238 | NSCA’s Essentials of Training Special Populations virus worldwide being HIV-1 (3, 76). Human muscle wasting, weakness, fatigue, diarrhea, rare immunodeficiency virus-1 was identified in 1984 cancers, and swollen or enlarged lymph nodes. as the primary causative viral agent for AIDS (76). Stage 3 is the most severe stage of HIV, acquired In 1986, HIV-2 was discovered in AIDS patients immunode ciency disease, and is associated with in West Africa (37). a signi cant depletion of CD4 cells, in the pres- ence of malignancy and opportunistic infection Both HIV-1 and HIV-2 are spread via a host and cancers. This stage can take 2 to 15 years to transmitting the virus through a portal of exit develop (219). into another host or reservoir. This often occurs through the transmission of bodily uids, such Common Medications Given as blood, semen, and vaginal secretions (5). Thus, to Individuals With HIV/AIDS engaging in behaviors that put people in direct contact with these secretions, such as unprotected There is no cure for AIDS or HIV; however, with the sexual intercourse and sharing contaminated advent of new antiviral agents, many individuals intravenous needles, increases an individual’s risk infected with HIV are living much healthier and of contracting the virus—as does receiving con- higher-quality lives than those diagnosed several taminated blood via transfusion, blood products, decades ago (125). Thus treatment and management and organ transplants (76). The CDC reported in options focus on suppressing the symptoms associ- 2010 that 63% of new HIV transmissions were ated with this disorder for as long as possible. See men who had had sexual intercourse with men medications table 7.5 near the end of the chapter. compared to 25% of individuals infected through The pharmacological intervention of HIV medicines heterosexual sex and 8% by injection (39). In addi- is called antiretroviral therapy (ART). Commonly tion, this virus may also be transmitted from nurs- used HIV medication classes include nucleoside ing mothers who are infected with HIV/AIDS via reverse transcriptase inhibitors (NRTIs), also breast milk to their children (5). When compared known as analogues or “nukes,” non-nucleoside to HIV-1, the HIV-2 immunode ciency appears to reverse transcriptase inhibitors (NNRTIs), protease develop more slowly with milder symptoms, and inhibitors, fusion inhibitors, entry inhibitors, inte- is initially less infectious in the early stages but grase inhibitors, and pharmacokinetic enhancers. becomes more so as the disease progresses. The HIV regimen requires a combination of these medications from different drug classes (11). Human immunode ciency virus attacks white blood cells of the immune system, CD4 helper T Highly active antiretroviral therapy (HAART) cells, which are critical to immune function. The is a method used to reduce the number of HIV destruction of these cells leads to a progressive particles in the blood as measured by viral load, deterioration of the immune system, making thus improving T-cell count and immune func- individuals more susceptible to opportunistic tion (3). However, Malita and colleagues (139) infections, unusual cancers, and other abnor- reported that individuals using HAART for an malities (3, 166) such as nephropathy and renal extended period of time may be at increased failure (153). risk of developing cardiovascular and metabolic complications (79). Highly active antiretroviral There are three stages associated with HIV (3, therapy has been associated with the develop- 136, 166). Symptoms vary based on the stage of ment of lipodystrophy syndrome, indicative of infection (219). In stage I acute HIV infection, increased central adiposity (lipohypertrophy), individuals are able to transmit HIV but remain and peripheral lipoatrophy, peripheral insulin asymptomatic and relatively healthy, though resistance, chronic kidney disease (44, 153), dia- they may experience in uenza-type symptoms. betes, dyslipidemia (128), hypertriglyceridemia, Individuals may remain in stage 1 for months to osteoporosis, and osteopenia. years. Stage 2, often referred to as AIDS-related complex (ARC), is characterized by asymptomatic Many of the drugs, especially NRTIs and HIV infection (8) with a moderate reduction in NNRTIs, bind and alter (or block) the reverse CD4 cells and the development of more pro- transcriptase enzyme that the HIV virus uses to nounced signs and symptoms, such as weight loss,
Immunologic and Hematologic Disorders | 239 make copies of itself. A risk of myocardial infarc- muscle weakness, chronic diarrhea leading to tion and lactic acidosis is associated with NRTIs; dehydration, and opportunistic infection may therefore, caution should be used with exercise. significantly reduce exercise capacity (166). For NRTIs have been found to impair mitochondrial this reason, while exercise is encouraged in all function and reduce insulin sensitivity, making stages of HIV, it is particularly recommended that individuals more susceptible to type 2 diabetes individuals engage in strength and conditioning mellitus (80). activities in the early stages of this disease as this may help forestall or reverse disease progression Pharmokinetic enhancers are used to increase (78). the effectiveness of other drugs used in the HIV regimen, by reducing the breakdown of those Aerobic training is commonly used to help drugs. Anti-infectives and antineoplastics are improve cardiovascular tness, improve fatigue prescribed to help stave off opportunistic infec- levels, and reduce central body fatness (139, 155, tions. Protease inhibitors (PIs) block the enzyme 191). In addition, nutritional intervention and sup- protease, which spreads HIV to other cells. Pro- plementation, androgen supplementation, growth tease inhibitors have greatly reduced the risk of hormone administration, and resistance training morbidity and mortality for those suffering from are commonly used to counteract the negative HIV/AIDS (3). effects associated with muscle wasting (68). Of these treatments, resistance exercise may be a pre- While these drugs are effective in the treatment ferred option because of affordability, its relatively of HIV and AIDS, they have side effects, as well as few side effects, and its availability. Furthermore, interactions with other drugs. Over an extended because muscular strength is positively affected period of time, individuals can develop resistance by resistance training, both functional ability and to the drugs. Secondary complications associated quality of life can be greatly improved (164). with ART are metabolic, causing an increase in risk factors for cardiovascular disease (CVD) such Exercise Recommendations as dyslipidemia, insulin resistance, and changes for Clients With HIV/AIDS in adiposity (198). Additionally, the endothelial dysfunction related to HIV replication is a deter- Program design guidelines for clients with HIV/ minant for arterial in ammation and thrombosis AIDS are summarized in table 7.5. Designing an (128). Risks for CVD are exponentially heightened exercise program for clients with HIV infection due to age, genetic predisposition (family history of is largely dependent on the stage of immunode- CVD), or choices related to lifestyle (smoking) (83). ficiency. Clients in stage 1 are typically asymp- Statins and other medications are taken to coun- tomatic, with relatively few training restrictions. teract the effects of ART. Other complications due However, with disease progression, exercise to medications include peripheral neuropathy (34). capacity may steadily diminish and physical exhaustion and muscular fatigue may become a Exercise is bene cial in helping with decreasing greater concern. central fat distribution but can increase periph- eral fat wasting. Persons with HIV/AIDS are at an Cardiorespiratory training is commonly rec- increased risk for hyperlipidemia and hypertri- ommended for clients with HIV as a method of glyceridemia; of course, exercise can be bene cial improving aerobic capacity and reducing the in helping to increase high-density lipoprotein likelihood of cardiovascular-related issues, such cholesterol while decreasing triglycerides (34). as atherosclerosis, myocardial infarction, hyper- tension, congestive heart failure, and sudden Effects of Exercise in ttcoraari<dn6iia0nc%g d(≥Ve.a6Ot0h2%o(-r1970h7%e,a1Vr.8tO9r2)a.otreEhirteehaserertrrvmaet)oedroeerrsaevtrievgeo()r4oc0au%ns Individuals With HIV/AIDS be recommended based on the client’s preference (191). However, disease status, symptoms, and Exercise participation has been associated with current tness level should be considered. improvements in immune function and long-term survival in HIV (189). However, with disease pro- gression, factors such as fatigue, muscle wasting,
240 | NSCA’s Essentials of Training Special Populations Table 7.5 Program Design Guidelines for Clients With HIV/AIDS Type of exercise Frequency Intensity Resistance training Frequency will vary based on postexertion Choose 8-10 exercises using a full-body Multijoint movements symptomatology approach. Strive for two or three sessions per week Slowly progress over time to 2-3 sets of a. Bodyweight resistance 8-12 repetitions. b. May use resistance bands, Begin conservatively, working up to three Use light to moderate intensity, 40-80% or four sessions per week. If tolerated, 1RM. suspension training, and manual sessions can be increased slowly over If doing multiple sets, consider 1-2 min resistance time. Sessions can be performed most, if between sets to start; be prepared to c. Basic weight training such as not all, days of the week. adjust as needed. resistance machines and free weights Intensity (moderate or vigorous) is subject Mode of resistance training can vary to the client’s preference, disease status, based upon how well exercise is tolerated symptoms, and current fitness level; strive Aerobic training for 30 min of continuous exercise. Aerobic exercise mode should be low to Tolerance may vary widely between moderate impact. clients. Mode of aerobic training can vary based 8-10 static stretches, held 5-10 s initially, on how well exercise is tolerated. progressing to 20 s as tolerated Flexibility training Full-body flexibility exercises, starting with static stretching References: (89, 155, 177, 191) Resistance training is also a commonly pre- Key Point scribed exercise modality as it has the potential to signi cantly in uence muscle performance For clients with HIV/AIDS, implement resistive via increases in lean body mass and strength. exercises and other therapeutic exercises as toler- However, appropriate resistance training proto- ated to maintain muscle strength and function cols and guidelines are dif cult to nd for this and prevent muscle wasting. Assess exercise population. Resistance training at high intensi- tolerance frequently. ties (>80% 1RM) for relatively short periods has a positive in uence on the accrual of lean body sets per exercise for the higher-volume muscular mass in persons with HIV without compromising endurance training (89). immune function and is independent of the side effects associated with hormone therapies (68). Finally, strength and conditioning activities are considered low risk for the transmission of HIV It is recommended that resistance training because there is little exposure to bodily uids. programs for persons with HIV concentrate on However, cuts, scrapes, bloody noses, and open multijoint exercises emphasizing large muscle wounds increase exposure to bodily uids and groups. Training intensity should generally be may increase the risk of HIV transmission. Thus, at a moderate level (60-80% 1RM), which should any time blood or body uids, excluding sweat, allow for comfortable performance of 8 to 12 are present, standard precautions should be fol- repetitions per set. Alternatively, lighter-intensity lowed to minimize risk of disease transmission. muscular endurance training (40-60% 1RM) can For this reason, it is recommended that the exer- be performed with 15 to 25 repetitions per set. Ini- cise professional be familiar with the universal tial training should use one set per exercise, and standard precautions as recommended by with training volume increased very gradually the CDC (1, 187). as tolerated by the client but not to exceed two
Case Study HIV/AIDS Sex: Female 2. Remain asymptomatic Age: 32 3. Improve health and maintain current immune function Height: 5 feet, 5 inches (1.65 m) Intake Weight: 140 pounds (64 kg) Before Mrs. N began her exercise program, Body fat: 27% her physician had encouraged her to seek the advice of a knowledgeable exercise profes- Body mass index: 23.3 sional. Other than diminished capacity, she has no physical limitations. She performed a Resting heart rate: 70 beats/min 3-minute step test for aerobic capacity, push-up test for upper body endurance–strength, and Blood press.ure: 130/76 mmHg the leg press test for lower body strength. Test Estimated VO2: 19.6 ml · kg−1 · min−1 (from the results con rmed a low capacity for her age and 1.5-mile [2.4 km] walk/run test) sex. The exercise professional recommended a progressive resistance training program, cardi- History opulmonary exercise, and exibility exercise. It was also recommended that she seek dietary The client, Mrs. N, has been infected with advice from a registered dietician to help pro- HIV for over 10 years. Before her infection, she mote health. played softball and ran the 400-m hurdles in college. Post-HIV diagnosis, she became more Initial Training sedentary due to fear of aggravating or trig- gering symptoms of the disease. She was also Training sessions began with low-impact aerobic reluctant to join a gym because she had been training three times per week. Mrs. N’s choice told by a previous health club that the patrons of activity was stationary cycling and she began and staff were fearful of handling equipment at 40% of her heart rate reserve for 20 minutes. after she had used it. She would like to begin Aerobic training was followed by resistance an exercise program again. However, she has training and basic static stretching. A full-body not been physically active, other than walking, approach to resistance exercise was used, as was for the last three years. She walks for 20 to 30 basic dynamic stretching. Eight to 10 exercises minutes three times per week. Recently she were performed for 30 seconds, 8 to 10 exercises participated in a research study investigating for one set. The repetition range was 12 to 15. the effects of a HAART on T-cell activation A combination of bodyweight and dumbbell during asymptomatic HIV infection. During exercises was chosen. the study she complained of fatiguing very easily and experienced mild nausea and diar- Exercise Progression rhea. However, after she completed the study her symptoms subsided and she is currently Over a period of two months, the exercise asymptomatic. professional progressed Mrs. N’s aerobic train- ing to four days per week with alternating Goals modes of riding a stationary cycle and walk- ing on a track. Mrs. N’s intensity increased to Mrs. N would like to work on the following goals: 1. Strengthen her body and improve her physical capacity (continued) 241
242 | NSCA’s Essentials of Training Special Populations HIV/AIDS (continued) Outcomes 60% heart rate reserve and each session was After eight weeks of training, a retest of muscular lengthened to 30 minutes. Also, Mrs. N’s exercise endurance and strength demonstrated signi cant professional recommended a split resistance iwneclrleaasseV.sOi2nmuapxp.eMr arsn.dNl’oswheeralbtohdhyasstrreenmgatihneads training routine; over the four days, she com- good despite side effects from the medications. pletes two full-body workouts and instead of one set per body part, Mrs. N did two or three sets. Training Recommendations and Contraindications for Clients With HIV/AIDS 1. Implement resistive exercises and other exercises as tolerated to maintain muscle strength and function and prevent muscle wasting. 2. Use extreme caution during aerobic exercise and other forms of exercise. 3. Monitor exercise tolerance frequently for excessive fatigue and weakness. 4. Use Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infec- tions established by the Centers for Disease Control and Prevention. SICKLE CELL DISEASE has been declared a global health problem by the World Health Organization (64). It has been Sickle cell disease is a group of inherited blood suggested that those with low socioeconomic disorders that is characterized by a genetic muta- conditions are at a higher risk of experiencing tion of hemoglobin. This abnormality can cause an sickle cell disease, but this has been refuted in alteration of the shape of the red blood cell into a other studies suggesting it is more of a lack of lengthened sickle profile (15). Sickle cell anemia, education and participation in research studies the most common and most severe of all of the (17). The life expectancy for someone with sickle forms of sickle cell disease, occurs when there cell disease is now 40 to 60 years of age (com- are two abnormal sickle genes for hemoglobin; pared to only 14 years in 1973) in the United sickle cell trait has one normal and one sickle States due to improvements in health care (159). hemoglobin gene. Between 80,000 and 100,000 people in the United States have sickle cell disease (129). The National History and Demographics of Collegiate Athletic Association mandates sickle Sickle Cell Disease cell trait screening in all athletes due to the risks involved with sport participation. The sickle cell mutation was first recognized in Africa (51). The condition is most common in Pathophysiology of Sickle Cell individuals of African descent (64) but also affects Disease individuals of Arab, Indian, and Hispanic nation- alities (15, 159). It is least common in Caucasian Sickle cell disease can be diagnosed from birth. individuals. It is estimated that the number of Signs and symptoms associated with the disease babies born with sickle cell disease between 2010 are swelling of the hands and feet, fatigue and and 2050 will be over 14 million, and the disease jaundice, acute crises associated with certain
Immunologic and Hematologic Disorders | 243 triggers, and chronic pain. When the red blood over-the-counter medications, such as aspirins cell of someone with sickle cell anemia becomes and ibuprofen, to prescription medications such deoxygenated, the response is to change into an as hydroxyurea for pain, antiplatelet therapy or elongated sickle or crescent shape. Cells of this blood thinners, antioxidants, and anti-inflamma- shape have a shorter life span than normal cells. tory medications. Nonsteroidal anti-inflamma- Additionally, the altered shape and lack of flex- tory medications (ibuprofen) are typically given ibility make it more difficult for blood to flow for acute and chronic pain, while morphine is through the microvasculature (51). Individuals commonly prescribed to combat pain associated with sickle cell disease suffer from pain (also with acute chest syndrome and other acute and called crises) due to the decrease in blood flow to chronic pain. Many of these medications may be tissue. This decrease in blood flow is associated associated with numerous side effects, including with vascular occlusion and arterial and venous nausea, vomiting, gastrointestinal distress, and thromboembolism (67) due to inflammation, constipation. Due to splenic dysfunction, individ- endothelial dysfunctions, and hypercoagulation uals with sickle cell disease are at a high risk for of the red blood cells (156). Those with sickle life-threatening bacterial infections (pneumonia, cell disease are at a higher risk for early mortality influenza, salmonella, staphylococcus, and chla- due to multiorgan damage. The malformed sickle mydia) that affect the blood, lungs, bones, brain, cells and hypercoagulation cause the red blood and brain stem (159). Therefore, penicillin is cells to stick to one another, causing thrombosis commonly prescribed prophylactically (138), and to form and to affect many organ functions. The medical records are checked to make sure people loss of blood flow to tissues can lead to infection, are up to date on their vaccinations. Hydroxyurea acute chest syndrome (damage to the lungs due is used to help reduce pain associated with sickle to reduced blood flow), stroke, and pulmonary cell disease but can reduce the effectiveness of the hypertension (137). The spleen is responsible for immune system. Other therapies associated with acting as a filter for the blood and getting rid of sickle cell disease are red blood cell transfusion infection. In the case of the spleen, the sickle cells and hematopoietic stem cell transplantation. To reduce the blood flow from the spleen, causing date, hematopoietic stem cell transplantation is anemia, infection, and septicemia (7, 111, 159). considered the only cure for sickle cell disease Anemia can range from mild to moderate and (65). even severe depending on the individual. Other major tissues can be affected as well, such as the Effects of Exercise in eyes, kidneys, liver, bones, and joints. Individuals With Sickle Cell Disease Quality of life conditions associated with sickle cell disease, such as low cognitive function and Connes and colleagues (51) report limited impaired attention, result from the pain and research on the effects of aerobic exercise in indi- sleep disorders corresponding with insuf cient viduals with sickle cell anemia. Exercise capacity peripheral capillary oxygen saturation (SPO2) is lower in children and young adults with this (106). Supplementary oxygen can be bene cial in disease (132) due to adaptations in the vascular helping to improve sleep and raise low SPO2 levels. structure, low hemoglobin concentrations, and reduced blood flow to the tissue (12). Those with Common Medications Given to Individuals With Sickle Cell Key Point Disease For clients with sickle cell disease, obtain medical According to the CDC (40), treatment for sickle permission for physical training depending on cell disease is largely based on symptomatol- the level of severity. Monitor exercise capacity ogy. See medications table 7.6 near the end of closely. the chapter. Treatment options can range from
