Lesson 19: Exercise and Special Populations Programming Flashcards
What 3 factors does the US Center for Disease Control and Prevention estimate a reduction in would dramatically reduce chronic disease?
- Poor diet
- Physical inactivity
- Smoking
What is the SOAP note an acronym for?
Subjective
Objective
Assessment
Plan
What is the SOAP Note used for?
It is used by healthcare providers to document patient progress.
SOAP stands for subjective, objective, assessment and plan - what does each of these mean?
- Subjective is the observations that include the client’s own status report with a description of symptoms, challenges, progression.
- Objective is measurements of vital signs, height, weight, age, posture, nutrition log and exercise test results.
- Assessment is a brief summary of their current status based on both subjective and objective measurements.
- Plan is the next steps within the program.
Over time, what do SOAP notes document patterns of?
a client’s self-image
What is a comorbidity?
When someone has more than one disorder.
What are 6 cardiovascular disorders that around 80.7 million Americans suffer from?
Dyslipidemia Coronary Artery Disease Congestive Heart Failure Hypertension Stroke Peripheral Vascular Disease
What are 7 well-established risk factors that contribute to cardiovascular disease?
- Family history
- Hypertension
- Smoking
- Diabetes
- Age
- Dyslipidemia
- Lifestyle
Atherosclerotic Heart Disease/Coronary Artery Disease is characterized by?
A narrowing of the coronary arteries that supply the heart muscle with blood and oxygen.
What is Atherosclerotic Heart Disease/CAD a result of/to?
It is an inflammatory response within the arterial walls resulting from an initial injury - due to HBP, elevated levels of low-density lipoprotein, cholesterol, elevated blood glucose or other chemical agents - and the deposition of lipid-rich plaque and calcified cholesterol.
What are myocardial infarctions a result of?
They are a result of the rupture of vulnerable plaques and the release of thrombotic substances that narrow or completely constrict the diameter of an artery.
What is Atherosclerosis the underlying cause of?
Cerebral and peripheral vascular diseases
What are some indications of Atherosclerosis? (4)
Angina, heart attack, stroke, intermittent claudication.
What is claudication?
A pain that is caused by too little blood flow to your legs and arms.
What is dyslipidemia?
An abnormal amount of lipids within your blood.
What test should all clients with documented CAD have done and why?
A maximal graded exercise test that is supervised by a physician.
This determines their functional capacity and cardiovascular status to establish a safe exercise level.
What defines a low-risk cardiac client?
- an uncomplicated clinical course in the hospital
- no evidence of resting or exercise-induced ischemia
- functional capacity greater than 7 METs after 3 weeks of any hospitalization
- normal ventricular function with an ejection fraction greater than 50%
- no significant resting or exercise-induced arrhythmias
What are the workout/session guidelines for clients with CAD?
Perform one set of 12-15 reps using 8-10 exercises that target major muscle groups twice a week.
What are some signs/symptoms of cardiovascular disease or issues that would cause a PT to terminate an exercise session?
- angina
- dyspnea (extreme shortness of breath)
- lightheadedness/dizziness
- pallor (pale appearance)
- rapid heart rate above targets
What type of exercises should be avoided when working with a client with CAD and why?
Isometric exercises because they can dramatically raise BP and that associated work of the heart.
What intensity should clients with CAD start and progress to?
Low risk CAD clients just beginning an exercise programme should start at 40-50% of HRR or an RPE of 9-10 or 20-30 beats over their resting heart rate.
Low risk clients that already exercise can progress to an intensity of 60-85% of HRR, RPE 11-14.
What should the duration of exercise be when working with clients with CAD?
The total duration should be gradually increased to 30 mins or more of continuous interval training with warm-up/cool down time added.
What is the frequency of exercise for clients with CAD?
3-5 days of aerobic training
2 days of resistance
What is considered as high blood pressure and low blood pressure?
High is when your systolic blood pressure is equal to or over 140mmHg and low is when your diastolic blood pressure is equal to or lower than 90mmHg
What is defined as prehypertension?
An untreated systolic blood pressure of 120 - 139 mmHg or an untreated Diastolic blood pressure of 80 - 89 mmHg
Approx those that have experienced a first heart attack, stroke or who have Coronary Heart Failure have blood pressure higher than ___/___ mmHg
140/90 mmHg
It is estimated that each ___mmHg rise in SBP or ___mmHg rise in DBP doubles the risk of developing cardiovascular disease.
20 mmHg SBP
10 mmHg DBP
What are 4 important lifestyle components that are important for controlling hypertension and augmenting a client’s pharmacological intervention?
Exercise
Weight loss
Sodium reduction
Reduced fat/alcohol intake
Regularly performing 150 mins of exercise per week has been shown to reduce SBP by an average of __ to __ mmHg
2 - 6 mmHg
What is the post-exercise decrease in blood pressure related to? How long can the decrease persist for?
It is related to a reduced peripheral vascular resistance that is not compensated for by an increase in cardiac output and can persist up to 22 hours.
What is post-exercise hypotension?
a prolonged decrease in resting blood pressure in the minutes and hours following acute exercise
What can the potential magnitude of SBP and DBP reductions be in post-exercise hypotension?
15 and 4 mmHg for SBP and DBP
If someone’s BP reading was 140/90, what does this tell you?
That they have high blood pressure aka hypertension.
If someone’s BP reading was 110/70, what does this tell you?
That they are within a normal blood pressure range.
If someone’s BP is 90/50, what does this tell you?
They have low blood pressure, anything below 90 SBP and 60 DBP means it is low.
What is orthostatic hypotension?
a condition in which your blood pressure falls significantly when you stand up quickly
When should an exercise session be discontinued in relation to BP?
- When the SBP or DBP rise to 250mmHg or 115mmHg.
- If the SBP fails to increase with increasing workload
- If the SBP drops 20 or less in mmHg.
When using HR to determine intensity with a client that is hypertensive, what should the heart-rate range be?
It should be at the lower end of the HRR so 40-65%.
What duration can a trainer gradually increase to when working with a client that is hypertensive?
You can work up to 40 - 60 minutes per session depending on the medical history and clinical status of the individual.
This can be continuous or intermittent.
How often should hypertensive clients work out?
4 - 7 times a week
Why would exercise on a daily basis be good for hypertensive clients?
Due to the acute hypotensive effect of exercise that lowers your resting BP.
