Exercise in People with Frailty Exercise in People with Frailty Syndroms Syndroms

Frailty syndrome (Frailty syndrome ( 衰弱綜合症衰弱綜合症 ))

is a collection of symptoms or markers, is a collection of symptoms or markers, primarily due to the primarily due to the aging-relatedaging-related loss and loss and dysfunction of skeletal muscle and bone, that dysfunction of skeletal muscle and bone, that place (mostly) older adults at increased risk of place (mostly) older adults at increased risk of adverse events such as death, disability, and adverse events such as death, disability, and institutionalizationinstitutionalization

SarcopeniaSarcopenia

from the Greek meaning “poverty of flesh”from the Greek meaning “poverty of flesh”

is the degenerative loss of skeletal muscle is the degenerative loss of skeletal muscle mass and strength associated with aging (0.5-mass and strength associated with aging (0.5-1% loss per year after the age of 25).1% loss per year after the age of 25).

this loss of muscle mass may be caused by this loss of muscle mass may be caused by different cellular mechanisms than those different cellular mechanisms than those which cause which cause muscle atrophymuscle atrophy

Than there is a replacement of muscle fibres Than there is a replacement of muscle fibres with fat and an increase in with fat and an increase in fibrosisfibrosis

Muscle Structure and AtrophyMuscle Structure and Atrophy

is a debilitating process that results in an is a debilitating process that results in an extensive loss of muscle function and mass extensive loss of muscle function and mass resulting in worsening of quality of life. It can resulting in worsening of quality of life. It can take place with aging and inadequate food take place with aging and inadequate food intake; it may also develop as a result of nerve intake; it may also develop as a result of nerve injuryinjury

Some of the treatments, such as anabolic Some of the treatments, such as anabolic steroids (testosterone) and insulin-like growth steroids (testosterone) and insulin-like growth factor 1 (IFG-1), raise concerns about safety factor 1 (IFG-1), raise concerns about safety and effectivenessand effectiveness

Researchers discovered that des-acyl ghrelin Researchers discovered that des-acyl ghrelin has a direct anti-atrophic activity on the has a direct anti-atrophic activity on the skeletal muscle of mice with muscular atrophy skeletal muscle of mice with muscular atrophy caused by either denervation (nerve injury) or caused by either denervation (nerve injury) or fastingfasting

PathologyPathologyFiber-type changes in sarcopeniaFiber-type changes in sarcopenia– During sarcopenia, there is a decrease in "type 2" fiber During sarcopenia, there is a decrease in "type 2" fiber

circumference (Type II), with little to no decrease in circumference (Type II), with little to no decrease in "type I" fiber circumference (Type I)."type I" fiber circumference (Type I).

Loss of satellite cell functionLoss of satellite cell function– sarcopenia, is in part caused by a failure in satellite sarcopenia, is in part caused by a failure in satellite

cell activation.the ability to repair damaged muscles cell activation.the ability to repair damaged muscles or respond to nutritional signals is impaired.or respond to nutritional signals is impaired.

Loss of anabolic signalsLoss of anabolic signals– Extreme muscle loss is often a result of both Extreme muscle loss is often a result of both

diminishing anabolic signals, such as growth hormone diminishing anabolic signals, such as growth hormone and testosterone, and promotion of catabolic signals, and testosterone, and promotion of catabolic signals, such as pro-inflammatory cytokinessuch as pro-inflammatory cytokines

DiagnosisDiagnosis

1) A low muscle mass, >2 standard deviations 1) A low muscle mass, >2 standard deviations below that mean measured in young adults below that mean measured in young adults (aged 18–39 years in the 3rd NHANES (aged 18–39 years in the 3rd NHANES population) of the same sex and ethnic population) of the same sex and ethnic background, and background, and

2) Low gait speed (e.g. a walking speed below 2) Low gait speed (e.g. a walking speed below 0.8 m/s in the 4-m walking test).0.8 m/s in the 4-m walking test).

Management Management

DrugsDrugs– Testosterone, anabolic steroids, Human Growth Testosterone, anabolic steroids, Human Growth

hormone, DHES, and hormone, DHES, and non-steroid androgen non-steroid androgen receptor modulators (SARMs)receptor modulators (SARMs)

Diet NutritionDiet Nutrition– An extract (EGb 761) from the plant Ginkgo An extract (EGb 761) from the plant Ginkgo

biloba (added to drinking water) was shown to biloba (added to drinking water) was shown to reduce the muscle loss in a rat reduce the muscle loss in a rat

ExerciseExercise

– Body’s function depends on regular and Body’s function depends on regular and lifelong exercise to maintain integritylifelong exercise to maintain integrity

– increases in activity have been shown to be increases in activity have been shown to be beneficial in settings of sarcopenia; exercise beneficial in settings of sarcopenia; exercise even in the very old can increase strength even in the very old can increase strength and muscle function.and muscle function.

