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Study Unit

Preparing for SpecialSituationsBy

Nancy Berkoff, R.D., Ed.D., C.C.E.

About the Author

Dr. Nancy Berkoff is a registered dietitian and certified chef withmore than 25 years of experience in the health and wellness field.She holds a bachelor’s degree in nutrition and food technology, amaster’s degree in nutrition education, and a doctoral degree invocational education. In addition to her academic degrees, Dr. Berkoff is a European-trained chef and a Fellow of the Instituteof Food Technologists.

Dr. Berkoff began her fitness and nutrition career in high school,when several of her relatives were diagnosed with hypertension secondary to sedentary lifestyles and poor diet. It was up to her toplan menus and prepare appealing foods for them. Eventually,word spread about her cooking prowess, and Dr. Berkoff wasselected to provide nutritious and hydrating snacks for her highschool fencing and tennis teams. As a result, her career in fitnessand nutrition was born.

Since then, Dr. Berkoff has taken her love of fitness and nutritionto several Olympics and Special Olympics, where she has served as a food coach. She currently works closely with personal trainers,professional sports trainers, lifestyle coaches, and personal chefs to design and coordinate food and fitness regimens.

Copyright © 2008 by Penn Foster, Inc.

All rights reserved. No part of the material protected by this copyright may bereproduced or utilized in any form or by any means, electronic or mechanical,including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Requests for permission to make copies of any part of the work should be mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton,Pennsylvania 18515.

Printed in the United States of America

3/3/14

All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalized. Use of a term in this text should not beregarded as affecting the validity of any trademark or service mark.

Everyone who can exercise should exercise. Fitness profes-sionals and health care professionals can play a crucial rolein getting people to exercise. People need to understand whatexercises they should do to maintain a maximum level of fitness throughout their lives. Fitness professionals need toset an exercise example and be able to adapt exercise pro-grams for people with special needs.

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Previe

wPrevie

wWhen you complete this study unit, you’ll beable to

• Explain why it’s important for people to exercise

• Suggest how health care professionals and fitness professionals can partner to encourage clients to adoptlifelong regular exercise habits

• Supply information about the benefits of lifelong exercise

• Provide guidelines for exercise for people with diabetes

• Provide guidelines for exercise for people with asthma

• Describe an exercise program for pregnant women,including appropriate and inappropriate movements

• Suggest exercise parameters for older adults and children

• List typical exercise limitations for people with lower-back pain

• Detail the types of medical conditions that prohibit exercise

Remember to regularly check “My Courses” on your student homepage.Your instructor may post additional resources that you can access toenhance your learning experience.

INTRODUCTION 1

Who Can Safely Exercise? 2Common Excuses for Avoiding Exercise 4Just Say No 5

EXERCISE AND SPECIAL POPULATIONS, PART 1 10

Pregnant Women 10Children 15Seniors 17

EXERCISE AND SPECIAL POPULATIONS, PART 2 22

Diabetics 22Individuals with Metabolic Syndrome 26Individuals with Heart Disease 27Individuals with Hypertension 27Cancer Patients 30Arthritis Sufferers 30Individuals with Lower-Back Pain 32Asthmatics 34Individuals with COPD 35Other Special Populations 36

BASIC FITNESS PROGRAMS FOR PEOPLE WITH MEDICAL CONDITIONS 38

Proper Monitoring before Exercise 38Proper Warm-Up 39New Goals and Objectives 39Proper Cool-Down 40Fitness Tips for Special Populations 41

SELF-CHECK ANSWERS 45

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Contents

Contents

1

INTRODUCTION

In a survey done by Patient Care magazine, patients wereasked if they would exercise if advised to do so by a physi-cian or health care professional. Thirty-five percent stronglyagreed, and 58 percent agreed. Many said that they wouldappreciate their physician writing an exercise “prescription”and “hooking them up” with a fitness consultant and/orexercise facility. Sounds like a plan, right?

Once clients understand that exercise is a lifelong commit-ment and that they don’t need to start off with an intensiveprogram to obtain benefits, they may be more willing to tryan exercise program. The fitness professional might temptclients by naming some of the many benefits of exercise:

• Lowered risk of heart disease

• Lowered cholesterol and other blood lipid levels

• Decreased risk of certain cancers

• Possibly improved glycemic control for diabetes (for example, better control over blood sugar levels)

• Decreased blood pressure

• Increased psychological well-being

• Improved ability to handle stress

Preparing for SpecialSituations

Preparing for Special Situations2

The following box is an excerpt from an article from USAToday that extols the benefits of exercise in maintaining personal health.

Who Can Safely Exercise?

In general, almost all people can participate in some type ofexercise (Figure 1). Although some people require a doctor’sclearance before exercise, the great majority of people will be cleared for activity and encouraged to participate in anexercise program by their physicians. In 1998, the AmericanCollege of Sports Medicine (ACSM) found that as of 1998, atleast 40 percent of the American population didn’t engage inany leisurely physical activity.

Popular Prescription: Exercise for the Ill

The National Institute on Aging reports that “if exercise could bepacked into a pill, it would be the single most widely prescribed,and beneficial, medicine in the nation.”

Heart Disease: The American Heart Association says physical inactivity is a risk factor for the country’s number-one killer: cardiovascular diseases. Regular exercise can cut blood pressure,cholesterol, and obesity—resulting in a 40 percent less risk ofdying of cardiovascular disease.

Osteoporosis: Affects millions of postmenopausal women and elderly men. Resistance work and low-impact aerobics can help to prevent bone loss.

Arthritis: Exercise can improve endurance, muscle strength, jointflexibility, and range of motion.

Backaches: One of the important factors in back/spine health isoverall fitness and muscle tone. Cardiovascular fitness helps tomaintain bone mass that’s important for a healthy spine, accordingto Dr. Andrew Feldman, an orthopedic physician, author of TheJock Doc’s Body Repair Kit.

Depression: Consistent exercise can greatly reduce depression,anxiety disorder, and other common mental illnesses. It canincrease feelings of well-being and improve self-image and how you handle stress. Exercise can create a natural “high.”

(Source: USA Today, March 7, 2004)

Preparing for Special Situations 3

Many health-related organizations encourage individuals toincrease their levels of physical activity and fitness as a meansto prevent weight gain, maintain a healthy body composition,and decrease the incidence of disease. Numerous studies havefirmly established that the benefits of participating in regularexercise far outweigh the risk of remaining sedentary. Physicalactivity decreases the incidence of stroke, high blood pressure,diabetes, several types of cancer, and depression.

Fortunately, most sedentary individuals can begin a low- tomoderate-intensity exercise program without extensive medicalscreening, which they often consider a barrier to participation.However, medical authorities are a bit more cautious in thecase of previously sedentary individuals over 45 years of ageparticipating in a more vigorous exercise program. In mostcases, high-risk individuals interested in participating in anexercise program can, with the clearance of a physician.

