Periodized and non-periodized resistance training programs on body composition and physical function of older women

Experimental Gerontology 121 (2019) 10–18

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Periodized and non-periodized resistance training programs on body composition and physical function of older women

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Hélio José Coelho-Júniora,b, , Ivan de Oliveira Gonçalvezc, Ricardo Aurélio Carvalho Sampaioa, Priscila Yukari Sewo Sampaioa, Eduardo Lusa Cadored, Mikel Izquierdoe, Emanuele Marzettib,f, Marco Carlos Uchidaa a Applied Kinesiology Laboratory–AKL, School of Physical Education, University of Campinas, Av. Érico Veríssimo, 701, Cidade Universitária “Zeferino Vaz”, Barão Geraldo, CEP: 13.083-851 Campinas, SP, Brazil b Università Cattolica del Sacro Cuore, Rome, Italy c Center of Health Sciences, University of Mogi das Cruzes, Mogi das Cruzes, Brazil d School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil e Department of Health Sciences, Public University of Navarre, CIBERFES (CB16/10/00315), Pamplona, Navarre, Spain f Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy

A R T I C LE I N FO

A B S T R A C T

Section Editor: Christiaan Leeuwenburgh

Background and purpose: Although combining classical resistance (RT) and power training (PT) might be an efficient strategy to achieve optimal enhancements in body composition and physical function in older adults, the most effective approach to combine these different types of exercise training is still unknown. Periodization, an organizational model that refers to a succession of cycle that will vary in exercise intensity and/or volume to allow for the training stimulus to remain biologically challenging and effective, may represent an interesting approach. Among the different types of periodization, daily undulating periodization (DUP) has attracted considerable attention given its superiority in comparison to nonperiodized (NP) RT programs to elicit neuromuscular improvements in young adults. However, whether a DUP program combining PT and traditional RT can produce similar or greater improvements in body composition and physical function in older adults than a NP RT program has not yet been established. Therefore, the present study compared the effects of a DUP and NP programs on body composition and physical function in healthy community-dwelling older women. Methods: Forty-two older women (60–79 years) were randomized into one of the three experimental groups: NP, DUP, and control group (CG). Body composition and physical function were assessed at baseline and after the intervention. The sessions of exercises were performed twice a week over 22 weeks. In NP, the two exercise sessions were based on three sets of 8–10 repetitions at a “difficult” intensity (i.e., 5–6) prescribed based on the Rating of Perceived Exertion (RPE) scale. In DUP, the first session was based on PT (three sets of 8–10 repetitions at a “moderate” intensity, i.e., 3, performed as fast as possible), while the second session was similar to the NP. Results: There were no significant changes in body composition in any of the groups. Relative to baseline, participants assigned to NP showed significant improvements in countermovement jump (+55.7%), timed “Up and Go” (TUG) test (−43.2%, faster), walking speed (+12.0%), and one-leg-stand (+154.5%). In contrast, DUP only improved TUG performance (−53.2%, faster). Conclusion: NP and DUP improved physical function in community-dwelling older women, with greater improvements in physical parameters only observed after NP.

Keywords: Elderly Power training Sarcopenia Frailty Muscle mass Mobility

Abbreviations: 1RM, 1-repetition maximum; ACSM, American College of Sports and Medicine; ANOVA, analysis of variance; BI, Baumgartner index; BMI, body mass index; CG, control group; DUP, daily undulating periodization; ES, effect size; FES-I, Falls Efficacy Scale-International; HC, hip circumference; IHG, isometric hand grip; JI, Janssen index; KCL, Kihon checklist; NP, non-periodized; PT, power training; RM, repetition maximum; RPE, rating of perceived exertion; RT, resistance training; TUG, timed “Up and Go”; WC, waist circumference ⁎ Corresponding author at: Applied Kinesiology Laboratory–AKL, School of Physical Education, University of Campinas, Avenida Érico Veríssimo, 701, Cidade Universitária “Zeferino Vaz”, Barão Geraldo, CEP 13.083-851 Campinas, State of São Paulo, Brazil. E-mail address: [email protected] (H.J. Coelho-Júnior). https://doi.org/10.1016/j.exger.2019.03.001 Received 11 January 2019; Received in revised form 23 February 2019; Accepted 4 March 2019 Available online 09 March 2019 0531-5565/ © 2019 Published by Elsevier Inc.

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1. Introduction

greater adaptations when compared with a high-intensity NP RT, while the older individuals are submitted to a low cardiovascular and osteoarticular stress (Coelho-Júnior et al., 2017a, 2017b, 2018). To the best of our knowledge, whether a DUP program combining PT and traditional RT can produce similar or greater improvements in body composition and physical performance in older adults than a NP RT program has not yet been established. Therefore, the present study aimed at investigating the effects of two different RT programs — NP and DUP — on body composition and physical function in communitydwelling older women. Our hypothesis was that DUP would cause similar or greater improvements in body composition and physical function of older adults than NP.

