The Old Do Not Need Gentle Movement

Picture from NRI Nation

I was very surprised to read that older adults need more than gentle movement. They need strength. Yes, a lot of stength if you read the following review by Toien et al (2025). This is in contrast to current guidelines which recommend low to moderate intensity (60-70 percent of 1 RM) and slow to moderate concentric velocity.

The review showed convincing benefits of maximal strength training (MST) in healthy and 'diseased' older adults including frail and post stroke patients. Training performed with heavy (80-84 percent) of 1 RM and very heavy loads (>85% of 1 RM).

Key benefits were increased strength gains (2.5 percent per session). 4.5 percent increases in muscle power per session. Increase in Type II muscle fiber size, decrease in oxygen cost of walking and stair climbing. It also helps with balance.

MST uses loads of about 90% of 1 RM, which can only be performed a maximum of 3-5 reps, 3-5 sets and maximum intentional concentric velocity.

Here are the guidelines. Do 4 sets of 4 reps at about 90% of 1 RM or 4 RM. Do this 2 to 3 times a week. Single set options are also effective twice  a week. Prioritize lower body compound lifts e.g. leg press, squats, step ups since strength reduction is more effective in lower compared to upper limbs with increasing age. Moreover the lower limbs are crucial for walking during everyday activities. 

Picture from article

For this, a horizontal leg press (pictured above) may be ideal over a free weight squat since technique and safety will minimally limit the intensity of the load. The health care provider needs to consider the main challenges of the specific disease or individual. Those with osteopenia or osteoporosis will benefit from axial loading through the spine to stimulate bone density enhancement. The hack squat or horizontal leg press where the back can be reclined to ensure loading through the spine is recommended to attain this axial loading of the spine while also protecting the impact of the heavy load. 

Some diseases or injuries may require other exercises to target an affected or impaired muscle or muscle group. Examples may include the bench press for wheelchair users, dorsiflexion for foot drop patients or hip abduction following hip surgery. Also note that very heavy unilateral (or single leg) strength training induces adaptations in the untrained, opposite injured limb. This is useful during acute or chronic periods of immobilization to limit the loss of function in the immobilized limb.

Supervised training are encouraged since it improves safety and confidence.

It is a very interesting read since it is good to have evidence that it is safe to use the heavier strength training lifts compared to the current guidelines. I am wondering if the 4 sets of 4 repetitions at 90 percent of 1 RM for older patients is a recipe for injury. Is the volume and frequency of the MST sustainable for the long term?

Reference

Toein T, Berg OK, Modena R et al (2025). Heavy Strength Training In Older Adults: Implications For Health, Disease And Physical Performance. J Cachexia Sar Muscle. 16(2): e13804. DOI: 10.002/jcsm.13804

Intense Static Stretching Versus Strength Training For Muscle Growth

Static stretching device

Who says that strength training is needed to make muscles bigger and stronger? A study published 2 days ago showed that intense static stretching of the pectoralis major (chest) muscles 4 times a week produced similar hypertrophy gains to strength training done 3 times a week. 

What? Just as effective as strength training? I was surprised to say the least. Well you know I am not a big fan of static stretching at all. Skeptical? I was too!

81 participants were allocated to 3 groups in this study. A static stretching group, strength training and control group. Pec stretching was done for 8 weeks, 4 days per week for 15 minutes per day. Those in the strength training group trained 3 times a week doing 5 x12 repetitions. All the subjects were instructed to maintain their regular exercise routine during the study. They exercised at least twice a week in a wide range of sports like fitness training, team sports or strength-endurance training. 

Results showed significant strength increase in the static stretching and strength training group compared to the control group. There were no significant differences between the static stretching and strength training group.

There was moderate muscle thickness increases in the static stretching and strength training group compared to the control group. Muscle thickness was measured using ultrasound imaging. There was actually no difference between the static stretching  and strength training group.

Range of motion test

In terms of range of motion (ROM), static stretching group had significant moderate ROM increases compared to the strength training group. No difference in ROM between the strength training and control group.

It has been suggested that the shared underlying physiological mechanism between stretching and strength training is the high stretching tension both produces to induce stretch mediated hypertrophy (Warneke et al, 2023). This tension translates into chemical signals that stimulate anabolic processes to generate new muscle tissue.

Wow. Increased size, strength and range in 8 weeks compared to strength training. However, note that static stretching via a stretching device like in this study needed a second person to assist and adjust the stretching device. Moreover, regular strength training can prevent osteoporosis and sarcopenia.

