138 | NSCA’s Essentials of Training Special Populations Recommended Readings Johansen, KL and Painter, P. Exercise in Individuals with CKD. Am J Kidney Dis 59:128-134, 2012. Johnson, CA, Levey, AS, Coresh, J, Levin, AA, Lau, J, and Eknoyan, G. Clinical practice guidelines for chronic kidney disease in adults: part I. De nition, disease stages, evaluation, treatment, and risk factors. Am Fam Physician 70:869-876, 2004. National Kidney Foundation. K/DOQU clinical practice guidelines for chronic kidney disease: evaluation, classi cation, and strati cation. Am J Kidney Dis 39:S1-S266, 2002. Saran, R, Li, Y, Robinson, B, Abbott, KC, Agodoa, LY, Ayanian, J, Bragg-Gresham, J, Balkrishnan, R, Chen, JL, Cope, E, and Eggers, PW. U.S. renal data system 2015: annual data report: epidemiology of kidney dis- ease in the United States. Am J Kidney Dis 67:A7, 2016. Smart, NA, Williams, AD, Levinger, I, Selig, S, Howden, E, Coombes, JB, and Fassett, RG. Exercise and Sports Science Australia (ESSA) position statement on exercise and chronic kidney disease. J Sci Med Sport 16:406-411, 2013. walk test or other valid assessments of functional Exercise guidelines for clients with chronic capacity has been demonstrated in individuals kidney disease or ESRD include performing with ESRD (158). An increased ability to carry aerobic endurance training most or all days of out activities of daily living, as well as increased the week at a moderate intensity of 40% to <60% overall physical activity and functioning, has heart rate reserve or 12 to 13 RPE. Clients should been reported (158). Studies of resistance train- aim for 20 to 60 minutes of activity, whether inter- ing in individuals with ESRD have demonstrated mittent or continuous, with an overall goal of 150 increased muscle strength as well as other ana- minutes of aerobic endurance activity per week, bolic effects (94, 99, 100). depending on the level of physical functioning. Caution is recommended for vigorous intensity Aerobic and resistance exercise have been exercise (5). Resistance training can be done two shown to reduce cardiovascular risk factors, or three days a week, with one set of 10 to 15 and studies have reported a variety of bene cial repetitions per exercise at 70% to 75% 1RM (5). effects including reductions in oxidative stress, in ammation, and blood pressure in clients with CONCLUSION chronic kidney disease or ESRD (94, 95, 100, 158, 161, 177, 184). A key point of this chapter is that chronic metabolic disorders such as obesity, type 2 diabetes mellitus, Exercise Recommendations type 1 diabetes mellitus, and dyslipidemia are for Clients With Chronic largely preventable and that it has been consist- Kidney Disease ently shown that inclusion of regular exercise and a healthy diet can significantly reduce the risk of The exercise recommendations for clients with contracting these diseases. The role of exercise in chronic kidney disease or ESRD are similar to the management and treatment of these common those for older adults and the management of metabolic disorders has been demonstrated to be comorbidities such as diabetes and hypertension safe and effective. Exercise professionals can play (94, 96, 99, 158). It is advised that these recom- a key role in the support of individuals with meta- mendations be considered in light of each client’s bolic diseases; however, a thorough understanding functional capacity. Medical clearance should of the signs and symptoms, associated medications, be obtained before exercise programming. The and response to exercise for individuals with met- exercise program should include aerobic and abolic diseases is necessary. resistance training (184) and flexibility exercises.
Metabolic Conditions and Disorders | 139 Key Terms myalgias myxedema adipokines nocturnal hypoglycemia atherogenic obesity autonomic neuropathy overweight dyslipidemia postprandial euthyroid renin-angiotensin-aldosterone glomerular filtration rate reverse cholesterol transport goiter silent ischemia hyperthyroidism statins hypoglycemia subclinical hypothyroidism hypothyroidism intima ketoacidosis Study Questions 1. Which of the following is considered to be the most essential behavior to prevent weight regain? a. 60 to 90 minutes a day of physical activity b. regular assessment of leptin levels in the blood c. 3 days per week of a comprehensive resistance training program d. restriction of the level of carbohydrate in the diet, especially simple sugars 2. Which of these lipid-related blood elements is properly defined? a. chylomicrons: the primary form of fat in the body b. triglycerides: most likely contributor to atherosclerosis c. low-density lipoproteins: primary carriers of blood cholesterol d. very low density lipoproteins: remove cholesterol from the blood vessel walls 3. Which of the following exercise limitations or symptoms is likely to be present in a hyperthyroid client? a. reduced heart contractility b. faster heart rate recovery c. higher heart rate but slower response to increase of intensity d. lower blood pressure but higher rate of respiration during exercise 4. Which of the following exercise parameters falls outside the recommended exercise prescription for individuals with chronic kidney disease? a. An RPE between 14 and 16 is recommended. b. Exercise should be done only following medical clearance. c. Aerobic exercise should be performed most days of the week. d. Clients should accumulate at least 150 minutes of aerobic exercise per week.
Medications Table 4.1 Common Medications Used to Treat Obesity Drug names Mechanism of action Most common side Effects on exercise effects orlistat (Xenical, Alli) Lipase inhibitors, block Stomach pain, gas, diarrhea, Unknown cardiovascular and absorption and digestion of leakage of oily stools metabolic effects; gastric fatty acids symptoms are common and Paresthesia, dizziness, dysgeusia may affect exercise Combination Acts as a serotonin receptor (rancid taste sensation), Unknown cardiovascular and drug consisting of agonist; phentermine insomnia, constipation, dry metabolic effects; may decrease phentermine and is a sympathomimetic mouth, insomnia, GI disorders, resting or exercise heart rate topiramate (Qsymia) and anorectic (depresses anxiety, depression or both; may increase risk of lorcaserin (Belviq) appetite), and topiramate hypoglycemia in persons with is an anticonvulsant with type 2 diabetes Extended-release weight loss side effects form of naltrexone Exact mechanism of action Headache, dizziness, Unknown cardiovascular and and bupropion not known; believed to generalized GI symptoms metabolic effects; may decrease (Contrave) decrease food consumption including diarrhea and resting or exercise heart rate and promote satiety by constipation; Caution: or both; may increase risk of selectively activating drug interactions include hypoglycemia in persons with serotonin receptors in the selective serotonin reuptake type 2 diabetes brain (activation of these inhibitors (SSRIs), monoamine receptors may help a person oxidase inhibitors (MAOIs), eat less and feel full after bupropion, and some botanical eating smaller amounts of supplements food) Bupropion is an Suicidal thoughts, seizure risk, Increased resting heart rate and antidepressant medication and added effects with alcohol; blood pressure (therefore may that may decrease appetite; Caution: do not drink alcohol cause an abnormal heart rate naltrexone may also curb with Contrave and blood pressure response to hunger and food cravings exercise) References: (23, 53, 132, 153) 140
Medications Table 4.2 Common Medications Used to Treat Type 2 Diabetes Drug class and names Mechanism of action Most common side effects Effects on exercise insulin (Humulin, Novolin, Replaces the insulin Pain, redness, swelling or itching Increases release of injected Lantus); includes rapid-acting normally produced by beta at the injection site; hypoglycemia insulin if the injection is given (Humalog, Humulin R, Novolin R), cells of the pancreas; both and resulting symptoms may in active skeletal muscle; rapid- and intermediate-acting human and animal forms of occur; other less common side increases uptake of glucose combination (Humalog 50/50, the hormone are used effects include allergic reactions from arterial blood (which can Humalog 70/30, Novolin 70/30), and hypokalemia cause hypoglycemia); Note: and long-acting (Humulin U, exercise decreases insulin Lantus, Levemir) forms resistance Oral hypoglycemic drugs come in many different forms and have many different effects. The following is a sample of several classes. Sulfonylureas glipizide (Glucotrol) Stimulate the beta cells to Hypoglycemia, weight gain, Increased risk of hypoglycemia; glimepiride (Amaryl), glyburide produce and release more insulin nausea, skin rash Note: need to monitor pre- and (Diabeta, Glynase) (many drugs are fast-acting) postexercise blood glucose levels until response to exercise is predictable Dipeptidyl peptidase-4 (DPP-4) inhibitors saxagliptin (Onglyza), sitagliptin Stimulate the release of insulin Upper respiratory tract Very little information on (Januvia), alogliptin (Nesina), by preventing breakdown of infection, sore throat, interactions with exercise; linagliptin (Tradjenta) glucagon-like peptide 1 (GLP-1) headache; inflammation Caution: possible increased and inhibit the release of glucose of the pancreas (from risk of hypoglycemia due to from the liver sitagliptin) exercise Biguanides metformin (Fortamet, Inhibit gluconeogenesis and the Nausea, diarrhea, lactic May increase exercise heart Glucophage, others) release of glucose from the liver, acidosis (rarely) rate response to submaximal improve insulin sensitivity, may exercise and interfere with the promote modest weight loss and glucose-lowering action of the modest decline in LDLs drug Thiazolidinediones rosiglitazone (Avandia), Improve insulin receptor Heart failure, heart attack, May improve exercise capacity; pioglitazone (Actos) sensitivity to insulin in muscle, stroke, liver disease Caution: possible increased liver, and adipocytes; inhibit the risk of hypoglycemia due to release of glucose from the liver; exercise may slightly increase HDLs Alpha-glucosidase inhibitors acarbose (Precose), miglitol Slow the absorption and GI discomfort and other Caution: possible increased (Glyset) breakdown of carbohydrate in GI symptoms including gas risk of hypoglycemia due to tract and diarrhea exercise Combination drugs kazano (alogliptin and Stimulate the release of insulin Heart failure, heart attack, Very little information on metformin), oseni (alogliptin and by preventing breakdown of stroke, liver disease (from interactions with exercise; pioglitazone) GLP-1, inhibit the release of pioglitazone); Caution: possible increased glucose from the liver, improve upper respiratory tract risk of hypoglycemia due to insulin sensitivity; may promote infection, sore throat, exercise (from alogliptin and modest weight loss and modest headache, inflammation pioglitazone); decline in LDLs (from metformin) of the pancreas (from may increase exercise heart and improve insulin receptor alogliptin); rate response to submaximal sensitivity in muscle, liver, and nausea, diarrhea, lactic exercise; may interfere with adipocytes; may slightly increase acidosis (rarely) (from glucose-lowering action (from HDLs (from pioglitazone) metformin) metformin); may improve exercise capacity References: (8, 50, 135) 141
Medications Table 4.3 Common Medications Used to Treat Type 1 Diabetes Drug class and names Mechanism of Most common side Effects on exercise action effects Increases release of injected Rapid-acting insulin: lispro Replaces the insulin Pain, redness, insulin if the injection is given (Humalog), aspart (Novolog), glulisine normally produced swelling or itching in active skeletal muscle; (Apidra) by beta cells of the at the injection site; increases uptake of glucose Short-acting insulin: regular Humulin pancreas hypoglycemia and from arterial blood (which can (also called Humulin R), Velosulin (for resulting symptoms may cause hypoglycemia) insulin pump) Blunts the increase in occur Intermediate-acting insulin: Hypurin blood glucose levels Affects purposeful and isophane (also called NPH) after eating Redness, swelling, desired blood glucose increase Long-acting insulin: insulin glargine bruising, or itching at from preexercise snack and (Basaglar, Lantus, Toujeo), insulin the injection site, loss of may result in decreased detemir (Levemir) appetite, stomach pain, performance excessive tiredness, May or may not decrease pramlintide (Symlin)* dizziness, cough, sore exercise submaximal and throat, joint pain maximal heart rate, lower Angiotensin-converting enzyme Reduce high Dry cough, dizziness, submaximal and maximal (ACE) inhibitors* blood pressure (if light-headedness, blood pressure applicable) fainting, headaches, May attenuate aerobic training fatigue benefits and increase myalgias Statins* Reduce risk (or levels, GI discomfort, when combined with exercise if already raised) of headaches, muscle high blood lipids aches, drowsiness, dizziness, myopathy, liver damage *These medications do not directly affect blood glucose levels, but are taken by individuals who have type 1 diabetes to help manage their disease. References: (8, 35, 49, 134, 203, 204) 142
Medications Table 4.4 Common Medications Used to Treat Abnormal Lipid Levels Drug class and names Most common side effects Effects on exercise May attenuate aerobic training Statins, HMG-CoA reductase inhibitors benefits and increase myalgias when combined with exercise lovastatin (Mevacor), GI discomfort, headaches, muscle pravastatin (Pravachol), simvastatin aches, drowsiness, dizziness, No known effect on exercise responses (Zocor), atorvastatin (Lipitor), myopathy, liver damage unless hypotension occurs, then may rosuvastatin (Crestor), ezetimibe and increase heart rate responses simvastatin combination (Vytorin, May increase the risk of myalgias when Zetia-Zocor) combined with exercise No known effects on exercise Niacin responses No known effects on exercise niaspan (Niacor), Slo-niacin (over the Flushing of the face, neck, itching, responses counter) dizziness, hypotension No known effects on exercise responses Fibrates, fibric acid GI discomfort, aching muscles (more gemfibrozil (Lopid), fenofibrate (Tricor), likely if also using a statin), rash, bezafibrate (Bezalip) possible damage to gallbladder GI discomfort, heartburn, gas, Bile acid binding resins constipation cholestyramine (Questran), GI discomfort colesevelam (Welchol), colestipol (Colestid) Cholesterol absorption blocker ezetimibe (Zetia) Omega-3 fish oil No significant side effects Lovaza (as a prescription), over-the-counter supplements References: (51, 130, 190) 143
Medications Table 4.5 Common Hormones Used in Thyroid Replacement Therapy Hormone type Drug names Most common Effects on exercise Synthetic levothyroxine (Levothroid, side effects Increased heart rate and Levoxyl, Synthroid, Hyperthyroid symptoms from blood pressure during Synthetic combination Unithroid) overdosing, tachycardia, submaximal and maximal Natural (from animal palpitations, cardiomyopathy exercise, tachycardia glands) levothyroxine (Synthroid) + possible, tremors, anxiety, liothyronine (Cytomel) weight loss, nervousness, loss Essentially the same as for thyroid (Armour thyroid) of sleep synthetic Essentially the same as for Essentially the same as for synthetic synthetic Essentially the same as for synthetic References: (54, 182) Medications Table 4.6 Common Therapies Used to Treat Hyperthyroidism Therapy Drug names Most common Effects on exercise Antithyroid drugs methimazole (Tapazole), side effects May increase exercise heart propylthiouracil Can cause hypothyroidism rate and blood pressure β-blockers propranolol (Inderal), Lower exercise heart rate metoprolol (Lopressor, Fatigue, decreased HDLs, and blood pressure Toprol XL) increased triglycerides, increased cholesterol, No identified effects on Iodine 131 (radioisotope Radioiodine impotence, increased blood exercise therapy to ablate the glucose thyroid) May cause complete destruction of thyroid requiring lifelong replacement therapy References: (52, 131, 182) 144
Pulmonary Disorders 5 and Conditions 145 Kenneth W. Rundell, PhD James M. Smoliga, DVM, PhD, CSCS Pnina Weiss, MD, FAAP After completing this chapter, you will be able to ◆ understand the distinguishing physiological and physical characteristics of asthma, exercise-induced bronchoconstriction, pulmonary hypertension, chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, and cystic fibrosis; ◆ recognize and identify the major signs or symptoms of asthma, exercise-induced bronchoconstriction, pulmonary hypertension, chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, and cystic fibrosis; ◆ understand the major medication groups and their effects on individuals and the exercise response for those with asthma, exercise-induced bronchoconstriction, pulmonary hypertension, chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, and cystic fibrosis; ◆ identify, program, and administer appropriate exercise for asthma, exercise-induced bronchoconstriction, pulmonary hypertension, chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, and cystic fibrosis; and ◆ understand modifications, precautions, and the need to terminate exercise for asthma, exercise-induced bronchoconstriction, pulmonary hypertension, chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, and cystic fibrosis. The contributors would like to thank Sara Chelland for her assistance in the preparation of this chapter.
