Risk factors, contraindications, relative contraindications, benefits, and exercise suggestions for special populations

ABSOLUTE contraindications to pregnancy exercise

-Hemodynamically significant heart disease

-Incompetent cervix cervical insufficiency, or cerclage

-Intrauterine growth restriction

-Multiple gestation at risk for premature labor

-Persistent second or third trimester bleeding

-Placenta previa after 26-28 wk of gestation

-Preeclampsia or pregnancy-induced hypertension

-Premature labor during the current pregnancy

-Restrictive lung disease

-Ruptured membranes

-Severe anemia

-Uncontrolled or poorly controlled hypertension

-Uncontrolled thyroid disease

-Uncontrolled type 1 diabetes

-Unexplained persistent vaginal bleeding, such as in second or third trimester Other serious cardiovascular, respiratory, or systemic disorder

RELATIVE contraindications for pregnancy

-Anemia or symptomatic anemia Cervical dilation Chronic bronchitis

-mild/moderate respiratory disease, or other respiratory disorders

-Eating disorder

-Extreme morbid obesity

-Heavy smoker

-History of extremely sedentary lifestyle

-History of spontaneous preterm birth, premature labor, miscarriage, or fetal growth restriction

-Malnutrition or extreme underweight

-Mild/moderate cardiovascular disease

-Orthopedic limitations

-Poorly controlled seizure disorder

-Poorly controlled type 1 diabetes

-Recurrent pregnancy loss

-Unevaluated maternal cardiac dysrhythmia

-Other significant medical conditions

Guidelines for pregnant exercise

● Check with health care provider before exercise

● WU and CD ● Major muscle group resistance training for multiple reps (12-15) should be used. Isometrics and motionless standing should be avoided

● Include pelvic floor training

● Begin with short sessions and increase to at least 20-30 minutes a day gradually for most or all days of the week.

● Walking, swimming, or group exercise are favored for reducing injury risk and continuing program through pregnancy

● Exercise should not continue past the point of fatigue and never reach exhaustive levels. Comfortable and talkable.

● Avoid straining or stretching to discomfort

● Supine position should be avoided after first trimester

● Large increases in body temp should be minimized through hydration, clothing, and environment. Hot yoga/pilates should be avoided.

● Stay well hydrated and avoid exercising in hot and humid conditions

● Wear proper footwear and clothing

● Use equipment in good condition

● Sports and activities that have a potential for even mild abdominal trauma or loss of balance should be avoided.

● Do not exercise with fever

● See health care provider if you bleed, have a large amount of discharge, or swelling in face or hands ● Gradual exercise may begin 4-6 weeks after normal vaginal delivery and 8-10 weeks for cesarean delivery (with clearance).

Guidelines for resistance training for children

● Qualified adults should provide supervision and instruction.

● The training environment should be safe and free of hazards.

● Resistance training should be preceded by a 5- to 10-minute dynamic warm-up.

● Begin with 1 or 2 sets of 8 to 12 repetitions of a variety of exercises.

● Include exercises for the upper body, lower body, and midsection.

● Increase resistance gradually (e.g., about 5% to 10%) as resistance training skill competency improves.

● Resistance train two or three nonconsecutive days per week.

● Children should cool down with less intense calisthenics and static stretching.

● Vary the resistance training program over time to optimize gains and prevent boredom

Resistance training benefits for Children

-30-40% strength gains in short term programs (Adaptations are purely neural and androgens cannot induce hypertrophy due to low volume)
-Intrinsic adaptations (contraction coupling, myofibrillar packing, and muscle fiber composition) lead to better motor skills and coordination

-increase bone mineral density

-development of motor performance skills

-weight control

-better cardiometabolic health

-better mental health

-supports M-V participation

How to prepare kids in sports.

-To prepare kids for sports they should participate in a supervised integrative conditioning program (if 2-3 months no exercise) with strength training and drills to enhance agility, balance, coordination, and power.

-May need to spend a lot of time on fundamental skills instead of sports specific skills.

-Acute and overuse injuries are significantly reduced if development on strength and general fitness skills are prioritized.

-Young female athletes are more prone to knee injuries so it may be important to them.

-6-8 weeks of general conditioning recommended but ideally year round conditioning and strength training needed.

Resistance training accommodations for Overweight Youth

-Overweight youth may like resistance training as it is short burst with rest.

-Important component for building strength and confidence in overweight youth so that they may participate in M-V activities and lose weight.

Resistance training progression for youth

-Start with 1-2 sets of light-moderate weight (<60% of estimated 1RM) for 8-12 reps for introductory

-increase to 60-80% estimated 1RM as they get stronger and more complex exercises.

-Heavier loads may be used for exceptional competency.

-Intensity and volume of resistance training needs to be systematically varied over time to prevent overuse and overtraining.

