The Old Athlete Problems

The Old Athlete  

Galen said it first and more recently, the American Heart Association, that you have a fixed number of heart beats in a life time. 2.5 billion.  

“The first accurate measurements of body mass versus metabolic rate in 1932 showed that the metabolic rate R for all organisms follows exactly the 3/4 powerlaw of the body mass, i.e., R M3/4. Called Kleiber's Law. It holds good from the smallest bacterium to the largest animal (see Figure 01). The relation remains valid even down to the individual components of a single cell such as the mitochondrion, and the respiratory complexes (a subunit of the mitochondrion).It works for plants as well. This is one of the few allencompassing principles in biology” (www.universe-review.ca/R10-35metabolic.htm) What needs to be further investigated are pharmacological methods to minimize aging such as use of the Polypill, growth hormones, and testosterone supplements

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Physiological changes of ageing 

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Care of the older athleteExercise programmes for older people 

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Injuries and problems of older athletes 

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Ongoing care 

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Nutrition 

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Athletic performance 

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Conclusion

It is difficult to define what an “older athlete” is. Masters competitions start at age 25 for swimming and at 35 to 40 for athletics. People of all ages regularly compete in marathons. James Tomkins at age 43 was in the Australian Rowing 8 at Beijing 2008 Games. Unheard of not so long ago. In pre-history, man rarely needed to consider the ageing process. Life was short and the hunter gatherer did not live long beyond a decrease in ability and performance. In the modern day, athletic performance has become less vital for life, but has remained important into old age. Older people have an interest in maintaining health and some go further to maintain a competitive edge. Sports medicine for older athletes is not only about competitive performance. The benefits of exercise are many but so, unfortunately, are those who do not partake of them. The goal

is as much to encourage a healthy active lifestyle as it is to help the older competitor (Fig. 1). Physiological Changes of Ageing Along with the awareness of our own mortality, we have an understanding that our bodies will age. Ageing is a universal process, causing progressive structural and functional loss. There are theories of why we age. Leonardo da Vinci, after careful anatomical studies, concluded that thickening blood vessels were the cause. Even today, the cause of the aging process remains unknown. Ageing causes a decrease in the number, function and regeneration of cells. This leads to structural and functional changes in the older person. Fig. 2 shows the physical changes of ageing that are affected by exercise. It clearly shows that the loss of function is due as much to disuse and inactivity as to ageing itself. What needs to be further investigated are pharmacological methods to minimize aging such as use of the Polypill, growth hormones, and testosterone supplements. 1 Figure 2 Regular exercise slows the effects of age on body systems   System                        Ageing Changes                          Effect of Exercise  

 

 

Muscle

∙          mass and strength lost slowly

∙        can be minimalised with

 

       with ageing  

exercise

 

 

 

 

∙                    power decreases

 

 

 

 

 

 

Bone

∙          mass loss after age 35,

 

 

       increases after age 55

∙        bone loss reduced by 

 

 

regular exercise and good 

 

∙            trabecular bone lost before

 

       cortical

 

 

 

∙          faster loss in post­menopausal

 

       women

nutrition           

 

 

 

∙          decrease in total body calcium      

 

 

∙          loss of elasticity (may increase ∙        weight bearing exercise

Cartilage

osteoarthritis

may slow changes

 

∙            greatest risk in knee, hip, 

 

 

ankle,

impact WILL worsen 

 

        spinal facets

degenerative arthritis if already 

 

present. The more joints are 

 

 

used( cyclic loading) the  quicker they wear out and  need to be replaced.

 

 

 

Ligaments 

∙         lose elasticity with age

∙        stretching before and after

and tendons

      (increase in sprains and strains)

        exercise maintains

 

 

        flexibility

 

∙         decreased flexibility

 

 

 

∙       regular use maintains

 

∙         loss of flexibility and range of 

      strength and suppleness

 

motion

 

 

      may increase joint and muscle

 

      injury

   

 

∙         decrease in conduction velocity  ∙         reaction times are faster if

Nervous

and

System

       number of neurons/axons

maintained by use

  ∙         slower reactions and speed   ∙        loss of vision and hearing

2 Figure 2 (Cont’d)   System                          Ageing Changes                                      Effect of Exercise

