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117

Original scientific article                                          UDC: 796.012.61-053.9
received: 2016-12-26

The effecTs of differenT eXercise-based 
inTervenTions on funcTional fiTness of older 

adulTs

Armin PARAVLIĆ1, Uroš MARUŠIČ1,2, Mitja GERŽEVIČ2, Felicita URzI3,             
Boštjan ŠIMUNIČ1

1 Science and Research Centre Koper, Institute for Kinesiology Research, Garibaldijeva 1, 6000 
Koper, Slovenia

2 University of Primorska, Faculty of Health Sciences, Polje 42, 6310 Izola, Slovenia
3 University of Primorska, Faculty of Mathematics, Natural Sciences and Information 

Technologies, Department of Biodiversity, Glagoljaška 8, 6000 Koper, Slovenia

Corresponding author:
Boštjan ŠIMUNIČ

Science and Research Centre Koper, Institute for Kinesiology Research,
Garibaldijeva 1, 6000 Koper, Slovenia

Tel.: +386 5 66 37 700
E-mail: bostjan.simunic@zrs-kp.si

ABSTRACT

Ageing is a multifactorial process associated with several irreversible functional 
and cognitive alterations of human body and determined by genetic and environmental 
factors. We aimed to investigate the effects of three physical activity interventions of 
40 independently living older adults before and after a 3-month training period. Thirty 
female (69.6 ± 5.3 years) and ten male (70.6 ± 5.4 years) participants were randomly 
assigned into a physical exercise group (PEG; N = 9), a concurrent physical and co-
gnitive exercise group (PEG + COG; N = 10), a physical exercise with additional 10 
g of BCAA daily supplementation group (PEG+BCAA; N = 11), and a control group 
(CG; N = 10). All three groups performed the same physical exercise program for 12 
weeks, three days a week for 45 − 60 minutes per session. Pre- and post-measurements 
were performed using a standardized functional fitness assessment tool for older adults 
i.e. Senior Fitness Test battery, upgraded with the Four Square Step Test (FSST) and 
Grip Strength Test (GST). When intervention groups were pooled, we found moderate 
to low improvements in the Chair Stand Up, Timed Up and Go, FSST and Six-minute 
Walk Tests (all P < .001). However, those improvements were intervention-specific with 
highest improvements found in the PEG for the FSST (P = .004) and Six-minute Walk 
Test (P = .004); in the PEG + COG for the Timed Up and Go Test (P < .001); and in 



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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

the PEG+BCAA for body mass (P = .012) and the Chair Stand Up Test (P < .001). 
Although the sample size was low, our study provides further evidence of different in-
terventional exercise-based programs that can benefit the population of independently 
living older adults.

Keywords: ageing, senior fitness test, frailty, cognition, diet, interventions.

UČINEK RAZLIČNIH INTERVENCIJSKIH PROGRAMOV NA
FUNKCIONALNO TELESNO PRIPRAVLJENOST ZDRAVIH

STAREJŠIH ODRASLIH

IZVLEČEK

Staranje je pogojeno z več dejavniki, ki vodijo v funkcionalne in kognitivne spre-
membe, v močni soodvisnosti od genetskih in okolijskih dejavnikov. Cilj raziskave je 
bil preučiti učinkovitost treh 3-mesečnih gibalnih intervencij na 40 funkcionalno neod-
visnih starejših preiskovancih, 30 žensk (69,6 ± 5,3 let) in 10 moških (70,6 ± 5,4 let). 
Preiskovanci so bili naključno razdeljeni v štiri skupine: gibalna intervencija (PEG; N 
= 9), gibalno-kognitivna intervencija (PEG+COG; N = 10), gibalno-prehranska inter-
vencija z 10 gramov dodatkov BCAA dnevno (PEG+BCAA; N = 11) in kontrolna sku-
pina (CG; N = 10). Vse tri intervencijske skupine so  12 tednov izvajale enako gibalno 
vadbo, tri vadbe na teden v trajanju posamezne vadbe 45-60 minut. Meritve smo opra-
vili pred in po koncu intervencij z uporabo standardiziranega testa telesne pripravlje-
nosti za starejše (Senior Fitness Test battery) in dodatno še testa štirih kvadratov (Four 
Square Step Test – FSST) ter testa silovitosti stiska pesti (Grip Strength Test – GST). Ko 
smo vse tri intervencijske skupine združili, smo ugotovili nizko do srednje napredovanje 
v testih vstajanja s stola, vstani in pojdi, FSST in hoje na 6 minut (vsi P < 0,001). Kljub 
temu pa smo ugotovili, da so bili napredki odvisni od specifične intervencije, saj so pre-
iskovanci v skupini PEG najbolj napredovali v FSST (P = 0,004) in hoji na 6 minut (P 
= 0,004); v skupini PEG+COG v vstani in pojdi (P < 0,001); in v skupini PEG+BCAA 
v telesni masi (P = 0,012) in vstajanju s stola (P < 0,001). Navkljub nizkemu številu 
preiskovancev, smo dokazali vpliv različnih gibalnih intervencij, ki lahko pomembno 
prispevajo populaciji starejših, funkcionalno neodvisnih preiskovancev.

