Rehabilitation and Women’s Health: Major Insights on a Major Health Issue

If you were asked to name the worst medical epidemic in the United States today, you might guess heart disease. It would be a noble guess, but it would be wrong. Today, currently half of all women over the age of 62 suffers from osteoporosis. It will afflict more than 40 million women by the year 2,000, and cost billions in health care dollars. How will rehabilitation fit in? Two ways Ð prevention, and prompt treatment. By promoting exercise and healthy diets to women during child bearing years (20-38 years), they can certainly reduce the risk of acquiring the disease in the first place. By having referrals for orthopedic assessments, and complete exercise programming immediately after diagnosis, we may save most of the health care dollars in medical treatments that would normally be spent on these patients.

A diet rich in leafy green vegetables, fiber, low in fat, and of course, high in calcium (among the other 72 trace minerals, according to Dr. Joel Wallach) is the first step in prevention. Exercise Ð especially strength training, is the second most important step. A properly prescribed program will increase density in the femoral neck and lumbar vertebrae, where it is needed most. This section will concentrate on the most important areas of the body to strengthen, what types of exercises to perform, and the proper progression to perform them in to enhance muscular and bone development.

Section #1 – hip area. Comprising the largest muscles in the body, the hip area is the foremost section to train. The most important types of machines to condition this area are the leg press, and total hip machine. The leg press is a compound exercise, working the muscles of the hip and thigh. The hip machine is an isolation exercise, concentrating the gluteus maximus. These machines are preferable to free weights to start out with because the learning curve is less, and improvements can be made with less chance of injury.

Section #2 – upper body. Working the upper body major muscles (chest, shoulders, back) comprises section #2, and provides resistance to the bones of the upper vertebrae, long bones of the arms, and ribs. Photo #2 illustrates a weight-assisted machine for working the chest area (dip exercises), and the back (pull up exercises).

The most important element of program design for this group is training progression, as the goal is to strengthen weak and porous bone to its natural density. A beginning program would start with low intensity, and more repetitions. It would look something like this:

PHASE I: (Low intensity)	Sets	Reps*	Rest Period
Chest Dips	2-3	10-15	2-3 minutes
Lat Pulls	2-3	10-15	2-3 minutes
Hip Extensions	3-4	10-15	2-3 minutes
Leg Press	3-4	10-15	2-3 minutes

After a period of adaptation (phase I), it is time to increase the intensity, and change the number of sets and reps. [* = where 30 repetitions are possible with a maximum effort].

PHASE I: (Medium intensity)	Sets	Reps*	Rest Period
Chest Dips	3	10-10-8	3-5 minutes
Lat Pulls	3	10-10-8	3-5 minutes
Hip Extensions	4-(5)	10-8-6-4	3-5 minutes
Leg Press	4-(5)	108-6-45	3-5 minutes

[Leave 4-6 reps to spare at the end of each set]

The goal is to progress to a level that is is perceived as difficult, strengthens the musculature, and over time (4-8 months), has a positive effect on the bone density (as seen by DEXA scan). According to the sports medicine literature, the MES (minimal essential strain) is about 1/10th the amount of force required to fracture a bone, so the amount of stress placed on bones through strength training does not have to be in maximal exertions. Medically, the density should improve from Ð10% loss to normal (0% loss in bone).

Both of the phases of training can be manipulated by the therapist depending on the initial conditioning level of the participant. Training should proceed in phases, as staying with the same level of resistance will not improve bone density or muscle strength.

Rehab in Women’s Cardiovascular Diseases

As women are increasing their risks for developing both heart disease and lung cancer, rehabilitation programs should play an important role in both reducing the complications of these diseases, and health care costs associated with long term affliction.

In the area of cardiovascular therapy, this area is not as pronounced as orthopedic rehabilitation. None the less, basic cardiovascular education and treatment programs are necessary for the following reasons: First Ð more women are being diagnosed with cardiovascular events (heart disease, emphysema, cancer, peripheral vascular disease). With this increase in the number of cases, the health care costs also rise concomitantly. Second Ð the current medical system is ill prepared to give patients the necessary time for information regarding therapy and education strategies. This is where allied health professionals (physical therapy, dietetics, exercise physiology, occupational therapy, etc.) play such a vital role. The cost of a referral, assessment, education, and therapy plan is far less than medical intervention that may occur within one year of the initial diagnosis.

Information from the Women’s Health Data Book (1992 Ð Jacob’s Institute, Washington, DC) states that although women make more frequent visits to physician offices than do men, they do not receive as much intervention. This may be seen in the fact that many oncologists do not refer women who have had surgery for breast cancer for physical therapy. It would seem a logical extension of their health care, but it is not routine.

Rehab and Health Care Costs

In 1994, futurist John Naisbitt predicted a $188 billion cost savings by the implementation of wellness programs in major businesses in the US. If this amount may be extrapolated to include the health care system, might we see an even greater savings. Although rehab per se is not primary prevention, any type of patient education may have a preventive effect on patients in the future. Rehab programs that promote healing for an acute event, but also give education on ADL may save unforeseen medical costs.

