Hello and welcome to post 50 of Strength & Conditioning for Therapists – we’ve reached the half-century. Wahoo. I hope you’re still doing well and that you’re back to work. As a therapist or someone involved in exercise prescription I imagine that you’re pretty busy, or will be in the very near future. In your work have you ever questioned: is heavy strength training safe for older adults?

Commensurate with this COVID-19 epidemic we’re likely to have an equally large pandemic of deconditioning that will disproportionally affect older adults. As such I think it’s pertinent to address the topic of strength training in older adults. A question I get asked a lot (!) is if it’s safe and beneficial to perform heavy resistance training with older and potentially more frail individuals?

Exercise For Older Adults

I’m often asked about exercise prescription for older adults. People seem to be a little more confident and comfortable with exercise to improve cardiovascular fitness I feel by comparison to muscle strengthening exercise. Perhaps this is because loading older people has historically been viewed as ‘risky’ because they’re often perceived as weak and frail. To load them up with heavy training therefore might seem counterintuitive; we don’t want to cause injury do we?

Hmmm. When I first encountered this body of opinion en-mass (quite a few years ago now), I must say that it didn’t quite sit with me. A corollary of this position is that we progressively decrease exercise intensity as people become weaker and more frail? Surely not?! We don’t do this with athletes; can you imagine what would happen to performance? So why do this with older people?

Management Of Osteoarthritis

I ruminated on this a lot and then decided whilst I was in post in Edinburgh to do some research. I was leading a research collaboration between the University of Edinburgh, the Trauma and Orthopaedic Department of the Royal Infirmary and Queen Margaret University. It really struck me how much more we could do for hip fracture and knee replacement patients (and other cohorts) through targeted resistance exercise. Nothing rocket science, just simple strength training, in fact any resistance training.

Before conducting any interventions, I wanted to check how well we understood resistance exercise prescription in the rehabilitation literature. The result of this systematic review:

“Considerations of the Principles of Resistance Training in Exercise Studies for the Management of Knee Osteoarthritis; A Systematic Review”

was published three years ago and quite frankly I was shocked by my own conclusions. The results showed that the principles of resistance training were inconsistently applied within the exercise design and were inadequately reported. This means that although all of the 34 studies included explicitly cited their intervention was strength training, protocols varied from unloaded knee extensions against a rolled up towel; various exercises with resistance bands and weighted machine leg press. There was often limited or no measurement of exercise intensity and rest wasn’t even mentioned by half of the studies.

The Propagation Of Fear

If you’re interested in my critique of the literature and approach to exercise prescription, you can access the full paper here on ResearchGate. The main reason for mentioning this SR was highlight the rational used by some of the studies to justify sub-optimal approach to muscle strengthening. Low-intensity protocols eg. 50%-60% of 10 RM were used to “avoid the possibility of injury caused by excessive strain

I find this disappointing and quite frankly lazy. Sorry. But here’s why.

  1. I’m yet to find any scientific evidence that shows progressive strength training (remember we’re using load relative to each individual) carries significantly more risk of injury in older adults vs. the young. In fact there’s a wealth of peer-reviewed literature documenting the efficacy of progressive strength training programs even in the very elderly.
  2. This rationale for low intensity was indeed referenced. BUT to an unpublished dissertation written in Spanish, which didn’t even investigate the possibility of injury caused by excessive strain in older adults. That statement, therefore, wasn’t data driven.

Whilst absolutely students can be forgiven for anecdotes and non-data driven assertions, I would expect better from esteemed authors and accomplished scientists. To simply take verbatim an unsupported statement from a prior paper (and paper before that etc..) to shape the design of your main intervention for your randomised clinical trial seems somewhat inappropriate.

Don’t get me wrong, I’m definitely not perfect; I’ve had many manuscript and grant application rejections, peer-reviewed and (unsolicited) criticisms, which I’m open to and I really don’t know everything. But, I do know that this has hugely contributed to the rationalising of sub-optimal exercise prescriptions and the propagation of fear of loading those who need it most, and that really disappoints me.

Is Heavy Strength Training Safe For Older Adults?

RIGHT. Let’s get positive 🙂 or Get Physical. This video will cheer you up – nothing much to do with this post, but possibly the best exercise video ever made!

Anyways, thankfully (!) we’re now starting to see a greater volume of research exploring the benefits of resistance training in older populations. AND, it’s becoming a topic of conversation, which is great!

Save the critical review of different loading intensities, reps, to failure or not to failure for another time. In keeping with the theme of this post I want to highlight a study, which is a part of an ongoing major clinical trial from Prof Belinda Beck’s group called the LIFTMOR Trial. You may have heard of it and I’ve certainly mentioned it more than once before. If you haven’t let me give you a quick synopsis of this RCT (randomised controlled trial) and you’ll see why I’ve mentioned it in this post.

The LIFTMOR Trial

Title: “High-Intensity Resistance and Impact Training (HIIT) Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial”

Watson et al. (2018). J Bone Miner Res. 33(2):211-220.

Oh heck: “high-intensity“, “impact” – doing this stuff with osteoporotic women is a recipe for disaster, right? These people are surely too frail. These are some of the opinions I’ve previously encountered.

Methods

Participants: 101 post menopausal women (>58 yrs) with low bone mass. 20% reported an osteoporotic fracture within last 5 year which resulted from a fall. Randomly allocated to intervention (HIIT) or home-based exercise (CON).

Intervention: 8 months, twice weekly HIIT. Month 1 low load / body weight focussed on technique and familiarisation. By Month 2 all participants were completing: 5 x 5 at 80%-85% 1RM: of deadlift, overhead press, back squat, plus jumping chin-ups with drop landing.

CON: same duration as HIIT of home based exercise at 10-15 reps <60% 1RM of lunges, calf raises, forward raises and stretching.

Outcome Measures: BMD (bone mineral density) via DEXA. Physical Performance: Maximal isometric muscle force of lower limb and back extensor muscles. timed up-and-go test (TUG), 5 times sit-to-stand test (STS), functional reach test and maximal vertical jump test on a force plate.

Now just let me ask here … are you gulping, are you fearful; does even the assessment send you into a spin??? Well let me tell you not only was the HIIT programme efficacious with great compliance (mean 92%), there wasn’t a high incidence of MSK injuries. In fact there was only one adverse event reported, which was a minor lower back spasm in the HIIT group.

Results

So, what happened? I’ve tabularised most of the outcome measures for you below showing % improvement from pre- to post intervention. A minus (-) sign indicates scores got worse.

There were significant differences between groups in all of the above indices and yes, in favour of the HIIT intervention. There are some quite dramatic between group differences too. Check out the muscle strength scores – not surprising given the specificity of the intervention. Some benefits were even seen in functional measures (TUG, STS) and in BMD.

Summary

So, what can we say in answer to the question “is heavy strength training safe for older adults?” I think it’s a resounding yes, when done properly and progressively. And not just that, it can be blooming’ effective! Clearly this conclusion isn’t based on a single study, I’d encourage you to do a literature search of your own and see if you can find any further studies in the the elderly / older adults. You might need to use terms like maximal strength training, heavy resistance training etc. to bring up relevant results to evaluate. But I assure you, more and more studies are emerging.

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