Substantial reductions in functional capacity are commonly observed during aging. Although a high prevalence of disability is observed in both genders, older women seem to be most frequently and severely affected (Leveille et al., 2000). Women are therefore at higher risk of poor health-related outcomes, such as sarcopenia, frailty, and disability (Beard et al., 2016). Physical exercise, mainly resistance training (RT), is recommended by the American College of Sports and Medicine (ACSM) (ChodzkoZajko et al., 2009) and many research groups (Marzetti et al., 2017; Phu et al., 2015) as a primary remedy to counteract sarcopenia in older adults. According to the ACSM position stand, traditional RT programs based on 8–10 exercises with 2–3 sets of 8–12 repetitions performed at moderate to high intensity involving major muscle groups should be performed by older adults at least twice weekly (Chodzko-Zajko et al., 2009). Compelling evidence indicates that muscle power — the capacity to generate strength in a short-time interval — shows earlier and greater declines during the aging process relative to muscle strength and muscle mass (Lauretani et al., 2003). This neuromuscular characteristic deserves concern since some aspects of physical function are more dependent on muscle power than on strength (e.g., gait speed, stair climbing) (Reid and Fielding, 2012). Hence, based on the principle of specificity, which states that improvements in a physical capability will occur if the program of exercise includes exercises for that specific skill, the prescription of RT for older adults should also include power training (PT) (Cadore and Izquierdo, 2018). PT is a type of non-fatiguing RT in which concentric muscle contractions are performed as fast as possible at light-to-moderate loads (Izquierdo et al., 1999). Because of these characteristics, it seems plausible to assume that light-to-moderate PT may elicit lower cardiovascular and osteoarticular stress (Coelho-Júnior et al., 2017a, 2017b, 2018), avoid pain (e.g., delayed onset muscle soreness) (Uchida et al., 2009), and improve exercise adherence, being especially attractive to older adults. In addition, it is worth mentioning that even though PT is performed at lower intensities than RT, it may induce similar (Henwood et al., 2008) or greater (Miszko et al., 2003) neuromuscular adaptations in some physical function tests. Based on these premises, the combination of RT and PT has been recommended (Chodzko-Zajko et al., 2009) as an efficient strategy to exercise programs which aim to achieve optimal enhancements in body composition and physical function in older adults (Hakkinen et al., 1998; Häkkinen et al., 2002; Newton et al., 2002). However, the most effective approach to combine RT and PT exercises is still unknowledge. In this regard, RT periodization, a systematic organizational process of altering the training variables (e.g., volume, rest, intensity) over time to allow for the training stimulus to remain biologically challenging and effective, while minimizing the potential for injuries (Chodzko-Zajko et al., 2009; Issurin, 2010; Williams et al., 2017), may represent an interesting approach. Different types of RT periodization have been devised and tested for effectiveness and applicability in the last decades (Williams et al., 2017). One that has attracted considerable attention is the daily undulating periodization (DUP) model (Poliquin, 1988), which is characterized by marked changes in the training phases within a microcycle (Issurin, 2010). Some evidence has proposed a slight superiority of DUP to elicit neuromuscular adaptations when compared with non-periodized (NP) and other models of periodization in young adults (Rhea et al., 2002; Simão et al., 2012), while investigations have shown similar improvements after DUP and NP RT programs in older adults (Conlon et al., 2016, 2017; Hunter et al., 2001). However, none of the studies has included PT in the DUP program. In our view, PT fits perfectly in a DUP program, because a session at light-to-moderate load is already part of the program, and a DUP program composed of PT and traditional RT may promote similar or

2. Material and methods 2.1. Study design and participants This was an interventional, controlled, single-blind randomized study that aimed at investigating the effects of two different models of RT on body composition and physical function in a sample of community-dwelling older women. No participants were aware of the treatment assignments for the duration of the study, while all researchers, including evaluators, exercise supervisors, and those responsible for statistical analysis knew where the participants were allocated. Ethics approval was granted by the University of Campinas Human Research Ethics Committee (Protocol No. 835.733). All participants provided written informed consent prior to participating. All study procedures were conducted following the principles of the Declaration of Helsinki. The study was registered as a clinical trial in Clinicaltrial.gov (identifier: NCT03443375). Volunteers were recruited through advertisements from the Center for Older Adults of the city of Poá, SP, Brazil, prior to cluster randomization and were considered eligible for inclusion if they were at least 60-year-old, lived in the community, post-menopausal from at least one year, and were independent to perform the basic and instrumental activities of daily living according to Katz et al. (1963) and Pfeffer et al. (1982) indexes, respectively. People who presented a clinical diagnosis of cardiovascular, metabolic, pulmonary disease, neurological and/or psychiatric diseases, skeletal muscle disorders, comorbidities associated with greater risk of falls (e.g., overall weakness, balance problems), history of smoking or alcohol abuse in the last 5 years, self-reported falls in the previous six months, self-reported malnutrition, illiteracy, and having participated in a structured physical exercise training programs in the past six months prior to the beginning of the study were excluded. We also excluded candidates who were prescribed hormone replacement therapy and/or psychotropic drugs. A physician and a certified nurse were responsible for evaluating the selection criteria. All volunteers received physician authorization to participate in the trial. The power of the sample size was determined using G*Power version 3.1.9.2 on the basis of the magnitude of the mean differences among the three groups. Considering an ES of 0.80, a power of 80%, and a level of significance set at 5%, the sample size necessary was estimated to be of 34 volunteers. A computer-generated list of random numbers was used by an independent researcher to randomize the participants into one of three experimental groups: non-periodized (NP), daily undulating periodization (DUP), and control group (CG), before baseline evaluations. 2.2. Outcomes Primary outcomes were divided into two domains: body composition and physical function. A detailed description of the outcomes assessed in the present study can be found in supplemental content (see text document, Supplemental Digital Context 1). All participants were 11

