“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.

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

Parts of this talk stolen from

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

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.

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

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.

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

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

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.

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

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.

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

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

Work gravity distance

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

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).

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.

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.

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

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

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

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

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

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

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.

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.

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.

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: 220 - 50 = 170 bpm Hrmax 170 x .70 =119 bpm 170 x .85 = 145 bpm Target exercise range: 119 - 145 bpm

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

Example: 60 y.o. with resting HR of 70 bpm Lower Limit Higher Limit Maximal HR 160 160 Resting HR -70 -70 HRR 90 90 Conditioning intensity x .60 x .80 54 72 Resting HR + 70 + 70 Target HR 124 142

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.

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 3.7 - 7.4 6 - 9 6 - 10 2 - 3 4 - 7 8 - 12 9 8.7 4 - 9

Rating of Perceived Exertion Category RPE Scale Category-Ratio RPE Scale 6 0 Nothing at all 7 Very, very light 0.5 very,very weak 8 1 Very weak 9 Very light 2 Weak 10 3 Moderate 11 Fairly light 4 Somewhat strong 12 5 Strong 13 Somewhat hard 6 14 7 Very strong 15 Hard 8 16 9 17 Very hard 10 Very, very strong 18 * Maximal 19 Very, very hard 20 Using the 15-point scale: - a perceived exertion rating of 12-13 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 12-16 (“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.”

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

Duration of activity Conditioning period (excludes warm up and cool down periods) may vary from 15-60 minutes typically 20-30 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.

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)

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.

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 20-30 minutes before increasing the intensity.

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

Sample Progression Program

“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

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

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.”)

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

“Catflexing”

“Catflexing”

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;

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!

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

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

The End Thank you!