A 12-week pilot project on physical activity was introduced in a day habilitation setting to a group of 12 older adults with intellectual disability and a variety of physical and behavioral conditions. Our purpose was to determine whether (a) this intervention would positively impact physical function in this population, (b) consumers would choose to participate in physical activity sessions, and (c) day habilitation staff could sustain this program beyond the intervention period. Findings indicate that 92% of participants experienced improvement in at least one domain of physical function, physical activity sessions remained a popular activity choice for consumers, and many participants sustained functional gains 1 year after habilitation staff assumed responsibility for sessions.
Our purpose in conducting this pilot project was to develop and implement a physical activity intervention in a day habilitation setting for older adults with intellectual disability in an effort to introduce physical activity and choice of a movement-oriented activity. Our rationale for this project was based on factors that are actively shaping the provision of care to individuals with developmental disabilities as well as the predisposition toward deconditioning that is increasing in this population as it ages. The first factor is the trend toward person-directed or person-centered care, models in which the needs and preferences of clients are beginning to form the basis of care plans. Another factor is the increasing longevity of individuals with developmental disabilities (Janicki, Dalton, Henderson, & Davidson, 1999). These individuals are now living beyond their “work” years, and they are encountering medical illnesses often associated with aging. A third factor is the pervasive trend toward consumer choice. The push toward assuming personal responsibility for one's own well-being, together with the ability of the individual with developmental disabilities to retire, more available leisure time, and the introduction of more lifestyle choices were catalysts for development of this project.
One of the greatest risk factors or loss of conditioning is overweight status. Overweight status/ obesity is a major problem for at least one third of the population without disabilities. Overweight status is defined as a Body Max Index (BMI) of 25 to 29.9 kg/m2; obesity is defined as a BMI of over 30 kg/m2 (Pi-Sunyer et al., 1995). The documented rates among populations of children and adults with intellectual disabilities (Eichstaedt & Lavay, 1992) and those with Down syndrome (Rubin, Rimmer, Chicoine, Braddock, & McGuire, 1998), however, are even higher. In a recent health survey conducted in New York State, Janicki and coworkers documented that the average BMI of adults with intellectual disabilities over the age of 40 living in group homes is 28.9 kg/m2 (Janicki et al., 2002). There is evidence that type of residence also influences overweight status/obesity rates. Individuals with Down syndrome living in a family setting, for example, have an even higher incidence than those living in group homes (Rubin et al., 1998).
Overweight status/obesity is related to many health-related and social problems in the general population, including higher risks of developing specific diseases, poor self-image, and difficulty with job placement and retention. This status confers risk for osteoarthritis of the knee, gall bladder disease, obstructive sleep apnea, and certain forms of cancer (U.S. Preventative Services Task Force, 1996) and is highly linked to coronary heart disease, the leading cause of mortality in the United States. Several overweight status/obesity-related disorders that increase coronary heart disease risk, such as type 2 diabetes and hypertension, are also causes of noncoronary heart-disease-related morbidity and mortality (Eckel, 1997; Kraus, Winston, Fletcher, & Grundy, 1998; Pi-Sunyer, 1999). Although more research needs to be conducted, researchers have described the relationship between overweight status/obesity and specific coronary heart disease risk factors in several populations of adults with intellectual disabilities (Beange, McElduff, & Baker, 1995; Draheim, McCubbin, & Williams, 2002). Robertson et al. (2002) stated that increasing physical activity is the most effective single intervention to improve the health status of a population of adults with intellectual disabilities. Aside from medical and social consequences, overweight status/obesity can be detrimental to daily life in that it levies adverse consequences in physical function. Individuals who have overweight status/ obesity commonly avoid physical activities and choose sedentary activities for their leisure time. Participation in physical activity is often short-lived because individuals with developmental disabilities frequently experience negative emotions and feelings of “I can't” and tend to slow down or stop because of discomfort (Wehman et al., 1982). The result may be deconditioning, a reversible and multisystem physical condition that has the potential to cause difficulties with ambulation and mobility as well as the performance of self-care, vocational/ habilitative, and leisure activities (Bottomley, 1994).
