ReseachArticle - Hindawi Publishing...

Research ArticleEffects of Two Types of 9-Month Adapted Physical ActivityProgram on Muscle Mass Muscle Strength and Balance inModerate Sarcopenic Older Women

G Piastra 1 L Perasso 2 S Lucarini 1 F Monacelli 34 A Bisio 2 V Ferrando 25

M Gallamini6 E Faelli 2 and P Ruggeri 2

1Liguria Region Public Health Service-ASL4 Chiavarese 16043 Chiavari Italy2Department of Experimental Medicine (DIMES) University of Genoa 16132 Genoa Italy3Department of Internal Medicine and Medical Specialties (DIMI) University of Genoa 16132 Genoa Italy4Hospital Policlinic San Martino Section of Geriatric Medicine 16132 Genoa Italy5Department of Neuroscience Ophthalmology Genetics and Maternal-Infantile Sciences (DINOGMI) University of Genova16132 Genova Italy

6Ben-Essere Sport andWellness Association Rapalloird-Sector Liguria Region Registry 16132 Genoa Italy

Correspondence should be addressed to A Bisio ambrabisiounigeit

Received 11 May 2018 Revised 12 September 2018 Accepted 2 October 2018 Published 18 October 2018

Academic Editor Astrid Bergland

Copyright copy 2018 G Piastra et alThis is an open access article distributed under theCreative Commons Attribution License whichpermits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

The present study aimed to evaluate the effects of two types of 9-month adapted physical activity (APA) program based ona muscle reinforcement training and a postural training respectively on muscle mass muscle strength and static balance inmoderate sarcopenic older women The diagnosis of sarcopenia was done in accordance with measurable variables and cut-offpoints suggested by the European Working Group on Sarcopenia in Older People (EWGSOP) Seventy-two participants wererandomly assigned to two groups themuscle reinforcement training group (RESISTANCE) (n=35 699plusmn 27 years) and the posturaltraining group (POSTURAL) (n=37 700plusmn28 years) Body composition muscle mass skeletal muscle mass index (SMI) andhandgrip strength (HGS) were evaluated for sarcopenia assessment whereas Sway Path Sway Area Stay Time and Spatial Distancewere evaluated for static balance assessment Sixty-six participants completed the study (RESISTANCE group n=33 POSTURALgroup n=33) Significant increases of musclemass SMI and handgrip strength values were found in the RESISTANCE group aftermuscle reinforcement program No significant differences appeared in the POSTURAL group after postural training FurthermoreRESISTANCE group showed significant improvements in static balance parameters whereas no significant differences appearedin the POSTURAL group On the whole the results of this study suggest that the APA program based on muscle reinforcementapplied on moderate sarcopenic older women was able to significantly improve muscle mass and muscle strength and it was alsomore effective than the applied postural protocol in determining positive effects on static balance

1 Introduction

The older population in the world is predicted to increase bythreefold within 50 years from 600million people in 2000 toover two billion in 2050 This increase may be viewed as oneof societyrsquos greatest achievements but preserving older adultsrsquoindependence and quality of life remains one of the majorclinical and public health challenges [1] A severe change asso-ciated with aging is the progressive and apparently inevitable

process of loss of muscle mass and strength [2] referred to assarcopenia [3] Although consensus definition and diagnosiscriteria have not been reached the bidimensional nature ofsarcopenia is increasingly accepted encompassing both thequantitative and qualitative declines of skeletal muscle andbeing characterized by a loss of muscle mass strength andpower [4 5]This condition which involves primarily women[6] has been associated with the atrophy of fast twitch typeII muscle fibers and the substitution of functional tissues by

HindawiBioMed Research InternationalVolume 2018 Article ID 5095673 10 pageshttpsdoiorg10115520185095673

2 BioMed Research International

Table 1 Participant characteristics at baseline Data are means plusmn SDRESISTANCE (n=35) POSTURAL (n=37) p-value

Age (years) 699plusmn27 700plusmn28 nsHeight (cm) 162plusmn002 159plusmn001 nsBody mass (kg) 6386plusmn175 6377plusmn215 nsBody mass index (kgm2) 2434plusmn072 2523plusmn086 nsHandgrip strength (kg) (mean of the two sides) 1784plusmn497 1786plusmn53 ns

adipose and fibrotic tissues that have reduced rates of proteinsynthesis thus leading to reduced muscle efficiency [7]

The impaired state of health induced by sarcopenia isclosely related to a risk of adverse outcomes such as physicaldisability poor quality of life impaired ability to performactivities of daily living [8 9] and mostly important riskof falls and fractures which represent the main causes of adownward spiral of loss of confidence and social withdrawalwhich may ultimately lead to loss of independence [10] Thedecrease in maximal muscle strength could be a main causeof postural instability [11] and the consequent reduced abilityof old adults to adequately react to unexpected perturbationsand to successfully regain balance is important intrinsic riskfactor for falling [12ndash14]

Exercise has been shown to reduce the incidence of fallsby 13 to 40 which has led to a broad consensus amongexperts that older adults should be offered exercises thatincorporate elements of balance and strength training [15]Pieces of evidence support the notion that regular physicalactivity in combination with appropriate nutritional supportis the most effective strategy for improving sarcopenia andphysical function and preventing disability [16] There arefour types of exercises recommended in adapted physicalactivity (APA) for older adults aerobic exercises progressiveresistance training flexibility exercises and balance training[17] Particularly progressive resistance training has beendemonstrated to attenuate development of sarcopenia byimproving muscle size and function reducing balance andflexibility problems and reducing also the risk of develop-ment of other sarcopenia-related comorbidities [18]The roleof exercise in sarcopenia was investigated in several studies[19ndash22] but to the best of our knowledge no standardizedtraining protocol has been developed for healthy olderpeople to induce positive quantitative and qualitative effectson muscle function and to improve balance The aim ofthis study was to evaluate the effects on muscle mass andmuscle strength and on static balance of two types of 9-month adapted physical activity (APA) programs based onmuscle reinforcement training and postural training [23]respectively in moderate sarcopenic older women