● Improved Aerobic and Muscular Fitness

● Faster return to prepregnancy weight, strength, and flexibility

● More Energy Reserve

● Shorter Active phase of labor and less pain

● Less Maternal Weight gain

● Improved mood, self-concept, and psychological well-being

● Reduced stress, anxiety, and depression

● Increased Likelihood of adopting permanent healthy lifestyle habits

● Decreased risk of gestational diabetes mellitus (diabetes first diagnosed during pregnancy)

○ Adaptations for insulin and metabolism improve glucose tolerance ● Decreased risk of cesarean and operative vaginal delivery

● Reduced risk of preeclampsia (pregnancy induced hypertension)

○ Reduced due to physical and psychological benefits of exercise

● Few obstetric interventions

● Facilitated recovery from labor

● Reduced postpartum belly

● May be helpful for low back pain, pelvic floor muscle dysfunction, pregnancy-related urinary incontinence, and chronic musculoskeletal conditions.

Cardiovascular Guidelines of Pregnant Women

-RPE scale and Talk Test are best since pregnancy alters HR and O2 consumption. RPE on 6-20 scale, 13-14 is moderate intensity for pregnant women (conversational)

-30 minutes 5x a week.

-Women active before pregnancy may hit 14-17 RPE and adjust intensity and duration based on how they feel.

-Hypotension caused by supine position after first trimester due to restricted venous return of blood due to the uterus.

-Supine position exercises should be phased out before the second trimester.

-Transition core exercises to quadruped or side lying position.

-Upper and lower body resistance exercises in seated position.

-Due to changes in center of gravity, weight machines might be best later in pregnancy particularly with sedentary individuals before pregnancy.

Respiratory considerations with Pregnant Women

-Increase in minute ventilation by almost 50% resulting in a 10-20% increase in oxygen use at rest.

-Less oxygen available for aerobic exercise.

-Uterus can interfere with diaphragm movement increasing the effort to breathe and decreasing subjective workload and maximum exercise performance.

-Pregnant women should not go to high levels of fatigue or exhaustion.

-Avoid Valsalva maneuver.

Mechanical considerations in Pregnant Women

-Center of mass changes due to breast and belly growth lead to balance, body control, and movement mechanics changes.

-Women should not participate in activity that would compromise joints (due to laxity during pregnancy), have a risk of falling, or scuba diving(to avoid decompression sickness to the fetus).

-Pelvic floor exercises are important for postural support and urinary incontinence during and after pregnancy.

Metabolic considerations of Pregnant Women

-Pregnant women use 300 more calories a day.

-Pregnant women should attain adequate intake of nutrition dense foods with calcium, vitamin b12, vitamin D, iron, and folic acid.

-All pregnant women should receive nutrition counseling from qualified professional to develop healthy habits that can be continued postpartum.

Thermoregulation considerations for Pregnant Women

-Exercise-associated rises in the body temp may be most likely in the first trimester of pregnancy so proper clothing, hydration, and environmental surrounding are important.

-Overheated clients must take a break and decrease intensity and begin the cool down.

-Severe headaches, dizziness, and disorientation are indications of potential serious conditions that require referral to health care providers.

-Educate women on proper guidelines.

Warning signs that indicate stopping exercise and seeking medical attention for pregnant women

● Vaginal Bleeding

● Abdominal Pain

● Regular painful contractions

● Amniotic fluid leakage

● Dyspnea before exertion

● Dizziness

● Headache

● Chest pain

● Muscle weakness affecting balance

● Calf pain or swelling

Postpartum Care

-women recovering from birth

-caring for the newborn, and managing additional challenges (lack of sleep, pain, fatigue, urinary incontinence, or mental health disorders).

-Comprehensive medical assessment with physical, social, and psychological well-being to address immediate needs and set long-term stage for postpartum care should be done.

-Diabetes, hypotension, other obesity related disorders, and accumulations of adipose tissue will also need care.

-Optimal postpartum care should promote overall health and well being of women.

-Moderate intensity activity can reduce postpartum depression.

-By selecting enjoyable physical activity, socializing with family and friends, realistic goals, women can improve a variety of physiological and psychological factors during postpartum period.

-Gradual return to activity should be done.

Recommendations for personal trainers working with kids

-Provide close supervision, and listen to each child's concerns.

-Speak to children using words they understand.

-Greet each child by name on arrival.

-Praise children for doing a good job.

-Realize that children are active in different ways than adults.

-Design activities that ensure equal participation and enjoyment.

-Gradually progress the fitness program.

-Play down competition and focus on skill improvement, personal successes, and having fun.

-Remind children that it takes time to learn new skill and get in shape.

-Offer a variety of activities and avoid regimentation.

-Emphasize the importance of healthy food choices.

-Inform parents about the benefits of regular physical activity.

Older Adult Benefits to exercise (muscle mass, BND, Energy expenditure, Body fat

● Increased muscle mass: Significant increase in mass similar to younger adults. 1 lb per month over the first few months and reduces or reverses sarcopenia muscle loss.

● Increased BMD: 80% 1RM protocols develop muscle and BMD. BMD increases after several months and increases by 1% per year.

● Increased Energy Expenditure: Microtrauma in exercised muscle leads to need for protein and energy from carbs to build muscle. Burns calories during and after exercise. 7% elevation in resting energy expenditure (100 calories at rest).

● Reduced Body Fat: Used calories during and after exercise. Monthly muscle gain of 1lb and monthly fat loss of 1.5lbs during the first few months especially in the intraabdominal area.

