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The biomechanical mechanism of how strength

and power training improves walking speed in
old adults remains unknown

Article in Ageing research reviews · March 2013

Impact Factor: 4.94 · DOI: 10.1016/j.arr.2013.03.001 · Source: PubMed

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 Ageing Research Reviews 12 (2013) 618–627

Contents lists available at SciVerse ScienceDirect

Ageing Research Reviews

journal homepage: www.elsevier.com/locate/arr

Review

The biomechanical mechanism of how strength and power training

improves walking speed in old adults remains unknown
C.M.I. Beijersbergen a , U. Granacher b , A.A. Vandervoort c , P. DeVita d , T. Hortobágyi a,∗
a
University Medical Center Groningen, Center for Human Movement Sciences, Groningen, The Netherlands
b
University of Potsdam, Department of Training and Movement Sciences, Potsdam, Germany
c
The University of Western Ontario, Faculty of Health Sciences, School of Kinesiology, Canadian Centre for Activity and Aging, Canada
d
East Carolina University, Department of Kinesiology, Greenville, NC, USA

a r t i c l e i n f o a b s t r a c t

Article history: Maintaining and increasing walking speed in old age is clinically important because this activity of daily
Received 9 January 2013 living predicts functional and clinical state. We reviewed evidence for the biomechanical mechanisms of
Received in revised form 4 March 2013 how strength and power training increase gait speed in old adults. A systematic search yielded only four
Accepted 7 March 2013
studies that reported changes in selected gait biomechanical variables after an intervention. A secondary
Available online 15 March 2013
analysis of 20 studies revealed an association of r2 = 0.21 between the 22% and 12% increase, respectively,
in quadriceps strength and gait velocity in 815 individuals age 72. In 6 studies, there was a correlation of
Keywords:
r2 = 0.16 between the 19% and 9% gains in plantarflexion strength and gait speed in 240 old volunteers age
Aging
Strength training 75. In 8 studies, there was zero association between the 35% and 13% gains in leg mechanical power and
Power training gait speed in 150 old adults age 73. To increase the efficacy of intervention studies designed to improve
Gait biomechanics gait speed and other critical mobility functions in old adults, there is a need for a paradigm shift from
conventional (clinical) outcome assessments to more sophisticated biomechanical analyses that examine
joint kinematics, kinetics, energetics, muscle-tendon function, and musculoskeletal modeling before and
after interventions.
© 2013 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
2. Age-related mechanical plasticity of gait: a distal-to-proximal shift in muscle function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
2.1. Walking kinematics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
2.2. Effects of age on hip joint function during gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
2.3. Effects of age on knee joint function during gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
2.4. Effects of age on ankle joint function during gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
3. Scant biomechanical evidence for how strength interventions increase gait speed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
3.1. Search toward effects of specific strength and power training on gait characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
3.2. Selection criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
3.3. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
4.1. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
4.2. Evaluation of the four intervention studies identified by the systematic search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
4.3. Association between improvements in gait speed and muscle strength and power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
5.1. The role of relative effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
5.2. Biomechanical mechanisms of interventions increasing gait speed in old adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624

∗ Corresponding author at: Center for Human Movement Sciences, University Medical Center Groningen, A. Deusinglaan 1, Room 334, Building 3215,
9700 AD Groningen, The Netherlands. Tel.: +31 50 363 2645; fax: +31 50 363 3150.
E-mail address: t.hortobagyi@umcg.nl (T. Hortobágyi).

1568-1637/$ – see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.arr.2013.03.001
 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627 619

