Intervention for the maintenance and improvement of physical function
and quality of life among elderly disaster victims of the Great East Japan
Earthquake and Tsunami

Chieko Greiner RN, PHN, PhD, Kana Ono RN, Chizuru Otoguro RN,
PHN, MS, Kyoko Chiba RN, PhD, Noriko Ota RN, PHN, MS

PII: S0897-1897(16)00039-2
DOI: doi: 10.1016/j.apnr.2016.02.006
Reference: YAPNR 50781

To appear in: Applied Nursing Research

Received date: 4 January 2016

Revised date: 26 February 2016
Accepted date: 26 February 2016

Please cite this article as: Greiner, C., Ono, K., Otoguro, C., Chiba, K. & Ota, N.,
Intervention for the maintenance and improvement of physical function and quality of
life among elderly disaster victims of the Great East Japan Earthquake and Tsunami,
Applied Nursing Research (2016), doi: 10.1016/j.apnr.2016.02.006

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 ACCEPTED MANUSCRIPT

Intervention for the maintenance and improvement of physical function and quality of life

among elderly disaster victims of the Great East Japan Earthquake and Tsunami

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Running Head: Intervention for elderly disaster victims

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Chieko Greiner, RN, PHN, PhD1

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Kana Ono, RN2

Chizuru Otoguro, RN, PHN, MS3

Kyoko Chiba, RN, PhD3

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Noriko Ota, RN, PHN, MS4
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1. Graduate School of Health Sciences, Kobe University

2. Himawari Fukushikai, Social Welfare Corporation

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3. The Japanese Red Cross College of Nursing, Tokyo, Japan

4. Faculty of Medicine, Tottori University

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Corresponding author

Chieko GREINER, RN, PhD

Graduate School of Health Sciences, Kobe University

7-10-2 Tomogaoka, Suma-ku, Kobe-city, 654-0142, Japan

Phone & Fax: +81-78-796-4520

E-mail: greiner@harbor.kobe-u.ac.jp

Running Head: Intervention for elderly disaster victims

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Abstract

Purpose: The purpose of this study was to examine the effectiveness of an exercise class

implemented in an area affected by the Great East Japan Earthquake and Tsunami for

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maintaining and improving physical function and quality of life (QOL) among elderly

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victims.

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Methods: Participants were 45 elderly disaster victims. To measure the effectiveness of the

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exercise classes, results on the Functional Reach Test (FRT), Timed Up and Go Test (TUG),

One-leg Standing Balance (OSB), and Chair Stand Test (CST) were measured at the

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beginning of the exercise classes, and after 3 and 6 months. In order to assess health-related
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QOL, the 8-item Short-Form Health Survey (SF-8) was carried out at the beginning of the

exercise classes, and after 1, 3, and 6 months.

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Results: 27 of the 45 people who consented to participate continued the program for 6 months

and were used for analysis. Analysis of the results for FRT, OSB, and CST showed significant
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improvements (respectively, p=.000, .007, and .000). SF-8 showed significant increases for

the subscales of bodily pain (p=.004), general health perception (p=.001), and mental health
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(p=.035).
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Conclusions: By continuing an exercise program for 6 months, improvements were seen in

lower limb muscle strength and balance functions. Effectiveness for HRQOL was also

observed.

Keyword: exercise; disaster; intervention; physical function; quality of life

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1. Introduction

The Great East Japan Earthquake and Tsunami of March 11, 2011 was an unprecedented

major earthquake disaster that resulted in over 18,000 deaths or missing persons (National

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Police Agency, 2015). The major cause of the immense damage was the onslaught of a

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tsunami that far exceeded all predictions, robbing many people of their homes and forcing

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them to live in temporary housing. As of November 2014, over 89,000 victims of the disaster

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were still living in temporary housing, and over 124,000 people were living as evacuees in

public and private housing (Reconstruction Agency, 2014).

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After the earthquake and tsunami, victims were forced to leave their homes and live in
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temporary housing in unfamiliar communities and difficult environments (Koyama et al.,

2014). Among elderly people in particular, the ability to adapt to changes in the environment
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was low (World Health Organization Centre for Health Development, 2013), and difficulties

in building new human relations together with contraction of their sphere of activities led to a
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decline in activities of daily living (ADL). Many elderly people remained shut in their homes

and suffered decline of physical function, and many more are at risk of the same (Motoya,
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2013).
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Exercise is the main intervention method for maintaining and improving the physical

function of elderly people, and it also contributes to improvement in balance function (Lee &

Cho, 2014), which in turn helps to prevent falls and broken bones among the elderly.

