Journal of Aging and Health
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The Effects of Resistance Training and Walking on Functional Fitness in Advanced Old Age
Robert Simons and Ross Andel
J Aging Health 2006; 18; 91
DOI: 10.1177/0898264305281102
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JOURNAL
10.1177/0898264305281102
Simons,
Andel
OF /AGING
EXERCISE
AND AND
HEALFUNCTION
TH / February
AL2006
FITNESS
The Effects of Resistance Training
and Walking on Functional
Fitness in Advanced Old Age
ROBERT SIMONS
Bonsai Spa & Wellness Clinic, Largo, Florida
ROSS ANDEL
University of South Florida, Tampa, Florida
The authors assessed the effects of resistance training and walking exercise on measures of functional fitness. Sixty-four volunteers (average age 83.5 years) from an
independent-living facility were randomly assigned to walking, resistance training,
or control groups. Participants in the walking and resistance-training groups engaged
in two exercise sessions per week for 16 weeks. Measures of functional fitness
included upper and lower body strength, hip and shoulder flexibility, agility and balance, coordination, blood pressure, and resting heart rate. Repeated measures analysis of variance was used to examine pretest to posttest differences. Both exercise
groups showed significant improvements relative to control group in upper and lower
body strength, shoulder flexibility, and agility and balance exercise. Findings demonstrate that exercise can lead to improvements in multiple domains of functional fitness
even among very old, previously sedentary individuals, possibly making activities of
daily living easier to perform.
Keywords:
resistance training; walking; functional fitness; older adults
Inevitably, age leads to some functional decline and greater likelihood
of difficulties in performing activities of daily living. Functional
decline in older adults appears to be influenced by levels of physical
activity (e.g., Hubert, Bloch, Oehlert, & Fries, 2002). Review studies
AUTHORS’ NOTE: Many thanks to William Haley for his helpful comments on an earlier
version of this manuscript. For further information contact: Ross Andel, University of South
Florida, School of Aging Studies MHC 1321, 4202 E. Fowler Ave, Tampa, FL 33620. Phone:
813-974-9743, Fax: 813-974-9754, E-mail: [email protected]
JOURNAL OF AGING AND HEALTH, Vol. 18 No. 1, February 2006 91-105
DOI: 10.1177/0898264305281102
© 2006 Sage Publications
91
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JOURNAL OF AGING AND HEALTH / February 2006
indicate that physical inactivity is related to accelerated depletion of
functional reserves and deficits in muscle strength and neuromuscular
activation, leading to increased incidence of functional problems,
frailty, and falls (King, Rejeski, & Buchner, 1998; Mazzeo & Tanaka,
2001; Van der Bij, Laurant, & Wensing, 2002; Spiraduso, 1995). At
the same time, sedentary lifestyle is still common among older adults
and appears to increase with advancing age. According to the Third
National Health and Nutrition Examination Survey (Christmas &
Andersen, 2000), physical inactivity rates among American adults
average 26% for ages 45 to 64, 27% at ages 65 to 74, and 46% at ages
older than 75 years.
Growing evidence supports the notion that physical activity can
offset age-related functional decline and preserve independence longer into old age. For example, the positive effect of walking on health
has been recognized for centuries. Hippocrates wrote around 400 B.C.
that “Walking is man’s best medicine” (Spiraduso, 1995, p. 17).
Recent scientific studies provide evidence that walking can improve
functional health in old age (Brown & Holloszy, 1993; Hamdorf &
Penhall, 1999; Wong, Wong, Pang, Azizah, & Dass, 2003). Resistance training has also gained attention as a strategy to support functional health in older adults (e.g., Brandon, Boyette, Lloyd, & Gaasch,
2004; Campbell, Crim, Young, & Evans, 1994; Fiatarone et al., 1994).
Age-related decrements in muscle strength, power, and flexibility
occur naturally across middle and older adulthood (e.g., Hurley &
Hagberg, 1998). For example, strength is estimated to decrease by
40% to 50% between 25 and 80 years of age (American College of
Sports Medicine, 1998). In the Framingham study, 40% of women
between the ages of 55 and 64, 45% of women aged 65 and 74, and
65% of women between 75 and 84 years of age were unable to lift 10
pounds (Jette & Branch, 1981). Many of the same women also
reported having difficulties with performing normal household work.
