1. A presentation to Harvard
University PM&R Residents
06/08/10
Stephan Esser MD
www.esserhealth.com

2. Disclosures
• Industry funding
– Head Industries
– Nike/Wilson
– Penn
• Personal Tie-in
– I am an addict

3. Exercise and
the Elderly
Stephan Esser USPTA,MD
6/8/10

4. Who Cares?

6. Goals
• Define basic concepts
• Explore national trends
• Review recommendations for exercise
• Discuss common benefits of exercise
• Discuss Basic Physiology of Aging
• Clinical Pearls and Experiential Piece

7. Define Elderly
• State of mind or a number
• Biology or chronology

8. Western World
• Elderly > 65
• Very Old > 80
• Very, very old >100

9. Some parts of the world

11. National Trends
• Age > 65 ≈ 13%
• 1900: 3 million
• 2000: 30 million
• 2030: 1:5 will be ≥ 65
• Fastest growing: ≥ 85
• 4 mill. (2000) to 19 mill. (2050)

12. Internationally
• Slide of elderly other countries

13. Summary

14. Basics of Exercise

15. Exercise
movement of the body
resulting in the
enhancement of health
and improvement of
function

16. Categories of exercise
• Leisure time Exercise: organized sports,
running, gym activities, rehabilitation etc.
• Lifestyle Exercise: activity incorporated into our
daily pattern of life
– eg: parking in the distant portion of the parking lot rather then the first
bumper, taking the stairs instead of the elevator etc.

17. Types of exercise
• Cardiovascular
• Strength/Resistance Training
• Core Stability/Balance
• Flexibility/Coordination

18. US Gov. Reccomendations
30 minutes/day
4-5 days a week
150 min/wk

19. Benefits of Exercise
• Reduces risk of
– Heart Disease ≈ 40%
– Obesity: ≈ 30-100%
– Stroke ≈ 50%
– Type 2 Diabetes ≈ 50%
– Hypertension ≈ 50%
– Disability delayed ≈15 years
– Colon Cancer ≈ 25-40%
– Breast Cancer ≈ 20%-44%
– Osteoporosis ≈ 20+%
• As many as 250,000 deaths per year in the
United States are attributable to a lack of
regular physical activity

20. Exercise and Mental Health
• Regular Exercise:
– Reduces risk of:
• Depression
• Anxiety
• ADD/ADHD
• Alzheimers Dementia
– Improves:
• Mental Clarity, test scores, focus

21. Rates of Exercise

22. Exercise Trends
• > 60% of adults are not regularly
active
• 25% are not active at all
• By age 75 1:3 men and 1:2 women
engage in NO physical exercise

23. “Many people have arthritis and rheumatism;
they get bum knees, a bum back. A lot of guys
get a little pain in the toe or knee and then they
won't exercise. Well gee, you have 640 muscles
in your body. There may be a few exercises you
can't do, but there are hundreds you can do!”
Jack Lallane

24. Summary
• More citizens > 65 than ever before
• Exercise is a powerful preventive
and vitalizing modality
• Few achieve the recommended
goals of exercise

25. Basic Physiology of
Aging

26. The Physiology of Aging
• Cardiovascular:
– 20-30%  in CO by 65
– Max. 02 uptake  by 9-5% per
decade, for sedentary men and
women
–  Vascular elasticity = 10-40 mm Hg
SBP/DBP
– Maximum HR  app.10 bpm/decade

27. Physiology of Aging
• Respiratory:
– FVC of 40 to 50% by age 70
– in chest wall compliance
– Maximum Ventilation
– in Alveolar size and conc.

