Sarcopenia - Shifting the Paradigm
Photo by Michael Mroczek on Unsplash
Sarcopenia... What the heck is that?!" I can hear you ask. I admit that it is not a very widely known term; however, it is in fact an actual medical diagnosis that is becoming more and more recognized. Sarcopenia is such a new concept that it is not even recognized in some countries. In Australia for example, medical schools are not even discussing this diagnosis, despite the fact that 30-40 per cent of those over 65 in Australia are likely affected with this disease. This is according to an article about sarcopenia that was just published this month in The Sydney Morning Herald. I found this to be extremely interesting when considering that falls are a geriatric issue discussed the world over, by the World Health Organization no less. Yet, a disease process that is resulting in falls, injury, death, and disability for aging adults is not even recognized across the globe!! WOW. The good news is that by gaining more and more recognition in the US, perhaps we can lead the way in prevention. The full article I am referring to can be found by clicking this link or copying to your web browser: www.smh.com.au/national/the-big-new-disease-that-doesn-t-officially-exist-in-australia-20180702-p4zp11.html?btis
So, what is it anyway? WARNING: We are about to get "sciency" here. Let the inner geek in you breathe a little. It won't hurt, I promise... According to the article cited above, an American scientist named Irwin H. Rosenburg coined the name sarcopenia in the 1980s. He invented the term by combining the Greek words sarco meaning "flesh" and penia, meaning "loss." The hallmark of the disease is a progressive loss of muscle mass through the decades.
Here are some facts from research regarding sarcopenia:
What causes this phenomenon? As we mentioned earlier, lack of physical activity is the number one cause. As a natural part of aging sexual hormones decline, cell death rates increase, and the efficiency of mitochondrial function (contain cellular DNA and produces ATP, the power source of all organ functions) becomes impaired. This results in changes to the muscle tissue and the bones. Without physical activity this will be an accelerated decline.
Another very important factor to consider is nutrition and absorption. If one's diet is deficient in protein, and without certain supplements such as Vitamin D, there will be nothing for the body to use to build up muscle tissue. When combined with a protein efficient diet, physical activity can actually aid in protein synthesis, as evidence indicates that the mechanical load placed on the muscle cells through exercise directly enables the muscle cell membrane's ability to synthesize protein (Narici et al, 2006).
In summary, sarcopenia is a highly likely condition past the age of 50 and has been found to increase mortality independent of age and other disease processes. Physical activity and exercise is the means to prevent this condition from rearing it's ugly head. My mission is to help as many people as possible to prevent this condition and to age successfully. The paradigm shift that is needed is to move from failure to frailty to function to fun. Remember, the deadliest object in your home is your favorite comfy chair. In the United States, they have loved many of us to an early death.
Plantar Fasciitis, or plantar fibromatosis, is a foot condition that is characterized by heel pain that can extend into the arch of the foot. It is normally worse first thing in the morning upon standing, and can also increase after prolonged standing throughout the day. An increase in standing activity prior to the start of the pain is typical, i.e., you started a new job where you were on your feet for hours on end on a concrete floor, etc. Weight can be an issue with this condition, though this is not thought to be a causative factor. One thing to note is that in 75% of cases the foot is a normal type, rather than high arches, collapsed arches, etc. Whatever the cause and whatever age it hits you, it can cause your exercise routine to come to a grinding halt. It hurts that much. In some cases osteophytes, or bone spurs, can form where the plantar fascia attach to the calcaneus bone in the heel. I wanted to address this topic due to the fact that plantar fasciitis, like many conditions out there, is not often addressed by a physical therapist. More often the individual sees their orthopedic physician or a podiatrist and is prescribed orthotics, resting night splints, and often corticosteriod injections. None of these treatments is wrong, but why is physical therapy not part of the recommended treatment? As we dive into this topic, I wanted to recommend some general advice for those suffering with plantar fasciits, but also to point to the evidence that physical therapy should always be included when trying to deal with this problem. Tissue changes that occur and result in this condition did not happen overnight and skilled physical therapy is needed to improve the tissue impairments that resulted in the pain condition.
