Objective: The aim of this study was to examine the effects of high weight loss on knee joint loads during walking in participants with knee osteoarthritis (OA).Design: Data were obtained from a subset of participants enrolled in the Arthritis, Diet, and Activity Promotion Trial (ADAPT). Complete baseline and 18-month follow-up data were obtained on 76 sedentary, overweight or obese older adults with radiographic knee OA. Three-dimensional gait analysis was used to calculate knee joint forces and moments. The cohort was divided into high (> 5%), low (< 5%), and no (0% or gain) weight loss groups.Results: From baseline body weight, the high weight loss group lost an average of 10.2%, the low weight loss group lost an average of 2.7%, and the no weight loss group gained 1.5%. Adjusted 18-month outcome data revealed lower maximum knee compressive forces with greater weight loss (P = 0.05). The difference in compressive forces between the high weight loss and no weight loss groups was due primarily to lower hamstring forces (P = 0.04). Quadriceps forces were similar between the groups at 18-month follow-up. There was no difference between the groups in 18-month joint space width or Kellgren Lawrence scores.Conclusions: These results suggest that a 10% weight loss in an overweight and obese osteoarthritic population elicits positive changes in the mechanical pathway to knee OA by having lower knee joint compressive loads during walking compared to low and no weight loss groups. The difference in compressive forces was due, in large part, to reductions in hamstring co-contraction during the initial portion of the stance phase. (C) 2010 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

OBJECTIVE:The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was a randomized, single-blind clinical trial lasting 18 months that was designed to determine whether long-term exercise and dietary weight loss are more effective, either separately or in combination, than usual care in improving physical function, pain, and mobility in older overweight and obese adults with knee osteoarthritis (OA).METHODS:Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older, with a body mass index of > or =28 kg/m(2), knee pain, radiographic evidence of knee OA, and self-reported physical disability, were randomized into healthy lifestyle (control), diet only, exercise only, and diet plus exercise groups. The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included weight loss, 6-minute walk distance, stair-climb time, WOMAC pain and stiffness scores, and joint space width.RESULTS:Of the 316 randomized participants, 252 (80%) completed the study. Adherence was as follows: for healthy lifestyle, 73%; for diet only, 72%; for exercise only, 60%; and for diet plus exercise, 64%. In the diet plus exercise group, significant improvements in self-reported physical function (P < 0.05), 6-minute walk distance (P < 0.05), stair-climb time (P < 0.05), and knee pain (P < 0.05) relative to the healthy lifestyle group were observed. In the exercise group, a significant improvement in the 6-minute walk distance (P < 0.05) was observed. The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures. The weight-loss groups lost significantly (P < 0.05) more body weight (for diet, 4.9%; for diet plus exercise, 5.7%) than did the healthy lifestyle group (1.2%). Finally, changes in joint space width were not different between the groups.CONCLUSION:The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone.

Osteoarthritis (OA) of the knee leads to restrictions of physical activity and ability to perform activities of daily living. Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability. The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was developed to test the efficacy of lifestyle behavioral changes on physical function, pain, and disability in obese, sedentary older adults with knee OA. This controlled trial randomized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups: Healthy Lifestyle Control; Dietary Weight Loss; Structured Exercise; or Combined Exercise and Dietary Weight Loss. The weight-loss goal for the diet groups was a 5% loss at 18 months. The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory. Exercise training consisted of aerobic and strength training for 60 minutes, three times per week in a group and home-based setting. The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index. Other measurements included timed stair climb, distance walked in 6 minutes, strength, gait, knee pain, health-related quality of life, knee radiographs, body weight, dietary intake, and cost-effectiveness of the interventions. We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks. The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA.

