Anyone coaching older adults, just make sure
you're checking their fracture history, you know,
if they do have any of those fragility fractures
or things that could indicate that they have
low bone density. Maybe you can even ask them
if they have their bone density report and you
can make sure that you have all the information
and you know exactly what their baseline bone
health status is like. Hi, Amy. It's my pleasure
to have you on Evidence Strong Show. If you could
briefly introduce yourself. Hi, thanks for having
me, Alex. Great to talk about another, you know,
research, study and exercise with someone who's
pro -exercise. So my name's Amy Harding. I'm
a research fellow from Griffith University. I'm
in the School of Allied Health, Sport and Social
Work. So I've been researching musculoskeletal
conditions for about 10 years now. I'm currently
working on an MRFF funded project. So that's
like an Australian government funded study. study,
the stop fracture study, and we're implementing
a referral pathway to exercise and trying to
embed that into the osteoporosis model of care.
So from a little bit of a different background
than maybe some of your people that follow you
and watch you. Now, the background is very relevant
because today we're talking strength training
and aging. So let's try to build some kind of
background. What would you have to say about
aging? Well, it's a privilege, obviously, to
become old. But we know from all of the demographic
data that's coming out about the population in
Australia and in a lot of countries that the
percentage of the population that are older is
increasing. And we've also got life expectancy
that's increasing. So we know that people are
living for longer and we want to try and keep
them healthier for longer as well. So I guess
in Australia, the Australian Institute for Health
and Welfare did a report a couple of years ago
and they said that one in six Australians were...
over 65, which is 16 % of the population. That
might not seem like much in relative terms, but
when we talk about absolute terms, that's 4 .2
million older people. So that's a big chunk of
the population. So aging itself, back to your
question, what happens when we get older? Well,
specifically with musculoskeletal conditions,
we're thinking about things like sarcopenia.
So that's like loss of muscle mass and muscle
strength and function. Osteoporosis, which is
my area of interest. That's reduced bone density
and an increased propensity to fracture. And
then we've got other things like osteoarthritis.
So we see our joints, our cartilage starts to
get a little bit, you know, worse for wear as
well. Apart from musculoskeletal conditions with
aging, we've got metabolic, neurological, cardiovascular
conditions. So there's lots of things that can
deteriorate as we get older. But the great thing
is exercise can ameliorate all of those conditions.
So keeping active is really important. Probably
the other thing to remember is that one in four
older adults have a fall every year. So falling
is also a really big risk of injury for this
group. So that's something else that can also
be improved with exercise. So that's your balance.
Falling, let's just add a little bit of relevance.
So the fall is a problem already because it's
a risky event. But then what happens after the
fall is risky too. Could we speak a little bit
about that? Yeah. So when we're thinking about
older adult that fall, a lot of them will have
low bone density. So they might have osteopenia
or osteoporosis. So the fall itself might not
be that bad. It might be something like a trip
or a slip. So from standing height hitting the
ground. So not particularly, you know, a big
change in height. the fall. But they can have
things like fractures, you know, fracturing their
wrist, bones in their hand, their shoulder. But
the big one is really fracturing a hip. So when
some people, older people fall, they might fracture
their hip. They have some really bad health outcomes
after that. So a lot of them will lose their
independence. So they need to go and live in
aged care or even worse, they just remain in
hospital. Their health deteriorates. Their morbidity
and mortality is huge with hip fracture. So when
we're thinking about falling, the kind of big
one we want to avoid is the hip. fracture. So
let's talk a little bit about your PhD and two
other studies associated with it. The goal is
simple, get people better, but specifically what
you are aiming for. Yeah, so I guess our research
group has always been interested in musculoskeletal
conditions. My supervisor for my PhD, who's now
my kind of my boss in my research role, she had
done a study called the Liffmore study with one
of the other PhDs in our research group. So the
Liffmore study was looking at a particular kind
of exercise program. So that was a high intensity
resistance and high impact training program.
