1. Exercise Prescription For Special Populations David Arnall, Ph.D., PT.

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

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

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

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

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

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

8. l 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 ?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.Exercise causes the GLUT-4 transporters in muscle cells to migrate to the cell membrane and pickup glucose from the circulation.

10. l Acute and chronic exercise improves glycemic control and stimulates improved GLUT-4 performance and #’s of transporters. l These changes are restricted to the muscles that are being trained.

11. Type I Diabetes l A Suggested Starting Ex. Program l Mode : Aerobic l Frequency : 7 days a week l Duration : 20-30 minutes l Intensity : 45% - 85% of Max HR l Borg Scale : 10 - 14 RPE

12. Some Ideas :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 l A Suggested Starting Ex. Program l Mode : Aerobic l Frequency : 4 days a week l Duration : 15 - 60 minutes l Intensity : 45% - 70% of Max HR l Borg Scale : 10 - 14 RPE

14. Some Ideas :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 l Avoid exercising during peak insulin activity for Type I diabetics l Always exercise with a partner l Carry money with you so you can call for help l Wear good foot wear

16. l Practice scrupulous foot inspections l Inject the insulin (Type II diabetics) in muscle groups not involved in the exercise training l Do not exercise if your blood glucose is in excess of 300 mg/dl

17. l 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. l If your blood glucose is close to 80 - 100 mg/dl pre-exercise, eat before exercising

18. l Learn to decrease insulin requirements once exercise is a routine part of your daily schedule l Never take beta-blockers because they mask the symptoms of hypoglycemia

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

20. l Tingling In The Extremities l Hunger l Headaches l Anxiety

21. l Irritability l Seizures l Drowsiness l Slurred Speech

22. Patients With Hypertension l Most patients ( 90% ) will have Essential Hypertension or hypertension of unknown origin l Some may have hypertension due to renal disease or other causes such as pheochromocytoma

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

26. l 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.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 ……. l 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. l 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 l A Suggested Starting Ex. Program l Mode : Aerobic l Frequency : 3 - 4 days/week l Duration : 15 - 30 minutes l Intensity : 40% - 70% of SLGXT l Borg Scale : 10 - 14 RPE

31. Things To Think About ……. l Patients with HTN should : l Avoid weight lifting for the first several weeks of their exercise program l Not routinely be engaged in isometric exercises

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

33. l Restrict alcohol consumption l Stop smoking l Avoid stress

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

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

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

38. l dysrhythmias l breech presentation l excessive obesity l extreme underweight

39. history of bleeding during pregnancyhistory of bleeding during pregnancy extremely sedentary lifestyleextremely sedentary lifestyle history of intrauterine growth retardationhistory of intrauterine growth retardation history of precipitous birthshistory of precipitous births

40. l A Suggested Starting Ex. Program l Mode : Aerobic l Frequency : 3 days a week l Duration : 15 - 30 minutes l Intensity : 50% - 70% of Max HR l Borg Scale : 10 - 14 RPE

41. Some things to Think About …. l Exercise in a cool environment with a low humidity (80:80 rule) l Wear high quality shoes with good arch support l Be sure the Mother is well hydrated

42. l Exercise with a partner in case Mother needs help l Wear an abdominal support l Make sure that the Mother is well nourished l Do not exhaustively exercise

43. Patients Who Are HIV + l 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….. l Mild/moderate ex. is immunosupportive - it enables the CD4+, NK killer cells, and the CD8+ killer cells l Heavy exercise is immunosuppressive

45. l A Suggested Starting Ex. Program l Mode : Aerobic l Frequency : 3 days a week l Duration : 15 - 20 minutes l Intensity : 50% - 80% of Max HR l Borg Scale : 10 - 14 RPE

46. Patients With Intermittent Claudication l 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.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. l 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. l 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. l A Suggested Starting Ex. Program l Mode : Aerobic Weight Bearing Exercises l Frequency : 3 days/week l Duration : QID > BID > QD for periods up to 15 - 60 minutes l Intensity : Grade II ---> III Pain

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

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

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

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

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

58. Considerations……... l 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. l 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 l 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 l Type I Osteoporosis : occurs with menopause in female patients and is associated with an accelerated loss of trabecular bone. l It is characterized by crush fractures of the spine within 20 years after the onset of menopause (Ages 50 - 75).

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

63. Type II Osteoporosis l Type II osteoporosis is associated with advancing age (> 70) and involves the loss of trabecular and cortical bone. l It is characterized by fractured hips and wedge fractures of the vertebral bodies (Ages 70 +).

