Week 14: Ex Rx with Special Considerations

Children and adolescents are defined as

individuals aged 6 to 19 years or “youth”

“youth”

children or adolescents aged 6 - 19 years

% of 6-11 yr olds meeting PA guidelines

approximately 42%

% of 12-15 yr olds meeting PA guidelines

approximately 7.5%

% of 16-19 yr olds meeting PA guidelines

approximately 5%

Children and adolescents are typically

more physically active than their adult counterparts

The 2018 PA guidelines for Americans call for children and adolescents to engage in

at least 60 minutes/day of moderate to vigorous intensity PA and to include vigorous PA, resistance exercise, and bone loading activity on at least 3 days/week

How often should children and adolescents include vigorous PA, resistance exercise, and bone loading activity according to The 2018 PA guidelines for Americans

at least 3 days/week that counts towards the 60 minutes/day

Recommended that children limit total screen time to

less than 2 hours/day

Screen time is a marker for

sedentary behavior

Screen time/sedentary behavior in youth has been linked to

• increased weight

• increased adiposity

• depressive symptoms

• decreased overall fitness

• elevated BP, blood lipids, and glycohemoglobin levels

Children and adolescents are physiologically adaptive

to endurance exercise training, resistance training, and bone loading exercise

Exercise training in children and adolescents produces improvements in

cardiometabolic risk factors, weight control, bone strength, and psychosocial well-being and may help prevent sports-related injuries

Most young individuals are healthy and are able to start

moderate intensity exercise training w/o medical screening and vigorous exercise after safely participating in mod exercise

B/c prepubescent children have immature skeletons

younger children should not participate in excessive amounts of vigorous intensity exercise

Children and adolescents: physiological responses to acute, graded exercise are qualitatively similar to

those seen in adults

Children have much lower ________ than adults limiting their ability to perform sustained vigorous intensity exercise

anaerobic capacity

Quantitative differences b/w children and adults

• body mass

• muscle mass

• height

Children and adolescents exercise testing

are generally not indicated unless there is a health concern

Children and adolescents exercise testing protocol

should be based on the reason the test is being performed and the functional capability of the child/adolescent

They should be familiarized with test protocol and procedures before testing to minimize stress and maximize potential for successful valid test

Children and adolescents ergometers

Treadmill and cycle ergometers are typically used.

Treadmill ergometer use in Children and adolescents exercise testing

tends to elicit a higher peak oxygen uptake (VO2peak) and maximal HR

Cycle ergometer use in Children and adolescents exercise testing

provides less risk for injury but needs to be correctly sized for the child/adolescent

Children and adolescents may require

extra motivation and support during the exercise test compared to adults

FITNESSGRAM test battery includes

• body comp (BMI or skinfold)

• cardiorespiratory fitness (1-min walkrun, PACER)

• Muscular fitness (curl-up test, pull-up/push-up tests)

• flexibility (sit-and-reach test)

Commonly used in school-based setting for testing Children and adolescents

FITNESSgram

Physiologic Responses to acute exercise in children compared to adults

Higher: Relative oxygen uptake, HR, and respiratory rate

Lower: Absolute O2 uptake, cardiac output, stroke volume, SBP, DBP, tidal volume, minute ventilation, respiratory exchange ratio

Children and adolescents should be encouraged to participate in various physical activities that are

enjoyable and age-appropriate

Children and adolescents ExRx: PA in young children should include

unstructured active play - short sporadic bursts of moderate and vigorous intensity PA alternating with brief periods of rest

Do the small bouts of PA in Children and adolescents count towards FITT recommendations?

Yes

Frequency (F) of Aerobic exercise recommended for Children and adolescents

Daily; include vigorous intensity at least 3 days/week

Frequency (F) of Resistance exercise recommended for Children and adolescents

at least 3 days/week

Frequency (F) of Bone Strengthening exercise recommended for Children and adolescents

at least 3 days/week

Intensity (I) of Aerobic exercise recommended for Children and adolescents

MOderate (noticeable increase in breathing) to vigorous intensity (substantial increase in HR and breathing)

Intensity (I) of Resistance exercise recommended for Children and adolescents

use of body weight as resistance or 8-15 submaximal reps of an exercise to the point of moderate fatigue with good mechanical form

Intensity (I) of Bone Strengthening exercise recommended for Children and adolescents

Variable with emphasis on activities that produce moderate to high bone loading through impact or muscle force production

Time (T) of Aerobic exercise recommended for Children and adolescents

as part of at least 60 mins/day of exercise

Time (T) of Resistance exercise recommended for Children and adolescents

as part of at least 60 mins/day of exercise

Time (T) of Bone Strengthening exercise recommended for Children and adolescents

as part of at least 60 mins/day of exercise

Type (T) of Aerobic exercise recommended for Children and adolescents

Enjoyable and developmentally appropriate activities, including tag/running games, hiking/brisk walking, hopping, skipping, jumping rope, swimming, dancing, sports

