Exercise Prescription For Special Populations

Important Ideas To Remember Mode of exercise Intensity of exercise Duration of exercise Frequency of exercise Rate of progression

Special Populations Patients With Diabetes Patients With Hypertension Expectant Mothers

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

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

All diabetics have special needs : good hydration adequate blood glucose before exercise aerobic exercise of moderate intensity do not excessively fatigue

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

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.

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 A Suggested Starting Ex. Program 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 A Suggested Starting Ex. Program 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 pre-exercise blood glucose was very low

General Considerations 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

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

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

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

Know the signs of hypoglycemia : Sweating Loss of co-ordination Mood swings Dizziness Lightheadedness

Tingling In The Extremities Hunger Headaches Anxiety

Irritability Seizures Drowsiness Slurred Speech

Patients With Hypertension 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

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

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

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 ……. 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.

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 A Suggested Starting Ex. Program 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 ……. Patients with HTN should : Avoid weight lifting for the first several weeks of their exercise program Not routinely be engaged in isometric exercises

Avoid exhaustive exercise Reduce % BF if appropriate Limit salt intake

Restrict alcohol consumption Stop smoking Avoid stress

Expectant Mothers 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…. There are absolute contraindications to exercise. They are : heart disease ruptured membranes history or presence of premature labor

multiple fetuses vaginal or uterine bleeding placenta previa an incompetent cervix history of spontaneous abortions

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

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

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 …. 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

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

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 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.

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.

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.

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

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

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 Renal failure usually occurs in the 4th through the 7th decade. The largest single group of patients in renal failure are patients with diabetes.

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

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

A Suggested Starting Ex. Program Mode : Aerobic - walking, biking Frequency : 3 days/week Duration : 20 - 60 minutes Intensity : To Tolerance

Considerations……... 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.

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 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 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 : estrogen deficiency increased bone resorption activity too much glucocorticosteroid intake alcoholism

Type II Osteoporosis 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 +).

Other factors effecting osteoporosis : 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……... Estrogen replacement therapy reduces bone resorption by 50% - 60% - is enhanced with progesterone Calcium 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

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

Exercise should be weight bearing Types of exercise should be varied to take continual stress off of the same joints

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