How to Get Our Older Adult Clients Confident With Activities of Daily Living

Below is an article I wrote for the RMTAO magazine ” Massage Therapy Today”. In it, I talk about the importance of exercise for older adults and why health care practitioners should get this age population moving !

Activities of daily living (ADL) are vital for independent living. ADLs can be defined as
routine activities done daily with little, to no assistance. These can be broken down into basic
ADLs and instrumental ADLs. Common basic ADLs consist of: transferring, toileting, bathing
and dressing. All are essential and necessary for an independent lifestyle. While instrumental
ADLs include: shopping and housework, again helpful towards living an independent lifestyle,
but not necessarily essential. ADLs are completed throughout life, however as we age, we begin
to lose some of the postural control and muscular strength we once had. Because of the decline in
strength and loss of postural control during aging, falls and accompanied injuries are likely to
occur more often during ADLs in older adults.
Falls commonly happen during ADLs that require transferring bodyweight, such as
walking and stair climbing (Robinovitch et al., 2012). This is possibly due to the older adult
shifting their bodyweight incorrectly. This transpires when their centre of mass falls outside of
their base of support, causing an increase in sway. For an active adult, young or old, this would
be easy to counteract because of muscular strength, proprioception and sense of balance.
However, this is a whole other story for an older adult whose muscle strength has declined, and
they do not feel comfortable or confident in moving as they once did.
This lack of muscle strength and lack of mobility can result in older adults not feeling
confident enough to move around and do activities that are important to everyday life (ADLs).
They may feel scared to do any activity because of the risk of a fall. This fear of falling can
create a cycle where an older adult may become more afraid to do certain activities by
themselves. The longer they wait to do them, the worse the outcome may become. This can lead
to a further loss of muscular strength, consequently causing them to do less than they were able
to do before. Turning into a greater loss of independence and an increase in that fear of falling.
One way to decrease the risk of falls and the fear of falling in the older adult population is
to promote physical activity. Exercises that do not present as a challenge, can easily be done at
home and do not create too much fatigue are great ways for older adults to maintain strength and
independence.
The common reason older adults start to limit their activities of daily living is due to
muscular strength (Robinovitch et al., 2012). A decrease in muscle strength leads to a flurry of
problems such as a change in posture, decreased mobility and increase in fatigability. A loss of
muscle strength is going to happen as we age, however the rate of which is lost can be slowed
down, if every day strengthening exercises are taught to older adults. If strengthening exercises
can be promoted within a clinic with older adults, an increase in overall wellbeing and sense of
independence can be restored.
Moreover, an easy way to see muscle imbalances and where possible weak muscles are,
can simply be done by evaluating an older adult’s posture. The typical posture among the older
adult population is seen as hunched back, decreased lumbar flexion, increased hip flexion and
forward head posture. This posture shows us there are muscle imbalances and stiffness among
the spine and surrounding joints. For example, the hips tend to be more flexed due to a loss of
muscle strength in the knee extensors. In order to compensate for the weakness, there is an
increase in hip flexion to take the load off those knee extensors (Hortobagyi, et al. 2003). Thus,
important strength exercises to teach older adults can range from hamstring curls and squats to

