Exercise Prescription For Special Populations Exercise Prescription For Special Populations

I. General Principles

Exercise prescription should always include :

a) the mode of exercise
b) the intensity of exercise
c) the duration of exercise
d) the frequency of exercise
e) the rate of progression of the patient's physical activity

These parameters should be taken into account whether you are prescribing exercise for the healthy individual or the patient with disease. In all cases, the exercise prescription should be developed with careful consideration for the individual's health history, risk factor profile, the patient's strength and flexibility, any orthopedic conditions that may exist, behavioral characteristics, personal goals and availability of exercise facilities.

II. Special Populations

A. Patients With Diabetes

Patients with diabetes fall into two general classifications of disease - Type I diabetes mellitus also known as insulin-dependent diabetes mellitus. This form of diabetes is usually associated with children because it is often diagnosed during the formative years. It is characterized by a the following symptoms :

These patients usually have very high blood glucose levels when they are initially seen by a physician. They urgently need to be medically managed. Consequently, these young patients are immediately hospitalized and the medical staff tries to quickly bring the blood glucose back down to normal levels between 80 - 120 mg/dl. After they have been regulated, they are commited to a lifetime of insulin injections that will keep their blood sugar between 80 - 200 mg/dl. The cause of Type I insulin-dependent diabetes mellitus is thought to be an autoimmune destruction of the beta cells in the pancreas which normally produce insulin. Since these young patients can no longer produce insulin, they must be supplemented to insure proper availability of glucose to body tissues, especially to the brain and spinal cord.

Type II diabetes mellitus usually occurs in the 4th decade of life. These patients are frequently obese and lead sedentary lifestyles. In the case of Type II diabetics, they cannot use the insulin they are producing - a condition called peripheral resistance. For reasons that are not entirely clear, the insulin will bind to its receptor but the usual celular response - the uptake of insulin from the blood into the cell - does not readily occur. Therefore, blood glucose rises and the patient becomes hyperglycemic. Oddly enough, Type II diabetics often produce supernormal concentrations of insulin. They are seldom low insulin producers.

The exercise prescription for these two types of diabetic populations is somewhat different. In the case of Type I diabetics, the emphasis is on glucose regulation. Hence, these patients are encouraged to exercise 7 days a week. On the other hand, in the case of Type II diabetics, the emphasis is on weight reduction and increased physical activity. For these reasons they are encouraged to exercise 3-5 times a week since they do produce insulin and absolute glucose regulation is not the primal reason for the exercise prescription.

Below is a suggested initial exercise prescription for both Type I and Type II diabetic patients.

ParametersType I DiabeticsType II diabetics
Frequency7 days/week5 days/week
Duration20-30 minutes30-60 minutes
Intensity45% - 85% MHR45% - 70% MHR
Borg Scale10-14 RPE10-14 RPE

Whenever you work with patients with diabetes, the following considerations should be mentioned along with the exercise prescription :

B. Patients With Hypertension

Hypertension is divided up into several classes as seen in the table below :

Blood Pressure ClassificationSystolic Pressure in mm HgDiastolic Pressure in mm Hg
Normal Blood Pressure
Below 130
Below 85
High Normal Blood Pressure
Mild Hypertension
Moderate Hypertension
Severe Hypertension
Very Severe Hypertension

Any person with hypertension should be evaluated for other coronary risk factors. As always, any male who is 40 years of age or older or any woman who is 50 years or older should have a graded exercise test at the hands of a competant physician. The graded exercise test (GXT) clears the patient for exercise if there was no symptoms of cardiac stress during the GXT. However, if there were signs of cardiac stress, the GXT sets the limits of the exercise prescription by letting the medical staff know at what point during the GXT the symptoms occured. At the point where symptoms appeared, the physician should have noted the blood pressure, heart rate and the maximum METs attained during a specific stage in the GXT protocol. This is known as a symptom limited GXT (SLGXT). It defines for you, the exercise prescriptionist, just how hard to push the patient in the rehabilitation program. The following recomendations appear in the table below for a beginning exercise program for a person with hypertension:

Exercise Parameters
Exercise Prescription
Aerobic Exercise
3-4 times/week
15-30 minutes
40%-70% of SLGXT Values
Max. Exercise BP
40%-70% of SLGXT Systolic Pressure
Borg Scale
10 -14 RPE

As with any exercise program, it is important to have a 5-10 minute warm up period during which the patient performs exercise at an intensity lower than that which is performed during the steady state exercise period of the prescription. Likewise, it is important that there be a 5-10 minute cool down period after the exercise period is finished. Most coronary incidents occur in the recovery period after exercise. The cool down period allows the body to recover from the exercise in a sensible manner.

Resistance weight training is not recommended until several weeks of the aerobic exercise program has been completed. It is important for the exercise specialist to feel comfortable with the patient's response to the exercise regimen before adding on anaerobic exercise which, in the case of weight lifting, can cause the blood pressure to rise dramatically. You should always stress with your patients that all exercise must be done without ever doing a Valsalva manuever.

You should be very familiar with the medications your patient is taking. In the case of anti-hypertension medications, it is critical that the patient take them regularly. It is your responsibility to remind the patient and insist that they take their medication for hypertension.

