Why You Need To LOAD and CHALLENGE Your Older Patients
We are afraid to really work and challenge our elderly patients. Students are guilty of it. New grads are guilty of it. And even veteran physical therapists are guilty of it. Stuck in a never-ending cycle of straight leg raises and bodyweight bridges, it's no wonder Evelyn has barely improved since her last re-eval and her insurance company is giving you grief.
It's not a terrible crime (it actually is) and we've all been guilty of it. I certainly was. The first time I treated an older patient (we're talking at least 87 years old and just as many pounds soaking wet), I was terrified. I was convinced that the simplest of demand placed on this poor woman's body would cause her to disintegrate into a fine dust. But SURPRISE! It didn't happen. Sure enough, through gentle prodding (shoving) by my clinical instructor, I persevered and was ultimately successful in treating this woman.
In my case, that was the inexperience talking. But for others, the story might be different. It might be a case of "what's the point? They're old!" or "It's not worth the risk or potential lawsuit." Not only is this extremely unethical and unprofessional, it's also downright disrespectful to that individual and what the human body is capable of. Does the Overload Principle or Wolff's Law suddenly cease to exist after a certain age? Doubt it. Otherwise, with the increasing age of the population, the physical therapy profession would be in deep trouble.
That said, here are a few reasons why you must be challenging and LOADING these individuals:
1. Combats the muscle mass and strength losses of age
This age-related phenomenon is known as sarcopenia. Beginning at around the 4th decade of life [that's 30 years old by the way, can you hear the clock ticking?], evidence shows that skeletal muscle mass and strength begins declining in a linear fashion - with up to 50% of mass being lost by the 8th decade of life. And then even more of a decline after this point. The good news is that life-long strength training may help to compensate for this loss. But wait - why does it happen in the first place? Well, it's multifactorial (muscle fiber/neuronal changes, poor nutrition, obesity, inflammatory conditions), but a big reason is EXERCISE. Or lack there of.
So what type of exercise and how much? Research by De Vos et al. shows that after 8-12 weeks (2 days/week), HIGH-intensity training (ranging between 70-80% of their one-rep max) was the best strategy to improve whole-body peak power, strength, and endurance in the elderly including individuals greater than 80 years old. And this was compared to groups that performed lower- and moderate-intensities. When controlling for intensity (at 70% one-rep max), a different study by Fielding found that training at a higher velocity (in this case, performing the concentric phase of an exercise as fast as possible) was more effective at improving peak power of the lower extremity than training at a lower velocity. This particular finding may have rehab implications for when a person needs to work on improving getting off the floor or a low chair.
2. Makes people more functional in their daily lives
This point feeds off of the last one. What's more important than sheer muscle strength and size is knowing how to use it when it's needed! The improvement in muscle function induced by the aforementioned strength training results in improved functional capacity of the individual. And research would seem to support that claim. In a study by Fiatarone, improvements in muscle size and strength were found after 10 weeks of high-intensity progressive training, with particular interest in the fact that 4 subjects in the exercise group that initially needed a walker only needed a cane afterwards. That is a life-changing improvement! Another study utilized a multicomponent training strategy (incorporating strength, balance, aerobic, flexibility, and coordination components) to improve sit-stand performance, walking speed, and stair-climbing speed - all of which were still present at 6 months following cessation!
These effects can likely be magnified through appropriate exercise selection as well. Many of the mentioned studies above tended to use machines (seemingly for perceived safety and convenience) however I strongly believe in the use of fundamental lifting patterns - per the squat, deadlift, lunge, press, etc. All of which are excellent movements that every person can benefit from and more importantly mimic a ton of ADLs.
3. May attenuate or prevent bone mineral density loss
Aging also comes with declines in bone mineral density that usually leaves largely women more prone to osteoporosis and consequential fractures than men. Clearly, a fracture to the hip or a vertebral body at an advanced age can carry large quality of life and functional implications leading to significant increases in overall mortality. All efforts in this case should be made to prevent this from happening. The good news is that we may be able to make an impact here. A systematic review of 21 studies by Zehnacker revealed evidence to support the effectiveness of high-intensity training to improve bone mineral density in women with osteoporosis and osteopenia. This effect was seen particularly when interventions ran for greater than 11 months. Shorter duration interventions (4-8 months) still however showed that the exercise groups had less bone loss than non-exercise control groups. Admittedly other studies have shown variable results: with either no effect on bone mineral density and one even showing a decrease after an exercise intervention. As always, more and more well-designed studies will assist in arriving at a definite conclusion.
EDIT: As I was writing this, I was made aware of a new study that just recently came out. In this one, a physical therapist guided 37 elderly women through a resistance training intervention 3x/week for 16 weeks. Exercises that targeted large muscle groups of the lower and upper body at 50-80% one-rep max were used. This resulted in a 6% improvement in hip bone mineral density and increases in a protein marker related to bone formation. An important take-home result however was that measured bone mineral density returned to baseline at 1-year follow-up, highlighting the overall importance of CONSISTENCY in training.