Musculoskeletal deficits are being recognized as an important underlying cause of the onset of frailty and increased incidence of falls with
age (e.g., Fiatarone & Evans, 1993; Hurley & Hagberg, 1998) as well
as difficulties performing daily and leisure activities such as carrying
grocery bags, cooking, gardening, and traveling (Spiraduso, 1995).
Exercise programs appear to support muscular, functional, and
cardiovascular health. Intervention studies with older adults report
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Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
93
measurable gains in muscle mass and strength following resistancetraining programs (Akima et al., 2001; Cavani, Mier, Musto, &
Tummers, 2002; Fiatarone et al., 1990). Others found exercise-related
increase in balance, agility, and flexibility (Cavani et al., 2002) and
neuromuscular function (Hakkinen & Hakkinen, 1995; Taaffe, Duret,
Wheeler, & Marcus, 1999) as well as reduced incidence of falls
(Buchner et al., 1997; Province et al., 1995). Finally, moderate exercise may support cardiovascular function in older adults (Myers,
2003).
Increasing attention has been paid to the role of exercise in health
promotion in old age. However, still little is known about benefits of
exercise among sedentary individuals in advanced old age although
older adults older than 80 years of age are the fastest growing segment
of the population (U.S. Bureau of the Census, 1996) and have a higher
likelihood of living a sedentary life than younger cohorts (Christmas
& Andersen, 2000).
This study explored the effects of 16 weeks of resistance training
and walking exercise on measures of functional and cardiovascular
fitness in a sample of adults in advanced old age who were sedentary
prior to the study and lived independently in a community. The goal
was to assess the effects of the two types of exercise on multiple measures of functional fitness, namely, upper and lower body strength,
flexibility, agility and dynamic balance, coordination, and cardiovascular fitness. A secondary goal was to explore feasibility and usefulness of walking and resistance training among these individuals. We
hypothesized that both training groups would outperform the control
group on the examined measures of functional fitness. We also
expected that the training groups would be able to adhere to their
exercise routines for the duration of the study.
Method
PARTICIPANTS
The study included 64 residents (45 women, 19 men) from an independent living facility. This type of facility provides meal and activity
services for the residents but typically does not assist with activities of
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JOURNAL OF AGING AND HEALTH / February 2006
daily living. Potential volunteers were recruited through community
paper and newspaper advertisements, announcements in the community, and a study presentation. The inclusion criteria were (a) clearance to participate in an exercise program by the primary physician,
(b) lack of regular (2 to 3 times a week) engagement in strenuous
physical activity for at least 1 year prior to the study, and (c) being at
least 65 years of age at the time of study initiation. In addition, the participants were ambulatory, nonhypertensive, nondiabetic, and nondemented. All participants were Caucasian. The study was approved
by the Institutional Review Board at the University of South Florida.
Several participants in each group used canes, walkers, and electrical transports for safety and convenience but were able to perform
their prescribed exercise routines. Participants were on average 83.5
years of age (SD = 6.2, range 66 to 96 years). Only five participants
were less than 75 years of age. Women accounted for 73% of the
sample.
Participants were randomly assigned to one of two exercise groups
or a control group. Twenty-one participants (15 women, 6 men) were
assigned to the resistance-training program, 18 participants (11 women,
7 men) were assigned to the walking program, and 21 participants (18
women, 3 men) were assigned to the control group. Participants were
informed that the intervention programs would be made available to
all participants on the completion of the study. Four participants
dropped out during the course of the study, 2 for nonstudy related illnesses and 2 for personal reasons. Of these 4 participants, 1 was from
the walking group, 2 were from the resistance-training group, and 1
was from the control group.
PROCEDURES
All participants regardless of group assignment completed a pretest
and posttest that consisted of measures of functional fitness including
upper and lower body muscle strength, joint flexibility, agility and
balance, coordination, and cardiovascular health. Participants in the
resistance-training group and the walking group also completed two
exercise sessions per week for a period of 16 weeks.
All participants were encouraged to attend a series of six 1-hour
health lectures that were given at approximately 3-week intervals
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Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
95
throughout the 16-week intervention by one of the authors. The lecture topics were aging in the 21st century, senior fitness program
development, balance and stability training, aging and the mind,
aging and nutrition—Part 1, aging and nutrition—Part 2.
