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AMERICAN COLLEGE OF SPORTS
MEDICINE
HEALTH/FITNESS INSTRUCTOR
WORKSHOP
EXERCISE PROGRAMMING
INCLUDING EXERCISE
CONSIDERATIONS FOR SPECIAL
POPULATIONS
PRESENTER:
Edward C. Chaloupka , Ph.D., P.T.,
FACSM
Professor
Department of Health and Exercise
Science
Rowan University
Basic Exercise Programming
Considerations
Principles of Training
• Overload Principle
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•
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•
Frequency
Intensity
Duration
Mode
• Specificity Principle
• Reversibility Principle
American College of Sports
Medicine (ACSM) Guidelines
• For Developing Cardiovascular Endurance
• Frequency – 3x/wk
• Intensity – 50-85% maximum heart rate
reserve or 50-85% maximum
oxygen uptake reserve
• Duration – 20-60 minutes
• Mode – rhythmical and continuous
ACSM Guidelines Continued
• For Developing Muscular Strength
• 8-10 separate exercises using major
muscle groups
• 8-12 repetitions of each exercise to
volitional fatigue
• 2-3 days/wk
• For Developing Muscular Endurance
• 15- 20 repetitions to volitional fatigue
ACSM Guidelines Continued
• For Developing Muscular Flexibility
• 5-15 minutes of moderate aerobic activity
prior to stretching
• 2-3 days/wk after each aerobic workout
• Hold each position for 10-30 sec
• Repeat each stretch 4 times
Components of Exercise Prescription
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Frequency
Duration
Intensity
Mode
Progression
Monitoring Exercise Intensity
• Training Heart Rate Range
• % maximum heart rate (HR)
• % heart rate reserve (HRR) (Karvonen Formula)
• Training HR = (max HR - rest HR) X intensity
percentage + RHR
• Example -- 20 y.o., rest HR = 70 bpm
• Training HR = (200 - 70) X 70% + 70 = 161 bpm
• 75% HHR = 85% max HR
Warm-Up
• Group of exercises performed immediately
before an activity
• Provides adjustment from rest to exercise
• 5-20 minutes depending on sport and
environmental conditions
• Active warm-up prior to vigorous stretching
Cool-Down
• Purpose is to slowly decrease heart rate and lower
body temperature
• Active recovery promotes faster decrease in
muscle and blood levels of lactic acid
• Active recovery keeps the leg muscle “pump”
going and prevents pooling of blood in the legs
• Active recovery lessens chance of catecholamine
produced cardiac irregularities in high risk persons
Environmental Considerations
• High air temperature and relative humidity
increase risk for hyperthermia
• Normal core temperature = 37 deg. C
• Possible death at 45 deg. C
• Factors affecting susceptibility to heat injury:
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•
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Fitness level
Hydration
Clothing
Metabolic Rate
Wind
Environmental Considerations
Continued
• Cold air temperature increases risk for
hypothermia
• Factors related to hypothermia
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Insulation—clothing and subcutaneous fat
Air temperature
Wind—accelerates heat loss (Windchill)
Water vapor pressure—low in cold air which
increases evaporation and heat loss
Environmental Considerations
Continued
• Air pollution caused by ozone, sulfur dioxide and
carbon monoxide
• Ozone—generated by combining UV light and
internal combustion engine emissions. Decreases
pulmonary function
• Sulfur Dioxide—fossil fuels (refineries). Causes
bronchoconstriction in asthmatics
• Carbon Monoxide—fossil fuels, coal, oil, gasoline,
wood and cigarette smoking. Decreases oxygen carry
capacity of blood
Medical Considerations For Exercise
• Physician Clearance
• Medical History
• Medication Profile
Programming Considerations for
Special Populations
Coronary Disease
Coronary Artery Disease
(CAD)
• Narrowing of coronary arteries usually
caused by arteriosclerosis (pathological
condition resulting in thickening, hardening
and loss of elasticity of arterial walls)
Risk Factors
• hypertension BP >140/90 mmHg
• elevated blood lipids
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total cholesterol > 200 mg/dl
LDL > 160 mg/dl (less than 2 risk factors)
> 130 mg/dl (2 or more risk factors)
> 100 mg/dl with CHD
HDL < 35 mg/dl
triglycerides > 400 mg/dl
Risk Factors Continued
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obesity
cigarette smoking
diabetes mellitus
psychological stressors
family hx early onset atherosclerosis
Risk Factors Continued
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alcohol consumption
physical inactivity
age
gender—males 35-44 y.o. mortality rate 6x
greater than females
• elevated levels of homocysteine
Coronary Heart Disease (CHD)
• Myocardial damage due to insufficient
blood flow. The disease is caused by
pathological changes in the coronary
arteries sufficient to interfere with adequate
blood flow.
