, answers, recognition,

the overcoming of physical or environmental issues, andsympathy, and encouragement.

learning experiences/findings related to exercise habitswere selected by the exercise instructors. Groups ofDuring the last month of the 3 -month exerciseclass, the participants were encouraged to lead muscle

participants who exercise together were able to post

strengthening exercises for each other or to assist oth-short announcements regarding their activities.

er participants to ensure that they have acquired the

The NMP and AC groups received health newslet-

proper skills and knowledge to continue their exercise

ters with a similar format. They included a greeting

habits after completion of the class. At the end of thefrom an exercise instructor and scientific information

3 -month exercise class, a lecture was conducted by aabout health（i.e., information about diet, managing knee

university professor to encourage exercise maintenance.

pain, prevention of falls and heat syndrome）but did not

The exercise diaries were provided to the participants

include exercise information and were mailed four times

for one year to continue recording their exercises com-during the one-year follow-up period.
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The mailing support program continued from theno support will be provided between the one- and two-

post-intervention assessment（month 3）to the one-year follow-up assessments. The participants used theyear follow-up assessment（month 15）. To determine

same exercise diaries and tri-axial accelerometer for 12

whether this program leads to long-term exercise habitsmonths, and were encouraged to maintain their exercise

via goal setting, self-monitoring, and problem solving,

habits.

C

D
E

A

F
B

G
Figure 2. An example of an exercise diary. Each exercise diary included sections for goal setting［A］, recording ofdaily exercises（steps, brisk walking time, strength and flexibility exercises, other exercises, and falls）［B］, exercise
completed over the month［C］, injuries from falls［D］, self-evaluation［E］, reflection on exercises performed overthe month［F］, and feedback from an instructor［G］.

C
A
D

B
E
Figure 3. An example of an exercise newsletter. Each exercise newsletter consisted of sections containing a greetingby an exercise instructor［A］, scientific information regarding exercise［B］, a list of participantʼ s names whoachieved their exercise goals［C］, comments from participants［D］, and announcements［E］. These newsletterswere designed to promote long-term exercise adherence by older people by expanding their knowledge about
exercise, provide social support from the exercise instructors, and strengthening their self-efficacy by demonstratingthat their friends are also exercising.
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Assessments will be conducted at baseline and at theAdverse events, which may be related to the mailing

3 -, 9 -, 15 -, and 27 -month follow-ups（Table 1）by trained

support program, will be assessed via questionnaires ad-

assessors who are blinded to the group allocations. To

ministered at the end of the program.

maintain blinding, the participants will be instructed not
to reveal their group allocations or programs to the asBody weight and fat and muscle volumes will be mea-

sessors.

sured by multi-frequency bioelectrical impedance analysis（MC- 980 A, TANITA Inc., Tokyo, Japan）. Body
The primary outcome measure is exercise adherence atheight, spinal curvature, and lower limb length will also

the 27 -month follow-up. Exercise adherence will be as-

be measured.

sessed in terms of brisk walking, muscle strengthening,

Disease diagnosis and prescribed medications

and stretching. The amount of actual exercise relative

will be assessed using participant medicine notebooks.

to the amount of total recommended exercise during

Smoking, drinking, and living statuses, outing frequency,

the follow-up period will be used to assess the outcome

unintentional weight loss, the number of falls in the lastmeasure. Participants who do not provide an exercise

year, fall-related injuries, fear of falling, urinary inconti-

diary will be followed up by telephone.

nence, the Tokyo Metropolitan Institute of Gerontology
Index of Competence 27）, and mobility limitation 28） will
be assessed via questionnaires. Falls and fall-related

Functional ﬁtness will be evaluated using the Senior

injuries will be monitored via exercise diaries that the

Fitness Test battery 21）, which consists of six items

participants will be asked to complete each day.

designed and validated to assess the physiological parameters that support physical mobility in older adults.
. 21） reported a high validity coefﬁcient（c）for: Focus-group interviews of partici-

older adults on all tests（c  0 . 75）. The physical ﬁtness

pants（with low, medium, and high adherence）will beparameters selected are lower and upper body strength,

conducted to identify the effective components of the

Riklilower and upper body ﬂexibility, agility/dynamic bal-

mailing support program. To ensure for objectivity, theance and aerobic endurance. The items will be evalu-

interview will be conducted by a co-author who is anated, respectively, using the following tests: 30 -s chair

expert in qualitative analyses and has no other contact

stand（repetitions）, arm curl（repetitions）, chair sit-and-with the participants during the study. The interviews

reach（cm）, back scratch（cm）, 8 -ft up-and-go（s）, andwill be conducted three times. The groups will consist

