Dr. Phillips, Is it necessary to join a gym to do strength training? Are there effective strength training exercises can be done in the home, without expensive equipment? – Jane

Hi Jane,

Joining a gym for strength training does have some advantages. You usually have the benefit of attractive surroundings, well maintained equipment and trained personnel to provide instruction (although this can vary considerably in quality so ‘let the buyer beware’ (carpe diem!!). In the ‘best’ gyms you also have the opportunity to socialize and make new friends. The downside for beginners is that gyms can be intimidating – and of course you do have to pay that membership fee! The good news is that strength training can be done anytime and almost anywhere. In addition to the sophisticated equipment found in many gyms today, there is a whole range of strength training ‘equipment’ suitable for home use, ranging from rubber bands and tubing, vinyl covered dumbbells, and wrist or ankle weights that attach with Velcro fastenings. These can be purchased at minimal expense from sports outlets or even the sports sections of most large multi purpose stores. I have had much success in my research with this kind of equipment.

The Centers for Disease Control (CDC) have recently made available on the internet a publication entitled “Growing Stronger: Strength training for older adults”, which provides comprehensive guidance and instruction for those who wish to commence a strength training program. This publication has been produced by highly respected researchers in our field and the best news of all is that it may be downloaded free from the CDC website at http://www.cdc.gov/nccdphp/dnpa/physical/growing_stronger/index.htm

If you are planning to start a strength training program this publication would be a great place to start.

Dr. Phillips, I am an exercise physiologist and wellness director for a senior community. We are debating the merits of several different tools for fitness and functional testing for our population. Ideally it would be "standardized" enough to compare data from several sources, yet at the same time allow some customization of the tests to be administered. In addition, having a computer software to facilitate tracking of outcomes would be desirable too. Do you have any products or tools that you prefer and could recommend to us? - Thank you in advance, Dan

Hi Dan,

There are several functional tests out there that would seem to be in your interest area. I have listed three major ones below with descriptive information taken directly from their respective sites. All are well validated tools - the first one listed being my tool of choice – and the only one of the three that includes computer software to output results.

1. The Senior Fitness Test (Software, video and manual).
The Senior Fitness Test Software is a companion resource to the Senior Fitness Test Manual. The program will help you in tracking the test scores of older adults, comparing the scores to national norms, and printing useful reports on participants' functional fitness levels. It offers calculators and several options for reports that can be used in conjunction with the Senior Fitness Test - the answer to the need for a simple, easy-to-use battery of tests to assess the functional fitness of older adults. The test is safe and enjoyable for older adults, it meets scientific standards for reliability and validity, and it has accompanying performance norms based on actual performance scores of over 7,000 men and women between the ages of 60 and 94. The manual, video and computer software can be purchased from Human Kinetics publishers @ http://www.humankinetics.com/

2. The Continuous-Scale Physical Functional Performance Test (CS-PFP)
The CS-PFP is based on ordinary activities of daily life, performed at maximal effort within the bounds of safety and comfort. It requires standard conditions and utilizes a scripted dialogue. All tasks are quantified by time, distance, or weight. Each task is scored 0-to-100 based on an empirically derived range established from data gathered on older adults with a broad range of individual functional abilities. The test yields a total score (0-100) that is the average of five separate physical domain scores: upper body strength, lower body strength, flexibility, balance and coordination, and endurance. The test may be accessed @ http://www.coe.uga.edu/cs-pfp/cspfp_test.html

3. Short Physical Performance Battery (SPPB)
This test battery devised by researchers at the NIA assesses lower body function in older adults. A substantial body of research has been published on the predictive value of this test for future disability. A CD-ROM is available at the URL below though to date no tracking software has been produced.http://www.nia.nih.gov/research/intramural/edb/resources.htm

Dear Expert, I coordinate a program called Exercise for the Homebound. We supply in-home evaluation (social work, nursing and P.T.) and supply a volunteer Exercise leader to go into the home of the more frail homebound older adult to exercise side by side every week (2 or 3 times) to help them remain strong and increase strength). This program takes over where Medicare ends and absolutely helps to maintain functional fitness, reduces isolation and provides education while reducing re-hospitalization. My question is: "why are home heath care and doctors so resistant to this kind of prevention? I don't think the concept of prevention and wellness are understood by the community serving Medicare patients. Any advice?? – Lorna

Hi Lorna,

I suspect that everyone reading this website – and everyone involved with ICAA - is right there with you! I teach a Physical Activity and Public Health graduate class and coincidentally we discussed this very topic last week – without unfortunately coming up with any solutions! At present only about 3% of health care expenditures go towards prevention (Schauffler and Chapman. Health Promotion and managed care: Surveys of California’s health plans and population. American journal of Preventive Medicine, 14, 161-167, 1998). If this situation is to be improved at all, the answer, in my opinion, will be both political and financial, and perhaps more the latter! I am optimistic however that progress is being made, since more ‘financial bottom line’ data is becoming available. For example a recent RAND review of falls prevention programs examined the research evidence relating to their cost benefit and/or cost savings. The two recommendations of this report were as follows

1. There is strong evidence that falls prevention programs are effective at preventing falls, and therefore ways are needed to better integrate these programs into the current care received by seniors.