PURPOSE: The purpose of this study was to document changes in lower extremity strength and balance over a 30-month period in older adults with chronic knee pain, and to identify relationships among these variables that may prove useful in designing a subsequent clinical intervention trial. METHODS: The participants were a cohort of 480 adults over 65 years of age with chronic knee pain. Measurements included: 1) force platform dynamic balance measure of the center of pressure excursion during a forward and subsequent backward lean, 2) isokinetic strength measures of concentric and eccentric knee flexion and extension and concentric ankle plantar flexion and dorsiflexion, and 3) body mass index and a knee pain scale to measure obesity and knee pain, respectively. Strength and balance measures were standardized (Z scores) to compare different variables on the same scale. RESULTS: A maximum-likelihood analysis revealed an overall significant decline in standardized knee (baseline: .0568 ± .0280; 30 month: −.0766 ± .0372; p < .001) and ankle (baseline: .0209 ± .0270; 30-months: −.0968 ± .0486; p = .012) strength, and standardized balance (baseline: .5797 ± .0052; 30-month: .5459 ± .0063; p < 0.001) after a 30-month follow-up period. Participants with greater knee strength at baseline had less expected decline in balance at follow-up than their weaker counterparts (4.2% vs. 7.7% for the 75th versus 25th percentiles of strength; p = 0.023). The absolute decline in balance over 30 months was similar regardless of baseline ankle strength; however, those with greater baseline knee strength had a significantly smaller decline in balance. CONCLUSIONS: We conclude that adults age ≥ 65 yr. with chronic knee pain experience significant declines in balance and lower extremity strength over a 30-month period. This study presents a strong rationale for incorporating weight training into an exercise prescription for older adults with chronic knee pain. Funded by grants from the National Institutes of Health: R01AR42388, M01-RR00211

OBJECTIVES:To document changes in lower extremity strength and balance over a 30-month period in older adults with chronic knee pain, and to identify relationships among these variables that may prove useful in designing a subsequent clinical intervention trial. METHODS:This longitudinal, 30-month, observational study was designed to examine the association of physical, psychological, social, and environmental factors with severity and progression of physical disability caused by chronic knee pain. This article will focus on 2 physical measures: strength and dynamic balance. The participants were a cohort of 480 adults 65 years of age or older with chronic knee pain. Measurements included: 1) force platform dynamic balance measure of the center of pressure excursion during a forward and subsequent backward lean, 2) isokinetic strength measures of concentric and eccentric knee flexion and extension, and concentric ankle plantar flexion and dorsiflexion, and 3) body mass index and a knee pain scale to measure obesity and knee pain, respectively. RESULTS:A maximum-likelihood analysis revealed an overall significant decline in knee (P < 0.001) and ankle (P = 0.012) strength, and balance (P < 0.001) after a 30-month followup period. Participants with greater knee strength at baseline had less expected decline in balance at followup than their weaker counterparts (4.2% versus 7.7% for the 75th versus 25th percentiles of strength; P = 0.023). However, the absolute decline in balance over 30 months was similar regardless of baseline ankle strength. CONCLUSIONS:Adults age >or=65 years with chronic knee pain experience significant declines in balance and lower extremity strength over a 30-month period. Moreover, greater knee and ankle muscular strength is associated with better balance. Previous studies have shown that weight training is effective in improving balance in older adults with knee osteoarthritis. Taken together, these studies present a strong rationale for incorporating weight training into an exercise prescription for older adults with chronic knee pain.

OBJECTIVE: To examine the relationship between muscular strength and dynamic balance in a sample of older adults with knee pain and to determine the role that obesity and severity of knee pain play in the ability to maintain balance.DESIGN: Cross-sectional study designed to examine the association between strength and balance in a cohort of older adults with chronic knee pain.SETTING: A university health and exercise science center.PARTICIPANTS: A cohort of 480 adults age 65 and older with knee pain.MEASUREMENTS: Force platform dynamic balance measure of the center of pressure excursion during a forward and subsequent backward lean. Isokinetic strength measures of concentric and eccentric knee flexion and extension and concentric ankle plantar flexion and dorsiflexion. Body mass index (BMI) and a knee pain scale were used to measure obesity and knee pain, respectively.RESULTS: A regression model was developed to investigate the relationship between dynamic balance and muscular strength while controlling for gender, BMI, radiographic severity, knee pain, and foot length. Knee strength alone explained 18.4% of the variability in dynamic balance. The addition of knee pain, BMI, radiographic severity, gender, and foot length explained an additional 6.7%. When the knee-ankle interaction, ankle strength, and knee strength-pain interaction variables were added to the regression model, 28.9% of the variability in dynamic balance was explained.CONCLUSIONS: Strength appears to play a significant role in maintaining balance in an older, osteoarthritic population. We found that mean knee strength accounted for approximately 19% of the variability in dynamic balance. Hence, greater knee strength was associated with better dynamic balance. The best dynamic balance performances occurred in participants that had a combination of strong knees and strong ankles. However, knee osteoarthritic patients with weak knee strength could still maintain high levels of dynamic balance by having strong ankle strength. Moreover, we have shown that obesity is associated with attenuated dynamic balance performance and that poorer balance is associated with higher pain scores in the presence of weaker knees. For stronger knees, however, pain does not appear to be related to balance.

