THE POSTMENOPAUSAL FEMALE & THE ROLE OF EXERCISE

Farah Hameed, MD

Assistant Professor

Columbia University Medical Center

Department of Rehabilitation and Regenerative Medicine

Post-Menopausal Women

• Musculoskeletal effects of menopause• Osteoarthritis• Osteoporosis• Sarcopenia

• Exercise benefits in post-menopausal female

• Exercise Rx for the post-menopausal female

Effects of Estrogen• Cartilage

• Chondroprotective

• Subchondral bone• Regulates bone growth and remodeling

• Synovium• Increases synovial levels

• Muscles • Promotes myoblast proliferation

Martín-Millán M1, Castañeda S. Estrogens, osteoarthritis and inflammation. Joint Bone Spine. 2013 Jul;80(4):368-73.

Osteoarthritis• 27 million Americans• F>M (after age 50)• Other risk factors

• Genetics• Weight• Prior injury

• With similar amounts of radiographic changes – OA is more symptomatic in women

Helmick et al, 2008; http://www.arthritis.org/media/newsroom/media-kits/Osteoarthritis_fact_sheet.pdf

Osteoporosis• Decrease in bone density • Most common type of bone disease• 50% of women over age 50• Symptoms: loss of height, kyphosis,

low-trauma fracture• Diagnosis: Bone Densitometry, +/-

labs, XR

Gass M1, Dawson-Hughes B. Preventing osteoporosis-related fractures: an overview. Am J Med. 2006 Apr;119(4 Suppl 1):S3-S11.

Osteoporosis and Fracture Risk

Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.

Age-Related Changes in Body Composition

• lean body mass

• % body fat

• weight

• height

Kyle UG1, Genton L, Hans D, Karsegard VL, Michel JP, Slosman DO, Pichard C. Total body mass, fat mass, fat-free mass, and skeletal muscle in older people: cross-sectional differences in 60-year-old persons. J Am Geriatr Soc. 2001 Dec;49(12):1633-40.

Sarcopenia

Sarcopenia- the age-associated loss of skeletal muscle mass and function.

Rosenberg, 1989

Evans W. What is Sarcopenia. J Gerentol. 1985; 50A:5-8.

Epidemiology

 Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with

functional impairment and physical disability. J Am Geriatr Soc. 2002 May;50(5):889–96.

Strength• Greater decline in strength than muscle mass

• Declines 15% in 6th and 7th decades and 30% after the 7th decade• Greater decline in lower body vs. upper body strength • Greater decline in extensors vs. flexors

• Power declines more than strength and muscle mass • Weakness a more powerful predictor of morbidity/mortality in the

elderly than muscle mass

Goodpaster BH, Park SW, Harris TB, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition Study. J Gerontol A Biol Sci Med Sci. 2006;61: 1059–1064.

Framingham Study% of women that can not lift 10 lbs

% of women that can not lift 10 lbs Age

40% 55-64

45% 65-74

65% 75-85

Jetter, AM, Branch LG. The Framingham disability study: II-Physical disability among the aging. Am. J Public Health 71: 1211-1216. 1981.

EXERCISE

Exercise – The Facts

• Inactivity increases with age• By age 75, about 50% women

engage in no physical activity• Walking & gardening are most

popular• The loss of strength/stamina

attributed to aging is, in part, caused by inactivity

http://www.cdc.gov/nccdphp/sgr/women.htm

Exercise Benefits During Menopause• Studies have shown that

regular exercise/physical activity leads to:• Improved physical and mental

health• Improved quality of life• Reduced symptoms of

menopause in those who exercised

• Choosing activity is important

Stojanovska L1, Apostolopoulos V2, Polman R3, Borkoles E3. To exercise, or, not to exercise, during menopause and beyond. Maturitas. 2014 Apr;77(4):318-23.

Exercise and Body Composition

•Moderate intensity aerobic exercise reduces total body fat

•Decrease in visceral fat

TOTH, MJ.; BECKETT, T; POEHLMAN, ET. Physical activity and the progressive change in body composition with aging: current evidence and research issues. Med Sci Sports Exerc. 1999; 3 (11 suppl): S590-6.

Activity Guidelines: > 65 years• Follow adult guidelines

• 150 min of mod intensity/week• 75 min vigorous intensity/week• 10 min intervals• Strengthening 2d/w

• When not possible, be as physically active as abilities/conditions allow

• Do exercises that maintain or improve balance to reduce risk for falling

Haskell et al, ACSM/AHA, MSSE, 2007

Exercise and Osteoarthritis• What role does physical activity have on progression of

arthritis?• Evidence suggest that (moderate) exercise does not accelerate

development of OA• Possible increased risk of OA with competitive sports participation,

particularly early in life, and with competition at an elite level• Increased risk of OA in the presence of obesity, trauma, occupational

stress, and alignment problems of the lower extremities

Running and Arthritis

• Lack of conclusive evidence that running causes arthritis• No increase in 60 yo runners (180 min/w x 12 years)• No increase in runners up to 28 mi/wk• Higher incidence was seen > 65 mi/wk• No increase in complaints of joint pain in runners vs. non-runners

• Pace may be better predictor

• Runners with arthritis may have faster progression of arthritis compared to non-runners

Lane et al, 1986 & 1993; McDermott et al, 1983; Kujala et al, 1995

Strength Training • Older individuals can substantially

increase their strength with resistance exercise training

• Similar strength gains older vs. younger

• Muscle strength increases in response to training between 60-100% of 1RM

• 15% people over 55 strength train

 Bautmans I1, Van Puyvelde K, Mets T. Sarcopenia and functional decline: pathophysiology, prevention and therapy. Acta Clin Belg. 2009 Jul-Aug;64(4):303-16.

