1. “Because it’s there.” George Leigh Mallory (1924)
A famous English journalist and adventurist, Mallory provided this famous retort in response to repeated questioning as to why he wanted to climb Mt. Everest. Mallory died on the mountain and his remains were finally found just a few years ago.

2. My Get-Up-and-Go Has Got Up and Gone
Presented by
Jeffrey Pearson, D.O.
Industrial & Sports Medical Center
San Marcos, CA

3. Parts of this talk stolen from

4. “Anyone can get old. All you have to do is live long enough.”
Groucho Marx

5. Our Older Population
People >65 years of age make up 12.5% of the population.
By 2050, estimated to be ~25%.
Americans have an increasing life expectancy:
Women live 18.6 years past 65.
Men live 14.7 years past 65.

6. Problems associated with aging
Elderly tend to be more sedentary than their younger colleagues.
Tend to suffer from medical problems that result in
functional impairment
less independence
greater utilization of healthcare services

7. How fitness can help Healthy lifestyle leads to a healthier life.
With exercise, people lead a more carefree life-style.
Exercise leads to less time spent in hospital/medical office.

8. “Old age is when everything that doesn’t hurt doesn’t work.”
Anonymous

9. With maturity comes change...
Cardiovascular
 maximum heart rate [HRmax=220-age]
Neurologic
 nerve conduction velocities; proprioception
Musculoskeletal
 bone loss,  muscle strength,  flexibility
 vertebral disc size/strength
Other
respiratory system, metabolism
Cardiovascular
decreased maximu, heart rate
Elevated systolic and diastolic blood pressure
decreased cardia output and stroke volume
Respiratory
Increase in work of breathing by 20%
Renal
decreased ability to strain blood
Metabolic
decreased water content
increased body fat.
Decreased glucose tolerance
decreased musle mass
Decline in resting metabolic rate
Neuropsych
decreased brain mass and cognitive function
decreased nerve conduction

10. When do disabilities begin?
Onset around age 60 for both sexes.
Nearly ¹/³ of people over 65 years of age have some impairment in performing activities such as walking.

11. “If I'd known I was gonna live this long, I'd have taken better care of myself.”
Eubie Blake

12. Benefits of exercise: general
Serves 2 major purposes
preventive
“lifetime pattern of physical activity ameliorates the ravages of aging.”
flexibility and strengthening program may reduce incidence of falls and bedsores.
therapeutic
Patients with strokes, arthritis, and fractures may regain some function.

13. Benefits of exercise: specifics
Cardiovascular
cardiac output/cardiovascular fitness, cholesterol profile, BP control
Respiratory capacity/function
Bone and muscle strength, flexibility, coordination
Psychological
mood,self-esteem
socialization

14. SI units of work are Joules (J) (1 Joule = 1 Newton meter).
W = KEf - KEi
KE = ½mv 2
Exercise is Work
Have to carry my sorry carcass x distance….
W = Fs W = (ma)s
= (v 2 - v02)/2 W = 1/2m(v 2 - v02) = KEf - KEi
PEg = mgy

15. Work
gravity
distance

16. “I'm not afraid of death, I just don’t want to be there when it happens.”
Woody Allen

17. Exercise: How safe is it?
Cardiovascular (CV) Disease
Leading cause of death in U.S.
Sudden/unexpected death is common in populations w/ high rates of CV disease.
Most sudden deaths occur in middle-aged and older individuals w/ advanced CAD and occur during a variety of activities, including exercise.
NOTE: cause of death in these cases is due to CAD and not exercise (although may be contributing factor).

18. Exercise: How safe is it?
Risk of death transiently increased during actual exercise period, but decreased for the rest of the day.
The overall risk of cardiac arrest for active men is much lower than sedentary men.
Everything is relative:
There has been a considerable increase in adult exercise participation over the past 20 years without a concomitant increase in sudden death rates in the United States.
Studies consistently show lower all-cause death rates in more physically active groups.

19. Exercise: How safe is it?
In Summary:
The risk of serious medical complications during exercise is low, but is higher than during sedentary activities.
The overall benefit/risk ratio for an active way of life is favorable.
Moderate exercise has the potential to enhance the health of many sedentary individuals and should be widely recommended.

