86 • Therapeutic exercise, aging, and chronic illness
Physiological improvements and health benefits dur-
ing an exercise-based comprehensive rehabilitation
program in medically complex patients
Taro P. Smith, Ph.D.1, Sarah L. Kennedy, Ph.D.1, Marci Smith, M.S.2,
Sander Orent, M.D., and Monika Fleshner, Ph.D1.
1 Dept. of Integrative Physiology, University of Colorado at Boulder,
Boulder, CO 80309
2 Division of Kinesiology and Health, University of Wyoming, Laramie,
Running title: Therapeutic exercise, aging, and chronic illness
Objectives: To determine the effects of an exercise-based comprehensive rehabili-
tation program on the physiological, health, and cost benefit in medically com-
Design: Case series
Setting: Comprehensive rehabilitation centers.
Participants: Elderly chronically ill men (n = 39, age = 75.3 ± 1.4) and women
(n = 74, age = 76.5 ± 0.9 years)
Intervention: Patients participated in individualized physical therapy with thera-
peutic exercises (stretching, strengthening, endurance, balance, sitting and stand-
ing dynamic exercises) three times/week for three months under the supervision of
Measurements: Upper (back) and lower (leg flexors) extremity strength, aerobic
power as measured by metabolic equivalents (METS) at 80% of age predicted
maximal heart rate (APMHR), physical functioning and mental health as
assessed by the Short Form-36 (SF-36) questionnaire, and medical events (falls,
physician visits, and hospitalizations) questionnaire was collected at baseline and
after three months of the program.
Results: Strength measures improved by ~30% (Ρ < 0.05) as well as aerobic
power improved by ~25% (Ρ < 0.05) over the three-month period. There were
significant improvements in two of the SF-36 Physical Component Scales: Physi-
cal Functioning (P < 0.05) and Role Physical (P < 0.05); plus, there were signif-
icant improvements in all four of the Mental Component Scales: Vitality (P <
Address Correspondence to:
Monika Fleshner, Dept. of Integrative Physiology, Campus Box 354, University of Col-
orado at Boulder, Boulder, CO 80309, 303 492-1483 (Office), (Fax), fleshner@col-
0.05), Social Functioning (P < 0.05), Role Emotional (P < 0.05), and Mental
Health (P < 0.05). There were significant reductions in fall rate (P < 0.05), physi-
cian visits (P < 0.05), and hospitalizations (P < 0.05).
Conclusion: Patients improve physical capacity, which result in improvements in
health status with concurrent reductions in healthcare utilization during a com-
prehensive rehabilitation program. (Exerc. Immunol. Rev. 12, 2006: 86-96)
Key words: Exercise; rehabilitation; aging; chronic illness
The elderly population in the U.S. is growing rapidly and is currently estimat-
ed at ~35 million people over the age 65 . Increases in the aging population
pose some severe consequences. Eighty percent of people >65 years is living
with a chronic illness (e.g., Parkinson’s, balance deficits, chronic pain, coro-
nary artery disease, hypertension, diabetes, etc.) . The chronically ill popu-
lation suffers from decreased function, endurance, mental health, ability to
perform activities of daily living (ADL), independence, and balance, along
with an additional myriad of problems.
The increase in the elderly population, with its concurrent elevation in
chronic illness and pain and subsequent utilization of health services, will
result in an exponential increase of health care expenditures. For example, falls
are a foremost health care cost for the over 65 population, presumably due to
balance deficits and weakness associated with either aging or secondary to a
illness or disease state (e.g., stroke, Parkinson’s) . The high incidence of
injury from falls can be attributed in part to low bone mass in the elderly (high-
er occurrence of fractures)  and low muscle mass (since soft tissue can
attenuate fall impact); furthermore, greater than 90% of hip fractures may
result from falls . Other rising costs include the increased need for hospital-
izations, medications, and physician office visits. Therefore, it is important to
find ways to counter the decline in health status with advancing age.
