not permitted.

It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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EUR J ­PHYS REHABIL MED 2013;49:131-43

Role of exercise on sarcopenia in the elderly

N. MONTERO-FERNÁNDEZ 1, J. A. SERRA-REXACH 2

® A
T C
H DI
Sarcopenia leads to a loss of strength, later on to a de- 1Geriatric Department, University Hospital Gregorio
creased functional status, impaired mobility, a higher Marañón, Madrid, Spain
risk of falls, and eventually an increased risk of mortal- 2Chair Geriatric Department, University Hospital Gregorio

ity. There are many factors responsible for the decline Marañón Complutense University, Madrid, Spain

IG E
of muscle mass and muscle strength associated with
aging, although the complex, multi-factorial mecha-
R M
nisms driving the sarcopenic process are not clearly
understood. Physical inactivity or a decreased physical

S
activity level is a part of the underlying mechanisms arcopenia, initially defined as an age-related loss
of sarcopenia and therefore physical activity can be
seen as an important factor to reverse or modify the of muscle mass,1 is now considered a syndrome
P A

development of this condition. Several treatments have characterized by progressive and generalized loss of
been proposed for the treatment of this loss of muscle skeletal muscle mass and strength associated with
O V

and strength, but there is no doubt that exercise rep- ageing.2 It is a complex medical condition that pre-
resents the most important approach to prevent and dicts mobility, disability, leading in turn to loss of
treat sarcopenia. In this review, we describe first the
C ER

independence, a higher risk of falls, reduced quality

conceptual distinctions between the terms sedentary
behaviour, physical activity and exercise. In addition, of life, increased health care costs and eventually an
Y

we review the benefits of physical activity in the eld- increased risk of mortality.3
erly population, including lower mortality and func- Even in healthy persons, muscle mass declines at
tional independence, and discuss the four categories approximately 1% per year from the peak between
IN

for specific recommendations for exercises (aerobic
exercise, progressive resistance exercise, flexibility
and balance). Finally we discuss the principles govern-
ing the prescription of physical activity for older peo-
M
20 and 30 years old, and accelerates from 50 years,
particularly in the lower extremities.
This decline occurs gradually in men, whereas it

ple with sarcopenia and make some specific advices
for how to engage older adults in appropriate exercise.
Key words: Sarcopenia - Exercise - Motor activity - Postural
balance - Lifestyle.
“Lack of activity destroys the good condition of every
human being while movement and methodical physical
or other proprietary information of the Publisher.
occurs sharply in women after menopause.4, 5 There
are many factors responsible for this decline of mus-
cle mass and muscle strength associated with aging.
It seems that the anabolic potential of skeletal mus-
cle may be reduced in the elderly. Insulin resistance,
inflammation, hormonal alterations, perturbations in
muscle metabolism and decreased muscle prolifera-

exercise save it and preserve it”.
Plato
Corresponding author: N. Montero-Fernández, Hospital General
Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007
Madrid, Spain. E-mail: nmonterof@yahoo.es
tion are the main changes involved. In addition to
the aging process, there have been identified several
risk factors that favor its appearance, most notably
sedentary lifestyle, female gender and some organ
diseases.3, 6 Overall, the most prominent cause of
sarcopenia is inactivity. Although it does not com-

