Training in Special Populations Issues of Aging

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Training in Special Populations Issues of Aging

• March 18 2009
• Cathy Ciolek, PT, DPT, GCS

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OBJECTIVES

• The student will
• Understand the benefits of exercise for older
  adults
• Understand exercise prescription for healthy
  older adults
• Recognize issues associated with exercise for
  patients with chronic conditions

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OUTLINE OF PRESENTATION

• AGING
• Exercise
• Strength/resistance
• Aerobic
• Flexibility
• Disease specific
• Diabetes
• Osteoporosis
• Etc

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Normal Aging vs Pathology
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Sad facts with aging

• Community dwelling elderly over 75
• 16 could not lift 10 pounds
• 21 could not walk up 10 steps
• 29 could not walk ¼ mile (1300 feet)
• 28 could not stoop, crouch and kneel
• Vital and Health Statistic, National Health
  Interview Survey 2002 www.cdc.gov/nchs/nhis.htm
  www.cdc.gov/nchs/nhis.htm

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Physical Benefits of Exercise

• Increase muscle mass and strength
• Reduce total body fat stores
• Improves motor unit recruitment
• Improves agility and flexibility
• Increased bone density
• Improves aerobic capacity

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Psychological Benefits

• Improves sleep
• Sleep more deeply
• Sleep longer
• Wake less often
• Reduces depression
• Increase self-esteem

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Benefits of Physical Training for Disease
Prevention

• Arthritis- reduces pain and stiffness, increases
  strength and flexibility
• Diabetes- improves glycemic control
• Osteoporosis- improves bone density
• CV Disease- improves lipid profile
• Obesity- improves metabolism

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Ultimate Goal of Exercise

• Focus
• Increase physical performance and quality of life
• To prevent disability and disease progression
  through the modification of risk factors

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Functional Benefits

• Higher physiological capacity
• Lower risk of premature mortality
• Physically active adults are more likely to
  survive to age 80 or beyond and had ½ the risk of
  dying with disability compared to their sedentary
  peers.
• Leveille S, et al. Aging successfully until
  death in old age. Am J Epidemiol. 1999
  149654-664.

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Compliance Issues

• Older adults underestimate their exercise
  capacity for fear of injury and often refrain
  from increasing the intensity of exercise that is
  needed.
• Show them what they are capable of doing
• Support of family and friends
• Positive feedback

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What tests and measures can you use to test
strength, endurance, etc?- MMT but what else?
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Functional Strength tests

• Chair Rise Test- sit to stands in 30 seconds
• Women Men
• 60-64 12-17 reps -60-64 14-19 reps
• 70-74 10-15 reps - 70-74 12-17 reps
• 80-84 9-14 reps -80-84 10-15 reps
• Rickli RE, Jones CJ. Senior Fitness Test Manual.
  Human Kinetics, Champaign, IL 2001 pg143

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6 minute walk test

• How far can the patient walk in 6 minutes?
• 2200 feet is the norm for 60-65 years old men
• 1800 feet for 60-65 year old females
• Rickli RE, Jones CJ. Senior Fitness Test Manual.
  Human Kinetics, Champaign, IL 2001 pg143

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Principles of Exercise

• Adapt vs Challenge
• Overload
• Task Specificity

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Adapt Vs Challenge

• Adapt environment to promote safety
• However, challenge in PT to expand edges of safe
  function, challenge to new and difficult tasks
• How can we challenge transfers?
• How can we challenge balance?
• How can we challenge gait?

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Overload

• Requires nearly maximal muscle tension with
  relatively few repetitions
• Higher intensity effort at or near maximal effort
  will produce a significantly greater effect
• Dale Avers, evidence based exercise interventions
  for older adult 2005 lecture notes.

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Specificity

• Strength training is specific to area of body
  being trained
• Specific to contraction type, speed
• Example Walking does not specifically increase
  strength, just walking distance or speed!

