Abstract

AIMS

the purpose of this study was to assess the effects of a supervised dance intervention based on video game choreography on isokinetic concentric and eccentric knee peak of torque (PT), quadriceps and hamstrings cross sectional area (CSA) and functionality in community-dwelling older women.

METHODS

Forty-seven older women were allocated in Control Group (CG, n=25) and Intervention Group (IG, n=22). The IG performed dance based on video game choreography (Dance Central, XBOX 360®, Kinect), during 12 weeks, ~40 minutes, 3x/week, without foam (1-6week) and with foam and visual disturbances (7-12 week). The pretest-training-posttest assessments included: isokinetic concentric and eccentric knee PT and CSA (Magnetic resonance imaging) of quadriceps and hamstrings and functional tests.

RESULTS

The light-to-moderate-intensity 12-weeks training increased 8.5% the eccentric PT of quadriceps at 60°/s (p=0.04) and 1.3% quadriceps CSA (p=0.02).

CONCLUSIONS

These findings suggest that dance training based on video game choreography can enhance PT and induce hypertrophy in community-dwelling older women.

Keywords:
aged; virtual reality; dance training Brazilian Register of Clinical Trials (ReBec) (RBR-8xkwyp)

INTRODUCTION

It is well described in literature that muscle strength and power exercises are effective in improving muscle strength, mass and power, and the functionality, components that are closely related to the maintenance of functional independence and the ability to perform daily living activities in older adults(¹1 Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 2011;22(4):78-83.

2 McPhee JS, French DP, Jackson D, Nazroo J, Pendleton N, Degens H. Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology. 2016;17(3):567-580. -³3 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011. ). However, it is estimated that the number of old participants who frequently practice strength training is less than 10%(⁴4 Clemson L, Singh MAF, Bundy A, Cumming RC, Manollaras K, O’loughlin P, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. 2012;345:e4547-e4547. ) and the low adherence may be related to the repetitive and tedious characteristics of this type of training, reported by participants(⁵5 Studenski S, Perera S, Hile E, Keller V, Garcia J. Interactive video dance games for healthy older adults interactive video dance games for healthy older adults. J Nutr Health Aging. 2010;14(10):850-852.).

In this way, the practice of exercise using video game, also called as exergames, has been adopted by several studies and classified as fun and motivating by aged_{(⁵5 Studenski S, Perera S, Hile E, Keller V, Garcia J. Interactive video dance games for healthy older adults interactive video dance games for healthy older adults. J Nutr Health Aging. 2010;14(10):850-852.,⁶6 Jorgensen MG, Laessoe U, Hendriksen C, Nielsen OBF, Aagaard P. Efficacy of nintendo wii training on mechanical leg muscle function and postural balance in community-dwelling older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(7):845-852. )} . This type of training is effective in improving gait and postural control, balance and mobility and reducing fear of falling(⁷7 Duque G, Boersma D, Loza-Diaz G, Hassan S, Suarez H, Geisinger D, et al. Effects of balance training using a virtual-reality system in older fallers. Clin Interv Aging. 2013;8:257-263. ). Studies verified isometric strength increment after Tai-Chi and Yoga virtual reality-based exercise during 8 weeks, 3 times/week (t/w)(⁸8 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: A pilot study. Arch Phys Med Rehabil. 2013;94(5):937-943. ) and after exergames that involved 3 balance and 5 strength exercises, 3 t/w during 16 weeks(⁹9 Gschwind YJ, Schoene D, Lord SR, Ejupi A, Valenzuela T, Aal K, et al. The effect of sensor-based exercise at home on functional performance associated with fall risk in older people - a comparison of two exergame interventions. Eur Rev Aging Phys Act. 2015;12:11. ).Jorgensen, Laessoe, Hendriksen, Nielsen, Aagaard(⁶6 Jorgensen MG, Laessoe U, Hendriksen C, Nielsen OBF, Aagaard P. Efficacy of nintendo wii training on mechanical leg muscle function and postural balance in community-dwelling older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(7):845-852. )conducted a 2 t/w training using different balance and strength Wii Fit games, during 10 weeks, and found improvement in maximal leg muscle strength (maximal voluntary contraction and rate of force development) and overall functional performance (Timed Up and Go test, 30-second repeated Chair Stand Test and fear of falling) in community-dwelling older adults. Still, dance based on video game choreography have also been used to improve balance, reaction time and functionality(⁵5 Studenski S, Perera S, Hile E, Keller V, Garcia J. Interactive video dance games for healthy older adults interactive video dance games for healthy older adults. J Nutr Health Aging. 2010;14(10):850-852.,⁶6 Jorgensen MG, Laessoe U, Hendriksen C, Nielsen OBF, Aagaard P. Efficacy of nintendo wii training on mechanical leg muscle function and postural balance in community-dwelling older adults: A randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(7):845-852. ).