146 | NSCA’s Essentials of Training Special Populations Regular physical activity promotes health and Key Point provides positive benefits to those suffering from chronic heart disease, diabetes, and other ailments; Asthma is a chronic disease of the lungs charac- however, benefits of regular exercise for individ- terized by airway inflammation, which leads to uals with lung disease are less clear. Reduced airway remodeling and hyperresponsiveness. corticosteroid use, improved quality of life scores, and decrease in severity of exercise-induced Pathology and bronchoconstriction (EIB) have been associated Pathophysiology of Asthma with improved cardiopulmonary fitness from aer- obic exercise (231, 309). Yet paradoxically, there Asthma prevalence in the United States has is evidence that aerobic endurance exercise may increased dramatically in the last 30 years (53); contribute to asthma and EIB (280, 281). Likewise, however, this increase may in part be due to air pollution has been associated with new-onset increased asthma awareness and overdiagno- asthma and chronic obstructive pulmonary dis- sis (190). Airborne pollutants from a variety of ease (COPD) (121, 151, 175, 248). This chapter combustion sources (e.g., coal- and oil-burning explores the beneficial and detrimental effects of furnaces, internal combustion engines and high exercise as related to asthma, pulmonary hyper- automobile traffic, and gas cooking stoves) as well tension, COPD, chronic restrictive pulmonary as high ozone levels can aggravate existing asthma disease, and cystic fibrosis. and may be responsible for new-onset asthma in individuals who are genetically susceptible (162, ASTHMA 199). Changes in bacterial and viral infections, altered microflora, and diet may also contribute to Asthma is a chronic inflammatory lung disease allergic disease (278). Reduction in infection and that affects an estimated 25 million people in the contact with the microbial environment during United States, 6 million of whom are children (8, prenatal and early life (i.e., the hygiene hypothesis) 54). In the United States, medical costs are esti- can affect the maturation of a normal immune mated to be over $53 billion per year, and more response (155). Diminished microbial exposure than 10.5 million school days are lost annually during infancy may also affect sensitization to because of asthma (7). Asthma results in approx- allergens (38, 158). Immune responses are primed imately 3,500 deaths annually (9 per day) in the in utero and reshaped during postnatal allergen United States (53). Although roughly 90% of all exposure. The sensitivity to environmental anti- individuals with asthma have a bronchoconstrict- gens depends on the immunologic memory initi- ing response to exercise and exercise can trigger ated during antigen encounters of early life (154). a severe exacerbation, exercise-related asthma deaths are relatively uncommon with approxi- Low socioeconomic status (SES) is associated mately nine per year in the United States (34); with unfavorable conditions of high allergens such in these, mild intermittent or persistent asthma as dust mites, cigarette smoke, and cockroaches was identified. (318). Exposures have also been identi ed as a risk for the development of asthma (46). Asthma sever- Exercise-related exacerbations generally occur ity and related mortality are twice as common in in approximately 10% of the population (248, persons with low SES; however, the prevalence 251); however, in some sports the prevalence is of asthma is greater among those with high SES much higher. For example, with ice rink athletes, (301). This may be related to better health care Nordic skiers, and swimmers, the prevalence of and asthma diagnosis in the high-SES population. EIB is greater than 25% (210). Exercise-induced bronchoconstriction occurs in people with appar- A high prevalence of asthma has been reported ent asthma and those without apparent asthma. for African Americans (109, 167). African Amer- In either case, the mechanism is in ammatory; icans also suffer from a fourfold higher asthma however, the precise trigger may differ from mortality rate than Caucasians (202). Even after person to person (231, 309). SES factors were accounted for, African Americans and Hispanics were shown to be at greater risk
Pulmonary Disorders and Conditions | 147 than Caucasians for both adult and childhood resident in ammatory cells in the airway causing onset of asthma (188). more persistent in ammation. Chronic in amma- tion, characteristic of moderate to severe asthma, Several studies (47, 52, 302) suggest that is de ned by resident in ammatory cells, airway asthma is a risk factor for obesity because of remodeling, and persistent respiratory symptoms. decreased exercise in this population, although Figure 5.1 reveals the structural changes in a recent studies (31) support obesity as a risk for person with asthma. asthma. Airway obstruction and peak ow vari- ability are increased in obese populations while Degrees of Asthma Severity a decrease in fat mass and body mass index is related to improved airway function. A variety of factors or indices are used to classify asthma status; however, a key indicator of sever- In asthma, mast cells, eosinophils, T lympho- ity is the degree to which medication is needed cytes, macrophages, neutrophils, and epithelial to alleviate the symptoms (63). A classification cells may all be actively involved in the in am- system is shown in table 5.1. matory process and airway hyperresponsiveness (63, 309). Symptoms of asthma include recur- Pathology and rent episodes of wheezing, breathlessness, chest Pathophysiology of EIB tightness, and coughing (especially during the morning and night, or in response to allergen Exercise-induced bronchoconstriction is defined exposure or exercise). Asthma episodes are as a transient narrowing of the airways during or associated with air ow obstruction that typically after the cessation of exercise (231). This response resolves spontaneously within 1 hour (309). An typically resolves spontaneously within an hour acute response is characterized by activation of postexercise. According to most diagnostic crite- airway in ammatory cells, whereas the subacute ria, EIB is defined as a 10% or greater decrease in response involves persistent in ammation from Muscle Smooth muscle contraction of Airway bronchioles wall Narrowed airway Mucus Inflamed airway wall Figure 5.1 Schematic of a normal airway and a constricted airway of a person with asthma. Note the smooth muscle constriction, thickened mucosal layer, thickened basement membrane, denuded epithelium, and increased in ammatory cells of asthmatic airway. Based on D. Doeing and J. Solway, 2013, \"Airway smooth muscle in the pathophysiology and treatment of asthma,\" Journal of Applied Physiology 114:834-843. E4822/NSCA Special Populations/Fig. 05.01/530934/HR/R1 from: E6834/Walsh Flanagan/Fig. 07.10/545223/HR/R1
148 | NSCA’s Essentials of Training Special Populations Table 5.1 Components of Asthma Severity by Clinical Features Before Treatment Severity Days with Nocturnal Lung Interference Short-acting symptoms awakenings function with normal sβy2-magpotonmistcuosnetrfoolr activity Intermittent <2 days/week <2 times/month Nexoarcmearbl aFtEiVon1 sb;etween None <2 days/week FpEreVd1icotrePdE;F >80% Mild >2 days/week 3 or 4 times/month FEV1/FVC normal Minor limitation >2 days/week but not persistent but not daily >1 time/week but FpEreVd1icotrePdE;F >80% Some limitation daily, and not more than Moderate Daily not nightly FEV1/FVC normal Extreme 1 time on any day persistent Throughout the 7 times/week FpEreVd1icotrePdE;F 60% to 80% limitation Daily Severe day FEV1/FVC reduced 5% Several times per day persistent FpEreVd1icotrePdE;F <60% FEV1/FVC reduced >5% FEV1 = forced expiratory volume in the first second; FVC = forced vital capacity; PEF = peak expiratory flow. Reprinted, by permission, from B. Carlin, 2013, Asthma. In Clinical exercise physiology, 3rd ed., edited by J.K. Ehrman, R.M. Gordon, P.S. Visch, and S.J. Keteyian (Champaign, IL: Human Kinetics), 342. forced expiratory volume in the first second of ness can also be related to the allergen response a maximal exhalation (FEV1). Exercise-induced or inhalation of airborne pollutants during bronchoconstriction can occur in those with exercise. Following the humidi cation process apparent asthma and those without apparent consequential to dry air inhalation, water loss asthma. Exercise is the most common instigator from the airway surfaces increases osmolarity in of an asthma attack. This hyperresponsive reac- airway cells; this is followed by an in ux of water tion to exercise occurs in approximately 90% of into the cells to restore osmolarity and trigger individuals who have asthma and, for those who an in ammatory mediator release, which subse- have mild asthma, EIB may be the only apparent quently causes bronchial smooth muscle constric- expression of the disease (14). tion (231, 309). The severity of the exercise- related response is determined by ventilation rate, Key Point ambient air water content and temperature during exercise, and the presence of an allergen (231). Exercise-induced bronchoconstriction (EIB) is a condition in which there is a narrowing of the Normally, water loss from the humidi cation airways during or following exercise. process in the airways is continuously replen- ished via epithelial cells and submucosa (13, 60); Exercise-induced bronchoconstriction preva- however, evidence indicates that alterations in lence has been estimated to be 4% to 20% in the the subepithelial basement membrane may be in general population (25, 231, 309, 313) and 11% to part responsible for an observed decrease in the 55% in speci c sport populations (183, 193, 252, ability to adequately respond to this airway sur- 310, 313), with the highest prevalence found in face evaporative water loss (169, 179). This may winter sport athletes (310). necessitate the recruitment of smaller airways into the humidi cation process, enhancing airway Exercise-induced bronchoconstriction is typ- hyperreactivity (13). ically instigated by water loss from the airway surfaces consequential to the humidi cation of Although the exercise environment may be inspired air during exercise (15-17). Exercise- the primary determinant of the EIB response in related in ammation and airway hyperresponsive- individuals with and without apparent asthma, it has been postulated that the mode of exercise
Pulmonary Disorders and Conditions | 149 may play a role, albeit minor, when ventilation is inflammation and accompanying symptoms that affected (252). For example, the prevalence and allows the individual with asthma or EIB to lead intensity of EIB are lessened when the mode of a normal, physically active life. The key to a suc- exercise is swimming and the environment is a cessful treatment, however, is the design of an pool, where the temperature is relatively warm individualized treatment strategy. and humidity is very high (51). However, to the contrary, high airway hyperresponsiveness Medical intervention can control respiratory and asthma have been identi ed in competitive symptoms and offset lung function decline over swimmers; high trichloramine levels at the pool time. Optimal treatment is the elimination of or surface are thought to be the cause (51, 263). reduction in airway in ammation and exacerba- In stark contrast to an indoor swimming pool, tions, to minimize the use of rescue inhalers, and the environmental conditions of an indoor ice to reduce emergency department visits and hos- arena include low temperatures and humidity in pitalizations. Successful treatment should strive conjunction with high levels of particulates and to achieve optimal baseline pulmonary function pollutants ( gure 5.2). The ultra ne particles and a reduction of symptoms. emitted during ice resurfacing have been shown to exacerbate the asthmatic response, and chronic Common Medications Given exposure can result in new-onset asthma (121, to Individuals With Asthma 193, 238, 249). and EIB Therapy of Asthma and EIB Classic medications to treat asthma and EIB can be divided into two primary categories; however, Although a cure is currently unknown, several a novel class of biologics called monoclonal anti- pharmacotherapeutic agents are effective in the bodies has emerged that demonstrates efficacy treatment of asthma and EIB. These treatments in moderate to severe allergic asthma and high can support the removal or attenuation of airway eosinophilic asthma (35, 146). Because asthma is 160 × 103 140 × 103 Outside air 120 × 103 Preresurfacing rink air 100 × 103 Postresurfacing rink air PM1∙cm-3 80 × 103 60 × 103 40 × 103 20 × 103 *** 0 Electric Fossil fueled Zamboni fuel source rFinigkus dreuri5n.g2priPmaertuicsualagteehmoautrtse(r2(9<E14m.802e2am/sNumSrCeiAnm_deSnipatemsc)i.eaNlt_ePoro)tepmutleahataiostuntsrh/eFed05pin.a0r2ot/5iuc3tu0sli9ad3te5e/ammihra-aRtnt1edr at ice level in seven ice concentration in the ice arena air is more than 20 times greater than that of the ambient air outside of the ice arena. Data from K. Rundell, 2003, \"High levels of airborne ultra ne and ne particulate matter in indoor ice arenas,\" Inhalation Toxicology 15: 237-250.
150 | NSCA’s Essentials of Training Special Populations considered a disease of chronic airway inflamma- β2-Adrenergic Agonists tion, one group of medications, known as control- lers, aims to provide long-term control by reducing β2-adrenergic agonists are potent bronchodila- inflammation. Medications in this category are tors used in prophylaxis and rescue from acute taken on a daily basis and provide the foundation asthma exacerbation and EIB and are one of the for asthma management (62). Other medications, most effective preventive therapies for EIB (309) known as relievers, are used to relieve acute because they improve pulmonary function in obstruction, bronchoconstriction, or both. Drugs nearly all individuals suffering from EIB (18). in this category are taken on an as-needed basis and are often used to supplement the controllers The short-acting β2-adrenergic agonists (41, 67, 231, 309). (SABAs) are functionally similar to long-acting β2-agonists (LABAs); they relax airway smooth Inhaled Corticosteroids muscle, improve air ow, decrease vascular permeability, and moderately inhibit mediator The National Institutes of Health defines anti-in- release (67, 314). Long-acting β2-agonists are flammatory medications as those that decrease effective only for a short duration, with a peak inflammatory markers, resulting in reduced bronchodilatory effect within 60 minutes of airway hyperresponsiveness (67). Inhaled corti- administration (231, 309). Common recommen- costeroids (ICSs) are an effective, frequently used dations include one inhaler per month as the anti-inflammatory medication in the treatment of maximal dosage; daily use implies a need for asthma (67, 314). Inhaled corticosteroids present improved asthma control (i.e., via an ICS) (314). significantly fewer adverse effects than oral cor- For example, it is recommended that if SABAs ticosteroids (OCSs) and are generally well toler- are used more than two or three times per week, ated (35, 67). With long-term use, ICSs improve an alternative treatment plan, such as the use of pulmonary function and reduce inflammation in corticosteroids, should be examined and imple- individuals with asthma and also improve control mented (231). Moreover, SABAs were not found of bronchial hyperresponsiveness (BHR). Despite to prevent postexercise decreases in FEV1 in elite that, ICS treatment plans longer than three weeks speed skaters when compared to no medication have shown diminished improvements in resting (313) ( gure 5.3). FEV1 (296), peak expiratory flow (PEF) (28, 108, 136), frequency of symptoms (28, 108), and BHR Long-acting β2-agonists function similarly to (136, 231, 309). SABAs (i.e., prevent bronchoconstriction and improve expiratory ow), thereby reducing the Leukotriene Modi ers frequency and intensity of asthma, EIB episodes, or both (33, 70). The effects of a LABA may last Leukotriene modifiers demonstrate efficacy in up to 12 hours, which can be particularly helpful providing prophylaxis (preventive treatment) for individuals with overnight asthma symptoms for asthma and EIB; however, their effectiveness (219). Long-acting β2-agonists have, however, varies between individuals, with protection rang- been associated with increased mortality risk, ing from none to 100% (89, 116, 309). Additionally, so it is unclear whether daily use is safe. In con- leukotriene modifiers can allow a reduction in the junction with this, daily use of at least one LABA dose of an ICS (89, 164). Thus, while it appears (salmeterol) has been shown to result in rapidly that leukotrienes are involved in the pathogenesis diminishing effectiveness of its long-duration of asthma and EIB, evidence that leukotriene mod- effects in as little as one month (66). It should ifiers are not 100% effective (250, 309) supports also be noted that LABAs are not recommended the notion of multiple mediator involvement in as standalone medications and should be used airway inflammation and BHR. However, it should only in conjunction with an ICS. be noted that leukotrienes seem to play a primary role in eosinophilic asthma (138). A summary of medications given to individu- als with asthma and EIB is found in medications tables 5.1 and 5.2 near the end of the chapter.
Pulmonary Disorders and Conditions | 151 0 -2 1998 -4 2000 Percent fall in FEV1 -6 -8 -10 -12 -14 -16 -18 -20 5 10 15 Baseline Time post 1000 m speed skating time trial challenge (min) eFploiigtsetuesrxheeorrc5tis.te3r.acNkPoosspsigteeenxdierscckaiasnettedirmse.cpVrEreoa4al8vus2eee2mss/NeianSnrCetFsAEf_ofVSrr1optmbehceeifβaolg2_-rrPeaeogaapotnuenldasitstifotodnilenslo/ctFewr0er5ivan.e0sgen3/ta5iino3S0nFA9E3wBV6Ae1/mrmethr-eenRaao2tstmuerdeendfot arinta5ne,iyg1ph0tu,lEmoIrBo-1np5aormsyitifnivuuentce-s tion measured. Initial testing was done during the 1998 season and follow-up testing was done during the 2000 season. Data from R.L. Wilber, K.W. Rundell, and D.A. Judelson, 2001, Presented at the Thematic Poster Session, Science in Winter Sports, under the title \"Mid expiratory ow rates of cold weather athletes with exercise induced asthma.\" Effects of Exercise in Key Point Individuals With Asthma and EIB While approximately 10% of the general pop- ulation exhibits EIB, considerably greater prev- As previously mentioned, a higher prevalence of alence is reported in sport participants such asthma and EIB has been found in cross-country as cross-country skiers, ice rink athletes, and skiers, ice rink sport athletes, and swimmers (51, swimmers. 248, 263), with respective causes likely from high minute ventilation breathing of cold dry air, air Most individuals with asthma are susceptible to high in combustion emission pollutants, or air EIB, yet their ability to exercise is often not limited with high trichloramine levels found in indoor (248). In cases in which resting lung function is pool air. Exercise in high-ozone air has also been impaired, exercise can be compromised (248). shown to cause acute decreases in lung function However, most individuals with asthma are able in both the asthmatic and nonasthmatic popula- to exercise, compete in sports symptom-free, and tions (248, 263). Most recently, long-term expo- improve their overall quality of life (80). Note that sure to ozone while exercising has been related to despite an extensive review paper by Del Giacco the development of new-onset asthma in the child ianntdencsoitlyle(a4g0u%esto(7<96)0c%onV.cOlu2 dorinhgeatrhtartatme oredseerravtee)- athlete (163). Studies on elite Nordic skiers (252, aerobic exercise improves cardiovascular tness 313), ice rink athletes (193, 238, 251, 313), swim- in a person with asthma or EIB, there is not con- mers (110, 263), and youth soccer players (121) sensus that exercise creates an improvement in support the development of new-onset asthma baseline lung function or BHR (50). and EIB from exercise-induced oxidative stress.
