Gregory L. Welch MS ATCPhysical training for the older adult has become an area of great interest over the past five years. Current research has assured personal trainers that healthy older adults can participate in standard training programs. It is also encouraging that regular physical activity has been shown to produce physiological improvements regardless of age. (Pollack 1971).
Because you are working one on one, you can further the wellness of older adults by translating the benefits of general exercise into a program specific to “real-life function.” The more information you can acquire from individuals regarding their specific needs, the better you can customize their exercise programs.
Of course, any older client will require medical clearance. Take careful notice of any training restrictions the physician may indicate, and telephone the physician if you have any questions.
Real-Life Function
One of the more striking characteristics of the aging process is impaired motor performance (Wiswell et al.1990), which is demonstrated in the slowing of movements, the loss of fine coordination and a decrease in maximum strength. Training for real-life function as I’m using the term means helping clients regain or improve their ability to stand up, sit down and maintain general independence. These activities require coordination, synchronization and a certain amount of strength.
Functional tasks can range from the simplest self-care to executive-level occupational responsibilities (Reuben & Solomon 1989). To help clarify the description of these tasks, three categories of function have been defined:
Basic Activities of Daily Living (BADL) include bathing, eating, dressing, using the toilet, transferring from one place to another, and walking.
Intermediate or Instrumental Activities of Daily Living (IADL) include such tasks as cooking, shopping and light housework.
Advanced Activities of Daily Living (AADL) are recreational, occupational or community service functions.
The older client most often seen by the personal trainer will generally range between the IADL and AADL categories.
Evaluating Functional Ability
Analysis of functional ability does not require a lot of statistical normative data. Older adult clients are the least concerned about how they compare to the norm. Instead, they are very concerned with their own progress, which you can record and report.
When designing an exercise program for older adults, you can address functional tasks in the interview phase. You can usually determine clients’ levels of independence by simply asking them about their ability to get out of bed, dress, prepare meals, shop and perform other daily activities.
A lot of information can also be acquired through observation of functional mobility. Does the person need assistance getting up from the floor or from a bench? Make your observations part of your notes.
Even if you are unsure of the individual’s basic functional capabilities, using the typical screening tests considered it standard in our industry, such as the step test or bike ergometer, may actually be putting the cart before the horse. An older adult may not score well on a simple step test due to nonspecific joint pain, an inflamed tendinous attachment or muscle cramping-all of which are common in a deconditioned older adult.
Failing to complete the test makes the client feel worse. He or she may even leave the test facility in pain, which may increase the next day. After going to all this trouble, the trainer still doesn’t have any more information, and may end up with one less client.
Prior to administering any standard test of muscular strength, endurance or flexibility, it is prudent to ascertain total body active range of motion or mobility. Begin with single-joint movements (shoulder flexion, extension, abduction and adduction) and progress through multijoint actions (shoulder flexion simultaneous to internal rotation and scapular elevation). By observing the movement, you can identify discomfort, immobility and perhaps muscle weakness within these ranges of motion.
Next, you can hand the client a very light weight, such as a one-pound dumbbell, and ask her or him to repeat the above movements. Gradually increase the resistance, and observe carefully. You may observe a number of things:
1. If there is a limit to the range of motion, it may indicate joint intolerance (Hyatt 1994). There can be so much intolerance that the muscle can’t overcome it and range of motion will be stopped. If you suspect joint intolerance (possibly due to an arthritic condition), refer the client to an appropriate medical professional for further evaluation.
2. If the client can move through a full range of motion without pain, but has difficulty raising the arm with a specific resistance (indicated by the muscle “quivering”), the problem is more likely muscle weakness. Observation will help you determine what level of resistance to begin with. The weight of the body part alone may be sufficient to begin the training program.
3. The client may feel strain or discomfort, which you can identify by her or his facial expression. Or the client may
move the joints through the range of motion without discomfort, but then the following day she or he may feel pain (a classic symptom of people who do too much too soon). To determine if this is the case, you can ask, “After what we did yesterday, do you feel any discomfort?” Be conservative with your progression.
It makes sense to determine what issues of motor performance may actually hinder the desired objective of a given test. The priority should be to train the “weak links of the chain” first-and test later.
