Kanda et al. Environmental Health and Preventive Medicine
https://doi.org/10.1186/s12199-019-0798-4(2019) 24:44

Environmental Health andPreventive Medicine

RESEARCH ARTICLE

Open AccessLong-term effects of low-intensity training
with slow movement on motor function ofelderly patients: a prospective
observational study
Kanae Kanda1* , Yutaka Mori2, Kunihisa Yamasaki2, Hiroko Kitano2, Aya Kanda2 and Tomohiro Hirao1

Abstract
Background: Slow-motion training, which comprises exercising using extremely slow-movements, yields a training
effect like that of high-intensity training, even when the applied load is small. We developed a slow-training
exercise program that allows elderly people to safely use their own body weight without a machine. Previously, it
was confirmed that functional gait and lower limb muscle strength were improved by low-intensity training using
bodyweight training for 3 months. This study evaluated the long-term effects of low-intensity training using bodyweight with slow-movements on the motor function of frail, elderly patients.
Methods: Ninety-six elderly men and women aged 65 years or older whose level of nursing care was classified aseither support required (1 and 2) or long-term care required (care levels 1 and 2) volunteered to participate. Twofacilities were used. Participants at the first facility used low-intensity training using body weight with slowmovements (low-stress training [LST] group, n = 65), and participants at another facility used machine training(MT group, n = 31). Exercise interventions were conducted for 12 months, once or twice per week, depending on
the required level of nursing care. Changes in motor function were examined.
Results: Post-intervention measurements based on the results of the chair-stand test after 12 months showedsignificant improvements from pre-intervention levels (P < 0.0001) in the LST group and MT group. Although theability of performing the Timed Up & Go test and the ability to stand on one leg with eyes open improved in bothgroups, no significant change was observed. When changes after 12 months were compared between the twogroups, no significant difference was observed for any variables.
Conclusions: Slow body weight training for 12 months without a machine improved the lower limb muscle
strength. Therefore, it could have the same effects as training using a machine.
Trial registration: UMIN000030853. Registered 17 January 2018 (retrospectively registered).
Keywords: Body weight, Frail elderly, Long term, Motor function, Slow movement, Training* Correspondence: oda@med.kagawa-u.ac.jp
1
Department of Public Health, Faculty of Medicine Kagawa University, 1750-1
Ikenobe Miki-cho Kita-gun, Takamatsu, Kagawa 761-0793, Japan
Full list of author information is available at the end of the article© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kanda et al. Environmental Health and Preventive Medicine(2019) 24:44

Background
Declining motor function due to aging increases
nursing care needs and the risk of falls, and it hasvarious effects on health, life expectancy, and life
prognoses. Muscle strength in the lower limbs alters
faster than in the upper limbs, and it begins to
decline rapidly around 60 years of age [1]. Metaanalyses from previous studies suggests that muscularstrength training for the elderly improves bodyfunction, even in the elderly population with significant functional decline, thus establishing the possibility of improving muscle function with strength
training [2, 3]. Recently, low-intensity exercise withslow-movement and tonic force generation (low-stresstraining [LST]) [4], which involves slow-movements
while maintaining muscle tension that allows theachievement of substantial muscle hypertrophy using
a relatively light load, has been developed, and evidence of its effects are being continuously accumulated. LST is a collective term that refers to muscle
training during which the load is increased and decreased extremely slowly. We developed a slowmotion weight training program using one’s own
body weight that can be easily performed by frail
elderly subjects at home. In a previous study, it was
confirmed that walking function and lower limb
muscle strength were improved by slow training
using one’s own body weight for 3 months [5]. In thisstudy, exercise training was performed by elderly individuals for 12 months, and whether long-term improvements were achieved was examined.

