Welcome to FOXcast OT. A podcast for clinicians made by clinicians. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org
JIMMY MCKAY, PT, DPT Alright, welcome to FOXcast, I’m your host, physical therapist, Jimmy McKay. Today gonna try something a little bit different. Going to critically appraise articles for other clinicians who maybe don’t have the time to read some of this research at the moment. A lot of people talk about wanting to have access to the latest research and, you know, with the amount of information we have access to. Wouldn’t it be great to be able to kind of distill it down into something really quick and digestible you can just listen to on your drive to or from work? So that’s what we’re trying to do here today. Let’s introduce the people we have on the show today from left to right. No stranger to the program, Megan Mitchell, physical therapist with FOX Rehab. Megan, welcome back to the show.
MEGAN MITCHELL, PT, DPT Hi Jimmy. Thank you so much.
JIMMY MCKAY, PT, DPT And Connie Lewis is coming back as well.
CONNIE LEWIS, PT, DPT, GCS Hi, thanks for having me back.
JIMMY MCKAY, PT, DPT So the idea is you guys both took a look at an article in order to really break it down. Really go through your thought process for the things that you were thinking your feeling about this particular paper and what you guys ultimately can get out of it. And really the big takeaway for the audience is what can you now do with it? What can you do with it and in which patients can you apply is this research to? The title of the article you guys took a look at was functional performance with age, the role of long term strength training. This was recently published in The Journal of Geriatric Physical Therapy. Author Unhjem et al faculty of medicine the Norwegian University of Science Technology. So start this off. Let’s talk about that impact factor we’re talking about that just before the article got underway we want to take a look at where this was actually published right So just because something was published doesn’t mean you should take it on equal ground if it’s published somewhere else. So talk about what impact factor is it in this particular article.
CONNIE LEWIS, PT, DPT, GCS The impact factor ranks the importance of a journal by calculating an average of the number of times selected articles of that particular journal have been cited by other articles within the last few years. So basically the higher the impact factor the more highly ranked the Journal. For comparison, the New England Journal of Medicine has a highest journal impact factor of all general medical journals with the number of seventy point six seven. The journal that we’re looking at, Journal of Geriatric physical therapy has an impact factor of two point two eight three. Is this bad? Definitely not. In 2017, only thirty-nine point four percent of all journals had an impact factor of two or greater only the top five percent of journals have impact factors equal or greater than six.
JIMMY MCKAY, PT, DPT That’s an awful scale, like, average is like 3.5-4 and this one’s got a 70 but all right. So so what we’re saying is the Journal of Geriatric physical therapy good journal to reference if you’re talking about physical therapy interventions or testing in geriatric physical therapy. All right so let’s walk with purpose. Like why. Let’s start with the why—why did the author and his colleagues decide to do this?
MEGAN MITCHELL, PT, DPT What they were looking at really was a long term strength training and how that related to functional performance. Basically two things they were comparing the strength of functional performance between older adults who participate in strength training as well as those that just participated in recreational activities such as hiking and walking. They wanted to look at. OK. If you were strength training into older age are you performing better in functional tasks such as sit to stands and climbing up stairs? And is that better than just participating in hiking and golfing and other activity?
JIMMY MCKAY, PT, DPT It was great article look at especially with physical therapist because we always like to say load it, strengthen stronger is better, be stronger live longer. I suppose that some taglines that we use in and around geriatric physical therapy. So, where do we where do we go next? How about the IMRaD which I actually googled before we started this. The IMRaD is kind of a framework really. So how you would look at the introduction methods results and discussion. IMRAD. So walk us through IMRaD how you would go through that. We’ll start with the introduction.
MEGAN MITCHELL, PT, DPT Yeah absolutely. So in the introduction, the authors outlined how age-related decline and muscle strength is associated with the reduction of functional performance of everyday tasks. Such as chair rising and stair climbing as well as walking and balance. Something that FOX clinicians we definitely know all too well. And something that I thought was interesting when they had pointed this out was I was slightly confused if they were saying that this strength loss was due to the actual aging process or if this is just something common that was found in older adults. And they didn’t delve into that exactly, but later on in the introduction, they do mention that master athletes have the same amount of strength that they tested in 20-year-olds. So if you continue to strengthen your muscles you’re not going to lose all of that muscle mass. So it’s not completely due to the actual natural aging process but more so due to lifestyle choices such as participating in recreational activities instead of strength training. Which is definitely common that I’ve seen at least among my clients. How about you Connie?
