The Aging Musculoskeletal System Flashcards
What is the most common self-reported medical conditions in the US for adults?
Musculoskeletal diseases
Type I, IIa and IIb fibers
I: Oxidative, slow twitch, aerobic
IIa: aerobic, oxidative but also glycolytic pathways
IIB: anaerobic, glycolytic pathways
Sarcopenia definition
Age related loss of skeletal muscle mass, related to decreases in bone mass. Prevalence of sarcopenia in people with osteoporosis 50%
What 4 factors are related to muscle mass?
Age, weight, physical activity, and bone density
Cost of sarcopenia in 2000
18.5 billion, about 1.5% of healthcare costs.
Age related sarcopenia affects which type of muscle fibers the most?
Type II
2 most important components of the fibrous extra cellular matrix?
Collagen and elastin, insoluble proteins
What do proteoglycans, elastin, and collagen do?
Proteoglycans provide hydration, stabilize collagen networks, resist compressive forces. Collagen: tensile strength. Elastin: elasticity
2 types of bone
Cortical, (shaft) and cancerous or trabelucar (vertebrae, ends of bones, spongy)
Where does bone loss occur initially with osteoporosis ?
Trabecular bone
Describe the process of bone loss in women
20-30% loss of cancerous bone and 5-10 of cortical bone continuing for 4-8 years. Then enter slower phase, similar to men, of 20-25% for rest of lift.
3 major factors affecting bone loss
Hormones: e.g. Parathyroid, calcitonin, estrogen,
Nutrition
Diseases e.g. Celiac, chron, RA
Definition of frailty-factors-5 factors
Clinical syndrome with 3 or more of the following:
Weakness in grip strength
Slow walking speed
Low physical activity
Unintentional weight loss (10 lbs in past year)
Self-reported exhaustion
Normative values for the 6MWT in apparently healthy men and women:
60-69
70-79
80-89
Men: 560 Women: 505 Men: 530 Women: 490 Men: 446 Women: 382
What is the Senior Fitness Test by Rikli and Jones?
6MWT, 2 minute step test, limits ceiling effect in high-functioning adults.
Overweight BMI
Obese
> /equal to 25
Great than or equal to 30
Kg/meters squared
Obese cutoffs for waist circumference
102 cm in men (40 in)
85 cm 35in in women
Normal waist to hip ratios
Men: less than or equal to 1.0
Women: less than or equal to .8
A height loss of more than how many cm suggests vertebral compression fracture?
2
Single best predictor of decline in health and function
Slow gait speed
A normal gait speed in well-functioning older adults of less than _____ m/s identifies those at high risk of functional limitation, hospitalization, and death
1
Normal gait speed values for men and women <80 and >80
1.1 and .8
Those that perform the TUG in ______ generally dependent
20, 30
Community dwelling older women should be able to complete the TUG in ____ seconds or less
12
One leg stance time for
50-59
60-69
70-79
29
22
14
Four square step test: those greater than ____ seconds history of falls, less than ____ seconds no history of falls in the previous 6 months
15
The cutoff score of 45 on the Berg can be good for what and problematic for what?
Sensitivity of only 25-45% to predict those at risk of falls, but does have a high specificity for those not at risk of falls. Page 5
Positive likelihood ratios more helpful, for example, <40 5.19 PLR of predicicting multiple falls
Cutoff score for Fullerton Advanced Balance scale
Less than or equal to 25 out of 40 can predict community dwelling older adults at high risk of falling
5TSTS normal scores
60-69
70-79
80-89
- 4
- 6
- 7
30 second chair rise norms
60-69
70-79
80-89
14
13
12
Ankle plantar flexion test, how performed, values men and women 61-80 years
Test stopped if lose 50% ROM, LOB, knee flexion
4.1 men, 2.7 women
Normal mean grip strength range for women 60 through >85 and men
Women: 20 decreasing to 14 with age (about 2 less for non-dominant hand)
Men: 35 down to 20
How to measure kyphosis with flexible ruler, clinical kyphosis is what value
100 time thoracic width/thoracic length. > or equal to 13
A wall occipital distance of greater than _____ cm in women rules in a thoracic fracture with high accuracy
7 cm, but if 0cm does not rule one out
Positive rib/pelvis distance findings
Less than or equal to 2 fingerbreadths, further evaluation should be performed, greater than 2 rules out lumbar vertebral fractures with high degree of certainty
What does the chair sit and reach test measure? How is it done?
