AMERICAN COLLEGE OF SPORTS MEDICINE HEALTH/FITNESS INSTRUCTOR WORKSHOP

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AMERICAN COLLEGE OF SPORTS MEDICINEHEALTH/FITNES
S INSTRUCTOR WORKSHOP

• EXERCISE PROGRAMMING INCLUDING EXERCISE
  CONSIDERATIONS FOR SPECIAL POPULATIONS

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PRESENTER Edward C. Chaloupka , Ph.D., P.T.,
FACSM

• Professor
• Department of Health and Exercise ScienceRowan
  University

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Basic Exercise Programming Considerations
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Principles of Training

• Overload Principle
• Frequency
• Intensity
• Duration
• Mode
• Specificity Principle
• Reversibility Principle

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American College of Sports Medicine (ACSM)
Guidelines

• For Developing Cardiovascular Endurance
• Frequency 3x/wk
• Intensity 50-85 maximum heart rate
• reserve or 50-85 maximum
  oxygen uptake reserve
• Duration 20-60 minutes
• Mode rhythmical and continuous

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ACSM Guidelines Continued

• For Developing Muscular Strength
• 8-10 separate exercises using major
• muscle groups
• 8-12 repetitions of each exercise to
  volitional fatigue
• 2-3 days/wk
• For Developing Muscular Endurance
• 15- 20 repetitions to volitional fatigue
  

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ACSM Guidelines Continued

• For Developing Muscular Flexibility
• 5-15 minutes of moderate aerobic activity
  prior to stretching
• 2-3 days/wk after each aerobic workout
• Hold each position for 10-30 sec
• Repeat each stretch 4 times

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Components of Exercise Prescription

• Frequency
• Duration
• Intensity
• Mode
• Progression

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Monitoring Exercise Intensity

• Training Heart Rate Range
• maximum heart rate (HR)
• heart rate reserve (HRR) (Karvonen Formula)
• Training HR (max HR - rest HR) X intensity
  percentage RHR
• Example -- 20 y.o., rest HR 70 bpm
• Training HR (200 - 70) X 70 70 161 bpm
• 75 HHR 85 max HR

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Warm-Up

• Group of exercises performed immediately before
  an activity
• Provides adjustment from rest to exercise
• 5-20 minutes depending on sport and environmental
  conditions
• Active warm-up prior to vigorous stretching

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Cool-Down

• Purpose is to slowly decrease heart rate and
  lower body temperature
• Active recovery promotes faster decrease in
  muscle and blood levels of lactic acid
• Active recovery keeps the leg muscle pump going
  and prevents pooling of blood in the legs
• Active recovery lessens chance of catecholamine
  produced cardiac irregularities in high risk
  persons

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Environmental Considerations

• High air temperature and relative humidity
  increase risk for hyperthermia
• Normal core temperature 37 deg. C
• Possible death at 45 deg. C
• Factors affecting susceptibility to heat injury
• Fitness level
• Hydration
• Clothing
• Metabolic Rate
• Wind

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Environmental Considerations Continued

• Cold air temperature increases risk for
  hypothermia
• Factors related to hypothermia
• Insulationclothing and subcutaneous fat
• Air temperature
• Windaccelerates heat loss (Windchill)
• Water vapor pressurelow in cold air which
• increases evaporation and heat loss

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Environmental Considerations Continued

• Air pollution caused by ozone, sulfur dioxide and
  carbon monoxide
• Ozonegenerated by combining UV light and
  internal combustion engine emissions. Decreases
  pulmonary function
• Sulfur Dioxidefossil fuels (refineries).
  Causes bronchoconstriction in asthmatics
• Carbon Monoxidefossil fuels, coal, oil,
  gasoline, wood and cigarette smoking. Decreases
  oxygen carry capacity of blood

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Medical Considerations For Exercise

• Physician Clearance
• Medical History
• Medication Profile

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Programming Considerations for Special Populations
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Coronary Disease
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Coronary Artery Disease (CAD)

• Narrowing of coronary arteries usually caused by
  arteriosclerosis (pathological condition
  resulting in thickening, hardening and loss of
  elasticity of arterial walls)

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Risk Factors

• hypertension BP gt140/90 mmHg
• elevated blood lipids
• total cholesterol gt 200 mg/dl
• LDL gt 160 mg/dl (less than 2 risk factors)
• gt 130 mg/dl (2 or more risk factors)
• gt 100 mg/dl with CHD
• HDL lt 35 mg/dl
• triglycerides gt 400 mg/dl

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Risk Factors Continued

• obesity
• cigarette smoking
• diabetes mellitus
• psychological stressors
• family hx early onset atherosclerosis

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Risk Factors Continued

• alcohol consumption
• physical inactivity
• age
• gendermales 35-44 y.o. mortality rate 6x greater
  than females
• elevated levels of homocysteine

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Coronary Heart Disease (CHD)

• Myocardial damage due to insufficient blood flow.
  The disease is caused by pathological changes in
  the coronary arteries sufficient to interfere
  with adequate blood flow.

