Gene, a 77-year-old retiree, has been in quarantine for the previous 10 months. He was not comfortable leaving his house to go to the gym and has declined invitations to do virtual (online) training. Hence, Gene has lost significant muscle mass, has been prescribed increased quantities of medications for Type II diabetes and high blood pressure. Additionally, his wife reports she has seen his muscle mass, bone density and health rapidly decline. He has lost his appetite and his quality of sleep has also suffered. Gene was prescribed an anti-depressant by his primary care physician to address associated lethargy and depression.   

Joel, an 85-year-old male, has left his house a total of five times in the previous 10 months. Through his wife’s encouragement, he continued his at-home workouts and even increased the frequency of his sessions from two to three times per week once the quarantine moved beyond four weeks. During this time, Joel has increased his lean muscle mass, improved his balance and his wife reports his legs are ‘rock solid and his energy has never been better.’ 

While Joel exemplifies the benefits of maintaining an active lifestyle and improving his muscle mass while in quarantine, he is in the minority. Unfortunately, there are millions of older adults just like Gene who are experiencing the deleterious impacts of quarantine and the sedentary lifestyle on their physical as well as emotional health. This is such a vital and overlooked aspect of health because many older adults may never fully recover in the event they contract a life-threatening disease.

This sentiment is summed up succinctly by (English and Paddon-Jones 2021):

“Thus, with advancing age, it becomes increasingly likely that even a brief, clinically mandated period of bed rest could initiate a serious decline in muscle strength and functional capacity, i.e., a “tipping point” from which some may not fully recover.”

This article will discuss how the Medical Fitness Professional (MFP) who focuses on educating and empowering their older clients can positively impact those experiencing sarcopenia-related health issues. Also included will be a brief discussion about the barriers to exercise suggestions the MFP can implement to address these issues. Finally, MFP’s will be empowered to utilize an education-first strategy while positioning themselves to attract more individuals that will seek out their expertise. 

The Impact of Sarcopenia-Related Multisystem Deconditioning

Sarcopenia, or age-associated loss of muscle density and strength, is a major health problem even when not in a period of quarantine. The loss of muscle mass is associated with all-cause mortality including cardiovascular disease, diabetes, cognitive decline, depression and an increased risk of falls (Kirwan et. al. 2020). The average adult over 30 years of age experiences a 3-8% loss of muscle mass per decade (English and Paddon-Jones 2010). This means that a sedentary individual could literally experience between 9-24% loss of muscle strength and function by the time they reach 60 years of age. Furthermore, 71% of older American males and 42% of older American females present with moderate levels of sarcopenia.

Unfortunately, this problem is exacerbated by periods of forced inactivity, for example, while bedridden. Young adults can experience a 5-6% decrease in muscle strength per week when bedridden (English and Paddon-Jones 2010). Because older adults begin with less lean muscle tissue than their younger counterparts, they are extremely susceptible to multisystem deconditioning and the subsequent health issues associated with the loss of muscle, strength and endurance. 

Sarcopenia is extremely concerning in vulnerable populations (example: older adults) as well as those with comorbidities (example: those with cancer). Muscle atrophy, weakness and pain (myalgia) is even greater after a significant illness and corresponding bedrest. It’s been reported that .5-6% losses in muscle mass per day can occur increasing risk of deteriorating health (Casey et. al. 2021). A 1.7% loss of muscle mass occurs in as little as 2 days and 5.5% after only 7 days of bed rest (Kirwan et. al. 2021). Additionally, 50% of patients experience ongoing myalgia and associated weakness which can last months after recovering from COVID-19 (Casey et. al. 2021). Additionally, the loss of smell, taste and appetite after illness leads to further losses in muscle mass as well as nutritional deficiencies potentially leading to further deterioration of one’s health. 

The Sarcopenia Solution

While its etiology is multifactorial, decreased physical activity and poor nutrition are the two primary aspects contributing to the progressive loss of muscle mass in both the sedentary populations and those with chronic health issues (Kirwan et. al. 2020). Kirwan et. al. recommends that resistance exercise “…be considered of prime importance in attempting to halt and even reverse the progression sarcopenia.” Additionally, Web MD suggests that “The primary treatment for sarcopenia is exercise, specifically resistance training or strength training (downloaded from WebMD 2021). 

