Tricks of the Trade
Since older adults are so diverse in their abilities, fitness levels, health conditions and interests, it is not realistic to use one assessment battery for everyone. However, a thorough review of each older-adult client’s health status—including current health conditions, past surgeries/injuries, medications and goals—is appropriate. This information helps determine which types of assessments an individual may need, as well as which particular assessments to perform.
We prefer assessments that indicate functional ability, are quick and inexpensive to perform, and have been specifically validated for an older population. Assessments we routinely use include the 30-Second Chair Stand Test; the Eight-Foot Timed Up-and-Go Test; either the Berg Balance Scale (for lower-functioning clients) or the Fullerton Advanced Balance Scale (for higher-functioning clients); the modified Clinical Test of Sensory Interaction and Balance; a posture analysis; and basic information such as height, weight, blood pressure and body com- position. For fit clients, we use some standard fitness assessments typically used with younger populations.
It is important to perform multiple assessments that target different domains of function (i.e., strength, agility, balance, etc.) to obtain a well-rounded view of a client’s abilities. This may mean making some modifications. For example, sometimes a new client is so weak she cannot even perform a single chair stand without using her arms. Instead of giving her a zero (which is her official score) and making her feel defeated, we allow her to perform the test using her arms as a modification. This gives us a baseline score that we can use for comparison down the road. If she can do five chair stands using her arms now and 10 later, then she will have shown significant improvement.
We are blessed to have a physical therapy clinic in our facility. Many times, new clients have an orthopedic issue that is beyond our scope of practice to assess. In these cases, we refer clients directly to the physical therapist for an evaluation. They may begin a therapy routine that is independent of their fitness training, or the therapist may simply provide the trainer with guidelines to deal with problem areas. This collaboration ensures that clients are receiving the best possible care for their needs.
Cody Sipe, PhD
Co-Owner, Miracles Fitness
West Lafayette, Indiana
Every personal trainer has his or her own “tools” of the trade. However, I feel that recreating the wheel is not necessary. FallProof!™: A Comprehensive Balance and Mobility Training Program by Debra J. Rose, PhD (Human Kinetics 2010), is my go-to manual.
I have expanded the typical assessment to make it more complete. Here in South Florida, older adults walk barefoot, in sandals and in sneakers. They walk on sand, grass, tree roots and cracked sidewalks. I take these conditions into consideration and incorporate them into my initial training plan.
I ask a new client questions to help determine his risk of falling. For example: Has he previously fallen? Does he have impairments (visual, auditory, urinary, etc.)? What medications does he take (a huge risk factor)? What is his mental status? What, if any, ambulatory aids does he use? While he is relaxing and answering my questions, I take baseline blood pressure and heart rate data. I take posture photographs against a grid, and then we move on to the assessment.
Our typical assessment includes 15 tests for strength, endurance, balance, agility and flexibility. We alternate upper-body and lower-body tests to avoid fatigue.
We use several different assessments to assess fall risk and balance ability—the Romberg Balance Test is a common one. We retest with the client standing on a balance pad performing a tandem walk and then a one-leg stance on the floor and on a balance pad. Next, the client does an Eight-Foot Timed Get-Up-and-Go Test, as well as a standing-reach test first on the floor and then on a balance pad.
For flexibility of the lower body, we like the Chair Sit-and-Reach Test; for the upper body, the Back Scratch Test.
For muscular strength and endurance assessment, we do modified push-ups against a kitchen counter until fatigue or loss of form; arm curls for 30 seconds and for 1 minute, to determine strength versus endurance; and a sit-to-stand assessment for lower body, taking a count at 30 seconds and at 1 minute.
For cardiovascular endurance, we do either a 2-minute march (step in place) test or an actual step test with a 3-inch or 6-inch step.
It’s important to save the results of the assessments; however, we don’t compare results among clients. After 3 months, we retest to determine the effectiveness of the program. As an adjunct to the written scores, we take video or photographs of clients’ efforts. Sometimes clients don’t feel any different, but when we visually compare tests side by side—either from photographs or a video—the changes can be exciting for clients and/or their families to see. Someone other than the trainer should operate the camera during assessment, so that the trainer can ensure that clients stay safe.