28. Physiology of Aging
• Muscles
–40%  in muscle mass by 70
–  muscle fiber size & #
–30%  in strength by 70

29. Physiology of Aging
• Skeletal health:
– 1%  in bone mass/yr after 35
– Post-menopause 2-3%  per year for
5-10 yrs
–  rates of OA, sponylo-arthropathy,
general joint dysfunction and
degeneration

30. Physiology of Aging
• Connective Tissue:
–  elasticity
– shortened muscle fibers
–  synovial fluid volume
– Up to 15% reduction in nerve cond.
–  Hgb, Hct, RCM

31. So we
are all
falling apart!

32. Disuse
• Bedrest:
–  BMD, increased bone resorption
–  muscle mass and strength
–  muscle fiber size
–  fatty infiltration of muscle
– Impaired O2 exchange
–  Cardiac function, efficiency

33. • “A review of biologic changes commonly
attributed to the process of aging
demonstrates the close similarity of
most of these to changes subsequent to
Disuse and Aging
a period of enforced physical inactivity.
The coincidence of these changes from
the subcellular to the whole-body level of
organization, and across a wide range of
body systems, prompts the suggestion
that at least a portion of the changes that
are commonly attributed to aging is in
reality caused by disuse and, as such, is
Walter Bortz MD subject to correction. There is no drug in
current or prospective use that holds as
much promise for sustained health as a
lifetime program of physical
exercise.”(JAMA 1982;248:1203-1208)

34. “There may be no single feature of age-related
decline that could more dramatically affect
ambulation, mobility, calorie intake, and
overall nutrient intake and status,
independence, breathing, etc. than the
decline in lean body mass.”
Aging, Atrophy and Apoptosis:Failing “A’s” for Frailty
National Conference on Aging

35. J Am Geriatr Soc. 2002 May;50(5):889-96.
Low relative skeletal muscle mass (sarcopenia) in older persons is
associated with functional impairment and physical disability.
• NHANES III Data
• 4,504 adults aged 60 and older.
• Evaluated Skeletal muscle mass as estimated
from bioimpedance analysis measurements
• Class I sarcopenia when SMI = 1-2 SD of young
adult values
• Class II sarcopenia when SMI ≤ 2 SD of young
adult values

36. “The likelihood of functional impairment and
disability was approximately two times
greater in the older men and three times
greater in the older women with class II
sarcopenia than in the older men and women
with a normal SMI These observations provide
strong support for the prevailing view that
sarcopenia may be an important and
potentially reversible cause of morbidity and
mortality in older persons.”

37. Wien Klin Wochenschr. 2009;121(23-24):757-64.
Efficacy of systematic endurance and resistance training on muscle strength
and endurance performance in elderly adults--a randomized controlled
trial.
• Older Individuals randomized to either endurance
training (ET) and resistance training (RT)
• Evaluated changes in lean muscle, strength,
endurance, O2
• RT leads to a genuine increase in lean body mass
and muscle strength in healthy elderly adults

38. Sports Med. 2000 Oct;30(4):249-68.
Strength training in the elderly: effects on risk factors for age-related
diseases.
• (i) produces substantial increases in the strength, mass,
power and quality of skeletal muscle
• (ii) can increase endurance performance
• (iii) normalizes blood pressure in those with high normal
values
• (iv) reduces insulin resistance
• (v) decreases both total and intra-abdominal fat
• (vi) increases resting metabolic rate in older men
• (vii) prevents the loss of BMD with age
• (viii) reduces risk factors for falls
• (ix) may reduce pain and improve function in those with
osteoarthritis in the knee region

40. Arch Phys Med Rehabil. 1996 Apr;77(4):399-405.
Health-related fitness test battery for adults: aspects of reliability.
• Balance:
– standing on one leg with eyes open for balance
• Flexibility
– side-bending of the trunk for spinal flexibility
• Upper Body Strength
– modified push-ups for upper body muscular function
• Lower Body Strength
– jump and reach and one leg squat

