Advances in Physical Education
2012. Vol.2, No.2, 54-60
Published Online May 2012 in SciRes (http://www.SciRP.org/journal/ape) http://dx.doi.org/10.4236/ape.2012.22010
54
Physical Activity and Mobility Function in Elderly People Living
in Residential Care Facilities. “Act on Aging”: A Pilot Study
Monica E. Liubicich1, Daniele Magistro1, Filippo Candela2, Emanuela Rabaglietti2,
Silvia Ciairano1,2
1University Interfaculty School of Motor Science (SUISM), Research Centre in Motor and Sport Science,
University of Turin, Turin, Italy
2Department of Psychology, University of Turin, Turin, Italy
Received February 15th, 2012; revised March 18th, 2012; accepted March 27th, 2012
The present study aims at investigating the changes between pre-test and post-test in mobility function,
balance, and gait after a physical activity program in a sample of elderly people. Forty-four individuals
living in residential care facilities were recruited, with a mean age of 85 (SD = 6.6) in the control group
and 84.26 (SD = 7.4) in the intervention group. We collected baseline and post-test measurements for the
Tinetti Test. The findings showed that the physical activity intervention had a positive effect on physical
functions. There was a statistically significant change between the means of the two groups over time; the
intervention groups showed a stable condition with respect to overall mobility function, balance, and gait
while the control group showed decreased performance at the post-test. These results underline that even
in critical conditions, relatively simple training may promote a more positive adjustment to old age.
Keywords: Aging; Physical Functioning; Exercise; Balance; Gait; Mobility Function
Introduction
Demographic projections and epidemiological studies show
that throughout western society the population is getting older
and older and that aging may be associated with an increase in
disability and frailty, although most of the elderly population
stay relatively healthy for a long time (World Health Organiza-
tion, 2002; Aromaa & Koskinen, 2004; Stenzelius, Westergreen,
Thorneman, & Rahm Hallberg, 2005). The level of decline of
older people in physiological and psychological aspects (Shum-
way-Cook & Woollacott, 2000) is characterized by great indivi-
dual variations due to both personal factors (idiosyncratic life
events and personal characteristics) and extrinsic factors (envi-
ronmental and social contexts and opportunities) that lead to
significant differences in performance (Spirduso, Francis, &
MacRae, 2005). However, around 20% of people aged 70 or
above experience limitations in carrying out daily activities
and/or are affected by physical disabilities, resulting in a loss of
autonomy (Manton & Land, 2000; Pennix et al., 2002).
Among all other aspects, motor skills also decrease as indi-
viduals grow older (Shea, Park, & Braden, 2006; Voelcker-Rehage
& Alberts, 2005) and especially certain parameters such as ba-
lance, flexibility, and strength, which are predictors of depend-
ence in the Activities of Daily Living (ADLs) (Guralnik et al.,
2000).
The present study represents the continuation of a series of
pilot research projects (Ciairano, Liubicich, & Rabaglietti, 2010)
that investigate the positive effects of a physical activity pro-
gram on physical functioning in an Italian sample of older peo-
ple in residential care facilities. In our previous research we
focused on the psychological aspects of older people and health
perceptions, while this present study analyzes objective aspects
related to the physicality of older people.
Description of the Problem
Motor difficulties, the inability to manage daily activities,
and serious illnesses are risk factors for becoming dependent on
others and subsequent institutionalization (Hirvensalo, Ratanen,
& Heikkin, 2000; Laukkanen, Leskin, Kauppinen, Sakari-Rantala,
& Heikkinen, 2000; Agüero-Torres, von Strauss, Viitanen, Win-
bland, & Fratiglioni, 2001; Rockwood et al., 2004).
With respect to ways of facing the dependence of older peo-
ple on others, different European countries have different wel-
fare politics and/or cultural traditions to deal with this problem
(Anttonen & Sipila, 1996; Bettio & Platenga, 2004; Lucchetti,
Mazzoni, Principi, & Greco, 2007). Generally speaking, in nor-
thern European and especially Scandinavian countries, the wel-
fare ratio addressed to the aging population is very high, and
institutionalization is more likely proposed to very ill elderly
who cannot receive sufficient medical care in their own homes.