2. There is strong evidence to support adding a falls prevention rehabilitation program as a new Medicare benefit. Such a program would be eligible to beneficiaries who have fallen, and would encompass a multifactorial risk assessment with a supervised exercise program.

My advice therefore would be to gather information such as this from multiple sources, including your own participants where possible. Include, when available cost saving as well as ‘health saving’ outcomes from your facility, and continue to be an advocate. In a for-profit health care system, dollars make sense!

Check out the complete RAND report, downloadable as a pdf from

http://www.cms.hhs.gov/healthyaging/fallspi.asp?

Why don't insurance companies (medical or life) give incentives for people to be physically active? I see the smoking question all the time, and I have heard that weight may become a qualifier, but exercise seems to be overlooked. – Florence

Hi Florence,

This is another sweeping question similar to the one regarding prevention above! The argument against insurance companies reimbursing or providing some kind of financial incentive to become physically active is I believe, in part, to do with

  • The fact that this physical activity is a volitional behavior, considered to be entirely the ‘personal responsibility’ of the individual involved, and
  • The problem of verification of activity status – how do you define ‘active’ and how do you know the individual is and continues to be ‘active’. It’s a tough one!

On the positive side I do see corporate wellness programs offering free memberships, or incentives of other kinds to those who wish to become, or are physically active. However on a national scale I believe that unless and until the case for prevention and cost effectiveness/cost saving is powerfully made, the situation will stay much as it is at present. I am optimistic that this will be the case as I indicate in my answer above.

Dr. Phillips, If a person has osteoarthritis what are the positive and negative effects of strength training on arthritics? Where can I go for research information regarding this matter? – Judy

Hi Judy,

People with Arthritis Can Exercise!!! This is not just a motivational statement but the name of a well established and successful exercise program known as P.A.C.E. which includes both aerobic and strength training information. Check this and other great information out on the Arthritis Foundation web site @ http://www.arthritis.org/default.asp

Dear Dr. Phillips, At my residential facility, we have used the Rikli and Jones protocol for the effects of strength training for the independent Residents and have discovered remarkable outcomes. We are presently launching a program for Residents for the Nursing and Rehabilitation Center and the Alzheimer’s unit. We will be using NuSep, and Free weights for group exercise and individual exercise. It is a multidisciplinary project involving nursing, rehabilitation and fitness as facilitators. Some Residents are ambulatory, some non-ambulatory. We would greatly appreciate your advice on appropriate assessments for evaluating and measuring outcomes for physical function, mental health and quality of health. Thank you for your consideration. – Muire

Hi Muire,

I have provided some information on physical function/functional fitness assessments above. The three protocols I list are of course performance based, but in your situation it may also be appropriate to utilize some self-report outcomes in this area. A number of validated tools are available to assess physical function and health related quality of life – including aspects of mental health. I would also suggest assessing Falls risk in your facililty - and recommend Debra Rose’s recent book “Fallproof“ which provides a comprehensive guide to assessement and intervention. You may obtain this book from the Human Kinetics website @ http://www.humankinetics.com/ (go to site and enter book title in search field). I have listed the self report tools below. Your new program sounds great - Good luck!

1. Medical Outcome Study Short Form (SF-36) Tarlov AR, Ware JE, Jr., Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA. Aug 18 1989;262(7):925-930. Also @ http://www.sf-36.org/
NOTE: there are now also SF-12 and SF-8 versions of this questionnaire

2. The Sickness Impact Profile Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Medical Care. Aug 1981;19(8):787-805.

3. Late Life Function and Disability Instrument Haley SM, Jette AM, Coster WJ, et al. Late Life Function and Disability Instrument: II. Development and evaluation of the function component. J Gerontol A Biol Sci Med Sci. Apr 2002;57(4):M217-222.

4. Ferrans and Powers Quality of Life Index Ferrans CE, Powers MJ. Psychometric assessment of the Quality of Life Index. Research in Nursing Health. Feb 1992;15(1):29-3.

Dr. Phillips, I teach a balance class to senior adults at a large continuing care community in Springfield, VA where I emphasize strength training as a central pillar in improving balance. I quote all the statistics showing the value of strength training in general for seniors, but I have little data that show a direct correlation of strength training to balance improvement. Do you know of studies that provide compelling evidence of what strengthening the muscles will do for balance in the elderly? My students are particularly skeptical of the value of upper body strength training. Also, what are your favorite strength training exercises for improving balance? Thanks much! – Betty

Hi Betty,

Maintaining and increasing strength is clearly very important to ‘successful aging’ in older adults, but is only one of several contributing components to balance and falls risk, which explains the lack of a consistent and direct association between strength and balance improvement. Multiple systems contribute to balance; the sensory systems (vision, somatosensory, and vestibular); motor systems (which act on the sensory information) and cognitive systems (attention, memory and intelligence) which helps to interpret and adapt our responses. Since many older adults suffer from strength deficits of various kinds I am sure you have had much success with your current strength training program. If balance is your primary outcome however, I would suggest that you expand the parameters of your program to include assessment and interventions to impact other balance components. I highly recommend the recent book ‘FallProof’ by Dr. Debra Rose. I have just reviewed this book for the Journal of Aging and Physical Activityhttp://www.humankinetics.com/products/journals/submissions.cfm?jid=JAPA and found to it be the most comprehensive book on Falls Prevention I have read. It covers all aspects of assessment and intervention as well as providing questionnaires you can copy and use in your own program. I think you would find it a valuable addition to your program. It also addresses the importance of upper body strength (e.g. invaluable to maintaining balance when lifting and carrying objects whether moving or standing still). To answer your final question, I have no ‘favorite’ strength exercises, only appropriate ones (!) prescribed on the basis of a comprehensive pre-assessment.