CHD Continued
• exercise-induced complications—most
occur in individuals with underlying heart
disease or congenital abnormalities. A
cardiac event during exercise is not
common in individuals without heart
disease. Exercise induced cardiac problems
in those older than 35 tend to be due to
CHD while those in individuals younger
than 35 tend to be due to cardiovascular
structural abnormalities.
CHD Continued
• familial trait—there is a genetic
predisposition to the development of CHD.
The risk of a myocardial infarction (MI) is
high when a MI or sudden death in a male
first-degree relative occurs before age 55
and a female first-degree relative before age
65.
CHD Continued
• Nicotine in tobacco smoke causes an
increase in heart rate and blood pressure
that increases the work of the heart (an
increase in the rate-pressure product or
double product). Nicotine may also
increase platelet adhesiveness increasing
blood viscosity. Carbon monoxide in
tobacco smoke decreases the oxygen
carrying capacity of red blood cells to the
heart muscle.
CHD Continued
• psychological stress—individuals with
severe anxiety or frequent outbursts of
anger exhibit higher levels of cardiac
reactivity (characterized by increased heart
rate, systolic blood pressure and peripheral
resistance) as well as increased coronary
artery spasms and sudden death
Coronary Disease Continued
• Exercise Guidelines--guidelines are
generalized due to multiple coronary
diseases (e.g. CAD, CHD, myocardial
infarction, coronary artery bypass graft,
valvular disease, congestive heart failure,
cardiac transplant, aneurysm, angina,
cardiac arrhythmias )
Coronary Disease Continued
• Exercise Guidelines (continued)
• General Considerations-•
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general low fitness levels
monitor for abnormal exercise response
awareness of other medical conditions
In-patient (Phase I) cardiac rehabilitation
Out-patient (Phases II-IV) cardiac rehabilitation
Coronary Disease Continued
• Aerobic/Endurance
• 40-70% of vo2 peak
• 3-7 d/wk
• 20-40 min
• Strength
• higher repetitions, lower resistance
• 2-3 d/wk
• Flexibility
• 2-3 d/wk
Pulmonary Dysfunction
Asthma/Exercise Induced
• causative factors—asthma is characterized
by increased airway reactivity to various
stimuli including exercise. During an attack
biochemical mediators are released due to
mast cell degranulation causing airway
smooth muscle constriction
(bronchospasm).
Asthma Continued
• Physical stimuli such as cooling and
evaporation across airway epithelium
during exercise or cold air exposure may
directly stimulate the release of biochemical
mediators. Individuals with exercise
induced asthma may demonstrate normal
airway function at rest but may develop
bronchospasm during or after exercise.
Asthma Continued
• preventative measures—
• identification and elimination of precipitating agents
(pollens, dust mites, animal dander, drugs, foods,
wine, exposure to fumes and chemicals)
• education to improve compliance with medication
Asthma Continued
• Preventative measures (continued)
• pharmacological agents—inhaled corticosteriod
bronchodilators as preventative medicine (can be
used on an ongoing basis) and inhaled cromolyn
sodium (used up to 15 minutes before beginning
exercise) to stabilize mast cells before exercise
• optimizing inhaled or oral bronchodilator therapy
Chronic Obstructive
Pulmonary Disease (COPD)
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chronic asthma
chronic bronchitis
pulmonary emphysema
chronic bronchiolitis
Pulmonary Dysfunction
Exercise Guidelines
• Exercise induced asthma (EIA)
• individuals are often asymptomatic (or
minimally symptomatic) between
exacerbations. This population of
individuals should be able to engage in
vigorous exercise training.
Modifications to Exercise Program
for EIA
• warm-up and cool-down periods
• type of exercise--outdoor running exacerbates EIA,
swimming reduces incidence
• length of exercise--long, intense continues exercise
causes more EIA than short bursts
• intensity of exercise-high intensity (above 80-90% of
maximal heart rate) causes more EIA
• nasal rather than mouth breathing
• wear a mask or scarf in cold weather
• monitor exercise environment for potential allergens
and irritants
Exercise Guidelines COPD
• COPD—these individuals are often elderly
and have high co-existing impairment of
other organ systems. If oxygen saturation
drops below + 90% (pulse oximetry) or
arterial blood oxygen drops below 55 torr
(arterial blood gas) supplemental oxygen
should be used via nasal cannula.