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CHD Continued

• exercise-induced complicationsmost occur in
  individuals with underlying heart disease or
  congenital abnormalities. A cardiac event during
  exercise is not common in individuals without
  heart disease. Exercise induced cardiac problems
  in those older than 35 tend to be due to CHD
  while those in individuals younger than 35 tend
  to be due to cardiovascular structural
  abnormalities.

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CHD Continued

• familial traitthere is a genetic predisposition
  to the development of CHD. The risk of a
  myocardial infarction (MI) is high when a MI or
  sudden death in a male first-degree relative
  occurs before age 55 and a female first-degree
  relative before age 65.

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CHD Continued

• Nicotine in tobacco smoke causes an increase in
  heart rate and blood pressure that increases the
  work of the heart (an increase in the
  rate-pressure product or double product).
  Nicotine may also increase platelet adhesiveness
  increasing blood viscosity. Carbon monoxide in
  tobacco smoke decreases the oxygen carrying
  capacity of red blood cells to the heart muscle.

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CHD Continued

• psychological stressindividuals with severe
  anxiety or frequent outbursts of anger exhibit
  higher levels of cardiac reactivity
  (characterized by increased heart rate, systolic
  blood pressure and peripheral resistance) as well
  as increased coronary artery spasms and sudden
  death

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Coronary Disease Continued

• Exercise Guidelines--guidelines are generalized
  due to multiple coronary diseases (e.g. CAD, CHD,
  myocardial infarction, coronary artery bypass
  graft, valvular disease, congestive heart
  failure, cardiac transplant, aneurysm, angina,
  cardiac arrhythmias )

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Coronary Disease Continued

• Exercise Guidelines (continued)
• General Considerations--
• general low fitness levels
• monitor for abnormal exercise response
• awareness of other medical conditions
• In-patient (Phase I) cardiac rehabilitation
• Out-patient (Phases II-IV) cardiac rehabilitation

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Coronary Disease Continued

• Aerobic/Endurance
• 40-70 of vo2 peak
• 3-7 d/wk
• 20-40 min
• Strength
• higher repetitions, lower resistance
• 2-3 d/wk
• Flexibility
• 2-3 d/wk

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Pulmonary Dysfunction
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Asthma/Exercise Induced

• causative factorsasthma is characterized by
  increased airway reactivity to various stimuli
  including exercise. During an attack biochemical
  mediators are released due to mast cell
  degranulation causing airway smooth muscle
  constriction (bronchospasm).

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Asthma Continued

• Physical stimuli such as cooling and evaporation
  across airway epithelium during exercise or cold
  air exposure may directly stimulate the release
  of biochemical mediators. Individuals with
  exercise induced asthma may demonstrate normal
  airway function at rest but may develop
  bronchospasm during or after exercise.

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Asthma Continued

• preventative measures
• identification and elimination of precipitating
  agents (pollens, dust mites, animal dander,
  drugs, foods, wine, exposure to fumes and
  chemicals)
• education to improve compliance with medication

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Asthma Continued

• Preventative measures (continued)
• pharmacological agentsinhaled corticosteriod
  bronchodilators as preventative medicine (can be
  used on an ongoing basis) and inhaled cromolyn
  sodium (used up to 15 minutes before beginning
  exercise) to stabilize mast cells before exercise
• optimizing inhaled or oral bronchodilator therapy

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Chronic Obstructive Pulmonary Disease (COPD)

• chronic asthma
• chronic bronchitis
• pulmonary emphysema
• chronic bronchiolitis

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Pulmonary DysfunctionExercise Guidelines

• Exercise induced asthma (EIA)
• individuals are often asymptomatic (or minimally
  symptomatic) between exacerbations. This
  population of individuals should be able to
  engage in vigorous exercise training.

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Modifications to Exercise Program for EIA

• warm-up and cool-down periods
• type of exercise--outdoor running exacerbates
  EIA, swimming reduces incidence
• length of exercise--long, intense continues
  exercise causes more EIA than short bursts
• intensity of exercise-high intensity (above
  80-90 of maximal heart rate) causes more EIA
• nasal rather than mouth breathing
• wear a mask or scarf in cold weather
• monitor exercise environment for potential
  allergens and irritants

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Exercise Guidelines COPD

• COPDthese individuals are often elderly and have
  high co-existing impairment of other organ
  systems. If oxygen saturation drops below 90
  (pulse oximetry) or arterial blood oxygen drops
  below 55 torr (arterial blood gas) supplemental
  oxygen should be used via nasal cannula.