20. “I have the rest of my life to improve, but it may take longer than that.”
Ashleigh Brilliant

21. Beginning an exercise program
Physician’s assessment
review patient’s needs and goals
outline progressive steps to achieve goals
refocus unrealistic goals!
Patient education
avoiding injuries
nutrition

22. The Medical Evaluation
History
past/current illnesses; previous injuries (and level of rehabilitation achieved); current medications
functional capacity
Examination
assess function
cardiovascular and musculoskeletal systems
sensory: vision, hearing, proprioception
assess nutrition
Conditions requiring caution
viral infection or cold
chest pain
irregular heart beat
exercise-induced asthma
prolonged, unaccustomed physical activity
conduction disturbances in heart
Conditions requiring moderation
extreme heat and high relative humidity
extreme cold (especially with strong winds)
following heavy meals
high altitudes
significant musculoskeletal injuries

23. The Exercise Prescription
Mode of activity
Intensity of exercise
Duration of exercise
Frequency of exercise
Rate of progression

24. Mode of activity Any activity that uses
large muscle groups
can be maintained for a prolonged period
rhythmic in nature
Key purpose of most exercise prescriptions is to increase or maintain functional capacity
aerobic endurance activities

25. Endurance Activities Group 1
easily maintained at a constant intensity and inter-individual variability in energy expenditure is low
walking, jogging, cycling

26. Endurance Activities Group 2 Group 3
rate of energy expenditure related to skill, but for given individual may provide constant intensity
swimming, cross-country skiing
Group 3
Highly variable in intensity
dancing, basketball, racquetball
When precise control of exercise intensity is necessary, as in early stages of a rehabilitation program, Group 1 and 2 activities are recommended.
Group 3 activities can be extremely useful because of the enjoyment provided in a physically active setting and because they may direct participatn’s attention away from anxieties, worries, and boredom.

27. Old Joke (Pre-Viagra)
Q: How many 50-year-olds does it take to screw in a light bulb?
A: None; their screwing days are long gone.

28. Intensity of exercise
Conditioning sessions should be maintained at 40-85% of functional capacity.
Healthy adults typically: 60-70%
Cardiac patients: start at 40-60%
Ideally, the participant should feel rested, and not
fatigued, within an hour following exercise.

29. Target exercise range: 119 - 145 bpm
Heart Rate Method #1
Simple fixed percentage of HR method
70-85% of maximal heart rate corresponds to about 60-80% of functional capacity.
HRmax=220-age
Example: = 170 bpm Hrmax
170 x .70 =119 bpm 170 x .85 = 145 bpm
Target exercise range: bpm

30. Heart Rate Method #2 Heart Rate Reserve/Range Method
60-80% of the HRR corresponds to 60-80% of the functional capacity.
Calculate the HRR
HRmax - HRresting = Heart Rate Reserve (HRR)
Calculate conditioning intensity
Multiply HRR by desired intensity
Calculate target HR
Add HRresting

31. Example: 60 y.o. with resting HR of 70 bpm
Lower Limit Higher Limit
Maximal HR
Resting HR
HRR
Conditioning intensity x x .80
Resting HR
Target HR

32. How doctors look at intensity (Feel free to forget this stuff right away)
METs
one MET is equivalent to the amount of energy used at rest (oxygen uptake of 3.5 ml/kg/min)
Varies with speed of movements and changes in resistance
ADL’s require 5 METs
METS
Exercise capacity as measured in METS provides clinically relevant data. Patients should be able to meet a minimal exercise requirement of 5 METS, which corresponds to basic activities of daily living. Those who cannot achieve this level, even with a normal ECG, generally have a poor prognosis. Another important marker is 10 METS. If patients with CAD can reach this level, they are considered aerobically fit and their prognosis is likely to be similar whether they're treated with medical therapy or revascularization.
Beyond 13 METS, abnormal ECG findings are more likely to be falsely positive, and the patient's prognosis tends to be good. Arrhythmias in an elite athlete exercising above 13 METS, for example, often can be attributed to athletic heart syndrome, and a work-up may not be necessary.

33. Leisure activities in MET’s
Billiards
Bowling
Boxing (sparring)
Climbing hills
Cycling (pleasure)
Dancing (social, square, tap)
Dancing (aerobic)
Fishing (from bank)
Football (touch)
Golf (cart)
(Walking/carrying bag)
Handball
Rope skipping
Running (12 minute mile)
Shuffleboard
Tennis
2.5
2 - 4
8.3
5 - 10
3 - 8
6 - 9
6 - 10
2 - 3
4 - 7
8 - 12 9
8.7
4 - 9

34. Rating of Perceived Exertion
Category RPE Scale Category-Ratio RPE Scale
Nothing at all
7 Very, very light very,very weak
Very weak
9 Very light 2 Weak
Moderate
11 Fairly light 4 Somewhat strong
Strong
13 Somewhat hard 6
Very strong
15 Hard 8
17 Very hard Very, very strong
* Maximal
19 Very, very hard 20
Using the 15-point scale:
- a perceived exertion rating of corresponds to approximately 60% of the heart range range
- A rating of 16 corresponds to approximately 85% of the heart range range.
- Consequently, most participants should exercise within the RPE range of (“somewhat hard” to “hard”).
[NOTE: small percentage of participants tend to select unrealistic PRE scores, hence this method may be inappropriate for them.
“Fast enough so that you can talk, but not sing.”