244 | NSCA’s Essentials of Training Special Populations sickle cell anemia are at an increased risk of lung A recent study (210) compared the effects of incremental cycle ergometer exercise in individ- and cardiac dysfunction. According to Alvarado uals with sickle cell anemia and healthy individu- als. The exercise was a single bout of incremental and colleagues (16), children with sickle cell exercise to ventilatory threshold. Monitoring postexercise showed no signi cant hematologic anemia have a tendency to demonstrate impaired changes in either sickle cell anemia or healthy subjects. This study indicates that light- to heart rate recovery following maximal exercise. moderate-intensity aerobic exercise may be ben- e cial and safe in individuals with sickle cell This is associated with an autonomic nervous anemia. However, as emphasized by the investi- gators, further research is needed to help quantify system dysfunction, specifically, vagal function. the exact amount and intensity of exercise that can safely be prescribed. Low oxygen saturation and high ventilation rate Exercise Recommendations with exercise often lead to hypoxia, which can for Clients With Sickle Cell Disease parreecloipwitearteV.vOa2rmiaabxiliatnydinanthaeerhoebairct rate. Also noted thresholds (12). Two studies have reported positive effects of exer- cise in clients with sickle cell anemia. Strength Anemic situations such as hypoxia, cardiopul- and aerobic exercise in children of less than 30 minutes allowed a decrease in the use of anal- monary disease, and inflammation can result in gesics as well as improving range of motion in some areas of the body (13). More recently, Tinti reduced exercise capacity. The 6-minute walk and colleagues (197) published a case study on the positive effects of aquatic exercise consisting test is often used to indirectly measure exercise of aerobic exercise and stretching for 45 minutes twice a week. Results showed a reduction in pain, capacity in children. small strength increases, and improved life qual- ity. Clearly, more research is needed to address the As reported by Eichner (72) in the realm of lack of solid exercise prescription recommenda- tions for clients with sickle cell anemia. Connes sport, exertional sickling is the number one and colleagues (51) recommend that clients with sickle cell disease begin slowly and progress based leading killer of athletes in National Collegiate upon how well exercise is tolerated, avoid extreme temperature exposure and hydrate frequently, and Athletic Association Division I football. These incorporate frequent rest breaks with exercise bouts up to 20 minutes. There are no consistencies deaths all occurred during the conditioning in exercise recommendations. Recommendations need to be based on the client’s exertional capacity phase and consisted of sudden cardiac arrest, and symptomatology. It is advised that clients with a known enlarged spleen avoid contact asthma, and exertional heatstroke. Eichner sports (209). recommends that athletes be screened before participation. There is discussion as to whether these athletes should be allowed to play at all. However, so as to not exclude them from exercise that is bene cial, these athletes are encouraged not to go all out but to set their own pace, rest- ing periodically. Those with sickle cell disease are not recommended to participate in maximal testing. Athletes should be educated on the warning signals and learn to heed the warnings and seek medical help. Exercise professionals and coaches should monitor environmental conditions and adjust athletes’ workloads and intensities accordingly. Exertional rhabdomyolysis or sickling has been identi ed in active duty soldiers. Exertional sickling and exertional heat illness pose a risk for sudden death for military personnel just as it does with athletes (73). The intense nature of the conditioning of the soldier shares many of the dangers associated with conditioning for sports. Therefore, recommendations are similar.
Case Study Sickle Cell Disease Sex: Male press test for lower body strength. Test results con rmed a low capacity for his age and sex. Race: African American The exercise professional recommended a progressive resistance training program, cardi- Age: 25 opulmonary exercise, and exibility exercise. It was also recommended that he seek dietary Height: 6 feet, 5 inches (1.96 m) advice from a registered dietician to help pro- mote health. Weight: 240 pounds (109 kg) Initial Training Body fat: 32% Training sessions began with low-impact car- Body mass index: 28.5 diovascular training three times per week. Mr. T’s choice of activity was water walking or jog- Resting heart rate: 60 beats/min ging and swimming due to its low impact. He tolerates the water walking and jogging fairly Blood pressure: 120/70 mmHg well at a light intensity for 20 minutes. He has enjoyed some resistance training along with History basic static stretching. A full-body approach to resistance exercise was used at a light intensity, Mr. T, a young man diagnosed with sickle cell with 10 to 12 repetitions increasing to a mod- disease at birth, wants to begin an exercise pro- erate intensity, and one set of a combination gram. He has not been physically active, other of bodyweight and dumbbell exercises was than walking, for the last ve years. Before chosen. that he had participated in a high-intensity program. While doing pull-ups and sit-ups Exercise Progression he began to experience severe leg and back pain. He continued to exercise, and during a Over a period of two months Mr. T continued to 2-mile (3.2 km) run he began to have severe do his water walking and jogging and gradually leg cramps that continued hours after exercis- increased his ability to swim to four days per ing, along with symptoms similar to those for week. Cardiovascular training was conducted the u. His symptoms continued to intensify four days per week for 30 minutes. He began to the point that he went to the emergency to alternate training sessions between the pool, room. There he was diagnosed with exertional the treadmill and elliptical, and the weights. He rhabdomyolysis. was able to increase to a full-body workout of two or three sets at a moderate to high intensity, Goals making sure to breathe properly. Mr. T would like to work on the following goals: Outcomes 1. Lose weight and fat mass In three months’ time, with his workout program Mr. T has noted some weight and fat loss with a 2. Improve aerobic and physical capacity repeated body composition and now weighs 230 without sickling pounds (104 kg) at 28% body fat. His weights and aerobic work have been bene cial in improv- Intake ing his aerobic capacity as well. Before Mr. T began his exercise program, his physician had encouraged him to seek the advice of a knowledgeable exercise professional. Other than diminished capacity, he has no physical limitations. He performed a 6-minute walk test for aerobic capacity, push-up test for upper body endurance–strength, and the leg 245
246 | NSCA’s Essentials of Training Special Populations Training Recommendations and Contraindications for Clients With Sickle Cell Disease 1. Obtain medical permission for physical training depending on the level of severity. 2. Physical capacity should be evaluated before starting exercise programming. 3. Physical activity should be limited to less than 20 minutes with frequent breaks. 4. Exercise professionals should be very aware of how clients respond to training and be willing to adjust frequency, intensity, and time as needed. Avoiding activities that prove too taxing on the cardiovascular system is vital to this process. 5. All training should be light intensity and should be progressed as needed based on tolerance to activity. 6. Resistance training can include many different modes. Monitor intensity levels accordingly, ensuring that the client is breathing properly. 7. Alternative modes of training are also useful. Consider aqua exercise as a possible form of aerobic exercise. 8. Consider avoiding contact sports, especially in persons with an enlarged spleen. 9. Hydration is important. 10. Use caution in extreme weather conditions. HEMOPHILIA is more common in males than females. Since the disease is recessive and on the X chromo- Hemophilia is a genetic disease that occurs due to some, females with the disease would have both a lack of specific blood protein factors that allow parents as carriers; but males, who have a single clotting (221). Depending on the severity of the X chromosome, would need only a single parent disease, a person with hemophilia may have mild as a carrier for the disease (221). Hemophilia A symptoms (e.g., slower clotting than normal) or occurs in 1 in 5,000 male live births, hemophilia more severe symptoms such as severe bleeding B in 1 in 30,000 (142). Diagnosis of the disease that requires medical intervention. It is impor- usually occurs by 6 years of age, and often earlier tant to remember that hemophilia has a “range when the disease is severe (221). Most individuals of severity,” depending on the level of deficiency with hemophilia are deficient in clotting factor in one of the protein factors (221). Severe hemo- VIII (218). philia usually appears within the first 18 months of life (122). The severity of hemophilia A or B is A study of U.S. demographics, comorbidities, commensurate with the percentage of circulating and health status found that those living with clotting factor activity. Individuals with levels hemophilia experience a wide variety of comor- less than or equal to 1% activity are categorized bidities (57). In this study of 141 participants with as having severe disease, those with 2% to 5% as hemophilia A and B, 47.5% had liver disease. The having moderate disease, and those with 6% to rate of liver disease in the U.S. population is 1.1%. 40% as having mild hemophilia (178). The rate of HIV infection in this population was 14.2%, as compared to 0.25% in the U.S. population. History and Demographics of The same investigation found that almost 50% of Hemophilia persons with hemophilia were overweight or obese. As compared to the older participants, those at the Hemophilia is hereditary and is carried recessively younger end of the age spectrum were more obese on the X chromosome (188). This means that it than overweight (57). The average occurrence of hemophilic joint arthritis in this population was
Immunologic and Hematologic Disorders | 247 33.3%. This average was higher in the older end of from human plasma. This treatment includes this population spectrum (44%). In comparison, injecting the missing protein (clotting factor) into the arthritis rate among U.S. males aged 18 to 44 is the person’s vein. Clotting factor VIII is used for 6.8% (57). Forsyth and colleagues (82) found that hemophilia A, while clotting factor IX is used spontaneous joint bleeding was reported in 76% of for hemophilia B (159). This process allows for persons with hemophilia. Joint bleeding typically immediate use of the protein to facilitate clotting. progresses from early synovitis to ultimate end- Treatments are determined based on bleeding stage, irreversible joint damage (140). patterns and severity of the disorder. Regular treatment is referred to as prophylaxis, and Pathophysiology of treatment that is provided on an as-needed basis Hemophilia is referred to as “on-demand” (157). According to the National Institutes of Health (159), other Severe hemophilia is typically identified in types of treatment are also possible. Desmopressin infancy, often due to knowledge of family his- is a man-made hormone used to treat people who tory or unusual bleeding (221). According to have mild hemophilia A. This hormone stimulates the Mayo Clinic (145), hemophilia A is the most the release of clotting factor VIII. Desmopressin is common type of hemophilia, characterized by not known to interfere with exercise response or insufficient clotting factor VIII. Hemophilia B adaptations. Antifibrinolytic medicines are used is the second most common type, caused by in conjunction with gene replacement therapy to insufficient clotting factor IX. Hemophilia C is help keep blood clots from breaking down. These the mildest form, caused by insufficient clotting medications are not known to interfere with factor XI. Since there is no cure for hemophilia, exercise response or adaptations, but may have the key is to control the disease. This is typically side effects that make exercise unpleasant. See accomplished by using clotting factors. Before medications table 7.7 near the end of the chapter. clotting factors VIII and IX were isolated, the life span for an individual with hemophilia was Effects of Exercise in quite short. Before the 1940s, the average life Individuals With Hemophilia span of a person with hemophilia was 27 years; with technological improvements it increased Anderson and Forsyth (18) note that people to 60 years by the 1980s (218). A survey of the with bleeding disorders vary widely in how they 2007 Healthcare Cost and Utilization Project– respond to taking part in sport and exercise. Nationwide Inpatient Sample (NIS) found that the Unfortunately, inactivity among people with mortality rates of hemophilia patients (2.2%) were hemophilia is all too common. Despite concerns, comparable to the all-cause in-hospital mortality there is little doubt as to the positive benefits of rates (1.9%) (87). The overall median age of death exercise for persons with hemophilia. As with for hemophilia-related hospitalizations was 68.3 healthy populations, regular exercise can signif- years as opposed to 72.3 years for all hospitali- icantly improve quality of life (154). Individuals zations. With the development of recombinant with hemophilia are at risk for joint bleeding factor production, the risk of AIDS and hepatitis and may have preexisting joint damage from transmission with clotting factor administration previous bleeds (81). This means that exercise has been minimized (218). programming should be conservative. Although the literature is relatively limited, it appears that Common Medications individuals with hemophilia respond positively to Given to Individuals With aerobic, resistance, and aquatic training (25, 188). Hemophilia People with hemophilia who engage in resist- According to the National Hemophilia Founda- ance training programming will bene t from tion, the preferred treatment for hemophilia is muscular strength increases as the muscles factor replacement therapy with factors made around affected joints are strengthened (104). The bene ts of resistance training for this
248 | NSCA’s Essentials of Training Special Populations population are multifold. Tiktinsky and col- for clients with hemophilia is recommended in leagues (196) researched the effect of resistance conjunction with medical treatment (188). For- training on people with severe hemophilia and syth and colleagues (81) recommend a regular found that in addition to muscular strength physical activity program including strength, increases, bleeding frequency decreased from two aerobic, balance, and range of motion activities or three times per week to one or two times per to help reduce the risks of osteoporosis, falls, and week. This investigation also documented two hemophilia-related joint changes. It is advisable people with hemophilia who had engaged in long- that the person programming exercise for clients term resistance training (more than 11 years); with hemophilia be familiar with the disease. they reported a marked decrease in bleeding Forsyth and colleagues (81) recommend that this frequency and severity. Another study that used person be someone associated with a hemophilia resistance training as part of a training regimen treatment center. With any type of exercise, it is reported no exercise-induced pain or bleeding important that people with hemophilia be given as a result of exercise (154). This investigation exercise options based on their capabilities. For noted improvements in joint motion, muscular instance, joint pain and limited range of motion strength, and distance walked in 6 minutes. The may necessitate the use of alternative forms of greatest gains were seen in those with the most exercise. Given the rather sparse and varied severe joint damage and comorbidities. nature of investigations of exercise and hemo- philia, providing solid guidelines is difficult. Aerobic exercise has also been found to be ben- However, what has been done has been progres- e cial. In response to an acute high-intensity aer- sive over time and shown to be safe and effective. obic exercise session to volitional fatigue, Groen With regard to resistance training, research sug- and colleagues (94) found signi cant increases in gests that training can occur between two and clotting factor VIII in persons with mild and mod- five times per week. Starting at the lower end of erate hemophilia A. Moderate aerobic exercise was this frequency spectrum, as well as those of other found to be more effective than mild at improv- intensity indicators, is advisable upon initiating ing markers of bone metabolism and handgrip a program. Investigations have used a full-body strength in individuals with moderate hemophilia approach, fewer multijoint exercises, and more A. Improvements in clotting factors also occurred isolated muscle group approaches. Intensity in persons with moderate hemophilia as a result of ranges are suggested to be between one and three moderate-intensity aquatic exercise (25). Regular sets, 10 to 20 repetitions (40-70% 1RM), 1 to 2 aquatic exercise has also been found to improve minutes of rest. Modes of resistance training can muscular strength around affected joints. Not vary from resistance bands to machine weights, much has been published regarding exibility pro- isometric exercises, and free weights. gramming and hemophilia. However, Anderson and Forsyth (18) state that stretching is one of the Typically clients with hemophilia have low most important parts of a conditioning program. cardiopulmonary tness. Initially, light- to mod- Mulvany and colleagues (154) used a stretching erate-level aerobic exercise is preferable. Mulvany program as part of a conditioning program. In and colleagues (154) used the estimated MHR this investigation, signi cant improvements in formula (i.e., 220 − age) to develop individualized range of motion were found in all joints. As with exercise training programming with a progression healthy populations, regular exercise can signi - cantly improve quality of life among people with Key Point hemophilia (154). Advances in prophylaxis have made it easier and Exercise Recommendations safer for people with hemophilia to exercise; for Clients With Hemophilia however, bleeding due to injury is still possible. Always consider the timing of treatment in rela- Program design guidelines for clients with tion to physical activity. hemophilia are summarized in table 7.6. Exercise
Immunologic and Hematologic Disorders | 249 Table 7.6 Program Design Guidelines for Clients With Hemophilia Type of exercise Frequency Intensity Resistance training Frequency will vary based on postexertion Avoid movements involving significant symptomatology. impact. Multijoint movement considerations Begin with two sessions per week, Choose 8-10 exercises, using a full-body a. Bodyweight resistance depending on total volume. Once approach. b. Resistance bands, suspension acclimated, consider a split program in Start with 1 set of 10-20 repetitions at training, and manual resistance which different body parts are exercised by 40-70% 1RM. c. Basic weight training such as day to achieve greater frequency up to 5 1-3 sets can be used depending on resistance machines and free times per week. training level. weights Set intensity should fall short of volitional fatigue at first and may Mode of resistance training can vary progress. based on how well exercise is tolerated. Increases in intensity beyond this If tolerated well, basic weight training point should be based on postexercise can be used. symptomatology. If doing multiple sets, consider 1-2 min Aerobic training Begin conservatively, using two or three between sets to start; be prepared to sessions per week, possibly more than once adjust as needed. Aerobic exercise mode should be per day with use of interval training. If low impact and well tolerated. No tolerated, sessions can be increased slowly Begin with 15- to 20-min sessions with a mode-specific contraindications are over time. Sessions can be performed 3-4 progression from 50% to 70% MHR. implicated. days per week. Progress to 30-min sessions most days Can also exist as a regular training program of the week. a. Water aerobics if other forms of exercise are not well b. Walking tolerated. 8-10 dynamic, low-amplitude stretches c. Cycling held for 30 s at first, then progressing d. Rowing up to 60 s. Stretching intensity should Mode of aerobic training can vary not reach the point of pain but rather based on how well exercise is tolerated. muscle tautness. Flexibility training Full-body, passive, static, flexibility exercises References: (18, 25, 81, 94, 104, 154, 188, 196) from 50% to 70% estimated maximal heart rate. adults gradually increase aerobic exercise until While some success has been shown with an 30 minutes of moderate-intensity activity is acute high-intensity bout, not much is known achieved on most days of the week. Flexibility about how such exercise will be tolerated over training should include a full-body approach. time. Exercise sessions should start out at 15 to Static stretches should be slow and gentle and held 20 minutes of continuous exercise two or three for at least 30 seconds. Over time, the number and times per week. Aquatic exercise may also be used duration of stretches can be increased. Should to achieve a desired aerobic effect. The National bleeding occur, stretches should cease until bleed- Hemophilia Foundation (18) recommends that ing is under control.