64. l Other factors effecting osteoporosis : l Smoking l Sedentary - no exercise l Excessive ETOH consumption l Low dietary calcium intake l Prolonged amenorrhea l 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 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.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……... l Estrogen replacement therapy reduces bone resorption by 50% - 60% - is enhanced with progesterone l Calcium supplementation - calcium carbonate is the best supplement - 1500 mg/day

67. Fosamax - encourages osteoblasisFosamax - encourages osteoblasis Vitamin D - 800 IU per dayVitamin D - 800 IU per day Calcitonin - inhibits osteoclasisCalcitonin - inhibits osteoclasis Thiazide diuretics cause calcium resorption from the glomerular filtrateThiazide diuretics cause calcium resorption from the glomerular filtrate

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

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

70. l A Suggested Starting Ex. Program l Mode : Aerobic & Weight Bearing l Frequency : 3 - 5 days a week l Duration : 20 - 30 minutes l Intensity : 50% - 70% of Max HR l Borg Scale : 10 - 14 RPE

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

72. l Water aerobics, swimming, kick boards and wogging are all good for conditioning even though they are not weight bearing l Water exercises are helpful because they increase ROM and increase muscle strength

73. Rheumatoid Arthritis Criterion For Classifying A Patient With RA - must have 4 out of 7Criterion For Classifying A Patient With RA - must have 4 out of 7 Morning stiffness lasting more than 1 hour before improvementMorning stiffness lasting more than 1 hour before improvement Arthritis in at least 3 joints - PIP, MCP, wrist, elbow, knee, ankle, MTP joints, etc.Arthritis in at least 3 joints - PIP, MCP, wrist, elbow, knee, ankle, MTP joints, etc.

74. Simultaneous involvement of bilateral jointsSimultaneous involvement of bilateral joints At least one area of involvement must be in the wrist, MCP, or PIP jointAt least one area of involvement must be in the wrist, MCP, or PIP joint

75. Rheumatoid nodules over bony prominences or next to jointsRheumatoid nodules over bony prominences or next to joints A positive serum rheumatoid factorA positive serum rheumatoid factor Radiological changesRadiological changes

76. Functional Capacity Criteria American Rheumatology Association Class 1 : complete ability to carry on usual duties without handicapsClass 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 jointsClass 2 : adequate ability for normal activities despite handicap, discomfort, or limited motion at one or more joints

77. Class 3 : ability limited to little or none of the duties of usual occupation or to self-careClass 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-careClass 4 : incapacitated, largely or wholly. Bedridden or confined to a wheelchair; litle or no self-care

78. Clinical Effects Of The Disease PainPain Lost ROMLost ROM Lost joint integrityLost joint integrity Reduced work capacityReduced work capacity Muscular weakness & wastingMuscular weakness & wasting Onset of osteoporosis & fragilityOnset of osteoporosis & fragility

79. Class 1 patients can do any type of exercise but should probably should not perform hard physical exercise.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 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.

80. Class 4 patients by definition are too incapacitated for weight bearing exercise but may participate in non- weight bearing exercise modes - i.e. - water exercises where their weight is supportedClass 4 patients by definition are too incapacitated for weight bearing exercise but may participate in non- weight bearing exercise modes - i.e. - water exercises where their weight is supported

81. Exercise Prescription ModeMode must be matched to the level of disease - class 1, 2, 3, or 4must be matched to the level of disease - class 1, 2, 3, or 4 must be matched to the number of involved jointsmust be matched to the number of involved joints must be matched with subjective symptoms in mindmust be matched with subjective symptoms in mind

82. Mode Choices Influenced By....Mode Choices Influenced By.... need to be low impactneed to be low impact use large muscle groups in a rhythmic slow fashionuse large muscle groups in a rhythmic slow fashion exercises emphasizing ROMexercises emphasizing ROM static exercises for strengthstatic exercises for strength

83. Good Mode Choices…..Good Mode Choices….. Tai ChiTai Chi woggingwogging treadmilltreadmill stationary or free bikestationary or free bike soft or light reboundingsoft or light rebounding swimming or snorkelingswimming or snorkeling

84. Frequency…..Frequency….. 3-5 days/week3-5 days/week variable depending on phase of the disease - remissions or exacerbationsvariable depending on phase of the disease - remissions or exacerbations patient education to know when to rest & postpone exercisepatient education to know when to rest & postpone exercise

85. Duration……Duration…… 15-45 minutes per exercise bout15-45 minutes per exercise bout variable day to day depending on symptomsvariable day to day depending on symptoms need to remember longer warm up and cool down sessionsneed to remember longer warm up and cool down sessions

86. Intensity…..Intensity….. activity fraction of :.4 -.6 if GXT data is availableactivity fraction of :.4 -.6 if GXT data is available 75% of age-adjusted HR in the non- cardiopulmonary population75% of age-adjusted HR in the non- cardiopulmonary population Borg scale of 10 - 13Borg scale of 10 - 13 low impactlow impact variable day-to-day depending on the symptomsvariable day-to-day depending on the symptoms

87. Monitoring the patient during exercise ……Monitoring the patient during exercise …… Borg scaleBorg scale Dyspnea ScaleDyspnea Scale Pain ScalePain Scale Blood pressure & HRBlood pressure & HR Auscultate the lungsAuscultate the lungs

88. Resources Exercise Testing and Exercise Prescription For Special Cases : Theoretical Basis & Clinical Application, 2nd ed., Lea & Fibeger Publishers, 1993 by James S. SkinnerExercise 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.ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, Human Kinetics Publishers, 1997.

89. Sports & Exercise for Children with Chronic Health Conditions, Human Kinetics Publishers, 1995 by Barry Goldberg.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.ACSM’s Guidelines for Exercise Testing & Prescription, 5th edition, Williams & Wilkins Publishers, 1995.