targeted resistance training to improve … · by joseph f. signorile,ph.d. learning objectives...

TARGETED RESISTANCE TRAINING TOIMPROVE INDEPENDENCE AND REDUCEFALL RISK IN OLDER CLIENTSby Joseph F. Signorile, Ph.D.

Learning ObjectivesReaders will learn the multidi-mensional nature of resistancetraining. Information will be pro-vided that will allow readers tomodify common resistance train-ing protocols and learn noveltechniques to target goals inher-ent to the aging process Theyalso will learn how specific proto-cols can be structured to maxi-mize benefits.

Key words: Resistance Training,Training Specificity, Translation,Exercise Prescription

Volume 20 | Number 5

Copyright © 2016 American C

lder persons (60 years of age and older) constitute the fastest growing seg-ment of our population with an expected increase from 43.1 million in
O2012 to a projected 83.7 million in 2050 (72). The loss of muscle andneuromuscular performance with age eventually leads to reduced phys-ical independence, increased fall risk, and declining quality of life in
older persons (49,62). Maintaining function and independence arguably is more impor-tant than increasing life expectancy (50). Given the increase in the elderly population,the social and economic burdens of declined physical function are a major public healthconcern. In recognition of this dilemma, an overriding goal of the U.S. Department ofHealth and Human Services’ Healthy People 2020 initiative is to reduce the proportionof older adults with moderate-to-severe functional limitations (47). Interventions thatcan successfully address these concerns are imperative to the well-being of older personsand society as a whole (46). Resistance training has proven to be an effective modalityfor addressing the needs of older individuals; however, the specific loading techniques,movement patterns, and protocols available to the clinician vary considerably. Carefulmanipulation of these training variables allows targeted prescriptive exercise designs thatcan address the particular needs of the individual and effectively reflect the AmericanCol-lege of SportsMedicine’s (ACSM’s) Exercise isMedicine® initiative. This article will presentprotocols designed to address individual needs and explain the theories behind theirdesign and implementation. Sidebar 1 presents definitions that may prove helpful asyou read this article. In addition, although diagnostic testing is beyond the scope of thisarticle, Sidebar 2 presents references for tests that you may use to track clients’ progressand recognize how to use the techniques included in this article to maximize clients’progress.

www.acsm-healthfitness.org 29

ollege of Sports Medicine. Unauthorized reproduction of this article is prohibited.

Sidebar 1. Helpful Definitions.Agonist-Antagonist Coactivation: The coordinated firing ofthe agonist (prime mover) and antagonist (opposing) muscles,presumably to maintain degree of joint stability.

Classic Training Continuum: The repetition training continuum (4)or repetition maximum continuum (39) states that thenumber of repetitions allowed by changing resistanceresults in specific training adaptations.

Executive Function: A diverse neuropsychological conceptthat includes the physical and cognitive skills necessary toinitiate, implement, and maintain goal-specific activities andto modify activities as goals change (97). Therefore, executivefunction may be considered a multifaceted concept includingfactors such as selecting proper responses, blocking ineffectiveresponses, improving motor capacity, and showing the cognitiveflexibility to change goals (97).

Isokinetic Training: A specialized training system using adynamometer that restricts movement speed (89,101).

Motor Unit Recruitment: Progressively activating motor neuronsand their associated muscle fibers to increase force andpotentially power output.

Linear Periodization: The classic periodization scheme thattypically begins with high work volumes, low intensities, andlow-skill work and progresses through targeted microcycles(approximately 1 wk) and mesocycles (multiple weeks) tolow-volume, high-intensity work with increasing concentration onskill work.

Lower Body Power Asymmetry: Differences in power productionbetween the lower limbs (92).

Proprioception: The perception of the relative positions of one’sbody parts (88).

Rate Coding: Increases or decreases in the firing frequency of amotor unit to affect force production and/or movement speedof the motor fibers being innervated.

Synchronization of Synergistic Muscles: Matched motor unitdischarges (firing patterns) across muscles that perform thesame or similar actions with the intent of increasing strengthor power.

Surfing the Force-Velocity Curve: As illustrated in Figure 4, someactivities may require more strength for their successfulcompletion, whereas others may be more dependent on speedof movement. I coined this phrase decades ago to indicate thatyou can target these activities by changing force-velocityrelationships along the curve. The word surfing came to mindbecause the power and force-velocity curve both remindedme of ocean waves (87).

