Effects of long-term resistive training on mobility and strength in older adults with diabetes

Metabolic and functional factors associated with a change in resting metabolic rate among older adults with type 2 diabetes- results from the CEV-65 randomized trial

Aims

This study evaluated the effects of circuit resistance training (CRT), a vegetarian/Mediterranean diet (VegMedD), and empagliflozin on Resting Metabolic Rate (RMR) in older adults with Type 2 Diabetes (T2DM).

Methods

67 participants from CEV-65 trial (≥65 years, 61 % female) were randomly assigned to CRT, VegMedD, or empagliflozin for 10 weeks. Assessments included RMR, medical, metabolic, nutritional, anthropometric and functional measurements. RMR changes were analyzed using paired t-tests, effect sizes, and repeated analysis of variance.

Results

No significant RMR differences were found between groups at baseline and post-intervention with minor RMR increases in 16 (CRT) to 25 % (VegMeD/empagliflozin). Factors correlating with RMR changes included sleep hours (r = 0.25), fat percentage (r = -0.27), leg strength (r = 0.29), and systolic blood pressure (r = 0.24). Except for blood pressure, all the other variables predicted RMR changes (R 2  = 0.22).

Conclusions

CRT, VegMedD, and empagliflozin showed similar effects on RMR in elderly with T2DM. Factors predicting changes in RMR are sleep hours, fat percentage, and leg strength, with those who increased/did not change their RMR presenting greater improvement in the aforementioned variables. These findings highlight the potential of these factors as therapeutic targets for improving metabolic health and warrant further investigation.

Strength-trained adults demonstrate greater corticoreticular activation versus untrained controls

The rapid increase in strength following strength-training involves neural adaptations, however, their specific localisation remains elusive. Prior focus on corticospinal responses prompts this study to explore the understudied cortical/subcortical adaptations, particularly cortico-reticulospinal tract responses, comparing healthy strength-trained adults to untrained peers. Fifteen chronically strength-trained individuals (≥2 years of training, mean age: 24 ± 7 years) were compared with 11 age-matched untrained participants (mean age: 26 ± 8 years). Assessments included maximal voluntary force (MVF), corticospinal excitability using transcranial magnetic stimulation (TMS), spinal excitability (cervicomedullary stimulation), voluntary activation (VA) and reticulospinal tract (RST) excitability, utilizing StartReact responses and ipsilateral motor-evoked potentials (iMEPs) for the flexor carpi radialis muscle. Trained participants had higher normalized MVF (6.4 ± 1.1 N/kg) than the untrained participants (4.8 ± 1.3 N/kg) (p = .003). Intracortical facilitation was higher in the strength-trained group (156 ± 49%) (p = .02), along with greater VA (98 ± 3.2%) (p = .002). The strength-trained group displayed reduced short-interval-intracortical inhibition (88 ± 8.0%) compared with the untrained group (69 ± 17.5%) (p < .001). Strength-trained individuals exhibited a greater normalized rate of force development (38.8 ± 10.1 N·s-1/kg) (p < .009), greater reticulospinal gain (2.5 ± 1.4) (p = .02) and higher ipsilateral-to-contralateral MEP ratios compared with the untrained group (p = .03). Strength-trained individuals displayed greater excitability within the intrinsic connections of the primary motor cortex and the RST. These results suggest greater synaptic input from the descending cortico-reticulospinal tract to α-motoneurons in strength-trained individuals, thereby contributing to the observed increase in VA and MVF.

Group-Based Trajectory Modelling of Changes in Mobility over Six Years in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

To investigate temporal changes in mobility in community-based people with type 2 diabetes, Fremantle Diabetes Study Phase II (FDS2) data were analysed. The baseline assessment included the Timed Up and Go (TUG) test, which was repeated biennially for up to six years. Group-based trajectory modelling (GBTM) identified TUG trajectory groups in participants with ≥2 tests. Independent associates of group membership were assessed using multinomial regression. Of 1551 potential FDS2 participants, 1116 (72.0%; age 64.9 ± 11.0 years, 45.6% female) were included in the modelling. The best-fitting GBTM model identified two groups with linear, minimally changing trajectories (76.2% and 19.4% of participants; baseline TUG times 8 ± 2 and 12 ± 3 s, respectively), and a third (4.5%; baseline TUG 17 ± 5 s) with a TUG that increased over time then fell at Year 6, reflecting participant attrition. Both slower groups were older, more likely to be female, obese, and had greater diabetes-associated complications and comorbidities. Almost one-quarter of the FDS2 cohort had clinically relevant mobility impairment that persisted or worsened over six years, was multifactorial in origin, and was associated with excess late withdrawals and deaths. The TUG may have important clinical utility in assessing mobility and its consequences in adults with type 2 diabetes.

Diet, exercise, and pharmacotherapy for sarcopenia in people with diabetes

Diabetes prevalence is increasing rapidly in older people, and sarcopenia is prevalent as a novel complication, particularly in patients with type 2 diabetes mellitus (T2DM). Therefore, sarcopenia prevention and treatment in these people is necessary. Diabetes accelerates sarcopenia through several mechanisms, such as hyperglycemia, chronic inflammation and oxidative stress. The effects of diet, exercise, and pharmacotherapy on sarcopenia in patients with T2DM need to be considered. In diet, low intake of energy, protein, vitamin D, and ω-3 fatty acid are associated with sarcopenia risk. In exercises, although intervention studies in people, especially older and non-obese patients with diabetes, are few, accumulating evidence shows the usefulness of exercise, particularly resistance exercise for muscle mass and strength, and aerobic exercise for physical performance in sarcopenia. In pharmacotherapy, certain classes of anti-diabetes compounds have possibility of preventing sarcopenia. However, much data on diet, exercise, and pharmacotherapy were obtained in obese and non-elderly patients with T2DM, demanding actual clinical data on non-obese and older patients with diabetes.