OBJECTIVE: The purposes of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis, and to compare the effects of exercise plus dietary therapy with exercise alone on gait, strength, knee pain, biomarkers of cartilage degradation, and physical function.DESIGN: Single‐blind, two‐arm, randomized clinical trial conducted for 24 weeks.SETTING: A university health and exercise science center.PARTICIPANTS: Twenty‐four community‐dwelling obese older adults aged ≥ 60 years, body mass index ≥ 28, knee pain, radiographic evidence of knee osteoarthritis, and self‐reported physical disability.INTERVENTION: Randomization into two groups: exercise and diet (E&D) and exercise alone (E). Exercise consisted of a combined weight training and walking program for 1 hour three times per week. The dietary intervention included weekly sessions with a nutritionist utilizing cognitive‐behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb (6.8 kg) over 6 months.MEASUREMENTS: All measurements were conducted at baseline and 3 and 6 months, except for synovial fluid analysis, which was obtained only at baseline and 6 months. In addition, weight was measured weekly in the E&D group. Physical disability and knee pain were measured by self‐report and physical performance was measured using the 6‐minute walk and stair climb tasks. Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing. Synovial fluid was analyzed for levels of total proteoglycan, keratan sulfate, and interleukin‐1 β.RESULTS: Twenty‐one of the 24 participants completed the study, with one dropout in the E&D group and two in the E group. The E&D group lost a mean of 18.8 lb (8.5 kg) at 6 months compared with 4.0 lb (1.8 kg) in the E group (P = .01). Significant improvements were noted in both groups in self‐reported disability and knee pain intensity and frequency as well as in physical performance measures. However, no statistical differences were found between the two groups at 6 months in knee pain scores or self‐reported performance measures of physical function. There was no difference in knee strength between the groups, with both groups showing modest improvements from baseline to 6 months. At 6 months, the E&D group had a significantly greater loading rate (P = .03) and maximum braking force (P = .01) during gait. There were no significant between‐group differences in the other biomechanical measures. Synovial fluid samples were obtainable at both baseline and 6 months in eight participants (four per group). The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 ± 37.1 to 71.5 ± 23 ng/μg total proteoglycan. The level of IL‐1 decreased from 25.3 ± 9.8 at baseline to 8.3 ± 6.1 pg/mL. The decrease in IL‐1 correlated with the change in pain frequency (r = –0.77, P = .043).CONCLUSIONS: Weight loss can be achieved and sustained over a 6‐month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention. Both exercise and combined weight loss and exercise regimens lead to improvements in pain, disability, and performance. Moreover, the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone. A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population.

OBJECTIVES:To examine the effects of 18-month aerobic walking and strength training programs on static postural stability among older adults with knee osteoarthritis. DESIGN:Randomized, single-blind, clinical trial of therapeutic exercise. SETTING:Both center-based (university) and home-based. PARTICIPANTS:A cohort of 103 older adults (age = 60 years) with knee osteoarthritis who were participants in a large (n = 439) clinical trial and who were randomly assigned to undergo biomechanical testing. INTERVENTION:An 18-month center- (3 months) and home-based (15 months) therapeutic exercise program. The subjects were randomized to one of three treatment arms: (1) aerobic walking; (2) health education control; or (3) weight training. MEASUREMENTS:Force platform static balance measures of average length (Rm) of the center of pressure (COP), average velocity (Vel) of the COP, elliptical area (Ae) of the COP, and balance time (T). Measures were made under four conditions: eyes open, double- and single-leg stances and eyes closed, double- and single-leg stances. RESULTS:In the eyes closed, double-leg stance condition, both the aerobic and weight training groups demonstrated significantly better sway measures relative to the health education group. The aerobic group also demonstrated better balance in the eyes open, single-leg stance condition. CONCLUSIONS:Our results suggest that long-term weight training and aerobic walking programs significantly improve postural sway in older, osteoarthritic adults, thereby decreasing the likelihood of larger postural sway disturbances relative to a control group.

