Take an educated, purposeful approach when designing programs for a special population that is growing in size and needs focused attention.
The aging of our global population and the significant increase in numbers predicted over the next 20–30 years (Pew Research Center 2009) offers a unique opportunity and challenge for fitness professionals. When it comes to training older adults, we must look at what we’ve been doing, evaluate its effectiveness and move forward with ideas and methods that work. Personal trainers who are so determined to create the most effective and functional program that they compromise safety must change their approach if they want to continue working with this population.
It’s cruial that trainers fully understand the needs and conditions of older adults. Some trainers make no distinction between their 30-, 40-, 50-, 60- and even 70-year-old clients and use the same program for them all. The result is a routine that shifts erratically between safe and unsafe, effective and ineffective. On the other end of the spectrum are trainers who worry so much about injuring a mature client that they play it extremely safe, providing a virtually ineffective program. None of these approaches is optimal or even acceptable. As a personal trainer, how do you determine the most appropriate and effective methods for training mature clients?
The following seven principles of functional training for older adults emerge from empirical evidence and insights gleaned over years of working with a variety of older clients. This article also reviews some of the most significant research findings on the topic and provides practical recommendations in areas where the evidence is unclear or equivocal.
1. Assess, prioritize and train all components of function. Mature adults want and need to improve or maintain their functional abilities. However, it appears that traditional training methods, such as resistance training, may not be effective.
In 2001, Keysor and Jette published a paper with the provocative title “Have We Oversold the Benefit of Late-Life Exercise?” They critically reviewed 31 studies that assessed the effects of exercise interventions (strength, cardiovascular and flexibility) in subjects aged 65 and older. Analysis showed very strong post-training improvements in impairment-level factors, such as strength, joint range of motion, aerobic capacity and body composition. However, improvements in function measures—such as gait speed, chair rise time, stair climbing, balance and weighted-lifting tasks—were inconsistent and not as strong. The authors noted that the subjects who improved most on impairment-level factors were not necessarily the ones who improved most on functional measures.
Latham and colleagues (2004) took this approach one step further and analyzed only randomized controlled trials that used progressive resistance training (PRT)—considered the gold standard by many—as the intervention. All subjects were 60 or older. The findings confirmed what Keysor and Jette had suggested a few years earlier: while there was a large positive effect on muscular strength following PRT, the effect on functional ability was small to moderate. Latham and colleagues’ analysis: Strength gains do not equate to similar functional gains. More recently, an extensive literature review determined that there is limited evidence to show that PRT as a single intervention improves balance in older adults (Orr, Raymond & Fiatarone Singh 2008).
The above findings may surprise you. However, an adequate understanding of function puts these findings in perspective. Strength is not function. Strength is merely one (albeit an important one) of many components that contribute to functional ability. Consider the evidence for muscular power. The data consistently show that muscular power has a closer relationship with functional performance than does muscular strength. The evidence also reveals that power training is a potentially more effective intervention than PRT for improving function (Sayers 2008; Hazell, Kenno & Jakobi 2007; Porter 2006).
There are two reasons for these findings:
1. Many daily tasks rely on power for successful completion (e.g., stair climbing and rising from a chair).
2. Power is a combination of two functional components (strength and contractile velocity).
To significantly improve older clients’ functional performance capacity, you will likely need to address multiple components simultaneously. It’s hard to address a client’s individual needs without first assessing them. Therefore, you should begin each client’s training with a thorough needs and goals assessment. The results will show you which functional components to work on first and how to prioritize the rest.
Don’t fall into the trap of believing you must develop a “well-rounded routine” for your mature clients. Well-rounded routines may be fine for many populations, but older adults need a focused and prioritized routine. A basic PAR-Q may be sufficient for a 20- or 30-year-old-client, but when a client is over 50, or especially over 70, you need to obtain a thorough health history and discuss medical issues and training goals with the client. This information gathering will indicate which functional assessments are needed.
It is beyond the scope of this article to describe the bevy of assessments available, but ideally you will be knowledgeable and qualified enough to perform many different kinds of assessments that address the components of function. With the validation of new protocols (e.g., the seated medicine ball throw as a test of upper-body power), this area is continuously developing (Harris et al. 2011).