Disabilities relating to functional instability can range from multisensory deficits (for example, in vision, touch, spatial awareness or hearing) and decreasing proprioception (balance) to diseases such as arthritis, apraxia and pseudobulbar palsy (Tinetti 1986). Parkinson’s disease can also affect a variety of functions, including rising from a chair and stepping. Cerebellar disease can be responsible for instability when turning. Buchner and Larson (1987) relate functional impairments in patients with Alzheimer-type dementia (ATD). Abnormal gait and balance have also been observed in ambulatory patients with ATD (Visser 1983).
Issues In Program Planning
Because assessing individual function is the primary component of program design for older adults, you should immediately eliminate chronological stereotypes. Discriminatory assumptions-such as those that lump older adults between 60 and 70 years old as recreationally active and those over 80 years old as happy just to be able to get off a bus-put an automatic ceiling on potential ability.
Broad Generalizations.
Evans and Rosenburg (1991) state that the measurement of biological age is a calculation that must be done one person at a time, since chronology offers few clues. It is unduly restrictive to make generalizations regarding the older population. Consider the following generalizations:
Elevated Arms: The broad statement that older adults should not raise their arms above their head against any resistance is illogical. Granted, this maneuver can increase blood pressure, but only if the arms are left in that position for an extended period of time. From a biomechanical standpoint, there can be a risk of impingement with a high number of repetitions. However, for anyone who places household objects in overhead cabinets, a shoulder press exercise can be quite helpful for maintaining the integrity of the shoulder joint and the strength of the associated muscles.
Squats: The same perceptual problem seems to exist with the squat. Many fear the squat is too aggressive for older adults. Yet anyone who sits in a chair and stands up again is performing a squatting motion. The squat is arguably one of the most important exercises for functioning in real life.
Muscular Strength
Very few movements are produced by the musculature of one joint without additional musculature working to stabilize the other joints in the body. With the squatting exercise, for example, there is a great deal of work occurring to stabilize the joints in the upper body so the primary lower-body action can continue successfully.
“When very frail people want to exercise, many doctors recommend walking because they think it’s safe. But people who are weak and have terrible balance are likely to fall. They should get strength training before they start walking,” writes Dr. Maria Fiatarone, assistant professor in the Division on Aging at Harvard Medical School. A walking program is best performed after the body has been prepared to sustain the activity.
Falls and Gait Instability
These are among the most serious problems facing the aging population. Accidents are the fifth leading cause of death in people age 65 and older, and falls constitute two thirds of these accidental deaths (Rubenstein 1988). One study of persons 75 years of age and older suggested that the predisposition to fall may result from the accumulated effect of multiple disabilities. Even the “fear of falling” has been reported as a viable cause of falling (Tinetti et al. 1988).
Measuring a full gait cycle is an excellent way to ascertain information about real-life function. One way to measure stride length is to wet the feet, ask the person to walk and then measure from the point of heel strike of one extremity to the point of heel strike of the same extremity, which constitutes one full gait cycle. (Normal stride length averages 1.5 meters [not quite five feet]. Remember, do not be too concerned about the norms. What matters is the individual’s performance.)
A decreased stride length most likely reflects instability or muscle weakness during support of the opposite leg (Trueblood & Rubenstein 1991). Again, stabilization becomes crucial in the performance of a primary action. Assisted squatting would be highly appropriate, and step-up and balancing exercises would also be helpful.
For example, if your client has difficulty standing on both feet, that’s the base level skill to improve. Progress to swaying right to left, then to holding a small stride and rocking back and forth to work on balance. Then progress to standing on one leg next to a stable object she or he can grab, then practice doing a heel lift.
Another consideration is the speed of the normal gait pattern. According to Visser (1983), the gait pattern slows five to 15 percent due to aging. This is an important consideration in real life when, for example, an older adult needs to cross the street within the time permitted by a stoplight.
As personal trainers, we are at a tremendous advantage working one on one with the older adult. It’s most important for all of us involved with this population to share information. Then and only then can older adults count on real-life fitness programming.
Case Study
The Client:
Billie S. is a 74-year-old with Parkinson’s disease.
During the interview, I ascertained that Billie’s current category of function was between BADL and IADL. Parkinson’s disease obviously furthered her already sedentary lifestyle. She was also contending with mild hypertension and osteoporosis.
However, the most important information I acquired in our initial discussion was that Billie was afraid. She had a fear of walking outside and of climbing stairs. As with many older adults, her real fear was of falling. Plus, the fatigue and muscular rigidly of Parkinson’s decreased her hip and knee flexion and ankle dorsiflexion, making it difficult for her to climb stairs.
