Edited by: Gary Sinoff, University of Haifa, Israel
Reviewed by: Tomasz Kostka, Medical University of Lodz, Poland; Hein van Hout, Amsterdam University Medical Center, Netherlands
This article was submitted to Geriatric Medicine, a section of the journal Frontiers in Medicine
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The use of progressive strength training among the elderly has become an accepted part of evidence-based practice for preventive and rehabilitative care. Exercise is undoubtedly one of the pillars for resilient aging. While research has shown impressive outcomes from strength training, the challenge remains to get elderly persons to exercise. Here we describe a Finnish-Singaporean cross-national project that provides a unique opportunity to evaluate the implementation of strength training in settings where it had previously not been applied. We report from the first 2 years of implementation using assessment data and surveys directed to frontline therapists responsible for the implementation. The strength training concept was progressively implemented in 24 elder care locations in Singapore including residential homes, day rehab/care centers, and senior activity centers. Each location was provided with training, support, gym equipment and technology solutions. It remained for individual sites to enroll elderly to the program, to perform assessments, and to direct the progressive strength training. Based on data from the first 2 years of implementation, improvements in lower body muscle strength were found in Leg Curl (ave 11.1–48.8%), Leg Extension (ave 10.2–24.0%) and Hip Abduction/Hip Adduction (ave 7.0–15.8%). Of the trained therapists, 95% strongly agreed or agreed to some extent that the implementation had been successful. The practice-based evidence from the project has demonstrated that it is feasible to implement progressive strength training in real life settings, using technology. While the implementation initially required handholding and support, the approach yielded consistent improvement rates in muscle strength comparable to results from randomized clinical trials (meta-analysis studies). Significant improvement rates in muscle strength were found in all three types of sites, demonstrating that gym training can be employed broadly in elder care. The Senior Activity Centers offer an interesting model for reaching seniors with preventive actions at an early stage. The data support a 3-month training as an effective intervention of introducing strength training in elder care settings, promoting healthy aging.
The aging population presents a global challenge. Old age is often associated with limitations of physical function, frailty, chronic diseases, and a consequent increase in the need for health services which translate into a higher economic burden for the society. The decline in physical functions and onset of chronic diseases also affect the elderly's quality of life. This has triggered a societal investigation in attenuating the age-related decline in physical function while increasing the years on independent living. A growing body of systematic evidence supports the importance of both exercise therapy and physical activity as prevention and treatment of specific diseases (
Progressive strength training in particular, is an important exercise therapy (
While evidence-based research and practice have shown the importance of exercise and physical activity for health, the challenge remains to get people to exercise and to introduce exercise in clinical and other settings of elder care. There are many excuses not to exercise, but aging should not be one of them. The question is how to adapt academic research on evidence-based practices (EBP) to concrete situations “outside the laboratory” and embed them in the real world. This touches on the topic of “practice based evidence” (PBE) which is about developing evidence from real-life practices (
In the area of strength training Singapore's elder care has provided a unique opportunity for gathering practice-based evidence. Gyms for the elderly has not been part of standard practice, that is, none of the participating sites had previously applied gym technology for strength training. To facilitate the implementation three companies and a University partner came together to develop a solution. The package presents a combination of gym technology and assessment instruments making it possible to evaluate the persons' physical condition and training on a continuous basis. The project, Gym Tonic (
Each site was provided with a selected set of gym training machines (for core muscle group training), standardized assessments and targeted training for the therapists and specialists running the program. The adoption of new technology was planned as an implementation project. The companies provided the technological base for Gym Tonic (measurement devices, gym machines, and IT-solutions), and developed an integrated software solution for pulling different information systems together. The University partner played the role of research investigator, designing assessment protocols, training therapists and specialists from the participating organizations. To entice the elderly to first join and then stay on the Gym Tonic program, a behavioral change strategy was adopted, primarily making the exercise regime safe, simple, hassle-free and motivating.
