Transcript Medical Concerns for the Aging Athlete

Help, I’m Getting Older!
Medical Concerns for the
Aging Athlete
Gregory R. Czarnecki, D.O.
Internal & Sports Medicine
Hartford Healthcare Medical Group
Glastonbury, CT
President, Connecticut Osteopathic Medical Society
Interim DME, UConn Osteopathic Internal Medicine Residency
Connecticut Podiatric Medical Association, April 11, 2015
Goals
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Review and understand benefits of exercise
throughout one’s lifespan and adaptive changes that
occur with aging.
Increase awareness of Exercise is Medicine
Learn tools for exercise prescription.
Review current exercise guidelines in the adult
population
Understand the role and recommendations for
exercise testing.
Highlight special considerations (medications,
treatments, etc.) in the aging athlete.
The ACSM guidelines for physical
activity (exercise) are:
1.
2.
3.
4.
5.
20 minutes per day 3 days per week.
30 minutes per day 3 days per week.
20 minutes per day 5 days per week.
30 minutes per day 5 days per week.
30 minutes per day most days of the week.
Strength training is incorporated into
these recommendations. What
is/are the recommended minimum
day(s) or sessions for incorporating
strength training?
1.
2.
3.
4.
5.
1 day/week
2 days/week
3 days/week
4 days/week
5 days/week
At what age range does physiologic
(adaptive) muscle hypertrophy cease
despite strength training?
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a. 60-69
b. 70-79
c. 80-89
d. 90-99
e. No age limit
Who’s an aging athlete?
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http://healthjournal.upmc.com/0605/SeniorGames.htm
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Loading Race - Dominic Filiou -
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Masters Athletes
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Masters level = age 35 +
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5 year-increments on
competitive groups,
includes 100+ category.
National Senior Games
(Senior Olympics) = age
50 and up.
Masters swimming = age
19+
More Master’s Levels
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Master’s cycling: 30+ or 35+
USA Track and Field: 30+; 40 for distance
running
Medical concerns
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Performance decline
Medical co-morbidities
Injury prevention
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Injury/Resection of 15-34% of the meniscus => increased
contact pressure by up to 350%
Medication risks
Where are you headed?
i238.photobucket.com/.../mirounrelnew.jpg
Changes with Aging
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Cardio
Pulm
MS
Neuro
Metabolic
Cellular
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http://www.dailygalaxy.com/my_weblog/2007/09/end-of-aging.html
Cardiovascular Changes
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↓HRmax
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6-10 bpm/decade
↑BP, PVR during max exercise
↓VO2 Max (maximal oxygen consumption)
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↓5-15% per decade after age 25
Pulmonary Changes
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↓VC
↑RV
↓ Elasticity
Translates to increases in work of breathing,
perceived exertion
Musculoskeletal Changes
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↓muscle mass, aka - sarcopenia– greater loss
of type 2 fibers
Peak muscle mass @ age 30
 Age 50 => decline
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↓bone mass (0.5% per year after age 40),
↓tensile strength of tendons/ligaments
↑muscle stiffness
Neurologic Changes
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↓ balance
↓ coordination
↓ reaction time
autonomic dysfunction
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↓thirst mechanism
Impaired thermoregulation
Metabolic Changes
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↑cholesterol
↓ metabolic rate
Weight gain
 Central obesity
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Cellular changes
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Mitochondrial dysfunction
Defects in electron transport chain
 Uncoupling of oxidative phosphorylation due to
hydrogen leak across inner membrane
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Leading to decreased ATP + apoptosis.
 Selective preference to type 2 muscle fibers.
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The Descent…
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O’Connor, Just the facts
Sedentary lifestyle
associated with
work, family,
acute/chronic
medical conditions.
Give rebirth to
exercise in one’s
daily life.
? Average American Family?
How much is preventable with
exercise?
What’s the point?
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Routine exercise associated with
prevention/reduction of medical
conditions including:
CAD
 HTN
 Obesity
 DM-2
 Dyslipidemia
 Osteoporosis
 Anxiety/depression
 Cancer
 Constipation!
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Getting Started – the history
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What is planned activity/activities?
Current level of training?
Vision impairments? (cataracts, glaucoma)
Hearing loss?
Chest pain, exertional dyspnea, palpitations,
syncope?
Signs of neurologic/autonomic dysfunction?
Musculoskeletal history
Co-morbidities
Medications
Getting Started - exam
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Blood pressure; orthostatics if history
suggestive
Cardiac, lung, carotid auscultation
Femoral pulses
Neuro – coordination, balance, proprioception,
strength, sensation
Musculoskeletal – joint deformities, effusions,
ROM, biomechanics, FEET.
Skin integrity
Exercise is Medicine
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Campaign launched by the American College of
Sports Medicine (ACSM) in collaboration with
the American Medical Association (AMA).
For physicians of all specialties
Prescribing Exercise
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Set realistic goals and expectations.
