4 Effects on the Exercise Response Low physical work capacity.Higher risk for coronary artery disease and may exhibit myocardial ischemia during exercise (testing).Hypertensive response may occur during exercise despite the absence of hypertension at rest.Must consider glucose intolerance as well.
5 Effects of Exercise Training Exercise training is effective in decreasing the BW in moderately obese clients.However, it may not be effective in the morbidly obese.When body weight is reduced through regular exercise, body fat is reduced and lean tissue is maintained or increased.Those with the least lean mass to begin with have the most lean mass to gain during training.
6 Effects of Exercise Training Obese individuals may already have a significant amount of lean mass (beneath the adipose) due to the overload from the excess fat increases in lean mass may not be as significant.Ultimately, resistance training can increase the lean mass of almost any population.Exercise affects body fat distribution by promoting regional fat loss in the abdominal sites.
7 Effects of Exercise Training Fat loss through exercise is more efficient for clients with upper body fat distribution (significantly decreases risk of diseases).Exercise may be one of the most important factors in the maintenance of weight loss.Exercise has profound effects of glucose metabolism in the obese client:Decreased fasting glucose and insulinDecrease insulin resistanceIncreased glucose tolerance
8 Management & MedsThe primary objective of obesity management is the reduction of fat weight with the preservation of lean body weight.The client most likely to be successful is:Slightly or moderately obeseHas upper body fat distributionHas no history of weight cyclingHas a sincere desire to lose weightBecame overweight as an adult
9 Management & MedsBehavioral change focuses on dietary and activity habits toward weight reduction.Those who are morbidly obese (BMI > 40) may need more invasive interventions:Starvation dietsGastric BypassJaw wiringIntragastric balloonsFat excisionAnti-obesity meds
10 Recommendations for Exercise Testing The primary reason to conduct exercise testing is to determine exercise prescription to determine physical work capacity.Assessment should include:Medical & weight historyMotivation and readiness for changeNutrition & eating habitsBody compositionExtent of the obesityDistribution of body fatReasonable target weightAssessment for potential injury
11 Recommendations for Programming Goal is to optimize calorie burn yet minimize the potential for injury.Remember the E (enjoyment) in FITTE and exercise should fit the lifestyle.Consider the energy expenditure of the actual exercise and the recovery periodDebate over exercising once or twice a day.The literature supports total kcals expended rather than concerning oneself with whether the kcals are coming from fat or CHO stores.
12 Recommendations for Programming Mode: Aerobic exerciseLow-weight bearing exerciseWalkingIncrease activities of daily livingResistance trainingFrequency: 5+ times/wkDuration: 40-60’/day or 20-30’ 2x/dayIntensity: 40-70% or 70-85%
13 Special Considerations Injury prevention is very important; also injury history.Thermoregulation, neutral temp & humidityAdequate flexibility, warm-up and cool-down sessionsGradual progression of intensity & time; emphasize duration vs. intensityUse of low-impact or non-wt-bearing exercise; pool??Adequate hydrationClothing should be loose fittingEquipment modification might be neededFrequent follow ups
17 Effects of Exercise Training (ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, 2nd Ed)Increased max oxygen consumptionImproved ventilatory response to exerciseRelief of anginal symptomsIncreased heart rate variabilityModest decrease in body weight, fat stores, BP, blood profile componentsIncrease in high density lipoproteinsImproved psychosocial well-being and self-efficacyProtection against the triggering of myocardial infarction by strenuous physical exertion (> 6 METs).
18 Recommendations for Programming Use lower intensity due to higher riskKeep below threshold of angina, significant arrhythmias or symptoms of exercise intoleranceInterval training considerations for those with:Very low aerobic capacity
19 Recommendations for Programming (ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, 2nd Ed)Large muscle, rhythmic group exercise, ie) walking, biking, rowing, stairclimbing) is appropriate for outpatient physical conditioning (phase II-IV).Training benefits do not transfer from the legs to the arms, and vice versa, both sets of limbs should be exercised.Mild to moderate resistance training can also provide a safe and effective method for improving cardiovascular function and other fitness parameters.
20 Recommendations for Programming Aerobic Exercise:Frequency: minimum 3 non-consecutive days/wkDuration: 20-40’ continuous or accumulated activityIntensity: 40-80% max HRR (heart rate reserve; RPE (rated perceived exertion (Borg)Need longer warm-up & cool-down periodsMax benefit requires 5-6 hrs/wk of physical activityCircuit Weight Training:Frequency: 2-3 days/wkDuration: 20-40’Intensity: 40-50% max (no valsalva)1-3 sets of reps8-12 different exercises
21 Special Considerations Monitor for abnormal symptomsAvoid high intensity exercise in post-myocardial infarction clients.Supervision suggested for moderate- to high-risk clients.Be aware that many post-MI clients have peripheral arterial disease and/or diabetesIf possible, select equipment that can be adjusted in 1-MET incrementsIncreasing muscular strength is an important component of a program for post myocardial infarction patient.