Cardiovascular

∙          lower VO2 max  

∙        exercise can maintain 

 

 

VO2 max  

 

∙          less anaerobic endurance

 

 

 

 

 

∙          lower cardiac output and maximum 

∙        can stop endurance 

 

heart rate

loss

 

 

 

 

∙          increased risk of coronary artery 

∙        slows decline in 

 

disease

maximum heart rate

 

 

∙          slower return of heart rate to resting 

∙        aerobic exercise more 

value  

effective than anaerobic may  decrease risk of CAD

∙          increased vascular resistance   Respiratory 

∙          decreased compliance

∙        regular exercise 

System

 

reduces respiratory changes 

 

∙          reduced airflow

 

 

 

 

 

∙          increased effort of breathing

   

Some ageing body systems have implications on the way older people exercise (Fig. 3). Refer to the section Guidelines for Exercise for further recommendations. Figure 3 Exercise implications for some ageing body systems   System                          Ageing Changes                                      Effect of exercise  

 

 

Renal

∙            glomeruli loss decreases filtration

∙          Ensure fluids

System

 

∙        Avoid very hot weather

 

∙          loss of total body water (higher risk of

∙        Break up workout

 

       dehydration.

 

  Skin

∙          Thinning of skin decreases thermal

 

 

Insulation

∙        Use sunscreens, hats

 

 

 

 

∙          Skin becomes more fragile

∙        Well fitting footwear

 

 

 

 

∙          Epidermis looser – predisposes to 

 

 

blisters

 

 

 

∙          Reduction in defense to UV radiation Thermo

∙          Reduced heat dissipation

∙        Heat tolerance may be 

Regulation

 

less

 

 

 

 

 

 

Presentation

∙            Slower healing

∙        Longer rest periods after 

 

injury 

 

In general, functional reserves decrease with age. To attain the same performance, the older athlete must push closer to the body’s limits. Care of the Old Athlete The aspects to consider are: •

Exercise for older people

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Injuries and problems of older athletes

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Previous sporting activity – ongoing care of athletes as they age

Exercise Programmes for Older People  Goals of an Exercise Programme

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The ultimate goal of an exercise programme is to improve quality of life. It aims to:

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improve aerobic capacity

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increase strength and energy

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improve balance 

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increase self-esteem

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improve sleep patterns

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improve independence

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provide social interaction and enjoyment

 

Exercise Evaluation

Any older person starting an exercise programme should be evaluated for risk factors that make them prone to injury or may limit their activity. History The history should include previous and current medical conditions, medication, current nutritional status and previous injuries. Risk factors for coronary artery disease and diabetes mellitus should be identified. A less rigorous exercise programme is recommended for those with two or more risk factors. 4 Cardiovascular Screening A cardiac stress test should be performed if the patient has one of the following:  

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recent myocardial infarction or coronary artery bypass surgery (Fig. 4).Major risk factors for cardiovascular disease (obesity, hypertension, hypercholesterolaemia, family history, smoking). 

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A pacemaker-fixed rate or demand 

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Use of chronotropic/inotropic medication 

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At least 70% of the maximum heart rate based on age should be achieved.

Stress testing is unnecessary for gentle exercise (non-competitive swimming, walking, bowls). Echo studies of the carotids and heart are useful. Musculoskeletal Evaluation The older athlete is more prone to musculoskeletal injury and is slower to recover than a younger athlete. Musculoskeletal evaluation is therefore important. Evaluate: Muscle strength – Most injuries to the mature athlete involve the lower limbs. Assessment of knee and ankle is therefore necessary. The athlete should be able to generate enough force to lift at least half his/her body weight. Flexibility – The ankle should have at least 10° of dorsiflexion. The hip should have at least a 60° arc of motion. Check for hip flexion contractures, iliotibial band tightness and rectus femoris tightness. Deformity and joint pain – Check for hallux valgus, genu valgum, femoral anteversion, arthritis and discrepancies in leg length. Sensory Testing Check for sensory deficits in the limbs, vision, hearing and colour perception. Exercise Prescription

A good exercise prescription should include intensity, exercise mode, duration, frequency and progression. Intensity  

Intensity is an important variable in exercise prescription. There are several ways to determine intensity levels.