neutral rowing and Lat pulldowns. These four exercises alone will allow the strength to increase
in the quadriceps, hamstrings, glutes, and the back muscles, bringing the body closer to a neutral
posture. This neutral posture means less sway is occurring, therefore, there is more stability
within the body and a fall is less likely to occur.
Furthermore, the muscle stiffness found around the spine, hip, knees and ankles equate to
a lack of mobility. The decrease in mobility can occur suddenly (from trauma, such as falling) or
can be progressive over time. The progressive loss of mobility can be from factors such as
obesity and osteoarthritis and this is where preventive physical activity must be promoted with
older adults. (Rantakokko, Manty & Rantaneno., 2013). Again, the focus should be on
strengthening the lower extremities and increasing their confidence with balance activities. This
will potentially lead to increase in mobility of the joints that are important during sit-to-stands
and stair climbing. Most often, older adults do not realize the subtle changes they made to their
everyday lifestyle to make activities easier to do, such as walking slower or using an aid
(Rantakokko, Manty & Rantaneno., 2013).
So, common mobility exercises we can talk to our older adults clients about can include:
thoracic extension and rotation exercises, sit-to-stands, anterior pelvic tilts and shoulder blade
retractions. All these exercises can stretch the areas, and work the joints in the range of motion
they should be moving in. Even going for a walk every day around the block can increase an
older adult’s confidence that they are capable of living an independent life.
In addition to a lack of mobility from muscle stiffness in older adults, a feeling of fatigue
is commonly felt among older adults. Muscular fatigue in older adults can occur more quickly
after exercises and during ADLs, leading to a decline in independence (Enoka & Stewart, 1992).
Muscular fatigue is an acute impairment in the ability to exert force (Enoka& Stewart,1992). It
can contribute to already stiff joints (Gribble and Hertel, 2004; Lundin et al,1993), altered
proprioception (Ribeiro et al, 2006;Gribble and Hertel, 2004;Lundin et al,1993) and cause a
decrease in muscular strength (Forestieret al,2002;Vuillermeet al,2002; Moore et al,2005; Hatton
et al, 2013).
Apart from having the muscles fatigued, there is also the sense of fatigability.
Fatigability, which describes how fatigued a person gets in relation to defined activities, can be
reported as a ratio of self-reported fatigue to activity level work performance. The
higher the fatigability, the more likely a person is to terminate their activity before completion
(Eldadah et al, 2010). Therefore, it can be concluded that fatigue leads to reduced physical
activity (Moore et al, 2005)
Hence, it is important to also highlight endurance exercises for older adults. This can
mean showing isometric exercises where they hold a position for about 10 seconds at a time. The
main goal is to show these exercises as not challenging and something that can easily be added to
their everyday routine. Do they travel in a car every day? Tell them to do a chin tuck against the
head rest at every red light they hit. Do you find they have weak hips? Have your client
internally rotate their leg into a table while they’re sitting. As a massage therapist, it is important
to treat in all aspects, and that means promoting and educating our clients in strength training,
endurance training and mobility training.
As mentioned above, muscle stiffness and fatigue are limiting factors in an older adults’
independence with one of the causes being a decrease in muscle strength. As therapists, we can
work with clients to help decrease pain they may be feeling, decrease any tension in muscles that

may be contributing to a lack of mobility, but if the strength in the muscle is not where it should
be, the problems we are spending an hour to help with, will never truly be corrected. Once older
adults have the sense of strength returning and the feelings of pain and fatigability decreasing,
then introduce more types of exercise and even increase the challenge of the exercises, safetly.
Taking the time to educate older adults in movement and exercise can help regain their
confidence when it comes to activities of daily living.
This Winter, I challenge all of us to put the priority of introducing strengthening
exercises to our older adult clients. They are coming to us to feel better, so we owe it to them to
help them feel better in all aspects of their physical wellbeing.

Rantakokko, M., Mänty, M., & Rantanen, T. (2013). Mobility decline in old age. Exercise and
sport sciences reviews, 41(1), 19.
Robinovitch, S. N., Feldman, F., Yang, Y., Schonnop, R., Lueng, P. M., Sarraf, T.,Loughin M.
(2012). Video capture of the circumstances of falls in elderly people residing in longterm care:
An observational study. The Lancet, doi:10.1016/S0140-6736(12)61263-X
Moore, J. B., Korff, T., & Kinzey, S. J. (2005). Acute effects of a single bout of resistance
exercise on postural control in elderly persons.(author abstract).Perceptual and Motor Skills,
100(3), 725.
Eldadah, B. A. (2010). Fatigue and fatigability in older adults. Pm&r, 2(5), 406-413.
doi:10.1016/j.pmrj.2010.03.022
Vuillerme, N., Danion, F., Forestier, N., & Nougier, V. (2002). Postural sway under muscle
vibration and muscle fatigue in humans. Neuroscience Letters,333(2), 131-135. doi
10.1016/S0304-3940(02)00999-0
Forestier, N., Teasdale, N., & Nougier, V. (2002). Alteration of the position sense at the ankle
induced by muscular fatigue in humans.(statistical data included). Medicine and Science in
Sports and Exercise, 34(1), 117.
Hatton, A. L., Menant, J., Lord, S., Lo, J., & Sturnieks, D. L. (2013). The effect of lower limb
muscle fatigue on obstacle negotiation during walking in older adults. Gait & Posture, 37(4),
506-510. doi:10.1016/j.gaitpost.2012.09.004

Gribble, P. A., & Hertel, J. (2004). Effect of hip and ankle muscle fatigue on unipedal postural
control. Journal of Electromyography and Kinesiology,14(6), 641-646.
doi:10.1016/j.jelekin.2004.05.001
Lundin TM, Feuerbach JW, Grabiner MD. (1993) Effect of plantarflexor and dorsiflexor fatigue
on unilateral postural control. Journal of Applied Physiology;9:191-20.

Ribeiro, F., Mota, J., & Oliveira, J. (2007). Effect of exercise- induced fatigue on position sense
of the knee in the elderly.European Journal of Applied Physiology, 99(4), 379-385.
doi:10.1007/s00421-006-0357-8

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