Download Special needs and guidelines for training a client with Arthritis

Chapter 8
CHRONIC DISEASES AND
EXERCISE
You will remember from Chapter 4 that having a chronic disease usually doesn’t mean that
a person can’t exercise. If you have a client with a chronic disease, both you and the client
need open communication with the client’s physician. You need to be sure the disease is
stable before prescribing exercise. Suggest that your clients discuss with their doctors the
signs and symptoms that indicate trouble during exercise.
There was a sample form letter included in Chapter 4 for you to send to the client’s physician to disclose your role as a personal trainer. Make sure you ask for the doctor’s input
about any limitations that might be necessary for that patient. Due to legal issues related to
new privacy laws called HIPPA, it might be difficult—if not impossible—to obtain information from a physician before the client grants permission for disclosure. In other words,
the doctor will usually require a written release from the patient before answering your
questions. Be aware that the doctor might not know much detail about exercise. Focus your
discussion on discovering pertinent information about flare-ups or acute conditions that
might limit exercise in this particular situation. Request specific descriptions of signals that
would indicate trouble. Depending on the problem and the type of medical treatment that
has been administered, there could be an exercise protocol already established by a therapist or physician. ASK FOR IT! The time you take to request this information from both
the doctor and the client will not only protect you if a future problem does arise, but it will
help you build a rapport with numerous physicians who might make referrals to you in the
future.
Next we will look at chronic diseases and some of the drugs used to treat these diseases.
You will also learn to identify the special concerns related to exercise for each condition.
Your goal with new clients will be to work at a very gradual and moderate pace to ease them
into their programs regardless of whether they have a special condition or not. This should
be an easy task given what you already know about exercise and armed with the information in the next section!
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ARTHRITIS
As you learned in an earlier chapter, arthritis is a general term that refers to many different
types of rheumatic diseases. They all cause pain, stiffness, and swelling in the joints and
their connective tissue. At this point, we will address the most common forms which are
osteoarthritis and rheumatoid arthritis. Osteoarthritis is characterized by joint pain but
not necessarily inflammation. It is commonly known as “wear-and-tear” arthritis because
it results from a combination of aging, irritation, and abrasion. It is the leading cause of
disability in older individuals and typically affects the articular cartilage in the synovial
cavities at large, weight-bearing joints. Rheumatoid arthritis, on the other hand, is an
inflammatory, multijoint and multisystem disease that affects the cardiac and pulmonary
systems as well. It is an autoimmune disorder in which the person’s immune system attacks
its own cartilage and synovial membranes which leads to the accumulation of synovial
fluid within the joint cavity. Thus, it is characterized by acute episodes of joint pain and
stiffness. This form of arthritis is usually bilateral which means that if one wrist is affected,
the other is also likely to be affected to some degree. Your clients with rheumatoid arthritis
will tend to fatigue quickly, so help them pace themselves accordingly.
Most of the treatment strategies and exercise guidelines for osteoarthritis and rheumatoid
arthritis are similar. No matter how severe their condition, older adults with arthritis need
to participate in physical activity programs to prevent further deterioration from the condition. People are often reluctant to begin a program because they are afraid of hurting
themselves; they think exercise will do more harm than good. They try to protect their
joints by not using them, but this just makes the joints weaker and less flexible.
Arthritis is classified into four levels or classes based on its severity. Class 1 means that the
person is totally independent with little pain, while Class 4 means they are totally dependent and disabled by pain. You will probably be working with people in the Class 1 and 2
ranges. People in Class 3 and 4 will typically be under the care of a physical therapist.
Your clients, especially those with arthritis, need to be taught to distinguish between the
different “types” of pain. We sometimes distinguish pain as “bad pain” vs. “good pain.” A
better description might be “pain” vs. “soreness.”
Good pain, or soreness, is felt in the muscle, not in the joint. It stops within a few minutes after exercise ends. There is less soreness associated with each subsequent exercise
session. Normally, soreness is what we all experience to some extent when we exercise.
Bad pain occurs in or near the joint, continues to hurt after exercise is complete, and
does not improve with future sessions. It might even worsen with time. This usually
indicates a problem with a joint or a muscle that is not normal.
Special concerns:
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The goal with arthritic clients is to limit progression of the existing damage in the
affected joints. Consequently, the focus should be on posture, strength, and flexibility.
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Do not over-fatigue muscles as this can increase joint pain.
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Mild isometric exercises are helpful, especially during flare-ups, but remember isometric contractions are contraindicated for people with high blood pressure.
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Remind your clients to take pain medication about one hour before exercising.