Furthermore, maintenance and improvement of physical function seem to be linked to

improved quality of life (QOL) among elderly people.

In Japan, people in preventive care services help elderly people engage in activities

classified as requiring support to prevent decline of physical function (Hirano, Kawahara, &

Saeki, 2014). However, in the disaster-affected areas, these support services were not

operational for some time after the disaster, and it has been reported that approximately 24%

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of elderly disaster victims who did not require care 1 month after the disaster were

experiencing difficulties in walking 7 months after the disaster (Okawa, 2013). This tendency

was particularly prevalent among elderly people living in temporary housing, with the main

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reasons being the decrease in opportunities to go out and reduced opportunities for activities

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inside and outside the home (Okawa, 2013). According to longitudinal research by Tomata et

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al. (2014), the rate of elderly people being newly recognized as having a disability under the

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Long-Term Care Insurance (LTCI) system in the year after the disaster was significantly

higher in the disaster-affected areas than in areas not affected by the disaster.

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Many exercise intervention studies have already been carried out with elderly people (Lim
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& Son Hong, 2010; Sung, 2009; Taguchi, Higaki, Inoue, Kimura, & Tanaka, 2010; Kim et al.,

2012; Purath, Keller, McPherson, & Ainsworth, 2013), and meta-analysis studies (Chou,
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Hwang, & Wu, 2012; de Vries et al., 2012) and systematic reviews (Valenzuela, 2012;

Giné-Garriga, Roqué-Fíguls, Coll-Planas, Sitjà-Rabert, & Salvà, 2014) have also been done;
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however, there have been no studies on the effectiveness of exercise intervention among

elderly people affected by the disaster who are living a very different lifestyle in a very
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different environment than usual.

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The aim of this study was to examine the effectiveness of an exercise class implemented

over a 6-month period in the area affected by the Great East Japan Earthquake and Tsunami,

in terms of maintaining and improving physical function and QOL among elderly victims of

this disaster.

2. Methods

2.1. Study participants

Participants were elderly people living in Pacific coastal areas who were affected by the

Great East Japan Earthquake and Tsunami. Locations were selected through convenience

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sampling, and a request to carry out the research was made to the city’s Department of Health

and Welfare. After receiving permission from city authorities to conduct the research, a

location in which to hold the exercise class was selected with the advice of city authorities.

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Damage in this area was immense, and the area had large-scale temporary housing. A leaflet

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advertising the exercise class was distributed in temporary housing in the participating area,

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and volunteers were recruited. The class had two sessions, one with 23 participants in the

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morning and one with 22 participants in the afternoon, for a total of 45 participants.

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2.2. Development of the exercise program and design of the exercise class pamphlet
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An exercise pamphlet was designed with the co-researchers for the launch of the exercise

class. The pamphlet included an illustrated exercise program that could be completed at home,
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notes on the need for exercise, points to pay attention to when exercising, strategies for

continuing to exercise, and points to check before engaging in exercise. For the exercise
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program, issues such as the intensity and volume of exercise were developed with the advice

of a physiotherapist. An original calendar and stamp were distributed to the participants, with
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space for a stamp below the date. In order to determine the amount of activity outside the
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exercise class, participants were requested to use the stamp when they exercised at home, as

well as when they participated in the study’s exercise program. Participants were requested to

bring the calendar to the exercise class each time, and they received a sticker for participation

in the class.

2.3 Implementation of the exercise class

Each exercise class lasted approximately 1 hour, with 40 minutes spent on the exercises

shown in the pamphlet, and 20 minutes devoted to social time and for the participants to

drink tea. The exercise class was led by an instructor who was qualified as a public health

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nurse, with the help of two assistants. The exercise class met continuously once a week for 24

weeks. The period of implementation of the exercise class was February to July 2012.

