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Training in Special Populations Issues of Aging

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Understand the benefits of exercise for older adults ... No ballistic movements. Frailty. Result of. Biological aging. High burdens of chronic disease ... – PowerPoint PPT presentation

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Title: Training in Special Populations Issues of Aging


1
Training in Special Populations Issues of Aging
  • March 18 2009
  • Cathy Ciolek, PT, DPT, GCS

2
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

3
OUTLINE OF PRESENTATION
  • AGING
  • Exercise
  • Strength/resistance
  • Aerobic
  • Flexibility
  • Disease specific
  • Diabetes
  • Osteoporosis
  • Etc

4
Normal Aging vs Pathology
5
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

6
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

7
Psychological Benefits
  • Improves sleep
  • Sleep more deeply
  • Sleep longer
  • Wake less often
  • Reduces depression
  • Increase self-esteem

8
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

9
Ultimate Goal of Exercise
  • Focus
  • Increase physical performance and quality of life
  • To prevent disability and disease progression
    through the modification of risk factors

10
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.

11
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

12
What tests and measures can you use to test
strength, endurance, etc?- MMT but what else?
13
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

14
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

15
Principles of Exercise
  • Adapt vs Challenge
  • Overload
  • Task Specificity

16
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?

17
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.

18
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!

19
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

20
Exercise Prescription Guidelines
  • Similar to any other population in general
  • Consider
  • Baseline physiological state and response to
    exercise stimuli
  • Comorbid conditions and medications

21
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

22
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

23
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)

24
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

25
Warning Signs
  • Chest pain
  • Palpitations
  • Feelings of weakness, pale, clammy, fainting
  • Dizziness or light-headedness

26
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.

27
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)
28
Exercise Recommendations for Optimal Aging
29
Exercise Recommendations for Optimal Aging
30
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

31
Exercise Intensity
  • To increase aerobic fitness
  • 60-80 of MHR
  • Sedentary individuals
  • Begin at 50 MHR
  • Gradually progress

32
Target Heart Rate
  • AGE THR (220-age60-80)
  • 50 years 102-136
  • 60 years 96-128
  • 70 years 90-120
  • 80 years 84-112

33
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

34
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

35
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

36
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

37
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)

38
Postural Stability/Balance
  • Tai Chi and standing yoga
  • Tandem walking
  • Single leg stance
  • Stepping over objects
  • Perturbation

39
Flexibility
  • Recommendations
  • Slow sustained stretch
  • 20-30 seconds hold
  • No ballistic movements

40
Frailty
  • Result of
  • Biological aging
  • High burdens of chronic disease
  • Malnutrition
  • Extremely sedentary

41
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

42
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

43
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

44
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.

45
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

46
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

47
Dont feed into poor postural habits
  • Conduct extension dominant exercises
  • Stretch shortened
  • muscles

48
Aging and Chronic Conditions
Source CDC National Health Interview Survey 2006
49
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

50
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

51
Exercise Recommendations for People with CV
Disease
52
Exercise Recommendations for People with
Hypertension
53
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.
54
Type 2 Diabetes Mellitus
  • Impaired glucose metabolism
  • Predisposition to DM
  • Reductions in muscle mass
  • Insulin Sensitivity
  • Associated with obesity

55
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
56
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

57
Hypoglycemia- Signs/Symptoms
  • Trembling
  • Palpitations
  • Weakness
  • Sweating
  • Intense hunger
  • Confusion, altered behavior, drowsiness or coma
    may occur if the blood glucose becomes very low.

58
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

59
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

60
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.

61
Diabetes Exercise Benefits
  • Improved glucose management
  • Weight control
  • Improved lipid profiles
  • Reduction of hypertension
  • Increased work capacity

62
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

63
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

64
Diabetes Chronic Exercise
  • Lower resting and submaximal HR
  • Increased stroke volume
  • Enhanced O2 extraction
  • Lower resting and exercise blood pressure

65
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

66
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

67
Diabetes Exercise
  • Exercise Intensity
  • Heart Rate (HR)
  • 60-80 of max heart rate
  • Rating of Perceived Exertion (RPE)
  • 10-13

68
Diabetes Exercise
  • Program Duration
  • Begin 10-15 minutes
  • Progress to minimum of 30-60 minutes
  • Goal is to achieve appropriate energy expenditure

69
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

70
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

71
Diabetes Resistance Training
  • PRECAUTIONS
  • Hypertension
  • Limit sustained isometrics
  • Retinopathy
  • Appropriate supervision is necessary
  • Cardiovascular complications
  • Monitor patients HR, BP, symptoms

72
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.

73
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)

75
Monofilament Testing
  • Lab time!

76
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

79
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

80
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

81
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

82
Exercise Recommendations for People with Arthritis
83
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

84
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.

85
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
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