1. Exercise in People with Frailty Syndroms

2. Frailty syndrome ( 衰弱綜合症 ) is a collection of symptoms or markers, primarily due to the aging-related loss and dysfunction of skeletal muscle and bone, that place (mostly) older adults at increased risk of adverse events such as death, disability, and institutionalization

3. Sarcopenia from the Greek meaning “poverty of flesh” is the degenerative loss of skeletal muscle mass and strength associated with aging (0.5- 1% loss per year after the age of 25). this loss of muscle mass may be caused by different cellular mechanisms than those which cause muscle atrophy Than there is a replacement of muscle fibres with fat and an increase in fibrosis

4. Muscle Structure and Atrophy

5. is a debilitating process that results in an extensive loss of muscle function and mass resulting in worsening of quality of life. It can take place with aging and inadequate food intake; it may also develop as a result of nerve injury Some of the treatments, such as anabolic steroids (testosterone) and insulin-like growth factor 1 (IFG-1), raise concerns about safety and effectiveness

6. Researchers discovered that des-acyl ghrelin has a direct anti-atrophic activity on the skeletal muscle of mice with muscular atrophy caused by either denervation (nerve injury) or fasting

7. Pathology Fiber-type changes in sarcopenia –During sarcopenia, there is a decrease in "type 2" fiber circumference (Type II), with little to no decrease in "type I" fiber circumference (Type I). Loss of satellite cell function –sarcopenia, is in part caused by a failure in satellite cell activation.the ability to repair damaged muscles or respond to nutritional signals is impaired. Loss of anabolic signals –Extreme muscle loss is often a result of both diminishing anabolic signals, such as growth hormone and testosterone, and promotion of catabolic signals, such as pro-inflammatory cytokines

8. Diagnosis 1) A low muscle mass, >2 standard deviations below that mean measured in young adults (aged 18–39 years in the 3rd NHANES population) of the same sex and ethnic background, and 2) Low gait speed (e.g. a walking speed below 0.8 m/s in the 4-m walking test).

9. Management Drugs –Testosterone, anabolic steroids, Human Growth hormone, DHES, and non-steroid androgen receptor modulators (SARMs) Diet Nutrition –An extract (EGb 761) from the plant Ginkgo biloba (added to drinking water) was shown to reduce the muscle loss in a rat

10. Exercise –Body’s function depends on regular and lifelong exercise to maintain integrity –increases in activity have been shown to be beneficial in settings of sarcopenia; exercise even in the very old can increase strength and muscle function. –Lack of exercise is currently thought to be a significant risk factor, increasing the likelihood of sarcopenia

11. Osteoporosis In osteoporosis the bone mineral density (BMD) is reduced, Bone microarchitecture is disrupted, And the amount and variety of proteins in bone is altered

12. a portion of a bone showing signs of osteoporosis (right) is contrasted with a portion of a healthy bone (left).

14. Estrogen's most important effect on osteoporosis appears to be prevention of bone breakdown, known as resorption. Healthy bones require a balance of osteoclasts (cells that breakdown bones) and osteoblasts (cells that make new bone)

15. As estrogen levels diminish, osteoclasts live longer than their counterparts, osteoblasts. This leads to bones being broken down at a rate much greater than they can be rebuilt, thus they grow weak and brittle.

16. Other Causes of Osteoporosis Diseases: many diseases can hamper the growth of new bone material. hyperthyroidism, disorders of the adrenal glands and pituitary gland, diabetes, and eating disorders. Medications: some medications can reduce bones ability to rebuild themselves. They are glucocorticoid medications, prednisolone, excess thyroid hormone replacement, the blood thinner heparin, and certain anti-convulsant medications.

17. Insufficient bone growth as a youth: Bones that didn’t get enough calcium early in life have a higher likelihood of becoming osteoporotic and fracturing as estrogen levels begin to decrease. Genetic factors: If a woman’s family members, especially her mother, have suffered from osteoporosis, the likelihood that she will develop the disease jumps dramatically. Genetics also helps determine the body type of a woman. If she inherited a small, thin body type, she is predisposed to osteoporosis.

20. Benefit of Exercise One of the best ways to strengthen your bones and prevent osteoporosis is by getting regular exercise. Even if you already have osteoporosis, exercising can help maintain the bone mass you have.

21. Weight-bearing Exercise for Osteoporosis Weight-bearing means one’s feet and legs support the body’s weight. –Walking –Hiking –Dancing –Stair climbing Walking as little as three to five miles a week can help build your bone health. For general health, at least half an hour of moderate to vigorous exercise five times a week. Forty-five minutes to an hour is even better.

