The Geriatric Athlete

Kurt Heinking

Growing numbers of senior athletes are exercising routinely and wanting to play competitive sports. Currently, the geriatric population comprises 12% of the total U.S. population. By the year 2030, 18% of our population will be over the age of 65, and by 2040 the mean life span will be in the 80s. The old-old, those over age 85, are the most rapidly growing segment of the population (1).

The United States Public Health Service declared that physical fitness and exercise is one of five priority areas in which improvement is expected to lead to substantial reduction in premature morbidity and mortality (2). Hundreds of studies delineating the beneficial effects of exercise have emerged. National recommendations advocating the development and maintenance of lifelong patterns of physical activity have been published. Many serious health problems in the elderly can be controlled, improved, or obliterated through moderate, consistent physical activity. There is considerable evidence that regular exercise, in conjunction with other risk-reducing behaviors, protects against an initial cardiac episode (primary prevention). It also aids in the recovery of patients with myocardial infarction, coronary bypass surgery, or angioplasty; and it reduces the risk of recurrent cardiac events (secondary prevention). Due to the beneficial effects of exercise and dietary modification, there has been a 30% decrease in coronary artery disease in the United States since 1960. Aerobic exercise and endurance training can also lead to numerous favorable metabolic effects. These include, but are not limited to, a more favorable lipid profile, control of obesity, decreased blood pressure, improved glucose tolerance, higher bone density, and an improved self-image.

However, this rise in physical activity has been accompanied by an increase in the number of sports-related injuries. It is estimated that over 17 million Americans seek medical care each year because of athletic and recreation-related problems (3,4,5). Considering that 12% of the population are over the age of 65, an enormous volume of elderly participants must be treated and educated on athletic-based injury. Regular exercise and appropriate training increase physical safety, reduce susceptibility to acute and chronic disease, and improve psychological outlook (6).

PHYSIOLOGIC CHANGES WITH AGING

The natural process of aging is based on the organism’s genetic makeup and capacity to respond to changes in the external environment with internal homeostasis. Although there is much to learn about aging, three theories on the mechanism have been proposed (1):

The immunologic theory.
The transcription theory.
The oxidative stress theory.

The immunologic theory states that changes in the thymus gland and immune system functions produce age-related changes. The transcription theory describes a defect in the repair of transcription errors and protein synthesis. The oxidative stress theory relates to the production of free radicals and their deleterious effects on the host’s organs and tissues. It is important to note that aging is relatively linear, with a 70-year-old aging at the same rate as a 40-year-old. Exercise improves a patient’s physiologic age; thus, although
a person may be chronologically 75 years old, he or she is physiologically only 55 years old. Exercise improves immune function and helps protect against the deleterious effects of free radicals. Aging affects all body systems; however, for the scope of this chapter, we concentrate on the musculoskeletal, cardiovascular, and neuroendocrine systems.

Aging athletes have losses in height, lean muscle mass, body water, and bone mineral density. Their connective tissue becomes less elastic and they lose flexibility. Their body fat increases; however, subcutaneous fat decreases. Systolic and, to a lesser extent, diastolic blood pressure increases, heart valves become thickened and sclerotic, and systemic peripheral resistance increases. There is decreased baroreceptor reflex activity, and altered electric neuronal conduction. Although resting cardiac output is unchanged, heart rate decreases and renal blood flow diminishes. There is a general increase in peripheral insulin resistance and impaired glucose tolerance. Neurologic function is also affected, along with postural instability, altered gait, and decreased reaction time. The sports medicine practitioner needs to understand these factors in injury diagnosis, management, and manual treatment. Because of the medical complexities of this age group, multidisciplinary care and a multidimensional treatment approach are necessary and beneficial (1).

RISK OF PARTICIPATION

The American College of Sports Medicine (ACSM) has developed a system to classify risk factors for individuals based on age and underlying cardiac condition (7). The three categories are as follows:

Apparently healthy individuals without known cardiac risk factors or evidence of underlying disease.
Higher risk individuals with one or more coronary risk factors.
Individuals with disease who have known active cardiopulmonary or metabolic diseases or who have symptoms suggestive of underlying disease that have not yet been evaluated.

