You are on page 1of 23

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/326059540

Effects of Interval Aerobic Training Program with Recovery bouts on


cardiorespiratory and endurance fitness in seniors

Article  in  Scandinavian Journal of Medicine and Science in Sports · June 2018


DOI: 10.1111/sms.13257

CITATIONS READS

4 146

10 authors, including:

Walid Bouaziz Elise Schmitt


University of Strasbourg CHRU de Strasbourg
23 PUBLICATIONS   136 CITATIONS    54 PUBLICATIONS   5,236 CITATIONS   

SEE PROFILE SEE PROFILE

Thomas Vogel François Lefebvre


Strasbourg, Academic Hospital, France CHRU de Strasbourg
209 PUBLICATIONS   1,245 CITATIONS    86 PUBLICATIONS   279 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Evaluation of quantitative and qualitative aspects of mitochondrial function and its regulation. View project

Ageing View project

All content following this page was uploaded by Pierre Olivier Lang on 13 July 2018.

The user has requested enhancement of the downloaded file.


Scandinavian Journal of Medicine & Science in Sports - PROOF

Effects of Interval Aerobic Training Program with Recovery


bouts on cardiorespiratory and endurance fitness in seniors

Journal: Scandinavian Journal of Medicine and Science in Sports

Manuscript ID SJMSS-O-206-18.R2

Manuscript Type: Original Article

Date Submitted by the Author: 23-Jun-2018

Complete List of Authors: Bouaziz, Walid; Geritaric Departement


Schmitt, Elise; University Hospitals of Strasbourg, Geriatric Department,
VOGEL, Thomas ; University Hospitals of Strasbourg, Geriatric Department,
PR

Lefebvre, Francois; University Hospitals of Strasbourg, Department of


Medical Information
Remetter, Romain; University Hospitals of Strasbourg, Functional
Explorations Department
OO

LONSDORFER, Evelyne; University Hospital, Physiology and Functional


Explorations; Strasbourg University, Federation of translational Medicine,
EA 3072, "mitochondrie, stress oxidant et protection musculaire"
Leprêtre, Pierre-Marie; University of Picardie Jules Verne, Laboratoire de
Recherche "Adaptations physiologiques à l'exercice et Réadaptation à
F

l'Effort", EA-3300, UFR-STAPS


Kaltenbach, Georges; University Hospitals of Strasbourg, Geriatric
Department
GENY, Bernard; Strasbourg University, Department of Physiology and EA-
3072, Faculty of Medicine,
LANG, Pierre-Olivier; Geriatric and rehabilitation , geriatric department;
Health and Wellbeing academy, Anglia Ruskin University

interval training, older adults, cardiorespiratory fitness, aerobic capacity,


Keywords:
endurance performance, sedentary, seniors

Scandinavian Journal of Medicine & Science in Sports - PROOF


Page 1 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 Effects of Interval Aerobic Training Program with Recovery bouts on cardiorespiratory
4
and endurance fitness in seniors
5
6
7
8 Walid Bouaziz1,2,3, Elise Schmitt1,2, Thomas Vogel1,2, François Lefebvre4, Romain
9 Remetter2,5, Evelyne Lonsdorfer2,5, Pierre-Marie Leprêtre6,7, Georges Kaltenbach1, Bernard
10
11 Geny2,5, Pierre-Olivier Lang8,9
12
13
14 1
Geriatric Department, University Hospitals of Strasbourg, Strasbourg, France.
15 2
16 Research laboratory Mitochondria, Oxidative stress and muscle resistance (MSP, EA-3072),
17 department of Physiology, Faculty of Medicine, Strasbourg University, Strasbourg, France.
18 3
19
Research Unit of the University of Rouen (CETAPS, EA-3832), Faculty of Sport Sciences, Mont
20 Saint-Aignan, France.
21 4
Department of Medical Information, University Hospitals of Strasbourg, Strasbourg, France.
22
23 5
Functional Explorations Department, University Hospitals of Strasbourg, Strasbourg, France
24 6
Laboratory of Exercise Physiology and Rehabilitation (APERE, EA-3300), UFR-STAPS, University
25
PR

26 of Picardie Jules Verne, Amiens, France.


27 7
Unit of cardiovascular rehabilitation, Hospital center of Corbie, Corbie, France.
28
OO

29 8
Health and Wellbeing Academy, Anglia Ruskin University, Cambridge, United Kingdom.
30 9
Montchoisi Clinic, Lausanne, Switzerland.
31
32
33
F

34 Corresponding author
35 Walid Bouaziz, PhD
36
37 University Hospitals of Strasbourg, Geriatric Department, 83 rue Himmerich, 67091
38
Strasbourg Cedex, France
39
40 Phone: +33(0)3.88.11.55.24 – Fax: +33(0)3.88.11.58.21
41
42 e-mail: walid.bouaziz.88@gmail.com
43
44
45
46
47 Running head: Effects of IATP-R in sedentary seniors
48
49
50
51
52
53
54
55
56
57
58 1
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 2 of 21