CONNIE LEWIS, PT, DPT, GCS Yeah I was just going to say that the authors do note that in the intro that physical activity patterns of most older adults characterized by those recreational activities you were talking about such as walking, hiking, they mentioned golf all of which are low force demand. So, in my opinion, they wanted to test the theory that these activities may not provide sufficient overload to yield high muscle strength. So you know they’re looking at strength training in older adults and our recreational activities enough?
MEGAN MITCHELL, PT, DPT Like I tell my clients all the time walking isn’t enough. It’s not comes up a line for what you need to do even though you might be walking even let’s say just to the kitchen and back that’s not enough to have sufficient. It’s not going to strengthen the muscles no. So that was the introduction.
JIMMY MCKAY, PT, DPT All right anything else that they were looking at in terms of other things in the literature?
MEGAN MITCHELL, PT, DPT So what’s different from this study than other studies is that in previous studies they looked at short term strength training programs so it ranged from about eight weeks to six months.
JIMMY MCKAY, PT, DPT And this is more like lifestyle.
MEGAN MITCHELL, PT, DPT Right. Exactly. So the group that they were really looking at was the master athlete. So those that have that are currently participating in a strength training program and these are all older adults averaging of the age of 71 years. Yes. We’ll go into that more later though.
JIMMY MCKAY, PT, DPT Who are the researchers looking at specifically?
MEGAN MITCHELL, PT, DPT Yes. So there are four different groups. They compared a group of long term strength-trained master athletes. They compared them to three different groups so they had recreationally active older adults, sedentary older adults, and then a young control group. It’s important to note that the young control group isn’t currently participating in the strength training program.
JIMMY MCKAY, PT, DPT Any problems so far with the setup that you’re the way you’re looking at it?
MEGAN MITCHELL, PT, DPT Yeah. They really didn’t define what they meant by master athlete.
CONNIE LEWIS, PT, DPT, GCS I was a little confused by that too because they said that these are individuals that have been competitive in weight and power training for 34 years is what they mentioned the article but I personally didn’t know what that meant by the 34 years. Is that an average of all of them? I didn’t get it right.
MEGAN MITCHELL, PT, DPT Exactly. When did they start and what is the strength program that they’re doing? I did find a definition of master athlete. It’s very broad. It just says someone who is older than 35 years who either trains for or takes part in athletic competitions often specifically designed for older participants.
JIMMY MCKAY, PT, DPT The super broad, I hate when in papers they use a term or definition they don’t define it actually when this is like the core group that we’re looking at right. So that’s a limitation or at least a point of confusion. Yes in this so far. So what about the methods section?
MEGAN MITCHELL, PT, DPT So this was a cross-sectional study and had four sample groups. There were 11th strength-trained master athletes with the mean age of 71. I don’t believe that they told us the range of the ages. So we don’t know what the youngest participant was and we don’t know who the oldest participant was. This was the only group that was reported to participating in a regular strength training program at least three times a week. They also had a group of recreationally active older adults with the mean age of 73. So they defined this as someone who was active more than one hour a week at least two times a week doing activities such as hiking, golf, cross-country skiing, cycling, and dancing. The third group consisted of 10 sedentary older adults with the mean age of 71. And they took part in activities less than two times a week. The last was the moderately active young reference group which consisted of nine individuals with the mean age of twenty-two.
JIMMY MCKAY, PT, DPT All right so we’re looking at older adults, master athletes average age of 71 who are regularly lifting and doing strengthening. Yes. Yeah, they’re looking people who are recreationally active. So people who move a lot, but not necessarily you know loading it and lifting and power training. Sedentary older adults and then moderately active young. In terms of mean age of 22. It’s a little bit different.
MEGAN MITCHELL, PT, DPT Right. And they don’t even say what that group does. But it’s interesting to note so the recreationally active older adults they’re still not meeting the guidelines that have been set for healthy living. So it’s only one hour, two times a week. And it doesn’t talk about the intensity.
JIMMY MCKAY, PT, DPT OK anybody excluded who’d they leave out?
MEGAN MITCHELL, PT, DPT Yes. Anyone with a cardiopulmonary disease, neurological disease or any acute pain that would restrict the testing procedures. All right.
JIMMY MCKAY, PT, DPT So that’s who they are. That’s who they excluded. Then what do they actually look at? Now we know the who, what they actually do?
