Life Begins at Forty!

Life Begins at Forty!

Key Words 85 Exercise, elderly, physiotherapy, health education, health promotion. Life Begins at Forty! by Naomi Carter Marie-Luce O’Driscoll Shou...

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Key Words 85 Exercise, elderly, physiotherapy, health education, health promotion.

Life Begins at Forty!

by Naomi Carter Marie-Luce O’Driscoll

Should the route to promoting exercise in elderly people also start in their forties?

Summary Exercise has many health benefits, including reducing cholesterol levels, reducing obesity, improving cardiovascular function, reducing the risks of coronary heart disease, improving muscle endurance and flexibility, reducing risk of injury and osteoporosis, and preserving function and mobility. In addition, it preserves reaction times and neurological functioning and can improve self-esteem and reduce depression and stress. The cost of managing the world’s health is rising as the global population ages. The UK Department of Health report The Health of the Nation (1993) suggests one way of reducing health-related costs, through specifically addressing the problem of falls and injuries of the elderly. Because exercise has the capacity to reduce falls, fractures, accidents and some medical conditions, and thus helps to avoid hospitalisation and associated institutionalisation, this paper suggests that an education and exercise promotion campaign may provide a means to this end. There are strong arguments in favour of targeting such an exercise campaign at the 40- to 50-year-old age group. It would maintain people’s exercise capacity as they age (Shephard, 1987), it would help to reduce falls and morbidity in later years, and bestow enhanced recovery from accidents and illness (Bird, 1992). Ultimately it would offer a means of achieving a reduction in the associated health costs of ageing described above. This paper offers the suggestion that physiotherapists have a role to play in developing and delivering such a health promotion campaign; encouraging people to find convenient, enjoyable, and varied exercise within safe programmes of activity.

Carter, N and O’Driscoll, M-L (2000). ‘Life begins at forty! Should the route to promoting exercise in elderly people also start in their forties?’ Physiotherapy, 86, 2, 85-93.

Introduction The world’s elderly population, defined as 65 years of age and over, is currently growing at a rate of 2.5% per year, faster than the overall total population (Suzman et al, 1992). Within this diverse group of people, individuals may be diagnosed as frail. Frailty is defined as the state of reduced physiologic reser ve associated with an increased susceptibility to functional decline and disability (Buchner and Wagner, 1992). Functional decline and the impairment of mobility increase the risk of falls, fractures

and functional dependency (Fiatarone et al, 1990). Fall-related injuries and loss of independence mean that a rapidly ageing population poses an enormous economic and social burden upon society. Identifying a means of decreasing frailty and prolonging independence makes sound economic sense in the current UK climate of financial constraint, particularly within healthcare (Chandler and Hadley, 1996). Government policy documents have identified this as an area to target in order that the health cost burden may be contained or reduced (DoH, 1993, 1998). Bortz (1982) suggested that a proportion of the changes that are commonly attributed to ageing are in reality caused by physical inactivity and, as such, can be reversed with exercise. Exercise is a very important factor in promoting long life and good health and is often under-estimated or ignored. Individuals who have engaged in regular physical activity throughout their lives tend to maintain a higher level of function and experience less decline in functional status (Rikli, 1986). It is postulated that exercise introduced to inactive individuals may slow or halt many of the changes associated with ageing. This premise begs the development of a national exercise campaign as a means of promoting health. However, in considering this some fundamental questions must be addressed. At whom should such an exercise campaign be targeted in order to ensure maximum health cost savings in exchange for the costs of the campaign? Would an exercise scheme targeting an elderly population prove economical or would it be dogged by poor motivation and adherence? If such a campaign were developed who should most appropriately do this, co-ordinate it, and deliver it? This paper aims to highlight the health Physiotherapy February 2000/vol 86/no 2


