Special Conditions

Edward M. Phillips

INTRODUCTION

Much of the material covered thus far addresses exercise prescription and the benefits of physical activity in the apparently healthy patient. Many of your patients, however, will present with illnesses or conditions that will impact their ability to undertake and continue a program of physical activity. In Chapter 3, we covered screening of these individuals to best assure their safety in initiating, maintaining, or increasing physical activity. In this chapter, we will focus on 10 different prevalent conditions and detail the use of exercise in managing these conditions or performing exercise with the conditions.

Despite the diversity of the conditions detailed in this chapter, the exercise prescription often follows the general recommendations for apparently healthy adults. In each section, we will focus on modifications and precautions to this general recommendation (Figure 13.1).

For each condition we will follow roughly the same format to make it easier for you to quickly find the salient information:

Illness or Condition
Definition
Prevalence and Incidence
Other treatments (medication, surgery, etc.)
Testing and screening, with reference to Chapter 3
Precautions
Exercise Prescription: Modifications from general recommendations

This selection of illnesses and conditions is not meant to be exhaustive. A more thorough description of the use of exercise in 46 conditions may be found in ACSM’s Exercise Management for Persons with Chronic Disease and Disability Book (1) or in the Guidelines for Exercise Prescription and Testing, Chapter 10, on Special Conditions (2). The following represent prevalent conditions that your patient will likely present:

Arthritis
Hypertension
Overweight/Obesity
Osteoporosis
Pregnancy
Cancer
Cardiovascular Disease
Older Adults
Depression
Diabetes

Figure 13.1 • Exercise Prescription for Healthy Adult.

ARTHRITIS

Definition

While there are over 100 rheumatic diseases, the most common conditions that your patients will present with include osteoarthritis and rheumatoid arthritis (3, 4). Osteoarthritis, or degenerative joint disease, primarily affects the joints in the weight bearing regions of the spine, hips, and knees, but often affects the hands as well. Rheumatoid arthritis is a condition of pathological activity of the immune system that commonly affects the joints.

Incidence and Prevalence

By 2020 more than 60 million people in the United States will be affected by these conditions. More than 80% of your patients above the age of 65 will present with some evidence of degenerative joint disease (osteoarthritis).

Other Treatments (5)

Weight loss
Education in self-management
Patient support groups
Appropriate footwear to reduce shock to lower extremities
Occupational Therapy
Physical Therapy
Assistive devices (canes, walkers, bracing)
Non-steroidal anti-inflammatory medications
Disease modifying medications for rheumatoid arthritis
Surgery for joint debridement and total joint replacement

Benefits of Exercise

Strengthening and maintenance of muscle strength around joints from resistance training
Reduced joint stiffness from stretching and physical activity

Screening

Avoid vigorous-intensity physical activity if there is an acutely inflamed joint being exercised. If lower extremity arthritis prevents comfortably walking on a treadmill or using a bicycle, consider using upper extremity exercise with an arm ergometer (a bicycle device for the arms). Be especially careful to allow for adequate warm-up time at a low intensity before pursuing a more strenuous exercise test. Isotonic, isokinetic, or isometric muscle strength can be assessed (2).

Exercise Prescription

As with many other conditions, the general recommendation for FITT (Frequency, Intensity, Time, and Type) follows those for apparently healthy adults.

Modifications: Your patients with acutely or chronically painful knees and hips commonly complain that even walking is difficult. You may recommend exercises with low stress across the lower extremity joints including bicycling, swimming, or walking in the water to reduce the effects of gravity. Exercise in warm water 83°-88°F (28-31°C) helps with pain reduction and relaxation of the muscles. Walking may be aided by a cane to partially unweight joints. As your patient progresses, emphasize increasing the time rather than the intensity of their activity.

Resistance training will directly strengthen the muscle weakness around the affected joint. This may comfortably begin with isometric contractions, such as straight leg raises for a painful knee that do not involve moving the affected joint. As your patient becomes stronger and more comfortable, you may then advise him to progress to isotonic training of the affected joints.