Many researchers have demonstrated, however, that interventions focusing on lifestyle and environment can yield positive outcomes in terms of weight reduction and increased physical fitness. This was found to be true for adults with severe or profound mental retardation, whether they lived in the community or in institutional settings (Tomporowski & Ellis, 1985; Tomporowski & Jameson, 1985). In addition, Heath and Fentem (1997) reported that increased physical activity was positively associated with prevention of disease, promotion of health, and maintenance of functional independence, and Santiago, Coyle, and Kinney (1993) reported that such activity promoted fitness and prevented secondary conditions in adults with physical disabilities. A few researchers have also found that individuals with developmental disabilities can be taught to carry out structured exercises (Croce & Horvat, 1992; Rimmer & Kelly, 1991; Suomi, 1992). With appropriate training, people with Down syndrome can achieve levels of motor performance similar to those described in the literature for individuals who are neurologically normal (Almeida, Corcos, & Latash, 1994). There is ample research to support the claim that exercise is beneficial for individuals with intellectual disabilities and other developmental disabilities (Croce & Horvat, 1992; Rimmer & Kelly, 1991; Tomporowski & Ellis, 1984; Tomporowski & Jameson, 1985) and that individuals in this population have the capacity to improve their physical fitness through structured exercise programs. Gains have been documented in reducing overweight status and in increasing cardiovascular fitness as well as muscular strength and endurance (Reid, Montgomery, & Seidl, 1985; Rimmer & Kelly, 1991). Fernhall (1993) published a comprehensive review of research on physical fitness programs in persons with intellectual disabilities.
Finally, this intervention is consistent with a couple of key recommendations made by the Aging Special Interest Research Group of the International Association for the Scientific Study of Intellectual Disabilities (Evenhuis, Henderson, Beange, Lennon, & Chicoine, 2000). One such recommendation is that people with intellectual disabilities, and their caregivers, receive appropriate and ongoing education regarding healthy living practices in areas such as nutrition, exercise, oral hygiene, and safety practices. A related recommendation suggests that people with intellectual disabilities should receive the same array of lifespan preventative health practices as those offered to the general population.
In this project we addressed the following research questions: Will a 12-week physical activity program that is focused on balance, mobility and gait, and strength and flexibility result in improved physical function for older adults with intellectual disabilities? Will consumers in a day habilitation setting choose to participate in this activity over time? Is it possible to sustain this program with day habilitation staff once the intervention is complete and the fitness trainers leave the setting?
This study was conducted at a day habilitation center in Rochester, New York, that serves older adults with intellectual disabilities. Research staff and fitness trainers worked closely with day habilitation staff to identify participants for the project. Criteria included ability to obtain consent either through the consumer or a proxy, medical stability, behavioral stability, sufficient sensory capabilities, and a minimum capacity for voluntary arm movements. Of the day habilitation population of 47 individuals, 15 were eligible for participation. They are described in Table 1. The reasons for ineligibility for the remaining 32 consumers (68%) are as follows: 12 were noncooperative (25.5%), consent was denied for 12 (25.5%), 4 had poor physical health (8.5%), and 4 (8.5%) were excluded for other reasons
This protocol was reviewed and approved by a university-based Institutional Review Board, by the regional Developmental Disabilities Service Office's Institutional Review Board, and by the administrative staff of the local day habilitation center. Approval was also obtained for the script that the research staff planned to use to obtain assent of participants at the time of participation in the baseline evaluation. This project was deemed to be one of minimal risk by all three entities. A letter describing the project was sent by the day habilitation administrator to the family members and guardians of each of the 14 potential subjects who were not able to provide consent, and proxy consents were obtained on their behalf. Only 1 subject was able to give informed consent on her own behalf. Risks and benefits were explained in great detail. The consent form provided assurance that participants would at no time be touched or manipulated by the investigators and that participants would initiate all activity.
Although standard fitness measures were used to assess performance of physical function, we modified a number of the tools for use with this population. The criteria for choosing the field fitness tests were based on the following considerations: The test (a) was accepted in the field of fitness professionals, (b) provided the ability to measure physical function, (c) was valid and reliable, (d) was appropriate for the intellectual and physical abilities of the participants, and (e) was not cost prohibitive. Because the fitness trainers and the tasks were not familiar to the consumers, the trainers spent 3 weeks at the site prior to the baseline evaluation getting to know the individuals, their physical limitations, their styles of communication, and their comfort levels with new things, new people, and other consumers. They were encouraged to try the fitness challenges prior to the baseline assessment. The measures included the following:
This test was adapted from the American Alliance for Health, Physical Education, Recreation & Dance (AAHPERD) Field Test (Osness et al., 1990). The elbow flexor test is measured by the number of times a weight can be raised from an extended elbow position to a flexed elbow position in 30 seconds. Women used a 4-pound weight and men used an 8-pound weight. To prevent shoulder involvement, participants were asked to squeeze a small stuffed animal with their upper arm against their side. Because this test measures the muscular strength of the elbow flexor muscles, having the participant immobilize the shoulder controlled all shoulder muscular involvement. Participants were instructed to squeeze their upper arm against the rib cage by hugging the stuffed animal, thereby allowing elbow extension without shoulder movement. The recorded measure was the number of repetitions completed in 30 seconds using the dominant arm.