Ključne besede: staranje, test telesne pripravljenosti za starejše, krhkost, dieta, in-
tervencija



ANNALES KINESIOLOGIAE • 7 • 2016 • 2

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inTroducTion

Ageing is a complex, multidimensional physiological process associated with a si-
gnificant changes in the structure and function of an organism that occur as a result 
of time flow (Grimby & Saltin, 1983; Salthouse, 2009; Vandervoort, 2002; Verhaeg-
hen, Steitz, Sliwinski, & Cerella, 2003; Wertz & Dronkers, 1990). These age-related 
changes negatively affect a broad range of tissues, major organ systems and functions 
(Harman, 1981; Weinert & Timiras, 2003). More specifically, aging process triggers 
alterations in body composition (i.e. gradual accumulation of body fat and its redistri-
bution to central and visceral depots), the loss of muscle mass or function (sarcopenia) 
and muscle weakness (dynapenia) along with other alterations in metabolic, cardiova-
scular or skeletal (osteopenia) systems (Baumgartner, 2000; Clark & Manini, 2008; 
Goodpaster et al., 2006; Haramizu, Ota, Hase, & Murase, 2011; Milanovic et al., 2013). 
With advancing age, these alterations become more pronounced, leading to physical 
and cognitive functions deterioration, which eventually increase prevalence of disabi-
lity and mortality risk (Atkinson HH, 2007; Kallman, Plato, & Tobin, 1990; Kokkinos, 
2012; Onder et al., 2002; Power, Dalton, & Rice, 2013; Salthouse, 2009; Topinková, 
2008). It is also known that functional (and cognitive) loss can be preventable and even 
reversible through timely detection of physical weakness and appropriate intervention 
(Fried, Ferrucci, Darer, Williamson, & Anderson, 2004).

Physical inactivity, a main risk factor for overall mortality, leads to severe acute de-
terioration of muscle mass and function that could be also irreversible if not recognized 
and contrasted (Pisot et al., 2016). As both lifespan and aged population are increasing 
(Klenk, Rapp, Büchele, Keil, & Weiland, 2007), the emerging problem should repre-
sent identification of optimal and timely pharmacological, surgical, dietary, exercise 
and cognitive interventions that can mitigate ageing-related changes on a number of 
levels (Rowe & Kahn, 1997).

The effects of medical interventions are often centered and specific (i.e. affecting 
only the targeted health-related issues) and often cause serious side effects (Meador, 
1994; Turjanski & Lloyd, 2005). Also, along with the high costs (i.e. lifelong drug 
usage) they might not represent the most desirable and effective strategies. In contrast, 
various exercise / physical activity interventions, when individually and professionally 
programed, have been proven to produce beneficial effects on physical and cognitive 
functions as well (Hallage et al., 2010; Hanson et al., 2009; Karavirta et al., 2011); even 
for population at-risk and / or patients (Flansbjer, Miller, Downham, & Lexell, 2008; 
Heyn, Abreu, & Ottenbacher, 2004; Morris, Dodd, & Morris, 2004). Accordingly, it 
is well established that regular physical activity is an efficient strategy for successful 
ageing (Kokkinos, 2012; Nelson et al., 2007; Taylor et al., 2004). Physical activity 
(PA) engagement increases life expectancy and improves the quality of life (Blair et 
al., 1989; Nelson et al., 2007; Paffenbarger, Hyde, Wing, & Hsieh, 1986). Further, it 
has been shown that PA reduces all-cause mortality (Blair et al., 1989; Kampert, Blair, 
Barlow, & Kohl, 1996; Nelson et al., 2007; Paffenbarger et al., 1986) by 22% even if 
practiced with a low dose (< 150 min/week) of moderate-to-vigorous intensity (Hupin 



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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

et al., 2015). However, additional benefits might be expected when the amount of PA 
progressively increases regarding both the intensity and the volume of exercise (Chod-
zko-zajko et al., 2009). Moreover, PA effects are positively correlated with a higher 
level of individual fitness (Kampert et al., 1996), where the percentage of  functional 
fitness decline (e.g. lower and upper body muscle strength, lower and upper body flexi-
bility, aerobic endurance, and motor agility / dynamic balance) is generally consistent 
with age-related declines in physical performance (Rikli & Jones, 1999).