6 -min walk（m）. In addition, hand grip strength willof several participants with low, medium, or high adher-

be assessed using a hand-held dynamometer（GRIP-D,

ence during the post-intervention period.
: The changes in muscle qual-

T.K.K. 5401 ; Takei Scientiﬁc Instruments, Tokyo, Ja-

ity over the study period will be assessed via muscle

pan）.
Social and psychological factors that potentiallystrength per muscle cross-sectional area 29 , 30）. Electro-

mediate the effects of a mailing support program on ex-

myography recordings of the rectus femoris, vastus

ercise adherence will be assessed. These factors include

lateralis and vastus medialis, obtained using a multi-tele-

the stages of readiness to exercise 22）, exercise self-effi-

meter system（WEB- 5000 ; Nihon Kohden Corp., Tokyo,

cacy 23）, exercise-related social support 24）, and a physi-

Japan）, and the thigh intermediate cross-sectional area,

cal activity enjoyment 25 , 26）.

measured by magnetic resonance imaging（AIRIS Light（0 . 25 -T）; Hitachi Medical Corp., Tokyo, Japan）, will
be assessed. The maximum isometric knee extension

The cost of the initial exercise classes and mailing sup-strength will be determined using a wire strain gauge

port program will be recorded.

dynamometer（μ Tas MF- 01 ; Anima Corp., Hamamatsu, Japan）.
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Table 1. List of measurements collected at baseline, 3-, 9-, 15-, and 27-month assessments
Category MeasurementsBL

M3 M9 M15 M27

Exercise adherence
‫ݲ‬

‫ݲ‬

✔P

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

✔S

‫ݲ‬

‫ݲ‬

‫ݲ‬

✔S

‫ݲ‬

‫ݲ‬

Monthly exercise diary (brisk walking (䍹3 METs using a tri-axial accelerometer),strength training, and stretching)
Exercise history (type, frequency, time, subjective intensity, and continuity)
Functional fitness
Senior fitness tests (30s-chair stand, arm curl, chair sit-and-reach, back scratch,
8-ft up-and-go, and 6-min walk), hand grip strength
Psychosocial factors
Physical activity enjoyment scale, social support, exercise self-efficacy, stages of
exercise behavior change, exhaustion on CES-D, general health perceptions/physical role
functioning on SF-36, Geriatric Depression Scale-revised
Economic evaluation
Adverse events‫ݲ‬

Health-related factors
Multi-frequency bioelectrical impedance analysis (body fat and muscle volumes), body

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

weight and height, spinal curvature, lower limb length
Disease diagnosis, prescribed medications, blood pressure, smoking, drinking, and living
statuses, outing frequency, unintentional weight loss, falls, fall-related injuries, fear of
falling, urinary incontinence, mobility limitation, Tokyo Metropolitan Institute ofGerontology Index of Competence
Qualitative study
Focus group interview a‫ݲ‬Comment descriptions (health issues, questions, achievements, commitment, excuses,

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

‫ݲ‬

etc.) in monthly exercise diaries
Study of muscle quality
Electromyography (rectus femoris and vastus lateralis/medialis), magnetic resonance‫ݲ‬

imaging (thigh intermediate cross-sectional area) b, maximum isometric knee extension b
ADL: activity of daily living, BL: baseline, CES-D: Center for Epidemiologic Studies Depression Scale, M: month, METs: metabolic
equivalents, SF-36: 36-Item Short Form SurveyaAssessed in a subsample (n = 18)

To maintain blinding, he will have no contact with the
To detect differences in exercise adherence between

participants and will use random numbers to identify

the intervention（75 %）and control groups（50 %）with

the group allocations. Missing data, including those from

80 % power and 5 % alpha error, 164 participants aredropouts, will be imputed using the multiple imputationneeded for final analysis. Considering a 10 % refusal andmethod, 31） with the exception of exercise adherence