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Exercise GuidelinesCOPD Continued

• Aerobic/Endurance
• Monitor dyspnea
• 1-2 sessions 3-7d/wk
• 30 min (shorter intermittent sessions initially)
• target intensityheart rate (HR) attained at a
  work rate equal to 85 of the peak work rate
  during an initial incremental test (other methods
  for target HR during exercise may not be
  appropriate due to ventilatory limitation,
  increased resting HR and considerable day-to-day
  variations in resting HR)

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Exercise GuidelinesCOPD Continued

• Strength
• low resistance, high repetitions
• 2-3d/wk
• Flexibility
• 3 sessions/wk
• Neuromuscular (walking, balance and breathing
  exercises)
• daily

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Metabolic Disorders
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Diabetes Mellitus (DM)

• Type 1 (Insulin Dependent, IDDM)
• absolute deficiency of insulin due to a marked
  reduction in pancreatic insulin-secreting beta
  cells. Insulin must be supplied by insulin
  injection or insulin pump. Cause is thought to
  involve an autoimmune response leading to the
  destruction of beta cells.

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Type 1 DM Continued

• Are prone to develop ketoacidosis with marked
  hyperglycemia. Can occur at any age but usually
  before the age of 30. Represents 10 to 15 of
  individuals with DM.

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DM Continued

• Type 2 (Non-Insulin Dependent, NIIDM)
• relative insulin deficiency. May have elevated,
  reduced or normal insulin levels but have
  hyperglycemic. Usually a combination of
  peripheral insulin resistance and defective
  insulin secretion.

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Type 2 DM Continued

• Resulting hyperglycemia causes beta cells to
  secrete more insulin that is usually ineffective
  in lowering blood glucose and further contributes
  to peripheral insulin resistance. Usually do not
  develop ketoacidosis. Usually occurs after the
  age of 40 but is becoming more common in younger
  individuals. Represents 85 to 90 of
  individuals with DM.

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Diagnostic Criteria for Diabetes

• Symptoms of diabetes plus casual plasma
  glucose concentration of gt200 mg/dL (11.1mmol/L)
  (casual is defined as any time of day without
  regard to time since the last meal) the classic
  symptoms of diabetes include polyuria,
  polydipsia, and unexplained weight loss or
• Fasting plasma glucose of gt126 mg/dL (7.0
  mmol/L) (fasting is defined as no caloric intake
  for at least 8 hours) or
• Two- hour plasma glucose of gt200 mg/dL during
  an oral glucose tolerance test the test should
  be performed as described by World Health
  Organization, using a glucose load containing the
  equivalent of 75 g anhydrous glucose dissolved in
  water

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Insulin Regulation

• blood levels of glucose
• blood levels of amino acids potentiate the
  glucose stimulus for insulin secretion
• gastrointestinal hormonesgastrin, secretin,
  cholecystokinin
• other hormonesglucagon, growth hormone,
  cortisol, progesterone and estrogen

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Metabolic Complications

• ketoacidosis
• dehydration
• retinopathy
• hypertension
• neuropathy
• nephropathy
• atherosclerosis
• poor wound healing

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Medications (DM)

• Type 1--most individuals use subcutaneous insulin
  injections consisting of a mixed insulin, split
  dose regimen. This includes a mixture of
  short-acting insulin and longer-acting (sustained
  release) insulin in morning and afternoon doses.

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Medications (DM) Continued

• Type 2--oral hypoglycemic agents that help
  restore peripheral insulin receptor sensitivity
  and stimulate pancreatic insulin release
• Type 1/Type 2--also antihypertensive,
  lipid-lowering and pain medications

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Exercise Benefits (DM)

• Type 1exercise is not considered a component of
  treatment in type 1 diabetes to lower blood
  glucose but individuals should exercise to gain
  other benefits normally associated with regular
  exercise

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Exercise Benefits (DM) Continued

• Type 2
• improved daily blood glucose control
• improved peripheral insulin sensitivity and
  insulin receptor affinity
• other benefits normally associated with regular
  exercise

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Precautions for Avoiding Hypoglycemic Events

• Measure blood glucose before, during and after
  exercise
• Avoid exercise during periods of peak insulin
  activity
• Unplanned exercise should be preceded by extra
  carbohydrate, e.g., 20 to 30 g/30 min of
  exercise insulin may have to be decreased after
  exercise
• If exercise is planned, insulin dosages must be
  decreased before and after exercise, according to
  the exercise intensity and duration as well as
  the personal experience of the patient insulin
  dosage reductions may amount to 50 to 90 of
  daily insulin requirements

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Precautions for Avoiding Hypoglycemic Events
Continued

• During exercise, easily absorbable carbohydrates
  may have to be consumed
• After exercise, an extra carbohydrate- rich snack
  may be necessary
• Be knowledgeable of the signs and symptoms of
  hypoglycemia
• Exercise with a partner

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Obesity
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Obesity

• Criteria
• Body Mass Index (BMI)
• moderately overweight/obese--27.1-30.0 kg/m2
• markedly overweight/obese--30.1-40.0 kg/m2
• morbidly obese--gt 40.0 kg/m2

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Obesity Continued

• Criteria (continued)
• Percentage body fat
• gt 25 males
• gt 32 females

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Obesity Continued

• Metabolic complicationsPrimary metabolic
  complication is the development of DM. In
  obesity the beta cells become less responsive to
  stimulation by increased blood glucose levels.
  In turn, the blood insulin levels do not increase
  when needed.

