Beliefs and Evidence about Strengthening in Older Adults

Beliefs and Evidence about Strengthening in Older Adults

A couple of weeks ago, a therapist asked the Section on Geriatrics listserv readership about their experiences using resistive exercise in geriatrics and/or home care. The therapist said he didn’t feel “max-out” repetitions worked in older individuals and preferred instead to prescribe 30-50 reps. He went on to say “I also seldom use weights with the elderly. And find theraband awkward generally. Maybe I'm not the only one..........” 

I would like to set the record straight here, as I did to the Geri list serv, with some Myth and Fact statements. I hope you will find this post enlightening as you intervene with older adults.

1. MYTH: Older adults can’t gain strength as they get older.

FACT:  FALSE! Older people gain strength in similar ways as young adults. Frontera et al, 1988, 1990 found a 2-3x increase in strength in 3-4 months (5%­/session) and 11.4% increase­ in muscle area with high intensity (70-80% 1RM) exercise (Nelson et al 1994; Fiatarone, 1994). Muscle strength increases with 60-100% 1RM training stimulus (McDonagh & Davies, 1984). The principle of overload must be incorporated as a major feature in an exercise prescription for older adults (ACSM 2000).

2. MYTH: Older adults don’t need to strength train.

FACT: FALSE! There is NO group more in need of strengthening than people on the verge of loosing function or who need to regain function. Age has been associated with a loss of muscle mass, strength, and muscle quality (Roubenoff 2000). Inactive older adults loose their strength and power reserve at the minimal rate of 1 and 3%/year respectively (Metter et al, 1997). Leg strength and power has been unequivocally correlated to functional independence (Galvao & Taaffe, 2005, Bassey et al, 2002, Mazzeo et al, 1998, Chandler et al, 1998). While strength loss is a normal aspect of aging, exercise can slow the rate of this loss by half and therefore allows older individuals to maintain their independence until the end of their lifespan (compression of morbidity).

3. MYTH: Strength gains are guaranteed to produce functional gains.

FACT: TRUE, if resistance is true overload. Leg strength and power have been unequivocally correlated with gait speed, stair climbing, and rising from a chair (Galvao & Taafee, 2005; Bassey et al 1998, 2002; Mazzeo et al, 1998, Chandler et al, 1998). Specifically improving power is an important aspect of functional training in older adults. In

4. MYTH: MMT is an appropriate way of assessing the strength necessary to get up out of a chair or stair climb.

FACT: FALSE! MMT was developed for individuals with polio. It is NOT valid to determine whether someone has enough strength to get up out of a chair or to climb stairs. I often see the term WFL used when someone has been determined to have 4 or 5/5 strength of the quads. However, even with 5/5 bilaterally, an individual may not be able to stand up without using his/her arms. Try this for yourself on an older patient. Clinically, the gold standard for testing dynamic muscle strength is the 1 repetition maximum (RM) which is the maximal amount of resistance/load that can be moved once and once only through full range. To calculate 1 RM, the following web site might be helpful http://www.exrx.net/Calculators/OneRepMax.html. Rikli & Jones 2001 have established normative data for the chair rise test from over 3000 60-90 year olds. They have established the chair rise test as a valid measure of quad strength; therefore I never use a MMT on the quads. It just isn’t accurate. The Rikli & Jones Senior Fitness Manual can be obtained at

http://www.humankinetics.com/products/showproduct.cfm?isbn=0736033564

5. MYTH: Low intensity exercise is appropriate for older adults, especially if they are frail.

FACT: Not true!  Functional improvements do NOT occur when exercise intensity is low (<50% 1RM) although modest strength gains will occur (Aniansson & Gustafsson 1981; Larsson 1982; Mazzeo 1998). The concept of task specificity is key for older individuals, but especially frail individuals where energy and strength reserves are low. For example, if you train the quad in an open chain manner, then you should expect the person to be a better kicker. However, if you train the quad by doing resisted chair rises (lowering the surface of the chair or using a weighted vest to increase intensity), you will see functional gains. De vreede (2005) compared task specific activities to resistive training and found in healthy older adults that both were effective. It seems the energy and strength required to do the task was the equivalent of moderate to high intensity.

