Empowering Senior Fitness

INTRODUCTIONThe no. 3 worldwide fitness trend in 2023 and 2024 was “fitness programs for older adults” (1). Although this ranking is encouraging, only 13.9% of U.S. adults 65 and older are meeting the federal physical activity guidelines for both aerobic and muscle-strengthening activities (2). Also concerning is the high number of exercise-related injuries occurring among this age group as presented in this article. In addition to focusing on increasing the number of seniors to participate in regular exercise, it is essential to implement safety strategies that minimize injuries. Exercise professionals (EPs) are encouraged to follow the five safety tips described in this article. DATA ANALYSIS OF EXERCISE INJURIES The injury data described in this section were obtained from the U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) utilizing the NEISS Estimates Query Builder (3). NEISS injury data are tracked and categorized by emergency departments (EDs) throughout the United States based on a representative sample of approximately 100 hospitals each year from all 5,000+ U.S. hospitals with emergency departments (4). While NEISS injury data serve as an important resource for risk management, caution is needed when interpreting the data. NEISS injury data are limited to ED visits. Certain exercise-related injuries are not recorded in NEISS injury data, e.g., when individuals choose to visit urgent care or consult their physician. Furthermore, NEISS injury data focus on musculoskeletal injuries only and do not include other exercise-related medical events such as sudden cardiac arrest. To determine the total number of injuries, national estimates are calculated from actual data collected by these emergency departments across various categories and subcategories of consumer products. Among the 15 consumer product categories, exercise-related injuries are recorded under the Sports & Recreation Equipment category. This category includes a subcategory labeled Exercise/Exercise Equipment with four specific product codes: Exercise (activity or apparel without equipment) (3299) Exercise equipment (3277) Personal fitness/activity trackers (5038) Weight lifting (activity, apparel, or equipment) (3265) NEISS Data: Exercise-Related Injuries Among Seniors on the Rise Exercise-related injury data for a 10-year period (2014 to 2023) were compiled using the four NEISS product codes under the Exercise/Exercise Equipment category (Table 1). TABLE 1 - Exercise-Related Injuries Among Adults Aged 65 Years and Older Over a 10-Year Period (2014–2023) Year Number of Injuries 2014 48,011 2015 51,082 2016 61,415 2017 72,052 2018 76,224 2019 77,187 2020 69,207 2021 72,942 2022 81,558 2023 91,354 Total 701,032 Table 1 reveals that from 2014 to 2023, there was a 90.28% increase (48,011 to 91,354) in the number of exercise-related injuries resulting in ED visits among adults aged 65 years and older. In 2020 and 2021, there was a decrease in the number of injuries likely due to the COVID-19 pandemic. Nevertheless, despite quarantining at home, these national injury estimates remained higher than those reported in 2016 or earlier. During this 10-year period, the most commonly injured body parts were the upper trunk, lower trunk, and head. The most common diagnoses were strains and/or sprains (102,958 cases) followed by fractures (100,850 cases) and contusions and/or abrasions (61,216 cases). While it is noteworthy that adults aged 65 years and older visit EDs for such injuries, it is important to recognize that these injuries can have serious consequences considering their age. Exercise-related injuries affecting the back and head, in particular, can progress into more severe conditions, such as vertebral damage or deterioration in the cervical and lumbar spine, or result in a concussion. To understand the severity of ED visits for exercise-related injuries, disposition information from 2014 to 2023 were analyzed. As shown in Table 2, 182,271 (26%) seniors sustained injuries that resulted in hospital admission or death following their ED visit. On average, approximately 1,500 people were admitted to the hospital each month, and 19 individuals died monthly from exercise-related injuries. Severe injuries and fatalities not only pose a significant health concern but also expose EPs and fitness facilities to potential costly lawsuits that may jeopardize their operations. TABLE 2 - Emergency Department Disposition Information Among Adults Aged 65 Years and Older Over a 10-Year Period (2014–2023) Disposition 65 Years and Older Admitted to hospital 180,009 Died in emergency department/Dead on arrival 2,262 Not admitted to hospital 518,763 In addition to the overall severity of these injuries, it also is important to examine demographic patterns, particularly sex differences. Understanding these patterns can help guide effective injury prevention strategies tailored to the needs of older adults. The Figure presents the annual number of