Group Training and Injury Management with Midlife Women

This month’s topic was brought about because of a question one of my students asked. The question was “I’m wondering if you can provide me some insight … I find it quite a challenge to deliver a group fitness class to midlife women when pretty much every woman in the class has a different problem. One woman has frozen shoulder the other pelvic floor dysfunction, the other plantar fascitiis, back pain, lots of inflammation in the hip. It goes on and on . How do I train these women without someone getting injured in the process?”

I’ve decided to devote this month to this question, because it’s nuanced (like everything), and also something I do myself in my group sessions. In fact, I’ve been actively targeting women who have hormone imbalances, mental illnesses, injuries; because I know I can help them with exercise. I also LOVE the challenge of modifying without making easier, and am able to pull modifications out of a hat for women in a millisecond. So this month, I’m going to share with you how I do it!

Firstly, lets touch on what is happening during midlife for women specifically:

1. They’re in the “care sandwich”^{1 2}– aging parents plus young or teenage children, sometimes with a paid job on top of that, and still doing the lions share of the housework³. This makes them time poor. Less time for physio, less time for eating well, less time for foam rolling, you name it -self care is the first thing to go⁴.
   
2. They’re peri-menopausal – peri menopause means that their Oestrogen and Progesterone levels are fluctuating, but ultimately declining over time. Both Oestrogen and Progesterone act on other systems and tissues in the body. As an example, Oestrogen has a role in joint laxity^{5 6}, so as it fluctuates, so does a woman’s stability, mobility, and co-ordination. On any given day she could be wobblier than usual, or tighter that usual, which will impact her ability and performance.
   Also in this time of life, she may be dealing with the consequences of the symptoms of menopause, include hot flashes, joint pain, and insomnia. All of these will impact their ability to move and train well.

   OR

3. She’s post-menopausal – this means getting used to a new body, finding her balance again, and adapting to life with low oestrogen. Symptoms of menopause can linger for up to 5 years post menopause, including the symptoms mentioned above. Oestrogen is also anti-inflammatory, so living life with less oestrogen predisposes you to a higher inflammatory effect of exercise and injury⁷.

So my first tip in training groups of midlife women in these circumstances, is to keep the program obscenely simple.

An as example, in your session you may have:

• Squats
• Push ups
• Lat pull down
• Lunges

Of the 10 women attending, one has frozen shoulder, another lower back pain, another plantar faciitis, another knee pain, another hip pain, another has arthritis in her hands and can’t hold dumbells. If your program is obscenely simple, then the modifications become simple too:

To make it interesting, every time to change the program it can be by changing the tool – not necessarily the exercise. For example, squats can be performed holing onto a pole for range, learning deep squats, or with dumbells, barbells, or as a front squat, unevenly loaded squat, staggered legs, etc.

Your session participants will learn their modifications too. So whilst I write them on the board, that’s mostly for myself. If the client has found a way to squat without knee/back/foot pain, they’ll usually remember it.

My Second tip in training groups of midlife women with varying injuries is to slow the pace.

If you missed last week, you can catch up here: https://www.facebook.com/share/v/1B6AJXmLHW/

If injury is a concern, then going SLOW will allow you to

a) keep the weights lighter while still loading them enough for a specific response, and

b) increase the feeling of safety and control int he person performing the movement.

Isometric – ie. Being still – is the ultimate slowness, and there’s a spectrum you can play with in between for variety.

So if we continue with our obscenely simple program from last week, and we continue talking about squats, your clients with knee injuries may do anything from⁸:

• wall sits (isometric)
• 3-5 sec descending squat to sitting (eccentric)
• 3 sec down/3 sec up (slow)
• down for 3, hold for 1, up for 1

What this does is start to load the tendons in a very specific way, one which triggers collagen synthesis and rebuilding. So while the whole group is doing squats, lat pull downs, and push ups, the knee injuries are doing isometric work in their squats, the shoulder injuries are holding planks instead of push ups, and the elbow injuries are doing 30-45sec forearm holds^{9 10}.

The other plus side of isometric and slow work in a group environment is that you don’t usually need to spot them – you can set them up and then move your attention elsewhere.

In regards to my second point “feelings of safety” – chronic psychological stress has been shown to impair recovery from exercise¹¹. Having a painful joint contributes to psychological stress, and being fearful of re-injuring yourself is also psychological stress. If you want your client to recover well from exercise, injury or not, they need to feel safe in your environment. For someone with a chronic, painful, injury, going slow can give them that sense of control and safety – especially if you explain it’s going to trigger collagen synthesis and help them heal.

