Special Considerations across the Lifespan: Pregnancy, Children and Youth, and Older Adults

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This chapter addresses exercise testing, prescription, and progression considerations for three conditions that may occur across the lifespan including pregnancy, children and youth, and older adults. Online case studies are available for each of these conditions.

PREGNANCY

Pregnancy is characterized by profound physiological and anatomical adaptations that ensure optimal accommodations to the increasing metabolic demands of both mother and fetus (5,26,43,51,91). Pregnancy involves a gestational period, typically between 38 and 40 weeks divided into trimesters, each characterized by unique physiological and anatomical adaptations (27,43,91). A thorough understanding of the physiological and anatomical adaptations that occur with pregnancy allows the fitness professional to safely and effectively design an exercise program.

Many of the physiological and anatomical adaptations that occur during pregnancy are related to increased plasma and tissue concentrations of hormones, growth factors, prostanoids, and other substances (43,51,91). Hemodynamic adaptations include an increase in total blood volume of approximately 30%–50% (43,51) associated with an increase in cardiac output of approximately 1,500 mL (51). The disproportionate increase in plasma volume (1,000 mL) compared with erythrocyte volume (500 mL) commonly results in dilutional anemia and fatigue (51). Resting heart rate (HR) increases by approximately 16 bpm and maximal HR decreases by approximately 4 bpm through the gestational period (43), resulting in a net reduction in gestational heart rate reserve (HRR) (51). Resting blood pressure (BP) remains fairly consistent in uncomplicated pregnancies as the significant increase in blood volume is offset by systemic peripheral vascular dilation (5,51). Diastolic BP decreases approximately 15 mm Hg by mid-pregnancy, and systolic BP remains similar to or slightly decreases compared with the nonpregnant state (51). A reduction in mean arterial BP occurs by mid-second trimester, gradually returning to prepregnancy levels (5,43,51). The hemodynamic adaptations that occur during pregnancy often result in soft tissue edema most commonly observed during the third trimester and presenting as lower leg and ankle edema (27). Increased glomerular filtration rate accompanied by increased diuresis presents as renal adaptations during pregnancy (91). The respiratory/ventilatory adaptations include increased tidal volume, bronchiole dilation, an increase in minute ventilation by approximately 30%–50%, an increase in absolute oxygen consumption both at rest and with activity, and a reduced carbon dioxide threshold (43).

The most prevalent visible anatomical adaptation during pregnancy is gestational weight gain (13,25,55,56,75,90) ranging from 10 to 16 kg (22 to 35 lb) (5) primarily distributed at the breasts and the abdominal region (5,27,43). The distributional pattern of gestational weight gain results in an anterior translation of the center of gravity, which increases the risk for balance complications, most prevalent during the second and third trimesters (5,27). The adaptive pelvic posture that occurs during pregnancy often results in a functional imbalance between hip flexors and hip extensors, resulting in pseudo-hamstring tightness and positional instability of the hip abductors (27). Lumbar-pelvic postural alterations result in compensatory shoulder girdle postural accommodations, altering glenohumeral joint and cervical spine mechanics (27). A physiological and structural adaption that occurs during pregnancy is laxity of ligamentous structures derived from increased levels of estrogen, progesterone, and relaxin (41,91) primarily occurring at the pubic symphysis to accommodate childbirth; yet, joint laxity is demonstrated systemically (12,27,43). Bone density loss occurs during pregnancy and lactation yet rarely results in osteoporosis (27).

Metabolic and musculoskeletal anomalies frequently plague women during pregnancy including gestational hypertension (27), preeclampsia (6), gestational diabetes mellitus (GDM) (10,30,62,85), low back pain (LBP) (38,88), diastasis recti abdominis (27), lower extremity edema (27), carpal tunnel syndrome (27), and tarsal tunnel syndrome (27), to name a few.

Preparticipation Health Screening, Medical History, and Physical Examination

The ePARmed-X+ Physician Clearance Follow-Up Questionnaire (Fig. 9.1) is the recommended screening tool utilized by physicians and other obstetric health care providers to provide medical clearance for exercise initiation or continuation during pregnancy (18,93). The PARmed-X was designed to establish a line of communication between the woman during gestation, the health care provider, and the fitness specialist (18). The PARmed-X incorporates a gestational safety and care continuum including sections on Safety Considerations and Reasons to Consult a Physician, ensuring participant safety with exercise and when unscheduled medical consultation may be warranted (18).

