Transcript Figure 15.2 - Rowan University

Chapter 15
Aging, Osteoporosis, and Arthritis
Hulda Crooks: oldest individual at age 91 to climb Mt. Whitney
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
What is Osteoporosis?
Osteoporosis is a bone- weakening
disease that develops gradually and
makes bones so fragile that they
fracture under normal use.
Osteoporosis is a "silent disease"
that progresses without any
outward sign, sometimes for
decades, until a fracture occurs.
These broken bones are often
caused by a minor fall or bump
which would not normally cause a
break. The sites most commonly
affected are the spine, hips, and
forearms.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Primary osteoporosis:
Type 1--Postmenopausal, accelerated decrease in bone
mass that occurs when estrogen falls.
Type 2--Age related, the inevitable loss of bone mass
with age in both men and women.
Secondary osteoporosis:
Develops at any age as a consequence of hormonal,
digestive, and metabolic disorders; bed rest and
weightlessness.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Osteoporosis
Prevalence
Afflicts 10 million,
causing 1.5 million
fractures (see Box
15.4):
spine (700,000)
hips (300,000)
forearms (250,000)
and other bones.
Figure 15.26
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Figure 15.27
Percentage
Osteoporosis
Low bone mass
45
40
35
30
25
20
15
10
5
0
2002
2010
Females
2020
2002
2010
Males
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
2020
Figure 15.28
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Detection of Osteoporosis
The National Osteoporosis Foundation
recommends that individuals follow these
guidelines regarding BMD testing (www.nof.org)
(typically with DEXA):
BMD testing should be performed on:
All women aged 65 and older regardless of risk factors.
Younger postmenopausal women with one or more risk
factors (other than being white, postmenopausal and
female).
Postmenopausal women who have experienced a bone
fracture (to confirm the diagnosis and determine disease
severity).
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
DEXA testing
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Prevention of Osteoporosis
Building strong bones, especially before the age
of 35, and then reducing bone loss in later
years, are the best strategies for preventing
osteoporosis.
Reduce risk factors (Box 15.5)
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Risk Factors for Osteoporosis
Personal history of fracture after age 45
Current low bone mass
History of fracture in a first degree relative
Being female
Being thin; small frame (weight less than 127 pounds)
Advanced age
A family history of osteoporosis
Estrogen deficiency (early menopause (< age 45) or surgery)
Abnormal absence of menstrual periods (amenorrhea)
Anorexia nervosa
Low lifetime calcium intake
Vitamin D deficiency
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Risk Factors for Osteoporosis (cont.)
Use of certain medications:
Oral glucocorticoids, excess thyroxine replacement, antiepileptic
medications, gonadal hormone suppression, immunosuppressive agents
Presence of certain chronic medical conditions:
Hyperthyroidism, chronic lung disease, endometriosis, cancer,
chronic liver/kidney disease, hyperparathyroidism, vitamin D
deficiency, Cushing’s disease, multiple sclerosis, sarcoidosis,
hemachromotosis
Low testosterone levels in men
An inactive lifestyle and minimal weight-bearing exercise
Current cigarette smoking
Excessive use of alcohol
Being Caucasian or Asian
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Osteoporosis Prevention
By about age 20, the average woman has acquired 98
percent of her skeletal mass. Building strong bones
during childhood and adolescence can be the best
defense against developing osteoporosis later. There are
five steps, which together, can optimize bone health and
help prevent osteoporosis. They are:
Step 1: A balanced diet rich in calcium and vitamin D
Step 2: Weight-bearing exercise
Step 3: A healthy lifestyle with no smoking or excessive
alcohol intake
Step 4: Talking to a healthcare professional about bone health
Step 5: Bone density testing and medication when appropriate
(see Box 15.6 and Figure 15.29).
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Nutrition Guidelines
The recommended diet for optimal bone health is consistent
with diets recommended for the prevention of other
diseases.
The most important nutrient for bone health is calcium.
Most Americans do not consume recommended levels of
calcium, but reaching these levels is a feasible goal. (See
Figure 15.30).
Calcium intake should be 1,000-1,200 mg per day for adults
(see Table 15.2). Significant food sources of calcium
include dairy products, calcium-set tofu, canned fishes with
bones, and other calcium-fortified foods (see also Health
and Fitness Activity 15.4).
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Nutrition (cont.)
Three 8-ounce glasses of low-fat milk each day, combined with
the calcium from the rest of a normal diet, is enough to meet the
recommended daily requirements for most individuals.
Foods fortified with calcium and calcium supplements can assist
those who do not consume an adequate amount of calcium-rich
foods.
Vitamin D is important for bone health. For many, especially
elderly individuals, getting enough vitamin D from sunshine is not
practical. These individuals should look to boost their vitamin D
levels through diet.
Young adults need 200 IU/day vitamin D, middle-aged adults 400
IU/day, and the elderly 600 IU/day (Figure 15.30).
Primary food sources of vitamin D are limited to fortified milk
(100 IU per cup), egg yolk (25 IU per yolk), fortified cereals, and
fish oils. Vitamin D is also available in supplements for those
unable to get enough through sunshine and diet.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
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The Exercise Connection
When force or stress is applied to a bone, the bone bends. For the bone to
become bigger and more dense, the stress must be above and beyond normal
levels.
