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How much will older adults exercise? A feasibility study of aerobic training combined with resistance… Falck, Ryan S; Davis, Jennifer C; Milosevic, Elizabeth; Liu-Ambrose, Teresa Jan 26, 2017

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RESEARCH Open AccessHow much will older adults exercise? Afeasibility study of aerobic trainingcombined with resistance trainingRyan S. Falck1,3, Jennifer C. Davis1,3, Elizabeth Milosevic2 and Teresa Liu-Ambrose1,3*AbstractBackground: Both aerobic training (AT) and resistance training (RT) have multidimensional health benefits for olderadults including increased life expectancy and decreased risk of chronic diseases. However, the volume(i.e., frequency*time) of AT combined with RT in which untrained older adults can feasibly and safely participateremains unclear. Thus, our primary objective was to investigate the feasibility and safety of a high-volume exerciseprogram consisting of twice weekly AT combined with twice weekly RT (i.e., four times weekly exercise) on a groupof untrained older adults. In addition, we investigated the effects of the program on physical function, aerobiccapacity, muscular strength, and explored factors related to participant adherence.Methods: We recruited eight inactive older adults (65+ years) to participate in a 6-week, single-group pre-postexercise intervention, consisting of 2 days/week of AT plus 2 days/week of progressive RT for 6 weeks. We recordedprogram attendance and monitored for adverse events during the course of the program. Participants were tested atboth baseline and follow-up on the following: (1) physical function (i.e., timed-up-and-go test (TUG) and short physicalperformance battery (SPPB)), (2) aerobic capacity (VO2max) using the modified Bruce protocol; and (3) muscularstrength on the leg press and lat pull-down. Post intervention, we performed qualitative semi-structured interviews of allparticipants regarding their experiences in the exercise program. We used these responses to examine themes that mayaffect continued program adherence to a high-volume exercise program.Results: We recorded an average attendance rate of 83.3% with the lowest attendance for one session being five outof eight participants; no significant adverse events occurred. Significant improvements were observed for SPPB score(1.6; 95% CI: [0.3, 2.9]), VO2max (8.8 ml/kg/min; 95% CI: [2.8, 14.8]), and lat pull-down strength (11.8 lbs; 95% CI: [3.3, 20.2]).Qualitative results revealed two themes that promote older adults’ adherence: (1) convenience of the program and(2) the social benefits of exercise.Conclusions: Our findings suggest untrained older adults can be successful at completing twice weekly AT combinedwith twice weekly progressive RT; however, these exercise programs should be group-based in order to maintainhigh adherence.Keywords: Older adults, Exercise, Aerobic training, Resistance training, Feasibility study* Correspondence: teresa.ambrose@ubc.ca1Faculty of Medicine, Aging, Mobility and Cognitive Neuroscience Laboratory,Centre for Hip Health and Mobility, Vancouver Coastal Health ResearchInstitute, Robert H.N. Ho Research Centre, 5th Floor, 2635 Laurel St,Vancouver, BC V5Z 1M9, Canada3Department of Physical Therapy, Faculty of Medicine, Aging, Mobility andCognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for BrainHealth, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver,BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Falck et al. Pilot and Feasibility Studies  (2017) 3:2 DOI 10.1186/s40814-016-0116-5BackgroundExercise has multidimensional health benefits for olderadults including (1) increased life-expectancy [1], (2) re-duced risk of chronic diseases such as cardiovasculardisease [2], type II diabetes mellitus [3] and dementia[4], and (3) improved mental health and well-being [5].Regular exercise provides distinct physiological benefitsfor older adults including improved physical function[6], aerobic capacity [7], muscular strength [8], and cog-nitive function [9]. As such, the potential benefits of ex-ercise cannot be understated.For older adults to gain maximum benefit from exer-cise requires the precise prescription of frequency, inten-sity, type, and time [10]. Frequency refers to how oftenthe exercise occurs, usually in days per week. Intensity isthe level of exertion during the exercise and can beexpressed via multiple methods (e.g., Borg rate of per-ceived exertion [11, 12], heart rate, repetition max-imum). Type refers to the modality of exercise, and timerefers to the duration of the exercise bout (in minutes).Each of these components is important towards elicitingthe dose-response