1
2
3 ABSTRACT
4
Interval aerobic training programs (IATP) improve cardiorespiratory and endurance
5
6 parameters. They are however unsuitable to seniors as frequently associated with occurrence
7
8 of exhaustion and muscle pain. The purpose of this study was to measure the benefits of an
9 IATP designed with recovery bouts (IATP-R) in terms of cardiorespiratory and endurance
10
11 parameters and its acceptability among seniors (≥70 years). Sedentary healthy volunteers
12
13
were randomly assigned either to IATP-R or sedentary lifestyle. All participants performed an
14 incremental cycle exercise and 6-minute walk test (6-MWT) at baseline and 9.5 weeks later.
15
16 The first ventilatory threshold (VT1); maximal tolerated power (MTP); peak of oxygen uptake
17
(VO2peak); maximal heart rate (HRmax); and distance walked at 6-MWT were thus measured.
18
19 IATP-R consisted of 19 sessions of 30-min (6×4-min at VT1 + 1-min at 40% of VT1) cycling
20
21 exercise over 9.5 weeks. With an adherence rate of 94.7% without any significant adverse
22 events, 9.5 weeks of IATP-R, compared to controls, enhanced endurance (VT1: +18.3 vs. -
23
24 4.6%; HR at baseline VT1: -5.9 vs. +0.2%) and cardiorespiratory parameters (VO2peak: +14.1
25
PR

vs. -2.7%; HRmax: +1.6 vs. -1.7%; MTP: +19.2 vs. -2.3%). The walk distance at the 6-MWT
26
27 was also significantly lengthened (+11.6 vs. -3.1%). While these findings resulted from an
28
interim analysis planned when 30 volunteers were enrolled in both groups, IATP-R appeared
OO

29
30 as effective, safe, and applicable among sedentary healthy seniors. These characteristics are
31
32 decisive for exercise training prescription and adherence.
33
F

34 Keywords: interval training, older adults, cardiorespiratory fitness, aerobic capacity,


35 endurance performance, sedentary, seniors
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58 2
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 3 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 Main text
4
1. INTRODUCTION
5
6 The body of evidence accumulated over the last decade report significant benefits of aerobic
7
8 training (AT) on cardiorespiratory and endurance performance1,2 together with different other
9 facets of individuals’ health3. AT, commonly defined as any exercise involving movement of
10
11 large muscle groups over a certain period of time (e.g., treadmill walking/running, walking,
12
13
cycling, or dancing),4 is now part of the preventive and therapeutic approach of many chronic
14 health conditions5. Guidelines recommended maintaining active life style with a minimum of
15
16 150 min moderate- or 75 min vigorous-intensity aerobic activity or an equivalent combination
17
per week6.
18
19 Among the different types of AT, interval AT programs (IATP) are the most efficient to
20
21 improve cardiorespiratory and endurance performances, and general health7-9 including older
22 adults10,11. However, based upon our experience11, this type of program is often less well-
23
24 tolerated in seniors compared to younger counterparts.12 Indeed, sustaining such a high
25
PR

exercise intensity over several weeks is frequently associated with muscle pain and rapid
26
27 exhaustion, and the suspension of the IATP.
28
By designing a lightweight protocol including recovery bouts (IATP-R) we hypothesized to
OO

29
30 better fit with seniors’ capacities while enhancing maximal cardiorespiratory and endurance
31
32 parameters. This has been investigated in a random way in sedentary seniors aged 70 or older.
33
F

34
35 2. MATERIALS AND METHODS
36
37 2.1. Study design
38
The study was a prospective and open-label randomized controlled trial as specific exercise
39
40 training program makes blind design very challenging4. It was conducted in the frame of the
41
42 “Physical Aptitude Assessment for Health” consultation (CAPS in French language) of the
43 University Hospitals of Strasbourg (France). Using a computer-generated random numbers
44
45 secure online platform (CleanWEB™), a methodologist of the Clinical Investigation Centre
46
47 of the University Hospitals of Strasbourg independently assigned with 1:1 ratio sedentary
48 seniors to IATP-R or maintained sedentary lifestyle. The primary outcome was the first
49
50 ventilatory threshold (VT1) and secondary were heart rate (HR) at baseline VT1, peak of
51
oxygen uptake (VO2peak), maximal heart rate (HRmax), maximal tolerated power (MTP), and
52
53 distance walked at the 6-minute walk test (6-MWT). The inclusion period was originally
54
55 planned in the protocol over nearly three years (i.e., from December 2014 to October 2017).
56 However, the effective period of recruitment was finally limited to one year (i.e., from
57
58 3
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 4 of 21

1
2
3 November 2016 to October 2017) because of logistical issues. The recruitment flow chart is
4
detailed in figure 1.
5
6 The local ethic committee had approved this experimental protocol (IDRCB: 2014-A00872-
7
8 045/PRI: 2013-HUS; N°5830) which has been registered on ClinicalTrials.gov (Identifier:
9 NCT02263573).
10
11
12
13 2.2. Population study and inclusion/non-inclusion criteria
14 Following a call of research subjects, seniors were invited to participate in this study with no
15
16 financial incentives. A directed advertising edited in the local newspapers; and spread by
17
radio as well as posters and flyers in local community centres, in general practitioners and
18
19 physiotherapists’ offices, and in catering organizations for seniors was intended for
20
21 prospective subjects. To be eligible, volunteers had to be aged 70 years or over and
22 functionally independent. They had to be sedentary (i.e., International Physical Activity
23
24 Questionnaire score <2). Thus selected, volunteers completed a medical interview during
25
PR

which an electrocardiogram (ECG) and a full physical examination were carried out. During
26
27 the physical examination, anthropometric parameters, resting HR, and blood pressure were
28
recorded. Body height was measured by using an electronic height measure (Soehnle®); the
OO

29
30 body composition (i.e., total body weight, percentage of body fat, and fat-free mass) was
31
32 analyzed with a bioelectrical impedance analysis (Tanita®, TBF-300) on morning after 8h of
33
F

