Exercise Progression for maintenance of muscle and bone in

the older person

Dawn Skelton

Do we wrap older people in cotton wool?

Older peoples progression in terms of intensity is up to us!!

Summary of session

• Effects of ageing and

inactivity/sedentary behaviour.

• Improving strength, power and bone

density in different settings and

functional/health abilities of older

people.

• The role of the physiotherapist - How

do we implement the evidence in

practice?

3 Dimensions of Human Frailty

TIME

DISEASE DISUSE

HUMAN FRAILTY

Spirduso, 1995

Sedentary Behaviour Active bone and strength loss

• No standing activity leads to active loss of bone and muscle

• 1 wk bed rest leg strength by ~ 20%

• 1 wk bed rest spine BMD by ~1%

• Sedentary Behaviour linked to low BMD (independent of physical activity).

• Nursing home residents and those in hospital spend 80-90% of their waking day seated or lying down

(Krolner 1983; Tinetti 1988; Skelton 2001; Dallas Bed Rest Studies 1966-present; Chastin et al. 2011; Beyer 2002)

It’s never too late!

• The lower the baseline level of physical activity, the greater the health benefit associated with an increase in physical activity

(Haskell 1994)

• A 12 week high Intensity Strength Training programme in >90 yr olds doubled their strength

(Fiatarone, 1990)

• Cochrane Review – PRT improves: – Improves strength and function

– Reduces pain (Liu et al. 2009)

ACSM Position Stand 2007 Resistance Training Older People

• Frequency: – At least 2 days/wk

• Intensity: – Between hard (5–6) and very hard (7–8) intensity on a scale of

0 to 10.

• Type: – Progressive weight training program or

– weight bearing calisthenics

– 8-10 exercises involving the major muscle groups, 8-12 reps

– Functional - stair climbing, chair rises.

Resistance Training Continuum

15 12 10 8 6 Reps

30% 50% >60% >70% >80% of IRM of IRM of IRM of IRM of IRM

Low weight Heavy weight

High Reps Low Reps

Endurance Strength

ACSM Position Stand 2004 Physical Activity and Bone Health

• Basic principles of training:

– Specificity (site)

– Overload (progressively)

– Reversibility (Keep at it)

– Initial values (lower starting BMD, greater response)

– Diminishing Returns (plateau / ceiling)

Basically same advice for strength training!

Unipedal standing for the oldest?

• RCT, n= 94 postmenopausal women

• Control vs Exercise

• Exercise – 6 months, single leg stand for 1 min per leg 3 x per day

– Those aged >=70 years (n=31) had significant increase in hip BMD

– Those aged <70 did not

J Bone Min Metab 2009 - Sakai et al

Cochrane Review 2011 • 43 RCTs considered, 4320 participants

• Small but significant improvement in BMD (spine, total hip and trochanter)

– Combination exercise - Effective on NOF, Trochanter and Spine

– Jogging, vibration and jumping - Effective on Total Hip and Trochanter

– Strength training (high load, low rep) - Effective on NOF and Spine

– Single Leg Standing - Effective on Hip

– In combination with drugs (HRT, Ca etc) – generally better than

exercise alone but small numbers

• Dose response on duration

• Non-significant reduction in fractures

• Falls most prominent adverse effect!

Falls prevention

• All exercise studies (17% reduction)

• Greatest effects (38% reduction):

– Challenging balance component

– Dosage >50 hours

– Progressive Strength training included

– No walking programmes

• Different programmes for different populations

– Primary prevention – Tai Chi, FaME etc.

– Secondary Prevention – Otago, FaME etc.

Sherrington et al. 2011; Skelton et al. 2005; Campbell et al., 1997;

Wolf et al. 1997; Iliffe et al. 2014

Walking has many benefits

But, generally DOES NOT improve strength, power or bone density Unless brisk (beware fallers), with added weight

So what does this mean in practice?

• Are you providing consistent positive messages?

• What works and what to avoid

• What is progression?

Are we doing harm to older patients?

Stroke Patients in a rehabilitation ward spent only 8.3% of their day in an upright position Are we contributing to patients/residents (and their family members) fear of activity or avoidance of activity by not making activity “normal” on our wards or in care homes?

Egerton T et al. (2006) Hong Kong Physiotherapy Journal 24; 8-15; Skelton DA et al. (2014) Agility (CSP) Summer: 20

Exercise components:

• Weight-bearing/ impact

• Resistance/ strengthening

• Posture

• Balance

• Flexibility

• Functional activities

• 2-3 times weekly

Types of exercise to AVOID:

Undue compressive strain on the spine:

Spinal flexion

Spinal rotation, especially with loading

High risk movement patterns

High impact work (unless “fit”)

Brisk walking in fallers

Increasing load to fast with OA/RA

Sinaki & Mickelson (1982)

Ebrahim et al. (1997); Sherrington et al. (2011)

Progression - Equipment

• Start with body weight & functional

– Eg. sit to stands to break sedentary behaviour!

• Progress to weights or resistance bands

– Depending on safe use, availability

– Ankle weights (Otago progressed to 8kg!)

– Weight belts (body fixed)

– Bands (progress to black bands by 12 weeks!)

– Easily show participant the progression

• Progress (if willing!) to free weights / gym….

Support and Encouragement

A programme is more than a series of exercises

• Examples from successful falls and exercise programmes

• A range of strategies that support participants eg.

– Goal setting and self monitoring

– Overcoming obstacles and difficulties

– Educating the participant

– Highlighting successes

– Providing individual and group support

Consistent Messaging

• What they should feel in the muscle

– Warmth, slight shake, tension, NOT pain

• How they should feel the next day

– Feel they have used that muscle “never knew I had that muscle”

• How often and when to rest

– At least 2x preferably 3x times a week

– Enough that the next day (when you rest) you know you used those muscles the day before!

• Over time should be able to do more, with more weight/resistance and would have to do more to get the “next day” feeling!

Consistent Messaging

• You are never too old

• Pain is NEVER good but muscle discomfort after exercise is

• We need strong muscles to – Maintain independence

– Play with our grandchildren

– Care for someone

– Fight infection

– Protect our joints and bones

– Protect our brains and memory

– Stay warm

• Need to continue….. Use it or lose it!

Acknowledgment: John Sheerin

Questions

dawn.skelton@gcu.ac.uk

http://www.gcu.ac.uk/seniorsusp/

http://profound.eu.com/

Exercise and Osteoporosis Prevention and Management Guidelines

http://www.iofbonehealth.org/exercise-recommendations

http://www.csp.org.uk/publications/physiotherapy-guidelines-management-osteoporosis