benefits of exercise; but most import-antly, each exercise program requires a sufficient—butsafe—amount of volume (i.e., frequency*time) and inten-sity to elicit adaptation [13].Two different types of exercise training (i.e., aerobictraining (AT) and resistance training [RT])—when ma-nipulated through a controlled progression in volumeand intensity—consistently demonstrate benefits forhealthy aging including cardiovascular health, mobility,and quality of life [14]. AT consists of repetitive move-ments specifically targeting the cardiovascular system[15]. Strong and accumulating evidence suggests AT isan important contributor to healthy aging and canpositively impact older adult cardiovascular health, lipidprofile, glucose tolerance, body composition, and bonedensity [16]. RT consists of muscle-strengthening exer-cises typically performed with free weights or machines.These exercises may cause positive adaptations in a myr-iad of factors including (1) markedly increased musclemass, strength, and power; (2) improved body compos-ition; (3) mobility and balance; and (4) improved qualityof life [17, 18]. As such, current recommendations suggestolder adults regularly engage in (1) moderate intensity AT5 days/week for at least 30 min/session or 3 days/week ofvigorous intensity for at least 20 min/session; (2) moderateintensity RT at least twice per week; and (3) participatingin more AT and RT should be encouraged [14]. While thecurrent ACSM guidelines are indeed a worthwhile goal,there are no specific guidelines for untrained older adults(i.e., have not previously engaged in exercise training inthe past 6 months) regarding the maximum total volumeof exercise training that is a safe and feasible startingpoint. Thus, an important next step is to determinewhether untrained older adults who are initiating anexercise program can tolerate high volumes of exercisetraining.Another essential component of establishing an effect-ive exercise program is understanding the factors thatmotivate adherence. While current guidelines suggestolder adults should engage in regular physical activity ofat least 150 min per week [14], most older adults areunable to meet these recommendations [19]. The mostcommon barriers to meeting these guidelines include (1)poor health, (2) environmental barriers, and (3) a lack ofknowledge of how to safely participate in physical activ-ity or an exercise program [20]. These barriers can alsosignificantly affect long-term exercise adherence [21]and thus prevent older adults from experiencing thelong term benefits of exercise training. As such, identify-ing factors for what makes older adults more likely toengage in—and adhere to—regular exercise training isan important line of inquiry.The safety and feasibility of older adults engaging inboth AT and RT concurrently is also not well established.Previous research suggests older adults can safelycomplete a 3 days/week exercise program consisting ofAT and RT in each exercise session [22] and 4 days/weekof AT alone [23]. While this preliminary evidence ispromising, it is still unknown what the underlying fac-tors of high-volume exercise programs are which makeolder adults more likely to adhere [24]. Thus, researchillustrating the experiences of older adults at exercisevolumes greater than 3 days/week is needed. This quali-tative information could shed light on ways to makehigher volumes of exercise feasible and enjoyable forolder adults.Hence, as an important next step, we examined thefeasibility and safety of a 6-week exercise program foradults ≥65 years of age consisting of twice weekly ATcombined with twice weekly RT. We also investigated ifthis exercise program would lead to improvements in (1)physical function, (2) aerobic capacity, and (3) musclestrength. Finally, we examined the experiences of olderadults engaged in high-volume exercise and the factorsrelated to program adherence.MethodsThis study was designed as a single group pre-post exer-cise intervention. This study was approved by VancouverCoastal Health Research Institute and the University ofBritish Columbia’s Clinical Research Ethics Board(H15-02181). All participants provided written informedconsent.ParticipantsWe recruited eight community dwelling older adults(65+ years) from December 1, 2015–January 9, 2016,Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 2 of 11via advertisement at both University of British Columbiaand Vancouver General Hospital, British Columbia,Canada. Interested individuals contacted the study coord-inator via telephone. We then performed a brief telephonescreening to determine study eligibility, and individualswho appeared to meet study criteria were invited to an in-formation