Fig. 1 Flowchart detailing the timeline for participants

Page 2 of 8

Methods
ParticipantsThis study included elderly men and women aged 65
years or older, living at nursing care facilities in Osaka,
who required a level of nursing care classified as either
support required (care levels 1 and 2) or long-term carerequired (care levels 1 and 2). Participants who met anyof the following criteria were excluded from the study:(1) those who had difficulty participating in the exercise
program because of apparent cognitive symptoms, (2)those who had physical limitations due to effects of disease aggravation or when discontinuation of the ongoingprogram was determined to be a better option, (3) when
it became difficult for the participant to continue the exercise program on a regular basis; (4) when the attending
physician determined that the participant had to stopusing day services because of the effects of diseases, and(5) other people who the physician in charge of the research program determined as being inappropriate forinclusion. The participants were recruited between Marchand August 2016 from two facilities. Participants at thefirst facility performed exercise rehabilitation therapy using
LST (the LST group), and participants at the other facility
performed exercise rehabilitation therapy using a machine(the control group). The study flowchart is shown in Fig. 1.
Exercise programs and exercise machines were provided
by Sin Cire Co., Ltd.
Interventions (LST group)

We developed an LST program based on a previous
program [5]; for 12 months, participants underwent theKanda et al. Environmental Health and Preventive Medicine(2019) 24:44

Page 3 of 8

Fig. 2 Change in the chair-stand test (the CS-30 test) score following LST training. Two-way repeated measures were used to compare values
between the two groups in intra-individual variation. Data are presented as mean (95% confidence interval). LST(*), MT (#); P < 0.05. P values lessthan 5% were considered significant in both cases. LST low-stress training (low-intensity exercise with slow movement and tonic force
generation), MT machine training, SD standard deviation

exercise interventions once or twice per week, depending on the individual’s required level of nursing care.
Regarding the amount of physical exercise, two sets ofsix different types of exercise (to strengthen the thighs,
lower legs, buttocks, abdomen, chest, and back) were
performed at a pace of eight times per minute (all exercises were performed with a hold time of 1–2 s with arest period of 1–2 s); the sets of exercises were separatedby 1-min breaks. Specifically, the training consisted of
the following: thigh exercises involved participants holding a bar with both hands while in the standing positionand performing squats while sitting on a chair, lower leg
exercises involved participants holding a bar with both
hands while in the standing position and performing acalf raise, gluteal exercises involved participants holding
a bar with one hand while in the standing position andperforming a knee-up by using one leg each time, andabdominal exercises involved participants placing a ballin front of their abdomen while in the sitting position,
tilting the upper half of their body forward while holding
the ball with their hands, and performing abdominal
muscle exercises. Additionally, chest exercises involved
participants sandwiching a ball between the back andthe back of a chair, raising the arms to the height of thechest, pulling the elbows backwards against the scapulae,
and sticking out the chest. Back exercises involved participants squeezing a ball with the back while sticking
out the chest and sandwiching the ball between the backand the back of the chair. All exercises were performed by
combining slow-movements and 3-s intervals of rhythmicbreathing. Each participant was instructed to consciously
maintain muscle activity as long as possible. All participants were instructed to follow the same exercise program
under the guidance of a specialized instructor.

Control (machine training group)

The control group was subjected to low-intensity machine
training (MT) using a normal speed. The MT consisted of aprogram combining body area-specific muscle strengthtraining exercises using a hydraulic weight-training machine [6–8]. Regarding the amount of physical exercise,two sets of seven different types of exercise (to strengthen
the thighs, lower legs, buttocks, chest, back, shoulders, andabdomen) were performed at a pace of 15 times per minute(all exercises were performed with a hold time of 1–2 s witha rest period of 1–2 s), and the sets were separated by 1min breaks. Details of the muscle training were as follows:(1) thigh (femoral region) exercise involved flexion and extension movements of the knee joint performed using a
Leg Extension/Curl® machine (GH-104; ALPS Electric Co.,
Ltd., Tokyo, Japan), (2) lower leg exercise involved up-anddown movements of the lower extremities performed usinga Stepster® (TB-699; Takada-Bed Co., Ltd., Sennan, Japan),(3) buttocks (gluteal region) exercise involved abduction
and adduction movements of the hip joint performed using
an Abduction/Adduction® (GH-102; ALPS Electric Co.,
Ltd., Tokyo, Japan). (4) chest (thoracic region) exercise
comprised a chest press performed using a home gym
machine, (5) back (dorsal region) exercise comprised apull-down performed using a home trainer, (6) shoulder
exercise involved arm raising and lowering movements performed using a home trainer, and (7) arm exercise involved
arm curls performed using a home trainer. A single training
device (YMHT-250; Yamato Human Co. Ltd., Tokyo,
Japan) was used for the latter four exercises.
Measurements

