Resistance Training for the Aging Adult: An Evidence Based Approach

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2 Resistance Training for the Aging Adult: An Evidence Based Approach Brent A. Alvar, Ph.D., CSCS*D, RSCC*D, FNSCA, FACSM Professor Associate Dean of Research NSCA Board of Directors Research/Academic

3 What is Evidence Based Exercise Prescription? Goals for the Talk 1. Convince you to use an Evidence Based Approach 2. Provide an example for Resistance training in Aging Adults

4 EBP Evidence Based Practice Exercise Professionals Incorporating the Best available evidence into the everyday training of clients Or A systematic approach to the training of clients based on the current best evidence from peer-reviewed research and professional reasoning. Based on the Needs Analysis English, K.L. et all (2012) SCJ

5 Systematic Process EBP is a systematic process that requires a conscientious and judicious search of available research to find the current best evidence for a given topic Not blindly following the experts Or base on casual readings or a few abstracts Continuous process requiring long term commitment Keeping an open mind

6 Search for evidence Professionals should not simply search for evidence, they must search for the best evidence. There will likely be supporting and refuting evidence Job is to uncover the best evidence It is continuous and may change over time ACSM Position Stands

7 Experienced professional reasoning The experience of a Exercise Professional is an integral part of the practice. For example with new techniques/programs Often there is no evidence or limited evidence Base the program on proven techniques Let professional reasoning fill the gaps

8 Needs analysis and specificity Program will only be effective if it is based on the needs of the client Programs that address these specific needs using the current best evidence, and professional reasoning when solid evidence is lacking will maximize program outcomes

9 EBP is a 5 step Process

10 Step 1 Develop a Question: Is performing 3 sets per exercise superior to performing 1 set per exercise over the course of an 8 12 week resistance training program for improving upper and lower muscular strength in recreationally trained athletes Specifically define the following: Population: Recreationally trained athletes Intervention: Resistance Training Program Comparison: Single vs. Multiple sets Outcome: Upper and lower body 1RM Time: 8 12 weeks

11 Dose Response for Volume Increase in Strength ( Effect Size) Trained Untrained Athletes Sets per Muscle Group

12 Step 2 Find evidence (Ovid; Ebsco; PubMed; Cochran Review; Google Scholar) Search peer reviewed articles; discuss with other professionals and academics Evidence Based Resistance training for older adults Reviewed over 1200 articles Utilized over 100 articles in the direct analysis Had two co author experts Combined 60+ years of professional experience Will be reviewed by two outside content experts

13 Step 3 Evaluate the evidence Weigh the evidence according to its reproducibility and potential for bias

14 Step 4 Incorporate the evidence into practice Decision should be based on the strength of available research evidence, athlete/client preferences, budgetary restriction and professional judgment Example multiple sets (how many is enough?)

15 Step 5 Reevaluate the evidence Stay abreast of the current literature to ensure that practices are aligned with recent scientific findings Example Static Stretching vs Dynamic Stretching Where are we? In a recent study 75% of D1 coaches (including certified coaches believed the preactivity group stretching prevented injury and 69.6% believe it improved performance (69.6%) In another recent study only 3% of coaches used Dynamic Stretching exclusively before practice. Why is there still a lag? Dose Response effect associated with decrease in force associated with SS (Kay et al systematic review MSSE) Judge, L.W. et al SCJ 2012

16 Resistance Training for the Aging Adult

17 Step 1 Develop a Question What are the evidence based guidelines to provide a synthesis of current literature regarding the influence of Progressive Resistance Training (PRT) for improving and maintaining health and functional fitness of older adults

18 Step 2 Find evidence Databases (Pubmed, Medline, Cochrane Evidence0Based Medicine, Health and pschcosocial Instruments, Cumulative Index to Nursing and Allied Health and SPORTDiscus) Keywords Resistance training, strength, hypertrophy, power, progressive resistance training and older adults 1271 documents were identified 101 articles were used

19 Step 3 Evaluating the evidence (areas considered): Background Low Levels of Muscular Strength and Power leading to functional impairment (Dynapenia) All Cause Morbidity and Mortality Cardiometabolic Consequences of Aging and Sarcopenia

20 Dynapenia Sarcopenia is the age related loss of muscle mass Age related loss of muscle strength is only partially explained by the reduction in muscle mass Dynapenia is the age related loss of muscle strength and power Manini & Clark J Gerontol A Biol Sci Med Sci Jan;67(1):28 40.