Exercise Guidelines
COPD Continued
• Aerobic/Endurance—
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Monitor dyspnea
1-2 sessions 3-7d/wk
30 min (shorter intermittent sessions initially)
target intensity—heart rate (HR) attained at a work
rate equal to 85% of the peak work rate during an
initial incremental test (other methods for target HR
during exercise may not be appropriate due to
ventilatory limitation, increased resting HR and
considerable day-to-day variations in resting HR)
Exercise Guidelines
COPD Continued
• Strength
– low resistance, high repetitions
– 2-3d/wk
• Flexibility
– 3 sessions/wk
• Neuromuscular (walking, balance and
breathing exercises)
– daily
Metabolic Disorders
Diabetes Mellitus (DM)
• Type 1 (Insulin Dependent, IDDM)
• absolute deficiency of insulin due to a
marked reduction in pancreatic insulinsecreting beta cells. Insulin must be
supplied by insulin injection or insulin
pump. Cause is thought to involve an
autoimmune response leading to the
destruction of beta cells.
Type 1 DM Continued
• Are prone to develop ketoacidosis with
marked hyperglycemia. Can occur at any
age but usually before the age of 30.
Represents 10% to 15% of individuals with
DM.
DM Continued
• Type 2 (Non-Insulin Dependent, NIIDM)
• relative insulin deficiency. May have
elevated, reduced or normal insulin levels
but have hyperglycemic. Usually a
combination of peripheral insulin resistance
and defective insulin secretion.
Type 2 DM Continued
• Resulting hyperglycemia causes beta cells
to secrete more insulin that is usually
ineffective in lowering blood glucose and
further contributes to peripheral insulin
resistance. Usually do not develop
ketoacidosis. Usually occurs after the age of
40 but is becoming more common in
younger individuals. Represents 85% to
90% of individuals with DM.
Diagnostic Criteria for Diabetes
• Symptoms of diabetes plus casual plasma glucose concentration of
>200 mg/dL (11.1mmol/L) (casual is defined as any time of day
without regard to time since the last meal); the classic symptoms of
diabetes include polyuria, polydipsia, and unexplained weight loss; or
• Fasting plasma glucose of >126 mg/dL (7.0 mmol/L) (fasting is
defined as no caloric intake for at least 8 hours); or
• Two- hour plasma glucose of >200 mg/dL during an oral glucose
tolerance test; the test should be performed as described by World
Health Organization, using a glucose load containing the equivalent of
75 g anhydrous glucose dissolved in water
Insulin Regulation
• blood levels of glucose
• blood levels of amino acids potentiate the
glucose stimulus for insulin secretion
• gastrointestinal hormones—gastrin,
secretin, cholecystokinin
• other hormones—glucagon, growth
hormone, cortisol, progesterone and
estrogen
Metabolic Complications
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ketoacidosis
dehydration
retinopathy
hypertension
neuropathy
nephropathy
atherosclerosis
poor wound healing
Medications (DM)
• Type 1--most individuals use subcutaneous
insulin injections consisting of a mixed
insulin, split dose regimen. This includes a
mixture of short-acting insulin and longeracting (sustained release) insulin in morning
and afternoon doses.
Medications (DM) Continued
• Type 2--oral hypoglycemic agents that help
restore peripheral insulin receptor
sensitivity and stimulate pancreatic insulin
release
• Type 1/Type 2--also antihypertensive, lipidlowering and pain medications
Exercise Benefits (DM)
• Type 1—exercise is not considered a
component of treatment in type 1 diabetes
to lower blood glucose but individuals
should exercise to gain other benefits
normally associated with regular exercise
Exercise Benefits (DM)
Continued
• Type 2—
• improved daily blood glucose control
• improved peripheral insulin sensitivity and
insulin receptor affinity
• other benefits normally associated with
regular exercise
Precautions for Avoiding Hypoglycemic
Events
• Measure blood glucose before, during and after exercise
• Avoid exercise during periods of peak insulin activity
• Unplanned exercise should be preceded by extra
carbohydrate, e.g., 20 to 30 g/30 min of exercise; insulin
may have to be decreased after exercise
• If exercise is planned, insulin dosages must be decreased
before and after exercise, according to the exercise intensity
and duration as well as the personal experience of the
patient; insulin dosage reductions may amount to 50 to 90%
of daily insulin requirements
Precautions for Avoiding Hypoglycemic
Events Continued
• During exercise, easily absorbable carbohydrates may have
to be consumed
• After exercise, an extra carbohydrate- rich snack may be
necessary
• Be knowledgeable of the signs and symptoms of
hypoglycemia
• Exercise with a partner
Obesity
Obesity
• Criteria
• Body Mass Index (BMI)
– moderately overweight/obese--27.1-30.0 kg/m2
– markedly overweight/obese--30.1-40.0 kg/m2
– morbidly obese--> 40.0 kg/m2
Obesity Continued
• Criteria (continued)
• Percentage body fat
– > 25% males
– > 32% females
Obesity Continued
• Metabolic complications—Primary
metabolic complication is the development
of DM. In obesity the beta cells become
less responsive to stimulation by increased
blood glucose levels. In turn, the blood
insulin levels do not increase when needed.
