Mike Lukich, age 61, a special population of one: Gold medalist 1968 gymnastics, world class power lifter.

First human to deadlift 3xs their body weight, current world champion in cycling (road & mountain bike.)

CHAPTER 5

SPECIAL POPULATIONS

5-1

SPECIAL POPULATIONS Todays trainers need to have a wide variety of tools in their toolboxes in order to accommodate the ever-changing demands placed upon them by the industry and the market. Along with those changing demands comes the changing medical climate in our country. We frequently find people beginning to manage their own health care and ultimately the future of their health and well-being. To begin the investigation of these individuals, let us look at who these people are and what needs they actually have. The place to begin an investigation would be to look at what types of people fall into these groups. The fact is, the vast majority in this country is on some level, a part of some special needs culture. In general, there seems to be the impression that a lack of symptoms would indicate no disease. As with hypertension and HIV, there are many silent killers whose problems may not surface for quite some time. There also can be the masking of symptoms where a problem may appear very different than the actual cause. This gives more reason for the trainer to insist on a yearly physical, not only for new clients, but for existing clients as well. Once this medical screening has taken place, the trainer can then be more prepared to deal with the needs of clients that may come their way. The trainer then must evaluate whether or not they are capable of handling the needs of this particular individual. This chapter will look at the most common special populations. There are however, a growing number of other special situations that must be addressed by continuing research by the trainer. Discussions should take place regularly between the medical community servicing these people and the trainer to keep the clients changing needs as the primary focus of their training. Accepted guidelines are already in place for many of these special groups; however more investigation is necessary. General Guidelines for Dealing with Chronic Disease Before considering training a person with a chronic disorder, a fitness professional must take into account several things. The first and most important is, whether or not the fitness professional is qualified to help the client in his or her current condition, and whether the benefits outweigh the risks for this person. Once these questions have been considered, the trainer must gather all information pertaining to the current condition of the client. A complete comprehensive medical history is necessary pertaining to that persons health history. The trainer must be aware of all medications the clients ingest and their impact on the training process. It is also advisable for the trainer to discuss with the attending physician, all special considerations regarding that particular disease. Then and only then, will the trainer be ready to begin the training process. At the first meeting, the trainer should discuss with the client objectives for the first four or five training sessions. Assuming control of the training progression is crucial. These individuals need to establish faith in that youll lead them toward health and well being. Because of the current status of the clients health, both the trainer and client must understand training sessions may be limited at first. Remember, to someone who is ill or extremely weak, a minute or two of exercise may be sufficient. The components of the first few training sessions may be an evaluation of the persons posture, balance, stability, mobility and strength. These five functions are essential to have and to maintain a certain quality of life. When dealing with anyone who is in a chronic state of disease or pain, the goal of the trainer is to keep that person independent for as long as possible or to keep them from losing ground.
5-2

Even such standards as target heart rate may not be accurate representations of the effectiveness of the training session. The Rate of Perceived Exertion may be a more accurate way to monitor the level of intensity of the session. The normal protocols for target heart rate and fitness are not standards designed for people with special needs. Once a definitive starting point has been established, it is time to discuss a realistic method of communication. The trainer must have some sort of benchmark for normal events in the life of the chronically ill patient and unusual or stressful events surrounding the workout. It will be necessary to review the difference between normal signs of exertion and warning signs surrounding specific problems this person may incur. These discussions should take place before the training session and during it as well. Many people cannot differentiate between: 1. Normal fatigue and fatigue from over-training. 2. Normal pain as in a challenging set and pain from their disease.

4. Elevated heart rate from strenuous exercise and heart arrhythmia.

3. Normal elevations in breathing and labored breathing from over-exertion or a respiratory problem.

This can be further complicated by the fact that many other treatments can either mask or make the symptoms worse. People who experience chronic pain may be accustomed to pain and have a tendency to ignore warning signs. An important evaluative technique is to have a rating system for things that fall from the realm of the norm. For example: 1. Abnormal discomfort or pain out of the norm, but only of minimal levels. 2. Moderate to medium pain or discomfort that distracts them from normal conversation and seems to dissipate quickly after a set is over.

4. Excruciating or unbearable pain or discomfort. These symptoms definitely do not subside following cessation of the exercise. None of these symptoms should ever be ignored. Keep in mind, many of the common treatments for these chronic states of illness may have an impact on the clients overall ability. Medications commonly prescribed can alter such things as exercise; resting heart rate; blood pressure before, during and after exercise; inflammation in and around the joint capsules; and pain, or the perception thereof. Exercising may increase the functional capacity of a person with chronic disease. However, trainers must be realistic in their approach to the goals of these clients. It is extremely important to remember you cannot prescribe, diagnose or practice medicine. There are limits and guidelines for you and your clients safety. No longer are bed rest and inactivity the preferred treatments for chronic disease. Instead prevention, postponement, and rehabilitation are the benchmarks of treatment today. The more people assume responsibility for their health and wellness, the more trainers will be seen as the interim health care providers of the future.

3. High levels of pain that present a definite distraction to the workout and which the client cannot ignore. These symptoms may not dissipate following cessation of the set.