41. American College of Sports Medicine Position Stand. Exercise
and physical activity for older adults.
• Participation in a regular exercise program is an effective intervention/ modality to
reduce/prevent a number of functional declines associated with aging. Further, the
trainability of older individuals (including octo- and nonagenarians) is evidenced by their
ability to adapt and respond to both endurance and strength training. Endurance training can
help maintain and improve various aspects of cardiovascular function (as measured by
maximal VO2, cardiac output, and arteriovenous O2 difference), as well as enhance
submaximal performance. Importantly, reductions in risk factors associated with disease
states (heart disease, diabetes, etc.) improve health status and contribute to an increase in
life expectancy. Strength training helps offset the loss in muscle mass and strength typically
associated with normal aging. Additional benefits from regular exercise include improved
bone health and, thus, reduction in risk for osteoporosis; improved postural stability, thereby
reducing the risk of falling and associated injuries and fractures; and increased flexibility and
range of motion. While not as abundant, the evidence also suggests that involvement in
regular exercise can also provide a number of psychological benefits related to preserved
cognitive function, alleviation of depression symptoms and behavior, and an improved
concept of personal control and self-efficacy. It is important to note that while participation in
physical activity may not always elicit increases in the traditional markers of physiological
performance and fitness (e.g., VO2max, mitochondrial oxidative capacity, body composition)
in older adults, it does improve health (reduction in disease risk factors) and functional
capacity. Thus, the benefits associated with regular exercise and physical activity contribute
to a more healthy, independent lifestyle, greatly improving the functional capacity and quality
of life in this population.

42. Summary
• Much atrophy, weakness, frailty and disease
risk are associated with disuse and de-
conditioning
• These can be modified by adopting a habit of
regular exercise

43. Experiential Piece

44. Clinical Pearls
• The Sharpened Romberg's test:
– In the tandem stance, the patient places
one foot in front of the other, heel
touching toe, with his or her eyes closed.
A patient who is not able to maintain this
position for more than 10 seconds is at
increased risk for falls.

45. Clinical Pearls
• The Unipedal Balance Test
– is used to detect subtle balance
impairments. The patient is asked to stand
on one foot with the other foot raised 2
inches off the floor and not touching the
other ankle or foot. Increased fall risk is
associated with an inability to remain in
that position for at least 5 seconds.

46. Clinical Pearls
• The timed 360-degree turn test
– assesses dynamic balance. The
patient is asked to turn in a circle
while taking steps. An inability to
complete the maneuver in less than
4 seconds indicates an increased risk
of falling.

47. Clinical Pearls
• 180-degree turn test
– where the number of steps the patient needs
to turn halfway around is counted.
Staggering during the turn, an inability to
pivot during the turn, using five or more
steps to complete the turn, or taking 3
seconds or longer to accomplish the turn are
indicative of problems in turning while
walking.

48. Clinical Pearls
• The five times sit to stand test
– is used to assess lower extremity strength. The
patient is asked to rise from a standard chair, with
arms folded across the chest, five times
consecutively. The ability to rise from a chair
requires vision, proprioception, balance, and
sensorimotor skills. An inability to complete the
maneuver, standing and sitting back down in less
than 14 seconds, indicates an increased level of
disability.

49. Clinical Pearls
Get up and Go Test

50. J Am Geriatr Soc. 2001 May;49(5):664-72.
Guideline for the prevention of falls in older persons. American Geriatrics Society,
British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on
Falls Prevention.
• The AGS/BGS guidelines
– Timed Up and Go Test (TUGT) as a screening tool
for identifying older people at increased risk of
falls. Indicator of ‘basic mobility’
– 3 retrospective studies have examined the
relationship between TUGT performance and falls
in community-dwelling people.
– a TUGT cut-point of 14 seconds significantly discriminated between the faller and non-faller groups.
Using this criterion, 13/15 subjects from both groups were correctly classified, providing a sensitivity
and specificity for identifying falls outcome of 87%. Rose et al. [6] used a similar classification of faller
status (no falls versus two plus falls in the past year) in their study of 134 subjects. A considerably
lower cut-point (10 seconds) was identified as optimal for discriminating between non-fallers and
recurrent fallers. With this criterion the overall prediction rate was 80%: specificity 86% and
sensitivity 71%. The third study comprised 157 subjects classified as either fallers (one plus fall in the
past year) or non-fallers [7]. In this sample, the TUGT had very high sensitivity with 98% of the 109
fallers being correctly classified, but considerably lower sensitivity, with only 15% of the 48 non-
fallers being correctly classified.

