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Musculoskeletal Problems of the Obese and the Elderly (or “How do we prevent functional decline in the two fastest growing segments of our population?”) Rochelle M. Nolte, MD CDR USPHS Obesity Epidemic NHANES Adult Obesity 80% 70% 66% Overwt 60% 50% 40% 31% Obese 30% 20% 10% 1962 1972 1978 1992 Hedley et al, JAMA 291(23) 2004 2002 NHANES Prevalence of Overweight Youth Ages 2-19 National Center for Health Statistics, Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004 Exercise (Activity) Prescription for Adults New Hopkins Projections By 2015: • 75% of adults overwt or obese • 41% will be frankly obese Epidemiologic Reviews. 2007. 29(1): 6-28 Epidemiology of Geriatrics • 2009: – 39 million seniors – 14% of the US population – 37% of health care costs • 2030 – 70 million seniors – 20% of the US population – 50% of health care costs Obesity Epidemic Modifiable Risk Factors “Actual Causes of Death” Mokdad, JAMA, 2004 “Dis-fitness” Cycle Age Related Change New or Existing Illness Increased Disease Risk Illness Risk Factors Reduced Physical Activity Physiologic changes with age • Height declines appx 1cm/decade /p 50 • More accelerated for women /p 60 • Wt increases 30’s 40’s 50’s (visceral fat) • Wt stabilizes 50’s -70’s, then decreases • Fat free mass decreases 2-3%/decade • RMR, muscle protein synthesis rate, fat oxidation all decrease Physiologic changes with age • Perception of precision movements may be altered • Sensory, motor, and cognitive changes alter biomechanics – How much is age v. disease process? • Flexibility and joint ROM decreases • Muscle and tendon elasticity decreased Physiologic changes with age • Isometric, concentric, and eccentric strength decline after age 30-40 – decline accelerates after age 65-70 • Power declines faster than strength • Muscle endurance declines with age • Reaction time increases • Simple and repetitive motions slow Physiologic changes with age • Decrease in muscle mass – Loss of mass and contractile strength – Strength loss exceeds mass loss • Estimate a 30% loss of mass from age 30-80 • Estimate a 60% loss of strength from age 30-80 – Exercise improves both strength and mass – Decline in GH, IGF-1, and sex hormones – Greater loss of fast-twitch (type II) Physiologic changes with age • Bone density – Bone is dynamic tissue • Constantly remodeling in equilibrium – Bone mass peaks in 20’s – Thought to decrease 0.5% or more q yr /p 40 – Women lose 2-5% q yr starting 2-3 yr before menopause and lasting 5-10 years Osteoporosis • Low bone mass • Microarchitechtrual • • deterioration Enhanced bone fragility Increased risk of fracture Osteoporosis epidemiology • 10 million people in US • 34 million with • • osteopenia in US About 2 million osteoporotic fx/year in US After age 65 – 1 in 2 women will sustain an osteoporotic fx – 1 in 5 men will sustain an osteoporotic fx Osteoporosis costs • 2.5 million physician • • • visits per year >400,000 hospital admissions per year >180,000 nursing home admissions Projected annual direct costs $25 billion Hip Fractures • • • • • • • 300,000 hip fractures per year in US Over ½ occur in >80 year old patients ½ of hip fracture patients go to NH ½ d/c’d to NH become long-term resident One year mortality is 20%-24% 60% never return to baseline function > ½ women >75 prefer death to hip fx Osteoporosis Management • Goals of osteoporosis management – Prevention of fracture – Stabilization or increase of bone mass – Relief of sx of fx and skeletal deformity – Maximization of physical function Osteoporosis Prevention Osteoporosis Prevention • Adequate caloric • intake Exercise – Weight-bearing – Swimming – Intermittent dynamic loading • Avoid tobacco • Avoid/decrease alcohol intake Osteoporosis Prevention • 92% of total bone • • mass by age 18 99% by age 26 Bone mass not obtained during this time cannot be made up later Osteoporosis prevention • Different sites • • mature at different ages Peak bone mass complete by age 16 in the femoral neck Later in lumbar spine and distal radius Definition of Osteoarthritis Disease of the joints characterized by: – Progressive articular – – – cartilage loss New subchondral bone formation New bone and cartilage formation at joint margins Low level synovitis & PAIN! Clinical Diagnosis – Joint Pain – Typical Pain Pattern – Xray Findings – Standing films – AP with 30 deg flexion – No Sign of Zebras Etiology of Osteoarthritis • Growth of cartilage and bone at the joint margins leads to osteophytes which can restrict movement • Chronic synovitis