5-3

As the trainer begins to work on specific exercises, there should be a realistic thought process for decision making. This thought process should include such things as: mechanical ability, control, and challenge. Specifically, defining the joint ranges that are ideal and those that are available as a result of the limitations of the special group is essential. In other words, is the normal or optimal level of movement also the desirable one for this particular problem? Can this person control movement throughout the entire range, or is some other skill needed to accomplish this task? Once the two processes have been accomplished, it is then time to address how to add challenge to the movement. Normally, challenge may be accomplished through increased resistance. However, this does not represent the only form of challenge and in many cases not the most desirable form. Other components to add to challenge include, speed, balance, amount of movement, direction of resistance or form of resistance can and should also be implemented to protect the joints from further damage. Aging and Its Effects on the Bodys Systems The one common thread that exists throughout society is that we are all aging. Although specific limitations do not exist for this group as a whole, there are concerns one must have when working with them. Exercise history is a huge consideration, along with any age-related illnesses on how to better serve this special group. Normal aging carries with it some changes in how the body adapts to physical challenge and metabolism. Among those changes are steady hormonal decline, lower maximum oxygen uptake, neurological interference and structural changes associated with bone loss and rigidity. Each of these changes can impact the training process in a unique manner. A steady hormone decline, lack of exercise and proper nutrition are key elements in the loss of lean muscle tissue and the increase of adipose tissue in older populations. Even when a person exercises for the majority of his or her life, the decline of hormones such as testosterone and human growth hormone will prevent one from maintaining the muscle mass of a younger person. Crucial to this whole process is that many older adults do not consume enough calories and do not get adequate amounts of protein when exercising to increase overall muscle mass. Advances have been made in the arena of hormone management as a supplement to the loss associated with aging. As a result of hormone declines and a steady decrease in activity, many older persons experience dramatic decreases in muscle mass and strength. Increasing exercise in their lives can offset some of this loss. There are specific areas where loss of strength can actually be the reason their independent lifestyle is diminished or even taken away altogether. Specifically, we can look at the areas of hip flexion, knee extension, knee flexion, adduction and abduction of the hip. In most cases, it is better to look at loading through the joint rather than across it. Examples of this would be a leg press or squats versus knee extension and flexion. If the weight selected is minimal and the speed is controlled, it may be acceptable for the client to use such exercises as knee extension and knee flexion. Axial alignment of the machine to the knee would also be a major concern. Exercises such as the multi hip for hip flexion and hip extension are important for maintaining walking and climbing steps and curbs. Additionally, there is the issue of training the musculature that allows the foot to dorsal and plantar flex. Weakness in any of these areas can virtually halt all freedom of mobilization. Resistance training is a crucial element of any fitness program. When working with an older individual, the trainer should try to use resistance training for the added benefit of bone density. As the muscle pulls on its insertion point, bone density will improve dramatically in those sites.
5-4

For older persons, rate of perceived exertion scales are probably more accurate to assess the effect of training. Lower maximum oxygen uptake is normal with aging, so a person cannot expect to achieve the same target heart rate they achieved for training in previous years. For the very elderly, even maintaining a specific fitness level may actually be progression in terms of the clients ability. Beyond that, there are issues of balance for the aging person. Therefore, some time should be allotted each day to work on these skills. Attention should be paid to stabilization, lateral, forward and backward movement. Stepping to the side, back, up and down steps, standing on one foot with eyes open, one eye closed, and both eyes closed would be examples of exercises for the specific purpose of improving balance and stability. Taking a step over a small block and holding for a few seconds with one-foot elevated would be a higher level of challenge than the first moves. Progression could gradually lead to walking on a slide board with slippers, so further stabilization would be required. A stability ball would be a great tool for core strength and stabilization with gradual progression to the round ball. Remember, falling is very dangerous for the older client. The trainer should consider safeguards as they practice these skills. Aside from these challenges, many older people suffer not so much from aging, but the diseases that commonly coincide with it. To become an educated trainer is of paramount importance to ensure safety and allow for a positive training experience. Workouts must be scheduled with adequate rest and recovery time, without too much lapse between workouts, or the very aged may lose ground in their personal fitness level. This elderly group is growing in number every day and in the next 20 years promises to be a major part of the worlds population. A trainers client base can expand dramatically by reaching out to the older client. AIDS/HIV AIDS/HIV are diseases that strike fear in the hearts of most people. They are insidious diseases that have no apparent symptoms at their onset. For years the symptoms may lie dormant, working slowly at attacking the bodys ability to fight disease and infection. The client who has HIV may go a very long time without knowing they have it. The risks of infection for the client become great as the disease progresses. At the stage where the AIDS virus takes hold, the most important role a trainer may play is that of wellness protector. It is crucial the AIDS patient follows a healthy diet regimen, exercise to the best of their ability, and rest. Problems like weakness are overwhelming when these patients are at their worst. As a result, this client may be overtraining for their level on that given day. Evaluation of their current ability must be done on a day-to-day basis. It is important trainers wash their hands to protect the patient from being exposed to other infections. Possibly the most important function of the trainer is that of support for these who face their mortality from a heartless disease. Arthritis Arthritis, a disease commonly associated with inflammation of the joint surfaces, can result in two processes of disease. These two forms can result in inflammation of the joint surfaces and pain associated with that inflammation. Both can interfere with the normal ranges of motion available to those joints
5-5

because of swelling and inflammation. Although both diseases may exhibit similar symptoms, they are distinctly different in terms of the level of disability a person may experience as a result of the form arthritis takes. Osteoarthritis is a progressive form of arthritis. The damage to the joint surfaces is progressive and irreversible. Patients with Osteoarthritis (OA) experience constant pain. The most accepted form of treatment for patients with OA is a non-steroidal anti-inflammatory (NSAID) or for less severe cases, some form of analgesic. The other form of arthritis is known as Rheumatoid Arthritis (RA). This form is an autoimmune process resulting in inflammation of the synovial fluid contained in the bursa sacks of the joint surfaces. Typically RA is seen in the distal joints such as the fingers. RA patients experience periods of pain and relatively pain free periods. For persons with either form of arthritis, weight-bearing exercise may not be the best choice for exercise. Instead, water exercise or stationary bicycling may provide them with the greatest relief. Close attention should be paid to less extreme joint positions, how far the resistance is from the joint motion that is occurring, and any anatomical limitations that may occur naturally, but may be exacerbated through the progression of this disease. Seat height for the stationary bike should also be adjusted to decrease excessive force on the knee in the pedaling motion. When choosing weight-training exercises, loading lightly across the joint may actually be better tolerated than through the joint. Arthritis can cause a narrowing of the space between the joints, so compression caused by loading through the joints can cause greater pain. In any case, exercise intensity should be manipulated in respect to their level of tolerance of pain on any given day. On days where symptoms are mild to moderate, the patient may be able to tolerate greater levels of intensity. One of the greatest dangers for the person with arthritis is that the treatment masks the symptoms and the tendency to over-train is increased. In these situations, the risk of injury to the joints may be greater. Therefore, it may be necessary to modify the mode of exercise to reduce risk of damage to the joint surface. Cancer Today the medical community at large realizes the benefit of exercise for the afflicted. Not the least of which happens to be the cancer victim. There is substantial benefit for the person that is undergoing chemotherapy on several fronts. First, there is the fact that exercise raises the spirits of the person who is dealing with the debilitating effects of the therapy. Second is the long-term benefit of those managing their treatment more successfully. The trainer must be cautious not to cause damage to the client due to a lack of understanding of the prescribed medical treatment and the impact of certain exercises on that treatment. Chemotherapy can cause any or all of the following symptoms: Sweating Nausea General weakness

