Special Populations
Special Populations
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Obese
Cardiac
Diabetes
Hypertension
Osteoporosis
Chronic Obstructive Pulmonary Disease
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Asthma
Bronchitis
Emphysema
 Arthritis
 Pregnancy
The Obese Client
Effects on the Exercise
Response
 Low physical work capacity.
 Higher risk for coronary artery disease and
may exhibit myocardial ischemia during
exercise (testing).
 Hypertensive response may occur during
exercise despite the absence of hypertension
at rest.
 Must consider glucose intolerance as well.
Effects of Exercise Training
 Exercise training is effective in decreasing the
BW in moderately obese clients.
 However, it may not be effective in the
morbidly obese.
 When body weight is reduced through regular
exercise, body fat is reduced and lean tissue
is maintained or increased.
 Those with the least lean mass to begin with
have the most lean mass to gain during
training.
Effects of Exercise Training
 Obese individuals may already have a
significant amount of lean mass (beneath the
adipose) due to the overload from the excess
fat  increases in lean mass may not be as
significant.
 Ultimately, resistance training can increase
the lean mass of almost any population.
 Exercise affects body fat distribution by
promoting regional fat loss in the abdominal
sites.
Effects of Exercise Training
 Fat loss through exercise is more efficient for
clients with upper body fat distribution
(significantly decreases risk of diseases).
 Exercise may be one of the most important
factors in the maintenance of weight loss.
 Exercise has profound effects of glucose
metabolism in the obese client:
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Decreased fasting glucose and insulin
Decrease insulin resistance
Increased glucose tolerance
Management & Meds
 The primary objective of obesity management
is the reduction of fat weight with the
preservation of lean body weight.
 The client most likely to be successful is:
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Slightly or moderately obese
Has upper body fat distribution
Has no history of weight cycling
Has a sincere desire to lose weight
Became overweight as an adult
Management & Meds
 Behavioral change focuses on dietary and
activity habits toward weight reduction.
 Those who are morbidly obese (BMI > 40)
may need more invasive interventions:
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Starvation diets
Gastric Bypass
Jaw wiring
Intragastric balloons
Fat excision
Anti-obesity meds
Recommendations for Exercise
Testing
 The primary reason to conduct exercise
testing is to determine exercise prescription 
to determine physical work capacity.
 Assessment should include:
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Medical & weight history
Motivation and readiness for change
Nutrition & eating habits
Body composition
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Extent of the obesity
Distribution of body fat
Reasonable target weight
Assessment for potential injury
Recommendations for
Programming
 Goal is to optimize calorie burn yet minimize
the potential for injury.
 Remember the E (enjoyment) in FITTE and
exercise should fit the lifestyle.
 Consider the energy expenditure of the actual
exercise and the recovery period
 Debate over exercising once or twice a day.
 The literature supports total kcals expended
rather than concerning oneself with whether
the kcals are coming from fat or CHO stores.
Recommendations for
Programming
 Mode: Aerobic exercise
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Low-weight bearing exercise
Walking
Increase activities of daily living
Resistance training
 Frequency: 5+ times/wk
 Duration: 40-60’/day or 20-30’ 2x/day
 Intensity: 40-70% or 70-85%
Special Considerations
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Injury prevention is very important; also injury history.
Thermoregulation, neutral temp & humidity
Adequate flexibility, warm-up and cool-down sessions
Gradual progression of intensity & time; emphasize
duration vs. intensity
Use of low-impact or non-wt-bearing exercise; pool??
Adequate hydration
Clothing should be loose fitting
Equipment modification might be needed
Frequent follow ups
The Cardiac Client
With focus on the Post-myocardial infarction
Cardiovascular Diseases
 Myocardial Infarction
 Coronary Artery Bypass Graft Surgery
 Angina & Silent Ischemia
 Atrial Fibrillation
 Pacemakers
 Valvular Heart Disease
 Chronic Heart Failure
 Cardiac Transplant
 Hypertension
 Peripheral Arterial Disease
 Aneurysms
Effects of Exercise Training
(ACSM’s Exercise Management for Persons with Chronic Diseases &
Disabilities, 2nd Ed)
 Increased max oxygen consumption
 Improved ventilatory response to exercise
 Relief of anginal symptoms
 Increased heart rate variability
 Modest decrease in body weight, fat stores, BP,
blood profile components
 Increase in high density lipoproteins
 Improved psychosocial well-being and self-efficacy
 Protection against the triggering of myocardial
infarction by strenuous physical exertion (> 6 METs).