The primary outcome was the difference in mean values
obtained from the Timed Up & Go test (TUG) used toKanda et al. Environmental Health and Preventive Medicine(2019) 24:44

evaluate the ability to perform compound motions. To
determine TUG results [9, 10], we measured the timerequired to rise from the chair and stand, walk to thelandmark 3 m ahead, and return to the chair and sit
again. During each session, the measurements were performed twice, and the best value was recorded.
The secondary outcomes were the differences in meanvalues of the chair-stand test (lower-limb muscle strength)and of the one-leg standing test with eyes open (balanceability). The chair-stand test comprised the CS-30 test[11], during which the number of times the participant sat
down and stood up within a 30-s period was measured
once. For the one-leg standing test with eyes open [12],we measured the time during which the participant wasable to lift the foot from the floor and maintain it in thesame position. A duration of 60 s was considered the maximum, and each measurement was performed twice.
Participant characteristics that were recorded included
their age at study initiation, sex, level of nursing carerequired, body weight, and blood pressure at rest. The
body weight of each participant was measured using a
Tanita body composition meter (BC-705N; Tanita Corp.,
Tokyo, Japan). The blood pressure of each participant at
rest (systolic pressure and diastolic pressure) was measured
in the sitting position using a Terumo electronic bloodpressure monitor (ES-P2000; Terumo Corp., Tokyo, Japan)
after the participant had rested for 5 min.
Sample size calculation

To observe significance levels (alpha = 0.05, power = 0.8,
standard deviation = 5.0, effect size = 3.0) that reflected
the average differences in the TUG, which was theprimary outcome, it was estimated that each grouprequired 45 participants [13–15]; this sample size wascalculated using JMP Pro 12.0 (SAS Institute Inc.,
Cary, NC, USA).
Statistical analysis

The results are expressed as the mean value ± standard
deviation, minimum value, and maximum value. Comparisons between values measured before the intervention and those measured after 3 months and 12 months
were performed using the repeated measures analysis ofvariance. Comparisons between the two groups in termsof variations were performed using an unpaired t test.
Hazard ratios less than 5% were considered significant
for both groups. The statistical analysis was performed
using JMP Pro 13.0.
Ethics statement

Informed consent was obtained from the participants.
This study was approved by the Ethics Committee ofKagawa University Faculty of Medicine and Graduate
School of Medicine (approval number: Heisei28–128).

