Help, I’m Getting Help, I’m Getting Older!Older!

Medical Concerns Medical Concerns for the Aging for the Aging

AthleteAthleteGregory R. Czarnecki, D.O.Gregory R. Czarnecki, D.O.

Internal & Sports MedicineInternal & Sports MedicineHartford Healthcare Medical GroupHartford Healthcare Medical Group

Glastonbury, CTGlastonbury, CTPresident, Connecticut Osteopathic Medical SocietyPresident, Connecticut Osteopathic Medical Society

Interim DME, UConn Osteopathic Internal Medicine ResidencyInterim DME, UConn Osteopathic Internal Medicine Residency

Connecticut Podiatric Medical Association, April 11, 2015Connecticut Podiatric Medical Association, April 11, 2015

GoalsGoals Review and understand benefits of exercise Review and understand benefits of exercise

throughout onethroughout one’’s lifespan and adaptive changes that s lifespan and adaptive changes that occur with aging. occur with aging.

Increase awareness of Exercise is Medicine Increase awareness of Exercise is Medicine Learn tools for exercise prescription.Learn tools for exercise prescription. Review current exercise guidelines in the adult Review current exercise guidelines in the adult

populationpopulation Understand the role and recommendations for Understand the role and recommendations for

exercise testing. exercise testing. Highlight special considerations (medications, Highlight special considerations (medications,

treatments, etc.) in the aging athlete. treatments, etc.) in the aging athlete.

The ACSM guidelines for The ACSM guidelines for physical activity (exercise) physical activity (exercise)

are:are:

1.1. 20 minutes per day 3 days per week.20 minutes per day 3 days per week.

2.2. 30 minutes per day 3 days per week.30 minutes per day 3 days per week.

3.3. 20 minutes per day 5 days per week.20 minutes per day 5 days per week.

4.4. 30 minutes per day 5 days per week.30 minutes per day 5 days per week.

5.5. 30 minutes per day most days of the 30 minutes per day most days of the week.week.

Strength training is Strength training is incorporated into these incorporated into these

recommendations. What recommendations. What is/are the recommended is/are the recommended

minimum day(s) or sessions minimum day(s) or sessions for incorporating strength for incorporating strength

training?training?1.1. 1 day/week1 day/week

2.2. 2 days/week2 days/week

3.3. 3 days/week3 days/week

4.4. 4 days/week4 days/week

5.5. 5 days/week5 days/week

At what age range does At what age range does physiologic (adaptive) physiologic (adaptive)

muscle hypertrophy cease muscle hypertrophy cease despite strength training? despite strength training?

a. 60-69a. 60-69 b. 70-79b. 70-79 c. 80-89c. 80-89 d. 90-99d. 90-99 e. No age limite. No age limit

WhoWho’’s an aging athlete?s an aging athlete?

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Masters AthletesMasters Athletes Masters level = age 35 Masters level = age 35

++ 5 year-increments on 5 year-increments on

competitive groups, competitive groups, includes 100+ category.includes 100+ category.

National Senior Games National Senior Games (Senior Olympics) = (Senior Olympics) = age 50 and up.age 50 and up.

Masters swimming = Masters swimming = age 19+age 19+

More Master’s LevelsMore Master’s Levels

Master’s cycling: 30+ or 35+Master’s cycling: 30+ or 35+ USA Track and Field: 30+; 40 for USA Track and Field: 30+; 40 for

distance runningdistance running

Medical concernsMedical concerns

Performance declinePerformance decline Medical co-morbiditiesMedical co-morbidities Injury preventionInjury prevention

Injury/Resection of 15-34% of the meniscus => increased Injury/Resection of 15-34% of the meniscus => increased contact pressure by up to 350%contact pressure by up to 350%

Medication risksMedication risks

Where are you headed?Where are you headed?

