Measuring physical activity levels

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Measuring physical activity levels is of increasing importance for clinicians. In the second in our major research series, we highlight a tool in the area of public health to do just this.

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Anatomy of a study

Physical activity is as important in old age as earlier in life. Staying active can help an older person maintain their ability to carry out the tasks for daily living. Researchers and practitioners are increasingly interested in assessing older people’s PA levels, particularly for use within falls prevention trials, but have stumbled on the lack of a suitable tool.

This study describes the development and testing of a simple, reliable and accurate telephone interview for assessing older adults’ PA. Phone-FITT was designed around the needs of older adults. It is short, simple and easily administered by telephone, and includes response options appropriate for older adults. It gives a score for the PA in household chores, another for recreational activity and a total score.

This is the sort of public health approach physiotherapists need to be engaging with ~ Bridget Hurley

In the questionnaire, household chores and short bouts of PA lasting one to 15 minutes come at the beginning, with the interviewee asked about their typical week in the last month. It then moves on to recreational and structured exercise such as walking or playing golf, and asks about the last year.

Phone-FITT measures the frequency, duration and intensity for each reported activity. Frequency was interrogated through open-ended questioning and duration by asking interviewees to pick from a list of four options.

Researchers decided not to use the conventional metabolic equivalent for measuring intensity, partly because it is less accurate in an older age group and also because it may be less relevant for outcomes such as falling where balance and muscle-strengthening activities are more important. Instead, they relied on a simple method based on the talk test, which measures a person’s ability to talk during exercise.

The raw data are then scored, giving a measure of the interviewee’s PA. In the study, it took between four and 19 minutes to complete the interview with an average of 10 minutes.

The study involved testing Phone-FITT for reliability and validity. In other words, would it produce consistent results and measure accurately an individual’s PA levels?

The researchers tested the reliability with 43 Canadian World War II and Korean War veterans and their caregivers living in the community who were recruited from a falls prevention study. They completed Phone-FITT twice with a week in between each time. The results showed the interview was reliable.

They tested validity with a group of 48 people aged over 70 from an exercise programme. When the two samples were compared, results indicated the Phone-FITT summary scores could discriminate between more and less active individuals.

The researchers conclude this study provides preliminary evidence for the reliability and validity of the Phone-FITT, which was designed to assess PA in community-dwelling older adults, across the full range of functional independence. It could be useful for quickly and easily identifying older adults who might benefi t from increased PA; for examining trends in PA in population-based studies; for identifying correlations between PA and changes in outcomes, and determining whether an intervention successfully increases PA levels.

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What does it tell us?

Older people are the biggest users of health and social care services and with around a third of adult life now lived after the age of 65, UK governments are focusing on ‘active ageing’ and pushing for individuals of all ages to increase physical activity in order to maintain independent living and well-being.

Fact file

Research: Phone-FITT – a new telephone-based physical activity assessment tool.

Lead investigator: Dawn Gill, senior fellow at the National Alzheimer’s Coordinating Center, Department of Epidemiology, University of Washington.

Publication: To view the publication, you need to login to the site.

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Physiotherapists are experts in enabling physical activity for the prevention and rehabilitation of disease, injury and movement dysfunction. This study highlights a key tool, which physiotherapists can utilise to provide reliable and valid assessments of physical activity levels of the older adult population, something that has been lacking in clinical practice. The recent government push for increasing physical activity levels focuses on the need to build activity into everyday life and to acknowledge less structured ways of achieving recommended levels for older adults of 30 minutes, fi ve times a week. The

Phone-FITT does just that by including assessment of household chores as a contribution to daily physical activity levels.

Tailoring a questionnaire to the patient population is essential to collect relevant and meaningful data, and involving input from your local older adult population will help to maximise the effectiveness of this tool.

Though not established yet in the Phone-FITT, normal values and standardised categories of physical activity will develop as clinicians engage with this tool and collect baseline data from their patient population, which is useful for understanding individual or various population levels of physical activity.

This is the sort of public health approach physiotherapists need to be engaging with: assessing demographics of a defi ned population, understanding the inequalities that exist and designing services to address these in order to drive health improvement. This approach to understanding inequalities in populations is certainly the direction physiotherapists must engage with as the NHS and healthcare move towards a focus on prevention.

This research highlights the need for physiotherapists to be evaluating not only their physical activity assessments but also the effectiveness of the exercise they prescribe as a result. Physical activity is a core pillar of physiotherapy and a core contribution to public health. Physiotherapists need to ensure they are maximising their capacity to contribute to improving the public health of the nation through physical activity prescription.

Bridget Hurley, CSP professional adviser (Move for Health project lead)

Clinician’s view: ‘This has value’

Bhanu Ramaswamy, left, is consultant physiotherapist at Derbyshire County primary care trust. She has admitting rights to a rehabilitation ward at Chesterfi eld’s Walton Community hospital. Her post is part funded by Sheffi eld Hallam University, making research, development and audit an integral part of her job.

