What Occupational Therapy can teach us about cycling and “the elderly”

An article and case study combining three of my favourite things: cycling, older adults, and OT.

I love bikes. I love riding them, building them, cleaning them, the whole nine yards. The sheer ingenuity of the wheel simply doesn’t get old for me.

I also love seeing people get on a bike that gives them joy. Finding the right bike for the occasion is magical (it’s why I have (cough) five bikes) and finding the right bike for the person is the same. It is a happiness to which nothing else compares.

I’m an Occupational Therapist (OT) by training. Quick primer if you’re not familiar with the profession:

Occupational therapy provides practical support to empower people of all ages to facilitate recovery and overcome barriers preventing them from doing the activities (or occupations) that matter to them. This support increases people’s independence and satisfaction in all aspects of life. — Royal College of Occupational Therapists

And a little more on how we do that:

An occupational therapist will consider all of the patient’s needs — physical, psychological, social and environmental. This support can make a real difference giving people a renewed sense of purpose, opening up new horizons, and changing the way they feel about the future.

An OT is essentially a person-centered Project Manager. We help individuals to regain their level of functional independence, in any situation, and facing any barriers:

[IMAGE DESCRIPTION: image showing the multiple areas OT can help with]

The reason we’re successful Project Managers is because we’re holistic. We work with people, we don’t just tell them what they need to do, or write a prescription and send them on their way.

[IMAGE DESCRIPTION: cartoon by @makedaisychains with two cats saying “Occupational Therapists ask “what matters to you” not “what’s the matter with you?””]

I’ve worked in a few different clinical rotations, but my area of passion is older adult health and social care. For a multitude of reasons, I don’t see a lot of older adults on bikes here in the UK, and while I can’t claim to have all the answers or be able to put the world to rights, I do have a few ideas I’d like to share. One is about modifications, and the other is about perceptions.

Mods and rockers: personalising the cycling experience

Martyn Ashton, a personal hero and one of the most celebrated British mountain bike and stunt riders of all time, broke his back not once, but twice. He was left with life changing injuries: total lower body paralysis. Martyn continues to ride, to this day, using a variety of different bikes as it is a meaningful and enjoyable activity for him. He’s just found ways around the challenges.

[IMAGE DESCRIPTION: Martyn Ashton sits in a manual wheelchair, looking at his heavily customised Canyon mountain bike complete with secure seat to strap his legs and torso into]

Martyn is the Occupational Therapist’s dream — in fact, when I was studying to be an OT, I was thrilled to open our notes one day to find an entire case study on his adaptations.

OT is full of adaptive equipment and assistive technology. It’s how we see the world:

Recovering from a recent stroke which has left you with lasting hemiplegia (one-sided paralysis) but really missing cooking your own meals? You can do this. Let’s get you set up with some pre-chopped veg from the frozen aisle, or a chopping board that has spikes to hold things in place so you can chop one handed:

[IMAGE DESCRIPTION: functional chopping board with spikes and one-handed holding mechanism]

Suffering from rheumatoid arthritis, struggling to do your bra up and finding that it’s really affecting your self esteem? I got you hun. We can look into magnetic clasps, front-fastening bras, athletic-style bras, or this excellent Bra Angel — whatever works best for you:

[IMAGE DESCRIPTION: the Bra Angel adaptive equipment usage instructions]

Living with crippling labyrinthitis and finding it impossible to bend down and put your shoes on without feeling like you’re going to vomit or pass out? You’re in luck, my friend. There are a number of options for addressing this, the most “fly” being the new Nike GO FlyEase:

[IMAGE DESCRIPTION: person slipping on and off the Nike GO FlyEase shoes (which have a hinge in the middle) without having to use their hands]

Overcoming challenges and doing a lot of lateral thinking is how OTs do their job. I cannot stress enough how valuable and empowering this is — and yet the profession seems chronically and continually poorly-recognised because people get confused by the word “occupation”. Sometimes I feel we’re seen as the weird cousins of physiotherapy (with whom we work closely) and social work, and then someone gets us mixed up with Occupational Health and I have to start my explanation all over again from a different angle.

