2012. Vol.3, No.5, 384-392
Published Online May 2012 in SciRes (
Copyright © 2012 SciRes.
Physical Activity, Fine Manual Dexterity and a Coach’s
Self-Efficacy in a Physical Activity Program for Older
Persons Living in Residential Care Facilities
Monica Emma Liubicich1, Daniele Magistro1, Filippo Candela2,
Emanuela Rabaglietti1,2, Silvia Ciairano1,2
1University Interfaculty School in Motor Science (SUISM), Research Center in Motor and Sport Science,
University of Turin, Turin, Italy
2Department of Psychology, University of Turin, Turin, Italy
Received February 2nd, 2012; revised March 9th, 2012; accepted April 11th, 2012
This study aimed at assessing the efficacy of a physical activity intervention on a group of older elderly
individuals living in residential care facilities, in terms of the functionality of their upper limbs, hands,
and fingers. It also aimed at determining if the coaches’ level of self-efficacy can contribute to the effi-
cacy of the physical activity program. The project involved 44 institutionalized older persons: Their mean
age was 84.3 (SD = 7.4) in the experimental group and 85 (SD = 6.6) in the control group; they were all
self-sufficient. Seven female coaches, with degrees in physical education and an average age of 29 (SD =
4.4), conducted the physical activity program for 16 weeks. The participants were pre- and post-tested for
hand and finger strength with dynamometers. The coaches’ level of perceived self-efficacy was assessed
through a self-reported questionnaire (Caprara, 2010). The results obtained by using non-parametric sta-
tistical techniques, due to the small sample size, confirmed that the physical activity intervention had
positive effects on the fine manual dexterity of the elderly in the experimental group, and the high level of
self-efficacy perceived by the coaches influenced the effects of the physical training. The results empha-
size the importance of setting realistic objectives, and prove that the choice and training of coaches is
fundamental for physical exercise practiced in a condition of frailty, such as that of older people living in
residential care facilities.
Keywords: Elderly; Physical Activity; Coach; Self-Efficacy
There are a growing number of elderly individuals in our so-
ciety (World Health Organization, 2002). Generally speaking, a
longer lifespan may be associated with an increase in disabili-
ties in the frailest bracket of the population (WHO, 2002;
Hardy, Dubin, Holford, & Gill, 2005; Stenzelius, Westergreen,
Thorneman, & Rahm Hallberg, 2005). In fact, many older peo-
ple have grave difficulties using objects in their daily life be-
cause they have lost a certain amount of manual dexterity. For
instance, they may have difficulties in using small objects, in
opening and closing coffee machines, getting dressed and so on.
These difficulties may strongly negatively affect their activities
of daily living (ADL), with negative cascade effects over sev-
eral fields of application, such as inviting friends to one’s home
or going out to meet them. Thus, given the role of fine manual
dexterity on activities of daily living we need to explore the
most convenient way to maintain this and prevent its loss of
functioning. The present study tackles this issue.
Manual dexterity is the ability to execute controlled, accurate,
and coordinated movements using the hands and fingers in
daily activities such as writing, chopping, and knitting. Various
studies have shown that both fine manual dexterity (Hackel,
Wolfe, Bang, & Canfield, 1992; Mathiowetz, Weber, Kashman,
& Volland, 1985) and motor coordination decline with age
(Desrosiers, Hebert, Bravo, & Dutil, 1995). This decline can be
attributed to neuromuscular changes, to the decrease in the
number and increase in size of motor neurons, and changes in
the contractile capacity of muscles (Vaillancourt, Larsson, &
Newell, 2003; Martin, Sale, & Semmler, 2005).
Moreover, some studies have highlighted age-related changes
in finger strength and in the independent and synergistic inter-
action of fingers (Oliveira, Shim, Loss, Petersen, & Clarke,
2006; Potter, Kent, Lindstrom, & Lazarus, 2006; Shinohara,
Latash, & Zatsiorsky, 2003).
Some research has also proven that there is a strong connec-
tion between hand strength and health problems, disability, and
mortality (Rantanen, Volpato, Ferrucci, Heikkinen, Fried, &
Guralnik, 2003; Snih, Markides, Ottenbacher, & Raij, 2004).
As previously said, the loss of fine manual dexterity has severe
consequences on the elderly’s autonomy in activities of daily
living. In particular, the changes in fine manual dexterity seem
to limit the ability to perform basic tasks such as moving ob-
jects, getting dressed, eating, and writing, and may hence affect
quality of life Scherder, Dekker, & Eggermont, 2008; Topin-
kovà, 2008). Specifically, the decrease in finger strength, which
represents an important parameter related to hand functioning,
may have a significant impact on these basic daily abilities
(Carmeli, Patish, & Coleman, 2003).
In addition, the loss of autonomy in activities of daily living,
whether related to fine manual mobility and/or to other mobility
problems, may cause a series of negative consequences such as
the loss of independence (Paterson, Govindasamy, Vidmar,
Cunningham, & Koval, 2004; Huang, Perera, VanSwearingen,
& Studenski, 2010), institutionalization (Bharucha, Pandav,
Shen, Dodge, & Ganguli, 2004) and mortality (Millàn-Calenti,
Tubio, Pita-Fernandez, Gonzales-Abràldes, Lorenzo, Fernàndez-
Arruty, & Maseda, 2010). These negative consequences may
lead to a further worsening of the general health condition and
the quality of life of the elderly, limiting their self-sufficiency
or forcing them to live in residential care facilities (Guralnik,
Alecxih, Branch, & Wiener, 2002; Lubitz, Cai, Kramarow, &
Lentzner, 2003).
Thus, since we know that the loss of manual dexterity is as-
sociated with a loss of autonomy and a worsening quality of life
of the elderly, it is important to intervene regarding this physi-
cal ability (Scherder, 2008; Taekema, Gussekloo, Maier,
Westendorp, & De Craen, 2010). For this reason, specific in-
tervention programs that improve and/or maintain the stability
of fine manual dexterity, contributing to the maintenance of the
elderly’s self-sufficiency, can be an important resource: among
all possible intervention programs we can apply in this kind of
context, physical activity programs appear to be particularly
interesting. We already know that physical activity can protect
older people who are in a situation of physical and psychosocial
frailty, playing an important role in terms of mobility function
and preserving the skills they need to retain a good level of
autonomy. Several studies have confirmed the positive effects
of physical activity programs on motor functions in independ-
ent elderly individuals aged between 65 and 75 who are living
in their own homes (among others, see: Hauer, Becker, &
Beyer, 2006; van der Bij, Laurant, & Wensing, 2002). Specifi-
cally, recent studies have shown that physical activity can im-
prove the strength of the hands and fingers (Baker, Atlantis, &
Fiatarone Singh, 2007; Keogh, Morrison, & Barrett, 2007).