Recommendations for Programming
 Use lower intensity due to higher risk
 Keep below threshold of angina, significant
arrhythmias or symptoms of exercise
intolerance
 Interval training considerations for those with:
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Very low aerobic capacity
Recommendations for Programming
(ACSM’s Exercise Management for Persons with Chronic Diseases &
Disabilities, 2nd Ed)
 Large muscle, rhythmic group exercise, ie)
walking, biking, rowing, stairclimbing) is
appropriate for outpatient physical conditioning
(phase II-IV).
 Training benefits do not transfer from the legs
to the arms, and vice versa, both sets of limbs
should be exercised.
 Mild to moderate resistance training can also
provide a safe and effective method for
improving cardiovascular function and other
fitness parameters.
Recommendations for Programming
 Aerobic Exercise:
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Frequency: minimum 3 non-consecutive days/wk
Duration: 20-40’ continuous or accumulated activity
Intensity: 40-80% max HRR (heart rate reserve;
RPE (rated perceived exertion 11-15 (Borg)
Need longer warm-up & cool-down periods
Max benefit requires 5-6 hrs/wk of physical activity
 Circuit Weight Training:
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Frequency: 2-3 days/wk
Duration: 20-40’
Intensity: 40-50% max (no valsalva)
1-3 sets of 10-15 reps
Special Considerations
 Monitor for abnormal symptoms
 Avoid high intensity exercise in post-myocardial
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infarction clients.
Supervision suggested for moderate- to high-risk
clients.
Be aware that many post-MI clients have peripheral
arterial disease and/or diabetes
If possible, select equipment that can be adjusted in
1-MET increments
Increasing muscular strength is an important
component of a program for post myocardial
infarction patient.
The Diabetic Client
Overview
 A chronic metabolic disease characterized by
an absolute or relative deficiency of insulin that
results in hyperglycemia.
 Are at risk for developing microvascular &
macrovascular complications.
 Silent ischemia is common for those who have
had the disease a long time.
 Many classifications of the disease:
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Type I
Type II
Gestational
Other
Overview – Type I Diabetes
 Of the 16 million people with diabetes in US,
5-10% have Type I.
 An absolute deficiency of insulin.
 Insulin must be supplied by injection or pump.
 Usually occurs < age 30 but can occur at any
age.
Overview – Type II Diabetes
 Considered to have a relative insulin
deficiency because while insulin levels are
elevated, reduced or normal, they present
with hyperglycemia.
 Pathophysiology is unclear but believed to be
multifactoral.
 Believed it is due to:
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Peripheral tissue insulin resistance
Defective insulin secretion
Overview – Type II Diabetes
 Glucose does not readily enter the tissues
and blood glucose causes the pancreas to
secrete more insulin in an attempt to maintain
normal blood glucose concentrations.
 Obesity significantly contributes to the insulin
resistance.
 80% of the people with type-II are obese at
onset.
Overview – Type II Diabetes
 Genetically influenced – found in studies of
twins.
 Onset occurs with few or no classic
symptoms and many go undetected until
organ damage has occurred.
 Usually occurs > age 40.
 Some develop < age 30 – maturity onsetdiabetes of youth.
Effects on the Exercise
Response
 Diabetics do not respond to exercise in a
normal manner.
 The effect of diabetes on a single exercise
session is dependent of several factors:
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Use & type of medication: insulin or oral agents
Timing of med administration
Blood glucose level prior to exercise
Timing, amount, and type of previous food intake
Presence & severity of diabetic complications
Use of other meds secondary to diabetic
complications
Intensity, time, and type of exercise
Effects of Exercise Training
 Exercise is considered to be one of the
cornerstones of diabetes care.