This test was adapted from the Williams-Greene Test of Physical and Motor Function (Williams & Greene, 1990). Participants were told to sit in a chair. On the “go” signal, they were asked to move to an upright standing position with hands on hips. The score is the number of times the participant reached a standing position within 30 seconds. The score was the average of three trials.
Range of motion—shoulder
For this task, the investigators covered a round wooden tabletop, 1.22 m in diameter, with felt. Velcro strips were placed throughout the felt across the entire surface. The tabletop was secured in a vertical position so that the surface resembled a wall. A chair was placed in a specific location next to the felt-covered surface (i.e., participants sat parallel to the tabletop). Investigators asked the participants to sit in the chair, reach up, and place a small, sponge ball at the highest location possible. A goniometer was used to measure the degrees of motion at the shoulder joint for flexion, and the final score was the average of three trials.
Range of motion—hip
A string with bells attached was stretched between two upright poles. The poles were calibrated to measure degrees of motion from the hip joint. Participants were asked to lift their leg to “ring” a bell. The string was raised in uniform increments after each successful trial. Trials continued until the participant caught on to the task, after which three trials were repeated. The final score was the average of three trials.
Mobility and gait
This measure was also based on the Williams-Greene Test of Physical and Motor Function. Participants were asked to walk 3.1 m on a 0.30 m straight path, which was made of wood boards secured to the floor for safety. The participants were requested to begin on the signal “go,” and they were encouraged to use a natural gait. Time was recorded to the nearest 0.1 second, and the final score represented the average time for three trials.
We employed a pretest–posttest study design. The 12-week intervention was designed to meet several goals. First, the sessions were developed based on American College of Sports Medicine's (1995) standards for group exercise classes, namely, to include components such as warm-ups, aerobic exercise, and a cool down. Second, the program was structured to meet the Surgeon General's guidelines (U.S. Department of Health and Human Services, 1996) for 30 minutes of physical activity per day, and the trainers strived to achieve this goal within each 45-minute session. The sessions were scheduled 4 days per week. A wide variety of factors influenced the selection of activities within these sessions, including the broad range of cognitive abilities among the participants; fear of the unknown and the challenge of change; safety issues; variability in learning times, medical issues, tolerance for interpersonal contact, communication abilities, ability to be self-directed, and cognitive levels; creation of a perception of “fun” as opposed to “work” or a “test”; space constraints; and cost. Each session consisted of the following four segments:
Warm-up activities included stretching, gross-motor movement, dancing, and games.
The physical movement segment included dancing, ball and parachute games, and balance activities. The trainers strived to get the participants to engage in weight-bearing aerobic activities for 3 to 4 minutes per set for three sets. The ball used in this activity was a jingle ball with a 0.56 m diameter. Other weight-bearing activities incorporated into this segment included games of sit-and-stand, marching, side-stepping, and walking in place—forward and backward; dancing; and pass the ball with feet and hands.
Strength training was focused on upper body. This segment included weights of 0.91, 1.36, or 1.81 kg either hand-held or secured to forearm area. Participants were encouraged to carry out one set of 5 repetitions, which was increased as tolerated to a maximum of 2 sets of 10 repetitions. Strength training focused on lower body included weights of 0.91, 1.13, or 1.36 kg. Weights were secured either to the ankle or held on the thigh, and participants were encouraged to carry out 3 sets of 5 repetitions. In addition, participants performed seated leg extensions and hip flexion exercises. For upper and lower body-strength training, the trainers encouraged independent activity.
Closing activities included stretching and gait and balance training.
The fitness trainers administered the same physical function assessments at the end of the 12-week intervention and then again after 1 year. The 1-year follow-up was not originally planned, so the day habilitation staff carrying out the physical activity program to that point was not aware that the participants would be evaluated once again.