The Importance of Women’s Health Issues

As issues of prevention and cost savings become more of a fixture in women’s health, professionals who wish to work with in this area should have an understanding of the elements that comprise a complete women’s health package. Some of the most important areas are summarized below:

1. Reproductive Health – From nutritional information, to moderate exercise, to sexuality issues, to post partum guidance, many health promotion topics during pregnancy are not discussed in the physician’s office. Therefore, a complete strategy on diet, stress reduction, posture and mobility, exercise, hygiene, etc. should be made available during pregnancy, and perhaps should be the responsibility of allied health care professionals.
   

   
   

2. Infectious Diseases – Sexually transmitted diseases such as syphilis and antibiotic-resistant gonorrhea have risen in the past 25 years in women of all ethnic backgrounds. The increased risk of acquiring HIV from heterosexual contact is up in women in alarming rates. Many women who may be at increased risk (due to ethnic background, economic status, etc.) may not even be aware of their risks. Again, health education is important as an intervention strategy to disseminate information in schools, health clinics, and in private practices to alert women to risks with infectious diseases.
   

   
   

3. Menopause – The issue of medical intervention in menopause is still controversial, because many treatments themselves may have adverse effects on health (such as estrogen therapy and the increased risk of cancer, and oophorectomy and the increased risk of heart disease). For over five years it has been stated that a diet low in fat and high in vitamin supplements, and regular exercise may actually lower (or eliminate) estrogen therapy in many women.
   

   
   

4. Mental Health – From anorexia to bulemia, to stress, to depression, mental health disorders affect millions of women each year, and lead to decreased productivity in the work place, problems at home and with children, and account for many suicides each year. In 1988, suicide was the eighth leading cause of death in the United States. Although many do not associate these types of conditions as so serious that they cause death, but their seriousness cannot be overstated. The ability to treat these conditions will improve the health of almost 10% of high school students with eating disorders, 8% of women who suffer from depression, and almost 1 out of 3 women in this country who suffer from stress great enough to cause physical or emotional problems in their lives.
   

   
   

5. Addictive Behaviors – Smoking has been on the rise with teenage women for over a decade. Alcohol use is also more prevalent in certain age and socioeconomic groups. As stated by former surgeon general C. Everett Koop, MD; “If we as a nation are to affect the overall health of the general public, we must first strive to reduce the incidence of smoking and drinking in all segments of our society”. Addictive behaviors also includes drug abuse (cocaine, marijuana, amphetamines, etc.). For some women, addictive behaviors sets in motion their reliance of the medical system to deal with their problems (low birth weight babies, overdoses on drugs, etc.). The obvious but hard to achieve self reliance and empowerment is the goal of mental health workers who deal with these conditions.
   

   
   

6. Violence – The murder of Nicole Brown Simpson has raised the national consciousness about domestic violence. The issue of abuse, rape, incest, and other violent acts against women are major parts of a total women’s health package, and should be understood by all allied health care workers. By understanding the elements of abuse, appropriate referrals may take place, and a complete recovery may be set in motion.
   

   
   

7. Health Promotion – All of the above conditions could be improved by the implementation of health promotion strategies into treatment. Improper diet has been associated with everything from poor school performance to violent crime. Regular exercise not only improves physiological parameters, but also has profound effects on psychological aspects of health (such as depression). Many medical treatments involve drugs, which themselves have side-effects. True health promotion may have positive influences upon patient care, and health care costs, which leads us to our next section.
   

   
   

8. Access to Health Care – Access to proper health care is determined on need (and perceived need), ability to pay, health status, and acceptability of services. Health promotion experts agree that health promotion at any level may reduce the overall costs of health care, and our system that in many cases rewards persons for being sick (free emergency room care) is creating a burden on our society that may soon overwhelm us financially.

In conclusion, women’s health issues will play a more prominent role in today’s and tomorrow’s health care system. The aspects of prevention and quality rehabilitation will be factors because of their long-term intervention strategies and ability to reduce health care costs. The role in which health promotion and rehab can affect change in the above-discussed aspects of women’s health will be key to the success and growth of both of these important elements of the health care system.

References

1. Greenwald, S. Menopause, Naturally. Volcano Press, Volcano, CA, 1984.

2. Whitney, E.N., Hamilton, E.M.N. Understanding Nutrition, 3rd Edition. West Publishing Company, St. Paul, MN, 1984.

3. Bompa, T.O. Periodization of Strength: The New Wave in Strength Theory. Veritas Publishing, Toronto, Canada 1993.

4. A Profile of Women’s Health in America. Women’s Health Data Book. Coyright 1992 by the Jacobs Institute, 409 12th St.,Washington, DC 20024.

5. Baechle, T. (ed). Essentials of Strength and Conditioning. Human Kinetics Publishers, Champaign, IL 1994.

About the Author

Eric Durak is the director of Medical Health and Fitness, a research and consulting firm based in Santa Barbara. He specializes in exercise programs for special population groups, and has published scientific articles in: The American Journal of Obstetrics and Gynecology, Diabetes Care, and The Somatics Journal. He is the author of Cancer, Exercise, Wellness, and Rehabilitation, published this year.