Bullo Et Al. 2017 (V)

ordic Walking can be incorporated in the exercise prescription to increase aerobic capacity, strength and quality of life for
elderly: a systematic review and meta-analysis. (doi: 10.1089/rej.2017.192 Rejuvenation Research

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DOI: 10.1089/rej.2017.1921
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Nordic Walking can be incorporated in the exercise prescription to
Nordic Walking can be incorporated in the exercise prescription to increase aerobic capacity, strength and quality of life for elderly: a systematic review and meta-analysis. (DOI: 10.1089/rej.2017.1921)
increase aerobic capacity, strength and quality of life for elderly: a
systematic review and meta‐analysis.
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Running head: Nordic walking for elderly wellbeing
Bullo Valentina1, Gobbo Stefano1, Vendramin Barbara1, Duregon Federica1, Cugusi Lucia2,
Di Blasio Andrea3, Bocalini Danilo Sales4, Zaccaria Marco1, Bergamin Marco1, Ermolao
Andrea1
Rejuvenation Research
1
Sport and Exercise Medicine Division, Department of Medicine, University of Padova,
Italy
2
Department of Medical Sciences ‘M. Aresu’, University of Cagliari, Cagliari, Italy
3
Department of Medicine and Aging Sciences ‘G. d’Annunzio’, University of Chieti‐Pescara,
Italy
4
Translational Physiology Laboratory, Post‐Graduation Program in Physical Education, São
Judas Tadeu University, São Paulo, Brazil, Post‐Graduation Program in Aging, São Judas
Tadeu University, São Paulo, Brazil

ordic Walking can be incorporated in the exercise prescription to increase aerobic capacity, strength and quality of life for elderly: a systematic review and meta-analysis. (doi: 10.1089/rej.2017.192

5378
Keywords
Word count
Dr. Marco Bergamin, Ph.D.

Email: marco.bergamin@unipd.it
Via Giustiniani, 2 ‐ 35128 Padova (Italy)
Address for correspondence and reprints
Telephone: +39 049 8214429 ‐ Fax: +39 049 8215862
Elderly, Nordic Walking, Systematic Review, Exercise Prescription
2
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Abstract
The aim of this systematic review and meta‐analysis was to summarize and analyze the
effects of Nordic Walking on physical fitness, body composition and quality of life in the
elderly.
Methods: keyword “Nordic Walking” associated with “elderly” AND/OR “aging” AND/OR
“old subjects” AND/OR “aged” AND/OR “older adults” were used in the onlines database
Medline, Embase, PubMed, Scopus, PsycINFO and SPORTDiscus. Only studies written in
English language and published in peer‐reviewed journals were considered. A meta‐
analysis was performed and effect sizes calculated.
Results: 15 studies were identified; age of participants ranged from 60 to 92 years old.
Comparing with a sedentary group, effect sizes showed that Nordic Walking was able to
improve dynamic balance (0.30), functional balance (0.62), muscle strength of upper (0.66)
and lower limbs (0.43), aerobic capacity (0.92), cardiovascular outcomes (0.23), body
composition (0.30) and lipid profile (0.67). It seemed that Nordic Walking had a negative
effect on static balance (‐0.72). Comparing with a walking (alone) training, effect sizes
showed that Nordic Walking improved the dynamic balance (0.30), flexibility of the lower
body (0.47) and quality of life (0.53). Walking training was more effective in improving
aerobic capacity (‐0.21). Comparing Nordic Walking with resistance training, effect sizes
showed that Nordic Walking improved dynamic balance (0.33), muscle strength of the
lower body (0.39), aerobic capacity (0.75), flexibility of the upper body (0.41), and the
quality of life (0.93).
Conclusions: Nordic Walking can be considered as a safe and accessible form of aerobic
exercise for the elderly population, able to improve cardiovascular outcomes, muscle
strength, balance ability and quality of life.
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Introduction
The worldwide increase of old people was associated with the requirement of new
strategies for the management of their needs, with particular attention for the
preservation of functional capacity and promotion of their quality of life 1. In fact, the
aging process was characterized by the decrease of physical and cognitive capacities with a
high risk of developing chronic disease and disability 2. In particular, heart disease, stroke,
chronic respiratory disorders, cancer and dementia are computed as the major causes of
death and disability among elderly 3. The “active aging” was one of the World Health
Organization (WHO) prevention policies, considered as “the process of optimizing
opportunities for health, participation and security to enhance quality of life as people
age” 1. Definitely, physical activity was strongly recommended to the elderly population
and its positive key‐role in the age‐related physical decline was associated to the
enhancement of quality of life 2.
In the last decades, different forms of physical activity were proposed and adapted to the
elderly population, in alternative to the traditional training. Nevertheless, their
effectiveness was not so clear. For this reason, interests among researchers in these
activities were growing, to clarify their effectiveness in the physical capacities, but also on
mood and quality of life. An example was the Pilates training, which was largely practiced
by the population, but only few studies reported its effectiveness in term of development
of physical performance and wellbeing in the elderly 4.
Walking was considered one of the most common physical activities in the world 5. It is a
natural movement, rarely associated with physical injury and easy to be practiced by
people of all ages, including the elderly 6. Walking can be performed in different
environments with no needs of particular equipment, overcoming some common barriers
as the lack of time, fitness level and money 6. Moreover, the regular practice of walking
activity was largely recommended for the overall health 7, with the reduction in the all‐
cause mortality and in the risk to develop non‐communicable diseases 8. A particular type
of walking technique is the Nordic Walking (NW). NW is a form of brisk walking, utilizing a
walking pole, which actively engages the trunk and upper limbs during walking,
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maintaining the natural gait, while the hands are performing an open‐close cycle in an
alternating manner. Due to the high muscle masses involved, NW produces a higher
cardiorespiratory workload compared to the normal walking 9, despite any difference in
the perceived exertion 10. Generally, NW is characterized by a submaximal regular increase
of both heart rate and cardiac output together with a reduction of peripheral vascular
resistance, in order to support the contemporaneous work of a big volume of muscle mass
not requiring the expression of high intensity strength. According to the walking speed and
the ground characteristics, NW may be a whole‐body aerobic or alternated
aerobic/anaerobic discipline. For example, interval training NW was used in obese
subjects, to increase energy expenditure and weight loss 11.
Since outdoor physical activity seemed to be more effective than indoor activity, and it
could therefore increase the adherence to exercise 12, this systematic review and meta‐
analysis aimed to summarize and analyze the effectiveness of NW interventions on the
physical fitness, the body composition and the quality of life in the elderly population.
Methods
Study design
This is a systematic qualitative review and meta‐analysis of the literature, aimed to analyze
the effects of NW programs on the physical fitness, the body composition and the quality
of life in the elderly population. The Preferred Reporting Items for Systematic Reviews and
Meta‐Analyses (PRISMA) guidelines and flow chart diagram were used as a reporting
structure for this systematic review and meta‐analysis 13, 14.
Literature search
Literature research was conducted from June to July 2017. The keyword “Nordic Walking”
associated with “elderly” AND/OR “aging” AND/OR “old subjects” AND/OR “aged” AND/OR
“older adults” was used in the online databases MEDLINE, Embase, PubMed, Scopus,
PsycINFO and SPORTDiscus.
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Inclusion and exclusion criteria
Only studies published in indexed and peer reviewed journals, written in English language,
were considered for this review. In order to be included, articles needed to meet the
following criteria, formulated on the base of the PICO model 14, 15: a) including subjects ≥
60 y.o.; b) delivering a supervised or a not supervised NW training intervention; c) the
presence or not of the control group, with different characteristics (sedentary, other
exercise intervention); d) physical fitness, body composition and quality of life evaluations;
e) randomized controlled trials (RCTs), non‐randomized controlled trials (noRCTs), quasi‐
experimental design (Q‐E). Both males and females from all races and different states of
health were included. Furthermore, only original articles were accepted for the analysis.
All studies not evaluating outcomes through pre‐ and post‐intervention comparisons, as
well as cross sectional studies and case reports were excluded. Published abstracts,
dissertation materials, or conference presentations were not considered eligible
documents.
Study quality assessment
The quality of the studies was assessed applying an adapted nine criteria checklist
provided by the Cochrane Collaboration Back review Group 16. As in previous reviews 4, 17,
the checklist had to be marginally adapted to rate the strength of the evidence. Each study
in the review was scored based on the following nine criteria: (1) ‘Was the method of
randomization adequate?’; (2) ‘Were the groups similar at baseline regarding the outcome
measures?’; (3) ‘Were inclusion and exclusion criteria adequately specified?’; (4) ‘Was the
drop‐out rate described adequately?’; (5) ‘Were all randomized participants analyzed in
the group to which they were allocated?’; (6) ‘Was the compliance reported for all
groups?’; (7) ‘Was Intention‐to‐treat analysis performed?’; (8) ‘Was the timing of the
outcome assessment similar in all groups?’; (9) ‘Was a follow‐up performed?’. When the
study provided a satisfactory description, a positive value was assigned (+). If the criterion
description was considered absent, unclear, or lacked the specified content, a negative
value was assigned (−). A study was qualita vely judged as high quality if it showed a
positive score on 5 to 9 of the criteria; otherwise, it was considered a low quality study.
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Data extraction and synthesis
Two researchers independently examined all abstracts of the sourced studies from the
literature. Suitable studies were analyzed with major detail for meeting eligibility criteria.
Additional articles were sourced by reviewing the reference sections. A final quality
eligibility check of each study was performed by the two researchers. The individual
searches were combined, compared, and reviewed for applicability, where a consensus
was made regarding study inclusion. In case of discrepancies, the review process was
repeated and a third researcher was consulted. A K‐Cohen’s coefficient of 0.98 indicated a
perfect agreement between researchers; one study was excluded cause subjects age lower
than 60 years 18. Quality assessment using the modified Cochrane methodological quality
criteria was then independently applied and discussed before final quality scores were
assigned (Tab. 1). The same researchers who screened titles, abstracts, full texts and
references performed quality assessment. Several domains were identified for
categorization of the study results. In particular, studies were analyzed in regard to static
and dynamic balance, muscle strength, flexibility, aerobic capacity, cardiorespiratory
parameters, body composition, lipid profile and glucose sensitivity, and quality of life.
*** Please, add here Table 1 ***
Data analysis
Meta‐analyses were performed using random‐effect models, with confidence intervals set
at 95%, standard mean difference (ES) was calculated through Review Manager 5.3
software (Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).
The ES was calculated as standardized mean difference ΔMean/SDpooled where ΔMean is
the difference between the post intervention mean of the NW and Control Group, and
SDpooled is the mean of the post intervention standard deviation, summarizing the different
tests evaluating the same parameter. Overall ES consisted on NW group compared with all
the different control groups, including Sedentary Group (SG), Walking Training Group (WT)
and Resistance Training group (RE). Also ES of NW with specific control groups (SG or WT
or RE) was calculated (Tab. 4). The ES is a measure of the effectiveness of a treatment, and
it helps to determine whether a statistically significant difference is a difference of
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practical concern. Interpretation was performed according to Cohen’s guideline where an
ES value of 0.20 indicates a small effect, ES of 0.50 indicates a medium effect and ES higher
than 0.80 indicates a large effects 19.
Studies description and results
A total of 353 studies resulted from the literature search. Appling inclusion and exclusion
criteria, 15 studies were considered eligible for this review (Fig. 1). Sample sizes ranged
from 18 to 95 subjects, with age ≥ 60 y.o.. Interventions lasted from 6 to 35 weeks, with a
frequency of 2 or 3 times per week. Table 2 summarized the characteristics of the studies.
Finally, table 3 reported all results of the included studies.
***Please, add here Fig. 1***
Four studies were classified as high quality 20‐23, and 11 as low quality 24‐34. Moreover, 5
studies reported the timing of outcomes assessment 24, 25, 27, 28, 31, 9 studies executed
randomization procedures 20‐23, 26, 29, 31, 32, 34, 4 reported the compliance of the intervention
20, 23, 25, 28
, 10 the dropout rate 20‐24, 28, 30, 31, 34, 2 used the intention‐to‐treat analysis 20, 23, 3
a blinding evaluator 21‐23, and 1 executed a follow‐up evaluation 23.
***Please, add here table 2 and table 3***
Static and dynamic balance
Four studies evaluated static balance with field and laboratory tests. After 12 weeks of NW
training, were recorded an improvement in the static balance (One‐leg Stance test 133.9%
29
; Functional Reach Test 6.3% 28; Forward Reach Test 0.9% 22, and Upward Reach Test
2.2% 22). Only one study found statistical difference with the laboratory evaluation with a
force platform in open eyes condition (3%) 24. Comparing NW and SG, ES suggested that
NW had a negative effect on static balance (ES = ‐0.72), while NW seemed to produce
similar effects than WT (ES = ‐0.08) and RE (ES = ‐0,07).
In 7 studies dynamic balance was evaluated by 8‐foot up and go 20, 23, 24, 27, 28 and Time Up
and Go test (TUG) 26, 30. Significant improvements after 8 weeks (16.9% 23) 12 (4.7% 28;
9.3% 26), 16 weeks (15.3% 23), 35 weeks (7.6% 30) and one year (20.3% 23) of NW training
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were recorded, whereas laboratory evaluation reported no significant changes after 9
weeks 20. In comparison with the different control groups, ES suggested a small to medium
effect on dynamic balance (SG = 0.30; WT = 0.30; RE = 0.33).
Functional balance was evaluated in 2 studies with the Fullerton Advanced Balance Scale
(FABS) and the Berg Balance Scale (BBS). In both, significant improvements of 6.2% 30 and
4.5% 21 after 35 and 6 weeks of NW were found. ES showed a medium to large effect of
NW in the functional balance compared with SG (0.62), while NW seemed to carry out
comparable effects of WT (ES = 0).
Muscle strength
Eight studies analyzed muscle strength changes after a NW program. Lower limb strength
evaluated by the sit‐to‐stand test recorded a significant improvement of 25.9% 29, 22.4%
31
, 12.6% 28, 9.5% 27 and 10% 24 after 12 weeks of NW, an increase of 10.7% 23 after 8
weeks, 15.3% 20 after 9 weeks, 13.6% 23 after 16 weeks, and 17.9% 23 after one‐year follow
up. Ossowski and colleague 26 measured isometric knee extension and flexion strength.
Twelve weeks of NW induce an improvement of 11% and 22.1% in peak torque knee
isometric extension and flexion 26. No significant changes were found after 35 weeks of
NW, evaluated by the 5‐times sit‐to‐stand test 30. Analyzing NW effects on lower limbs
strength with the different control groups, ES showed a small to medium effect (0.43, NW
vs. SG), such as compared with RE (0.39). Whereas, NW and WT seemed to indicate similar
effects.
Upper limb strength evaluated by the Arm Curl 30s test showed an improvement of 19.7%
20
after 9 weeks of NW, and an improvement of 19.7% 31 and 11.6% 28 were found after 12
weeks, whereas no statistical difference was found in Lee’s 12 weeks NW intervention 29.
Song and colleagues evaluated the upper limb strength also by Handgrip test, recording an
increase of 11.8% after 12 weeks of NW 31. In comparison with a SG, ES analysis showed
that NW had a medium to large effect on muscle strength (0.74). On the contrary, WT and
RE seemed to have the same effects.

