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Help, I’m Getting Older! Medical Concerns for the Aging Athlete Gregory R. Czarnecki, D.O. Internal & Sports Medicine Hartford Healthcare Medical Group Glastonbury, CT President, Connecticut Osteopathic Medical Society Interim DME, UConn Osteopathic Internal Medicine Residency Connecticut Podiatric Medical Association, April 11, 2015 Goals Review and understand benefits of exercise throughout one’s lifespan and adaptive changes that occur with aging. Increase awareness of Exercise is Medicine Learn tools for exercise prescription. Review current exercise guidelines in the adult population Understand the role and recommendations for exercise testing. Highlight special considerations (medications, treatments, etc.) in the aging athlete. The ACSM guidelines for physical activity (exercise) are: 1. 2. 3. 4. 5. 20 minutes per day 3 days per week. 30 minutes per day 3 days per week. 20 minutes per day 5 days per week. 30 minutes per day 5 days per week. 30 minutes per day most days of the week. Strength training is incorporated into these recommendations. What is/are the recommended minimum day(s) or sessions for incorporating strength training? 1. 2. 3. 4. 5. 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week At what age range does physiologic (adaptive) muscle hypertrophy cease despite strength training? a. 60-69 b. 70-79 c. 80-89 d. 90-99 e. No age limit Who’s an aging athlete? http://healthjournal.upmc.com/0605/SeniorGames.htm www.killington.com/winter/mountain/inter active_gallery/daily_photos/pictureoftheday 443/@@popup Masters Athletes Masters level = age 35 + 5 year-increments on competitive groups, includes 100+ category. National Senior Games (Senior Olympics) = age 50 and up. Masters swimming = age 19+ More Master’s Levels Master’s cycling: 30+ or 35+ USA Track and Field: 30+; 40 for distance running Medical concerns Performance decline Medical co-morbidities Injury prevention Injury/Resection of 15-34% of the meniscus => increased contact pressure by up to 350% Medication risks Where are you headed? i238.photobucket.com/.../mirounrelnew.jpg Changes with Aging Cardio Pulm MS Neuro Metabolic Cellular http://www.dailygalaxy.com/my_weblog/2007/09/end-of-aging.html Cardiovascular Changes ↓HRmax 6-10 bpm/decade ↑BP, PVR during max exercise ↓VO2 Max (maximal oxygen consumption) ↓5-15% per decade after age 25 Pulmonary Changes ↓VC ↑RV ↓ Elasticity Translates to increases in work of breathing, perceived exertion Musculoskeletal Changes ↓muscle mass, aka - sarcopenia– greater loss of type 2 fibers Peak muscle mass @ age 30 Age 50 => decline ↓bone mass (0.5% per year after age 40), ↓tensile strength of tendons/ligaments ↑muscle stiffness Neurologic Changes ↓ balance ↓ coordination ↓ reaction time autonomic dysfunction ↓thirst mechanism Impaired thermoregulation Metabolic Changes ↑cholesterol ↓ metabolic rate Weight gain Central obesity Cellular changes Mitochondrial dysfunction Defects in electron transport chain Uncoupling of oxidative phosphorylation due to hydrogen leak across inner membrane Leading to decreased ATP + apoptosis. Selective preference to type 2 muscle fibers. The Descent… O’Connor, Just the facts Sedentary lifestyle associated with work, family, acute/chronic medical conditions. Give rebirth to exercise in one’s daily life. ? Average American Family? How much is preventable with exercise? What’s the point? Routine exercise associated with prevention/reduction of medical conditions including: CAD HTN Obesity DM-2 Dyslipidemia Osteoporosis Anxiety/depression Cancer Constipation! Getting Started – the history What is planned activity/activities? Current level of training? Vision impairments? (cataracts, glaucoma) Hearing loss? Chest pain, exertional dyspnea, palpitations, syncope? Signs of neurologic/autonomic dysfunction? Musculoskeletal history Co-morbidities Medications Getting Started - exam Blood pressure; orthostatics if history suggestive Cardiac, lung, carotid auscultation Femoral pulses Neuro – coordination, balance, proprioception, strength, sensation Musculoskeletal – joint deformities, effusions, ROM, biomechanics, FEET. Skin integrity Exercise is Medicine Campaign launched by the American College of Sports Medicine (ACSM) in collaboration with the American Medical Association (AMA). For physicians of all specialties Prescribing Exercise Set realistic goals and expectations. What activities