References

Warneke K, Wirth K, Keiner M et al (2023). Comparison Of The Effects Of Long-lasting Static Stretching And Hypertrophy Training On Maximal Strength, Muscle Thickness And Flexibility In The Plantar Flexors. Eur J Appl Physiol. 123(8): 1773-1787. DOI: 10-.1007/s00421-023-05184-6

Wohlann T, Warneke K, Kalder V et al (2024).Influence Of 8-weeks Of Supervised Static Stretching Or Resistance Training Of Pectoral Major Muscles On Maximal Strength, Muscle Thickness And Range Of Motion. Eur J Appl Physiol. DOI: 10.1007/s00421-023-05413-y

Scoff Not At Elastic Resistance Bands

Tan Howe Liang (pictured below) is still the strongest man I know. Yes, the same Tan Howe Liang that won Singapore's first ever medal at the 1960 Rome Olympics. He was a senior gym instructor at the gym at the old National Stadium and we often bumped into each other when I was still working there. I was always amazed when he told stories about his training days. Mind you, he could still squat with very heavy weights whenever I saw him train then. 

Silver at the Rome Olympics, SNOC picture

But don't fret if you don't have easy access to a gym or other fancy, expensive gym equipment. Other than your bodyweight, elastic resistance bands can be great for strengthening muscles too.

Not many of you may believe me if I said that training with elastic bands can be just as effective as training with weights for strengthening muscles.

The following systematic review and meta-analysis is possibly the first to compare the effects of strength training for strength gains with elastic tubes and bands versus conventional devices (dumbbells and weight machines).

The search identified 365 articles, of which eight studies were within the inclusion criteria comprising of 224 individuals between 15 to 88 years old. All subjects were performing regular strength training. In these groups were physically active individuals, athletes, individuals with coronary heart disease and moderate chronic obstructive pulmonary diseases.

Results of the meta-analysis showed that there is no superiority for both upper and lower limbs between training performed with elastic bands and training with free weights on strength gains. This was consistent across groups mentioned above and also when compared with a control group in the elderly, individuals with osteoarthritis and even fibromyalgia. 

The authors conclude that training with elastic bands is just as good as conventional resistance for promoting strength gains in different populations using diverse protocols. 

Having elastic bands at home to train with eliminates the need to travel to the gym and this may be more practical and a lot cheaper for certain people who may find it difficult to go to a gym. patients will have greater adherence to strengthening programs too. 

Personally I feel elastic bands are great for strengthening and correcting muscular imbalances. I still use them on a very regular basis. Especially after my accident.

Exercising with bands in my back brace in 2013

Do not let anyone tell you that you are wasting time if you are not using heavy weights and expensive equipment. Effective strength training can be achieved with body weight, free weights and especially elastic bands too.

We have managed to rehabilitate many national athletes back from injury and even avoid surgery in many cases using elastic bands to strengthen the injured areas. Especially in cases when a weight plate/ bar is initially too heavy and risk further injury and load to the person's joints.

Reference

Lopes JSS, Machado AF, Micheletti JK et al (2019). Effects Of Training With Elastic Resistance Versus Conventional Resistance On Muscular Strength: A Systematic Review and Meta-analysis. Sage Open Med. DOI: 10.1177/2050312119831116.

Don't neglect the legs

Many Physiotherapists Cannot Prescribe Exercise?

Teaching Ronald Susilo how to ride

I definitely don't agree with the following research (Barton et al, 2021) which concluded that physiotherapists cannot prescribe physical activity and exercise well for people with muscle and joint pain/ problems. Let me explain further.

I was asked to go to court last year to be questioned by the lawyer of the insurer (for the truck driver) for my accident in 2013. Yes, after waiting for almost 7 years, and numerous adjournments by the other party, the hearing was finally scheduled. 

Their lawyer questioned why I needed physiotherapy after my accident and he added that "isn't physiotherapy just doing some exercises". If so then I would not need to attend any more sessions and just do the exercises at home and the insurer would not have to pay anymore.

I explained that he (and perhaps the general public) may think when you see a physiotherapist, all the physiotherapist does is to teach you strengthening exercises for your pain or condition. But teaching strengthening exercises isn't the only thing physiotherapists do. At least not at our clinics anyway. 

But physiotherapists in Singapore can definitely teach exercises, especially in the hospital setting. That's what my patients tell me anyway.

Back to the study. 1,352 physiotherapists from 56 countries were surveyed. Most agreed that their job requires exercise prescription of aerobic exercise (75%) and resistance/ strength training (89%) to patients with muscle and joint pain/ problems. 