34 fasting, 48h after the last physical exercise, and after bladder voiding. The body mass index
35 was calculated as weight divided by height squared (kg/m²). According to present and past-
36
37 medical history, the Charlson index13 was considered to define the burden of comorbidities
38
(i.e., low (0≤score≤1), medium (2≤score≤4), or high level (≥5)) (Table 1). All conditions that
39
40 contra-indicated IATP-R were then also identified (e.g., uncontrolled hypertension, current
41
42 history of severe musculoskeletal and musculotendinous disorders, fibromyalgia, and un-
43 corrected visual impairment). In addition, individuals with significant cognitive impairment
44
45 (i.e., delirium, amnestic disorders or dementia), undergoing chemotherapy for cancer, or
46
47 suffering from any acute infection were not enrolled. Finally, all medications were reviewed
48 and listed, and participants taking beta-blockers and/or any other negative chronotropic drugs
49
50 were not included. Were secondarily excluded all participants demonstrating chest pain, high
51
blood pressure, rhythm disorder, ST segment deviation, and/or respiratory problems during
52
53 the IET. During the medical interview, instructions about the IATP-R were provided and all
54
55 participants had to sign the informed consent before final inclusion.
56
57
58 4
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 5 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 2.3. The incremental exercise test (IET)
4
In both study groups and blind to the participants’ group allocation, a cardiologist conducted
5
6 an incremental maximal exercise tests (IET) at baseline and 9.5 weeks later (Figure 2). The
7
8 IET were performed on an upright electronically braked cycle ergometer (Ergoselect 2,
9 MSE®) in the air-conditioned room (22.0±0.5°C), two hours after a light breakfast. Minute
10
11 ventilation, O2 uptake and CO2 output were measured on a breath-by-breath basis by means of
12
13
an open-circuit metabolic chart with rapid O2 and CO2 analyzers (MEDGRAPHICS, MSE®).
14 The pneumotachograph was calibrated with a 3-l calibration syringe, and the gas analyzers
15
16 with reference gases. The breath-by-breath data were averaged over 20-second periods. HR
17
was monitored continuously during the test with an ECG (T12, Mortara®). Each participant
18
19 performed a maximal effort according to the criteria of the American Thoracic Society and
20
21 the American College of Chest Physicians14 (i.e., predicted VሶO2peak achieved and/or a plateau
22 is observed; predicted MTP is achieved; predicted HRmax is achieved; peak exercise
23
24 ventilation approaches or exceeds maximal ventilation capacity; respiratory exchange ratio
25
PR

26 ≥1.15; patient exhaustion/Borg Scale rating of 9–10 on a 0-to-10 scale) to determine MTP
27 (Watts – W), ܸሶ O2peak (L.min-1), maximal ventilation (ܸሶ E) (L.min-1) and HRmax (bpm). The
28
VT1 (W) was determined graphically using the ܸሶ O2 (L.min-1), ܸሶ CO2 (L.min-1) and ܸሶ E (L.min-
OO

29
30 1
31 ) curves. It was confirmed by the method of Beaver et al.15 based on computerized regression
32 analysis of the ܸሶ CO2 versus ܸሶ O2 slopes. After a 3-min warm-up at 20 W, charge increments
33
F

34 of 10 W.min-1 were monitored up to exhaustion (10-15 minutes). Additional spirometric


35
36 parameters were obtained via a body plethysmograph, and included maximal minute
37 ventilation (MMV) (L.min-1), forced vital capacity (FVC – L), forced expiratory volume in
38
39 one second (FEV1 – L) and the FEV1/FVC ratio.
40
41
42 2.4 The 6-minute walk test
43
44 In all participants, a trained physiotherapist, blind to the allocation, conducted a 6-MWT, at
45 baseline and 9.5 weeks later (Figure 2). The walk test was carried out 24h after each IET. All
46
47 participants were then asked to cover the maximum possible distance (in meter) over 6-min
48
49 by walking in accordance with usual instructions16 in a 50-m long unobstructed corridor.
50
51
52 2.5. The Interval Aerobic Training Program with Recovery bouts (IATP-R)
53
For all participants enrolled in the training group, the IATP-R was performed on an upright
54
55 electronically braked cycle ergometer (Ergoselect 2, MSE®) in an air-conditioned room
56
57
58 5
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 6 of 21

1
2
3 (22.0±0.5°C) of the CAPS. The IATP-R consisted of a 30-min cycling workout twice a week
4
over 9.5-week (i.e., for 19 sessions). As depicted by figure 2, each session involved six 5-min
5
6 bouts of exercise combining 4-min cycling at the measured pre-intervention VT1 workload
7
8 (called “BASE”) and 1-min cycling at 40% of the pre-intervention VT1 workload (called
9 “RECOVERY”). All sessions started with 3-min warm-up and finished with a recovery period
10
11 of 3-min. During exercise, HR was continuously recorded (Suunto T6c, Vantaa, Finland). The
12
13
HR mean value was calculated every 3-min of each series of 4-min and taken as the “target
14 value” for the entire training program. When the exercise tolerance improved with training,
15
16 for each HR decrease of 10 bpm a 10% increase in the ”BASE” was done, while the
17
“RECOVERY” bouts values remained constant.
18
19
20
21 2.6 Control group
22 For participants assigned to the control group, it was asked to maintain their current sedentary
23
24 life style. This was controlled by phone call of the study investigator on a weekly basis during
25
PR

all the study period. Participants were then asked to confirm that they were not engaged in any
26
27 specific exercise or training program since their inclusion. At the end of the study protocol,
28
controls were offered to engage an IATP.
OO