So we call that HIRED just for the acronym. So
that training program was in postmenopausal women
with low bone density. So they had an osteopenia
or osteoporosis. So that original study, the
LIFTMORE study was done by Dr. Steve Watson and
they found some really fantastic results in that
study. So they had really excellent increases
in bone density. at the spine, some changes in
the hip and some geometric changes as well. So
sometimes we can have changes in the geometry
of the proximal femur or the femoral neck that
will make it more resistant to fracture. So you're
making the bone stronger because it's changing
its geometry, but it may not necessarily been
changing the actual density. So there's some
other kind of factors that come into play there.
So the LIFTMORE study basically found that it
was effective at reducing their risk of and reducing
their risk of fracture. So they had better balance.
They had better muscle strength, better mobility.
Therefore, you know, if you're less likely to
fall, you're less likely to fracture. And the
bone density was also increased. So their bones
were stronger and they were less likely to fall.
So overall, that's a fantastic result. Awesome.
And then you decided to do your study. So what
your study was about? Yeah. So then we decided,
well, we know this exercise program is effective
in women. Now we need to know if it's equally
as effective. in men. So we just replicated the
same exercise protocol in older men. So that
was 45 and older, and they had a low bone density
as well. So we use a particular kind of machine
called a DEXA scanner or a bone density scanner.
So we should be able to quantify what their bone
density is like when they join this study. So
every participant in our study, the LIFMOR for
men study had osteopenia and osteoporosis. So
that's just low bone density or low bone mass.
So then we did the same protocol with the high
-risk exercise program. And we did that for eight
months. And we basically did a whole lot of measures
before and after the eight months. So we could
look at the fall and fracture risk the same as
what we did in the LIFTMORE study. All right.
So I think it's a good time to, because coaches
will be super interested to hear about what the
program, the exercise program consisted of. Yeah,
sure. So the program, the high -risk program
was high -intensity resistance and high impact.
So the high -intensity... resistance component
was some compound movement exercises using barbells.
And we aimed for 80 to 85 % of one repetition
maximum or one RM. So that was different exercises
that are targeting specific muscles around the
bones that we want to try and increase the density
of. So that's the spine and the top of the femur,
the top of the thigh bone. So we did a deadlift
and squat and then an overhead prep to get some
axial load as well. So they were the three resistance
training exercises. exercises. The impact exercise
was kind of like doing a chin up on a chin up
bar and then dropping to have a little bit of
a heavy impact on the ground. So that was, we
call it like a drop chin. So some people might
be familiar with like drop jumps and things like
that. So that's where we're working on getting
impact through the bones. That's awesome. And
how was it twice a week, three times? How often
the participants were? Yeah, they did twice weekly
exercise. So we think that that's a good achievable
amount for people. Also, a lot of the recommendations
for resistance training and older adults out
there really say twice weekly strengthening.
So we thought that was something good that people
could fit into their calendar. So something achievable
twice weekly. All right. And you'll run the study
for eight months. Yeah, we did eight months.
Generally, when we're talking about being able
to detect changes in bone density, you need at
least a minimum of six months. Six to 12 months
is kind of the range that most researchers will.
work on. Anything less than six months, it's
a little bit unlikely that you'll be able to
detect change using the kind of device that we
scan the bones on. So that's the bone density
or the DEXA scanner. So we've just added a little
bit more for the eight months just to make sure
we were catching everything. So the changes in
the muscle will be visible even to the naked
eye will be visible faster probably, but bone
requires repetitive loading for a long period
of time. Why do you think it is? So bone density...
It's just the way that all the little cells work
in the bone kind of microenvironment where they
actually need a full kind of remodeling cycle.
So they lay down little bones, kind of little
cells chew away at the bone and then some other
cells move in and lay down new bone density.
So that's quite a kind of long process in comparison
to when we're looking at muscle changes like
hypertrophy or hyperplasia. They happen a lot
faster. So that's why some of the studies look
at bone density. take a little bit longer. How
did you structure the progression? Yeah. So the
intensity we were aiming for was 80 to 85 % of
1RM. So we did some 1RM testing and a couple
of time points in the study as well, just to
ensure we were at the right intensity. We also
used a Borg scale. So some coaches might be familiar
with that. That's a scale where you can kind
of, I guess, a participant or a client can stand
there and kind of rate how hard the exercise
is based. on a scale. So we used a 6 to 20 Borg
scale and they were aiming for 16 and higher.
