Modifying the Program for Geezers Case Study: John C by Jonathon Sullivan MD, PhD, SSC | February 09, 2017 Background John C. is an 89 year-old WWII-era veteran and resident at an independent living facility for Seniors in the Detroit Metro area. He is an avid reader and recently has digested both popular press articles and biomedical abstracts on the role of strength decline in aging and the potential of training older adults for strength and muscle restoration and retention. In the course of his research, he discovered Starting Strength and our facility and elected to investigate the potential for barbell training in his own situation. John is in good health and retains fair mobility and balance. He is somewhat vision and hearing-impaired, but is still highly independent and engaged. He does feel that he is deconditioned and losing muscle and strength, and wishes to hang on to as much lean tissue and function as possible. Assessment John underwent the standard Greysteel initial interview and assessment on August 18, 2016. No absolute contraindications to barbell-based strength training were identified during the interview. I immediately noted that John has some degree of spinal immobility and thoracic kyphosis. His ability to stand fully upright is limited, and both his knees and hips are unable to extend completely. Nevertheless, he has minimal gait impairment, and is able to participate in virtually all activities of daily living. He occasionally suffers from mild “dizziness,” which he describes as lightheadedness without vertigo or pre-syncopal sensation, and he does have some diffuse joint pain. I determined that none of these findings constituted a contraindication to barbell training. After a very brief, low-intensity warmup on an exercise bike, I took John to the platform, where he demonstrated the ability to stand from a chair unassisted, using hip drive as in the squat. However, John displayed significant age-related degenerative shoulder and elbow mobility limitations which precluded any possibility of a standard barbell back squat. These same shoulder mobility limitations prevent him from attaining the top position of the standing overhead press, with the elbows locked in extension and the load balanced directly over the shoulder joints. For this reason, I made the determination that the press is contraindicated for John. John has mild-to-moderate thoracic kyphosis and could not lay flat for a standard bench press. However, he was able to assume a supine position on an inclined bench, with soft supports for his upper back, cervical spine and head. He then demonstrated the ability to perform an incline bench press with a broomstick without discomfort. Again, he has limited extension of the elbows, a potential safety issue, but it was determined that with very careful spotting this movement would be accessible and productive for him. Finally, John was able to deadlift an 8 lb kettlebell with absolutely no difficulty or discomfort. At this juncture, about 10 minutes after beginning the physical assessment, he expressed grave disappointment that no actual barbells had been utilized. In a fit of rank appeasement and optimism, I offered John the opportunity to attempt a standard barbell deadlift using a 15-lb technique bar and 5-lb technique plates. He successfully completed this exercise at 25 lbs without difficulty or discomfort. John tolerated the entire assessment well, and elected to undertake regular training. Prescription Based on John’s performance and limitations, I prescribed a training program for him focused on primary strength acquisition and muscle retention, with secondary improvements in exercise tolerance, mobility, and balance. Program John is somewhat deconditioned, but I felt he could tolerate a 2-day modified novice program with careful, judicious increases in loading. John began with the following modified novice program. Day 1 – MondayDay 2 – Friday Squat 3x5Squat 3x5 Barbell Curl 3x5Incline Bench 3x5 Deadlift 1x5Deadlift 1x5 As the deadlift progressed and became much heavier than the squat, I replaced the deadlift with conditioning work on Friday. Day 1 – MondayDay 2 – Friday Squat 3x5Squat 3x5 Barbell Curl 3x5Incline Bench 3x5 Deadlift 1x5HIIT: 60s rounds on stationary bike Exercise Selection and Modification John displays a number of structural and mobility limitations which indicate individualized exercise selection and performance. Squat: John cannot perform a back squat in the usual fashion, and although he can stand from a chair, I thought he was too weak to perform loaded squats to full depth. I therefore put him on a program of assisted chair squats. These rapidly progressed to unassisted chair squats, and then to loaded chair squats with kettlebells. All of these modifications were performed so as to emulate as closely as possible the low-bar squat and maximize recruitment of the posterior chain (hip drive). John has always performed his squats or squat variants at every session (Monday and Friday). John made excellent progress on this protocol and quickly exhausted the potential for progressive loading with kettlebells. He remained, however, too weak for a standard safety bar. Therefore I implemented a safety-bar analogue, using wrist straps around a 10-lb training bar. Knots were placed in the distal end of the straps for increased security of grip. On our first attempt, John demonstrated the ability to maintain the bar on his back below the scapular spines and perform an unassisted back squat to the chair. At the next session, we progressed to a 15-lb training bar capable of accepting standard plates. Once his squat had increased by a few more pounds, John was introduced to box squats at incrementally lower depths until he could perform a below-parallel low-bar box squat. Linear progression then took over in earnest. John performs a strap-assisted back squat