288 | NSCA’s Essentials of Training Special Populations protocols have not been developed for this popu- physician or other health care professional. After lation. Therefore at this time, resistance training receiving clearance, clients who sustained TBIs for persons with TBI should be based on modi ed may participate in both resistance training and versions of recommended programming for the cardiovascular training. Often people who have general population. Program design guidelines sustained head injuries, regardless of the severity, for clients with TBI are summarized in table 8.5. have cognitive or processing deficits; therefore, instructions should be especially clear and pos- Exercise Modi cations, sibly be given multiple times. Precautions, and Contraindications for Clients These clients may also have motor impair- With Traumatic Brain Injury ments, and adjustments to exercise will have to be made on an individual level. For example, if a Although recent evidence has demonstrated client has poor balance or coordination, she may the safety and efficacy of exercise in patients bene t from seated machine exercises as opposed with PCS and TBI, it is not recommended that to free weight activities. Clients who have sus- exercise professionals train these clients until tained TBIs may display autonomic system dys- they receive full clearance to exercise from their function and heart rate variability; therefore, heart rate is not a good measure of exercise intensity in this population. Table 8.5 Program Design Guidelines for Clients With Traumatic Brain Injury Type of exercise Frequency Intensity Volume Begin with one or two sessions Initially do four to eight Start with 1 set per exercise of Resistance training per week. exercises with resistance of 10-12 reps. Possibly progress to 4 days per 50-60% 1RM, emphasizing Possibly increase to 2-3 sets Modes of training week, split routine. single-joint approach. per exercise. a. Weight training machines If multiple sets, then have 1-2 b. Bodyweight resistance Begin with one session per Begin with light intensity of 55 min between sets. c. Elastic tubing week. toon<B6o5rg%6M- tHoR2, 0or-pRoPinEtosfc9a-le11. Begin with 15- to 20-min Progress to 3 or 4 days per Increase intensity gradually. sessions. Aerobic training week. Gradually increase to 20- to 40-min sessions. Modes of training a. Cycling b. Rowing c. Reciprocal press–pull exercise d. Circuit training e. Walking References: (14, 155) Case Study Traumatic Brain Injury Mr. G, a 35-year-old businessman, was involved a nearby tness facility associated with a med- in a serious motor vehicle accident two months ical clinic. Mr. G’s neurologist has cleared him ago. He sustained a moderate TBI and received to exercise under the supervision of an exercise inpatient physical therapy before moving back professional, and he is enrolled in a program of to live with his parents. He is unable to drive or three sessions per week of 1 hour each. return to work and currently uses a wheelchair. Mr. G has access to a bus, made available by the Mr. G’s neurologist has provided instructions city to those with disabilities, in order to access that he should exercise only at light intensity so as to keep his heart rate and blood pressure
Neuromuscular Conditions and Disorders | 289 responses to low levels; he should avoid the to <65% MHR) followed by low-intensity static Valsalva maneuver and should remain seated stretching for each major muscle group. Over for all exercise. Before his accident Mr. G had a four months Mr. G progressed to 30 minutes BMI of 27; however, at the start of his outpatient per session of aerobic exercise on various seated exercise program, it was 33. He also is predia- ergometers, three times per week, and one betic and has been diagnosed with depression. weekly session of light machine weights. Mr. He is currently taking an anticonvulsant, an G was closely supervised and spotted during antidepressant, ibuprofen, and baclofen (a med- all activities. ication that affects the chemical balance in the motor system of the brain) to control bodily After three months of training, Mr. G was movements. able to walk small distances with the assistance of a roller walker and increased his ability to Mr. G started his sessions with a light-inten- perform upper body activities of daily living. sity warm-up on a recumbent bicycle followed He decreased his body weight and increased his by mild partner-assisted mobility exercises. He self-esteem. While Mr. G is not yet able to live then completed 15 minutes of aerobic recum- independently, his progress toward his goals has bent arm–leg ergometry at light intensity (55% motivated him to continue his exercise program. Recommended Readings Archer, T. In uence of physical exercise on traumatic brain injury de cits: scaffolding effect. Neurotox Res 21:418-434, 2012. Archer, T, Svensson, K, and Alricsson, M. Physical exercise ameliorates de cits induced by traumatic brain injury. Acta Neurol Scand 125:293-302, 2012. Griesbach, G. Exercise after traumatic brain injury: is it a double-edged sword? Am Acad Phys Med Rehabil 3:S64-S72, 2011. Hassett, L, Moseley, A, Tate, R, and Harmer, A. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database Syst Rev 2:CD006123, 2009. Mossberg, K, Amonette, W, and Masel, B. Endurance training and cardiorespiratory conditioning after traumatic brain injury. J Head Trauma Rehabil 25(3):173-183, 2010. STROKE are transient ischemic attacks (TIAs), which are referred to as “mini-strokes” and are a result of A stroke is a serious vascular event involving a temporary blood clots. loss of neurological functions related to an acute interruption of blood flow to the brain. Stroke Pathology of Stroke is also commonly known as a cerebrovascular accident (CVA), named for the disrupted vascular Interruption of blood flow prevents the necessary flow to brain structures. The two main variations delivery of oxygen and vital nutrients, including of stroke are ischemic stroke, in which blood flow glucose, to the network of brain tissues. The brain is interrupted by a physical blockage, and hemor- uses glucose as the primary energy source, and rhagic stroke, which occurs as a result of bleeding as glucose is not stored in the brain, the time of in the brain. Approximately 80% of all strokes ischemic blockage is critical. The outcomes of are ischemic and 10% to 15% are hemorrhagic stroke are also related to the location of the block- in origin (161). The remaining cases of stroke age of blood flow and to the amount of brain tissue influenced. A right-side stroke generally produces
290 | NSCA’s Essentials of Training Special Populations paralysis on the left side of the body, visual limita- blood pressures produced by drug overdoses tions, and memory loss (173). A stroke to the left and adverse reactions that limit blood ow to side of the brain commonly results in paralysis of the brain (90, 239). the right side of the body, limitations in speech, and memory loss (117). Paralysis, total or partial, Hemorrhagic strokes are caused by the rupture of one side of the body as a result of a disease or of a blood vessel due to damage to the vascular injury to the CNS is referred to as hemiplegia. structure, such as cerebral aneurysms or chronic high blood pressure (225). Aneurysms are areas of Pathophysiology of Stroke ballooning on a blood vessel due to weakening of the vessel wall. Over time, particularly with high A number of controllable and uncontrollable risk blood pressure, the bulging area may rupture, factors are associated with the development of causing bleeding into the brain. strokes. Controllable risk factors of stroke rep- resent life habits that can be altered in order to Common Medications Given reduce risk. Factors that increase the risk of stroke to Individuals Who Have Had a include smoking, high blood pressure, arterial Stroke disease, diabetes, abnormal lipid profiles, inactive lifestyles, and obesity (226, 252). Reversing any Individuals who have had a stroke are prescribed of these controllable risk factors will presumably medications that may assist with recovery and reduce the risk of developing a stroke. Some risk that may help prevent another stroke from occur- factors of stroke are not controllable, including ring. Two types of blood thinner medications are age, sex, heredity, race, and history of prior stroke used to lower the risk of the formation of blood (113). While a stroke can occur in persons with clots. Antiplatelet drugs reduce the aggregation a wide range of these factors, the risk of stroke or clumping together of blood platelets (245). is greater if the person is older, male, or African Blood clots are formed when blood platelets stick American or if the person or an immediate family together. Anticoagulant medications also reduce member has a history of stroke (91, 113, 119). the formation of blood clots but through different chemical actions (80). While these medications are Ischemic strokes are caused by three primary quite effective in reducing the risk of subsequent mechanisms, including thrombosis, embolism, strokes by reducing blood viscosity or “thickness,” and global ischemia. Thrombotic strokes are they also increase the risk of bleeding complica- produced by blockage of an artery by a clot tions (92). Some physicians may recommend that (thrombus) that forms on blood vessels of the the individual on anticoagulants avoid vigorous brain (246). Fatty deposits and cholesterol build physical activity or contact sports. Side effects of up on the inner lining of blood vessels, creating antiplatelet and anticoagulant medications include an irritating in uence that stimulates the for- nausea and upset stomach, which may limit the mation of clots. A focal embolic stroke is caused ability to participate in exercise training sessions. when a blood clot that is formed somewhere in the body other than the brain, such as the Individuals who have sustained a stroke are heart, travels to the brain via the bloodstream commonly prescribed different types of medica- (254). If the clot, known as an embolus, makes tions to reduce high blood pressure, which is a it to the brain via the bloodstream, it may block primary risk factor for experiencing subsequent the ow of blood through an arterial structure, strokes. Hypertensive medications frequently thus causing damage to the brain tissue supplied used by stroke patients include angiotensin II with blood, oxygen, and nutrients by that artery. receptor blockers, ACE inhibitors, β-blockers, Global ischemic stroke occurs if blood ow to the calcium channel blockers, and diuretics, each of entire brain is interrupted by a systemic restric- which exhibit different mechanisms of action for tion such as myocardial infarction. Damage to reducing high blood pressure but also may reduce brain tissue is related to the time the brain is the ability of the individual to engage in stressful deprived of oxygen and glucose. Global ischemic exercise due to side effects such as dizziness, stroke can also be caused by particularly low drowsiness, tiredness, and fatigue.
Neuromuscular Conditions and Disorders | 291 Persons who are poststroke will likely also need has indicated that structured physical condition- to treat other multiple morbidities commonly ing programs past the nine-month window can associated with strokes. For example, many per- provide continued enhancement of aerobic tness, sons who have sustained a stroke also present strength, and functional capacity (264). with hypertension, high cholesterol, diabetes, or some combination of these (129, 255). Thus, Aerobic exercise training has been shown to when developing an exercise program for these be capable of enhancing peak oxygen uptake individuals, it is vital to consider all comorbidities and workload while reducing submaximal blood and their respective medications, side effects, and pressures with both cycle ergometry training and effects on exercise responses. Refer to the applica- various forms of treadmill training. Potempa (194) ble chapters in this book for further information. reported that a 10-week program of cycle ergometry See medications table 8.6 near the end of the in 43 persons with hemiplegia produced enhance- chapter for a summary of medications given to ment of cardiovascular tness similar in magnitude individuals who have had a stroke. to that commonly shown in people without disabil- ity participating in similar programming. Effects of Exercise in Individuals Who Have Had a Stroke Treadmill training has been shown to provide similar increases in values of peak oxygen uptake Following stroke, the primary causes of death are during gait, with reduced energy cost at submaximal- recurrent strokes and coronary arterial disease effort walking indicating improved gait ef ciency (CAD). Additionally, between 25% and 50% of (133). Following treadmill training, persons with these persons require assistance in the perfor- hemiplegic gait displayed signi cantly faster mance of activities of daily living (179). This ina- overground walking in a 6-minute walk test with bility to perform basic daily tasks has been related enhanced values of peak oxygen consumption. to physiological deconditioning, preexisting Interestingly, Macko and associates (133) reported cardiovascular disease, or dramatically reduced svieglnoicitcyanant adspsoecaikatviaolnusebseotfwV.eOen2,twrehaidlemdiullrtartaiionninogf efficiency of gait and other upright activities (54, treadmill training per session was signi cantly 196). Individuals with stroke hemiplegia exhibit related to performance of the 6-minute walk test. energy uptake during walking that is two to three Treadmill training therefore may provide a means times greater than that of the general population of exercise training that transfers directly to gait walking at the same pace (101). They also exhibit pace and aerobic endurance. peak values of oxygen uptake that are approxi- mately 50% of those displayed by healthy persons The treadmill also provides a means of upright of the same age (111, 132). These issues tend to gait training for persons unable to do this over limit activity in the lifestyles of persons following ground with full bodyweight loading. With the stroke, leading to further physical deconditioning, use of handrails for weight shifting and loading particularly of the cardiovascular system (231). support and through the use of bodyweight unloading systems (harnesses attached to over- The rehabilitation process following stroke was head support), the amount of loading can be traditionally limited to the rst six to nine months reduced. Training intensity can be increased following the acute episode based on the assump- with either greater treadmill speed or increased tion that most, if not all, motor recovery would treadmill elevation; the latter may be useful in take place within that period (19, 35). The primary increasing intensity with a comfortable pace of rehabilitation goals include increasing activity walking. Treadmill bodyweight support systems levels, particularly with regard to activities of also reduce, or eliminate completely, the need daily living, reducing the incidence of recurring for arm support–unloading, thereby providing strokes, and improving aerobic tness. In the the ability to coordinate the upper and lower clinical setting, aerobic tness has commonly extremity reciprocal movements important to been addressed with task-speci c activities rather coordinated gait. than generalized exercise conditioning. Research Limitations in gait ef ciency and motor coor- dination of many important daily tasks were
292 | NSCA’s Essentials of Training Special Populations traditionally attributed, to a great degree, to the of the paretic limb were found to be particularly state of hypertonia or spasticity common in per- weakened at baseline, suggesting that speci c sons following stroke (37). Because a vital goal of attention should be given to the knee exors with rehabilitation in this population is the improve- training in order to achieve greater levels of knee ment of the control and quality of movement, extension and improved gait ability. control of spasticity was seen as the principal issue to address. However, research has shown Exercise Recommendations that spasticity is not the primary impairment for Clients Who Have Had a following stroke; rather, muscular weakness is the Stroke principal limitation to function poststroke (180). For example, muscular weakness is signi cantly The body of literature supports the use of aerobic associated with decreased gait velocity and perfor- mance of important activities of daily living, such training in persons following stroke using exer- as bodyweight transfer during walking. cise of the legs, arms, or combined arm and leg More recent research in this area has shown that resistance training of the lower extremi- pacotpivuiltaiteiso.nRiesc4o0m%mteon<d6e0d%troafinV.iOn2gpienatkenosrithyefaorrt this ties does provide signi cant improvements of rate muscle strength, power, and endurance in both the affected and nonaffected limbs of persons reserve. Training frequency is recommended at with hemiplegia poststroke. Lee and colleagues (124) reported that 12 weeks of high-intensity three to seven days per week, with training duration resistance training resulted in improvements in muscular strength, power, and endurance, ranging from 20 to 60 minutes per session. Inter- while three 30-minute cycle ergometry training sessions per week for 12 weeks produced no sig- mittent programs of treadmill training (multiple ni cant changes in muscle function. Resistance training consisted of two sets of 80% 1RM for the shorter bouts per session) may prove particularly movements of hip extension and exion, knee extension and exion, and ankle plantar exion beneficial in more deconditioned clients until they in each of the three weekly sessions. are capable of completing longer sessions. The effects of an intensive training program consisting of high-intensity resistance train- Research also suggests that resistance training ing, body weight–supported treadmill training, aerobic exercise, and functional training were following stroke in persons with hemiparesis described by Jorgensen and associates (102). Resistance training movements included semi- should be similar to programming for persons seated leg press, leg extension, leg curl, and seated leg press, with relative training intensity increas- who are elderly. Recommendations for resistance ing weekly from 12RM to 4- to 8RM levels during the 12-week program. Training was performed training poststroke include 8 to 10 exercises unilaterally for three to ve sets per exercise with recovery periods of 90 seconds between sets. The performed three times weekly. Training intensity ndings of this study included improvements of should begin with 50% to 60% 1RM and progress the agonist muscle neurological activation with enhanced twitch torque, which were associated to 60% to 85% 1RM. In order to place appropri- with increased muscular strength during con- centric, eccentric, and static contractions with ate stresses on the paretic limb, it is advisable to enhanced gait performance. The reduced neuro- logical activation at baseline was highly related concentrate on unilateral movements. to muscular weakness. The hamstring muscles Most persons who have sustained a stroke also present with other special conditions or comor- bidities and are likely taking medications for those conditions. For example, many, if not most, of these clients (poststroke) also have CAD and hypertension (47, 176). When designing the indi- vidualized exercise program, it is vital to consider and plan for potential compounded effects of the multiple special conditions, as well as possible interactions of the respective medications. It is common for persons who have sustained a stroke to have limitations in communication and mental processing. A signi cant number of these clients have problems with written communica- tion (writing and reading) as well as trouble with speech and understanding verbal cues (222). It is necessary to provide these clients with multiple
Neuromuscular Conditions and Disorders | 293 means of communication, including verbal cues as and unaffected sides of the body can be trained well as visual examples of the exercise techniques. independently or with alternating bilateral move- Program design guidelines for clients who have ments. Exercise equipment that allows reciprocal had a stroke are summarized in table 8.6. movements of the right and left limbs provides a particularly useful means of exercise training in Exercise Modi cations, many persons poststroke. The reciprocating push- Precautions, and ing–pulling upper extremity actions of the arm Contraindications for Clients levers on some arm and leg cycle ergometers or Who Have Had a Stroke recumbent steppers provide a means by which the affected limb can be guided through the exercise A common outcome following stroke is paralysis range of motion by the nonaffected limb. Special- or limitations in motor control. Paralysis gener- ized mitts and gloves can be used to increase grip ally occurs on one side of the body (i.e., the side of the affected hand. Similarly, recumbent cycles opposite the side of the brain in which the stroke and steppers can be used for conditioning affected occurred). For example, damage to the right side lower extremities. When using this strategy, it is of the brain may affect the left-side arm, left leg, or important to make sure that the client’s affected the entire left side of the body. The limitations in limb is fully capable of moving passively through motor control may be accompanied by reduced or the range of exercise motion. a total lack of sensation from the paralyzed region (87). Reduced visual awareness on the affected Limitations in motor control and sensory side is not uncommon, which reduces the ability awareness can also affect body stability, especially of the individual to respond to changes in the if the lower extremities and torso are affected environment in that field of view. (171). With reduced ability to self-stabilize, it is imperative to use exercise equipment that Limitations in motor control and sensory provides external stabilization. For example, awareness on one side of the body necessitate recumbent cycles would be preferred over upright the inclusion of unilateral exercise movements stationary cycling. The use of exercise machines in the exercise program. Training the affected with stable back support may prove advantageous, side of the body independent of the unaffected especially in early phases of training, compared to side will ensure conditioning of the region or training with free weights without body support. regions that are most compromised. The affected That said, a goal of the exercise program may be to gradually strengthen the weakened stroke-affected Table 8.6 Program Design Guidelines for Clients Who Have Sustained a Stroke Type of exercise Frequency Intensity Volume Start with 1 set per exercise of Resistance training Begin with one or two sessions Begin with 8-10 exercises 10-12 reps. per week. with resistance of estimated Possibly increase to 2-3 sets Modes of training Possibly progress to 4 days per 50-60% 1RM (and progress to per exercise. a. Weight training machines week, split routine. 60-85% 1RM), emphasizing If multiple sets, then have 1-2 b. Bodyweight resistance multijoint approach. min between sets. c. Elastic tubing Begin with 15- to 20-min Begin with one session per iBonretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 sessions. Aerobic training week. <75% MHR, or RPE of 9-13 on Gradually increase to 30-min Progress to 2 or 3 days per Borg 6- to 20-point scale. sessions. Modes of training week. Increase intensity gradually. a. Cycling b. Rowing c. Arm crank exercise d. Reciprocal press–pull exercise e. Treadmill walking References: (14, 180, 189)
294 | NSCA’s Essentials of Training Special Populations muscles in order to enhance the ability to self-sta- support (chest strap) wrapped around the client bilize. The amount of external stabilization must and back support, moving gradually to less snug be very gradually reduced, if possible, in order and then loosened support, and then eventually to safely progress. For example, when using a progressing to use of the exercise station relying resistance training selectorized machine, the on the back support without a chest strap. exercise sessions may start with a snug torso Case Study Stroke Mr. H, 45 years old, is a former college football recumbent bicycle, recumbent arm–leg ergom- lineman who had a large stroke six months etry, or an upright elliptical holding on with ago. Mr. H had both in- and outpatient physical both hands. After the warm-up, Mr. H reviewed therapy but no longer has insurance bene ts. rhythmic breathing and exhaling during resist- He currently cannot drive, is not able to return ance training before starting his strengthening to work, and can walk unsteadily with a cane program. At rst, all strengthening exercises but refuses to use a walker. Mr. H can take the were performed with resistance machines; bus to the tness center, and his wife signed however, over time Mr. H was able to progress him up to work with an exercise professional. to upright activities with light free weights. He She registered him for three sessions per week required close supervision and spotting during for 1 hour each. Mr. H agreed to the training all activities. After resistance training, he was sessions and stated that he would like to do instructed in balance activities on even and powerlifting as he had in the past to prepare uneven surfaces. Sessions ended with stretching for football. activities. In view of Mr. H’s balance limitations, the initial stretching was proprioceptive neu- Both Mr. H’s cardiologist and neurologist romuscular facilitation (PNF) with instructor cleared him to exercise at the tness center with assistance and gradually introduced controlled supervision. They both stated that the patient passive stretching. should not hold his breath; they also noted that care was warranted because Mr. H had poor bal- After three months of training, Mr. H was ance. Mr. H had a BMI of 35, hypertension, diabe- able to walk without his cane more steadily. He tes, and depression. He took the following medi- decreased his body weight and the amount of cations: insulin, an ACE inhibitor, a β-blocker, a insulin that he needed, and increased his bal- statin, an anticoagulant, and an antidepressant. ance and self-esteem. He is still working toward his goals of powerlifting and driving. Mr. H’s sessions started with a warm-up on a Recommended Readings Billinger, SA, Arena, R, Bernhardt, J, Eng, JJ, Franklin, BA, Johnson, CM, MacKay-Lyons, M, Macko, RF, Mead, GE, Roth, EJ, Shaughnessy, M, and Tang, A. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45:2532-2553, 2014. Eng, JE. Fitness and Mobility Exercise (FAME) Program for stroke. Top Geriatr Rehabil. 26(4):310-323, 2011. National Stroke Association. HOPE: A Stroke Recovery Guide. Chapter 4, Movement and Exercise. www. stroke.org/sites/default/ les/resources/NSA-Hope-Guide.pdf. Accessed December 19, 2016. Pak, S and Patten, C. Strengthening to promote functional recovery poststroke: an evidence-based review. Top Stroke Rehabil. 15(3):177-199, 2008.