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Changes with AgingChanges with Aging Cardio Cardio Pulm Pulm MSMS Neuro Neuro Metabolic Metabolic CellularCellular

http://www.dailygalaxy.com/my_weblog/2007/09/end-of-aging.htmlhttp://www.dailygalaxy.com/my_weblog/2007/09/end-of-aging.html

Cardiovascular ChangesCardiovascular Changes

↓↓HRHRmaxmax

6-10 bpm/decade 6-10 bpm/decade ↑↑BP, PVR during max exerciseBP, PVR during max exercise ↓↓VO2 Max (maximal oxygen consumption)VO2 Max (maximal oxygen consumption)

↓↓5-15% per decade after age 255-15% per decade after age 25

Pulmonary ChangesPulmonary Changes

↓↓VCVC ↑↑RVRV ↓ ↓ ElasticityElasticity

Translates to increases in work of breathing, Translates to increases in work of breathing, perceived exertionperceived exertion

Musculoskeletal ChangesMusculoskeletal Changes

↓↓muscle mass, aka - sarcopenia– greater loss muscle mass, aka - sarcopenia– greater loss of type 2 fibersof type 2 fibers Peak muscle mass @ age 30Peak muscle mass @ age 30 Age 50 => declineAge 50 => decline

↓↓bone mass (0.5% per year after age 40), bone mass (0.5% per year after age 40), ↓↓tensile strength of tendons/ligaments tensile strength of tendons/ligaments ↑↑muscle stiffnessmuscle stiffness

Neurologic ChangesNeurologic Changes

↓ ↓ balancebalance ↓ ↓ coordinationcoordination ↓ ↓ reaction timereaction time autonomic dysfunctionautonomic dysfunction

↓↓thirst mechanismthirst mechanism Impaired thermoregulationImpaired thermoregulation

Metabolic ChangesMetabolic Changes

↑↑cholesterolcholesterol ↓ ↓ metabolic ratemetabolic rate

Weight gainWeight gain Central obesityCentral obesity

Cellular changesCellular changes

Mitochondrial dysfunctionMitochondrial dysfunction Defects in electron transport chainDefects in electron transport chain Uncoupling of oxidative phosphorylation due to Uncoupling of oxidative phosphorylation due to

hydrogen leak across inner membranehydrogen leak across inner membrane

Leading to decreased ATP + apoptosis. Leading to decreased ATP + apoptosis. Selective preference to type 2 muscle fibers.Selective preference to type 2 muscle fibers.

Sedentary lifestyle Sedentary lifestyle associated with associated with work, family, work, family, acute/chronic acute/chronic medical conditions.medical conditions.

Give rebirth to Give rebirth to exercise in oneexercise in one’’s s daily life. daily life.

OO ’’Connor, Just the factsConnor, Just the facts

The Descent…The Descent…

? Average American ? Average American Family?Family?

How much is preventable with How much is preventable with exercise?exercise?

WhatWhat’’s the point?s the point? Routine exercise associated with Routine exercise associated with

prevention/reduction of medical prevention/reduction of medical conditions including: conditions including: CADCAD HTNHTN ObesityObesity DM-2DM-2 DyslipidemiaDyslipidemia OsteoporosisOsteoporosis Anxiety/depression Anxiety/depression CancerCancer Constipation!Constipation!

Getting Started – the Getting Started – the historyhistory

What is planned activity/activities?What is planned activity/activities? Current level of training?Current level of training? Vision impairments? (cataracts, glaucoma)Vision impairments? (cataracts, glaucoma) Hearing loss?Hearing loss? Chest pain, exertional dyspnea, palpitations, Chest pain, exertional dyspnea, palpitations,

syncope?syncope? Signs of neurologic/autonomic dysfunction? Signs of neurologic/autonomic dysfunction? Musculoskeletal historyMusculoskeletal history Co-morbiditiesCo-morbidities MedicationsMedications

Getting Started - examGetting Started - exam Blood pressure; orthostatics if history Blood pressure; orthostatics if history

suggestivesuggestive Cardiac, lung, carotid auscultationCardiac, lung, carotid auscultation Femoral pulsesFemoral pulses Neuro – coordination, balance, proprioception, Neuro – coordination, balance, proprioception,

strength, sensationstrength, sensation Musculoskeletal – joint deformities, effusions, Musculoskeletal – joint deformities, effusions,

ROM, biomechanics, ROM, biomechanics, FEETFEET.. Skin integritySkin integrity

Exercise is MedicineExercise is Medicine

Campaign launched by the American Campaign launched by the American College of Sports Medicine (ACSM) College of Sports Medicine (ACSM) in collaboration with the American in collaboration with the American Medical Association (AMA).Medical Association (AMA).