exercise-related injuries among older adults by sex from 2014 to 2023. Overall, injury counts for both males and females have steadily increased over the past decade. Notably, from 2014 to 2016, females consistently experienced more injuries than males. However, beginning in 2017, the numbers became more comparable, with males slightly exceeding females in several years. Most recently, in 2023, males reported a noticeably higher number of injuries (47,822 cases) compared to females (43,532 cases). This shift may reflect changing patterns in exercise participation or differing risk exposure between sexes.Figure: Number of exercise injuries among adults aged 65 years and older by sex over a 10-year period (2014–2023).In terms of the injured body part, the upper trunk was the most commonly affected area for both sexes. However, males experienced significantly more upper trunk injuries (87,860 cases) than females (60,511 cases). In contrast, females reported a higher number of lower trunk injuries (56,994 cases) compared to males (47,674 cases). Interestingly, all parts of the body were the third most injured site for males (43,764 cases), while they ranked sixth for females (24,793 cases), suggesting that males may be more prone to generalized or multisite injuries. For females, the head was the third most commonly injured body part (37,689 cases). Regarding diagnoses, fractures were the most common injury among females (68,082 cases), followed by strains and/or sprains (55,138 cases), and contusions and/or abrasions (33,579 cases). For males, the most frequent diagnoses were strains and/or sprains (47,820 cases), followed by fractures (32,770 cases) and contusions and/or abrasions (27,637 cases). These findings suggest that females may be more prone to severe injuries such as fractures. This may be due to such factors like lower bone density. Males, on the other hand, may be more prone to soft tissue injuries. NEISS Data: High Number of Pickleball Injuries Among Older Adults NEISS studies also have shown a high number of injuries in older adults who play pickleball, which is a very popular sport among seniors. One 10-year (2013-2022) NEISS study found that most injuries occurred in those aged 65 to 80 years, with 643 actual injuries and 40,507 estimated injuries (5). Among this age group, falls accounted for 71.5% of the injuries, with fractures and strains/overuse being the most common types of injuries. Another 10-year (2010–2019) NEISS study involving players ≥60 years of age found that pickleball-related injuries due to slip/trip/fall/dive injury mechanisms predominated, with the most common diagnoses being strains/sprains, fractures, and contusions (6). Males were more likely to experience strains/sprains, whereas females were more likely to have fractures. Injury Prevention In addition to exercise-related injuries, many injuries have occurred among seniors while participating in pickleball. When an injury occurs, they will likely have to refrain from the activity until the injury heals. In some cases, they may not return to certain activities due to the fear of reinjury. Injuries while participating in pickleball raise the following question: Is it best to play pickleball to get fit or get fit to play pickleball? From an injury prevention perspective, the latter is best. Authors of a recent article (7) provide recommendations for pickleball off-court training programs for older adults that will help prevent injuries and optimize performance. They describe a circuit-training program that includes activities such as (a) power/explosiveness, (b) plyometric training, and (c) resistance training. By obtaining adequate power, strength, balance, etc., seniors will likely experience fewer falls that are a common cause of not only pickleball injuries but also many other injuries.Falls among older adults (65 and older) reflect the leading cause of fatal and nonfatal injuries. In 2023, 41,400 seniors (65 and older) died as a result of preventable falls, and in 2022, more than 3.5 million were treated in emergency departments due to fall-related injuries (8). Given these data, it is important that EPs design/deliver programs that focus on fall prevention. Articles in this issue of the Journal, as well as previous issues (9,10), have addressed fall prevention. SAFETY TIPS EPs have a legal duty to provide reasonably safe programs. Reasonably safe means developing and implementing risk management strategies that help minimize foreseeable risks of injuries (11) such as the strategies described in the following five safety tips. Safety and risk management responsibilities of fitness facility/program managers are covered elsewhere (11,12), e.g., equipment maintenance, hiring/training/supervision of employees, emergency action plans, facility supervision, compliance with safety laws, and protective legal documents. Safety Tip No. 1: Obtain Credentials and Practical Skills of a Qualified Exercise Professional A recent article in this Journal (13) described