152 | NSCA’s Essentials of Training Special Populations A 24-week study by Dogra and colleagues (84) Percent change 10 * ** included three aerobic training sessions a week FEV1 * ** * at a minimum of 70% of maximal heart rate (MHR)—with a 5% increase every three weeks to 0 * ** a minimum of 85% MHR—and one set per week -10 ** ** * of resistance training exercises targeting the major -20 muscle groups. Halfway through the program, -30 participants followed a self-administered pro- -40 gram that allowed personalization; for example, exercise mode was based on individual preference 20 FEF50 (outdoor jogging, treadmill, recumbent or upright 0 cycling, and elliptical or rowing machines), and -20 ve weekly sessions were encouraged. The result -40 was a signi cant improvement of measures of -60 quality of life, asthma control, and aerobic tness. Mod Light Mod 5' 10' 15' The EIB response typically occurs after exer- Exercise Recovery cise is stopped in the 6- to 8-minute-duration challenge test, but during longer bouts of exercise FaniEgd4u8a2rf2te/eNr5S3C.46A_mSCpinehucaitaenl_sgPeoofpinuinlaFttEeiorVnv1sa/alF-n0tyd5p.0Fe4E/eF553x0e09rdc4i2us/ermi,nhg-R1 a gradual decline in lung function occurs and is alternating 6-minute periods of moderate- and followed by a larger fall in FEV1 upon the cessa- light-intensity exercise. Note the dynamic nature of tion of exercise (32). Type of exercise (constant pulmonary function between exercise intensities but vs. interval), intensity, and duration determine the overall decline over 36 minutes. whether bronchoconstriction occurs during or at cessation of exercise, or not at all (32). Based on K.C. Beck, K.P. Offord, and P.D. Scanlon, 1994, “Bronchoconstriction occurring during exercise in asthmatic Lung function in the EIB challenge test most subjects,” American Journal of Respiratory and Critical Care Medicine often involves bronchodilation during the exercise 149: 352-357. bout followed by falls in expiratory ow rates 5 to 20 minutes after exercise (125, 277). The exercise exercise period with a pattern of improvement bronchodilation is likely attributable to the larger during the moderate-intensity period and deterio- tidal volumes during exercise causing airways to ration during the light-intensity period ( gure 5.4). be stretched open, thus providing a mechanical protection against EIB (32). Exercise Recommendations for Clients With Asthma and EIB After tidal volume decreases when exercise is stopped or intensity decreased, bronchoconstric- The prevalence of asthma and EIB in clients and tive in uences dominate. Beck and colleagues athletes who compete in environments that are (32) found that during 36 minutes of steady-state known to trigger asthma and EIB attacks (e.g., exercise, an initial bronchodilation occurs within cold and dry) supports the fact that exercise is the rst few minutes, followed by a steady decline possible for clients with these conditions. Exercise in lung function for the remaining period of exer- prescription recommendations for clients with cise. Until this study, the decline in exercising asthma and EIB should be based on the results of lung function had gone unnoticed simply because exercise testing and assessment, including a bron- challenge tests were of short duration. During chial challenge test, so the exercise professional interval exercise, lung function in the individual is aware of the client’s threshold and response with asthma uctuates with exercise intensity; to exercise intensity, duration, mode, and, when it increases with high intensity and decreases possible, environmental stimuli. during the rest interval. Beck and colleagues (32) also evaluated lung function during 36 minutes of It is important for clients with asthma and EIB interval exercise consisting of 6-minute alternating to have adequate control of their symptoms and moderate- and light-intensity bouts. Lung function condition before initiating an exercise program. demonstrated a gradual fall during the 36-minute Commonly, aerobic exercise is paired with phar-
Pulmonary Disorders and Conditions | 153 maceutical therapy as a method to improve BHR, The intensity and duration of an aerobic exercise capacity, and quality of life in clients with moderate or severe asthma (101, 114). The workout need to begin at a lower level and exercise professional should be aware that clients with asthma or EIB typically use a preexercise gradually progress so as to not cause an exac- (15 minutes) medication such as a SABA, a mast cell stabilizing agent, or an inhaled anticholinergic erbation of symptoms. As a client’s tness level agent (231). In conjunction, clients with asthma or EIB often take a daily controller medication improves, athneienxteerncsiisteyporfof4e0ss%iontoal<s6h0o%uldV.sOtr2ivoer that may include an ICS or leukotriene receptor to assign antagonist (231). Although this comprehensive strategy greatly reduces the risk of the exercise heart rate reserve for 20 to 60 minutes three to session causing an adverse event (107), it is still recommended that the client and exercise profes- ve times a week using an exercise mode that sional, with input and approval from the client’s physician or other health care professional, deter- involves rhythmic and continuous movement mine an individualized action plan before starting a program in case of an exacerbation of symptoms. of large muscle groups (19, 79, 213, 272). For Exercise guidelines for clients with asthma or example, a client with asthma or EIB can start EIB include several speci c recommendations. First, a 10- to 15-minute preworkout warm-up is with walking, then progress to a walk–jog pro- highly recommended (176, 231, 276). An effective warm-up—especially using variable or interval gram, then a run-only program. When clients high-intensity exercise, as opposed to continuous high- or light-intensity exercise (231, 276)—may are able to 9h0a%ndV.leO2viogrohroeuarst-irnatteenrseisteyrsveeswsiiotnhs- produce a refractory period up to 2 hours (231) that of ≥60% to reduces a client’s propensity to develop EIB (203). out an exacerbation of symptoms, they can do interval training workouts of 10 to 30 seconds of high-intensity exercise followed by 30 to 90 seconds of rest (213). For clients with asthma or EIB, the design of an initial resistance training program is similar to common guidelines for beginning, untrained individuals (two or three sessions a week of two to four sets using moderate loads) (19, 272). Tables 5.2 and 5.3 show a summary of the aer- obic and resistance training guidelines for clients with asthma and EIB. Table 5.2 General Aerobic Exercise Guidelines for Clients With Asthma and EIB Parameter Guideline Frequency 3-5 sessions per week Intensity 40% to <60% V. O2 or heart rate reserve Mode Large muscle mass activities (e.g., walking) Duration 20-60 min of continuous activity References: (19, 79, 213, 272) Table 5.3 General Resistance Training Guidelines for Clients With Asthma and EIB Parameter Guideline Frequency 2-3 sessions per week Intensity Moderate (60-80% 1RM) Repetitions 6-12 Sets 2-4 References: (19, 272)
Case Study Asthma Ms. S is a 26-year-old graduate student. She was her issues. After measurement of her resting never involved in organized sport but decided lung function and the ability of a β2-agonist she needed to get physically t and set a goal of to improve her function, it was decided that completing a marathon. She began a running she would undergo a challenge test. Her rest- program but found that she was not making any ing FEV1 was 110% of the age-, sex-, height- progress. She reported, “I am wheezing and feel- predicted value, and she did not improve her ing a bit tight in the chest after about a block and FEV1 by at least 12% after β2-agonist admin- half of running; when I slow to a walk, it seems istration. However, this was likely because to get worse and I get this cough.” She added her daily use of the prescribed β2-agonist for that she had these symptoms year-round but approximately one month now resulted in the that they were worse during the allergy season. development of a tolerance (tachyphylaxis). This persisted for approximately one month into The high predicted FEV1 suggested that there her program. She was getting nowhere in terms was minimal chronic in ammation, and the of achieving her goal of completing a marathon. initial bene t provided by the preexercise use of the β2-agonist is suggestive of EIB. Ms. S did Despite Ms. S’s persistent attempt to train, her test positive for grass allergy, which was cur- tness was not improving. This led her to her rently in season, and dust mites and had mild family physician, who suggested that she might to moderate nasal congestion, runny nose, and have EIB. He prescribed a β2-agonist to be used postnasal drip indicative of rhinoconjunctivitis. before her workout sessions. She felt better and The challenge test was scheduled a week later, was able to run for about 30 minutes by the end and Ms. S was given instructions to not use the of the rst week. By the end of the second week β2-agonist except as a necessary rescue during of daily β2-agonist use, that old feeling of wheez- the week leading up to the test. The result from ing, chest tightness, and cough returned and the challenge test showed a substantial posttest she was back to walking after the rst or second fall in FEV1 of 77%, suggesting very hyperreac- block of running. She then made an appointment tive airways (a fall of 10% is considered positive). with an asthma specialist to be evaluated for Recommended Readings Bonini, M and Palange, P. Exercise-induced bronchoconstriction: new evidence in pathogenesis, diagnosis and treatment. Asthma Res Pract 1:2, 2015. Del Giacco, SR, Firinu, D, Bjermer, L, and Carlsen, KH. Exercise and asthma: an overview. Eur Clin Respir J 2:27984, 2014. Dogra, S, Kuk, J, Baker, J, and Jamnik, V. Exercise is associated with improved asthma control in adults. Eur Respir J 37:318-323, 2011. Lucas, SR and Platts-Mills, TA. Physical activity and exercise in asthma: relevance to etiology and treatment. J Allergy Clin Immunol 115:928-934, 2005. WebMD. Asthma health center. 2016. www.webmd.com/asthma/guide. Accessed October 28, 2016. 154
Pulmonary Disorders and Conditions | 155 PULMONARY Pathology and HYPERTENSION Pathophysiology of PH Pulmonary hypertension (PH) is both a hemody- The pulmonary circulatory system is a high-flow, namic and pathophysiological condition in which low-pressure, low-resistance system relative to the mean pulmonary arterial pressure is greater than rest of the circulation, with resting peak systolic 25 mmHg at rest (118). Pulmonary hypertension pressure <25 mmHg and diastolic pressure <10 may be further subdivided into six different cate- mmHg, such that normal mean pulmonary arte- gories representing a variety of pathophysiological rial pressure (PAP) is 14 ± 3 mmHg at rest. Right mechanisms (118). Thus, management for an atrial and ventricular pressure during diastole individual with a diagnosis of PH does not simply is generally <5 mmHg, which is a pressure suf- involve following a general protocol, but rather ficient to allow a favorable pressure gradient for must consider the type of PH and underlying venous blood from systemic circulation to return factors specific to each individual case. to the right side of the heart. In accordance with the general principles of cardiovascular physi- Pulmonary arterial hypertension (PAH) is a ology, increases in blood pressure are rooted in speci c clinical condition characterized by PAH in an increase in cardiac output or an increase in the absence of other causes of precapillary hyper- vascular resistance. In PH, the latter is generally tension (118). Pulmonary arterial hypertension the causative mechanism, though the root of may have many underlying origins, including increased pulmonary vascular resistance is quite heredity and drug toxicity, or may be idiopathic varied. (i.e., have an unknown cause). All causes of PAH produce similar pathophysiological changes in Previous classi cation systems of PH divided the cardiopulmonary system. However, PAH is it into primary and secondary conditions, and rare, with an estimated incidence of 1 in 100,000 though this schema is overly simplistic and has to 1,000,000 individuals (208). Nonetheless, the been abandoned (118), there remains value in individual economic impact of PAH is substantial, understanding how various pathological con- with a 2015 systematic review reporting a range ditions can lead to the development of PH. The of approximately $2,500 to $12,000 per month pathogenesis of PH leads to decreased functional of direct costs to each individual, plus unknown diameter of the lumen of pulmonary arteries indirect costs (135). and veins, depending on the category of PH. For instance, primary vasoconstriction, thromboem- The general condition of PH is not uncommon, bolic blockages, and parasitic infestations may all with estimates of up to 1% of the global popu- decrease blood vessel diameter and thus increase lation, where it is often associated with other vascular resistance. Under hypoxic conditions, as chronic cardiopulmonary or infectious diseases in various chronic pulmonary diseases (229, 247) (150, 208, 229). The incidence and underlying and sleep apnea (171), pulmonary arterial smooth cause of PH have considerable geographic var- muscle contracts to cause vasoconstriction. This iation, due to differences including population mechanism normally promotes ventilation– genetics, environment, infectious disease, and perfusion matching, but in chronic hypoxic lung medical care. Further, differences in methodology disease, the increased pulmonary vascular resist- between registries create barriers in accurately ance resulting from hypoxic pulmonary vasocon- understanding the epidemiology of PH (201). striction leads to the development of PH (106). Pulmonary hypertension is commonly associ- ated with hypoxic cardiopulmonary diseases, Pulmonary hypertension can lead to further including COPD and diffuse parenchymal lung systemic effects such as increased pulmonary diseases (229, 247). vascular resistance, which necessitates greater pressures in the right ventricle for blood to be
156 | NSCA’s Essentials of Training Special Populations ejected into the pulmonary circulation. This viduals with PAH, these physiologic responses causes overload in the right ventricle and subse- may impair gas exchange in individuals with quent dilation and, ultimately, right-sided heart hypoxic lung diseases (229). Thus, there is not a failure. Blood pooling in the right side of the heart single standard pharmacotherapeutic regimen for can lead to congestion in the vena cava and the treating PH; rather, the type of PH and associated hepatoportal circulation, which can cause liver comorbidities must be considered. dysfunction. Additionally, increased blood pres- sure can lead to pulmonary and systemic edema. Pharmacotherapy in PH is dependent on the classi cation of the disease; thus there is not a Animal model data also suggest that respiratory speci c drug pro le that can be used for all indi- function is impaired in PH due to diaphragmatic viduals with PH. However, there are medications muscle ber weakness and atrophy (76), which that are approved for managing PAH, and various contributes to dyspnea (labored breathing) and pharmacotherapy algorithms are available with fatigue during exercise. Indeed, individuals with varying degrees of evidence (118, 119). Pharmaco- idiopathic PAH experience inspiratory and expir- therapy for PAH is targeted at improving function atory muscle weakness (207). This may be attrib- and delaying progression of the disease and more uted to respiratory muscle overload (214). There invasive procedures, such as lung transplantation. is also evidence that this dysfunction extends Various clinical outcome measures are used to beyond the diaphragm and affects skeletal muscles assess the effectiveness of pharmacotherapy, but globally (228). improved exercise performance can be expected in successfully managed individuals. Given that PH negatively in uences the heart, lungs, vascular system, and respiratory muscles, Vasoreactivity testing may be performed in it follows that exercise capacity is limited in PAH individuals with PAH, and those who are vasore- and that this negatively in uences quality of life active may be treated with relatively high doses (137). Interestingly, resting hemodynamic param- of calcium channel blockers. Vasoreactive indi- eters were not found to be related to quality of life viduals with baseline tachycardia are generally in individuals with PAH (137). treated with diltiazem, and those with baseline bradycardia are generally treated with nifedipine. The signs and symptoms of PH are generally Generally, few individuals respond favorably to nonspeci c, including dyspnea, fatigue, general calcium channel blockers; those with idiopathic, signs of cardiovascular dysfunction (e.g., syncope heritable, and drug-induced PAH are most likely [fainting], angina, various heart murmurs), and to respond (118, 119). signs of pathologically elevated systemic blood pressure (e.g., ascites, edema, jugular distension). The three distinct targets of interest for speci c A detailed description of diagnostic and prognos- pharmacological management of PAH are the tic tests is beyond the scope of this chapter but is endothelin, nitric oxide, and prostacyclin path- achieved through specialist referral and includes ways, which counter vasoconstrictor pathways a variety of imaging procedures, blood tests, and or activate vasodilator signaling pathways. For direct measurement of right ventricular pressure individuals with PAH who are not vasoreactive via catheterization (118, 119). or respond poorly to calcium channel blockers, monotherapy targeting one of the relevant sign- Common Medications Given aling pathways is indicated. Endothelin receptor to Individuals With PH antagonists, such as ambrisentan, bosentan, and macitentan, may be used to counter pulmonary It is important to recognize that pharmacotherapy vasoconstriction induced by elevated levels of targeted toward individuals with PAH is not nec- endothelin-1. Phosphodiesterase inhibitors, such essarily the same as that for PH, due to differences as sildena l, tadala l, and vardena l, act through in the pathophysiology. While pharmacotherapy inhibiting degradation of cyclic guanosine that causes vasodilation to reduce pulmonary monophosphate (cGMP), which improves nitric vascular resistance should be beneficial to indi- oxide bioavailability and thus promotes vasodila-
Pulmonary Disorders and Conditions | 157 tion. Vasodilation is also promoted through drugs resistance system, with the pulmonary arteries that activate the prostacyclin pathway, including having limited ability to dilate beyond that at prostacyclin analogues (e.g., beraprost, epopros- rest (115). The lung is relatively fully perfused tenol, iloprost, and treprostinil) and selective at rest; but during exercise, recruitment of addi- prostacyclin receptor agonists (e.g., selexipag). tional blood vessels in less perfused regions helps There is good clinical evidence for each of these accommodate some of the increase in cardiac classes of drugs, but limited data regarding com- output to offset changes in pulmonary arterial parative ef cacy preclude recommendation for a pressure. As cardiac output rises during high-in- monotherapy of choice for most individuals with tensity exercise, there is limited room to decrease PAH. Combination therapy targeting two or more pulmonary vascular resistance compared to that signaling pathways may be useful for managing of the systemic circulation. Accordingly, PAP PAH. Much of the evidence for combination normally rises during high-intensity exercise (71). therapy is centered on sequential combination However, in some individuals the exercise-in- therapy, such that one class of drugs is initiated duced increase in PAP is actually pathological, and additional pharmacological management and is referred to as exercise pulmonary hyper- is added as needed to achieve targeted clinical tension. outcomes. However, there is currently limited evidence for using combination therapy as a rst The classi cation of exercise pulmonary hyper- line of pharmacological management (118, 119). tension is less straightforward than that for resting PH, since an increased mean PAP during exercise Drugs used in the management of PAH may occurs in all healthy individuals. Exercise pul- be effective for some, but not all, of the other monary hypertension is characterized by a high categories of PH. For instance, there is some evi- PAP accompanied by symptoms of PH, such as dence, though not strong, that individuals with breathlessness, which are not present at rest. This PH due to left heart disease may bene t from PAH condition may occur in individuals with mild left pharmacotherapy. Conversely, there is essentially heart disease or pulmonary vascular dysfunction no evidence for use of PAH drugs in individuals that is not severe enough to induce these effects with PH due to lung disease or hypoxia, and under resting conditions (147). Previously, a mean vasodilators may impair gas exchange. Given PAP of >30 mmHg during exercise was considered the multifactorial nature of PAH and other types diagnostic for exercise pulmonary hypertension, of PH, it is possible that individuals may also but it is possible for healthy, t individuals to be managed with other types of drugs, such as achieve this criterion during high-intensity anticoagulants, antiarrhythmics, diuretics, angi- exercise. Newer research indicates that a mean otensin-converting enzyme (ACE) inhibitors, and PAP of >30 mmHg, when combined with a total β-blockers, depending on underlying pathology. pulmonary resistance of >3 mmHg · min−1 · L−1, Yet the combination of PAH-speci c drugs with has a high sensitivity and speci city for discrim- antihypertensive agents may cause systemic inating between healthy individuals and those hypotension. with pulmonary vascular disease or right heart disease (147). A summary of medications given to individuals with PH is found in medications table 5.3 near the Because exercise can trigger PH before it man- end of the chapter. ifests at rest, exercise testing may be useful in the identi cation of the early stages of PH by revealing Effects of Exercise in subclinical impairments in right ventricle contrac- Individuals With PH tility in individuals with conditions associated with PH (61). For instance, in systemic sclerosis, Pulmonary arterial pressure normally rises pulmonary vascular resistance may be elevated during high-intensity exercise in healthy fit and require increased right heart contractility at individuals due to increased cardiac output. rest, which leads to irreversible right heart failure. The pulmonary circulation is normally a low- However, individuals may be asymptomatic at rest