The answer to these health problems may lie in the investigation of com-
prehensive rehabilitation programs that utilize active-based physical therapy
protocols involving therapeutic exercise. However, clinical programs, other
than cardiac and pulmonary rehabilitation and preventative programs, have
been slow to emerge as a standard treatment due to limitations in medical
direction and supervision to handle the complex medical problems that those
with chronic illnesses present. These patient populations need a carefully
planned exercise prescription with regular assessments to monitor modes and
intensities of work, medication interaction, disease interaction, and medical
events . Many older patients who have an orthopedic malady may have one
or more diagnoses of chronic illness. Of all the treatment options, such as hos-
pice care, medications, and surgical intervention, only active treatment options
address recovery in terms of function, overall medical status, and future pre-
Older adults who undergo regular physical training have marked
improvements in strength and aerobic power . Physically frail adults who
Therapeutic exercise, aging, and chronic illness • 87
are placed in a physical therapy program focus on improving strength improve
functional ability . Older people that exercise on a regular basis are more
resistant to chronic illness. As such, there are clear recommendations that the
elderly maintain regular physical activity to help offset functional decline and
offset risk for illness .
The association of mental health and chronic illness is a complex issue,
as medical conditions are a risk factor for mental disorders such as depression
and conversely depression is a risk factor for medical illness. For example,
frequency of negative emotions are a significant predictor of coronary heart
disease  and depressive symptoms are greater in patients with chronic ill-
ness . Physical exercise interventions may lead to improved mental health
in chronically ill patients, as evidenced by improved state anxiety scores in
cardiac rehabilitation patients  and improved mental health, as assessed by
the mental health inventory of the Short Form-36 (SF-36) health questionnaire,
in chronic low back patients following a 12 week cycle ergometry program
The evidence in the medical literature clearly indicates the utility of
active interventions in the chronically ill; furthermore, many patients are
afflicted with multiple diagnoses and orthopedic limitations. However, due to
the diverse complications with frail elderly, such as of falls, a multidisciplinary
team is necessary to address various areas such as gait training, strengthening,
and coordination . Therefore, the purpose of the present article is to
describe the changes in outcomes following a medically-directed comprehen-
sive rehabilitation program utilizing a team of physicians, physical therapists,
and exercise physiologists to supervise therapeutic exercises in medically com-
plex elderly patients. Specifically, our aim is to quantify the changes in both
mental and physiological outcomes. Strength and exercise workload, as they
relate to health status (physical functioning and mental health status), as meas-
ured by the Short Form – 36 questionnaire (SF-36), as well as changes in
health care utilization, as measured by fall rates, hospitalizations, and physi-
cian visits during the program.
The following protocol was approved by the Human Research Committee at
the University of Colorado - Boulder. Medical data from 113 chronically ill
elderly men (n = 39, age = 75.3 ± 1.4) and women (n = 74, age = 76.5 ± 0.9
years) were retrospectively analyzed for changes in response to therapy. Sub-
jects were diagnosed with three or more of the following: hypertension, coro-
nary artery disease (CAD), chronic obstructive pulmonary disease (COPD),
type II diabetes, muscle disuse/atrophy, severe deconditioning, osteoporosis,
gait abnormality, stroke, obesity, balance deficit, Parkinson’s Disease, degener-
ative joint disease, and/or orthopedic issue. Patients were living independently
either in their own home or in independent living communities. Each patient
met monthly with a medical doctor (M.D.) to ensure that the patient did not
have any serious changes in medical condition that would adversely affect the
patient during any therapeutic exercises. The M.D. would also screen for any
88 • Therapeutic exercise, aging, and chronic illness
contraindications to exercise that the patient might have, and give guidelines to
address any limitations to ensure patient safety.