38 to 50 percent of the physiotherapists reported that they were not confident and had no training/ skills to prescribe aerobic exercise and resistance/ strength training (50 to 67%). Only 11% were able to give the correct guidelines for aerobic exercise and resistance/ strength training (21%).

62 to 79 percent  felt that their packed schedule (seeing too many patients), access to equipment/ space and lack of opportunity to attend professional development affected their ability to prescribe guidelines for effective exercise. 

The authors concluded that many physiotherapists lack training and knowledge to give advice for physical activity, and to prescribe resistance/ strength training and aerobic exercise to people with muscle and joint pain.

The general public (and the lawyer that quizzed me) thinks that all a physiotherapist does is teach exercise for treatment. Is that what you think?

Reference

Barton CJ, King MG, Dascombe G et al (2021). Many Physiotherapists Lack Preparedness To Prescribe Physical Activity and Exercise To People With Musculoskeletal Pain: A Multi-national Survey. Phy Therapy in Sport. DOI: 10.16/j.ptsp.2021.02.002.

How To Increase Range Of Motion

All the kids posed for this picture

A typical comment from many of our patients is that they have been stretching all the time but their muscles still feel tight. 

Range of motion (ROM) is necessary as part of our health and important during sports performance. And static stretching is often prescribed to get better ROM gains. We know from previous research that static stretching is effective in improving our range of motion. 

However, the latest systematic review/ meta-analysis shows that strength training (ST) is just as effective as static stretching in getting improvements in ROM.

The researchers pooled data together and found eleven good quality studies comprising 452 participants to derive the following results.

Interventions lasted between 5 and 16 weeks while training frequency ranged from two to five times a week. Subjects included healthy sedentary subjects, subjects who already participate in ST subjects with fibromyalgia and subjects with chronic neck pain. There were also elderly adults who had difficulties in one of four tasks, transferring, bathing, walking and going to the toilet.

Both ST and static stretching groups showed significant improvement in ROM in seven of the studies. Differences between the groups were non significant. They did not find any significant differences in active and passive ROM for both ST and stretching. Dynamic stretching did not improve ROM in any of the groups.

You must be wondering how ST helps to improve ROM that is not statistically distinguishable from static stretching. The authors wrote that ST with an eccentric focus requires the muscles to produce forces in a lengthened position. This is what helps improve ROM. They also found that concentric strength training improves ROM when full range is required.

One study demonstrated significant reductions in pain associated with increases with strength, suggesting that decreased pain sensitivity may be another mechanism in which ST help increase ROM. Another mechanism may be an improved agonist-antagonist co-activation helping ROM gains.

The authors concluded that both ST and static stretching can improve ROM both in the short and long term suggesting that there are both neural and mechanical factors at work. Both ST and stretching can be prescribed to help improve ROM. If one does not respond or adhere well to a stretching program, they can switch to strength training instead.

What does that all mean you (if you did not understand the discussion above)? If you're looking to get an increase in your range of motion say in your knee joint, you can do eccentric strengthening exercises with some stairs at home. This previous article explains everything in a simple manner.

Just remember that static stretches are best done after exercise as just one bout of static stretching can slow you down as well as reduce your maximum strength.

Reference

Afonso J, Ramirez-Campillo R, Moscao J et al (2021). Strength Training Is As Effective As Stretching For Improving Range Of Motion: A Systematic Review And Meta-analysis. DOI: 10.31222.osf.io/2tdfm

Will You Lose All Your Strength During The Circuit Breaker If You Cannot Lift Weights?

Lunging with a 10 kg bag of rice 

We are currently at the end of week 3 of the circuit breaker (or modified lock down) in Singapore. Most of my patients who strength train are not able to take part in their usual exercises and training regimes. This is true especially for my bodybuilding and avid gym going patients, since gyms and other exercise centers are closed.

Not many of them have an ideal home gym for strength training during this period. So for them, there's a real threat of detraining (loss of strength) for them and other sporting populations. Any loss in muscle strength, power, muscle atrophy may affect future performance, injury risk and self esteem.

A recently published study (Blocquiaux et al 2020) studied older male patients (58-70 years old) during a 12 week whole body resistance training program. The subjects stopped training for 12 weeks and then resumed training for another 12 weeks.

Decent strength gains were made at 8 weeks (22%), and 12 weeks (36%) in leg strength (similar for upper limb).

What was most interesting was that all the strength gains (36%) during the initial 12 weeks were not completely lost during the 12 weeks of no training. 14% was lost during this period.

