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Issue 4

Table of Contents

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Evidence-based recommendations for resistance and power training to prevent frailty in community-dwellers

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • Frailty is affecting nearly 14% of community dwelling older adults every year and is posing a public health problem that can be managed better
  • Frailty is reversible with resistance and power training
  • Applying resistance and power training looks nearly identical to its application across other populations

 

To say that we have much to go over for Issue 4 is an understatement. We are going to delve more into the realm of age than we have prior, and we are kicking it off with our first article: Evidence based recommendations for resistance and power training to prevent frailty in community dwellers. This article attempts to and successfully outlines the issues with and concerns around frailty, not only on a personal level but also on a public health and community level as well. It doesn’t stop there though. It goes on (for 18 whole pages) to create a great resource that we are going to distill down here regarding what it is that we as clinicians and coaches can do to help those experiencing frailty.

Not only does it go over the burden that frailty brings onto a community, but it offers a solution in a big was regarding two things:

  • Resistance training
  • Power training

Let’s first start with a definition.

“Frailty: a reversible state of increased vulnerability to health related adverse events, including disability and mortality which occurs separately and faster than normal aging as a result of heterogeneous physical, psychological and social impairments with high within-individual variability.”

I’m sure as rehab professionals or coaches we can all think of someone or a handful of people that may have fallen into this category. It is a tough place for the patient to be and it is a tough place for those trying to help.

What this paper calls the Frailty Phenotype consists of 5 parameters or indicators of frailty:

  • Weight loss
  • Muscle weakness
  • Exhaustion
  • Slowness
  • Sedentary behavior

 

To be considered as someone who is currently experiencing frailty, you would need to check 3 of these criteria off to be considered frail. About 44 in every 1000 community dwelling older adults become frail every year with a mean incidence of 13.6%. The reason why we really don’t like to see anyone get within these parameters should be easy to spot, but I’m going to help clear it up.

They are at higher risk of:

  • Falls
  • Impairment in mobility
  • Disability in the activities of daily living
  • Incident hospitalization
  • Death

 

Not only that, but the move from robust to frail increases spending 101% including things like inpatient care, pharmacological therapy and nursing care.

 

 

Now that the crash course of frailty is out of the way, we can all agree it’s not great and generally and something to be avoided. So how does that work and if someone is experiencing frailty, what is it that we can do to help them? Let’s look back to the parameters of the Frailty Phenotype. When looking at them, one can’t help but notice that a lot of those things, actually most of those things would invariably improve with something like physical activity. Not only physical activity, but one of the slickest activities: moving weights!

This paper outlines not only resistance training (exercise in which muscle contractions are performed against or to sustain a resistance commonly at low to moderate velocity) but also power training (the capacity to generate force in a short time interval).

Resistance Training

“Resistance training is arguably the best therapeutic tool to improve frailty” – this paper

I know that I (Joe) am super biased as a regular lifter of weights and participant in moving things both quickly and slowly, but this paper really just serves resistance training up on a platter for my biases. Some of the papers that this one references boasts as much as 116% improvement in muscle power, 58% improvement in sit to stand performance, 9% improvement in muscle cross sectional area, 48% improvement in gait speed and 174% improvement in lower limb muscle strength.

What’s not to love here?

Frail people getting yolked is exactly what we need in today’s day and age.

The benefits don’t stop there though: Resistance training improved short and long term memory, attention/concentration, global cognitive function and dual task performance!

“But wait! There’s more!” – Billy Mays

Depressive symptoms also took a (smaller but still non-zero) hit when it came to resistance training:

  • “Depressive symptoms are significantly reduced after resistance training programs”
  • “Short resistance training sessions were more likely to ameliorate depressive symptoms”
  • “Physical exercise might improve autonomy and independence, thereby increasing a person’s self confidence to engage in social activities”

That last one is a biggie because low social engagement plays into frailty as well. You’ll recall that slowness, exhaustion and sedentary behavior are part of the Frailty Phenotype, so living alone, not talking to people, feeling without family support or staying home most of the time contribute to what is called Social Frailty. To wrap up resistance training, in theory at least, we know that it will improve muscle mass, muscle strength, bone density, gait speed, confidence, depression and independence. Who wouldn’t utilize this to the max? What is the max? Let’s get through the short section on power training first.

Power Training

The reason that the power section is shorter is that it has similar but slightly different effects on the human. It still utilizes resistance, just faster. Why focus on power? Well it turns out its quicker to decay than just strength itself.