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Obesity Continued

• Metabolic complications (continued)--In addition,
  obesity decreases the number of insulin receptors
  in insulin target cells. Other complications of
  obesity are hypertension, elevated serum
  cholesterol levels and decreased
  cardiorespiratory function.

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Criteria for Weight Loss Program

• Provides intake of not lower than 1200 kcal/day
  for normal adults and allows for a proper
  distribution of foods to meet the nutritional
  requirements. (Note this requirement may not be
  appropriate for children, older individuals, and
  athletes)
• Includes foods acceptable to the dieter in terms
  of sociocultural background, usual habits, taste,
  costs, and ease in acquisition and preparation
  however, these foods should be low in total fat,
  saturated fat, cholesterol, and sodium
• Provides a negative caloric balance (not to
  exceed 500 to 1000 kcal/day), resulting in
  gradual weight loss without metabolic
  derangements, such as ketosis
• Results in a maximal weight loss of 1 kg/week

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Criteria for Weight Loss Programs Continued

• Includes the use of behavior modification
  techniques to identify and eliminate diet habits
  that contribute to malnutrition
• Includes an exercise program that promotes a
  daily caloric expenditure of more than 300 kcal.
  For many participants, this may be best
  accomplished with moderate-intensity, long-
  duration exercise, such as walking
• Provides that new eating and physical activity
  habits can be continued for life to maintain the
  achieved lower body weight

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Hypertension
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Hypertension (HTN)

• Criteria
  Systolic
  Diastolic (mmHg)
  (mmHg)
• Normal lt 130 lt85
• H. Normal 130-139 85-89
• HTN
• Stage 1 (Mild) 140-159 90-99
• Stage 2 (Mod) 160-179 100-109

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HTN Continued

• HTN Criteria continued
  Systolic
  Diastolic (mmHg)
  (mmHg)
• Stage 3 (Severe) 180-209 110-119
• Stage 4 (V. Severe) gt210 gt120

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HTN Continued

• Associated complicationsIncreased incidence of
• cerebral vascular accident (CVA)
• CHD
• atherosclerosis
• impaired cognitive function
• thickening and stiffening of medium and small
  blood vessels
• retinopathy
• nephropathy

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HTN Continued

• Medicationsinitiation of drug therapy should
  consider
• severity of HTN
• presence or absence of target-organ disease
• presence or absence of other medical conditions
  and CHD risk factors

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HTN Continued

• Pharmacological agents
• alpha blockersblock adrenergic vascular smooth
  muscle receptors which promotes a decrease in
  vascular resistance
• beta blockersblock adrenergic receptors in the
  heart decreasing heart rate and myocardial
  contraction force
• alpha-beta blockers

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HTN Continued

• Pharmacological agents (continued)
• calcium channel blockersblock entry of calcium
  into vascular smooth muscle inhibiting
  contraction leading to vasodilation and decreased
  vascular resistance
• angiotensin-converting enzyme inhibitorsinhibit
  transformation of angiotensin I to angiotensin II
  (angiotensin II is a vasoconstrictor)
• diureticsdecrease fluid volume within the
  vascular system

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Lifestyle Modifications for Hypertension

• Lose weight if overweight
• Limit alcohol intake to no more than 1 oz (30 mL)
  of ethanol (e.g., 24 oz 720 mL of beer, 10 oz
  300 mL of wine, or 2 oz 60 mL of 100 proof
  whiskey) per day or .5 oz (15 mL) of ethanol per
  day for women and lighter-weight people
• Increase aerobic physical activity (accumulate 30
  to 45 minutes most days of the week)
• Reduce sodium intake to no more than 100 mmol/d
  (2.4 g of sodium or lt6 g of sodium chloride)
• Maintain adequate intake of dietary potassium
  (approximately 90 mmol/d or 3.5 g/d)

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Lifestyle Modifications for Hypertension Continued

• Maintain adequate intake of dietary calcium and
  magnesium for general health
• Stop smoking
• Reduce intake of dietary saturated fat and
  cholesterol for overall cardiovascular health

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Recommendations for Exercise Training and Testing
for Hypertensives Continued

• Mass exercise testing is not advocated to
  determine those individuals at high risk for
  developing hypertension in the future as a result
  of an exaggerated exercise BP response. However,
  if exercise test results are available and an
  individual has a hypertensive response to
  exercise, this information does provide some
  indication of risk stratification for that
  patient and the necessity for appropriate
  lifestyle counseling to ameliorate this increase.
  In certain instances, medication changes may be
  appropriate

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Recommendations for Hypertensives Continued

