L29 - Exercise Recommendations in Clinical Populations

• Reduction in CVD Risk Factors with Exercise
• Effects of Exercise on CVD Risk Factor:

  • Hypertension
  • Decrease BP at rest
  • Dyslipidemia
  • Increase HDL cholesterol
  • Decrease triglycerides
  • Obesity
  • Decrease total body fat
  • Decrease visceral body fat
  • Much more important in obesity as is around organs
  • Diabetes
  • Decrease insulin needs
  • Increase glucose tolerance
  • Decrease inflammation
  • Sign for all NCDS (good)
• What are the health benefits of PA?

  • Regular PA reduces your risk of:
  • Dementia by up to 30%
  • All cause mortality by 30%
  • Cardiovascular disease by up to 35%
  • Type 2 diabetes by up to 40%
  • Colon cancer by 30%
  • Breast cancer by 20%
  • Depression by up to 30%
  • Hip fractures by up to 60%
  • Reminded that exercise reduces risk of many diseases
• Hypertension - Stats:

  • Increasing prevalence
  • High BP highly prevalent in European & more so in females
  • 13% of all deaths globally
  • Biggest risk factor is physical inactivity (is for most NCDs) → therefore is one of biggest killers in NZ & worldwide
  • Those with lower SES have higher incidence of hypertension
• Hypertension - high BP:

  • High blood pressure: 110 mm Hg / 70 mm Hg
  • Systolic BP (110 mm Hg)
  • When heart contracting
  • Diastolic BP (70 mm Hg)
  • When hearts relaxing
  • Often measured at brachial artery (superficial)
  • Pressure high here, is everywhere
• Guidelines for Categorising Hypertension:

  • Normal
  • SBP = 90-119 mm Hg
  • DBP = 60-79 mm Hg
  • Prehypertension
  • SBP = 120-139 mm Hg
  • DBP = 80-89 mm Hg
  • Stage 1 Hypertension
  • SBP = 140-159 mm Hg
  • DBP = 90-99 mm Hg
  • Stage 2 Hypertension
  • SBP = >160 mm Hg
  • DBP = >100 mm Hg
  • Any elevation increases risk of CVD
  • Now have more focus on prehypertension than prev did
  • Tend to rise/fall together (1 elevated other elevated)
  • 1 rarely elevates on its own
• High BP causes:

  • Endothelial cells damaged
  • Myocardial infarction
  • Aneurysm
  • Stroke
  • Harms endothelial cells that line blood vessels
  • Tiny cracks create plaques = problem
  • Like a garden hose - will rupture if too much pressure
• Hypertension:

  • Major CVD risk factor
  • Leads to increased risk of CVD, stroke, heart failure, peripheral vascular disease & chronic kidney disease
  • Diagnosis: BP >140/90 mmHg or if on antihypertensive medications
  • Recommended lifestyle modifications to decrease BP in hypertensive individuals:
  • Regular PA
  • Similar decrease as meds
  • Smoking cessation (as nicotine inflames endothelial cells)
  • Weight management
  • Reduced sodium consumption (more salt, hold onto more water = high blood volume; high BP)
  • Moderation of alcohol consumption
  • Healthy diet
  • Can result in deprescribing medication when possible
• Hypertension & Exercise:

  • Initially BP go up in exercise but reduced after exercise
  • Post-exercise hypotension
  • 30-45 min of aerobic exercise decreases SBP by 10-20 mmHg for 1-3 hrs (after exercise)
  • So should be active every day (is when will get chronic reduction in BP)
  • Exercise training decreases BP by 5-7 mmHg
  • Aerobic training - primarily focus on
  • Moderate intensity resistance training only with aerobic training
  • Flexibility exercises
  • After warm up or during cool down
  • Follow guidelines for healthy adults
• ExRx & Hypertension: Special Considerations

  • Avoid exercise if: SBP >200 mmHg at rest &/or DBP >110 mmHg at rest
  • Too high will increase more with exercise not good = dangerous
  • Recommended BP during exercise: SBP <220 mm Hg &/or DBP <105 mm Hg
• ExRx & Hypertension: Special Considerations

  • Individuals with uncontrolled severe hypertension (BP >180/110 mmHg):
  • Start exercise only after medical clearance & prescribed pharmacological therapy
  • Usually on medication 1st so are safe to start exercising
• ExRx & Hypertension: Special Considerations

  • Perform resistance training in a combination with aerobic training only (bc/ aerobic really important)
  • Avoid valsalva manoeuvre during resistance training
  • Hypertensive individuals are often overweight or obese
  • ExRx should promote caloric expenditure (through diet changes)
• Dyslipidemia - Stats:

  • Increased prevalence
  • Higher cholesterol in European men & slightly more in high SES (diet related)
• Cholesterol/Dyslipidemia:

  • High cholesterol = dyslipidemia
  • Is a lipid molecule that helps maintain structure of cell membranes
  • Get new cholesterol from food
  • Most of our cholesterol is obtained through recycling
  • Precursor to:
  • Steroid hormones
  • Bile acids
  • Vitamin D
  • Cholesterol not bad
  • Most of what we need all ready in our body (recycled)
• 2 Main Types of Cholesterol

  • 2 main types:

  1. HDL (High Density Lipoprotein) - good cholesterol (is big)
  2. Remove cholesterol from cells
  3. Help reverse atherosclerosis
  4. LDL (Low Density Lipoprotein) - bad cholesterol (is small)
  5. Gets ingested by macrophages & forms plaques
• Atherosclerotic plaques = Increase concentration of LDL

  • Myocardial infarctions
  • Strokes
  • Peripheral vascular disease
• Dyslipidemia:

