Special Populations

Special Populations Obese Cardiac Diabetes Hypertension Osteoporosis Chronic Obstructive Pulmonary Disease Asthma Bronchitis Emphysema Arthritis Pregnancy

The Obese Client

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.

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.

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.

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 insulin Decrease insulin resistance Increased glucose tolerance

Management & Meds The 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 obese Has upper body fat distribution Has no history of weight cycling Has a sincere desire to lose weight Became overweight as an adult

Management & Meds Behavioral change focuses on dietary and activity habits toward weight reduction. Those who are morbidly obese (BMI > 40) may need more invasive interventions: Starvation diets Gastric Bypass Jaw wiring Intragastric balloons Fat excision Anti-obesity meds

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 history Motivation and readiness for change Nutrition & eating habits Body composition Extent of the obesity Distribution of body fat Reasonable target weight Assessment for potential injury

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 period Debate 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.

Recommendations for Programming Mode: Aerobic exercise Low-weight bearing exercise Walking Increase activities of daily living Resistance training Frequency: 5+ times/wk Duration: 40-60’/day or 20-30’ 2x/day Intensity: 40-70% or 70-85%

Special Considerations Injury prevention is very important; also injury history. Thermoregulation, neutral temp & humidity Adequate flexibility, warm-up and cool-down sessions Gradual progression of intensity & time; emphasize duration vs. intensity Use of low-impact or non-wt-bearing exercise; pool?? Adequate hydration Clothing should be loose fitting Equipment modification might be needed Frequent follow ups

The Cardiac Client With focus on the Post-myocardial infarction

Cardiovascular Diseases Myocardial Infarction Coronary Artery Bypass Graft Surgery Angina & Silent Ischemia Atrial Fibrillation Pacemakers Valvular Heart Disease Chronic Heart Failure Cardiac Transplant Hypertension Peripheral Arterial Disease Aneurysms

Effects of Exercise Training (ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, 2nd Ed) Increased max oxygen consumption Improved ventilatory response to exercise Relief of anginal symptoms Increased heart rate variability Modest decrease in body weight, fat stores, BP, blood profile components Increase in high density lipoproteins Improved psychosocial well-being and self-efficacy Protection against the triggering of myocardial infarction by strenuous physical exertion (> 6 METs).

Recommendations for Programming Use lower intensity due to higher risk Keep below threshold of angina, significant arrhythmias or symptoms of exercise intolerance Interval training considerations for those with: Very low aerobic capacity

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.

Recommendations for Programming Aerobic Exercise: Frequency: minimum 3 non-consecutive days/wk Duration: 20-40’ continuous or accumulated activity Intensity: 40-80% max HRR (heart rate reserve; RPE (rated perceived exertion 11-15 (Borg) Need longer warm-up & cool-down periods Max benefit requires 5-6 hrs/wk of physical activity Circuit Weight Training: Frequency: 2-3 days/wk Duration: 20-40’ Intensity: 40-50% max (no valsalva) 1-3 sets of 10-15 reps 8-12 different exercises

Special Considerations Monitor for abnormal symptoms Avoid 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 diabetes If possible, select equipment that can be adjusted in 1-MET increments Increasing muscular strength is an important component of a program for post myocardial infarction patient.

The Diabetic Client

Overview A 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 I Type II Gestational Other

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.

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 resistance Defective insulin secretion

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.

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.

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 agents Timing of med administration Blood glucose level prior to exercise Timing, amount, and type of previous food intake Presence & severity of diabetic complications Use of other meds secondary to diabetic complications Intensity, time, and type of exercise

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 meds Decrease body fat Decrease cardiovascular disease risk Stress Reduction Prevent Type-II diabetes in the first place

Management & Meds Careful 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.

Recommendations for Programming Must be individualized Predictable and consistent in frequency, intensity, and time Type I – daily exercise recommended for best sugar regulation Shorter duration (20-30’) Type II – 3-5x/wk Lower intensity, longer duration Be aware of contraindications for exercise such as illness or infection. Be on guard for hypoglycemia.

Special Considerations Insulin adjustments by physician only. Insulin dosage may be warranted 30-60 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 15-30 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

The Hypertensive Client

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.

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.

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!

Management & Meds Beta Blocker Ace Inhibitor Calcium Channel Blocker Diuretic Antihistamines/Cold meds Tranquilizers Antidepressants Alcohol Nicotine Caffeine

Management & Meds The 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.

Recommendations for Programming Mode: Aerobic exercise Frequency: 3-7 d/wk Duration: 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.

