SEM 4 - Aging Adults wk 4- waiting for wk 4 live session

body composition changes in aging adults

Physiologic changes

↓ Lean body mass

• ↓ Muscle mass

• ↓ Creatinine production

• ↓ Skeletal mass

• ↓ Total body water

• ↑ Percentage adipose tissue

clinical changes

Changes in drug levels

• ↓ Strength

• Susceptibility to dehydration

Muscle Changes with Aging

Greater loss of type II fibers as age

Remaining type II fibers decrease in size

• Neuromuscular junction adaptive remodeling

• Muscle fibers replaced with fat or collagen

• Decrease in size of motor unit

• Increase in collagen

• Decrease in elastin

Connective Tissue Changes with Aging (Cartilage)

↓ Water content

• ↑ Fibrous tissue

• ↓ Chondrocytes for repair

• ↓ Hyaluronic acid - less lubrication

• ↓ Tissue height

• ↑ Susceptibility to failure

**THink iV discs (less water and more fibrous tissue so more tearing)

Joint Changes with Aging

Physiologic changes

Degeneration of cartilaginous tissues

• Fibrosis

• ↑ Cross-linking of collagen

• Loss of tissue elasticity

Clinical changes

Tightening of joints / Decreased

flexibility

• Susceptibility to osteoarthritis

Bone Changes with Aging

Decreased ________ activity leads to ______ bone mass and density

osteoblast // decreased

Bone Changes with Aging

Decreased _____ absorption (particularly in trabecular bone)

(spongy part of the bone)

calcium

Bone Changes with Aging

Decreased bone ______ strength due to qualitative changes in bone mineral content and structure

tensile

most prevelent self reported limitations

musculosketal conditions by far (arthritis leading followed by back and neck injuries)

sacropenia

The progressive loss of skeletal muscle mass and strength with aging

Muscle mass decreases approximately_____ per decade after the age of 30 and this rate of decline is even higher after the age of 60

3–8%

Sarcopenia is a _____ process

multifactorial

________ increases the risks of falls and vulnerability to injury and, consequently, can lead to functional dependence and disability

Sarcopenia

Estimates of sarcopenia prevalence vary from _____, depending on the definition used

9.9 to 40.4%

Contributing Factors to sacropenia

Disuse atrophy

Loss of alpha motor neurons

Hormonal changes - more in women

Inflammatory effects

Mitochondrial dysfunction

Oxidative stress

Altered caloric intake/nutrition - inadequate protein intake

Physical activity levels

Assessment for sacropenia

• muscle mass

• muscle strength

• physcal erfromance

• grip stregth or MMT or gait speed or balance assessment

SARC-F

s - strength

a - assistance in walkingn

r - rise from a chair

c - climb stairs

f - falls

we are asking not watching them do it

Clinical Implications of sacropenia

All cause mortality

• Postoperative infection

• Longer hospital stay

Patients with sarcopenia are at increased risk of falls and increased degree of functional limitations and disabilities.

Interventions for sacropenia

Resistance Training

Endurance Training

Nutritional Consultation

Osteoporosis

increased bone weakness that increases the suspectibility of a broken bone

Systemic skeletal disease with low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.

osteoporsis

After attaining peak bone mass at age ____, men and women lose bone at a rate of approximately _____% per year, respectively.

30

0.3% and 0.5

Bone loss in _____ is accelerated further by a deficiency in ____ at a rate of 2% year during menopause and continues for 6 years thereafter.

women // estrogen

Osteoporotic fractures

(fragility fractures, low-trauma fractures)

falll from standing height or anything with no trauma

One in ____women and up to one in four men over age 50 will break a bone due to osteoporosis.

two

Fractures of the hip and spine are associated with an increased _____ rate of 10 to 20 percent.

