Abstract
[Purpose] To examine the associations of independent access to transportation with life-space mobility and physical activity among users of day-care rehabilitation facilities. [Participants and Methods] We monitored the physical activity of 24 participants attending day-care rehabilitation facilities using an accelerometer. We categorized activity as sedentary behavior (1.0–1.5 metabolic equivalents [METs]), light-intensity physical activity (1.6–2.9 METs), and moderate-to-vigorous physical activity (≥3.0 METs) and calculated daily averages for each. Life-space was assessed using the Life-Space Assessment scores. Participants were divided into two groups: those with independently available transportation and those without. We compared the life-space and physical activity levels between the groups. [Results] Life-Space Assessment scores were significantly higher among participants with available transportation than among those without available transportation. However, no significant difference was found in overall physical activity. [Conclusion] Transportation availability was associated with a larger life-space but was not significantly associated with physical activity.
Key words: Physical activity, Life-space, Transportation
INTRODUCTION
Many older adults require caregiving in their daily lives due to conditions such as stroke sequelae, fractures, or Parkinson’s disease1). In Japan’s long-term care insurance system, various caregiving services are available for individuals who need assistance with daily activities. Day-care rehabilitation facilities allow individuals to travel from their homes to a rehabilitation center, where they can receive functional training from physical therapists2). The primary goal of these facilities is to help users maintain physical function, thereby supporting their ability to live independently. Increased physical activity plays a crucial role in preserving muscle strength and walking ability over the long term3, 4). Therefore, encouraging day-care rehabilitation facility users to remain physically active and work toward maintaining their functional abilities is essential for sustaining at-home living and preventing deterioration that could lead to the need for long-term care.
Vigorous physical activity has been shown to provide various benefits, such as maintaining walking ability and cognitive function5, 6), preventing cardiovascular diseases7), and reducing mortality8). As increasing physical activity level is a critical aspect of overall health maintenance9), the factors that influence the amount of physical activity of older individuals have been extensively explored. Various factors, including physical and mental function, social background, and climate-related conditions, affect physical activity levels in this demographic10, 11). Life-space represents another such significant factor12). It is defined as the extent of an individual’s movement in daily life, has been shown to narrow with aging, and is associated with both motor and executive function13, 14). Tsai et al.12) reported a positive correlation between life-space and physical activity levels. Another study showed that physical activity levels were higher in individuals with larger life-spaces, even when requiring caregiver support or walking devices15). These findings suggest that a larger life-space may promote more vigorous physical activity.
However, among day-care rehabilitation facility users, long-distance outdoor mobility is often difficult due to disease-related declines in physical function. For these individuals, the use of transportation is considered a key means of expanding their life-space. Moreover, previous studies have shown that the use of public transportation can contribute to increased levels of physical activity16, 17). In addition, it is important to consider the level of independence in using transportation. When transportation depends on others, such as family members, an individual’s freedom of movement is restricted, which may limit opportunities for physical activity. Among day-care rehabilitation facility users, the relationship between the independent use of transportation, life-space, and physical activity levels has not been thoroughly examined. Therefore, the purpose of this study was to investigate the relationship between the independent use of transportation and life-space and physical activity among day-care rehabilitation facility users. Promoting physical activity plays a crucial role in maintaining the health of older adults and is a key public health issue.
PARTICIPANTS AND METHODS
Among an initial total of 25 day-care rehabilitation facility users, we included 24 with sufficient measurements of physical activity time in this study. Participants were recruited from the day-care rehabilitation facilities of Kanazawa Red Cross Hospital, which provide services under the Long-Term Care Insurance system. Kanazawa Red Cross Hospital is located in a suburban residential area on the outskirts of Kanazawa City, Japan. The surrounding environment can be characterized as suburban, with a relatively high dependence on private automobiles. Although there is a bus stop near the hospital, making access by bus feasible, the nearest train station is located at a certain distance, and traveling to the hospital by train is uncommon. Most participants in this study were presumed to reside near hospitals. However, as residential addresses were not collected, we did not consider participants’ home locations or commuting distances in the assessment of life-space. The inclusion criteria were the ability to walk independently, regardless of the use of walking devices or orthotic devices, and having a Mini-Mental State Examination score of ≥24. We explained the purpose of the study and its method, involving the wearing of an accelerometer, to the participants both verbally and in writing, and obtained informed consent from all participants. This study was approved by the Medical Ethics Review Committee of Kanazawa University (Approval No.: 111067-1).