Individuals who participate in a fitness screening and whoare classified as moderate or high risk should be further evaluated by their physician before embarking on a vigorousexercise program. Men older than age 45 and women olderthan age 55 with two or more risk factors are consideredmoderate risk. Those who are high risk have either beendiagnosed with cardiovascular disease or show signs orsymptoms of the illness. Risk factors may include a familyhistory of disease, whether the person is a smoker, high

FIGURE 1—Although somepeople can’t exercise due to age or medical condition,most people will benefitfrom it.


blood pressure and cholesterol levels, elevated fasting glucoselevels, and measured levels of obesity. Major signs and symp-toms of disease may include pain or discomfort in the chest,neck, jaw, arms, or other areas; shortness of breath at rest orwith mild exertion; dizziness; unusual fatigue with everydayactivities; palpitations; intermittent leg pain; or a knownheart murmur.

Individuals shouldn’t be deterred from exercise because they’reclassified as moderate or high risk. In most cases, exercise canreduce the risk of developing disease, improve quality of life,and prolong life expectancy. Fitness professionals should workwith health care professionals to encourage their clients toexercise by providing information about exercise, perhaps inthe form of pamphlets, guest lectures, or Web pages.

Common Excuses for Avoiding Exercise

Health care professionals may become discouraged that theirpatients tend to relapse from established exercise routines.There seem to be hundreds, if not thousands, of reasons notto exercise. Do any of these sound familiar?

• I don’t have any free time.

• I have no one who will exercise with me.

• I don’t have anyone to drive me to the gym.

• Exercise is boring.

• I’m too tired most of the time.

• It hurts.

• I’m afraid it will hurt.

• I’m too old.

• I have too many health problems.

• I can’t afford it.


Be prepared to help health care professionals address andnegate these excuses. Some techniques to suggest to healthcare professionals:

• Write an individualized recommendation on a prescriptionnote or special form; people are more likely to followadvice when they assume it’s tailor-made for them and is a “prescription,” just like medication.

• Ask patients to keep a journal, to be reviewed at eachvisit by the physician.

• Explain to previously inactive patients what to do in case of mild soreness.

• Have a fitness professional as a consultant and have ateam meeting that includes the patient and the healthcare and fitness professionals.

• Have a variety of materials handy to provide to patients:hotlines with an “exercise message of the day,” pam-phlets, Web sites, and exercise videos. Such materialscan help to maintain the patient’s interest in exercise.

Just Say No

Although most low-risk, and some moderate-risk, individualsare usually able to exercise without medical supervision, high-risk patients/clients don’t necessarily have that luxury. They’regenerally able to participate in an exercise program only underthe direction of a physician or qualified supervisor, such as anexercise physiologist (Figure 2). Individuals classified as high-risk may exhibit symptoms such as

• The presence of complex ventricular dysrhythmias during exercise testing or recovery

• Presence of angina or other significant symptoms (forexample, unusual shortness of breath, lightheadedness,or dizziness at low levels of exertion) during exercise testing or recovery

• A high level of silent ischemia during exercise testing or recovery


• Presence of abnormal hemodynamics, or blood circulation,with exercise testing (for example, chronotropic incompe-tence, or flat or decreasing systolic blood pressure withincreasing workloads) or recovery (for example, severe postexercise hypotension)

Other signs and symptoms of disease may prevent an individ-ual from participating in any sort of exercise program, stillother indicators may require an individual exercise onlyunder medically supervised conditions in environments suchas a clinically supervised lab or the cardiac wellness unit of a hospital. In the first case, a patient exhibiting one or moreabsolute contraindications shouldn’t participate in any sort of exercise program until symptoms have stabilized. Theseare called absolute contraindications and include

• A recent significant change in the resting ECG suggestingsignificant ischemia, recent myocardial infarction (withintwo days), or other acute cardiac event

FIGURE 2—High-riskclients, such as those with injuries, are able toparticipate in an exerciseprogram only under thedirection of a physician or qualified supervisor.


• Unstable angina

• Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise

• Symptomatic severe aortic stenosis

• Uncontrolled symptomatic heart failure

• Acute pulmonary embolus or pulmonary infarction

• Acute myocarditis or pericarditis

• Suspected or known dissecting aneurysm

• Acute systemic infection, accompanied by fever, bodyaches, or swollen lymph glands. In the second case, aphysician would determine the risk-to-benefit ratio on a case-by-case basis before permitting a patient to participate in a supervised exercise program.

A physician may also recommend avoiding exercise if any relative factors demonstrate properties of excessive risk.These “physician determined” markers are called relative contraindications to exercise and include

• Left main coronary stenosis

• Moderate stenotic valvular heart disease

• Electrolyte abnormalities (for example, hypokalemia or hypomagnesia)

• Severe arterial hypertension (for example, systolic bloodpressure of >200 mmHG and/or a diastolic blood pressureof >110 mmHG at rest)

• Tachydysrhythmia (a heart rhythm greater than 100beats per minute) or bradydysrhythmia (a heart rhythmless than 60 beats per minute)

• Hypertrophic cardiomyopathy and other forms of outflowtract obstruction

• Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise

• High-degree atrioventricular block

• Ventricular aneurysm


• Uncontrolled metabolic disease (for example, diabetes;thyrotoxicosis, which is an excess of thyroid hormone; or myxedema, which is a life-threatening complication of hypothyroidism)

• Chronic infectious disease (for example, mononucleosis,hepatitis, AIDS)

• Mental or physical impairment leading to the inability to exercise adequately

Fitness professionals aren’t qualified to diagnose these disorders and aren’t generally qualified to work with thesepopulations until cleared by a physician, but we’ll discussexercise prescriptions for cardiac patients in a later section.Other situations may arise when the fitness professionalneeds to coordinate with a health care professional beforeworking with a client.

For example, say a former client returns to your exerciseclass and tells you she’s just had a joint replacement, suchas a hip, knee, or shoulder. Her doctor told her she couldexercise, but to “just take it easy.” This is a case when thefitness professional needs to coordinate with the client’sphysician or physical therapist to establish which movementsare acceptable and unacceptable, the use of weight-bearing or non-weight-bearing activities, and so on.

As a fitness professional, you’re responsible for overseeing the well-being of your clients. This can include pushing thema little harder as well as telling them when to tone it down.It’s important for the fitness professional to know when tosay “no” to exercise, for his or her client’s safety and contin-ued well-being. This is both a legal and ethical responsibility.

Maintain good records and a good rapport with your clients.This will help you to collect all the information you need toensure a safe workout, geared to individual levels of abilityand health.


Self-Check 1At the end of each section of Preparing for Special Situations, you’ll be asked to pause and check your understanding of what you’ve just read by completing a “Self-Check” exercise. Answering these questions will help you review what you’ve studied so far.Please complete Self-Check 1 now.

1. List some of the benefits of exercise.

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2. Who can generally exercise safely?

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3. What medical conditions might prevent a person from exercising?

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4. How can a health care professional motivate a patient to exercise?

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Check your answers with those on page 45.


EXERCISE AND SPECIAL POPULATIONS, PART 1

There’s an old saying that active people seek active lifestyles. It has always been hard to tell if exercise is associated withimproved health or whether healthy people are naturally drawn to more active tasks. In the mid-1980s, studies began to show that people who engaged in exercise had reduced riskof developing certain types of diseases, including heart diseaseand other cardiovascular disorders. Research also suggestedthat regular exercise could help to reduce premature mortality,or, in other words, help people live longer. These results wereindependent of gender, geographic location, body weight, andmedical conditions such as high blood pressure and familyhistory of a particular disease.

Scientists have been studying the effects of exercise on specialpopulations for about 20 years. Special populations are groupsof people with diseases and/or metabolic conditions who areunder the care of physicians or other health care professionals.

