american college of sports medicine health/fitness instructor workshop exercise programming...

AMERICAN COLLEGE OF SPORTS MEDICINE

HEALTH/FITNESS INSTRUCTOR WORKSHOP

EXERCISE PROGRAMMING INCLUDING EXERCISE

CONSIDERATIONS FOR SPECIAL POPULATIONS

PRESENTER:

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

Professor

Department of Health and Exercise Science

Rowan University

Basic Exercise Programming Considerations

Principles of Training

• Overload Principle• Frequency

• Intensity

• Duration

• Mode

• Specificity Principle

• Reversibility Principle

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

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

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

Components of Exercise Prescription

• Frequency

• Duration

• Intensity

• Mode

• Progression

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

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

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

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

Environmental Considerations Continued

• Cold air temperature increases risk for hypothermia

• Factors related to hypothermia• Insulation—clothing and subcutaneous fat• Air temperature• Wind—accelerates heat loss (Windchill)• Water vapor pressure—low in cold air which

increases evaporation and heat loss

Environmental Considerations Continued

• Air pollution caused by ozone, sulfur dioxide and carbon monoxide

• Ozone—generated by combining UV light and internal combustion engine emissions. Decreases pulmonary function

• Sulfur Dioxide—fossil fuels (refineries). Causes bronchoconstriction in asthmatics

• Carbon Monoxide—fossil fuels, coal, oil, gasoline, wood and cigarette smoking. Decreases oxygen carry capacity of blood

Medical Considerations For Exercise

• Physician Clearance

• Medical History

• Medication Profile

Programming Considerations for Special Populations

Coronary Disease

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)

Risk Factors

• hypertension BP >140/90 mmHg

• elevated blood lipids• total cholesterol > 200 mg/dl

• LDL > 160 mg/dl (less than 2 risk factors)

• > 130 mg/dl (2 or more risk factors)

• > 100 mg/dl with CHD

• HDL < 35 mg/dl

• triglycerides > 400 mg/dl

Risk Factors Continued

• obesity

• cigarette smoking

• diabetes mellitus

• psychological stressors

• family hx early onset atherosclerosis

Risk Factors Continued

• alcohol consumption

• physical inactivity

• age

• gender—males 35-44 y.o. mortality rate 6x greater than females

• elevated levels of homocysteine

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.

CHD Continued

• exercise-induced complications—most 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.

CHD Continued

• familial trait—there 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.

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.

CHD Continued

• psychological stress—individuals 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

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 )


• 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


• 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

Pulmonary Dysfunction

Asthma/Exercise Induced

• causative factors—asthma 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).

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.

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

Asthma Continued

• Preventative measures (continued)• pharmacological agents—inhaled 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

Chronic Obstructive Pulmonary Disease (COPD)

• chronic asthma

• chronic bronchitis

• pulmonary emphysema

• chronic bronchiolitis

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.

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

Exercise Guidelines COPD

• COPD—these 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.

Exercise GuidelinesCOPD Continued

• Aerobic/Endurance—• Monitor dyspnea

• 1-2 sessions 3-7d/wk

• 30 min (shorter intermittent sessions initially)

• target intensity—heart 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)

Exercise GuidelinesCOPD Continued

• Strength– low resistance, high repetitions– 2-3d/wk

• Flexibility– 3 sessions/wk

• Neuromuscular (walking, balance and breathing exercises)– daily

Metabolic Disorders

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.

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.

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.

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.

Diagnostic Criteria for Diabetes

• Symptoms of diabetes plus casual plasma glucose concentration of >200 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 >126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake for at least 8 hours); or

• Two- hour plasma glucose of >200 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

Insulin Regulation

• blood levels of glucose

• blood levels of amino acids potentiate the glucose stimulus for insulin secretion

• gastrointestinal hormones—gastrin, secretin, cholecystokinin

• other hormones—glucagon, growth hormone, cortisol, progesterone and estrogen

Metabolic Complications

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

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.

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

Exercise Benefits (DM)

• Type 1—exercise 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

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

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

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

Obesity

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--> 40.0 kg/m2

Obesity Continued

• Criteria (continued)

• Percentage body fat– > 25% males– > 32% females

Obesity Continued

• Metabolic complications—Primary 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.

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.

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

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

Hypertension

Hypertension (HTN)

• Criteria— Systolic Diastolic

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

HTN Continued

• HTN Criteria continued Systolic

Diastolic (mmHg) (mmHg)

• Stage 3 (Severe) 180-209 110-119

• Stage 4 (V. Severe) >210 >120

HTN Continued

• Associated complications—Increased incidence of:

• cerebral vascular accident (CVA)• CHD• atherosclerosis• impaired cognitive function• thickening and stiffening of medium and small blood

vessels• retinopathy• nephropathy

HTN Continued

• Medications—initiation 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

HTN Continued

• Pharmacological agents—• alpha blockers—block adrenergic vascular smooth

muscle receptors which promotes a decrease in vascular resistance

• beta blockers—block adrenergic receptors in the heart decreasing heart rate and myocardial contraction force

• alpha-beta blockers

HTN Continued

• Pharmacological agents (continued)• calcium channel blockers—block entry of calcium

into vascular smooth muscle inhibiting contraction leading to vasodilation and decreased vascular resistance

• angiotensin-converting enzyme inhibitors—inhibit transformation of angiotensin I to angiotensin II (angiotensin II is a vasoconstrictor)

• diuretics—decrease fluid volume within the vascular system

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 <6 g of sodium chloride)

• Maintain adequate intake of dietary potassium (approximately 90 mmol/d or 3.5 g/d)

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

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

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


• 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


• 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


• 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

Musculoskeletal Disorders

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

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



• 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


• 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)

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

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

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

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

Arthritis Continued


• Strength—• as per pain tolerance

• 2-3 repetitions building to 10-12

• 2-3d/wk

• Flexibility—• 1-2 sessions/d

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)

Low Back Pain (LBP)

LBP Continued

• it is important to first determine the cause for LBP before initiating an exercise program

• acute LBP (<2-3wk duration) is commonly treated (excluding surgical intervention) by pharmacological agents and therapeutic modalities

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)

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 > strength)

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

Children

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

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

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

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

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

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

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

Elderly

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

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

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

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

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

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

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

-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

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

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

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

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

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)

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

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

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 individual’s 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

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”


• 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 user’s 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)


• 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

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

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

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)

Pregnancy

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

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

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

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

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 Exercises—strengthen pelvic floor

(gluteals, abdominal obliques, iliopsoas)• Start exercise post-partum +3-6 weeks

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

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.

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.

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)

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 (>6-8/h) that may suggest onset

of premature labor• Unexplained abdominal pain • Insufficient weight gain (<1.0 kg/month during last two

trimesters)

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