With respect to the very elderly, the guidelines of the American
College of Sports Medicine (ACSM, 2000) state that physical
activity programs designed for the guests of residential care
facilities should focus on the objective of preserving the skills
that are functional to their independence, educating the partici-
pants towards maintaining an active lifestyle through individual
psychophysical wellbeing. In fact, some research has shown
that older elderly individuals benefit from physical activity in
terms of their overall wellbeing and a decreased risk of devel-
oping illnesses that might lead to disability (among others, see:
Rejeski & Mihalko 2001; Peri, Kerse, Robinson, Parsons, Par-
sons, & Latham, 2008; Malbut, Dinan, & Young, 2002; Jessup,
Horne, Vishen, & Wheeler, 2008). Therefore, a specific physi-
cal activity intervention designed for the maintenance of
autonomy in the elderly of residential care facilities can be an
important resource because it helps the elderly maintain their
residual physical abilities, also contributing to a better psycho-
logical condition (Kasser & Ryan, 1999) and limiting the risk
of mortality (Blair, 1999). However, few studies have analyzed
physical activity programs designed for the guests of residential
care facilities, i.e. the frailest bracket of the population which
runs the highest risk of losing its autonomy.
We know that some physical activity interventions work bet-
ter than others, but the reasons behind this have rarely been
investigated (Booth, Owen, Bauman, Clavisi, & Leslie, 2000).
The “oldest old” often decide to participate in physical activity
because they want to preserve the skills that allow them to be
independent (Fried, Ferrucci, Darer, Williamson, & Andreson,
2004; Gill, Baker, Gottschalk, Peduzzi, Allore, & Van Ness,
2004). In particular, the elderly in residential care facilities
need to be highly motivated, supported by those around them,
able to appreciate the advantages of physical activity, and have
a positive attitude towards training (Wilcox, Tudor-Locke, &
Ainsworth, 2002). Elderly people need to be supported, to have
a guide who shows them how to be active (Dye & Wilcox,
2006), and helps them in training exercises, which must have
achievable goals. For this reason, the role of trained profession-
als who conduct physical activity programs can play a crucial
role not only in the elderly’s decision to take part in a physical
activity program but also in their determination to participate
actively and consistently, which might help in achieving the set
The efficacy of trained professionals depends on their own
self-efficacy regarding their work: according to Bandura (1997),
self-efficacy is defined as “the belief in one’s capabilities to
organize and execute the courses of action required to manage
prospective situations” (Bandura, 1997: p. 2). The importance
of self-efficacy has been confirmed by various studies that have
investigated the role of teachers’ self-efficacy in an educational
context (Rivkin, Hanushek, & Kain, 2005; Pianta & Stuhlman,
2004). The perception of a teacher’s self-efficacy has been
defined as the level of ability the teacher thinks he/she has to
influence the performance and learning abilities of his/her stu-
dents, promoting learning, motivation and autonomy, and deal-
ing successfully with the work environment and decisions re-
lated to work objectives (Bandura, 1997). Many studies have
highlighted that a high level of teacher self-efficacy is associ-
ated with support to students (Jina, 2002), students’ academic
achievements (Caprara, Barbaranelli, Steca, & Malone, 2006;
Ross, 1992) and also with the use of efficient group manage-
ment strategies (Gordon, 2001). These results are similar to
those of some of our previous studies which demonstrated that
a physiotherapist’s high level of self-efficacy is associated with
the improved movement abilities of injured individuals (Raba-
glietti, Roggero, Mosca, Barberis, & Ciairano, 2003). Thus, the
self-efficacy beliefs of professionals who work with specific
people (i.e. students, athletes) seem to have an important role
on the effectiveness of each specific intervention.
Despite these results, to our knowledge, no attention has
been paid to the role of the professionals conducting physical
activity sessions within a complex learning context, such as that
of residential care facilities for the elderly. This is more impor-
tant considering instructors work with one of the frailest seg-
ments of the population, the institutionalized elderly. This study
is aimed at addressing these lacks.
Research Aims
The present study represents a continuation of our previous
research, which demonstrated the positive effects of physical
training on an Italian sample of older people in residential care
facilities, in relation to both psychological (Ciairano, Liubicich,
& Rabaglietti, 2010) and motor aspects (Liubicich, Magistro,
Candela, Rabaglietti, & Ciairano, 2012). We continued investi-
gating the effects of physical activity on the elderly population,
trying to provide a more comprehensive description of the
In this study, we focus on upper limb motor function and we
try to determine if the physical activity program offered to our
Copyright © 2012 SciRes. 385
participants affected both right and left hand strength and
thumb-index and index-thumb pinch. Moreover, we wish to
ascertain if the effects were moderated by the activity coaches’
perception of their own self-efficacy.
Our objectives can be summarized by the following research
1) Did participation in the physical activity program have an
effect on right and left hand strength, the right and left
thumb-index and index-thumb pinch of the elderly?
2) Are the effects of the physical activity program on hand
strength and finger pinch moderated by the perception of the
activity coaches’ self-efficacy?
In line with recent studies (Baker et al., 2007; Keogh et al.,
2007), we hypothesize that a physical activity program has a
positive effect on upper limb motor skills, specifically on hand
and finger strength. Also, we hypothesize that the coaches’
self-efficacy can be interpreted as a moderator effect: In fact,
given the important role of the self-efficacy of professional
workers (Caprara et al., 2006; Jina, 2002; Rabaglietti et al.,
2003), we posit that those who participated in activities con-
ducted by coaches possessing a high level of perceived self-
efficacy enjoyed greater positive effects on their motor skills
than the elderly who had low self-efficacy instructors.
Study Design and Methods
The intervention was introduced in two Piedmont Region
residential care facilities in northern Italy, and another residen-
tial care facility also in Piedmont Region was used as control
group: Currently, more than 5,000 older people of the Piedmont
Region live in residential care facilities (Banchero, 2009). First,
from the list offered by the Health Office of the Piedmont Re-
gion, we selected 30 facilities that have similar features in
terms of accordance with the National Health Service, number
and typology of guests (range from 80 to 120), intermediate
social and economic conditions of the guests (all the guests in
these facilities are requested to pay even a small amount for the
care they receive), and services offered to the guests (presence
of on-site emergency services, healthcare operators, physio-
therapists, and psychologists). The facilities that were selected
accommodate both self-sufficient older people (i.e., individuals
who can walk, eat, and use the bathroom independently) and
dependent older people (requiring assistance in basic activities
of daily living), even if at this stage we are especially interested
non self-sufficient older people. The facilities are both public
and private institutions, but even the private institutions have
the same standards as public facilities because they are linked
to the Public Health Service through a funding agreement.
