injury prevention

Strength After Sixty – Resilience Against Frailty: Part II

May 21, 2015 By Dan Cenidoza 15 Comments

If we look at the physical aspects of frailty as discussed in Part 1 of this article, it is evident that the strength, mobility and stability of the musculoskeletal system declines as we age. Exercise is the only remedy for this. There is no pill you can take to move better or become stronger. With the proper training, movement and physical strength can be restored, and maintained, at any age. If you are young, consider strength training as part of your retirement planning. If you are old, better get started now.

This article will discuss some of the basic activities of daily living (ADLs) and exercises that best support them. The exercises can be scaled to be appropriate for anyone, regardless of their current physical condition.

Rising from a seated position to standing (and vice-versa) and walking are foundational ADLs. We will assume that our hypothetical trainee can stand and walk, but not much more (injured or wheelchair bound individuals will be discussed in another article). From a strength coach’s perspective, we want to strengthen and improve the ADLs of the sitting to standing transition as well as walking. Squats are the most high-yield exercise to achieve this goal. “Bad knees” and “bad backs” are the most common reasons trainees give to avoid squatting. Properly instructed squats with thoughtful progressions can often surmount these obstacles and get an aging trainee squatting safely and pain free.

Many older trainees may have been told by their physicians (who most often have no strength training background) that they should never squat. It is probably a safe bet that their doctor has not told them that they should never get out of a chair or rise from the toilet seat. Squatting is a fundamental movement for these crucial daily activities. The best starting exercise to train standing from a seated position in senior fitness circles is called “chair stands” (“box squats” in powerlifting).

Box squats allow for this important movement to be performed at varying ranges of motion. Typically, the greater the depth of a squat, the more strength, mobility and stability are tested. A lack of any one of those things could compromise how deep a person could and should squat. For the lowest functioning individuals, we will use double stacked chairs and do bodyweight squats; for the high functioning individuals, we will do full squats with added weight.

Case Studies:

Mrs. Ethel was a 92 year old woman with severe kyphosis (aka hunch back). She walked using a walker with her head looking straight down. Her posture was so bad that when you passed her in the hallway she had to turn to the side to look up at you. Mrs. Ethel could barely stand even from a double-stacked chair, so that’s where we started. She was challenged to not use her arms to assist, to stand a little taller at the top of each rep and descend under control (no “plopping”). A sticky note was placed on the wall in front of her to look up at, and it was gradually raised higher over the course of her program. She would probably never stand completely upright again but we countered the effect gravity was having on her with simple cues like “stand tall” and “look up”. As her leg strength increased we moved to a single chair (lower starting position); first allowing use of the arms for assistance and then without. With 20 repetitions being her “max” she never needed an additional load.

Compare this to Mr. Frank, a 85 year old man who exercised regularly since he left the military 50 years ago. He could squat to below parallel and his range of motion was limited only by arthritic knees and his preference for biceps curls instead. He could also maintain proper form under a load. Although shoulder mobility might prevent him from holding a barbell behind his back as in a true powerlifting squat, dumbbells and kettlebells could be held as a front or goblet squat. Mr. Frank has more options available to him for progression as he could safely increase weight, repetitions and on good days even try to go lower (albeit with less weight).

By squatting deep and with a load, we can improve the strength, mobility and stability qualities required to stand up and walk. Appropriate squat depth and load will vary significantly with each individual. It is helpful to remember the concepts of hormesis and allostasis covered in the beginning of Strong Medicine when deciding on the proper “dose” for squatting. With these concepts in mind, proper dosing can be successfully prescribed by the fitness professional well-versed in squatting mechanics (see Marty Gallagher’s previous article on the squat for a master class). The squat is a basic human movement that you will need to do for the rest of your life if you plan to be independent into old age. Performing this exercise regularly will not only maintain strength, but also develop both the mobility and stability that is crucial for preventing frailty.

The other exercise that translates extremely well to ADLs for the senior is the deadlift. This deadlift is one of THE best cures for osteoporosis. The deadlift and the partial deadlift allow for heavier loads to be used to maximize bone density and prevent muscle wasting. Deadlifting is a pure strength movement that can be scaled to the senior population. This lift is based on the hip hinge movement and contrary to idea that deadlifts are “bad for the back”, a proper deadlift can rehabilitate a weak back. Neurosurgeon Patrick Roth, M.D. prescribes a kettlebell deadlift as part of his spine rehabilitation program in his excellent book The End of Back Pain.