It is known that increasing muscle strength can promote increases in muscle mass(¹⁰10 Schoenfeld BJ. The mechanisms of muscle hypertrophy and their application to resistance training. J Strength Cond Res. 2010;24(10):2857-2872.). Studies that performed traditional aerobic and muscle strength and power exercises reported increases in cross-sectional area (CSA) and/or muscle volume after 12 weeks (3-4 t/w) of aerobic exercise on a stationary bicycle(¹¹11 Harber MP, Konopka AR, Douglass MD, Minchev K, Kaminsky LA, Trappe TA, et al. Aerobic exercise training improves whole muscle and single myofiber size and function in older women. Am J Physiol Regul Integr Comp Physiol. 2009;47306:1452-1459. ), 12 weeks (3 t/w) of power exercises (30%-50% 1RM)(¹²12 Frontera WR, Hughes VA, Krivickas LS, Kim S-K, Foldvari M, Roubenoff R. Strength training in older women: early and late changes in whole muscle and single cells. Muscle Nerve Only. 2003;28(5):601-608. ) and 16 weeks (2 t/w)(¹³13 Wallerstein LF, Tricoli V, Barroso R, Rodacki ALF, Russo L, Aihara AY, et al. Effects of strength and power training on neuromuscular variables in older adults. J Aging Phys Act. 2012;20(2):171-185. )of strength and power exercises. Although studies with virtual games reported an increase in muscle isometric strength(⁸8 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: A pilot study. Arch Phys Med Rehabil. 2013;94(5):937-943. ,⁹9 Gschwind YJ, Schoene D, Lord SR, Ejupi A, Valenzuela T, Aal K, et al. The effect of sensor-based exercise at home on functional performance associated with fall risk in older people - a comparison of two exergame interventions. Eur Rev Aging Phys Act. 2015;12:11. ), no one was found investigating the effects of virtual games on muscle mass and concentric and eccentric torque, which are required to perform the activities of daily living. Still, the skeletal muscle remodeling response to concentric and eccentric exercises, as a dance training performed in closed chain, can be different when the concentric and eccentric torque are assessed by an isokinetic dynamometer(¹⁴14 Cepeda, CC, Lodovico, A, Fowler, N, Rodacki A. Effect of an 8-week ballroom dancing programme on muscle architecture in older adult females. J Aging Phys Act. 2015;23:607-612. ,¹⁵15 Franchi MV. , Reeves ND, Narici VM . Skeletal muscle remodeling in response to eccentric vs. concentric loading: Morphological, molecular, and metabolic adaptations. Front Physiol. 2017;8:1-16. ).

Nevertheless, there is a lack of evidence of exergames training effects on functionality and muscle function in the aged, that can be explained by the absence of exercise parameters prescription such as: frequency, duration, progression and intensity of video game training and small sample size ¹⁶16 Rodrigues EV, Valderramas SR, Rossetin LL, Gomes ARS. Effects of video game training on the musculoskeletal function of older adults - A systematic review and meta-analysis. Top Geriatr Rehabil. 2014;30(4):238-245. ,¹⁷17 Molina KI, Ricci NA, de Moraes SA, Perracini MR. Virtual reality using games for improving physical functioning in older adults: a systematic review. J Neuroeng Rehabil. 2014;11(1):156. . Thus, the aim of this study was to investigate the effects of a supervised dance intervention based on video game choreography on isokinetic concentric and eccentric knee peak of torque (PT), quadriceps and hamstrings cross sectional area (CSA) and functionality in older women. The potential findings can improve the understanding about skeletal muscle responses to different types of exercise, enabling health professionals to choose the one that best suits their population goals.

METHODS

DESIGN

This was a non-randomized controlled trial, approved by the Research Ethics Committee of the Health Sciences Division of the Federal University of Parana (UFPR), Brazil (CAAE: 36003814.2.0000.0102) and all participants signed the informed consent.

PARTICIPANTS

The inclusion criteria were: community-dwelling older women living in Curitiba and its metropolitan area, Parana, Brazil; independent older women [according to Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)](¹⁸18 Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of Illness in the Aged. Jama. 1963;185(12):914. ,¹⁹19 Lawton MP, Moss M, Fulcomer M, Kleban MH. A research and service oriented multilevel assessment instrument. J Gerontol. 1982;37(1):91-99. ); > 65 years; low to moderately activity level [Human Activity Profile (HAP)](²⁰20 Souza AC, Magalhaes LDC, Teixeira-Salmela LF. Cross-cultural adaptation and analysis of the psychometric properties in the Brazilian version of the Human Activity Profile. Cad Saude Publica. 2006;22(12):2623-2636. ); without cognitive impairment [Mini-Mental State Examination (MMSE)](²¹21 Bertolucci PHF, Campacci SR, Juliano A. O Mini-Exame do Estado Mental em uma população geral: Impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7.); without severe symptoms in hip and knee [Lequesne’s Algofunctional Questionnaire](²²22 Marx FC, De Oliveira LM, Bellini CG, Ribeiro MCC. Tradução e validação cultural do questionário algofuncional de Lequesne para osteoartrite de joelhos e quadris para a língua Portuguesa. Rev Bras Reumatol. 2006;46(4):253-260. ) accepting scores between 0 (no impairment) to 7 (moderate, mild involvement); without neurological disease and/or trauma, orthopedic fixation or prosthesis, and metallic or non-metallic implants. Volunteers also should not have uncontrolled diseases (cardiac, respiratory, kidney, liver, osteoporosis, hypertension, diabetes I and diabetes II and endocrine); do not use medications that affect balance (benzodiazepines and neuroleptics); have normal visual acuity, even with use of contact lenses or glasses (score of Snellen: < 20/70 (ICD-10 - International Classification of Diseases)]. Participants who did not take part in training sessions and/or did not participate in post 12 weeks’ evaluations were excluded from the analysis.

