Transcript Musculoskeletal Issues in the Geriatric Athlete

Musculoskeletal Problems of the
Obese and the Elderly
(or “How do we prevent functional decline in the two
fastest growing segments of our population?”)
Rochelle M. Nolte, MD
CDR USPHS
Obesity Epidemic
NHANES Adult Obesity
80%
70%
66% Overwt
60%
50%
40%
31% Obese
30%
20%
10%
1962
1972
1978
1992
Hedley et al, JAMA 291(23) 2004
2002
NHANES
Prevalence of Overweight Youth Ages 2-19
National Center for Health Statistics, Prevalence of Overweight Among Children
and Adolescents: United States, 2003-2004
Exercise (Activity) Prescription for Adults
New Hopkins Projections
By 2015:
• 75% of adults overwt or obese
• 41% will be frankly obese
Epidemiologic Reviews. 2007. 29(1): 6-28
Epidemiology of Geriatrics
• 2009:
– 39 million seniors
– 14% of the US population
– 37% of health care costs
• 2030
– 70 million seniors
– 20% of the US population
– 50% of health care costs
Obesity Epidemic
Modifiable Risk Factors
“Actual Causes of Death”
Mokdad, JAMA, 2004
“Dis-fitness” Cycle
Age
Related
Change
New or
Existing
Illness
Increased
Disease
Risk
Illness
Risk
Factors
Reduced
Physical
Activity
Physiologic changes with age
• Height declines appx 1cm/decade /p 50
• More accelerated for women /p 60
• Wt increases 30’s 40’s 50’s (visceral fat)
• Wt stabilizes 50’s -70’s, then decreases
• Fat free mass decreases 2-3%/decade
• RMR, muscle protein synthesis rate, fat
oxidation all decrease
Physiologic changes with age
• Perception of precision movements may
be altered
• Sensory, motor, and cognitive changes
alter biomechanics
– How much is age v. disease process?
• Flexibility and joint ROM decreases
• Muscle and tendon elasticity decreased
Physiologic changes with age
• Isometric, concentric, and eccentric
strength decline after age 30-40
– decline accelerates after age 65-70
• Power declines faster than strength
• Muscle endurance declines with age
• Reaction time increases
• Simple and repetitive motions slow
Physiologic changes with age
• Decrease in muscle mass
– Loss of mass and contractile strength
– Strength loss exceeds mass loss
• Estimate a 30% loss of mass from age 30-80
• Estimate a 60% loss of strength from age 30-80
– Exercise improves both strength and mass
– Decline in GH, IGF-1, and sex hormones
– Greater loss of fast-twitch (type II)
Physiologic changes with age
• Bone density
– Bone is dynamic tissue
• Constantly remodeling in equilibrium
– Bone mass peaks in 20’s
– Thought to decrease 0.5% or more q yr /p 40
– Women lose 2-5% q yr starting 2-3 yr before
menopause and lasting 5-10 years
Osteoporosis
• Low bone mass
• Microarchitechtrual
•
•
deterioration
Enhanced bone
fragility
Increased risk of
fracture
Osteoporosis epidemiology
• 10 million people in US
• 34 million with
•
•
osteopenia in US
About 2 million
osteoporotic fx/year in US
After age 65
– 1 in 2 women will sustain
an osteoporotic fx
– 1 in 5 men will sustain an
osteoporotic fx
Osteoporosis costs
• 2.5 million physician
•
•
•
visits per year
>400,000 hospital
admissions per year
>180,000 nursing
home admissions
Projected annual
direct costs $25 billion
Hip Fractures
•
•
•
•
•
•
•
300,000 hip fractures per year in US
Over ½ occur in >80 year old patients
½ of hip fracture patients go to NH
½ d/c’d to NH become long-term resident
One year mortality is 20%-24%
60% never return to baseline function
> ½ women >75 prefer death to hip fx
Osteoporosis Management
• Goals of osteoporosis
management
– Prevention of fracture
– Stabilization or
increase of bone mass
– Relief of sx of fx and
skeletal deformity
– Maximization of
physical function
Osteoporosis Prevention
Osteoporosis Prevention
• Adequate caloric
•
intake
Exercise
– Weight-bearing
– Swimming
– Intermittent dynamic
loading
• Avoid tobacco
• Avoid/decrease
alcohol intake
Osteoporosis Prevention
• 92% of total bone
•
•
mass by age 18
99% by age 26
Bone mass not
obtained during this
time cannot be made
up later
Osteoporosis prevention
• Different sites
•
•
mature at different
ages
Peak bone mass
complete by age 16
in the femoral neck
Later in lumbar spine
and distal radius
Definition of Osteoarthritis
Disease of the joints
characterized by:
– Progressive articular
–
–
–
cartilage loss
New subchondral bone
formation
New bone and cartilage
formation at joint
margins
Low level synovitis
& PAIN!