Examine sits with one leg straight, hands on top of one another, reaches toward toes, distance from tip of middle finger to tips of toes is the score. If further than toes, positive value, if less than toes, negative value. Not appropriate for someone with osteoporosis
Physical Performance Test. 2 versions, and cut-off score
Is a multidimensional test 7 and 9 items, 7 doesn’t have 2 stair climbing tasks. 0-4, unable to most capable. 15 is cutoff score with sens and spec in the the 70s
What is the Senior Fitness Test?
Multidimensional. 7 items to assess UE and LE strength and flexibility, aerobic endurance, agility/dynamic balance. Norms 60-94 year in 5 year increments
Difference in 6MWT and 400m corridor walk test?
400 meter people generally work harder
Arthritis effects what percentage of adults 65 and older
1 in 2, 50%
Non-modifiable risk factors for arthritis:
Age, genetics
Modifiable risk factors for arthritis:
weight, joint injuries, infections, occupations involving repetitive squatting,
Others include reduced proprioception, poor joint biomechanics e.g. Laxity, and muscle weakness and inactivity
OARSI recommendation for arthritis
Physical activity (strength, aerobic, water) and use of NSAIDs but also confirms GI toxicity of non-selective NSAIDs and increased risk of MI for selective rofecoxib p 9
Corticosteroid injections vs hyaluronate
Hyaluronate slower onset but prolonged symptomatic relief
3 progressive stages of RA
- Swelling of synovium, causing pain, warmth, stiffness, erythema, joint effusion
- Rapid division and growth of cells causing thickening of synovium
- Release of enzymes from inflamed cells causing bone and cartilage destruction.
Interventions recommended for RA
High intensity strength and aerobic training, quad strengthening
Top 3 fractures due to osteoporosis
Most common: vertebral, then wrist, then hip, and both morbidity and mortality are increased following hip and vertebral fractures
Shumway Cook deterred those without mobility impairments demonstrate which throughout the community?
Driving, walking 1200 feet per errand, maintaining walking speed of those around them, carrying packages weight 7 lbs, negotiating 2 flights of stairs, walking on grass, reaching multiple directions, changing directions and head orientation, avoiding collisions with pedestrians
Shumway cook found how many community dwelling people had falls at 6 month follow up, how many had more than 2, and how many re-admitted to the hospital?
53%, 62% more than 2, 18% hospital
What happens to the ligamentum flavum aging?
Increase in elastin which decreases capacity to provide stability
3 factors that can limit spine degeneration
Physical activity, proper nutrition, avoidance of smoking
Low back disorder account for _____% of all health care visits for people 75 or older
81
Hayden et all found that what reduced the most pain and what improved function the most in terms of low back pain
Stretching-pain, strengthening, function, combined with another modality such as NSAIDs, manual therapy, passive modalities
What did Rackwitz et all find about spinal segmental stabilization exercises
More effected than general practitioner treatments for low back pain and equally as effective as other physical therapy interventions
How are correlations in shoulder and neck pain similar?
Women, less education, several other health issues
About what percent of people aged 50 to more than 80 have rotator cuff tears?
51%
ROM limitations with adhesive capsulitis?
ER first, then IR and And
Which disease often corresponds with adhesive capsulitis
DM, and recovery less favorable for these people too
How to best treat adhesive capsulitis most recent evidence
Supervised neglect (don’t force it) AROM and pendulum within limits of pain, NSAIDs, better than pushing beyond the pain threshold. Also PT and steroid injection better short term relief than either other.
When is hydroplasty/hydraulic distinction indicated for adhesive capsulitis
If no ROM improvements in 3 months. Manipulation may be used for people who don’t improve after 6 months
AAOS guidelines for GH arthritis 5 points
Inconclusive evidence to recommend for or against PT, pharmacy, or inject. Corticosteroids for initial treatment of GHJO
Weak evidence to support use of injectable viscosupplementation
Inconclusive evidence regarding arthroscopic treatments such as debridement, chondroplasty,
Total shoulder is an option, keeled or pegged all polyethylene cemented glenoid components is best, not to be performed in people with irreparable tear
“Unable to recommend for or against PT following shoulder arthroplasty”
What is a Colles fracture?
