468 | How Strength Training Protocols Improve Gait Outcome Measures in Older Adults - a research review

[00:00:05] Welcome to the Optimal Body Podcast. I'm Dr. Jen and I'm Dr. Dom and we are doctors of physical therapy bringing you the body tips and physical therapy pearls of wisdom to help you begin to understand your body, relieve your pains and restrictions and answer your questions. Along with expert guests, our goal of the Optimal Body Podcast is really to help you discover what optimal means within your own body. Let's dive in.

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[00:01:58] So today we're talking about walking and gait speed and why it's so important. We actually recently interviewed a good friend of ours who were relaunching a program that we did with them, but she talks about how walking and gait needs to be considered the sixth vital sign. Yeah, that's an interesting episode that we'll talk about. Yeah, that comes out next week and we are diving in today on that also and why walking is so important.

[00:02:27] And what I think is cool. So we're going to review one of the recent research articles that has come forward to really kind of define walking, especially as we get older, because it's not really something we think about when we're young, but we're going to talk about why it matters to start thinking about it, whatever age you're at.

[00:02:45] And particularly as we get older, like what is going to be impacted and how we can improve our gait and our walking so that we're thinking about longevity and we're thinking about our health long term, you know. And this research article, just to say what it is, is called Resistance Training Effects on Gait Parameters in Older Adults, a Systematic Review with Multi-Level Meta-Analysis and Meta-Regression.

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[00:04:34] That's T-H-I-S-I-S-N-E-E-D-E-D.com and use code OPTIMAL to get 20% off your first order. So mainly what they're looking at is any research study that was a high level of research that looked at strength training and how that impacted outcomes related to gait. And they group all these studies together.

[00:04:59] And the cool thing about this is this essentially allowed the researchers to look at strength training interventions and compare it to control populations that were really doing nothing. They were more so passive control populations. But also comparing it to other interventions like walking, resistance band exercises like you might get at some physical therapy offices, people who are doing yoga programs.

[00:05:26] And so it was able to compare it across a lot of different interventions as well as against a passive control person who's doing nothing. And I think that when we think about walking in general, again, it doesn't become important to us like when we're quote young and healthy, like, oh, we can walk. Walking's not a limiting factor to us.

[00:05:47] It's just one of those things that doesn't become important until it's important because you can't do it as well or because you have pain or you're slowing down. And at that point, that is when we've lost some of the strength, power, balance, confidence needed to walk effectively. And it's much more difficult to build it back at that point than it is to start focusing on some of those things when you are quote unquote young and healthy.

[00:06:16] And one of the things we measure when it is something that is impacted and we're paying attention to is the speed at which we're walking. And that can, you know, determine so many things for us. And so it's really like how fast can we walk? You know, how fast can we get from one point to another? And sometimes people aren't thinking about that until it's like, well, I don't live in New York or, you know, somewhere where people are walking around a ton and needing to hustle somewhere. But it's not just about hustling.

[00:06:45] It's literally our longevity of how we're how quickly we can move forward in each step that we take. And if that is significantly slowing down, that is an impact to our longevity. There's tons of statistics on gait speed. And we're not even talking about fast gait speed or a fast walking speed like you might be using in New York or somewhere that's busy and you're just trying to hustle and bustle. This is average self-selected gait speed.

[00:07:13] And there are studies that show as that drops, there is a correlation, a positive correlation with higher mortality, higher rates of falls, higher rates of cognitive decline. So it really like correlates heavily as your gait speed drops. Perhaps some of these other diagnoses or instances of falls, mortality in general, the risk increases. And of course, it's a it's a correlation.

[00:07:41] It's not like, hey, your gait speed falls. You're going to have cognitive decline. No, there's a lot that plays into that picture. But I think the premise is that people that are maintaining a higher walking speed later in life also have a lot of other things going for them. Likely higher amounts of muscle mass that is allowing them to keep their strength and power higher, which is likely impacting and allowing them to keep balance a little bit better.

[00:08:05] So it's this whole picture that this one stat of walking speed is telling us a lot about a person. And it's kind of shocking. Like the article pointed out that almost half of Americans over 65 walks lower than 0.8 meters per second, which is roughly like you're walking 1.8 miles per hour. So it's quite leisurely. It's quite slow.

[00:08:33] And so this is why, you know, we're talking about because this is one of the major, you know, measurements that we're testing as physical therapists, particularly in a clinic, especially when it comes to reducing your fall risk and seeing your overall mortality. And that 0.8 meters per second is significant because that's the clinical benchmark for, quote unquote, slow gait.

[00:08:57] And it's at that gait speed where somebody would have difficulty getting across the street at a red light or, you know, if the walk sign came up, they'd have difficulty getting across the street in time and just, again, doing those functional things throughout the day. One thing that they found in this study is that the single biggest modifiable factor driving gait speed, which was more significant than balance, range of motion or someone's fear of following was their muscular power.