2. Make educated and thoughtful decisions. Fitness professionals have more training options than ever and therefore must prudently select methods, techniques, specific exercises, progressions, equipment and environments. If you do a proper and thorough assessment, this task becomes significantly easier. As mentioned earlier, the myth of the well-rounded routine is entrenched in our minds, and we may feel guilty if we don’t train every major muscle group or if we work a muscle but not its antagonist (e.g., biceps but not triceps). The client, however, is going to commit a limited amount of time to exercising. Why waste it by including movements that don’t serve a specific purpose according to the individual’s needs and goals?
The choices you make determine the client’s results. While there are some general similarities among mature clients, they are not all the same, so don’t stereotype them. In fact, this population is the most heterogeneous of any age group and brings to the table tremendous diversity in terms of functional abilities, chronic diseases, experiences and other factors. Cookie-cutter programs are therefore the least likely to be effective.
Besides believing the “well-rounded routine” myth and stereotyping clients, there are other obstacles that can get in the way of making purposeful decisions. One is using unstable surfaces—such as foam pads, balance cushions, wobble boards and BOSU® Balance Trainers—to make exercises “more functional.” When using this equipment, many trainers throw around terms like “core stability” without fully understanding what the terms mean. Although these devices have become popular, there is little empirical evidence to support their use with most populations, and researchers have identified several disadvantages to using them (Anderson & Brehm 2005; Brehm & Anderson 2006; Schilling et al. 2009).
Variation can serve an important function when it comes to bolstering retention and providing progressions, but don’t stress variety at the expense of consistency. Variety for its own sake is likely to backfire in the long term. You need to be able to explain precisely why you are including a particular exercise for an older adult and how you are asking the client to perform it (equipment, sets, reps, resistance level, speed, body position, etc.). Can you defend your choices with evidence or sound clinical/professional reasoning? If not, you are not making a purposeful decision and must return to your assessment and educate yourself on the needs of the client.
3. To prepare for functional demands, integrate movement patterns by training in all three planes. Life is three-dimensional. People reach, bend, lean, turn, twist, stoop and change directions constantly. We all continually face challenges in the frontal, sagittal and transverse planes. Why, then, are exercises for older adults so one-dimensional?
Are our bodybuilding roots still a heavy influence? While functional training methods and tools are becoming more popular, the majority of the industry still seems to focus on the aesthetic goals of younger clients. This means using machines or free weights to isolate individual muscle groups for maximum hypertrophy.
In addition, many still regard sarcopenia (age-related loss of muscle mass) as the primary enemy of function with advancing age (Tschopp, Sattelmayer & Hilfiker 2011). If muscle loss is the enemy, then it would seem the “cure” must be to maximize muscle mass gains through heavy resistance training (using bodybuilding methods and equipment). But heavy strength training is not necessarily the answer—there are other options.
One case in point comes from Joseph F. Signorile, PhD. In his recent book, Bending the Aging Curve: The Complete Exercise Guide for Older Adults (Human Kinetics 2011), Signorile explains the importance of using multiplanar exercises and describes an interventional approach for turning fitness gains into functional gains. He describes a periodized model in which a physiological training cycle is followed by a translational motor learning cycle.
The physiological training cycle focuses on improving primary components of fitness—such as strength, flexibility and aerobic capacity—through traditional methods. The translational training cycle focuses on increasing functional capacity through multidimensional motor-control tasks of increasing complexity. Strategies for increasing task complexity include using multiple joints, shifting to dynamic tasks, altering the base of support, adding object manipulation, using multiple directions and multitasking.
The basic stationary lunge is an example. During the physiological training cycle, the lunge can be performed in a typical manner, using dumbbells for extra resistance as needed, because the focus is simply on building strength in the lower extremities. During the translational motor learning cycle, the stationary lunge becomes more complex because now the goal is to improve motor control/coordination and “teach” the client how to use her newfound strength to complete functional tasks successfully. Complexity can be accomplished by making the lunge multidirectional; requiring the client to pick up and put down an object (such as a telephone book) with each lunge; or asking her to respond to changing verbal demands.