158 | NSCA’s Essentials of Training Special Populations in the early stages of the disease, but the observa- Exercise Recommendations for Clients With PH tion of right ventricular impairment at rest can be useful in demonstrating the otherwise unnoticed presence of pulmonary vascular dysfunction so Pulmonary arterial hypertension is a chronic that it can be treated before it leads to irreversible disease and does not have a cure, but treatments right heart failure. Likewise, PAH is generally to diminish symptoms and slow the progression diagnosed late in the disease process (159), and of the disease may be quite efficacious. Exercise therefore it is possible that exercise testing may was previously thought to be dangerous to clients be useful in detecting it earlier. with PH, as it was thought that increased stress Exercise testing may be used to determine on the cardiopulmonary system could acceler- severity of PAH and provides valuable information ate heart failure. However, a significant body of trhegaatrVd. Oin2gppearokgonfolseisss. Laboratory testing indicates evidence demonstrates that exercise is beneficial than 10.4 ml · kg−1 · min−1 is in improving symptoms, exercise capacity, and associated with poorer prognosis, as is inability activities of daily living in clients with PAH and to exceed a systolic blood pressure of >120 mmHg other forms of PH (21, 24, 118, 134, 206). during peak exercise. Field tests of functional aer- A systematic review and meta-analysis focused obic capacity are also useful in evaluating PH, and on clients with PAH and inoperable chronic throm- the 6-minute walk test is commonly used for this boembolic PH revealed that exercise Vt.rOai2pneinakg purpose. Interpretation of walk test scores must increased the 6-minute walk distance and consider confounding factors that can in uence within three weeks of program initiation, which test results, such as age and musculoskeletal func- was generally maintained in studies of 12- to tion; therefore general recommendations, rather 15-week duration (319). Further, the meta-analysis than speci c targets, are most useful in under- (319) revealed improved quality of life and physical standing the V.fuOn2pcteiaoknaolf capacity of individuals functioning following 15 weeks of training. The with PAH. A more than 15 ml · kg−1 · exercise protocols generally consisted of a combi- min−1 and a 6-minute walk test result of >500 m nation of aerobic activity (i.e., treadmill walking, (547 yd) are considered factors that contribute to stationary cycling, or both) and resistance train- a “stable and satisfactory” prognosis. In younger, ing. Some studies included speci c respiratory more physically healthy individuals, >500-m muscle training and mental training. While Yuan (547-yd) walk distances may be achieved even by and colleagues (319) demonstrated that exercise is those with severe PAH, which makes this test less bene cial for those with PH, the meta-analysis was meaningful in this population. limited to speci c PH populations, which yielded Various measurements obtained during exercise only 12 studies (449 individuals). have been demonstrated to be a better predictor of Details of individual exercise protocols vary, long-term s(u14r1v)i.vDaluthrianngreexsetirncgispeu, almloownaVr. yOh2peemaok-, dynamics but many share similar underlying structure. A high PVR, and a small change in heart rate relative commonly followed model of exercise program- to rest are all associated with poorer prognosis in ming in PH studies is three weeks of in-hospital individuals with PAH (312). Additionally, cardiac training followed by 12 weeks at home. The initial index (cardiac output divided by body surface three weeks allows clients to become familiar area) during exercise, but not rest, is related to with correct exercise techniques, learn how to aerobic function in PAH, and is one of the key gauge proper intensity, and build con dence predictors of survival in PAH (59, 141). Likewise, in their ability to perform the exercise. These the relationship between mean PAP and cardiac initial three weeks may also include some edu- output during exercise is linked to transplant- cational components regarding the importance of free survival of PH (141). Pulse oximetry values adhering to the program and understanding the that drop more than 10% below resting levels are expected bene ts. It may be bene cial to collect also associated with poorer prognosis. baseline and posttraining outcome data related to physical tness (i.e., the 6-minute walk test) and
Pulmonary Disorders and Conditions | 159 quality of life following the initial few weeks of Given the previously described respiratory training to determine if the program is effective muscle dysfunction in PAH (76, 207, 214), speci c and to assist in convincing the client of the value respiratory muscle training may be of particular of exercise. bene t to clients with PH and has been included as a component of many of the training studies (319). The components of exercise protocols also Kabitz and colleagues (168) reported improved share many similarities. Mereles and colleagues respiratory muscle strength and exercise capacity (206) performed the rst major trial on the com- following 15 weeks of a combination of exercise bination of exercise and respiratory training in and respiratory training in clients with PAH. Like- severe PH. This protocol used interval training wise, Saglam and colleagues (253) reported that on a cycle ergometer, alternating between 30 six weeks of inspiratory muscle training improved seconds of lower-intensity and 60 seconds of pulmonary parameters, 6-minute walk distance, higher-intensity exercise for 10 to 25 minutes fatigue severity, and dyspneic symptoms. per day in an in-patient setting. In that protocol, the higher-intensity training was 60% to 80% of Despite the evidence supporting the ef cacy of heart rate achieved during initial maximal exer- exercise training for improving exercise capac- cise test. Limitations for exercise intensity were ity and activities of daily living for clients with based on the client’s subjective physical exertion, PH, the number of randomized controlled trials a peak heart rate not more than 120 beats/min, remains small, with insuf cient data to de ne and pulse oximetry values greater than 85%. optimal factors such as intensity, duration, and Additionally, participants walked 60 minutes mode, and so there is no consensus on speci c per day, performed 30 minutes of light resistance guidelines for exercise programming for clients training, and did 30 minutes of speci c respira- with PH (119). In general, it is recommended that tory muscle training ve days per week. Upon clients with PH should be physically active within discharge, individuals were asked to continue the tolerance of their symptoms (118) and perform a similar routine, albeit for slightly decreased a combination of sustained light- to moderate-in- duration and frequency. tensity workloads (20), speci c respiratory muscle training, and resistance training. These programs Subsequent exercise protocols for PH have are typically aimed at improving physical func- used both interval and continuous training and tion and quality of life. It is also recommended have varied the approach to the aerobic exercise that these clients undergo medically supervised component. For instance, Chan and colleagues testing to determine their symptom thresholds (57) and Weinstein and colleagues (311) had indi- for exercise intensity and duration before initiat- viduals walk for 30 to 45 minutes at 70% to 80% ing an exercise program. High-intensity aerobic of heart rate reserve two or three times per week, or resistance training that exacerbates a client’s while Grünig and colleagues (134) combined cycle symptoms or could elicit the Valsalva maneuver ergometer interval training and walking similarly should be avoided (119). However, it must be to Mereles (206). Fox and colleagues (113) took noted that exercise programs may be speci c to the approach of prescribing interval training for each subtype of PH. Further, exercise is often the rst six weeks of rehabilitation, followed by performed in combination with pharmacotherapy. continuous aerobic exercise in the second six weeks of rehabilitation, and included stair climb- Key Point ing in both components of the program. Such an approach may be useful for clients who are not Exercise training programs for clients with able to initially engage in long periods of con- pulmonary hypertension commonly include tinuous activity. In addition, the general skeletal the combination of light- to moderate-intensity muscle dysfunction that has been associated with training, specific respiratory muscle training, and PAH (319) indicates that inclusion of resistance resistance training. Importantly, clients should training in many published training protocols is be tested in a medically supervised environment justi ed (319). to determine their symptom thresholds before beginning an exercise program.
Case Study Pulmonary Hypertension A 63-year-old generally sedentary male with heart rate of 108 beats/min and had a pulse a body mass index (BMI) of 28 kg/m2 initially presented to his general practitioner with Vo.xOi2mmetarxytreesatidnign.gHoef 92%. He did not undergo a chief complaint of breathlessness while was prescribed exercise at engaging in physically demanding activities, such as mowing the lawn and other infrequent a target heart rate between 105 and 140 beats/ laborious tasks. A physical exam revealed hypertension, but no other obvious signs of min. He began walking for exercise, gradually cardiovascular disease. Referral to a cardiolo- gist to address the cause of dyspnea revealed progressing from 15 minutes to 30 minutes, mild left ventricular dysfunction and PH, based on diagnostic imaging ndings. The client did four days per week. Additionally, he underwent not undergo catheterization or other invasive diagnostic procedures. Given that he was not supervised exercise training twice per week, dyspneic during lighter-intensity activity (e.g., walking the dog), he was considered to be in the during which he performed stationary cycling. relatively early stages of disease. He was pre- scribed an antihypertensive agent, encouraged The cycling was continuous intensity for the to make dietary modi cations, and encouraged to engage in a more physically active lifestyle rst two weeks, during which he averaged 105 to slow progression. He was referred to an outpatient clinic to undergo supervised exer- to 112 beats/min for 20 minutes, with mild cise training, where he underwent exercise testing. He achieved 625 m (684 yd) in the dyspnea at higher intensities. Interval training 6-minute walk test, in which he achieved a was then incorporated into his exercise routine, consisting of 2 minutes of higher intensity (115- 125 beats/min) with 3 minutes of light pedaling as active recovery. Additionally, he performed three sets of deep breathing exercises at the end of each supervised training session. Over the course of six weeks, he progressed to 30 min- utes of continuous cycling, averaging 115 beats/ min without dyspnea. He reported that his symptoms of breathlessness during mowing the lawn and strenuous housework were reduced considerably, though not entirely absent. Recommended Readings Galiè, N, Humbert, M, Vachiery, JL, Gibbs, S, Lang, I, Torbicki, A, Simonneau, G, Peacock, A, Noordegraaf, AV, Beghetti, M, and Ghofrani, A. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 37:67-119, 2016. Newman, J and Robbins, I. Exercise training in pulmonary hypertension. Circulation 14:1448-1449, 2006. Pandey, A, Garg, S, Khunger, M, Garg, S, Kumbhani, DJ, Chin, KM, and Berry, JD. Ef cacy and safety of exercise training in chronic pulmonary hypertension: systemic review and meta-analysis. Circ Heart Fail 8:1032-1043, 2015. Pulmonary Hypertension Association. Recommendations for exercise in patients with PAH. 2016. www. phassociation.org/Patients/ExerciseConsensus. Accessed November 1, 2016. Yuan, P, Yuan, XT, Sun, XY, Pudasaini, B, Liu, JM, and Hu, QH. Exercise training for pulmonary hyperten- sion: a systematic review and meta-analysis. Int J Cardiol 178:142-146, 2015. 160
Pulmonary Disorders and Conditions | 161 CHRONIC OBSTRUCTIVE Pathology of COPD PULMONARY DISEASE Chronic obstructive pulmonary disease is char- Chronic obstructive pulmonary disease (COPD) acterized by progressive emphysema, chronic is a progressive lung disease characterized by bronchitis, or both, and results in decreases in emphysema and chronic bronchitis, which FEV1 and FEV1/FVC (forced vital capacity). These decrease lung function. There is no known cure, declines reflect both the reduction in exhalation and only heart disease and cancer kill more force available and decline in lung capacity as a Americans than COPD. In the United States, result of emphysema and obstruction to airflow more than 11 million people have been diagnosed in the smaller airways. Chronic obstructive with COPD while millions more are affected but pulmonary disease is characterized by airway undiagnosed (11). Worldwide, COPD mortality is wall thickening and by inflammatory cells in rising (10), and the disease is responsible for over the airways. Neutrophils, T lymphocytes, and $36 billion in annual health care costs (9). Women B lymphocytes are all present and contribute are 37% more likely to have COPD than men, and to lung function decline. However, airway wall about half of the deaths are in women (10). The thickening is strongly related to the progression number of individuals with COPD has increased of COPD (151). As COPD progresses, small air- by approximately 41% since 1982 (266). ways become occluded by inflammatory mucus, which is a defining feature of chronic bronchitis. Currently, smoking cessation is the only inter- Obstruction of the small airways in COPD occurs vention that has conclusively been shown to slow by remodeling that is related to tissue repair and the rate of lung function decline (286). Symptoms attenuated mucociliary clearance (151). include chronic cough, sputum production, shortness of breath, exercise intolerance, muscle Pathophysiology of COPD wasting, gas trapping, and frequent respiratory infections (266). Eighty to ninety percent of COPD is related to smoking while the remainder is likely due to envi- Treatment is typically SABAs, LABAs, anticho- ronmental exposure to toxic gases and particles linergics, ICSs, or a combination of these drugs (218). Despite the effects of smoking, Salvi and (217). Additionally, individuals should have an Barnes (257) presented data suggesting that the annual u shot and the pneumococcal vaccine burden of nonsmoking COPD is much higher than (217). Diagnosis of comorbid COPD and asthma previously believed; an estimated 25% to 45% of occurs in 15% to 20% of individuals (189, 192, individuals with COPD have never smoked. Other 200, 270). These individuals tend to experience factors that have been associated with COPD more rapid disease progression than those with include exposure to air pollutants such as dust, either disease alone (123, 170). Bronchial hyper- cooking fumes, and internal combustion fumes; responsiveness and the diagnosis of asthma have a history of repeated lower respiratory tract infec- been associated with greater decline in FEV1 in tions during childhood; pulmonary tuberculosis; both smokers and nonsmokers (181, 246, 284). chronic asthma; poor nourishment; poor SES; and The presence of BHR in individuals with COPD an alpha-1 deficiency (12). Sood and colleagues has been associated with an increase in exacer- (269) reported that exposure to wood smoke was bations and mortality (157), and the coexistence associated with a 70% increased risk of COPD in of asthma and COPD is associated with increased both men and women in the United States, and health care utilization (271). that this association remained even after adjust- ment for age, tobacco smoking, and educational Key Point attainment. Likewise, biomass or coal cooking has been identified as high risk for COPD in low- and Chronic obstructive pulmonary disease (COPD) middle-income countries (126). is a progressive inflammatory lung disease that causes airflow obstruction due to thickened Airway in ammation also plays an important airway walls and inflammatory mucus due to the role in disease progression (82, 127, 128, 151, 235). effects of emphysema and chronic bronchitis. The intensity of in ammation relates to the degree
162 | NSCA’s Essentials of Training Special Populations of air ow obstruction (82), and may result from cells to prevent tachyphylaxis (265). The combina- oxidant-induced damage. About 3% of all COPD tion also facilitates translocation of glucocorticoid cases can be attributed to a genetic de ciency of receptors into the nucleus of in ammatory cells, alpha-1 antitrypsin, a condition that occurs in thereby amplifying the anti-in ammatory activity about 1 in 1,500 to 3,000 Americans of European of the corticosteroid (265). Combination therapy descent. The main function of alpha-1 antitrypsin of a LABA with an ICS improves symptom scores is to protect the lungs from in ammation caused and reduces exacerbations by a third compared by infection and inhaled irritants (130, 299). to a placebo (265). Common Medications Given Histone deacetylase-2 (HDAC-2) is signi cantly to Individuals With COPD reduced in airway tissue from individuals with COPD compared with healthy nonsmokers (196). Inhaled SABAs are referred to as a “rescue” med- Histone deacetylase-2 has also been implicated ication and used as needed. In some cases, how- in sensitivity to corticosteroids and plays a key ever, inhaled SABAs are used daily. For example, role in suppressing in ammatory expression in albuterol and levalbuterol are often prescribed to the airways (282). Increasing HDAC-2 expres- be used as needed, while ipratropium, an anticho- sion, activation, or both can be an approach to linergic drug, is used as a standalone drug or in reversing corticosteroid resistance in COPD (165). combination with albuterol (Combivent). Further, p38-kinase activity increases (42, 204) and interleukin production decreases (42, 58) Inhaled LABAs are used daily and should not in individuals with COPD. (Interleukin causes be used as rescue medication for an acute exac- neutrophils to migrate, in this case, into the air- erbation because they do not immediately open ways.) Another change includes a considerable the airways. Long-acting β2-agonists, such as sal- increase in phosphatidylinositol-4,5-bisphosphate meterol, formoterol, and arformoterol, are inhaled 3-kinase (PI3K) activity in individuals with COPD twice daily and provide 12 hours of bronchodi- (156). The result is a loss of sensitivity to ICSs (42). lation. Indacaterol is also a LABA that provides 24-hour protection with a single dose, whereas A summary of medications given to individuals tiotropium is a long-acting 24-hour anticholiner- with COPD is found in medications table 5.4 near gic bronchodilator. the end of the chapter. Inhaled corticosteroids act as an anti- Effect of Exercise in in ammatory medication and are often used in Individuals With COPD combination with a LABA and are taken twice daily. Examples include Advair ( ovent and sal- Exercise is considered an essential component meterol), Dulera (mometasone and formoterol), of pulmonary rehabilitation in individuals with Symbicort (budesonide and formoterol), and COPD (75, 120, 184, 220, 254). Decreased exercise Breo ( uticasone and vilanterol). Daily ICS treat- capacity and loss of muscle strength disable an ments are used to stabilize symptoms and reduce individual with COPD, increase time off work, in ammation and mucus production, especially increase social isolation, and contribute to mor- with individuals who have chronic bronchitis. tality (78, 300). Exercise training by individuals A number of studies have shown ICSs to be less with COPD can increase exercise capacity and ef cacious in COPD (29, 186, 225, 258), but an improve quality of life, both socially and during ICS combined with a LABA has bene cial airway daily activities (120). Additionally, an aerobic anti-in ammatory effects not seen with ICSs alone endurance exercise training program has been (72). The combination of an ICS with a LABA bron- found to decrease systemic inflammation with a chodilator improves lung function and decreases decrease in serum C-reactive protein and interleu- exacerbations as well as the frequency of rescue kin (303). The observed decreased dyspnea from medication use (40, 140, 215, 222). Long-acting an exercise training program in this population β2-agonists and corticosteroids may interact to is not the result of improvement in lung function prevent downregulation of β2-receptors in airway but rather from peripheral changes (303).