Initially, older women from senior groups, public health care ambulatories from Curitiba, PR, Brazil and its metropolitan area were invited to take part of this study from March to May of 2015. Besides, flyers explaining this study and inviting older women were handed out in many places at Curitiba such as: churches, universities, hospitals and public health care ambulatories. Then, senior women interested in participating to our study underwent the screening assessments, applied by Physical Therapists and Physical Trainer, and then were evaluated by Geriatrician doctor in July of 2015.

Fifty-two participants were included and submitted to musculoskeletal assessments, before and after 12 experimental weeks (August to November of 2015). Afterward the pre assessment, participants choose to take part of Intervention Group (IG, n= 23) or Control Group (CG, n=29).

The IG performed supervised dance intervention based on video game choreography, 3t/w, during 12 weeks and the CG committed not to modify their lifestyle during this period. After allocation 3 subjects from CG withdrew and 1 participant from IG dropped out due to hospitalization during the experimental period, and after the finals evaluations, one CG participant was excluded from analysis because had insufficient data. Therefore, 25 older women from CG and 22 from IG completed the study (Figure 1).

OUTCOMES

The primary outcomes were quadriceps (Q) and hamstrings (H) concentric and eccentric isokinetic PT and cross sectional area (CSA). Isokinetic PT was evaluated by a Physical Therapist, using Biodex System 4 Dynamometer (Biodex Medical Systems, Shirley, New York) in Center of Motor Behavior Studies at Federal University of Parana. The CSA was assessed using Magnetic Resonance Imaging (MRI) equipment (Siemens Magnetom Avanto 1.5T) at Diagnóstico Avançado por Imagem (DAPI).

For the isokinetic PT evaluations, all participants were tested in the dominant lower leg after answering the question “which leg would you use to kick a ball?”(²³23 Webber SC, Porter MM. Reliability of ankle isometric, isotonic, and isokinetic strength and power testing in older women. Phys Ther. 2010;90(8):1165-1175. ,²⁴24 Hartmann A, Knols R, Murer K, De Bruin ED. Reproducibility of an isokinetic strength-testing protocol of the knee and ankle in older adults. Gerontology. 2009;55(3):259-268. ).

Before starting the test, the subjects completed a warm-up[walking throw a 30 meter straight corridor until reaching the target heart rate (HR) for warming-up (40% to 60% of HR reserve)](²⁵25 Pescatello, L.; Arena, R.; Riebe D. TP. General principles of exercise prescription. In: ACSM’s guidelines for exercise testing and prescription. Vol 9 ed. ; 2014:269-279.). The average time obtained for warm-up was 2 minutes. Once they reached the target HR, the participants sat on the dynamometer chair (chair back angle of 85°) secured by adjustable straps in the trunk, waist and thigh, and with the input shaft of the dynamometer aligned with their knee axis of rotation. To get familiarized with test protocol, participants performed 2-4 passive repetitions followed by 1 set of 4 submaximal continuous repetitions. Then, 1 set of 3 maximal continuous voluntary flexion-extension were performed and considered for analysis. This process was done to evaluate knee concentric and eccentric strength, at 60°/s and 180°/s, with 2 minutes of rest among the tests(²³23 Webber SC, Porter MM. Reliability of ankle isometric, isotonic, and isokinetic strength and power testing in older women. Phys Ther. 2010;90(8):1165-1175. ,²⁶26 Khoganaamat K, Sadeghi H, Sahebozamani M, Nazari S. Effect of Seated leg press exercise on knee extensor strength in elderly. Middle-East J Sci Res. 2013;18(6):732-737. ,²⁷27 Gallon D, Rodacki ALF, Hernandez SG, Drabovski B, Outi T, Bittencourt LR, et al. The effects of stretching on the flexibility, muscle performance and functionality of institutionalized older women. Braz J Med Biol Res. 2011;44(3):229-235. ), and 60º of range of motion (ROM)(²⁶26 Khoganaamat K, Sadeghi H, Sahebozamani M, Nazari S. Effect of Seated leg press exercise on knee extensor strength in elderly. Middle-East J Sci Res. 2013;18(6):732-737. ). Participants received verbal encouragement in order to reach the maximal strength through the full available ROM at every trial(²⁶26 Khoganaamat K, Sadeghi H, Sahebozamani M, Nazari S. Effect of Seated leg press exercise on knee extensor strength in elderly. Middle-East J Sci Res. 2013;18(6):732-737. ,²⁷27 Gallon D, Rodacki ALF, Hernandez SG, Drabovski B, Outi T, Bittencourt LR, et al. The effects of stretching on the flexibility, muscle performance and functionality of institutionalized older women. Braz J Med Biol Res. 2011;44(3):229-235. ). After the tests the subjects performed 2 repetitions of 30 seconds stretching exercises for extensor and flexor knee joint at orthostatic position.

