Training Principles for Elite Senior Athletes

Barry A. Franklin, PhD*, Angela Fern, MS, and John Voytas, MD

Address*Beaumont Health Center, Preventive Cardiology, 4949 Coolidge Highway, Royal Oak, MI 48073, USA. E-mail: bfranklin@beaumont.edu

Current Sports Medicine Reports 2004, 3:173–179Current Science Inc. ISSN 1537-890xCopyright © 2004 by Current Science Inc.

IntroductionThe graying of America is now becoming a reality. Those over80 are the fastest growing segment of the population, andthose over age 65 are projected to double to 70 million by theyear 2030. As the “old old” increase, so too will their hetero-geneity and interests in preventive health care, especially inattenuating functional declines that lead to frailty anddependence on others. The use of alternative medicines andtherapies, already embraced by approximately 40% of thepopulation, and other potential fountains of youth will alsoincrease. As the senior population becomes more comfort-able with the electronic information age and rapid access tohealth news, primary care physicians will assume a vital rolein designing wellness and optimal aging programs. Essentialto this program is physician guidance on the efficacy andsafety of a structured plan of physical exercise, including rec-reational sports, competition, or both. Ideally the condition-ing regimen will include strength, aerobic, and balancetraining, as well as stretching exercises. Evidence supporting

the benefits of physical activity and exercise in persons aged75 and older continues to grow, with apparent reductions infalls and fractures [1], improved muscle strength and endur-ance [2], a lower incidence of coronary artery disease (CAD)[3], and reduced cardiovascular and all-cause mortality [4].Although some decline in physiologic functions may beinevitable, numerous factors or biomarkers can be favorablyaffected by regular physical activity (Table 1). As an activeparticipant in their senior patients’ wellness plan, the primarycare physician needs to formulate a consistent, cost-effectivemeans of evaluation prior to recommending vigorous or evencompetitive physical activity for their active senior patients.

Competitive masters athletes are those persons, generally40 years of age and older, who participate in organized teamor individual sports that require systematic training and orga-nized competition against others [5••]. These athletes mayinclude highly trained, competitive individuals who continueto compete after their college or professional careers end butalso include “walk-up” competitors (sometimes referred to asweekend warriors) with only sporadic training regimens, aswell as those who resume competition after years of physicalinactivity. Organized masters events may include swimmingor other aquatic sports such as diving and water polo, trackand field, soccer, rowing, basketball, tennis, racquet sports,weight lifting, orienteering, rugby, ice hockey, cycling, and ski-ing. In addition, there are escalating numbers of participantsin endurance sports such as 10k races, marathons, long-dis-tance road racing, and triathlons, and more recently, competi-tion in ultramarathons and so-called extreme sports.

This article reviews the physical conditioning regimensand performance potential of elite senior athletes, with spe-cific reference to aging and cardiorespiratory function, cardio-vascular risks of masters competition, preparticipationscreening, training principles, motivational considerations,and accomplishments.

Aging and Cardiovascular FunctionThe influence of age on aerobic capacity or maximal oxygenconsumption (VO2max) in men and women is shown inFigure 1. Although there is little difference in VO2max amongboys and girls between 6 and 12 years of age, values for ado-lescent and adult women average approximately 15% to 25%lower than for men. However, there is considerable debate asto whether these differences arise from cultural or biologicfactors. A change in the habitual level of physical activity at

Despite the passage of time, masters athletes are still capable of incredible performances. Nevertheless, overuse injuries are the most common challenge in this escalating cohort. The incidence of exertion-related cardiovascular events is also greater among older athletes, especially men, highlighting the importance of a thorough preparticipation medical evaluation before entry into senior athletic training programs and competition. Accordingly, masters athletes with a moderate to high risk for coronary artery disease, who desire to enter vigorous competitive events, should undergo peak or symptom-limited exercise testing. Training programs for senior athletes should be individually tailored and focus on the predominant energy pathways and performance requirements for a given sport. Although competition and “personal bests” are important, protection against sickness and disability are increasingly listed as the primary participative motives of older athletes.

