Here is a quick tip: For engaging people with dementia in strengthening exercises that are effective, beneficial, and easy to initiate, close the chain.
Do you know the difference between open kinetic chain and closed kinetic chain exercises? It’s pretty simple. If you have a dumbbell in your hand and you’re lifting it up and down, it’s an open chain exercise. The end of your arm is free to move. If you get on the floor and do a push up, it is closed chain- your hands and feet are fixed.
Open chain exercises are great for targeting an isolated muscle and a specific movement. Rotator cuff rehabilitation protocols will most definitely consist of open chain range of motion and strengthening movements that improve the motion provided by each of the rotator cuff muscles.
Closed chain are better for larger muscle groups and patterns of movement. Closed chain exercises are also known as functional exercises. Functional exercise- the philosophy endorsed by popular fitness companies like CrossFit- trains groups of muscles to perform functional movements. Squatting leads to an improved ability to stand up and sit down. Planks help stabilize the core, which decreases back pain, and improves the ability to change positions, roll in bed, and lift things. Pushing a weighted sled, carrying a weighted kettlebell, and pulling up your own body weight all imitate movements we perform in everyday life. CrossFit has enjoyed such success because it makes sense for the body, and participants can see the benefits when they perform the same movements for a functional purpose.
For someone with cognitive impairment, closed chain exercises are the preferred method for several reasons. Firstly, functional movement makes sense. Pushing a shopping cart, lifting a bucket, and carrying a stack of books are familiar movement patterns, and they require the stimulation of many muscle groups. You simply get more bang for your buck with a functional movement than an isolated one.
Secondly, repetitive open chain exercises require sustained cognitive functions like initiation, attention, sequencing, and memory. Persons with dementia have a hard time performing an isolated movement with good quality and mechanics beyond a repetition or two. Do you want them to count out loud, or do you want them to raise the dumbbell over their heads? Oh, and then you want them to lower the weight too. And then attend your cues and initiate it again? Expecting follow through and carryover for each step is a tall order without good alternating attention and an inherent understanding of the purpose of the exercise.
The last reason- and I think this is the most overlooked and most important reason- is that degenerating brains need the sensory feedback found in functional movement. We see this in folks in the later stages of dementia- they reach for furniture to touch, for railings to pull on, for carts or walkers to push. They make sense of their environments through tactile feedback.
Have you ever noticed when you stand on one foot and start to lose your balance, that just touching the wall with one finger is enough right the ship? We are wired to integrate sensory input from our sensory organs (eyes, ears, skin, mouth, and nose) to master awareness of where we are in our environment (proprioception). When that sensory processing system degenerates, we recruit more sensory input from more sources to guide the movement response.
And resistance just feels good. Pushing, pulling, lifting, and carrying are primitive movement patterns that babies are quick to master early in development. These movements are still well known to our brains long after higher cognitive functions have deteriorated.
Take home message: Open chain exercise don’t provide the sensory feedback or recruitment of large muscle groups that fuel a good movement response. Provide opportunities for closed chain exercises that are tied to highly familiar functional movements. Start with hand against hand pushing and pulling. Try resisted rowing movements using a stick or cane. Strengthen legs with squats at the sink instead of quad sets with ankle weights. Provide lots of tactile input (hands, feet, and trunk… with resistance!), and see how much better the proprioceptive response will be, and the more secure and safe the person will feel in their environment.
This article in Women’s Health nails it: http://www.womenshealthmag.com/fitness/97-year-old-woman-doing-squats