Therefore, interventions including both endurance and strength activities (Nelson 
et al., 2007) alone or along with dietary manipulation and / or cognitive interventions 
might be plausible strategies that might counteract the aforementioned negative chan-
ges and risks, making older adults’ life more comfortable (Ball, Berch, & Helmers, 
2002; Buchman et al., 2012; Harman, 1981; Marusic et al., 2016; Pišot et al., 2015). 
Accordingly, there is ample evidence suggesting that the combination of proper dieting 
(Fiatarone et al., 1994; Kim et al., 2012; Messier et al., 2004) and PA could show grea-
ter benefits on functional fitness than either intervention alone.

The current Recommended Dietary Allowance for the minimum protein intake for 
adults, including older adults population, is 0.8 g protein / kg BM / day (WHO, 2007). 
However, recent research results suggest that the recommended protein intake does not 
promote optimal health or protect older adults from age-related body changes (Morley 
et al., 2010; Paddon-Jones & van Loon, 2012; Volpi et al., 2003). Based on new eviden-
ce, the PROT-AGE Study Group recommends an average daily intake in the range of 
1.0 to 1.2 g / kg BM / d for healthy older adults, 1.2 to 1.5 g / kg BM / d for those who 
have acute or chronic diseases and 2.0 g / kg BM / d for people with severe illness or 
injury or with recognizable malnutrition (Bauer et al., 2013).

The consumption of higher protein diet, at least 1.2 to 1.6 g / kg BM / day of high-
-quality protein with concentrated source of essential amino acids, including branched 
amino acids (BCAA) leucine, could prevent age-related sarcopenia, the loss of muscle 
mass and strength. Including ~30 g of protein per meal seems a successful strategy to 
achieve optimal health outcomes in adults (Phillips, Chevalier & Leidy, 2016). 

Exercise greatly increases energy expenditure and promotes oxidation of BCAAs 
(Rennie, 1996). BCAAs are regulators of protein metabolism and are key metabolic 
precursors for glutamine and alanine synthesis (Choudry, Karinch & Souba, 2006). 
These properties have suggested that BCAAs may have interesting and clinically-rele-
vant metabolic effects. The effects of BCAA supplementation before and after exercise 
has beneficial effects for decreasing exercise-induced muscle damage and are responsi-
ble for the direct stimulation of muscle protein synthesis and the suppression of exerci-
se-induced protein breakdown (Coombes & McNaughton 2000; Fujita & Volpi, 2006; 
MacLean, Graham & Saltin, 1994; Nosaka, 2003). In addition, amino acids, particular-
ly BCAAs, may be used clinically to attenuate diet-induced muscle atrophy (Layman, 
2003) and prevent sarcopenia in older adults (Koopman et al., 2006; Volpi et al., 2003; 
Volpi et al., 2007). 

Various cognitive training approaches revealed considerable beneficial effects in 
improving specifically targeted cognitive abilities (i.e. memory, reasoning and proces-



ANNALES KINESIOLOGIAE • 7 • 2016 • 2

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sing speed) (Ball et al., 2002; Edwards et al., 2005; Saczynski, Willis, & Schaie, 2002), 
with some evidence of positive transfer to non-specifically trained cognitive functions 
and activities of daily living (Ball et al., 2002; Marušič et al., 2016; Willis, Tennstedt, 
Marsiske, & et al., 2006). For example, the study by Edwards et al. (2005) provides 
evidence that speed processing training has the potential to enhance everyday functions 
that help to maintain independence and quality of life, particularly when the training is 
targeted toward individuals who most need it. In a five-year study, Willis et al. (2006) 
showed that cognitive training resulted in lower functional decline in self-reported in-
strumental activities of daily living, which was evident up to 5 years after the initiation 
of the intervention. Furthermore, a multidimensional intervention which combined diet, 
exercise, cognitive training and vascular risk monitoring, showed 25 % better results in 
cognitive functions as compared to the controls (Ngandu et al., 2015). Regarding the 
aforementioned positive influence of cognitive and PA interventions and their training 
specificity, their combined effects might have greater effects on instrumental activities 
of daily living or even functional fitness. Moreover, Theill et al. (2013) investigated the 
effects of a simultaneously performed motor-cognitive training compared to a single 
cognitive training and to controls. They concluded that the combined motor-cognitive 
training presents a promising concept to improve cognitive and motor-cognitive dual-
-task performance, offering greater potential on daily functioning, which usually invol-
ves the recruitment of multiple abilities and resources rather than a single one.