174 Training

the time of puberty is most likely an important cultural orsocial factor. On the other hand, women have more body fat(and less metabolically active muscle mass) than men. Theaverage concentration of hemoglobin is also lower amongwomen, resulting in a reduced oxygen-carrying capacity ofarterial blood.

Cross-sectional and longitudinal studies have now shownthat, beginning in the early 20s, there is an average decrementin VO2max of about 10% per decade, which generally approx-imates 1 to 2 metabolic equivalents (METs; 1 MET = 3.5 mLO2/kg/min). Table 2 shows a progressive decrease in pre-dicted VO2max values for healthy active and sedentary menand women from age 20 to 70 years [6]. Part of this decline isthe inevitable result of biologic aging, with associateddecreases in pulmonary and gas exchange, maximum breath-ing capacity, maximum heart rate, and muscle mass; but partis also a consequence of increased sedentary living. The possi-bility that the normal age-related decline in VO2max might beattenuated by endurance exercise training in older individualssuggests a potential survival benefit for participation in orga-

nized master sports. An aerobic capacity of less than 5 METsgenerally indicates a higher mortality group, whereas an exer-cise capacity of 10 METs or more identifies a group with anexcellent long-term prognosis, regardless of the underlyingextent of coronary disease [7]. Fortunately, with each 1-METincrease in exercise capacity there appears to be an approxi-mate 10% reduction in mortality.

Although systolic blood pressure continues to increasewith age, presumably due to progressive arterial stiffening,diastolic blood pressure generally plateaus in the sixthdecade and decreases thereafter. The prevalence of hyperten-sion is higher among men than women at younger ages, butthe reverse is true in older individuals. Moreover, higherlevels of habitual physical activity and VO2max at baselineare associated with a reduced incidence of hypertension overtime, especially in white men. One meta-analysis thatfocused specifically on the effects of aerobic exercise onblood pressure in normotensive and hypertensive men andwomen over 50 years of age reported a statistically significantreduction of approximately 2 mm Hg for resting systolicblood pressure and a nonsignificant decrease of approxi-mately 1 mm Hg for resting diastolic blood pressure [8].Although these reductions in systolic blood pressure mayseem small from a clinical perspective, they are associatedwith 14% and 9% reductions in the risk of stroke and CAD,respectively, in the general population [9].

Influence of Physical Conditioning and Athletic TrainingEndurance exercise training generally augments the VO2maxby 10 to 25%, primarily due to an increase in the heart’sstroke volume and, to a lesser extent, widening of the arterial-venous oxygen difference. The magnitude of training-inducedimprovement in aerobic capacity generally shows an inverserelationship with habitual physical activity and initialVO2max [10,11]. Thus, sedentary individuals (with low base-line VO2max) tend to show the greatest percentage increase inmaximal oxygen consumption with physical conditioning.The relative increase in VO2max consequent to endurancetraining in the elderly is similar to that reported in middle-aged and younger adults [12•], and there appears to be no sexdifference in exercise trainability. Improvement in VO2maxwith exercise training also shows a positive correlation withthe conditioning frequency, intensity, and duration.

VO2max values (expressed relative to body weight) inelite and championship athletes vary from a high of 94 mL/kg/min (~ 27 METs), reported in a cross country skier, tovalues in the low to mid 40s for selected athletes participat-ing in anaerobic-type sports. Virtually all world-class endur-ance athletes, including elite distance runners and Nordiccross country skiers, have a VO2max of 60 to 70 mL/kg/min(soccer players, cyclists, race walkers, elite swimmers, Alpineski racers, rowers, orienteers, and ultramarathoners). Incontrast, the reported VO2max of masters athletes, basket-ball players, national-class fencers, and volleyball players is

Table 1. Comparison of the effects of aging and exercise on selected physiologic and psychosocial variables

Aging Exercise

Aerobic fitness ↓ ↑Resting metabolism ↓ ↑Blood fats ↓ ↑Blood pressure ↓ ↑Body fatness ↓ ↑Muscle mass ↓ ↑Insulin sensitivity ↓ ↑Joint mobility ↓ ↑Bone density ↓ ↑Psychologic well-being ↓ ↑

↓ —deterioration; ↑ —improvement.