mortality

_______ may result in limitation of ambulation, depression, loss of independence, and chronic pain.

Fractures

Prevalence of Osteoporosis

higher in women and 65 and older

Prevalence of Low Bone Mass

higher in women but not signifantly

primary - TYPE 1 osteoposis - post menopausal

loss of estrogen

bone reabsoption exceeding bone formation

predomiately lose in trabular bone compared with cortical bone

higher risk for spinal and risk fractures

primary - TYPE 2 osteoposis - age related

both male and female

long term calcium defiency (thinning if bone)

loss of the cortical outer bone and trabecular bone

results in hip fx

secondary osteoposis

clearly defineable ideological mechanism

common in diabetes

long term use of cortical steosids

Risk Factors for osteoposis

Age - rise in parathyroid hormone level

Genetics - white people have the greatest risk of osteoposis

Nutrition - high cafeine, animal protein,

Lifestyle - cig use, low PA

Endocrine - menopsaul age, obesisty

Assessment for osteoposis

bone mineral denisty using an Xray (usually spine hip and forearm)

shows a T score (healthy young adult in your age)******

shows a ZSCORE - This compares bone density with other people of your age, gender, and size. • -2.0 means that you have less bone mass than someone your age.

T score cut offs

-1 to -2.5 low bone density (osteopenia)

lower than -2.5 is osteoposisis

Clinical Implications

Decrease in overall height

Increased thoracic kyphosis

Breathing difficulties

Abdominal pains

Digestive discomfort

Pain

Impact of mobility

Impact on quality of life

Physical Therapy Examination - for osteoposis

Anthropometric measure: height

• Muscle performance

• Posture: thoracic kyphosis

• Range of motion

• Ergonomics and body mechanics

• Gait, locomotion, and balance

Wall-occiput test

test thoracic kyposis or thoracic vesteral fracture

should be 0 cm

rib pelvis distance test

rib pelvis distance of 2 or less fingerbreaths is positve

Physical Therapy Interventions for osteoposis

Increase and/or maintain bone density

Posture and body mechanics - extension exercises

Balance and fall prevention

Pharmacological Treatment for osteoposis

calcium

anti-restortive

vit D

**less than -2.5 requires aggressive therapy with anti abortive agents

Fractures and the Aging Adult

The most common fractures in older adults are vertebral fracture from compression or trauma, followed by hip and distal radius fractures.

most common low energy trauma fx

veteral fx then hip fx

Patients report a lower quality of life at _____ to _____ months after a fracture.

12 and 24

(veterbal fx)

Physical Therapy s/p Vertebral Fracture

Minimize bed rest

• Patient education

Body mechanics - avoid bending and twisting

Stabilization exercises - need a strong core

• Exercise

• Spinal extensions (DO NOT WANT TO BE IN FLX)

• Strengthening

• Postural re-training - focus on getting them more upright

• Ergonomics

• Balance exercise******

only 40-60 percent are diagnosed that have a veteral fx

Vertebral Augmentation (2)

Percutaneous vertebral augmentation:

• Vertebroplasty

• Vertebroplasty entails injecting liquid cement into a collapsed vertebral body through a needle

• Kyphoplasty

• Kyphoplasty involves percutaneously injecting a balloon into the vertebral body, inflating it to

restore vertebral height, and injecting cement to reduce pain

More than 95% of hip fractures are caused by _____

falling, usually by falling sideways.

Women experience _____ of all hip fractures

three-quarters

_______ are associated with significant morbidity, mortality, loss of independence, and financial burden

Hip fractures

Hip Fracture – Surgical Management ——— Open Reduction Internal Fixation (ORIF) and tx

Secure the fragments of the femur to each other (fixation) by using metal plates, screws, wires, or pins.

Post Operative Rehabilitation

• ROM

• LE strengthening

• Mobility training

• WBing precaution is variable*****

Hip Fracture – Surgical Management ———Hemiarthroplasty and THA and tx

Hemiarthroplasty

• If the femoral head is fractured, but the acetabulum is intact, a hemiarthroplasty may be indicated.