Obesity Continued
• Metabolic complications (continued)--In
addition, obesity decreases the number of
insulin receptors in insulin target cells.
Other complications of obesity are
hypertension, elevated serum cholesterol
levels and decreased cardiorespiratory
function.
Criteria for Weight Loss Program
• Provides intake of not lower than 1200 kcal/day for normal adults
and allows for a proper distribution of foods to meet the nutritional
requirements. (Note: this requirement may not be appropriate for
children, older individuals, and athletes)
• Includes foods acceptable to the dieter in terms of sociocultural
background, usual habits, taste, costs, and ease in acquisition and
preparation; however, these foods should be low in total fat,
saturated fat, cholesterol, and sodium
• Provides a negative caloric balance (not to exceed 500 to 1000
kcal/day), resulting in gradual weight loss without metabolic
derangements, such as ketosis
• Results in a maximal weight loss of 1 kg/week
Criteria for Weight Loss Programs
Continued
• Includes the use of behavior modification techniques to
identify and eliminate diet habits that contribute to
malnutrition
• Includes an exercise program that promotes a daily caloric
expenditure of more than 300 kcal. For many participants,
this may be best accomplished with moderate-intensity,
long- duration exercise, such as walking
• Provides that new eating and physical activity habits can
be continued for life to maintain the achieved lower body
weight
Hypertension
Hypertension (HTN)
• Criteria—
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Systolic
(mmHg)
< 130
130-139
Normal
H. Normal
HTN
Stage 1 (Mild) 140-159
Stage 2 (Mod) 160-179
Diastolic
(mmHg)
<85
85-89
90-99
100-109
HTN Continued
• HTN Criteria continued
Systolic
(mmHg)
• Stage 3 (Severe)
180-209
• Stage 4 (V. Severe) >210
Diastolic
(mmHg)
110-119
>120
HTN Continued
• Associated complications—Increased
incidence of:
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cerebral vascular accident (CVA)
CHD
atherosclerosis
impaired cognitive function
thickening and stiffening of medium and small
blood vessels
• retinopathy
• nephropathy
HTN Continued
• Medications—initiation of drug therapy
should consider:
• severity of HTN
• presence or absence of target-organ disease
• presence or absence of other medical
conditions and CHD risk factors
HTN Continued
• Pharmacological agents—
• alpha blockers—block adrenergic vascular smooth
muscle receptors which promotes a decrease in
vascular resistance
• beta blockers—block adrenergic receptors in the
heart decreasing heart rate and myocardial
contraction force
• alpha-beta blockers
HTN Continued
• Pharmacological agents (continued)
• calcium channel blockers—block entry of calcium
into vascular smooth muscle inhibiting contraction
leading to vasodilation and decreased vascular
resistance
• angiotensin-converting enzyme inhibitors—inhibit
transformation of angiotensin I to angiotensin II
(angiotensin II is a vasoconstrictor)
• diuretics—decrease fluid volume within the vascular
system
Lifestyle Modifications for Hypertension
• Lose weight if overweight
• Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (e.g.,
24 oz [720 mL] of beer, 10 oz [300 mL] of wine, or 2 oz [60 mL] of
100 proof whiskey) per day or .5 oz (15 mL) of ethanol per day for
women and lighter-weight people
• Increase aerobic physical activity (accumulate 30 to 45 minutes most
days of the week)
• Reduce sodium intake to no more than 100 mmol/d (2.4 g of sodium
or <6 g of sodium chloride)
• Maintain adequate intake of dietary potassium (approximately 90
mmol/d or 3.5 g/d)
Lifestyle Modifications for Hypertension
Continued
• Maintain adequate intake of dietary calcium and magnesium for
general health
• Stop smoking
• Reduce intake of dietary saturated fat and cholesterol for overall
cardiovascular health
Recommendations for Exercise Training and Testing
for Hypertensives Continued
• Mass exercise testing is not advocated to determine those
individuals at high risk for developing hypertension in the future
as a result of an exaggerated exercise BP response. However, if
exercise test results are available and an individual has a
hypertensive response to exercise, this information does provide
some indication of risk stratification for that patient and the
necessity for appropriate lifestyle counseling to ameliorate this
increase. In certain instances, medication changes may be
appropriate
Recommendations for Hypertensives
Continued
• Endurance exercise training by individuals who are at high risk for
developing hypertension will reduce the rise in BP that occurs with
age, thus justifying its use as a nonpharmacologic strategy to reduce
the incidence of hypertension in susceptible individuals
• Endurance exercise training will elicit an average reduction of 10 mm
Hg for both systolic and diastolic BP in individuals with stage 1 or
stage 2 essential hypertension(BP in the range of 140 to 179/90 to 109
mm Hg) and even greater reductions in BP in patients with secondary
hypertension due to renal dysfunction
Recommendations for Hypertensives
Continued
• The recommended mode, frequency,
duration, and intensity of exercise are
generally the same as those for low risk
individuals. Exercise training at somewhat
lower intensities (e.g., 40 to 70% VO2 max)
appears to lower BP as much as, if not more
than, exercise at higher intensities, which
may be especially important in specific
hypertensive populations, such as elderly
Recommendations for Hypertensives
Continued
• Based on the high number of exercise-related health benefits and low
risk for morbidity and/or mortality, it seems reasonable to recommend
exercise as part of the initial treatment strategy for individuals with
stage 1or stage2 essential hypertension.