Undulating Periodization: A form of nonlinear periodization,the most popular being daily undulating periodizationincorporating alternating days of hypertrophy, strength,and power/speed each week, whereas weekly undulatingperiodization uses this pattern across a 3-week repeatingcycle (17).

Sidebar 2. Suggestions for Testing to AssessClients’ Needs.

LOWER BODY STRENGTH

30-Second Chair Stand

Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as ameasure of lower body strength in community-residing olderadults. Res Quar Exerc Sport. 1999;70(2):113–9.

UPPER BODY STRENGTH

30-Second Arm Curl

James TW. The 30-second arm curl test as an indicator of upperbody strength in older adults. 1999.

Grip Strength Test

National Institutes of Health. NIH Toolbox. Grip Strength Test.http://www.nihtoolbox.org/WhatAndWhy/Motor/Strength/NIH%20Toolbox%20Grip%20Strength%20Test/Pages/default.aspx.

LOWER BODY POWER

30-Second Chair Stand

Smith WN, Del Rossi G, Adams JB, et al. Simple equations topredict concentric lower-body muscle power in older adultsusing the 30-second chair-rise test: a pilot study. Clin IntervAging. 2010;5(5):173–80.

Ramp Power Test

Signorile JF, Sandler D, Kempner L, Stanziano D, Ma F, Roos BA.The ramp power test: a new method of power assessmentduring a functional task for older individuals. J Gerontol.2007;62A:1266–73.

UPPER BODY POWER

Gallon-Jug Shelf Transfer Test

Signorile JF, Sandler D, Ma F, et al. The gallon-jug shelf-transfertest: an instrument to evaluate deteriorating function in olderadults. J Aging Phys Act. 2007;15:56–74.

Seated Medicine Ball Throw

Harris C, Wattles AP, DeBeliso M, Sevene-Adams PG, Berning JM,Adams KJ. The seatedmedicine ball throw as a test of upper bodypower in older adults. J Strength Cond Res. 2011;25(8):2344–8.

LOWER BODY ENDURANCE

Two-Minute Walk Test

National Institutes of Health. NIH Toolbox. 2-Minute Walk Test.http://www.nihtoolbox.org/WhatAndWhy/Motor/Endurance/Pages/NIH-Toolbox-2-Minute-Walk-Endurance-Test.aspx.

Static Half-Squat Test

McIntosh G, Wilson L, AffleckM, Hall H. Trunk and lower extremitymuscle endurance: normative data for adults. J RehabilOutcomes Meas. 1998;2:20–39.

RESISTANCE TRAINING FOR ELDERLY

30 ACSM’s Health & Fitness Journal® September/October 2016

Copyright © 2016 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

http://www.nihtoolbox.org/WhatAndWhy/Motor/Strength/NIH%20Toolbox%20Grip%20Strength%20Test/Pages/default.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Strength/NIH%20Toolbox%20Grip%20Strength%20Test/Pages/default.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Endurance/Pages/NIH-Toolbox-2-Minute-Walk-Endurance-Test.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Endurance/Pages/NIH-Toolbox-2-Minute-Walk-Endurance-Test.aspx

BALANCE AND FALL RISK

Standing Balance Test

National Institutes of Health. NIH Toolbox. Standing Balance Test.http://www.nihtoolbox.org/WhatAndWhy/Motor/Balance/Pages/Balance.aspx.

Functional Reach Test

Duncan PW, Weiner DK, Chandler J, Studenski S. Functionalreach: a new clinical measure of balance. J Gerontol.1990;45:M192–7.

Timed Up-and-GoTest

Podsiadlo D, Richardson S. The timed “up & go”: a test of basicfunctional mobility for frail elderly persons. J Am Geriatr Soc.1991;39:142–8.

Balance Evaluation Systems Test (BESTest)

Horak FB, Wrisley DM, Frank J. The balance evaluation systemstest (BESTest) to differentiate balance deficits. Phys Ther.2009;89(5):484–98.

Profile of Mood States (POMS) Test

Tinetti ME. Performance-oriented assessment of mobility problemsin elderly patients. J Am Geriatr Soc. 1986;34:119–26.