We assessed physical activity between September and November 2023, using an accelerometer (HJA-750C Active Style Pro; Omron, Kyoto, Japan). This device is equipped with a triaxial acceleration sensor and calculates the activity intensity using a unique algorithm based on the detected acceleration. The calculated activity intensity has been validated and shown to have a high correlation with values obtained via the metabolic monitoring method18, 19). It measures activity intensity starting from 1.0 metabolic equivalent (MET) in increments of 0.1 MET. Based on previous studies, the epoch length was set to 60 s20, 21).
We classified physical activity as sedentary behavior (SB) for 1.0–1.5 METs, light-intensity physical activity (LPA) for 1.6–2.9 METs, and moderate-to-vigorous physical activity (MVPA) for ≥3.0 METs and calculated the daily average for each category. The percentage of sedentary time over the total wear time was calculated using the following formula:
We also calculated %LPA and %MVPA using similar approaches. The participants wore the accelerometers for ≥7 days. These devices were attached to the waist and had to be worn at all times, except during bathing, changing clothes, and sleeping. To ensure validity, previous studies have recommended that accelerometers be worn for ≥4 days, with a minimum daily wear time of 600 min22, 23). In this study, we used the average daily values of SB, LPA, and MVPA over 7 days for analysis. These 7 days were generally selected from the day after the start of monitoring, and any day with clearly insufficient wear time was excluded and replaced with the subsequent day to ensure 7 days of valid data. Only participants whose average daily wear time over the selected 7 days exceeded 600 min were included in the final analysis.
We used the Life-Space Assessment to evaluate the life-space among the participants. This assessment, developed by Baker et al.24), has been widely used in previous studies12, 16). It divides life-space into six domains, namely Bedroom, Home, Outside, Neighborhood, Town, and Unlimited, and assigns a score ranging from 0 to 120 points based on mobility frequency and level of independence, with higher scores indicating larger life-spaces. A Japanese version of this assessment has been developed, and its validity has been confirmed25).
We asked the participants the following two questions during a structured interview: “Do you drive a car yourself? Yes/No” and “Can you use public transportation independently? Yes/No”. In this structured format, two trained staff members conducted the interviews; each participant was interviewed face-to-face by one of the two staff members in a one-on-one setting. Responses were recorded at the time of the interview, and no audio recordings were made. We did not collect information regarding possession of a driver’s license, ownership of a private vehicle, or past driving history. We classified participants who were able to either drive themselves or use public transportation independently as the group with available transportation, and those who were unable to do either as the group without available transportation. Therefore, their transportation to day-care rehabilitation facilities relies on either family assistance or the use of transportation services. We assessed motor function as a potential confounding factor that could influence both life-space and physical activity using the timed up-and-go (TUG) test. This test measured the time required for participants to stand up from a chair, walk 3 m along a straight path, turn around, walk back, and sit down again. For our TUG test, we allowed participants to use any walking or orthotic device that they normally used. We conducted the test twice and recorded the shortest time as the final result. We conducted life-space assessments, interviews regarding transportation availability, and TUG measurements concurrently with physical activity evaluations. Two physical therapists performed all assessments.
We used the Shapiro–Wilk test to examine the normality of each evaluated variable. As SB, MVPA, and %MVPA did not follow a normal distribution, nonparametric tests were used to analyze these variables. We divided the participants into two groups based on their independent transportation availability responses and compared the evaluated variables between the two groups. We used an independent-samples Student’s t-test or Mann–Whitney U test to make these comparisons, as appropriate. All statistical analyses were performed using SPSS version 29 (IBM Corp., Armonk, NY, USA), with statistical significance set at p<0.05.
RESULTS
The participants’ characteristics are presented in Table 1. Thirteen participants were classified as having available transportation, whereas the remaining 11 were classified as not having available transportation. Among those with available transportation, four participants drove cars and 11 used public transportation.