2 Materials and Methods

21 Participants Initially 82 potential participants wereassessed for eligibility from the community through adver-tisements in the notice board of the Public Health ServiceASL 4 Chiavari Italy and in the local newspaper andthe screening period was conducted between August andSeptember 2016

The recruitment process consisted of amedical evaluationto assess their good health and the absence of any contraindi-cation to participation in adapted physical activity programs

Participants were required to be at least 65 years of ageand they were excluded if they had a pacemaker (due to theuse of bioelectrical impedance analysis) or previous healthproblems such as neurological or cardiovascular diseases thatwould limit participation in the APA programs

During enrolment 10 potential participants wereexcluded because 6 did not meet inclusion criteria and theother 4 declined to participate

At the end of the recruitment 72 participants wereenrolled for the study and they were randomly divided intotwo groups assigned to one of the two APA programs musclereinforcement training group (RESISTANCE) (n=35) andpostural training group (POSTURAL) (n=37) Two out of35 participants of the RESISTANCE group and 4 out of 37participants of the POSTURAL group did not complete thetraining programs A flow diagram of the study is reported inFigure 1

The participant characteristics of the two groups atbaseline are reported in Table 1

The experimental protocol was approved by the EthicsCommittee of the University of Genoa and after explainingthe aim and the procedure of the study all participants gavetheir informed consent for intervention

22 Sample Size Estimation of sample size for this inves-tigation was performed using handgrip strength as one ofour primary outcome measures Sample size was estimatedcombining the normative data and the genuine change ingrip strength determined in previous works [24 25] Theseassumptions generated a desired sample size of at least 30participants However we recruited 72 participants 35 in theRESISTANCE group and 37 in the POSTURAL group toallow for drop-out during the intervention period

23 Testing Procedures Testing was conducted before (T0)and after (T1) the APA intervention

231 Food Questionnaire Before starting the APA programall the participants were asked to answer to a food question-naire in order to check a balanced daily intake of nutrients

232 Anthropometry and Body Composition Body massand height were measured to the nearest 01 kg and 05cm respectively using a mechanical column scale and astadiometer Body composition evaluation was performedusing a bioimpedance scale (InBody 320 GBC BioMed NZ)

BioMed Research International 3

Assessed for eligibility (n=82)

Excluded (n=10)Not meeting inclusion criteria (n=6)Declined to participate (n=4)

Randomized (n=72)

Allocated to muscle reinforcement traininggroup (n=35)

Received allocated intervention (n=35)Did not receive allocated intervention (n=0)

Allocated to postural training group (n=37)Received allocated intervention (n=37)Did not receive allocated intervention (n=0)

Lost to follow-up (declined) (n=2) Lost to follow-up (declined) (n=4)

Enrolment

Allocation

Follow-Up

AnalysisAnalyzed(n=33)Excluded from analysis (n=0)

Analyzed (n=33)Excluded from analysis (n=0)

Figure 1 Flow diagram of the study

at least 2 hours after the meal and participants were requiredto wear light clothing with bare feet After ensuring properfeet placement and hold of hand electrodes participantswere instructed to stay relaxed during the measurementsmaintaining a normal standing position with arms andlegs extended The parameters used to measure the bodycomposition were weight (Kg) body mass index (BMI) andmuscle mass (Kg)

The skeletal muscle mass (SM) was calculated with theregression equation (1) as described by Janssen et al [26]

SM (kg) = [(Ht2119877 times 0401) + (gender times 3825)

+ (age times minus0071)] + 5102(1)

whereHt is height in centimetersR is BIA resistance in ohmsfor gender men = 1 and women =0 and age is in years

The same authors defined SM index (SMI) consideringSMI as SM (Kg) obtained from the above-mentioned predic-tion equation adjusted for the squared height (SMheight2 Kgm2)

233 Sarcopenia Assessment Sarcopenia was diagnosed inaccordance with EWGSOP criteria [8] Particularly weadopted the followingmeasurable variables and cut-off pointsto diagnose sarcopenia presented in the above cited EWG-SOP report SMI using BIA predicted skeletal muscle mass(SM) equation (SMheight2) and the handgrip strengthConcerning SMI the cut-off values used by the EWGSOP

were moderate sarcopenia when SMI is between 851 and1075 kgm2 (men) or 576 and 675 kgm2 (women) andsevere sarcopenia when SMI is le850 kgm2 (men) or le575kgm2 (women) [27] HGS cut-off values for the diagnosisof sarcopenia were le 30 kg (men) and le 20 kg (women)[8 27] All the participants in our study showed a moder-ate sarcopenia Muscle strength was assessed by handgripstrength a proxy index of overall muscle strength [28]measured with a Jamar hydraulic hand-held dynamometer(Sammons Preston Rolyan Bolingbrook IL USA) with thesecond handle position for all participants and expressed inkg [29] Additionally the Jamar hand dynamometer has beenshown to have acceptable concurrent validity in young andadults [30 31] Participants seated on a chair with their feetflat on the floor holding the handgrip with their wrist inline with their elbow and they were instructed to press thedynamometer as hard as possible Participants performed amaximum voluntary isometric contraction of finger flexormuscles three measurements were taken with 10-secondintervals between each trial for both body sides (dominantand nondominant) and mean value of the two body sideswas indicated as whole body handgrip strength (HGS) Themaximum values were considered for statistical analysis [32]

234 Static Balance All participants performed the balanceassessment on a static force platform (ARGO RGMMedicalDevices SpA Genoa Italy)TheARGO static force platformhas a large platform surface area (600 x 600 mm) and a highsampling frequency (100 Hz) This platform even with shortmeasurement times allows a reliable harmonic analysis ofsway density parameters [33]


Participants were asked to stand with their feet joinedand parallel on the barefoot with their arms hanging loose atsides and with closed mouth and unclenched teeth lookingat a target placed at their eye level about 1 m in front of themin an acoustically isolated room and darkened when theywere in closed eyes (CE) condition Participants executed twotrials in two different randomized modalities with open eyes(OE) and with closed eyes (CE) Each assessment lasted 40seconds preceded by a 5-second waiting time that allowedthe participants to become familiar with the position thusreducing the adaptation artifact [34 35]The parameters usedto evaluate the static balance were as follows

