Evidence

[Participant 1] I knew I was looking for something to help me because I felt I’d come to a standstill. 

[Participant 2] It’s very sociable, it’s just fun to come to. 

[Participant 3] It has helped and my knee don’t hurt so much. 

[Participant 4] I was okay, but I started to feel that climbing steps was a bit difficult for me. And I think it did help quite a lot, because now I look at steps and I have no fear of them. 

[Participant 5] I think if I didn’t have the exercises, I wouldn’t be so mobile as I am. 

[Participant 6] I’m very grateful to Steve, because he did say to me when we first started talking about this shoulder business, that it would be much better to exercise it than to go into surgery, which is what the medical people wanted. And my shoulder feels a lot stronger and much less painful. And I’ve told the surgeon that I don’t want to go ahead with the surgery, and why, and he said he thought it was an eminently sensible decision. So one up for exercise, Steve. [laughs]

[Steve – instructing the session] So we’re gonna go into a hill dig with a bicep curl, just tapping the heel in front, a little bend in your knees. 

[Steve – being interviewed] The format changes from week to week, but all focusing around whole body movements, balance and cardiovascular work. Just to try and give them a good variety of an exercise session. We normally start off with a warm-up, then we go on to the main section and then finish off with some stretching. And we then finish off with a cup of tea and a bit of cake. 

The ones the group are most challenged with are balance based work, so standing on one leg or walking in like a tightrope format. However, they have improved massively since we first started. Things like sit to stands as well, so getting out of a functional movement pattern like from a chair. That’s normally quite difficult for them, but as you can see today they’ve progressed quite a long way. Overall, I think as a group they’ve massively improved over the year that they’ve done it. 

[Participant 7] I have arthritis in my knees and when I left work two years ago I was walking with a stick in the wintertime. Now I don’t do that. I carry a folding stick for emergencies, but most of the time I walk unaided. 

[Participant 8] My general physical situation, that is all improved. Which enables me to do what I’m doing and continue doing it. 

[Participant 9] I had rheumatoid arthritis and I think the exercises help and keep me going. My kids all say ‘go for it mother’, you know, ‘keep going’. So yeah I think it’s very helpful. 

[Participant 10] I just wanted to know at my age what I can do, when you’re at the age of over 70s, what you can really do. So I started to exercise, walk first and then exercise, and then I found it easy to run. 

[Participant 11] It’s helped my balance a lot to what it was. And I just enjoy coming and having a chat, a bit of social too. I look forward to every week.

[Participant 12] I’m 88 years of age, just. And this has made a huge difference in my life. It’s very hard to find the reason for it. I think it’s the social thing, the feeling of being part of a group 

[Participant 13] We soon made friends amongst each other, and I think we’ve become quite close in our friendships now. 

[Participant 14] It does people good to have somewhere to go, meet people they’ve got to know quite well and have a good laugh. It all helps towards good health, I think. 

[Participant 9] Hopefully I can carry on walking, dancing and all those sorts of things. 

[Participant 13] I’m convinced that if I don’t keep going, I’ll go backwards and I don’t want that to happen. I think the aim of all of us is to keep us as healthy and mobile as we can. And we’re doing it in such a nice way. 

[Interviewer] And you’ll continue coming to these sessions? 

[Participant 5] Oh, so as long as they last and as long as I last. [laughs]

[Participant 1] I’m never going to be as I was then, I recognize that fact. But I’m jolly well going to be as fit as I can be.

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This is a plain English summary of an original research article

Regular group exercise sessions for older people led to improvements in their mobility, which were sustained even after the classes stopped. Research also found the sessions were cost-effective; they saved money compared to expected care costs if people remained less active.

Low levels of physical activity are linked with frailty in older people. But few people over 65 are as active as the NHS recommends. Many people in this age group have mobility problems, which reduce their quality of life.

Previous research has shown that regular physical activity improves mobility and the chances of living independently. However, the interventions used were often expensive and it was not known if benefits were sutained in the long-term.