session.Participants were eligible if they (1) were between 65–80 years of age, (2) were not regularly exercising for thepast 6 months (>60 min/week), (3) did not have any sig-nificant musculoskeletal issues, (4) were not diagnosedwith peripheral neuropathy, (5) did not have a high riskfor cardiac complications during exercise, (6) had notpreviously suffered a stroke, (7) had no moderate-to-severe respiratory diseases, (8) score >24/30 on themini-mental state exam (MMSE; [25]), and (9) did nothave any other medical condition precluding them fromexercise.We provided potential participants who attended theinformation session with details of the study and allowedthem to ask questions. Study personnel scheduled con-sent and screening sessions for interested participants.Those who remained eligible were scheduled for baselineassessment.MeasuresTrained staff members administered all testing proce-dures. A trained exercise physiologist was present for allexercise testing sessions.DemographicsAt study entry, we obtained general health history anddemographic information by questionnaire. In addition,we ascertained height and body weight using a calibratedstadiometer and a balance-beam scale, respectively.Height and weight were used to determine body massindex (BMI; kg/m2).Feasibility and safetyTo determine the feasibility of the program, we collectedattendance records from each AT and RT session. Weconsidered the exercise program to be feasible if wemaintained >50% attendance for all sessions and aver-aged >80% attendance per session. In addition, we moni-tored and recorded adverse events during the course ofthe study to determine the safety of the program.Physical functionWe assessed physical function of the participants usingthe timed-up-and-go test (TUG) [26] and the shortphysical performance battery (SPPB) [27]. For the TUG,participants rose from a standard chair, walked a dis-tance of three meters, turned, walked back to the chair,and sat down [26]. We recorded the time in seconds tocomplete the TUG, based on the average of two separatetrials. For the SPPB, participants were assessed on per-formances of standing balance, walking (4 m), and sit-to-stand. Each component is rated out of 4 points, for amaximum of 12 points; a score <9 predicts subsequentdisability [27].Aerobic capacityWe measured maximal aerobic capacity (VO2max) usingthe modified Bruce protocol [28], which is a submaximalgraded exercise test. The modified Bruce protocol is fre-quently used to estimate VO2max in older populations,due to the reduced level of stress it places upon the par-ticipant [28]. We monitored participant blood pressureand heart rate throughout the treadmill test according tostandard procedures and terminated the test when theparticipant reached volitional fatigue. VO2max was cal-culated using the following formula as recommended byBruce and colleagues [29]:Estimated VO2max ¼ 6:70 – 2:82  Sex þ 0:056  Timewhere the weighting factor is 1 = females and 2 =malesand time is recorded in seconds.Muscular strengthWe assessed muscular strength for all RT machines onKeiser pressurized air resistance machines (KeiserCorporation: Fresno, CA) using the 10-repetition max-imum (10-RM) test. We measured muscular strengthduring the second week of the exercise program in orderto allow participants to become acclimated with usingthe RT machines properly and to avoid excessive risk ofinjury during 10-RM testing. At follow-up testing, legpress, and lat pull-down were retested to determineupper- and lower-body strength gains.The 10-RM is generally used for older adult po-pulations due to the reduced absolute intensity of theexercise, as well as for increased safety [30–32]. Weestimated initial loads for the 10-RM test based on re-searcher experience and feedback from verbal questionspertaining to training history. If the participant reached12 repetitions, and reported being able to do more, thenthe participant was given a 5-min rest period followedby a subsequent 10-RM test wherein we increased theresistance by approximately 20%. This process was re-peated until the participant reached fatigue within 10repetitions. We then estimated 1-RM for the strengthexercises according to established guidelines [33]. Theseestimations were used to calculate the RT intensity forthe remainder of the program, with the target of trainingbeing 60–65% of 1-RM.Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 3 of 11ProcedureFollowing baseline testing, participants underwent6 weeks of four times weekly exercise training. Eachsession was approximately 60 min and included (1) a10-minute warm up, (2) 40 min of training (AT orRT), and (3) a 10-min cool down. We kept attend-ance records for all sessions, which were led by atrained exercise physiologist and assisted by multiplestaff members. We monitored the intensity of each train-ing session using the 20-point Borg rating of perceivedexertion (RPE) [11, 12].AT programTable 1 details the AT protocol. The AT twice-weeklyprogram followed a previously used protocol for olderadults [34, 35]. All sessions involved walking outside atan age-specific heart rate reserve (HRR) which graduallyprogressed from 45% HRR in the first week to 60% HRRin the final week of the program. Participants wore heartrate monitors at each AT session and were instructed tomaintain a target heart rate based on the %HRR. Once aparticipant reached their prescribed target heart rate,they were instructed to maintain the heart rate for theremainder of the session. The staff monitored the partic-ipants at 15-min intervals for their heart rate and RPE.RT programTable 2 details the twice-weekly RT protocol. During thefirst week of training, we instructed participants on theuse of the six RT machines. During the second session ofRT in the second week, participants tested for 10-RMstrength on all exercises. In all subsequent weeks of train-ing, participants performed the exercises using weight pre-scribed based off of estimations of %1-RM. The programleader increased the resistance if the exercise appearedvery easy for the participant or if the participant felt theintensity of the exercise was light (i.e., RPE <10).In-depth interview at study completionWe conducted in-depth, open-ended follow-up inter-views with all eight participants in order to understandtheir experiences of the program. We conducted thesesemi-structured interviews via an interpretivist perspec-tive in order to understand the complex world of livedexperience [36]. These interviews lasted approximately20 min and took place at the Centre for Hip Health andMobility at Vancouver General Hospital.We used nine open-ended questions in each interview,designed to elicit responses about program satisfactionand potential areas for improvement. Participants weremade aware that the purpose of the interview was tobetter understand their experiences during the exerciseprogram. Questions examined the following: (1) overallprogram experience, (2) most enjoyable and leastenjoyable aspects of the program, (3) easiest and mostdifficult aspects of the program, (4) subjective improve-ments in quality of life, (5) areas of the program partici-pants would change, (6) thoughts on committing to a sixmonth exercise program, (7) likelihood to continue thisexercise program longer than 6 months, (8) thoughts onthe cost and benefit of a four times per week exerciseprogram, and (9) preferences for either AT or RT. Whenwarranted, the interviewer used prompters to stimulatefurther elucidation of ideas. The same trained femaleauthor (EM) conducted, recorded, and transcribed allinterviews to ensure consistency across the data set.Data analysisWe scored all measures according to standard proce-dures and assessed whether changes in outcome mea-sures differed from zero using a one-sample t test. Foreach outcome measure, change was calculated as follow-up minus baseline. We present 95% CIs for each of thestatistical tests performed. We also calculated the ob-served effect size (Cohen’s d) for each outcome of inter-est using the following formula: (mean post test −meanbaseline)/(baseline standard deviation). Because of oursmall sample size, these calculations helped to determinethe potential clinical meaningfulness of the results inaddition to statistical significance. Conventions of small(d = 0.20), medium (d = 0.50), and large (d = 0.80) wereused [37]. The results of these hypothesis tests and effectsizes should be treated with caution and as preliminary,given our small sample size.We analyzed the follow-up interview transcripts ac-cording to the three stages of qualitative analysis out-lined by Carpenter and Suto [36]: data reduction, datadisplay, and conclusion drawing/verification. Briefly, inthe initial data reduction stage, two authors (RSF andEM) repeatedly read the transcripts in order to highlightsections of data that informed the research question. Wethen assigned codes to data fragments with similarmeanings and overlapping codes were then grouped intocategories. In the subsequent phase of analysis, thesecategories of data were refined and clustered together toform preliminary themes by two of the authors (RSF andEM). The tentative themes were then summarized in atable to provide a visual representation of the data, thusfacilitating further examination of patterns, relationships,and meanings. Lastly, in the conclusion drawing andverification stage, two of the authors established a final-ized set of overarching themes (RSF and EM).ResultsParticipant characteristicsParticipant characteristics are described in Table 3. Themajority of the participants were female (75.0%) and non-smokers (87.5%) and had a mean age of 73.6 ± 1.6 years.Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 4 of 11Table1AerobictrainingprogressionWeek1Week2Week3Week4Week5Week6ExerciseTime%HRRaTime%HRRTime%HRRTime%HRRTime%HRRTime%HRRAerobictrainingday1Warmup10min35%10min35%10min40%10min40%10min40%10min40%Training40min45%40min50%40min55%40min55%40min60%40min60%Cooldown10min35%10min35%10min40%10min40%10min40%10min40%Time%HRRTime%HRRTime%HRRTime%HRRTime%HRRTime%HRRAerobictrainingday2Warmup10min35%10min35%10min40%10min40%10min40%10min40%Training40min45%40min50%40min55%40min55%40min60%40min60%Cooldown10min35%10min35%10min40%10min40%10min40%10min40%a %HRR:estimated%heartratereserveFalck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 5 of 11Table2ResistancetrainingprogressionExerciseWeek1Week2Week3Week4Week5Week6Resistancetrainingday1Set1Set2Set1Set2Set1Set2Set1Set2Set1Set2Set1Set2RepsRepsRepsReps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×RepsLegpress12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Backrow12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Hamstringcurl12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Latpull-down12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Bicepcurl12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Tricepsextension12–121260%×1260%×1260%×1260%×1265%×1065%×1065%×1265%×12Wallpushups––––––8810101010Bodyweightsquats––––––8810101010Resistancetrainingday2Set1Set2Set1Set2Set1Set2Set1Set2Set1Set2Set1Set2RepsRepsRepsReps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×Reps%RM×RepsLegpress15–1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Backrow15−1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Hamstringcurl15–1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Latpull-down15–1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Bicepcurl15–1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Tricepsextension15–1010-RMtest60%×1060%×1060%×1060%×1065%×865%×865%×1065%×10Wallpushups––––––88101088Bodyweightsquats––––––88101088Note:Duringweek1andweek2ofRT,participantswereinstructedtochoose“easyandcomfortable”weightstouseforeachRTexercise.A10-repetitionmaximum(10-RM)testwasperformedattheendofweek2.%RM:estimated%of1-repetitionmaxFalck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 6 of 11Mean BMI was 24.5 ± 5.3 kg/m2. The most common co-morbidity was osteoporosis (25.0%).Feasibility and safetyParticipant attendance is described in Fig. 1. Participantattendance averaged 83.3% per session. The lowest at-tendance per session was five participants (i.e., 62.5%),which occurred twice. Two individuals had 100.0%attendance. We observed no significant adverse eventsduring the course of this study.Changes in outcome measuresChanges in outcome measures are summarized in Table 4.We calculated a moderate effect size improvement forTUG (d = −0.34), although we did not find a significantimprovement after 6 weeks. There was a significant im-provement in SPPB score following the program (1.6; 95%CI: [0.3, 2.9], p = 0.02) and found to be a large effect size(d = 1.12). Estimated lat pull-down 1-RM improved sig-nificantly (11.8 lbs; 95% CI: [3.3, 20.2], p = 0.02) with alarge effect size (d = 1.46). We also found a trend towardssignificant improvement in estimated leg press 1-RM(97.1 lbs; 95% CI: [−8.1, 202.3], p = 0.06) with a large effectsize (d = 0.97). We found a significant improvement inVO2max (8.8 ml/kg/min; 95% CI: [2.8, 14.8], p = 0.01) witha large effect size (d = 1.36).Responses to follow-up interviewsWe identified two parent themes: (1) factors impactingprogram satisfaction (Table 5) and (2) barriers for con-tinued participation (Table 6). Factors influencing pro-gram satisfaction included (1) program convenience, (2)program novelty, and (3) social benefits of exercise. Bar-riers for continued participation included long waittimes during the RT sessions and other commitmentsoutside of the exercise program.Factors impacting program satisfactionParticipants were more likely to enjoy the program ifthey found the scheduling of classes and location to beTable 3 Participant characteristics (N = 8)Participant characteristic Mean (SD) or frequency (%)Females 87.5%Age 73.4 (1.6)BMI (kg/m2) 24.1 (5.6)ComorbiditiesOsteoporosis 25.0%Skin cancer 12.5%Type 2 diabetes 12.5%Smoking statusNever smoked 87.5%Former smoker 12.5%Baseline physical performanceTimed up-and-go (s) 7.1 (3.4)SPPBa score 10.6 (1.4)Estimated 1-RM leg press 388.2 (277.8)Estimated 1-RM lat pull-down 94.5 (48.7)VO2max (ml/kg/min)b 39.4 (8.6)aShort physical performance batterybMaximal aerobic capacity measured by modified Bruce protocolFig. 