Association Between Physical Exercise Interventions Participation and Functional Capacity in Individuals with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Controlled Trials

Background

The prevalence of type 2 diabetes mellitus increases with age, and people with type 2 diabetes are more affected by reductions in functional performance. Although exercise interventions are recommended for people with diabetes, it is relevant to assess the effects of different training modes on the available functional outcomes. Therefore, our purpose was to systematically assess the effect of different physical exercise modalities in patients with type 2 diabetes with an average age of 45 years or older on outcomes used to measure functional capacity.

Methods

A systematic review and meta-analysis of controlled trials was conducted. Seven databases were searched from January 1987 to December 2021 (PubMed, Physiotherapy Evidence Database, Cochrane Library, SPORTDiscus, and in grey literature: Open Grey and Google Scholar). Eligible studies should last 8 weeks or longer, comparing structured exercise training and non-exercise control for one out of six pre-specified functional capacity outcomes (Timed Up and Go test, chair stands, walking performance, upper-limb muscle strength, lower-limb muscle strength, physical fitness parameter), in patients with type 2 diabetes, aged ≥ 45 years. The risk of bias was assessed with the Downs & Black checklist. Pooled mean differences were calculated using a random-effects model, followed by sensitivity and meta-regression analyses.

Results

Of 18,112 references retrieved, 29 trials (1557 patients) were included. Among these, 13 studies used aerobic training, 6 studies used combined training, 4 studies used resistance training, 3 studies had multiple intervention arms and 3 studies used other types of training. Exercise training was associated with an increase in functional capacity outcomes, as reflected by changes in 6-min walk test (n = 8) [51.6 m; 95% CI 7.6% to 95.6%; I² 92%], one-repetition maximum leg-press (n = 3) [18.0 kg; 95% CI 4.0% to 31.9%; I² 0%], and maximum oxygen consumption (VO_2max) (n = 20) [2.41 mL/kg·min; 95% CI 1.89% to 2.92%; I² 100%] compared with control groups. In sensitivity and subgroup analyses using VO_2max as outcome and stratified by type of study (randomized and non-randomized controlled clinical trials), duration of diabetes diagnosis, and sex, we observed overlapping confidence intervals. Meta-regression showed no association between glycated hemoglobin (HbA1C) levels and VO_2max [p = 0.34; I² 99.6%; R² = 2.6%]. In addition, the quality of the included studies was mostly low.

Conclusion

The results indicate that structured physical exercise programs might improve functional capacity in patients with type 2 diabetes, except for the upper-limb muscle strength. However, we could not identify potential effect predictors associated with directional summary estimates.

Trial registration This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42020162467); date of registration: 12/15/2019. The review protocol is hosted at the Open Science Framework (OSF) (Preprint https://doi.org/10.31219/osf.io/kpg2m).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00422-1.

Sociodemographic characteristics associated with self-care and quality of life among community-dwelling older adults with type 2 diabetes

AIMS

To assess how well community-dwelling older adults in Singapore were coping with their diabetes, and the sociodemographic characteristics that were associated with their level of coping.

METHODS

This was a cross-sectional study involving 257 older adults. Multiple regression was used to assess the associations between various sociodemographic characteristics and coping measures of present quality of life and level of self-care.

RESULTS

Older adults mainly sought care in the primary care setting. They were not coping well given their mean scores for diabetes-dependent quality of life and the self-care index were -3.57 and 3.55 respectively. Compared to those with post-secondary education, individuals who had no formal (adjusted B -0.92, p 0.003), primary level (adjusted B -0.76, p < 0.001) and secondary level (adjusted B -0.50, p < 0.02) education reported lower present quality of life. Those with prior lowest skill level occupations were less likely to consume a healthy diet per week than those with prior highest skill level occupations (adjusted B -1.48, p 0.004).

CONCLUSIONS

There should be provision of diabetes self-care interventions targeting older adults in Singapore especially for those with lower education and work skill levels. As the first line of contacts, primary care providers should advocate for diabetes self-care and develop community-based interventions for these priority groups.

Safety and Effectiveness of Long-Term Exercise Interventions in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Physical exercise is beneficial to reduce the risk of several conditions associated with advanced age, but to our knowledge, no previous study has examined the association of long-term exercise interventions (≥ 1 year) with the occurrence of dropouts due to health issues and mortality, or the effectiveness of physical exercise versus usual primary care interventions on health-related outcomes in older adults (≥ 65 years old).

OBJECTIVE

To analyze the safety and effectiveness of long-term exercise interventions in older adults.

METHODS

We conducted a systematic review with meta-analysis examining the association of long-term exercise interventions (≥ 1 year) with dropouts from the corresponding study due to health issues and mortality (primary endpoint), and the effects of these interventions on health-related outcomes (falls and fall-associated injuries, fractures, physical function, quality of life, and cognition) (secondary endpoints).

RESULTS

Ninety-three RCTs and six secondary studies met the inclusion criteria and were included in the analyses (n = 28,523 participants, mean age 74.2 years). No differences were found between the exercise and control groups for the risk of dropouts due to health issues (RR = 1.05, 95% CI 0.95-1.17) or mortality (RR = 0.93, 95% CI 0.83-1.04), although a lower mortality risk was observed in the former group when separately analyzing clinical populations (RR = 0.67, 95% CI 0.48-0.95). Exercise significantly reduced the number of falls and fall-associated injuries, and improved physical function and cognition. These results seemed independent of participants' baseline characteristics (age, physical function, and cognitive status) and exercise frequency.

CONCLUSIONS

Long-term exercise training does not overall influence the risk of dropouts due to health issues or mortality in older adults, and results in a reduced mortality risk in clinical populations. Moreover, exercise reduces the number of falls and fall-associated injuries, and improves physical function and cognition in this population.