Vol. 49 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 131

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
MONTERO-FERNÁNDEZ Role of exercise on sarcopenia in the elderly
pletely revert with exercise, the absence of physical
activity (PA) accelerates muscle mass loss.
Different strategies have been tested for its treat-
ment: human growth hormone, androgens, estro-
gens in women, nutritional treatment and exercise.
Of all the therapeutics available, PA with or without
dietary supplementation has shown its efficacy in
increasing skeletal muscle mass.
Before we provide in this review more informa-
tion detailing the role of exercise in sarcopenia, we
will briefly offer some definitions of terms in order
to avoid misunderstandings, errors and inconsisten-
® A
cies using this terminology. Casperson et al. attempt-
ed 27 years ago to provide a common framework
T C
for researches from different fields to communicate.7
Physical activity (PA) is any bodily movement pro-
duced by contraction of skeletal muscle that sub-
H DI
stantially increases energy expenditure, although the
intensity and duration can vary substantially.8 Base-
line activity is, however, the smallest increments
IG E
of body movements produced by skeletal muscle
contractions that increases energy above sedentary
R M
behaviors (e.g., standing, slow walking, lifting very
light objects, etc.).9 Consistent with this definition,
individuals who do only baseline activity are not
sedentary, per se, but are still considered to be inac-
P A
tive. PA may be measured in terms of METs (meta-
bolic equivalents), units used to estimate the meta-
O V
bolic cost (oxygen consumption) of PA. One MET
equals the resting metabolic rate of approximately
C ER
3.5 mL O2/kg/min, and represents the approximate
rate of oxygen consumption of a seated adult at
Y
rest. Moderate physical activity includes activity per-
formed at an intensity of 3 to 6 METs (leisure cy-
cling, moderate effort swimming, playing golf walk-
IN
ing, general cleaning at home, or lawn mowing), or
the equivalent of walking briskly at approximately
5 to 8 kilometers (3 to 5 miles) per hour.10 Vigorous
M
physical activity includes activity performed at >6
METs, such as running, rope jumping, and calisthen-
ics (e.g., push-ups, pull-ups, sit-ups, jumping jacks).
Exercise is a subcategory of leisure time PA in
which planned, structured, and repetitive bodily
movements are performed to improve or maintain
one or more components of physical fitness. Partici-
or other proprietary information of the Publisher.
pation in exercise and the accumulation of PA have
been shown to result in improvements in physical
fitness that is a set of attributes that contribute to the
ability to perform physical work: cardiorespiratory
endurance, skeletal muscular endurance, skeletal
132 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE February 2013
muscular strength, skeletal muscular power, speed,
flexibility, agility, balance, reaction time, and body
composition.10
Sedentary behaviors (SB) are defined as a way
of living or lifestyle that requires minimal PA and
that encourages inactivity through limited choices,
disincentives, and/or structural or financial barriers.8
They include the time spent sitting or lying which
has been shown to be a modifiable risk factor of car-
diovascular disease, type 2 diabetes mellitus, obesity,
some cancers, skeletal health. Moreover they have a
negative impact on some aspects of mental health,
overall mortality, disablement and frailty as well as
poor quality of life, independently from physical ac-
tivity levels.11 Besides that, SB affects muscle physi-
ology, lead to weakness and accelerates sarcopenia.
But it would be feasible that these age related de-
clines in muscle mass and function were also the
principal drivers of increased SB among aging per-
sons.12, 13
Finally, lifestyle modification refers to the use of
opportunities in a person’s daily routine to increase
energy expenditure (e.g., manually open doors, car-
ry groceries, use stairs rather than elevators, parking
further from entrances) and substitute active for sed-
entary leisure time.14
The purpose of this review is to examine whether
the different types of exercise show to be beneficial
for treatment and prevention of sarcopenia among
older adults.
Mechanisms of sarcopenia
Muscle mass is the primary determinant of
strength. Males are generally stronger than females
primarily because they have larger muscle mass. The
loss of muscle mass during the ageing process is
clinically important as it leads to reduced strength
and exercise capacity, both of which are required
undertaking normal daily living activities. Although
we will all lose muscle mass as we age, individual
differences in the rate of loss in muscle mass, the
age at which muscle mass starts to decline, and the
individual’s peak muscle mass, determine the im-
pact that sarcopenia has on functional ability.15
Several physiological mechanisms are involved in
the cause of the syndrome including changes affect-
ing neuromuscular transmission, muscle and tendon
architecture, fiber composition, excitation-contrac-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Role of exercise on sarcopenia in the elderly MONTERO-FERNÁNDEZ
tion coupling, and metabolism.16 Throughout the
human aging process, the loss of strength in old age
is predominantly accounted for by reduced mus-
cle mass and myofibrillar protein content in conse-
quence of a combination of progressive fiber loss
and fiber atrophy. The aging process is often char-
acterized by investigators as a selective loss of fast-
twitch fibers in muscle.17 Some recent findings sug-
gest that surviving fibers are still prone to plasticity
in response to different functional demands such as
physical exercise; this response helps elderly muscle
to compensate to partially correct muscle size deficit
® A
in an attempt to maintain optimal force-generating
capacity.18
T C
Sarcopenia is also associated with increased con-
centrations of proinflamatory cytokines and acute
phase reactants, and several cytokines have direct,
H DI
detrimental effects on skeletal muscle leading to the
loss of myofibers and the consequent disruption of
contractile function.19
IG E
On the other hand, anabolic hormones such as
growth hormone, testosterone and estrogen fall with
R M
ageing, which causes a decrease of its trophic ef-
fect and produces muscle atrophy. Other changes in
muscle leading to a loss of strength include infiltra-
tion into muscle by fat, which is a powerful predic-
P A