• Individuals with more marked elevations in BP should add endurance
exercise training to their treatment regimen only after initiating
pharmacological therapy; exercise may reduce their BP further, allow
them to decrease their antihypertensive medications, and attenuate
their risk for premature mortality
Recommendations for Hypertensives
Continued
• Resistance training is not recommended as
the primary form of exercise training for
hypertensive individuals. With the exception
of circuit weight training, resistance training
has not consistently been shown to lower BP.
Thus, resistance training is recommended as
a component of a well rounded fitness
program, but not when done independently
Musculoskeletal Disorders
Osteoporosis
• systemic skeletal disease characterized by
low bone mineral density (BMD) leading to
bone fragility and increased risk of fracture
• Osteoporosis exercise related prevention
goals—
• to increase bone mass during and just after periods
of growth
• to maintain bone mass or decrease the rate of loss in
adulthood
• to decrease incidence of falls in older adults
Osteoporosis Continued
• Exercise Guidelines—
• Aerobic-• walking, cycling, swimming (activities with a
weight-bearing component are associated with a
higher BMD than those without a weight-bearing
component)
• 40-70% of peak HR
• 3-5d/wk
• 20-30 min/session
Osteoporosis Continued
• Exercise Guidelines (continued)
• Strength-• dumbbells, weight machines
• 50% of 1 repetition maximum (1 RM) or 70% of 3
RM
• 2-3 sets of 8 repetitions
• 2 d/wk for 20-40 min
• Flexibility-• 5-7 d/wk
Osteoporosis Continued
• Special Considerations—
• long-term effect on bone mass conservation will
require at least 9-12 mo of exercise training
• avoid flexion of spine and stooping with forward
flexion (can increase vertebral fractures)
• cardiac complications (due to older age of most
individuals with osteoporosis)
• start with low workouts and progress slowly due to
low muscular strength in many individuals with
osteoporosis
• amenorrheic and postmenopausal women
(hypoestrogenism)
Arthritis
• Osteoarthritis (OA)-localized to affected
joint or joints due to wear and tear and
appears first as a deficit in articular cartilage
(most commonly affected joints are the
hands, spine, hips and knees)
• Characterized by joint pain and stiffness
Arthritis Continued
• Rheumatoid arthritis (RA)-autoimmune
systemic inflammatory condition (most
commonly affected joints are the wrists,
hands, knees, feet and cervical spine)
• Characterized by morning stiffness, acute and
chronic inflammation and chronic pain and joint
instability
Arthritis Continued
• Gout-urates of sodium deposits in the joints
(most commonly affected joints are the
wrists, ankles, knees as well as the great
toe)
• Characterized by acute joint inflammation and pain
Arthritis Continued
• Exercise Guidelines-• Aerobic—
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60-80% of peak HR or 40-60% of Vo2max
ratings of perceived exertion (RPE) 11-16
3-5d/wk
5 min session progressing to 30 min session
progression of duration over intensity
Arthritis Continued
• Exercise Guidelines (continued)
• Strength—
• as per pain tolerance
• 2-3 repetitions building to 10-12
• 2-3d/wk
• Flexibility—
• 1-2 sessions/d
Arthritis Continued
• Special Considerations—
• avoid overstretching unstable joints
• low resistance and low impact exercise
recommended
• spinal involvement may cause radiculopathy
• avoid morning exercise with RA due to morning
stiffness
• cardiac implications (due to older age of most
individuals with arthritis)
Low Back Pain (LBP)
LBP Continued
• it is important to first determine the cause
for LBP before initiating an exercise
program
• acute LBP (<2-3wk duration) is commonly
treated (excluding surgical intervention) by
pharmacological agents and therapeutic
modalities
LBP Continued
• Exercise Guidelines—
• little scientific evidence exists that exercise
has any direct effect on reducing low back
pain
• general conditioning can be useful for the
overall health of the individual with LBP as
well as reducing the incidence of low back
injury (can be started 2 wks after onset of
LBP)
LBP Continued
• Exercise Guidelines (continued)
• low impact aerobic exercise (e.g. walking) can
provide very low levels of supporting tissue load
while activating supporting back musculature
• low back muscle endurance and strengthening
exercises can reduce incidence of low back injury
(endurance > strength)
LBP Continued
• Exercise Guidelines (continued)
• flexibility exercise (unloaded flexion-extension) can
be initiated in individuals with LBP after the spine
has been stabilized and after endurance and strength
conditioning has occurred
• abdominal exercise that produces low back spine
compression
• exercises can be performed daily
Children
Guidelines for Strength Training for
Children
• All strength- training activities should be supervised
and monitored closely by appropriately trained