Chronic Infections

Muscular Weakness

Loss of Bone Mass-bone fractures

5-6
Rev. 10/2006

Dehydration

Electrolyte Imbalance Lowered Endurance Extreme Fatigue Anemia

Severe Weight Loss Loss of Appetite Stomach Distention due to Malnourishment

Only a portion of the challenge is due to the disease itself. The other challenge lies in the approach to the training program. The trainer should not have the client training with free weights, as there can be problems with balance which can be dangerous. Machines are usually preferable. There should be considerable thought to aerobic activity as the heart undergoes extreme stress as a result of chemotherapy. It is also dangerous for the client to do any kind of high impact aerobic activity due to the risk of bone fractures. Chemo causes an osteoporosis-like condition. Bruising can also readily occur, so be careful to avoid pressure on the skin or friction during exercise. Diabetes Mellitus There are two forms of diabetes. Type I is insulin-dependent and is commonly referred to as juvenile-onset diabetes. This form results from a pancreatic deficiency in insulin production. Therefore, the person who suffers from Type I diabetes may be forced to take insulin injections on a regular basis. Type II is commonly referred to as non-insulin dependent or maturity-onset diabetes. This form is commonly a result of obesity and may be treated successfully with diet modifications and exercise. As they lose weight, Type II diabetics may experience some lower level of symptoms. With either type of diabetes, it is a good idea to check insulin levels before and after exercise to avoid severe swings in blood glucose levels. These changes can appear for up to four to six hours after an exercise session. To compensate for this training effect, it may be necessary for the diabetic to take a smaller dosage of insulin or to increase carbohydrate intake before the onset of exercise. The following are good general policies when working with a diabetic: 1. Monitor blood glucose frequently when initiating an exercise program.

3. Inject insulin in an area that is not active during exercise. If the person is working upper body, the lower body may be a good site. 4. Avoid exercise during periods of peak insulin activity. 5. Eat carbohydrate snacks before and during prolonged exercise bouts. 6. Be knowledgeable of the signs and symptoms of hypoglycemia.
5-7

2. Decrease the insulin dosage (by 1 to 2 units as prescribed by the physician) or increase the carbohydrate intake (10 to 15 grams per one half hour of exercise) prior to an exercise bout.

7. Recommend that the person with diabetes always exercise with a partner.
Rev. 10/2006

Other precautions may include:

1. Proper shoes and practice of good foot hygiene.

2. Beta-blocking medications may be unable to experience hypoglycemic symptoms and/or angina. 3. Exercise in excessive heat may cause problems due to anhidrosis. As a rule, diabetics can participate in the same type of exercises as the general public. People with the complication of obesity should look at non weight-bearing activities to avoid orthopedic problems especially with the foot. Daily exercise is advisable for the insulin dependent diabetic so regular patterns of insulin injections and eating may be established. The non-insulin dependent diabetic requires exercise at least five days per week in order to expedite calorie expenditure to maximize weight reduction. The duration of exercise is specific to the type of diabetes. For type I individuals 20 to 30 minutes of daily exercise is recommended. On the other hand, the non-insulin dependent diabetic may need to exercise 40 to 60 minutes in order to facilitate weight loss and overall caloric expenditure. With regards to intensity, the Type I diabetic can perform the regular target heart rate range for other healthy adults (40 to 85% of their functional capacity). The Type II diabetic, however, may need to train closer to the 40 to 60% range because of the increased frequency and duration of their exercise bouts. There are a few instances where these guidelines may not be advisable and therefore, it is in the best interest of the trainer and the client, to discuss the particulars of the disease with their physician. Rate of Perceived Exertion is always a good benchmark, and if the person is in a really de-conditioned state, it may be a better barometer of their relative condition. When exercising at higher levels of intensity, there is a greater risk of hypoglycemic reaction; therefore, it may be necessary to monitor blood glucose levels closely for 24 to 48 hours immediately after high intensity sessions. Its advised to keep some fast acting sugar foods close by in case of an emergency. Fibromyalgia This is a bizarre condition. A doctor makes a diagnosis when a person has had pain in at least 11 of the 18 characteristic tender points for three months or longer. Other symptoms can include extreme fatigue, sleep problems, headaches irritable bowel disorders and depression. The majority of people who suffer from fibromyalgia are women of childbearing age, but men, children and older people also develop this disorder. However, many diseases have these symptoms. The thing to remember is muscle soreness is the primary symptom In fact, Fibromyalgia was originally called "Fibrositis, which means inflamed muscles. When people complained about the soreness and the medical practitioner found no inflammation it was thought the condition might be psychological. Diagnostic criteria for the condition was not recognized until 1990. Many physicians today are not that familiar with fibromyalgia. What causes fibromyalgia is still a mystery. Researchers believe it has something to do with the way the brain and central nervous system (CNS) interprets pain. Elevated levels of certain neurochemicals in the CNS have been noted in people with fibromyalgia.
5-8
Rev. 11/2006

There is no cure nor standard treatment methods. Because of the lack of effective Medicine, people must take a holistic self-care approach, and through trial and error discover what modalities and therapies work best. Cognitive-behavioral therapy programs help correct the destructive ways of thinking. Work on their "attitude" or outlook on life and keep them accountable. That's why exercise can help. The benefits of exercise include: stronger and healthier muscles and joints, self-confidence, empowerment, better sleep, better moods, stress reduction and depression and, forces the client out of the house to interact with other people. Use your common sense. Each exercise program should be individualized and include input from other healthcare providers. Walking, cycling, swimming are a few aerobic activities, while strength training and stretching should be moderate and performed at appropriate levels. Don't push this client physically. Imagine they're in an "overtrained" state. Open up dialogue with your client. Keep the workout fun. Keep the conversation and experience upbeat and positive. I hope you dont encounter many clients with this disorder. For their sake. Hypertension Hypertension or high-blood pressure, is a very common problem. Many clients who experience this problem are not commonly thought of in terms of a special population. Genetics can be a major factor. From all outward appearances they are normal, healthy adults. Once they have been diagnosed with hypertension, they may be on a medication that controls their problem. Regular, daily cardiovascular exercise can lower high blood pressure overall. Weight loss can also improve the problem significantly. When exercising with a person with hypertension, the trainer must pay attention to the following: For the same given workload, upper body compared to lower body ergometry will increase heart rate and systolic blood pressure, hence, avoid lifting weight over their heads. Breathing should be a controlled flow of oxygen throughout the entire set. They should never practice the valsalva maneuver. Exercises should be done with a loose handgrip. Lower sodium intake. The client should never do exercises with their head below the level of their heart.