Neuromuscular Conditions and Disorders | 295 SPINAL CORD INJURIES of movement and sensation. If a SCI results in total loss of volitional movement (paralysis) and Spinal cord injury (SCI) is an injury or disease total loss of sensory functions, then the injury process of the spinal cord that results in altered is deemed “complete,” while “incomplete” SCIs motor, sensory, or autonomic functioning (or are those in which there is some preservation some combination of these). Injuries to the spinal of sensory or motor function below the spinal cord can limit motor ability and sensation to lesion. Thus, a person characterized as having differing degrees depending on the location and motor-complete tetraplegia at the C5 level is severity of damage to the cord. The spinal cord expected to show strong elbow flexors without is the primary conduit for all neural communi- volitional control of wrist extensors or elbow cation between the brain and most of the rest of extensors or any muscles of legs or torso. the body (except the optic nerve). In general, the higher the level of SCI in the vertebral column, Accurate assessment of the motor and sensory the more widespread the damage, as such injuries functioning following SCI is typically performed commonly affect all tissues with more distal nerve within the clinical setting by a physician or more roots (238). Injuries of the cervical region affect likely a physical therapist. The exercise profes- the upper and lower extremities as well as the sional should not attempt to determine the level trunk, producing a state of tetraplegia (in the past of SCI himself, but rather work with the clini- referred to as quadriplegia). Persons with paraple- cian’s assessment. Certainly, documentation of gia have sustained a spinal injury at the thoracic the clinical motor-sensory–based classi cation or lumbar vertebral levels, causing impairment of the SCI provides a vital perspective on which in the lower extremities and some portion of the all subsequent goals and programming should be trunk. While these two terms are useful, more based. The level of SCI inherently refers to the spe- specific terminology provides increased accuracy ci c musculature and the associated movements of communication regarding specific neurological that are signi cantly affected, thereby in uencing capabilities. total and regional work capacity, incidence of joint imbalances and instabilities, and the ability The number of persons in the United States to proximally stabilize. Autonomic dysfunctions living with SCI was estimated by the National in tissues below full CNS control include altered Spinal Cord Injury Statistical Center in 2012 circulatory patterns, central hemodynamic func- (168) to be between 236,000 and 327,000 indi- tioning, and thermoregulatory responses, all of viduals. According to statistics generated by data which should be considered when one is devel- from regional SCI centers, approximately 80.6% oping exercise programming for persons with of persons with SCI were male, with the highest SCI. A state of autonomic dysre exia, a serious rates of SCI between the ages of 16 and 30 years. potentially life-threatening condition, may be The average age at SCI was 41 years. About 57% exhibited by persons with SCI (220). of persons with SCI were considered paraplegic (21.6% complete, 21.4% incomplete), with 43% Autonomic dysre exia develops when noxious of new injuries classi ed as tetraplegia (40.8% stimuli applied below the point of spinal lesion incomplete, 15.8% complete). at the T4 level or above produce quite intense increases of heart rate and blood pressure. Thus, Pathology of Spinal Cord clinical determination of SCI level provides a Injuries needed component for the activities of the exercise professional. Spinal cord injuries are commonly described using a system denoting both the functional level Pathophysiology of Spinal of the spinal lesion and the relative degree of func- Cord Injuries tional deficit, referred to as “completeness” (148). First, the level of SCI indicates the last descending The spinal cord is a large complicated bundle of nerve root associated with exhibited full function nerves that carries neural impulses between the brain and the rest of the body. The cord itself is
296 | NSCA’s Essentials of Training Special Populations surrounded by a series of bony rings, the verte- Individuals with SCI may also be prescribed brae, which make up the spinal column. This medications for bladder control and depression, arrangement allows considerable protection of the as well as for autonomic dysre exia. Bladder con- spinal cord while also allowing a good amount trol medications such as Ditropan may produce of motion as a function of the summation of states of dizziness, drowsiness, and weakness, movement between multiple vertebral spaces. which would presumably limit the capability to However, traumatic injuries and disease processes exercise intensely. Depression medications such can introduce mechanical stresses that produce as Prozac, Zoloft, and Wellbutrin may also make damaging effects on the spinal cord, whether or the client dizzy, drowsy, fatigued, or nauseous and not there is vertebral body injury. The cord can should be viewed as potentially negatively affect- be partially or completely cut (transected) or ing exercise performance. Persons with SCI may can be contused (bruised) by trauma. Secondary exhibit the serious life-threatening condition of damage of the spinal cord may also result from autonomic dysre exia, in which intense increases edema, or swelling, which restricts circulatory of heart rate and blood pressure are produced. The flow into the region. individual may be prescribed medications such as sublingual Nitrostat or Catapres, which reduce The most common cause of SCI is motor vehicle hemodynamic stresses. In the case of autonomic related (39%), followed by falls (28%) and acts of dysre exia, the remainder of the exercise session violence (15%) (168). Approximately 8% of SCI should be immediately cancelled and immediate are attributed to sport activities. Acts of violence, medical support should be acquired. now the third highest cause of SCI nationally, are the primary source of SCI in several major Effects of Exercise in urban cities. Individuals With Spinal Cord Injury Common Medications Given to Individuals With Spinal It is well established that persons with SCI can Cord Injury engage in purposeful exercise activities using the intact musculature above the point of spinal lesion No pharmaceutical treatment has been shown to (69, 95). However, several factors tend to limit be effective in the reversal of the damage from a the physiological responses to volitional upper SCI. However, medications are commonly pre- extremity exercise with SCI, thereby reducing scribed for the negative symptoms, such as both peak exercise capacity (95). First, depending orthopedic and neurogenic pain, spasticity, blad- on the level of SCI, less active muscle mass is der control, and depression. See medications table available to contribute to the force generation 8.7 near the end of the chapter for a summary of and stabilization involved in exercise. Secondly, medications given to individuals with SCI. Non- ascending levels of SCI are also associated with steroidal anti-inflammatory drugs (NSAIDs) are greater levels of autonomic dysfunctions, thereby commonly prescribed for joint pain associated limiting exercise capacity due to reduced hemo- with overuse from manual wheelchair locomo- dynamic responses to upper extremity exercise. tion and other activities of daily living performed with the upper extremities. Persons with SCI also There is also a well-established association experience neurogenic pain, which is usually bweotrwkeceanptahceitlyevaesldoefteSrCmI ianneddtwheituhpV.pOe2rpeexatkre. mThitiys treated with medications such as tricyclic drugs association between level and severity of SCI with and selective serotonin and norepinephrine reup- exercise capacity is the basis for the classi ca- take inhibitors. These medications are known to tion used in Paralympic sport competition (120). frequently produce side effects including nausea, Persons with complete SCI above the T4 level are drowsiness, sedation, light-headedness, dizziness, devoid of sympathetic cardio-acceleration pro- and muscle weakness, which may significantly cesses, with elevation of HR limited to withdrawal reduce the ability of the individual to exercise of parasympathetic in uences, thereby limiting vigorously or to maintain balance.
Neuromuscular Conditions and Disorders | 297 HRpeak to approximately 120 to 125 beats/min circuits of CRT, each circuit consisting of three (81, 247). Thus, persons with cervical-level SCI pairs of resistance exercises (1 minute each) and (tetraplegia) exhibit dramatically reduced work three 2-minute bouts of arm cranking, were per- capacity due to restrictions in available active formed three times weekly over a 16-week train- musculature, as well as reduced cardiac output, ing period. Circuit resistance training produced thereby limiting delivery of oxygen and nutrients s(1ig3n-4i 0c%a)natnednVh.Oan2pceeamke(n2t9%of) muscular strength with improvements to the exercising muscles. Persons with SCI below the T6 level generally do exhibit sympathetic drive in lipid pro les. and HRpeak similar to persons without physical The speci c effects of resistance training and disability (134). However, people with paraple- aerobic endurance training in persons with par- gia also display decreased venous return from aplegia have been compared. Jacobs and associ- the paralyzed lower limbs, limited cardiac end- ates (93) assigned matched pairs of persons with diastolic volumes, and reduced levels of stroke paraplegia to either aerobic endurance training or volume (209). Even with a compensatory elevation resistance training for three weekly sessions over of HR, persons with SCI paraplegia exhibit a state a 12-week period. The aerobic endurance training of circulatory hypokinesis in which a reduced program consisted of 30 minutes of arm cranking cardiac (oV.uOtp2)u,ttihsusseerenqfuoirrianggivaegnrleeavteelr of oxygen at 70% to 85% of HRpeak. The resistance training uptake degree of group performed three sets of 10 repetitions at six oxygen extraction at any given level of cardiac exercise stations with intensity ranging from 60% output, leading to earlier local muscle fatigue (94). to 70% of 1RM. The aerobic oefnVd. Our2apnecaek training group displayed 11.8% gain with no It may seem intuitive that resistance training would prove bene cial for the persons with SCI signi cant changes observed in muscular strength due to the increased reliance on upper extremity or power. Conversely, muscular strength and work efforts. Wheelchair locomotion, transfers, power signi cantly increased in the resistance and weight shifts are necessary activities in the tV.rOai2npienagk group for all exercise maneuvers, with increasing 15.8%. The results of this lives of this population, thereby establishing a need for the generation of high forces in the upper investigation indicate that resistance training body in order to carry out basic activities of daily is a means of training for persons with SCI that living. Over 40 years agcoa,nNtliylsesolenvaatneddaVs.sOo2cwiaittehs provides signi cant enhancement of cardiorespi- (172) reported signi ratory functioning as well as signi cant increases increased triceps strength in a group of persons in muscular strength and power. with SCI paraplegia following a seven-week Exercise Recommendations for Clients With Spinal Cord conditioning program. More recently, Davis (44) Injury oexf a7m0%inVe.dOt2hpeeeafkfefcotrs of an arm cranking intensity 20-minute training sessions aV.sOc2poneatrka.stSetdrewngitthh 40-minute sessions at 40% The general exercise recommendations for per- gains were limited to the moderate-intensity condition and to the shoulder sons with SCI do not vary dramatically from those extensors and elbow exor muscles, indicating established for the general population in terms of that arm cranking is not an appropriate mode of training intensity, duration, frequency, or specific- training for functional strength as the gains were ity. Exercise programming recommendations for not re ected in the muscles most commonly used persons with SCI should be in accordance with in activities of daily living. those set forth by the U.S. Department of Health Circuit resistance training (CRT) was exam- and Human Services (244): 150 minutes a week ined in persons with paraplegia in a program of of aerobic training at a moderate intensity or 75 high-intensity resistance exercises performed in minutes a week at a combination of moderate agonist–antagonist pairs (e.g., shoulder press, and vigorous intensity. Initial sessions, though, lat pulldown) alternated with periods of high- stoho<u6l0d%beV. Oat2 a light to moderate intensity (30% or heart rate reserve) for 15 to 20 paced, low-intensity arm cranking (96). Three
298 | NSCA’s Essentials of Training Special Populations minutes. Intensity and duration should be Exercise Modi cations, increased gradually, with duration increasing to Precautions, and 30-minute sessions for two or three weekly ses- Contraindications for Clients sions. Resistance training should be performed With Spinal Cord Injury with all major muscle groups available on two or more days per week, initially with light intensity Conditioning of persons with SCI requires revi- (40-60% 1RM). Resistance training intensity may sions in the training environment in order to be increased progressively to 60% to 85% 1RM. provide a safe and efficacious training setting. Spinal cord injuries alter functioning of several Persons with SCI are limited to exercise of the major body systems, requiring modifications of muscle groups under volitional control, usually the exercise movements and strategies from those the muscle groups innervated by nerve roots appropriate for the general population. above the point of spinal lesion. Aerobic training is commonly limited to arm cranking exercise The most notable characteristic of a motor- or wheelchair propulsion activities. Resistance complete SCI is the total lack of volitional control training is best performed using well-stabilized of muscles below the point of the spinal injury weight training machines. Specialized weight (i.e., muscular paralysis). Exercise conditioning machines have been developed for exercise from of persons with SCI is generally limited to those the wheelchair, which is the preferential mode muscle groups innervated by nerve roots arising for this population. The alternative, transferring above the injury point. Persons with paraplegia the client to and from general resistance training are capable of exercising with the arms and much equipment, carries a substantial risk to both the of the torso (depending on injury level), while client and the exercise professional and should be persons with tetraplegia are limited to muscular performed only with additional specialized train- actions within the upper extremities (see gure ing on the transfer process. Resistance training 8.1). Thus, exercise capacity is dramatically lower can also be undertaken in the wheelchair using in clients with SCI compared to the general public handheld weights and with resistance bands and and is related to the level and completeness of tubing. Program design guidelines for clients with injury. SCI are summarized in table 8.7. Table 8.7 Program Design Guidelines for Clients With Spinal Cord Injury Type of exercise Frequency Intensity Volume Begin with one or two sessions Begin with 8-10 exercises Start with one set per exercise Resistance training per week. with resistance of 40-60% of 10-12 reps. Possibly progress to 4 days per 1RM, emphasizing multijoint Possibly increase to 2-3 sets Modes of training week, split routine. approach. per exercise. a. Weight training machines Intensity may be increased to If multiple sets, then have 1-2 and free weights 60-85% 1RM as tolerated. min between sets. b. Bodyweight resistance c. Elastic tubing Aerobic training Begin with one session per Bionretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 Begin with 15- to 20-min Modes of training week. <75% MHR, or RPE of 9-13 on sessions. Progress to 2 or 3 days per Borg 6- to 20-point scale. Gradually increase to 30-min a. Arm crank exercise week. Increase intensity gradually. sessions. b. Reciprocal press–pull exercise References: (95, 242)
Cervical Neuromuscular Conditions and Disorders | 299 vertebrae Tetraplegia: Spinal cord lesion resulting in complete or incomplete paralysis of the arms and legs Thoracic vertebrae Paraplegia: Spinal cord lesion resulting in complete or incomplete paralysis of the legs Lumbar vertebrae Sacral vertebrae Figure 8.1 Vertebral ranges for tetraplegia and paraplegia. E4822/NSCA_Special_Populations/F08.01/531171/mh/KH-R3 With a reduced amount of muscle mass under initially concentrate on antagonist movements in volitional control and available for exercise train- wheelchair propulsion, wheelchair transfers, and ing, it might seem appropriate to increase the weight shifts (i.e., pulling actions). volume of work applied to those muscle groups available. However, this is not appropriate and Many upper body exercise activities are effec- would eventually result in overtraining and tively performed in the general population using increased risk of injuries. Similarly, it would be stabilization forces generated by the lower extrem- prudent to concentrate the most intense exercise ities and torso. Persons with lower limb paralysis efforts on those muscle groups used by people in are unable to produce such steadying effects and wheelchairs during daily life activities, including would be unsafe in many generalized exercise wheelchair propulsion, wheelchair transfers, and positions. Thus it is often necessary to use strap- weight shifts. It is vital to consider that those move- ping around the torso and weight machine or ments can be relatively intense and are performed wheelchair in order to establish a safe and effective repetitively on a daily basis, because emphasizing base of support for more intense training. the major muscle groups that contribute to those movements (anterior deltoid, pectorals, triceps) Partial or complete paralysis of the lower arms with substantial training volume and intensity and hands dramatically reduces gripping force. could introduce serious overuse syndromes with Persons with cervical-level SCI may exhibit quite potential for injury. Thus it is recommended that limited gripping abilities but retain the ability to resistance training programs for persons with SCI generate substantial forces in the more proximal musculature such as the biceps and deltoid muscles. Specialized mitts and gloves with attaching
