1. Exercise Prescription For Special Populations

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

3. Special Populations Patients With Diabetes Patients With Hypertension
Expectant Mothers

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

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

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

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

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

9. 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.

10. 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.

11. Type I Diabetes A Suggested Starting Ex. Program Mode : Aerobic
Frequency : 7 days a week
Duration : minutes
Intensity : 45% - 85% of Max HR
Borg Scale : RPE

12. 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

13. Type II Diabetes A Suggested Starting Ex. Program Mode : Aerobic
Frequency : 4 days a week
Duration : minutes
Intensity : 45% - 70% of Max HR
Borg Scale : RPE

14. 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

15. 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

16. 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

17. 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 mg/dl pre-exercise, eat before exercising

18. 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

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

20. Tingling In The Extremities
Hunger
Headaches
Anxiety

21. Irritability
Seizures
Drowsiness
Slurred Speech

22. 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

23. 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

24. Categories Of Hypertension

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

26. 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.

27. 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.

28. 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.

29. 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.

30. Hypertension A Suggested Starting Ex. Program Mode : Aerobic
Frequency : days/week
Duration : minutes
Intensity : 40% - 70% of SLGXT
Borg Scale : RPE

31. 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

32. Avoid exhaustive exercise
Reduce % BF if appropriate
Limit salt intake

33. Restrict alcohol consumption
Stop smoking
Avoid stress

34. 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.

35. The ACSM Guidelines State….
There are absolute contraindications to exercise. They are :
heart disease
ruptured membranes
history or presence of premature labor

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

37. There are relative contraindications to exercise. They are :
high blood pressure
anemia or other blood disorder
thyroid disease
diabetes

38. diabetes
dysrhythmias
breech presentation
excessive obesity
extreme underweight

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

40. A Suggested Starting Ex. Program
Mode : Aerobic
Frequency : 3 days a week
Duration : minutes
Intensity : 50% - 70% of Max HR
Borg Scale : RPE

41. 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

42. 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

43. 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.

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

45. A Suggested Starting Ex. Program
Mode : Aerobic
Frequency : 3 days a week
Duration : minutes
Intensity : 50% - 80% of Max HR
Borg Scale : RPE

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

47. 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.

48. 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.

49. 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.

50. A Suggested Starting Ex. Program
Mode : Aerobic Weight Bearing Exercises
Frequency : 3 days/week
Duration : QID > BID > QD for periods up to minutes
Intensity : Grade II ---> III Pain

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

53. 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.

54. 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.

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

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

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

58. 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.

59. 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.

60. 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.

61. 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 ).

62. Type I osteoporosis is associated with :
estrogen deficiency
increased bone resorption activity
too much glucocorticosteroid intake
alcoholism

63. 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 +).

64. Other factors effecting osteoporosis :
Smoking
Sedentary - no exercise
Excessive ETOH consumption
Low dietary calcium intake
Prolonged amenorrhea
Nulliparity - women who bore no children

65. 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.

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

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

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

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

70. A Suggested Starting Ex. Program
Mode : Aerobic & Weight Bearing
Frequency : days a week
Duration : minutes
Intensity : 50% - 70% of Max HR
Borg Scale : RPE

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

72. 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