Aging Clinical and Experimental Research

Assessment of lower extremity muscle power in

functionally-limited elders
Damien Callahan2, Edward Phillips1,2,3, Robert Carabello1,Walter R. Frontera3, and
Roger A. Fielding1,2,3
1Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center

on Aging at Tufts University, Boston, MA, 2Human Physiology Laboratory, Department of Health Sciences, Sargent
College of Health and Rehabilitation Sciences, Boston University, Boston, MA, 3Department of Physical
Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA

ABSTRACT. Background and aims: The purpose of INTRODUCTION

this study was to assess the reliability and concurrent va- Skeletal muscle strength, defined as the maximum
lidity of a new methodology to evaluate lower extremity capacity to generate force, declines with advancing age (1,
muscle power in older, functionally limited men and 2). Decrements in strength have been associated with loss
women. Methods: A cross sectional evaluation was per- of function and increased disability (3). However with
formed on 58 older men (n=27) and women (n=31) age, muscle power, the product of force and velocity, has
(74.2±0.9 years). Knee and hip (leg press) and knee ex- been shown to decline earlier and more precipitously
tensor power were evaluated on pneumatic and isokinetic than muscle strength (4).
resistance equipment. Incremental single attempt power Isokinetic power of the ankle flexors has been report-
(IP) testing utilized a single attempt at attaining maximum ed to be 7.5 times lower in institutionalized recurrent “fall-
power at each of six external resistances and was com- ers” compared to “non-fallers” (5) and leg extensor pow-
pared to multiple attempt pneumatic power (MP) testing er has been shown to explain 85% of the variance in gait
determined by the highest of 5 attempts at achieving speed in nursing home residents (6). In community
maximum power at two set resistances and also with pow- dwelling, older individuals, lower extremity muscle pow-
er determined by isokinetic dynamometry. Results: Leg er has also been demonstrated to be a strong independent
press extension MP yielded significantly greater power predictor of performance-based measures of physical
than IP at both low (mean=225.3±11.85 and function (7, 8) and self-reported disability (9). In fact, re-
183.9±11.52 watts respectively, p<0.001) and high cent studies have found measures of lower extremity
(mean=249.7±15.25 and 201.7±13.18 watts respec- power to be more predictive of physical functioning than
tively, p<0.001) external resistances. Knee extension strength (10, 11).
MP also produced significantly greater power when com- Although lower extremity power has emerged as a crit-
pared to IP at low (mean=82.4±4.45 and 69.7±4.28 ical determinant of impairment in older individuals, no sin-
watts respectively, p<0.001) and high (mean=93.7±6.3 gle measure of lower extremity power has been adopted
and 83.2±5.93 watts respectively, p<0.001) external and universally applied. Approaches to the measure-
resistances. MP testing exhibited excellent reliability at ment of muscle power in older individuals have included:
both low (leg press extension: Intra Class Correlation modified cycle ergometer anaerobic power testing (12),
(ICC)=0.93, knee extension: ICC=0.87) and high (Leg isokinetic dynamometry (5, 8), unloaded leg extensor
press extension: ICC=0.85, Knee Extension: ICC=0.91) power evaluation (13), and assessments using dynamic
external resistances. MP knee extension at 70% 1 RM al- pneumatic resistance training equipment (9). However,
so showed good agreement with average isokinetic pow- limitations exist in all of these methods including the
er (R2=0.636). Conclusions: These findings support availability of equipment, participant safety, lack of task
the reliability and concurrent validity of MP for the specificity, and financial cost.
evaluation of muscle power in older individuals. The use of dynamic, pneumatic resistance equip-
(Aging Clin Exp Res 2007; 19: 194-199) ment for the evaluation of muscle power has been re-
©2007, Editrice Kurtis ported most frequently (14-16). One protocol using

Key words: aging, pneumatic, reliability, strength.

Correspondence: Roger A. Fielding, Ph.D., Director, Nutrition, Exercise Physiology, and Sarcopenia Laboratory Jean Mayer USDA, Hu-
man Nutrition Research Center on Aging, Tufts University, 711 Washington St., Boston, MA 02111, USA.
E-mail: [email protected]
Received March 20, 2006; accepted in revised form May 31, 2006.

