EXERCISE PRESCRIPTION FOR SPECIAL CASES

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EXERCISE PRESCRIPTION FOR SPECIAL CASES

• 1. Rheumatoid Arthritis
• Symptoms - pain, swelling, stiffness of small
  peripheral joints, female preponderance (31),
  progressive course
• Systemic Disorders - pericarditis, vasculitis,
  pleuritis, pulmonary fibrosis, neuropathy,
  episcleritis, amyloidosis
• Functional Capacity - class 1-4 (complete ability
  to carry all duties without handicap, little or
  no self - care, bedridden)

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• Muscular Weakness, Low Endurance
• Exercise precription
• CLASS 1 - any type of exercise - best bicycle
• CLASS 2, 3 - in low activity phases - cycling,
  walking, heated pool exercise, exeptionally
  jogging)
• CLASS 4 - few patients perform physical activity
  (supported - in water).
• Effect of Exercise in RA
• Beneficial effect on physical, psychologic,
  social performances.

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2) Osteoporosis

• Definition - bone atrophy
• Osteoporosis Type I - related to menopause,
  accelerated trabecular bone loss
• Osteoporosis Type II - age related, after age 70
• Other Causes of Osteoporosis
• Immobilization, drug related (corticosteroids,
  anticonvulsants, bone-marrow disorders,
  connective tissue dis.)
• Symptoms
• Pain (mainly of the spinal column), fractures
  (spine, wrist, hip, wedge fractures of vertebrae).

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• Diagnosis
• Symptoms, x-ray, densitometric evaluation (dual
  photon absorptiometry)
• Exercise Prescription
• 1) Affecting Osteoporosis Risk Factors
  (20 min., 3 days/week, 40 - 70 ? of HR
  reserve)
• 2) Reducing Risk of Fractures
  Water exercise, resistance
  training, weight bearing, 2 - 3 times/week

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3) Spinal Disorders and Low Back Pain

• Incidence - majority of adults, mostly a result
  of activity - related spinal disorders. Most
  frequent cause of limitation to activities of
  daily living including work, housekeeping,
  school, recreation

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• Symptoms
• ACUTE low back pain - (accidents, inappropiate
  weight lifting), bed rest, resolve spontaneously.
• CHRONIC PAIN - anatomic changes of the spine
  (discopathies, spondylarthrosis, Bechterev
  disease)

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• Exercise for Prevention of Low Back Pain
• Isometric endurance of the back muscles.
  Strengthening abdominal muscles, flexibility
  hyperextension back exercise
• PRECRIBING DIFFERENT EXERCISE PROGRAMS FOR
  DIFFERENT SUBGROUPS OF PATIENTS!
• Emphasis on flexibility, muscle strengthening,
  endurance conditioning, pain management, education

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4) Bronchial Asthma

• Definition - chronic inflammatory disorder of the
  airways, clinically manifested by
  dyspnea, dry cough in response to different
  triggers (allergens, infection, exercise) caused
  by diffuse narrowing of bronchial tree.

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• Incidence - 5? of adults, 10? in children
• Diagnosis - familial history (presence
  of atopy - ekzema, rhinitis, conjunctivitis).
  Symptoms, physical examination, pulmonary
  function tests (bronchoconstrictor,
  bronchodilatory), skin prick tests, IgE.

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• Exercise Induced Asthma (EIA)
• Decrease in FEV1 ? 15 ? following exercise,
  symptoms of cough, wheezing
• More frequent in runners, long - distance ski -
  runers, cyclists, less frequent in swimming sports

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• Prevention of EIA
• SELECTION of the type of exercise, environment,
  duration and intensity of
  exercise
• Warm-up Period important
• Drugs - salbutamol, formoterol - approval for
  competitive athletes
• Olympic Games - 1984
• USA - 594 athletes, 67 (11.2 ?) suffered EIA,
  won 41 medals (15 gold, 20 silver,
  6 bronze)