  • “Muscle power declines earlier and faster and is associated with mobility tasks more closely that muscle strength”
  • “Lower limb muscle strength was reduced by 20-30% in middle aged women, whereas greater reductions (~50%) were observed in lower limb muscle power.

Not only does it go faster, but it’s also a better predictor of poor mobility compared to lower limb muscle strength. So now that we’ve gotten all of that great selling for resistance and power training done, we need to take a look at practical application. The main goal of Across The Continuum is to teach those who interact with people from pediatrics all the way to those who may unfortunately be experiencing frailty, programming and managing fitness follows the same formula, and we see that play out in this paper.

Just like every other athlete out there, this paper goes over the following:

  • Frequency
  • Load
  • Volume
  • Exercise selection
  • Training load

 

Frequency

The number of training sessions performed in a given period.

In the past we have talked about what’s called a dose dependent response or a dose response relationship. Simply the amount of benefit that one receives from physical activity is closely related to the amount performed.

“Greater muscle strength gains and improvements in more physical function tests have been observed with high frequency (2-3 days/week) RT protocols.”

That being said, this paper does make the distinction that something is better than nothing.

“Public health programs offering RT/PT once a week might provide substantial neuromuscular and cognitive gains.”

Although they do continue to say that to maximize things like physical performance and socialization that at least twice a week is probably a good idea. They even say that 3-4 days a week could offer additional benefits, but logistics and organizing (group sessions) get a little hairy. But they make a great point! If we are looking at someone who is doing nothing except existing in a cycle of sedentary behavior, catabolism, comorbidities and isolation, one day a week is going to be more than enough as a starting point.

Loading

The amount of weight lifted during the exercise sessions.

Now this section goes a couple ways:

High intensity is better than low to moderate intensity to improve muscle strength

  • We are invoking the Specific Adaptation to Imposed Demands (SAID) principle here. Mainly, they will develop better ability to produce a lot of force if they are producing a lot of force in training

 

Low to moderate loads should be used while performing power training as speed is going to be a main focus

  • High intensity power training may generate too much fatigue and hamper the attempts at performing on other exercises

Volume

The number of exercises, sets and repetitions performed during an exercise session.

Keeping with dose response relationship knowledge, surprise! More volume = more gains.

There is a distinction here just like in loading that if higher volume is either not appropriate or not available, “low volume resistance training may improve neuromuscular parameters.”

Exercise Selection

There is a lot more to consider than you might think when it comes to exercise selection. Or not. Maybe you’re a genius. If so, please email me for an intern position. The low hanging fruit, of course, what is the goal of the program? Considering we are aiming at a niche (frailty) the goal should be to get in as much activity as manageable without doing things like overshooting when they haven’t got a good chronic workload built up.

Also consider things like session time, equipment availability and patient physical and cognitive status.  There is a cue from this paper to focus mainly on closed chain, lower limb training because lower limb muscle strength and power seem to show a greater age related loss and are better predictors of mobility limitations than upper limb muscles.

Training load

This one is interesting as it seems to depend on cognitive status. They propose an interesting way to manage this.

Normally we would recommend something like the Rate of Perceived Exertion (RPE) which is a 0-10 (really 5-10) scale of subjective intensity. Zero being akin to laying on the floor, sedentary and 10 being maximum effort. But, they pose the idea that someone experiencing frailty may have cognitive change and may not be able to accurately rate what it is that they are feeling.

How do we remedy this?

Facial expression!

“Facial expressions have been proposed as possible methods to identify physical effort during resistance exercise. Changes in facial expression became more evident, according to exercise intensity and muscle fatigue.”

So if it looks (facially) like they are struggling, they probably are!

These authors were also nice enough to make a nice summary table for me to stick in here:

 

We talk until we are blue in the face about the importance of physical activity regarding morbidity and mortality and getting people doing as much as they can manage. If there existed any population that needed it (anything) the most, it would be frailty.

 

References:
  1. Coelho-Júnior, H.J., Uchida, M.C., Picca, A. et al. Evidence-based recommendations for resistance and power training to prevent frailty in community-dwellers. Aging Clin Exp Res 33, 2069–2086 (2021). https://doi.org/10.1007/s40520-021-01802-5

 

Heterogeneity in resistance training-induced muscle strength and mass responses in men and women of different ages

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • Men and women across all ages demonstrate similar responses to resistance training regarding muscle size and strength
  • There are large group variations between how men and women of the same age group respond to similar resistance training programs
  • Adjusting programs based on response should be done to make the most of the type of responder the athlete is

 

Keeping the benefits of muscular strength and size in the forefront of your brain, lets dive into the next study. This one will (thankfully) be a shorter read than the previous one, but the contents are just as interesting and helpful.