Effects of resistance training using elastic bands on muscle strength with or without a leucine supplement for 48 weeks in elderly patients with type 2 diabetes

Type 2 diabetes is associated with sarcopenia. Resistance training and appropriate nutritional therapy are reported to be effective for muscle strength and mass. This study aimed to evaluate the effect of resistance training using elastic bands at home combined with a leucine-rich amino acid supplement on muscle strength, physical function, and muscle mass in elderly type 2 diabetes. We conducted a 48-week prospective single-center randomized controlled trial in 60 patients who were randomly allocated to one of three groups: control (C), resistance exercise (R), and resistance exercise plus supplement (RL). R and RL groups performed daily bodyweight resistance training with elastic bands exercises at home, and the RL group also took 6 g of a leucine-rich amino acid supplement daily. Knee extension strength (muscle strength), grip strength, usual gait speed (physical function), muscle mass, and cognitive function were assessed at 0 and 48 weeks. Although the change in knee extension strength from baseline was significantly increased by 6.4 Nm (95% CI 1.0, 11.7) in the RL group (p = 0.036), no significant difference was observed among the three groups (p = 0.090). Physical function, muscle mass, and cognitive function also had no changes during the study period among the three groups. No additive effect of a leucine-rich amino acid supplement on muscle strength or mass was observed. Although a post hoc analysis comparing with or without resistance training (C group vs. R + RL group) found that knee extension strength was significantly increased (p = 0.028), and cognitive decline was less (p = 0.046) than in the C group.

Physical fitness in older adults: Is there a relationship with the modified Functional Movement Screen™?

INTRODUCTION

The modified Functional Movement Screen™ (mFMS) has been used to screen for mobility, stability, motor control, and balance in older adults, yet, its relationship to measures of physical fitness is not fully understood. The purpose of this study was to determine the association between mFMS scores and measures of physical fitness in older adults. A secondary aim was to determine physical fitness differences depending on mFMS Lower Body Motor Control Screen scores.

METHODS

One hundred and eight older adults completed this cross-sectional study. Measurements of physical fitness included: Handgrip Strength (HG), Back-Leg Strength Dynamometer (BLS), 8 foot Up and Go (8UG), Vertical Jump (VJ), Medicine Ball Throw (MBT), Chair Stand (CST), Arm Curl (AC), and 6-Minute Walk test (6 MW). The mFMS consisted of four screens: Shoulder Mobility Screen (SMS), Deep Squat (DS), Active Straight Leg Raise (ASLR), and a Lower Body Motor Control Screen (LB-MCS). Spearman's R correlations determined associations between physical fitness tests and mFMS scores (DS, SMS, ASLR). Independent t-tests or Mann Whitney U tests determined whether individuals who passed the LB-MCS displayed higher physical fitness scores.

RESULTS

The DS was significantly correlated with all fitness measures (p < 0.05). Higher DS scores were associated with better HG (r = 0.31), BLS (r = 0.49), VJ height (r = 0.54), MBT (r = 0.41), CST (r = 0.57), AC (r = 0.30), 6 MW (r = 0.50), and 8UG (r = -0.61) performance. Individuals who passed the LB-MCS displayed superior BLS, 8UG test, and 6 MW test performance (p < 0.05).

DISCUSSION & CONCLUSION

Higher DS scores are associated with higher physical fitness scores. Individuals who passed the LB-MCS displayed better physical fitness scores. Practitioners may desire to use the mFMS to measure physical fitness in older adults.

Efficacy of community-based self-care interventions to improve biophysical, psychosocial or behavioural outcomes among community-dwelling older adults with type 2 diabetes: A systematic review and meta-analysis

AIMS

This review assessed the efficacy of self-care interventions to improve biophysical, psychosocial or behavioural outcomes among older adults with diabetes.

METHODS

Computerised and manual searches were performed. A total of 18 randomised control trials were included in the review, of which eight were subsequently included in the meta-analysis.

RESULTS

Most studies were from the United States of America and adopted a collaborative approach with participants. The specific needs of older adults were often not considered, and there was a predominance of biophysical measures. Meta-analysis revealed that among intervention condition participants, there were improvements in HbA1c (pooled weighted mean difference (WMD) -0.33, 95%CI -0.48 to -0.17), systolic blood pressure (WMD -1.55, 95%CI -2.93 to -0.18), diastolic blood pressure (WMD -1.41 95%CI -2.08 to -0.20), triglyceride (WMD -13.25, 95%CI -23.31 to -3.20), high-density lipoprotein (WMD 2.05, 95%CI 1.04 to 3.06) and Diabetes Self-Care Activities score (mean 4.10, 95%CI 3.11 to 5.10) compared to the control group. There was no significant change for low-density lipoprotein (WMD -5.93, 95%CI -12.08 to 0.22).

CONCLUSIONS

While continuing to adopt a collaborative approach, future self-care interventions should incorporate psychosocial and behavioural outcomes, consider the specific needs of older adults, and focus on more ethnically diverse populations.

Health behaviors a year after an early intervention exercise and education program for people with Parkinson's disease

Aim: To evaluate the impact of an early intervention program on exercise behavior and mood in people with Parkinson's disease (PD) 1 year following participation. Patients & methods: Education and exercise program participants (n = 152) were followed up for 1 year. Changes in exercise behavior and mood and factors associated with these changes were examined. Results: At follow-up, 28% more participants exercised (p < 0.001). Changes in the proportion reporting depression (12% reduction; p = 0.10) or anxiety (4% increase, p = 0.09) were not statistically significant. Conclusion: An education and exercise program promoted positive exercise behavior change sustained for a year, supporting the importance of early intervention for people with PD. Future research should explore sustainable ways to encourage prolonged behavior change, including regular follow-up.

