特殊人群的运动处方（英文）

I. General Principles

Exercise prescription should always include :

a) the mode of exercise

b) the intensity of exercise

c) the duration of exercise

d) the frequency of exercise

e) the rate of progression of the patient's physical activity

These parameters should be taken into account whether you are prescribing exercise for the healthy individual or the patient with disease. In all cases, the exercise prescription should be developed with careful consideration for the individual's health history, risk factor profile, the patient's strength and flexibility, any orthopedic conditions that may exist, behavioral characteristics, personal goals and availability of exercise facilities.

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II. Special Populations

A. Patients With Diabetes

Patients with diabetes fall into two general classifications of disease - Type I diabetes mellitus also known as insulin-dependent diabetes mellitus. This form of diabetes is usually associated with children because it is often diagnosed during the formative years. It is characterized by a the following symptoms :

• polyuria - frequent urination throughout the day and night often amounting to many liters to gallons per day

• polydipsia - urgent thirst making the patient drink copious fluids as a result of the polyuria

• polyphagia - the patient is always eating - a result of poor glucose availability to the central nervous system

These patients usually have very high blood glucose levels when they are initially seen by a physician. They urgently need to be medically managed. Consequently, these young patients are immediately hospitalized and the medical staff tries to quickly bring the blood glucose back down to normal levels between 80 - 120 mg/dl. After they have been regulated, they are commited to a lifetime of insulin injections that will keep their blood sugar between 80 - 200 mg/dl. The cause of Type I insulin-dependent diabetes mellitus is thought to be an autoimmune destruction of the beta cells in the pancreas which normally produce insulin. Since these young patients can no longer produce insulin, they must be supplemented to insure proper availability of glucose to body tissues, especially to the brain and spinal cord.

Type II diabetes mellitus usually occurs in the 4th decade of life. These patients are frequently obese and lead sedentary lifestyles. In the case of Type II diabetics, they cannot use the insulin they are producing - a condition called peripheral resistance. For reasons that are not entirely clear, the insulin will bind to its receptor but the usual celular response - the uptake of insulin from the blood into the cell - does not readily occur. Therefore, blood glucose rises and the patient becomes hyperglycemic. Oddly enough, Type II diabetics often produce supernormal concentrations of insulin. They are seldom low insulin producers.

The exercise prescription for these two types of diabetic populations is somewhat different. In the case of Type I diabetics, the emphasis is on glucose regulation. Hence, these patients are encouraged to exercise 7 days a week. On the other hand, in the case of Type II diabetics, the emphasis is on weight reduction and increased physical activity. For these reasons they are encouraged to exercise 3-5 times a week since they do produce insulin and absolute glucose regulation is not the primal reason for the exercise prescription.

Below is a suggested initial exercise prescription for both Type I and Type II diabetic patients.

Parameters Type I Diabetics Type II diabetics

Mode Aerobic/Anaerobic Aerobic/Anaerobic

Frequency 7 days/week 5 days/week

Duration 20-30 minutes 30-60 minutes

Intensity 45% - 85% MHR 45% - 70% MHR

Borg Scale 10-14 RPE 10-14 RPE

Whenever you work with patients with diabetes, the following considerations should be mentioned along with the exercise prescription :

• Avoid exercising during periods of peak insulin activity

• Always exercise with a partner in case the patient needs help

• Carry money with you so that you can make a phone call for help

• Know the signs of hypoglycemia - lightheadedness, diaphoresis, palpitations, loss of motor control, changes in mood, etc.

• Wear good foot wear

• Practice scrupulous foot inspections for fissures, blisters or reddened areas

• Inject the insulin into a muscle mass that does not directly participate in the physical work

• Learn to drop your insulin requirement once you understand how exercise effects your insulin needs

• Do not take beta-blockers because they mask the symptoms of hypoglycemia

• Never exercise if your blood glucose is over 300 mg/dl because you are out of control and must see your physician

• If your glucose is between 110 - 280 mg/dl, it is okay to start exercise

• Learn to monitor your blood glucose every thirty minutes of continued exercise

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B. Patients With Hypertension

Hypertension is divided up into several classes as seen in the table below :

Blood Pressure Classification Systolic Pressure in mm Hg Diastolic Pressure in mm Hg