OTHER Older Adult benefits from exercise

● Enhanced Mental and Emotional Health

● Improved Physical Abilities

● Improved Mitochondrial Function

● Reduced Diabetes Risk

● Reduced CVD Risk

● Reduced Risk of Certain Cancers and Treatment Side Effects

Aerobic Training Benefits for Older Adults

-Benefits health and quality and quantity of life.

● Improvements in Heart to pump blood and rest between pumps

● More effective and efficient blood delivery network and circulatory system. Increased size, number, and tone of blood vessels.

● Blood becomes a more effective and efficient transporter. RBC count goes up.

-Improve VO2max by up to 25% depending on factors.

-Reduce risk of premature deaths.

-Less fit men have a 3.4x greater relative risk of death.

-Lower BP

-better blood lipid profiles

-reduced ab fat

-enhanced insulin sensitivity

-improved mitochondrial function

-increased brain volume of white and gray matter.

-Older adults should participate in both aerobic endurance and strength training

Resistance Training Guidelines for Older Adults

-Cumulatively address all muscle groups
-Multijoint exercise focus, performed before single jointed exercise

-Single Joint exercise supplemental
-Acceptable range is 60-90% 1RM

-4-16 reps allowed
-Start with 10-15 reps, progress to a resistance for 8-12, advanced clients can do resistance for 4-8

-Older women and men only should progress to 85% 1RM for safety

-2-4 or 3-4 sets for maximal benefits (Start with 1 set for untrained individuals)

-2-for-2 rule (progress 5%)

-2-3x nonconsecutively a week

-Perform in a pain free range

-Avoid valsalva maneuver

Aerobic Training Guidelines for Older Adults

-Rhythmic movements are best with large muscle groups (walking, jogging, running)

-Those that cannot walk or stand can do weight supported exercise

-Moderate intensity (65-75% max HR, 5-6 RPE, talk in regular sentences)

-vigorous exercise (jogging/running 75%-95% max HR, 7-8 RPE, limits speech)

-30-60 minutes of moderate intensity daily, or 20-30 minutes of vigorous intensity

-150 minutes accumulated

-5x a week for moderate intensity, 3x for vigorous, 4x for a combination

Considerations for Older Adults

-Older adults should check with physician before beginning a conditioning program.

-Emphasize resistance training for musculoskeletal system and aerobic endurance for cardiovascular system.

-If both are performed in the same session, the order is personal preference.

-WU and CD needed and stretching after physical activity.

-Keep records of training and document progress/issues.

-Periodic body composition assessments to determine FFM and body fat changes.

Fall Prevention

-Most prevalent cause of injury in older adults.

-Muscular weakness leads to falls, most chose to reduce activity instead of training causing even more weakness.

-Balance training needed for those who fall often.

-Stable postures to less stable postures

-less to more challenging locomotor movements

-higher to lower sensory input.

-Resistance training recommended for strength.

Obesity Rates in Men and Women from varying age groups in USA

• 20-39: Men 40.3%, Women 39.7%

• 40-59: Men: 46.4% Women: 43.3%

• 60+: Men 42.2%, Women: 43.3%

Risks for Obesity and Overweight in Children

• Risk for heart disease (High cholesterol and bp.) increased in overweight children

• Type 2 diabetes increased dramatically in children

• Overweight adolescents have 70% chance of becoming overweight or obese adults and is increased to 80% if one or more parents is obese/overweight

• Social discrimination is most immediate consequence

Overweight and Obesity BMI Ranges, BMI differences in men and women, death from BMI

Overweight : BMI 25-29.9. Obese: BMI >= 30. BMI overestimates in high FFM individuals and underestimates for low FFM (old) individuals.

Overweight and Obesity are the second biggest cause of preventable death in the US.

Overweight vs Obese

● People who are obese have significantly greater excess weight (particularly adipose tissue mass, than overweight people. Obese individuals have more fat mass than FFM.

● Obese people have larger positive energy balance over a longer time than overweight people. Caused by decreased activity and increased food consumption.

● An obese person has high resting metabolic rate and expends more energy on activities than overweight people. Moving heavy mass requires energy,

Fat Distribution

Gynoid obesity (pear shaped body): Fat deposits in hips and thighs.

Android Obesity (apple shaped body): fat in trunk and abdomen).

Fat in the abdomen outside body fat% is an independent predictor of type 2 diabetes, hypertension, and CVD.

Successful weight management programs

-Consist of a combination of diet modifications, increased activity, and lifestyle modifications.

-Finding ways to be more active at work or at home, find a community of people who enjoy healthy eating more than not and exercise and socializing.

-Reduce unhealthy lifestyle habits (smoking or drinking).

Dietary Modifications for Obese people

-Refer clients to a RD for obesity, diabetes, and hyperlipidemia.

-Diet must follow cultural and ethnic background and food preferences.

-Should take into account cost and availability of foods and decrease food intake that lead to other CVD risk factors.

-Diet should follow the Dietary Guidelines for Americans and meet the Dietary Reference Intakes for all nutrients.

-Motivate client to adhere to diet.

-Create a deficit of 500-1000 cals a day (NHLBI) to facilitate weight loss of 1-2lbs a week taking into account daily exercise expenditure.

