Transcript Document 7155480

Exercise Prescription For
Special Populations
David Arnall, Ph.D., PT.
Important Ideas To Remember
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Mode of exercise
Intensity of exercise
Duration of exercise
Frequency of exercise
Rate of progression
Special Populations
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Patients With Diabetes
Patients With Hypertension
Expectant Mothers
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Patients Who Are HIV +
Patients With Intermittent
Claudication
Patients In End-Stage Renal Failure
Patients With Osteoporosis
Patients With Diabetes
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are two types of diabetes with
different exercise prescription needs :
Type I Diabetes Mellitus
 Type II Diabetes Mellitus
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• All diabetics have special needs :
good hydration
 adequate blood glucose before
exercise
 aerobic exercise of moderate
intensity
 do not excessively fatigue
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Type I Diabetes Mellitus
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They cannot get adequate glucose
clearance from the blood because
their beta cells in the pancreas are
not producing insulin.
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With 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.
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Acute and chronic exercise improves
glycemic control and stimulates
improved GLUT-4 performance and
#’s of transporters.
These changes are restricted to the
muscles that are being trained.
Type I Diabetes
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A Suggested Starting Ex. Program
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Mode : Aerobic
Frequency : 7 days a week
Duration : 20-30 minutes
Intensity : 45% - 85% of Max HR
Borg 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
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A Suggested Starting Ex. Program
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Mode : Aerobic
Frequency : 4 days a week
Duration : 15 - 60 minutes
Intensity : 45% - 70% of Max HR
Borg 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
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Avoid exercising during peak insulin
activity for Type I diabetics
Always exercise with a partner
Carry money with you so you can
call for help
Wear good foot wear
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Practice scrupulous foot inspections
Inject the insulin (Type II diabetics)
in muscle groups not involved in the
exercise training
Do not exercise if your blood glucose
is in excess of 300 mg/dl
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Learn to monitor your blood glucose
and determine if there is a duration
and intensity that regularly
decreases your blood glucose in a
dependable fashion.
If your blood glucose is close to 80 100 mg/dl pre-exercise, eat before
exercising
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Learn to decrease insulin
requirements once exercise is a
routine part of your daily schedule
Never take beta-blockers because
they mask the symptoms of
hypoglycemia
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Know the signs of hypoglycemia :
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Sweating
Loss of co-ordination
Mood swings
Dizziness
Lightheadedness
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Tingling In The Extremities
Hunger
Headaches
Anxiety
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Irritability
Seizures
Drowsiness
Slurred Speech
Patients With Hypertension
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Most patients ( 90% ) will have
Essential Hypertension or
hypertension of unknown origin
Some may have hypertension due to
renal disease or other causes such as
pheochromocytoma
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It 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
Systolic BP Diastolic BP
Normal
< 140
< 90
Mild HTN
140 - 159
90 - 99
Moderate HTN
160 - 179
100 - 109
Severe HTN
180 - 209
110 - 119
Very Severe HTN > 209
> 119
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Any patient with moderate to severe
hypertension should be evaluated for
other coronary artery risk factors
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Ideally, 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 …….
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If 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.
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If 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.
Hypertension
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A Suggested Starting Ex. Program
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Mode : Aerobic
Frequency : 3 - 4 days/week
Duration : 15 - 30 minutes
Intensity : 40% - 70% of SLGXT
Borg Scale : 10 - 14 RPE
Things To Think About …….
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Patients with HTN should :
Avoid weight lifting for the first
several weeks of their exercise
program
 Not routinely be engaged in
isometric exercises
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Avoid exhaustive exercise
Reduce % BF if appropriate
Limit salt intake
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Restrict alcohol consumption
Stop smoking
Avoid stress
Expectant Mothers
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Pregnancy 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….