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Flexibility
Four studies examined muscular flexibility. After 12 weeks of NW, back scratch recorded a
significant improvement in upper limb flexibility (44.6% 28), such as sit‐and‐reach test in
lower limb flexibility (75.4% 28, 175% 27). Whereas after 9 weeks, an improvement of 92.5%
only in Sit‐and‐reach test was found 20. Comparing NW with WT and RE, NW was more
efficient than WT to enhance the lower limbs flexibility (0.47) 28, and it was also more
efficient than RE to improve the upper limbs flexibility (0.41) 28. Compared with SG, NW
did not produce any effects on upper limbs and lower limbs.
Aerobic capacity, and cardiovascular outcomes
Nine studies analyzed aerobic capacity with field and clinical lab test. Only one study not
found significant increases with field test. After 6 weeks of NW training, 6’ walk test
improved by 22.3% 21 and by 13.9% 34, such as after 8 weeks (7,5% 23), 12 weeks (10.1% 26),
16 weeks (13.3% 23) and one‐year follow‐up (14.3% 23). 12’ walk test increased by 10.9% 28

and 5‐m walk test increased by 14.3% 21, both after 6 weeks of NW. Furthermore, 2‐
minute step test recorded an improvement of 14.2% 20, 9% 27 and 9.4% 30 after 9, 12 and
35 weeks of NW intervention. Also 15s marching on the spot test (MOS) recorded
significant improvement after 8, 16 and one‐year follow up 23. ES of 0.92 showed a large
effect of NW compared with SG, as well as in comparison with RE (ES = 0.75). On the
contrary, WT was more effective than NW in improving this specific capacity, with a small
effect in favor of WT (ES = ‐0.21).
Three studies evaluated NW effects on cardiovascular outcomes. On one hand, significant
improvements in duration of effort (14.1%), maximum effort load (13.4%), VO2max (13.6%)
and systolic blood pressure (SBP) (3.6%) were recorded after 6 weeks. On the other hand,
no significant changes were found in time at Anaerobic threshold, O2‐pulse, diastolic blood
pressure (DBP) and daily heart rate 34. In addition, 12 weeks of NW proved to produce a
significant decrease in SBP (4.4%), DBP (3.9%), average value of arterial blood pressure
(4.1%), first and second peak of SBP (3.6% and 4.5%) and in augmentation index corrected
at heart rate 75 per minute (2.5%) 33. Kortas and colleagues found significant improvement
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in VO2max after 35 weeks of NW (2.4%) 25. An ES of 0.23 indicates a small effect on
cardiovascular outcomes.
Body composition
Six studies analyzed NW effects on body composition. Right 8 weeks of NW did not
produce any significant changes in the body composition evaluated through Bioelectrical
Impendence Analysis (BIA) 32, while 12 weeks of NW produced a decrease in body weight
(1.6% 26, 1.7% 31, 4.1% 33), in Body Mass Index (BMI) (1.5% 26, 2% 31, 3.7% 33), in percentage
of body fat (3.8% 31, 5.3% 26) and in waist circumference (2.4%) 33, such as an increase in
muscle mass (3.9% 31, 2.1% 26). Kortas and colleague found significant reduction in body
weight (0.9%), percentage of body fat (4.8%) and total body water (0.9%), and increase in
muscle mass (1.1%) after 35 weeks of NW 25. Only two studies compared NW with a SG,
and an ES of 0.30 suggested that 12 weeks of NW producing a small effect on body
composition variation 26, 31. Comparing NW with WT, ES indicated that the two types of
training were similarly able to modify the body composition outcomes (0.07).
Lipid profile and glucose sensitivity
In three studies lipid profile was evaluated. 12 weeks of NW produced a significant
reduction of total cholesterol (5.8% 31) and triglycerides levels (7.1% 31). In particular, high
density lipoprotein (HDL) increased in two studies (15.4% 31, 6.4% 27) and decreased in
another one (3% 33), but no significant changes in low density lipoprotein (LDL) were
found. In details, NW had a medium to large effect compared with SG (ES = 0.67), while
after a WT and a NW training lipid profile were modified 31.
Glucose sensitivity showed significant modification with a concurrent reduction in C‐

reactive protein (CRP) (20% 33) and HOMA‐IR (10.1% 33).
Quality of life
Four researches focused on depression, fragility, sleep quality, pain and lower limb
functional capacity. Six weeks of NW training did not produced significant improvements in
21
pain score and lower limb functional capacity , while longer intervention proved
significant improvement in pain 23, depression scale 29, 32, fragility index 29, and sleep
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32
quality . In particular, depression symptoms showed significant changes after NW
training, with an improvement of 53.5% 32 and by 56.5% 29 after 8 and 12 weeks of
training. Moreover, a large ES classified NW as a physical activity more effective than WT
(1.1) 32 and RE (1.07) 29 to reduce depression symptoms.
Also improvements in sleep quality (63.5% 32) and frailty index (34.4% 29) were found. In

details, large ES in sleep quality comparing with WT (1.09) 32, and in frailty index comparing
NW with RE (0.81) 29 was found.
***Please, add here table 4***
Discussion
The aim of this systematic review was to summarize and analyze the effects of NW training
on physical capacity, body composition and quality of life in elderly people. The results
showed that NW was capable to produce improvements on strength, balance, flexibility,
body composition, aerobic capacity and cardiopulmonary outcomes, lipid profile, glucose
sensitivity and quality of life in elderly. Nevertheless, the low quality and the heterogeneity
of the studies suggested the needs of larger high‐quality clinical trials in order to increase
evidence about the effectiveness of NW.
In this research analysis, 16 studies comparing NW training to other type of exercise
programs (n = 7) 21‐23, 28, 29, 31, 32 or to sedentary groups (n = 6) 20, 26, 28, 30, 31, 34, while 4 study
has not the control group 24, 25, 27, 33. However, NW for elderly population indicatively
followed the American College of Sport Medicine (ACSM) training recommendations for
aerobic activity 2 with the advantage in the use of poles to ensuring the safety in frail
elderly.
Static and dynamic balance
Balance ability is an important physical capacity since it is related to fall risk. Indeed, all
year people who fall are about 30% over 65, with higher rates over 75 y.o. 35. The largely
used definition of body balance was related to the bodily capacity in the contrast of
external forces, to maintain body stability and postural control. Four studies evaluated the
static balance, showing significant and clinically meaningful improvements after 12 weeks
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of NW. Comparing NW with WT, RE and SG, RE intervention induced the higher
improvement on the static balance (+10.6%), similarly to the WT (+9.7%), while NW
showed a lower increase (+6.3%). According to ES analysis, WT and RE interventions
seemed to be more effective than NW alone to improve the static balance. Unexpected
results were the ES of NW compared with the SG. In fact, NW seemed to have a negative
effect on the static balance (FRT), despite the significant improvement. We speculated that
there was a baseline difference between NW and SG, that finally affected the computing of
the ES (which resulted as negative), despite the improvement on NW and the concurrent
decrease on SG 28. On the other hand, Lee et al. found NW more effective than RE to
improve static balance 29, as initially expected by the same Authors and confirming their
hypothesis.
NW showed improvements in dynamic balance, but with diverse results. Differently from
the static, which these effects appeared as not completely definite, dynamic balance has
been clearly influenced showing a general positive outcome after the training protocols. In
particular, after one‐year follow‐up evaluation of NW, a higher improvement was reported
23
. Analogously, 35 weeks induce 7.6% increase in dynamic balance 30, such as 4.7%
improvement after 12 weeks 28, even if in a lower extent. The duration of the protocols
seemed to have a role in the magnitude of change, in this case, with higher changes in
longer duration protocol. Finally, static and dynamic balance, simulating activity of daily
life, were quantified using FAS and BBS. In both studies 21, 30, significant improvements
were detected. NW has medium to large effect after 35 weeks intervention 30, while NW
and WT influenced functional balance in the same manner 21.
Muscle strength
NW is characterized by an active involvement of lower and upper limbs, guaranteeing
potential benefits for both upper‐ and lower‐body. Among the five studies aimed to
analyze NW effects on strength, one was defined as a high quality study comparing the
intervention group with a sedentary group 20, and one high quality compared with
resistance group 23, reporting a significant improvement in lower 20, 23 and upper limbs
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strength 20, according to the other two studies founded significant improvement after 12
weeks of NW 28, 31.
Data analysis showed a general improvement of strength in both conditions NW and WT.
Comparing the two modalities, upper‐ and lower‐limb strength were changed with similar
effects, lightly differently from upper‐ and lower‐body. As expected, participants who
underwent WT, showed a positive trend in developing higher lower limb strength (0.36 31.
On the other side, upper limb strength was improved in NW participants (0.36 31). These
results are corroborated if comparing muscular activation, in fact EMG signals showed a
higher percentage of activation of upper limbs in NW, with an inferior activation of lower
limbs 10. From a different perspective, comparing NW vs. RE, both studies after 12 weeks
different findings 28, 29. Lee et al. study showed significant improvement in the overall
strength with larger effects on lower limb and medium effect on upper limbs in favor of
NW 29, contrarily, Takeshima et al. showed significant improvements with small effects on
lower limbs and medium effect in the upper ones in favor to the RE 28. These results could
be due to the difference in the walking surface used in the two studies. In Takeshima et al.
protocol, NW was performed on an asphalt track 28, while Lee performed two session
indoor with treadmill and one session outdoor in hilly park or mountain with a broad
increasing in the muscular commitment 29.
Flexibility
Flexibility, and also the range of motion, plays a key‐role in the development of the
activities of daily living. In this paper, limited findings were reported for the flexibility.
Indeed, only four studies focused on upper and lower limbs flexibility, and only two
compared it with different groups, and baseline evaluations were largely different among
them 20, 28. Lower limbs flexibility has been found significantly improved in two studies, but
Parkatti et al. found a larger improvement despite the shorter training period. Probably,
the introduction of specific stretching exercise and postures in the warm‐up and cool‐
down program, had a pivotal explanation in the progress of this capacity 20. Despite no
significant variations were recorded for the upper‐limb flexibility, ES showed a small to
medium effect on shoulders. In this case, it is likely that the significance in the lower‐limb
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and not in upper‐ flexibility could be ascribed again to the stretching specific intervention,
that was more focused on the lower bodily region than in the upper one 20. This hypothesis
agreed with Kortas et al. taht found a significant improvement only in upper limb flexibility
due to the specific exercise of mobility performed for shoulder, and not for the lower limb
27
.
NW seemed to induce the higher percentage of improvement after 12 weeks of
intervention, compared with WT and RE 28, while, upper limb flexibility improved only in
one study. Takeshima et al. showed significant changes in NW, WT and RE with the higher
percentage in RE 28.
Aerobic capacity, and cardiovascular parameters
Aerobic capacity was largely analyzed in the included studies, comparing NW effects with
SG, WT and RE. In general, the involvement of upper‐ and lower‐limb determined
improvements in the aerobic capacity after NW programs. With more details, NW
produces a small to medium effect (0.46 20), a medium to large effect (0.62 30), and three
large effects (1.11 34, 1.62 28, 1.05 26). One hypothesis for this difference could be endorsed
to the weekly frequency of the training, with larger ES when NW was performed for 3
times per week 26, 28, 34. Comparing NW and RE interventions, improvements were found in
the aerobic capacity for both modalities. As expected, NW intervention showed a medium
to large effect on aerobic capacity compared to RE 28. Figueiredo et al. includes NW and a
WT into a rehabilitation programme to analyze its effect and feasibility. In this way, the
upper limb activity was compared in term of benefit for the aerobic component. Twenty
min. of NW in 2 weekly sessions, for 6‐week, significantly increased the distance scored in
the 6 min. walking test, with a 22.3% improvement in favor of the NW group. 21.
Takeshima and colleagues found similar improvements on the aerobic capacity comparing
NW with WT (10.6%, 10.9%). Although ES showed a small to medium effect in favor to the
WT (‐0.45) 28, this result appeared as unexpected and in contrast with the literature. The
activity (muscular) of the upper body during NW, increased the energy expenditure with
higher oxygen consumption and HR between NW and WT performed at the same walking
speed 10. In Takeshima et al. study, both interventions were performed for all participants
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with a HR range of 100‐120 bpm. This standardized intensity could have affected the
results, because investigators did not consider the subject variability, with a different
exercise stimulus leading to potential different effects of training in each subject 28.
Moreover, in that protocol, the optimal economical individual speed was not considered.
This speed could be different from that of walk, belonging in turn to different training
intensity 10.
Only one study analyzed cardiovascular parameters. NW intervention determined a