-Calories load is determined with caloric calculation formulas and trial and error adjustments.

-Women should eat no less than 1200-1500 calories a day

-men should consume no lower than 1500-1800 calories a day.

-1200-1600 appropriate for women who exercise daily or weigh 165lbs or more

Guidelines for activity for Obese and Overweight people

-Moderate activity (burns about 150 cals a day) for 30 minutes most days of the week are recommended for clients who are overweight or obese and beginning a program

-Guidelines also promote a progression to 50 minutes a day 5 days a week for long-term weight loss and maintenance (some may go to 60-90 minutes).

-Progression is important start small and then grow to moderate intensity activity at high volumes.

Lower Level Clients (Obese and Overweight)

● Walk after lunch

● Walk to coworkers desk or office instead of using the phone

● Use stairs

● Walk to pick up lunch

● Get off bus or subway one stop early and walk the rest of the way

● Park in space at the mall that is farther from entrance

● Walk to the neighborhood minimart to pick up things

● Walk the dog

● Do yard work

● Play actively with children or grandchildren

Exercise considerations for Obese and Overweight people

-Heat Intolerance: Decreased ability to properly thermoregulate the body is a result of insulation from fat. Loose clothes are best and lowering the intensity of the workout to fit comfort and prevent heat emergency. Temperature controlled environments may help too.

-Movement Restriction and Limited Mobility: Fat mass may make it difficult to stretch or do certain exercises. Modifications may be necessary to get benefit.

-Weight-Bearing Stress: Low Impact activities can reduce stress on joints. Sustained single-limb support can impose stress on joints especially the hips. Alternate the leg frequently during balance activities on one leg.

-Posture Problems and Low Back Pain: The hip flexors are strong in obese/overweight people due to moving a lot of mass, stretching them is needed to maintain balance within the abdominal region. Ab training is a must to increase strength to deal with the stress on the back. Strengthening the upper back muscles and stretching the chest muscles are a must too.

-Balance Concerns: Include balance training on progressive basis with observation, correction, and spotting.

-Hyperpnea and Dyspnea: Hyperpnea (increase respiratory rate) and dyspnea (labored or difficult breathing) during exercise can be uncomfortable and lead to anxiety. Obese people experience it more due to low functional capacity. Ensure proper intensity is maintained (use interval training at t

Aerobic Conditioning for Obese/Overweight individuals

-5 days a week to ensure maximum caloric expenditure.

-Ensure they meet daily activity levels required.

-Low fitness level patients (hard to walk around the track without needing to rest) should do circuit training alternating between walking intervals and training intervals.

Flexibility Training for Obese and Overweight

-Prevent injury and maintain ROM around joints.

-Light stretching can be included in warm up and more intense stretching during CD (due to warmness and pliability). Modified for clients if needed.

Aerobic conditioning Guidelines for Obese/Overweight

-Minimum recommendation = 30 min most days of the week (150 min/week) ≥5 days/week to maximize caloric expenditure

-Eventual goal = 300 min/week Moderate intensity (40%-59% VO R or HRR) to vigorous intensity (≥60% VO₂R or HRR)

Resistance training in Obese/Overweight

-2 or 3 days/week on nonconsecutive days

-1 or more sets initially progressing to 2-4 sets of 8-12 reps per set

-Initial loads of 60-70% 1RM

-Training for each major muscle group (chest, shoulders, upper and lower back, abdomen, hips, and legs)

-Gradual load increases

Flexibility Training for Obese/Overweight

2 or 3 days/week Hold static stretches for 10-30 s, 2-4 repetitions of each exercise.

Program for those with Hyperlipidemia

Sufficient activity for cardiovascular health and reduction of cholesterol are:

● Normal time of moderate and vigorous activity volume (150, 75 mins)

● Combination of them

● Two days of moderate to high-intensity muscle strengthening activities for additional benefits. Provide a well rounded resistance, aerobic, and flexibility program.

-Any activity is better than no activity.

Dietary Considerations for Hyperlipidemia

-Problems come from saturated and trans fats not dietary cholesterol.

-Do not replace fats with carbs as that decreases HDL levels and increases TGs replace with healthy fats.

-Fat intake should come from monounsaturated or polyunsaturated fats from non tropical oils, nuts, and fatty fish. (Omega-3 fats are polyunsaturated fats that decrease CVD risk, lower TGs, prevent irregular HR and Heart Attack, lower BP. and come from fish and nuts/seeds).

-Add fish to 2 meals a week and add plant-based omega 3 sourced fats.

Criteria for Metabolic Syndrome (MetS)

Persons having three or more of criteria have MetS:

● Abdominal obesity (waist >40 in in men and >35 in women)

● Hypertriglyceridemia: >=150mg/dL

● Reduced HDL-C: <40mg/dl in men and <50mg/dL in women

● Elevated BP: >= 130/80

● Elevated Fasting Glucose: >= 100mg/dL

Diagnosis and symptoms for Diabetes

Excessively high or uncontrolled blood glucose levels, symptoms include:

● Increased frequency of urination

● Increased thirst

● Increased appetite

● General weakness.