51. Clinical Pearls
• Get up and Go Test:
– Pt seated on 46-cm-high chair
– Stand up
– Walk 3 m at their usual walking pace
– Turn 180°
– Walk back to the chair
– Sit down
• >10 seconds =  risk of falls

52. • Sensitivity of a modified version of the 'timed get up and go' test to predict fall risk in the elderly: a pilot study.
• Giné-Garriga M, Guerra M, Marí-Dell'Olmo M, Martin C, Unnithan VB.
• FPCEE Blanquerna, Universitat Ramon Llull, Department of Physical Activity and Sport Sciences, Císter 34, 08022 Barcelona,
Spain.
• Abstract
• The purpose of this study was to assess the sensitivity of a modified version of the 'Timed Get Up and Go' (TGUG) test in
predicting fall risk in elderly individuals, using both a quantitative and qualitative approach in individuals older than 65 years.
Ten subjects (83.4+/-4.5 years) undertook the test twice. To assess inter-rater reliability, three investigators timed the two
trials using a stopwatch (quantitative). The reproducibility of a qualitative evaluation of the trials was accomplished by the
completion of an assessment questionnaire (AQ) at each trial by three investigators. To assess the agreement between the
three investigators, the coefficients of reliability (CR), intra-class correlation coefficients (ICC) and limits of agreement were
determined for the total time to do the test (TT). The weighted Kappa K of Cohen and ICC was calculated for the AQ. Inter-
group comparison: 60 subjects (74.2+/-4.9 years) were divided equally into four groups: (1) sedentary with previous history
of falls, (2) sedentary without history of falls, (3) active with history of falls, and (4) active without history of falls. All of them
undertook the modified TGUG test once. One investigator undertook the timing and completed the AQ. CR values for the TT
were above 98% and with ICC of TT=0.999. The differences in TT between the three investigators' measures ranged from
0.19-0.55 s S.D. of the mean difference. Weighted Kappa K of Cohen ranged 0.835-0.976, with ICC of AQ=0.954. Inter-group
comparison study. Significant differences (p<0.05) were noted between the mean score of TT of Group 4 and the rest of the
groups, and between Groups 2 and 1. Significant differences (p<0.05) were noted between the mean score of points obtained
in the AQ of Group 1 and the rest of the groups. The modified version of the TGUG test demonstrated good sensitivity for
detecting fall risk in elderly individuals, and good inter-tester reliability from both a quantitative and qualitative perspective.

53. • Age Ageing. 2008 Jul;37(4):442-8. Epub 2008 May 30.
• Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's global judgement and fall history
in evaluating fall risk in residential care facilities.
• Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L.
• Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE-901 87 Umeå, Sweden.
ellinor.nordin@physiother.umu.se
• Abstract
• OBJECTIVES: to evaluate and compare the prognostic validity relative to falls of the Timed Up-and-Go test (TUG), a modified
Get-Up-and-Go test (GUG-m), staff's judgement of global rating of fall risk (GLORF) and fall history among frail older people.
DESIGN: cohort study, 6-month prospective follow-up for falls. Participants: 183 frail persons living in residential care
facilities in Sweden, mean age 84 years, 73% women. METHODS: the occurrence of falls during the follow-up period were
compared to the following assessments at baseline: the TUG at normal speed; the GUG-m, a rating of fall risk scored from 1
(no risk) to 5 (very high risk); the GLORF, staff's rating of fall risk as 'high' or 'low'; a history of falls in the previous 6 months.
These assessment tools were evaluated using sensitivity, specificity and positive and negative likelihood ratios (LR(+) to rule
in and LR(-) to rule out a high fall risk). RESULTS: 53% of the participants fell at least once. Various cut-off values of the TUG
(12, 15, 20, 25, 30, 35, 40 s) and the GUG-m showed LR(+) between 0.9 and 2.6 and LR(-) between 0.1 and 1.0. The GLORF
showed an LR(+) of 2.8 and an LR(-) of 0.6 and fall history showed an LR(+) of 2.4 and an LR(-) of 0.6. CONCLUSIONS: in this
population of frail older people, staff judgement of their residents' fall risk as well as previous falls both appear superior to
the performance-based measures TUG and GUG-m in ruling in a high fall risk. A TUG score of less than 15 s gives guidance in
ruling out a high fall risk but insufficient information in ruling in such a risk. The grading of fall risk by GUG-m appears of very
limited value.
• PMID: 18515291 [PubMed - indexed for MEDLINE]Free Article