In 2014 a clinical practice guideline (CPG) for treating plantar fasciitis was published in the Journal of Orthopedic and Sports Physical Therapy (JOSPT). You may not be able to access this free without a membership, but the link to the full text article is here. In this CPG, the strongest evidence suggests that the best interventions for plantar fasciitis are a combination of manual therapy, specific stretching, taping, custom orthotics/inserts, and night splints. These received an A (strong evidence) by the reviewers for best evidence. Among the poorest evidence? It's what you might expect (or at least what I would expect): ultrasound, E-stim, phonophoresis, iontophoresis, etc. These received a C for evidence, which correlates to weak evidence. Knowing this, will you be satisfied with just receiving treatments that have the least evidence for success? With this knowledge, it should be apparent that physical therapy is needed with plantar fasciitis and is an imperative part of the management of this issue. The caveat to this statement is that physical therapy that emphasizes the techniques with best evidence is the only physical therapy worth pursuing. Beware of the classical approach of physical agents such as ultrasound, E-stim, etc. as these modalities can aid in some relief, but only temporarily. We want real tissue changes here and we also want improved function.
A few months ago, I ran across a great infographic that was shared through the Academy of Geriatric Physical Therapy. I will link you to this post here. This is a fantastic summary of what a home exercise regimen should look like when self-treating plantar fasciitis, because it addresses flexibility of the ankle and calf muscles, maximally stretches the plantar fascia, and also addresses load shifting away from the medial portion of the foot with the shoe insert. I liked that the infographic emphasized that with the shoe insert you aren't changing position or biomechanics, but rather alleviating the load and stress off of the sensitive and overloaded tissue. I would argue that manual therapy to improve the pliability of the tissues (flexibility and ability to stretch) is crucial and therefore a PT is needed for this hands-on treatment in addition to the self-help exercises. It should be noted that the evidence cited in the CPG above only supports short term relief of the pain with stretches and exercises. For long term relief you will need manual therapy techniques as well as proper footwear.
The point is, if plantar fasciitis has taken the fun out of your daily routine and you have been instructed to stop activities that you previously enjoyed, it's time to try to go back to what you enjoy. Reach out to a physical therapist to help you address this issue alongside your current treatment. Chances are, if it isn't getting any better, the approach is incomplete. Call today or fill out the contact form below and we will get in touch with you.
There are many physical conditions that could be a barrier to exercise â that is, unless you know a skilled exercise expert who can guide you along the way. This topic of barriers to exercise is very important to me, and I am passionate about empowering people to be as physically active and fit as possible, even with chronic illnesses. This will be a continued series for the next few months as we dive into various perceived, or in some cases actual barriers to fitness and active lifestyle. Does exercise take your breath away? Actually, in this case I mean in the literal sense. For this first installment I want to address respiratory problems. In general, respiratory diseases fall into two categories: obstructive and restrictive.
âObstructive respiratory diseases that are more common in the population are asthma, COPD, emphysema, and chronic bronchitis. For the purposes of exercise prescription, I will focus on asthma and COPD and the implications for exercise. It is certainly possible to exercise safely and effectively with either condition.
Asthma is an autoimmune condition that results in spasm in the large airways (bronchi) as well as increased mucous secretion. This results in blockage of the airway, thus the fact that it is an obstructive respiratory disorder. Asthma can make it difficult to breathe in or out and attacks can be triggered by high intensity exercise. For many this may seem impossible to deal with when trying to exercise, but by applying the FITT principle (Frequency, Intensity, Time, and Type) it is possible to progress to more intense exercise with the guidance of a physical therapist. As a general example:
Frequency: 3-5 days per week
Intensity: 30-40% of maximum heart rate (light) working up to 60-80% of maximum heart rate (high intensity/vigorous).
Time: 20-60 minutes per day (either continuous or intermittent)
Type: Walking or stationary cycling
Calculating your heart rate maximum and percentages is a topic for another time, but suffice it to say that with such a guideline you will likely improve control of your asthma and decrease risk of hospitalization. Another alternative to cycling and walking is swimming, which is also cardiovascular exercise.
Some considerations for exercise with asthma:
1. Do not attempt an unsupervised exercise regimen without the expertise of a physical therapist. Developing an individualized exercise prescription that is safe depends upon your individual vital signs and monitored response to exercise.