-Diagnosis is based on two separate fasting glucose levels of 126 mg/dL or higher or 2 hour post-prandial (after a meal) plasma glucose measurements higher than 200 mg/dL with a glucose load of 75g or two casual blood glucose readings of the same amount.

-Leads to damage in eyes, kidneys, nerves, heart, and blood vessels leading to blindness, renal failure, and LE amputations.

Considerations for Diabetes

-Must keep complications like hypoglycemia in mind (low blood sugar).

-Medical screening to assess glycemic control and complications should be done before exercise program initiates along with cardiac stress testing for those also at risk of heart disease (35+ years old, type 2 diabetes for more than 10 years or type 1 for more than 15, and those with evidence of microvascular disease).

-Those with organ damage need to be carful and abstain from exacerbating physical activities.

-You should use low impact exercises instead of high-impact along with proper footwear.

-Dizziness, weakness, or shortness of breath are signs of cardiac disease.

Glycemic Control for Diabetes

The biggest risk is hypoglycemia (65mg/dL or lower). Hypoglycemia may be influenced by

● Increased exercise intensity

● Increased duration

● Inadequate caloric intake before exercise

● Excessive insulin dose

● Insulin injection into exercising muscle

● Colder temperatures.

Signs are:

-Sweating

-Hunger

-Palpitations

-Headache

-Tachycardia

-Anxiety

-Tremor

-Dizziness

-Blurred vision

-Confusion

-Convulsion

-Syncope

-Coma

The CPT should never advise a client about insulin use or meal timing only a physician.

-Regular episodes of lack of blood glucose control, the client should be sent back to the doctor for care.

Aerobic Guidelines for Diabetics

-3-7 days a week 20-60 minutes per day at moderate to vigorous intensities primarily based on perceived “moderate” and “very hard” intensity. WU and CD.

-Greater emphasis on vigorous intensity if not contra-indicated and work to voluntary fatigue.

Resistance Training Guidelines for Diabetics

-2-3 days a week with at least 1 set of 8-10 different exercises using the major muscle groups.

-10-15 reps following adequate progression to lower rep ranges and higher weight.

-For those 50+ and have hypertension more reps (12-15+) may be more suitable.

Flexibility and Other training for Diabetics

-2+ days a week for each major muscle/tendon group.

-Minimal effects on diabetes related issues.

-50+ with diabetes should do balance 2-3 times a week since balance and flexibility are reduced with age (especially with neuropathy).

Contraindications to exercise for Diabetics

-Blood glucose >250 mg/dl and ketones in urine for type 1 diabetes

-Blood glucose >300 mg/dl without ketones for type 1 diabetes

-Client is not feeling well or is dehydrated Proliferative retinopathy-clients with this condition should avoid strenuous high-intensity activities

-Severe kidney disease

-Loss of protective sensation in the feet (peripheral neuropathy)—clients with this condition should avoid outdoor walking and jogging (swimming or biking is recommended)

-Acute illness, infection, or fever

-Evidence of underlying CVD that has not been medically evaluated

Select Warning Signs that require a referral to a Physician for Anorexia Nervosa

-Dramatic loss of weight Denial;

-feelings of being fat even when thin;

-obsession with weight, diet, and appearance

-Use of food rituals or avoidance of social situations involving food

-Obsession with exercise;

-hyperactivity

-Sensitivity to cold

-Use of layers of baggy clothing to disguise weight loss

-Fatigue (in later stages)

-Decline in work, school, or athletic performance

-Growth of baby-fine hair over face and body (lanugo)

-Yellow tint to skin, palms, and soles of feet (from high levels of carotene)

-Hair loss, dry hair, dry skin, brittle nails

-Loss of muscle mass and tone

-Slow pulse at rest;

-light-headedness on standing up quickly

-Frequent constipation, abdominal pain, cold intolerance, lethargy or excess energy

Select Warning Signs for Bulimia Nervosa that require a referral to physician

-Difficulties with activities that involve food

-Deceptive behaviors related to fooр

-Self-induced vomiting Laxative, diuretics, or enema use

-Excessive exercise

-Overconcern with body shape

-Weight fluctuations of more than 10 pounds (4.5 kg)

-Traces of odor of vomit on the breath

-Scabs or scars on knuckles

-Swollen, persistently puffy face and cheeks

-Broken blood vessels in the face and eyes

-Sore throat and dental problems

-Abdominal symptoms Rapid weight changes of 2 to 5 pounds (0.9- 2.3 kg) overnight

-Erratic performance in work, sport, and academics

-Lacerations of the oral cavity

-Diarrhea

-Constipation

-Fatigue

-Anxiety or depression

Select Warning Signs for BED that require referral to physician

-Evidence of binge eating

-Does not appear comfortable eating around others

-Shows extreme concern with body weight and shape

-Eating more rapidly than normal

-Periods of uncontrolled, impulsive, or continuous eating

-Eating in secret

-Avoiding social situations, particularly those involving food

-Eating normal quantities in social settings and bingeing when alone

-Low self-esteem and embarrassment over physical appearance

-Feeling extremely distressed, upset, and anxious during and after a binge episode

-Fluctuations in weight

-Low self-esteem

Program Design for those with Eating Disorders

-Require the client recovering from an eating disorder to see a physician for a complete medical exam before returning to or continuing an exercise program.