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5) Chronic Obstructive Pulmonary Disease

• Definition
• Chronic inflammatory disorder of the airways,
  causing obstruction which is progressive not
  reversible after bronchodilating drugs,
  clinically manifested by productive cough and
  dyspnoea
• Incidence 10 of adults over 40, men prevalence
  (3 - 41).
• Etiology 90 cigarette smoke, others (repeated
  infectious bronchitis, occupation in dusty
  environment, alfa - 1 antitrypsin deficiency

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• Diagnosis - history, physical examination
  (? expiration, adventitious breath
  sounds, diminished vesicular breathing) pulmonary
  function tests (irreversible airways obstruction,
  increased residual volume, decreased diffusing
  capacity).
• Classification into 4 steps (GOLD)
• mild, moderate, severe, very severe - according
  to FEV1.
• Exercise Prescription
• part of total approach to patient care (optimal
  medical care, increased physical and social
  activity)

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• Grade 1 Disability (FEV1 ? 60, VO2 max ? 25,
  normal PCO2 , SaO2 )- submaximal exercise, 30 -
  60 min. every other day.
• Grade 2 Disability - (FEV1 ? 60, VO2 max
  ? 25, SaO2 ? 90) - 60 80 of ventilatory
  capacity (FEV1 x 35), short time exercise to
  breathlessness
• Grade 3 Disability (FEV1 ? 40, VO2 max ? 15,
  SaO2 ? 90 during exercise) - training of muscle
  groups (respiratory muscles, pattern of
  breathing).
• Grade 4 Disability (FEV1 ? 40, VO2 max ? 7,
  SaO2 ? 90 at rest) - exercise related to
  dyspnoea, fatigue, headache, oxygen
  supplementation
• Individualization for each patient

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6) Metabolic Syndrome

• Definition
• Presence of obesity, dyslipidemia, hypertension,
  diabetes, insulin resistance

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• Importance - high risk factor of cardiovascular
  disorders (ICHD, heart failure, ischaemic
  cerebral strokes, renal failure)
• Treatment
• Aggressive multi - factorial intervention.
• Most important - THERAPEUTIC LIFESTYLE CHANGE,
  INCORPORATING MODERATE PHYSICAL ACTIVITY PROVED
  EFFECTS OF EXERCISE weight loss, decrease of LDL
  - cholesterol, increased HDL - cholesteral,
  decrease of blood pressure, decrease
  of insulin resistance.
• Exercise Prescription
• Regular exercise 3 - 5 days/week, longer
  duration (30 - 60 minutes), intensity
  approximately 40 60 VO2
  max. (not exceeding 7 METs).

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7) Cystic Fibrosis

• Definition - inherited disorder, transmitted as
  an autosomal recessive trait.
• Gene causing the disease - CFTR (cystic fibrosis
  transmembrane regulator)
• CFTR protein controlles flux of chloride ions
  into and out of the cells lining airways and
  other endocrine glands (pancreas, intestine,
  sweat glands).
• Decreased water - in airways - thick secretions -
  impede breathing, less secretions of digestive
  enzymes.
• Symptoms - cough, wheezing, dyspnoea, frequent,
  bulky, foul - smelling stools, high lipid content.

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• Diagnosis - high concentrations of sodium and
  chloride in the sweat.
• EXERCISE TOLERANCE decreased (malnutrition,
  dyspnoea, increased energy expenditure)
• EXERCISE PROGRAM
• Prescription of aerobic exercise -
  individualized
• Type of activity - enjoying for patient
• Intensity - middle grade (50 - 70 of
  individuals maximal capacity - according HR)
• Exercise should be encouraged as part of the
  regular routine

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8) End-stage Renal Disease

• Definiton
• Chronic renal failure with diminished renal
  function, requiring renal replacement therapy
  such as dialysis or transplantation
• Causes - hypertension, diabetes, chronic
  infection, congenital abnormalities, autoimmune
  processess

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• Symptoms - fatigue, anorexia, nausea, malaise,
  edema, dyspnoea.
• Physical functioning and performance decreased.
• Exercise Prescription - participation in moderate
  physical activity.
• Patients who are weak - benefit from strength -
  training intervention, resistance and aerobic
  exercise initiated at low intensity, slowly
  progressed as tolerated.
• Incorporation of exercise into the dialysis
  session may increase patient participation and
  tolerance of exercise.