Figure 1. Influence of age on maximal oxygen consumption (VO2max) in men and women.

Training Principles for Elite Senior Athletes • Franklin et al. 175

between 40 and 50 mL/kg/min (Fig. 2). Although intensiveathletic training may elicit a 25% or more increase inVO2max, it has become increasingly apparent that naturalendowment (ie, an exceptional genetic background), ratherthan training per se, plays the primary role in producing aworld-class endurance athlete.

Cardiovascular Risks of Masters SportsBecause of the high prevalence of cardiovascular disease inthis country, and our preoccupation with sports and exer-cise, there are numerous reports, both in the medical litera-ture and the lay press, of exercise-related cardiovascularcomplications. Although the exact etiology of sports-relatedsudden cardiac death is rarely known at the scene, autopsyseries usually confirm some form of underlying organicheart disease. Atherosclerotic CAD is the most commonform of heart disease relevant to the masters population as acause of nonfatal or fatal cardiovascular events [13]. Com-mon findings, accounting for up to 85% of sports-relatedsudden cardiac death, include severe atherosclerosis, rup-tured aorta, hypertrophic cardiomyopathy, idiopathic leftventricular hypertrophy, myocardial bridging, and anoma-

lous origin of the left coronary artery. Other postmortemfindings include irregularities of the conduction system,myocarditis, aortic stenosis, right ventricular dysplasia andmitral valve prolapse [14•]. Thus, the combination of exer-cise and a diseased or susceptible heart, rather than the exer-cise itself, seems to be the major acute cardiovascular risk ofphysical activity in this cohort. Electrocardiographic anoma-lies such as sinus arrhythmia, sinus pauses, first degree atrio-ventricular (AV) block, second degree AV block (Mobitz typeI, II), complete heart block, atrial fibrillation and flutter,wandering atrial pacemaker and AV nodal rhythms have alsobeen reported in highly trained masters athletes.

The frequency with which acute myocardial infarctionand sudden cardiac death occurs during organized mastersprograms is not known with precision; however, such unto-ward events are not rare in older athletic populations [5••].Among older athletes (> 35 years), available estimates suggestthat the frequency of sudden cardiac death is in the range ofone in 15,000 joggers per year [15] or one in 50,000 partici-pants in marathons [16], with a marked predominance ofdeaths in men. These data highlight the importance of prepar-ticipation medical evaluations before entry into senior ath-letic training programs and competition [5••].

Table 2. VO2max of healthy active and sedentary* men and women

Men Women

Age, y Active, METs Sedentary, METs Active, METs Sedentary, METs

20 16.5 14 10.5 10.122 16.1 13.7 10.3 9.924 15.7 13.5 10.1 9.726 15.4 13.2 9.9 9.428 15 12.9 9.8 9.230 14.7 12.7 9.6 932 14.3 12.5 9.4 8.834 14 12.2 9.2 8.636 13.6 11.9 9.1 8.438 13.3 11.7 8.9 8.240 12.9 11.4 8.7 842 12.6 11.2 8.5 7.844 12.2 10.9 8.3 7.646 11.9 10.7 8.1 7.448 11.5 10.4 8 7.250 11.2 10.2 7.8 752 10.8 9.9 7.6 6.854 10.5 9.7 7.5 6.656 10.1 9.4 7.3 6.458 9.8 9.1 7.1 6.260 9.4 8.9 6.9 662 9.1 8.6 6.7 5.864 8.7 8.4 6.5 5.666 8.4 8.1 6.4 5.468 8 7.9 6.2 5.270 7.7 7.6 6 5

*Subjects who do not exert themselves sufficiently to develop sweating at least once per week.(Adapted from Bruce et al. [6].)

