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					     Health & Disability Issues Facing
             Female Veterans

                           David X. Cifu, M.D.
Acting National Director                              Chief, PM&R Services
VHA PM&R Services                                     Richmond VAMC

                    Herman J. Flax, M.D. Professor and Chairman
                  Department of Physical Medicine and Rehabilitation
                         Virginia Commonwealth University


                               David.Cifu@VA.GOV                             1
                    Overview

• Female veterans represent 7% of all
  Veterans receiving care in the VA.

• 1.7 million female Veterans.

• Many common issues with all Veterans,
  but also unique health and disability
  challenges


                                          2
                   Overview

• Pain/Arthritis

• Obesity

• TBI

• Mental Health

• Cardiovascular

• Osteoporosis
                              3
                    Pain/Arthritis

• Spine
  – Degenerative disk disease
  – Acute and chronic radiculopathy


• Fibromyalgia
  – Diffuse pain and muscle soreness
  – Linkages with mental health disorders


• Joint
  – Degenerative and inflammatory arthritis
  – Injury related dysfunction
                                              4
                    Pain/Arthritis

• Spine
  – Low back and neck pain #1 reason for practitioner
    visits and 1/3 of persons over 45 years will have
    abnormal MRI of spine.
  – Degenerative changes to spine from job or life
    activities is primary cause of problem
  – Acute injury may begin degenerative cascade or
    exacerbate it
  – Whole body conditioning is critical to management
  – Focal treatments (medications, therapy,
    modalities, injection) may help acute exacerbation.
  – Limited role for surgery.
                                                          5
                   Pain/Arthritis

• Fibromyalgia
  – Complex condition related to hypersensitivity of
    nerves and muscles
  – Worsened by stress, anxiety and depression
  – More commonly seen in women’
  – Exacerbated by acute injury
  – Management includes whole body conditioning,
    good sleep hygiene, antidepressants for pain, and
    supportive counseling
  – Limited role for passive treatments (massage,
    heat, injections)

                                                        6
                    Pain/Arthritis

• Arthritis
  – By age 60, 100% have histological changes of OA
    degeneration; 40% report arthritis, and 10% have
    activity limitations. Arthritis affects over 60% of
    women and 50% of men aged 70 years or older.

  – Aerobic exercise, such as walking or aquatics, in
    both rheumatoid arthritis and osteoarthritis
    patients, is reported to increase aerobic capacity
    and 50-foot walking time while decreasing
    depression and anxiety, when compared to range
    of motion.
                                                          7
                      Pain/Arthritis
– As evidenced in recent consensus statements by both the
  National Institute of Health and the American Geriatrics
  Society, exercise is recognized as an effective treatment in
  the primary, secondary and tertiary prevention of
  osteoarthritis and its consequences.

– Reductions in disability have been reported with group,
  individual and home-based exercise programs, with no clear
  difference seen when modes of exercise are directly
  compared

– At present, the consensus is that exercise for patients with
  OA is safe, does not cause disease progression and rather
  than increasing pain actually contributes to the reduction of
  pain
                                                                  8
                               Mild TBI

• Sports, vehicular and combat-related exposures
  that result in a concussion are common
   – Alteration or loss of consciousness for up to 30 minutes
   – Lack of full memory for incident
   – Loss of recall for all events just before or after incident


• Symptoms of headache, dizziness, insomnia
  memory and attention problems, and irritability
  are common for the first 2-6 weeks.

• Persistent symptoms after 3 months are rare.

                                                                   9
                        Mild TBI

• Early evaluation of concussion is important.

• Early return to activities has been shown to
  reduce symptoms.

• Persistent symptoms that are not improving after
  2-4 weeks should be treated.

• Repeated concussions (especially untreated) may
  predispose to long-term sequelae.


                                                     10
                 Behavioral Health

• Depression, Anxiety, or Stress
  – Symptoms may be situational, endogenous
    (abnormalities of brain, medications or hormones),
    or a combination of factors.
  – Early assessment and management is important.
  – Life skills training, adjustment skills training, and
    supportive counseling are effective.
  – Regular exercise and conditioning are effective.
  – Medication management is effective.
  – “Waiting it out” is not effective.


                                                            11
                               Obesity

• 60% of Americans are overweight (BMI >25)
   – BMI = weight/height in inches
   – Eating habits are not conducive to healthy lifestyle
   – Most Americans do not understand appropriate diet


• Obesity either directly causes or contributes to
   –   Joint and spine arthritis
   –   Fibromyalgia pain
   –   Cardiac disease (hypertension, heart disease)
   –   Liver disease (Cirrhosis)
   –   Renal disease
   –   Disability

                                                            12
                                   Obesity

• Weight reduction
  – Diets
     • Fad diets have 2% success rate at 2 years
     • Lifestyle diets [Mediterranean (high complex carbs/monosaturated oils)
       and Adkins (high protein/low carbs)] have better long term results
  – Surgery
     • Has fair long-term results (66% reduction), when combined with diet
     • Majority of surgical interventions on women
     • Relatively high complication rate (20-40%)
  – Medications
     • Fair short term results, but poor long term
     • Systemic risks
  – Exercise
     • Good short term results
     • Poor-Fair long term results unless accompanied by lifestyle diet
     • Improves ratio of muscle to fat, but may encourage increased appetite
                                                                                13
                     Cardiovascular

• Cardiovascular
  – Obesity, poor diet, limited exercise, lifestyle
    choices (smoking), and genetics contribute to
    systemic cardiovascular disease
     • Heart
     • Kidney
     • Extremities
  – Women may have accelerated disease after
    menopause, but no clear effect of HRT
  – Diet, exercise, and close medical follow-up


                                                      14
                         Hypertension

• The benefits of exercise on hypertension are age
  independent.

