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
NHANES Prevalence of Overweight Youth Ages 2-19 National Center
for Health Statistics, Prevalence of Overweight Among Children and
Adolescents: United States, 2003-2004
Slide 5
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
Slide 6
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
Slide 7
Obesity Epidemic Modifiable Risk Factors Actual Causes of Death
Mokdad, JAMA, 2004
Slide 8
Dis-fitness Cycle Increased Disease Risk Reduced Physical
Activity Illness Risk Factors Age Related Change New or Existing
Illness
Slide 9
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
Slide 10
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
Slide 11
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
Slide 12
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)
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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 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
Slide 22
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
Slide 23
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!
Slide 24
Clinical Diagnosis Joint Pain Typical Pain Pattern Xray
Findings Standing films AP with 30 deg flexion No Sign of
Zebras
Slide 25
Pathogenesis of Osteoarthritis An Interplay of Factors Dieppe,
American Academy of Orthopaedic Surgeons, 1995
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
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)
Slide 30
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
Slide 31
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
Slide 32
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
Slide 33
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
Slide 34
Which is higher risk for OA?
Slide 35
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
Slide 36
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
Slide 37
Strong Risk Factor for OA Joint Trauma
Slide 38
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
Slide 39
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.
Slide 40
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
Slide 41
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
Slide 42
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)
Slide 43
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
Slide 44
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
Slide 45
Exercise is EXCELLENT Treatment for OA
Slide 46
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
Slide 47
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 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
Slide 51
Slide 52
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)
Slide 53
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
Slide 54
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
Slide 55
Exercise (Activity) Prescription for Kids Why Exercise Works in
Kids
Slide 56
- 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
Slide 57
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
Slide 58
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
Slide 59
Exercise (Activity) Prescription for Older Adults Exercise and
Aerobic Capacity VO2 Max Age 8020 Active Active + Aging Reduced
Activity + Weight Gain Sedentary Exercise Intervention
Slide 60
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
Slide 61
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
Slide 62
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
Slide 63
Exercise (Activity) Prescription for Older Adults A little more
about balance Static Dynamic Intensity=sensory or time
Slide 64
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
Slide 65
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