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curl, 5th) lateral arm raise, 6th) calf raise, 7th) arm curl, 8th) triceps pushdown, and 9th) abdominal crunch. The number of sets was increased during the first month, such that one set was performed in the 1st week, two sets in the 2nd and 3rd week, and 3 sets in the 4th week and thereafter. Exercises were performed with 12–15 submaximal repetitions avoiding fatigue (i.e., inability to complete a repetition in a full range of motion) at an “easy” intensity according to Rating of Perceived Exertion (RPE, CR-10) adapted Borg scale (Foster et al., 2001). The main RT period was the same for NP and DUP. Volunteers performed the same exercises and the total volume of repetitions (number of sets × number of repetitions) was equalized between exercise groups. In this period, a second list of exercises was included (i.e., Training B), which consisted of 1st) squat on the chair (until 90° knee flexion), 2nd) chest press, 3rd) seated leg curl, 4th) seated row, 5th) frontal arm raise, 6th) calf raise, 7th) arm curl, 8th) triceps pushdown, and 9th) abdominal crunch. This list of exercise was included to facilitate the execution of exercises without machines and/or dumbbells. Training A was performed in the first week session, while training B was performed in the second week session. Exercises were performed three times (sets) of 8–10 submaximal repetitions with a 1-min rest interval period provided between sets in the full range of motion. All groups performed a brief warm-up at the beginning of each session, which was based on one set of 12–15 repetitions at “easy” (i.e., RPE = 2) intensity (Foster et al., 2001). Exercise intensity and the velocity of concentric muscle contraction were modified differently for each group according to the peculiarities of each type of RT, as recommended by the ACSM (Chodzko-Zajko et al., 2009). In particular, the NP group performed the exercise sessions at a “difficult” (i.e., RPE = 5–6) intensity (Foster et al., 2001) using machines (Johnson Health Tech, Taichung, Taiwan) and free weights. The exercise cadence was 2 s for both concentric and eccentric contractions. To offer a power session for DUP, concentric contractions were performed as fast as possible, while the eccentric contractions were performed within 2 s, training B. In addition, all exercises were performed at a “moderate” (i.e., RPE = 3) intensity (Foster et al., 2001) using elastic bands (progressive order of intensity [color], yellow, red, green, and blue) (TheraBand, Akron, OH). Training A in DUP was the same that was performed by NP (three sets of 8–10 repetitions at a “difficult” intensity using machines and free weights) with an exercise cadence of 2 s for both concentric and eccentric contractions. To ensure the required movement velocity, the participants were verbally encouraged and supervised. Each exercise session lasted approximately 40 min. In an attempt to offer the volunteers a more favorable physiological environment, exercise groups performed a regenerative week every four weeks (i.e., tapering). During this week, sessions were based on 3 sets of 12–15 submaximal repetitions of each exercise, at “easy” (i.e., RPE = 2) intensity (Foster et al., 2001). The design of each group across the intervention is included in the supplemental content (see figure, Supplemental Digital Context 2). The training load was adjusted based on the RPE method, using the CR-10 (Foster et al., 2001). RPE was reported after the end of each set of exercise and, if the participant reported a RPE below the expectation, the weight was increased by 2–5% for upper extremity exercises and 5–10% for lower extremity exercises (Chodzko-Zajko et al., 2009).

instructed to refrain from engaging in intense physical activity for 96 h before the evaluations and 12-hour fast was required before the evaluation of body composition. Height and weight were measured using medical graded stadiometer and scale, respectively. The body mass index (BMI) was calculated as the weight (kg) divided by the square of height (m2). Fat mass and appendicular and total muscle mass were determined by bioelectrical impedance analysis (TanitaInnerScan50v, TANITA Corporation, Tokyo, Japan) under standard conditions (Coelho Júnior et al., 2015). An anthropometric tape (flexible and inextensible) (Sanny®, São Paulo, Brazil) was used to measure waist (WC) and hip (HC) circumferences (World Health Organization, 2011). The Baumgartner (BI) and Janssen indexes (JI) were determined by using the formulas (Cruz-Jentoft et al., 2010): a) BI = appendicular muscle mass / height2; b) JI = (total muscle mass / body weight) ∗ 100. All physical and functional tests were administered by two experienced assessors. One researcher was responsible for detailing the operational procedures, demonstrating the test before the evaluation, quantifying the performance, and evaluating the motor gesture. The other assessor ensured the safety of the participant. After explanation and before tests, volunteers performed a familiarization trial to ensure they understood the test. Then, the volunteers performed all tests in triplicate, and the mean result was recorded, except for the one-leg stand for which the best result was used in the analysis. A 1-minute rest was allowed between two consecutive trials. Six physical and functional tests were administered: 1) isometric hand grip (IHG) (Mathiowetz et al., 1984), 2) isometric knee extensor strength (Morita et al., 2018), 3) countermovement jump (Coelho Junior et al., 2017), 4) timed “Up and Go” (TUG) (Podsiadlo and Richardson, 1991), 5) 10-m walking speed (Middleton et al., 2016), and 6) one-leg stand test (Vellas et al., 1997). Verbal encouragement was provided to ensure that volunteers achieved the best possible performance during IHG, isometric knee extensor strength, and countermovement jump tests. Muscle quality has been proposed as an important determinant of physical function, since its take into consideration both muscle quantity and function (Straight et al., 2015). In the present study, muscle quality of upper and lower extremities was determined by using the formulas: c) Upper extremity muscle quality: IHG / upper extremity muscle mass; d) Lower extremity muscle quality: isometric knee extensor strength / lower extremity muscle mass. Food intake was assessed at baseline to characterize the sample using a three-day food diary, including two days during the week and one day over the weekend. Nutritional assessment was performed using the NutWin software, version 1.5 (UNIFESP, São Paulo, Brazil). Secondary outcomes included fear of falling (Falls Efficacy ScaleInternational [FES-I]) (Camargos et al., 2010) and frailty risk (Kihon checklist [KCL]) (Sewo Sampaio et al., 2014). 2.3. Resistance training program