21 Lets take a look at some of the research How does Strength or Resistance Training translate into some sort of Health Related Benefits

22 Strength and Physical Function 3069 men and 589 women (30 82yrs) who received a clinical examination including strength evaluation at the Cooper Clinic between 1980 and 1989 Follow up after 5 yrs Brill, P.A. et al. (2000). Medicine and Science in Sports and Exercise 32 (2),

Strength and Physical Function Treadmill time 23.4 19.6 18.6 14.1 % Functional Problems 3.2 8.

23 Strength and Physical Function Treadmill time % Functional Problems Brill, P.A. et al. (2000). Medicine and Science in Sports and Exercise 32 (2),

24 Strength and Physical Function Study found that maintenance of strength throughout the lifespan may reduce the prevalence of functional limitation A threshold level of strength may be required to perform basic activities of daily living and to participate in activities designed to maintain cardiorespiratory fitness and physical function Brill, P.A. et al. (2000). Medicine and Science in Sports and Exercise 32 (2),

25 RT and Syndrome X Cardiometabolic effects of resistance training

26 Metabolic Syndrome What is metabolic syndrome? Coexisting risk factors that places an individual at high risk for all cause and cardiovascular mortality and for the development of diabetes Jurca, et. al., (2005). Medicine and Science in Sports and Exercise 37 (11),

27 Metabolic Syndrome Metabolic Syndrome was defined by having 3 or more of the following criteria: Abdominal Obesity (waist girth > 102cm [40inches ]) High triglycerides (TG) ( 1.69mmol L 1 [150 mg dl 1 ] Low high density lipoprotein (HDL) C (<1.04mmol L 1 [40mg dl 1 ]) High blood pressure (BP) 140mm Hg systolic or 85mm Hg diastolic or self reported hypertension High fasting glucose ( 6.1mmol L 1 [110 mg dl 1 ] or self reported diabetes Jurca, et. al., (2005). Medicine and Science in Sports and Exercise 37 (11),

28 Metabolic Syndrome #1 cont. Asymptomatic men aged 20 80yrs length of study Cooper Clinic in Dallas After excluding men with existing medical issues, 3233 men remained in the study Jurca, et. al., (2005). Medicine and Science in Sports and Exercise 37 (11),

29 Metabolic syndrome incidence rates across muscular strength categories P Linear Trend < (n = 1239) P Linear Trend <0.05 P Linear Trend < (n = 1249) 50+ (n = 745) Low Low-Moderate Moderate - High High Adapted from - Jurca, et. al., (2005). Medicine and Science in Sports and Exercise 37 (11),

30 Metabolic Syndrome Study #1 Conclusion Men in the highest strength category had a 34% lower risk of developing metabolic syndrome than men in the lowest strength category. Jurca, et. al., (2005). Medicine and Science in Sports and Exercise 37 (11),

31 Metabolic Syndrome Study #2 Men with high muscular strength have lower mortality rates both with and without the Metabolic Syndrome (MS). Study 8807 men (42.7+/ 9.6yrs) Muscular strength was quantified by combining body weight adjusted 1 repetition maximum measures for leg and bench presses. Jurca, et. al., (2004). Medicine and Science in Sports and Exercise 36 (8),

32 Prevalence of Metabolic Syndrome Low Low/Mod Mod/High High Low Moderate High Cardiovascular Fitness Quartile of Muscular Strength Adapted from - Jurca, et. al., (2004). Medicine and Science in Sports and Exercise 36 (8),

Summary Cardiorespiratory fitness and muscular strength were independently associated with metabolic syndrome prevalence in healthy middle aged men Muscular strength appears to

33 Summary Cardiorespiratory fitness and muscular strength were independently associated with metabolic syndrome prevalence in healthy middle aged men Muscular strength appears to add to the protective effects of cardiorespiratory fitness even among overweight and obese men Jurca, et. al., (2004). Medicine and Science in Sports and Exercise 36 (8),

34 Exercise Prescription Guidelines for the Aging Adult Evaluating the evidence

35 Frequency Evidence Based Guideline for the FREQUENCY of Resistance Training Exercise Recommendations REFERENCES EVIDENCE CATEGORY 2 3 days/week (87, 88) A1 2 3 days/week (89, 90) A2 2 3 days/week (40, 73, 74, 91 94) B1 2 3 days/week (95 97) B2 Overall Categorization for Frequency of Resistance Training Exercise = A1 Overall Recommendation = Engage in a structured progressive resistance training program 1 day per week and progress to 2 3 days per week as tolerated.

