Category: Bodybuilding, Strength, & Conditioning

She struggled to stand up from her chair. Once on my exam table, it took all of her strength to roll from her side to her stomach. She needed help to return back to her side, then back to a sitting position. During our initial chat, she informed me that she fell a few nights ago next to her bed and couldn’t pull herself back up. She had to wait on the floor until morning when her son in law heard her calling for help.

Her diagnosis? Nothing in particular. I was initially called a few weeks prior to help with her low back pain, which we had resolved, and now I was asked to help with balance and strengthening.

An endless number of pathologies and problems can plague our elder years, but none more commonly degrades day to day living of the elderly as fragility and weakness.

Sarcopenia and Fall Risk

Sarcopenia is age-related loss of muscle mass (sarco: muscle, penia: little) that can start in our 40s. By the time we are 80, we can potentially have lost 50% of our muscle mass. It’s a much bigger problem than we think.

Age-related frailty cause elderly individuals to be less steady, unbalanced, and unconfident in their ability to go out and navigate the world. It can cause people to fall more often. Secondary issues to sarcopenia often can include osteoporosis, metabolic syndrome, sleep disruptions, and greater chances of all-cause mortality.

Add on a sedentary lifestyle that often leads to sarcopenia, and you may end up with sarcopenic obesity, characterized by high body fat percentages combined with low levels of muscle mass. The result is an individual who has an even harder time moving because of the extra weight on their frame.

All of this creates the perfect storm of difficulty standing up from a chair (or the floor, god forbid if they fall), difficulty navigating stairs, recovering from a stumble, and an increased risk of falling. Sarcopenia is a known major contributor to falling, and falling can cause serious medical complications.

So what do we do? If sarcopenia is the culprit and root cause of many of these problems, we must aim to slow or reverse this process.

The Squat/Sit to Stand

If there is one exercise I can prescribe for the above patient vignette, it is the squat or sit to stand. It is the exercise that addresses as many problems as possible with a single movement.

The gut reaction may be to overhaul this individual’s entire lifestyle, but we know that drastic changes are not sustainable unless they are on board. Most people will not be agreeable to a full lifestyle change.

Tests that involve the sit to stand have been shown to effectively measure global muscle strength of the legs, hips, and trunk. It is almost the perfect exercise.

The sit to stand is excellent because it is simple and easily scalable. If it gets too easy, you either hold a weight in your hands or progress to staggered stance, single leg, or free standing squat variations.

Sit to Stand Technique

To perform the sit to stand, sit in a chair where your knees are bent to at least 90 degrees. Scoot towards the front of the chair and bring your heels back behind the knees. Lean forward, and stand upwards by pushing your feet straight into the floor. Preferably, your hands should be held in front of you for balance or crossed in front of your chest.

The most common mistake with the sit to stand is sitting too far back and having the heels too far forward. This will cause you to swing your torso forward, using momentum to stand. The sit to stand should purely be a vertical movement, not a forward movement.

If the basic sit to stand is too difficult, sit on top of a pillow or use a taller chair to decrease the range of motion. Once you are able to perform at least 3 sets of 10 repetitions, decrease the height of the chair.

Progressing the Sit to Stand

There are numerous ways to progress the sit to stand. My preferred way is to have the individual hold a weight close to their chest like a goblet squat.

Another way is to stagger the stance, effectively turning the exercise into a 1.5 legged sit to stand.

The natural progression from here is a single legged sit to stand.

From here, you can progress to the free standing squat

The Squat Technique

Stand with a shoulder-width stance. Apply a slight external rotation force through the feet (as if you are trying to rotate your feet outwards but don’t let your feet actually move). This will engage the glute (buttock) musculature. Initiate the movement by pushing your hips slightly back, bend through the knees, and squat down over your feet. You will likely be leaning forward to some degree. If you have long legs, you will probably be leaning forward to a greater degree. This is fine.

Maintaining the external rotation force through your legs, push yourself back up into the starting position. Note that if you have uninjured knees, it is perfectly safe to allow your knees to travel past your toes.

Battle Frailty

Ideally, the sit to stand or squat will be a part of a larger, more comprehensive strength program. However, we already know that large changes to a lifestyle unfamiliar with exercise are unsustainable.

Most of my patients don’t want dozens of exercises to choose from. They want to be shown a few things they can do to maintain their strength and balance. The sit to stand or squat is almost always one of them.

Following the inclusion of this exercise, every single one of my patients and clients score better in strength and functional testing. They also report being able to walk faster, having better balance, navigating stairs easier, and being more confident in their day to day movements.

It is no coincidence that people from certain areas of the world live longer. Individuals from Okinawa, Japan, historically have always sat on the floor. As a result, they need to perform a full range squat numerous times a day. These people regularly live past 90 and 100, all the while staying active and mobile.

Studies have shown that strength training alone decreases all-cause mortality. One specific study showed that grip strength is a reliable predictor of longevity. The problem of elderly frailty is huge, and strength training is the main weapon that we must utilize to combat it.

As the population grows older each year, this problem is only going to get worse. We can start by just doing one exercise.

Further Reading

Porto JM, Peres-Ueno MJ, de Matos Brunelli Braghin R, Scudilio GM, de Abreu DCC. Diagnostic accuracy of the five times stand-to-sit test for the screening of global muscle weakness in community-dwelling older women. Exp Gerontol. 2023;171:112027. doi:10.1016/j.exger.2022.112027
https://www.sciencedirect.com/science/article/pii/S0531556522003369

López-Bueno R, Andersen LL, Koyanagi A, et al. Thresholds of handgrip strength for all-cause, cancer, and cardiovascular mortality: A systematic review with dose-response meta-analysis. Ageing Res Rev. 2022;82:101778. doi:10.1016/j.arr.2022.101778
https://www.sciencedirect.com/science/article/pii/S1568163722002203?via%3Dihub

García-Hermoso A, Cavero-Redondo I, Ramírez-Vélez R, et al. Muscular Strength as a Predictor of All-Cause Mortality in an Apparently Healthy Population: A Systematic Review and Meta-Analysis of Data From Approximately 2 Million Men and Women. Arch Phys Med Rehabil. 2018;99(10):2100-2113.e5. doi:10.1016/j.apmr.2018.01.008
https://pubmed.ncbi.nlm.nih.gov/29425700/

Donini LM, Busetto L, Bischoff SC, et al. Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement. Obes Facts. 2022;15(3):321-335. doi:10.1159/000521241
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9210010/#:~:text=Sarcopenic%20obesity%20is%20characterized%20by,from%20obesity%20or%20sarcopenia%20alone.