2.4. Control group (CG)

The current investigation was carried out over a total of 26 weeks, with the first and the last two weeks dedicated to evaluations. The RT program was divided into two periods: 1) 4-week familiarization period, and 2) 18-week main RT period. In both the 4-week familiarization and the 18-week main RT, all training sessions occurred twice a week in the morning, with a minimum interval of 48 h between two consecutive sessions, under the supervision of three experienced exercise trainers. The exercise program was individualized and conducted in pairs. The familiarization period consisted of nine exercises for major muscle groups (i.e., Training A). Exercises were performed in this sequence: 1st) seated row, 2nd) leg press, 3rd) chest press, 4th) seated leg

Participants randomized to the CG were recruited according to the same criteria applied for those allocated into the treatment groups. In CG, participants maintained their usual habits during the whole duration of the study and were asked to refrain from engaging in physical exercise programs. To ensure that the volunteers were not exercising on a regular basis, face-to-face or phone contacts were performed every 15 days.

12

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Fig. 1. Flowchart of the present study. CG = control group, DUP = daily undulating periodization, NP = nonperiodized.

cause significant effects on body composition, and there were no significant differences between the groups for any parameter. However, it is worth noting that changes from baseline to week 23 in total muscle mass of NP (+6.4%) received a large ES classification, while DUP changes (+4.0%) showed a medium ES. Table 3 shows functional measurements. NP showed significant improvements on countermovement jump (+55.7%; P ≤ 0.01), TUG (−43.2%, faster; P < 0.001), walking speed (+12.0; P = 0.01), and one-leg stand (+154.5%; P = 0.01). The time-course analysis revealed that the countermovement jump (+52.9%; P ≤ 0.01), TUG (−38.4%, faster; P ≤ 0.001), and walking speed tests (+10.4%; P ≤ 0.01) were significantly improved from the 14th week, while one-leg stand only reached significance at the 23rd week. In addition, a lower time to perform TUG was found in the 14th and 23rd weeks when compared to baseline and 5th week (P < 0.001 for both). Significant results were accompanied by a Large ES classification. Absolute and relative IHG and isometric strength of the knee extensors, and lower- and upper-limb muscle quality were not changed in response to NP. However, it should be stressed that changes from baseline to week 23 in absolute and relative isometric strength of knee extensors (+19.1% and + 25.0%, respectively) received a Large ES classification. Regarding DUP, only TUG performance was improved after 23 weeks (−53.2%, Large ES; P ≤ 0.001). In addition, better TUG performance was observed in the 14th and 23rd when compared with baseline and 5th week (P ≤ 0.001 for both). There were no significant differences among groups for any parameter.

2.5. Statistical analyses Data are shown as mean ± standard deviation (SD), except for fat, which is shown as percentage ± SD. Normality of data was tested using the Kolmogorov-Smirnov test. Baseline comparisons among groups were performed using one-way analysis of variance (ANOVA) followed by Tukey's post-hoc test as appropriate. A group × time repeated-measures ANOVA followed by Dunnet post-hoc test was performed to detect differences among different times of evaluations and treatments. Cohen's effect size (ES) was calculated to assess the size of the results. The level of significance was set at alpha = 5% (P < 0.05) and all analyses were performed using the GraphPad Prism 6.0. (San Diego, CA). The intention-to-treat principle was applied to the analysis of the outcomes for all participants based on their assigned treatment, after excluding volunteers who had missed four or more exercise sessions in a recurrent and sequential manner according to the records. 3. Results The flowchart of the present study is shown in Fig. 1. One-hundred three volunteers were recruited for the present study and 60 accepted to be evaluated for eligibility criteria. Of these, six had a diagnosis of type 2 diabetes mellitus, four had sustained myocardial infarction, three reported a fall event in the last 12 months, and two declined further assessment, leaving a total of 45 older women who were randomized into the three groups (i.e., NP, DUP, and CG). From baseline to the 26th week, adherence to exercise was 88% in the NP and 90% in the DUP group. Six participants withdrew from the trial, four from the NP and two from the DUP group. All withdrawals were due to personal reasons. Table 1 lists the main characteristics of study participants at baseline according to group allocation. DUP had lower appendicular muscle mass and BI when compared with NP and CG at baseline. There were no differences among groups for the other general characteristics, body composition, physical performance and/or nutritional characteristics. Body composition is shown in Table 2. Exercise training did not

4. Discussion In the present RCT, RT caused significant changes in functional parameters in community-dwelling older women. RT also reduced frailty risk according to KCL scores. Nevertheless, only NP elicited changes in physical parameters and fear of falling. NP produced greater and earlier improvements in physical function than DUP. Greater changes in KCL were also observed in NP when compared with DUP. Different to the present study, previous investigations demonstrated 13

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Table 1 Participants characteristics at baseline according to group allocation. Variables

NP (n = 10)

DUP (n = 12)

CG (n = 14)

P-value

General characteristics Age (years) Kihon checklist (points) Fear of falling (points)