tor of future disability and mortality.19 This has been
designated as sarcopenic obesity or myosteatosis.20
O V
Clearly sarcopenia worses by disuse and a sed-
entary life produces greater and more rapid loss of
C ER
muscle than active life. Evidence from observational
and intervention studies are beginning to show that
Y
disuse may actually be the underlying reason for
muscle atrophy and weakness, rather than aging,
per se.21 Following some periods of disuse that oc-
IN
cur with increasing frequency in the elderly, for ex-
ample, due to illness or hospitalization, the rate of
sarcopenic muscle loss is accelerating,22 even some-
M
thing as benign as a reduction in daily step counts,
can accelerate sarcopenic muscle loss, from which it
is more difficult for the elderly to recover.
Furthermore, poor nutrition is well-known to
contribute to sarcopenia. Certain conditions have
the strong potential to coincide with sarcopenia in
accelerating the progression of muscle atrophy in
or other proprietary information of the Publisher.
older adults. Among these conditions are co-morbid
diseases common to older individuals such as can-
cer, kidney disease, organ failure, diabetes, and pe-
ripheral artery disease.23
The influence of PA in sarcopenic muscle can be
Vol. 49 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 133
described in relation to several of the factors act-
ing on muscle in age-related processes. The effects
of PA in elderly subjects, measurable at cell level,
involves beneficial outcomes on muscle anabolism,
muscle energetic metabolism, oxidative stress, mus-
cle inflammation, muscle denervation, muscle and
tendon architecture and muscle mechanical exci-
tation-contraction coupling.16 Increasing PA could
be effective for reducing chronic inflammation in
elderly people with sarcopenia. On the other hand,
regular PA can thus partially correct the acceleration
of sarcopenic progression related to inactivity and
poor nutrition.23
However, these factors are not common to all eld-
erly and/or sarcopenic individuals. Within clinical
study cohorts, a large degree of heterogeneity exists
that complicates the work of clinical and transla-
tional scientists studying sarcopenia. Furthermore,
variability in lifestyle and disease conditions induces
different atrophy-related mechanisms and degrees
of atrophy. Therefore, global therapeutic approach-
es are unlikely to prove equally effective in all mod-
els of sarcopenia.
Benefits of physical activity and aging
Exercise is believed to be the most effective of all
interventions proposed to improve quality of life and
functionality in older adults. Since the first paper of
Morris in the early 1950s 24 describing the relation
between inactivity and coronary heart disease, there
has been a wealth of scientific evidence about the
benefits of exercise prescription for health-related
and quality of life benefits.25, 26 However, there is
still scepticism between elderly people, clinicians,
investigators and health authorities, about the role
of PA for disease prevention and treatment in the
older, particularly in frail adults. Although the pro-
motion of exercise can’t avoid the aging process, PA
can minimize the physiological effects of a SB and
increase active life expectancy by limiting the de-
velopment and progression of chronic disease and
disabling conditions.26
It is never too late to become physically active.
For older adults, the benefits of PA, including lower
mortality and functional independence, occur with
initiation and maintenance of exercise. Even indi-
viduals who were previously sedentary but initiate
exercise as late as age 85 demonstrate a significant
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
MONTERO-FERNÁNDEZ Role of exercise on sarcopenia in the elderly
survival benefit in three years in comparison to indi-
viduals who were sedentary.27
The physiological, cardiovascular and neuromus-
cular adaptive response to regularly performed ex-
ercise in the elderly has been repeatedly demon-
strated to be similar to those of younger adults.
Older individuals who practice exercise regularly
get higher VO2max and higher maximal cardiac out-
put with PA when compared to matched sedentary
controls. These improvements are lower in older
versus young people, but similar if we focus only
on the relative values changes. The exercise training
® A
attenuates the age related loss of arterial compliance
and preserves the endothelial function even in pre-
T C
viously sedentary older men, in a very similar way
to what occurs in younger people. Finally, even very
old individuals maintain the capability of increas-
H DI
ing the synthesis rate of muscle contractile proteins
in response to resistance exercise, as we have sug-
gested earlier in this review.28-30
IG E
All older adults, including the oldest ones, those
with multiple morbidities, or those who are in
R M
chronic care facilities, are likely to benefit from PA.
Participation in any amount of PA will result in some
health benefit as some PA is better than none. A de-
scription of the benefits of exercise and a full discus-
P A
sion of types of exercise and their recommendations
for older adults will be offered in next sections.
O V
Large observational studies suggest that regular
exercise in older populations reduces risk of all-
C ER
cause mortality for most individuals.27, 31, 32 These
beneficial effects appear to be dose-dependent,
Y
even in older adults with chronic diseases.33 It oc-
curs in despite the increasing likelihood of comor-
bidity, frailty, dependence, and ever-shortening life
IN
expectancy, remaining and even starting to be phys-
ically active increases the likelihood of living longer
and functionally independent.34 Regular PA increas-
M
es life expectancy through its influence on chronic
diseases development and treatment and also limits
the impact of secondary aging through restoration
of functional capacity in previously sedentary older
adults.
Increasing PA in old age improves quality of life,
psychological health and is associated with bet-
or other proprietary information of the Publisher.
ter mental health and social integration, improves
anxiety, depression and self efficacy for PA in older
adults.35 The relationship between neurological dis-
orders and sarcopenia are discussed in detail in an-
other review in this issue.
134 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE February 2013
The patterns of change in body composition seen
in usual aging include a gradual increase in adipos-
ity and loss of skeletal muscle and bone mass in
both men and women from 25 to approximately 65