MEGAN MITCHELL, PT, DPT OK. So this was actually it was a one-time thing so it was a two-hour session where they tested each individual on a couple of different functional tests and then two strength tests. So the functional tests consisted of a balance test, a walking speed test, a chair rise test and then stair climbing test. So, with those tests, the balance—what they used was a force plate where they assess postural sway and they did this in two different single like standing exercises. Which I did like. So one was just static standing for 10 seconds and the second one was 30 seconds with a cognitive task which included repeating a series of numbers backwards to a specific beat. So I did like that they added that extra component. However, the Balanced test was a static standing balance. So when talking about the research later on looking at balance I don’t know if this was a good measure of balance. But we’ll talk about that later. The second was a 10-meter walking speed test. The chair test was just the five times that to stand and then the stair climbing important to note that they had to climb 12 steps as fast as they could without using a handrail.
CONNIE LEWIS, PT, DPT, GCS So this is where I thought they were actually looking at the power component of lower extremity strength. But when they said they weren’t going to use a railing I thought that added a potential balance factor. So I thought that might have hindered some of their results.
MEGAN MITCHELL, PT, DPT Right. Well, what was more interesting was that all of the participants were able to complete this without holding onto the railing.
CONNIE LEWIS, PT, DPT, GCS And how many older adults that we know can actually do that?
MEGAN MITCHELL, PT, DPT Correct. So when they define sedentary and this recreationally active this they might be a higher-level function performing patients than what we would typically see.
CONNIE LEWIS, PT, DPT, GCS And I think that they mentioned that in the limitations we’ll get to later. Okay. All right.
MEGAN MITCHELL, PT, DPT They also did two tests that looked at strength and then the rate of force development. So for these, they gave the participants a 10-minute break that was actually between each functional test and then for this strength test they then took a 15-minute break and performed a 1 rep max using a horizontal leg press. They said that it took them about three to five trials to get their 1 rep max which is important to note. So it didn’t take them too long to get that. So the muscles weren’t too fatigued and then they also tested their rate of force development. So at that power like that.
JIMMY MCKAY, PT, DPT All right. So now we just went over what they were putting them through the single-leg balanced test. The walking speed test, stairs, chair rise. Results.
MEGAN MITCHELL, PT, DPT So it’s important to note that first the off their words no differences observed in their age body weight or height between the three older adult groups which could have affected their strength or their power.
JIMMY MCKAY, PT, DPT There was no—there were no difference. Good.
CONNIE LEWIS, PT, DPT, GCS So they’re testing on similar individuals so we can believe the results.
MEGAN MITCHELL, PT, DPT So they found for the one RM test they found that master athletes were stronger than active older adults.
So the people who lift those people are stronger than the people who hike and are active. Got it. I want to make sure we’re clear.
MEGAN MITCHELL, PT, DPT Good. Yes. And when they looked at the rate of force development they saw no differences observed between master athletes and young adults. As well as no differences between recreationally active and sedentary.
JIMMY MCKAY, PT, DPT So what does that mean anyway way. No difference between master athletes young adults so yes great people who live in older adults who lift and young adults.
MEGAN MITCHELL, PT, DPT Who and they don’t define ambiguous about that. But we know that when you’re younger you’re participating in more activities that involve that power you’re probably—I mean, more stairs to begin with, those two groups were similar.
JIMMY MCKAY, PT, DPT No difference. Correct. And then no difference between recreationally active and sedentary?
MEGAN MITCHELL, PT, DPT So that means that if you’re participating in things like walking or hiking or golfing you’re not really working on that power component.
CONNIE LEWIS, PT, DPT, GCS How many times my mom my own mother says to me, Well I walk every day. And I yell at her and I say that is not strength training and this we have this argument all the time.
JIMMY MCKAY, PT, DPT And this is never a thing where you know a couple of us as we record this are wearing these things on our wrist where we get to 10,000 steps a day and you feel like you’ve accomplished something, that’s got this goal.
CONNIE LEWIS, PT, DPT, GCS That is not strength training. OK. All right let’s focus on that. We’re moving to next?
MEGAN MITCHELL, PT, DPT OK. So let’s see here. So for the chair rise test master athletes and the young group perform better than the active adult and sedentary.
JIMMY MCKAY, PT, DPT Still consistent. Right. Exactly.
MEGAN MITCHELL, PT, DPT With the power. So that’s what we just talked about. Yeah. So again like we were talking about before there was no difference with the chair rise test between the active and sedentary group. So again consistent with the power.