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2.4 Items measured

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Each Participant’s age, sex, and height were recorded at the beginning of the exercise

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classes. Weight, blood pressure, state of health, implementation of exercise and length of

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time spent exercising, sleeping time, and conditions being treated were recorded at the

beginning of the exercise classes, 3 months after starting, and 6 months after starting. In

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order to measure the effectiveness of the exercise classes, results on the Functional Reach
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Test (FRT), Timed Up and Go Test (TUG), One-leg Standing Balance (OSB), and Chair

Stand Test (CST) were measured. These indicators were also measured at the beginning of
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the exercise classes, 3 months after starting, and 6 months after starting. In order to assess

health-related QOL (HRQOL), the Japanese version of the 8-item Short-Form Health
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Survey (SF-8) was used at the beginning of the exercise classes, 1 month after starting, 3

months after starting, and 6 months after starting. The 1-month measurement was performed
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assuming that HRQOL would change more quickly than physical function.
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2.4.1. FRT

Participants were asked to stand with their feet shoulder-width apart with one arm elevated

at 90 degrees, and to then reach forward as far as possible from that position. The distance of

reach was measured. Measurements were taken twice, and the higher measurement was used

(Won et al., 2014; Duncan, Weiner, Chandler, & Studenski, 1990).

2.4.2. TUG

From a seated position, the participant was given a signal, and then the time it took to stand

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up, walk 3 meters and back, and sit down again was measured using a stopwatch. Participants

were instructed to walk at a normal, comfortable speed. Measurements were taken twice, and

the shorter time was used (Salb et al., 2015).

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2.4.3 OSB

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Participants were asked to balance on one leg by raising either foot and to keep their eyes

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open. The time that balance was maintained was recorded. The test ended when the raised

foot touched the ground, or when the foot on the ground moved. Measurements were taken

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twice with a stopwatch, up to a maximum of 120 seconds, and the higher measurement was
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used (Abe et al., 2014).
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2.4.4 CST

Participants were asked to sit on a chair with both arms crossed over their chest. With arms
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still crossed, they were asked to stand so that their legs were fully extended. The time

required to repeat the action of sitting and standing 10 times was measured (Segura-Ortí &
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Martínez-Olmos, 2011).
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2.4.5. SF-8 Japanese version

SF-8 is an HRQOL instrument, and is a shortened version of the 36-item Short-Form

Health Survey (SF-36). The eight question items of SF-8 are identified as the most

representative items for the eight sub-scale concepts on the SF-36, namely, physical

functioning (PF), role physical (RP), bodily pain (BP), general health perception (GH),

vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH) (Roberts,

Browne, Ocaka, Oyok, & Sondorp, 2008; Fukuhara & Suzukamo, 2004). These are

categorized as two summary scores (physical component summary score, PCS; mental

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component summary score, MCS), and standard values for Japanese citizens (mean score 50)

on each item and on the two summary scores are calculated (Fukuhara & Suzukamo, 2004).

If the score is lower than 50, HRQOL is interpreted as being lower than that of the mean

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Japanese person. There are different versions of SF-8 that apply to the past month, the past

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week, and the past 24 hours, but this study used the version for the past month.

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2.4.6. Exercise class records

A report on the implementation of the exercise class was written every week. The report

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included the date of implementation, time of implementation, number of class participants,
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overview of implementation, condition of the participants, comments from the participants

about the exercise class, and reasons for absence.

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2.5. Ethical considerations

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The study was implemented after receiving approval from the Institutional Review Board

of the first author’s university, with the consent of the Department of Health and Welfare in
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the city where the study took place and the director of the center in which the exercise classes
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were held. Participants received a written and oral explanation of the aims, methods,

voluntary nature of the study, and protection of anonymity, and participated in the study after

giving signed consent.

2.6. Methods of analysis

Analysis of variance (ANOVA) was carried out for FRT, TUG, OSB, and CST in order to

examine the effectiveness of engaging in exercise. ANOVA was also used to analyze changes

in HRQOL (SF-8). Multiple comparisons using the Bonferroni method were also carried out

for items showing significant differences to confirm the point at which changes appeared.

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3. Results

3.1. Overview of study participants

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Of the 45 people who consented to participate in the study, 35 continued the exercise

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classes for at least 3 months and 27 continued for 6 months; therefore, the data of the 27

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participants who continued for 6 months were used for analysis (Figure 1). The mean age of

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the participants was 70.1 (standard deviation, SD=5.0), and 26 were women (Table 1).

Reasons for not being able to continue classes included poor physical condition, caring for

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family members, broken bones and surgery, returning to work, and moving to other areas
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(Table 2).
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3.2. Changes in engagement in exercise

Frequency of exercise and length of time spent on exercise in daily life was investigated
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before the beginning of exercise classes, 3 months after starting, and 6 months after starting.