Pulmonary Disorders and Conditions | 163 Exercise Recommendations weakness is one of the extrapulmonary manifes- for Clients With COPD tations of COPD (323). Although several studies have shown improve- Resistance training, aerobic endurance train- ment in peripheral muscle strength, gas exchange, ing, and a combination resistance and aerobic and aerobic endurance capacity with exercise endurance training program have similar ef cacy interventions, there is no consensus on the opti- for clients with COPD (160). As such, the program mal exercise program, as intensity and duration can be designed around the client’s preference to should be individualized to reflect the severity of maximize compliance. Improvements in exercise symptoms (120) (see table 5.4). The addition of tolerance and an increase in muscle strength are resistance training to aerobic training in clients indicative of a successful rehabilitation program. with COPD (120) (see table 5.5) is associated with significantly greater increases in muscle Key Point strength and mass, but does not provide additional improvement in exercise capacity, dyspnea, or It is important that clients who have COPD quality of life (37, 323). However, the addition of follow both an aerobic training program and resistance training to an aerobic endurance pro- a resistance training program to improve their gram seems a reasonable strategy since muscle quality of life. Table 5.4 General Aerobic Exercise Guidelines for Clients With COPD Parameter Guideline Frequency 3-5 days per week Intensity 30-80% of peak work rate* Mode Walking or cycling Duration 20-60 min/session* *Intensity and duration of exercise should be individualized to reflect the severity of symptoms. Reference: (120) Table 5.5 General Resistance Training Guidelines for Clients With COPD Parameter Guideline Frequency 2-3 days per week Intensity Light to moderate; 40-80% 1RM Repetitions 8-12 Sets 1-4 Rest periods between sets 2-3 min Exercises 8-12 mostly large muscle groups and multijoint Reference: (120)
Case Study Chronic Obstructive Pulmonary Disease Mr. B is 60 years old and played ice hockey from due to work and family obligations. As a result, a very young age through college. Thereafter, he he gained about 40 pounds (18 kg), and he began exercised daily and competed in running and to notice that it was more dif cult going up stairs cross-country ski races through his 20s and 30s. and that he was short of breath even with just light He grew up in a house where both parents were physical activity. He attributed this to old age and smokers, and he remembers long rides in the car the extra body weight. He also noticed that he with the windows up and his parents smoking. was constantly coughing, and he had contracted When Mr. B began cross-country ski racing, it pneumonia three times in the last four years. did not take too long before he was winning and training long hours. He began to develop With encouragement from his wife, Mr. B a postrace hack and seemed to be sensitive to scheduled an appointment with a pulmonologist. the volatilized fumes in the ski wax room, a Findings demonstrated that his FEV1 was 63% place that he frequented on a daily basis. After of predicted values with an FEV1/FVC ratio of 15 years of living in Vermont, heating with 68%. The reduced FEV1 of 63% of predicted value wood, and spending most winter nights in the coupled with the FEV1/FVC ratio less than 0.70 wood-burning sauna, his family moved south. suggests that Mr. B may have moderate COPD according to the Global Initiative for Chronic Over time, Mr. B gradually stopped exercising Obstructive Lung Disease criteria (table 5.6). Table 5.6 Classification of COPD for Individuals With FEV1/FVC Ratios Less Than 0.70 Classification Post-bronchodilator FEV1 reading (% of predicted) Mild ≥80% Moderate 50-79% Severe 30-49% Very severe <30% Adapted, by permission, from Global Initiative for Chronic Obstructive Lung Disease, 2016, Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Recommended Readings Iepsen, UW, Jørgensen, KJ, Ringbaek, T, Hansen, H, Skrubbeltrang, C, and Lange, P. A systematic review of resistance training versus endurance training in COPD. J Cardiopulm Rehabil Prev 35:163-172, 2015. National Heart, Lung, and Blood Institute. What Is COPD? 2014. www.nhlbi.nih.gov/health/health-topics/ topics/copd/. Accessed January 27, 2017. Pothirat, C, Chaiwong, W, Phetsuk, N, Liwsrisakun, C, Bumroongkit, C, Deesomchok, A, Theerakittikul, T, and Limsukon, A. Long-term ef cacy of intensive cycle ergometer exercise training program for advanced COPD patients. Int J Chron Obstruct Pulmon Dis. 10:133-144, 2015. Salvi, SS and Barnes, PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet 374:733-743, 2009. Spruit, MA, Singh, SJ, Garvey, C, ZuWallack, R, Nici, L, Rochester, C, Hill, K, Holland, AE, Lareau, SC, Man, WDC, and Pitta, F. An of cial American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 188:e13-e64, 2013. Wootton, SL, Ng, LC, McKeough, ZJ, Jenkins, S, Hill, K, Eastwood, PR, Hillman, DR, Cecins, N, Spencer, LM, Jenkins, C, and Alison, JA. Ground-based walking training improves quality of life and exercise capacity in COPD. Eur Respir J 44:885-894, 2014. 164
Pulmonary Disorders and Conditions | 165 CHRONIC RESTRICTIVE 3 to 6 cases per 100,000 for intrinsic lung diseases, PULMONARY DISEASE the prevalence for idiopathic pulmonary brosis (IPF) is 27.9 to 63 cases per 100,000 (234). The Restrictive disease occurs from conditions that prevalence for adults aged 35 to 44 is 2.7 per cause the restriction of lung expansion, loss of 100,000 and 175 cases per 100,000 for adults lung tissue, and a decrease in gas diffusion both older than 75 years of age (273). In the United in and out of the lungs. Dyspnea is compensated States, the prevalence of sarcoidosis is 10 to 40 per for by rapid breathing and shallow breaths. 100,000 and is 10 to 17 times higher in African Chronic restrictive pulmonary disease (CRPD) Americans (273), with 1 in 10,000 persons having is characterized by a decrease in total lung capac- severe kyphosis (273). ity (TLC), a modestly preserved FEV1, airway resistance, and a decreased FVC that result in Therapy of CRPD a FEV1/FVC ratio greater than 80%. Restrictive lung disease is also characterized by a reduction Treatment strategies for CRPD are on an individ- in functional residual capacity (FRC, the volume ual basis depending on disease severity, stability, of air in the lungs when respiratory muscles are and clinical history. Nonpharmacological treat- fully relaxed). ments focus on avoiding airborne irritants (e.g., combustion exhaust and airborne trichloramines Pathology and from indoor pools) and ceasing smoking and Pathophysiology of CRPD exposure to second-hand smoke, maintaining blood oxygen levels over 90% (as measured by Individuals with CRPD and disorders of the pul- pulse oximetry), participating in a structured monary parenchyma (the covering of the lungs) exercise program (including breathing exercises, may experience increased effort of breathing and anxiety management, nutritional counseling, and an exercise-related desaturation from a decreased health education), and considering flu and pneu- gas transfer. In disorders of the pleura and tho- monia vaccinations. racic cage, the abnormal compliance of the res- piratory system results in a ventilation–perfusion For individuals who have end-stage CRPD mismatch and desaturation. Severe conditions of and have exhausted their treatment options with the spine, such as kyphosis, can result in respira- no attenuation of disease progression, a lung tory failure and obesity and have been shown to transplant is an option. The number of lung dramatically reduce FRC (166). transplants performed each year in the United States is 1,400 with 2,000 on a waiting list at any Restrictive diseases are generally classi ed as given time (142). The 1-year survival rate after intrinsic or extrinsic (table 5.7). Intrinsic restrictive a lung transplant is about 90% with the 5-year disease is characterized by general brosis of lung survival rate of approximately 55%; only 33% parenchyma, while extrinsic resistive disease may survive 10 years (142). The median survival rate involve the chest wall, pleura, respiratory muscles, or for adult recipients of a dual lung transplantation neuromuscular disorders. Dust, gases, fumes, ber- is 5.7 years, with bilateral transplants having a glass, and asbestos are occupational and environ- better survival rate of 7 years (320). The primary mental irritants that can cause CRPD. Additionally, reason that individuals die from lung transplants radiation, medications, poisons, and autoimmune is because of chronic rejection and subsequent responses all have been linked to CRPD. deterioration of the transplanted lung. However, immunosuppression decreases the effectiveness The prevalence and incidence of these condi- of the immune system, leaving the individual tions vary. While there is an overall prevalence of vulnerable to infections.
166 | NSCA’s Essentials of Training Special Populations Table 5.7 General Classifications of Intrinsic and Extrinsic Restrictive Pulmonary Diseases Disease or condition INTRINSIC Pneumoconiosis Cause or description Radiation fibrosis Condition due to dust or environmental exposures (e.g., asbestosis, black lung, siderosis). Hypersensitivity pneumonitis A complication of radiation treatment. Acute respiratory distress syndrome Allergic reaction to inhaled particles. Widespread inflammation triggered by another disease such as pneumonia or from Infant respiratory distress syndrome trauma. A developmental insufficiency of surfactant in the lungs. It is the leading cause of death Tuberculosis in premature infants. An infectious disease that is more common in individuals with HIV/AIDS and those who Idiopathic pulmonary fibrosis smoke. Approximately 5-10% of the U.S. population tests positive. Idiopathic interstitial pneumonia No known cause. Involves the pulmonary interstitium and is associated with smoking. Sarcoidosis Affects the pulmonary interstitium. May be related to pneumonia or drug toxicity. Eosinophilic pneumonia Can affect any organ and may be due to an abnormal immune response. High eosinophils; cause can be medication or an environmental trigger, parasitic Lymphangioleiomyomatosis infection, cancer, or immune response. Rare systemic disease that causes cystic lung destruction. Predominately in young Langerhans cell histiocytosis women with tuberous sclerosis complex. Rare disease that occurs almost exclusively in cigarette smokers. Abnormal proliferation Alveolar proteinosis of Langerhans cells that results in fibrosis. Rare disease characterized by accumulation of surfactant in alveoli, disrupting gas Disease or condition exchange. Trigger can be environmental exposure, malignancy, or lung infection. Kyphosis, pectus carinatum, pectus excavatum EXTRINSIC Obesity, diaphragmatic hernia, ascites Cause or description Nonmuscular diseases of upper thorax. Lungs may not function optimally and gas exchange can be affected. Obesity has been associated with asthma and affects tidal volume while breathing. Ascites is the accumulation of fluid in the peritoneal cavity usually caused by cirrhosis or liver disease. Reference: (49) Common Medications Given suppression, and weight gain (4-6, 297). Further, to Individuals With CRPD Hanada and colleagues (139) found that long-term OCS treatment contributed to muscle weakness in The pharmacological treatment of CRPD includes individuals with interstitial lung disease. A com- corticosteroids, cyclophosphamide, nintedanib, bination of an ICS and a LABA has been shown to pirfenidone, and supplemental oxygen therapy. decrease frequency and severity of acute episodes Oral corticosteroids are used to suppress the and improve lung function in individuals with immune system and decrease inflammation and combined IPF and emphysema (86). are often supplemented with co-trimoxazole and macrolides for individuals with IPF who have Cyclophosphamide suppresses in ammation a rapid progression of respiratory failure (226). and has been used to treat certain forms of pul- Unfortunately, OCS use has been associated with monary brosis. Cyclophosphamide treatments increased risk of fracture and cataracts, adrenal result in lung function stabilization in most indi- viduals with brotic interstitial lung disease (260).