29
30
31
32 2.7 Statistical analysis
33
F

34 Statistical analyses were performed under Bayesian paradigm and computed with R (version
35 3.2.2) and WinBUGS (version 1.4.3) software. The sample size calculation was calculated for
36
37 the primary outcome (VT1) and based on a between-time difference of 15 in the IATP-R
38
group and 0 in the control group, and a between-time covariance of 15. The power was
39
40 computed using simulations in a linear mixed model and was estimated to be 81%, with a type
41
42 I error rate of 5%. The expected sample size was 130 overall (i.e., 65 per group). In the study
43 protocol, an interim analysis was originally planned when 60 participants were recruited (i.e.,
44
45 30 in each group). According to the direction and magnitude of the results, the study could be
46
47 then discontinued.
48 For the primary outcome, the intention to treat analysis was computed with a hierarchical
49
50 model with fixed and random effect according to the following model: Yijk = β0 +
51
β1×treatmenti + β2×timej + β3× (treatmenti×timej) + β4×subjectk + εijk. The effect of the
52
53 intervention was estimated by the interaction term β3.
54
55 For the secondary outcomes, in the intention to treat analyses, hierarchical Bayesian logistic
56 and linear regressions were considered according to the variable considered.
57
58 6
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 7 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3
4
For the descriptive analyses, results were expressed for numerical data as mean ± standard
5
6 deviation; for categorical variables, number and percentage are presented. Normality of the
7
8 distributions was tested using the Shapiro-Wilk, and was also assessed graphically using a
9 normal quintile plot. For the comparison of the participants’ characteristics at baseline,
10
11 according to the study group, the credibility interval of β1 was used.
12
13
For the computation, low informative prior probabilities (i.e., a β mean equal to 0 and its
14 variance equal to 1000) then more informative prior probabilities were considered for a
15
16 sensibility analysis. For the posterior probability distributions, 95% credibility intervals were
17
calculated and posterior probabilities of a difference given the data, written down P or
18
19 probability, were given. This probability has not the same significance than the usual p-value
20
21 (i.e., significant threshold). A probability >0.975 or <0.025 was considered as statistically
22 significant. In Bayesian paradigm there is no inflation of the alpha type I error with interim
23
24 analyses.
25
PR

26
27 3. RESULTS
28
The data presented resulted from the interim analysis. As planned in the experimental
OO

29
30 protocol, 60 volunteers (44 women; 16 men; mean age 73.8±3.2 years; age range: 70-83
31
32 years) were enrolled. Their characteristics at baseline are detailed in Table 1 according to the
33
F

34 allocated group. No difference was observed between the two groups in terms of
35 anthropometric parameters, main medical conditions and pre-intervention cardiorespiratory
36
37 parameters.
38
39
40 3.1 Adherence rate and adverse events
41
42 Among participants, 56/60 successfully completed the study protocol (figure 1); withdrawals
43 in both groups were related neither to the training program nor to the sedentary period. In the
44
45 IATP-R group, 27/30 volunteers have completed 19/19 training sessions; 2 participants 10/19
46
47 and 5/19 sessions respectively; and 1 has left the training program after the consent form was
48 signed. With an adherence rate of 94.7% (defined as mean percentage of the exercise
49
50 prescription), and with a total of 555 sessions, no adverse events or health problems directly
51
attributable to the IATP-R were reported.
52
53
54
55 3.2 Effects of the IATP-R
56 3.2.1 Maximal cardio-respiratory parameters
57
58 7
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 8 of 21

1
2
3 Compared to controls, 88.9% of the IATP-R participants who have completed 19/19 sessions
4
(n=27) have seen their cardiorespiratory parameters improved during the final IET; 11.1%
5
6 remained stable in their performance level. Globally, all parameters were improved (MTP:
7
8 +19.2% vs. -2.3%; VO2peak: +14.1% vs. -2.7%; and HRmax: +1.6% vs. -1.7%) compared to
9 controls (Figure 3 and Table 2). With respect to MMV values no difference was measured
10
11 between the 2 groups and between final and baseline IET within each group.
12
13
14 3.2.2 Endurance parameters
15
16 Compared to controls, among the IATP-R volunteers who have completed 19/19 sessions
17 (n=27), 81.5% have seen their endurance parameters improved during the final IET; 18.5%
18
19 remained stable. Compared to controls, all endurance parameters were improved (VT1:
20
+18.3% vs. -4.6%; HR at baseline VT1: -6.0% vs. +1.5% and distance walked at 6-MWT:
21
22 +11.6% vs. -3.1%) (Figure 3 and Table 2).
23
24
25
4. DISCUSSION
PR

26
27 This study aim was to measure the benefit, safety and acceptability of an IATP-R in sedentary
28
seniors. After only 9.5 weeks of training, in addition to reporting significant improvements in
OO