Stretching helps maintain flexibility. Gentle movement through the full available range of motion may safely be advised even when your patient experiences inflammation and pain.

Patient Education

Patients should understand the vital role of resistance training to help maintain strong muscles around the affected joint, and will reduce stress across the joint. For example, strengthening the quadriceps and hamstrings will provide support to arthritic knees. Arthritic patients who initiate a program of exercise must understand that some discomfort while exercising or for two hours after they exercise should be expected, and does not indicate that they are injuring their joints. If the pain continues well after the first two hours or exceeds their general level of joint pain, they should be counseled to reduce the duration and/or intensity in their next session. It is quite reasonable to time the exercises with their period of least severity of pain and/or after taking pain medications.

The impact of arthritic conditions on your patient’s function is critical. As such, exercises may appropriately focus on maintaining common activities such as transferring from sit-to-stand or step-ups to maintain independence in daily living.

HYPERTENSION

Definition

Hypertension is defined by a resting systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg. Blood pressure as low as 120/80 mm Hg is considered pre-hypertension (6) and puts your patient at a higher risk for ischemic heart disease and stroke. See Table 13.1 for blood pressure classification scheme. Essential hypertension, where the cause of the high blood pressure is not known, accounts for 90% of the incidence.

Incidence and Prevalence

Approximately 65 million Americans have high blood pressure. A majority of your older patients will have hypertension. Fortunately, the beneficial reduction of blood pressure through exercise occurs regardless of age.

TABLE 13.1 Classification and Management of Blood Pressure for Adults†

				Initial Drug Therapy
BP Classification	SBP mm Hg	DBP mm Hg	Lifestyle Modification	Without Compelling Indication	With Compelling Indications
Normal	<120	And <80	Encourage	No
Prehypertension	120-139	Or 80-89	Yes	No antihypertensive drug indicated	Drug(s) for compelling indications.‡
Stage 1 Hypertension	140-159	Or 90-99	Yes	Antihypertensive drug(s) indicated	Drug(s) for compelling indications.‡ Other antihypertensive drugs, as needed.
Stage 2 Hypertension	≥160	Or≥100	Yes	Antihypertensive drug(s) indicated. Two-drug combination for most.§
†Treatment determined by highest BP category. ‡ Compelling indications include heart failure, post-myocardial infarction, high coronary heart disease risk, diabetes, chronic kidney disease, and recurrent stroke prevention. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg. § Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure. Adapted from National High Blood Pressure Education Program. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). 2003; 3:5233.

Other Treatments

Weight loss
DASH Diet (Dietary Approaches to Stop Hypertension)
Medications

Benefits of Exercise

Reductions of 5-7 mm Hg are achieved in patients who are hypertensive who maintain an aerobic training program (7). Blood pressure is also lowered at submaximal exercise workloads. Immediately after aerobic exercise, your patient will experience lower blood pressure from post-exercise hypotension.

Because of the marked overlap of overweight/obesity and hypertension, the exercise program should be designed to help with weight reduction and maintenance of weight loss. This will involve working toward a longer period of exercise each week. (Please see Overweight/Obesity section below.)

Screening

Patients with resting SBP ≥200 mm Hg or DBP ≥110 mm Hg should not undergo exercise testing nor be allowed to exercise. Patients on beta-blockers may have reduced exercise capacity during testing due to the medication. Because of the chronotropic effect of these medications, the patient’s perceived exertion might be a more appropriate measure than heart rate during screening and exercise sessions.

Exercise Prescription

As with many other conditions, the general recommendation for FITT (Frequency, Intensity, Time, and Type) follows those for apparently healthy adults with the following precautions.

Your patients are stratified into three different risk groups according to their blood pressure level and presence of other cardiovascular risk factors, target organ damage, or clinical cardiovascular disease (see Table 13.1 Blood Pressure Classification). While patients with hypertension need medical evaluation before formal exercise testing, the majority of your patients with hypertension can safely initiate moderate-intensity aerobic exercise. If the patient is in the most-severe risk group and wishes to pursue moderate-intensity exercise, he should be referred for a symptom-limited graded exercise test. The same recommendation holds for any hypertensive patient who would like to train at a vigorous intensity.