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9. CHILDREN WITH HEART DISEASE
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Congenital heart disease

1. Left-to-right shunts atrial septal defect (ASA)
   ventricular septal defect (VSD), patent ductus
   arteriosus
2. Obstructive aortic stenosis (AS), pulmonary
   stenosis (PS), coarctation of aorta
3. Complex lesions Fallot tetralogy, transpositions
   of great arteries

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Diagnosis

• Physical examination, x-ray, echocardiography,
  catheterization, angiography

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Excercise capacity (EC)

• in ASD normal or slightly decreased,
  until shunt flow exceeds 40
  of pulmonary blood flow
• in VSD small defects (lt 3 mm) normal EC.
  Large surgical repair necessary EC limited
  after surgery normal of slightly decreased

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In AS and PS

• EC directly related to the degree of peak
  pressure gradient, after surgical of balloon
  angioplasty no limitation of EC.
• In cyanotic lesions EC very limited, after
  successful surgery light exercise recommended

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Disorders of cardiac rhythm

• Exercise testing evaluation of hearts response
  to physical activity, bring out occult
  arrhythmias, assistance in diagnosis of
  arrhythmias in patients with palpitations,
  syncope, light-headennes, exercise testing in
  combination with Holter ECG monitoring complex
  information of rhythm disorders, mainly in
  problems with sinus node function and conduction
  system

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Attitude toward exercise and sport

• most children with heart disease without or with
  heart surgery no restriction to recreational
  sports activities, physical education.
  Cardiomyopathy, chronic myocarditis steered
  away from all competitive sports and many
  exercise activities (mainly weight training,
  strenuousexercise). Total abstinence from
  physical activities is not required.

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10. VALVULAR AND CONGENITAL HEART DISEASE IN
ADULTS

• Valvular heart disease mitral valve prolaps,
  mitral valve stenosis and insufficiency,
  tricuspidal valve stenosis and insufficiency,
  aortic stenosis and incompetence, pulmonary
  stenosis and insuficiency

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Diagnosis

• Symptoms, physical examination, exhocardiography,
  X-ray, catheterisation functional cassification
  according to the degree of tolerable physical
  activity NYHA I IV

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Exercise programs

• AIM improving working capacity
  of sceletal muscles.
  Intensity 40 50 of VO2max,
  4 5/week, 20 30 min.
• Possible adverse effects arrhythmia, anginal
  pain, acute heart failure, syncope.

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Congenital heart disease in adults

• very rare nowadays
  (ASD more than 50 )
• Exercise testing help for assessing functional
  status, cardiac arrhythmias
• Physical work capacity is either normal or
  slightly below normal

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11. LOW FUNCTIONAL CAPACITY

• Definition individuals with functional capacity
  of 5 METs or less
  (NYHA class III-IV) due to cardiovascular
  disease.
• Etiology 80-85 coronary heart disease (CHD)
  others cardiomyopathy, valvular, congenital
  heart disease
• Symptoms dyspnoea, dizziness, syncope, fatigue
  during exercise

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Low functional capacity

• Diagnosis history, physical examination,
  x-ray, echo, catheterization, exercise
  ECG, Holter monitoring
• Exercise testing strict medical supervision
  during exercise tests! Start exercise at a very
  low level (1 2 METS)
• Exercise prescription lower intensities,
  greater duration, greater frequency (5 10 min
  several times a day).
• Benefit from training carrying on daily
  activities without symptoms, psychologic effect.