29
30 maximal cardiorespiratory and endurance parameters, this study demonstrated the good
31
32 adherence rate and safety of the IATP-R. These findings resulted from an interim analysis
33
F

leading to premature discontinuation of the study. In order to make easier comparisons with
34
35 previous reports and similar studies, the effects of the IATP-R have been presented as
36
37 percentage of change instead of absolute values20.
38 To the best of our knowledge, this is the first randomized trial that provides evidence of the
39
40 effectiveness, safety and feasibility of IATP-R in seniors. Commonly, a training program is
41
42 considered as feasible when the adherence rate is >75%21. The great adherence rate reported
43 with IATP-R was much higher than those usually reported with common IATP22-25. It was
44
45 explained by the design of the program that was supervised and personalized. These criteria
46
are known to be more effective in reducing the risk of injury and in improving performance
47
48 among seniors compared to home-based or un-supervised programs26. In addition, the active
49
50 recovery bouts corresponding to periods of sub-lactate threshold work rates have probably
51 facilitated the lactate removal27 and hence reduced the associated-fatigue. They also
52
53 contributed to increase the exercise tolerance and finally the program acceptability28.
54
55 Regarding endurance parameters, the improvement associated with IATP-R is of great
56 importance and specifically for seniors. Indeed, seniors perform their everyday activities at an
57
58 8
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 9 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 intensity level that corresponds to that of VT1 rather than to that of VO2peak10. Additionally,
4
since the VT1 is a direct and objective readout of cardiopulmonary capacity, the intensity of
5
6 the exercise was determined individually according to physical capacity. This was
7
8 independent of the patient’s motivation29. Thus, this study reported an improvement in VT1 by
9 18.3% which was nearly of similar amplitude to the 20.0 and 21.5% improvement reported by
10
11 Vogel et al.10 and Beale et al.22 respectively. Likewise, we measured a significant decrease of
12
13
6% in HR at baseline VT1 after the IATP-R, which is similar to that observed in Vogel et al.10
14 with IATP. Moreover, IATP-R significantly improved the distance walked at the 6-MWT by
15
16 56 meters (+11.6%). This result is in line of previous reports30,31.
17
Globally, in spite of a reduced total volume of physical activity, IATP-R induced also
18
19 enhancement in aerobic capacities of similar extends to which previously reported with
20
21 common IATP. Thus, in seniors, Coker et al.32, Foster et al.33, Perini et al.24, and Vogel et
22 al.10 reported a significant improvement in VO2peak of 14 to 17% after 9 to 12-week of IATP.
23
24 This magnitude of VO2peak enhancement was also similar to those measured after medium-
25
(i.e., 14-24 weeks)34,35 and long-term (i.e., >24 weeks)36 AT programs. Thus, Lovell et al.34
PR

26
27 and Villareal et al.35 demonstrated a significant increase by 15.0 and 18.7% after 16 and
28
24week of AT. After 24-week, the VO2peak enhancement reported by Evans et al.36 was of
OO

29
30 15.0%. Well beyond the exact magnitude of the improvement, VO2peak values must be also
31
32 interpreted in the light of what exercise capacity represents exactly in seniors. Indeed, several
33
F

34 studies have reported an accelerated rate of decline in VO2peak per decade after the 7th decade
35 (i.e., 20 vs. 10% for the global population). Thus, although for most healthy adults VO2peak has
36
37 little bearing on everyday life, for sedentary seniors, perform some activities of daily living
38
becomes greatly dependent on VO2peak37. Furthermore, VO2peak is also considered as the most
39
40 powerful predictor of mortality compared to other well-established risk factors4. Every 3.5
41
42 ml/kg/min increase in VO2peak has been associated with a 12% extension in overall survival38.
43 The median absolute gain in VO2peak measured in the present study was 3.4 ml/kg/min.
44
45 Three main reasons can explain the benefits of the IATP-R. The first one was the personalized
46
47 design of the program according to the VT1 value obtained during the baseline IET. Thus, the
48 intensity of the IATP-R was adjusted to the real capacities of each volunteer. Second, session
49
50 after session the workload of the “BASE” was adapted according the evolution of the HR.
51
Thus, the exercise workload and intensity were adjusted according to the progress of the
52
53 participant. The third reason was the interval rather than continuous design of the program.
54
55 Indeed as reported in the literature39, this has contributed to the benefits measured in terms of
56 cardiorespiratory and endurance parameters in this sedentary senior’s population. In middle-
57
58 9
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 10 of 21

1
2
3 aged populations, IATP is definitely the optimal design to maximize peripheral muscle and
4
central cardiorespiratory adaptation whereas continuous is only associated with greater O2
5
6 extraction8,9. Specifically, it has been established that when muscle work increases through
7
8 IATP, the oxidative pathway is challenged8,9. Lactate accumulation is then reduced through
9 oxidative phosphorylation during the low intensity period intervals. The decrease in blood
10
11 lactate induced by training led also to slowing down the glycogen breakdown that in turn
12
13
favors a more efficient oxidative pathway40. Thus, by inducing greater central and peripheral
14 adaptations, IATP is significantly more efficient than continuous in improving aerobic
15
16 capacity in seniors10. With a similar volume of physical activity, IATP results in lower HR,
17
VO2 consumption, ventilation and blood lactate O2 uptake compared to continuous.
18
19 Moreover, IATP is better tolerated than continuous39.
20
21 This study has also some limitations. First, the sample size is relatively modest. However, it
22 was apparently enough powerful to measure a significant improvement in endurance and
23
24 cardiorespiratory capacities. But the generalization of the results is restricted by the voluntary-
25
PR

based recruitment and the healthy status of the volunteers whilst sedentary and aged. Finally,
26
27 the study sample was also small to analyze any effect of gender.
28
OO

29
30 5. PERSPECTIVE
31
This study demonstrates that the IATP-R enhances maximal cardiorespiratory and endurance
32
33 parameters in addition to be safe and feasible in sedentary seniors. However, potential
F