Normal Blood Pressure Below 130 Below 85

High Normal Blood Pressure 130-139 85-89

Mild Hypertension 140-159 90-99

Moderate Hypertension 160-179 100-109

Severe Hypertension 180-209 110-119

Very Severe Hypertension >209 >119

Any person with hypertension should be evaluated for other coronary risk factors. As always, any male who is 40 years of age or older or any woman who is 50 years or older should have a graded exercise test at the hands of a competant physician. The graded exercise test (GXT) clears the patient for exercise if there was no symptoms of cardiac stress during the GXT. However, if there were signs of cardiac stress, the GXT sets the limits of the exercise prescription by letting the medical staff know at what point during the GXT the symptoms occured. At the point where symptoms appeared, the physician should have noted the blood pressure, heart rate and the maximum METs attained during a specific stage in the GXT protocol. This is known as a symptom limited GXT (SLGXT). It defines for you, the exercise prescriptionist, just how hard to push the patient in the rehabilitation program. The following recomendations appear in the table below for a beginning exercise program for a person with hypertension:

Exercise Parameters Exercise Prescription

Mode Aerobic Exercise

Frequency 3-4 times/week

Duration 15-30 minutes

Intensity</CENTER< td> 40%-70% of SLGXT Values

Max. Exercise BP 40%-70% of SLGXT Systolic Pressure

Borg Scale 10 -14 RPE

As with any exercise program, it is important to have a 5-10 minute warm up period during which the patient performs exercise at an intensity lower than that which is performed during the steady state exercise period of the prescription. Likewise, it is important that there be a 5-10 minute cool down period after the exercise period is finished. Most coronary incidents occur in the recovery period after exercise. The cool down period allows the body to recover from the exercise in a sensible manner.

Resistance weight training is not recommended until several weeks of the aerobic exercise program has been completed. It is important for the exercise specialist to feel comfortable with the patient's response to the exercise regimen before adding on anaerobic exercise which, in the case of weight lifting, can cause the blood pressure to rise dramatically. You should always stress with your patients that all exercise must be done without ever doing a Valsalva manuever.

You should be very familiar with the medications your patient is taking. In the case of anti-hypertension medications, it is critical that the patient take them regularly. It is your responsibility to remind the patient and insist that they take their medication for hypertension.

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C. Exercise During Pregnancy

It is very important for any person to stay in close contact with their physicians, especially if they have any of the coronary risk factors such as : diabetes, physical inactivity, smoking, hyperlipidemia, hypertension, obesity, or a strong family history for CAD.

Pregnancy is not a sickness or a disease condition. However, there are several signs and symptoms that should either preclude the beginning of an exercise program or terminate exercise if a program has already started. The absolute contraindications for exercise during pregnancy are listed below:

• heart disease

• ruptured membranes and loss of the Bags of Water

• premature labor

• multiple fetuses

• vaginal or uterine bleeding

• placenta previa

• an incompetant cervix

• a history of spontaneous abortions or miscarriages

There are relative contraindications to continued exercise or the beginning of an exercise program. these are listed below :

• high blood pressure

• anemia or other blood disorders

• thyroid disease

• diabetes

• irregular heart rhythms

• breech presentation

• excessive obesity

• extreme underweight

• history of precipitous births

• history of bleeding during pregnancy

• extremely sedentary lifestyle

• history of intrauterine growth retardation

The following exercise recommendations should be personalized to each pregnant female for whom you write an exercise prescription:

Exercise Parameters Exercise Recommendation

Mode No Impact to Soft Impact - Aerobic

Frequency 3 days/week

Duration 15-20 minutes

Intensity 50%-70% of Age Adjusted HR

Borg Scale 10 - 14 RPE

The following are key recommendations for persons who wish to exercise during preganancy :

• exercise in an environment that is less than 80-85 degrees Farhenheit and in a place where the humidity is less than 80%

• make sure that the shoes you wear are high quality shoes providing as much arch support and contact cushion against impact

• make sure that you are always well hydrated

• try to find an abdominal support that will support your abdomen during exercise especially in the last trimester- seek your physicians recommendations

• exercise with another person in case you need medical assistance

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D. Exercising With HIV

This disease is characterized by a gradual loss of the body's immune defense particularly of the cell mediated defense or the T-cell system. The AIDS virus targets the CD4+ cells (T4+ Helper Cell) disabling these cells from mediating either cell mediated defense (T cell system) or humoral defense (B cell system). When the CD4+ cell population falls below 200/ml, then the diagnosis has traditionally shifted from being HIV infected to a diagnosis of AIDS. At this point the body is attacked by opportunistic diseases which would otherwise have been effectively fought by the immune defense system.