Pregnant Women

Pregnant women were one of the first special populations to be studied with regard to exercise. For many years, healthcare professionals believed that exercise would harm thedeveloping fetus and cause problems during pregnancy anddelivery. Interestingly, this theory was widely held only indeveloped countries, where many women didn’t engage in a lot of physical activity.

However, over the past 15 years a plethora of research has been conducted on the effects of exercise on pregnantwomen, from their response to different exercise programsto their birth outcomes. The results have been impressive:Pregnant women who perform regular, moderate exerciseduring pregnancy seem to do better physically than thosewho are inactive. Studies of the cardiovascular responses ofpregnant women have shown that women can maintain andeven improve their cardiovascular, respiratory, and aerobiccapacities with exercise. Although there’s a slight decrease


in overall uterine blood flow during moderate exercise due to redistribution of blood flow to the working muscles, bloodflow to the placenta appears to be adequate. Today, the consensus is that an active lifestyle is better for both motherand baby (Figure 3).

FIGURE 3—Recent studies suggestthat low-impact exercise is beneficialfor both expecting mothers and theirunborn babies.

Because pregnancies and responses to exercise are so individ-ualistic, women should clearly understand the importance of consulting their physicians before initiating or continuingany exercise program during pregnancy. Lifestyle and activityadjustments during pregnancy are determined by a woman’sprepregnancy fitness level. Women suffering from complica-tions of pregnancy (for example, preeclampsia) may beprohibited from engaging in physical activity of any kind. Early in the pregnancy, a pregnant woman should have a thorough medical examination to rule out complications thatwould make exercise inappropriate. At this time, the physician


can provide specific information about signs or symptoms towatch during the course of the pregnancy. All fitness activitiesmust be cleared and supervised by a woman’s ob/gyn.

Current research highlights the need for healthy pregnantwomen to perform low-impact aerobic exercise (Figure 4).Such low-impact exercise will help with metabolism after the second trimester. Low-impact exercise will also help toavoid injuring joints that are being softened up in the thirdtrimester for delivery. For example, walking one to two times a day following meals seems to help burn excess energy and is a great low-impact activity. Water aerobic exercises with aspecial buoyancy vest can help the pregnancy woman stay inshape without stressing to joints. Such exercises can be per-formed using the basic fitness guidelines of 20 to 30 minutes,three to four days per week. Note that the heart rate should be kept in the low end of the training zone to prevent thebody’s core temperature from rising excessively.

Pregnant women should be discouraged from exercising athigh levels of intensity, exercising in the supine position, ordoing sudden bursts of movement due to decreases in cardiacreserve (the difference between resting and maximum heartfunction) caused by the increased demands of pregnancy.Women can become more flexible during pregnancy; therefore,

FIGURE 4—Low-impactexercise that doesn’tcause excessive stress on the muscles and jointsis often recommended for pregnant women.


the risk of injury during exercise increases. Joint laxity (loose-ness) is caused by the release of the hormone relaxin. Specialcare should be taken to prevent slips, falls, and extremeranges of motion.

Pregnant women should be vigilant in monitoring ambient tem-perature during exercise. Exercise increases body temperature,and this increase can be harmful to the fetus. Be extremelyconservative if exercising in hot, humid environments. Whenindoors, make sure that air flow is adequate by turning onfans or opening doors.

The ability to continue exercising during the first trimester isvery individualistic, due to varying degrees of morning sick-ness, mild weight gain, and general fatigue. Exercise in thesupine position isn’t recommended after the first trimester.Some modes of exercise may prove too difficult during the sec-ond and third trimesters. Individual responses to higher bodyweight, edema, varicose veins, and increased joint mobilityshould dictate which modes of exercise are safe and palatable.

The following general guidelines pertain to exercising during pregnancy:

• All pregnant women should have a thorough medicalexamination prior to engaging in any type of exercise.There are absolute contraindications for aerobic exerciseduring pregnancy that a woman’s physician might not be aware of until an examination is conducted.

• Don’t increase the amount of exercise from that performed prior to pregnancy.

• Don’t participate in sports with a high risk of injury,such as contact sports.

• Don’t perform exercises that require a supine position for longer than five minutes. The weight of the fetus mayreduce blood flow to the legs. After the first trimester,supine exercises shouldn’t be performed because theymay compromise blood flow to the fetus.

• Avoid exercises that require a lot of balance, such as fast dancing or treadmill walking.

• Wear appropriate support for the feet and breasts.


• The pulse should stay at the low end of the target heartrate zone. Don’t ever exceed 130 beats per minute.

• Select non-weight-bearing exercises, such as swimmingor water aerobics or seated exercises.

• Stay hydrated.

• Avoid exercising in the heat! Elevated body temperatureand lack of blood flow can injure the fetus.

• In the last trimester, avoid exercises that can cause joint strain.

• Stop exercising immediately and call a physician if any of the following conditions occur: shortness of breath,dizziness, numbness or tingling in any part of the body,abdominal pain, vaginal bleeding.

The American College of Obstetricians and Gynecologists concludes that exercise during pregnancy is safe for mostwomen if participants are carefully monitored by their physicians and if they understand and adhere to the following guidelines:

1. Exercise goals should be discussed with a physician.

2. Don’t initiate a vigorous exercise program shortly beforeor during pregnancy.

3. Gradually reduce the intensity, duration, and frequencyof exercise during the second and third trimesters.

4. Avoid exercising in hot, humid environments.

5. Try to walk or run on flat, even surfaces.

6. Always wear supportive shoes while walking or running.

7. When running or other modes of exercise becomeuncomfortable, try other forms of aerobic exercise, suchas swimming, cycling, or running in water.

8. Extend warm-up and cool-down periods from 5 to 10 oreven 15 minutes.

9. Body temperature should never exceed 101°F and shouldbe taken immediately after exercise. If body temperatureexceeds 101°F, modify exercise intensity and duration, as needed.


10. Use the rating of perceived exertion scale rather thanheart rate to monitor exercise intensity. Choose a work-out intensity that’s comfortable. Pounding heart rates,breathlessness, or dizziness are indicators that intensityshould be reduced.

11. Eat a small snack before exercise to help avoid hypoglycemia (low blood sugar).

12. Drink plenty of water before, during, and after exercise.

13. Avoid overstretching or going beyond normal joint rangeof motion.

14. Any unusual physical changes, such as vaginal bleeding,severe fatigue, joint pain, or irregular heartbeat, shouldimmediately be reported to your physician.

Children

Children respond to exercise similarly to the way adults do.With the proper encouragement, any child in good health isusually more than willing to by physically active. Sadly, inthe United States childhood obesity has increased over recentdecades. In addition, American children exhibit poor levels ofstrength, particularly in the upper body. Yet the trend today is moving toward less physical activity in our public schools.

How can this trend be reversed? Adults need to let childrenknow that exercise is important, that it should be done consis-tently, and that it can be fun! Children should be included in exercise routines at home. Parents should plan weeklyactivities and vacations that include enjoyable components of physical activity. Schools should mandate that childrenparticipate in structured physical education classes eachweek. Ideally, children would attend physical educationclasses at least three times a week. However, currentattempts at curriculum change have tried to reduce the number of physical education classes in favor of other educational opportunities.