For physicians of all specialtiesFor physicians of all specialties

Prescribing ExercisePrescribing Exercise

Set realistic goals and expectations.Set realistic goals and expectations. What activities does your patient enjoy?What activities does your patient enjoy? What limitations/barriers to exercise exist?What limitations/barriers to exercise exist? Include cardiovascular (aerobic), strength Include cardiovascular (aerobic), strength

training, flexibility and proprioceptive/balance training, flexibility and proprioceptive/balance training. training.

Mode, intensity, duration, frequency.Mode, intensity, duration, frequency.

Things to discussThings to discuss Warm up, cool downWarm up, cool down Gradual changes in intensity/duration/frequencyGradual changes in intensity/duration/frequency Goal = Goal = most days of week for moderate-most days of week for moderate-

intensity exercise ≥30 min; 2 or more days per intensity exercise ≥30 min; 2 or more days per week for strength/resistance trainingweek for strength/resistance training (limit (limit increase to 5%/week)increase to 5%/week)

Allow recovery time to avoid common overuse Allow recovery time to avoid common overuse injuriesinjuries

Possible medication interactions, hydration, Possible medication interactions, hydration, nutrition, patientnutrition, patient’’s concerns/fears. s concerns/fears.

Exercise TestingExercise Testing

Formal exercise testing remains controversial Formal exercise testing remains controversial for pre-participation in exercise.for pre-participation in exercise.

Yield greatest in symptomatic adults and Yield greatest in symptomatic adults and intermediate pre-test probability.intermediate pre-test probability.

Questions for the patient should address Questions for the patient should address planned activity and goals.planned activity and goals. If moderate activity, testing If moderate activity, testing ““not necessary,not necessary,”” but but

recommended if vigorous. recommended if vigorous.

ACSMACSM’’s guidelines for s guidelines for exercise testing prior:exercise testing prior:

For any For any high riskhigh risk pt planning moderate or pt planning moderate or vigorous exercise (HR=cardio-pulm disease or vigorous exercise (HR=cardio-pulm disease or suggestive symptoms, DM, renal, hepatic dysfn)suggestive symptoms, DM, renal, hepatic dysfn)

For For moderate riskmoderate risk pt (M>45, F>55 pt (M>45, F>55 OROR with with 2/more risk factors - +Fam hx, +tob, HTN, ↑chol, 2/more risk factors - +Fam hx, +tob, HTN, ↑chol, obesity, sedentary lifestyle, fasting BG >110 x2 obesity, sedentary lifestyle, fasting BG >110 x2 measurements) – only recommended for vigorous measurements) – only recommended for vigorous exercise (>6 mets)exercise (>6 mets)

Not necessary in low risk group (asymptomatic, Not necessary in low risk group (asymptomatic, M<45, F<55)M<45, F<55)

Intensity GradingIntensity Grading

http://www.cdc.gov/nccdphp/dnpa/physical/pdf/http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdfPA_Intensity_table_2_1.pdf

MET – ratio of exercise metabolic MET – ratio of exercise metabolic raterate 1 MET = energy expenditure for sitting 1 MET = energy expenditure for sitting

quietly; 3.5ml O2 uptake/kg/min. quietly; 3.5ml O2 uptake/kg/min. Will vary by ageWill vary by age

Grading IntensityGrading Intensity As percentage of max HR (220-age +/- 10 As percentage of max HR (220-age +/- 10

BPM):BPM): 50-63% = light50-63% = light 90-114 in 40yo90-114 in 40yo 64-76% = moderate64-76% = moderate 115-137115-137 77-93% = vigorous77-93% = vigorous 138-167138-167

As percentage of Heart Rate Reserve (HRmax As percentage of Heart Rate Reserve (HRmax - resting HR):- resting HR): 20-39% = light20-39% = light 84-107; assume rHR 6084-107; assume rHR 60 40-59% = moderate40-59% = moderate 108-131108-131 60-84% = vigorous60-84% = vigorous 132-161132-161

Talk TestTalk Test Light – able to sing Light – able to sing

during your activityduring your activity Moderate – able to hold Moderate – able to hold

conversation during conversation during activityactivity

Vigorous – Vigorous – winded/breathless – canwinded/breathless – can’’t t carry-on conversation carry-on conversation during exercise. during exercise.