176 Training

Preparticipation Medical ScreeningDespite the explosion of medical technology over the pasttwo decades, the essential component of a medical evaluationremains the history and physical examination, especially forthe geriatric patient. In evaluating the safety and benefits of anintended physical training program for a senior athlete, it iscritical to identify previous and future activities, particularly ifthe new activity is different. For example, the 70-year-oldfemale power walker who learns about the potential benefitsof resistance training for osteoporosis would benefit from asupervised orientation on proper technique and appropriateweight progression. In addition, the exercise environment aswell as the patient’s medical status should be considered, as inthe 75-year-old male avid tennis player who plans to take upmountain biking. Chronic conditions such as osteoarthritis,hearing loss, and low vision from macular degeneration, glau-coma, and cataracts become important when assessing partic-ipation in vigorous exercise for senior athletes, especially if itis outdoors. Fortunately, arthritic conditions can often beovercome with medication, stretching, strength training, andencouragement [17•]. Also important in the history are ques-tions regarding exertional shortness of breath, dizziness orlightheadedness, as well as any noticeable chest, joint, orlower extremity pain or discomfort during recent physicalactivity. A focused musculoskeletal [17•] examination wouldbe indicated if a history of recent joint swelling or pain isgiven. As with younger athletes, the majority of injuries inseniors during aerobic or resistance training are musculo-skeletal, due in large part to inadequate warm up, impropertechnique, aggravation of a previous injury, overuse, or com-binations thereof.

For the senior athlete already committed to a lifetime ofvigorous physical activity (eg, running, jogging, speed walk-

ing, racquet sports, heavy yard work, weight lifting), an indi-vidual cardiac risk assessment is strongly advised. Thepersonal and family history and physical examination formaster’s athletes should adopt the 12 relevant points of theAmerican Heart Association preparticipation screening rec-ommendations (Table 3) [18]. Particular attention should bepaid to the increasing number of senior athletes who have aknown history of controlled hypertension or diabetes. Basiclaboratory work such as hemoglobin, fasting blood sugar, lip-ids and lipoproteins, and a renal panel would be appropriateif not obtained in the past year. New heart murmurs orcarotid bruits also require evaluation before the primary carephysician can approve vigorous athletic activity in their seniorpatients. Because peripheral vascular occlusive disease pro-vides a strong predictor of underlying CAD, examination oflower extremity pulses and, if indicated, measurement of theankle/brachial index, is simple and clinically useful. Further-more, it is recommended that those master athletes having amoderate to high cardiovascular risk profile for CAD, andwho desire to enter vigorous competitive situations, undergopeak or symptom-limited exercise testing [5••]. Additionalcardiovascular testing should also be considered (eg, diagnos-tic echocardiography), if clinically warranted.

Training PrinciplesThe major objective in physical training is to bring aboutspecific metabolic and physiologic adaptations in order toimprove athletic performance. This requires adherence to acarefully planned and executed conditioning regimen, withspecific reference to the frequency and length of workouts,type of training, speed, intensity, duration, and repetition ofactivity, notwithstanding coaching, encouragement, and

Figure 2. Average VO2max values (mL/kg/min) for various athletic groups.

Training Principles for Elite Senior Athletes • Franklin et al. 177

intrinsic/extrinsic motivation. Although these factors mayvary, depending on the competition and performance goal,it is possible to identify several principles of physiologicconditioning common to predominant energy pathwaysand performance classifications: strength-power (eg, powerlift, high jump, shot put, tennis serve); anaerobic power-endurance (eg, 200- to 400-meter dash, 100-yard swim);and, aerobic endurance (eg, > 0.5-mile run). Interval,continuous, and Fartlek training can be used effectively forconditioning these different energy systems; however, theformer seems to be the most desirable for promotingchanges in the anaerobic energy systems. Of critical impor-tance are the progressive overload principle, the specificity ofexercise principle, the individual difference principle (ie,benefits are optimized when training programs are designedto meet the individual needs and capacities of the partici-pants), and the reversibility principle (ie, detraining occursrapidly when an individual stops training).