The primary analysis was based on an aggregate difference score, combining several measured dimensions. This score was computed for each subject in an effort to maximize the power of detecting an overall effect while avoiding multiple comparisons issues, in light of the small sample size. This approach also allowed us to utilize data from every subject, even if some measurements were missing for a few participants; in such cases, the differences for the missing dimensions were conservatively set to zero. The score was calculated as follows.
where ROM (range of motion) was the average of left and right shoulder and left and right hip (in degrees); mobility and gait was converted from number of seconds to walk 3.66 m to a rate (no. of mm per second), prior to differencing; lower body rate converted number of chair rises per 30 seconds to number of chair rises per minute; upper body rate converted number of bicep curls per 30 seconds to number of bicep curls per minute.
This score was computed for the 12 participants who completed the initial 12-week intervention. Three of the original 15 participants were dropped from the analysis for the following reasons: 1 was hospitalized due to unrelated medical problems, 1 was not able to participate in a group setting due to behavioral problems, and 1 had stopped attending the day habilitation program.
Did Participants Improve in Performance of Physical Function After 12 Weeks?
We used Wilcoxon's signed rank test to evaluate the significance of the observed aggregate difference score, comparing baseline measures to those following the 12-week intervention. The median difference score was 8.43, 2-tailed p = .0015. Of the 12 participants, 11 (92%) improved, as measured by the aggregate difference score. The change in median scores between baseline and posttest measures was 2.3 times higher for males than females, although this change was not statistically significant. Similarly, there was a slight positive correlation between improvement in aggregate scores and IQ, but there was no age effect.
A descriptive profile of group performance on individual parameters of physical function is presented in Table 2. This table contains median scores as well as the first and third quartile for each measure at baseline, at the time of the 12-week posttest, and at the 1-year posttest. If a subject was missing left hip range of motion, it was imputed by his or her right hip range of motion; similarly, for shoulder range of motion, if a subject did not complete the mobility and gait test, his or her time was assumed to be longer than those who did. Table 3 contains the quartiles of change scores for each of the physical function measures between baseline and the 12-week posttest and between baseline and the 1-year posttest.
During the initial 12-week intervention period, a majority of study participants improved in each dimension of physical function. In upper body strength, the median change for the 12 participants was 8.5 bicep curls per minute; 10 participants improved and the performance of 1 subject declined. For lower body strength, the median change was 1.5 sit-to-stand repetitions per minute; 9 participants improved on the order of between 1 and 7 repetitions, 1 subject experienced a decrease of 2 repetitions, and 1 experienced no change in performance. The range of motion in the left shoulder improved in the aggregate by 20 degrees. Ten participants improved in the range of 4 to 73 degrees, and 2 lost minimal range of motion, with losses of 1 and 5 degrees. Changes in range of motion for the right shoulder were similar. Taken together, the group of participants improved by 14 degrees, with improvements ranging from 3 to 62 degrees. Nine participants improved, 2 lost minimal range of motion of 2 and 5 degrees, and 1 subject experienced no change. Mobility and gait is the only measure in which a reduction in scores represents an improvement. The aggregate mean change was 0.79 seconds. Of the 10 individuals who participated in pre- and posttest measures, 8 improved between 0.5 and 10.6 seconds and 2 lost speed by 0.6 and 2.1 seconds. Of all the physical function measures tested, the fewest participants improved in range of motion in the hip joints. In the left hip, the group improved by 2 degrees. Of the 12 participants, 7 improved by 4 to 43 degrees, and 4 lost range of motion between 3 and 23 degrees. Similarly, the range of motion in the right hip improved in the aggregate by 1 degree; 7 participants improved between 2 and 39 degrees, and 4 lost between 4 and 46 degrees. Mean scores and standard deviations (SDs) for each performance task are presented in Table 4.
Table 5 shows a comparison of weights for the 12 study subjects from the baseline assessment to the 12-week follow-up to the 1-year follow-up. Because baseline weight was not available for 1 of the subjects, the pre–post comparison could only be calculated for 11 of them. Between baseline and 12 weeks, 4 participants lost weight and 7 gained weight. The mean change in weight for this period of time was a gain of 0.68 kg (SD = 1.93). Between baseline and 1 year, again 4 participants lost weight and 7 gained weight. The mean change in weight for this period of time was a gain of 2.99 kg (SD =10.46).