benefits of exercise and the associated potential health cost savings. It will explore why an exercise promotion package might best be targeted at 40- to 50-year-olds rather than older people. It will consider appropriate exercise prescription, and present the role that might be taken by physiotherapists in such a campaign. Finally, it will briefly state ways in which such an exercise campaign might be funded and implemented. Why Bother to Exercise? Exercise has been shown to have numerous health benefits (Pert, 1997). The benefits of exercise to the whole population, irrespective of age, include reducing the risk of cardiopulmonary problems, improving cardiovascular function, and strengthening the musculoskeletal system (Pert, 1997). Exercise is also linked with improving psychological well-being (RCP, 1991). Regular aerobic exercise is thought to promote a great increase in life expectancy as it helps preserve neurological functioning or enhance it in those who have been sedentary (Foley and Gregg, 1994). Key Benefits of Exercise for Older People Staying active appears to help minimise some of the problems of ageing which include increased body fat, reduced muscular strength and flexibility, loss of bone mass, lower metabolic rate and slower reaction times (Foley and Gregg, 1994). However, the benefits gained from an exercise programme depend upon the nature and amount of exercise undertaken, as will be discussed later. It is suggested that an exercise promotion package aimed at an ageing population may produce benefits in six broad areas: ■ Maintaining well-being. ■ Reducing the risk of falls ■ Preserving functional ability. ■ Reducing the risk of fractures. * The 'Exercise on Prescription' schemes are part of the national promotional campaign led by the Health Education Authority. It is a physical activity strategy to enhance the nation's health, whereby doctors prescribe exercise as part of treatment to help avoid heart disease, strokes and mental issues.

■ Reducing medical problems. ■ Saving healthcare costs.

Maintaining Well-being Exercise is postulated to prevent or slow down intellectual decline (Spirduso, 1975). It is thought to enhance mood, memory and psychological function and also to reduce stress and depression, all of which are important for maintaining well-being and

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health (RCP, 1991). This is particularly the case when exercise is undertaken in groups. For example, the majority of the ‘Exercise on Prescription’ schemes* show that just being a member of a scheme has a wide range of positive social and psychological effects (Riddoch et al, 1998). It is thought that group cohesiveness exerts a positive therapeutic influence upon attendance, participation and the impact of an exercise programme upon individuals (Yalom, 1975). It is believed that such group activities are beneficial in mental illness through reducing social isolation and improving self-confidence (PATF, 1995). ‘Exercise on Prescription’ programmes have been found particularly effective for anxious or depressed individuals and for those who report ill health, but in whom no illness can be detected (Riddoch et al, 1998). Reducing the Risk of Falls Insufficient exercise is associated with weak muscles, poor balance and gait, as well as accelerated bone loss (NIH, 1996). These are key risk factors accountable for falls in elderly people. It has been estimated that approximately half of older adults hospitalised for fall-related injuries are ultimately discharged to nursing homes (Sattin et al, 1990) and so the costs of falls, to society and the health ser vice, are substantial. It has been shown that exercise offers potential benefits in reducing the risk of falls (NIH, 1996) by improving balance, strength and flexibility (Province et al, 1995; Rikli and Edwards, 1991). Exercise has been seen to increase muscle strength and endurance (Pert, 1997; Fiatarone et al, 1990), and tendon strength and flexibility (Pert, 1997), and to reduce static sway (Judge et al, 1993). Where these benefits of exercise are reaped, so falls may be prevented and subsequent hospitalisation avoided (Shephard, 1987). The psychological benefits of exercise may also contribute to a reduction in the risk of falls in older people. There is a significant association between falls and the use of hypnotic and antidepressant drugs (Blake et al, 1988). If exercise helps to reduce depression and stress, as previously suggested, fewer drugs may be taken and falls may be less frequent. Preserving Functional Ability As has been described, compromised exercise tolerance and functional ability in older people can increase the risk of falls. It

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can also decrease the ability to get up after a fall, making individuals fearful of falling and so reluctant to mobilise. This may contribute to a spiral of physical, functional and social decline through reducing activity, limiting social interaction and constraining activities of daily living (Walker and Howland, 1991). This loss of functional ability and independence may culminate in hospitalisation or institutionalisation (Tinetti et al, 1993). Exercise may help to restore people’s confidence in their ability to move about safely and get up after falls. It can help reduce the physiological and psychological changes due to inactivity. Ultimately exercise offers a means of retaining or restoring sufficient fitness, physically and mentally, to enable everyday tasks to be done comfortably, easily and efficiently (Bortz, 1982; Fentem et al, 1988). Reducing the Risk of Fractures Exercise has been shown to decrease the risk of bony injury (Pert, 1997). It is suggested that exercise can reduce the risk of osteoporosis (Pert, 1997), possibly even reversing the process (McArdle et al, 1991; Dargie and Grant, 1991). This in turn may reduce the number of fractures when falls do occur. It has been suggested that regular exercise may reduce the risk of fractures by as much as half, thereby preventing some 20,000 hip fractures each year (Law et al, 1991). Reducing Medical Problems A loss of physical endurance may lead to the development of medical complications requiring costly healthcare. Exercise has been shown to prevent common conditions experienced in old age, such as non-insulindependent diabetes mellitus, peripheral vascular disease, hypertension and ischaemic heart disease (Young and Dinan, 1994). Additionally, the benefits of regular exercise include dramatically reducing the risk of coronary heart disease, reducing blood pressure (Duncan et al, 1985), and helping to lower cholesterol levels (Heath et al, 1983). It is also possible to facilitate weight control due to changes in metabolic functioning, thus also helping to reduce obesity and obesity-related disease (Pert, 1997). Providing Health Cost Savings The reduced morbidity from medical conditions, accidents, falls and fractures