So that was kind of another way of being able
to ensure we're in the right intensity. I did
all of the coaching of the classes myself and
I find people are really responsive, even individuals
that have never really been in a gym before,
to being able to quantify their intensity by
using repetitions in reserve. So that's where
you're able to kind of train them and teach them
that how many reps did you feel like you... could
do after you'd finished your set. If you felt
like you had two or three more in the tank, we
can add a little bit more load to the barbell.
So that's a really easy way of the client also,
or the participant being able to control what
their intensity is like as well. Okay. In terms
of testing, so one repetition maximum with older
adults, some people may be a little bit reserved.
What would you say to that? Well, we did it in
our study at 12 and 24 weeks. So they had a little
bit. of time. They'd developed their technique.
They were familiar with the exercises, their
tissues, and that it had time to adjust to that
kind of activity, particularly for people where
they're not familiar with doing the gym and they
might be a novice, so to speak. I found that
was quite easy to do. If you've developed a good
technique with people and they understand why
they're doing what they're doing, 1RM testing
is completely fine for me. I understand reservations
some coaches might have. really easily do like
a 3RM or a 5RM or even just an AMRAP as well
is a really great way of checking intensity.
So you can use some online calculators to work
out what kind of load they need to be at to get
a certain intensity. In respect to your question,
me, myself, I had no issues with the 1RM testing.
It was fine. Okay. In terms of participants,
how did they perceive the program? I guess we
started with a familiarization period where they
developed a real... good foundation. So they
had really good movement patterns. And then we
just gradually, you know, increased the load
over time. They felt really comfortable. They
knew that I knew what I was doing and they understood
what the exercises were targeting and why we
were doing that kind of program so they could
improve their bone health and, you know, reduce
their risk of fallen fracture. Generally, you
know, older people might be a little bit turned
off by the gym. It's not some an environment
that they like. But I think when people know
that ultimately they're going to be healthier.
They're going to be happier. They're going to
have a longer life. They're going to reduce their
risk of lots of conditions. They might not particularly
like the exercise, but you know, they know that
they need to do it. And gradually, once you get
past that kind of three month mark, you see people
really going, oh, you know what? I actually really
like this. This is great. Like, I feel like I'm
coming in. I'm doing something that people don't
expect me to be able to do. I feel really like
empowered. So I don't know that I think. People
get a switch once they get past that like six
month mark or that three month mark where they're
like, oh, wow, this is actually great. So we
actually did some interviews after the completion
of the study with all the participants. And a
lot of them had continued to do resistance training,
either set up a little gym at home or even gone
and engaged an exercise physiologist or like
you, a physio who was continuing to do some exercise
programming for them. So they'd, you know, completely
fallen. in love with exercise and resistance
training. So yeah, I think if people know that
it is good for them, it will like drive them
to do it a little bit. I even see that the work
you guys doing could have some, the clinic could
have some collaboration with weightlifting gyms
or powerlifting gyms in the area and just send
these people to the coaches there and where they
can keep the group environment, the encouragement
and the progression so they actually get stronger
and have opportunity to be involved. in competing
or, you know, just supporting other people who
do the same. I think that could be a really good
collaboration. Our research group, we were really
lucky in that we have a great head of our research
group, Professor Belinda Beck, who's been my
mentor for 10 years now. So we found all of these
great results from our studies, like the one
that I did for my PhD, the LIFMO for men and
the LIFMO for women before that. So then we did
another study with another PhD after mine called
the MedEx OP study. So they replicate. the same
exercise program again. And we found all of these
results and Professor Belindebeck was like, this
is too good not to be able to have people out
there accessing. This is so good for health and,
you know, reducing fracture, reducing falls.
We've got to roll it out in the public. So she
actually started the bone clinic in Brisbane.
So that's a translational research facility that
she runs. So people can go there and do the exercise
program, which is called the Enero exercise program.
So that's exactly. based on what we did in all
of our studies. So they can go to the clinic
in a real world scenario and do the exercise
program with an exercise physiologist. And they're
having some fantastic results over a number of
years now, more than six years in the clinic
at the bone clinic. And that exercise program
and Nero is also at allied health clinics all
around the world and around Australia. So we
found this fantastic program and now people can
go and do the evidence -based. program exercise
professionals. So that's really fantastic. That's
amazing. You used something called biodensity.