Given the growing evidence that PRT is not the optimal method for improving function, then utilizing a multiplanar approach to improve motor control and train additional components of function appears warranted.
4. Make isolation-type movements a supplementary or complementary component of the program rather than its primary component. It’s tempting to consider exercises in a dichotomous way: either/or, black/white, good/bad. Ask yourself this question: Are the biceps important in functional tasks? Without biceps strength, it would certainly be hard to pull a lawnmower or open a door. And lifting a jug of milk, carrying luggage (or virtually anything for that matter), vacuuming or even pulling on a pair of pants would become much more difficult or even impossible. Therefore, for someone who lacks enough biceps strength to perform these or other functional tasks, doing biceps curls is functional exercise.
What about doing leg extensions to strengthen the quadriceps? Or shoulder presses to improve deltoid strength? As discussed earlier, using isolated PRT techniques for individual muscle groups offers some benefits for combating sarcopenia, building strength and, to a lesser degree, improving function. So it’s difficult to conclude that these exercises are not functional. Rather, let’s view them along a functional continuum, with some exercises having a more distant relationship to functional performance and others having a closer relationship.
While you must always consider individual clients’ needs, evidence points to making multidimensional exercises that address more than one component of function the primary focus for your mature clients (Baker, Atlantis & Fiatarone Singh 2007). Isolation-type movements are best for improving the strength of a targeted muscle group, yet strength is only one of the components that you must address. Significant improvements in muscle strength don’t necessarily equate to similar improvements in functional performance (Latham et al. 2004). Therefore, it is advisable to use isolation-type movements when indicated.
For example, a client who struggles (or is unable) to rise independently from a chair is probably suffering from a lower-extremity strength deficit. In this case it is advisable to perform some isolation movements to build strength in the quadriceps, glutes, hamstrings and calves for a short period of time. As soon as possible, however, this individual should engage in exercises that develop proprioception, balance, center-of-gravity control, postural stability and visual and somatosensory feedback, which—if impaired—are also likely to limit the client’s ability to rise from a chair.
5. Have mature clients perform exercise movements in the seated position only when absolutely necessary or when it serves a specific purpose. Seated exercise interventions have proved to be inferior to standing (weight-bearing) exercise interventions in several areas, including mobility and balance (Vogler et al. 2009). Mobility is a critical component for the continued health and longevity of mature adults. Loss of mobility can lead to a downward “death spiral” of declining health and activity levels. It is also a critical component of life satisfaction for many mature adults.
Loss of mobility usually means loss of independence. Related to this is the risk of falling. Falls are a significant threat to the mature population and often lead to hospitalization, long-term care or death (Rubenstein 2006). Performing exercises in a standing, weight-bearing position whenever possible will help improve mobility and reduce fall risk. Let’s take a look at some of the many advantages that standing exercises offer over seated ones.
Standing uses many more muscle groups than sitting and is a more complex neuromuscular challenge that requires greater degrees of strength, proprioception, center-of-gravity control and postural stability. A recent literature review on effective balance training protocols (Sherrington et al. 2011) recommended the following as best practices:
1. Train and challenge the base of support (e.g., narrow stance, tandem stance, one foot).
2. Train center-of-gravity control.
3. Modify or reduce the use of the upper body (such as hands).
Of these three, training center-of-gravity control is the only one that can be addressed in a seated position—and the level of challenge is much lower than it is when standing. This isn’t to say that seated exercise doesn’t have its place. Like any other tool, you can use it judiciously to address an individual’s needs.
For example, seated exercises may be purposeful when
- a client is becoming fatigued;
- a client is not ready for higher-level progressions involving postural position or cannot adequately control center of gravity (e.g., seated marches or forward leans);
- the movement involves sit-to-stand transitions;
- you want to remove postural or other variables for teaching/instructional purposes or to maximize force production (e.g., strength and power gains);
- a client is frail and/or at the lowest end of the functional spectrum (e.g., in rehabilitation, in a nursing home) (Baum et al. 2003);
- a client has mobility impairments and you cannot adequately spot her (e.g., in a group exercise setting); or
- a client has a lower-extremity impairment precluding him from performing exercises in a standing position.