Case Study Hemophilia Sex: Male Intake Race: Hispanic Having consulted with his hemophilia treatment center, Mr. R has located a certi ed exercise Age: 19 professional who knows about his condition. The exercise professional took a full medical Height: 5 feet, 8 inches (1.73 m) history. Due to limited range of motion as well as joint pain, exercise testing was not possible. Weight: 220 pounds (100 kg) As an alternative, the exercise professional performed a walk test for time to assess Mr. R’s Body fat: 29% aerobic capabilities and a dynamometer battery for strength. Bioelectric impedance was used to Body mass index: 33.5 measure body composition. The exercise profes- sional made a referral to a registered dietician Resting heart rate: 72 beats/min who was knowledgeable about hemophilia. Blood pressure: 142/94 mmHg Initial Training Temperature: Normal Due to the client’s condition, slow progression was necessary. In addition, alternative forms History of training were required to accommodate limited ranges of motion. The primary training Mr. R is a 19-year-old college student with factor emphasis of the program was to help increase IX de ciency (hemophilia B). His disease severity cardiopulmonary capacity, overall muscular is classi ed as moderate. He was diagnosed with strength especially around the affected joints, this disease at 5 years old following episodes of and muscular exibility. Frequency of resistance intense bruising and bleeding. He has experi- training was variable until any joint swelling or enced joint tenderness, pain with movement, and other symptomatology subsided. Mr. R’s initial decreased range of motion. Due to his symptoms, strengthening program was based on his avail- he has avoided physical activity for many years. able range of motion at each joint and history As a result he has gained a signi cant amount of pain. The most fragile joints were targeted of weight during his teenage years. In turn, his for this early phase of training. This generally joint problems have gotten worse. He routinely consisted of exercises performed at 40% to receives factor IX for acute bleeds and recombi- 50% of the client’s tested isometric maximum nant factor IX for replacement therapy from a voluntary contraction (MVC), which was used hemophilia care center. His physician has also as a guide. All exercises were performed for one prescribed NSAIDs for his joint pain. Working set of 10 repetitions within the pain-free range during college is important to Mr. R; however, of motion, below the point of volitional fatigue. maintaining a job has been dif cult. Mr. R has Exercise options could include resistance bands, come to the realization that his condition is not bodyweight exercises, dumbbell exercises, or improving and that he needs to make a change other functional strengthening activities. Cardi- for the better. He consulted his physician for ovascular training was performed twice weekly further advice and was advised to exercise. and was low impact. Exercises chosen consisted of aquatic exercise, treadmill, or cross-country Goals skiing. Typical intensity began at 50% MHR. The goal was to reach 10 to 20 minutes of Mr. R would like to work on the following goals: 1. Reduce the amount of pain he experiences on a daily basis 2. Improve quality of life 3. Reduce body weight to take stress off joints 4. Make physical exercise a regular part of his treatment program 250
consistent activity. If this goal was not reached training sessions. Set volume increased from in one interval, 5- and 10-minute intervals were one to three sets per body part. Repetitions pro- used to reach it. Flexibility training followed gressed to the 10 to 20 range. Aerobic training cardiovascular training, as the brous joints of progressed to three or four 30-minute sessions persons with hemophilia are more responsive per week at 70% of the client’s MHR. Low-impact to the warming of active exercise. To begin, movements were still used. The same full-body stretches were held for 20 to 30 seconds within approach to exibility was maintained; however, the pain-free range of motion. the length of static stretches gradually increased up to 60 seconds. Exercise Progression Outcomes With adequate adaptation, resistance training intensity increased by 5% to 10% per week up to Mr. R’s progression took longer than antici- a maximum of 70% of the client’s MVC. Training pated, but he was eventually able to adopt a frequency was increased to three or four times regular program. With persistence, he was able per week. With the strengthening of the most to increase muscular strength around his most affected joints, a full-body approach could now affected joints. This made a de nite difference be used. Full-body training was divided into two in his physical capabilities and in his daily life. Training Recommendations and Contraindications for Clients With Hemophilia 1. Obtain medical permission for physical training depending on the level of severity. 2. Physical capacity should be evaluated before starting exercise programming. 3. Evaluate joint range of motion limitations before exercise selection. 4. Coagulation medication should be available for potential light to moderate bleeds. 5. Use estimated MHR to help determine aerobic exercise intensity. 6. Flexibility exercise should be performed after active warm-up. 7. Be prepared for progressions in all health-related tness areas to take much longer than in apparently healthy clients. 8. Exercise professionals should be very aware of how clients respond to training and be willing to adjust frequency, intensity, and time as needed. Avoiding painful movement is vital to this process. 9. All training should be light and low impact. 10. Resistance training can include many different modes but should begin sparingly until tol- erance can be determined. Consider bodyweight activities, lower-level modes of resistance such as tubes and bands, and machine- and free-weight movements. 11. Avoid ballistic motions when training. Use smooth, controlled movements that will reduce the chance of injury and allow proper control of movement. 12. Consider aerobic modes initially that are predictable modes of exercise so the client can more effectively exercise in a steady state. 13. Alternative modes of training are also useful. Consider aqua exercise as a possible form of aerobic exercise. 251
252 | NSCA’s Essentials of Training Special Populations Recommended Readings Cheatham, SW. Fibromyalgia: current concepts for the strength and conditioning professional. Strength Cond J 35(4):11-18, 2013. Coelho, JD and Cameron, KL. Hemophilia and resistance training: implications for the strength and con- ditioning professional. Strength Cond J 21(5):30-33, 1999. Dawes, J and Stephenson, MD. ONE-ON-ONE: training those with chronic fatigue. Strength Cond J 30(6):55- 57, 2008. Ferreira, MP and Norwood, JM. Strength training for the athlete with HIV/AIDS: practical implications for the performance team. Strengh Cond J 19(6):50-57, 1997. Williams, C and Dawes, J. Guidelines for training individuals with lupus. Strength Cond J 29(2):56-58, 2007. CONCLUSION provided in this chapter are general, and it is critical to remember that each client is an individ- Immunologic and hematologic disorders are ual. Furthermore, in some instances, clients with serious life-altering diseases. It is important for the disorders discussed in this chapter respond the exercise professional to recognize signs and to exercise differently from healthy clients. Even symptoms of these diseases. It may be that an if a client is asymptomatic, the exercise profes- individual has a previous undiagnosed illness, sional should always remember the existence of and recognition by the exercise professional will the chronic disorder. The bene ts of exercise for allow proper diagnosis by appropriate medical both improved health and quality of life cannot professionals. be underestimated. The quali ed exercise profes- sional can have a positive impact on individuals When working with clients who have previ- with immunologic and hematologic disorders by ously diagnosed immunologic and hematologic recognizing limitations and designing exercise disorders, the exercise professional should moni- programming that adapts to meet the needs and tor the client to ensure that the exercise prescrip- abilities of the client. tion is bene cial and not harmful. The guidelines Key Terms highly active antiretroviral therapy (HAART) human immunodeficiency virus (HIV) acquired immune deficiency syndrome inflammation (AIDS) kinesiophobia lupus erythematosus biological response modifiers nonsteroidal anti-inflammatory drugs chronic fatigue syndrome corticosteroid (NSAIDs) discoid lupus erythematosus postexertional malaise disease-modifying antirheumatic drugs prophylaxis rheumatoid arthritis (DMARDs) sickle cell disease fibromyalgia systemic autoimmune diseases hemophilia systemic lupus erythematosus hemophilia A hemophilia B hemophilia C
Immunologic and Hematologic Disorders | 253 Study Questions 1. Which of these is a characteristic of rheumatoid arthritis? a. occurs more frequently in men b. usually affects neck and back first c. is curable with regular exercise and medication d. originates with immune system attack on joint synovial lining 2. What is the difference between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? a. SLE affects only T-cells. b. DLE is not an autoimmune disease. c. SLE does not shorten life expectancy. d. DLE does not usually affect internal organs, only the skin. 3. A colleague presents the following initial exercise plan for a sedentary new client with lupus. p6e0r%wVe. eOk2.pReaeksisftoarn3c0e Walking on a treadmill at minutes a day, twice a week to start, progressing to four times training beginning with eight bodyweight exercises covering all major muscle groups, 1 set each at 50% estimated 1RM at a frequency dictated by symptoms. Full-body flexibility exercises held for 5 seconds, daily after treadmill exercise completed. Given this scenario, what recommendation should the exercise professional make? . a. Reduce treadmill intensity to 30% VO2peak. b. Increase resistance training to 4 days per week. c. Split treadmill exercise into three 10-minute bouts. . d. Eliminate flexibility exercises until treadmill intensity progresses to 70% VO2peak. 4. The most important consideration for clients with hemophilia when one is designing an exercise program is a. infection control b. postexertional malaise c. side effects from DMARDs and related medications d. the potential for joint damage and limits on range of motion
Medications Table 7.1 Common Medications Used to Treat Rheumatoid Arthritis Drug class and names Mechanism of action Most common side effects Effects on exercise NSAIDs (nonsteroidal anti-inflammatory drugs) celecoxib (Celebrex), NSAIDs block formation of Upset stomach, headache, easy NSAIDs are not known diflunisal (Dolobid), etodolac COX-1 and COX-2 enzymes bruising, hypertension, fluid to have negative effects (Lodine), ibuprofen (Advil, that control the formation retention, dyspepsia, gastritis, on exercise performance; Motrin, Rufen), meloxicam of prostaglandins. COX-1 increased risk of heart attack or however, some delay in (Mobic), nabumetone enzymes control the stroke, reduced blood clotting, exercise-induced fatigue has (Relafen), naproxen formation of prostaglandins reduced kidney function in those been associated with NSAID (Naprosyn, Aleve), oxaprozin involved in normal organ with hypertension or preexisting intake. Some evidence (Daypro, Duraprox), function, and COX-2 enzymes kidney problems, elevated liver suggests that NSAIDs may piroxicam (Feldene), control the formation of enzymes, worsened asthma or attenuate exercise recovery. salsalate (Disalcid), sulindac prostaglandins involved in inflammatory bowel disease, (Clinoril), tolmetin (Tolectin), the body’s inflammatory severe headache and neck ketoprofen (Orudis, Oruvail) response. By blocking stiffness, possible skin rashes the prostaglandins, the individual experiences less swelling and pain. Corticosteroids prednisone, prednisolone, Corticosteroids slow and Acne, Cushing’s syndrome, Corticosteroids are not hydrocortisone, stop the processes in the weight gain, redistribution of known to interfere with methylprednisolone (Medrol); body that make molecules fat, increased skin fragility, hair exercise performance or dexamethasone (Decadron); involved in the inflammatory growth on the face, irritability, exercise responses. triamcinolone (Aristospan); response. In addition, these agitation, psychosis, mood swings, Long-term health methylprednisolone (Solu- drugs also reduce the activity insomnia, increased susceptibility adaptations can be negated Medrol); topical steroids of the immune system by to infections, stomach irritations or as increases in cholesterol, affecting the function of the ulcers, irregular menses, potassium weight, and blood pressure white blood cells. deficiency, increased cholesterol are possible. and triglycerides, suppressed growth in children, necrosis of bone, osteoporosis, cataracts, glaucoma, muscle weakness, premature atherosclerosis, pregnancy complications Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) methotrexate, Reduce the progression of Weight gain, nausea and vomiting, The reduction of hydroxychloroquine, joint damage; often taken in severe infection, stomach pain, inflammation should cause sulfasalazine, leflunomide, combination with biologics diarrhea, cancer, kidney damage, an improvement in physical cyclophosphamide, liver problems, increased risk of function. azathioprine infection, skin rash Monitor for any unusual weakness and fatigue. Assess functional ability and disability associated with DMARDs. Assess for dizziness that might affect gait, balance, and other functional activities. Monitor pulmonary function during exercise. 254
Drug class and names Mechanism of action Most common side effects Effects on exercise Biologics Each medication stops the Serious infections, tuberculosis, abatacept, adalimumab, inflammatory response lymphoma, congestive heart Be alert for seizures or anakinra, certolizumab differently; slows, modifies, failure increased seizure activity. pegol, etanercept, infliximab, or stops the disease Assess for joint pain. golimumab, rituximab Monitor for dizziness or trembling that might affect JAK (a subcategory of DMARDs) gait, balance, or other functional activities. tofacitinib Is an inhibitor, blocks certain Bronchitis, headache, high pathways involved in the cholesterol, low blood counts, Possibly beneficial for body’s immune response increased liver enzymes; nasal, skeletal muscle adaptation. inflammation, gastrointestinal issues References: (46, 100, 147, 161, 211) 255
Medications Table 7.2 Common Medications Used to Treat Lupus Drug class and names Mechanism of action Most common side Effects on exercise effects NSAIDs (nonsteroidal anti-inflammatory drugs) celecoxib (Celebrex), diflunisal NSAIDs block formation of Upset stomach, headache, easy NSAIDs are not known (Dolobid), etodolac (Lodine), COX-1 and COX-2 enzymes bruising, hypertension, fluid to have negative effects ibuprofen (Advil, Motrin, Rufen), that control the formation retention, dyspepsia, gastritis, on exercise performance; meloxicam (Mobic), nabumetone of prostaglandins. increased risk of heart attack or however, some delay in (Relafen), naproxen (Naprosyn, (COX-1 enzymes control stroke, reduced blood clotting, exercise-induced fatigue Aleve), oxaprozin (Daypro, the formation of reduced kidney function in those has been associated with Duraprox), piroxicam (Feldene), prostaglandins involved with hypertension or preexisting NSAID intake. salsalate (Disalcid), sulindac in normal organ function, kidney problems, elevated liver Some evidence suggests (Clinoril), tolmetin (Tolectin), and COX-2 enzymes enzymes, worsened asthma or that NSAIDs may ketoprofen (Orudis, Oruvail) control the formation of inflammatory bowel disease, attenuate exercise prostaglandins involved in severe headache and neck recovery. the body’s inflammatory stiffness, possible skin rashes response. By blocking the prostaglandins, the individual experiences less swelling and pain.) Corticosteroids prednisone, prednisolone, Corticosteroids slow Acne, Cushing’s syndrome, Corticosteroids are not hydrocortisone, and stop the processes weight gain, redistribution of known to interfere with methylprednisolone (Medrol); in the body that make fat, increased skin fragility, hair exercise performance dexamethasone (Decadron); molecules involved in the growth on the face, irritability, or exercise responses. triamcinolone (Aristospan); inflammatory response. agitation, psychosis, mood However, long-term methylprednisolone (Solu- In addition, these drugs swings, insomnia, increased health adaptations can Medrol); topical steroids also reduce the activity susceptibility to infections, be negated as increases of the immune system by stomach irritations or ulcers, in cholesterol, weight, affecting the function of irregular menses, potassium and blood pressure are the white blood cells. deficiency, increased cholesterol possible. and triglycerides, suppressed growth in children, necrosis of bone, osteoporosis, cataracts, glaucoma, muscle weakness, premature atherosclerosis, pregnancy complications Antimalarial medications Antimalarial drugs Potential side effects can include Antimalarial medications hydroxychloroquine (Plaquenil), help control lupus skin rashes and pigment change, are not known to chloroquine (Aralen), quinacrine by modulating the dry skin, loss of appetite, interfere with exercise (Atabrine) immune system without abdominal bloating, stomach performance, responses, predisposing the individual cramps, and retinal damage; or adaptations. to infection, protecting less common side effects Secondary side effects against UV light, and include headaches, muscle could make exercising improving skin lesions that aches, weakness, nervousness, uncomfortable. don’t respond to topical irritability, dizziness, neurological treatment therapy. side effects, and exacerbation of psoriasis. 256