300 | NSCA’s Essentials of Training Special Populations straps have been developed to provide gripping level. In these persons, heart rate acceleration in those unable to grip independently. Likewise, is limited to withdrawal of parasympathetic wrist straps (similar to those used with shrugs drive, with peak HR values restricted to 120 and deadlifts by powerlifters) can be used for to 125 beats/min. Thus, persons with SCI these purposes. While these devices can provide tetraplegia have dramatic limitations in their a means to increase work efforts in persons with ability to increase cardiac output and delivery SCI, it is important that the exercise professional of needed oxygen and nutrients to exercising supervise exercise at all times, as these devices musculature. are usually not appropriate for independent use. Persons with cervical SCI or with paraplegia Persons with SCI also exhibit dysfunction of above T4 are also at risk of autonomic dysre- the autonomic nervous system. People with SCI paraplegia present signi cantly reduced levels of exia, which can be life threatening. In this case, venous return from the paralyzed lower extremi- noxious stimuli arising from below the spinal ties. This limits the magnitude of ventricular lesion are inappropriately processed, resulting in dangerous cardiovascular responses such as dra- lling and therefore stroke volume, as well as matic increases of HR and blood pressure (220). reducing the stretch of the cardiac chamber and These noxious stimuli can range from blisters subsequently the effects of the Frank-Starling to over lled bladder or bowels or injuries of the law. Persons with SCI tetraplegia exhibit even lower extremities. If the source of the autonomic greater de cits in venous return associated with dysre exia cannot be immediately identi ed, the proportionally greater amount of paralyzed with adjustments eliminating the problem, the muscle mass (75). client should be immediately transported to an emergency medical facility. Sympathetic neural drive is dramatically lim- ited or absent in persons with SCI above the T4 Case Study Spinal Cord Injury Mr. L, 26 years old, sustained a SCI as a The exercise professional discussed exercise result of an automobile accident four years training with him and determined that Mr. L ago. His spinal injury was classi ed as a was not interested in a “special” program but motor-sensory–complete SCI at the T8 level. would prefer training in a manner as similar to John lives independently, drives his car with what he perceived as “normal” as possible. He hand controls, and uses a manual wheelchair. He explained that before his SCI, he enjoyed a pro- is currently not employed. Since discharge from gram consisting of a cardiovascular warm-up, the rehabilitation hospital about three years ago, followed by static stretching and then a series he has been relatively inactive. Before his injury, of resistance training exercises. Based on his Mr. L was quite active, having participated in experiences and his preferences, the exercise high school and community recreational sports professional designed an appropriate program. and training regularly at the community tness center. Mr. L has experienced shoulder and Mr. L’s training program initially included two elbow pain, which increases the challenges asso- sessions weekly, with each session comprising ciated with wheelchair locomotion and transfers. a cardiovascular training period, a exibility He is taking Ditropan, a prescription medication period, and a resistance training segment. His for control of involuntary muscle spasms. He cardiovascular training was carried out with measured 69 inches (1.75 m) in height and 186 a NuStep ergometer, which allowed reciprocal pounds (84 kg) in weight. upper extremity press–pull movements. Ini- tial cardiovascular sessions were 15 minutes. Mr. L’s rehabilitation physician approved Flexibility training was carried out with static him for exercise training without restriction. stretching movements with assistance from the
Neuromuscular Conditions and Disorders | 301 exercise professional. Emphasis was placed on training had increased to 30 minutes daily the anterior deltoids and pectoral muscles. Resist- with resistance training load increased to ance training was performed with a circuit of three sets of each resistance training session. wheelchair-accessible weight training machines. After three months of exercise training, Mr. L One set of 8 to 12 repetitions each of chest press, reported little to no shoulder or elbow pain. He seated row, shoulder press, lat pulldown, biceps expressed a great deal of appreciation for the curl, and triceps extension was completed. opportunity to engage in what he had always enjoyed: exercise. After four weeks, the NuStep cardiovascular Recommended Readings Jacobs, PL and Beekhuizen, KS. Appraisal of physiological tness in persons with spinal cord injury. Top Spinal Cord Inj Rehabil 10(4):32-50, 2005. Jacobs, PL and Nash, MS. Exercise recommendations for individuals with spinal cord injury. Sports Med 34(11):727-751, 2004. Turbanski, S and Schmidbleicher, D. Effects of heavy resistance training on strength and power in upper extremities in wheelchair athletes. J Strength Cond Res 24(1):8-16, 2010. EPILEPSY Epilepsy is caused by an excessive electrical discharge in the brain that disrupts the normal Epilepsy is not a single disorder, but a collection pattern of brain electrical activity. This is seen of disorders with the common characteristic of when the brain releases more excitatory signals recurring seizure activity. A seizure is a sudden than inhibitory signals. The threshold between surge in the electrical activity of the brain that excitatory and inhibitory signals that the brain may affect an individual’s appearance or actions can withstand before the consequence of a seizure for a short period. Epilepsy is now considered a is genetically predetermined. The outcomes of the disease and is defined by any of the following (59): seizures depend on where and how much of the brain was affected. The durations of seizures range • At least two unprovoked (or re ex) seizures from seconds to minutes, often with disorienta- occurring more than 24 hours apart. tion after the seizure ends. Seizure activity also ranges in severity. More severe seizures exhibit • One unprovoked (or re ex) seizure and a signs such as uncontrolled and uncoordinated probability of further seizures similar to the movements or convulsions, which affect various general recurrence risk (at least 60%) after physical and mental functions and may lead to two unprovoked seizures, occurring over the unconsciousness (58). Less severe seizures may next 10 years. be characterized by blank staring, lip smacking, and jerking movements of the arms and legs (182). • Diagnosis of an epilepsy syndrome. This means that epilepsy is considered resolved Pathology of Epilepsy for individuals who had an age-dependent epilepsy syndrome but are now past the People with epilepsy can experience one or more applicable age, or those who have remained types of seizures. Seizures are now classified seizure-free for the last 10 years, with no sei- into two general types: primary generalized and zure medicines for the last 5 years.
302 | NSCA’s Essentials of Training Special Populations partial–focal (16). Primary generalized seizures genetics, lead poisoning, and infections (men- involve both sides of the brain, while partial sei- ingitis or encephalitis) (208). While the exact zures affect only part of the brain. In addition to physiological cause of epilepsy cannot be deter- classification of epilepsy by seizure type, it can mined in the majority of cases, it is important to also be classified into seizure syndromes, taking determine what may be causing the seizures in more variables into account. There are many the individual before designing a treatment plan subtypes of seizures, and exercise professionals in order to maximize its effectiveness. are encouraged to consult with their client’s physician or other health care professional and Common Medications Given the Epilepsy Foundation (www.epilepsy.com) for to Individuals With Epilepsy more information on the specific type of seizures that are affecting their client. In diagnosing epi- See medications table 8.8 near the end of the lepsy, physicians order a battery of tests including chapter for a summary of medications given to a combination of blood work, medical history, individuals with epilepsy. These medications neurological examination, positron emission are known to have potential side effects such as tomography (PET) scans, computed tomography fatigue, digestive disorder, dizziness, and blurred (CT) scans, and magnetic resonance imaging vision (51, 156, 203). They have also been asso- (MRI). The best means of diagnosing epilepsy is ciated with behavioral changes, depression, and monitoring using an electroencephalogram for suicidal ideation (156). While these side effects one or two days, as well as videotaping seizures in may have serious adverse influences on the ability order to determine what type of seizures a person to perform exercise, it is vital that people never has and subsequently the treatment. discontinue their medication without notifying their physician or other health care professional, Although most seizures cannot be foreseen, as this could increase seizures and place them at there are a few things that people with epilepsy increased risk. The primary issue is to maintain can avoid because they are considered seizure the medication at particular levels in the blood to triggers. The most important thing a person with control seizure activity. If the goals of the exer- epilepsy can do to avoid seizures is to take medica- cise conditioning program include loss of body tions as prescribed. Other triggers include eating weight, then the medication dosage may need to or drinking certain foods, changes in hormone be adjusted if a side effect is weight gain. However, levels, stress, sleep patterns, and photosensitivity the supervising physician should always coordi- (sensitivity to ashing lights at certain intensities) nate adjustment of medication levels. (76, 135, 191, 229, 250). Cases of epilepsy that do not respond to drug Although there is no central database that treatment are termed intractable, and other treat- keeps track of either the incidence or prevalence ment options may be attempted, including special of seizure activity or epilepsy, epidemiologists diets, complementary therapy, vagus nerve stimu- have made estimates using a variety of sources. lation (VNS), or surgery (15, 125, 229). If a person Epilepsy is estimated to affect more than 3 mil- is diagnosed with underlying brain damage that lion Americans, with the greatest incidence rates causes seizures, surgery may be an option (86). occurring during the rst year of life and in those 55 years and older (78). African Americans have a People with epilepsy often suffer from depres- higher chance of developing epilepsy than Cauca- sion or mood disorders caused directly or indi- sians; however, it is more common for a Caucasian rectly by their seizures, in addition to the potential to have uncontrolled epilepsy (34, 71, 105). for depression from the antiseizure medications. Depression can also stem from the challenges Pathophysiology of Epilepsy associated with leading a normal life with epilepsy (106, 156). Further, depression may be initiated Epilepsy is caused by abnormal brain function. by seizure activity caused by damage to the area Some suggested causes include head injury, brain of the brain that is responsible for emotion (20). damage during or before birth, brain tumors,
Neuromuscular Conditions and Disorders | 303 Effects of Exercise in The primary concern for the exercise pro- Individuals With Epilepsy fessional when working with a client who has epilepsy is the potential for seizure activity The safety and efficacy of exercise in persons with during or following training sessions. As the epilepsy have been demonstrated in two studies association of seizures and exercise is very low, from the same research group in Brazil (46, 248). training programs for persons with epilepsy Physiological and electroencephalographic (EEG) are similar to programming recommended for responses to acute exhaustive cardiorespiratory persons without disability (227). Resistance treadmill testing in individuals with both juvenile training should begin with one set each of 8 myoclonic epilepsy and temporal lobe epilepsy to 10 exercise movements with emphasis on were compared with those in control cohorts multijoint movements. Training intensity should without epilepsy. It was found that people with be progressed from 50% to 60% 1RM (initial epilepsy exercised less and had a significantly loading) to 60% to 85% 1RM, and volume should lower resting metabolic rate and resting oxygen be increased to three or four weekly sessions as consumption compared to control groups. Indi- tolerated. Aerobic training should start with one viduals with epilepsy also had decreased EEG i1n5t-emnsinituyt(e3s0e%sstioon<6w0e%ekVl.yOw2 oitrhhleigahrttrtaotemroedseerrvaete) activity during and following exercise as com- and should be increased progressively to two pared to before exercise. These studies not only or three weekly 30-minute sessions. Program demonstrate the positive effect that exercise has design guidelines for clients with epilepsy are on EEG activity, but also highlight the impor- summarized in table 8.8. tance of exercise to maintain a healthy BMI in persons with epilepsy due to their lower resting Exercise Modi cations, metabolism. Precautions, and Contraindications for Clients McAuley and colleagues (145) demonstrated With Epilepsy the ef cacy of a 12-week exercise intervention in persons with epilepsy. Subjects were assigned to The Epilepsy Foundation advocates physical activ- either a control group or an exercise intervention ity and exercise. Exercise in most cases does not group that participated in strength, aerobic, and trigger seizures unless the client is overly fatigued or overheated (8, 192). If this is the case, precau- exibility training three days per week. Results tions should be taken to give the client adequate indicated that exercise did not affect seizure fre- breaks, and exercise should be performed in a cool quency in those with active seizures. Quality of environment. Otherwise sport participation and life as well as strength, peak oxygen consumption, exercise are strongly encouraged for those with aerobic endurance time, and body composition well-managed epilepsy. were, however, improved in the exercise group. When working with a person who has epilepsy, Exercise Recommendations it is important to know rst aid procedures in for Clients With Epilepsy case a seizure occurs. In most cases, seizures do not last long; they end naturally, and the exercise Persons with epilepsy have traditionally been professional should not try to stop them (or any discouraged from active participation in programs subsequent movements) (32). Important rst aid of exercise training due to the misconception that tips include not putting anything in the victim’s increased activity may induce seizure activity mouth, protecting the head from further injury or increase the frequency of seizures. Actually, during the seizure, loosening tight- tting cloth- exercise-induced seizures are rare, and increased ing, and securing the area from anything the vic- levels of activity have been associated with tim’s head might hit. In addition, do not give the reduced seizure frequency, with the expected benefits of improvements in cardiovascular and psychological health (8).
304 | NSCA’s Essentials of Training Special Populations Table 8.8 Program Design Guidelines for Clients With Epilepsy Type of exercise Frequency Intensity Volume Begin with one or two Begin with 8-10 exercises Start with one set per exercise Resistance training sessions per week. with resistance of 50-60% of 10-12 reps. Possibly progress to 4 days per 1RM, emphasizing multijoint Possibly increase to 2-3 sets Modes of training week, split routine. approach. per exercise. a. Weight training machines Increase intensity gradually to If multiple sets, then have 1-2 and free weights Begin with one session per 60-85% 1RM as tolerated. min between sets. b. Bodyweight resistance week. iBonretgehniensaiwrttyirtoahftel3ig0rhe%tsettorovme<,o65d05e%%raVtt.eoO2 Begin with 15- to 20-min c. Elastic tubing Progress to 2 or 3 days per <75% MHR, or RPE of 9-13 on sessions. week. Borg 6- to 20-point scale. Gradually increase to 30-min Aerobic training Increase intensity gradually. sessions. Modes of training a. Walking b. Cycling c. Rowing d. Arm crank exercise e. Reciprocal press–pull exercise References: (227) victim anything to eat or drink or any medications or has diabetes. A status event (nonstop seizures) until the person is fully conscious. After a seizure is always a medical emergency. Also, seeking has occurred, victims tend to be disoriented or further care for individuals who just experienced tired and describe having a headache. Recovery their rst seizure is advisable. can take minutes to hours, and the person should be allowed suf cient time to rest before being If a person experiences frequent seizures, cer- expected to move. tain types of exercise, such as lifting free weights and upright treadmill exercises, are contrain- During tonic–clonic seizures (person loses dicated. It should be up to all clients and their consciousness, muscles stiffen, and convulsions physician or other health care professional to occur), clients may stop breathing during the tonic weigh the risk and bene ts associated with the phase but are often able to breathe again during expected gains from particular types of exercise the clonic phase. If they do not resume breathing, against the danger of possibly having a seizure cardiopulmonary resuscitation (CPR) or rescue while performing this type of exercise. breathing should be started immediately. Clients may also vomit and have incontinence during a Swimming is generally a good form of exercise tonic–clonic seizure. To prevent choking and aid for persons with epilepsy; however, it can be very in breathing, positioning the victim on the left dangerous if someone has a seizure or becomes side may be bene cial. unconscious in the water. To be safe, people with epilepsy should always swim in an area with a The following are reasons to call for emergency lifeguard. Finally, contact sports are potentially medical services during any type of seizure: dangerous; a participant can hit the head and sus- having dif culty breathing, a seizure lasting tain a concussion, which could trigger a seizure. longer than 5 minutes, two seizures in a row People with epilepsy should discuss participation without regaining of consciousness, and a seizure in contact sports with their physician or other in water. One should call for emergency medical health care professional before participation is services also if the person is pregnant or is injured permitted (205).