CONNIE LEWIS, PT, DPT, GCS Basically starting to confirm their original hypotheses with this one.
MEGAN MITCHELL, PT, DPT Correct. So now we’re looking at the stair-climbing test. They found that master athletes did better than both the active and sedentary groups. And the young comparison group did better than Master athletes. OK. And there was no difference again between the active incentive here.
JIMMY MCKAY, PT, DPT That’s the big I mean for me so far only halfway through this. That’s like, the big take home. Is that active we think you know should be weight you should be better measurably better.
CONNIE LEWIS, PT, DPT, GCS It is. There is a big difference there. You have to load the muscle groups.
JIMMY MCKAY, PT, DPT OK. Moving on to what walking speed.
MEGAN MITCHELL, PT, DPT OK. So here is where the recreationally active kind of have a slight advantage when they were looking at walking speed. There was only a difference observed between the sedentary older adult group and the other three groups. So only the sedentary did poorly on the walking speed compared to the others.
JIMMY MCKAY, PT, DPT Really the difference here is we move those active adults. They did better here.
MEGAN MITCHELL, PT, DPT Correct.
CONNIE LEWIS, PT, DPT, GCS Right. So speed is good, but does it really correlate with strength? Right. And I think is what they’re talking about. So I think there’s something more to do with the speed as a balance component than the strength component that they’re looking at here.
MEGAN MITCHELL, PT, DPT Right. And Exactly and so what they found was that there was a correlation between the one RM test and the chair rise test. As well as the one RM and the stair-climbing power ability. There was also a correlation between stair climbing and chair rising ability. So again like we said before that strength and power translates over into the ability to stand up from a chair faster and climb upstairs faster.
CONNIE LEWIS, PT, DPT, GCS So just because you’re walking down the road doesn’t mean you can get up from a chair. How sad is that?
JIMMY MCKAY, PT, DPT Yeah. And I think a lot of people think that you know getting your steps in and being I mean recreationally active you think would be fantastic. And we’re seeing these things at least in this particular study. How did the authors summarize? We’re going to summarizing the findings. What did they state is these things?
MEGAN MITCHELL, PT, DPT Right. So like we talked about they were able to show that master athletes are stronger and have more power and they exhibited better functional performance compared to other older adults during the more force demanding functional tasks such as the chair rising and stair climbing. But let’s not forget that they had those two other tests that static standing balance as well as the walking speed. So during those less forced demanding tasks that I just talked about. There were no differences observed between the master athletes and the active older adults. But both groups were better than the sedentary older adult.
JIMMY MCKAY, PT, DPT And so less demanding tasks the recreational athletes are actually going to perform well.
CONNIE LEWIS, PT, DPT, GCS Less force demanding. Less force. OK.
MEGAN MITCHELL, PT, DPT That’s clear. Yes exactly. And so at least this does conclude that something is better than nothing.
JIMMY MCKAY, PT, DPT Good a win for something.
MEGAN MITCHELL, PT, DPT Yes but not enough. Right. I did like how they touched on the biomechanical analysis that have shown that how chair rising and stair climbing require more than twice the power output of muscles surrounding the knee joint than what is used for regular walking. Which goes back to what a lot of my patients told me while I walk all the time you know why is it hard for me to get up or climb stairs. There is a difference in the strength and power component is just these activities versus just walking yeah.
MEGAN MITCHELL, PT, DPT Mean it’s two different systems totally different.
JIMMY MCKAY, PT, DPT All right. Discussion part of the analysis Strengths weaknesses that you saw maybe want to bring back up that we’ve just mentioned already or that the authors actually called themselves out on.
MEGAN MITCHELL, PT, DPT Yes. So they I did like that when they tested everyone they were doing at the same time of the day because we know that with older adults timing could be important as well as you know when it relates to when they’re eating. So the authors did point out a weakness in the fact that the master athletes actually do have higher strength and may be stronger than the average older adult. They also pointed out that their recreational activity group might have a higher activity level than the average older adults which is good.
JIMMY MCKAY, PT, DPT We wanted to test that. Right. I mean that’s what you wanted to see.
MEGAN MITCHELL, PT, DPT Correct. But when it relates to Fox clinicians this might not be specifically translated over.
CONNIE LEWIS, PT, DPT, GCS OK. But the average age you see,
JIMMY MCKAY, PT, DPT Is not right. OK. It’s probably closer to which group.