36 Intensity Evidence Based Guideline for the INTENSITY of each Resistance Training Exercise INTENSITY/REPETITIONS REFERENCES EVIDENCE CATEGORY High Intensity (3, 99, 100, 103, 104) A1 Between the 6 15 repetition Range (105, 106) A2 High Intensity (89, 100) A2 Between the 8 15 repetition Range (40, 91 94, 98, 101) B1 (8 12or10 15reps) Low progressing to High Intensity (73, 98, 101) B1 10 (96) B2 Overall Categorization for Intensity of Resistance Training Exercise = A1 Overall Recommendation = Begin with a weight or activity that can be done at least 8 times and progress to 15 repetitions, progressing from low to high intensity. Once 15 repetitions can be accomplished two sessions in a row increase the resistance (1 2lbs upper body; 2 4lbs lower body) or progress to a higher level exercise.

37 Volume Evidence Based Guideline for the number of SETS per muscle group or per Resistance Training Exercise SETS REFERENCES EVIDENCE CATEGORY Multiple (108, 109) A1 Single, but recommends Multiple for additional gains (110) A2 2 3 (89) A2 Single (40, 73, 101) B1 1 3 (91, 102) B1 2 4 (92, 94) B1 3 (96) B2 Overall Categorization for Volume (sets) of Resistance Training Exercise = A1 Overall Recommendation = Begin with one set of each exercise and progress to three sets of each exercise accordingly.

38 Rest Interval Evidence Based Guideline for the amount REST between sets is necessary for Resistance Training Exercise REST INTERVAL REFERENCES EVIDENCE CATEGORY 1 5minutes (111, 112) A1 1 2minutes (89, 113) A2 1 3minutes (98) B1 1 2minutes (96, 114) B2 1 3minutes (115) B2 Overall Categorization for REST between sets for Resistance Training Exercise = A1 Overall Recommendation = Begin with three to five minutes of rest between exercises to ensure recovery. Reduce the rest period as tolerated without negatively impacting desired number of repetitions per set. If specifically focusing on muscular hypertrophy, reduce the rest interval to approximately one minute or 30 seconds for muscular endurance.

39 Step 4 Putting it into Practice:

40 Warm up Warm up: 5 minutes of light exercises designed to prepare the participant for muscle conditioning and to improve overall flexibility. For example: begin with a light paced walk for a few minutes or as long as tolerated (up to 2 3 minutes) followed by some general range of motion (ROM) exercises. ROM exercises should be done in a slow and controlled movement pattern. The movement is meant to allow the muscles to activate and move the joint in a normal pain free pattern. This would be my Dynamic Warm up for Aging

41 ROM Exercises Examples of full body ROM exercises Ankle circles, Ankle flexion/extension, Knee flexion/exension, Hip abduction adduction, Hip rotation, Forward flexion, Wrist flexion/extension, Elbow flexion/extension, Shoulder flexion/extension, Shoulder abduction/adduction, Head to shoulder

42 Muscular Conditioning Muscular conditioning: 30 minutes of exercises designed to improve muscular strength, hypertrophy, power and endurance. Most of the exercises use body weight or light weights (hand held dumbbells or ankle weights with typical resistance of 1 to 10 pounds ) and are progressive in nature (i.e., participant advances to higher intensity exercises at their own pace, according to personal ability to tolerate the exercises and accommodate the increases in demand). Generally, these exercises are performed for one set of 8 to 15 repetitions each, progressing to three sets of 15 repetitions each. Rest period between sets can begin with 3 to 5 minutes and decrease without negatively impacting desired number of repetitions per set.

43 Program Design Program design: Each resistance training program should include one exercise per designated muscle group. There are a total of 11 different muscle groups in the outlined exercises. To design the program, begin with the first exercise in for each designated muscle group. The program should encourage one set of each exercise with a weight or resistance that allows between 8 to 15 repetitions.

44 Progression The following can be used as a general guideline for progression of exercise in this population: Begin with one preferably two days per week Perform one set per exercise at 8 15 repetition Increase to two sets per exercise session Begin with 3 5 minutes rest between sets Take enough rest between sets, so that fatigue does not have a negative impact on the desired number of repetitions per set Increase to three days per week Increase to three sets per exercise session Progress to next exercise

45 Variation Variation, or periodization, entails the systematic process of altering one or more program variables(s) over time to allow for the training stimulus to remain challenging and effective. Based on Hans Selye s General Adaptation Syndrome Most commonly volume and intensity

