Move Forward Guide
Physical Therapist's Guide to
Sarcopenia and Frailty
Frailty is a common syndrome among older people. It's associated with an increased risk of falling and increased hospitalization, disability, and death. The risk of becoming frail increases in the oldest-old, especially those aged 80 or older. Most older adults in nursing homes are frail. Sarcopenia, which is a decrease in the amount and quality of muscle, is a major contributor to frailty. The 5 factors for frailty are:
- Unintended weight loss (more than 10 pounds in the past year)
- General feeling of exhaustion 3 or more days per week
- Muscle weakness
- Slow walking speed
- Low levels of physical activity
- Keep moving! The more you sit or lie down, the more strength and energy you'll lose, and your heart health will be affected, too.
- You might feel overwhelmed by thought of moving around, but you can start slow and make small changes.
- Your physical therapist can work with your health care team or with you individually or in a group to safely improve your strength, speed, and balance—so you can get back to the activities you want to do!
- Having an exercise partner increases your chances of success.
What Is Frailty, and How Does Sarcopenia Contribute to It?
Not all older people are frail. You may be considered to be frail if you have 3 of 5 factors:
- Unintended weight loss (more than 10 pounds in the past year)
- General feeling of exhaustion on 3 or more days per week
- Muscle weakness
- Slow walking speed
- Low levels of physical activity
Having 1 or 2 of the above factors might indicate a risk for frailty, called "pre-frailty."
Frailty is a vicious circle. If you feel exhausted, you are more likely to just "sit around" or lie in bed. In turn, being inactive results in a loss of muscle and strength. When the quality and quantity of muscle decreases (sarcopenia), your cardiovascular system is affected too, and your energy reserve decreases. So, because it takes so much effort for you to move, you move less. Think of it this way: people with less leg strength and less muscle mass than people who are stronger actually use almost 90% their energy reserve to maintain their walking speed, whereas the people who are stronger use only 64%.
How Can a Physical Therapist Help?
Your physical therapist will perform an evaluation that includes:
- A review of your history, including any weight loss, health conditions, previous falls, and any devices that you might be using for stability, such as a walker or cane
- A review of your medications, especially to identify whether they might be contributing to your feelings of fatigue and whether they might interfere with increased exercise
- Tests for walking speed (called "gait speed")
- Tests of leg strength, such as ability to rise from a chair
- Muscle strength tests, such as grip strength
- Distance walk tests to measure your exercise capacity
- Tests of your balance and your risk of falling
Your physical therapist will serve as an important member of your health care team and will work closely with you to design a treatment program. Your physical therapist's overall purpose is to help you reach your goals for mobility and activities that are meaningful to you.
Your therapist will show you how you can start slow and make small changes. You can do this even while you're watching TV: you can stand up during each commercial for the entire length of that commercial, and then sit back down again.
Improve Your Strength and Speed
Your physical therapist will design exercises targeted to strengthen your legs and your trunk:
- Different muscle groups might be exercised on every other day; that way, every day you can exercise without tiring out one part of your body too much.
- You're likely to get the best results by exercising often, with increasing weights and multiple sets
People with sarcopenia and frailty can make very rapid progress during the early part of their rehabilitation. Research shows that physical therapist-supervised, high-intensity exercise is not harmful to people with frailty.
Because sarcopenia and frailty can make you move slowly, your therapist will monitor how fast you are able to do your strengthening and walking exercises. For instance, the therapist might instruct you to do one set of an exercise as fast as possible, decreasing the weight if necessary. The therapist might use intervals of fast-paced walking and chair stands. You also might be asked to increase your speed during training for daily activities such as dressing.
Return You to Your Daily Activities
Physical therapists design what's called "functional exercise," which can help you resume activities that you've had difficulty doing or stopped doing. Special exercises and training will increase your confidence in your ability to keep your balance and reduce your risk of falling. The exercises might be done with a group and might include folding clothes in a standing position, vacuuming, emptying and loading a refrigerator, making a bed, and getting in and out of a bed.
Improve Your Balance and Agility
Because falls are common in people who are frail, your physical therapist will develop a balance training program that might include:
- Practicing tasks of stepping up and down a stair with and without support
- Rapidly changing directions while you walk
- Walking on different type surfaces and with different lighting, such as with sunglasses on or under bright light
- Turning your head while you’re walking or doing tasks
Educate the Family
Your physical therapist can educate both you and your family about the negative effects of prolonged sitting and bed rest. The therapist will show how to use a pedometer to count the number of steps you take, a timer to signal the need to get up and move, and how to reduce your dependence on aids such as scooters or lift chairs. Your therapist will help you set goals for the number of steps to take (a target within 10,000 steps per day is recommended) and how much aerobic activity to do.
Modify Your Home for Safety
Your physical therapist will work with you and your family to modify your home to reduce hazards that might put you at a higher risk of falling. Modifications might include:
- "Anchoring" area rugs to avoid slips and trips
- Moving cords to avoid trips
- Changing the lighting to decrease glare and increase light
- Bathroom adaptations such as rails and grab bars
When you get stronger, your physical therapist can work with you to find an activity group or an exercise partner, so that you can
Can this Injury or Condition be Prevented?