• Endurance exercise training by individuals who
  are at high risk for developing hypertension will
  reduce the rise in BP that occurs with age, thus
  justifying its use as a nonpharmacologic strategy
  to reduce the incidence of hypertension in
  susceptible individuals
• Endurance exercise training will elicit an
  average reduction of 10 mm Hg for both systolic
  and diastolic BP in individuals with stage 1 or
  stage 2 essential hypertension(BP in the range of
  140 to 179/90 to 109 mm Hg) and even greater
  reductions in BP in patients with secondary
  hypertension due to renal dysfunction

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Recommendations for Hypertensives Continued

• The recommended mode, frequency, duration, and
  intensity of exercise are generally the same as
  those for low risk individuals. Exercise training
  at somewhat lower intensities (e.g., 40 to 70
  VO2 max) appears to lower BP as much as, if not
  more than, exercise at higher intensities, which
  may be especially important in specific
  hypertensive populations, such as elderly

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Recommendations for Hypertensives Continued

• Based on the high number of exercise-related
  health benefits and low risk for morbidity and/or
  mortality, it seems reasonable to recommend
  exercise as part of the initial treatment
  strategy for individuals with stage 1or stage2
  essential hypertension.
• Individuals with more marked elevations in BP
  should add endurance exercise training to their
  treatment regimen only after initiating
  pharmacological therapy exercise may reduce
  their BP further, allow them to decrease their
  antihypertensive medications, and attenuate their
  risk for premature mortality

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Recommendations for Hypertensives Continued

• Resistance training is not recommended as the
  primary form of exercise training for
  hypertensive individuals. With the exception of
  circuit weight training, resistance training has
  not consistently been shown to lower BP. Thus,
  resistance training is recommended as a
  component of a well rounded fitness program, but
  not when done independently

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Musculoskeletal Disorders
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Osteoporosis

• systemic skeletal disease characterized by low
  bone mineral density (BMD) leading to bone
  fragility and increased risk of fracture
• Osteoporosis exercise related prevention goals
• to increase bone mass during and just after
  periods of growth
• to maintain bone mass or decrease the rate of
  loss in adulthood
• to decrease incidence of falls in older adults

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Osteoporosis Continued

• Exercise Guidelines
• Aerobic--
• walking, cycling, swimming (activities with a
  weight-bearing component are associated with a
  higher BMD than those without a weight-bearing
  component)
• 40-70 of peak HR
• 3-5d/wk
• 20-30 min/session

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Osteoporosis Continued

• Exercise Guidelines (continued)
• Strength--
• dumbbells, weight machines
• 50 of 1 repetition maximum (1 RM) or 70 of 3 RM
• 2-3 sets of 8 repetitions
• 2 d/wk for 20-40 min
• Flexibility--
• 5-7 d/wk

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Osteoporosis Continued

• Special Considerations
• long-term effect on bone mass conservation will
  require at least 9-12 mo of exercise training
• avoid flexion of spine and stooping with forward
  flexion (can increase vertebral fractures)
• cardiac complications (due to older age of most
  individuals with osteoporosis)
• start with low workouts and progress slowly due
  to low muscular strength in many individuals with
  osteoporosis
• amenorrheic and postmenopausal women
  (hypoestrogenism)

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Arthritis

• Osteoarthritis (OA)-localized to affected joint
  or joints due to wear and tear and appears first
  as a deficit in articular cartilage (most
  commonly affected joints are the hands, spine,
  hips and knees)
• Characterized by joint pain and stiffness

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Arthritis Continued

• Rheumatoid arthritis (RA)-autoimmune systemic
  inflammatory condition (most commonly affected
  joints are the wrists, hands, knees, feet and
  cervical spine)
• Characterized by morning stiffness, acute and
  chronic inflammation and chronic pain and joint
  instability

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Arthritis Continued

• Gout-urates of sodium deposits in the joints
  (most commonly affected joints are the wrists,
  ankles, knees as well as the great toe)
• Characterized by acute joint inflammation and pain

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Arthritis Continued

• Exercise Guidelines--
• Aerobic
• 60-80 of peak HR or 40-60 of Vo2max
• ratings of perceived exertion (RPE) 11-16
• 3-5d/wk
• 5 min session progressing to 30 min session
• progression of duration over intensity

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Arthritis Continued

• Exercise Guidelines (continued)
• Strength
• as per pain tolerance
• 2-3 repetitions building to 10-12
• 2-3d/wk
• Flexibility
• 1-2 sessions/d

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Arthritis Continued

• Special Considerations
• avoid overstretching unstable joints
• low resistance and low impact exercise
  recommended
• spinal involvement may cause radiculopathy
• avoid morning exercise with RA due to morning
  stiffness
• cardiac implications (due to older age of most
  individuals with arthritis)

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Low Back Pain (LBP)
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LBP Continued

• it is important to first determine the cause for
  LBP before initiating an exercise program
• acute LBP (lt2-3wk duration) is commonly treated
  (excluding surgical intervention) by
  pharmacological agents and therapeutic modalities