The MRI axial images of quadriceps and hamstrings muscles were assessed by a specialist in radiology. The images were obtained from the dominant leg, with 9 mm thickness, 1 mm gap, 20 ms of echo time and a 442 ms repetition time, in a 256 x 256 pixels matrix. An initial axial T1 image was captured to determine the perpendicular distance from greater trocanter of the femur to the inferior femur condyle border. The muscle images were obtained at 50% of this distance(¹³13 Wallerstein LF, Tricoli V, Barroso R, Rodacki ALF, Russo L, Aihara AY, et al. Effects of strength and power training on neuromuscular variables in older adults. J Aging Phys Act. 2012;20(2):171-185. ), with participant in supine position and most relaxed as possible(²⁸28 Silva-Couto MA, Prado-Medeiros CL, Oliveira AB, Alcântara CC, Guimarães AT, Salvini TF, et al. Muscle atrophy, voluntary activation disturbances, and low serum concentrations of IGF-1 and IGFBP-3 are associated with weakness in people with chronic stroke. Phys Ther. 2014;94(7):957-968.,²⁹29 Prado-Medeiros CL, Silva MP, Lessi GC, Alves MZ, Tannus A, Lindquist AR, et al. Muscle atrophy and functional deficits of knee extensors and flexors in people with chronic stroke. Phys Ther. 2012;92(3):429-439.).

The CSA was analyzed using the Image J software (Version 1.46r, National Institutes of Health, Bethesda, MD, USA). The external borders of the quadriceps and hamstrings were outlined, excluding bone, subcutaneous and intermuscular fat. The quadriceps and hamstrings muscle CSA areas (measured in cm(²2 McPhee JS, French DP, Jackson D, Nazroo J, Pendleton N, Degens H. Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology. 2016;17(3):567-580. )) were automatically calculated by summing pixels of the indicated tissues and multiplied by the pixel surface area(³⁰30 Ross R, Rissanen J, Pedwell H, Clifford J, Shragge P. Influence of diet and exercise on skeletal muscle and visceral adipose tissue in men. J Appl Physiol. 1996;81(6):2445-2455.). Each muscle group was measured three times by the same researcher and the average value of the three measurements was considered for the analysis(²⁸28 Silva-Couto MA, Prado-Medeiros CL, Oliveira AB, Alcântara CC, Guimarães AT, Salvini TF, et al. Muscle atrophy, voluntary activation disturbances, and low serum concentrations of IGF-1 and IGFBP-3 are associated with weakness in people with chronic stroke. Phys Ther. 2014;94(7):957-968.,²⁹29 Prado-Medeiros CL, Silva MP, Lessi GC, Alves MZ, Tannus A, Lindquist AR, et al. Muscle atrophy and functional deficits of knee extensors and flexors in people with chronic stroke. Phys Ther. 2012;92(3):429-439.).

The secondary outcomes were functionality assessed by functional mobility test (Timed Up and Go - TUG)(³¹31 Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29(2):64-68.), Gait Speed (GS)of 10 meters test(³²32 Rogers ME, Rogers NL, Takeshima N, Islam MM. Methods to assess and improve the physical parameters associated with fall risk in older adults. Prev Med (Baltim). 2003;36(3):255-264.,³³33 Graham JE, Ostir GV, Fisher SR, Ottenbacher KJ. Assessing walking speed in clinical research: a systematic review. J Eval Clin Pract. 2008;14(4):552-562. ) and Five Times Seat to Stand Test (FTSS)(³⁴34 Bohannon RW. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills. 2006;103(1):215-222.). All these tests were assessed by Physical Therapists and Physical Trainer in the Prevention and Functional Rehabilitation Unit and and Metabolic Unit at Clinics Hospital/Universidade Federal do Paraná.

The covariates were falls and anthropometric data (weight, height and body mass index - BMI). About the fall history, the participants answered if they had experienced a fall during the last 12 months(³⁵35 Bento PCB, Pereira G, Ugrinowitsch C, Rodacki ALF. The effects of a water-based exercise program on strength and functionality of older adults. J Aging Phys Act. 2012;20(4):469-483.).

INTERVENTION PROTOCOL

The dance training based on video game choreography was performed in a group of 19 older women on average per training session, 3 times per week, ~ 40minutes per session, during 12 weeks. The control group did not take part in any intervention protocol and was instructed to maintain their lifestyle during the experimental period.

The Dance Central game and XBOX 360® with Kinect motion sensor were used. All the training sessions started with warm-up (10 minutes) in which the dance movements that would compose the choreography of that training session were taught by the Physical trainer, at first without music. Then the “perform it” game mode was played once, in which the participants could perform the choreography with all the movements learned before, with music and the game avatar. At the main session part (20 minutes), the “dance battle” mode, in which the whole choreography was repeated twice, without interval, was performed four times and then, the training session finished with relaxation and breathing exercises (10 minutes). Six dance rhythm musics were selected: Funkytown, Galang’ 05, Down, Brick House, Jungle Boogie, Days Go by, and all of them were played only in the easy level. A different song was danced every week until the seventh week, when they were repeated in the same sequence, as described in Box 1.