Focus on larger muscle groups rather than smaller ones. Avoid lifting heavy weights above their head unsupported.

Frequency is important. 30 minutes or more a day is recommended by the ACSM (American College of Sports Medicine) at a moderate level. People using beta-blockers might be subject to heat illness when exercising. Extend the cool-down period. Antihypertensives such as alpha-blockers, may cause blood pressure to lower too much if exercise is stopped abruptly.

Overweight and obese adults should combine regular exercise and weight loss.

Obesity Obesity may be defined as a body fat level that is elevated enough to increase the risk of disease. The American College of Sports Medicine (ACSM) defines obesity in women and men as greater than 32% and 25% respectively.
Rev. 11/2006

5-9

These diseases may include hormonal changes, joint related problems, high blood pressure, diabetes or coronary problems to name a few. The objective of the obese person should be to increase the overall caloric expenditure and to increase the basal metabolic rate as well. This can be accomplished by participating in a program that includes limiting caloric intake, increased caloric expenditure through cardiovascular exercise and weight training to maintain lean muscle tissue. The most important phase of the exercise solution is to find a program that appeals to the individual. Quite often these people have experienced a number of failures with past exercise programs and diets. It is important to discuss their concerns and frustrations so that the fitness professional is better equipped to overcome their fears of another failure. It is also extremely important to discuss schedules to insure a regular routine.

before

after

Such individuals are often extremely sedentary so the more consistent time schedule the greater their chance for success. Adherence is the key. Regular, consistent exercise will yield a higher caloric expenditure. With the obese person, there is a greater than average risk for joint distress because of the excess weight. When choosing exercises for this population, the trainer must consider whether or not the equipment can handle their clients weight or size. Additionally, the trainer must consider the comfort of their client while performing these exercises. Choosing non-weight-bearing activities may be necessary for some period of time. Consideration for any other health problems the client may be experiencing could be necessary to accommodate the overall needs of this client. Diseases such as diabetes, hypertension, and arthritis would be common among those with obesity. Cardiovascular Disease Cardiovascular disease is a broad-based category for anyone experiencing any disease associated with the cardiovascular system. These diseases include arteriosclerosis, myocardial infarctions, any signs or symptoms associated with these illnesses, congestive heart failure, bypass surgery, transplants, and the list goes on. To assume a trainer is qualified to handle these infirmities can be a rather high liability. In order to better prepare for these situations, communication is once again of paramount importance. The trainer must have contact with the patients primary cardiovascular specialist. There are important issues to be addressed with regards to the person with any form of cardiovascular disease. Each of these categories carries its own set of circumstances and cannot be addressed fairly without greater detail than we can provide in this chapter. Many of the diseases associated with the cardiovascular system are readily improved with regular exercise. Rate of perceived exertion scales is a better method of measure than almost any standard scale available. Medications commonly associated with the treatment for these problems can make it more challenging to assess the client with common measuring devices like target heart rate scales. For more information specifically regarding the medications and their side effects, please refers to ACSMs Guidelines for Exercise Testing and Prescription.
5 - 10

Asthma Asthma is a respiratory problem characterized by labored breathing and a shortness of breath accompanied by wheezing. Attacks can be initiated by exercise, aspirin, pollutants, emotions and allergic reactions to animals or dust. There are a variety of drugs and procedures to help prevent asthma attacks or provide relief when one occurs. Exercise-induced asthma (EIA) is initiated by exercise and can occur 5 to 15 minutes or 4 to 6 hours following exercise. (1) Most asthmatics experience EIA as opposed to the nonallergic population. Cold air and specific intensities and durations of exercise may cause EIA. Running causes more attacks than cycling or walking which causes more attacks than swimming. (2) A warm-up within an hour of strenuous activity will help reduce the severity of an attack. Structure a training session with a normal warm-up and mild to moderate activity structured into 5 minute segments. Swimming is better because the air above the water tends to be warmer and contains more moisture. Sometimes it helps to cover the face with a mask or a scarf when exercising in cold weather. The client should consult their physician to fine tune their medications to prevent the attacks. It might be a good idea for the exerciser to carry an inhaler and use it at the first sign of wheezing. Osteoporosis This is a brittle bone disease that occurs primarily in women at or near menopause due to the lack of estrogen. (See Menopause below). In fact, osteoporosis is more related to menopause than to a womans chronological age. If detected early, much can be done to offset its progression. There are medications available which can spur the rapid development of new bone formation. Type I osteoporosis is related to fractures of the vertebrae and the distal radius in 55- to 65-year olds, and is eight times more common in women than in men. (3) If estrogen treatment is started early in menopause, it may prevent bone loss. However, if started too late (years after menopause) medication cannot replace the lost bone, but will maintain the existing bone.(4) Type II osteoporosis, experienced by those age 70 and above, may result in hip, pelvic and distal humerus fractures and is twice as common in women. (5) A woman who has a family history of osteoporosis should begin a regular program of weight bearing exercise and resistance training at an early age. Additionally, she should consider eliminating caffeinated beverages from her diet. Excessive caffeine intake may cause diuresis, therefore reducing the absorption of calcium. However, the effects are minimal compared to smoking and drinking alcohol.