Table 1. Participant characteristics (n=24).
| Characteristics | ||
| Age (years) | 74.4 ± 6.3 | |
| Sex | ||
| Male | 8 (33%) | |
| Female | 16 (67%) | |
| Support and Care level | ||
| Support 1 | 6 (25%) | |
| Support 2 | 10 (42%) | |
| Care 1 | 2 (8%) | |
| Care 2 | 6 (25%) | |
| Medical history | ||
| Cerebrovascular diseases | 6 (25%) | |
| Orthopedic diseases | 15 (63%) | |
| Neurological diseases | 3 (12%) | |
| SB (min/day) | 547 ± 449 | |
| LPA (min/day) | 313 ± 111 | |
| MVPA (min/day) | 22.6 ± 22.0 | |
| %SB (%) | 61.2 ± 13.4 | |
| %LPA (%) | 36.3 ± 12.5 | |
| %MVPA (%) | 2.6 ± 2.3 | |
| Life-Space Assessment Score | 53.2 ± 19.4 | |
| TUG (s) | 13.8 ± 6.5 | |
| Drives a car | 4 (17%) | |
| Uses public transportation | 11 (46%) | |
| Has transportation available | 13 (54%) | |
Values are presented as means ± standard deviations or numbers (%). Support and care levels are based on the Long-Term Care Insurance system in Japan. SB: sedentary behavior; LPA: light-intensity physical activity; MVPA: moderate-to-vigorous physical activity; TUG: Timed Up-and-Go Test.
Participants with available transportation had significantly higher Life-Space Assessment scores than those without available transportation; however, no significant differences were observed in any physical activity or motor function measures (Table 2).
Table 2. Comparison based on transportation availability.
| Available transportation (n=13) | No available transportation (n=11) | |
| Age (years) | 74.4 ± 6.9 | 74.5 ± 6.1 |
| SB (min/day) | 485 ± 141 | 619 ± 244 |
| LPA (min/day) | 310 ± 86.8 | 316 ± 138 |
| MVPA (min/day) | 26.0 ± 27.1 | 18.6 ± 14.4 |
| %SB (%) | 58.9 ± 10.4 | 63.7 ± 16.5 |
| %LPA (%) | 38.0 ± 9.2 | 34.2 ± 15.8 |
| %MVPA (%) | 3.0 ± 2.8 | 2.1 ± 1.7 |
| Life-Space Assessment Score | 60.8 ± 21.0 | 44.5 ± 13.5 * |
| TUG (s) | 12.3 ± 6.7 | 15.6 ± 6.1 |
The independent-samples Student’s t-test was used for Age, LPA, %SB, %LPA, Life-Space Assessment Score, and TUG, while the Mann–Whitney U test was used for SB, MVPA, %MVPA. *p<0.05. SB: sedentary behavior; LPA: light-intensity physical activity; MVPA: moderate-to-vigorous physical activity; TUG: Timed Up-and-Go Test.
DISCUSSION
In this study, we examined the relationship between the availability of transportation, life-space, and physical activity among day-care rehabilitation facility users. Based on previous studies indicating that life-space expansion is associated with increased physical activity12), we hypothesized that individuals with available transportation would have larger life-spaces and higher physical activity levels. However, the results showed that although people with access to transportation had a larger life-space, there was no significant difference in their physical activity levels.
Our results revealed that transportation availability is associated with larger life-spaces. Tran et al.16) also reported that the use of private cars and public transportation contributed to the expansion of life-spaces, which aligns with our findings. One report concluded that >90% of community-dwelling adults used some means of motorized transportation to travel ≥3 km from home26). This implies that transportation availability may be essential for traveling to areas classified as “town” or beyond in the Life-Space Assessment. Furthermore, participants in this study were users of day-care rehabilitation services. Day-care rehabilitation users are a population that experiences difficulties in daily functioning and participates in rehabilitation. In this population, it is likely that practical outdoor walking for mobility is challenging. Therefore, the use of transportation may be essential for expanding life-space. No association was observed between transportation availability and physical activity. Even when individuals had access to transportation and a larger life space, this may not have contributed to increased physical activity. This result differs from previous studies reporting positive associations between life-space and physical activity. This pattern may reflect characteristics specific to the day-care rehabilitation users included in this study. Gough et al.27) reported that having opportunities to exercise at destinations plays an important role in increasing physical activity associated with out-of-home mobility. Among day-care rehabilitation users, even with a larger life-space, opportunities to exercise may be limited, or underlying factors may make it difficult for them to engage in exercise.
