This document discusses various special populations that require special consideration for exercise prescription, including the elderly, those with cardiac issues, diabetes, hypertension, osteoporosis, asthma, COPD, and pregnant women. For each population, it describes characteristics of the condition and provides guidance on exercise goals, testing, prescription parameters, and precautions. The key recommendations are to consult a physician, start low intensity and gradually progress exercise, and focus on improving functional capacity, management of risk factors, and quality of life. Chair exercises are recommended for those with limited mobility.

1. BY: DR REETA PT
MSPT (LNH), BSPT (JPMC) DPT.D (JPMC)
SENIOR LECTURER.
IPMR DUHS

2. SPECIAL POPULATION
 It is often meant as a collective term for a group of
people with certain health-related conditions or
groups of individuals who exhibit medical conditions
that impair health and functional ability
OR
 Patients with circumstances or conditions that require
special attention

3. Special Populations
 Cardiac
 Elderly
 Diabetes
 Hypertension
 Osteoporosis
 Chronic Obstructive Pulmonary Disease
 Asthma
 Pregnancy

4. Exercise and the Elderly
 The number of older individuals (over age sixty-five) in the
United States will double between 2000 and 2030 as the
 Older individuals are a special challenge from the standpoint
of exercise prescription due to the usual presence of chronic
disease and physical activity limitations.
 However, participation in physical activity and exercise will go
a long way in preventing the progress of diseases and in
extending the years of independent living

5.  Maximal aerobic power decreases in the average population
after the age of twenty at the rate of about I% per year
 The vast majority of people experience a steady decline in
V02 max so that by sixty years of age, their ability to engage
comfortably in normal activities is reduced.
 This initiates a vicious cycle that leads to lower and lower
levels of cardio respiratory fitness, which may not allow
them to perform daily tasks In turn, this affects elderly
people's quality of life and independence, which may
necessitate reliance on others

6. Exercise for older people
 Keeping Active into older age is the key to saying fit,
mobile and independent.
 Exercise can keep elders strong and healthy
 A physical activity program is useful in dealing not
only for cardio respiratory fitness but also for the
osteoporosis that is related to the sudden hip fractures
that can lead to more inactivity and death

7. Recommendation
 The guidelines for exercise training programs for older
adults are similar to those for younger people but
medical exam and risk factor screening are essential
 So Before starting exercise programs elderly
individuals should consult their physician.

8.  Low impact exercises
 Pace of all movement should be slow to moderate
 Progression should be very gradual
 Fast movement avoided to prevent postural
hypotension
 Exercise focus should be on to encourage elders to
become more physically active like walk the store, use
the stairs
 Encourage elders to keep joint flexible by moving,
stretching and bending

10. Exercise Goals
 Maintenance of functional capacity for independent
living
 Reduce risk of cardiovascular disease
 Improved strength & endurance
 Improved flexibility
 Retardation of progression of chronic diseases
 Improve psychological well being
 Reduces depression & anxiety
 Improve socialization

11. Exercise Prescription
 Mode/Type : comprehensive fitness program including
cardio respiratory, flexibility and strength training.
 Weight-bearing endurance activities (tennis, stair climbing,
jogging, at least, intermittently during walking), activities
that ,involve jumping (volleyball, basketball), and
resistance exercise.
 Non weight bearing for those elderly who have
degenerative joint disease like stationary cycling, water
exercises and chair exercises are best

12. Exercise Prescription
 Intensity: Low to moderate than moderate to high, in
terms of bone loading.
 Frequency Weight-bearing activities 3-5 times/week;
resistance exercise 2-3 times/week
 Duration: Start with short 10 to 15 minutes/ day and
progress to 30-60 min/day OF a combination of weight-
bearing endurance activities and resistance exercise that
targets all the muscle groups

13. Adaptations
•Chair exercises are ideal for older people or those
with limited mobility
•The exercises facilitate movement at an appropriate
level to increase fitness without adding the
unnecessary risk that can arise during higher
intensity, higher impact activity
•Chair exercises focus on functional fitness and
improve participants' ability to perform the standard
activities of daily living.