Case Study Epilepsy Mr. W is a 62-year-old retired re ghter who of the supervising physician to carry out exer- began experiencing epileptic seizures with no cise training. The physician cleared Mr. W to other health-related issues. He reported reduced exercise based on general recommendations consciousness in a variety of settings, with as long as seizure activity was not observed concerns regarding safety while driving his to increase in frequency or severity. Mr. W car. He also shared that his wife had observed participated in three weekly exercise sessions, that during conversations he had been tending with each session including a cardiovascular to ramble on confusedly. He had no history of training segment, a exibility segment, and sustaining a head injury. a strengthening segment. The cardiovascular training began with 15-minute treadmill walks, Neurological examination revealed that with duration increased gradually to 20- to Mr. W had abnormal electrical discharges of 30-minute segments of treadmill, stationary the right temporal lobe of his brain. Magnetic biking, or rowing. Flexibility training included resonance imaging ndings were negative. Mr. 20-second stretches of major muscle groups for W responded well to the prescription medicine one or two sets each. The strengthening seg- Tegretol, which controlled the seizure activity. ments began with one set of 8 to 12 repetitions Mr. W had been relatively inactive since retiring of four to eight exercises per session. Training from the re department at the age of 58. He volume was increased gradually to three sets of was 6 feet (183 cm) tall and weighed 232 (105 kg) pounds. He was aware that he should return ve to eight repetitions at 70% to 85% 1RM with to his previous active lifestyle especially as a eight exercises per session. means to control his body weight. However, he was tentative regarding exercising with epilepsy After 12 weeks of training with the exercise without supervision or guidance. Mr. W sought professional, Mr. W had reduced his body weight out the assistance of an exercise professional by 7 pounds (3 kg). He also reported a signif- with advanced certi cation in working with icantly increased energy level and increased persons with special conditions. ability to carry out his daily tasks. He did not report any seizure activity since beginning the The exercise professional gained the approval Tegretol medication and the exercise training. Recommended Readings Arida, RA, Cavalheriro, EA, da Silva, AC, and Scorza, FA. Physical activity and epilepsy. Sports Med 38(7):607-615, 2008. Arida, RA, Guimarães de Almeida, AC, Cavalheiro, EA, and Scorza, FA. Experimental and clinical ndings from physical exercise as complementary therapy for epilepsy. Epilepsy Behav 26:273-278, 2013. Dubow, JS and Kelly, JP. Epilepsy in sports and recreation. Sports Med 33(7):499-516, 2003. Fountain, NB and May, AC. Epilepsy and athletics. Clin Sports Med 22(3):605-616, 2003. Howard, GM, Radloff, M, and Sevier, TL. Epilepsy and sports participation. Curr Sports Med Rep 3(1):15- 19, 2004. 305
306 | NSCA’s Essentials of Training Special Populations CONCLUSION or disease. People with neurological disorders commonly exhibit characteristics that require It is well established that active lifestyles, spe- condition-specific recommendations for exercise, cifically participation in well-designed exercise as well as appropriate precautions and contraindi- programs, provide significant benefits across cations, in order to experience effective and safe populations regardless of chronological age, sex, training. This chapter provides an overview of the training status, and current health condition. most common neurological disorders, with dis- These benefits include important health bene- cussions of their pathology and pathophysiology, fits as well as enhanced functional performance in order to give readers a basic understanding of of daily activities. Unfortunately, persons with the unique physiological functioning of persons physical disability or chronic disease are known with the given condition (with emphasis on how to be less active than persons without disability this differs from what is seen in the general appar- or disease (85). The lack of active participation ently healthy population). Specific recommenda- is commonly related to limited background in tions for exercise activities as well as precautions exercise training in general and specific con- and contraindications have also been provided for cerns related to the person’s particular disability each condition. Key Terms multiple sclerosis muscular dystrophy aneurysm myelin ataxia paraplegia autonomic dysreflexia Parkinson’s disease bradykinesia pseudohypertrophy cerebral palsy quadriplegia demyelination remission diplegia seizure embolus spasticity epilepsy stroke exacerbation tetraplegia flare-up traumatic brain injury hemiplegia hypertonia Study Questions 1. Which of the following is a nonprogressive neurological disorder? a. cerebral palsy b. multiple sclerosis c. Parkinson’s disease d. muscular dystrophy 2. Which of the following is a symptom of demyelination? a. joint pain b. persistent bleeding c. pseudohypertrophy d. reduced muscle coordination
Neuromuscular Conditions and Disorders | 307 3. A client with cerebral palsy is ambulatory, but walks stiffly with flexed hip and knees in both legs. There is no obvious deficit in upper body coordination. Which form of CP is the client likely suffering from? a. ataxic b. spastic hemiplegia c. athetoid d. spastic diplegia 4. Which of the following is true regarding resistance training programming for a client with traumatic brain injury? a. Perform only machine exercises, no free weights. b. Treadmill walking is preferred to cycling or rowing. c. Rest period between sets should be at least 2 to 3 minutes. d. There are currently no consistent, specific recommendations for resistance training in TBI patients.
Medications Table 8.1 Common Medications Used to Treat Multiple Sclerosis Drug class and names Mechanism of action Most common side effects Effects on exercise Disease-modifying drugs interferon β-1a (Avonex, Anti-inflammatory and Associated with injection sites: Potential for reduced exercise Rebif, Plegridy) immunomodulatory effects redness, itching, skin dimpling capacity and balance potentially via inhibition Potential for reduced recovery of T-cell activation and between training sessions proliferation, apoptosis of autoreactive T cells, induction of regulatory T cells, inhibition of leukocyte migration across blood–brain barrier, cytokine modulation, and potential antiviral activity interferon β-1b (Betaseron, Same as above Flu-like symptoms: aches, fatigue, Same as above Extavia) fever, chills glatiramer acetate Exact mechanisms are Potential for reduced white Same as above (Copaxone, Glatopa) unknown but believed to blood cells with increased risk of modify immune responses via infections specific suppressor T cells teriflunomide (Aubagio) Inhibit synthesis of Diarrhea, abnormal liver tests, Potential for reduced exercise dihydroorotate dehydrogenase, nausea, and hair loss; potential capacity thereby reducing production of for liver problems and birth activated T and B lymphocytes defects natalizumab (Tysabri) Bind to white blood cells and Linked with progressive multifocal Potential for reduced exercise prevents them from crossing leukoencephalopathy (PML), a capacity blood–brain barrier and rare viral disease of the brain attacking the CNS mitoxantrone (Novantrone) Chemotherapy that Heart damage, leukemia Potential for reduced exercise suppresses the immune capacity system; suppresses the production of T cells, B cells, and macrophages; reduces proinflammatory cytokines; inhibits macrophage-mediated myelin degradation Corticosteroids prednisone (Deltasone), Reduce inflammation of the High blood glucose levels, Potential for reduced exercise methylprednisolone (Solu- CNS depression, anxiety capacity Medrol), dexamethasone (Decadron) Antispasticity, muscle relaxants baclofen (Kemstro, Inhibit reflexes at the spinal Drowsiness, muscle weakness, Potential for reduced exercise Gablofen, Lioresal) level dizziness, headache, low blood capacity, muscle strength, pressure, anxiety, numbness or power, and balance tingling, digestive discomfort, fever tizanidine (Zanaflex) Increase presynaptic inhibition Same as above Potential for reduced exercise of motor neurons capacity, muscle strength, power, and balance 308
Drug class and names Mechanism of action Most common side effects Effects on exercise Sedatives Enhance the inhibitory effects Drowsiness, sleepiness, reduced Potential for reduced exercise diazepam (Valium), of GABA, supraspinal sedative coordination, slurred speech, capacity, muscle strength, clonazepam (Klonopin) effects loss of appetite, blurred vision, power, and balance headache Potential for reduced exercise Fatigue-relieving The exact mechanism of Drowsiness, dizziness, blurred capacity, muscle strength, amantadine (Symmetrel), action of amantadine and vision, nausea, nervousness, power, and balance modafinil (Provigil), modafinal is not known. May trouble sleeping, headache armodafinil (Nuvigil) be associated with antiviral Potential for reduced exercise activity, immune-mediated Insomnia, dizziness, drowsiness, capacity Antidepressants activity, or an amphetamine- fatigue, tremor, nausea, Potential for reduced exercise fluoxetine (Prozac), type effect. headache, loose stools, capacity and body awareness sertraline (Zoloft), The exact mechanism of action dyspepsia, anorexia bupropion (Wellbutrin) is not known. Believed to be Insomnia, loose stools, dizziness, Bladder control associated with inhibition of drowsiness, weakness, sleep oxybutynin (Ditropan), serotonin uptake by CNS. problems, dyspepsia, nausea, tolterodine (Detrol) Competitive antagonist of headache, paresthesia, decreased acetylcholine at postganglionic libido and ejaculation, anorexia References: (43, 163, 257) muscarinic receptors 309
Medications Table 8.2 Common Medications Used to Treat Parkinson’s Disease Drug class and names Mechanism of action Most common side effects Effects on exercise Dizziness, light-headedness, Potential for reduced levodopa–carbidopa Levodopa converts to nausea, vomiting, sleep problems, balance and exercise (Sinement) dopamine in the brain. headache capacity Carbidopa prevents conversion of levodopa Nausea, hallucinations, sedation Potential for reduced into dopamine in the including sudden sleepiness and exercise capacity and bloodstream, allowing more light-headedness due to low blood balance of it to get to the brain. pressure Potential for reduced Risk of dyskinesia (involuntary exercise capacity and Dopamine agonists movements), diarrhea balance Potential for reduced pramipexole (Mirapex), Activates dopamine Nausea, insomnia, dry mouth, exercise capacity ropinirole (Requip) receptors to mimic the light-headedness, constipation; function of dopamine in the confusion and hallucinations can Potential for reduced brain occur in elderly persons with PD exercise capacity Drowsiness, hallucinations, purple COMT (catechol-O-methyl transferase) inhibitors skin mottling, ankle swelling Potential for reduced balance and exercise entacapone (Comtan) Prolongs the effect of Can impair memory and cognitive capacity dopamine by blocking processes Potential for reduced breakdown by enzymatic Nausea, vomiting, headache, balance and exercise actions increased sweating, dizziness, capacity drowsiness, yawning, runny nose, MAO-B (monoamine oxidase B) inhibitors hand or foot swelling, pale skin, flushing rasagiline (Azilect), Reduce breakdown of selegiline (Eldepryl, Zelapar) dopamine in the brain via inhibition of the brain enzyme monozmine oxidase B (MOA-B), which metabolizes brain dopamine amantadine (Symmetrel) Indirect dopamine- releasing actions and direct stimulation of dopamine receptors Anticholinergics benztropine (Cogentin), Restore balance of dopamine trihexyphenidyl (Trihex) and acetylcholine in the brain by reducing the amount of acetylcholine apomorphine (Apokyn) Acts as a nonselective dopamine agonist and an agonist of adrenergic receptors References: (43, 186, 256) 310
Medications Table 8.3 Common Medications Used to Treat Muscular Dystrophy Drug class and names Mechanism of action Most common side effects Effects on exercise Corticosteroids Reduce inflammation of High blood glucose levels, May limit exercise capacity prednisone (Deltasone), the CNS depression, anxiety methylprednisolone (Solu- Potential for reduced Medrol), dexamethasone Slow the activity of the Cough, elevated blood potassium exercise capacity and (Decadron) enzyme ACE, thereby levels, low blood pressure, balance ACE inhibitors decreasing the production dizziness, headache, drowsiness, May significantly limit benazepril (Lotensin), of angiotensin II and weakness exercise capacity and captopril (Capoten), allowing vascular dilation Fatigue, nausea, cold hands, balance enalapril (Vasotec), Act as competitive headache, upset stomach, lisinopril (Prinivil), quinapril agonists to block receptor constipation, diarrhea, dizziness, (Accupril), ramipril (Altace) sites for epinephrine and shortness of breath β-blockers norepinephrine acebutolol (Sectral), propranolol (Inderal), atenolol (Tenormin), bisoprolol (Zebeta), metoprolol (Lopressor), nadolol (Corgard), timolol (Blocadren), sotalol (Betapace), nebivolol (Bystolic) References: (43, 141, 261) 311
Medications Table 8.4 Common Medications Used to Treat Cerebral Palsy Drug class and names Mechanism of action Most common side effects Effects on exercise Antispasmodics Inhibit reflexes at the spinal Potential for reduced baclofen (Kemstro, level Drowsiness, muscle weakness, exercise capacity and Gablofen, Lioresal) dizziness, headache, low blood balance Increase presynaptic pressure, anxiety, numbness or Potential for reduced tizanidine (Zanaflex) inhibition of motor neurons tingling, digestive discomfort, exercise capacity and botulinum toxin (Botox) Block release of acetylcholine fever balance from nerve endings Same as above Potential for reduced diazepam (Valium) exercise capacity and Exert the following types Allergic reactions, rash, itching, balance clonidine (Catapres) of effects: anxiolytic, muscle stiffness, shortness of Potential for reduced sedative, muscle relaxant, breath, diarrhea, stomach pain, exercise capacity and Anticonvulsants anticonvulsant, and amnestic loss of appetite, weakness, fever, balance lamotrigine (Lamictal), Agonist of alpha-2 adrenergic cough, injection site reactions Potential for reduced oxcarbazepine (Trileptal) system Memory issues, drowsiness, exercise capacity and dizziness, muscle weakness, balance Anticholinergics Mechanisms of restlessness, nausea, drooling, benztropine (Cogentin), anticonvulsant effects are blurred or double vision, skin Potential for reduced trihexyphenidyl (Trihex) unknown; known to inhibit rash, loss of libido exercise capacity and voltage-sensitive sodium Dry mouth, drowsiness, balance channels irritability, mood issues, sleep Restore balance of dopamine problems, headache, ear pain, Potential for reduced and acetylcholine in the brain fever, constipation, diarrhea, exercise capacity and by reducing the amount of increased thirst, loss of libido reduced capacity for acetylcholine independent exercise Dizziness, tremors, loss of training coordination, headache, double or blurred vision, nausea, vomiting, dry mouth, back pain, menstrual irregularities, sleep problems Can impair memory and cognitive processes References: (43, 140, 258) 312
Medications Table 8.5 Common Medications Used by Persons With Traumatic Brain Injuries Drug class and names Mechanism of action Most common side effects Effects on exercise Potential for reduced Anticonvulsants exercise capacity and balance sodium valproate Block voltage-dependent Hair loss, amnesia, anorexia, ataxia, Potential for reduced (Depakote), gabapentin sodium channels and confusion, double vision, drowsiness, exercise capacity and (Neurontin), topiramate augment brain levels of speech issues, insomnia, nausea, balance (Topamax), carbamazepine GABA diarrhea, tremor, vomiting, weight (Tegretol) gain Potential for reduced exercise capacity and Antidepressants balance Potential for reduced citalopram (Celexa), Inhibit the CNS reuptake of Blurred vision, cardiac palpitations, exercise capacity and amitriptyline (Elavil), serotonin in the brain confusion, constipation, dizziness, balance paroxetine (Paxil), sertraline drowsiness, dry mouth, hypotension, (Zoloft) insomnia, numbness, seizures, skin Potential for reduced rashes, sweating, tremor, urinary exercise capacity and retention balance Antipsychotics Potential for reduced exercise capacity and quetiapine (Seroquel) Mechanism not known but Blurred vision, dizziness, dry mouth, balance proposed as an agonist dystonia, headache, hypotension, Potential for reduced of dopamine type 2 and parkinsonism, tremor, urinary exercise capacity and serotonin type 2 receptors retention, weight gain balance Pain management acetaminophen, ibuprofen, Inhibit the activity of Burning sensation, constipation, naproxen sodium cyclooxygenase-1 (COX- dizziness, gastrointestinal irritation 1) and cyclooxygenase-2 and bleeding, heartburn, nausea, (COX-2) and therefore sedation, tingling, vomiting reduce synthesis of prostaglandins and thromboxanes Motor system medications caclofen (Gablofen, Lioresal) Inhibit reflexes at spinal Abdominal cramps, confusion, level constipation, depression, diarrhea, dizziness, dyskinesia, euphoria, fatigue, headache, nasal congestion, nausea, psychotic episodes, vomiting tizanidine (Zanaflex) Increased presynaptic Dry mouth, upset stomach, dizziness, inhibition of motor neurons drowsiness, fatigue, tiredness, constipation, nausea, headache cyclobenzaprine (Amrix) Mechanism is unknown Dry mouth, dizziness, fatigue, constipation, nausea, dyspepsia, sleepiness Anti-anxiety alprazolam (Xanax), Bind to the gamma subunit Abnormal sleep patterns, sedation, chlordiazepoxide (Librium), of the GABAA receptor, drowsiness, altered cognition, clanozepam (Klonopin) increasing the frequency of weakness, unsteadiness channel opening, increasing chloride ion conductance and inhibition of action potentials References: (28, 43, 143) 313
Medications Table 8.6 Common Medications Used to Treat Stroke Drug class and names Mechanism of action Most common side effects Effects on exercise Anticoagulant warfarin (Coumadin) Prevent blood clots from Nausea, loss of appetite, forming and existing clots stomach–abdominal pain, risk of from getting larger serious bleeding Antiplatelet medicines aspirin, clopidogrel (Plavix) Keep platelets in the blood Nausea, upset stomach, stomach from sticking together pain, diarrhea, rashes, itching Angiotensin II receptor blockers (ARBs) candesartan (Atacand), Act to block type I Dizziness, headache, drowsiness, Potential for reduced eprosartan (Teveten), angiotensin receptors, nausea, vomiting, diarrhea, cough, exercise capacity and irbesartan (Avapro), losartan thereby reducing elevated potassium levels, low balance (Cozaar), olmesartan (Benicar), vasoconstriction blood pressure, muscle or bone telmisartan (Micardis), pain, rashes valsartan (Diovan) ACE inhibitors benazepril (Lotensin), captopril Inhibit the production Dizziness, headache, drowsiness, Potential for reduced (Capoten), enalapril (Vasotec), of angiotensin II, a diarrhea, low blood pressure, exercise capacity and lisinopril (Prinivil), quinapril vasoconstrictor that also weakness, cough, rashes balance (Accupril), ramipril (Altace) promotes sodium and water retention β-blockers acebutolol (Sectral), Block receptor sites Fatigue, cold hands, headache, Potential for reduced propranolol (Inderal), atenolol for epinephrine and upset stomach, constipation, balance and exercise (Tenormin), bisoprolol norepinephrine on diarrhea, dizziness, shortness of capacity (Zebeta), metoprolol adrenergic beta receptors breath (Lopressor), nadolol (Corgard), of sympathetic nervous timolol (Blocadren), sotalol system, thereby decreasing (Betapace), nebivolol (Bystolic) descending sympathetic nerve drive Calcium channel blockers amlodipine (Norvasc), Interfere with voltage- Light-headedness; low blood Potential for reduced diltiazem (Cardizem, Dilacor, operated calcium channels pressure; slower heart rate; exercise capacity and Tiazac), nicardipine (Cardene), in cell membrane, thereby drowsiness; constipation; swelling balance nifedipine (Procardia), promoting vasodilatory of feet, ankles, and legs; increased nisoldipine (Sular), verapamil activity appetite; gastroesophageal reflux (Calan, Verelan) disease (GERD) Diuretics chlorothiazide (Diuril), Suppress the sodium Dizziness, light-headedness, Potential for reduced chlorthalidone (Thalitone), chloride cotransporter blurred vision, loss of appetite, exercise capacity and hydrochlorothiazide leading to inhibition of itching, stomach upset, headache, balance (Microzide) NaCl reabsorption in the weakness distal convoluted tubules of kidneys furosemide (Lasix), torasemide Inhibit the Na+/K+/2Cl− Dizziness, light-headedness, Potential for reduced (Demadex) transporter protein in walls blurred vision exercise capacity and of ascending loop of Henle; balance reabsorption of NaCl 314