When the participants resumed training for another 12 weeks, they were stronger at the end of the second 12 week period than the first. It took them 8 weeks or thereabouts to regain what they lost in 12 weeks.

So if we were to compare with our current circuit breaker period (3 weeks and counting), don't be too discouraged. You can probably gain back what you lost. Hopefully it will take less time too looking at that study (Blocquiaux et al 2020) . For those of you who bike, run, row or do other endurance sports, there is a similar pattern observed for cardiovascular fitness too.

Now, lets look at female subjects. Correa et al (2016) studied a group of older women, and this time the period of no training was a whole year. The female participants gain an increase of 75% in strength after an initial 12 week training period. Much of these gains were lost after a year, back to baseline levels. However, after another 12 weeks or training, they gained a lot of this strength back, they were just 15% off their first 12 week training period.

So, another glimmer of hope for those of you who strength train. Though I'm hoping our circuit breaker will not be a year long!

If you make do with whatever you can find at home to strength train to failure albeit with a lighter weight, you will stave off some of the losses. That's what I try to do.

Many people are dealing with all sorts of mental and motivational issues other than physical and financial ones so exercise may be way down on their list of priorities. But if you can still exercise, it will definitely lift your mood Ludyga et al (2020).


References

Blocquiaux S, Gorski T et al (2020). The Effect Of Resistance Training, Detraining And Retraining On Muscle Strength And Power, Myofibre Size, Satellite Cells And Myonuclei In Older Men. Expt Gerontology. 133: 110860. DOI: 10.1016/j.exger.2020.110860

Correa CS, Cunha G et al (2016). Effects Of Strength Training, Detraining and Retraining In Muscle Strength, Hypertrophy And Functional Tasks In Older Female Adults. Clin Physiol Funct Imaging. 6(4): 306-310. DOI: 10.1111/cpf.12230.

Luduga S, Gerber M et al (2020). Systematic Review And Meta-analysis Investigating Moderators Of Long-term Effects Of Exercise On Cognition In Healthy Individuals. Nat Human Behav. DOI: 10.1038/s41562-020-0851-8

Aerobic Exercises Key To Aging Well?

Me on the left. Picture by Jeffrey Keng from Cycleworx

Slightly more than a year ago, I wrote that strength training may be just as important (if not more) than aerobic exercises. Why? Strength training has been found to decrease rates of early and cancer related death.

And earlier this year I disagreed with a funded study by Les Mills International when the article suggested that lifting weights was more beneficial for losing weight compared to running or cycling (aerobic exercises).

Now, some new research seems to show that aerobic exercises (like running, cycling, rowing or swimming) can make our cells younger. That same study found that weight training may not cause the same physiological changes in our cells.

Way back in 2009, a study found that competitive middle-aged runners had extended telomeres compared to inactive people of the same age. What are telomeres? All of us have telomeres at the tips of our chromosomes. Telomeres help protect our cells from damage and have been found to shorten and fray as a cell ages.

Many of the researchers in that 2009 study came together for this recent study to investigate whether exercise would change our telomeres.  They also wanted to know what type of exercise were needed and whether intensity played a part. It is hypothesized by the scientists that exercise helps lengthen the telomeres.

The researchers recruited a group of healthy middle aged men and women who did not exercise. They were tested for  their aerobic fitness and telomere length. In addition, blood markers of telomerase (an enzyme that influences telomere length) were tested as well.

Some in this group were randomly assigned to continue with their lives as normal as a control group. They did no exercises.

Others started a supervised program of brisk walking or running for 45 minutes three times a week or a high intensity interval program of four minutes of strenuous exercise followed by four minute rests with this repeated four times.

A third group took up weight training, doing a circuit of resistance exercises three times a week.

Heart rates were monitored and the exercise program was carried out for six months. Results were tested after this and all the subjects who exercised were found to be more aerobically fit.

At molecular level however, there were differences. Those who did the aerobic exercises and interval training had much longer telomeres than before starting the exercise program and more telomerase activity.

Those who weight trained and those in the control group (who did not exercise) had no change in telomere length. Some even had shortened telomere lengths.

Those who did weight training produced less nitric oxide, which is thought to affect telomerse activity and contribute to lengthening telomeres.

Even though weight training was strenuous, overall heart rate was lower compared to running in the study. This results in less blood flow and probably less physiological response from the blood vessels.

The researchers suggested that exercise needs to be aerobically taxing to extend telomere length and slow cellular level aging. In this aspect, endurance exercise was clearly ahead of resistance training.

The findings do not indicate that weight training does not combat aging as it also helped improved fitness, which itself is a very important indicator of longevity.