Excessively low body fat can also contribute to the tendency toward osteoporosis. It is recommended that a person who wants to increase bone density perform weight bearing activity on a regular basis. Walking and jogging are considered better than bicycling and swimming for maintaining bone in the hip and spine, but for the unfit, the latter activities are recommended. In general it is the magnitude of the high force that is most beneficial rather than the high number of repetitions of low force repetitions. Whenever possible, progress to weight bearing exercise. Studies have shown that weight bearing exercises that are not significantly different from daily loading patterns such as walking will not have enough stimuli to provide new bone formation. Don't disregard your clients condition however. High impact aerobics or high impact activities would not be recommended. Resistance exercise will also increase bone density cross sectionally. Avoid exercises that cause large compressive forces on the spine or spinal flexion against resistance such as abdominal crunches because these movements may cause fractures or compromise fragile vertebral bodies. (10) If a person is in the advanced stages of the disease, it is necessary to be aware of the risk of stress fractures even in walking. Fatigue causes a greater risk of stress fractures because of the lack of stability.
5 - 11

Adequate intake of dietary calcium and vitamin D can also help prevent and treat the disease. Since most women take in less than the RDA (see nutrition chapter) they should focus on getting adequate amounts of calcium. The National Osteoporosis Foundation (NOF) recommends 1,200 mg per day for postmenopausal women not taking estrogen. Adults younger than 50 need 1000mg a day, pregnant or lactating women or adults older than 50 should consume 1,200 mg a day. (11) Menopause This is the point in a womans life when menstruation stops permanently, signifying the end of her ability to have children. This change of life is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones. This process actually begins about 3 to 5 years before the final menstrual period. This transitional phase is called the climacteric, or perimenopause. Menopause is considered complete when a woman has been without periods for 1 year. (6) Some women notice little difference in their bodies or moods, while others find the change extremely bothersome and disruptive. Hot flashes, which are sudden sensations of intense heat in the upper part or all the body are a common symptom of menopause. These flashes occur sporadically and often start several years before other signs of menopause. (7) They gradually decline in frequency and intensity as a woman ages and can last up to five years. A reduced sex drive is possible for some women but for others, the condition can be liberating, increasing their interest in sex. Mood swings, behavioral problems, incontinence, vaginal and urinary infections may also occur. Menopause also brings changes in the level of fats in a womans blood. LDL cholesterol appears to increase while HDL decreases in postmenopausal women as a direct result of estrogen deficiency. A concern for the personal trainer is the associated bone loss due to the lack of estrogen. Researchers believe that an ounce of prevention is worth a pound of cure. The peak amount of bone attained before menopause and the rate of the bone loss will determine the health of a womans skeleton. Research has found that low-impact activities, such as walking, are not effective exercise interventions for preventing bone loss in this population. A program should include exercises that provide a substantial load on bone, such as jogging and weight training. With resistance training, a woman will be able to fight this disease. Its your job to help her do just that. Multiple Sclerosis Multiple sclerosis (MS) is a chronic neurological disease that involves the central nervous system, specifically the brain, spinal cord, and optic nerves. MS can cause problems with muscle control and strength, vision, balance, sensation, and mental functions. The brain, spinal cord, and optic nerves are connected to one another by nerves and nerve fibers. A protein coating called myelin surrounds and protects the nerve fibers. When myelin becomes inflamed or is destroyedthis is called demyelinationthe result is an interruption in the normal flow of nerve impulses through the central nervous system. The process of demyelination and subsequent disruption of nerve impulse flow is the disease known as MS.
5 - 12

Injured tissue called lesions or plaques form in areas of demyelination. In many cases, the cells (oligodendrocytes) that create myelin are destroyed, as are the nerve fibers (axons). The body is then not able to heal the myelin or nerve fibers, which further contributes to disability. Generally, MS follows one of four courses, which are called: Relapsing-remitting, where symptoms may fade and then recur at random for many years. Secondary progressive, which initially follows a relapsing-remitting course. Later on, it becomes steadily progressive.

Progressive relapsing, where steady deterioration of nerve function begins when symptoms first appear. Symptoms appear and disappear, but nerve damage continues. The cause of MS is unknown. There may be a genetic link because a person's risk of MS is higher when a parent has MS. Geographic location also may play a role. MS is more prevalent in colder regions that are further away from the equator. Researchers have made a connection between a person's geographic location during childhood and the risk of MS later in life, suggesting that a childhood viral illness or other environmental factors may make a person more likely to develop the disease. Some evidence suggests that people who move from a high-risk area to a low-risk area, or the reverse, before the age of 15 take on the risk associated with their new area. If they are older than 15, they retain the risk associated with their old area. A problem with the immune system occurring early in life may trigger the onset of MS in some people. The "trigger" may be a viral infection. In susceptible people, the viral infection may start an autoimmune reaction in which the immune system attacks its own myelin. Symptoms vary according to which parts of the central nervous systemincluding the brain, spinal cord or optic nervesare damaged by inflammation and the destruction of myelin. Symptoms similar to those of MS can occur with other conditions and do not necessarily mean you have MS. The most common early symptoms of MS include: Muscle symptomsmuscle weakness, leg dragging, stiffness, a tendency to drop things, a feeling of heaviness, clumsiness, or a lack of coordination. Visual symptomsblurred, foggy, or hazy vision, eyeball pain (especially with movement), blindness, or double vision. Optic neuritis (a sudden loss of vision and eye pain) is a fairly common initial symptom, occurring in up to 23% of those who develop MS.

Primary progressive, where the disease is progressive from the start.

Less common early symptoms include: Sensory symptomstingling, a pins-and-needles sensation, numbness, a band like tightness around the trunk or limbs, or electrical sensations moving down the back and limbs.

Balance symptomslightheadedness or dizziness, and a spinning feeling (vertigo).