Here are some aerobic exercise guidelines for children:

1. Children should participate in sustainable activities thatuse large-muscle groups. Normally, a child’s “play” timeconsists of short-burst, high-energy exercise.

2. Specific times should be dedicated to these sustainedexercise periods to teach consistency in exercising.

3. Exercise duration will vary with the age of the child, thechild’s exercise experience, and the exercise intensity.

4. Start the exercise session at low intensity and progressgradually. The warm-up and cool-down periods don’tneed to be as long as in an adult class, but they shouldbe included nonetheless. The child should be able toconverse with you (the talk test) while exercising withoutgasping for air.

5. Two to three days per week of aerobic exercise should be sufficient.

6. Be creative! Children should feel that exercise is fun.

Here are some resistance-training guidelines for children:

1. Teach proper stretching technique as a way to warm up before starting exercise.

2. Children should be supervised at all times by a compe-tent adult, and their training area should be checkedregularly for hazards and possible safety issues.

3. Children should be taught how to breathe properly. Theyshould never perform single maximal lifts. Never let achild use a weight so heavy that he or she can’t perform atleast eight repetitions.

4. Teach children proper exercise form. Proper exerciseform and the reasoning behind it will stay with them alifetime and help prevent injuries now and in the future.

5. Children should rest at least one to two minutes or morebetween sets. They should also have scheduled days offbetween training days.


6. Children should be taught proper hydration and itsimportance before, during, and after exercise.

7. Children need to be taught how and when to communi-cate to their teachers and parents when they’re tired or injured.

Seniors

Anyone who reads a newspaper from time to time realizesthat the population of the United States is getting older. Duemostly to modern medicine and health promotion, by theyear 2030 approximately 20 percent of the U.S. populationwill be over the age of 65. Life is being extended, but moreimportantly, what is the quality of this extended life? Cancommonsense eating habits and consistent exercise positivelyaffect these extended lives? Absolutely.

Quality of life for many people, especially for older adults, can be measured by the ability to perform so-called activities of daily living, or ADLs. Although ADLs may become increas-ingly more difficult with age, research suggests that anyone,regardless of age, can increases his or her heart and vascularfitness and become stronger through consistent, safe exer-cise. Initiating and consistently performing cardiovascularexercise and resistance training will make performing ADLseasier. These are facts that have been proven time and timeagain. It’s never too late to start an exercise program.

Aging is a normal biological process, and its signs includeloss of height, reduction in overall muscle mass, gray hair,wrinkles, changes in eyesight, and, to some degree, loss ofcoordination. Signs of aging that may not be as noticeableinclude changes in the functioning of the cardiovascular(heart and arteries), endocrine (hormones), respiratory(lungs), and musculoskeletal (muscles, bones, and joints)systems as well. Although the full extent to which thesechanges may be positively affected by exercise isn’t known, it has been shown through research that negative changes in these systems can at least be minimized and in manycases reversed toward higher fitness levels.


Researchers at Tufts University in Boston found increases instrength in persons older than 80 years old who engaged in a strength-training program, with some participants showingincreases totaling over 170 percent. Even after only a periodof limited exercise, participants still tested higher in strengththan before they entered the program. Ambulatory and non-ambulatory participants also showed increases in strength.Exercises can be adapted for those who must exercise seated,rather than standing (Figure 5). No excuses!

Before beginning an exercise program, older adults shouldsee their physician for clearance to exercise. The fitness pro-fessional should have a complete medical history, evidence of a completed physical, clearance from the client’s physician,and possibly a medically supervised treadmill test. Dependingon the physician’s recommendations and the presence orabsence of known cardiovascular risk factors, a treadmill testmay or may not be warranted.

FIGURE 5—A wide range of exercises can be performed while seated, lessening the impact on thejoints for elderly clients.


The Society of Geriatric Cardiologists recommends that sen-iors perform moderate-intensity exercise, such as walking orwater aerobics. To avoid injury, seniors should start a newexercise program slowly, for example 10 to 15 minutes atfirst, adding about 5 minutes per session every two to threeweeks. Seniors should avoid high-impact strenuous activities,such as jogging or jumping. Walking has been shown to have a positive impact on cardiovascular fitness, and the use ofaerobic machines may provide an improvement in workloadover time without impacting on joints (Figure 6). Thera-Bandsor rubber tubing are helpful in introducing resistance exercise.Seniors can begin training with very light weights, building upto 10 to 15 repetitions.

The International Council on Active Aging (ICAA) suggeststhat exercise can help to alleviate chronic diseases in theolder population. The ICAA offers the following guidelines:

1. Get a check-up—see if special modifications are needed.

2. Know your exercise options.

3. Determine your participation style: Classes or alone? Dayor night?

4. Start slowly.

5. Make a date—do it with a friend.

FIGURE 6—Walking hasbeen show to have a positive impact on the cardiovascular fitness of older adults.


6. Set specific short- and long-term goals (for example,Wednesday and three months from now).

7. Make a list with anticipated benefits of exercise and post it on the refrigerator.

8. Invest in good shoes, hats, sunglasses, and other accessories that will make exercise more comfortable.

9. Shop for a facility or exercise area.

10. Make choices that you can stick with.

Consider the following when planning an exercise programfor an older adult:

1. The exercise program should include all aspects of fitness training, including low- to moderate-intensityaerobic training, flexibility and balance training, andresistance training.

2. Low-impact, non-weight-bearing activities such ascycling, swimming, and chair/floor exercises are advis-able for those with arthritis or poor joint mobility.

3. Older adults should strive to become more physicallyactive in all of their daily activities. This includes usingthe stairs instead of elevators and walking fairly shortdistances instead of driving.

4. Warm-up and cool-down periods should be extended to 15 minutes each.

5. Extreme environmental conditions should be avoided.

6. If initial functional capacity is low, exercise in shorterdurations at least four to five times per week. Graduallyincrease exercise duration to 30 to 60 minutes depend-ing on the client’s medical history and health status.


Self-Check 21. In general, should pregnant women exercise? If so, suggest some guidelines.

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2. Identify some limitations when performing strength-training exercises with children.

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3. Describe the benefits of exercise for seniors.

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EXERCISE AND SPECIAL POPULATIONS, PART 2

Diabetics

Diabetes mellitus, often referred to simply as diabetes, ischaracterized by disordered metabolism and abnormally highblood sugar resulting from insufficient levels of the hormoneinsulin. Diabetes mellitus is characterized by reduced insulinsecretion by the beta cells of the pancreas and/or reducedsensitivity to insulin. Diabetes causes abnormalities in themetabolism of carbohydrates, proteins, and fats. The symp-toms of diabetes aren’t always evident in the early stages.Diabetics are at greater risk for many health problems,including kidney failure, nerve disorders, eye problems, heartdisease, and poor blood circulation. The two main types ofdiabetes are insulin-dependent diabetes mellitus (IDDM, sometimes called type 1 diabetes) and non-insulin-dependentdiabetes mellitus (NIDDM, sometimes called type 2 diabetes).

IDDM is caused by the destruction of insulin-producing betacells in the pancreas and leads to little or no insulin secre-tion. Insulin deficiency causes higher-than-normal levels ofglucose to remain in the blood because of reduced uptakeand storage of glucose by the cells in the body. Consistentlyelevated blood glucose levels is called hyperglycemia. Thesymptoms of IDDM include excessive thirst and hunger, frequent urination, blurred vision, weight loss, and recurrentinfections. The onset of IDDM is usually in childhood.

