Special Populations and Exercise: A New Era In Fitness

Introduction

There is an old adage that active people seek active lifestyles, and that Darwin’s theory of natural selection applies to exercise. It has always been hard to truly tell if exercise is associated with improved health, or whether healthy people are naturally drawn to more active tasks. For those who are still not convinced about the benefits of exercise as part of a healthier lifestyle, it has been a tough argument to refute.

Back in the mid 1980’s evidence started to mount that if people engaged in exercise over periods of time, they may reduce their chances of acquiring certain types of diseases, such as heart disease, and other cardiovascular disorders. Research also pointed out that regular exercise may reduce premature mortality, thus assisting persons in living longer through maintaining a healthy lifestyle. These results were independent of their gender, places where they lived, their body weight, and other types of medical conditions, such as blood pressure status, and family history of a particular disease.

The concept of exercise in the past ten years has moved into a new realm – that of looking at the the effects of exercise on special populations. Special populations groups are persons with diseases, and other metabolic conditions that are usually under the care of physicians or other health care personnel.

Exercise and Special Populations – Pregnancy

One of the first special population groups to be studied directly under exercise conditions were pregnant women. For many years previously, obstetricians felt that exercise may harm the developing baby and cause unnecessary problems during pregnancy and delivery. This was in the absence of any concrete scientific information.

Over the past 15 years there have been many research reports on the effects of exercise on pregnant women, from their response to different exercise programs, to their birth outcomes. The results have been impressive, in that most women seem to fair better physically when performing regular moderate exercise regimens than those who remain sedentary over the course of their pregnancies. Although there is still a lag between information presented in journals and articles, and what many physicians recommend, the consensus today is that an active lifestyle with this group may be better for both mom and baby.

Current reports highlight the need for pregnant women to perform low-impact aerobic exercise that will help with metabolism after the second trimester, and not injure joints that are being softened up in the third trimester for delivery. Walking 1-2 times per day after meals seems to help burn excess energy, and aerobic exercises such as the UBE (Upper Body Ergometer), and Aqua-Jogging^TM in a pool with a special buoyancy vest are two very good ways to stay in shape without excess stress to joints. They can be performed using basic fitness guidelines of 20-30 minutes, 3-4 days per week, keeping the heart rate in the training zone. Your physician should be kept abreast of your fitness program, and any unusual situations should be discussed with him/her.

Exercise and Seniors

Another special population group receiving attention in the medical literature and lay person press is the senior age group (55 years and over). For most of this century we were told that gaining weight, losing strength, developing disease, and losing energy were simply a part of the natural aging process. With the growing number of studies looking at exercise and life span, body fat loss, increasing strength, and reducing the incidence of certain diseases, through regular exercise over the years, it is becoming clear that inactivity – not aging per se, is the culprit in most, if not all, types of chronic diseases.

The senior population has had a boost for performing fitness routines with a report from Tufts University in Boston showing increases in strength in persons over 80 years old. Strength changes were demonstrated in subjects over a training program, with increases totaling over 170%. Even after a period of detraining, subjects still tested higher in strength scores than before they entered the program.

These results clearly show the need for incorporating moderate exercise programming at any age. The beneficial effects are being seen in groups once thought to have no business being in the workout environment.

Two areas of most concern to seniors are both bone and muscle weakness – the former with the concept of osteoporosis, and the latter with a decline in muscle strength and endurance over time. Again, walking has been shown to have an impact on cardiovascular fitness, and the use of aerobic machines may provide an improvement in workload over time without the impact on joints. Thera-Bandsª or rubber tubing are helpful with a beginning resistance exercise training program, and signing up with an exercise class, or having an instructor consult individually is helpful in getting a program started. Common sense, moderation, and proper exercise progression provide the intensity stimulus in the first month or so of exercise training.

Populations at risk for disease

For pregnant women and seniors, the benefits of regular exercise have been highlighted both in research and health periodicals. The question still remains if these particular populations are any more susceptible to disease because of their status. So, if we as our original question – does exercise help enhance health levels, or do they naturally select exercise to start out with?

The study of medical populations may give us a clue as to how exercise may be beneficial at improving health, independent of other variables that may contribute to health in the first place (such as genetics, dietary factors, where you live, etc.).

Diabetes affects over 20 million Americans, with over 5,000 new cases of diabetes being diagnosed every week. For over 70 years exercise has been touted as being part of the trilogy of treatment for persons with diabetes (along with a proper diet, and regular insulin routine). However, exercise has received little practical impetus from the health community, mainly because no one was sure what type of exercise, or how much was needed to actually impact diabetes care. Inactivity is seen as one of the major risk factors for development of diabetes over time, as is increased the likelihood of developing glucose intolerance, and insulin resistance. These factors are the reasons why many older adults develop diabetes later in life.

With the publication of three relevant research studies in 1991 and 1992, the question of exercise and its benefits for diabetes has been answered to a greater degree.