 Exercise benefits include:
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Improved blood glucose control (except for
Type I)
Improved insulin sensitivity & lower doses of
meds
Decrease body fat
Decrease cardiovascular disease risk
Stress Reduction
Prevent Type-II diabetes in the first place
Management & Meds
 Careful monitoring of blood glucose and
attention to balancing food intake and meds
are needed for safe participation.
 Watch for hypoglycemia – the effects of both
insulin and oral agents may cause.
 If exercise sessions are due to exceed 60’,
test blood glucose during exercise.
 Should avoid exercise if blood glucose level
is below 60.
Recommendations for
Programming
 Must be individualized
 Predictable and consistent in frequency, intensity,
and time
 Type I – daily exercise recommended for best sugar
regulation
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Shorter duration (20-30’)
 Type II – 3-5x/wk
 Lower intensity, longer duration
 Be aware of contraindications for exercise such as
illness or infection.
 Be on guard for hypoglycemia.
Special Considerations
 Insulin adjustments by physician only.
 Insulin dosage may be warranted 30-60 minutes ahead of
session.
 Those with type I must consider food intake with exercise.
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In general, 1 hour of exercise requires an additional 15 g of
carbohydrates before OR after exercise.
If exercise is vigorous or of longer duration, an added 15-30
g of carbohydrates for every hour may be needed.
 Be aware of proper precautions such as glucose tabs,
hydration, foot care, medical identification.
 Inject into the non-exercising limbs
The Hypertensive Client
Overview
 ~ 50 million individuals have an elevated
blood pressure or are taking meds for it.
 In these people, the risk of heart disease
increase progressively with higher levels of
both systolic and diastolic blood pressure.
 Hypertension is based on the average of 2 or
more readings taken at each of 2 or more
visits after an initial screening.
Effects on the Exercise
Response
 Usually see a rise in the systolic blood
pressure from baseline in those with
hypertension who are not medicated.
 The response may be exaggerated or
diminished in certain people.
 Those will hypertension will usually have a
higher systolic blood pressure than those who
don’t have hypertenstion.
 The diastolic blood pressure may not change
or may rise slightly probably due to impaired
vasodilatory response.
 Studies show a decrease in systolic blood
Effects of Exercise Training
 Endurance training may elicit an average reduction of
~ 10 mmHg in both systolic and diastolic blood
pressure in stage I & II hypertension.
 Physically active clients with hypertension who also
have good cardiovascular fitness levels have a lower
mortality rate than sedentary and less fit people.
 Heavy resistance exercise has been shown to
increase systolic and diastolic blood pressure.
 Circuit weight training is the exception to this
however. It is OK to do!
Management & Meds
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Beta Blocker
Ace Inhibitor
Calcium Channel Blocker
Diuretic
Antihistamines/Cold meds
Tranquilizers
Antidepressants
Alcohol
Nicotine
Caffeine
Management & Meds
 The goal is to prevent sickness and death associated
with high blood pressure and to control blood
pressure by the least intrusive means possible.
 Blood pressure should be lowered and maintained
below 140/90 while controlling other modifiable
cardiovascular risk factors at the same time.
 Must rely on the RPE (rated perceived exertion) scale
vs. TTZ (target training zone) for monitoring exercise.
 Be aware of the possibility of hypotension as a result
of antihypertensive agents that reduce total
peripheral resistance by vasodilation.
Recommendations for Programming
 Mode: Aerobic exercise
 Frequency: 3-7 d/wk
 Duration: 30-60’
 Intensity: 40-70%
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Exercising at lower intensities appears to
lower blood pressure as much as, if not more
than, higher intensity exercise.
This is very important in the elderly and those
who also have chronic diseases
w/hypertension.