What is the difference between an ischemic stroke and a hemorrhagic stroke?
An Ischemic Stroke is when the blood supply to the brain is cut off and a Hemorrhagic Stroke is when a blood vessel in the brain burts.
What drug is used to treat an Ischemic stroke and how long after a stroke should is be administered?
t-PA (tissue plasminogen activator)
within 3 hours
What are the warning signs of a stroke?
- numbness or weakness of face, arm, legs
- sudden confusion or trouble speaking/understanding others
- sudden trouble seeing in one or both eyes
- sudden walking problems, dizziness or loss of balance/coordination
- sudden severe headache with no known cause
After a stroke, what will you have a significant increased risk for?
A recurrent stroke or myocardial infarction.
What are the metabolic changes after a stroke?
- impaired glucose tolerance
- type 2 diabetes
What are some risk factors for a stroke?
- smoking
- high blood pressure
- heart disease
- previous stroke
- physical inactivity
- transient ischemic attacks
What are transient ischemic attacks (TIA)?
Momentary reductions in oxygen delivery to the brain which results in sudden headache, dizziness, blackout and/or temporarily neurologic dysfunction.
What does rehabilitation following a stroke typically look at?
It focuses on optimizing basic activities of daily living skills such as:
- regaining balance
- coordination
- functional independence
As well as preventing recurrent strokes and complications.
What is fibrinolytic activity?
The system responsible for dissolving blood clots.
Clinicians consider the window for motor improvement following a stroke to be within the first _ to _ months.
3 - 6 months
What are some varied exercise modalities that can be used following a stroke?
- bike ergometer
- water exercise
- weight-supported treadmill exercise
- gait, balance and coordination activities
What is peripheral vascular disease and what is it caused by?
PVD is when a build-up of fatty deposits in the arteries and restricts blood supply to leg muscles, it is caused by atherosclerotic lesions in one or more peripheral arterial and/or venous blood vessels.
Why is Peripheral Vascular Disease an important medical concern?
Because of the high risk of concomitant (naturally accompanying) coronary and cerebral artery disease.
What modes of exercise are suitable for someone that is recovering from a stroke?
- walking
- stationary and recumbent bicycling
- upper-extremity ergometers
- water exercises
It depends on their limb function following the stroke.
What should the duration start at and gradually increase to for clients recovering from a stroke?
It should start with short bouts of 3-5 mins and gradually increase to bouts of 30 mins over time.
What should the frequency of exercise be for clients recovering from a stroke?
Preferably 5 days a week but may need to start at 3 and increase.
What are the risk factors for Peripheral Vascular Disease?
- hyperlipidemia
- smoking
- hypertension
- diabetes
- family predisposition
- physical inactivity
- obesity
- stress
What is hyperlipidemia?
When your blood has too many lipids such as cholesterol or triglycerides.
What is Peripheral Artery Occlusive Disease and how does it come about?
Peripheral Artery Occlusive Disease is a result of atherosclerosis of the arteries of the lower extremities.
It is when blood flow distal to the lesion is reduced and impacts ambulation.
What are the most common lower-extremity lesion sites?
- abdominal aorta
- iliac
- femoral
- popliteal
- tibial arteries
What is ambulation?
The ability to walk without assistance.
What is Peripheral Vascular Occlusive Disease characterized by?
It is characterized by muscular pain caused by ischemia/lack of blood flow to the muscle which is the result of spasms or blockages and referred to as claudication.
What is the subjective grade scale for Peripheral Vascular Disease?
Grade 1 - definite discomfort/pain at initial/modest levels
Grade 2 - moderate discomfort/pain but client’s attention can be diverted
Grade 3 - intense pain in which client’s attention cannot be diverted
Grade 4 - excruciating and unbearable pain
What improvements are associated with exercise for those with Peripheral Vascular Disease?
- changes in blood viscosity (thickness)
- changes in capillary/mitochondrial density
- increased oxidative and glycolytic enzymes
(therefore improved oxygen utilization)
- improved walking mechanics
- improved pain perception
What are the goals of an exercise programme for a client with Peripheral Vascular Disease?
- to improve arterial flow
- to increase oxygen extraction
- to improve walking mechanics that ultimately decrease oxygen demand
Why is education of symptoms, foot care and nutrition important for those with Peripheral Vascular Disease?
Because of the anxiety that is associated with the pain that individuals experience with PVD.
Why is walking one of the preferred exercises for someone with Peripheral Vascular Disease?
Because it promotes ischemia which may be the primary stimulus for development of collateral circulation and other improvements in oxidative metabolism.
To improve exercise capacity, what should a PT encourage their clients with PVD to do when walking/exercising?
To walk to the point of intense pain (between Grade 1 & 3) before stopping. When the pain stops during resting, repeat the activity.
For clients with PVD, claudication should be stimulated within 2-6 minutes of walking, what should a trainer do when the client can withstand 8-12 minutes of continuous walking?
They should increase the client’s walking pace or increase the total activity time.
What may clients with Peripheral Vascular DIsease also have underlying?
Coronary Artery Disease
Clients should avoid exercising in cold air or water to reduce the risk of ____________.
vasoconstriction
What are well-recognized lipid parameters with the highest correlation to Cardiovascular Disease?
- elevated levels of total cholesterol and Low-density Lipoprotein
- suboptimal levels of high-density lipoprotein cholesterol
- elevated levels of triglycerides
What is endothelial dysfunction? And what is it associated to?
Endothelial Dysfunction is a condition in which the endothelial layer (the inner lining) of the small arteries fails to perform all of its important functions normally.
It is associated with chronically high levels of triglycerides.
What is cholesterol and where is it found?
Cholesterol is a waxy, fat-like substance found in all cell membranes and transported in the blood plasma.
What is cholesterol an essential component of?
- cell function
- production of hormones
- production of vitamin D
- production of bile acids that assist fat digestion
How does cholesterol travel through the body?
It is transported via blood plasma and is attached to a protein referred to as lipoprotein.
What are the primary lipoproteins?
- low-density lipoprotein
- very low-density lipoprotein
- high-density lipoprotein
- non-HDL cholesterol
How much of the body’s total serum cholesterol is carried in low-density lipoprotein?
60-70%
How much of the body’s total serum cholesterol is carried via very low-density lipoprotein? What is VLDL also a carrier of?
10-15% and it is a major carrier of triglycerides
Where is High-density Lipoprotein produced and how much of the body’s total cholesterol does it contain?