All patients underwent three months of therapeutic exercise under the direction
of an M.D. and physical therapist, and under the daily direct supervision of the
medical doctor, physical therapist, and clinical exercise physiologist in a com-
prehensive rehabilitation center. The M.D. was available in case of medical
emergency and to provide general medical support. The physical therapist
would work with the patients who had an orthopedic barrier to perform the
therapeutic exercise program. The physiologist would monitor the patient’s
blood pressure, oxygen saturation, heart rate, and perceived exertion on a daily
basis. The physical therapists and physiologists would also monitor the thera-
peutic exercise progress and modify the daily intensity of the program as need-
ed, as well as monthly following physiological testing.
The subjects performed therapeutic exercises three times/week for 60 minutes per
session via a combination of cardiorespiratory equipment, strength equipment,
balance training, dynamic stabilization, and functional movements. Strength test-
ing on resistance machines were performed at baseline, then monthly, for the fol-
lowing body parts: knee extensors via leg extension, knee flexors via seated ham-
string curl, biceps via seated biceps machine, and back via lat pull down. Testing
consisted of a ten repetition maximum test where each patient would progressive-
ly have the load increased with each exercise until they could no longer complete
ten repetitions (reps) without break in proper biomechanics. Data were recorded
as weight in pounds for the ten repetitions.
On strengthening modalities (leg flexion, etc.) patients would complete
three sets of ten repetitions of each exercise at 70-90% of their ten-repetition
maximum. Patients were carefully directed to ensure that orthopedic limita-
tions were addressed during the program, as well as other guidelines to ensure
safety for other diagnoses (e.g. osteoporosis and hypertension). Functional
exercises included working with gym balls, balance activities, therapeutic
bands in attempt to increase function with activities of daily living.
All subjects performed work on either a treadmill or cycle ergometer two
to three times per week for three months to develop functional endurance and
balance. Testing was performed at baseline, repeated each month, and consist-
ed of a graded submaximal exercise to 80% of age predicted maximal heart
rate (APMHR) on treadmill; however, subjects with balance deficits or gait
abnormalities were tested on cycle ergometer. Cardiorespiratory fitness was
recorded in metabolic equivalents (METS) attained at 80% of APMHR. Daily
sessions would work subjects between 70-90% of their tested value. Exercise
intensity was increased as each testing session demonstrated improvement.
Assessment of physical functioning and mental health:
The SF-36 questionnaire is a widely used and previously validated  health
questionnaire and was utilized to assess physical functioning and mental
health. All subjects completed the SF-36 health questionnaire at baseline and
Therapeutic exercise, aging, and chronic illness • 89
repeated at three months. Forms contain 36 questions that consist of four cate-
gories pertaining to physical functioning and the remaining pertaining to men-
tal health. The forms were then scored using the standard SF-36 formula, with
0 being the lowest score and 100 being the best score for each category.
All patients completed a medical events questionnaire at the initial visit and at
three months. The number of hospitalizations, falls, and M.D. visits for the
prior three month period were recorded for each individual patient. Visits to
the M.D. or hospitalization for any reason was included (e.g., pre-planned vis-
its, procedures, etc.).
Strength and cardiorespiratory data were analyzed using repeated measures
ANOVA with gender as an independent variable (P < 0.05). Gender groups were
pooled for SF-36 and health care utilization analysis to increase the power for
subjective questionnaires and were analyzed using repeated measures ANOVA (P
Select subject characteristics are in
Table 1. No adverse events were
reported in subjects in conjunction
with this exercise program. Percent-
age of subjects with primary diag-
noses are presented in Table 2.
Both male and female subjects had a
significant increase in leg flexor
strength [F (1,110) =165.87; P <
0.0001; Fig. 1A] and back strength [F
(1,111)=108.54; P < 0.0001 Fig. 2A]
over time. There was a difference in
strength between men and women for
leg flexors [F (1,110) = 19.14; P <
0.0001) and back strength [F (1, 111)
=26.07; P < 0.0001].