Anyway — enough on that tangent. The bottom line is that there’s basically nothing an OT can’t help you achieve without a few modifications and a bit of thinking outside the box. At the end of the day, we prioritise — and champion — the lived experience of the person we’re supporting.

I’m going to explain a bit about perceptions of older adults, and take a look at an example of a bike that I think is excellent.

Cycling and “the elderly”

I’ve been asked before if I have any tips for “bikes for the elderly”. Though always well-intentioned, I find this a tiresome and misleading question.

For starters, it’s not a particularly good word to use as it carries (and perpetuates) stereotypes. I much prefer “older adults”.

Additionally, “the elderly” is not a homogenous group. Their defining, uniting characteristic is nothing but their decade (or thereabouts) of birth. Nothing more. Book after book in gerontology will demonstrate to you through data and anecdote that chronological age gives absolutely no predictive insight into functional ability, fitness level or personal preference.

Telling me someone is between 65 and 100 tells me nothing about the sort of bike that would suit them and their needs best.

You find the bike to fit the person and their needs and preferences, not their demographic. For instance, for years I’ve rolled my eyes at the “women’s” specific bikes marketed towards me inaccurately — which simply took a “man’s” bike and followed the classic industry line: “shrink it & pink it”.

The next, very practical, problem with this question: what does it mean for a bike to be “for the elderly”? Can you answer this without invoking stereotypes or clearly displaying an unconscious bias? All too often, a Google for “xyz for elderly” brings up ageist images that perpetuate this idea that all older adults have the same needs and functional capacity, because they are usually designed by people who are not older adults. The good people at the Centre for Ageing Better work tirelessly in this field and recently released an excellent age-positive image library:

[IMAGE DESCRIPTION: older Sikh man riding a bicycle outside in the sun]

We need to be more specific, and more person-centered. The best way to do this is to look at the data.

What actually makes a difference, according to the research

I find well-intentioned people often want to focus a lot on “fitness” and under-appreciate additional (and alternative) aspects of how cycling can impact the lives of older adults.

  1. Balance

Fitness is wonderful, but interestingly, balance is more important than fitness for reducing falls — the second leading cause of accidental or unintentional injury deaths worldwide, and the largest cause of emergency hospital admissions for older people in the UK.

I can refer you here to the most excellent resource — Camilla Cavendish’s “Extra Time: 10 Lessons For Living Longer Better”:

In 2017, [Sir Muir Gray] and colleagues calculated that the UK could save several billions a year from ‘even modest improvements in fitness’ to stop older people crossing the line from independence to dependence: needing carers or going into a home. […] The fitness gap can be narrowed, Gray argues, from any age. Even 90-year-olds can improve their strength with relatively small amounts of exercise.

Three months of balance and gait training, and mild weight-bearing exercises, can reduce falls — which are responsible for 5 times as many hospitalisations among the over-65s as any other injury. […] In the UK, 10 percent of ambulances are called out for older people who have fallen over.

And Dr Anna Dixon, Chief Exec of the UK’s Centre for Ageing Better:

There is strong evidence that strength and balance exercises can reverse muscle wasting and thereby prevent falls.

Cycling is excellent for balance, as well as being a low intensity aerobic workout which builds strength in multiple muscle groups.

2. Providing meaning and improved mental health, regardless of physical health state

There is research from a specifically OT perspective explaining how and why cycling is meaningful. Cycling has the ability to “alter a person’s mind-set and their emotions”, and contributes towards a person’s identity. It keeps people active, and connected to others. It has been shown to significantly improve mental health and executive function in individuals with schizophrenia. People in the early stages of Parkinsons — an incurable, progressive neurological disorder which 53 million people live with worldwide — may see their symptoms dramatically improve with the introduction of indoor cycling to their treatment plan. The US National Institute on Ageing is very close to finishing a multi-year randomised control trial (RCT) to measure how cycling affects people living with Alzheimers disease.