OBJECTIVES: To examine the effect of diet and exercise-induced weight loss on bone mineral density in overweight postmenopausal women.DESIGN: A I-year prospective, randomized clinical trial.SETTING: Two university medical school research centers.PARTICIPANTS: Sixty-seven overweight postmenopausal women, a subset of the women who participated in the Trial of Nonpharmacological Interventions in the Elderly (TONE) to control hypertension. The participants were assigned randomly to one of four groups: usual care, weight loss only, sodium restriction only, or combined weight loss/sodium restriction.INTERVENTION: All TONE participants in the treatment groups attended regular dietary intervention sessions to lose weight, reduce sodium intake, or both that they might refrain from using antihypertensive medications for a period of 15 to 36 months (median = 29 months).MEASUREMENTS: Bone mineral density (BMD) assessed by dual energy X-ray absorptiometry (DXA), serum and urine markers of bone metabolism, and other demographic and clinical data were collected at baseline, 6 months, and 12 months.RESULTS: Women assigned to the weight loss interventions lost 9.2 +/- 1.2 lbs (mean +/- SE) at 6 months and 7.7 +/- 2.0 lbs at 12 months compared with 1.8 +- 1.0 Ibs at 6 months and 1.9 +/- 1,6 Ibs at 12 months for those assigned to no weight loss intervention (P <.0001). Weight loss was correlated with a decrease in total body BMD (P =.004) and an increase in osteocalcin (P =.004) after controlling for baseline bone measures, intervention assignment, and other baseline covariates. Regression analyses indicated that total body BMD decreased by 6.25 +/- 2.06 g/cm(2) x 10(-4) for each pound of -weight loss.CONCLUSIONS: Voluntary weight loss in overweight postmenopausal women is associated with modest decrease in total body BMD. Clinicians recommending weight loss for older postmenopausal women may need to include recommendations for reducing the risk of bone loss.

OBJECTIVES:To explore initially how low levels of physical activity influence lower body functional limitations in participants of the Longitudinal Study of Aging. Changes in functional limitations are used subsequently to predict transitions in the activities of daily living/instrumental activities of daily living (ADL/IADL) disability, thus investigating a potential pathway for how physical activity may delay the onset of ADL/IADL disability and, thus, prolong independent living.DESIGN:Analysis of a complex sample survey of US civilian, noninstitutionalized population aged 70 years and older in 1984, with repeated interviews in 1986, 1988, and 1990.SETTING AND PARTICIPANTS:Analyses concentrated on 5151 men and women targeted for interview at all four LSOA interviews.MEASUREMENTS:Characteristics used in analyses: gender, age, level of physical activity, comorbid conditions including the presence of hypertension, diabetes, arthritis, and atherosclerotic heart disease, levels of functional limitations, and ADL/IADL disability.RESULTS:Transitional models provide evidence that older adults who have varying levels of disability and who report at least a minimal level of physical activity experience a slower progression in functional limitations (OR = .45, P < .001 for severe vs less severe limitations). This low level of physical activity, through its influence on changes in functional limitations, is shown to slow the progression of ADL/IADL disability.CONCLUSIONS:Results from analyses provide supporting evidence that functional limitations can mediate the effect that physical activity has on ADL/IADL disability. These results contribute further to the increasing data that seem to suggest that physical activity can reduce the progression of disability in older adults.

Background: National guidelines recommend consideration of step down or withdrawal of medication in patients with well-controlled hypertension, but knowledge of factors that predict or mediate success in achieving this goal is limited.Objective: To identify patient characteristics associated with success, in controlling blood pressure (BP) after withdrawal of antihypertensive medication.Design: The Trial of Nonpharmacologic Interventions in the Elderly tested whether lifestyle interventions designed to promote weight loss or a reduced intake of sodium, alone or in combination, provided satisfactory BP control among elderly patients (aged 60-80 years) with hypertension after withdrawal from antihypertensive drug therapy. Participants were observed for 15 to 36 months after attempted drug withdrawal.Main Outcome Measures: Trial end points were defined by (1) a sustained BP of 150/90 mm Hg or higher, (2) a clinical cardiovascular event, or (3),a decision by participants or their personal physicians to resume BP medication.Results: Proportional hazards regression analyses indicated that the hazard (+/-SE) of experiencing an end point among persons assigned to active interventions wa 75% +/- 9% (weight loss); 68% +/- 7% (sodium reduction), and 55% +/- 7% (combined weight loss/sodium reduction) that of the hazard for those assigned to usual care. Lower baseline systolic BP (P<.001), fewer years since diagnosis of hypertension (P<.001), fewer years of antihypertensive treatment (P<.001), and no history of cardiovascular disease(P=.01) were important predictors of maintaining successful nonpharmacological BP control throughout follow-up, based on logistic regression analysis. Age, ethnicity, baseline level of physical activity, baseline weight, medication class, smoking status, and alcohol intake were not statistically significant predictors. During follow-up, the extent of weight loss (P =.001) and urinary sodium excretion (P =.04) were associated with a reduction in the risk of trial end points in a graded fashion.Conclusions: Withdrawal from antihypertensive medication is most likely to be successful in patients with well- controlled hypertension who have been recently (within 5 years) diagnosed or treated, and who adhere to lifestyle interventions involving weight loss and sodium reduction. More than 80% of these patients may have suer cess in medication withdrawal for longer than 1 year.