PRETEST AND POSTTEST ASSESSMENTS
All pretest and posttest measures were administered by trained
instructors who were selected for this part of the study from the Fountains Fountain of Youth Fitness Center or Simons Fitness Enterprises
personal training staff. These instructors were blind to the intervention status.
We assessed muscle strength using a manual developed by the
American Alliance for Health Physical Education, Recreation, and
Dance (AAHPERD; Osness, 1990)—Functional Fitness Assessment
for Adults Over 60. The 24-hour test-retest reliability of the measures
was assessed by several studies and was .80 or higher, with most values more than .90 (see Osness, 1990, pp. 21, 22). In agreement with
the AAHPERD manual, participants were tested for lower and upper
body muscle strength using one-repetition maximum (1-RM) method
where participants are asked to perform one full-strength repetition of
a particular exercise two or three times, following a short warm-up.
The highest value was recorded.
Strength. Lower body strength was measured as total pounds from
the 1-RM on leg extensions, leg curl, and leg press machines. Leg
extensions and leg press reflect quadriceps strength and leg curls
reflect hamstring strength. Upper body strength was measured as total
pounds from the 1-RM on lat pull-down, upper back, and chest press
machines. Lat pull-down targets latissimus dorsi, one of the major
back muscles. The upper back exercise resembles a rowing motion but
with no leg movement, targeting deltoid and scapular muscles. Chest
(or bench) press targets chest muscles, particularly the pectoralis
major, as well as triceps and deltoid muscles. All testing repetitions
were initially demonstrated and performed with strict adherence to
proper form (slow movement and full range of motion) for both
testing accuracy and safety.
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JOURNAL OF AGING AND HEALTH / February 2006
Flexibility. To measure general flexibility, we used the Sit-AndReach test from the AAHPERD manual. During this test, the participant sits on the floor with the knees extended and reaches as far
forward as possible. Distance reached was assessed in inches. Joint
flexibility was further assessed with a mechanical goniometer at the
shoulder joint and the hip joint as degrees of movement. Shoulder
flexibility was a composite of scores attained on shoulder abduction
and shoulder flexion. We measured shoulder abduction and shoulder
flexion from the side position (arm vertical) to the highest point
attained without torso movement. Hip flexibility was measured as
maximum hip flexion. Participants performed hip flexion from the
supine position (thigh horizontal) to the highest point attained with
knee bent. All flexibility assessments were taken on the right side of
the body.
Eye-hand coordination. We used the Soda-Pop test from the
AAHPERD manual. While seated, participants were timed as they
grasped, turned upside down, and replaced three unopened soda cans
that are 5 inches apart. The better time (in seconds) from two trials was
recorded.
Agility and balance. We used the Agility and Dynamic Balance test
from the AAHPERD manual. The score was calculated as total time
(in seconds) needed to repeatedly stand up from an armless chair,
negotiate a short obstacle course made from three cones, sit down, and
lift the feet. Two cones were placed five feet to either side of the chair
and six feet behind the chair.
Cardiovascular health. We assessed resting heart rate (number of
beats per minute) and systolic and diastolic blood pressure. Participants were allowed a minimum of 10 min of rest. Readings were taken
in a seated position.
INTERVENTION
Trained instructors from the Fountains Fountain of Youth Fitness
Center or Simons Fitness Enterprises personal training staff were
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Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
97
selected to provide supervision for the intervention part of the study.
Prior to each intervention session, participants were supervised through
a warm-up routine that included neck rotations, volume breathing, triceps stretch (i.e., one hand at a time behind the back), shoulder turn
(i.e., reach behind the shoulder blade), two-legged rock, a hamstring
stretch, and a knees-to-chest stretch.
Resistance-training program. As part of the warm-up, participants
were allowed and encouraged to perform several repetitions, with no
resistance on each machine to reduce the risk of injury. The initial
weight per exercise machine, representing pounds of resistance, was
set at 75% of the individual’s 1-RM from the initial assessment (pretest). Each workout consisted of six strength exercises performed on
six Keiser machines: leg extensions, leg curls, leg press, lat pull-down,
rowing movement, and chest press.