The findings of this study suggest that, among day‐care rehabilitation facility users, having access to independent transportation is associated with a wider life-space, but not with higher levels of physical activity. This insight may provide an important viewpoint for considering strategies to promote physical activity in this population. Although previous studies have reported a positive association between life-space and physical activity12), our findings did not support this relationship among day-care users. This discrepancy may be explained by the characteristics of this population, who require rehabilitation services as a result of functional decline. In addition, as suggested in previous studies, the type and purpose of outings may influence physical activity levels27). Therefore, even if life-space is expanded, it may not lead to increased physical activity unless individuals actively engage in physical activities at their destinations. Taken together, these findings suggest that simply expanding life-space or ensuring access to independent transportation may not be sufficient to promote physical activity in this population. Rather, it may be important to facilitate opportunities for engagement in physical activity within accessible, supportive, and safe environments where individuals can participate with confidence despite functional limitations. In particular, developing such opportunities in healthcare or community settings may be important for day-care rehabilitation users.
This study had some key limitations. First, as this was a cross-sectional study, causal relationships between the analyzed factors could not be established. Thus, future longitudinal studies are warranted to examine such causalities. Second, the participants in this study were users of a day-care rehabilitation facility, representing a population with specific characteristics related to physical and functional decline. Therefore, caution is required when generalizing these findings to the broader community-dwelling older adult population. Third, this study was conducted at a single facility with a relatively small sample. Expanding the sample in future studies may facilitate a more detailed analysis of factors influencing physical activity by incorporating additional variables related to life-space and transportation availability. Additionally, we used the Life-Space Assessment as an indicator of life-space, but did not evaluate specific outing destinations. As destination type may also influence physical activity levels, future studies should consider this aspect. Similarly, when assessing transportation availability, we did not collect detailed information on the type of public transportation used (e.g., buses or trains), and the effects on physical activity may differ depending on the type of transportation used. This factor may be important when examining the relationship between life-space expansion and physical activity. In addition, we did not assess the availability or proximity of public transportation near participants’ homes, which may have influenced the results. Specifically, future studies should distinguish between private and public transportation (e.g., buses and trains) and consider environmental factors (e.g., accessibility between home and public transportation).
This study examined the association between the independent availability of transportation and both life-space and physical activity among users of day-care rehabilitation facilities in Japan. The findings suggest that having independently available transportation is significantly associated with a larger life-space; however, its impact on physical activity levels may be limited. When considering strategies to promote physical activity, simply expanding life-space through transportation may not necessarily lead to an effective increase in physical activity. It is important to consider factors such as the type of transportation used and the nature of the activities undertaken at the destinations.
Funding
The authors report no particular sources of funding associated with the work reported herein.
Conflict of interest
The authors report there are no competing interests to declare.
Acknowledgments
The authors would like to thank all participants and staff who contributed to this study.
REFERENCES
- 1.Momose A, Yamaguchi S, Okada A, et al. : Factors associated with long-term care certification in older adults: a cross-sectional study based on a nationally representative survey in Japan. BMC Geriatr, 2021, 21: 374. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ministry of Health, Labour and Welfare. White Paper & Reports—Annual Health, Labour and Welfare Report. https://www.mhlw.go.jp/english/wp/index.html (Accessed Dec. 19, 2025)
- 3.Shephard RJ, Park H, Park S, et al. : Objectively measured physical activity and progressive loss of lean tissue in older Japanese adults: longitudinal data from the Nakanojo study. J Am Geriatr Soc, 2013, 61: 1887–1893. [DOI] [PubMed] [Google Scholar]
- 4.Adachi T, Kamiya K, Kono Y, et al. : Predicting the future need of walking device or assistance by moderate to vigorous physical activity: a 2-year prospective study of women aged 75 years and above. BioMed Res Int, 2018, 2018: 1340479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Adachi T, Kono Y, Iwatsu K, et al. : Duration of moderate to vigorous daily activity is negatively associated with slow walking speed independently from step counts in elderly women aged 75 years or over: a cross-sectional study. Arch Gerontol Geriatr, 2018, 74: 94–99. [DOI] [PubMed] [Google Scholar]