During resistance training, your patient should be instructed to avoid Valsalva maneuver by learning to breathe throughout the exercise. If your patient is being treated with alpha-blocker, calcium channel blocker, or vasodilators, she must be instructed to watch for sudden reductions in blood pressure after exercise. These patients should be monitored during exercise and in the cool-down period. Diuretic therapy may induce hypokalemia or
cardiac dysrhythmias. Diuretics and beta-blockers may cause hypoglycemia in some individuals (see Diabetes section, below). These same medications may affect thermoregulatory function and cause heat intolerance. Exercise capacity may be reduced by beta-blockers. Exercise should be stopped for SBP ≥250 mm Hg and/or DBP ≥115 mm Hg.

Patients with cardiovascular disease (ischemic heart disease, heart failure, or stroke) may undergo vigorous-intensity exercise training under medical supervision.

OVERWEIGHT AND OBESITY

Definition, Prevalence, and Incidence

More than 66% of American adults are classified as overweight as indicated by a BMI ≥25 kg/m². Nearly one-third are obese, with BMI ≥30 kg/m², and 5% are extremely obese, with BMI ≥40 kg/m² (8). As a rule of thumb, if your 5-foot-3-inch female patient is 30 pounds overweight, she is considered obese. As detailed in Chapter 14, obesity is a rising concern for children and adolescents with 14%-18% overweight. In youth, overweight is classified as ≥85th percentile of BMI for age and gender (8).

Other Treatments

Medications
Bariatric surgery
Weight loss regimens through caloric restriction
Support groups

Weight management boils down to finding the proper balance of energy intake and energy expenditure. For your patients who have habitually taken in more calories than they use, the result is an excess of energy stored as fat. Rebalancing so that your patient expends more than he takes in will result in weight loss. An appropriate weight loss goal for overweight and obese individuals to achieve significant health benefits (9) is 5%-10%. This rather modest weight loss goal (as little as a 15-pound loss in a 300-pound individual) is consistent with the discussion in the chapters on motivation (Chapters 4, 5, 6) that stress setting achievable goals and taking small steps to begin the process. Even so, maintaining weight loss is notoriously difficult, with one-third to half of weight regained within a year of completing the diet or medication regimen (10).

Weight loss regimens with reduced caloric intake and increased burning of calories through more physical activity and exercise result in 9%-10% loss of weight (10). Interestingly, physical activity has little impact on the amount of weight lost in the first six months, compared to dieting (9); however, adequate physical activity is critical to maintaining weight loss (11). Stated another way,
exercise alone won’t get the weight off, but exercise is essential to keeping the weight off.

Meeting the recommended minimal physical activity with moderate-intensity exercise at around 6 calories per minute performed for at least 150 minutes per week results in approximately 900 kcal of energy expenditure in exercise. The National Weight Control Registry at the University of Colorado reports that individuals who have lost at least 30 kilograms and kept this weight off for at least five years maintain weekly exercise of 2800 kcal (12).

Testing and Screening

The co-morbidities commonly associated with overweight and obesity (e.g., hypertension, diabetes, and heart disease) may increase the required level of screening before exercise testing or commencing an exercise regimen. With obese individuals, walking on a treadmill may not be practical. Testing or exercise on a cycle with an appropriate seat may be appropriate. Anticipate extremely low exercise capacity in patients who are overweight and obese. Start exercise as low as 2-3 METs and advance as slowly as 0.5 METs during testing or exercise sessions.

Exercise Prescription: Modifications From General Recommendations

For overweight and obese patients, the general recommendations for the exercise prescription follow those of apparently healthy adults for aerobics, resistance, and flexibility. The minimum dose of 150 minutes per week of moderately intense physical activity confers the general health benefits. The modification for overweight and obese patients is to increase the frequency to five or more days per week to maximize caloric expenditure. Intensity may start at moderate and increase to vigorous to obtain higher levels of physical fitness. Similarly, time in exercise should be increased from 30 minutes to 60 minutes daily (or longer), again to burn more calories. The type of exercise will generally involve large muscle groups, such as walking or cycling. Resistance training will help balance the exercise program.