years of age, after which total body weight declines.
These age-related changes have important clinical
implications as they may negatively impact metabol-
ic, cardiovascular and musculoskeletal function and
they are independently associated with declining
performance as well as increased risk for disability
and mortality in older persons.37, 38 Physically active
older adults compared to sedentary have less total
and abdominal body fat and greater muscle mass in
the limbs and higher bone mineral density.39
The relative risk of developing many chronic dis-
eases (cardiovascular disease, type 2 diabetes, hy-
pertension, obesity and certain cancers), the preva-
lence of degenerative musculoskeletal conditions
(osteoporosis, arthritis, sarcopenia) and disability in-
creases with advancing age.8, 25, 40 A graded relation-
ship between exercise and the development of these
common chronic conditions and some geriatric syn-
dromes (cognitive impairment, frailty, disability, mo-
bility impairments, falls, urinary stress incontinence,
insomnia) has been observed even in the elderly
population. The mechanisms of this preventive ex-
ercise effect involve decrease body weight, mainte-
nance of muscles and tendons strength, decrease es-
trogens levels and LDL cholesterol, decrease blood
pressure and insulin resistance and hyperinsuline-
mia. Also PA is a main therapeutic intervention for
the treatment and management of these chronic dis-
eases 8, 40, 25 and for their associated disability, al-
though traditional medical approach usually do not
address disuse and deconditioning accompanying
these kind of diseases.
Exercise also reduces likelihood of falls and fall-
related injuries.41 More than one-third of community-
living older adults fall each year and approximately
10% of falls result in serious clinical consequences.
Falls are not only associated with morbidity and
mortality, but are also linked to poorer overall func-
tioning and early admission to long-term care facili-
ties.42 PA reduces risk of falls and injuries from falls
43 even in the oldest old,44 both in the community
both as residential population, improving strength,
endurance and body mechanics.
As reviewed in several epidemiological studies 45-
47 regular practice PAS exercise is associated with
decreased risk for activities of daily living disabil-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Role of exercise on sarcopenia in the elderly MONTERO-FERNÁNDEZ
ity. Decline in function and loss of independence
are not an inevitable consequence of aging. Given
the high prevalence and impact of chronic health
problems among older patients, evidence-based
interventions to address these problems become
increasingly important to maximize both the quan-
tity and quality of life for older adults. Additionally,
many small studies have reported the benefits of PA
on physical capacity and precursors of physical dis-
ability (increasing muscle strength, aerobic capacity
and bone density),32 even in frail elderly persons.47,
48 Physically active adults are more likely to survive
® A
to age 80 or beyond and had approximately on half
risk of dying with disability compared to their sed-
T C
entary counterparts.48
H DI
Types of exercise
There are four types of exercises recommended
IG E
for older adults: aerobic, progressive resistance, flex-
ibility and balance training.
R M
Aerobic exercise (AE)
It is a form of structured PA characterized by
P A
rhythmic and repetitive movements of large mus-
cles, for sustained periods that depends primarily
O V
on the use of oxygen to meet energy demands
through aerobic metabolism, and that is structured
C ER
and intended to generate improvements in car-
diorespiratory fitness, body composition, and/or
Y
cardiometabolic health.49 Examples of aerobic ac-
tivities include brisk walking, jogging, swimming,
water aerobics, tennis, aerobic exercises classes,
IN
dancing and bicycle riding.
Although advancing age is accompanied by an
accelerating reduction of AE capacity, that is ex-
M
acerbated by many comorbidities common to the
elderly, it has long been linked to improvements
in cardiovascular fitness and endurance capacity in
older adults, both in healthy and diseased individu-
als. Notwithstanding that AE is believed to largely
decreases most of risk factors for cardiometabolic
diseases and attenuates chronic inflammation, with
or other proprietary information of the Publisher.
minimal effects on muscle mass and strength, it can
increase the cross-sectional area of muscle fibers.50
AE can also reduce body fat including intramuscular
fat which in turn improves the functional role of
muscle relative to body weight.51, 52
Vol. 49 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 135
Progressive resistance exercise (PRE)
It is a form of structured PA that is generally de-
fined as exercise that requires muscles to generate
force to move or resist weight, with the intensity
increasing as physical capacity improves. Structured
PRE relies on anaerobic metabolism to meet energy
demands and examples of PRE activities include lift-
ing weights, working with resistance bands, doing
calisthenics using body weight for resistance (such
as push-ups, pull-ups, and sit-ups), climbing stairs,
carrying heavy loads, and heavy gardening.49
Several studies and systematic reviews have shown
that even in the elderly, PRE increases muscle mass,
muscle power and muscle strength.47 Although ini-
tially these results on the improved function were
unclear, the recent systematic review by Liu and
Lathman 53 has shown to be an effective interven-
tion for improving physical function in the elderly
and therefore delaying disability, which is the main
adverse event of sarcopenia.
Several investigations have reported that after
even short durations of PRE, protein synthesis rate
and neuromuscular adaptive-responses among eld-
erly adults were similar to that of young subjects,
despite a much lower pre-exercise rate.54-56
PRE improves modestly cardiorespiratory fitness,
particularly for previously sedentary older adults,
decreases risk of fall, increases bone mineral density
and tendon strength, and improves various cardi-
ometabolic risk factors in the absence of weight loss
(decreased LDL-cholesterol 57, 58 and triglycerides,57
reductions in blood pressure,59 increases in HDL-
cholesterol 58 and improves glucose homeostasis
and insulin sensitivity).
PRE attenuates development of sarcopenia by
many ways: improving muscle size and function, re-
ducing balance and flexibility problems and reduc-
ing also the risk of development of many sarcope-
