IMPORTANCE Timing and coordination exercises may be an important addition to community-based health promotion exercise programs to improve walking in older adults.OBJECTIVE To compare the effectiveness of the On the Move group exercise program, which focuses on the timing and coordination of movement, with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability of older adults.DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized, single-blind intervention trial. Thirty-two independent living facilities, senior apartment buildings, and senior community centers were randomized to On the Move (16 sites; 152 participants) or usual care (16 sites; 146 participants). Participants were 65 years or older, able to ambulate independently with a gait speed of at least 0.60 m/s, able to follow 2-step commands, and were medically stable. INTERVENTIONS Exercise classes were 50 minutes, twice a week for 12 weeks and had 10 or fewer participants per class. On the Move consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and stretching exercises. The usual-care program consisted of warm-up, strength, endurance, and stretching exercises. MAIN OUTCOMES AND MEASURES The primary outcomes were self-report of function and disability (Late Life Function and Disability Instrument) and mobility (6-minute walk distance and gait speed) assessed by blinded individuals. RESULTS Participants (mean [SD] age, 80.0 [8.1] years) were mostly female (251 [84.2%]) and white (249 [83.6%]) and had a mean (SD) of 2.8 (1.4) chronic conditions. Intervention groups were similar on baseline characteristics. Postintervention, 142 (93.4%) participants in On the Move and 139 (95.2%) participants in usual care completed testing. On the Move had greater mean (SD) improvements than the usual-care group in gait speed (0.05 [0.13] vs −0.01 [0.11] m/s; adjusted difference = 0.05 [0.02] m/s; P = .002) and 6-minute walk distance (20.6 [57.1] vs 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = .03). Attendance was greater in the usual-care program compared with On the Move (95 [65.1%] vs 76[50.0%] attended Ն20 classes; P = .03). There were no significant differences in any of the other primary or secondary outcomes. CONCLUSIONS AND RELEVANCEThe On the Move group exercise program was more effective at improving mobility than a usual-care exercise program, despite lower attendance. Additional research examining the impact of the intervention on long-term disability outcomes is needed before recommending routine implementation into clinical practice.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01986647

Background Group exercise programs for older adults often exclude the timing and coordination of movement. Stakeholder involvement in the research process is strongly encouraged and improves the relevance and adoption of findings. We describe stakeholder involvement in the design of a clinical trial of a group-based exercise program that incorporates timing and coordination of movement into the exercises. Methods The study was a cluster randomized, single-blind intervention trial to compare the effects on function, disability and mobility of a standard group exercise program and the “On the Move” group exercise program in older adults residing in independent living facilities and senior apartment buildings, and attending community centers. Exercise classes were twice weekly for 12 weeks delivered by study exercise leaders and facility activity staff personnel. Outcomes The primary outcomes function, disability and mobility were assessed at baseline and post-intervention. Function and disability were assessed using the Late Life Function and Disability Instrument, and mobility using the Six-Minute Walk Test and gait speed. Stakeholders Patient and provider stakeholders had significant input into the study aims, design, sample, intervention, outcomes and operational considerations. Summary A community-based exercise program to improve walking can be developed to address both investigator identified missing components in current exercise to improve walking and stakeholder defined needs and interest for the activity program. Involvement of stakeholders substantially improves the relevance of research questions, increases the transparency of research activities and may accelerate the adoption of research into practice.

Background Traditional exercise programs for older adults, which focus on aerobic and strength training, have had only modest effects on walking. Recently, a motor learning exercise program was shown to have greater effects on walking when compared to a traditional exercise program. Translating this novel motor learning exercise program into a group exercise program would allow it to be offered as an evidence-based community-based program for older adults. Objective To translate a walking rehabilitation program based on motor learning theory from one-on- one to group delivery (On the Move©) and evaluate multiple aspects of implementation in older adults with impaired mobility. Design The translation process involved multiple iterations including meetings of experts in the field (Phase I), focus groups (Phase II) and implementation of the newly developed program (Phase III). Phase III was based on a one- group model of intervention development for feasibility, safety, potential effects and acceptability. Setting Community sites including two independent living facilities, an apartment building and a community center. Participants Adults 65 years of age or older who could ambulate independently and who were medically stable. Thirty-one adults, mean age 82.3±5.6 years, were eligible to participate. Methods The group exercise program was held twice a week for twelve weeks. Main Outcome Measurements Acceptability of the program was determined by retention and adherence rates and a satisfaction survey. Risk was measured by adverse events and questions on perceived challenge and safety. Mobility was assessed pre and post intervention by gait speed, figure of eight walk test (F8WT), and six minute walk test (6MWT). Results Modifications to the program included adjustments to format/length, music, education, and group interaction. The 12 week program was completed by 24/31 entrants (77%). Adherence was high with participants attending on average 83% of the classes. Safety was excellent with only one subject experiencing a controlled non-injurious fall. There was preliminary evidence for improved mobility after the intervention: gait speed improved from 0.76±.21 to 0.81±.22 m/s, p=.06; Figure 8 Walk Test from 13.0±3.9 to 12.0±3.9 s, p=.07; and Six Minute Walk Test from 246±75 to 281±67 meters, p=.02. Conclusions The group-based program was safe and acceptable to older adults with impaired mobility and resulted in potentially clinically meaningful improvements in mobility.

The closing of hospitals has exacerbated challenges for older adults in accessing healthcare, especially those living in economically underserved settings. Through focus groups and a community-engaged approach, our study examined and documented the emergent health needs of older adults following the closing of a local hospital in an economically disadvantaged community. Focus groups were reconvened to assess progress and health needs over time. Analyses of the focus groups (n=37, mean age 77, 84% female) illustrated the impact of the closure and the emergence of the following dominant themes: perceptions of the hospital system, including feelings of abandonment and social isolation; transportation challenges in accessing health care resources; and lack of knowledge and literacy regarding available health care and obtaining health services. Discussion sessions with hospital administrators and participants afforded an opportunity for sharing data and additional assessment. The data and relationships developed with community participants and health system representatives resulted in the production of an information resource about access to health services, tailored for older adults.

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