Regarding frequency of exercise, while nine participants replied that they did no exercise at
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all before the exercise classes began, this number dropped to 0 after 6 months. While two
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people replied that they exercised three times a week or more before the exercise classes

began, this rose to 15 people after 3 months and 13 people after 6 months. In terms of time

spent exercising, the number of people exercising less than 30 minutes was 21 before the

exercise classes began, but dropped to 15 people after 3 months and 12 people after 6 months.

In contrast, the number of people replying that they exercised 30 to 60 minutes rose from five

people before classes began to ten people after 3 months and 12 people after 6 months (Table

3).

3.3. Changes in physical function

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Analysis of the results of changes in FRT, TUG, OSB, and CST before beginning exercise

classes, 3 months after starting, and 6 months after starting showed significant improvements

in FRT (p=.000), OSB (p=.007), and CST (p=.000) (Table 4). In order to confirm the point at

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which significant changes took place, multiple comparisons using the Bonferroni method

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were conducted. Results showed a significant difference in FRT and CST between before

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beginning classes, and 3 months and 6 months after starting (p<.05). For OSB, a significant

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difference was evident between before beginning classes and 3 months after starting (p<.05).

These results suggest that significant improvements in physical function were already evident

after 3 months of continuing exercise.

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3.4. Changes in HRQOL
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Analysis of the results of changes in SF-8 before beginning exercise classes, 1 month after

starting, 3 months after starting, and 6 months after starting showed significant increases for
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BP (p=.004), GH (p=.001), and MH (p=.035). In order to confirm the point at which

significant increases took place, multiple comparisons using the Bonferroni method were
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conducted. Results showed significant increases in BP and GH between before beginning

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classes and 1 month after starting (p<.05). For MH, a significant tendency was apparent

between before beginning classes and 6 months after starting (p=.072). Scores for BP were

lower than the mean score for Japanese people before beginning classes, but were slightly

higher than the mean score for Japanese people at 1 month, 3 months, and 6 months after

starting classes. However, the score for GH was only higher than the mean for Japanese

people 1 month after starting classes. MH gradually rose after starting exercise classes, but

was still lower than the score of the mean Japanese person 6 months after starting classes

(Table 5).

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3.5. Effectiveness of participation in exercise classes based on participants’ comments

Comments on the effectiveness of exercise classes taken from the records of exercise

classes are shown in Table 6. Participation in exercise classes not only improved physical

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function but also had a positive effect on improvement of sleeping patterns and psychological

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aspects.

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4. Discussion

For elderly people affected by the Great East Japan Earthquake and Tsunami disaster who

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participated in the exercise classes, exercise intervention continued over 6 months
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significantly improved participants’ FRT, OSB, and CST results. These study results show

that the implementation of regular exercise intervention with elderly people affected by a
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disaster is effective in improving their motor and balance functions. Additionally, the study

showed that implementation of exercise classes led to increased frequency of exercise and
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greater time spent daily on exercise among participants, showing that implementation of

exercise classes contributes to establishing habits of exercising among elderly people affected
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by a disaster. In terms of QOL, out of the eight SF-8 concepts, significant improvements were
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observed for BP, GH, and MH, suggesting that implementation of exercise classes is linked to

improvement in some aspects of HRQOL.

The results of multiple comparisons on the statistically significant FRT, OSB, and CST

found that all showed significant improvement after 3 months, suggesting that 3 months of

exercise intervention has a certain effectiveness. For FRT and CST, a further significant

improvement was seen between 3 months and 6 months, suggesting that long-term

continuation of exercise is linked to further improvement of muscle strength and balance

functions. On the other hand, no significant improvement was evident in TUG. In a

meta-analysis related to exercise intervention effectiveness with elderly people,

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improvements in gait speed and ADL could be seen, but significant effects in TUG were not

evident (Chou, Hwang, & Wu, 2012). According to results of the study by Savva et al. (2013),

TUG is effective for identifying frail elderly people among the total population of elderly

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people, but it is weak in discriminating between prefrail or frail elderly people, and nonfrail

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people. It seems that this characteristic of TUG may have influenced the results.

