Functional aging Exam 2

What are we looking for in a functional test

Core standards of reliability and validity

A way to compare (criterion or normative values) in order to make an evaluation

Six minute walk test: equipment

Clipboard, stopwatch, and cones spaced 10’ apart

Six minute walk test: Procedure. Where are you as a clinician?

Simply tell them to walk for 6’ at a comfortable speed. We are measuring HOW FAR they go to compare to normative standards

Maybe walk near them if they are potentially going to falll

6’ Walk test: meausurments

We are measuring HR and the total distance traveled.

The distance will be converted from meters to yards and then compared to normative values

Six minute walk test: What can we do with this test?

We can use the HR data collected to determine the proper HR zone. So it should helps w/ program dev

TWO minute walk test: What should they do first?

They should complete a PAR-Q: Screens for red flags that indicates thyme may need medical clearance before doing the 2’ step test

Two minute walk test: Equipment

Clipboard, stopwatch, Hip

Two minute walk test: How high will the knee go during the stepping?

Midway point between patella and greater tronchanter

Two minute step test: procedure

1. Give them an object for stability

2. Say GO and the individual begins stepping with their right leg in place. They will try to get as many steps as possible within the time limit

3. Only count the right knee

4. Ensure the participants knee is getting to the proper height

5. Let them slowly walk for 1’ as a cooldown

Two minute step test: eval

Compare w/ normative value

This test has been correlated/validated against other measures of aerobic fitness (1 minute ewalk time and a treadmill test @85% max HR

A part of the functional fitness standards

Figure 8 walk test: Procedure and what to look for

Have them start in the middle of two cones and have them walk in a figure 8 pattern.

We are measuring time and number of steps. increased amount of steps indicates compromised biomechanics (as it kind of measures confidence).

Do you see increased steps in turning points? Indicates impedance or lack therof.

Figure 8 walk test: eval

There is no normative or criterion data. There is only one study with folks who had a fear of falling and a group without and the respective time and steps.

Preferred walking speed

Equipment: clipboard, measuring tape or cones, stopwatch

PWS: procedure and measurments

Give them a significant difference so their speed normalizes

Tell them to walk at a pace as fast as they are comfortable walking

Fore each trial calculate time it took and gait speed

PWS: Trials

Trial 2: Have them count backwards as they walk

Trial 3: Have them list as many animals as they can

Trial 4:Have them walk as fast as possilble

PWS: EVAL

You have criterion values for both natural walking speed and maximal walking speed. If you dont meet the criterion you may have a risk of experiencing a fall

8ft timed up and go test: Equipment

2 chairs, measuring tape, stopwatch

8ft timed up and go test: procedure

Evaluate how they get into and out of the chair!

Tell them to get up and out of the chair as fast as possible, walk around a cone 8ft away, and get into the chair

We score the time it takes to complete

8ft timed up and go test: eval

You have normative values that you will compare to for sex and age group

Part of the functional fitness standards

And again look out for HOW they complete the test

Dynamic gait index: Equipment

Clipboard, cones, shoe box

DGI: Grading:

3: Normal

2: Mild impairment

1: moderate impairment

0: Severe impairment

DGI: 1st one procedure

Have them walk at their normal speed from 0 to 20 feet.

Watch for how they ambulate. This is a subjective assessment NOT timed. You are assessing how they ambulate (decreased stride rate, increased width, patternless gait, needing assistance, etc.)

BE BEHIND THEM

DGI: 2

0 to 5: Normal

5 to 10: fast

10 to 15 slow

15 to 20: normal

INSTRCUTE them to change to these speeds

Evaluate how difficult or smooth it is for them to change speeds. How deviating is their gait, how much contrast between speeds, how is their balance, etc.

DGI: 3

Gait with horizontal head turns

Start walking

5: look right

10 look left

15 look straight

We are challenging the visual and vestibular system (which tells us where our heads is in space)

Their gait may disturb with turns such as wider gaits, more steps, less distance with each steps, walking aid, loss of balance,

4: DGI

Gait with vertical head turns:

Look up

Look down

Look straightt again

We are challenging the visual and vestibular system (which tells us where our heads is in space)

Their gait may disturb with turns such as wider gaits, more steps, less distance with each steps, walking aid, loss of balance,

DGI: 5

This is full 20ft, then have them stop and pivot to turn around and stop. They must do it within 3 seconds.

DGI: 6

Step over shoebox

Have it placed at 10

They walk for 20 feet and step over the shoebox

Do they need to alter their gait to step over??

DGI 7:

Step around obstacles that are placed at 6 and 12.