Special Considerations
 Do not exercise if systolic blood pressure >
200 or diastolic blood pressure > 115
 700 kcal/wk should be the initial goal
 2000 kcal/wk should be the long term goal
The COPD Client
(Chronic Obstructive
Pulmonary Disease)
Overview
 Imposes multiple pathophysiological problems:
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Ventilatory Impairments
Abnormalities of Gas Exchange
CV Impairments
Muscular Impairments
Symptomatic Limitations
Psychological Disturbances
Effects of Exercise Training
 Regular participation in exercise can cause
positive changes in COPD client:
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Cardiovascular reconditioning
Desensitization to dyspnea
Improved ventilatory efficiency
Increased muscle strength
Improved flexibility
Improved body comp
Improved balance
Enhanced body image
Recommendations for Programming
(Asthmatics)
 Must be controlled
 Take meds and have meds with them
 Extended warm-up
 Lower intensity, increase duration
 Purse-lipped breathing
 Adequate hydration
 Avoid cold, pollution, high pollen
Recommendations for
Programming (COPD)
 Mode: Aerobic exercise such as walking or
biking
 Frequency: 3-7 d/wk
 Duration: 30’ or shorter intermittent
 Intensity: duration is more important than
intensity. Rated perceived exertion 11-13/20
 Resistance training should be low resistance,
high reps, 2-3 d/wk
Special Considerations
 Rated perceived exertion is preferred
methods of monitoring intensity.
 Patients usually respond best to exercise in
mid to late morning.
 Avoid extremes in temperature and humidity.
Osteoporosis
Peak Bone Mass
 Depends upon:
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Your inherited ability to make bone
The amount of Calcium you consume
Your exercise level
 Peak bone mass is reached at about age 30.
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Beyond age 30, bone mass steadily decreases.
 Making the right lifestyle choices during peak
bone-mass building years and afterward may
contribute to a higher peak bone mass and
decrease risk of osteoporosis.
Why Should You Care?
 Osteoporosis is preventable!
 No cure for osteoporosis…only treatment.
 One out of every two women and one out of every
eight men over age 50 will have an osteoporosisrelated fracture in their lifetime.
 Fractures of the hip and spine result in:
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Disability
Decreased independence
Decreased quality of life
Increased risk of death
 Multi-billion dollar cost to our health-care system
annually.
Osteoporosis in the Lumbar Spine
Osteoporosis makes the normal honeycomb matrix inside your
bones (left) more porous. Under a microscope, osteoporotic bone
(right) looks like a steel bridge with many girders missing.
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Osteoporosis in the Lumbar
Spine
Four Steps to Prevent Osteoporosis
(From the National Osteoporosis Foundation)
A balanced diet rich in calcium and
vitamin -D
2. A healthy lifestyle without smoking and
excessive alcohol use.
3. Bone density testing and medication when
appropriate.
4. Weight-bearing exercise (and a program
that incorporates balance training for fall
prevention).
1.
Which Type of Exercise Is Best to
Prevent Osteoporosis?
 Resistance training combined with
cardiovascular training (bike or walking) is
the best recommendation for an exercise
program for a patient with osteoporosis.
(ACSM)
 The level of exercise depends upon age and
the level of osteoporosis that is present.
Which Type of Exercise Is Best to
Prevent Osteoporosis?
 Younger or middle-aged individuals are
typically safe to engage in high impact
activities which may increase bone mineral
density.
 Older individuals may be permitted in high
impact exercises providing that osteoporosis
is not severe; however, it may increase the
risk of a fracture.
Which Type of Exercise Is Best
to Prevent Osteoporosis?
 Weight bearing Exercises (min of 4 days/wk)
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Activity that is done with your feet in contact with the
ground so the force of gravity acts through the
skeleton.
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Activities that involve carrying your own body weight.
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Walking
Dancing
Racquet Sports
Jogging
Stair Climbing
Hiking
These activities apply tension and pressure to the
muscles and bones.
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Stimulates the body to increase/maintain bone density in
response to the additional stress.
Resistance Training Offers
Protective Benefits
 Resistance training appears the offer the most
benefits for increases in muscular strength and
bone density… even in the elderly.
 Patients with severe osteoporosis should
initially be supervised to ensure proper form
and technique.
 Increases muscular strength  minimize falls.
 Current recommendations include:
 1 set of 15 repetitions
 8-10 exercises (avoid spinal flexion, maintain upright
posture)
 Performed ~4 days per week
Effectiveness of Exercise
 The effectiveness of exercise in the
prevention of osteoporosis is dependant
upon principle of Progressive Overload.