does your patient enjoy? What limitations/barriers to exercise exist? Include cardiovascular (aerobic), strength training, flexibility and proprioceptive/balance training. Mode, intensity, duration, frequency. Things to discuss Warm up, cool down Gradual changes in intensity/duration/frequency Goal = most days of week for moderateintensity exercise ≥30 min; 2 or more days per week for strength/resistance training (limit increase to 5%/week) Allow recovery time to avoid common overuse injuries Possible medication interactions, hydration, nutrition, patient’s concerns/fears. Exercise Testing Formal exercise testing remains controversial for pre-participation in exercise. Yield greatest in symptomatic adults and intermediate pre-test probability. Questions for the patient should address planned activity and goals. If moderate activity, testing “not necessary,” but recommended if vigorous. ACSM’s guidelines for exercise testing prior: For any high risk pt planning moderate or vigorous exercise (HR=cardio-pulm disease or suggestive symptoms, DM, renal, hepatic dysfn) For moderate risk pt (M>45, F>55 OR with 2/more risk factors - +Fam hx, +tob, HTN, ↑chol, obesity, sedentary lifestyle, fasting BG >110 x2 measurements) – only recommended for vigorous exercise (>6 mets) Not necessary in low risk group (asymptomatic, M<45, F<55) Intensity Grading http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_I ntensity_table_2_1.pdf MET – ratio of exercise metabolic rate 1 MET = energy expenditure for sitting quietly; 3.5ml O2 uptake/kg/min. Will vary by age Grading Intensity As percentage of max HR (220-age +/- 10 BPM): 50-63% = light 64-76% = moderate 77-93% = vigorous 90-114 in 40yo 115-137 138-167 As percentage of Heart Rate Reserve (HRmax - resting HR): 20-39% = light 40-59% = moderate 60-84% = vigorous 84-107; assume rHR 60 108-131 132-161 Talk Test Light – able to sing during your activity Moderate – able to hold conversation during activity Vigorous – winded/breathless – can’t carry-on conversation during exercise. Now that they’re exercising… Doc, it hurts me when I do this… Sure, it hurts, but I just deal with it… I stopped _______ because I hurt my ______. Can I still run, bike, swim, etc.? Words of caution Overuse injuries account for majority of musculoskeletal complaints in the adult athlete – 70% of injuries in experienced athletes over 60. Training errors increase risk of injury. Biomechanics, training surfaces, recovery time are all important considerations in injury prevention. Common “Overuse” Injuries Rotator cuff disorders: tendonitis/bursitis/impingement Golfer’s elbow Tennis elbow Carpal Tunnel Syndrome Jumper’s knee Runner’s knee ITB friction syndrome Achilles tendonitis Plantar fasciitis Overuse or Dysfunctional Use? Why do baseball pitchers commonly develop shoulder and elbow problems? Maybe it’s both… How can we help keep these athletes “going strong?” Activity modification; cross-training Correct biomechanics OMT Physical Therapy Medications ↑ROM Strengthening ↑ Proprioception NSAIDs, Tylenol Opiates? Injections Surgery? Common findings in Tendinosis include: a. Inflammatory cells including neutrophils b. Avascularity c. Tendon thinning d. All of the above e. None of the above Tendinosis/Tendonopathies Focal area of degeneration due to incomplete healing, repetitive loading/stress, tissue hypoxia. Lack of inflammatory mediators on biopsy. Neovessel formation. Tendon thickening. Tendinosis Alfredson, AMSSM 18th Annual Meeting Emerging Injections Prolotherapy Sclerotherapy Autologous Blood Platelet-rich Plasma Stem Cells What about steroids? Osteoarthritis OA affects 15% of US population. Over 70% over age 70 will have x-ray evidence of OA. Clinical symptoms are widely varied. Joint stiffness +/- effusion; decreased active and passive ROM Physical Activity and OA Does exercise increase your risk for OA? Moderate mechanical loading is necessary to maintain healthy articular cartilage. (Griffin) A disruption in the joint homeostasis can begin the shift to degradative process. Sports after joint replacement? Concerns: hardware failure, joint dislocation, periprosthetic fracture Low impact recommended (level C) Activities will vary based on experience prior to joint replacement and anticipated level of impact Contact sports and high-impact activities not recommended (level C) Medication Considerations ? Side-effects that may impair sport or put athlete at risk? NSAIDS