Chisholm et al. (8) developed a self-administered set of seven questions known as the Physical Activity Readiness Questionnaire. On this questionnaire, individuals responding yes to any question should consult a physician before implementing an exercise program. Individuals classified as higher risk or individuals with disease in the sports medicine categories should be evaluated by a physician before beginning exercise.

PRE-PARTICIPATION

Treating geriatric athletes is challenging for the sports medicine specialist because of the involvement of one or several comorbid health conditions and their treatments, all of which is in addition to any sports injury. For instance, exercising can be difficult if an athlete has to take a beta-blocker and diuretic to control blood pressure, and rehabilitation can be even worse. Therefore, a modified pre-participation physical in elderly athletes is crucial in order to properly issue an exercise prescription. The pre-participation history and physical examination have numerous functions, with screening for life-threatening conditions topping the list. Elderly athletes may have atypical presentations of diseases and underreported symptoms. It is also difficult for the practitioner to determine if their symptoms are due to the natural process of aging or due to an undiagnosed medical condition. Their pain tolerance is usually increased, and they do not typically bother seeing a doctor for nuisance-type problems. They may be in denial over their visual or hearing loss, urinary incontinence, or diminished sexual functioning. Some of their symptoms may be due to drug interactions or medication side effects. A functional approach to their history is important to address their activities of daily living (ADL) and instrumental activities of daily living (IADL).

In 1996 the American Heart Association with the 26th Bethesda Conference on Cardiovascular
Health produced a document entitled Cardiovascular Screening of Competitive Athletes (9,10). Although these guidelines are clinically useful, there is no nationally accepted form for completing the pre-participation physical examination. However, the following are goals and objectives that should be considered during the pre-participation examination:

Establish rapport with the athlete.
Perform a screening musculoskeletal examination with emphasis on evaluation for the presence of somatic dysfunction (most often done by an osteopathic physician).
Screen for life-threatening conditions.
Decide eligibility or restriction of play (based on classification of sport: contact, limited contact, noncontact).
Determine disqualifying medical conditions for sport participation.
Evaluate the function of the musculoskeletal system and prior injuries.
Record a baseline mini-mental status examination.
Check for communicable diseases.
Counsel/educate on athletic injury prevention and cancer screening examinations based on the population.
Evaluate for injury potential and areas of performance enhancement.
Educate the athlete on closed head injury, use of ergogenic aids, and proper protective equipment.

The physical examination is a screening examination only, but it should include a thorough cardiac evaluation in at least two positions, carried out with maneuvers. In the older population, the physician should focus on these four systems:

Cardiopulmonary.
Peripheral vascular.
Musculoskeletal.
Metabolic and endocrine.

Cardiopulmonary

Baseline resting electrocardiograms, echocardiography, and cardiac stress testing are valuable in this population. Each individual’s cardiac risk factors, lifestyle, and physical examination should be taken into consideration. The athlete’s safety comes first. Athletes with strong family histories or prior events should be evaluated by a cardiologist. Protocols for the evaluation of athletes at risk are beyond the scope of this chapter but should not be ignored. The reader is referred to the ACSM guidelines for exercise testing and prescription (9,10).

Peripheral Vascular

A history of smoking, claudication, and especially rest pain is important to elucidate. Palpation reveals a cool extremity in arterial problems, a swollen tender extremity in venous problems, and a tense, woody feel in compartment syndromes. Older athletes may have chronic deep venous thromboses, phlebitis, and varicosities. A hand-held Doppler ultrasound is useful in the office. If arterial compromise is suspected, the ankle/brachial index and segmental pressures are valuable initial examinations. An angiogram, although somewhat invasive, is the gold standard. Duplex ultrasonography is useful for determining patency of the arterial and deep venous systems. Often in an athlete, an exercise-induced compartment syndrome is confused with a vascular obstruction. If this is a concern, intracompartmental pressures can be measured before and after exercising.