1. VO2 max : VO2 max represents the ability of an athlete to extract oxygen from the environment and use it to generate ATP during work. Training is induced during exercise at 40 – 85% VO2 max. 

2. Maximum heart rate (HRmax): HRmax can be calculated using (220 – age) + 15. Intensity can then be expressed as a percentage of HRmax 55.90%. HRmax is the level recommended by the American College of Sports Medicine to induce training. 

3. Metabolic Equivalent Units (METs): A MET represents the VO2 at rest (35mL/kg/min). The maximum MET level (MML) is the maximum intensity level for an athlete. This can be determined by exercise testing. Optimum intensity recommended is 40-85% MML. The work intensity of different activities (in METS) can be read off pre-existing tables. This allows the athlete to choose an activity most suited to his/her target MET level (Fig. 5). Figure 5 MET         Activity                      METs  

 

Level walking at

           3.0

4 km/h

 

 

           8.4

Jogging at 8 km/h

 

 

         10.0

Swimming, 30 metres/

 

minute

 

 

  6.0 – 10.0

Tennis

 

 

  7.0 – 15.0

Soccer  

Exercise Rhythmic activity utilising large muscle groups is preferred. Some weight bearing is also recommended. Duration 16-60 minutes continuously at a moderate intensity is ideal. Frequency A minimum of 3 to a maximum of 5 days a week (except obese athletes who require a daily low intensity programme). Progression Increase intensity, duration and frequency as fitness improves. Aim to keep the heart rate in the desired training range. Only one variable should be increased in any session. Guidelines for Exercise The DOs and DONTs of exercise for mature athletes are shown in Figure 6. Figure 6   Guidelines for exercise in the older athlete                      

 

                         Dos

                             DONTs

 

 

    set realistic goals

   high impact activities ∙          

∙          

    exercise within the limits of the

   extremely hot, humid conditions causing

    exercise tolerance test

   dehydration (especially if on diuretic therapy)

 

 

∙       

∙       

∙       

 

    exercise aerobically using large muscle

   Extreme cold (causing frostbite,

    groups (jogging/cycling/swimming)

   Hypothermia, cold­induced angina and

 

   Bronchospasm)

∙       

 

    incorporate weight bearing activities

∙        

    into their programme (for prevention of 

 

osteoporosis)

   the Valsalva manoeuvre (especially if

∙       

   hypertensive/coronary prone)

∙       

 

    wear appropriate clothing and footwear

∙        

∙       

 

o       

   high levels of pollution (athletes with

   increase activity gradually

   chronic airways limitation)

∙       

 

 

∙        

   have rest periods during exercise

 

 

   abrupt changes in amount/intensity of

∙       

   training

   warm up and cool down sufficiently

 

 

∙        

∙       

 

 

   prolonged sun exposure (predisposing

   treat injuries quickly and adequately

   to skin cancers  

  ∙           exercise with a partner

7 Injuries and problems of older athletes Injuries Figure 7 shows the aetiology of exercise=related injuries in the aged. Many are running or walking related with fewer trauma injuries from contact sports. Overuse injuries for 70% of injuries seen in the ageing athlete. These tend to progress slowly. Be neglected by the athlete and present late. They may b slow to respond and have been self-treated by the athlete. Locations of injury in the old resemble those in the young, with knee, foot and lower leg being the most common (Fig. 8). The strength and flexibility with age leads to less impact absorption in the lower limb. More knee and foot injuries are the result. Overuse superimposed on tissue degeneration lead to shoulder, tendon and ligament injuries. Osteoarthritis symptoms are common in older athletes and may actually be due to another problem. The prevalence of osteoarthritis in the aged can be misleading. Misdiagnosis can occur often – injury conditions (such as meniscal tear of extra-articular soft tissue damage) are labeled osteoarthritis, resulting in appropriate treatment.