Type (T) of Resistance exercise recommended for Children and adolescents

Muscle strengthening physical activities can be unstructured (ex. playing on the playground, climbing tress, tug-of-war) or structured and appropriately supervised (push-ups, pull-ups, lifting weights, working with resistance bands)

Type (T) of Bone Strengthening exercise recommended for Children and adolescents

Physical activities that produce high impact and tension on the bones, such as jumping, running, resistance training, or hopscotch

Children and Adolescents: Special Considerations

• May safely participate in strength training activities under supervision. Adult guidelines may be applied

• Avoid hot, humid environments, be properly hydrated, and appropriately modify activities

• Efforts made to decrease sedentary activities and increase activities that promote lifelong activity and fitness

B/c of immature thermoregulatory systems, youth should

avoid hot, humid environments, be properly hydrated, and appropriately modify activities

Term defined as individuals greater than or equal to 65 years old and individuals 50-64 yr with clinically significant conditions or physical limitations that affect movement, physical fitness, or physical activity

Older Adult

Older adults represent a diverse

spectrum of ages and physiologic capabilities

Health and functional status are often better indicators

of ability to engage in PA than chronological age

Benefits of PA in Older Adults

• Slowing physiological changes of aging that impair exercise capacity

• Optimizing age-related changes in body comp

• Promoting psychological and cognitive well-being

• Managing chronic diseases

• Reducing the risks of physical disability

• Increasing longevity

Least physically active of all age groups

Older adults

Only ___ of individuals aged >65 yr engage in regular aerobic and muscle strengthening

12%

Less than ____ of individuals aged >85 yr are engaging in regular aerobic and muscle strengthening activities

5%

Effects of aging on selected physiologic and Health-related Variables

Lower: HRmax, Max CO, Absolute & Relative max oxygen uptake reserve, vital capacity, muscular strength, flexibility, bone mass, fat-free body mass, glucose tolerance

Higher: Resting and exercise BP, Residual volume, % BF

Longer recovery time

Slower reaction time

Older Adults and Exercise Testing

Most do not require an exercise test prior to initiating a moderate intensity PA program

If exercise testing is recommended, the associated ECG has higher sensitivity and lower specificity than in younger age groups, producing a higher rate of false positives

The increase prevalence of cardiovascular, metabolic, and orthopedic problems among older adults increases the overall likelihood of an early test termination

Do older adults require an exercise test prior to initiating mod intensity PA program?

Most do not. If exercise testing is recommended, the associated ECG has higher sensitivity and lower specificity than in younger age groups, producing a higher rate of false positives

Initial load of Exercise testing for Older adults

should be light (<3 METs) and workload increments should be small

What increases the likelihood of early test termination among older adults?

The increase prevalence of cardiovascular, metabolic, and orthopedic problems

Workload increments for older adults

should be small/minimal (0.5-1.0 MET) for those with low work capacities

A cycle ergometer may with preferable for older adults with

poor balance, poor neuromotor coordination, impaired vision, impaired gait patterns, WB limitations, and/or foot problems

What may be a factor in early test termination for older adults even when using a cycle ergometer?

local muscle fatigue

Adding a treadmill handrail may be required when testing older adults b/c

of reduced balance, decreased muscular strength, poor neuromotor coordination, and fear

Handrail support for gait abnormalities will

reduce the accuracy of estimating peak MET capacity based on exercise duration or peak workload achieved

Older adults Exercise testing: Treadmill workload may need to be

adapted according to walking ability by increasing grade rather than speed

Many older adults exceed

the age-predicted HRmax during a maximal exercise test, which should be taken into account when considering test termination

Older adults: The influence of prescribed medications on the ECG and hemodynamic responses to exercise

may differ from usual expectations

What has largely replaced exercise stress testing for the assessment of functional status of older adults

Physical performance testing

Most physical performance tests require

little space, equipment, and cost; can be administered by lay or health fitness personnel with minimal training; and are considered extremely safe in healthy and clinical populations

Commonly used Physical Performance Tests

• Senior Fitness Test

• Short Physical Performance battery

• Usual Gait speed

• 6-min walk test

• Continuous scale physical performance test

Physical Performance Test: Senior Fitness Test

7 items: 30s chair stand, 30s arm curls, 8 ft up and go, 6-min walk, 2 min step test, sit and reach, and back scratch

30 min total administration time

Cutpoint indicative of Lower Function: less than 25th percentile of age-based norms

Physical Performance Test: Short Physical Performance battery

A test of LE functioning that combines scores from usual gait speed and timed tests of balance and chair stands; scores range from 0-12 with higher score indicating better functioning

Administration time: 10 minutes

Cutpoint indicative of Lower Function: 10 points

Physical Performance Test: Usual gait speed

Usually assessed as the better of 2 trails of time to walk a short distance (3-10 m) at a usual pace

Administration time: <2 min

Cutpoint indicative of Lower Function: 1 m . s

Physical Performance Test: 6-min Walk Test

Widely used as an indicator of cardiorespiratory endurance; assessed as the most distance an individual can walk in 6 min. A chnage of 50 m is considered a substantial change

Administration time: <10 min

Cutpoint indicative of Lower Function: less than 25th percentile of age-based norms