BACKGROUND:National guidelines recommend consideration of step down or withdrawal of medication in patients with well-controlled hypertension, but knowledge of factors that predict or mediate success in achieving this goal is limited.OBJECTIVE:To identify patient characteristics associated with success in controlling blood pressure (BP) after withdrawal of antihypertensive medication.DESIGN:The Trial of Nonpharmacologic Interventions in the Elderly tested whether lifestyle interventions designed to promote weight loss or a reduced intake of sodium, alone or in combination, provided satisfactory BP control among elderly patients (aged 60-80 years) with hypertension after withdrawal from antihypertensive drug therapy. Participants were observed for 15 to 36 months after attempted drug withdrawal.MAIN OUTCOME MEASURES:Trial end points were defined by (1) a sustained BP of 150/90 mm Hg or higher, (2) a clinical cardiovascular event, or (3) a decision by participants or their personal physicians to resume BP medication.RESULTS:Proportional hazards regression analyses indicated that the hazard (+/- SE) of experiencing an end point among persons assigned to active interventions was 75% +/- 9% (weight loss), 68% +/- 7% (sodium reduction), and 55% +/- 7% (combined weight loss/sodium reduction) that of the hazard for those assigned to usual care. Lower baseline systolic BP (P < .001), fewer years since diagnosis of hypertension (P < .001), fewer years of antihypertensive treatment (P < .001), and no history of cardiovascular disease (P = .01) were important predictors of maintaining successful nonpharmacological BP control throughout follow-up, based on logistic regression analysis. Age, ethnicity, baseline level of physical activity baseline weight, medication class, smoking status, and alcohol intake were not statistically significant predictors. During follow-up, the extent of weight loss (P = .001) and urinary sodium excretion (P = .04) were associated with a reduction in the risk of trial end points in a graded fashion.CONCLUSIONS:Withdrawal from antihypertensive medication is most likely to be successful in patients with well-controlled hypertension who have been recently (within 5 years) diagnosed or treated, and who adhere to life-style interventions involving weight loss and sodium reduction. More than 80% of these patients may have success in medication withdrawal for longer than 1 year.

Purpose: To examine the validity of the Physical Activity Scale for the Elderly (PASE) among individuals with disability. Methods: A sample of 471 participants (mean age = 71.36) in an epidemiological study of chronic knee pain completed the PASE and self-report measures of knee pain, perceived physical function, satisfaction with physical function, and importance of physical function. A 6-min walk test and an isokinetic assessment of knee strength were also administered. Results: PASE scores were significantly correlated in expected directions with performance on the 6-min walk, knee strength, frequency of knee pain during transfer, and perceived difficulty with physical functioning. Gender and age were identified as significant moderators of PASE scores and the scale's construct validity was supported by testing a conceptually driven hypothesis regarding patterns of physical activity. Conclusions: These results support the PASE`s validity for the assessment of physical activity among older adults with pain and disability.