C. Exercise During Pregnancy

It is very important for any person to stay in close contact with their physicians, especially if they have any of the coronary risk factors such as : diabetes, physical inactivity, smoking, hyperlipidemia, hypertension, obesity, or a strong family history for CAD.

Pregnancy is not a sickness or a disease condition. However, there are several signs and symptoms that should either preclude the beginning of an exercise program or terminate exercise if a program has already started. The absolute contraindications for exercise during pregnancy are listed below:

There are relative contraindications to continued exercise or the beginning of an exercise program. these are listed below :

The following exercise recommendations should be personalized to each pregnant female for whom you write an exercise prescription:

Exercise Parameters
Exercise Recommendation
No Impact to Soft Impact - Aerobic
3 days/week
15-20 minutes
50%-70% of Age Adjusted HR
Borg Scale
10 - 14 RPE

The following are key recommendations for persons who wish to exercise during preganancy :

D. Exercising With HIV

This disease is characterized by a gradual loss of the body's immune defense particularly of the cell mediated defense or the T-cell system. The AIDS virus targets the CD4+ cells (T4+ Helper Cell) disabling these cells from mediating either cell mediated defense (T cell system) or humoral defense (B cell system). When the CD4+ cell population falls below 200/ml, then the diagnosis has traditionally shifted from being HIV infected to a diagnosis of AIDS. At this point the body is attacked by opportunistic diseases which would otherwise have been effectively fought by the immune defense system.

Prior to the diagnosis of AIDS, a person is simply seropositive for the HIV virus. Before the AIDS diagnosis is rendered, the following exercise recommendations can be applied on a case by case basis :

Exercise Parameters
Exercise Recommendations
Aerobic Exercise & Strength Training
3 times/week
15-20 minutes
60%-80% 0f Age Adjusted MHR
Borg Scale
10 - 14 RPE

It is important to remember that HIV positive individuals should be constantly aware of their CD4+ count. They should not be overtly fatigued by the exercise program. It is well known that heavy exercise is immunosuppressive. Moderate exercise stimulates the immune defense system and enables the CD4+ cell, the NK killer cells and the CD8+ killer cells to perform their function in an enhanced fashion. Therefore it is critical that the HIV + patient understand with crystal clarity that all execise should be moderate exercise and performed in light of their CD4+ count. Exercise can be progressed if sensibly done.

E. Intermittent Claudication

Intermittent claudication is a peripheral vascular disease characterized by leg pain with and without exercise. It is associated with the following : smoking, diabetes mellitus, hyperlipidemia, hypertension, high fat diets, and a strong family history for this malady. Leg pain is excruciating at times and is heightened with activity. However, exercise is a prescriptive treatment and the following recommendations are suggested :

Weight Bearing Exercises
QID --> BID --> QD
Work Towards 30-60 Minutes/QD Session
Grade II --> III Ischemic Pain

If the patient's pain is severe with small doses of exercise, it will be necessary to have several short bouts of exercise with rest in between exercise. Weight bearing exercise is preferred but in severe cases, it may be necessary to start out with non-weight bearing exercise like stationary bicycling or water activities. It will be necessary to eventually move to weight bearing exercises such as rebounding or treadmill walking. It will be necessary to prepare the patient with some education as to the benefits of exercise which are as follows : decrease in the symptoms of pain with exertion, improved circulation, increased peripheral sensitivity to insulin, collateralization of the blood flow, increased work capacity, improved quality of life, and finally the possible reversal of the atherosclerotic processes. These will have to be convinced that exercise is beneficial. Determined love and concern for their welfare will build the patient's confidence in the treatment and in you.

The following ischemia scale will help you quantify the patient's ischemic discomfort during exercise and will be an important documentation tool that will show that over time, the patient's pain is decreasing with training.

Ischemic Grades
Pain Discriptors
Grade I Pain
Discomfort but can continue exercise
Grade II Pain
Moderate Discomfort : Patient's Attention Can Be Diverted W/ Conversation
Grade III Pain
Intense Pain : Patient's Attention Cannot Be Diverted
Grade IV Pain
Excruciating Unbearable Pain : Must Stop Exercise

F. Patients With End-Stage Renal Failure Requiring Dialysis

Renal failure usually occurs in the 4th through the 7th decade in patients who have diabetes or patients who have been exposed to toxic chemicals or who have some form of kidney disease.

These patients are very debilitated because they have been sedentary and incapable of significant exercise for many months to years. These patients characteristically have wasted musculature which eventually incapacitates them. Activities of daily living are very difficult. Typically these patients have extensive muscle wasting, hypertension, hyperlipidemia, muscle cramping, bone disease, fatigue and psychosocial disorders.

Exercise is therapeutic for these patients because it tends to blunt or even reverse some of the insidous changes that occur in end-stage renal failure. Exercise prescription recommendations are as follows :

Exercise Parameters
Exercise Recommendations
Bicycling During Dialysis
3 times/week
Progress To 30-45 minutes
Tolerance Of The Patient

All exercise prescription has to take into account the unique pathology of the patient. Modifying the prescription to the patient's needs is the "art" of the science we apply.

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