So could we talk a little bit about that? So
this is a kind of machine that was, I guess,
a little bit more popular in North America than
it was here. So we had this biodensity machine
and there wasn't too much research about the
effectiveness and the safety of it. So that biodensity
machine is essentially kind of a multi -station
machine where you're doing a near maximal isometric
contraction. So it was kind of like a chest press,
a leg press, a stimulated kind of deadlift and
almost like an underhand chin up. So some kind
of similar movements to what we had in the high
rate protocol. So that biodensity machine, we
then thought, well, we can also look at that
in our study, lift more for men. So they were
the two groups. One group did the high rate program.
One group did the biodensity machine. We matched
the frequency for the two groups as well. That
biodensity machine now is the OsteoStrong so
that people might be familiar with that name.
There's a few centers popping up around Australia
now. Generally they only recommend or the manufacturers
recommend once weekly so we just did the twice
weekly just so it was matching the frequency
for the two groups in the study. We were looking
at about 35 in each group so they had really
good compliance almost 78 percent completed the
whole eight months which is generally quite good
in a research study kind of setting. So yeah,
then we then did the same measures pre and post
and we compared all of the results between the
two groups. We did a really quite a big suite
of measures. I guess kind of the key ones were
related to bone density. So that was using the
DEXA. So we looked at lumbar spine, femoral neck
and total hip bone mineral density. So that's
just like the massive bone at particular parts
of your skeleton. We also looked at scan. parts
of the forearm and the leg. It's something called
a PQCT or a peripheral quantitative computer
tomographer. That's basically a 3D scan. So the
bone density scanner is only two dimensional.
This PQCT scan is 3D. So we can look at the volume
and the area of the bone and the muscle as well.
And then we also did a lot of other measures
that coaches might be familiar with, like things
about balance and mobility. So tandem walk, climbed
up and go five. times sit to stand, functional
reach tests. So some kind of battery of pretty
commonly used tests in, I guess, exercise studies.
So that would facilitate comparison with other
studies as well. So yeah, a whole lot of measures
that we looked at, all really indirectly related
to a fall and fracture risk. Amazing. All right,
are we ready for the results? Okay. So I guess
that the kind of the key things were with the
results that the higher group saw a 4 .1 % increase
in lumbar spine bone mineral density. which is
really fantastic because as we age, we tend to
see a decline in bone density. So even maintaining
or increasing bone density is something that
is fantastic. So that was the kind of the main
key result. They also increased their trochanteric
bone mineral density. So that's a particular
part of your femur where a lot of muscles attach.
And that was 2 .8 % increase there. So some really
good improvements in the bone density. That was
also a little bit higher than what was observed
in the biodensity. group when we did the between
group comparisons. So yeah, slightly better increases
in bone density for the high rate group versus
the higher density group. You mentioned that
then the natural history is that people lose
some bone density as we age. Well, how much of
a loss it is? That varies a little bit depending
on what ethnicity and what kind of age bracket
you're looking at. But generally, it's about
in the realm of 2 .5 % per year for men, slightly
more for women. after menopause with the withdrawal
of estrogen, they get a little bit more of a
rapid and more marked decline in bone density
than men. So maintenance of bone mass is an excellent
outcome and then even improving it is even better.
So we know from some of the research out there
that, you know, even a one to two percent increase
in bone mineral density can translate to a five
to ten percent reduction in fracture risk. Are
there any tools to predict or without sending
participants? clients for DEXA scans, are there
any way to assess bone health in older adults?
I guess when you're thinking about risk factors
for fracture, you can really ask some very easy
questions to determine that, like a history of
fragility fracture. So that means a fracture
from a trip or a slip or even something as simple
as coughing or twisting. So if you have a fracture
in the past, that automatically increases your
risk of having subsequent fractures. So that's
a really easy question to ask. If you're a coach,
when you're doing your, you know, pre -screening
with someone, you know, have you had a fracture?
What kind of denarii around are those fractures?
And then you can work out if maybe it wasn't,
you know, a low trauma or a minimal trauma fracture.
