Exercise Prescription For Special Populations

David Arnall, Ph.D., PT.

Important Ideas To Remember
qMode of exercise qIntensity of exercise qDuration of exercise qFrequency of exercise qRate of progression

Special Populations
qPatients With Diabetes qPatients With Hypertension qExpectant Mothers

qPatients Who Are HIV + qPatients With Intermittent Claudication qPatients In End-Stage Renal Failure qPatients With Osteoporosis

Patients With Diabetes
qThere are two types of diabetes with different exercise prescription needs :
qType I Diabetes Mellitus qType II Diabetes Mellitus

• All diabetics have special needs :
qgood hydration qadequate blood glucose before exercise qaerobic exercise of moderate intensity qdo not excessively fatigue

Type I Diabetes Mellitus
qThey cannot get adequate glucose clearance from the blood because their beta cells in the pancreas are not producing insulin.

qWith loss of native insulin production, they are constrained to exogenously supplement themselves with insulin and to chronically exercise.

• How does exercise help blood glucose clearance ?
• Exercise causes the GLUT-4 transporters in muscle cells to migrate to the cell membrane and pickup glucose from the circulation.

qAcute and chronic exercise improves glycemic control and stimulates improved GLUT-4 performance and #’s of transporters. qThese changes are restricted to the muscles that are being trained.

Type I Diabetes
qA Suggested Starting Ex. Program
qMode : Aerobic qFrequency : 7 days a week qDuration : 20-30 minutes qIntensity : 45% - 85% of Max HR qBorg Scale : 10 - 14 RPE

• Some Ideas : – Need to exercise 7 days per week for glycemic control - not worried about weight control – Need to check blood glucose every 30 minutes unless pre-exercise blood glucose was very high

Type II Diabetes
qA Suggested Starting Ex. Program
qMode : Aerobic qFrequency : 4 days a week qDuration : 15 - 60 minutes qIntensity : 45% - 70% of Max HR qBorg Scale : 10 - 14 RPE

• Some Ideas : – Needs to exercise 4-5 days per week for weight control – Do not need to check blood glucose every 30 minutes unless preexercise blood glucose was very low

General Considerations
qAvoid exercising during peak insulin activity for Type I diabetics qAlways exercise with a partner qCarry money with you so you can call for help qWear good foot wear

qPractice scrupulous foot inspections qInject the insulin (Type II diabetics) in muscle groups not involved in the exercise training qDo not exercise if your blood glucose is in excess of 300 mg/dl

qLearn to monitor your blood glucose and determine if there is a duration and intensity that regularly decreases your blood glucose in a dependable fashion. qIf your blood glucose is close to 80 100 mg/dl pre-exercise, eat before exercising

qLearn to decrease insulin requirements once exercise is a routine part of your daily schedule qNever take beta-blockers because they mask the symptoms of hypoglycemia

qKnow the signs of hypoglycemia :
qSweating qLoss of co-ordination qMood swings qDizziness qLightheadedness

qTingling In The Extremities qHunger qHeadaches qAnxiety

qIrritability qSeizures qDrowsiness qSlurred Speech

Patients With Hypertension
qMost patients ( 90% ) will have Essential Hypertension or hypertension of unknown origin qSome may have hypertension due to renal disease or other causes such as pheochromocytoma

qIt will be important to find out the cause for the patient’s hypertension if it does not fall into the category of essential hypertension

Categories Of Hypertension
Category Normal Mild HTN Moderate HTN Severe HTN Systolic BP Diastolic BP < 140 140 - 159 160 - 179 180 - 209 < 90 90 - 99 100 - 109 110 - 119 > 119

Very Severe HTN > 209

qAny patient with moderate to severe hypertension should be evaluated for other coronary artery risk factors

qIdeally, any male over the age of 40 years or a female over the age of 50 years must have a GXT before an exercise prescription is written.

Know The Rules
• The American College of Sports Medicine Guidelines For Exercise Testing & Prescription is the authority on exercise prescription. Read and place at your disposal the criterion for patient inclusion in and exclusion from exercise programs.

ACSM Guidelines Say …….
qIf the resting pre-exercise blood pressure is >200/115, you should consider not exercising at all. The patient should be referred to their physician for improved control.

qIf the exercising blood pressure is >260/115, you should stop the exercise bout or at the very minimum reduce the intensity of the exercise bout.

qA Suggested Starting Ex. Program
qMode : Aerobic qFrequency : 3 - 4 days/week qDuration : 15 - 30 minutes qIntensity : 40% - 70% of SLGXT qBorg Scale : 10 - 14 RPE

Things To Think About …….
qPatients with HTN should :
qAvoid weight lifting for the first several weeks of their exercise program qNot routinely be engaged in isometric exercises

qAvoid exhaustive exercise qReduce % BF if appropriate qLimit salt intake

qRestrict alcohol consumption qStop smoking qAvoid stress

Expectant Mothers
qPregnancy is not a sickness or a disease condition. However, there are several conditions that you should be aware of that may impact the mother’s ability to exercise.