24 OverviewA chronic metabolic disease characterized by an absolute or relative deficiency of insulin that results in hyperglycemia.Are at risk for developing microvascular & macrovascular complications.Silent ischemia is common for those who have had the disease a long time.Many classifications of the disease:Type IType IIGestationalOther
25 Overview – Type I Diabetes Of the 16 million people with diabetes in US, 5-10% have Type I.An absolute deficiency of insulin.Insulin must be supplied by injection or pump.Usually occurs < age 30 but can occur at any age.
26 Overview – Type II Diabetes Considered to have a relative insulin deficiency because while insulin levels are elevated, reduced or normal, they present with hyperglycemia.Pathophysiology is unclear but believed to be multifactoral.Believed it is due to:Peripheral tissue insulin resistanceDefective insulin secretion
27 Overview – Type II Diabetes Glucose does not readily enter the tissues and blood glucose causes the pancreas to secrete more insulin in an attempt to maintain normal blood glucose concentrations.Obesity significantly contributes to the insulin resistance.80% of the people with type-II are obese at onset.
28 Overview – Type II Diabetes Genetically influenced – found in studies of twins.Onset occurs with few or no classic symptoms and many go undetected until organ damage has occurred.Usually occurs > age 40.Some develop < age 30 – maturity onset-diabetes of youth.
29 Effects on the Exercise Response Diabetics do not respond to exercise in a normal manner.The effect of diabetes on a single exercise session is dependent of several factors:Use & type of medication: insulin or oral agentsTiming of med administrationBlood glucose level prior to exerciseTiming, amount, and type of previous food intakePresence & severity of diabetic complicationsUse of other meds secondary to diabetic complicationsIntensity, time, and type of exercise
30 Effects of Exercise Training Exercise is considered to be one of the cornerstones of diabetes care.Exercise benefits include:Improved blood glucose control (except for Type I)Improved insulin sensitivity & lower doses of medsDecrease body fatDecrease cardiovascular disease riskStress ReductionPrevent Type-II diabetes in the first place
31 Management & MedsCareful monitoring of blood glucose and attention to balancing food intake and meds are needed for safe participation.Watch for hypoglycemia – the effects of both insulin and oral agents may cause.If exercise sessions are due to exceed 60’, test blood glucose during exercise.Should avoid exercise if blood glucose level is below 60.
32 Recommendations for Programming Must be individualizedPredictable and consistent in frequency, intensity, and timeType I – daily exercise recommended for best sugar regulationShorter duration (20-30’)Type II – 3-5x/wkLower intensity, longer durationBe aware of contraindications for exercise such as illness or infection.Be on guard for hypoglycemia.
33 Special Considerations Insulin adjustments by physician only.Insulin dosage may be warranted minutes ahead of session.Those with type I must consider food intake with exercise.In general, 1 hour of exercise requires an additional 15 g of carbohydrates before OR after exercise.If exercise is vigorous or of longer duration, an added g of carbohydrates for every hour may be needed.Be aware of proper precautions such as glucose tabs, hydration, foot care, medical identification.Inject into the non-exercising limbs
37 Overview~ 50 million individuals have an elevated blood pressure or are taking meds for it.In these people, the risk of heart disease increase progressively with higher levels of both systolic and diastolic blood pressure.Hypertension is based on the average of 2 or more readings taken at each of 2 or more visits after an initial screening.
38 Effects on the Exercise Response Usually see a rise in the systolic blood pressure from baseline in those with hypertension who are not medicated.The response may be exaggerated or diminished in certain people.Those will hypertension will usually have a higher systolic blood pressure than those who don’t have hypertenstion.The diastolic blood pressure may not change or may rise slightly probably due to impaired vasodilatory response.Studies show a decrease in systolic blood pressure during the initial hours following 30-45’ of moderately intense exercise.
39 Effects of Exercise Training Endurance training may elicit an average reduction of ~ 10 mmHg in both systolic and diastolic blood pressure in stage I & II hypertension.Physically active clients with hypertension who also have good cardiovascular fitness levels have a lower mortality rate than sedentary and less fit people.Heavy resistance exercise has been shown to increase systolic and diastolic blood pressure.Circuit weight training is the exception to this however. It is OK to do!