OSTEOPOROSIS

Definition

Osteoporosis is a disease of the bones characterized by low bone mineral density (BMD) and susceptibility to fracture from alteration of the microarchitecture of the bone. Osteoporosis in postmenopausal women and men 50 years of age or older is defined by BMD T-score of the lumbar spine, total hip, or femoral neck of more than 2.5 standard deviations below the young adult mean value, with or without accompanying fractures (13,14,15,16). Your patients are at risk for fractures even if their BMD scores are above this threshold, especially if the patients
are elderly. Hip fractures are associated with the greatest increased risk of death and disability.

Incidence and Prevalence

More than 10 million Americans 50 years of age and older have osteoporosis and another 34 million are at risk (17).

Benefits of Exercise

Decreased osteoporotic fractures by increased peak bone mass
Slowed rate of bone loss with aging
Reduced fall risk due to improved muscle strength and balance (18, 19)
Higher bone mass achieved in childhood, adolescence, and young adulthood through adequate physical activity is maintained into adulthood

Other Treatments

Dietary or supplementation of calcium
Vitamin D supplementation and/or exposure to sunlight
Hormone Replacement: Estrogen and progesterone
Medications

Precautions

“There are currently no established guidelines regarding contraindications for exercise for people with osteoporosis” (2). Common sense prevails, however, and patients should be advised to stay away from any exercise that causes or exacerbates pain. Twisting, bending, or compression of the spine and high impact loading or explosive movements should be avoided. As such, maximal muscle strength testing may be contraindicated in patients with severe osteoporosis. Forward flexion of the spine, even without loading, places the spine at greatly increased risk of spinal compression fractures (20).

If your patient has severe vertebral osteoporosis, then alternatives to walking may be preferable when choosing the type of exercise.

Balance may be affected by the forward shift in the center of gravity in patients with vertebral compression fractures. As discussed in exercise for older adults, exercises to improve balance and reduce the chances of falling should be addressed. Even the frailest older adults should be prescribed an activity regimen to avoid further bone loss from bed rest.

Exercise Prescription

To preserve bone health, prescribe exercise in your patients at risk for osteoporosis as defined by low bone mass, age, and female gender (17).

Frequency: Weight-bearing aerobic activities three to five days per week, and resistance exercise two to three days per week

Intensity: Moderate (eight to 12 repetitions for resistance exercise) to high intensity (five to six repetitions for resistance exercise); moderate-intensity aerobic activity (40-60% of HRR) (see Chapter 8 for definitions.)

Time: 30 to 60 minutes per day, combination of weight bearing aerobic and resistance activities

Type: Weight-bearing aerobic activities include walking and intermittent jogging, stair climbing, or tennis. Your patients may also pursue exercises that involve jumping, such as volleyball and basketball. These types of exercise help to stimulate strengthening of the bones. In addition, backstrengthening exercises (while avoiding flexion of the spine) can help the supporting muscles of the spine and thereby reduce spine fractures (20).

For patients with osteoporosis, the previous exercise prescription may be modified to avoid the high-intensity resistance exercises, although patients may be able to progress to this level. Patients with osteoporosis will not be encouraged to pursue jumping exercises or running. Non-weight-bearing exercises, such as swimming and bicycling, still confer general health benefits, muscle strengthening, and some improvements in bone health through muscle traction on the bone.

PREGNANCY

Definition

Unlike most of the conditions covered in this chapter, pregnancy is not a disease or illness. Like many other medical conditions, however, pregnancy does cause physiological changes in the body that can influence exercise participation and potentially make clinicians wary of prescribing exercise. The American College of Obstetrics and Gynecology (ACOG) and the ACSM recommend that exercise is just as important during pregnancy. Despite these recommendations, studies have shown that pregnant women (excluding those whose pregnancies are considered high-risk) are less likely to be meeting the ACSM/ AHA-recommended exercise levels (21). Therefore, as a clinician, it is particularly important to recommend exercise to patients who are currently or planning to become pregnant, with the exception of women whose pregnancies are classified as high-risk (see high-risk pregnancy below). As well as the general benefits of exercise, pregnant women are encouraged to exercise so as to have less fatigue, to benefit from better control of weight gain, and to possibly experience shorter labor (22).