The best treatment for sarcopenia and frailty is to prevent them from ever happening. Physical therapists can evaluate frailty risk factors in older people who are living in the community and provide:
- Strengthening exercises and physical activities designed to prevent sarcopenia
- Balance training and fall-risk assessments
Research indicates that community exercise programs encourage participation in social and physical activity and that specific strengthening and balance exercise may be particularly useful for people who are identified as "pre-frail."
Real Life Experiences
Mary L. is an 87-year-old woman who lives with her daughter's family. Her daughter has brought her to a physical therapist because her physical activity level and mobility are declining. The physical therapist conducts an evaluation and learns that Mary had ovarian cancer 20 years ago and currently has atrial fibrillation, high blood pressure, and urinary incontinence. She is taking 8 medications, which increases her risk of falling, and has fallen twice in the past year without a fracture. She feels exhausted, has lost 15 pounds in the past year, and sits or lies down for almost the whole day. She isn't able to rise from a chair without assistance, walks very slowly, and can't walk more than 30 feet before sitting down. Balance tests show that she has trouble keeping her balance.
A high-intensity exercise program (2 or 3 times per week for 8 weeks) to strengthen her leg muscles doesn't improve Mary's ability to get around in her community, but she does begin to walk longer distances. The physical therapist decides to develop a "circuit training program" of activities important to Mary, such as folding towels, setting a table, walking to answer the phone, dressing, making a bed, emptying small trash cans, and sweeping. The first time Mary attempts the circuit program, she is constantly on the move for a half hour, never asking to sit down. Her daughter incorporates household activities at home that quickly result in Mary cooking, getting herself out of bed in the morning, dressing herself, and having a more positive mood.
After 18 weeks of physical therapy once per week, Mary's walking speed and walking distance and and her ability to get up from a chair have improved dramatically, and balance testing indicates that her risk of falling has decreased. Mary's physical activity has improved from 380 steps per week to 11,000 steps per week—and she is able to attend her granddaughter's college graduation.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in geriatric physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with sarcopenia and frailty.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of frailty. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Peterson MD, Gordon PM. Resistance exercise for the aging adult: clinical implications and prescription guidelines. Am J Med. 2011;124:194–198. Article Summary on PubMed.
Cesari M. Role of gait speed in the assessment of older patients. JAMA. 2011. Article Summary on PubMed.
Gine-Garriga M, Guerra M, Pages E, et al. The effect of functional circuit training on physical frailty in frail older adults: a randomized controlled trial. J Aging Phys Act. 2010;18:401–424. Article Summary on Pubmed.
Hairi NN, Cumming RG, Naganathan V, et al. Loss of muscle strength, mass (sarcopenia), and quality (specific force) and its relationship with functional limitation and physical disability: the Concord Health and Ageing in Men Project. J Am Geriatr Soc. 2010;58:2055–2062. Article Summary on PubMed.
Ling CH, Taekema D, de Craen AJ, et al. Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. CMAJ. 2010;182:429–435. Free Article.
Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38:105–113. Article Summary on PubMed.
Snyder A, Colvin B, Gammack JK. Pedometer use increases daily steps and functional status in older adults. J Am Med Dir Assoc. 2010 October 7 [Epub ahead of print]. Article Summary on PubMed.
Avers D, Brown M. White paper: strength training for the older adult. J Geriatr Phys Ther. 2009;32:148–152, 158. Article Summary on PubMed.
Fritz S, Lusardi M. White paper: "walking speed: the sixth vital sign" [erratum in: J Geriatr Phys Ther. 2009;32:110]. J Geriatr Phys Ther. 2009;32:46–49. Article Summary on PubMed.
Hubbard RE, Fallah N, Searle SD, et al K. Impact of exercise in community-dwelling older adults. PLoS One. 2009;4:e6174. Free Article.
Peterson MJ, Giuliani C, Morey MC, et al. Physical activity as a preventative factor for frailty: the health, aging, and body composition study. J Gerontol A Biol Sci Med Sci. 2009;64:61–68. Free Article.
Daniels R, van Rossum E, de Witte L, et al. Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res. 2008;8:278. Free Article.
Orr R, Raymond J, Fiatarone Singh M. Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials. Sports Med. 2008;38:317–343. Article Summary on PubMed.
Bohannon RW. Number of pedometer-assessed steps taken per day by adults: a descriptive meta-analysis. Phys Ther. 2007;87:1642–1650. Free Article.
Marcus RL, Graybill CS, Lastayo PC. Impaired muscle and mobility: the road from menopause to frailty. Clin Obstet Gynecol. 2007;50:776–789. Article Summary on PubMed.
Janssen I. Influence of sarcopenia on the development of physical disability: the Cardiovascular Health Study. J Am Geriatr Soc. 2006;54:56–62. Article Summary on PubMed.
Acknowledgments: Dale Avers, PT, DPT, PhD, and APTA's Section on Geriatrics