6. Summary and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625

Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626

1. Introduction capacity become incorporated into the movements of ADLs and in

case of gait, produces longer steps and faster walking. Although a
Aging, whether along healthy or non-healthy paths, modifies handful of studies did examine how specific interventions affect
human gait. While aging after age 50 modifies many gait char- selected biomechanical variables in relation to gait speed, no stud-
acteristics, shorter steps and slower walking speed may be the ies to date have reported the association between improvements
most functionally meaningful. The magnitude of the reductions in in maximal voluntary strength and power and the improvements
step length and walking speed are associated with the magnitude in lower extremity joint kinetics and energetics, identifying the
of any decline in health while aging. Consequently, self-selected mechanisms behind intervention-induced improvements in gait
habitual gait speed measured on a level surface is a marker and speed. The aim of the present review was to draw attention to a
predictor of many clinical conditions, including daily function, critical gap in our understanding as to how interventions improve
late-life mobility, independence, falls, fear of falls, fractures, mental mobility functions in old adults in general and, in particular, how
health, cognitive function, adverse clinical events, hospitalization, strength and power training improve gait speed in old adults. We
institutionalization, and survival (Abellan van Kan et al., 2009; addressed the question, ‘What is the biomechanical mechanism of
Atkinson et al., 2007; Dargent-Molina et al., 1996; Granacher interventions increasing gait speed in old adults?’ First we review
et al., 2011a; Guralnik et al., 2000; Ijmker and Lamoth, 2012; the age-related reorganization of mechanical output at the hip,
Potter et al., 1995; Studenski et al., 2011; Viccaro et al., 2011; knee, and ankle joints during gait and link these torques to the
Watson et al., 2010; Weuve et al., 2004). Gait speed in old adults, maximal torque available in the lower extremity joints. Finally, we
i.e., age over 70, that is similar to young adults’ speed signifies review the effects of strength interventions on gait biomechanics,
multi-systemic wellbeing and slowed gait suggests clinical or summarize the potential mechanisms, and make recommendations
sub-clinical impairments (Abellan van Kan et al., 2012). for future research.
Usual gait speed decreases up to 16% per decade starting already
at age 60 (Abellan van Kan et al., 2009, 2012; Bassey et al., 1982; 2. Age-related mechanical plasticity of gait: a
Bendall et al., 1989; Himann et al., 1988). Many old adults’ usual gait distal-to-proximal shift in muscle function
speed decreases to the functionally inadequate levels of 0.8 m/s and
even slower (Abellan van Kan et al., 2009), signifying mobility dis- 2.1. Walking kinematics
ability. The slowing of gait perpetuates physical inactivity because
the time needed to cross the street or reach a destination becomes Healthy aging after age 50 produces profound modifications in
too long and old adults lose motivation to ambulate (Bollard and gait. Step length, step rate and their product, walking velocity, are
Fleming, 2012). Step length shortens and gait speed slows due to fundamental sagittal plane biomechanical descriptors of walking.
sarcopenia, dynapenia, reduced joint range of motion, weakness, Self-selected walking velocity is lower in old (∼1.15 m/s) com-
fatigue, and lower dynamic stability (Abellan van Kan et al., 2012; pared with young (∼1.32 m/s) adults (Himann et al., 1988; Judge
Clark and Manini, 2012; Manini and Clark, 2012; Mitchell et al., et al., 1996; Kerrigan et al., 1998; Ko et al., 2009; McGibbon and
2012). Additional reasons for short step length and reduced gait Krebs, 2004; Schimpl et al., 2011). This decline in walking velocity
speed are the desire to walk with a greater sense of stability and is associated with reduced step length (Hageman and Blanke, 1986;
the strategy to avoid high forces causing joint pain (Abellan van Kerrigan et al., 1998, 2001; Ko et al., 2009; McGibbon and Krebs,
Kan et al., 2009). Maintaining usual gait speed in old age is of major 2004; Ostrosky et al., 1994; Winter et al., 1990) and increased step
clinical and functional significance as it is clear that old individuals rate or cadence (Judge et al., 1996). The increase in cadence however
with faster usual and maximal gait speeds have greater longevity is not sufficient to offset the decrease in step length, thereby reduc-
(Abellan van Kan et al., 2009; Studenski et al., 2011; Ostir et al., ing velocity. Furthermore and as a consequence of reduced step
2007). Further, although as yet not directly proven, these cross- length, double support time increases with concomitant reductions
sectional studies support the attractive hypothesis that increasing in single support and swing times (Begg and Sparrow, 2006; DeVita
step length and gait speed may even increase longevity. and Hortobágyi, 2000). It is thought that these latter adaptations
Unsurprisingly there is a massive ongoing preventative effort increase dynamic stability in the elderly (DeVita and Hortobágyi,
to improve old adults’ abilities to successfully perform activities of 2000). Whereas more recent studies suggest that another strategy
daily living (ADLs) (e.g., (Fielding et al., 2011). Within this effort a to improve stability with aging is a wider support base or step width
clear target is to slow the rate of gait speed loss in healthy old adults (Dean et al., 2007). Overall, it is well documented that basic gait
and to restore gait speed in those patients who suffer from mobility kinematics, including walking velocity and its related factors, are
disability and such other clinical conditions as cancer, neuropathy, changing with age.
and osteoarthritis. Numerous interventions, applying resistance, Locomotion biomechanics have been compared between young
power, balance, and specific locomotor training have demonstrated and old adults while walking at both identical and different,
remarkable increases in maximal voluntary muscle strength and self-selected walking velocities. Both comparisons are important
power up to 85% and as much as 53% in gait speed (Granacher and identify different aspects about locomotion biomechanics in
et al., 2011a; Mian et al., 2007a). The common element of the old adults. Self-selected velocities are more ecologically sound and
intervention studies that provides the pretext for this review is a identify behaviorally meaningful age-related differences in gait.
complete absence of addressing the mechanisms of how interven- The slower walking speed typically selected by old adults manifests
tions increase gait speed in old adults. Although clinicians routinely itself in lower joint torques and powers and these directly produce
prescribe interventions for old adults (Fielding et al., 2011), we do shorter steps and lower velocity (DeVita and Hortobágyi, 2000).
not know how, if at all, does the intervention-improved physical Due to the shorter steps, old adults also produce less work per step
620 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627