Now that theyNow that they’’re re exercising…exercising…

Doc, it hurts me when I do this…Doc, it hurts me when I do this… Sure, it hurts, but I just deal with it…Sure, it hurts, but I just deal with it… I stopped _______ because I hurt my ______.I stopped _______ because I hurt my ______. Can I still run, bike, swim, etc.?Can I still run, bike, swim, etc.?

Words of cautionWords of caution Overuse injuries account for Overuse injuries account for

majority of musculoskeletal majority of musculoskeletal complaints in the adult complaints in the adult athlete – 70% of injuries in athlete – 70% of injuries in experienced athletes over experienced athletes over 60.60.

Training errors increase risk Training errors increase risk of injury.of injury.

Biomechanics, training Biomechanics, training surfaces, recovery time are surfaces, recovery time are all important considerations all important considerations in injury prevention. in injury prevention.

Common Common ““OveruseOveruse”” InjuriesInjuries

Rotator cuff disorders: Rotator cuff disorders: tendonitis/bursitis/impingementtendonitis/bursitis/impingement

GolferGolfer’’s elbows elbow Tennis elbowTennis elbow Carpal Tunnel SyndromeCarpal Tunnel Syndrome JumperJumper’’s knees knee RunnerRunner’’s knees knee ITB friction syndromeITB friction syndrome Achilles tendonitisAchilles tendonitis Plantar fasciitisPlantar fasciitis

Overuse or Dysfunctional Overuse or Dysfunctional Use?Use?

Why do baseball pitchers commonly develop Why do baseball pitchers commonly develop shoulder and elbow problems?shoulder and elbow problems?

Maybe itMaybe it’’s both…s both…

How can we help keep these How can we help keep these athletes athletes ““going strong?going strong?””

Activity modification; cross-trainingActivity modification; cross-training Correct biomechanicsCorrect biomechanics OMTOMT Physical TherapyPhysical Therapy

↑↑ROMROM StrengtheningStrengthening ↑ ↑ ProprioceptionProprioception

MedicationsMedications NSAIDs, TylenolNSAIDs, Tylenol Opiates?Opiates?

InjectionsInjections Surgery?Surgery?

Common findings in Common findings in Tendinosis include:Tendinosis include:

a. Inflammatory cells including a. Inflammatory cells including neutrophils neutrophils

b. Avascularityb. Avascularity c. Tendon thinningc. Tendon thinning d. All of the aboved. All of the above e. None of the abovee. None of the above

Tendinosis/Tendinosis/TendonopathiesTendonopathies

Focal area of degeneration due to Focal area of degeneration due to incomplete healing, repetitive incomplete healing, repetitive loading/stress, tissue hypoxia.loading/stress, tissue hypoxia.

Lack of inflammatory mediators on Lack of inflammatory mediators on biopsy.biopsy.

Neovessel formation. Neovessel formation. Tendon thickening. Tendon thickening.

TendinosisTendinosis

Alfredson, AMSSM 18Alfredson, AMSSM 18thth Annual Annual MeetingMeeting

Emerging InjectionsEmerging Injections

ProlotherapyProlotherapy SclerotherapySclerotherapy Autologous BloodAutologous Blood Platelet-rich PlasmaPlatelet-rich Plasma Stem CellsStem Cells

What about steroids?What about steroids?

OsteoarthritisOsteoarthritis

OA affects 15% of US population.OA affects 15% of US population. Over 70% over age 70 will have x-ray Over 70% over age 70 will have x-ray

evidence of OA.evidence of OA. Clinical symptoms are widely varied. Clinical symptoms are widely varied. Joint stiffness +/- effusion; decreased active Joint stiffness +/- effusion; decreased active

and passive ROMand passive ROM

Physical Activity and OAPhysical Activity and OA

Does exercise increase your risk for OA?Does exercise increase your risk for OA? Moderate mechanical loading is necessary to Moderate mechanical loading is necessary to

maintain healthy articular cartilage. (Griffin)maintain healthy articular cartilage. (Griffin) A disruption in the joint homeostasis can begin A disruption in the joint homeostasis can begin

the shift to degradative process.the shift to degradative process.

Sports after joint Sports after joint replacement?replacement?