While the strength and conditioning industry has long recognized and advocated the benefits of resistance training, getting individuals to comply with the recommended daily activity levels has been a challenge. The challenges to older adults remaining physically active have only been complicated by quarantine. Several organizations including the World Health Organization (WHO) have provided suggestions for getting the recommended 150-300 minutes of vigorous-intensity physical activity per week. To achieve this number while in quarantine, WHO Europe suggests taking short, active breaks, indoor walking and following an online exercise program. 

Since quarantine has forced the closure of many commercial facilities and due to the fact that many older adults are reluctant to leave their house, online or virtual exercise programs have become increasingly popular. Online platforms including but not limited to Zoom, Google and Facebook make it easy to create small group meetings which provide a powerful tool for educating, providing guided exercise programming and increasing socialization, all of which are vital in combatting sarcopenia and isolation-related depression that occurs with prolonged quarantine.  

While historically it has been a barrier to exercising at home, novel equipment such as resistance bands make training at home both practical and functional. Resistance bands provide a low-cost option as compared to free weights (Kirwan et. al. 2021). While Sanchez-Sanchez et. al. (2019) found resistance bands did not provide as much benefit for older adults experiencing sarcopenia as compared to moderate to vigorous exercise, anecdotal finds report contrary findings. Progressive overload utilizing varying tensions of resistant bands and novel anchoring positions has been clinically shown to increase muscle mass, improve joint health and foster confidence in older adults when incorporated into an overall resistance training program (Osar and Linkul 2021). 

In addressing sarcopenia, the importance of nutrition cannot be overstated. High-quality protein (25-30 grams with each meal) to increase muscle mass is part of the lifestyle program recommended by English and Paddon-Jones (2010). Additionally, the consumption of nutrient-dense, calorie-sparse foods like roots, leaves, fruits and seeds can have a positive hormonal effect (Mattioli et. al. 2020) thereby improving mood and quality sleep, both of which are necessary to the overall health and vitality in older adults. 

Solutions to the 3 Greatest Barriers to Resistance Training

Finally, while the benefits of resistance training for addressing sarcopenia are obvious, it would be remiss to leave this article without including a brief discussion covering a few of the barriers to older adults participating in physical activity. One of the greatest barriers for many adults participating in a physical activity program is the reluctance to be proactive about their health care. In part, this is because older adults haven’t been properly educated about the vital importance and their responsibility in self-care. Additionally, even when properly educated, older individuals are rarely given specific instructions and/or directions to achieving success. 

Solution: In addition to the in-session education, the MFP looking to maintain their current clients and wanting to attract more individuals, should dedicate several hours per week to educating their community. Invite current and past clients to participate in a no-cost, regularly scheduled webinar, podcast or virtual training on a relevant health topic. Encourage them to invite their friends, family and colleagues. It is important that these events be education-based rather than focused on selling one’s services. Include at least one simple, actionable health nugget – a bodyweight exercise, mindset habit or healthy shake recipe, for example – that the participants can easily incorporate into their current lifestyle. 

Another important barrier for older adults is the reluctance to seek out a fitness professional because the fitness industry has largely catered their offerings to younger, healthier individuals. This has discouraged countless numbers of individuals from exercising and made it increasingly challenging for the MFP to differentiate their services from the general personal trainer that is often ill-equipped in training the older adult. 

Solution: The number one method for differentiating oneself and to enroll older adults is to highlight current client’s success. Highlighting a current client’s success eliminates the temptation to spend needless time discussing why one’s education is superior to someone else’s. For example, the MFP should highlight clients who can successfully garden or play with their grandchildren or hike because of the resistance training program they’ve been performing. Older individuals need to see, and will, in turn, be empowered by, seeing others just like them achieving success with physical activity programs. Seeing one their own age successfully accomplish things they would like to be participating in will help foster a natural curiosity. This curiosity can ultimately lead to a conversation where the MFP discusses how a tailored program can also help them accomplish their health and fitness goals. 

Additionally, Fitness Professionals like Jackie Bachmeier (Evolution Fitness and Wellness) and Robert Linkul (Training the Older Adult), both of whom cater to training the older adult population, deliver the specific equipment (including resistance bands, hooks and self-myofascial release tools) they want their clients to utilize during their programs. This removes an additional obstacle while adding huge value to the client. 

The third major barrier to online training are technology-associated challenges. While many have legitimate technology challenges, the resourceful and proactive MFP can help remove that obstacle and ease older adults’ in their online transition. 