Second, we randomly selected four of these facilities from
the list and all of them agreed to participate in the study; how-
ever, we needed to exclude one facility because after a prelimi-
nary investigation with the director we found that we were
unlikely to find enough seniors who would fulfill all three in-
clusion criteria (see participant requirements below) in order to
create a physical activity group (we need at least 4 - 5 partici-
pants). Then, we assigned the two remaining facilities to the
experimental condition and one to the control condition.
The individuals in both the intervention and the control
group were selected by the director of the residential care facil-
ity, a trained physician, from among all the elderly people liv-
ing 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, Folstein, & McHugh, 1975) was used to evaluate
cognitive functions, and all the older people reached or ex-
ceeded the minimum score of 23. The participants were in-
formed that participation in the study was voluntary and confi-
dential. All the selected elderly agreed to participate and gave
their informed consent, in accordance with Italian law and the
ethical code of the Association of Italian Psychologists (AIP,
The sample was comprised of 44 people, 16 (36%) of who
were males (2 in the control group and 14 in the experimental
groups) and 28 (64%) females (9 in the control group and 19 in
the experimental groups). We did not find any differences be-
tween the experimental and control group (χ = 2.1, d.f. = 1, p
= .27). The mean age was 85 for the control group (SD = 6.6),
and 84.26 (SD = 7.4) for the experimental group (t-test = –.34
d.f. = 41, p = .73). All the participants lived permanently in the
residential care facilities. With regards to marriage status, the
majority (N = 26) were widows/widowers or married (N = 8),
while others had never married (N = 7) or were divorced (N =
3): No differences were found between the experimental and
control groups (χ = 3.7, d.f. = 3, p = .29). In terms of education,
two levels were considered: “low”, corresponding to compul-
sory education (only primary school) and “high”, corresponding
to additional non-compulsory education (more than primary
school): Also, we did not find significant differences between
the two groups (χ = 2.1, d.f. = 1, p = .64). The average level of
education of the participants 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 a compulsory education, similar
to 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 in this regard between the
experimental and control groups (χ = 3.2, d.f. = 1, p = .35).
With regards to previous participation in organized exercise or
sporting activities, the majority of the individuals (N = 27) had
never participated, with no differences between the experiment-
tal and control groups (χ = 1.3, d.f. = 1, p = .31). The main
characteristics of the participants are described in Table 1.
Description of the Intervention
The intervention consisted of 2 sessions per week of 45 min-
utes each for 16 weeks, over a period of roughly 5 months. It
was presented to 7 groups of 4 - 5 self-sufficient older persons
living in residential care facilities. The sessions were conducted
by instructors, all of who had university degrees in physical
education and sports-related fields and specialized in physical
fitness training for older people (Ciairano et al., 2006). The set
of activities was specifically designed for this research. The
intervention protocol focused on three specific objectives: mo-
bility, balance, and resistance strength. It was designed to
gradually engage and interest the participants in a variety of
different activities, by using both conventional and unconven-
tional instruments (such as stools, sticks, clubs, hoops, balloons,
foam balls, towels, paper cups, pins, bowls, paper tissues,
scarves, and trays) and by emphasizing the playful side of said
Copyright © 2012 SciRes.
Table 1.
Characteristics of participants (N).
Control Experimental
Variable Category
N % N %
Female 9 82 19 58
Male 2 18 14 42
No 8 73 19 58
Past participation
in physical
activities Yes 3 27 14 42
Northern Italy 10 91 30 91
Central Italy / / 2 6
Region of
Southern Italy 1 9 1 3
Never married 1 9 6 18
Married 1 9 7 21
Widow/Widower 9 82 17 52
Marital status
Divorced / / 3 9
Past job Manual labor 10 91 21 64
Non-manual labor 1 9 12 36
Level of
education Only primary school9 82 24 73
More than primary
school 2 18 9 27
Age Mean (SD) 85
In addition, the personnel working in the facilities informed
the instructors every day about each participant’s condition,
including minor physical problems, so that no potentially dan-
gerous movements were required during the training sessions.
Furthermore, special care was taken to provide the older per-
sons with plenty of time to perform each movement, avoiding
activities that could be perceived as too intense, embarrassing,
or difficult.
The 7 coaches who conducted the training program were all
women, with a mean age of 29 (SD = 4.4; range 26 - 34). They
all had university degrees in physical education and sports-
related fields, and specializations in adapted physical education.
The coaches 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 those instructors who
achieved a final grade higher than the 95th percentile of the
grade distribution for these subjects. All the selected coaches
agreed to participate in the study and received a small stipend
for travel expenses incurred in order to conduct the physical
activity program. The activity was recognized as part of their
professional training.
We tested both the experimental and the control group with a
battery of psychological and physical instruments, before and
after the physical activity program. We performed biomechani-
cal tests on hand-grip strength and individual finger-pinch
strength for both hands. Individual finger-pinch strength was
measured using a squeeze dynamometer, precision .5 kg
strength, in two different ways (Imrhan & Loo, 1989): with the
fleshy part of the index finger in opposition to the thumb; with
the thumb pressing from above in opposition to the side of the
index finger.
The two tests were performed with the individuals in a stan-
dard position, sitting and holding the instrument while their
elbows rested on a table (Imrhan & Rahman, 1994). A dyna-
mometer was used to measure the grip strength of the entire
hand, precision 1 kg strength (Imrhan & Loo, 1989). We used a
standard table (Imrhan & Rahman, 1994) and a chair with an
adjustable height so that the subjects sat with their forearms
resting on the tabletop at a 90-degree angle to the body and kept
their backs straight. The tests were performed individually,
alternating between the left and right hand for both-hand
strength and the finger pinch.
We also presented the coaches with a self-efficacy scale at
the beginning of the physical activity program. The self-report
questionnaire (taken from Caprara, 2001), made up of 22 items,
was aimed at assessing the ability to positively influence the
environment and prepare it for the introduction of a physical
activity program for the elderly, the adoption of major sources
of self-efficacy, as well as the ability to promote the physical
activity program among the elderly (“How capable did you
feel?” 1 = Not at all, 2 = A little, 3 = Quite, 4 = Very). We
tested the reliability of the scale by means of Cronbach’s α and
we obtained a score of .93. We did not experience any particu-
lar problems while administering the instruments. For this study,
we consider the coaches’ self-efficacy to be the moderator.