In this study, researchers tested a less expensive, easy-to-implement 12 month programme aimed at changing health behaviours (REACT programme). People over 65 were offered regular group exercise classes which focused on strength, balance, mobility and cardiovascular fitness, and were intended to be fun, socially interactive, and to build a community. A comparison group received advice on healthy ageing. A year after the programme ended, researchers compared mobility levels between the exercise group and the advice group.

In Autumn 2022, the city of Bristol will be the first to roll-out the REACT programme. The research team is working with commissioners and service providers in order to make the programme available nationally. Researchers stress that meaningful health benefits can be achieved at any age, even among people with reduced mobility.

Further information on physical activity for older people is available on the NHS website.

What’s the issue?

Most people become less mobile as they age. Only 1 in 10 of those aged 65 and over are active for 150 minutes per week, as recommended by the NHS. People living in deprived areas are less active than others.

Almost half (44%) of this age group has some form of disability. Mobility problems are the most often reported and include difficulties in walking, balancing, and getting up from chairs. These problems reduce quality of life and contribute to high health and social care costs. They are linked with frailty and increase the chance of falling.

Previous research has shown that older people who are physically active remain healthy longer than their inactive peers. Regular physical activity improves strength, balance and flexibility and allows people to live independently for longer. It is linked with fewer hospital admissions.

Studies to date have tested interventions that were often difficult to maintain over the long-term, costly, and unlikely to be made widely available. This project explored more affordable solutions. The research team wanted to see if exercise sessions for older people improved their mobility a year after sessions were stopped.

What’s new?

The study included 777 people aged 65 years and older. They all had mobility difficulties that affected their everyday lives. Two-thirds (66%) were female, the average age was 78 years and most (95%) were White.

Participants were recruited from 35 primary care practices in England. One group (advice group) received 3 sessions of advice about healthy ageing, covering topics such as healthy eating, dealing with dementia, and volunteering. The advice did not refer to exercise.

The other (exercise) group received 12 months of regular group sessions. Charity or leisure centre staff delivered exercise sessions in the community to groups of up to 15. They personalised exercises according to each person’s abilities and encouraged socialising afterwards. This group was also offered sessions to build motivation, overcome barriers and maximise enjoyment. The sessions promoted exercise classes, home-based exercise, and active travel (such as walking). On average, people attended 2 in 3 (68%) of the planned sessions.

The researchers found that people in the exercise group:

  • were more mobile than those in the advice group at 24 months (a year after the sessions stopped), scoring 8.1 vs 7.6 on a scale that measures walking speed, balance and leg strength
  • self-reported that they were more mobile, more physically active, and doing more muscle-strengthening exercise than the advice group, at 6, 12 and 24 months after the sessions stopped
  • used less health and social care, saving £725 per person in 24 months, which was more than the cost of the programme (£622 per person); long-term savings could be higher.

The researchers concluded that the exercise intervention prevented the decline in mobility, and was cost-effective to deliver.

Why is this important?

The researchers say this is the first study to show long-lasting improvements in older people with reduced mobility. They found that the 12 month REACT programme improved mobility, and that improvements were sustained for 12 months after the sessions had stopped. Participants in the exercise group attended most sessions, which suggests that they enjoyed going.

Affordable, enjoyable group sessions with socialising afterwards could improve people’s willingness to attend. Some participants said the sessions improved their wellbeing and they looked for alternative classes when the intervention finished. One man said: "I was distraught when I lost my balance and couldn’t walk and I just thought well that’s it, but I made a comeback with REACT... it kick-started me again."

In the exercise group, improvements in mobility were small. They were only just above the threshold for improvement (defined at the beginning of the study). However, the researchers say that, among older adults who are frail or becoming frail, these small changes have been shown to be meaningful. In addition, those who attended the most exercise sessions (more than 75% sessions) had greater improvements than those attending fewer sessions.

What’s next?

In Autumn 2022, the REACT programme will be rolled out in Bristol for 12 months, as part of the Bristol, North Somerset, and South Gloucestershire Integrated Care System (ICS) Ageing Well Programme. The research team will evaluate its implementation and continue to engage with commissioners and service providers in the UK to identify ways of embedding the programme more widely.