Pulmonary Disorders and Conditions | 167 The drug is predominately taken orally but may · min−1, tidal volume reserve of 0.48 L/breath, also be administered intravenously. Nintedanib and a minute ventilation-to-carbon dioxide ratio is an anti brotic kinase inhibitor drug approved at the anaerobic threshold of 34 as cutoff points to treat IPF in the United States. In clinical trials, associated with mortality in individuals with IPF. nintedanib has been shown to slow the decline in Leuchte and colleagues (185) found that comorbid lung function in mild-to-moderate IPF (245). Pir- PH signi cantly contributed to exercise limita- fenidone is an anti brotic and anti-in ammatory tions in individuals with severe lung brosis and drug approved to treat IPF in the United States, suggested that treatment of PH may be bene cial Europe, Canada, and Asia. In clinical trials, pir- in these individuals. fenidone has been shown to slow progression of mild-to-moderate IPF (262). Cardiopulmonary exercise testing (CPET) for exercise tolerance evaluation should be done to Supplemental oxygen therapy is also a treat- aid in diagnosis and prognosis as well as for devel- ment strategy for CRPD. Because scar tissue oping effective targeted treatments. Cardiopulmo- in the lungs diminishes movement of oxygen nary exercise testing can identify the presence of from the alveoli to the bloodstream and carbon comorbidities in approximately 38% of individuals dioxide from the blood to the alveoli, oxygen with IPF (291). Resting cardiopulmonary function levels decrease in the blood in individuals with can show moderate pulmonary restriction and CRPD. Therefore, supplemental oxygen might be impairments in diffusion capacity. Multifactorial prescribed, but if oxygen levels are always low limitations for a moderately diminished aerobic (<90%), then continuous supplemental oxygen capacity can be revealed during CPET, although may be required. functional capacity can be normal. In a study by Vainshelboim and colleagues (291), aerobic A summary of medications given to individuals capacity of 13.4 ml · kg−1 · min−1 (62% of predicted) with CRPD is found in medications table 5.5 near was reduced with the presence of abnormalities the end of the chapter. in pulmonary gas exchange and desaturation, circulatory impairments, inef cient ventilation, Effects of Exercise in and skeletal muscle dysfunction; however, func- Individuals With CRPD tional capacity measured by the 6-minute walk test was normal (distance = 505 m [552 yd], 99% Pulmonary fibrosis is characterized by dimin- of predicted). ished exercise capacity due to progressive pul- Key Point monary restriction, decreased FVC, ventilatory People who have CRPD benefit from cardio- pulmonary exercise testing because the results inefficiency, impaired gas exchange, low oxygen reveal an individual’s tolerance for exercise, which is an important factor to consider when saturation, and dyspnea (205, 241). A characteris- developing an effective exercise program. tic of IPF is lowered arterial oxygen pressure and In another study, Porteous and colleagues (237) suggested that right ventricular morphology, saturation during exercise (152, 180). Exercise pulmonary vascular resistance, and FVC may improve exercise capacity in individuals with is typically recommended for individuals with IPF. They found that right ventricular dilation was associated with a decrease of 50.9 m (56 lung disease although it may not improve fibrotic yd) in the 6-minute walk test. For each 200-ml reduction in FVC, the walk distance decreased by scarring. It will, however, improve the cardio- 15 m (16 yd) (237). vascular system and the ability of the muscles to use oxygen and decrease symptoms of dyspnea, thereby allowing a higher quality of life (88). Exercise is also helpful in preventing the decondi- tioning and weakness that occur when individuals with CRPD become less active due to dyspnea. Exercise capacity is generally related to the severity of the disease. Vainshelboim and col- lweaatgtuse(s37(299k2g) mid/emnitni ),eVd. Oa2ppeeaakk work rate of 62 of 13.8 ml · kg−1
168 | NSCA’s Essentials of Training Special Populations Exercise Recommendations clients with IPF (despite disease progression) or for Clients With CRPD brotic sarcoidosis (279). After completion of the Current evidence indicates that exercise training 12-week program, exercise capacity (as measured in clients with CRPD is safe and beneficial at by the 6-minute walk test) improved by 10% in improving dyspnea and measures of quality of 13 of 24 subjects (54.2%), 7 with IPF and 6 with life (88, 290). Whole-body exercise training is a sarcoidosis (279). primary component of pulmonary rehabilitation for interstitial lung disease (ILD), and the stand- The 6-minute walk test has been shown to be ard exercise prescription for other chronic lung a valid and responsive endpoint that can provide diseases is effective in ILD. The program often objective and clinically relevant information about includes eight weeks of training with at least two the functional status and prognosis of clients supervised sessions per week and a minimum with IPF. An analysis of 338 individuals with 30 minutes of aerobic training in each session. IPF showed that a baseline 6-minute walk test However, the unique presentation and underlying was signi cantly correlated with lung function pathophysiology of ILD can require modifications measurements, patient-reported outcomes, and in exercise prescription. Clients with connective quality of life measures. Compared to the base- tissue disorders may present with joint pain that line, a change in the 6-minute walk test showed requires alterations in exercise, which may involve stronger correlations with change in lung function a reduction in weight-bearing exercise. Clients measurements and quality of life measures (216). with severe disease may present with severe dysp- V.OI2m, lparcotvaetemtehnrtessihnodldy,spanndeaq, u6a-mlitiynuotfelwifealskctoersets, nea that can limit the intensity of exercise and have been noted from pulmonary rehabilitation training progression. Because exercise-induced exercise programs in clients with IPF (77, 289, hypoxemia is common in ILD and is more severe 293, 294). Pulmonary rehabilitation programs than seen in other chronic lung diseases, reha- can also improve body composition and help bilitation programs should include supplemental the client maintain an appropriate body weight. oxygen therapy. Pulmonary rehabilitation pro- Excess body weight can increase dyspnea during grams should also offer the opportunity to address daily activities and affect the overall health of the management of comorbidities, symptoms, and the client as discussed in other chapters. Clients psychological factors (153). with IPF and a BMI of >30 kg/m2 who received a bilateral lung transplant were 1.71 times more It has been shown that a three-month rehabilita- likely to die within 90 days than bilateral lung tion program can signi cantly improve symptoms transplant recipients with a BMI of 18.5 to 30 and physical activity levels in clients with IPF kg/m2 (131). Rehabilitation programs can be (122). This investigation also showed that while inpatient, outpatient, or combined, or they can in the rehabilitation program, the rehabilitation be community-based programs. group maintained higher levels of physical activity throughout the three-month program than the Given that CRPD refers to many diseases that control group. Also, symptom scores improved by are collectively grouped, research to determine 9 ± 22 in the rehabilitation group and worsened exercise guidelines typically focuses on one of in the control group (16 ± 12) (122). During a these conditions. This restricts the capacity to three-month follow-up in that study, self-reported provide, or at least raises caution about providing, physical activity levels (i.e., a metabolic equivalent global exercise prescription recommendations of task-minutes) in the rehabilitation group were for clients with CRPD. At a minimum, it is rec- not different than those of the control group, ommended that clients with CRPD be tested in a demonstrating reversal of activity in the rehabil- medically supervised setting to determine their itation group; however, scores after the 6-minute symptom thresholds for exercise intensity and walk tests did not change signi cantly. duration before initiating an exercise program, and that an individualized training plan based on A 12-week physical training program has been these results be designed and implemented by a shown to improve or maintain exercise capacity in quali ed exercise professional.
Case Study Chronic Restrictive Pulmonary Disease Mr. J, a 69-year-old male with rheumatoid mented. Treatment involved pharmacological arthritis, presented at his annual checkup with interventions for mild-to-moderate IPF and a 10-month history of respiratory symptoms that an antidepressant. Mr. J was vaccinated for included thoracic pain, chronic dry cough, and in uenza and pneumococci and referred to an dyspnea upon exertion. His history included outpatient rehabilitation center. six years of working construction, where he had repeated exposure to berglass insulation Mr. J’s exposure to tobacco smoke, berglass, and asbestos. Mr. J also grew up in a smoking and asbestos should not be ignored, especially household. He also had a smoking history of considering his reported dyspnea during exercise approximately eight years after college but and initial test results. His subsequent test results managed to quit. At age 32, he began an exercise suggested IPF. His smoking and environmental program, and after 20 years he stopped exercis- exposure combined with dyspnea, chronic cough, ing because of work and life demands. At 64, he and rheumatoid arthritis were suggestive of DIP, began exercising again and could not believe while the CT scan indicated emphysema. how hard it was to get back in good physical condition. He began with a walking program ve The pulmonary rehabilitation program days per week and after about six months began should include exercise training, nutritional jogging, but he got very dyspneic. He thought it counseling, energy-conserving techniques, was probably the extra weight he had put on, but breathing strategies, and psychological coun- as he lost weight, the dyspnea did not improve seling. The exercise program should be based and he gradually stopped exercising. on pulmonary function test results, a physical exam, 6-mi.nute walk test results, and perhaps Pulmonary function tests revealed a modest exercising VO2, oxygen saturation, and disease decline of 10% below predicted FEV1 with an stage. The program should include a plan to FVC of 78% of predicted. On subsequent visits, improve aerobic endurance and muscle strength Mr. J performed a 6-minute walk test (he covered to enable Mr. J to better carry out daily activities. 300 m [328 yd], with an exercise oxygen satu- The plan should include exercises for both arms ration of 84%), and a high-resolution computed and legs using a treadmill, stationary bike, or tomography (CT) chest scan was performed (it resistance training exercises. If long-duration revealed emphysema). Mr. J was diagnosed with exercise sessions are too dif cult, the plan may combined pulmonary brosis and emphysema involve short sessions repeated with rest breaks and desquamative interstitial pneumonia (DIP). in between. While Mr. J is exercising, his blood oxygen levels may be monitored with a pulse Treatment options were discussed and imple- oximeter attached to a nger. Recommended Readings Kagaya, H, Takahashi, H, Sugarwara, K, Kasai, C, Kiyokawa, N, and Shikoya, T. Effective home-based pulmonary rehabilitation in patients with restrictive lung diseases. Tohoku J Exp Med 218:215-219, 2009. Markovitz, GH and Cooper, CB. Rehabilitation in non-COPD: mechanisms of exercise limitation and pulmonary rehabilitation for patients with pulmonary brosis/restrictive lung disease. Chron Respir Dis 7:47-60, 2010. Troosters, R, Gosselink, R, Janssens, W, and Decramer, M. Exercise training and pulmonary rehabilitation: new insights and remaining challenges. Eur Respir Rev 19:24-29, 2010. Vogiatzis, I, Zakynthinos, G, and Andrianopoulos, V. Mechanisms of physical activity limitation in chronic lung diseases. Pulm Med 2012:634761, 2012. 169
170 | NSCA’s Essentials of Training Special Populations CYSTIC FIBROSIS occur (315). Cholestasis is also often present in individuals with CF and can cause cholelithiasis, Cystic fibrosis (CF) is one of the most common liver injury, and cirrhosis (174). It is hypothesized life-limiting autosomal recessive diseases in the that the obstruction of the vas deferens produces Caucasian population. As of 2015 there were azoospermia and infertility (242, 298). 28,983 people living with CF in the United States (69). In the 1960s, the predicted median age of Pulmonary disease is the leading cause of survival was 10 years; however, in 2015 it was 41.7 mortality and morbidity in individuals with CF years (69). From 2000 to 2015, the percentage of (36). Individuals born with CF have normal lungs, individuals in whom CF could be detected at birth but thick secretions are inadequately cleared from increased from 3.1% to 59.6% (69). the airways. The airways become in amed and injured, which leads to bacterial colonization. Pathology and Initially, infants are colonized with organisms Pathophysiology of CF such as staphylococcus aureus or haemophilus in uenza (267). Later in life, individuals with Cystic fibrosis is a multiorgan system disease CF are colonized with more virulent organisms caused by a mutation in a protein called the cystic such as pseudomonas aeruginosa (267), resulting fibrosis transmembrane regulator (CFTR), which in irreversible airway injury or bronchiectasis is located on the membrane of many cells and (a condition in which the walls of the bronchi allows chloride and water to move out of cells into are thickened from in ammation and infection), the lumen of many organs. Cystic fibrosis trans- which leads to deterioration in lung function and membrane regulator is located in cells that line potentially respiratory failure (242). The increased the airway, sinuses, pancreas, intestine, bile duct, airway in ammation causes hemoptysis that sweat gland, and vas deferens, which accounts for erodes into bronchial veins or arteries and may the clinical features. When the CFTR is defective, cause acute failure. secretions outside the cell are not hydrated with water. Secretions become thick and viscous and Individuals with CF develop cough, wheezing, may obstruct the organs. Local inflammation also and bronchitis as their airways are hyperreactive occurs, which may injure and destroy the cells. and bronchoconstrict in response to irritants, exercise, and viral and bacterial infections. As Almost all individuals with CF have signif- the disease progresses, they develop worsening icant sinusitis (74). In 85% of individuals, the lower airway obstruction and frequent exacerba- pancreas is destroyed and the digestive exocrine tions characterized by an increased cough with enzymes cannot be produced (26, 242). Pancreatic productive sputum, dyspnea, hemoptysis, dete- insuf ciency causes malnutrition, diarrhea, and rioration in lung function, and weight loss (111). fat-soluble vitamin de ciency. In the second to Because of their COPD, illness, and malabsorption third decades of life, pancreatic endocrine func- of vitamins and minerals, individuals with CF tion is often impaired and individuals develop can develop postural abnormalities such as tho- diabetes (87, 315). In the gastrointestinal tract, racic kyphosis, decreased bone mineral density, obstruction from viscous secretions may result musculoskeletal pain, and arthritis (22, 45, 230). in intestinal obstruction, and rectal prolapse may Therapy and Common Key Point Medications Given to Individuals With CF Clients who have CF are at a greater risk than others to have diabetes, so an exercise profes- Therapy for CF is characterized as preventive and sional, as directed by the client’s physician or rescue. The primary therapy is geared toward other health care professional, may need to improving mobilization of secretions, minimizing modify the client’s exercise program to account inflammation and lung injury, and decreasing for any limitations. bacterial colonization (195, 242). The cornerstone of CF therapy is chest physiotherapy (224). Chest
Pulmonary Disorders and Conditions | 171 physiotherapy may be performed individually by Effects of Exercise in controlled, active breathing and coughing exer- Individuals With CF cises. It may also be administered manually by a caregiver using percussion and postural drainage. Unfortunately, individuals with CF participate Mucous clearance can be augmented by vests that in fewer hours of vigorous physical activity than give high-frequency chest compression (112). their healthy counterparts (221). However, aero- Handheld devices may also increase clearance by bic and anaerobic physical training have positive providing oscillation or positive expiratory pres- effects on their exercise capacity, strength, lung sure to the airways (112). Playing a wind instru- function, and health-related quality of life (212, ment, singing, and jumping on trampolines have 240). Physical training has also been used to also been shown to be effective ways to promote improve sputum clearance and improve pulmo- mucous clearance (73). nary function (244, 322) and it may be as effective as conventional percussion and postural drainage A number of other agents are important in (55, 244, 321). maintaining pulmonary function and decreasing exacerbations in individuals with CF. Inhaled However, in individuals with CF, both the pul- hypertonic saline hydrates demonstrate ef cacy monary disease and malnutrition may limit the in improving clearance of secretions (243, 283). ability to exercise (64, 232, 288). Progressive lung Inhaled dornase alfa is used to reduce the viscosity disease is associated with ventilatory limitation of the purulent secretions to aid in clearance (132, and dyspnea. Individuals with severe lung dis- 209). Oral ibuprofen and corticosteroids have also ease can develop arterial hypoxemia and carbon been used to decrease in ammation (27, 209). dioxide retention with exercise (30, 104, 129). Persons with CF are at risk for severe dehydration Antibiotics are administered both preventively from exercise (177). They have elevated levels of and for exacerbations. For example, nebulized sodium chloride in their sweat and can develop antibiotics such as aminoglycosides are used to hyponatremic hypochloremic dehydration and decrease bacterial colonization in individuals colo- are also at risk for pneumothorax and hemoptysis nized with pseudomonas (100). Oral azithromycin, (103, 172). In addition, an individual with CF has which has anti-in ammatory and antibiotic prop- a higher than normal loss of sodium chloride in erties, may be given as a preventive measure (256). the sweat, which can lead to a diminished thirst For individuals with pulmonary exacerbations, drive and possible voluntary dehydration (177). oral antibiotics are routinely given (44); however, if there is no clinical improvement, then intravenous Exercise Recommendations antibiotics are typically prescribed (65). Finally, for Clients With CF ivacaftor targets the defective CFTR and improves lung function in individuals with CF. It is useful to have baseline cardiopulmonary exercise testing on clients with CF before begin- Nutritional support is of the utmost importance ning an exercise program in order to assess their in individuals with CF who have pancreatic insuf - current level of fitness and to enable effective exer- ciency associated with malabsorption of fats, vita- cise programming. Cardiopulmonary responses mins, and minerals. Better lung function has been to exercise, including intensity and duration of correlated to better nutritional status (268). Oral exercise before the onset of coughing or other pancreatic enzymes are commonly administered, symptoms, a baseline maximal heart rate, and as well as fat-soluble vitamins (A, D, E, and K) to a goal rate of perceived exertion (for subsequent improve lipid digestion and absorption in pancreatic- exercise prescription purposes), should be deter- insuf cient individuals with CF (39, 83, 85, 99). mined in this initial assessment (144). In addition, high-calorie nutritional supplements are routinely given because of the generally low The initial assessment should also include an nutritional status in these individuals (1). evaluation of the client’s posture, neuromuscular control of the muscles of the trunk (especially the A summary of medications given to individuals abdominal muscles, obliques, lumbar extensors, with CF is found in medications table 5.6 near the end of the chapter.