Thus, the effects of physical training alone or in combination with dietary inter-
ventions, as well as cognitive training, on physical and cognitive functions are well 
documented, while there are almost no experimental studies that directly compare the 
effects of these interventions or its combination between each other and / or controls. 
Furthermore, the aforementioned studies mainly include community-dwelling older 
adults where outcome measures were specific cognitive abilities and daily activities as-
sessed by participants’ self-reports and / or with only a few physical performance tests. 
Thus, the influences of combined interventions in healthy, independent older adults in 
respect to functional fitness are unknown. In addition, according to our knowledge, this 
type of interventional study is one of the first performed among Slovenian older adults.

Therefore, the aim of this study was to compare the effects of three different 3-month 
interventions on functional fitness of healthy older adults chosen among the population 
of independently living Slovenians. We hypothesized that all three intervention groups 
(physical exercise only; combined physical and cognitive exercise; combined physical 
exercise and diet supplement) will have significant effects on physical fitness in com-
parison to the control group (CG).



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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

METHODS

Participants

After the initial screening of 195 older adults, we recruited 40 individuals of which 
30 were females (69.2 ± 5.3 years) and ten males (70.6 ± 5.4 years). The participants 
were randomly assigned to one of three intervention groups: i) a physical exercise group 
(PEG), ii) a concurrent physical and cognitive exercise group (PEG+COG), iii) a physi-
cal exercise with additional branched-chain amino acids (BCAA) daily supplementa-
tion group (PEG+BCAA) or iv) in a control group (CG). The final sample of the study 
included nine participants in PEG (age: 68.7 ± 5.3 years, height: 165.5 ± 6.9 cm, body 
mass: 71.5 ± 13.7 kg), ten in PEG+COG (age: 70.6 ± 5.4 years, height: 162.3 ± 6.7 cm, 
body mass: 68.8 ± 15.1 kg), eleven in PEG+BCAA (age: 69.9 ± 6.8 years, height: 166.2 
± 8.1 cm, body mass: 73.2 ± 9.1 kg) and ten in CG (age: 68.9 ± 3.4 years, height: 161.8  
± 5.1 cm, body mass: 64.4 ± 8.4 kg). The participants were healthy volunteers without 
serious cardiovascular or musculoskeletal diseases. The inclusion criteria were: i) at 
least 65 years old, ii) independently living at home (i.e. performing everyday activities 
without mobility aids), iii) residents of the city of Ljubljana (where the measurements 
were performed) and iv) feeling healthy and able to walk 2 km without stopping and 
using walking aids. All the participants provided a written informed consent to partici-
pate in the study according to Helsinki − Tokyo Declaration. The study obtained ethical 
approval from the National Medical Ethics Committee of the Republic of Slovenia.

Interventions

Each intervention lasted for 12 weeks, 3 times per week (altogether 34 sessions), 
with individual sessions’ duration of 45 to 60 minutes. Each training session was per-
formed at the same time of the day (starting at 10 a. m.). Thus, the training sessions 
consisted of three parts explained in details in Table 1 (on the left side). The volume 
and intensity in the second (main) part of the session was controlled by the ratio of the 
working and resting training time. At the beginning of the intervention (weeks 1 to 3) 
the working time for each exercise was 20 seconds with 40 seconds rest (work / rest 
ratio was 1:2); from week 4 to week 8 the ratio was 1:1 (30 s : 30 s) and at the end of 
the intervention (from week 9 to week 12) the ratio was 2:1 favouring the working time. 

PEG and PEG+BCAA intervention consisted of the same physical activity program. 
The participants in the PEG+BCAA group were receiving orally 10 g of BCAA supple-
ment immediately after each training session, three times per week and at the same time 
on the days without training. 



ANNALES KINESIOLOGIAE • 7 • 2016 • 2

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Armin PARAVLIĆ, Uroš MARUŠIČ, Mitja GERŽEVIČ, Felicita URzI, Rado PIŠot, Boštjan ŠIMUNIČ: tHE EFFECtS oF DIFFERENt  ..., 117–137
Ta

bl
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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

Comparing with PEG and PEG+BCAA intervention program, PEG+COG interven-
tion consisted of similar physical exercises, while cognitive tasks were added. During 
the warm up exercises, each participant in PEG+COG received a list of words that he / 
she needed to remember and report at the end of each session, see Table 1. (mid-side). 
The lists of words were different for each participant and were changing each session. 
The main part consisted of the same physical exercises as for the PEG with additional 
cognitive tasks targeting on working and short-term memory, attention, mental rotation 
and visual-spatial perception. Examples of cognitive tasks were naming animals on 
a certain letter, counting backwards, listing all flavours that remind you of summer 
etc. while performing physical exercises. Finally, during the flexibility and relaxation 
exercises, the participants in PEG+COG were asked to disclose previously delivered 
list of words. 

Participants in the CG had only pre- and post-measurement screening with no spe-
cific interventions in-between and were asked to maintain their usual daily activities. 