Analysis Strategy
In order to verify our research hypothesis, we carried out
non-parametric tests on independent and dependent samples.
Non-parametric tests are used when there are uncertainties
about the normalcy of distribution of the variables being invest-
tigated, often due to small sample size.
To evaluate the effect of the physical activity program on the
considered motor variables, we used the Mann-Whitney U test
for independent samples. We then compared the post-test val-
ues of the experimental group and of the control group. The
hypothesis that self-efficacy acts as a moderator was tested
indirectly, due to the small sample size. First of all, we divided
the experimental sample into two subgroups based on the
self-efficacy score of their respective coaches: a group with low
self-efficacy and a group with high self-efficacy. This was ac-
complished by calculating the median of the self-efficacy scale
score of 74 (range = 22 - 88, min = 64, max = 85). We found
that 3 of the 7 coaches were at high self-efficacy, while the
other 4 were at low self-efficacy.
Second, we performed the statistical analysis by using the
Wilcoxon test for dependent samples. We compared the pre-test
and post-test mean ranks of the motor variables’ scores sepa-
rately for the two experimental subgroups, the first included
individuals who had worked under the supervision of a high
self-efficacy instructor and the second included individuals who
had worked under the supervision of a low self-efficacy in-
structor. This procedure was applied to both groups of instruct-
tors (both high and low self-efficacy). We compared the Z
scores of each of the two self-efficacy subgroups for each mo-
Copyright © 2012 SciRes. 387
Copyright © 2012 SciRes.
tor variable under investigation in order to check whether the
group of older persons supervised by high self-efficacy coaches
displayed more significant post-test improvements than the
group supervised by low self-efficacy instructors. All the
non-parametric tests were carried out using the Monte Carlo
methods and, to further support our theoretical hypotheses, we
also performed an effect size analysis. All analyses were con-
ducted using the SPSS version 18.0 statistical package.
First of all, we verified whether participating in the physical
activity program had positive effects on hand strength and the
thumb-index pinch by comparing the post-test scores of the
experimental group to those of the control group (Table 2). The
data show that at the end of the physical activity program the
experimental group displayed increased right-hand strength (Z
= –2.082, p < .037, effect size = –.21) and left-hand strength (Z
= –2.055, p < .040, effect size = –.21) in comparison to the con-
trol group.
Concerning the thumb-index pinch, statistically significant
differences emerged between the experimental group and the
control group in relation to index-thumb strength in the right
hand (Z = –2.410, p < .016, effect size = –.24). No differences
were detected between the two groups in relation to right hand
thumb-index strength (Z = –1.529, p < .126), left hand thumb-
index strength (Z = –.446, p < .656), and left hand index-thumb
strength (Z = –1.827, p < .068).
As mentioned above, to verify the hypothesis that the
coaches’ self-efficacy acts as a moderator, we compared the
pre-test and post-test values of the older persons coached by
low self-efficacy instructors and those coached by high self-
efficacy instructors. When analyzing right-hand strength (Table
3), we saw that at the end of the program the rank did not
change for the group of older individuals coached by low self-
efficacy instructors (z = –1.268, p = .227), whereas it changed
for those coached by high self-efficacy instructors (z = –2.074,
p = .034, effect size = –.35). The right hand thumb-index pinch
values did not undergo any significant changes in the group
coached by low self-efficacy instructors (z = –1.792, p = .084),
while it changed in the group coached by high self- efficacy
instructors (z = –2.970, p = .002, effect size = –.46). The left
hand thumb-index pinch values did not undergo any significant
changes in the group coached by low self-efficacy instructors (z
= –.159, p = .876), while it changed in the group coached by
high self-efficacy instructors (z = –2.474, p = .011, effect size =
–.37). The right hand index-thumb pinch values did not un-
dergo any significant changes in the group coached by low
self-efficacy instructors (z = –.079, p = .959), while it changed
in the group coached by high self-efficacy instructors (z =
–2.371, p = .02, effect size = –.36). Lastly, the left hand in-
dex-thumb pinch values did not undergo any significant
changes in the group coached by low self-efficacy instructors (z
= –1.019, p = .329), while it changed in the group coached by
high self-efficacy instructors (z = –2.605, p = .007, effect size =
The objective of this study was to investigate how participa-
tion in a physical activity program affects the upper limb motor
skills of a sample of elderly people living in residential care
facilities in Piedmont, Italy. Moreover, it aimed at ascertaining
if the coaches’ level of perceived self-efficacy acts as a mod-
erator on the motor skills, hand strength, and finger strength of
the participants.
As for the first research hypothesis, we wanted to determine
whether participating in a physical activity program can, in time,
lead to improved hand strength. Several studies acknowledge
the fact that palm grip strength is an important biomechanical
parameter representative of overall muscle strength as well as
an indicator of those clinical conditions that influence self-
sufficiency/frailty in older persons (Ishizaki, Watanabe, Suzuki,
Shibata, & Haga, 2000; Michel-Pellegrino, Lia, Hewsona,
Hogrel, & Duchêne, 2009; Tainaka, Takizawa, Katamoto, &
Aoki, 2009). The data gathered through our investigation pro-
vide some interesting insight into this issue:
After completing the physical activity protocol, right and left
Table 2.
Results of the non-parametric test for independent samples. Difference between experimental and control group—median (Me), mean (M), standard
deviation (SD), Z-value and p, effect size (ES) for the dependent variables.
Pre-test Post-test
Experimental Control Experimental Control
Dependent v ariables
Right-hand strength 3 4.1 4 0 2.84.5Z = –1.861
p < .063 / 3 4.75.40 2.1 4.4
Z = –2.082
p < .037 –.21
Left-hand strength 3.5 4.2 5.1 0 2.13.6Z = –2.259
p < .024 –.23 2 4.36.5 0 1.4 2.8
Z = –2.055
p < .040 –.21
Right thumb-index strength 4 4.2 1.1 3.5 4.82 Z = –.059
p < .953 / 4 4.72.13 4.1 2.5
Z = –1.529
p < .126 /
Left thumb-index strength 4 3.9 1.9 3.5 3.91.3Z = –.079
p < .937 / 4 3.7 1
Z = –.446
p < .656 /
Right index-thumb strength 4 3.9 1.6 2.5 3.32.1Z = –1.512
p < .130 / 4 4 1.72 3 2.6
Z = –2.410
p < .016 –.24
Left index-thumb strength 3.5 3.8 1.8 3 3.31.6Z = –.939
p < .348 / 2.8 1.6
Z = –1.827
p < .068 /
Table 3.