Benefits and Harms of Exercise Therapy for Patients With Diabetic Foot Ulcers: A Systematic Review

AIM

Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer (DFU) are unknown. We therefore aimed to systematically review the benefits on health-related quality of life (HRQoL) and harms of exercise therapy for patients with DFU.

METHODS

We searched 6 major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials (RCTs) to assess potential benefits on HRQoL and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.

RESULTS

We included 10 published publications of 9 trials and results from 2 unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.

CONCLUSIONS/INTERPRETATION

Protective strategies are often preferred over therapeutic exercise that might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation including detailed description of adverse events and an exercise program in a semisupervised or fully supervised setting.

What makes long-term resistance-trained individuals so strong? A comparison of skeletal muscle morphology, architecture, and joint mechanics

The greater muscular strength of long-term resistance-trained (LTT) individuals is often attributed to hypertrophy, but the role of other factors, notably maximum voluntary specific tension (ST), muscle architecture, and any differences in joint mechanics (moment arm), have not been documented. The aim of the present study was to examine the musculoskeletal factors that might explain the greater quadriceps strength and size of LTT vs. untrained (UT) individuals. LTT (n = 16, age 21.6 ± 2.0 yr) had 4.0 ± 0.8 yr of systematic knee extensor heavy-resistance training experience, whereas UT (n = 52; age 25.1 ± 2.3 yr) had no lower-body resistance training experience for >18 mo. Knee extension dynamometry, T1-weighted magnetic resonance images of the thigh and knee, and ultrasonography of the quadriceps muscle group at 10 locations were used to determine quadriceps: isometric maximal voluntary torque (MVT), muscle volume (Q_VOL), patella tendon moment arm (PTMA), pennation angle (QΘ_P) and fascicle length (QF_L), physiological cross-sectional area (QPCSA), and ST. LTT had substantially greater MVT (+60% vs. UT, P < 0.001) and Q_VOL (+56%, P < 0.001) and QPCSA (+41%, P < 0.001) but smaller differences in ST (+9%, P < 0.05) and moment arm (+4%, P < 0.05), and thus muscle size was the primary explanation for the greater strength of LTT. The greater muscle size (volume) of LTT was primarily attributable to the greater QPCSA (+41%; indicating more sarcomeres in parallel) rather than the more modest difference in F_L (+11%; indicating more sarcomeres in series). There was no evidence in the present study for regional hypertrophy after LTT.

NEW & NOTEWORTHY Here we demonstrate that the larger muscle strength (+60%) of a long-term (4+ yr) resistance-trained group compared with untrained controls was due to their similarly larger muscle volume (+56%), primarily due to a larger physiological cross-sectional area and modest differences in fascicle length, as well as modest differences in maximum voluntary specific tension and patella tendon moment arm. In addition, the present study refutes the possibility of regional hypertrophy, despite large differences in muscle volume.

The effect of cognitive function on mobility improvement among community-living older adults: A 12-week resistance exercise intervention study

The purpose of the study was to investigate the association between baseline cognitive function and improvement in mobility after 12 weeks of resistance training (3 times/week; 3 sets, 6-8 repetitions at 75-80% of the 1-repetition maximum) among community-dwelling older adults in Iceland (N=205, 73.5±5.7 years, 57.0% female). Body composition, physical activity status, cardiovascular risk factors, 6-minute walk test (6MWT), and Mini-Mental State Examination (MMSE) were measured. The linear regression model was used to examine the association between baseline MMSE and mobility improvement. Mean distance of 6MWT was 462.8±71.6 meter at baseline and mean change after the exercise intervention was 33.7±34.9 meter. The mean MMSE score at baseline was 27.6±1.9. After adjusting for baseline covariates, we found that baseline MMSE score was significantly associated with improvement in mobility among older adults after the exercise intervention. Cognitive function strongly influences the effect of exercise intervention on mobility among older adults.

Continuous Movement Monitoring of Daily Living Activities for Prevention of Diabetic Foot Ulcer: A Review of Literature

Lower extremity ulcers represent the most ominous, feared, and costly complications of diabetes mellitus. The aim of this review is to highlight the role of daily life physical activities (PAs) and continuous movement monitoring (CMM) in the prevention of foot ulcers. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute, in turn, to the development of additional risk factors such as foot deformities and/or joint and muscular alterations. Moreover, a deficit of balance, posture abnormalities, followed by gait alterations, increases the risk of ulceration. PA can play a key role in the management of patients with diabetes and in the prevention of ulcers; however, even if it has been reported that some of these risk factors significantly improve after a few weeks of exercise therapy (ET), the real preventive role of ET has not yet been demonstrated. These uncertain results can occur due to some limitations in the management of the same relationship between PA and diabetic foot prevention. Technological advances during the last years enable timely management of overall daily PA. The use of these modern technologies and devices allows CMM assessment and description of daily PA even in the long term. The data collected from these devices can be used to properly manage patients' PA and thus contribute to the prevention of foot ulcers.

Impact of a motivational resistance-training programme on adherence and body composition in the elderly

Lack of physical activity is one of the major causes for obesity and functional disability in the elderly. Including regular exercise in the elderly's lifestyle is not an easy task. The main objective was to analyse the effect of a motivational resistance-training programme on satisfying the individual's psychological needs, level of self-determination and body composition. A quasi-experimental study was performed with 47 volunteers (29 females, 18 males) of 67-75 years of age, divided into two groups: experimental (n = 27) and control (n = 20). A 12-week intervention programme was performed, with a total of 36 sessions. The results of the inter-group analysis indicated significant differences in the post-test measurement between the experimental group and the control group (in favour of the experimental group) regarding basic psychological needs. The experimental group, in comparison to the control group, significantly decreased their percentage of fat mass and increased muscle mass. Body weight and BMI values increased in the control group, while significantly decreasing in the experimental group. In conclusion, the motivational resistance-training programme in the elderly gave rise to positive significant changes at the physical, psychological and social levels, according to the definition of health by the World Health Organization.