Age, obviously, the older we get, the kind of
most likely the lower your bone density. So you
can ask them, you know, what the age might be.
If they're drinking alcohol or smoking cigarettes,
that's some other kind of key risk factors for
fracture and poor bone health. So you can ask
some of those questions independently. of having
the bone density scan. That's something really
easy for coaches to do. But generally, I think
most women over 50 probably most likely would
have had a DEXA scan done or a bone density scan
done. So there's heaps of great resources out
there. Healthy Bones Australia, if any coach
is interested in learning a bit more about bone
health, pop Healthy Bones Australia into your
search engine and they've got fact sheets on
there. You can learn a lot more about osteopenia
and osteoporosis. So I think that's a really
good starting point. point if you're a coach
out there and you don't know too much about this
this world yeah start with that that's a really
good resource as well all right so in terms of
bone density you found improvement how the participants
how did they do in other manner yeah so they
um increase their muscle cross -sectional area
in their forearm which is um which was great
as well and some of the geometry of the bone
at the forearm and the leg improved for the higher
group not too many changes in in the those kinds
of things for the biodensity group. So yeah,
HIRA was definitely superior with some of those
geometric changes and the muscle cross -sectional
area. Some of the other things that improved
were the five -time sit -to -stand and the timed
up -and -go. So the HIRA group saw some improvements
in their, just their general mobility and physical
function as well. Yeah, their five -time sit
-to -stand for the HIRA group improved. We also
did some handheld dynamometer. So that's like
a little device you can measure. muscle force
with. They also improved their back muscle and
leg muscle strength as well. So, you know, as
you would expect with any kind of compound movement,
barbell by 80 to 85 % of 1RM, we saw strength
improvement. So that was great. And that was
actually more in the higher group than what we
saw in the biodensity group, which I guess would
somewhat be related to it being an, you know,
isometric or a near isometric contraction. They're
not really going through a lot of, you know,
eccentric, concentric. movements there. Awesome.
I have a question about the biodensity. So you
said that it was effective in improving bone
density in the axial, so kind of, you know, this
direction. So the bones like spine and hip bones,
thigh bones, these would be the ones that are
influenced, not so effective in influencing the
upper body bone density, would you say? Yeah,
it didn't have too much effect at the radius
in the forearm. we did those PQCT scans or those
3D scans. Why do you think it happened? I think
with the, I guess the population that we're looking
at, they were, you know, relatively untrained,
I guess you could say, like not many of them
had any background doing resistance training
or any kind of strengthening exercise. They were
generally doing a lot of just weight bearing,
cardio based walking, you know, stair climbing,
jog, little bit of jogging, cycling, so non -weight
bearing. activity. So really, I guess they did
have enough stimulus to get a little tiny increase
in bone density, but nothing too significant.
Definitely the higher rate group was superior
with the bone density changes. Okay. And the
exercise also gave participants that increases
in the functional tasks. So they opened better
movers and bigger muscles. Yeah. All that good
stuff that we love about resistance training.
It seems like not all... not only the intervention
was effective, but it was life changing. So these
people changed their lifestyle after having the
support for eight months. No doubt that that
was very smooth introduction to strength training,
very structured, monitored, safe. And after that,
they decided this is good for me. I will continue.
Yeah, definitely. I think I'd really instilled
in them how important it was for them to focus
on their health and if they wanted to age well
to continue. to be active you know you try and
reduce your time being sedentary make sure you're
doing weight bearing exercise like still do your
walking still do your cycling your swimming all
the things you love but make sure you keep doing
your resistance training and your impact and
those additional kind of balance exercises so
we don't want you to fall we want you to stay
upright we want you to stay strong so yeah they've
continued I really instilled in them how important
it was I think I gave them a good kind of foundation
like I said earlier to exercise and resistance
training and they've just continued on, which
is really nice to see. Some of them had, you
know, aside from all the measures we took, they
just reported how much better they felt, how
much more energy they had, how better, how much
more their joints and their function were better.
They had, you know, their knees that would be
like, oh, I've got a bit of a niggle in my knee.
The knees felt better. The hips felt better.
