Q: FOR A COMPLETE EXERCISE PROGRAM, NEUROMOTOR EXERCISE TRAINING HAS BEEN RECOMMENDED, ALONG WITH AEROBIC ACTIVITY, RESISTANCE TRAINING, AND FLEXIBILITY EXERCISES. WHAT IS “NEUROMOTOR EXERCISE TRAINING”? IS THIS A NEW RECOMMENDATION FOR EVERYONE?
A: In 2011, the American College of Sports Medicine published a position stand entitled “Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise.” The position stand includes this summary statement (5): “A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults.” The position stand examines the potential benefits for each of the listed exercise program components, along with the level of evidence currently available to support the recommendations given.
EXERCISE PROGRAM COMPONENTS
Consider the first three components included in the position stand (6), which also are included in the Physical Activity Guidelines for Americans (8). Cardiorespiratory exercise (or aerobic exercise) is recommended 3 to 5 days each week depending on the intensity. For moderate aerobic exercise, 30 to 60 minutes per day (150 minutes or more per week) is recommended. For vigorous aerobic exercise, 20 to 60 minutes per day (or 75 minutes per week) is suggested. Resistance training focusing on muscular fitness is recommended 2 to 3 days per week in a program that targets each major muscle group using equipment and/or body weight activities. Single sets can be effective, in particular, for individuals new to resistance training or older exercisers, although 2 to 4 sets are recommended for strength and power development for most adults. For new exercisers, 10 to 15 repetitions are recommended, whereas most adults will benefit from a range of 8 to 12 repetitions. Flexibility exercises may include static, dynamic, ballistic, or proprioceptive neuromuscular facilitation on 2 to 3 days per week, although for greatest improvements, daily stretching is recommended.
Neuromotor exercise training is the fourth component included in the position stand (6). ACSM’s Guidelines for Exercise Testing and Prescription, eighth edition, includes a similar category with a slightly different term — neuromuscular exercise (1). Neuromotor exercise training incorporates various motor skills, including balance, coordination, gait, agility, and proprioceptive training. Some activities combining neuromotor exercise, resistance exercise, and flexibility (e.g., tai chi, yoga) also fall under this category. Definitive recommendations on the amount of neuromotor exercise training are not yet available because of the variability in research studies. The position stand does recommend at least 2 to 3 days per week and notes that beneficial programs typically include at least 20 to 30 minutes per session (to total 60 minutes or more per week) (6). These recommendations are still tentative because of limited data. Examples of approaches to improve balance are provided in Box 1, and an example of a progressive program is provided in the Table (3).
EVIDENCE LEVEL FOR EXERCISE RECOMMENDATIONS
Within the position stand, the level of evidence for various recommendations is categorized at different levels depending on published research (6):
- “A” level (randomized controlled studies with extensive data)
- “B” level (randomized controlled studies, but the data are more limited)
- “C” level (nonrandomized observational studies)
- “D” level (simple consensus of the panel of writers).
A randomized study is one in which there is a control group (typically a nonexercise group similar to the exercise group in all other aspects) compared with a treatment group (this would be the individuals engaging in a particular exercise training program). The study participants are placed into either the control group or the treatment group randomly. In other words, the group assignment is by chance rather than individuals selecting for themselves or the researchers making purposeful assignments. In contrast, a nonrandomized observational study simply studies a group of individuals at particular time points. Relationships between certain exercise behaviors and outcomes can be found, but the ability to confirm a cause-and-effect relationship is not possible because other factors may have an influence. For example, in a recent study, individuals who consume more nuts have been found to have decreased prevalence of a number of risk factors for heart disease (7). This study was an observational study, so researchers could not say that eating more nuts decreases heart disease risk because there may have been other characteristics or behaviors of the nut eaters that promoted good heart health. Observational studies often lead to randomized controlled experimental studies that can shed light on specific ways a particular food or activity impacts health.
For the recommendation regarding the value of cardiorespiratory and resistance exercise to improve physical fitness and health, the evidence is Level A — very strong (6). Similarly, the evidence that flexibility exercises improve and maintain joint range of motion is Level A (6). The ability of neuromotor exercises and other activities like tai chi and yoga to improve or maintain physical function and to decrease falls in older adults at risk of falling has an evidence Level B, which means there are no substantial studies published at this time to support the claim (6) (see Box 2 for more information on fall prevention). When considering the benefit of neuromotor exercises on young adults and middle-aged adults, the evidence level is D, which indicates that the authors of the position stand felt that benefits logically would occur but did not have sufficient studies to substantiate the claim (6). Although research data are lacking for these age groups, potential benefits may be realized, in particular, for individuals who participate in activities involving agility, balance, and other motor skills.
As an example of the difficulty in summarizing research, consider tai chi. Tai chi is a Chinese martial art that includes slow continuous movements. These movements incorporate a number of fitness-related elements, including strength and balance, along with posture alignment and concentration (9). Although many studies have been published related to the impact of tai chi on balance and fall prevention, summarizing them is difficult because of variations in balance measurements, the type of tai chi exercise (different styles include yang, wu, or tai chi chih), and the duration/experience with tai chi (9). There are 10 to 100 posture forms, and the extent of training in studies varies from an hour per week for a month to more intense programs, including 1 hour every morning for a year (5). Given the variability in research study designs and outcome measures, at this point, tai chi or other types of neuromotor exercise training is recommended for older adults but at a B level of evidence (6).
Based on the available evidence, neuromotor exercises focusing on balance, coordination, gait, agility, and proprioceptive training are recommended as part of a comprehensive exercise program (including cardiorespiratory, resistance, and flexibility exercises) for older individuals (6). Younger and middle-aged adults also may benefit if engaging in activities relying on agility, balance, and other motor skills.
1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 380 p.
2. American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 868 p.
3. American College of Sports Medicine. ACSM’s Complete Guide to Fitness & Health. Bushman BA, editor. Champaign (IL): Human Kinetics; 2011. 396 p.
4. Centers for Disease Control and Prevention Web site [Internet]. Atlanta (GA): Home and recreational safety: Falls among older adults. Centers for Disease Control and Prevention; [cited 2012 May 11]. Available from: http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
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7. O’Neil CE, Keast DR, Nicklas TA, Fulgoni VL. Nut consumption is associated with decreased health risk factors for cardiovascular disease and metabolic syndrome in U.S. adults: NHANES 1999–2004. J Am Coll Nutr. 2011; 30 (6): 502–10.
8. U.S. Department of Health and Human Services Web site [Internet]. Atlanta (GA): 2008 Physical Activity Guidelines for Americans
. 2008 [cited 2011 Aug 2]. Available from: http://www.health.gov/paguidelines
9. Wu G. Evaluation of the effectiveness of Tai Chi
for improving balance and preventing falls in the older population — A review. J Am Geriatr Soc. 2002; 50: 746–54.