with dehydration ACE with NSAID/dehydration Beta-blocker on HR/performance Diuretics Antibiotics – Quinolones Insulin/sulfonylureas Steroids Antihistamines It is never too late to start Benefits of strength training seen even in the frail elderly. Improved get-up-and-go Improved spontaneous activity Reduced falls and obstacle avoidance For Your Aging Athletes: Beware of potential overuse patterns Correct biomechanics Judicious use of injections Goals will change Activities may change Medications: 1st do no harm Exercise IS medicine Conclusion Multitude of risk reductions through exercise. Encourage exercise most days of week for moderate-intensity exercise ≥30 min; 2 or more days per week for strength/resistance training. Exercise prescription should be integral to patient care. Mode, frequency, intensity, duration. Cardiovascular, strength, proprioception, flexibility. Overuse injuries common in the mature athlete. Patient education is crucial. Treatments aim to improve biomechanics (joint forces, muscle balance, and external forces), reduce pain, and allow preservation of function, maintaining quality of life. Stay fit, stay young. Questions? References: Bartz RL, Laudicina L, Osteoarthritis after sports knee injuries. Clin Sports Med 24 (2005) 39-45. Bishop JY, Flatlow EL. Management of glenohumeral arthritis: a role for arthroscopy? Orthop Clin N Am, 34 (2003) 559-566. Brill PA, Probst JC et al., Clinical Feasibility of a free-weight strength-training program for older adults. The Journal of the American Board of Family Practice. v11(6), Nov/Dec 1998: 445-451. Clegg DO et al., Glucosamine, Chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med; 354n8, Feb 23, 2006: 795-808. Brophy RH, Marx RG. Osteoarthritis following shoulder instability. Clin Sports Med, 24 (2005) 47-56. Gorsline RT, Kaeding CC. The use of NSAIDs and nutritional supplements in athletes with osteoarthritis: prevalence, benefits, and consequences. Clin Sports Med 24 (2005) 71-82. Hochberg MC. Nutritional supplements for knee osteoarthritis – still no resolution. N Engl J Med; 354n8, Feb 23, 2006: 858-860. Mellion et al. Team Physician’s Handbook, 3rd edition, Hanley & Belfus, Inc. 2002. Montellese P, Dancy T. The acromioclavicular joint. Prim Care Clin Office Pract, 31 (2004) 857-866. Snibbe JC, Gambardella RA. Use of injections for osteoarthritis in joints and sports activity. Clin Sports Med 24 (2005): 83-91 Williams CM. “The geriatric athlete.” Sports Medicine: Just the Facts, edited by Francis G. O’Connor et al., McGraw-Hill Medical Publishing Division, NY, 2005. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician - 15-FEB-2008; 77(4): 453-60 Mazzeo RS, Cavanagh P, et al. ACSM Position Stand: Exercise and physical activity for older adults. Medicine & Science in Sports and Exercise, v30(6):992-1008, June 1998. Griffin TM, Guilak F. The role of mechanical loading in the onset and progression of osteoarthritis. Exerc. Sport Sci. Rev., Vol. 33, No. 4:195-200, 2005. Images in this presentation obtained via www.google.com – images (unless otherwise specified) More References: Nicholls MA, Selby JB, Hartford JM. Athletic activity after total joint replacement. Orthopedics, v25, No. 11:1283-7, November 2002. Bellamy N, Campbell J, et al., Intraarticular corticosteroid for treatment of osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons, Ltd. Issue 3, 2007. Bellamy N, Campbell J, et al., Viscosupplementation for the treatment of osteoarthritis of the knee (Review). The Cochrane Collaboration, Wiley & Sons, Ltd. Issue 3, 2007. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997), National Academies Press. Edelson R, Burks RT, Bloebaum RD. Short-term effects of knee washout for osteoarthritis. American Journal of Sports Medicine, v23, No. 3: 345-349, May 1995. Moseley JB, Wray NP, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial results of a pilot study. American Journal of Sports Medicine, v24, No. 1: 28-34, Jan 1996. Moseley JB, O’Malley K, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM, v347, No. 2: 81-88, July 11, 2002. Haskell WL, Lee IM, et al. Physical activity and public health: updated recommendations for adults from the American College of Sports Medicine and the American Heart Association. Circulation 116:1081-1093, 2007. American College of Sports Medicine, ACSM’s Guidelines for exercise testing and prescription, 7th edition, Lippincott Williams & Wilkins, 2006.