In southern European countries, traditionally the family com-
pensates for low levels of public welfare, and institutionalize-
tion is more likely to be proposed to older people who are alone
or who have a very weak social network that cannot support
them in their daily activities. Irrespectively to the cause of in-
stitutionalization, we know that it represents an adjunctive chal-
lenge for the elderly. In fact the study by Galloway and Jokl (2000)
showed that at least 30% of older people experience deeper and
quicker physical decline after entering residential care facilities,
probably also because in these institutions older people lose
their usual pattern of daily habits and their social context at the
same time.
Although the institutionalization of elderly people is not de-
sirable in principle, it is undeniable that it is the only reason-
able solution especially at very high levels of frailty. Thus, we
need to explore in which ways we can prevent the decline of older

M. E. LIUBICICH ET AL.
people who are also in the precarious condition of institution-
alization in order to avoid that this decline becomes a greater
loss for the elderly themselves, at a greater cost for society, and
to endorse more lively participation within the facilities.
We know that physical activity can be used, also at older
ages, for promoting the overall wellbeing of individuals (Gal-
loway & Jokl, 2000). Several studies have shown that physical
activity interventions lead to modifications in behavior related
to the risk of falls (Barnett, Smith, Lord, Williams, & Baumand,
2003; Suzuki, Kim, Yoshida, & Ishizaki, 2004; Means, Rodell,
& O’Sullivan, 2005), since even limited movement can initiate
a process of change over the short or medium term (van der Bij,
Laurant, & Wensing, 2002). Besides this, as reported in the
meta-analysis carried out by Beswick et al., (2008), increasing
the amount of daily physical activity reduces the risk of institu-
tionalization, hospital admissions, falls, and disabilities.
Different types of training have proven to be capable of im-
proving the motor skills and the quality of life of elderly people
(Baker, Atlantis, & Fiatarone, 2007), in particular if the abilities
of each individual are taken into account in terms of intensity
and workload. The World Health Organization guidelines (1999)
identify aerobic endurance, resistance strength, flexibility, and
balance as related to the health of the elderly. Aside from this,
these guidelines suggest group physical activity in order to
promote increased psycho-social benefits and to provide further
motivation to continue the program and persevere in older peo-
ple. The older people showed some preference for the physical
activity programs that include exercises designed to improve
balance as well as flexibility and gait (Norton, Galgali, & Cam-
pbell, 2001; Day et al., 2002). In compliance with the indica-
tions provided by the American College of Sports Medicine
(2000), physical activity programs designed for the elderly who
are already in residential care facilities have to be addressed at
preserving the skills that are functional towards maintaining
independence as long as possible, slowing down the processes
that may lead to disability, and educating the elderly about an
active lifestyle. These indications also emphasize that daily
physical activity and physical activity programs may contribute
to overall individual wellbeing and play a key role in prevent-
ing a wide range of different illnesses. Some interventions
showed specific positive effects on strength, flexibility, mobil-
ity, and balance (Rydwik, Frandin, & Akner, 2004). What is
generally acknowledged is that it is crucial to design interven-
tions that are able to prevent the most negative consequences of
institutionalization, like the loss of acceptable levels of auton-
omy, which in turn may start a negative vicious cycle of con-
stant deterioration. Despite widespread awareness of this, very
few studies, especially in countries outside the northern Euro-
pean ones, have addressed the issue of investigating the effi-
cacy of interventions specifically aimed at improving mobility
function and/or its stable maintenance, which is the basis for
preserving autonomy as long as possible in very old groups of
people. The majority of the previous studies concentrated on
the younger bracket of the elderly population (aged between 65
and 75) living in normal condi- tions (among others see: Marsh,
Miller, Rejeski, Huttona, & Kritchevsky, 2009; Bird, Hill, Ball,
& Willimans, 2009). The present study aims at considering
older institutionalized elderly in a southern European country.
Purpose
We looked at two groups of older people living in three resi-
dential care facilities to describe the physical functioning changes
from pre-test to post-test in relation to their participation in a
physical activity program.