Consumer participation in physical activity sessions
Of the 15 individuals who participated in the initial 12-week intervention, 12 (80%) were still participating at the time of the 1-year posttest. The mean attendance rate for the 12-week session was 75%; data on attendance were not collected formally after the conclusion of the intervention period.
The intervention was based on the premise that by allowing the consumers the ability to choose their level of participation, the physical activity would become a self-motivating activity. The participants were to a great extent self-selected; that is, those who indicated a desire to participate and those on whose behalf we were able to obtain consent were included in the study. This intervention was developed in concert with the World Health Organization's Inclusion International Principles, in which self-determination and self-advocacy, residential options, and recreation and leisure rights are paramount (Evenhuis et al., 2000).
During the intervention, participants chose their level of participation. In fact, participants were allowed to decide on a daily basis whether and to what extent they wanted to participate. We found that, for the most part, participation reflected the physical capacity of each person. On a few occasions, a participant did not feel like doing all the activities, whereupon they were encouraged to watch and join in at any point. At no point were they forced to take part nor were they manipulated (physically manipulated or touched in any way). Appropriate exercise-spotting and limb-patterning were done to ensure proper execution of strength training and to ensure safety and efficiency for the exercise movement. During the intervention, “leaders” and “friends” became the motivators for participation. Investigators used the relationships between the participants to encourage full involvement. The leaders often helped by counting out the number of repetitions, demonstrating how to perform an exercise, or being the first to practice a skill. At the end of each session, the participant signed their name, made a mark, or received a paper that represented their participation for the day. The cognitive level of the individual determined which type of log was used. Participants would share their logs and experiences with their homeroom friends. Eventually, other consumers became interested in becoming part of the intervention because of the positive experiences the participants were able to convey. Toward the end of the intervention, other consumers came to participate.
The biggest impact of the self-directed approach was realized after the intervention ended. The staff found that so many consumers wanted to join the exercise group that eventually three groups were formed to accommodate them all. In addition, they were rotated in and out of the exercise groups each month to allow all interested individuals to take part. The program staff re-evaluates the program groups each month based upon consumer interest, individual summary plans, and staff observations.
After 1 year we repeated the analysis, this time comparing the baseline scores with scores following 1 year of participation in the activity program. The median difference score of 10.78, 2-tailed p = .002, was strong evidence that the improvement after 12 weeks was not transient. Further analyses indicated no observable relationship between performance of physical function and IQ, gender, or age, although the small sample size limited the power of these secondary analyses.
The median aggregate 1-year posttest scores for each measure of physical function are presented in Table 2, and the median change scores for physical function performance between baseline and the 1-year posttest are presented in Table 3. After 1 year, many of the participants continued to improve in one or more aspects of physical function performance. For upper body strength, the group's score improved by 7.0 curls per minute. This represents an improvement of between 2 and 18 curls per minute for 8 participants, a decline of 2 curls per minute for 1 subject, and no change in score for 1 subject. In lower body strength, 10 participants experienced an improvement of 2.0 sit-to-stand repetitions per minute; 7 improved between 2 and 7 repetitions, 2 performed between 1 and 7 fewer repetitions, and 2 participants did not change. The greatest number of participants improved in shoulder range of motion. For the left shoulder, the group experienced an improvement of 20 degrees, with 9 participants showing improvement, no participants declining, and 2 showing no change. Improvement scores ranged from 2 to 83 degrees. In the right shoulder, the group experienced an improvement of 19 degrees. Again, 9 participants improved, and 2 experienced only minimal loss of motion of 2 and 4 degrees; improvements ranged between 2 and 38 degrees. Mobility and gait also improved for the group by 1.4 seconds: 7 participants improved between .3 and 10.4 seconds and 2 lost .9 and 1.0 seconds, respectively. As in the 12-week posttests, again, the greatest declines were found in hip range of motion scores. The aggregate mean score for the group for left hip range of motion improved by 23.0 degrees, representing an improvement for 7 participants and a decline in physical function for 3 participants; individual change scores for this measure ranged from −46 to 48 degrees. The aggregate improvement for the right hip range of motion was 27.0 degrees. Six participants experienced improvement between 16 and 61 degrees, and 4 participants lost range of motion in this joint by between 6 and 35 degrees.