The selected music and their order of execution in the training protocol were based on the American College of Sports Medicine(³⁶36 Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ, et al. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009. ) recommendations for neuromotor training that include exercises as follow: “ 1) progressively difficult postures that gradually reduce the base of support (e.g., two-legged stand, semi tandem stand, tandem stand, one-legged stand), 2) dynamic movements that perturb the center of gravity (e.g., tandem walk, circle turns), 3) stressing postural muscle groups (e.g., heel stands, toe stands), or 4) reducing sensory input (e.g., standing with eyes closed)”. Thus, the sequence of choreographed songs chosen increased progressively the difficulty of movements, from bipedal support to one standing leg movements; movements at the same support basis to movements with lateral and forward displacement; plantar flexion, jumps and squat movements. Besides, to increase the training complexity, the participants performed the exercises with low lighting from the 7th to 12th week, on a 19m(²2 McPhee JS, French DP, Jackson D, Nazroo J, Pendleton N, Degens H. Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology. 2016;17(3):567-580. ) of polyurethane foam with 5cm of thickness(³⁷37 Islam MM, Nasu E, Rogers ME, Koizumi D, Rogers NL, Takeshima N. Effects of combined sensory and muscular training on balance in Japanese older adults. Prev Med (Baltim). 2004;39(6):1148-1155.)and 33 of density which supports 70 - 100kg. From the 10th to 12th week colorful and flashing lights were added to promote visual inputs perturbation.

The game was projected on a white wall and the sound amplified, facilitating the viewing and the hearing by all participants. All the sessions were supervised by Physiotherapists and led by a Physical Trainer. Their functions were: implement the training and give all the necessary orientations, ensure the safety of participants mainly regarding to the risk of falling, prevent the incorrect movements, give feedback to participants on their performance, note their HR, rating perceived exertion (RPE) and their presence at each session.

The Physical Trainer was the person captured by Kinect system. The intervention was performed in group, however the Kinect system captured only one player, i.e., the physical trainer. So, participants danced following the avatar projected on a white wall, but the performance feedback given by the Kinect system was related to the Physical Trainer who conducted the dance exercises. However, the participants received verbal stimulus and positive feedback from professionals during the dance training.

To control training intensity, the HR was collected at pre and post of each session and after the warm-up (moment 1), 10^th (moment 2) and 20^th (moment 3) minutes of dance training in each session. The percent of HR Reserve (%HRR) were considered to calculate the intensity of training using the exercise HR response at moment 1, 2 and 3. For the %HRR the equation was [%HRR =((HR achieved - HR rest )/HRR ) x 100](²⁵25 Pescatello, L.; Arena, R.; Riebe D. TP. General principles of exercise prescription. In: ACSM’s guidelines for exercise testing and prescription. Vol 9 ed. ; 2014:269-279.,³⁸38 Guderian B, Borreson LA, Sletten LE, Cable K, Stecker TP, Probst MA, et al. The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. J Sport Med Phys Fit. 2010;50(4):436-442.). And to evaluate the perception of effort during exercise, participants answered about their perceived both cardio respiratory and muscle RPE(³⁹39 Morishita S, Yamauchi S, Fujisawa C, Domen K. Rating of perceived exertion for quantification of the intensity of resistance exercise. Int J Phys Med Rehabil. 2013;1(9):1-4.) using the Borg 6 -20 scale, after the warm-up (moment 1), 10^th (moment 2) and 20^th (moment 3) minutes of dance training.

Only the moments 2 and 3 of HR and RPE were considered for analysis, because these were the moments when the cardiovascular and neuromuscular systems were more required. The cutoffs for intensity of training according to %HRR (bpm) and RPE (score) were respectively: very light (<30; <9); light (30-39; 9-11); moderate (40-59; 12-13); vigorous (60-89; 14-17); near maximal to maximal (≥90; ≥18)(²⁵25 Pescatello, L.; Arena, R.; Riebe D. TP. General principles of exercise prescription. In: ACSM’s guidelines for exercise testing and prescription. Vol 9 ed. ; 2014:269-279.). To compare the training intensity with and without foam, only the 3rd session of the 1^st, 6^th and 12^th were considered for analysis

The Blood pressure was checked in accordance with the 6^thBrazilian Hypertension Guidelines(⁴⁰40 Nobre F, Sp A, Saad CI, et al. VI Diretrizes Brasileiras. VI Diretrizes Bras Hipertens - Soc Bras Cardiol. 2010;95:1-51.)by the stethoscope method, using a sphygmomanometer (Premium) and stethoscope (Premium) prior to the beginning of each testing session and immediately after the cool down.