It is produced in the intestine and liver and contains 203-0% of the body’s total cholesterol.
What is non-HDL cholesterol the sum of?
Low-density lipoprotein + very low-density lipoprotein and intermediate density lipoprotein
What findings have studies found concerning aerobic exercises influence on dyslipidemia?
That aerobic exercise:
- may reduce LDL cholesterol by 3-6 mg/dL
- may reduced non-HDL cholesterol by 6mg
- has no consistent effect on triglycerides
- has no consistent effect on HDL cholesterol
What findings have been found concerning moderate-intensity resistance training and dyslipidemia?
That moderate-intensity resistance training performed 3 days a week may reduce LDL cholesterol, triglycerides and non-HDL cholesterol by 6 - 9mg and has no effect on HDL cholesterol.
The impact of exercise on blood lipid profiles is most profound with corresponding ______ in body fat.
decreases
What modes of exercise are recommended for clients with Dyslipidemia?
Aerobic activities such as walking, jogging, cycling, swimming unless contraindicated by other health conditions.
Resistance training twice a week.
What intensity/duration should clients with Dyslipidemia start with in a programme?
Their focus should be on duration, starting at 15 mins and building to 30-60 mins per day to complete a total of 150-200 mins each week. The intensity should begin low-moderate and potentially progress to short bouts of vigorous-intensity depending on their condition.
How often should those with dyslipidemia work out?
5 days per week
Diabetes causes abnormalities in the metabolism of…
carbohydrates, protein and fat
What is diabetes characterized as?
High levels of blood glucose resulting from defects in insulin production, insulin action or both.
How is diabetes diagnosed?
Healthcare providers use a fasting plasma glucose (FPG) test or an oral glucose tolerance test (OFTT).
What fasting glucose level indicates diabetes?
More than or equal to 126mg/dL
What fasting glucose level indicates prediabetes?
Between 100-125mg/dL
What causes Type 1 Diabetes?
When the body’s immune system destroys pancreatic beta cells that are responsible for producing insulin.
What is type 1 diabetes also referred to as?
insulin-dependent diabetes mellitus
What are beta cells?
Cells within the body that create insulin that therefore controls the level of glucose in the blood.
When does Type 1 Diabetes usually occur and what is the required medication solution?
Type 1 Diabetes can occur at any age but usually appears in children or young adults.
It requires regular insulin injections or a pump to regulate blood glucose levels.
What are the typical symptoms of Type 1 Diabetes?
- thirst
- hunger
- frequent urination
- weight loss
- blurred vision
- recurrent infections
During periods of insulin deficiency, a higher-than-normal level of glucose remains the blood. What is this a result of and lead to?
Reduced glucose uptake and storage.
It leads to the excess glucose (in the blood) being excreted in the urine which leads to thirst, reduced appetite and weight loss.
What is hyperglycemia?
Chronically elevated blood glucose levels
What is Type 2 Diabetes characterized by?
Type 2 Diabetes is insulin resistance in which the cells do not utilize insulin properly but the demand for it continues to rise and eventually causes the pancreas to lose its ability to produce insulin - which leads to frequent hyperglycemia.
Is Type 2 Diabetes insulin dependent or non-insulin dependent?
Non-insulin dependent
What is the more popular form of diabetes?
Type 2
What is Gestational Diabetes?
A form of glucose intolerance that occurs during pregnancy.
What are women with Gestational Diabetes more at risk for?
- gestational hypertension
- preeclampsia
- caesarean section delivery
- sevenfold increased risk of developing diabetes later in life
What does ‘twofold’ refer to in diabetes treatment?
Twofold is to normalize glucose metabolism and prevent diabetes-associated complications and disease progression.
Which type of diabetes responds better to exercise? Why does the other not?
Type 2 Diabetes responds better.
Studies have failed to show an improvement of glycemic control in type 1 diabetics but there are still other benefits like reduced CAD risk, increased insulin-receptor sensitivity.
What are 3 known improvements of exercise that are present in type 2 diabetes?
- reduced body weight
- improved lipid profiles
- improved hypertension fibrinolysis
What is hypertension fibrinolysis?
It is impaired fibrinolytic balance, mainly expressed as elevated levels of plasma PAI-1 and decreased t-PA activity, has been described in patients with hypertension.
What risk is their for diabetics with excessive blood glucose elevation?
With excessive blood glucose elevation, blood fats rise to become the primary energy source which puts diabetics at greater risk for heart disease.
What should happen before starting an exercise programme with a diabetic client?
They should receive clearance from their physician.
What should be measured before and after every session with diabetic clients?
Their blood glucose level.
If a diabetic client’s blood glucose pre-exercise level is below 100mg/dL, what should you do?
You should delay or postpone the session.
It may increase with additional carbohydrate consumption.
If a diabetic client’s blood glucose pre-exercise level is above 300mg/dL, what should you do?
You should delay or postpone the session as this shows their blood glucose is not under control.
If a diabetic client’s blood glucose is above 250mg/dL and they present with ketosis, what should you do?
You should postpone or delay the session as their blood glucose is not under control.
What are some signs of ketosis?
- bad breath
- appetite suppression
- short term fatigue
- short term performance decrease
- weight loss
- increased ketones in blood/breath/urine
What are the primary goals of exercise for clients with type 1 diabetes?
Better glucose regulation and reduced heart disease risk.
Why is RPE preferred during exercise programmes as opposed to heart rate measurements for clients with diabetes?
Because there is a potential inaccuracy in the HR measurement as a result of complications such as autonomic and peripheral neuropathy.
Why should long-duration and high-intensity exercises be avoided when working with Type 1 diabetic clients?
Long-duration increases the risk of hypoglycemia and high-intensity increases the risk of hypergycemia.
What are the primary goals of exercise for clients with type 2 diabetes?
Better glucose regulation and weight loss.
What are the metabolic control precautions that a PT should take before exercise with a diabetic client?
Avoiding exercise if Fasting Glucose Levels are over/equal to 250mg, ketosis is present or Blood Glucose Levels are over 300mg with no ketosis.
If glucose levels are below 100mg, then ingest some carbs and see if they level out.
Why should a diabetic client avoid injecting insulin into the primary muscle group about to be used during exercise?
Because it will be absorbed more quickly and potentially result in hypoglycemia.
What are the 10 exercise precautions for clients with diabetes?
