Comparison of Traditional and Recent
Approaches in the Promotion of Balance
and Strength in Older Adults
Urs Granacher,1
Thomas Muehlbauer,1
Lukas Zahner,2
Albert Gollhofer3
and Reto W. Kressig4
1 Institute of Sport Science, Friedrich-Schiller University, Jena, Germany
2 Institute of Exercise and Health Science, University of Basel, Basel, Switzerland
3 Institute of Sport and Sport Science, University of Freiburg, Freiburg, Germany
4 Basel University Hospital, Division of Acute Geriatrics, Basel, Switzerland
Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
2. Literature Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
2.1 Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
2.2 Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
2.3 Quality Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
3. Balance Training in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
3.1 Traditional Balance Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
3.2 Perturbation-Based Balance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
3.3 Multitask Balance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
4. Resistance Training in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
4.1 Traditional Resistance Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
4.2 Power or High-Velocity Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
5. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Abstract Demographic change in industrialized countries produced an increase in
the proportion of elderly people in our society, resulting in specific healthcare
challenges. One such challenge is how to effectively deal with the increased
risk of sustaining a fall and fall-related injuries in old age. Deficits in postural
control and muscle strength represent important intrinsic fall risk factors.
Thus, adequate training regimens need to be designed and applied that have
the potential to reduce the rate of falling in older adults by countering these
factors. Therefore, the purpose of this review is to compare traditional and
recent approaches in the promotion of balance and strength in older adults.
Traditionally, balance and resistance training programmes proved to be effective
in improving balance and strength, and in reducing the number of
falls. Yet, it was argued that these training protocols are not specific enough
to induce adaptations in neuromuscular capacities that are specifically
needed in actual balance-threatening situations (e.g. abilities to recover
balance and to produce force explosively). Recent studies indicated that
REVIEW ARTICLE
Sports Med 2011; 41 (5): 377-400
0112-1642/11/0005-0377/$49.95/0
ª 2011 Adis Data Information BV. All rights reserved.
perturbation-based or multitask balance training and power/high-velocity
resistance training have the potential to improve these specific capacities
because they comply with the principle of training specificity. In fact, there
is evidence that these specifically tailored training programmes are more
effective in improving balance recovery mechanisms and muscle power than
traditional training protocols. A few pilot studies have even shown that these
recently designed training protocols have an impact on the reduction of fall
incidence rate in older adults. Further research is needed to confirm these
results and to elucidate the underlying mechanisms responsible for the
adaptive processes.
1. Introduction
The world population is increasingly becoming
‘old’. According to the United Nations, the
proportion of older people aged ‡60 years in the
world has grown from 8% to 10% between 1950
and 2000, and by 2050 the proportion of this population
worldwide is expected to be as high as
22%.[1]
A serious concern, particularly of developed
countries, is that an older age structure
would undermine the sustainability of the public
healthcare system, since per capita health expenditures
are five times higher for people older than
75 years of age than for those aged 25–34 years.[2]
One reason for high medical treatment costs in
the elderly seems to be an increased prevalence
of sustaining falls and fall-related injuries:[3,4]
28–35% of individuals over the age of 65 years
suffer at least one fall over a 1-year period,[5,6]
and the occurrence increases to 32–42% in adults
over the age of 75 years and to 56% of adults
between the ages of 90 and 99 years.[7,8]
About
20% of falls need medical attention; 15% of those
result in severe injuries like joint dislocations, soft
tissue bruises and contusions. The remaining 5%
cause fractures, with femoral neck fractures occurring
at a rate of 1–2% in community-dwelling
older adults.[9]
The aetiology of falls is generally considered to
be multifactorial, involving extrinsic (environmental)
and intrinsic (patient-related) circum-
stances.[10]
Numerous epidemiological studies
have identified a multitude of extrinsic and intrinsic
risk factors for falling in older adults.[11-15]
Extrinsic factors include loose rugs, obstructed
walkways, inadequate handrails, etc.[16]
In terms
of intrinsic fall risk factors, impaired postural
control under single (e.g. walking/standing) and
particularly multitask conditions (e.g. walking/
standing while talking), and deficits in maximal
and particularly explosive force production of
lower extremity muscles, have most frequently
been reported to increase the risk of falling in the
elderly population.[17,18]
Age-related changes in
postural control can be attributed mainly to cognitive
impairment,[19]
visual, vestibular and proprioceptive
dysfunctions[20]
and muscle weakness.[21]
The decline in maximal and explosive force production
is primarily caused by a reduced excitability
of efferent corticospinal pathways[22]
resulting in
lower levels of central muscle activation,[23]
a gradual
loss of spinal motoneurons due to apopto-
sis,[24]
a subsequent decline in muscle fibre number
and size (sarcopenia),[25]
changes in muscle archi-
tecture[26]
and decreases in tendon stiffness.[27]
Given these detrimental effects of ageing, it is
important to design and apply adequate intervention
programmes that are able, for example,
to delay or even reverse age-related constraints
within the neuromuscular system. Recently, it was
reported that postural control and strength are
two independent neuromuscular capacities.[28]
Thus, the authors suggested that the abilities to
control posture and to produce force should be
trained complementarily. This finding is reinforced
by a recent meta-analysis, which provides
evidence that, in particular, the combination of
balance- and strength-promoting exercises has an
impact on both intrinsic fall risk factors, such as
deficits in postural control and muscle weakness,
and on fall rate (up to 50% reduction).[29]
In
recent years, a trend towards more specifically
378 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
designed balance and resistance training programmes
has been noted in the literature. It
is argued that perturbation-based or multitask
balance training programmes as well as power or
high-velocity strength training programmes are
more effective than traditional balance or resistance
training programmes in attenuating or even
reversing intrinsic fall risk factors in old age.[30-38]
Thus, the objective of this review is to describe
and discuss traditional and particularly recent
approaches in balance and resistance training
regarding the effects of these training regimens on
intrinsic fall risk factors, i.e. postural control and
strength in older adults.
2. Literature Search
2.1 Search Strategy
Two reviewers performed systematic electronic
searches on MEDLINE, PubMed, SportDiscusÒ
and Web of Science. The last search was performed
on 25 June 2010. A search filter containing
medical subject headings (MeSH) terms was
applied. The primary search included permutations
of keyword combinations for the following
PICO (Patient/population and/or problem, Intervention,
Comparison/control intervention and
Outcome or effects)[39]
categories:
1. Patient/population and/or problem: ‘aged’,
‘ageing’, ‘aging’, ‘elderly’, ‘geriatric’, ‘older adults’,
‘senior’.
2. Intervention: ‘balance training’, ‘sensorimotor
training’, ‘perturbation exercise’, ‘step training’,
‘dual-task training’, ‘resistance training’, ‘strength
training’, ‘high-velocity strength training’, ‘power
training’, ‘weight training’.
3. Comparison/control intervention: ‘intervention
versus no treatment’, ‘intervention versus
usual care programme’, ‘traditional intervention
versus recent intervention’.
4. Outcome: ‘balance’, ‘gait’, ‘walking’, ‘stance’,
‘standing’, ‘postural stability’, ‘postural control’,
‘body sway’, ‘strength’, ‘power’, ‘physical
function’.
The MeSH terms for each PICO category were
connected using the ‘AND’ operator. Furthermore,
we set limits on the types of article (i.e.
randomized or clinical controlled trial, peerreviewed
journal article), ages (i.e. ‡60 years),
species (i.e. humans), text options (i.e. full text)
and languages (i.e. English). Results of the initial
search are summarized in figure 1. In a secondary
search, articles from the reference list of included
articles were screened using the same criteria as
applied to the initial citation search.
2.2 Selection Criteria
Studies were included in the review if they
(i) were randomized or clinical controlled trials
published in peer-reviewed journals; (ii) had study
participants who were aged ‡60 years (except
otherwise stated due to a limited amount of studies
available); and (iii) had incorporated at least
one balance or strength outcome measure. Studies
were excluded if they (i) did not meet the
minimum requirements of an experimental study
design (e.g. case reports); (ii) did not meet the
minimum requirements regarding training design
(e.g. volume, frequency or intensity statements);
and (iii) were not written in English. Based on the
inclusion and exclusion criteria, two independent
reviewers screened citations of potentially relevant
publications. If the citation showed any
potential relevance, it was screened at the abstract
level. When abstracts indicated potential
inclusion, full text articles were reviewed for
inclusion. A third-party consensus meeting was
held if two reviewers were not able to reach
agreement on inclusion of an article.
2.3 Quality Assessment
Two reviewers independently performed quality
assessments of included studies, and disagreements
were resolved during a consensus meeting
or rating by a third assessor. Initially, methodological
quality was assessed using the Physiotherapy
Evidence Database (PEDro) scale[40]
because
it had previously shown good reliability.[41,42]
This scale rates randomized controlled trials from
0 to 10. The PEDro scores are presented in tables I
and II for the respective studies. Given that only
a few but highly relevant perturbation-based and
dual-task balance training studies are available,
we decided to include articles in this review that
Neuromuscular Performance in Seniors 379
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
do not fully meet the high standards of the PEDro
scale.
3. Balance Training in Older Adults
3.1 Traditional Balance Training
Traditionally, balance training has been used
to rehabilitate ankle and knee joint injuries. More
recently, the application area of balance training
was expanded to the geriatric population with the
purpose of fall prevention. However, in contrast
to resistance training, there are hardly any scientific
guidelines concerning contents, optimal duration
and intensity in balance training. Thus,
there is a large variation in these parameters.
With regard to content, even Tai Chi can be
classified as balance training in the broadest
sense. Yet, primarily static and dynamic exercises
on stable and unstable surfaces during bipedal or
monopedal stance with eyes open or closed represent
the core of traditional balance training.
Regarding optimal duration of balance training,
reported training periods range from 2 days,[34]
over 4 and 13 weeks[36,74]
to 1 year.[75]
A recent
systematic review on balance training in healthy
individuals clarifies this issue by indicating that
balance training programmes performed at least
10 minutes per day, 3 days per week for 4 weeks
have the potential to improve balance ability.[76]
Training intensity often varies in balance training
in terms of diverse conditions regarding the base
of support (e.g. bipedal vs monopedal stance), the
sensory input (e.g. eyes open vs eyes closed) and
task complexity (e.g. single task balance training
vs multitask balance training). In a recent position
stand on exercise and physical activity for
older adults, the American College of Sports
Medicine[77]
provided preliminary exercise prescription
guidelines that included the following:
1. Progressively difficult postures that gradually
reduce the base of support (e.g. two-legged stand,
semi-tandem stand, tandem stand, one-legged
stand).