(1) Sway Path (SP) (mms) defined as Length of theSway Path normalized with respect to the duration of theacquisition interval

(2) Sway Area (SA) (mm2s) defined as the Sway Area bythe radius connecting each subsequent point of the statoki-nesigram to the average position of the Centre of Pressure(COP) normalized with respect to the duration of theacquisition interval

(3) Stay Time (ST) (s) the mean Stay Time spent bythe COP trace in the neighbourhood of each peak over theobserved sway of each subject

(4) Spatial Distance (SD) (mm) the average displacementof the COP trace between one peak and the next one

24 APA Exercises The two different APA programs wereperformed twice a week for 36 weeks and every sessionlasted for 60 minutes The APA sessions were performed in agym and conducted by an instructor in groups of amaximumof 20 participants

Each session of the muscle reinforcement training wasdivided into three phases (1) standing 151015840 warming up andmotor coordination exercises (2) standingon the ground301015840 muscle toning at lowmoderate intensity for differentmuscular districts (primarily abdominal and both lower andupper limbs) with low weight loads (05 1 or 15Kg) (3)cooling down 151015840 and relaxationstretching of the musclesystems with specific exercises [23]

Each session of the postural training was divided intothree phases (1) standing 101015840-151015840 cardiovascular activationshoulder and coxofemoral joints mobilization lower limbsreinforcement (2) sitting 101015840-151015840 neck and shoulders mobi-lization (3) on the ground 5-301015840 spine mobilization abdom-inal muscles reinforcement gluteal and spine extensor mus-cles reinforcement spine stretching hamstring and psoasmuscle reinforcement and self-stretching and final relaxation[23]

Both muscle reinforcement exercises and postural exer-cises were adapted to the participantrsquos abilities and wereprogressive in repetitions and difficulties over time

25 Data Analysis Shapiro-Wilcoxon tests were used toevaluate whether the outcome variables were normally dis-tributed

SM SMI and HGS of the two groups were normallydistributed and were compared before (T0) and after (T1)the intervention by means of a repeated measure ANOVAwith TIME (2 levels T0 and T1) as within-subject factor

and GROUP (2 levels RESISTANCE and POSTURAL) asbetween-subject factor Newman-Keuls post hoc test wasused to evaluate significant interactions

Static balance data of the RESISTANCE and POSTU-RAL groups acquired with CE and OE were not normallydistributed Therefore Mann-Whitney tests were used toevaluate differences between groups at each time epoch (T0and T1) whilst Wilcoxon tests were applied to assess changesin each group Significance for all procedures was set at a levelof 005

Data are presented as mean plusmn SD for normally distributeddata and asmedian associated with the interquartile range fornot normally distributed data

3 Results

31 Effects on Sarcopenia Thestatistical analysis on leanmassexpressed as of the total weight and in kg showed asignificant effect of the factor TIME ( F(164)=2270plt0001 kg F(164)=1825 plt00001) Furthermore a signifi-cant TIMElowastGROUP interaction appeared ( F(164)=2482plt00001 kg F(164)=2953 plt00001) and post hoc com-parisons revealed a significant increase of lean mass valuesfrom T0 to T1 only in the RESISTANCE group (meanplusmnSD T0=3010plusmn844 T1=3311plusmn729 kg T0=1950plusmn659 kgT1=2125plusmn605 kg) whilst not significant differences appearedin the POSTURAL group (meanplusmnSD T0=3052plusmn593 T1=3045plusmn551 kg T0=1985plusmn739 kg T1=1963plusmn649 kg)

Data concerning skeletal muscle mass (SM) values before(T0) and after (T1) the intervention program are repre-sented in Figure 2(a) The results of the statistical analy-sis showed a significant main effect of the factor TIME(F(164)=1776 plt0001) and a significant TIMElowastGROUPinteraction (F(164)=2904 plt00001) Post hoc test revealeda significant increase of SM value only in the RESIS-TANCE group (meanplusmnSD T0=1731plusmn116 kg T1=1902plusmn658kg plt0001) whilst no differences were found between T0and T1 in the POSTURAL group (meanplusmnSD T0=1759plusmn731kg T1=1753plusmn639 kg)

The statistical analysis on SMI values showed a significanteffect of the factor TIME (F(164)=1989 plt00001) and asignificant TIMElowastGROUP interaction (F(164)=2920plt00001) A significant increase of SMI values was foundonly after muscle reinforcement program (meanplusmnSDT0=648plusmn275 kgm2 T1=736plusmn231 kgm2 plt0001) Nosignificant differences appeared after POSTURAL training(meanplusmnSD T0=674plusmn246 kgm2 T1=667plusmn217 kgm2) (seeFigure 2(b))

Results of the handgrip test are represented in Figure 2(c)The statistical analysis on the mean of HGS of both handsshowed a significant effect of the factor TIME (F(164)=794plt001) and a significant interaction between TIME andGROUP (F(164)=1437 plt0001) A significant increase ofHGS values was found only in the RESISTANCE group(meanplusmnSD T0=1784plusmn491 kg T1=1986plusmn522 kg plt0001)and no differences appeared in the POSTURAL group(meanplusmnSD T0=1784plusmn525 kg T1=1755plusmn485 kg)


T0 T1

ResistancePostural

14

16

18

20

22

SM (k

g)

lowastlowastlowast

(a)

T0 T1

ResistancePostural

4

5

6

7

8

SMI (

kgm

2 )

9

10

lowastlowastlowast

(b)

T0 T114

16

18

20

22

HG

S (k

g)

ResistancePostural

lowastlowastlowast

(c)

Figure 2 Values of skeletal muscle mass (SM) (a) skeletal muscle mass index (SMI) (b) and handgrip strength (HGS) (c) of the musclereinforcement training group (RESISTANCE black lines) and postural training group (POSTURAL grey lines) before (T0) and after (T1)the intervention Values are means plusmn SE lowastlowastlowast indicates plt0001