- Metabolic control before exercise
- Blood glucose monitoring before/after
- Food intake
- Avoid insulin injection into primary muscle groups about to be used
- Avoid exercise during periods of peak insulin activity
- Exercise at the same time each day with a regular pattern of diet, medication, duration, intensity
- Exercise with a partner and medical tag
- Proper hydration to avoid dehydration
- Focus on careful foot hygiene and proper footwear
- Do not ignore pain
What is the metabolic syndrome?
A cluster of conditions that increases a person’s risk for developing heart disease, type 2 diabetes and stroke.
What is Metabolic Syndrome characterized as?
- abdominal obesity
- atherogenic dyslipidemia
- increased BP
- insulin resistance
- prothrombotic state
- proinflammatory state
What ethnic groups is metabolic syndrome more prevelant in?
African Americans, Hispanics and Native Americans.
The American Health Association and National Heart, Lung and Blood Institute recommends that metabolic syndrome is identified when 3 or more of the following components are present:
- elevated waist circumference (men = over 40inches, women = over 35 inches)
- elevated triglycerides of 150mg
- reduced high-density lipoprotein cholesterol (med = below 40mg, women below 50mg)
- increased BP of 130/86mmHg
- elevated fasting blood glucose over 100mg
What is metabolic syndrome associated with?
Physical inactivity, excessive caloric intake, obesity, genetics and aging.
What is the primary treatment objective for Metabolic Syndrome?
To reduce the risk for developing cardiovascular disease and type 2 diabetes.
What were the effects of removing abdominal adipose tissue via liposuction on metabolic syndrome?
The removal of fat via liposuction showed no improvement in insulin resistance or risk factors meaning the role of diet and exercise are necessary for achieving the metabolic benefits of weight loss.
What BMI states that a person is obese?
Respectively over or equal to 25-3kg/m.
Those with Metabolic Syndrome are usually obese but what other conditions should be considered when creating a programme?
Underlying Coronary Artery Disease, hypertension, dyslipidemia.
ACSM recommends that overweight/obese individuals should accumulate ___ to ____ of physical activity each week.
200 to 300 mins
At what intensity should those with metabolic syndrome exercise at?
An RPE of fairly light to somewhat hard (11-13 on 6-20 scale) and gradually progress as their conditioning improves and weight loss occurs.
Should someone with metabolic syndrome focus on duration or intensity more in an exercise programme?
Duration as they should be encouraged to partake in a physically active lifestyle not just a couple activities a week.
What mode of exercise should those with metabolic syndrome start with and progress to in a new programme?
They should begin with low-impact activities and non-weight bearing activities if overweight and suffering musculoskeletal challenges.
Resistance training is beneficial for those with no complications.
What is asthma characterized as?
A chornic inflammatory disorder that is characterized by recurring symptoms such as shortness of breath, wheezing, coughing and chest tightness.
What triggers asthamatic attacks/symptoms?
- environmental triggers such as allergens (dust, mold)
- irritants (air pollution)
- viruses
- stress
- cold air
- exercise
What is the inflammatory response of an asthmatic attack?
Airway hyperresponsiveness and airway obstruction due to constriction of smooth muscle around the airways, swelling of mucosal cells and/or increased secretion of mucus.
Why should asthmatic clients receive clearance from their physician before starting an exercise programme?
To avoid exercise-induced-asthma and for guidance on potential triggers, medication use and what to do should an asthmatic episode take place during/after exercise.
What are some medications that are provided to asthmatic clients to lessen or prevent Exercise Induced Asthma epiodes?
- bronchodilators
- anti-inflammatory agents
Why should asthmatic clients under go longer and more gradual warm-up/cool down periods?
As to prevent stronger hyperventilation and an exercise-induced episode.
A gradual warm-up will especially allow some to utilize the refractory period to lessen the bronchospastic response during higher intensity exercise.
What is the refractory period?
Rest period between exercise
What guidelines should a PT follow to assist in developing, monitoring and progressing an exercise program for clients with asthma? (9)
- client should always have rescue medication and know how to use it
- clients should drink plenty fluids before, during, after to prevent dehydration
- clients should avoid triggers
- Gradual and prolonged warm up/cool down periods
- Keep the initial intensity low and gradually increase over time
- Constantly look for early signs of an attack
- if medication does not relieve attack, activate emergency medical system
- Exercise is usually best responded mid-to-late morning for asthmatic clients
- Well-controlled asthmatic clients can use guidelines for general population for cardiovascular/strength training
Why is swimming a good mode of exercise for asthmatic clients?
Because it allows them to inhale the moist air just above the surface of the water as opposed to dry air.
How often should people with asthma train?
at least 3-5 times a week
What should you recommend to an asthmatic client that experiences symptoms during longer duration?
To break up their exercise into intermittent exercise intervals such as 2/3 10 min sessions as opposed to one longer session.
What is cancer characterized as?
Uncontrolled growth and spread (metastasis) of cells within the body.
What does mestatasis refer to?
The development of secondary malignant growths at a distance from a primary site of cancer.
When do cancer cells develop?
When the DNA of normal cells is damaged, mutations are produced that affect the orderly, controlled process.
The damaged DNA and mutations result in uncontrolled cell growth, formation of tissues masses called tumors and sometimes these metastasize to other areas of the body via blood and lymph systems.
What does DNA stand for?
Deoxyribonucleic Acid
How do malignant cells and benign cells spread within the body?
Malignant cells typically metastasize whereas benign cells stay locally at the site of the origin and don’t spread.
Why can benign cells still pose a threat to life in canercous situations?
Because whilst they are local, don’t spread and harmless, if they continue to grow within the local area they can compress and/or interfere with vital organs & systems and their bodily functions.
What are some risk factors to cancer?
- environmental exposures (pollution, UV lights, chemicals)
- lifestyle practices (smoking, inactivity, alcohol, diet)
- medical interventions
- viral infections
- genetic traits
- gender
- aging
Studies have shown that walking at a brisk pace for 3 - 5 hours per week will decrease breast cancer relapse by ___%.
50%
What is the goal of exercise in the treatment of cancer?
To maintain and improve cardiovascular conditioning, prevent musculoskeletal deterioration, reduced symptoms such as nausea and fatigue and improve their mental wellbeing.
Why should an exercise program be specific to a client’s type of cancer, treatment and needs?
Because what may be low intensity to one client will be high intensity to another.