2. Always have your rescue inhaler with you, even if exercise has not provoked an attack.
3. Minimize the chance of bronchospasm (asthma attack) by choosing a safe environment for exercise. If you are prone to allergies, donât walk or jog outdoors, at least not at first. Indoor tracks or even inside of your home could be safer. Also, some pools have a high chlorine content, which can induce attack. Pools that are salinated (salt water) are good and pools designed for aquatic physical therapy are even better due to the fact that they are kept above body temperature (typically around 100 degrees F) and the space is kept humid and warm, which can aid in keeping airways open and relaxed.
Chronic Obstructive Pulmonary Disease, or COPD, is typically associated with tobacco abuse and results in air becoming trapped inside the lungs when exhaling due to blockage of the airways with secretions and constricted bronchi. Due to the air being trapped in the lungs, gas exchange becomes imbalanced resulting in increased CO2 in the bloodstream. If left unchecked, hypoxia, or too little O2 saturation in the blood, can result and present a medical emergency. That may sound a bit scary, but safe exercise is possible with COPD. In fact, there are huge benefits. One example of clinical research in this area comes from Ferreira, et al in 2009 where they cite the benefits found in a simple walking program. The program was conducted three (3) days per week for twenty (20) minutes for a total of two (2) months. The results they found were:
A similar exercise prescription to asthma would be effective. Even if wearing supplemental oxygen, a monitored exercise program can still be developed and have positive results. Interval training has also been found to be very effective for COPD. Interval training involves combinations of different exercises such as warm up stretches/light walking, followed by upper body and lower body resistance exercises, then cool down. Typically rest periods last as long as the exercise, so for example, a typical interval session might look like warming up by walking for 1 minute, stretch for 1 minute, then doing 20 mini squats, then fast walking for 1 minute, then resting for 1 minute, etc. With COPD the exercises are usually of shorter duration and also have a 1:1 ratio of rest to exercise. For a client with COPD (as an example), I would likely recommend 30 seconds of walking at regular pace, followed by 30 seconds rest, then 30 seconds of marching in place, 30 seconds rest, 30 seconds worth of mini squats, 30 seconds rest, etc and the following may be applied:
Frequency: 3-4 days per week aerobic, 2-3 days per week strengthening
Intensity: Light to moderate (30-60% max heart rate) and progress to 80% max heart rate for aerobics. 50-80% of 1 rep maximum for resistance/strengthening exercise
Time: 15-20 minute sessions
Type: Interval training (similar to above), resistance training for lower and upper body major muscle groups, aerobic exercise.
Some considerations for exercise with COPD:
1. Again. Do not attempt an unsupervised exercise regimen without the expertise of a physical therapist. Developing an individualized exercise prescription that is safe depends upon your individual vital signs and monitored response to exercise.
2. Always time exercise for the peak times with your bronchodilator medication. That way you get the most bang for your buck in terms of ability to bring air in and out due to the airways being more open.
3. Stop smoking! Please. Iâll just leave it at that.
For restrictive pulmonary diseases, the picture isnât so rosy. These diseases include pulmonary fibrosis, sarcoidosis, etc. This results in inability to inspire enough air into the lungs due to lack of expansion. Hypoxia, chronic shortness of breath, and eventual decline in the function of the alveoli in the lungs (the small sacs that fill with air and exchange gases) make exercise extremely difficult, if not impossible, for some individuals. Many individuals will eventually need lung transplant or be placed on hospice for the long term. The main thing to consider is maintaining the best quality of life possible by maintaining an airway, promote adequate oxygenation, manage dyspnea, and to prescribe exercise with adequate rest periods for best tolerance of exercise. As an example, I have treated a gentleman that has ankylosing spondylitis, a skeletal condition resulting in spinal fusion and rib stiffness, as well as a new diagnosis of Amyotropic Lateral Sclerosis (ALS or Lou Gehrig's disease). He required the use of a machine to assist in his breathing while sleeping, and attached to supplemental oxygen, as well as elevation of the head of the bed while sleeping. Despite the impairments and restrictive respiratory issues, he was able to tolerate shorter sessions that involved walking with his walker for as far as tolerated, or bed exercises, or repeated sit to stand. Additions of any other exercises proved to be too much for him, but he was still able to tolerate activity each time and actually made some progress. For him, the goal was to stay as functional as possible for as long as possible, though ultimately his medical issues will eventually be terminal. This is to illustrate that it is still possible to exercise with such conditions.