Having adequate rest between sets also slows the pace of the session more broadly, and further increases their feelings of safety (you may even find them opting to jump on the assault bike when they’re feeling better!!).

When Training Mid-Life Women who are carrying varying injuries – Consider their Nervous Systems and Let the Client be the Expert in Their Own Body…

I’m going to speak from experience a bit now, so take or leave what I say, but some of your client’s pain could be a warning from their nervous systems^{12 13 14}, rather than an injury. Today I will explain why I think this happens in women more than men, but before I start, I do realise I’ve made a leap of logic here, based on my own lived experience.

Women of my age (i’m 44) have been told their whole lives to shut up, that they’re inconvenient, and they’re too much, they need to be less, smaller, more “feminine” (which generally aligns with “helpless” in my view).

There’s good research that shows women will speak less when men are in the room, and when they do contribute, they only have to speak 30% of the time for them to be judged as “outspoken”. If they speak 15% of the time, their contribution is considered equal¹⁵. Women are also interrupted a lot (usually by men, the ratio in this paper men interrupt women at a ratio 24:1 Women interrupting women), have their ideas stolen and reused as someone else’s, and are generally taken less seriously^{16 17}.

These things contribute to what’s called “The Confidence Gap” between men and women – illustrated by research that showed men need to meet only 60% of a job’s criteria to feel like they could apply for it, where a women needs to meet 100% of the criteria before she applies¹⁸.

In a gym setting, this means that a woman may second guess herself, and do movements that she thinks she “should” despite the fact that it feels wrong to her. This response will be more likely if there are men in the room, or her trainer is male. As such, I encourage my female clients to speak up, to complain, to let me know when something doesn’t feel right, and I take them seriously when they do.

This is my primary strategy to down regulate their nervous systems in a gym and exercise environment (which will usually up-regulate them¹⁹). When the client trusts themselves, and they trust you not to push them where they feel unsafe, they can relax their vigilance. Now if you’re a male trainer, you’ll have to work harder at it; suppress your urge to interrupt, allow her to speak her truth, and take her seriously even her beliefs don’t align with yours. If your client’s pain is even partially due to nervous system factors, this approach should mean less pain generally, more confidence, and a client that’s more willing to give new things a go.

Many things in mid-life up-regulate a mid-life woman’s nervous system, which we touched on a couple of weeks ago. It’s a special time in a woman’s life where’s there are competing demands from many different directions and very little support. With this in mind, other ways that I down-regulate their nervous systems include:

• The group environment: women’s nervous systems love socialising^{20 21}.
• Women’s only environment: women feel safer, can speak, and be heard ^{22 23}.
• Meditation: the 5min we do at the end of every session goes a long way to setting them up for a calmer day, and more balanced hormonal system^{24 25}.
• Touch: I touch my clients (appropriately) and also set up games where they touch eachother²⁶.
• Earthing/grounding: we spend as much time as possible barefoot and outside. Touching the earth for 60 minutes a day can re-calibrate cortisol and diurnal rhythms^{27 28 29}.
• We training in the morning: for the same reason as above, because exercise is a stressor, we exercise when cortisol levels are already high, to allow for the gradual decrease in the afternoon and evening.
• Seeing nature: just looking at it can help calm the nervous system, relax their body, do more with less pain, and enhance their recovery³⁰.

Considering your client’s nervous systems and allowing them to be the experts in their own bodies may resolve some of your client’s pain all together, but even if it doesn’t, it will mean the client keeps training with you in spite of their injuries.

When I am Training Multiple Mid-Life Women with Multiple Different Injuries – I spend more time on anti-inflammatory behaviours.

Exercise is in itself inflammatory, and so is eating. Inflammation in and of itself is not a bad thing, but what’s harmful is the constant, low level inflammation that never goes away. Now Oestrogen in it’s Oestradiol form is an anti-inflammatory hormone, but in it’s Estrone form is inflammatory. During midlife we gradually stop producing Oestradiol and continue producing Estrone with our fat cells³¹. For this reason, mid-life women will be more inflamed than they were before. This is one of theories behind why women are more susceptible to neurodegenerative disease later on – so considering it now is vital³²!

Mitigating inflammation in our sessions goes a long way to helping these women feel better, so that they can continue training injured, or their injury goes away all together.