See how they navigate the turns and see how their balance is. The usual things, width, step frequency, etc.

DGI 8:

Walking up and down stairs

Do they need rail? Do they need two feet or can they alternate?

DGI EVAL

Score outta 24. 20 is the criterion. Below indicates elevated fall risk.

Height: Changes with age

Height loss begins at 30 and declines with age

It declines at 1cm per decade After age 60

Between 30-80 men lose 2 inches while women lose 3

Reasons for height loss with aging

1. Vertebral compression over time

2. Decrease in disk height due to fluid loss

3. Postural changes (slump)

   1. Because of kyphosis, osteoperosis, and Age related disc degeneration

4. The foot arch becomes less pronounced (lax ligament)

Postural changes with age

A constant anterior torque is placed on the spine

1. The spine is an elastic rod. The COM lies in front of the “rod”. Thus gravity gives it an anterior torque.

An erect spine is maintained (against the force of gravity) with the posterior ligaments and the erector spinal muscles.

These supporting tissues become weaker making this resistance of gravity more difficult

The result is thoracic kyphosis

Disc degeneration: Why does it happen? Why do the discs become thinner? How does the load change? How does the body compensate??

There are 6 steps to this equation

1. As spoken about earlier, the posterior ligaments and muscles relax, resulting in my kyphosis and anterior disc compression

2. The nucleus pulposus loses water (which remember is the cushion inside the jelly filled donut. The disc is now thinner

3. Because the disc is thinner, the anterior part of the disc is compressed while the posterior part is placed under tension. This leads to a kyphotic spine shape

4. The annulus fibrosis begins to degenerate and tear due to the tension. This happens at the part of greatest tension, the posterior or posterior arterial annulus. As a result the disc begins to buldge or protrude out,

5. The body wants to compensate for the abnormal loading so it will create new bone and that new bone is called osteophytes or bone spurs and it’s essentially a response to the abnormal stress. This compensation is an attempt to create more surface area to absorb load. unfortunately, this is a maladaptive attempt to compensate for the load, and instead can result in other pathologies.

6. Finally, there is osteoarthritis of the facet joints. This is as a result of both the anterior tilt of the vertebrae and the thinning of the disc which results in more stress being loaded onto the facet joints this results in osteoarthritis.

How may you visualize this degeneration with imaging?

You may recall that osteophytes or bone spurs are a result of abnormal stress being placed on the vertebral bodies osteophytes can be viewed on x-ray. The shortened or abnormal disk space is also visible on an x-ray.

Kyphosis

A disease characteristic of exaggerating, kyphotic characteristic. This is anterior bending of the spine.

Osteoporosis leading to exaggerated kyphosis

There is a natural kyphotic curve to the spine. This means that there is already naturally a slight anterior load to the spine with respect to the middle and posterior part of the vertebral disc. When osteoporosis begins since there is already a greater anterior pressure on the disc, that means that there is the propensity for the fracture of the disc to be anterior overtime. These micro fractures can change the curvature of the spine leading to hyperkyphosis.

Intervertebral disc degeneration relation to kyphosis

Again, since there is already a slight kyphotic character to the spine thinning of the discs exacerbates kyphosis. again, this is due to water loss in the intervertebral disc. specifically in the nucleus, Pulsa.

Possible explanation for decline of weight in elder population

One: leaner individuals potentially had a better chance for survival

Two: the elder generation is leaner than the current generation

Three: the actual aging process results in less water, a decline of metabolic rate less muscle and less exercise

Four: increased instances of disease lead to muscle wasting

Five: a decrease water weight. This is a result of a decline in receptors or sensors that detect thirst otherwise other adults are at a greater risk of dehydration.

Changes in adipose tissue; effects

Subcutaneous adipose tissue thins

Issues with thermoregulation

More accumulations in the visceral (around organs)

Doses of medications may need to be altered because of the changes in body water and adipose tissue (esp with medications that effect water balance

High visceral fat stresses organs. Results in type II, High cholesterol, etc. Chronic diseases

Field tests for adipose tissue

Standard ones; DEXA and BODPOD (according to him gold standard in this pop)

Default option: Waist circumference measurements

Flags: Males greater than 40 inches, women greater than 35 inches

Apple shape is more associated with visceral adipose tissue accumulation

Pear shape is more associated with cancer and osteoarthritis, but not as bad.

Visceral fat is linked to those chronic diseases because of organ stress

Interventions for excess adipose

Promote general activity. WiLL EFFECT visceral impacts, not much subcutaneous

Aerobic exercise is the king (repeated steady state). Results in Reduced adipose weight, waist to hip circumference.