Where to start• For a sedentary person, walking is feasible • To start resistance training :

• Perform 8-10 repetitions of 8-10 exercises for major muscle groups

• Start with 40% of one repetition maximum and increase slowly

• Resistance training initially requires professional instruction/machines

• Warm-up and cool-down with stretching should be a part of every exercise session

Asikainen TM1, Kukkonen-Harjula K, Miilunpalo S. Exercise for health for early postmenopausal women: a systematic review of randomized controlled trials. Sports Med. 2004;34(11):753-78.

Strength Training Recommendations

Taaffe DR. Sarcopenia--exercise as a treatment strategy. Aust Fam Physician. 2006 Mar;35(3):130-4.

Exercise in Osteoarthritis • Combination of:

• Strength training (ST)• Active range of motion exercise• Aerobic activity

• Strength training: • Resistance-based lower limb, hip and quadriceps strengthening

exercises

• Water-based exercise in knee and hip OA found benefits for function and quality of life

• Reductions in pain and disability for overweight patients with OA were found with weight loss (5% in 20 wks)

McAlindon TE1, Bannuru RR2, Sullivan MC2, Arden NK3, Berenbaum F4, Bierma-Zeinstra SM5, Hawker GA6, Henrotin Y7, Hunter DJ8, Kawaguchi H9, Kwoh K10,Lohmander S11, Rannou F12, Roos EM13, Underwood M14. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.

Exercise in Osteoarthritis

McAlindon TE1, Bannuru RR2, Sullivan MC2, Arden NK3, Berenbaum F4, Bierma-Zeinstra SM5, Hawker GA6, Henrotin Y7, Hunter DJ8, Kawaguchi H9, Kwoh K10,Lohmander S11, Rannou F12, Roos EM13, Underwood M14. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.

Managing Osteoporosis• Julius Wolff (1891) – Bone, in a healthy subject, will adapt

to the loads under which it is placed• Exercise Bone remodeling• Primary goal is reducing fracture risk

• Slow/stop bone loss• Increase bone mass/improve bone architecture• Maintain/increase bone strength• Minimize risk of falls

Exercise Recommendations: Osteoporosis

• Exercises can increase bone mass if they increase muscle mass and strength

• Muscles to target to help with posture and prevent falls:• Back extensors• Lower extremity muscle groups – such as the knee and hip

extensors, hip flexors, dorsiflexors and plantarflexors

• Compound movements can be effective way to target all these areas

Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.

Exercise in Osteoporosis• Focus on improving agility, balance and posture

• Avoid high impact activities • Avoid activities with a risk of fall• Avoid repeated/resisted trunk flexion movements

• Moderate intensity physical activity can help improve balance and agility, thereby minimizing falls• Among women 75 or older, exercise has been shown to reduce risk

of fall and injury by 75%

Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.

T’ai Chi• Flowing, meditative movements• Greater loading than walking• Reduces risk of falling

• Meta-analyses investigating t’ai chi found strong favorable benefits of t’ai chi for improving pain and physical function in individuals with OA

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Yan JH1, Gu WJ, Sun J, Zhang WX, Li BW, Pan L. Efficacy of Tai Chi on pain, stiffness and function in patients with osteoarthritis: a meta-analysis. PLoS One. 2013 Apr 19;8(4):e61672 Wayne PM1, Kiel DP, Buring JE, Connors EM, Bonato P, Yeh GY, Cohen CJ, Mancinelli C, Davis RB. Impact of Tai Chi exercise on multiple fracture-related risk factors in post-menopausal osteopenic women: a pilot pragmatic, randomized trial. BMC Complement Altern Med. 2012 Jan 30;12:7.

Endurance Training Recommendations

• Type• Intensity- Moderate (RPE)• Duration-≥30min/day• Frequency- ≥ 5 days/ week (total ≥ 150 min/wk

• Or• Intensity-Vigorous • Duration- ≥ 20min/day• Frequency- ≥ 3 days/week (total ≥ 75 min/wk)

Strength Training Recommendations

• Frequency: 2-4 days per week, with 48hrs between training sessions• Duration: 20-45 minutes • Type: multi joint preferred, machine vs free weight • Intensity: up to 65-85% of 1 RM • Repetitions: 10-15 • Monthly adjustments- overload principle

Thank You for Your Attention