What is a health deficiency risk of chemotherapy and/or radiation that should be taken into account by a physician/PT?
That the client may be anemic due to the chemo/radiation and therefore require reduced exercise intensity or weight-bearing activities.
What are the 9 guidelines a PT should follow when working with a cancer patient/client?
- Physician clearance must be obtained and PT should gain exercise recommendations/precautions from them
- Client must start slow and gradually progress duration over intensity
- Intensity should be light - moderate and may vary day to day based on treatment/fatigue
- Clients in remission may be able to work at higher intensities with physician approval
- Resistance training should utilize light weights with 10-15 repetitions
- Proper warm up and cool down phases must be incorporated
- Clients with numbness in the feet or have balance challenges are at higher risk for falls and should use stable equipment/surfaces
- Any skin that has been exposed to radiation or surgical wounds should not be exposed to chlorine
- Clients should eat a well-balanced diet and drink plenty of fluids
What precaution should a cancer patient with neutropenia and those taking medications consider?
That they should avoid public gyms and avoid exercise if there is a fever of 38 degrees.
What is neutropenia?
Low white blood cell counts
What precaution should a cancer patient that has experienced frequent vomiting/diarrhea consider?
That they may be dehydrated and in a mineral imbalance and should drink lots of fluids and check with their physicians before resuming exercise.
What should a PT watch for in a cancer patient client?
Swollen ankles
Unexplained weight gain
Shortness of breath at rest
Limited exertion
What precaution should a cancer patient that has thrombocytopenia and/or taking blood thinners consider?
That they have an increased risk of bruising and bleeding and should avoid activities that raise the risk of physical contact and falls.
What is thrombocytopenia?
Low platelet counts
If a cancer patient is experiencing unrelieved pain, nausea or vomiting or any other concerning symptoms - what should a PT do?
Postpone exercise until physician clearance is obtained.
What should cancer clients that have a catheter avoid?
Aquatic exercise and other exposures that may lead to infections, resistance training that incorporates exercises in that catheter area as to avoid dislodging it.
How long should a client wait to partake in exercise after chemotherapy or radiation therapy?
2 hours as any increase in circulation may impact the effects of therapy.
What modes of exercise are recommended for cancer clients?
- Weight-bearing exercises can be good for cardiovascular recovery phases.
- low-impact or non-weight-bearing aerobic machines can be suitable for those more fragile
- Aquatic exercise can be good for those with hand and foot numbness from treatment (if they are not undergoing radiation or have a catheter)
What intensity should cancer clients exercise at?
Light to moderate intensity for most.
Clients in remission and with good conditioning may increase but it should be adjusted with each session depending on the client’s response to treatment/exercise and any symptoms that arise.
What duration of exercise is recommended for cancer clients?
Low-functioning clients should start with short-bouts of exercise, 3-5 mins in duration with frequent rest breaks. This should progress to 10 min intermittent bouts and gradually up to 30-40 mins.
What frequency of exercise should cancer clients partake in?
A cardiovascular and flexibility programme can be done daily but strength training should be done only 2-3 times a week with at least 24 hours of rest in between.
What is osteoperosis characterized by?
Bone mineral density (BMD), it is characterized by low bone mass and disrupted microarchitecture.
What is the biggest risk of osteopersosis?
Structural weakness and increased risk for fracture - and recurring fractures.
What are the most common fracture sites?
- proximal femur (hip)
- vertebrae (spine)
- distal forearm (wrist)
Why are hip fractures the most devastating?
Because they are associated with severe disability and increased mortality.
What is osteopenia?
A bone density between 1 and 2.5 s.d which is below normal BD but not as low as osteoporosis. It is the precursor to osteoperosis.
During early growth years, the rate of bone ______ is typically greater than the rate of bone _________, resulting in an overall gain in bone mineral.
formation
resorption
What is bone resorption?
the process by which osteoclasts break down the tissue in bones and release the minerals, resulting in a transfer of calcium from bone tissue to the blood
What is a bone strain? What does it lead to?
A small deformation of bone that results from mechanical stress applied to the bone.
It stimulates bone deposition and associated gains in bone mass and strength.
What type of exercise is recommended for bone strain?
Weight-bearing exercises such as jogging, hopping, skipping, jumping and other plyometric exercises.
Why should bone loading forces be above those incurred with acts of daily living for increased bone strain?
Because higher loading forces = higher stress which = greater strain and results in greater bone mass/strength gains.
What frequency of bone straining loading forces may have the greatest impact on bone formation?
Shorter, frequent sessions of multiple and brief loading that are separated by a few hours of recovery.
(so the bones are constantly being strained as to progress)
What exercise might clients with osteoporosis need to avoid to prevent further injury/falls?
- spinal flexion, crunches and rowing machines
- jumping and high-impact aerobics
- trampolines and step aerobics
- abducting/adducting legs against resistance
- pull on the neck with hands behind head
Why should you supplement weight-bearing activities with traditional aerobic exercises for those with osteoporosis?
to stimulate cardiovascular conditioning
At what intensity of weight-bearing activities should clients with osteoporosis partake in?
Weight bearing activities are best performed at high intensities as to promote high strain and stimulate bone adaptation.
8 rep max
For prevention of osteoporosis, what duration of exercise should clients follow?
The number of strain impacts can be small (50 to 100) so duration of loading activities can be short (5 - 10 mins) depending on the activity chosen.
At what frequency should clients with osteoporosis exercise at?
Multiple loads of bone-loading exercises are more effective that a single longer-duration session.
What is the difference between osteoarthritis and rheumatoid arthritis?
Osteoarthritis is a degenerative joint disease that leads to deterioration of cartilage and development of bone growth at the edges of joints.
Rheumatoid arthritis is a chronic and systemic inflammatory disease and is characterized by joint pain, swelling, stiffness and contractures.
What are contractures?
Permanent tightening of tissues that makes it hard to move.
What does osteoporosis result from?
Overuse, traumua, obesity, degeneration of the joint cartilage that takes place with age.
What are treatment options for arthritis?
Medication, physical therapy, physiotherapy, occupational therapy, surgery.
What are the 4 classes of Rheumatoid Arthritis?
Class 1 - completely able to perform usual ADL
Class 2 - able to perform usual self-care and vocational activities, limited in avocational activities
Class 3 - able to perform usual self-care, but limited in voactional/avocational activities
Class 4 - limited ability to perform usual self care, vocational/avocational activites
What are the primary goals of an exercise programme for those with arthritis?