Berg Balance Test

Berg KO, Maki BE, Williams JI, et al. Clinical and laboratorymeasures of postural balance in an elderly population.Arch Phys Med Rehabil. 1992;73:1073–80.

One-Leg Stand Test

Vellas BJ, Wayne SJ, Romero L, et al. One-leg balance is animportant predictor of injurious falls in older persons. J AmGeriatr Soc. 1997;45:735–8.

Fall Risk for Older People in the Community (FROP-com)

Russell MA, Hill KD, Blackberry I, Day LM, Dharmage SC. Thereliability and predictive accuracy of the falls risk for olderpeople in the community assessment (FROP-com) tool. AgeAgeing. 2008;37:634–9.

GAIT

Four-Meter Gait Speed Test

National Institutes of Health. NIH Toolbox. 4-meter Gait SpeedTest. http://www.nihtoolbox.org/WhatAndWhy/Motor/Locomotion/Pages/NIH-Toolbox-4–Meter-Walk-Gait-Speed-Test.aspx.

FUNCTIONAL PERFORMANCE/DAILY ACTIVITY BATTERIES

Short Physical Performance Battery (SPPB)

Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physicalperformance battery assessing lower extremity function:association with self-reported disability and prediction ofmortality and nursing home admission. J Gerontol Med Sci.1994;49:M85–94.

Senior Fitness Battery

Rikli RE, Jones CJ. Development and validation of a functional fit-ness test for community-residing older adults. J Aging Phys Act.1999;7:129–61.

Continuous-scale Physical Functional Performance Test (CS-PFP 10)

Cress ME, Petrella JK, Moore TL, et al. Continuous-scale physicalfunction performance test: validity, reliability, and sensitivity ofdata for the short version. Phys Ther. 2005;85:323–35.

Health, Aging, and Body Composition (Health ABC) Test

Simonsick EM, Newman AB, Nevitt MC, et al. Measuring higherlevel physical function in well-functioning older adults:expanding familiar approaches in the health ABC study.J Gerontol A Biol Sci Med Sci. 2001;56(10):M644–9.

TEXTS

Rikli R, Jones CJ. Senior Fitness Test Manual. 2nd ed.Champaign (IL): Human Kinetics; 2013.

Signorile JF. Bending the Aging Curve. Champaign (IL): HumanKinetics; 2011.


Copyright © 2016 American College of Sports Medicine. U

SARCOPENIA AND DYNAPENIASarcopenia (sarco = muscle; penia = deficiency or lack) was tradi-tionally defined as a decline in muscle mass. The classic defini-tion was a sex-specific decline in muscle mass below twostandard deviations of normal young men and women (Figure 1)(28). This definition encouraged concentration on increases inmuscle mass rather than on muscle function (strength, power,endurance). Given this goal, and likely the dominant influ-ence of bodybuilding on the design of resistance training work-outs, most of the early work with older persons concentratedon hypertrophy-based protocols (22,41). The evolution of thedefinition, which incorporates functions such as walking speedand grip strength, and the prevalent use of the term dynapenia

Figure 1. The classic sarcopenia curve. Note that the redportion of the curve is two standard deviations (97.6%)below the muscle cross-sectional area of sex-matchedyounger population.


nauthorized reproduction of this article is prohibited.

http://www.nihtoolbox.org/WhatAndWhy/Motor/Balance/Pages/Balance.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Balance/Pages/Balance.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Locomotion/Pages/NIH-Toolbox-4--Meter-Walk-Gait-Speed-Test.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Locomotion/Pages/NIH-Toolbox-4--Meter-Walk-Gait-Speed-Test.aspxhttp://www.nihtoolbox.org/WhatAndWhy/Motor/Locomotion/Pages/NIH-Toolbox-4--Meter-Walk-Gait-Speed-Test.aspx

Figure 2. The asymptotic nature of training adaptations.(Adapted from: Moritani T, deVries HA, Neural factorsversus hypertrophy in the time course of muscle strengthgain. American Journal of Physical Medicine. 1979;58(3):115–130. Used with permission) (13).