Prior to the diagnosis of AIDS, a person is simply seropositive for the HIV virus. Before the AIDS diagnosis is rendered, the following exercise recommendations can be applied on a case by case basis :

Exercise Parameters Exercise Recommendations

Mode Aerobic Exercise & Strength Training

Frequency 3 times/week

Duration 15-20 minutes

Intensity 60%-80% 0f Age Adjusted MHR

Borg Scale 10 - 14 RPE

It is important to remember that HIV positive individuals should be constantly aware of their CD4+ count. They should not be overtly fatigued by the exercise program. It is well known that heavy exercise is immunosuppressive. Moderate exercise stimulates the immune defense system and enables the CD4+ cell, the NK killer cells and the CD8+ killer cells to perform their function in an enhanced fashion. Therefore it is critical that the HIV + patient understand with crystal clarity that all execise should be moderate exercise and performed in light of their CD4+ count. Exercise can be progressed if sensibly done.

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E. Intermittent Claudication

Intermittent claudication is a peripheral vascular disease characterized by leg pain with and without exercise. It is associated with the following : smoking, diabetes mellitus, hyperlipidemia, hypertension, high fat diets, and a strong family history for this malady. Leg pain is excruciating at times and is heightened with activity. However, exercise is a prescriptive treatment and the following recommendations are suggested :

Mode Weight Bearing Exercises

Frequency QID --> BID --> QD

Duration Work Towards 30-60 Minutes/QD Session

Intensity Grade II --> III Ischemic Pain

If the patient's pain is severe with small doses of exercise, it will be necessary to have several short bouts of exercise with rest in between exercise. Weight bearing exercise is preferred but in severe cases, it may be necessary to start out with non-weight bearing exercise like stationary bicycling or water activities. It will be necessary to eventually move to weight bearing exercises such as rebounding or treadmill walking. It will be necessary to prepare the patient with some education as to the benefits of exercise which are as follows : decrease in the symptoms of pain with exertion, improved circulation, increased peripheral sensitivity to insulin, collateralization of the blood flow, increased work capacity, improved quality of life, and finally the possible reversal of the atherosclerotic processes. These will have to be convinced that exercise is beneficial. Determined love and concern for their welfare will build the patient's confidence in the treatment and in you.

The following ischemia scale will help you quantify the patient's ischemic discomfort during exercise and will be an important documentation tool that will show that over time, the patient's pain is decreasing with training.

Ischemic Grades Pain Discriptors

Grade I Pain Discomfort but can continue exercise

Grade II Pain Moderate Discomfort : Patient's Attention Can Be Diverted W/ Conversation

Grade III Pain Intense Pain : Patient's Attention Cannot Be Diverted

Grade IV Pain Excruciating Unbearable Pain : Must Stop Exercise

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F. Patients With End-Stage Renal Failure Requiring Dialysis

Renal failure usually occurs in the 4th through the 7th decade in patients who have diabetes or patients who have been exposed to toxic chemicals or who have some form of kidney disease.

These patients are very debilitated because they have been sedentary and incapable of significant exercise for many months to years. These patients characteristically have wasted musculature which eventually incapacitates them. Activities of daily living are very difficult. Typically these patients have extensive muscle wasting, hypertension, hyperlipidemia, muscle cramping, bone disease, fatigue and psychosocial disorders.

Exercise is therapeutic for these patients because it tends to blunt or even reverse some of the insidous changes that occur in end-stage renal failure. Exercise prescription recommendations are as follows :

Exercise Parameters Exercise Recommendations

Mode Bicycling During Dialysis

Frequency 3 times/week

Duration Progress To 30-45 minutes

Intensity Tolerance Of The Patient

All exercise prescription has to take into account the unique pathology of the patient. Modifying the prescription to the patient's needs is the "art" of the science we apply.​​​