to chair depth. John has since progressed to below-parallel box-squats. I do not presently contemplate removing the box. John’s proprioception and balance demonstrate age-related declines that, while they may demonstrate moderate improvement over time, will probably never permit safely or productively squatting without this adjunct. John touches the box with his glutes and then drives his hips up. He does not settle his weight onto the box. At the date of this writing John has attained a maximum of 3 sets of 5 at 81 lbs in this modification. He later developed mild unilateral knee discomfort during a warmup set of squats. His exam was unrevealing and he had minimal discomfort with non-loaded activity or with deadlifts. Given his demographic, I am always extremely judicious with John. I decided to deload the exercise by 20% until this discomfort resolved, which it did after a few sessions, and John is within a few workouts of re-attaining an 80-lb squat. Deadlift: John is able to perform the standard deadlift exercise, and has done so since his induction into regular training. He began with twice weekly deadlifts for single sets of five. As the deadlift grew heavier, it was relegated to Mondays only, for a single set of five. As the deadlift grew heavier still, we instituted a simple rep-progression approach for this exercise, as detailed in Practical Programming for Strength Training and The Barbell Prescription. He and his family have observed improvements not only in strength, but in his posture and gait. John began with a 15-lb training bar and 5-lb technique plates. On November 21, 2016, about 12 weeks into his training and 4 days before his 90th birthday, John pulled 100 lbs for a set of five. Currently, he deadlifts 125 lbs for reps. John performs the standard barbell deadlift. Pictured is the full extent of his spinal, hip, and knee extension, all of which have undergone mild improvement since the introduction of training. Incline Bench Press: Initial assessment suggested that John would be able to tolerate and progress on this modification. He performs this movement on Fridays. As previously noted, he requires careful spotting, but is able to perform the exercise without discomfort and demonstrates excellent control of the bar. Due to structural and mobility limitations he has reduced ability to retract the scapulae for optimal biomechanical performance of the movement, but he is progressing well. John started with an empty 15-lb bar. He currently bench presses 51.5 lbs for 3 sets of 5. John cannot lay supine on a flat bench, but can perform the bench press from a low incline position. Barbell Curls: John cannot safely perform the standing overhead press, which is the other standard upper body exercise in our program (in addition to the bench). While considerable upper body strength can be developed with the bench alone, the press is valuable in part because it is performed standing, which introduces the component of balance into the upper body workout. As a substitute for the press, I assigned barbell curls. These are not strict curls, but rather, as described in Starting Strength and The Barbell Prescription, a multi-joint movement that allows for the use of the shoulder joint. Barbell curls have a significant eccentric component, and were introduced only after John had gained strength on the bench and demonstrated that he was not particularly vulnerable to delayed onset muscle soreness. John started with a 10-lb training bar and advanced from there, training the movement on Mondays between the squat and the deadlift. Currently, he curls 44 lbs for 3 sets of 5. John performs standing barbell curls as a substitute for the standing overhead press. Bike Conditioning: Since the deadlift was relegated to once-weekly training, John finishes each Friday session with a high-intensity interval workout on the exercise bike. Currently, he performs at a resistance of “4,” 60 seconds on, 60 seconds off, for a total of five intervals, followed by a cool-down. I suspect that he detests this part of the workout, but he understands its importance and undertakes it with good humor. Recovery Factors As I am merely a coach, physiologist, and physician, I am proscribed by Michigan law from giving my clients individual nutrition advice. However, I directed John to resources he might find helpful. He maintains a moderate caloric excess and a target protein intake of 1g protein/lb bodyweight/day, with adequate carbohydrate and fiber intake. He does not track his macronutrients. John is in an excellent residential environment with good social support systems and a supportive, loving family. He has access to a primary care physician and follows up regularly. He does his best to maintain good sleep hygiene, and while he is physically active outside the gym (active rest), he does not engage in activities of such intensity or volume as to interfere with his recovery from training. He does not shoot heroin, smoke crack, or watch Reality TV. He lives clean. Response John’s progress on this program has been excellent, as documented above. His response follows the classic family of strength training curves to be expected in a novice of any age. Only the absolute load values, not the overall pattern of progress, reflect John’s nine decades of life. Aside from an idiopathic bout of mild knee pain (now resolved), he reports minimal to no soreness and improved function, strength, and stamina. This case demonstrates the ability of the octagenarian/nonagenarian to respond to training stimuli with improvements in strength and other fitness parameters, and illustrates how a classic novice program and exercise selection can be tailored to the limitations and needs of the individual athlete, with enormous potential to increase fitness, decrease frailty, and improve the quality of life of our most venerable and treasured fellow citizens.