Results of the non-parametric test for dependent samples. Pre- and post-test difference for older persons with low and high self-efficacy instructors—
median (Me), mean (M), standard deviation (SD), Z-value and p, effect size (ES) for the dependent variables.
Experimental Experimental
Low Self-efficacy High Self-efficacy
Pre-test Post-test Pre-test Post-test
Dependent v ariables
Right-hand strength 4 3.5 2.6 0 3.56.3Z = –1.268
p < .227 / 2 5.6 4.4
Z = –2.074
p < .034 –.35
Left-hand strength 3.5 3 2.5 0 3.46.8Z = –.424
p < .751 / 3 5 6.3
Z = –.493
p < .661 /
Right thumb-index strength 3 3.7 2.1 4 4.82.2Z = –1.792
p < .084 / 4.6 2
Z = –2.970
p < .002 –.46
Left thumb-index strength 3.8 4 1.9 4 4 2.1Z = –.159
p < .876 / 4 3.81.94 4 1.8
Z = –2.474
p < .011 –.37
Right index-thumb strength 4 4.1 1.6 4 4.21.7Z = –.079
p < .329 / 4 3.9 1.8
Z = –2.371
p < .02 –.36
Left index-thumb strength 4 4.4 2.1 3.5 3.71.9Z = –1.019
p < .329 / 3 3.6 1.6
Z = –2.605
p < .007 –.40
hand strength functions improved in the experimental group,
but the same did not happen in the control group. Hence, hand
strength seems to have been influenced by the multi-modal
exercises (Baker et al., 2007) included in the physical activity
protocol, which comprised of aerobic, balance, flexibility, and
resistance-strength activities with the use of small instruments.
Research performed on samples of older persons of both gen-
ders with a mean age of 80 has proven that resistance training
programs lasting for 12 weeks with 2 sessions a week can in-
crease muscle strength (Sullivan, Roberson, Smith, Price, &
Bopp, 2007; Helbostad, Sletvold, & Moe-Nilssen, 2004). Co-
herent with their findings, the results of our research point out
that simple physical activity programs can activate/reactivate
motor functions in older elderly and help preserve the strength
ranges needed to be able to lead an independent life for as long
as possible.
We also wanted to determine if the older persons who par-
ticipated in the physical activity program displayed improved
right and left hand finger functions in terms of index-thumb and
thumb-index pinch. The data gathered through our investigation
did not differ from that found in the literature about the older
population (Keogh et al., 2007; Ranganathan, Siemionow,
Saghal, & Yue, 2001).
Our research questions also concerned the coaches’ level of
perceived self-efficacy and their ability to act as moderator on
hand and finger strength. As hypothesized, there seems to be a
relationship between motor functioning and the level of self-
efficacy. Our results confirm that the coaches’ level of per-
ceived self-efficacy has a strong influence on successful par-
ticipation in a physical activity program, which leads partici-
pants to continue their training and benefit from the re-activa-
tion of their motor skills. As our analysis proves, hand and
finger strength results increase greatly in the groups coached by
instructors with a high level of perceived self-efficacy. Hence,
instructors with a higher level of self-efficacy seem to be more
skilled in managing the variables and in implementing the ad-
justments needed to work with small groups of older elderly
individuals. In particular, they seem to be able to detect those
aspects that can act as barriers to motivation (Schutzer &
Graves, 2004) and to the successful taking up and continuation
of a physical activity program (McAuley, Morris, Motl, Hu,
Konopack, & Elavsky, 2007).
The coach’s trust in his/her skills to manage the learning
process and his/her ability to successfully deal with decisions
about the targets the students, in our case the older persons, can
achieve (Bandura, 1997) greatly influences the performance of
those receiving motor or sports training (Horn, 2008). High
self-efficacy coaches are aware of the aims of the research pro-
tocol, know how important it is to meet deadlines so that the
activity can be carried out in compliance with the instructions
received, and apply the protocol rigorously. Moreover, they
possess suitable teaching skills to successfully lead their group
and to influence the development of a positive attitude towards
physical activity (Feltz, Chase, Moritz, & Sullivan, 1999).
Therefore, the level of self-efficacy possessed by each instruc-
tor is an important variable that affects motor results in groups
of older elderly individuals, just like it does in the case of
high-level athletes.
The limitations of our research are mainly linked with: the
small sample size (although the participants actually mirror the
situation in Italian residential care facilities) and the absence of
follow-up sessions (to determine if the improvements were
permanent or if booster sessions were needed.)
In spite of the above, some stimulating observations can be
drawn from our study. Firstly, physical activity can positively
influence the preservation/improvement of hand and finger
strength through specific training that includes targeted strength
exercises. If hand function decreases with aging, individuals are
destined to progressively lose their autonomy in managing the
daily activities that require strength and dexterity in manipulat-
ing handheld objects, which are fundamental for eating, drink-
ing, and looking after oneself (Carmeli et al., 2003). An indi-
vidual’s independence in daily activities decreases progres-
sively and unevenly also in relation to functionality deficits:
Eating, dressing, and looking after personal hygiene are related
to good upper-limb functioning, whereas going to the bathroom
Copyright © 2012 SciRes. 389
autonomously depends on good lower-limb functioning (Huang
et al., 2010). It is, therefore, necessary to design interventions
for the preservation of autonomy in daily activities, by imple-
menting protocols to limit the loss of—rather than to improve
—motor skills in older elderly.
Another observation that can be drawn from our research re-
gards the issue of moderation, an aspect which has been mostly
overlooked in the literature about samples of older elderly.
Understanding moderation effects on the efficacy of targeted
physical activity programs will have a positive influence on the
promotion of independence and health among the elderly living
in residential care facilities.
It is particularly important to investigate the role of those
who are conducting physical activity programs for the older
elderly, since this can help design appropriate intervention pro-
tocols that take into account the specific characteristics of the
targeted age bracket (Martens, 2004). As already pointed out in
our previous research (Ciairano, Musella, Gemelli, Liubicich,
Rabaglietti, & Roggero, 2006), a good coach must possess a
range of skills that address the individual as a whole—i.e. skills
concerning teaching techniques and communication, the man-
agement of variables deriving from the intervention’s context,
and the protocols designed for each participant—based on indi-
vidual needs and potential. Hence, the presence of suitably
trained professional coaches will add value to physical activity
programs, which will play a crucial role in preserving the inde-
pendence of older persons living in residential care facilities.