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Aging Clin Exp Res 19: 194-199, 2007 Leg power assessment in the elderly
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pneumatic resistance exercise employing a single trial of fracture in the previous 6 months. Other exclusion criteria
leg power at each of six external resistances (IP) at vary- included uncontrolled hypertension (>150/90 mmHg) and
ing percentages of the 1 repetition maximum (1 RM) has the presence of neuromuscular disease or drugs affecting
shown excellent reliability in young as well as older in- neuromuscular function. Participants had to demonstrate
dividuals (7, 9, 17-19). Although reliable, the IP protocol functional limitation as defined by a score of 10 or below
may not be optimal for all applications particularly in on the Short Physical Performance Battery (SPPB) (21).
functionally-limited elders. In particular, one limitation in The SPPB is a twelve-point summary scale characterizing
this protocol is the performance of a single repetition at performance for three tests including balance, habitual gait
each external resistance which prevents any assessment and repeated chair-rise that is predictive of morbidity
of the variability of this measure between trial attempts. and mortality in older individuals (21). Participants meet-
Nor is it known whether IP yields the highest absolute ing these preliminary qualifications were examined by a
power scores compared to evaluation protocols that al- physician and underwent a supervised graded exercise test
low more familiarization and repetition at each external on a treadmill prior to enrollment.
resistance. Furthermore, no systematic evaluation of Testing was performed twice, at the same time of
this method, which has demonstrated reliability, has day separated by one week. The entire testing procedure
been conducted with alternative protocols using pneu- was performed in approximately 60 minutes. All partic-
matic resistance exercise equipment or with the well ipants were tested by the same evaluator and used the
established clinical assessment of leg power using isoki- same equipment and procedures. Before initiating testing,
netic dynamometry. each participant was familiarized with the equipment via
The purpose of the present study was to evaluate the visual demonstration of its use, and practice at very low re-
concurrent validity and reliability of a new protocol for as- sistance.
sessing lower extremity muscle power with pneumatic re-
sistance equipment in mobility-limited, older, community Pneumatic Resistance Testing
dwelling men and women. We propose that the new Knee extension (KE) strength and power were tested
testing protocol which allows for multiple attempts at using knee extension pneumatic strength training equip-
achieving maximum velocity and therefore maximum ment (K400, Keiser Sports Health Equipment Inc., Fres-
power will yield significantly higher performance and no, CA). Participants were seated with knees in 90 de-
better reliability than measurement protocols involving a grees of flexion and an adjustable seat back was posi-
single attempt at varying external resistances that are tioned so that the participant’s femoral lateral epicondyle
currently widely applied. A secondary objective was to was aligned with the axis of rotation of the machines
compare the new protocol with a well established and lever arm. Participants extended their knee against a pad
widely used clinical measurement for power assessment us- positioned one inch proximal to the medial maleolus. The
ing isokinetic dynamometry. pneumatic strength training equipment in these tests
utilizes cylinders pressurized with air to provide variable
METHODS resistance. Actuation of the lever arm compresses air in
Study Population the cylinder, while metered compression of the gas
Recruitment was centered in the Boston area and ac- within the cylinder provides resistance. An ultrasonic
complished through advertisements in local publica- system mounted on the cylinder monitors relative move-
tions and through the Harvard Research Cooperative ment over time allowing for the calculation of distance,
Program on Aging volunteer database. Participants velocity, and consequently, work and power. These val-
were enrolled in a large randomized exercise intervention ues are viewed on a configurable digital display. Software
trial, but all strength and power testing were adminis- engineered for this equipment calculated work and pow-
tered prior to the start of the training. All volunteers er during the concentric phase of each repetition by
signed an informed consent form and were made aware sampling system pressure (equivalent to force) and po-
of all potential risks and benefits associated with pro- sition 400 times per second. Average power was calcu-
cedures of the study prior to enrollment. This study lated from data collected between 5% and 95% of the
was approved by the Boston University Institutional concentric phase. The first and last five percent of the
Review Board. measured range of motion are not analyzed on this
Participants were eligible for the study if they were equipment in order to minimize the effect of signal
community dwelling and aged 65 years or older. They noise at the beginning and end of each movement.
were excluded if they had acute or terminal illness, cog- There were no significant differences for measurements
nitive impairment as defined by a score of 23 or below on of strength or power between right and left legs and da-
the Folstein Mini Mental State Examination (20), suf- ta are presented for the left leg only.
fered from symptomatic coronary artery disease, unstable Leg press extension (LP) strength and power were
congestive heart failure, or had a myocardial infarction or tested using pneumatic bilateral seated leg press equip-