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Exercise Prescription for Strength Training

• 8-10 exercises
• At least 2xs/week
• 8-12 reps
• Consideration of eccentric loading, power and
  closed chain principles
• ACSM/AHA 2007 Guidelines

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Exercise Prescription Guidelines

• Similar to any other population in general
• Consider
• Baseline physiological state and response to
  exercise stimuli
• Comorbid conditions and medications

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CDC ACSM Recommendations

• Every US adult should accumulate 30 minutes or
  more of moderate-intensity physical activity on
  most, preferably all, days of the week.
• http//www.cdc.gov/nccdphp/dnpa/physical/recommend
  ations/index.htm

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Moderate Activities

• Washing/waxing a car for 45-60 minutes
• Wheeling self in wheelchair for 30-40 minutes
• Walking 1 ¾ miles in 35 minutes (20 minutes per
  mile)
• Bicycling 5 miles in 30 minutes
• Dancing fast for 30 minutes
• Walking 2 miles in 30 minutes (15 minutes per
  mile)
• Water aerobics for 30 minutes
• Stair walking for 15 minutes

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Contraindications- Absolute

• Recent and significant changes in ECG
• Recent complicated myocardial infarction
• unstable angina
• uncontrolled ventricular arrhythmia
• uncontrolled atrial arrhythmia that compromises
  cardiac function
• Third degree AV block without pacemaker
• acute suggestive heart failure
• Acute infections
• significant emotional distress (psychosis)

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Contraindications- Relative

• Resting diastolic gt 115, systolic gt 200
• Moderate valvular heart disease
• Known electrolyte abnormalities
• Fixed rate pacemaker (relatively used)
• Uncontrolled metabolic disease
• Chronic infectious disease
• Neuromuscular, musculoskeletal or rhuematoid
  disorders that are exacerbated by exercise

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Warning Signs

• Chest pain
• Palpitations
• Feelings of weakness, pale, clammy, fainting
• Dizziness or light-headedness

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Medications

• Can adversely impact activity tolerance
• Can alter cardiac response to activity
• Most significant in NOA clinic is Beta Blockers.
  These limit the patients ability to increase
  heart rate thus heart rate is a poor indicator of
  exercise tolerance/response.

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Warm-up (10minutes)
Stretching (hold 10-30 seconds 1-2
repetitions) (5-10 minutes)
Resistance or balance training (60-80
1RM) (10-20 minutes)
Aerobic exercise (20-60 minutes)
Cool down (10 minutes)
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Exercise Recommendations for Optimal Aging
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Exercise Recommendations for Optimal Aging
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Exercise Intensity

• Common method
• HR
• Moderate Intensity
• MHR of 50-70
• MHR
• 220 age 60-80
• 208 (0.7 age)
• RPE
• 12 13 somewhat hard moderate intensity

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Exercise Intensity

• To increase aerobic fitness
• 60-80 of MHR
• Sedentary individuals
• Begin at 50 MHR
• Gradually progress

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Target Heart Rate

• AGE THR (220-age60-80)
• 50 years 102-136
• 60 years 96-128
• 70 years 90-120
• 80 years 84-112

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Strength/Resistance Training

• BENEFITS
• 2-3 fold increase in strength in 3-4 months
• Initial strength gains likely mediated by neural
  adaptations allowing for greater recruitment
• Modest increases in muscle size with prolonged
  resistance training
• Significant correlation between muscle strength
  and preferred walking speeds

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Strength/Resistance Training

• BENEFITS
• Adjunct to weight loss interventions
• Increase in resting metabolic rate
• Increase energy intake to maintain body weight
• Increase energy requirements
• Decrease body fat mass
• Maintain metabolically active tissue
• Maintain/increase bone mineral density and total
  body mineral content

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Strength/Resistance Training

• Contraindications
• ACC AHA recommend exercise stress testing
  before they start vigorous exercise
• Men gt 40 years
• Women gt 50 years
• Risk of exercise may outweigh benefits in some
• Aggravate pre-existing disease
• Angina, arthritis, osteoporosis, stage III HTN
• ACSMs Guidelines for Exercise Testing and
  Prescription

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Strength/Resistance Training

• Guidelines for healthy older adults
• Start low intensity and progress slowly to allow
  for adaptation
• 30-40 of 1RM for upper body
• 50-60 of 1RM for lower body
• When can comfortably lift weight 12 reps with
  good form and is perceived to be somewhat hard
  (rpe 12-13), 5 can be added
• Strive to progress to a higher intensity (rpe
  15-15, hard)
• If the patient can not lift the weight a minimum
  of 8 times, then the weight should be reduced for
  the next training session
• Progression to a higher weight should occur every
  1-2 weeks at this intensity level

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Strength/Resistance Training