172 | NSCA’s Essentials of Training Special Populations and scapular retractors), and alignments of the (149), but it can be accomplished with heart rate monitoring, measures of dyspnea, or a Borg or spine, shoulder, scapulae, and rib cage. Clients OMNI scale of perceived exertion. The OMNI scale combines an exertion scale that is linked to with CF recruit abdominal muscles at lower a verbal and pictorial representation of increas- ing states of exertion ranging from not tired at workloads of exercise, earlier in the respiratory all (0) to very tired (10) [(149)]. Children with CF appear capable of using the OMNI scale to cycle, and to a higher recruitment level than cli- regulate exercise intensity (149). Initially, vital signs such as respiratory rate, oxygen saturation, ents without CF (56). Further, young adults with and rate of perceived exertion should also be monitored closely. CF have compromised plate-like axial trabecular Key Point morphology that may increase fracture independ- Ventilatory limitations and fluctuating health ent of normal bone mineral density (239). status will affect the ability of a client who has CF to determine intensity during an exercise A number of exercise programs for clients session. In conjunction with objective clinical monitoring, the client can use a Borg or OMNI with CF have demonstrated an increase in both scale to subjectively describe exercise intensity. aerobic and anaerobic capacity, improvement in Aerobic exercise should optimally include three to ve sessions per week and reach 70% of peak pulmonary function, and strengthened ventilatory heart rate for 20 to 30 minutes (259, 261); however, exercise should be terminated if the Borg scale muscles (23, 133, 145, 173, 261). Improved sputum reaches 7 (on a 10-point scale). If necessary, the intensity should be modi ed to allow 30 minutes clearance has also been related to exercise and in the target heart rate range. Ideal exercises are walking and cycling. The client should have a is likely a mechanical airway clearance from the cooldown period of light exercise for 10 minutes (68). See table 5.8 for a summary of the general increased exercising ventilation (182). However, aerobic exercise guidelines for clients with CF. moderate-intensity exercise has been shown to While some research evidence exists as to the ef cacy of resistance training for clients with CF block respiratory epithelial cell sodium channels, for improving various measures of strength and quality of life, there are currently insuf cient which could result in decreased mucus viscosity data to provide guidelines for optimal resistance and enhanced expectoration (143). V.MOo2 rmeoavxera,rea higher physical activity level and positively related to survival in CF (211, 236). Although most CF training studies have focused iomnparoevroedbilcuntgrafiunnicntgionan, dV.Oh2amveaxd, emonstrated dyspnea, and quality of life (259, 261, 287), anaerobic training may have different effects than aerobic training (43). Both aerobic and anaerobic training have been shown to improve muscle strength and muscle size, resulting in an increase in lean muscle mass (173, 227, 261). Therefore, the training program could include a variety of activities adapted to a client’s needs and preferences to promote compli- ance and consistency for the long term. Clients need to learn how to assess their own exertion level; this is often dif cult due to ven- tilatory limitations and uctuating health status Table 5.8 General Aerobic Exercise Guidelines for Clients With CF Parameter Guideline Frequency 3-5 days per week Intensity 40-70% of peak heart rate* Mode Walking, treadmill, cycling Duration 20-30 min Note: Maintaining adequate hydration pre-, during, and postexercise is very important. *Intensity should be modified to allow 30 minutes in target heart rate range. References: (259, 261)
Pulmonary Disorders and Conditions | 173 training prescription (233, 264, 295). Studies have reinforce the program and reassess tolerance in a largely individualized prescribed programming client with CF. Also, after any pulmonary exacer- based on initial testing results, and while the bations, the client’s exercise tolerance will need to weight of available evidence is positive, systematic be reassessed, and therefore a new program will reviews highlight that this individualized approach need to be devised. If the client with CF develops limits the ability to provide speci c guidelines. a new oxygen requirement, formal cardiopulmo- General guidelines include focusing on training the nary exercise testing should also be repeated. postural muscles (187, 197), making the loads pro- gressive (227, 255, 295), and mobilizing tight joints In addition, it is very important for clients with and retraining the muscles that support them. CF to maintain adequate hydration before, during, and after exercise. To aid with this, they should be Once an exercise program is implemented, it encouraged to exercise during the cooler morning is worthwhile to have a follow-up evaluation to or evening hours or go to an air-conditioned facility. Case Study Cystic Fibrosis Terrell, a 17-year-old male with CF, was referred 50 ml · kg−1 · min−1, which was 77% of predicted. He was instructed to use the cycle ergometer for an exercise program. Lung function testing for 30 minutes daily, keeping his targeted heart rate close to 110 beats/min and Borg score less revealed that he had a mild decrease in FEV1 of than 5. He was monitored during his exercise 2.96, which was 78% of his predicted normal for two weeks and intensities were adjusted as necessary. This would serve as one of his value. He underwent cardiopulmonary testing three daily recommended periods of chest physiotherapy. using bicycle ergometry and reached 120 watts (734 kgm/min) with a maximal heart rate of 145 beats/min. His Borg score Vw. Oa2spe6ak(ownaas 10-point scale) at maximum. His Recommended Readings Bradley, J and Moran, F. Physical training for cystic brosis. Cochrane Database Syst Rev 5:1-59, 2011. Cropp, GJ, Pullano, TP, Cerny, FJ, and Nathanson, IT. Exercise tolerance and cardiorespiratory adjustments at peak work capacity in cystic brosis. Am Rev Respir Dis 126:211-216, 1982. Dwyer, TJ, Alison, JA, McKeough, ZJ, Daviskas, E, and Bye, PT. Effects of exercise on respiratory ow and sputum properties in patients with cystic brosis. Chest 139:870-877, 2011. Mogayzel, PJ, Naureckas, ET, Robinson, KA, Mueller, G, Hadjiliadis, D, Hoag, JB, Lubsch, L, Hazle, L, Saba- dosa, K, Marshall, B, and the Pulmonary Clinical Practice Guidelines Committee. Cystic brosis pulmonary guidelines: chronic medications for maintenance of lung health. Am J Respir Crit Care Med 187:680-689, 2013. O’Neill, PA, Dodds, M, Phillips, B, Poole, J, and Webb, AK. Regular exercise and reduction of breathlessness in patients with cystic brosis. Br J Dis Chest 81:62-69, 1987. Radtke, T, Nolan, SJ, Hebestreit, H, and Kriemler, S. Physical exercise training for cystic brosis. Paediatr Respir Rev 19, 42-45, 2016. Ratjen, F and Tullis, E. Cystic brosis. In Clinical Respiratory Medicine: Expert Consult. 4th ed. Spiro, SG, Silvestri, GA, and Agusti, A, eds. Philadelphia: Elsevier, 568-579, 2012. Rowe, SM, Miller, S, and Sorscher, EJ. Cystic brosis. N Engl J Med 352:1992-2001, 2005. Zach, M, Oberwaldner, B, and Hausler, F. Cystic brosis: physical exercise versus chest physiotherapy. Arch Dis Child 57:587-589, 1982.
174 | NSCA’s Essentials of Training Special Populations CONCLUSION of EIB if appropriate understanding of the patho- physiology of the condition and corresponding This chapter examined and explained how regu- individualized attention are devoted to triggers, lar physical activity can provide various positive medication, and exercise stimuli. The exercise benefits to persons with lung disease, including professional can have a profound positive impact improvements in symptom expression, overall on the quality of life, health, and fitness of cli- health, quality of life, reduced medication use, ents with asthma, exercise-induced bronchoc- muscular and cardiovascular strength, and pul- onstriction, pulmonary hypertension, chronic monary performance. The effects of an exercise obstructive pulmonary disease, chronic restrictive program also include a decrease in the severity pulmonary disease, and cystic fibrosis. Key Terms forced expiratory volume in the first second (FEV1) asthma bronchiectasis forced vital capacity cardiac index functional residual capacity chronic obstructive pulmonary disease idiopathic prophylaxis (COPD) pulmonary arterial hypertension (PAH) chronic restrictive pulmonary disease (CRPD) pulmonary arterial pressure (PAP) cystic fibrosis (CF) pulmonary hypertension (PH) cystic fibrosis transmembrane regulator pulmonary parenchyma syncope (CFTR) tachyphylaxis dyspnea exercise-induced bronchoconstriction (EIB) exercise pulmonary hypertension Study Questions 1. Which class of medications improves pulmonary function for nearly all clients who experience exercise-induced bronchoconstriction? a. leukotriene modifiers b. β2-adrenergic agonists c. inhaled corticosteroids d. monoclonal antibodies 2. A decrease in FEV1 is the primary diagnostic evidence for which of the following disorders? a. chronic obstructive pulmonary disease b. chronic restrictive pulmonary disease c. pulmonary hypertension d. asthma 3. Nutritional support for clients with cystic fibrosis might include which of the following? a. vitamin A, D, E, and K supplements b. high-fiber foods c. glycolytic enzymes d. calcium supplements
Pulmonary Disorders and Conditions | 175 4. For clients with pulmonary hypertension, which of the following is true regarding exercise prescription? a. Interval training has been shown to be effective, but exercise testing should be done to determine severity of the disease. b. The Valsalva maneuver is actually encouraged, because it can improve respiratory muscle strength. c. Only light exercise is recommended, because moderate or higher intensity can increase pulmonary arterial blood pressure to harmful levels. d. Exercise is effective for clients with pulmonary arterial hypertension but not for clients for whom the cause of hypertension is unknown. Medications Table 5.1 Common Anti-In ammatory Controller Medications Used to Treat Asthma and EIB Drug name beclomethasone dipropionate Chemical family budesonide Corticosteroid flunisolide Corticosteroid fluticasone propionate Corticosteroid triamcinolone acetonide Corticosteroid montelukast Corticosteroid zafirlukast Leukotriene modifier zileuton Leukotriene modifier salmeterol Leukotriene modifier theophylline Long-acting β2-agonist Methylxanthine References: (95, 198) Medications Table 5.2 Common Short-Acting Reliever Medications Used to Treat Asthma and EIB Drug name albuterol Chemical family bitolterol metaproterenol Short-acting β2-agonists pirbuterol Short-acting β2-agonists terbutaline Short-acting β2-agonists methylprednisolone Short-acting β2-agonists prednisolone Short-acting β2-agonists prednisone Oral corticosteroid ipratropium bromide Oral corticosteroid References: (95, 198) Oral corticosteroid Anticholinergic
Medications Table 5.3 Common Medications Used to Treat PH Drug class and names Mechanism of action Most common side effects Effects on exercise Endothelin receptor antagonists ambrisentan (Letairis), Block endothelin receptors Peripheral edema, headache, Improve exercise bosentan (Tracleer), of the smooth muscle flushing, throat irritation and tolerance and delay time macitentan (Opsumit) of blood vessels, thus respiratory tract infections, to worsening clinical inhibiting pulmonary nausea, anemia, syncope symptoms vasoconstriction Phosphodiesterase inhibitors sildenafil (Revatio), tadalafil Inhibition of cyclic GMP Headache, dyspepsia, nausea, No change in exercise (Adcirca), vardenafil degradation thereby flushing, visual disturbances, capacity (Levitra, Staxyn) increasing nitric oxide myalgia bioavailability and subsequently increasing vasodilation Prostacyclin analogues epoprostenol (Flolan, Activate the prostacyclin Headache, hypotension, flushing, Possible small Veletri), iloprost (Ventavis), pathway flulike symptoms, cough, throat improvement in exercise treprostinil (Tyvaso) irritation, nausea capacity or no change depending on symptom class level References: (96, 117, 161, 191, 275) 176
Medications Table 5.4 Common Medications Used to Treat COPD Drug class and names Mechanism of action Most common side effects Effects on exercise Headache, tachycardia, Improve exercise Short-acting (4-6 h) bronchodilators palpitations, muscle tremors, tolerance by achieving anxiety, nausea relief of COPD β(V2e-angtoolninis,tCs:oamlbbuivteernotl), Cause bronchodilation Headache, cough, dry “cotton” symptoms salbutamol (Airomir), by binding to airway mouth No ergogenic effect levalbuterol (Xopenex HFA) βre2s-ualdtrinegneinrgsicmroeoctehptmorusscle relaxation of the airways Headache, tachycardia, May improve lung palpitations, muscle tremors, function during anticholinergics: ipratropium Causes bronchodilation (via anxiety, nausea exercise, but research (Atrovent) smooth muscle relaxation) Headache, cough, dry “cotton” results inconsistent by nonselectively inhibiting mouth May improve exercise muscarinic acetylcholine tolerance receptors, thereby reducing Short-term use: fluid retention, acetylcholine availability of the hypertension, hyperglycemia, No significant effect on parasympathetic nerves that mood changes, skeletal muscle exercise capacity cause bronchoconstriction atrophy; long-term use: weight gain, osteoporosis, easy bruising, No significant effect on Long-acting (up to 12-24 h) bronchodilators myopathy and cataracts, exercise capacity increased risk of infections, (βS2e-aregvoennits)t,sf:osramlmoteetreorol l Cause bronchodilation stomach ulcers (Foradil Aerolizer), by binding to airway Sore mouth or throat, hoarse arformoterol (Brovana), βre2s-ualdtrinegneinrgsicmroeoctehptmoruss,cle voice, yeast infections in throat or indacaterol (Arcapta relaxation of the airways mouth Neohaler) anticholinergics: tiotropium Cause bronchodilation (via (Spiriva), aclidinium bromide smooth muscle relaxation) (Tudorza Pressair) by nonselectively inhibiting muscarinic acetylcholine receptors, thereby reducing acetylcholine availability of the parasympathetic nerves that cause bronchoconstriction Oral corticosteroids prednisolone (Prelone) Airway anti-inflammation and decrease mucus production Inhaled corticosteroids Glucocorticoids bind to airway budesonide (Pulmicort), receptors resulting in reduced fluticasone (Flovent), lung inflammation and mometasone (Asmanex) decreased mucus production References: (2, 102, 148, 223, 285, 305-308, 317) 177
Medications Table 5.5 Common Medications Used to Treat CRPD Drug class and names Mechanism of action Most common Effects on exercise Oral corticosteroids Immunosuppressant and side effects May cause hypertension, prednisone (Sterapred) anti-inflammatory agent Increased risk of fracture myasthenia and cataracts, risk of No known effect Immunosuppressive cytotoxic agents adrenal suppression, weight gain May increase exercise azathioprine (Azasan, Inhibit immune cell growth Blood in urine or stools, tolerance Imuran), cyclophosphamide and proliferation thereby bleeding gums, chest pain, (Cytoxan), methotrexate decreasing autoimmune lower back or side pain, (Trexall, Rheumatrex) activity; suppress stomach pain, cough, inflammation shortness of breath Abdominal pain, diarrhea, Antifibrotic inhibitors nausea, vomiting, dizziness, dyspepsia, fatigue, skin rash, nintedanib (Ofev), Decrease lung fibrosis weight loss pirfenidone (Esbriet, through inhibition or Pirfenex, Pirespa) downregulation (or both) of various growth factor receptors; anti-inflammatory effects via reduced inflammatory mediators References: (3-6, 90, 92, 194, 274, 297, 316) 178
Medications Table 5.6 Common Medications Used to Treat CF Most common Effects on exercise Drug class and names Mechanism of action side effects No effect No effect Inhaled hypertonic saline Mucolytic Cough, sore throat, chest No known effect tightness No known effect Inhaled antibiotics No known effect tobramycin (Bethkis), Antibacterial Cough, sore throat, chest aztreonam (Cayston) tightness, fever, bloody, runny or stuffy nose Recombinant deoxyribonuclease dornase alfa (Pulmozyme) Mucolytic; acts by Change in or loss of voice, hydrolyzing excess DNA in throat discomfort, skin rash pulmonary mucus Cystic fibrosis transmembrane regulator (CFTR) gene potentiator ivacaftor (Kalydeco) Increases the likelihood Dizziness, headache, the defective CFTR channel body aches, abdominal or will remain open, allowing chest pain, cough, nasal chloride ions to pass through congestion and thus decreasing mucus viscosity Pancreatic enzymes pancrelipase (Creon, Breakdown of carbohydrate, Headache, diarrhea, Pancreaze) protein, fat due to pancreatic nausea, abdominal pain, insufficiency constipation, mucus membrane irritation References: (81, 91, 93, 94, 97, 98, 105, 178, 304) 179
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Cardiovascular Conditions 6 and Disorders Ann Marie Swank, PhD, CSCS Carwyn Sharp, PhD, CSCS,*D After completing this chapter, you will be able to ◆ describe the physiological effects of various cardiovascular conditions and disorders on an individual’s health, fitness, and physical activity capacity; ◆ understand the effects of key medications associated with treatment of various cardiovascular conditions and disorders on physiological systems and the responses to exercise; ◆ design and implement a safe, effective, and efficient individualized exercise program for those affected by cardiovascular conditions and disorders; and ◆ understand the roles and responsibilities of the exercise professional as part of the team working with individuals affected by cardiovascular conditions and disorders to effectively and efficiently improve health, fitness, and physical capacity. 181