Drug class and names Mechanism of action Most common side Effects on exercise effects Immunosuppressive medications azathioprine (Imuran), Immunosuppressive Increased risk of infection, Immunosuppressive mycophenolate mofetil medications suppress suppressed signs of illness, medications are not (Cellcept), cyclosporine (Neoral, the attack by interfering increased cancer risk, nausea, known to interfere with Sandimmune, Gengraf), with the synthesis of vomiting, stomach pain, exercise performance or methotrexate (Rheumatrex), DNA to keep the cells of diarrhea, liver test abnormalities, exercise responses. leflunomide (Arava), the immune system from hepatitis, pancreatitis, allergic Secondary side effects cyclophosphamide (Cytoxan), dividing. reaction, headache, dizziness, could make exercising chlorambucil (Leukeran), nitrogen tremors, skin rashes, possible regularly difficult due to mustard (Mustargen) anemia, uric acid production enhanced susceptibility to infections. DHEA (dehydroepiandrosterone) DHEA is a mild male Acne, facial hair growth, oily DHEA is not known to hormone that has not skin, excessive sweating, lowered interfere with exercise been approved by the high-density lipoprotein in some capacity, response, or FDA for the treatment of women, increased estrogen adaptations. lupus. Although DHEA levels in postmenopausal women levels are commonly low in individuals with inflammatory diseases like lupus, the exact mechanism by which it works remains controversial. References: (58, 143, 158, 195, 208) 257
Medications Table 7.3 Common Medications Used to Treat Chronic Fatigue Syndrome Drug class and names Mechanism of action Most common side effects Effects on exercise Upset stomach, headache, easy NSAIDs are not known NSAIDs (nonsteroidal anti-inflammatory drugs) bruising, hypertension, fluid to have negative effects retention, dyspepsia, gastritis, on exercise performance; celecoxib (Celebrex), NSAIDs block formation of increased risk of heart attack or however, some delay in diflunisal (Dolobid), COX-1 and COX-2 enzymes stroke, reduced blood clotting, exercise-induced fatigue has etodolac (Lodine), ibuprofen that control the formation reduced kidney function in those been associated with NSAID (Advil, Motrin, Rufen), of prostaglandins. (COX-1 with hypertension or preexisting intake. meloxicam (Mobic), enzymes control the formation kidney problems, elevated liver Some evidence suggests nabumetone (Relafen), of prostaglandins involved in enzymes, worsened asthma or that NSAIDs may attenuate naproxen (Naprosyn, normal organ function, and inflammatory bowel disease, exercise recovery. Aleve), oxaprozin (Daypro, COX-2 enzymes control the severe headache and neck Duraprox), piroxicam formation of prostaglandins stiffness, possible skin rashes Potential side effects may (Feldene), salsalate involved in the body’s Headache, agitation, nausea, make the process of exercise (Disalcid), sulindac (Clinoril), inflammatory response. By vomiting, constipation, dry uncomfortable. A physician or tolmetin (Tolectin), blocking the prostaglandins, mouth, reduced sexual drive, other health care professional ketoprofen (Orudis, Oruvail) the individual experiences less restlessness, slightly increased should be consulted if swelling and pain.) heart rate, interactions with other symptoms become too drugs severe. Antidepressants Increased risk of infection, Immunosuppressive amitriptyline (Elavil), There are multiple classes of suppressed signs of illness, medications are not known doxepin (Sinequan), antidepressant drugs. Based increased cancer risk, nausea, to interfere with exercise desipramine (Norpramin), on the class of antidepressant, vomiting, stomach pain, diarrhea, performance or exercise nortriptyline (Pamelor), these drugs work through liver test abnormalities, hepatitis, responses. clomipramine (Anafranil), different mechanisms. Tricyclic pancreatitis, allergic reaction, Secondary side effects could imipramine (Tofranil, antidepressants affect headache, dizziness, tremors, make regularly exercising Janimine), bupropion brain chemicals involved in skin rashes, possible anemia, uric difficult due to enhanced (Wellbutrin), nefazodone pain management. Other acid production susceptibility to infections. (Serzone), mirtazapine antidepressants affect Appetite suppression, headache, Possible greater power (Remeron), fluoxetine different neurotransmitters. upset stomach, increased blood output, enhanced aerobic (Prozac), sertraline (Zoloft), Serotonin reuptake inhibitors pressure, dizziness, dry mouth, endurance, and resistance paroxetine (Paxil), cymbalta (SSRIs) interfere with nervousness, sleeplessness or to fatigue. Prevalent use of (Duloxetine) the natural reuptake of insomnia, weight loss stimulant medications may neurotransmitters. interfere with heart rate response during exercise. Immunosuppressive medications azathioprine (Imuran), Immunosuppressant mycophenolate mofetil medications suppress the (Cellcept), cyclosporine attack by interfering with (Neoral, Sandimmune, the synthesis of DNA. This Gengraf), methotrexate keeps the cells of the immune (Rheumatrex), leflunomide system from dividing. (Arava), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), nitrogen mustard (Mustargen) Stimulants caffeine, dexamphetamine, Stimulants work by increasing methylphenidate, modafinil dopamine levels in the brain. Therapeutic stimulants increase dopamine in a slow and steady manner similar to the way it is produced naturally in the brain. 258
Drug class and names Mechanism of action Most common side effects Effects on exercise Sleep aids zolpidem tartrate (Ambien), Sleep aids work through a Dry mouth, daytime drowsiness, Potential side effects may eszopiclone (Lunesta), variety of mechanisms. Many blurred vision, constipation, make the process of exercise zaleplon (Sonata), rozerem prescription sleep aids work difficulty urinating, muscle uncomfortable. (Ramelteon), lorazepam on select gamma-amino relaxation, euphoria, poor (Ativan), triazolam (Halcion), butyric acid (GABA) receptors memory temazepam (Restoril), in the brain that control levels diazepam (Valium), of alertness or relaxation. alprazolam (Xanax), diphenhydramine References: (24, 26, 58, 133, 143) 259
Medications Table 7.4 Common Medications Used to Treat Fibromyalgia Drug class and names Mechanism of action Most common side effects Effects on exercise Drugs used as pain relievers pregabalin (Lyrica): Licensed as Pregabalin binds to the alpha Blurred vision, drowsiness, fluid Potential side effects an antiepileptic, used to treat 2 delta subunit of voltage- retention in peripheral areas, lack may make the process of chronic pain gated Ca+ channels in the of coordination, weight gain, loss exercise uncomfortable. A central nervous system. of ability to focus, dizziness, dry physician or other health mouth care professional should be consulted if symptoms become too severe. Antidepressants amitriptyline (Elavil), doxepin There are multiple classes Headache, agitation, nausea, Potential side effects (Sinequan), desipramine of antidepressant drugs. vomiting, constipation, dry may make the process of (Norpramin), nortriptyline Based on the class of mouth, reduced sexual drive, exercise uncomfortable. A (Pamelor), clomipramine antidepressant, these drugs restlessness, slightly increased physician or other health (Anafranil), imipramine work through different heart rate, interactions with care professional should (Tofranil, Janimine), bupropion mechanisms. Tricyclic other drugs be consulted if symptoms (Wellbutrin), nefazodone antidepressants affect become too severe. (Serzone), mirtazapine brain chemicals involved in (Remeron), fluoxetine (Prozac), pain management. Other sertraline (Zoloft), paroxetine antidepressants affect (Paxil), cymbalta (Duloxetine) different neurotransmitters. Serotonin reuptake inhibitors (SSRIs) interfere with the natural reuptake of neurotransmitters. Analgesics—pain killers acetaminophen (Tylenol), These generally are centrally Analgesics can cause allergic Potential side effects tramadol (ConZip, Rybix, ODT, acting in that they decrease symptoms like hoarseness, may make the process of Ultram) the perception of pain by swelling, difficulty breathing, exercise uncomfortable. A reducing the flow of pain hives, itching, itching rash, upset physician or other health signals from the brain. stomach, constipation, diarrhea, care professional should dizziness, and headache. be consulted if symptoms become too severe. NSAIDs (nonsteroidal anti-inflammatory drugs) celecoxib (Celebrex), diflunisal NSAIDs block formation of Upset stomach, headache, easy NSAIDs are not known (Dolobid), etodolac (Lodine), COX-1 and COX-2 enzymes bruising, hypertension, fluid to have negative effects ibuprofen (Advil, Motrin, that control the formation retention, dyspepsia, gastritis, on exercise performance; Rufen), meloxicam (Mobic), of prostaglandins. (COX-1 increased risk of heart attack or however, some delay in nabumetone (Relafen), enzymes control the stroke, reduced blood clotting, exercise-induced fatigue naproxen (Naprosyn, Aleve), formation of prostaglandins reduced kidney function in those has been associated with oxaprozin (Daypro, Duraprox), involved in normal organ with hypertension or preexisting NSAID intake. piroxicam (Feldene), salsalate function, and COX-2 kidney problems, elevated liver Some evidence suggests (Disalcid), sulindac (Clinoril), enzymes control the enzymes, worsened asthma or that NSAIDs may attenuate tolmetin (Tolectin), ketoprofen formation of prostaglandins inflammatory bowel disease, exercise recovery. (Orudis, Oruvail) involved in the body’s severe headache and neck inflammatory response. By stiffness, possible skin rashes blocking the prostaglandins, the individual experiences less swelling and pain.) 260
Drug class and names Mechanism of action Most common side effects Effects on exercise Sleep aids zolpidem tartrate (Ambien), Sleep aids work through Dry mouth, daytime drowsiness, Potential side effects eszopiclone (Lunesta), zaleplon a variety of mechanisms. blurred vision, constipation, may make the process of (Sonata), rozerem (Ramelteon), Many prescription sleep difficulty urinating, muscle exercise uncomfortable. lorazepam (Ativan), triazolam aids work on select gamma- relaxation, euphoria, poor (Halcion), temazepam amino butyric acid (GABA) memory, and morning tiredness (Restoril), diazepam (Valium), receptors in the brain that alprazolam (Xanax), control levels of alertness or diphenhydramine relaxation. Muscle relaxants cyclobenzaprine (Amrix, Act primarily within the Blurred vision, dizziness, light- Potential side effects Fexmid, Flexeril) central nervous system at headedness, drowsiness, dryness may make the process of the brain stem to reduce of mouth exercise uncomfortable. tonic somatic motor activity influencing both gamma and alpha motor system. References: (33, 58, 133, 143, 165) 261
Medications Table 7.5 Common Medications Used to Treat HIV/AIDS Drug class and names Mechanism of action Most common side effects Effects on exercise Nucleoside reverse transcriptase inhibitors (NRTIs) abacavir (Ziagen), Inhibit reverse transcriptase, Nausea, vomiting, hypersensitivity, Risk of myocardial infarction didanosine, emtricitabine, cause DNA chain termination lethargy, fatigue, cough, myalgia, and lactic acidosis lamivudine, stavudine, arthralgia, malaise, chills, tenofovir disoproxil, lactic acidosis, mitochondrial zidovudine, azidothymidine toxicity, dilated cardiomyopathy, (AZT) neuropathy Non-nucleoside reverse transcriptase inhibitors (NNRTIs) delavirdine, efavirenz, NNRTIs bind to and alter Fatigue, headache, diarrhea, Sudden and severe change etravirine, rilpivirine the enzyme HIV needs to increased amylase, increased in muscle strength or energy make copies of itself (reverse liver enzyme, nausea, vomiting, level transcriptase). Inhibit viral decreases in bone mineral density, synthesis. Increase CD4 cell dyslipidemia, hepatotoxicity, count. Slow progression of hypersensitivity reaction, fat HIV infection and decrease redistribution, insomnia, severe severity. rash with or without fever Protease inhibitors (PIs) atazanavir, darunavir, Block protease, an enzyme Headache, depression, Arrhythmias, palpitations, fosamprenavir, indinavir, that HIV needs to make insomnia, heart block, nausea, chest discomfort, shortness nelfinavir, ritonavir, copies of itself. Prevent abdominal pain, hyperglycemia, of breath, fainting, fatigue saquinavir, tripranavir maturation of virus. Increase fat redistribution, myalgia, or weakness all possible. CD4 cell counts and decrease fever, spontaneous bleeding, May affect blood glucose viral load with slowed hemophilia, intracranial levels. progression of HIV. hemorrhage, decrease in bone May affect gait and balance. mineral density, myocardial Use caution with aerobic infarction, cholelithiasis, kidney exercise and assess exercise stone, insulin resistance, GI tolerance frequently. intolerance, hepatitis, jaundice, trunk fat increase, chronic kidney disease increase, renal atrophy Fusion inhibitor enfuvirtide Blocks HIV from entering Fatigue, conjunctivitis, cough, Monitor for excessive fatigue CD4 cells of the immune pneumonia, sinusitis, diarrhea, and weakness. system. Prevents entry of nausea, abdominal pain, HIV 1 into cells by interfering anorexia, dry mouth, pancreatitis, with the fusion of the virus weight loss, injection site with cellular membranes. reaction, myalgia, limb pain, Improves CD4 cell count. hypersensitivity reactions, herpes simplex Entry inhibitor maraviroc Blocks proteins on the CD4 Hepatotoxicity, dizziness, cough, Musculoskeletal pain, cells that HIV needs in order upper respiratory tract infection, muscle tenderness, or to enter the cells abdominal pain, appetite disorder, weakness is possible. rash, musculoskeletal pain, May affect gait, balance, allergic reaction, fever, immune and other functional reconstitution syndrome, increased activities. risk of infection 262
Drug class and names Mechanism of action Most common side effects Effects on exercise Integrase inhibitors dolutegravir, elvitegravir, Block HIV integrase, an Dizziness, fatigue, myocardial Monitor for symptoms of raltegravir enzyme HIV needs to make infarction, abdominal pain, myocardial infarction. copies of itself; decreased gastritis, hepatitis, vomiting, viral replication and renal failure, decrease in bone Dizziness or weakness might resistance to other agents affect gait, balance, or mineral density, dyslipidemia, functional activities. nausea, diarrhea, lipohypertrophy, May cause an increase in rhabdomyolysis, weakness, blood pressure, muscle increase in creatine phosphokinase cramps, and twitching, levels, insomnia, depression, rash, edema, and weight gain headache from water retention May cause anemia, which causes unusual fatigue, shortness of breath with exertion Pharmokinetic enhancers cobicistat Used in HIV treatment to increase the effectiveness of an HIV medicine in an HIV regimen References: (34, 46, 80) 263