(dyna = power; penia = deficiency or lack), has redirected atten-tion as it relates to this topic toward muscle function rather thansize (24,28). Simply defined, dynapenia is a loss of strength, power,or endurance that can be expected to lead to an increased risk forfunctional loss and mortality in older persons (24,28). The distinc-tion between sarcopenia and dynapenia is especially relevantto training prescription because muscle size has a progressivelyweaker relationship to neuromuscular function as we age.

HYPERTROPHYIn this section, we will concentrate on prescriptions addressingthe classic definition of sarcopenia by examining protocols thatmaximize hypertrophy. Resistance training programs that targethypertrophy traditionally use high work volume by combiningmultiple sets and exercises with moderate to moderately heavyloading patterns (54,64). These patterns usually are coupled withintermediate-length recoveries to maximize total work duringeach session (54,64). Although there are a number of controlledstudies that have demonstrated significant hypertrophic responsesin older persons using standard strength training programs (22,41)and low training volumes, increases likely are not optimal whenusing protocols that fail to concentrate on maximizing total work(38). The relationship between work volume, with associated fa-tigue, and hypertrophy is supported in a recent meta-analysis byCsapo and Alegre (29) that reported significant gains in musclemass were seen after moderate-intensity (approximately 50% one-repetition maximum (1 RM) and high-intensity (approximately80% 1 RM) training as long as the volume of training is held high(8–11 reps for 2–4 sets) and sufficient recovery (approximately1.5–3 min between sets and machines, respectively) is provided.

A final concept may be applicable when clinicians work withnovice clients or those using daily undulating periodization duringthe early stages of training. There are data suggesting that whentargeting increases in cross-sectional area in previously untrained,detrained, and to-some-extent-trained clients, low-repetition/high-load (4 sets, 3–5 reps; approximately 87%–93% 1 RM) andintermediate-repetition/moderate-load (3 sets, 9–11 reps; approx-imately 73%–77% 1 RM) training can produce similar levels ofhypertrophy (19,84). This is not unexpected given the asymptoticnature of the training curve (13). In other words, improvementsare greatest early in the training cycle (first 6–8 wks) and thenshow exponentially reduced levels of adaptation until a near-plateau is reached (Figure 2) (88).

STRENGTHOf all the performance variables associated with resistance train-ing, the most evident to the general public and most healthprofessionals is strength. Although increases in strength arecommonly associated with increases in muscle cross-sectionalarea, this relationship clearly is not absolute. In fact, the correla-tion betweenmuscle size and strength becomes progressively lessrobust with age because it is influenced by the quality of muscleand connective tissue as well as reductions in voluntary muscleactivation (24). For example, knee extensor isokinetic strength

32 ACSM’s Health & Fitness Journal®


(see Sidebar 1 for definition) measured at 120 degrees/secondshowed a correlation of 0.889 with quadriceps cross-sectionalarea in men ages 19 to 34 years, but declined to 0.623 in menages 65 to 77 years old (73). The lack of correlation betweenmuscle mass and strength further argues for the use of differenttraining strategies between protocols designed to target strengthand hypertrophy.

There is nearly universal agreement that maximal increasesin strength are associated with the heaviest training loads, asshown in the classic training continuum (19). This has been con-firmed in two reviews and a meta-analysis that examined dose-response relationships during progressive resistance training.All three concluded that intensity was the greatest effector ofstrength gains, with a resistance level of approximately 80%1RM and higher being optimal (57,58,76). This recommenda-tion incorporates a somewhat lower minimum value than thatcontained in the 87.5%-to-92.5% range recommended byCampos et al. (19) in younger lifters. In addition, in their meta-analysis examining dose-response relationships during strengthtraining, Rhea et al. (80) suggest that for previously untrained per-sons having less than 1 year lifting experience, training loads ofapproximately 60% 1RM provide sufficient stimulus. This is es-pecially important because every training program involving be-ginners or deconditioned individuals should incorporate a tissueadaptation period where gradual increases in load and volume al-low restructuring of muscle and connective tissue before the op-timal overload is applied (88).

The impact of resistance training on strength in subjectsranging from 67 to 97 years also can be attributed to three neu-romuscular events: 1) voluntary muscle activation (recruitment

September/October 2016


and rate coding), 2) agonist-antagonist coactivation (5), and3) synchronization of synergistic muscles (69) (see Sidebar 1). Al-though there is considerable support for increased activation andsynchronization as controlling factors, the impact of agonist-antagonist coactivation remains undetermined (5). The greatestincreases in neuromuscular activity in this older population wererecorded at a resistance ranging from 70% to 80% 1RM usingthree sets of three repetitions three times per week (5).