41 Management & MedsThe goal is to prevent sickness and death associated with high blood pressure and to control blood pressure by the least intrusive means possible.Blood pressure should be lowered and maintained below 140/90 while controlling other modifiable cardiovascular risk factors at the same time.Must rely on the RPE (rated perceived exertion) scale vs. TTZ (target training zone) for monitoring exercise.Be aware of the possibility of hypotension as a result of antihypertensive agents that reduce total peripheral resistance by vasodilation.
42 Recommendations for Programming Mode: Aerobic exerciseFrequency: 3-7 d/wkDuration: 30-60’Intensity: 40-70%Exercising at lower intensities appears to lower blood pressure as much as, if not more than, higher intensity exercise.This is very important in the elderly and those who also have chronic diseases w/hypertension.
43 Special Considerations Do not exercise if systolic blood pressure > 200 or diastolic blood pressure > 115700 kcal/wk should be the initial goal2000 kcal/wk should be the long term goal
45 The COPD Client (Chronic Obstructive Pulmonary Disease)
46 Overview Imposes multiple pathophysiological problems: Ventilatory ImpairmentsAbnormalities of Gas ExchangeCV ImpairmentsMuscular ImpairmentsSymptomatic LimitationsPsychological Disturbances
47 Effects of Exercise Training Regular participation in exercise can cause positive changes in COPD client:Cardiovascular reconditioningDesensitization to dyspneaImproved ventilatory efficiencyIncreased muscle strengthImproved flexibilityImproved body compImproved balanceEnhanced body image
48 Recommendations for Programming (Asthmatics) Must be controlledTake meds and have meds with themExtended warm-upLower intensity, increase durationPurse-lipped breathingAdequate hydrationAvoid cold, pollution, high pollen
49 Recommendations for Programming (COPD) Mode: Aerobic exercise such as walking or bikingFrequency: 3-7 d/wkDuration: 30’ or shorter intermittentIntensity: duration is more important than intensity. Rated perceived exertion 11-13/20Resistance training should be low resistance, high reps, 2-3 d/wk
50 Special Considerations Rated perceived exertion is preferred methods of monitoring intensity.Patients usually respond best to exercise in mid to late morning.Avoid extremes in temperature and humidity.
53 Peak Bone Mass Depends upon: Your inherited ability to make boneThe amount of Calcium you consumeYour exercise levelPeak bone mass is reached at about age 30.Beyond age 30, bone mass steadily decreases.Making the right lifestyle choices during peak bone-mass building years and afterward may contribute to a higher peak bone mass and decrease risk of osteoporosis.
54 Why Should You Care? Osteoporosis is preventable! No cure for osteoporosis…only treatment.One out of every two women and one out of every eight men over age 50 will have an osteoporosis-related fracture in their lifetime.Fractures of the hip and spine result in:DisabilityDecreased independenceDecreased quality of lifeIncreased risk of deathMulti-billion dollar cost to our health-care system annually.
57 Four Steps to Prevent Osteoporosis (From the National Osteoporosis Foundation) A balanced diet rich in calcium and vitamin -DA healthy lifestyle without smoking and excessive alcohol use.Bone density testing and medication when appropriate.Weight-bearing exercise (and a program that incorporates balance training for fall prevention).
58 Why Should You Exercise? To increase (or maintain) bone mass densityTo increase overall health & fitnessTo improve balance and agilityTo aid in fall prevention
59 Which Type of Exercise Is Best to Prevent Osteoporosis? Resistance training combined with cardiovascular training (bike or walking) is the best recommendation for an exercise program for a patient with osteoporosis. (ACSM)The level of exercise depends upon age and the level of osteoporosis that is present.
60 Which Type of Exercise Is Best to Prevent Osteoporosis? Younger or middle-aged individuals are typically safe to engage in high impact activities which may increase bone mineral density.Older individuals may be permitted in high impact exercises providing that osteoporosis is not severe; however, it may increase the risk of a fracture.
61 Which Type of Exercise Is Best to Prevent Osteoporosis? Weight bearing Exercises (min of 4 days/wk)Activity that is done with your feet in contact with the ground so the force of gravity acts through the skeleton.Activities that involve carrying your own body weight.Walking Jogging HikingDancing Stair ClimbingRacquet SportsThese activities apply tension and pressure to the muscles and bones.Stimulates the body to increase/maintain bone density in response to the additional stress.