FIGURE 9.1. ePARmed-X+ Physician Clearance Follow-Up Questionnaire+. (Reprinted with permission from the PAR-Q+ Collaboration and the authors of the PAR-Q+ [Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin].)

Exercise Testing Considerations

Maximal exercise testing is not indicated for women who are pregnant unless medically authorized and performed with medical supervision (1,3,5). The PARmed-X will assist the medical provider and the fitness professional in determining if exercise testing is required (93).

Exercise Prescription and Progression Considerations

Physical Activity and Exercise during Pregnancy

Because of its dynamically adaptive nature, pregnancy presents a challenge for fitness professionals regarding achievement of optimal gestational and postpartum outcomes for both mother and offspring. There is general consensus regarding physical activity during pregnancy among the American College of Obstetricians and Gynecologists (ACOG) (3), Society of Obstetricians and Gynaecologists of Canada (SOGC) (26), Canadian Society for Exercise Physiology (CSEP) (26), Royal College of Obstetricians and Gynaecologists (RCOG) (73), The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (Sports Medicine Australia [SMA]) (78), and the American College of Sports Medicine (ACSM) (4,5,28). The available data strongly support and recommend physical activity prior to conception, during the gestational period, and through the postpartum period for healthy women with uncomplicated pregnancies not presenting with absolute and/or relative contraindications to exercise (Box 9.1). Initiation or continuation of an exercise program should be encouraged through the gestational period unless the woman presents with warning signs requiring exercise termination and medical consultation (see “Special Considerations for Exercise and Pregnancy” and Box 9.2). See Box 9.3 for the current committee opinion recommendations from ACOG regarding physical activity and exercise during pregnancy and through the postpartum period.

Box 9.1

Contraindications for Exercising during Pregnancy

Absolute Contraindications	Relative Contraindications
Hemodynamically significant heart disease	Severe anemia
Restrictive lung disease	Unevaluated maternal cardiac dysrhythmia
Incompetent cervix or cerclage	Chronic bronchitis
Multiple gestation at risk of premature labor	Poorly controlled type 1 diabetes
Persistent second- or third-trimester bleeding	Extreme morbid obesity
Placenta previa after 26 weeks of gestation	Extreme underweight (BMI less than 12)
Premature labor during the current pregnancy	History of extremely sedentary lifestyle
Ruptured membranes	Intrauterine growth restriction in current pregnancy
Preeclampsia/pregnancy-induced hypertension	Poorly controlled hypertension
	Orthopedic limitations
	Poorly controlled seizure disorder
	Poorly controlled hyperthyroidism
	Heavy smoker

Reprinted with permission from American College of Obstetricians and Gynecologists. Physical Activity and Exercise During Pregnancy and the Postpartum Period. Committee Opinion Number 650. Washington (DC): American College of Obstetricians and Gynecologists; 2002. 8 p.

From American College of Obstetricians and Gynecologists. Physical Activity and Exercise During Pregnancy and the Postpartum Period. Committee Opinion Number 650. (Replaces Committee Opinion Number 267, January 2002). Washington (DC): American College of Obstetricians and Gynecologists; 2015. 8 p.

Box 9.2

Warning Signs to Stop Exercise during Pregnancy

Vaginal bleeding or (amniotic) fluid leakage

Shortness of breath prior to exertion

Dizziness, feeling faint, or headache

Chest pain

Muscle weakness

Calf pain or swelling

Decreased fetal movement

Preterm labor

From American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postpartum period. ACOG Committee Opinion Number 267. Washington (DC): American College of Obstetricians and Gynecologists; 2002. 3 p.

Box 9.3

Current Committee Opinion Recommendations from the American College of Obstetricians and Gynecologists Regarding Physical Activity and Exercise during Pregnancy and the Postpartum Period

Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements.

A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise.

Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.

Obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy. Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered.

Regular physical activity during pregnancy improves or maintains physical fitness.

Regular participation in moderate-intensity physical activity during pregnancy has been demonstrated to be beneficial for both mother and fetus (5,55). See Box 9.4.