he Balanced Budget Act of 1997 (BBA) is the most T significant piece of healthcare legislation since the cnactnient of Medicine and Medicaid in 19 65. The BBA was signed into law by the President on August 7, 1997, and will be implemented over a 5-year period. It is a hodgepodge of provisions that dramatically changes government-funded medical services. The general provisions of the bill are known; however, many of the rules and regulations to implement the law have yet to be written. A copy of the bill can be obtained from the Health Care Finance Administration internet site at www.hcfa.gov/regs/budget97.htm. The essence of BBA is that it slows the rate of growth in spending for the Medicare program by approximately $1 16 billion over 5 years. The greatest amount of spending reduction comes in reduced payments to hospitals ($40 billion), followed by reductions in payments for managed care ($21.8 billion), home health care ($1 6.2 billion), and skillcd nursing services ($9.5 billion). Payments to physicians will be reduced by $5.3 billion. The BBA will extend the life of the Medicare trust fund that pays for Medicare Part-A services through 2010. The BBA also restructures payments to healthcare providers and provides more options to Medicare beneficiaries. This article highlights the provisions of the BBA that affect the practice of geriatric medicine most. It details neither the reductions in payments to hospitals (except to say that your hospitals will have lower margins from services provided for Medicare patients) nor the provisions dealing with graduate medical education, fraud and abuse, payments to rehabilitation hospitals, or provisions related to Medicaid, with the exception of the change in the Program for All Inclusive Care for the Elderly (PACE). The provisions that are covered fall into three general areas: the Medicare+ Choices program, office-based practice, and postacute care services.

CONTEXT:Nonpharmacologic interventions are frequently recommended for treatment of hypertension in the elderly, but there is a paucity of evidence from randomized controlled trials in support of this recommendation.OBJECTIVE:To determine whether weight loss or reduced sodium intake is effective in the treatment of older persons with hypertension.DESIGN:Randomized controlled trial.PARTICIPANTS:A total of 975 [corrected] men and women aged 60 to 80 years with systolic blood pressure lower than 145 mm Hg and diastolic blood pressure lower than 85 mm Hg while receiving treatment with a single antihypertensive medication.SETTING:Four academic health centers.INTERVENTION:The 585 obese participants were randomized to reduced sodium intake, weight loss, both, or usual care, and the 390 nonobese participants were randomized to reduced sodium intake or usual care. Withdrawal of antihypertensive medication was attempted after 3 months of intervention.MAIN OUTCOME MEASURE:Diagnosis of high blood pressure at 1 or more follow-up visits, or treatment with antihypertensive medication, or a cardiovascular event during follow-up (range, 15-36 months; median, 29 months).RESULTS:The combined outcome measure was less frequent among those assigned vs not assigned to reduced sodium intake (relative hazard ratio, 0.69; 95% confidence interval [CI], 0.59-0.81; P<.001) and, in obese participants, among those assigned vs not assigned to weight loss (relative hazard ratio, 0.70; 95% CI, 0.57-0.87; P<.001). Relative to usual care, hazard ratios among the obese participants were 0.60 (95% CI, 0.45-0.80; P<.001) for reduced sodium intake alone, 0.64 (95% CI, 0.49-0.85; P=.002) for weight loss alone, and 0.47 (95% CI, 0.35-0.64; P<.001) for reduced sodium intake and weight loss combined. The frequency of cardiovascular events during follow-up was similar in each of the 6 treatment groups.CONCLUSION:Reduced sodium intake and weight loss constitute a feasible, effective, and safe nonpharmacologic therapy of hypertension in older persons.

Context.-Nonpharmacologic interventions are frequently recommended for treatment of hypertension in the elderly, but there is a paucity of evidence from randomized controlled trials in support of this recommendation.Objective.-To determine whether weight loss or reduced sodium intake is effective in the treatment of older persons with hypertension.Design.-Randomized controlled trial.Participants.-A total of 875 men and women aged 60 to 80 years with systolic blood pressure lower than 145 mm Hg and diastolic blood pressure lower than 85 mm Hg while receiving treatment with a single antihypertensive medication.Setting.-Four academic health centers.Intervention.-The 585 obese participants were randomized to reduced sodium intake, weight loss, both, or usual care, and the 390 nonobese participants were randomized to reduced sodium intake or usual care, Withdrawal of antihypertensive medication was attempted after 3 months of intervention.Main Outcome Measure.-Diagnosis of high blood pressure at 1 or more follow-up visits, or treatment with antihypertensive medication, or a cardiovascular event during follow-up (range, 15-36 months; median, 29 months).Results.-The combined outcome measure was less frequent among those assigned vs not assigned to reduced sodium intake (relative hazard ratio, 0.69; 95% confidence interval [CI], 0.59-0.81; P<.001) and, in obese participants, among those assigned vs not assigned to weight loss (relative hazard ratio, 0.70; 95% CI, 0.57-0.87; P<.001). Relative to usual care, hazard ratios among the obese participants were 0.60 (95% CI, 0.45-0.80; P<.001) for reduced sodium intake alone, 0.64 (95% CI, 0.49-0.85; P=.002) for weight loss alone, and 0.47 (95% CI, 0.35-0.64; P<.001) for reduced sodium intake and weight loss combined. The frequency of cardiovascular events during follow-up was similar in each of the 6 treatment groups.Conclusion.-Reduced sodium intake and weight loss constitute a feasible, effective, and safe nonpharmacologic therapy of hypertension in older persons.

