Presentation delivered by Chris Hattersley and Tom Maden-Wilkinson at the UKSCA Health and Wellbeing symposium.

1. STRENGTH TRAINING FOR
OLDER ADULTS
CHRIS HATTERSLEY
MSc Physio, MCSP
MSc S & C, ASCC, CSCS
@hattersley4
DR TOM MADEN-WILKINSON
PhD, Neuromuscular Function & Ageing
Senior Research Fellow, Sheffield Hallam University
@TMadenWilkinson
What the public health messaging should be

2. Muscle weakness & the ageing population is a
major public health concern!
The Problem
‘The problem is not the problem, what we are doing
about the problem is the problem’
But…

3. Background Information
• Over 65’s are the most rapidly
expanding population demographic
• At substantial risk of the age related
muscular disease sarcopenia
• Lack of strength is highly correlated
with limitations in daily living,
disability and early mortality
• Decline is initially neurological and
then structural
• Increasing emphasis on the healthy
100 year life span

4. Strength levels through the lifespan
• Decline starts at 45 with major drops at
65 and 80, accelerates more rapidly with
disuse and increases chance of disability
(Bell et al, 2016).
• ‘50% of the physical decline associated
with ageing is actually disuse atrophy
resulting from inactivity’ (Jette et al,
1999).
• 100,000’s of hospital admissions per
year for sarcopenia, osteopenia,
osteoporosis for the elderly (Cruz-Jentoft
et al, 2010).
• Covert and happens over many years -
‘saving for retirement starts in early life’.
45y point of
‘accelerated aging’.

5. Health care needs of our ageing
population
Report by Age UK highlights substantial ADL difficulties & comorbidity risk in older adults,
Meta analysis of 100,000+ over 65’s shows increased strength improves ADL performance

6. The Cost of Muscle Weakness
Cost to the individual;
• Associated with increased risk of functional
impairment, poor health-related quality of
life, physical frailty, premature death.
Health care costs;
• An average cost increase of £2707 for a
sarcopenic patient
• Estimated annual total cost = £2.5 billion

7. ‘Muscle strengthening maintenance
activities’
• A large emphasis is placed on ‘muscle
strengthening activities’ despite very little
evidence supporting these methods
• Low intensities that do not improve strength,
physical function or physiological reserves
• At best should be categorized as ‘muscle
maintenance activities’ and categorized in a
group with any general physical activity /
exercise
• Detracts from the evidence based message
that progressive resistance training (and
making this more accessible) should be the
primary focus

8. (Falsified) Muscle strengthening
participation rates
Only 12% of > 65’s meet aerobic & strength guidelines, and…
‘Some pursuits such as cycling, swimming, squash and football were also included
as muscle-strengthening, possibly leading to some overestimate of the number of
participants meeting the muscle-strengthening guideline’

9. The Real Problem
- Lack of routine strength testing / sarcopenia screening in the health
care system and health / fitness sector
- A major emphasis placed on ‘muscle strengthening maintenance
activities’ that have poor evidence
- Strength training not emphasised as the primary countermeasure to
prevent and reduce muscle weakness
- S & C professionals not included in muscle strength guidelines
- Know – do gap identified between research and practical
implementation
- Skills and resources gap between healthcare / medical and health /
fitness sector

10. The Solution
Test and Train

11. The case for strength testing
Identify Risk
- Sarcopenia screening (EWGSOP-2) to
identify those most at risk of adverse
outcomes
- ‘Red flag’ detection for those with
critically low scores
- Important in primary care and acute
setting, physio’s & GP’s
- Needs to be followed by intervention
Promote Strength
- Strength monitoring / norms to
promote high levels of strength
- The higher your score, the higher your
reserve of strength
- Examples provided with grip strength
and 1 min sit to stand scores
- Can use other measures 5RM etc

12. Key Research – Strength Testing

13. Muscle strength is a vital sign

14. How do we find those most at risk ?
Strength
Assessment
Muscle Mass
Assessment
Functional
Assessment
Grip
Strength
5 Sit to
Stands
DXA BIA Gait
Speed
Timed
Up And
Go
SPPB
400m
Walk
M < 27kg
F < 16kg
> 15
seconds
M < 20kg
Muscle Mass
F < 15kg
Muscle mass
<0.8
m/s
Score
< 8
>20s
> 6
mins
Cruz- Jentoft et al., Age and Ageing, 2018.
SARC-F
Questionnaire
Population level focus is needed
on these assessments.