NIDDM is the most common type of diabetes, affecting 90percent of all diabetics. It most often occurs in adults whoare overweight or obese and who don’t get regular physicalactivity (Figure 7). It’s characterized by a reduced sensitivity of insulin target cells to available insulin in the bloodstream.People with type 2 diabetes are at risk for hypoglycemia; that is, low blood sugar. Classic symptoms may or may notbe apparent. NIDDM is often reversible with permanentweight loss.


For IDDM, glucose regulation is attained through regular glucose assessment, proper diet, exercise, and appropriateinsulin medication. Although the role of exercise with IDDMpatients hasn’t been well demonstrated, people can improvetheir functional capacity, reduce their risk for coronary arterydisease, and improve insulin receptor sensitivity and numberwith a program of regular physical activity.

For NIDDM, glucose regulation is attained through lifestylechanges that include a proper diet, weight management, exer-cise, and insulin or oral medication. Diet and exercise resultsin weight loss and weight control, improved circulation andcardiorespiratory fitness, and a reduced need for insulin.

All diabetics should consult their physician to develop a pro-gram of diet, exercise, and medication before beginning anyfitness program. People with diabetes must manage their bloodsugar level throughout the day, keeping it in the normal range.This balance is achieved through self-monitoring. Most peoplewith diabetes use a small reflectance meter and sample ofblood from a finger stick to measure their blood sugar levels(Figure 8). Self-monitoring is the cornerstone of good diabetescontrol and can help avoid long-term complications of the disease, such as blindness, gangrene, and heart disease.

FIGURE 7—Physical activitycan greatly benefit yourclients.


In the past, physicians discouraged people with diabetes from exercising. A nurse with type I diabetes, Paula Harper,didn’t buy it. She organized the Diabetes Exercise and SportsAssociation (DESA) in 1985 to “teach healthy and safe exer-cise strategies in the treatment and prevention of diabetes.”The DESA has several goals: to educate people with diabetesabout the importance of exercise, to create opportunities forthem to participate in competitive and recreational athleticactivities, and to promote networking.

People with diabetes can perform most types of exercise aslong as self-monitoring is part of their program. As with other medical conditions, it’s imperative that a person withdiabetes have a full physical before beginning an exerciseprogram. The fitness professional should consult with theclient’s physician to produce an individual exercise program forimproved health.

Important points to consider are as follows:

1. Don’t inject insulin into primary muscle groups that will be used during exercise because it will be absorbedtoo quickly. This will result in hypoglycemia (low bloodsugar) and is very dangerous.

FIGURE 8—Blood-glucosemeters help individualswith diabetes monitor the sugar levels in theirbloodstream.


2. Diabetics should work closely with their physician todetermine the right insulin dosage and check their blood glucose levels frequently.

3. Always carry juice or candy in case of hypoglycemia.

4. Better glucose control can be achieved by exercising at the same time each day.

5. Avoid exercise during periods of peak insulin activity.

6. A carbohydrate snack should be consumed before and during prolonged exercise.

7. Check regularly for cuts, blisters, and signs of infectionon the feet. Use only good-quality exercise shoes.

8. Don’t begin exercise if blood glucose is below 70 mg/dlor greater than 150 mg/dl. All diabetics should havespecific guidelines to follow from their physician.

9. People with diabetes should never exercise alone.

10. It’s important to carefully monitor how clients’ blood glucose levels respond to different types and intensity of exercise.

11. Late-night exercise should be avoided, because bloodglucose levels can’t be measured during sleep.

People with IDDM face two potential problems during or following exercise: lack of insulin, causing hyperglycemia;and too much insulin, causing hypoglycemia. Hypoglycemia,or low blood sugar, can be extremely dangerous, because itmay cause unconsciousness and possible coma. Becauseexercise has an insulin-like effect on the body, it’s imperativethat any diabetic consult with his or her physician so that aplan of action and precaution can be established before initiating exercise. Obviously, the fitness professional shouldbe well versed in the client’s personal diabetic history andconstantly vigilant in watching for signs of trouble.

By knowing a client’s current blood sugar levels, it’s possible to safely plan the intensity and duration of exercise. If a clienthas had diabetes for longer than 10 years, it might be a goodidea to stick with low-impact exercises to guard against damaging the feet, which may have some neuropathy (nerve damage).


Individuals with Metabolic Syndrome

Metabolic syndrome, or syndrome X, is a group of cardiovascu-lar risk factors that appear together. An individual is diagnosedwith metabolic syndrome if three or more of the following factors are present: insulin resistance, high blood pressure,chronic low-grade inflammation, impaired lipid profiles, and,most important, abdominal obesity. It’s estimated that 47 million Americans have some form of metabolic syndrome,which increases the risk not only of cardiovascular disease and diabetes, but also of early mortality.

When a person becomes overweight or obese, the endocrineorgans begin to release cellular chemicals that cause normalfunctions to become dysfunctional. This is referred to as low-grade inflammation. Inflammatory chemicals are released bycells, which causes shifts in normal protective cellular activity,leading to hypertension, poor blood lipid profiles, and type IIdiabetes. Obesity, specifically abdominal fat (visceral storageunder the muscle), is believed to have a great effect on inflam-mation and metabolic syndrome, and as such should be thefirst concern an exercise prescription should address. Luckily,stored visceral fat is very metabolic and burns off easier thanfat in the hips and thighs.

When dealing with obese patients with metabolic syndrome,it’s important to keep a few considerations in mind:

• Begin at a moderate intensity of 40 to 60 percent of the heart rate reserve and use primarily large-musclegroups in aerobic activities. As the client progresses,increase the intensities as appropriate, keeping in mindthat older individuals might not want to progress to vigorous intensities.

• Exercise five to seven times a week for 45 to 60 minutesper session and try to burn at least 1,000 kilocalories,progressing to 2,000 kilocalories, per week.

• Incorporate resistance training into the prescription twoto three times a week.


• Because metabolic syndrome incorporates so many dis-eases and factors, keep them in mind when prescribingexercise. Hypertension and diabetes, for example, alsocall for specific guidelines.

Individuals with Heart Disease

The importance of exercise for those with heart disease can’tbe evidenced more clearly than by the requirement of physical-activity programs as soon as possible following heart surgery.With shortened hospital stays now the norm, patients withuncomplicated issues may be begin self-care activities duringthe first 24 to 48 hours of their stay and be released as soonas three to four days after surgery. The ultimate goal of a cardiac rehabilitation program is to help a person return tonormal activities of daily living and experience an improvedquality of life. Certain subclasses of heart disease will followspecial considerations, although all medically supervised cardiac rehabilitation programs follow the same basic setup.

The cardiac exercise prescription is divided into four phases.The first phase is the inpatient phase, during which time thepatient is progressed from rising to self-care to short walkswithin the hospital, with or without assistance, three to fourtimes a day. The second, or outpatient, phase lasts up to 12weeks. In this phase, the patient begins low-intensity activitythat provides a training effect but doesn’t overtax the body’ssystems. During the third phase, the patient may receive inter-mittent ECG observation as intensity is increased (to a pointbelow where symptoms may return) and remains at this leveluntil the physician sees fit to progress to the fourth phase. Inthe fourth phase, the patient is no longer monitored or super-vised and is capable of maintaining a safe exercise program on his or her own.