67.0 ± 6.2 5.9 ± 3.9 21.7 ± 4.9

66.7 ± 5.1 6.0 ± 3.6 23.7 ± 7.3

66.7 ± 4.6 5.3 ± 2.2 19.5 ± 2.9

0.98 0.83 0.14

Energy intake (kcal/d) Carbohydrate (g/d) Fat (g/d) Protein (g/d)

Nutritional characteristics 1312 ± 276 1669 ± 652 203 ± 77 242 ± 74 32 ± 17 55 ± 31 61 ± 28 63 ± 36

1757 ± 225 230 ± 31 62 ± 10 72 ± 29

0.26 0.63 0.11 0.83

Weight (kg) Height (cm) Body mass index (kg/m2) Total muscle mass (kg) Fat (%) Waist circumference (cm) Hip circumference (cm) W/H ratio (cm)

Anthropometry and body composition 71.7 ± 12.9 68.2 ± 12.2 153 ± 0.0 158 ± 0.0 30.2 ± 4.1 27.8 ± 6.2 37.8 ± 3.2 37.5 ± 3.8 41.9 ± 6.3 39.1 ± 8.5 98.7 ± 12.2 94.1 ± 11.9 107.4 ± 10.8 104.3 ± 12.7 0.9 ± 0.0 0.9 ± 0.0

69.3 ± 20.4 160 ± 0.1 27.0 ± 7.7 40.5 ± 3.4 36.0 ± 9.6 93.6 ± 16.8 105.9 ± 14.1 0.8 ± 0.0

0.61 0.18 0.15 0.16 0.21 0.13 0.16 0.14

Physical capabilities IHG (kg) Isometric strength of the knee extensors (kg) Countermovement jump (cm) Lower-limb muscle quality (kg/kg) Upper-limb muscle quality (kg/kg)

23.4 ± 3.6 19.1 ± 3.2 7.0 ± 3.2 3.0 ± 0.7 12.2 ± 2.9

One-leg stand test (s) TUG (s) Walking speed test (m/s)

8.8 ± 9.2 10.4 ± 2.6 1.25 ± 0.14

24.9 ± 3.8 20.0 ± 9.0 9.5 ± 4.3 3.2 ± 1.2 13.2 ± 1.8

23.7 ± 2.7 19.9 ± 4.2 11.2 ± 3.5 3.2 ± 0.7 12.7 ± 2.4

0.56 0.93 0.08 0.83 0.66

15.8 ± 6.5 12.2 ± 4.5 1.15 ± 0.17

11.6 ± 10.6 10.1 ± 1.4 1.27 ± 0.38

0.20 0.21 0.89

Physical function

Data are shown as mean ± SD. NP = non-periodized; DUP = daily undulating periodized; CG = control group; KI = Katz index; PI = Pfeffer index; GDS = Geriatric depressive scale; BI = Baumgartner index; JI = Janssen index; W/H = waist to hip; IHG = isometric handgrip; TUG = timed “Up and go”.

concentric contraction, regardless of exercise intensity (Kraemer et al., 1996). de Vos et al. (2008), for example, found that PT using loads of 20%, 50%, or 80% 1RM produced similar improvements in muscle power in community-dwelling older adults. It was possible to hypothesize that including a session of PT in a DUP program could cause similar (Henwood et al., 2008) or greater (Miszko et al., 2003) neuromuscular adaptations than those observed after regular RT programs. Other variables associated with RT prescription may be identified as responsible for the differences between the training groups. As mentioned previously, although the neuromuscular adaptations elicited by PT seem to occur independent of exercise intensity, de Vos et al. (2008) observed that changes in peak power were correlated with those in fat free mass in the 80% 1RM group, but not in the other groups, suggesting a role of anabolic adaptations in the physical and functional alterations. In the present study, a 4% increase in total muscle mass (medium ES) was observed in DUP, while NP showed a 6.4% increase (large ES). Furthermore, most studies investigating DUP proposed a greater frequency than that used in the present study (2 vs. 3 days per week) (Conlon et al., 2016, 2017; Hunter et al., 2001). Therefore, to investigate if these variables have a role in the impact of DUP programs on physical parameters and function, future DUP designs should include more RT sessions in combination with power exercise sessions performed at moderate (~50% 1RM) intensities. As a practical application of our results, the greater improvements seen in physical capabilities and function after NP may be strongly associated with the reduction of fear of falling and the larger improvement in KCL observed in this group, since poor physical performance is significantly associated with fear of falling (Higuchi et al., 2004), besides being a key criterion in the characterization of frailty according to KCL (Sewo Sampaio et al., 2016). Therefore, health professionals should choose to prescribe NP programs to healthy older women. Nevertheless, DUP programs also demonstrated beneficial effects