Ways that I incorporate anti-inflammatory behaviours into a session include:

• Meditation and mindfullness has been shown to reduce inflammation and the corresponding health effects such as autoimmune disease, allergies, and pain³³. I make sure we spend 5 minutes meditating in every single session, so in the very least they’re getting 1-2 opportunities a week.
• Touch: gentle stroking has been shown to modulate pain and inflammatory markers³⁴. Whilst I don’t go around stroking my clients, I do provide opportunities for hugs, correctional touch, pats on the back and high-fives.
• Earthing/grounding: this is where you come in direct contact with the earth, although cement works too. Touching the ground has been shown to reduce chronic, systemic inflammation, which improves immune response and accuracy, reduces pain, and promotes healing³⁵. We train inside/outside, and I like them to be barefoot as much as possible for this and other reasons.
• Engagement with nature: Whenever possible we stop and watch the local wildlife, spend time on the soft sand, and sometimes even immerse ourselves in the ocean, because positive experiences in nature are anti-inflammatory³⁶!
• Increasing anti inflammatory foods: this is a massive topic in and of itself, and I tend to guide my clients towards these eating behaviours one module at a time, but eating a diet that in high in anti-inflammatory minerals and nutrients (and low in pro-inflammatory factors and chemicals) has been shown to have a powerful effect on systemic inflammation³⁷. I choose to educate my clients in this over a long period of time, rather than lecturing them mid session.

If you noticed similarities between this week’s advice and last week’s advice on considering their nervous systems – you’d be right to see them! Inflammation and Hyper-Vigilant nervous systems go hand in hand, and calming one will calm the other³⁸.

When I am training groups of injured mid-life women – I build in “rest” to the sessions.

Building rest breaks into their session does a number of things:

1. Gives them time to do the things they’re not doing at home. Their physio exercises, their releases, their foam rolling, stretches, and mobilisers…
2. Allows their nervous systems to down regulate a bit
3. Gives them time to socialise and talk, build relationships and feel connected
4. Allows decent time to pass so that they can recover enough to lift heavy again in their next set, without trying to lift heavy on fatigued (and possibly injured) muscles and joints.
5. It means that only so many of them are lifting at one time, allowing ME time for corrections and modifications.

So my sessions are an hour, and approximately 25% of that session, or 15min, is rest!

Rest is also important between sessions. They do not have to train with me everyday to get a result, in fact, I’ll only offer a maximum of 2, or 4 sessions in overload weeks. Any more is just not necessary for optimal health. Instead, I encourage them to walk, or do activities that bring them joy, like gardening, pickleball, or swimming.

You don’t have to be afraid of rest in your sessions, not every client is looking for a flogging, not every client deserves a flogging, and not every client will benefit from a flogging. This group, more than others, will benefit from safety.

Finally, consider protein, especially collagen protein intake.

As a personal trainer, you cannot prescribe supplements, write diets, or create meal plans within your scope of practise. So unless you have appropriate qualifications, what is in scope is to guide towards the Australian eating guidelines, or other appropriately qualified health professionals.

Personally, I follow Dr Stacy Sims, who recommends around 2g per kilo of body weight of protein per day³⁹. You can help your client work this out too. Most of my female clients manage about 100g of protein per day through their food, and personally, I make up the difference with Collagen protein, and share that personal choice with my clients.

I know collagen has it’s critics. It is not a complete protein. However it is exceedingly easy for the body to break down and digest what it needs when the protein comes in the form of collagen peptides.

In addition, musculoskeletal pain is one of the more common, severe and impactful symptoms of perimenopause, I want to do everything in my power to ease that burden for my mid-life women⁴⁰. Because Oestrogen is tied up with collagen synthesis, our joints are more easily damaged in mid- and late life, and take longer to heal⁴¹. However collagen and exercise together have been shown to reduce joint pain and improve tendon thickness⁴² more than exercise alone.

Another review found that collagen supplementation significantly enhanced joint stability, reduced pain, and accelerated recovery from injuries such as Achilles tendinopathy. Collagen supplementation combined with resistance training improved muscle strength, body composition, and recovery markers better than training alone⁴³.

So whilst I guide my mid-life clients towards whole food guidelines, if they must supplement to get enough protein, then I make sure it has collagen peptides in it as well, because of the impact specifically on joints.

Which brings me to the last part of the question that instigated this topic: what courses to do to get better at managing groups of mid life women? Here are a few that I would recommend:

BURRELL EDUCATION

https://burrelleducation.com/menopause-transition-3rd-age-woman/

AWPT

https://www.awptuniversity.com/offers/JcByh2uo/checkout

CLARE HOZACK

https://clarehozack.au/product/thriving-mid-life-women-bundle/

https://clarehozack.au/product/biomechanics-female-body/

REFERENCES