6. Order the training session components according to the energy level they require. Place more complicated, multicomponent movements earlier in the routine and less complicated, isolation-type movements later. During the course of a session, it is typical for energy and focus to wane as muscle and mental fatigue set in. With mature clients, a potentially dangerous scenario can ensue when this loss of energy and focus interacts with poor functional capabilities, with the result being greater risk of injury (discussed further in principle 7). The longer the session, the more likely that attention and performance deficits will occur.
Much of the personal training industry has moved to shorter 30- and 45-minute sessions instead of the traditional 60-minute session. This approach appears to work well with mature clients, for whom 60 minutes can be too long. Recognize that a decline in energy and focus is likely, and include dynamic balance tasks, gait variations, agility drills (ladder, dot, obstacles) and multiplanar movements in the beginning of the session. Leave isolated strength training, seated movements and floor-work till nearer the end.
Don’t confuse complexity with intensity. An isolated strength movement is not complex, but it can be very intense depending on the resistance challenge. Just because a movement is performed closer to the end of a session does not make the movement easier. The difference is that you are systematically removing variables from the equation to ensure success. For example, a standing dumbbell shoulder press on a foam pad relies on maintaining proper trunk stabilization and whole-body balance control in addition to working the deltoids. However, performing the same movement in a seated position with a backrest removes most of the postural stabilization and balance control so that more focus goes to the deltoids.
Note that when exercise takes place on an unstable surface, force production capabilities decrease because it takes more energy to stabilize the joints. Performing a squat on the floor allows the client to direct the majority of forces upward and maximize the weight lifted. However, performing a squat on a balance pad requires energy to keep the knees aligned and to keep the center of mass over the base of support (feet). As a result, the weight lifted decreases.
7. Maximize client safety and success by taking a holistic approach to training. When you take mature clients off selectorized machines and onto the floor to perform standing, dynamic, multidimensional exercises of increasing complexity, risk increases. Therefore, take appropriate measures to safeguard your clients.
As discussed in principle 1, always begin with an appropriate pre-exercise evaluation that includes a thorough health history and functional assessment. Just the knowledge that Jane has had a hip replacement, George has peripheral neuropathy from diabetes, William is unstable during lateral movements and Susan has poor vestibular input increases the chances of keeping them injury-free.
The primary concern is the likelihood of a fall. Many movements you teach will either rely on good balance (and stability) or challenge balance control mechanisms. A good trainer is always diligent about monitoring for the potential of a fall. Taking attention off a client to chat with someone or to watch television—even for a moment—can lead to disastrous results. Always be close enough to provide aid if needed and be in the position/direction in which the person is most likely to fall. For example, if a client is doing a stationary lunge with his right foot forward, then you need to stand to his right side because that is the direction in which he has the least resources for recovery. If he falls to the left, it’s easier for him to use both hands to stop his fall, and he might be able to step forward with his left leg. Other environmental factors to consider include the following:
- having enough space to perform the movement (including enough “stumble room” as a buffer)
- having adequate lighting
- reducing audio and visual distractions
- not allowing other exercisers to interfere
While you want to challenge your clients, it’s crucial to minimize risk by using solid teaching and motor-learning strategies. Break down complicated moves into parts. If a client is successful with the parts, then put together bigger pieces until she completes the full movement pattern. Don’t progress an exercise without first requiring the client to master its basic movements. Progressions implemented too quickly can lead to frustration, failure and, potentially, injury.
These principles may be difficult to adhere to, depending on the situation. The mature population is diverse in age, gender, functional ability, chronic-disease status, interests and concerns. Add to this diversity the varied environments in which we train (personal training studios, retirement centers, senior centers, homes, outdoors) and the available resources (equipment, pool, assessment tools) and it is unlikely there is any one ideal that can be universally adopted. However, these seven principles can serve as a valuable guide in helping you achieve better outcomes with your mature clients.