PT on the Net Research

Age, Function and Integrated Training


By the middle of this century, it is estimated that the number of Americans over the age of 65 will reach approximately 70 million (nearly one in five residents will be considered elderly). As America’s population ages, it is increasingly faced with the issue of mortality, longevity and quality of life.

Unfortunately, aging has come to be associated with degeneration and the limited functional ability of the elderly. However, research shows that musculoskeletal degeneration may not be entirely age-related and that certain measures can be taken to prevent functional immobility. Typical forms of musculoskeletal degeneration in the elderly include osteoporosis, arthritis (osteoarthritis), and low back pain (LBP).

While some researchers have demonstrated atrophy of specific musculature among patients who exhibit LBP, others indicate that degeneration of the skeletal structures is not a result or cause of LBP. In addition, obesity is related to a loss or degeneration of muscle mass. In fact, most of these degenerative conditions can be connected to a loss of muscle mass and/or strength in general.

This degenerative processes can lead to a decrease in the functional capacity of the elderly as defined by their strength and proprioceptive responses. Perhaps the most important functional capacity affected is that of ambulating (walking). The decreased ability to move freely in one’s own environment not only reduces the physical and emotional independence of an individual; it also can lead to an increase in the degenerative cycle.

Many people who exhibit one or more of these degenerative conditions may tend to shy away from known remedies such as resistance training out of fear of injury or feelings of inadequacy. Rather, they opt for convenient forms of relief such as walkers, wheelchairs or motorized carts. Although valuable tools in their own respect, these may not be the best remedy, or even necessary, and can further facilitate the degenerative process.

It has been demonstrated, however, that many of the structural deficits responsible for decreased functional capacity in the elderly (loss of muscle strength and proprioception) can be slowed and even reversed. Upon this premise, the following paper will accomplish the following:

  1. Define function
  2. Compare this definition to the abilities of the elderly population to construct a foundation for the necessity of proper training regimens
  3. Review the four areas of musculoskeletal degeneration as they relate to proper functioning
  4. Detail the effects of functionally integrated training on the degenerative process.

Function

Function is described as integrated multi-dimensional movement that requires proper proprioceptive responses to the environment. Proper proprioceptive responses involve the ability to accelerate, decelerate and dynamically stabilize forces upon, within and throughout the body. This ensures proper movement of the affected joints. Simoneau and Krebs demonstrated this in a study on gait analysis. They showed that elderly people with a history of falling had a decreased ability to effectively decelerate their momentum near the time their foot touched the ground. Therefore, someone is deemed functional if they posses the ability to perform all daily activities with proper proprioceptive responses (acceleration, deceleration and dynamic stabilization) to their environment.

Function and the Elderly

The ability of the elderly to perform Activities of Daily Living (ADL) decreases with age. In 1996, the Administration on Aging (AOA) demonstrated that more than one-third the elderly population reported limitations resulting from chronic health conditions such as arthritis, heart disease and diabetes. Furthermore, approximately 14 percent of the elderly population reported difficulty performing ADL, with 21 percent encountering difficulty with Instrumental Activities of Daily Living (IADL). Table 1 lists some of the common ADL and IADL for the elderly:

ADL

IADL

Bathing

Preparing meals

Eating

Shopping

Dressing

Managing money

Getting around

Using the telephone

 

Doing housework

 

Taking medication

Table 1

Many of the chronic health conditions experienced by the elderly result in an inability to effectively move within their environment. In other words, their functional capacity to properly ambulate is reduced. With the decreased ability to get around, the elderly often rely upon an artificial means of support (balance) for assistance. This compensation can facilitate their degenerative state much like a muscle will atrophy without use. By not using the body’s own support mechanisms, they begin to shut down, leading to an increased risk of falling.

Areas of Dysfunction

Experts have determined that four distinct musculoskeletal dysfunctions have an effect on proper function in the elderly. As previously discussed, these include osteoporosis, arthritis, and LBP. Each of these dysfunctions, either independently or when combined with one another, can have a profound affect on the functional capacity (ambulating) of the elderly.

Osteoporosis

Osteoporosis is most commonly associated with, and is most prevalent in, postmenopausal women. However, it must also be noted that the occurrence of osteoporosis increases with age in men as well. In either case, osteoporosis can have a deleterious effect on an individual.

Resulting from a decrease in bone mineral density (BMD), osteoporosis commonly affects the neck of the femur and the lumbar vertebrae. Located in the region of the body where all forces summate, these structures represent the core or center of gravity for the body. Decreased BMD places the core in a weakened state and thus, more susceptible to injury, such as a fracture.

Cummings et al point out that the risk of hip fractures doubles every five years in postmenopausal women over the age of 50. Furthermore, Lindsay notes that osteoporosis affects more than 25 million people each year, resulting in approximately 1.5 million hip fractures. Of these 1.5 million hip fractures, only 20 percent of the patients return to a normal functional status.