Potentially relevant papers identified and
screened for retrieval concerning (...):
Balance training
(n = 72)
Resistance training
(n = 109)
Duplicate papers excluded
(n = 4)
Potentially relevant papers
remaining (n = 68)
Papers excluded on basis
of title or abstract (n = 31)
Papers excluded on basis
of eligibility criteria (n = 11)
Papers excluded on basis
of eligibility criteria (n = 43)
Papers retrieved for more
detailed evaluation (n = 37)
Included papers (n = 26) Included papers (n = 32)
Papers retrieved for more
detailed evaluation (n = 75)
Papers excluded on basis
of title or abstract (n = 27)
Potentially relevant papers
remaining (n = 102)
Duplicate papers excluded
(n = 7)
Fig. 1. Flowchart illustrating the different phases of the search and selection of the balance/resistance training studies.
380 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Table I. Studies examining the impact of perturbation-based and multitask balance training on balance performance in older adults
Study (y) No. of subjects; sex;
exercise group; age (y)
Training
regimen;
volume
Frequency Intensity Balance gain PEDro
score
Mynark and Koceja[34]
(2002)
10; F (5), M (5); EG; ‡65 PBBT; 2 d 1 ·/d NA Improvements in regulation of the Hoffman
reflex ( › 19–21%; p < 0.05) and in static sway
area ( › 10%; p < 0.05)
3
Rogers et al.[43]
(2003) 8; F (4), M (4); EG; ‡63 PBBT; 3 wk 2 ·/wk 53 trials each
session
Improvements in step initiation time
( › 7–19%; p < 0.01), and in step completion
time ( › 17–28%; p £ 0.05). No significant
improvements in step length
2
Jo¨bges et al.[44]
(2004) 14; F (8), M (6); EG; ‡41a
PBBT; 2 wk 2 ·/d 20 min each
session
Improvements in length of compensatory
steps ( › 88%; p < 0.001), step initiation time
( › 30%; p < 0.001), step length ( › 11%;
p = 0.026), cadence ( › 9%; p = 0.03), gait
velocity ( › 20%; p = 0.007) and in double
support time ( › 48%; p = 0.046). No
significant improvements in measures of
static postural control
0
Shimadaet al.[45]
(2004) 32; F (11), M (3); EG;
F (14), M (4); TEG; ‡66
PBBT; 6 mo 1–3 ·/wk 600 min total
sessions
Improvements in reaction time during
unperturbed ( › 32%; p = 0.015) and
perturbed walking ( › 34%; p = 0.007), in oneleg
standing time ( › 60%; p = 0.017) and in
FRT ( › 42%; p < 0.001)
3
Marigold et al.[46]
(2005) 30; F (7), M (23); AG; 31;
F (10), M (21); SWG; ‡50b
PBBT; 10 wk 3 ·/wk 60 min each
session
Improvements in postural reflex onset
latency ( › 4–17%; p £ 0.05), step reaction
time ( › 16%; p = 0.005), BBS ( › 10%;
p < 0.001) and in TUG ( › 17%; p < 0.001)
8
Silsupadol et al.[47]
(2006) 3; F (2), M (1); EG; ‡82 MTBT; 4 wk 3 ·/wk 45 min each
session
Improvements in BBS ( › 6–45%) in DGI
( › 10–17%) and in TUG ( › 8–25%)
1
Yang et al.[48]
(2007)
25; F (5), M (7); CG; F (6),
M (7); EG; range 45–80b
DTWT; 4 wk 3 ·/wk 30 min each
session
Improvements in gait speed ( › 30%;
p < 0.001), cadence ( › 15%; p < 0.001),
stride time ( › 0.2%; p = 0.007) and stride
length ( › 18%; p = 0.003)
6
Continued next page
NeuromuscularPerformanceinSeniors381
ª2011AdisDataInformationBV.Allrightsreserved.SportsMed2011;41(5)
Table I. Contd
Study (y) No. of subjects; sex;
exercise group; age (y)
Training
regimen;
volume
Frequency Intensity Balance gain PEDro
score
Sakai et al.[32]
(2008)
43; F (26), M (19); EG; ‡68 PBBT; 1 d 1 ·/d 5 min Improvements in the degree of body sway
( › 7%; p < 0.01), stride time ( › 3%; p < 0.01)
and integral EMG ( › 5–13%; p < 0.01) of
muscles compensating for the perturbation
impulse. No significant improvements in the
latency EMG of muscles compensating for
the perturbation impulse
1
Silsupadol et al.[49]
(2009) 21; F (7); ST; F (10), M (4);
DT; ‡65
MTBT; 4 wk 3 ·/wk 45 min each
session
No significant improvements in gait speed
and stride length. Improvements in ankle
joint inclination angle ( › 30–56%; p = 0.04)
5
Silsupadol et al.[36]
(2009) 21; F (7); ST; F (10), M (4);
DT; ‡65
MTBT; 4 wk 3 ·/wk 45 min each
session
Improvements in single-task gait speed
( › 3–14%; p = 0.02) for ST and DT, in dualtask
gait speed ( › 17–18%; p < 0.001) for DT,
and in BBS (› 10–15%; p< 0.001) for STand DT
7
Brauer and Morris[50]
(2010)
20; F (8), M (12); EG; ‡39b
MTBT; 1 d 1 ·/d 20 min Improvements in single- ( › 13%; p < 0.001)
and dual-task ( › 4–12%; p < 0.05) gait speed
and in single- ( › 12%; p < 0.001) and dualtask
( › 5–16%; p < 0.01) step length
1
Granacher et al.[51]
(2010) 11; F (7), M (4); EG; ‡67 MTBT; 6 wk 3 ·/wk 60 min each
session
Improvements in stride time variability during
single- ( › 35%; p = 0.02) but not dual- and
triple-task walking
6
Mansfield et al.[52]
(2010) 30; F (7), M (7); CG;
16; F (8), M (8); EG; 64–80
PBBT; 6 wk 3 ·/wk 30 min each
session
Improvements in frequency of multi-step
reactions ( › 31%; p = 0.034) and foot
collisions ( › 67%; p = 0.005) following
surface translation and in grasping reactions
( › 19%; p = 0.004) following cable pull
7
Schwenk et al.[53]
(2010) 49; F (18), M (11); CG;
F (13), M (7); EG; ‡67c
DT; 12 wk 2 ·/wk 60 min each
session
Changes in dual-task cost in gait speed
( › 38%; p = 0.086), cadence ( › 27%;
p = 0.846), stride length ( › 98%; p = 0.074),
stride time ( › 30%; p = 0.750) and single
support ( › 32%; p = 0.459)
5
a Patients with PD.
b Patients with CS.
c Patients with dementia.
·/d = times per day; ·/wk = times per week; AG = agility exercise group; BBS = Berg balance scale; CG = control group; CS = chronic stroke; DGI = dynamic gait index; DP = dementia
patients; DT = dual-task balance training group; DTWT = dual-task walking training; EG = exercise group containing physical therapy, stretching and gait training; EMG =
electromyogram; F = female; FRT = functional reach test; M = males; MTBT = multitask balance training; NA = not available; PBBT = perturbation-based balance training;
PD = Parkinson’s disease; PEDro = Physiotherapy Evidence Database; ST = single-task balance training group; SWG = stretching/weight-shifting exercise group; TEG = treadmill
exercise group containing perturbed walking on a treadmill; TUG = timed up-and-go test; › indicates an increase in percentage change (e.g. from pre- to post-testing).
382Granacheretal.
ª2011AdisDataInformationBV.Allrightsreserved.SportsMed2011;41(5)
Table II. Studies examining the impact of power or high-velocity resistance training on balance and strength performance in older adults
Study (y) No. of subjects;
sex; age
Training
regimen;
volume
(wk)
Frequency
(·/wk)
Intensity
(%)a
Sets; reps Balance gain Strength gain PEDro
score
Ha¨kkinen et al.[54]
(1998)
21; F (10), M (11);
‡64
PT; 24 2 50–80 3–4; 10–15 ND Improvements in maximal isometric
(M: › 36%; p < 0.001; F: › 57%;
p < 0.001) and dynamic (M: › 21%;
p < 0.001; F: › 30%; p < 0.001) leg
extensor strength
2
Ha¨kkinen et al.[55]
(2000)
10; F (5), M (5); ‡62 PT; 24 2 50–80 3–4; 10–15 ND Improvements in maximal isometric leg
extension values ( › 23–29%; p < 0.001)
1
Earles et al.[56]
(2001)
18; F (11), M (7);
‡70
HVRT; 12 3 50–70 3; 10 Improvements in gait
velocity ( › 5%; p < 0.001).