What activities does your patient enjoy?
What limitations/barriers to exercise exist?
Include cardiovascular (aerobic), strength
training, flexibility and proprioceptive/balance
training.
Mode, intensity, duration, frequency.
Things to discuss
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Warm up, cool down
Gradual changes in intensity/duration/frequency
Goal = most days of week for moderateintensity exercise ≥30 min; 2 or more days per
week for strength/resistance training (limit
increase to 5%/week)
Allow recovery time to avoid common overuse
injuries
Possible medication interactions, hydration,
nutrition, patient’s concerns/fears.
Exercise Testing
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Formal exercise testing remains controversial
for pre-participation in exercise.
Yield greatest in symptomatic adults and
intermediate pre-test probability.
Questions for the patient should address
planned activity and goals.
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If moderate activity, testing “not necessary,” but
recommended if vigorous.
ACSM’s guidelines for exercise
testing prior:
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For any high risk pt planning moderate or
vigorous exercise (HR=cardio-pulm disease or
suggestive symptoms, DM, renal, hepatic dysfn)
For moderate risk pt (M>45, F>55 OR with
2/more risk factors - +Fam hx, +tob, HTN, ↑chol,
obesity, sedentary lifestyle, fasting BG >110 x2
measurements) – only recommended for vigorous
exercise (>6 mets)
Not necessary in low risk group (asymptomatic,
M<45, F<55)
Intensity Grading
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http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_I
ntensity_table_2_1.pdf
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MET – ratio of exercise metabolic rate
1 MET = energy expenditure for sitting quietly;
3.5ml O2 uptake/kg/min.
 Will vary by age
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Grading Intensity
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As percentage of max HR (220-age +/- 10
BPM):
50-63% = light
 64-76% = moderate
 77-93% = vigorous
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90-114 in 40yo
115-137
138-167
As percentage of Heart Rate Reserve (HRmax
- resting HR):
20-39% = light
 40-59% = moderate
 60-84% = vigorous
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84-107; assume rHR 60
108-131
132-161
Talk Test
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Light – able to sing
during your activity
Moderate – able to hold
conversation during
activity
Vigorous –
winded/breathless –
can’t carry-on
conversation during
exercise.
Now that they’re exercising…
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Doc, it hurts me when I do this…
Sure, it hurts, but I just deal with it…
I stopped _______ because I hurt my ______.
Can I still run, bike, swim, etc.?
Words of caution
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Overuse injuries account for
majority of musculoskeletal
complaints in the adult
athlete – 70% of injuries in
experienced athletes over
60.
Training errors increase risk
of injury.
Biomechanics, training
surfaces, recovery time are
all important considerations
in injury prevention.
Common “Overuse” Injuries
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Rotator cuff disorders:
tendonitis/bursitis/impingement
Golfer’s elbow
Tennis elbow
Carpal Tunnel Syndrome
Jumper’s knee
Runner’s knee
ITB friction syndrome
Achilles tendonitis
Plantar fasciitis
Overuse or Dysfunctional Use?
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Why do baseball pitchers commonly develop
shoulder and elbow problems?
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Maybe it’s both…
How can we help keep these athletes
“going strong?”
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Activity modification; cross-training
Correct biomechanics
OMT
Physical Therapy
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Medications
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↑ROM
Strengthening
↑ Proprioception
NSAIDs, Tylenol
Opiates?
Injections
Surgery?
Common findings in Tendinosis
include:
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a. Inflammatory cells including neutrophils
b. Avascularity
c. Tendon thinning
d. All of the above
e. None of the above
Tendinosis/Tendonopathies
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Focal area of degeneration due to incomplete
healing, repetitive loading/stress, tissue hypoxia.
Lack of inflammatory mediators on biopsy.
Neovessel formation.
Tendon thickening.
Tendinosis
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Alfredson, AMSSM 18th Annual Meeting
Emerging Injections
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Prolotherapy
Sclerotherapy
Autologous Blood
Platelet-rich Plasma
Stem Cells
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What about steroids?
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Osteoarthritis
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OA affects 15% of US population.
Over 70% over age 70 will have x-ray
evidence of OA.
Clinical symptoms are widely varied.
Joint stiffness +/- effusion; decreased active
and passive ROM
Physical Activity and OA
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Does exercise increase your risk for OA?
Moderate mechanical loading is necessary to
maintain healthy articular cartilage. (Griffin)
A disruption in the joint homeostasis can begin
the shift to degradative process.
Sports after joint replacement?
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Concerns: hardware failure, joint dislocation,
periprosthetic fracture
Low impact recommended (level C)
Activities will vary based on experience prior
to joint replacement and anticipated level of
impact
Contact sports and high-impact activities not
recommended (level C)
Medication Considerations
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? Side-effects that may impair sport or put
athlete at risk?
