geriatric considerations for exercise prescription

8/9/2019 Geriatric Considerations for Exercise Prescription

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Geriatric Considerations forExercise Prescription

Pennsylvania State Meeting

October 26-27, 2013

Bill Staples PT, DHS, DPT, GCS, CEEAA

President, Section on Geriatrics

Effect of Exercise on Health

Posing the question does exercise

prevent or treat disease in olderpersons? is analogous to asking

does medication prevent or treat

disease in older persons?

Fiatarone & Singh, Journal of Gerontology, 2002, Vol. 57ANo. 5

Objectives

Identify the factors that affectexercise in the elderly

Identify difficulties inherent indescribing patients by theirchronological age

Compare and contrast normal aging

Describe potential impact of exerciseon the aging process

Objectives

Describe age-related changes thataffect exercise

Describe special considerations forsenior clients

Describe exercise training guidelinesand additional precautions when

managing the care of older adults

Baby Boomer Exercise

When youre young, you challengeyour body. When youre old your

body challenges you!Unknown

http://tinyurl.com/2u3pbz

Introduction

Rehab of older adults has evolvedinto an area of specialty practice

Based on evidence that aging causesthe body to respond differently to:

Injury

Disease

Exercise
http://tinyurl.com/2u3pbzhttp://tinyurl.com/2u3pbzhttp://tinyurl.com/2u3pbz


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Introduction

Considerable growth, now and in thefuture, of the older population

Tremendous increase in individualsreaching old age

The definition of old age ischanging due to: Life expectancy

Medical care

Social practices

Chronological AgeDescriptions

Middle age 45-64 years

Young old 65-74 years

Older 75-84 years

Old-old 85-99 years

Oldest-old 100+ years

Aging: Impact of Rehabilitation

No perfect definition of the agingprocess

Aging refers to a process occurringin living organisms

With aging comes an increasedprobability of: Illness and disease

Chronic debilitating condition

Loss of function


Elderly often contend with multipleconditions (co-morbidities)

Physical injury and impairments areamong the most prevalent healthproblems of aging

mobility independence

disability


Disability leads to increased* : Mortality

Hospitalizations

SNF placement

Use of informal and formal home healthcare

Cost

* Gill et al, 2003


Rehab programs should be designedto:

Restore function and mobility

Decrease pain (acute and chronic)

Decrease disability

Prolong independence

Improve quality of life


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Aging

Is NOT homogeneous

Theories of aging differ Genetic

Damage

Imbalance

Is aging an illness?

Death in America

50% of all deaths in U.S. due to

some sort of heart disease 70% deaths from heart disease

result from a stroke or heart attack

Much of heart disease is preventablewith healthy lifestyle includingexercise

Aging

Process differs among individuals

Variability and health status muchgreater in older populations

Many adults are capable of highdegrees of activity and functionalabilities

Others display physiologic age wellbeyond chronological age due tochronic disease process

Aging

Should NOT use chronological age todetermine potential for recovery orappropriateness for rehabilitation!

Comprehensive evaluation is basisfor treatment

Clinician must recognize potential on

the individuals ability to participatein rehab

Biological Aging Changes

Normal aging changes: 0 functionalimpairments or dysfunction in absence ofpathology

Maximal work capacity- gradual decline,not noticed until critical capacity lost

Women especially susceptible due to smallerinitial muscle mass

Impacts functional status 10 years before men

Physiologic Reserve Over time

Loss of adaptability Development of impairment

Functional limitations

Disability

Loss of reserve function anddefined as frailty

Frailty Failure

Regular exercise proven toprevent/reduce functional declineslinked to aging


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Exercise Capacity-Vicious Cycle

Usual aging- decreased

exercise capacityIncreased perception

of effort/injury

Avoidance of activityExacerbation of age-

related/disuse

declines

Normal vs. Pathological Aging

Normal aging changes occur as a

result of passage of time and are freeof pathological conditions i.e.

Presbyopia (farsightedness)

Presbycusis (hard of hearing)

Menopause

Normal vs. Pathological Aging

Pathological Osteoarthritis

Osteoporosis

CAD

Sarcopenia

Many conditions can be prevented orlessened with:

Early and effective intervention Appropriate patient education

Follow through

Physical Activity

However: 66% of people over 75 do nothing in

terms of physical activity*

50% of people 65-74 do nothing

42% of people 45-64 do nothing

*Defined as 20 min. of exercise 3x/week*Mokdad et al, 2001

Good Health Habits Start inMiddle Age

Middle aged adults (45-64) that began Eating 5 servings fruit/veg per day Exercised 2 hours per week Kept weight down Did not smoke

Decreased risk of heart disease by 35%and death by 45%

Of 16,000 individuals, only 8.5% werefollowing these 4 guidelines at start of 6-year study. By the end, another 8.4% hadjoined. (still only 17%!)

King, D Amer J Med. 2007

Consequences of Inactivity*Hypokinetics

Deconditioning Accelerated

Loss of muscle mass & strength

Bone demineralization

Loss of neuromuscular control

Functional decline

Disuse accelerates the aging process

Heightened risk for falls

Hospitalization/SNF

*Gill et al 2004


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Cost of Sedentary Lifestyle

Estimated that U.S. could save $50Billion per year in SNF care alone ifseniors increased activity level*

*Janssen,

2004

Required Tasks of CommunityDwelling Older Adults*

Walk a minimum of 1000 ft per errand

Often make 2-3 trips per day Carry packages avg. 6.7 lbs while walking Frequently encounter stairs, curbs, slopes Engage in frequent postural transitions

Change direction, look up, reach up, movebackwards, sharp turn

Multi-tasking So make rehab functional

* Shumway-Cook et al 2002

Exercise and Health

Answer makes sense only whenexercise is described in terms of:

Modality

Dose (frequency, intensity)

Duration of exposure

Compliance with prescription

In relation to disease, syndrome,biological aging

Myths about aging andphysical activity

High intensity is not for olderpersons

Resistive exercise will injure olderpersons

Older persons do not have the samefunctional demands as younger

persons Older persons will accommodate

rather than challenge

Exercise??

If exercise werea pill wouldeveryone takeit?

Exercise and Health

Answer makes sense only whenexercise is described in terms of:

Modality

Dose (frequency, intensity)

Duration of exposure

Compliance with prescription

In relation to disease, syndrome,biological aging


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Exercise screening

Pre-screened by MD to r/o CVD, ASHD

ACSM: Stress test men >45, women >55

or known CAD, or 2 risk factors HTN, smoking, obesity, HDL, sedentary

lifestyle, family hx of CAD, DM, knownpulmonary disease

PT Physical limitations (osteoporosis)

Goals (fitness vs. senior Olympics)

Areas of interest (gardening, walking etc.)

Endurance Training

Role of aerobic exercise

Builds endurance

Necessary for function, ADLs

Lowers serum triglycerides

Raises HDLs

Lowers systolic and diastolic BP

Lowers blood glucose levels

Cardiovascular Exercise SlowsBiological Changes of Aging Decrease CAD and stroke

Increases VO2 max

Lower fasting glucose and insulin levels

Lowers blood pressure

Adaptation to chronic activity can markedlyattenuate decrements in exercise capacitydue to aging

Exception: maximal heart rate

Cardiovascular Exercise SlowsBiological Changes of Aging

Improves HDL levels, lowerstriglycerides and total cholesterol

Improves body composition with 1-4%reduction in body fat

Lowers risk for falls

Increases strength,

reduces depression

Reduces risk for diabetes

Contraindications

Recent ECG change or MI

Unstable angina

Third degree heart block

Acute CHF

Uncontrolled HTN

Uncontrolled metabolic disease (DM)


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Relative contraindication

Cardiomyopathy

Valvular heart disease

Complex ventricular ectopy

Cardiac rhythm originating elsewherethan the SA node

Exercise prescriptionACSM (2006)

Intensity: Max HR assessed directly

thru age predicted (PMHR) PMHR = 220-age

Training range between 60-85% maxHR

May not be accurate in the elderly

Exercise prescription

Example70 y.o.

Goal 60-85% PMHR for training (THR)

PMHR = 220 -70 =150 bpm

150 x 85% = 128 bpm

150 x 60% = 90 bpm

Training range 90-128 bpm

Karvonen Method

Factors in resting heart rate (HRrest) to

calculate target heart rate (THR), using a range

of 5085% intensity:

THR = ((HRmax HRrest) % intensity) + HRrest

Example for someone age 70 with a HRmaxof

150 and a HRrestof 70:

50% Intensity:((150 70) 0.50) + 70 =110

bpm

85% Intensity: ((150 70) 0.85) + 70 = 138bpm

Exercise prescription

Tanaka et al 2001, hypothesized this mayunderestimate HR max in older adults

Alternative 2080.7 x age = HR max

2080.7 x 70 (age) = ?

20849 = 159

159 x .85 = 135

159 x .60 = 95

Target range 95-135 or slightly higher thanACSM 2006. ACSM 2010 uses this.

Monitoring Endurance

Heart rate can give you a goodmeasure BUT because older adultsmay have multiple disease processesongoing, in addition to medications,that it is best to use the RPE!

ACSM 2010 has different HRrecommendations for differentdiseases


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Anaerobic & Aerobic Exercise:Body Composition

Reduces adipose tissue, visceral fat Prevention & Rx of insulin resistance

syndrome, CVD, gall bladderdysfunction, Type 2 diabetes, types ofcancer, hypertension, stoke, OA

Frequency?

Range from 3-6 days /week to

2x/week Dependant on intensity and duration

Dependant on functional capacity

Duration

Ranges 20-60 min (most 20-30 min)

Does not include warm up or cooldown

Typically inversely related tointensity

May increase secondary to training

effect

Intensity

Cardiovascular

Moderate activity, total 30 min. perday (sessions as short as 10 min.),minimum 3 days/week

Requires 3-6 METS or 4-7 kcals/min

Examples of moderateintensity exercise

Fishingstand, castand walk along bank

Canoeing leisurely (2-4 mph)

Mowing the lawn withwalk behind powermower

Home repair, painting

Examples of moderateintensity exercise (cont.)

Walking briskly (3-4 mph)

Cycling leisurely (


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Strengthening of the OlderAdult

Principles of Intervention

Overload

Task specificity

Adapt vs. challenge

Benefits Prevent/slow strength decline

associated with aging

Decrease resting BP

Systolic 5mmHg,

Diastolic 3mmHg

Improved blood lipid profile

Weight loss

Improved wound healing

Increased bone density

Strengthening exercise

Strengthening may be the most criticalparameter of exercise and may besafer for people with

COPD (Simpson, 1992)

CHF (Pu et al, 2001; Levinger, 2005;)

Arthritis (Fransen et al 2002)

Than aerobic exercise. Especially inthe elderly.

Why

Because aerobic exercise is typicallya whole body (running, swimming) orminimally a half-body (cycling) whichrequires a great deal of effort andenergy for an inactive person.

Strengthening is performed one

muscle group at a time for shortduration.

Loss of strength leads to:

Functional limitations Gait speedLE power relationship

Bassey et al Clin ical Science 1992

Sit to standhip and leg strength

Gross et al Gait and Posture 1998

Fallsrisk of falls

Whipple et al JAGS 1987

ADLsindices

Hyatt et al Age and Ag ing 1990

Functional needs

Percentage strength requirements (legextension) in elderly

- 80% sit to stand

- 78% ascending stairs

- 88% descending stairs

- Frail 97% for sit to stand

Hortobagyi et al, J Gerentol Med Sci 2003


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Improved PsychologicalWell-being

Participation in physical activity:

More positive psychological attributes

Decreased incidence and prevalence ofdepression

Effects most noticeable in elderly withco-morbidities

Muscle Mass and Aging

Overloading muscle can largely avert

losses of muscle mass and strength Older men who lifted weight for 12-17

years > men 40-50 years younger(strength)

PRE of 3-6 months can increase musclestrength 40-150%, depending on subjectcharacteristics

Increase LBM (lean body mass) andmuscle fiber by 10-30%

Overload

Must be individualized and applies to:

Intensity

Duration

Frequency

Speed

Overload

Muscle strength is best developed byusing weights at levels that evokenearly maximal muscle tension withrelatively few repetitions

Any overload will result in strengthdevelopment, but higher intensity

effort at or near maximal effort willproduce a significantly greater effect

Intensity Older adults gain strength similarly to the

young

2-3x in strength in 3-4 months, 11.4% inmuscle area (Frontera 1990, Fiatarone 1994)

Strength with 60-100% 1RM training(McDonagh & Davis 1984)

Overwhelming evidence that low intensityproduces only modest gains in strength

With 80% 1RM significant gains even in thevery old (Fiatarone 1990, Evans 1999)

High intensity is safe even in the frail elderly

Relationship between strength& Function

Leg power is powerful predictor offunctional decline (Mazzeo et al 1990)

Walking speed and LE strengthstrong predictor for SNF placement(Guralink et al, 1994)

Loss of LE strength strongest singlepredictor for institutionalization(Judge et al 1996)


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Functional strength vs.Absolute strength

Often a deficit between the two

Functional strength isusable/integrated strength andincorporates velocity (force x velocity= power)

Increasing functional strengthincreases absolute strength

Training functionally meets the criteriaof specificity

Power & Function

Power was a better predictor of

physical function than isometric orisotonic strength (Bean et al 2003)

Leg power and self-report of physicalactivity had strongest correlationwith function (Foldvari 2000)

Frequency

ASCM: 2-3x/week

48 hour rest

Frequency/Duration/Intensity

2x/week gives 80-90% all strengthgains in untrained individuals(compared to up to 6x/week)

1 set as effective as 2 or 3 (with properintensity)

75-85% of 1 repetition max

8-12 reps (set must go to muscularfailure)

1 set saves time/better compliance

Task Specificity

Low resistance, high reps lead toendurance improvement (increase inmitochondria), but little change in strength(Moffroid & Whipple)

Important for function Multiplanar

Balance dominated

Asymmetrical

Velocity specific

Progressive

Eccentric (stairs, transfers)

Open or closed kinetic chain

Specificity

The more frail the more important

May be an alternative to intenseresistance (Page, 2003)


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Function

Specificity includes functional task

training Patient-centered (driven)

Meaningful

Progression

Try to keep load at 80% 1RM, 8-12reps Typically reps then load

McCartney 1996 suggests q 2weekeval

Early strength gains 10-15%/weekfirst 8 weeks may be due more toneural factors (Evans 1999, Bemben & Murphy 2001,

Phillips 2000)

Flexibility

ACSM recommends flexibilitytraining in older adults esp. shoulder,neck, upper & lower trunk, and hipregions.

Freland 2002 suggests hold for 60sec in older adults

How many exercises

Henry et al, 1998 looked at eldercompliance

Study looked at 2, 5, 8 exercises

2 ex group had best compliance

Injury

NO evidence to support higher rateof injury in elders with intensity(Rooks 1997, DiFabio 2001, Barnard 1999,Coleman 1996)

No adverse cardiac events with highresistance or Valsalva maneuver(Gordon 1995, McCartney 1996, Barnard1999, Vermill 1999, Kaelin 1999)

ACSM recommendations

5-10 minute warm-up includesstretching

30 min/day 3x/week Walking bicycling, swimming, running

Resistance training: use proper bodymechanics (quality not quantity)

Include large muscle groups

Cool-down with stretching


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Summary of strengthening forthe elderly

< 5 exercises

1-3x/week

1 set, 80% 1rep max

8-12 reps

Considerations for power, eccentricloading, closed/open chain, andfunctional/task training

Summary

Several major research studies have considered

the numerous factors that seem to predict the

need for eventual institutionalization, and LACK ofleg strength was found to be the single mostimportant predictor. Not blood pressure, or heartdisease, or diabetes, or arthritis but rather leg

strength. The lesson is clear. If you want to avoidthe nursing home, youd better take good care of

your legs.

Walter M Bortz II MD, Professor Stanford University

Fun facts for home ex

Soup can = lb

Can of tomatoes = 1lb

Jar peanut butter = 2 lbs

Bag of sugar = 5 lbs

Gallon of milk = 8 lbs

Chronic Diseases Amenable toExercise

Lack of exercise contributes to chronicdisease:

CVD

Stroke

Type 2 Diabetes

Obesity

Hypertension

OA Depression

Osteoporosis

Chronic Diseases Amenable toExercise

Exception: Progressive Diseases ofthe CNS

However:

Lack of physical activity exacerbatessymptoms and hastens loss offunctional mobility

Prevention of Chronic Disease andIncreased Longevity

Evidence that both healthy andchronically ill are candidates forpreventive exercise

Preventive ex appropriate for:

Community-dwelling

Institutionalized


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Adverse Effects of Exercise:Community, Institutional Settings

Rare

Associated withincrease in activitythat is too suddenand not gradual

Walking programs

Jogging programs

Weight lifting (veryrare)

Hamstrings, feet-most commonareas

Improper footwear

Adverse Effects of Exercise:Experienced Senior Athletes

Strains mostcommon

Hamstrings, calf,adductors,quads

Rotator cuffmuscles andtendons

Sprains Ankle

Knee

Fractures

Rare,associatedwith cycling

Adapt vs. Challenge

First responsibility is to make pt.safe

After that need to increase challenge

Remember what is needed forcommunity living

Strength changes

Early effects of ex:

Deconditioned-Neural Adaptation(therapy)

Long-term effects of ex:

Stronger-Hypertrophy (fitness)

Challenge with

Changing surfaces, uneven Obstacles

Impose activities with gait

Increase speed

Complex gait activities Heel/toe walking

Side-stepping, cross-overs, braiding

Tandem, backwards

Age-related Musculoskeletal

Changes that affect exercise

Muscle mass and strengthDecreases 30% between ages 60-90

Muscle fiber

Type II decreases 50% between 60-90,decreases 1% per year after age 30 with noexercise

Motor unitDecrease recruitment

Speed of movement

Decreases


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AgeRelated Changes

BoneTensile strength decreases, by age 70 a

decrease of 10-15% peak bone mass

Joint flexibilityReduced by 25-30% over the age 70

TendonsBecome less elastic and easier to tear

CartilageCollagen fibers increase cross-linkage

increasing the density of tissues reducingmovement

Cells

Rate of cellular division decreases

and becomes irregular The functional effectiveness of

enzymes within the cells does notdiminish with age

ELASTIN FIBERS

Dehydrate and increase crosslinkage with age

With the decreased elasticity, thefibers become rigid and frayed

Elastin fibers are ultimately replacedwith collagen fibers which decreases

mobility leading to shortening anddistortion of the tissue

GLYCOPROTEIN

Production and release ofglycoprotein results in dehydrationof tissues

Results in water content decrease inmuscles and tendons causingstiffness and rupture at less stress

than in younger ages

HYALURONIC ACID

Regulates the viscosity of tissues todecrease friction between tissuelayers with movement

As this secretion decreases, greaterfriction occurs resulting in the wearand tear between tissues

MUSCLE MASS Age Changes-

Sarcopenia

Between age 20 and 80: 20-30% muscle mass loss occurs

Greatest loss is between 50 -80 years of age

Muscle strength decreases 15% per decadebetween 50-70

Muscle strength decreases 30% between 70-80

Muscle mass is replaced by fat and collagendeposits resulting in no change in overall girthor volume measurements


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Muscle Fibers

As muscle fibers are lost, remaining

have to work harder to produce thesame force

Energy demands are raised resultingin fatigue and decreased endurance

Muscle fiber hypertrophy can occurin remaining fibers to increasestrength and function in even thevery old

Muscle Mass changes

Begins at age ~40: muscle mass will

decrease .5-1%/year over youth size By age 75: there is ~30-40% decrease

in muscle mass

As one ages there is an increase infat and a decrease in Muscle mass

Muscle vs. Fat

As muscle fibers are lost, fat isdeposited

Fat is not as metabolically active asmuscle

Older people gain weight easier thanyoung

CARTILAGE

The collagen in cartilage holds lesswater with age

The rate of collagen and elastinsynthesis decreases resulting indehydration and stiffness

fraying of cartilage.

CARTILAGE

With loss of movement, nutrition tocartilage is reduces resulting inthinning of cartilage and less abilityto dissipate forces across joints:Results in damage and frictionleading to tearing and fraying ofcartilage.

Age Changes

COLLAGEN CHANGES Main supportive protein in skin,

tendons, bone, cartilage, andconnective tissue

As we age, collagen becomes:

Irregular in shape

Less uniformed, less parallel in nature

Less mobile and slower to respond

cross linkages

nutrient movement thru tissues


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MUSCLE STRENGTH DECREASE

0

10

20

30

40

50

60

70

80

90

100

20 30 40 50 60 70 80 90

Normal change

Inactive

Review

Slow Twitch Type I muscles are

highly oxygenated and used in ADLs Fast Twitch Type II muscles are used

in more intense activity/resistancetraining

Motor Unit Level:

Decrease number of motor neurons

Decrease number of muscle fibers

Type II decreases more rapidly than TypeI

By age 75, there is more Type I fibersthan Type II, EVEN in Senior athletes

Typical Changes with Aging

Reduced flexibility in the lowerextremity joints

Decreased strength of the ankles,knees and hips

Less control of momentum

Decreased coordination and

Typical Changes with Aging

Decreased reflexes and increasedreaction time

Vision and sensory changes

Gait: slower speed, shorter step,narrow stride width

Balance Static:

Decreased as a result of decreasedankle strength

Dynamic: Decreased hip, ankle and stepping

strategies

Increase use of sway

Sway accounts for dynamic balancein 80 y.o 50 % more than in 40 y.o.


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Changes

All the changes combine to cause

impairments, functional limitationsand disability

FunctionalChanges

Posture:

Tight knee flexors Tight hip flexors

Increased lumbarlordosis

Tight Pectoralmuscles

Disease/Impairment Functional

limits/disability1.Decrease muscle strength

2.Decrease aerobic capacity

Deconditioning/falls

Deconditioning/falls

3.Vasomotor instability Syncope/dizziness

Baroreceptor insensitivity

4.Decrease total body H2O Dehydration

5. Decreased bone density Fracture risk

6. Fragile skin Wounds

7. Altered thirst, taste, smell Dehydration/malnutrition

Evidence supports the idea thatexercise can overcome some ofthese impairments and limitations!

Evidence Do strength/ROM relate to function?

YES!!!!! Musculoskeletal impairments (LE

strength and ROM), have a strongrelationship to function, especially inolder adults.Beissner KL, et al., Muscle Force and Range ofMotions as Predictors of Function in Older Adults.Phys Ther 2000. Jun;80(6):556-63.

Evidence

High intensity training.not just forthe young!

Average of 174% strength gains after8 weeks of high intensity training.This correlated improved mobility toresidents up to 96 years old!

High-Intensity Training in Nonagenarians. Effects on

Skeletal Muscle. Fiatarone M, et al., JAMA June

1990. 263(22):3029-34.


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Dynamic Exercise

Light work:

Works only Type I muscle fibers

Good for cardiac patients to start

Heavy work: Works Type II muscle fibers

First 2 weeks it is the neural componentthat is stimulated

Work at 80% of 1 rep max

Exercise and pathology

Osteoarthritis

TKA, THP Hip fracture

Osteoporosis

Frailty

Falls

Depression

Cardiovascular& pulmonary

CVA

Parkinsons

Skeletal Changes affectingExercise

OA: S&S

Stiffness

Joint pain

Crepitis

Inability to perform tasks

These can range from mild to severe.Pain with weight bearing

Palpable warmthBony enlargement

OA

The breakdown and eventual loss ofthe cartilage of one or more joints

Osteoarthritis occurs when thecartilage begins to fray, wear anddecay. In some cases, all thecartilage wears away leaving thebones of the joint to rub against eachother.

1 in 4 will develop symptomatic hipOA by age 85; women> men

Osteoarthritis Muscle weakness contributes to

symptoms (esp quads) 2ojoint reactionforces

Adults > 65 with chronic knee painexperience significant declines inbalance and LE strength over 30 monthperiod (Messier 2002)


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OA

OA afflicts 20 million

Obesity risk by almost 2x

THR, TKR on the rise

2004: 431,485 TKR; 225,900 THR

2015: 1.4M TKR; 600,000 THR

Medicare wont be able to pay for all

these!

New guidelines! Require exercise

Osteoarthritis

proprioception contributes to

development of OA Programs that incorporate

proprioceptive training withstrengthening decrease symptomsbetter

Osteoarthritis

Strongest quads show less kneecartilage loss (Amin 2006)

Patellar/shoulder taping: reduces painand allows increase in function (Quilty 2003, Hinman 2003)

Proper alignment is vital to PRE

Walking, jogging, recreational ex.

Does not risk of OA (Felson 2007) Obesity increases risk, but no extraincrease with exercise

OA PACE: People with Arthritis Can Exercise

Program

8 weeks: decreased pain & fatigue, increasein function (chair stand, 10# lift), increasedself-efficacy.

program that focuses on stretching,flexibility, balance, low impact aerobics, andstrength training exercises

CDC funded

http://www.cdc.gov/arthritis/funded_science/projects/pace-people-with-arthritis-can-exercise.htm

Differentiating age-related changesfrom osteoarthritic changes

Age Related Changes OA

Cartilage Decreasedhydration

Increasedhydration/swelling

SubchondralBone

Thinning Thickening

Synovium No Change Swelling

OA

The majority of persons over the ageof 65 and 80% over the age of 75have radiographic evidence of OA inat least one joint.

Can affect any joint; most commonlyseen in the hands and weight bearing

joints primarily the hips and knees.


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OA

The proper exercise program for the

elderly individual needs to considerany underlying pathology andmodified for successful results

Strengthening ex pain, function

Exercise in water has been shown toreduce pain.

Proper footwear pain

Exercise and OA

The risk of immobility is greater than

the risk of exercise and can lead tofurther aging changes.

Stronger muscles generally reducestress on the joint surfaces bycorrecting abnormal biomechanics

Exercise can initially increase thesymptoms but not cause an increasein the damage to the joints

Musculoskeletal dysfunction

Musculoskeletal agingChanges in cell andtissue functionSarcopeniaJoint laxity

Musculoskeletal underuse/misuseLack of exerciseAbnormal joint loading

Risk FactorsObesityJoint instability

Joint injuryGeneticsAnatomy

OSTEOARTHRITIS

TJR

Joint replacement is a last step when: Walking and stair climbing is difficult

Pain at rest and at night is not controlled

6-week presurgical ex program canimprove post-op status (TKA & THR);and reduce odds of requiring inpatientrehab stay

Rooks et al. Arthr i ts Rheum.2006.15;55(5):700-8.

Total Knee Arthroplasty

Quad strength 62% from pre-op. at1 month post-op

4%/day with immobilization

With high intensity ex can return topre-op in 2 months (Mizner 2005)

Evidence

Strengthen quads, including legpress if FWB

If significant quad insufficiencypresent, add e-stim for 1st6 weeks


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Gender Bias

Study from Canadian Med Asso c J.

March 2008

Orthopedic surgeons were 2x morelikely (33% to 67%) to recommend TKRto men over women with samesymptoms

Total Hip Arthroplasty

At one year 10-18% strength deficit

around hip (Trudelle-Jackson 2004)

Hip abductor strength directly relatedto return to home, risk for falls,function, gait status

Hip Fracture Hip Fracture 75% fail to return to previous level (Weinrich

2004)

At 2 months post: (Magaziner 2000)

98% had some dependency walking 10 feet

At 6 months post: (Magaziner 2003)

Only 8% climbed a flight of stairs

15% could walk across a room independently

6% could walk half a mile

At 24 months:

50% still had difficulty walking 10 feet independently

Hip Fracture Post: 53.3% fell, 62,5% of these fell >2x, 18%

sustained injuries requiring re-hospitalization

Predictors for fall 6 months post (Shumway-Cook 2005)

Previous use of assistive device 3.15x

Hx one fall prior to fx 8.77x

At 2 years post (Norton 2000)

4x more likely to be homebound

3x more likely dependent for ADLs

The more PT in hospital the better mobility 2months later. (Penrod 2004)

Hip Fracture

At 8-12 weeks moderate stabilityfrom bone callus is achieved Time to begin aggressive strengthening

and wean from assistive device(Weinrich 2004)

High intensity exercise for 3mo & 6mo have been shown to gait speed,distance, balance and function(Binder 2004, Mangione 2005)


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Issues for acute hip injury

SLR

Greater stress on hip joint with SLR thannormal unsupported gait (Strickland1992)

SLR = 3x body weight

Maximal isometric abduction greaterpeak pressures than SLR or unsupportedgait. (Krebs 1991)

Issues for acute hip injury

Forces of hip abductors during gait =

2.5x body weight Forces on hip joint during stair

climbing = 7x body weight

Forces on hip duringrunning/jumping = 10x body weight

Davy et al 1988

Spinal Stenosis

Degeneration of the intervertebral discwhich results in collapsing of the disc.

The collapsed disc and subsequent facetarthrosis narrows the neuroforamen and

compresses the nerve root.

The ligamentous laxity causes vertebralsubluxation and osteophyte formation

resulting in spinal stenosis

Spinal Stenosis

The neuroforamen is narrower withlumbar extension than with flexion.

The patient with spinal stenosis willprefer to sit and flex versus standingwith extension.

The obstruction can also impaircerebrospinal fluid circulation and

produce the neuroischemia.

Spinal Stenosis

Spinal stenosis primarily reflects discand facet degeneration but as timeprogresses,

Spondylolisthesis can occur.

Costs $1 billion annually

Slow progression of disease

S&S

Numbness, weakness, cramping,pain in Les, feet, buttocks Compresses spinal nerves

Similar to disc

Stiffness in LEs

LBP

Decreased LE sensation

Loss of bladder and bowel functionin severe cases


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S&S

Often have absent lordosis

Stooped posture when standing orwalking

Prefer to use walker, grocery cart,w/c to enable forward lean

This can increase risk for falls

Intervention

Pharmacological Interventions:

NSAIDS ; Lodine; ibuprofen

Analgesics:Hydrocodone,acetaminophen

Education on proper bodymechanics

Restriction of aggravating activities

Spinal stabilization

Intervention

Aerobic conditioning utilizing astationary bike/treadmill

Aquatic exercise to reduce the stresson the spinal joints.

Manual stretching, musclestrengthening

Flexion decreases symptoms,extension aggravates

The goal of should be 30 minutes ofexercise 3x/week.

Later Interventions Epidural Steroid Injections

short term relief only

success rates are only 85%

The best results seem to occur with patientswho have had decompression surgery at oneor two levels and no spondylolisthesis

Surgical Decompression

laminectomy X-STOP IPD procedure: less invasive, metal

implant that limits spinal extension

Complications

Patients with osteoporosis andspinal stenosis will often develop acompression fracture proximal to thefusion.

Pelvic fractures are often seen after alumbosacrel fusion due to theincreased stress on the pubic ramiduring rotation

Osteoporosis

A disease characterized by low bonemass and structural deterioration ofbone tissue, leading to bone fragilityand increased susceptibility tofracture.


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Bone Basics

Bone grows in length up to age 25

Osteoblasts can continue to lay downnew bone until age 30

10-15% of skeleton is demineralized andcan be renewed each year

Osteoclasts take calcium out of blood toput in blood stream

Osteoclasts take out in one month whatosteoblasts takes 3 months to replenish

Bone Basics

Bone mass accounts for 75-85% of

bone strength 25 year olds absorb 75 % of available

calcium, 60 year olds 30-40 %

Physical inactivity can lose 1 % ofbone mass/week

Trabecular bone loss begins age 30-40

Cortical bone loss begins age 40-50

Bone Remodeling Cycle

Osteoclastactivity: bonebreakdown

Osteoblastactivity: boneformation

Normal balance =turnover of 10% corticaland 30-40% trabecular

bone remodeled per year

Type I (post menopausal)

Trabecular bone loss is 3x thenormal loss

Bone loss is greater in first 5 yrsafter menopause

10-15 yrs after menopause the lossrate decreases

Most associated with vertebrate andwrist fractures

Trabecular Bone Type II (age related)

Loss beginning at age 30

At age 40:

less bone is formed than is reabsorbed

loss is .3-.5 %/yr.

Decrease ability to absorb calcium

Associated with hip fracture


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Height

Disc height maintains or slight

increases with age Does decrease during day, but

replenishes at night

Loss of height is a decrease invertebral height (body ofvertebrate)as a result of decreasebone mass not disc

Osteoporosis - Diagnosis

Through Bone Scan

Visualization

Arm measurement

Men DO get osteoporosis

1-2 million in U.S.

8-13 Million have osteopenia

500,00 hospital admissions (fx)

Men sustain 25-30% of hip fractures

Associated with low testosterone

Arch Intern Med.

2008;168:47-54 Mortality rate is 2x

Article on Blackboard

A major public health threat:

Healthy People 2010 identifies this as thesecond focus area to address to improvethe quality of life in the USA

44 million Americans have the disease orhave low bone mass (osteopenia)

Occurs in both men and women

4x more likely in women. 1 in 12 men (low

estrogen)

Affects all age groups and ethnic groups

A major public health threat:

Affects the physical independence indaily activities

Responsible for 1.5 million fracturesannually

Direct expenditures as a result of thefractures at $13.8 billion/year and rising

Pharmacological Interventions: Toslow bone loss

Fosamax/Boniva: in both men andwomen

Actonel: in women and men

Raloxifene: in women, selectiveestrogen receptor modulator

Calcitonin: in postmenopausalwomen greater than 5 years andrelatively healthy


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Some problems

Use of bisphosphates (Actonel,

Fosamax) is linked to bone necrosis,esp. jaw. Journal of Rheumatology .Feb 2008

Fosamax may also cause chronicallyirregular heartbeat (atrial firillation)by 86% Arch Int Med. Feb 2008.

Fractures

Fractures are more highly related to

decrease bone mass than any otherage related factor

Most common fractures (in order):vertebral, hip, wrist

Fractures

Femoral neck

ORIF: poorer outcomes thanhemiarthroplasty

Hip fractures: DM = higher riskdespite higher BMD (bone mineraldensity) (higher body weight?)

Visual impairment?, sensation?, CVD?

Diabetes Care2007;30:835-41.

Surgeries

THR, ORIF

Vertebroplasty: for comp. fxs

Injection of cement

+/- risk for adjacent fx

Lab

Flexicurve video


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Research shows:

Exercise can gain bone mass

dynamic bone loading exercises ofwalking, jogging and stair climbing

Strength training stimulates bone at themuscular skeletal junctions

Rest periods to prevent desensitizationmay double anabolic responses tomechanical loading

Contraindicated exercises includevertebral flexion exercises

Evidence

Significant relationships were recorded

between dynamic leg strength and BMD ofthe femoral neck and lumbar spine

Effects of one-year of resistance training on the

relation between muscular strength and bone

density in elderly women. Rhodes. Br J Spts Med.

2000

Osteoporosis

Resistive exercises appear toincrease bone mass density

Increase back muscle extensors

Women with weak back extensors are2.7% more likely to suffer acompression fracture

Exercise

May work best to build bone duringbone growth, with some lastingbenefits, but may erode away whenexercise stops

In adulthood, small increments

No evidence that ex fractures

Issues for osteoporosis

Avoid trunk flexion, especially withresistance

Careful with dynamic body weight ex.


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PT Intervention

BEST exercise program

Designed at Johns Hopkins

http://www.citracal.com/best/

Exercise videos

AGING JOINTS

Foot/Ankle

80% of people 65 and older have footdysfunction

Loss of flexibility of the ligamentousstructure between the 26 bones ofthe foot

Decrease range of motion and shape,therefore the reason to measure yourfoot when buying new shoes

Decreased ankle strength affectsbalance and mobility

Knee

Degenerative changes in weightbearing joints increases and the kneechanges are 2x as common as theankle or hip

Women have a 50% greater strengthloss and greater magnitude of varus-

valgus deformity than men possiblydue to the decrease in estrogen aftermenopause

Hip

The weight bearing surface of the hipis covered with cartilage which crackand shred over time resulting infissures

Degenerative joint disease and hipbursitis are the common complaints

The synovial membrane thickens andare less mobile unable to protect the

joint

Hip

Common findings include: hipflexion contractures, weakness,iliotibial band contractures, anddisuse atrophy from habitual sitting

60% of gait cycle is in stance and35% in one legged stance, thereforehip instability and weakness willaffect gait
http://www.citracal.com/best/http://www.citracal.com/best/


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Spine

The spine tries to stabilize itself with

bone remodeling resulting in bonespurs or widening of the vertebralbody

Postural changes as result oftightening of the pectoral musclesand habitual sitting

Cervical Spine

The disc changes by a decrease in

size and number of the collagenresulting in less elasticity, andposterior migration which begins theforward head posture

Long anterior neck muscles shortenand the suboccipital muscles tight tokeep head in vertical alignment

Cervical Spine

Decrease cervical range of motioncan begin as early as age 30

Bifocals/trifocals, pillows forsleeping, computer usage can allcontribute to neck changes

Shoulder

Shoulder pain is more frequent inwomen than men

Deltoid muscles are the mostoverworked and rotator cuff the leastworked of all shoulder muscles

Shoulder

Decrease supraspinatus strengthresults in superior migration of thehumerus and ultimately impingementin the subacromial region

Increased thoracic kyphosis as aresult of back changes increasesshoulder problems.

Hand

Multitude of small joints, cartilage,and muscles predisposes the handto aging effects

Routine daily stresses on the jointsof the hands add up over time

Joint protection techniques, utilizinglarger joints, energy conservationand pacing all help to reduce handdysfunctions


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Frailty Definition: 3 or more

Unintentional wt loss of > 10 lbs in last year

Self-reported exhaustion

Weakness (lowest 20% grip strength forage

Slow walking speed (lowest 20%)

Low physical activity

1-2 of these factors signal intermediatefrailty with risk to become frail in 3-4years (Fried 2001)

Frailty and ResistanceExercise

Appears to be a major weapon to

combat frailty 80% 1rm:

174% in 90+ older adults 3x/week for 8weeks; 3 sets of 8 (1stweek 50%)

227% gain knee flexor, 107% gain kneeextensors

Evans 1999

Frailty and ResistanceExercise

Resistive ex in hospital improvedstrength, sit to stand. Gait speed and4 of 6 non-ambulatory pts. Becameambulatory (Sullivan 2001)

Falls Resistive exercise increases balance,

gait velocity, climbing power and sitto stand

Falls

Decreased incidence of falls forthose placed on exercise programs

Resistive ex.

Balance ex.

Tai Chi

Xi Gong

Yoga

More about this in lecture 5

Depression

Mod high intensity exercise improvesself scores

Depression doesnt limit gains from

physical activity Singh 2002


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Cardiovascular Disease

Resistance exercise may be more

tolerable that aerobic exercise ifischemic threshold is low due toheart rate response to training

Diabetes

Resistance exercise is as, if not more

effective than aerobic ex. inimproving glucose intolerance andrisk reduction

COPD

Exercise improves muscle strengthand endurance, dyspnea, QOL

COPD

Fewer repetitions are toleratedbetter, single set, 2-3x/week.

Progress from 50% to 80% 1RM

Time exercise sessions afterbronchodilator med peak

Use oxygen as needed

Monitor vitals, RPE (Borg)

CHF

No longer contraindicated, but mustmonitor vitals signs

CVA

Overload principle (Weiss 2001)

One-year s/p

12 weeks, 2x/week, 70% 1RM

68% increase in strength, 12% balance,sit to stand improved

Treadmill supported gait


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Parkinsons Rigidity leads to flexor

muscle and soft tissue

shortening, extensormuscle and soft tissuelengthening Relaxation exercises

Strengthening increasesstride length, LE strength,gait velocity, head angle

8 weeks, 60% 1RM (Goede2001)

Parkinsons

Exaggerated exercises

Forced exercise

Boxing training

http://ptjournal.apta.org/content/suppl/2010/12/29/91.1.132.DC1/Combs.mov

Causes of Inactivity inSeniors

Lack of motivation or apprehension

Lack of resources, or knowledge ofthem

Social/cultural issues

Environmental barriers - e.g.,equipment, room to exercise, place to

walk, transportation Inability to assume positions/postures

Causes of Inactivity

Fear Falling, getting injured, not doing it right

Acute illness

Co-existing diseases/disabilities(incontinence)

Unpleasant sensations associated withexercise

Muscle soreness, shortness of breath Lack of knowledge

Benefits of ex., proper methods for performingex.

Exercise and Older Adults

Inactivity Increases with Age

Percent

60

50

40

30

20

10

0en Women

60-69

70-79

80+

60-69

70-79

80+

Inactivity

Today, about 28% to 34% of adults 65to 74 and 35% of adults 75 years andolder are INACTIVE.

By 2030, demographers expect thenumber of older people to double,from 35 million to 70 million.
http://ptjournal.apta.org/content/suppl/2010/12/29/91.1.132.DC1/Combs.movhttp://ptjournal.apta.org/content/suppl/2010/12/29/91.1.132.DC1/Combs.movhttp://ptjournal.apta.org/content/suppl/2010/12/29/91.1.132.DC1/Combs.movhttp://ptjournal.apta.org/content/suppl/2010/12/29/91.1.132.DC1/Combs.mov


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Factors that Improve ExerciseAdherence in Seniors

Motivationis the best discriminator forolder adults who enroll and adhere to

and/or drop outStrategies to improve motivation: Effective exercise leader

Continuity

Type of programvariety, cross-training

Have FUN!!

Self-efficacy

Expected outcomes

Consulting/counseling

Assess: type/freq/intensity/duration

Advise: importance of ex

Agree: shared decision making

Assist: printedmaterials/calendar/resources

Arrange: Follow-up/referral to specialist

Exercise Leader

KEY TO SUCCESS IS MOTIVATION!!!

Encourage participation, assess,instruct

Demonstrate caring

Aware of participants differences

Well-organized

Able to establish rapport with group Begin slow and advance slowly (to

avoid pain, SOB)

Type of Exercise or Activity Programs

Group Programs

Strength Training Walking Yoga Tai Chi Feldenkrais

http://rehabyoga.com

Dancing Qi gong Chair w/c ex. Floor ex. Mechanical

Bicycles Treadmills

Ellipticals Stair steppers

Individualized Programs

Individualized, even within groups

Some seniors prefer to exercisealone

Find out who these individuals are

One-on-one interview

Customized program

Exercise and Aging

Regular exercise has been shown todecrease morbidity in older adults

Despite this fact, less than 25% of theolder population exercises atrecommended level!

Only 37% of PT pts cont. HEP 6monthsafter D/C*

Why?*Forkan Phys Ther 2006;86:401-410
http://rehabyoga.com/http://rehabyoga.com/


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Barriers

Disabilityspecialized

program/exercises from PT Fear of injury/Fallinginitial

supervision 1 on 1

Habitneed to incorporate into dailyroutine

Lack of education

Income level

Barriers (cont.)

Environmentalweather

Cognitive declinekeep it simple

Lack of nutritionmeals on wheels,education

Self-Efficacy

Factors that affect self-efficacy:

Age

Gender

Previous experience

Ability to ManagePerceived Barriers!

Take Care of theBarriers to Exercise

Location

Transportation

Personallyappealing

Client-centeredgoals

Opportunities forsuccess

Addressdiscomforts

Deal with Barriers

Fear! Safety, falling

Address embarrassments

Encourage questions

Acknowledge each success

Buddy or partner system


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Deal with Barriers

Environment Safe, pleasant, health-enhancing Convenient

Societal/cultural issues

Customize Program Favorite activities, specific goals

If co-existing disease/disability

Outcome Expectations

Stronger outcome expectations

associated with starting exercise andmaintaining it

Clear and accurate

Realistic?

Special for Seniors

Rely heavily oninstructor

Enjoy interactionwith a group, maybe more effective(own age)

Contributes toself-esteem

Physical Activity:A Key to Wellness and

Successful Aging

Wellness

A lifelong interactive process ofbecoming aware of and practicinghealthy choices to create a moresuccessful and balanced lifestyle.

How do I teach my seniors?

How do I stress the importance ofexercise?

How does a PT tell theirpatients about theimportance of exercise?


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Physical Activity ImprovesIntellectual Function by:

Helping maintain cognitive function

(e.g. memory and concentration) Decreasing stress and anxiety

Improving mood

Reducing depression

Physical Activity ImprovesSocial Function by:

Increasing independence

Creating a stimulating,and often supportive,environment

Improving family time

Increasing socialnetworks andinvolvement

How Do I Get Started?

Check with your doctor

Visit a physical therapist

Start slowly

Integrate different physical activitycomponents into your life

Choose activities you enjoy

Get a buddy

Getting Started

The National Institute on Aging haspublished the 2009 version ofExercise and Physical Activity: YourEveryday Guide from the NationalInstitute on Aging. Best of all it isfree!

http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/

How Do I Choose an Activity?

Consider including multiplecomponents

Enjoyable

Accessible

Convenient

Variety

Meeting Their Needs

Considerations forgroup programs:

Class size

Instructor experience

Amount of assistancethey need

Intensity and variety ofprogram
http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/


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Physical Activity May Include:

Walking

Swimming orparticipating in awater exerciseclass

Playing a sport youenjoy

Physical Activity May Include

Lifting weights or

exercising withelastic bands

Taking a tai chi orsenior yoga class

Dancing

Joining a localsenior exerciseclass

What If I Have PhysicalLimitations?

Choose an activity thataccommodates yourabilities Use something sturdy for

support

Use a cane or walker duringactivities

Exercise sitting

Consult a physicaltherapist to help youchoose an activity

How Do I Begin a PhysicalActivity Session?

Warm up for 10 minutes

How Much Time Do I Need tobe Active For?

Warm-up should be followed by atleast 30 minutes of effortful physicalactivity.

How Much Time Do I Need toBe Active For?

30 - 60 minutes a day of endurance,strengthening, balance and flexibilityactivities


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How Much Effort is Needed?

Begin slowly and

pace yourself.

You should be ableto carry on aconversation duringthe activity.

How Do I Finish a PhysicalActivity?

Finish your session with a 10

minute cool down and a tallglass of water.

How Many Days A WeekShould I Be Active?Try to do 3x per week, more can be better

1

3

5

7

How might I expect to feel?

When you first begin a physicalactivity program or advance yourcurrent activities it is normal to feel:

Mild muscle stiffness, burning, orfatigue that decreases in 24 hours

Mild increase in heart rate withcontinued activity, but that returns to

normal in 5 minutes

Stop to Rest if You Experience

Shortness of breath(cant complete sentence)

Dizziness

Heart rate that exceeds prescribedtarget rate

Onset or worsening of pain

Chest pain

What Does Progress LookLike?

Minor improvement

in 2-3 weeks

Significant improvement in 2-3months

Can lead to improved

Lifestyle and function!


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Getting Back on Track

Illness

Vacation Injury

Lose gains Resume

when youcan

10% per week

missed

Effort

Speed

Distance

Lifetime Goals:Maintaining Fitness Level

Be realistic

Be consistent

Find a buddy

Journal / chart progress

Will you berunning a miniwhen you are82?

Pearls of Wisdom

Muscle training can hypertrophyremaining Muscle fibers therebydecreasing the Fat to Muscle ratio

Lower extremity muscle strength isaffected greater than upper strength

Remaining muscle still have endurance

unless co-morbidity is present Strength training will improve balance

and decrease fall risk

Summary Aerobic/cardiovascular endurance

Substantial improvements in almost allaspects of CV function

Muscular strength Individuals of all ages and disease states

can benefit from PRE

Can help maintain independence

Balance and coordination Prevents falls, improves gait

Other improves mental function, bone health

Summary

Improved max aerobic capacity Increased max voluntary ventilation

Greater A-VO2difference and strokevolume

Lowered vascular resistance

Increased muscle strength (slow andreverse decline)

Reduced involutional bone loss

Increased bone mineral content


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Summary

Decreased body fat/increased leanbody mass

Improved glucose tolerance

Lower lipid concentrations &elevated HDL

Improved flexibility

Improved balance

Decreased risk for falls

Improved functional performance

geriatric considerations for exercise prescription

Documents