Solution: Both Robert and Jackie have dedicated specific time to helping technology-challenged clients understand and develop the confidence in using social media and related platforms. While it may seem a hassle in the beginning, when they recognize the relative ease and benefits of online training, many older clients will enjoy the process and in turn encourage their family, friends and colleagues to join in. For example, Jackie’s 83-year-old client Lillian commented that had she realized how easy technology was, she would have done virtual training earlier. She’s since referred her husband and several of her friends to Jackie’s programs. 

Conclusion

Sarcopenia is a rampant problem in older adults, complicating existing health issues and leaving this population particularly vulnerable to prolonged periods of inactivity. Exercise, particularly resistance training, and nutrition are two components that show strong evidence in improving muscle mass, improving health and reducing the risks of all-cause morbidity. By focusing older adults upon the factors within one’s control – i.e., physical activity, nutrition and mindset – the Medical Fitness Professional are well positioned to be the solution for both their current as well potential clients. By addressing the three major barriers to being physically active, the MFP can help their current clients regain their health and, in the process, differentiate themselves and attract more individuals that need, want and will pay for their expertise. By adopting these best-practices, the MFP can successfully position themselves as a major player in the solution to the sarcopenia dilemma.  

Dr. Evan Osar is a Chiropractic Physician, an adjunct faculty member with Rocky Mountain University of Health Sciences (Motor Control) and educator with the Integrative Movement Institute. He has authored “Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction” and Amazon #1 Best Seller, “The Psoas Solution“. He developed the Integrative Movement System™, an evidence-based approach to improving clinical outcomes and helping patients perform at their highest level. Dr. Osar is currently in private practice in Chicago, IL and educates health and fitness professionals that specialize in posture, corrective exercise and medical fitness for the older adult population. 

References

Casey P, Ang Y, Sultan J. COVID-19-induced sarcopenia and physical deconditioning may require reassessment of surgical risk for patients with cancer. World J Surg Oncol. 2021 Jan 11;19(1):8. doi: 10.1186/s12957-020-02117-x. PMID: 33430881; PMCID: PMC7798369.

English, K. L., & Paddon-Jones, D. (2010). Protecting muscle mass and function in older adults during bed rest. Current opinion in clinical nutrition and metabolic care, 13(1), 34–39. https://doi.org/10.1097/MCO.0b013e328333aa66

Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss. Geroscience. 2020 Dec;42(6):1547-1578. doi: 10.1007/s11357-020-00272-3. Epub 2020 Oct 1. PMID: 33001410; PMCID: PMC7528158.

Mattioli, A. V., Sciomer, S., Cocchi, C., Maffei, S., & Gallina, S. (2020). Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease. Nutrition, metabolism, and cardiovascular diseases : NMCD, 30(9), 1409–1417. https://doi.org/10.1016/j.numecd.2020.05.020

Osar, E. and Linkul, R. (2021). The Arthritis Training Solution 2.0. Training the Older Adult Live (Virtual). 

Sánchez-Sánchez, J. L., Mañas, A., García-García, F. J., Ara, I., Carnicero, J. A., Walter, S., & Rodríguez-Mañas, L. (2019). Sedentary behaviour, physical activity, and sarcopenia among older adults in the TSHA: isotemporal substitution model. Journal of cachexia, sarcopenia and muscle, 10(1), 188–198. https://doi.org/10.1002/jcsm.12369

Web MD. Sarcopenia with Aging. Downloaded 2/15/21 from https://www.webmd.com/healthy-aging/guide/sarcopenia-with-aging

World Health Organization. #healthy at home. Downloaded 2/15/21 from  https://www.who.int/campaigns/connecting-the-world-to-combat-coronavirus/healthyathome?gclid=EAIaIQobChMItpfrsInt7gIV7vLjBx1pAwf0EAAYAyAAEgKgTfD_BwE

World Health Organization (Europe). Stay Physically Active During Self Quarantine. Downloaded 2/15/21 from https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/publications-and-technical-guidance/noncommunicable-diseases/stay-physically-active-during-self-quarantine

In a previous blog, Core Exercise, Part 1: Fad, Fashion or Fundamental?, I proposed that core exercise is not just about training the abs since the core is a more integrated, comprehensive functional unit that simply includes the abs as one element. In Part 2, I want to stress how the abs actually function – not based on EMGs or ultrasounds – in doing movements we train with in the gym that correspond to real life.