5 - 13

As MS progresses, symptoms may include stiff movement (spasticity), tremors, pain, difficulty controlling urination, depression, and difficulty thinking clearly (cognitive impairment). MS is diagnosed when lesions (injured tissue from demyelination) occur in more than one area of the central nervous system at different timesmeaning a neurologist can verify that you had at least two episodes of MS. Each episode must have lasted at least 24 hours, and be confirmed by neurological examination or neurological tests. Symptoms alone do not necessarily mean you have MS. If you have MS, a magnetic resonance image (MRI) test usually shows changes in more than one area of the central nervous system that have developed at more than one point in time. Not all changes seen on an MRI scan indicate MS, but criteria have been developed for diagnosing MS with MRI. The diagnosis can be difficult to make because early symptoms are usually vague. Medications such as interferon beta, glatiramer acetate, and mitoxantrone can reduce the frequency and severity of attacks in people with relapsing- remitting MS and may reduce or delay future disability. Interferon beta and mitoxantrone may also slow the progression of secondary progressive MS. Most specialists now agree that permanent damage to the nervous system may occur early on, even while your symptoms are still quite mild. Early treatment may help prevent or delay some of this damage. Corticosteroids may be given during a relapse to reduce inflammation and shorten the attack. Other medications can relieve some of the symptoms of MS, such as fatigue, depression, urinary problems, sexual difficulties, pain, and muscle stiffness (spasticity). Dealing with the physical, practical, and emotional demands of MS is not easy for those affected by the disease or for their families and caregivers. With treatment, however, many people with MS can and do find ways to cope with their disease. Some people try complementary therapies, such as diets or dietary supplements, acupuncture, biofeedback, and massage therapy. None of these have been shown to reduce relapses or change the course of the disease. Some treatments, such as massage therapy and yoga, may improve your overall sense of well-being. According to Multiple Sclerosis: Current Status and Strategies for the Future (2001) Institute of Medicine (IOM), Patients with motor deficits need an exercise program that takes their impairment into account. Pools are helpful because they are safe and allow for a wider variety of exercises. They also increase body cooling, thereby reducing the problem of thermosensitivity. In general, because increased body temperature can block conduction in damaged nerves, exercise programs should be designed to avoid overheating. An assessment of exercise history, including activities of daily living, and a fitness evaluation should be obtained prior to the initiation of an exercise program. Exercises that increase flexibility, strength, coordination, and balance are particularly helpful. Lack of motivation to exercise is likely, especially when a person does not feel well, and a supportive, proactive, and pleasant exercise environment is especially important. Although exercise training does not appear to influence relapse rates, exercise programs should sometimes be modified or temporarily discontinued during relapses. Weakness, fatigue, spasticity, and ataxia make exercise difficult for people with MS, and even brief exercise bouts can cause symptoms to appear or increase, but improvement in fitness not only can help offset these difficulties, it can reduce fatigue and depression and improve quality-of-life.
5 - 14

Additionally Newswise.com, February 22, 2005 Exercise Therapy Builds Strength, Mobility in MS Patients, states that Exercise therapy can improve muscle strength, mobility and other signs of fitness in people with multiple sclerosis, according to a recent review of studies. Nine high quality studies provide strong evidence that exercise therapy can make a difference in the daily living and quality of life of those with the disease, say Dr. Bernard Uitdehaag and colleagues of the Vrije Universitei Medical Centre in the Netherlands. Exercise therapy also improved the mood of MS patients in exercise therapy programs, compared to patients who did not participate in the therapy. The researchers did not find any evidence that exercise therapy affected patients fatigue or their sense of how ill they were. Despite the evidence supporting exercise for MS patients, however, Uitdehaag says its too early to recommend systematic referral of patients for exercise training. So far, there is no clear indication of how much exercise is beneficial for people who have various types of the degenerative disease, Uitdehaag explains. Only patients who seem able to exercise and who are sufficiently motivated to train should begin the therapy, he says. Patients for exercise training should also be referred to therapists with sufficient experience in treating MS patients, Uitdehaag says. The review appears in the January issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic. Exercise therapy probably does not affect the disease process itself, according to co-author Dr. Gert Kwakkel. He says exercise may help patients learn to compensate (for) their existing deficits. Systematic physical training may reduce disuse, in particular for those who suffer from fatigue. The average age of patients in the reviewed studies ranged from 34 to 51 years old, with varying types and severities of multiple sclerosis. The researchers suggest future studies should include a greater number of older individuals, severely disabled patients and patients who have been living with the disease for more than 18 years. The studies also included a wide range of exercise programs and definitions of improved health and fitness, making it difficult to decide what kinds of exercise are best for MS patients. Uitdehaag and colleagues found no evidence that any specific exercise therapy programs were better for health and mobility than other exercise programs. The researchers also found no signs in any of the studies that exercise therapy was harmful to the health of MS patients. The National Multiple Sclerosis Society suggests that MS patients exercise with frequent rest breaks, since heat can aggravate MS symptoms. With this type of exercise-rest-exercise patterns, physical therapy may be quite effective, with very good results, according to the Societys recommendations. In conclusion, clients with MS need to remember to consult their physician about a multiple sclerosis exercise program, ensure that the multiple sclerosis exercise program includes stretching, strengthening, and cardiovascular (aerobic) activity. With the right amount of exercise to ensure benefits without injury or fatigue, increase the duration of exercise little by little, monitor intensity and dont over-exert, stay cool by wearing light clothes, drinking cool liquids, and using a fan, spray bottle, or cooling device, and be consistent by choosing forms of multiple sclerosis exercise that they enjoy, you will be able to help your clients manage their condition. Pregnancy This is not a disease, but a condition. There are special problems associated with exercise and pregnancy. Whether or not a woman has exercised prior to the pregnancy is the first consideration for the trainer. If the woman is not accustomed to exercise, now may not be the best time to begin. Regular exercise (3 times per week) is preferable to intermittent activity. Her doctor will need to advise her as to the merit of starting to exercise at this stage. A womans history in other pregnancies may also be a
Rev. 10/2006