Obviously, a remedy is needed. One proposed solution is the introduction of resistance training to potential and current sufferers of osteoporosis. It has been demonstrated that individuals who partake in resistance training have a higher BMD than those who do not. However, resistance training has been shown to improve BMD by less than five percent. Some researchers believe that this does not represent an increase, which could prevent fractures from occurring. In fact, Courtney et al estimate that a 20 percent increase in BMD would be necessary to offset fractures. Thus, it has been suggested that incorporating training that focused on the prevention of falls, rather than strength alone, would be more advantageous for the elderly.

Therefore, integrated training regimens that focus on enhancing proprioceptive responses, which occur daily in unpredictable situations, might better facilitate the needs of the elderly. Simply put, training programs that emphasize balance and the ability to navigate within one’s own environment might produce better results. When combined with resistance training to increase BMD, these regimens would provide better balance (proprioceptive responses), enhancing ambulating in the elderly.

Arthritis

According to the AOA, arthritis (osteoarthritis) is the most common chronic condition among the elderly. Table 2 lists other chronic conditions and their frequency of occurrence.

Chronic Condition

Occurrence per 100 Elderly

Arthritis

49

Hypertension

40

Heart Disease

31

Hearing Impairments

28

Orthopedic Impairments

18

Cataracts

16

Sinusitis

15

Diabetes

13

Table 2

Research indicates that people exhibiting osteoarthritis have a decrease in strength and proprioception. Wegner et al have demonstrated that individuals with arthritis have a decreased ability to balance while standing. Slemenda et al notes that the loss in knee-extensor strength was a strong predictor of osteoarthritis. Furthermore, Hurley et al and O’Reilly et al show that patients with osteoarthritis exhibit increased muscle inhibition of their knee extensors. Simply, these patients were not able to effectively activate their knee-extensor musculature to optimal levels.

Balance (proprioception) and muscle strength are vital components of ambulating and therefore, any deficit in these areas could potentially negatively affect one’s ability to efficiently walk. Pai et al supports this claim in a study that showed a significant decrease in dynamic balance for elderly people with a history of falling.

It used to be common practice for arthritic patients to avoid strenuous exercise. However, research on the effects of training on the symptoms of arthritis has begun a conceptual revolution. Tufts University shows that a 12-week strength-training program provided relief from arthritic symptoms. Hurley et al demonstrates that a four-week training regimen, which included proprioceptive training, decreased muscle inhibition and increased muscle strength in patients with moderate muscle inhibition.

Low Back Pain

Low back pain affects 80 percent of the adult population. Research shows that LBP has a direct effect on postural stability (balance), specifically demonstrated by a deficit of balance on one foot. As proper walking mechanics constitute the ability to balance on foot,  it is easy to see the effect LBP can have on efficient ambulating.

Luoto et al notes that patients exhibiting LBP have deficits in motor sills and coordination in addition to ineffective coupling of muscles in the pelvic region. This has been supported by research on in the lumbo-pelvic region. Richardson and colleagues have noted the importance of specific co-contractions such as the transversus abdominis and multifidus in people without LBP. It has also been demonstrated that these co-contractions are not observed in patients with LBP.

Faulty recruitment (motor skill) of muscles such as the transversus abdominis is also shown in patients with LBP. This improper recruitment of stabilizing muscles lends itself to instability of the core and ultimately can lead to altered gait patterns. Herein lies the need for proper training regimens.

Research has demonstrated the effectiveness of proper training for the relief of and reversal of LBP. Risch et al showed that isolated movement involving trunk extension was effective in increasing strength and decreasing LBP. Hides et al have demonstrated the efficiency of a treatment protocol consisting of re-education of the core-stabilizing muscles rather than strength or endurance exercise. Relief using this protocol occurred within one week and was not related to hypertrophy.

Conclusion

Aging is often associated with musculoskeletal degeneration, which can greatly affect the functional capacity of the elderly. However, research has shown that musculoskeletal degeneration may not be entirely age-related.

Fielding points out that LBP becomes significant around the age of 35, not an age generally accepted as elderly. Suter and Herzog note that arthritis is a condition that may incur as a result of injury mechanisms and not necessarily as a result of aging. Perhaps one of the biggest contributors to musculoskeletal degeneration is sarcopenia (a decrease in muscle mass), demonstrated by Hurley and Hagberg to be a vital component to decreased function in the elderly.

It has been clearly demonstrated that degenerative conditions in the elderly can be reversible with proper training. However, research also points out that strength training alone may not be sufficient. Thus, integrated training may provide additional benefit.

Integrated training is necessary because of the nature of deficits associated with degenerative conditions. Researchers note a significant decrease in proprioceptive abilities in persons exhibiting one of these conditions. Meyers et al points to the notion that neuromuscular impairments to gait constitute a great risk in falling, as seen in the elderly. Wegner et al also demonstrates that balance and proprioception decreased in patients with arthritis. Luoto et al noted the decreased ability to balance on one foot in persons exhibiting LBP.

Training protocols that emphasize proprioceptive (neuromuscular) challenges (integrated training) have been suggested and implemented. These training protocols operate on the premise that exercise should mimic the functional challenges experienced in everyday living. Thus, they need to emphasize acceleration, deceleration and dynamic stabilization in all planes of motion. In turn, this establishes neuromuscular efficiency and proper motion.

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