The authors acknowledge Regione Piemonte, Assessorato
Ricerca, Innovazione e Sviluppo Bando Scienze Umane 2009,
for their contribution to this ACT ON AGING pilot study.
A.I.P. [Italian Association of Psychology] (1997) Codice Etico della
ricerca psicologica [Ethical code for psychological research]. Roma,
IT: AIP. Accessed 6 August 2009.
American College of Sports Medicine, (2000). ACSM’s guidelines for
exercise testing and prescription (6th ed.). Baltimore: Williams &
Baker, M. K., Atlantis, E., & Fiatarone Singh, M. A. (2007). Multi-
modal exercise programs for older adults. Age and Ageing, 36, 375-
381. doi:10.1093/ageing/afm054
Banchero (2009). L’assistenza agli anziani non autosufficienti in Italia.
Rapporto 2009 a cura di N.N.A. (Network Non Autosufficienza).
Rapporto promosso dall’IRCSS—INCRA per l’Agenzia nazionale
per l’invecchiamento.
Bandura, A. (1997). Self-Efficacy: The exercise of control. New York:
Freedman and Company.
Bharucha, A. J., Pandav, R., Shen, C., Dodge, H. H., & Ganguli, M.
(2004). Predictors of nursing facility admission: A 12-year epidemic-
ological study in the United States. Journal of the American Geriat-
rics Society, 52, 434-439.
Booth, M. L., Owen, N., Bauman, A., Clavisi, O., & Leslie, E. (2000).
Social-cognitive and perceived environment influences associated
with physical activity in older Australians. Preventive Medicine, 31,
15-22. doi:10.1006/pmed.2000.0661
Bowling, A., & Grundy, E. (1997). Activities of daily living. Changes
in functional ability in three samples of elderly and very elderly peo-
ple. Age and Ageing, 26, 107-114. doi:10.1093/ageing/26.2.107
Caprara, G. V. (2001). La valutazione dell’autoefficacia. Costrutti e
strumenti. Trento: Erickson.
Caprara, G. V., Barbaranelli, C., Steca, P., & Malone, P. S. (2006).
Teachers’ self-efficacy beliefs as determinants of job satisfaction and
students’ academic achievement: A study at the school level. Journal
of School Psychology, 44, 473-490. doi:10.1016/j.jsp.2006.09.001
Carmeli, E., Patish, H., & Coleman, R. (2003). The aging hand. Journal
of Gerontology Series A Biological Sciences Medical Sciences, 58M,
146-152. doi:10.1093/gerona/58.2.M146
Ciairano, S., Liubicich, M. E., & Rabaglietti, E. (2010). The effects of a
physical activity program on the psychological wellbeing of older
people in a residential care facility: An experimental study. Ageing &
Society, 30, 609-626. doi:10.1017/S0144686X09990614
Ciairano, S., Musella, G., Gemelli, F., Liubicich, M., Rabaglietti, E., &
Roggero, A. (2006). Progettazione degli interventi di promozione
dell’attività motoria per gli anziani e formazione degli istruttori:
Punti di forza e criticità. Giornale Italiano di Psicologia dello Sport,
1, 13-21.
Ciairano, S., Musella, G., Gemelli, F., Liubicich, M. E., Rabaglietti, E.,
& Roggero, A. (2006). Un intervento di promozione dell’attività
motoria e la salute fisica e psicologica degli anziani all’interno di una
residenza: valutazione di processo e di risultato. Giornale Italiano di
Psicologia dello Sport, 1, 3-11.
Cole, K.J. (2006). Age-related directional bias of fingertip force. Ex-
perimental Brain Researc h , 175, 285-291.
Costa, G., Migliardi, A., & Gnavi, R. (2006). Verso un profilo di salute
[Towards a Profile of Health]. Servizio Centrale Comunicazione,
Città di Torino, Turin, Italy.
Desrosiers, J., Hebert, R., Bravo, G., & Dutil, E. (1995) Upper-extre-
mity motor co-ordination of healthy elderly people. Age and Ageing.
24, 108-112. doi:10.1093/ageing/24.2.108
Dye, C., & Wilcox, S. (2006). Beliefs of low-income and rural older
women regarding physical activity: You have to want to make your
life better. Women & Health, 43, 115-134.
Feltz, D. L., Chase, M. A., Moritz, S. E., & Sullivan, P. J. (1999). A
conceptual model of coaching efficacy: Preliminary investigation and
instrument development. Journal of Educational Psychology, 4, 765-
776. doi:10.1037/0022-0663.91.4.765
Ferrucci, L., Guralnik, J. M., Studenski, S., Fried, L. P., Culter, G. B.
Jr., & Walston, J. D. (2004). Designing randomized, controller trials
aimed at preventing or delaying functional decline and disability in
frail, older persons: A consensus report. Journal of the American
Geriatric Society, 52, 625-634.
Folstein, M., Folstein, S., & McHugh, P. R. (1975). Mini-Mental State:
A practical method for grading the cognitive state of patients for the
clinician. Journal of Psychiatric Research, 12, 189-198.
Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Andreson, G.
(2004). Untangling the concepts of disability, frailty, and comorbid-
ity: Implications for improved targeting and care. Journal of Geron-
tology Series A Medical Science , 59, 255-263.
Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, L. R. (2007). Pre-
dicting nursing home admission in the U.S.: A meta-analysis. Bio-
medcentral Geriatrics, 7, 1-14.
Gill, T. M., Baker, D. I., Gottschalk, M., Peduzzi, P. N., Allore, H., &
Van Ness, P. H. (2004). A prehabilitation program for the prevention
of functional decline: Effect on higher-level physical function. Ar-
chives of Physical Medicine and Rehabilitation, 85 , 1043-1049.
Gordon, L. M. (2001). Higher teacher efficacy as a marker of teacher
effectiveness in the domain of classroom management. Paper pre-
sented at the annual meeting of the California Council on Teacher
Education, San Diego, CA.
Guralnik, J. M., & Simonsick, E. M. (1993). Physical disability in older
Americans. The Journal of Gerontology, 48, 3-10.
Guralnik, J. M., Alecxih, L., Branch, L. G., & Wiener, J. M. (2002).
Medical and long-term care costs when elderly become more de-
pendent. American Journal of Public Health, 92, 1244-1245.
Copyright © 2012 SciRes.
Hackel, M. E., Wolfe, G. A., Bang, S. M., & Canfield, J. S. (1992).