5 - 15

consideration for the exercise recommendation. Once these issues have been addressed, it may be safe to begin exercise. In the first trimester of pregnancy, a woman has only a few limitations. Attention must be paid to heart rate. Prior guidelines dictated a woman should not exceed a pulse rate of more than 140 beats per minute (bpm) during any cardiovascular exercise. However, the revised guidelines by the American College of Obstetricians and Gynecologists give the green light to elevate their heart rate beyond 140 bpm. Coupled with this is the need to pay attention to core temperature elevation. Prolonged elevation of either of these can cause damage to the fetus. Pregnant women should stop exercising when fatigued and must not exercise to exhaustion. In the second trimester, balance begins to be a concern as the size of the baby increases. It is necessary to protect the woman and the child by using machines for training versus free weights, or by standing very close in order to protect her from falling if she does lose her balance. In this trimester as well, she may need to discontinue prone and supine exercise. The size of the baby at this point may make it uncomfortable to lie on her abdomen. As for the supine position, it can cause a decrease in the blood flow to the pelvic region and may interfere with the safety of the baby. Women who continue abdominal crunches after the abdomen becomes distended should be aware of the potential for diastasis, or separation of the rectus abdominis muscle. Once the connective tissue in the center of this muscle becomes torn, it can take years to repair and may never fully return to its prepregnancy, undamaged state. Although the ACOG Guidelines discourage supine positioning, do not misconstrue this guideline to suggest that abdominal muscles should not be worked during pregnancy. In reality, the opposite is true. The transverse abdominals are instrumental in providing support for the lower back and growing abdomen and in pushing the baby out during delivery. The use of isometric stabilization exercises or isolation contractions for the transverse may be more beneficial for maintaining strength in the core area as long as the trainer continues to monitor the clients breathing to insure blood pressure does not increase dramatically. Any type of exercise involving the potential for even mild abdominal trauma should be avoided. The third trimester presents greater risk of loss of balance because of the weight now suspended in front of the normal center of gravity for the pregnant woman. Additionally, the woman has the need to keep the heart rate and core temperature lowered due to the risk of early labor. By this time the woman may be experiencing breathlessness during even mild levels of exertion. She may experience lower levels of energy as well. The weight of the pregnancy at this point is probably close to 26 to 30 pounds on average so the woman is working much harder to move around in her daily life. Hydration, proper nutrition, rest and relaxation should become primary concerns for the woman still trying to maintain her exercise habit. Pregnant women should consume water at regular intervalsat least every 10 minutesthroughout the exercise, drinking no less than 16 to 32 ounces during an hour-long session and the same amount after exercising. According to the 1989 RDA Recommended Dietary Allowances, pregnant women require an additional 300-500 kilocalories per day (Possibly more if they exercise regularly), depending on what stage or trimester they are in. Alcohol is not a toxin as we metabolize all kinds of alcohol from our foods everyday. However, ingesting alcoholic beverages in large quantities can become toxic. According to ADA American Dietetics Association moderate alcohol intake is safe for a pregnant mother.
5 - 16
Rev. 10/2006

Stretching can be done with caution because of the production of relaxin, produced primarily by the placenta. This hormones key purpose is to soften ligaments throughout the body, especially in the pelvic girdle. This hormone is abundant during pregnancy because of the bodys need to open the birth pathways, however it is indiscriminate and affects all the bodys ligaments, so it impacts all joints of the body, especially those at the bottom of her feet. Prolonged periods of motionless standing should be avoided. Pregnant women who spend large portions of their days standing or performing impact activities such as running or stair-climbing are at a greater risk of stretching these ligaments. For this reason, movements that place any joint at risk should be modified. For instance, sideways shuffling moves place lateral force at the ankle, knee and hip joints. Stretching a pregnant woman can permanently impact her joints but can be done with caution. Insure your clients do not take their joints beyond their normal range of motion, even though the relaxin effect may allow for greater movement. Stretch the pectorals and anterior delts to offset the stress from weight gain in the chest. The hip flexors and quadriceps will benefit from a little extra attention because of the lordosis effect of pregnancy. The side-lying position is an effective position for optimizing blood flow from the mother to the fetus. For women with no weight training experience, lunges are not recommended. Pregnant women who are experienced weight lifters can perform lunges with light weights, in a stationary position, using a wall or chair for support and stability. Lunges pose two threats to expecting moms: First, dynamically performed, weighted lunges apply a great deal of force to the knee joints, which are less stable than usual during pregnancy. Second, the potential for loss of balance increases due to the changing center of gravity and could result in injury to a joint or the abdomen if a fall occurs. The adductors, abductors, hamstrings, gluteals and quadriceps require extra attention in preparation for labor and delivery. Many of the physiological changes of pregnancy persist four to six weeks postpartum. Pregnancy exercise routines should be resumed gradually. Lupus There are three primary types of lupus; systemic lupus erythematosus, discoid lupus erythematosus and drug-induced lupus. Systemic lupus erythematosus or SLE is the most common type of lupus and appears in two different forms, non-organ threatening and organ-threatening. Organ-threatening can cause severe damage to the kidneys, heart, liver, lungs, joints and/or brain. Discoid lupus is a chronic disorder characterized by a red rash that normally appears on the face or scalp. Drug-induced lupus is caused by medications and typically exhibits the same symptoms as SLE. Once the medications are discontinued the symptoms usually stop. Although symptoms can differ dramatically between individuals, the most common include joint pain, skin fatigue and skin rashes. However, other symptoms can include edema in the legs or around the eyes, swollen glands, hair loss, light sensitivity and mouth ulcers. (8) What causes lupus. Lupus can imitate or be similar to other diseases so it could take months or years before an accurate diagnosis can be achieved. The exact pathology of lupus is unknown. Numerous factors such as genetics, environment and hormonal factors are possible causes of lupus. Lupus is an autoimmune disorder which
5 - 17

develops when the bodys own immune system, which normally protects against cancers and invading infections, begins to attack patients own tissues. This occurs first through the production of autoantibodies. Antibodies are immune system cells that attack foreign microbes. Auto-antibodies attack a persons own cells. As the attack continues, other immune system cells join the fight. This leads to inflammation, blood vessel abnormalities and deposition of immune system cells in organs which cause tissue damage. Diagnosis Diagnosis of SLE may be suspected on the basis of symptoms, but is confirmed by a series of blood tests. The antinuclear antibody (ANA) is present in virtually all patients with lupus. Other tests such as the anti-double strand DNA (dsDNA) and anti-smith antibodies (SM) are more specific and are used to confirm the diagnosis of lupus. The American College of Rheumatology has designated 11 specific criteria; four or more of which must be present to be diagnosed with lupus. (9) SLE occurs ten times more often in women than in men. It typically affects people in their twenties and thirties. It is almost more common in certain ethnic groups, particularly in Afro-Americans and Asians. Currently there is no cure for lupus. The American College of Rheumatology criteria for a positive diagnosis of lupus Malar rash rash on the cheeks Discoid rash having a disc shape Photosensitivity Mucocutaneous ulcers oral or nasopharyngeal Athritis Pleuritis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder positive finding of antiphospholipid antibodies Antinuclear antibody abnormal titer of ANA Exercise and lupus Physical activity can be very beneficial for individuals with lupus. It can help cope with fatigue, increase energy and increase self-efficacy. Be careful; excessive exercise is not necessarily better. Moderate intensities are recommended. A full body routine focusing on the large muscle groups with 2-3 sets of 10-12 repetitions on 2-3 days a week. Too much exercise may cause symptoms to flare up. Stretching can help normal joint movement and maintain or increase flexibility. Cardiovascular exercise is excellent, especially cycling and water exercises because they are less jarring to the joints. Its better to start with less duration and more frequent bouts during the day until the individual can perform one long session of cardiovascular exercise. Communication and compassion are keys when training someone with lupus.
5 - 18

