AMERICAN COLLEGE OF SPORTS MEDICINE HEALTH/FITNESS INSTRUCTOR WORKSHOP

1. AMERICAN COLLEGE OF SPORTS MEDICINEHEALTH/FITNESS INSTRUCTOR WORKSHOP EXERCISE PROGRAMMING INCLUDING EXERCISE CONSIDERATIONS FOR SPECIAL POPULATIONS

2. PRESENTER:Edward C. Chaloupka , Ph.D., P.T., FACSM Professor Department of Health and Exercise ScienceRowan University

3. Basic Exercise Programming Considerations

4. Principles of Training • Overload Principle • Frequency • Intensity • Duration • Mode • Specificity Principle • Reversibility Principle

5. American College of Sports Medicine (ACSM) Guidelines • For Developing Cardiovascular Endurance • Frequency – 3x/wk • Intensity – 50-85% maximum heart rate reserve or 50-85% maximum oxygen uptake reserve • Duration – 20-60 minutes • Mode – rhythmical and continuous

6. ACSM Guidelines Continued • For Developing Muscular Strength • 8-10 separate exercises using major muscle groups • 8-12 repetitions of each exercise to volitional fatigue • 2-3 days/wk • For Developing Muscular Endurance • 15- 20 repetitions to volitional fatigue

7. ACSM Guidelines Continued • For Developing Muscular Flexibility • 5-15 minutes of moderate aerobic activity prior to stretching • 2-3 days/wk after each aerobic workout • Hold each position for 10-30 sec • Repeat each stretch 4 times

8. Components of Exercise Prescription • Frequency • Duration • Intensity • Mode • Progression

9. Monitoring Exercise Intensity • Training Heart Rate Range • % maximum heart rate (HR) • % heart rate reserve (HRR) (Karvonen Formula) • Training HR = (max HR - rest HR) X intensity percentage + RHR • Example -- 20 y.o., rest HR = 70 bpm • Training HR = (200 - 70) X 70% + 70 = 161 bpm • 75% HHR = 85% max HR

10. Warm-Up • Group of exercises performed immediately before an activity • Provides adjustment from rest to exercise • 5-20 minutes depending on sport and environmental conditions • Active warm-up prior to vigorous stretching

11. Cool-Down • Purpose is to slowly decrease heart rate and lower body temperature • Active recovery promotes faster decrease in muscle and blood levels of lactic acid • Active recovery keeps the leg muscle “pump” going and prevents pooling of blood in the legs • Active recovery lessens chance of catecholamine produced cardiac irregularities in high risk persons

12. Environmental Considerations • High air temperature and relative humidity increase risk for hyperthermia • Normal core temperature = 37 deg. C • Possible death at 45 deg. C • Factors affecting susceptibility to heat injury: • Fitness level • Hydration • Clothing • Metabolic Rate • Wind

13. Environmental Considerations Continued • Cold air temperature increases risk for hypothermia • Factors related to hypothermia • Insulation—clothing and subcutaneous fat • Air temperature • Wind—accelerates heat loss (Windchill) • Water vapor pressure—low in cold air which increases evaporation and heat loss

14. Environmental Considerations Continued • Air pollution caused by ozone, sulfur dioxide and carbon monoxide • Ozone—generated by combining UV light and internal combustion engine emissions. Decreases pulmonary function • Sulfur Dioxide—fossil fuels (refineries). Causes bronchoconstriction in asthmatics • Carbon Monoxide—fossil fuels, coal, oil, gasoline, wood and cigarette smoking. Decreases oxygen carry capacity of blood

15. Medical Considerations For Exercise • Physician Clearance • Medical History • Medication Profile

16. Programming Considerations for Special Populations

17. Coronary Disease

18. Coronary Artery Disease (CAD) • Narrowing of coronary arteries usually caused by arteriosclerosis (pathological condition resulting in thickening, hardening and loss of elasticity of arterial walls)

