Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People Maria A. Fiatarone, Evelyn F. O'Neill, Nancy Doyle Ryan, Karen M. Clements, Guido R. Solares, Miriam E. Nelson, Susan B. Roberts, Joseph J. Kehayias, Lewis A. Lipsitz, and William J. Evans ABSTRACT Background Although disuse of skeletal muscle and undernutrition are often cited as potentially reversible causes of frailty in elderly people, the efficacy of interventions targeted specifically at these deficits has not been carefully studied. Methods We conducted a randomized, placebo-controlled trial comparing progressive resistance exercise training, multinutrient supplementation, both interventions, and neither in 100 frail nursing home residents over a 10-week period. Results The mean (±SE) age of the 63 women and 37 men enrolled in the study was 87.1 ±0.6 years (range, 72 to 98); 94 percent of the subjects completed the study. Muscle strength increased by 113 ±8 percent in the subjects who underwent exercise training, as compared with 3 ±9 percent in the nonexercising subjects (P<0.001). Gait velocity increased by 11.8 ±3.8 percent in the exercisers but declined by 1.0 ±3.8 percent in the nonexercisers (P = 0.02). Stair-climbing power also improved in the exercisers as compared with the nonexercisers (by 28.4 ±6.6 percent vs. 3.6 ±6.7 percent, P = 0.01), as did the level of spontaneous physical activity. Cross-sectional thigh-muscle area increased by 2.7 ±1.8 percent in the exercisers but declined by 1.8 ±2.0 percent in the nonexercisers (P = 0.11). The nutritional supplement had no effect on any primary outcome measure. Total energy intake was significantly increased only in the exercising subjects who HOME | SUBSCRIBE | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | HELP | Advanced Search Search NEJMSEARCHInstitution: UNIVERSITY OF MISSOURI | Sign In as Individual | Contact Subscription Administrator at Your Institution | FAQ Volume 330:1769-1775 June 23, 1994 Number 25Next Abstract Letters Add to Personal ArchiveAdd to Citation ManagerNotify a FriendE-mail When Cited PubMed CitationPage 1 of 19NEJM -- Exercise Training and Nutritional Supplementation for Physical Frailty in Very ...8/11/2007http://proxy.mul.missouri.edu:4777/cgi/content/full/330/25/1769also received nutritional supplementation. Conclusions High-intensity resistance exercise training is a feasible and effective means of counteracting muscle weakness and physical frailty in very elderly people. In contrast, multinutrient supplementation without concomitant exercise does not reduce muscle weakness or physical frailty. The decline in muscle strength and mass during aging1,2 has been linked to physical frailty, falls, functional decline, and impaired mobility in very elderly people3,4,5. Although many factors, including chronic illness, a sedentary lifestyle, nutritional deficiencies, and aging itself, may contribute to muscle weakness and loss of skeletal-muscle mass in people of advanced age,6,7,8,9,10 currently only skeletal-muscle disuse11,12 and undernutrition13,14,15 are potentially preventable or reversible with targeted interventions. Muscle dysfunction associated with malnutrition may improve with nutritional supplementation in younger patients16,17. Even in healthy elderly men, a multinutrient supplement augmented muscle hypertrophy, although not muscle strength, during a resistance training regimen similar to the one described here18. We hypothesized that physical frailty is partially mediated by skeletal-muscle disuse and marginal nutritional intake, and should therefore be reduced by interventions designed to reverse these deficits. Methods Study Design Detailed descriptions of the rationale and design of the Boston FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) study19 and the entire FICSIT trial20 have been published elsewhere. Briefly, the Boston FICSIT study was a randomized, placebo-controlled, 10-week clinical trial in which the subjects were assigned to receive lower-extremity resistance training, a multinutrient supplement, both treatments, or a placebo activity and supplement. The study was approved by the human investigations review committees at New England Medical Center and the Hebrew Rehabilitation Center for Aged, and written informed consent was obtained from each subject. Study Population Volunteers were recruited from the residents of a 725-bed facility providing long-term care of the elderly. The criteria for inclusion were residential status, an age over 70 years, and the ability to walk 6 m. Subjects were excluded if they had severe cognitive impairment, rapidly progressive or terminal illness, acute illness or unstable chronic illness, myocardial infarction, fracture of a lower extremity within the six months before the study, or insulin-dependent diabetes mellitus; if they were on a weight-loss diet or undergoing resistance training at the time of enrollment; or if tests of muscle strength revealed a musculoskeletal or cardiovascular abnormality. Page 2 of 19NEJM -- Exercise Training and Nutritional Supplementation for Physical Frailty in Very ...8/11/2007http://proxy.mul.missouri.edu:4777/cgi/content/full/330/25/1769Interventions Resistance Training Subjects assigned to exercise training underwent a regimen of high-intensity progressive resistance training21 of the hip and knee extensors 3 days per week for 10 weeks. These muscle groups were chosen because of their importance in functional activities22. For each muscle group, the resistance was set at 80 percent of the one-repetition maximum (the maximal load that could be lifted fully one time only)23. To maintain the intensity of the stimulus, the load was increased at each training session, as tolerated by the subject. Strength testing was repeated every two weeks to establish a new base-line value. Training sessions lasted 45 minutes and were separated by one day of rest. Each repetition lasted six to nine seconds, with a one- to two-second rest between repetitions and a two-minute rest between the three sets of eight lifts. All exercise sessions were supervised individually by a single exercise trainer, who was a certified therapeutic recreation specialist. The knee extensors were trained with the use of the UNEX II chair (J.A. Preston, Clifton, N.J.). The hip extensors were trained in the first 53 subjects with the use of a wall-mounted