Individuals with HypertensionOne in four American has hypertension, and at least 50 million Americans are taking antihypertensive medications.An individual with hypertension, or high blood pressure, has a blood pressure greater than 140/90 mmHg. The ACSM


indicated that hypertension causes over 700,000 strokes and 280,000 stroke deaths annually and is one of the mostprevalent forms of heart disease in America.

Hypertension has been shown to be related to the developmentof coronary artery disease, stroke, congestive heart failure, leftventricular hypertrophy (enlargement of that chamber of theheart), and peripheral vascular disease. In layman’s terms,hypertension means that the various components of the cardiovascular system are operating with too much pressureon a daily basis. As with any closed, pressurized system, con-stant pressure above what the system is designed to handlecan, and probably will, cause problems.

The first-line treatment for hypertension is nondrug therapy,which can include weight reduction, salt restriction, andincreased physical activity. Many people with hypertension are overweight or have risk factors for heart disease.

Different types of exercise have different effects on blood pressure (Figure 9). Resistance training raises both systolicand diastolic blood pressure during the performance of theexercise. Aerobic exercise raises only the systolic pressureand has a relaxation effect that lowers blood pressure follow-ing exercise. Establishing an exercise prescription to managehypertension and lower systolic and diastolic levels to accept-able levels is key to hypertension management. Interestingly,aerobic exercise needs to be performed at a low to moderateintensity for only 10 minutes to generate the relaxation effect.

Most individuals with hypertension don’t enter a medicallysupervised program, but if they’re medicated for hypertensionor have a measured resting blood pressure of 160/100 mmHg,they should be cleared by their physician before they begin toexercise. The ACSM offers the following guidelines:

• Use large-muscle groups in aerobic activities at an inten-sity of 40 to 70 percent VO2 or heart rate reserve (HRR).

• Train three to seven days a week for 30 to 60 minutes.


• Resistance training shouldn’t be the primary form of exercise for a hypertensive individual because of its effects on blood pressure levels. Individuals can incor-porate low-weight/high-repetition movements into a program.

If a client is managing his or her hypertension with drugtherapy, it’s important to follow exercise recommendationsfrom his or her doctor. These recommendations should be followed to the letter.

Consider the following guidelines when working with hypertensive clients:

1. Don’t hold the breath or strain excessively when exercis-ing. This can cause added pressure within the body.Exhale when exerting force and inhale when returningfrom exertion.

2. Use light to medium weights with higher repetitions.

FIGURE 9—Because blood-pressurelevels can rise during exercise, it’simportant for health and fitness professionals to design safe andbeneficial exercise programs forclients who have hypertension.


3. Don’t continue to exercise if any abnormal signs orsymptoms appear before, during, or after exercise.Consult a doctor.

4. Getting up quickly from the floor or from a bent overposition may cause dizziness.

5. Keep up to date on the client’s medications.

6. The client should check his or her blood pressure often.

In addition to exercise, people with high blood pressureshould maintain a normal body weight, consume a diet high in fruits, vegetables, and low-fat dairy, emphasizingpotassium-rich foods and restricting sodium, caffeine, andalcohol intake.

Cancer Patients

Dr. Deepak Chopra, the author of Quantum Healing, hasadded much to discussions on the effects of positive lifestylechanges on cancer patients. Patients who perform medita-tion, regular exercise, and dietary interventions have had abetter recovery from their cancer-related therapies.

Exercise plays an important part in recovery from cancer byhelping cancer patients to strengthen weak muscles and togain energy for daily work activities. Exercise can also helpcancer patients to boost self-esteem as they successfully per-form tasks and achieve goals. Moderate walking and waterexercise programs have been successful with this group. Inthe future, exercise may be a larger part of every cancerpatient’s recovery package.

Arthritis Sufferers

Some people with arthritis suffer pain with every movement.So why should they exercise? Exercise has been shown tolessen the pain and inflammation of chronic rheumatoidarthritis. Programs such as PACE (People with Arthritis CanExercise) have opened doors for those with arthritis, offeringexercise options and demonstrating the effects of exerciseover prolonged periods of time.


The most common forms of arthritis are rheumatoid andosteoarthritis. Osteoarthritis is sometimes referred to asdegenerative joint disease. Over the lifespan, cartilage wearsaway, leaving two surfaces of bone in contact with eachother. This form of arthritis is very common, affecting 85 percent of all Americans over the age of 70.

Rheumatoid arthritis is caused by inflammation of the mem-brane surrounding a joint and is commonly associated withpain and swelling in one or more joints. This type of arthritisaffects about three percent of women and one percent of menin America.

The severity and specific form of arthritis will dictate thecourse of treatment taken and may involve medicine, physicaltherapy, physiotherapy, occupational therapy, and/or jointreplacement. The ultimate goal is pain-free movement.

Individuals with arthritis can participate in a program of regular exercise. Exercise can build stronger muscles andbones and improve cardiovascular fitness and well-being.However, people with arthritis shouldn’t exercise duringinflammatory flare-ups, because exercise can aggravate orworsen the inflammation. Exercise programs should strive to balance rest, immobilization of affected joints, and appro-priate exercise to reduce the severity of the disease.

Consider the following tips when working with people witharthritis:

• Encourage low-impact activities, such as stationarycycling, rowing, and water fitness classes.

• Initially, exercise should be of low intensity with frequentsessions of work each week. Extend the warm-up andcool-down periods to 10 minutes each.

• Put all joints through their full range of motion daily tomaintain mobility.

• If pain is persistent during or following an exercise ses-sion, take a day or two of rest. Although pain in arthriticpeople is normal, work just up to the point of pain, butnot past it.


• Instruct clients on proper body alignment, which shouldbe followed at all times. Special precaution should betaken for those with hip replacements.

• Use isometric strengthening exercises, which place theleast amount of stress on the joint itself.

Individuals with Lower-Back Pain

A back injury is the number-one disability for people under theage of 45. It’s estimated that 80 percent of the U.S. populationwill experience lower-back pain at some point in their lives andfive percent of these people will develop chronic lower-backpain. Lower-back pain accounts for 10 percent of all chronichealth conditions in the United States, 25 percent of days lost from work, and 25 percent of all worker’s compensationclaims, representing annual payments of $2.5 to $7 billion dollars. Reducing back-injury rates is a top priority for nearlyall employers.

The causes of lower-back pain can be elusive; however, fourcommon causes have been identified:

• Herniated disc—A rupture of the outer layers of fibersthat surround the gelatinous portion of the disc.

• Spondylolisthesis—Forward sliding of the body of onevertebra on the vertebra below it.

• Trauma—Pain due to an accident.

• Degenerative disc disease—Progressive structural degeneration of the intervertebral discs.

Lower-back problems can be associated with an imbalance of strength and flexibility of the lower back and abdominalgroups and/or poor flexibility in the hamstrings and hipflexor muscles. Excess body weight, smoking, and decreasedphysical activity strongly correlate with lower-back pain. Lowendurance in the large muscle groups, especially the backextensors, can lead to lower-back pain. Prevention or treat-ment of lower-back pain should include exercises for the lowback and core to strengthen the abdominal muscles and aerobic training.