Each bone in the body must be stressed to grow strong (see Box 15.7, 15.8).
Physical activities such as walking or swimming do not place enough stress on
the bones to improve their strength. Activities such as team sports, running, and
racket sports are most effective. (See Figure 15.31 and Box 15.7, 15.8).
Young bone is more responsive to exercise stress than old bone (60% built
during adolescence).
Muscle strength is an important predictor of strong and dense bones among
older adults (Figure 15.32).
Exercise alone cannot prevent or cure osteoporosis. Osteoporosis prevention
and treatment demands a multifaceted approach through diet, exercise, and
appropriate medications.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Box 15.7 Physical Activity and Osteoporosis
Recommendations from the Office of the Surgeon General
Meet general activity guidelines (at least 30 minutes a
day for adults and 60 minutes for children) AND engage
in strength- and weight-bearing activities.
Bones require a lifelong commitment to physical activity
and exercise.
Physical activity will only affect bone at the skeletal sites
that are stressed (or loaded) by the activity.
For bone gain to occur, the stimulus must be greater than
that which the bone usually experiences.
Complete lack of activity, such as periods of immobility,
causes bone loss.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Box 15.7 Physical Activity and Osteoporosis
Recommendations from the Office of the Surgeon General
Any activity that imparts impact (such as jumping or
skipping) may increase bone mass more than will lowand moderate-intensity, endurance-type activities, such
as brisk walking.
Load-bearing physical activities such as jumping need
not be engaged in for long periods of time to provide
benefits to skeletal health. In fact, 5–10 minutes daily
may suffice.
Physical activities that include a variety of loading
patterns (such as strength training or aerobic classes)
may promote increased bone mass more than do
activities that involve normal or regular loading patterns
(such as running).
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Box 15.9
Exercise Prescription for Prevention of Osteoporosis
The BEST exercise program consists of three 60-75 minute supervised sessions
each week, and has the following six components:
1. Warm-up (5 to 10 minutes): Walk for 5 to 10 minutes before beginning other
components
2. Progressive weight bearing (25 minutes): This involves several types of activities
such as walking with a weighted vest, stepping, stair climbing, etc.
3. Resistance exercises with large-muscle groups (20 minutes): Perform eight
resistance exercises using machines and free weights, emphasizing the large muscle
groups of the arms, legs, upper and lower trunk; build to two sets of 6-8 repetitions
maximum with 45-60 seconds rest between sets.
4. Resistance exercises with small-muscle groups (10 minutes): Perform exercises
using a physiotherapy ball, elastic bands, and free-weights (1-3 pound dumbells).
5. Abdominal strengthening (5 minutes): Train the abdominal muscles with a
variety of lower extremity movements with the spine stabilized. Use ankle weights
to increase resistance.
6. Stretching and balance (5 minutes): Perform a variety of stretching and balance
exercises.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Arthritis
Arthritis afflicts 43 million (60 million by
2020) (Figure 15.36).
Arthritis means joint inflammation, a
general term that includes over 100 kinds
of rheumatic diseases (see Figure 15.37).
Rheumatic diseases are those affecting
joints, muscles, and connective tissue,
which make up or support various
structures of the body.
Arthritis is usually chronic, meaning that it
lasts a lifetime.
The early warning signs of arthritis include
pain, swelling, and limited movement that
lasts for more than two weeks.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Fig. 15.36
Age 65+
47.8
Age 45-64
28.8
Age 18-44
7.9
Women
24.3
Men
17.1
Hispanic/Latino Americans
11.7
Non-Hispanic Blacks
19.4
Non-Hispanic Whites
23
All adults
20.8
0
10
20
30
40
50
Prevalence of doctor-diagnosed arthritis (%)
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
60
Figure 15.37
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Definitions, Arthritis
Osteoarthritis begins when joint cartilage breaks down, sometimes
eroding entirely to leave a bone-on-bone joint. Most common in
feet, knees, hips, and fingers (Figure 15.38).
Third most common is rheumatoid arthritis, an autoimmune
disease which affects 2.1 million Americans, three times more
women than men. It can strike at any age, but usually appears
between ages 20 and 50.
Rheumatoid arthritis starts slowly over several weeks to months.
The small joints of the hands and the knee joint are most
commonly affected.
In general, rheumatoid arthritis is frequently related to severe
complications and decline in ability to function, with most patients
dying 5 to 15 years earlier than those who are nonafflicted.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Figure 15.38
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Risk Factors for Arthritis
Non-modifiable Risk Factors
Age: The risk of developing most types of arthritis
increases with age.
Gender: Most types of arthritis are more common in
women, accounting for 60% of all cases. Gout is
more common in men.
Genetic: Genes have been identified that are
associated with a higher risk of certain types of
arthritis, such as rheumatoid arthritis and systemic
lupus erythematous.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Risk Factors for Arthritis
Modifiable Risk Factors
Overweight and Obesity: Excess weight can
contribute to both the onset and progression of knee
osteoarthritis.