Changes in hand function in the aging adult as determined by the
Jebsen test of hand function. Physic al Therapy, 72, 373-378.
Hardy, S. E., Dubin, J. A., Holford, T. R., & Gill, T. M. (2005). Transi-
tions between states of disability and independence among older
persons. American Journal o f Epidemiology, 161, 575-584.
Hauer, K., Becker, C. U., & Beyer, N. (2006). Effectiveness of physical
training on motor performance and fall prevention in cognitively
impaired older persons. American Journal of Physical Medicine &
Rehabilitation, 85, 847-857.
Helbostad, J. L., Sletvold, O., & Moe-Nilssen, R. (2004). Effects of
home exercises and group training on functional abilities in home-
dwelling older persons with mobility and balance problems. Aging
Clinical and Experimental Re se ar c h, 16, 113-121.
Horn, T. S. (2008). Coaching effectiveness in the sport domain. In T. S.
Horn (Ed.), Advances in Sport Psychology (3rd ed., pp. 239-267)
Champaign, IL: Human Kinetics.
Huang, W. W., Perera, S., VanSwearingen, J., & Studenski, S. (2010).
Performance measures predict onset of activity of daily living diffi-
culty in community-dwelling older adults. Journal of the American
Geriatric Society, 58, pp. 844-852.
Imhran, S. N., & Loo, C. H. (1989). Trends in finger pinch strength in
children, adults, and the elderly. Human F actors, 31, 689-701.
Imhran, S. N., & Rahman, R. (1994). The effects of pinch width on
pinch strengths of adult males using realistic pinch-handle coupling.
International Journal of Industrial Ergonomics, 16, 123-134.
Ishizaki, T., Watanabe, S., Suzuki, T., Shibata, H., & Haga, H. (2000).
Predictors for functional decline among nondisabled older Japanese
living in a community during a 3-year follow-up. Journal of the
American Geriatric Society, 48, 1424-1429.
Jessup, J. V., Horne, C., Vishen, R. K., & Wheeler, D. (2003). Effects
of exercise on bone density, balance, and self-efficacy in older
women. Biological Research for Nursing, 4, 171-180.
Jina, S. Y. (2002). Teacher characteristics as predictors of teacher-
student relationships: Stress, negative affect, and self-efficacy. Social
Behaviour and Personality: An International Journal, 30, 485-493.
Kallinen, M., Sipila, S., Alen, M., & Suominen, H. (2002). Improving
cardiovascular fitness by strength or endurance training in women
aged 76-78 years. A population-based, randomized study. Aging
Clinical Experimental Resear ch , 16, 113-121.
Keogh, J.W., Morrison, S., & Barrett, R. (2007). Strength training
improves the tri-digit finger-pinch force control of older adults. Ar-
chive Physiology Medi cine Rehabilitation, 88, 1055-1063.
Lavile d’Epinay, C., & Spini, D. (2007). Le grand age. Un domaine de
recherché recent. Gérontologie et Société, 123, 31-54.
Lavile d’Epinay, C., Pin, S., & Spini, D. (2001). Présentation de
Swilso-o, une étude longitudinale suisse sur la grand age. L’exemple
de la dynamique de la santé fonctionnelle. L’Année Gérontologique,
15, 78-96.
Lee, L. L., Arthur, A., & Avis, M. (2008). Using self-efficacy theory to
develop interventions that help older people overcome psychological
barriers to physical activity: A discussion paper. International Jour-
nal of Nursing Studies, 45, 1690-1699.
Lidz, C., Fisher, L., & Arnold, R. M. (1992). The erosion of autonomy
in long-term care. New York: Oxford University Press.
Liubicich, M. E., Magistro, D., Candela, F., Rabaglietti, E., & Ciairano
S., (2012) Physical activity and mobility function in elderly people
living in residential care facilities. “Act on Aging”: A pilot study.
Advances in Physical Education, 2.
Lubitz, J., Cai, L., Kramarow, E., & Lentzner, H. (2003). Health, life
expectancy, and health care spending among the elderly. The New
England Journal of Medicine, 349, 1048-1055.
Malbut, K. E., Dinan, S., & Young, A. (2002). Aerobic training in the
“oldest old”: The effect of 24 weeks of training. Age and Ageing, 31,
255-260. doi:10.1093/ageing/31.4.255
Malbut-Shennan, K., & Young, A. (1999). The physiology of physical
performance and training in old age. Coronary Artery Diseases, 10,
37-42. doi:10.1097/00019501-199901000-00007
Martens, R. (2004). Successful coaching. Human Kinetics, Champaign,
Martin, L. J., Sale, M. V., & Semmler, J. G. (2005). Age-related dif-
ferences in corticospinal control during functional isometric contrac-
tions in left and right hands. Journal of Applied Physiology, 9, 1483-
Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985) Adult
norms for the nine hole peg test of finger dexterity. Occupational
Therapy Journal of Research, 5, 24-37.
McAuley E., Morris, K. S., Motl, R. W., Hu, L., Konopack, J. F., &
Elavsky, S. (2007). Long-term follow-up of physical activity behav-
iour in older adults. Healt h Psychology, 26, 375-380.
Michel-Pellegrino, V., Lia, K., Hewsona, D., Hogrel, J. Y., & Duchêne,
J. (2009). Techniques d’évaluation à domicile de la qualité de
l’équilibre et de la force de préhension chez la personne âgée en
perte d’autonomie. Elsevier Masson, IRBM, 30, 262-267.
Millàn-Calenti, J. C., Tubio, J., Pita-Fernàndez, S., Gonzàles-Abraldes,
I., Lorenzo, T., Fernàndez-Arruty, T., & Maseda, A. (2010). Preva-
lence of functional disability in activities of daily living (ADL), in-
strumental activities of daily living (IADL) and associated factors, as
predictors of morbidity and mortality. Archives of Gerontology and
Geriatrics, 50, 306-310.
Nakagawa, K., Inomata, N., Konno, Y., Nakasawa, R., Hagiwara K., &
Sakamoto, M. (2008). The characteristic of a simple exercise pro-
gram under the instruction of physiotherapists for general elderly
people and frail elderly people. Journal of Physical Therapy Science,
20, 197-203. doi:10.1589/jpts.20.197
Netz, Y., Wu, M.-J., Becker, B. J., & Tenenbaum, G. (2005). Physical
activity and psychological well-being in advance age: A meta-
analysis of intervention studies. Psychology and Aging, 2, 272-284.