15. Benefits of participation
 Improved risk factor profile e.g. higher HDL and lower
LDL cholesterol, improved insulin sensitivity, and
lower blood pressure
 Increased strength and VO2max
 VO2 max refers to the maximum amount of oxygen
that an individual can utilize during intense or maximal
exercise

16. Asthma
 A respiratory problem characterized by a shortness of
breath accompanied by a wheezing sound
 Due to:
 Contraction of smooth muscle of airways
 Swelling of muscosal cells
 Hyper secretion of mucus
 May be caused by allergic reaction, exercise, aspirin,
dust and pollutants

17. Asthma: Diagnosis & Causes
 Diagnosed by using pulmonary-function testing (PFT)
 Agent causes influx of Ca++ into mast cells
 Release of chemical mediators histamine
 Which triggers asthma attack
 Bronchoconstriction
 Bronchoconstriction reflex via vagus nerve
 Inflammation response

18. Proposed Mechanism by which an
Asthma Attack Is Initiated

19. Prevention and Relief of Asthma
 Prevention
 Avoidance of allergens
 Immunotherapy
 Treatment
 Cromolyn sodium
 2-agonists
 Theophylline

20. Exercise prescription
 Mode: perform dynamic exercise such as walking
swimming and cycling. Upper body exercises
 Intensity: low intensity dynamic exercise
 Also based on patient fitness status and limitations
 Frequency: 3 to 4 times per week
 Duration: longer and more gradual warm up and cool
down more than 10 mints
 Total time increased gradually 20 to 45 mints.

21. Exercise-Induced Asthma (EIA)
 Caused by cooling/drying of respiratory tract
 Increases osmolarity on surface of mast cell
 Reducing the chance of an attack
 Warm-up
 Short-duration exercise < 5 mints
 Treatment
 -agonist

22. Chronic Obstructive Pulmonary
Disease (COPD)
 Includes chronic bronchitis, emphysema, and
bronchial asthma
 Can create irreversible changes in the lung
 Can severely limit normal activities
 Treatment includes:
 Medication (including supplemental O2)
 Breathing exercises
 Dietary therapy
 Exercise

23. Testing and Training COPD Patients
 Medical exam including exercise testing
 FEV1 : It represents the proportion of a person's vital capacity
that they are able to expire in the first second of forced
expiration..
 VO2max
 Maximum exercise VE
 Blood gasses (PO2 and PCO2)
 Training goals include
 Reduced reliance on O2 and medications
 Improved ability to complete daily activities

24. Exercise prescription
 Mild exercise training
 Aerobic exercises
 Do the best they can

25. Hypertension
 Defined as >140 or >90
 Increase risk of coronary heart disease
 Exercise and diet can be used as a non-drug treatment.
 Precautions
 Blood pressure should be monitored for those on
medications

26. Hypertension
ACSM Guidelines, Gordon 1997
 Loss of weight if overweight
 Limit alcohol intake
 Reduce sodium intake
 Maintain adequate dietary K+, Ca2+, Mg2+
 Stop smoking
 Reduce dietary fat, saturated fat, and cholesterol intake

27. Exercise prescription
 Intensity: light to vigorous activity, Moderate range (40%-85%
V02 max), is effective and can be accomplished with lifestyle
activities as well as structured exercise programs.
 Duration: Thirty minutes
 Frequency: three or more days per week and progress to
Preferably all, days of the week
 Gordon indicates that the combination of intensity, frequency,
and duration should result in a weekly physical activity energy
expenditure of 700 (initially) to 2,000 (goal) kcal

28. CARDIAC REHABILITATION
 Exercise training is now an accepted part of the therapy used to
restore an individual who has some form of coronary heart
disease (CHD)
 Cardiac rehabilitation is a programme of exercise and
information sessions that help people to get back to everyday
life as quickly as possible.
 To help people in the hospital community and home.
 Prove that exercise is not scary.
 Reducing risk of happening again.