(Winter et al., 1990). Matched velocity comparisons on the other Additional studies are needed to resolve these clinically critical
hand have value because these show neuromuscular adaptations inconsistencies in knee function during gait.
strictly due to aging physiology without the confounding effects
of age and velocity. We note that while horizontal velocities are
2.4. Effects of age on ankle joint function during gait
often monitored or controlled in these studies, vertical kinematics
are typically completely unmonitored and unconstrained (but see
In contrast to the findings on knee biomechanics, mechanical
(Persch et al., 2009). Differences in vertical displacement profiles
changes at the ankle joint during walking and due to age are highly
between young and old, for example, would be a direct outcome of
consistent within the literature (McGibbon, 2003). Old vs. young
differences in muscle work and would be associated with different
adults maintain their position of the foot closer to the anatomical
metabolic and mechanical costs of walking. While the observed
position during stance phase and they show less range of motion in
age-related gait differences such as the increased metabolic cost
the gait cycle (DeVita and Hortobágyi, 2000). Many studies reported
of walking in old adults may be related to altered neural activation
old adults to walk with a reduced plantarflexion peak position just
during gait (Hortobagyi et al., 2011; Peterson and Martin, 2010), it
before push-off (Cofre et al., 2011; DeVita and Hortobágyi, 2000;
is possible that such differences are also due to vertical kinematics
Kerrigan et al., 1998; Monaco et al., 2009; Silder et al., 2008) and also
(Dean et al., 2007; Mian et al., 2007a).
with a reduced plantarflexion torque during late stance (DeVita and
Hortobágyi, 2000) compared with young. Furthermore, it is clearly
2.2. Effects of age on hip joint function during gait
reported that healthy old adults have reduced ankle plantarflexor
power output during push-off compared with their younger coun-
Comparisons made at both identical and different velocities
terparts when gait speeds are matched (Cofre et al., 2011; DeVita
have shown significant changes with age in joint kinematics and
and Hortobágyi, 2000; Monaco et al., 2009). Ankle power genera-
kinetics at the hip, knee and ankle joints. Old compared with young
tion during push-off plays an important role in forward progression
adults show greater range of motion at the hip throughout each
of the body, and consequently the reduction in stride length and
gait cycle (Cofre et al., 2011; DeVita and Hortobágyi, 2000; Silder
increased double leg support that occur with increasing age can be
et al., 2008). Along with greater hip range of motion, old adults
at least partially attributed to the reduction in power production of
walk with larger internal hip extensor torque and positive power
the calf muscles.
in early stance phase and more internal hip flexor torque and posi-
Overall old adults use lower plantarflexor torque and generate
tive power during late stance compared with young adults (DeVita
less positive ankle power during push-off and there is a concur-
and Hortobágyi, 2000). The duration of the hip extensor torque
rent increase in peak hip extension power during early stance
and power generation was also longer in old compared to young
and peak hip flexor power generation during late stance. Fig. 1
adults, producing larger total angular impulse and work at the
shows this “redistribution of joint powers” and the overall dis-
hip (DeVita and Hortobágyi, 2000). Overall, old adults increase hip
tal to proximal shift in muscle function, a phenomenon coined as
range of motion, torque, power and work during walking compared
the age-related mechanical plasticity of human gait (DeVita and
to young adults when gait velocity is matched. In fact, it appears
Hortobágyi, 2000). Numerically, there was an 19% reduction in
that a wider step width (i.e., more dynamic stability) is associated
mass-normalized ankle power and 38% increase in hip power as
with increased hip muscle activity without concurrent changes
healthy volunteers walked at a range of speeds between 1.0 and
in the activation of ankle evertors and invertors (Winter, 1995).
1.5 m/s in 8 studies (Cofre et al., 2011; DeVita and Hortobágyi, 2000;
Further, increased hip joint function with age was also important
Judge et al., 1996; Kerrigan et al., 1998; McGibbon and Krebs, 2004;
for increasing walking velocity. Old adults increased their walking
Monaco et al., 2009; Savelberg et al., 2007; Silder et al., 2008) (Table
velocity from comfortable to fast pace by increasing the internal
S1, online supplement).
hip extensor torque and positive power in early stance or their hip
flexion torque and positive power in late stance (Graf et al., 2005;
Judge et al., 1996; Kerrigan et al., 1998).

