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## Complete Summary

#### GUIDELINE TITLE

Progressive resistance training.

#### BIBLIOGRAPHIC SOURCE(S)

Mobily K, Mobily P. Progressive resistance training. Iowa City (IA):
University of Iowa Gerontological Nursing Interventions Research Center,
Research Dissemination Core; 2004 Feb. 28 p. \[31 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Mobily K, Mobily P.
Progressive resistance training. Iowa City (IA): University of Iowa
Gerontological Nursing Interventions Research Center, Research
Dissemination Core; 1998. 25 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Low muscle strength

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Geriatrics\
Nursing

#### INTENDED USERS

Allied Health Personnel\
Nurses\
Physical Therapists\
Physicians

#### GUIDELINE OBJECTIVE(S)

To improve and maintain the functional fitness of older adults through
Progressive Resistance Training (PRT)

#### TARGET POPULATION

Elderly patients with or at risk for low muscle strength and/or falls

#### INTERVENTIONS AND PRACTICES CONSIDERED

Progressive resistance training which involves the use of weights and
other forms of resistance (i.e., Therabands™) to provide resistance in a
series of exercises with intent of increasing muscle strength

#### MAJOR OUTCOMES CONSIDERED

-   Functional fitness performance as measured by the use of the
    Functional Fitness Assessment and Progressive Resistance Training
    (PRT) Management Monitor

-   Incidence and severity of falls before, during, and after
    Progressive Resistance Training program

-   Functional ability

-   Ability to carry on independent living and self-care activities

-   Patient-reported level of quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

MEDLINE searches using the following key words: strength training;
progressive resistance training; weight training; older adults; elderly;
senior citizens. Also the following key journals were used: Journal of
Aging and Physical Activity, Journal of Gerontology, Journal of the
American Geriatrics Society. The search was for publications from 1985
forward.

#### NUMBER OF SOURCE DOCUMENTS

56

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

A = Evidence from well-designed meta-analysis

B = Evidence from well-designed controlled trials, both randomized and
nonrandomized, with results that consistently support a specific action
(e.g., assessment, intervention or treatment)

C = Evidence from observational studies (e.g., correlational descriptive
studies) or controlled trials with inconsistent results

D = Evidence from expert opinion or multiple case reports

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Review by two experts using a common critique format.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Clinical Validation-Trial Implementation Period\
External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline has been implemented and evaluated in a senior center.
Articles which address this are:

Mobily KE, Mobily PR, Lane BK, Semerjian TZ. Using progressive
resistance training as an intervention with older adults. Therapeutic
Recreation Journal 1998; 32:42-53.

Mobily KE, Mobily PR. Reliability of the 60+ functional fitness test for
older adults. J of Aging & Physical Activity 1997; 5:150-162.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The rating scheme for strength of evidence (A,B,C,D) is defined at the
end of the Major Recommendations field.

**Assessment for Progressive Resistance Training**

Assessment for progressive resistance training consists of two separate
measures:

1.  Assessment of physical activity readiness

2.  Assessment of functional fitness

**Assessment of Physical Activity Readiness**

Prior to beginning this or any program of regular physical activity, the
older adult should be screened using any of a number of good health
screening devices (e.g. the **Physical Activity Readiness Questionnaire
\[rPAR-Q\])** (Evidence grade = B). Whatever health screening device is
used, anyone reporting a contraindication for exercise should obtain a
physician\'s approval to participate in the program.

**Assessment of Functional Fitness**

The most comprehensive assessment inventory is the 1996 **Functional
Fitness Assessment for Adults Over 60 Years** (Evidence grade = C)
developed by the Council on Aging and Adult Development of the American
Association for Active Lifestyles and Fitness, an association of the
American Alliance of Health, Physical Education, Recreation, and Dance
(AAHPERD).

The tests of fitness are designed to be administered under conditions of
minimal risk to the participant.

Measurement of each of the five functional fitness criteria is as
follows:

-   Flexibility

-   Agility and dynamic balance

-   Coordination

-   Strength and muscle endurance

-   Endurance

**Description of Intervention**

The following Progressive Resistance Training (PRT) intervention program
describes activities that should begin on a two-month, three workouts
per week basis.