Diagnosis

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History – common features are: 

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→aggravation by activity 

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→pre-existing condition 

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→trauma or increased intensity of training 

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Physical examination

These suffice for 70-84% of injuries in this group. Investigators that may be useful in the remainder are: x-rays, CT, blood chemistry, bone scan and arthroscopy. Treatment Injuries in the older athlete are often managed conservatively.  RICE  Decrease activity level 15-25% until symptoms resolve

Rebuild training level slowly Drugs (NSAIDS and others) →“start low, go slow” →older athletes use many regular medications – beware drug interactions →prolonged therapy may be necessary due to slower healing in the aged

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Physiotherapy (exercises, ultrasound) 

•

Exercise to build muscle strength (such as quadriceps in knee injury)

8

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Bracing (in achilles tendinitis, ankle instability) 

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Local corticosteroid (see Figure 17, Chapter 3)

Only 24% of injuries require surgery. Specific sports have been studied and the effect of age on injury risk varies (Fig. 9). Figure 9   Age effect on sports related injuries for specific sports                      

 

                         Sport

  Age effect on injury risk

 

 

Soccer

  ↑ acute arm injury risk

 

 

 

 

Marathon/long

  varies from no increased injury to sport most

Distance running

  affecting injury risk

 

 

 

 

Running

   no effect

 

 

 

 

Golf

   more overuse shoulder injuries  in older golfers

 

 

 

 

Orienteering

   more muscle ruptures in older athletes

 

   more acute injuries

 

 

 

 

Ball games

   increased accident rates  

Osteoporosis Osteoporosis is the condition where the rate of bone absorption exceeds the rate of bone formation. Bone mass begins to decline at age 40 in both sexes. Bone loss further accelerates in women after menopause. The ageing process contributes to osteoporosis by slowing the resorption and redeposition of components of the bone matrix (Fig. 10). There is also an age-related decrease in total body calcium. The result is an increase in fractures, especially of the hip and vertebral column. Osteoporosis poses major problems for the older person just beginning an exercise programme. He/she should start slowly and cautiously, allowing time for the skeletal system to adapt. Studies have shown that regular physical activity (especially resistance-type activity) and good nutrition can increase bone mineral content in all age groups. Beginning an exercise programme, even late in life, can be beneficial to the skeleton. However, an excessive amount of training seems to be detrimental to the skeleton, indicating that an optimal amount of exercise may exist. Bone density studies are important and consideration for bone sparing medication given ( eg alendronate) Ongoing care

Often the older athlete is a younger athlete to train throughout life. Former athletes may have problems arising from pat sporting activity. There are some common consequences from the “past sins” of a training history. It is possible that increased osteoarthritis is found among former elite athletes (Fig. 11). Power sport participants are more likely to have premature osteoarthritis. Endurance running has also been considered as a factor in osteoarthritis. Other arthrosis, especially of the hip and knee, seem to be more common in past athletes. Soccer players and weight lifters have had more mild lumbar disc changes than nonathletes, but the overall incidence of back pain is lower. In general, previous injury during a sporting career can return as a chronic condition if the older athlete does not take adequate precautions. Older athletes soon learn that the ageing body is less forgiving than in their youth. Other Issues Nutrition Whether to perform competitively or to improve general health, the older athlete’s exercise programme requires a good diet. The older athlete needs to maintain the same mix of food groups as that of younger athletes. If involved in endurance training, carbohydrates need to be increased to 60-70% of the diet (Fig. 12). Adequate protein is essential (vegetarian diets must be well planned). Vitamin supplements can only be of assistance if the dietary intake is inadequate. Iron is especially important for distance runners. All older athletes must pay attention to calcium intake to support bone mineral density. The Polypill is very useful and has been shown to extend life by 10 years in men over 55.. Dehydration is more common in the aged. Drinking water prior to, during and post-exercise reduced risk of heat and dehydration (see Chapter 4). Athletic Performance With the advent of masters competitions, older people are increasingly taking up or returning to competitive sports. The age divisions of some sports reflect that peak athletic performance tends to decrease with age (Fig. 13 and Fig. 14). Short distance running, jumping and some throwing events are more affected. Long distance running decreases less. Conclusion As the population ages, it becomes more important that the mature members of society remain active and healthy to reduce health costs. Encouraging exercise and sporting activity among older people will reduce the social and economic costs of an elderly population in failing health.

Many Western countries are experiencing shortage in labour and are dependent on old people to work longer. Older people use sport for diverse reasons: health, social contacts and also high level competition. The physician must be ready to advise each individual according to their sporting goals and situation. With adequate advice and care, there is little reason why the older person should not continue to enjoy the many benefits of sport. 11