Exercise for Special

Populations

BY: DR REETA PT
MSPT (LNH), BSPT (JPMC) DPT.D (JPMC)
SENIOR LECTURER.
SIPMR
Exercise and the Elderly
Objectives
1. Describe the difference between Type 1 and Type 2
diabetes

2. Contrast how a diabetic responds to exercise when

blood glucose is "in control, " compared to when it is
not

3. Explain why exercise may complicate the life of a Type 1

diabetic, while being a recommended and primary part
of a Type 2 diabetic undertaking an exercise program
Objectives
4. Describe the changes in diet and insulin that might be
made prior to a diabetic undertaking an exercise
program

5. Describe the sequence of events leading to an asthma

attack, and how cromolyn sodium and β-adrenergic
agonists act to prevent and/or relieve an attack

6. Describe the cause of exercise-induced asthma and

how one may deal with this problem
Objectives
7. Contrast chronic obstructive pulmonary disease
(COPD) with asthma in terms of causes, prognosis,
and the role of rehabilitation programs in the return
to "normal" function

8. Identify the types of patient populations that one

might see in a cardiac rehabilitation program and the
types of medications that these individuals may be
taking
Objectives
9. Contrast the type of exercise test used for cardiac
populations with the test used for the apparently
healthy population

10. Describe the physiological changes in the elderly that

result from an endurance-training program.

11. Describe the guidelines for exercise programs for

pregnant women
SPECIAL POPULATION
It is often meant as a collective term for a group of
people with certain health-related conditions or
groups of individuals who exhibit medical conditions
that impair health and functional ability
OR
Patients with circumstances or conditions that require
special attention
Special Populations
Cardiac
Elderly
Diabetes
Hypertension
Osteoporosis
Chronic Obstructive Pulmonary Disease
Asthma
Pregnancy
Exercise and the Elderly
Older individuals are a special challenge
from the standpoint of exercise
prescription due to the usual presence
of chronic disease and physical activity
limitations.

 However, participation in physical

activity and exercise will go a long way
in preventing the progress of diseases
and in extending the years of
independent living
Maximal aerobic power decreases in the average population
after the age of twenty at the rate of about I% per year

The vast majority of people experience a steady decline in

V02 max so that by sixty years of age, their ability to engage
comfortably in normal activities is reduced.

This decline leads to lower and lower levels of cardio

respiratory fitness, which may not allow them to perform
daily tasks In turn, this affects elderly people's quality of
life and independence, which may necessitate reliance on
others
Exercise for older people
Keeping Active into older age is the key to saying fit,
mobile and independent.

Exercise can keep elders strong and healthy

A physical activity program is useful in dealing not

only for cardio respiratory fitness but also for the
osteoporosis that is related to the sudden hip fractures
that can lead to more inactivity and death
Recommendation
The guidelines for exercise training programs for older
adults are similar to those for younger people but
medical exam and risk factor screening are essential

So Before starting exercise programs elderly

individuals should consult their physician.
 Start with Low impact exercises
Pace of all movement should be slow to moderate
Progression should be very gradual
Fast movement avoided to prevent postural
hypotension
Exercise focus should be on to encourage elders to
become more physically active like walk the store, use
the stairs
 Encourage elders to keep joint flexible by moving,
stretching and bending
Stretching Exercises
Balance Exercises
Chair Exercises
Core Exercises
Cardio and Low-Impact Exercises
Strength Exercises
Exercise Goals
Maintenance of functional capacity for independent
living
Reduce risk of cardiovascular disease
Improved strength & endurance
Improved flexibility
Retardation of progression of chronic diseases
 Improve psychological well being
Reduces depression & anxiety
Improve socialization
Exercise Prescription
Mode/Type : comprehensive fitness program including
cardio respiratory, flexibility and strength training.

Weight-bearing endurance activities (tennis, stair

climbing, jogging, at least, intermittently during
walking), activities that ,involve jumping (volleyball,
basketball), and resistance exercise.

Non weight bearing for those elderly who have

degenrative joint disease like stationary cycling, water
exercises and chair exercises are best
 Exercise Prescription
Intensity: Low to moderate than moderate to high, in
terms of bone loading.

Frequency Weight-bearing activities 3-5 times/week;

resistance exercise 2-3 times/week

Duration: Start with short 10 to 15 minutes/ day and

progress to 30-60 min/day OF a combination of weight-
bearing endurance activities and resistance exercise that
targets all the muscle groups
Adaptations
•Chair exercises are ideal for older people or those
with limited mobility

•The exercises facilitate movement at an appropriate

level to increase fitness without adding the
unnecessary risk that can arise during higher
intensity, higher impact activity

•Chair exercises focus on functional fitness and

improve participants' ability to perform the standard
activities of daily living.
Benefits of participation
Improved risk factor profile e.g. higher HDL and lower
LDL cholesterol, improved insulin sensitivity, and
lower blood pressure

Increased strength and VO2max

VO2 max refers to the maximum amount of oxygen
that an individual can utilize during intense or maximal
exercise
 Exercise for Special Populations

Exercise During Pregnancy

Exercise During Pregnancy
Pregnancy places special demands on a woman due to
the developing fetus's needs for calories, protein,
minerals, vitamins, and of course, the physiologically
stable environment needed to process these nutrients.