similar improvements in physical and functional parameters in untrained community-dwelling healthy older adults after long-term NP and DUP programs (Conlon et al., 2016, 2017; Hunter et al., 2001). Discrepancies between the studies may be attributed to the lower exercise intensity used in the present study. Indeed, past studies (Schoenfeld et al., 2015) and meta-analyses (Raymond et al., 2013) demonstrated greater improvements in muscle strength after high-load RT programs when compared with low- and moderate-load RT. In the present investigation, although NP was performed at a difficult intensity, the PT of DUP was conducted at a moderate intensity, which represents approximately 50% of 1-repetition maximum (1RM) (Day et al., 2004). On the other hand, participants enrolled by Hunter et al. (2001) and Conlon et al. (2016, 2017) performed RT sessions at 50–80% 1RM and 5–15 repetition maximum (RM), respectively. Therefore, findings of the present study confute our initial hypothesis and suggest that moderate-load PT combined with high-load strength training in a DUP program does not elicit equivalent physical adaptations than an RT program involving exclusively high loads (i.e., NP). From a physiological point of view, the size of the recruited motor unit increases according to the muscle tension generated during contraction (size principle) (Mendell, 2005). It seems to be important, because improvements in muscle mass, strength, and power after RT commonly occur in response to morphological and/or functional changes in type II muscle fibers (Floeter, 2010), which present a high prevalence in large motor units (Schoenfeld et al., 2016). Therefore, the heavier loading performed by NP probably induced the recruitment of large motor units, and, consequently, type II muscle fibers causing greater improvements in physical parameters and function in comparison to DUP. Nevertheless, the plausibility behind our DUP program was based on the capacity of PT to reduce the high threshold activation of large motor units. In fact, it is believed that high-threshold motor unit recruitment can be achieved by PT in response to the high velocity of 14

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Table 2 Body composition in the three experimental groups over 26 weeks. NP (n = 10)

DUP (n = 12)

CG (n = 14)

2

BMI (kg/m ) Baseline 5th week 14th week 23rd week ES (classification) Δ%

28.6 ± 4.5 (26.0–31.2) 29.2 ± 4.7 (26.2–32.2) 28.6 ± 3.1(26.4–30.9) 30.0 ± 4.3 (26.9–33.1) −0.50 (medium) 4.9

Baseline 5th week 14th week 23rd week ES (classification) Δ%

41.9 ± 6.3 (38.1–45.8) 43.3 ± 5.3 (39.9–46.7) 39.2 ± 3.6 (36.6–41.9) 41.7 ± 3.6 (36.1–46.6) 0 (unclassifiable) −0.5

Baseline 5th week 14th week 23rd week ES (classification) Δ%

37.7 38.0 40.3 40.1

27.8 ± 62.2 (24.2–31.4) 28.0 ± 63.3 (24.3–31.7) 28.1 ± 6.4 (24.0–32.2) 27.9 ± 6.2 (23.9–31.9) 0 (unclassifiable) 0.4

27.0 ± 7.7 (22.6–31.5) – – 27.5 ± 8.0 (22.9–32.1) 0 (unclassifiable) 1.9

39.1 ± 8.5 (34.2–44.0) 40.4 ± 7.3 (36.2–44.6) 41.6 ± 7.1 (37.1–46.1) 39.1 ± 8.7 (33.6–44.7) 0 (unclassifiable) 0

36.0 ± 9.6 (30.4–41.6) – – 36.8 ± 9.5 (31.3–42.3) 0 (unclassifiable) 2.2

Total muscle mass (kg) 37.5 ± 3.8 (36.1–39.0) 37.8 ± 4.0 (36.2–39.5) 37.9 ± 5.9 (35.2–40.5) 39.0 ± 4.0 (37.2–40.8) −0.56 (medium) 4.0

40.5 ± 3.4 (38.4–42.5) – – 40.2 ± 4.3 (37.6–42.8) 0 (unclassifiable) 0.7

Fat (%)

± 3.1 (35.9–39.5) ± 3.3 (35.9–40.2) ± 3.5 (37.7–42.8) ± 1.6 (38.9–41.2) −1.34 (large) 6.4

BI (kg/m2) Baseline 5th week 14th week 23rd week ES (classification) Δ%

7.1 ± 0.8 (6.5–7.7) 6.9 ± 1.2 (6.0–7.8) 7.2 ± 1.3 (6.3–8.2) 7.2 ± 1.0 (6.5–8.0) 0 (unclassifiable) 0

6.4 ± 0.6 (6.0–6.8) 6.6 ± 1.1 (5.8–7.3) 6.9 ± 1.0 (6.2–7.6) 7.0 ± 0.9 (6.4–7.6) 0 (unclassifiable) 9.4

7.4 ± 1.2 (6.7–8.1)a – – 7.9 ± 1.3 (7.1–8.7) 0 (unclassifiable) 6.8

58.4 ± 6.6 (54.1–62.6) 57.2 ± 9.1 (51.4–63.0) 53.1 ± 8.3 (47.8–58.4) 57.0 ± 8.4 (51.6–62.3) 0.14 (unclassifiable) −2.4

61.8 ± 13.4 (53.7–70.0) – – 66.2 ± 22.0 (52.9–79.5) −0.27 (small) 7.1

94.1 ± 11.9 (87.2–101.1) 93.5 ± 11.3 (96.9–100.0) 91.0 ± 3.7 (82.6–99.3) 0.37 (small) −3.3

93.6 ± 16.8 (83.9–103.4) – 94.7 ± 17.0 (84.8–104.6) −0.06 (unclassifiable) 1.2

104.3 ± 12.7 (96.9–111.6) 104.9 ± 11.1 (98.4–111.3) 102.7 ± 13.4 (94.1–111.2) 0.15 (unclassifiable) −1.53

105.9 ± 14.1 (97.7–114.1) – 103.4 ± 15.3 (94.5–112.2) 0.13 (unclassifiable) −2.36

0.90 ± 0.0 (0.8–0.9) 0.89 ± 0.0 (0.8–0.9) 0.88 ± 0.0 (0.8–0.9) 0 (unclassifiable) −2.2