positive impact in the OMNI scale, which was similar to the Borg RPE scale, indicating the
bodily adaptive response to the physical effort; this improvement (0.80) took place with a
concurrent improvement in the VO2max (0.70) 34. O‐2 pulse, predictive to assess the efficacy
of cardiovascular parameters, was examined by Vaitkevicious and colleagues, their study
included participants aged ≥ 80 y.o., founding a significant improvement in this parameter
36
after 6‐month of exercise . Choumiuk and colleagues did not find a significant
improvement in the O‐2 pulse after 6 weeks of NW. It is likely that adaptation need longer
periods to be revealed, even if a small to medium effect was found (0.31) 34.
Body composition
NW and WT are two aerobic activities able to ameliorate the body composition in elderly
people. Twelve week of NW induced meaningful change in term of weight loss, BMI and
waist circumference 26, 31, 33. Compared with a SG, the effects were quantified as small to
medium, in the reduction of weight (0.34), BMI (0.33) and body fat percentage (0.43) 26, 31.
The comparison with the walking alone protocol should be interpreted considering that
two studies administered the same intervention (3‐time per week, 50‐60 min. with
progressive intensities monitored through HR and/or RPE), the only difference was the
duration of training which was 8 weeks 32 or 12 31. Fat free mass (FFM) and basal
metabolism were significantly improved in both NW and WT, with greater changes in the
NW group. Effect on FFM was influenced in medium to large effect (0.53), while basal
metabolism in small to medium effect (0.23). BMI, skeletal muscle mass and body fat
percentage showed contrasting findings, despite the two similar exercise protocol.
Probably, the uncontrolled diet could be influenced these results; more concretely, in one
Page 17 of 70

17
paper all improvements were in favor of the NW group 32, in the other in favor of the WT
31
.
Lipid profile and glucose sensitivity
In obese menopausal women, 6 weeks of NW induced a significant reduction of glucose
sensitivity 37. Also in the Kawamoto et al. study, glucose tolerance was significantly
improved after their 12 weeks NW protocol, while no significant changes were recorded
on the lipid profile 33. Despite data appeared as clear, these clinical outcomes needs
deeper analyses and a control group to compare the results. With similar trend also the
interpretation for the lipid profile should be performed since only two studies analyzed the
effects of NW; the first one comparing it with SG and WT. Significant changed after 12
weeks of NW were found in the total cholesterol (0.98), HDL (0.55) and triglycerides (0.43).
Conversely, LDL change was not statistically significant, despite the medium to large effect
on NW (0.75) 31. Comparing NW with WT, TC and LDL resulted as modified with the same
degree of influence, while WT generated a small to medium effect on triglyceride and HDL
31
. At the light of these results, it is not possible to quantify the minimal dose, in term of
frequency and quantity, as well as intensity of NW, to determine a meaningful
improvement in lipid profile.
Quality of life
Cognitive decline, depression and decrease of sleep quality are common age‐related
conditions due to the ageing. About 40‐70% of elderly suffers from chronic sleep
disturbances, with related physical, social, and psychological weakness affecting the
activity of daily living. It has been demonstrated that regular physical activity is associated
with better sleep quality 38. Park et al. found significant improvement after 8 weeks of WT
and NW in the quality of life and sleep quality, both performed from 40% to 75% of HR 32.
According to data reported in another study, regular moderate‐intensity exercise,
performed at 60‐75% of HR, improved the sleep quality in elderly with moderate sleep
complaints, increasing also sleep duration 39.Compared with RE, 12 weeks of NW has larger
effects in quality of life and depression. This large effect could be influenced by the
outdoor sessions of NW, which were potentially implicated as beneficial in the depressive
Page 18 of 70

18
symptomatology than indoor activities 40. Bieler and colleagues analyzed the short and
long effects of NW, RE and Home Exercise (HE) in the quality of life of elderly with hip
osteoarthritis. The main findings was that NW had the major improvement in quality of life
than RE and HE in short and long term 23.
Limitations
There are some limitations that should be considered in the application of our findings.
Firstly, the majority of participants are women. Future studies need to recruit more
gender‐balanced group, with specific intervention effects, included compliance and
dropout ratio. Secondly, the low quality and number of studies limited the reliability of our
consideration. Indeed, only six studies reported a randomization and specified the
homogeneity of groups at baseline and the range of compliance were explicated only in
three studies. The scientific evidences of NW training take advantage from relevant
elements such as intensity and compliance, to quantify the dose response of outcomes
analyzed in this review. Moreover, the environment of the intervention is an important
determinant for the analysis. Indeed, indoor and outdoor exercise can result in different
outcomes, such as the ground (plane or hilly). Finally, the comparison between different
types of training programs potentially limits the analysis of the effects on NW intervention.
Future studies should also better identify intensity and progression targets of the training,
investigating the potential to incorporate NW programs with other exercise modalities to
promote overall wellness in elderly populations, especially for the muscular strength and
balance.
Conclusions
NW can be considered as a safe and accessible form of aerobic exercise for the elderly
population, able to improve aerobic capacity, muscle strength, balance performance and
quality of life. Only one study reported some adverse effects (low back pain, hip pain, and
one fall), thus it can be considered as a safe and advisable activity for elderly. Although
further research is needed, our results indicate that clinicians who consider NW for
exercise prescription are suggested to recommend NW at least twice per week, at

Page 19 of 70
Author Disclosure Statement
No competing financial interests exist.
exercises, especially for the lower limb, and balance exercise, such as PET.
current conditioning. Moreover, NW could be incorporated with supplemental strength
moderate to vigorous rate of perceived exertion (from 13‐14 to 15‐16) depending on
19
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exercise on the parameters of the cardiovascular system in patients over 65 years of age.
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community‐based subjects aged 80 and older: a pilot study. J Am Geriatr Soc. Dec
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37. Wiklund P, Alen M, Munukka E, et al. Metabolic response to 6‐week aerobic
exercise training and dieting in previously sedentary overweight and obese pre‐
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38. Van Someren EJ. Circadian and sleep disturbances in the elderly. Exp Gerontol. Dec
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39. King AC, Oman RF, Brassington GS, et al. Moderate‐intensity exercise and self‐rated
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ncorporated in the exercise prescriptionRejuvenation to increase aerobic capacity, strength and quality of life for elderly: a systematic review and meta-analysis. (doi:
Research
as been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ fro
n the exercise prescription Downloaded capacity,
to increase aerobicby Tuftsstrength and quality
University of life for
package NERLelderly: a systematic
from review and meta-analysis.
online.liebertpub.com (DOI: 10.1089/rej.2017.1921)
at 07/31/17. For personal use only.
reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

(2016)
Citation
Ossowski et al.
Lee et al. (2015)
Kawamoto et al.
Park et al. (2015)
Virág et al. (2015)
Kocur et al. (2015)
Bieler et al. (2016)
Gmiat et al. (2017)
Kortas et al. (2017)
Randomization
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+
+
+
+
+
procedure
Similarity of study
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groups
Inclusion or
Table 1: Quality assessment of the included studies
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exclusion criteria
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Compliance
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Intention‐to‐treat
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Timing of outcomes
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Follow‐up
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Research

Page 25 of 70
(2012)
(2012)
(2013)
(2014)
Chomiuk et al.
Figueiredo et al.
Takeshima et al.
Song et al. (2013)
Parkatti et al. (2012)
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aerobic capacity, strength and quality of life for elderly: a systematic review and meta-analysis. (doi:
Page 26 of 70

For personal use only.