From a qualitative and anecdotal perspective, I believe the joy of cycling applies to all humans of all ages.

There exists an incredible range of accessories and alternative parts that can make cycling accessible (and enjoyable), and many initiatives exists to get people with dementia cycling (Positive Spin) or indeed those with any type of dis- or different ability (Wheels for Wellbeing):

[IMAGE DESCRIPTION: older woman using a hand-operated tricycle and smiling]

There is no doubt that customisation of a bike can hold the key to making it the right “fit” — making it meet the needs of the person.

When people have asked me in the past about “bikes for their elderly friend/family member”, it comes from a place of care. I understand this. They often want to optimise between helping them keep active, and not being in danger. All too often, however, the individual’s own wishes are not brought into the conversation under a misguided belief that people who cycle a lot “know a lot about bikes”. As an ardent cyclist, I understand this perspective!

What I don’t know, however, is what the person in question values, and what compromises they would prefer to make. I see the same thing happening with my volunteer work with Age UK — older adults having tablets bought for them, and having no say in the purchase or setup or use cases, leading to lower engagement. As I acknowledged at the beginning, it’s more complex than this — I know — but it’s a pattern I see so often. Call it what you will, it’s all the same: patient-centered care, continuous stakeholder engagement, user-driven design, good manners and empathy.

What A Good One Looks Like (WAGOLL)

WAGOLL is a great concept from teaching. It’s especially powerful in product design (writing “user stories” is how Product Managers get software engineers to understand the basic lived experience of an end user they will likely never meet). Stories are, as Peter Stroh says, “a primary way of distilling and coding information in memorable form.” The following example (taken from a cycling acquaintance ) is a WAGOLL. It doesn’t matter about the individual modifications: what matters is that his dad’s wishes were incorporated and his individual needs met, rather than something being made for him based simply on his diagnosis or age. The modifications are function-specific, not age-specific.

My dad suffers from Parkinson’s but has always been a keen cyclist and used to race and we trained together when I was a child, but he lost confidence and balance as his illness got worse.

The bike is a Surly Crosscheck I converted to disc brakes (more effective than usual “rim” brakes) and 650b (very slightly smaller wheels).

[IMAGE DESCRIPTION: photo of my acquaintance’s father’s bike]

My experience was to include the following:

  • hydraulic disc brakes
  • low bottom bracket
  • big tyres
  • low toptube
  • bars level with saddle position (not much higher and not any lower — comfort is king)
  • good fit
  • big grippy pedals
[IMAGE DESCRIPTION: close up photo of my acquaintance’s father’s bike, showing the head tube and rising handlebar stem]

Lastly, I fitted a dropper seatpost because Parkinson’s messes with the ability to get on a bike and he refused to have a dropped seat tube. It was very important for him that the bike didn’t look any different.

Isn’t this lovely?!

Parkinsons interrupts the brain’s ability to initiative movement in certain scenarios and can heavily impact walking. However, cycling requires a different neural configuration and bodily balance somehow, so cycling is — even in people with advanced symptoms — less affected than walking. Imagine how liberating that is.

I don’t want to give you advice on “bikes for the elderly”. I’m an Occupational Therapist. I want you to speak to the person who needs a bike and ask them what their functional requirements and personal preferences are, and go from there. Whether they want a basket, a bell, panniers, mudguards. If they want brakes that are made for smaller hands, or if the area they’re planning to ride in means gears would be a good idea, and worth the weight trade-off. What kind of locking mechanism would make their life easiest. What colour they would like it to be. What matters to them.

Thanks for reading. Finally, I’ll leave you with this most heartwarming story giving a perfect example of Occupational Therapy and cycling.

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Lucy Mitchell

Lucy Mitchell

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Technical Writer. Former NHS OT and software developer in health tech. I like bikes and plants. www.ioreka.dev