DATA ANALYSIS

The sample size calculation was based on a distribution assuming two independent groups. For this, the GPower 3.1.9 program was used considering an effect size of 0.8 (large), an error type I of 0.05 and power analysis of 0.78, estimating 52 people for the sample size. Along the intervention and after post assessment, there was a sample loss of 5 individuals, which guaranteed the analysis, in a post-hoc evaluation, a power equivalent to 0.74 for a sample size of 47.

The data was tested for normality distribution using the Kolmogorov-Smirnov and Lilliefors. The median and interquartile range were used to demonstrate the data at the baseline characteristics. To compare the variables at baseline Mann Whitney U Test was used for IADL, ADL and Algofunctional index of Lequesne for knee and hip; number of falls through Chi⁽²⁾ of k proportion test and the others baseline variables analyzed by the independent student t-test. The primary and secondary outcomes were described as mean difference and 95% confidence intervals. The comparisons between IG and CG were adjusted by age using is Analysis of Covariance (ANCOVA) and Bonferroni post hoc test in case of statistical significance (p≤0.05). To compare the intensity of the training among the 3rd sessions of the 1st, 6th and 12th week the General Linear Models ANOVA repeated measures, assuming Gaussian distribution, followed by post hoc Tukey was used for RPE and HR. The Intraclass Correlation Coefficient (ICC) was calculated to verify the intra-rater reliability to the CSA’s measures. It was considered the intra-rater concordance among the 3 measures in the first day and 3 measures after 1 month. The Standard Error of the Measurement (SEM) was estimated to verify the reliability of intra rater score differences to measure the CSA, considering SEM equal to the SD (standard deviation of the measurements) multiplied by the square root of one minus the ICC.

The SPSS (version 20; SPSS, Inc., Chicago, IL) was used to calculate the ICC. The 7.0 Statistic (Stat Soft Inc 7.0) was used to the others analysis. In all statistical tests, significance was set at ≤0.05.

RESULTS

BASELINE CHARACTERISTICS

Considering the baseline characteristics, there was difference between the groups only in the height. The average age of the sample was 70.2 years-old. The CG and IG were classified as independent, normal weight by BMI, without cognitive alterations and as moderately active. Seventeen subjects (36%) from both groups reported falls in the previous 12 months. About the lower limb joints functional capacities the participants showed mild symptoms (Table 1).

FEASIBILITY AND SAFETY OF THE INTERVENTION

Considering 12 weeks of supervised dance training based on video game choreography performed 3 times per week totaled 36 sessions, the participants performed an average of 31 interventions sessions, representing about 86% of adherence rate and 96% of adherence to the training period. No serious advent related to the intervention was reported and in all the sessions, the participants were overseen by Physiotherapists and a Physical Trainer.

EFFECTS OF THE INTERVENTION

The eccentric PT of quadriceps at 60°/s and the quadriceps CSA increased 8.5% and 1.3% in IG, respectively. There were no significant differences between groups (p>0.05) in the other variables.

INTENSITY OF TRAINING

The intensity was light-to-moderate and there was no significant difference of HR comparing the moments 2 (10^th minute) and 3 (20^thminute) (p> 0.05) and comparing weeks 1, 6 and 12 (p> 0.05), i.e., when the exercises were performed with and without foam. There was no significant difference in RPE comparing weeks 1, 6 and 12 (p> 0.05), however, RPE increased at moment 3 in relation to 2 in all weeks (p = 0.008) (Figure 2). Considering these data the video game dance training protocol was performed in a light-to-moderate intensity.

DISCUSSION

The supervised dance intervention based on video game choreography, performed in a light-to-moderate intensity, improved muscle function, detected by the 8.5% increase in eccentric PT of quadriceps at 60°/s and the 1.3% increase in quadriceps CSA.

Studies have found increase in isometric strength in lower limbs after virtual reality training based on unsupervised balance and strength exercises during 16 weeks with training progression increasing the task’s difficulty and the number of sets, weight or repetitions(⁹9 Gschwind YJ, Schoene D, Lord SR, Ejupi A, Valenzuela T, Aal K, et al. The effect of sensor-based exercise at home on functional performance associated with fall risk in older people - a comparison of two exergame interventions. Eur Rev Aging Phys Act. 2015;12:11. ) and based on game’s movements of Tai chi and Yoga, carried out for 8 weeks(⁸8 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: A pilot study. Arch Phys Med Rehabil. 2013;94(5):937-943. ). The increase in isometric strength found in both studies is due to the balance exercise and the loads used during the training(⁹9 Gschwind YJ, Schoene D, Lord SR, Ejupi A, Valenzuela T, Aal K, et al. The effect of sensor-based exercise at home on functional performance associated with fall risk in older people - a comparison of two exergame interventions. Eur Rev Aging Phys Act. 2015;12:11. ) and the Tai chi and Yoga exercises performed which demand isometric strength to stay in the positions(⁸8 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: A pilot study. Arch Phys Med Rehabil. 2013;94(5):937-943. ), further, the older adults were not stratified by sex. In contrast, in our study, the training was carried out with female older indicating the specific gain for women. There was no use of load and even so the dance training based on video game choreography increased 8.5% in the eccentric PT of quadriceps at 60°/s, probably due to the dynamics movements required to perform the dance training in our study.