34
35 benefits on functional and cognitive performances, and cardiovascular risk factors have still to
36 be addressed in similar and in less healthy aged populations with specific age-associated
37
38 chronic conditions.
39
40
41 ACKNOWLEDGEMENTS
42
43 We would like to thank the study participants for taking part in this trial. We are also grateful
44
to Cecile Dufour, Julien Bahlau, and Cedric Momas for their technical support in writing this
45
46 manuscript and Richard Medeiros and Katherine Jumel for their editorial assistance.
47
48
49 Funding information
50
51 This study was funded by the Department of Clinical Research and Innovation of the
52
53
University Hospitals of Strasbourg.
54
55
56
57
58 10
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 11 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 Conflicts of Interest
4
The authors declare that they have no competing interests regarding the publication of this
5
6 article.
7
8
9 Trial registration
10
11 ClinicalTrials.gov NCT02263573. Registered October 1, 2014.
12
13
14
15
16
17
18
19
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58 11
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 12 of 21

1
2
3 References
4
1. Tanaka H, Seals DR. Invited Review: Dynamic exercise performance in Masters athletes:
5
6 insight into the effects of primary human aging on physiological functional capacity. J
7
8 Appl Physiol (1985) 2003;95:2152–2162.
9 2. Ferketich AK, Kirby TE, Alway SE. Cardiovascular and muscular adaptations to
10
11 combined endurance and strength training in elderly women. Acta Physiol Scand
12
13
1998;164:259–267.
14 3. Stathokostas L, Jacob-Johnson S, Petrella RJ, Paterson DH. Longitudinal changes in
15
16 aerobic power in older men and women. J Appl Physiol (1985) 2004;97:781–789.
17
4. Bouaziz W, Vogel T, Schmitt E, Kaltenbach G, Geny B, Lang PO. Health benefits of
18
19 aerobic training programs in adults aged 70 and over: a systematic review. Arch Gerontol
20
21 Geriatr 2017;69:110–127.
22 5. Health topic. Physical activity 2018. World Health Organization (online). Available at:
23
24 http://www.who.int/topics/physical_activity/en/. Accessed February 25, 2018.
25
PR

6. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al.
26
27 American College of Sports Medicine position stand. Quantity and quality of exercise for
28
developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in
OO

29
30 apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc
31
32 2011;43:1334–1359.
33
F

34 7. Helgerud J, Hoydal K, Wang E, Karlsen T, Berg P, Bjerkaas M, et al. Aerobic high-


35 intensity intervals improve VO2max more than moderate training. Med Sci Sports Exerc
36
37 2007;39:665–671.
38
8. Gibala MJ, Little JP, Macdonald MJ, Hawley JA. Physiological adaptations to low-
39
40 volume, high-intensity interval training in health and disease. J Physiol 2012;590:1077–
41
42 1084.
43 9. Daussin FN, Ponsot E, Dufour SP, Lonsdorfer-Wolf E, Doutreleau S, Geny B, et al.
44
45 Improvement of VO2max by cardiac output and oxygen extraction adaptation during
46
47 intermittent versus continuous endurance training. Eur J Appl Physiol 2007;101:377–383.
48 10. Vogel T, Leprêtre PM, Brechat PH, Lonsdorfer E, Benetos A, Kaltenbach G, et al. Effects
49
50 of a short-term personalized Intermittent Work Exercise Program (IWEP) on maximal
51
cardio-respiratory function and endurance parameters among healthy young and older
52
53 seniors. J Nutr Health Aging 2011;15:905–911.
54
55 11. Vogel T, Lang PO, Schmitt E, Kaltenbach G, Bouaziz W. [The “physical aptitude for
56 health consultation” in a geriatric unit]. Soins Gerontol 2016;21:20–23.
57
58 12
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 13 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 12. Biddle SJ, Batterham AM. High-intensity interval exercise training for public health: a
4
big HIT or shall we HIT it on the head? Int J Behav Nutr Phys Act 2015;12:95.16.
5
6 13. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating
7
8 the Charlson comorbidity index and score for risk adjustment in hospital discharge
9 abstracts using data from 6 countries. Am J Epidemiol 2011;173:676–82.
10
11 14. American Thoracic Society; American College of Chest Physicians. ATS/ACCP
12
13
Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med
14 2003;167:211–77.
15
16 15. Beaver WL, Wasserman K, Whipp BJ. A new method for detecting anaerobic threshold
17
by gas exchange. J Appl Physiol (1985) 1986;60:2020–2027.
18
19 16. Kervio G, Carre F, Ville NS. Reliability and intensity of the six-minute walk test in
20
21 healthy elderly subjects. Med Sci Sports Exerc 2003;35:169–7419.
22 17. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung
23
24 volumes and forced ventilatory flows. Report Working Party Standardization of Lung
25
PR

Function Tests, European Community for Steel and Coal. Official Statement of the
26
27 European Respiratory Society. Eur Respir J 1993;16:5–40.
28
18. Hansen JE, Sue DY, Wasserman K. Predicted Values for Clinical Exercise Testing. Am
OO

29
30 Rev Respir Dis 1984;129:S49–55.
31
32 19. Wasserman K, Hansen JE, Sue DY, Whipp BJ, Casaburi R. Principles of exercise testing
33
F

34 and interpretation: Including pathophysiology and clinical applications. 3rd Ed.