associated with exercise may result in healthcare cost savings. Where exercise results in maintained or recovered function and reduced need for medication, further savings are possible (Brechue and Pollock, 1996). It is estimated that the health benefits and consequent cost savings would become evident soon after exercise programmes are implemented for middle-aged people, and much more than offset the costs due to injury from exercise (Nicholl et al, 1994). Why Promote Exercise for 40- to 50-year-olds? There has been a shift of emphasis in healthcare policy away from responding to illness towards preventing the onset of illness by actively promoting lifestyle changes, including regular physical exercise (Nicholl et al, 1994). Such policy changes are supported by findings that primary health education directed at ‘healthy’ people has been shown to help prevent health problems from arising (Ewles and Simnett, 1995). If we educate adults in their 40s then there is a chance that we can prevent some of the common conditions experienced in old age, which we have described in the previous section. It is possible that an improved quality of life and a small extension of lifespan may be gained through pursuit of an endurance exercise programme started at or before the age of 40. This suggestion is supported by research in rats where exercise before the age of 400 days, corresponding to about 40 years in humans, was shown to have these health gains (Shephard, 1987). Additionally, Shephard (1987) discovered that when middle-aged men trained regularly, the usual 10-15% decline in exercise capacity and aerobic fitness was forestalled. These active men maintained the same values for blood pressure, body mass and maximum VO2 as men of 45. It has been suggested that individuals who exercise regularly in midlife may regain functional ability more quickly following hospitalisation (Bird, 1992). This additional benefit of exercise is particularly significant in the current climate of ever-shortening periods of time available for rehabilitation following acute admissions (Smith et al, 1995). Psychologically there may be advantages to targeting exercise programmes at individuals in their middle years. It is postulated that when people reach the age of 40 years, they are hit by the powerful images of morbidity

Authors Naomi Carter MCSP BSc is a junior physiotherapist at Selly Oak Hospital, Birmingham. This article was developed from part of her final year coursework towards her degree. Marie-Luce O’Driscoll BSc GradDipPhys MCSP is a lecturer in physiotherapy at the University of East Anglia. She edited and advised throughout the development of this work for publication.

Address for Correspondence Miss N Carter Physiotherapy Department Selly Oak Hospital Raddlebarn Road Selly Oak Birmingham West Midlands B29 6JD.

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and mortality through experiences and the media. Facing physical ailments for the first time, such as the first experiences of low back pain; facing physical inadequacies -- for instance seeing their children display greater strength, speed or stamina than their parents; and watching previously healthy parents advance into old age, are all experiences which may coincide with the outset of the fifth decade. Added to this cocktail, individuals are bombarded with images from the media where energy and youth are portrayed as glamorous and desirable. There are relatively few positive role models for the over-40s, and where they do exist they are usually inextricably bound up with trying to appear and behave in a youthful manner. Consequently the fifth decade is often one in which people choose to consider their future, re-evaluating their lives, health and habits. In the ‘Exercise on Prescription’ schemes the studies that targeted participants in an appropriate state of readiness to change have had the most encouraging results (Riddoch et al, 1998). It therefore seems ideal to promote exercise to this age group, harnessing the fear of ageing to achieve a positive end. Furthermore it has been suggested that younger people may be more enthusiastic to learn and less resistant to change of habit than elderly individuals (Simpson and Mandelstam, 1995). The experiences of Chandler and Hadley (1996) substantiate such a suggestion; they found that exercise programmes for frail subjects suffered from poor recruitment and large drop-out rates. Consequently it may be more cost-effective to channel resources into a campaign aimed at younger people, when recruitment, retention and impact upon individuals can be expected to be greater. The financial arguments for targeting the 40- to 50-year-old age group are also convincing. Shephard (1987) states that an employee fitness programme improved perceived health to the point that individual workers were using about 0.5 fewer hospital bed-days per year and making fewer visits to their doctors. It is estimated that 187 million working days are lost every year in the UK due to sickness, resulting in a £12 billion tax on business (DoH, 1998). In addition to the health cost savings to be made through improving the health of an ageing population, targeting exercise programmes at a pre-retirement population may also affect statistics regarding lost work. Physiotherapy February 2000/vol 86/no 2