Two years ago, researchers from The University of California looked at alumni records from former university students to see who had been exercising regularly since their graduation from college (as far back at 1927). University records keep tabs on all students as to job occupation, health status, medical visits, leisure time activity, etc. Data was collected for many years, and when it was analyzed, it was found at alumni who exercised frequently (3 or more times per week), had less incidence for developing adult onset diabetes. Their risk for developing diabetes was almost half that of persons who did not exercise at all. This finding was independent of their family history of diabetes, and other physical factors, such as body weight and blood pressure status.

Within that same year another study was published in the British medical journal, the Lancet, with essentially the same results as the University of California study, only this time in an entirely different group of people, using the same type of research methods. This ongoing investigation is called the Nurse’s Health Study – which looks at health objectives in a sample of the nation’s nurses, was the data base. Information was collected from this group over years to assess health status in these women. After comparing those who exercised regularly versus their sedentary counterparts, the same type of results appeared. Those who exercised had almost a 33 percent less incidence of acquiring diabetes over time, independent of other factors.

Almost a year after the first publication, the Physician’s Health Study looked at exercising doctors and compared them with non-exercising counterparts. Again, those physicians who exercised at least 2 to 4 days per week had less incidence for diabetes development by about 30%, and those who exercised 5 or more days per week reduced their risk by 40%.

These series of investigations lend clear evidence to the concept of a protective effect of regular exercise in different population groups who may be at risk for developing disease over the course of their lifetimes. As scientists follow other groups of persons over years, we will learn more about the effects of exercise on mortality statistics, medical care, and enhanced quality of life for individuals.

Persons with diabetes should be concerned with keeping blood sugar levels at normal ranges throughout the day. They must avoid low blood sugar (hypoglycemia) due to prolonged exercise, as well. This balance is achieved through self blood sugar monitoring – using a small reflectance meter and sample of blood from a finger stick to keep track of sugar levels in the bloodstream. Self blood sugar monitoring is the cornerstone of good diabetes control, and may help avoid long term complications of the disease, such as blindness, gangrene, and heart disease.

Most exercises can be performed with diabetic persons, as long as self monitoring is part of their program. By knowing current sugar levels, they can safely plan the intensity and duration of their exercise. If they have had diabetes for longer than 10 years, lower impact exercises may be beneficial to guard against damaging feet, which may have some neuropathy (nerve damage). Consulting with personal physicians, and exercise specialists will produce individual exercises programs for improved health.

Medical populations

Exercise with medical patients started with cardiac rehabilitation. Patients were weaned into low intensity exercise programs using aerobic machines, later walking programs, and at the present, supervised exercise consisting of aerobics, weight training, and stretching programs. Their exercise options have grown as to what types of programs they can perform, and how it may effect their risk for cardiac abnormalities later in life. The goal for cardiac rehab programs to date is to reduce the incidence of recurrent heart problems in patients who have undergone bypass surgery, or had previous heart attacks.

For persons at risk, exercise may have an impact on reducing the occurrence, or severity of disease. What about persons who are already afflicted with a disease, such as high blood pressure?

One in four American has hypertension, and exercise has been studied as to its effects on blood pressure for over 25 years. Most persons who exercise regularly know that training raises blood pressure during the performance of the exercise itself. Many health professionals have been reluctant to tell their patients to exercise because of this fact.

However, exercise training over time reduces blood pressure levels. The key is finding the right type of exercise program that will not raise blood pressure much during exercise, and have beneficial long-term effects.

It has been found that moderate aerobic training (walking, aerobic machines, swimming, etc.) have little effect on blood pressure levels, if they are performed at a certain heart rate range. Regular exercise is best at keeping blood pressure levels in check. Sporadic training routines have little effect in the long run, and persons may not get into their exercising “groove” in terms of figuring out their heart rate, and their exercise intensity.

Dr. Deepak Chopra, the author of “Quantum Healing”, has added much information as to the effects of changing lifestyle and its effect on cancer patients. Those who perform meditation, regular exercise, and dietary interventions have had a better recovery from their cancer-related therapies. Exercise plays an important part of cancer recovery by strengthening weak muscles, adding more functional capacity in persons who have little energy for daily work activities, and boosting self-esteem though successful performance of tasks, and achieving goals. Moderate walking and water exercise programs have been successful with this group. The use of rubber tubing substitutes for dumb bells in terms of muscle strengthening. In the future exercise may be a part of every cancer patient’s recovery package.

One of the most interesting areas of exercise and medical populations is the effect exercise has on blood lipids. As heart disease is the worst chronic disease afflicting Americans, anything that can reduce cholesterol and other blood fats in the diet, and by other means is regarded highly.

It seems that aerobic exercise (and to some extent, strength training), has an effect on lowering total cholesterol with exercise. It raises the protective cholesterol (HDL), and reduces the atherosclerotic-producing cholesterol (LDL), along with cholesterol sub-fractions which may have an effect on health status. Judging by its effects on hyperlipidemia (high fat levels in the blood), patients with this disorder may use exercise as a type of medicine, and the right “prescription” may help reduce their blood fat levels, reducing their chance of suffering a cholesterol-related heart problem.

