Special Considerations for Other Populations

How much resistance activity should children and adolescents participate in?

≥ 3 days a week

Consider unstructured or body weight activities, playground equipment, tree climbing etc. Just moderate to high bone-loading activities

What is the general goal of physical activity for children and adolescents?

60 minutes of moderate to vigorous physical activity per day

What types of exercise is encouraged for kids?

Daily, unstructured activity with the simple goal of reducing sedentary behavior

How should asthma change your exercise prescription?

It doesn't really, if it is pharmacologically managed, FITT principles are appropriate as adjusted to individual capabilities.

However, you should avoid cold environments or allergens/pollutants (check air quality)

What results may be inaccurate in children with asthma?

AMPHR

In inpatient cardiac rehab, how soon should PT be initiated?

12-24 hours

What is the typical, general progression of PT for an inpatient cardiac rehab pt?

Orthostatic stress to basic self-care to supervised ambulation

What should always be assessed when working with an inpatient cardiac rehab pt?

VITALS!!

What indications suggest a patient is ready for daily ambulation?

No new or recurrent chest pain in prior 8 hours

Stable or falling creatine kinase and troponin levels

No indication of decompensated heart failure

Normal cardiac rhythm and stable ECG for prior 8 hours

What indications suggest a patient should discontinue daily ambulation?

DBP ≥ 110 mmHg

SBP decreases > 10 mmHg with increasing workload

Significant arrhythmia

2nd or 3rd degree heart block

Angina, dyspnea, ECG indications of ischemia

What is commonly included in outpatient cardiac rehabilitation?

-CV risk factor assessment and education on aggressive lifestyle modification

-Education and support for lifestyle changes

-Development and implementation of safe and effective personalized exercise plan

-Monitoring with goal of improving BP, lipids, cholesterol, and/or diabetes

-Psychological assessment and counseling

-Return to vocational and recreational activities

What are the goals of rehabilitation for an outpatient cardiac rehab patient?

-Develop and assist implementation of safe and effective formal exercise, PA, and lifestyle program

-Provide supervision and monitoring to detect changes in clinical status

-Provide ongoing surveillance to health care providers to enhance medical management

-Return to vocational and recreational activities or modification of activities based on clinical status

-Provide individual and caregiver education to optimize secondary prevention

What are common macrovascular complications associated with diabetes?

o Cardiovascular disease

o Cerebrovascular disease

o Peripheral vascular disease

What are common microvascular complications associated with diabetes?

o Peripheral neuropathy

o Retinopathy

o Nephropathy

What are the ACSM recommendations for patients with diabetes mellitus?

o If sedentary, seek medical clearance prior to beginning exercise, independent of desired intensity

o Testing generally not necessary when beginning light to moderate activity if asymptomatic for CVD

What are the ADA's recommendations for patients with diabetes mellitus?

o Medical clearance not warranted prior to beginning light to moderate intensity activity in individuals asymptomatic for CVD

o Consider ECG stress testing in those who have been sedentary and want to participate in vigorous intensity activities

What is the optimal pre-exercise blood glucose range?

90-250 mg/dL

Wehn is blood considered hypoglycemic? Hyperglycemic?

Hypoglycemia: < 70 mg/dL

o Rule of 15: Eat 15 g of carbs, recheck in 15 minutes

Hyperglycemia: > 250 mg/dL

o Check for ketoneuria

When should you cease activity in patients with diabetes?

When blood glucose is >350 mg/dL

How does exercise impact blood glucose levels?

o Resistance training and vigorous aerobic activity may increase or attenuate decline in blood glucose levels during exercise

o Vigorous and HIIT may facilitate blood glucose control

o Note increased risk for tendinopathy, limited joint mobility

If a patient with DM has retinopathy, how might you need to adapt your exercise plan?

Consider referral to opthamology prior to initiating vigorous/high-intensity activities; avoid Valsalva maneuver

If a patient with DM has peripheral neuropathy, how might you need to adapt your exercise plan?

Enforce regular foot checks, limit weight bearing activities as needed

If a patient with DM has autonomic neuropathy, how might you need to adapt your exercise plan?

o Monitor BP, HR, hydration, and thermoregulation closely

o HR/BP response may be blunted, use RPE to determine intensity

If a patient with DM has neuropathy, how might you need to adapt your exercise plan?

o No restrictions for tolerable moderate intensity aerobic or resistanceactivities

o Begin at low intensity/volume

If you plan on less than 30 minutes of low-intensity exercise, how much extra glucose intake may be necessary during exercise?

< 90 mg/dL to start = 10-15g during exercise

> 90 mg/dL to start = None

If you plan on less than 30-60 minutes of moderate intensity exercise, how much extra glucose intake may be necessary during exercise?

< 90 mg/dL to start = 30-45g during exercise

90-180 mg/dL to start = 15g during exercise

> 180 mg/dL to start = none

If you plan on less than more than 60 minutes of moderate intensity exercise, how much extra glucose intake may be necessary during exercise?

< 90 mg/dL to start = 45g per hour of exercise

90-180 mg/dL to start = 30-45g per hour of exercise

> 180 mg/dL to start = 15g per hour of exercise

What is currently considered resting hypertension?