The objective of this research is to test the effects of a physic-
cal activity program on mobility function, in particular balance
and gait which are strictly related to walking, in the case of insti-
tutionalized elderly people.
We assumed that participating in a physical activity program
could improve or at least retain an elderly person’s mobility
function as a whole and/or in its two components of balance
and gait, or keep it constant over time. As anticipated, physical
activity may be a protective factor for the institutionalized eld-
erly and it increases so that the individuals can be independent
for as long as possible (Fried, Ferrucci, Darer, Williamson, &
Anderson, 2004; Gill et al., 2004).
Methods
Study Desi gn
The intervention was introduced in two residential care fa-
cilities of the Piedmont region in the north of Italy and another
residential care facility, in the same area, was used as the con-
trol group: Currently, more than 5000 older people of the
Piedmont region live in residential care facilities (Banchero, et
al., 2009). First, from the list offered by the Health Office of the
Piedmont Region, we selected 30 facilities that have similar
features in terms of their accordance to the National Health
Service, the number and typology of guests (range from 80 to
120), the intermediate social and economic conditions of the
guests (all the guests in these facilities are requested to contrib.-
ute a small amount for the care they receive), and services of-
fered to the older people (presence of nurses, healthcare opera-
tors, physiotherapist, and psychologist). Second, we randomly
extracted six of these facilities from the list and all of them
agreed to participate in the study. Third, we excluded three of
the facilities because we did not find enough self-sufficient
seniors in order to create a physical activity group. Then we
assigned two of the remaining facilities to the experimental
condition and one to the control condition.
The facilities that were selected accommodate both self-suf-
ficient older people (i.e., individuals who can walk, eat, and use
the bathroom independently) and dependent older people (re-
quiring assistance in the basic activities of daily life). All of
them are private institutions, but linked to the Public Health
Service through a funding agreement.
Physical Activity Intervention
General—This intervention consisted of two one-hour sessions
per week for 16 weeks. It was offered to a group of self-suf-
ficient older people living in a residential care facility. The
physical activity was done in small groups and qualified in-
structors conducted the sessions. All the instructors had a uni-
versity degree in physical education and sports-related fields
and were specialized in physical fitness training for the elderly
(Ciairano et al., 2006). They were selected on the basis of their
results in the university courses “Adapted Physical Activity”
and “Health and Old Age”. That is, we selected only people
who achieved a final grade higher than the 95th percentile of
the grade distribution for each of these subjects.
The set of activities was specifically designed for our re-
search. The intervention protocol, as advised by the American

M. E. LIUBICICH ET AL.
College of Sports Medicine (2007), focused on three specific
objectives: mobility, balance, and resistance strength. The in-
tervention was organized so as to reproduce the movements and
gestures of daily life, considering the three aims above. The
intervention was designed with a gradual increase of the pa-
rameters of work intensity and complexity of exercise.
Participants
In each residential care facility the older participants, both
the intervention group and the control group, were selected by
the director of the residential care facility, who is a trained phy-
sician, from among all the older people living in the facility.
The three criteria for inclusion were: 1) self-sufficiency (see
above), 2) absence of serious chronic and/or acute diseases, and
3) intact cognitive functions, which were directly verified by
the researchers. The Mini Mental Test (Folstein & McHugh
1975) was used to evaluate cognitive functions, and all the par-
ticipants reached or exceeded the minimum score of 23.
First, our study was approved by the Ethical Committee of
the University of Turin, and second the participants were in-
formed that participation in the study was voluntary and confi-
dential. All the selected individuals agreed to participate and
gave their written informed consent, in accordance with Italian
law and the ethical code of the Italian Association of Psycholo-
gists (1997).
Those who were included in the experimental group partici-
pated in the physical activity program, while the control group
was comprised of individuals who did not participate in the
program and continued their normal activities planned in the
facility. With respect to the physical activity of the older people
in the control group, they simply continued their free activity of
walking in the facility’s garden since they are self-sufficient
individuals.