Page 4 of 8

Results
The baseline characteristics of the study participants areshown in Table 1. There were 65 participants in the LSTgroup (mean age 80.6 ± 6.1 years) and 31 in the control
group (mean age 80.4 ± 5.7 years). To assess the current
medical history, information regarding major diseases,
for which nursing care was required, was collected.
Among these diseases, joint diseases were the most common, followed by hypertensive diseases. All participants
completed the 12-month exercise training program. Before the intervention, the values of each index showedno significant differences between the two groups. The
CS-30 test results were only significantly different between the two groups at baseline. For both groups, theaverage number of weekly exercise sessions performedby the study participants were 1.8 times per week. No
adverse events resulting from participation in the exercise training programs were reported.
Participants’ motor functions prior to the LST program were compared using repeated measures with thatafter 3 months and 12 months of training; the results
showed significant improvements in the chair-stand test(comprised the CS-30 test) performance (23.1 ± 7.8 times
before the exercise training program and 25.1 ± 7.8
times at 3 months, and 27.4 ± 9.2 times at 12 months;
P < 0.0001) (Table 2, Fig. 2). The TUG results indicated no significant changes in the ability to perform
compound motions (mean, 12.2 ± 5.7 s prior to the exercise training program and 11.6 ± 5.7 times at 3 months,
and 12.2 ± 7.8 s at 12 months; P = 0.3351). Although theability to stand on one leg with eyes open tended to improve, no significant change was found (pre-intervention
mean 11.4 ± 13.1 s; mean at 3 months 12.8 ± 14.2 s, meanat 12-months 13.4 ± 15.1 s; P = 0.2124). A comparison ofblood pressure at rest using the values prior to the exercise training program showed that body weight, systolicpressure, and diastolic blood pressure changed significantly for the LST group after 12 months of exercise.
For the MT group, the results showed significant improvements in the chair-stand test results (17.4 ± 7.3
times prior to the exercise training program and 18.3 ±7.6 times at 3 months, and 22.0 ± 9.1 times at 12 months;
P < 0.0001). The TUG results indicated no significant
changes (mean, 14.7 ± 6.4 s prior to the exercise training
program and 13.7 ± 5.7 times at 3 months, and 14.3 ± 9.5
times at 12 months; P = 0.5564). Although the ability tostand on one leg with eyes open seemed to improve, nosignificant change was found (pre-intervention mean
16.5 ± 21.6 s; mean 15.0 ± 21.0 s at 3 months, 10.3 ± 15.2
s at 3 months; P = 0.2191). A comparison of blood pressure at rest using the values found prior to the exercise
training program showed that systolic pressure had decreased significantly after 12 months of exercise. There
was no significant change in body weight. However,(2019) 24:44

Kanda et al. Environmental Health and Preventive Medicine

Page 5 of 8

Table 1 Baseline characteristics of the study participants
Baseline variables

LST group (n = 65)
Mean ± SD

P value

MT group (n = 31)

Minimum

Maximum

Mean ± SD

Minimum

Maximum

Female sex (%)

50 (76.9)

25 (80.6)

0.6838Age (years)

80.6 ± 6.1

669380.4 ± 5.770910.8809Body weight (kg)54.7 ± 10.3

30.4

84.3

57.3 ± 11.3

36.4

80.1

0.2799

Systolic blood pressure (mmHg)

131.2 ± 18.1

95

185

129.9 ± 21.

95

181

0.7540

Diastolic blood pressure (mmHg)

67.6 ± 10.7

4192

68.6 ± 10.7

4389

0.6710Timed Up & Go test (s)12.2 ± 5.7

6.4

32.0

14.7 ± 6.4

6.5

31.8

0.0567

One-leg balance with an open eye (s)11.4 ± 13.0

0.37

60.0

16.5 ± 21.6

1.02

60.0

0.1534CS-30 test (counts/30 s)

23.1 ± 7.8

2

4317.4 ± 7.3

632

Smoking status (%)

1 (1.5)2 (6.4)

Cerebrovascular diseases

16

9Heart diseases

13

7

Malignant neoplasm

96

Respiratory diseases

5

2

Joint diseases

61

22

Dementia

52

Parkinson disease20Diabetes

7

3

Visual/hearing disorder

17

3

Fracture/fall

15

8

Spinal cord injury

10Hypertensive diseases

22

12

Others26

140.00110.1997

Current medical history (multiple answers)

Values are presented as means ± standard deviation, minimum value, and maximum value
All P values compared the characteristics of the LST and MT groups using unpaired t tests or Chi-squared tests
LST low-stress training (low-intensity exercise with slow movement and tonic force generation), MT machine training, SD standard deviation

significant improvements were observed in systolicblood pressure and the ability to rise from the chair as aresult of training conducted for 12 months in bothgroups. Based on the pre-intervention values and findings after 12 months of exercise, there were no significant differences in changes observed between the twogroups (Table 3).