No significant improvements in
6-m walk distance and in singleleg
stance time
Improvements in maximal leg press
power ( › 22%; p = 0.004) and strength
( › 22%; p < 0.001)
5
Izquierdo et al.[57]
(2001)
11; M; ‡62 PT; 16 2 50–80 3–4; 10–15 ND Improvements in maximal isometric
force ( › 26%; p < 0.001)
2
Fielding et al.[58]
(2002)
30; F; ‡72 HVRT; 16 3 70 3; 8–10 ND Improvements in leg press
( › 35%; p < 0.001) and knee extensor
( › 25%; p < 0.001) strength and leg press
( › 97%; p < 0.002) and knee extensor
( › 33%; p < 0.001) power
4
Miszko et al.[59]
(2003)
39; F (9), M (6);
CG; F (7), M (6);
PG; F (6), M (5);
SG; ‡65
PT; 16 3 50–80 3; 6–8 Improvements on the CS-PFP
( › 15%; p < 0.05)
No significant improvements in strength
parameters
3
Sayers et al.[60]
(2003)
15; F; ‡65 HVRT; 16 3 70 3; 8 Improvements in tandem walk
( › 8%; p = 0.03) and stair climb
time ( › 9%; p < 0.001). No
significant improvements in chairrise
time and gait velocity
ND 3
Continued next page
NeuromuscularPerformanceinSeniors383
ª2011AdisDataInformationBV.Allrightsreserved.SportsMed2011;41(5)
Table II. Contd
Study (y) No. of subjects;
sex; age
Training
regimen;
volume
(wk)
Frequency
(·/wk)
Intensity
(%)a
Sets; reps Balance gain Strength gain PEDro
score
Bean et al.[61]
(2004)
10; F; ‡70 HVRT; 12 3 NA 3; 10 Improvements chair rise time
( › 8%; p < 0.05). No significant
improvements in gait speed and
single-leg stance time
Improvements in leg press power
( › 12–36%; p < 0.05)
5
Kongsgaard et al.[62]
(2004)
6; M; ‡65b
HVRT;12 2 80 4; 8 Improvements in maximal gait
time ( › 14%; p < 0.01) and stair
climbing time ( › 17%; p < 0.05)
Improvements in lower extremity
strength ( › 15–37%; p < 0.01) and peak
power ( › 19%; p < 0.01)
3
De Vos et al.[63]
(2005)
112; F (68), M (44);
‡60
PT; 8–12 2 20, 50,
80
3; 8 ND Improvements in muscle strength
( › 13–20%; p £ 0.001) and muscle power
( › 14–15%; p £ 0.05) performance
6
Henwood and
Taaffe[64]
(2005)
25; F (17), M (8);
‡60
HVRT; 8 2 33, 55,
75
3; 6–8 Improvements in 6-m backward
walk ( › 7%; p < 0.01), floor rise
to standing ( › 10%; p < 0.05) and
chair rise ( › 10%; p < 0.05) times
Improvements in upper ( › 29%; p £ 0.01)
and lower ( › 43%; p £ 0.01) extremity
strength and lower knee extensor power
( › 17%; p £ 0.002)
4
Henwood and
Taaffe[65]
(2006)
23; F (14), M (9);
‡65
HVRT; 8 2 45, 60,
75
3; 8 Improvements in 6-m walk
( › 7%; p < 0.01) and chair rise
( › 12%; p < 0.05) times
Improvements in upper ( › 10–25%;
p £ 0.05) and lower ( › 10–43%; p < 0.01)
extremity strength
5
Holviala et al.[66]
(2006)
22; W; ‡60 HVRT; 21 2 40–80 2–5; 8–15 Improvements in 6-m walk
( › 3%; p < 0.05)
Improvements in maximal isometric
force ( › 20%; p < 0.001) and rate of force
development ( › 18–31%; p < 0.01)
3
Orr et al.[67]
(2006)
12; F (68), M (44);
‡60
PT; 8–12 2 20, 50,
80
3; 8 Improvements in balance
performance ( › 1–11%;
p = 0.006)
Improvements in muscle strength
( › 13–20%; p < 0.004) and in muscle
power ( › 14–15%; p < 0.004)
performance
7
Bottaro et al.[68]
(2007)
11; M; ‡60 HVRT; 10 2 60 3; 8–10 Improvements in 8-ft (2.4-m) upand-go
test ( › 15%; p < 0.05)
and in 30-sec chair stand test
( › 43%; p < 0.05)
Improvements in dynamic upper ( › 28%;
p < 0.05) and lower ( › 27%; p < 0.05)
body strength and upper ( › 37%;
p < 0.05) and lower ( › 31%; p < 0.05)
body power
3
Continued next page
384Granacheretal.
ª2011AdisDataInformationBV.Allrightsreserved.SportsMed2011;41(5)
Table II. Contd
Study (y) No. of subjects;
sex; age
Training
regimen;
volume
(wk)
Frequency
(·/wk)
Intensity
(%)a
Sets; reps Balance gain Strength gain PEDro
score
Caserotti et al.[69]
(2008)
65; W; 60–65
(old communitydwelling
women
[n = 40]); 80–89
(very-old
communitydwelling
women
[n = 25])
HVRT; 12 2 75–80 4; 8–10 ND 60–65 y: improvements in peak force
( › 22%; p < 0.001), rate of force
development ( › 18%; p = 0.003), and
jumping height ( › 10%; p = 0.002);
80–89 y: improvements in peak force
( › 28%; p = 0.005), rate of force
development ( › 51%; p = 0.005), and
jumping height ( › 18%; p = 0.05)
2
Henwood et al.[70]
(2008)
19; F (12), M (7);
‡65
PT; 24 2 40–75 3; ‡8 Improvements in the 6-m
backwards walk ( › 16%;
p £ 0.001), chair rise time
( › 13%; p = 0.004) and FRT
( › 9%; p < 0.05)
Improvements in upper ( › 19–21%;
p £ 0.05) and lower ( › 35–125%;
p £ 0.05) maximal strength and upper
( › 70–78%; p £ 0.05) and lower
( › 55–65%; p £ 0.005) peak power
4
Reid et al.[37]
(2008)
23; F (12), M (11);
‡65
PT; 12 3 70 3; 8 ND Improvements in maximal muscle knee
extensor strength ( › 49%; p < 0.01) and
power ( › 55%; p < 0.01)
5
Marsh et al.[71]
(2009)
15; F (9), M (6); ‡65 PT; 12 3 40–70 3; 8–10 ND Improvements in maximal knee
extension ( › 34%; p = 0.003) and leg
press ( › 41%; p < 0.001) power, and
knee extension ( › 20%; p = 0.02) and leg
press ( › 22%; p = 0.03) strength
3
Nogueira et al.[72]
(2009)
20; M; 60–76 PT + TRT;
10
3 40–60 3; 8–10 ND Improvements in leg extensor strength
(PT: › 27%; p < 0.05; TRT: › 27%;
p < 0.05) and leg extensor power (PT:
› 31%; p < 0.05; TRT: › 8%; p < 0.05)
3
Webber and
Porter[73]
(2010)
50; W; 70–88 PT; 12 2 80 3; 8–10 Changes in reaction time
( › 2%; p < 0.51) and movement
time ( › 8%; p < 0.20)
Changes in dorsi flexor peak power
( › 27%; p < 0.89) and plantar flexor peak
power ( › 17%; p < 0.84)
5
a Intensity is with 1RM unless otherwise stated.
b Patients with chronic obstructive pulmonary disease.
·/wk = times per week; 1RM = one-repetition maximum; BW = bodyweight; CG = control group; CS-PFP = Continuous Scale Physical Functional Performance; F = female;
FRT = functional reach test; HVRT = high-velocity resistance training; M = males; NA = not available; ND = no data; PEDro = Physiotherapy Evidence Database; PEG = power exercise
group; PT = power training; reps = repetitions; SEG = strength exercise group; TRT = traditional resistance training; › indicates an increase in percentage change (e.g. from pre- to
post-testing).
NeuromuscularPerformanceinSeniors385
ª2011AdisDataInformationBV.Allrightsreserved.SportsMed2011;41(5)
2. Dynamic movements that perturb the centre of
gravity (e.g. tandem walk, circle turns).
3. Stressing postural muscle groups (e.g. heel
stands, toe stands).
4. Reducing sensory input (e.g. standing with eyes
closed).
Despite the wide variety of contents, training
duration and intensity in balance training, convincing
results were obtained over recent years
regarding the effects of balance training on both
intrinsic fall risk factors (e.g. deficits in postural
control and muscle strength) and the reduction
of fall incidence rate.[74,75,78]
In this regard,
Steadman et al.[79]
reported that 6 weeks of balance
training with two training sessions per week
improved the performance in clinical balance and
mobility tests in elderly subjects aged ‡60 years.
Granacher et al.[80]
examined the effects of a
13-week balance training programme (three training
sessions per week) for men between the ages of 60
and 80 years and its effects on performance in clinical
balance tests (functional reach test, tandem
walk test) and on the ability to compensate for
medio-lateral perturbation impulses while standing
on a two-dimensional balance platform. After training,
performance in the clinical balance tests was
significantly improved and summed oscillations of
the balance platform were significantly reduced together
with an improved activation of muscles
compensating for the perturbation impulse. In a
more functional approach, Granacher et al.[74]
investigated
the impact of a 13-week balance training
programme (three training sessions per week) in
elderly men on the ability to compensate for decelerating
gait perturbations while walking on a
treadmill. Balance training resulted in a decrease in
onset latency and an enhanced reflex activity in the
prime mover compensating for the decelerating
perturbation impulse. Furthermore, Rochat et al.[81]
reported that 10 weeks of low-intensity balance
training (one training session per week) produced
significant improvements in gait speed, stride length
and falls efficacy in older adults who were fearful
of falling (figure 2). In another study, Granacher
et al.[78]
were able to show that 13 weeks of balance
training (three training sessions per week) improved
maximal and explosive force production capacity of
the leg extensors in a cohort of healthy elderly men
between the ages of 60 and 80 years. Recently, the
effects of a 16-week Tai Chi programme (one
training session per week) on measures of postural
control and walking ability were investigated in
older community-dwelling older adults with a mean
age of 69 years.[82]
Postural sway under different
task conditions (e.g. standing on the floor or on a
foam mat) and choice stepping reaction time, i.e. the
ability to step as quickly as possible on one of four
randomly illuminated rectangular panels, were significantly
improved in the Tai Chi group after
training but not in the control group.
Given the potential of balance training and
Tai Chi in old age to counteract a large number of
intrinsic fall risk factors, it can be expected that
these training regimens have a significant effect
on fall incidence rate in older adults. In fact,
Madureira et al.[75]
investigated the impact of a
1-year balance training programme (static and
dynamic exercise) with one session per week on
their performance in different functional mobility
18
Change per study
Mean change of all studies
15
12
9
Changeingaitspeed(%)
6
3
0
Traditional BT Recent BT
Training mode
−3
−6
−9
Fig. 2. Percentage of change in gait speed following traditional or
recent approaches in balance training (BT). For clarity, more circles
and triangles are plotted than there are studies in which gait speed
was measured because a number of studies involved the assessment
of more than one intervention (see table I).
386 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
tests (e.g. Berg balance scale [BBS], timed upand-go
test [TUG]) as well as on the rate of falling
in women aged ‡65 years. After training, the intervention
group showed improvements in functional
mobility in terms of a significantly higher
BBS score and a reduced time to complete the
TUG. Notably, this enhancement was paralleled
by a significant reduction in the number of falls in
the intervention compared with the control
group. In terms of Tai Chi, Li et al.[83]
reported
that a 6-month Tai Chi programme performed
three times per week, is effective in decreasing the
number of falls, risk for falling and fear of falling
in physically inactive persons aged ‡70 years.
Only scarce information is available regarding
adaptive mechanisms following balance training
in old age, which is why results from different
age groups have to be consulted. In his 2003
publication, Gollhofer[84]
assumed that adaptive
processes following balance training take place
mainly at a spinal level due to the high intermuscular
activation frequencies observed during
stabilization tasks on unstable platforms. Recently,
Taube et al.[85]
investigated cortical and
spinal adaptations in young adults following
4 weeks of balance training (three training sessions
per week) by means of Hoffmann reflex
stimulation, transcranial magnetic stimulation,
and conditioning of the Hoffmann reflex by
transcranial magnetic stimulation. After training,
the authors observed an improved postural stability
accompanied by a decrease in motorevoked
potentials during stance perturbation on
a treadmill. At the same time, Hoffmann reflexes
were decreased despite an unchanged background
EMG during the performance of a balance
task. This could imply that balance training
induced changes in the regulation of human erect
posture in terms of a shift from cortical to subcortical
areas. Thus, supraspinal rather than
spinal mechanisms seem to be responsible for the
training-induced postural improvement.[85]
In
other words, after balance training, less neural
effort might be required for the regulation of
posture due to increased task automatization.