Arthritis patients have had to deal with pain their joints with every movement. So why should they exercise – as exercise makes joints move in lots of directions, and sometimes with a heavier load than just getting around? Exercise has been shown with this group to have beneficial effects of lessening the pain and inflammation of chronic rheumatoid arthritis. Programs such as PACE (People with Arthritis Can Exercise) have opened doors for persons and given them options as to what types of exercises they can perform, and the effects of exercise over prolonged periods of time.

Exercise has been shown to have beneficial effects in patients with Cystic Fibrosis, Post-Polio Syndrome, Raynaud’s Syndrome, End-Stage Renal Disease, Pulmonary Disease, and Peripheral Vascular Disease. Exercise is also being studied as to its beneficial effects on newer diseases such as HIV/AIDS, and Chronic Fatigue Syndrome. The American College of Sports Medicine has set guidelines for exercise professionals on dealing with these types of patients during exercise situations. With a joint effort by the health care community, patients who would have never thought of using exercise as part of their medical treatment may be working with their exercise specialist in addition to their doctor, nurse, dietitian, or physical therapist.

A Basic Medical Exercise Program

What constitutes a medical exercise program? Does an adult onset diabetic person have a different exercise program than an arthritic patient? As exercise programming is as individual as people, no two should have the exact type of program. Whether patients are working out in a supervised exercise setting, or participating in an aerobic exercise class, there are a few types of guidelines that are universal, and may help structure individual exercise.

1. Proper monitoring before exercise. Whether is is blood sugar monitoring, using a blood pressure cuff, taking a temperature reading, or stepping on the scale, performing a physical reading pre-exercise is important to see how hard and long you may be able to perform.
2. Proper warm-up. In a class full of students, or on your own, getting the muscles prepared for exercise is as easy as doing some light aerobic movements, and large-muscle stretching activities to get ready for the body of the exercise.
3. New goals and objectives. The goals for therapeutic exercises are – pain free movement, improved functional ability, learning new body movements, and perfecting technique on whatever type of exercise you are performing. If people thought about improving their technique in the weight room, or the aerobic dance floor, they would decrease their risks of ever having an injury – as the competitive nature of exercise takes a back seat to self-improvement and self-awareness. It has been said that Socrates learned to dance at 70 years of age because he felt that a part of himself needed improvement. Therapeutic exercise is half education, and half workout. Teaching patients new physical skills, and offering them instruction on how to deal with new movement is part of the objectives. It differs from mainstream exercise programs where individuals need much less guidance. The rewards are not just improvements in physical condition, but new tools to work with on their own (at home), and hopefully a new found sense of self acceptance and confidence to become healthier, and more self reliant.
4. Proper warm-down. In sports, warm down may mean a few stretches before going home. The importance of proper warm down in therapeutic situations cannot be overlooked. It is time for breathing (slow, proper belly breathing), it is a time for reflection and relaxation, and getting yourself “centered”, and it is a time to let the muscles flush out the extra work they have been asked to perform, and be able to function properly the next day without undue soreness. For patients who have been in stressful healing situations, the warm down serves as their focus to reduce pain, increase mental strength, and increase their own healing abilities.

There is no one type of exercise routine for medical situations, so no sample program is listed. A bit of reading and investigating by the individual will help them gain access to qualified professionals to help them start on their own program.

Tomorrow’s Exercise

Exercise in medicine, despite all of the research expounding its benefits, is still in its infancy. There are scattered programs around the country that provide exercise therapy for medical patients. Many health professionals are hesitant to refer patients to health clubs, as most employees are not well versed in medical aspects of disease. For those with extensive exercise physiology backgrounds, setting up private practice is also difficult, as the profession is not a licensed entity.

None the less, the future of exercise with medical populations seems to gaining momentum. More types of out-patient programs are cropping up, and some hospitals have adopted a rehabilitative format, performing therapy services in addition to acute patient care.

We would hope that it is part of a change in the system that now pays an enormous amount of money for medical procedures, to one which will help pay costs for “preventive health care”, which would include diet and exercise as the main components. Time will tell as to how the current political administration will handle today’s health care issues. If individuals are aware of the benefits of exercise therapy for special population needs, perhaps they will seek out exercise instruction in their community, and make a change in the system by themselves.

About the author:

Eric P. Durak received his Master’s degree in Exercise Physiology from the University of Michigan in 1986. His research and clinical interests include exercise applications for special populations groups, such as diabetes (IDDM, NIDDM, GDM), pregnancy, and metabolic disorders. He has published scientific articles in: The American Journal of Obstetrics and Gynecology, Diabetes Care, Sports Training, Medicine, Rehabilitation, and The Somatics Journal. He is the author of “Exercise and Diabetes – a Guidebook for Health Professionals, published through Medical Health and Fitness, based in Santa Barbara, CA.