Campaign Issues Adherence to Exercise Adherence to exercise programmes is notoriously poor. There is a typical drop-out rate from exercise programmes of around 50% within six months of starting, possibly due to lack of motivation, time and convenience (Robison and Rogers, 1994). However, long-term participation in exercise programmes is essential to obtain the associated health benefits (ACSM, 1990) and ways of promoting this need to be investigated (NIH, 1996). It has been postulated that images of morbidity and mortality perceived in the fifth decade may contribute to exercise uptake and adherence, but these alone may not be enough. Within the ‘Exercise on Prescription’ schemes other factors have been identified which may improve adherence. These include easy access to facilities, a wide variety of settings, supportive and safe non-‘sporty’ environments, flexibility of activities such as homebased or lifestyle-based exercises, low-cost alternatives, promotion by the media, family support, extrinsic motivational techniques such as mileage allowances for cycling to work, counselling, super vision and monitoring by exercise specialists, and individual exercise programmes tailored to each patient’s needs (Riddoch et al, 1998). The latter point was also emphasised by Thomas (1995) who believed that interaction with a healthcare professional helped increase compliance levels by providing a realistic and enthusiastic role model. The ‘Exercise on Prescription’ schemes showed that an important motivating factor for some patients was having an ‘expert’ on hand (Riddoch et al, 1998). What Type of Exercise? It has been recommended that the emphasis for a sedentary population should be upon developing the habit of regular physical activity (ACSM, 1986). Generally, it has been recommended that people should exercise three times a week (Verdery, 1997; Thomas, 1995; ACSM, 1990) with a minimum of 20-30 minutes aerobic activity (Thomas, 1995; ACSM, 1990). However, the proposal from The Health of the Nation (DoH, 1993) and recent research (Riddoch et al, 1998; PATF, 1995) is to encourage people to build up to taking 30 minutes of moderate activity a day, five days a week. The intensity of exercise prescribed

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should be dictated by the person participating. An initial stress test can be used to ascertain the level of exercise a client can safely undertake (Finlayson, 1997; Thomas, 1995). However, many authors believe it is preferable to use a lower exercise intensity (Thomas, 1995; Williams, 1994; ACSM, 1990). This is because higher intensities present a greater risk of musculoskeletal injury, can cause patients discomfort and, in some, may carry a greater cardiovascular risk (Williams, 1994). Moreover, a gentle exercise programme has been seen to be an important factor in maintaining adherence levels (Epstein et al, 1984). The American College of Sports Medicine (1990) believes that the intensity needs to be enough to produce an increase in heart rate, sweating and rate of respiration, which Thomas (1995) recommends is 50% of VO2 max. To achieve all-round fitness, strength training with resisted exercise should also be considered (Finlayson, 1997). Circuit training may be advantageous as it enables variety in modes of exercise, while exercising most large muscle groups (Finlayson, 1997). An exercise programme which increases muscle strength is correlated with improved function and independence (Verdery, 1997). Recent research has shown that intervention which uses balancing exercises, strength training and low impact aerobic exercises appears to be the most promising at reducing the risk of falls (NIH, 1996). However, there is also some evidence to suggest that short bursts of high intensity activity such as brisk walking or stair climbing can be equally beneficial, provided they are repeated several times a day (PATF, 1995; Shephard, 1992; Fletcher et al, 1990). Indeed, Kerr (1999) suggests that partaking in physical activity which already forms part of normal daily life, such as walking to the next bus stop or using the stairs, provides an individualised approach requiring less of a major change in behaviour and is therefore more likely to be maintained over time. Paley (1997) states that improvements in aerobic capacity could be achieved by simple brisk walking programmes because walking can improve cardiovascular fitness, lower extremity strength and joint mobility (Walker and Howland, 1991). Worcester et al (1993), who prescribed twice weekly formal exercises with daily walking on the remaining days, also support this. A variety of exercise is also a crucial aspect to staying fit, as it helps reduce the monotony of exercise, while increasing the