However, further research is necessary to clarify
whether the training-induced adaptive processes
responsible for improvements in postural control
observed in young adults can be transferred to
elderly adults.
3.2 Perturbation-Based Balance Training
Recently, more specifically designed balance
training programmes – so-called ‘perturbationbased
training regimens’ – have begun to receive
attention.[33]
This approach is based on the fact
that slips and trips account for 30–50% of falls in
community-dwelling older adults.[86,87]
Thus,
compensatory strategies for recovery of equilibrium
play a vital functional role in preventing
falls. The successful recovery of balance demands
the centre of mass to remain within the boundaries
of the base of support. This compensatory
mechanism can be achieved by different movement
strategies (ankle, hip and step strategy).[88]
In an actual fall situation, in-place strategies such
as the ankle and hip strategy could be insufficient
to recover balance, which is why a step is used to
bring the support base back into alignment under
the centre of mass. These change-in-support reactions
(step strategy) can provide a much larger
degree of stabilization, compared with in-place
reactions where the base of support does not
change.[89]
It has been reported that neural control
of change-in-support reactions evoked by
postural perturbation differ in some fundamental
way from volitional limb movements.[89]
Given
that recovery strategies are not under direct volitional
control, it is not possible to train this
specific capacity through voluntary exercises alone.
However, since most balance training programmes
include voluntarily controlled exercises only, it was
suggested that adequate training regimens should
comply with the principle of training specificity
and involve the use of perturbation-based ex-
ercises.[31]
The principle of training specificity
requires that a person should experience training
conditions (e.g. perturbation exercises) that
match real-life conditions (e.g. balance recovery
situations) as closely as possible. This fundamental
principle of successful exercise prescription
applies to anyone regardless of sex, level of
physical activity or health status.[90]
Recently, Sakai et al.[32]
were able to show
that a short-term perturbation-based training
Neuromuscular Performance in Seniors 387
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
programme (one session with 20 perturbation
impulses) on a treadmill produced acute adaptations
in terms of significant decreases in postural
sway during slip-perturbed gait in a cohort of
community-dwelling elderly subjects with a mean
age of 71 years. This finding was paralleled by an
improved activation of muscles compensating
for the perturbation impulse. In an earlier study,
Mynark and Koceja[34]
investigated whether
subjects older than 65 years of age show acute
adaptations in the soleus muscle Hoffman reflex
following short-term (2 days) perturbation-based
balance training. After the first day of training, a
significant down-regulation of the Hoffman reflex
was observed (19%). On day 2, the Hoffman
reflex was decreased by 21% in elderly subjects,
indicating that the potential to functionally
modulate reflex output persists despite the effects
of ageing. In addition to the changes observed in
Hoffman-reflex amplitude, the down-training of
the Hoffman reflex also seemed to have a functional
impact on the static balance of elderly
subjects resulting in a significant 10% decrease in
the area of static sway from pre- to post-test.
Perturbation-based balance training programmes
were not only applied in short-term exercise
regimens but also in long-term training programmes.
Marigold et al.[46]
determined the effect of
two different community-based group exercise
programmes on functional balance (e.g. BBS),
mobility (e.g. TUG), postural reflexes (e.g. step
reaction time, onset latency following platform
translations), and falls in older adults (mean age
68 years) with chronic stroke. Participants were
randomly assigned to an agility exercise group
(e.g. standing in various postures, walking with
various challenges, standing perturbations, etc.)
or a stretching/weight-shifting exercise group (e.g.
low-impact stretching, Tai Chi-like movements).
Both groups exercised three times a week for
10 weeks. For both types of exercise programmes,
training improved functional balance and mobility,
and led to shorter latencies in postural reflexes
and to faster step reaction time. Notably,
the agility group demonstrated greater improvement
in step reaction time and postural reflex
onset latency, as well as a trend toward greater
improvement in the TUG. In addition, the total
number of falls experienced during platform
translations was reduced to a larger extent in the
agility than the stretching/weight-shifting group
after the interventions.
Jo¨ bges et al.[44]
scrutinized the impact of
compensatory step training in outpatients with
Parkinson’s disease (mean age 61 years) on the
ability to compensate for unexpected perturbation
impulses while standing, as well as on various
gait parameters. Training was conducted for
2 weeks with two training sessions per day
(weekends were excluded), and consisted of repetitive
pulls to the patient’s back and pushes to
the person’s right and left side applied by a physiotherapist.
The strength of the pulls and pushes
was adapted to the degree of the patient’s individual
postural instability. After training, a
significant increase in length of compensatory
steps was observed, which was accompanied by a
significantly shorter step initiation time. In addition,
significant training-induced increases in gait
velocity and step length, as well as decreases in
double support time, i.e. time in which both feet
contact the floor during walking, were found
during normal walking.
In another study with healthy older adults
(mean age 70 years), Rogers et al.[43]
showed that
a 3-week period (two training session per week)
of either voluntary or waist-pull-induced step
training significantly reduced step initiation time,
i.e. the time interval from the onset of a reaction
stimulus cue until the vertical ground reaction
force under the stepping limb equals zero at foot
lift-off. Moreover, compared with voluntary step
practice, the waist-pull-induced step training resulted
in a significantly greater improvement in
reaction time stepping.
In a comparative approach, Shimada et al.[45]
investigated the effects of two types of exercise
programmes (perturbed walking on a treadmill
and exercise containing physical therapy, stretching
and gait training) on the ability to compensate
for gait perturbations, on functional reach performance
and on fall rate in long-term care facility
residents and outpatients aged 66–98 years.
After 6 months of training (one to three training
sessions per week), significant improvements in
reaction time during perturbed walking and in
388 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
functional reach performance were seen in the
perturbed walking group but not in the exercise
group with physical therapy, stretching and gait
training. The number of falls occurring in the
treadmill exercise group was 21% lower than that
in the multi-component exercise group (odds
ratio for falls 0.4). However, this difference was
not significant, possibly due to the small sample
size utilized in this study (n = 18 treadmill group
vs 14 multi-component group). Recently, it was
suggested to conduct a water-based balance training
programme that includes perturbation exercises
to improve stepping responses.[91]
Water
seems to provide a safe environment for perturbation
exercises and may thus reduce the occurrence
of exercise-induced fear of falling, which
could be present during exercising on land. For
therapists and practitioners, a schematic illustration
of progression in perturbation-based balance
training is presented in figure 3.
3.3 Multitask Balance Training
In accordance with the principle of training
specificity, effective fall-prevention programmes
should not only include balance-recovery reactions
but also multitask balance exercises, because
gait instability, and thus risk of falling, increases
even when shared attention or dual-tasks
(e.g. walking while talking) are performed.[18]
In
this regard, Brauer and Morris[50]
investigated the
impact of a 20-minute dual-task walking training
session on acute adaptations in gait characteristics
of people with Parkinson’s disease. Participants
performed a series of 10-m walking trials under
seven conditions: gait only, and with six different
added tasks varying by task type (e.g. motor,
cognitive), domain (e.g. postural, manual manipulation,
language, calculation, auditory, visuospatial)
and difficulty level. Following training,
step length increased when performing five of
the six added tasks, indicating that transfer of
dual-task training when walking occurred across
task types and domains. Improvements in gait
speed were present in three of the six added tasks
(figure 2). When other gait variables were examined,
such as step length variability, few improvements
with training were found. Thus, dual-task
training has the potential to induce acute improvements
in specific gait characteristics of
people with Parkinson’s disease.
Regarding long-term training effects,
Granacher et al.[51]
investigated the impact of a
6-week balance training programme in healthy
older adults with an age range of 65–80 years on
the variability of their walking pattern both
with and without dual and triple tasking, while
concurrently performing a cognitive (backward
Progression
3. Large perturbation:
→ step strategy
Instructor
ComComCom
Patient
2. Medium perturbation:
→ hip strategy
Instructor Patient
omCom Com
1. Weak perturbation:
→ ankle strategy
Instructor Patient
ComCom Com
Fig. 3. Schematic illustration of progression in perturbation-based balance training. Com = centre of mass (the three different arrow thicknesses
indicate an increase in the applied severity of the perturbation).
Neuromuscular Performance in Seniors 389
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
counting) and/or motor interference task (holding
two interlocked sticks in front of the body).
Balance training was conducted three times a
week and training intensity was intensified by
including additional motor interference tasks
(e.g. catching and throwing a ball while performing
a balance exercise) and by increasing
the number of sets and/or the duration of single
exercise sets. Balance training resulted in statistically
significant reductions in stride time variability
under single- (only walking) but not
dual- (walking + cognitive/motor interference) or
triple-task walking (walking + cognitive + motor
interference). In addition, significant improvements
in the motor interference task, but not in
the cognitive interference task, were found while
walking. Findings showed that improved performance
during single-task walking did not transfer
to walking under dual- or triple-task conditions,
suggesting multiple-task balance training as an
alternative training modality. Improvement of
the secondary motor but not cognitive task may
indicate the need for the involvement of motor,
and particularly cognitive, tasks during balance
training.
Silsupadol et al.[36]
investigated the effects of
single-task versus dual-task balance training with
fixed-priority instructions and dual-task balance
training with variable-priority instructions on
gait speed under single- (only walking) and dualtask
conditions (walking while concurrently performing
an arithmetical task) in elderly adults.
Single-task balance training involved the performance
of balance exercises only (e.g. standing
with eyes closed, tandem standing). The participants
receiving dual-task balance training with
fixed-priority instructions practiced balance tasks
while simultaneously performing cognitive tasks
(e.g. naming objects), and were instructed to
maintain attention on both postural and cognitive
tasks at all times. Participants in the dual-task
balance training with variable-priority instructions
performed the same exercises as the fixed
instruction dual-task balance training group, but
spent half the session focused on balance and half
focused on cognitive task performance. Training
lasted for 4 weeks with three training sessions a
week. Gait speed was obtained at baseline, in the
second week, at the end of training and in the
twelfth week after the end of training. Following
training, participants in all exercise groups significantly
improved performance on single-task
gait speed (figure 2). However, dual-task training
(fixed and variable-priority instruction) was superior
to single-task training in improving walking
under dual-task conditions. In fact, only
participants who received dual-task training
walked significantly faster after the training when
simultaneously performing a cognitive task. In
addition, only dual-task balance training with
variable-priority instructions resulted in a dualtask
training effect in the second week and
maintained the training effect at the 12-week
follow-up. These findings suggest that older
adults are able to improve their walking performance
under dual-task conditions only when
specific types of training, i.e. dual-task training,
are performed. Furthermore, it seems that training
balance under single-task conditions may not
generalize to balance control in dual-task con-
texts.[36]
This finding further strengthens the
principle of training specificity when designing
fall-preventive interventions. In fact, Oddsson
et al.[92]
followed this principle when introducing
a concept for balance training that incorporates
voluntary exercises as well as perturbation and
dual-task exercises to improve balance control.