90 • Therapeutic exercise, aging, and chronic illness
Diagnosis % of Patients
Coronary Artery Disease
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
Degenerative Joint Disease
Table 2. Subject Problem List
All subjects were diagnosed with a mini-
mum of three diagnoses
Age (years) Height (in)Weight (lbs)
Women (n = 74)
75.3 ± 1.4
76.5 ± 0.9
67.6 ± 0.3
62.9 ± 0.3
193.7 ± 8.6
157.0 ± 4.6
Table 1. Subject Characteristics
Mean ± Standard Error of Measurement (SEM)
Both male and female subjects had
significant increase in METs at 80%
of APMHR from baseline [F(1,99) =
96.96; P < 0.0001; Fig. 2]. However,
there were no differences between
men and women [F(1,99) = 0.0054; P
There was an improvement in two of
the physical components of the SF-36
questionnaire over time (Table 3):
Physical Functioning [F (1,107) =
6.84; P < 0.05] and Role Physical
[F(1,105) = 8.0035; P < 0.01]. How-
ever, there were no differences in
Bodily Pain [F(1,108) = 1.7410; P =
0.1898] and General Health [F(1,106)
= 0.7753; P = 0.3806].
There was an improvement in
all mental components of the SF-36
questionnaire over time: Mental
Health [F (1,105) = 4.8339; P <
0.05], Role Emotional [F(1,102) = 6.56; P < 0.05] Social Functioning
[F(1,107) = 12.3756; P < 0.001], and Vitality [F (1,105) = 12.5013; P < 0.001].
Therapeutic exercise, aging, and chronic illness • 91
Figure 1 Improvements in Leg Strength Both male and female patients had significant
improvements in lower (1A) and upper (1B) extremity strength over a three-month period.
*P < 0.05 compared to baseline.
Figure 2 Improvement in Workload Both
male and female patients had significant
improvements in workload attained at 80%
of APMHR over a three-month period. *P <
0.05 compared to baseline.
Figure 1 A
Figure 1 B
There were significant reductions in hospitalization rate [F (1, 94) = 4.1814; P
< 0.05; Fig. 3A], fall rate [F (1, 98) = 16.0353; P < 0.001; Fig. 3B], and physi-
cian visits [F (1, 90) = 13.3043; P < 0.001; Fig. 3C].
92 • Therapeutic exercise, aging, and chronic illness
Physical Component Scales:
Mental Component Scales:
Initial Month 3
41.4 ± 2.3
26.2 ± 3.3
55.7 ± 2.3
57.8 ± 1.8
45.7 ± 2.4*
34.5 ± 3.5*
58.1 ± 2.2
59.1 ± 1.8
43.2 ± 2.0
66.8 ± 2.6
59.2 ± 4.2
72.0 ± 1.7
49.3 ± 2.0*
75.2 ± 2.5*
69.1 ± 3.7*
75.2 ± 1.6*
Table 3. SF-36 Scores
Mean ± SEM. *Denotes signifi-
cantly different than baseline (P
Figure 3 A
Figure 3 B
Figure 3 C
Figure 3 Reduction of medical event
During the program, patients significantly
decreased the rate of hospitalizations (3A),
falls (3B), and physician office visits (3C)
as assessed by number of events over the
prior three-month period. *P < 0.05 com-
pared to baseline.
The present findings of this paper demonstrate marked improvements in
strength, workload, SF-36 measures (physical functioning and mental health),
and importantly a concurrent reduction in medical utilization and events. The
goal of this program was aimed at optimizing gains in function and health sta-
tus. Both cardiorespiratory and strengthening modes of exercise were utilized
since concurrent training optimizes many aspects of functional fitness .
Furthermore, therapeutic exercises, aimed at improving balance and function,
were also utilized.