[00:09:27] Now, we're not just talking about strength here. Power. Power is how fast you are able to move weight or how fast you're able to apply your strength. Now, this is why we're talking about it today, because it isn't just a problem for people in their 70s. Like muscle loss starts in our 30s. So we have to start thinking about what we're doing and what is going to be the biggest bang for our buck. And I think that's what majority of people want to understand.

[00:09:54] Like if I'm going to not have a lot of time, but I'm understanding that I need to focus on some strength training, like what is going to be those exercises that are going to really move the needle to help keep me healthy long term? And you say muscle loss starts in our 30s. That's if we're not doing anything to prevent that muscle loss. Again, I think this whole muscle loss and a we lose muscle every year as we age again, that's in the average person. And that's in what we see in populations.

[00:10:23] That isn't every individual because there are people doing some of the things to prevent that muscle loss. So this is why Physio Network created this big review with which is rather than doing one tiny little study, they pulled 92 different studies into something called that the systematic review that had 6000 plus participants.

[00:10:42] So it allows you to apply the data that you get from this over, you know, the data becomes more significant because the more people you have in a research study, the more you can kind of generalize and apply the results. And the main focus of the study was does resistance training or strength training specifically impact some of these gait outcome measures and improve gait in older adults? I mean, overall, what they found was that resistance training produced significant improvements in strength.

[00:11:11] Strength and gait outcomes. And both are clinically meaningful, especially when we're talking about this longevity aspect in this predictor of mortality, which makes a lot of sense. You're doing strength training. Hopefully you're going to see strength outcomes improve. And then the other thing is, hey, we're just strength training, but we still see significant improvements in gait.

[00:11:33] And we saw significant improvements in gait at really high effect sizes and effect sizes is something that's used in statistics to essentially say a large percentage of people in this strength training group are performing better than the average of the control group. So the time to up and go. It's a study where you get up from a chair, walk to a certain point. Yeah, a test. Yeah. Sorry.

[00:11:59] A test where you get up from a chair, walk to a certain point, like around a cone, turn around, sit back down. Another one walking distance. Walk as far as you can until you have to stop. Number three was gait speed. The time to up and go. There was a huge effect size, which essentially meant 90 plus percent of people were performing better than the average person in the control group. Walking distance. Gait speed had walking distance on moderate to large effect size. Gait speed had close to a moderate effect size.

[00:12:29] Again, this is just showing that in this data set, so many of these people are performing better than the passive controls. And again, this was just from doing strength training. No other interventions. Which makes complete sense. I mean, if you think about the time to up and go as well, that's a sit to stand. So getting up from a chair, which is going to improve if you're strength training, and then being able to propel yourself forward at a quick speed, turn around and come back down. So, I mean, it completely makes sense.

[00:12:56] But what we're looking at and what we need to remember is that we're not going to get change and muscle growth, strength growth from not challenging the muscles. And that's what often happens too often when we're thinking about these therapy plans or these rehab exercises, when you're wanting to prevent falls.

[00:13:17] Like we're underdosing individuals way too much where we're giving them these TheraBand exercises or these seated exercises or standing behind a chair and just moving your leg out to the side. If we are not stimulating the muscle to where it is going close to failure, right? Like you cannot perform more repetitions, then we're not going to have a significant change. This is something like I drill into my mom so much because she is in her 70s.

[00:13:46] She's used to Pilates, yoga, moving through exercises really quickly. Things that she could do for hours straight without stopping. And using two to three pound weights as she was, you know, exercising throughout her life. So, she's not used to slowing it down, moving with more intention, challenging her muscles to a place that is close to failure, which now she's kind of afraid of that. So, it's like having to retrain the system.

[00:14:11] But you guys, you have to understand like what they found here was that machines and free weights target the low targeting the lower body is what moved the needle, not your banded exercises. Which is why in a lot of senses, it's so important to have older individuals do this with somebody like a physical therapist, especially physical therapist that's a little bit forward minded about dosing someone correctly.

[00:14:34] I feel like someone who's 75, 80 plus and walks into your clinic really slowly, maybe they're using a walking device or something. We kind of view them as frail and we show them that they're frail because we just have them laying on a mat doing these exercises. When in reality, we need to be focused on these functional things like squatting, getting up and down from a toilet, getting up and down from a low chair that they're struggling with.

[00:15:01] Because if we're not working on those things or working on those things weighted, we're not going to grow their confidence doing those things by having them do clamshells on a bed. So, I'm really stoked to see that banded exercises had basically no impact compared to the passive control in these outcome measures. The study compared with specific exercises, which specific exercises drove the biggest improvements in gait?