– Lack of exercise is currently thought to be a Lack of exercise is currently thought to be a significant risk factor, increasing the significant risk factor, increasing the likelihood of sarcopenialikelihood of sarcopenia

Osteoporosis Osteoporosis

In osteoporosis the bone mineral density In osteoporosis the bone mineral density (BMD) is reduced, (BMD) is reduced,

Bone microarchitecture is disrupted, Bone microarchitecture is disrupted,

And the amount and variety of proteins in And the amount and variety of proteins in bone is alteredbone is altered

a portion of a bone showing signs of osteoporosis (right) is contrasted with a portion of a healthy bone (left).

Estrogen's most Estrogen's most important effect on important effect on osteoporosis appears to osteoporosis appears to be prevention of bone be prevention of bone breakdown, known as breakdown, known as resorption.resorption.Healthy bones require a Healthy bones require a balance of osteoclasts balance of osteoclasts (cells that breakdown (cells that breakdown bones) and osteoblasts bones) and osteoblasts (cells that make new (cells that make new bone)bone)

As estrogen levels As estrogen levels diminish, osteoclasts diminish, osteoclasts live longer than their live longer than their counterparts, counterparts, osteoblasts. This leads osteoblasts. This leads to bones being broken to bones being broken down at a rate much down at a rate much greater than they can be greater than they can be rebuilt, thus they grow rebuilt, thus they grow weak and brittle.weak and brittle.

Other Causes of OsteoporosisOther Causes of Osteoporosis

DiseasesDiseases: many diseases can hamper the growth : many diseases can hamper the growth of new bone material. hyperthyroidism, of new bone material. hyperthyroidism, disorders of the adrenal glands and pituitary disorders of the adrenal glands and pituitary gland, diabetes, and eating disorders.gland, diabetes, and eating disorders.

MedicationsMedications: some medications can reduce : some medications can reduce bones ability to rebuild themselves. They are bones ability to rebuild themselves. They are glucocorticoid medications, prednisolone, excess glucocorticoid medications, prednisolone, excess thyroid hormone replacement, the blood thinner thyroid hormone replacement, the blood thinner heparin, and certain anti-heparin, and certain anti-convulsant convulsant medications.medications.

Insufficient bone growth as a youthInsufficient bone growth as a youth: Bones : Bones that didn’t get enough calcium early in life have that didn’t get enough calcium early in life have a higher likelihood of becoming osteoporotic a higher likelihood of becoming osteoporotic and fracturing as estrogen levels begin to and fracturing as estrogen levels begin to decrease.decrease.Genetic factorsGenetic factors: If a woman’s family members, : If a woman’s family members, especially her mother, have suffered from especially her mother, have suffered from osteoporosis, the likelihood that she will osteoporosis, the likelihood that she will develop the disease jumps dramatically. develop the disease jumps dramatically. Genetics also helps determine the body type of Genetics also helps determine the body type of a woman. If she inherited a small, thin body a woman. If she inherited a small, thin body type, she is predisposed to osteoporosis.type, she is predisposed to osteoporosis.

Benefit of ExerciseBenefit of ExerciseOne of the best ways to strengthen your One of the best ways to strengthen your bones and prevent osteoporosis is by bones and prevent osteoporosis is by getting regular exercise. Even if you already getting regular exercise. Even if you already have osteoporosis, exercising can help have osteoporosis, exercising can help maintain the bone mass you have. maintain the bone mass you have.

Weight-bearing Exercise for Weight-bearing Exercise for OsteoporosisOsteoporosis

Weight-bearing means one’s feet and legs Weight-bearing means one’s feet and legs support the body’s weight. support the body’s weight. – WalkingWalking– HikingHiking– DancingDancing– Stair climbingStair climbing

Walking as little as three to five miles a week Walking as little as three to five miles a week can help build your bone health. For general can help build your bone health. For general health, at least half an hour of moderate to health, at least half an hour of moderate to vigorous exercise five times a week. Forty-five vigorous exercise five times a week. Forty-five minutes to an hour is even better.minutes to an hour is even better.

Swimming and water exerciseSwimming and water exerciseSwimming is not a weight-bearing exercise, because Swimming is not a weight-bearing exercise, because the buoyancy of the water counteracts the effects of the buoyancy of the water counteracts the effects of gravity. gravity.