The programme is performed on five different
levels where levels 1–4 focus on the skill to
maintain balance (voluntary control) and level 5
adds perturbation exercises that focus on the skill
to recover balance (automatic postural corrections),
as well as dual-task exercises providing a
cognitive load during the execution of a balance
task. The feasibility of the concept has been
demonstrated in elderly fallers.[93]
For therapists
and practitioners, a schematic illustration of
progression in multitask balance training is presented
in figure 4. A detailed list of studies that
conducted perturbation-based or multitask balance
training is given in table I.
In summary, our outlines indicate that studies
following the traditional or recent approach in
balance training are heterogeneous in terms of
training volume, training frequency and training
intensity. Nevertheless, most of these studies were
390 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
effective in inducing acute or long-term adaptations
in the postural control system. However,
there is evidence that perturbation-based balance
training is even more effective than traditional
balance training in improving balance recovery
mechanisms following perturbation impulses.
Furthermore, it seems plausible to argue that
multitask conditions should be applied in balance
training because only multitask and not singletask
balance training improves performance in
multitask walking. Since training volume, frequency
and intensity were rather heterogeneous
in both traditional and recent approaches in balance
training, it appears that training specificity
in particular could be the major determinant responsible
for the enhanced effectiveness of perturbation-based
and multitask balance training
over traditional balance training.
4. Resistance Training in Older Adults
Currently, resistance training programmes in
the geriatric context mainly comprise three major
methodological approaches: (i) high-intensity resistance
training conducted at moderate movement
speed, with loads corresponding to 70–80%
of one-repetition maximum (1RM)[94,95]
– the
1RM is defined as the load that can be lifted only
once; (ii) high-velocity or power training conducted
at maximum speed during the concentric
phase and released at moderate speed during the
eccentric phase of the exercise, with loads of
20–80% of 1RM;[37,58]
and (iii) eccentric resistance
training (also called negative resistance
training) conducted at moderate movement speed
with high mechanical loads.[96,97]
It has been argued
that negative work intervention programmes
are particularly suited for elderly people
because high mechanical loads can be produced
at low energetic costs. In fact, LaStayo et al.[98]
reported that the energy cost of eccentric work is
approximately four times less than that of concentric
work at a comparable external load. For a
review on this topic see Roig et al.[99]
However,
the implementation of eccentric resistance training
as an intervention programme for elderly
people is hard to realize because the performance
of resistance training in isolated eccentric contraction
mode requires special training equipment
(e.g. an isokinetic device). Further, intense
guidance during training is mandatory and demands
highly qualified personnel as well as a
personnel-intense therapist-to-participant ratio.
This is why eccentric resistance training was
mainly applied in a scientific context and to a lesser
extent in large-scale intervention programmes.
Progression
Patients
Com
1. Single task 2. Dual task 3. Triple task
635
632
611
Com
Blue
Yellow
Green
Com
Fig. 4. Schematic illustration of progression in multitask balance training. Com = centre of mass (arrows indicate displacements of the Com).
Neuromuscular Performance in Seniors 391
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Due to these exercise-specific limitations of eccentric
resistance training, we decided to focus
our review on high-intensity resistance training
and high-velocity or power training, which can be
applied in large-scale intervention programmes
and group exercises.
4.1 Traditional Resistance Training
The specific effects of resistance training in
the elderly have been explored scientifically for
many years. Early research from the 1970s and
the 1980s was methodologically limited and quite
conservative in terms of the intensity of the exercise
prescription. At that time, it was assumed
that resistance training for older adults could
only induce neural adaptations but not muscle
hypertrophy (for a review see Porter and
Vandervoort[100]
). However, in the late 1980s and
early 1990s, new insights were gained regarding
the real potential of resistance training for older
adults, partly due to improved testing equipment,
but also because of a better understanding of
dose-response relations. Frontera et al.[101]
and
Fiatarone et al.[94]
were among the first to prove
that high-intensity resistance training conducted
at 80% of 1RM is a feasible, safe and effective
means to induce large increases in muscle
strength (up to 227% increase in lower extremity
strength)[101]
and function (48% higher tandem
gait speed).[94]
CT scans indicated significant increases
in muscle mass of the quadriceps (9.3%)
following 12 weeks of training with three training
sessions a week.[101]
Today, it is well known that
resistance training using heavy loads (>70% of
1RM) is more effective than low-intensity training
in terms of strength gains and increases in
muscle mass.[102]
It was reported that heavyresistance
strength training leads to gains in muscle
cross-sectional area ranging between 5–12% in
elderly individuals as evaluated by MRI or CT
scanning.[103]
In addition, neural factors – such as
an increased activation of the prime movers (improved
recruitment pattern, discharge rate and
synchronization of motor units), an improved
coactivation of the synergists and a reduced
coactivation of the antagonist muscles – have
been discussed as potential adaptive mechanisms
following resistance training in older adults.[104]
Changes in muscle architecture in terms of an
increased fascicle length and pennation angle[105]
as well as increased tendon stiffness[106]
may also
account for an enhanced strength performance
following resistance training in older adults. Yet,
it seems that resistance training increases strength
but has less-clear effects on balance abilities.
Recently, it was shown that 13 weeks of heavyresistance
strength training with three training
sessions per week had an impact on maximal and
explosive force production[95]
in elderly men but
not on the ability to compensate for platform[95]
or gait perturbation impulses.[74]
A recent systematic
review of randomized controlled trials on
the efficacy of resistance training on balance
performance in older adults found similar re-
sults.[107]
In addition, Latham et al.[102]
could not
find a clear effect of resistance training on various
measures of standing balance among 789 participants
(effect size = 0.11). This rather limited
adaptive potential of traditional resistance training
restricted to variables of strength could be
the reason why, to the authors’ knowledge, no
clear fall-preventive effect could be shown for
resistance training alone.[108]
Due to the well
documented impact of resistance training on
bone mineral content in the elderly,[109-112]
it
could be speculated that resistance training does
not influence the risk of sustaining a fall in old
age but does influence the risk of sustaining a fallrelated
fracture. Further research is necessary to
prove this hypothesis.
4.2 Power or High-Velocity Resistance Training
The ability to generate force rapidly in advancing
age declines more precipitously than
maximal strength[113]
and is, in a fall-threatening
situation, more relevant for preventing a fall than
the capacity to produce maximal strength.[114]
In
an actual fall risk situation (e.g. unexpected stop
during standing in a driving bus/train), the time
taken to produce maximal strength is too long to
recover successfully from the balance threat. In
fact, there is evidence that lower extremity muscle
strength and power are predictors of the risk
of falling.[115,116]
Therefore, it is of paramount
392 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
importance to apply resistance training programmes
that have the potential to specifically enhance
explosive force production capacity. It has
been suggested that high-velocity and power
training have a greater impact on explosive force
production in the elderly than heavy-resistance
strength training.[38]
Fielding et al.[58]
were among the first to investigate
the impact of a 16-week high- versus
low-velocity resistance training regimen on variables
of muscle strength (1RM) and power
(force · velocity) of the knee and leg extensors in
elderly women with self-reported disability. Both
training groups exercised three times per week at
an intensity of 70% of 1RM. After training, both
groups improved their leg extensor 1RM strength
(high velocity 35%; low velocity 33%) and knee
extensor 1RM strength (high velocity 45%; low
velocity 41%) to a similar extent. However, those
in the high-velocity strength training group experienced
significantly greater improvements in
leg press peak muscle power than those participants
in the low-velocity training group (high
velocity 97%; low velocity 45%). Improvements
in knee extensor peak power were not significantly
different between the high- (33%) and
low-intensity (25%) groups.
In a similar study design, Henwood et al.[70]
investigated the impact of a 24-week high-velocity
or constant-velocity resistance training regimen
conducted twice a week on measures of dynamic
and isometric muscle strength and peak muscle
power. Participants in the high-velocity strength
training group performed three sets with eight
repetitions using maximal movement velocity.
The first set was conducted at 45% of 1RM,
the second set at 60% of 1RM, and the third set
at 75% of 1RM. The constant-velocity resistance
training group performed three sets with eight
repetitions at 75% of 1RM using moderate movement
velocity. Following training, the average
change in dynamic muscle strength (across six
exercises) amounted to 51% for the high-velocity,
and 48% for the constant-velocity resistance
training group. Maximal isometric strength significantly
increased in the high-velocity group
(30%) and in the constant-velocity group (24%).
Significant training-induced increases in peak
muscle power were observed for both exercise
groups (high velocity 51%; constant velocity
34%). Overall, no significant differences between
exercise groups emerged following training. Yet,
it is important to note that these gains in muscle
strength and power occurred for the high-velocity
group using a reduced total workload per exercise
session compared with the constant-velocity
group. Thus, these findings support the efficiency
of using high-velocity varied resistance training
protocols in older adults as a means to enhance
muscle strength and power. Recently, it was
shown that older adults aged 60–65 years, and
particularly those aged 80–89 years, benefit from
12 weeks of power training (two training sessions
per week) in terms of large increases in the rate of
force development (21% and 51%, respectively)
and muscle power of the leg extensors (12% and
28%, respectively).[69]
Miszko et al.[59]
scrutinized the effects of a
16-week power or strength training programme
with three training sessions a week on maximal
strength and peak anaerobic power of the leg
extensors as well as physical function in communitydwelling
older adults (mean age 73 years). Intensity
in strength training progressed from 50%
to 70% of 1RM by week 8, and then remained at
80% of 1RM for weeks 9–16. Intensity in power
training was the same as in strength training
for the first 8 weeks. After 8 weeks, the programme
was altered to increase muscle power.
Each subject performed three sets of 6–8 repetitions
at 40% of 1RM value as fast as possible.
Miszko et al.[59]
found that power training was
more effective than strength training for improving
whole-body physical function on the continuous
scale physical functional performance test, which
assesses 16 everyday tasks with components for
the lower body, the upper body, balance, coordination
and endurance. In addition, results indicated
that both programmes were equally effective for
improving maximal strength. The strength training
group were significantly stronger than the control
group following training; however, there were no
significant differences between the exercise groups.