Motivated by an article in Women’s Health, “17 Back Exercises Every Woman Should Add to Her Workout ASAP“, I was pleasantly pleased to see exercises listed with a by-line that said “It’s not all about the abs, you guys”. The thrust of the article and exercises was that the back is important, too. I’d add that the back is MOST important and that anything you do to strengthen the back, especially with some of the unilateral exercises described, is even BETTER for the abs than crunches.

While some of the exercises were simply simple adaptations of traditional exercises, such as the overhand and underhand bent over row, or were clearly aimed at the anterior core – the abs – they highlight the message I often bring to my sessions with clients.

AS A PERSONAL FITNESS TRAINER, IT’S MY GOAL TO PROVIDE SAFE AND EFFECTIVE EXERCISES THAT ENHANCE A PERSON’S HEALTH, WELLNESS, AND FUNCTION.

With this mission statement, first and foremost in my mind when I approach a training session with whomever at whatever stage of health or fitness they are in, my goal is to train them to move and perform ADLs or recreational activities with less strain and stress to their bodies. Especially their spines!

Recognizing that many come in wishing to do something about their guts, I comply with some abs-specific exercises when they are ready for them. But first I aim to train the core as I defined it in the Part 1 blog.

Let’s, for now, leave out of consideration the person with a low back issue such as a ruptured disk or chronic low back pain (LBP). These kinds of issues require gentle step-by-step approaches akin to physical therapy-type exercises before venturing into real-life functional exercises just to get the core working. Which leads me to my framework for working the core, but really any muscle.

There are 5 layers to muscle function:

1. activation
2. endurance
3. strength
4. power
5. speed

Activation is a neuromuscular bioelectrical event whereby an exercise causes muscles to engage – that is, to fire – so that they learn or re-learn how to do what they were supposed to do. Imagine a stroke victim unable to move a toe. It is the essence of core stabilization. If therapists can get the person’s focus on moving the toe, and the toe actually moves again, that means nerve signals went from the brain down the spine and into the legs all the way to the toe. When the muscle receives those signals, even though it’s been weakened by the stroke itself, it starts to twitch. When the twitch becomes large enough, it fires enough fibers to make the toe move… even a little.

When it comes to core exercise, first we want the muscles to get engaged, to fire, but not to generate movement – that is, to first do an isometric hold. So, for example, taking the bent over row as a case in point, by bending over, with both feet on the floor and one hand supported on a bench or chair, the other holding a weight, the core engages to prevent rotation toward the side that holds the weight. In other words, almost every muscle of the core is activated even as you focus on bringing the weight toward the ribs. Take the support arm away and now the core is super-activated as it now has to support the upper torso plus the weight(s). It’s not a back exercise anymore, it’s a total core exercise as even the abs engage to stiffen the spine against the pulls of gravity and of the lumbar erectors.

Endurance is the next phase of training. This doesn’t mean simply running for miles on end. It means that a muscle can be activated and engaged for longer periods of time than simply to make any particular movement. This entails multiple repetitions (reps) and sets and even exercises that target that muscle. This is initially done with lower resistances so that the exercise is learned properly and all moving parts and stabilizing parts are able to do their jobs properly.

When it comes to core endurance, we often do high reps of crunches or bridges and call it a day. But the reality is our core works even while sitting, especially while standing and most importantly while moving. Thus an exercise that engages core muscles in functional positions or patterns of movement is more functional than one that isolates one section at the expense of others.

For example, taking the alternating bent over reverse fly (#14 of the article above), we see a long lever arm moving outward to the side as the trainee tries to stay parallel to the floor. Each subsequent movement by each arm applies a torque to the core that tries to bend and twist it. Doing multiple reps actually trains the core to stabilize for a long period of time, more so than if you do both arms at the same time. For one thing, the anti-rotation component doesn’t exist to the same degree in the bilateral move as it does in the unilateral. For another, assuming you can do the same number of reps with a particular weight whether bilateral or unilateral, the time under tension is longer for the alternating reverse fly; almost double if not more. (One could argue that you could even use a higher load as you have more rest between reps doing one arm at a time.)

Strength is the ability to apply force… or resist load. This entails lifting heavier weights in order to optimize one’s ability to apply a lot of force. Usually, this is measured as a function of %RM, or percentage of maximal repetition. That is, if you can curl 30# one time, that is your 1RM; if you can do it 10 times, it’s your 10RM. Thus, if you do 15# curls, you are training at 50% of your 1RM.