2.3. Effects of age on knee joint function during gait

Gait changes at the knee showed greater knee flexion during

initial contact but less knee flexion in early stance for old com-
pared with young adults (DeVita and Hortobágyi, 2000). Reduced
flexion in early stance was the primary kinematic adaptation pro-
ducing the more erect walking pattern with a lower knee extensor
torque seen in old adults. Adaptations in knee torque as a con-
sequence of age are inconsistent: knee extensor angular impulse
during early stance, representing knee extensor torque, was lower
in one (DeVita and Hortobágyi, 2000) but similar in another study
(McGibbon and Krebs, 2004). In fact, when normalized to mass
and height, old adults walked with greater knee extensor torque
and concomitant negative work and negative peak powers dur-
ing loading response (Monaco et al., 2009). Based on their mean
mass and height values their non-normalized data would appear to
show even larger torque and power for old adults compared with
young. These discrepancies in knee torque results led to additional
contradictory results in knee joint power because there was less Fig. 1. Mechanical plasticity of old adults’ gait. Body mass normalized hip, knee,
positive and negative work, and therefore less power output at the and ankle power during stance phase of gait, showing a 38% shift in function to hip
extensors concomitant with an 19% reduction in ankle plantarflexor power in old
knee in one case (DeVita and Hortobágyi, 2000), whereas others
adults during the stance phase of gait. Joint powers were recorded under 6 walking
reported greater power output for old compared with young adults conditions ranging in walking speed between 1.0 and 1.5 m/s in 7 studies. * p = 0.050
(Cofre et al., 2011; McGibbon and Krebs, 2004; Monaco et al., 2009). at hip and p = 0.022 at ankle between young and old adults.
 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627
Fig. 2. Flowchart describing the systematic search.
In summary, these data illustrate that there are multi-focal age-
related adaptations in gait kinematics and kinetics. Next we review
the evidence for strength interventions causing adaptations in gait
biomechanics and increases in old adults’ gait speed.
3. Scant biomechanical evidence for how strength
interventions increase gait speed
Based on 55 studies, a previous review analyzed the effects
of exercise interventions on locomotor function in old adults
(Mian et al., 2007a). The nature of interventions varied widely and
included strength, power, balance, flexibility, aerobic, and mobility
exercise protocols or combinations thereof. Most studies used self-
selected gait velocity as a primary outcome to quantify the effects
of an intervention along with performance-oriented tests such
as fast walking velocity, stair climbing velocity, 6-min walk dis-
tance, and up-and-go test time. As expected, self-selected velocity
increased 14% and the time to perform the walking tests decreased
12%, suggesting that old adults adapt and benefit from exercise
therapy through improvements in spatio-temporal gait character-
istics (Mian et al., 2007a). However, the review also highlighted
the remarkable omission in the literature as to how little we know
about the biomechanical mediators of increased walking velocity
associated with exercise interventions, a mechanism that remains
unknown today.
3.1. Search toward effects of specific strength and power training
on gait characteristics
To address the issue of biomechanical mediators and extend the
previous review (Mian et al., 2007a), we conducted a systematic
621
literature search up to November 2012 using the following terms
in the MEDLINE and COCHRANE search: (“aged [MeSH]”) AND
(“gait [MeSH]” OR “locomotion [MeSH]” OR “walking [MeSH]” OR
“ambulation [Text Word]”) AND (“exercise [MeSH]” OR “resistance
training [MeSH]” OR “power training [Text Word]”) AND “biome-
chanics [MeSH]” OR “kinetics [MeSH]” OR “power [Text Word]” OR
“joint [Text Word]”. The search was limited to English language
and age ≥65. Duplicates appearing in both searches were removed.
Fig. 2 summarizes the searches.
3.2. Selection criteria
Studies were included in the review if: (a) study participants
were aged ≥65 years; (b) performed strength or power intervention
(except otherwise stated due to a limited number of studies avail-
able), and (c) if a study incorporated at least one gait biomechanical
outcome measure. Studies were excluded if: (a) participants had a
history of neurological disease, (b) participants were amputees or
used prosthesis; or (c) they were not written in English. Based on
these criteria, we analyzed the abstracts of any potentially rele-
vant papers and performed accordingly content analysis of the full
paper.
3.3. Quality assessment
Two reviewers assessed the methodological quality of the
included studies using the Physiotherapy Evidence Database
(PEDro) scale. The PEDro scale rates randomized controlled trials
from 0 to 10 with a score above 6 representing high quality (Maher
et al., 2003).
622 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627
4. Results
The flow chart in Fig. 2 summarizes the systematic review. The
search identified 724 studies (MEDLINE n = 669; COCHRANE n = 55).
After the elimination of 30 duplicates and 675 studies based on
title or abstract, additional 15 studies were eliminated based on
eligibility criteria. In the end, four studies met the inclusion criteria
and were retained for analysis.
4.1. Quality assessment
The mean quality score for the 4 included studies was 5.5 ± 2.4
(range, 2–7). We included a single arm study without a control
group, scoring only 2. The other three studies had a PEDro score
between 6 and 7, suggestive of high quality (Persch et al., 2009;
Hartmann et al., 2009; McGibbon et al., 2003).
4.2. Evaluation of the four intervention studies identified by the
systematic search
Hartmann et al. examined the effects of a 12-week strength
training program with and without foot gymnastics on muscle
strength and gait kinematics measured with a trunk accelerometer
in healthy old adults age 76 (Hartmann et al., 2009). Knee and ankle
strength increased 14–46% (p < 0.05) and gait parameters improved
1–11%, with gait speed and step length improving similarly 6.6%
and 5.0% in the two groups (p < 0.05). The training program supple-
mented with foot gymnastics increased ankle range of motion to
11.9◦ from 11.1◦ (p = 0.036). The authors did not compute or report
the association between changes in strength and gait kinematics.
Persch et al. observed that 12 weeks of strength training
improved maximal isometric strength of the hip, knee, and ankle
muscles 60% and also increased step length (0.14 m), gait speed
(0.13 m/s), and cadence (11 steps/min) (all p < 0.05) in healthy
adults age 61 (Persch et al., 2009). After strength training, sub-
jects struck the ground with 3.7◦ , 2.6◦ , and 1.1◦ more peak hip,
knee, and ankle flexion and walked with 5.6◦ , 0.8◦ , and 4.0◦ more
hip, knee, and ankle range of motion in the stance phase (all
p < 0.05). Despite the larger flexion in the lower extremity joints,
somewhat paradoxically, the vertical displacement of the center of
mass decreased 8 mm (p < 0.01), suggesting a less dynamic albeit
faster gait. Changes in plantarflexor strength were associated with
changed in cadence r2 = 0.30 (p < 0.05) but not with changes in gait
speed. Changes in knee extensor strength correlated with changes
in stride length r2 = 0.44 (p < 0.05) and changes in hip flexor strength
correlated with changes in stride length r2 = 0.17 (p < 0.05). Thus,
improved knee extensor function through training plays a relatively
more important role in improving gait speed than changes in ankle
and hip flexor function.
McGibbon et al. compared the effects of 6 weeks of strength
or functional training in small samples of old adults age 75,
with at least one lower extremity impairment (McGibbon et al.,
2003). Functional training improved leg strength (26%) significantly
more than strength training (16%). Functional training improved
gait velocity significantly (p = 0.001) more (0.178 m/s increase)
than strength training (0.055 m/s increase). Ankle kinetics dur-
ing gait improved 56% in the functional training group and 9%
in the strength-training group (difference p = 0.024) as measured
by ankle plantarflexor mechanical energy expenditure but only
the functional group improved knee kinetics 108% compared with
27% decrease in the strength-training group (difference p = 0.038).
Hip extensor mechanical energy expenditure decreased 10% after
functional but increased 97% after strength training (difference
p = 0.053). Although improvements in gait were similar in the two
groups, the authors concluded that improved coordination of mus-
cle power mediated the improved mobility in the functional group.
The authors did not compute or report the association between
changes in strength and gait kinematics and kinetics.
Cao et al. showed that a 12-week-long intervention consisting
of aerobic, balance, strength, coordination, and walking exercises
did not improve step length and gait velocity. However, old adults’
gait became more dynamic as they walked with more hip flexion at
heel-contact and toe-off in the stance and through the swing phase
(Cao et al., 2007). Further, there was more knee flexion at heel-
contact and during swing-phase and more ankle plantarflexion at
toe-off. The dynamic range of motion at the ankle increased 3.7◦
(p < 0.05). Even though the authors used the 30-s chair stand test
to indirectly measure leg strength, they attributed the changes in
gait kinematics to improvements in ankle strength. The authors did
not compute or report the association between changes in strength
and gait kinematics.
4.3. Association between improvements in gait speed and muscle
strength and power
Based on an extensive search and analysis of the literature,
we found limited biomechanical evidence to explain how inter-
ventions in general and strength and power training in particular
improve walking speed in old adults. Current evidence is insuffi-
cient and inconsistent to explain how and if at all newly acquired
strength and power become incorporated in the locomotor muscles
that drive the limbs during gait. In lieu of kinematic and kinetic gait
data, we argue that the next best available evidence to determine if
improved muscle strength is a moderator of increase in gait speed
is to quantify the association between improvements in gait speed
and gains in muscle strength and power.
We were able identify 4 studies that reported such correla-
tions. Judge et al. reported r2 = 0.31 (p > 0.05) association between
leg strength and gait speed in 31 community-dwelling adults age
82 before a strength training intervention and stated that this
association did not change after the intervention, suggesting no
independent role for muscle strength in improving gait speed
(Judge et al., 1993). Persch et al. observed an association of r2 = 0.44
(p = 0.001) and r2 = 0.17 (p = 0.049) between changes in knee exten-
sor and hip flexor strength, respectively, and stride length (thus
indirectly with gait speed) in 14 old adults age 61 (Persch et al.,
2009). Hruda et al. reported r2 = 0.22 and r2 = 0.18 (both p < 0.05)
between changes in leg extensor power and, respectively, changes
in 8-ft up-and-go and 6-minute walk time in 18 healthy old adults
age 85 (Hruda et al., 2003). Granacher et al. found a non-significant
association of r2 = 0.04 between changes in plantarflexor strength
and gait velocity as a result of an 8-week-long strength and bal-
ance intervention performed in 17 healthy adults age 56 (Granacher
et al., 2011b). Overall, improvements in leg strength accounted for
23% of the variation in old adults’ improved gait speed.
To pinpoint the role of individual muscles, we identified 20 stud-
ies and extracted data for changes in maximal voluntary quadriceps
strength and gait velocity. The twenty studies represent a total of
815 subjects with a mean age of 72, which we think fully captures
the relation between quadriceps strength and improvements in gait
speed in old adults. On the average, there were 30 subjects per study
who exercised for 18 weeks. Gait speed was assessed over an aver-
age distance of 22 meter or timed over 5.5 min. Initial and final gait
speed was 1.25 (range 0.45–2.01) and 1.38 (0.49–2.35) m/s, a 12%
increase. Mean quadriceps strength was 134 (10–423) at baseline
and improved 22% to 171 (8–753) Nm after interventions. Based
on the data in these 20 studies, Fig. 2A shows an association of
r2 = 0.21 (p < 0.018) between the changes in quadriceps torque and
gait speed (Table S2, online supplement).
Because the largest declines occur in plantarflexor compared
with knee and hip joint powers during gait (Fig. 1), we identi-
fied studies that measured the changes in maximal plantarflexor
 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627 623