[00:15:29] These are the things that people want to hear. Yeah. Ankle plantar flexion, so calf raises, makes a lot of sense. Calf is the biggest muscle. The power from the calf is one of the biggest things that helps propel us in gait. Hip abduction, so exercises, weighted exercises, that we're working on the outsides of the hips. Again, that's the muscle that helps us stand upright when we're on one leg. And multi-joint leg presses and squats.

[00:15:59] Again, what we just said, those are the things that promote function, that are going to help us learn better how to use those legs and coordinate that strength through something like gait. And especially if you are intimidated to start to load heavier or increase the weight. These are all exercises that you don't have to feel like you need to put on a lot of load.

[00:16:22] We can increase your calf raise just by elevating the surface, making your heels drop lower and then having you elevate. And now you're moving through a fuller range of motion. You're going to fatigue, especially if you haven't been doing that. Or you can progress to moving two legs up, one leg down, or even single leg heel raises. So there's so many ways that we can progress these exercises, hip abduction.

[00:16:46] I think a lot of times we're seeing it with like a cable or a band where you're just standing and moving your leg out to the side. But if I just lay on my side now to work against gravity, so now if I have a band or weight, I'm not only resisting against that band, but I'm resisting against gravity. So I'm overloading it without putting a heavy load, without putting a heavy weight.

[00:17:10] So it's really cool to know that there are ways that we can create more of that challenge, you know, without feeling a loss of confidence, I would say. Yeah. And all the exercises that they looked at, all the resistance training styles that they looked at, progressive overload and supervised.

[00:17:31] So a program that was progressive and supervised had the biggest effect size of any of the training programs with the key here being progressive overload. Back to your mom's example, you can work with and curl and squat with the same two to three pound dumbbell every day for the rest of the year. And you're not going to make meaningful movement in your strength or power gains because you're not progressively overloading the muscles. They're just doing what they're used to.

[00:18:00] So I'll give you examples of things because my mom is 73, right? And so this is something that I'm focused on, especially when she has knee osteoarthritis and it really is slowing her down in her gait and impacting her gait. So for hip abduction, think of clamshells. Clamshells is such a common exercise that a lot of people do, but something that we've been doing to progress. My mom is putting a weight on her knee. So she extends the bottom leg straight.

[00:18:28] She puts a weight on the top knee bent and then she has to only move through that hip to lift that weight. And so that's helping to overload and create some challenge in that hip to hopefully help to promote strength gains opposed to just doing TheraBand clamshells or having to do it standing, which kind of would impact her balance a little bit right now. When it comes to squats, squats are really hard for her.

[00:18:56] So we're going to an elevated surface. So a sit to stand. And rather than just having her do a weight, if she doesn't feel confident with that, we kick one foot in front. So she's kind of offsetting where she still has some balance from that other leg, but she's working more on like a single leg having to control her way down and up. And that's a way that we're overloading, you know, in order to create enough challenge and change.

[00:19:20] Your mom's not doing pistol squats by any means, but increasing the amount that she's putting through one leg. Again, she still does stairs. She still does all these things. She needs to be able to control her body weight on one leg. And to those of you who might be listening, saying like, hey, you're talking about 70, 80 year olds. Like, why is this important to me in my 30s and my 40s and my 50s?

[00:19:44] Well, to what we talked about at the beginning, if we do nothing or if we are not resistance training, that is when we see population wide a decrease in our muscle volume, a decrease in our strength and power. On an annual basis, especially decade over decade, the losses, if we're not doing any conscious strength training is pretty profound. One of the ways to combat against that is to get into some regular strength training, power training programs.

[00:20:14] Yeah. And what we recommend starting with is two to three times a week of strength training. And even if you were just thinking, OK, adding in heel raises are some kind of squat, whether it's on a leg press or doing like a goblet squat, some kind of hip abduction exercise. We've talked about a couple now, like laying on your side with the leg straight or laying on your side with holding a weight and focusing on your lower body exercises being the ones that we talked about.

[00:20:42] How are you doing your calf raises? How are you improving them? How are you doing your hip abduction exercises, which we've talked about ways? How are we doing either a goblet squat, a sit to stand or a leg press? Right. And those can be like your lower body focuses. But then maybe you're adding a little upper body focus pushups. You do starting against the wall, starting, you know, like there's so many ways and then a row. Like if you focused on those five things at first.

[00:21:06] And really, if you're doing goblet squats and a deadlift variation, again, upper body strength training also has its place and has importance. But if you're doing and loading through a goblet squat and a deadlift variation, you're going to be getting great upper body activation. You're going to be neat because you need to hold the weight goblet squat. You need to hold it out front. You are using your press muscles, deadlift. You're using more of your pull muscles by pulling through your shoulder blades and your lats.

[00:21:33] And again, if you start loading those up, those are the more important ones in this study as related to gait. And something else I want to point out, we've mentioned this on another podcast as well. But when it comes to, you know, really making those meaningful changes in strength, like because we talked about it, it's got to be challenging enough. Right. What we're looking at is you have to be under 30 repetitions. So how how much can you lift this load to failure?