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There are absolute contraindications
to exercise. They are :
heart disease
 ruptured membranes
 history or presence of premature
labor
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multiple fetuses
 vaginal or uterine bleeding
 placenta previa
 an incompetent cervix
 history of spontaneous abortions
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There are relative contraindications
to exercise. They are :
 high blood pressure
 anemia or other blood disorder
 thyroid disease
 diabetes
diabetes
 dysrhythmias
 breech presentation
 excessive obesity
 extreme underweight
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• history of bleeding during
pregnancy
• extremely sedentary lifestyle
• history of intrauterine growth
retardation
• history of precipitous births
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A Suggested Starting Ex. Program
 Mode : Aerobic
 Frequency : 3 days a week
 Duration : 15 - 30 minutes
 Intensity : 50% - 70% of Max HR
 Borg Scale : 10 - 14 RPE
Some things to Think About ….
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Exercise in a cool environment with
a low humidity (80:80 rule)
Wear high quality shoes with good
arch support
Be sure the Mother is well hydrated
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Exercise with a partner in case
Mother needs help
Wear an abdominal support
Make sure that the Mother is well
nourished
Do not exhaustively exercise
Patients Who Are HIV +
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Persons 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…..
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Mild/moderate ex. is immunosupportive it enables the CD4+ , NK killer cells, and
the CD8+ killer cells
Heavy exercise is immunosuppressive
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A Suggested Starting Ex. Program
 Mode : Aerobic
 Frequency : 3 days a week
 Duration : 15 - 20 minutes
 Intensity : 50% - 80% of Max HR
 Borg Scale : 10 - 14 RPE
Patients With
Intermittent Claudication
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Intermittent 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.
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When 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.
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It 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.
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A Suggested Starting Ex. Program
 Mode : Aerobic Weight Bearing
Exercises
 Frequency : 3 days/week
 Duration : QID > BID > QD for
periods up to 15 - 60 minutes
 Intensity : Grade II ---> III Pain
Ischemic Grades Pain Descriptors
Grade I Pain
Mild Pain - Can Continue
Grade II Pain
Moderate Pain - Patient Can
Be Diverted From Pain
Intense Pain - Patient Can't
Be Diverted From Pain
Excruciating Pain - Must
Stop Exercise
Grade III Pain
Grade IV Pain
Strategies…...
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These patients may have to be
convinced to exercise - they must
walk in pain for as long as they
can tolerate it.
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These 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
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Renal failure usually occurs in the
4th through the 7th decade.
The largest single group of patients
in renal failure are patients with
diabetes.
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Patients in renal failure typically are
frail individuals and may have
extensive muscle wasting, HTN,
hyperlipidemia, muscle cramping,
bone disease, fatigue & psychosocial
problems.
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Exercise is therapeutic for these
patients because it blunts the
wasting effects of sedentary living.
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A Suggested Starting Ex. Program
 Mode : Aerobic - walking, biking
 Frequency : 3 days/week
 Duration : 20 - 60 minutes
 Intensity : To Tolerance
Considerations……...
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These 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.
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They 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
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These 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
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Type I Osteoporosis : occurs with
menopause in female patients and is
associated with an accelerated loss of
trabecular bone.
It 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
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 estrogen deficiency
 increased bone resorption
activity
 too much glucocorticosteroid
intake
 alcoholism
Type II Osteoporosis
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Type II osteoporosis is associated
with advancing age (> 70) and
involves the loss of trabecular and
cortical bone.
It is characterized by fractured hips
and wedge fractures of the vertebral
bodies (Ages 70 +).
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Other factors effecting osteoporosis :
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Smoking
Sedentary - no exercise
Excessive ETOH consumption
Low dietary calcium intake
Prolonged amenorrhea
Nulliparity - 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……...
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Estrogen replacement therapy
reduces bone resorption by 50% 60% - is enhanced with progesterone
Calcium supplementation - calcium
carbonate is the best supplement 1500 mg/day
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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
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A Suggested Starting Ex. Program
 Mode : Aerobic & Weight Bearing
 Frequency : 3 - 5 days a week
 Duration : 20 - 30 minutes
 Intensity : 50% - 70% of Max HR
 Borg Scale : 10 - 14 RPE
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Exercise should be weight bearing
Types of exercise should be varied to
take continual stress off of the same
joints
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Water aerobics, swimming, kick
boards and wogging are all good for
conditioning even though they are
not weight bearing
Water 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
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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
Resources
• 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.