Based on the existing scientific evidence concerningexercise guidelines for healthy adults, the American Collegeof Sports Medicine offers the following recommendationsfor the quantity and quality of training for developing andmaintaining cardiorespiratory fitness, body composition,muscular strength and endurance, and flexibility in healthyadults, including young, middle-aged, old, and very old(80+ year) cohorts [19•,20]:

1. Frequency of training: 3 to 5 days per week.2. Intensity of training: 55%–65% to 90% of maximum

heart rate, or 40%–50% to 85% of maximum oxygen uptake reserve or maximum heart rate reserve; although the recommended relative intensity for training remains constant, regardless of age, the

absolute intensity of training, expressed as METs, decreases with increasing age [20].

3. Duration of training: 20 to 60 minutes of continuous or intermittent (minimum of 10-minute bouts accumulated throughout the day) aerobic activity.

4. Mode of activity: any activity that uses large muscle groups, which can be maintained continuously, and is rhythmical and aerobic in nature, for example, walking, jogging (in place or moving), running, stationary or outdoor cycling, swimming, skipping rope, rowing, cross country skiing, stair climbing, skating, and various endurance game activities.

5. Resistance training: one set of eight to 10 exercises that condition major muscle groups 2 to 3 days per week is recommended (at least initially); however, multiple-set regimens may provide greater benefits if time allows; most persons should complete eight to 12 repetitions of each exercise, to volitional fatigue; however, for older and more frail persons (approximately 50–60 years of age and above), 10 to 15 repetitions per set may be more appropriate [21].

6. Flexibility training: these exercises should stretch the major muscle groups, be performed at least four repetitions per muscle group for a minimum of 2 to 3 days per week, and include appropriate static, ballis-tic, or modified proprioceptive neuromuscular facili-tation (contract/relax, hold/relax, active/assisted) techniques; the elite senior athlete may, however, far exceed these thresholds and physical training dosages (ie, points 1–6) in order to achieve the performance levels that are required for competition.

Motivational ConsiderationsThe Senior Olympic Games, which were initiated in 1969 inCalifornia, afford competitive, older athletes the opportunityto make and break records. The Senior Olympics, which arenow a national event, are staged every 2 years in the summer(odd-numbered years) and winter (even-numbered years).The most recent summer games were held in Virginia in 2003and boasted an impressive 27,000 qualifiers. Participants 50years of age to 100+ are categorized into 5-year age incrementsfor competition [22].

Senior athletes have the advantage of experience as wellas an “advanced level of self-understanding from training,competing, failing, and succeeding.” However, there arenumerous day to day diversions from high level trainingregimens, including family, professional, and social responsi-bilities. Motivation is widely regarded as one of the mostimportant variables underlying success [12•]. The motives ofmasters athletes include age-related health challenges (eg,obesity, cancer, coronary artery bypass surgery), the desire tobreak records, longevity, quality of life, and specific individ-ual performance goals. Other encouraging stimuli for seniorsinclude camaraderie and “a way of keeping life fresh and

Table 3. American Heart Association consensus panel recommendations for preparticipation screening

Family historyPremature sudden deathHeart disease in surviving relatives

Personal historyHeart murmurSystemic hypertensionFatigabilitySyncopeExertional dyspneaExertional chest pain

Physical examinationHeart murmur*Femoral pulsesStigmata of Marfan syndromeBlood pressure measurement

*Precordial auscultation is recommended in both supine/sitting and standing positions to identify heart murmurs consistent with dynamic left ventricular outflow tract obstruction.(Adapted from Maron et al. [18].)

178 Training

exhilarating” [23]. According to one clinical psychologist,“masters athletes want to live a healthy life for a lengthy time,stay in shape and expect exercise to be the elixir of life.”Seniors want exercise to provide protection against sicknessand disability [24]. Accordingly, personal best and competi-tion may not be as high a priority as compared with theiryounger counterparts [25].