 The amount of exercise needed to obtain
increases in bone mass depends upon the
person’s current level of physical activity –
Sedentary vs. Active
Effectiveness of Exercise
 Gains made in bone mineral density will
only be maintained as long as the exercise
is continued. (ACSM)
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Individuals should not assume that a short
period of exercise (weeks or months) will
achieve long-term effects on their bones.
 Approximately 9 months to 1 year are
required to detect a significant change in
bone mass. (ACSM)
Exercise Recommendations
(ACSM)
 The following areas of focus are quite
appropriate for those with osteoporosis:
Coordination & Balance Training
 Strength Training
 Flexibility Training
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Exercise Recommendations
 Walking program
 Safe mode of exercise
 Should provide the needed benefits
 Non Weight Bearing Activities
 For those with significant fragility
 Should consider pool activities as an alternative to
weight bearing exercise
 Minimal improvements in bone mineral density noted
Exercise “No No’s” For Osteoporosis
 Avoid jerky, rapid movements while performing
exercises.
 Avoid high impact exercises that impart high loads to
the skeleton:
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Jogging/Running
High impact aerobics
Jumping
 Avoid exercises involving forward bending or excessive
twisting at the waist:
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LiftingRowing machine
Sit ups
Bowling
Golf
Tennis
 Avoid activities that increase risk of falling:
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Trampolines
Slippery floors
Step aerobics
Skating
Safety Tips Around the House
 Proper mechanics during lifting is absolutely
critical - avoid forward bending
 Be careful vacuuming, sweeping, mopping,
and gardening due to the high degree of
bending and twisting of the spine
 Use straddle stance with knees slightly bent.
 Use rocking motion to shift body weight, keep
straight back.
Osteoporosis
 It is never too early or too late to start a
prevention program.
 Resistance training combined with
cardiovascular training is the best exercise
program for a patient with osteoporosis.
 Exercise cannot substitute for hormones at
menopause. A program of Hormone
Replacement Therapy & Exercise combined is
most effective in preventing further bone loss.
Osteoporosis
 Non-weight bearing exercises are more
appropriate for those who have severe
osteoporosis.
 To protect one’s bone mass density, an
exercise program must be life long and
performed consistently.
 Habitual inactivity results in a downward
spiral in physiologic functions.
Special Considerations
 Be aware of clients anxiety about falling.
 Keep environment free of hazards.
 Wall railing are helpful.
 Monitor balance drills closely to avoid
mishaps during exercise sessions.
The Arthritic Client
Overview
 There are more than 100
rheumatological diseases, each having
varying degrees of articular and systemic
involvement.
 2 most common:
Osteoarthritis – a.k.a. Degenerative joint
disorder
 Rheumatoid arthritis – inflammatory disease
due to an autoimmune response against
joint tissue.
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Effects on the Exercise
Response
 Inflammatory rheumatic diseases can affect
cardiac and pulmonary function.
 This must be considered before performing
any vigorous exercise.
 If current flare-ups are occurring, post-pone
exercise.
 Pain, stiffness and BM inefficiency can
increase metabolic cost of exercise by ~ 50%.
Effects of Exercise Training
 These clients are able to participate in
regular, conditioning exercise to improve all
aspects of fitness and health.
 The most immediate benefit of exercise for
this group is to diminish effects of inactivity.
 These clients respond favorably to a lowmoderate, gradually progressed exercise
program.
Recommendations for
Programming
 Low impact exercises
 Avoid activities with quick movements
 Focus on range of motion & strengthening
muscles
 Exercise intensity varies with disease activity
and pain level (15’ twice/day).
 Use low intensity and duration during initial
phase
 Alternate modes of exercise to include interval
or cross training
 Set time goals vs. distance goals
Recommendations for
Programming
 Avoid:
 Overstretching
 Climbing
stairs
 Contact sports
 Activities requiring prolonged 1-legged
standing
 Activities requiring rapid stop & go
Special Considerations
 Be aware of the need for joint protection
 Avoid overstretching unstable joints
 Avoid medial & lateral forces
 High-rep, high-resistance, high impact not
recommended
 Depression may be an obstacle to lifestyle
change