32 Effects on Balance Parameters The static balance dataare represented in Figure 3 and the descriptive statistics arereported in Table 2 The results of the Mann-Whitney testcomparing the parameters of the two groups showed signif-icant differences after the treatment whilst no differenceswere observed at baseline Furthermore the results of theWilcoxon test comparing the parameters related to eachgroup acquired in T0 and T1 epochs revealed significantdifferences between the effects evoked in the two groupsHereafter we will report only significant results

321 Sway Path (SP) Wilcoxon tests comparing the SwayPath acquired with close eyes (SP CE) before and aftertreatments revealed a significant decrease of its value aftermuscle reinforcement training (Z=353 plt0001) and a sig-nificant increase after the postural training (Z=329 plt0001)When the test was repeated with eyes open a significantdecrease was observed after muscle reinforcement training(Z=394 plt0001) whilst no differences were observed in thePOSTURAL groupThe different effects of the two treatmentsappeared also when comparing Sway Path values at T1 in both


Table 2 Static balance data expressed as median associated to the interquartile range CE closed eyes OE open eyes ns not significant

RESISTANCE training group POSTURAL training group RESISTANCE vsPOSTURALT0 T1 p T0 T1 p

Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001

Spatial distance (mm)

CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005

conditions (CE and OE) indeed SP in RESISTANCE groupwas significantly lower than SP in POSTURAL group (CEZ=-323 plt001 OE Z=-246 plt005) Data are representedin Figures 3(a) and 3(b)

322 Sway Area (SA) In the RESISTANCE group Sway Areadecreased significantly after the treatment in both conditions(CE Z=501 plt0001 OE Z=489 plt0001) whilst no differ-ences were observed in the POSTURAL group Furthermorethe Mann-Whitney test comparing SA at T1 showed in bothconditions that SA associated with the RESISTANCE groupwas significantly lower than that associated with the POSTU-RAL group (CE Z=-296 plt001 OE Z=-223 plt005) Dataare represented in Figures 3(c) and 3(d)

323 Stay Time (ST) After the intervention ST increasedsignificantly only in the RESISTANCE group in both con-ditions (CE Z=401 plt0001 OE Z=469 plt0001) whilst asignificant decrease after the postural training was observedonly in CE condition (Z=249 plt005) The comparisonbetween the two groups at T1 showed that ST associated withRESISTANCE group was higher than that in the POSTURALgroup in both conditions (CE Z=365 plt0001 OE Z=264plt001) Data are represented in Figures 3(e) and 3(f)

324 Spatial Distance (SD) In the RESISTANCE group theresults of the Wilcoxon tests showed a significant decreaseof SD value in both conditions (CE Z=444 plt0001 OEZ=474 plt0001) whilst a significant increase was obtainedafter the postural training only in CE condition (Z=272plt001) Data are represented in Figures 3(g) and 3(h)

4 Discussion

The results of this study performed in moderate sarcopenicolder women demonstrate that the RESISTANCE groupshowed significant improvements in muscle mass and func-tion after the proposed muscle reinforcement programwhereas no significant differences were found in the POS-TURAL group after the adopted postural training Fur-thermore the muscle reinforcement program was able toinduce in RESISTANCE group significant improvements instatic balance parameters whilst no significant differencesin these values were found in the POSTURAL group afterthe postural training On the whole the proposed musclereinforcement program was able to induce positive effectsboth on sarcopenia and on postural parameters

Sarcopenia is closely related to a risk of adverse outcomesincluding poor quality of life and impaired ability to performactivities of daily living [8 9] but mostly important itincreases the risk of falls and fractures [10] At the same timethe decrease in muscle strength could be also an importantcause of postural instability [11] and therefore it representsan intrinsic risk factor for falling by reducing the ability ofolder adults to adequately react to unexpected perturbationsand to successfully regain balance [12ndash14]

Structured physical activity interventions are known todelay the onset of disability in older adults improving clinicaloutcomes such as physical performance gait speed overallsurvival fall risk and quality of life [36] So far there areheterogeneous findings regarding the effects of exercise inter-ventions on the maintenance of functional fitness includingsarcopenia [37]


T0 T1RESISTANCEPOSTURAL

lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)


lowastlowastlowast lowast

(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)


lowastlowastlowastlowastlowastlowast

lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)


lowastlowastlowastlowast

(g)

02

04

06

08

10

12

14

16

18

ST O

E (s

) lowastlowastlowast lowastlowast


(h)

Figure 3 Static balance data of the RESISTANCE and POSTURAL groups acquired with closed eyes (CE) and open eyes (OE) before (T0)and after (T1) the intervention SP Sway Path SA Sway Area ST Stay Time and SD Spatial Distance Values aremedians plusmn SE lowastlowastlowast indicatesplt0001 lowastlowast indicates plt001 and lowast indicates plt005

Two milestone studies have been performed to stand-ardize exercise interventions and elders related outcomemeasurements [38ndash40] Namely the LIFE study was aimedat investigating the effectiveness of physical interventions insedentary community dwelling older adults without comor-bidity The main results indicated that the longitudinalimprovement of functional fitness was a general positive endpoint by virtue of a structured moderate physical activity

program compared with health education program Al-though reduced major disability over 26 years was observedhigh heterogeneity of important cut points was identifiedrepresenting a clinical important challenge

The SPRINT study was also aimed at assessing longitudi-nal mobility disability prevention in older adults by virtue ofcombined nutritional and physical interventions to improvesarcopenia and physical frailty This study was geared to


produce systematic advancements in the management offrail older adults by a multifactorial set of interventions thatincluded physical activity

A recent systematic analysis has pointed out how exerciseinterventions are beneficial to body composition and mus-cle strength [41] However the training effect is generallyinconsistent due to heterogeneity in exercise mode durationand intensity which makes a generalization of trainingapproaches impossible [42 43]