SBP ≥ 130, DP ≥ 80 mmHg, and/or taking antihypertensive medication

True or false: Exercise related reduction in BP are independent of age.

True

What should you encourage for patients with hypertension?

Multimodal exercise reflecting personal preferences; at a higher frequency of ≥90-150 mins per week (mod intensity of 40-59%)

How does hypertension affect exercise cooldown?

Some antihypertensive medications may result in excessive reduction in post-exercise BP; gradually terminate activity and increase cool down time

What recommendations does the ACSM make for adults with arthritis?

Recommendations are generally consistent with guidelines for healthy adults, with consideration for disease activity, pain, joint integrity, functional limitation, and personal preference

What is a critical component to exercise prescription for patients with arthritis?

o Adequate warm-up and cool-down (> 5-10 min.) is critical, should include controlled movements through full joint ROM

o Consider very short bouts for those restricted by pain or joint mobility; increase 5-10 min. every 1-2 weeks for first 4-6 weeks

Prescription for patients with fibromyalgia myst be highly individualized. However, there are some general rules. Describe them.

o Frequencies of 1-2 days/week are beneficial; symptom reductiongreater at 3 days/week

o Begin with short bouts at light or very light intensities (< 30% HRR), progressing to light to moderate intensity as tolerated

o Use RPE for self-regulation

o Education for realistic expectations and goal-setting - benefits may not be evident for 7 weeks or more

o Consider group and/or supervised settings initially, but must foster exercise independence for long term adherence

Progressive destruction of CD4 cells, associated with HIV, results in immunosupression. What are some common symptoms seen in the body?

o Cardiovascular and metabolic abnormalities

o Fatigue and loss of appetite

o Malabsorption and chronic diarrhea

o Anemia and micronutrient deficiency

o Muscle wasting and loss of lean musclemass

o Osteopenia and osteoporosis

o Respiratory infections and tuberculosis

o Peripheral neuropathy

True or false: Exercise is strongly recommended at all stages of HIV.

True as there is no evidence of exercise-induced immunosuppression

Are there contraindications for exercise in patients with HIV?

No, there are no establish guidelines

What is the exercise regimen recommendations for patients with HIV?

o Exercise tolerance and/or peak VO2 may be low; heart rate response may be altered

o Adaptations to exercise may be prolonged

o Encourage weight-bearing activities, reduced sedentary time

What are some important considerations for patents with cancer?

o Exercise is safe during and after cancer treatment

o Exercise testing is recommended for most cancer survivors, but not required prior to walking, resistance, or flexibility activities

o Consider medical evaluation for those with metastatic disease, persistent treatment-related side effects, or significant comorbidities

o Overall exercise recommendations consistent with guidelinesfor healthy adults

o Sedentary behavior is an independent risk factor for cancer-specific mortality

o Tailor exercise to address health and fitness issues causing greatest morbidity and risk for mortality

o Emphasize resistance training for sarcopenia or cachexia, minimal aerobic training

More than 45% of those with ___________ have diabetes, are sedentary, and possess low functional capacity

End stage renal disease

Training in patients with end-stage renal disease can increase _____ by 17-23%

VO2

Describe trends seen in patients on hemodialysis.

o Fitness level likely very low

o No contraindications to exercise during or post-dialysis

o Use RPE to monitor intensity

Describe trends seen in patients on peritoneal dialysis.

o ↑ comfort if abdominal cavity is emptied

o Avoid activities involving full hip flexion

True or false: Polypharmacy is common and may affect exercise response /tolerance.

True

There is an important line common in patients on dialysis. There should be absolutely no pressure or weight placed on it. What is the line? How does it affect taking vitals?

A/V Fistula; do NOT take blood pressure on the arm with an A/V fistula.

Cardiorespiratory fitness up to ______% worse than age-matched sedentary peers.

40

THe VO2 peak in stroke survivors is on average ______.

15-18ml/kg/min

Exercise can improve: (in stroke survivors)

Exercise capacity (10-20%), quality of life, and reduce risk of secondary events

What are some necessary precaution to take when working with stroke survivors?

o Avoid Valsalva maneuver

o Consider harness or body weightsupport for walking

o Begin at slow speeds, progressgradually

o Use caution when using HR to determine intensity - APMHR is rarely achieved

o Onset of local and general fatigue may precede cardiovascular targets

o Consider motor and cognitive abilitiesin choice of modality

Stroke survivors are at an increase risk of...

Increased risk of acute cardiac events- monitor vitals, esp. blood pressure

What are the absolute indications to discontinue exercise in stroke survivors?

o SBP > 250 or DBP > 115 mmHg

o > 10 mmHg decrease in SBP

o BP < 90/60 mmHg

Strong, unequivocal evidence the exercise reduces risk of falls and injuries in patients with ________.