35 Philadelphia: Lippincott Williams & Wilkins; 1999. 556 p.
36
37 20. Teodorescu AR, Moran R, Usher M. Absolutely relative or relatively absolute: violations
38
of value invariance in human decision making. Psychon Bull Rev 2016;23:22–38.
39
40 21. Linke SE, Gallo LC, Norman GJ. Attrition and adherence rates of sustained vs.
41
42 intermittent exercise interventions. Ann Behav Med 2011;42:197–209.
43 22. Wisloff U, Stoylen A, Loennechen JP, Bruvold M, Rognmo O, Haram PM, et al. Superior
44
45 cardiovascular effect of aerobic interval training versus moderate continuous training in
46
47 heart failure patients: a randomized study. Circulation 2007;115:3086–3094.
48 23. Beale L, McIntosh R, Raju P, Lloyd G, Brickley G. A Comparison of High Intensity
49
50 Interval Training with Circuit Training in a Short-Term Cardiac Rehabilitation
51
Programme for Patients with Chronic Heart Failure. Int J Phys Med Rehabil 2013;1:151.
52
53 24. Prado DM, Rocco EA, Silva AG, Rocco DF, Pacheco MT, Silva PF, et al. Effects of
54
55 continuous vs interval exercise training on oxygen uptake efficiency slope in patients with
56 coronary artery disease. Braz J Med Biol Res 2016;49:e4890.
57
58 13
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 14 of 21

1
2
3 25. Perini R, Fisher N, Veicsteinas A, Pendergast DR. Aerobic training and cardiovascular
4
responses at rest and during exercise in older men and women. Med Sci Sports Exerc
5
6 2002;34:700–708.
7
8 26. American College of Sports Medicine. Physical activity programs and behavior
9 counseling in older adult populations. Med Sci Sports Exerc 2004;36:1997–2003.
10
11 27. Billat LV. Interval training for performance: a scientific and empirical practice. Special
12
13
recommendations for middle- and long-distance running. Part I: aerobic interval training.
14 Sports Med 2001;31:13–31.
15
16 28. Bogdanis GC. Effects of Physical Activity and Inactivity on Muscle Fatigue. Front
17
Physiol 2012;3:142.
18
19 29. Gitt AK, Wasserman K, Kilkowski C, Kleemann T, Kilkowski A, Bangert M, et al.
20
21 Exercise anaerobic threshold and ventilatory efficiency identify heart failure patients for
22 high risk of early death. Circulation 2002;106:3079-84.
23
24 30. Vogel T, Lang PO, Schmitt E, Lepretre PM, Kaltenbach G, Goette-Di Marco P, et al.
25
PR

Effects of a personalized nine weeks intermittent exercise working program on left


26
27 ventricle filling function in middle-aged women with mild diastolic dysfunction. Eur
28
Geriatr Med 2014;5:165–171.
OO

29
30 31. Martins RA, Neves AP, Coelho-Silva MJ, Veríssimo MT, Teixeira AM. The effect of
31
32 aerobic versus strength-based training on high-sensitivity C-reactive protein in older
33
F

34 adults. Eur J Appl Physiol 2010;110:161–169.


35 32. Coker RH, Williams RH, Kortebein PM, Sullivan DH, Evans WJ. Influence of exercise
36
37 intensity on abdominal fat and adiponectin in elderly adults. Metab Syndr Relat Disord
38
2009;7:363–368.
39
40 33. Foster VL, Hume GJ, Byrnes WC, Dickinson AL, Chatfield SJ. Endurance training for
41
42 elderly women: moderate vs low intensity. J Gerontol 1989;44:M184–188.
43 34. Lovell DI, Cuneo R, Gass GC. Can aerobic training improve muscle strength and power
44
45 in older men? J Aging Phys Act 2010;18:14–26.
46
47 35. Villareal DT, Aguirre L, Gurney AB, Waters DL, Sinacore DR, Colombo E, et al.
48 Aerobic or Resistance Exercise, or Both, in Dieting Obese Older Adults. N Engl J Med
49
50 2017;376:1943–1955.
51
36. Evans EM, Racette SB, Peterson LR, Villareal DT, Greiwe JS, Holloszy JO. Aerobic
52
53 power and insulin action improve in response to endurance exercise training in healthy
54
55 77-87 yr olds. J Appl Physiol (1985) 2005;98:40–45.
56
57
58 14
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 15 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 37. Bouaziz W, Kanagaratnam L, Vogel T, Schmitt E, Dramé M, Kaltenbach G, et al. Effect
4
of Aerobic Training on Peak Oxygen Uptake Among Seniors Aged 70 or Older: A Meta-
5
6 Analysis of Randomized Controlled Trials. Rejuvenation Res 2018.
7
8 doi:10.1089/rej.2017.1988. [Epub ahead of print].
9 38. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and
10
11 mortality among men referred for exercise testing. N Engl J Med 2002;346:793–801.
12
13
39. Morris N, Gass G, Thompson M, Bennett G, Basic D, Morton H. Rate and amplitude of
14 adaptation to intermittent and continuous exercise in older men. Med Sci Sports Exerc
15
16 2002;34:471–477.
17
40. Phillips SM, Green HJ, Tarnopolsky MA, Grant SM. Increased clearance of lactate after
18
19 short-term training in men. J Appl Physiol (1985) 1995;79:1862–1869.
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58 15
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 16 of 21