Pregnancy causes a number of physiological changes in the body’s response to exercise. Although it is important to appreciate these changes, they should not prohibit most women from participating in an exercise program while pregnant. With respect to its effect on exercise, one of the most significant changes is the increase in resting energy expenditure resulting in increased
effort required to exercise (23). This increased energy consumption results in a higher [V with dot above]O2 (oxygen consumption), cardiac output, and stroke volumes; however, maximal heart rate appears to remain unchanged (23). Increases in energy expenditure also result in a greater difficulty removing heat from the body. Table 13.2 provides some tips to help pregnant women avoid overheating while exercising.

Benefits

Maintenance of prenatal aerobic and musculoskeletal fitness levels
Prevention of excessive maternal weight gain
Facilitation of labor and recovery from labor
Promotion of good posture
Prevention of gestational glucose intolerance
Prevention of low back pain
Improved psychological adjustment to the changes of pregnancy (24, 25)

Exercise Screening and Testing

Clearly, women who are pregnant are not immune to other medical conditions such as diabetes or cardiovascular disease. Therefore, the medical screening described in Chapter 3 should still be applied to pregnant women who want to begin an exercise program. Gestational diabetes mellitus is one of the most common complications of pregnancy (26, 27). In addition to the general medical screening described in Chapter 3, the ACOG recommends using the “Physical Activity Readiness Medical Examination for Pregnancy,” published
by the same group as the PAR-Q (see Chapter 3) (22). This easy-to-use screening tool is freely available at http://www.csep.ca/forms.asp.

TABLE 13.2 Exercise Tips for Pregnant Women

•	Changes in body shape and weight will affect balance. Avoid unstable positions and take extra care not to fall
•	Drink plenty of fluids before, during, and after exercising
•	Avoid overheating while exercising:
	○	Dress in layers and wear comfortable, loose-fitting clothes that permit evaporation of sweat
	○	Exercise in cooler or well-ventilated places (or times of the day)
	○	Avoid swimming in warm or hot water and avoid immersion in hot tubs
	○	Be aware of the early symptoms of heat illness: nausea, dizziness, headache, poor coordination, and apathy.
•	Set realistic exercise goals, bearing in mind the fact that exercise will become more difficult as the pregnancy progresses
•	Avoid exercising on your back (supine) in the second and third trimesters
Adapted from: Soultanakis-aligianni, 2003, and Thompson, 2007

Exercise Prescription

The American College of Obstetrics and Gynecology (ACOG) recommends that pregnant women should exercise with similar safeguards as non-pregnant women, provided that there are no medical or obstetric complications during the pregnancy (22, 28, 29). Most women who were active before pregnancy can and should continue to exercise (22, 28). Early in the pregnancy, previously active women may continue to train at their prepregnancy parameters (frequency, time/duration, intensity, and type). These parameters should naturally decrease and be modified, as the pregnancy progresses (22). In general, women who were sedentary prior to their pregnancy and whose pregnancies are not considered high-risk are safe to begin a low- or moderate-intensity program (22).

Based on these recommendations (28), the following exercise prescription is recommended for pregnant women without medical or obstetric complications:

Frequency: Same as ACSM/AHA recommendations: at least five times per week if exercising at moderate intensity, and at least three times each week if exercising at vigorous intensity

Intensity: For women who were previously sedentary, begin exercising at low to moderate intensity. Women who were previously active are initially encouraged to continue exercise at the same intensity (30). As the pregnancy progresses, the intensity usually decreases naturally (22).

Time: Same as ACSM/AHA recommendations

Type: The type of exercise that pregnant women participate in is a matter of personal choice. Contact sports, scuba diving, or other activities that might possibly cause abdominal distress should be avoided during pregnancy (30

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