The following activities should be performed as part of the PRT program.
During each 40-minute session, participants should complete the
following activities:

-   **Warm-up**. 5 minutes of light exercises designed to prepare the
    participant for muscle conditioning and to improve overall
    flexibility

-   **Muscular conditioning**. 30 minutes of exercises designed to
    improve muscular strength and endurance. Most of the exercises use
    *light weights* (hand-held dumbbells with typical resistance of 1 to
    10 pounds for most exercises) and are progressive in nature (i.e.,
    participant advances to higher demand levels at their own pace,
    according to personal ability to tolerate the exercises and
    accommodate the increases in demand). Generally, these exercises are
    performed for three sets of 8 to 10 repetitions each, progressing to
    three sets of 15 repetitions each.

-   **Cool-down**. 5 minutes of light exercises (using some of the same
    flexibility exercises employed in the warm-up phase). The purpose of
    the cool-down is to return respiration levels back to normal levels
    and to stretch the muscles worked in the exercise session.

This program is consistent with recommendations by the American Alliance
for Health, Physical Education, Recreation, and Dance and weight
training authorities.

Any number of exercises can be introduced. Generally, most older adults
in normal health are able to complete eight different exercises at a
rate of three sets per exercise in about 30 to 40 minutes without
discomfort. Introduce at least one flexibility/stretching exercise
within the context of the workout. Also, try to introduce exercises that
will work all parts of the body, and include:

1.  Upper extremities and shoulder girdle

2.  Trunk and abdomen

3.  Lower extremities and pelvic girdle

Some examples of exercises that are frequently used to work the various
parts of the body include the following:

-   **Arm curls**. Hand weights are held at the sides with palms
    forward. Posture is upright, feet about shoulder-width apart, head
    erect, eyes forward. The participant then slowly curls
    [one]{.underline} of the hand weights toward the shoulder with the
    hand remaining in a palm forward position at all times. The weight
    is slowly returned to the starting position and the opposite weight
    is curled toward the shoulder. Hence, the exercise sequence stresses
    alternating movements by each extremity at a slow rate up to 8 to 15
    repetitions with each limb. Participants should begin with weight
    they can curl about eight times with their weakest limb. Once the
    participant can perform the exercise 15 times with each limb for
    three sets, then he/she may want to increase weight by about ten
    percent.

-   **Shoulder shrug**. Hand weights are held at the sides with palms
    facing inward. Posture is upright, feet about shoulder-width apart,
    head erect, eyes forward. The participant slowly shrugs the
    shoulders simultaneously and then returns the shoulders to resting
    position. Progression should follow the pattern described above for
    the arm curl; start with eight repetitions and work up to 15, then
    increase weight.

-   **Leg lunge**. Hand weights are held at the sides with palms facing
    inward. Posture is upright, feet about shoulder-width apart, head
    erect, eyes forward. The participant takes a stride forward with one
    leg, leaning so that the lead leg supports the person\'s weight. The
    participant next returns to the starting position by pushing back to
    an upright standing position with the lead leg. The exercise is
    repeated with the opposite leg. One set consists of 8 to 15
    repetitions [with each leg]{.underline}. Normally, three sets are
    completed. Progression is as described above for arm curls.

-   **Toe raises**. Hand weights are held at the sides with palms facing
    inward. Posture is upright, feet about shoulder-width apart, head
    erect, eyes forward. Both feet are simultaneously plantar flexed so
    that the participant slowly rises up on the \"balls\" of the feet.
    The contracted position should be held momentarily and then the
    participant slowly returns to the starting position. Three sets of 8
    to 15 repetitions are normal with progression following the
    description given in for the arm curl exercise.

-   **Rowing**. The participant bends at the waist, supporting the
    weight with one hand and one knee (on the same side) resting on a
    weight bench, or another short, stable object (e.g., chair, piano
    bench). A single hand weight is then held by the non-supporting hand
    and allowed to dangle inferiorly. On commencing the exercise the
    participant slowly pulls the weight upward toward the trunk (in a
    \"rowing\" motion), then returns the weight to the suspended
    starting position. Eight to 15 repetitions are completed with each
    upper extremity for three sets. Progression follows the same pattern
    described in the arm curl section.