26
Table 2. Characteristics of the included studies
(DOI: 10.1089/rej.2017.1921)
Author Subjects Grouping Training modality, program and intensity Duration and

frequency
at 07/31/17.
Gmiat et al. (2017) 27 elderly mean NW‐MVD Sup NW 12 weeks

age 67 F NW‐LVD Warm‐up: 10’ 60 minute
review and meta-analysis.
Main part: 40’ at the intensity of 60‐70% of maximal 3 d/w
online.liebertpub.com
ability based on 2000m walking test.
Cool down: 10’
Kortas et al. 35 elderly aged > NW (35) Sup NW 12 weeks

a systematic
(2017) 60 Warm‐up: 10’ 60 minute

from
Main part: 40’ at the intensity of 60‐70% of maximal 3 d/w
NERLelderly:
ability based on 2000m walking test. Week 1‐2

of life for
aimed to learn the correct technique and improve

package
flexibility of the upper limb. Week 3‐10 aimed to

and quality
Research
University
improve endurance, with the increase in volume

ncorporated in the exercise prescriptionRejuvenation to increase
Tuftsstrength
(walking kilometers). Week 11‐12 aimed to raise the
level of endurance by intensifying activities and
capacity,
walking at the fastest possible pace.
to increase aerobicby
n the exercise prescription Downloaded
Cool down: 10’
Page 27 of 70


27
Bieler et al. (2016) 152 elderly with HO RCT Sup/NoSup outdoor NW 16 weeks
(DOI: 10.1089/rej.2017.1921)
NW (50) 4‐week familiarization with slower progression. 60 minute

RE (50) Progressive intensity increasing walking distance and 3 d/w (2 Sup – 1
at 07/31/17.
HE (52) speed (12‐14 RPE). NoSup)

Sup/NoSup RE
Warm‐up: 10’ of bike
Main part: 50’ of exercise with machine.
Week 1‐4: Leg press, seated knee extension and
standing position hip extension performed from 50%
a systematic
of MVC (1 bilateral set of 20 repetition; 2 unilateral
from
sets of 15 repetition) to 75% of MVC (1 bilateral set
NERLelderly:
of 10 repetition; 3 unilateral sets of 10 repetition).
of life for
Week 5‐16: training was maintained at 75% of MVC,
package
adjusted every 2 weeks or when participants could

and quality
Research
University
perform more than 10 repetitions.
Tuftsstrength
Week 1‐16: Optional exercise in machine for back

and abdominal muscles, hip abductors, and
capacity,
adductors, and exercise with bands for muscle

groups around the hip.
Page 28 of 70


28
NoSup HE
(DOI: 10.1089/rej.2017.1921)
Exercise for hip range of motion, stretching and

strengthening exercises including a chair stand
at 07/31/17.
exercise, a pelvic‐lift, isometric hip flexion exercise in
the standing position, and gluteus medius muscle
exercise in the side lying position, progressed with

elastic bands and resistance.
Ossowski et al. 45 elderly aged 63‐ RCT Sup outdoor NW 12 weeks
(2016) 79 F NW (22) Warm‐up: 10‐13’ of isotonic exercises with poles to 60 minute
a systematic
CG (23) improve arm, leg, and torso flexibility, static and 3 d/w
from
dynamic balance
NERLelderly:
Main part: 40’ of walking at 50‐70% of HRmax.

of life for
Breathing exercises and isometric exercises with

package
emphasis on the muscles of the lower limbs
and quality
Research
University
Cool‐down: 7‐10’ of static and dynamic stretching
Tuftsstrength
Kocur et al. (2015) 57 elderly aged 65‐ RCT Sup outdoor NW 12 weeks

74 F NW (28) Warm‐up: 10’ of stretching 75 minute
capacity,
WT (29) Main part: 60’ (12‐14 RPE) 3 d/w

Cool‐down: 5’ of stretching
Page 29 of 70


29
NoSup WT
(DOI: 10.1089/rej.2017.1921)
Kortas et al. 37 elderly mean NW (37) Sup outdoor NW 32 weeks

(2015) age 67.7 F Warm‐up: 10’ 60 minute
at 07/31/17.
Main part: 40’ at 60‐70% of maximal ability based on 3 d/w
2000m walking test.
Cool‐down: 10’
Lee et al. (2015) 18 frail elderly aged RCT NW 12 weeks

> 70 NW (8) Week 1‐4: Indoor: walking on a treadmill. Outdoor: 60 minute
RE (10) walking at medium tempo with medium strength in a 3 d/w

a systematic
flat park; (2 times indoor, 1
from
Week 5‐8: Indoor: walking on a treadmill. Outdoor: times outdoor)

NERLelderly:
walking at medium tempo with medium strength in a
of life for
hilly park
package
Week 9‐12: Indoor: walking on a treadmill. Outdoor:
and quality
Research
University
walking at medium tempo with medium strength

Tuftsstrength
around a mountain with broad and low hills.
RE
capacity,
Whole‐body stretching and simple muscle strength

exercises, with the purpose to improve flexibility and
Page 30 of 70


30
muscle strength.
(DOI: 10.1089/rej.2017.1921)
Virág et al. (2015) 82 sedentary Q‐E Warm‐up: 10’ of flexibility exercises 35 weeks

elderly aged > 60 NW (41) Cool‐down: 10’ of stretching and breathing exercise 80 minute
at 07/31/17.
(70 F; 12 M) CG (41) First 10 weeks of supervised training and 25 weeks 2‐3 d/w
of no supervised, with a moderate intensity of 12‐14
RPE.
Park et al. (2015) 24 elderly with RCT NW and WT 8 weeks

depression and NW (12) Warm‐up: 10’ of stretching of muscles related to 50 minute
sleep disturbance WT (12) walking exercise (10 times, 3 sets for each muscle) 3 d/w

a systematic
mean age 75 Main part: 30’. Intensity for both groups was set at
from
40% of HR in the first 4 weeks, at 60% during weeks
NERLelderly:
5‐6 and 75% during weeks 7‐8.
of life for
Cool‐down: 10’
package
Kawamoto et al. 95 sedentary NW Sup NW 12 weeks

and quality
Research
University
(2014) elderly mean age Week 1: learn the correct technique 120 minute

Tuftsstrength
68 Intensity was set in the aerobic work zone. 3 d/w

(84 F; 11 M)
capacity,
Song et al. (2013) 67 sedentary Q‐E Sup NW and WT 12 weeks

elderly aged > 65 NW (21 F) Warm‐up: 10’ of isometric exercises with poles 60 minute
Page 31 of 70


31
F WT (21 F) (NW), or isometric exercises that did not harm the 3 d/w
(DOI: 10.1089/rej.2017.1921)
CG (25 F) knees (WT).
Main exercise: 35’ (week 1 at 11‐12 RPE; week 2‐6 at
at 07/31/17.
13‐14 RPE; week 7‐12 at 15‐16 RPE);
Cool‐down: 15’ of dynamic stretching exercises.
Takeshima et al. 65 sedentary noRCT Sup NW 12 weeks

(2013) elderly aged > 60 NW (17) Warm‐up: 10’ NW + WT: 50‐70

(37 F; 28 M) WT (16) Main part: 30’ (1‐8 weeks) and 40’ (9‐12 weeks). minute
RE (15) Walking performed to moderate to high intensity, 3 d/w

a systematic
CG (17) with an HR of 100‐120 bpm. RE: 50‐60 minute

from
Cool‐down: 10‐15’ 2 d/w
NERLelderly:
Sup WT
of life for
Same protocol of NW, but without poles.
package
Sup RE
and quality
Research
University
Warm‐up: 10‐15’
Tuftsstrength
Main part: 30’. Elastic resistance band exercise for

the major muscle group. The intensity was improved
capacity,
every 2/4 weeks, when the subject was able to

perform 20 repetitions. Intensity was progressively

Page 32 of 70


32
increase from 11‐13 to 15‐17 RPE
(DOI: 10.1089/rej.2017.1921)
Cool‐down: 10‐15’
Figueiredo et al. 26 patients aged RCT Supervised NW and WT 6 weeks
at 07/31/17.
(2012) 65‐92 NW (13) Warm‐up, walking and cool‐down phase. 20 minute

WT (13) Gait speed was determined by the subject, according 2 d/w
to what one felt was a comfortable pace.
Parkatti et al. 37 sedentary RCT Supervised NW 9 weeks

(2012) elderly aged > 65 NW (23) Warm‐up: 5’ of slow walking and stretching. 60 minute
(31 F; 6 M) CG (14) Stretching included heel and toe raise, hip and knee 2 d/w

a systematic
flexion, front and back minilunge, squat kayak

from
forward and backward, triceps extension, open

NERLelderly:
chest, back flexion, step squat, push‐up, straight

of life for
back squat, and forward flex.
package
Central part: 40’ of NW with 10’ of stretching in the
and quality
Research
University
middle
Tuftsstrength
Cool‐down: 5’ slow walking and stretching (warm‐up
exercises).
capacity,
Training intensity was based on subjective RPE, and

subjects were instructed to maintained the 60% of

Page 33 of 70


33
age‐predicted maximal HR.
(DOI: 10.1089/rej.2017.1921)
Chomiuk et al. 68 patients aged > RCT Warm‐up: 10’ 6 weeks

(2012) 65 (60 F; 8 M) NW (50) Main part: 30’ 50 minute
at 07/31/17.
CG (18) Cool‐down: 10’ 3 d/w

Intensity was defined as 60‐70% of maximal HR.

Abbreviation:
RCT: Randomized Controlled Trial; Q‐E: quasi‐experimental; noRCT: no‐completely Randomized Controlled Trial; MVD: Vitamin D concentration
a systematic
more than 20 ng/mL; LVD: Vitamin D concentration less than 20 ng/mL; Sup: Supervised; NoSup: Unsupervised; HO: Hip Osteoarthritis; RPE:
from
Rate of Perceived Exertion; MVC: Maximal Voluntary Contraction; HR: Heart Rate; NW: Nordic Walking; CG: Control Group; WT: Walking
NERLelderly:
Training; RE: Resistance Exercise; HE: Home Exercise; F: Female; M: Male; d/w: day/week
of life for
package

and quality
Research
University
n the exercise prescription Downloaded Tuftsstrength
capacity,
Page 34 of 70


34
Table 3. Results
(DOI: 10.1089/rej.2017.1921)
Gmiat et al. NW‐MVD Muscle strength Muscle strength Static balance

(2017) Isokinetic elbow extension 90° Sit‐to‐stand 30s (rep; Δ%) * EO Path Length (cm/s; Δ%)

at 07/31/17.
Left PKTQ (Nm; Δ%) 21±4; Δ10±15 39±5; Δ‐2±16

26±5; Δ‐4±31 Arm‐curl 30s (rep; Δ%) EO Area95 (cm/s; Δ%) *
Left ag/ant ratio 27±6; Δ9±16 0.6±0.4; Δ3±108

96±19; Δ2±36 Aerobic capacity EC Path Length (cm/s; Δ%)
Right PKTQ (Nm; Δ%) 2’ step test (meters; Δ%) 46±8; Δ5±19

25±4; Δ‐4±25 1032±76; Δ‐2±9 EC Area95 (cm/s; Δ%)
a systematic
Right ag/ant ratio Flexibility 1±1.3; Δ81±123

from
elderly:
101±15; Δ4±18 Back‐scratch (cm; Δ%) SR Path Length (cm/s; Δ%)

NERL
Isokinetic elbow flexion 90° 1±5; Δ‐17±106 134±41; Δ‐4±21

of life for
package
Left PKTQ (Nm; Δ%) Sit‐and‐reach (cm; Δ%) SR Area95 (cm/s; Δ%)

and quality
Research
24±5; Δ‐2±25 11±9; Δ8±143 5.4±2.3; Δ‐4±50

University
to increase
Right PKTQ (Nm; Δ%) Dynamic balance SL Path Length (cm/s; Δ%)

ncorporated in the exercise prescriptionRejuvenation
Tuftsstrength
25±3; Δ0±25 8‐ft up and go (s; Δ%) 143±60; Δ‐6±36

capacity,
Isometric elbow extension 4.62±0.6; Δ‐11±17 SL Area95 (cm/s; Δ%)

Left PKTQ (Nm; Δ%) 6±3.5; Δ‐23±80
28±6; Δ7±43
Research

Page 35 of 70
NW‐LVD
23±4; Δ5±29
33±6; Δ6±13
29±5; Δ0±24
25±7; Δ‐7±21
94±16; Δ9±19
33±8; Δ11±18
102±20; Δ1±30
Muscle strength
Left ag/ant ratio
Right ag/ant ratio
Left PKTQ (Nm; Δ%)
Left PKTQ (Nm; Δ%)
Left PKTQ (Nm; Δ%)
Right PKTQ (Nm; Δ%)
Isometric elbow flexion
Isokinetic elbow flexion 90°
Isokinetic elbow extension 90°
Flexibility
0±6; Δ24±94
21±3; Δ0±21
25±5; Δ‐8±87
Muscle strength
Aerobic capacity
1117±121; Δ‐3±7
Back‐scratch (cm; Δ%)
Arm‐curl 30s (rep; Δ%)
Sit‐and‐reach (cm; Δ%)
2’ step test (meters; Δ%)
Sit‐to‐stand 30s (rep; Δ%)
Δ%)
Δ%)
(cm/s; Δ%)
(cm/s; Δ%)
48±8; Δ4±27
37±5; Δ8±23
Static balance
EC Path Length
EO Path Length
EC Area95 (cm/s;
EO Area95 (cm/s;
0.7±0.3; Δ52±152
35
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36
25±6; Δ‐1±22 7±8; Δ‐14±68 1.1±0.6; Δ33±94
(DOI: 10.1089/rej.2017.1921)
Right PKTQ (Nm; Δ%) Dynamic balance SR Path Length