29. Cardiac Rehabilitation: Patient Population
 Those who have or have had:
 Myocardial infarction (MI)
 Coronary artery bypass graft surgery (CABG)
 Angioplasty (PTCA)
 Angina pectoris
 Medications
 -blockers (reduce work of the heart)
 Anti-arrhythmics (control dangerous heart rhythms)
 Nitroglycerine (reduce angina symptoms)

30. Cardiac Rehabilitation Testing
 Graded exercise testing
 ECG monitoring (12-lead)
 Heart rate and rhythm
 Signs of ischemia (ST segment depression)
 Blood pressure
 Rating of perceived exertion (RPE)
 Signs or symptoms (chest pain)
 Determination of myocardial blood flow

32.  Cardiac rehabilitation includes a "Phase 1” inpatient
exercise program that is used to help the patients make
the transition from the cardiovascular event (e,g" a
myocardial infarction that put them in the hospital) to the
time of discharge from the hospital
 After the patient is discharged from the hospital, a
"Phase II" program can be started.
 Warm-up with stretching, endurance, and strengthening
exercises, and cool-down activities are included

33. Phase 3: structured exercise and rehabilitation
 Graded exercise is a vital component of cardiac rehabilitation
group based exercise programme,
 The exercise programme is an 8 week course
 Each session lasts approx 90 minutes and is then followed by
educational talks which include medication, diet, exercise,
stress, relaxation
 Phase 4 – long term maintenance of physical activity and
lifestyle change
 To be effective, the changes you have made in the previous 3
phases of Cardiac Rehabilitation should be maintained for the
rest of your life.

34. Target three goals in cardiac rehabilitation
 Safety
 Fitness
 Risk factor management

35. Cardiac Rehabilitation: Exercise Programs
 Exercise prescription
 Based on GXT results
 MET level, heart rate, signs/symptoms
 Whole body, dynamic exercise
 Intensity, duration, and frequency based on severity of
disease
 Effects
 Increased functional capacity (VO2max)
 Reduced signs/symptoms of ischemia
 Improved risk factor profile

37. Termination Criteria from Exercise
 Any angina symptoms or feeling too breathless to
continue
 Feeling dizzy or faint
 Leg pain limiting further exercise
 Exceeds level of perceived exertion > 15 (Borg Scale)

38. Contraindication for Exercise
 Unstable or unresolved angina.
 Fever and acute systemic illness.
 Patient in severe pain.
 Resting blood pressure: SBP> 180mmHg, DBP> 100mmHg
 Significantly unexplained drop in blood pressure.
 Tachycardia
 New or recurrent symptoms of breathlessness, palpitation,
dizziness.
 Significant lethargy

39. Osteoporosis
 Osteoporosis is a loss of bone mass that primarily affects women
over fifty years of age and is responsible for 1.5 million fractures annually
 Type I osteoporosis is related to vertebral and distal radius fractures in
fifty- to sixty-five-year-olds and is eight times more common in women
than men.
 Type II osteoporosis, found in those aged seventy and above, results in
hip, pelvic, and distal humerus fractures and is twice as common in women
 The problem is more common in women over age fifty due to
menopause and the lack of estrogen
 Hormone replacement therapy (HRT) initiated early in menopause prevents
bone loss and can increase bone mineral density and reduce fracture risk

40.  However, such treatments are not without risks. HRT has been
associated with an increase in cardiovascular disease and
mortality and an increased risk of certain cancers.
 Given that prevention is better than treatment. attention is focused on
adequate dietary calcium and exercise throughout life
 Dietary calcium is important in preventing and treating osteoporosis
Although the daily calcium requirement is 1,000 mg per day
 There is clear evidence that vitamin D should be a part of any calcium
supplement aimed at the prevention and treatment of osteoporosis

41. Exercise During Pregnancy
 Pregnancy places special demands on a woman due to
the developing fetus's needs for:
calories, protein, minerals, vitamins,
and of course, the physiologically stable environment
needed to process these nutrients.
 Pregnant women should consult their physician prior
to beginning any exercise program