The ~30% improvement in strength found in this patient population trans-
lates to improved functional capacity. Our results are in agreement with Fiatarone
et al.  who demonstrated that severe weakness in older adults is reversed
through exercise training over a ten-week period. This would indicate that frailty
is in part due to the muscle inactivity associated with chronic illness, pain, and/or
bedrest, and this frailty is treatable. Brown et al.  demonstrated that elderly
subjects who performed strengthening exercises for the elbow flexors had a sig-
nificant gain in muscle strength (48%) and muscle cross sectional area (30.2%),
demonstrating the ability for elders to overcome muscle atrophy. In addition, eld-
erly subjects improve treadmill endurance, dynamic strength, and peak cycle
workloads in a resistance training only program, indicating that improved
strength is a key factor for improving function.
The improvement in workload as measured by a ~25% increase in METs
in our patients may be functionally significant as others have demonstrated that
a 15% improvement in aerobic capacity is of functional importance . In
addition to increased workload, cardiorespiratory exercises lead to positive
adaptations in nervous and endocrine system regulation, metabolic and func-
tional economy, functional stability, and has anti-atherosclerotic effects .
Improvements in workload in these patients may be of further importance, as
achieved workload (METs) during exercise testing provides prognostic value
for predicting mortality in the elderly [22, 23].
The SF-36 questionnaire indicated that the patients had a concurrent
improvement in two out of four on the physical functioning and four out of
four on the mental health components. The SF-36 has been used extensively as
a quality of life measure to assess health [24, 25] and is an indicator of physi-
cal performance in older adults . As such, our results reinforce the self-per-
ception of health with these patients with actual objective improvements in
workloads attained during the intervention. Improvement in mental health or
psychological affect following the intervention is of particular importance in
the medically complex patient population as depressed mood state serves as a
predictor of strength decline in the elderly .
The reductions in fall, physician visits, and hospitalization rates in
response to the program may be significant. For example, fall-related injuries
result in an average of $19,440/fall in healthcare costs  and falls are now
the eighth leading cause of death in the elderly . The high susceptibility to
injury and mortality with falling may be attributed to decrements in strength.
Both muscle strength (grip strength)  and muscle mass (corrected arm
muscle area) , are important predictors of mortality in the elderly, as well
Therapeutic exercise, aging, and chronic illness • 93
as muscle strength serves as a predictor of mortality following a bone fracture
in older people . Others have been successful in reducing the risk of falling
with multidimensional exercise programs . While we did not measure the
risk of falling per se we did demonstrate a ~60% reduction in the rate of falls
during the program, presumably due to the improvement in strength in the
Clearly, the medical community supports the use of active interventions
to address the needs of the chronically ill population. For instance, clear guide-
lines are presented for both heart disease and cardiopulmonary disease by the
American Heart Association  and the American Thoracic Society/Ameri-
can College of Chest Physicians . The U.S. Preventive Task Force recom-
mends that high fall risk elderly patients receive multi-factorial interventions
where adequate resources are available . This is important, as it should be
noted that many of the chronically ill have multiple diagnoses including ortho-
pedic maladies; therefore, careful restrictions and goals must be outlined for
each individual patient to provide proper intervention prescription. In the pres-
ent study, a team of physicians, physical therapists, and clinical exercise phys-
iologists treated the patients to address the multiple problems presented.
The results of the current study apply previous research in individual chronic
disease states (e.g., heart disease, cancer, etc.) to a genuine clinical setting and
in a large number of medically complex (multiple diagnoses) patients. Strong
functional outcomes are imperative in the medically complex populations as
there is a robust relationship between functional health status and mortality
. Paffenbarger et al.  demonstrated that all-cause mortality was signifi-
cantly lower among physically active subjects, suggesting that physical activi-
ty is an important factor for longevity. The present study works to apply these
functional and exercise principles to chronically ill patients. In conclusion,
integrated therapy interventions that aim to increase the functional strength
and functional capacity result in an improvement in ability to perform activi-
ties of daily living, psychological state, and a reduction in health care utiliza-
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