15. Grip Strength Norms
Build the strength bank account!

16. 1 Minute Sit to Stand Test
- This is a useful test because of the norms, but go for grip strength + 5 sit to
stands or 5 rep max squat depending on ability (more of a maximum strength
focus).

17. The case for strength training
- Confers unique health benefits which reduce risk of all
cause mortality (Stamatakis et al, 2018)
- Primary countermeasure to age related chronic disease
(McLeod et al, 2019)
- Increased performance in ADL’s (Unhjem et al, 2019)
- Reduces osteosarcopenia risk factors and falls /
fractures (Kirk et al, 2020)
- Reverses disability in older adults (Liu & Latham, 2011)
- Primary method to prevent & reverse hospital
acquired deconditioning (Falvey et al, 2015)
- Highlighted as the most effective and easiest to
implement intervention to combat sarcopenia and
physical frailty (Travers et al, 2019, Dent et al, 2019)

18. Key Research – Strength Training

19. Strength training is for everyone
Key principle: Progressive training that targets specific adaptations
through increased loading and progression of exercises that are
appropriately modified for the individuals level of ability.

20. Evidence based older adult S & C
resources

21. Preventative Approach
- The problem of muscle weakness in
older adults is widely known and has
devastating consequences in later
life.
- An increased emphasis on resistance
training from middle age is required
to alter the trajectory of ageing.
- Build the strength bank account!
The higher your level of strength
and muscle mass, the bigger your
physiological reserve is.

22. Key Participation Factors
-Flexible delivery options, including different
places of delivery, home or gym, mixture of 1-1
or group sessions etc
-Ongoing supervision and support by a
knowledgeable instructor (doesn’t need to be
every session)
-Using inclusive terminology and avoiding
negative age-related stereotypes
-Role models, peer advocates and social
interaction
- Encouragement from health care & medical
professionals is a motivating factor for older
adults to engage with RT
‘Resistance training causes strength gains in older individuals, provided the training duration is
sufficiently long, regardless of the combination of other training variables’ (Silva et al, 2014)

23. Key Programming Factors
- Consistency, education, enjoyment
- Progressive resistance training with a
particular emphasis on lower limb
musculature
- Multi-joint movements that transfer to
functional tasks
- Exercises that are scalable and can be
implemented in a range of settings
- High effort, minimal dose approach
- Benefits can be achieved with only 1
session per week but are optimised with
≥2

24. Key Exercises
Warm up: balance, multi-directional, multi-level transfers, co-ordination
Stand /
Squat
Lift / Carry Step / Lunge Upper body
push / pull
E.g. Squat, leg press, sit to
stand, jump
E.g. Medicine ball /
powerbag lift, dumbbell
deadlift, farmers walks,
yoke carry
E.g. Step up, split squat,
lunge, mini band side-
step, hop
E.g. Seated row, pulldown
Chest press, press up,
shoulder press, MB chest
throw
Modify: Range of motion, plane of movement, repetition velocity, load, effort, type of resistance.

25. The Solution
• Routine monitoring of strength diagnostics throughout
the health care system and the health / fitness sector.
• Greater emphasis on progressive resistance training as
the primary method to increase muscular strength in
middle aged and older adults (and less emphasis on
‘muscle strengthening maintenance activities’)
• Targeted approach to put the key participation and
programming factors into practice
• Greater integration between healthcare / medical and
health / fitness sector to support increased participation
in strength training (referral pathways etc.)
• Educate clinical and non clinical practitioners, S & C,
physio, nursing, GP’s, care home staff, personal trainers
etc.
• S & C for healthy ageing / older adults included on degree
programmes for Sport Science & Physio courses
Test
Train