Clinical Diagnosis
– Joint Pain
– Typical Pain Pattern
– Xray Findings
– Standing films
– AP with 30 deg flexion
– No Sign of Zebras
Etiology of Osteoarthritis
• Growth of cartilage and bone at the joint
margins leads to osteophytes which can
restrict movement
• Chronic synovitis and thickening of the
joint capsule further restrict movement
• Periarticular muscle wasting is common
and plays a major role in sx and disability
Symptoms of osteoarthritis
• PAIN (Articular cartilage is aneural)
– OA pain is not from the cartilage
• Stretching of nerve ending in periosteum covering
osteophytes
• Microfractures in subchondral bone
• Stretching of joint capsule
• Synovitis
• Ligament stretching or muscle pain
• STIFFNESS (esp. after inactivity)
Epidemiology of OA
• OA of the knee is the leading cause of chronic
disability in the elderly in developed countries
– Estimated $60 billion economic impact in US
– Decreased quality of life for > 20 million Americans
• In patients over the age of 55:
– Hip OA is more common in men
– IP and 1st MCP OA is more common in women
– Knee OA (with sx) is more common in women
Epidemiology of OA
• In patients under the age of 55:
– Joint distribution of OA is equal between men
and women
• Due to genetics or joint usage?????
– Mother and sister of a woman with DIP OA
are 2 & 3 X more likely to have the same
– Racial differences in prevalence and pattern of
joint involvement also point to genetic basis
Epidemiology of OA
• Age is the most
•
•
•
powerful risk factor
for OA
Women < 45 years of
age: 2% with OA
Women 45-64: 30%
with OA
Women >65: 68%
with OA
Epidemiology of OA
• Disability in subjects with knee OA
– More strongly associated with
QUADRICEPS WEAKNESS
– than with joint pain or radiographic severity
• Demographics associated with increased
likelihood of being symptomatic: women,
unemployed, divorced, poor social support
Which is higher risk for OA?
Strong Risk Factor for OA
Obesity
• 10 lb increase in
weight = 40%
increase in knee
osteoarthritis
• Larger effect in
women
(Felson et. al.
Ann Int Med 1992, Framingham
Heart Cohort data)
Epidemiology of OA
• Obesity is a risk factor for knee (and
hand) osteoarthritis
– In the highest quintile of BMI
• Relative risk of developing OA in the next 36 years
was 1.5 for men and 2.1 for women
• For SEVERE OA, the RR rose to 1.9 for men and
3.2 for women
– Weight loss of 5kg was associated with a 50%
reduction in the odds of developing OA
Strong Risk Factor for OA
Joint Trauma
Moderate Risk Factor for OA
Certain Vocational Activities
Jobs requiring
repetitive knee
bending/moderate
activity predict
higher rates of
osteoarthritis
Felson et al
Annals of Int Med 1992
Zhang W et al.
