This study resulted in notable significant improvements in functional performance, strength, endurance via 6 MW, PA, BMI and IQL among older individuals. At the crossover phase and follow-ups they retained their improvements above baseline status despite some attenuation in strength, IQL and PA. Furthermore, substantially positive changes were seen in participant’s lifestyle changes in daily PA behavior, both in endurance and strength training at crossover and follow-up phases. Results from this study clearly demonstrate that well organized longitudinal multimodal training intervention can improve several physiological as well as psychological factors for relatively long periods among old people.
Age-related trends within studies were remarkably similar and even though the sexes differ in levels of physical fitness, the observed age differences was similar within a given population . The effects from the training intervention in our study showed statistically improvements in functional performance, endurance via 6 MW and strength, PA, BMI and IQL. Similar positive health-related changes have been shown in several other studies [3, 4, 10–13].
In this study the participants were older and the training intervention and follow-up periods was longer than in most existing multimodal studies of PA that we compare to [4, 8, 9]. Our training design very clearly met the minimum standards recommended in guidelines for older individuals, both in the endurance and strength parts of the study [6, 25]. Generally, other multimodal training studies satisfied the strength part of recommendations, but not the endurance part, which results in smaller comprehensive improvements [10, 11, 13, 26]. For example, the results from body composition in our study showed that older subjects were able to achieve a decrease in BMI after six months of training, but at the same time enhance their strength. Similar results between this study and the findings of others were seen for gait speed, where functional decline was observed one month after the cessation of training .
The frequency, duration, and intensity employed in this study may have contributed to the improvement in 6 MW after the MTI. But the reason for the maintenance at crossover and follow-ups measurements lies arguably in lifestyle changes and self-organized training by the participants after the intervention period. A study  with training sessions twice per week showed clearly that this is not enough stimulus for measurable improvements as was evident in our study. Our intervention methods, with about 240 minutes per week of moderate-intensity exercise for six months, met the recommended 150 minutes per week of moderate-intensity aerobic activity, for the elderly .
These results also underline the importance for older people to participate in regular training for their quality of life . To the knowledge of the authors of the current study, few studies were available where 6-month multimodal training with 6- and 12-month follow-ups has been performed for this age group. In most prior studies, the participants were younger, had significantly worsened at the follow-up measurements, and were even worse after one year of follow-up compared to their baselines [9, 10]. Overall MTI outcomes in our study generally remained statistically better compared to baseline, and none were statistically lower. These long-term positive results are likely to have three main reasons. First, the use of reasonable and progressive training protocol with a desirable balance between the appropriate volume and intensity of the training sessions throughout the whole intervention period. Secondly, the ability of the participants to follow the main goals of this study: to stay independent and carry on with the PA after the MTI, and finally, the guidance part by health instructors, both in educating and encouraging the participants in their work. The validity of the last point needs further examination. In addition, the exercise program after MTI could be continued by the participants with less support from a health instructor. Instead of twelve to sixteen exercise sessions with a health instructor per month, we would recommend, based on our findings, two to four sessions with a health instructor per month, in addition, independent PA, to maintain endurance and strength.
This multimodal training intervention study had 6 and 12 months follow-up time-points. The results clearly demonstrated that this multimodal training program improved endurance as well as strength performance, decreased BMI and increased and maintained IQL in older individuals for a relatively long period of time. Hence, this type of training could have a clinically relevant impact on older individuals in the general population if applied to a large number of individuals. The use of educated health instructors during the training intervention and working closely with the people might help to maintain their performance after the formal training period. Such implementation seems to motivate and support older individuals who seek to maintain their physical health and IQL on their own over a long period of time. This was strongly supported by the observation that about 60% of the participants estimated that their walking duration per session was less than 15 minutes before they entered the study. On the other hand, about 90% had two to seven walking days per week, whereof over 70% said that they spent from 16 and up to 75 minutes in every walking session for up to a year after the training intervention.
This study had several strengths that address some of the limitations of previous multimodal training studies. Our objective was to influence participants’ lifestyles and everyday activities during the MTI, with a focus on individual responsibility and to prepare the participants to train independently after completing the immediate or the delayed intervention phase. Our training was based on international recommendations  and the methods and philosophy were similar to those that would be used in a sedentary population, with few allowances for age. The use of accelerometers to assess physical activity volume and intensity and the low dropout rate for this age-group can be classified as strength of this study.