182 | NSCA’s Essentials of Training Special Populations According to the Centers for Disease Control and mmHg and diastolic blood pressure between 80 Prevention, cardiovascular disease (CVD) is the and 89 mmHg (25). For nearly 95% of cases of leading cause of death in the United States for HTN in the United States, the cause is not known both men and women, even though a number (i.e., idiopathic) and the condition is referred to as of preventable risk factors for CVD have been primary hypertension (14). In contrast, secondary identified. As such, significant interest exists in HTN is caused by some other medical condition interventions, such as exercise, that prevent or such as renal dysfunction, drugs, or steroids (26). reduce these risks, subsequently decreasing the Hypertension is often called the “silent killer” due associated mortality and morbidity. This chapter to the lack of symptoms until the disease process addresses the essentials of exercise training for has signi cantly affected biological systems (16). individuals with the following cardiovascular conditions: hypertension, peripheral arterial Pathophysiology of disease, angina, chronic heart failure, myocardial Hypertension infarction, conduction disturbances, atrial fibrilla- tion, pacemakers, coronary artery bypass grafting The two determinants of blood pressure are (CABG), and other revascularization procedures. cardiac output and total peripheral resistance. Cardiac output is defined as the amount of blood The common underlying mechanism for these expelled from the heart each minute, which is conditions is the process of atherosclerosis, a function of blood volume. Total peripheral de ned as the development of plaque in arteries resistance is a measure of the tone or level of of the heart, periphery, brain, or more than one of constriction of the blood vessels. Elevations in these. Risk factors for the development of athero- either or both of these variables contribute to sclerosis include factors that cannot be modi ed, HTN. Conditions that contribute to higher blood including age, sex, and family history, and those volume and ultimately HTN include excess salt factors that can be modi ed, such as lipid pro le, intake, salt sensitivity, chronic kidney disease, exercise history, smoking, diabetes, and seden- and kidney dysfunction, among others (26). tary behavior. The exercise professional needs to Factors contributing to increased tone of blood consider a comprehensive program when working vessels include actions that increase sympathetic with individuals with cardiovascular issues—one tone and the associated increase in catecholamine that includes risk factor management as well as response, such as high stress levels, certain drugs, exercise programming. and exercise (20, 23). However, while various factors resulting in HTN (or more specifically, HYPERTENSION secondary hypertension) have been identified, it has been reported that 90% to 95% of cases are of Hypertension (HTN) is a considerable health unknown cause; these are referred to as primary or concern in the United States with almost one out essential hypertension (14). When blood pressure of three adults having the disease (39), which is has been elevated for an extended period of time, also a positive risk factor for CVD, the number one permanent damage to blood vessels, heart tissue, cause of mortality for both men and women in the and other organ systems can occur as a result of United States (45). While exercise has been shown the constant overload. This overload leads to cor- to be effective in the treatment and prevention of onary heart disease, stroke, renal failure, chronic HTN (45), prevalence and mortality continue to heart failure, and peripheral vascular disease (25). increase (5). Common Medications Hypertension is de ned as a systolic blood Given to Individuals With pressure greater than or equal to 140 mmHg or Hypertension a diastolic blood pressure greater than or equal to 90 mmHg (or both) con rmed on at least two The first treatment for HTN is to consider lifestyle separate occasions in adults (i.e., older than 18 changes including exercise, diet, and reduced years of age) (45). Prehypertension is de ned as a systolic blood pressure between 120 and 139
Cardiovascular Conditions and Disorders | 183 salt intake for those individuals who may be salt pressure, respectively, have been seen, as well as sensitive or may be consuming excess salt (20, a decrease of 3 to 4 mmHg for both systolic and 48). However, since blood pressure is a function diastolic blood pressure with resistance training of both blood volume (cardiac output) and blood (16). This is related in part to reduced catecho- vessel tone (total peripheral resistance), medica- lamine activity and an increase in vasodilation tions that affect these two entities are very effec- capacity of blood vessels (16). Weight loss also tive treatments for HTN (25). Diuretics (thiazides) contributes to the reduced resting and exercise decrease blood volume and therefore reduce blood blood pressure (9). pressure through this pathway. β-blockers, cal- cium channel blockers, angiotensin II receptor Exercise Recommendations blockers, and angiotensin-converting enzyme for Clients With Hypertension (ACE) inhibitors all have the potential to reduce blood vessel tone and thus reduce blood pressure Exercise programming recommendations for via this pathway. For some patients, combinations clients with HTN should be based on the results of medications are necessary to achieve effective of exercise testing and assessment such that the control of blood pressure (26). The effects of these exercise professional is aware of the blood pres- medications on exercise performance are listed in sure response to exercise intensity and duration. medications table 6.1 at the end of this chapter; In general, however, exercise recommendations however, of note, the medications to lower blood for clients with HTN include the following: pressure may affect heat tolerance as well as reduce heart rate response (β-blockers) to a given • The mode for aerobic training should be large level of exercise (45). Medications that affect blood muscle group activities such as walking, jog- vessel tone may also result in exertional hypoten- ging, or cycling with a frequency of most, if sion associated with positional changes such as not all, days of the week and 30 minutes or moving from a supine bench press to sitting or more of either continuous or accumulated standing (52). ebxeemrcoisdeetrhatreou(ig.eh.o, u4t0t%hetoda<y6. 0In%teVn. Osi2tyorshhoeualrdt rate reserve [16] or a rating of perceived Effects of Exercise exertion [RPE] of a 12 to 13 out of 20 on the in Individuals With Borg scale). Hypertension • Since postexercise is associated with reduced Normally during exercise, systolic blood pres- blood pressure for up to 4 hours, repeated sure increases while the diastolic pressure either bouts of exercise or performance of activities stays the same or is lowered (24, 57). During a of daily living that include higher levels of single (acute) exercise session, the blood pressure energy expenditure should be encouraged response for an individual with HTN may be throughout the day to enhance the positive normal, diminished, or exaggerated depending, exercise effects on blood pressure and tness in part, on the baseline value presented before gains (45). These bene ts include increased exercise and the effectiveness of the medications caloric expenditure, which may also be impor- bofeienxgertacikseent.rIaninaidndgi,tisounchtoatshienecxrepaescetdedV.bOe2nmefaixts, tant because obesity is often a comorbidity for increased efficiency (lower heart rate and blood clients with HTN. pressure at fixed submaximal workloads), and weight loss, individuals with HTN often expe- • Resistance training is recommended at a mod- rience significant drops in both systolic and erate level of 8 to 12 repetitions at 60% to 80% diastolic pressure. Meta-analyses have shown of one repetition maximum (1RM) using total that following an eight-week aerobic exercise body exercises for most clients (2, 16); however, program, reductions of approximately 5 mmHg some may bene t from lighter intensity (40% and 2 to 3 mmHg for systolic and diastolic blood to 60% 1RM) and higher volume (up to 15 rep- etitions) (16). A circuit weight training format may be most appropriate and is time ef cient.
184 | NSCA’s Essentials of Training Special Populations Sample exercises to assist the exercise profes- of 220 or a diastolic pressure of 105 may be sional in developing a resistance training pro- considered exercise termination criteria (19). gram for the client with HTN and a stepwise During resistance training, education regarding methodology for teaching clients have been breathing patterns to avoid a Valsalva maneuver developed (34). is important (19, 27). For the select patient who has been appropriately screened, high-intensity The most important consideration for the interval training (HIIT) may be appropriate, for exercise professional working with clients example, a metabolic resistance training protocol with HTN is to monitor blood pressure before, (29). Tables 6.1 and 6.2 summarize guidelines during, and after exercise (possible hypotensive for aerobic exercise and resistance training for response during recovery). A systolic pressure clients with HTN. Case Study Hypertension Mr. S presented to an exercise professional at reserve and working up to 80% for ve days per his local health club with the primary goals of week. In conjunction, resistance training two weight loss and increasing his “energy level.” He days per week using a circuit weight training is currently considered overweight with a BMI format was included. The exercise professional of 29. He is inactive and has a “desk job” selling also recommended that Mr. S perform the exer- insurance. He denies experiencing stress with cise programming at the health club so his blood his job or home life. His resting blood pressure pressure and symptom response to exercise is 118/76 controlled with an ACE inhibitor. He could be followed. Dietary counseling for his is 42 years old with a family history of HTN. weight management was encouraged, and he was further reminded to be consistent with his The exercise professional recommended a blood pressure medication regimen. 10-week progressive walking to walk–jog pro- gram at an intensity starting at 40% of heart rate Recommended Readings Contractor, AS, Gordon, TL, and Gordon, NF. Hypertension. In Clinical Exercise Physiology. 3rd ed. Ehrman, JK, Gordon, PM, Visich, PS, and Keteyian, SJ, eds. Champaign, IL: Human Kinetics, 137-154, 2013. Durstine, J, Moore, G, Painter, P, Macko, R, Gordon, B, and Kraus, W. Chronic conditions strongly associated with physical inactivity. In ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. 4th ed. Moore, G, Durstine, J, and Painter, P, eds. Champaign, IL: Human Kinetics, 71-94, 2016. Pescatello, LS, Franklin, BA, Fagard, R, Farquhar, WB, Kelley, GA, and Ray, CA. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc 36:533-553, 2004.
Cardiovascular Conditions and Disorders | 185 Table 6.1 Aerobic Exercise Guidelines for Clients With Hypertension Parameter Guideline Frequency Preferably 5-7 days per week Intensity 40 to <60% of V. O2 or heart rate reserve; or 12-13 RPE (on Borg 6- to 20-point scale) Mode Activities that engage large muscle groups such as walking Duration Minimum of 30 min per day, may be 3-6 bouts of 10 min Total weekly minutes 150 minimum to 250 or greater Reference: (16) Table 6.2 Resistance Training Guidelines for Clients With Hypertension Parameter Guideline Frequency 2-3 days per week, preferably every other day Intensity (can start at 40%) 60-80% 1RM Repetitions 8-12 (up to 15) Sets 1-3 Rest periods between sets 30-60 s Exercises 8-12 mostly large muscle groups and multijoint Progression 2-5 lb for upper body, 5-10 for lower body Reference: (16) PERIPHERAL estimated that IC occurs in only 10% to 40% of ARTERIAL DISEASE cases of PAD (18, 35). Peripheral arterial disease (PAD) is defined as a Pathophysiology of Peripheral narrowing of noncardiac arteries that may result Arterial Disease in reduction of blood flow (18, 35); it affects approximately 8.5 million adults in the United The underlying disease process for PAD is ath- States aged 40 years and older, with similar prev- erosclerosis, defined as a condition in which the alence in males and females (39). An individual arteries become narrowed and hardened due to may have clinical PAD in that there is significant an excessive buildup of plaque along the wall of blockage of blood vessels in the periphery, but the affected artery (18). Atherosclerosis is the up to two-thirds of individuals 40 years or older common underlying process for most cardiovas- who have PAD do not have symptoms (39). The cular conditions including angina, myocardial classic symptom of PAD is called intermittent infarction, and stroke. The primary difference claudication (IC), an aching or cramping feeling for each of these conditions is the location of the in the legs, calf, or buttocks (or more than one atherosclerosis, and for PAD the location is the of these) induced by exercise that is caused by noncoronary arteries such as those of the legs. insufficient blood flow to the muscles of the lower The main risk factors for atherosclerosis of the extremities and is relieved by rest. However, it is periphery resulting in PAD are smoking, hyper- lipidemia, and diabetes (18, 35).
186 | NSCA’s Essentials of Training Special Populations Common Medications Given Key Point to Individuals With Peripheral Arterial Disease Consistent and chronic exercise training by individuals with intermittent claudication results Common medications for treating PAD include those in an ability to do more external work before the for HTN (see medications table 6.1); antiplatelet– onset of pain. vasoactive agents such as cilostazol (Pletal); statins (for reducing cholesterol); and drugs that Exercise Recommendations inhibit blood clotting such as pentoxifylline, for Clients With Peripheral Plavix, and aspirin (18). See medications table 6.2 Arterial Disease near the end of the chapter. As is often the case with CVDs, PAD exists with comorbidities such All clients with known CVDs, such as PAD, should as diabetes and past myocardial infarction, so the obtain a medical clearance before commencing an exercise professional needs to be aware of not just exercise program. It is also highly recommended all medications and the potential interactions, that clients with PAD, regardless of symptom but also the influence of exercise (28, 38). With severity, undergo exercise testing before initi- the exception of the vasoactive agents, which ating an exercise program so that the exercise may increase exercise capacity for the individual professional can identify the level of exercise that with PAD, all other medications just listed have results in symptoms (e.g., onset of pain and time a neutral impact on exercise capacity. to maximal pain), postexercise ankle pressure can be established, exercise prescription baseline Effects of Exercise in information may be gathered (e.g., total walking Individuals With Peripheral distance before onset of pain), and, if not previ- Arterial Disease ously established, the presence of CVD may be determined (18). Not all cases of PAD exhibit IC. If IC exists, then Using the results of the exercise testing, it is during an acute exercise session the individual’s recommended that exercise professionals design a program with the primary goals of decreasing given level of external work is often limited by the cardiovascular risk factors and IC pain symptoms (18). Given the severe deconditioning of this onset of IC pain (18). The amount of work that can population, the recommended mode of activity is weight-bearing large muscle group exercise such be performed by those with IC is likely to be low as walking, which has the added advantage of working the gastrocnemius (particularly affected and depends in part on the severity of the lesion by PVD), more so than cycling or swimming (18, 35). The recommended intensity is 40% to <60% and the baseline fitness level of the individual. heart rate reserve, or claudication pain of 3 out of 4 (18), for 30 to 60 minutes of accumulated activ- aTsheinecxrpeaesceteddV.bOe2nmefaitxs, of exercise training, such ity, three to seven days per week (3, 18). These increased cardiovascular clients can bene t from intermittent training that entails exercising to a level of 3 out of 4 on efficiency (lower heart rate and blood pressure at a claudication pain scale (0 = no pain; 1 = onset of pain; 2 = moderate pain; 3 = intense pain; 4 = a fixed submaximal level of work), and decreased maximal pain), then resting until pain subsides and repeating the effort until 30 minutes with- weight are modest for individuals with PAD- out resting can be tolerated (3, 18). Resistance training can be performed three days per week induced IC because the associated onset of pain limits exercise intensity and duration. With chronic exercise training, individuals with IC associated with PAD demonstrate an increased amount of external work performed before the onset of IC pain occurs. The mechanism for this training effect is likely related to increased leg blood flow due to reduced tone of blood vessels, decreased blood viscosity, and a shift from reli- ance on anaerobic to aerobic metabolism (35).
Cardiovascular Conditions and Disorders | 187 with a moderate intensity of 10 to 12 repetitions It is also worthy to note that as clients with IC for one or two sets of upper and lower body exer- associated with PAD train and increase their t- cise (18). For clients with IC, their level of pain ness, comorbidities may become evident and will will determine the exercise intensity. For clients need to be addressed by the exercise professional with PAD and no IC, RPE can also be used to (38). Tables 6.3 and 6.4 summarize guidelines for determine exercise intensity (12 to 13 out of 20 aerobic exercise and resistance training for clients is recommended). with PAD. Table 6.3 Aerobic Exercise Guidelines for Clients With Peripheral Arterial Disease Parameter Guideline Frequency Preferably 3-7 days per week Intensity 40% to <60% heart rate reserve, but staying below level 3 out of 4 on the pain scale Mode Activities that engage large muscle groups such as walking Duration 30-60 min per day, may be 3-6 bouts of 10 min each References: (6, 35) Table 6.4 Resistance Training Guidelines for Clients With Peripheral Arterial Disease Parameter Guideline Frequency 2-3 days per week Intensity Moderate; 60-80% 1RM* Repetitions 10-12 Sets 1-2 sets each for upper and lower body Rest periods between sets 30-60 s Exercises 8-12 mostly large muscle groups and multijoint Progression 2-5 lb for upper body, 5-10 for lower body *Intensity for those with intermittent claudication will be determined by pain. Reference: (18) Case Study Peripheral Arterial Disease Ms. J has a history of type 2 diabetes treated Because of her obesity and low level of exer- for 20 years with metformin (a blood glucose– cise tolerance, a unique exercise program was lowering agent) and is morbidly obese with a developed. Two chairs without handles were BMI of 45. She has also been diagnosed with placed a short distance apart, and Ms. J walked PAD and has dif culty walking short distances between the chairs until her legs began to cramp. without profound cramping in her calf muscles Then she sat down at the second chair until the indicating IC. She rates her pain with walking pain of IC subsided. She continued this intermit- a level of 4 out of 4 on the IC pain scale. She tent training for 10 weeks and demonstrated a sought the help of an exercise professional at 200% increase in the distance covered between a local tness club for exercise programming. the chairs. She was also able to walk to her (continued)
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