Geriatric Strength Training What are we weighting for?

1. Geriatric Strength Training What are we weighting for? Michael L. Tuggy, MD Swedish Family Medicine

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

3. 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?

4. 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.

5. 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.

6. 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.

7. Big Bob’s Ballbearing Bananas Rollerskates & Floor Wax Inc

8. 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

9. What happens when we age to: • Cardiac output? • VO2Max? • Muscular strength? • Reflexes?

10. 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.

11. 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 < 3 mo.

12. Strength and the Aging Process (Con’t) • 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.

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

14. 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.

15. 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

16. 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

17. Swedish Family Medicine Study Biceps Triceps Gastroc Quad

18. Swedish Family Medicine Study (Cont.)

19. 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.

20. 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

21. 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.

22. 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.

23. 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

24. 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

25. “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.

26. Increasing intensity Principles of Functional Exercises • Static Balance - 3 planes • Dynamic balance - 3 planes • Lunges • Steps • Jumps • Hops Low High

27. Muscle groups for focused training • Upper extremity flexors and extensors • Shoulder girdle • Abdominal flexors and lumbar extensors • Thigh - quadriceps group • Calf- Gastrocnemius/soleus groups

28. “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.

29. 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.

30. “Yeah, Clem, I hurt. But y’ know, it’s a good kind of hurt.”

31. 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 ADL’s - extension of independent living for years.

32. 60 Active 40 Training effect VO2 Sedentary 20 Independence Level 20 40 60 80 Age VO2 Max and Independence Adapted from Shephard, RJ - 1993

33. Food For Thought Based on what we know, when should we start strength training? Target: Men and women in their 40’s - primary prevention of frailty.

34. 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.

35. Hey Doc,It’s Back!!