OBJECTIVE:To determine the effects of structured exercise programs on self-reported disability in older adults with knee osteoarthritis.SETTING AND DESIGN:A randomized, single-blind clinical trial lasting 18 months conducted at 2 academic medical centers.PARTICIPANTS:A total of 439 community-dwelling adults, aged 60 years or older, with radiographically evident knee osteoarthritis, pain, and self-reported physical disability.INTERVENTIONS:An aerobic exercise program, a resistance exercise program, and a health education program.MAIN OUTCOME MEASURES:The primary outcome was self-reported disability score (range, 1-5). The secondary outcomes were knee pain score (range, 1-6), performance measures of physical function, x-ray score, aerobic capacity, and knee muscle strength.RESULTS:A total of 365 (83%) participants completed the trial. Overall compliance with the exercise prescription was 68% in the aerobic training group and 70% in the resistance training group. Postrandomization, participants in the aerobic exercise group had a 10% lower adjusted mean (+/- SE) score on the physical disability questionnaire (1.71 +/- 0.03 vs 1.90 +/- 0.04 units; P<.001), a 12% lower score on the knee pain questionnaire (2.1 +/- 0.05 vs 2.4 +/- 0.05 units; P=.001), and performed better (mean [+/- SE]) on the 6-minute walk test (1507 +/- 16 vs 1349 +/- 16 ft; P<.001), mean (+/-SE) time to climb and descend stairs (12.7 +/- 0.4 vs 13.9 +/- 0.4 seconds; P=.05), time to lift and carry 10 pounds (9.1 +/- 0.2 vs 10.0 +/- 0.1 seconds; P<.001), and mean (+/-SE) time to get in and out of a car (8.7 +/- 0.3 vs 10.6 +/- 0.3 seconds; P<.001) than the health education group. The resistance exercise group had an 8% lower score on the physical disability questionnaire (1.74 +/- 0.04 vs 1.90 +/- 0.03 units; P=.003), 8% lower pain score (2.2 +/- 0.06 vs 2.4 +/- 0.05 units; P=.02), greater distance on the 6-minute walk (1406 +/- 17 vs 1349 +/- 16 ft; P=.02), faster times on the lifting and carrying task (9.3 +/- 0.1 vs 10.0 +/- 0.16 seconds; P=.001), and the car task (9.0 +/- 0.3 vs 10.6 +/- 0.3 seconds; P=.003) than the health education group. There were no differences in x-ray scores between either exercise group and the health education group.CONCLUSIONS:Older disabled persons with osteoarthritis of the knee had modest improvements in measures of disability, physical performance, and pain from participating in either an aerobic or a resistance exercise program. These data suggest that exercise should be prescribed as part of the treatment for knee osteoarthritis.

The purpose of this study was to determine the long-term effects of aerobic walking and weight training interventions on gait mechanics and knee pain in older adults with knee osteoarthritis (OA). One hundred three older adults (age ≥60 years) with radio-graphic evidence of knee OA were randomized to one of three treatment groups: aerobic walking, health education control, or weight training. Both exercise intervention groups exercised 3 days · week-1for 18 months. The aerobic group significantly improved temporal components of gait as well as knee and ankle joint kinematics relative to the health education group across the 18-month intervention. Moreover, the weight training group exhibited significantly greater ankle plantar flexion velocity. Analysis of the ground reaction forces indicated that the aerobic group exhibited significantly greater force relative to the health education group. Finally, both exercise groups exhibited significantly less knee pain than the health education group. The results suggest that long-term aerobic walking and, to a lesser extent, weight training regimens improve walking mechanics in older adults with knee osteoarthritis. These improvements in gait are associated with a reduction in knee pain during activities of daily living.