-   **Abdominal crunches**. The participant begins in a supine, lying
    position on an exercise mat. Legs are bent at the knees. No weight
    is used for this exercise, although a light weight may be used later
    by holding it behind the head with both hands. If the participant
    has no experience with this exercise, begin by just having the
    participant raise the head and \"look at his knees.\" It is not
    necessary to complete a traditional sit-up in order to improve
    abdominal strength. Start with 5 repetitions and progress to 15.
    Progression is implemented by increasing the difficulty of the
    exercise; the head raise method can be advanced as the participant
    demonstrates tolerance by picking the \"shoulder blades\" off the
    mat and finally by curling the chest toward the legs. [Make certain
    that the participant does not yank on his or her neck]{.underline};
    there should be ample space between the chin and the chest (perhaps
    place an orange or a tennis ball between chin and chest to ensure
    that the participants does not pull on his or her neck while the
    hands are placed behind the head). Pulling on the head may also be
    avoided by having the participant cross his hands across his chest
    while completing the exercise.

-   **Tricep extension**. Stand upright, feet about shoulder-width
    apart, head erect, eyes forward. The participant holds one hand
    weight and positions it behind the head with the elbow bent. The
    opposite hand is not holding a weight at this time. This starting
    position then has the weight behind the head with the hand holding
    the weight facing medially and the elbow facing forward. The weight
    is then slowly pushed superiorly (overhead) until the elbow is near
    complete extension. Eight to 15 repetitions [with each
    limb]{.underline} for three sets should be completed. Progression is
    as described in the arm curl exercise.

-   **Side bends**. Posture is upright, feet about shoulder-width apart,
    head erect, eyes forward. One hand holds a hand weight, while the
    other is positioned so that the hand is on the hip (iliac crest). To
    begin the exercise, the participant slowly bends side-ways to the
    side that has the weight. The participant then returns slowly to the
    starting position. This exercise is repeated 8 to 15 times on each
    side for three sets. The pattern for progression for this exercise
    is the same as for the arm curl.

-   **Quadriceps extension**. In a seated position (preferably a chair
    with arm rests), the participant hooks one foot under each end of an
    exercise band (e.g. Theraband™). While resting one foot on the
    floor, the other leg is then kicked forward (extended) against the
    resistance provided by the band. This exercise is repeated 8 to 15
    repetitions with each lower extremity for three sets. The exercise
    instructor should gauge the performance by having the participant
    begin with the lowest resistance band (bands may be purchased with a
    variety of tensile strengths). The participant should \"test\" the
    resistance provided by each band in turn until he/she determines the
    one consistent with performing eight to ten repetitions. Progression
    amounts to exercising with progressively more resistive bands when
    15 repetitions over three sets are performed comfortably.

-   **Hamstring curls**. In a standing position, the participant faces
    the back of a chair, or faces a window with a ledge the participant
    may grasp. Next, the participant stands on an exercise band with one
    foot, hooking the band under the sole of one foot. Next, he/she
    hooks the heel of the second foot under the free end of the band.
    While grasping the top of the chair or the window ledge the subject
    curls his/her leg by flexing at the knee, drawing the heel toward
    the buttocks on the same side. This exercise is repeated 8 to 15
    repetitions with each lower extremity for three sets. The correct
    resistance may be determined using the same procedure described
    above for the quadriceps extension exercise. Likewise, progression
    should follow the same procedure recommended for the quadriceps
    extension exercise described immediately above. The exercise
    instructor may have to help the participant position his/her feet
    correctly during the first few trials.

**Evaluation of Participant Outcomes and Process Factors**

In order to evaluate the use of this protocol among participants at risk
for low muscle strength, both outcome and process factors should be
evaluated.

**Outcome Factors**

Use the **Functional Fitness Assessment** (Evidence grade = C),
(described under \"Assessment of Functional Fitness\" in the original
guideline document) at one-month intervals following the start of the
PRT program. Compare baseline assessment with progress following each
month in the program. Also, the participant\'s functional fitness
performance may be compared to norms. An improvement in this functional
fitness should be observed following two months.