Total Hip Arthroplasty (THA)

• If the fracture involved the acetabulum, a total hip arthroplasty may be indicated

Post Operative Rehabilitation

• ROM

• LE strengthening

• Mobility training

• WBing precaution is variable

• Hemiarthroplasty tend to NOT have movement

restrictions (as with THA)

Hip Fracture – Conservative Management

Nonoperative treatment of hip fractures (bed rest or early weight bearing) was administered based on medical assessment of perioperative risk aka high risk and choosing to do it consertiviley but higher risk of death unless mobility training

Rehabilitation

• ROM

• LE strengthening

• Mobility training

• WBing precaution is often much more restrictive

Weight Bearing Considerations in the Aging Population

Patients with hip fracture may present with other limiting conditions including dementia.

• Consultation with the orthopedic surgeon if the patient cannot understand WB precautions:

“All or none” WBing for the patient who cannot comply with restrictive precaution

• Patient may be limited to bed mobility and transfers if the fracture is too unstable to allow WBing for up to 12 weeks

Factors Contributing to Bone Healing - favorable vs unfavorable

favorable

• Early mobilization

• early weight bearing

• maintain of reduction fx

• younger

• good nutrition

• minimal soft tissue damage

• patient compliance

unfavorable

• tobacco smoking

• comorbids

• vitamin def

• osteoposis

• infection

• irradiated bone

• mult fx

• corticosteroid use

Complications of Fracture

Loss of fixation or reduction

• Deep vein thrombosis or pulmonary emboli

• Nerve damage, such as paresthesia or paralysis

• Arterial damage, such as blood vessel laceration

• Compartment syndrome

• Infection

• Orthostatic hypotension ***********

Total Joint Arthroplasties

Total Hip Arthroplasty (THA)

Total Knee Arthroplasty (TKA)

Total Shoulder Arthroplasty (TSA)

prevelence of TKA or THA

highest - TKR F in 80-89

Total Hip Arthroplasty

• diagnosis for it

• types of approaches to a hip Arthroplasty

Reconstruction of the hip with prosthetic components

Diagnoses

• Arthritis

• Avascular necrosis

• Hip infection

• Congenital disorders

post. - directly to glute max and division of eternal rotators. hip is put in a flexed position and IR and adduction. it preserves the hip abductors.

lateral - disruption of the hip abductors (detaching them from the bone or taking bone off)'

anterior - between the TFL and the glute med. hip is dislocated anterorly

THA Precautions

anterior - bc youre putting it in the same position it was when it was dislocated

• no hip ext or ER

lateral - bc of trauma to the hip abductors

• Abduction restrictions

posterior - same position as surgery

• No flexion past 90°

  • No internal rotation

  • No adduction

Total Knee Arthroplasty

• Replacement of articular surfaces of the knee with prosthetic components

• Diagnoses —— Arthritis

Knee Immobilizer

used for a nerve block

support the limb in WB

PT Implications with THA and TKA

• PREHAB******

• Early functional mobility

  • Education on precautions

  • Therapeutic exercise

  • Gait training

  • Pain management

  • Safety

  • Edema control

Reverse Total Shoulder Arthroplasty

rotator cuff challenge

socket and ball switch place

deltoid becomes primary mover of the shoulder

TSA Precautions

Avoid shoulder active range of motion

• No lifting, pushing, or pulling objects with involved upper extremity

• No excessive shoulder motion behind back, especially into internal

rotation

• No excessive stretching, especially into external rotation

• No supporting body weight by hand on involved side

• No driving for at least 3 weeks

PT Implications s/p TSA

Early functional mobility

• Education on proper body mechanics

• Education on precautions

• Education on bracing

• ADL training

• Therapeutic exercise

• Pain management

Non-Weight Bearing - NWB

No weight may be placed through the extremity. Your foot may not touch the ground.

Toe Touch Weight Bearing - TTWB

Touch Down Weight Bearing - TDWB

Your toes may touch the ground while you are standing or sitting but you may not put any weight through it.

Partial Weight Bearing - PWB

A varying amount of weight (usually 25%, 50% or 75%) may be put through your extremity.

Full Weight Bearing - FWB

100% of weight can be accepted through the extremity.