Joint Injuries: Damage to a joint can contribute to
the development of osteoarthritis of that joint.
Infection: Many microbial agents can infect joints
and potentially cause the development of various
forms of arthritis.
Occupation: Certain occupations involving
repetitive knee bending are associated with
osteoarthritis of the knee.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Prevention of Arthritis
Obesity: Obesity is the main preventable risk factor.
Diet: Some studies suggest that higher intakes of red
meat and total protein as well as lower intakes of fruit,
vegetables, and vitamin C are associated with an
increased risk of arthritis, and that the Mediterraneantype diet may have protective effects.
Exercise: Keeping the muscles strong through regular
exercise while avoiding traumatic joint injury is an
important preventive strategy. There is growing
evidence that individuals who stay lean and fit as they
grow older are at a much lower risk for the development
of osteoarthritis compared to their obese and unfit
counterparts (Fig. 15.39). Thigh muscle weakness has
emerged as a predictor of future knee osteoarthritis.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Treatment of Arthritis
Lifestyle changes.
Exercise to strengthen muscles, weight loss to reduce stress on
joints and assistive devices such as canes and wall bars when
needed.
Joint protection.
Learning ways to limit the pressure on involved joints.
Medications.
Many excellent new drugs are available (Box 15.10).
Physical and occupational therapy.
Therapists work with patients to make their lives easier.
Patient education.
To inform patients about the disease, provide tools to help
overcome pain and help them adjust to their situation.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Osteoarthritis and Exercise
People with arthritis have weaker muscles, less joint
flexibility and range of motion, and lower aerobic
fitness. Exercise training can counter this.
Exercise training cannot retard the progression of
osteoarthritis or cure it (but greatly improves quality of
life).
Vigorous exercise does not increase the risk for
osteoarthritis unless the joint has an abnormality or
previous major injury.
Normal joints are well designed to withstand the
repetitive stress that comes with physical exercise.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Exercise Prescription
Guidelines
Quadriceps muscle weakness is a major risk factor for knee
osteoarthritis. Other risk factors include age, obesity,
inactivity, joint trauma and injury, female gender, and poor
joint biomechanics.
Developing an exercise program aimed at alleviating pain and
improving overall physical fitness is critical because the
primary concern for many osteoarthritis patients is
maintenance of functional independence.
Exercise training does not exacerbate pain or disease
progression, but neither does it improve the underlying disease
state of osteoarthritis. Regular exercise does decrease pain and
improving function in most patients, and improves their quality
of life.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Exercise Prescription
Guidelines (cont.)
The initial step in designing a physical activity program is
performing a comprehensive patient evaluation.
A complete history and physical examination are needed before prescribing
increased physical activity because many older adults have cardiovascular
disease.
Once disabilities and health problems have been inventoried and prioritized,
the patient and the health/fitness professional can set specific short- and
long-term goals, which will determine the exercises to be prescribed.
Initially, the program should involve supervised therapeutic
exercises that address the impairments (pain, limited joint range of
motion, or muscle weakness) contributing to functional problems.
As soon as these impairments begin to improve, a generalized
fitness program designed to improve health and functional capacity
should begin. Shortly after therapeutic exercise is initiated, fitness
training can begin and run in parallel.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Exercise Prescription
Guidelines (cont.)
Fitness training should include exercises to improve
flexibility, strength, and cardiorespiratory endurance.
See Figure 15.41.
Static stretching exercises should be chosen to help
decrease stiffness, increase joint mobility, and prevent softtissue contractures in the individual with osteoarthritis.
Joints, especially those that are painful, should not be
overstretched (i.e., stretched to a point that elicits pain), as
this may compromise stability. All movement should be
through the fullest possible pain-free range.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Exercise Prescription
Guidelines (cont.)
Strength training exercises should seek to increase the strength of
muscles that support the affected joints. Specific exercises should be
selected on the basis of the patient’s joint stability and degree of pain
and inflammation. Isometric exercises are recommended when joints
are acutely inflamed or unstable, and prepare the joint for more dynamic
movements. When the patient is ready, isotonic resistance training
should be initiated, and include one set of 8 to10 exercises, 4 to 6
repetitions each, 2 days per week. Resistance should begin at 40% of
the patient’s 1RM, and build gradually to 80% 1RM. The patient
should absolutely avoid muscle fatigue. The frequency of training
should be a maximum of 2 days per week. The progression of resistance
training intensity and volume should be gradual to allow time for
adaptation.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.
Exercise Prescription
Guidelines (cont.)
The type of aerobic exercise program depends on several
factors: the patient’s current disease activity, joint stability,
and resources and interests. The patient should choose a
variety of exercise options, to prevent overuse of specific
joints and to avoid exercise boredom. High-impact aerobic
training should be avoided. Intensity should be low to
moderate (an RPE between 10 and 13), and the
recommended volume for the beginner is a minimum of 20
to 30 minutes per day, 3-4 days per week. The progression
of aerobic training intensity and volume should be gradual
to allow time for adaptation.
Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
Copyright ©2007 McGraw-Hill Higher Education. All rights reserved.