• CONSIDER
• Because of natural physiological changes, the
  elderly may be more fragile and thus more
  susceptible to fatigue, orthopedic injuries, and
  CV complications
• Reduce intensity and progress more slowly because
  as a group, elderly adults are more sedentary
• Begin at a lower intensity (10-15 repetitions)
• Progress more slowly (every 2-4 weeks)

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Postural Stability/Balance

• Tai Chi and standing yoga
• Tandem walking
• Single leg stance
• Stepping over objects
• Perturbation

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Flexibility

• Recommendations
• Slow sustained stretch
• 20-30 seconds hold
• No ballistic movements

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Frailty

• Result of
• Biological aging
• High burdens of chronic disease
• Malnutrition
• Extremely sedentary

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The Frail Very Old

• Goals
• Minimizing biological changes of aging
• Reversing disuse syndromes
• Control of chronic disease
• Maximizing psychological health
• Increasing mobility and function
• Assisting with rehabilitation from acute
  chronic illnesses

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The Frail Very Old and Exercise

• BENEFITS
• Increased
• aerobic capacity
• Muscle strength
• Muscle mass
• Bone density
• Psychiatric

• BENEFITS
• Decreased
• Muscle bone atrophy
• CV deconditioning
• Postural hypotension
• Joint stiffness
• Diminished neural control of balance reflexes

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The Frail Very Old and Exercise

• IMPROVEMENTS
• Gait
• Velocity
• Balance
• Ability to rise from a chair
• Stair-climbing power
• Aerobic capacity
• Morale
• Depressive symptoms
• Energy intake

• BENEFITS
• Higher dietary intake
• Reducing risk of malnutrition
• Respond well
• Arthritis
• Diabetes
• CAD
• CHF
• COPD
• Depression
• Gait and balance disorders
• Falls
• Insomnia

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The Frail Very Old and Exercise

• CONTRAINDICATIONS
• Untreatable or serious conditions
• Inoperable aortic aneurysms
• Malignant ventricular arrhythmia related to
  exertion
• Severe aortic stenosis
• End-stage CHF
• Terminal illness
• Severe behavioral agitation in response to
  exercise participation in those with dementia or
  psychological illness
• These may be relative contraindications
  depending on severity of illness and quality of
  life issues.

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The Frail Very Old and Exercise

• PRECAUTIONS
• NOT frailty or extreme age
• Acute illness
• Unstable angina
• Uncontrolled diabetes
• HTN
• Asthma
• CHF
• Musculoskeletal pain
• Weight loss
• Falling episodes

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The Frail Very Old and Exercise

• Trainability
• Strength dependent more on stimulus than age and
  health status
• Best response in those with largest reserves of
  lean tissue
• Principles of specificity apply here as with young

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Dont feed into poor postural habits

• Conduct extension dominant exercises
• Stretch shortened
• muscles

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Aging and Chronic Conditions
Source CDC National Health Interview Survey 2006
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Benefits of Endurance Training

• CV
• 10-30 increase in VO2 max with prolonged
  endurance training
• Similar to young adults
• Function of training intensity
• CV disease risk factors
• Lower fasting glucose-stimulated plasma insulin
  levels
• Improved glucose tolerance insulin sensitivity
• Lower blood pressure
• Similar to young, hypertensive adults
• Improved body composition
• Similar to young adults
• 1-4 reduction in overall body fat even if body
  weight is maintained

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Endurance Training

• Adults with CV disease
• Greater reductions in VO2max maximal CO
  compared to healthy peers
• Same CV adaptations as younger patients
• Decreased HR at rest with submaximal exercise

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Exercise Recommendations for People with CV
Disease
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Exercise Recommendations for People with
Hypertension
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Prevalence of Diabetes by Age
Source 19992001 National Health Interview
Survey and 1999-2000 National Health and
Nutrition Examination Survey estimates projected
to year 2002.
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Type 2 Diabetes Mellitus

• Impaired glucose metabolism
• Predisposition to DM
• Reductions in muscle mass
• Insulin Sensitivity
• Associated with obesity

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Diabetes Ketoacidosis

• Early Warning Signs
• Thirsty
• Dry mouth
• Frequent urination
• High blood sugar levels
• High levels of ketones in the urine