Weight Bearing as Tolerated - WBAT

Safe to put full weight, but patient assesses the amount of weight to bear based on their comfort.

Joint Arthroplasty Complications

Fracture

• Aseptic loosening

• Hematoma

• Heterotopic ossification

• Infection

• Dislocation

• Nerve injury

• Vascular damage

• DVT/PE

• MI

• CVA

• Limb-length discrepancy

Ortho Pharmacology

Anesthesia Pain Medications Anticoagulants

Osteoarthritis (OA)

Focal loss of hyaline cartilage of joints with underlying bony changes

Osteoarthritis (OA) Radiographic Changes vs Clinical Symptoms

• Joint space narrowing

• Bony sclerosis

• Osteophyte development

• Pain • Swelling • Stiffness

causes of OA

Idiopathic - dont know the cause and can be Localized or General

secondary - result of something else - Trauma Congenital Metabolic

Almost _____ of adults aged ≥65 years have arthritis.

half (49.6%)

prevalence of OA was higher among:

Adults who did not meet physical activity recommendations

Adults with fair/poor health

Osteoarthritis: Risk Factors

Joint injury or overuse

Age

Gender - women are more likely to develop

Obesity -more weight and stress

Genetics

Race

core tx for knee OA for all types

• land exercises

• weight management

• stregth training

• water based ex

• self mgmt

for hip OA as well

Rheumatoid Arthritis (RA)

An autoimmune and inflammatory disease causing inflammation within the synovium of the joints

Three Stages to RA

1. Swelling of the synovium

2. Thickening of the synovium

3. Release of enzymes from the inflamed cells

clinical s/s

Joint damage

Pain

Loss of function

Disability

Rheumatoid Arthritis: Causes

unknown

Rheumatoid Arthritis: Prevalence and Complications

incidence rises in age

prevalence of RA was higher among:

• Premature heart disease

• Obesity

• Employment

Rheumatoid Arthritis: Risk Factors

Age Gender - women than men

Genetics - predisposed gene

Smoking

History of live births - women who have given birth

Early Life

Exposures

Obesity

Rheumatoid Arthritis: Treatment pharm vs non pharm

pharm

Disease-modifying antirheumatic drugs (DMARDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs)

nonpharm

Physical activity

• Education

• Smoking cessation

• Maintain a healthy weight

**they may have flairs

With aging, there is a greater loss of what muscle fiber type?

 

Type II fibers

 

Type I fibers

Type II fibers

Sarcopenia increases the risk of all of the following, except?

Vulnerability to injury

Disability

Falls

Osteoporosis

Osteoporosis

A T-score of __ indicates a diagnosis of osteoporosis.

-1 and above

-1 to -2.5

-2.5 and below

-2.5 and below

Which statement best describes Type 1 osteoporosis?

 

It results in a predominant loss of cortical bone.

 

It occurs primarily in post-menopausal women due to loss of estrogen.

 

It is an inevitable consequence of aging.

 

It leads to increased risk of primarily hip fractures.

It occurs primarily in post-menopausal women due to loss of estrogen.

Older men are at greater risk for hip fracture than older women. 

 

True

 

False

False

Following a total hip arthroplasty (THA) with an anterior approach, what positions should be avoided while performing rehabilitation exercises and activities of daily living?

Hip flexion greater than 90 degrees, adduction past mid-line, and internal rotation

Hip flexion greater than 90 degrees, adduction past mid-line, and external rotation

Hip extension past neutral and external rotation

Hip extension past neutral and internal rotation

Hip extension past neutral and external rotation

Following a reverse total shoulder arthroplasty, a patient relies on what muscle(s) to move and position the joint/arm?

 

Rotator cuff

 

Deltoid

 

Latissimus dorsi

 

Teres major

Deltoid

Osteoarthritis is associated with which of the following?

 

Joint discoloration

 

Swelling of the synovium

 

Pain, swelling, and stiffness

 

No evidence of radiographic changes

Pain, swelling, and stiffness