63 Resistance Training Offers Protective Benefits Resistance training appears the offer the most benefits for increases in muscular strength and bone density… even in the elderly.Patients with severe osteoporosis should initially be supervised to ensure proper form and technique.Increases muscular strength minimize falls.Current recommendations include:1 set of 15 repetitions8-10 exercises (avoid spinal flexion, maintain upright posture)Performed ~4 days per week
64 Effectiveness of Exercise The effectiveness of exercise in the prevention of osteoporosis is dependant upon principle of Progressive Overload.The amount of exercise needed to obtain increases in bone mass depends upon the person’s current level of physical activity – Sedentary vs. Active
65 Effectiveness of Exercise Gains made in bone mineral density will only be maintained as long as the exercise is continued. (ACSM)Individuals should not assume that a short period of exercise (weeks or months) will achieve long-term effects on their bones.Approximately 9 months to 1 year are required to detect a significant change in bone mass. (ACSM)
66 Basic Exercise Recommendations Programs should be individualized & enjoyableSelect a variety of exercises to avoid boredomConsider Cross Training:Ensures that different body parts are being used.Minimizes risk of injury by decreasing repetitive activities.Find a exercise partnerLink exercise with regular activitiesKeep an exercise log to monitor progress
67 Exercise Recommendations (ACSM) The following areas of focus are quite appropriate for those with osteoporosis:Coordination & Balance TrainingStrength TrainingFlexibility Training
68 Exercise Recommendations Walking programSafe mode of exerciseShould provide the needed benefitsNon Weight Bearing ActivitiesFor those with significant fragilityShould consider pool activities as an alternative to weight bearing exerciseMinimal improvements in bone mineral density noted
69 Exercise “No No’s” For Osteoporosis Avoid jerky, rapid movements while performing exercises.Avoid high impact exercises that impart high loads to the skeleton:Jogging/Running High impact aerobics JumpingAvoid exercises involving forward bending or excessive twisting at the waist:Lifting Rowing machine GolfSit ups Bowling TennisAvoid activities that increase risk of falling:Trampolines Step aerobicsSlippery floors Skating
70 Safety Tips Around the House Proper mechanics during lifting is absolutely critical - avoid forward bendingBe careful vacuuming, sweeping, mopping, and gardening due to the high degree of bending and twisting of the spineUse straddle stance with knees slightly bent.Use rocking motion to shift body weight, keep straight back.
71 Osteoporosis Begins In Childhood! The optimal time to begin exercise training to increase bone mineral density is before puberty.Want to reach the highest peak bone mass possible thus decreasing the risk of fractures later in life.Participation in athletics also has potential for increasing bone mineral density.Those sports/exercise that involve a high degree of impact (gymnastics/volleyball) are more beneficial to bone than those activities without impact loading (swimming, biking).
72 OsteoporosisIt is never too early or too late to start a prevention program.Resistance training combined with cardiovascular training is the best exercise program for a patient with osteoporosis.Exercise cannot substitute for hormones at menopause. A program of Hormone Replacement Therapy & Exercise combined is most effective in preventing further bone loss.
73 OsteoporosisNon-weight bearing exercises are more appropriate for those who have severe osteoporosis.To protect one’s bone mass density, an exercise program must be life long and performed consistently.Habitual inactivity results in a downward spiral in physiologic functions.
74 Special Considerations Be aware of clients anxiety about falling.Keep environment free of hazards.Wall railing are helpful.Monitor balance drills closely to avoid mishaps during exercise sessions.
77 OverviewThere are more than 100 rheumatological diseases, each having varying degrees of articular and systemic involvement.2 most common:Osteoarthritis – a.k.a. Degenerative joint disorderRheumatoid arthritis – inflammatory disease due to an autoimmune response against joint tissue.
78 Effects on the Exercise Response Inflammatory rheumatic diseases can affect cardiac and pulmonary function.This must be considered before performing any vigorous exercise.If current flare-ups are occurring, post-pone exercise.Pain, stiffness and BM inefficiency can increase metabolic cost of exercise by ~ 50%.
79 Effects of Exercise Training These clients are able to participate in regular, conditioning exercise to improve all aspects of fitness and health.The most immediate benefit of exercise for this group is to diminish effects of inactivity.These clients respond favorably to a low-moderate, gradually progressed exercise program.
80 Recommendations for Programming Low impact exercisesAvoid activities with quick movementsFocus on range of motion & strengthening musclesExercise intensity varies with disease activity and pain level (15’ twice/day).Use low intensity and duration during initial phaseAlternate modes of exercise to include interval or cross trainingSet time goals vs. distance goals
81 Recommendations for Programming Avoid:OverstretchingClimbing stairsContact sportsActivities requiring prolonged 1-legged standingActivities requiring rapid stop & go
82 Special Considerations Be aware of the need for joint protectionAvoid overstretching unstable jointsAvoid medial & lateral forcesHigh-rep, high-resistance, high impact not recommendedDepression may be an obstacle to lifestyle change