To overcome this difficulty we assigned a homoge-neous group of seventy-two older women with moderatesarcopenia according to EWGSOP criteria [8] to two typesof 9-month adapted physical activity program the firstone focused on muscle reinforcement and the second onefocused on postural exercises Due to the importance ofa balanced diet for sarcopenic people [44] before startingthe physical activity program all the participants were askedto answer to a self-administered food questionnaire thatdemonstrated that participants had a balanced daily intake ofnutrientsWe showed that themuscle reinforcement programsignificantly increased the absolute and the percent leanmassthe skeletal muscle mass (SM) and the skeletal muscle massindex (SMI) obtained by BIA predicted skeletal muscle mass(SM) equation (SMheight2) Furthermore this type of APAprogram applied to the RESISTANCE group significantlyimproved handgrip strength (HGS) a parameter that wellcorrelates with leg strength [8] sarcopenia and physicalfunction [43 44] The improvements in muscle mass SMIand muscle strength can be considered clinically relevantbecause the participants moved froma condition ofmoderatesarcopenia at baseline to a condition of normality after themuscle reinforcement intervention according to the criteriaused to diagnose sarcopenia

It has been reported that postural control is improvedby balance exercise intervention whereas strength exercisesor multicomponent interventions do not significantly influ-ence such postural measurements [45] In this study weinvestigated the effects of a muscle reinforcement protocolin improving balance parameters such as Sway Path SwayArea StayTime and SpatialDistance andwe compared theseeffects with those obtained in another group of moderatesarcopenic older women that underwent an APA programfocused on a postural training Our findings showed thatour muscle reinforcement program was more beneficial thanthe postural intervention in improving balance parametersof moderate sarcopenic older women Therefore under ourexperimental conditions the results of this study suggestthat the improvement of parameters for static balance canbe more effectively obtained by the enhancement of musclestrength and functioning than by a postural training This isan important achievement that obviously deserves further in-depth analysis including the coassessment of other posturalparameters as well as the evaluation of potential biases

A limitation of this study is the inability to establish a cleardose-response relationship along with individual functionalfitness trajectories due to the lack of baseline comprehensivegeriatric assessment and polypharmacy analysis In additionthe lack of osteoporosis assessment could prevent an accurateevaluation of osteosarcopenia a common clinical condition

in older people correlated with adverse clinical outcomesOn the other hand the strengths of the study lie in thereal-world assessment of an older adult population by astandardized adapted physical approach like that proposed inour APA project Another limitation of the study is that wedid not assess functional improvements in balance after theintervention period It would be interesting to investigate infurther studies whether the observed effects after a period ofspecific muscle reinforcement training are accompanied alsoby functional improvements

5 Conclusions

The present findings show the effectiveness of a musclereinforcement program on muscle mass and function aswell as on static balance parameters in moderate sarcopenicolder women thus suggesting that this type of interventioncould represent a significant approach to reducing importantrisk factors for falling such as sarcopenia and balanceimpairments However the limitations of this study and thepotential biases must be considered before drawing firm con-clusions and further studies are required to deeply evaluatethe effectiveness of different types of adapted physical activityprogram in muscle mass and function and in balance Onthe whole this study allows moving a step forward in theunderstanding of the clinical beneficial effects of adaptedphysical activity in an older population The longitudinalassessment of this population including physical activitytraining adherence over time that is part of an ongoing studyand the inclusion of geriatric assessment parameters will helpunderstanding the elders risk stratification on the basis offunctional fitness and frailty prevention

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Authorsrsquo Contributions

G Piastra and L Perasso contributed equally to the work

Acknowledgments

The authors acknowledge the entire staff of Ben-Essere thePresident Mario Franco Repetto Dr Silvia Crispino DrDebora Porzio DrMatteo Ronchi and all the D-EF TrainersTheir dedication made the setup and operation of the wholeprogram possible

References

[1] C Sherrington A Tiedemann N Fairhall J C T Closeand S R Lord ldquoExercise to prevent falls in older adults an


updated meta-analysis and best practice recommendationsrdquoPublic Health Research amp Practice vol 22 no 3-4 pp 78ndash832011

[2] A B Dufour M T Hannan J MMurabito D P Kiel and R RMcLean ldquoSarcopenia definitions considering body size and fatmass are associated with mobility limitations The framinghamstudyrdquo e Journals of Gerontology Series A Biological Sciencesand Medical Sciences vol 68 no 2 pp 168ndash174 2013

[3] I H Rosenberg ldquoSummary comments epidemiological andmethodological problems in determining nutritional status ofolder personsrdquo American Journal of Clinical Nutrition vol 50no 5 pp 1231ndash1233 1989

[4] R Rizzoli J-Y Reginster J-F Arnal et al ldquoQuality of life insarcopenia and frailtyrdquoCalcified Tissue International vol 93 no2 pp 101ndash120 2013

[5] TDamKW PetersM Fragala et al ldquoAn evidence-based com-parison of operational criteria for the presence of sarcopeniardquoe Journals of Gerontology Series A Biological Sciences andMedical Sciences vol 69 no 5 pp 584ndash590 2014

[6] I Janssen S B Heymsfield Z Wang and R Ross ldquoSkeletalmuscle mass and distribution in 468 men and women aged18ndash88 yrrdquo Journal of Applied Physiology vol 89 no 1 pp 81ndash882000

[7] B C Clark and TMManini ldquoSarcopenia Dynapeniardquo Journalsof Gerontology Series A Biological Sciences andMedical Sciencesvol 63 no 8 pp 829ndash834 2008

[8] A J Cruz-Jentoft J P Baeyens J M Bauer et al ldquoSarcopeniaEuropean consensus on definition and diagnosisrdquo Age andAgeing vol 39 no 4 Article ID afq034 pp 412ndash423 2010

[9] L Z Rubenstein and K R Josephson ldquoFalls and their preven-tion in elderly people what does the evidence showrdquo MedicalClinics of North America vol 90 no 5 pp 807ndash824 2006

[10] B Vellas F Cayla H Bocquet F De Pemille and J L AlbaredeldquoProspective study of restriction of acitivty in old people afterfallsrdquo Age and Ageing vol 16 no 3 pp 189ndash193 1987

[11] T Cattagni G Scaglioni D Laroche J Van Hoecke V Gre-meaux and A Martin ldquoAnkle muscle strength discriminatesfallers from non-fallersrdquo Frontiers in Aging Neuroscience vol 6article 336 2014