42. Major adaptations to pregnancy
 Blood volume increases 40–50%
 Oxygen uptake and heart rate are higher at rest and
during exercise
 Cardiac output is higher at rest and during
exercise in first two trimesters ƒLower in third
trimester
 Rating of perceived exertion may be the best method
of setting intensity

43.  Pregnancy is not a sickness or a disease condition.
However, there are several signs and symptoms that
should either preclude the beginning of an exercise
program or terminate exercise if a program has already
started
 Regular endurance exercise poses no risk to the fetus
and is beneficial for the mother

44. Absolute contraindications
 Significant heart disease
 Incompetent cervix
 Multiple gestation at risk for premature labor
 Persistent second- and third-trimester bleeding placenta
previa after 26 weeks of gestation
 Premature labor during the current pregnancy
 Ruptured membranes
 Pregnancy-induced hypertension/preeclampsia

45. Relative contraindications
 Severe anemia
 Unevaluated maternal cardiac arrhythmias
 Chronic bronchitis
 Poorly controlled Type 1 diabetes
 Extreme underweight (BMI < 12)
 History of extremely sedentary lifestyle
 Intrauterine growth restriction in current pregnancy
 Poorly controlled hypertension
 Orthopedic limitations
 Poorly controlled seizure disorder
 Poorly controlled hyperthyroidism

46. Exercise Recommendations
 Follow ACSM recommendation
 30 min/day of moderate-intensity activity on most,
preferably all, days
 Intensity determined by Rating of perceived exertion
 Talk test : The talk test is a simple way to measure relative intensity.
In general, if you're doing moderate-intensity activity you can talk, but
not sing, during the activity. If you're doing vigorous-intensity activity,
you will not be able to say more than a few words without pausing for a
breath.
 No supine exercise after first trimester

47. Diabetes
 Characterized by an absolute (type 1) or relative (type
2) insulin deficiency that results in hyperglycemia
 A major health problem and leading cause of death in
the United States
 More than 17 million with diabetes, only 11.1 million are
diagnosed

48. Diabetes
 Type 1 (Insulin Dependent diabetes Mellitus)
 Lack of insulin
 Develops early in life
 10% diabetic population
 Type 2 (Non Insulin Dependent diabetes Mellitus)
 Resistance to insulin
 Develops later in life
 90% diabetic population

49. Diabetes
Characteristics
Type 1
Insulin-dependent
Type 2
Non insulin-dependent
Another name Juvenile-onset Adult-onset
Proportion of all diabetics ~10% ~90%
Age at onset <20 >40
Development of disease Rapid Slow
Family history Uncommon Common
Insulin required Always Common, but not always
Pancreatic insulin None, or very little Normal or higher
Ketoacidosis Common Rare
Body fatness Normal/lean Generally obese

50. Exercise and Type 1 Diabetes
 Pre-exercise blood glucose level
 80 to 250
 Timing with insulin
 Should not exercise at time of peak insulin action
 Glucose monitoring
 During/after exercise
 Carbohydrate intake
 During recovery

51. Exercise and Type 2 Diabetes
 Blood glucose monitoring
 Exercise prescription
 4-7 times per week
 Promotes weight loss and sustained increase in insulin
sensitivity
 Minimum of 1,000 kcal/wk
 From all physical activity

52. American Diabetes Association
Goals for Nutrition Therapy
 Attain & maintain optimum metabolic outcomes:
 Maintain Blood glucose levels in normal range
 A lipid and lipoprotein profile that reduces the risk of
macrovascular disease
 Maintain Blood pressure level that reduces risk of
vascular disease
 Improve health through food choice and activity
 Address individual nutritional needs

53. Exercise prescription
 Mode: Endurance activities such as walking
swimming and cycling
 Intensity: 50% to 60% VO2 max gradually working up
to 60 to 70% VO2 max
 Frequency: 5 to 7 days a week for IDDM
 4 to 5 days a week for NIDDM may need to start
several daily session
 Duration: persons with IDDM should gradually work
up to 20 to 30 minutes per session
 For NIDDM 40 to 60 minutes is recommended