Finally, there has been considerable dialogue during the pastfew decades concerning the optimum number of sets to be usedto maximize strength gains. Despite earlier reviews supportingequal strength gains for single versus multiple sets (20,77), morerecent meta-analyses support the use of multiple over single setsfor strength development (79,80). However, single-set programsdo seem feasible during the initial stage when working with pre-viously untrained individuals or when maximizing strength isnot the primary objective (102). Alternatively, it may be arguedthat the use of multiple sets allows the individual to improve skilland technique as long as intensity and volume are controlledcarefully. Finally, results specific to older persons remain unde-termined (43).

POWERPower is the rate of doing work; therefore, it is the productof force and velocity of movement (87,88). The strong relation-ship between power and independence as we age is undeniable.Correlations have been reported between performance of activ-ities of daily living (ADL), the ability to rise from a chair, stairclimbing and gait speed and measures of leg extensor power(8,40,78,91). The relationship between reduced leg extensor,plantar flexor, and dorsiflexor power and falls also has been rec-ognized for more than three decades (3,101) with special em-phasis on increased risk due to lower limb power asymmetry(see Sidebar 1 for definition) (75,92).

With the onset of the new millennium, a number of studieshave demonstrated the effectiveness of high-velocity trainingfor power development and improved daily function in olderpersons (36,83,90). During the succeeding years, a great dealhas been learned about the training methods that can maximizethe development of mechanical power and its benefits to indi-viduals as they age. The variables associated with maximizingpower include optimal loading and the methods for providingtraining loads. Optimal loading can be defined as the percentageof maximal load that produces the highest power output. Thisconcept may seem rather simple at first; however, there are anumber of factors that can modulate this simple concept. Thefirst is the mechanics of the joint being trained.We have demon-strated in a number of studies that the response of specific mus-cle groups to power training varies because of the bony leversassociated with their structure (Figure 3) (42,89). Therefore, tomaximize gains for each exercise, loading must be adjusted toreflect these biomechanical differences. We have establishedthese loads for pneumatic (air pressure) training using Keiser



machines, and we are currently establishing loads for standardselectorized Cybex machines.

The concept of optimal loading also must be adjusted to ad-dress what is arguably a more important factor: loading to ad-dress independence and fall reduction. Concerning independencelet me harken back to a concept I presented more than a decadeago, “surfing the force-velocity curve” (see Sidebar 1 for defi-nition) (87). This concept embodies a simple idea that ulti-mately dictates loading for functionality: the loads used todevelop power should reflect the loads used during the activitiesbeing targeted by the training prescription applied. This con-cept is reflected in the work of Cuoco et al. (30). Succinctly,lower loads are used to train power at the velocity end of thecurve when movement speed is the dominant goal, as whentargeting gains in gait speed. In contrast, daily activities, suchas rising from a chair or climbing stairs that require greater workagainst gravity, dictate training at the load end of the curve(Figure 4).

As a final caveat, given that many researchers recognize thatpower training with older persons is based primarily on the at-tempt to move at near-maximal speeds (36,83,90), the trainingmodalities that can best support this type of training in a safeenvironment should be explored. Pneumatic resistance ma-chines are the most common tools used because of their smoothforce-angle curves and low levels of momentum. In addition, rub-ber tubing provides a practical, although somewhat limited, alter-native. Free weights are another feasible option; however, theiruse should be approached with caution because they present ahigher injury risk to the uninitiated or detrained individual withdeclining neuromuscular and connective tissue strength due toage. Finally, most research studies with older persons have incor-porated dumbbells and weighted bags rather than barbells, leav-ing loading patterns across more classic lifts such as squats orbench press undetermined (15,91,92). Currently, our laboratoryis comparing the use of selectorized and pneumatic machines toassess their relative effectiveness, safety, and acceptance with anolder population.