Drug class and names Mechanism of action Most common side effects Effects on exercise Diuretics (continued) Dizziness, light-headedness, loss Potential for reduced spironolactone (Aldactazide, Block entry of aldosterone of appetite, diarrhea, nausea, exercise capacity and Aldactone), triamterene into collecting duct and vomiting, headache, gas, stomach balance (Dyrenium, Dyazide, Maxzide) distal tubule of nephron, pain, rashes thereby preventing Dizziness, spinning sensation, Potential for reduced metolazone (Zaroxolyn) retention of sodium and drowsiness, tiredness, depression, exercise capacity and water muscle or joint pain, numbness, balance References: (43, 144, 259) Inhibit sodium tingling, nausea, stomach reabsorption; increased pain, loss of appetite, diarrhea, sodium delivery to distal constipation, headache, heart tubular exchange site palpitations produces increased potassium excretion 315
Medications Table 8.7 Common Medications Used With Spinal Cord Injury Drug class and names Mechanism of action Most common side effects Effects on exercise Potential for reduced exercise Pain management capacity and balance Potential for reduced exercise Nonsteroidal anti- Inhibit the activity of Stomach problems, kidney capacity and balance inflammatory drugs cyclooxygenase-1 (COX- problems, anemia, dizziness, Potential for reduced exercise (NSAIDs), acetaminophen, 1) and cyclooxygenase-2 swelling in legs, abnormal capacity and balance aspirin, ibuprofen, naproxen (COX-2) and therefore reduce liver blood tests, headaches, sodium synthesis of prostaglandins heartburn, nausea, easy bruising Potential for reduced exercise and thromboxanes capacity and balance pregabalin (Lyrica) The precise mechanism of Dizziness, sleep disorders, Potential for reduced exercise action for neuropathic pain peripheral edema, ataxia, fatigue, capacity and balance is not known, but this drug is weight gain, tremor, blurred or a GABA analogue that binds double vision, dry mouth Potential for reduced exercise to a subunit of voltage-gated capacity and balance calcium channels in the CNS. Potential for reduced exercise capacity and balance tramadol (Tramal), Act on presynaptic receptors Constipation, nausea, vomiting, Potential for reduced exercise oxycodone (Percocet), to inhibit neurotransmitter drowsiness, sedation, light- capacity and balance morphine (MS Contin, release headedness, dizziness, sweating Morphine Sulphate ER, Kadian), fentanyl (Sublimaze, Actiq, Duragesic, Fentora, Abstral, Lazanda), methadone (Dolophine), codeine Tricylic drugs amitriptyline (Elavil), Act as serotonin– Dry mouth, blurred vision, imipramine (Tofranil), norepinephrine reuptake constipation, drowsiness, clomipramine (Anafranil), inhibitors (SNRIs), thereby increased appetite leading doxepin (Sinequan), raising neurotransmitter to weight gain, orthostatic nortriptyline (Sensoval), concentrations hypotension, increased sweating desipramine (Norpramin) Selective serotonin–norepinephrine reuptake inhibitors (SSNRIs) desvenlafaxine (Pristiq), Inhibit reuptake of serotonin Nausea, dizziness, sweating, duloxetine (Cymbalta), and norepinephrine tiredness, constipation, insomnia, venlafaxine (Effexor), anxiety, headache, loss of venlafaxine XR (Effexor appetite XR), milnacipran (Savella), levomilnacipran (Fetzima) Antispasmodics baclofen (Kemstro, Gablofen, Inhibit reflexes at the spinal Drowsiness, muscle weakness, Lioresal) level dizziness, headache, low blood pressure, anxiety, numbness or tingling, digestive discomfort, fever tizanidine (Zanaflex) Increase presynaptic Same as above inhibition of motor neurons botulinum toxin (Botox) Block release of acetylcholine Allergic reactions, rash, itching, from nerve endings muscle stiffness, shortness of breath, diarrhea, stomach pain, loss of appetite, weakness, fever, cough, injection site reactions 316
Drug class and names Mechanism of action Most common side effects Effects on exercise Antispasmodics Exert the following types Potential for reduced exercise diazepam (Valium) of effects: anxiolytic, Memory issues, drowsiness, capacity and balance sedative, muscle relaxant, dizziness, muscle weakness, Potential for reduced exercise clonidine (Catapres) anticonvulsant, and amnestic restlessness, nausea, drooling, capacity and balance Agonist of alpha-2 blurred or double vision, skin Bladder control adrenergic system rash, loss of libido Potential for reduced exercise oxybutynin (Ditropan), Dry mouth, drowsiness, capacity and balance tolterodine (Detrol) Competitive antagonist irritability, mood issues, sleep of acetylcholine at problems, headache, ear pain, Potential for reduced exercise Autonomic dysreflexia postganglionic muscarinic fever, constipation, diarrhea, capacity and balance sublingual nitrates (Nitrostat) receptors increased thirst, loss of libido Potential for reduced exercise capacity and balance clonidine (Catapres) Form free radical nitric Insomnia, loose stools, dizziness, Potential for reduced exercise oxide (NO), which activates drowsiness, weakness, sleep capacity and balance trimethaphan camsylate guanylate cyclase, which problems, dyspepsia, nausea, (Arfonad) increases cyclic GMP headache, paresthesia, decreased Potential for reduced exercise resulting in vasodilation libido and ejaculation, anorexia capacity and balance Antidepressants Stimulate alpha- fluoxetine (Prozac), adrenoceptors of brain Headache, dizziness, light- sertraline (Zoloft), bupropion stem, thereby reducing headedness, nausea, flushing, (Wellbutrin) sympathetic outflow tingling under tongue Inhibit transmission between preganglionic and Dizziness, orthostatic postganglionic neurons hypotension, dry mouth, in the autonomic nervous headache, fatigue, skin reactions, system hypotension Urinary retention, orthostatic The exact mechanism hypotension, tachycardia, of action is not known. precipitation of angina, anorexia, Believed to be associated nausea, vomiting, dry mouth, with inhibition of serotonin extreme weakness, restlessness, uptake by CNS. vision problems, hives, itching Insomnia, dizziness, drowsiness, fatigue, tremor, nausea, headache, loose stools, dyspepsia, anorexia References: (33, 43, 142) 317
Medications Table 8.8 Common Medications Used to Treat Epilepsy Drug class and names Mechanism of action Most common side effects Effects on exercise Anticonvulsants Potential for reduced carbamazepine (Carbatrol, Mechanism of action remains Fatigue, vision issues, nausea, exercise capacity and Tegretol) unknown. dizziness, rash balance diazepam (Valium), Potential for reduced lorazepam (Ativan), Bind to benzodiazepine Tiredness, unsteady gait, nausea, exercise capacity and clonazepam (Klonopin) receptors, which increase depression, loss of appetite balance GABA affinity to coupled eslicarbazepine (Aptiom) GABAA receptors, leading to Potential for reduced lamotrigine (Lamictal) opening of chloride channels exercise capacity and and hyperpolarization balance levetiracetam (Keppra) Potential for reduced Block the voltage-gated sodium Dizziness, nausea, headache, balance oxcarbazepine (Oxtellar XR, channel vomiting, fatigue, vertigo, ataxia, Trileptal) blurred vision, tremor Potential for reduced perampanel (Fycompa) exercise capacity Inhibit voltage-sensitive sodium Dizziness, insomnia, rashes phenobarbital channels, calcium channels, Potential for reduced phenytoin (Dilantin) or both, leading to release of balance pregabalin (Lyrica) glutamate and aspartate Potential for reduced exercise capacity tiagabine (Gabitril) Bind to a synaptic vesicle Tiredness, weakness, behavioral topiramate (Topamax) glycoprotein, SV2A, and issues Potential for reduced inhibit presynaptic calcium exercise capacity zonisamide (Zonegran) channels, thereby reducing Potential for reduced neurotransmitter release balance Potential for reduced Block voltage-sensitive sodium Dizziness, sleepiness, headache, exercise capacity and channels vomiting, double vision, balance balance issues Potential for reduced exercise capacity and Act as a selective Serious effects including balance noncompetitive antagonist irritability, aggression, anger, Potential for reduced of AMPA receptors, the anxiety, paranoia, euphoria, exercise capacity and major subtype of ionotropic agitation, altered cognition balance glutamate receptors Potential for reduced exercise capacity and Inhibits GABAA postsynaptic Sleepiness, behavioral issues balance receptors leading to synaptic inhibition Block voltage-sensitive sodium Dizziness, fatigue, slurred speech, channels acne, rash, increased hair growth Reduce release of several Dizziness, sleepiness, dry mouth, neurotransmitters, apparently blurred vision, edema, weight by binding to alpha-2-delta gain, concentration issues subunits Block GABA uptake into Dizziness, fatigue, weakness, presynaptic neurons, increasing irritability, confusion postsynaptic receptor binding Block voltage-dependent Sleepiness, dizziness, speech sodium channels, augment issues, nervousness, memory and GABA activity, inhibit carbonic vision issues, weight loss anhydrase Block sodium and T-type Drowsiness, dizziness, unsteady calcium channels, act as a weak gait, kidney stones, headache, carbonic anhydrase inhibitor rashes References: (43, 204, 260) 318
Cognitive Conditions 9 and Disorders William J. Kraemer, PhD, CSCS,*D, FNSCA Brett A. Comstock, PhD, CSCS James E. Clark, MS, CSCS After completing this chapter, you will be able to ◆ describe the range of cognitive disorders and their respective etiologies; ◆ recognize the importance of individualization in the exercise prescription process; ◆ discuss the importance of encouragement, fun, and the environment in the exercise setting for people with cognitive disorders; and ◆ explain the difference between dementia and Alzheimer’s disease. 319
320 | NSCA’s Essentials of Training Special Populations Cognitive disorders encompass a wide range of programs for the persons involved. The necessary challenges and difficulties, including but not lim- background information about each disorder is ited to impaired brain function, anxiety and panic provided, including a summary of the disorder, disorders, and dementia. This chapter focuses on etiology and epidemiology, a review of bene ts specific considerations concerning health and that can be derived from utilization of exercise, fitness maintenance within some current major and nally general recommendations for exercise cognitive disorders. At the outset, it is important prescription that should be used in training. to stress that these discussions emphasize the It is important to note that within the context individuals involved rather than the disorders. of exercise and its various positive bene ts, Thus, one speaks of a young girl with Down syn- information concerning some of these cognitive drome, not a Down syndrome girl. This focus has disorders is limited. The authors used the best been a great challenge over the past many years available data to make recommendations, yet a and shows the respect needed for individuals who great deal of future study is needed and could experience such demands in their lives. provide signi cant bene t to individuals and practitioners within these populations. In addition to affecting brain properties before and after birth, many cognitive disorders are In the United States, according to the Centers accompanied by various motor function impair- for Disease Control and Prevention, there is ments. This chapter focuses on those disorders greater risk for obesity in children and adults that primarily affect the cognitive abilities of the with mobility issues or learning or intellectual person but, when appropriate, also addresses disabilities than in individuals who do not motor impairments. These cognitive disorders have a chronic condition (9, 19, 29). In many fall into two primary categories: developmen- cases this includes children and adults with tal disorders and neurodegenerative diseases. cognitive disorders. This may be manifested by Within the vast list of diagnosable developmental decreased opportunities for physical activity as disorders, the chapter discusses autism spec- recess and gym class are taken out of school trum disorder (ASD), Down syndrome (trisomy curriculums; other factors include decreases in 21), and intellectual disability (ID). (Please note physical activity as age increases and a mete- that even though intellectual disability has oric increase in sedentary pursuits. Poor food been referred to elsewhere and in the literature choices, poor economic conditions, and a lack as mental retardation, that terminology is not of cognitive understanding can also be major used in reference to these individuals.) From a contributors to the obesity epidemic in such similar vast list of diagnosable neurodegenera- populations. Individuals with cognitive disor- tive diseases, this chapter discusses dementia ders may be more vulnerable to these issues and Alzheimer’s disease. These disorders were due to even fewer opportunities for regular primarily chosen on the grounds of previously physical activity. This is also true for children established impact and the recently noted outside of a school setting, in part due to the increasing prevalence and the effect on individ- needed supervision and instruction by quali ed uals within the general population of the United professionals, which can make all the difference States. when available (37, 68). Other factors affecting opportunities for physical activity include the While reading this chapter, it is important to previously mentioned shortage of knowledge keep in mind that each of these disorders has var- on how to individualize an exercise program, as ying levels of manifestations and subsequent cog- well as the common practice of “preoccupying” nitive and physical disabilities. This variation of individuals with movies, TV, or other technology presentation is based on severity of the disorder (56). However, a real concern is the volunteering and individual differences within populations of of well-meaning adults trying to take the place those who are affected. Each of these disorders of trained professionals in providing exercise is individually presented, with useful infor- and sport-related activities. mation concerning implementation of exercise
Cognitive Conditions and Disorders | 321 GENERAL EXERCISE selection, as well as through the implementation CONSIDERATIONS FOR of varying lengths of rest between sets of each CLIENTS WITH COGNITIVE exercise and rest between exercises within a train- ing session. The selection of exercise should focus DISORDERS on all major muscle groups of the body within each exercise session. This exercise selection Before presenting general exercise recommenda- should also use a progressive pattern of periodi- tions for working with persons who have special zation over the length of the training program, needs and then the individual disorders and while rest time should be at least 2 to 3 minutes accompanying considerations for exercise, it is in length but ultimately is based on the client’s appropriate to discuss general considerations tolerance for the exercise itself. appropriate for all of the cognitive disorders within this chapter. These considerations focus Key Point on individualization of training session design to allow for the person to tolerate and consistently To individualize exercise programs for people complete workouts. While beyond the scope of with cognitive disabilities, exercise professionals this chapter, considerations for proper nutrition should consider not only the cognitive abilities and hydration are vital for optimal exercise and of the client but also any anatomic limitations to adaptive changes. In addition, the program needs exercise. to account for the client’s ability to learn and safely execute the exercises, as matching abilities and Although free weights may be ideal for many program design is vital from a motor learning populations, cognitive, anatomic, and biomechan- perspective. In other words, everyone may not ical issues may limit their effectiveness for special learn a movement or skill in the same manner populations. The second general consideration (e.g., with the exercise professional showing the is that the use of weight machines should be a movement and expecting the client to replicate starting point for the choice of exercise equipment it). This approach assumes that all neural brain when one is beginning a resistance training pro- functioning, from vision imaging to spatial move- gram with clients who have cognitive disabilities ment replication, is possible. ( gure 9.1). Learning can be made easier because the client can be “locked” into a set pattern of The ability to tolerate exercise is typically movement that can be safely and easily replicated diminished based on the unique characteristics throughout a workout session. The bene ts of of each of the disorders, but four considerations using machines when training these populations will guide the recommendations for each popu- are valid only if care is taken to “ t” the piece lation. These considerations are related to indi- of equipment to the client and the movement. vidualization, use of machines when beginning Thus, one can progress to heavier resistance more resistance training, progressive overload during quickly due to fewer demands on the motor capa- resistance training, and the use of aerobic endur- bilities needed to learn the exercise movement, ance exercise. as well as coordination. In addition, adequate amounts of time should be taken for progression Individualization is the rst general consider- of the program, with special attention to motor ation and should be central to the total program capabilities within the exercise movements as well design. This modi cation needs to take into as the metabolic demands of each exercise. The account not only the cognitive disabilities in the proper use of machines for these clients will allow client but also any anatomic limitations to exer- for an improvement of strength within primary cise. By considering cognitive and biomechanical patterns of movement and can allow for the client characteristics of the client, one can design an to work toward an increased workload (a hallmark exercise program to allow the person to be able of a progressive resistance training program). to tolerate the metabolic demand of the training session. Tolerance is developed through exercise
322 | NSCA’s Essentials of Training Special Populations Additionally, increase in the person’s strength may Figure 9.1 Machine exercises can be used to lead to a carryover of strength to other patterns stabilize the exercise movement to help strengthen of movement, allowing for improved functionality body parts, and they require little if any balance or and independence of the person throughout every- motor coordination. Even if balance and functional day life. Variations of free weight and machine skills are not developed, complementary exercises exercises can be found in a number of books, based on each client’s motor capabilities should be for example, Strength Training for Young Athletes, used in the choice of exercises. Weight machines Second Edition, or Designing Resistance Training can be used for strengthening when free weight Programs, Fourth Edition (31, 32). exercises demand too much skill and coordination. The third general consideration is that the © William Kraemer resistance training program should be a progres- sive program, with additional levels of resistance EXERCISE or increase of exercise intensity used to meet an RECOMMENDATIONS FOR increased tolerance of the metabolic demand of CLIENTS WITH COGNITIVE the workout. This progression typically starts with one set and later expands to two or three CONDITIONS AND sets per exercise using a varied range of 8 to 12 DISORDERS repetitions in a periodized format. The progres- sive resistance training program needs to take There are few specific recommendations for into account the ability to tolerate the metabolic exercise in persons with cognitive disorders due demands of the exercise program before adding to limited controlled studies in this area. For either repetitions, sets, or amount of resistance. context of what is usually done when working Additionally, the progression of the resistance with clients who have special needs, exercise training program should take into account the professionals can consult the general guidelines need or requirement for individual supervision of each exercise session and the total number of persons needed to supervise the client or group of clients. The last general consideration addresses aero- bic endurance exercise. Much like the limitations noted regarding resistance training are limitations related to aerobic endurance training. Because of the cognitive, anatomic, and biomechanical limi- tations that persons with these disorders exhibit, a general rule of thumb is that use of standard aerobic endurance training equipment may not be the best choice. Long-duration, repetitive activities may not suit the client’s preferences and could create negative attitudes toward this type of exercise. Instead, the creative use of various alternative physical activities, such as dancing to music, swimming, or water aerobics, may allow for greater tolerance to the exercise. As a function of being more enjoyable, the use of alternatives may lead to completion of more aerobic endurance exercise sessions, although this is speculation deserving of further study.