In any event, it is uncertain if these improvements can even be significant enough to prevent a stress or traumatic fracture from occurring. Life happens. Falls can still occur. Indeed the need for a multicomponent training strategy (addressing strength, balance, flexibility, coordination, etc) cannot be emphasized enough. Not only is this crucial in improving function and most importantly safety, but may also affect an individual's ability to RECOVER following a fracture.
4. Reduces anxiety and depression
The elderly often present with co-morbidities that either directly or indirectly contribute to anxiety and depression. Now this may be a can of worms I'm daring to open here but it's clearly a no brainer that many people feel pretty great after a bout of exercise or when they lead a generally active lifestyle. There are a number of theories for why this may be, including a positive effect on serotonin and beta-endorphins, an improved sense of self-efficacy and self-worth, and possibly the profound effects of social belonging and interaction. And while specifically addressing a person's anxiety and/or depression falls outside the scope of physical therapy practice, the effect that challenging exercise can have certainly merits its mention.
Studies seem to be far from conclusive on the matter. From what I've read, it matters less what specific intensity, mode, or frequency of exercise one follows, but rather the overall duration of each session and total length of the program that has an effect on mood (with better results coming from longer duration sessions and programs). Personally I believe steps should be taken to establish a positive and encouraging relationship with the individual, while considering what type of activity they enjoy and structuring a program around that. Of course, any intervention in this case should be considered an adjunct to psychotherapy and pharmacotherapy, and the appropriate referrals should be made if need be.
From this brief article, you can see clearly there are many potential benefits to really working and challenging this population. But listen carefully to this next point because it's important: this is NOT permission to be irresponsible.
What does this mean? Well you still must use the basic tools you possess as a professional to assure that they are capable of performing training of ANY intensity. This includes assessing available range of motion and strength, analyzing movement patterns for faults and safe execution, taking into consideration prior injuries and reports of pain, and most importantly: YOU MUST MONITOR THEIR VITALS before, during, and after exercise. There is no exception to this last point and it does not take long enough at all to excuse not doing.
Additionally, what does it mean if an individual isn't ready for higher intensity work? That's fine - everything must be modified and adjusted to an individual's activity level, function, health status, exercise response, and their stated goals. It is perfectly acceptable to begin at a lower intensity; just as long as they are appropriately progressed. Strength and conditioning principles still apply here and should be used.
Above all, consistency matters. Set individuals up for success by finding out what they enjoy doing, guiding and educating them in a well-designed and individualized program, and encouraging them to follow it well after they leave your care.
- Aagaard P, Suetta C, Caserotti P, Magnusson SP, Kjaer M. Role of the nervous system in sarcopenia and muscle atrophy with aging: strength training as a countermeasure. Scand J Med Sci Sports. 2010;20(1):49-64.
- Ciolac EG. Exercise training as a preventive tool for age-related disorders: a brief review. Clinics (Sao Paulo). 2013;68(5):710-7.
- Ciolac EG, Rodrigues-da-silva JM. Resistance Training as a Tool for Preventing and Treating Musculoskeletal Disorders. Sports Med. 2016;46(9):1239-48.
- Cussler EC, Lohman TG, Going SB, et al. Weight lifted in strength training predicts bone change in postmenopausal women. Med Sci Sports Exerc. 2003;35(1):10-7.
- De vos NJ, Singh NA, Ross DA, Stavrinos TM, Orr R, Fiatarone singh MA. Optimal load for increasing muscle power during explosive resistance training in older adults. J Gerontol A Biol Sci Med Sci. 2005;60(5):638-47.
- 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(25):1769-75.
- Fielding RA, Lebrasseur NK, Cuoco A, Bean J, Mizer K, Fiatarone singh MA. High-velocity resistance training increases skeletal muscle peak power in older women. J Am Geriatr Soc. 2002;50(4):655-62.
- Gómez-cabello A, Ara I, González-agüero A, Casajús JA, Vicente-rodríguez G. Effects of training on bone mass in older adults: a systematic review. Sports Med. 2012;42(4):301-25.
- Huovinen V, Ivaska KK, Kiviranta R, et al. Bone mineral density is increased after a 16-week resistance training intervention in elderly women with decreased muscle strength. Eur J Endocrinol. 2016;175(6):571-582.
- Ströhle A. Physical activity, exercise, depression and anxiety disorders. J Neural Transm (Vienna). 2009;116(6):777-84.
- Wipfli BM, Rethorst CD, Landers DM. The anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response analysis. J Sport Exerc Psychol. 2008;30(4):392-410.
- Zehnacker CH, Bemis-dougherty A. Effect of weighted exercises on bone mineral density in post menopausal women. A systematic review. J Geriatr Phys Ther. 2007;30(2):79-88.