To improve cardiovascular fitness and lower CAD risk, increase muscular endurance and strength and maintain/improve range of motion/flexibility around affected joints.
What should those with arthritis undergo before beginning an exercise programme?
A complete medical evaluation and obtain physician consent.
What are some guidelines for working with clients with arthritis?
- Focus on duration as opposed to intensity, gradually lengthen to 30 mins 3-5x a week
- Emphasize proper alignment and exercise technique to reduce fatigue and risk of injury
- Put all joints through full ROM at least once a day to maintain mobility
- Strength training should focus on increasing reps rather than weight - from 2/3 reps to 10/12
- Isometric exercises that strengthen the joint structure/muscle surrounding affected joint can avoid stress on the joint itself
- those with rheumatoid arthritis should not exercise during periods of inflammation
- intensity/duration should be modified to fit clients response, pain, changes in medication
- clients experiencing pain 2 hours post-exercise should have intensity lowered
- clients will be limited by joint pain more so than cardiovascular function
What are the exercise guidelines for individuals with a hip replacement?
- lift knee no higher than hip level or 90 degree flexion
- keep toes straight ahead (no duck/pigeon toes)
- no adduction past the midline
- focus on leg/hip abduction, lateral movements and strengthening
What mode of exercises are recommended for those with arthritis?
Non-weight bearing or non-impact activities such as elliptical training, cycling, warm-water aquatics as these reduce joint stress.
What intensity of exercise is recommended for those with arthritis?
Low-intensity/low-impact dynamic exercise generally around 9-15 RPE range using the 6-20 scale.
It should be based on the clients comfort level though.
What duration of exercise is recommended for those with arthritis?
Initially starting at 10-15 mins and gradually progressing to 30 mins or intermittent exercise with shorter durations.
Warm up/cool down should be greater than 10 mins.
What is Fibromyalgia?
A long-lasting widespread pain and tenderness at specific points on the body.
Fibromyalgia is considered an arthritis-related condition but does not cause inflammation or associated joint damage, why is it considered a rheumatic condition?
Because it impairs the joints and/or soft tissues and causes chronic pain.
What is the hypothesized reason/cause for fibromyalgia?
That it results when a genetically susceptible individual comes in contact with some environmental trigger that sets the symptoms in motion.
What are the most common symptoms of fibromyalgia?
- aches/pains similar to flu-like exhaustion
- multiple tender points
- stiffness
- decreased exercise endurance
- fatigue
- muscle spasms
- paresthesia
- excessive fatigue
- disruptive sleep patterns
- bowel/bladder irritability
- anxiety
- depression
- cognitive difficulties
- temporomandibular joint disorder
- sensitivity to loud noises
- allergic symptoms like nasal congestion/rhinitis
What is paresthesia?
A burning or prickling sensation usually felt in hands, arms, legs or feet.
The American College of Rheumatology developed criteria to diagnose Fibromyalgia, what is this criteria characterized by?
A history of widespread pain that occurs for longer than 3 months and in combination with pain on palpation of 11-18 tender point sites.
What is considered to be widespread pain?
When there is pain in the left side of the body, right side of the body, below and above the waist.
The American College of Rheumatology states pain on digital palpation of 11-18 tender point sites as a characterization for diagnosing Fibromyalgia, what are these sites?
- Occiput
- Low cervical
- Trapezius
- Supraspinatous
- Second Rib
- Lateral epicondyle
7 Gluteal - Greater Trochanter
- Knee
What are the typical treatment modalities for Fibromyalgia?
- treatment of underlying sleep disorder
- allergy testing/treatment
- medications such as analgesics, nonsteroidal anti-inflammatories, selective serotonin reuptake inhibitors, tricyclic antidepressants, muscle relaxants
- exercise
- relaxation techniques + other therapies
Why is aerobic exercise particularly suited for those with Fibromyalgia?
Because aerobic exercise has an analgesic and antidepressant effect that can reduce pain, depression and anxiety frequently associated with Fibromyalgia.
What should clients with Fibromyalgia do before starting a program?
Receive medical clearance and discuss their exercise goals with their physician.
What mode of exercise is recommended for those with Fibromyalgia?
- walking and low-impact activities
- light stretching daily
- resistance exercises using a band
What intensity on the 6-20 scale should those with Fibromyalgia perform at?
An RPE of 9-13
How many minutes a week should those with Fibromyalgia perform exercise?
Gradually progress to 150 mins or more a week of aerobic activity
What is the key goal for exercise with those suffering from Fibormyalgia?
To develop a regular pattern of exercise to reduce symptoms.
What is chronic fatigue syndrome characterized by?
Incapacitating fatigue that lasts at least 6 months and results in substantial reduction in occupational, recreational, social and educational activities. Does not improve with rest and worsens with physical/mental activity.
What are the common symptoms of chronic fatigue syndrome?
- memory/concentration problems
- unrefreshing sleep
- muscle/joint pain with no inflammation/redness
- headaches
- tender cervical or axillary lymph nodes
- recurrent sore throat
- extreme exhaustion for more than 24 hours after exercise
What is the criteria for diagnosing Chronic Fatigue Syndrome?
Unexplained, persistent fatigue that is not due to ongoing exertion and relieved through rest.
Four or more of the following symptoms present for 6+ months:
- impaired memory/concentration
- post-exertional malaise
- unrefreshing sleep
- muscle pain
- multi-joint pain with no swell/redness
- headaches of new type/severity
- sore throat
- tender cervical or axillary lymph nodes
What does the treatment regime look like for Chronic Fatigue Syndrome?
- moderating daily activity: slowing down, avoiding excessive activity and psychological stress
- gradually progressing exercise
- cognitive behaviour therapy: identifying negative beliefs and behaviours that may impact recovery
- treatment of depression
- treatment of pain: acetaminophen and NSAIDs to reduce pain and fever
- treatment of allergy-like symptoms: antihistamines and decongestants
Why is moderate-vigorous intensity activities not recommended for those with Chronic Fatigue Syndrome?
As this can cause exacerbation in fatigue and other symptoms and precipitate a full relapse that lasts for days or week.
What are the exercise guidelines for clients with Chronic Fatigue Syndrome?