nia-related comorbidities.60
The effectiveness and outcomes of this type of
exercise depends on some factors as intensity, train-
ing volume (sets by repetitions), frequency and type
of recommended exercises (isokinetic/variable re-
sistance/isoinertial), periods of recovery between
sets and frequency training.62 Different combination
of these variables (number of repetitions per set,
number of sets and rest between sets) originate dif-
ferent physiological responses. Thus in general, all
training programs induce certain improvements on
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
MONTERO-FERNÁNDEZ Role of exercise on sarcopenia in the elderly
strength, hypertrophy or muscle power. However,
certain combinations will have a particular emphasis
on one of these manifestations.
Volume of PRE measures the total amount of exer-
cise made and it is expressed in terms of the number
of repetitions, total kilograms raised, duration of the
session or period training. The best definition is the
total number of sets performed per unit of time. A
widely accepted definition for this is volume load
(VL), which takes into account the total number of
performed sets, repetitions and weight (kg) lifted
(i.e., (total repetitions [no.] x external load [kg]);
® A
however, since most published PRE studies for older
adults do not include VL as a prescription entity, it
T C
is difficult to draw conclusions regarding the dose-
response relationship.
Frequency is defined as the occurrence, per unit
H DI
of time (e.g., calendar week) that a full-body PRE
regimen is completed. Training frequency recom-
mended is 3-5 days per week. Train less than two
IG E
days a week does not produce a significant increase
in the maximal oxygen consumption. Moreover, the
R M
benefit  additional health training obtained above
five days a week is minimum, and the incidence of
injury can increase.
Intensity is commonly defined as the percentage
P A
of maximal ability for a given exercise (i.e., one-rep-
etition maximum [1RM]). Although this operational
O V
definition for intensity provides a more objective,
quantifiable unit than training fatigue or rating of
C ER
perceived exertion, current recommendations for
older adults still rely on a 0-to-10 RPE (perceived
Y
physical exertion) for moderate-intensity (5 to 6 out
of 10) and vigorous-intensity (7 to 8 out of 10) PRE.8,
40 Alternatively, intensity of PRE may be modified
IN
based on a targeted number of repetitions, or by
increasing loading within a prescribed repetition-
maximum range (e.g., 8-12 RM).61
M
Emphasis on muscle power (how fast the muscle
contracts) rather than strength alone may help pa-
tients retain the greatest amount of functional capac-
ity as they age. Regardless of age or health status,
continual improvement requires a progressively in-
creasing resistance as the patient becomes stronger.
But current recommendations for older adults do
or other proprietary information of the Publisher.
not reflect the viability of progression in PRE dosage
to accommodate a hierarchical muscular adaptive-
response to training, in spite of a significant body
of literature to support its safety and effectiveness.63
Besides that, recent evidence from two meta-anal-
136 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE February 2013
yses 21, 64 has revealed that PRE is effective for elicit-
ing significant strength adaptation and increases in
lean body mass among older adults, and that there
is a robust dose-response relationship such that vol-
ume and intensity are strongly associated with ad-
aptations.
However, it seems evident that the realization of
repetitions to failure with these excessive intensi-
ties may pose an unnecessary effort, besides being
detrimental for health and performance, not only for
these special population groups (e.g., aging, obesity,
diabetes) but also for most athletes. Furthermore,
there is little evidence that shows the superior ef-
fect of these intensities over other more lower (e.g.,
20RM-30RM) in previously untrained people.65 A re-
cent review, which analyzes which training intensi-
ties are correlated to strength increase in the eld-
erly,66 concludes that intensities are higher than the
low improvement in terms of maximum force but
not necessarily in terms of functional gains.
Flexibility exercises
It is the ability to move a joint through a complete
range of motion. This limited range of motion in
the hip, knee, and ankle joints may increase the risk
of falls and contribute to age-related gait changes.
Although there is scant research devoted to exam-
ining the impact of flexibility on health outcomes,
it is considered paramount to overall good physi-
cal health. Stretches can be static (assume position,
hold stretch, then relax); dynamic (fluid motion [e.g.,
Tai-Chi]); active (balance while holding stretch, then
moving [e.g., yoga]); or a combination (propriocep-
tive neuromuscular facilitation).49
Balance training
Postural hypotension, impaired proprioception,
vision, larger postural sway, slower gait velocity and
slower correcting reflexes are the major factors that
occur with age. Balance is the exercise that helps
maintaining stability during daily activities and other
exercises, preventing falls. It can be static (e.g., stand
on one leg) or dynamic (e.g., walk a tightrope), with
hand support as needed. Examples of balance train-
ing include tandem walking, standing on heels or
toes, walking on compliant surface such as foam
mattresses, maintaining balance on moving vehicles
such as bus or train, walking backward.49
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
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Role of exercise on sarcopenia in the elderly MONTERO-FERNÁNDEZ
Exercise interventions and sarcopenia
Although there is currently no consensus recom-
mendation for PA and exercise among older adults
with sarcopenia, there are some recommendations
for adults over the age 65 years for various types of
activity and specific guides for implementing such
programs. We will provide in the following section
an overview of current and specific recommenda-
tions, for PA in the elderly, many of which have
been proven to be useful in preventing or attenuat-
ing sarcopenia.8, 25, 40, 49, 67
® A
General recommendations
T C
Older adults are a varied group. Most, but not
all, have one or more chronic conditions that vary
H DI
in type and severity. All have experienced a loss of
physical fitness with age, some more than others.
This diversity means that some older adults can run
IG E
several miles, while others struggle to walk sever-