The sample comprised of 44 people, 16 of whom were males
(36%; 2 in the control group and 14 in the experimental group)
and 28 females (64%; 9 in the control group and 19 in the ex-
perimental group). We did not find differences between the
experimental and control group (χ = 2,1, d.f. = 1, p = .27). The
mean age was 85 (SD = 6.6) for the control group and 84.26
(SD = 7.4) for the experimental group (t-test = –.34, d.f. = 41, p
= .73). All the participants lived in the residential care facility
permanently. With regard to marriage status, the majority were
widows/widowers (N = 26) or married (N = 8), while others
had never married (N = 7), or were divorced (N = 3): No dif0
ferences were found between the experimental and control
group (χ = 3,7, d.f.= 3, p =.29). In terms of education, two lev-
els were considered: “low”, corresponding to compulsory edu-
cation (only primary school) and “high”, corresponding to addi-
tional non-compulsory education (more than primary school).
0In this case we also did not find significant differences be-
tween the two groups (χ = 2,1, d.f. = 1, p =.64). The average
level of education of the men and women in the sample was in
line with that of the age-matched national population (National
Institute of Statistics, 2006; Costa, Migliardi, & Gnavi 2006).
In fact, 75% of the participants had received only compulsory
education, exactly like about 70% of the national population.
Former occupations were divided into manual (N = 31) and
non-manual labor (N= 13) and there were no differences be-
tween the experimental and control group (χ = 3,2, d.f. = 1, p
=.35). With regard to previous participation in organized exer-
cise or sporting activities, the majority of individuals (N = 27)
had never participated and there were no differences between the
experimental and control group (χ = 1,3, d.f.= 1, p =.31). The
main characteristics of the participants are described in Table 1.
Procedure
The mobility functions (Köpke & Meyer, 2006) of balance
and gait in the elderly were assessed using the Tinetti Test (Ti-
netti, 1986). The version of the Tinetti Test used for this study
included a total of 16 items that corresponded to the mobility
functions: 9 items corresponded to balance, and 7 to gait. Of the
items, 11 had a score ranging from 0 to 2, 6 items had a score
ranging from 0 to 1, with a maximum total score of 28 for mo-
bility functions. The maximum scores were 16 for balance and
12 for gait. The higher the total score, the better the perform-
ance. All participants had to perform the Tinetti Test twice,
during the pre-test and post-test.
Data and Statistical Analysis
We ran repeated measures analyses of variance for each of
the aspects considered in the present study. In every model, we
examined one between-factor experimental condition (intervene-
tion and control group) and one within-factor condition of time
(pre-test and post-test). In addition, we examined the interaction
term between the experimental condition and the time.
Results
In general, the intervention group and the control group dif-
fered with respect to the mobility function (total Tinetti Test) as
well as balance (Tinetti Test balance subscale) and gait (Tinetti
Test gait subscale) (Table 2). Mobility function was higher in
the intervention group (19.48 vs. 7.95); balance was also higher
in the intervention group (11.78 vs. 4.36), and the same was
true for gait (7.82 vs. 3.31).
The differences between the intervention and the control
group were statistically significant for the mobility function (F
= 26.72, p < .001, η2 = .383), balance (F = 34.43, p < .002, η2
= .445), and gait (F = 14.08, p < .001, η2 = .247).
As for the effects of the intervention (Figure 1), mobility
function decreased between the pre-test and post-test in the
control group (from 11.36 to 4.54), while it remained relatively
stable in the intervention group (from 20.09 to 18.88). The
interaction between the condition and the time was significant
and there were noticeable differences concerning the decrease
in mobility function between the intervention group and the
control group (F = 7.15, p < .011, η2 = .143).
For what concerns balance (Figure 2), a decrease between
the pre-test and post-test was observed in the control group
(from 6.64 to 2.64), while it remained relatively stable in the
experimental group (from 11.97 to 11.59). The interaction be-
tween condition and time was significant, the decrease in bal-
ance was markedly different when looking at the intervention
group and the control group (F = 7.24, p < .010, η2 = .144).
Finally, the control group (Figure 3) showed a decrease in gait
(from 4.73 to 1.91), while the intervention group remained stable
(from 8.24 to 8.24). Also in this case, there were significant differ-
ences in the decrease of their gait (F = 5.26, p < .027, η2 = .109).