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LBP Continued

• Exercise Guidelines
• little scientific evidence exists that exercise
  has any direct effect on reducing low back pain
• general conditioning can be useful for the
  overall health of the individual with LBP as well
  as reducing the incidence of low back injury (can
  be started 2 wks after onset of LBP)

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LBP Continued

• Exercise Guidelines (continued)
• low impact aerobic exercise (e.g. walking) can
  provide very low levels of supporting tissue load
  while activating supporting back musculature
• low back muscle endurance and strengthening
  exercises can reduce incidence of low back injury
  (endurance gt strength)

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LBP Continued

• Exercise Guidelines (continued)
• flexibility exercise (unloaded flexion-extension)
  can be initiated in individuals with LBP after
  the spine has been stabilized and after endurance
  and strength conditioning has occurred
• abdominal exercise that produces low back spine
  compression
• exercises can be performed daily

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Children
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Guidelines for Strength Training for Children

• All strength- training activities should be
  supervised and monitored closely by appropriately
  trained personnel
• No matter how big, strong, or mature the
  individual appears, remember that he or she is
  physiologically immature
• The primary focus, at least initially, should be
  directed at learning proper techniques for all
  exercise movements and developing an interest in
  resistance training

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Guidelines for Strength Training Children
Continued

• Proper techniques should be demonstrated first,
  followed by gradual application of resistance or
  weight
• Proper breathing techniques (ie.,no
  breath-holding) should be taught
• Stress that exercises should be performed in a
  manner in which the speed is controlled, avoiding
  ballistic (fast and jerky) movements

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Guidelines for Strength Training Children
Continued

• Avoid the practice of power lifting and body
  building
• Perform full-range, multi-joint exercises (as
  opposed to single-joint exercises)
• Be sure participant can understand and follow
  directions

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Strength Training Exercise Prescription for
Children

• Intensity
• Avoid repetitive use of maximal amounts of weight
  in strength training programs until reaching
  Tanner stage 5 (adolescence) level of development
  maturity
• Weight loads should be used that permit 8 or more
  repetitions to be completed per set, since heavy
  weights can be potentially dangerous and damaging
  to the developing skeletal and joint structures

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Strength Training Exercise Prescription for
Children Continued

• Intensity Continued
• It is not recommended that resistance exercise be
  performed to the point of severe muscular fatigue
• As a training effect occurs, achieve an overload
  initially by increasing the number of
  repetitions, and then by increasing the absolute
  resistance

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Strength Training Exercise Prescription for
Children

• Duration
• Perform 1 to 2 sets of 8 to 10 different
  exercises(with 8 to 12 repetitions per set),
  ensuring that all of the major muscle groups are
  included (in early stages of training, 1 set
  should be performed until proper technique is
  demonstrated)
• Rest at least 1 to 2 minutes between exercises,
  and intersperse rest days between training days

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Strength Training Exercise Prescription for
Children Continued

• Frequency
• Limit strength training sessions to twice per
  week and encourage children and adolescents to
  participate in other forms of physical activity

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Elderly
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Exercise Testing, Changes With Aging

• Resting Heart Rate - no change
• Maximal Heart Rate- decrease
• Maximal Cardiac Output- decrease
• Resting and Exercise BP- increase
• Maximal oxygen uptake- decrease
• Residual volume- increase
• Vital Capacity- decrease
• Reaction time- increase

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Exercise Testing, Changes With Aging Continued

• Muscular strength- decrease
• Bone mass- decrease
• Flexibility- decrease
• Fat-free body mass- decrease
• Percent body fat- increase
• Glucose tolerance- decrease
• Recovery time- increase

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Considerations for Testing the Elderly

• For those with expected low work capacities, the
  initial workload should be low (2 to 3 METS) and
  workload increments should be small (.5 to 1.0
  METS), e.g., Naughton protocol
• A cycle ergometer may be preferable to a
  treadmill for those with poor balance, poor
  neuromuscular coordination, impaired vision,
  senile gait patterns, weight-bearing limitations,
  and foot problems

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Considerations for Exercise Testing the Elderly
Continued

• Added treadmill handrail support may be required
  due to reduced balance, decreased muscular
  strength, poor neuromuscular coordination, or
  fear. Handrail support or gait abnormalities,
  however, can reduce the accuracy of estimating
  peak MET capacity based on exercise duration or
  peak workload achieved
• Treadmill speed may need to be adapted according
  to walking ability
• For those who have difficulty adjusting to the
  exercise equipment, the initial stage may need to
  be extended, the test restarted, or the test
  repeated

113
Considerations for Exercise Testing the Elderly
Continued

• Exercise- induced arrhythmias are more frequent
  in the elderly than in other age groups
• Prescribed medications are common and may
  influence exercise electrocardiographic and
  hemodynamic responses