Box 9.4

Benefits of Physical Activity before and during Pregnancy

Some benefits associated with regular physical activity before and during the gestational period include a reduced risk of the following:

Preeclampsia (6)

Gestational hypertension (HTN), GDM (85,86)

Systemic inflammation (84)

Excessive gestational weight gain (53)

Gestational obesity (55)

Gestational low BP (38,88)

Generalized musculoskeletal discomfort (26)

Urinary incontinence (65)

Having a baby with macrosomia (86)

Interventional delivery (9)

Cesarean birth (9)

Preterm birth (9)

Low–birth-weight baby (11,17)

Prevention/improvement of depressive symptoms

Prevention of postpartum weight retention (55)

Women who continue with a healthy lifestyle and those who adopt a healthy lifestyle throughout pregnancy, inclusive of regular aerobic exercise, demonstrate specific activity-related adaptations, compared with sedentary peers, similar to the nonpregnant state such as reduced resting HR, increased stroke volume, enhanced glucose utilization, enhanced thermoregulation, and increased volume of oxygen consumed per unit time (O₂) response at a given HR (5,51).

Target HR ranges based on age and fitness level that correspond to moderate-intensity exercise have been validated and adopted for low-risk women who are pregnant (2,25,53,56) (Table 9.1). Women who demonstrate at-risk pregnancies determined by the PARmed-X for Pregnancy, or determined through medical examination, characterized as high-risk women who are pregnant, should proceed with exercise planning only if cleared for exercise by their physician.

Table 9.1

Target Heart Rate Zones that Correspond to Moderate-Intensity Exercise for Healthy Low-Risk Women Who Are Pregnant and Lower Intensity Exercise Target Heart Rate Zones for Low-Risk Women Who Are Pregnant and Overweight or Obese

BMI 18.9−24.9 kg∙ m⁻²
Age (yr)	Fitness Level	Heart Rate Range (bpm)
<20	—	140–155
20–29	Low	129–144
	Active	135–150
	Fit	145–160
30–39	Low	128–144
	Active	130–145
	Fit	140–156
BMI ≥25 kg ∙ m⁻²
Age (yr)		Heart Rate Range (bpm)
20–29		102–124
30–39		101–120

From Davenport MH, Charlesworth S, Vanderspank D, Sopper MM, Mottola MF. Development and validation of exercise target heart rate zones for overweight and obese pregnant women. Appl Physiol Nutr Metab. 2008;33:984–9. doi:10.1139/H08-086; Mottola MF. Exercise and pregnancy: Canadian guidelines for health care professionals. Wellspring. 2011;22(4):1–4; Mottola MF. Physical activity and maternal obesity: cardiovascular adaptations, exercise recommendations, and pregnancy outcomes. Nutr Rev. 2013;71(suppl 1):S31–6. doi:10.1111/nure.12064; and Mottola MF, Davenport MH, Brun CR, Inglis SD, Charlesworth S, Sopper MM. O_2peak prediction and exercise prescription for pregnant women. Med Sci Sports Exerc. 2006;38(8):1389–95.

Types of Prescribed Exercises for Pregnancy

The prescribed resistance training session should contain a warm-up and cool-down component of approximately 8 minutes in duration each, and resistance exercises for 20–30 minutes with approximately 1 minute rest between sets and approximately 2 minutes rest between exercises (60). Greater rest time should be allotted for less fit women (69). Resistance can safely be derived from use of body weight resistance, resistance bands, resistance tubing, light dumbbells, water resistance, and appropriately positioned resistance machines (9,60,69).

Exercises that promote lumbar-pelvic girdle and scapular-cervical postural stabilization, maintenance of muscle tone, flexibility, and general conditioning should be emphasized in order to minimize the deleterious effects of the postural adaptations common during pregnancy (34,51,60,69). Exercises performed in the supine position (lying on one’s back) are contraindicated, and exercises performed in the prone position (lying on one’s stomach) should be avoided beyond the first trimester (53). Resistance training can safely be performed in the seated position with lumbar support in order to avoid overloading posturally compromised joints (69). Exercises such as lunges, straight-legg deadlifts, and deep squats should be avoided during the gestational period (69). Exercise prescription should be individually designed based on specific needs and goals; therefore, the exercise specialist should be able to competently substitute a specific exercise for an exercise that has been contraindicated for the woman who is pregnant in order to avoid adverse outcomes.