voluntary torque and gait speed before and after strength training.
In 6 such studies, representing 240 subjects with a mean age of 75,
participants exercised for 22 weeks. Gait speed was assessed over
21 m or 5.3 min. Initial and final gait speed was 1.21 (0.81–1.38)
and 1.30 (1.02–1.48) m/s, a 9% increase, and plantarflexor strength
was 79 (21–372) and 94 (25–383) Nm, 19% higher, after interven-
tion. Fig. 2B shows an association of r2 = 0.16 (p = 0.432) between
the changes in strength and gait speed in the 6 studies (Table S2,
online supplement).
Considering the increasing emphasis on power vs. strength
training to improve function and gait speed in old adults (Reid
and Fielding, 2012), we have identified 8 studies that measured
leg power and gait speed before and after power training, repre-
senting 150 subjects age 73. On the average, 17 subjects per study
exercised for 12 weeks. Gait speed was assessed over an average
distance of 5.7 m. Initial and final gait speed was 1.15 (0.54–1.26)
and 1.26 (0.78–1.99) m/s, a 13% improvement, and leg power was
170 (6–613) and 228 (7–803) W, signifying a 19% improvement.
Fig. 2C shows an association of r2 = 0.00 (r2 = 0.005 after the removal
of a value of near 50% change in gait speed, p = 0.990) between the
changes in leg power and gait speed in the 8 studies (Table S2,
online supplement).

5. Discussion

It is known that muscle strength in old adults is related to

ADL performance, including walking and that strength training
improves many physiological characteristics in old adults, resulting
in better mobility and higher walking speed (Chandler et al., 1998;
Granacher et al., 2011a; Judge et al., 1993). Yet we have identified
a key gap in our understanding as to how interventions improve
mobility function in general and how, in particular, strength and
power interventions improve gait speed in old age. In short, despite
these known associations, increases in muscle strength are poorly
correlated with increases in step length and gait velocity in old
adults. We discuss the role of relative effort in mechanical plastic-
ity of gait and candidate mechanisms of how strength interventions
improve gait speed.