Exercise interventions for the improvement of falls-related outcomes among older adults with diabetes mellitus: A systematic review and meta-analyses

INTRODUCTION

Falls as a complication of diabetes mellitus (DM) can have a major impact on the health of older adults. Previous reviews have demonstrated that certain exercise interventions are effective at reducing falls in older people; however, no studies have quantified the effectiveness of exercise interventions on falls-related outcomes among older adults with DM.

METHODS

A systematic search for all years to September 2015 identified available literature. Eligibility criteria included: appropriate exercise intervention/s; assessed falls-related outcomes; older adults with DM. Effect sizes were pooled using a random effects model. Positive effect sizes favoured the intervention.

RESULTS

Ten RCTs were eligible for the meta-analyses. Exercise interventions were more effective than the control condition for static balance (0.53, 95% CI: 0.13 to 0.93), lower-limb strength (0.63, 95% CI: 0.09 to 1.18), and gait (0.59, 95% CI: 0.22 to 0.96). No RCTs assessed falls-risk; one RCT reported 12month falls-rate, with no differential treatment effect observed.

CONCLUSION

Exercise interventions can improve certain falls-related outcomes among older adults with DM. Substantial heterogeneity and limited numbers of studies should be considered when interpreting results. Among older adults, where DM burden is increasing, exercise interventions may provide promising approaches to assist the improvement of falls-related outcomes.

Changes in agonist neural drive, hypertrophy and pre-training strength all contribute to the individual strength gains after resistance training

PURPOSE

Whilst neural and morphological adaptations following resistance training (RT) have been investigated extensively at a group level, relatively little is known about the contribution of specific physiological mechanisms, or pre-training strength, to the individual changes in strength following training. This study investigated the contribution of multiple underpinning neural [agonist EMG (QEMG_MVT), antagonist EMG (HEMG_ANTAG)] and morphological variables [total quadriceps volume (QUADS_VOL), and muscle fascicle pennation angle (QUADSθ _p)], as well as pre-training strength, to the individual changes in strength after 12 weeks of knee extensor RT.

METHODS

Twenty-eight healthy young men completed 12 weeks of isometric knee extensor RT (3/week). Isometric maximum voluntary torque (MVT) was assessed pre- and post-RT, as were simultaneous neural drive to the agonist (QEMG_MVT) and antagonist (HEMG_ANTAG). In addition QUADS_VOL was determined with MRI and QUADSθ _p with B-mode ultrasound.

RESULTS

Percentage changes (∆) in MVT were correlated to ∆QEMG_MVT (r = 0.576, P = 0.001), ∆QUADS_VOL (r = 0.461, P = 0.014), and pre-training MVT (r = -0.429, P = 0.023), but not ∆HEMG_ANTAG (r = 0.298, P = 0.123) or ∆QUADSθ _p (r = -0.207, P = 0.291). Multiple regression analysis revealed 59.9% of the total variance in ∆MVT after RT to be explained by ∆QEMG_MVT (30.6%), ∆QUADS_VOL (18.7%), and pre-training MVT (10.6%).

CONCLUSIONS

Changes in agonist neural drive, quadriceps muscle volume and pre-training strength combined to explain the majority of the variance in strength changes after knee extensor RT (~60%) and adaptations in agonist neural drive were the most important single predictor during this short-term intervention.

Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

Exercise interventions in polypathological aging patients that coexist with diabetes mellitus: improving functional status and quality of life

In elderly populations, diabetes is associated with reduced muscle strength, poor muscle quality, and accelerated loss of muscle mass. In addition, diabetes mellitus increases risk for accelerated aging and for the development of frailty syndrome. This disease is also associated with a polypathological condition, and its complications progressively affect quality of life and survival. Exercise interventions, including resistance training, represent the cornerstones of diabetes management, especially in patients at severe functional decline. This review manuscript aimed to describe the beneficial effects of different exercise interventions on the functional capacity of elderly diabetics, including those at polypathological condition. The SciELO, Science Citation Index, MEDLINE, Scopus, SPORTDiscus, and ScienceDirect databases were searched from 1980 to 2015 for articles published from original scientific investigations. In addition to the beneficial effects of exercise interventions on glycemic control, and on the cardiovascular risk factors associated with diabetes, physical exercise is an effective intervention to improve muscle strength, power output, and aerobic power and functional capacity in elderly diabetic patients. Thus, a combination of resistance and endurance training is the most effective exercise intervention to promote overall physical fitness in these patients. In addition, in diabetic patients with frailty and severe functional decline, a multicomponent exercise program including strength and power training, balance exercises, and gait retraining may be an effective intervention to reduce falls and improve functional capacity and quality of life in these patients.

Diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment

Lower extremity ulcers represent a serious and costly complication of diabetes mellitus. Many factors contribute to the development of diabetic foot. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute in turn to the growth of additional risk factors such as limited joint mobility, muscular alterations and foot deformities. Moreover, a deficit of balance, posture and biomechanics can be present, in particular in patients at high risk for ulceration. The result of this process may be the development of a vicious cycle which leads to abnormal distribution of the foot's plantar pressures in static and dynamic postural conditions. This review shows that some of these risk factors significantly improve after a few weeks of exercise therapy (ET) intervention. Accordingly it has been suggested that ET can be an important weapon in the prevention of foot ulcer. The aim of ET can relate to one or more alterations typically found in diabetic patients, although greater attention should be paid to the evaluation and possible correction of body balance, rigid posture and biomechanics. Some of the most important limitations of ET are difficult access to therapy, patient compliance and the transitoriness of the results if the training stops. Many proposals have been made to overcome such limitations. In particular, it is important that specialized centers offer the opportunity to participate in ET and during the treatment the team should work to change the patient's lifestyle by improving the execution of appropriate daily physical activity.