23±6; Δ6±31 8‐ft up and go (s; Δ%) (cm/s; Δ%)
at 07/31/17.
Isometric elbow extension 4.82±0.5; Δ‐10±8 121±28; Δ‐6±14

Left PKTQ (Nm; Δ%) SR Area95 (cm/s;
26±7; Δ18±30 Δ%)
Right PKTQ (Nm; Δ%) 5.7±1.5; Δ‐11±44
29±7; Δ9±22 SL Path Length
Isometric elbow flexion (cm/s; Δ%)
a systematic
Left PKTQ (Nm; Δ%) 120±22; Δ‐4±16
from
34±7; Δ3±29 SL Area95 (cm/s;
NERLelderly:
Right PKTQ (Nm; Δ%) * Δ%)
of life for
31±8; Δ12±28 4.9±1.2; Δ‐13±48
package
Kortas et al. NW (35) Body composition Lipid profile Dynamic balance

and quality
Research
University
(2017) Weight (kg) TC (mg/dl) 8‐ft up and go (s)

Tuftsstrength
68.4±10 to 68.9±9.4 230.7±46.9 to 231.3±41.6 3.7±0.7 to 3.4±0.6

BMI (kg/m2) HDL (mg/dl) * Muscle strength
capacity,
26.2±3.8 to 26.4±3.6 70.8±19.3 to 75.3±21.1 Sit‐to‐stand 30s

BF (kg) LDL (mg/dl) (rep) *

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37
24±7.5 to 24.3±7.3 137.9±43.5 to 133.9±39.3 21±4 to 23±5
(DOI: 10.1089/rej.2017.1921)
BF (%) TG (mg/dl) Arm‐curl 30s (rep)

34.2±6.6 to 34.6±7.5 110.3±43.1 to 111.1±43.9 29±4 to 30±4
at 07/31/17.
FFM (kg) * Flexibility
44.5±4.2 to 44.7±5.2 Back‐scratch (cm)
TBW (kg) 0±7 to ‐1±8
32.6±3.1 to 32.8±3.8 Sit‐and‐reach (cm)
Aerobic capacity *
2’ step test (meters) * 4±11 to 11±9
a systematic
145±17 to 158±26
from
Bieler et al. NW (50) Muscle strength Aerobic capacity Quality of life

NERLelderly:
(2016) Sit‐to‐stand 30s (rep) 6’ walk (m) Task‐specific self‐

of life for
T0: 14±4.1 T0: 532.9±122.2 efficacy

package
T2m: 15.5 (0.4; 2.7) * T2m: 572.9 (21; 60) * T0: 65.8±30.1

and quality
Research
University
T4m: 15.9 (0.8; 3.0) * T4m: 603.9 (43; 101) * T2m: n.d.

Tuftsstrength
T12m: 16.5 (1.2; 3.7) * T12m: 608.9 (40; 113) * T4m: n.d. **

TSC (s) MOS (rep) T12m: n.d.
capacity,
T0: 10.5±3.3 T0: 21.6±6.9 ASAS pain

T2m: 9.1 (‐2.4; ‐0.3) * T2m: 24.7 (1.1; 5.2) * T0: 63.4±17.9

Research

RE (50)
T0: 5.9±1.6
T0: 13.8±4.2
Muscle strength
Dynamic balance
8‐ft up‐and‐go (s)
T4m: 5 (‐1.4; ‐0.4) *
T2m: 14.2 (‐0.3; 1.2)
T4m: 14.7 (0.2; 1.6) *
T2m: 4.9 (‐1.7; ‐0.3) *
T4m: 8.8 (‐2.9; ‐0.6) *
Sit‐to‐stand 30s (rep)
T12m: 4.7 (‐1.7; ‐0.6) *
T12m: 8.6 (‐3.3; ‐0.5) *
Data n.d.
6’ walk (m)
SF‐36 (score)
Quality of life
T0: 520.3±86.2
Aerobic capacity
T4m: 531.3 (‐7; 29)
T4m: 25 (1.1; 5.6) *
T2m: 521.3 (‐13; 16)
T12m: 26.3 (2.1; 7.4) *
efficacy
T2m: n.d.
T4m: n.d.
T2m: n.d.
T4m: n.d.
T2m: n.d.
T2m: n.d.
T12m: n.d.
T12m: n.d.
T12m: n.d.
symptoms
ASAS other
T0: 85±14.1
T4m: n.d. **
T0: 80.4±6.9
T0: 65.2±24.9
Quality of life
ASAS function
Task‐specific self‐
38
Page 38 of 70
Research

Page 39 of 70
HE (52)
TSC (s)
T0: 5.7±1.4
T0: 9.9±2.3
T12m: 5.2 (‐1; 0)
Muscle strength
Dynamic balance
T4m: 5.3 (‐0.7; 0) *
T4m: 9.3 (‐1.2; 0.1)
T2m: 9.6 (‐0.9; 0.2)
T12m: 9.5 (‐1.3; 0.5)
T12m: 14.9 (‐0.1; 2.2)
T2m: 5.3 (‐0.8; ‐0.1) *
Data n.d.
MOS (rep)
T0: 21.8±6.2
SF‐36 (score)
Quality of life
Aerobic capacity
T4m: 22.8 (‐1.4; 3.4)
T12m: 24.2 (‐0.1; 4.9)
T12m: 526.3 (‐22; 34)
T2m: 23.3 (0.1; 2.8) *
T4m: n.d.
T2m: n.d.
T4m: n.d.
T2m: n.d.
T4m: n.d.
T2m: n.d.
T12m: n.d.
T12m: n.d.
T12m: n.d.
T12m: n.d.
ASAS pain
symptoms
ASAS other
T4m: n.d. **
T0: 79.8±15.9
T0: 86.6±15.6
T0: 67.8±19.5
Quality of life
ASAS function
39
Research

TSC (s)
T0: 10±2.7
T0: 5.7±1.4
T0: 14.6±4.2
Dynamic balance
T2m: 15 (‐0.5; 1.3)
T2m: 5.4 (‐0.8; 0.1)
T4m: 9.3 (‐1.3; 0.0)
T2m: 9.6 (‐1.1; 0.3)
T12m: 5.3 (‐1.1; 0.2)
T12m: 9.4 (‐1.7; 0.6)
T12m: 16 (0.1; 2.8) *
T4m: 15.7 (0.1; 2.0) *
T4m: 5.2 (‐0.8; ‐0.1) *
Data n.d.
MOS (rep)
6’ walk (m)
T0: 22.8±6.1
SF‐36 (score)
Quality of life
T0: 524.7±83.2
T4m: 23 (‐1.9; 2.4)
T4m: 542.7 (‐3; 38)
T2m: 532.7 (‐9; 25)
T12m: 548.7 (‐7; 56)
T2m: 22.1 (‐2.5; 1.1)
T12m: 23.1 (‐3.1; 3.8)
efficacy
T4m: n.d.
T2m: n.d.
T4m: n.d.
T2m: n.d.
T4m: n.d.
T2m: n.d.
T12m: n.d.
T12m: n.d.
T12m: n.d.
ASAS pain
symptoms
ASAS other
T0: 84±13.4
T0: 78.5±15.2
T0: 56.3±16.7
T0: 62.8±26.5
ASAS function
Task‐specific self‐
40
Page 40 of 70
Page 41 of 70


41
T2m: n.d.
(DOI: 10.1089/rej.2017.1921)
T4m: n.d.
T12m: n.d.
at 07/31/17.
Ossowski et NW (23) Body composition Muscle strength Muscle strength

al. (2016) Weight (kg) * PKTQ k‐ext (Nm) * PKTQ k‐flex (Nm)
68.3±9.4 to 67.2±9.2 104.1±29 to 115.6±33.3 *,**

BMI (kg/m2) * Mean PKTQ k‐ext (Nm) * 41.7±14.3 to

26.8±3.9 to 26.4±3.8 98±28.8 to 108.9±32.1 50.9±15.5
SMM (kg) * PKTQ k‐ext/ Weight (Nm/kg) *,** Mean PKTQ k‐flex

a systematic
23.4±2.7 to 23.9±2.8 1.5±0.4 to 1.7±0.4 (Nm) *,**

from
BF (%) * PK‐HG (kg) 38.7±13.7 to

NERLelderly:
36±6.6 to 34.1±6.3 22.7±4 to 23.1±4.4 48.2±15.3

of life for
SMI (kg/m2) * Mean PK‐HG (kg) PKTQ k‐flex/

package
9.1±0.9 to 9.3±0.8 21.5±3.9 to 21.5±4.3 Weight (Nm/kg)

and quality
Research
University
Dynamic balance PK‐HG/ Weight (kg) *,**

Tuftsstrength
TUG (s) * 0.3±0.1 to 0.4±0.1 0.6±0.2 to 1.8±0.2

5.8±0.6 to 5.3±0.8 Aerobic capacity
capacity,
6’ walk (m) *,**
611.2±51.4 to
Page 42 of 70


42
673±55.5
(DOI: 10.1089/rej.2017.1921)
CG (22) Body composition Muscle strength Muscle strength

Weight (kg) PKTQ k‐ext (Nm) * PKTQ k‐flex (Nm)
at 07/31/17.
70.8±10.6 to 70.7±10.7 109.9±26.5 to 104.7±22 39.9±14.2 to

BMI (kg/m2) Mean PK k‐ext (Nm) * 41.3±11.1
27.6±3.1 to 27.5±3.2 104.4±24.8 to 100.3±22.4 Mean PKTQ k‐flex

SMM (kg) PKTQ k‐ext/ Weight (Nm/kg) (Nm) *

23.4±2.4 to 23.4±2.4 1.6±0.3 to 1.5±0.3 37±14.1 to
BF (%) PKTQ‐HG (kg) 39.4±11.2

a systematic
38±5.7 to 38±5.3 22.1±3.4 to 21.3±2.8 PKTQ k‐flex/

from
SMI (kg/m2) Mean PK‐HG (kg) Weight (Nm/kg)

NERLelderly:
9.1±0.5 to 9.1±0.5 20.2±3.2 to 19.2±2.7 0.6±0.2 to 0.6±0.2

of life for
Dynamic balance PK‐HG/ Weight (kg) Aerobic capacity

package
TUG (s) 0.3±0.1 to 0.3±0.1 6’ walk (m)

and quality
Research
University
5.7±0.6 to 5.7±0.6 608.9±79.3 to
Tuftsstrength
600.4±78.6
Kocur et al. NW (28) Static balance Static balance
capacity,
(2015) FwRT (cm) * UwRT (cm) *,**

114.8±3.4 to 115.8±4.6 105.5±5.9 to 107.8±5.5
Page 43 of 70


43
FwRT COP (mm) UwRT COP (mm)
(DOI: 10.1089/rej.2017.1921)
89.05±10.3 to 85.1±9.4 87.13±10.3 to 82±12.2
WT (29) Static balance Static balance
at 07/31/17.
FwRT (cm) * UwRT (cm) *,**
115.9±3.8 to 116.7±4.1 105.2±3.7 to 105.9±4.4
FwRT COP (mm) UwRT COP (mm)
84.8±13.2 to 80.5±13.2 84.6±13.8 to 81.9±12.8
Kortas et al. NW (37) Body composition Body composition Cardiovascular
(2015) Weight (kg) * BF (%) * parameters

a systematic
69.4±10.2 to 68.8±10.6 33±6.4 to 31.4±6.7 VO2max (ml/kg/min)

from
2
BMI (kg/m ) FFM (kg) * *
NERLelderly:
25.6±2.9 to 25.3±3.1 45.8±5.8 to 46.3±5.8 29.7±3.5 to

of life for
BF (kg) * TBW (kg) * 30.4±3.7

package
23±6.5 to 21.7±6.7 33.6±4.2 to 33.9±4.2
and quality
Research
University
Lee et al. NW (8) Static balance Muscle strength Quality of life