The most remarkable outcome of this project is that it documented the feasibility of introducing physical activity to a group of older adults with intellectual disabilities and relatively severe cognitive and physical functional disabilities. The participants included individuals with profound and severe mental retardation. Of the 12 individuals enrolled at baseline, 5 were classified as having severe to profound; 1, moderate; 4, mild; and 2, borderline mental retardation. In addition, this study population included individuals with a multitude of characteristics that might have ordinarily excluded them from participation in a physical activity project. For example, only 4 of the 15 participants could ambulate independently, 7 were nonverbal, and 3 were visually impaired. Heretofore, individuals with these characteristics would not have been considered as potential research participants. Despite the medical, physical function, psychobehavioral and intellectual challenges this sample brought to the intervention site, each participant experienced improvement in some aspect of physical function. In this small pilot-study population, safe and inexpensive fitness interventions resulted in either the maintenance of physical function or a reversal of deconditioning.
The generalizability of both the findings and the experience of conducting this project was great. The project design was well-grounded in the realities and constraints that providers of service to developmentally disabled populations encounter. We carried out the intervention at a day habilitation site in small shared spaces, using simple, readily available equipment; participants were not transported to “ideal” settings. In addition, the intervention was inexpensive; the total cost of the equipment for this program was approximately $130. Furthermore, many of the gains in physical function that were attained following the 12-week intervention were, for the most part, sustained after 1 year of physical activity sessions conducted by the day habilitation staff. This evidence of “buy-in” by direct care staff is an additional positive element. The physical activity interventions were viewed as beneficial to consumers, enjoyable, and easy to implement. Because this methodology is easily reproducible, we have begun to develop a train-the-trainer curriculum for staff working throughout the developmental disabilities field.
Another positive feature of this project was our use of widely accepted standards in the fitness industry. We adapted standardized, validated fitness measures designed to measure physical function for use in this special population and incorporated the Surgeon General's physical activity guidelines for older adults into the sessions.
Without question, the most limiting factor of this research is that inherent in most pilot projects—the small sample size. The second greatest methodological limitation is the heterogeneity of this small group and its resultant variability, as illustrated by the large SDs and ranges associated with most of the measures of physical function. Aggregations of changes in mean scores tell us so little about the impact that this experience had on individual consumers. This is especially apparent for the measures of physical function, for which aggregate change scores hovered around zero (such as hip range of motion where the aggregate score did not reflect the actual changes in physical function that participants experienced). This reality suggests that a presentation of case studies might be more illustrative of the results that this project actually produced. An anecdote may bring this point to life. One consumer, who was not originally part of the intervention but who began exercising as a result of her own interest, is now walking within the building without her walker. Her participation in the exercise group has improved both her confidence and strength to the point that she feels comfortable ambulating without her walker. This is merely one of the many success stories that resulted from this project.
Another limitation of this project serves as an opportunity for the next step in this line of research. The outcome measures for this pilot project were limited to physical function, and the analysis focused on the extent to which these scores were either different from baseline or statistically significant. The extent to which statistical significance translated into clinical significance or improved quality of life was not addressed. Other dimensions worth more longitudinal investigation include changes in aerobic fitness, weight and weight-related comorbidities, sleep patterns, calorie intake, participation in and contributions to the life of the facility or the household, and socialization levels. Cost-effectiveness studies analyzing changes in health care utilization, prescription drug use, and use of assistive devices, for example, might also warrant investigation.
Perhaps the best characterization of the significance of this small pilot project is as a first step to infinite possibilities in a changing field, where aging, personal choice, personal responsibility, and wellness are being introduced to populations who have had limited opportunities to engage in health-promoting activities.
This research was funded, in part, with support from the University of Rochester Older Americans Independence Center (Rochester Area Pepper Center), Grant AG10643. The authors thank Amy Mitchell, Director of Day Services, Lifetime Assistance; Frank Moreland, Clinical Coordinator for Greece Day Treatment; Senior Moments; Senior Moments' staff and consumers.
Authors: Carol Ann Podgorski, PhD (email@example.com), Executive Director, and Karen Kessler, BS, CPT, Program Manager Education Services, Center for Lifetime Wellness, Monroe Community Hospital, University of Rochester Medical Center, 435 E. Henrietta Rd., Rochester, NY 14620. Barbara Cacia, BS, PO Box 16547, Rochester, NY 14616. Derick R. Peterson, PhD, Assistant Professor, University of Rochester Medical Center, Department of Biostatistics and Computational Biology, 601 Elmwood Ave., Rochester, NY 1464. C. Michael Henderson, MD, Assistant Professor, University of Rochester, Highland Hospital, 1000 South Ave., Rochester, NY 14620