Many healthcare professionals are of the opinion that regular physical activity, correctly perfonned, can offer a relatively safe means of acquiring improved health for elderly. subjects. '-2-3 However, chronologic aging is an unmodifiable factor that increases an individual's exercise risk.4 Careful exercise rehabilitation is necessary for maximal therapeutic effects to be obtained while keeping patient risk to a minimum. EXERCISE NOT INDICATED FOR ALL CASES As people age, there is a greater chance that they will exhibit higher incidences of incapacitating conditions. Contraindications to an immediate exercise rehabilitation program include active carditis, heart failure, myocardial infarction in the past six-to-eight weeks, and unstable angina.5 Recent pulmonary embolism or deep venous thrombosis, uncontrolled hypertension and diabetes, uncontrolled epilepsy, and acute febrile illness are also contraindications, as are such ECG abnormalities as ventricular tachycardia, second or third-degree atrioventricular block, and sick sinus syndrome.5>6'7 Useful screening procedures include a careful health history, cardiovascular evaluation with an ECG, and an exercise test. Ideally me submaximal oxygen consumption should be measured at the same time. EXERCISE RECOMMENDATIONS Exercise, initially at least five days a week, is recommended in uncomplicated cases. Emphasis is placed on the duration rather than on the intensity of aerobic exercise. A long, relatively low-intensity regimen places less stress on the coronary circulation and reduces the risk of serious mus-culoskeletal injury. Muscle and flexibility exercises should be used in the warm-up phase before walking, jogging, or cycling. Isotonic exercises with lighter weight, with many repetitions, are recommended initially for at-risk cases. Isometric exercises are avoided. The pulse should be checked during and after exercise; the working heart rate, determined on exercise testing, should never be exceeded. Adequate fluid replacement during exercise is important. Subjects should be taught to breathe correctly during static exercise. Licensed supervision is necessary initially in patients at risk, such as those who have had myocardial infarction. With adequate precautions, exercise can be a useful and safe practice for properly-selected patients. There are not enough sophisticated exercise test systems in the world-not to mention a sufficient supply of gerontol-ogists, cardiologists, internists, family practitioners, or exercise physiolo-gists-to safely test the entire geriatric population at large. A lot of common sense and the preselection of the population at risk would seem to be the practical alterrtative. What is at issue is the memorization of a list of given contraindications versus good clinical practice and the inherent flexibility of practicing both the science and the art of rehabilitation. Emphasizing the importance of an adequate warm-up, submaximal pace of exercise, and a cooling-off period, as well as a general awareness of the environmental pressures, appeals to many, far more than recommending the obligatory checking of pulse rates and committing the healthy person to a checklist similar to that for a 747 preflight takeoff. Many healthcare professionals tend to be compulsive, but it may be equally important to be careful that we not inflict our compulsions on a passive patient population to an inappropriate degree. EFFECTS AND RESPONSE Payton,9 et al, report of the physiologic effects of aging and the response to rehabilitation. Gross muscle atrophy appears to be primarily an aging change, resulting from loss of both number and size of muscle fibers. Mitochondrial activity declines, and patchy degeneration of myofibrils is observed. Changes in the joint surfaces, ligaments, tendons, and other connective tissues predispose elderly persons to the onset of overt pathologic change, as in the arthritides. The cellular changes and disuse result in decreased strength and flexibility. Age-induced cardiovascular alterations include a rise in blood pressure and a decrease in stroke volume. Reduced tolerance of stress results. Neurologically, a functional slowing of response is observed, although the quality of response may increase. Perceptual changes, apart from those involving sight and hearing, include an increase in postural sway and decreased conduction time at the myo-neural junction and along neurons themselves, predisposing the elderly to loss of balance and injury. Depressed endocrine function undoubtedly underlies the reduced ability of elderly persons to cope with physical stress and preserve homeostasis. Many of the so-called "normal" changes attributed to aging might equally well be considered changes caused by disuse. Alternatively, some interaction between the aging process and disuse may be operative. In either case, the results of studies on exercise in elderly subjects are encouraging. A number of