MUSCULAR ENDURANCEBefore examining the importance of muscular endurance to olderpersons, it is first important to distinguish between muscular andcardiovascular endurance. Although these two concepts are notcompletely independent nor mutually exclusive, clear physiologicaland functional distinctions can be made when defining each. Car-diovascular endurance is “the ability of the circulatory and respiratorysystem to supply oxygen during sustained physical activity” (37)whereas muscular endurance can be defined as the ability of a skeletalmuscle to maintain a specific power output (88).

Muscular endurance is a critical factor in maintaining inde-pendence (6,85) and reducing fall risk (85,94) in older persons.It also is associated with reduced proprioception (see Sidebar 1for definition) (66). Because daily tasks each require their owncritical absolute strength level for effective performance, older per-sons likely will require a greater proportion of their maximum



Figure 3. Note that high-speed training increased power in the leg extensors (A) because of the long third class lever systemassociatedwith knee extension. In contrast, the ankle plantar flexors (B) showed their greatest improvements with low-speed,high-load training because the ankle joint is a second class lever with a resistance arm that is shorter than its force arm (89).


strength than younger individuals to perform each task, and theirability to perform these tasks for extended durations will be pro-portionally reduced (6,85).

Although increasing muscle strength may increase muscu-lar endurance, specific protocols are available to target mus-cular endurance (15). For example, we have demonstratedthe effectiveness of a high-repetition resistance training pro-tocol based on ACSM guidelines at increasing muscular en-durance. Subjects performed two sets of 15 to 25 repetitionsfor 11 exercises at 50% 1 RM, and high speeds were encouragedduring the concentric phases of the lift to target the maintenanceof a specific power output. They were allowed 1 to 2 minutes re-covery between sets, with minimal recovery between machines.Upper and lower body exercises were alternated. Loading wasincreased as necessary to maintain resistance levels. Our re-sults showed that this training protocol not only reduced powerdeclines during 20-repetition leg and chest press tests; these im-provements also were evident in ADL performance tests (Baileyet al., personal communication). Our results reflect the trainingcontinuum proposed by Campos et al. (19), who noted thatmuscle endurance could best be increased using two sets ofhigh-repetition training (20–28 RM) with a 1-minute recoverybetween sets (see sidebar 1 for definition).



BIOMECHANICAL SPECIFICITY AND ACTIVITIES OFDAILY LIVINGIn most of the resistance training studies done with older partic-ipants, the exercises were performed using standard weighttraining machines. These machines usually dictate that:

• The individual is seated;• The movement of the handles follows a fixed, linear path;• Isolated or limited kinetic chain patterns are used; and,• Core muscles are rarely involved except as stabilizers.

Although, as noted above, resistance training enhances neuro-muscular performance, these increases translate only modestlyinto improvements in daily activities (60,76). A feasible explanationfor this low level of positive transfer is the lack of biomechanical spec-ificity because the movement patterns used during machine-basedtraining often fail to mirror those used during daily activities (21).

A number of researchers have addressed this issue by provid-ing exercise programs that mimic or even replicate ADL (2,10,11,32,63). Many of these exercises, however, fail to providethe external loading patterns that effectively improve neuromus-cular capacity during resistance training.

This limitation can be addressed using exercises that allowmore degrees of freedom such as free weights or cable machines,



Figure 4. "Surfing the force-velocity curve" to provideload-specific training targeting specific daily activities.Notice that an activity like rising from a chair requires aconsiderably higher percentage of a person’s body weightto be moved against gravity than walking along a levelsurface. Therefore, the loading for the former would betoward the load end of the curve, whereas the loading for thelatter is toward the velocity end of the curve (constructedusing concepts from Signorile (87) and Cuoco et al (30)).

Figure 5. The use of cable machine training to engage thecore muscles as part of a kinetic movement chain (A,B) that reflects the transfer of a pot to a shelf (C, D).

with the latter providing a safer environment and less challeng-ing learning curve. These modalities allow exercises to be per-formed in a standing position using movement patterns thatprovide transfer of forces from the lower to upper body throughthe core muscles in kinetic sequences common to many daily ac-tivities such as transfer tasks, house cleaning, and gardening (Figure5 A-D). However, this does not negate the use of standard weighttrainingmachines, which can target daily activities that incorporatemore linear or isolated movement patterns and can provide higherloads (Figure 6A, B). Furthermore, as illustrated in Figure 7A-H,band or tube resistance exercise may be used in lieu of weighttraining machines where this equipment is not available.