In a recently conducted study,[37]
high-velocity
power training and traditional slow-velocity progressive
resistance training yielded similar increases
Neuromuscular Performance in Seniors 393
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
of lower extremity power in older adults with mobility
limitations. It is of interest to note that after
12 weeks of training (three training sessions a
week), no significant changes in total leg lean
mass assessed by dual-energy x-ray absorptiometry
occurred over the course of the intervention
in any group. Thus, the authors hypothesized that
neuromuscular adaptations rather than muscle
hypertrophy may account for the investigated
gains in muscle strength and power.[37]
Similarly,
Fielding et al.[58]
suggested that changes in motor
unit recruitment and activation seem to be primarily
responsible for increased peak power following
16 weeks of high-velocity resistance training (three
training sessions per week).
Returning to the results of Miszko et al.[59]
regarding the impact of power or resistance training
on measures of physical function, Henwood
and Taafe[64]
confirmed these results by demonstrating
that 8 weeks of high-velocity resistance
training (two training sessions per week) produced
larger improvements in tests of physical
performance, i.e. the floor rise to standing test,
the 6-m walk test, the repeated chair rise test, and
the lift and reach test than traditional strength
training. In a later study, however, Henwood
et al.[70]
reported that 24 weeks of high-velocity or
constant resistance training (two training sessions
per week) resulted in similar improvements in
the 6-m fast walk, chair rise, stair climbing and
functional reach task.
From a functional point of view, it is of interest
to know whether power training has an impact
on balance in older adults, since balance
control is an important component of physical
performance. In this regard, Orr et al.[67]
investigated
the effects of a 10-week power training
(two sessions per week) programme at one of
three intensities (20%, 50% and 80% of 1RM) on
balance performance in sedentary healthy older
adults. Irrespective of training intensity, significant
improvements were observed in peak power,
strength and endurance of lower extremity
muscles. Notably, in the low-intensity group
(20% of 1RM) training-induced improvements in
balance were significantly higher than in the high
(80% of 1RM) and medium (50% of 1RM) exercise
groups, indicating that a low-load highvelocity
regimen might be particularly well suited
for the promotion of balance in older adults.
However, the question regarding the most effective
training intensity in power training with
older adults is still under debate. The American
College of Sports Medicine, for instance, recommended
that healthy older adults should perform
one to three sets using light to moderate resistance
(40–60% of 1RM) for six to ten repetitions
with high-movement velocity. In contrast to these
recommendations, it was reported that 8–12 weeks
of power training with high loads (80% of 1RM)
induced larger gains in muscle power, strength and
endurance than power training with medium
(50% of 1RM) and low loads (20% of 1RM).[63]
It
has to be mentioned that the risk of sustaining an
injury during training was greater in the highintensity
group than that of the medium- and
low-intensity groups. This has to be put into
perspective though, since the rate of adverse
18
15
12
9
Changeingaitspeed(%)
6
3
0
Traditional RT
Training mode
Recent RT
−3
−6
−9
Change per study
Mean change of all studies
Fig. 5. Percentage of change in gait speed following traditional
or recent approaches in resistance training (RT). For clarity,
more circles and triangles are plotted than there are studies in
which gait speed was measured because a number of studies
involved the assessment of more than one intervention (see
table II).[117-127]
394 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
events for strength testing (16 events, 4711
strength tests [0.34%]) and power training (four
events, 1633 training sessions [0.25%]) was rather
low.[63]
In another study, the effects of a heavyresistance
training with explosive concentric
contractions in elderly men with chronic obstructive
pulmonary disease was investigated on
muscle strength, power and physical perfor-
mance.[62]
Following 12 weeks of training (two
training sessions per week), significant improvements
in isometric (14%) and isokinetic (18%)
knee extension strength, leg extension power
(19%), quadriceps cross-sectional area (4%),
maximal gait speed (14%) and stair climbing time
(17%) were observed (figure 5). Notably, no
training-related injuries were reported in this
cohort of elderly men suffering from chronic
disease. For therapists and practitioners, a schematic
illustration of training load and contraction
mode in power/high-velocity resistance training is
presented in figure 6. A detailed list of studies that
conducted power/high-velocity resistance training
is given in table II.
In summary, our review indicates that highintensity
resistance training and power or
high-velocity resistance training are effective in
improving muscle strength/power and functional
capacity even though major determinants of the
respective study designs (e.g. training volume,
frequency, intensity) were rather heterogeneous
across the traditional and recent approaches.
Yet, there is preliminary evidence that power
training with particularly high loads is more effective/efficient
in increasing power than traditional
resistance training. Further, it seems that
power training compared with resistance training
is more beneficial in improving measures of
physical function. More specifically, there is evidence
that especially low-intensity power training
is well suited to enhance balance in older adults.
Given the heterogeneity in study designs across
traditional and recent approaches in resistance
training, it appears that the specificity of the
contraction mode (moderate vs high velocity)
may represent an important determinant for
producing substantial gains in muscle power and
functional capacity. This result complies with the
principle of training specificity and suggests that
ballistic contractions should be incorporated in
resistance training for older adults.
5. Conclusions
During the last 30 years, intense research efforts
have been undertaken regarding the effects
of balance and resistance training on measures of
postural control and strength in older adults. In
general, these training regimens appear to be
feasible, safe and effective. There is evidence that
traditional balance training has an impact on
postural control, physical function, and strength
and fall rate in older adults. Based on preliminary
1. Starting position 2. Concentric action
One repetition
3. Eccentric action
Load
80%
1RM
20%
1RM
A
B
80%
1RM
20%
1RM
A
B
High-velocity
movement
speed
Load
80%
1RM
20%
1RM
A
B
Moderate-
velocity
movement
speed
Load
Fig. 6. Schematic description of power or high-velocity resistance training. 1RM = one-repetition maximum.
Neuromuscular Performance in Seniors 395
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
data, it seems plausible to argue that specific types
of balance training (perturbation-based and multitask)
are particularly effective in promoting balance
recovery mechanisms and variables of postural
control under single and multitask conditions. This
could indirectly imply that these training regimens
may have a larger impact on fall rate than
traditional balance training programmes. However,
this important issue needs to be confirmed
in future studies.
Traditional approaches have proven that resistance
training particularly enhances strength
performance but has limited effect on physical
function. Thus, recent studies focused on the
impact of power or high-velocity strength training
and found that this training regimen seems to
have larger effects on explosive force production
and physical function than traditional resistance
training. However, clear dose-response relations
need to be established for power training.
Additional verification is needed regarding the
underlying neuromuscular mechanisms responsible
for training-induced adaptive processes following
perturbation-based/multitask balance training and
power/high-velocity resistance training.
Acknowledgements
No sources of funding were used to assist in the preparation
of this review. The authors have no conflicts of interest
that are directly relevant to the content of this review.
References
1. United Nations. World population prospects: the 2004 revision.
New York: United Nations, 2005
2. Reinhardt UE. Does the aging of the population really
drive the demand for health care? Health Affairs 2003; 22
(6): 27-39
3. Stevens JA, Corso PS, Finkelstein EA, et al. The costs of
fatal and non-fatal falls among older adults. Inj Prev 2006;
12 (5): 290-5
4. Rubenstein LZ. Falls in older people: epidemiology, risk
factors and strategies for prevention. Age Ageing 2006; 35
Suppl. 2: 37-41
5. Campbell AJ, Reinken J, Allan BC, et al. Falls in old age: a
study of frequency and related clinical factors. Age Ageing
1981; 10 (4): 264-70
6. Blake AJ, Morgan K, Bendall MJ, et al. Falls by elderly
people at home: prevalence and associated factors. Age
Ageing 1988; 17 (6): 365-72
7. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls
among elderly persons living in the community.
N Engl J Med 1988; 319 (26): 1701-7
8. Downton JH, Andrews K. Prevalence, characteristics
and factors associated with falls among the elderly living
at home. Aging 1991; 3 (3): 219-28
9. Kannus P, Parkkari J, Koskinen S, et al. Fall-induced injuries
and deaths among older adults. JAMA 1999; 281
(20): 1895-9
10. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ,
et al. Risk factors in falls among the elderly according to
extrinsic and intrinsic precipitating causes. Eur J Epidemiol
2000; 16 (9): 849-59
11. Alexander NB, Goldberg A. Gait disorders: search for
multiple causes. Cleve Clin J Med 2005; 72 (7): 586-600
12. Jensen J, Nyberg L, Gustafson Y, et al. Fall and injury
prevention in residential care: effects in residents with
higher and lower levels of cognition. J Am Geriatr Soc
2003; 51 (5): 627-35
13. Lord SR, Dayhew J. Visual risk factors for falls in older
people. J Am Geriatr Soc 2001; 49 (5): 508-15
14. Moreland JD, Richardson JA, Goldsmith CH, et al. Muscle
weakness and falls in older adults: a systematic review
and meta-analysis. J Am Geriatr Soc 2004; 52 (7): 1121-9
15. Nnodim JO, Alexander NB. Assessing falls in older adults:
a comprehensive fall evaluation to reduce fall risk in older
adults. Geriatrics 2005; 60 (10): 24-8
16. Carter SE, Campbell EM, SansonFisher RW, et al. Environmental
hazards in the homes of older people. Age
Ageing 1997; 26 (3): 195-202
17. Granacher U, Zahner L, Gollhofer A. Strength, power, and
postural control in seniors: considerations for functional
adaptations and for fall prevention. Eur J Sport Sci 2008;
8 (6): 325-40
18. Beauchet O, Annweiler C, Dubost V, et al. Stops walking
when talking: a predictor of falls in older adults? Eur J
Neurol 2009; 16 (7): 786-95
19. Whitman GT, Tang Y, Lin A, et al. A prospective study of
cerebral white matter abnormalities in older people with
gait dysfunction. Neurology 2001; 57 (6): 990-4
20. Shaffer SW, Harrison AL. Aging of the somatosensory
system: a translational perspective. Phys Ther 2007; 87
(2): 193-207
21. Hurley MV, Rees J, Newham DJ. Quadriceps function,
proprioceptive acuity and functional performance in
healthy young, middle-aged and elderly subjects. Age
Ageing 1998; 27 (1): 55-62
22. Sale MV, Semmler JG. Age-related differences in corticospinal
control during functional isometric contractions in
left and right hands. J Appl Physiol 2005; 99 (4): 1483-93
23. Macaluso A, Nimmo MA, Foster JE, et al. Contractile
muscle volume and agonist-antagonist coactivation account
for differences in torque between young and older
women. Muscle Nerve 2002; 25 (6): 858-63
24. Terao S, Sobue G, Hashizume Y, et al. Age-related changes
in human spinal ventral horn cells with special reference to
the loss of small neurons in the intermediate zone: a
quantitative analysis. Acta Neuropathol 1996; 92 (2):
109-14
396 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
25. Lexell J, Taylor CC, Sjostrom M. What is the cause of the
ageing atrophy? Total number, size and proportion of
different fiber types studied in whole vastus lateralis
muscle from 15- to 83-year-old men. J Neurol Sci 1988; 84
(2-3): 275-94
26. Narici MV, Maganaris CN, Reeves ND, et al. Effect of
aging on human muscle architecture. J Appl Physiol 2003;
95 (6): 2229-34
27. Narici MV, Maganaris CN, Reeves N. Muscle and tendon
adaptations to ageing and spaceflight. J Gravit Physiol
2002; 9 (1): 137-8
28. Granacher U, Gruber M, Gollhofer A. Force production
capacity and functional reflex activity in young and elderly
men. Aging Clin Exp Res. Epub 2009 Nov 27
29. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions
for preventing falls in older people living in the
community. Cochrane Database Syst Rev 2009; (2):
CD007146
30. Mansfield A, Peters AL, Liu BA, et al. A perturbationbased
balance training program for older adults: study
protocol for a randomised controlled trial. BMC Geriatr
2007; 7: 12
31. Maki BE, Cheng KC, Mansfield A, et al. Preventing falls in
older adults: new interventions to promote more effective
change-in-support balance reactions. J Electromyogr
Kinesiol 2008; 18 (2): 243-54
32. Sakai M, Shiba Y, Sato H, et al. Motor adaptations during
slip-perturbed gait in older adults. J Phys Ther Sci 2008;
20 (2): 109-15
33. Maki BE, McIlroy WE. Change-in-support balance reactions
in older persons: an emerging research area of clinical
importance. Neurol Clin 2005; 23 (3): 751-83
34. Mynark RG, Koceja DM. Down training of the elderly
soleus H reflex with the use of a spinally induced balance
perturbation. J Appl Physiol 2002; 93 (1): 127-33
35. Sayers SP. High-speed power training: a novel approach
to resistance training in older men and women: a brief
review and pilot study. J Strength Cond Res 2007; 21 (2):
518-26
36. Silsupadol P, Shumway-Cook A, Lugade V, et al. Effects
of single-task versus dual-task training on balance
performance in older adults: a double-blind, randomized
controlled trial. Arch Phys Med Rehabil 2009; 90 (3):
381-7
37. Reid KF, Callahan DM, Carabello RJ, et al. Lower extremity
power training in elderly subjects with mobility
limitations: a randomized controlled trial. Aging Clin Exp
Res 2008; 20 (4): 337-43
38. Porter MM. Power training for older adults. Appl Physiol
Nutr Metab 2006; 31 (2): 87-94
39. Richardson W, Wilson M, Nishikawa J, et al. The wellbuilt
clinical question: a key to evidence-based decisions.