Medications Table 7.6 Common Medications Used to Treat Sickle Cell Disease Drug class and names Mechanism of action Most common side effects Effects on exercise Upset stomach, headache, easy NSAIDs (nonsteroidal anti-inflammatory drugs) bruising, hypertension, fluid NSAIDs are not known retention, dyspepsia, gastritis, to have negative effects celecoxib (Celebrex), diflunisal NSAIDs block formation of increased risk of heart attack or on exercise performance; (Dolobid), etodolac (Lodine), COX-1 and COX-2 enzymes stroke, reduced blood clotting, however, some delay in ibuprofen (Advil, Motrin, that control the formation reduced kidney function in those exercise-induced fatigue has Rufen), meloxicam (Mobic), of prostaglandins. (COX-1 with hypertension or preexisting been associated with NSAID nabumetrone (Relafen), enzymes control the kidney problems, elevated liver intake. naproxen (Naprosyn, Aleve), formation of prostaglandins enzymes, worsened asthma or Some evidence suggests oxaprozin (Daypro, Duraprox), involved in normal organ inflammatory bowel disease, that NSAIDs may attenuate piroxicam (Feldene), salsalate function, and COX-2 severe headache and neck exercise recovery. (Disalcid), sulindac (Clinoril), enzymes control the stiffness, possible skin rashes tolmetin (Tolectin), ketoprofen formation of prostaglandins Seizures, diarrhea, epigastric Watch for seizures. (Orudis, Oruvail) involved in the body’s distress, nausea, vomiting, Monitor for allergic reactions inflammatory response. By pseudomembranous colitis, and anaphylaxis. blocking the prostaglandins, interstitial nephritis, rash, Assess muscle aches and joint the individual experiences urticaria, leukopenia, allergic pain (arthralgia). Monitor for less swelling and pain.) reaction (anaphylaxis), signs of fatigue, weakness, superinfection myalgia, or leukopenia Penicillin (fever, sore throat, signs of Drowsiness, anorexia, diarrhea, infection). Binds to bacterial cellular nausea, vomiting, constipation, Monitor injection site for wall, resulting in cell death hepatitis, stomatitis, dysuria, pain, swelling, and irritation. infertility, renal tubular Hydroxyrea dysfunction, alopecia, erythema, Be alert for signs of pruritus, rashes, leukopenia, leukopenia (fever, sore Interferes with DNA anemia, thrombocytopenia, throat, signs of infection), synthesis; may alter hyperuricemia, chills, fever, thrombocytopenia (bruising, characteristics of red blood malaise nose bleeds, bleeding gums), cells; death of rapidly or unusual weakness and replicating cells; decreased fatigue due to anemia. frequency of painful crises Assess drowsiness that might and decreased need for affect gait, balance, and transfusions in sickle cell other functional activities. anemia Implement resistance exercises and aerobic training to maintain muscle strength and aerobic capacity. Use caution with aerobic exercise. Assess tolerance frequently (blood pressure, heart rate, fatigue levels). References: (46, 149) 264
Medications Table 7.7 Common Medications Used to Treat Hemophilia Drug class and names Mechanism of action Most common side effects Effects on exercise Antidiuretic, antihemorrhagic drugs desmopressin acetate Desmopressin releases Headache, nausea, upset stomach Side effects may make (DDAVP) clotting factor VIII from or stomach pain, diarrhea, exercise unpleasant, but where it is stored in the flushing of the face, water are not known to interfere body tissues. retention with exercise response or adaptations. Antifibrinolytic agents Amicar acts by stopping Upset stomach, pain in the Side effects may make epsilon aminocaproic acid the activity of the enzyme stomach, tiredness, dizziness, exercise unpleasant, but (Amicar) plasmin, which dissolves diarrhea are not known to interfere clots Pale skin, trouble breathing with with exercise response or exertion, unusual bleeding or adaptations. tranexamic acid Blocks the breakdown of bruising, tiredness or weakness, Side effects may make (Cyklokapron) clots, thereby preventing dizziness, diarrhea exercise unpleasant, but bleeding are not known to interfere with exercise response or adaptations. Blood product Cryoprecipitate is a source This is a replacement therapy and There are no known side cryoprecipitate of clotting factor VIII, is not known to have side effects. effects that would affect fibrinogen, fibronectin, exercise response or clotting factor IX. adaptation. References: (157, 159) 265
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Neuromuscular 8 Conditions and Disorders Patrick L. Jacobs, PhD, CSCS,*D, FNSCA Stephanie M. Svoboda, MS, DPT, CSCS Anna Lepeley, PhD, CSCS After completing this chapter, you will be able to ◆ describe the physiological characteristics of the various neurological disorders; ◆ discuss the health-related consequences for each of the special populations with neurological disorders; ◆ explain how different neurological disorders affect the ability to exercise, acute exercise responses, and chronic adaptation to exercise training; ◆ explain the benefits of appropriate exercise conditioning in persons with various neurological disorders; and ◆ design appropriate exercise programming specific to the needs of individuals with particular neurological disorders. 267
268 | NSCA’s Essentials of Training Special Populations The nervous system is a complex, highly special- Nonprogressive neurological disorders are ized organized network of nerve cells respon- conditions that do not continue to exhibit declin- sible for the coordination of all volitional and ing neurological functioning following an initial involuntary actions and functions of the human episode of disease or mechanical injury. There are body. The nervous system anatomically consists signi cant reductions in function with an initial of the central nervous system (CNS), made up episode with no further primary declines there- of the brain and spinal cord, and the peripheral after. These nonprogressive conditions include nervous system (PNS), which includes nerves cerebral palsy, stroke, head injury, and spinal cord that connect the CNS with the rest of the body, injury. Nonprogressive disorders are generally a including skeletal muscle and organs. Function- result of traumatic injury to the CNS, either the ally, the PNS is divided into the somatic system, brain or spinal cord. which mediates volitional movement; the auto- nomic system, which is responsible for control Key Point of internal organs; and the enteric system, which regulates the gastrointestinal system. The PNS is Common progressive neuromuscular disorders also composed of ascending (afferent or sensory) include multiple sclerosis, Parkinson’s disease, and descending (efferent or motor) neural tracts. and muscular dystrophy. Cerebral palsy, trau- matic brain injury, stroke, and spinal cord injury Neuromuscular disorders are medical condi- are nonprogressive neurological disorders. tions that result in a decline in functioning of the body’s various nervous systems or the muscular MULTIPLE SCLEROSIS system. These medical conditions may arise from biological causes or from genetic defects. Neuro- Both voluntary and involuntary actions of the logical disorders may also be caused by injuries human body are controlled and coordinated by to the brain or spinal cord or in some cases by the nervous system. The functional units of the degenerative diseases. The location and severity nervous system, neurons, possess the unique of the tissue damage determine the short-term ability to generate electrochemical signals that are outcomes of the injury or disease process, as well transmitted along the neural axon. Some neurons as the long-term potential for recovery. Direct are surrounded by a myelin sheath. Myelin is a trauma to the brain may result in cerebral palsy fatty white substance that establishes an elec- if the injury occurs during pregnancy, during trically insulating layer, or sheath, around the childbirth, or within the rst three years of life. neuron that is essential for proper functioning of Injury to the adult brain produces traumatic brain the nervous system. The myelin sheath increases injury, while interruption of blood ow to the electrical resistance across the neuron membrane, brain may result in a stroke. Multiple sclerosis thereby preventing leakage of electrical impulses. and Parkinson’s disease are neurological disease processes that affect the peripheral nerves and the Demyelination, the loss of the myelin sheath, brain tissue in different populations. is the primary characteristic of some neurode- generative autoimmune diseases in which the Neuromuscular disorders can be classi ed as deterioration of the myelin layer dramatically either progressive or nonprogressive. Progressive weakens the electrochemical signals. Signi cant neurological disorders are conditions that involve loss of myelin slows or blocks all electrochemical a continuing and progressive deterioration of signals from the brain to the body. functioning. These disorders include multiple sclerosis, Parkinson’s disease, and muscular The most common of these diseases is multi- dystrophy. These progressive neuromuscular ple sclerosis, which affects either or both of the conditions vary in rate of development and CNS (brain and spinal cord) and the PNS. Other commonly have periods of relapse and periods neurodegenerative autoimmune diseases that of remission. Progressive neuromuscular disor- involve loss of myelin include transverse myelitis, ders are generally caused by disease processes or Guillain-Barre syndrome, leukodystrophy, genetic factors. and Charcot-Marie-Tooth disease. Common
Neuromuscular Conditions and Disorders | 269 characteristics of these diseases include muscular individuals and can last anywhere between days weakness, tingling or numbness, visual limita- and months. Exacerbations are interrupted by tions, heat sensitivity, reduced coordination and remission periods, or times in which patients’ balance, fatigue, and disturbance of cognitive neurological functions stabilize and do not processes including speech, memory, or both. worsen. During remission, people may return to their preexacerbation condition with no symp- Pathology of Multiple toms, or they may experience some small ongoing Sclerosis symptoms (166). Multiple sclerosis (MS) is a progressive autoim- Fifteen percent of MS cases are diagnosed as mune disorder characterized by deterioration primary progressive, which is a type of MS in of the myelin sheath. The myelin sheath covers which neurological function deteriorates from billions of nerve cells in the body, and its pur- disease onset without any signi cant remissions, pose is to aid in the speed and transmission of although the symptoms may brie y plateau or CNS signals. In individuals with MS, the myelin possibly even appear to be temporarily improved. sheath and the underlying neurons undergo Otherwise, these patients experience slowly dete- demyelination that leads to a breakdown in signal riorating neurological function (166). transmission. Of the 85% of relapsing–remitting MS cases, Individuals af icted with the disease experi- 50% will be considered as secondary progres- ence a wide array of symptoms that vary between sive within the rst 10 years of diagnosis and individuals (36, 84). These symptoms are due 90% within 25 years (240). These individuals will to the breakdown in nerve signal transmission experience less recovery following attacks and and depend on where exactly the demyelization disability progressing over time with deteriorating occurs. Individuals most commonly experience neurological function (166). fatigue, numbness, walking problems, balance impairments, coordination impairments, bladder Pathophysiology of Multiple dysfunction, bowel dysfunction, vision problems, Sclerosis dizziness, vertigo, sexual dysfunction, cognitive dysfunction, pain, emotional changes, spasticity, Multiple sclerosis is most commonly seen in and depression (12, 24, 36, 42, 84, 112, 195). In Caucasian women (224). Women are two to three addition, other less common symptoms may be times more likely to develop the disease than men, seen, such as speech disorders, swallowing prob- and Caucasians are twice as likely to develop the lems, headache, hearing loss, seizures, tremors, disease as any other race (181). The disease is most breathing problems, and itching (11, 60, 178). often diagnosed between the ages of 20 and 40 and Despite these symptoms, people with the disease is the most prevalent neuromuscular disease seen experience a normal life span. It is often dif cult in young adults (72, 202). The National Multiple to diagnose MS, as these symptoms can appear Sclerosis Society estimates that 2.3 million people similar to symptoms of other diseases. are affected worldwide (138, 166). Although MS is most commonly seen in adults, estimates suggest Individuals affected by MS also experience a that 8,000 to 10,000 individuals under 18 years wide range of disease courses and outcomes. There old suffer from this disease (164). are four types of MS: relapsing–remitting, secondary progressive, primary progressive, and progressive– The de nitive cause of MS is unknown; how- relapsing. Eighty- ve percent of cases are initially ever, scientists offer four possible explanations diagnosed as relapsing–remitting MS (26). In for its origin: immunologic, environmental, these cases, patients experience clearly de ned infectious, and genetic (228). Some speculate exacerbations or are-ups. These are times when that individuals with MS experience an abnormal the CNS experiences in ammation and in turn, immune-mediated response in which myelin and previously seen symptoms rapidly worsen or nerve bers are attacked by the body (202). Spe- new symptoms arise. Exacerbations vary among ci cally, the myelin sheath is attacked by a white blood cell group called T cells. In turn, this causes
270 | NSCA’s Essentials of Training Special Populations tissue damage and in ammation, leading to scar Individuals with MS are commonly prescribed tissue (sclerosis) and blockage in signal transmis- medications in three primary categories. First, sion. This blockage in signal transmission causes after they have been diagnosed with MS, a phy- messages to become lost or distorted, leading to sician is likely to prescribe a disease-modifying the symptoms of MS. drug in an attempt to reduce the frequency and severity of attacks, reduce the damage to the CNS, Secondly, scientists hypothesize that MS may be and slow the progression of the disease (193). caused by environmental factors. (9). This theory Some of these medications, such as interferon, originated from epidemiological data showing that have the potential for reducing the capacity to persons are more susceptible to MS the farther they exercise as well as the capacity to recover between live from the equator. (219). Along the same lines, training sessions. it was also theorized that these individuals get less sunlight, leading to less vitamin D, and therefore Secondly, if a person with MS is experiencing do not receive the positive impact that vitamin D a signi cant exacerbation interfering with her has on immune function. (9). In addition, a pattern ability to function or her safety, a physician may of children being born in an environment with a administer a large dose of corticosteroid to reduce low risk for developing MS and moving to a high- the time of the are-up (130). Corticosteroid med- risk environment before puberty increased their ications such as prednisone and methylpredniso- chances of developing the disease (5, 10). lone reduce in ammation of the CNS but carry with them a risk of reducing exercise capacity. Scientists have also shown that demyelination and in ammation can be caused by viruses; there- Finally, individuals with MS may also take fore they are looking at several different viruses medications to help manage the following symp- or bacteria as a possible cause for MS: measles, toms: bladder and bowel dysfunction, depres- canine distemper, human herpes virus-6, Epstein- sion, erectile dysfunction, dizziness and vertigo, Barr, and Chlamydia pneumoniae (9, 100). fatigue, nausea and vomiting, pain, itching, spas- ticity, and tremor (70, 73, 211). Medications may Finally, the role of a person’s genetics in rela- alleviate these symptoms, which may allow an tion to developing MS is being explored (79). increased ability to engage in purposeful exercise Individuals may be genetically susceptible to but training. Conversely, side effects of these medi- may not directly inherit MS; however, there may cations include drowsiness, dizziness, blurred be certain gene markers making a person more vision, fatigue, and weakness, which may reduce susceptible to developing MS if exposed to the exercise capacity and balance. necessary stimuli. For example, if a person has a Effects of Exercise in rst-degree relative with the disease, the chances Individuals With Multiple increase from 1 in 750 to 1 or 2 out of 40 that he Sclerosis or she will also develop the disease (165). The efficacy for exercise, specifically resistance Common Medications Given training, in persons with MS has been widely to Individuals With Multiple established (116). The goals of an exercise program Sclerosis for persons with MS are to improve and maintain important functions such as activities of daily Multiple sclerosis is a disease process without living. Participating in exercise will not cure or a cure. The progression of MS and the associ- slow the disease progression (48), but it will allow ated symptoms vary appreciably with a variety people to experience a higher quality of life (152). of medical treatments for those symptoms. See Progressive resistance training (PRT) has been medications table 8.1 near the end of the chapter shown to positively affect strength. For example, for listings of common medications for persons Dodd and colleagues (55) assigned individuals with MS, the mechanism of action, and the most with relapsing–remitting MS to either a PRT group common side effects of those drugs as well as or a control group for 10 weeks. After training common effects of these medications on the ability to engage in exercise training.