Osteoarthritis Research Society
International recommendations
for the management of hip and
knee OA, Pt II: OARSI evidencebased, expert consensus
guidelines.
Osteoarth and Cartilage 2008;
16:137-62.
Lose Weight if Overweight/Obese
(LOE 1a)
• 10 lb / 40% rule
• Break that vicious
•
cycle:
Team approach is
critical
Pain and
stiffness
Disuse
Weight
Gain
Educate Your Patients(LOE 1a)
• Objectives of
•
•
•
•
•
treatment
Changes in lifestyle
Importance of
exercise
Pacing yourself
Weight reduction if
needed
Unloading of joints
Management/Treatment of OA
• Goals
– Educate patient about disease and
management
– Improve function
– Control pain
– Alter disease process and its consequences
• (we just don’t know that much about biomarkers
and disease-modifying drugs just yet……)
Management/Treatment of OA
• No known cure for OA
• HOWEVER
– Impaired muscle function
– Reduced fitness
• Affect pain and dysfunction
• Are amenable to therapeutic exercise
Treatment of Osteoarthritis Overview
• Nonpharmocologic Measures
– Education, Weight loss, Exercise, & Bracing
• Pharmacologic Measures
– Analgesics, Glucosamine, Injectables
• Alternative Therapies
– Accupuncture, Dietary Supplementation
• Surgery
Exercise is EXCELLENT
Treatment for OA
Passive ROM
Active ROM
Isometric Strength
(tighten muscle w/o
motion)
Aerobic
Conditioning
Isotonic
Strengthening
Goal Activity
Shoulder
Buddy Stretch
Codmans
Finger Wall Climb
Wheelchair aerobics
Wall presses
Arm ergometer
Swimming
Rotator Cuff
Theraband
Evidence for Benefit from
Exercise
in Treating OA
• Regular aerobic walking
for knee OA
– LOE 1a for knee OA
– LOE IV for hip OA
• Home-based quad
strength exercises
– LOE 1a for knee OA
– LOE IV for hip OA
• Water-based exercise
for hip OA
– LOE 1b
What Kinds of Exercise are OK?
• Little evidence-based recommendations
• Common sense advice
– Avoid further trauma
– Wise to avoid high-risk activities
– Listen to your joints
X
Prevention of OA
Prevention of Osteoarthritis
• Weight reduction (IA)
• Recreational
•
•
•
exercise/sports (IA)
Maintain physical
fitness (IB)
Avoid obesity (IB)
Participate in
adequate physical
exercise (IB)
Prevention of OA
• Current studies
– Isokinetic exercise for improving knee flexor
and extensor muscles in healthy adults to
assess safety and effectiveness
– Will also assess in adults with neurological,
orthopedic, and rheumatological conditions
• Currently < 1% of money spent on
Osteoarthritis is spent on research
Overview
Physicians, their Patients & Exercise
• 47% of primary care physicians include
an exercise history as part of their initial
examination (Self Report)
• Only 13% of patients report physicians
giving advice about exercise
• Physically active physicians are more
likely to discuss exercise with their
patients
Eakin, Am J Prev Med, 2005
Abramson, Clin J Sport Med, 2000
Walsh, Am J Prev Med, 1999
Exercise (Activity) Prescription for Kids
Train Up A Child…
• 25% of obese preschoolers become obese
• 80% of obese 14 year-olds remain obese
• 70% of obese children who lose weight
will maintain that loss as adults
• BMI at 18 years stronger predictor of DM2
than at ANY other age
Allen, J Pediatr, 2007
Flegal, Physiol Behav, 2005
“Train up a child in the
way he should go: and
when he is old, he will
not depart from it.”