-Do not prescribe a vigorous exercise program.

-Help the client engage in a well-rounded program of aerobic conditioning, resistance training, and flexibility exercise.

-Ensure adequate hydration and rehydration.

-Encourage the client to ingest an adequate dietary intake.

-Encourage the client to consume 200 to 400 kcal of complex carbohydrates during the first 30 to 90 minutes after an exercise session.

-Schedule exercise sessions so that the client does not exercise every day and takes two or three days off a week.

-Check the client's blood pressure and pulse.

-Do not allow high-impact exercises (like jumps) if the client has a stress fracture.

-Maintain regular communication with the client's physician, RD, and other health care professionals.

-If a client experiences any of the following signs or symptoms, he or she should seek medical clearance before continuing the exercise program: light-headedness, irregular heartbeat, nausea, injuries, abnormal blood pressure levels or pulse.

5 clinical examples of OSFEDS

These are 5 clinical examples of OSFED from DSM:

● Atypical AN (aligns with AN but weight is still within or above normal range)

● BN of low frequency or duration

● BED of low frequency or duration

● Purging disorder

● Night eating syndrome

Hypertension Causes

Occurs without a known cause (idiopathic disease) (95% idiopathic, 5% known causes). The small 5% of cases may be curable with lifestyle changes and medication. Signs are often not shown until a cardiac event (“silent killers”).

Treatment for Hypertension

-Nonpharmacologic interventions (proper exercise, weight loss, and diet changes)

-general lifestyle changes (adequate sleep, reduce sodium intake, adequate potassium intake, limiting alcohol intake

-aerobic activity 90-150 minutes a week

-eating fruits and veggies and foods low in fat, stop smoking).

-Dietary Approaches to Stop Hypertension (DASH) entails reducing sat fat, cholesterol, and total fat intake.

-Emphasizes fruits, veggies, low-fat dairy, whole-grain, fish, poultry, and nuts.

-Reductions in red meat, sweets, and sugar beverages.

- Increase foods in magnesium, potassium, calcium, protein, and fiber.

-Medications include Beta-blockers, calcium channel blockers, ACE inhibitors, ARBS diuretics, and alpha blockers.

-Diuretics cause blood volume depletion.

-Calcium channel blockers, alpha/beta blockers cause vasodilation which can cause blood pooling

-ACE/ARBs affect the kidney’s vasculature and can cause blood pooling.

-They require longer cool down especially after walking, jogging, running, and resistance training.

-Beta blockers decrease HR, use RPE scale for these clients.

Safety considerations for Hypertension

-220 mmHg or 105 mmHG (SYS or DS) calls for stopping exercise.

-Gradual progression especially in intensity, extended cold down recommended.

-Moderate intensity will optimize the risk-to-benefit ratio

-take BP before, during peak, and after exercise ensures client safety and helps with adjustments.

Contraindications for Hypertension

Any activity that increases intrathoracic pressure and decreases return of blood to heart and cardiac output. NO VALSALVA MANEUVER

Aerobic guidelines for Hypertension

Aerobics performed 5-7 times a week with minimum of 30 minutes at moderate intensity(40-59% VO2max/HRR or and RPE of 12-13)

Resistance Training guidelines for Hypertension

-Rest interval for resistance training should be 2-3 minutes for physiological compensation from exercise which is necessary for medical hypertension control.

2-3 days a week

- 2-4 sets of 8-12 reps per major muscle group for >=20 minute session.

-Moderate Intensity (60-70% 1RM), older and novice should start at 40-50%.

Goals for clients with Hypertension

-Increase VO₂max and ventilatory threshold.

-Increase maximal work and aerobic endurance.

-Increase caloric expenditure.

-Control blood pressure.

-Increase muscular strength and endurance.

Risks for Myocardial infarction (MI) (heart attack), Stroke, and Peripheral Artery Disease (PAD)

-Diabetes

-high blood cholesterol

-hypertension

-obesity

-smoking

-family history

-and lifestyle choices

Guidelines for Patients with MI

-Need clearance from surgeon or cardiologist or both.

-Medical professionals establish a training range and intensity level and should provide a MET level or CO2peak/max for the CPT as a baseline.

-The program should be sent to the doctor for approval.

-Monitor abnormal signs and symptoms (chest pain, palpitations, shortness of breath, diaphoresis, nausea, neck pain, arm pain, back pain, sense of doom).

-May have other diseases (comorbid).

Exercise components for Post-MI patients

-Perform extended WU and CD, include both upper and lower body aerobics, avoid breath holding in all exercise.

-Monitor chest pain dizziness, shortness of breath, and BP before during and after each session.

-3-5 days 20-60 minutes at 40-80% VO2 or HRR or RPE of 12-16 aerobics.

-Resistance Training 2-3 days a week 10-15 reps of 8-10 exercises total working all major muscle groups at moderate intensity (60-80% 1RM or RPE of 11-13)

Goals for client with MI

-Increase aerobic capacity.

-Decrease blood pressure.

-Reduce risk of coronary artery disease.

-Increase ability to perform leisure, occupational, and daily living activities.

-Increase muscular strength and endurance.