The volume of exercise prescribed to the woman during pregnancy will be dependent on the woman’s training status, musculoskeletal condition, and other individual factors that could vary day to day. Common exercise volume recommendations during pregnancy included one to two sets of 10–15 repetitions performed for six to eight exercises (9,34,60). The frequency, intensity, type, and time (FITT) table (Table 9.2) summarizes the frequency, intensity, time, type, volume, and progression (FITT-VP) recommended by the ACSM for pregnancy.

TABLE 9.2 FITT RECOMMENDATIONS ACROSS THE LIFESPAN

ACSM FITT Principle of the ExR_x

Chronic Medical Condition	Frequency (How often?)	Intensity (How hard?)	Time	Type (What kind?) Primary	Resistance	Flexibility	Special Considerations
Healthy Adult	≥5 d ∙ wk⁻¹ of moderate exercise, or ≥3 d ∙ wk⁻¹ of vigorous exercise, or a combination of moderate and vigorous exercise on ≥3–5 d ∙ wk⁻¹ is recommended.	Moderate to vigorous. Light-to-moderate intensity exercise may be beneficial in deconditioned individuals.	If moderate intensity: ≥30 min ∙ d⁻¹ to total 150 min ∙ wk⁻¹. If vigorous intensity: ≥20 min ∙ d⁻¹ to total 75 min ∙ wk⁻¹.	Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature is recommended.	2–3 d ∙ wk⁻¹ (nonconsecutive)	2–3 d ∙ wk⁻¹; static stretch 10–30 s; 2–4 repetitions of each exercise	Sedentary behaviors can have adverse health effects, even among those who regularly exercise. Adding short physical activity breaks throughout the day may be considered as a part of the exercise.
Children and Adolescents	Daily	Most should be moderate (noticeable increase in HR and breathing) to vigorous intensity (substantial increases in HR and breathing). Include vigorous intensity at least 3 d ∙ wk⁻¹.	As part of ≥60 min ∙ d⁻¹ of exercise	Enjoyable and developmentally appropriate activities, including running, brisk walking, swimming, dancing, bicycling, and sports such as soccer, basketball, or tennis	≥3 d ∙ wk⁻¹	N/A	Bone-strengthening activities include running, jump rope, basketball, tennis, resistance training, and hopscotch.
Older Adults	≥5 d ∙ wk⁻¹ for moderate intensity; ≥3 d ∙ wk⁻¹ for vigorous intensity; 3–5 d ∙ wk⁻¹ for a combination of moderate and vigorous intensity	On a scale of 0–10 for level of physical exertion, 5–6 for moderate intensity and 7–8 for vigorous intensity	30–60 min ∙ d⁻¹ of moderate-intensity exercise; 20–30 min ∙ d⁻¹ of vigorous-intensity exercise; or an equivalent combination of moderate- and vigorous-intensity exercise; may be accumulated in bouts of at least 10 min each	Any modality that does not impose excessive orthopedic stress such as walking. Aquatic exercise and stationary cycle exercise may be advantageous for those with limited tolerance for weight-bearing activity.	≥2 d ∙ wk⁻¹	≥2 d ∙ wk⁻¹
Women Who Are Pregnant	≥3–5 d ∙ wk⁻¹	Moderate intensity (3–5.9 METs; RPE of 12–13 on the 6–20 scale); vigorous-intensity exercise (≥6 METs; RPE 14–17 on the 6–20 scale) for women who were highly active prior to pregnancy or for women who progress to higher fitness levels during pregnancy	~30 min ∙ d⁻¹ of accumulated moderate-intensity exercise to total at least 150 min ∙ wk⁻¹ or 75 min ∙ wk⁻¹ of vigorous-intensity aerobic exercise	A variety of weight- and non–weight-bearing activities are well tolerated during pregnancy (e.g., hiking, group exercise, swimming).	2–3 d ∙ wk⁻¹ (nonconsecutive)	≥2–3 d ∙ wk−1 with daily being most effective