[12] K Karamanidis A Arampatzis and L Mademli ldquoAge-relateddeficit in dynamic stability control after forward falls is affectedby muscle strength and tendon stiffnessrdquo Journal of Electromyo-graphy amp Kinesiology vol 18 no 6 pp 980ndash989 2008

[13] S Bierbaum A Peper K Karamanidis and A ArampatzisldquoAdaptational responses in dynamic stability during disturbedwalking in the elderlyrdquo Journal of Biomechanics vol 43 no 12pp 2362ndash2368 2010

[14] S Bierbaum A Peper K Karamanidis and A ArampatzisldquoAdaptive feedback potential in dynamic stability during dis-turbed walking in the elderlyrdquo Journal of Biomechanics vol 44no 10 pp 1921ndash1926 2011

[15] Panel on Prevention of Falls in Older Persons and AmericanGeriatrics Society and British Geriatrics Society ldquoSummaryof the updated American Geriatrics SocietyBritish GeriatricsSociety clinical practice guideline for prevention of falls in olderpersonsrdquo Journal of the American Geriatrics Society vol 59 no1 pp 148ndash157 2011

[16] R Calvani A-M Joseph P J Adhihetty et al ldquoMitochondrialpathways in sarcopenia of aging and disuse muscle atrophyrdquobiological chemistry vol 394 no 3 pp 393ndash414 2013

[17] NMontero-Fernandez and J A Serra-Rexach ldquoRole of exerciseon sarcopenia in the elderlyrdquo European Journal of Physical andRehabilitation Medicine vol 49 pp 131ndash143 2013

[18] R Orr J Raymond and M F Singh ldquoEfficacy of progressiveresistance training on balance performance in older adultsa systematic review of randomized controlled trialsrdquo SportsMedicine vol 38 no 4 pp 317ndash343 2008

[19] M Bonnefoy C Cornu S Normand et al ldquoThe effects ofexercise and proteinndashenergy supplements on body compositionand muscle function in frail elderly individuals a long-termcontrolled randomised studyrdquo British Journal of Nutrition vol89 no 5 pp 731ndash739 2003

[20] D Bunout G Barrera P De La Maza et al ldquoThe impactof nutritional supplementation and resistance training on thehealth functioning of free-living chilean elders Results of 18months of follow-uprdquo Journal of Nutrition vol 131 no 9 pp2441ndash2446 2001

[21] R A Fielding N K LeBrasseur A Cuoco J Bean K Mizerand M A Fiatarone Singh ldquoHigh-velocity resistance trainingincreases skeletal muscle peak power in older womenrdquo Journalof the American Geriatrics Society vol 50 no 4 pp 655ndash6622002

[22] W Kemmler S von Stengel K Engelke L Haberle J LMayhew and W A Kalender ldquoExercise body compositionand functional ability a randomized controlled trialrdquoAmericanJournal of Preventive Medicine vol 38 no 3 pp 279ndash287 2010

[23] G Piastra S Lucarini P Cavagnaro L Ganzarolli and GVaccaro ldquoMass performance of adapted physical activity Apopulation strategy to prevent frailty setting-up and runningthe service-8 years of experiencerdquo Journal of Yoga and Physio-therapy vol 1 no 3 pp 555ndash562 2017

[24] NMMassy-Westropp T KGill AW Taylor RW Bohannonand C L Hill ldquoHand Grip Strength Age and gender stratifiednormative data in a population-based studyrdquo BMC ResearchNotes vol 4 no 127 2011

[25] J E Nitschke J M McMeeken H C Burry and T A MatyasldquoWhen is a change a genuine change A clinically meaningfulinterpretation of grip strength measurements in healthy anddisabled womenrdquo Journal of Handerapy vol 12 no 1 pp 25ndash30 1999

[26] I Janssen S B Heymsfield R N Baumgartner and R RossldquoEstimation of skeletal muscle mass by bioelectrical impedanceanalysisrdquo Journal of Applied Physiology vol 89 no 2 pp 465ndash471 2000

[27] I Janssen R N Baumgartner R Ross I H Rosenberg and RRoubenoff ldquoSkeletal muscle cutpoints associated with elevatedphysical disability risk in older men and womenrdquo AmericanJournal of Epidemiology vol 159 no 4 pp 413ndash421 2004

[28] C H Y Ling D Taekema A J M de Craen J GusseklooR G J Westendorp and A B Maier ldquoHandgrip strength andmortality in the oldest old population the Leiden 85-plus studyrdquoCanadian Medical Association Journal vol 182 no 5 pp 429ndash435 2010

[29] M J Peters N S I Van E K Vanhoutte M Bakkers and DP A Van ldquoRevised normative values for grip strength with theJamarrdquo J Peripher Nerv Syst vol 6 pp 47ndash50 2011

[30] J F Amaral M Mancini and J M Novo Junior ldquoComparisonof three hand dynamometers in relation to the accuracy andprecision of the measurementsrdquo Brazilian Journal of Physicalerapy vol 16 no 3 pp 216ndash224 2012


[31] V Mathiowetz ldquoComparison of Rolyan and Jamar dynamome-ters for measuring grip strengthrdquo Occupational erapy Inter-national vol 9 no 3 pp 201ndash209 2002

[32] M Vaz S Thangam A Prabhu and P S Shetty ldquoMaximalvoluntary contraction as a functional indicator of adult chronicundernutritionrdquo British Journal of Nutrition vol 76 no 1 pp9ndash15 1996

[33] M Gallamini G Piastra D P Matteo Ronchi F Scoppa andF Bertora ldquoInstrumental assessment of balance functional per-formance a numerical score to discriminate defective subjectsa retrospective studyrdquo Journal of Novel Physiotherapies vol 6no 5 article 305 2016

[34] L Baratto M Jacono and P Morasso ldquoAcquisition time inthe stabilometric test on force platformrdquo Italian Journal ofRehabilitation Medicine-MR vol 20 no 11 pp 103ndash108 2006