Measurements

All groups were tested before (pre) and after (post) the interventions. On the test-
ing day, the participants completed all Senior Fitness Test items (Rikli & Jones, 1999; 
2001) in order to determine subjects’ lower and upper body strength, flexibility, agility, 
aerobic endurance and dynamic standing balance. The Senior Fitness Test consists of 
six assessment items (i.e. the Chair Stand Test, Arm Curl Test, Chair Sit and Reach 
Test, Back Scratch Test, Timed Up and Go Test and Six-Minute Walk Test). The Chair 
Stand Test assesses lower body strength. Each subject completed two practice repeti-
tions and one 30-second test trial. The recorded score was the total number of stands 
executed correctly within 30 seconds. The Arm Curl Test assesses upper body strength. 
Each subject completed two practice repetitions and one 30-second test trial sitting on 
a chair. Women used 2.5 kg, while men 3.5 kg barbells. The score was the total number 
of arm flexions and extensions through the full range of motion in 30-seconds. The 
Chair Sit and Reach Test assesses lower body flexibility. Each subject completed two 
practice trials and two test trials. The score was the longest distance achieved between 
the extended fingers and the tip of the toe. The Back Scratch Test assesses upper body 
flexibility. Each subject completed two practice trials and two test trials. The score was 
the shortest distance achieved between the extended middle fingers. The Timed Up and 
Go Test assesses agility and dynamic balance. Each subject completed one practice trial 
and two test trials. The score was the shortest time to rise from a seated position, walk 
8 feet, turn around the cone, and return to the seated position. The Six-Minute Walk 
Test assesses aerobic endurance. The score was the total distance walked in six minutes 
around the two cones 15 m apart. 

Additional to the Senior Fitness Test battery, participants also performed the Four 
Square Step Test / FSST (Dite & Temple, 2002) and the Grip Strength Test. The FSST 
involves stepping over 4 canes that are laid on the ground at 90° angles to each other 



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(like a “plus” sign). The canes were 90 cm in length as first described by Dite and 
Temple (2002). Subjects were asked to stand in 1 square facing forward with their 
shoes on. They then rotated clockwise around the “plus sign” by moving forward, to 
the right, backward, to the left. The patients then reversed their path and moved in a 
counterclockwise direction. The instructions were as follows: “Try to complete the 
sequence as fast as possible without touching the sticks. Both feet must make contact 
with the floor in each square. If possible, face forward during the entire sequence.” 
(Dite & Temple, 2002). Each subject had 1 practice trial and 2 timed trials; with all 
subjects completing the testing within 5 minutes. If a patient touched the cane, lost 
his / her balance, or did not place both feet in the square, he / she was asked to repeat 
the trial. The best score achieved was used for further analysis. Maximal grip strength 
was measured bilaterally with a portable Jamar Hydraulic Hand Dynamometer (Sam-
mons Preston, Rolyan, Bolingbrook, IL, USA). In accordance with American Society 
of Hand Therapy recommendations, subjects were seated with their shoulders in 0° 
abduction and neutral rotation, their elbows in 90° of flexion, and their forearms in 
neutral pronation / supination. The average of three and two maximal repetitions was 
used for further analysis. 

Habitual dietary intake was assessed by three-day food record and the participants 
were asked to continue habitual diet during the study adding 10 g of BCAA each day 
at 11 AM.

Statistical Analysis

All data are presented as means ± standard deviations. Data were analysed using 
SPSS software (version 20.0). After confirming normality and homogeneity of distribu-
tion using Shapiro-Wilk and Leven test, a 1-way analysis of variance (ANOVA) was 
used to compare baseline values between the groups. A two-way, repeated measures 
ANOVA was performed to determine changes within groups over time (pre to post) and 
between groups. Firstly, we compared the pooled interventions group (PEG) vs. CG 
(2x2 repeated measure ANOVA), and also each intervention group separately vs. CG 
(2x4 repeated measures ANOVA). Individual group changes from pre- to post period 
were assessed using the Paired-sample Student’s t-test (two-tailed). The level of sig-
nificance was set at 0.05. When significant changes were confirmed, the effect size was 
calculated as the mean change found in a variable divided by the standard deviation at 
baseline of that variable; an effect size of 0.10 – 0.19 was considered very small, 0.20 – 
0.49 small, 0.50 – 0.79 moderate, 0.80 – 1.19 large, 1.20 – 1.99 very large and 2.00 or 
greater was considered a huge effect (Sawilowsky, 2009).



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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

resulTs

Initially, 67 participants were randomly divided in 4 groups; however, 40 of them 
passed > 90 % of sessions adherence with both pre- and post-testing. A vast majority of 
drop-out was a consequence of holidays, trips and large daily travel distances to admit 
sessions. There was no injury occurrence during this study. The average adherence to 
interventions was more than 80 %.