She says: ‘At fi rst sight this looks like an exciting tool. If you think about a community rehab ward where patients are medically stable, then having something like this – that would give us an idea of what their physical activity levels were before admission – would be really useful.’ At present, physical activity levels are not measured with a tool such as Phone-FITT. Instead, patients are questioned as to their current activities and an effort is made to return to this, if appropriate.

Ms Ramaswamy sees other uses. ‘We could also use it to help people think about whether they are doing enough physical activity to keep themselves fit by doing follow up interviews six weeks or six months after discharge.’

While acknowledging the idea is exciting, she notes limitations with the study, saying: ‘It was very confusing to read and does not give any useful information about what scores to expect for different groups.’

Nevertheless, she is positive about its potential. ‘Realistically, I thought I would try it out on about fi ve people and get an idea of what it might achieve in practice. I like it as an idea and I think it has value.’

Reflections on research

The first thing Dawn Gill (pictured below) emphasises about this research is that it is in its infancy. ‘This is preliminary evidence in one sample,’ she says. ‘There are some things that will need to be taken into consideration when moving it to other samples.’

This in part stems from the way the study came about. Dr Gill was just starting her PhD looking into physical activity in older people. Her supervisor was running a study on falls prevention in older adults and needed a tool to measure PA. ‘We came up with the project from there,’ she says.

The strength of Phone-FITT is that it measures the low intensity activities that older people actually carry out, such as the household chores. ‘These are not usually captured in PA interviews,’ says Dr Gill.

The decision to make it telephone administered was purely pragmatic. The falls prevention study, to which it was linked, involved a fi nal follow-up telephone interview with the veterans and their caregivers.

‘This worked in our favour because the people involved knew us and knew the team and were happy with the telephone,’ says Dr Gill. Phone-FITT could be adapted for a face-to-face interview, she feels. ‘It might be possible in future to consider its use in other places such as the physician’s offi ce to quickly and easily identify someone who could benefi t from exercise on prescription.’

She cites two limitations. The fi rst was the research team’s failure to involve older people in the design (although their choice of which recreational activities to include was based on their frequency in population-based samples of older adults). This is something she would love to see take place if other researchers were to pick up and adapt Phone-FITT.

The other limitation is the tool’s ability to measure intensity. While the study showed Phone-FITT was good for measuring frequency and duration, the intensity measure ‘did not work out as planned’, says Dr Gill. ‘That’s something that needs to be further evaluated.’

Looking to the future, she would like to see more research, including whether the Phone-FITT can detect changes in PA and to see whether it can be used with frailer groups of older people. ‘We tested the validity of the Phone-FITT with very active older people. I think it has the potential to be used with a frailer population, such as to examine physical activity in older adults with Alzheimer’s disease.’

Another important question for clinical research to address is whether or not the Phone-FITT is acceptable for use in a clinical setting. In addition, Dr Gill says, ‘It will be important for population researchers to obtain population norms, as this would give clinicians an idea of their client’s PA level relative to others within the same age group.’

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Clinician’s view: ‘Useful... but further work needed’

Ruth Redhead, left, is falls prevention service team lead for Hammersmith and Fulham in London. She is employed by Imperial College healthcare trust but works in the community. Her client group has an average age of 82.

She says: ‘The main way to reduce people’s risk of falling is to improve their strength and balance through exercises. Increasing physical activity if at all possible helps Spotlight on research people to stay fi t and well.

It taps into newer thoughts and ideas and things you might wish
Ruth Redhead

At present, she does not use any measures specifi c to physical activity and describes Phone-FITT as ‘potentially interesting’, noting that ‘it taps into newer thoughts and ideas and things you might potentially wish to measure’. Ms Redhead says: ‘In principle a tool to measure physical activity may be useful, if the agreed aim of therapy is to affect activity levels: with some clients this may be one of our aims.’ She adds: ‘Perhaps something like this could also be used in areas such as cardiac or pulmonary rehab.’

However, she is unsure whether she could use it at the current time for two reasons. ‘From a research perspective, it is being used in large population groups to monitor trends or to look at the correlations between physical activity and quality of life. I wonder how useful it would be at the individual level I work at?’ She also questions whether, on a clinical level, an accelerometer would be more useful, or an activity diary or simple goal attainment. Her other concern is around how culturally specific it is.

‘I work in an urban area with a diverse cultural population and diverse socioeconomic conditions. I am not sure how many 80-year-old Afro-Caribbean women play golf. Would it simply demoralise people to be asked about gardening?’

Overall, she sees the tool as perhaps being more useful for large research studies than for clinical practice.

Research into practice

  • try it out with a few patients. Even without normal data with which to compare, it will still provide information about patients’ physical activity levels
  • repeat the measurement at a follow-up to see if Would it be benefi cial to measure physical activity levels in your client group? If so, these tips should help their activity level has changed
  • adapt for your own needs. Work with patients to identify appropriate activities, and adjust questions as necessary
  • telephone or face-to-face? Phone-FITT was developed as a telephone interview tool, but it is easily usable for face-to-face interviews. Which would suit your client group?
  • look out for more research using this tool

Further information

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This text on this page was last updated on 21 Oct 2008.