Cognitive Conditions and Disorders | 323 adopted by the U.S. Department of Health and For resistance exercise it is recommended that clients train each major muscle group two or three Human Services (DHHS) (72) for developing exer- days each week, and that using very light or light intensity is best for older persons or previously cise workouts and programs for healthy adults. sedentary adults starting exercise, with two to four sets of each exercise to help adults improve However, the actual exercise prescription must strength and power. These exercise recommen- dations are appropriate as guidance for exercise be individualized and the exercise progression programming for clients with cognitive disorders. The response to exercise acutely and over time tolerated for successful development of health, does not vary dramatically due to a cognitive condition. fitness, and function. Exercise prescriptions need Proper progression in a periodized format to be carefully monitored when one is working from a base program starting at one set of 8 to 12 repetitions with regard to resistance and sets can with diverse clients who have various cognitive be implemented as tness levels increase. Also, if the recommended duration of a single exercise and intellectual challenges. In cases in which the bout is not tolerable, enjoyable, or practical, then accumulating these amounts throughout the day general recommendations are unattainable due is permitted. This exibility is a necessity, as any opportunity for physical activity within these to limitations, a lower frequency or intensity (or populations is far more bene cial to health and quality of life than acquiescing to the trend of an both) can be selected. increasingly sedentary existence. Program design guidelines for clients with cognitive conditions Clients with cognitive conditions and disorders and disorders are summarized in table 9.1. should begin their aerobic training program by performing one or two 10- to 20-minute sessions <a6w0e%ekV. Oat2 a light to moderate intensity (30% to or heart rate reserve). As a person pro- gresses, he or she can strive to meet the DHHS recommendations of attole<a6s0t 1%50V.Om2inourtehseoafrtmroadte- erate-intensity (40% reserve) aerobic exercise per week (72). This can be attained with 30 to 60 minutes of moderate- minitnenusteitsyoefxveirgcoirsoeu(s-vientdeanyssitpye(r≥w6e0e%k-)9o0r%20V. Oto26o0r heart rate reserve) exercise (three days per week). Table 9.1 Program Design Guidelines for Clients With Cognitive Conditions and Disorders Type of exercise Frequency Intensity Volume Begin with one or two sessions Begin with very light to light Start with 1 set per exercise of Resistance training per week intensity and slowly and 8-12 reps and increase to 2-4 Increase to two or three progressively increase to sets per exercise as appropriate Modes of training weekly sessions as tolerated 8-10RM If multiple sets, then rest 1-2 a. Weight training machines Recovery periods of 2-4 min min between sets and free weights Begin with one session per Begin with 10- to 20-min b. Bodyweight resistance week Bihneetagernintsriwtaytite(h3r0elis%gehrttvoteo)<m60o%derV.aOte2 or sessions c. Elastic tubing Five sessions/week OR PROGRESS TO 30- to 60-min/session Aerobic training Three sessions/week OR rMtoeso<edr6ev0rea%)teV.iOnt2eonrsihteya(r4t0r%ate 20- to 60-min/session Modes of training a. Treadmill walking b. Cycling c. Arm and leg cycling d. Rowing e. Aquatic exercise f. Aerobic dance OR y (≥60%-90% VV. Oig2ooror uhseainrtternastiet reserve)
324 | NSCA’s Essentials of Training Special Populations AUTISM SPECTRUM other symptoms pertaining to sensory cues are DISORDER also key players in the behavior of children and adolescents with ASD (39, 42, 57). It is worth Autism spectrum disorder (ASD) is a complex noting that children and adolescents with ASD, in group of conditions that are behaviorally defined some situations, can exhibit outbursts and cause and have multiple etiologies with varying levels physical harm to themselves or to others. This of severity (33). This group of disorders is char- usually happens if a sudden change is forced upon acterized by deficits in social communication them, if frustration builds from not being able to and social interaction and restrictive repetitive communicate properly, or if they have a sensitivity behaviors, interests, and activities. These include issue with their sensory system (39, 42, 53, 61). sensitivity to sensory stimuli of all kinds (taste, touch, smell, sound, and sight); stereotyped History and Demographics of behaviors, including various physical actions like Autism Spectrum Disorder body rocking, hand clapping, and echolalia or repetitive vocalizations; obsession with an object The Centers for Disease Control and Prevention or topic of interest; and an insistence on sameness. (CDC) reported in 2012 that 1 in 68 births in the United States had ASD (21). This represented Pathology of Autism the fastest-growing disability, as the prevalence Spectrum Disorder increased by 6% to 15% each year from 2002 to 2010. It is estimated that 3.5 million people live in The conditions included in ASD are pervasive the United States with ASD, with a greater rate in developmental disorder—not otherwise specified boys (1 in 42) compared with girls (1 in 189) (16). (PDD-NOS), childhood disintegrative disorder (CDD), Asperger’s syndrome, and classical autism The numbers of ASD diagnoses are undenia- (6). Classical autism can be either mildly severe bly on the rise from past estimates. However, it (high functioning) or very severe (low function- is unclear how much of this increase is due to a ing) (33). Individuals with Asperger’s syndrome true increase in prevalence or to a broadening of mainly have detriments in social interaction but the diagnostic criteria. When assessing whether have normal to above-average cognitive function. or not a child has ASD, medical and allied health Childhood disintegrative disorder (CDD) (also (i.e., psychologists) professionals consult the known as Heller’s syndrome) is characterized diagnostic criteria set forth by the Diagnostic and by a loss of previously acquired language, social Statistical Manual of Mental Disorders: DSM-5 (6), skills, and various motor skills. Pervasive devel- and it should be noted that previous editions did opmental disorder—not otherwise specified not include Asperger’s or PDD-NOS with ASD (PDD-NOS) differs from the other conditions in (4, 5, 7). With these two disorders included in being the most difficult form of ASD to diagnose. the ASD diagnosis, there is a good chance that Autism spectrum disorders are usually diagnosed prevalence rates are on the rise because pop- anywhere from after the first 14 months to three ulations are being accounted for that have not years of life and persist through adulthood (57). previously been included in the estimates (33, 34, An emerging body of evidence supports the effi- 61). In addition to the inclusion of the spectrum cacy of early, intense behavioral and cognitive of disorders, the increase in prevalence may be intervention strategies to improve language and in part due to the increase in public awareness social function, which provide the most successful of ASD (33, 34, 61). outcomes possible to those diagnosed with ASD (34, 42). Pathophysiology of Autism Spectrum Disorder The core de ciencies of ASD are impairments in communication and social interactions, and Children and adolescents with and without ASD engagement in repetitive or stereotypic behav- are more likely to be overweight or obese due to iors (39, 53, 61). In addition to these symptoms, the trend of decreasing physical activity as age increases (26, 54). This is most likely attributable
Cognitive Conditions and Disorders | 325 to decreased opportunities for physical activity risk of musculoskeletal injury, increased cog- as recess and gym class are taken out of school nitive function, and decreased risk factors for curriculums and sedentary pursuits increase. cardiovascular disease (i.e., obesity and over- Children and adolescents with ASD are suscep- weight), among others. In children with ASD, tible to this same trend; however, they may be exercise has been shown to have positive effects. more vulnerable to it because of the small number For instance, cognitive function and time spent of opportunities for physical activity outside of doing learning activities improve in children and school, a shortage of programs tailored to their adolescents with ASD after an exercise bout. The needs, and the common practice of preoccupying major cause of this increase in cognitive function them with movies, TV, or other media (54). is the decrease in stereotypic behaviors (40, 60) that occurs in a dose–response relationship. This Common Medications Given results in greater academic engagement because to Individuals With Autism increased physical activity leads to decreased Spectrum Disorder anxiety and stress reactivity (40, 60). It has also been shown that multiple exercise bouts and vig- It is important to understand that there are no orous intensity produce greater and longer-lasting medications that can cure ASD or even treat the reductions in stereotypic behavior in this popu- main symptoms of ASD. Medications are used to lation (40). help some people deal with some of the related symptoms (e.g., to help manage high energy levels, In the general population, there exists a trend the inability to focus, depression, or seizures) for adolescents to be more sedentary than chil- (51). The two main categories of medications dren, either due to decreased opportunity for used include selective serotonin reuptake inhibi- physical activity or because of increased sedentary tors (SSRIs) and antipsychotic agents. The SSRIs, pursuits (54). Children and adolescents with ASD such as citalopram, fluoxetine, and sertraline, are are not apart from this trend (10, 26). Being habit- used to address depression, anxiety, and obsessive ually active can lead to increased weight control, behaviors. Side effects of these medications can which can decrease the risk of health problems include insomnia, increased agitation, and weight associated with inactivity, such as hypertension, gain. Persons with ASD may also be prescribed obesity, and diabetes. Since a trend of these health antipsychotic medications such as haloperidol, concerns exists in this population, increasing the risperidone, or thioridazine. These medications amount of physical activity in youth with ASD alter effects of brain chemicals and have been should be a primary goal for health, wellness, and shown, in many cases, to reduce aggressive or medical professionals. self-harming behavior. Antipsychotic medications can have side effects such as sleepiness, tremors, Training Considerations for and weight gain. Clients With Autism Spectrum Disorder Effects of Exercise in Individuals With Autism Based on the available evidence with this popu- Spectrum Disorder lation, the following recommendations might be a starting point for an exercise training program The benefits of regular physical activity are well (43). It is recommended that exercise training with documented, and seemingly, the overall effects of persons with ASD include a variety of activities exercise are no different for individuals with and that are enjoyable and developmentally appropri- without ASD (8, 44, 55, 66). ate for the client based on a behavioral model for teaching. Many exercises are difficult to perform, These effects include increased cardiovascu- from basic jumping to walking, pulling, pushing, lar health, increased lean body mass, decreased and so on, due to ASD. Thus, each workout pro- adiposity, weight control, increased strength, gram must be developed within the scope of the increased balance and coordination, decreased client’s ability to progress. However, the option is
326 | NSCA’s Essentials of Training Special Populations open for use of all the typical activities if they can The rest periods used should allow for complete be properly taught by the exercise professional recovery between sets, as too short a rest period and achieved by the client challenged with ASD. increases physiological stress. This has to be interfaced with behavioral learning approaches A basic progressive resistance training program as well. Typically, 2 to 3 minutes between sets for persons with ASD may be initiated with one set and exercises is a starting point to make sure the each of several movements for 8 to 12 repetitions client can tolerate the exercise (e.g., showing no per set. If possible and with time, up to three sets signs of nausea or dizziness and ready to take on may be performed using a varied program with the next set or exercise without extreme fatigue). different intensities from 8 to 12 repetitions in a periodized format. Two or three exercise sessions Many clients with ASD have signi cant gait and should be performed per week. Tolerance of the posture disorders, and exercise activities may not workout will be determined by progressive addi- be of obvious interest, thus requiring behavioral tion of sets for a particular muscle group; however, modi cations in teaching. not all exercises need to be performed for the same number of sets in a workout. Verbal exchanges between an instructor and a youth with ASD should be emotionally neutral Exercise should be performed with moder- (no up and down intonations), free of jargon, and ate intensity (physical activity that noticeably free of sarcasm and rhetoric (63, 75) so as to make increases breathing, sweating, and heart rate) to communication no more dif cult than it already is vigorous intensity (physical activity that substan- for youths with ASD. This will minimize frustration tially increases breathing, sweating, and heart rate), and distraction during conversations, which can with the understanding that gaining intensity in lessen the possibility of outbursts and potentially an exercise may be challenging. The progression increase learning ability (63, 75). To further mini- should be matched with behavioral strategies to mize the sensory stimulation, the room and clothing pique and maintain interest. Thus, the exercise should be kept as neutral as possible as well (75). programming for someone with ASD should be creatively and individually prescribed. The initial Key Point recommendation is to include 20 to 30 minutes of moderate-intensity aerobic activity accumulated When working with clients with ASD, it is ideal over the day for three days a week (66). The activity if the environment (room, clothing, music) and can also incorporate several different modalities to verbal exchanges are kept as neutral as possible. maintain interest and enjoyment. Verbal exchanges should be emotionally neutral and free of jargon, sarcasm, and rhetoric. Case Study Autism Spectrum Disorder Maria is an exercise professional at the local posture issues. Coach Maria anticipates that it health club, which has started to provide classes may be dif cult to teach the leg press movement, for special populations, including ASD, to help as it may not be seen by Laura as interesting or with basic tness and strength development. She fun; she may rather do some other activity that has a solid understanding of exercise training catches her attention, such as bouncing on the and holds appropriate certi cation for general- big pink Swiss ball. Using a behavioral strategy, ized tness training (Certi ed Personal Trainer) Coach Maria has explained to Laura that once and an advanced certi cation for exercise train- she completes a set of leg press exercises she can ing of special populations (Certi ed Special then bounce on the pink Swiss ball. Pairing the Population Specialist). leg press—or for that matter any weight training exercise—with another activity that Laura liked Laura is a 15-year-old female with ASD and proved to be an effective way to motivate and has the expected gross motor imbalances and
Cognitive Conditions and Disorders | 327 engage her with a basic workout. Coach Maria’s movement with her hands so Laura feels the goal was to teach the exercise so that Laura correct movement. However, as with coaching could do a set of 10 repetitions with a light load any client, it is important for the coach to ask if to begin with over the rst several weeks. Coach it is okay to touch the client and to explain why Maria will look for other activities Laura might before doing so. In the case of Laura, since she is 15 years old, it is also important to discuss nd interesting in the weight room to serve as a this with her parents to ensure that they provide behavioral pairing with another exercise. consent before any training is initiated. As Laura learns the exercise, prompts can be gradually Coach Maria also knows that verbal praise withdrawn so she can complete the activity for the exact thing Laura did correctly with the independently. Once the exercise is taught and exercise is vital and knows not to use general other exercises are progressively added to the praise like “Good going, way to go” but rather workout routine, gradual loading can be added, “Great job pushing the weight up with your legs.” making sure that the exercise techniques are She knows that depending on Laura’s cognitive correct and that the toleration of the movement capabilities, getting her set in the seated leg is acceptable. Again, Coach Maria knows that press machine and showing her how to grab verbal encouragement and careful observation as the handles and then push out with her legs is to acceptability and effectiveness of the reward not simple. Coach Maria also knows that when pairing need to be constantly assessed. she practices the movement with Laura with no load she may need to help by guiding her leg Recommended Readings Autism Speaks. Sports, exercise, and the bene ts of physical activity for individuals with autism. 2009. www. autismspeaks.org/science/science-news/sports-exercise-and-bene ts-physical-activity-individuals-autism. Accessed November 29, 2016. Lochbaum, MR and Crews, DJ. Exercise prescription for autistic populations. J Autism Dev Disord 25:335- 336, 1995. Pardo, CA and Eberhart, CG. The neurobiology of autism. Brain Pathol 17:434-447, 2007. Zhang, J and Grif n, AI. Including children with autism in general physical eduation: eight possible solu- tions. JOPERD 78:33-50, 2007. DOWN SYNDROME which not all of the chromosome is triplicated or not all cells of the body carry the extra chro- Down syndrome (DS) is a genetic disorder that mosome. The distinctive facial look, such as flat results in a trisomy (three copies) of the 21st face and slanting eyes, and delays in growth are human chromosome (52). The fundamental basis characteristic of DS. is that individuals with DS have 47 chromosomes instead of the usual 46. This third chromosome, Down syndrome can be associated with delays which constitutes the genotype of the individual, in growth and lower cognitive and intellectual can have highly varied effects on expression of capabilities. The range is wide, with some indi- the phenotype of an individual characteristic viduals having very low IQs and others much (e.g., heart structure, cognitive capabilities, and higher (35). Interestingly, the average reported other pathologies). There are cases of very rare IQ of those with DS has increased in the past forms of DS (less than 6%) called Translocation few years. The average IQ of an adult with DS is Down syndrome or Mosaic Down syndrome in approximately 50, with about 40% in the mild intellectual disability range of 50 to 70. An IQ of
328 | NSCA’s Essentials of Training Special Populations 50 matches the mental age of an 8- to 9-year-old, characteristics of individuals with DS often lead and average IQ in the general adult population to difficulties with early childhood motor patterns ranges from 70 to 130. Recently it has been shown and learning of both generalized social and self- that DS can be combined with ASD, complicating care skills (see section on intellectual disability) many aspects of behavioral and developmental throughout childhood and into adulthood (74). capabilities. Down syndrome is not curable and is not related to race, nationality, religion, or Common Medications Given socioeconomic status. to Individuals With Down Syndrome Pathology of Down Syndrome There is no drug treatment for DS itself; however, The most common origin of the genetic causes individual care by a physician or other health of DS occurs during the formation of the egg care professional who understands the syndrome (meiosis of the gamete) within the ovary (74). is vital, as other conditions such as dementia, Although there is some debate over the cause of epilepsy, and mental health issues have been the development of the trisomy, the only estab- associated with DS, particularly in children (50). lished relationships between the mother and a A variety of supplements (i.e., amino acids and child with DS are advanced age of the mother (>35 antioxidants) and pharmaceutical interventions years old) and a younger mother who is a heavy (e.g., drugs that affect brain activity) have been smoker (13). Interestingly, since there are more used, but they have largely yielded negative, births among younger women, 80% of newborns inconclusive, and even some adverse results (50). with DS in the United States are born to mothers under 35 years old (17). As already noted, individ- Effects of Exercise in uals with DS have a wide range of symptoms from Individuals With Down mild to severe, including delays in both mental Syndrome and physical development (13, 28, 74). Because of the developmental delay in both Demographics of Down mental and physical maturation, the population Syndrome of individuals with DS presents special cases for the development and design of exercise programs, According to the CDC, approximately one in every which can be complicated by additional ASD. 700 babies in the United States is born with DS Individuals with DS have generalized muscle (i.e., almost 6,000 babies per year), making DS weakness, poor cardiovascular fitness, impaired the most commonly diagnosed chromosomal motor coordination, and poor exercise economy, condition in the United States (27). Some epi- which leads to an inability to perform exercise for demiological evidence has indicated that DS is prolonged periods of time (22, 64). These physi- one of the most commonly identified causes for cal limitations (6, 22, 64) diminish the ability to developmental delay in children (74). perform many activities of daily living. To com- plicate these issues, DS to a certain extent hinders Pathophysiology of Down cognitive function in most individuals with the Syndrome syndrome, which may impede compliance with necessary exercise programs. Characteristics of individuals with DS include a delay in mental maturation (see section on intel- Most exercise programs for individuals who lectual disability); muscle weakness (hypotonia); have DS focus on increasing cardiovascular tness short stature; cardiac anomalies; flat face profile and aerobic endurance along with an increase in with short and low-set ears and upslanting of muscle strength through incorporation of vari- the palpebral fissures that is accompanied by a ous exercise paradigms (6, 22, 64). By increasing protruding, broad, and furrowed tongue; curved cardiovascular tness and generalized muscle fifth finger and a single palmar crease; and a gap strength, the person will have increased economy between the hallux and the second toe (74). These of movement and increased time to fatigue, which
