Special Populations. Obese Cardiac Diabetes Hypertension Osteoporosis Chronic Obstructive Pulmonary...

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.


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.


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

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

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 ClientWith 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


(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).


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.


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


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


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.


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


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.


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.


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.


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.


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


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


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.

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Osteoporosis in the Lumbar Spine

Four Steps to Prevent Osteoporosis(From the National Osteoporosis Foundation)

1. A balanced diet rich in calcium and vitamin -D

2. A healthy lifestyle without smoking and excessive alcohol use.

3. Bone density testing and medication when appropriate.

4. Weight-bearing exercise (and a program that incorporates balance training for 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)

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

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.


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

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.

Overview

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%.


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


Avoid: Overstretching Climbing stairs Contact sports Activities requiring prolonged 1-legged

standing Activities requiring rapid stop & go


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

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