personnel
• No matter how big, strong, or mature the individual
appears, remember that he or she is physiologically
immature
• The primary focus, at least initially, should be directed
at learning proper techniques for all exercise
movements and developing an interest in resistance
training
Guidelines for Strength Training
Children Continued
• Proper techniques should be demonstrated first,
followed by gradual application of resistance or
weight
• Proper breathing techniques (ie.,no breath-holding)
should be taught
• Stress that exercises should be performed in a manner
in which the speed is controlled, avoiding ballistic
(fast and jerky) movements
Guidelines for Strength Training
Children Continued
• Avoid the practice of power lifting and body building
• Perform full-range, multi-joint exercises (as opposed
to single-joint exercises)
• Be sure participant can understand and follow
directions
Strength Training Exercise Prescription
for Children
• Intensity
– Avoid repetitive use of maximal amounts of weight
in strength training programs until reaching Tanner
stage 5 (adolescence) level of development
maturity
– Weight loads should be used that permit 8 or more
repetitions to be completed per set, since heavy
weights can be potentially dangerous and damaging
to the developing skeletal and joint structures
Strength Training Exercise Prescription
for Children Continued
• Intensity Continued
– It is not recommended that resistance exercise be
performed to the point of severe muscular fatigue
– As a training effect occurs, achieve an overload
initially by increasing the number of repetitions,
and then by increasing the absolute resistance
Strength Training Exercise Prescription
for Children
• Duration
– Perform 1 to 2 sets of 8 to 10 different
exercises(with 8 to 12 repetitions per set), ensuring
that all of the major muscle groups are included (in
early stages of training, 1 set should be performed
until proper technique is demonstrated)
– Rest at least 1 to 2 minutes between exercises, and
intersperse rest days between training days
Strength Training Exercise
Prescription for Children Continued
• Frequency
– Limit strength training sessions to twice per week
and encourage children and adolescents to
participate in other forms of physical activity
Elderly
Exercise Testing, Changes With Aging
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•
•
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•
Resting Heart Rate - no change
Maximal Heart Rate- decrease
Maximal Cardiac Output- decrease
Resting and Exercise BP- increase
Maximal oxygen uptake- decrease
Residual volume- increase
Vital Capacity- decrease
Reaction time- increase
Exercise Testing, Changes With Aging
Continued
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•
•
•
•
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•
Muscular strength- decrease
Bone mass- decrease
Flexibility- decrease
Fat-free body mass- decrease
Percent body fat- increase
Glucose tolerance- decrease
Recovery time- increase
Considerations for Testing the Elderly
• For those with expected low work capacities, the
initial workload should be low (2 to 3 METS) and
workload increments should be small (.5 to 1.0
METS), e.g., Naughton protocol
• A cycle ergometer may be preferable to a treadmill
for those with poor balance, poor neuromuscular
coordination, impaired vision, senile gait patterns,
weight-bearing limitations, and foot problems
Considerations for Exercise Testing the Elderly
Continued
• Added treadmill handrail support may be required due to
reduced balance, decreased muscular strength, poor
neuromuscular coordination, or fear. Handrail support or gait
abnormalities, however, can reduce the accuracy of estimating
peak MET capacity based on exercise duration or peak workload
achieved
• Treadmill speed may need to be adapted according to walking
ability
• For those who have difficulty adjusting to the exercise
equipment, the initial stage may need to be extended, the test
restarted, or the test repeated
Considerations for Exercise Testing the Elderly
Continued
• Exercise- induced arrhythmias are more frequent
in the elderly than in other age groups
• Prescribed medications are common and may
influence exercise electrocardiographic and
hemodynamic responses
Mode of Exercise for the Elderly
• The exercise modality should be one that does not
impose excessive orthopedic stress
• Walking is an excellent mode of exercise for many
elderly
• Aquatic exercise and stationary cycle exercise
may be especially advantageous for those with
reduced ability to tolerate weight -bearing activity
Mode of Exercise for the Elderly
Continued
• The activity should be accessible, convenient, and
enjoyable to the participant- all factors directly
related to exercise adherence
• A group setting may provide important social
reinforcement to adherence
-Intensity for Exercise Prescriptions for the
Elderly Continued