54. • Age Ageing. 2007 Jan;36(1):78-83. Epub 2006 Dec 15.
• A comparison of different balance tests in the prediction of falls in older women with vertebral fractures: a cohort study.
• Morris R, Harwood RH, Baker R, Sahota O, Armstrong S, Masud T.
• Nottingham City Hospital, UK. rmorris2@ncht.trent.nhs.uk
• Abstract
• BACKGROUND: people with vertebral fractures are at high risk of developing hip fractures. Falls risk is important in the
pathogenesis of hip fractures. AIM: to investigate if balance tests, in conjunction with a falls history, can predict falls in older
women with vertebral fractures. METHODS: a cohort study of community-dwelling women aged over 60 years, with
vertebral fractures. Balance tests investigated were: 5 m-timed-up-and-go-test (5 m-TUG), timed 10 m walk, TURN180 test
(number of steps to turn 180 degrees ), tandem walk, ability to stand from chair with arms folded. Leg extensor power was
also measured. OUTCOME MEASURE: fallers (at least one fall in a 12 month follow-up period) versus non-fallers. RESULTS:
one hundred and four women aged 63-91 years [mean=78 +/- 7], were recruited. Eighty-six (83%) completed the study. Four
variables were significantly associated with fallers: previous recurrent faller (2+ falls) [OR=6.52; 95% CI=1.69-25.22], 5 m-
TUG test [OR=1.03; 1.00-1.06], timed 10 m walk [OR=1.07; 1.01-1.13] and the TURN180 test [OR=1.22; 1.00-1.49] [P <0.05].
Multi-variable analysis showed that only two variables, previous recurrent faller [OR=5.60; 1.40-22.45] and the 5 m-TUG test
[OR=1.04; 1.00-1.08], were independently significantly associated with fallers. The optimal cut-off time for performing the 5
m-TUG test in predicting fallers was 30 s (area under ROC=60%). Combining previous recurrent faller with the 5 m-TUG
improved prediction of fallers [OR=16.79, specificity=100%, sensitivity=13%]. CONCLUSIONS: a previous history of recurrent
falls and the inability to perform the 5 m-TUG test within 30 s predicted falls in older women with vertebral fractures.
Combining these two measures can predict fallers with a high degree of specificity (although a low sensitivity), allowing the
identification of a group of patients suitable for fall and fracture prevention measures

55. • Aging Clin Exp Res. 2005 Jun;17(3):181-5.
• Concurrent and predictive validity of "getting up from lying on the floor".
• Bergland A, Laake K.
• Faculty of Health Sciences, Oslo University College, Oslo, Norway. Astrid.Bergland@hf.hio.no
• Abstract
• BACKGROUND AND AIMS: Older age, higher morbidity and lower functional capacity are associated with fall injuries.
Inability to get up from the floor is associated with older age, higher morbidity and lower functional capacity. The purpose of
this study was to assess the concurrent and predictive validity of the ability of elderly women to get up from lying on the
floor. METHODS: In a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%) living in
the community, baseline registrations of ability to get up from lying on the floor, health and function were recorded. Serious
fall injuries during the subsequent year served as the outcome. RESULTS: 240 (78.2%) managed to get up independently. The
highest independent association was with items primarily related to mobility, e.g., ability to climb steps and performance on
the Timed Up & Go test (TUG). However, arthrosis of the hip and difficulty with walking indoors were among the variables
independently associated with the ability to get up from lying on the floor. During the follow-up year, 50.5% experienced
falls, of which one in four resulted in serious injury and one in eight in a fracture. The ability to get up from lying on the floor
was a significant predictor of serious fall-related injury (OR 2.1). Among those who experienced a fall, the risk of injury was
markedly higher for those unable to rise (OR 3.7). The positive predictive value of being unable to rise for serious injury was
0.30, indicating that nearly one out of three of the elderly women with such problems are predicted to experience a serious
fall-related injury during the following 12 months. CONCLUSIONS: The test "get up from lying on the floor" is a marker of
failing health and function in the elderly and a significant predictor of serious fall injuries.