Need strength training to maintain muscle

Skin changes with age

The actual skin will thin. More susceptible to bruising or other kinds of damage. This is also because of a loss of collagen and elastic fibers.

The skin is basically much more sensitive to damage.

Decreased oil and sweat glands activity: issues with thermoregulation because of this

Flexibility changes w/ age

Flexibility decreases by about 15% per decade

Why is flexibility important

Flexibility impacts your ROM and thus exercise and ADL

What does flexibility depend on

Flexibility depends on the states of joints, tendons, ligaments, and muscles

Loss of flexibility leads to

Impairs ADLs

Increased risk of soft tissue injuries

Flexibility is ____ specific

Joint

Flexibilty test: Sit and reach

Chair sit and reach; they try to touch their toes

Hamstring flexibility (indirectly) and other structures

Older adults with low back pain score low on this because tight hamstring shifts stress to low back. Hamstring muscles not letting pelvis rotate

Gold standard

Back scratch test

Assesses upper body flexibility

Allows you to complete daily activities of iving

Assesses shoulder ROM indirectly

What is distance between the fingers?

Osteoporosis

Loss of webbing, very porous. This will impact the trabecula/cancellous bone.

Reason why femoral neck fracture is more common because it is mostly cancellous

Why is osteoperosis known as the silent disease

Not easy to track. Symptoms are the fracture, no other feelings.

Diagnosis of osteoperosis

Measure BMD, measures thickness of bone. Accounts for most of bone strength

DEXA is how we do this

T score evaluation; where do they fall in the spectrum of their population and age, using SD.

Risk factors for osteoperosis: modifiable

Sex hormones: estrogen (f) and testosterone (m) are key for BMD.

When women go through menopause they decrease in estrogen why more prominent.

Reduced calcium or vitamin D intake

Inactive or sedentary lifestyle

Long term medication use may impact BMD

Excessive alch

Smoking

Osteoperosis: non modifiable

Women> men (risk) (lower bone mass and meonpause)

Aging increases risk

Body size; naturally thinner bones

Ethnicity: white or Asian > African or Hispanic (in terms of risk)

Family history/genetic predisposition

Prevention of osteoperosis

Avoid: sed lifestyle, stop smoking, stop drinking

Make them talk to the doctor (me 🙂 )

Tell them to eat milk, yougurt, cheese leafy greens for calcium

Tell them to supplement with calcium maybe

For vitamin 😩 tell them to eat egg yolk, fish, liver.

Go outside for vit D

Maybe supplement

EXERCISE!!! LIFT FUCKING HEAVY WEIGHTS!!!

Osteoperosis intervention study

They saw that wolfs law: gradual increase of stress applied to the bone leads to hypertrophy, was true

High to moderate HIT training can preserve or increase BMD at clinically relevant site.

High intensity shows best results and increased BMD. Moderate just decreased slope of decline.

Muscle changes ___ bone changes

Preceeds

Exercises that improve BMD

Jumpimg

Hoping

Skipping

Dancing

WEIGHT BEARING STUFF!!!!!!

Gotta be a lot of weight

Gotta be careful with some people, like those with mobility issues (osteoarthritis for example)

These gains are specific to the spot that is being used/stimulated

General recommendations for BMDe exercises

Resistance: 3X per week, 2-3 sets of 8-10 reps

60-80% of 1RM

Impact exercise: 3-7 X per week: 50 jumps per session, high impact. Multi directional

Sarcopenia

Illness related loss of muscle mass, strength or function. Atrophy is muscle loss, sarcopenia is where the muscle itself loses size

What % of older adults have sarcopenia?

1/3 of those over 60: 26 billion!!!!

Diagnosing Sarcopenia: methods

DEXA scan to see muscle mass loss

Diagnosis of loss of muscle strength with functional tests

Diagnosis of loss of muscle function with functional tests

Physical burden of sarcopenia

Loss of muscle function and abillity

Impacts general physical activities, like standing or walking or doing yard work etc.

Strength impacts balance so that declines

Early fatigue during any physical activity

Muscle pain

Emotional and social burden of sarcopenia

Fear of injury, thus avoids going out (reduces social interactions)

Embarrassment of physical limitations leads to decreased social interactions and general overall wellbeing

All of this leads to isolation

Difficulties caring for themselves and living independently

sarcopenic obesity

Sarcopenia + obesity

• much greater risk of adverse health outcomes

• Higher risk of being unable to complete IADLs qualifying for disability

  • IADLs are instrumental activities of daily living, neccessary for being handling their household.