Altogether the Gym Tonic concept comprises five key components:
The gym technology used for the strength training includes the following machines, Leg Extension/Curl, Leg Press, Chest Press, Lat Pull, Abdomen/Back, and Hip Abduction/Adduction (
The protocols for assessing physical functions were designed using existing and validated tests. The objective was to apply measurement technology whenever possible, thus giving the most accurate measures of physical functions. The assessment protocol (Welmed) included isometric strength measurements with Leg Extension/Curl and Hip Abduction/Adduction. The isometric strength measurements were conducted by attaching a Performance Recorder unit to the gym devices (
The training of clinical staff was conducted in Finland. Two persons from each site, mainly physiotherapists and exercise therapists, were sent to Finland to be trained. The 4-day course included performing the assessments, how to conduct progressive strength training with elderly, how to create an individual exercise plan, and lectures on exercise as medicine. In addition, 2 days were allocated for site visits to demonstrate how gyms for elderly are being operated in Finland. Four batches of frontline staff were trained in Finland during the first 2 years of implementation. After the training, the students had to perform five Welmed assessments in their own facilities cases prior to a written and practical exam (with a real participant) to be certified for Gym Tonic. The practical exams were carried out in Singapore, also giving the Finnish educators a possibility to audit the gyms and test sites to ensure data quality. The persons trained were given time to learn in practice before the final exam. Additional support was provided through five webinars during the 2 years of implementation. Some support was also provided by the local vendor in Singapore.
The recommended progressive strength training period for elderly was set at 3 months, twice a week with two sets of exercises at each machine. The average time for every session was around 30–45 min. The assessments were performed at the start and at the end of the training period, and follow-ups at 3-month intervals if the training continued. Printed participant profiles and progress reports were shared with the elderly when viable. The profile reports included target values developed for motivating the elderly to exercise. The progression of the training was suggested to be adjusted in terms of the repetition maximum (RM). The notation × RM means the resistance level at which one can do a given maximum number × of repetitions. A smaller number of maximum repetitions × mean s a higher resistance level. Resistance level had been set to 15RM for weeks 1–2, 10RM for weeks 3–7 and 8RM for weeks 8–12. Thus, with increasing load the maximum repetitions should go down. The sites were given freedom to roll out the implementation as they found best. It remained up to the Gym Tonic sites to enroll participants into the gyms, no rigid inclusion or exclusion criteria were used, as most people who have the capacity to function in a gym will benefit from strength training. The centers generally advised the elderly to seek doctor's clearance especially for those who had underlying medical conditions. It was up to the trained staff to perform the pre and post assessments, and to direct the progressive resistance training in the gyms with the help of assistants and other staff.
To entice the elderly to join (or even try) and stay on the program, we adopted a behavioral change strategy primarily to make the exercise regime safe, simple, hassle-free and motivating. Pre-training briefing was conducted, and the benefits of strength training was shared with them. To make it hassle-free, the elderly were welcome to exercise in their everyday clothes. Their pre-programmed exercises were automatically retrieved from their RFID smart card and there was no need for them to remember or manually adjust any loads. To make it simple and easy, training intervention was also kept short, around 30–45 min, and the elderly were only expected to exercise twice a week. During the training period, the therapists and specialists were encouraged to update the elderly on their progress.
The sites were given considerable freedom to roll out the implementation. This was deliberate as we wanted to evaluate the adoption of strength training in real environments. The main goal of the research was to learn from the implementation using the data, subsequently randomization, control groups etc. was not part of the set up. It was up to the sites to recruit participants to the program, based on who they thought could participate in gym training. Participation was voluntary and safety considerations were assessed by the health professionals at the sites. From clinical trials, we already know that strength training is very effective for the elderly. The PBE approach means taking what is known for from clinical trials, putting knowledge into practice, and evaluating the results. The main issue is then whether the adoption of the concept has resulted in successful outcomes or not. This can be evaluated mainly by comparing the results from practice to results research (meta studies) in the field. In addition, we used reference groups in Finland and Singapore where we had applied identical technology for both strength training and follow up. Finally, we targeted the frontline therapists with questionnaires to gather data on the experiences from the implementation.
We limit the discussion to the adoption of strength training and measurable outcomes mainly strength improvements.
A total of 24 locations in Singapore had adopted the Gym Tonic approach at the time of data analysis. Assessment labs/gyms had been successfully set up in three types of settings:
Residential Facilities (7 sites)—RES
Day Rehab/Dementia Day Care/Senior Care Centers (14 sites)—DAY
Senior Activity/Community Centers (3 sites)—ACT.