The participants followed their habitual diet and the estimated dietary intake was 
not different between the beginning and the end of the study. The mean daily protein 
intake was 0.92 ± 0.3 g / kg BM / day. 

There were no significant differences in pre-tests between PEG and CG, neither in 
all four groups nor individually. The results from the 2 x 2 repeated measures ANOVA 
indicated a significant main effect of time for chair stand (F[1,38] = 17.4; p < .001; η2 = 
.31), the timed up and go (F[1,38] = 8.49; p = .006; η2 = .183), and the six-minute walk 
(F[1,38] = 11.46; p = .002; η2 = 0.232) tests, while the arm curl (F[1,38] = 4.07; p = 
.051; η2 = .090) and the four square step test (F[1,38] = 3.55; p = .067; η2 = .085) were 
near-significant. There were significant time x group interaction effects for the timed 
up and go (F[1,38] = 6.93; p = .012; η2 = .154) and the four square step test (F[1,38] = 
5.76; p = .021; η2 = .132). Furthermore, in Table 2, paired sample t-tests indicated that 
participants in PEG performed better at the post-test compared to the pre-test in lower 
body strength, agility, dynamic standing balance, and aerobic endurance, while the CG 
did not improve in any test performed.

Results of the 4x2 repeated measures ANOVA confirmed main time effect for body 
mass (F[3,38] = 5.06; p = .031; η2 = .123), the chair stand (F[3,38] = 34.34; p < .001; η2 

= .488), the arm curl (F[3,38] = 7.64; p = .009; η2 = .177), the timed up and go (F[3,38] 
= 23.24; p < .001, η2 = .392), the four square step (F[3,38] = 12.0; p < .001; η2 = .251) 
and the 6-minute walk (F[3,38] = 20.1; p < 0.001; η2 = .359), while the back stretch 
(F[3,38] = 3.30; p = .078; η2 = .084) and the grip strength (F[3,38] = 3.36; p = .075; η2 = 
.085) were near-significant. There were significant time x group interaction effects for 
the timed up and go (F [3,38] = 3.36;, p = .029; η2 = .219), while in the four square test 
(F[3,38] = 2.31; p = .093; η2 = .161) was almost significant.

The paired sample t-tests indicated that the participants in PEG improved in back 
stretch for 100 % (p = .005), the timed up and go for 8.3 % (p = .022), the four square 
step for 13 % (p = .004), and the 6-minute walk for 9.6 % (p = .004), while for the chair 
stand up the improvement was near-significant (p = .052). The PEG+COG improved in 
chair stand up for 26.1 % (p = .017), the timed up and go for 15.6 % (p < .001) and the 
four square step for 8.8 % (p = .014). Moreover, PEG+BCAA improved significantly 
in almost all functional tests performed; the chair stand up for 35.3 % (p < .001), the 
arm curl for 16.6 % (p = .023), timed up and go for 15.8 % (p = .028), the four square 
step for 16.6 % (p = .043), the 6-minute walk for 10.9 % (p = .004), and had lower body 
mass for 1.8 % (p = .012) at post-test (Table 3).



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Ta

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.



128

Armin PARAVLIĆ, Uroš MARUŠIČ, Mitja GERŽEVIČ, Felicita URzI, Rado PIŠot, Boštjan ŠIMUNIČ: tHE EFFECtS oF DIFFERENt  ..., 117–137

ANNALES KINESIOLOGIAE • 7 • 2016 • 2

Table 3: Pre- to post-comparison between physical group (PEG), physical-cognitive 
group (PEG+COG), physical-dietary group (PEG+BCAA), and control group (CG).

PEG (n=9) PEG+COG 
(n=10)

PEG+BCAA 
(n=11) CG (n=11)

P (d) P (d) P (d) P (d)

Body mass 
(kg)

pre 71.6
±13.7

68.8
±15.1

73.2
±9.17

64.4
±8.41

post 69.6
±13.5

.068 
(.14)

67.7
±13.8 .109 (-) 71.9

±9.79
.012 
(.14)

64.0
±12.5 .831 (-)

Body Mass 
Index

pre 25.98
±3.65

26.01
±5.14

26.48
±2.79

24.64
±3.46

post 25.24
±3.41 NA 25.61

±4.63 NA 26.02
±3.06 NA 23.95

±4.07 NA

Chair stand 
up (reps)

pre 20.0
±4.12

17.2
±2.48

14.9
±5.24

18.1
±3.44

post 23.6
±5.38

.052 
(.86)

21.7
±4.49

.017 
(1.81)

20.2
±4.89

<.001 
(1.01)

19.6
±4.78

.110 
(.21)