Aging Clin Exp Res, Vol. 19, No. 3 195

D. Callahan, E. Phillips, R. Carabello, et al. Aging Clin Exp Res 19: 194-199, 2007
©2007, Editrice Kurtis

ment (K400, Keiser Sports Health Equipment Inc, measure isokinetic knee extensor peak torque (N-m) and
Fresno, CA). Participants were seated so that their power (watts) at 90° sec-1. Velocity was set and held
feet were flat on the foot plates, with their toes and constant at 90° sec-1 for the peak torque measures us-
knees slightly angled outward, and their knees in 90 de- ing a PC attached to the dynamometer. As with the
grees of flexion. The participants were instructed to pneumatic testing, participants were seated with knees
push through their heels and toes with a smooth con- in 90 degrees of flexion and an adjustable lever arm was
trolled motion until their legs were almost fully extend- positioned such that its axis of rotation was aligned with
ed. The bilateral leg press machine utilized the same the participant’s femoral lateral epicondyle. A shin
technology to produce the pneumatic resistance and to pad at the end of the lever arm was positioned one inch
calculate distance, velocity, work, and power as the proximal to the medial maleolus. During isokinetic
knee extension equipment. testing, participants were instructed to extend and
Strength as defined as the 1RM was measured for then flex their leg as quickly and forcefully as possible
both tests as reported previously (19). Each participant six times in rapid succession. Peak torque was record-
was instructed to perform a unilateral knee extension ed as the best of these six repetitions. Average isokinetic
(knee extension testing) and a bilateral knee and hip ex- power was evaluated concurrently with measures of
tension (leg press testing) through his or her full range of isokinetic torque at 90° sec-1. A PC interfaced with the
motion. Following a few attempts at very low resis- equipment calculated average power per repetition
tance to establish an individual’s range of motion, the ex- from torque produced through the complete concentric
ternal resistance was progressively increased until the range of motion. The highest value from 6 attempts
participant could no longer complete a repetition was recorded.
through their full range of motion. A lighted bar on the
digital display that corresponded to excursion of the lever Statistical analysis
arm was used to confirm achievement of full range of Data were analyzed using SPSS and StatView software
motion for each attempt. Throughout the testing pro- packages. All values are reported as means ± standard er-
cedure a rest period of approximately 2 minutes was ror. Two way, fixed model intraclass correlation coeffi-
provided between repetitions. cients were used to determine test/retest reliability using
The incremental single attempt power (IP) protocol SPSS data editors. StatView software was used for the
was applied unilaterally to each leg at six relative in- analysis of simple regression between measures of strength
tensities equal to 40%, 50%, 60%, 70%, 80%, and and power. Paired t tests were used to assess mean dif-
90% of the measured 1RM. Participants were instruct- ferences between MP and ISP testing at 40% and 70%
ed to complete a single repetition as quickly as possible 1RM. Statistical significance was accepted at p<0.05.
through their full range of motion at each external re- Comparisons between MP, IP, and isokinetic tests were
sistance. At each resistance setting, participants per- performed on results obtained from the second evaluation
formed one maximal effort with a 30 second rest be- in all participants.
tween repetitions.
Multiple Attempt Power (MP) was then measured af- RESULTS
ter a 5 minute rest for both exercises. Each participant Participant characteristics
was instructed to again complete each repetition as Fifty-eight volunteers (27 male, 31 female) complet-
quickly as possible through their full range of motion at ed all aspects of the study protocol. Participants were
a resistance equal to 40% of 1RM for both tests. This aged 74.2±0.9 and had an SPPB score of 7.7±0.2.
was repeated four more times for a total of five repeti- Body mass was 78.8±2.16 kg and BMI was 28.9±0.8
tions, each separated by 30 seconds. The highest mea- kg⋅m-2. No adverse effects nor untoward outcomes
sured power was recorded as the MP 40%. External were reported by any of the participants from the test-
resistance was then raised to 70% 1RM and the partic- ing procedures.
ipant was again instructed to extend their leg as quickly
as possible through five repetitions. The highest of these MP testing vs IP testing
values was then recorded as the MP 70%. We specifically Leg press extension (LP) and knee extension (KE) test-
chose these two relative intensities because we have ing produced excellent agreement between IP and MP at
previously shown that participants generate maximum both 40% and 70% 1 RM (LP: r2=0.85 and 0.84, re-
power (MP 70%) and maximum velocity (MP 40%) at spectively, and KE: r2=0.88 and 0.95, respectively,
these specific relative intensities (11). p<0.001). However MP testing demonstrated signifi-
cantly greater leg power at both resistances for each of
Isokinetic dynamometry the individual exercises (Fig. 1). With leg press extension,
A Cybex II isokinetic dynamometer (Computer at an external resistance equal to 40% 1 RM, MP test-
Sports Medicine, Inc., Stoughton, MA) was used to ing generated 18% higher power than IP testing