Distal radius
Menz et all found what 3 factors in the ankle accounted for up to 59% of balance
Ankle flexibility, plantar tactile sensitivity, toe plantar flexor strength
AAOS Recommendations for knee OA 7 points
Evidence inconclusive for values directing force brace for medial OA
Lose weight
Low impact aerobic fitness, quad strengthening, ROM
Glucosamine and/or chondroitin or hydrachloride not recommended
Acetaminophen and NSAIDS can help
Intra-articulate injections recommended for short-term pain relief
Needle lovage and arthroscopy not recommended
How can a rigid orthotic be beneficial for the foot?
Help overpronation, decrease excessive motion at the ankle, knee, and hip, and to improve balance
Diabetic osteoarthropathy, definitions, also called? Treatment as soon as diagnosed radiographically
Charcot joint, rare but can cause severe consequences due to risk for wounds. Should have immediate relief of pressure, custom fitted walking boot, rest.
Vertebroplasty vs Kyphoplasty
Both transpedicular approach, both cement injects, but kypho. Balloon used first to create cavity so less chance of cement leakage, . Both increased risk of adjacent vertebral body fracture due to altered loading patterns.
Which type of patient can benefit from an interspinous process device?
Someone with stenosis who has relief of buttock/LE pain with spine flexion and return of pain upon standing
Oh et al found that poor prognosis for rotator cuff repair if what 3 factors
Full thickness tear, symptoms >1 year, functional weakness/disability. Surprisingly Age not a factor. There is limited literature on the indications for a timing of RCR.
Indications for hemiarthroplasty of shoulder
If sufficient glenoid cartilage, if RC tendons irreparably torn, if glenoid bone insufficient to receive a glenoid component
Benefit of TSA compared to hemi in people with RA
Better long term pain relief, ER, elevation, ROM, lower revision rate
TSA post op guidelines for sling, PROM, immobilizer
Immobilized during day 1 week, at night 1 month, sling 4 weeks, PROM initiated day one postop and continues for 5 weeks. Limits of PROM determined by surgeon. At 3 weeks pulleys, at 5 weeks AAROM and stretching with wand, and light ISO started.
Most common cement for THA?
Polymethylmethacrylate, cemented allows for full weight-bearing immediately
What did Suetta et al find about THA rehab in groups with standard rehab (home-based, exercises without resistance) standard rehab plus NMES, and SR plus resistance training
Length of stay shorter for RT, functional skills improved for both RT and NMES. Quad cross-sectional area increased in RT and NMES, but more with RT, but decreased SR. Basically rehab with closely monitored RT is the best
What did Trudell-Jackson and Smith find about THA and what to do about people not achieving full strength after first bout of therapy
At 4 -12 months gave experimental group individual home-based program for 8 weeks, control group just had ROM and isometric exercises, the experimental group had improvement on function, strength, postural stability, suggesting return to PT after several months should be considered.
Which 4 components need to be considered when prescribing exercise
Mode, frequency, duration, intensity
What does the 2007 Physical Activity and Public Health in Older Adults: Recommendation from ACSM and AHA say for aerobic intensity
Reps for resistance training
Flexibility training
Balance training
50% to 85% of VOR, or 5-6/10 RPE
10-15 may be more appropriate than 8-12 if frail
Stretching for 10 minutes on all days that aerobic/resistance training occurs.
Balance insufficient evidence that it should be incorporated for people who don’t have history of falls
See P20 for table for exercise recommendations
P 20!
According the the ACSM, people at low risk of cardiovascular events meet which criteria, therefore may not need exercise testing prior to program. Which should have testing?
No Testing: Men <45 women <55, asymptomatic, no more than one risk factor
Testing: Greater than these ages, 2 or more risk factors for vigorous exercise. If high risk e.g. Symptoms or known disease recommend testing even for moderate exercise
What are the ACSM cardiovascular risk factors? 7
Family history Cigarette smoking HTN Dyslipidemia >200mg/dL or HDL <40 LDL >130 Impaired fasting glucose Obesity Sedentary lifestyle
What did Miszko et all find about power training?