Discussion
It was confirmed that muscle strength of the lower limbs
improved with LST for 12 months. Previous studies havereported that LST using an exercise machine enlarges thequadriceps muscle of healthy elderly people [16]. As amechanism to obtain muscle strengthening effects, repetitive slow exercise sustains muscle contraction constantly
and limits muscle blood flow during LST. Oxygen saturation in the muscle is lowered and the secretion of growth
hormones is increased [4]. Even with weight training, it
was thought that a mechanism similar to LST improved
leg muscle strength. The muscle strength of the lower

limbs greatly affected the continuation of exercise [17].
For frail elderly people, whose task was to continue exercising, it was suggested that LST is useful for long-term
maintenance and improvement of limb muscle strength.
Regarding the compound walking ability, although there
was significant improvement at 3 months, it returned tothe same level after 12 months as before training. Therefore, improvements in walking ability may not be sustainable in the long term. It is important for elderly individuals
to try to maintain improvement in their walking ability
because decreased walking speed is strongly related to decreased ability to perform activities of daily living [18].
Therefore, it was considered necessary to devise measures such as increasing variations in exercise programs
and changing load settings according to the ability of
the individual.
No significant change was observed in balance. Amongthe physical fitness factors, changes in balance conspicuously occur due to aging, and due to fluctuations in thecenter of gravity, individuals experience falls [19]. The

Kanda et al. Environmental Health and Preventive Medicine(2019) 24:44

Page 6 of 8

Table 2 Comparisons between values measured before intervention and those measured 3 months later and 12 months later
Baseline
Mean ± SD

3 months
Mean ± SD

12 months
Mean ± SD

P value

Body weight (kg)54.7 ± 10.4

54.4 ± 10.6

55.2 ± 11.1

0.0225

Systolic blood pressure (mmHg)

131.2 ± 18.2

122.7 ± 17.5

125.8 ± 14.3

0.0008

Diastolic blood pressure (mmHg)

67.6 ± 10.7

63.9 ± 10.8

66.7 ± 10.7

0.0236

Timed Up & Go test (s)12.2 ± 5.7

11.6 ± 5.6

12.2 ± 7.8

0.3351

LST group (n = 65)

One leg balance with an open eye (s)11.4 ± 13.1

12.8 ± 14.2

13.4 ± 15.2

0.2124CS-30 test (counts/30 s)

23.1 ± 7.8

25.1 ± 7.8

27.4 ± 9.2< .000157.3 ± 11.3

57.8 ± 11.4

57.7 ± 11.1

0.6426

MT group (n = 31)
Body weight (kg)Systolic blood pressure (mmHg)

129.9 ± 21.0

130.0 ± 21.6

123.5 ± 18.0

0.0273

Diastolic blood pressure (mmHg)

68.6 ± 10.7

69.8 ± 12.4

66.3 ± 9.7

0.1211

Timed Up & Go test (s)14.7 ± 6.4

13.7 ± 5.7

14.3 ± 9.5

0.5564One leg balance with an open eye (s)16.5 ± 21.6

15.0 ± 21.0

10.3 ± 15.2

0.2191

CS-30 test (counts/30 s)

17.4 ± 7.3

18.3 ± 7.6

22.0 ± 9.1< .0001

Data are presented as the mean ± standard deviation and mean change
One-way repeated measures ANOVA were used to compare values measured before the intervention and those measured at 3 months and 12 months
P < 0.05. P < 5% was considered significant in both groups
LST low-stress training (low-intensity exercise with slow movement and tonic force generation), MT machine training