Cognitive Conditions and Disorders | 329 will in turn increase functional independence taining or improving cardiovascular function (22, 64). Most of this increase in functional inde- pendence is achieved through musculoskeletal (14). However, as previously noted, there may adaptations resulting from the incorporation of structured resistance training or aerobic endur- be a better choice for aerobic endurance training ance training programs, normally within group or community training settings (6, 22, 64). through the use of dancing to music, swimming, Resistance exercise has been shown to be and water aerobics for these clients. Research effective in improving leg strength and functional performance (e.g., stair ascent and descent) in has shown that music and dance is a universal adults with DS compared to subjects who did not train over a 10-week period (25). The combination medium for exercise activities and DS (67) and can of resistance and aerobic endurance training has also shown aerobic tness improvements in adults provide the external motivation for movement as with DS (45). A 12-week program included three sessions per week of aerobic endurance training well as add an important social element to exercise performed for 30 minutes per session at 65% to 85% of peak oxygen consumption. Additionally, programming. The only concern for such group resistance training was performed two days a week and consisted of two rotations in a circuit activities is that some clients with DS have noise of nine exercises at a 12-repetition maximum (12 RM) resistance load. Improvements in peak sensitivity and may need headsets to dampen the oxygen consumption and walking speed were observed. Thus, resistance training is an impor- noise to acceptable levels. tant modality to include in an exercise program for individuals with DS. It is recommended that exercise programming Exercise Recommendations for persons with DS include three days per week for Clients With Down Syndrome of aerobic endurance training using creative The following recommendations are made based modalities and an interesting environment to on the available evidence for this population; they include aerobic exercise as well as resistance stimulate interest. Aerobic training intensity for training in programming for clients with DS (45). Although it is important for all individuals, proper hofigV.hOer2-pfueankc.tiTohneindgucrlaietinotns should be 50% to 70% drinking behavior before, during, and after exer- for aerobic endurance cise is vital to maintain needed hydration levels in people with DS. This is even more important training should be between 15 and 30 minutes due to potential limitations in the capability of the sweat glands in those with DS to adequately cool per session. This time may be broken into smaller the body during exercise. Thus, careful attention to environmental conditions, exercise demands, units such that completion of small and easier and symptoms of heat illness is needed. tasks can be acknowledged through verbal rec- The aerobic endurance training should use activities such as walking or jogging patterns to ognition or physical reward for accomplishment assist with independence of the client with DS following training. Walking in most clients with- of a goal; also psychological encouragement can out orthopedic issues can serve as an important cardiovascular activity that is effective in main- help the person move toward the next task to be achieved within the exercise session. Two or three days of resistance training per week are recommended for exercise program- ming of persons with DS. The resistance program should be designed to enhance muscle strength and function and should include major muscle group exercises to stimulate the body’s muscula- ture. Initially standard resistance training exer- cises can be used, with determinations made on an individual basis, for example, if motor control is of the pro ciency needed to use free weights or machines. Loading is also individualized based on understanding and tolerance of the increased load. Again, metabolic intensity needs to be carefully monitored and addressed with rest periods from 2 to 3 minutes between sets and exercises to provide adequate recovery and reduce any symptoms of undue fatigue, as the primary goal is to increase muscular strength. It is recommended that resist- ance training sessions for clients with DS be no more than 45 minutes in length. Cognitive learning capabilities related to each exercise movement must be individually assessed.
330 | NSCA’s Essentials of Training Special Populations Motor capabilities for a particular exercise must be pVm.rOaey2dmincatoextdafoVp.rpOlt2ymhweasxiet;hctihlnieetnmhtisossmpt olaipykuebllayeticooannu,lsyeas8foa0rc%ttuhoaisfl kept in mind, and in some cases weight machines discrepancy stems from poor economy of exercise can assist in reducing balance and control issues (ms6he,onu2d2lde,db6et4h)o.aftFgiorfreeaxttheeirrsciimrseepatoseorstntai,nnicgtehitsahusasnbeedV.e,OnV.2Orme2capoxemaink- and thereby lead to faster development of strength. determining heart rate intensity for training (22). Incorporating free weight exercises is important to help develop motor capabilities more related As with individuals with ASD, one has to work to real-world demands. As previously stated, to make sure that the client with DS can learn and progression, periodization, and individualization mimic the movement patterns of the exercise. of programs are needed and often can follow the Due to limitations in translation of information, basic concepts of training for younger athletes one cannot assume that visual demonstration can due to similarities in cognitive function (31). A be replicated. It is important to understand that variety of exercises can be used, including both in DS, informational processing in the brain is free weights and machines, but they should different and time delays exist. address each body part and include some multi- joint exercises. Care is needed to monitor potential issues with heat tolerance as DS can affect the normal func- Exercise Modi cations, tioning of sweat glands; thus the environmental Precautions, and challenges and the exercise intensity interactions Contraindications for Clients are important factors to carefully monitor in any With Down Syndrome exercise program. Because of the cognitive impairments, success- Key Point ful exercise programs for persons with DS have needed to incorporate the following modifications Exercise professionals should carefully monitor into program designs: a high ratio of instructors to participants for overheating, as some clients with exercise participants and the utilization of various Down syndrome do not sweat as much as the reward programs for participation (64). Secondary typical population. to the rewards system is a need to understand that using general guidelines for exercise testing Case Study Down Syndrome Coach James, an exercise professional, works as learn in the same way and that some were much a tness instructor at a tennis club that started higher functioning than others. But the goal was offering recreational sessions for children and to encourage activity, movement, socialization, adults with DS. Each session used courts dedi- and fun with the sport of tennis. cated to different skill levels and motor capabili- ties, and accordingly, four groups of clients were Having experience with special populations created after a period of assessments. The groups and holding the appropriate professional special- re ected the differential abilities of each client ized certi cations in strength training, Coach to perform basic skills in tennis and the level James wanted to add a tness component to of motor function each exhibited. An adapted the tennis program for persons with DS. He physical education teacher provided “teaching” designed a modi ed program based in part seminars and educated the tennis coaches who on the basic circuit weight training program volunteered to work with these special clients. in the tennis club’s tness facility. With the It was clear that not all individuals with DS tennis groups already divided based on motor skill functions and learning aptitudes, he knew
which of the groups would need additional create the rst workout. A 2- to 3-minute rest coaches to help administer the group workouts. was used between the exercises, and careful In this case he decided he would use the same monitoring of the clients’ tolerance was needed. approach the tennis program used: a coaching To begin, only one circuit was performed. Over buddy for each client during the circuit weight time some of the major muscle group exercises training program. were progressed to heavier loads in the circuit (6 to 8 repetitions) with rest periods monitored. The rst task was to ensure that each exercise The coach also varied the circuits for loading station had appropriate equipment (a machine, and progressively changed the exercises, but Swiss ball, or free weight) for each client. was careful to always monitor technique and Coach James tested each program participant toleration of each client. through the circuit individually to determine the appropriate exercise choices and the ability to The circuit weight training program followed properly perform the exercises. He noted which the tennis practices that included a lot of running exercises presented greater learning challenges and balance activities in the warm-ups. All of the to each client (e.g., if someone could not stand clients took a 20-minute rest and hydration break with a barbell without having balance issues). after the tennis activity before the circuit training Appropriate substitutions or modi cations to the workout. As with the indoor tennis session, water equipment were then made. Eventually, the goal and hydration were stressed as being important was for each coach to take each client through the during and after all activities. The clients with circuit weight training workout without loading. DS all reported that they enjoyed the program and felt that they were “getting in good shape.” Coach James had understood that getting Eventually Coach James plans to make the circuit a client ready to do a circuit weight training training program available for times away from workout would take practice involving lead-up the tennis activity to spread the activity pro le activities and motivational encouragement to over the week. The program would have to promote and maintain interest in doing the provide more available time options and proper workout. This was a big challenge, and rewards supervision to be successful, but Coach James is played a role. Once this preparatory phase up to the task to improve the tness and health was completed, the workout started; light or of individuals with DS. no weights (12 to 15 repetitions) were used to Recommended Readings Cowley, P, Ploutz-Snyder, L, Baynard, T, Heffernan, K, Jae, S, Hsu, S, Lee, M, Pitetti, K, Reiman, M, and Fernhall, B. The effect of progressive resistance training on leg strength, aerobic capacity and functional tasks of daily living in persons with Down syndrome. Disabil Rehabil 33:2229-2236, 2011. Dodd, KJ and Shields, N. A systematic review of the outcomes of cardiovascular exercise programs for people with Down syndrome. Arch Phys Med Rehabil 86:2051-2058, 2005. Li, C, Chen, S, Meng How, Y, and Zhang, AL. Bene ts of physical exercise intervention on tness of individuals with Down syndrome: a systematic review of randomized-controlled trials. Int J Rehabil Res 36:187-195, 2013. Mendonca, G, Pereira, F, and Fernhall, B. Effects of combined aerobic and resistance exercise training in adults with and without Down syndrome. Arch Phys Med Rehabil 92:37-45, 2011. Shields, N, Taylor, N, and Dodd, K. Effects of a community-based progressive resistance training program on muscle performance and physical function in adults with Down syndrome: a randomized controlled trial. Arch Phys Med Rehabil 89:1215-1220, 2008. Stratford, B and Ching, EY. Responses to music and movement in the development of children with Down's syndrome. J Ment De c Res 33:13-24, 1989. 331
332 | NSCA’s Essentials of Training Special Populations INTELLECTUAL DISABILITY bility prevalence, the percentage of people with all impairments remains about the same at 18.7%. Intellectual disability (ID), also known as general Recent statistics indicated that approximately 0.5% cognitive disabilities or mental retardation (see of Americans, or about 1.2 million people aged 15 note at beginning of chapter), typically devel- years and older, and 4.5% or 1.7 million children ops before a child reaches the age of 18 years aged 6 to 15 years, had an ID (70, 71). Additionally, (48). Delay in cognitive (mental) maturation is 944,000 adults had other developmental disabili- characteristic of ID, resulting in significantly ties including autism and cerebral palsy. below-average scores on tests of mental ability, or intelligence, and further characterized by Pathophysiology of limitations in the ability to function in areas of Intellectual Disability daily life—that is, communication skills, ability to perform activities of self-care, and ability to Intellectual disability does not have a singular perform appropriately within social situations cause. The mechanisms by which ID manifests including school activities (48). are specific to the syndromes that accompany it. Our physiological understanding of these mecha- Pathology of Intellectual nisms is in its relative infancy and is a fertile area Disability of research. Although we have already noted the outcomes of ID in a general way, the causes can be Even though there is a delay in mental matura- genetic or neurobiological in origin. The proper tion, individuals with ID can and do learn new development of the brain, neurons, and synapses skills; however, they develop these skills at a is vital to proper function and cognition. Anatomic much slower rate than do children with average malformations and defects in the control of synap- intelligence (48). Intellectual disability can be togenesis are underlying causes of many forms of caused by injury, disease, or a brain abnormal- ID. The particulars of the cutting-edge understand- ity during gestation or soon after birth. The ing of ID are complex and require in-depth exami- following are some of the most common known nation, which is somewhat out of the scope of this causes (18): book, but are discussed by Picker and Walsh (58). • Down syndrome Common Medications • Fetal alcohol syndrome Given to Individuals With • Fragile X syndrome Intellectual Disability • Genetic conditions (e.g., cri-du-chat syn- Any medications prescribed for individuals with drome, Prader-Willi syndrome) ID reflect the growing concept in medicine of a • Infections (e.g., congenital cytomegalovirus) “personalized approach.” No cures exist for the • Birth defects that affect the brain (e.g., hydro- multitude of IDs. New drugs are being developed on a continuous and regular basis for specific cephalus or cortical atrophy) facets of specific IDs, but exercise therapy is one • Asphyxia during the birthing process aspect that has shown promise for improving • Metabolic conditions, such as phenylketonuria physical and neurological function. It is impor- tant for the professionals who work with special (PKU), galactosemia, and congenital hypo- populations to ensure that their participants are thyroidism cleared by a physician or other health care pro- fessional and to be aware of medical aspects that Demographics of Intellectual may affect physical exercise and performance. Disability Additionally, musculoskeletal exams are impor- tant before activity to ensure that the exercise will Data from the U.S. Census Bureau (71) indicate not compromise function or safety (e.g., orthotic that the number of people with disabilities is on needs for foot, knee, or spine issues may exist). the rise, with 56.7 million people having a dis- ability in 2010, an increase of 2.2 million since 2005. Interestingly, despite the increase in disa-
Cognitive Conditions and Disorders | 333 Effects of Exercise in Aerobic endurance exercise for persons with Individuals With Intellectual ID can be performed three or four days a week Disability using a variety of modalities, from walking to dance, step aerobics, water aerobics, or stationary Individuals with ID are able to achieve health cycling, with the goal of improving cardiovascular benefits from exercise similar to those for the function and health. Resistance training should general population. Research suggests that exer- be based on a progressive program that includes cise can temporarily enhance neural activity and major muscle group exercises to stimulate the cognitive performance in individuals with ID, body’s musculature. As such, resistance training but the long-term meaning of this enhancement should use multiple sets and should be perio- is generally unknown (24, 38, 41). Also, although dized, with the loading and stress of the workouts there are developmental disorders in the brain adapted to each client’s speci c challenges and and its connections, skeletal muscle is usually capabilities. Persons with ID should engage in developed normally (15). Thus, adaptations and resistance training a minimum of two days a week benefits of muscular stimulation, along with in order to achieve signi cant bene ts, with three its downstream effects on different levels of days of training per week for persons capable of physiological systems, should occur similarly the increased training volume. to those for an individual without ID (65). In general, persons with ID have been shown to Exercise Modi cations, improve cardiovascular fitness (62, 73), muscu- Precautions, and lar strength (59), balance (69), and quality of life Contraindications for Clients (36). However, it should be noted that there are With Intellectual Disability relatively few controlled studies on the exercise effects in this population. Also, many studies on Exercise activities for persons with ID should individuals with ID and exercise include partic- be modified according to the client’s particular ipants with DS, as well as very general exercise intellectual capabilities. As basic movement regimens. Although this serves as a good foun- patterns may be limited in association with cog- dation, future study designs should use a greater nitive limitations, more complicated activities range of ID types and exercise modalities. These may not be appropriate. Exercise tasks may be modalities should be creative yet safe, should simplified in order to allow safe success in the account for individual physical limitations, and most basic movement patterns, with exercise should attempt to incorporate traditional exercise technique gradually but progressively adjusted modalities and techniques. in complexity as tolerated. The relatively sim- plified nature of weight training machines and Training Considerations for cycling equipment provides an appropriate initial Clients With Intellectual training option for many persons with ID. Some Disability clients with ID may be capable of incorporating free weight training, which may be more benefi- General training considerations for clients with cial to the development of strength and transfer ID follow the basic principles already discussed to real-life tasks. with regard to all persons with cognitive disor- ders, and are similar to those for clients with DS. Key Point Exercise prescription for persons with ID should be individualized to meet people’s specific needs In work with clients who have intellectual disabil- for different target goals to improve physical ity, care must be taken to ensure that the person function, health, and fitness. The exercise pro- can perform the exercises correctly. Movement gramming should be developed with appreciation patterns may need to be simplified, and the of the challenges each client with ID must deal person should be able to perform the move- with in everyday life. ments properly before increasing load or volume.