The researchers are fine tuning the training programme for session leaders to ensure that the programme is routinely delivered in a standard way.

People from all ethnic groups showed similar improvements with the exercise interventions. However, most participants were White. The researchers aim to further test the programme to explore ways to engage people from diverse ethnic groups more successfully.

Finding people to take part in this study was challenging. The researchers are now exploring whether the scale used in this study to measure mobility could also be used to identify people who will benefit from the programme.

You may be interested to read

This Alert was based on: Stathi A, and others. Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (Retirement in Action) randomised controlled trial. Lancet Public Health 2022;7:e316-e326

The recruitment of participants to the REACT trial: Withall J, and others. The tribulations of trials: lessons learnt recruiting 777 older adults into REtirement in ACTion (REACT), a trial of a community, group-based active aging intervention targeting mobility disability. The Journals of Gerontology: Series A 2020;75:12

The cost-effectiveness of the REACT programme: Snowsill TM, and others. Cost-effectiveness of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: an economic evaluation of the REACT (Retirement in Action) trial. Lancet Public Health 2022;7:e327-e334.

A paper exploring the delivery of the REACT programme: Cross R, and others. Delivery fidelity of the REACT (REtirement in ACTion) physical activity and behaviour maintenance intervention for community dwelling older people with mobility limitations. BMC Public Health 2022;22:1112

To roll-out the REACT team in Bristol, the team is working with the charity Age UK Bristol and Bristol Health Partners Active Lives Integration Team, a collaboration between academics, clinicians, commissioners and members of the public.

The REtirement in ACTion (REACT) study: the featured video (above), in which participants discuss their experiences of the exercise classes.

REtirement in ACTion - programme: video in which the REACT researchers discuss the benefits of exercise for mobility.

REtirement in ACTion - results: a video explaining the main results of the REACT study.

Funding: This work was supported by the NIHR Public Health Research Programme. Two of the researchers were supported by the Oxford NIHR Biomedical Research Centre.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

Through the REACT study we have shown that the downward spiral of declining mobility that many people face as they get older is avoidable. It can be prevented, and in many cases reversed through an exercise programme that is individually tailored and progressive. At least one REACT exercise session per week seems sufficient to provide clinically meaningful benefits on mobility and it is highly cost-effective. This is a strong public health message to give to older adults, both in the UK and around the world.”

Afroditi Stathi, Professor of Physical Activity and Community Health, University of Birmingham 

Lived experience 

I have exercised intensely all my life. I have lost the use of my left side and use a wheelchair when I go out of the home. But I continue to exercise to maintain my mobility and to help fight the ageing process.

Most people talk the talk about exercise but don’t actually do it. The number of potential participants was much greater than the number who eventually took part. This reflects the population’s attitude to taking part in activity. Those who attend group sessions tend to be more motivated; even the control group in this study was attempting to do something.

Group and social activities promote competition, companionship and routine. These are important to all aspects of health. They encourage people to complete the programme and continue beyond. Those who engage meaningfully will benefit greatly.

I’d like to know whether the programme would be value for money if rolled out nationally.

Ian Prince, Public Contributor, Lincoln 

Clinician 

This thoughtful study could lead to better care and management of people with reduced mobility. The findings could influence system-wide approaches. They could also be incorporated into individual’s care management plans.

Karen Bowley, Senior Matron for Stroke and Neurology, Royal Wolverhampton NHS Trust 

Member of the public

I have worked with elderly people in a residential home. My concern is how the intervention would be delivered in the real world. The trainers delivering the programmes may not be as qualified as those in the study. People taking part probably would not receive the same amount of attention as the participants in the study. There might not be refreshments and socialising at the end of the session.

In the study itself, the intervention group received more input from trainers and researchers than the control group. Some in the intervention group might not have enjoyed the extensive testing but they probably benefited from it. People may have changed their behaviour because they were being observed.

Even so, the findings may promote suitable exercise programmes for older people.

Julian Ashton, Public Contributor, Abingdon, Oxon  

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