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Aging Clin Exp Res 19: 194-199, 2007 Leg power assessment in the elderly
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MP Reliability and Validity

1a
300 All measures of power showed excellent reliability
(Tables 1a and 1b). In all cases, MP demonstrated greater
*
250 * reliability than the IP procedure. Knee extension MP
testing at 70% 1 RM also showed good agreement with
200 assessment of isokinetic knee extensor power at 90°
Power (W)

sec-1 (r2=0.64, p<0.001) (Fig. 2).

150
DISCUSSION
100 The major finding from the present study is that the ab-
solute power output generated during knee extension
50
exercise is significantly greater with the MP testing pro-
tocol than with the IP testing protocol. Although the re-
0
LP 40 LP 70 liability of both testing protocols was excellent, reliability
of the MP test protocol was slightly better than the IP test
1b protocol. Finally, the MP test protocol exhibited good
120 agreement with knee extension average power mea-
* sured by isokinetic dynamometry, an established test of
100
musculoskeletal performance (22).
*
80
Power (W)

Table 1 - Leg press (a), and (b) knee extension power and reliability
60 (1 repetition maximum=1 RM; single trial of leg power at each of
six external resistances=IP; multiple attempt pneumatic pow-
40 er=MP). All power units are in Watts.

Power Intra Class

20 (mean±SE) Correlation

0 a. Leg Press Extension

KE 40 KE 70 1 RM 559.1 (25.71) 0.97
IP 40% 183.9 (11.52) 0.75
Fig. 1 - Left knee extensor power (1a) and Leg press (1b) power MP 40% 225.3 (11.85) 0.93
production from single attempt pneumatic power testing proto- IP 70% 201.7 (13.18) 0.76
col (ISP) (filled bars) and multiple attempt pneumatic power MP 70% 249.7 (15.25) 0.85
testing protocol (MP) (open bars) at 40% and 70% of 1RM. MP
testing resulted in significantly greater power at both 40% and b. Knee Extension
70% 1RM when compared to ISP (asterisks indicate p<0.001). 1 RM 64.7 (3.5) 0.92
IP 40% 69.7 (4.28) 0.80
MP 40% 82.4 (4.45) 0.87
IP 70% 83.2 (5.93) 0.78
(225.3±11.8 vs 183.9±11.5 watts, respectively, MP 70% 93.7 (6.30) 0.91
Isokinetic (90°) 60.6 (3.03) 0.84
p<0.001) (Table 1a) and MP was also associated with a
22% higher velocity (87.1±2.7 vs 71.0±3.0 cm⋅s-1,
respectively, p<0.00) (Table 2a). At 70% 1 RM, MP for
leg press extension generated 19% greater power than Table 2 - Leg press (a) and (b) knee extension velocity (single tri-
IP testing (249.7±15.2 vs 201.7±13.2 watts, respec- al of leg power at each of six external resistances=IP; multiple at-
tempt pneumatic power=MP). Leg press extension velocity units
tively, p<0.001) (Table 1a) and MP was also associated are in cm/sec. Leg extension velocity units are in radians/sec.
with a 24% higher velocity (56.8±2.6 vs 45.8±2.3
cm⋅s-1, respectively p<0.00) (Table 2a). At an external Velocity
(mean±SE)
resistance of 40% 1 RM, on the knee extension, MP
testing generated 15% higher power than ISP testing a. Leg Press Extension
(82.4±4.4 vs 69.7±4.3 watts, respectively, p<0.001) IP 40% 71.04 (2.96)
MP 40% 87.09 (2.71)
(Table 1b) and was also associated with a 16% higher ve- IP 70% 45.84 (2.34)
locity (2.4±0.1 vs 2.1±0.1 rad⋅s-1, respectively, p<0.00) MP 70% 56.79 (2.63)
(Table 2b). At 70% 1 RM, MP generated 11% greater b. Knee Extension
power than IP testing (93.7±6.3 vs 83.2±5.9 watts, re- IP 40% 2.09 (0.07)
spectively, p<0.001) (Table 1b) and was also associated MP 40% 2.43 (0.07)
IP 70% 1.62 (0.07)
with a 15% higher velocity (1.6±0.1 vs 1.9±0.1 rad⋅s-1, MP 70% 1.87 (0.07)
respectively, p<0.00) (Table 2b).

