THE
POSTMENOPAUSAL
FEMALE & THE ROLE OF EXERCISE
Farah Hameed, MD
Assistant Professor
Columbia University Medical Center
Department of Rehabilitation and Regenerative Medicine
Post-Menopausal Women
• Musculoskeletal effects of
menopause
• Osteoarthritis
• Osteoporosis
• Sarcopenia
• Exercise benefits in post-
menopausal female
• Exercise Rx for the postmenopausal female
Effects of Estrogen
• Cartilage
• Chondroprotective
• Subchondral bone
• Regulates bone growth and remodeling
• Synovium
• Increases synovial levels
• Muscles
• Promotes myoblast proliferation
Martín-Millán M1, Castañeda S. Estrogens, osteoarthritis and inflammation. Joint Bone Spine. 2013 Jul;80(4):368-73.
Osteoarthritis
• 27 million Americans
• F>M (after age 50)
• Other risk factors
• Genetics
• Weight
• Prior injury
• With similar amounts of radiographic changes – OA is
more symptomatic in women
Helmick et al, 2008; http://www.arthritis.org/media/newsroom/media-kits/Osteoarthritis_fact_sheet.pdf
Osteoporosis
• Decrease in bone density
• Most common type of bone disease
• 50% of women over age 50
• Symptoms: loss of height, kyphosis,
low-trauma fracture
• Diagnosis: Bone Densitometry, +/labs, XR
Gass M1, Dawson-Hughes B. Preventing osteoporosis-related fractures: an overview. Am J Med. 2006 Apr;119(4 Suppl 1):S3-S11.
Osteoporosis and Fracture Risk
Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.
Age-Related Changes in Body Composition
•  lean body mass
•  % body fat
•  weight
•  height
Kyle UG1, Genton L, Hans D, Karsegard VL, Michel JP, Slosman DO, Pichard C. Total body mass, fat mass, fat-free mass, and skeletal muscle in
older people: cross-sectional differences in 60-year-old persons. J Am Geriatr Soc. 2001 Dec;49(12):1633-40.
Sarcopenia
 Sarcopenia- the age-associated loss of skeletal muscle
mass and function.
 Rosenberg, 1989
Evans W. What is Sarcopenia. J Gerentol. 1985; 50A:5-8.
Epidemiology
Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with
functional impairment and physical disability. J Am Geriatr Soc. 2002 May;50(5):889–96.
Strength
•
Greater decline in strength than muscle mass
•
•
•
Declines 15% in 6th and 7th decades and 30% after the 7th decade
Greater decline in lower body vs. upper body strength
Greater decline in extensors vs. flexors
• Power declines more than strength and muscle mass
• Weakness a more powerful predictor of morbidity/mortality in the
elderly than muscle mass
Goodpaster BH, Park SW, Harris TB, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition
Study. J Gerontol A Biol Sci Med Sci. 2006;61: 1059–1064.
Framingham Study
% of women that can not lift 10 lbs
% of women that can not lift 10 lbs
Age
40%
55-64
45%
65-74
65%
75-85
Jetter, AM, Branch LG. The Framingham disability study: II-Physical disability among the aging. Am. J Public Health 71: 1211-1216. 1981.
EXERCISE
Exercise – The Facts
• Inactivity increases with age
• By age 75, about 50% women
engage in no physical activity
• Walking & gardening are most
popular
• The loss of strength/stamina
attributed to aging is, in part,
caused by inactivity
http://www.cdc.gov/nccdphp/sgr/women.htm
Exercise Benefits During Menopause
• Studies have shown that
regular exercise/physical
activity leads to:
• Improved physical and mental
health
• Improved quality of life
• Reduced symptoms of
menopause in those who
exercised
• Choosing activity is important
Stojanovska L1, Apostolopoulos V2, Polman R3, Borkoles E3. To exercise, or, not to exercise, during menopause and beyond. Maturitas. 2014
Apr;77(4):318-23.
Exercise and Body Composition
•Moderate intensity
aerobic exercise
reduces total body fat
•Decrease in visceral
fat
TOTH, MJ.; BECKETT, T; POEHLMAN, ET. Physical activity and the progressive change in body composition with aging: current evidence and research
issues. Med Sci Sports Exerc. 1999; 3 (11 suppl): S590-6.
Activity Guidelines: > 65 years
• Follow adult guidelines
• 150 min of mod intensity/week
• 75 min vigorous intensity/week
• 10 min intervals
• Strengthening 2d/w
• When not possible, be as physically active as
abilities/conditions allow
• Do exercises that maintain or improve balance to reduce
risk for falling
Haskell et al, ACSM/AHA, MSSE, 2007
Exercise and Osteoarthritis
• What role does physical activity have on progression of
arthritis?