Special Considerations Do not exercise if systolic blood pressure > 200 or diastolic blood pressure > 115 700 kcal/wk should be the initial goal 2000 kcal/wk should be the long term goal

The COPD Client (Chronic Obstructive Pulmonary Disease)

Overview Imposes multiple pathophysiological problems: Ventilatory Impairments Abnormalities of Gas Exchange CV Impairments Muscular Impairments Symptomatic Limitations Psychological Disturbances

Effects of Exercise Training Regular participation in exercise can cause positive changes in COPD client: Cardiovascular reconditioning Desensitization to dyspnea Improved ventilatory efficiency Increased muscle strength Improved flexibility Improved body comp Improved balance Enhanced body image

Recommendations for Programming (Asthmatics) Must be controlled Take meds and have meds with them Extended warm-up Lower intensity, increase duration Purse-lipped breathing Adequate hydration Avoid cold, pollution, high pollen

Recommendations for Programming (COPD) Mode: Aerobic exercise such as walking or biking Frequency: 3-7 d/wk Duration: 30’ or shorter intermittent Intensity: duration is more important than intensity. Rated perceived exertion 11-13/20 Resistance training should be low resistance, high reps, 2-3 d/wk

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.

Osteoporosis

Peak Bone Mass Depends upon: Your inherited ability to make bone The amount of Calcium you consume Your exercise level Peak 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.

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: Disability Decreased independence Decreased quality of life Increased risk of death Multi-billion dollar cost to our health-care system annually.

Osteoporosis in the Lumbar Spine Osteoporosis makes the normal honeycomb matrix inside your bones (left) more porous. Under a microscope, osteoporotic bone (right) looks like a steel bridge with many girders missing. © 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.  A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "Mayo Clinic Health Information,"  "Sharing our Tradition of Trusted Answers" and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.

Osteoporosis in the Lumbar Spine

Four Steps to Prevent Osteoporosis (From the National Osteoporosis Foundation) A balanced diet rich in calcium and vitamin -D A 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).

Why Should You Exercise? To increase (or maintain) bone mass density To increase overall health & fitness To improve balance and agility To aid in fall prevention

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.

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.

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 Hiking Dancing Stair Climbing Racquet Sports These activities apply tension and pressure to the muscles and bones. Stimulates the body to increase/maintain bone density in response to the additional stress.

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 repetitions 8-10 exercises (avoid spinal flexion, maintain upright posture) Performed ~4 days per week

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

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)

Basic Exercise Recommendations Programs should be individualized & enjoyable Select a variety of exercises to avoid boredom Consider Cross Training: Ensures that different body parts are being used. Minimizes risk of injury by decreasing repetitive activities. Find a exercise partner Link exercise with regular activities Keep an exercise log to monitor progress

Exercise Recommendations (ACSM) The following areas of focus are quite appropriate for those with osteoporosis: Coordination & Balance Training Strength Training Flexibility Training

Exercise Recommendations Walking program Safe mode of exercise Should provide the needed benefits Non Weight Bearing Activities For those with significant fragility Should consider pool activities as an alternative to weight bearing exercise Minimal improvements in bone mineral density noted

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 Jumping Avoid exercises involving forward bending or excessive twisting at the waist: Lifting Rowing machine Golf Sit ups Bowling Tennis Avoid activities that increase risk of falling: Trampolines Step aerobics Slippery floors Skating

Safety Tips Around the House Proper mechanics during lifting is absolutely critical - avoid forward bending Be careful vacuuming, sweeping, mopping, and gardening due to the high degree of bending and twisting of the spine Use straddle stance with knees slightly bent. Use rocking motion to shift body weight, keep straight back.

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).

Osteoporosis It 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.

Osteoporosis Non-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.

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.

The Arthritic Client

Overview There are more than 100 rheumatological diseases, each having varying degrees of articular and systemic involvement. 2 most common: Osteoarthritis – a.k.a. Degenerative joint disorder Rheumatoid arthritis – inflammatory disease due to an autoimmune response against joint tissue.

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%.

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.

Recommendations for Programming Low impact exercises Avoid activities with quick movements Focus on range of motion & strengthening muscles Exercise intensity varies with disease activity and pain level (15’ twice/day). Use low intensity and duration during initial phase Alternate modes of exercise to include interval or cross training Set time goals vs. distance goals

Recommendations for Programming Avoid: Overstretching Climbing stairs Contact sports Activities requiring prolonged 1-legged standing Activities requiring rapid stop & go

Special Considerations Be aware of the need for joint protection Avoid overstretching unstable joints Avoid medial & lateral forces High-rep, high-resistance, high impact not recommended Depression may be an obstacle to lifestyle change