All patients should be screened for lower-back pain risk fac-tors. Physician clearance should be given before exercising ifa patient has experienced recent lower-back strain or injury.People with diagnosed lower-back pain should avoid the following movements:

• Unsupported forward flexion (bending at the waist)

• Twisting at the waist with turned feet, especially whencarrying a load

• Lifting both legs at the same time when lying on theirback or stomach

• Any rapid movements such as twisting, forward flexionat the waist, or hyperextension, which is bending back-wards at the waist as the body is in a straight line whileeither standing or lying on the stomach

The following are some important points to consider whenworking with a client with lower-back pain:

1. Clients with current lower-back pain or a history oflower-back pain should get specific recommendationsfrom a physician before beginning exercise.

2. Always use proper exercise form and body alignment.

3. Always maintain neutral pelvic alignment and an erecttorso during any exercise movements.

4. Avoid head-forward positions with the chin tilted up.

5. Always bend at the knees when leaning forward, lifting,or lowering any object.

6. Make sure to thoroughly warm up and cool down beforeand after exercise.

7. Perform resistance and flexibility exercises for the lowerback, abdominals, hamstrings (back of upper leg), andhip flexors (front or upper leg).

8. If a client experiences lower-back pain during or afterexercise, have the client sit or lie down and apply ice tothat area. Take a few days off to rest the muscles thatmay have been strained.


Asthmatics

Asthma is a reactive airway disease characterized by short-ness of breath, wheezing, and coughing. It’s one of the mostcommon respiratory disorders and affects people of all ages.Asthma is caused by muscles constricting around the airway;swelling of cells that produce mucous; or increased secretion of mucous.

During exercise, 80 percent of asthmatics experience what’sreferred to as exercise-induced asthma, or EIA. EIA is charac-terized by moderate obstruction and isn’t life-threatening;however, the asthmatic should have a bronchodilating inhaleravailable at all times. Asthmatics should be aware that theseverity of an EIA attack is related to the intensity of exercise,the ventilatory (breathing) requirement of that particular exer-cise, and environmental conditions, such as cold, dry air. Theexact causes of EIA aren’t well understood.

Most people with controlled asthma will benefit from regularexercise, which will help reduce the breathing required fordaily tasks. Studies have shown that regular exercise canreduce the number and severity of EIA attacks.

Asthmatics can safely participate in cardiorespiratory exerciseas long as they’re cleared by a physician. People with asthmaneed to coordinate their medication and exercise program, so a health care professional is an important part of the team.

The following guidelines concern exercising with asthma:

1. Asthmatics should have a medication/treatment plan to prevent EIA attacks before beginning any exercise program and have a bronchodilating inhaler with themat all times.

2. Reduce exercise intensity if asthma symptoms occur.

3. Using an inhaler several minutes before exercise mayreduce the occurrence of EIA attacks.

4. Drink plenty of fluids before and during exercise.

5. Use at least a 10 minute warm-up before and a 10minute cool-down after exercise.


6. EIA symptoms will more likely occur when exercising inextreme environmental conditions, such as high or lowtemperature, high pollen count, and heavy air pollution.Exercise indoors as conditions warrant.

7. Only stable asthmatics should exercise.

8. Anyone with a respiratory disorder should be carefullyfollowed by his or her physician.

9. Upper-body exercises, such as arm cranking, rowing,and cross-country skiing, might not be appropriatebecause of the higher breathing demands.

10. Swimming may be beneficial due to the moist air abovethe surface of the water.

Individuals with COPD

The combination of emphysema and bronchitis is referred toas chronic obstructive pulmonary diseases, or COPD.

Emphysema is caused by overinflation of the alveoli, resultingfrom a breakdown of the alveoli wall. The alveoli are at the endof the lung’s tubular system that carries oxygen and carbondioxide. The actual exchange of these gases between the lungsand the blood occurs at the alveoli. Overinflation of the alveolicauses a significant decrease in respiratory function. The classic symptoms of this disease are chronic breathlessnessand coughing.

Bronchitis is characterized by inflammation of the bronchialtubes that are part of the lung’s tubular system. Inflammationof the mucous membranes may occur as well. Bronchitis isprimarily caused by cigarette smoking, although it can becaused by air pollution and occupational exposure. An acutebout of bronchitis can be caused by a cold or exposure to dust particles or fumes and may last several days or weeks.Chronic bronchitis, in most cases, lasts a lifetime.

People with COPD may benefit from mild exercise training.These individuals should be carefully screened by a certifiedpersonal trainer and followed closely by their physician.Although most people with COPD don’t improve their


pulmonary function, they can realize benefits such asreduced anxiety, weight loss, and stress and an improvedability to perform daily activities.

Consider the following important points when working withclients with COPD:

• Extensive pulmonary tests should be completed and theindividual cleared for exercise by a physician before anyexercise program initiated.

• Refer to exercise guidelines for asthmatics listed abovefor specifics.

• People with COPD should have a bronchodilating inhalerwith them at all times.

• People with COPD should perform breathing exercises to help strengthen their respiratory muscles.

• Supplemental oxygen might be required during exercise.

• Any exerciser should be fully recovered from a bout ofacute bronchitis before resuming exercise.

• If a COPD patient’s performance in a non-medically super-vised program worsens, he or she should participate in apulmonary rehab program until symptoms improve.

Other Special Populations

Exercise has been shown to benefit people suffering from cystic fibrosis, post-polio syndrome, Raynaud’s syndrome,end-stage renal disease, pulmonary disease, and peripheralvascular disease. The benefits of exercise are also beingexamined with regards to HIV/AIDS and chronic fatigue syndrome.

The American College of Sports Medicine has set guidelinesfor exercise professionals on dealing with these types ofpatients during exercise situations. Patients who would havenever thought of using exercise as part of their medical treat-ment are now working with exercise specialists in addition totheir doctors, nurses, dietitians, and physical therapists.


Self-Check 31. Identify the major concern when working with a client with diabetes.

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2. List some guidelines for exercising with asthma.

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3. How does exercise benefit arthritic patients?

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BASIC FITNESS PROGRAMS FOR PEOPLE WITH MEDICALCONDITIONSWhat constitutes a medical exercise program? Does an adultwith diabetes have a different exercise program than a personwith arthritis? Because exercise programming is customized tothe client, no two people should have the exact same type ofexercise program. However, whether working out in a super-vised exercise setting or participating in an aerobic exerciseclass, a few guidelines for working with people with medicalconditions are universal and may help structure individualexercise programs.

Proper Monitoring before ExerciseWhether it’s blood sugar monitoring, using a blood pressurecuff, taking a temperature reading, or stepping on the scale,performing a physical reading pre-exercise is important indetermining how hard and long a client might be able to perform (Figure 10). Depending on your facility, a designatedstaff member may be responsible for performing these measurements and making appropriate decisions about their exercise program or a health care professional may bepresent to assist.

FIGURE 10—Physicalmeasurements and readings taken prior to the start of an exerciseregimen can help fitnessprofessionals gauge thesafety and effectiveness of exercise for clients.


Proper Warm-Up

Preparing the muscles for exercise is as easy as doing somelight aerobic movements and large-muscle stretching activi-ties to get ready for the body of the exercise (Figure 11). Thewarm-up may be the total exercise for the day or it may be aprelude to an exercise session, depending on the individual.No matter what type of exercise or length of exercise session,everyone should warm up!