5.1. The role of relative effort

When young and old adults walk at a speed of 1.5 m/s in a lab-
oratory, the mechanical power output of muscles supporting the
body and then driving the leg from stance to swing becomes reor-
ganized with age: the locus of function shifts to the proximal hip
muscles from the distal ankle muscles (Fig. 1). The reduction in
ankle muscle mechanical output can reach as much as 27% (DeVita
and Hortobágyi, 2000) with a 12% reduction still present even if old
compared with young adults walk 13% faster (Kerrigan et al., 1998).
Expressing leg mechanical output recorded during gait in rela-
tion to the maximal available effort allows us to operationalize
mechanical plasticity of gait. The idea is that the reduced ankle
function seen in old adults’ gait is associated with a reduction in
maximal voluntary torque generation. There is strong evidence for
a preferential decline in structure and function of nerves and mus-
cles of lower compared with upper extremity due to age (for a
review see (DeVita and Hortobágyi, 2000). However, the reductions
in hip and knee muscle strength compared with the ankle plan-
tarflexors strength were similar in men age 75. In addition, ankle
plantarflexors compared with hip extensors were only 8% weaker
in women age 73 (Danneskiold-Samsoe et al., 2009). Therefore, the
distal vs. proximal weakness within the lower extremity may be
less robust than the differences between upper and lower extrem-
ities. Still, using these limited data, Fig. 4 shows for the first time
the relative effort during gait, i.e., the level of effort used at the hip,
Fig. 3. Associations between changes in gait speed and changes in leg strength or
power based on studies in the literature. Panel A: Association between changes in
maximal voluntary quadriceps knee extension torque and gait speed measured on
a level surface in 20 studies. There are 26 data points in the graph because a few
studies reported multiple measures of muscle strength or gait speed. The associa-
tion is characterized by y = 063x + 14.3 and r2 = 0.21 (p < 0.018). Panel B: Association
between changes in maximal voluntary plantarflexor torque and changes in gait
speed measured on level surface in 6 studies. There are 12 data points in the graph
because several studies reported multiple measures of muscle strength or gait speed.
The association is characterized by y = 0.58x + 13.8 and r2 = 0.16 (p = 0.421). Panel C:
Association between changes in maximal voluntary leg power and changes in gait
speed measured on level surface in 8 studies. There are 9 data points in the graph
because 1 study reported multiple measures of leg power or gait speed. The associ-
ation is characterized by y = 0.02x + 34.6 and r2 = 0.00 (p = 0.996). The removal of the
extreme value at the right does not affect the association. Table S2 lists the source
data and references used to construct the graphs in panels A, B, and C.
knee, and ankle joints as a percent of the maximal torque avail-
able at the same joints (cf. also (Hortobágyi et al., 2003). Because
maximal torque loss is similar in hip, knee, and ankle extensors
(Danneskiold-Samsoe et al., 2009), the torques generated during
gait are the primary determinants of relative effort. The relative
624 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627

5.2. Biomechanical mechanisms of interventions increasing gait

speed in old adults

The most obvious mechanism of an intervention designed to

improve muscle strength and gait speed is that the newly acquired
muscle strength and power increases joint torques and powers that
support the leg in stance phase, provides the energy for the push off,
and drives the limb into swing. Fig. 5 provides one model that con-
siders a successful incorporation of newly acquired strength into
gait (Fig. 5A) and shows another model that predicts an increase in
gait speed with little or no incorporation of newly acquired muscle

Fig. 4. Relative effort during gait in young and old adults, computed as the percent
of mechanical output measured during gait relative to the maximal voluntary torque
measured on an isokinetic dynamometer at 30◦ /s (hip, knee) and 15◦ /s (ankle). The
gait data are based on 7 studies presented also in Fig. 1. The isokinetic torque data are
based on the only study to date that report maximal hip, knee, and ankle voluntary
torques within the same person (Danneskiold-Samsoe et al., 2009). Please refer to
the text for further interpretation of these data.

