Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 194

Beginning in 1990,¹³⁰ with the first report of high‐intensity resistance training in nonagenarians, it has been shown that exercise interventions inclusive of robust resistance training increase muscle strength in frail older individuals.^17,131‐133 As expected, most of the studies reported improved strength using resistance training programmes^132,133 or multicomponent exercise interventions, including resistance training.^17,131 Nevertheless, some studies did not find significant changes in muscle strength in this population, which may be related to the use of home‐based exercise interventions,¹³⁴ few weight‐bearing exercises,¹³⁵ or very low workloads¹⁰⁶ that may not have provided sufficient stimuli for inducing strength gains. The use of scales of perceived exertion rather than strength testing to guide progression of loads during resistance training in frail older people is another factor that may limit the stimulus and consequently reduce the magnitude of adaptations.¹³⁶

Exercise interventions also reduce the incidence of falls in older adults with physical frailty.^{17,133,135,137} Most studies have used multicomponent exercise programmes including the combination of resistance training, balance and/or gait retraining,^17,135 and (less commonly) only resistance exercises¹³³ or an alternative exercise intervention such as Tai Chi.¹³⁷

Several trials have also investigated the effects of exercise interventions on gait ability in frail older people, with conflicting results. Whereas some studies showed improvements in gait ability after the physical training period,^{17,132,138,139} others found no improvement.¹⁷ Interestingly, the bulk of studies that demonstrated enhancements in gait ability utilised multicomponent exercise programmes,^{4,17,138‐140} while others used only resistance exercises¹³³ or a combination of aerobic training and yoga.¹⁴¹

Based on the evidence that multicomponent exercise interventions are more effective in improving most, if not all, of the frailty syndrome hallmarks (i.e., poor balance, reduced muscle strength, poor gait ability, and increased incidence of falls), it is recommendable that this type of intervention, which includes resistance training, gait retraining, and balance exercises, among others (i.e., occupational therapy) be prescribed to prevent frailty syndrome in the elderly, as well as in people with pre‐frailty.^5,6,136,142 Recently, the Vivifrail Project, an EU‐funded project that is part of the Erasmus+ programme, focuses on providing training and design material to promote and prescribe such physical exercise in older adults^143‐145 (www.vivifrail.com).

In addition, because of the strong associations between functional capacity test performance and muscle power output or rate of force development in the healthy elderly,^6,92,95 explosive resistance training has emerged as an essential intervention to improve functional capacity in older adults, including those who are frail.^5,6 Indeed, in a 12‐week multicomponent exercise programme including explosive resistance training applied in institutionalised frail nonagenarians, improvements were observed in muscle cross‐sectional area, muscle fat‐infiltration, maximal strength, muscle power output, balance, gait, and sit‐to‐stand ability, along with a reduction in the incidence of falls.^4,17 Therefore, explosive resistance training should always be considered in exercise interventions to improve frail older individuals' functional capacity.

One potential adverse event related to muscle power training is injury to tendons/cartilage, particularly of the rotator cuff and knee, where degenerative tears are commonplace,¹⁰⁴ or exacerbation of abdominal/inguinal hernias.¹⁴⁶ Interestingly, a systematic review of the effects of resistance training in frail older adults reported only one case of shoulder pain related to resistance training intervention out of 20 studies and 2544 subjects.¹⁴⁷ Notwithstanding, to prevent injuries that could interrupt the exercise programme and its benefits, screening for such problems is critical, care must be taken in the workload and volume progression, and heavy and repetitive workloads, as well as unfavourable positioning (such as an overhead or military press in rotator cuff disease), should be avoided.