1
2
3 Figure Captions
4
Figure 1: Flow chart of the study
5
6 Note: IATP-R: interval aerobic training program with recovery bouts; IATP: interval aerobic training program
7
8
9 Figure 2: Protocol design of the study
10
Note: VT1: first ventilatory threshold; IET: incremental exercise test; IATP-R: interval aerobic training program
11
12 with recovery bouts; 6-MWT: 6-minute walk test; IATP: interval aerobic training program
13
14
15 Figure 3: Box plot of maximal cardio-respiratory and endurance parameters in control and
16
17 training groups before and after the study
18 Note: CG: control group, TG: training group, VO2peak: peak of oxygen uptake, HRmax: maximal heart rate, MTP:
19
maximal tolerated power, VT1: first ventilatory threshold, HR: heart rate, 6-MWT: 6-minute walk test
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58 16
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 17 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3 Table 1: Baseline characteristics of the 60 study subjects presented according to the study group
4 Control group IATP-R group
5 Subjects’ characteristics
N = 30 N = 30
6
7 Age (years ± SD) 74.3 ± 3.4 72.9 ± 2.5
8 Female, n (%) 23 (76.6) 21 (70.0)
9
Anthropometric parameters
10
11 Weight (kg ± SD) 77.8 ± 13.9 77.4 ± 15.4
12 Body fat (kg ± SD) 37.6 ± 8.3 35.1 ± 8.4
13
Free-fat mass (kg ± SD) 46.0 ± 6.7 47.0 ± 9.2
14
15
2
Body mass index (BMI – kg/m ± SD) 28.8 ± 5.1 28.7 ± 5.6
16 Normal weight (18.5 ≤ BMI ≤ 24.9), n (%) 6 (20.0) 7 (23.3)
17
Overweight (25.0 ≤ BMI ≤ 29.9), n (%) 12 (40.0) 10 (33.3)
18
19 Obesity (30.0 ≤ BMI ≤ 40.0), n (%) 12 (40.0) 13 (43.3)
20 Main medical conditions
21
22 Charlson Comorbidity Index (mean ± SD) 3.8 ± 1.3 4.0 ± 1.7
23 Hypertension, n (%) 11 (36.7) 12 (40.0)
24 Diabetes mellitus type 2, n (%) 3 (10.0) 6 (20.0)
25
PR

26 Pulmonary disease, n (%) 1 (3.3) 1 (3.3)


27 Dyslipidemia, n (%) 9 (30.0) 9 (30.0)
28
Osteoporosis, n (%) 4 (13.3) 6 (20.0)
OO

29
30 Osteoarthritis, n (%) 4 (13.3) 3 (10.0)
31 Depression, n (%) 2 (6.6) 4 (13.3)
32
Smoking, n (%) 1 (3.3) 1 (3.3)
33
F

34 Pre-intervention spirometric parameters (%)


35 Measured FVC / theoretical FVC 95.24 96.52
36
Measured FEV1 / theoretical FEV1 97.28 98.00
37
38 Pre-intervention IET (%)
39 Measured VO2peak / theoretical VO2peak 98.93 97.11
40
Measured MTP / theoretical MTP 93.24 96.52
41
42 Measured HRmax/ theoretical HRmax 88.5 94.4
43 Note: SD: standard deviation, IATP-R: interval aerobic training program with recovery bouts, FVC: forced vital capacity,
44
FEV1: forced expiratory volume in one second, IET: incremental exercise test, MTP: maximal tolerated power, VO2peak: peak
45
46 of oxygen uptake, HRmax: maximal heart rate
47 Equations for the theoretical values (Spirometric and IET parameters):
48 - Theoretical FVC (L) for women = 4.43×height (m) – 0.026×age (years) – 2.8917
49 - Theoretical FVC (L) for men = 5.76×height (m) – 0.026×age (years) – 4.3417
50
- Theoretical FEV1 (L) for women = 3.95×height (m) – 0.025×age (years) – 2.6017
51
52 - Theoretical FEV1 (L) for men = 4.30×height (m) – 0.029×age (years) – 2.4917
53 - Theoretical VO2peak (ml.min-1) = weight (kg)×(50.75 – 0.372×age (years))18,19
54 - Theoretical MTP (Watts) = (Theoretical VO2peak – Theoretical VO2 at rest)/10.1; where theoretical VO2peak (ml.min-1) =
55
weight (kg)×(50.75 – 0.372×age (years)) and theoretical VO2 at rest (ml.min-1) = 5.8×(weight (kg))18,19
56
57 - Theoretical HRmax (beats/min) = 210 – (0.65×age (years))18,19
58
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 18 of 21

1
2
3 Table 2: Effects of IATP-R on maximal cardio-respiratory and endurance parameters
4
β3 95% CI Probability (%)
5
6 Endurance parameters
VT1 14.65 9.06 ; 20.19 99.99
7 HR at baseline VT1 -8.37 -11.82 ; -4.99 00.00
8 6-MWT 73.84 57.62 ; 89.60 99.99
9 Maximal cardiorespiratory parameters
10 VO2peak 3.33 2.0 ; 4.65 99.99
11 HRmax 5.81 1.85 ; 9.80 99.70
12 MTP 22.08 15.31 ; 28.82 99.99
13
Note: Significance of the results is expressed as probability (%). The result is considered as significant when the probability
14
15 is close to 100% or 0%.
16 β3: interaction term, CI: credibility interval, VT1: first ventilatory threshold, HR: heart rate, 6-MWT: 6-minute walk test,
17 VO2peak: peak of oxygen uptake, HRmax: maximal heart rate, MTP: maximal tolerated power
18
19
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 19 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Scandinavian Journal of Medicine & Science in Sports - PROOF Page 20 of 21

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF
Page 21 of 21 Scandinavian Journal of Medicine & Science in Sports - PROOF

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
PR

26
27
28
OO

29
30
31
32
33
F

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 Scandinavian Journal of Medicine & Science in Sports - PROOF

View publication stats