Pregnant women should consult their physician prior

to beginning any exercise program
Major adaptations to pregnancy
Blood volume increases 40–50%

Oxygen uptake and heart rate are higher at rest and

during exercise

Cardiac output is higher at rest and during exercise in

first two trimesters ƒ Lower in third trimester

Rating of perceived exertion may be the best method

of setting intensity
Pregnancy is not a sickness or a disease condition.
However, there are several signs and symptoms that
should either preclude the beginning of an exercise
program or terminate exercise if a program has already
started
Absolute contraindications
 Absolute contraindications for aerobic exercise during pregnancy include

 Significant heart disease

 Restrictive lung disease,
 Incompetent cervix
 Multiple gestation at risk for premature labor,
 Persistent second- and third-trimester bleeding placenta previa after 26
weeks of gestation
 Ruptured membranes, and preeclampsia
 Pregnancy-induced hypertension.
Relative contraindications
Severe anemia
Unevaluated maternal cardiac arrhythmias
Chronic bronchitis
Poorly controlled Type 1 diabetes
Extreme underweight (BMl < 12)
History of extremely sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure disorder
Regular endurance exercise poses no risk to the fetus
and is beneficial for the mother
Exercise Recommendations
Follow ACSM recommendation
 30 min/day of moderate-intensity activity on most,
preferably all, days
 Intensity determined by:
 Heart rate ƒ
Rating of perceived exertion
“Talk test”
No supine exercise after first trimester
Hypertension
Defined as >140 or >90
Increase risk of coronary heart disease
Exercise and diet can be used as a non-drug
treatment
Precautions
Blood pressure should be monitored for those on
medications
Hypertension
ACSM Guidelines, Gordon 1997
Loss of weight if overweight
Limit alcohol intake
Reduce sodium intake
Maintain adequate dietary K+, Ca2+, Mg2+
Stop smoking
Reduce dietary fat, saturated fat, and cholesterol
intake
Exercise prescription
Intensity: light to vigorous activity, Moderate range (40%-
85% V02 max), is effective and can be accomplished with
lifestyle activities as well as structured exercise programs.

Duration: Thirty minutes

Frequency: three or more days per week and progress to

Preferably all, days of the week

Gordon indicates that the combination of intensity, frequency,

and duration should result in a weekly physical activity energy
expenditure of 700 initially) to 2,000 (goal) kcal
CARDIAC REHABILITATION
Exercise training is now an accepted part of the therapy used to
restore an individual who has some form of coronary heart
disease (CHD)
Cardiac rehabilitation is a programme of exercise and
information sessions that help people to get back to everyday
life as quickly as possible.
To help people in the hospital community and home.
Prove that exercise is not scary.
Reducing risk of happening again.
Cardiac Rehabilitation: Patient Population
Those who have or have had:
Myocardial infarction (MI)
Coronary artery bypass graft surgery (CABG)
Angioplasty (PTCA)
Angina pectoris

Medications
-blockers (reduce work of the heart)
Anti-arrhythmics (control dangerous heart rhythms)
Nitroglycerine (reduce angina symptoms)
Cardiac Rehabilitation Testing
Graded exercise testing
ECG monitoring (12-lead)
 Heart rate and rhythm
 Signs of ischemia (ST segment depression)

Blood pressure
Rating of perceived exertion (RPE)
Signs or symptoms (chest pain)
 Determination of myocardial blood flow
Cardiac rehabilitation includes a "Phase 1” inpatient
exercise program that is used to help the patients
make the transition from the cardiovascular event
(e,g" a myocardial infarction that put them in the
hospital) to the time of discharge from the hospital

After the patient is discharged from the hospital, a

"Phase II" program can be started.
Warm-up with stretching, endurance, and
strengthening exercises, and cool-down activities are
included
Phase 3: structured exercise and rehabilitation

 Graded exercise is a vital component of cardiac rehabilitation

group based exercise programme,
 The exercise programme is an 8 week course
 Each session lasts approx 90 minutes and is then followed by
educational talks which include medication, diet, exercise, stress,
relaxation

 Phase 4 – long term maintenance of physical activity and

lifestyle change

 To be effective, the changes you have made in the previous 3 phases

of Cardiac Rehabilitation should be maintained for the rest of your
life.
 Target three goals in cardiac rehabilitation

Safety
Fitness
Risk factor management
 Cardiac Rehabilitation Exercise Programs
 Exercise prescription
 Based on GXT results
 MET level, heart rate, signs/symptoms
 Whole body, dynamic exercise
 Intensity, duration, and frequency based on severity of disease

 “MET” is another name for metabolic equivalent; a measure

of exercise intensity based on oxygen consumption. More
specifically, a single MET is defined as the amount of oxygen a
person consumes (or the energy expended) per unit of body
weight during 1 minute of rest.