Musculoskeletal

The musculoskeletal screening should include not only evaluation of symptomatic joints, but a focused palpatory examination, and motion testing of body areas that contain significant tissue texture abnormality. Osteopathic findings should not be separated out from the orthopedic conditions that present. Is postural imbalance contributing to the athlete’s problem or complaint? Is the painful extremity on the concave or convex side of a spinal lateral curve? Is a flat thoracic kyphosis contributing to an extension dysfunction in the upper thoracic region? Is there a crossover pattern in the cervicothoracic junction or thoracolumbar region? Does an increased thoracic kyphosis contribute to
protracted shoulders and an anteriorly translated humeral head position?

Musculoskeletal problems may prevent the athlete from doing the aerobic exercise necessary to achieve the benefits. These factors may appear during the physical examination, or they may become apparent when the athlete starts exercising. The osteopathic physician is in a unique position to evaluate and treat musculoskeletal complications so that the athlete can realize the benefits of aerobic exercise.

Metabolic and Endocrine

Diabetic athletes have significant subcutaneous palpatory findings. These findings resemble a doughy feel similar to putty underneath the skin. The upper thoracic area (T1-T4) is a common place to find these changes. These changes typically are worse when their glucose is not well controlled. In the type 2, overweight diabetic, the upper thoracic kyphosis is usually increased, which may contribute to pain or muscular tension in the cervical spine. A combination of diabetic control, weight loss, manual treatment, and exercises to strengthen the rhomboids and lower trapezius is beneficial.

MANUAL MEDICINE APPROACH TO THE GERIATRIC ATHLETE

Many musculoskeletal injuries or athletic-based illnesses have a somatic component that is never diagnosed or addressed during treatment. Not only does treatment need to incorporate the original injury and associated somatic dysfunctions, it should take into account the chronic diseases and medications as well.

Elderly active athletes often demonstrate palpatory evidence of somatic dysfunction. The type, location, duration, and severity of the somatic dysfunction must be determined. The somatic dysfunction in this population may be related to their chief complaint, or to another illness, injury, or condition. The art of treating these patients lies within the determination of how much and what somatic dysfunction is clinically significant, and then what to do about it. Many manipulative techniques need to be modified or adjusted to be safely and effectively applied to the elderly athlete. Proficiency in indirect technique is an especially important skill for sports medicine clinicians to acquire, as it presents less stress to the elderly body.

Functional Screening Examination

The standing screening examination in the older athlete is performed in the same fashion as for the general population; however, it is not uncommon to find some differences. During the osteopathic standing structural examination, it is common to see various asymmetries of bony landmarks, muscular development, and soft tissues. The left and right halves of the body when viewed from a midsagittal plane are not typically bilaterally symmetrical.

Observation of these asymmetries begins as the athlete walks into the room. Viewing the athlete walking from more than one angle is also advantageous. Spinal asymmetries can also be palpated during active or passive motion. Static asymmetry is very different than functional asymmetry. The osteopathic standing structural examination looks for positional asymmetries of various anatomic landmarks and evaluates anterior-posterior and lateral spinal curvature. Standing asymmetry may or may not be clinically relevant unless it is a component of a TART (Tissue texture change, Asymmetry, Restriction of motion, Tenderness); then it has structural and functional implications. Standing asymmetries are basically a snapshot in time of what form the body’s structure is maintaining under the influence of gravity. Long-term adaptations to these asymmetries become “fixed,” with functional implications.

Dynamic asymmetry occurs as an athlete walks or runs, steps up or down, balances or jumps, or performs a sit-up or other exercise. Mitchell described a motion cycle of walking in which various postural asymmetries and arthrodial patterns change based on the phases of gait (13). This type of evaluation is clinically useful for the geriatric athlete because the concept can be expanded into the athlete’s daily activities or sport.
Have the athlete mimic motions and body positions that he or she repetitively uses throughout the day. Does the athlete frequently extend the neck? What happens to the anatomic landmarks as he or she does this? Does the athlete reach to the right from a sitting position? What happens to the scapula when he or she does this? Have the older athlete stand balancing on the left foot on a 2-in.-high beam, or stepping up and down. What happens to the levelness of the iliac crests as he or she does this? To lumbar lordosis? To the head position? Now repeat the evaluation on the right foot.

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