Special Considerations for Special Populations Any trainer who considers helping a person who falls into one of the many categories that could be conceived as a special needs group should consider the tremendous responsibility involved. These people deserve more than a person who practices gym science. It takes dedication and research to do the kind of job their needs may require, but the rewards of having helped improve the quality of a persons life are immeasurable. Give yourself an opportunity to experience the magic of a life with quality and commitment. Medications Commonly Seen in a Fitness Facility Angiotensin Converting Enzyme Inhibitors (ACE inhibitors) Trade name of Agents: Capoten, Vasotec, Prinivil, Zestril. Accupril, Capozide, Lotensin, Altace and Monopril. Major Use: Hypertension, post Myocardial Infarction Mechanism of Action: Blocks formation of angiotensin Exercise Prescription: Normal Important: ACE inhibitors are contraindicated during pregnancy

Antiarrhythmic Agents Trade name of Agents: Dilantin, Enkaid, Mexitil, Moricizine, Procan, Pronestyl, Quinaglute, Quinidex, Tambocor, Tonocard Major Use: Treatment of arrhythmia (irregular heartbeats). Action: Help normalize rhythm disturbances, but may react in different ways Exercise Prescription: Individuals on anti-arrhythmia drugs should consult their physician before undertaking an exercise program.

Antihyperlipidemic Agents Trade names of Agents: Mevacor, Lopid, Lorelco, Nicolar, Questran, Colestid, Zocor, Pravachol and Lescol. Major Use: Treatment of hyperlipidemia. Mechanism of Action: Can vary with each drug. Exercise Prescription: Not much effect on heart rate and blood pressure, but may cause ectopic beats. Must consult with physician before commencing an exercise program.

5 - 19

Anti-Hypertensive Agents Diuretics Trade name of Agents: Esidrix, Diuril, Midamor, Dyrenium, Dyazide, Enduran, Bumex, Maxzide, Hygrotin, Lasix, Aldactone, Hydrodiuril and Hygroton. Major Use: Edema, Hypertension Mechanism of Action: Diuretics have the ability to increase excretion of fluids and electrolytes from the body. By lowering the blood volume, blood pressure will lower as well. Exercise Prescription: Low potassium levels due to loss of electrolytes could provoke dangerous arrhythmias. A person receiving diuretic therapy should have their serum potassium levels monitored regularly. If potassium levels are normal, then normal exercise activities and appropriate heart rates can be prescribed. Diuretics may alter electrocardiographic patterns.

Beta Blockers Trade name of Agents: Levatol, Zebeta, Inderal, Lopressor, Kerlone, Cartrol, Corgard, Tenomin, Sectral, Blocadren and Visken Major Use: Treatment of angina, arrhythmias, hypertension and migraine headaches. Mechanism of Action: Blocks beta-receptors of the sympathetic nervous system leading to a reduced blood pressure at rest and during exercise, as well as a decreased exercise heart rate. Ternomin and Lopressor do not have as much of an effect on resting heart rate as the other beta-blockers. Exercise Prescription: Since beta-blockers decrease heart rate, clients taking these drugs will be unable to attain predicted maximal heart rates. The RPE scale should be used with this type of client. These individuals should consult their physician before beginning an exercise program.

Brochodilators/Sympathomimetic Agents Trade name of Agents: Theo-Dur, Bronkosol, Aluprent, Intal, Proventil, Brething and Ventolin. Major Use: Prevention of correction of Asthma (bronchospasm). Mechanism of Action: Varies, and will promote bronchodilation. Exercise Prescription: Normal. Individuals suffering from asthma should carry an inhaler with them at all times. Ask for feedback on how theyre feeling throughout the training session.

Calcium Channel Blockers Trade Name of Agents: Procardia, Calan, Vaxcor, Nimotop, Cardizem, Carden, DynaCirc, Plendil, Isotopin, Adalat, Norvasc and Cardene.
5 - 20

Major Uses: Hypertension, angina and coronary heart spasm. Mechanism of Action: Blocks calcium channels in smooth muscle and cardia muscle, leading to decreased blood pressure. Expect lower blood pressure reading when performing submaximal testing. Exercise Prescription: Consult with physician before beginning an exercise program.

Vasodilators/Alpha Blockers Trade name of agents: Apresoline, Cardura, Hytrin, Loniten and Minipress. Major Use: Hypertension Mechanism of Action: Blocks alpha receptors in smooth muscle, causing dilation of blood vessels. Exercise Prescription: Consult a physician before beginning exercise program prescription.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Howly, T. Edward, Franks, Don, B., Health & Fitness Instructors Handbook, Human Kinetics (1997) Howly, T. Edward, Franks, Don, B., Health & Fitness Instructors Handbook, Human Kinetics (1997) Howly, T. Edward, Franks, Don, B., Health & Fitness Instructors Handbook, Human Kinetics (1997) Howly, T. Edward, Franks, Don, B., Health & Fitness Instructors Handbook, Human Kinetics (1997) Johnson & Slemenda (1987) Nihgov/health/chip/nia/menop/men2. Nihgov/health/chip/nia/menop/men2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Betheseda, MD: National Institute of Health, 2003 http://www.rheumatology.org/search/search.asp?templ=home&aud=home. Witske, A. Kara, Clinical Exercise Specialist Manual, pg.369 Witske, A. Kara, Clinical Exercise Specialist Manual, pg.364

5 - 21