Shari Kalkstein, PTA, CSCS
President/Owner, Fortify Your Frame Inc.
Cooper City, Florida
These days, older adults cover the whole spectrum of physical abilities. A thorough health history form will shed light on any medications a client is taking that might interfere with heart rate or blood pressure or cause other physical limitations. Of equal importance is our initial discussion when clients share how active they are and how confident they are in their physical abilities.
If clients haven’t been active recently and lack physical confidence, I begin assessing with easier physical tasks. If they’ve been exercising regularly and are confident in their physical abilities, I’ll start assessments at higher levels of difficulty. I recommend that all clients take each assessment exercise to his or her own perceived limits, which helps ensure people don’t go too hard or too fast or risk an injury on our first day.
When it comes to submaximal cardiovascular testing for older adults, it’s important to ramp up the intensity slowly, which gently encourages the joints to move. I enforce a strict 10-minute warm-up at a low intensity and then raise the intensity at 5- to 10-minute intervals, getting the client’s approval before making the increase. I ask clients to let me know when they’re at a perceived exertion of 8 on a scale of 1–10, and I note their heart rate and the highest level of exertion they achieve within their comfort zone.
For strength assessment, a few basic large-muscle-group movements are sufficient. For example, clients with no limitations could do a squat on a chair, with or without weight; a bench press; and a bent-over row. If clients haven’t been active, I’ll start them off with a smaller weight. If they’ve been active, I’ll start them off with more weight, aiming for a 12- to 15-rep maximum. If I don’t hit the mark the first time, I’ll increase or decrease the weight the second time. I have clients complete no more than three sets, to avoid overdoing it. I take note of any posture and alignment issues while clients are exercising, so that we can work on them during the course of our training. For the next assessment, we’ll use the highest weight clients completed and see how many more reps they can do.
Many older and younger adults alike don’t know how to activate the core muscles. The core mostly comprises slow-twitch muscle fibers and can handle more sets and reps than other areas; therefore, I have clients move from easy to hard exercises to find the most intense abdominal exercise they can do without losing form. For example, can clients activate their abdominal muscles (pull their belly in and up without holding their breath)? If so, can they do a simple leg-lowering exercise without hyperextending their lower back? Can they do a plank on their knees without drooping? How about a plank on their toes? For older adults with osteoporosis or osteopenia, the major concern is not doing movements that curl the spine.
When testing balance, I’ll have older adults stand next to a wall for support, if necessary. I time how long clients can stand with one foot on the floor. If this is too easy, I progress to varying levels of tree pose (foot at calf; foot at inner thigh; hands out to side, at prayer and overhead), noting how long they can hold each pose.
Like younger adults, older adults tend to sit for long periods, so flexibility tests for the associated muscle groups are important. A seated hamstring-stretch test is a good low-back and hamstring test. A client with osteoporosis can lie down in neutral posture and put a strap around her foot. The prone quadriceps stretch is an important assessment for the hip. For shoulder mobility measurement, the client stands with back and arms against the wall, palms facing up. She brings her arms up in a semicircle, and I note how high she can get her hands without lifting her arms from the wall or bending her elbows. Finally, a standing profile picture of the entire body is a great record of the client’s posture.
Building client-trainer trust is important. In my first conversation with a new client, I ask about the client’s health, as well as about family and hobbies, among other things. Since it’s important that clients feel comfortable doing new and challenging things, I explain during the assessment what we’re doing and why, and I do my best to help clients feel safe. Depending on how well they’re handling the assessment, we may cover half of the testing on the first meeting and save the rest for the second session, or we may get through the entire protocol in one session. Either way is effective.
After about 6 months of training, I use the same exercises to measure improvement.
Luci Gabel, MA, MBA
CEO, LuciFit LLC
San Francisco Bay Area and Washington, DC