• A comprehensive meta-analysis in women and
  two comprehensive reviews demonstrate that
  moderate intensity aerobic exercise, regardless
  of the exercise mode, can produce
   – a 2% reduction in systolic blood pressure (~11mmHg)
   – produce a 1% reduction in diastolic blood pressure (~8
     mmHg)
   – reduce left ventricular hypertrophy in patients with more
     advanced hypertension.
                               Kokkinos: Cardiol Clin 2001; 19:507-16
                               Kelley: Hypertension 2000; 35:838-43     15
                   Hypertension

• A meta-analysis specifically addressing the role
  aerobic plus resistive exercise suggests that
  improvements can be achieved of 2% and 4% for
  resting systolic and diastolic blood pressure,
  respectively.
                        Kokkinos: Cardiol Clin 2001; 19:507-16



• Recommendations are for hypertensive patients
  are to undergo a combined exercise program
  including aerobic and resistance training.



                                                                 16
            Coronary Heart Disease


• For individuals with coronary heart disease, a
  systematic review of the effectiveness of exercise
  only and exercise in the context of a
  comprehensive cardiac rehabilitation program on
  mortality. Using a meta-analytic approach, they
  reported that total cardiac mortality was reduced
  by 31% and 26%, respectively.
                         Jolliffe: Cochrane Database Syst Rev 2001




                                                                     17
            Congestive Heart Failure

• Recent consensus statements from national and
  international sources emphasizing the need for
  exercise training in the treatment of congestive
  heart failure.
• Exercise improves
   – CHF symptoms
   – maximal and submaximal exercise capacity
   – many pathophysiological mechanisms underlying CHF,
     including abnormalities of heart rate, skeletal muscle
     myopathy, cytokine expression and ergoreceptor function.

                      Witham: J Am Geriatr Soc 2003; 51:699-709.
                      Recommendations for exercise training in chronic
                      heart failure patients. Eur Heart J 2001; 22:125-35.
                                                                             18
                         Osteoporosis
• The estimated lifetime risk of hip fracture for a white woman
  aged 50 in the USA is 17% as opposed to only 6% for a
  white man of the same age.

• Fractures of the vertebrae (spine), proximal femur (hip) and
  distal forearm (radius) are considered to be quintessential
  osteoporotic fractures and commonly occur with only mild
  or moderate trauma.

• In addition to fractures, osteoporosis can limit mobility by
  increasing the fear of failing in the elderly leading to many
  of the side effects of immobility.

               Lim: Arch Phys Med Rehabil. 2000 Mar;81(3 Suppl 1):S55-9

                                                                          19
                  Osteoporosis

• Osteopenia or low bone mass – hip BMD greater
  than 1 SD below the young adult female mean (T
  score <-1 and >-2.5)

• Osteoporosis – hip BMD 2.5 SD or more below
  the young adult female mean (T score -2.5)

• Severe osteoporosis – hip BMD 2.5 SD or more
  below the young adult female mean in the
  presence of one or more fragility fractures.


                                                   20
           Osteoporosis with Fracture
• Use of clinical risk factors in assessing patients allows
  more accurate risk-stratification than BMD alone.

• Risk factors for fracture which are independent of BMD
  include:
  age                         previous fragility fracture

  low body weight             glucocorticoid therapy

  cigarette smoking           neuromuscular impairment

  poor visual acuity          impaired tandem walk and gait
                              speed

                              Kanis: Lancet. 2002 Jun 1;359(9321):1929-36.   21
          Osteoporosis with Fractures

• Woman’s Health Initiative (WHI) trials demonstrated that the
  HRT group had fewer hip and vertebral fractures than the
  control group (Relative Risk of 0.66 for both types of
  fractures).
               Women's Health Initiative Investigators: JAMA. 2002;288:321-333




• Biphosphanates prevent further loss of bony
  mass and, in women, decreases risk of spine
  fractures.




                                                                                 22
                        Osteoporosis
• In most countries, supplementation is needed by women to
  achieve an adequate calcium intake of 1200 – 1500 mg per
  day.

• Vitamin D supplementation is necessary in the northern
  United States and most likely in other climates where sun
  exposure is limited for a significant portion of the year. The
  recommended dose of Vitamin D is between 400 and 2000
  units per day.

• Calcitonin is a peptide hormone produced by thyroid C
  cells. Nasal spray calcitonin has been shown to reduce
  vertebral but not peripheral fractures.


                                                                   23
                   Osteoporosis

• Regular weight bearing physical activity
  enhances bone maintenance.

• Fitness may protect people from fractures by
  reducing the risk of falls as well.

• Daily exercise focusing on both balance and
  weight bearing such as Tai Chi Chuan may help
  retard bone loss in the weight-bearing bones of
  postmenopausal women.


                                                    24
                   Summary

• Preventative care and medical f/u is key to
  health and limiting disability.

• Healthy lifestyle choices (diet, exercise,
  not smoking) outweigh all medical factors.

• Even after the advent of disease, a
  combination of strengthening,
  conditioning and functional exercises can
  allow for enhanced independence and
  decreased disease.                            25
“To Care For Him Who Shall Have
Borne the Battle, And For His Widow
and Orphan”
                     - Abraham   Lincoln




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