al blocks. Starting an exercise program later in life
R M
can significantly reduce risk factors even if a person
was sedentary when he or she was younger, so we
should avoid ageism when we are prescribing exer-
cise. Several areas should be emphasized in promot-
P A
ing PA in older adults:8, 25, 26, 40
—— Before arranging for an exercise program,
O V
physicians should consider and identify specific
activities that a patient prefers, according to their
C ER
social preferences, cultural norms, exercise history,
readiness, motivation, self-discipline and short and
Y
long term goals and logistics.
—— An activity plan is recommended for all older
adults. This plan should be individualized with spe-
IN
cific objectives and tasks and tailored according to
chronic conditions and activity limitations, risk for
falls, individual abilities and fitness.
M
—— The PA prescription should be done in the
same manner as clinicians prescribe drugs for a
disease. The plan has to define what, how, when,
where, and how often each activity will be done.
For example “Take a 10-minute walk, three times
a day, every day of the week. Choose a speed that
allows you to talk but that is moderately hard work.
or other proprietary information of the Publisher.
The distance is not important, but make sure to walk
for the entire 10 minutes”.
—— The progression of activities (duration and in-
tensity) should also be individual: a conservative ap-
proach may be necessary for the most deconditioned
Vol. 49 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 137
and physically limited older adults to minimize the
risk of injury. Many months of activity at less than
recommended levels is appropriate for very decon-
ditioned older adults as they increase activity in a
stepwise manner. In addition, activity plans need to
be re-evaluated when there are changes in health
status.
—— Muscle strengthening activities and/or balance
training may need to precede aerobic training activi-
ties among very frail individuals.
—— Proper warm-up and stretching are particular-
ly important with careful instruction on balance and
breathing. A warm-up with aerobic activity usually
consists of short intervals of low-intensity movement
(e.g., walking for 5 minutes).
—— Sensory impairments, such as hearing loss,
can make it difficult to instruct older adults. There-
fore, speaking loudly and slowly, using visual aids,
and demonstrating exercises are all techniques that
help older adults become active.
—— Supervision, monitoring, teaching, and en-
couragement are essential, recognizing that long ad-
aptation periods may be needed as deconditioned
elderly may develop aches and pains as they begin
a more active lifestyle. Supervision is best when it
comes from people familiar with the special needs
of the elderly.
—— Finally, in the absence of contraindications,
protein intake should be about 1.5 g/kg per day
to elicit a robust acute muscle protein synthetic re-
sponse above that seen at rest. Evidence suggests
that the elderly may need to distribute this protein
intake evenly throughout the day. Studies combining
protein supplements with exercise have obtained
the best outcomes when supplementation is admin-
istered immediately after exercise. The use of pro-
tein supplements without exercise, however, has not
had any effect on muscle mass.68
Lifestyle modifications
Prescriptions should encourage patients to limit
sedentary activities such as television watching
and computer use, as recent studies also show that
breaking up sedentary time can be beneficial. This
can include behaviors that result in a transition from
sitting to a standing position or from standing still to
beginning to walk. Useful goals include structuring
activity into a normal daily routine, as self transpor-
tation (walking, bicycling), take stairs instead eleva-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
MONTERO-FERNÁNDEZ Role of exercise on sarcopenia in the elderly
tors, parking further from entrances, go shopping,
do home tasks.25, 26, 40
Specific recommendations for exercise
Although maintenance or increases in leisure time
PA is known to support preservation of function
and longevity, there are also well-recognized health
benefits associated with structured and progressive
exercise.62
The exercise prescription for elderly patients does
not differ significantly from the prescription for
® A
younger adults. It is recommended that adults par-
ticipate in a minimum of 150 minutes of moderate
T C
intensity or 60 minutes of vigorous PA per week.
Older adults with functionally limiting chronic dis-
eases should be as active as their medical conditions
H DI
allows in order to reduce sedentary behavior.40
There is some public awareness of the PA guide-
lines recommending aerobic exercise on 5 or more
IG E
days of the week. However, very few clinicians and
elderly people are knowledgeable about the other
R M
recommended components of a PA plan, and the
prevalence of older adults performing activities to
address muscle strengthening, flexibility, and bal-
ance is low.
P A
Aerobic
O V
exercise
Guidelines from the AHA and the ACSM suggest to
C ER
promote and maintain health 30-60 minutes per day
of moderate-intensity aerobic activity on five days
Y
each week, or 20-30 minutes of vigorous-intensity
activity on three days each week, or some combina-
tion of the two, with no more than two consecutive
IN
days between bouts.40, 49 The types of exercise in-
clude any modality that does not impose excessive
orthopaedic stress, activities such as brisk walking,
M
swimming, and recumbent cycling/stepping that are
usually well tolerated by older individuals. However,
unless other specified by a primary care physician
or cardiologist, individuals may also progress to oth-
er modalities such as jogging, hiking, rowing, and
stair-climbing. Aquatic exercise and stationary cycle
exercise may be advantageous for those with lim-
or other proprietary information of the Publisher.
ited tolerance for weight bearing activity. Sessions
should be a minimum of 10 minutes for intermittent
AE, and intended to reach energy expenditure goals
of a minimum of 100-250 kcal per session. Activi-
ties do not have to be done at one time but can be
138 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE February 2013
spread throughout the day in short time allotments.
Moderate-intensity aerobic activity involves a mod-
erate level of effort relative to an individual’s aerobic
fitness. On a 10-point scale, where sitting is 0 and
all-out effort is 10, moderate-intensity activity is a 5