and thickening of the joint capsule further restrict movement • Periarticular muscle wasting is common and plays a major role in sx and disability Symptoms of osteoarthritis • PAIN (Articular cartilage is aneural) – OA pain is not from the cartilage • Stretching of nerve ending in periosteum covering osteophytes • Microfractures in subchondral bone • Stretching of joint capsule • Synovitis • Ligament stretching or muscle pain • STIFFNESS (esp. after inactivity) Epidemiology of OA • OA of the knee is the leading cause of chronic disability in the elderly in developed countries – Estimated $60 billion economic impact in US – Decreased quality of life for > 20 million Americans • In patients over the age of 55: – Hip OA is more common in men – IP and 1st MCP OA is more common in women – Knee OA (with sx) is more common in women Epidemiology of OA • In patients under the age of 55: – Joint distribution of OA is equal between men and women • Due to genetics or joint usage????? – Mother and sister of a woman with DIP OA are 2 & 3 X more likely to have the same – Racial differences in prevalence and pattern of joint involvement also point to genetic basis Epidemiology of OA • Age is the most • • • powerful risk factor for OA Women < 45 years of age: 2% with OA Women 45-64: 30% with OA Women >65: 68% with OA Epidemiology of OA • Disability in subjects with knee OA – More strongly associated with QUADRICEPS WEAKNESS – than with joint pain or radiographic severity • Demographics associated with increased likelihood of being symptomatic: women, unemployed, divorced, poor social support Which is higher risk for OA? Strong Risk Factor for OA Obesity • 10 lb increase in weight = 40% increase in knee osteoarthritis • Larger effect in women (Felson et. al. Ann Int Med 1992, Framingham Heart Cohort data) Epidemiology of OA • Obesity is a risk factor for knee (and hand) osteoarthritis – In the highest quintile of BMI • Relative risk of developing OA in the next 36 years was 1.5 for men and 2.1 for women • For SEVERE OA, the RR rose to 1.9 for men and 3.2 for women – Weight loss of 5kg was associated with a 50% reduction in the odds of developing OA Strong Risk Factor for OA Joint Trauma Moderate Risk Factor for OA Certain Vocational Activities Jobs requiring repetitive knee bending/moderate activity predict higher rates of osteoarthritis Felson et al Annals of Int Med 1992 Zhang W et al. Osteoarthritis Research Society International recommendations for the management of hip and knee OA, Pt II: OARSI evidencebased, expert consensus guidelines. Osteoarth and Cartilage 2008; 16:137-62. Lose Weight if Overweight/Obese (LOE 1a) • 10 lb / 40% rule • Break that vicious • cycle: Team approach is critical Pain and stiffness Disuse Weight Gain Educate Your Patients(LOE 1a) • Objectives of • • • • • treatment Changes in lifestyle Importance of exercise Pacing yourself Weight reduction if needed Unloading of joints Management/Treatment of OA • Goals – Educate patient about disease and management – Improve function – Control pain – Alter disease process and its consequences • (we just don’t know that much about biomarkers and disease-modifying drugs just yet……) Management/Treatment of OA • No known cure for OA • HOWEVER – Impaired muscle function – Reduced fitness • Affect pain and dysfunction • Are amenable to therapeutic exercise Treatment of Osteoarthritis Overview • Nonpharmocologic Measures – Education, Weight loss, Exercise, & Bracing • Pharmacologic Measures – Analgesics, Glucosamine, Injectables • Alternative Therapies – Accupuncture, Dietary Supplementation • Surgery Exercise is EXCELLENT Treatment for OA Passive ROM Active ROM Isometric Strength (tighten muscle w/o motion) Aerobic Conditioning Isotonic Strengthening Goal Activity Shoulder Buddy Stretch Codmans Finger Wall Climb Wheelchair aerobics Wall presses Arm ergometer Swimming Rotator Cuff Theraband Evidence for Benefit from Exercise in Treating OA • Regular aerobic walking for knee OA – LOE 1a for knee OA – LOE IV for hip OA • Home-based quad strength exercises – LOE 1a for knee OA – LOE IV for hip OA • Water-based exercise for hip OA – LOE 1b What Kinds of Exercise are OK? • Little evidence-based recommendations • Common sense advice – Avoid further trauma – Wise to avoid high-risk activities – Listen to your joints X Prevention of OA Prevention of Osteoarthritis • Weight reduction (IA) • Recreational • • • exercise/sports (IA) Maintain physical fitness (IB) Avoid obesity (IB) Participate in adequate physical exercise (IB) Prevention of OA • Current