35. “Time is a great teacher, but unfortunately it kills all its pupils.”
Hector Berlioz

36. Duration of activity
Conditioning period (excludes warm up and cool down periods) may vary from minutes
typically minutes
this length required to improve or maintain functional capacity
Significant cardiovascular improvements have been obtained with exercise sessions of 5-10 minutes duration with an intensity of more than 90% of functional capacity. However, high intensity-short duration sessions are not desirable for most participants and better results are obtained with lower intensities and longer durations.
Such programs are preferred because they may carry lower risk of orthopedic injury.
Multiple short bouts (approximately 10 minutes) of exercise distributed throughout the day may be optimal for some participants.

37. Frequency of Exercise Sessions
Depends, in part, upon the duration and intensity of the exercise session
Functional capacity <3 METs
5 minute sessions, several times/day
Functional capacity 3-5 METs
1-2 daily sessions
Functional capacity >5 METs
at least 3x/wk on alternate days (aim for 5 days total)

38. Rate of Progression Initial conditioning stage
usually lasts 4-6 weeks, but depends upon initial functional capacity and rate of adaptation.
Should include light calisthenics and low level aerobic activities with which the participant experiences a minimum of muscle soreness.
Discomforts usually arise when program fails to allow for gradual adaptation.
Person with low fitness level or limited by CAD may spend as many as 6-10 weeks in the initial phase, while the participant with a higher fitness level may not need to participate more than a few weeks in the initial phase
Necessity for individual modifications cannot be overemphasized; health status must be considered in the rate of progression.
At onset of exercise program, individual goals need to be established. Must be realistic. Develop a system of rewards (tangible or intangible), too.

39. Rate of Progression Improvement conditioning stage
Typically lasts 4-5 months.
Aerobic conditioning is progressed at a more rapid rate.
Intensity increased to target level
Duration increased every 2-3 weeks
Less fit individuals may need more time.
Duration of exercise should be increased to minutes before increasing the intensity.

40. Rate of Progression Maintenance conditioning stage
Usually begins after first 6 months of training
Participant reaches satisfactory level of cardiorespiratory fitness
Should review the conditioning objectives
More enjoyable or variable activities may be substituted for those used previously
helps avoid dropping out due to boredom of repetition

41. Sample Progression Program

42. “I am sick of all this nonsense about beauty being only skin deep
“I am sick of all this nonsense about beauty being only skin deep. That’s deep enough. What do you want, an adorable pancreas?”
Jean Kerr

43. Other Fitness Components
Flexibility
Lack of flexibility may be associated with increase risk for low back pain and other injuries
Stretching exercises should be performed slowly, in a controlled manner
15-20 seconds per repetition
4 repetitions of a particular stretch per set
at least 3x/week

44. Other Fitness Components
Muscular strength and endurance
No direct relationship to cardiorespiratory fitness or functional capacity
however, many tasks require some degree of strength, e.g. lifting/moving objects
The stronger the individual, the less stress placed upon the body performing tasks
Strength exercises help to maintain muscle mass as we become older (“Use it or lose it.”)

45. Other Fitness Components
Muscular strength and endurance
Begin with low resistance, high repetitions to develop muscle tone
20-30 reps with light weight per set
Optimal strength gains occur when the resistance allows for no more than 5-8 repetitions of a movement, for 3 sets
you can still make strength gains with lower resistances

47. “Catflexing”

48. “Catflexing”

49. Nutrition Carbohydrates for fuel Protein for re-building
60%+ of total daily calories
complex>simple
Protein for re-building
15%+ of total daily calories
Fat for energy storage (1 lb. = 3500 Kcal)
25% (or less) of total daily calories
avoid saturated and hydrogenated types
Simple/Refined sugars:
refining strips substance of nutritional value
High simple sugars promote insulin release;
Insulin stores fat in cells.
Protein: fat often found in protein sources, so be careful.
Choose lean meat; trim visible fat;

50. Nutrition Fluids Sodium Plain water best for most people
Drink 1-2 eight ounce glasses before exercise
Repeat every 20 minutes of exercise
Sodium
Normal daily intake about 2000 mg
Never consume salt tablets on hot days!

51. Injury/Illness Treatment and Prevention
Ice is nice!
P.R.I.C.E.S.
Sunscreen
SPF 15 or greater
Proper footwear
Tie shoelaces!

52. “The secret of staying young is to live honestly, eat slowly, and lie about your age.”
Lucille Ball

53. The End
Thank you!