- Proverbs 22:6
Exercise (Activity) Prescription for Kids
Exercise Works for Children
Factors that Alter Body Fat, Body Mass, and FatFree Mass in Pediatric Obesity
LeMura LM, Mazeikas MT
• Meta-analysis of 30 RCT
• Ages: 5 - 17
• Pre & post intervention body composition
–Exercise “highly effective” treatment for pediatric
obesity…low intensity, long duration exercise
–Aerobic exercise combined with resistance
training
Med Sci Sports Exerc, 2002
Exercise (Activity) Prescription for Kids
Why Exercise Works in Kids
Exercise (Activity) Prescription for Kids
Guidelines for Pediatric Exercise
 60 minutes of activity each day
(minimum)
 Moderate-to-vigorous activity
 Can accumulate in small bouts,
wide variety of sports & activities
- American Academy of Pediatrics
- American College of Sports
Medicine
Relative Risk of Total Mortality
Good
News
forPrescription
Your Patients
Exercise
(Activity)
for Adults
Adults, Exercise & Mortality:
Fit (regular exercise)
5.7
Unfit (no exercise)
Good News
for Your Patients
3.8
3.2
1.9
1.4
1.0
Normal Overweight
(BMI 25-30)
Weight
Obese
(BMI 31- 36)
(BMI 18 – 24)
From Lee, Am J Clin Nutr, Mar 1999
Exercise (Activity) Prescription for Older Adults
Fitness and Functional Status
Normal
Healthy
Adults
Near
Frail
Function
THRESHOLD
Poor
Frail
Adults
Low
Strength
High
Established Populations for Epidemiologic Studies of the Elderly (EPESE) .
J Gerontology, 1994;49(3):M109-15
Exercise (Activity) Prescription for Older Adults
Exercise and Aerobic Capacity
Active
VO2 Max
Active +
Aging
Reduced
Activity +
Weight Gain
Sedentary
Exercise Intervention
20
80
Age
Exercise (Activity) Prescription for Older Adults
Strength: Use It & Lose Less of it
Losses
•Aerobic
Sedentary people lose
Activity
•
large amounts of muscle
NOT
mass IS
(20-40%)
6% sufficient
per decade loss of
Lean Body Mass (LBM)
to stop this loss!
Gains
• Lean body mass
•
•
increases 1-3 kg
Resistance training
improves strength by
a range of 40-150%
Muscle fiber area 10-30%
BOTTOM LINES:
1. MUSCLE STRENGTHENING EXERCISES REQUIRED
2. MUST INCLUDE BALANCE+FLEXIBILITY IN OLDER ADULTS
3. FEWER FALLS, FRACTURES, DISUSE, FRAILTY
AND SARCOPENIA
Exercise (Activity) Prescription for Older Adults
What’s Different for Older
Adults?
2009 ACSM Guidelines For Older Adults
• Endurance
– Frequency
• Daily
– Duration
• Moderate
– 30-60min/d total
• Vigorous
– 20min/d continuous
– Type
• Walk, aquatic, cycle
• Resistance
– Frequency
• 2 days per week
– Intensity
• 5-6 or 7-8 out of 10
– Type
• Progressive weight
training or weightbearing calisthenics
• 8-12 reps of 8-10 ex’s
Exercise (Activity) Prescription for Older Adults
What’s Different for Older
Adults?
2009 ACSM Guidelines For Older Adults
• Flexibility
– Frequency
• At least 2 days/week
– Intensity
• 5-6/10 (moderate)
– Type
• Any activity that
maintains or increases
flexibility. Do static
rather than ballistic
• Balance exercises
– No specific
recommendations 2/2
lack of evidence
– Recommend using
increasingly difficult
postures (two-legged,
tandem, one-legged,
eyes closed, etc)
Exercise (Activity) Prescription for Older Adults
A little more about balance
Static
Dynamic
Intensity=sensory or time
Exercise (Activity) Prescription for Older Adults
Tool #5
http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A50894CA4E537D4C/0/NIA_Exercise_Guide407.pdf
Summary
• Functional decline and
•
disability can be
managed by physical
activity
Physical activity
begun in childhood
can prevent obesity
and frailty in
adulthood
Questions or comments?