Each exercise was performed for one set of 10 repetitions. When 10
repetitions were completed with proper exercise form for three to five
consecutive workouts the weight load was increased by 5%. A proper
exercise form was defined as relatively slow movement and full range
of motion. All training repetitions were performed in approximately 7
s, with 2 s for each lifting movement (concentric muscle action), 4 s
for each lowering movement (eccentric muscle action), and a 1 s pause
at full muscle contraction to avoid momentum as a factor. All training
repetitions were executed through the full range of joint movement as
determined by the participant’s functional ability and freedom from
discomfort. The duration of the training sessions varied across participants but averaged between 15 and 20 min of overall duration and 6
min of muscle activity, as each of the six training exercises required
about 1 min of muscle activity.
The trained instructors initially assisted participants getting on and
off the machines, setting the seat positions, and designating the weight
at the appropriate resistance level. They also provided participants
with encouragement, feedback, and reinforcement throughout the
workout. Some participants, after a period of time, were paired up to
perform the exercise circuit with someone of similar abilities. However, all participants were supervised throughout the duration of the
study, especially for periodic resistance increases.
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JOURNAL OF AGING AND HEALTH / February 2006
Walking program. The walking program consisted of two walking
sessions per week during the period of 16 weeks. The initial walk
length and pace were determined at the beginning of the study based
on a preassessment performance during a timed, 880-yard walk. Participants were monitored individually and encouraged to gradually
increase the distance of their walks and reduce the elapsed time. However, the walks were self-paced and no maximum time was set to complete the exercise. An outdoor walk course and an indoor inclement
weather course were designated. Participants performed their walks
on the same day at the same time to enhance exercise adherence and
lessen the supervisory task. All walks were supervised and recorded,
and participants were encouraged to increase pace and distance
walked.
ANALYSES
We used paired t tests to calculate within-group pretest-to-posttest
differences. Given the number of comparisons performed, these analyses should only be considered exploratory. We used one-way analysis of variance (ANOVA) to test between-group differences in age and
baseline (pretest) scores.
To explore differences in performance on functional fitness measures attributable to intervention, we performed separate pairwise
comparisons within a 2(group: walking or resistance training vs. control) × 2(test: pretest vs. posttest) mixed-design repeated measures
analyses of variance (RM-ANOVA). The first factor was betweengroups and the second factor was within-groups. Comparing each
exercise group separately against the control group allowed the most
direct examination of our main hypothesis—to explore the effects of
any exercise on functional measures—and reduced the chances of
committing Type II error because of the relatively small sample size.
Similar pairwise comparisons were performed, for example, by
Brandon et al. (2004), Buchner et al. (1997), and Fiatarone et al.
(1994) in studies similar to ours.
We used the procedure general linear model (GLM) for unbalanced
designs from the SAS statistical software package (SAS Institute,
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Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
99
1999a) for one-way and repeated measures ANOVAs. This procedure
calculates a general linear model and is preferred over SAS procedure
ANOVA for its ability to account for differences in sample size across
treatment groups (SAS Institute, 1999b). The main goal of these analyses was to test the statistical significance of the group-by-test interaction. When group-by-test interaction was significant, the post hoc
Tukey’s test of honestly significant differences was used to explore
the direction of the differences identified by the significant interaction. The level of statistical significance was set at a two-tailed .05
level in all analyses. This level was automatically adjusted by the
Tukey’s test for comparison-wise Type I error.
To avoid multiple comparisons within the same domain in the main
analyses, we used composite measures of upper body strength (sum of
lat pull-down, chest press, and upper back), lower body strength (sum
of leg extensions, leg curl, and leg press), and shoulder flexibility
(sum of shoulder flexion and shoulder adduction). We used z scores to
account for variations in score ranges across these measures. Variables within each composite were highly correlated (r = .78 or higher).
Results
The average age was 81.6 years (SD = 3.3) in the walking group,
84.6 years (SD = 4.5) in the resistance-training group, and 84.0 years
(SD = 3.3) in the control group. One-way ANOVA yielded no significant between-group differences in age.
Mean scores, standard deviations, and within-group pretest to
posttest comparisons for all functional fitness measures are presented
in Table 1. There were no significant differences in pretest performance across the three groups. Overall, paired sample t tests indicated
that participants in the walking and resistance-training groups performed better at posttest compared to pretest on all functional measures and had lower systolic blood pressure at posttest. The control
group improved in lat pull-down and coordination and worsened in
shoulder adduction and agility and balance. The results from
2(group) × 2(test) RM-ANOVAs follow.