The ACSM Guidelines State….
qThere are absolute contraindications to exercise. They are :
qheart disease qruptured membranes qhistory or presence of premature labor

qmultiple fetuses qvaginal or uterine bleeding qplacenta previa qan incompetent cervix qhistory of spontaneous abortions

qThere are relative contraindications to exercise. They are : qhigh blood pressure qanemia or other blood disorder qthyroid disease qdiabetes

qdiabetes qdysrhythmias qbreech presentation qexcessive obesity qextreme underweight

• history of bleeding during pregnancy • extremely sedentary lifestyle • history of intrauterine growth retardation • history of precipitous births

qA Suggested Starting Ex. Program qMode : Aerobic qFrequency : 3 days a week qDuration : 15 - 30 minutes qIntensity : 50% - 70% of Max HR qBorg Scale : 10 - 14 RPE

Some things to Think About ….
qExercise in a cool environment with a low humidity (80:80 rule) qWear high quality shoes with good arch support qBe sure the Mother is well hydrated

qExercise with a partner in case Mother needs help qWear an abdominal support qMake sure that the Mother is well nourished qDo not exhaustively exercise

Patients Who Are HIV +
qPersons with HIV may exercise according to their desires as long as their CD4+ count is above 200/ml. CD4+ counts below this number set the condition for a diagnosis of AIDS and exercise should be on a case by case basis.

Things To Remember…..
q Mild/moderate ex. is immunosupportive it enables the CD4+ , NK killer cells, and the CD8+ killer cells q Heavy exercise is immunosuppressive

qA Suggested Starting Ex. Program qMode : Aerobic qFrequency : 3 days a week qDuration : 15 - 20 minutes qIntensity : 50% - 80% of Max HR qBorg Scale : 10 - 14 RPE

Patients With Intermittent Claudication
qIntermittent claudication (IC) is a peripheral vascular disease characterized by leg pain with exercise.

• Intermittent claudication occurs because of obstruction of blood flow through the arteries of exercising leg muscles. It is the obstruction of blood flow by fatty plagues (arteriosclerosis) that leads to the intense pain during exercise.

qWhen the patient walks for several minutes, the amount of blood that the muscle needs does not perfuse through the obstructed arteries. The patient then feels moderately intense to severe pain.

qIt has been shown that after a six week exercise program, the patient can walk three times more distance without leg pain than before the exercise training was begun.

qA Suggested Starting Ex. Program qMode : Aerobic Weight Bearing Exercises qFrequency : 3 days/week qDuration : QID > BID > QD for periods up to 15 - 60 minutes qIntensity : Grade II ---> III Pain

Ischemic Grades Pain Descriptors Grade I Pain Grade II Pain Grade III Pain Grade IV Pain Mild Pain - Can Continue Moderate Pain - Patient Can Be Diverted From Pain Intense Pain - Patient Can't Be Diverted From Pain Excruciating Pain - Must Stop Exercise

qThese patients may have to be convinced to exercise - they must walk in pain for as long as they can tolerate it.

qThese patients may have to exercise several times a day for small durations of time in order to build up to a sustained intensity of steady state exercise.

Patients In End-Stage Renal Failure
qRenal failure usually occurs in the 4th through the 7th decade. qThe largest single group of patients in renal failure are patients with diabetes.

qPatients in renal failure typically are frail individuals and may have extensive muscle wasting, HTN, hyperlipidemia, muscle cramping, bone disease, fatigue & psychosocial problems.

qExercise is therapeutic for these patients because it blunts the wasting effects of sedentary living.

qA Suggested Starting Ex. Program qMode : Aerobic - walking, biking qFrequency : 3 days/week qDuration : 20 - 60 minutes qIntensity : To Tolerance

qThese patients should be exercised in the first half of their dialysis session to avoid the fatigue they experience at the end of dialysis. A recumbent bike is useful.

qThey should be encouraged to walk and perform weight bearing exercise on their off-dialysis days to blunt the osteoporosis that many of them sustain because of sedentary lifestyles.

Patients With Osteoporosis
qThese patients experience bone wasting that eventually leads to pathological fractures of the long bones and the vertebral column - a $ 7 billion health care problem.

Type I Osteoporosis
qType I Osteoporosis : occurs with menopause in female patients and is associated with an accelerated loss of trabecular bone. qIt is characterized by crush fractures of the spine within 20 years after the onset of menopause (Ages 50 - 75).

