Working with the older client: Part 1

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

Introduction
According to the 2012 Census, people over the age of 65 make up almost 14% of the US
population. That means there are over 43 million seniors (adults 65 or older) today, with the
numbers continuing to grow, reaching 70 million by 2030. This aging population creates a
unique opportunity for the fitness professional to work with. In this article, we will review
the effects of aging on the musculoskeletal system, learn simple functional assessments and
understand benefits of strength strengthening. In part 2, strength training guidelines and
programming for common aging conditions will be discussed.
Effects of Aging on the Musculoskeletal System
The aging process involves changes to various structures and numerous systems within the
body. Research has shown that skeletal muscles change with age, specifically type II, where
there is a decreased in these fibers, that atrophy over time, and decrease in size (Brunner et
al. 2007). Research has consistently shown that muscle strength decreases with age(Lindle
RS, Metter E. 1997). Physiologically it has been studied that maximal strength capacity
reaches a peak sometime around the second or third decade of life, and by the fifth decade,
begins a gradual decline(Peterson et al. 2010). The strength of people in their 80s is about
40% less than that of people in their 20s(Chiung-Ju Liu, 2011). The decline in muscle
strength is associated with an increased risk of falls and physical disability in older adults.

Functional assessments of older client

Balance tests
Assessing an older clients balance needs to be objective and not guesswork. There are many
tests available, but few are objective, measureable, and supported with research as the timed
up and go test and the sit to stand test.
1)Timed Up and Go Test
Use a standard armchair. Place the line ten feet from the chair. The score is the time
taken in seconds to complete the task. The subject is encouraged to wear regular
footwear and to use any customary walking aid. No physical assistance is given.
Give the following instructions:
Rise from the chair
Walk to the line on the floor (10 feet)
Turn, return to the chair
Sit down again

Figure 1. TUG test

Scoring: Persons who take 10 seconds or less to complete this sequence of maneuvers are at
low risk of falling. Persons who take >20 seconds to complete this sequence are at high risk
of falling(Bohannon, RW., 2006).

2)Sit to stand test

Have the client sit with their back against the back of the chair. Ask the client to stand from
the seated positing, counting each stand aloud so that the client remains oriented. Stop the
test when the patient achieves the standing position on the 5th repetition.
Scoring-Age Norms:
Age
60-69
70-79
80-89

Time(seconds)
11.4
12.6
14.8

Figure 2. Sit to stand test

3) Functional squat
The squat is a classic fundamental primal movement someone typically performs on a daily
basis. Whether it is to perform to pick something up or move something. The squat is a
movement that requires proper ankle and hip mobility, while stability is required at the knee
and lumbar spine. Understanding the functional anatomy and muscle recruitment is fundamental
when prescribing this exercise with any client.
!

Figure 3. Squat picture

Figure 4. Squat analysis

Movement Analysis:
As the body descends, the hip flexors concentrically contract with slight lumbar flexion,
while the knees undergo flexion, glute maximus and hamstrings eccentrically contract. At the
ankle, dorsiflexion occurs, where the anterior tibialis(concentrically contracts) while the
gastrocnemius eccentrically contracts.
Returning to an upright position(vertical), the opposite occurs. The hip flexors
eccentrically contract, there is slight lumbar extension, while the knee transitions from
flexion to extension. Hip extension occurs via the glute maximus, while the hamstrings
concentrically contract.

Ankle plantar flexion occurs with the concentric contraction of the gastrocnemius while
there is eccentric contraction of anterior tibialis.

Benefits of Strength Training for improving function in older adults

Muscles behind the movement

There are numerous benefits of strength training for older adults. However, it is important
to understand the muscles behind everyday movement. Large muscle groups, including
shoulders, arms, trunk, hips and legs, are important to perform activities of daily
living(ADLs) and are susceptible to the aging process, training should targets these muscle
groups. The latissimus dorsi muscle (assists with sit to stand). Glute maximus is a primary
hip extensor muscle involved in walking and climbing stairs. The hamstring muscles are
important in flexing the knee and extending the hip, which are involved in everyday activities
such as walking, sit to stand, and negotiating stairs. Glute medius and minimus muscles are
lateral stabilizers that are important for getting in and out of bed or car or stepping into a
bathtub.

Figure 5.
Glute
maximus
muscle

Figure 6.
Glute medius muscle

Research: Benefits of Strength Training and Balance

Strength training physiologically improves strength of bones and connective tissue, size of
fast and slow-twitch fibers, reduces blood pressure, improves blood flow with many more
benefits. Research has shown specifically that strength training improves gait
mechanics(Persch et al. 2009), reduces the risk for falls in the elderly (Karlson, MK et al.
2013, Trombetti, A et al. 2011, Sherrington et al. 2008 & Zhen-Bo, Cao, et al 2006).
Balance defined is defined as the ability to maintain an upright posture during both
static and dynamic tasks(Benjuya, Melzer, & Kaplanski, 2004). Maintaining balance
involves a complex interaction among the sensory, vestibular and visual systems.
Aging dampens reaction time and muscle strength impairing, in some people, the ability to
control a fall. In older adults, possessing lateral stability is a key contributor to maintaining
balance control. Lateral stability is controlled by both the glute medius and glute minimus
muscles (Orr, R., et al. 2008).

It has been shown there are several contributing factors that contribute to a person with
falling. One major factor is leg weakness, particularly in hamstrings and glute maximus.
Which has been commonly reported as an important fall-risk factor. Individuals exhibiting
this sign have 4.9 times the risk of falling than people with normal strength (Bird, L. et al.,
2009, & Rubenstein, 2006).
Studies by (Nolan, M et al. 2010 and Ozcan et al. 2005 and Moreleand, JD 2004) identify
that ankle mobility, specifically lack of dorsiflexion is another contributing factor for
increased falls in seniors.
Finally, several studies found that decreased plantar flexion strength is a contributing
factor. (Menz et al. 2005) examined 171 men and women with a mean age 80.1, had their
foot posture, range of motion, strength, and vision, sensation, strength, reaction time, and
balance examined over a 12 month period. Results: seventy-one participants (41%) reported
falling during the follow-up period. Those who fell exhibited decreased ankle flexibility,
decreased plantar tactile sensitivity, and decreased plantarflexor strength.
Additional factors including impaired proprioception (joint position sense), decreased
flexibility and fear of falling (Visual Analogue Scale) as risk factors for falls per the research.
Summary
Aging is inevitable. Falls can be prevented. Arming yourself with more knowledge about the
body will enable you to help your clients age gracefully reaching optimal health. A multicomponent exercise intervention program that consists of strength, endurance, and balance
training appears to be the best strategy for improving gait, balance, and strength, as well as
reducing the rate of falls in elderly individuals(Cadore, E., 2013).
Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS is the CEO of Pinnacle
Training & Consulting Systems(PTCS). A continuing education company, that provides
educational material in the forms of home study courses, live seminars, DVDs, webinars,
articles and mentoring, teaching the foundation science, functional assessments and practical
application behind human movement. Chris is both a dynamic physical therapist with 16
years experience, and a personal trainer with 20 experience, an experienced international
fitness presenter, writes for various websites and international publications, consults and
teaches seminars on human movement. For more information, please visit www.pinnacletcs.com.

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REFERENCES CONTINUED
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