Arm curl 
(reps)

pre 20.7
±3.35

19.2
±3.52

17.4
±4.36

18.9
±3.84

post 22.9
±4.85

.126 
(.66)

19.7
±2.83

.740 
(.14)

20.4
±4.43

.023 
(.67)

19.7
±3.19 .235 (-)

Sit and 
reach (cm)

pre 9.11
±13.12

1.60
±9.43

-0.45
±8.75

7.30
±15.1

post 6.44
±8.80 NA 0.90

±12.0 NA -2.90
±9.13 NA 6.30

±11.9 NA

Back 
stretch 
(cm)

pre -3.11
±9.14

-4.00
±10.5

-5.55
±9.99

0.50
±7.70

post .00
±8.06 NA -4.40

±13.8 NA  -3.90
±10.0 NA 1.70

±8.20 NA

Timed up 
and go (s)

pre 4.42
±0.24

5.17
±0.64

5.38
±1.85

4.65
±0.52

post 4.05
±0.40

.022 
(1.48)

4.36
±0.41

<.001 
(1.26)

4.53
±1.00

.028 
(.46)

4.62
±0.46 .790 (-)

Grip 
strength 
(kg)

pre 34.6
±8.58

32.7
±10.2

28.7
±7.53

30.0
±4.94

post 33.88
±8.78 NA 32.1

±8.22 NA 27.5
±9.15 NA 29.1

±4.79 NA

4 square 
step (s)

pre 6.23
±1.13

6.80
± 1.01

6.90
±2.93

6.41
±1.54

post 5.41
±1.08

.004 
(.72)

6.20
±0.78

.014 
(.59)

5.75
±1.86

.043 
(.39)

6.51
±1.38 .778 (-)

6 min walk 
(m)

pre 557
±55.3

542
±53.6

517
±86.6

596
±81.8

post 611
±57.0

.004 
(.97)

555
±58.8

.343 
(.25)

574
±73.6

.004 
(.66)

621
±75.4

.286 
(.31)

NA – Not Applicable as time or time x group interaction effects were not confirmed.
P – Significance level of Paired-sample t-test.
d – Effect size.



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disscussion

Individual intervention groups have small sample sizes, therefore, we compared 
cumulative effects of all three interventions, by pairing all intervention groups together 
and contrasting vs. the CG. Thus, the results showed significant time effects for Chair 
Stand Up, the Timed Up and Go, and the Six-Minute Walk tests in interventions group, 
while the CG did not improve in any test. Furthermore, certain meaningful interactions 
were seen in respect to the timed up and go as well for the four square test, suggesting 
that the applied physical training program influenced mostly agility and dynamic stan-
ding balance, which was expected in relation to physical intervention program design. 
The effects were large (the chair stand up), moderate (the timed up and go and the 6 
min walk) and small (the 4 square step). When all groups were compared between each 
other individually, there was significant improvement observed in physical fitness tests 
after three months of interventions compared to the baseline in all intervention groups, 
except in CG, where body mass decreased only in PEG+BCAA.  

Our findings are consistent with findings from the literature (Chang et al., 2004). 
Although we cannot compare our interventions directly regarding the training design, 
their results are similar with ours, which suggests that older people could benefit from 
various supervised physical exercise programs. However, the intensity and the volume 
of exercise is important as demonstrated by Cyarto et al. (2008) when comparing the ef-
fects of home-based resistance training, group-based resistance training, and group-ba-
sed walking on functional ability in older adults. After 20 weeks of training with only 
two weekly sessions, they showed that both groups of resistance training experienced 
improvements in strength, lower-body flexibility, and agility / dynamic balance while 
there were no observed improvements in the walking group. Therefore, frequency of 
two sessions per week used in the aforementioned study was far below those generally 
suggested (i.e. 30 minutes in duration and up to five weekly sessions) in order to pro-
mote and maintain health (Nelson, et al., 2007, Haskell, et al., 2007).

Taken together, the results of some systematic reviews and meta-analysis (Cer-
mak, de Groot, Saris, & van Loon, 2012; Cruz-Jentoft et al., 2014; Finger et al., 2015; 
Nowson & O'Connell, 2015) which assessed the effect of combined intervention with 
protein supplementation and resistance exercise on muscle mass and the function in 
aged population, show the inconsistency of studies to prove the effectiveness of protein 
supplementation. Overall, the studies show the capacity of such intervention for elec-
ting gains in fat-free mass, a limited evidence for improvement in muscle strength, but 
no significant improvement to increase muscle function in older adults. The variation 
among studies regarding the supplementation protocols, protein sources, and amounts 
used are making it difficult to reach firm conclusions on this question. It was proposed 
that older adults need higher levels of protein intake due to their lower responsiveness 
to the anabolic stimulus (Baum, Kim, & Wolfe, 2016). In fact, larger experiments that 
have demonstrated a significant functional benefit from combined intervention with 
resistance exercise and protein intake exceeded the range from inadequate intakes to 



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ANNALES KINESIOLOGIAE • 7 • 2016 • 2

optimal protein intakes (≥1.2 g/kg BM/day) and lasting for few months (Chalé et al., 
2012; Tieland et al., 2012). 