6. MYTH: Strength can improve in as little as two weeks.

FACT: Partially true! Strength gains even with low to moderate intensity exercise are seen in the first two weeks. This response is attributed to neural adaptation that is not affected by age (Bemben & Murphy, 2001; Phillips, 2000). Achieving good form while increasing intensity is good practice during the period of neural adaptation. I have found this early response in strength to be a great motivator. In frail older adults, a strength gain of 10-15% per week with 80% 1RM was seen (Evans, 1999). Despite the fact that strength gains are seen within 2 weeks, these gains cannot be attributed to hypertrophy or to an increase in cross sectional area of Type I and Type II muscle fibers. Therefore to avoid rapid detraining effects, an individual needs to perform resistive exercise for 6-16 weeks minimum to achieve hypertrophy. Thereafter, 1x week can maintain strength if done at the same intensity (Lexell et al, 1995; Graves et al, 1988). 

7. MYTH: 3 sets of 15-30 reps is the preferred exercise prescription to improve function in an older individual.

FACT: FALSE! In Berger’s original study (1962) that found 3 sets achieved more strength gains than 1 set, only a 2.3% increase in younger, healthy males was realized. Many studies have shown that 1 set at 60-80% 1RM (8-15 reps) is entirely sufficient to achieve desired strength gains in younger and older untrained individuals (Galvao & Taaffe, 2005; Feigenbaum et al 1999; Messier & Dill 1985; Silvester et al, 1981; Stowers et al, 1983; Carpinelli 2002; Starkey, 1996; Vincent 2002; Hass 2000).

8. MYTH: Older individuals with pathology are better off engaging in aerobic exercise and shouldn’t engage in moderate to high resistive exercise.

FACT: Not true! Resistive exercise may be safer for people with COPD (Simpson et al 1992; Bernard 1999), CHF (Pu et al 2001), and arthritis (Fransen et al 2002) than aerobic exercise. Blood pressure responses are less intense with resistive exercise as compared with aerobic exercise (Martel et al, 1999; McCartney 1999). Following a program of high intensity resistive exercise in individuals with CAD, reductions in systolic pressure, diastolic pressure, and the rate-pressure product of 17-27% were found (McCartney 1999). Pierson et al in 2001 found that older individuals exercising at both 50% and 80% 1RM increased their aerobic capacity by 20% and 23% respectively.

9. MYTH: It is not safe for older adults to exercise at high intensities. 

FACT: FALSE! Older adults of any age exercising at 80% 1RM have demonstrated safe, effective gains in strength of up to 273% (in 90+ y.o.) depending on initial baseline (Fiatarone 1990; Evans 1999) (based on the curvilinear relationship Bean et al 2004).

FACT: There is no evidence of adverse cardiac or other homodynamic events with high resistance exercise (Gordon et al, 1995; McCartney 1999; 1996; Barnard et al 1999; Verrill 1999; Kaelin 1999; de Vos et al <platform presentation at 2005 American Gerontolgical Society Annual Meeting>).

FACT: There is no evidence that supports a higher rate of injury with higher resistive loads when appropriately supervised (Rooks et al, 1997; Di Fabio 2001, Barnard et al 1999, Coleman et al 1996). Higher resistance requires good form and proper technique necessitating the skills of a PT (the definition of skilled care!). However, individualization is key here. If pain is present and limiting the ability to perform a maximum contraction, then what the person is able to do may be their 1RM.

10. MYTH: Ok, so it may be good for older folks to exercise at high intensities, but they aren’t going to do it!

FACT:  Many older folks LIKE (relatively) the intensity of exercise (60-80%) because they can see the results (remember – in as little at 2 weeks). I believe many people are not “compliant” with a HEP because they don’t see the benefits – often because of poor form or inadequate resistance. They DO need to be taught how to exercise with intensity, which increases their confidence and self-efficacy that exercise does work. Nelson et al (1994) demonstrated a whopping 87% compliance rate in the high intensity (87% 1RM for 52 consecutive weeks) intervention group compared with a 60% compliance rate in the control group. Again, individualization is the key. Imagine if every time you went to the doctor you got the same prescription? Certainly your confidence and enthusiasm for complying would diminish.