Oliveira, M. A., Shim, J. K., Loss, J. F., Petersen, R. D., & Clark, J. E.
(2006). Effect of kinetic redundancy on hand digit control in children
with DCD. Neuroscience Lett e r s , 4 1 0 , 42-46.
Paterson, D. H., Govindasamy, D., Vidmar, M., Cunningham, D. A., &
Koval, J. J. (2004). Longitudinal study of determinants of depend-
ence in an elderly population. Journal of American Geriatrics Soci-
ety, 52, 1632-1638. doi:10.1111/j.1532-5415.2004.52454.x
Pearlin, L. I., & Mullan, J. T. (1992). Loss and stress in aging. In M. L.
Wykle, E. Kahara, & J. Kowal (Eds.) Stress and health among the
elderly (pp. 117-132). New York: Springer.
Peri, K., Kerse N., Robinson E., Parsons M., Parsons J., & Latham N.
(2008). Does functionally based activity make a difference to health
status and mobility? A randomized controlled trial in residential care
facilities (The Promoting Independent Living Study; PILS). Age and
Ageing, 37, 57-63. doi:10.1093/ageing/afm135
Pianta, R. C., & Stuhlman, M. W. (2004). Teacher-child relationships
and children’s success in the first year of the school. School Psy-
chology Review, 33, 444-458.
Potter, N. L., Kent, R. D., Lindstrom, M. J., & Lazarus, J. A. (2006).
Power and precision grip force control in three-to-five-year-old chil-
dren: Velocity control precedes amplitude control in development.
Experimental Brain Research, 172, 246-260.
Rabaglietti, E., Roggero, A., Mosca Barberis, P., & Ciairano, S. (2003).
Le convinzioni di autoefficacia nel recupero degli infortuni: Una
ricerca longitudinale. Giornale Italiano di Psicologia dello Sport, 3,
Ranganathan, V. K., Siemionow, V., Saghal, V., & Yue, G. (2001).
Effects of aging on hand function. Journal of American Geriatric
Copyright © 2012 SciRes. 391
Copyright © 2012 SciRes.
Society, 49, 1478-1484. doi:10.1046/j.1532-5415.2001.4911240.x
Rantanen, T., Volpato, S., Ferrucci, L., Heikkinen, E., Fried, L. P., &
Guralnik, J. M. (2003). Handgrip strength and cause-specific and to-
tal mortality in older disabled women: Exploring the mechanism.
Journal of American Geriat r i c Society, 51, 636-641.
Rejeski, W. J., & Mihalko, S. L. (2001). Physical activity and quality of
life in older adults. Journal of Gerontology Series A Biological Sci-
ences Medical Sciences, 56, 23-35.
Rivkin, S. G., Hanushek, E. A., & Kain, J. F. (2005). Teachers, schools,
and academic achievement. Econometrica, 73, 417-458.
Ross, J.A. (1992). Teacher efficacy and the effects of coaching on
student achievement. Canadian Journal of Education, 17, 51-65.
Scherder, E., Dekker, W., & Eggermont, L. (2008). Higher-level hand
motor function in aging and (preclinical) dementia, its relationship
with (instrumental) activitiesof daily life—A mini-review. Geron-
tology, 54, 333-341. doi:10.1159/000168203
Schutzer, K., & Graves, B.S. (2004). Barriers and motivations to exer-
cise in older adults. Preventive Medicine, 39, 1056-1061.
Shinohara, M., Latash, M.L., & Zatsiorsky, V.M. (2003). Age effects
on force produced by intrinsic and extrinsic hand muscles and finger
interaction during MVC tasks. Journal of Applied Physiology, 95,
Shinohara, M., Scholz, J.P., Zatsiorsky, V.M., & Latash, M.L. (2004).
Finger interaction during accurate multi-finger force production tasks
in young and elderly persons. Experimental Brain Research, 156,
282-292. doi:10.1007/s00221-003-1786-9
Snih, S., Markides, K.S., Ostir, G.V., Ray, L., & Goodwin, J. (2003).
Predictors of recovery in activities of daily living among disabled
older Mexican-Americans. Aging Clinical Experimental Research,
15, 315-320.
Snih, S., Markides, K.S., Ottenbacher, K.J., & Raij M.A. (2004). Hand
grip strength and incident ADL disability in elderly Mexican-
Americans over a seven-year period. Aging Clinical Experimental
Research, 16, 481-486.
Stenzelius, K., Westergreen, A., Thorneman, G., & Rahm Hallberg, I.
(2005). Patterns of health complaints among people 75+ in relation to
quality of life and need of help. Archives of Gerontology and Geriat-
rics, 40, 85-102. doi:10.1016/j.archger.2004.06.001
Sullivan, D.H., Roberson, P.K., Smith, E.S., Price, J.A., & Bopp, M.M.
(2007). Effects of muscle strength training and megestrol acetate on
strength, muscle mass, and function in frail older people. Journal of
the American Geriatric Soc i e ty, 55, 20-28.
Taekema, D.G., Gussekloo, J., Maier, A.B., Westendorp, R.G.J., & De
Craen, A.J.M. (2010). Handgrip strength as a predictor of functional,
psychological and social health. A prospective population-based
study among the oldest old. Age and Ageing, 39, 331-337.
Tainaka, K., Takizawa, T., Katamoto, S., & Aoki, J. (2009). Six-year
prospective study of physical fitness and incidence of disability
among community-dwelling Japanese elderly women. Geriatric and
Gerontology International, 9, 21-28.
Topinkovà, E. (2008). Aging, disability and frailty. Annals of Nutrition
& Metabolism, 52, 6-11. doi:10.1159/000115340
van der Bij, A.K., Laurant, M.G.H., & Wensing, M. (2002). Effective-
ness of physical activity interventions for older adults. American
Journal of Preventive Medicine, 22, 120-133.
Vaillancourt, D.E., Larsson, L., & Newell, K. M. (2003). Effects of
aging on force variability, single motor unit discharge patterns, and
the structure of 10, 20, and 40 Hz EMG activity. Neurobiology of
Aging, 24, 25-35. doi:10.1016/S0197-4580(02)00014-3
Wilcox, S., Tudor-Locke, C.E., & Ainsworth, B.E. (2002). Physical
activity patterns, assessment, and motivation in older adults. In R. J.
Shephard (ed.), Gender, physical activity and aging (pp. 13-39).
Boca Raton: CRC Press.
World Health Organization (2002). Active ageing: A policy framework.
Ageing and Life Course Team, Non-Communicable Disease Preven-
tion and Health Promotion Department. Geneva: WHO.