- 6.Doi T, Makizako H, Shimada H, et al. : Objectively measured physical activity, brain atrophy, and white matter lesions in older adults with mild cognitive impairment. Exp Gerontol, 2015, 62: 1–6. [DOI] [PubMed] [Google Scholar]
- 7.Amagasa S, Machida M, Fukushima N, et al. : Is objectively measured light-intensity physical activity associated with health outcomes after adjustment for moderate-to-vigorous physical activity in adults? A systematic review. Int J Behav Nutr Phys Act, 2018, 15: 65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Frith E, Loprinzi PD: Accelerometer-assessed light-intensity physical activity and mortality among those with mobility limitations. Disabil Health J, 2018, 11: 298–300. [DOI] [PubMed] [Google Scholar]
- 9.Taylor D: Physical activity is medicine for older adults. Postgrad Med J, 2014, 90: 26–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Franco MR, Tong A, Howard K, et al. : Older people’s perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature. Br J Sports Med, 2015, 49: 1268–1276. [DOI] [PubMed] [Google Scholar]
- 11.Hasegawa J, Suzuki H, Yamauchi T: Impact of season on the association between muscle strength/volume and physical activity among community-dwelling elderly people living in snowy-cold regions. J Physiol Anthropol, 2018, 37: 25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tsai LT, Portegijs E, Rantakokko M, et al. : The association between objectively measured physical activity and life-space mobility among older people. Scand J Med Sci Sports, 2015, 25: e368–e373. [DOI] [PubMed] [Google Scholar]
- 13.Parker M, Baker PS, Allman RM: A life-space approach to functional assessment of mobility in the elderly. J Gerontol Soc Work, 2002, 35: 35–55. [Google Scholar]
- 14.Johnson J, Rodriguez MA, Al Snih S: Life-space mobility in the elderly: current perspectives. Clin Interv Aging, 2020, 15: 1665–1674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Souma K, Yokogawa M, Uchiyama K, et al. : Association of life-space with light-intensity and moderate to vigorous-intensity physical activity in older adults using daycare rehabilitation facilities. Physiother Theory Pract, 2024, 40: 856–864. [DOI] [PubMed] [Google Scholar]
- 16.Tran Y, Hashimoto N, Ando T, et al. : Associations between motorized transport access, out-of-home activities, and life-space mobility in older adults in Japan. BMC Public Health, 2022, 22: 676. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Laverty AA, Webb E, Vamos EP, et al. : Associations of increases in public transport use with physical activity and adiposity in older adults. Int J Behav Nutr Phys Act, 2018, 15: 31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Oshima Y, Kawaguchi K, Tanaka S, et al. : Classifying household and locomotive activities using a triaxial accelerometer. Gait Posture, 2010, 31: 370–374. [DOI] [PubMed] [Google Scholar]
- 19.Ohkawara K, Oshima Y, Hikihara Y, et al. : Real-time estimation of daily physical activity intensity by a triaxial accelerometer and a gravity-removal classification algorithm. Br J Nutr, 2011, 105: 1681–1691. [DOI] [PubMed] [Google Scholar]
- 20.Izawa KP, Shibata A, Ishii K, et al. : Associations of low-intensity light physical activity with physical performance in community-dwelling elderly Japanese: a cross-sectional study. PLoS One, 2017, 12: e0178654. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Amagasa S, Fukushima N, Kikuchi H, et al. : Light and sporadic physical activity overlooked by current guidelines makes older women more active than older men. Int J Behav Nutr Phys Act, 2017, 14: 59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Migueles JH, Cadenas-Sanchez C, Ekelund U, et al. : Accelerometer data collection and processing criteria to assess physical activity and other outcomes: a systematic review and practical considerations. Sports Med, 2017, 47: 1821–1845. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Skender S, Ose J, Chang-Claude J, et al. : Accelerometry and physical activity questionnaires—a systematic review. BMC Public Health, 2016, 16: 515. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Baker PS, Bodner EV, Allman RM: Measuring life-space mobility in community-dwelling older adults. J Am Geriatr Soc, 2003, 51: 1610–1614. [DOI] [PubMed] [Google Scholar]
- 25.Harada K, Shimada H, Sawyer P, et al. : [Life-space of community-dwelling older adults using preventive health care services in Japan and the validity of composite scoring methods for assessment]. Nihon Koshu Eisei Zasshi, 2010, 57: 526–537 (in Japanese). [PubMed] [Google Scholar]
- 26.Chaix B, Kestens Y, Duncan S, et al. : Active transportation and public transportation use to achieve physical activity recommendations? A combined GPS, accelerometer, and mobility survey study. Int J Behav Nutr Phys Act, 2014, 11: 124. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Gough C, Lewis LK, Barr C, et al. : Community participation of community dwelling older adults: a cross-sectional study. BMC Public Health, 2021, 21: 612. [DOI] [PMC free article] [PubMed] [Google Scholar]