Like I wrote before, current research shows that both strength training and aerobic exercises are necessary to be healthy and functional. So run, bike or lift weights, (or whatever exercise you prefer) as they are all beneficial, it's much more important to keep moving.

I wanna for live a long time, so I lift weights too

References

Werner CM, Furster T et al (2009). Physical Exercise Prevents Cellular Senescence In Circulating Leococytes And In The Vessel Wall. Circulation. 120 (24): 2438-2437. DOI: 10.1161/CirculationHA.109.861005.

Werner CM, Hecksteden A (2018). Differential Effects Of Endurance, Interval And Resistance Training On Telomerase Activity And Telomere Length In A Randomized Controlled Trial. Euro Heart J. ehy585. https://doi.org/10.1093/eurheatj/ehy585.

Barbells Or Bikes?

Both weight training and aerobic exercises are necessary

I came across this article recently which suggested lifting weights was more beneficial for losing weight compared to hopping on your bike for a ride or going for a run. The article suggested that burning calories via strength training will help you lose more fat than burning the same amount of calories doing moderate aerobic exercises.

Those headlines are good for creating media buzz but I'll say that it's not totally true if you look at that particular study in detail.

Now, before you say I'm biased, bear in mind I've written earlier how strength training is just as important as aerobic exercise. After not strength training for almost nine years, I started strength training again last year after I realize I was losing muscle mass with each passing year.

The study was funded by Les Mills International, a New Zealand company behind BodyPump, a barbell workout class. That means the study was commissioned by Les Mills International, thereby having a vested interest in promoting weight training.

There were only 12 female subjects in that particular study. They were tested during and after a resistance training workout (a BodyPump class) compared to a steady state moderate intensity session on a stationary bike.

In both workouts, the female subjects burned around 335 calories and had increase in levels of Human Growth Hormone (HGH), which is known for rapidly build muscle and to promote fat burning.

The women's HGH levels were 56 percent higher after the weight training session (light to moderate weights with high reps) compared to the steady state cycling session. Now, many previous research has shown increases in HGH levels in response to weight or resistance training, even in the elderly.

That's another reason why I resumed weight training, to make sure I get those doses of HGH, believed to be the elixir of youth, but that's probably another post.

For weight loss, the results were not unexpected as our metabolic rate stays up for a few hours after weight training. This ensures that more calories are being used even after training.

Bear in mind that strength training affects your body differently compared to aerobic (or cardio) exercises even if the calories burnt are similar. The headlines of this article generated by media buzz may claim that strength training is superior to cardio, but current research shows that both are necessary to be healthy and functional.

Actually, another study (Nindl et al, 2014) found that doing two hours of cardio boosted HGH secretion more than one to two hours of strength training.

As runners, cyclists and triathletes, we don't just exercise to burn a certain number of calories. I certainly don't. I do so because I love that adrenaline rush, the release of endorphins that I don't get with strength training. If I can solve some other problems while running, well, that'a a real bonus.

In my group rides, we don't always go at 68 percent heart rate (like the study), we do put the hammer down at times (at Coastal road), or surge up hills when we go up Mount Faber or NTU. I'm sure you do the same while riding with your friends or running intervals.

When we push the pace, our heart rate as well as our HGH levels soar. A study on sprint interval (Stokes et al, 2002) showed that doing just one 30 second sprint interval caused HGH levels to increase more than 430 percent!

Next time you feel your legs burning when your friends try to drop you, it's a good sign you're gonna have elevated levels of HGH.

So run, bike and lift weights, they are all beneficial but don't be too worried about counting how much calories you're burning.

If you're trying to lose weight, don't be too obsessive over what calories you are eating or what you are using.  As human beings, we are athletes, not Bunsen burners. Calories from drinking coconut juice or eating an avocado are processed differently by your body compared to drinking Coke or eating donuts or fried kuay tiao.


References

Harris N, Kilding A et al (2018). A Comparison Of The Acute Physiological Responses To BODYPUMP Versus Iso-caloric And Iso-time Steady State Cycling. J Sci Med Sp. DOI: 10.1016/j.jsams.2018.02.10.

Nindl BC, Pierce JR et al (2014). Twenty-hour Growth Hormone Secretory Profiles After Aerobic And Resistance Exercise. Med Sci Sp Ex. 46(10): 1917-1927. DOI: 10.1249/MSS.0000000000000315.

Stokes KA, Nevill ME et al (2002). The Time Course Of The Human Growth Hormone Response To A 6s And a 30s Cycle Ergometer Sprint. J Sports Sci. 20(6): 487-494.