• Much more energy required to complete same tasks as older adults

Muscular strength

Maximal force producing ability

When we measure this we usually measure one or more groups

Usually expressed in Absolute or relative terms (BW)

Aging effect on muscle strength

Usually about a 1.5-2.5% decrease per year. Smaller from 50-70, greater from 70 onwards. So it ramps up

Low strength is associated with

Death

Disability

Falls

Physiological basis of muscle strength loss: Nervous system

• Loss of CNS and PNS function

  • Loss of motor neurons

  • Decreased firing capacity at high frequencies

  • Less capacity to activate existing muscle fibers (if there are 100 available motor units, and a young person may activate 95, it may decline to like 70

Physiological basis of muscle strength loss: Muscle changes

Overall muscular changes

• Reduced muscle mass, especially in sedentary individuals

• Reduced capillary density and thus decreased nutrition

Muscle fiber changes

• Decreased # of muscle fibers

• Reduced cross sectional area (so its smaller) especially our big type IIs

• Decreased muscle quality

• Reduced specific tension (less force per CSA of muscle. So the muscle machinery is less powerful)

  • Reduced velocity of contraction

Muscle strength and falls. What can prevent fall Risk

Muscle weakness is the biggest risk factor for falls. This is both for lower extremity weakness (1.76) and upper extremity weakness (1.5) for risks of any falls.

Strength training (duh)

Resistance training effect on strength

25-100%+ increase in absolute muscle strength is possible with strength training. A 20% increase in hypertrophy is also possible.

An improved neural function is also obtained with increased strength training

RESISTANCE training and chronic disease

Resistance training can help decrease the symptoms of many chronic diseases such as:

Arthritis

Diabetes

Osteoperosis

Obesity

Delays declines in ADLs and anything where you gotta move

Along with strength what is neccessary to prevent a fall

A faster stepping speed reaction. Because improved gait and balance measures (a result of strength) do not help with a successful balance recovery

Power

Ability to rapidly generate force

A given force is generated faster

Obviously it declines with age

Short term power

Anaerobic power; maximal work over short period of time

immediate power

Explosive power

1-2 seconds

Immediate first burst of activity

Why does power reduce in aging population? In relation to strength how fast is it lost

Loss of muscle mass, type II fibers

Decreased capacity for higher firing rates of motor neurons

High velocity capacity of machinery is lost

Power is lost faster than strength

Aging: aspects that result in decreased stepping speed reaction

Longer reaction times

Less rapid force production

Reduced speed of movement

Fallers vs non faller; aspects

Fallers have longer reaction times

Reduced speed of movement

Slower step velocity in any direction (lateral or in place)

What does muscular power aid with in elder adults

Challenging ADLs

May help with catching oneself (faster stepping speed)

How to train strength and power? Balance?

We are going to use high velocity resistance training

Balance do low intensity ir less that 60% of 1RM

For strength and power do 70% or higher of 1RM

The high velocity component is neccessary for power improvements

Motor skills

Tasks or activities that have specific goals to achieve

• proficiently is measured as the capacity to voluntarily control body segments/ joints

  • Must be learned or relearned to achieve goal

Motor learning

Increased capacity to perform a skill

• it is a permanent improvement from practice

Improvement

Performance improves over time

Consistency

Performance of skill is more consistent over tim

Persistence

Performance persists over a long period of time

Adaptability

Improvements can be translated across a variety of contexts and environments

Stability

When faced with internal or external perturbations performance has an increased capacity to remain stable

reduced attention demands

As one progresses partaking in the motor skill requires less of their intention or cognitive bandwidth

Retention tests

A test administered after a period of time is passed from practice to assess the permanence of such skill learning

We are assessing persistence

Transfer tests

The skill is performed in a novel context to assess adaptability of the motor skill learned

does aging decrease the capacity to learn a motor skill

Yes

How does General general motor skills contrast with younger folk?

Their skills are less accurate and slower, and they also have inter trial variance at a higher level meaning they are less consistent

Can Age related decline trajectory of motor skills be changed with practice

Yes

Neurological changes with age that results in slowness

dendrites and synapses die leading to the slowness that is observed in aging populations it is an interruption of the neural network

can the brain adapt, regardless of age what’s the specific mechanism of such adaptations or neuroplastic?

Yes, as possible new den against synaptic connections, as well as modulation of neurochemical concentrations can occur as a result of physical activity. Those morphological changes expand the neural network. Again, physical activity maintains brain function.

how fast may older adults learn simple tasks, in comparison to younger people? More complex tasks?

Just as fast

Not as fast

Older adults capacity to learn novel motor tasks

Can learn them on a similar level to younger people except

• Less smooth

• Slower

• Les able to predict movements