Exercise considerations for CVA

-Challenges depend on the part of the brain affected.

-Loss of motor function in face, arm, leg, or mouth (daily task difficulty).

-Hearing, speaking, or understanding spatial arrangements or ignore one side of the body.

-CVA affected side of the brain affects the opposite side of the body.

-Program must begin where CVA rehab left off.

-CPT needs to have close contact with rehab team to establish goals and direction

Exercise components for CVA

Clearance, recommendations, limitations, and current exercise information from primary medical and rehab providers. Rehab program is followed for 3-6 months after stroke.

-Program with CPT focuses on maintaining active lifestyle, stroke and cardiovascular event prevention, and improving physical function.

-Recommended that they do a stress test with physicians.

-Balance and stability issues or medication side effects mean machine-based and supported exercise may be warranted initially and CPT must be close by for all exercise.

-Lower intensities needed for exercise (due to decrease in peak capacity and increased energy costs). -Avoid excessive BP and Valsalva.

-Resistance training in healthy limbs help the compromised limb.

-Neuromuscular exercises to develop new pathways to affected limbs via recruitment of dormant channels.

-Balance and coordination activities 2-3 days a week (hand-eye especially).

-Mood changes, decreased motivation, and anxiety are common in CVA patients.

Aerobic and Resistance exercise guidelines for CVA

-Aerobics 3-5 days a week 20-60 minute sessions at 40-70% VO2 or HRR or RPE 11-14.

-Resistance exercise 2 nonconsecutive days 1-3 set 8-15 reps at 50-70% 1RM for 8-10 exercises for all muscle groups at RPE of 11-14.

Flexibility training for CVA

-Flexibility is important as CVA patient experiences joint contractures due to lack of motion in joint leading to calcified joint due to bone remodeling.

- ROM exercises should be performed before/after each session (for as little as 5 minutes) and on non training days.

-Static and PNF stretching 2-3 days a week 2-4 reps with a 10-30s hold.

Stages of PAD

Stages of PAD

● No symptoms to Debilitating leg muscle pain

● LE ulcerations or infections

● Limited ability to walk longer distances

● Decreased quality of life.

PAD exercise considerations

-PAD may cause cardiac event so client should be cleared from a cardiac view point with a stress test.

-Aggressive lifestyle changes and hyperlipidemia management must occur.

-As the oxygen demand in muscles increases the pain in the patient increases, work within accordance with the physician.

-PAD is cardiovascular so they require same programming and monitoring considerations as CVD and hypertension.

-Limited walking ability due to severe ache and pain they will need to stop sit down and rest.

-PAD clients can make substantial gains in LE exercise, walking, and stair negotiation.

SET training

-Treadmill-based supervised exercise training (SET) 3 times a week for 12-26 weeks is effective and safe therapy for improving walking capacity for all PAD clients.

-Improved blood flow regulation, muscle metabolic function, and walking biomechanics.

-Goal is to walk as longer with shorter rest until it is continuous.

-SET performed in hospital or rehab with cardiovascular monitoring.

-SET includes walking to a 3-4 pain based on scale (mild to moderate). With a short rest period until symptoms completely resolve (2-5 minutes) repeated and progressed so that sessions last from 10-30 minutes up to 60 minutes.

Resistance training and home based walking for PAD

-Home Based walking, resistance training, and flexibility using frequency, intensity, timing, and type principles are helpful for PAD clients.

-6-8 resistance exercises for all major muscle groups but focus on large LE musculature (if time is limited) 2 times a week 60-80% 1RM 2-3 sets 8-12 reps

COPD treatment

-Exercise is the best way to improve muscle function and exercise tolerance.

-COPD clients are often in pulmonary rehab programs with aerobic exercise and inspiratory muscle training.

-Resistance training is also important for muscle strength and lung function.

-Combined home-based programs help skeletal and respiratory muscles.

EIB phases

-EIB can occur 2-5 minutes after starting, peaks after 10 minutes, and resolves and hour after exercise stops.

-1-6 hours after exercise bronchoconstriction 1-6 hours (late phase) can occur due to airway edema and depends on severity and environmental conditions.

Asthma Action Plans (AAP)

-They should stick to an asthma action plan (AAP).

-AAP is a written worksheet that identifies the processes and actions that will prevent worsening of symptoms and guidance for when to contact health care providers or emergency service.

-CPT should encourage health care provider to make AAP if the client does not have one. A

-AP includes emergency contact information, contact information of health care provider, asthma classification, current medications and their uses, triggers for asthma.

Exercise considerations for Asthma and EIB

-Lower tolerance for exercise due to decreased lung function, EIB, muscular deconditioning, and decreased aerobic fitness.

- EIB sensitive to humidity and temperature, exercise should be avoid in the extremes of both.

Exercise guidelines for EIB and Asthma

-Slowly build large muscle aerobic activity to reduce risk and severity of EIB.

-Short periods of activity with longer rest periods.

-Use dyspnea scale early on and throughout programming

-The client should stay within a 3-4 on the scale to control intensity of exercise.

-Consistently perform 10-15 minute variable intensity aerobic warm-up to reduce risk of EIB during higher intensity exercise.

-CD period should allow airway temp to return to normal gradually and monitor responses related to bronchoconstriction is standard.