 Effects
 Increased functional capacity (VO2max)
 Reduced signs/symptoms of ischemia
 Improved risk factor profile
Termination Criteria from Exercise
Any angina symptoms or feeling too breathless to
continue
Feeling dizzy or faint
Leg pain limiting further exercise
Exceeds level of perceived exertion > 15 (Borg Scale)
Contraindication for Exercise
Unstable or unresolved angina.
Fever and acute systemic illness.
Patient in severe pain.
Resting blood pressure: SBP> 180mmHg, DBP> 100mmHg
Significantly unexplained drop in blood pressure.
Tachycardia
New or recurrent symptoms of breathlessness, palpitation,
dizziness.
Significant lethargy
 Diabetes
Characterized by an absolute (type 1) or relative (type
2) insulin deficiency that results in hyperglycemia

A major health problem and leading cause of death in

the United States

More than 17 million with diabetes, only 11.1 million

are diagnosed
Diabetes
Type 1 (Insulin Dependent diabetes Mellitus)
Lack of insulin
Develops early in life
10% diabetic population

Type 2 (Non Insulin Dependent diabetes Mellitus)

Resistance to insulin
Develops later in life
90% diabetic population
Exercise and Type 1 Diabetes
Pre-exercise blood glucose level
80 to 250

Glucose monitoring
During/after exercise

Carbohydrate intake
During recovery
Exercise and Type 2 Diabetes
Blood glucose monitoring
Exercise prescription
4-7 times per week
 Promotes weight loss and sustained increase in insulin
sensitivity
Minimum of 1,000 kcal/wk
 From all physical activity
American Diabetes Association
Goals for Nutrition Therapy
Attain & maintain optimum metabolic outcomes:
Maintain Blood glucose levels in normal range
A lipid and lipoprotein profile that reduces the risk of
macrovascular disease
Maintain Blood pressure level that reduces risk of
vascular disease
Improve health through food choice and activity
Address individual nutritional needs
Exercise prescription
Mode: Endurance activities such as walking
swimming and cycling
Intensity: 50% to 60% VO2 max gradually working up
to 60 to 70% VO2 max
Frequency: 5 to 7 days a week for IDDM
4 to 5 days a week for NIDDM may need to start
several daily session
Duration: persons with IDDM should gradually work
up to 20 to 30 minutes per session
For NIDDM 40 to 60 minutes is recommended
Asthma
A respiratory problem characterized by a shortness of
breath accompanied by a wheezing sound
Due to:
Contraction of smooth muscle of airways
Swelling of muscosal cells
Hyper secretion of mucus

May be caused by allergic reaction, exercise, aspirin,

dust and pollutants
Prevention and
Relief of Asthma
Prevention
Avoidance of allergens
Immunotherapy
Treatment
Cromolyn sodium
2-agonists
Theophylline
Exercise prescription
Mode: perform dynamic exercise such as walking
swimming and cycling. Upper body exercises
Intensity: low intensity dynamic exercise
Also based on patient fitness status and limitations
Frequency: 3 to 4 times per week
Duration: longer and more gradual warm up and cool
down more than 10 mints
Total time increased gradually 20 to 45 mints.
Exercise-Induced Asthma (EIA)
Caused by cooling/drying of respiratory tract
Increases osmolarity on surface of mast cell
Reducing the chance of an attack
Warm-up
Short-duration exercise < 5 mints
Treatment
-agonist
Chronic Obstructive Pulmonary Disease
(COPD)
Includes chronic bronchitis, emphysema, and
bronchial asthma
Can create irreversible changes in the lung
Can severely limit normal activities
Treatment includes:
Medication (including supplemental O2)
Breathing exercises
Dietary therapy
Exercise
Exercise prescription
Mild exercise training
Aerobic exercises
Do the best they can
Reference Book
EXERCISE PHYSIOLOGY
Theory and Application to Fitness and Performance, 9th
edition Scott K. Powers & Edward T. Howley

Exercise physiology, A thematic Approach By: Tudor

Hale, University College Chichester, UK.

Exercise physiology , Exercise, Performance and

Clinical applications By Robert A. Robergs