  • Abnormal blood lipid & lipoprotein concentrations:
  • Increased total cholesterol
  • Increased triglycerides
  • Increased LDL cholesterol, &/or decreased HDL cholesterol (double problem)
  • Major CVD risk factor
  • Medications: Statins
  • Lifestyle modifications can alter lipid profile
  • Increase PA
  • Diet changes (less saturated fat)
• Dyslipidemia: Exercise Guidelines

  • Most are similar to healthy adults
• Dyslipidemia: Special Considerations

  • Emphasis on healthy lifestyle
  • Aerobic exercise - primarily
  • Resistance & flexibility exercises are additional, but should not be ignored
  • Consider other conditions (diabetes, hypertension, obesity) & modify ExRx accordingly
• Diabetes Mellitus - Stats:

  • Increasing prevalence (for all NCDs)
  • Estimated 44% of adults living with diabetes are undiagnosed
  • Low & middle income countries - can’t get access to health care they need (so are undiagnosed)
  • Symptoms:
  • Thirst
  • Frequency urination
  • Slow healing of wounds
  • Check, esp for clients over 55 yrs
  • Type 2 is a developing disease
• Diabetes Mellitus:

  • Body has trouble moving glucose from blood into cells
  • Blood sugar levels constantly high
  • Normally insulin stimulated with high blood glucose
  • Type 1 Diabetes
  • Blood glucose stays increased bc/ of autoimmune destruction of the pancreas - insulin can’t be released
  • Type 2 Diabetes
  • Body makes insulin but cells are insulin resistant
• Diabetes Mellitus:

  • Major health problems; increase in prevalence worldwide
  • Body can’t process sugar properly due to decrease insulin secretion, decrease insulin action, or both
  • Complications of DM: (most important for exercise training)
• Complications of Diabetes Mellitus:

  • Macrovascular
  • Coronary artery disease (from damage to blood vessels)
  • Stroke
  • Peripheral vascular disease (claudication)
  • Blocked, not enough O2
  • Immediate pain (after 30s of walking → send to get checked)
• Complications of Diabetes Mellitus:

  • Microvascular
  • Eyes damage (retinopathy)
  • Kidney damage (nephropathy)
  • Nerve damage (neuropathy)
  • Higher risk of balance problems & therefore falls
  • People with these ‘-opathies’ shouldn’t undertake resistance exercise without a doctors advice
  • Damage to blood vessels; if untreated or poorly managed
  • Vascular dementia - so some may forget as well
• Diabetes: Exercise Guidelines

  • Similar to those of a healthy adult
• Diabetes: Special Considerations

  • Take into account comorbidities when designing ExRx for diabetic clients
  • Many will be overweight or obese
  • Due to low initial fitness, many will require at least 150 min/week of MVPA to achieve optimal CVD risk reduction (start low & go slow)
  • Diabetics should have proper footwear & check their feet
  • Chance of having big wounds on feet & not knowing
  • Slow healing so decrease balance
  • From neural damage
  • Seek professional advice if the person is taking medications (for all NCD clients) + if not sure ask for help
• Low Back Pain is very common
• Non-specific Musculoskeletal Pain:

  • No specific finding (85% of LBP patients)
  • Unilateral, dull pain
  • Radiates down to the thigh but not beyond the knee
  • Muscular tension/pain/stiffness localised (or without leg pain)
  • Just 1 leg (if is 2 is something else)
• Non-specific Musculoskeletal Pain:

  • Treatment
  • Increase mobility
  • Massage
  • Apply heat or cold
  • Physical therapy +
  • Chiropractic
  • Meds:
  • NSAIDs
  • Cyclobenzaprine
  • Tizanidine
  • Typically resolves within 2-4(6) weeks regardless of treatment
• Low Back Pain:

  • Anywhere bw/ 4% & 33% of adult population experience LBP at any given point in time, & recurrent episodes of LBP can occur in over 70% of cases
  • Previous LBP is one of the strongest predictors for future back pain episodes (educate client)
  • Current best evidence guidelines for treating LBP indicate PA as a key component in managing the condition
• Low Back Pain:

  • To reduce the probability of disability, individuals with LBP should stay active, continue ordinary activity within pain limits; avoid bed rest, & return to work asap
  • Experience pain (pain signals), body saying somethings wrong; don’t disregard them
  • 2 different types of pain:
  • Dull - is continuous; not very specific, under 5, usually okay to continue if doesn’t get worse
  • Sharp - body saying NO (above 5 on 1-10 scale), slow down
• Low Back Pain ExRx:

  • Clinical practice guidelines for management of subacute (6-12 weeks pain) & chronic LBP (>12 weeks pain) as well as recurrent LBP are encouraged to staying PA & avoiding bed rest
  • PA very important
• Low Back Pain ExRx:

  • In chronic LBP, ExRx that incorporate individuals tailoring, supervision, stretching, & strengthening are associated with the best outcomes
  • Individualised better for any program but especially for LBP
• Low Back Pain Special Considerations:

  • Limit any activity that causes an increase in symptoms, particularly spread of pain into lower limbs
  • Such as walking down hill
  • Certain exercises or positions may aggravate symptoms of LBP
  • Push ups, can worsen it
• Low Back Pain Special Considerations:

  • Repeated movements & exercise that promote centralisation (ie a reduction of pain in the lower limb from distal to proximal), are encourage to reduce symptoms in patients with acute LBP with related lower extremity pain
  • To get better core strength (balance)
• Low Back Pain Special Considerations:

  • Flexibility exercises are generally encouraged as part of an overall programme
  • Consider progressive, low intensity aerobic exercise for individuals with chronic LBP with generalised pain (pain in more than 1 body area)
  • If in doubt tell them to go to the physio
  • Therapy helps reduce symptoms
  • Can be cured form LBP