NSAIDS with dehydration
 ACE with NSAID/dehydration
 Beta-blocker on HR/performance
 Diuretics
 Antibiotics – Quinolones
 Insulin/sulfonylureas
 Steroids
 Antihistamines
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It is never too late to start
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Benefits of strength
training seen even in the
frail elderly.
Improved get-up-and-go
Improved spontaneous
activity
Reduced falls and
obstacle avoidance
For Your Aging Athletes:
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Beware of potential
overuse patterns
Correct biomechanics
Judicious use of
injections
Goals will change
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Activities may change
Medications: 1st do no
harm
Exercise IS medicine
Conclusion
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Multitude of risk reductions through exercise.
Encourage exercise most days of week for moderate-intensity
exercise ≥30 min; 2 or more days per week for strength/resistance
training.
Exercise prescription should be integral to patient care.
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Mode, frequency, intensity, duration.
Cardiovascular, strength, proprioception, flexibility.
Overuse injuries common in the mature athlete. Patient education
is crucial.
Treatments aim to improve biomechanics (joint forces, muscle
balance, and external forces), reduce pain, and allow preservation
of function, maintaining quality of life.
Stay fit, stay young.
Questions?
References:
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Bartz RL, Laudicina L, Osteoarthritis after sports knee injuries. Clin Sports Med 24 (2005) 39-45.
Bishop JY, Flatlow EL. Management of glenohumeral arthritis: a role for arthroscopy? Orthop Clin N
Am, 34 (2003) 559-566.
Brill PA, Probst JC et al., Clinical Feasibility of a free-weight strength-training program for older
adults. The Journal of the American Board of Family Practice. v11(6), Nov/Dec 1998: 445-451.
Clegg DO et al., Glucosamine, Chondroitin sulfate, and the two in combination for painful knee
osteoarthritis. N Engl J Med; 354n8, Feb 23, 2006: 795-808.
Brophy RH, Marx RG. Osteoarthritis following shoulder instability. Clin Sports Med, 24 (2005) 47-56.
Gorsline RT, Kaeding CC. The use of NSAIDs and nutritional supplements in athletes with
osteoarthritis: prevalence, benefits, and consequences. Clin Sports Med 24 (2005) 71-82.
Hochberg MC. Nutritional supplements for knee osteoarthritis – still no resolution. N Engl J Med;
354n8, Feb 23, 2006: 858-860.
Mellion et al. Team Physician’s Handbook, 3rd edition, Hanley & Belfus, Inc. 2002.
Montellese P, Dancy T. The acromioclavicular joint. Prim Care Clin Office Pract, 31 (2004) 857-866.
Snibbe JC, Gambardella RA. Use of injections for osteoarthritis in joints and sports activity. Clin
Sports Med 24 (2005): 83-91
Williams CM. “The geriatric athlete.” Sports Medicine: Just the Facts, edited by Francis G. O’Connor
et al., McGraw-Hill Medical Publishing Division, NY, 2005.
Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am
Fam Physician - 15-FEB-2008; 77(4): 453-60
Mazzeo RS, Cavanagh P, et al. ACSM Position Stand: Exercise and physical activity for older adults.
Medicine & Science in Sports and Exercise, v30(6):992-1008, June 1998.
Griffin TM, Guilak F. The role of mechanical loading in the onset and progression of osteoarthritis.
Exerc. Sport Sci. Rev., Vol. 33, No. 4:195-200, 2005.
Images in this presentation obtained via www.google.com – images (unless otherwise specified)
More References:
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Nicholls MA, Selby JB, Hartford JM. Athletic activity after total joint replacement.
Orthopedics, v25, No. 11:1283-7, November 2002.
Bellamy N, Campbell J, et al., Intraarticular corticosteroid for treatment of
osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons,
Ltd. Issue 3, 2007.
Bellamy N, Campbell J, et al., Viscosupplementation for the treatment of
osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons,
Ltd. Issue 3, 2007.
Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and
Fluoride (1997), National Academies Press.
Edelson R, Burks RT, Bloebaum RD. Short-term effects of knee washout for
osteoarthritis. American Journal of Sports Medicine, v23, No. 3: 345-349, May
1995.
Moseley JB, Wray NP, et al. Arthroscopic treatment of osteoarthritis of the knee: a
prospective, randomized, placebo-controlled trial results of a pilot study. American
Journal of Sports Medicine, v24, No. 1: 28-34, Jan 1996.
Moseley JB, O’Malley K, et al. A controlled trial of arthroscopic surgery for
osteoarthritis of the knee. NEJM, v347, No. 2: 81-88, July 11, 2002.
Haskell WL, Lee IM, et al. Physical activity and public health: updated
recommendations for adults from the American College of Sports Medicine and the
American Heart Association. Circulation 116:1081-1093, 2007.
American College of Sports Medicine, ACSM’s Guidelines for exercise testing and
prescription, 7th edition, Lippincott Williams & Wilkins, 2006.