Dr. Phillips, Alliance Rehab's SeniorFITness Program is a wellness program specifically designed to assist older adults improve their ability to perform daily activities and enhance their quality of life. We currently provide this service to residents living in Independent, Assisted, and Skilled Nursing Homes, as well as those who frequent community senior centers. We are presently serving over 7,000 seniors across 5 states, and we continue to grow. As a result of our interest in quality management, we have developed a Best Practice Standards Commitee which is designed to bring the best practice methods together from the industry literature as well as our own 79 delivery sites. As we work through our process of assessment, training, and wellness programming a few questions have arisen. Is there a well-accepted method for measuring muscular strength in the older adult which is safe, reproducable, and involves more than one muscle group. I am familiar with the Arm Curl test utilized in the Senior Fitness Test (Cal State Fullerton), but this represents only one component. We utilize Nautilus 2ST strength and Keiser strength conditioning equipment in many of our program locations with much success, but we are reluctant to perform Repetition Max testing since many of our participants are frail. Do you have any suggestions? How are you measuring Quality of Life changes in older adults participating in fitness / wellness programs? Is there an instrument you can recommend? Are there any videos for practitioners you might recommend which focuses on Yoga, Tai Chi, or Pilates instruction for the older adult? Thank you for your time and expertise in responding to my inquiries. I look forward to hearing from you at your convenience. Best of health. - Vic Arellano, Vice President, SeniorFITness Alliance Rehab, Inc.

Hi Vic,

Congratulations on your extensive programs for older adults. It sounds as if you are doing a great job! To answer your initial question, for measuring maximal isotonic exercise, the 1RM (and RM variations) is by far the most well accepted strength measure. Over the last 10 years or so I and many other researchers have used this as a maximal strength outcome measure in a wide variety of older adult populations - including with frail individuals – with no adverse effects. You don’t mention what kind of strength testing you actually use – but I assume from your comments that it is submaximal in nature.

An appropriate measure of strength will of course depend on your desired outcomes. If you are less concerned with ‘absolute strength’ (ie the RM approach) and more with ‘functional strength’ you have some alternatives. For example you could use grip strength which I have found to correlate well with functional performance or manual muscle testing, using a hand held digital dynamometer (try a Google search for a variety of options). I have also used chair stands as a ‘surrogate’ measure of ‘functional leg strength’. All of these would be reproducible and provide a measure of ‘strength’. Another alternative, though perhaps less reproducible, would be to utilize RPE (Rating of Perceived Exertion) as the outcome measure. In this approach you would empirically identify a fairly challenging (but non maximal) resistance which the individual could perform 10 times. Ascertain their RPE at the end of this set and again post intervention for the same resistance. In terms of quality of life I have found the SF-36 and its versions to be very appropriate tools – see my more detailed comments and additional references above. Good luck with your programs!

Dr. Wayne, I have long heard that one major downside of menopause is that muscles can no longer build up strength because there is no estrogen - is this true? – Maureen

Hi Maureen,

Decrease in Estrogen levels in women going through menopause certainly does accelerate both bone and muscle mass loss, particularly in the first few years after onset. This does not mean however that strength gains are not possible – on the contrary a substantial number of scientific studies have documented both muscle mass and strength increases following progressive resistance training programs. These effects have been reported for men and women even in their 90’s (See my study, Phillips & Hazeldene. Strength and muscle mass changes in elderly men following maximal isokinetic training. Gerontology. 42: 114-120, 1996 and that of Fiatarone et al. High intensity strength training in nonagenarians: effects on skeletal muscle. Journal of the American Medical Association 263: 3029-3034, 1990.). You should also check out the CDC book “Growing Stronger: Strength training for older adults” I describe above for more great benefits from strength training.

Hi Dr. Phillips, I am a sixty year-old woman and teach 3 step low-impact, moderate to high intensity aerobics classes and one high intensity spinning class a week. I also walk my dog at a moderate pace for about 40 to 50 minutes daily. I have noticed some discomfort in my knees lately and have been wearing knee support braces, which seems to help some. What do you recommend? Thank you, Sharon

Hi Sharon,

Difficult to be definite on this one with such little information. Your discomfort could be arthritis, or, considering the impressive amount of daily activity you and your dog are getting, it could be some kind of overuse reaction. My advice would be to get a referral to a sports medicine physician or physical therapist. Once you have identified the source of the problem, and perhaps its prognosis, you will have a better idea of the remedy.

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