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Some clients like a hot shower or some other form of heat to loosen up joints before
exercise. Others prefer ice for aching joints. Applying an ice pack or other cold compress is probably best after a workout because the cold tends to decrease blood flow to
the area which can actually increase the risk for injury during use of the joint. A bag
of frozen vegetables makes a good “ice pack” at the end of a workout. It is flexible,
cheap, and reusable.
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Any exercise that causes pain two hours or more after exercise should be changed or
replaced.
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Discomfort or soreness is okay. PAIN from the exercise itself is NOT okay.
‡
Watch carefully for an exercise that is causing increased pain. Clients often won’t
complain about pain for fear of disappointing you, their trainer. They just get used to
it and drive on.
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“No pain, no gain” is a WRONG attitude! It should be “WHERE THERE IS PAIN,
THERE IS NO GAIN!”
‡
While stretching is extremely important, avoid overstretching. Some clients can hold a
stretch for only a few seconds.
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Always warm up slowly and completely to ensure that the joints are as warm and supple as possible.
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Do not expect clients to keep joints in the same position for too long. Prolonged
stretching of a single joint, or even just holding a joint in one position for too long,
can make it difficult to straighten the joint without pain.
‡
Use only pain-free range of motion. Stop exercising if PAIN occurs.
‡
Daily range of motion exercises, especially first thing in the morning, can really
decrease morning stiffness. Help clients design a program to be done at home.
‡
Short and frequent exercise sessions are best. Vary endurance and strength training
on different days. During acute episodes or flare ups, avoid exercising the affected
joint.
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For strength exercises, use tubing or hand weights with a lower level of resistance.
Compensate by doing a higher number of repetitions to fatigue the muscle.
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It is especially important to choose tubing with a lower resistance because the intensity level increases as the band is stretched. Therefore, the greatest resistance is
encountered when the muscle is past its range of mechanical advantage.
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Try to do range of motion exercises even during a flare up.
‡
Some people might never be able to tolerate resistance exercise, but they might be
able to tolerate weight bearing exercise.
‡
Make sure your client is aware of the mood benefits of exercise. Many people with
chronic conditions (especially arthritis) are prone to depression; make certain they
know that exercise has been proven to be as effective as medication in fighting
depression for most people.
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‡
For the client with severe arthritis, water exercise in a pool kept at 90o will be the best
choice, if available. If it is not available, try to find an activity that can be tolerated.
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For clients who are unable to do continuous activity, try doing a minute or two on one
type of machine, rest for 30 seconds, and then switch to another type of machine that
uses different joints.
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Take things slowly and don’t forget to provide frequent rest periods. To accommodate
these extra rest periods, you might just have to schedule as much as 60 minutes to
allow for 30 minutes of work. Remember that the duration and frequency of exercise
is more important than the intensity. This is true for everyone, but especially for
seniors with arthritis.
‡
Many people with arthritis suffer from low back pain. Proceed cautiously, but encourage lower back strengthening exercises. You will learn more in Chapter 9, but remember you want extension, not flexion!
LOW BACK PAIN
Let’s briefly look at back pain and exercise. While back pain is common among all ages, it is
often a chronic problem for older persons, especially those with arthritis. It is usually classified as either chronic or acute pain. Chronic pain lasts for longer than three months, and
the recommended treatment includes exercise. Acute back pain, on the other hand, lasts
less than three months, and the symptoms often clear within a few days to a few weeks
when treated with anti-inflammatory drugs and rest. Exercise might or might not be
advised for those with acute back pain.
Special concerns:
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If you have clients who have been seeing a physician or therapist, make sure they have
been released or cleared for physical activity.
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Consider secondary conditions like arthritis, heart disease, or osteoporosis when
designing a program.
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Your major goal for a person with back pain should be to prevent overall deconditioning.
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Be aware that people who have experienced acute episodes might be TERRIFIED of
re-injuring their backs. You need to be supportive and understanding.
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Input from the physician or physical therapist is a good idea when designing low back
exercises for anyone suffering from low back pain. Again, make sure the client has
been cleared to resume activity and ask if there is already an exercise regimen in
place.
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Remember good pain vs. bad pain. Stay within the client’s pain threshold and watch
out for sharp pain. Clients who have been in therapy know the warning signs. Have
them tell you their guidelines; you can learn a lot of practical information from them
that might even apply to other clients with back pain.
‡
Aerobic exercise that puts minimal stress on the back is necessary to encourage
endurance training. The exact mode of exercise will vary from patient to patient, but
a recumbent bike is often a good choice.
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‡
Strength and flexibility are also important. In the initial stages of exercise, use the
abdominal crunch or pelvic tilt to strengthen abs and back extension exercises (but
not the Roman Chair) to strengthen the back. If the client has chronic pain but has
not been under a doctor’s care, these exercises are a good place to begin.
‡
If in doubt, use your committee or refer to the appropriate professional.
PAIN
“Years ago, people who were in pain were told to rest,” says Edward Laskowski, M.D., a
physical medicine and rehabilitation specialist and co-director of the Sports Medicine
Center at Mayo Clinic, Rochester, Minn. “But now we know the exact opposite is true.
When you rest, you become deconditioned – which may actually contribute to chronic
pain.”
Regular exercise is an all-around weapon in the fight against chronic pain and can:
1.
2.
3.
4.
5.
6.
7.
Prompt the body to release endorphins, which are the body's natural pain relievers
and help alleviate anxiety and depression.
Help build strength—and the stronger the muscles, the more force and load that will
be taken off bones and cartilage.
Increase flexibility to allow joints to move through a full range of motion, which can
decrease aches and pains.
Improve sleep quality by lowering stress hormones, resulting in better sleep.
Boost energy levels, giving a person more energy to cope with chronic pain.
Help maintain a healthy weight, which will reduce stress on the joints (weight loss is
another way to improve chronic pain).
Enhance mood and contribute to an overall sense of well-being.
It is not a bad thing (actually it is a very smart thing!) to be concerned about hurting a person who has chronic pain when you are designing an exercise program for them. But,
unless the pain they are experiencing is “protective pain”, a well-designed program will be
very beneficial for them. With that said, working with people recovering from injuries, surgery, chronic diseases or undergoing medical rehabilitation demands advanced training.
The inexperienced personal trainer (even with a degree), and/or certified personal trainer
without advanced training, is not in a position to safely work with at-risk clients and could
be vulnerable to costly legal action. And even if you are qualified to work with these clients,
you need to make certain that they do not have conditions that need the attention of a physician or other specialist and you also need to verify that the person has been “released” or
cleared for exercise if they have been under the care of a medical professional.
Given the flood of at-risk older clients in the fitness setting, trainers must utilize suitable
preactivity screening methods to identify members who may need medical clearance and/
or medically supervised programs or a trainer with advanced skills. Studies have shown
that more than 25% of all clubs surveyed do not complete preactivity screenings. It is not
clear the percentage of personal trainers working independently that do not perform adequate screening prior to working with a new client. Proper screening of a new client is
essential in deciding if there are conditions that need to be assessed by a therapist or physi-
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cian prior to exercise or if the person needs to be referred to a trainer with more experience
than you have.
The general exercise guidelines for a client that who has no significant chronic pain, or one
with pain who has been released from therapy and is in a stable phase, are much the same
as for all older adults. In general:
‡ Aerobic exercise.
For physical conditioning, start slowly at a safe point for your client's current abilities. Over several months, work up to a regular routine of working
out for 20 to 30 minutes, three to five times a week. Low-impact exercise such as biking, the elliptical and walking are often good choices, and swimming may be especially effective for those with joint disease.
‡ Strength training. Start with a resistance that allows your client to perform 12 to 15
repetitions and try to work major muscle groups in the upper body, lower body and
core.
‡ Stretching. Increasing flexibility can be a helpful component of pain relief. Prescribe
a consistent stretching routine. Gentle stretching exercises like yoga or body movement exercises such as Pilates are good choices as well.
A good rule of thumb for your clients that have chronic aches and pains is to have them
keep a journal of what they are feeling and when they are feeling it. If you notice patterns or
particular aches after certain types of exercise—and after two weeks there is no improvement—then you should recommend the client see a physical therapist, orthopedic doctor,
or other health professional if they have not done so previously. As you already know, a
small amount of muscle soreness one or two days after exercise is normal. Another rule of
thumb is to discontinue or modify any exercise that causes pain or increases an already
existing pain for more than two hours after the exercise.
Your clients, especially those with arthritis, need to be taught to distinguish between the
different “types” of pain. We sometimes distinguish pain as “bad pain” vs. “good pain.” A
better description might be “pain” vs. “soreness.”
Good pain, or soreness, is felt in the muscle, not in the joint. It stops within a few minutes after exercise ends. There is less soreness associated with each subsequent exercise session. Normally, soreness is what we all experience to some extent when we exercise.
Bad pain occurs in or near the joint, continues to hurt after exercise is complete, and does
not improve with future sessions. It might even worsen with time. This usually indicates a
problem with a joint or a muscle that is not normal.
COPD (INCLUDING ASTHMA)
Chronic obstructive pulmonary disease (COPD) includes emphysema, chronic bronchitis,
and asthma. In all of these disorders, either the lungs are inefficient or ventilation is compromised. Exercise can improve efficiency in ventilation, increase cardiovascular function,
and increase muscular strength—all of which enhance breathing function and reduce dyspnea (difficulty breathing).
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