1 Attendance averaged 83.33% per session with two sessions having the lowest attendance of 62.50%Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 7 of 11convenient. Several participants noted that they enjoyedthe class more because it was early in the morning, andit was close to where they lived. The novelty of the train-ing program also directly related to participant satisfac-tion. For example, participants enjoyed that AT was anew experience because they had never been to severalof the walking locations. Several participants also notedthe outdoor setting of the AT sessions as a contributingfactor to their satisfaction with the program. Participantsdescribed how being outdoors contributed to their en-joyment of exercise.Another factor, which impacted participant satisfac-tion, was the social environment of the classes. Par-ticipants thought the instructors created a welcomingenvironment by addressing them using their names andbeing encouraging during the exercise sessions. This en-vironment gave participants more motivation during theexercise sessions. Several participants had access to exer-cise facilities for independent use; however, they oftenexpressed apprehension about exercising on their own.Participants described the atmosphere of these facilitiesas “unfriendly” and thus did not make them feel like ex-ercising regularly. By comparison, our exercise programallowed participants to form new friendships, whichmade exercise more enjoyable. Social engagement withother participants was also cited as a contributing factorto overall satisfaction.Barriers to continued participationWhen asked about their preference between AT and RT,the participants preferred AT. While the reasons for thispreference were not always explicitly stated, several par-ticipants later discussed how they were unfamiliar withor nervous about using machines. In addition, partici-pants often had to wait for others to complete a station.These wait times sometimes made RT tedious and slow.Participants discussed the possibility of breaking theclass into smaller groups according to their speed oroverall ability. Dividing the RT sessions into smallerTable 4 Changes in outcomes and effect sizesOutcome Mean (95% CI) t value p value Cohen’s dΔTimed up-and-go (s) −1.5 (−5.0, 2.9) −0.96 0.37 −0.34ΔSPPB scorea 1.6 (0.3, 2.9) 2.98 0.02 1.12ΔEstimated 1-RMbleg press (lbs.)97.1 (−8.1, 202.3) 2.37 0.06 0.97ΔEstimated 1-RMlat pull-down (lbs.)11.8 (3.3, 20.2) 3.58 0.02 1.46ΔVO2max (ml/kg/min)c 8.8 (2.8, 14.8) 3.60 0.01 1.36aShort physical performance batterybRepetition maximumcMaximal aerobic capacity measured by modified Bruce protocolTable 5 Factors influencing program satisfactionProgram convenience• “My kids want me to join [a] seniors exercise group, but then parkingis very expensive there…I can just walk here.”• “Ten in the morning is perfect for exercise and walking. It’s only anhour and it’s in the morning, and then you’ve done something goodand have the rest of the day”Program novelty• “My favorite part was going down [to the water] where I haven’twalked before. It was so beautiful and it was a totally new experiencebecause I had never walked down there.”• “A first I was anxious because of the machines that we will be using…Yeah, I said ‘mhm I can’t remember the name of what we’re doing’ soI said ‘can I get pictures of these machines?’ because my kids will askme what am I doing or what are the things that I use and I can’t even[tell them].”Social benefits of exercise• “I enjoyed the people here; they were all great – very helpful everyone of them… Motivation is if you have somebody, I find myselfpersonally, that helps a lot.”• “I joined the [gym] for a while, well for one month. I went three timesand all three times when I asked the girl there at the desk if she wouldshow me how certain machines work, every time, all three times, shesaid ‘I’m just going on my break in a few minutes’. Yeah, and she’s theonly one on the desk, you know that was there to help. Yeah, and itwasn’t a very friendly place anyway. There were just people doing theirown thing and yeah… so I cancelled my membership in one month.Yeah I’m not going to put myself through a thing where I’m unhappybecause I don’t know what to do and how to do it. When you’re asenior that kind of thing is kind of devastating – when you don’t knowhow a machine works and you want to get fit, you know.”• “I enjoyed also the group, the very small group, and it’s good that youget to know these people. And talking while walking is really goodtoo… I didn’t feel tired because I was walking and talking at the sametime, so I really enjoyed that.”