[35] A Ruhe R Fejer and B Walker ldquoCenter of pressure excursionas a measure of balance performance in patients with non-specific low back pain compared to healthy controls A system-atic review of the literaturerdquoEuropean Spine Journal vol 20 no3 pp 358ndash368 2011

[36] R M Henderson M E Miller R A Fielding et al ldquoMain-tenance of physical function 1 year after exercise interventionin at-risk older adults follow-up from the LIFE studyrdquo eJournals of Gerontology Series A Biological Sciences andMedicalSciences vol 73 no 5 pp 688ndash694 2018

[37] F Ramalho R Santos-Rocha M Branco et al ldquoEffect of 6-month community-based exercise interventions on gait andfunctional fitness of an older population a quasi-experimentalstudyrdquo Clinical Interventions in Aging vol Volume 13 pp 595ndash606 2018

[38] W J Rejeski R A Fielding S N Blair et al ldquoThe lifestyleinterventions and independence for elders (LIFE) pilot studyDesign andmethodsrdquo Contemporary Clinical Trials vol 26 no2 pp 141ndash154 2005

[39] R A Fielding W J Rejeski and S Blair ldquoThe lifestyleinterventions and independence for elders study design andmethodsrdquo Journals of Gerontology Series A Biological Sciencesand Medical Sciences vol 66 pp 1226ndash1237 2011

[40] M Pahor J M Guralnik W T Ambrosius et al ldquoEffect ofstructured physical activity on prevention of major mobilitydisability in older adults the LIFE study randomized clinicaltrialrdquoe Journal of the American Medical Association vol 311no 23 pp 2387ndash2396 2014

[41] L Vlietstra W Hendrickk and D L Waters ldquoExercise inter-ventions in healthy older adults with sarcopenia a systematicreview and metalnalysisrdquo Australasian Journal on Ageing vol37 no 3 pp 169ndash183 2018

[42] J Steele K Raubold W Kemmler J Fisher P Gentil and JGiessing ldquoThe effects of 6 months of progressive high effortresistance training methods upon strength body compositionfunction and wellbeing of elderly adultsrdquo BioMed ResearchInternational vol 2017 Article ID 2541090 14 pages 2017

[43] U K Sahin N Kirdi E Bozoglu et al ldquoEffect of low-intensityversus high-intensity resistance training on the functioningof the institutionalized frail elderlyrdquo International Journal ofRehabilitation Research vol 41 no 3 pp 211ndash217 2018

[44] J E Morley J M Argiles W J Evans S Bhasin D Cella NE Deutz et al ldquoNutritional recommendations for the man-agement of sarcopenia Society for Sarcopenia Cachexia andWasting Diseaserdquo Journal of the American Medical DirectorsAssociation vol 11 no 6 pp 391ndash396 2010

[45] D C Low G S Walsh and M Arkesteiijn ldquoEffectiveness ofexercise interventions to improve postural control review andmetanalysis of centre of pressure measurmentsrdquo Sport med vol47 pp 101ndash112 2017

Stem Cells International

Hindawiwwwhindawicom Volume 2018


MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine


Behavioural Neurology

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

Submit your manuscripts atwwwhindawicom


Table 1 Participant characteristics at baseline Data are means plusmn SDRESISTANCE (n=35) POSTURAL (n=37) p-value

Age (years) 699plusmn27 700plusmn28 nsHeight (cm) 162plusmn002 159plusmn001 nsBody mass (kg) 6386plusmn175 6377plusmn215 nsBody mass index (kgm2) 2434plusmn072 2523plusmn086 nsHandgrip strength (kg) (mean of the two sides) 1784plusmn497 1786plusmn53 ns

adipose and fibrotic tissues that have reduced rates of proteinsynthesis thus leading to reduced muscle efficiency [7]

The impaired state of health induced by sarcopenia isclosely related to a risk of adverse outcomes such as physicaldisability poor quality of life impaired ability to performactivities of daily living [8 9] and mostly important riskof falls and fractures which represent the main causes of adownward spiral of loss of confidence and social withdrawalwhich may ultimately lead to loss of independence [10] Thedecrease in maximal muscle strength could be a main causeof postural instability [11] and the consequent reduced abilityof old adults to adequately react to unexpected perturbationsand to successfully regain balance is important intrinsic riskfactor for falling [12ndash14]

Exercise has been shown to reduce the incidence of fallsby 13 to 40 which has led to a broad consensus amongexperts that older adults should be offered exercises thatincorporate elements of balance and strength training [15]Pieces of evidence support the notion that regular physicalactivity in combination with appropriate nutritional supportis the most effective strategy for improving sarcopenia andphysical function and preventing disability [16] There arefour types of exercises recommended in adapted physicalactivity (APA) for older adults aerobic exercises progressiveresistance training flexibility exercises and balance training[17] Particularly progressive resistance training has beendemonstrated to attenuate development of sarcopenia byimproving muscle size and function reducing balance andflexibility problems and reducing also the risk of develop-ment of other sarcopenia-related comorbidities [18]The roleof exercise in sarcopenia was investigated in several studies[19ndash22] but to the best of our knowledge no standardizedtraining protocol has been developed for healthy olderpeople to induce positive quantitative and qualitative effectson muscle function and to improve balance The aim ofthis study was to evaluate the effects on muscle mass andmuscle strength and on static balance of two types of 9-month adapted physical activity (APA) programs based onmuscle reinforcement training and postural training [23]respectively in moderate sarcopenic older women

2 Materials and Methods

21 Participants Initially 82 potential participants wereassessed for eligibility from the community through adver-tisements in the notice board of the Public Health ServiceASL 4 Chiavari Italy and in the local newspaper andthe screening period was conducted between August andSeptember 2016

The recruitment process consisted of amedical evaluationto assess their good health and the absence of any contraindi-cation to participation in adapted physical activity programs

Participants were required to be at least 65 years of ageand they were excluded if they had a pacemaker (due to theuse of bioelectrical impedance analysis) or previous healthproblems such as neurological or cardiovascular diseases thatwould limit participation in the APA programs