credentials that qualified EPs should possess, e.g., certifications such as the ACSM Exercise Physiologist® and ACSM Clinical Exercise Physiologist®. Also described was the importance of competency-based educational programs that focus on developing essential practical skills. A competent, qualified EP has obtained both proper credentials and practical skills. Seniors will likely have various medical conditions and take certain medications. EPs need to be aware of these medical conditions/medications and take them into consideration when designing/delivering reasonably safe and effective programs. In addition to obtaining ACSM certifications, it is recommended that EPs who work with seniors earn the ACSM Exercise is Medicine® (EIM) credential. The EIM credential signifies that the EP has met educational requirements to help individuals with medical conditions to adopt and maintain an active lifestyle (14). EPs also should refer to resources (15–17) that address exercise guidelines/precautions regarding medical conditions as well as complete continuing education courses such as those offered by ACSM that cover specific medical conditions, e.g., cancer, diabetes, etc. Safety Tip No. 2: Conduct Medical History, Medical Clearance, and Fitness Assessments ACSM (15) recommends conducting a preexercise evaluation that includes having individuals complete a preparticipation screening questionnaire, some of which may not include certain medical conditions, physical/cognitive abilities, and medications that call for medical clearance and data necessary to prepare a proper exercise program. Therefore, facilities/programs serving those with comorbidities may need to use a medical history questionnaire that is more comprehensive than a screening tool (15). Examples of medical history questionnaires are available (12,17), and ACSM (15) provides a list of the medical history components to be considered. Facilities/programs that serve older adults should consider having a medical advisor (or committee) who can assist with the (a) development of a medical history questionnaire, (b) criteria that warrant medical clearance, and (c) procedures for obtaining medical clearance (11). Once these procedures are complete and prior to conducting fitness assessments, the qualified EP should review the medical history data with each senior client to clarify certain conditions and document any additional information on the questionnaire such as (a) arthritis — what type of arthritis and (b) hypertension — what stage such as stage 1 or 2. During this inquiry, EPs also can obtain the short and long-term goals of their clients as well as engage them in various motivational interviewing techniques (18). Once these steps are completed, EPs should determine if conducting a fitness assessment (and designing/delivering an exercise program) for the client is within their scope of practice, i.e., does the EP have the credentials and practical skills needed to properly conduct fitness assessments, given the client's medical conditions (11). If not, a proper referral may be necessary. According to ACSM (15), unless exercise testing is medically needed, fitness assessments such as physical performance tests can be used, e.g., the Senior Fitness Test and the Short Physical Performance Battery as well as assessments for muscle power and fall risk. However, certain tests should not be done or may need modifications given the senior's medical history. For example, the sit to stand test designed to assess functional lower extremity strength in older adults may not be appropriate for seniors who experience orthostatic hypotension because they are likely to become dizzy or lightheaded. A qualified EP should be able to make such determinations. In addition to ACSM (15), EPs should be familiar with resources (16,17,19,20) that provide guidelines and precautions regarding fitness assessments for older adults. See the article “The ‘Power’ of Assessments for Optimizing Fitness, Function, and Fall Risk in Older Adults” in this issue (21). Safety Tip No. 3: Prepare Written Lesson Plans EPs need to prepare written lesson plans for each session or class they teach. For personal fitness trainers, the lesson plan reflects an individual exercise prescription that may include measuring vital signs (e.g., blood pressure, glucose levels) for certain clients. For group exercise leaders, the lesson plan describes the activities to be taught in each class. ACSM (15) describes the FITT (frequency, intensity, time, and type) recommendations for older adults. These FITT principles should be reflected in the conditioning activities (e.g., aerobic, resistance [strength and power], neuromotor) listed in the lesson plan along with warm-up and cool-down activities. A template of such a lesson plan is available elsewhere (11). After each session/class, EPs also should prepare a written reflection/evaluation documenting any situations that may have occurred and any notations for the next session/class (11). When