• Type I osteoporosis is associated with : qestrogen deficiency qincreased bone resorption activity qtoo much glucocorticosteroid intake qalcoholism

Type II Osteoporosis
qType II osteoporosis is associated with advancing age (> 70) and involves the loss of trabecular and cortical bone. qIt is characterized by fractured hips and wedge fractures of the vertebral bodies (Ages 70 +).

qOther factors effecting osteoporosis :
qSmoking qSedentary - no exercise qExcessive ETOH consumption qLow dietary calcium intake qProlonged amenorrhea qNulliparity - women who bore no children

• By the age of 80 years, 1 out of 3 women will fracture their hips while only 1 out of 6 men will experience a fractured hip. • By the age of 90, women have lost 50% of their trabecular bone while men have lost only 20% - 25% of their trabecular bone mass.

Some Solutions……...
qEstrogen replacement therapy reduces bone resorption by 50% 60% - is enhanced with progesterone qCalcium supplementation - calcium carbonate is the best supplement 1500 mg/day

• • • •

Fosamax - encourages osteoblasis Vitamin D - 800 IU per day Calcitonin - inhibits osteoclasis Thiazide diuretics cause calcium resorption from the glomerular filtrate

• Testosterone - increases bone mass in men and women • Parathyroid hormone - in combination with estrogen helps bone mass

• Bisphosphonates - etidronate, residronate, alendronate all inhibit bone resorption • Exercise is helpful in blunting the onslaught of osteoporosis

qA Suggested Starting Ex. Program qMode : Aerobic & Weight Bearing qFrequency : 3 - 5 days a week qDuration : 20 - 30 minutes qIntensity : 50% - 70% of Max HR qBorg Scale : 10 - 14 RPE

qExercise should be weight bearing qTypes of exercise should be varied to take continual stress off of the same joints

qWater aerobics, swimming, kick boards and wogging are all good for conditioning even though they are not weight bearing qWater exercises are helpful because they increase ROM and increase muscle strength

Rheumatoid Arthritis
• Criterion For Classifying A Patient With RA - must have 4 out of 7 • Morning stiffness lasting more than 1 hour before improvement • Arthritis in at least 3 joints PIP, MCP, wrist, elbow, knee, ankle, MTP joints, etc.

• Simultaneous involvement of bilateral joints • At least one area of involvement must be in the wrist, MCP, or PIP joint

• Rheumatoid nodules over bony prominences or next to joints • A positive serum rheumatoid factor • Radiological changes

Functional Capacity Criteria
American Rheumatology Association

• Class 1 : complete ability to carry on usual duties without handicaps • Class 2 : adequate ability for normal activities despite handicap, discomfort, or limited motion at one or more joints

• Class 3 : ability limited to little or none of the duties of usual occupation or to self-care • Class 4 : incapacitated, largely or wholly. Bedridden or confined to a wheelchair; litle or no self-care

Clinical Effects Of The Disease
• • • • • • Pain Lost ROM Lost joint integrity Reduced work capacity Muscular weakness & wasting Onset of osteoporosis & fragility

• Class 1 patients can do any type of exercise but should probably should not perform hard physical exercise. • Class 2 & 3 patients may perform most types of aerobic exercise as long as their disease process is not in an active phase. If the disease process is active & progressive, then no-load light workouts are advised.

• Class 4 patients by definition are too incapacitated for weight bearing exercise but may participate in nonweight bearing exercise modes - i.e. water exercises where their weight is supported

Exercise Prescription
• Mode
• must be matched to the level of disease - class 1, 2, 3, or 4 • must be matched to the number of involved joints • must be matched with subjective symptoms in mind

• Mode Choices Influenced By....
• need to be low impact • use large muscle groups in a rhythmic slow fashion • exercises emphasizing ROM • static exercises for strength

• Good Mode Choices…..
• Tai Chi • wogging • treadmill • stationary or free bike • soft or light rebounding • swimming or snorkeling

• Frequency…..
• 3-5 days/week • variable depending on phase of the disease - remissions or exacerbations • patient education to know when to rest & postpone exercise

• Duration……
• 15-45 minutes per exercise bout • variable day to day depending on symptoms • need to remember longer warm up and cool down sessions

• Intensity…..
• activity fraction of : .4 - .6 if GXT data is available • 75% of age-adjusted HR in the noncardiopulmonary population • Borg scale of 10 - 13 • low impact • variable day-to-day depending on the symptoms

• Monitoring the patient during exercise ……
• Borg scale • Dyspnea Scale • Pain Scale • Blood pressure & HR • Auscultate the lungs

• Exercise Testing and Exercise Prescription For Special Cases : Theoretical Basis & Clinical Application, 2nd ed., Lea & Fibeger Publishers, 1993 by James S. Skinner • ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, Human Kinetics Publishers, 1997.

• Sports & Exercise for Children with Chronic Health Conditions, Human Kinetics Publishers, 1995 by Barry Goldberg. • ACSM’s Guidelines for Exercise Testing & Prescription, 5th edition, Williams & Wilkins Publishers, 1995.

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