Our next article: Heterogeneity in resistance training-induced muscle strength and mass responses in men and women of different ages. It has a bit of age to it (only 6 years) but it focuses on and summarizes about 15 years’ worth of similar studies regarding the differences and similarities between ages and sexes regarding training adaptations. This study is what’s called a retrospective analysis, meaning that the researchers of this group have run studies in the past that contain information that can be applied to the task at hand.

That task being figuring out the range of human muscle responses to 20-24 weeks systematic and supervised resistance training regarding muscle size and strength in previously untrained younger and older individuals. If you didn’t get a chance to read the previous 10-page wall of text about frailty and the importance of slinging weights around, lets quickly revisit here.

“Muscle strength has been shown to be inversely associated with risk of mortality and cardiovascular disease.”

Also,

“Loss of muscle mass leads to a reduction in metabolic rate, and consequently gains in body fat.”

And finally,

“The significance of an individual’s ability to increase muscle size due to resistance training may ultimately influence multiple risk factors by enhanced insulin sensitivity and to counteract the deteriorating effects of sarcopenia.”

As you can see, it continues to be not only a good idea, but of high importance to gain and maintain muscle mass and strength through our years (attempting to avoid that Frailty Phenotype from the previous article). Looking at the methods of this retrospective analysis, they were able to include 287 subjects in the intervention group and 72 subjects in the control group.

They were placed into 3 different age groups: below 45 years, 45-60 years and over 60 years. The resistance training, they performed was between 20 and 24 weeks and included total body programs twice a week with at least 2 rest days between. Sounds familiar to the frailty resistance training programming recommendations. The control group was advised to continue with their normal low frequency and intensity recreational activity and to not perform any resistance training.

There is an unfortunately interesting thing that can confound findings in a control group like this. Mainly if they know that you are performing a study that you’re included in, and they tell you not to resistance train, there is some percentage of subjects in the control group that may put 2 and 2 together and figure out that there may be something good about resistance training that they are trying to find out, and start doing some anyway, despite being told not to.

So these different studies did different measures of muscle cross sectional area prior to initiating the 20-24 week protocols. The three methods (that almost all measured quadriceps cross sectional area) were ultrasound, MRI and DXA scan (whole body). Luckily they only used one method of measuring strength: horizontal leg press. They measured bilateral concentric strength of the hip and knee extensors and plantar flexors.

Time to tally the scores. What did they find?

Muscle strength

  • From pre to post resistance training, 1RM and 1RM/body mass ratio increased significantly in all age groups of trainees in both men and women
  • When all age groups were combined, relative 1RM in women was higher compared to me
  • Absolute change in 1RM did not differ statistically significantly between men and women
  • The highest responders of men gained 10-20% muscle strength
  • The highest responders of women gained 20-30% muscle strength
  • No statistically significant interactions were found between sex, age or sex and age regarding muscle strength responses to resistance training

 

Muscle size

  • Muscle size increased significantly in men and in women with no differences between them
  • No statistically significant interactions were found between sex, age or sex and age regarding muscle size responses to resistance training
  • None of the determinants investigated (age, sex, baseline and training induced changes in BMI, 1RM an 1RM/body mass ratio) predict resistance training induced change in muscle size

 

Take a moment to analyze the graphs below. We can see that all three age groups in change in muscle strength improved about 21%. We can also see that all three age groups in change in muscle size improved about 4.8%. Another thing to note here is how widely the variations between genders of the same age group swing and how similar the distribution between ages is in that same variation.

 

There are some people who responded robustly to these 20-24 week programs in all age groups and all genders, just like there were some people who not only didn’t respond well, but responded negatively to the point that they lost muscle strength and muscle size.  That’s not to say that they just don’t respond well to resistance training at large, but it’s likely that the program that didn’t work for these individuals just wasn’t for them, or they just aren’t on the high responder side of the bell curve regarding response to anabolic stimulus.

Where do we as coaches and clinicians come into play here? Adjusting programming and making sure that we are keeping up with our athletes and tracking responses over time. Building a relationship and open communication lines with athletes is of the utmost priority so trends in either a good or bad direction can be seen and received if noticed by either party.

 

References: