Musculoskeletal Problems of the Obese and the Elderly (or “How do we prevent functional decline in the two fastest growing segments of our population?”)

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 Hedley et al, JAMA 291(23) 2004 80% 70% 60% 50% 40% 30% 20% 10% 1962 1972 1978 1992 2002 66% Overwt 31% Obese

NHANES Prevalence of Overweight Youth Ages 2-19 National Center for Health Statistics, Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004

By 2015: 75% of adults overwt or obese 75% of adults overwt or obese 41% will be frankly obese 41% will be frankly obese Epidemiologic Reviews. 2007. 29(1): 6-28 Exercise (Activity) Prescription for Adults New Hopkins Projections

Epidemiology of Geriatrics 2009: 2009: 39 million seniors 14% of the US population 37% of health care costs 2030 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 Increased Disease Risk Reduced Physical Activity Illness Risk Factors Age Related Change New or Existing Illness

Physiologic changes with age Height declines appx 1cm/decade /p 50 Height declines appx 1cm/decade /p 50 More accelerated for women /p 60 More accelerated for women /p 60 Wt increases 30s 40s 50s (visceral fat) Wt increases 30s 40s 50s (visceral fat) Wt stabilizes 50s -70s, then decreases Wt stabilizes 50s -70s, then decreases Fat free mass decreases 2-3%/decade Fat free mass decreases 2-3%/decade RMR, muscle protein synthesis rate, fat oxidation all decrease RMR, muscle protein synthesis rate, fat oxidation all decrease

Physiologic changes with age Perception of precision movements may be altered Perception of precision movements may be altered Sensory, motor, and cognitive changes alter biomechanics Sensory, motor, and cognitive changes alter biomechanics How much is age v. disease process? Flexibility and joint ROM decreases Flexibility and joint ROM decreases Muscle and tendon elasticity decreased Muscle and tendon elasticity decreased

Physiologic changes with age Isometric, concentric, and eccentric strength decline after age 30-40 Isometric, concentric, and eccentric strength decline after age 30-40 decline accelerates after age 65-70 Power declines faster than strength Power declines faster than strength Muscle endurance declines with age Muscle endurance declines with age Reaction time increases Reaction time increases Simple and repetitive motions slow Simple and repetitive motions slow

Physiologic changes with age Decrease in muscle mass 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 30% loss of mass from age 30-80 Estimate a 60% loss of strength 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 density Bone is dynamic tissue Constantly remodeling in equilibrium Constantly remodeling in equilibrium Bone mass peaks in 20s 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 Low bone mass Microarchitechtrual deterioration Microarchitechtrual deterioration Enhanced bone fragility Enhanced bone fragility Increased risk of fracture Increased risk of fracture

Osteoporosis epidemiology 10 million people in US 10 million people in US 34 million with osteopenia in US 34 million with osteopenia in US About 2 million osteoporotic fx/year in US About 2 million osteoporotic fx/year in US After age 65 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 2.5 million physician visits per year >400,000 hospital admissions per year >400,000 hospital admissions per year >180,000 nursing home admissions >180,000 nursing home admissions Projected annual direct costs $25 billion Projected annual direct costs $25 billion

Hip Fractures 300,000 hip fractures per year in US 300,000 hip fractures per year in US Over occur in >80 year old patients Over occur in >80 year old patients of hip fracture patients go to NH of hip fracture patients go to NH d/cd to NH become long-term resident d/cd to NH become long-term resident One year mortality is 20%-24% One year mortality is 20%-24% 60% never return to baseline function 60% never return to baseline function > women >75 prefer death to hip fx > women >75 prefer death to hip fx

Osteoporosis Management Goals of 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

Adequate caloric intake Adequate caloric intake Exercise Exercise Weight-bearing Swimming Intermittent dynamic loading Avoid tobacco Avoid tobacco Avoid/decrease alcohol intake Avoid/decrease alcohol intake

Osteoporosis Prevention 92% of total bone mass by age 18 92% of total bone mass by age 18 99% by age 26 99% by age 26 Bone mass not obtained during this time cannot be made up later Bone mass not obtained during this time cannot be made up later

Osteoporosis prevention Different sites mature at different ages Different sites mature at different ages Peak bone mass complete by age 16 in the femoral neck Peak bone mass complete by age 16 in the femoral neck Later in lumbar spine and distal radius Later in lumbar spine and distal radius

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 Definition of Osteoarthritis & PAIN!

Clinical Diagnosis Joint Pain Typical Pain Pattern Xray Findings Standing films AP with 30 deg flexion No Sign of Zebras

Pathogenesis of Osteoarthritis An Interplay of Factors Dieppe, American Academy of Orthopaedic Surgeons, 1995

Pathogenesis of Osteoarthritis Age Related Changes to Cartilage Intrinsic Factors Water content Proteoglycan content Matrix integrity Age Related Change Decreases in: Water content Proteoglycan synthesis Collagen x-linking Size of Aggrecan, GAG & Hyaluronic acid Increases in: Crystals/Calcification Loeser, Rheum Dis Clin North America, Aug 2000 Hyaluronic Acid Core Protein- Aggrecan Chondroitin Sulfate Chain Link Glycoprotein

Articular Cartilage: Where the rubber meets the road The Living Sponge The Living Sponge Shock Absorption = Water Content + Proteoglycan Synthesis Shock Absorption = Water Content + Proteoglycan Synthesis Limited Supply!! One Time Offer!! Limited Supply!! One Time Offer!! Sure Bets: Death, Taxes, & Cartilage Fibrillation Sure Bets: Death, Taxes, & Cartilage Fibrillation

Etiology of Osteoarthritis Growth of cartilage and bone at the joint margins leads to osteophytes which can restrict movement 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 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 Periarticular muscle wasting is common and plays a major role in sx and disability

Symptoms of osteoarthritis PAIN (Articular cartilage is aneural) PAIN (Articular cartilage is aneural) OA pain is not from the cartilage Stretching of nerve ending in periosteum covering osteophytes Stretching of nerve ending in periosteum covering osteophytes Microfractures in subchondral bone Microfractures in subchondral bone Stretching of joint capsule Stretching of joint capsule Synovitis Synovitis Ligament stretching or muscle pain Ligament stretching or muscle pain STIFFNESS (esp. after inactivity) STIFFNESS (esp. after inactivity)

Epidemiology of OA OA of the knee is the leading cause of chronic disability in the elderly in developed countries 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: In patients over the age of 55: Hip OA is more common in men IP and 1 st 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: In patients under the age of 55: Joint distribution of OA is equal between men and women Due to genetics or joint usage????? 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 Age is the most powerful risk factor for OA Women < 45 years of age: 2% with OA Women < 45 years of age: 2% with OA Women 45-64: 30% with OA Women 45-64: 30% with OA Women >65: 68% with OA Women >65: 68% with OA

Epidemiology of OA Disability in subjects with knee 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 Demographics associated with increased likelihood of being symptomatic: women, unemployed, divorced, poor social support

Which is higher risk for OA?

10 lb increase in weight = 40% increase in knee osteoarthritis 10 lb increase in weight = 40% increase in knee osteoarthritis Larger effect in women Larger effect in women (Felson et. al. Ann Int Med 1992, Framingham Heart Cohort data) Strong Risk Factor for OA Obesity

Epidemiology of OA Obesity is a risk factor for knee (and hand) osteoarthritis 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 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 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

Jobs requiring repetitive knee bending/moderate activity predict higher rates of osteoarthritis Felson et al Annals of Int Med 1992 Moderate Risk Factor for OA Certain Vocational Activities

Zhang W et al. Osteoarthritis Research Society International recommendations for the management of hip and knee OA, Pt II: OARSI evidence- based, expert consensus guidelines. Osteoarth and Cartilage 2008; 16:137-62.

Lose Weight if Overweight/Obese (LOE 1a) 10 lb / 40% rule 10 lb / 40% rule Break that vicious cycle: Break that vicious cycle: Team approach is critical Team approach is critical Disuse Weight Gain Pain and stiffness

Educate Your Patients (LOE 1a) Objectives of treatment Objectives of treatment Changes in lifestyle Changes in lifestyle Importance of exercise Importance of exercise Pacing yourself Pacing yourself Weight reduction if needed Weight reduction if needed Unloading of joints Unloading of joints

Management/Treatment of OA Goals Goals Educate patient about disease and management Improve function Control pain Alter disease process and its consequences (we just dont know that much about biomarkers and disease-modifying drugs just yet) (we just dont know that much about biomarkers and disease-modifying drugs just yet)

Management/Treatment of OA No known cure for OA No known cure for OA HOWEVER HOWEVER Impaired muscle function Reduced fitness Affect pain and dysfunction Affect pain and dysfunction Are amenable to therapeutic exercise Are amenable to therapeutic exercise

Nonpharmocologic Measures Nonpharmocologic Measures Education, Weight loss, Exercise, & Bracing Pharmacologic Measures Pharmacologic Measures Analgesics, Glucosamine, Injectables Alternative Therapies Alternative Therapies Accupuncture, Dietary Supplementation Surgery Surgery Treatment of Osteoarthritis Overview

Exercise is EXCELLENT Treatment for OA

Evidence for Benefit from Exercise in Treating OA Regular aerobic walking for knee OA Regular aerobic walking for knee OA LOE 1a for knee OA LOE IV for hip OA Home-based quad strength exercises Home-based quad strength exercises LOE 1a for knee OA LOE IV for hip OA Water-based exercise for hip OA Water-based exercise for hip OA LOE 1b

What Kinds of Exercise are OK? Little evidence-based recommendations Little evidence-based recommendations Common sense advice 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) Weight reduction (IA) Recreational exercise/sports (IA) Recreational exercise/sports (IA) Maintain physical fitness (IB) Maintain physical fitness (IB) Avoid obesity (IB) Avoid obesity (IB) Participate in adequate physical exercise (IB) Participate in adequate physical exercise (IB)

Prevention of OA Current studies 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 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 47% of primary care physicians include an exercise history as part of their initial examination Only 13% of patients report physicians giving advice about exercise Only 13% of patients report physicians giving advice about exercise Physically active physicians are more likely to discuss exercise with their patients 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 (Self Report)

25% of obese preschoolers become obese 25% of obese preschoolers become obese 80% of obese 14 year-olds remain obese 80% of obese 14 year-olds remain obese 70% of obese children who lose weight will maintain that loss as adults 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 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 Train Up A Child

Meta-analysis of 30 RCT Meta-analysis of 30 RCT Ages: 5 - 17 Ages: 5 - 17 Pre & post intervention body composition Pre & post intervention body composition Exercise highly effective treatment for pediatric obesitylow intensity, long duration exercise Aerobic exercise combined with resistance training resistance Factors that Alter Body Fat, Body Mass, and Fat- Free Mass in Pediatric Obesity LeMura LM, Mazeikas MT Med Sci Sports Exerc, 2002 Exercise (Activity) Prescription for Kids Exercise Works for Children

Exercise (Activity) Prescription for Kids Why Exercise Works in Kids

- American Academy of Pediatrics - American College of Sports Medicine 60 minutes of activity each day (minimum) Moderate-to-vigorous activity Can accumulate in small bouts, wide variety of sports & activities Exercise (Activity) Prescription for Kids Guidelines for Pediatric Exercise

1.0 1.4 1.9 3.2 3.8 5.7 Normal Weight (BMI 18 24) Overweight (BMI 25-30) Obese (BMI 31- 36) Relative Risk of Total Mortality From Lee, Am J Clin Nutr, Mar 1999 Unfit (no exercise) Fit (regular exercise) Good News for Your Patients Exercise (Activity) Prescription for Adults Adults, Exercise & Mortality: Good News for Your Patients

Exercise (Activity) Prescription for Older Adults Fitness and Functional Status Function Strength Poor Normal LowHigh Healthy Adults Frail Adults Near Frail THRESHOLD 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 VO2 Max Age 8020 Active Active + Aging Reduced Activity + Weight Gain Sedentary Exercise Intervention

Exercise (Activity) Prescription for Older Adults Strength: Use It & Lose Less of it Losses Sedentary people lose large amounts of muscle mass (20-40%) Sedentary people lose large amounts of muscle mass (20-40%) 6% per decade loss of Lean Body Mass (LBM) 6% per decade loss of Lean Body Mass (LBM) Gains Lean body mass increases 1-3 kg Lean body mass increases 1-3 kg Resistance training improves strength by a range of 40-150% Resistance training improves strength by a range of 40-150% Muscle fiber area 10-30% Muscle fiber area 10-30% Aerobic Activity IS NOT sufficient to stop this loss! 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 Whats Different for Older Adults? Endurance Endurance Frequency Daily Daily Duration Moderate Moderate 30-60min/d total Vigorous Vigorous 20min/d continuous Type Walk, aquatic, cycle Walk, aquatic, cycle Resistance Resistance Frequency 2 days per week Intensity 5-6 or 7-8 out of 10 Type Progressive weight training or weight- bearing calisthenics 8-12 reps of 8-10 exs 2009 ACSM Guidelines For Older Adults

Exercise (Activity) Prescription for Older Adults Whats Different for Older Adults? Flexibility Flexibility Frequency At least 2 days/week At least 2 days/week Intensity 5-6/10 (moderate) 5-6/10 (moderate) Type Any activity that maintains or increases flexibility. Do static rather than ballistic Any activity that maintains or increases flexibility. Do static rather than ballistic Balance exercises Balance exercises No specific recommendations 2/2 lack of evidence Recommend using increasingly difficult postures (two-legged, tandem, one-legged, eyes closed, etc) 2009 ACSM Guidelines For Older Adults

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-A508- 94CA4E537D4C/0/NIA_Exercise_Guide407.pdf

Summary Functional decline and disability can be managed by physical activity Functional decline and disability can be managed by physical activity Physical activity begun in childhood can prevent obesity and frailty in adulthood Physical activity begun in childhood can prevent obesity and frailty in adulthood

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Documents

Musculoskeletal Problems of the Obese and the Elderly (or “How do we prevent functional decline in the two fastest growing segments of our population?”)