Time course of improvement of metabolic parameters after a 12 week physical exercise programme in patients with type 2 diabetes: the influence of gender in a Nigerian population

Gender is a major determinant of the outcomes of many health interventions. This study documents the order of significant improvements in metabolic parameters of patients with type 2 diabetes mellitus (T2DM) having metabolic syndrome within 12 weeks of physical exercise programmes. Twenty-nine patients, mean age 49.6 ± 3.7 years, presenting with high fasting plasma glucose, high triglycerides, hypertension, and high waist circumference undertook a thrice weekly aerobic and endurance exercise programme in addition to their drugs and diet. Variables were assessed at baseline and end of every two weeks for twelve weeks. Compared with baseline, significant improvement (P < 0.05) in the metabolic parameters occurred in this order for the male participants: fasting glucose (2nd week), triglycerides and waist circumference (4th week), and systolic blood pressure (12th week). For the female participants, it was fasting glucose (4th week), triglycerides (6th week), and waist circumference (10th week). Regardless of the gender, fasting glucose was the first to improve significantly, followed by triglycerides. Hypertension did not improve significantly at all in the female participants as they may require more than twelve weeks of therapeutic exercise for any significant improvement in hypertension.

Community-based physical activity interventions for treatment of type 2 diabetes: a systematic review with meta-analysis

Evidence suggests engaging in regular physical activity (PA) can have beneficial outcomes for adults with type 2 diabetes (TD2), including weight loss, reduction of medication usage and improvements in hemoglobin A1c (HbA1c)/fasting glucose. While a number of clinical-based PA interventions exist, community-based approaches are limited. The objective of this study is to conduct a systematic review with meta-analysis to assess the effectiveness of community-based PA interventions for the treatment of TD2 in adult populations. A search of peer-reviewed publications from 2002 to June 2012 was conducted across several electronic databases to identify interventions evaluated in community settings. Twenty-two studies were identified, and 11 studies reporting HbA1c as an outcome measure were pooled in the meta-analysis. Risk of bias assessment was also conducted. The findings demonstrate community-based PA interventions can be effective in producing increases in PA. Meta-analysis revealed a lowering of HbA1c levels by -0.32% [95% CI -0.65, 0.01], which approached statistical significance (p < 0.06). Our findings can guide future PA community-based interventions in adult populations diagnosed with TD2.

Effect of 12-week resistance exercise program on body composition, muscle strength, physical function, and glucose metabolism in healthy, insulin-resistant, and diabetic elderly Icelanders

BACKGROUND

Insulin is a stimulator of skeletal muscle protein anabolism and insulin resistance might therefore negatively affect muscle protein metabolism. We investigated muscle mass and physical function before and after a resistance exercise program in participants with prediabetes or type 2 diabetes mellitus (T2DM) in comparison to healthy controls.

METHODS

This was a secondary analysis of a randomized controlled intervention designed to investigate resistance training among older adults. Glucose metabolism status was not a selection criteria for the trial, and group designation was done retrospectively. Participants (N = 237, 73.7 ± 5.7 y, 58.2% women) participated in a 12-week resistance exercise program (3 times/week; three sets, six to eight repetitions at 75%-80% of the one-repetition maximum), designed to increase strength and muscle mass of major muscle groups. Body composition, muscular strength, timed up and go test, 6-minute walk for distance, and blood chemical variables were measured at baseline and endpoint.

RESULTS

Participants completing the study (n = 213) experienced significant changes in muscle strength or muscle function, which did not differ significantly between healthy (n = 198), prediabetic (n = 20), and T2DM participants (n = 17). Changes in serum glucose during the intervention differed by group: only glucose improved significantly in the prediabetic group, glucose and triacylglycerol improved significantly in the healthy group, whereas no serum parameter improved significantly in the T2DM group.

CONCLUSIONS

A 12-week resistance exercise program improves muscle strength and muscle function to a similar extent in healthy, prediabetic, and T2DM elderly people. However, according to our data, T2DM participants do not experience favorable changes in fasting glucose or HbA(1C).

Effects of 14-Week Tai Ji Quan Exercise on Metabolic Control in Women with Type 2 Diabetes

The present study investigated the effects of 14 weeks of practicing Tai Ji Quan (TJQ) on metabolic control and lipid metabolism in women with type 2 diabetes. Twenty Beijing female residents (57.4 ± 6.2 years) were recruited and were randomly assigned to either the TJQ training or the control group. In the TJQ group, the exercise duration was 1 hour per day and 5 days a week for 14 weeks. FPG, GSP, FPI, TC, HDL-C, LDL-C, TG, resting blood pressures and heart rate were measured before and after the 14 weeks in the 2 groups. It was found that after 14 weeks, the TJQ group had significantly lower FPG, GSP, TG and higher FPI concentration, whereas there were no significant differences in TC, HDL-C and LDL-C. It was concluded that TJQ exercise could be used as an intervention tool to improve glycaemic control and serum TG level in the elderly people. Future research with TJQ of different styles and exercise of different intensities were recommended.