During enrolment 10 potential participants wereexcluded because 6 did not meet inclusion criteria and theother 4 declined to participate

At the end of the recruitment 72 participants wereenrolled for the study and they were randomly divided intotwo groups assigned to one of the two APA programs musclereinforcement training group (RESISTANCE) (n=35) andpostural training group (POSTURAL) (n=37) Two out of35 participants of the RESISTANCE group and 4 out of 37participants of the POSTURAL group did not complete thetraining programs A flow diagram of the study is reported inFigure 1

The participant characteristics of the two groups atbaseline are reported in Table 1

The experimental protocol was approved by the EthicsCommittee of the University of Genoa and after explainingthe aim and the procedure of the study all participants gavetheir informed consent for intervention

22 Sample Size Estimation of sample size for this inves-tigation was performed using handgrip strength as one ofour primary outcome measures Sample size was estimatedcombining the normative data and the genuine change ingrip strength determined in previous works [24 25] Theseassumptions generated a desired sample size of at least 30participants However we recruited 72 participants 35 in theRESISTANCE group and 37 in the POSTURAL group toallow for drop-out during the intervention period

23 Testing Procedures Testing was conducted before (T0)and after (T1) the APA intervention

231 Food Questionnaire Before starting the APA programall the participants were asked to answer to a food question-naire in order to check a balanced daily intake of nutrients

232 Anthropometry and Body Composition Body massand height were measured to the nearest 01 kg and 05cm respectively using a mechanical column scale and astadiometer Body composition evaluation was performedusing a bioimpedance scale (InBody 320 GBC BioMed NZ)




Randomized (n=72)





Enrolment

Allocation

Follow-Up







+ (age times minus0071)] + 5102(1)





















3 Results






T0 T1

ResistancePostural

14

16

18

20

22

SM (k

g)

lowastlowastlowast

(a)

T0 T1

ResistancePostural

4

5

6

7

8

SMI (

kgm

2 )

9

10

lowastlowastlowast

(b)

T0 T114

16

18

20

22

HG

S (k

g)

ResistancePostural

lowastlowastlowast

(c)







Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001


CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005





4 Discussion






lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)



(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)



lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)



(g)

02

04

06

08

10

12

14

16

18

ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of






















Randomized (n=72)





Enrolment

Allocation

Follow-Up







+ (age times minus0071)] + 5102(1)





















3 Results






T0 T1

ResistancePostural

14

16

18

20

22

SM (k

g)

lowastlowastlowast

(a)

T0 T1

ResistancePostural

4

5

6

7

8

SMI (

kgm

2 )

9

10

lowastlowastlowast

(b)

T0 T114

16

18

20

22

HG

S (k

g)

ResistancePostural

lowastlowastlowast

(c)







Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001


CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005





4 Discussion






lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)



(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)



lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)



(g)

02

04

06

08

10

12

14

16

18

ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of


































3 Results






T0 T1

ResistancePostural

14

16

18

20

22

SM (k

g)

lowastlowastlowast

(a)

T0 T1

ResistancePostural

4

5

6

7

8

SMI (

kgm

2 )

9

10

lowastlowastlowast

(b)

T0 T114

16

18

20

22

HG

S (k

g)

ResistancePostural

lowastlowastlowast

(c)







Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001


CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005





4 Discussion






lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)



(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)



lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)



(g)

02

04

06

08

10

12

14

16

18

ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of




















T0 T1

ResistancePostural

14

16

18

20

22

SM (k

g)

lowastlowastlowast

(a)

T0 T1

ResistancePostural

4

5

6

7

8

SMI (

kgm

2 )

9

10

lowastlowastlowast

(b)

T0 T114

16

18

20

22

HG

S (k

g)

ResistancePostural

lowastlowastlowast

(c)







Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001


CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005





4 Discussion






lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)



(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)



lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)



(g)

02

04

06

08

10

12

14

16

18

ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of






















Sway path (mms)

CE 1678[13162421] 1544[1213 2059] lt0001 1957[1402 2496] 2359[1582 2942] lt0001 T0 nsT1 plt001

OE 1176[927 1465] 975[758 1176] lt0001 1213[1015 1368] 1123[1016 1368] ns T0 nsT1 plt005

Sway area (mm2s)

CE 4064[2875 5939] 2655[1685 4996] lt0001 4438[20046856]

5225[2713 7698] ns T0 nsT1 plt001

OE 1936[1284 3215] 1268[914 1711] lt0001 1899[1158 2749] 1774[1350 2489] ns T0 nsT1 plt005

Stay time (s)

CE 065[049 073] 087[059 110] lt0001 059[043 088] 048[035 069] lt005 T0 nsT1 plt0001

OE 111[081 131] 137[101 185] lt0001 099[087 138] 109[089 135] ns T0 nsT1 plt001


CE 671[451 871] 465[307 697] lt0001 619[386 941] 770[479 1061] lt001 T0 nsT1 plt001

OE 378[255 431] 261[199 341] lt0001 328[257 433] 306[274 415] ns T0 nsT1 plt005





4 Discussion






lowastlowastlowast

lowastlowastlowast

lowastlowast

0

5

10

15

20

25

30

SP C

E (m

ms

)

(a)

0

5

10

15

20

25

30

SP O

E (m

ms

)



(b)

SA C

E (m

m2 s

)

0

10

20

30

40

50

60

70


lowastlowastlowast

lowastlowast

(c)

0

10

20

30

40

SA O

E (m

m2 s

) 50

60

70

lowast


lowastlowastlowast

(d)

02

04

06

08

10

12

14

16

18ST

CE

(s)



lowast

(e)

0123456789

SD C

E (m

m)

lowastlowast

lowastlowast


lowastlowastlowast

(f)

0123456789

SD O

E (m

m)



(g)

02

04

06

08

10

12

14

16

18

ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of





















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SP C

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(a)

0

5

10

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SP O

E (m

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)



(b)

SA C

E (m

m2 s

)

0

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(c)

0

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SA O

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SD C

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SD O

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08

10

12

14

16

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ST O

E (s



(h)












5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of


























5 Conclusions


Data Availability






Acknowledgments


References





















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of






































































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of



















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