-   For the individual implementing the PRT program, this information
    will provide information about how effective the program is.

-   For the participant, this information can be rewarding and,
    hopefully, encouraging enough to motivate continued participation in
    a program of regular exercise.

The **PRT Management Monitor** described in Appendix C in the original
guideline document is an outcome measure that is based upon participant
interviews and that elicits specific information regarding the PRT
program and increases in functional fitness. Please use the Monitor on
an at least monthly basis.

Other participant outcomes may be included as dictated by the specific
aims of the program and for each individual participant. Examples of
other outcomes that can be assessed include:

1.  Record number of and severity of reported falls before, during, and
    after the PRT program.

2.  Record functional ability through standardized tests (e.g., tests of
    hand function, functional reach, sit-to-stand, timed up-and-go).

3.  Record reported ability to carry on independent living and self-care
    activities.

4.  Record any increases in the participant\'s reported level of quality
    of life.

**Process Factors**

A sample of the nurses and/or physicians who are using this protocol
need to be given the **Process Evaluation Monitor** (see Appendix D in
the original guideline document) approximately one month following
his/her use of the protocol. The purpose of this monitor is to determine
his/her understanding of the protocol and to assess the support for
carrying out the protocol.

**Rating Scheme for Strength of Evidence**

A = Evidence from well-designed meta-analysis

B = Evidence from well-designed controlled trials, both randomized and
nonrandomized, with results that consistently support a specific action
(e.g. assessment, intervention or treatment)

C = Evidence from observational studies (e.g. correlational descriptive
studies) or controlled trials with inconsistent results

D = Evidence from expert opinion or multiple case reports

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improve patient\'s prospects for independent living

-   Reduce risk of falls

-   Enhance commitment to regular exercise

-   Increase overall quality of life

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This evidence-based practice is a general guideline. Patient care
continues to require individualization based on patient needs and
requests.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Dissemination of assessment and outcomes management tools to appropriate
nursing areas at the University of Iowa Hospitals and Clinics.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Mobily K, Mobily P. Progressive resistance training. Iowa City (IA):
University of Iowa Gerontological Nursing Interventions Research Center,
Research Dissemination Core; 2004 Feb. 28 p. \[31 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2004 Feb)

#### GUIDELINE DEVELOPER(S)

University of Iowa Gerontological Nursing Interventions Research Center,
Research Translation and Dissemination Core - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

University of Iowa Hosptials & Clinics, Univeristy of Iowa College of
Nursing

#### SOURCE(S) OF FUNDING

National Institute of Nursing Research, NIH (Grant \# P30 NR03979)

#### GUIDELINE COMMITTEE

University of Iowa Gerontological Nursing Interventions Research Center
Research Dissemination Core

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Kenneth Mobily, PhD, CTRS; Paula Mobily, PhD, RN

*Series Editor*: Marita G. Titler, PhD, RN, FAAN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Mobily K, Mobily P.
Progressive resistance training. Iowa City (IA): University of Iowa
Gerontological Nursing Interventions Research Center, Research
Dissemination Core; 1998. 25 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core, 4118
Westlawn, Iowa City, IA 52242. For more information, please see the
[University of Iowa Gerontological Nursing Interventions Research Center
Web
site](http://www.nursing.uiowa.edu/products_services/evidence_based.htm).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on August 1, 1998. The information
was verified by the guideline developer on December 1, 1998. This
summary was updated by ECRI on June 8, 2004. The information was
verified by the guideline developer on August 5, 2004.

#### COPYRIGHT STATEMENT

This summary is based on content contained in the original guideline,
which is subject to terms as specified by the guideline developer. These
summaries may be downloaded from the NGC Web site and/or transferred to
an electronic storage and retrieval system solely for the personal use
of the individual downloading and transferring the material. Permission
for all other uses must be obtained from the guideline developer by
contacting the University of Iowa Gerontological Nursing Intervention
Research Center, Research Dissemination Core.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008