0.88 ± 0.0 (0.8–0.9) – 0.91 ± 0.1 (0.8–0.9) 0 (unclassifiable) 3.4

JI (kg) Baseline 5th week 14th week 23rd week ES (classification) Δ%

54.1 52.9 57.1 55.0

± 5.9 (49.3–57.8) ± 5.4 (48.4–56.1) ± 3.4 (54.7–59.6) ± 7.0 (49.9–60.0) −0.32 (small) 1.7 Waist (cm)

Baseline 5th week 23rd week ES (classification) Δ%

98.7 ± 12.2 (91.6–105.9) 98.5 ± 10.4 (91.8–105.2) 102.0 ± 10.6 (94.3–109.6) −0.36 (small) 3.3

Baseline 5th week 23rd week ES (classification) Δ%

107.4 ± 10.8 (101.1–113.7) 109.7 ± 10.4 (103.0–116.3) 107.2 ± 8.5 (101.1–113.3) 0 (unclassifiable) −0.19

Baseline 5th week 23rd week ES (classification) Δ%

0.92 ± 0.0 (0.8–0.9) 0.89 ± 0.0 (0.8–0.9) 0.95 ± 0.0 (0.9–0.1) 0 (unclassifiable) 3.2

Hip (cm)

W/H ratio

Data are shown as mean ± SD. NP = non-periodized; DUP = daily undulating periodized; CG = control group; BI = Baumgartner index; JI = Janssen index; W/ H = waist to hip; ES = effect size; a: P < 0.05 vs. DUP.

Although the use of RPE method has been endorsed by several experts and ACSM as a feasible method for training load adjustment in clinical practice, most investigations with older adults are based on maximal tests (e.g., 1RM, 10RM) or maximum repetitions. If, on the one hand, these methods demonstrate good reliability, an extensive literature to comparisons, and several adjusted protocols, on the other hand, its use in clinical practice is limited. In this regard, our findings support the use of the RPE method as a reliable tool for load prescription in RT programs for older adults. There are some limitations in the present study to mention. The first limitation is that only relatively healthy older women were enrolled which does allow extending our findings to the male gender or to older

with important clinical applications. Furthermore, PT is a non-fatiguing exercise, which can be performed with tools other than machines and dumbbells, such as elastic bands and medicine balls. These features may render PT a more feasible type of RT because it can be performed outdoors or even at home. Indeed, a common report of the volunteers of the present study after the session of PT was that they did not feel as tired as they felt on the days when they performed the session of strength training. Thus, if an older adult cannot go to the gym twice a week, our DUP program seems to be an interesting option to maintain or even improve physical function. Another practical aspect of the present study that deserves attention is the prescription of training load according to the RPE method. 15

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Table 3 Physical function in the three experimental groups over 26 weeks. NP (n = 10)

DUP (n = 12)

CG (n = 14)

24.9 ± 3.8 (22.4–27.3) 24.7 ± 5.0 (21.5–28.0) 23.8 ± 4.6 (20.9–26.8) 24.7 ± 4.3 (22.0–27.5) 0 (unclassifiable) −0.8

23.7 ± 2.7 (22.2–25.3) – – 22.9 ± 2.4 (21.3–24.6) 0.50 (medium) −3.4

IHG (kg) Baseline 5th week 14th week 23rd week ES (classification) Δ%

23.4 23.8 24.8 24.6

± 3.6 (20.8–26.0) ± 2.6 (21.9–25.7) ± 2.9 (22.7–26.9) ± 2.6 (22.7–26.5) −0.39 (small) 5.1

Baseline 5th week 14th week 23rd week ES (classification) Δ%

0.78 0.80 0.87 0.83

± 0.16 (0.54–1.03) ± 0.16 (0.60–1.40) ± 0.12 (0.69–1.06) ± 0.14 (0.63–1.08) −0.33 (small) 6.4

Baseline 5th week 14th week 23rd week ES (classification) Δ%

19.1 19.2 23.0 23.6

Baseline 5th week 14th week 23rd week ES (classification) Δ%

0.64 0.64 0.81 0.80

Relative IHG (kg/kg) 0.98 0.94 0.88 0.92

± 0.19 (0.65–1.25) ± 0.22 (0.46–1.21) ± 0.23 (0.49–1.22) ± 0.23 (0.48–1.23) 0.28 (small) −6.1

0.92 ± 0.21 (0.65–1.31) – – 0.89 ± 0.34 (0.44–1.93) 0.10 (unclassifiable) 3.2

Isometric strength of the knee extensors (kg) ± 3.2 (16.8–21.4) 20.0 ± 9.0 (14.2–25.8) ± 6.0 (14.9–23.6) 22.9 ± 8.6 (17.4–28.4) ± 5.6 (18.9–27.1) 18.8 ± 5.9 (15.0–22.6) ± 6.3 (21.0–26.3) 19.4 ± 6.5 (15.2–23.5) −0.84 (large) 0.13 (unclassifiable) 19.1 −3.0

19.9 ± 4.2 (17.5–22.4) – – 23.3 ± 10.1 (17.4–29.1) −0.52 (medium) 17.1

Relative isometric strength of the knee extensors (kg/kg) ± 0.15 (0.47–0.91) 0.78 ± 0.36 (0.34–1.68) ± 0.21 (0.30–1.09) 0.88 ± 0.37 (0.26–1.48) ± 0.23 (0.42–1.29) 0.70 ± 0.27 (0.27–1.22) ± 0.17 (0.70–1.29) 0.71 ± 0.25 (0.41–1.24) −0.99 (large) 0.22 (small) 25.0 −8.9