Tuftsstrength
(2015) One‐leg stance (s) * Sit‐to‐stand 30s (rep) *,** KHCFAT (sc) *,**

22.4±18.8 to 52.4±28.3 18.9±4.1 to 23.8±3.3 3.2±1.1 to 2.1±1.1
capacity,
Arm‐curl 30s (rep) GDS (sc) *,**
29.8±5.4 to 31.1±3.9 2.3±2.2 to 1.0±1.4
Page 44 of 70


44
RE (10) Static balance Muscle strength Quality of life
(DOI: 10.1089/rej.2017.1921)
One‐leg stance (s) * Sit‐to‐stand 30s (rep) KHCFAT (sc)

25.7±30.5 to 38.0±28.5 19.5±3.0 to 19.7±3.4 3.2±1.7 to 3.4±1.8
at 07/31/17.
Arm‐curl 30s (ep) GDS (sc)
29.4±4.7 to 28.5±4.4 3.5±2.7 to 3.5±2.7
Virág et al. NW (41) Functional balance Aerobic capacity Strength

(2015) FAS (sc) * 2’ step test (rep) * 5‐times Sit‐to‐

T0: 32.2±4.9 T0: 68.1±18.1 stand (s)
T10: 33.1±4.5 T10: 71.5±17.1 T0: 14.2±3.4

a systematic
T35: 34.2±4.5 T35: 74.5±19.4 T10: 14.3±3.4

from
Dynamic balance T35: 13.9±3.5
NERLelderly:
TUG (s)
of life for
T0: 9.2±2.1 *
package
T10: 8.7±1.8
and quality
Research
University
T35: 8.5±1.6
Tuftsstrength
CG (41) Functional balance Aerobic capacity Strength

FAS (sc) 2’ step test (rep) 5‐times Sit‐to‐
capacity,
T0: 32.3±4.7 T0: 66.2±15.3 stand (s)

T10: 32.1±4.7 T10: 64.7±14.8 T0: 13.3±2.4

Research

Page 45 of 70
(2015)
Park et al. NW (12)
TUG (s)
BDI (sc) *
T8: 4.6±1.8
T4: 5.4±1.5
T0: 12.6±3.3
T8: 11.4±2.3
T4: 14.6±2.6
T0: 24.5±4.2
T0: 10.4±2.5
PSQI‐K (sc) *
T10: 10.6±2.5
T35: 31.4±4.4
T35: 10.8±2.5
Quality of life
Dynamic balance
BF (%)
FFM (kg)
SMM (kg)
T8: 20.1±5.1
T4: 22.4±5.8
T0: 25.6±6.7
T8: 54.7±5.5
T4: 52.6±5.0
T0: 50.7±6.6
T8: 35.9±7.5
T4: 30.5±5.8
T0: 27.9±3.7
T35: 63.8±14.6
Body composition

rate (kcal)
T8: 21.8±1.9
T4: 23.1±2.6
T0: 24.9±2.7
BMI (kg/m2)
T10: 13.2±2.4
T35: 13.5±2.3
Basal metabolic
T8: 1557.4±104.5
T4: 1503.9±103.1
T0: 1434.8±113.8
Body composition
45
Research

Kawamoto
et al. (2014)
WT (12)
NW (95)
WC (cm) *
T8: 7.6±3.3
PSQI‐K (sc)
T8: 13.9±2.1
T4: 17.7±3.7
T0: 24.4±4.3
BDI (sc) *,**
Weight (kg) *
Quality of life
T0: 12.3±3.0 *
BMI (kg/m2) *
T4: 8.5±3.0 *,**
Body composition
24.4±3.1 to 23.5±2.8
56.4±9.5 to 54.1±8.7
BF (%)
FFM (kg)
SMM (kg)
LDL (mg/l)
TG (mg/dl)
Lipid profile
T8: 21.8±5.7
T4: 22.4±6.6
T0: 21.8±6.4
T8: 51.5±6.2
T4: 51.3±6.4
T0: 51.9±6.3
T0: 28.8±3.7
95.0 to 99.0
T8: 28.9±4.2
HDL (mg/l) *
T4: 28.5±3.9 **
Body composition
66.0±15.0 to 64.0±15.0
64.0±9.0
HR (bpm)
rate (kcal)
66.0±9.0 to
parameters
T8: 22.3±2.7
T4: 22.6±3.6
T0: 22.6±3.3
BMI (kg/m2)
Brachial SBP
Cardiovascular
Basal metabolic
T8: 1532.1±108.6
T4: 1477.5±137.0
T0: 1493.4±137.9
Body composition
46
Page 46 of 70
Research

Page 47 of 70
86.0±9.2 to 83.9±7.7
HOMA‐IR *
1.19 to 1.07
0.05 to 0.04
Glucose sensitivity
132.0±29.0 to 128.0±32.0
High sensitivity CRP (mg/l) *
(mmHg) *
(mmHg) *
(mmHg) *
(mmHg) *
(mmHg) *
93.0±11.0
74.0±10.0
128.0±22.0
132.0±20.0
131.0±19.0
Radial SBP2
Radial SBP1
97.0±12.0 to
77.0±11.0 to
Brachial DBP
Brachial MAP
134.0±21.0 to
137.0±20.0 to
137.0±20.0 to
47
Page 48 of 70


48
Radial AI75 (%) *
(DOI: 10.1089/rej.2017.1921)
91.4±9.8 to
89.1±8.2
at 07/31/17.
Song et al. NW (21) Body composition Muscle Strength Lipid profile

(2013) Weight (kg) * HG (kg) * TC (mmol/L) *
59.6±5.2 to 58.6±5.2 22.0±4.1 to 24.6±3.9 5.2±0.8 to 4.9±0.8

BMI (kg/m2) * Sit‐to‐stand 30s (rep) * TG (mmol/L) *

24.5±1.7 to 24.0±1.8 16.1±2.5 to 19.7±2.4 1.4±0.5 to 1.3±0.4
TBW (l) Arm‐curl 30s (rep) * HDL (mmol/L) *

a systematic
28.8±2.0 to 28.8±2.4 22.9±2.6 to 27.4±3.0 1.3±0.2 to 1.5±0.3

from
SMM (kg) * LDL (mmol/L)
NERLelderly:
20.6±1.6 to 21.4±1.6 3.7±0.8 to 3.4±0.6
of life for
BF (%) *
package
34.2±4.1 to 32.9±4.4
and quality
Research
University
WT (21) Body composition Muscle Strength Lipid profile

Tuftsstrength
Weight (kg) * HG (kg) * TC (mmol/L) *

57.2±8.8 to 56.4±8.9 22.7±3.6 to 25.2±3.8 5.2±0.7 to 5.0±0.6
capacity,
BMI (kg/m2) Sit‐to‐stand 30s (rep) * TG (mmol/L)

23.2±2.9 to 23.0±3.1 16.6±3.2 to 21.1±4.0 1.3±0.4 to 1.2±0.4

Page 49 of 70


49
TBW (l) Arm‐curl 30s (rep) * HDL (mmol/L)
(DOI: 10.1089/rej.2017.1921)
28.8±4.3 to 29.2±4.4 23.5±3.1 to 26.1±4.1 1.5±0.4 to 1.7±0.5

SMM (kg) * LDL (mmol/L)
at 07/31/17.
20.3±2.6 to 21.2±2.9 3.4±0.8 to 3.5±0.9
BF (%) *
31.9±6.2 to 30.7±5.6
CG (25) Body composition Muscle Strength Lipid profile

Weight (kg) HG (kg) TC (mmol/L)
60.7±6.9 to 60.8±7.1 22.9±4.5 to 21.5±5.5 5.7±0.8 to 5.7±0.8

a systematic
BMI (kg/m2) Sit‐to‐stand 30s (rep) TG (mmol/L)

from
25.0±2.9 to 24.9±3.1 17.1±3.5 to 17.6±2.6 1.6±0.5 to 1.5±0.5

NERLelderly:
TBW (l) * Arm‐curl 30s (rep) HDL (mmol/L)

of life for
29.1±2.9 to 29.7±2.8 22.1±3.4 to 22.6±4.0 1.3±0.3 to 1.3±0.4

package
SMM (kg) LDL (mmol/L)
and quality
Research
University
20.9±1.5 to 21.4±1.7 3.9±0.9 to 3.9±0.7
Tuftsstrength
BF (%)
34.7±5.7 to 34.1±5.9
capacity,
Takeshima NW (17) Muscle Strength Flexibility Dynamic balance

et al. (2013) Sit‐to‐stand 30s (rep) *
Research

WT (16)
Muscle Strength
Aerobic capacity
Aerobic capacity
12’ walk (m) *,**
25.3±3.5 to 26.6±3.2
24.3±4.0 to 26.6±3.9
24.9±4.7 to 27.8±4.4
24.7±6.0 to 27.8±5.4
Arm‐curl 30s (rep) *,**
Sit‐to‐stand 30s (rep) *,**
1142.0±77.0 to 1266.0±89.0
Flexibility
FRT (cm) *
Static balance
SVcomp (deg/sec)
1.0±0.3 to 0.9±0.2
28.7±4.9 to 30.5±2.8
6.9±13.2 to 12.1±11.5
‐8.0±14.2 to ‐6.0±13.7
‐9.2±16.1 to ‐5.1±13.6
Back scratch (cm) *,**
Sit‐and‐reach (cm) *,**
92.4±7.2
78.6±10.6
91.7±9.8 to
75.3±12.2 to
77.6±12.2 to
EPEcomp (%)
EPEcomp (%)
MXEcomp (%)
Dynamic balance
4.5±0.6 to 4.2±0.5
4.3±0.3 to 4.1±0.4
8‐ft up and go (s) *
8‐ft up and go (s) *
50
Page 50 of 70
Research

Page 51 of 70
RE (15)
Muscle Strength
Aerobic capacity
12’ walk (m) *,**
12’ walk (m) *,**
25.7±5.2 to 31.7±4.1
24.2±5.4 to 29.3±4.7
Sit‐to‐stand 30s (rep) *,**
1187.0±97.0 to 1313.0±112.0
1143.0±108.0 to 1180.0±133.0
Flexibility
FRT (cm) *
FRT (cm) *,**
Static balance
Static balance
SVcomp (deg/sec)
1.0±0.3 to 0.9±0.2
‐3.2±9.5 to ‐0.1±9.4
3.1±18.3 to 5.0±17.3
29.0±3.9 to 31.8±5.5
8.2±12.2 to 11.5±12.4
90.8±7.7
75.1±10.0
73.6±10.0
90.7±6.3 to
85.3±10.3 to
69.9±14.7 to
EPEcomp (%)
MXEcomp (%)
MXEcomp (%)
8‐ft up and go (s)
Dynamic balance
4.5±0.5 to 4.2±0.5
51
Research

Figueiredo
CG (17)
NW (13)
12’ walk (m)
Muscle Strength
Aerobic capacity
Aerobic capacity
Arm‐curl 30s (rep)
24.7±4.3 to 25.2±3.5
25.7±6.0 to 27.3±5.1
1099.0±86.0 to 1128.0±77.0
FRT (cm)
Flexibility
Static balance
Back scratch (cm)
SVcomp (deg/sec)
SVcomp (deg/sec)
0.8±0.2 to 0.7±0.1
1.0±0.2 to 1.0±0.2
Sit‐and‐reach (cm)
Functional balance
32.2±3.5 to 31.3±3.9
32.0±6.3 to 35.4±5.4
10.5±11.7 to 9.2±11.8
‐5.7±14.3 to ‐7.1±14.8
97.1±5.0
88.9±8.6
81.6±10.6
92.2±4.9 to
78.6±10.4 to
EPEcomp (%)
Quality of life
MXEcomp (%)
8‐ft up and go (s)
Dynamic balance
4.5±0.5 to 4.5±0.4
52
Page 52 of 70
Page 53 of 70