Neuromuscular Conditions and Disorders | 271 two times per week for 10 weeks, the PRT group guidelines for clients with MS are summarized improved their strength, muscular endurance, in table 8.1. Persons with MS may benefit from fatigue level, and quality of life more than the using seated resistance machines as opposed to control group. upright free weight activities if their balance is compromised. Resistance training should be initi- Another research team examined the effects of ated with resistance levels at the 15RM (repetition an eight-week PRT program in subjects with MS. maximum) level for one to three sets each of four These subjects improved their isometric strength, to eight exercises using a total body program. muscular endurance, maximal power, muscular Training criteria can potentially be increased hypertrophy, and walking speed following the progressively but slowly, over weeks, to three or intervention (48). A third research group also four sets per exercise at 8RM to 15RM intensity demonstrated the ef cacy of PRT in people with for two or three sessions per week. MS; subjects in this study were assigned to either a PRT group or a control group. Individuals in the The modes of aerobic training suitable for intervention group trained their lower extremity persons with MS include indoor recumbent muscles two times per week for 12 weeks. At the cycling, arm–leg ergometry, aquatic exercise, conclusion of 12 weeks, the PRT group improved and treadmill walking. Aerobic training recom- their muscle strength and functional mobility (38). mendations call for two or three weekly sessions Filipi and colleagues (65) examined the effects at a light to moderate intensity beginning with of PRT on balance and gait parameters as well 10- to 40-minute sessions. These clients will also as muscular strength in patients with MS. These bene t from a general static stretching program of individuals exercised two times per week for six low-duration stretching, as opposed to dynamic months. They demonstrated improvements in bal- stretching, since persons with MS are quite prone ance, gait, and muscle forces generated during gait. to spasticity and many have balance limitations (167). Exercise Recommendations for Clients With Multiple Aquatic exercise, either swimming laps or par- Sclerosis ticipating in cardiovascular or resistance training in the pool, is a popular and ef cient way for this Clients with MS can benefit from both resistance population to exercise (197). The water temper- and aerobic training (38, 39). Program design ature should be kept cool, less than 85°F (29°C), to avoid overheating (108). Table 8.1 Program Design Guidelines for Clients With Multiple Sclerosis Type of exercise Frequency Intensity Volume Start with 1-3 sets per exercise Resistance training Begin with one or two sessions Begin with four to eight of 10-12 reps. per week. exercises with resistance of Potentially increase to 3-4 sets Modes of training Increase to two or three 15RM emphasizing multijoint per exercise. a. Weight training machines weekly sessions as tolerated. approach. Increase intensity If multiple sets, then 1-2 min and free weights slowly and progressively to 8- between sets. b. Bodyweight resistance to 10RM. c. Elastic tubing Recovery periods of 2-4 min. Begin with 10- to 20-min sessions. Aerobic training Begin with one session per iBonretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 Gradually increase to 30- to week. <75% MHR, or RPE of 9-13 on 40-min sessions. Modes of training Progress to 2-3 days per week. Borg 6- to 20-point scale. a. Treadmill walking Increase intensity gradually. b. Cycling c. Arm and leg cycling d. Rowing e. Aquatic exercise References: (38, 39)
272 | NSCA’s Essentials of Training Special Populations Exercise Modi cations, Key Point Precautions, and Contraindications for Clients Persons with MS should always perform exercise With Multiple Sclerosis training in well-ventilated areas with relatively cool temperatures. Even slight increases in inter- Fatigue is a common symptom seen in clients with nal body temperature may acutely limit nerve MS (121). This may limit a person’s ability to exer- conduction in demyelinated nerves and over cise on a given day. To avoid further increasing time may hasten further demyelination. fatigue, exercise should not be performed maxi- mally or to volitional fatigue or failure. In addi- should remain well hydrated in order to further tion, all exercises need to be progressed slowly. combat heat stresses. Clients with MS are very sensitive to external Another concern arises when a client is expe- and internal increases in heat (45). An increase riencing an exacerbation, or are-up. Exercise in internal body temperature of as little as half should be discontinued until the attack has a degree can further complicate a demyelinated completely subsided. When it is deemed safe to nerve’s ability to conduct an impulse (199). Due to return to exercise, it may be necessary to adjust this sensitivity, exercise should be performed in the exercise prescription to match the person’s a cool (72-76°F [22-24°C]) indoor air-conditioned new level of ability. It is possible for people to facility; exercise in the sun or any humid envi- regain all preattack functions, but they may now ronment is not recommended. Sensitivity to the also have some new symptoms. heat may be further compromised by a decreased sweating response seen in some clients with MS Also, clients with MS often use wheelchairs, (45). Pre- and postexercise cooling is a good canes, and walkers. Persons administering exer- strategy for helping with the natural increase in cise programs to this population should be famil- temperature with exercise. In addition, the client iar with proper use of this equipment and proper ways of aiding transfers. Case Study Multiple Sclerosis Mrs. F is a 46-year-old woman who was diag- self-reported that she has not exercised in years. nosed with relapsing–remitting MS four years The exercise professional started Mrs. F’s ago. She works at home on the computer. She has dif culty getting around the community exercise sessions in a cool-water pool. The ses- and recently started walking with a rolling sions began with shallow-end water walking walker that has a folding seat. She gets fatigued and deep-end water “jogging” for cardiovascu- easily. She wanted to do more activities outside lar conditioning. Mrs. F was also instructed in of her home, so she enrolled at a tness center. resistance exercises with aqua-dumbbells and Her daughter hired an exercise professional to work with Mrs. F three days per week for an exibility activities. hour at a time. After one month of water activities, Mrs. Mrs. F’s neurologist cleared her to exercise F started exercising in the gym for half of with instructions not to exercise if she is having her sessions. She started her sessions with a an exacerbation of symptoms or if she is overly cardiovascular warm-up of either recumbent fatigued on a particular day. Mrs. F is taking cycling or recumbent arm–leg ergometry. She disease-modifying drugs, has a body mass performed strengthening exercises using the index (BMI) of 32, and has prehypertension. She seated machines in the gym. Next, she per- formed balance and posture activities. All ses- sions concluded with static stretching.
Neuromuscular Conditions and Disorders | 273 After three months of training, Mrs. F and did not experience any exacerbations. She self-reported that she felt better than she had improved her muscular strength and endur- in years and had more energy. She started ance, exibility, aerobic endurance, and ability working outside of her home three half-days to get around the community. She also reduced per week. In the three-month period, she her blood pressure slightly and improved her canceled two sessions due to feeling fatigued BMI to 30. Recommended Readings Dalgas, UE, Stenager, E, and Ingemann-Hansen, T. Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training. Mult Scler 14:35-53, 2008. Kjølhede, TK, Vissing, K, and Dalgas, U. Multiple sclerosis and progressive resistance training: a systematic review. Mult Scler 18(9):1215-1228, 2012. Latimer-Cheung, A, Pilutti, L, Hicks, A, Martin Ginis, K, Fenuta, A, MacKibbon, K, and Motl, R. Effects of exercise training on tness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Arch Phys Med Rehabil 94:1800-1828, 2013. Motl, R and Pilutti, L. The bene ts of exercise training in multiple sclerosis. Nat Rev Neurol 8:487-497, 2012. White, L and Dressendorfer, R. Exercise and multiple sclerosis. Sports Med 34(15):1077-1100, 2004. PARKINSON’S DISEASE for smooth and coordinated body movements. The hallmark signs of PD include tremor of a limb, Parkinson’s disease (PD) is a progressive neuro- bradykinesia (slowness of movement), rigidity, logical disorder that influences volitional move- and poor balance (97). In addition, individuals ment. This disease develops slowly and is most may demonstrate small, cramped handwriting, prevalent in older persons. The most common stiff facial expressions, a shuffled walk or a fes- symptom of PD is muscular tremors. However, tinating gait pattern, muffled speech, difficulty this disease commonly results in muscular swallowing, and depression (97, 127). Diagnosis of stiffness and slow movements. Other symptoms PD is difficult and may be done only after a thor- include a lack of facial expression, lack of arm ough examination by a neurologist. Additional swing during walking, and slurred speech. While blood work and magnetic resonance imaging tests there is no cure for PD at this time, medications may be ordered to rule out other diseases that also may reduce the symptoms. show parkinsonism symptoms, but there is no one test that can identify PD (30). Each case is unique Pathology of Parkinson’s in that the progression and level of disability vary Disease greatly between individuals (187). Parkinson’s disease is the second most common Pathophysiology of neurodegenerative disease. It is a progressive Parkinson’s Disease brain disorder caused by the death or impairment of neurons in the substantia nigra region of the The cause of PD is currently unknown. Spec- brain. These neurons are responsible for the pro- ulation exists that there might be a genetic or duction of dopamine, a chemical that sends mes- environmental link to PD (4). Approximately sages to the area of the brain that is responsible 15% to 25% of people with PD report having a
274 | NSCA’s Essentials of Training Special Populations relative with PD (185). Scientists are studying carry increased risk of blurred vision, drowsi- gene mutations that affect dopamine cell func- ness, and confusion with limitations in memory tion, but no definitive result has been obtained (207, 230). The COMT inhibitors are used to yet (223). Being exposed to environmental toxins prolong the duration of activity of levodopa (103). such as manganese, carbon monoxide, and cer- Common side effects of COMT inhibitors include tain peptides may increase the risk of developing drowsiness and dyskinesia (involuntary muscle PD (114). movements) (6). Medications table 8.2 near the end of the chapter provides an outline of the Common Medications side effects of each of these drug classes and the Given to Individuals With limitations (e.g., reduced exercise capacity and Parkinson’s Disease balance) that these medications may place on the capacity of the person to engage in regular There are currently no medications to slow or stop training sessions. the progression of PD, but there are many med- ications used to treat the associated symptoms. If medications are not successful in treating Most PD symptoms are due to a lack of dopamine; the symptoms of PD, the individual may be a therefore, increasing dopamine can help a person candidate for brain surgery (253). A deep brain to experience more natural body movements and stimulator is implanted into the brain with the less stiffness (232). goal of minimizing symptoms. The most commonly prescribed medication Effects of Exercise in used in the treatment of PD is levodopa (22), Individuals With Parkinson’s which is altered by brain enzymes to produce Disease dopamine; this in turn minimizes the slowness, stiffness, and tremor commonly seen in PD. It was previously thought that people with PD Common side effects of levodopa include nausea should not participate in resistance training pro- and loss of appetite as well as light-headedness, grams for fear of increasing rigidity (206); how- confusion, hallucinations, and reduced blood ever, studies have found that resistance training in pressure (78, 249). These side effects could poten- individuals with PD improves numerous outcome tially limit exercise capacity and ef ciency or measures. Resistance training has been shown to place the individual at increased risk of injury. increase muscle strength, mobility and walking Levodopa was rst used 30 years ago, and since capacity, muscular endurance, balance, and fat- then another class of drugs, dopamine agonists, free mass in people with PD (21). has been developed. The different dopamine agonists vary in chemical structure, duration of People with PD have been shown to expe- action, and side effects but may also reduce the rience strength gains similar to those in age- capacity for exercise training and balance. matched peers without PD following an eight- week resistance training program, in which In addition to levodopa and dopamine agonists, participants trained the lower body two times other medications are available to improve body per week (210). In addition to documenting coordination that work by mechanisms other increased strength, this study also found that than via dopamine receptors. These medications people with PD increased their stride length, are classi ed as anticholinergic, monoamine oxi- walking velocity, and postural angles following dase B (MAO-B) inhibitors, catechol-O-methyl resistance training. transferase (COMT) inhibitors, and others, each of which has several brand names (98, 265). Another research group examined the effects of two different training interventions on balance Anticholinergic medications are used to outcome measures in individuals with PD (89). reduce spasm activity in persons with PD but In this study, subjects with PD were assigned to
Neuromuscular Conditions and Disorders | 275 either a balance training intervention or a pro- jects with PD were assigned to either a standard gram with balance training and high-intensity care group or a resistance training group that resistance training. Both groups trained three underwent eight weeks of lower extremity times per week for 10 weeks. Both training groups exercise two days per week. The training group increased their performance during a balance increased leg press strength more than the con- test, but this increase was more profound in trol group after the eight-week training period the group that included resistance training. In (213). addition, both groups improved their strength; however, the strength gains were much higher in Exercise Recommendations the combined group. for Clients With Parkinson’s Disease Dibble and colleagues (53) examined the safety and feasibility of high-force eccentric Persons with PD may benefit from participation resistance training for individuals with PD. in appropriate programs of exercise. However, the Participants engaged in 12 weeks of eccentric research on the application of exercise training ergometer training three times per week. It was in persons with PD has not established specific found that creatine kinase levels did not exceed recommendations for this group. Therefore, rec- the threshold for muscle damage, subjective ommendations for exercise with PD are typically reports of muscle soreness were low, participants based on the general recommendations for older were compliant, and total work and isometric adults. Program design guidelines for clients force increased over time. In another study, the with PD are summarized in table 8.2. Resistance same research group contrasted the effects of a training may be performed initially with one set 12-week eccentric resistance training ergometer each of several exercise movements, emphasizing intervention with an evidence-based exercise multijoint exercises. Training should begin with program (52). Both groups trained three days per light to moderate resistance levels of 40% to 80% week for 10 weeks. The eccentric training group 1RM for 10 to 12 repetitions per set. Frequency displayed signi cantly greater improvements of training may begin with one or two sessions in all outcome measures including gait speed, per week and increase to three or four weekly timed up and go, quality of life measures, and sessions as tolerated. muscle force. In addition to a sound aerobic and resistance In 2007, Hass and colleagues not only added training program, these clients will likely bene t to the body of literature with evidence for the from balance training. Clients with PD have a ef cacy of resistance training in individuals with dif cult time moving their center of mass outside PD but also demonstrated the ef cacy of creatine their base of support, and also have poor reaction monohydrate in people with PD (82). Subjects times, which can result in falls. They should be were assigned to either a creatine or a placebo instructed in basic reaching and balance activities; group; all subjects in the study participated in however, it may not be appropriate to exercise two sessions per week of resistance training for on unstable surfaces (foam, BOSU, BAPs board, 12 weeks. Muscle endurance and fat-free mass and so on). increased in both groups; both groups improved their one repetition maximum (1RM) strength Clients with PD also tend to become rigid and (more in the creatine group), and the creatine develop contractures over time. These clients can group also signi cantly improved the three- bene t from stretching, exibility, and mobility repetition sit-to-stand time. programs for all major muscle groups and joints. Speci cally, clients with PD tend to develop The effects of a moderate-volume, high-load a kyphotic posture, so more time should be resistance training program in individuals with spent on stretching their anterior trunk muscles PD have also been examined. In one study, sub-
276 | NSCA’s Essentials of Training Special Populations Table 8.2 Program Design Guidelines for Clients With Parkinson’s Disease Type of exercise Frequency Intensity Volume Resistance training Begin with one or two Begin with 8-10 exercises Start with 1 set per exercise sessions per week. with resistance of 40-60% of 10-12 reps. Modes of training Potentially progress to 4 days 1RM (and progress to 60-80% Increase to 2-3 sets per a. Weight training machines per week, split routine. 1RM), emphasizing multijoint exercise as tolerated. and free weights approach. If multiple sets, then 1-2 min b. Bodyweight resistance between sets. c. Elastic tubing Begin with one session per iBonretgehniensaiwrttyirtoahftle3ig0rhe%tsettorovme<,o6od0re%5ra5V%t.eO2 Begin with 15- to 20-min Aerobic training week. to <75% MHR, or RPE of 9-13 sessions. Progress to 4 or more days per on Borg 6- to 20-point scale. Gradually increase to 30-min Modes of training week as tolerated. Increase intensity gradually. sessions. a. Walking b. Cycling c. Rowing d. Reciprocal press–pull exercise Reference: (61) (abdominal muscles) rather than performing loss of balance. Also, because of tremor and poor trunk exion exercises like crunches. coordination, upright or free weight exercise might not be safe in this population. These clients Exercise Modi cations, should not use a treadmill and instead can bene t Precautions, and from walking over ground or using a stationary Contraindications for Clients bicycle with foot straps. Along the same lines, With Parkinson’s Disease these clients should typically use resistance train- ing machines rather than free weights. Safety is the most important consideration when working with a person with PD. As previously In addition to safety, clients with PD should mentioned, these clients experience changes ask their physician when is the best time to exer- in their movement patterns, such as a slower cise given their medication schedule. There is a walking speed, decreased ability to pick up their window after taking medication during which feet, decreased speed of movement, and poor symptoms are most controlled, and this would balance. These clients find it difficult adapting to likely be the best time for a client to exercise. a dynamic environment; therefore, the exercise Clients should also be reminded that it is very professional should take care to train at times important not to skip taking their medications when the facility is not too busy or provide a quiet unless instructed to do so by their physician. room to exercise in. In addition, the floor should be clear of anything the client could trip over The exercise professional must be cognizant (exercise equipment, area rugs, cords, and so on). that heart rate, blood pressure, and thermoregu- lation might have to be monitored more closely Depending on the person, the client may be a in clients with PD due to autonomic nervous candidate to participate in group classes or may system dysfunction (269). These clients are at need closer supervision. The exercise professional risk for orthostatic hypotension and should be should be near the client at all times in case of a reminded to avoid the Valsalva maneuver. Finally, they are more susceptible to fatigue and should be instructed to work at submaximal levels.