Overall, respiratory issues can be worked around to allow you to have an active lifestyle and improved quality of life. As a physical therapist certified in exercise prescription for aging adults, this is exactly what I can help people to do every day. So, take a deep breath, and let's get you moving!
Low back pain is common…VERY common. According to an article published by the American Physical Therapy Association in November of 2017, low back pain (LBP) affects nearly two-thirds of Americans! There is a great need for education on prevention of LBP as well as what to do once you begin to experience it yourself.
The cost of LBP to the United States healthcare system is enormous, and much of this cost is related to surgical intervention. Though surgery is by far the most expensive intervention for LBP, orders for musculoskeletal imaging, such as MRI, CT, and X-rays, are also quite costly. This is important because forward-thinking healthcare should be working towards reducing unnecessary costs to the consumer. The fact of the matter is that non-specific LBP does not need to be "diagnosed" through imaging in order to be treated by a physical therapist. If you were to do X-rays and MRIs of the spines of the majority of Americans, even those in their 20s, you would find impairments. However, many of those same Americans would also have never experienced LBP.
Every part of the human body ages, including the joints and the intervertebral disks of the back. Through the natural aging process those disks lose water content resulting in the gradual loss of space between the vertebrae. Furthermore, joints endure natural wear and tear over time that may result in arthritis due to inflammation of the cartilage. These impairments do not always cause pain and should not be the sole reason that clients are referred out for surgery or even for physical therapy.
I have treated many clients with non-specific LBP, without ever having seen a scan or X-ray, and have successfully resolved or drastically improved their symptoms allowing them to return to leisure activities and family life. In one particular case, my evaluation concluded that adhesions in the connective tissue (tendons, ligaments, etc.) were the cause of the discomfort in addition to restrictions in range of motion. In other words, the cause of LBP was not spinal. However,you can easily imagine that imaging prior to physical therapy might have resulted in a misdiagnosis of "degenerative joint disease" or "degenerative disk disease" for this client, which could then have led to unnecessary, invasive, and possibly unsuccessful treatments such as injections or surgery.
As a Doctor of Physical Therapy I am highly trained in differential diagnosis. Therefore, I am able to distinguish between a condition that I have the knowledge and skills to treat and one that merits immediate medical attention. In another case that I will never forget, I evaluated a client, who was referred to me directly by her primary care physician. An MRI was performed prior to her referral, but the results had not yet been reviewed by the physician by the time she arrived for her physical therapy evaluation. By asking probing questions, carefully listening to her description of symptoms, and examining her physically, I was able to determine that something was seriously wrong and that she needed immediate medical help, not physical therapy.
A motor vehicle accident that caused severe flexion of her spine was the instigator of her symptoms. She arrived at my clinic in severe pain and was visibly in tears as I was evaluating her. She described pain that radiated to both rib cages, buttocks, and legs. This report was an immediatered flag and prompted me to ask whether she had experienced any changes in bowel or bladder function. With a look of great surprise, she replied that she had indeed been unable to hold her urine or feces since the accident. This is a serious sign of damage to the central nervous system and a potential medical emergency. I immediately stopped my evaluation and called her physician to report that I suspected a mid-thoracic level posterior-central disk herniation. I informed my client that physical therapy was not recommended and reassured her that I was in communication with her physician. A half hour after our initial conversation, her physician called me again because he had just received the MRI results and was shocked at what he saw – a posterior-central disk herniation pressing into the spinal cord – a very dangerous medical situation. He thanked me profusely for communicating with him and stated that he had already placed a call to a neurosurgeon for immediate follow-up for the client. Although it was not the best news, my client was able to get the care that she needed based on my prompt communication with her physician.
The main point of this article is not to say that imaging in the presence of LBP is never necessary, but rather that it is over-utilized in our health care system. I highly recommend that if you or a loved one have LBP, you seek the advice of a physical therapist as a first course of action. In most states, a physician referral is not required for you to seek out the help of a physical therapist immediately. The same APTA article mentioned above stated that 37% or fewer of people that experience LBP actually seek professional treatment. Don't be one of those people. Take action and be empowered!
Dr. Michael Hyland, DPT, CEEAA has been a physical therapist since 2012. He is a Certified Exercise Expert for the Aging Adult and an expert in Parkinson's Disease. He owns Hyland Physical Therapy and Wellness in Broken Arrow, OK