Geriatric Strength Training What are we weighting for?

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Geriatric Strength Training What are we
weighting for?

• Michael L. Tuggy, MD
• Swedish Family Medicine

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When I get the urge to exercise, I just lay down
and it goes away. . . -- W.C. Fields
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Illustrative Case

• 91 y.o. WF living alone at home, presents with
  history dizziness and of multiple falls and
  recent left chest contusion.
• P.E. localized tender left 9th rib,
  mid-axillary line
• Dx Rib fracture
• Plan now what do you next?

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Scope of the Problem of the Frail Elderly

• 10-20 of patient over 72 and 40 of nursing home
  patients are unable ambulate unassisted.
• Increase numbers of osteoporetic patients as
  population ages.
• Decades of sedentary lifestyles leading to
  significant weakness and atrophic changes.

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Exercise in the Elderly

• 92 of patients over 65 do not exercise
  vigorously
• 66 are sedentary
• 66 of women over age 74 cannot lift more than
  4.5 kg overhead one time.

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Risks Associated with Frailty

• Falls and their sequelae - a leading cause of
  morbidity and death in older women
• Social isolation - depression
• Inability of self-care- malnutrition.

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Big Bobs Ballbearing Bananas Rollerskates
Floor Wax Inc
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Attitudes toward Strength Training

• You want me to
• do what?
• Elderly feel its too late to start
• Doubtful of benefit
• Physicians often unaware of benefits

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What happens when we age to

• Cardiac output?
• VO2Max?
• Muscular strength?
• Reflexes?

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Cardiac output

• Myth decrease in cardiac output is a normal
  process of aging
• Reality
• Decreases in cardiac and pulmonary function are
  due to disease processes, not age. Cardiac output
  is maintained with changes in stroke volume.

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Strength and the Aging Process

• Myths Exercise capacity
• Aging decreases VO2 Max due to decreased cardiac
  output.
• Reality
• Disuse atrophy leads to decrease muscle mass and
  strength
• The less the mass, the lower the VO2 Max .
• In healthy geriatric patients, VO2 Max can be
  maintained or improved 10-30 in lt 3 mo.

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Strength and the Aging Process (Cont)

• Myth as you age, you inevitably loose strength
• Reality
• Muscle mass can be significantly increased with
  strength training from 20-130 depending on the
  protocol
• Long term atrophic changes can be radically
  reversed.

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Reflexes and Balance

• Myth as we age, our reflexes slow and loose
  their adaptive capability
• Reality
• Balance can be substantially improved with
  training

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Principles of Strength Training

• Very high intensity with less than 10
  repetitions. 80 1 Rep. Max. 2- 3 sets of reps.
• Eccentric work induces most rapid growth
• Should achieve fatigue at 10-12 repetitions.
• Weight should be increased as capacity increases.
• Every other day schedule.
• Combine with stretching to avoid tendon strain.

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Methods of Strength Training

• Isometric - fixed muscle length applied to load
• moderate improvement in strength
• Isotonic - shortening muscle length with work
  load applied
• Eccentric - lengthening muscle with work load
  applied.
• maximal strength increase

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Physiologic Effects of Strength Training

• Muscular changes
• enlarges white fibers
• enhanced anaerobic metabolism
• Cardiovascular effects
• increased vascular flow to muscle groups
• transient hypertension
• Hormonal effects - Growth hormone stimulation
  (18-fold), improved glucose metabolism and
  glycogen stores

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Swedish Family Medicine Study
Biceps
Triceps
Gastroc
Quad
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Swedish Family Medicine Study (Cont.)
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Recent Studies on Geriatric Strength Training

• FISCIT Studies - on going nationwide.
  Preliminary results high intensity training is
  most beneficial for elderly.
• Nichols (1993) - (80 of 1RM ) 20 -65 increase
  in strength in most muscle groups in 6 months
• Ettinger (1997) - improved arthritis pain and
  functional tests with strength training.

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Recent Studies on Geriatric Strength Training,
(Cont.)

• Judge (1994) - (Isokinetic 60-75) - 20 increase
  in 3 weeks. (? Enough weight)
• Fiatorone (1990) - (80 1RM) - ten 90 y.o. males
  for 8 wks. - 136 increase in strength of
  quadriceps group. Gait speed from 13 cm/sec to
  20 cm/sec.
• Strength persisted beyond 4 weeks post cessation
  of exercise

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Who should strength train?

• Very few contraindications-
• Severe CAD
• Advanced valvular heart disease
• In large studies, lower morbidity in exercising
  populations
• More than 90 of your patients
• are free to strength train.

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Physiologic Effects of Endurance Training

• Muscular changes
• expansion of red fibers
• improved aerobic metabolism, O2 transport.
• Cardiovascular effects
• increased stroke volume, decrease baseline HR
• responsive autonomic system
• Hormonal effects
• improved glucose metabolism - extended duration
  to replenish glycogen stores.

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Risks of Strength vs. Endurance Training

• Strength - increase risk of stroke and vasospasm
  (theoretical)
• Not seen in large cohort studies (FISCIT)
• aggravation of DJD (not common -opposite shown to
  occur)
• Endurance - increased risk of arrhythmia or
  vasospasm (even post-exercise). (documented)
• Overuse injuries more common

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The Ideal Exercise Program

• Warm up - stretches
• focused on hip, knee, back, neck
• Aerobic exercises
• walking, swimming
• based on tolerance
• Strength training
• focused muscle groups
• replicate functional activities

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Methods of Endurance Training

• Aerobic training level of at least 20 minutes
  three times per week.
• High repetition, low intensity exercise.
• Graduated program increasing over weeks to
  prevent overuse complications
• Periodic rest periods (reduce intensity to half
  every 3-4 weeks)

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Functional Strength Training

• Series of exercises that replicate movements that
  are commonly performed.
• Added intensity by use of gravity, dumbells
  (5-10), types of movements
• Measure number of reps, amount of reach, duration
  of exercise, etc.

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Principles of Functional Exercises

• Static Balance - 3 planes
• Dynamic balance - 3 planes
• Lunges
• Steps
• Jumps
• Hops

Low
High
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Muscle groups for focused training

• Upper extremity flexors and extensors
• Shoulder girdle
• Abdominal flexors and lumbar extensors
• Thigh - quadriceps group
• Calf- Gastrocnemius/soleus groups

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Equipment-less Exercises

• Milk jug or dumbbells- adjust weight by fluid
  volume
• Biceps curls
• Shoulder girdle - butterfly exercise
• Push -ups (if needed modify initially- torso
  raises only), overhead lifts
• Abdominal crunches or sit-ups
• Sit to stand exercises, two-leg squats or one-leg
  squats or lunges
• Toe raises - one leg.

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Modifications

• Retro-patellar pain isometrics quad sets or leg
  extensions with foot deviated externally
• Low back pain/DJD half-sit ups or isometric pull
  for 10 sec. holds
• DJD of knees multiple range isometrics with 10
  -15 sec holds.

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Yeah, Clem, I hurt. But y know, its a good
kind of hurt.
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So what will my patients gain?

• Improved self-image/esteem
• Greater confidence in ability to function outside
  of home
• Large increase in strength of multiple muscle
  groups
• Greater independence in ADLs - extension of
  independent living for years.

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VO2 Max and Independence
Adapted from Shephard, RJ - 1993
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Food For Thought

• Based on what we know, when should we start
  strength training?
• Target Men and women in their 40s - primary
  prevention of frailty.

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Summary

• Strength training - high intensity, brief
  duration.
• Can be performed at home, 3 times a week
• Rapid initial strength gains
• Translation into gains in independent living, and
  self-esteem.

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