Potential AccomplishmentsSeveral elite senior athlete accomplishments are worthy ofrecognition, especially in the 80+ age group. The first, a 101-year-old man, was the oldest US track and field athlete com-peting in the 60-yard dash and shot put in Boston, MA(March 2003). He became active at the age of 80 in track andfield, after nearly a 50-year absence from the sport [26]! Thesecond, an 80-year-old man, was the oldest triathlete tofinish the AARP TriUmph Classic 50+ Swim-Bike-Run in SanDiego, CA (July 2003). At the time, he had completed 158marathons and 31 Ironman triathlons [27].

Representative of those 70 to 80 years old is a male tri-athlete who, in May 2003, was 75 years old. He admitted toa life-long interest in fitness, beginning with amateur boxingand 5-mile daily runs. Middle age brought competition inthe Ironman triathlon in Hawaii. “Middle old age” evolvedto a 2003 training schedule of approximately 2 hours ofdaily running, swimming, bicycling, or weight lifting [28].In contrast, a female runner who falls into the “young old”category of 60 to 70 years broke the 1-mile world record forher age group (60–64 years) at the US track and field com-petition in March 2003, in Boston, MA. Amazingly, runningwas not her sport until the year 2000, when she startedrunning to relieve stress [26].

ScoringAs an adjunct to traditional scoring (ie, using time), age-adjusted tables or norms can be used. This method, thoughnot widely employed, validate senior athletes abilities in mas-ters track and field, long-distance running, and race walking,regardless of their finish time. The tables were devised to“attempt to correct a person’s performance based on age” bythe World Association of Veteran Athletes. Grading is deter-mined by age, sex, and the corresponding world records. Thisenables individuals of different ages to be compared for anygiven event. In simplistic terms, the score is expressed as a per-centage (eg, > 80% = national class; > 90% = world class) andrepresents the ideal or best possible time in the prime years.

ConclusionsIt is an impressive fact that many older persons can functionperfectly well. Arthur Rubenstein played very demandingcompositions at the age of 88 and Andre Segovia, at the age of

91, was still giving concerts on the classical guitar. ClarenceDeMar competed in over 1000 distance races over a 60-yearperiod, winning the prestigious Boston marathon seventimes—a record that has never been equaled. Moreover, thelate Larry Lewis, a well-known San Francisco waiter, contin-ued his jogging program into his 103rd year of life. Appar-ently, through regular training or practice, vigorousneuromuscular and cardiovascular activities can be main-tained even at advanced ages. The lesson seems clear: declinesin bodily function and psychosocial well-being among seniorathletes appear to be considerably less than those shown forthe healthy sedentary population [29,30].

References and Recommended ReadingPapers of particular interest, published recently, have been highlighted as:• Of importance•• Of major importance

1. Tinetti ME, Baker DI, McAvay G, et al.: A multifactorial interven-tion to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994, 33:821–827.

2. Fiatarone MA, O’Neill EF, Ryan ND, et al.: Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994, 330:1769–1775.

3. Hakim AA, Curb JD, Petrovich H, et al.: Effects of walking on coronary heart disease in elderly men: the Honolulu Heart Program. Circulation 1999, 100:9–13.

4. Glass TA, de Leon CM, Marottoli RA, et al.: Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999, 319:478–483.

5.•• Maron BJ, Araújo CGS, Thompson PD, et al.: Recommendations for preparticipation screening and assessment of cardiovascular disease in masters athletes. Circulation 2001, 103:327–334.

This landmark article provides prudent insights and advice to physicians concerning the screening and detection of cardiovascular disease, as well as recommendations for sports clearance and eligibility in masters athletes.

6. Bruce RA, Kusumi F, Hosmer D: Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. Am Heart J 1993, 85:546–562.

7. Franklin BA: Survival of the fittest: evidence for high-risk and cardioprotective fitness levels. Curr Sports Med Rep 2002, 1:257–259.