Continuous Scale Physical Performance Test

2 versions -long and short - are available. Each consists of senal performance of daily living tasks such as carrying a weighted pot of water, donning and removing a jacket, getting down and up from the floor, climbing stairs, carrying groceries, etc. Scores range from 0 to 100 with higher scores representing better functioning

Administration time: 60 min

Cutpoint indicative of Lower Function: 57 points

Exercise Rx to older adults applies to

all ages. Age should not be a barrier to PA b/c positive improvements are attainable at any age

The relative adaptations to exercise and the % of improvement in the components of physical fitness among older adults

are comparable with those reported in younger adults and are important for maintaining health and functional ability and attenuating many of the physiologic changes that are associated with aging

The appropriate Ex Rx for Older Adults should include

a multi-component program that combines aerobic exercise, resistance training, balance and flexibility exercises

Low aerobic capacity, muscle weakness, and deconditioning contribute to loss of independence in which age group

Older adults

Individuals who are frequent fallers or have mobility limitations may also benefit from

specific neuromotor exercises to improve balance, agility, and proprioceptive training

For healthy younger adults, mod to vigorous intensity PAs are defines relative to

METs

For older adults, activities should be defines relative to

an individual’s physical fitness within the context of a perceived 10-point physical exertion scale which ranges from 0 (effort equivalent to sitting) to 10 (an all-out effort), with moderate intensity defined as 5 or 6 and vigorous intensity as greater than 7

Frequency (F) of Aerobic exercise recommended for Older Adults

at least 5 days/week for moderate intensity

at least 3 days/week for vigorous intensity

3-5 days/week for a combination of moderate and vigorous intensity

Intensity (I) of Aerobic exercise recommended for Older Adults

On a scale of 0-10 for level of physical exertion

5-6 for moderate intensity

7-8 for vigorous intensity

Time (T) of Aerobic exercise recommended for Older Adults

30-60 minutes/day of moderate intensity exercise

20-30 minutes/day of vigorous intensity exercise

or an equivalent combination of mod and vigorous exercise - may be accumulated throughout the day

Type (T) of Aerobic exercise recommended for Older Adults

Any modality that does not impose excessive orthopedic stress such as walking. Aquatic and stationary cycle exercise may be advantageous for those with limited tolerance for WB activities

Frequency (F) of Resistance exercise recommended for Older Adults

at least 2 days/week

Intensity (I) of Reisistance exercise recommended for Older Adults

Progressive weight training: Light intensity (40-60% 1-RM) for beginners; progress to moderate to vigorous intensity (60-80% 1-RM)

Alternatively, moderate (5-60 to vigorous (7-8) intensity on a 0-10 scale

Power training: light to moderate loading (30-60% of 1-RM)

Time (T) of Resistance exercise recommended for Older Adults

progressive weight training: 8-10 exercises involving the major muscle groups; at least 1 set of 10-15 reps for beginners; progress to 1-3 sets of 8-12 reps for each exercise

Power training: 6-10 reps with high velocity

Type (T) of Resistance exercise recommended for Older Adults

Progressive or power weight training programs or WB calisthenics, stair climbing, and other strengthening activities that use the major muscle groups

Frequency (F) of Flexibility exercise recommended for Older Adults

at least 2 days/week

Intensity (I) of Flexibility exercise recommended for Older Adults

Stretch to the point of feeling tightness or slight discomfort

Time (T) of Flexibility exercise recommended for Older Adults

Hold stretch for 30-60 s

Type (T) of Flexibility exercise recommended for Older Adults

Any physical activities that maintain or increase flexibility using slow movements that terminate in static stretches for each muscle group rathet than rapid ballistic movements

Stats of individuals over the age of 65 experiencing falsl in the US every year

1 in 4 individuals

Leading cause of fatal injury and the most common cause of nonfatal trauma related hospital admissions amongst older adults

Falls

What is effective in reducing and preventing falls if performed 2-3 days/week in older adults

Neuromotor exercise training, which combines balance, agility, and proprioceptive training

General Recommendations for older adults: Fall prevention

• Progressively difficult postures that gradually reduce the base of support (2-legged stand, semitandem stand, tandem stand, and 1-legged stand)

• Dynamic movements that perturb the center of gravity (tandem walk and circle turns)

• Stressing postural muscle groups

• Reducing sensory inoput

• Tai chi

Intensity and duration of PA should be light at the beginning in particular for older adults who

are highly deconditioned, functionally limited, or have chronic conditions that affect their ability to perform physical tasks

Progression of PA in older adults

should be individualized and tailored to tolerance and preference; a conservative approach may be necessary for the most deconditioned and physically limited older adults

Resistance training becomes more important when?

with increasing age and muscular strength decreases rapidly with age, especially for those >50 yr

Considerations for strength training with older adults

use of selectorized machines or free weights, initial training sessions should be supervised and monitored by personnel who are sensitive to the special needs of older adults

Older adults may particularly benefit from power weight training b/c

this element of muscle fitness declines most rapidly with aging, and insufficient power has been associated with a greater risk of accidental falls