46 Program Design Calf Double Straight Leg Calf Raise Double Bent Leg Calf Raise Single Straight Leg Calf Raise Single Bent Leg Calf Raise Hamstrings Prone Leg Curl Standing Leg Curl Stiff Legged Deadlift Hip Abduction/Adduction Lying Abduction Lying Adduction Standing Adduction Standing Abduction Side Lunge Abdominals/Erector Spinae Modified Plank Plank Quadruped Single Arm/Single Leg Balance Side Plank Curl up Mid Back Scapular Wall Slide One Arm Dumbbell Row Bent Over Y s Bent Over W s Shoulder Joint/Girdle Standing shoulder scaption Standing shoulder abduction Shoulder press Bicep curl with Shoulder Press Quadriceps Muscles Supine Short Arc Knee Extension Knee Extension Chair squat Squat Lunge Glutes Double Legged Hip Bridge Quadruped Glute Extension Donkey Kick Single Leg Hip Bridge Hip Flexor Supine Single leg Hip Flexion Standing Bent Knee Hip Flexion Pectorals (Chest) Wall Push Up Chest Press Modified Push Up Arms Biceps Curl Triceps Kickback

47 Calf Exercises Double Straight Leg Calf Raise Double Bent Leg Calf Raise Single Straight Leg Calf Raise Single Bent Leg Calf Raise

48 Quadriceps Exercises Supine Short Arc Knee Extension Knee Extension Chair squat Squat Lunge orthocorept.com

49 Hamstring Exercises Prone Leg Curl Standing Leg Curl Stiff Legged Deadlift

50 Glute Exercises Double Legged Hip Bridge Quadruped Glute Extension Donkey Kick Single Leg Hip Bridge revivept.blogspot.com

51 Hip Abduction/Adduction Exercises Lying Abduction Lying Adduction Standing Adduction Standing Abduction Side Lunge

52 Hip Flexor Supine Single leg Hip Flexion Standing Bent Knee Hip Flexion bestdaybiomechanics.com patients.dartmouth hitchcock.org

53 Abdominals/Erector Spinae Exercises Modified Plank Plank Quadruped Single Arm/ Single Leg Balance Side Plank Curl up pedia.com

54 Pectorals (Chest) Exercises Wall Push Up Chest Press Modified Push Up fitvillains.tumblr.com

55 Mid Back Exercises Scapular Wall Slide One Arm Dumbbell Row Bent Over or Incline Bench Y s Bent Over or Incline Bench W s ideas.thenest.com

56 Arm Exercises Biceps Curl Triceps Kickback

57 Shoulder Joint/Girdle Exercises Standing shoulder scaption Standing shoulder abduction Shoulder press Bicep curl with Shoulder Press ohdarlingdays.co.za

58 How do you know you are making progress? Pick your assessment tool For example the Functional Fitness Assessment

59 Assessment of Functional Fitness Flexibility Agility and dynamic balance Coordination Strength and muscular endurance Endurance Evidence Grade C Osness, 1996

60 Flexibility Trunk/Leg Flexibility Test

61 Agility and Dynamic Balance

62 Strength and muscle endurance In a seated position, (chair should not have arms), and using the dominant hand, the participant grasps a weight (8 lbs. for men, 4 lbs. for women). Next, the participant flexes the forearm, bringing the weight upwards toward the shoulder until the forearm touches the bicep. The strength and muscle endurance score is the number of repetitions completed in 30 seconds. The participant is limited to one trial.

63 Endurance The participant walks an 880 yard measured course at a comfortable pace. The endurance score is the length of time required to complete the 880 yard course. The participant is limited to one trial.

64 Overall Assessment Flexibility: ASSESSMENT TIMES Pre PRT Time 1 Time 2 Time 3 Measure the number of inches reached to the nearest half inch for each trial (.0 or.5). The best trial is recorded as the score. Agility and Balance: Measure the time for each trial to the nearest 0.1 seconds. The best trial is recorded as the score. Co ordination: Score: Measure the time of each test trial to the nearest 0.1 of a second. The best trial is recorded as the score. Strength and Muscle Endurance: Score: Number of repetitions in 30 seconds. Endurance: Score: Length of time (in minutes and seconds) required to complete 880 yards.

65 Step 5 Reevaluate the evidence I would imagine that is why you are here Putting a label on what you are currently doing and giving you a framework to improve on your current practice.

66 Final Thoughts There is an inherent need for progression and periodization in resistance training if an individual desires continual improvements in strength. Progression in RT is dependent upon the development of appropriate and specific training goals and should be an individualized process This is no single one right resistance training exercise prescription, but use the Best Evidence (science) to base your programming

67 Thank you Feel free to contact me at : balvar@rmuohp.edu

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