19. Risk Factors • hypertension BP >140/90 mmHg • elevated blood lipids • total cholesterol > 200 mg/dl • LDL > 160 mg/dl (less than 2 risk factors) • > 130 mg/dl (2 or more risk factors) • > 100 mg/dl with CHD • HDL < 35 mg/dl • triglycerides > 400 mg/dl

20. Risk Factors Continued • obesity • cigarette smoking • diabetes mellitus • psychological stressors • family hx early onset atherosclerosis

21. Risk Factors Continued • alcohol consumption • physical inactivity • age • gender—males 35-44 y.o. mortality rate 6x greater than females • elevated levels of homocysteine

22. Coronary Heart Disease (CHD) • Myocardial damage due to insufficient blood flow. The disease is caused by pathological changes in the coronary arteries sufficient to interfere with adequate blood flow.

23. CHD Continued • exercise-induced complications—most occur in individuals with underlying heart disease or congenital abnormalities. A cardiac event during exercise is not common in individuals without heart disease. Exercise induced cardiac problems in those older than 35 tend to be due to CHD while those in individuals younger than 35 tend to be due to cardiovascular structural abnormalities.

24. CHD Continued • familial trait—there is a genetic predisposition to the development of CHD. The risk of a myocardial infarction (MI) is high when a MI or sudden death in a male first-degree relative occurs before age 55 and a female first-degree relative before age 65.

25. CHD Continued • Nicotine in tobacco smoke causes an increase in heart rate and blood pressure that increases the work of the heart (an increase in the rate-pressure product or double product). Nicotine may also increase platelet adhesiveness increasing blood viscosity. Carbon monoxide in tobacco smoke decreases the oxygen carrying capacity of red blood cells to the heart muscle.

26. CHD Continued • psychological stress—individuals with severe anxiety or frequent outbursts of anger exhibit higher levels of cardiac reactivity (characterized by increased heart rate, systolic blood pressure and peripheral resistance) as well as increased coronary artery spasms and sudden death

27. Coronary Disease Continued • Exercise Guidelines--guidelines are generalized due to multiple coronary diseases (e.g. CAD, CHD, myocardial infarction, coronary artery bypass graft, valvular disease, congestive heart failure, cardiac transplant, aneurysm, angina, cardiac arrhythmias )

28. Coronary Disease Continued • Exercise Guidelines (continued) • General Considerations-- • general low fitness levels • monitor for abnormal exercise response • awareness of other medical conditions • In-patient (Phase I) cardiac rehabilitation • Out-patient (Phases II-IV) cardiac rehabilitation

29. Coronary Disease Continued • Aerobic/Endurance • 40-70% of vo2 peak • 3-7 d/wk • 20-40 min • Strength • higher repetitions, lower resistance • 2-3 d/wk • Flexibility • 2-3 d/wk

30. Pulmonary Dysfunction

31. Asthma/Exercise Induced • causative factors—asthma is characterized by increased airway reactivity to various stimuli including exercise. During an attack biochemical mediators are released due to mast cell degranulation causing airway smooth muscle constriction (bronchospasm).

32. Asthma Continued • Physical stimuli such as cooling and evaporation across airway epithelium during exercise or cold air exposure may directly stimulate the release of biochemical mediators. Individuals with exercise induced asthma may demonstrate normal airway function at rest but may develop bronchospasm during or after exercise.

33. Asthma Continued • preventative measures— • identification and elimination of precipitating agents (pollens, dust mites, animal dander, drugs, foods, wine, exposure to fumes and chemicals) • education to improve compliance with medication

34. Asthma Continued • Preventative measures (continued) • pharmacological agents—inhaled corticosteriod bronchodilators as preventative medicine (can be used on an ongoing basis) and inhaled cromolyn sodium (used up to 15 minutes before beginning exercise) to stabilize mast cells before exercise • optimizing inhaled or oral bronchodilator therapy

35. Chronic Obstructive Pulmonary Disease (COPD) • chronic asthma • chronic bronchitis • pulmonary emphysema • chronic bronchiolitis

36. Pulmonary DysfunctionExercise Guidelines • Exercise induced asthma (EIA) • individuals are often asymptomatic (or minimally symptomatic) between exacerbations. This population of individuals should be able to engage in vigorous exercise training.