In general, the effect of the intervention explains a proportion
of variance—around 10% - 15%—which is reasonably high
when considering the small sample size of the present study
according to Cohen (1988).
56

M. E. LIUBICICH ET AL.
Table 1.
Characteristics of participants (N, %).
Group
Variable Category
Control Experimental
N % N %
Female 9 82 19 58
Gender Male 2 18 14 42
No 8 73 19 58
Past participat ion in physical activitie s Yes 3 27 14 42
North Italy 10 91 30 91
Center Italy / / 2 6 Original Region
South Italy 1 9 1 3
Never married 1 9 6 18
Married 1 9 7 21
Widow 9 82 17 52
Family condition
Divorced / / 3 9
Past job Manual 10 91 21 64
Non manual 1 9 12 36
Level of education Only Primary School 9 82 24 73
More than Primary School 2 18 9 27
Age Mean (SD) 85 (6.6) 84.26 (7.4)
Table 2.
Results of repeated measures ANOVA. Mean (M), Standard Deviation (DS), Main Effects (ME), and interaction effects (IE) for the dependent vari-
ables related to mobility functions of elderly people.
Group Time Group * Time
Dependent
variables Control
M (SE)
Experimental
M (SE)
Pre-test
M (SE)
Post-test
M (SE)
Control
Pre
M (SE)
Control
Post
M (SE)
Experimental
Pre
M (SE)
Experimental
Post
M (SE)
ME
Group ME Time
IE
Group *
Time
Tinetti
Total
7.95
(1.93)
19.48
(1.1)
15.73
(1.29)
11.71
(1.17)
11.36
(2.24)
4.54
(2.04)
20.09
(1.27)
18.88
(1.16)
F(1,43) = 26.7
2
p < .001
η2 = .383
F(1,43) = 14.63
p < .001
η2 = .254
F(1,43) =
7.15
p < .011
η2 = .143
Tinetti
Balance
4.36
(1.06)
11.78
(.60)
9.30
(.70)
7.11
(.69)
6.64
(1.22)
2.64
(1.19)
11.97
(.70)
11.59
(.68)
F(1,43) = 34.4
3
p < .002
η2 = .445
F(1,43) = 10,62
p < .001
η2 = .198
F(1,43) = 7.2
4
p < .010
η2 = .144
Tinetti
Gait
3.31
(1.04)
7.82
(.60)
6.48
(.67)
4.66
(.60)
4.73
(1.17)
1.91
(1.04)
8.24
(.67)
8.24
(.67)
F(1,43) = 14.0
8
p < .001
η2 = .247
F(1,43) = 17.52
p < .001
η2 = .289
F(1,43) = 5.26
p < .027
η2 = .109
Figure 2. Figure 1.
Balance.
Mobility function.

M. E. LIUBICICH ET AL.
Figure 3.
Gait.
Discussion
The objective of this study was to investigate how participa-
tion in a physical activity program affects the mobility func-
tions of a group of elderly people staying in residential care
facilities, focusing in particular on its effects on balance and
gait. As for the first research hypothesis, we wanted to deter-
mine if participating in a physical activity program can improve
an elderly person’s mobility function or keep it stable over time.
Mobility, understood as the ability to independently move
around in one’s environment, is a fundamental expression of an
individual’s autonomy. A decrease in mobility function is often
a predictor of future health issues that might lead to disability.
In line with the reference literature about the effects of physical
activity on a comparable sample with a similar health condition
and age, (Nakagawa et al., 2008; Netz, Wu, Becker, & Tenen-
baum, 2005; Snow, Shaw, Winters, & Witzke, 2000), the re-
sults of our research seem to point to physical activity as an
indispensable tool to preserve residual skills and to curb their
loss, which is fundamental in order to be independent when
walking.
Secondly, we assumed that our specifically designed physical
activity program would improve both the balance and gait of
institutionalized elderly people and preserve these over time.