investigators have reported significant improvement in functional capacity and performance after elderly subjects have undergone a period of training. Beneficial psychologic effects of exercise, including improved cognitive function, have also been described. Rehabilitation for elderly persons is designed to prevent or reverse the sequelae of disuse, combat the effects of disuse in ill patients, and reverse functional losses caused by trauma and disease. Procedures are similar to those used with other age groups, but the frequency may be altered as well as the intensity and duration. Sensitivity to psychosocial factors is necessary for clinical success with elderly persons. EXERCISE TESTING Exercise stress testing in geriatric patients has been somewhat controversial because of possible risks, but all patients with peripheral vascular disease can determine the degree of functional limitation. Older patients may not be comfortable with standard treadmill protocols. A protocol starting at a lower workload and increased more gradually may be more useful than standard protocols. Some flexibility in the use of testing is permissible without jeopardizing the standardization of results in terms of workload achieved. A cycle ergometer may provide an alternative to some elderly patients who fear the treadmill or are unsteady. Early fatigue and light-headedness due to deconditioning and vasoregulatory inefficiency must be kept in mind in testing elderly subjects. Significant calcific aortic stenosis may prevent an appropriate systolic pressure rise with exercise. Geriatric patients should be considered for exercise testing on the basis of the same criteria as those used in any other age group, but particular attention should be given with regard to the flexible use of exercise protocols, coaching and reassurance, and maintenance of alertness for any difficulties. In this way, safe and informative testing can be performed on most elderly patients. There was an initial concern that exer- cise testing in the geriatric patient might be associated with an increased frequency of complications. This has been shown not to be the case, if common sense, modified protocols, and a certain flexibility are applied. It should be pointed out that this is a very positive and necessary use of testing, because this group of patients often has coronary artery disease, and it has exactly the same implications in terms of diagnosis and prognosis for recovery from coronary artery events. It may be even more important to identify the subtleties of activity that may be permitted for the elderly. It should be emphasized that a cycle ergometer can be a sturdier platform for some elderly people than a treadmill, especially in the setting of unstable back, knee, or hip disease. «J* Dr. Kim D. Christensen is co-director of the SportsMedicine & Rehab Clinics of Washington, a multidisciplinary group of clinics. Dr. Christensen is a popular speaker at numerous conventions and participates as a team physician and consultant to high school and university ath- Continued on page 40... i REHABILITATION ...from page 39 letic programs, as well as Being a chiropractic faculty member. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the current president of the ACA Rehab Council. He recently received the "Founding Father" award at the annual ACA meeting from the American Chiropractic Rehabilitation Board. He has participated in college sports, and has served as a trainer, coach and team doctor. Dr. Christensen is the author of numerous publications and texts encompassing musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Avenue, Ridgefield, WA 98642. REFERENCES /. Kostka T Berthouze SE, Lacour J, Bonnefoy M. The symptomatology of upper respiratory tract infections and exercise in elderly people. Med Sci Sports Exerc 2000; 32(1):46-51. 2. Ross MC, Bohannon AS, Davis DC, Gurchiek L. The effects of a short-term exercise program on movement, pain, and mood in the elderly. Results of a pilot study. J Holist Nurs 1999; 17(2): 139-147. 3. Jozsi AC, Campbell WW, Joseph L, Davey SL, Evans WJ. Changes in power with resistance training in older and. younger men and women. J Gerontol A Biol Sci Med Sci 1999; 54(11):M591-596. 4. Short KR, Nair KS. The effect of age i on protein metabolism. Curr Opin Clin Nutr Metab Care 2000; 3(l):39-44. 5. Gordon NF et al. Exercise — the need for careful prescription. S Afr Med J 1982; 62(2):47-49. 6. Hendricks E, Hendricks CD. Aging in Mass Society. Cambridge, MA: Win-trope, 1977. 7. Shephart RJ. Management of exercise in the elderly. Can J Appl Sport Sci 1984; 9(3):109-120. 8. Landin RJ et al. Exercise testing and training of the elderly patient. In Wenger NK (ed.J, Exercise and the Heart. Philadelphia: FA Davis, 1985: 201-218. 9. Payton OD et al. Aging process. Implications for clinical practice. Phys Ther 1983; 63(l):41-48. 10. Las left LJ, Amsterdam EA, Mason DT. IM, pp. 53-61, September 1980. «j»