[00:22:04] Not just fatigue where it feels like tired, but you rest for a second and you can go right back into it. But like literal failure, maybe you're not going all the way there, but you're getting, you know, two to three repetitions close to failure. So if you're not feeling comfortable going the heaviest, maybe you're doing 15 to 20 reps at a lower weight, but you can still get to that failure mark. Yeah. Trying to do like a five rep to failure if you're not used to strength training is a bit intimidating.

[00:22:31] And we're not talking about failure like you collapsed to the ground on the last repetition. It's like I noticed that I struggled to do this repetition with good form. I noticed that I'm starting. Slow down a ton. I noticed that I'm starting to wiggle to get things up and I'm really feeling the burn. And that is part of the reason that I'm struggling with this.

[00:22:53] And again, I know strength training doesn't sound super attractive to everyone, especially if you are someone like your mom who was a career Pilates gal or yoga or running. You know, she has done a lot of different forms of exercise, which are great. And it hasn't always been easy for her to get into it. I think one of the reasons she does enjoy doing it is because she gets to do it with you. Which I enjoy too. And I think that's great where having the social aspect is great.

[00:23:20] Right. Also, when we're talking about training to failure, that alone can also be intimidating to people. Which per this study, people who weren't used to strength training, the most effective programs were progressive and supervised. Supervision is the next part where if you're listening to this and you're like, I really want to get into strength training because I'm in my 50s, later 50s. Haven't done a lot of strength training in my life. Go see a PT.

[00:23:47] Before you go to them, call the office and say, I want to be with somebody who can help me work on real strength training. I don't want any of these frilly exercises using bands on the bed. I want to be doing squats and deadlifts. Who can I see? And hopefully at your local clinic or a clinic nearby, you can find somebody who can do that with you.

[00:24:09] Or they could at least work, like recommend a trainer that they, you know, maybe they'll assess you and then they'll send you to a trainer who can program it really well for you. You know, so there's different ways that we can really approach it. But main thing being like, we don't expect people to spend an hour in the gym. Like research shows 30 minutes, a minimum of 30 minutes, just starting to move, just starting to do some of these exercises and finding what that means for you.

[00:24:36] Finding where your point is, where you're slowing down the weight, it's getting tougher. You're actually challenging yourself. Like maybe that is just doing a set, you know, and getting used to the movement. I think that's okay. But we have to find some way of challenging ourselves beyond just a burn. And that's what we often feel when we're talking about our little pulses or holding and we're doing things in Pilates, which I taught Pilates, love Pilates. I have Pilates reformer myself.

[00:25:04] However, it's different when we're talking about meaningful changes to strength and actually making an impact in what they're showing on our longevity and our mortality. This is where, you know, we're hoping that the message comes across. It is so important to progressively and safely start to challenge yourself beyond just getting to the burn or, you know, doing these exercises that aren't challenging our system enough.

[00:25:30] And so, of course, in a big review study like this, there are always limitations. There's always limitations to research. Again, when you're looking at 92 different studies, it's tough to find things that were done exactly the same way. So making direct comparisons can be difficult where we always say, here are the results. We did all the statistics. And what's the study?

[00:25:58] There's lies, damn lies and statistics or something like that. I remember my statistics for us. They're always used to say something like that. So I hope I didn't get that wrong. But so, yeah, direct comparison can be tricky. There are limitations to the research, but I think some of these clinical implications and the improvements that we saw in many of the studies with these strength training, you know, protocols, it's real. And it's something that we need to start paying attention to.

[00:26:26] Everyone's talking about strength training right now. So it is also a trendy thing. And longevity. Everyone's talking about longevity. But we're going to talk about longevity. Exercise is one of the best things that you can do. Yeah, resistance training and having this new focus on gait speed, which we're going to talk about more next week on the podcast. But gait speed should be a vital sign based on all of the research that is behind it.

[00:26:49] And as our gait speed goes down or gets below certain thresholds, we have much higher increased risks of certain poor health outcomes or even mortality. Yeah. So hopefully if you know someone that is maybe resistant to strength training or doesn't understand the importance of this, especially if we're talking about our parents or people we care about and we want in our life. Or is noticing they're walking slowing down and is frustrated about it.

[00:27:16] Hopefully this is something that you can take away and see what you can start to implement. Thank you so much for sticking around for another episode. I hope you learned a ton. Pass it along to people. And I don't want you to forget that Dr. Courtney and I, a chiropractor and a physical therapist, are coming together and hosting a free webinar when it comes to our health and overall longevity. We're going to do some assessments together. We're going to really look at the body as a whole and see what is most important that we should be focusing on.

[00:27:43] This is completely free and we'll have it linked up in our show notes to sign up.