• Late Warning Signs
• Constant fatigue
• Dry, flushed skin
• Nausea, vomiting, or abdominal pain
• SOB
• Fruity odor on breath
• Hyperventilation
• Confusion/difficulty paying attention

Treatment insulin and fluids
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Glucose Physiology

• Diabetics show small decrease in blood glucose
  and insulin secretion during prolonged exercise
• Replenishing glycogen stores takes 24-48 hours
• Post-exercise recovery causes enhanced insulin
  sensitivity
• May need to skip subsequent insulin injection to
  prevent hypoglycemia

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Hypoglycemia- Signs/Symptoms

• Trembling
• Palpitations
• Weakness
• Sweating
• Intense hunger
• Confusion, altered behavior, drowsiness or coma
  may occur if the blood glucose becomes very low.

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Hypoglycemia- Management

• Clients need to ingest simple (fast acting)
  sugars such as glucose pills or orange juice
• If found minimally responsive they require
  immediate care

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Glucose Levels

• Ideal pre-exercise 120-180 mg/dL
• Limits 100 250 mg/dL(ADA limits)
• Postpone exercise if
• gt 200 mg/dL and ketones in urine
• gt 300 mg/dL
• Take snack prior to exercise lt100mg/dL

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What were the major findings of the Diabetes
Prevention Project? Knowler et al 2002

• This is the first major clinical trial of
  Americans at high risk for type 2 diabetes to
  show that lifestyle changes in diet and exercise
  and losing a little weight can prevent or delay
  the disease.
• Participants who made lifestyle changes reduced
  their risk of getting type 2 diabetes by 58
  percent.
• The lifestyle intervention was effective for
  participants of all ages and all ethnic groups.

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Diabetes Exercise Benefits

• Improved glucose management
• Weight control
• Improved lipid profiles
• Reduction of hypertension
• Increased work capacity

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Diabetes Exercise

• Improved glucose management
• Acutely lowers blood glucose
• Synergist with insulin
• Improves insulin sensitivity
• Implications
• Liver glucose production decreases
• Muscle glucose utilization increases normally

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Diabetes Exercise

• Short lived (approx 48-72 hours)
• Regular exercise is recommended
• Aerobic and resistance training most beneficial
• May also benefit from balance if have peripheral
  neuropathies

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Diabetes Chronic Exercise

• Lower resting and submaximal HR
• Increased stroke volume
• Enhanced O2 extraction
• Lower resting and exercise blood pressure

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What if your patient cant exercise at a high
enough intensity

• Then low level (50 VO2max, 5X/week for 1 hour)
  is indicated
• Unrealistic expectations

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Diabetes Exercise

• Aerobic and Resistance Training
• Frequency
• 3-5X/week
• Acute response only lasts 72 hours
• Intensity
• 40-70 VO2max for cardiorespiratory endurance
• Safety, Comfort, Adherence

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Diabetes Exercise

• Exercise Intensity
• Heart Rate (HR)
• 60-80 of max heart rate
• Rating of Perceived Exertion (RPE)
• 10-13

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Diabetes Exercise

• Program Duration
• Begin 10-15 minutes
• Progress to minimum of 30-60 minutes
• Goal is to achieve appropriate energy expenditure

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Diabetes Exercise

• Exercise Mode
• It doesnt matter as long as its safe and
  effective
• Walking, Stationary cycling, Swimming
• Resistance Training
• All major muscle groups
• Lower resistance ? higher reps

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Diabetes Exercise

• PRECAUTIONS
• Insulin use and strenuous exercise can cause
  hypoglycemia
• What can you do?
• Insulin injection
• Should be at least 1 hour prior to exercise

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Diabetes Resistance Training

• PRECAUTIONS
• Hypertension
• Limit sustained isometrics
• Retinopathy
• Appropriate supervision is necessary
• Cardiovascular complications
• Monitor patients HR, BP, symptoms

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Diabetes Exercise

• Peripheral Neuropathy
• Check the feet daily- teach self check monthly
  with disposable monofilaments
• Weight bearing exercises should be used with
  caution in brittle or seriously at risk feet.

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Exercise Recommendations for People with Diabetes
74
Peripheral Neuropathy

• Often leads to decreased positional sense at the
  foot/ankle as well as motor and/or sensory
  changes
• Therapy should focus on impairments
• if weak, try to strengthen
• If balance loss- work on strategies to compensate
  for decreased positional sense or re-teach via
  other joints awareness (wall leans/standing on
  foam)

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Monofilament Testing

• Lab time!