Concerns: hardware failure, joint dislocation, Concerns: hardware failure, joint dislocation, periprosthetic fractureperiprosthetic fracture

Low impact recommended (level C)Low impact recommended (level C) Activities will vary based on experience prior Activities will vary based on experience prior

to joint replacement and anticipated level of to joint replacement and anticipated level of impact impact

Contact sports and high-impact activities not Contact sports and high-impact activities not recommended (level C)recommended (level C)

Medication Medication ConsiderationsConsiderations

? Side-effects that may impair sport or put ? Side-effects that may impair sport or put athlete at risk?athlete at risk? NSAIDS with dehydrationNSAIDS with dehydration ACE with NSAID/dehydrationACE with NSAID/dehydration Beta-blocker on HR/performanceBeta-blocker on HR/performance DiureticsDiuretics Antibiotics – QuinolonesAntibiotics – Quinolones Insulin/sulfonylureasInsulin/sulfonylureas SteroidsSteroids AntihistaminesAntihistamines

It is never too late to It is never too late to startstart

Benefits of strength Benefits of strength training seen even training seen even in the frail elderly.in the frail elderly.

Improved get-up-Improved get-up-and-goand-go

Improved Improved spontaneous activityspontaneous activity

Reduced falls and Reduced falls and obstacle avoidanceobstacle avoidance

For Your Aging Athletes:For Your Aging Athletes:

Beware of Beware of potential overuse potential overuse patternspatterns

Correct Correct biomechanicsbiomechanics

Judicious use of Judicious use of injectionsinjections

Goals will Goals will changechange

Activities may Activities may changechange

Medications: 1Medications: 1stst do no harmdo no harm

Exercise IS Exercise IS medicinemedicine

ConclusionConclusion Multitude of risk reductions through exercise. Multitude of risk reductions through exercise. Encourage exercise most days of week for moderate-intensity Encourage exercise most days of week for moderate-intensity

exercise ≥30 min; 2 or more days per week for strength/resistance exercise ≥30 min; 2 or more days per week for strength/resistance training.training.

Exercise prescription should be integral to patient care. Exercise prescription should be integral to patient care. Mode, frequency, intensity, duration.Mode, frequency, intensity, duration. Cardiovascular, strength, proprioception, flexibility. Cardiovascular, strength, proprioception, flexibility.

Overuse injuries common in the mature athlete. Patient education Overuse injuries common in the mature athlete. Patient education is crucial. is crucial.

Treatments aim to improve biomechanics (joint forces, muscle Treatments aim to improve biomechanics (joint forces, muscle balance, and external forces), reduce pain, and allow preservation balance, and external forces), reduce pain, and allow preservation of function, maintaining quality of life.of function, maintaining quality of life.

Stay fit, stay young. Stay fit, stay young.

Questions?Questions?

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Images in this presentation obtained via www.google.com – images (unless Images in this presentation obtained via www.google.com – images (unless otherwise specified)otherwise specified)

More References:More References: Nicholls MA, Selby JB, Hartford JM. Athletic activity after total joint Nicholls MA, Selby JB, Hartford JM. Athletic activity after total joint

replacement. Orthopedics, v25, No. 11:1283-7, November 2002. replacement. Orthopedics, v25, No. 11:1283-7, November 2002. Bellamy N, Campbell J, et al., Intraarticular corticosteroid for treatment Bellamy N, Campbell J, et al., Intraarticular corticosteroid for treatment

of osteoarthritis of the knee (Review). The Cochrane Collaboration, of osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons, Ltd. Issue 3, 2007.Wiley & Sons, Ltd. Issue 3, 2007.

Bellamy N, Campbell J, et al., Viscosupplementation for the treatment of Bellamy N, Campbell J, et al., Viscosupplementation for the treatment of osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons, Ltd. Issue 3, 2007.& Sons, Ltd. Issue 3, 2007.

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Moseley JB, OMoseley JB, O’’Malley K, et al. A controlled trial of arthroscopic surgery Malley K, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM, v347, No. 2: 81-88, July 11, 2002. for osteoarthritis of the knee. NEJM, v347, No. 2: 81-88, July 11, 2002.

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American College of Sports Medicine, ACSMAmerican College of Sports Medicine, ACSM ’’s Guidelines for exercise s Guidelines for exercise testing and prescription, 7th edition, Lippincott Williams & Wilkins, testing and prescription, 7th edition, Lippincott Williams & Wilkins, 2006. 2006.