Eric P. Durak MScIntroduction
As exercise principles move from the athletic realm to the medical setting, it is important for fitness instructors have a good working knowledge of many types of conditioning programs, but also be able to apply them to situations other than athletic populations.
The concept of exercise prescription is thought to be reserved for “health care professionals”. Exercise prescription is the application of fitness principles to persons with a medical condition. Although no exercise professional should diagnose a disease, or try to treat diseases in a medical fashion, if they have a working knowledge of the condition they are working with, and have read most of the medical/sports medical literature to see how other programs have been constructed, then they should be able to prescribe a program for patients with information from the referring physician, and in many instances recommendations from physical therapists on orthopedic limitations for each person, as well. The ability to work with other allied health professionals (physicians, physical therapists, occupational therapists, dietitians) will be important in prescribing exercise in these special population groups. This article highlights current scientific research concerning special populations, give specific medical concerns regarding each group, and when appropriate, detail sample programs that will benefit both the club member, as well as the instructor.
What Constitutes A Special Population?
A special population may be defined in terms of exercise as a group with a special medical condition who may require expertise and supervision to overcome that medical situation. Other special populations may just need to improve their skill levels and knowledge, or increase awareness and social interaction of conditioning by participating in a regular physical activity.
The need for applying exercise to these groups is becoming more important, as more scientific information becomes available as to the efficacy of therapeutic programs. Therefore, the medical conditions in this series will highlight general physiology of each condition, and give information regarding exercise. Keeping in contact with physicians and allied health workers will be an important aspect of working with these groups, and fitness professionals who work with special populations will themselves become a member of the health care team.
Diabetes Mellitus
One of the more prevalent special population groups are diabetic patients. Diabetes is is defined as impaired glucose metabolism, and is one of the most common medical problems in the United States today. It is the third leading cause of death in this country, because of the complications which are undetected by those afflicted manifest themselves into cardiovascular heart disease and stroke, eye disease and blindness, kidney failure, muscle disease, and damage to almost every internal organ. One of the keys to treating diabetes is to prevent its onset, or prevent complications from arising once the disease has been diagnosed.
The use of exercise in diabetes patients has shown improvement in glucose tolerance and overall metabolism, and improvement in overall blood glucose control, cholesterol and strength. Exercise in general (aerobic or strength training) has an insulin like effect on glucose uptake into cells.
Aerobic training programs in diabetes should consist of moderate to low impact (to guard against injury to feet and lower legs), and should be built up to regarding both intensity and time. Starting with walking is one of the most beneficial forms of exercise in diabetes, and for those with lower extremity problems, using arm crank exercises or other non-impact aerobic machines is also beneficial.
Progressive resistance programs for diabetic persons should consist of moderate weights to improve muscle tone and posture, and improve their blood sugar control. Because these patients may have had diabetes for a long time, it is important for them to have visited their doctor, and have had a medical exam before participating in any regular program. Physicians are responsible for administering the initial medical screen and stress test. They should also be involved in follow up routine exams to monitor patient progress in their diabetes management. If the patient has any questions about an exercise program, the doctor should be familiar with personnel who are trained in the area, and are willing and capable of working with their patient in prescribing exercise.
Recommendations
The following table highlights information for exercise and diabetes.
General recommendations
- Carry a home glucose monitor and use it before and after each aerobics
class. Record blood sugar values.
- Carry some available short acting glucose solution and know when to use it. (apples, orange juice boxes, hard candy are excellent examples).
- Have identification handy in case of an emergency. Instructors should know that if a member becomes dizzy, faint-like, or drunk-like, then some glucose feeding may be necessary. Life Savers, or a sugar drink (orange juice) should be administered without reservation within seconds of the beginning of these symptoms. Call for medical assistance. The best assurance against insulin shock (hypoglycemia), is to test blood sugar levels before EACH session.
Contraindications
- Glucose <100 or >300 mg/dl means NO exercise until food or insulin is administered.
- Diabetic complications usually mean that exercise is not medically advised. If a new member has a diagnosis of any complication, check with their physician before starting any program.
- Outward signs of blisters on hands or feet, cardiac problems, high lipid levels.
- Excessive amounts of weights lifted (>50% of estimated maximal voluntary contraction) for persons with overt complications, or physician recommendation.
- Performing Valsalva Maneuver while training
Diabetes and exercise research has been performed for many years. Mechanisms of cell action, as well as community-based conditioning programs have been published, as well. Exercise programming as part of today’s health care system can only take place when a majority of fitness professionals learn the basics of diabetes physiology, learn some of the basics of the health care system, and negotiate with physicians to work with their patients. This relationship will ensure that diabetes patients may embark on a more healthful lifestyle in addition to their general medical care. Exercise will aid in their weight maintenance, glucose control, cardiovascular risk reductions, and improve physical strength and endurance. This combination will make for an improved patient and a more efficient health care delivery system.
References
1. Basmajian, JV, Wolf, SL. Therapeutic Exercise. 5th edition. Williams and Wilkens, Baltimore, MD 1990.
2. Bray, GA, Gray, DS. Obesity II: Treatment. Western Journal of Medicine. 149:555-71, 1988.
3. Durak, EP, Jovanovic-Peterson, L, Peterson, CM: Randomized crossover study of the effect of resistance training on glycemic control, muscular strength, and cholesterol in type I diabetic men. Diabetes Care. 13:1039-43, 1990.
4. Graham, C. Lasko-McCarthey, P. Exercise options for persons with diabetic complications. Diabetes Educator. 16:212-20, 1990.
5. Horton, E.S. The role and management of exercise in diabetes mellitus. Diabetes Care. 11;2:201-11, 1988.
6. Manson, J.E., Nathan, D.M., Krolewski, A.S., Stamphfer, M.J., Willet, W.C. et al. A prospective study of exercise and incidence of diabetes among US male physicians. JAMA. 268;1:63-67, 1992.
7. Peterson, C.M., Dupuis, A., Levine, B.S., et al. Feasibility of improved blood glucose control in patients with IDDM. Diabetes Care. 2;4:329-35, 1979.
8. Pollack, ML, Wilmore, JH, Fox, SM. Exercise in Health and Disease. Saunders Publishing, 1986.
9. Schwartz, R.S., Exercise training in the treatment of diabetes mellitus in elderly subjects. Diabetes Care. 13;5:277-84, 1990.
Eric Durak is a clinical exercise physiologist and health educator. He is special populations advisor to the International Sports Sciences Association, and is the director of the Fitness Therapistª course.
Jim Strohecker
Tom Ferguson MD