Swimming will improve cardiovascular fitness and Swimming will improve cardiovascular fitness and muscle strength. People with severe osteoporosis or muscle strength. People with severe osteoporosis or kyphosis (hunching of the upper back) who are at kyphosis (hunching of the upper back) who are at high risk of bone fractures may find that swimming high risk of bone fractures may find that swimming is their preferred activity. is their preferred activity.

Water exercise, such as aqua aerobics and Water exercise, such as aqua aerobics and hydrotherapy, is also recommended. Consult with hydrotherapy, is also recommended. Consult with doctor or health care professional. doctor or health care professional.

Resistance Exercise for OsteoporosisResistance Exercise for Osteoporosis

Resistance exercise increases bone density and reduces the Resistance exercise increases bone density and reduces the risk of fractures.risk of fractures.– Free weights or weight machines at home or in the Free weights or weight machines at home or in the

gym gym – Resistance tubing that comes in a variety of strengths Resistance tubing that comes in a variety of strengths – Water exercises - any movement done in the water Water exercises - any movement done in the water

makes your muscles work harder.makes your muscles work harder.Two or three times a week. Gradually adding weight or Two or three times a week. Gradually adding weight or repetitions and on different muscles - arms, chest, repetitions and on different muscles - arms, chest, shoulders, legs, stomach, and back. do not resistance shoulders, legs, stomach, and back. do not resistance training on the same muscle group two days in a row. Give training on the same muscle group two days in a row. Give each muscle group time to recover. each muscle group time to recover.

Flexibility Exercise for OsteoporosisFlexibility Exercise for Osteoporosis

Important form of exercise for osteoporosis.Important form of exercise for osteoporosis.

Having flexible joints helps prevent injury. Having flexible joints helps prevent injury. – Regular stretches Regular stretches – T'ai chi T'ai chi – Yoga Yoga 

PrecautionPrecaution

Talk to your doctor before beginning any Talk to your doctor before beginning any exercise program exercise program

Weight-bearing exercise does not have to be Weight-bearing exercise does not have to be high impact. high impact.

Already have osteoporosis, be careful of Already have osteoporosis, be careful of exercises that involve bending and twisting at exercises that involve bending and twisting at the waist the waist

Muscle weaknessMuscle weaknessRefers to the inability to exert force with one's Refers to the inability to exert force with one's skeletal muscles.skeletal muscles.Muscle weakness is also a symptom used to Muscle weakness is also a symptom used to describe a number of different conditions, describe a number of different conditions, including: lack of muscle strength, malaise, including: lack of muscle strength, malaise, dizziness or fatiguedizziness or fatigueWeakness often follows muscle atrophy and a Weakness often follows muscle atrophy and a decrease in activity, such as after a long bout decrease in activity, such as after a long bout of bed rest as a result of an illness. of bed rest as a result of an illness. There is also a gradual onset of muscle There is also a gradual onset of muscle weakness as a result of sarcopeniaweakness as a result of sarcopenia

ClassificationClassificationTrue weaknessTrue weakness (Objective weakness or (Objective weakness or neuromuscular) describes a condition where the force neuromuscular) describes a condition where the force exerted by the muscles is less than would be exerted by the muscles is less than would be expected, for example muscular dystrophy. Patient expected, for example muscular dystrophy. Patient suffers from amyotrophic lateral sclerosis (ALS), suffers from amyotrophic lateral sclerosis (ALS), motor neurons are damaged and can no longer motor neurons are damaged and can no longer stimulate the muscles to exert normal force. stimulate the muscles to exert normal force.

Perceived weaknessPerceived weakness (Subjective weakness or non- (Subjective weakness or non-neuromuscular) describes a condition where a person neuromuscular) describes a condition where a person feels more effort than normal is required to exert a feels more effort than normal is required to exert a given amount of force but actual muscle strength is given amount of force but actual muscle strength is normal, for example chronic fatigue syndrome (CSF)normal, for example chronic fatigue syndrome (CSF)

Myasthenia GravisMyasthenia Gravisis true muscle weakness and a primary is true muscle weakness and a primary symptom of a variety of skeletal muscle symptom of a variety of skeletal muscle diseases, including muscular dystrophy and diseases, including muscular dystrophy and inflammatory myopathy. This disorder occurs inflammatory myopathy. This disorder occurs in neuromuscular junctionin neuromuscular junction

muscle strength is normal when resting, but muscle strength is normal when resting, but true weakness occurs after the muscle has been true weakness occurs after the muscle has been subjected to exercisesubjected to exercise

AstheniaAsthenia

is a medical term denoting symptoms of is a medical term denoting symptoms of physical weakness and loss of strengthphysical weakness and loss of strength