These were the number of sites that had received funding by the Lien Foundation for setting up the gyms. The pooled data obtained from the first 2 years of implementation provided the research data. Measurement and assessment data from 399 persons (72 ± 11.4 y, M 53%, F 47%) were included in the research database. These persons were checked and confirmed to have participated in at least one 3-month gym intervention period. During the implementation period about 1,500 participants had registered for Gym Tonic (
The Gym Tonic process and the data collection. Thousand five hundred participants were registered. The sites were asked to deliver data on those who had properly completed the 12-week training and the pre and post assessments (
Participant characteristics (
Age (y) | M | 65.3 | 11.8 | 72.4 | 11.6 | 69.8 | 7.8 |
F | 78.4 | 10.3 | 74.6 | 10.8 | 72.4 | 8.4 | |
BMI (kg/m2) | M | 24.0 | 4.1 | 23.5 | 3.9 | 24.5 | 3.5 |
F | 23.6 | 4.9 | 24.6 | 4.4 | 25.8 | 4.7 | |
ADLh (0–6) | All | 0.85 | 1.06 | 0.67 | 0.88 | 0.00 | 0.00 |
CPS (0–6) | All | 2.01 | 1.06 | 1.29 | 1.26 | 0.24 | 0.49 |
COMM (0–8) | All | 1.95 | 1.86 | 1.22 | 1.53 | 0.27 | 0.83 |
The effectiveness of training was analyzed from a before and after perspective comparing pre and post exercise assessments (
Pre-post changes for tests (
LegExt Right (kgf/kg) | M | 0.97 | 1.07 | 10.2 | 0.021 | 1.08 | 1.20 | 11.0 | 0.000 | 1.47 | 1.56 | 6.1 | 0.307 |
F | 0.67 | 0.79 | 18.6 | 0.004 | 0.76 | 0.87 | 13.7 | 0.000 | 0.87 | 1.02 | 16.3 | 0.000 | |
LegExt Left (kgf/kg) | M | 0.96 | 1.07 | 11.5 | 0.021 | 1.04 | 1.17 | 12.6 | 0.000 | 1.39 | 1.61 | 16.0 | 0.006 |
F | 0.68 | 0.79 | 17.4 | 0.002 | 0.76 | 0.87 | 14.6 | 0.000 | 0.82 | 1 | 21.3 | 0.000 | |
LegCurl Right (kgf/kg) | M | 0.43 | 0.52 | 20.8 | 0.001 | 0.52 | 0.57 | 11.1 | 0.001 | 0.69 | 0.87 | 24.0 | 0.009 |
F | 0.33 | 0.39 | 19.8 | 0.079 | 0.34 | 0.43 | 28.3 | 0.000 | 0.38 | 0.52 | 36.0 | 0.000 | |
LegCurl Left (kgf/kg) | M | 0.40 | 0.53 | 31.6 | 0.000 | 0.49 | 0.55 | 12.7 | 0.008 | 0.67 | 0.85 | 27.7 | 0.000 |
F | 0.31 | 0.40 | 32.4 | 0.013 | 0.33 | 0.42 | 25.6 | 0.000 | 0.34 | 0.51 | 48.8 | 0.000 | |
HipAbd (kgf/kg) | M | 0.73 | 0.82 | 12.9 | 0.000 | 0.77 | 0.81 | 5.1 | 0.011 | 1.1 | 1.16 | 6.3 | 0.073 |
F | 0.60 | 0.68 | 13.9 | 0.011 | 0.60 | 0.66 | 11.4 | 0.000 | 0.77 | 0.84 | 9.3 | 0.001 | |
HipAdd (kgf/kg) | M | 0.77 | 0.86 | 11.7 | 0.001 | 0.88 | 0.95 | 7.3 | 0.000 | 1.26 | 1.35 | 7.0 | 0.037 |
F | 0.68 | 0.72 | 6.0 | 0.117 | 0.62 | 0.72 | 15.8 | 0.000 | 0.76 | 0.86 | 13.9 | 0.000 | |
FTSTS (sec) | M | 15.04 | 14.60 | −2.9 | 0.298 | 15.73 | 14.65 | −6.9 | 0.094 | 12.39 | 10.43 | −14.6 | 0.067 |
F | 15.49 | 13.29 | −14.2 | 0.295 | 17.67 | 16.09 | −8.9 | 0.019 | 13.42 | 11.89 | −11.4 | 0.005 | |
BBS Short (score 0–16) | M | 9.92 | 10.82 | 9.0 | 0.006 | 8.62 | 9.45 | 9.7 | 0.005 | 13.11 | 13.11 | 0.0 | 1.000 |
F | 9.31 | 9.84 | 5.7 | 0.329 | 8.05 | 8.83 | 9.6 | 0.017 | 12.2 | 12.33 | 1.0 | 0.698 | |
FAT (%) | M | 22.77 | 22.17 | −2.6 | 0.164 | 22.28 | 22.22 | −0.2 | 0.764 | 22.91 | 23.28 | 2.4 | 0.365 |
F | 33.18 | 33.68 | 1.5 | 0.685 | 35.05 | 35.64 | 1.7 | 0.033 | 36.59 | 36.7 | 0.3 | 0.774 | |
SPEEDN (m/s) | M | 0.81 | 0.90 | 11.4 | 0.030 | 0.69 | 0.69 | −0.8 | 0.753 | 1.02 | 1.01 | −0.1 | 0.980 |