New Goals and Objectives

The goals for therapeutic exercises can be pain-free movement,improved functional ability, learning new body movements,and perfecting techniques (Figure 12).

Therapeutic exercise is half education and half workout.Teaching patients new physical skills and offering instructionon how to deal with new movement is part of the objectivesfor special populations. This differs from mainstream exerciseprograms, where individuals need much less guidance. Therewards aren’t just improvement in physical condition, but

FIGURE 11—This step class is warming up with some light aerobic exercise.


FIGURE 12—Therapeuticexercise can help reducepain, improve functionalability, and perfect technique.

new tools to work with on their own (at home) and hopefullya new-found sense of self-acceptance and self-confidence tobecome healthier and more self-reliant.

Proper Cool-Down

In sports, the cool-down might consist of a few stretchesbefore going home. The importance of proper cool-down intherapeutic situations can’t be underestimated. It’s a time forbreathing (slow, proper breathing); it’s a time for reflectionand relaxation and becoming “centered”; and it’s a time to letthe muscles flush out the extra work they’ve been asked toperform so that they’re able to function properly the next daywithout undue soreness (Figure 13). For patients who havebeen in stressful healing situations, the cool-down reducespain, increases mental strength, and enhances their ownhealing abilities.


There’s no one type of exercise routine that will fit everypatient who has a medical condition, so no sample program is listed. From your studies and from collecting individualclient information, you’ll be able to put together appropriateexercise programs.

Fitness Tips for Special Populations

“Special populations” might sound like the newest trend orlatest fitness market to target, but the reality is that it refers to large numbers of people who aren’t well served by the fitness community.

Exercise programs for special populations can be incorporatedinto fitness facilities in varying ways. For example, a fitnessfacility might offer physical therapy patients a free 30-day trialas they continue their rehabilitation. Senior citizen programscan be divided into different skill levels for both active seniorsand the sedentary and frail. Programs for special populations

FIGURE 13—The cool-down periodduring therapeutic exercise is often a time of reflection and relaxation.


can include group exercise, yoga, aquatic programs, arthritisand fibromyalgia programs, walking programs, social activities,and strength training.

To continue to meet the fitness needs of special populations,facilities will likely need to increase the number of educationalprograms offered and to strengthen relationships with medicalprofessionals. They’ll also need to obtain qualified staff mem-bers to work with special populations. Qualified staff membersshould have formal/accredited training in designated areas.For example, a client who has had a heart attack or heart surgery shouldn’t be working with a trainer who hasn’t hadformal training in cardiac rehab. Before working with any specific population, a trainer or class instructor should knowthe exercise guidelines for that condition and should haveexperience implementing them.


Self-Check 41. What are the basic steps for exercise for a person with a medical condition?

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2. What kinds of programs can be offered for special populations?

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CPT Online

Here is an example of a low-impact total-body chair workout routine:

http://www.youtube.com/watch?v=2AuLqYh4irI


NOTES

Self-Check 11. Lowered risk of heart disease; lowered cholesterol and

other blood lipids; decrease in risk of certain cancers;possibly improved glycemic control for diabetes; decreasein blood pressure; lessening of depression and increasein psychological well-being; better able to handle stress

2. Fortunately, most sedentary individuals can begin a low-to moderate-intensity exercise program without extensivemedical screening, which they often consider a barrier to participation. However, medical authorities are a bitmore cautious in the case of previously sedentary indi-viduals over 45 years of age participating in a morevigorous exercise program. In most cases, high-risk individuals interested in participating in an exercise program can with the clearance of a physician.

3. A recent significant change in the resting ECG suggestingsignificant ischemia, recent myocardial infarction (withintwo days), or other acute cardiac event; unstable angina;uncontrolled cardiac dysrhythmias causing symptoms orhemodynamic compromise; symptomatic severe aorticstenosis; uncontrolled symptomatic heart failure; acutepulmonary embolus or pulmonary infarction; acutemyocarditis or pericarditis; suspected or known dissectinganeurysm; acute systemic infection, accompanied by fever,body aches, or swollen lymph glands

4. Write an individualized recommendation on a prescrip-tion note or special form; people are more likely to followadvice when they assume it’s tailor-made for them and is a “prescription,” just like medication. Ask patients tokeep a journal to be reviewed at each visit by the physi-cian. Explain to previously inactive patients what to doin case of mild soreness. Have a fitness professional as a consultant; have educational materials handy, such aspamphlets, Web sites, or exercise videos; offer hotlineswith an “exercise message of the day.”

45

Answers

Answers

Self-Check 21. Pregnant women can exercise if they’re cleared to do

so by their physician. Guidelines include the following:coordinate all exercise plans with the client’s physician;don’t increase the amount of exercise to more than thatperformed prepregnancy; avoid contact sports; don’t perform exercises that require you to lie on your back for more than five minutes; avoid exercises that require alot of balance, such as fast dancing or treadmill walking;wear support for feet and breasts; monitor your pulseand stay at the low end of the target heart rate zone;select non-weight-bearing exercises; stay properlyhydrated; avoid exercising in the heat; in the lasttrimester, avoid exercises that may cause joint strain;stop exercising immediately and call the physician if the client exhibits shortness of breath, dizziness, numb-ness or tingling, abdominal pain, or vaginal bleeding.

2. They should never perform single maximal lifts. Never let a child use a weight so heavy that he or she can’t perform at least eight repetitions.

3. Aging is a normal biological process, and its signsinclude loss of height, reduction in overall muscle mass,gray hair, wrinkles, changes in eyesight, and, to somedegree, loss of coordination. Signs of aging that may not be as noticeable include changes in the functioningof the cardiovascular (heart and arteries), endocrine (hormones), respiratory (lungs), and musculoskeletal(muscles, bones, and joints) systems as well. Althoughthe full extent to which these changes may be positivelyaffected by exercise isn’t known, it has been shownthrough research that negative changes in these systemscan at least be minimized and in many cases reversedtoward higher fitness levels.

Self-Check Answers46

Self-Check 31. People with diabetes must keep their blood sugar within

the normal range throughout the day. They must avoidlow blood sugar (hypoglycemia) due to prolonged exer-cise, as well. Note that hypoglycemia can also result frominjecting oneself in the exercising muscles shortly beforeexercise. Blood sugar self-monitoring is the cornerstoneof good diabetes control and can prevent long-term com-plications of the disease, such as blindness, gangrene,and heart disease.

2. Reduce exercise intensity if asthma symptoms occur; usean inhaler several minutes before exercise to reduce theoccurrence of EIA attacks; drink plenty of fluids beforeand during exercise; warm up before and cool down afterexercise; avoid exercising in extreme environmental con-ditions; only stable asthmatics should exercise; anyonewith a respiratory disorder should be carefully followedby their physician; upper-body exercises might not beappropriate because of the higher breathing demands;swimming may be beneficial due to the moist air abovethe surface of the water.

3. Exercise has been shown to have beneficial effects oflessening the pain and inflammation of chronic rheuma-toid arthritis.

Self-Check 41. Proper monitoring before exercise; proper warm-up;

new goals and objectives; proper cool-down

2. Group exercise, yoga, aquatic programs, arthritis andfibromyalgia programs, walking programs, social activities, and strength training

Self-Check Answers 47

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