ACP J Club 1995; 123: 12-3
40. Physiotherapy Evidence Database. PEDro scale, 2010
[online]. Available from URL: http://www.pedro.org au/
english/downloads/pedro-scale/ [Accessed 2010 Jun 25]
41. Tooth L, Bennett S, McCluskey A, et al. Appraising the
quality of randomized controlled trials: inter-rater reliability
for the OTseeker evidence database. J Eval Clin
Pract 2005; 11 (6): 547-55
42. Maher CG, Sherrington C, Herbert RD, et al. Reliability of
the PEDro scale for rating quality of randomized controlled
trials. Phys Ther 2003; 83 (8): 713-21
43. Rogers MW, Johnson ME, Martinez KM, et al. Step
training improves the speed of voluntary step initiation
in aging. J Gerontol A Biol Sci Med Sci 2003; 58 (1):
46-51
44. Jo¨ bges M, Heuschkel G, Pretzel C, et al. Repetitive training
of compensatory steps: a therapeutic approach for postural
instability in Parkinson’s disease. J Neurol Neurosurg
Psychiatry 2004; 75 (12): 1682-7
45. Shimada H, Obuchi S, Furuna T, et al. New intervention
program for preventing falls among frail elderly
people: the effects of perturbed walking exercise using a
bilateral separated treadmill. Am J Phys Med Rehabil
2004; 83 (7): 493-9
46. Marigold DS, Eng JJ, Dawson AS, et al. Exercise leads to
faster postural reflexes, improved balance and mobility,
and fewer falls in older persons with chronic stroke. J Am
Geriatr Soc 2005; 53 (3): 416-23
47. Silsupadol P, Siu KC, Shumway-Cook A, et al. Training of
balance under single- and dual-task conditions in older
adults with balance impairment. Phys Ther 2006; 86 (2):
269-81
48. Yang YR, Wang RY, Chen YC, et al. Dual-task exercise
improves walking ability in chronic stroke: a randomized
controlled trial. Arch Phys Med Rehabil 2007; 88 (10):
1236-40
49. Silsupadol P, Lugade V, Shumway-Cook A, et al. Trainingrelated
changes in dual-task walking performance of elderly
persons with balance impairment: a double-blind,
randomized controlled trial. Gait Posture 2009; 29 (4):
634-9
50. Brauer SG, Morris ME. Can people with Parkinson’s disease
improve dual tasking when walking? Gait Posture
2010; 31 (2): 229-33
51. Granacher U, Muehlbauer T, Bridenbaugh S, et al. Balance
training and multi-task performance in seniors. Int J
Sports Med 2010; 31 (5): 353-8
52. Mansfield A, Peters AL, Liu BA, et al. Effect of a perturbation-based
balance training program on compensatory
stepping and grasping reactions in older adults: a randomized
controlled trial. Phys Ther 2010; 90 (4): 476-91
53. Schwenk M, Zieschang T, Oster P, et al. Dual-task performances
can be improved in patients with dementia: a
randomized controlled trial. Neurology 2010; 74 (24):
1961-8
54. Ha¨ kkinen K, Kallinen M, Izquierdo M, et al. Changes in
agonist-antagonist EMG, muscle CSA, and force during
strength training in middle-aged and older people. J Appl
Physiol 1998; 84 (4): 1341-9
55. Ha¨ kkinen K, Alen M, Kallinen M, et al. Neuromuscular
adaptation during prolonged strength training, detraining
and re-strength-training in middle-aged and elderly people.
Eur J Appl Physiol 2000; 83 (1): 51-62
56. Earles DR, Judge JO, Gunnarsson OT. Velocity training
induces power-specific adaptations in highly functioning
older adults. Arch Phys Med Rehabil 2001; 82 (7): 872-8
57. Izquierdo M, Ha¨ kkinen K, Ibanez J, et al. Effects of
strength training on muscle power and serum hormones in
Neuromuscular Performance in Seniors 397
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
middle-aged and older men. J Appl Physiol 2001; 90 (4):
1497-507
58. Fielding RA, LeBrasseur NK, Cuoco A, et al. High-velocity
resistance training increases skeletal muscle peak power in
older women. J Am Geriatr Soc 2002; 50 (4): 655-62
59. Miszko TA, Cress ME, Slade JM, et al. Effect of strength
and power training on physical function in communitydwelling
older adults. J Gerontol A Biol Sci Med Sci 2003;
58 (2): 171-5
60. Sayers SP, Bean J, Cuoco A, et al. Changes in function
and disability after resistance training: does velocity
matter? A pilot study. Am J Phys Med Rehabil 2003; 82
(8): 605-13
61. Bean JF, Herman S, Kiely DK, et al. Increased Velocity
Exercise Specific to Task (InVEST) training: a pilot study
exploring effects on leg power, balance, and mobility in
community-dwelling older women. J Am Geriatr Soc
2004; 52 (5): 799-804
62. Kongsgaard M, Backer V, Jorgensen K, et al. Heavy
resistance training increases muscle size, strength and
physical function in elderly male COPD-patients: a pilot
study. Respir Med 2004; 98 (10): 1000-7
63. de Vos NJ, Singh NA, Ross DA, et al. Optimal load for
increasing muscle power during explosive resistance
training in older adults. J Gerontol A Biol Sci Med Sci
2005; 60 (5): 638-47
64. Henwood TR, Taaffe DR. Improved physical performance
in older adults undertaking a short-term programme
of high-velocity resistance training. Gerontology 2005; 51
(2): 108-15
65. Henwood TR, Taaffe DR. Short-term resistance training
and the older adult: the effect of varied programmes
for the enhancement of muscle strength and functional
performance. Clin Physiol Funct Imaging 2006; 26 (5):
305-13
66. Holviala JH, Sallinen JM, Kraemer WJ, et al. Effects
of strength training on muscle strength characteristics,
functional capabilities, and balance in middle-aged and
older women. J Strength Cond Res 2006; 20 (2): 336-44
67. Orr R, de Vos NJ, Singh NA, et al. Power training improves
balance in healthy older adults. J Gerontol A Biol
Sci Med Sci 2006; 61 (1): 78-85
68. Bottaro M, Machado SN, Nogueira W, et al. Effect of high
versus low-velocity resistance training on muscular fitness
and functional performance in older men. Eur J Appl
Physiol 2007; 99 (3): 257-64
69. Caserotti P, Aagaard P, Buttrup LJ, et al. Explosive heavyresistance
training in old and very old adults: changes in
rapid muscle force, strength and power. Scand J Med Sci
Sports 2008; 18 (6): 773-82
70. Henwood TR, Riek S, Taaffe DR. Strength versus muscle
power-specific resistance training in community-dwelling
older adults. J Gerontol A Biol Sci Med Sci 2008; 63 (1):
83-91
71. Marsh AP, Miller ME, Rejeski WJ, et al. Lower extremity
muscle function after strength or power training in older
adults. J Aging Phys Act 2009; 17 (4): 416-43
72. Nogueira W, Gentil P, Mello SN, et al. Effects of power
training on muscle thickness of older men. Int J Sports
Med 2009; 30 (3): 200-4
73. Webber SC, Porter MM. Effects of ankle power training on
movement time in mobility-impaired older women. Med
Sci Sports Exerc 2010; 42 (7): 1233-40
74. Granacher U, Gollhofer A, Strass D. Training induced
adaptations in characteristics of postural reflexes in elderly
men. Gait Posture 2006; 24 (4): 459-66
75. Madureira MM, Takayama L, Gallinaro AL, et al. Balance
training program is highly effective in improving functional
status and reducing the risk of falls in elderly
women with osteoporosis: a randomized controlled trial.
Osteoporos Int 2007; 18 (4): 419-25
76. DiStefano LJ, Clark MA, Padua DA. Evidence supporting
balance training in healthy individuals: a systemic review.