There is a deadlift variation that is appropriate for anyone. For some a load is not appropriate at first, but everyone should be taught the hip-hinging movement central to the deadlift. Arguably, the hip hinge should even be taught before the squat, especially considering that squatting “starts” at the hips.

Another benefit to the deadlift is that it has a shorter range of motion, making it safer for more people. It is also a less technical movement, making it easier to learn. A good coach can teach the hip hinge and tell when individuals are ready to progress. Again, progressions can be made in the form of additional load or greater ROM. As a rule, I use where the wrist falls on the body during the exercise to determine where people can safely pull from. If technique can be maintained to a point where the crease of the wrist passes the knee for instance, then the trainee can pull from there. Setting up at this height will allow for a 2-3 inch “buffer” so the lifter is not pulling from his/her end-ROM.

Paula Hip Hinge — *Paula is able to maintain a neutral spine to a point where her wrists touch her knees in a hip hinge movement, thus making a knee-height partial deadlift a safe range of motion for her.*

A brief note on set up.

Any powerlifter reading this will know how to set up a power cage for rack pulls. To pretty much everyone else reading this those last few words are foreign, especially to your average 60+ year old exerciser. This is unknown territory that can be downright frightening to some people. Fortunately there are machines that allow set up for partial deadlifts with adjustments as simple as pressing a button. Many senior centers are equipped with pneumatic or computerized machines to allow user friendly solutions to older adults. Unfortunately you will see few “racks” in these centers. We can speculate on why that is the case (i.e. liability, funding, misuse, lack of qualified personnel, etc) or we can make a call to action for fitness centers to offer deadlifting options. The importance of real weight bearing exercise to combat sarcopenia, osteoporosis and frailty syndrome cannot be overstated. Partial range of motion deadlifts must be made available to the population who are at most at risk if we are to reinforce our position against frailty. If this means expensive equipment or powerlifting coaches posted by the powercages in every senior center, so be it. The cost of equipment is minimal and justified by the potential for improving the quality of life and avoiding catastrophic injuries such as hip fractures from falls.

Paula Power Rack Lift — Paula has moved out of osteopenia and into normal range bone density at 57 years of age. Here she is working on her retirement plan making strength deposits with 225lbs, pulling from the rack for a safe range of motion to maintain pristine technique for her current mobility.

Aging is a process that we all face. Strength training is a necessary component to aging successfully, but we need effective methods. So much of senior fitness boils down to the end goals of standing tall, and standing strong. We need the right balance between mobility and stability, and for most of us, strengthening the posterior and stretching the anterior. When properly programmed, the squat and the deadlift address the core activities of daily living for the senior. These two exercises alone give people a simple approach to not just exercising, but improving the quality of their lives. Humans are meant to lift weight and load their bodies. If we can get more intersection and synergy between the powerlifting community and the retirement community, geriatric health and senior fitness will flourish.

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Dan Cenidoza, BS, CSCS is a personal trainer, professional strongman and owner of Art & Strength in Baltimore, Maryland. He has a degree in exercise science and specializes in kettlebells and strength & conditioning. His mission is to instruct and inspire people to live stronger, healthier lives. artandstrength.com facebook.com/artandstrength

Strength After Sixty – Resilience Against Frailty: Part I

April 30, 2015 By Dan Cenidoza 16 Comments

Strength After Sixty

The topics of osteoporosis, sarcopenia, and the frailty syndrome are extremely important for anyone over the age of 60 or anyone planning to be in the future. This article will look at the need for preventative measures, the means to healthy aging of the musculoskeletal system, and the steps you can take to ensure that you will live out your years on this earth strong and physically capable.

Osteoporosis is a well-known condition involving decreased bone density with aging that most people are familiar. Sarcopenia is a disease of muscle loss and weakness that is the lesser known evil-twin of osteoporosis but just as important to understand. These two conditions comprise the public health problem known as frailty syndrome, which has unfortunately become increasingly common in aging adults.

Frailty syndrome is technically defined as “a decline in the functional reserves with several alterations in diverse physiologic systems, including lower energy metabolism, decreased skeletal muscle mass and quality, and altered hormonal and inflammatory functions.”

For a more user-friendly definition picture in your mind a stereotypical “old person.” You think of little gray haired men and women who are hunchbacked and have trouble walking. They are too weak to even stand, and look as if they would shatter with a minor fall. That image is what many of us now associate with the word “old.” No one wants to become the embodiment of this image as we age. We cannot slow the passing of the years, our chronological age, but we do not have to succumb to frailty. Strength training is not just for the young. You can become stronger and more resilient in your 60’s, 70’s, 80’s and even 90+. Strength training is arguably more important for the aging person and absolutely essential for healthy aging.