Furthermore, performing exercises on the foam may have stimulated the knee semi-flexion to adjust the stability during exercise and this has promoted increase in eccentric PT of quadriceps, probably in consequence of the changes the dance promoted in the support basis, direction and speed that required concentric and eccentric contractions(¹⁴14 Cepeda, CC, Lodovico, A, Fowler, N, Rodacki A. Effect of an 8-week ballroom dancing programme on muscle architecture in older adult females. J Aging Phys Act. 2015;23:607-612. ). And, considering dance exercise is performed in a closed kinetic chain, at standing position, it may have promoted co-contraction of the quadriceps and hamstring muscles to maintain the joints stability(⁴¹41 Nobre TL. Comparison of exercise open kinetic chain and closed kinetic chain in the rehabilitation of patellofemoral dysfunction: an updated revision. Clin Med Diagnostics. 2012;2(3):1-5.), also enhancing lower limbs strength.

The increase in eccentric PT of quadriceps at 60 °/s may have contributed to the quadriceps CSA increment in this study. Eccentric actions have greater effect on muscle hypertrophy because the increase in the active tension developed by the contractile elements particularly collagen in extracellular matrix and titin. It is theorized that the hypertrophic superiority of eccentric exercise is due to a reversal of the size principle of recruitment, resulting in selective recruitment of fast-twitch fibers. Besides, eccentric contractions result in additional recruitment of previously inactive motor units, promoting the muscle hypertrophy(¹⁰10 Schoenfeld BJ. The mechanisms of muscle hypertrophy and their application to resistance training. J Strength Cond Res. 2010;24(10):2857-2872.).

One study followed 1678 well-functioning older men and women over 5 years and found the thigh CSA decline 3.2% in female older (n=865) and 4.9% in male older (n=813), representing 0.64% and 0.98% over a year, respectively(⁴²42 Delmonico MJ, Harris TB, Visser M, Park SW, Conroy MB, Velasquez-Mieyer P, et al. Longitudinal study of muscle strength, quality, and adipose tissue infiltration. Am J Clin Nutr. 2009;90(6):1579-1585.). Comparing to our results, the light-to-moderate dance training based on video game choreography performed 12 weeks enhanced 1.27% in the quadriceps CSA that overcame 2 years of muscle mass loss. Another study (⁴³43 Frontera W, Hughes VA, Fielding RA, Fiatarone M, Evans W, Roubenoff R. Aging of skeletal muscle: A 12-yr longitudinal study. J Appl Physiol. 2000;88(15):1321-1326.)also found decline of 16.1% in quadriceps CSA and 14.9% hamstrings CSA in the same older men (n=9), with initially 65.4 old over 12 years, representing a loss of 1.34% in quadriceps and 1.24% in hamstrings over one year. It could be hypothesized that the increase in quadriceps CSA found in our study is equivalent to the value of annual loss, but the authors have assessed the CSA in male, limiting this comparison. However, the dance protocol performed in this study may be prescribed to increase quadriceps CSA in community older women.

In relation to the intensity of training, in our study it was light-to-moderate considering both the HR and the RPE. Other studies(³⁸38 Guderian B, Borreson LA, Sletten LE, Cable K, Stecker TP, Probst MA, et al. The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. J Sport Med Phys Fit. 2010;50(4):436-442.,⁴⁴44 Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging. 2012;27(3):589-600.) using Nintendo Wii Fit the intensity of training was moderate assessed by HRR parameters, light intensity using RPE(³⁸38 Guderian B, Borreson LA, Sletten LE, Cable K, Stecker TP, Probst MA, et al. The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. J Sport Med Phys Fit. 2010;50(4):436-442.) or did not present significant differences(⁴⁴44 Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging. 2012;27(3):589-600.). It might be as a result of the game's type because in our study the participants performed the dance training based on video game choreography developing large movements in different positions not only standing on the balance board as useing Nintendo Wii Fit games.

We found that the HR remained stable during the training while the RPE increased at the moment 3 (20^th minutes of training), when the cardiovascular and neuromuscular systems were more required. Another study found similar behavior and the authors reported that the RPE increase occurred from the middle to the end of exercise session and it is not correlated to HR, that can be explained by the psychobiological model, which postulates perception of effort is the conscious awareness of the central motor command sent to the active muscles, independent of peripheral afferent feedback signals(⁴⁵45 Azevedo A, Matos LF, Nakamura FY, Pereira G. Perception of effort monitors internal load during compounded circuit training. Motriz. 2016;22(1):90-93.). Thus, the RPE can increase even when the HR is stable and can be used to monitor the exercise intensity and to detect the exercise tolerance(⁴⁵45 Azevedo A, Matos LF, Nakamura FY, Pereira G. Perception of effort monitors internal load during compounded circuit training. Motriz. 2016;22(1):90-93.).

