1. Special Populations

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

3. The Obese Client

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 insulin
Decrease insulin resistance
Increased glucose tolerance

8. 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

9. 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

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 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

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 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.

12. 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%

13. 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

15. The Cardiac Client With focus on the Post-myocardial infarction

16. 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

17. 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).

18. 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

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/wk
Duration: 20-40’ continuous or accumulated activity
Intensity: 40-80% max HRR (heart rate reserve; RPE (rated perceived exertion (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 reps
8-12 different exercises

21. 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.

23. The Diabetic Client

24. 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

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 resistance
Defective 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 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

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

31. 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.

32. 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.

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

36. The Hypertensive Client

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!

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

41. 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.

42. 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.

43. 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

45. The COPD Client (Chronic Obstructive Pulmonary Disease)

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

47. 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

48. 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

49. 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

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.

52. Osteoporosis

53. 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.

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

55. 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.
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56. Osteoporosis in the Lumbar Spine

57. 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).

58. 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

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 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.

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 repetitions
8-10 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 & 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

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

68. 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

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 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

70. 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.

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. 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.

73. 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.

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.

76. The Arthritic Client

77. 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.

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 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

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

82. 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