114
Mode of Exercise for the Elderly

• The exercise modality should be one that does not
  impose excessive orthopedic stress
• Walking is an excellent mode of exercise for many
  elderly
• Aquatic exercise and stationary cycle exercise
  may be especially advantageous for those with
  reduced ability to tolerate weight -bearing
  activity

115
Mode of Exercise for the Elderly Continued

• The activity should be accessible, convenient,
  and enjoyable to the participant- all factors
  directly related to exercise adherence
• A group setting may provide important social
  reinforcement to adherence

116
-Intensity for Exercise Prescriptions for the
Elderly Continued

• To minimize medical problems and promote
  long-term compliance, exercise intensity for
  inactive elderly people should start low and
  individually progress according to tolerance and
  preference
• Many older persons suffer from a variety of
  medical conditions thus, a conservative approach
  to increasing exercise intensity is warranted
  initially
• Exercise need not be vigorous and continuous to
  be beneficial a daily accumulation of 30 minutes
  of moderate-intensity exercise provides health
  benefits

117
Intensity for Exercise Prescriptions for Elderly
Continued

• Longer- duration or higher-aerobic intensity
  offers additional health benefits, although it
  can lead to greater risk of cardiovascular and
  musculoskeletal problems and lower compliance to
  a long term exercise plan
• The intensity guidelines and precautions
  established for younger people for aerobic
  exercise training generally apply to the elderly

118
Intensity for Exercise Prescriptions for the
Elderly Continued

• A measured peak heart rate is preferable to an
  age predicted peak heart rate when prescribing
  aerobic exercise because of the variability in
  peak heart rate in persons over 65 years of age
  and their greater risk of underlying coronary
  artery disease
• Use of percentage of peak heart rate to calculate
  a target heart rate range in the elderly may
  provide a more accurate estimate of percentage of
  peak VO2 than the heart rate reserve method
• Elderly persons are more likely than young
  persons to be taking medications that can
  influence peak heart rate

119
Duration for Exercise Prescriptions for the
Elderly Continued

• Exercise duration need not be continuous to
  produce benefits thus those who have difficulty
  sustaining exercise for 30 minutes or who prefer
  shorter bouts of exercise can be advised to
  exercise for 10 minute periods at different times
  throughout the day
• To avoid injury and ensure safety, older
  individuals should initially increase exercise
  duration rather than intensity

120
Frequency for Exercise Prescriptions for the
Elderly

• Exercise performed at moderate intensity should
  be undertaken most days of the week
• If exercise is undertaken at a vigorous level, it
  should be performed at least 3 times per week,
  with exercise and no exercise days alternated

121
Resistance Training Guidelines for the Elderly

• Intensity
• Perform at least 1 set of 8 to 10 exercises that
  use all the major muscle groups (e.g., gluteals,
  quadriceps, hamstrings, pectorals,latissimus
  dorsi, deltoids, and abdominals)
• Each set should involve 10 to 15 repetitions that
  elicit a perceived exertion rating of 12 to 13
  (somewhat hard)

122
Resistance Training Guidelines for the Elderly
Continued

• As a training effect occurs, achieve an overload
  initially by increasing the number of
  repetitions, and then by increasing the
  resistance
• When returning from a lay-off, start with
  resistances of 50 or less of previous training
  intensity, then gradually increase the resistance

123
Resistance Training Guidelines for the Elderly
Continued

• Frequency
• Resistance training should be performed at least
  twice a week, with at least 48 hours of rest
  between sessions
• Duration
• Sessions lasting longer than 60 minutes may have
  a detrimental effect on exercise adherence.
• Adherence to guidelines should permit individuals
  to complete total body resistance training
  sessions within 20 to 30 minutes

124
Practical Guidelines for Resistance Training for
the Elderly

• The major goal of the resistance training program
  is to develop sufficient muscular fitness to
  enhance an individuals ability to live a
  physically independent lifestyle
• The first several resistance training sessions
  should be closely supervised and monitored by
  trained personnel who are sensitive to the
  special needs and capabilities of the elderly
• Begin (the first 8 weeks) with minimal resistance
  to allow for adaptations of the connective tissue
  elements

125
Practical Guidelines for Resistance Training
Continued

• Teach proper training techniques for all of the
  exercises to be used in the program
• Instruct older participants to maintain their
  normal breathing pattern while exercising
• Stress that all exercises should be performed in
  a manner in which the speed is controlled (no
  ballistic movements should be allowed)
• Perform the exercises in a range of motion that
  is within a pain- free arc

126
Practical Guidelines for Resistance Training
Continued

• Perform multi-joint exercises (as opposed to
  single-joint exercises)
• Given a choice, use machines to resistance train,
  as opposed to free weights (machines require less
  skill to use, protect the back by stabilizing the
  users body position, and allow the user to start
  with lower resistances, to increase by smaller
  increments, and to more easily control the
  exercise range of motion)

127
Practical Guidelines for Resistance Training
Continued

• Never permit arthritic participants to
  participate in strength training exercises during
  active periods of pain or inflammation
• Engage in a year- round resistance training
  program
• Routine activities, such as domestic work,
  gardening, and walking, may help to maintain
  muscular strength