Case Study Parkinson’s Disease Mr. B is a 72-year-old man who was diagnosed more con dent, he began arriving to his appoint- with PD by a neurologist one year before joining ments early and performing his cycling before the tness center. He has a mild resting tremor his sessions with the exercise professional. After and a decrease in walking speed; he fell one Mr. B felt comfortable cycling on his own, he time at home last year but was not injured. Mr. spent the beginning of his sessions walking while B completed two months of physical therapy supervised. During walking he was coached to after the fall but had not been exercising since stand upright, swing his arms, and take long being discharged from physical therapy. When steps. The coach stayed close to Mr. B during this he joined the tness center, he reported that he activity in the event of loss of balance. was too nervous to exercise alone and would like to work with an exercise professional three After the cardiovascular warm-up, Mr. B per- times per week; he reported that he could afford formed resistance training for all major muscle 30-minute sessions. After meeting Mr. B for a groups. He used the following machines most consultation, the exercise professional learned often: leg press, leg curl, leg extension, chest that he would like to become active again and press, shoulder press, seated row, triceps exten- is afraid of falling. sion, and biceps curl. Exercises were performed for three sets of 10 repetitions with a 45-second The neurologist cleared Mr. B for exercise but break in between sets. did not give any speci c instructions or precau- tions. Mr. B was taking levodopa, his BMI was 27, After resistance training, Mr. B was instructed and his blood pressure was 123/75 mmHg. He in double- and single-leg balance activities on even had no other signi cant past medical or surgical surfaces. All sessions concluded with exibility history or cardiovascular contraindications to activities focusing on all major muscles with an exercise. emphasis on trunk extension and knee extension. Mr. B’s exercise sessions consisted of recum- After three months, Mr. B feels more con dent bent cycling, supervised overground walking, in the weight room and trains on Saturdays with- strength training using machines, balance train- out his coach. He reports no longer being fearful ing, and exibility training. Mr. B began his rst of falling at home and feels more satis ed with sessions with cycling to warm up. As he became his life. He has increased his strength, cardiovas- cular endurance, balance, exibility, and posture. Recommended Readings Brienesse, L and Emerson, M. Effects of resistance training for people with Parkinson’s disease: a systematic review. J Am Med Dir Assoc 14:236-241, 2013. Dibble, L, Addison, O, and Papa, E. The effects of exercise on balance in persons with Parkinson’s disease: a systematic review across the disability spectrum. J Neurol Phys Ther 33:14-26, 2009. Falvo, M, Schilling, B, and Earhart, G. Parkinson’s disease and resistive exercise: rationale, review, and recommendations. Mov Disord 23(1):1-11, 2008. Goodwin, V, Richards, S, Taylor, R, Taylor, A, and Campbell, J. The effectiveness of exercise interventions for people with Parkinson’s disease: a systematic review and meta-analysis. Mov Disord 23(5):631-640, 2008. Lima, LO, Scianni, A, and Rodrigues-de-Paula, F. Progressive resistance exercise improves strength and physical performance in people with mild to moderate Parkinson’s disease: a systematic review. J Physiother 59(1):7-13, 2013. 277
278 | NSCA’s Essentials of Training Special Populations MUSCULAR DYSTROPHY later in life, between ages 5 and 10, and progress more slowly (109). Individuals with BMD also Muscular dystrophy (MD) is a group of progres- experience muscle cramps (234). Boys with DMD sive muscular disorders characterized by damage and BMD eventually need to use wheelchairs for to the muscle’s structure and progressive muscle locomotion. They also tend to have lower than weakness. Some authorities argue that there average IQs, cognitive impairments, and learning are more than 30 types of MD, but most agree disabilities (267). Boys with DMD used to survive that there are 9 primary types. The two most only into their teens due to complications with the common types are Duchenne (DMD) and Becker heart and respiratory muscles, but with advances (BMD) (68). In both DMD and BMD, there is a in medical care are now living into their 30s; boys dysfunction with the muscle protein dystrophin with BMD survive into mid or late adulthood (174). Dystrophin is responsible for keeping the (128, 188). muscle cells intact. Individuals with DMD have a complete lack of dystrophin, while those with The most common adult form of MD is myo- BMD have dystrophin but it only partially func- tonic (MMD) (99). Myotonic MD affects women tions properly. Both DMD and BMD are X-linked and men equally, is inherited, occurs in 1 in 8,000 recessive disorders, which means that they must live births, and is usually seen in people between be inherited from a mother who is a carrier of the 20 and 30 years old (162). There are two types of disease. The two types affect boys almost exclu- MMD, type 1 and type 2, named for two different sively (150); the rate of inheriting DMD and BMD gene abnormalities (243). Individuals with MMD is 1 in 3,500 and 1 in 20,000 per live male births, are unable to relax their muscles and have the respectively (157). highest rate of mental retardation; their disease progresses slowly (190). People with MMD also Pathology and have contractures, breathing and swallowing Pathophysiology of Muscular problems, cataracts, heart problems, and insulin Dystrophy resistance (217). The first signs of DMD or BMD include muscle The six other types of MD are congenital, weakness and clumsiness (41). In DMD, these Emery-Dreifuss, facioscapulohumeral, limb- signs are first seen in boys between the ages of 1 girdle, distal, and oculopharyngeal (57). In and 4 years (23). A parent or teacher may notice order to diagnose MD, a neurologist rst per- that the boy is not keeping up with his male peers, forms a physical examination looking for muscle for example in running, jumping, stair climbing, weakness. The physician also tests the blood for and even rising from the floor. These boys often elevated levels of the enzyme creatine kinase, develop a modified strategy using their arms to get performs genetic testing of the DNA, and performs up from the floor, called Gowers’ sign (31). They a muscle biopsy (158). may also develop large calf muscles, called pseu- dohypertrophy, not because the muscle is really Common Medications Given enlarged but rather because it has been replaced to Individuals With Muscular with scar tissue (146). These children may also Dystrophy have poor balance and walk with a wider than normal stance. The first muscles that are affected Currently, no pharmaceutical approaches have are muscles of the hip, pelvis, thigh, and shoulder; been shown to be effective in reversing MD. How- later, the muscles of the arms, legs, and trunk are ever, corticosteroids, specifically prednisone, are also involved, including the muscles of the heart commonly prescribed to people with MD in order and lungs (146). The signs and symptoms seen to minimize symptoms and slow disease progres- in BMD are similar to those in DMD but develop sion. These medications (e.g., prednisone and methylprednisolone) have the potential side effects of high glucose levels, depression, and anxiety,
Neuromuscular Conditions and Disorders | 279 which may limit the capacity of some persons with following the cycling and the combined inter- MD to participate in regular exercise training. vention. Overall this study demonstrated that Also, individuals with MD tend to develop heart conditions; therefore, they may be taking prolonged cycling may acutely fatigue the some type of heart medication depending on their symptoms and pathology. Common heart quadriceps muscles, which will negatively medications include various ACE (angioten- sin-converting enzyme) inhibitors and β-blockers, affect strength; 3 minutes of stair climbing may which may reduce the ability of the individual to participate in exercise training due to reductions warm up the lower extremity muscles for future in circulation that lead to side effects such as dizziness, low blood pressure, drowsiness, and strength tasks; and combined strengthening, weakness. See medications table 8.3 near the end of the chapter for a summary of medications used stretching, and aerobic activities with rest in the treatment of MD. breaks may be best for those with DMD. Effects of Exercise in Individuals With Muscular In 1979, DeLateur and Giaconi examined the Dystrophy effects of submaximal isokinetic quadriceps train- Overall, little controlled research has examined the efficacy of exercise in people with MD; most ing in four boys with DMD. The boys strengthened published works regarding exercise recommen- dations are expert opinions or case studies or only one leg for four or ve days per week for are based on rodent models (139, 147). The use of exercise in persons with MD is somewhat con- six months. Over the course of training and two troversial (77), but most experts recommend that those with DMD and BMD not perform traditional years following the intervention, the strength- resistance training (221). trained leg was able to produce more force than In 2012, Alemdaroglu and colleagues exam- ined the acute hemodynamic responses and the untrained leg until the disease progressed to fatigue levels in relation to three different types of exercise in ambulatory boys with DMD (2). the point at which the boys were not able to exert The three exercise interventions were 3-minute stair climbing; 40-minute cycling; and 40 enough force to extend their knees. No adverse minutes of combined stretching, strengthen- ing, and aerobic activity. Heart rate increased effects of the intervention were reported; however, signi cantly after stair climbing and combined exercise, but not with cycling. All three exer- all the boys eventually lost their strength as the cise interventions increased fatigue directly following activity, but did not negatively affect disease progressed. activities of daily living within the day following the intervention. There was an acute decrease Sveen and colleagues (233) examined the in strength following cycling and an increase in strength following stair climbing, no change effects of aerobic training in men with BMD in acute strength following the combined inter- vention. Time to rise from the oor increased compared to men without oBfMthDe.irAV.lOl 2smubajxecfotsr cycled for 30 minutes at 65% a total of 50 times over a 1V.2O-w2 meeakx period. Those with BMD improved their more than the control group; cyclists with BMD also improved the strength of their quadriceps muscles. Indi- viduals with BMD did not exhibit increased plasma creatine kinase levels or display any other adverse effects. This study suggests that cycling at a submaximal work level is safe and effective for those with BMD. Tollback and colleagues (237) examined the effects of a high-intensity resistance training pro- gram in adults with MMD. The program included three sets of 10 repetitions of knee extensions with one leg at 80% of 1RM, performed three times per week for 12 weeks; the other leg served as the control. After the 12-week intervention, 1RM strength was signi cantly greater in the trained leg, and no adverse effects were noted. This inves- tigation provides some evidence of the safety and ef cacy of high-intensity resistance training in adults with MMD.
280 | NSCA’s Essentials of Training Special Populations Exercise Recommendations researchers have expressed concerns regarding for Clients With Muscular resistance training (particularly eccentric muscle Dystrophy actions) potentially exacerbating progression of the MD processes (137). Therefore, at this time Children with MD will most likely be receiv- it is recommended that participation of persons ing some type of physical therapy or exercise with MD in resistance training be limited to intervention at school, in their homes, or at an light-intensity training using isokinetic or pneu- outpatient center. Exercise professionals should matic training equipment that provides concentric be aware of the activities that a child with MD resistance without eccentric stresses. Resistance is already involved in and his weekly sched- training should be initiated with one set of sev- ule. These clients are susceptible to fatigue and eral multijoint movements, with low levels of increased muscle damage, so if they are already concentric resistance performed one time weekly. exercising elsewhere or have a busy weekly Resistance levels and training volume may be schedule, they may not qualify for an additional increased very slowly as tolerated. exercise intervention. Exercise Modi cations, Program design guidelines for clients with Precautions, and MD are summarized in table 8.3. Clients who are Contraindications for Clients not exercising elsewhere can bene t from a light With Muscular Dystrophy exercise program including submaximal aerobic activity and exibility training. The light aerobic Clients with MD are very susceptible to muscle activity can be performed either in a warm-water damage and fatigue; therefore, they should never pool, on a stationary recumbent bicycle, or on an be encouraged to exercise maximally. The exer- arm–leg ergometer. Aerobic training should be cise professional should also listen to clients’ performed initially with one weekly session of subjective reports of fatigue or pain and stop the 15 to 20 minutes in duration. Over time, training activity at their request. All stretches should be duration may be increased slowly to 30 minutes performed slowly and held for at least 60 seconds. per session and volume to two or three training In addition, clients with MD should not perform sessions per week (160). In addition, these clients eccentric resistance training. Their daily activities can bene t from a light stretching program of all are already causing some muscle damage (77, 136, major muscle groups, especially their calf muscles. 137), and it is important not to increase the rate of damage. Because each case is so individual, a The bene ts of resistance training in persons case study is not included for this condition. with MD have been demonstrated in a number of scienti c investigations (2, 49). However, other Table 8.3 Program Design Guidelines for Clients With Muscular Dystrophy Type of exercise Frequency Intensity Volume Begin with one session per Initially 8-10 exercises with Start with 1 set per exercise Resistance training week. resistance of 40-60% 1RM, of 10-12 reps. Progress to 4 days per week, emphasizing multijoint Possibly increase to 2-3 sets Modes of training* split routine, as tolerated. approach. per exercise. a. Weight training machines If multiple sets, then have 1-2 (e.g., isokinetic or pneumatic) min between sets. b. Elastic tubing Begin with 15- to 20-min sessions. Aerobic training Gradually increase to 30-min sessions. Modes of training Begin with one session per Bionretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 a. Walking week. <75% MHR, or RPE of 9-13 on b. Cycling Progress to 2 or 3 days per Borg 6- to 20-point scale. c. Rowing week. Increase intensity gradually. d. Reciprocal press–pull exercise *Minimize (or, ideally, eliminate) the eccentric component of resistance training exercises. References: (77, 136, 137)
Neuromuscular Conditions and Disorders | 281 Recommended Readings Eagle, M. Report on the muscular dystrophy campaign workshop: exercise in neuromuscular diseases Newcastle, January 2002. Neuromuscul Disord 12:975-983, 2002. Gianola, S, Pecoraro, V, Lambiase, S, Gatti, R, Ban , G, and Moja L. Ef cacy of muscle exercise in patients with muscular dystrophy: a systematic review showing a missed opportunity to improve outcomes. PLoS One 8(6):e65414, 2013. Grange, R and Call, J. Recommendations to de ne exercise prescription for duchenne muscular dystrophy. Exerc Sport Sci Rev 35(1):12-17, 2007. Markert, C, Ambrosio, F, Call, J, and Grange, R. Exercise and Duchenne muscular dystrophy: toward evidence- based exercise prescription. Muscle Nerve 43:464-478, 2011. Markert, C, Case, L, Carter, G, Furlong, P, and Grange R. Exercise and Duchenne muscular dystrophy: where we have been and where we need to go. Muscle Nerve 45:746-751, 2012. CEREBRAL PALSY about 75% of all cases (252a). A hypertonic state is evident with spastic CP, as this form develops Cerebral palsy (CP) is a group of nonprogressive, from damage that interferes with the uptake of permanent neurological disorders that are caused GABA (gamma-aminobutyric acid), the primary by a variety of birth injuries. These disorders inhibitory neurotransmitter (107). Limitations in affect the CNS and are primarily characterized GABA uptake interfere with “normal” control of by limitations in motor control affecting body neural excitability and muscle tone. Depending movement and posture. While the disorder of CP on the extremities affected, spastic CP may pres- is considered “static,” as the condition is expected ent in conditions of spastic hemiplegia, spastic to remain relatively stable throughout life, the diplegia, or spastic tetraplegia (198). Spastic hemi- symptoms due to the disorder may alter over plegia affects one side of the body, with damage time, either improving or worsening. States of to one side of the brain resulting in deficits in hypertonia (excessive muscle tone) and spastic- the opposite side of the body. These persons are ity (excessive muscle tone with increased tendon generally ambulatory but often require assistive reflexes) are exhibited in almost half of the cases devices (e.g., ankle–foot orthoses) to assist gait of CP (13, 50). Motor deficits commonly displayed on the affected side (154). Persons with spastic by persons with CP include a lack of motor coor- diplegia present deficits in the lower extremities dination with volitional movements (ataxia); tight with little or no upper extremity spasticity (66). muscles; exaggerated reflexes (spasticity); and a These individuals are usually fully ambulatory but number of gait abnormalities including crouched exhibit a scissoring gait pattern with some degree gait, scissoring gait, and walking on the toes (64, of flexed knees and hip during gait. Spastic tetra- 241). The motor effects of CP range from slight plegia affects all four extremities, thereby being clumsiness to impairments that prevent almost all the most restrictive to independent gait due to coordinated movements (88). Individuals with CP excessive muscle tone and tremors that interfere also exhibit a number of complications aside from with energy-efficient movements (25). motor control, which may include epilepsy, com- munication disorders, and impaired cognition (74). The second primary type of CP is ataxic CP. This variation is caused by damage to the cere- Pathology of Cerebral Palsy bellum and is less common (less than 10% of all CP cases) (183). Individuals with ataxic CP tend There are several forms of CP, including spastic, to display limitations in movement coordination ataxic, and athetoid–dyskinetic variations. Spas- with decreased muscle tone. Functional de cits tic CP is the most common form, occurring in may include problems with writing or typing or upright balance, particularly during gait.