8. Kelley GA, Sharpe KK: Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2001, 56:M298–M303.

9. Pescatello LS, Franklin BA, Fagard R, et al.: Exercise and hypertension. Med Sci Sports Exerc 2004, 36:533–553.

10. Pollock ML, Foster C, Knapp D, et al.: Effect of age and training on aerobic capacity and body composition of master athletes. J Appl Physiol 1987, 62:725–731.

11. Marti B, Howald H: Long-term effects of physical training on aerobic capacity: controlled study of former elite athletes. J Appl Physiol 1990, 69:1451–1459.

12.• Menard D, Stanish WD: The aging athlete. Am J Sports Med 1989, 17:187–196.

A well-written review, peppered with scientific data and anecdotal information, highlighting the fact that up to 50% of the physiologic decline associated with old age may be reversed.13. Maron BJ, Epstein SE, Roberts WC: Causes of sudden death in

competitive athletes. J Am Coll Cardiol 1986, 7:204–214.

Training Principles for Elite Senior Athletes • Franklin et al. 179

14.• Franklin BA, Fletcher GF, Gordon NF, et al.: Cardiovascular evalua-tion of the athlete: issues regarding performance, screening, and sudden cardiac death. Sports Med 1997, 24:97–119.

A comprehensive review summarizing the physiologic basis and rationale for cardiovascular evaluations in athletes, with specific reference to electrocardiographic anomalies, cardiorespiratory fitness, medications, atherosclerotic and nonatherosclerotic causes of sudden cardiac death, identification of athletes at risk, and the limitations of conventional screening programs.15. Thompson PD, Funk EJ, Carleton RA, et al.: Incidence of death

during jogging in Rhode Island from 1975 through 1980. JAMA 1982, 247:2535–2538.

16. Maron BJ, Poliac LC, Roberts WC: Risk for sudden cardiac death associated with marathon running. J Am Coll Cardiol 1996, 28:428–431.

17.• Scott WA, Couzens GS: Treating injuries in active seniors. Phys Sportsmed 1996, 24:63–68.

A well-written paper, in a question and answer format, that provides a practical approach to managing overuse injuries, the most common sports injuries among older patients.18. Maron BJ, Thompson PD, Puffer JC, et al.: Cardiovascular

preparticipation screening of competitive athletes: a statement for health professions from the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association. Circulation 1996, 94:850–856.

19.• Mazzeo RS, Cavanagh P, Evans WJ, et al.: Exercise and physical activity for older adults. Med Sci Sports Exerc 1998, 30:992–1008.

This comprehensive scientific review highlights that participation in regular physical activity (both endurance and strength exercises) elicits a number of favorable physiologic and psychosocial responses that contribute to health aging.

20. Pollock ML, Gaesser GA, Butcher JD, et al.: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998, 30:975–991.

21. Pollock ML, Franklin B, Balady GJ, et al.: Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription. Circulation 2000, 101:828–833.

22. Senior Olympics News Update. www.SeniorJournal.com/news/sports

23. In the long run: the Senior Games in Orlando, Florida next month will put older but fitter athletes on display. Time Magazine. September 27, 1999:154, 107.

24. Moss N: The psychology of the aging athlete. Clin Sports Med 1991, 10:431–444.

25. Ogles B, Masters K: Older versus younger adult male marathon runners: participative motives and training habits. J Sport Behav 2000, 23:130.

26. Lamb G: Ageless athletes. The Christian Science Monitor. May 14, 2003.

27. Roth C: C’mon tri it! IDEA Personal Trainer 2003, 14:6.28. Rotsein G: Senior Olympics: athletes share a commitment to

fitness and fun. Post-Gazette. May 20, 2003.29. Pollock ML, Mengelkoch LJ, Graves JE, et al.: Twenty-year

follow-up of aerobic power and body composition of older track athletes. J Appl Physiol 1997, 82:1508–1516.

30. Mengelkock LJ, Pollock ML, Limacher MC, et al.: Effects of age, physical training, and physical fitness on coronary heart disease risk factors in older track athletes at twenty-year follow up. J Am Geriatr Soc 1997, 45:1446–1453.