20 % dropout rate, a total of 230 participants were re-data, for which missing data indicates termination of ex-

cruited.

ercise.
Linear mixed-effects models will be used to assess
the effects of group, time and the group × time inter-A co-author who is blinded to the group allocations will

action on all primary and secondary outcomes. If a sub-conduct pre-planned statistical analyses of the primarystantial difference in a variable is observed at baseline,

and secondary outcomes with an intention-to-treat basis.

then it will be adjusted using analysis of covariance.
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people from the preparation and contemplation stages

Bonferroni adjustment will be applied for post-hoc multiple comparisons. The chi-square test will be used forinto the action stage. The mailing program is expectedcategorical variables.

to guide the participants into the maintenance stage,
which is essential for acquiring the enduring health ben-

The data will be analyzed using IBM SPSS Statis-

efits of regular exercise（Figure 4）.

tics software, version 21（SPSS Inc., IL, USA）,and Stata

In an RCT performed by Kriska

14 . 0（StataCorp, TX, USA）
, and the level of significance. 32）, long-term exercise adherence was encouraged among mid-

will be set at 5 %.

dle-aged women using a monthly log, social gatherings,
birthday, sympathy and get-well cards, phone calls andDiscussion
This study will be the first RCT to examine the effecthome visits, newsletters, and awards. Although the trialof a post-exercise class mailing program on long-term

demonstrated success, with increasing walking activities

exercise adherence among community-dwelling olderof the women over two years, the effect of long-term

adults. The mailing program coordinated with an exer-

exercise adherence on physical function was not eval-cise class cultivates self-regulatory skills, such as goaluated 32）. Although walking is a widely accepted form

setting and self-monitoring. We hypothesize that theof exercise 33 , 34）, the intensity of walking at home may

participants in the MP group will maintain significantly

not always be sufficient to improve the physical fitness

higher exercise adherence at the 15 - and 27 -month fol-of older adults 35）. In our current trial, brisk walking（low-ups compared to those in the NMP and AC groups.

3 . 6 METs）was performed, and its duration was used

Their increased exercise adherence at the 15 -monthfor self-monitoring. Brisk walking, which is equivalentfollow-up will support the effectiveness of the mailingto moderate- to vigorous-intensity physical activity, is

support program, which will be indirectly supervised bysignificantly associated with lower-extremity perfor-

exercise instructors. Higher exercise adherence at themance 36 , 37）. Further study is necessary to determine

27 -month follow-up will indicate retention of self-reg-

effective methods for promoting adherence to muscle

ulatory skills and incorporation of exercise into theirstrengthening and ﬂexibility exercises among older

daily lives. According to the trans-theoretical model ofadults, as these exercises are essential for maintaining

exercise behavior change 22）, an exercise class can shift

their functional fitness levels 38 , 39）.

Maintenance• Exercising regularly for six months
or longer

Action• Exercising regularly for lessthan six months

Mailing program
12 months

Exercise class
3 months

Preparation• Exercising some but not
regularly

Contemplation• Intending to exercise

Precontemplation• No intention to
exercise

Figure 4. Hypothesized role of the mailing program in the stages of exercise behavior change. The mailing programis expected to bring participants from the action stage into the maintenance stage, which is most important forachieving the enduring health benefits of regular exercise.
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Long-term exercise adherence in all of our study

Referencesgroups will likely be slightly higher than usual because

１）

American College of Sports Medicine, Chodz-

the participants will be aware that they are being ob-

ko-Zajko WJ, Proctor DN, et al.: American College ofserved 40）. However, this study can accurately examineSports Medicine position stand. Exercise and physicalwhether long-term exercise adherence is higher in theactivity for older adults Med Sci Sports Exerc, 2009 ;MP group than in the NMP group. Although the mailing

41 : 1510 - 1530 .

program is expected to play an important role in main-

２）

Morey MC, Pieper CF, Crowley GM, Sullivan RJ,

taining long-term exercise adherence, the effect of the

Puglisi CM: Exercise adherence and 10 -year mortal-

initial exercise class is not negligible. The brisk walking,ity in chronically ill older adults J Am Geriatr Soc,

muscle strengthening and flexibility exercises were2002 ; 50 : 1929 - 1933 .

selected for their high feasibilities at home. Exercises

３）

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