334 | NSCA’s Essentials of Training Special Populations Determining the ability to perform the to multiple sets of the same movements, and exercise movements properly is vital before potentially progressing to circuit training with any loading. The process of learning the cor- the learned movements. Loading, rest periods, rect execution of exercise movements may be and exercise should be balanced to create a tol- enhanced through the use of a part–part–whole erable stress and to strengthen muscles with the teaching process in which more complicated goal of enhancing locomotion and movements movements are reduced to simpler movement in everyday life. Verbal recognition or physical segments. Progressively, the exercise movement reward for accomplishment of a goal, as well as segments may be combined to produce complete psychological encouragement to move toward exercises. Similarly, initial training may consist the next task, should be incorporated into all of one set of a few movements, progressing exercise sessions. Case Study Intellectual Disability Mr. J is a 24-year-old man diagnosed with ID initial exercise program Rudy designed included since birth. He lives with his parents and two two sessions per week with both aerobic and younger sisters and is employed as a grocery anaerobic components. The initial sessions began carryout person. Other than his work-related with comfortable treadmill walking with no duties, Mr. J had been relatively inactive most of incline for 10 minutes, gradually increasing pace his life. Due to his sedentary lifestyle and appre- and elevation per session for up to 30 minutes. ciation of pizza, his body weight progressively Following the treadmill walking, Mr. J completed increased to over 275 pounds (125 kg) with a a series of eight machine weight training exer- body mass index (BMI) value of 41.8. Mr. J began cises emphasizing large multijoint movements. experiencing low back pain and needed to take Resistance was adjusted to allow for one circuit frequent breaks at work. Family and friends of 8 to 12 repetitions per exercise. The load was regularly suggested exercise and diet programs, increased to two sets per exercise in week 3. but Mr. J was not interested. After the rst month of training, Mr. J Mr. J had always been a big sports fan, closely reported virtually no low back pain and following the local professional and college increased energy in his workplace. Body weight teams. Recently, he had been invited to partici- had decreased only 2 pounds (1 kg) with this pate in the Special Olympics program. After very careful consideration, Mr. J decided that he was rst month of exercise training. Rudy met with interested in bowling and archery (two sports not Mr. J and discussed his progress and goals at requiring a great amount of movement). After his this point. Mr. J stated that he was ready to make an increased effort with the goal of signif- rst competition, he became very committed to icant improvements in the next six months to his new sport pursuits, with a new interest in a prepare for a big Special Olympics competition. more active lifestyle. However, he was clear that Together, they revised the training program to his interest was in improved sport performance include three weekly gym sessions and increased and that he was not concerned with weight loss. training volume to three circuits of the resist- ance training series per session. Mr. J agreed Mr. J’s parents had a family membership at that his performance in bowling and archery the local tness center and knew that one of the might improve if he was able to reduce his body exercise professionals, Rudy, had a specialized weight. Rudy helped him make an appointment certi cation in training of persons with special with a nutritionist for guidance in that area. Mr. conditions. Rudy met with Mr. J and determined J shared with Rudy that his competitions and that his program should be as independent as pos- training had changed his life and given him an sible. Again, Mr. J stressed that he was interested in sport performance for his Special Olympics increased sense of his own potential. competitions and “not just working out.” The
Cognitive Conditions and Disorders | 335 Recommended Readings Bartlo, P and Klein, PJ. Physical activity bene ts and needs in adults with intellectual disabilities: systematic review of the literature. Am J Intellect Dev Disabil 116:220-232, 2011. Chapman, DP, Williams, S, Strine, T, Anda, R, and Moore, M. Dementia and its implications for public health. Prev Chronic Dis 3:A34, 2006. Podgorski, C, Kessler, K, Cacia, B, Peterson, D, and Henderson, C. Physical activity intervention for older adults with intellectual disability: report on a pilot project. Ment Retard 42:272-283, 2004. Rimmer, J, Heller, T, Wang, E, and Valerio, I. Improvements in physical tness in adults with Down syn- drome. Am J Ment Retard 109:165-174, 2004. DEMENTIA AND dementia is challenging based on their functional ALZHEIMER’S DISEASE understanding and on how much impairment exists at the time of an initial intervention and Dementia is an umbrella term for a collection over time. of symptoms relating to a loss of memory and brain function that interferes with daily life (18). Pathology of Dementia and Dementia can be caused by a number of disor- Alzheimer’s Disease ders affecting the brain, including Alzheimer’s disease and other pathological states such as Individuals with cognitive impairments can have Huntington’s disease, Parkinson’s disease, and significantly impaired intellectual functioning Creutzfeldt-Jakob disease, or can result from a that interferes with normal activities and social vascular stroke. It is estimated that over half of relationships, and may eventually lead to a loss of cases with dementia are related to Alzheimer’s the ability to solve both simple and complex prob- disease (2). A medical diagnosis for dementia lems and is thereby defined by the National Insti- occurs only when two or more of the following tutes of Health as dementia (49). The progression cognitive functions are significantly impaired of dementia can lead to an inability to maintain without loss of consciousness: memory, language emotional control; and individuals may eventu- skills, ability to focus attention, reasoning and ally experience various behavioral problems, that judgment, and visual perception. Some causes is, agitation, delusions, or hallucinations, which (e.g., vitamin deficiencies, drug interactions) of over time can develop into personality changes. dementia can be treated and the condition may be Although dementia is associated with aging, there reversible. Accurate diagnosis is needed so appro- is no age delineation regarding when it occurs priate treatments can be initiated to mitigate the within the life span (23). problems and avoid misdiagnosis. For example, while dementia is frequently thought to be related Alzheimer’s disease (AD) is an irreversible, to Alzheimer’s disease, this may not be correct. progressive brain disease that slowly and pro- Without a medical diagnosis, the situation can be gressively destroys memory and thinking skills, confusing, particularly as an individual starts to eventually including the ability to carry out the realize some of the symptoms. simplest tasks (49). This disease is tiered into a tri-level diagnosis (mild, moderate, or severe) that Currently, despite ongoing research every year, is based on the severity of memory and cognitive Alzheimer’s disease is degenerative and incurable. dif culties along with a loss of self-care skills This pathology progressively worsens over time, that occur over the lifetime. It is known that whereas dementia may be more static. Working both younger and older people are at risk for the with individuals who have Alzheimer’s disease or development of AD; however, the disease usually begins after age 60, and the risk progressively
336 | NSCA’s Essentials of Training Special Populations increases with age (23). While there is no de ni- up when the normal process of breaking down tively known cause for AD, a combination of risk and eliminating amyloid protein fragments is factors and causes for its development appears faulty. Alzheimer’s disease is also related to neu- to be present. These may include a genetic rofibrillary tangles in which tau protein, a critical predisposition for the disease (modi cation of factor in the integrity of the neural microtubules, the APOE gene) along with limitation in one or degenerates into tangles of filaments. While the more components of an “active lifestyle” (i.e., accumulation of amyloid plaque and neurofibril- being physically active, participating in mentally lary tangles is part of the normal aging process, stimulating activities, and having frequent social with AD the rate of accumulation is much greater, interactions) (20). Additionally, there is growing leading to progressive and accelerated decline in support for associations between the onset of AD cognitive function compared to normal. Oxidative and age of the individual, a family history of AD, stress, or damage to cellular structures by toxic high blood pressure, high total cholesterol, and a oxygen molecules called free radicals, is also history of diabetes (23). regarded as a pathology characteristic of AD. Demographics of Dementia Those who develop AD and dementia tend and Alzheimer’s Disease to have poor lifestyle and general tness (3). However, there is no known causal relationship The prevalence of dementia within the overall between either disease and trained status of the population varies with age. There is a 13.5% prev- individual. Research indicates that cardiovascular alence in the U.S. population for individuals 80 to disease and related risk factors increase the risk 84 years old, 30.8% for those aged 85 to 89 years, of dementia and AD. Behavioral and psychological 39.5% for those aged 90 to 94 years, and 52.8% interventions are often used before medications, for those older than 94 years (23). The percent of due to ef cacy issues (3). Exercise is among the new cases of dementia reported per year ranges treatments that can improve dementia or slow its from 6% for the population from 80 to 84 years progression, as well as possibly bene tting cogni- up to 20.7% among those over 94 years old. tive function in populations with AD. In general, exercise can improve brain structure and function The development of AD with aging is not typi- through improvements in vascular health (for a cal or normal, albeit the greatest known risk factor detailed review, see Tarumi and Zhang, 2014). for the disease is increased age (most common with 65+ years of age), followed by genetic factors. Common Medications Given However, an estimated 5% of people with AD have to Individuals With Dementia early-onset Alzheimer’s, which is also known as and Alzheimer’s Disease younger-onset disease; this can occur in individ- uals in their 40s or 50s. The CDC estimates that Currently, there is no cure or means to prevent as many as 5 million Americans have some level the progression of AD. However, there are med- of AD. It is further estimated that about 5% of the ications commonly prescribed for reduction of population between 65 and 74 years old has some symptoms, such as memory loss (49). Cholinest- level of AD and that nearly half of those aged 85 erase inhibitors are prescribed to individuals with and older may have the disease (23). AD for symptoms such as memory loss, confusion, and reasoning problems (49). These medications Pathophysiology of Dementia (Aricept, Exelon, Razadyne) slow the breakdown and Alzheimer’s Disease of acetylcholine and have been shown to delay the progression of symptoms for up to a year in The development and causes of AD are not known approximately half of those with AD (1). Potential but are thought to be associated with neural deg- side effects of cholinesterase inhibitors include radation due to the buildup of proteins by amyloid nausea, vomiting, and loss of appetite. plaques (between neurons) and neurofibrillary tangles (within neurons). Amyloid plaque builds Another class of medication, memantine (Namenda), is generally prescribed to persons
Cognitive Conditions and Disorders | 337 with moderate to severe AD for the symptoms Key Point related to memory, reasoning, and attention and the performance of simple tasks (46, 49). In the early phases of dementia and Alzheimer’s Memantine regulates glutamine activity and disease, more conventional exercises may be may temporarily slow symptom development. realistic; but as the conditions progress, signif- This medication can produce side effects includ- icant modifications may be necessary, and the ing headaches, confusion, and dizziness (49). exercise professional may need to consult with Cholinesterase inhibitors and memantine may the individual’s physical therapist, physician, or limit exercise performance primarily in relation other health care professional. to symptoms such as nausea, confusion, and dizziness. Training Considerations for Clients With Dementia or Effects of Exercise in Alzheimer’s Disease Individuals With Dementia and Alzheimer’s Disease Exercise may well improve cognitive and age-related losses in many clients with demen- The ability of someone with dementia to safely tia, yet highly individual variation is to be and effectively participate in exercise activities considered (11). Exercise recommendations is affected by where the individual is on the for persons with dementia or AD are related to spectrum of the disorder. In the early phases of the functional state of the client whether in a dementia and AD, more conventional exercises home-based program, a specialized nursing care may be realistic, while in later stages, exercise facility, or a hospital program. With early phases may be achieved only in a wheelchair or in of the pathologies, more conventional guidelines bed. Although exercise has been purported to and programs with well-established resistance enhance cognitive function throughout the life and aerobic exercise components can be applied span, the specific mechanisms through which (30). However, as the conditions progress, many this occurs are still a topic of intense investiga- clients with dementia or AD will need signif- tion. In general, exercise can have conflicting icant modifications to this programming. For effects on dementia and AD, most likely due to example, while in some cases group activities the stage of the disease or the rate of progression. may be appropriate, most people require indi- With higher-functioning patients, improvement vidual implementation with consults from their may occur in executive function, memory, cog- physical therapist, physician, or other health nitive function, and rating of functional status; care professional due to the progressive decline but with lower-functioning individuals, little if in cognitive function and associated physical any change may be detected (47). Additionally, capacities. Behavioral issues stemming from exercise may indirectly affect cognition by anger and agitation may also require creative improving stress levels and sleep quality, as well approaches for maintaining participation. The as reducing elements of chronic disease that can exercise professional should be prepared to affect cognitive function (12). Also, specific to handle any outburst of anger or aggression with the type of exercise performed, improvements in the understanding that these are reflections of cardiovascular fitness, muscular strength, bal- a disease process and not a personal attack. ance, and other determinants of functional inde- This may mean having adequate support in the pendence can be expected in this population. exercise environment or unit to support the Studies incorporating specific manipulations calming of the situation, including the known of the program variables of intensity, duration, caregiver at certain states of the disease. The volume, exercise choice, and others should be loss of memory can make each day a new one conducted to elucidate which programs better that requires repetition of directions, encour- enhance cognitive function, physical health, agement, and evaluation of status. and function.
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