J Strength Cond Res 2009; 23 (9): 2718-31
77. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA,
et al. American College of Sports Medicine position
stand: exercise and physical activity for older adults. Med
Sci Sports Exerc 2009; 41 (7): 1510-30
78. Granacher U, Gruber M, Strass D, et al. The impact of
sensorimotor training in elderly men on maximal and explosive
force production capacity. Deut Z Sportmed 2007;
58 (12): 446-51
79. Steadman J, Donaldson N, Kalra L. A randomized controlled
trial of an enhanced balance training program to
improve mobility and reduce falls in elderly patients. J Am
Geriatr Soc 2003; 51 (6): 847-52
80. Granacher U, Gruber M, Gollhofer A. The impact of sensorimotor
training on postural control in elderly men.
Deut Z Sportmed 2009; 60 (12): 387-93
81. Rochat S, Martin E, Piot-Ziegler C, et al. Falls self-efficacy
and gait performance after gait and balance training in
older people. J Am Geriatr Soc 2008; 56 (6): 1154-6
82. Voukelatos A, Cumming RG, Lord SR, et al. A randomized,
controlled trial of tai chi for the prevention of falls:
the Central Sydney tai chi trial. J Am Geriatr Soc 2007; 55
(8): 1185-91
83. Li F, Harmer P, Fisher KJ, et al. Tai Chi and fall reductions
in older adults: a randomized controlled trial. J Gerontol
A Biol Sci Med Sci 2005; 60 (2): 187-94
84. Gollhofer A. Proprioceptive training: considerations for
strength and power production. In: Komi PV, editor.
Strength and power in sport. Oxford: Blackwell Publishing,
2003: 331-42
85. Taube W, Gruber M, Beck S, et al. Cortical and spinal
adaptations induced by balance training: correlation between
stance stability and corticospinal activation. Acta
Physiol 2007; 189 (4): 347-58
86. Gabell A, Simons MA, Nayak US. Falls in the healthy
elderly: predisposing causes. Ergonomics 1985; 28 (7):
965-75
87. Lord SR, Ward JA, Williams P, et al. An epidemiological
study of falls in older community-dwelling women: the
Randwick falls and fractures study. Aust J Public Health
1993; 17 (3): 240-5
88. Woollacott MH, Shumway-Cook A, Nashner LM. Aging
and posture control: changes in sensory organization and
muscular coordination. Int J Aging Hum Dev 1986; 23
(2): 97-114
398 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
89. Maki BE, McIlroy WE. The role of limb movements in
maintaining upright stance: the ‘‘change-in-support’’
strategy. Phys Ther 1997; 77 (5): 488-507
90. Reilly T, Morris T, Whyte G. The specificity of training
prescription and physiological assessment: a review.
J Sports Sci 2009; 27 (6): 575-89
91. Melzer I, Elbar O, Tsedek I, et al. A water-based training
program that include perturbation exercises to improve
stepping responses in older adults: study protocol for a
randomized controlled cross-over trial. BMC Geriatr
2008; 8: 19
92. Oddsson LIE, Boissy P, Melzer I. How to improve gait and
balance function in elderly individuals: compliance with
principles of training. Eur Rev Aging Phys Act 2007; 4 (1):
15-23
93. Boissy P, Yurkow J, Chopra A, et al. Balance training in
the elderly using Swiss ball: a pilot study [abstract]. Arch
Phys Med Rehabil 2000; 81 (10): 1463
94. Fiatarone MA, Marks EC, Ryan ND, et al. High-intensity
strength training in nonagenarians: effects on skeletal
muscle. JAMA 1990; 263 (22): 3029-34
95. Granacher U, Gruber M, Gollhofer A. Resistance training
and neuromuscular performance in seniors. Int J Sports
Med 2009; 30 (9): 652-7
96. LaStayo PC, Ewy GA, Pierotti DD, et al. The positive
effects of negative work: increased muscle strength and
decreased fall risk in a frail elderly population. J Gerontol
A Biol Sci Med Sci 2003; 58 (5): 419-24
97. Mueller M, Breil FA, Vogt M, et al. Different response to
eccentric and concentric training in older men and
women. Eur J Appl Physiol 2009; 107 (2): 145-53
98. LaStayo PC, Reich TE, Urquhart M, et al. Chronic eccentric
exercise: improvements in muscle strength can
occur with little demand for oxygen. Am J Physiol 1999;
276 (2): 611-5
99. Roig M, O’Brien K, Kirk G, et al. The effects of eccentric
versus concentric resistance training on muscle strength
and mass in healthy adults: a systematic review with metaanalysis.
Br J Sports Med 2009; 43 (8): 556-68
100. Porter MM, Vandervoort AA. High-intensity strength
training for the older adult: a review. Topics Geriatr Rehabil
1995; 10 (3): 61-74
101. Frontera WR, Meredith CN, O’Reilly KP, et al. Strength
conditioning in older men: skeletal muscle hypertrophy
and improved function. J Appl Physiol 1988; 64
(3): 1038-44
102. Latham NK, Bennett DA, Stretton CM, et al. Systematic
review of progressive resistance strength training in older
adults. J Gerontol A Biol Sci Med Sci 2004; 59 (1): 48-61
103. Aagaard P, Suetta C, Caserotti P, et al. Role of the nervous
system in sarcopenia and muscle atrophy with aging:
strength training as a countermeasure. Scand J Med Sci
Sports 2010; 20 (1): 49-64
104. Ha¨ kkinen K. Ageing and neuromuscular adaptation
to strength training. In: Komi PV, editor. Strength
and power in sport. Oxford: Blackwell Publishing, 2003:
409-25
105. Seynnes OR, de Boer M, Narici MV. Early skeletal muscle
hypertrophy and architectural changes in response to
high-intensity resistance training. J Appl Physiol 2007;
102 (1): 368-73
106. Reeves ND, Narici MV, Maganaris CN. Strength training
alters the viscoelastic properties of tendons in elderly humans.
Muscle Nerve 2003; 28 (1): 74-81
107. Orr R, Raymond J, Fiatarone SM. Efficacy of progressive
resistance training on balance performance in older
adults: a systematic review of randomized controlled
trials. Sports Med 2008; 38 (4): 317-43
108. Latham NK, Anderson CS, Lee A, et al. A randomized,
controlled trial of quadriceps resistance exercise and vitamin
D in frail older people: the Frailty Interventions
Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc
2003; 51 (3): 291-9
109. McMurdo ME, Mole PA, Paterson CR. Controlled trial of
weight bearing exercise in older women in relation to bone
density and falls. BMJ 1997; 314 (7080): 569
110. Wolff I, van Croonenborg JJ, Kemper HC, et al. The effect
of exercise training programs on bone mass: a meta-analysis
of published controlled trials in pre- and postmenopausal
women. Osteoporos Int 1999; 9 (1): 1-12
111. Liu-Ambrose TY, Khan KM, Eng JJ, et al. Both resistance
and agility training increase cortical bone density in
75- to 85-year-old women with low bone mass: a 6-month
randomized controlled trial. J Clin Densitom 2004; 7 (4):
390-8
112. Suominen H. Muscle training for bone strength. Aging Clin
Exp Res 2006; 18 (2): 85-93
113. Skelton DA, Greig CA, Davies JM, et al. Strength, power
and related functional ability of healthy people aged 65-89
years. Age Ageing 1994; 23 (5): 371-7
114. Suetta C, Magnusson SP, Beyer N, et al. Effect of strength
training on muscle function in elderly hospitalized
patients. Scand J Med Sci Sports 2007; 17 (5): 464-72
115. Perry MC, Carville SF, Smith IC, et al. Strength,
power output and symmetry of leg muscles: effect of age
and history of falling. Eur J Appl Physiol 2007; 100 (5):
553-61
116. Shigematsu R, Rantanen T, Saari P, et al. Motor speed and
lower extremity strength as predictors of fall-related bone
fractures in elderly individuals. Aging Clin Exp Res 2006;
18 (4): 320-4
117. Judge JO, Underwood M, Gennosa T. Exercise to improve
gait velocity in older persons. Arch Phys Med Rehabil
1993; 74 (4): 400-6
118. Judge JO, Lindsey C, Underwood M, et al. Balance improvements
in older women: effects of exercise training.
Phys Ther 1993; 73 (4): 254-62
119. Sipila S, Multanen J, Kallinen M, et al. Effects of strength
and endurance training on isometric muscle strength and
walking speed in elderly women. Acta Physiol Scand 1996;
156 (4): 457-64
120. Buchner DM, Cress ME, de Lateur BJ, et al. The effect of
strength and endurance training on gait, balance, fall risk,
and health services use in community-living older adults.
J Gerontol A Biol Sci Med Sci 1997; 52 (4): 218-24
121. Singh NA, Clements KM, Fiatarone MA. A randomized
controlled trial of progressive resistance training in
depressed elders. J Gerontol A Biol Sci Med Sci 1997; 52
(1): 27-35
Neuromuscular Performance in Seniors 399
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
122. Schlicht J, Camaione DN, Owen SV. Effect of intense
strength training on standing balance, walking speed, and
sit-to-stand performance in older adults. J Gerontol A
Biol Sci Med Sci 2001; 56 (5): 281-6
123. Tyni-Lenne R, Gordon A, Jensen-Urstad M, et al. Aerobic
training involving a minor muscle mass shows greater
efficiency than training involving a major muscle mass
in chronic heart failure patients. J Card Fail 1999; 5 (4):
300-7
124. Englund U, Littbrand H, Sondell A, et al. A 1-year
combined weight-bearing training program is beneficial
for bone mineral density and neuromuscular function in
older women. Osteoporos Int 2005; 16 (9): 1117-23
125. Judge JO, Whipple RH, Wolfson LI. Effects of resistive
and balance exercises on isokinetic strength in older persons.
J Am Geriatr Soc 1994; 42 (9): 937-46
126. Topp R, Mikesky A, Wigglesworth J, et al. The effect of a
12-week dynamic resistance strength training program on
gait velocity and balance of older adults. Gerontologist
1993; 33 (4): 501-6
127. Topp R, Mikesky A, Dayhoff NE, et al. Effect of resistance
training on strength, postural control, and gait velocity
among older adults. Clin Nurs Res 1996; 5 (4): 407-27
Correspondence: Prof. Dr Urs Granacher, Institute of Sport
Science, Friedrich-Schiller-University, Seidelstr. 20, 07749
Jena, Germany.
E-mail: urs.granacher@uni-jena-de
Dr Thomas Muehlbauer, Institute of Sport Science, FriedrichSchiller-University,
Seidelstr. 20, 07749 Jena, Germany.
E-mail: t.muehlbauer@uni-jena.de
400 Granacher et al.
ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)