Our results concerning balance and gait are very similar to
those reported in the literature. Indeed, physical activity pro-
grams based on resistance strength training presented to sam-
ples of institutionalized older people do help preserve their
lower limb strength or slightly increase it (Jessup, Horne,
Vishen, & Wheeler, 2003), which is directly related to walking
autonomously. As for balance, issues such as the physiological
aging process, the loss of straightening reflexes, a decrease in
muscular strength to preserve an upright posture, the vulner-
ability of sensory organs, as well as an increase in swaying
justify the postural instability typical of the older ages. Hence,
elderly individuals must concentrate and completely focus their
attention in order to keep their balance. The various compo-
nents of gait undergo changes simply due to the natural aging
process. The initiation of steps, its height, continuity and sym-
metry, path deviation, and turning while walking are compo-
nents of gait that mirror an older person’s confidence and effi-
ciency in walking. If difficulties in keeping one’s balance and
walking are ascertained through the Tinetti Test (Tinetti, 1986),
this can help predict an increased risk of falls. As for the as-
sumption that the older individuals who participated in our
physical activity program improved or retained these functions
to a higher extent than the control group, the results indicate
that walking skills were preserved in the intervention group
more so than in the control group. Our research seems to sup-
port the hypothesis that physical activity programs can trigger
positive changes even in the short term, thus enabling elderly
individuals to better manage those actions that imply simple
movements, such as moving from place to place within one’s
dwelling, going to the bathroom autonomously, and taking short
walks.
When comparing the intervention group to the control group,
the variation between pre-test and post-test data in relation to
the age of the sample and to the institutionalized condition,
highlights the protective function played by physical activity on
the health of the older elderly, for whom a good overall physic-
cal condition is a key precondition for an independent daily life.
Facing and accepting the challenges of a changing body, redis-
covering the joys of movement, and socializing, as well as once
again learning to trust oneself, preserving one’s skills and ap-
plying them to daily living in order to retain one’s autonomy as
long as possible—all of this can be turned into a great chance to
promote health and to prevent a wide range of risks faced by
the elderly.
The limitations of this study mainly concern the small num-
ber of individuals in the sample, justified by the difficulties in
recruiting older people living in residential care facilities that
were self-sufficient and met the criteria of our research. Resi-
dential care facilities in Italy are actually becoming more and
more the places where the oldest elderly live in a situation of
frailty and are no longer able to lead a fully independent life
(Banchero et al., 2009). Moreover, their dependence on others
in daily life activities is most likely linked to the progress of old
age and to the fact that some debilitating diseases have become
chronic.
Despite the limitations concerning the sample type, some
stimulating observations can be drawn from our study. Firstly,
this study is one of the first research projects carried out in
Italian residential care facilities with the purpose of investigat-
ing the effects of motor training on a sample of institutionalized
older people. The reference literature mostly regards intervene-
tions carried out in northern European and north American
countries, which are not indicative of the Italian context that is
characterized by a different social and healthcare system and in
which the elderly are mostly looked after by their relatives.
Secondly, this study fits into the new line of research on the
most frail segment of the population—the older elderly in resi-
dential care facilities—evidence that frailty is a process that
requires great attention in the future from researchers in order
to predict those elderly who are at risk of ADL dependence and
to identify effective interventions, such as physical training
programs, to prevent or delay the onset of dependence (Guilley
et al., 2008). Moreover, individual psychological resources can
play an important role in the maintenance of these benefits in
the short and medium term: in the oldest of the elderly the
maintenance of these activities is strategic for both physical and
psychological wellbeing (Caplan & Schooler, 2003).
Conclusion
Considering the growing numbers of the weaker portion of
the population, made up of people over 80 who live in a institu-
tion, this study proves that simple physical activity programs,
conducted by suitably trained instructors with a degree in physical
58

M. E. LIUBICICH ET AL.
education or sports-related fields, can bring about changes in
the physical functioning of the elderly. Setting realistic goals
and designing activity protocols that take scientific evidence
into consideration (in relation to the type, intensity, and fre-
quency of the physical training) might lead to constructing and
implementing interventions that are useful to improving the
general adjustment of citizens and their quality of life.
Acknowledgements
The authors acknowledge Regione Piemonte, Assessorato
Ricerca, Innovazione e Sviluppo Bando Scienze Umane 2009,
for contributing to this ACT ON AGEING pilot study.
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