number of muscle groups being worked. Familiarity with a variety of exercises is also important when illness or injury interfere with exercise participation. Exercising may then be sustained by substituting the usual activity for another familiar one, for example swimming instead of running when recovering from running injuries (Buchner and Wagner, 1992). While we have stated that the long-term cost savings associated with exercise far outweigh the costs of sports-related injuries which might be sustained, it still remains important that this group of people be educated to warm-up and cool-down correctly when exercising to reduce the risk of sports-related injury. Overcoming Barriers to Exercise Some of the personal or intrinsic barriers to exercise were identified earlier and it was indicated that professionals might contribute significantly in enabling individuals to overcome these. If success is to be achieved in the long term, however, multiple levels of intervention are required. These interventions need to be organisational, environmental and societal as well as personal (PATF, 1995; Robison and Rogers, 1994; Yoshida et al, 1988). It is important to help overcome barriers, which include ageism and views about what is appropriate activity for later life. Lack of facilities, lack of transport, limited financial resources, and lack of knowledge about alternative forms of effective exercise all need to be addressed (O’Brien and Vertinsky, 1991). However, it must be acknowledged from the start that even if all these problems can be overcome no campaign will achieve unified attendance and satisfy all participants (Riddoch et al, 1998). Possible strategies to promote long-term exercising include: ■ Marketing the exercise campaign through

the media – newspapers, billboards, advertisements on public transport, Internet and magazines. Television can be used to promote exercises through commercials and editorial and dedicated programmes. ■ National and local government subsidy of

transport to leisure centres and crèche facilities. Priority for funding of increased lighting in parks, more cycle paths, possibly even consideration of funding Physiotherapy February 2000/vol 86/no 2


more radical schemes such as cycling allowances. Central government finance to support community schemes and fitness awards for local communities or districts. ■ Drawing upon the experience and work

of the ‘Exercise on Prescription’ schemes, it is important that a variety of physical activities is available to the community, catering for many tastes. A structured exercise programme for independent performance should be defined at initial intrerview, with follow-up dates, group classes, ideas of how to exercise at home, community walks, cycle rides, local dances, etc. ■ Leisure centres should offer incentives to

exercise such as reduced prices and promotional packages to encourage adherence, for example 10 hours of physical activity giving entitlement to half an hour of massage without charge, or one free swimming session. ■ Professionals such as physiotherapists in

the workplace promoting a more active lifestyle to those working in a sedentary environment, using simple strategies such as encouraging them to use the stairs, walk to the corner shop or possibly cycle to work, as well as offering to hold exercise classes in the workplace to address motivation and time barriers (Pert, 1997). ■ Educational leaflets and videos in doctors’

surgeries in association with local physiotherapists, offering talks or introduction to exercise groups within the surgery. Evaluation of these and other strategies is essential before it is possible to identify the most successful and cost-effective means of promoting exercise and adherence to exercise in the long term. A cohort study is also needed to ensure that exercise uptake will be maintained in people reaching their 50s and 60s after an exercise promotional and educational campaign in their 40s to 50s. Are Physiotherapists Most Appropriate? The ‘More People, More Active, More Often’ paper (PATF, 1995) suggests that health professionals should develop their role in promoting physical activity. It seems Physiotherapy February 2000/vol 86/no 2

that physiotherapists are appropriately skilled and ideally suited to taking on such activities. We have identified that professional involvement in exercise schemes may improve adherence to exercise. Physiotherapists recognise the physical and psychological benefits of exercise and are well versed in the art of motivating people. The results from exercise programmes have demonstrated that when design and delivery are firmly rooted in physiological and psychological theory the outcomes are better (Pert, 1997; Riddoch et al, 1998). Physiotherapists operate out of a strong theoretical base, and understand the importance of communicating this to their clients. They are skilled at calling upon this knowledge to tailor exercise appropriately to a cross-section of people with diverse health needs in group and one-to-one settings. Dislike of sport, fear of injury and lack of experience of enjoyment in exercise may all be intrinsic barriers to participation in exercise. Wills and Campbell (1992) believe that people should be given guidance to overcome their perceived barriers to exercise and be encouraged to set their own goals. Physiotherapists are highly skilled in motivating patients in healthcare settings, taking a holistic view of the individuals they meet and involving their clients in setting goals for treatment. Such skills would be easily transferred to exercise programmes for healthy adults. Furthermore, physiotherapists involved in such programmes would then be ideally placed to advise upon and treat any musculoskeletal injuries should they arise during the course of exercise, as well as giving advice on footwear and exercise activities outside the class. In summary, from the evidence above, it seems that physiotherapists would be highly appropriate professionals to educate individuals, construct safe and effective exercise programmes, and within these encourage ‘enjoyment, independence, personal choice and individual effort’ which have been identified as important to adherence (PATF, 1995). Nevertheless, while physiotherapists may be the ideal professionals to lead exercise programmes in such a campaign, it is recognised that long-term success will depend on a wide coordinated multilevel approach (PATF, 1995). Physiotherapists will therefore need to be part of a team of players to include administrators, assistants, occupational health professionals, dieticians and