effort is the highest at the ankle; the above-maximal level is prob-

ably caused by the differences in joint positions where the peak
torques occur during gait and the isokinetic tests, the differences in
contraction velocities in the two conditions and by the differences
in subject characteristics between the 7 gait studies (Cofre et al.,
2011; DeVita and Hortobágyi, 2000; Judge et al., 1996; Kerrigan
et al., 1998; McGibbon and Krebs, 2004; Monaco et al., 2009;
Silder et al., 2008) and the one study reporting the isokinetic data
(Danneskiold-Samsoe et al., 2009). Nonetheless, the data suggest
that old adults walk near the maximal capacity of the ankle joint,
presumably causing ineffective push-off, shorter steps, and slower
gait. Apparently, the 35% increase in hip power is insufficient to
compensate for the reduction in ankle function and walking speed
decreases in old adults (DeVita and Hortobágyi, 2000). Mechani-
cal plasticity predicts that improving maximal voluntary strength
of the hip and knee muscles may have little impact on gait speed
because relative effort is low in these joints. In contrast, improving
maximal capacity of ankle plantarflexors may have a large impact
on gait (speed) as long as there is an enabling mechanism that
allows the use of the newly acquired strength.
The high relative effort at the ankle suggests that interventions
should focus on improving plantarflexion function. The expec-
tation is that the ankle torques and concomitantly gait velocity
would increase. This expectation assumes that old adults possess
an enabling mechanism that moderates the use of the newly
acquired strength into function. However, the results of this review Fig. 5. Conceptual models of how strength and power training interventions
provide virtually no evidence for either element of this expecta- improve gait speed in old adults. A: Old adults walked (filled column) just below
their maximal ability (open column) pre-training. The narrow difference between
tion. First, about 80% of interventions explicitly target the knee
the filled and open columns suggests a high relative effort during gait. Training
extensors even though, as this review has uncovered it (Fig. 1), increased maximum ability and adults now walk with more force than they pre-
the age-related changes in knee kinetics are minimal vis-à-vis the viously had yet with lower effort relative to their maximal ability. Maximal ability
20–40% reductions in maximal voluntary knee extension torque (open column) is quantified by joint torques measured through inverse dynamics
(Danneskiold-Samsoe et al., 2009; Hortobágyi et al., 1995). As of analysis in a test exercise such as a maximal leg press. In this model, old adults
are able to incorporate newly acquired muscle strength as shown by the increased
now, no interventions have specifically targeted the ankle plan- filled column in post- compared to pre-test. There is currently no evidence for the
tarflexors, which operate at the highest relative effort (Fig. 1), and incorporation model. B: Similar to the Model in A, old adults walked (filled column)
linked such changes in strength to changes in ankle kinetics in the just below their maximal ability (open column) pre-training. The narrow difference
same subjects. Second, the overall consensus from the 34 stud- between the filled and open columns suggests a high relative effort during gait.
Training increased maximum ability and adults now walk with more force than they
ies included in our analysis is that strength and especially power
previously had but not much more force, denoted by the small difference between
gains are weakly or not at all associated with changes in gait speed the two filled columns pre- and post-training. That is, the relative effort decreased
(Fig. 3), joint kinematics, and kinetics. Although these interven- less in Model B than in Model A. However, the effort needed to walk (filled column in
tions improve neuromuscular function 25% and old adults walk 11% post-test) is still below the pre-training maximum (open column in pre-test). This
faster, the evidence is weak that old adults walk faster because they model predicts little incorporation of newly acquired strength into gait. There is
indirect biomechanical evidence for this model. Ultimately, either mechanism still
use the newly acquired physical abilities in gait (Tables S1-2, online must act through the final common pathway of higher muscle force generation that
supplements). increases kinetic energy and gait speed.
 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627
strength (Fig. 5B). To date, there is no gait kinetics data to verify the
incorporation model (Fig. 5A). The little biomechanical data avail-
able show an inconsistent picture. Kinematic analysis revealed a
key role for knee function (Persch et al., 2009), whereas mechani-
cal energy expenditure analysis showed a decreased role for knee
function in gait speed adaptations (McGibbon et al., 2003). Even
within the same study, the pattern of association between changes
in strength and function was inconsistent: improved plantarflex-
ion and hip function (6◦ more flexion) was marginally associated
(r2 = 0.17, p = 0.049) with gait speed but changes in knee function
and gait speed correlated r2 = 0.44 (p = 0.001) (Persch et al., 2009).
The 6◦ more hip flexion is in line with predictions by mechani-
cal plasticity (i.e., a shift of function to hip from the ankle) but then
these changes poorly correlated with gait speed. On the other hand,
mechanical plasticity predicts not much need for a change at the
knee (due to its low relative effort), yet increases in quadriceps
strength correlated strongest with changes in gait speed (r2 = 0.44,
p = 0.001). This last piece of data provides perhaps the first still
somewhat unconvincing hint that old adults may be able to incor-
porate a small portion of the newly acquired voluntary strength
into knee function and causing changes in gait speed. Puzzlingly,
a composite exercise program improved muscle strength 14% and
produced kinematic adaptations at the hip, knee, and ankle joints.
However, the larger range of motions, and presumably accelera-
tions, at these joints did not increase gait speed (4%, n.s.) (Cao et al.,
2007). Thus, an intervention can modify gait biomechanics without
a putative increase in gait speed.
Although conceptually and empirically functional performance,
including gait speed, is associated with leg power ∼r2 = 0.50 (Bean
et al., 2004; Cuoco et al., 2004; Fielding et al., 2002; Reid and
Fielding, 2012) and modeling studies show increased gait speed
with increased muscle power (Liu et al., 2008; Neptune et al., 2008,
2009; Pandy and Andriacchi, 2010; Pandy et al., 2010), our find-
ing that improvements in leg power had r2 = 0.00 association with
improvements in gait speed was unexpected (Fig. 2C, Table S2). We
interpret these data to mean that mechanism of adaptation in gait
speed in response to power training is unknown and not under-
stood. An extensive analysis of adaptations to strength and power
training in a previous review (Granacher et al., 2011a) provides a
perspective for our finding of this low association between changes
in gait speed and changes in leg power. The idea is that perhaps the
changes in gait speed and leg power association would become
much stronger if future studies followed more closely the exercise
specificity principle by having old adults exercise at low intensi-
ties (20–40% of maximum power) improving both gait speed and
leg power (Orr et al., 2006). However, the mechanism is very likely