0.78 ± 0.22 (0.43–1.07) – – 1.00 ± 0.50 (0.28–2.07) −0.56 (medium) 28.2

Countermovement jump (cm) 9.5 ± 4.3 (6.7–12.3) 12.1 ± 4.3 (9.3–14.8) 12.1 ± 6.3 (8.1–16.2) 12.6 ± 6.0 (8.7–16.5) −0.58 (medium) 32.6

Baseline 5th week 14th week 23rd week ES (classification) Δ%

7.0 ± 3.2 (4.7–9.4) 10.4 ± 4.0 (7.4–13.3) 10.7 ± 3.4 (8.2–13.1)a 10.9 ± 3.8 (8.1–13.7)a −1.0 (large) 55.7

11.2 ± 3.5 (9.2–13.3) – – 10.2 ± 3.0 (8.3–12.2) 0.33 (small) −8.9

Baseline 5th week 14th week 23rd week ES (classification) Δ%

10.4 ± 2.6 (5.0–14.0) 10.0 ± 1.8 (6.8–13.4) 6.4 ± 1.5 (4.5–9.7)a,b 5.9 ± 1.1 (4.4–7.8)a,b 2.25 (large) −43.2

Baseline 5th week 14th week 23rd week ES (classification) Δ%

1.25 ± 0.14 (0.83–1.43) 1.31 ± 0.14 (0.88–1.56) 1.38 ± 0.08 (1.07–1.65)a 1.40 ± 0.17 (0.93–1.68)a −0.96 (large) 12.0

Walking speed (m/s) 1.15 ± 0.17 (0.86–1.54) 1.17 ± 0.18 (0.76–1.48) 1.27 ± 0.12 (0.93–1.52) 1.25 ± 0.16 (0.86–1.60) −0.60 (medium) 8.7

1.27 ± 0.38(0.47–1.69) – – 1.36 ± 0.25 (0.74–1.66) 0.27 (small) 7.1

Baseline 5th week 14th week 23rd week ES (classification) Δ%

8.8 ± 9.2 (2.2–15.4) 15.2 ± 9.7 (8.3–22.2) 20.6 ± 11.1 (12.6–28.6) 22.4 ± 10.7 (14.8–30.0)a −1.47 (large) 154.5

One-leg stand test (s) 15.8 ± 6.5 (11.6–20.0) 19.6 ± 8.5 (14.1–25.0) 18.1 ± 8.7 (12.5–23.6) 19.2 ± 10.6 (12.5–26.0) −0.48 (small) 21.5

11.6 ± 10.6 (5.5–17.8) – – 18.9 ± 9.5 (13.3–24.7) −0.73 (medium) 62.9

Baseline 5th week 14th week 23rd week ES (classification) Δ%

3.0 ± 0.7 (2.1–4.0) 2.9 ± 0.9 (1.3–4.5) 3.4 ± 1.0 (1.8–5.6) 3.5 ± 0.6 (3.0–5.1) −0.76 (medium) 16.6

TUG (s)

Baseline 5th week 14th week 23rd week ES (classification)

12.2 12.3 11.7 11.6

± 2.2 (8.1–16.3) ± 3.4 (8.7–16.7) ± 1.8 (8.5–14.9) ± 1.8 (8.4–15.3) 0.29 (small)

12.2 ± 4.5 (7.9–23) 10.4 ± 2.7 (6.7–16.1) 6.5 ± 1.4 (4.9–9.3)a,b 5.7 ± 0.7 (4.8–7.2)a,b 2.0 (large) −53.2

10.1 ± 1.4 (8.0–13.0) – – 11.1 ± 2.3 (8.0–15.0) −0.52 (medium) 9.9

Lower-limb muscle quality (kg/kg) 3.2 ± 1.2 (1.5–5.4) 3.6 ± 1.4 (1.8–5.6) 3.4 ± 1.0 (1.8–5.6) 3.4 ± 1.0 (1.8–5.6) −0.18 (unclassifiable) 6.25

3.2 ± 0.7 (1.6–4.7) – – 3.4 ± 1.7 (1.8–8.3) −0.15 (unclassifiable) 6.25

Upper-limb muscle quality (kg/kg) 13.2 ± 1.8 (10.8–16.3) 12.9 ± 2.9 (8.0–17.6) 11.8 ± 2.5 (8.2–16.8) 12.1 ± 3.1 (8.3–16.3) 0.43 (small)

12.7 ± 2.4 (8.1–16.3) – – 12.0 ± 2.7 (8.4–18.3) 0.27 (small)

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Table 3 (continued) NP (n = 10) Δ%

DUP (n = 12)

−4.9

−8.3

CG (n = 14) −5.5

Data are shown as Mean ± SD. NP = non-periodized; DUP = daily undulating periodized; CG = control group; IHG = isometric handgrip; TUG = timed “Up and go”; ES = effect size. a P < 0.05 vs baseline. b P < 0.05 vs 5th week.

adults with specific conditions (e.g., sarcopenia, frailty). Second, as above mentioned, other studies investigated DUP programs with a higher frequency of sessions per week than we used in the present study (3 vs. 2) and this issue should be investigated in future studies. Third, the lack of a NP group composed by PT and RT performed at the same intensity limits our understanding regarding the effects of PT intensity on neuromuscular adaptations. Fourth, improvements on frailty risk after NP were based on KCL scores and could not be similar if this parameter was assessed by other tools (e.g., Fried's criteria). Finally, more studies are necessary to consolidate the use of RPE as a method to prescribe PT.

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