Alzheimers

What special considerations should be made with exercise in patients with Alzheimers?

o Symptom severity may be lowest in morning

o Ensure adequate warm-up and cool-down periods; monitor vitals

o Long, continuous bouts are safe and effective in preclinical and early stages, but likely not feasible in later stages

o Consider bouts of 10 min or less for those with metabolic, cardiovascular, joint, and muscle atrophy complications

o Moderate intensity training and HIIT is safe and feasible, multi-modal exercise may facilitate adherence

o Frequent cueing, close supervision may be necessary

o Involve caregivers whenever possible

What are the clinical features of Parkinson's?

o Resting tremor

o Bradykinesia, dyskinesia, akinesia

o Rigidity

o Postural instability and balance impairment

o Adaptive responses (e.g. contracture, reducedaerobic capacity, etc.)

What are the goals of exercise for patients with Parkinson's?

o Reduce symptoms

o Reduce rate of progression

o Reduce comorbidities

o Prevent complications

o Improve functional abilities and QOL

In Parkinson's patients _____ _________ is common.

Autonomic neuropathy

(Heart rate response may be blunted; medications may cause transient exercise bradykinesia and/or tachycardia; Monitor for orthostatic hypotension, impaired thermoregulation)

True or false: High-intensity aerobic training is safe and may attenuate disease progression; consult with physician if autonomic neuropathy is suspected.

True

What should be emphasized in an exercise regimen written for a patient with Parkinson's?

o Emphasize flexibility and ROM, esp. upper extremities, trunk mobility and axial rotation, and cervical flexibility

o Incorporate balance and functional activities

o Coordinate with medication schedule

Participation in exercise is often limited by what in patients with MS?

o Fatigue (primary and/orsecondary)

o Impaired thermoregulation (esp.heat sensitivity)

o Bowel/bladder dysfunction

o Spasticity / rigidity

o Cognitive impairments

o Mobility impairments

What are the benefits of exercise for patients with MS?

o Reduced risk of cardiovascular disease

o Increased walking speed & endurance

o Increased muscle strength

o Improved balance

o Reduced fatigue

o Reduced depression

o Improved health-related QOL

What is the Uhthoff phenomenon?

transient (< 24 hour) exacerbation of neurological symptoms (esp. vision) associated with exercise or elevated body temperature

o Cooling strategies

o Adjust exercise time and/or intensity

If a patient with MS easily fatigues, what changes can be made?

emphasize major muscle groups to minimize total number of exercises; allow ample rest time (e.g. 2-5 minutes)

What is the most common SCI?

Incomplete tetraplegia

What impairments are common in patients with L2-S2 SCI?

lack bowel and bladder control; upper extremities and trunk fully intact

What impairments are common in patients with T6-L2 SCI?

respiratory and muscle control depend on functional capacity of abdominal musculature

What impairments are common in patients with T1-T6 SCI?

impaired thermoregulation, orthostasis, autonomic dysreflexia

What impairments are common in patients with C5-C8 SCI?

upper extremity involvement

What impairments are common in patients with C4-above SCI?

Ventilator dependent (C3,4,5 keeps diaphragm alive)

What is autonomic dysreflexia?

Unregulated spinally-mediated reflex response; can be life threatening

What are the symptoms of autonomic dysreflexia?

Sudden onset of hypertension, bradycardia, headache, flushed skin, goose bumps, sweating, nasal congestion

Above injury: flushed, bradycardic, throbbing headache

Below injury: Pale, cool & clammy skin, hypertension

If you suspect your patient is experiencing autonomic dysreflexia, what should you do?

o Immediately transfer to sitting

o Look for source of irritation (pinched skin,kinked catheter tube, tight clothing, etc.)

What elicits autonomic dysreflexia??

Often elicited by FES cycling, occasionally NMES

o Preceding FES with NMES may attenuate effects

What is the best way to monitory for autonomic dysreflexia?

Exercise in seated position; monitor BP throughout exercise (every 3-5 minutes)

What stages/phases are associated with spinal cord injuries?

o Beginning: Inactive, unlikely to achieve sufficient exercise volume in3 months

o Intermediate: Currently not meeting guidelines, but possible in next3 months

o Advanced: Currently meeting guidelines; maintenance and management to prevent overuse injuries

What is the minimal recommendation for SCI exercise?

20-30 minutes of moderate-to-vigorous activity 2-3 times/week, gradually progress 5 min/week with goal of ≥ 150' per week

Many SCI patients will develop muscular fatigue _________ achieving sufficient cardiovascular challenge

Before

What components should be included in an SCI exercise regimen?

o Include resistance training for all major innervated muscles

o Encourage daily, slow stretching; avoid overstretching

o Balance pushing and pulling to prevent overuse injuries – esp. rotator cuff

o Abdominal binders, TED hose may be needed due to orthostasis

o Empty bowel and bladder prior to exercise

o Closely monitor vitals, temperature, and hydration

o Skin protection and monitoring!

Motor neuron degeneration results inprogressive:

o Weakness

o Muscular atrophy

o Spasticity

o Mobility impairment

o Restrictive respiratory impairment

o Speech & swallowing dysfunction

o Fatigue

o Depression

o Cognitive/emotional disturbance

What exercise recommendations are there for patients with progressive motor neuron diseases?

There are none, as exercise does not alter the course of the disease. Possible improvements in functional ability, cardiopulmonaryfunction, and QOL, but not in strength or disease progression