282 | NSCA’s Essentials of Training Special Populations The third and nal form of CP is athetoid or associated with the disease. As seizures or the dyskinetic, which occurs in about 25% of all cases tendency for seizures is apparent in approximately (177). Athetoid CP is characterized by mixed 60% of persons with CP (268), antiseizure med- muscle tone, which limits the ability to hold ications are commonly used (118). A depressant upright sitting or walking postures (201). This CP effect on the CNS is produced with most antisei- condition also may limit the ability to hold and zure drugs, which may have a limiting effect on control items such as pencils. exercise capacity as well as producing states of mental confusion, irritability, or dizziness (78). Pathophysiology of Cerebral Antispasmodics and muscle relaxers are also Palsy commonly prescribed to persons with CP as they reduce muscle tone, which may otherwise inter- Cerebral palsy is caused by complications during fere with efficient performance of daily activities early development of the brain. These complica- (263). However, these medications may increase tions may arise during pregnancy, during child- a sense of lethargy and drowsiness, thereby birth, or during infancy and up to three years of introducing a limiting effect of these drugs on life (169). During pregnancy, a number of factors the performance of daily activities, including the can influence neurological development of the fetus capacity for exercise training. See medications leading to development of congenital CP. First, table 8.4 near the end of the chapter for a summary infections, including rubella (German measles) of medications used in the treatment of CP. and toxoplasmosis (caused by a parasite carried in cat feces and undercooked meat), may damage Effects of Exercise in the developing nervous systems (212). Secondly, Individuals With Cerebral Palsy congenital CP can be caused by jaundice in the fetus or newborn as a result of Rhesus (Rh) factor The need for exercise in persons with CP was incompatibility between the mother and fetus that destroys the blood cells of the fetus (18). However, demonstrated by the early work of Lundberg (131), in the majority of cases, it is not possible to deter- mine the specific cause of congenital CP (1). in which the exercise capacity and aerobic power During the process of childbirth, a number of of children with spastic diplegia were compared events may also occur that result in a state of CP. The very process of birthing involves a degree with findings in peers without physical disabil- of physical and metabolic stresses that may in some cases result in physical damage to the still- ity. Results indicated that the children with CP developing nervous systems (175). In particular, oxygen deprivation and head trauma during the displayed physical work capacity less than half labor process have been associated with increased incidence of permanent brain damage and CP (62). Vt.hOa2t, of their age-matched peers. Peak values of While brain damage from lack of oxygen in the heart rate, ventilation rate, and blood lac- developed CNS is generally limited to the cerebral cortex, anoxic injury in the developing brain may tate concentrations were also significantly lower. likely affect development of the entire cerebrum and result in loss of gray and white matter (3). Fernandez (63) examined the effects of an eight- Common Medications Given week training program with two exercise sessions to Individuals With Cerebral Palsy weekly, consisting of 30 minutes of training with Persons with CP are generally prescribed medica- an arm and leg ocfycV.lOe 2eprgeoamk e(pteeraakt work intensities tions for treatment of the secondary complications of 40% to 70% oxygen uptake). Tichaenteiegnhht-awneceekmteranitnoinf gV.pOr2opgeraamk (p1r2o%d)u.cHedowsigevneifr-, the authors also noted that only one of the seven study participants continued with the exercise activities after the formal research program finished. The authors concluded that while the population of persons with CP presents very poor fitness levels and that their study demonstrated the ability to significantly enhance fitness, partici- pation in such programming appears to be limited by a number of barriers, including availability
Neuromuscular Conditions and Disorders | 283 of resources, transportation, cost, and medical Exercise conditioning for clients with CP concerns. should be based on the same general recommen- The application of resistance training in per- sons with CP has been scienti cally justi ed dations as set forth for the overall population. by associations between muscular strength and endurance with important functional outcomes Aerobic training should begin Vw. Oit2hpeaankinortehnesaitryt (216, 235). There is a direct relationship between equivalent to 30% to <60% of lower extremity strength (particularly of the knee extensors) and gait ef ciency and gross motor rate reserve for 15- to 20-minute training sessions capabilities (216). Similarly, upper extremity muscular strength and endurance are highly asso- with one to two sessions weekly. However, if the ciated with both anaerobic and aerobic wheelchair propulsion (151). client is limited in her ability to perform contin- Resistance training in persons with CP pro- uous exercise, then the aerobic training may be duces gains in strength, muscular endurance, and power similar to those exhibited in persons divided into multiple shorter bouts of exercise, without physical disability (40, 149, 153, 184, 200, 215). Furthermore, programs of resistance training performed either in the same training session with have been shown to produce gains in tness levels that are matched by enhancements in measures a recovery period between bouts or in separate of functional abilities (126, 251). For example, resistance training has been shown to improve training sessions. gait capabilities in ambulatory persons with CP. Speci c recommendations for resistance train- ing by clients with CP are not well established. The limited amount of work in this area does not lend itself to general recommendations, as most evidence is based on children with CP and the disease process includes a diverse group of disorders with a variety of levels of functioning. Therefore, the general recommendations for adults are appropriate, with two modi cations. First, the use of free weights may not be indicated for Exercise Recommendations many with this disease due to limitations in static for Clients With Cerebral Palsy and dynamic balance. It is generally held that single-joint movements are appropriate for initial training. Secondly, resistance intensity should be Persons with CP exhibit significantly lower established based on the individual client’s func- levels of exercise capacity, including lower mus- tional capacity, as many with CP display reduced Vc.uOl2apresatkrenvagltuheas.ndMeontodrurlaimnciteaatisownselal lasso reduced exercise ef ciency. Initial resistance training restrict intensity for clients with CP may begin at a lower gait efficiency, requiring considerably more level than the general recommendations of 60% to energy uptake during ambulation than in persons 80% 1RM for 8 to 12 repetitions. In many cases, who do not have disability. Strength training pro- initial intensity levels of 50% to 60% 1RM are grams have been shown to be effective at increas- appropriate. Program design guidelines for clients ing gait capabilities in persons with CP. Thus, with CP are summarized in table 8.4. both resistance training and upright mobility Exercise Modi cations, Precautions, and activities, such as treadmill training and walking Contraindications for Clients With Cerebral Palsy over ground, may be used in programs designed to Persons with CP who are ambulatory may be capa- promote increased performance of upright activi- ble of exercising with standard exercise devices such as stationary bicycles, steppers, and elliptical ties including independent ambulation. However, devices. Arm exercise devices, such as arm crank devices or recumbent steppers with arm levers, are it is also beneficial to include exercise activities appropriate for cardiovascular training of clients that do not require substantial gross motor coor- dination in order to provide exercise conditioning effects without the limitations associated with lack of coordination. Cycling, steppers, and ellipti- cal devices may provide a means of cardiovascular training without the limitations associated with more complicated gait tasks.
284 | NSCA’s Essentials of Training Special Populations Table 8.4 Program Design Guidelines for Clients With Cerebral Palsy Type of exercise Frequency Intensity Volume Start with 1 set per exercise of Resistance training Begin with one or two sessions Begin with four to eight 10-12 reps. per week. exercises with resistance of Possibly increase to 2-3 sets Modes of training Possibly progress to 4 days per 50-60% 1RM, emphasizing per exercise. a. Weight training machines week, split routine. single-joint approach. If multiple sets, then 1-2 min b. Bodyweight resistance between sets. c. Elastic tubing Begin with one or two sessions Bionretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 Begin with 15- to 20-min per week. <75% MHR, or RPE of 9-13 on sessions. Aerobic training Progress to three to five Borg 6- to 20-point scale. Gradually increase to 30-min sessions per week. Increase intensity gradually. sessions. Modes of training Can be performed in multiple a. Cycling shorter bouts if unable to b. Rowing complete continuously. c. Seated arm–leg cycling References: (14, 159) with CP who use a wheelchair for locomotion. The in order to provide a stable supported point of selection of the exercise device should be based contact with the equipment. Care should be taken on the program goals. If the goals are to enhance to ensure that the limbs are capable of the range of upright mobility via improved gross coordination, motion dictated by the device. Movement should then less stabilized systems, such as treadmill or never be forced against a muscle under spasm. overground walking, may be appropriate. Pro- grams emphasizing training volume may be more Key Point effective using more supportive equipment such as recumbent cycles. Spasticity is a condition of excessive muscle tone or stiffness, with increased tendon reflexes, that It may be necessary to use specialized appara- may interfere with movement and may be a tus in order for some persons with CP to effec- result of damage within the CNS. Muscles under tively and safely use standard exercise equipment. spasm activity should never undergo forced For example, it may be appropriate to strap the feet movement against the spasm. onto foot pedals or the hands onto level handles Case Study Cerebral Palsy Gloria is a 13-year-old with CP. She is able to Gloria’s neurologist provided clearance for her walk with a cane and wears bilateral ankle–foot to participate in the program. She has no other orthoses. Gloria works with a physical thera- medical contraindications for exercise. Gloria’s pist at school but not during the summertime. sessions began with a cardiovascular warm-up Gloria’s sister is taking gymnastics lessons at a on the recumbent bicycle. She required slight assistance to get on and off the bicycle safely. tness center, and Gloria’s parents would like her Next, she participated in strength training using to work with an exercise professional while her weighted balls, BOSU balls, and resistance bands. sister is at gymnastics. Gloria’s parents signed All major muscle groups were trained using a her up for three 1-hour sessions per week for circuit to keep Gloria engaged. After resistance the summer.
Neuromuscular Conditions and Disorders | 285 training, Gloria practiced balance while playing BOSU. All sessions ended with static stretching. catch. The exercise professional would guard Gloria expressed that she had a lot of fun Gloria from falling while her father would toss her the ball. Gloria also participated in balance exercising at the tness center this summer and training using a BOSU ball. She was closely and would like to come back next year. Her parents carefully spotted by the exercise professional were very pleased with her sessions. She was able as she completed various standing tasks on the to maintain all strength and range of motion that she had previously achieved. Recommended Readings Damiano, DL, Vaughan, C, and Abel, MF. Muscle response to heavy resistance exercise in children with cerebral palsy. Dev Med Child Neurol 37:731-739, 1995. Fernandez, JE and Pitetti, KH. Training of ambulatory individuals with cerebral palsy. Arch Phys Med Rehabil 74(5):468-472, 1993. Kramer, J and MacPhail, H. Relationships among measures of walking ef ciency, gross motor ability, and isokinetic strength in adolescents with cerebral palsy. Pediatr Phys Ther 10:3-8, 1994. MyChild at CerebralPalsy.org: The Ultimate Resource for Everything Cerebral Palsy. www.cerebralpalsy. org. Accessed May 24, 2016. TRAUMATIC in the emergency room based on whether the BRAIN INJURIES injury caused unconsciousness and if so how long unconsciousness lasted, and the individu- A traumatic brain injury (TBI) is an acquired al’s verbal, motor, and eye-opening responses to injury to the brain that takes place when a sudden stimuli (67). A physician may also order computed traumatic force causes damage to the brain tissue. tomography scans or magnetic resonance imaging Traumatic brain injuries can occur due to an scans of the brain to determine the extent of the external force striking the head or as a result of injury. the head traumatically making contact with an object. If the trauma does not result in the skull With mild TBIs, including concussions, either being fractured or penetrated, then the injury is a loss of consciousness did not result or the indi- referred to as a closed head injury. Closed head vidual was unconscious for 30 minutes or less. injuries tend to result in damage to the brain that Symptoms typically present at, or soon after, the is relatively widespread or diffuse. Open head injury but may not develop for weeks afterward. injuries are TBIs in which the skull is penetrated When an individual appears dazed or confused by an object, causing damage to specific regions or loses consciousness, a mild TBI is diagnosed. of the brain tissue. The injury is classi ed as a concussion when a change in mental status is observed. Pathology of Traumatic Brain Injury Moderate TBIs result in loss of consciousness for more than 20 minutes but less than 6 hours. Traumatic brain injuries can be classified based The symptoms of moderate TBIs are similar to on severity ranging from mild to moderate and those of mild TBIs but are more serious and last severe (214). Brain injuries are usually graded longer. The individual may be confused for a period of days to weeks. Physical, cognitive, and behavioral performance may be impaired for
286 | NSCA’s Essentials of Training Special Populations months and potentially for life. Severe TBIs are swelling, resulting in more diffuse damage of the generally a result of dramatic head wounds, both brain tissue (266). closed head injuries and penetrating injuries to the head, resulting in unconsciousness lasting There are two distinct phases of TBI, each more than 6 hours. These more severe injuries affecting brain integrity and function (110). First, result in signi cant damage to the brain tissue the injury impact is considered as the source of with a range of physical and behavioral outcomes primary mechanical damage to the brain. Second- involving most aspects of daily life. Outcomes ary damage develops as a result of altered cranial of moderate to severe TBIs are determined by a mechanisms subsequent to the initial trauma. number of factors including the severity of the ini- Ischemia of the brain and intracranial hyperten- tial insult, the nature of the functional de cits, the sion are examples of secondary insults that may signi cance of the outcomes to the individual, and signi cantly alter brain blood ow (hyper- or the resources available for rehabilitation. Mod- hypoperfusion), brain metabolism, and brain oxy- erate to severe TBIs commonly result in de cits genation. The composite of direct tissue damage in cognition, speech and language, and sensory and altered circulatory patterns commonly pro- awareness. Physical issues include the potential duces further damage and in ammation leading for muscular paralysis and spasticity that may to neuronal cell death (110). affect the performance of many important daily tasks. A number of emotional and behavioral Primary mechanical damage from TBIs can be concerns such as increased irritation, aggression, affected by preventive means but is not apprecia- depression, lack of motivation, or dependency bly responsive to therapeutic measures (104). In may become primary issues of concern. contrast, the secondary damage from TBI, from limited circulation or in ammation, tends to be Although there is a continuum for classifying more responsive to therapeutic treatments (7). the severity of brain injuries, all brain injuries are serious medical emergencies. Even concussions, Common Medications Given which often go undiagnosed, can result in seri- to Individuals With Traumatic ous brain dysfunction (56). For this reason, some Brain Injury professional groups, such as the National Athletic Training Association (NATA), recommend not rely- There are no medications to treat the actual brain ing heavily on grading systems in the treatment of injury; however, physicians prescribe a variety of persons with TBI (27). According to the Centers for medications to treat patients’ specific symptoms. Disease Control and Prevention, in 2010 approx- See medications table 8.5 near the end of the imately 2.5 million people sustained TBIs, with chapter for a summary of medications given to concussion as the most common type (29). individuals with TBI. Patients may be prescribed analgesics for pain management, anticoagulants Pathophysiology of Traumatic to prevent blood clots, antispasticity drugs, or Brain Injury anticonvulsants to prevent seizures. Side effects of opioid analgesics include nausea, drowsiness, The most common causes of TBIs are falls, motor urinary retention, and orthostatic hypotension, vehicle accidents, being struck by objects, and which could in some cases limit exercise capacity assaults (236). The effects of any brain injury (170). Anticoagulants, such as warfarin, carry a depend on the cause of the injury, the location of risk of increased bleeding, so some would recom- the injury, and the severity of the injury. Injuries mend avoiding high-contact sports and activities that result in contusions, lacerations, or intrac- that put the individual at high risk for injuries. ranial hemorrhage tend to produce focal damage Anticonvulsants, also known as antiseizure medi- of the brain (115). In contrast, injuries producing cations, have known side effects including fatigue, intense acceleration and deceleration of the brain digestive disorder, dizziness, and blurred vision. If are associated with axonal injuries and brain a patient is having psychological dysfunction, he may be prescribed anti-anxiety, antipsychotic, or
Neuromuscular Conditions and Disorders | 287 antidepressant medications. A patient may also be weeks and received exercise information with prescribed muscle relaxants, sedatives, or stimu- instructions to perform four additional 30-minute lants. All of these medication categories have the training sessions each week without supervi- potential to limit exercise capacity and balance. sion. During the supervised weekly session, the participants were also provided encouragement. Effects of Exercise in Following the 10-week aerobic training program, Individuals With Traumatic scores on the Beck Depression Inventory were Brain Injury signi cantly improved, indicating less depres- sion. These ndings are important because many The safety of aerobic training in people with people who sustain TBIs also experience altera- postconcussion syndrome (PCS) was demon- tions in mood and depression (218). strated by Leddy and associates (122). The Balke treadmill test was used to effectively monitor Although many concussion programs use headache symptoms in concussed persons who resistance training in their return to play proto- were asymptomatic at rest. Test results were used col, at this time there are no published research to determine the appropriate submaximal aerobic studies in support of or against this training. training zone for persons with PCS. The same research group (123) also later reported the safe Exercise Recommendations and effective application of the Buffalo Concus- for Clients With Traumatic sion Treadmill Test to prescribe aerobic exercise Brain Injury following a concussion. Many people who have sustained a TBI lead seden- Bhambhani and colleagues (17) demonstrated tary lifestyles and exhibit low levels of aerobic and the effects of a 12-week circuit training program muscular endurance, which further limit their abil- on cardiorespiratory responses and body com- ity to perform important activities of daily living position in individuals with moderate to severe and may subsequently lead to increased incidences TBI. Individuals performed 1 hour of aerobic and of secondary disabilities such as heart disease and resistance exercise three times per week. At the diabetes. Therefore, participation in well-designed completion of the study, there were no differences exercise programs may provide a means to enhance in body composition, but the peak values of power physical fitness levels as well as abilities to engage output, oxygen uptake, and ventilation rate were in more challenging life activities. all signi cantly greater following the aerobic and resistance training program. While speci c recommendations for exercise training have not been established for persons In 2009, Hassett and colleagues compared the who have sustained a traumatic head injury, gen- effects of a tness center exercise program and a eral recommendations for the older population home exercise program for individuals with TBI may be modi ed for this population. Aerobic (83). Both groups performed strength and aero- training should start with a light intensity of bic training three times per week for 12 weeks 55% to <65% MHR for 15- to 20-minute bouts in a similar fashion, with only the location and of exercise in one or two weekly sessions (155). supervision being different. After completing As tolerated, exercise duration may be increased the program, both groups improved their 20-m to 20 to 40 minutes per session for three or four shuttle time, with no difference between groups. sessions per week. Persons with brain injury This study demonstrates the bene ts of exercise may have limitations in upright stability, both in individuals with TBI regardless of supervision. seated and standing, and stationary cycling and rowing may be appropriate modes of training in The effects of aerobic exercise on depression such cases. and quality of life in persons with TBIs were examined by Wise and associates (262). Subjects Resistance training has been shown to provide performed one weekly 30-minute session of aer- signi cant bene ts to persons with brain inju- obic exercise with an exercise professional for 10 ries. Unfortunately, speci c resistance training
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