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Elderly people affected by a disaster tend to experience decline of ADL due to changes in

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their environment and reduction of levels of activity inside and outside the home. By the time

the intervention began in February 2012, approximately 11 months had already passed since

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the earthquake disaster. It is likely that many elderly people had already suffered decline of
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physical function in the period from when the disaster occurred and the launch of exercise

classes (Tomota et al., 2014), and it can be argued that this intervention provided an effective
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approach for people at risk of requiring care. However, decline of physical function of elderly

people affected by the disaster was already reported as being evident in the 7th month after the
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earthquake disaster (Okawa, 2013). Therefore, it is desirable in the future to intervene at an

earlier stage when exercise intervention for elderly people affected by a disaster is planned.
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In many previous studies, exercise intervention has not been proved to be linked to
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improvement of QOL (Chou, Hwang, & Wu, 2012; de Vries et al., 2012). In this study too,

overall improvement in HRQOL was not proved. However, of the eight sub-concepts of

HRQOL, significant improvements in the three sub-concepts of BP, GH, and MH were

evident. As seen in the comments from the participants, exercise contributed not only to

muscle strength and balance functions but also to pain relief, as shown by the cases of

improvements in knee pain or finger pain caused by tenosynovitis. Since the only

sub-concept of the eight to exceed the mean scores of Japanese people after intervention was

pain, it seems that exercise intervention is particularly effective in combating pain. Pain is

said to be subjective, having significant effects on psychological state (Ochsner et al., 2006),

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and for elderly people affected by disaster who are experiencing stress on an everyday basis,

the significance of pain alleviation could be great. Pain alleviation was not a direct objective

of this exercise intervention, but it may be a new topic for investigation in the future.

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This exercise program was implemented in group format. Relationships between

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participants in the group are important for continuing participation, and so the social event of

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drinking tea together was established to facilitate communication between participants after

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the program. After their familiar homes were washed away in the tsunami that followed the

earthquake, many elderly people were forced to live in temporary housing (Koyama et al.,

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2014). The ability of elderly people to adapt to new environments tends to be reduced (World
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Health Organization Centre for Health Development, 2013), it is not easy for them to move

from familiar communities to new communities in temporary housing where they know few
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people, and their sphere of activities often narrows (Motoya, 2013). Given this situation, it

seems that building relationships between the participants was not only important for
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continuation of the exercise classes but also for the psychological stability of the participants.

Given the fact that the mental health concept of HRQOL improved significantly and that
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comments from participants included both statements that participation in the class was their
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greatest pleasure and ones that the exercise class helped them keep up their spirits, the study

results suggest that establishment of a site of interaction had a meaningful influence and a

positive effect not only on continuing participation in the exercise classes but also on the

psychological state of elderly people affected by disaster. Establishment of this kind of

meeting space seems to be an important factor in implementing exercise intervention in

disaster-affected areas.

Results related to everyday implementation of exercise showed improvement in the

frequency of and time spent on exercise by many participants. This can be seen as a positive

effect of continued participation in the exercise classes. Furthermore, calendars were

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distributed to each participant in this study, and when they engaged in some form of exercise

at home, such as going out for a walk, this was displayed visually. In this way, it seems that

the participants could objectively see their own exercise habits, which was linked to their

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motivation to engage in exercise at home, resulting in improvements in frequency of and time

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spent exercising. In this study, this was done to understand the participants’ engagement in

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exercise, but it seems that it is necessary to examine the effectiveness of using visual tools

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that enable participants to see their own exercise situation objectively in conjunction with

exercise intervention in a future study.

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The number of participants at the start of the exercise classes was 45, but the number who
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managed to continue for 6 months was 27. Almost all participants were living in temporary

housing, and a number of participants had to give up participation for reasons such as moving,
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starting work, or taking care of family members. There were also participants who dropped

out due to broken bones or leg injuries, and there is a danger that this had some kind of effect
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on the results.

Limitations of the study are that because it was a pre- and post-intervention test method, it
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was difficult to select and compare an experimental group and control group by random
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sampling due to the characteristic of participants being elderly people affected by disaster.

Also, exercise class implementation was only in one location, which may have created some

bias in the results as the number of people who dropped out was considerable.

5. Conclusion

By continuing exercise class meetings once a week for elderly people affected by a disaster

for 6 months, significant improvements were seen in lower limb muscle strength and balance

functions. In terms of HRQOL, significant improvements were observed in BP, GH, and MH.

It is suggested that elderly people who have suffered from a disaster tend to be fully

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occupied with getting through everyday life for several months after the disaster, but once the

foundations of daily life such as moving into temporary housing are assured, initiatives to

maintain and improve physical function are required as early as possible.