FACT: Recognize that years ago, when >75 aged individuals were sick or hurt, they went to bed (remember all the pelvic traction and bed rest we used for LBP?)! Older individuals need to be taught that there isn’t value in bed rest – in fact bed rest (and hospitalizations) are deadly for older individuals (Gill 2004). Additionally, people who haven’t routinely exercised throughout their life will need a lot of encouragement, positive attitude, and evidence. Intensity may be a foreign concept to them. Explaining the principle of dose helps – you get out of it what you put into it (Spirduso 2001). Strength is going to allow them freedom of mobility, prevent falls, and prevent osteoporotic fractures (Nelson 1994; Sinaki 2002) alleviate depression, and improve the immune system (Fiatarone Singh 2002). Older adults, especially frail ones, can’t afford not to do it – and in light of these effects, we are obligated to be the best salespeople we can.

TIP: Functional evaluation outcome tools are a great way to motivate individuals and to objectively document functional loss and progress. When an individual can only perform 5 chair rises (10% of their age group), the evidence can be a powerful motivator. Additionally, you can easily and objectively monitor changes.

11. MYTH: Elastic bands and exercise balls aren’t appropriate for older adults.

FACT: It’s not the mode but intensity that is important. To get functional strength gains, you need to use appropriate resistance. Rarely will I use yellow Theraband after the individual can execute proper form. Many of my patients/clients use blue, black and gray Theraband as they progress their exercise program. In fact, I have just completed a 10 week research study using elastic bands and exercise balls to build strength and balance skills with a group of relatively high functioning older adults. We measured a 30% strength gain on average in biceps curls, chair stands, and dorsiflexion strength placing most of the individuals in at least the 75% for their age group. These folks worked at an average intensity of 14 (hard level) on the Borg Scale of Perceived Exertion (Borg 1982).

In summary, there is EVERY reason to use resistance exercise with older adults. I believe that to not apply appropriate exercise principles based on ACSM guidelines and the literature (and there is a lot of it out there) is ageist and unethical. My hope is that some day, instead of avoiding appropriate resistance for fear of a lawsuit, you will fear a lawsuit because you under treated someone! With the Medicare cap again realized, it is imperative to maximize every visit an older individual has available. IMHO, to do otherwise is grounds for malpractice.

It is disheartening to hear a PT not respecting the power of exercise. It is the most effective tool we have to improve function in an older person. There is so much evidence to support resistive exercise that others outside of our profession will use it (and well they should) if we don’t recognize its significance and use it appropriately.

Thank you for allowing me this opportunity to post on my favorite topic. I’ll keep you abreast of the latest evidence about exercise and older adults.

Dale Avers PT, DPT, PhD

 

Comments

[Selena Horner]

Nice job, Dale. Those myths aren't only believed by medical professionals - many of the elderly believe them too!

[DavidPenn]

Dale,
Unfortunately, the undertreatment of our most senior group is rampant. We have really stepped up our approach to strength training by incorperating a system called SuperSlow (http://www.superslow.com/) high intensity strength training. Although not the only mode used at our facility, it is loved by the seniors since the word "slow" does not scare them away and make them think they are going to be doing training like their grandkids. We have not had one senior injured and have taken this population to exhaustion in less than 3 minutes per exericse.
Great post and thank you very much for the information. I also enjoyed your presentation at PPS 2 years ago.
David Penn,PT,DPT,OCS

[Rob Wainner]

Dale,

I have been meaning to write you with kudos for some time now for your "most excellent" post. Thanks for sharing the evidence...and disabusing me of some of my anachronsitic notions.

We all need updating

Thanks

Rob

Prepare Daily

[Ed]

Dale,
Thanks for completing my lecture on strength training for the elderly for next fall. This was an awesome post that I am passing on to all of my students. Well said.

[SOG knives]

Interesting ideas... I wonder how the Hollywood media would portray this?