Healthy aging is more than the absence of disease, according to the World Health Organization (WHO): “For most older people, the maintenance of functional ability has the highest importance” (WHO 2015). Colin Milner, founder and CEO of the International Council on Active Aging in Vancouver, British Columbia, echoes these comments. “When looking at the healthy aging market today, the focus is all about function,” he says. “The World Report on Ageing and Health (WHO 2015) focuses on function as a key element, because loss of functional abilities significantly impacts life quality. Having a chronic health issue, like diabetes or high blood pressure, is manageable, but if I can’t stand up, everything changes.”
What’s driving the relevance of functional training? (1) Older adults are a growing demographic, and (2) people are living longer. By 2030, the number of adults aged 65 or older in the U.S. will more than double to approximately 71 million (Papa, Dong & Hassan 2017). A man reaching age 65 today can expect to live, on average, to be 84, and a woman can expect to be 87 (Social Security Administration 2017). This presents an opportunity from a third driver: healthcare costs. “From a revenue perspective, active older adults are the only fitness market that’s still growing and doesn’t have enough trainers to serve them,” says Ken Baldwin, director of education and training for Perform Better Australia in Brisbane. “Loss of independence puts great stress on our health systems. . . . Certain countries are already looking at how qualified fitness professionals can help this demographic.”
Lifelong physical activity, combined with specific functional training, is key to maintaining physical independence. Ability losses that are typically age-associated are really related to how one’s life has been conducted (WHO 2015). Fitness professionals who intend to work with older adults need to understand functional training basics. “To be maximally effective, a trainer will need to individualize an exercise program within six functional domains: neuromuscular; musculoskeletal; balance; mobility; cardiorespiratory; and cognition,” says Cody Sipe, PhD, vice president of the Functional Aging Institute in Searcy, Arkansas. While movements overlap several domains, Sipe says a deeper understanding of each one is important when designing maximally effective programs.
This article gives an overview of functional training, along with current research and insight into the following pillars: strength, balance, mobility and cardiovascular fitness.
First and foremost, according to Sipe, functional training is an outcome, not a method. Carol Ewing Garber, PhD, past president of the American College of Sports Medicine, adds: “The idea of functional training is to design a fitness program that mirrors common daily life activities, like getting out of a chair, making a bed, lifting laundry baskets, going shopping, gardening, etc. In older adults, as fitness declines . . . many find it increasingly difficult to do usual tasks or to engage in enjoyable activities. Functional training is important for all adults, because declines in physical function occur over a period of years. When one has lost enough fitness to notice these changes, they have been building up gradually over time.”
Here are key characteristics of functional training:
It entails specific goals. Functional training both promotes overall life quality and particularizes programs to promote strength, endurance and mobility. “Learning is specific to the task,” says Mary E. Sanders, PhD, adjunct professor and clinical exercise physiologist at the Reno School of Medicine in Nevada. “The training outcome has to be learning a skill that’s important, practical and impacts quality of life.”
It involves movement patterns and integrated fitness. “With functional training, we think about which movements and fitness components—strength, aerobic endurance, etc.—contribute to a particular activity,” says Garber. “Functional training combines aspects of multiple components, also termed multimodal exercise, because [in] activities of daily living [ADL], a movement might require flexibility and strength or muscular endurance and aerobic fitness or neuromotor fitness—balance, agility and coordination—and aerobic endurance.” Functional exercises include pushing and pulling, rising and lowering, rotation, locomotion, and more.
It involves assessment and individualization. Designing functional training programs is highly individual because older adults vary widely. Some may need help getting out of bed, while others need to know how to compete athletically with pre-existing, age-related conditions. “Terminology is important here,” says Pat VanGalen, MS, owner of Active and Agile, from Glenmont, New York. “Training is for functional health, fitness and performance. I use a tier system.”
It must be progressive. Experts stress progressive training and continual evaluation and program modification to address new goals. “Designing training programs for older adults should begin where they are, include gradual progression of intensity, duration and complexity, and consider both mental and physical comfort,” says Terry Ferebee Eckmann, PhD, professor and chair of the teacher education and kinesiology department at Minot State University in Minot, North Dakota. For example, many clients may need to begin with 30-minute sessions because that’s all they can tolerate.
Numerous studies show that progressive resistance training is a foundation to begin training and can improve functional capacity in older adults, including aspects of gait, balance and stability (Papa, Dong & Hassan 2017). It also benefits cardiovascular function, metabolism and heart disease risks (WHO 2015).