• “I liked the walking I guess…because it was outdoors and it wasspring and I could see life coming, the return of life.”Table 6 Barriers to continued participationLong wait times during RT sessions• “When we do the weights that time, a little bit we had to wait, a littlebit down time. But I don’t think there’s another way to do it. Unlesswe were trained and we were told what’s the program we can do onour own, and you don’t have to wait, have the down time. Sometimesit feels a little bit long, a little bit boring. But in general I think it’s okay.But if you are in the group and somebody is really slow they drag thewhole group.”• “What I thought would have helped is if we had been groupedaccording to our capability. Because some of us, we’re not the samesize and we’re not the same age and some people were faster… you[wouldn’t] have to change the settings as much.”Other activity commitments• “Yeah I probably could [continue to participate]. As long as it wasn’t inthe summer because in May, June, July, August, and September I lawnbowl…and I’m getting quite good at it so I go on the oddtournament now. So that kind of takes up some of my time.”• “In fact, I don’t mind to participate. And to be honest, I like to take partof it, but I have to know ahead of time because I don’t want to quit inthe middle of the program. If I commit to something, I rather finish, tocomplete it, right.”Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 8 of 11groups of individuals at a similar level of fitness mayhave improved participant enjoyment.When asked about participating in a longer exerciseprogram, many participants expressed a desire to do so;however, it was clear each individual had other priorities.Some participants felt continued involvement in a longerexercise program was possible, but they needed to makesure they had the time to commit to the program.DiscussionWe found that older adults can feasibly and safely par-ticipate in a high-volume exercise program consisting ofboth AT and RT. The strong adherence to our 6-weekhigh-volume exercise program also resulted in signifi-cant improvements in physical function, VO2max, andmuscular strength. Finally, our qualitative results provideevidence that the social environment and the conveni-ence of the program were strongly related to adherence.Our participants were able to safely complete and ad-here to a high-volume exercise program for 6 weeks,with an average attendance rate of 83.3% per session.Moreover, the quantitative results of our study showlarge improvements in physical function, aerobic cap-acity, and muscular strength following just 6 weeks oftraining; however, these results should be treated withcaution and as preliminary, given the small sample size.Other studies have found similarly large improvementsin each of these domains following exercise training.Taaffe and colleagues [38] found large-scale improve-ments in physical function and muscular strength ofolder adults from RT as little as once a week, althougholder adults were trained for 24 weeks in this study.Cress and others [39] found a 6-month combined ATand RT program had large-scale improvements in phys-ical function, VO2max, and muscular strength. However,our results indicate large improvements in both VO2maxand muscle strength can occur from a much more ab-breviated training period via high-volume exercise. Thus,older adults engaged in a high-volume exercise programmay be able to more rapidly achieve the benefits of exer-cise training.The results of our semi-structured interviews alsoillustrate that program convenience, the physical andsocial environment, and the lack of self-efficacy with RTall influenced continued adherence to our high-volumeexercise program. Participants found that the accessibil-ity of the program influenced their continued adherence.Previous research has shown accessibility of an exerciseprogram is directly related to exercise adherence in olderadults [20, 40]. Our qualitative results also suggested thesocial benefits of the exercise program were critical inkeeping people engaged in the program. Participants con-sistently mentioned the program gave them an opportunityto make new friends and have new experiences, whichhelped keep the program interesting. Social engagement isan important part of exercise for older adults [20, 24, 40],and thus, our findings further implicate social engagementas an important factor towards exercise adherence. Of finalnote, our data suggest AT is preferred over RT in olderadults. Walking was a highly familiar activity to the partici-pants whereas RT was often new, unfamiliar, and even ini-tially intimidating. Potentially, this lack of self-efficacy