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The term ‘athlete’ has many differing definitions, connotations and stereotypes. For many years, sport and exercise medicine physicians have treated every patient as an athlete to a greater or lesser extent with associated functional, work, sport and social expectations and demands. As we age alongside our patients, we empathise with their changing needs and abilities. People are living longer, but many do so in poor health and with reduced quality of life due to the presence of chronic diseases. Ageing is associated with multi-system decline, including musculoskeletal conditions. In the UK, the greatest cause of pain and disability are musculoskeletal conditions such as osteoarthritis and back pain, and these remain under-recognised as a public health priority.1 The presence of two or more long-term ailments (physical or mental), so called multi-morbidity, is increasingly common in patients from both high-income and low/middle-income economies. Indeed, in the UK, there are 15 million people living with one or more long-term condition accounting for 50% of general practitioner appointments, 70% of hospital bed days and 70% of health and social care budgets. For an ageing population, maintaining musculoskeletal health is essential to effectively apply and benefit from disease-specific and generic exercise guidance.
Why physical activity matters
While ageing is not synonymous with senescence, for many, it is a reality with declining health and accompanying chronic diseases that limit physical activity. This is of critical importance as physical activity can act as a lever for better health across many, if not all, long-term conditions including mental health. Yet by the age of 65 years, nearly half of patients with a heart, lung or mental health problem also have a musculoskeletal condition. This creates a ‘double jeopardy’ as the decline of musculoskeletal health impacts their ability to remain physically active and thus use exercise as medicine and in some cases threatens independent living. Consequently, as we age, maintenance of musculoskeletal health is a significant enabler for long-term physical activity, health and well-being. For patients with long-term musculoskeletal conditions, such as osteoarthritis, physical activity can reduce pain and enhance health and quality of life. However, patients may wish to be more physically active but struggle with their conditions and may have ‘internal’ barriers to effectively carry out exercise advice and options. Thus, a better understanding of self-efficacy and self-confidence is fundamental when trying to improve exercise adherence and enhance lifestyle for older people.
However, a paradox exists whereby use of disease-specific exercise prescription (such as from the Swedish physical activity in the prevention and treatment of disease: fysisk aktivitet i sjukdomsprevention och sjukdomsbehanding (Physical Activity book for prevention and treatment, FYSS) and the development of disease-based guidelines is supported, but simultaneously the commonality of many disease-based guidelines highlights the pragmatic need for clear and simple lifestyle advice messages.2 Exercise advice for older athletes should encourage healthy mixed cross-training rather than the pursuit of a single sport or activity. Many national physical activity guidelines are now specific for older people, adding weekly strengthening and proprioception to standard advice about cardiovascular exercise. It should be appreciated that such guidelines are founded on strong evidence for physical activity reducing cardiovascular mortality and morbidity, rather than the maintenance or enhancement of musculoskeletal health.
For the ageing athlete, we know that a history of competitive sport does not guarantee good health with advancing years, but continued physical activity does.3 Thus, the ability to remain physically active and reduce the adverse consequences of older age is fundamental. However, musculoskeletal health may be of concern for older athletes following a sporting career that led to overuse or acute injury, which alongside obesity predisposes to osteoarthritis. Indeed, research has shown that retired professional footballers who have suffered a significant knee injury during their careers are at greater likelihood of developing subsequent knee pain, radiographic and symptomatic knee osteoarthritis and undergoing knee arthroplasty. This is a function of their sport participation and past knee injury rather than the inevitable advancement of years.4Yet, while this group of retired athletes may have a higher prevalence of musculoskeletal morbidity, their overall health is better than controls with lower indices of cardiovascular disease, diabetes and enhanced mental health.4
Current research challenges
Sports clinicians have moved a long way from advocating rest as the treatment for ‘degenerative joint disease’. Indeed, exercise is now a cornerstone of treatment guidelines for osteoarthritis. However, the optimal modes of action for different types of exercise and phenotypes of osteoarthritis remain unclear. Thus, current research is directed towards a better understanding of the content and context of physical activity programmes and the relative efficacy of different types of exercise across the life course. A significant challenge is the detection of early musculoskeletal disease to enable effective prevention strategies across all populations. For osteoarthritis and the ageing athlete, there is currently no risk prediction model. This is exemplified by the lack of reliable biomarkers to identify or predict early osteoarthritis and the discordance between radiographic osteoarthritis and symptoms. These problems are the current focus of research with The Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis (http://www.sportsarthritisresearchuk.org). Our challenge is to encourage physical activity across the lifespan with an enhanced understanding of the relationships between sport, exercise, prior injury and musculoskeletal health.
Funding The author is part-funded by Arthritis Research UK, 10.13039/501100000341 (20194).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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