Increasingly, studies emphasize that muscle power—the ability to produce force rapidly—is more crucial to functional fitness than strength and mass are (Gianoudis et al. 2014). And, most recently, researchers have suggested that the importance of trunk muscles for balance and mobility in older adults has been underestimated or overlooked and that exercises for these muscles should be incorporated into programs to promote balance, functional performance and fall prevention (Granacher et al. 2013).
A research overview of progressive resistance training for functional abilities highlights the principles of specific goals and individualization. “You have to clearly set goals,” says Urs Granacher, PhD, faculty of human sciences in the division of training and movement sciences at the University of Potsdam, Germany. “If your aim is to fight dynapenia (loss of strength) or sarcopenia (loss of muscle mass), you have to focus on high-dose resistance training (70%–80% of 1-RM). If your aim is to improve mobility, then power training and core strength training are appropriate.”
Another functional training basic is balance, since progress in other fitness domains for older adults with compromised mobility is difficult without stability; balance training may improve the safety of certain cardiovascular activities (WHO 2015). Balance is a highly complicated system that involves sensory input, information processing and motor output.
“In general, frailer individuals need to work on static and slow dynamic balance tasks such as tandem stance, seated center-of-gravity control, standing weight-shifting, reaching and ankle/hip/step strategies,” says Sipe. “Higher-functioning individuals need to focus on dynamic balance tasks such as multidirectional stepping and lunging, agility patterns, and gait enhancement. Eventually they work toward reactive balance challenges, where a surprise perturbation is applied and they must react to maintain balance.”
Researchers note that high-challenge balance training or programs that incorporate exercises that target both muscular and somatosensory balance systems have been most effective for reducing fall risks in older adults (Gianoudis et al. 2014).
“Joint mobility is the core of functional movement,” says Sipe. The ability of joints to maintain full range of motion is highly relevant to enjoying functional independence in combination with muscular strength for tasks such as getting up off the floor or in and out of a bathtub. Very little research, however, focuses specifically on how to improve flexibility, and there is conflicting information regarding the relationship between flexibility interventions and functional outcomes (Stathokostas et al. 2012).
“Terms like flexibility need to be revisited, especially in light of how they’re measured,” notes VanGalen. “We need to consider flexibility versus mobility, one joint versus multijoint versus total kinetic chain integrity. [We need to think about] mobility to do what, how well, how often and in what environment.”
Practitioners agree, and preliminary research suggests that activities like yoga, Pilates or tai chi—that involve movement through a full range of motion—are effective (Campos de Oliveira, Goncalves de Oliveira & Apgrecida de Almeida Pires-Oliveira 2016). Studies of older men and women using a combination of stretching and rhythmic movements (yoga and tai chi) through full ranges of motion have shown improvements equal to supervised static stretching (Chodzko-Zajko et al. 2009). More research is required.
From a functional perspective, cardiovascular fitness is important for climbing stairs, going shopping and enjoying recreational activities; it also reduces cardiovascular disease risks and promotes mental well-being (Garber et al. 2011). Current research supports the physical activity guidelines of regular moderate- and vigorous-intensity exercise for those who can achieve it and regular light- to moderate-intensity activity for deconditioned persons, for health benefits. Any exercise is better than none (Garber et al. 2011). New research suggests that health improvements can be achieved at even lower doses of activity and that higher levels of exercise intensity and interval training for those who are able may provide more cardiovascular fitness, but whether these lower doses and higher intensities can achieve more risk reduction remains unclear (Fielding et al. 2017; Garber et al. 2011).
Aquatic exercise improves cardiovascular and muscular endurance and ADL performance in older adults, as reported by numerous studies (Sanders et al. 2016). Cardiovascular training is effective in water when correct protocols, speed and movements are used. A 2017 study validates the reliability of a shallow-water run test in comparison with a land-based treadmill test (Nagle et al. 2017). “The shallow-water run test is an important start to quantifying alternate methods to assess cardiovascular health and may lead to new outcome measures for people limited by land exercise,” says Sanders.
“Research in functional aging has increased exponentially over the past 10 years,” says Sipe. “Many different approaches all work to a certain degree, but no one specific approach is equally effective for everyone.” Best training practices continue to evolve. Older adults are highly diverse; many have chronic conditions. Trainers need extra education.
“Our responsibility as coaches and trainers is to prepare individuals to live, work, play or compete to the best of their ability in planned and reactive situations, to add purpose to living life for life,” says VanGalen. Fitness professionals who embrace functional training have an opportunity to transform lives and support older adults—not only adding years to their lives, but adding life to their years.