128
Flexibility Exercise Prescription for the Elderly
Continued

• Intensity
• Exercises should incorporate slow movement, e.g.,
  static stretches that are sustained for 10 to 30
  seconds
• At least four repetitions per muscle group should
  be performed
• The degree of stretch achieved should not cause
  pain, but rather mild discomfort

129
Flexibility Exercise Prescription Continued

• Frequency
• Stretching exercises should be performed a
  minimum of 2 to 3 d/wk and should be included as
  an integral part of the warm-up and cool-down
  exercises
• Duration
• The stretching phase of an exercise session
  should last long enough to exercise the major
  muscle/tendon groups
• an entire exercise session devoted to flexibility
  may be appropriate for deconditioned older adults
  who are beginning an exercise program

130
Stretching Guidelines for Older Adults

• Always precede stretching exercises with some
  type of warm-up activity to increase circulation
  and internal body temperature
• Stretch smoothly and never bounce
• Do not stretch a joint beyond its pain-free range
  of motion
• Gradually ease into a stretch, and hold it only
  as long as it feels comfortable (10 to 30 seconds)

131
Pregnancy
132
Potential Benefits to Prenatal Exercise Programs

• Improved aerobic and muscular fitness
• Facilitation of recovery from labor
• Enhanced maternal psychological well-being that
  may help counter feelings of stress, anxiety,
  and/or depression frequently experienced during
  pregnancy
• Establishment of permanent healthy lifestyle

133
Potential Benefits of a Prenatal Exercise Program
Continued

• More rapid return to pre-pregnancy weight,
  strength, and flexibility levels
• Fewer obstetric interventions
• Shorter active phase of labor and less pain
• Less weight gain
• Improved digestion and reduced constipation
• Greater energy reserve
• Reduced postpartum belly
• Reduced back pain during pregnancy

134
Contraindications for Exercising During Pregnancy

• Pregnancy-induced hypertension
• Preterm rupture of membrane
• Preterm labor during the prior or current
  pregnancy
• Incompetent cervix
• Persistent second to third trimester bleeding
• Intrauterine growth retardation

135
Summary of (ACOG) Recommendations for Exercise
During Pregnancy and Postpartum

• Women can continue to exercise and derive health
  benefits even from mild to moderate exercise
  routines
• Regular exercise (at least 3 times per week) is
  preferable to intermittent activity
• Women should avoid exercise in the supine
  position after the first trimester decreases
  cardiac output
• Exercise in incline or side-lying positions
• Prolonged periods of motionless standing should
  be avoided

136
Summary of (ACOG) Recommendations for Exercise
During Pregnancy and Postpartum Continued

• Caution with difficult balance positions
• Can exercise up to delivery with moderate aerobic
  exercise (heart rate 140 BPM)
• Light weights
• Kegel Exercisesstrengthen pelvic floor
  (gluteals, abdominal obliques, iliopsoas)
• Start exercise post-partum 3-6 weeks

137
Summary of (ACOG) Recommendations for Exercise
During Pregnancy and Postpartum Continued

• Women should be encouraged to modify the
  intensity of their exercise according to maternal
  symptoms.
• Pregnant women should stop exercising when
  fatigued and not exercise to exhaustion.
• Non-weight-bearing exercises, such as cycling or
  swimming, will minimize the risk of injury and
  facilitate the continuation of exercise during
  pregnancy

138
Summary of (ACOG) Recommendations for Exercise
Pregnancy and Postpartum Continued

• Any type of exercise involving the potential for
  even mild abdominal trauma should be avoided
• Pregnancy requires an additional 300 kcal/day to
  maintain metabolic homeostasis.

139
Summary of (ACOG) Recommendations for Exercise
Pregnancy and Postpartum Continued

• Pregnant women should augment heat dissipation by
  ensuring adequate hydration, appropriate
  clothing, and optimal environmental surroundings
  during exercise
• Physiologic and morphologic changes of pregnancy
  persist 4 to 6 weeks postpartum.

140
Reasons to Discontinue Exercise and Seek Medical
Advice During Pregnancy

• Any signs of bloody discharge from the vagina
• Any gush of fluid from the vagina (premature
  rupture of membranes)
• Sudden swelling of the ankles, hands, or face
• Persistent, severe headaches, and/or visual
  disturbance unexplained spell of faintness or
  dizziness
• Swelling, pain, and redness in the calf of one
  leg (phlebitis)

141
Reasons to Discontinue Exercise and Seek Medical
Advice During Pregnancy Continued

• Elevation of pulse rate or blood pressure that
  persists after exercise
• Excessive fatigue, palpitations, chest pain
• Persistent contractions (gt6-8/h) that may suggest
  onset of premature labor
• Unexplained abdominal pain
• Insufficient weight gain (lt1.0 kg/month during
  last two trimesters)