Their back felt better. And I was like, yeah,
this is what happens when you do resistance training
and you... doing it properly and you're doing
the right exercises and the right weight. So
I think coaches out there, it's really important
that they're there supervising, making sure people
have the right technique, making sure they've
got the right load progression. Yeah, all of
that good stuff that exercise scientists, you
know, exercise physiologists and physios can
do to help people keep living healthy long lives
and keep them out of hospital. So let's bring
it all together. What would be your advice for
coaches who want or will work with? older adults?
Yeah, so I think anyone coaching older adults,
just make sure you're checking their fracture
history, you know, if they do have any of those
fragility fractures or things that could indicate
that they have low bone density. Maybe you can
even ask them if they have their bone density
report and you can make sure that you have all
the information and you know exactly what their
baseline bone health status is like. There's
also some other really good resources out there
like Healthy Bones Australia, so you can make
sure. sure you increase your knowledge in that
area. Also the Exercise and Sport Science Australia
position statement on exercise prescription for
the prevention and management of osteoporosis.
God that's a mouthful but that was a paper that
was published back in 2017 in the Journal of
Science and Medicine in Sport. It's a really
excellent summary of osteoporosis and fracture
risk and then it goes through exercise kind of
programming and prescription for these older
adults. that might have low bone mass. And you
can kind of risk stratify them to determine what
kinds of activities and what kind of repetition
range, intensity range, and what kind of impact
you can do, depending on some of those easy questions
to ask, like fracture history and their bone
density results. So yeah, if you're interested,
make sure you check that one out. That could
be a good place to start. Also the Nero program,
you know, that's the licensed program where you
get a lot of additional training in the bone
health area. coaches like exercise physiologists
or physios were interested, you can also find
out more about the Nero exercise program. You
can access that online. They've got the Nero
Academy website, so you can check that out online.
I guess the important thing to remember is that
when we're thinking about older adults, improving
muscle strength, reducing their falls risk is
key. We know that most fractures happen when
people fall. So if you can prevent even the first
fall, you can hopefully prevent, you know...
90 % or nearly all of their fractures. And make
sure we keep the messaging positive as well about
what you can do. Supervision, you know, exercising
with the coach, watching you, making sure you've
got the correct technique, correct load progression
and intensity. That's really important as well.
So yeah, I guess just keep doing what you're
doing. Coaches always try and keep learning more,
particularly if it's an area that you might not
know a lot about. And there's heaps of good resources
out there. well. Anything special coaches should
be aware with postmenopausal women? I guess also
maybe check what other kind of medical conditions
and medications they might be on, particularly
if they are on any of the anti -osteoporosis
medicines. That's probably something important
to keep in mind, particularly if they decide
to discontinue any of those, just to keep a check
on everything and make sure they don't have any
change in their symptoms or any other pain or
niggles that are kind of on. going that might
need some further investigation, but generally
I think everyone should be doing resistance training
and strengthening their bones and muscles. People
might not realize that exercise can improve your
bone density. There's still a lot of people in
the clinical space and a lot of patients that
think that their bone density will never be improved
with anything but medication. So it's important
for coaches to know that exercise can improve
your bone density, which is key. Awesome. Thank
you. Two short questions. To finish, the first
one is what is your favorite exercise, like specific
exercise in the gym for you? What do you like?
I really like a deadlift. I really love any row,
anything row related. I used to love training
back in the gym. So I love the bent over row
that's just with a barbell. It feels so good.
I haven't been in the gym as much lately, but
I'm hoping I'll get back in there and I'll be
deadlifting and rowing. Awesome. Where people
can find you online if they want to follow? We
will ask a question. Where should they go? Yeah,
I'm on Twitter. I'm not particularly active,
but if you shoot a question or you follow me
there, so Amy underscore T underscore Harding.
I've got my photo there too, so you'll be able
to see the bright red hair in the picture. It
should be easy to find. Generally, if you wanted
to find me, you can just search Griffith University.
And if you pop my name in, it should take you.
We have like a little kind of staff research
page. And that should have my email address on
there too. Yeah. So you just feel free to reach
out. That's pretty much it. Twitter and emails.
That's where you'll find me. Awesome. That's
enough. Thank you so much, Amy. It was a pleasure.
Thanks, Alex. Great to have a chat and everyone
keep exercising. Yes.