• To minimize medical problems and promote long-term
compliance, exercise intensity for inactive elderly people
should start low and individually progress according to
tolerance and preference
• Many older persons suffer from a variety of medical
conditions; thus, a conservative approach to increasing
exercise intensity is warranted initially
• Exercise need not be vigorous and continuous to be
beneficial; a daily accumulation of 30 minutes of moderateintensity exercise provides health benefits
Intensity for Exercise Prescriptions for
Elderly Continued
• Longer- duration or higher-aerobic intensity
offers additional health benefits, although it
can lead to greater risk of cardiovascular
and musculoskeletal problems and lower
compliance to a long term exercise plan
• The intensity guidelines and precautions
established for younger people for aerobic
exercise training generally apply to the
elderly
Intensity for Exercise Prescriptions for the
Elderly Continued
• A measured peak heart rate is preferable to an age predicted peak
heart rate when prescribing aerobic exercise because of the
variability in peak heart rate in persons over 65 years of age and
their greater risk of underlying coronary artery disease
• Use of percentage of peak heart rate to calculate a target heart
rate range in the elderly may provide a more accurate estimate of
percentage of peak VO2 than the heart rate reserve method
• Elderly persons are more likely than young persons to be taking
medications that can influence peak heart rate
Duration for Exercise Prescriptions for the
Elderly Continued
• Exercise duration need not be continuous to
produce benefits; thus those who have difficulty
sustaining exercise for 30 minutes or who prefer
shorter bouts of exercise can be advised to
exercise for 10 minute periods at different times
throughout the day
• To avoid injury and ensure safety, older
individuals should initially increase exercise
duration rather than intensity
Frequency for Exercise Prescriptions for
the Elderly
• Exercise performed at moderate intensity should
be undertaken most days of the week
• If exercise is undertaken at a vigorous level, it
should be performed at least 3 times per week,
with exercise and no exercise days alternated
Resistance Training Guidelines for the
Elderly
• Intensity
– Perform at least 1 set of 8 to 10 exercises
that use all the major muscle groups (e.g.,
gluteals, quadriceps, hamstrings,
pectorals,latissimus dorsi, deltoids, and
abdominals)
– Each set should involve 10 to 15 repetitions
that elicit a perceived exertion rating of 12
to 13 (somewhat hard)
Resistance Training Guidelines for the
Elderly Continued
• As a training effect occurs, achieve an overload
initially by increasing the number of repetitions,
and then by increasing the resistance
• When returning from a lay-off, start with
resistances of 50% or less of previous training
intensity, then gradually increase the resistance
Resistance Training Guidelines for the
Elderly Continued
• Frequency
– Resistance training should be performed at least twice a
week, with at least 48 hours of rest between sessions
• Duration
– Sessions lasting longer than 60 minutes may have a
detrimental effect on exercise adherence.
– Adherence to guidelines should permit individuals to
complete total body resistance training sessions within 20 to
30 minutes
Practical Guidelines for Resistance
Training for the Elderly
• The major goal of the resistance training program is to develop
sufficient muscular fitness to enhance an individual’s ability to
live a physically independent lifestyle
• The first several resistance training sessions should be closely
supervised and monitored by trained personnel who are sensitive
to the special needs and capabilities of the elderly
• Begin (the first 8 weeks) with minimal resistance to allow for
adaptations of the connective tissue elements
Practical Guidelines for Resistance
Training Continued
• Teach proper training techniques for all of the
exercises to be used in the program
• Instruct older participants to maintain their normal
breathing pattern while exercising
• Stress that all exercises should be performed in a
manner in which the speed is controlled (no
ballistic movements should be allowed)
• Perform the exercises in a range of motion that is
within a “pain- free arc”
Practical Guidelines for Resistance
Training Continued
• Perform multi-joint exercises (as opposed to
single-joint exercises)
• Given a choice, use machines to resistance train,
as opposed to free weights (machines require less
skill to use, protect the back by stabilizing the
user’s body position, and allow the user to start
with lower resistances, to increase by smaller
increments, and to more easily control the exercise
range of motion)
Practical Guidelines for Resistance
Training Continued
• Never permit arthritic participants to participate in
strength training exercises during active periods of pain
or inflammation