In addition to considering muscle use patterns as they relateto ADL, we also should consider muscle targeting as it relatesto fall reduction. There are four muscle groups that receive min-imal attention during training, yet are critical for improvingbalance and reducing fall risk. Perhaps the most ignored, andcoincidentally the most important, are the dorsiflexors. A simplesearch of the literature will provide dozens of studies demon-strating the relationships of this muscle group to balance andfalls (88). A second muscle group that receives minimal trainingis the hip flexors. If you doubt the importance of these groups togait, simply put this article down and walk a few steps. Noticethat every step is initiated by flexing the hip and dorsiflexingthe foot. The inability to effectively perform these two move-ments reduces ground clearance andmakes walking over a crackin the sidewalk equivalent to stepping over a curb. The othertwo muscle groups that are habitually ignored are the hip



adductors and abductors. This predominantly sex-specificavoidance, with women as the predominant users, ignores thefact that there is a direct relationship between hip abductorand adductor function and fall risk (68) and related injury (23).In addition, as illustrated in Figure 8, weights can be used, inconjunction with postures that challenge center of gravity/baserelationships, to improve balance.

ENERGY EXPENDITURE AND BODY COMPOSITIONBecause of age-related declines in metabolic rate (34) and de-clining levels of physical activity (34), obesity is a common prob-lem facing aging individuals. The implications of this conditionrange from reduced capacity to perform ADL to increased inci-dence of metabolic disease. When a body mass index of morethan 30 kg/m2 is combined with sarcopenia, a state known assarcopenic obesity exists (56). Individuals with sarcopenic obe-sity are at greater risk for disability and loss of independencethan those who are merely obese or sarcopenic (9,81). Although



Figure 6. Similar patterns of movement associated withthe chair stand (A) and leg press (B) provide a hypotheticalbiomechanical argument supporting the use of this linearselectorized machine over cable training for thisparticular activity.

Figure 7. Examples of tube/band exercises that can be usedin lieu of standard resistance training machines including(A, B) trunk rotation, (C, D) overhead press, (E, F) chest press,and (G, H) squat.


typical high-intensity interval programs have proven somewhateffective in addressing obesity and some aspects of metabolicsyndrome in older (44) and younger populations (51,86), circuitresistance training programs have the capacity to elicit greatermetabolic cost than typical steady state (25) or traditional-strength programs (82). They also can add the additional bene-fits of providing overloads capable of increasing muscle massand neuromuscular function in older persons (7,82).

In addition to greater energy expenditure being generated bycircuit resistance training compared with heavy resistance (71)or traditional treadmill training (25), it also can produce signifi-cantly higher excess postexercise oxygen consumption (EPOC)than steady state training (14,71). Research has demonstratedthat explosive training at 60% 1 RM can produce greater energyexpenditures than slow training at 60% 1 RM or explosive train-ing at 80% 1 RM (64,65) and that minimizing recovery time be-tween exercises and sets seems the most effective strategy forincreasing EPOC (31). The following are other circuit trainingstrategies that have shown the potential to positively addressbody composition and increase energy expenditure:

• Used a combination of resistance and aerobic exerciseduring the circuit (48,67,74,98);

36 ACSM’s Health & Fitness Journal® September/October 2016

Copyright © 2016 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

Figure 8. Examples of resistance-assisted balance exercisesincluding (A, B) single-leg overhead press, (C, D) single-legcontralateral overhead press, (E, F) split squat, and (G, H)step-up.



• Prescribed intensity based on heart rate (12);• Used training frequencies higher than twice per week(1,45); and,

• Included dietary controls (55).

In summary, circuit-based resistance training, performed atmoderate loads and high velocities at least three times per week,seems most effective, especially when combined with a calorie-restricted diet.