53
et al. (2012) 6’ walk (m) * BBS (sc.) * Pain (sc)
(DOI: 10.1089/rej.2017.1921)
202.0±84.0 to 247.0±80.0 44.0±5.0 to 46.0±5.0 13.0±20.0 to

5‐m walk test (m/s) * 17.0±20.0
at 07/31/17.
0.7±0.2 to 0.8±0.2 LEFS (sc)
38.0±11.0 to
36.0±11.0
WT (13) Aerobic capacity Functional balance Quality of life

6’ walk (m) * BBS (sc.) * Pain (sc)
217.0±76.0 to 258.0±84.0 39.0±6.0 to 46.0±5.0 15.0±13.0 to

a systematic
5‐m walk test (m/s) 22.0±18.0
from
0.7±0.2 to 0.8±0.3 LEFS (sc)
NERLelderly:
38.0±15.0 to
of life for
39.0±15.0
package
Parkatti et NW (23) Muscle strength Aerobic capacity Flexibility

and quality
Research
University
al. (2012) Sit‐to‐stand 30s (rep) * 2’ step test (rep) * Sit‐and‐reach (cm)

Tuftsstrength
12.4±2.1 to 14.3±2.0 88.3±19.4 to 100.8±8.9 *
Arm‐curl 30s (rep) * Dynamic balance 5.3±11.4 to
capacity,
14.2±3.6 to 17.0±2.5 8‐ft up and go (s) 10.2±8.9

6.1±1.0 to 5.5±0.9 Back scratch (cm)
Page 54 of 70


54
‐6.3±8.7 to ‐
(DOI: 10.1089/rej.2017.1921)
5.2±8.3
CG (14) Muscle strength Aerobic capacity Flexibility
at 07/31/17.
Sit‐to‐stand 30s (rep) 2’ step test (rep) Sit‐and‐reach (cm)

13.6±2.6 to 13.9±2.6 94.3±18.7 to 95.0±16.5 10.3±14.1 to
Arm‐curl 30s (rep) Dynamic balance 10.6±14.4

15.7±3.6 to 16.0±3.3 8‐ft up and go Back scratch (cm)

5.6±0.6 to 5.6±0.6 ‐1.3±8.7 to ‐
2.4±9.6
a systematic
Chomiuk et NW (50) Cardiovascular parameters Cardiovascular parameters Cardiovascular

from
al. (2012) Load AP (W) Time AT (min) parameters

NERLelderly:
60.5±17.3 to 57.9±15.2 5.2±1.7 to 5.0±1.5 SBP (mmHg) *

of life for
Duration of effort (min) * O2‐pulse 134.6±13.1 to

package
7.1±1.9 to 8.1±1.8 8.8±2.3 to 10±3.7 129.7±11.8

and quality
Research
University
Max effort load (W) * VO2max (ml/kg/min) * DBP (mmHg)

Tuftsstrength
80.1±19.8 to 90.8±18.3 15.4±3.9 to 17.5±3.6 75.7±8.5 to

HR/24h (beats/min) 73.2±8.0
capacity,
6’ walk (m) *
Page 55 of 70


55
537.9±68.0 to
(DOI: 10.1089/rej.2017.1921)
612.9±80.9
CG (18) Cardiovascular parameters Cardiovascular parameters Cardiovascular
at 07/31/17.
Load AP (W) Time AT (min) parameters

62.1±11.0 to 57.5±11.8 5.4±1.1 to 5.1±1.3 SBP (mmHg)
Duration of effort (min) O2‐pulse 122.0±12.8 to

7.1±2.2 to 6.5±2.4 8.5±3.1 to 8.9±2.8 122.3±13.8

Max effort load (W) VO2max (ml/kg/min) DBP (mmHg)
80.7±22.3 to 74.6±24.1 14.8±3.5 to 14.6±5.2 70.7±8.4 to

a systematic
HR/24h (beats/min) 71.4±8.5
from
NERLelderly:
6’ walk (m)
of life for
519.8±77.1 to
package
522.2±81.6
and quality
Research
University

Tuftsstrength
Abbreviations: p < 0.05 * within group comparison, ** between groups comparison
Data are expressed as mean ± standard deviation; Δ (observed change mean) ± standard deviation; mean ± (confidence interval)
capacity,
NW: Nordic Walking; CG: Control Group; WT: Walking Training; RE: Resistance Exercise; HE: Home Exercise MVD: Vitamin D concentration
more than 20 ng/mL; LVD: Vitamin D concentration less than 20 ng/mL
Page 56 of 70


56
T0: test at baseline; T10: test after 10 weeks; T35: test after 35 weeks; T4: test after 4 weeks; T8: test after 8 weeks; T2m: test after 2 months; T4m:
(DOI: 10.1089/rej.2017.1921)
test after 4 months; T12m: test after 12 months;
PKTQ: Peak Torque; ag/ant: agonist/antagonist; EO: Eyes Open; EC: Eyes Closed; SR: Single Right; SL: Single Left; BMI: Body Mass Index; BF:
at 07/31/17.
Body Fat; FFM: Fat Free Mass; TBW: Total Body Water; TC: Total Cholesterol; HDL: High Density Lipoprotein; LDL: Low Density Lipoprotein; TG:
Triglyceride; TSC: Time 10‐steps climbing test; MOS: 15s marching on the spot; n.d.: not displayed; SF‐36: Medical Outcomes Study Short Form;
ASAS: The Arthritis Self‐Efficacy Scale; k‐ext: knee extension; PK: Peak; HG: Handgrip test; k‐felx; knee flexion; SMM: Skeletal Muscle Mass;
SMI: Skeletal Muscle Mass Index; TUG: Time Up and Go; FwRT: Forward Reach Test; COP: Center of Pressure; UwRT: Upward Reach Test;
KHCFAT: Korean Health Compliance Frailty Assessment Tool for the Elderly; GDS: Geriatric Depression Scale; FAS: Fullerton Advanced Balance
Scale; BDI: Back Depression Inventory; PSQI‐K: Korean version of Pittsburgh Sleep Quality Index; WC: Waist Circumference; CRP: C‐reactive
a systematic
protein; HOMA‐IR: Homeostasis of Model Assessment of Insulin Resistance; HR: Heart Rate; SBP: Systolic Blood Pressure; DBP: Diastolic Blood
from
Pressure; MAP: Mean Arterial Pressure; SBP1: first peak radial Systolic Blood Pressure; SBP2: second peak Diastolic Blood Pressure; AI75:
NERLelderly:
Augmentation Index corrected at heart rate 75 per minute; FRT: Functional Reach Test; SVcomp: mean of the four condition of Clinical Test of
of life for
Sensory Interaction for Balance; EPEcomp: Endpoint Excursion; MXEcomp: Maximum Excursion; BBS: Berg Balance Scale; LEFS: Lower
package
Extremity Functional Scale; AP: anaerobic point; AT: Anaerobic threshold; HR/24h: Heart Rate of 24 hour
and quality
Research
University

Tuftsstrength

capacity,
Research

Page 57 of 70

(2016)
Ossowski et al.
Bieler et al. (2016)
Gmiat et al. (2017)
BF (%)
SMM (kg)
Weight (kg)
SMI (kg/m2)
BMI (kg/m2)
No SG
No SG
No SG
NW vs SG
0.66 [0.06, 1.26]
0.29 [‐0.29, 0.88]
0.18 [‐0.41, 0.76]
0.33 [‐0.26, 0.92]
0.34 [‐0.25, 0.93]
Body composition
IV, Random, 95% CI
St. Mean Difference

No WT
No WT
No WT
NW vs WT
IV, Random, 95% CI
St. Mean Difference

No RE
No RE
NW vs RE
the analysis
Tabella 4: Effect Size of Nordic Walking compared with Sedentary Group, Walking Training and Resistance Exercise
IV, Random, 95% CI
St. Mean Difference
No data available for
57
Research

(Nm)
TUG (s)
(Nm/kg)
PK‐HG (kg)
0.6 [0.00, 1.20]
0.6 [0.00, 1.20]
0.3 [‐0.29, 0.89]
Muscle strength
0.64 [0.04, 1.24]
PKTQ k‐ext (Nm)
Dynamic balance
PKTQ k‐flex (Nm)
0.49 [‐0.11, 1.08]
0.38 [‐0.21, 0.97]
0.55 [‐0.05, 1.14]
Mean PK‐HG (kg)
Mean PHTQ k‐ext
PK‐HG/Weight (kg)
PKTQ k‐ext/Weight
58
Page 58 of 70
Research

Page 59 of 70
Kocur et al. (2015)

(Nm)
(Nm/kg)
6’ walk (m)
0.7 [0.09, 1.3]
0.9 [0.28, 1.51]
1.05 [0.42, 1.68]
0.64 [0.04, 1.24]
Aerobic capacity
Mean PHTQ k‐flex
PKTQ k‐flex/Weight
FwRT (cm)
UwRT (cm)
Static balance
0.38 [‐0.15, 0.9]
FwRT COP (mm)
‐0.2 [‐0.72, 0.32]
UwRT COP (mm)
‐0.01 [‐0.53, 0.51]
‐0.39 [‐0.92, 0.13]

59
Research

Lee et al. (2015)
Virág et al. (2015)
FAS
TUG
No SG
1.09 [0.62, 1.55]
Dynamic balance
Functional balance

No WT

GDS
KHCFAT
Arm‐curl 30s
Quality of life
No RE
Static balance
One‐leg stance
Sit‐to‐stand 30s
Muscle strength
1.07 [0.06, 2.08]
1.16 [0.14, 2.19]
0.81 [‐0.17, 1.78]
0.59 [‐0.36, 1.55]
0.48 [‐0.46, 1‐43]
60
Page 60 of 70
Research

Page 61 of 70
Park et al. (2015)

2’ step test
0.62 [0.17, 1.06]
Muscle strength
0.62 [0.18, 1.07]
Aerobic capacity
‐0.13 [‐0.57, 0.30]
5‐times Sit‐to‐stand
BF
BDI
FFM
SMM
PSQI‐K
Quality of life
1.11 [0.24, 1.98]
1.09 [0.22, 1.96]
1.10 [0.23, 1.97]
0.30 [‐0.50, 1.11]
0.53 [‐0.29, 1.34]
Body composition

61
Research

(2014)
Kawamoto et al.
Song et al. (2013)
HG
BMI
TBW
No SG
Weight
Arm‐curl 30s
Muscle strength
1.32 [0.67, 1.96]
0.82 [0.22, 1.43]
0.63 [0.03, 1.23]
0.34 [‐0.24, 0.93]
0.34 [‐0.24, 0.93]
Body composition
HG
BMI
BMI
TBW
No WT
Weight
Arm‐curl 30s
Muscle strength
‐0.42 [‐1.03, 0.2]
0.36 [‐0.26, 0.97]
0.23 [‐0.57, 1.03]
0.21 [‐0.60, 1.01]
Body composition
‐0.39 [‐1.00, 0.22]
‐0.30 [‐0.90, 0.31]
‐0.15 [‐0.76, 0.45]
Basal metabolic rate

No RE
62
Page 62 of 70
Research

Page 63 of 70
(2013)
Takeshima et al.
BF
TC
LDL
FRT
HDL
SMM
SVcomp
Triglyceride
Lipid profile
Static balance
0.75 [0.15, 1.35]
0.98 [0.37, 1.60]
0.55 [‐0.04, 1.14]
0.43 [‐0.16, 1.02]
0.22 [‐0.36, 0.81]
0.00 [‐0.58, 0.58]
0.34 [‐0.25, 0.92]
‐0.23 [‐0.90, 0.44]
‐1.24 [‐1.98, ‐0.49]
BF
TC
LDL
FRT
HDL
SMM
SVcomp
Triglyceride
Lipid profile
Static balance
0.00 [‐0.68, 0.68]
0.13 [‐0.48, 0.73]
0.14 [‐0.47, 0.74]
0.08 [‐0.52, 0.69]
0.11 [‐0.49, 0.72]
‐0.29 [‐0.98, 0.39]
‐0.48 [‐1.09, 0.14]
‐0.25 [‐0.85, 0.36]
‐0.43 [‐1.04, 0.18]
FRT
SVcomp
Static balance
0.49 [‐0.22, 1.19]
‐1.13 [‐1.89, ‐0.38]
63
Page 64 of 70