• Evidence suggest that (moderate) exercise does not accelerate
development of OA
• Possible increased risk of OA with competitive sports participation,
particularly early in life, and with competition at an elite level
• Increased risk of OA in the presence of obesity, trauma, occupational
stress, and alignment problems of the lower extremities
Running and Arthritis
• Lack of conclusive evidence that running causes arthritis
• No increase in 60 yo runners (180 min/w x 12 years)
• No increase in runners up to 28 mi/wk
• Higher incidence was seen > 65 mi/wk
• No increase in complaints of joint pain in runners vs. non-runners
• Pace may be better predictor
• Runners with arthritis may have faster progression of arthritis
compared to non-runners
Lane et al, 1986 & 1993; McDermott et al, 1983; Kujala et al, 1995
Strength Training
• Older individuals can substantially
increase their strength with
resistance exercise training
• Similar strength gains older vs.
younger
• Muscle strength increases in
response to training between 60100% of 1RM
• 15% people over 55 strength train
Bautmans I1, Van Puyvelde K, Mets T. Sarcopenia and functional decline: pathophysiology, prevention and therapy. Acta Clin Belg. 2009 Jul-Aug;64(4):303-16.
Where to start
• For a sedentary person, walking is feasible
• To start resistance training :
• Perform 8-10 repetitions of 8-10 exercises for major
muscle groups
• Start with 40% of one repetition maximum and
increase slowly
• Resistance training initially requires
professional instruction/machines
• Warm-up and cool-down with stretching
should be a part of every exercise session
Asikainen TM1, Kukkonen-Harjula K, Miilunpalo S. Exercise for health for early postmenopausal women: a systematic review of randomized controlled trials. Sports
Med. 2004;34(11):753-78.
Strength Training Recommendations
Taaffe DR. Sarcopenia--exercise as a treatment strategy. Aust Fam Physician. 2006 Mar;35(3):130-4.
Exercise in Osteoarthritis
• Combination of:
• Strength training (ST)
• Active range of motion exercise
• Aerobic activity
• Strength training:
• Resistance-based lower limb, hip and quadriceps strengthening
exercises
• Water-based exercise in knee and hip OA found benefits
for function and quality of life
• Reductions in pain and disability for overweight patients
with OA were found with weight loss (5% in 20 wks)
McAlindon TE1, Bannuru RR2, Sullivan MC2, Arden NK3, Berenbaum F4, Bierma-Zeinstra SM5, Hawker GA6, Henrotin Y7, Hunter DJ8, Kawaguchi
H9, Kwoh K10,Lohmander S11, Rannou F12, Roos EM13, Underwood M14. OARSI guidelines for the non-surgical management of knee osteoarthritis.
Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.
Exercise in Osteoarthritis
McAlindon TE1, Bannuru RR2, Sullivan MC2, Arden NK3, Berenbaum F4, Bierma-Zeinstra SM5, Hawker GA6, Henrotin Y7, Hunter DJ8, Kawaguchi
H9, Kwoh K10,Lohmander S11, Rannou F12, Roos EM13, Underwood M14. OARSI guidelines for the non-surgical management of knee osteoarthritis.
Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.
Managing Osteoporosis
• Julius Wolff (1891) – Bone, in a healthy subject, will adapt
to the loads under which it is placed
• Exercise  Bone remodeling
• Primary goal is reducing fracture risk
• Slow/stop bone loss
• Increase bone mass/improve bone architecture
• Maintain/increase bone strength
• Minimize risk of falls
Exercise Recommendations: Osteoporosis
• Exercises can increase bone mass if they increase
muscle mass and strength
• Muscles to target to help with posture and prevent falls:
• Back extensors
• Lower extremity muscle groups – such as the knee and hip
extensors, hip flexors, dorsiflexors and plantarflexors
• Compound movements can be effective way to target all
these areas
Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.
Exercise in Osteoporosis
• Focus on improving agility, balance and posture
• Avoid high impact activities
• Avoid activities with a risk of fall
• Avoid repeated/resisted trunk flexion movements
• Moderate intensity physical activity can help improve
balance and agility, thereby minimizing falls
• Among women 75 or older, exercise has been shown to reduce risk
of fall and injury by 75%
Tella SH1, Gallagher JC2. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol. 2014 Jul;142:155-70.
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T’ai Chi
• Flowing, meditative movements
• Greater loading than walking
• Reduces risk of falling
• Meta-analyses investigating t’ai chi found strong favorable
benefits of t’ai chi for improving pain and physical function
in individuals with OA
Yan JH1, Gu WJ, Sun J, Zhang WX, Li BW, Pan L. Efficacy of Tai Chi on pain, stiffness and function in patients with osteoarthritis: a meta-analysis. PLoS
One. 2013 Apr 19;8(4):e61672
Wayne PM1, Kiel DP, Buring JE, Connors EM, Bonato P, Yeh GY, Cohen CJ, Mancinelli C, Davis RB. Impact of Tai Chi exercise on multiple fracture-related
risk factors in post-menopausal osteopenic women: a pilot pragmatic, randomized trial. BMC Complement Altern Med. 2012 Jan 30;12:7.
Endurance Training Recommendations
Strength Training Recommendations
Thank You for Your Attention