COGNITIONThe link between cognitive function and exercise has generatedsignificant interest within the scientific and clinical communities.To date, however, the predominant exercise interventions thathave been linked to positive changes in cognitive function haveconcentrated on aerobic conditioning, and improvements havebeen hypothesized to be proportional to improved delivery ofoxygen and nutrients to neural tissues (26,99). Reviews do sug-gest that improved cognition requires high-intensity aerobic ex-ercise (26,99); however, improvements in aerobic capacity donot fully explain improvements in cognition (35). In addition,high-velocity circuit resistance training has been shown to im-prove cognition, psychiatric symptoms, and neuromuscular per-formance in overweight outpatients with schizophrenia andbipolar disorder (96). Four additional controlled trials supportthese results showing increases in cognition and executive func-tion (for definition see Sidebar 1) with resistance training (16,52,61,100). More recently, in a study of 324 healthy female twinsaged 43 to 73 years, Steves et al. (95) demonstrated that legpower was a significant predictor of cognitive aging and changesin global brain structure even when controlling for genetics anddevelopmental environment. And finally, a meta-analysis exam-ining the effects of exercise on depression indicated that im-provements were not mediated by increases in cardiovascularfitness (27). Therefore, improved cardiovascular fitness may beone facilitator of improved cognitive function, but increasedmo-tor capacity certainly is a major contributor.

The results of the study by Strassnig et al. (96) and a recentlycompleted study comparing ballroom and hip-hop aerobicdance (Nicole et al., personal communication) add a furtherconsideration when exploring resistance training designed toimprove cognition. The Strassnig study used a translational re-covery component where ADL-specific movements were prac-ticed. The dance study showed that greater increases inexecutive function occurred with ballroom compared with aer-obic hip-hop, even in the face of greater aerobic gains engen-dered by the latter. This was likely because of the need towork in coordinated patterns in response to changing auditorystimuli rather than the verbal cues and less complex imitativemovements during the hip-hop class.

When the results of these studies are considered as indicatorsof the most effective resistance training protocol for improvingcognition, two hypothetical protocols emerge. The first is a high-speed power-based circuit with recovery cycles that incorporate




ADL-specific translational cycles as recommended inmy Bending theAging Curve text (88) or high-speed power training using biomechan-ically specific movement patterns as previously described. Regard-less of the method used, there is little doubt, given results of animalstudies, thatmovement speed and complexity are each potent stim-ulators of cognitive capacity (53,59).

PERIODIZATIONPeriodization can simply be defined as a method of cycling vol-ume, intensity, and skill performance in a set pattern designedto maximize a specific goal while minimizing fatigue and the po-tential for overtraining. A comprehensive description of period-ization methods as they may be applied to older individuals isbeyond the scope of this article; however, I would like to concludewith some important considerations you should keep in mind:

• Recovery is as essential as overload for improving perfor-mance and related improvements in daily living;

• Both linear and undulating models can be effectivemethods for applying periodization (see Sidebar 1 fordefinitions);

• Taper periods during the periodization cycle are idealtimes to add ADL-specific movements to allow increasesin neuromuscular function to be translated into increasedindependence and reduced fall risk;

• After specific mesocycles, testing should be applied to pro-vide direction and allow the evolution of the client’s/patient’s training program;

• A gradual tissue-adaptation period should be incorpo-rated before beginning any program that will involvenovice or deconditioned individuals; and,

• Proper structuring of targeted training cycles will allow theexercise physiologist to maximize benefits and reduce thepotential for injury.

CONCLUSIONSResistance training is a potent tool for increasing independenceand reducing falls and related injuries in aging individuals; how-ever, to maximize the effectiveness of this tool, we must abandonthe one-dimensional anaerobic strength picture of resistance train-ing and recognize that by changing the structure of the workoutsand the methods by which overloads are applied, we can trulyrealize the multidimensional nature of this intervention for suc-cessful aging. Therefore, the application of resistance training asan effective clinical intervention for sarcopenia and dynapeniashould use concepts such as targeted loading, speed-specificpower training, and biomechanical specificity to maximizeimprovement.

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Disclosure: The author declares no conflict of interest and does not have anyfinancial disclosures.

nauthorized reproduct

Joseph F. Signorile, Ph.D., is a professor of Ex-ercise Physiology at the University of Miami De-partment of Kinesiology and Sport Sciences with ajoint appointment at the University of MiamiSchool of Medicine Center on Aging. He has beeninvolved in research using exercise to address inde-pendence and fall prevention for more than25 years, has more than 80 refereed manuscripts,

and has made 275 national and international scientific and 250 industrypresentations.


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