56. • Arch Phys Med Rehabil. 2004 Feb;85(2):284-9.
• Get up and go test in patients with knee osteoarthritis.
• Piva SR, Fitzgerald GK, Irrgang JJ, Bouzubar F, Starz TW.
• Department of Physical Therapy, SHRS, University of Pittsburgh, Pittsburgh, PA 15260, USA. srpst24@pitt.edu
• Abstract
• OBJECTIVE: To determine the reliability, minimum detectable change (MDC), and validity of the Get Up and Go (GUG) test.
DESIGN: Repeated-measures test-retest for reliability. Correlational study for validity. SETTING: Institutional practice.
PARTICIPANTS: Convenience sample of 130 people, 105 with knee osteoarthritis (OA) (80 women; mean age, 62+/-9 y) and
25 healthy controls (21 women; mean age, 57+/-8 y). INTERVENTIONS: Not applicable. Main outcome measures Western
Ontario and McMaster Universities Osteoarthritis Index, the Activity of Daily Living Scale of the Knee Outcome Survey, and
the 8 scales of the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Intratester and intertester
reliability was.95 (95% confidence interval [CI],.72-.98) and.98 (95% CI,.94-.99), respectively. The MDC, based on
measurements by a single tester and between testers, was 1.5 and 1.2 seconds, respectively. Time to perform the GUG test
was longer for persons with knee OA than it was for the controls (mean difference, 3.3s; 95% CI, 1.8-4.9). Correlations
between the GUG test and measures of physical function did not differ significantly from correlations between the GUG test
and measures that do not specifically evaluate physical function. CONCLUSIONS: The GUG test is reliable and has an MDC
that is adequate for clinical use. Validity of the GUG test as a single measure of physical function was not supported. Further
research should include testing a battery of performance-based measures of physical function.

57. Where it all started!
• Arch Phys Med Rehabil. 1986 Jun;67(6):387-9.
• Balance in elderly patients: the "get-up and go" test.
• Mathias S, Nayak US, Isaacs B.
• Abstract
• The "get-up and go test" requires patients to stand up from a chair,
walk a short distance, turn around, return, and sit down again. This
test was conducted in 40 elderly patients with a range of balance
function. Tests were recorded on video tapes, which were viewed by
groups of observers from different medical backgrounds. Balance
function was scored on a five-point scale. The same patients
underwent laboratory tests of gait and balance. There was agreement
among observers on the subjective scoring of the clinical test, and
good correlation with laboratory tests. The get-up and go test proved
to be a satisfactory clinical measure of balance in elderly people.

58. Clinical Pearls
• Simple in clinic or hospital evals can provide a
general sense of pt fall risk and foundational
fitness

60. Summary
• Aging is a natural part of living
• Atrophy, Sarcopenia and disability can be
slowed or prevented
• Simple, daily choices can alter our own and
our patient’s course
• Simple clinical evaluations can be of value
• We can have great influence in our patient’s
health

61. “Physical fitness can neither be
achieved by wishful thinking nor
outright
purchase.”
Joseph Pilates

62. “First say to yourself what you would be; and
then do what you have to do”
Epictectus
Greek Stoic Philosopher AD 55–AD 135

63. • BIBLIOGRAPHY
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