- all exercise should be followed by a rest period at 1:3 ratio (rest for 3 mins for each 1 min of exercise)
- deconditioned client should limit exercise to only activities of daily living until their symptoms are stable
- if exercise causes a flare up in symptoms, progress back to a level of exercise that was ok
- start with simple stretching and strengthening exercises using only body weight for resistance
- some may not tolerate an upright position so swimming or a recumbent bike may be useful
What are the differences between acute and chronic low back pain?
Acute lasts fewer than 3 months and chronic is over 3 months.
What are typical causes of low back pain?
- trauma
- injury
- disorders like arthritis, aging, osteoporosis
- overstrain/compression of the spine that results in a disc rupture/outward bulge that places pressure on 1/more of the 50 nerves rooted to the spinal cord
- spinal stenosis
- spinal degeneration
- spinal irregularities
What is spinal stenosis?
a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine
What are some lifestyle-related factors to low back pain?
- physical inactivity
- overweight/obesity
- poor posture
- poor sleeping position
- stress
- smoking
Why should those with low back pain be cleared by a physician before partaking in an exercise program?
Because exercise is both a cause and treatment/prevention of low back pain and knowing the cause of the pain will determine what exercises are suitable for the client.
What should the 3 primary components of an exercise programme around low back pain be?
- cardiorespiratory training
- resistance training
- core exercises
What should people with low back pain generally avoid when working out?
- unsupported forward flexion
- twisting at the waist with turned feet, especially when carrying a load
- lifting both legs simultaneously when in a prone/supine position
- rapid movements like twisting, forward flexion, hyperextension
What are the guidelines for training a client with low back pain?
- always be aware of proper alignment/form/posture
- always maintain neutral pelvic alignment and an erect torso during movements
- avod head-forward positions in which chin is tilted upwards
- when leaning forward/lifting/lowering an object, bend the knees
- quit smoking as it reduces blood flow to the lower spine
- if you experience pain after exercise, apply ice
What does Dr Stuart McGill recommend that clients with lock-bacp pain keep in mind?
- performing daily low back exercises have the most beneficial effect as opposed to only 3 times a week
- do not train through pain
- cardiovascular components with specific low-back exercises is most effective in both rehabilitation and injury prevention
- do not perform full range spine motion exercises when shortly rising from bed as fluid levels around the intervertebral discs change the stresses on the discs throughout the day
- train for muscular endurance not strength: more reps with less resistance
- there is no one guide for all, exercises differ based on the client’s own injury
What exercises are recommended daily for enhancing low back health, the muscle challenge/motor control system and maintenance of spine stability?
- cat-camel/cat-cow
- modified curl up
- birddog
- side bridge
What mode of exercise is recommended for clients with low back pain?
Walking, stationary biking, swimming, core strengthening, light resistance training, stretching.
What are 5 key facts about obesity?
- worldwide obesity has doubled since 1980
- in 2008, 1.5 billion adults over 20 were overweight, 200+ million men and 300+ million women we obese
- more than 1 in 10 of the world’s adult population is obese
- 65% of the world’s population live in countries where obesity kills more people than being underweight
- nearly 43 million children under 5 were overweight in 2010
What is obesity defined as?
An excessive amount of adipose tissue or body fat in relation to lean body mass.
What is the most common measure used to identify obesity/overweight? What is the formula for it?
Body Mass Index
weight (kg) / height (m)
What BMI defines an adult as overweight and obese?
25-29.9 kg/m = overweight
30+ kg/m = obese
What measurements may enhance the BMI categorization?
waist size and waist-to-hip-ratio
What lifestyle habits and cultural changes contribute to weight gain and obesity?
- caloric intake increased by 300cals per day
- an increase in microwaveable and ready-to-eat high-fat foods
- less at home meals, more eating out
- marketing makes it seem easier to buy sugary/high caloric foods
- 66% of americans do not meet physical activity guidelines, 22% report no activity
- increased likeliness of sedentary activities
- increased sedentary jobs
- increased time spent driving as opposed to biking/walking
What is overeating often related to?
Stress, portion size/value perceptions, high caloric-density foods
In studies ranging from 12-18 weeks, how many minutes of aerobic exercise per week showed to result an 11-16.5 lb loss and modest weight loss?
11-16.5 lb loss was associated with 225-450 minutes per week.
Modest weight loss was associated with 150 minutes per week.
Weight stability was defined as less than a __% change in body weight, a change of __% or more is considered clinically significant.
3% and 5%
What is an important primary concept that PT’s should consider whilst implementing weight loss programs for obese clients? (can help develop adherence)
That primary prevention of obesity starts with maintenance of current weight, not weight fluctuation.
Individuals undertaking non-medically supervised weight-loss initiatives can be encouraged to reduce energy intake by ___ to ____ kcal per day to elicit a weight loss of approximately 1-2 pounds per week.
500 - 1000 kcal
At what intensity should obese clients start at?
Low-moderate intensity, it should be gradually increased as their conditioning improves and using the RPE scale.
At what frequency should obese clients exercise at and why?
They should look to exercise 5-6 days a week to maximize their caloric expenditure.
They may need to start at 2-3 days until their conditioning improves.
What are the typical signs of aging?
- graying/loss of hair
- loss of height
- reduced lean body mass
- loss of skin elasticity/wrinkles
- thickening of nails
- changes in eyesight
- reduced coordination
Why is estimating training intensity based on HR not advised when working with older clients? What are your other options?
Basing training on HR is not advised because maximal heart rate declines with age. The RPE scale or talk test are more effective and unique to the client.
At what % does resting cardiac output and resting stroke volume decline as you age? When combined with a decline in MHR, what % does this lead to for overall cardiac output?
RCO declines by 1% per year upon reaching adulthood and stroke volume declines by 30% from ages 25 to 85.
This leads to a 30-60% decrease in overall cardiac output.
Due to a decrease in HR and SV, what is the % decline in maximal oxygen uptake (vo2) in older adults?
This decline is estimated to be a 8-10% per decade after the age of 30.
For each decade after 25, what % of muscle mass is lost and what are the reasons for it?
There is a 3-5% decrease in muscle mass due to changes in lifestyle and decreased us of the neuromuscular system.
As lean body mass declines with age, body fat typically increases - what are these changes due to?
Decreased muscle mass, basal metabolic rate and reduced/lack of physical activity.
What is the average % of reduction in basal metabolic rate between early adulthood and retirement?
10%
What is basal metabolic rate?