CONNIE LEWIS, PT, DPT, GCS Sedentary.
JIMMY MCKAY, PT, DPT Right. OK. I wanted to make sure before.
MEGAN MITCHELL, PT, DPT I wanted to do as to say but it’s something that’s exciting to point out then that would be if they had a lower-performing recreationally active older adults. The difference between the master athlete group and the recreationally active older adult group would be much different. And then you would really highlight the difference in the importance of strength training.
JIMMY MCKAY, PT, DPT OK. Bottom line conclusion in this what is it.
MEGAN MITCHELL, PT, DPT You must strength training alert and strength training is huge for older adults and that just walking and participating in activities though that’s important for a social component. It’s not enough for those functional tasks that they need in order to reduce their risk on need for caregivers or other assistance for help. And really maintain that independent lifestyle that we want for all of our clients.
CONNIE LEWIS, PT, DPT, GCS So Megan you say strength training. I want the listeners here to take away something. Some things that are very specific and you are an excellent clinician and what would you tell people who are working with older adults to start thinking about today after hearing about this study. What are they going to do differently tomorrow?
MEGAN MITCHELL, PT, DPT Dosage. So it’s important when you’re trying to strength train for older adults that we want it to be so that there is fatigue by the eighth rep. It’s important to note like what is fatigue. We don’t have to ask our clients when they’re fatigued. We can see it when their form starts to deteriorate. Yeah exactly. When their rate of breathing starts to increase we can tell that that’s when they are getting tired and that needs to happen their form needs to break by the eighth rep in order to work on strength.
CONNIE LEWIS, PT, DPT, GCS Stop telling people to do sets of 10. When people ask you you know how well how many these are am I gonna do? The answer is I don’t know. You’re going to keep going until I see that your form is changing. And if it’s more than eight guess what that load is probably not enough.
MEGAN MITCHELL, PT, DPT Two things like one when it comes. To fatigue in general when you ask them Are you tired? They are running at a general level of fatigue. More often than not when I show up at my client’s house, they’re already saying that they’re tired so that’s their relative baseline. So instead of doing that again look at their form. And when my clients when they get to 8 and they’re still doing well instead of saying like oh guess we gotta make it harder, I reframe it as congrats! That was way too easy! Now we have to make it where we’re actually going to challenge it where we’re going to produce some results. So it’s not a drag that I have to make it higher. This is exciting because you reach an awesome accomplishment.
CONNIE LEWIS, PT, DPT, GCS I love the way you phrase that. I think that’s important for a lot of our listeners to phrase it that way.
MEGAN MITCHELL, PT, DPT It’s definitely made a huge difference. To show it as an accomplishment instead of something that they have to dread.
JIMMY MCKAY, PT, DPT Changing a little bit of that perspective is huge.
MEGAN MITCHELL, PT, DPT Yeah. And then the other thing for a strength training is that we also really want to work on that power component so speed. So we wanted to it fast during the concentric phase and then slow with the eccentric phase. So this is helpful for the joints it really strengthens the muscles. So for sit-to-stands, a best way to do that is stand up as fast as you can and sit as slow as you can. And if that is counting to the beat of five, four, three, two, one. That tends to be really helpful.
JIMMY MCKAY, PT, DPT Anything else you guys want to add. I think there’s a good start. We’d love to hear from you guys as you’re listening, so if you if you’ve found value in these ladies breaking down this particular article and what you want to hear more. Feel free to reach out to us at foxrehab.org. Megan and Connie do the reading, you guys can take all the benefit.
CONNIE LEWIS, PT, DPT, GCS I just want to say thank you, Megan, for all of your hard work on this.
MEGAN MITCHELL, PT, DPT Thank you guys for having me.
JIMMY MCKAY, PT, DPT All right. Ladies. Thank you so much for highlighting the important research if you’d like a link to information about it. We’ll put it in the show notes of this episode.
Thanks for listening to FOXcastPT. It’s brought to you by FOX Rehabilitation. Fox clinicians work hard, love their work and get the respect they deserve. Sound good? Then you’ll love the autonomy to work in your own style and the support you get to achieve excellence. Plus, freedom and flexibility to have a personal life whether it’s your first day or you’ve been around for a while. Your contribution is acknowledged and rewarded. That’s what makes FOX a success. Happy, well-trained clinicians make great health care. Are you a fit for FOX? Find out now at foxrehab.org.