-Most individuals can improve muscular fitness with low risk of EIB with low resistance high rep resistance exercise 2-3 days a week.

-Increasing strength, muscular endurance, and neuromuscular coordination are similar to healthy clients.

-Untrained individuals should do low resistance (11-13 RPE) high reps (2-4 sets 10-15 reps) major muscle group exercise with extended rest intervals (3-4 minutes) for lower risk of EIB.

-No firm traditions, general FITT recommendations can be modified to each individual's capacity and capabilities.

Goals for all the phases of healing

Inflammatory: Control pain PRICE (passive modalities, rest, ice, compress, elevate)
Repair/Proliferation Phase: ROM, Balance, Strengthening, Flexibility
Remodeling: Maintain ROM and Flexibility. Balance, Strengthening, Functional Strengthening, Return to activity.

Disc Injury Contraindications

Lumbar Flexion and Rotation. Sit-up, KTC stretch, Spinal Twists, any exercise that increases of produces LE symptoms (pain, tingling, burning)

Disc Injury Indications

-Passive lumbar extension stretches

-Isometric abdominal and extensor strengthening, progressing to lumbar stabilization program while maintaining natural lordosis

Muscle Strain Contraindications

Passive Lumbar Flexion, Active Lumbar Extension (inflammatory phase only). KTC stretch.

Muscle Strain Indications

None during inflammatory phase, progressing to gentle flexion stretching, followed by extension strengthening

Spondylolysis and acute or subacute spondylolisthesis contraindications

Lumbar Extension, squat, shoulder press, push press

Spondylolysis and acute or subacute spondylolisthesis indications

-Knee-to-chest stretch

-Abdominal crunch

-Pelvic neutral stabilizations

-Isometric gluteal strengthening

Subacromial impingement syndrome contraindications

-Overhead or Painful motions.

-Shoulder press

-Lateral dumbbell raise with internally rotated shoulder

-Upright row above shoulder level

-Incline bench press

Subacromial impingement syndrome indications

-Rotator cuff strengthening exercises

-Pain-free exercises

-Posterior shoulder stretches

Shoulder Instability contraindications

-Anterior: combined external rotation with >90-degree abduction;

-horizontal abduction posterior to plane of torso

-Posterior: combined internal rotation, horizontal adduction, and flexion

-Inferior or multidirectional: full elevation, dependent arm
-Bench press

-Pec deck

-Push-up

-Behind-the-neck lat pulldown and shoulder press

-Pectoral stretches using externally rotated shoulder positions

Shoulder instability Indications

-Rotator cuff strengthening exercises

-Scapular strengthening

-Stabilization: static to dynamic

Rotator cuff pathology contraindications

-Resisted overhead movements

-Painful exercises

-Similar contraindications to subacromial impingement syndrome

Rotator Cuff pathology indications

-Rotator cuff strengthening exercises

-Eccentric loading exercises

Shoulder Modifications to Exercises

Shoulder press: Clients should lower the barbell in front of the head in order to minimize anterior shoulder stress.

Bench press: When lowering the bar, clients with shoulder dysfunction should not allow the bar to touch the chest at its lowest point in order to minimize anterior shoulder stress. A towel roll or bar pad may be used to limit depth. Clients should keep the upper arms near the body to limit horizontal abduction and decrease shoulder stress.

Pec deck or chest fly exercises: During the eccentric phase, clients with shoulder dysfunction should not allow the pads to pass behind the body at their most posterior position in order to minimize anterior shoulder stress.

Lat Pulldown: Clients should pull the bar down in front of the head in order to minimize anterior shoulder stress.

Conditions requiring shoulder Modifications

-Subacromial impingement syndrome

-Rotator cuff repair

-Rotator cuff tendinitis

-Glenohumeral joint instability (prior dislocation or subluxation)

-Acromioclavicular joint injury (separation)

-Glenohumeral joint osteoarthritis

Inversion ankle sprain contraindications

-Inversion with weight bearing

-Activities requiring loaded or full weight bearing based on pain and mobility tolerance

Inversion Ankle Sprain Indications

-Open chain ROM exercises and strength activities until weight bearing is permitted

-Functional progression and neuromuscular activities (balance and proprioceрtion) per tolerance

Anterior knee pain Contraindications

-Closed chain knee movements with >90 degrees of knee flexion

-Open chain knee movements 0 to 30 degrees of knee flexion

-Full squat; full lunge

-End range of leg (knee) extension

-Stair stepper with large steps

Anterior knee pain indications

-1/4 to 1/2 squat and leg press

-Partial lunge and leg (knee) curl

-Stair stepper with short, choppy steps

-Hip abductor, gluteus maximus, and gluteus medius strengthening

-Spinning or cycling

-Single-leg balance

Anterior cruciate ligament reconstruction contraindications

-Open chain knee movements <45 degrees of knee flexion

-End range of leg (knee) extension

Anterior cruciate ligament reconstruction indications

-3/4 squat and leg press

-Step-up Leg (knee) curl

-Stiff-leg deadlift

-Elliptical trainer

Total knee arthroplasty contraindications

-High-impact activity

-Full squat

-Full lunge