multi-factorial and interactive between biomechanical, physiolog-
ical, neurological and psychological factors.
Anyone will increase walking speed by generating more mus-
cle force and power but the current biomechanical data do not
bear out this mechanism. Fig. 5B describes a situation in which
old adults operate close to maximum effort pre-training. Train-
ing increases maximum effort and adults now walk with more
force than they previously had but not much more force and still
below the pretraining maximum. Old adults operating closer to
their performance limits (Hortobágyi et al., 2003) (Fig. 4) may
not as well incorporate newly acquired maximal strength into
locomotor tasks: they adopt strategies that allow them to use so far
unexploited resources more effectively. We speculate that perhaps
they use new and previously non-existent levels of muscle force
and power. They may increase the use of force to levels that were
already available before the intervention but for some reason were
unused. In particular, it seems an equally reasonable and untested
possibility that interventions improve gait speed because old adults
simply feel more comfortable after the intervention as they operate
at a lower effort relative to their maximal capabilities and exploit
625
already existing physiological resources and not because the new
levels of strength or power increases the mechanical output of the
ankle, knee, and hip joint muscles. Interventions may also increase
gait speed by improving the coordination between pairs of agonist
and antagonist muscles which in turn could reduce the metabolic
cost of transport and the relative effort (Hortobagyi et al., 2011;
Thomas et al., 2007a,b) and through an optimization of irregular
and variable gait (Lamoth et al., 2011; Springer et al., 2006; Stergiou
and Decker, 2011). Perhaps the mechanism acts through improved
psychological, “strength,” i.e., self-efficacy, less resistance to rotate
joints through the range of motion, or a motor unit effect in which
even if maximum strength is not increased, motor units are more
readily activated. Recent theories suggest that exercise may indeed
reduce the rate of falls through its beneficial effects on cognitive
function in old adults (Liu-Ambrose et al., 2013). There are also
profound age-related changes in tendon properties, including a
reduction in stiffness that can be modified by exercise training
(Narici and Maganaris, 2006; Reeves et al., 2006). Still, each and any
of these mechanisms must act through the final common pathway
of higher muscle force generation that increases kinetic energy and
gait speed.
Finally, we note that virtually any type of intervention even
those not designed explicitly to improve muscle strength and
power can increase gait speed. Walking speed increased follow-
ing balance, endurance, functional (Krebs et al., 2007), combination
(Cao et al., 2007; Mian et al., 2007b), walking training with (Thomas
et al., 2006) and without (Earles et al., 2001) body weight unloading,
and Tai Chi exercise (Wolf et al., 2006) (for a review see (Granacher
et al., 2011a; Mian et al., 2007a; Paterson et al., 2007). Any and all of
the interventions clinicians currently prescribe for old adults can
improve neuromuscular function and perhaps the increased gait
speed is a secondary but valuable outcome as are improvements in
balance and sit-to-stand. This generalized effects of interventions
may be related to the idea that functional improvements after an
intervention dot not scale to a dose–response relationship because
the stimulus for increasing gait speed is different in magnitude and
nature than the exercise dose that improves maximal voluntary
force and power (cf. (Mian et al., 2007a). That is, the stimulus to
increase gait speed is lower in magnitude than the stimulus for
strength gains so that training with high loads elicits a response
at lower level activities. After training old adults become stronger
and operate at lower relative levels of their maximal capacities and
thus more comfortable absolute levels.
6. Summary and recommendations
Clinicians routinely prescribe strength and power interventions
for old adults in an effort to improve ADL mobility, including
gait speed (Fielding et al., 2011; Reid and Fielding, 2012). The
present review shows that the biomechanical mechanisms of how,
if at all, the intervention-improved physical capacity becomes
incorporated into the movements of ADLs and in case of gait,
produces faster walking, is not known. An analysis of over 30
studies revealed that the association between improvements in
leg muscle strength and gait speed is r2 = 0.21 and between the
changes in leg power and changes in gait speed is r2 = 0.00. To
increase the efficacy of intervention studies designed to improve
gait speed and other critical mobility functions in old adults,
there is a need for a paradigm shift from conventional outcome
assessments to more sophisticated biomechanical analyses that
examine joint kinematics, kinetics, energetics, muscle–tendon
function, and musculoskeletal modeling before and after interven-
tions. Physiological, neurological, and psychological tests could
enhance the biomechanical studies and identify the full spectrum
of exercise-induced modifications in walking performance.
626 C.M.I. Beijersbergen et al. / Ageing Research Reviews 12 (2013) 618–627
We recommend that future studies perform whole body kine-
matic and kinetic analyses of gait before and after strength and
power training that targets hip, knee, and ankle muscles individ-
ually and in combination. The gait tests should be performed at a
self-selected pace and also at a fixed speed to identify adaptations
due to intervention and also due to age. The goal is to determine if
strength and power interventions that increase maximal voluntary
torque also increase lower extremity joint torques and powers and
if these changes are associated with changes in critical properties of
gait such as step length and gait speed. Many studies use compos-
ite interventions comprising 4–6 elements with clear intentions to
improve multiple aspects of mobility. However, it is not possible
to determine which specific element or an interaction between the
elements cause the biomechanical, physiological, and motor con-
trol adaptations in gait. There is a need to systematically examine
the effects of individually tailored interventions on the association
between changes in gait mechanics and neuromuscular outcomes.
Although this review focused on leg muscle function, the possi-
bility exists that interventions also affect trunk behavior, which,
in a proximal to distal direction, can affect the biomechanics of
leg muscles, hence gait speed. Studies are needed to determine if
interventions modify not only horizontal but also vertical kinemat-
ics of gait as such measures directly reflect muscle work, hence
metabolic and mechanical cost of gait. Future studies should deter-
mine if age uniformly affects hip, knee, and ankle muscles within
the same individuals. Such data would allow clinicians to more
effectively personalize intervention targets and determine if inter-
ventions reduce relative effort during gait, which we propose as a
critical marker of mobility and disability in old adults.
Conflict of interest
None declared.
Acknowledgements
We thank Dr. Alessio Murgia, Professor Dr. Bert Otten, and Dr.
Azusa Uematsu for their insightful comments.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.arr.2013.03.001.
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