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Diabetes

• Impairments
• Cardiovascular response
• Skin integrity
• Sensory integrity
• Motor strength
• Muscle function
• ROM
• Balance

• Functional Limitations
• Gait and mobility on even, uneven, indoor,
  outdoor surfaces
• Endurance
• ADL/IADL

77
Evidence for Exercise with OA Hip or Knee

• Strengthening and aerobic exercise can reduce
  pain and improve function and health status
• Group exercise and home exercise can be equally
  as effective
• Patients respond best with monitoring and/or
  inclusion of spouse
• Roddy E, et al. Evidence-based recommendations
  for the role of exercise in the management of OA
  of the hip or knee. Rheumatology 2005 4467-73.

78
Osteoarthritis

• 42 of respondents with arthritis reported ever
  having been advised by a health professional to
  increase their physical activity to help manage
  arthritis symptoms.
• Advice alone appears insufficient to promote
  increased physical activity.
• Fontaine KE, et al

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Ther Ex Progression for OA

• Open vs closed chain?
• Flemming et al 2005 found no difference
• Isometric when the joint is acutely inflamed or
  unstable
• 35 of max effort, progress to 75
• Progress to dynamic muscle training
• AGS Panel on OA and exercise 2001

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OA Exercise

• Get them moving as much as possible.
• Consider UE aerobics if cant sustain LE enough
  to attain aerobic level
• Open vs closed chain- find what works for this
  patient and get them started
• ROM, pain control, asst device- all as needed

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Osteoarthritis

• Impairments
• Joint ROM and integrity
• Muscle strength and function
• Cardiovascular response
• Pain
• Skin integrity/edema

• Functional Limitations
• Gait and functional mobility
• ADL and IADL
• Endurance

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Exercise Recommendations for People with Arthritis
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Wrap UP DM/Cardiovascular/OA

• Are we fixing the pathology?
• Not directly, but occasionally indirectly (DM)
• Can we fix the impairments?
• Yes
• Can we reduce the functional limitations?
• Yes
• Do we address participation in society
• Yes

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Designing the Program and Goals

• Set exercise program (and/or manual
  therapy/modalities) to address impairments to
  attain goals of decreasing functional limitations
• IE OA decreased joint mobility
• Plan to add joint mobilization, ther ex to
  increase ROM and strength to sustain ROM gains.

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Documentation!

• Initial evaluation and assessment should list the
  impairments and functional limitations. This is
  the PT Diagnosis for this patient.
• Plan should include the interventions to decrease
  impairment and functional limitations and
  perhaps increase participation to meet the
  patient goals!

86
References

• American Geriatrics Society Panel on Exercise and
  Osteoarthritis. Exercise prescription for older
  adults with osteoarthritis pain consensus
  practice recommendations. Journal of the American
  Geriatrics Society. 200149808-823

87
References

• Flemming BC, Oksendahl H, Beynnon BD Open or
  closed kinetic chain exercises after anerior
  cruciate ligament reconstruction? Exer Sports
  Sci Rev. July 200533(3)134-140.
• Fontaine KR, Bartlett SJ, Moonseong H. Are
  Health Care Professionals Advising Adults With
  Arthritis to Become More Physically Active?
  Arthritis and Rheumatism. 532279-283.
• Grafa CS. Beyond Quad Sets Therapeutic Exercise
  for Todays Older Adult. Topics in Geriatrics
  2005, Section on Geriatrics, APTA.
• Leveille S, et al. Aging successfully until
  death in old age. Am J Epidemiol. 1999
  149654-664.

88
References

• Knowler WC, et al. Reduction in the incidence of
  type 2 diabetes with lifestyle intervention or
  metformin.N Engl J Med. 2002 Feb
  7346(6)393-403.
• Roddy E, et al. Evidence-based recommendations
  for the role of exercise in the management of OA
  of the hip or knee. Rheumatology 2005 4467-73.
• Singh MAF. Exercise Comes of Age. J Gerontol.
  2002 57262-282.

89
References

• Nelson ME et al. Physical Activity and Public
  Health in Older Adults Recommendation from the
  American College of Sports Medicine and the
  American Heart Association. Circulation. 2007,
  116 1094-1105