forRT could be eventually overcome in a longer program [41];however, this is beyond the scope of this investigation. An-other likely reason for the general preference for AT overRT was the discomfort caused by progressive RT for un-trained older adults [42], and thus, strategies to improveolder adult enjoyment of RT are needed.LimitationsThe exercise program we used was only 6 weeks in dur-ation and thus may not have been long enough to elicit sig-nificant adaptations in some of our measures. Our exerciseprogram only examined moderate-intensity exercise (i.e.,AT: 45–60% HRR; RT: 60–70% 1-RM) and thus cannot de-termine whether older adults will safely and feasiblycomplete a high-intensity exercise program. The moderate-intensity of our exercise program was based on currentguidelines for older adults [14], which may be a more feas-ible starting point for an exercise program than high-intensity exercise. Thus, future research is needed onwhether older adults can engage in a high-volume, high-intensity exercise program. A final limitation is our resultsare only applicable to the training program currently usedand could be potentially much different had another fre-quency and/or intensity of training been used.ConclusionsOur study suggests healthy older adults can successfullycomplete a 6-week high-volume, moderate-intensity,multimodal exercise trial. Our study also provides usefulinsights into designing future high-volume exercise in-terventions. Specifically, our qualitative data suggest thatthe following may promote greater adherence: (1) smallgroups for RT, (2) if incorporating AT into the program,performing the exercise outside, and (3) scheduling clas-ses early in the day in order to maintain high adherenceto a high-volume exercise program.AbbreviationsAT: Aerobic training; BMI: Body mass index; HRR: Heart rate reserve;MMSE: Mini-mental state exam; RPE: Rate of perceived exertion; RT: Resistancetraining; SPPB: Short physical performance battery; TUG: Timed up-and-go test;VO2max: Maximal aerobic capacity 10-RM: 10 repetition maximum.AcknowledgementsWe would like to thank Michelle Munkacsy for her help with editing the firstdraft of the manuscript and for her help with organizing the study.Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 9 of 11FundingFunding for this project was provided by Jack Brown & Family Alzheimer'sResearch Foundation and Canadian Institutes of Health Research operatinggrant (MOP-341331-SDA) to TLA. RSF is funded by the University of BritishColumbia Rehabilitation Sciences Doctoral Scholarship. TLA is a CanadaResearch Chair in Physical Activity, Mobility, and Cognitive Neuroscience.Availability of data and materialsThe datasets from the current study are available from the correspondingauthor on reasonable request.Authors’ contributionsRSF wrote the first draft of the manuscript. TLA and JCD conceived the studyconcept and design. RSF and EM examined the qualitative data, and EM andJCD helped write the qualitative component of the manuscript. TLA and JCDwrote portions of the manuscript and provided critical review. All authorshave read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThis study was approved by the Vancouver Coastal Health Research Instituteand the University of British Columbia’s Clinical Research Ethics Board(H15-02181). All participants provided written informed consent.Author details1Faculty of Medicine, Aging, Mobility and Cognitive Neuroscience Laboratory,Centre for Hip Health and Mobility, Vancouver Coastal Health ResearchInstitute, Robert H.N. Ho Research Centre, 5th Floor, 2635 Laurel St,Vancouver, BC V5Z 1M9, Canada. 2Faculty of Medicine, School of Kinesiology,University of British Columbia, 6081 University Blvd, Vancouver, BC V6T 1Z1,Canada. 3Department of Physical Therapy, Faculty of Medicine, Aging,Mobility and Cognitive Neuroscience Laboratory, Djavad MowafaghianCentre for Brain Health, University of British Columbia, 212-2177 WesbrookMall, Vancouver, BC V6T 1Z3, Canada.Received: 14 August 2016 Accepted: 12 December 2016References1. Mazzeo RS, Cavanagh P, Evans WJ, Fiatarone M, Hagberg J, McAuley E, et al.Exercise and physical activity for older adults. Med Sci Sports Exerc.1998;30:992–1008.2. 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McAuley E, Jerome GJ, Marquez DX, Elavsky S, Blissmer B. Exerciseself-efficacy in older adults: social, affective, and behavioral influences.Ann Behav Med. 2003;25:1–7.42. MacIntyre DL, Reid WD, McKenzie DC. Delayed muscle soreness. SportsMed. 1995;20:24–40.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Falck et al. Pilot and Feasibility Studies  (2017) 3:2 Page 11 of 11


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