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potentially psychologists. Good communication between local GPs and the team would lead to a two-way stream of effective referrals. Members of the team could also support each other in providing measurements of health improvement, which are valid and objective. These are essential to encourage continued involvement from individuals and funding from government (Riddoch et al, 1998). In addition to involvement in the field it is suggested that physiotherapists at a professional level are well placed to be involved in developing, launching and coordinating a national exercise campaign aimed at promoting health in the workplace and the community. To some extent rudimentary steps have been taken in this direction; the Chartered Society of Physiotherapy has recently been consulted to evaluate existing referral schemes for the ‘Exercise on Prescription’ programmes and help create safe and effective new ones (Tonkin, 1999). The current funding of physiotherapy in the National Health Service is directed towards the treatment of pathophysiological problems. Little support is provided for health education other than the advice given alongside treatment. This financial arrangement prevents physiotherapists from developing their role as promoters of health. Unfortunately this short-term view means that the existing physiotherapy workforce will continue to be stretched, treating many conditions that might otherwise be prevented. Furthermore, while occupied in this way, the workforce and future physiotherapists in training will continue to view their primary role as one which addresses and rehabilitates specific pathologies rather than one of promoting health and preventing pathologies. Kerr (1999) states: ‘Too often it seems that we are concerned only with the specific problems which have necessitated physiotherapy, and ignore the total health picture.’ However, Kerr then goes on to say that ‘perhaps we do not see ourselves as having a role in promoting health-related activity. But who is in a better position, and indeed better qualified to do this than physiotherapists?’ If this cycle of events described above is to be altered, a change in central funding policy is necessary. For such policy changes to occur a long-term view of the nation’s health, straddling the term of office for any particular government, is essential.


Funding Health Cost Savings An exercise campaign aimed at decreasing the long-term health costs associated with ageing would need funds to market, resource and administer it. Funds might be raised from government, private and public sector employers, and individuals themselves. However, the difficulty of funding a campaign such as this is that outcomes are hard to measure because they are prospective over a long term. Riddoch et al (1998) point out that this necessitates patience, long-sightedness and a degree of vision on the part of government and organisations who find themselves required to bear the greater proportion of the funding burden. The motivation of raising funds at government level would be to satisfy the aspirations laid out in The Health of the Nation (DoH, 1993) and in the long term achieve a reduction in the health bill for an ageing population. At organisational level incentive for contributing to such a scheme may be derived from the potential to reduce the number of days of work lost through ill health. Whether such incentives are sufficient can only remain to be seen. The best hope of strengthening the case for funding a national exercise campaign remains the running of evaluated smaller schemes regionally. Conclusion An aim of The Health of the Nation (DoH, 1993) is to reduce accidents and falls among elderly people to help reduce health-related costs. One possible way to achieve this is through primary education and targeting adults before they reach old age. Exercise is a key behaviour that promotes good health and fitness. If adults in their 40s and 50s started to exercise, the vicious circle of decline which results from inactivity, reduced flexibility and strength might be prevented. Realistic individualised exercise programmes could encourage independence, strengthen the muscles and bones, and develop body awareness and balance skills. Physiotherapists could assume the leading role in educating and initiating this exercise campaign which might build a future of improved function, and reduce accidents and health-related costs for the growing elderly population.

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Key Messages ■ Exercise can help improve your health. ■ The health benefits of exercise could help to reduce health-related costs and satisfy the aims and objectives of The Health of the Nation (1993). ■ The cost of managing the nation's health is rising as the population ages.

■ Targeting an exercise campaign at the 40- to 50-year-old age group could be both beneficial for the individual and good for the nation's health and wealth. ■ Physiotherapists' unique training and skill mean we are ideally placed to co-ordinate and encourage an effective exercise campaign.

Physiotherapy February 2000/vol 86/no 2