Title: Training in Special Populations Issues of Aging
1Training in Special Populations Issues of Aging
- March 18 2009
- Cathy Ciolek, PT, DPT, GCS
2OBJECTIVES
- 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
3OUTLINE OF PRESENTATION
- AGING
- Exercise
- Strength/resistance
- Aerobic
- Flexibility
- Disease specific
- Diabetes
- Osteoporosis
- Etc
4Normal Aging vs Pathology
5Sad 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
6Physical 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
7Psychological Benefits
- Improves sleep
- Sleep more deeply
- Sleep longer
- Wake less often
- Reduces depression
- Increase self-esteem
8Benefits 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
9Ultimate Goal of Exercise
- Focus
- Increase physical performance and quality of life
- To prevent disability and disease progression
through the modification of risk factors
10Functional 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.
11Compliance 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
12What tests and measures can you use to test
strength, endurance, etc?- MMT but what else?
13Functional 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
146 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
15Principles of Exercise
- Adapt vs Challenge
- Overload
- Task Specificity
16Adapt 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?
17Overload
- 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.
18Specificity
- 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!
19Exercise 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
20Exercise Prescription Guidelines
- Similar to any other population in general
- Consider
- Baseline physiological state and response to
exercise stimuli - Comorbid conditions and medications
21CDC 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
22Moderate 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
23Contraindications- 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)
24Contraindications- 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
25Warning Signs
- Chest pain
- Palpitations
- Feelings of weakness, pale, clammy, fainting
- Dizziness or light-headedness
26Medications
- 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.
27Warm-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)
28Exercise Recommendations for Optimal Aging
29Exercise Recommendations for Optimal Aging
30Exercise 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
31Exercise Intensity
- To increase aerobic fitness
- 60-80 of MHR
- Sedentary individuals
- Begin at 50 MHR
- Gradually progress
32Target Heart Rate
- AGE THR (220-age60-80)
- 50 years 102-136
- 60 years 96-128
- 70 years 90-120
- 80 years 84-112
33Strength/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
34Strength/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
35Strength/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
36Strength/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
37Strength/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)
38Postural Stability/Balance
- Tai Chi and standing yoga
- Tandem walking
- Single leg stance
- Stepping over objects
- Perturbation
39Flexibility
- Recommendations
- Slow sustained stretch
- 20-30 seconds hold
- No ballistic movements
40Frailty
- Result of
- Biological aging
- High burdens of chronic disease
- Malnutrition
- Extremely sedentary
41The 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
42The 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
43The 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
44The 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.
45The 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
46The 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
47Dont feed into poor postural habits
- Conduct extension dominant exercises
- Stretch shortened
- muscles
48Aging and Chronic Conditions
Source CDC National Health Interview Survey 2006
49Benefits 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
50Endurance 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
51Exercise Recommendations for People with CV
Disease
52Exercise Recommendations for People with
Hypertension
53Prevalence of Diabetes by Age
Source 19992001 National Health Interview
Survey and 1999-2000 National Health and
Nutrition Examination Survey estimates projected
to year 2002.
54Type 2 Diabetes Mellitus
- Impaired glucose metabolism
- Predisposition to DM
- Reductions in muscle mass
- Insulin Sensitivity
- Associated with obesity
55Diabetes 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
56Glucose 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
57Hypoglycemia- Signs/Symptoms
- Trembling
- Palpitations
- Weakness
- Sweating
- Intense hunger
- Confusion, altered behavior, drowsiness or coma
may occur if the blood glucose becomes very low.
58Hypoglycemia- Management
- Clients need to ingest simple (fast acting)
sugars such as glucose pills or orange juice - If found minimally responsive they require
immediate care
59Glucose 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
60What 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.
61Diabetes Exercise Benefits
- Improved glucose management
- Weight control
- Improved lipid profiles
- Reduction of hypertension
- Increased work capacity
62Diabetes Exercise
- Improved glucose management
- Acutely lowers blood glucose
- Synergist with insulin
- Improves insulin sensitivity
- Implications
- Liver glucose production decreases
- Muscle glucose utilization increases normally
63Diabetes 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
64Diabetes Chronic Exercise
- Lower resting and submaximal HR
- Increased stroke volume
- Enhanced O2 extraction
- Lower resting and exercise blood pressure
65What if your patient cant exercise at a high
enough intensity
- Then low level (50 VO2max, 5X/week for 1 hour)
is indicated - Unrealistic expectations
66Diabetes 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
67Diabetes Exercise
- Exercise Intensity
- Heart Rate (HR)
- 60-80 of max heart rate
- Rating of Perceived Exertion (RPE)
- 10-13
68Diabetes Exercise
- Program Duration
- Begin 10-15 minutes
- Progress to minimum of 30-60 minutes
- Goal is to achieve appropriate energy expenditure
69Diabetes 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
70Diabetes 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
71Diabetes Resistance Training
- PRECAUTIONS
- Hypertension
- Limit sustained isometrics
- Retinopathy
- Appropriate supervision is necessary
- Cardiovascular complications
- Monitor patients HR, BP, symptoms
72Diabetes 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.
73Exercise Recommendations for People with Diabetes
74Peripheral 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)
75Monofilament Testing
76Diabetes
- 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
77Evidence 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.
78Osteoarthritis
- 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
79Ther 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
80OA 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
81Osteoarthritis
- 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
82Exercise Recommendations for People with Arthritis
83Wrap 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
84Designing 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.
85Documentation!
- 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!
86References
- 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
87References
- 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.
88References
- 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.
89References
- 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