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D. Callahan, E. Phillips, R. Carabello, et al. Aging Clin Exp Res 19: 194-199, 2007
©2007, Editrice Kurtis

Isokinetic Power (90 degrees/sec and LKE Power (MP at 70%) repeated attempts. Because of single attempts at different
250 percentages of the 1 RM, the power determined by IP
may be negatively influenced by practice effects, a con-
Pneumatic power

200
MP at 70%(W)

founder which may be reduced with repeated trials in-

150 R2 = 0.6361 herent with MP. We contend that this learning effect
may be minimized with the MP testing protocol.
100
In addition to the higher power output recorded during
50 the MP testing, this methodology has proven suitable
and as safe as other methods in this population of older
0
0 20 40 60 80 100 120 140 160 individuals with functional limitations. In the present
Isokinetic Power (W) study, MP 70% testing correlated well with average isoki-
netic power production (R2=0.636), indicating its con-
Fig. 2 - Simple regression analysis comparing left knee extensor current validity with a recognized measure of muscu-
power measured via MP 70% and average isokinetic power at 90°
sec-1. There was a significant positive correlation (R2=0.636) be- loskeletal performance but also, unlike isokinetic test-
tween measures (p<0.001). ing, is performed during dynamic movement and not at a
predetermined velocity. The relative lack of agreement and
the lower absolute power generated with isokinetic pow-
Lower extremity muscle power has emerged as a er testing compared to MP 70% may be due to the in-
strong independent predictor of performance-based mea- ability of the participant to maximally accelerate during the
sures of physical function (7, 8, 10-12) and self-reported fixed velocity isokinetic test and possible mechanical dif-
disability (9, 23). Several randomized trials of exercise in ferences between both testing procedures (eg: knee and
older individuals have evaluated the effects of various hip positioning). Therefore the MP methodology may be
resistance training interventions on lower extremity mus- more functionally relevant than isokinetic testing.
cle power (18, 19, 24-28). In addition, studies have ex-
amined the role of other anabolic interventions such as CONCLUSIONS
testosterone and growth hormone on lower extremity In summary, the MP test of leg power evaluated here
muscle power (29-31). However, all of these studies was highly reliable, demonstrated greater absolute pow-
have employed different methods to assess lower ex- er values than IP, had concurrent validity and was well tol-
tremity power and none, with exception of the study by erated in older individuals with functional limitations. In-
Skelton et al. (24), has used methodology and equip- vestigators are encouraged to utilize this newly validated
ment that has been evaluated for the reliability and validity and reliable measure of leg power in future cross sectional
of lower extremity power in older individuals. In the pre- and intervention studies in older individuals.
sent study, we present a methodology (MP testing pro-
tocol) that is feasible to perform in functionally limited old- ACKNOWLEDGEMENTS
er individuals, has concurrent validity with isokinetic dy- The authors wish to acknowledge the support of Dennis Keiser and
Keiser Sports Health Equipment (Fresno, CA). Subjects were recruit-
namometry, a widely accepted measure of power as- ed from a Volunteer Registry supported by the Hebrew SeniorLife In-
sessment, yields the greatest absolute power and demon- stitute for Aging Research, and grants from the National Institute on Ag-
strates excellent reliability in our sample. ing 5 P01 AG04390, Older Americans Independence Center SubGrant
Several cross sectional and intervention studies have 2 P60 AG08812 and Massachusetts Alzheimer’s Disease Research
used the incremental single attempt power (IP) test to eval- Center Subgrant 2 P50 AG05134. This work was supported by the
National Institute on Aging (NIA) grant number AG18844 and this work
uate leg power in older adults (18, 19, 25, 26). Al- is based upon work supported by the U.S. Department of Agriculture,
though there was excellent agreement between the IP and under agreement No. 58-1950-4-401. Any opinions, findings, con-
MP protocol, results from the present study indicate MP clusion, or recommendations expressed in this publication are those of
testing produces greater measures of power in function- the author(s) and do not necessarily reflect the view of the U.S. De-
partment of Agriculture.
ally-limited, older men and women when compared to IP
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