LST program conducted during this study did not involve exercises to improve balance. To improve the balance of elderly individuals, it is necessary to consider
the static and dynamic specificities of balance. Furthermore, it may be necessary to create static balance training programs that involve extending the holding timeof balancing on one leg and decreasing the stair climbing time. Exercises associated with activities of dailyliving, including those involving backward and forward
movements and changes in the center of gravity, mightneed to be added to exercise programs to improve balance in elderly individuals [20, 21]. In addition, it may
be necessary to gradually increase the level of difficulty,
rather than the quantity of exercises during training.
Individuals with significantly decreased resting bloodpressure at 3 months after LST also had significantly

Table 3 Comparison between the two groups in terms of variation
LST group (n = 65)
Mean (95% CI)

MT group (n = 31)
Mean (95% CI)

P value

Body weight (kg)− 0.30 (− 0.64 to 0.04)

0.49 (− 0.01 to 0.98)

0.0105

Systolic blood pressure (mmHg)− 8.52 (− 12.76 to − 4.29)

0.09 (− 6.04 to 6.23)

0.0239

Diastolic blood pressure (mmHg)− 3.74 (− 6.24 to − 1.23)

1.22 (− 2.40 to 4.85)

0.0278

Timed Up & Go test (s)− 0.60 (− 1.22 to 0.01)− 0.94 (− 1.83 to − 0.04)

0.3311Baseline – Month 3 later

One leg balance with an open eye (s)1.42 (−1.51 to 4.34)− 1.54 (− 5.77 to 2.69)

0.0910CS-30 test (counts/30 s)

2.06 (0.91 to 3.22)

0.90 (− 0.77 to 2.58)

0.2613

Body weight (kg)− 0.51 (− 0.28 to 1.30)

0.41 (− 0.74 to 1.56)

0.8877

Systolic blood pressure (mmHg)− 5.46 (− 9.61to − 1.32)− 6.42 (− 12.42 to − 0.42)

0.7949

Diastolic blood pressure (mmHg)− 0.89 (− 3.54 to 1.76)− 2.32 (− 6.16 to 1.52)

0.5441

Timed Up & Go test (s)0.07 (− 1.18 to 1.31)− 0.39 (− 2.20 to 1.42)

0.2245One leg balance with an open eye (s)1.97 (− 1.90 to 5.83)− 6.24 (− 11.84 to 0.64)

0.1294CS-30 test (counts/30 s)

4.34 (2.84 to 5.84)

4.58 (2.41 to 6.75)

0.8559Baseline – Month 12 later

An unpaired t test was used to compare values between the two groups in terms of variation
Data are presented as a mean (95% confidence interval)
P < 0.05. P < 5% was considered significant in both groups
LST low-stress training (low-intensity exercise with slow movement and tonic force generation), MT machine training

Kanda et al. Environmental Health and Preventive Medicine(2019) 24:44

decreased resting blood pressure at 12 months after LST.
Some studies have also shown that the antihypertensive
effects of physical exercise include certain notable mechanisms [22, 23] such as decreased circulating blood volume,
decreased cardiac output, and increased hormone levels
with antihypertensive effects. Our study suggested that
performing low-intensity exercise on a regular basis may
decrease blood pressure at rest. In addition, it also showedthat compared with high-load exercise training, low-loadslow-motion training is associated with greater suppression of increased blood pressure during exercise [24] anddecreased the risk of musculoskeletal injury, suggestingthat low-load slow-motion training can be performed relatively safely, even by elderly individuals and individuals
with low physical strength.
As a result of training for 12 months, significant improvements in lower limb muscle strength and systolicblood pressure were observed in the LST group and in
the MT group. No significant differences were foundbetween the LST and MT group at the 3-month interval.
Studies of active, healthy, elderly people comparedweight training using body weight at normal speeds andslow speeds, and it was reported that upper limb muscle
strength, lower extremity muscle strength, and maximum extension leg muscle strength improved in bothgroups [25]. In our study, elderly subjects performed
training using chairs and bars. Our findings showed thatsuch types of LST also improved motor function, and thatthe effects were similar to those of LST using exercise
machines.
There were several limitations to this study. First, themeasurements were limited to motor functions, and thestudy did not include any evaluation of cognitive functions or the risk of falls. Additionally, we could notmeasure the factors of diet that are important and related to frailty, and the number of remaining teeth [26].
We limited the measurement items to motor function inorder to reduce burden on patients, but in future studies, it is necessary to scrutinize the measurement items
related to frailty. Second, the exercised body parts were
not same between the LST group and machine training
group. Specifically, the machine training group performed shoulder and arm exercises in addition to lower
extremity and trunk exercises, although the LST groupperformed lower extremity and trunk exercises intensively. There is a possibility of over or under evaluating
the effect of machine training. Third, the underlying
mechanism of the effects of LST is still unknown. As amain result of this study, we reported that exercise improves the leg muscle strength of elderly individuals.
However, in order to measure leg muscle strength moreaccurately, it is necessary to measure muscle mass using
ultrasonography, computed tomography, magnetic resonance imaging, and dual-energy x-ray absorptiometry,