It represents the minimum amount of energy needed to keep your body functioning, including breathing and keeping your heart beating.
It is essentially the amount of calories you would burn if you were to do nothing for 24 hours.
Why is there a decline in balance and coordination with old age?
This is due to the loss of muscle mass and associated strength as well as a decline in sensory systems that provide the CNS with information regarding the body’s position in space.
What 3 systems provide the CNS with essential information to maintain balance?
- visual
- vestibular
- somatosensory
What signals does the the vestibular system send to our brain/CNS?
The vestibular system is a sensory system that is responsible for providing our brain with information about motion, head position, and spatial orientation
What signals does the somatosensory system send to our brain/CNS?
It sends signals concerning the conscious perception of touch, pressure, pain, temperature, position, movement, and vibration, which arise from the muscles, joints, skin, and fascia
What might a physician look at before clearing an older adult for a program?
Their medical history, physical and exercise tests.
What frequency and intensity of exercise is recommended for older adults?
Moderate-intensity aerobic physical activity should be performed for a minimum of 30 mins 5 days a week
or
20 mins of vigorous intensity 3 days a week
What modes of exercise are recommended for older adults?
- Endurance exercises such as low-impact aerobics, walking, cardiovascular equipments.
- Low resistance and high rep exercises
- Exercises that improve balance such as sideways walking, backward walking, toe walking, tai chi.
The greatest gains in bone mass in young adolescents/children occur when?
During the period just before or during puberty.
To minimize the risk of injury during resistance training, PT’s should adhere to what guidelines?
- obtain medical clearance or instructions regarding physical needs
- children should be properly supervised and use proper technique
- only exercise when facility is safe for them
- never perform single maximal lifts/sudden explosive movements
- teach proper breathing techniques
- never use broken equipment/ones they don’t fit
- rest for 1-2 mins between exercise
- drink plenty fluids before/during/after
- have full communication with coach
What are some muscle-strengthening exercises for children and adolescents?
Children - tug of war, modified push ups, tree climbing, swinging on playground bars
Adolescents - tug of war, push ups/pull ups, resistance exercises, climbing walls
What are some bone strengthening exercises for children and adolescents?
hopping, skipping, jumping, running, sports like gymnastics/basketball
Why are children more at risk of heat-related illnesses than adults?
- higher ratio of body surface area to mass
- lower exercise economy
- diminished sweating capacity
- lower cardiac output at a similar workload
What is hypnoatremia?
A low sodium content of around 135 mmol/L in the blood
How often should children and adolescents perform bone strengthening and muscle strengthening activities?
3 days a week
In which direction does COG change in pregnancy?
It moves up and outwards
Why are women more flexible during pregnancy?
Due to the hormone related joint laxity - realxin
During early months of pregnancy, hormonal signals stimulate increases in ?
heart rate
blood volume
stroke volume
cardiac output
Pregnant women with the following health conditions should not exercise:
- risk factors for pre-term labor
- vaginal bleeding
- premature ruptures of membrane
What guidelines should pregnant women follow in terms of exercising?
- do not begin a vigorous exercise program before/during pregnancy
- during 1st trimester, limit exercise to 30/40 mins 3 or 4 days a week
- if you were previously inactive, limit exercise to 15 mins if low intensity
- gradually reduce intensity, duration, frequency coming into the 2nd and 3rd trimesters
- use the RPE scale over HR to monitor intensity
- a pounding HR, breathlessness and dizziness suggest that intensity needs to be reduced
- body temp should not exceed 38 degrees
What exercises should pregnant women avoid?
- activities that require extensives jumping
- deep knee bends
- full sit ups
- double leg raises
- straight leg toe touches
- contact sports
- bouncing while stretching
- anything that risks falling
What signs dictate terminating an exercise session with a pregnant client?
- vaginal bleeding
- dizziness/feeling faint
- increased shortness of breath
- chest pain
- headaches
- muscle weakness
- calf pain/swelling
- uterine contractions
- decreased fetal movements
- fluid leaking from vagina
What mode of exercise is recommended for pregnant women?
Aerobic and strength-conditioning exercises such as brisk walking, elliptical training, stationary cycling, cross-country skiing (not downhill) and swimming.
At what RPE on the 6-20 scale should pregnant women exercise at?
9-13
Within the first 6 - 8 weeks postpartum, what is the goal for exercise?
To gradually increase physical activity as a means of relaxation, personal time and a regaining of the sense of control as opposed to improving physical activity.
After delivery, what guidelines should women follow?
- obtain physician clearance before resuming/starting an exercise program
- gradually begin exercising and increasing frequency/intensity
- start by walking each week
- avoid excessive fatigue and dehydration
- wear a supportive bra
- stop exercise if you feel unusual pain or you occur vaginal bleeding
How does body size and shape influence static postural stability?
By altering the location of the COG in overweight/obese individuals.
Research has shown that obese individuals shift their patterns of walking, what does this result in?
Taking force off the knees and displacing it to the ankles.
What is sarcopenia?
a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death.
Decreased ROM and loss of spinal flexibility in many older adults results in a _______ posture that is associated with a _______ displacement of the COG backward towards the heels.
stooped
vertical
When might a chair-seated exercise be suited for an individual?
When they have issues related to endurance, mobility and self-efficacy.
When doing seated chair exercises, what is important about the position?
The client’s back should be supported by the back of the chair and their feet in full contact with the floor.
What accessories can be added for in-pool use to increase intensity and challenge strength or provide more buoyancy to help an individual float during certain activities?
water bells, paddles, webbed gloves, ankle cuffs
A water temp of ___ to ___ works well for most older adults, especially those that suffer arthiritis.
83 F to 88 F
28 C to 31 C
For older adults with osteoporosis, is land-based training or aquatic exercise more preferred and why?
Land-based exercise is more preferred as it stimulates increases in bone mineral density.
For clients with osteoporosis and joint pain/disability, why is water exercise more so recommended?
To help maintain or enhance ROM with reduced pain, improve muscular strength and improve functional abilities therefore reducing risk of falls.
Why do women have more body fat and men have more muscle mass?
Because women have higher estrogen and men have higher testosterone levels.
Why are women’s VO2 Max often lowered compared to men?
Because women typically have lower hemoglobin levels due to menstrual blood losses and are at more risk to being anemic. This therefore reduces the oxygen carrying capacity of their blood which reduces VO2 Max.