Group that did 40% 1 rep max as fast as possible improved in physical function more than group that did 80% slowly
What did Westcott et all find about slower speed RT
10s concentric 4 second eccentric at 4-6 of 5RM had 50% greater strength gains than 2 second concentric 4 second eccentric 8-12 10RM
Benefit of eccentric training in older adults?
Less cardiovascular stress
USDA recommends ____L of water per day for men and _____L for women 51 or older
- 7
2. 7
USDA recommends _____ g/kg/day of protein for men, and ______ for women 50 or older
.8 or about 56 g/day for men
.8 or about 46 for women
The RDA for calcium in adults 50 or older is _____mg/day
1200
RDA for vitamin B12 for adults 50 and older is ____ micrograms (ug)/day
2.4, many adults malabsorb it so recommend fortified food or supplement, found in meet, fish, poultry
RDA for VitD in adults 50-70 is ______ IU/day and 70 and older is ______
400
600
what types of foods have VitD?
Fish liver oils, egg yolks, flesh of fatty fish
What is Vit D deficiency called in children vs adults
Rickets in kids
Osteomalacia
Normal serum range of Vit D
30-74 nanograms per mL, measured by 25-hydroxy VitD test [25(OH)D]
VitD deficiency associated with which symptoms?
Bone pain, muscle weakness, cognitive impairments, increased mortality from cardiovascular disease and some cancers
What did recent research find about the current recommendations for Vit D
Optimal serum concentration between 36 and 40, looked at LE function, falls, fractures, colorectal cancer, and dental health To reach these levels, 600 IU per day was inadequate, actually required about 1000 IU per day
What is the criteria called used to analyze and evaluate medication use to decrease medication related problems in older adults
Beers criteria
18 medications considered potentially inappropriate medications for older adults according to the Beers criteria P27
Analgesic propoxyphene (Darvon) Meperidine (Demerol) Pentazicine (Talwin) narcotic The NSAID indomethacin (Indocin) Trimethobenzamide (Tigan) Most muscle relaxants and antispasmodic Long acting benzodiazepines Amitriptyline and Amitriptyline combinations (Elavil, Limbitrol, Triavil) Antidepressant doxepin (Sinequan) Anxiolytics meprobamate (Miltown and Equanil) Reserpine Short acting dipyridamole (Persantine) Diphenhydramine All barbiturates except phenobarbital Orphenadrine (Norflex) Guanadrel (Hylorel) Doxazosin (Cardura) Thioridazine (Mellaril) Short-Acting nifedipine (Procardia and Adalat) Cimetidine (Tagamet)
These can depress CNS causing hypotension, sedation, weakness, falls injury
Which criteria may be better than the Beers for identifying a higher proportion of again adults requiring hospital admission due to drug-related events.
STOPP Screening Tool of Older Persons potentially inappropriate Prescriptions
7 types of drugs in the STOPP criteria
Tricyclic antidepressants
Long acting benzodiazepines
Long-term opiates
First generation antihistamines(increase falls)
Neuroleptics (when already prone to falls) “pine”
Vasodilators (when already prone to falls)
Oral corticosteroids, long term use (risk of osteoporotic vertebral fracture)
What can statins cause in older adults?
Myopathy-pain, decreased muscle strength, mitochondrial dysfunction
following termination of oral prednisone or prednisolone use, of 6.7 mg/d or more, it takes ______ (time) to reduce risk of fracture to a degree similar to people not taking them
1 year
Long term proton pump inhibitor use have increased risk of what type of fracture?
Hip, higher for men than women, calcium malabsorption may be why
What type of oral antidiabetic agent is associated with increased risk of fractures at the hip, spine, arm, foot, wrist, and hand
Thiazolidinediones
Also called glitazones
Can be used in combination with metformin or sulfonylureas
Insulin sensitizer
SSRIs associated with what type of fractures and what other problems
Minimal trauma fractures (fragility fractures)
Falls
Lower hip bone and spine mineral density
STOPP criteria contraindications for NSAIDs
Ulcers, HTN, hear failure, chronic renal disease, with warfarin. Shouldn’t be used as long term treatment for OA or chronic gout (when contraindication to allopurinol is not present-chronic heart failure, kidney failure, liver problems)