F | 0.57 | 0.56 | −1.7 | 0.697 | 0.60 | 0.65 | 8.5 | 0.061 | 0.89 | 0.94 | 5.2 | 0.197 | |
SPEEDF (m/s) | M | 1.11 | 1.21 | 8.7 | 0.024 | 0.95 | 0.97 | 1.8 | 0.576 | 1.56 | 1.6 | 2.7 | 0.679 |
F | 0.77 | 0.76 | −0.8 | 0.869 | 0.83 | 0.86 | 3.3 | 0.263 | 1.29 | 1.33 | 2.8 | 0.367 |
Average strength results (kgf/body weight) for a subgroup of 37 participants who trained for an extended period. LegExt_R, leg extension right leg; LegExt_L, leg extension left leg; HipAbd, hip abduction; HipAdd, hip adduction; LegCurl_R, leg curl right leg; LegCurl_L, leg curl left leg.
For comparison of outcomes, we used two smaller datasets, one from Singapore and one from Finland, where we had used identical assessment methods and gym technology for training with elderly (
Post-pre change in terms of improvement rate calculated as mean (post-pre)/mean (pre) for Right Leg Extension and Curl strength for Gym Tonic (
Individual exercise data was obtained from each training machine, providing the opportunity to analyze the progressiveness of the resistance training during the intervention period. The starting training load was calculated as the average for the first 2 weeks of training, and the ending load as the average of the final 2 weeks of the 90 days training period. The data indicated that the training was progressive with the load increment at an average of 21% toward the end of the intervention. Compared to the reference groups the progressiveness was somewhat lower. The average increase in training loads was 36% (F) and 57% (M) for the Ageility group and about 58% for FIN80 group.
The implementation process was evaluated using surveys. The survey studies were done about 3 years after the start of the implementation giving the respondents enough time and perspective to evaluate the implementation. Survey #1 was sent to those who had participated in the training in Finland (Group 1), and a total of 40 out of 49 answered (response rate 82%). Survey #2 was posted to those actively working with Gym Tonic, but not trained in Finland (Group 2), and a total of 22 out of 41 answered the survey (response rate 54%). At the time of answering the questionnaire, 70–80% of the respondents worked full time or part time with Gym Tonic.
The results from the two surveys were similar, we have therefore pooled them (
Implementation questionnaire. Staff responses of those trained in Finland for Gym Tonic (
On the open ended questions what had contributed to the success of the implementation the following factors were emphasized: strong sponsorship by foundation, good support by management, user friendly system, motivated trainers, seeing elderly improve after post-tests, good location of Gym Tonic sites (near persons' homes), good support from vendors, safe machines, dedicated staff and volunteers, proper training and good planning. On the question what had contributed to the lack of success the following causes were mentioned: lack of manpower, lack of trained staff/physiotherapists, finding suitable pool of participants, lengthy assessments, lack of supervision/follow-up, restrictions from supervising levels, lack of understanding of concept in the business sense, and lack of management's understanding of the program.