studies – Isokinetic exercise for improving knee flexor and extensor muscles in healthy adults to assess safety and effectiveness – Will also assess in adults with neurological, orthopedic, and rheumatological conditions • Currently < 1% of money spent on Osteoarthritis is spent on research Overview Physicians, their Patients & Exercise • 47% of primary care physicians include an exercise history as part of their initial examination (Self Report) • Only 13% of patients report physicians giving advice about exercise • Physically active physicians are more likely to discuss exercise with their patients Eakin, Am J Prev Med, 2005 Abramson, Clin J Sport Med, 2000 Walsh, Am J Prev Med, 1999 Exercise (Activity) Prescription for Kids Train Up A Child… • 25% of obese preschoolers become obese • 80% of obese 14 year-olds remain obese • 70% of obese children who lose weight will maintain that loss as adults • BMI at 18 years stronger predictor of DM2 than at ANY other age Allen, J Pediatr, 2007 Flegal, Physiol Behav, 2005 “Train up a child in the way he should go: and when he is old, he will not depart from it.” - Proverbs 22:6 Exercise (Activity) Prescription for Kids Exercise Works for Children Factors that Alter Body Fat, Body Mass, and FatFree Mass in Pediatric Obesity LeMura LM, Mazeikas MT • Meta-analysis of 30 RCT • Ages: 5 - 17 • Pre & post intervention body composition –Exercise “highly effective” treatment for pediatric obesity…low intensity, long duration exercise –Aerobic exercise combined with resistance training Med Sci Sports Exerc, 2002 Exercise (Activity) Prescription for Kids Why Exercise Works in Kids Exercise (Activity) Prescription for Kids Guidelines for Pediatric Exercise 60 minutes of activity each day (minimum) Moderate-to-vigorous activity Can accumulate in small bouts, wide variety of sports & activities - American Academy of Pediatrics - American College of Sports Medicine Relative Risk of Total Mortality Good News forPrescription Your Patients Exercise (Activity) for Adults Adults, Exercise & Mortality: Fit (regular exercise) 5.7 Unfit (no exercise) Good News for Your Patients 3.8 3.2 1.9 1.4 1.0 Normal Overweight (BMI 25-30) Weight Obese (BMI 31- 36) (BMI 18 – 24) From Lee, Am J Clin Nutr, Mar 1999 Exercise (Activity) Prescription for Older Adults Fitness and Functional Status Normal Healthy Adults Near Frail Function THRESHOLD Poor Frail Adults Low Strength High Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15 Exercise (Activity) Prescription for Older Adults Exercise and Aerobic Capacity Active VO2 Max Active + Aging Reduced Activity + Weight Gain Sedentary Exercise Intervention 20 80 Age Exercise (Activity) Prescription for Older Adults Strength: Use It & Lose Less of it Losses •Aerobic Sedentary people lose Activity • large amounts of muscle NOT mass IS (20-40%) 6% sufficient per decade loss of Lean Body Mass (LBM) to stop this loss! Gains • Lean body mass • • increases 1-3 kg Resistance training improves strength by a range of 40-150% Muscle fiber area 10-30% BOTTOM LINES: 1. MUSCLE STRENGTHENING EXERCISES REQUIRED 2. MUST INCLUDE BALANCE+FLEXIBILITY IN OLDER ADULTS 3. FEWER FALLS, FRACTURES, DISUSE, FRAILTY AND SARCOPENIA Exercise (Activity) Prescription for Older Adults What’s Different for Older Adults? 2009 ACSM Guidelines For Older Adults • Endurance – Frequency • Daily – Duration • Moderate – 30-60min/d total • Vigorous – 20min/d continuous – Type • Walk, aquatic, cycle • Resistance – Frequency • 2 days per week – Intensity • 5-6 or 7-8 out of 10 – Type • Progressive weight training or weightbearing calisthenics • 8-12 reps of 8-10 ex’s Exercise (Activity) Prescription for Older Adults What’s Different for Older Adults? 2009 ACSM Guidelines For Older Adults • Flexibility – Frequency • At least 2 days/week – Intensity • 5-6/10 (moderate) – Type • Any activity that maintains or increases flexibility. Do static rather than ballistic • Balance exercises – No specific recommendations 2/2 lack of evidence – Recommend using increasingly difficult postures (two-legged, tandem, one-legged, eyes closed, etc) Exercise (Activity) Prescription for Older Adults A little more about balance Static Dynamic Intensity=sensory or time Exercise (Activity) Prescription for Older Adults Tool #5 http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A50894CA4E537D4C/0/NIA_Exercise_Guide407.pdf Summary • Functional decline and • disability can be managed by physical activity Physical activity begun in childhood can prevent obesity and frailty in adulthood Questions or comments?