• Engage in a year- round resistance training program
• Routine activities, such as domestic work, gardening, and
walking, may help to maintain muscular strength
Flexibility Exercise Prescription for the
Elderly Continued
• Intensity
– Exercises should incorporate slow movement, e.g.,
static stretches that are sustained for 10 to 30
seconds
– At least four repetitions per muscle group should
be performed
– The degree of stretch achieved should not cause
pain, but rather mild discomfort
Flexibility Exercise Prescription
Continued
• Frequency
– Stretching exercises should be performed a minimum of 2 to 3
d/wk and should be included as an integral part of the warm-up
and cool-down exercises
• Duration
– The stretching phase of an exercise session should last long
enough to exercise the major muscle/tendon groups
– an entire exercise session devoted to flexibility may be
appropriate for deconditioned older adults who are beginning an
exercise program
Stretching Guidelines for Older Adults
• Always precede stretching exercises with some type
of warm-up activity to increase circulation and
internal body temperature
• Stretch smoothly and never bounce
• Do not stretch a joint beyond its pain-free range of
motion
• Gradually ease into a stretch, and hold it only as long
as it feels comfortable (10 to 30 seconds)
Pregnancy
Potential Benefits to Prenatal Exercise
Programs
• Improved aerobic and muscular fitness
• Facilitation of recovery from labor
• Enhanced maternal psychological wellbeing that may help counter feelings of
stress, anxiety, and/or depression frequently
experienced during pregnancy
• Establishment of permanent healthy
lifestyle
Potential Benefits of a Prenatal Exercise
Program Continued
• More rapid return to pre-pregnancy weight, strength, and
flexibility levels
• Fewer obstetric interventions
• Shorter active phase of labor and less pain
• Less weight gain
• Improved digestion and reduced constipation
• Greater energy reserve
• Reduced “postpartum belly”
• Reduced back pain during pregnancy
Contraindications for Exercising During
Pregnancy
•
•
•
•
•
•
Pregnancy-induced hypertension
Preterm rupture of membrane
Preterm labor during the prior or current pregnancy
Incompetent cervix
Persistent second to third trimester bleeding
Intrauterine growth retardation
Summary of (ACOG) Recommendations for
Exercise During Pregnancy and Postpartum
• Women can continue to exercise and derive health benefits
even from mild to moderate exercise routines
• Regular exercise (at least 3 times per week) is preferable to
intermittent activity
• Women should avoid exercise in the supine position after
the first trimester – decreases cardiac output
• Exercise in incline or side-lying positions
• Prolonged periods of motionless standing should be avoided
Summary of (ACOG) Recommendations for
Exercise During Pregnancy and Postpartum
Continued
• Caution with difficult balance positions
• Can exercise up to delivery with moderate
aerobic exercise (heart rate +140 BPM)
• Light weights
• Kegel Exercises—strengthen pelvic floor
(gluteals, abdominal obliques, iliopsoas)
• Start exercise post-partum +3-6 weeks
Summary of (ACOG) Recommendations for Exercise
During Pregnancy and Postpartum Continued
• Women should be encouraged to modify the intensity of
their exercise according to maternal symptoms.
• Pregnant women should stop exercising when fatigued and
not exercise to exhaustion.
• Non-weight-bearing exercises, such as cycling or
swimming, will minimize the risk of injury and facilitate the
continuation of exercise during pregnancy
Summary of (ACOG) Recommendations for
Exercise Pregnancy and Postpartum Continued
• Any type of exercise involving the potential for even mild
abdominal trauma should be avoided
• Pregnancy requires an additional 300 kcal/day to maintain
metabolic homeostasis.
Summary of (ACOG) Recommendations for
Exercise Pregnancy and Postpartum Continued
• Pregnant women should augment heat dissipation by
ensuring adequate hydration, appropriate clothing, and
optimal environmental surroundings during exercise
• Physiologic and morphologic changes of pregnancy
persist 4 to 6 weeks postpartum.
Reasons to Discontinue Exercise and Seek Medical
Advice During Pregnancy
• Any signs of bloody discharge from the vagina
• Any “gush” of fluid from the vagina (premature
rupture of membranes)
• Sudden swelling of the ankles, hands, or face
• Persistent, severe headaches, and/or visual disturbance;
unexplained spell of faintness or dizziness
• Swelling, pain, and redness in the calf of one leg
(phlebitis)
Reasons to Discontinue Exercise and Seek Medical
Advice During Pregnancy Continued
• Elevation of pulse rate or blood pressure that persists
after exercise
• Excessive fatigue, palpitations, chest pain
• Persistent contractions (>6-8/h) that may suggest onset
of premature labor
• Unexplained abdominal pain
• Insufficient weight gain (<1.0 kg/month during last two
trimesters)