The Evaluation:
Physical assessment with Billie began with mobility testing. By giving her various verbal cues, such as, “Reach for the sky” and “Cover up your ears with your arms,” I could begin to identify limitations in voluntary function. Further investigation revealed stiffness in the shoulder girdle, the appearance of a frozen right shoulder, and severe weakness throughout her body.
Billie’s gait pattern indicated severe impairment: Stride length was 25 percent of normal. Step width was greater than normal, which suggested weakness in stabilization of the weight-bearing leg. Step initiation was visibly cautious and resembled a shuffle..
Billie exhibited virtually no arm swing at the shoulder joint, and her elbows remained at approximately 90 degrees of flexion, with her arms drawn close to her torso. Verbal reminders were not sufficient to elicit a correction in arm swing.
Designing the Program:
Billie began a circuit weight training program. The variety of activities in circuit training is very specific to real life. In addition to accommodating a large volume of work in a short period of time, circuit training often allows muscular and metabolic fatigue to occur simultaneously.
Our first goal was strength training to build up Billie’s conditioning level so she could perform cardiovascular training. A secondary goal was to improve her confidence in her ability to move safely.
Billie exercised twice a week for approximately 30 minutes per session.
The circuit program was modified to exclude prone or supine positioning from the floor-or even from a bench- because of her fear of falling when getting up and down. Legs were the predominant focus. Upper-body work was generally performed from a seated position.
We placed a great deal of emphasis on stabilization. Body weight and dumbbells were chosen for this purpose. Balance training was used, progressing to balancing on one leg, and eventually to using the proprioception board. Multi-hip maneuvers (abduction, adduction, flexion and extension) led to a variety of gait patterning.
Billie wore a Polar heart monitor at all times during her workout. (I find the “at-a-glance” reading of the heart rate helpful to track progress as fitness level improves.)
Six-Month Evaluation:
Billie is able to climb three flights of stairs without stopping. This was a primary goal because the walking track is on the third floor. The walking track offers an environment free of obstacles and weather, so she can increase the aerobics component of her program. Her confidence has increased, and she now takes regular strolls outside in the evening with her husband.
There was only a slight improvement in Billie’s stride length. However, heel striking was more definite due to strengthened tibialis anterior muscles (trained by heel walking). Step initiation was also improved due to a strengthened gastrocnemius (trained with heel lifts). The greatest improvement, however, was in step width. Billie’s newfound strength in the hip and pelvis region allowed her to decrease her step width and her upper
body sway.
When reminded, Billie will now let her arms swing. Her cadence is improving, and her shoulders are relaxing. The right shoulder is still limited in active range of motion, but is pain free. She also has pain-free full range of motion with passive movement. The best news is that Billie’s motivation is increasing because her confidence in real-life functioning is increasing.
Circuit Weight Training
The order of the exercise circuit is changed frequently. Billie began with one set of five to seven repetions and either no weight or minimal weight. For example, she initially performed five leg extensions with 10 rounds.
This list shows her current training program. Weight load and repetitions have been gradually increased to this level. While this number of repetitions provides challenge, it is not an intensity that causes muscle failure. Since the training goal is function, muscle failure is not appropriate at this point in the program. Billie uses a combination of free weights and Keiser machines.
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Gait Training
2 sets, 20 yds each set:
Initially Billie held onto to me for support. As function improved, she became self-supporting while I walked alongside.
- Toe walking-walking on the balls of the feet with the heels lifted.
- Heel walking-contacting just the heels without rolling onto the balls of the feet.
- Side walking-stepping to the side, then bringing the feet together.
- Carioca walking-crossing one foot over the other while moving to the side.
- Back walking-walking backwards.
- Line walking-walking along a line on the floor
- Foot patterning (square or diagonal, upon command)-stepping to different portions of a quadrant defined by an X drawn on the floor.
Gregory L. Welch, MS, is an exercise physiologist and the president of SpeciFit An Agency of Wellness, located in Seal Beach, California. Greg lectures nationally, is on the board of advisors of the Lifespan Wellness Center at California State University at Fullerton, and is a member of the faculty of the American Academy of Fitness Professionals.
Jim Strohecker
Daniel Redwood DC
Tom Ferguson MD