Evidence-based risk assessment and recommendations for physical activity clearance: diabetes mellitus and related comorbidities1This paper is one of a selection of papers published in this Special Issue, entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer review process

Physical activity (PA) is one of the most powerful treatment options for persons with prediabetes or diabetes. However, some elevation in risk occurs with increased PA, at least initially, and certain precautions need to be made to lower these risks, particularly if these persons are unaccustomed to exercise. We conducted a standardized search of all adverse events associated with increased PA in persons with prediabetes or diabetes (type 1 or type 2) and provided evidence-based guidelines on PA screening in these apparently high-risk individuals. A systematic literature review was performed of all studies reporting on adverse events in persons with prediabetes or diabetes. Studies included were from all designs (retrospective and prospective including randomized controlled trials) and were assessed according to evaluation criteria adapted by a consensus panel. A total of 47 studies, involving >8000 individuals, were deemed eligible. A number of these studies identified a range of mild to severe acute risks with exercise (musculoskeletal injury, hypoglycemia, foot ulceration, proliferative retinopathy, hypotension, sudden death) but the overall prevalence was low. Based on several randomized controlled trials and prospective studies in which prescribed exercise was performed at a wide range of intensities, it appears that increased PA is a relatively safe procedure with no evidence of a loss of life. Based on our assessment of the available literature, we provide a new PA risk algorithm for persons with prediabetes and diabetes and comment on the role of the patient, the qualified exercise professional, and the patient’s physician in the risk screening process.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Resistance training in the treatment of the metabolic syndrome: a systematic review and meta-analysis of the effect of resistance training on metabolic clustering in patients with abnormal glucose metabolism

Over the last decade, investigators have given increased attention to the effects of resistance training (RT) on several metabolic syndrome variables. The metabolic consequences of reduced muscle mass, as a result of normal aging or decreased physical activity, lead to a high prevalence of metabolic disorders. The purpose of this review is: (i) to perform a meta-analysis of randomized controlled trials (RCTs) regarding the effect of RT on obesity-related impaired glucose tolerance and type 2 diabetes mellitus; and (ii) to investigate the existence of a dose-response relationship between intensity, duration and frequency of RT and the metabolic clustering. Thirteen RCTs were identified through a systematic literature search in MEDLINE ranging from January 1990 to September 2007. We included all RCTs comparing RT with a control group in patients with abnormal glucose regulation. For data analysis, we performed random effects meta-analyses to determine weighted mean differences (WMD) with 95% confidence intervals (CIs) for each endpoint. All data were analysed with the software package Review Manager 4.2.10 of the Cochrane Collaboration. In the 13 RCTs included in our analysis, RT reduced glycosylated haemoglobin (HbA(1c)) by 0.48% (95% CI -0.76, -0.21; p = 0.0005), fat mass by 2.33 kg (95% CI -4.71, 0.04; p = 0.05) and systolic blood pressure by 6.19 mmHg (95% CI 1.00, 11.38; p = 0.02). There was no statistically significant effect of RT on total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride and diastolic blood pressure. Based on our meta-analysis, RT has a clinically and statistically significant effect on metabolic syndrome risk factors such as obesity, HbA(1c) levels and systolic blood pressure, and therefore should be recommended in the management of type 2 diabetes and metabolic disorders.

Moderate resistive training maintains bone mineral density and improves functional fitness in postmenopausal women

Twenty five subjects were randomized to untrained (UN) and resistive-trained (RT) groups. The RT group exercised three sessions per week at 60%–70% of the load according to individual 1RM test during 24 weeks. Both groups were evaluated before and after protocol period assessing lumbar spine (LS) and femoral neck (FN) BMD by dual-energy X-ray absorptiometry, VO₂ max, and neuromuscular fitness. After 24 weeks, there were significant reductions in LS (0.89 ± 0.16% loss) and FN BMD (1.54 ± 0.35% loss) for UN but no change was found in the TR (LS: 0.01 ± 0.12% and FN: 0.04 ± 0.05% loss). The UN group had no changes in neuromuscular performance. However, RT exhibited a significant improvement on the functional fitness parameters evaluated, with the exception of agility. Our results indicate RT suppresses the decline in BMD and simultaneously improves the functional fitness of postmenopausal women without hormone replacement therapy, which may reduce fall risk and related bone fractures.

Progressive resistance exercise improves glycaemic control in people with type 2 diabetes mellitus: a systematic review

QUESTION

Is progressive resistance exercise a safe and effective form of exercise to improve glycaemic control in people with type 2 diabetes?

DESIGN

Systematic review with meta-analysis of randomised controlled trials.

PARTICIPANTS

People with type 2 diabetes mellitus.

INTERVENTION

Progressive resistance exercise.

OUTCOME MEASURES

The primary outcome was glycaemic control measured as percentage glycosylated haemoglobin (HbA1c). Secondary outcomes were body composition (lean body and fat free mass in kg), and muscle strength (% change in 1RM, dynamometry, change in maximum weight lifted).

RESULTS

The search yielded nine relevant trials that evaluated 372 people with type 2 diabetes. Compared to not exercising, progressive resistance exercise led to small and statistically significant absolute reductions in HbA1c of 0.3% (SMD -0.25, 95% CI -0.47 to -0.03). When compared to aerobic exercise there were no significant differences in HbA1c. Progressive resistance exercise resulted in large improvements in strength when compared to aerobic (SMD 1.44, 95% CI 0.83 to 2.05) or no exercise (SMD 0.95, 95% CI 0.58 to 1.31). There were no significant changes in body composition.

CONCLUSIONS

Progressive resistance exercise increases strength and leads to small reductions in glycosylated haemoglobin that are likely to be clinically significant for people with type 2 diabetes. Progressive resistance exercise is a feasible option in the management of glycaemia for this population.

Progressive resistance strength training for improving physical function in older adults

BACKGROUND

Muscle weakness in old age is associated with physical function decline. Progressive resistance strength training (PRT) exercises are designed to increase strength.

OBJECTIVES

To assess the effects of PRT on older people and identify adverse events.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 01, 2008), EMBASE (1980 to February 06 2007), CINAHL (1982 to July 01 2007) and two other electronic databases. We also searched reference lists of articles, reviewed conference abstracts and contacted authors.