The motivation of older people is difficult to maintain in exercise training carried out 3 times a week_{(⁵5 Studenski S, Perera S, Hile E, Keller V, Garcia J. Interactive video dance games for healthy older adults interactive video dance games for healthy older adults. J Nutr Health Aging. 2010;14(10):850-852.,⁵5 Studenski S, Perera S, Hile E, Keller V, Garcia J. Interactive video dance games for healthy older adults interactive video dance games for healthy older adults. J Nutr Health Aging. 2010;14(10):850-852.,³⁸38 Guderian B, Borreson LA, Sletten LE, Cable K, Stecker TP, Probst MA, et al. The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. J Sport Med Phys Fit. 2010;50(4):436-442.)} . Studies reported 97.5% of adherence in 12 weeks of training, 2 times a week(⁴⁴44 Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging. 2012;27(3):589-600.) and 97% of adherence in 6 weeks, 2 times a week(⁷7 Duque G, Boersma D, Loza-Diaz G, Hassan S, Suarez H, Geisinger D, et al. Effects of balance training using a virtual-reality system in older fallers. Clin Interv Aging. 2013;8:257-263. ). Despite these, results had indicated that lower frequency (2x/week) or lower training period (6 weeks) the exercise adherence may be higher. In our study, the adherence was 96% which could be explained by the type of exercise, supervision during the training and also the training session performed in group. This outcome agrees with Kim, Son, Ko, Yoon(⁸8 Kim J, Son J, Ko N, Yoon B. Unsupervised virtual reality-based exercise program improves hip muscle strength and balance control in older adults: A pilot study. Arch Phys Med Rehabil. 2013;94(5):937-943. ) that reported video game based training encourages participation and increases concentration and continuity in the exercise. In addition, supervised exercise can improve adherence to exercise and safety for individuals(²⁵25 Pescatello, L.; Arena, R.; Riebe D. TP. General principles of exercise prescription. In: ACSM’s guidelines for exercise testing and prescription. Vol 9 ed. ; 2014:269-279.). Moreover, the social network must be considered as an important factor that can increase adherence when the training sessions are performed in group as reported by other authors(⁴⁷47 Kimura K, Obuchi S, Arai T, Nagasawa H, Shiba Y, Watanabe S, et al. The influence of short-term strength training on health-related quality of life and executive cognitive function. J Physiol Anthropol. 2010;29(3):95-101.).

Regarding the functionality, there were no significant changes after the dance training in our study. Chen, Wei, Hsieh, Cheen, Chen, Kao(⁴⁸48 Chen PY, Wei SH, Hsieh WL, Cheen JR, Chen LK, Kao CL. Lower limb power rehabilitation (LLPR) using interactive video game for improvement of balance function in older people. Arch Gerontol Geriatr. 2012;55(3):677-682. ) found improvement in TUG and FTSS after 6 weeks of video-game-based power training (based on squat exercises with virtual interface) in community older adults, 2 times a week for 30 minutes. However, at baseline the results of TUG (IG: 17.15; CG: 15.98) and FTSS (IG: 17; CG: 1.17) at baseline were higher than the values obtained in this study TUG (IG: 8.8; CG: 8.1) and FTSS (IG: 9.6; GC: 9.3), demonstrating that the better the initial levels of functionality are, the more difficult it is to promote modifications in functionality.

The outcomes of the present study contribute to the prescription of dance intervention based on video game choreography to improve skeletal muscle function. However, this study presents some limitations as absence of sample randomization; absence of blinded evaluations; lack of evaluation of the primary and secondary outcomes after 6 weeks of training, to compare the results with and without foam; and the absence of muscle electrical activity analysis.

CONCLUSIONS

The light-moderate-intensity dance intervention based on video game choreography performed with and without unstable ground and visual disturbance improved quadriceps eccentric torque and induced hypertrophy. Moreover, the dance training protocol promoted a high attendance and adherence of community-dwelling older women. As a clinical application the dance training based on video game choreography can be prescribed to increase musculoskeletal function and muscle mass of aged community women.

For future research, we suggest the conduction of randomized control trials that investigate the reaction time and the myoelectrical activity to elucidate the neuromuscular aspects that might be involved in the response of skeletal muscle mass and torque to the supervised dance intervention based on video game choreography. It is also required the investigation about the skeletal muscle function after unsupervised dance intervention based on video game choreography in community-dewlling older women.

ACKNOWLEDGMENTS

The authors are grateful for the grants from Federal Institute of Parana (IFPR) and National Council for Scientific and Technological Development (CNPq/467987/2014-9) to Elisângela Valevein Rodrigues; for the CNPq financial support to Anna Raquel Silveira Gomes (308696/2012-3); to Clinics Hospital of Federal University of Parana (UFPR); Juridical Sciences Sector of UFPR and Broadcasting Department of IFPR for providing the rooms for assessments and training sessions; Professor Maria Eliana M. Schieferdecker and Professor Estela Iraci Rabito (Nutrition Department of UFPR) for the partnership in this project; Professor André L. F. Rodacki (Center of Motor Behavior Studies) of UFPR for the Biodex 4 equipment; Dr. André Francisco Gomes (Advanced Imaging Diagnostics - DAPI) for the MRI and Professor Tânia Salvini and Christiane L. Prado-Medeiros (Federal University of São Carlos (UFSCAR) for the technical support with CSA method).

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