Page 7 of 8

and it is desirable to clarify the mechanism of muscle
strengthening [27]. To improve the motor function inelderly people, it is necessary to understand the characteristics of dysfunction and deterioration of elderly
persons, and to further improve exercise programs.

Conclusions
Improvements in lower limb muscle strength and bloodpressure at rest were confirmed as short-term effects of
LST for frail, elderly subjects. It was suggested that slow
weight training using body weight could be performed
safely by frail, elderly people. Long-term improvements
as a result of exercise were observed.
Abbreviations
LST: Low-stress training (low-intensity exercise with slow movement andtonic force generation); MT: Machine training; TUG: Timed Up & Go
Acknowledgements
We thank all study participants, research assistants, colleagues, and Sin CireCo., Ltd. We would like to thank Editage (http://www.editage.jp) for English
language editing.
Authors’ contributions
KK conceived the study, participated in its design and coordination, anddrafted the manuscript. KK and TH participated in the research design andcontributed to the statistical analysis. YM and KT developed and supervised
the exercise program. HK and AK managed data collection and themeasurement equipment. All authors have read and approved the final
manuscript.
Funding
Funding for the development and implementation of the exercise program
was provided by Sin Cire Co., Ltd., and funding for data analysis andreporting the research results was provided by the Kagawa University of
Public Health classroom fee. No benefits were received from Sin Cire Co.,
Ltd., for this research. In addition, Sin Cire Co., Ltd., was involved in thedevelopment and implementation of exercise programs, but it was not
involved in the research design, analysis, or data reporting.
Availability of data and materials
The datasets supporting the conclusions of this article are included within
the article and its additional files.
Ethics approval and consent to participate
Informed consent was obtained from the participants. In addition, this study
was approved by the Ethics Committee of Kagawa University Faculty of
Medicine and Graduate School of Medicine (approval number Heisei28–128).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have competing interests. The study was
conducted in collaboration with Kagawa University and Sin Cire Co., Ltd. KK
is the director of Life, a specified nonprofit corporation that is anorganization related to Sin Cire Co., Ltd. YM, KY, HK, and AK are employeesof Sin Cire Co., Ltd. They were involved in the development andimplementation of exercise programs, but they were not involved in the
research design, analysis, or reporting. TY, HS, and TH declare no conflicts ofinterest.
Author details
1
Department of Public Health, Faculty of Medicine Kagawa University, 1750-1
Ikenobe Miki-cho Kita-gun, Takamatsu, Kagawa 761-0793, Japan. 2Sin Cire Co.,
Ltd, 14-29 Ogi-machi, Daito, Osaka 574-0033, Japan.

Kanda et al. Environmental Health and Preventive Medicine(2019) 24:44

Received: 8 January 2019 Accepted: 15 April 201922.
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