SELECTION CRITERIA

Randomised controlled trials reporting physical outcomes of PRT for older people were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

One hundred and twenty one trials with 6700 participants were included. In most trials, PRT was performed two to three times per week and at a high intensity. PRT resulted in a small but significant improvement in physical ability (33 trials, 2172 participants; SMD 0.14, 95% CI 0.05 to 0.22). Functional limitation measures also showed improvements: e.g. there was a modest improvement in gait speed (24 trials, 1179 participants, MD 0.08 m/s, 95% CI 0.04 to 0.12); and a moderate to large effect for getting out of a chair (11 trials, 384 participants, SMD -0.94, 95% CI -1.49 to -0.38). PRT had a large positive effect on muscle strength (73 trials, 3059 participants, SMD 0.84, 95% CI 0.67 to 1.00). Participants with osteoarthritis reported a reduction in pain following PRT(6 trials, 503 participants, SMD -0.30, 95% CI -0.48 to -0.13). There was no evidence from 10 other trials (587 participants) that PRT had an effect on bodily pain. Adverse events were poorly recorded but adverse events related to musculoskeletal complaints, such as joint pain and muscle soreness, were reported in many of the studies that prospectively defined and monitored these events. Serious adverse events were rare, and no serious events were reported to be directly related to the exercise programme.

AUTHORS' CONCLUSIONS

This review provides evidence that PRT is an effective intervention for improving physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported.

Interventions for promoting mobility in community-dwelling older adults

PURPOSE

The purposes of this review were to provide an updated report of intervention studies designed to enhance mobility in older adults and discuss the strengths and limitations of existing intervention studies and their implications for practice.

DATA SOURCES

Medline, CINAHL, and PsychInfo were searched to identify original research articles reporting interventions for promoting mobility in community-dwelling older adults.

CONCLUSION

Effective interventions for enhancing mobility in older adults include walking, aerobic exercise, and resistance training focusing on strength, balance, and flexibility. Group-based interventions show significant beneficial effects in increasing mobility. To obtain significant effects of physical activity interventions, the patient should participate in the exercise programs for at least 12 weeks. Strengths of existing clinical trials for promoting mobility in older adults include testing of various types of physical activity and training interventions and the use of an experimental design with a control group. The major challenges of creating mobility enhancement recommendations for older adults include detailing a mobility enhancement program will delay disability, creating a specific program dose for different populations by gender and ethnicity, and developing culturally appropriate mobility enhancement programs to improve adherence over time.

IMPLICATIONS FOR PRACTICE

Prescribing regular physical activity including aerobic exercise and resistance training in a primary care setting can be a beneficial approach to minimize progression of impaired mobility in older adults. The typical dose of the physical activity prescription is 20-60 min of aerobic activity three times weekly. Adherence to mobility enhancement recommendations by older patients can be followed up by in-person interview or use of mobility monitoring tools such as exercise diary or log.

Brisk walking compared with an individualised medical fitness programme for patients with type 2 diabetes: a randomised controlled trial

AIMS/HYPOTHESIS

Structured exercise is considered a cornerstone in type 2 diabetes treatment. However, adherence to combined resistance and endurance type exercise or medical fitness intervention programmes is generally poor. Group-based brisk walking may represent an attractive alternative, but its long-term efficacy as compared with an individualised approach such as medical fitness intervention programmes is unknown. We compared the clinical benefits of a 12-month exercise intervention programme consisting of either brisk walking or a medical fitness programme in type 2 diabetes patients.

METHODS

We randomised 92 type 2 diabetes patients (60 +/- 9 years old) to either three times a week of 60 min brisk walking (n = 49) or medical fitness programme (n = 43). Primary outcome was the difference in changes in HbA1c values at 12 months. Secondary outcomes were differences in changes in blood pressure, plasma lipid concentrations, insulin sensitivity, body composition, physical fitness, programme adherence rate and health-related quality of life.

RESULTS

After 12 months, 18 brisk walking and 19 medical fitness participants were still actively participating. In both programmes, 50 and 25% of the dropout was attributed to overuse injuries and lack of motivation, respectively. Intention-to-treat analyses showed no important differences between brisk walking and medical fitness programme in primary or secondary outcome variables.

CONCLUSIONS/INTERPRETATION

The prescription of group-based brisk walking represents an equally effective intervention to modulate glycaemic control and cardiovascular risk profile in type 2 diabetes patients when compared with more individualised medical fitness programmes. Future exercise intervention programmes should anticipate the high attrition rate due to overuse injuries and motivation problems.

Neuromuscular electrical stimulation versus volitional isometric strength training in children with spastic diplegic cerebral palsy: a preliminary study

BACKGROUND

To date, no reports have investigated neuromuscular electrical stimulation (NMES) to increase muscle force production of children with cerebral palsy (CP) using high-force contractions and low repetitions.

OBJECTIVE

The aims of this study were to determine if isometric NMES or volitional training in children with CP could increase muscle strength and walking speed and to examine the mechanisms that may contribute to increased force production.

METHODS

Eleven children with spastic diplegia were assigned to an NMES training group or to a volitional training group. Participants in the NMES group had electrodes implanted percutaneously to activate the quadriceps femoris and triceps surae muscles. The volitional group trained with maximal effort contractions. Both groups performed a 12-week isometric strength-training program. Maximum voluntary isometric contraction (MVIC) force, voluntary muscle activation, quadriceps and triceps surae cross-sectional area (CSA), and walking speed were measured pre- and post-strength training.

RESULTS

The NMES-trained group had greater increases in normalized force production for both the quadriceps femoris and triceps surae. Similarly, only the NMES group showed an increase in walking speed after training. Changes in voluntary muscle activation explained approximately 67% and 37% of the changes seen in the MVIC of the NMES and volitional groups, respectively. Quadriceps femoris maximum CSA increased significantly for the NMES group only.

CONCLUSIONS

This study was the first to quantitatively show strength gains with the use of NMES in children with CP. These results support the need for future experimental studies that will examine the clinical effectiveness of NMES strength training.