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100
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17.5
11.4
21.1
21.6
16.3
63.5
5.4
10.2
14.2
16.0
22.0
2.5
12
6
8
37.5
51.7
176.1
18.6
103.2
138.8
143.7
49.2
14.9
133
68
76
SD
50.8
28.1
45.0
M
SD
22.7
18.7
66.8
5.0
14.2
128*
70
76
9
4
6
149.5*** 12.6
150.7*** 15.2
44.8** 21.6
12.8**
2.8
47.1***
62.3***
191.4***
20.2*
116.4***
61.1** 20.2
37.2** 12.5
54.2*** 21.7
M
Posttest
133
70
75
142.0
144.4
50.8
15.1
29.8
45.2
183.8
17.9
102.7
55.2
32.1
48.1
M
13
9
6
10.0
10.0
22.4
2.7
20.3
19.1
81.9
3.6
6.4
20.0
16.2
17.7
SD
Pretest
SD
23.0
19.4
73.9
3.8
7.8
124*
68
75
11
6
6
151.9*** 10.8
153.0*** 10.2
41.4*
12.5
12.7*** 2.3
48.3***
61.2***
214.3***
19.5***
107.5***
65.5*** 22.1
41.6*** 17.7
55.9*** 21.5
M
Posttest
Resistance Training
Note. Paired sample t test statistic was used to calculate pretest to posttest differences in performance.
*p < .05. **p < .01. ***p < .001.
Upper body strength (pounds)
Lat pull-down
Chest press
Upper back
Lower body strength (pounds)
Leg extensions
Leg curl
Leg press
Flexibility test (inches)
Hip flexion (degrees)
Upper body flexibility (degrees)
Shoulder flexion
Shoulder adduction
Agility and balance (seconds)
Coordination (seconds)
Blood pressure (mm Hg)
Systolic blood pressure
Diastolic blood pressure
Resting heart rate (beats/min)
Variable
Pretest
Walking
Table 1
Means and Standard Deviations for Measures of Functional Fitness
128
68
73
146.9
152.0
50.3
15.6
30.0
39.0
138.8
19.3
103.1
46.9
30.0
42.9
M
9
8
5
15.9
13.9
16.5
2.9
17.2
17.2
66.9
5.3
22.1
16.5
12.6
14.7
SD
Pretest
M
14.1
16.2
68.5
4.2
20.7
129
70
77
12
5
12
140.8
30.7
138.4*
31.2
58.7** 16.9
13.5**
3.4
31.7
44.0
139.5
18.5
101.0
18.9
16.8
14.2
SD
Posttest
51.7*
30.0
42.1
Control
Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
101
WALKING GROUP VERSUS CONTROL GROUP
The RM-ANOVAs yielded a significant group-by-test interactions
for upper body strength (F[1, 38] = 11.68, p < .01), lower body
strength (F[1, 38] = 4.54, p < .05), shoulder flexibility (F[1, 38] =
12.41, p < .01), hip flexibility (F[1, 38] = 5.61, p < .05), and agility and
balance (F[1, 38] = 18.46, p < .001). The post hoc Tukey’s test comparisons indicated that all significant interactions reflected a performance gain of the walking group over the control group between pretest and posttest. The most substantial performance gains within the
walking group were in upper body strength (20%), coordination
(14%), lower body strength (12%), and hip flexibility (11%) (see
Figure 1).
RESISTANCE TRAINING GROUP VERSES CONTROL GROUP
The analyses yielded significant group-by-test interactions for
upper body strength (F[1, 41] = 9.85, p < .01), lower body strength
(F[1, 41] = 25.17, p < .001), shoulder flexibility (F[1, 41] = 14.29, p <
.01), agility and balance (F[1, 41] = 17.84, p < .001), and systolic
blood pressure (F[1, 41] = 4.32, p < .05), and a marginally significant
result for resting heart rate (F[1, 41] = 3.87, p = .06). Tukey’s tests
revealed that all results reflected an improvement in the resistancetraining group over the control group. The most substantial performance gains within the resistance-training group were observed in the
lower body strength (20%), agility and balance (20%), upper body
strength (17%), and coordination (16%) (see Figure 1).