listing activities in the lesson plans, EPs need to be sure all activities are reasonably safe and effective for each client and reflect (a) their medical conditions, (b) any recommendations and contraindications listed by the healthcare professional who completed and signed the medical clearance form, (c) fitness assessment data, and (d) their goals. Activities that focus on fall prevention need to be included, such as neuromotor (balance) and muscle power training (15). This issue of the Journal provides several informative articles regarding exercise prescription for older adults. Safety Tip No. 4: Provide Proper Instruction and Supervision Many injuries are due to improper instruction and supervision. According to legal scholar, the late Betty van der Smissen, “the lack of or inadequate supervision [meaning instruction and supervision] is the most common allegation of negligence” (22, p. 193). Injuries often occur because the EP had the client perform an activity (a) that was too intense or too advanced, given the client's health/fitness status, (b) before the client had first obtained skill levels to properly execute the activity, or (c) that was contraindicated given the client's medical conditions such as having a client who has a herniated disc perform an inappropriate exercise (11). EPs must possess excellent teaching skills. Too often, academic and certification preparation programs do not focus on the development of teaching skills. It is recommended that fitness facility/program managers provide this education and training. For older adults, this would include using effective teaching cues (verbal and visual) and how to teach (a) common modifications such as seated alternatives, (b) support options such as using the wall or a chair while standing, and (c) proper transitioning from one plane to another. Regarding activity intensity, EPs should be able to teach participants how to use the Borg scale of self-perceived exertion that is recommended for older adults (15). Employers have a vested interest to ensure their EPs are competent. In addition to the EP, they can be held liable if an injury occurred due to the improper instruction/supervision of one of their employees (11). Participants should be carefully supervised at all times and through all stages of their exercise progression, especially when they are beginners or performing a new exercise. Personal fitness trainers should always be with their clients. A limited number of older adults in a class (e.g., 10–15) is recommended so the group exercise leader can provide individual assistance to help ensure proper execution and closely monitor signs/symptoms of overexertion. Safety Tip No. 5: Educate Seniors When teaching seniors “what” exercises to perform and “how” to perform them, qualified EPs also educate them as to “why” exercising safely is important from an injury prevention perspective. EPs explain why (a) certain activities may not be appropriate given their health/fitness status, (b) safety principles are essential such as warm-up, cool-down, progression, and monitoring intensity, and (c) certain exercises are beneficial for fall prevention. Education to refute myths such as “no pain, no gain” is essential. According to Dr. Len Kravitz, “Any type of pain is a warning signal” (23, p. 166). Regarding “feel the burn,” he states that “None of the physiological mechanisms associated with ‘the burn’ have been demonstrated to have beneficial results for you” (23, p. 166). It is recommended that EPs refrain from using such slogans and use slogans such as “train, don't strain,” “if it hurts, don't do it,” and “exercise smarter, not harder,” which are more appropriate to minimize injury risks. Providing this education will empower seniors with knowledge and confidence while fulfilling the EP's responsibility of providing education related to reasonably safe/effective practices. Documentation of Safety Procedures EPs must keep a file of each client that includes the documents described in the above safety tips such as the medical history questionnaire, medical clearance form, fitness testing data, and lesson plans. Documentation is beneficial for many reasons such as serving as a portfolio of professional competency and providing evidence that the EP met the standard of care if ever faced with a negligence lawsuit. For example, courts may EPs i.e., to do what a professional would have if they have no of what was taught or occurred on the of an injury (11). The of this article was to provide a data regarding exercise injury among adults 65 and older and describe important safety tips that can minimize injuries. this age group, there was a significant increase in the number of injuries over the years with the most common injuries being and fractures. The safety tips described several responsibilities of EPs that to fewer injuries. As EPs are on the of senior To help seniors and maintain reasonably safe/effective exercise it is essential that EPs focus on injury prevention.