or 6 and produces noticeable increases in heart rate
and breathing. On the same scale, vigorous-intensity
activity is a 7 or 8 and produces large increases in
heart rate and breathing. For example, given the het-
erogeneity of fitness levels in older adults, for some
older adults a moderate-intensity walk is a slow
walk, and for others it is a brisk walk.49
However, the guidelines emphasize that for most
health outcomes, additional benefits occur as the
amount of PA increases through higher intensity,
greater frequency, and/or longer duration. The
guidelines stress that if older adults cannot do 150
min of moderate-intensity aerobic activity per week
because of chronic conditions, they should be as
physically active as their abilities and conditions al-
low.49
On the other hand, the minimal 150 minutes of
moderate-intensity PA per week may be insufficient
for weight loss for overweight or obese individu-
als. Older adults who are overweight may need the
equivalent of 300 minutes per week of moderate-
intensity PA to adequately mange weight control, in
conjunction with an appropriate diet.8
This recommended amount of aerobic activity
is in addition to routine activities of daily living of
light-intensity (e.g., self care, cooking, casual walk-
ing or shopping) or moderate-intensity activities
lasting less than 10 min in duration (e.g., walking
around home or office, walking from the parking
lot).40
Because an optimal effect on the mechanical and
metabolic properties of aged muscle cannot be ob-
tained by a single type of exercise, and considering
that AE is better than PRE for developing endurance
capacity, it has been suggested that these types of
exercises should be combined to combat the glo-
bal issues of sarcopenia in the elderly population.69,
70 As an original aerobic training program for sed-
entary aged people, aerobic interval training (AIT;
weekly exercise sessions with 4-minute repetitions
at a moderate aerobic intensity alternated with one-
minute repetitions at a sub-high aerobic intensity)
could next be considered in sarcopenia. AIT im-
proves aerobic capacity and maximal aerobic power
in sedentary aged subjects, while a sub-high aerobic
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Role of exercise on sarcopenia in the elderly MONTERO-FERNÁNDEZ
intensity repetitions program tends to increase the
metabolic stimulus to resistance exercise in an aero-
bic training program.71
Progressive resistance exercise (PRE)
The current guidelines also call for PRE to be per-
formed two or more nonconsecutive days per week,
using a single set of 8-10 exercises for the whole
body, and at a moderate (5-6 RPE out of 10) to vig-
orous (7-8 RPE out of 10) level of effort that allows
8-12 repetitions.8, 40
® A
The type of recommended exercise are muscle
strengthening activities that involve all the major
T C
muscle groups (legs, hips, chest, back, abdomen,
shoulders and arms), with a progressive weight
training program, stair climbing, and other strength-
H DI
ening activities that use the major muscle groups, or
weight bearing calisthenics (8-10 exercise involving
the major muscle groups of 8-12 repetitions each).
IG E
Do not forget about providing a-2 minutes of rest
between exercises. Some PRE training examples
R M
alternating between upper and lower body work,
should be the following:
—— upper body: chest press, shoulder press, tri-
ceps extension, biceps curl, lateral pull-down (up-
P A
per back);
—— midsection of the body: lower-back extension,
O V
abdominal crunch/curl-up;
—— lower body: quadriceps extension or leg press,
C ER
leg curls (hamstrings), calf raise.
Due to the disproportionate degree of muscle at-
Y
rophy and strength decline of the lower limb mus-
culature during aging,4 a PRE intervention model
for positive effects on lower-extremity strength is
IN
recommended to provide enhancement of overall
functional capacity.
The technique of this PRE prescription refers to
M
perform each exercise through a full range of mo-
tion, in a controlled rhythmic manner, and at a slow
to moderate speed, avoiding breath-holding and
straining (Valsalva manoeuvre) and emphasizing
proper body mechanics throughout each exercise.
They should be repeated until the point at which it
would be difficult to do another repetition without
or other proprietary information of the Publisher.
help.
Following a familiarization period, in which very
low dosage training takes place 1-2 times per week
it may be expected that older adults with sarcopenia
can benefit from gradual increases in training dos-
Vol. 49 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 139
age to accommodate improvements in strength and
muscle hypertrophy. Varying the type of exercises,
increasing the level of resistance; increasing by 5%
up to 40% of 1 RM for arm exercises and up to 60%
of 1 RM for leg exercises, adding a second set of
exercises without increasing level of resistance and
adding a third day of resistance training during the
week are some suggestions to pertain to progres-
sion in PRE.62
Flexibility
There are a small number of studies that have
documented the effects of flexibility exercises in
older populations. There is some evidence that flex-
ibility can be increased in the major joints by these
exercises; however, how much and what types of
flexibility exercises are most effective have not been
completely established.40 The ACSM recommenda-
tions states that flexibility exercise should be done
at least two days per week, ten minutes per day at a
moderate intensity (5-6) on a scale of 0 to 10 and in-
cluding exercise for the neck, shoulder, elbow, wrist,
hip, knee and ankle.40 Preferably, flexibility activities
are performed on all days that aerobic or muscle-
strengthening activity is performed.
Balance
There are no specific recommendations regard-
ing specific frequency, intensity, or type of balance
exercises for older adults. Preferably, older adults
at risk of falls should do balance training three or
more days a week. The exercises can increase in
difficulty by progressing from holding onto a stable
support (like furniture) while doing the exercises to
doing them without support. Participation in Tai-Chi
classes also improves balance and reduces the risk
of falls.
The ACSM guidelines recommend activities that
include the following:40 progressively difficult pos-
tures that gradually reduce the base of support (e.g.,
two-legged stand, semitandem stand, tandem stand,
one-legged stand); dynamic movements that perturb
the centre of gravity (e.g., tandem walk, backward
walking, sideways walking, heel walking, toe walk-