A condition in which the body lacks or has lost A condition in which the body lacks or has lost strength either as a whole or in any of its partsstrength either as a whole or in any of its parts

occurs in many chronic wasting diseases, such occurs in many chronic wasting diseases, such as anemia and cancer, in diseases of the as anemia and cancer, in diseases of the adrenal glandadrenal gland

also a side effect of some medications and also a side effect of some medications and treatments, such as Ritonavir (a protease treatments, such as Ritonavir (a protease inhibitor used in HIV treatment), vaccines inhibitor used in HIV treatment), vaccines such as the HPV vaccine Gardasil and fentanyl such as the HPV vaccine Gardasil and fentanyl patches (an opioid used to treat pain).patches (an opioid used to treat pain).is also commonly seen in patients suffering is also commonly seen in patients suffering from chronic fatigue syndrome, sleep from chronic fatigue syndrome, sleep disorders or chronic disorders of the heart, disorders or chronic disorders of the heart, lungs or kidneyslungs or kidneysDifferentiating between psychogenic asthenia Differentiating between psychogenic asthenia and true asthenia with muscular weakness is and true asthenia with muscular weakness is often difficult,often difficult,

Differential diagnosis Differential diagnosis

Central muscle weaknessCentral muscle weakness manifests as an manifests as an overall, bodily or systemic, sense of energy overall, bodily or systemic, sense of energy deprivation, deprivation,

Peripheral weaknessPeripheral weakness manifests as a local, manifests as a local, muscle-specific incapacity to do work.muscle-specific incapacity to do work.

Neural weaknessNeural weakness can be both central and can be both central and peripheralperipheral

Lactic acid Lactic acid

build-up was the cause build-up was the cause of muscle fatigueof muscle fatiguecan lower the sensitivity of contractile can lower the sensitivity of contractile apparatus to Caapparatus to Ca2+2+ but also has the effect of but also has the effect of increasing cytoplasmic Caincreasing cytoplasmic Ca2+2+ concentration concentration through an inhibition of the chemical pump through an inhibition of the chemical pump that actively transports calcium out of the cellthat actively transports calcium out of the cell

Lactic acid also has a negating effect on the Lactic acid also has a negating effect on the chloride ions in the muscles, reducing their chloride ions in the muscles, reducing their inhibition of contraction and leaving inhibition of contraction and leaving potassium ions as the only restricting influence potassium ions as the only restricting influence on muscle contractions, though the effects of on muscle contractions, though the effects of potassium are much less than if there were no potassium are much less than if there were no lactic acid to remove the chloride ionslactic acid to remove the chloride ions

PathophysiologyPathophysiology

The sodium channels The sodium channels spontaneously close, potassium spontaneously close, potassium channels open, and positively channels open, and positively charged charged potassium ions exitpotassium ions exit the the fiber. Chloride channels also stay fiber. Chloride channels also stay open, and negatively charged open, and negatively charged chloride ions enterchloride ions enter the fiber. All the fiber. All these actions cause the inside of these actions cause the inside of the fiber to become more negative the fiber to become more negative (“repolarized”). The muscle fiber (“repolarized”). The muscle fiber returns to its resting state, calcium returns to its resting state, calcium is pumped back into the internal is pumped back into the internal storage vesicles, and the fiber is storage vesicles, and the fiber is now ready to accept another surge now ready to accept another surge of positively charged ions in of positively charged ions in response to stimulation from a response to stimulation from a nerve fiber. (When several muscle nerve fiber. (When several muscle fibers are at rest, a muscle can fibers are at rest, a muscle can relax.)relax.)

Treatment Treatment Appropriate periods of restAppropriate periods of rest

Good hydration and nutrition and regular medical Good hydration and nutrition and regular medical care. (e.g. Treatment of muscle weakness caused by care. (e.g. Treatment of muscle weakness caused by electrolyte imbalance and/or dehydration) electrolyte imbalance and/or dehydration)

Rehabilitation, physical therapy, occupational therapy Rehabilitation, physical therapy, occupational therapy

Regular program of exercise may be recommendedRegular program of exercise may be recommended

Corticosteroid medications may be prescribed to Corticosteroid medications may be prescribed to reduce inflammation of the nervous systemreduce inflammation of the nervous system

Caused by bacterial infections generally involves Caused by bacterial infections generally involves antibiotic medicationsantibiotic medications

Caused by anemia may involve blood transfusionsCaused by anemia may involve blood transfusions

DiscussionDiscussion

What is frailty syndrome, why it is so What is frailty syndrome, why it is so important for aged people.important for aged people.

Why weight-bearing exercise has positive Why weight-bearing exercise has positive effect on osteoporosis.effect on osteoporosis.

Can you compose a exercise prescription Can you compose a exercise prescription for people with muscle weaknessfor people with muscle weakness