37. Modifications to Exercise Program for EIA • warm-up and cool-down periods • type of exercise--outdoor running exacerbates EIA, swimming reduces incidence • length of exercise--long, intense continues exercise causes more EIA than short bursts • intensity of exercise-high intensity (above 80-90% of maximal heart rate) causes more EIA • nasal rather than mouth breathing • wear a mask or scarf in cold weather • monitor exercise environment for potential allergens and irritants

38. Exercise Guidelines COPD • COPD—these individuals are often elderly and have high co-existing impairment of other organ systems. If oxygen saturation drops below + 90% (pulse oximetry) or arterial blood oxygen drops below 55 torr (arterial blood gas) supplemental oxygen should be used via nasal cannula.

39. Exercise GuidelinesCOPD Continued • Aerobic/Endurance— • Monitor dyspnea • 1-2 sessions 3-7d/wk • 30 min (shorter intermittent sessions initially) • target intensity—heart rate (HR) attained at a work rate equal to 85% of the peak work rate during an initial incremental test (other methods for target HR during exercise may not be appropriate due to ventilatory limitation, increased resting HR and considerable day-to-day variations in resting HR)

40. Exercise GuidelinesCOPD Continued • Strength • low resistance, high repetitions • 2-3d/wk • Flexibility • 3 sessions/wk • Neuromuscular (walking, balance and breathing exercises) • daily

41. Metabolic Disorders

42. Diabetes Mellitus (DM) • Type 1 (Insulin Dependent, IDDM) • absolute deficiency of insulin due to a marked reduction in pancreatic insulin-secreting beta cells. Insulin must be supplied by insulin injection or insulin pump. Cause is thought to involve an autoimmune response leading to the destruction of beta cells.

43. Type 1 DM Continued • Are prone to develop ketoacidosis with marked hyperglycemia. Can occur at any age but usually before the age of 30. Represents 10% to 15% of individuals with DM.

44. DM Continued • Type 2 (Non-Insulin Dependent, NIIDM) • relative insulin deficiency. May have elevated, reduced or normal insulin levels but have hyperglycemic. Usually a combination of peripheral insulin resistance and defective insulin secretion.

45. Type 2 DM Continued • Resulting hyperglycemia causes beta cells to secrete more insulin that is usually ineffective in lowering blood glucose and further contributes to peripheral insulin resistance. Usually do not develop ketoacidosis. Usually occurs after the age of 40 but is becoming more common in younger individuals. Represents 85% to 90% of individuals with DM.

46. Diagnostic Criteria for Diabetes • Symptoms of diabetes plus casual plasma glucose concentration of >200 mg/dL (11.1mmol/L) (casual is defined as any time of day without regard to time since the last meal); the classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss; or • Fasting plasma glucose of >126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake for at least 8 hours); or • Two- hour plasma glucose of >200 mg/dL during an oral glucose tolerance test; the test should be performed as described by World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water

47. Insulin Regulation • blood levels of glucose • blood levels of amino acids potentiate the glucose stimulus for insulin secretion • gastrointestinal hormones—gastrin, secretin, cholecystokinin • other hormones—glucagon, growth hormone, cortisol, progesterone and estrogen

48. Metabolic Complications • ketoacidosis • dehydration • retinopathy • hypertension • neuropathy • nephropathy • atherosclerosis • poor wound healing

49. Medications (DM) • Type 1--most individuals use subcutaneous insulin injections consisting of a mixed insulin, split dose regimen. This includes a mixture of short-acting insulin and longer-acting (sustained release) insulin in morning and afternoon doses.

50. Medications (DM) Continued • Type 2--oral hypoglycemic agents that help restore peripheral insulin receptor sensitivity and stimulate pancreatic insulin release • Type 1/Type 2--also antihypertensive, lipid-lowering and pain medications