The other way to look at it is by how many reps you are able to do. If you can do more than 12, you are essentially training endurance as you are now working below 50% 1RM. It is recommended you lift at loads that actually fatigue you anywhere from 8 to 12 reps to get strong.

AT THE LOWER END OF REPS, YOU ARE GETTING STRONGER WHILE AT THE UPPER END YOU’RE CLOSING IN ON ENDURANCE.

For the core, even though it’s just another muscle, the break point could endanger the spine so it’s usually not recommended to hit with high loads. That said, many exercises we do in the gym do actually involve the core at extremely high loads and never require isolating it. For example, a low-rep, high-load squat or power lift engages the core at extremely high load even though we tend to observe the legs or arm movements. But we could also do a standing cable row with a very heavy resistance which would fatigue the upper body in 8-12 reps but recognize that the core is also heavily challenged, making this an effective strength exercise for the core itself.

Power is the ability to produce lots of force quickly; it’s a function of speed but does not require actual speed. When the body tries to move quickly but the resistance prevents it, you’re engaging muscles, especially fast twitch, white fiber muscles, to produce speed, but the weight slows you down. Watch a powerlifter and you’ll note that he/she is hardly moving fast but is trying to do so with great effort. Now that’s power!

For core power, something as simple and basic as a squat and curl on the way up, assuming the resistance is greater than you could lift if you were simply standing or sitting down, would engage the core muscles rapidly in order to stiffen the spine. Likewise, a push-press, which is a shoulder overhead press performed off a partial squat, with speed, would constitute core power. The muscles that stabilize the lumbopelvic region would have to engage rapidly to propel the weights upward from the shoulder, then would have to contract isometrically very quickly to stabilize the spine against any backward bending resulting from the momentum of the weights from in front of the center line to on or behind it. If done with one arm, now you have to resist a lateral bending force on the core, too.

Finally, there’s speed, the ability to produce a high velocity movement. We know speed when we see it, in running, biking, etc. but in resistance training, we are often put off by it. The ability to move a light load very fast actually puts the joint in a dangerous position. Going back to the article, there are two exercises that should not be done fast: #4, the Good Morning, and #15, the Stability Ball Back Extension. I prefer to think of these as endurance exercises, maybe shifting into strength, but not power or speed.

But how could we do a core exercise to simulate speed? My preference is for the tubing torso rotation, especially with a controlled stopping point. As this video shows, with a modest resistance, you can move quickly. However, I would suggest stopping at 45 degrees past the mid-point as the resistance declines rapidly beyond that; thus there’s no counterforce applied by the tubing as the spine approaches the terminus of the tissues themselves. Nonetheless, you can see how, with slightly more resistance and with a controlled end point, core speed could be trained here.

Which brings me to the end.

In sum, core training is not muscle-specific. It involves, includes, entails and integrates many of the muscles we associate with the core. It takes into account the various elements of muscle training, from activation to high speeds, from endurance to power. Core training does not require, in fact, I’d say it actually is violated, by isolation exercises except where the person’s initial status requires it.

CORE TRAINING IS NOT A FAD, NOR IS IT A SEPARATE PART OF A WORKOUT SESSION. IT CAN BE PART AND PARCEL TO ANY IF NOT ALL EXERCISES SIMPLY BY DOING THINGS ON ONE LEG, WITH ONE ARM, WITH RESISTANCES COMING FROM VARIOUS DIRECTIONS (GRAVITY-DOWN, CABLE OR TUBE -HORIZONTALLY OR DIAGONALLY).

Core is neither a fad nor a fashion, it is fundamental, and now you know why and what-for to take your training to the next level.

Originally printed on stepsfitness.com. Reprinted with permission. Images courtesy of STEPS Fitness.

Dr. Irv Rubenstein graduated Vanderbilt-Peabody in 1988 with a PhD in exercise science, having already co-founded STEPS Fitness, Inc. two years earlier — Tennessee’s first personal fitness training center. One of his goals was to foster the evolution of the then-fledgling field of personal training into a viable and mature profession, and has done so over the past 3 decades, teaching trainers across through country. As a writer and speaker, Dr. Irv has earned a national reputation as one who can answer the hard questions about exercise and fitness – not just the “how” but the “why”.