This study has provided a comprehensive overview of implementing strength training in different elder care settings. Several lessons can be learned from the PBE viewpoint. The most important lesson is that strength training can be implemented successfully in real settings producing effective and repeatable outcomes. The study data showed significant improvements in muscle strength in each of the three settings including those living in the community and those residing in facilities. In terms of outcomes, the improvement rates in muscle strength were comparable to those reported in meta-analysis of research studies by for example, Lopez et.al., observing increases of 6.6–37% in maximal strength of strength training and multimodal training (
The data driven approach provided relevant information for understanding the implementation process. Several practice patterns could be drawn from the data. The first 3 months of resistance training produced the largest improvements in muscle strength. This suggests that a relatively short exercise period can be used for improving physical strength, where after the challenge is to maintain it. This finding is based on a relativiely small data set (
The surveys suggested that the implementation had been successful from the view of frontline staff. The adoption of new technology succeeded without major hurdles. Both therapists and specialists could be trained with a relatively short training course in the use of different technologies and applying strength training for elderly. The sites were able to independently plan and carry out the proposed interventions based on the training given. This is encouraging as training is usually a major component of implementing new concepts. The main challenge in the training was the cultural change of putting elderly persons in gyms. These issues had to be covered relatively extensively in the transition from a physically passive fall prevention to physically active fall prevention. From a policy perspective, the Senior Activity Centers offers an interesting model for reaching a large number of elderly in the community. In a densely populated city like Singapore such centers can be set up conveniently. Finally we may point out that the comprehensive assessment approach adopted here is in line with the philosophy behind the concept of intrinsic capacity (IC) as promoted by WHO (
The Gym Tonic project offers important insights and directions on how to implement progressive strength training on a large scale across different elder care settings. The following conclusions can be drawn from the study:
Positive outccomes:
The approach yielded consistent improvement rates in muscle strength comparable to results from randomized clinical trials (meta-analysis studies) showing that effective outcomes can be achieved in real life environments.
Significant improvement rates in muscle strength were found in all three types of sites demonstrating the vast potential of strength training to promote resilient aging.
The data supported a 3-month training intervention as an effective way of introducing strength training, this could be useful for policy makers looking for practical solutions in the war against frailty.
Frontline staff were successfully trained in the use of the technology for gym training and assessments, suggesting that technology solutions can be applied in real life practice for strength training.
Practice patterns could be detected using the data-driven approach highlighting the need and capabilities of information and assessment systems for decision making and continuous quality improvement.
Lessons learned:
Although frontline staff underwent structured training, some of them may not adhered fully to our assessment and training protocol due to manpower and other factors. To improve this, the project introduced regular refresher courses and also frequent on-site visits to improve the overall compliance.
Initially most organizations were using physiotherapists to run Gym Tonic, thus limiting the scalability of the programme given the high manpower cost and scarcity of resources. Many of them switched to hiring exercise therapists or wellness coaches, while leaving the physiotherapists to handle the more complex cases, for example elderly who are very frail and/or with medical conditions (especially those in the nursing homes).
While participants were briefed on their pre-assessment and post-assessment results prior and on completion of the intervention, some may not be able to comprehend and relate the results to their ADLs. Helping the trainers to explain and better relate the results this were improved and included in the training.
Getting community-dwelling frail elderly to participate is logistically challenging as transport and sometimes, caregiver may be needed as many of them need at least supervisory assistance. In addition, the time needed for them to complete the exercise is typically longer. To address this, most sites are now using the afternoon non-busy/quiet period (from 1–3 pm) to handle such elderly so as to give them more quality time and supervision.
As the data grows more lessons can be drawn for introducing strength training for elderly. The greatest challenges do not seem to be technological, but rather changing of mindsets and implementing concepts that work. This study was done to increase that knowledge. More practice-based evidence is needed for the industry, policy makers, and for an aging population to motivate people to use exercise as a key remedy and medicine for resilient aging.
The datasets generated for this study will not be made publicly available The researchers were given access to the data for analysis, but not make it publicly available.
Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.
MB and FB analyzed the data and wrote the paper. KT, GL, and LN have read and commented on the manuscript. All authors contributed to the article and approved the submitted version.
MB is a co-founder of RaiSoft. KT is a founder of Pulse Sync. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
We thank Lien Foundation for funding the technology and training for the project.