Discussion
The goal of this study was to examine the effects of walking and
resistance-training exercise on multiple measures of functional fitness
among individuals in advanced old age who were sedentary prior to
the intervention. The main finding was that both types of exercise led
to functional improvement in multiple domains relative to a control
group. These findings provide further evidence for the benefits
of exercise in advanced old age found previously (Fiatarone et al.,
1994). Although our sample included participants with age range
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102
JOURNAL OF AGING AND HEALTH / February 2006
20
Walking
15
Resistance training
% improvement
10
Control
5
0
(5)
(10)
(15)
Resting heart rate
Diastolic blood
pressure
Systolic blood
pressure
Coordination
Agility/balance
Hip flexibility
Shoulder flexibility
Lower body
strength
Upper body
strength
(20)
Figure 1. Average pretest to posttest improvement on measures of functional fitness in the
walking, resistance training, and control groups.
Note. Improvement in upper and lower body strength reflects more pounds lifted; improvement
in hip and shoulder flexibility reflects more degrees of range of motion; improvement in agility
and balance and coordination reflects shorter time of exercise completion; improvement on diastolic and systolic blood pressure reflects lower blood pressure; and improvement in resting heart
rate reflects fewer beats per minute. Values in negative show decline.
from 66 to 96 years, only 5 participants (3 in the walking group, none
in the resistance-training group, and 2 in the control group) were less
than 75 years of age. In addition, both exercise programs appeared to
be feasible to sustain, at least for the 16-week duration of the study.
Only 3 out of the 39 participants assigned to the two intervention
groups did not complete the study (10% attrition).
Both walking and resistance training led to substantial improvements in lower and upper body strength. In addition, we found
improved hip and shoulder flexibility as well as agility and balance in
both exercise groups, although these were not part of the intervention.
Flexibility exercises were part of the warm-up routine administered
before each exercise session. Cavani et al. (2002) found similar
improvements in flexibility in a relatively younger cohort after 6
weeks of training with stretching and resistance-training exercises.
Performing quick movements and changes in direction without losing
balance becomes increasingly challenging with age (Bassey et al.,
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Simons, Andel / EXERCISE AND FUNCTIONAL FITNESS
103
1992; Brown, Sinacore, & Host, 1995), potentially leading to higher
incidence of falls (Buchner et al., 1997; Province et al., 1995). Therefore, the observed improvement in agility and balance may have
important implications for functional ability.
These findings support the notion that the benefits of exercise in
this age group tend to be relatively universal, possibly because of relatively low levels of activity in advanced old age. In addition, it appears
that walking, which requires no special equipment and may be more
accessible to this age group than resistance training, may improve
overall functional fitness in a similar way as resistance training.
A paired-sample t test suggested a significant within-group reduction in systolic blood pressure in the resistance-training group (see
Table 1). This finding, although only exploratory, may point to a
potentially important health benefit given that systolic blood pressure
is considered a good indicator of sclerotic arterial changes indicative
of cardiovascular disease (e.g., Izzo, Levy, & Black, 2000). Several
previous studies found improvement in cardiovascular health following aerobic exercise (Hagerman et al., 2000; Myers, 2003) or resistance training (Harris & Holly, 1987). Possibly, higher intensity or
duration of training in our study may have led to cardiovascular
benefits in the main analyses.
The limitations of this study include the fact that test-retest results
were not available. Additionally, a delayed follow-up would have
been helpful in terms of the implications of our findings for long-term
functional health and a larger sample would improve statistical power.
Future research should examine the potential longer term benefits of
exercise in this age group. Finally, the participants in this study
resided in the same community. Although the participants were
encouraged not to share information about intervention programs during the duration of the study, contamination across the control and
intervention groups may have occurred. However, any contamination
within the control group would mean that the results found in this
study only underestimate the effect of intervention.
In conclusion, the findings of this study indicate that previously
sedentary adults in advanced old age can improve their functional fitness by engaging in a supervised exercise program. Both resistancetraining and walking programs yielded improvements on multiple
measures of functional fitness, suggesting that benefits of exercise in
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104
JOURNAL OF AGING AND HEALTH / February 2006
advanced old age may be universal rather than specific to the type of
exercise.
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