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AMERICAN COLLEGE OF SPORTS MEDICINE HEALTH/FITNESS INSTRUCTOR WORKSHOP

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Title: AMERICAN COLLEGE OF SPORTS MEDICINE HEALTH/FITNESS INSTRUCTOR WORKSHOP


1
AMERICAN COLLEGE OF SPORTS MEDICINE HEALTH/FITNES
S INSTRUCTOR WORKSHOP
  • EXERCISE PROGRAMMING INCLUDING EXERCISE
    CONSIDERATIONS FOR SPECIAL POPULATIONS

2
PRESENTER Edward C. Chaloupka , Ph.D., P.T.,
FACSM
  • Professor
  • Department of Health and Exercise Science Rowan
    University

3
Basic Exercise Programming Considerations
4
Principles of Training
  • Overload Principle
  • Frequency
  • Intensity
  • Duration
  • Mode
  • Specificity Principle
  • Reversibility Principle

5
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

6
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

7
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

8
Components of Exercise Prescription
  • Frequency
  • Duration
  • Intensity
  • Mode
  • Progression

9
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

10
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

11
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

12
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

13
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

14
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

15
Medical Considerations For Exercise
  • Physician Clearance
  • Medical History
  • Medication Profile

16
Programming Considerations for Special Populations
17
Coronary Disease
18
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)

19
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

20
Risk Factors Continued
  • obesity
  • cigarette smoking
  • diabetes mellitus
  • psychological stressors
  • family hx early onset atherosclerosis

21
Risk Factors Continued
  • alcohol consumption
  • physical inactivity
  • age
  • gendermales 35-44 y.o. mortality rate 6x greater
    than females
  • elevated levels of homocysteine

22
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.

23
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.

24
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.

25
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.

26
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

27
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 )

28
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

29
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

30
Pulmonary Dysfunction
31
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).

32
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.

33
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

34
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

35
Chronic Obstructive Pulmonary Disease (COPD)
  • chronic asthma
  • chronic bronchitis
  • pulmonary emphysema
  • chronic bronchiolitis

36
Pulmonary Dysfunction Exercise 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.

37
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

38
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.

39
Exercise Guidelines COPD 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)

40
Exercise Guidelines COPD Continued
  • Strength
  • low resistance, high repetitions
  • 2-3d/wk
  • Flexibility
  • 3 sessions/wk
  • Neuromuscular (walking, balance and breathing
    exercises)
  • daily

41
Metabolic Disorders
42
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.

43
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.

44
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.

45
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.

46
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

47
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

48
Metabolic Complications
  • ketoacidosis
  • dehydration
  • retinopathy
  • hypertension
  • neuropathy
  • nephropathy
  • atherosclerosis
  • poor wound healing

49
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.

50
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

51
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

52
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

53
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54
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

55
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

56
Obesity
57
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

58
Obesity Continued
  • Criteria (continued)
  • Percentage body fat
  • gt 25 males
  • gt 32 females

59
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.

60
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.

61
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

62
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

63
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64
Hypertension
65
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

66
HTN Continued
  • HTN Criteria continued
    Systolic
    Diastolic (mmHg)
    (mmHg)
  • Stage 3 (Severe) 180-209 110-119
  • Stage 4 (V. Severe) gt210 gt120

67
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

68
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

69
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

70
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

71
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)

72
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

73
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

74
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

75
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

76
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

77
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

78
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79
Musculoskeletal Disorders
80
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

81
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

82
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

83
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)

84
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

85
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

86
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

87
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

88
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

89
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)

90
Low Back Pain (LBP)
91
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

92
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)

93
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)

94
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

95
Children
96
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97
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98
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

99
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

100
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

101
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

102
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

103
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

104
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

105
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106
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107
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108
Elderly
109
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

110
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

111
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

112
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)
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