Although protein supplementation failed to point out consistent results, new evi-
dence shows that branched chain amino acids (BCAA), such as leucine, at a daily amo-
unt of either 2.5 g or 2.8 g in combination with resistance exercise may affect muscle 
protein synthesis, muscle recovery following illness, and muscle mass (Bauer et al., 
2013). Katsanos et al. (2006) demonstrate that the attenuated response of muscle pro-
tein synthesis in older adults, following the ingestion of small amounts of amino acids, 
can be reversed by the ingestion of additional amount of leucine. These data may expla-
in the role of BCAA, especially leucine in reversing the lack of response following the 
protein-based supplementation.

In our study, the PEG+BCAA group was supplemented with 10g BCAA immediate-
ly after the exercise. However, even not significantly different, this intervention group 
experienced greater improvements in leg strength compered to others. For example, 
leg strength improved most (35.3 %) in the PEG+BCAA group, while the PEG and 
PEG+COG groups improved less i.e. 26.1 % and 17.7 %, respectively, which is consi-
stent with previous findings (Verdijk et al., 2009). In the study by Verdijk et al. (2009), 
26 healthy older man, aged between 70 and 74 years were randomly assigned to a 
progressive, 12-week resistance-type exercise training program with (protein group) or 
without (placebo group) protein provided before and immediately after each exercise 
session (3 sessions per week, 20 g protein per session). Although they trained with the 
resistance intensity of 65 % to 75 %, both training groups showed improvements of 25 
% to 30 %, similar to our results. 

It is difficult to compare our results to other studies due to different exercise proto-
cols and supplementation used. A few studies that show improvement in functional out-
come in older adults included the participants who generally have an inadequate protein 
intake of 0.8 g / kg BM / day (Kim et al., 2012; Tieland et al., 2012).  Similarly, our 
participants had lower dietary protein intake (0.92 g / kg BM / day) than recommended 
(WHO, 2007) and, therefore, may benefit from the combined intervention.

Regarding aerobic endurance, only the PEG and PEG+BCAA improved for 9.6 % 
and 10.9 %, respectively. Bearing in mind that the PEG+COG had a more demanding 
cognitive aspect of exercise rather than physical, our results suggest that more than 30 
minutes of moderate intensity PA is needed to induce positive alterations in aerobic 
endurance in older population; and / or two exercise models should be performed sepa-
rately (i.e. not combined in the same task). Furthermore, future studies should include 
measurements of various cognitive-motor tasks. In 375 elderly community residents, 
Oswald and colleagues (2006) found significant training-related effects after five years 
of combined interventions. In detail, they showed that when compared with a non-tre-
atment group, both physical and cognitive status can be preserved on a higher level, as 
well as emotional status of involved participants (as reflected through fewer depressive 
symptoms). Our PEG+COG group was included in the so-called broad approach that 
targets multiple domains of cognitive processes, which might be more effective than a 
specific one that includes only a sole or limited-set targeted cognitive functions (Hol-



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tzer et al., 2006). Recent studies revealed that cognitive-based protocols can positively 
influence mobility-related outcomes in different population of older adults, namely, 
community-dwelling older adults (Smith-Ray et al., 2014), patients with Parkinson’s 
disease (Milman et al., 2014) and older adults during a prolonged bed rest (Marusic et 
al., 2015; Marusic et al., in press). Therefore, we can further speculate that lack of im-
provements in the PEG+COG group could also originate from inadequate measurement 
tests which were not sensitive enough to detect cognitive-motor related improvements.

conclusion

Our research findings indicate that physical activity, alone or combined with co-
gnitive and nutritional interventions could enhance functional fitness in older adults. 
More than 30 minutes of moderate-intensity physical activity, three times per week is 
needed for an improvement in aerobic endurance, while same volume of specific trai-
ning program is enough to induce positive alterations in dynamic balance and agility. 
Thus, when nutritional supplementation is added to physical exercise, results regarding 
functional strength task and body mass were more pronounced.

Acknowledgements

This study was part of the project Active and Quality Ageing in Home Enviro-
nment (A-Qu-A) financially supported by the Norwegian Financial Mechanism and 
the Republic of Slovenia Government Office for Development and European Cohe-
sion Policy. We would like to thank the research coordinator prof. Rado Pišot, Ph.D., 
all project partners and other researchers involved in the data collection process, 
students, participants, and everyone who helped.

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