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Acknowledgment

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The authors would like to thank all the people who participated in this study, as well as

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the instructor and staff of the support center where the study was held. This study was

supported by a grant from the MEXT “Program for Basic Strategic Research at Private

Universities”.
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Figure legends

Figure 1. Number of participants in each class at the point of measurement

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AM: Class A PM: Class B

Before intervention: 23
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After 3 months: 16 After 3 months: 19
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After 6 months: 13 After 6 months: 14

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Analyzed 27 participants
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Table 1. Characteristics
Sex Male: 1 Female: 26
Age 70.1 ± 5.0*
Height 148.7 ± 5.4*
Weight 54.0 ± 7.6*

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Sleeping time Under 6 hours 8

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6-8 hours 17

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Over 8 hours 2
*Mean ± Standard Deviation

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Table 2. Reasons for nonparticipation

Reasons Number Reasons Number
In poor physical 3 Family care 2
condition

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Fracture 2 Job 3

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Motivation 1 Errand 1

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Surgery 1 Foot injury 1
Moving 2 Unknown 2

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n=18

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Table 3. Changes of exercise implementation status

Before After 3 After 6
program months months
start

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3 days/week or more 2 15 13

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Frequency of 1-2 days/week 11 8 11

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exercise 1-3 days/month 5 2 3

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never 9 2 0
0-30 minutes 21 15 12
30-60 minutes 5 10 12

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Time of
1-2 hours 1 2 3
exercise/day
over 2 hours 0 0 0
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Table 4. Changes of physical function

Before After 3 months After 6 months p
Mean ± SD Mean ± SD Mean ± SD value
FRT (cm) 25.43 ± 7.89 30.56 ± 8.11 33.50 ± 6.69 .000

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TUG (s) 7.71 ± 1.49 7.49 ± 1.11 7.49 ± 1.27 .523

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OSB (s) 65.15 ± 50.03 81.41 ± 45.29 75.73 ± 45.78 .007

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CST (s) 21.55 ± 6.03 17.39 ± 3.50 16.35 ± 3.27 .000
FRT, TUG: n=27; OSB, CST: n=26 ANOVA

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SD = standard deviation
FRT = Functional Reach Test, TUG = Timed Up and Go Test,

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OSB = One-leg Standing Balance, CST = Chair Stand Test
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Table 5. Changes of SF8

Before After 1 months After 3 months After 6 months p
Mean ± SD Mean ± SD Mean ± SD Mean ± SD value
Items

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PF 47.61 ± 4.74 45.32 ± 8.30 45.43 ± 7.07 45.64 ± 9.19 .445

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RP 47.68 ± 7.88 45.47 ± 8.54 46.92 ± 6.36 45.97 ± 8.20 .601

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BP 45.31 ± 8.92 51.97 ± 6.13 50.75 ± 7.47 50.23 ± 10.25 .004
GH 45.09 ± 5.57 50.72 ± 5.27 48.12 ± 6.90 48.98 ± 7.25 .001

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VT 46.80 ± 5.85 47.81 ± 5.61 47.02 ± 5.98 46.88 ± 6.58 .861
SF 47.27 ± 9.18 45.64 ± 8.70 47.21 ± 8.84 45.70 ± 10.21 .694

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RE 48.02 ± 7.70 47.34 ± 6.34 48.44 ± 6.29 47.36 ± 7.75 .802
MH 44.79 ± 9.56 48.03 ± 7.13 48.22 ± 5.44 48.91 ± 6.09 .035
Summary scores
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PCS 45.94 ± 5.65 46.89 ± 6.08 46.19 ± 6.33 45.89 ± 7.65 .903
MCS 45.91 ± 8.33 46.85 ± 6.71 47.71 ± 6.30 47.39 ± 6.67 .597
n=27 ANOVA
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SD = standard deviation
Subscales: PF = physical functioning, RP = role physical, BP = bodily pain,
GH = general health perception, VT = vitality, SF = social functioning,
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RE = role emotional, MH = mental health

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Table 6. Participants’ voices

 I have poor circulation, but after doing the exercises, my hands became warm.
 I was able to sleep so well at night after the last exercise class that I cancelled
another appointment to take part in today’s class.

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 I had stenosing tenosynovitis, but after continuing the exercises, I am now able

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to extend my fingers easily.

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 Urinary incontinence has disappeared.
 I am not stumbling as much.

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 I am happy that my knee pain has disappeared.
 Now I can bend over and touch the floor.

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 Coming to this class is my greatest pleasure.
 The exercise class helps to keep up my spirits.
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