ing circle turns, standing from a sitting position,
walking on compliant surface such as foam mattress-
es, maintaining balance on moving vehicles such as
bus or train); stressing postural muscle groups (e.g.,
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
MONTERO-FERNÁNDEZ Role of exercise on sarcopenia in the elderly
heel stands, toe stands) and reducing sensory input
(e.g., standing with eyes closed).
Exercise precautions
Common problems with exercise in the elderly
are those related to comorbidity, which is a very fre-
quent condition in this group of age. It is not a con-
traindication by itself, but requires a careful medical
evaluation before beginning the exercise program. It
is appropriate to initiate activity at modest duration
and intensity with regimens that progress gradually
® A
over extended time intervals. Particularly in these
circumstances, it is important to limit activity to what
T C
a patient feels is comfortable, progressing in small
increments and prioritizing longer duration over
higher exercise intensity. Absolute contraindications
H DI
are mainly cardiovascular diseases: recent heart at-
tack, unstable angina, uncontrolled hypertension,
acute heart failure and blocking complete AV.62, 72
IG E
The elderly are extensive users of both prescrip-
tion and over-the-counter medications and they
R M
tend to use them chronically. These medications can
have negative effects on performance and they can
lead to increasing adverse effects. Clinicians should
be alert to elderly taking statins, beta-blockers and
P A
vasodilators drugs.73
The main risks of aerobic and strength training
O V
are the risk of musculoskeletal injuries and cardio-
vascular risk. Patients should be advised that muscle
C ER
soreness is normal at first and should subside in a
few weeks. If injury or illness interrupts an activity
Y
routine, resuming activity at a lower intensity level
is possible once sufficient healing has occurred. Any
potential risks of routine exercise do not outweigh
IN
its benefits, in the absence of a contraindication to
exercise.
General recommendations for safety, particularly
M
in the initial stages of exercise, include exercising
with one other person, carrying a cell phone to fa-
cilitate calling for emergency help, well-lit and ven-
tilated rooms and adhering to an activity level that is
comfortable and with normal breathing.74
These data support the notion that supervised or
group settings may be preferable for elders, with
or other proprietary information of the Publisher.
regard to both safety and compliance. It is necessary
to wear proper footwear and clothing, good nutri-
tion and liquid intake and adequate sleep. Exercise
machines have advantages for older, especially frail,
as the range of motion is easier to control. Chair and
140 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE February 2013
bed based exercise should be considered as a start-
ing point and used by frail patients.
Older adults face multiple barriers to practice ex-
ercise regularly and therefore experience difficulties
starting with a PA program and adhering to it. These
barriers include lack of knowledge about the benefi-
cial effects of PA, fear of falling and problems to find
and get to an exercise facility near home.75 A more
structured environment with classes (e.g., yoga, pi-
lates, dancing) or in a fitness center (with a trainer
or specialized equipment) may provide a variety of
activities that may engage the individual, but home-
based exercise (e.g., jogging, using an exercise bike)
may result in better adherence given low cost and
convenience. Data are lacking in determining the
optimal setting to perform exercise (e.g., outdoors
versus indoors, home versus fitness center).76, 77 A
systematic review of six trials evaluated the efficacy
of home-based versus hospital (center)-based exer-
cise programs in older adults.77 In the short-term,
center-based programs were superior to home-
based programs in patients with peripheral vascu-
lar disease. However, in the long-term, home-based
programs were superior to center-based programs
in terms of adherence.
Health care providers are perceived as respected
sources of health information and should thus take
an active role in promoting PA. However, less than
50% of older adults report that their physicians have
recommended exercise. The primary care setting
would appear to be a good place for health promo-
tion because most older adults visit their primary
care provider more than once a year.40 However,
most observational studies and randomized trials
have found conflicting results on whether usual
counselling in a primary care setting is sufficient to
effect behavioral change.78, 79
Conclusions
In conclusion, motivating older persons to in-
crease their physical activity level as well as provid-
ing safe access to exercise programs seems to be a
mandatory task. Many previous authors have pro-
vided data and interpretation critical to understand-
ing that muscle weakness, reduction in muscle mass
and reduction in PA occur during life span and lead
to sarcopenia and disability in some older people.
PA, which is a modifiable lifestyle behavior, can par-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Role of exercise on sarcopenia in the elderly MONTERO-FERNÁNDEZ
tially reverse this muscle dysfunction in the elderly,
as well as benefit every part of the body and sub-
stantially extend independent functional lifespan.
In addition to our traditional recommendations of
the health benefits of exercise in young people, we
should stress the harms of inactivity even in the old-
est adults and view the inactive elder population as
abnormal and consider them at high risk of disease
and disabilities.80
We would like to finish our review honoring Jer-
emy Morris, one of the first clinicians who advised
about the health benefits of exercise, remembering
® A
his last investigation paper, published in 2009, some
days before his dead at the age of 99:81 “We now
T C
know that regular physical activity of 150 minutes/
week of moderate intensity physical activity reduces
the risk of numerous chronic diseases, preserves
H DI
health and function (both physical and mental) into
old age, and extends longevity. The current chal-
lenge is to develop programs and interventions to
sedentary societies”. IG E
promote physical activity for all in our increasingly
R M
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Received on January 17, 2013.
Accepted for publication on January 23, 2013.

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