22. Swimming and water exercise Swimming is not a weight-bearing exercise, because the buoyancy of the water counteracts the effects of gravity. Swimming will improve cardiovascular fitness and muscle strength. People with severe osteoporosis or kyphosis (hunching of the upper back) who are at high risk of bone fractures may find that swimming is their preferred activity. Water exercise, such as aqua aerobics and hydrotherapy, is also recommended. Consult with doctor or health care professional.

23. Resistance Exercise for Osteoporosis Resistance exercise increases bone density and reduces the risk of fractures. –Free weights or weight machines at home or in the gym –Resistance tubing that comes in a variety of strengths –Water exercises - any movement done in the water makes your muscles work harder. Two or three times a week. Gradually adding weight or repetitions and on different muscles - arms, chest, shoulders, legs, stomach, and back. do not resistance training on the same muscle group two days in a row. Give each muscle group time to recover.

24. Flexibility Exercise for Osteoporosis Important form of exercise for osteoporosis. Having flexible joints helps prevent injury. Having flexible joints helps prevent injury. –Regular stretches –T'ai chi –Yoga –Yoga

25. Precaution Talk to your doctor before beginning any exercise program Weight-bearing exercise does not have to be high impact. Already have osteoporosis, be careful of exercises that involve bending and twisting at the waist

26. Muscle weakness Refers to the inability to exert force with one's skeletal muscles. Muscle weakness is also a symptom used to describe a number of different conditions, including: lack of muscle strength, malaise, dizziness or fatigue Weakness often follows muscle atrophy and a decrease in activity, such as after a long bout of bed rest as a result of an illness. There is also a gradual onset of muscle weakness as a result of sarcopenia

27. Classification True weakness (Objective weakness or neuromuscular) describes a condition where the force exerted by the muscles is less than would be expected, for example muscular dystrophy. Patient suffers from amyotrophic lateral sclerosis (ALS), motor neurons are damaged and can no longer stimulate the muscles to exert normal force. Perceived weakness (Subjective weakness or non- neuromuscular) describes a condition where a person feels more effort than normal is required to exert a given amount of force but actual muscle strength is normal, for example chronic fatigue syndrome (CSF)

28. Myasthenia Gravis is true muscle weakness and a primary symptom of a variety of skeletal muscle diseases, including muscular dystrophy and inflammatory myopathy. This disorder occurs in neuromuscular junction muscle strength is normal when resting, but true weakness occurs after the muscle has been subjected to exercise

29. Asthenia is a medical term denoting symptoms of physical weakness and loss of strength A condition in which the body lacks or has lost strength either as a whole or in any of its parts occurs in many chronic wasting diseases, such as anemia and cancer, in diseases of the adrenal gland

30. also a side effect of some medications and treatments, such as Ritonavir (a protease inhibitor used in HIV treatment), vaccines such as the HPV vaccine Gardasil and fentanyl patches (an opioid used to treat pain). is also commonly seen in patients suffering from chronic fatigue syndrome, sleep disorders or chronic disorders of the heart, lungs or kidneys Differentiating between psychogenic asthenia and true asthenia with muscular weakness is often difficult,

31. Differential diagnosis Central muscle weakness manifests as an overall, bodily or systemic, sense of energy deprivation, Peripheral weakness manifests as a local, muscle-specific incapacity to do work. Neural weakness can be both central and peripheral

32. Lactic acid build-up was the cause of muscle fatigue can lower the sensitivity of contractile apparatus to Ca 2+ but also has the effect of increasing cytoplasmic Ca 2+ concentration through an inhibition of the chemical pump that actively transports calcium out of the cell

33. Lactic acid also has a negating effect on the chloride ions in the muscles, reducing their inhibition of contraction and leaving potassium ions as the only restricting influence on muscle contractions, though the effects of potassium are much less than if there were no lactic acid to remove the chloride ions

34. Pathophysiology

35. The sodium channels spontaneously close, potassium channels open, and positively charged potassium ions exit the fiber. Chloride channels also stay open, and negatively charged chloride ions enter the fiber. All these actions cause the inside of the fiber to become more negative (“repolarized”). The muscle fiber returns to its resting state, calcium is pumped back into the internal storage vesicles, and the fiber is now ready to accept another surge of positively charged ions in response to stimulation from a nerve fiber. (When several muscle fibers are at rest, a muscle can relax.)

36. Treatment Appropriate periods of rest Good hydration and nutrition and regular medical care. (e.g. Treatment of muscle weakness caused by electrolyte imbalance and/or dehydration) Rehabilitation, physical therapy, occupational therapy Regular program of exercise may be recommended Corticosteroid medications may be prescribed to reduce inflammation of the nervous system Caused by bacterial infections generally involves antibiotic medications Caused by anemia may involve blood transfusions

37. Discussion What is frailty syndrome, why it is so important for aged people. Why weight-bearing exercise has positive effect on osteoporosis. Can you compose a exercise prescription for people with muscle weakness