64
Dynamic balance Dynamic balance Dynamic balance
(DOI: 10.1089/rej.2017.1921)
8‐ft up and go 8‐ft up and go 8‐ft up and go

0.98 [0.26, 1.69] 0.22 [‐0.47, 0.90] 0.22 [‐0.48, 0.91]
at 07/31/17.
EPEcomp EPEcomp EPEcomp

‐0.28 [‐0.95, 0.4] 0.47 [‐0.22, 1.17] 0.33 [‐0.37, 1.03]
MXEcomp MXEcomp MXEcomp

‐0.74 [‐1.44, ‐0.04] 0.21 [‐0.48, 0.89] 0.43 [‐0.27, 1.14]

Muscle strength Muscle strength Muscle strength
Sit‐to‐stand 30s Sit‐to‐stand 30s Sit‐to‐stand 30s

a systematic
0.09 [‐0.58, 0.77] 0.25 [‐0.44, 0.93] ‐0.29 [‐0.99, 0.41]

from
Arm‐curl 30s Arm‐curl 30s Arm‐curl 30s

NERLelderly:
0.64 [‐0.05, 1.33] 0.30 [‐0.38, 0.99] ‐0.89 [‐1.62, ‐0.16]

of life for
Flexibility Flexibility Flexibility

package
Back scratch Back scratch Back scratch

and quality
Research
University
‐0.14 [‐0.81, 0.54] ‐0.06 [‐0.75, 0.62] 0.41 [‐0.29, 1.11]

Tuftsstrength
Sit‐and‐reach Sit‐and‐reach Sit‐and‐reach

0.24 [‐0.43, 0.92] 0.47 [‐0.22, 1.17] 0.05 [‐0.65, 0.74]
capacity,
Aerobic capacity Aerobic capacity Aerobic capacity

12’ walk test 12’ walk test 12’ walk test

Research

Page 65 of 70
(2012)
Figuiredo et al.
Parkatti et al. (2012)

8‐ft up and go
Muscle strength
1.62 [0.83, 2.41]
Dynamic balance
0.12 [‐0.54, 0.79]

BBS
Pain
LEFS
6’ walk
Quality of life
5‐m walk test
Aerobic capacity
0.25 [‐0.52, 1.03]
0.00 [‐0.77, 0.77]
0.00 [‐0.77, 0.77]
‐0.45 [‐1.15, 0.24]
‐0.22 [‐0.99, 0.55]
‐0.13 [‐0.90, 0.64]
Functional balance

0.75 [0.03, 1.47]
65
Research

Load AP
Flexibility
2’ step test
6’ walk test
parameters
Back scratch
Arm‐curl 30s
Sit‐and‐reach
Cardiovascular
1.11 [0.53, 1.68]
Chomiuk et al. (2012) Aerobic capacity
Aerobic capacity
0.46 [‐0.21, 1.14]
0.03 [‐0.51, 0.57]
0.31 [‐0.36, 0.98]
0.35 [‐0.32, 1.02]
0.17 [‐0.49, 0.84]
Duration of effort
‐0.03 [‐0.70, 0.63]

66
Page 66 of 70
Research

Page 67 of 70
Static balance
Dynamic balance
Functional balance
Upper limb muscle
SBP
DBP
HR/24
Time AT
VO2max
O2‐pulse
Max effort load
0.70 [0.15, 1.26]
0.80 [0.25, 1.36]
0.80 [0.25, 1.36]
0.35 [‐0.19, 0.89]
0.31 [‐0.23, 0.85]
‐0.07 [‐0.61, 0.47]
‐0.59 [‐1.14, ‐0.04]
‐0.59 [‐1.14, ‐0.04]
0.62 [0.18, 1.07]
0.66 [0.43, 0.90]
0.30 [‐0.28, 0.88]
‐0.72 [‐1.70, 0.26]
0.00 [‐0.77, 0.77]
0.30 [‐0.10, 0.70]
0.16 [‐0.21, 0.52]
‐0.08 [‐0.31, 0.15]

0.33 [‐0.08, 0.73]
‐0.18 [‐1.64, 1.27]
‐0.07 [‐1.16, 1.03]
67
Page 68 of 70


68
strength
(DOI: 10.1089/rej.2017.1921)
Lower limb muscle 0.43 [0.20, 0.66] ‐0.10 [‐0.75, 0.55] 0.39 [‐1.03, 1.8]

strength
at 07/31/17.
Upper limb flexibility 0.09 [‐0.39, 0.56] ‐0.06 [‐0.75, 0.62] 0.41 [‐0.29, 1.11]

Lower limb flexibility 0.10 [‐0.37, 0.58] 0.47 [‐0.22, 1.17] 0.05 [‐0.65, 0.74]
Aerobic capacity 0.92 [0.56, 1.28] ‐0.21 [‐0.64, 0.21] 0.75 [0.03, 1.47]

Cardiovascular 0.23 [‐0.08, 0.55]
outcomes
Body composition 0.30 [0.12, 0.49] 0.07 [‐0.23, 0.36]

a systematic
Lipid profile 0.67 [0.37, 0.97] ‐0.11 [‐0.41, 0.19]

from
Quality of life 0.53 [‐0.11, 1.17] 0.93 [0.23, 1.64]

NERLelderly:
Depression 1.10 [0.23, 1.97] 1.07 [0.06, 2.08]

of life for
package
Frailty Index 0.81 [‐0.17, 1.78]
and quality
Research
Sleep quality 1.09 [0.22, 1.96]
University
to increase
Abbreviation
ncorporated in the exercise prescriptionRejuvenation
Tuftsstrength
NW: Nordic Walking; SG: Sedentary Group; WT: Walking Traning; RE: Resistance Exercise; CI: Confidence Interval; BMI: Body Mass Index; SMM:
capacity,
Skeletal Muscle Mass; BF: Body Fat; SMI: Skeletal Muscle Mass Index; TUG: Time Up and Go; PKTQ: Peak Torque; k‐ext: knee extension; PK:
Peak; HG: Handgrip test; k‐felx; knee flexion; FwRT: Forward Reach Test; COP: Center of Pressure; UwRT: Upward Reach Test; KHCFAT: Korean
Health Compliance Frailty Assessment Tool for the Elderly; GDS: Geriatric Depression Scale; TUG: Time Up and Go; FAS: Fullerton Advanced
Research

Page 69 of 70
Systolic Blood Pressure; DBP: Diastolic Blood Pressure.
Balance Scale; LEFS: Lower Extremity Functional Scale; AP: anaerobic point; AT: Anaerobic threshold; HR/24h: Heart Rate of 24 hour; SBP:
Water; LDL: Low Density Lipoprotein; HDL: High Density Lipoprotein; TC: Total Cholesterol; FRT: Functional Reach Test; SVcomp: mean of the
Balance Scale; BDI: Back Depression Inventory; PSQI‐K: Korean version of Pittsburgh Sleep Quality Index; FFM: Fat Free Mass; TBW: Total Body
four condition of Clinical Test of Sensory Interaction for Balance; EPEcomp: Endpoint Excursion; MXEcomp: Maximum Excursion; BBS: Berg
69

Figure legends
Fig. 1: Flow chart of the literature research

70
Page 70 of 70

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ordic Walking can be incorporated in the exercise prescription to increase aerobic capacity, strength and quality of life for

elderly: a systematic review and meta-analysis. (doi: 10.1089/rej.2017.192 Rejuvenation Research

16 weeks (13.3% 23) and one‐year follow‐up (14.3% 23). 12’ walk test increased by 10.9% 28

Glucose sensitivity showed significant modification with a concurrent reduction in C‐

Also improvements in sleep quality (63.5% 32) and frailty index (34.4% 29) were found. In

Only one study analyzed cardiovascular parameters. NW intervention determined a

responses: comparison between outdoor and indoor training. Menopause. Jul

control and gait parameters of women between the age 65 and 74: a randomized trial. J

29. Lee HS, Park JH. Effects of Nordic walking on physical functions and depression in

Author Subjects Grouping Training modality, program and intensity Duration and

Gmiat et al. (2017) 27 elderly mean NW‐MVD Sup NW 12 weeks

Kortas et al. 35 elderly aged > NW (35) Sup NW 12 weeks

(2017) 60 Warm‐up: 10’ 60 minute

ability based on 2000m walking test. Week 1‐2

aimed to learn the correct technique and improve

flexibility of the upper limb. Week 3‐10 aimed to

improve endurance, with the increase in volume

NW (50) 4‐week familiarization with slower progression. 60 minute

HE (52) speed (12‐14 RPE). NoSup)

adjusted every 2 weeks or when participants could

Week 1‐16: Optional exercise in machine for back

adductors, and exercise with bands for muscle

Exercise for hip range of motion, stretching and

exercise in the side lying position, progressed with

Main part: 40’ of walking at 50‐70% of HRmax.

Breathing exercises and isometric exercises with

Kocur et al. (2015) 57 elderly aged 65‐ RCT Sup outdoor NW 12 weeks

WT (29) Main part: 60’ (12‐14 RPE) 3 d/w

Kortas et al. 37 elderly mean NW (37) Sup outdoor NW 32 weeks

Lee et al. (2015) 18 frail elderly aged RCT NW 12 weeks

RE (10) walking at medium tempo with medium strength in a 3 d/w

Week 5‐8: Indoor: walking on a treadmill. Outdoor: times outdoor)

walking at medium tempo with medium strength

Whole‐body stretching and simple muscle strength

Virág et al. (2015) 82 sedentary Q‐E Warm‐up: 10’ of flexibility exercises 35 weeks

Park et al. (2015) 24 elderly with RCT NW and WT 8 weeks

sleep disturbance WT (12) walking exercise (10 times, 3 sets for each muscle) 3 d/w

Kawamoto et al. 95 sedentary NW Sup NW 12 weeks

(2014) elderly mean age Week 1: learn the correct technique 120 minute

68 Intensity was set in the aerobic work zone. 3 d/w

Song et al. (2013) 67 sedentary Q‐E Sup NW and WT 12 weeks

Takeshima et al. 65 sedentary noRCT Sup NW 12 weeks

(2013) elderly aged > 60 NW (17) Warm‐up: 10’ NW + WT: 50‐70

RE (15) Walking performed to moderate to high intensity, 3 d/w

CG (17) with an HR of 100‐120 bpm. RE: 50‐60 minute

Main part: 30’. Elastic resistance band exercise for

every 2/4 weeks, when the subject was able to

perform 20 repetitions. Intensity was progressively

(2012) 65‐92 NW (13) Warm‐up, walking and cool‐down phase. 20 minute

Parkatti et al. 37 sedentary RCT Supervised NW 9 weeks

(31 F; 6 M) CG (14) Stretching included heel and toe raise, hip and knee 2 d/w

flexion, front and back minilunge, squat kayak

forward and backward, triceps extension, open

chest, back flexion, step squat, push‐up, straight

Training intensity was based on subjective RPE, and

subjects were instructed to maintained the 60% of

Chomiuk et al. 68 patients aged > RCT Warm‐up: 10’ 6 weeks

CG (18) Cool‐down: 10’ 3 d/w

Gmiat et al. NW‐MVD Muscle strength Muscle strength Static balance

(2017) Isokinetic elbow extension 90° Sit‐to‐stand 30s (rep; Δ%) * EO Path Length (cm/s; Δ%)

Left PKTQ (Nm; Δ%) 21±4; Δ10±15 39±5; Δ‐2±16

Left ag/ant ratio 27±6; Δ9±16 0.6±0.4; Δ3±108

Right PKTQ (Nm; Δ%) 2’ step test (meters; Δ%) 46±8; Δ5±19