Frailty is what makes falls the leading cause of both fatal and nonfatal injuries among older adults.^{^[1]} Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.^{^[2]}

The financial cost of frailty is huge. In a 2002 study, the cost of an individual fall averaged between $14,306 and $21,270.^{^[3]} The cost increases rapidly with age and could easily exceed most peoples retirement savings. In 2013, the total direct medical costs of fall injuries for people 65 and older, adjusted for inflation, was $34 billion, and is expected to reach $54.9 billion by 2020.^{^[4]} ^{^[5]}

Fortunately there are steps we can take to avoid the bleak and costly condition of frailty as we age. Physical exercise is well recognized by both the layperson and the medical community as an essential part of a healthy lifestyle. Doctors will tell you the importance for “weight bearing” exercise when it comes to osteoporosis and sarcopenia. Unfortunately, there are only a very small percentage of physicians who actually know how to properly prescribe and program weight bearing, bone strengthening exercises.

Physicians are trained to diagnose and treat disease, but most do not have the expertise to write exercise prescriptions or coach weight training techniques. It is ironic that exercise, one of the most powerful disease-preventing modalities, is not taught in medical education.

In my opinion as a strength coach and fitness professional, that lack of basic education is why there seems to be lack of information coming from the medical community about effective weight-bearing exercise. If you look at the Surgeon General’s Report on Bone Health and Osteoporosis, strength training is underemphasized and casually mentioned along other activities such as walking, dancing and gardening. No one ever seems to mention that those who have the strongest muscles (such as weight lifters and powerlifters) also have the most dense bones, and never succumb to osteoporosis or sarcopenia.

It’s understandable why a physician who is not also a trained strength & conditioning specialist would not elaborate on such a topic, but most will confirm that loading the axial skeleton is what increases osteoblast activity, resulting in bone production. Because of the body’s hardwired adaptive response to loading, the heavier the load is, the stronger the bone. However no doctor in their right mind would tell their patient to go lift the heaviest weight they possibly can, especially if that person was already showing the signs of frailty syndrome.

I have the unique position of being strongman and a strength coach who has worked with the senior population for the last 10 years. As a young trainer, I begun my career at a retirement community, and in the same calendar year won the Maryland Strongest Man contest. I also did a stint working as a strength assistant for the Baltimore Ravens. I have since gone on to open my own gym and work with people of all ages and backgrounds. Senior fitness was my first paid position as a strength professional, and I still teach a weekly class at the same retirement community at which I started my career.

My work with seniors has highlighted the importance of the role strength training plays in health and longevity and countering the negative effects of frailty syndrome. I have seen people of 70, 80 and 90 years of age who, because of regular strength training, do not fit the characteristics we associate with “old.” I have documentation of post-menopausal women (those most at risk for osteoporosis) I have coached achieving increased bone mineral density measured by DEXA scans.

One of Dan’s clients, Tom (age 70) on left, and Strong Medicine co-author Marty Gallagher (age 65) on the right. Both are embodiments of strength after sixty.

I know how to program advanced powerlifting techniques and scale them to the senior population, and as much as I’d like to say “follow this exercise program to stronger bones” there are many things to consider in exercise prescription. There are obvious things such as which exercises for how many sets and reps, but there are more complex things like needs analysis, individual body mechanics, safety and technique. Just as a doctor would not write a drug prescription to a patient he has never met, I cannot write a cookie-cutter program to cover everyone reading this blog post. That being said, in part 2 of this article, I will cover some general techniques and principles for strength training an aging population. With the proper application of resistance training our potential for strength is limited only by the number of years we have left to train. Exercise is an individual responsibility and those who strive for strength will achieve it at any age. Survival truly is, of the strongest.

Editor’s comment:

The importance of this topic cannot be overstated. Dan has done an excellent job describing the problem we are facing with frailty in our ever-growing aging population. There is an unmet need for real strength training programs for our seniors that are both effective for reversing/preventing frailty and safe. If you are a trainer looking to make a huge impact on public health, start acquiring a skill set to work with this population. Dan has considerable experience and expertise in this area and is going to lay out some general training principles in Part II of this post so stay tuned…

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References:

^{^[1]}Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013

^{^[2]}Rubenstein LZ. Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595–6.

^{^[3]}Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan L. Falls in the Medicare population: incidence, associated factors, and impact on health care. Physical Therapy 2009.89(4):1-9.

^{^[4]}Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006a;12:290–5.

^{^[5]}Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science 1996;41(5):733–46.trial. The Gerontologist 1994;34(1):16–23.